October 2014
Health Insurance Marketplace Standard Preferred Drug List
Contents
Introduction .................................................................... I Therapeutic Class Drug List ........................................ 1
How preferred drugs are selected ................................... I Anti-Infective Agents ....................................................... 1
How member payment is determined .............................. I Biologicals ..................................................................... 13
How to use this list .......................................................... II Antineoplastic Agents ................................................... 15
Drugs used to treat multiple conditions .......................... II Endocrine and Metabolic Drugs ................................... 19
Generic drugs ................................................................. II Cardiovascular Agents .................................................. 38
Consider talking to your doctor about generic
Respiratory Agents ....................................................... 58
drugs ........................................................................... II Gastrointestinal Agents ................................................. 67
Coverage considerations ............................................... III Genitourinary Agents .................................................... 74
Specialty drugs .............................................................. IV Central Nervous System Drugs .................................... 77
Prime Therapeutics Specialty Pharmacy
Analgesics and Anesthetics .......................................... 95
program....................................................................... V Neuromuscular Drugs ................................................. 109
Abbreviation key ............................................................. V Nutritional Products .................................................... 118
Hematological Agents ................................................. 132
Topical Products ......................................................... 140
Miscellaneous Products .............................................. 164
Index........................................................................... 168
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 preferred drug list is regularly updated. Please visit bcbstx.com for the most up-to-date information.
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-M TX IVL © Prime Therapeutics LLC 10/14
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.
Preferred drug list 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 preferred 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 preferred 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.
I
BCBSTX Health Insurance Marketplace 5 Tier Standard Preferred Drug List October 2014
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 Standard Preferred Drug List October 2014
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.
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 Standard Preferred Drug List October 2014
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.
BCBSTX Health Insurance Marketplace 5 Tier Standard Preferred Drug List October 2014
IV
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.
Abbreviation key
cap ...................................................................... capsules
chew .................................................................. chewable
odt ............................................. orally disintegrating tabs
oint ..................................................................... ointment
conc ............................................................. concentrate
cr .......................................................... controlled release
ophth ................................................................. opthalmic
osm .......................................................... osmotic release
dr ............................................................. delayed release
ec ................................................................ enteric coated
powd..................................................................... powder
sa ............................................................ sustained action
effe................................................................. effervescent
equiv ................................................................ equivalent
sl ...................................................................... sublingual
soln ....................................................................... solution
er ...........................................................extended release
inhal................................................................... inhalation
sr .......................................................... sustained release
suppose ...................................................... suppositories
inj ......................................................................... injection
liq .............................................................................. liquid
susp ................................................................ suspension
tab ...........................................................................tablets
lotn ........................................................................... lotion
nebu ................................................................... nebulizer
td ................................................................... transdermal
V
BCBSTX Health Insurance Marketplace 5 Tier Standard Preferred Drug List October 2014
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
2014
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 Standard Formulary October 2014
1
CEFACLOR - cefaclor for susp 250
mg/5ml
4
cefuroxime axetil for susp
125 mg/5ml (Ceftin)
2
CEFACLOR - cefaclor for susp 375
mg/5ml
4
cefuroxime axetil tab 250 mg (Ceftin)
1
cefuroxime axetil tab 500 mg (Ceftin)
2
cefaclor cap 250 mg
2
CEPHALEXIN - cephalexin tab 250 mg
4
cefaclor cap 500 mg
2
CEPHALEXIN - cephalexin tab 500 mg
4
CEFACLOR ER - cefaclor monohydrate
tab sr 12hr 500 mg
4
cephalexin cap 250 mg (Keflex)
1
1
cephalexin cap 500 mg (Keflex)
1
cefadroxil cap 500 mg
2
cephalexin cap 750 mg (Keflex)
2
cefadroxil for susp 250 mg/5ml
2
cephalexin for susp 125 mg/5ml
1
cefadroxil for susp 500 mg/5ml
2
cephalexin for susp 250 mg/5ml
1
cefadroxil tab 1 gm
2
KEFLEX - cephalexin cap 250 mg
4
cefdinir cap 300 mg
2
KEFLEX - cephalexin cap 500 mg
4
cefdinir for susp 125 mg/5ml
2
KEFLEX - cephalexin cap 750 mg
4
cefdinir for susp 250 mg/5ml
4
SPECTRACEF - cefditoren pivoxil tab
200 mg (base equivalent)
4
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 200 mg (base equivalent)
4
SPECTRACEF - cefditoren pivoxil tab
400 mg (base equivalent)
4
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 400 mg (base equivalent)
2
SUPRAX - cefixime cap 400 mg
4
cefpodoxime proxetil for susp
100 mg/5ml
SUPRAX - cefixime tab 400 mg
3
cefpodoxime proxetil for susp
50 mg/5ml
2
SUPRAX - cefixime chew tab 100 mg
4
SUPRAX - cefixime chew tab 200 mg
4
cefpodoxime proxetil tab 100 mg
2
4
cefpodoxime proxetil tab 200 mg
2
SUPRAX - cefixime for susp 100
mg/5ml
cefprozil for susp 125 mg/5ml
2
4
cefprozil for susp 250 mg/5ml
2
SUPRAX - cefixime for susp 200
mg/5ml
2
SUPRAX - cefixime for susp 500
mg/5ml
4
cefprozil tab 250 mg
cefprozil tab 500 mg
2
CEFTIBUTEN - ceftibuten cap 400 mg
4
4
AZITHROMYCIN - azithromycin powd
pack for susp 1 gm
3
CEFTIBUTEN - ceftibuten for susp 180
mg/5ml
4
azithromycin for susp 100 mg/5ml
(Zithromax)
2
CEFTIN - cefuroxime axetil tab 250 mg
CEFTIN - cefuroxime axetil tab 500 mg
4
2
CEFTIN - cefuroxime axetil for susp 125
mg/5ml
4
azithromycin for susp 200 mg/5ml
(Zithromax)
azithromycin tab 250 mg (Zithromax)
1
CEFTIN - cefuroxime axetil for susp 250
mg/5ml
4
azithromycin tab 500 mg (Zithromax)
1
2
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
MACROLIDES
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
BIAXIN - clarithromycin tab 250 mg
4
BIAXIN - clarithromycin tab 500 mg
4
BIAXIN - clarithromycin for susp 250
mg/5ml
4
BIAXIN XL - clarithromycin tab sr 24hr
500 mg
4
BIAXIN XL PAC - clarithromycin tab sr
24hr 500 mg
4
clarithromycin for susp 125 mg/5ml
2
clarithromycin for susp 250 mg/5ml
(Biaxin)
2
clarithromycin tab sr 24hr 500 mg
(Biaxin xl pac)
2
clarithromycin tab 250 mg (Biaxin)
2
clarithromycin tab 500 mg (Biaxin)
2
DIFICID - fidaxomicin tab 200 mg
4
E.E.S. GRANULES - erythromycin
ethylsuccinate for susp 200 mg/5ml
4
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
4
ERY-TAB - erythromycin tab delayed
release 250 mg
4
ERY-TAB - erythromycin tab delayed
release 333 mg
4
ERY-TAB - erythromycin tab delayed
release 500 mg
4
4
ACTICLATE - doxycycline hyclate tab
75 mg
4
ERYPED 200 - erythromycin
ethylsuccinate for susp 200 mg/5ml
4
ACTICLATE - doxycycline hyclate tab
150 mg
4
ERYPED 400 - erythromycin
ethylsuccinate for susp 400 mg/5ml
4
ADOXA - doxycycline monohydrate cap
150 mg
4
ERYTHROCIN STEARATE erythromycin stearate tab 250 mg
•
4
ADOXA - doxycycline monohydrate tab
50 mg
4
ERYTHROMYCIN - erythromycin w/
delayed release particles cap 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
•
•
Dispensing Limits
2
Step Therapy
Prior Authorization
azithromycin tab 600 mg (Zithromax)
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
2014
ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate tab 400
mg
4
erythromycin ethylsuccinate tab
400 mg
2
•
erythromycin w/ delayed release
particles cap 250 mg
2
•
PCE - erythromycin w/ enteric coated
particles tab 333 mg
4
PCE - erythromycin w/ enteric coated
particles tab 500 mg
4
ZITHROMAX - azithromycin tab 250 mg
4
ZITHROMAX - azithromycin tab 500 mg
4
ZITHROMAX - azithromycin tab 600 mg
4
ZITHROMAX - azithromycin for susp
100 mg/5ml
4
ZITHROMAX - azithromycin for susp
200 mg/5ml
4
ZITHROMAX - azithromycin powd pack
for susp 1 gm
3
ZITHROMAX TRI-PAK - azithromycin
tab 500 mg
4
•
ZITHROMAX Z-PAK - azithromycin tab
250 mg
4
•
ZMAX - azithromycin extended release
for oral susp 2 gm
4
•
•
•
•
TETRACYCLINES
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
3
2
ADOXA PAK 1/150 - doxycycline
monohydrate tab 150 mg
4
•
doxycycline monohydrate tab
150 mg (Adoxa pak 1/150)
2
ADOXA PAK 2/100 - doxycycline
monohydrate tab 100 mg
4
•
doxycycline monohydrate tab 50 mg
(Adoxa)
2
ALODOX CONVENIENCE KIT doxycycline hyclate tab 20 mg w/
eyelid cleansers kit
4
•
doxycycline monohydrate tab 75 mg
(Adoxa)
2
4
AVIDOXY DK - doxycycline tab 100 mg
& suncreen & sal acid wash 2% kit
•
DYNACIN - minocycline hcl tab 50 mg
4
DYNACIN - minocycline hcl tab 75 mg
4
2
DYNACIN - minocycline hcl tab 100 mg
4
demeclocycline hcl tab 150 mg
2
MINOCIN - minocycline hcl cap 50 mg
4
demeclocycline hcl tab 300 mg
4
•
MINOCIN - minocycline hcl cap 75 mg
2
DORYX - doxycycline hyclate tab
delayed release 150 mg
MINOCIN - minocycline hcl cap 100 mg
4
DORYX - doxycycline hyclate tab
delayed release 200 mg
4
•
MINOCIN KIT - minocycline hcl cap 50
mg w/ acne care products kit
4
•
•
DOXYCYCLINE HYCLATE doxycycline hyclate cap dr particles
100 mg
4
•
MINOCIN KIT - minocycline hcl cap 100
mg w/ acne care products kit
4
•
doxycycline hyclate cap 100 mg
(Vibramycin)
1
doxycycline hyclate cap 50 mg
1
doxycycline hyclate tab delayed
release 100 mg
2
•
doxycycline hyclate tab delayed
release 150 mg (Doryx)
2
doxycycline hyclate tab delayed
release 75 mg
2
doxycycline hyclate tab 100 mg
1
doxycycline hyclate tab 20 mg
2
doxycycline monohydrate cap
100 mg (Monodox)
•
•
•
•
minocycline hcl cap 100 mg (Minocin) 1
minocycline hcl cap 50 mg (Minocin) 1
minocycline hcl cap 75 mg (Minocin)
2
minocycline hcl tab sr 24hr 135 mg
2
minocycline hcl tab sr 24hr 45 mg
2
•
minocycline hcl tab sr 24hr 90 mg
2
minocycline hcl tab 100 mg
2
•
minocycline hcl tab 50 mg
2
minocycline hcl tab 75 mg
2
MONODOX - doxycycline monohydrate
cap 50 mg
4
•
2
MONODOX - doxycycline monohydrate
cap 75 mg
4
•
doxycycline monohydrate cap
150 mg (Adoxa)
2
MONODOX - doxycycline monohydrate
cap 100 mg
4
•
doxycycline monohydrate cap 50 mg
2
4
•
doxycycline monohydrate cap 75 mg
(Monodox)
2
MORGIDOX 1X100MG - doxycycline
hyclate cap 1 x 100 mg w/ cleanser
kit
doxycycline monohydrate for susp
25 mg/5ml (Vibramycin)
2
4
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
ADOXA PAK 1/100 - doxycycline
monohydrate tab 100 mg
Drug Name
Step Therapy
Drug Tier
2014
4
NUTRIDOX - doxycycline monohyd cap
75 mg w/ omega 3-vit e cap kit
4
OCUDOX - doxycycline hyclate cap 50
mg & eyelid cleans & spray kit
4
ORAXYL - doxycycline hyclate cap 20
mg
4
SOLODYN - minocycline hcl tab sr 24hr
45 mg
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
90 mg
4
•
SOLODYN - minocycline hcl tab sr 24hr
105 mg
4
•
SOLODYN - minocycline hcl tab sr 24hr
115 mg
4
•
SOLODYN - minocycline hcl tab sr 24hr
135 mg
4
•
TETRACYCLINE HCL - tetracycline hcl
cap 250 mg
4
TETRACYCLINE HCL - tetracycline hcl
cap 500 mg
4
tetracycline hcl cap 250 mg
1
tetracycline hcl cap 500 mg
1
VIBRAMYCIN - doxycycline
monohydrate for susp 25 mg/5ml
4
4
•
VIBRAMYCIN - doxycycline calcium
syrup 50 mg/5ml
4
•
Dispensing Limits
NICAZELDOXY 60 KIT - doxycycline
monohyd tab 100 mg &multivit/
minerals tab kit
•
VIBRAMYCIN - doxycycline hyclate cap
100 mg
Drug Name
Step Therapy
NICAZELDOXY 30 KIT - doxycycline
monohyd tab 100 mg &multivit/
minerals tab kit
4
Prior Authorization
•
Drug Tier
4
Dispensing Limits
Prior Authorization
MORGIDOX 2X100MG - doxycycline
hyclate cap 2 x 100 mg w/ cleanser
kit
Drug Name
Step Therapy
Drug Tier
2014
FLUOROQUINOLONES
•
•
•
•
•
•
•
•
•
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
CIPRO - ciprofloxacin hcl tab 500 mg
(base equiv)
4
CIPRO XR - ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 500 mg (base eq)
4
CIPRO XR - ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 1000 mg(base eq)
4
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
2
ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
(Cipro)
2
ciprofloxacin hcl tab 100 mg (base
equiv)
2
ciprofloxacin hcl tab 250 mg (base
equiv) (Cipro)
1
ciprofloxacin hcl tab 500 mg (base
equiv) (Cipro)
1
ciprofloxacin hcl tab 750 mg (base
equiv)
1
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq) (Cipro xr)
2
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq) (Cipro xr)
2
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
5
FACTIVE - gemifloxacin mesylate tab
320 mg (base equiv)
4
ethambutol hcl tab 100 mg
(Myambutol)
2
LEVAQUIN - levofloxacin tab 250 mg
4
2
LEVAQUIN - levofloxacin tab 500 mg
4
ethambutol hcl tab 400 mg
(Myambutol)
LEVAQUIN - levofloxacin tab 750 mg
4
ISONIAZID - isoniazid syrup 50 mg/5ml
4
LEVAQUIN - levofloxacin oral soln 25
mg/ml
4
isoniazid & rifampin cap 150-300 mg
2
isoniazid tab 100 mg
1
levofloxacin oral soln 25 mg/ml
(Levaquin)
2
isoniazid tab 300 mg
1
levofloxacin tab 250 mg (Levaquin)
MYAMBUTOL - ethambutol hcl tab 100
mg
4
1
levofloxacin tab 500 mg (Levaquin)
1
4
levofloxacin tab 750 mg (Levaquin)
1
MYAMBUTOL - ethambutol hcl tab 400
mg
moxifloxacin hcl tab 400 mg (base
equiv) (Avelox)
2
MYCOBUTIN - rifabutin cap 150 mg
3
4
NOROXIN - norfloxacin tab 400 mg
4
PASER - aminosalicylic acid cr granules
packet 4 gm
OFLOXACIN - ofloxacin tab 400 mg
2
PRIFTIN - rifapentine tab 150 mg
3
ofloxacin tab 200 mg
2
pyrazinamide tab 500 mg
2
ofloxacin tab 300 mg
2
rifabutin cap 150 mg (Mycobutin)
2
ofloxacin tab 400 mg
2
RIFADIN - rifampin cap 150 mg
4
RIFADIN - rifampin cap 300 mg
4
RIFAMATE - isoniazid & rifampin cap
150-300 mg
4
rifampin cap 150 mg (Rifadin)
2
rifampin cap 300 mg (Rifadin)
2
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
4
•
SEROMYCIN - cycloserine cap 250 mg
4
4
•
SIRTURO - bedaquiline fumarate tab
100 mg (base equiv)
TRECATOR - ethionamide tab 250 mg
4
AMINOGLYCOSIDES
BETHKIS - tobramycin nebu soln 300
mg/4ml
5
NEO-FRADIN - neomycin sulfate soln
25 mg/ml
4
neomycin sulfate tab 500 mg
1
paromomycin sulfate cap 250 mg
2
TOBI - tobramycin nebu soln 300
mg/5ml
5
TOBI PODHALER - tobramycin inhal
cap 28 mg
5
tobramycin nebu soln 300 mg/5ml
(Tobi)
5
SULFONAMIDES
SULFADIAZINE - sulfadiazine tab 500
mg
4
ANTIMYCOBACTERIAL AGENTS
CYCLOSERINE - cycloserine cap 250
mg
6
4
•
•
•
•
•
ANTIFUNGALS
nystatin oral powder
2
ANCOBON - flucytosine cap 250 mg
4
ANCOBON - flucytosine cap 500 mg
4
BIO-STATIN - nystatin cap 500000 unit
4
BIO-STATIN - nystatin cap 1000000 unit 4
4
DIFLUCAN - fluconazole tab 50 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
nystatin tab 500000 unit
2
ONMEL - itraconazole tab 200 mg
4
SPORANOX - itraconazole cap 100 mg
4
1
SPORANOX - itraconazole oral soln 10
mg/ml
4
fluconazole for susp 40 mg/ml
(Diflucan)
2
SPORANOX PULSEPAK - itraconazole
cap 100 mg
4
fluconazole tab 100 mg (Diflucan)
1
terbinafine hcl tab 250 mg (Lamisil)
1
fluconazole tab 150 mg (Diflucan)
1
4
fluconazole tab 200 mg (Diflucan)
1
TERBINEX - terbinafine oral tab 250 mg
& hydrxyprop chitosan liq 1% kit
fluconazole tab 50 mg (Diflucan)
1
VFEND - voriconazole tab 50 mg
4
flucytosine cap 250 mg (Ancobon)
2
VFEND - voriconazole tab 200 mg
4
flucytosine cap 500 mg (Ancobon)
2
4
GRIFULVIN V - griseofulvin microsize
tab 500 mg
4
VFEND - voriconazole for susp 40 mg/
ml
•
•
•
2
•
GRIS-PEG - griseofulvin ultramicrosize
tab 125 mg
4
voriconazole for susp 40 mg/ml
(Vfend)
voriconazole tab 200 mg (Vfend)
2
voriconazole tab 50 mg (Vfend)
2
•
•
4
DIFLUCAN - fluconazole tab 200 mg
4
DIFLUCAN - fluconazole for susp 10
mg/ml
4
DIFLUCAN - fluconazole for susp 40
mg/ml
4
fluconazole for susp 10 mg/ml
(Diflucan)
GRIS-PEG - griseofulvin ultramicrosize
tab 250 mg
4
griseofulvin microsize susp
125 mg/5ml
2
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
2
griseofulvin microsize tab 500 mg
(Grifulvin v)
2
2
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
2
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
acyclovir cap 200 mg (Zovirax)
1
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
2
acyclovir susp 200 mg/5ml (Zovirax)
2
acyclovir tab 400 mg (Zovirax)
1
itraconazole cap 100 mg (Sporanox)
2
acyclovir tab 800 mg (Zovirax)
1
ketoconazole tab 200 mg
1
4
adefovir dipivoxil tab 10 mg
(Hepsera)
2
LAMISIL - terbinafine hcl tab 250 mg
LAMISIL - terbinafine hcl oral granules
packet 125 mg
4
APTIVUS - tipranavir cap 250 mg
3
LAMISIL - terbinafine hcl oral granules
packet 187.5 mg
APTIVUS - tipranavir oral soln 100 mg/
ml
3
4
Dispensing Limits
Prior Authorization
3
DIFLUCAN - fluconazole tab 150 mg
Drug Name
Step Therapy
Drug Tier
NOXAFIL - posaconazole susp 40 mg/
ml
4
Dispensing Limits
•
DIFLUCAN - fluconazole tab 100 mg
Step Therapy
4
Drug Tier
NOXAFIL - posaconazole tab delayed
release 100 mg
Drug Name
Prior Authorization
2014
ANTIVIRALS
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
7
FAMVIR - famciclovir tab 125 mg
4
FAMVIR - famciclovir tab 250 mg
4
FAMVIR - famciclovir tab 500 mg
4
FLUMADINE - rimantadine
hydrochloride tab 100 mg
4
FUZEON - enfuvirtide for inj 90 mg
5
HEPSERA - adefovir dipivoxil tab 10 mg
4
Dispensing Limits
Drug Tier
•
Step Therapy
Drug Name
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
3
BARACLUDE - entecavir tab 0.5 mg
3
BARACLUDE - entecavir tab 1 mg
3
BARACLUDE - entecavir oral soln 0.05
mg/ml
3
COMBIVIR - lamivudine-zidovudine tab
150-300 mg
4
•
4
•
INCIVEK - telaprevir tab 375 mg
5
COMPLERA - emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg
5
COPEGUS - ribavirin tab 200 mg
5
INFERGEN - interferon alfacon-1 inj 9
mcg/0.3ml
•
•
3
•
INFERGEN - interferon alfacon-1 inj 15
mcg/0.5ml
5
CRIXIVAN - indinavir sulfate cap 200
mg
•
3
•
INTELENCE - etravirine tab 25 mg
3
CRIXIVAN - indinavir sulfate cap 400
mg
INTELENCE - etravirine tab 100 mg
3
didanosine delayed release capsule
125 mg (Videx ec)
2
•
INTELENCE - etravirine tab 200 mg
3
3
didanosine delayed release capsule
200 mg (Videx ec)
2
•
INVIRASE - saquinavir mesylate cap
200 mg
•
•
•
•
3
•
didanosine delayed release capsule
250 mg (Videx ec)
2
•
INVIRASE - saquinavir mesylate tab
500 mg
3
•
didanosine delayed release capsule
400 mg (Videx ec)
2
•
ISENTRESS - raltegravir potassium tab
400 mg (base equiv)
3
•
EDURANT - rilpivirine hcl tab 25 mg
(base equivalent)
4
•
ISENTRESS - raltegravir potassium
chew tab 25 mg (base equiv)
3
•
EMTRIVA - emtricitabine caps 200 mg
3
ISENTRESS - raltegravir potassium
chew tab 100 mg (base equiv)
EMTRIVA - emtricitabine soln 10 mg/ml
3
4
•
EPIVIR - lamivudine tab 150 mg
4
ISENTRESS - raltegravir potassium
packet for susp 100 mg (base equiv)
4
KALETRA - lopinavir-ritonavir tab
100-25 mg
3
EPIVIR - lamivudine tab 300 mg
•
EPIVIR - lamivudine oral soln 10 mg/ml
3
•
EPIVIR HBV - lamivudine tab 100 mg
KALETRA - lopinavir-ritonavir tab
200-50 mg
3
4
EPIVIR HBV - lamivudine oral soln 5
mg/ml
4
KALETRA - lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
3
•
EPZICOM - abacavir sulfate-lamivudine
tab 600-300 mg
3
lamivudine tab 100 mg (Epivir hbv)
2
lamivudine tab 150 mg (Epivir)
2
famciclovir tab 125 mg (Famvir)
2
lamivudine tab 300 mg (Epivir)
2
famciclovir tab 250 mg (Famvir)
2
famciclovir tab 500 mg (Famvir)
lamivudine-zidovudine tab
150-300 mg (Combivir)
2
2
8
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
•
•
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
•
2
•
PEGASYS - peginterferon alfa-2a inj
180 mcg/0.5ml
5
•
2
PEGASYS - peginterferon alfa-2a inj kit
180 mcg/0.5ml
•
NORVIR - ritonavir cap 100 mg
3
•
NORVIR - ritonavir tab 100 mg
PEGASYS PROCLICK - peginterferon
alfa-2a inj 135 mcg/0.5ml
5
3
NORVIR - ritonavir oral soln 80 mg/ml
3
•
•
•
•
5
nevirapine tab 200 mg (Viramune)
5
•
OLYSIO - simeprevir sodium cap 150
mg (base equivalent)
5
PEGASYS PROCLICK - peginterferon
alfa-2a inj 180 mcg/0.5ml
3
•
LEXIVA - fosamprenavir calcium susp
50 mg/ml (base equiv)
3
•
MODERIBA - ribavirin tab 200 mg &
ribavirin tab 400 mg dose pack
5
MODERIBA - ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
5
MODERIBA 1200 DOSE PACK ribavirin tab 600 mg
5
MODERIBA 800 DOSE PACK - ribavirin
tab 400 mg
5
NEVIRAPINE - nevirapine susp 50
mg/5ml
4
nevirapine tab sr 24hr 400 mg
(Viramune xr)
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
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
•
•
•
•
•
•
•
PREZISTA - darunavir ethanolate tab 75 3
mg (base equiv)
3
PREZISTA - darunavir ethanolate tab
150 mg (base equiv)
3
PREZISTA - darunavir ethanolate tab
400 mg (base equiv)
3
PREZISTA - darunavir ethanolate tab
600 mg (base equiv)
3
PREZISTA - darunavir ethanolate tab
800 mg (base equiv)
3
PREZISTA - darunavir ethanolate susp
100 mg/ml (base equiv)
5
REBETOL - ribavirin cap 200 mg
Dispensing Limits
Prior Authorization
5
LEXIVA - fosamprenavir calcium tab
700 mg (base equiv)
Drug Name
Step Therapy
Drug Tier
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 80
mcg/0.5ml
Dispensing Limits
•
Step Therapy
5
Drug Tier
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 50
mcg/0.5ml
Drug Name
Prior Authorization
2014
•
•
•
•
•
•
•
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
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
9
RETROVIR - zidovudine cap 100 mg
4
RETROVIR - zidovudine tab 300 mg
4
•
•
•
•
RETROVIR - zidovudine syrup 10 mg/ml 4
3
REYATAZ - atazanavir sulfate cap 100
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
•
•
•
Dispensing Limits
stavudine cap 20 mg (Zerit)
Step Therapy
•
Prior Authorization
3
Drug Tier
RESCRIPTOR - delavirdine mesylate
tab 200 mg
Drug Name
Step Therapy
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2014
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 cap 50 mg
3
SUSTIVA - efavirenz cap 200 mg
3
SUSTIVA - efavirenz tab 600 mg
3
TAMIFLU - oseltamivir phosphate cap
30 mg (base equiv)
4
•
•
•
•
TAMIFLU - oseltamivir phosphate cap
45 mg (base equiv)
4
•
RIBASPHERE - ribavirin tab 600 mg
5
RIBASPHERE RIBAPAK - ribavirin tab
400 mg
5
TAMIFLU - oseltamivir phosphate cap
75 mg (base equiv)
4
•
RIBASPHERE RIBAPAK - ribavirin tab
600 mg
5
TAMIFLU - oseltamivir phosphate for
susp 6 mg/ml (base equiv)
4
•
RIBASPHERE RIBAPAK - ribavirin tab
200 mg & ribavirin tab 400 mg dose
pack
5
TIVICAY - dolutegravir sodium tab 50
mg (base equiv)
3
•
•
RIBASPHERE RIBAPAK - ribavirin tab
400 mg & ribavirin tab 600 mg dose
pack
TRIZIVIR - abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
3
5
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
3
•
RIBATAB - ribavirin tab 400 mg
5
TYZEKA - telbivudine tab 600 mg
4
RIBATAB - ribavirin tab 600 mg
5
valacyclovir hcl tab 1 gm (Valtrex)
2
RIBATAB - ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
5
valacyclovir hcl tab 500 mg (Valtrex)
2
5
VALCYTE - valganciclovir hcl tab 450
mg
3
ribavirin cap 200 mg (Rebetol)
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
10
•
•
•
•
VALCYTE - valganciclovir hcl for soln 50 3
mg/ml (base equiv)
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
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
VIDEX EC - didanosine delayed release
capsule 200 mg
4
•
4
•
ZOVIRAX - acyclovir cap 200 mg
4
VIDEX EC - didanosine delayed release
capsule 250 mg
ZOVIRAX - acyclovir tab 400 mg
4
VIDEX EC - didanosine delayed release
capsule 400 mg
4
•
ZOVIRAX - acyclovir tab 800 mg
4
ZOVIRAX - acyclovir susp 200 mg/5ml
4
VIRACEPT - nelfinavir mesylate tab 250
mg
3
•
ANTIMALARIALS
VIRACEPT - nelfinavir mesylate tab 625
mg
•
ARALEN - chloroquine phosphate tab
500 mg
4
3
VIRAMUNE - nevirapine tab 200 mg
VIRAMUNE - nevirapine susp 50
mg/5ml
3
•
•
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
2
4
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
2
VIRAMUNE XR - nevirapine tab sr 24hr
100 mg
3
•
chloroquine phosphate tab 250 mg
2
3
•
chloroquine phosphate tab 500 mg
(Aralen)
1
VIRAMUNE XR - nevirapine tab sr 24hr
400 mg
VIRAZOLE - ribavirin for inhal soln 6 gm
COARTEM - artemether-lumefantrine
tab 20-120 mg
4
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
3
•
MALARONE - atovaquone-proguanil hcl
tab 62.5-25 mg
3
VIREAD - tenofovir disoproxil fumarate
tab 250 mg
3
•
MALARONE - atovaquone-proguanil hcl
tab 250-100 mg
4
VIREAD - tenofovir disoproxil fumarate
tab 300 mg
VIREAD - tenofovir disoproxil fumarate
oral powder 40 mg/gm
•
mefloquine hcl tab 250 mg
2
3
4
ZERIT - stavudine cap 15 mg
4
ZERIT - stavudine cap 20 mg
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg
3
4
ZERIT - stavudine cap 30 mg
4
4
QUALAQUIN - quinine sulfate cap 324
mg
4
ZERIT - stavudine cap 40 mg
ZERIT - stavudine for oral soln 1 mg/ml
4
4
quinine sulfate cap 324 mg
(Qualaquin)
2
ZIAGEN - abacavir sulfate tab 300 mg
(base equiv)
•
•
•
•
•
•
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
ZIAGEN - abacavir sulfate soln 20 mg/
ml (base equiv)
3
•
2
zidovudine syrup 10 mg/ml (Retrovir)
2
zidovudine tab 300 mg
2
Dispensing Limits
zidovudine cap 100 mg (Retrovir)
Step Therapy
•
Prior Authorization
4
Drug Tier
VIDEX EC - didanosine delayed release
capsule 125 mg
Step Therapy
Drug Name
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2014
•
•
•
AMEBICIDES
YODOXIN - iodoquinol tab 210 mg
4
YODOXIN - iodoquinol tab 650 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
11
ANTHELMINTICS
4
ALBENZA - albendazole tab 200 mg
3
FLAGYL ER - metronidazole tab sr 24hr
750 mg
BILTRICIDE - praziquantel tab 600 mg
3
KETEK - telithromycin tab 300 mg
4
MEBENDAZOLE - mebendazole chew
tab 100 mg
3
KETEK - telithromycin tab 400 mg
4
4
STROMECTOL - ivermectin tab 3 mg
3
MEPRON - atovaquone susp 750
mg/5ml
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
ANTI-INFECTIVE AGENTS - MISC.
ALINIA - nitazoxanide tab 500 mg
4
ALINIA - nitazoxanide for susp 100
mg/5ml
4
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
CLEOCIN PEDIATRIC GRANULE clindamycin palmitate hcl for soln 75
mg/5ml (base equiv)
4
clindamycin hcl cap 150 mg (Cleocin)
1
TINDAMAX - tinidazole tab 500 mg
4
clindamycin hcl cap 300 mg (Cleocin)
1
tinidazole tab 250 mg (Tindamax)
2
clindamycin hcl cap 75 mg (Cleocin)
1
tinidazole tab 500 mg (Tindamax)
2
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
2
trimethoprim tab 100 mg
1
VANCOCIN HCL - vancomycin hcl cap
125 mg
4
DAPSONE - dapsone tab 25 mg
3
4
DAPSONE - dapsone tab 100 mg
3
VANCOCIN HCL - vancomycin hcl cap
250 mg
erythromycin-sulfisoxazole for susp
200-600 mg/5ml
2
vancomycin hcl cap 125 mg
(Vancocin hcl)
2
FLAGYL - metronidazole cap 375 mg
4
2
FLAGYL - metronidazole tab 250 mg
4
vancomycin hcl cap 250 mg
(Vancocin hcl)
4
XIFAXAN - rifaximin tab 200 mg
4
FLAGYL - metronidazole tab 500 mg
XIFAXAN - rifaximin tab 550 mg
3
12
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PRIMSOL - trimethoprim hcl oral soln 50 4
mg/5ml (base equiv)
4
SEPTRA DS - sulfamethoxazoletrimethoprim tab 800-160 mg
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
BIOLOGICALS
VACCINES
4
FLUARIX 2013-2014 - influenza virus
vaccine split preservative free inj
4
FLUBLOK 2013-2014 - influenza virus
vac recombinant hemagglutinin (ha)
inj
4
FLUCELVAX 2012-2013 - influenza
virus vaccine tissue-cultured subunit
inj
4
FLUCELVAX 2013-2014 - influenza
virus vaccine tissue-cultured subunit
inj
4
FLUCELVAX 2014-2015 - influenza
virus vaccine tissue-cultured subunit
inj
4
FLULAVAL QUADRIVALENT
201 - influenza virus vaccine split
quadrivalent im inj
4
4
AFLURIA PF 2011-2012 - influenza
virus vaccine split preservative free
inj
4
AFLURIA PF 2012-2013 - influenza
virus vaccine split preservative free
inj
4
AFLURIA PF 2013-2014 - influenza
virus vaccine split preservative free
inj
4
AFLURIA PF 2014-2015 - influenza
virus vaccine split preservative free
inj
4
AFLURIA 2011-2012 - influenza virus
vaccine split inj
4
AFLURIA 2012-2013 - influenza virus
vaccine split inj
4
AFLURIA 2013-2014 - influenza virus
vaccine split inj
4
FLULAVAL QUADRIVALENT
201 - influenza virus vaccine split
quadrivalent inj 0.5 ml
AFLURIA 2014-2015 - influenza virus
vaccine split inj
FLULAVAL 2011-2012 - influenza virus
vaccine split inj
4
4
4
ENGERIX-B - hepatitis b vaccine
(recombinant) susp 10 mcg/0.5ml
4
FLULAVAL 2012-2013 - influenza virus
vaccine split inj
4
FLULAVAL 2013-2014 - influenza virus
vaccine split inj
4
ENGERIX-B - hepatitis b vaccine
(recombinant) susp 20 mcg/ml
ENGERIX-B - hepatitis b vaccine
(recombinant) 10 mcg/0.5ml
FLULAVAL 2014-2015 - influenza virus
vaccine split inj
4
4
ENGERIX-B - hepatitis b vaccine
(recombinant) 20 mcg/ml
FLUMIST NASAL VACCINE 201 influenza virus vaccine live intranasal
liquid
4
4
FLUARIX QUADRIVALENT 2013 influenza virus vaccine split
quadrivalent inj 0.5 ml
4
FLUMIST QUADRIVALENT - influenza
virus vaccine live quadrivalent
intranasal susp
4
FLUARIX QUADRIVALENT 2014 influenza virus vaccine split
quadrivalent inj 0.5 ml
4
FLUVIRIN PF 2011-2012 - influenza
virus vaccine types a & b preservative
free inj
4
FLUARIX 2011-2012 - influenza virus
vaccine split preservative free inj
4
FLUVIRIN PF 2012-2013 - influenza
virus vaccine types a & b preservative
free inj
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
FLUARIX 2012-2013 - influenza virus
vaccine split preservative free inj
Step Therapy
•
•
Prior Authorization
3
Drug Name
Drug Tier
ZYVOX - linezolid for susp 100 mg/5ml
Dispensing Limits
3
Step Therapy
ZYVOX - linezolid tab 600 mg
Prior Authorization
Drug Name
Drug Tier
2014
13
FLUVIRIN PF 2013-2014 - influenza
virus vaccine types a & b preservative
free inj
4
FLUZONE PF 2013-2014 - influenza
virus vaccine split preservative free
inj
4
FLUVIRIN PF 2014-2015 - influenza
virus vaccine types a & b preservative
free inj
4
FLUZONE QUADRIVALENT 2013 influenza virus vaccine split
quadrivalent inj 0.25 ml
4
FLUVIRIN 2011-2012 - influenza virus
vaccine types a & b surface antigen
inj
4
FLUZONE QUADRIVALENT 2013 influenza virus vaccine split
quadrivalent inj 0.5 ml
4
FLUVIRIN 2012-2013 - influenza virus
vaccine types a & b surface antigen
inj
4
FLUZONE QUADRIVALENT 2014 influenza virus vaccine split
quadrivalent inj 0.25 ml
4
FLUVIRIN 2013-2014 - influenza virus
vaccine types a & b surface antigen
inj
4
FLUZONE QUADRIVALENT 2014 influenza virus vaccine split
quadrivalent inj 0.5 ml
4
FLUVIRIN 2014-2015 - influenza virus
vaccine types a & b surface antigen
inj
4
FLUZONE SPLIT 2012-2013 - influenza
virus vaccine split inj
4
4
FLUZONE SPLIT 2013-2014 - influenza
virus vaccine split inj
4
FLUZONE HIGH-DOSE PF 2012 influenza virus vac split high-dose
preservative free inj
FLUZONE SPLIT 2014-2015 - influenza
virus vaccine split inj
4
FLUZONE HIGH-DOSE PF 2013 influenza virus vac split high-dose
preservative free inj
4
IMOVAX RABIES (H.D.C.V.) - rabies
virus vaccine, hdc inj
4
4
INFLUENZA A (H1N1) MONOVA influenza a (h1n1) monovalent
vaccine live intranasal liquid
4
FLUZONE HIGH-DOSE PF 2014 influenza virus vac split high-dose
preservative free inj
4
MEDICAL PROVIDER EZ FLU
S - influenza virus vaccine split
quadrivalent inj kit 0.5 ml
4
FLUZONE INTRADERMAL - influenza
virus vaccine split intradermal inj 9
mcg/strain
4
MEDICAL PROVIDER EZ FLU S influenza virus vac types a & b
preservative free inj kit
4
FLUZONE PEDIATRIC PF 2012 influenza virus vaccine split
preservative free inj
4
PHYSICIANS EZ USE FLU KIT influenza virus vaccine types a & b
surface antigen inj kit
4
FLUZONE PEDIATRIC PF 2013 influenza virus vaccine split
preservative free inj
4
PNEUMOVAX 23 - pneumococcal
vaccine polyvalent inj 25 mcg/0.5ml
4
FLUZONE PEDIATRIC PF 2014 influenza virus vaccine split
preservative free inj
4
FLUZONE PF 2012-2013 - influenza
virus vaccine split preservative free
inj
4
PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent inj
25 mcg/0.5ml
14
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PNEUMOVAX 23/5 DOSE pneumococcal vaccine polyvalent inj
25 mcg/0.5ml
4
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
TOXOIDS
TETANUS TOXOID ADSORBED tetanus toxoid adsorbed inj 5 lf
4
TETANUS/DIPHTHERIA TOXOID tetanus-diphtheria toxoids (td) inj 2-2
lf/0.5ml
4
TRIPEDIA - diph, acellular pert & tet tox
inj 6.7 lf-46.8 mcg-5lf/0.5ml
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
PASSIVE IMMUNIZING AGENTS
HEPAGAM B - hepatitis b immune
globulin (human) inj soln
4
HIZENTRA - immune globulin (human)
subcutaneous inj 1 gm/5ml
4
HIZENTRA - immune globulin (human)
subcutaneous inj 2 gm/10ml
4
HIZENTRA - immune globulin (human)
subcutaneous inj 4 gm/20ml
4
HIZENTRA - immune globulin (human)
subcutaneous inj 10 gm/50ml
4
ADACEL - tet tox-diph-acell pertuss ad
inj 5-2-15.5 lf-lf-mcg/0.5ml
4
HYPERHEP B S/D - hepatitis b immune
globulin (human) im inj soln
4
BOOSTRIX - tet tox-diph-acell pertuss
ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml
4
HYPERRAB S/D - rabies immune
globulin (human) inj 150 unit/ml
4
DAPTACEL - diph, acellular pert & tet
tox inj 15 lf-10 mcg-5 lf/0.5ml
4
HYPERTET S/D - tetanus immune
globulin (human) inj 250 unit/ml
4
DECAVAC - tetanus-diphtheria toxoids
(td) inj 5-2 lfu
4
IMOGAM RABIES-HT - rabies immune
globulin (human) inj 150 unit/ml
4
DIPHTHERIA/TETANUS TOXOID diphtheria-tetanus tox adsorbed (dt)
im inj 25-5 unit/0.5ml
4
NABI-HB - hepatitis b immune globulin
(human) im inj soln
4
INFANRIX - diph, acellular pert & tet tox
inj 25 lf-58 mcg-10 lf/0.5ml
VARIZIG - varicella-zoster immune
globulin (human ) for inj 125 unit
4
4
KINRIX - diph-tetanus tox ad-acell pert
& polio virus, ipv vac inj
GRASTEK - timothy grass pollen
allergen ext tab sl 2800 bau
4
4
PEDIARIX - diph-tetanus tox-acell perthepatitis b-polio ipv vac inj
4
PENTACEL - diph-ac per-tet tox adpoliov-haemoph b poly vac for im
susp
4
TENIVAC - tetanus-diphtheria toxoids
(td) inj 5-2 lfu
4
ORALAIR - grass mixed pollen ext tab sl 4
300 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)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
5
•
15
AFINITOR - everolimus tab 10 mg
5
AFINITOR DISPERZ - everolimus tab
for oral susp 2 mg
CYCLOPHOSPHAMIDE cyclophosphamide tab 50 mg
3
ELIGARD - leuprolide acetate for
subcutaneous inj kit 7.5 mg
5
•
5
•
•
•
•
•
ELIGARD - leuprolide acetate (3 month)
for subcutaneous inj kit 22.5mg
5
•
5
•
•
ELIGARD - leuprolide acetate (4 month)
for subcutaneous inj kit 30 mg
5
AFINITOR DISPERZ - everolimus tab
for oral susp 3 mg
•
5
•
•
ELIGARD - leuprolide acetate (6 month)
for subcutaneous inj kit 45 mg
5
AFINITOR DISPERZ - everolimus tab
for oral susp 5 mg
•
3
EMCYT - estramustine phosphate
sodium cap 140 mg
3
ALKERAN - melphalan tab 2 mg
anastrozole tab 1 mg (Arimidex)
1
ERIVEDGE - vismodegib cap 150 mg
5
ARIMIDEX - anastrozole tab 1 mg
4
ETOPOSIDE - etoposide cap 50 mg
4
AROMASIN - exemestane tab 25 mg
4
exemestane tab 25 mg (Aromasin)
2
bicalutamide tab 50 mg (Casodex)
2
5
FARESTON - toremifene citrate tab 60
mg (base equivalent)
3
BOSULIF - bosutinib tab 100 mg
BOSULIF - bosutinib tab 500 mg
5
FEMARA - letrozole tab 2.5 mg
4
capecitabine tab 150 mg (Xeloda)
5
flutamide cap 125 mg
2
capecitabine tab 500 mg (Xeloda)
5
CAPRELSA - vandetanib tab 100 mg
5
GILOTRIF - afatinib dimaleate tab 20
mg (base equivalent)
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
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
3
CYCLOPHOSPHAMIDE cyclophosphamide tab 25 mg
16
•
•
•
•
•
•
•
•
•
•
•
•
5
•
•
GILOTRIF - afatinib dimaleate tab 30
mg (base equivalent)
5
•
•
GILOTRIF - afatinib dimaleate tab 40
mg (base equivalent)
5
•
•
GLEEVEC - imatinib mesylate tab 100
mg (base equivalent)
5
•
•
•
•
•
GLEEVEC - imatinib mesylate tab 400
mg (base equivalent)
5
•
•
•
HEXALEN - altretamine cap 50 mg
5
•
•
•
•
Dispensing Limits
5
•
•
•
•
•
Step Therapy
AFINITOR - everolimus tab 7.5 mg
Prior Authorization
5
Drug Name
Drug Tier
AFINITOR - everolimus tab 5 mg
Dispensing Limits
5
Step Therapy
AFINITOR - everolimus tab 2.5 mg
Prior Authorization
Drug Name
Drug Tier
2014
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
ICLUSIG - ponatinib hcl tab 15 mg
(base equiv)
5
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
LUPRON DEPOT - leuprolide acetate
for inj kit 7.5 mg
5
•
IMBRUVICA - ibrutinib cap 140 mg
5
5
5
5
5
MATULANE - procarbazine hcl cap 50
mg
•
•
INLYTA - axitinib tab 5 mg
•
•
•
LYSODREN - mitotane tab 500 mg
INLYTA - axitinib tab 1 mg
INTRON-A - interferon alfa-2b inj
6000000 unit/ml
5
•
•
•
•
MEGACE ORAL - megestrol acetate
susp 40 mg/ml
4
INTRON-A - interferon alfa-2b inj
10000000 unit/ml
5
•
megestrol acetate susp 40 mg/ml
(Megace oral)
2
INTRON-A W/DILUENT - interferon
alfa-2b for inj 10000000 unit
5
•
megestrol acetate tab 20 mg
1
megestrol acetate tab 40 mg
1
INTRON-A W/DILUENT - interferon
alfa-2b for inj 18000000 unit
5
•
5
•
•
INTRON-A W/DILUENT - interferon
alfa-2b for inj 50000000 unit
5
•
MEKINIST - trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
5
•
•
JAKAFI - ruxolitinib phosphate tab 5 mg
(base equivalent)
5
•
•
MEKINIST - trametinib dimethyl
sulfoxide tab 2 mg (base equivalent)
2
JAKAFI - ruxolitinib phosphate tab 10
mg (base equivalent)
5
•
mercaptopurine tab 50 mg
(Purinethol)
MESNEX - mesna tab 400 mg
3
JAKAFI - ruxolitinib phosphate tab 15
mg (base equivalent)
5
methotrexate sodium for inj 1 gm
2
1
JAKAFI - ruxolitinib phosphate tab 20
mg (base equivalent)
•
•
methotrexate sodium inj pf 25 mg/ml
5
methotrexate sodium inj 25 mg/ml
1
5
•
•
methotrexate sodium tab 2.5 mg
(base equiv)
1
JAKAFI - ruxolitinib phosphate tab 25
mg (base equivalent)
2
MYLERAN - busulfan tab 2 mg
3
letrozole tab 2.5 mg (Femara)
3
NEXAVAR - sorafenib tosylate tab 200
mg (base equivalent)
5
LEUCOVORIN CALCIUM - leucovorin
calcium tab 10 mg
•
•
3
NILANDRON - nilutamide tab 150 mg
3
LEUCOVORIN CALCIUM - leucovorin
calcium tab 15 mg
POMALYST - pomalidomide cap 1 mg
5
leucovorin calcium tab 25 mg
2
POMALYST - pomalidomide cap 2 mg
5
leucovorin calcium tab 5 mg
2
POMALYST - pomalidomide cap 3 mg
5
LEUKERAN - chlorambucil tab 2 mg
3
POMALYST - pomalidomide cap 4 mg
5
•
•
•
•
•
•
•
•
leuprolide acetate inj kit 5 mg/ml
5
4
LOMUSTINE - lomustine cap 10 mg
4
PURINETHOL - mercaptopurine tab 50
mg
4
PURIXAN - mercaptopurine susp 2000
mg/100ml (20 mg/ml)
4
LOMUSTINE - lomustine cap 40 mg
LOMUSTINE - lomustine cap 100 mg
4
LUPRON DEPOT - leuprolide acetate
for inj kit 3.75 mg
5
•
•
•
•
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
Prior Authorization
ICLUSIG - ponatinib hcl tab 45 mg
(base equiv)
Drug Name
Step Therapy
Drug Tier
2014
SOLTAMOX - tamoxifen citrate oral soln 4
10 mg/5ml (base equivalent)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
17
SPRYCEL - dasatinib tab 80 mg
5
SPRYCEL - dasatinib tab 100 mg
5
SPRYCEL - dasatinib tab 140 mg
5
STIVARGA - regorafenib tab 40 mg
5
SUTENT - sunitinib malate cap 12.5 mg
(base equivalent)
TASIGNA - nilotinib cap 150 mg
5
TASIGNA - nilotinib cap 200 mg
5
TEMODAR - temozolomide cap 5 mg
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 100 mg (Temodar)
5
5
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUTENT - sunitinib malate cap 25 mg
(base equivalent)
5
•
•
5
•
•
temozolomide cap 140 mg (Temodar)
5
SUTENT - sunitinib malate cap 37.5 mg
(base equivalent)
temozolomide cap 180 mg (Temodar)
5
SUTENT - sunitinib malate cap 50 mg
(base equivalent)
5
•
•
temozolomide cap 20 mg (Temodar)
5
temozolomide cap 250 mg (Temodar)
5
SYLATRON - peginterferon alfa-2b for
inj kit 296 mcg
5
•
temozolomide cap 5 mg (Temodar)
5
SYLATRON - peginterferon alfa-2b for
inj kit 444 mcg
•
tretinoin cap 10 mg
5
5
3
SYLATRON - peginterferon alfa-2b for
inj kit 888 mcg
5
•
TREXALL - methotrexate sodium tab 5
mg (base equiv)
3
SYLATRON - peginterferon alfa-2b for
inj kit 4 x 296 mcg
5
•
TREXALL - methotrexate sodium tab
7.5 mg (base equiv)
3
SYLATRON - peginterferon alfa-2b for
inj kit 4 x 444 mcg
5
•
TREXALL - methotrexate sodium tab 10
mg (base equiv)
3
SYLATRON - peginterferon alfa-2b for
inj kit 4 x 888 mcg
5
•
TREXALL - methotrexate sodium tab 15
mg (base equiv)
5
•
•
TABLOID - thioguanine tab 40 mg
3
TAFINLAR - dabrafenib mesylate cap
50 mg (base equivalent)
•
VANDETANIB - vandetanib tab 100 mg
5
5
•
•
TYKERB - lapatinib ditosylate tab 250
mg (base equiv)
VANDETANIB - vandetanib tab 300 mg
5
5
•
•
VOTRIENT - pazopanib hcl tab 200 mg
(base equiv)
5
TAFINLAR - dabrafenib mesylate cap
75 mg (base equivalent)
•
•
•
•
•
•
1
XALKORI - crizotinib cap 200 mg
5
tamoxifen citrate tab 10 mg (base
equivalent)
XALKORI - crizotinib cap 250 mg
5
•
•
tamoxifen citrate tab 20 mg (base
equivalent)
1
XELODA - capecitabine tab 150 mg
5
XELODA - capecitabine tab 500 mg
5
TARCEVA - erlotinib tab 25 mg
5
XTANDI - enzalutamide cap 40 mg
5
TARCEVA - erlotinib tab 100 mg
5
TARCEVA - erlotinib tab 150 mg
5
ZELBORAF - vemurafenib tab 240 mg
(base equivalent)
5
•
•
•
•
•
•
18
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Dispensing Limits
5
5
Step Therapy
SPRYCEL - dasatinib tab 70 mg
TARGRETIN - bexarotene cap 75 mg
Prior Authorization
5
Drug Name
Drug Tier
SPRYCEL - dasatinib tab 50 mg
Dispensing Limits
5
Step Therapy
SPRYCEL - dasatinib tab 20 mg
Prior Authorization
Drug Name
Drug Tier
2014
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
•
ZOLADEX - goserelin acetate implant
3.6 mg
4
DEXPAK 13 DAY - dexamethasone tab
1.5 mg taper pack
4
ZOLADEX - goserelin acetate implant
10.8 mg
4
DEXPAK 6 DAY - dexamethasone tab
1.5 mg taper pack
4
ZOLINZA - vorinostat cap 100 mg
5
4
ZYDELIG - idelalisib tab 100 mg
5
ENTOCORT EC - budesonide cap sr
24hr 3 mg
ZYDELIG - idelalisib tab 150 mg
5
4
ZYKADIA - ceritinib cap 150 mg
5
FLO-PRED - prednisolone acetate oral
susp 16.7 mg/5ml (15 mg/5ml base)
5
fludrocortisone acetate tab 0.1 mg
2
ZYTIGA - abiraterone acetate tab 250
mg
hydrocortisone tab 10 mg (Cortef)
2
ENDOCRINE AND METABOLIC DRUGS
hydrocortisone tab 20 mg (Cortef)
1
CORTICOSTEROIDS
hydrocortisone tab 5 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
•
•
•
•
•
•
•
•
•
•
budesonide cap sr 24hr 3 mg
(Entocort ec)
2
CELESTONE - betamethasone soln 0.6
mg/5ml
4
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
MEDROL - methylprednisolone tab 8
mg
4
3
DEXAMETHASONE - dexamethasone
tab 1 mg
MEDROL - methylprednisolone tab 16
mg
4
4
4
DEXAMETHASONE - dexamethasone
tab 2 mg
4
MEDROL - methylprednisolone tab 32
mg
DEXAMETHASONE - dexamethasone
soln 0.5 mg/5ml
MEDROL DOSEPAK methylprednisolone tab 4 mg dose
pack
4
3
dexamethasone elixir 0.5 mg/5ml
2
2
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
4
methylprednisolone tab 16 mg
(Medrol)
1
dexamethasone tab 0.5 mg
1
methylprednisolone tab 32 mg
(Medrol)
dexamethasone tab 0.75 mg
1
2
dexamethasone tab 1.5 mg
1
methylprednisolone tab 4 mg
(Medrol)
1
methylprednisolone tab 4 mg dose
pack (Medrol dosepak)
2
dexamethasone tab 4 mg
dexamethasone tab 6 mg
1
DEXPAK 10 DAY - dexamethasone tab
1.5 mg taper pack
methylprednisolone tab 8 mg
(Medrol)
2
4
MILLIPRED - prednisolone tab 5 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
19
4
MILLIPRED DP - prednisolone tab 5 mg
dose pack
4
ORAPRED - prednisolone sod
phosphate oral soln 15 mg/5ml (base
equiv)
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
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
1
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)
4
PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate oral
soln 25 mg/5ml (base eq)
1
prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone)
3
PREDNISONE - prednisone tab 50 mg
prednisone tab 10 mg
1
prednisone tab 10 mg dose pack
1
prednisone tab 2.5 mg
1
prednisone tab 20 mg
1
prednisone tab 5 mg
1
prednisone tab 5 mg dose pack
1
PRELONE - prednisolone syrup 15
mg/5ml (usp solution equivalent)
4
RAYOS - prednisone tab delayed
release 1 mg
4
RAYOS - prednisone tab delayed
release 2 mg
4
RAYOS - prednisone tab delayed
release 5 mg
4
UCERIS - budesonide tab sr 24hr 9 mg
4
VERIPRED 20 - prednisolone sod
phosphate oral soln 20 mg/5ml (base
equiv)
4
Dispensing Limits
1
Step Therapy
prednisone tab 1 mg
Prior Authorization
Dispensing Limits
Drug Name
Drug Tier
MILLIPRED - prednisolone sod
phosphate oral soln 10 mg/5ml (base
equiv)
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ANDROGEN-ANABOLIC
ANADROL-50 - oxymetholone tab 50
mg
4
•
ANDRODERM - testosterone td patch
24hr 2 mg/24hr
3
•
•
ANDRODERM - testosterone td patch
24hr 4 mg/24hr
3
•
•
ANDROGEL - testosterone td gel 25
mg/2.5gm (1%)
3
•
•
ANDROGEL - testosterone td gel 50
mg/5gm (1%)
3
•
•
•
•
PREDNISONE - prednisone oral soln 5
mg/5ml
ANDROGEL - testosterone td gel 20.25
mg/1.25gm (1.62%)
3
3
1
ANDROGEL - testosterone td gel 40.5
mg/2.5gm (1.62%)
3
•
•
PREDNISONE - prednisone tab 5 mg
dose pack
1
•
•
•
PREDNISONE INTENSOL - prednisone
conc 5 mg/ml
3
ANDROGEL PUMP - testosterone td gel 3
12.5 mg/act (1%)
ANDROGEL PUMP - testosterone td gel 3
20.25 mg/act (1.62%)
•
PREDNISONE - prednisone tab 10 mg
dose pack
20
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
4
•
ANDROXY - fluoxymesterone tab 10 mg 3
4
AVEED - testosterone undecanoate im
inj in oil 750 mg/3ml (250mg/ml)
4
AXIRON - testosterone td soln 30 mg/
act
2
danazol cap 100 mg
•
•
4
•
•
•
VOGELXO - testosterone td gel 50
mg/5gm (1%)
4
•
•
•
VOGELXO PUMP - testosterone td gel
12.5 mg/act (1%)
danazol cap 200 mg
2
danazol cap 50 mg
2
DELATESTRYL - testosterone
enanthate im in oil 200 mg/ml
4
DEPO-TESTOSTERONE - testosterone
cypionate im in oil 100 mg/ml
4
DEPO-TESTOSTERONE - testosterone
cypionate im in oil 200 mg/ml
4
FORTESTA - testosterone td gel 10mg/
act (2%)
4
METHITEST - methyltestosterone oral
tab 10 mg
4
OXANDRIN - oxandrolone tab 2.5 mg
4
OXANDRIN - oxandrolone tab 10 mg
4
oxandrolone tab 10 mg (Oxandrin)
2
oxandrolone tab 2.5 mg (Oxandrin)
2
STRIANT - testosterone buccal
mucoadhesive system 30 mg
•
Dispensing Limits
Prior Authorization
TESTRED - methyltestosterone cap 10
mg
Drug Name
Step Therapy
Drug Tier
•
ANDROID - methyltestosterone cap 10
mg
Dispensing Limits
Prior Authorization
4
Drug Name
Step Therapy
Drug Tier
2014
ESTROGENS
•
•
•
•
•
•
•
•
•
•
•
•
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 biweekly
0.025 mg/24hr
4
•
ALORA - estradiol td patch biweekly
0.05 mg/24hr
4
•
ALORA - estradiol td patch biweekly
0.075 mg/24hr
4
•
ALORA - estradiol td patch biweekly 0.1
mg/24hr
4
•
ANGELIQ - drospirenone-estradiol tab
0.25-0.5 mg
4
ANGELIQ - drospirenone-estradiol tab
0.5-1 mg
4
CENESTIN - estrogens, conjugated
synthetic a tab 0.3 mg
4
4
•
•
•
•
•
•
CENESTIN - estrogens, conjugated
synthetic a tab 0.45 mg
4
TESTIM - testosterone td gel 50
mg/5gm (1%)
4
•
•
CENESTIN - estrogens, conjugated
synthetic a tab 0.625 mg
4
TESTOSTERONE - testosterone td gel
50 mg/5gm (1%)
4
•
•
CENESTIN - estrogens, conjugated
synthetic a tab 0.9 mg
4
testosterone cypionate im in oil
100 mg/ml (Depo-testosterone)
2
•
•
CENESTIN - estrogens, conjugated
synthetic a tab 1.25 mg
4
testosterone cypionate im in oil
200 mg/ml (Depo-testosterone)
2
•
•
CLIMARA - estradiol td patch weekly
0.025 mg/24hr
4
•
testosterone enanthate im in oil
200 mg/ml
2
•
•
CLIMARA - estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
4
•
TESTOSTERONE PUMP - testosterone
td gel 12.5 mg/act (1%)
4
•
•
CLIMARA - estradiol td patch weekly
0.05 mg/24hr
4
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
21
ESTRACE - estradiol tab 2 mg
4
CLIMARA - estradiol td patch weekly
0.075 mg/24hr
•
estradiol & norethindrone acetate
tab 0.5-0.1 mg (Activella)
2
4
2
•
estradiol & norethindrone acetate
tab 1-0.5 mg (Activella)
estradiol tab 0.5 mg (Estrace)
1
estradiol tab 1 mg (Estrace)
1
estradiol tab 2 mg (Estrace)
1
estradiol td patch weekly
0.025 mg/24hr (Climara)
2
•
estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
2
•
estradiol td patch weekly
0.05 mg/24hr (Climara)
2
•
estradiol td patch weekly
0.06 mg/24hr (Climara)
2
•
estradiol td patch weekly
0.075 mg/24hr (Climara)
2
•
estradiol td patch weekly
0.1 mg/24hr (Climara)
2
•
ESTRASORB - estradiol transdermal
emulsion 4.35 mg/1.74gm
4
ESTROGEL - estradiol gel 0.06% (0.75
mg/1.25 gm metered-dose pump)
4
ESTROPIPATE - estropipate tab 3 mg
4
estropipate tab 0.75 mg
1
estropipate tab 1.5 mg
1
EVAMIST - estradiol transdermal spray
1.53 mg/spray
4
FEMHRT LOW DOSE - norethindrone
acetate-ethinyl estradiol tab 0.5
mg-2.5 mcg
4
FEMHRT 1/5 - norethindrone acetateethinyl estradiol tab 1 mg-5 mcg
4
FEMTRACE - estradiol acetate tab 0.45
mg
4
FEMTRACE - estradiol acetate tab 0.9
mg
4
ESTRACE - estradiol tab 1 mg
22
4
Step Therapy
•
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)
3
ENJUVIA - estrogens, conjugated
synthetic b tab 0.3 mg
3
ENJUVIA - estrogens, conjugated
synthetic b tab 0.45 mg
3
ENJUVIA - estrogens, conjugated
synthetic b tab 0.625 mg
3
ENJUVIA - estrogens, conjugated
synthetic b tab 0.9 mg
3
ENJUVIA - estrogens, conjugated
synthetic b tab 1.25 mg
2
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
2
esterified estrogens &
methyltestosterone tab 1.25-2.5 mg
4
ESTRACE - estradiol tab 0.5 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Prior Authorization
4
Drug Tier
CLIMARA - estradiol td patch weekly
0.06 mg/24hr
Step Therapy
Drug Name
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2014
JINTELI - norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
4
MENEST - esterified estrogens tab 0.3
mg
4
MENEST - esterified estrogens tab
0.625 mg
4
MENEST - esterified estrogens tab 1.25
mg
4
MENEST - esterified estrogens tab 2.5
mg
4
MENOSTAR - estradiol td patch weekly
14 mcg/24hr
4
MINIVELLE - estradiol td patch biweekly 4
0.0375 mg/24hr
MINIVELLE - estradiol td patch biweekly 4
0.05 mg/24hr
MINIVELLE - estradiol td patch biweekly 4
0.075 mg/24hr
MINIVELLE - estradiol td patch biweekly 4
0.1 mg/24hr
2
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
4
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
PREMARIN - estrogens, conjugated tab 4
0.3 mg
PREMARIN - estrogens, conjugated tab 4
0.45 mg
PREMARIN - estrogens, conjugated tab 4
0.625 mg
PREMARIN - estrogens, conjugated tab 4
0.9 mg
PREMARIN - estrogens, conjugated tab 4
1.25 mg
4
PREMPHASE - conj est 0.625(14)/conj
est-medroxypro ac tab 0.625-5mg(14)
4
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.3-1.5
mg
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.45-1.5
mg
4
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.625-2.5 mg
4
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.625-5
mg
4
VIVELLE-DOT - estradiol td patch
biweekly 0.025 mg/24hr
3
•
VIVELLE-DOT - estradiol td patch
biweekly 0.0375 mg/24hr
3
•
VIVELLE-DOT - estradiol td patch
biweekly 0.05 mg/24hr
3
•
VIVELLE-DOT - estradiol td patch
biweekly 0.075 mg/24hr
3
•
VIVELLE-DOT - estradiol td patch
biweekly 0.1 mg/24hr
3
•
AMETHYST - levonorgestrel-ethinyl
estradiol (continuous) tab 90-20 mcg
4
•
BEYAZ - drospirenone-ethinyl estradlevomefolate tab 3-0.02-0.451 mg
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
4
DESOGEN - desogestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
desogest-eth estrad & eth estrad tab 2
0.15-0.02/0.01 mg(21/5) (Mircette)
•
CONTRACEPTIVES
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
23
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
2
•
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg (24)/10
mcg (2)
4
•
desogestrel & ethinyl estradiol tab
0.15 mg-30 mcg (Desogen)
1
•
4
•
drospirenone-ethinyl estradiol tab
3-0.02 mg (Yaz)
2
•
LO MINASTRIN FE - norethin-eth
estrad-fe chew/tab 1 mg-10 mcg/10
mcg ther pack
4
•
drospirenone-ethinyl estradiol tab
3-0.03 mg (Yasmin 28)
2
•
LO/OVRAL-28 - norgestrel & ethinyl
estradiol tab 0.3 mg-30 mcg
4
•
ELLA - ulipristal acetate tab 30 mg
3
ESTROSTEP FE - norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg
4
LOESTRIN FE 1.5/30 - norethindrone
ace & ethinyl estradiol-fe tab 1.5
mg-30 mcg
4
•
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg
2
LOESTRIN FE 1/20 - norethindrone
ace & ethinyl estradiol-fe tab 1 mg-20
mcg
4
•
FALESSA - levonorgest-eth estrad tab
0.1 mg-20 mcg & fa tab 1 mg kit
4
LOESTRIN 1.5/30-21 - norethindrone
ace & ethinyl estradiol tab 1.5 mg-30
mcg
4
•
LOESTRIN 1/20-21 - norethindrone ace
& ethinyl estradiol tab 1 mg-20 mcg
4
FEMCON FE - norethindrone & ethinyl
estradiol-fe chew tab 0.4 mg-35 mcg
•
4
•
LOESTRIN 24 FE - norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg
(24)
4
GENERESS FE - norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
•
2
•
LOMEDIA 24 FE - norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg
(24)
4
levonorg-eth est tab 0.1-0.02mg(84)
& eth est tab 0.01mg(7)
(Loseasonique)
•
2
•
LOSEASONIQUE - levonorg-eth est
tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)
4
levonorg-eth est tab 0.15-0.03mg(84)
& eth est tab 0.01mg(7)
(Seasonique)
•
2
•
levonorgestrel & ethinyl estradiol tab
0.1 mg-20 mcg
2
•
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
1
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg
4
•
levonorgestrel & ethinyl estradiol tab
0.15 mg-30 mcg
2
•
MINASTRIN 24 FE - norethindrone aceeth estradiol-fe chew tab 1 mg-20
mcg (24)
levonorgestrel tab 1.5 mg (Plan b
one-step)
2
•
•
•
levonorgestrel tab 0.75 mg (Plan b)
MIRCETTE - desogest-eth estrad & eth
estrad tab 0.15-0.02/0.01 mg(21/5)
4
2
MODICON - norethindrone & ethinyl
estradiol tab 0.5 mg-35 mcg
4
•
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg
2
•
NATAZIA - estradiol valerate-dienogest
tab 3 mg /2-2 mg/2-3 mg/1 mg
4
•
NECON 1/50-28 - norethindrone &
mestranol tab 1 mg-50 mcg
4
•
24
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
NECON 10/11-28 - norethindrone-eth
estradiol tab 0.5-35/1-35 mg-mcg
(10/11)
4
•
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
(Ortho tri-cyclen)
1
•
NOR-QD - norethindrone tab 0.35 mg
4
•
NORDETTE-28 - levonorgestrel &
ethinyl estradiol tab 0.15 mg-30 mcg
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
2
4
•
•
4
•
norelgestromin-ethinyl estradiol td
ptwk 150-35 mcg/24hr (Ortho evra)
2
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
4
•
norethindrone & ethinyl estradiol tab
0.4 mg-35 mcg (Ovcon-35)
2
•
NORINYL 1+50 - norethindrone &
mestranol tab 1 mg-50 mcg
3
•
norethindrone & ethinyl estradiol tab
0.5 mg-35 mcg (Brevicon-28)
2
•
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015 mg/24hr
4
•
norethindrone & ethinyl estradiol tab
1 mg-35 mcg (Norinyl 1+35)
2
•
OGESTREL - norgestrel & ethinyl
estradiol tab 0.5 mg-50 mcg
3
•
norethindrone & ethinyl estradiol-fe
chew tab 0.4 mg-35 mcg (Femcon
fe)
2
•
ORTHO EVRA - norelgestromin-ethinyl
estradiol td ptwk 150-35 mcg/24hr
ORTHO MICRONOR - norethindrone
tab 0.35 mg
4
•
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
2
•
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
4
•
norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg (Loestrin 1/20-21)
2
•
4
•
norethindrone ace & ethinyl estradiol
tab 1.5 mg-30 mcg (Loestrin
1.5/30-21)
2
•
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg
ORTHO-CEPT - desogestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
4
•
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20)
2
•
ORTHO-CYCLEN - norgestimate &
ethinyl estradiol tab 0.25 mg-35 mcg
4
•
2
•
norethindrone tab 0.35 mg (Nor-qd)
2
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7)
2
•
•
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
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
OVCON-50 28 - norethindrone & ethinyl 4
estradiol tab 1 mg-50 mcg
4
PLAN B - levonorgestrel tab 0.75 mg
•
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg (Ortho-cyclen)
1
•
PLAN B ONE-STEP - levonorgestrel tab
1.5 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
4
•
•
•
•
•
25
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
SEASONALE - levonorgestrel & ethinyl 4
estradiol (91-day) tab 0.15-0.03 mg
4
SEASONIQUE - levonorg-eth est
tab 0.15-0.03mg(84) & eth est tab
0.01mg(7)
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
YAZ - drospirenone-ethinyl estradiol tab 4
3-0.02 mg
4
ZOVIA 1/50E - ethynodiol diacetate &
ethinyl estradiol tab 1 mg-50 mcg
PROGESTINS
•
PROMETRIUM - progesterone
micronized cap 200 mg
4
4
•
PROVERA - medroxyprogesterone
acetate tab 2.5 mg
4
•
PROVERA - medroxyprogesterone
acetate tab 5 mg
PROVERA - medroxyprogesterone
acetate tab 10 mg
4
•
•
•
•
•
acarbose tab 100 mg (Precose)
2
acarbose tab 25 mg (Precose)
2
acarbose tab 50 mg (Precose)
2
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
4
AYGESTIN - norethindrone acetate tab
5 mg
4
4
medroxyprogesterone acetate tab
10 mg (Provera)
1
ACTOS - pioglitazone hcl tab 15 mg
(base equiv)
4
medroxyprogesterone acetate tab
2.5 mg (Provera)
1
ACTOS - pioglitazone hcl tab 30 mg
(base equiv)
4
medroxyprogesterone acetate tab
5 mg (Provera)
1
ACTOS - pioglitazone hcl tab 45 mg
(base equiv)
AMARYL - glimepiride tab 1 mg
4
MEGACE ES - megestrol acetate susp
625 mg/5ml
4
AMARYL - glimepiride tab 2 mg
4
AMARYL - glimepiride tab 4 mg
4
norethindrone acetate tab 5 mg
(Aygestin)
2
4
progesterone im in oil 50 mg/ml
2
AVANDAMET - rosiglitazone maleatemetformin hcl tab 2-500 mg
progesterone micronized cap 100 mg
(Prometrium)
AVANDAMET - rosiglitazone maleatemetformin hcl tab 2-1000 mg
4
2
2
AVANDAMET - rosiglitazone maleatemetformin hcl tab 4-500 mg
4
progesterone micronized cap 200 mg
(Prometrium)
4
AVANDAMET - rosiglitazone maleatemetformin hcl tab 4-1000 mg
4
PROMETRIUM - progesterone
micronized cap 100 mg
AVANDARYL - rosiglitazone maleateglimepiride tab 4-1 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
ANTIDIABETICS
ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 30-1000 mg
26
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
AVANDARYL - rosiglitazone maleateglimepiride tab 4-2 mg
4
DEX4 GLUCOSE - glucose oral liquid
15 gm/59ml
4
AVANDARYL - rosiglitazone maleateglimepiride tab 4-4 mg
4
DEX4 NATURALS - glucose-vitamin c
chew tab 4-0.006 gm
4
AVANDARYL - rosiglitazone maleateglimepiride tab 8-2 mg
4
DEX4 POUCH PACK - glucose-vitamin
c chew tab 4-0.006 gm
4
AVANDARYL - rosiglitazone maleateglimepiride tab 8-4 mg
4
DEX4 QUICK DISSOLVE GLUCO glucose chew tab 4 gm
4
AVANDIA - rosiglitazone maleate tab 2
mg (base equiv)
4
DIABETA - glyburide tab 1.25 mg
4
DIABETA - glyburide tab 2.5 mg
4
AVANDIA - rosiglitazone maleate tab 4
mg (base equiv)
4
DIABETA - glyburide tab 5 mg
4
4
DRUG MART GLUCOSE - glucose
chew tab 4 gm
4
AVANDIA - rosiglitazone maleate tab 8
mg (base equiv)
4
BYDUREON - exenatide extended
release for susp pen-injector 2 mg
4
• •
DRUG MART GLUCOSE - glucosevitamin c chew tab 4-0.006 gm
4
BD GLUCOSE - glucose chew tab 5 gm
4
BYDUREON - exenatide extended
release for inj susp 2 mg
4
• •
DUETACT - pioglitazone hcl-glimepiride
tab 30-2 mg
4
BYETTA - exenatide soln pen-injector 5
mcg/0.02ml
4
• •
DUETACT - pioglitazone hcl-glimepiride
tab 30-4 mg
4
BYETTA - exenatide soln pen-injector
10 mcg/0.04ml
4
• •
FARXIGA - dapagliflozin propanediol
tab 5 mg (base equivalent)
FARXIGA - dapagliflozin propanediol
tab 10 mg (base equivalent)
4
CHLORPROPAMIDE - chlorpropamide
tab 100 mg
4
FORTAMET - metformin hcl tab sr 24hr
osmotic 500 mg
4
CHLORPROPAMIDE - chlorpropamide
tab 250 mg
4
FORTAMET - metformin hcl tab sr 24hr
osmotic 1000 mg
4
CVS GLUCOSE - glucose chew tab 4
gm
4
glimepiride tab 1 mg (Amaryl)
1
4
glimepiride tab 2 mg (Amaryl)
1
CVS GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
glimepiride tab 4 mg (Amaryl)
1
CVS GLUCOSE BITS - glucose chew
tab 1 gm
4
glipizide tab sr 24hr 10 mg (Glucotrol
xl)
1
CYCLOSET - bromocriptine mesylate
tab 0.8 mg (base equivalent)
4
glipizide tab sr 24hr 2.5 mg (Glucotrol
xl)
1
DEX4 - glucose chew tab 1 gm
4
1
DEX4 - glucose-vitamin c chew tab
4-0.006 gm
4
glipizide tab sr 24hr 5 mg (Glucotrol
xl)
glipizide tab 10 mg (Glucotrol)
1
DEX4 GLUCOSE - glucose chew tab 4
gm
4
glipizide tab 5 mg (Glucotrol)
1
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
27
glipizide-metformin hcl tab
2.5-250 mg
2
GLUCOVANCE - glyburide-metformin
tab 5-500 mg
4
glipizide-metformin hcl tab
2.5-500 mg
2
GLUMETZA - metformin hcl tab sr 24hr
modified release 500 mg
4
glipizide-metformin hcl tab 5-500 mg
2
4
GLUCAGEN - glucagon hcl (rdna) for inj
1 mg (base equiv)
4
GLUMETZA - metformin hcl tab sr 24hr
modified release 1000 mg
GLYBURIDE - glyburide tab 1.25 mg
4
GLUCAGEN HYPOKIT - glucagon hcl
(rdna) for inj 1 mg (base equiv)
4
GLYBURIDE - glyburide tab 2.5 mg
4
GLYBURIDE - glyburide tab 5 mg
4
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
3
glyburide micronized tab 1.5 mg
(Glynase)
1
GLUCOPHAGE - metformin hcl tab 500
mg
4
glyburide micronized tab 3 mg
(Glynase)
1
GLUCOPHAGE - metformin hcl tab 850
mg
4
glyburide micronized tab 6 mg
(Glynase)
1
GLUCOPHAGE - metformin hcl tab
1000 mg
4
glyburide tab 1.25 mg
1
4
glyburide tab 2.5 mg
1
GLUCOPHAGE XR - metformin hcl tab
sr 24hr 500 mg
glyburide tab 5 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
1
GLUCOSE - glucose-vitamin c chew tab
4-0.006 gm
4
glyburide-metformin tab 2.5-500 mg
(Glucovance)
1
glucose gel 40%
1
glyburide-metformin tab 5-500 mg
(Glucovance)
2
GLYNASE - glyburide micronized tab
1.5 mg
4
glucose oral liquid 15 gm/59ml
GLUCOTROL - glipizide tab 5 mg
4
GLUCOTROL - glipizide tab 10 mg
GLYNASE - glyburide micronized tab 3
mg
4
4
GLUCOTROL XL - glipizide tab sr 24hr
2.5 mg
4
GLYNASE - glyburide micronized tab 6
mg
4
GLUCOTROL XL - glipizide tab sr 24hr
5 mg
4
GLYSET - miglitol tab 25 mg
4
GLYSET - miglitol tab 50 mg
4
GLUCOTROL XL - glipizide tab sr 24hr
10 mg
4
GLYSET - miglitol tab 100 mg
4
4
GNP GLUCOSE - glucose chew tab 4
gm
4
GLUCOVANCE - glyburide-metformin
tab 1.25-250 mg
4
GNP GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
GLUCOVANCE - glyburide-metformin
tab 2.5-500 mg
GNP QUICK DISSOLVE GLUCOS glucose chew tab 4 gm
4
28
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
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
1
INSTA-GLUCOSE - glucose gel 77.4%
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
JUVISYNC - sitagliptin-simvastatin tab
50-10 mg
3
•
JUVISYNC - sitagliptin-simvastatin tab
50-20 mg
3
•
3
•
INVOKAMET - canagliflozin-metformin
hcl tab 50-500 mg
4
JUVISYNC - sitagliptin-simvastatin tab
50-40 mg
3
•
INVOKAMET - canagliflozin-metformin
hcl tab 50-1000 mg
4
JUVISYNC - sitagliptin-simvastatin tab
100-10 mg
3
•
INVOKAMET - canagliflozin-metformin
hcl tab 150-500 mg
4
JUVISYNC - sitagliptin-simvastatin tab
100-20 mg
3
•
INVOKAMET - canagliflozin-metformin
hcl tab 150-1000 mg
4
JUVISYNC - sitagliptin-simvastatin tab
100-40 mg
4
•
INVOKANA - canagliflozin tab 100 mg
3
KAZANO - alogliptin-metformin hcl tab
12.5-500 mg
INVOKANA - canagliflozin tab 300 mg
3
4
•
JANUMET - sitagliptin-metformin hcl tab
50-500 mg
3
KAZANO - alogliptin-metformin hcl tab
12.5-1000 mg
3
•
JANUMET - sitagliptin-metformin hcl tab
50-1000 mg
3
•
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
3
•
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500 mg
3
JANUMET XR - sitagliptin-metformin hcl
tab sr 24hr 50-500 mg
•
3
•
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000 mg
3
JANUMET XR - sitagliptin-metformin hcl
tab sr 24hr 50-1000 mg
•
3
•
KORLYM - mifepristone tab 300 mg
5
JANUMET XR - sitagliptin-metformin hcl
tab sr 24hr 100-1000 mg
4
JANUVIA - sitagliptin phosphate tab 25
mg (base equiv)
3
KROGER GLUCOSE - glucose chew
tab 4 gm
4
JANUVIA - sitagliptin phosphate tab 50
mg (base equiv)
3
KROGER GLUCOSE - glucose-vitamin
c chew tab 4-0.006 gm
LEADER GLUCOSE - glucose chew tab
4 gm
4
LEADER GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
LEADER QUICK DISSOLVE GLU glucose chew tab 4 gm
4
LONGS GLUCOSE - glucose chew tab
4 gm
4
LONGS GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
MEDICINE SHOPPE GLUCOSE glucose chew tab 4 gm
4
JANUVIA - sitagliptin phosphate tab 100 3
mg (base equiv)
4
JARDIANCE - empagliflozin tab 10 mg
•
•
•
•
JARDIANCE - empagliflozin tab 25 mg
4
JENTADUETO - linagliptin-metformin
hcl tab 2.5-500 mg
4
•
JENTADUETO - linagliptin-metformin
hcl tab 2.5-850 mg
4
•
JENTADUETO - linagliptin-metformin
hcl tab 2.5-1000 mg
4
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
29
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
MEIJER GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
OSENI - alogliptin-pioglitazone tab
25-30 mg
4
•
METAGLIP - glipizide-metformin hcl tab
2.5-250 mg
4
OSENI - alogliptin-pioglitazone tab
25-45 mg
4
•
metformin hcl tab sr 24hr osmotic
1000 mg (Fortamet)
2
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
2
metformin hcl tab sr 24hr osmotic
500 mg (Fortamet)
2
pioglitazone hcl tab 30 mg (base
equiv) (Actos)
2
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
1
pioglitazone hcl tab 45 mg (base
equiv) (Actos)
2
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
1
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
2
metformin hcl tab 1000 mg
(Glucophage)
1
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
2
metformin hcl tab 500 mg
(Glucophage)
1
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
2
metformin hcl tab 850 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 120 mg (Starlix)
2
4
nateglinide tab 60 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
3
•
PRECOSE - acarbose tab 100 mg
4
ONGLYZA - saxagliptin hcl tab 2.5 mg
(base equiv)
4
ONGLYZA - saxagliptin hcl tab 5 mg
(base equiv)
3
PREFERRED PLUS GLUCOSE glucose chew tab 4 gm
4
OSENI - alogliptin-pioglitazone tab
12.5-15 mg
4
•
PREFERRED PLUS GLUCOSE glucose-vitamin c chew tab 4-0.006
gm
4
•
PROGLYCEM - diazoxide susp 50 mg/
ml
4
OSENI - alogliptin-pioglitazone tab
12.5-30 mg
4
•
PX GLUCOSE - glucose-vitamin c chew
tab 4-0.006 gm
4
OSENI - alogliptin-pioglitazone tab
12.5-45 mg
4
•
RA GLUCOSE - glucose-vitamin c chew
tab 4-0.006 gm
4
OSENI - alogliptin-pioglitazone tab
25-15 mg
30
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
RELION GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
VALUE PLUS GLUCOSE - glucosevitamin c chew tab 4-0.006 gm
4
repaglinide tab 0.5 mg (Prandin)
2
3
repaglinide tab 1 mg (Prandin)
2
VICTOZA - liraglutide soln pen-injector
18 mg/3ml (6 mg/ml)
repaglinide tab 2 mg (Prandin)
2
4
RIOMET - metformin hcl oral soln 500
mg/5ml
4
WALGREENS GLUCOSE - glucose
chew tab 4 gm
4
SM GLUCOSE - glucose chew tab 4 gm
4
WALGREENS GLUCOSE - glucosevitamin c chew tab 4-0.006 gm
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
• •
Rapid-Acting Insulins
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
APIDRA - insulin glulisine inj 100 unit/ml
4
APIDRA SOLOSTAR - insulin glulisine
soln pen-injector inj 100 unit/ml
4
•
•
HUMALOG - insulin lispro (human) soln
cartridge 100 unit/ml
3
•
STARLIX - nateglinide tab 120 mg
4
4
•
HUMALOG - insulin lispro (human) inj
100 unit/ml
3
SYMLIN - pramlintide acetate inj 600
mcg/ml (base equiv)
•
4
•
HUMALOG KWIKPEN - insulin lispro
(human) soln pen-injector 100 unit/ml
3
SYMLINPEN 120 - pramlintide acetate
pen-inj 2700 mcg/2.7ml (1000 mcg/
ml)
•
3
•
SYMLINPEN 60 - pramlintide acetate
pen-inj 1500 mcg/1.5ml (1000 mcg/
ml)
4
NOVOLOG - insulin aspart inj 100 unit/
ml
NOVOLOG FLEXPEN - insulin aspart
soln pen-injector 100 unit/ml
3
•
TANZEUM - albiglutide for soln peninjector 30 mg
4
• •
NOVOLOG PENFILL - insulin aspart
soln cartridge 100 unit/ml
3
•
TANZEUM - albiglutide for soln peninjector 50 mg
4
• •
NOVOLOG PENFILL - insulin aspart inj
100 unit/ml
3
•
TGT GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
•
TOLAZAMIDE - tolazamide tab 500 mg
4
tolazamide tab 250 mg
2
TOLBUTAMIDE - tolbutamide tab 500
mg
4
TRADJENTA - linagliptin tab 5 mg
4
ULTILET GLUCOSE - glucose chew tab
4 gm
4
UP & UP GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
HUMULIN R - insulin regular (human) inj 3
100 unit/ml
3
HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500 unit/ml
NOVOLIN R - insulin regular (human) inj 3
100 unit/ml
3
NOVOLIN R RELION - insulin regular
(human) inj 100 unit/ml
4
RELION R - insulin regular (human) inj
100 unit/ml
VALUE PLUS GLUCOSE - glucose
chew tab 4 gm
4
•
Short-Acting Insulins
•
•
•
•
•
Intermediate-Acting Insulins
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
31
HUMALOG MIX 50/50 - insulin lispro
prot & lispro (human) inj 100 unit/ml
(50-50)
3
•
NOVOLOG MIX 70/30 PREFILL - insulin 3
aspart prot & aspart sus pen-inj 100
unit/ml (70-30)
HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus pen-inj
100 unit/ml (50-50)
3
•
Basal Insulins
HUMALOG MIX 75/25 - insulin lispro
prot & lispro (human) inj 100 unit/ml
(75-25)
3
HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus pen-inj
100 unit/ml (75-25)
3
•
HUMULIN N - insulin isophane (human)
inj 100 unit/ml
3
•
HUMULIN N KWIKPEN - insulin
isophane (human) susp pen-injector
100 unit/ml
3
•
HUMULIN N U-100 PEN - insulin
isophane (human) susp pen-injector
100 unit/ml
3
•
HUMULIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
3
•
HUMULIN 70/30 KWIKPEN - insulin
isophane & regular susp pen-inj 100
unit/ml (70-30)
3
•
HUMULIN 70/30 PEN - insulin isophane
& regular susp pen-inj 100 unit/ml
(70-30)
3
•
NOVOLIN N - insulin isophane (human)
inj 100 unit/ml
3
•
NOVOLIN N RELION - insulin isophane
(human) inj 100 unit/ml
3
•
NOVOLIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
3
•
NOVOLIN 70/30 RELION - insulin
isophane & regular (human) inj 100
unit/ml (70-30)
3
•
NOVOLOG MIX 70/30 - insulin aspart
prot & aspart (human) inj 100 unit/ml
(70-30)
3
•
32
•
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
3
LEVEMIR FLEXTOUCH - insulin
detemir soln pen-injector 100 unit/ml
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 100 mcg
(Synthroid)
1
levothyroxine sodium tab 112 mcg
(Synthroid)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
•
•
•
NATURE-THROID - thyroid tab 195 mg
4
NATURE-THROID - thyroid tab 260 mg
4
levothyroxine sodium tab 137 mcg
(Synthroid)
1
1
NATURE-THROID - thyroid tab 325 mg
(5 grain)
4
levothyroxine sodium tab 150 mcg
(Synthroid)
1
NATURE-THROID - thyroid tab 146.25
mg
4
levothyroxine sodium tab 175 mcg
(Synthroid)
1
NATURE-THROID NT-2.5 - thyroid tab
162.5 mg (2 1/2 grain)
4
levothyroxine sodium tab 200 mcg
(Synthroid)
1
propylthiouracil tab 50 mg
2
levothyroxine sodium tab 25 mcg
(Synthroid)
levothyroxine sodium tab 300 mcg
(Synthroid)
1
levothyroxine sodium tab 50 mcg
(Synthroid)
1
levothyroxine sodium tab 75 mcg
(Synthroid)
1
levothyroxine sodium tab 88 mcg
(Synthroid)
1
liothyronine sodium tab 25 mcg
(Cytomel)
2
liothyronine sodium tab 5 mcg
(Cytomel)
2
liothyronine sodium tab 50 mcg
(Cytomel)
2
methimazole tab 10 mg (Tapazole)
2
methimazole tab 5 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
Dispensing Limits
4
1
Step Therapy
NATURE-THROID - thyroid tab 130 mg
levothyroxine sodium tab 125 mcg
(Synthroid)
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
33
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
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
THYROLAR-1/4 - liotrix (t3-t4) tab 15
mg (3.1-12.5 mcg)
4
WESTHROID - thyroid tab 325 mg (5
grain)
4
THYROLAR-2 - liotrix (t3-t4) tab 120 mg
(25-100 mcg)
4
WESTHROID - thyroid tab 146.25 mg
4
WESTHROID-P - thyroid tab 16.25 mg
4
THYROLAR-3 - liotrix (t3-t4) tab 180 mg
(37.5-150 mcg)
4
WESTHROID-P - thyroid tab 32.5 mg
4
TIROSINT - levothyroxine sodium cap
13 mcg
WESTHROID-P - thyroid tab 48.75 mg
(3/4 grain)
4
4
4
4
WESTHROID-P - thyroid tab 65 mg
TIROSINT - levothyroxine sodium cap
25 mcg
WESTHROID-P - thyroid tab 97.5 mg
4
4
WESTHROID-P - thyroid tab 130 mg
4
TIROSINT - levothyroxine sodium cap
50 mcg
WP THYROID - thyroid tab 16.25 mg
4
TIROSINT - levothyroxine sodium cap
75 mcg
4
WP THYROID - thyroid tab 32.5 mg
4
4
TIROSINT - levothyroxine sodium cap
88 mcg
4
WP THYROID - thyroid tab 48.75 mg
(3/4 grain)
WP THYROID - thyroid tab 65 mg
4
TIROSINT - levothyroxine sodium cap
100 mcg
4
WP THYROID - thyroid tab 81.25 mg
4
4
4
WP THYROID - thyroid tab 97.5 mg
TIROSINT - levothyroxine sodium cap
112 mcg
WP THYROID - thyroid tab 113.75 mg
4
4
WP THYROID - thyroid tab 130 mg
4
TIROSINT - levothyroxine sodium cap
125 mcg
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
34
OXYTOCICS
CERVIDIL - dinoprostone vaginal inserts 4
10 mg
4
METHERGINE - methylergonovine
maleate tab 0.2 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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
4
1
Step Therapy
WESTHROID - thyroid tab 97.5 mg
thyroid tab 60 mg (1 grain) (Armour
thyroid)
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
alendronate sodium tab 35 mg
1
alendronate sodium tab 5 mg
2
alendronate sodium tab 70 mg
(Fosamax)
1
ATELVIA - risedronate sodium tab
delayed release 35 mg
4
BINOSTO - alendronate sodium
effervescent tab 70 mg
4
BONIVA - ibandronate sodium tab 150
mg (base equivalent)
4
BUPHENYL - sodium phenylbutyrate
tab 500 mg
5
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 oral soln 1
gm/10ml (10%)
4
•
CARNITOR SF - levocarnitine oral soln
1 gm/10ml (10%)
4
•
CYSTADANE - betaine powder for oral
solution
4
•
DDAVP - desmopressin acetate tab 0.1
mg
4
•
DDAVP - desmopressin acetate tab 0.2
mg
4
•
DDAVP - desmopressin acetate inj 4
mcg/ml
4
•
DDAVP - desmopressin acetate nasal
soln 0.01% (refrigerated)
4
•
•
•
•
DDAVP - desmopressin acetate nasal
spray soln 0.01%
4
desmopressin acetate inj 4 mcg/ml
(Ddavp)
2
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
2
desmopressin acetate nasal spray
soln 0.01% (Ddavp)
2
desmopressin acetate nasal spray
soln 0.01% (refrigerated)
2
desmopressin acetate tab 0.1 mg
(Ddavp)
2
desmopressin acetate tab 0.2 mg
(Ddavp)
2
DIDRONEL - etidronate disodium tab
400 mg
4
doxercalciferol cap 0.5 mcg
(Hectorol)
2
doxercalciferol cap 1 mcg (Hectorol)
2
doxercalciferol cap 2.5 mcg
(Hectorol)
2
EGRIFTA - tesamorelin acetate for inj 1
mg (base equiv)
5
•
EGRIFTA - tesamorelin acetate for inj 2
mg (base equiv)
5
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
4
Step Therapy
CARNITOR - levocarnitine tab 330 mg
•
•
Prior Authorization
Dispensing Limits
Drug Name
Drug Tier
ENDOCRINE and METABOLIC AGENTS - MISC.
5 •
ACTHAR HP - corticotropin inj gel 80
unit/ml
3
ACTONEL - risedronate sodium tab 5
mg
3
ACTONEL - risedronate sodium tab 30
mg
3
ACTONEL - risedronate sodium tab 35
mg
ACTONEL - risedronate sodium tab 150 3
mg
ALENDRONATE SODIUM - alendronate 4
sodium tab 40 mg
ALENDRONATE SODIUM - alendronate 4
sodium oral soln 70 mg/75ml
1
alendronate sodium tab 10 mg
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
35
ETIDRONATE DISODIUM - etidronate
disodium tab 400 mg
4
GENOTROPIN MINIQUICK somatropin for inj 2 mg
5
•
EVISTA - raloxifene hcl tab 60 mg
3
4
FORTEO - teriparatide (recombinant) inj
600 mcg/2.4ml
5
HECTOROL - doxercalciferol cap 0.5
mcg
HECTOROL - doxercalciferol cap 1 mcg
4
FORTICAL - calcitonin (salmon) nasal
soln 200 unit/act
4
HECTOROL - doxercalciferol cap 2.5
mcg
4
FOSAMAX - alendronate sodium tab 10
mg
4
•
HUMATROPE - somatropin for inj 5 mg
5
FOSAMAX - alendronate sodium tab 70
mg
HUMATROPE - somatropin for inj 6 mg
(18 unit)
5
4
•
•
•
•
•
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab 70-2800
mg-unit
HUMATROPE - somatropin for inj 12
mg (36 unit)
5
4
HUMATROPE - somatropin for inj 24
mg
5
•
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab 70-5600
mg-unit
4
HUMATROPE COMBO PACK somatropin for inj 5 mg
5
•
5
•
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
2
GENOTROPIN - somatropin for
subcutaneous inj 5 mg
5
•
INCRELEX - mecasermin inj 40 mg/4ml
(10 mg/ml)
5
GENOTROPIN - somatropin for inj 12
mg (13.8 mg overfill)
•
5
•
KUVAN - sapropterin dihydrochloride
powder packet 100 mg
5
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
•
5
•
KUVAN - sapropterin dihydrochloride
soluble tab 100 mg
5
GENOTROPIN MINIQUICK somatropin for inj 0.4 mg
•
5
•
levocarnitine oral soln 1 gm/10ml
(10%) (Carnitor)
2
GENOTROPIN MINIQUICK somatropin for inj 0.6 mg
5
•
levocarnitine tab 330 mg (Carnitor)
2
GENOTROPIN MINIQUICK somatropin for inj 0.8 mg
GENOTROPIN MINIQUICK somatropin for inj 1 mg
5
•
GENOTROPIN MINIQUICK somatropin for inj 1.2 mg
5
•
GENOTROPIN MINIQUICK somatropin for inj 1.4 mg
5
•
GENOTROPIN MINIQUICK somatropin for inj 1.6 mg
5
•
36
•
•
•
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
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
NORDITROPIN FLEXPRO - somatropin 5
inj 5 mg/1.5ml
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
GENOTROPIN MINIQUICK somatropin for inj 1.8 mg
Step Therapy
4
Drug Tier
ETIDRONATE DISODIUM - etidronate
disodium tab 200 mg
Drug Name
Prior Authorization
2014
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
5
•
RAVICTI - glycerol phenylbutyrate liquid
1.1 gm/ml
5
NORDITROPIN NORDIFLEX PEN somatropin inj 30 mg/3ml
5
risedronate sodium tab 150 mg
(Actonel)
NUTROPIN AQ - somatropin inj 10
mg/2ml
5
•
•
2
NUTROPIN - somatropin for inj 10 mg
ROCALTROL - calcitriol cap 0.25 mcg
4
5
•
ROCALTROL - calcitriol cap 0.5 mcg
4
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml
5
•
NUTROPIN AQ NUSPIN 5 - somatropin
inj 5 mg/2ml
5
•
NUTROPIN AQ PEN - somatropin inj 10
mg/2ml
5
•
NUTROPIN AQ PEN - somatropin inj 20
mg/2ml
5
•
octreotide acetate inj 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
5
•
SAMSCA - tolvaptan tab 30 mg
5
5
octreotide acetate inj 1000 mcg/ml
(1 mg/ml) (Sandostatin)
5
•
SANDOSTATIN - octreotide acetate inj
50 mcg/ml (0.05 mg/ml)
•
•
•
5
•
octreotide acetate inj 200 mcg/ml
(0.2 mg/ml) (Sandostatin)
5
•
SANDOSTATIN - octreotide acetate inj
100 mcg/ml (0.1 mg/ml)
5
•
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
5
•
SANDOSTATIN - octreotide acetate inj
200 mcg/ml (0.2 mg/ml)
5
•
octreotide acetate inj 500 mcg/ml
(0.5 mg/ml) (Sandostatin)
5
•
SANDOSTATIN - octreotide acetate inj
500 mcg/ml (0.5 mg/ml)
5
•
OMNITROPE - somatropin inj 5
mg/1.5ml
5
•
SANDOSTATIN - octreotide acetate inj
1000 mcg/ml (1 mg/ml)
3
OMNITROPE - somatropin inj 10
mg/1.5ml
5
•
SENSIPAR - cinacalcet hcl tab 30 mg
(base equiv)
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
OMNITROPE - somatropin for inj 5.8 mg 5
5
ORFADIN - nitisinone cap 2 mg
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 4 mcg (Zemplar)
2
raloxifene hcl tab 60 mg (Evista)
2
ROCALTROL - calcitriol oral soln 1 mcg/ 4
ml
SAIZEN - somatropin (non-refrigerated) 5
for inj 5 mg
SAIZEN - somatropin (non-refrigerated) 5
for inj 8.8 mg
5
SAIZEN CLICK.EASY - somatropin
(non-refrigerated) for inj 8.8 mg
5
SAMSCA - tolvaptan tab 15 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
•
2
Step Therapy
NORDITROPIN FLEXPRO - somatropin
inj 15 mg/1.5ml
5
paricalcitol cap 2 mcg (Zemplar)
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
NORDITROPIN FLEXPRO - somatropin
inj 10 mg/1.5ml
Drug Name
Step Therapy
Drug Tier
2014
•
•
•
•
•
•
•
•
37
5
•
•
SIGNIFOR - pasireotide diaspartate inj
0.6 mg/ml (base equiv)
5
•
•
SIGNIFOR - pasireotide diaspartate inj
0.9 mg/ml (base equiv)
5
•
•
SKELID - tiludronate disodium tab 200
mg (tiludronic acid equivalent)
4
sodium phenylbutyrate oral powder
3 gm/teaspoonful (Buphenyl)
5
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)
STIMATE - desmopressin acetate nasal 3
soln 1.5 mg/ml
3
SYNAREL - NAFARELIN ACETATE
NASAL SOLN 2 MG/ML
5
TEV-TROPIN - somatropin for
subcutaneous inj 5 mg
4
ZEMPLAR - paricalcitol cap 1 mcg
ZEMPLAR - paricalcitol cap 2 mcg
4
ZEMPLAR - paricalcitol cap 4 mcg
4
ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj 8.8
mg
5
CARDIOVASCULAR AGENTS
CARDIOTONICS
DIGOXIN - digoxin oral soln 0.05 mg/ml
4
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
38
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
4
LANOXIN - digoxin tab 125 mcg (0.125
mg)
4
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
4
LANOXIN - digoxin tab 250 mcg (0.25
mg)
4
ANTIANGINAL AGENTS
DILATRATE SR - isosorbide dinitrate
cap cr 40 mg
4
•
IMDUR - isosorbide mononitrate tab sr
24hr 30 mg
4
•
IMDUR - isosorbide mononitrate tab sr
24hr 60 mg
4
•
IMDUR - isosorbide mononitrate tab sr
24hr 120 mg
4
•
ISORDIL TITRADOSE - isosorbide
dinitrate tab 5 mg
4
ISORDIL TITRADOSE - isosorbide
dinitrate tab 40 mg
4
ISOSORBIDE DINITRATE - isosorbide
dinitrate tab 30 mg
1
ISOSORBIDE DINITRATE - isosorbide
dinitrate sl tab 2.5 mg
4
ISOSORBIDE DINITRATE - isosorbide
dinitrate sl tab 5 mg
4
isosorbide dinitrate tab cr 40 mg
2
isosorbide dinitrate tab 10 mg
1
isosorbide dinitrate tab 20 mg
1
isosorbide dinitrate tab 30 mg
1
isosorbide dinitrate tab 5 mg (Isordil
titradose)
1
isosorbide mononitrate tab sr 24hr
120 mg (Imdur)
1
isosorbide mononitrate tab sr 24hr
30 mg (Imdur)
1
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
SIGNIFOR - pasireotide diaspartate inj
0.3 mg/ml (base equiv)
•
1
Step Therapy
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 6
mg
5
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 5
mg
Drug Name
Step Therapy
Drug Tier
2014
isosorbide mononitrate tab sr 24hr
60 mg (Imdur)
1
isosorbide mononitrate tab 10 mg
2
isosorbide mononitrate tab 20 mg
1
MONOKET - isosorbide mononitrate tab
10 mg
4
MONOKET - isosorbide mononitrate tab
20 mg
4
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
NITRO-DUR - nitroglycerin td patch
24hr 0.3 mg/hr
4
NITRO-DUR - nitroglycerin td patch
24hr 0.4 mg/hr
4
NITRO-DUR - nitroglycerin td patch
24hr 0.6 mg/hr
4
NITRO-DUR - nitroglycerin td patch
24hr 0.8 mg/hr
4
nitroglycerin cap cr 2.5 mg
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray (400
mcg/spray)
4
NITROMIST - nitroglycerin lingual
aerosol 400 mcg/spray
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
NITROSTAT - nitroglycerin sl tab 0.3 mg 3
NITROSTAT - nitroglycerin sl tab 0.4 mg 3
NITROSTAT - nitroglycerin sl tab 0.6 mg 3
4
RANEXA - ranolazine tab sr 12hr 500
mg
4
RANEXA - ranolazine tab sr 12hr 1000
mg
BETA BLOCKERS
acebutolol hcl cap 200 mg (Sectral)
1
acebutolol hcl cap 400 mg (Sectral)
2
atenolol tab 100 mg (Tenormin)
1
atenolol tab 25 mg (Tenormin)
1
atenolol tab 50 mg (Tenormin)
1
BETAPACE - sotalol hcl tab 80 mg
4
BETAPACE - sotalol hcl tab 120 mg
4
1
BETAPACE - sotalol hcl tab 160 mg
4
nitroglycerin cap cr 6.5 mg
2
4
nitroglycerin cap cr 9 mg
2
BETAPACE AF - sotalol hcl (afib/afl) tab
80 mg
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/
spray
4
BETAPACE AF - sotalol hcl (afib/afl) tab
120 mg
4
4
nitroglycerin td patch 24hr 0.1 mg/hr
(Nitro-dur)
2
BETAPACE AF - sotalol hcl (afib/afl) tab
160 mg
betaxolol hcl tab 10 mg (Kerlone)
2
nitroglycerin td patch 24hr 0.2 mg/hr
(Nitro-dur)
2
betaxolol hcl tab 20 mg (Kerlone)
2
nitroglycerin td patch 24hr 0.4 mg/hr
(Nitro-dur)
bisoprolol fumarate tab 10 mg
(Zebeta)
2
2
2
bisoprolol fumarate tab 5 mg
(Zebeta)
2
nitroglycerin td patch 24hr 0.6 mg/hr
(Nitro-dur)
2
BYSTOLIC - nebivolol hcl tab 2.5 mg
(base equivalent)
4
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
BYSTOLIC - nebivolol hcl tab 5 mg
(base equivalent)
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
39
BYSTOLIC - nebivolol hcl tab 10 mg
(base equivalent)
4
BYSTOLIC - nebivolol hcl tab 20 mg
(base equivalent)
4
carvedilol tab 12.5 mg (Coreg)
1
carvedilol tab 25 mg (Coreg)
1
carvedilol tab 3.125 mg (Coreg)
1
carvedilol tab 6.25 mg (Coreg)
1
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
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
40
INNOPRAN XL - propranolol hcl
sustained-release beads cap sr 24hr
80 mg
3
INNOPRAN XL - propranolol hcl
sustained-release beads cap sr 24hr
120 mg
3
KERLONE - betaxolol hcl tab 10 mg
4
KERLONE - betaxolol hcl tab 20 mg
4
labetalol hcl tab 100 mg (Trandate)
1
labetalol hcl tab 200 mg (Trandate)
1
labetalol hcl tab 300 mg (Trandate)
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
100 mg (Toprol xl)
2
metoprolol succinate tab sr 24hr
200 mg (Toprol xl)
2
metoprolol succinate tab sr 24hr
25 mg (Toprol xl)
2
metoprolol succinate tab sr 24hr
50 mg (Toprol xl)
1
metoprolol tartrate tab 100 mg
(Lopressor)
1
metoprolol tartrate tab 25 mg
metoprolol tartrate tab 50 mg
(Lopressor)
1
nadolol tab 20 mg (Corgard)
1
nadolol tab 40 mg (Corgard)
1
nadolol tab 80 mg (Corgard)
1
pindolol tab 10 mg
2
pindolol tab 5 mg
2
PROPRANOLOL HCL - propranolol hcl
oral soln 20 mg/5ml
3
PROPRANOLOL HCL - propranolol hcl
oral soln 40 mg/5ml
3
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
propranolol hcl cap sr 24hr 120 mg
(Inderal la)
2
TOPROL XL - metoprolol succinate tab
sr 24hr 100 mg
4
propranolol hcl cap sr 24hr 160 mg
(Inderal la)
2
TOPROL XL - metoprolol succinate tab
sr 24hr 200 mg
4
propranolol hcl cap sr 24hr 60 mg
(Inderal la)
2
TRANDATE - labetalol hcl tab 100 mg
4
TRANDATE - labetalol hcl tab 200 mg
4
propranolol hcl cap sr 24hr 80 mg
(Inderal la)
2
TRANDATE - labetalol hcl tab 300 mg
4
1
ZEBETA - bisoprolol fumarate tab 5 mg
4
propranolol hcl tab 10 mg
1
ZEBETA - bisoprolol fumarate tab 10
mg
4
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
1
propranolol hcl tab 60 mg
2
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 120 mg
(Betapace af)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
CALCIUM CHANNEL BLOCKERS
ADALAT CC - nifedipine tab sr 24hr 30
mg
4
ADALAT CC - nifedipine tab sr 24hr 60
mg
4
2
ADALAT CC - nifedipine tab sr 24hr 90
mg
4
sotalol hcl (afib/afl) tab 160 mg
(Betapace af)
2
amlodipine besylate tab 10 mg
(Norvasc)
1
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
2
amlodipine besylate tab 2.5 mg
(Norvasc)
1
sotalol hcl tab 120 mg (Betapace)
1
1
sotalol hcl tab 160 mg (Betapace)
2
amlodipine besylate tab 5 mg
(Norvasc)
2
CALAN - verapamil hcl tab 80 mg
4
sotalol hcl tab 240 mg
1
CALAN - verapamil hcl tab 120 mg
4
sotalol hcl tab 80 mg (Betapace)
4
CALAN SR - verapamil hcl tab cr 120
mg
4
TENORMIN - atenolol tab 25 mg
TENORMIN - atenolol tab 50 mg
4
TENORMIN - atenolol tab 100 mg
CALAN SR - verapamil hcl tab cr 180
mg
4
4
TIMOLOL MALEATE - timolol maleate
tab 5 mg
3
CALAN SR - verapamil hcl tab cr 240
mg
4
TIMOLOL MALEATE - timolol maleate
tab 10 mg
3
CARDENE SR - nicardipine hcl cap sr
12hr 30 mg
4
TIMOLOL MALEATE - timolol maleate
tab 20 mg
3
CARDENE SR - nicardipine hcl cap sr
12hr 45 mg
4
TOPROL XL - metoprolol succinate tab
sr 24hr 25 mg
4
CARDENE SR - nicardipine hcl cap sr
12hr 60 mg
4
TOPROL XL - metoprolol succinate tab
sr 24hr 50 mg
4
CARDIZEM - diltiazem hcl tab 30 mg
4
CARDIZEM - diltiazem hcl tab 60 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
41
2
4
diltiazem hcl coated beads cap sr
24hr 240 mg (Cardizem cd)
2
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 180 mg
4
diltiazem hcl coated beads cap sr
24hr 300 mg (Cardizem cd)
2
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 240 mg
4
diltiazem hcl coated beads cap sr
24hr 360 mg (Cardizem cd)
2
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 300 mg
4
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
2
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 360 mg
4
diltiazem hcl coated beads tab sr
24hr 240 mg (Cardizem la)
2
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 120 mg
4
diltiazem hcl coated beads tab sr
24hr 300 mg (Cardizem la)
2
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 180 mg
4
diltiazem hcl coated beads tab sr
24hr 360 mg (Cardizem la)
2
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 240 mg
4
diltiazem hcl coated beads tab sr
24hr 420 mg (Cardizem la)
2
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 300 mg
4
diltiazem hcl extended release beads
cap sr 24hr 120 mg (Tiazac)
2
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 360 mg
4
diltiazem hcl extended release beads
cap sr 24hr 180 mg (Tiazac)
2
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 420 mg
4
diltiazem hcl extended release beads
cap sr 24hr 240 mg (Tiazac)
2
COVERA-HS - verapamil hcl tab sr 24hr
(controlled onset) 180 mg
4
diltiazem hcl extended release beads
cap sr 24hr 300 mg (Tiazac)
2
COVERA-HS - verapamil hcl tab sr 24hr
(controlled onset) 240 mg
4
diltiazem hcl extended release beads
cap sr 24hr 360 mg (Tiazac)
2
DILACOR XR - diltiazem hcl cap sr 24hr
240 mg
4
diltiazem hcl extended release beads
cap sr 24hr 420 mg (Tiazac)
2
diltiazem hcl cap sr 12hr 120 mg
2
diltiazem hcl tab 120 mg (Cardizem)
1
diltiazem hcl cap sr 12hr 60 mg
2
diltiazem hcl tab 30 mg (Cardizem)
1
diltiazem hcl cap sr 12hr 90 mg
2
diltiazem hcl tab 60 mg (Cardizem)
1
diltiazem hcl cap sr 24hr 120 mg
2
diltiazem hcl tab 90 mg
1
diltiazem hcl cap sr 24hr 180 mg
2
4
diltiazem hcl cap sr 24hr 240 mg
2
DYNACIRC CR - isradipine tab sr 24hr
5 mg
1
DYNACIRC CR - isradipine tab sr 24hr
10 mg
4
diltiazem hcl coated beads cap sr
24hr 120 mg (Cardizem cd)
felodipine tab sr 24hr 10 mg
2
42
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 120 mg
diltiazem hcl coated beads cap sr
24hr 180 mg (Cardizem cd)
Prior Authorization
4
Drug Name
Drug Tier
CARDIZEM - diltiazem hcl tab 120 mg
Dispensing Limits
4
Step Therapy
CARDIZEM - diltiazem hcl tab 90 mg
Prior Authorization
Drug Name
Drug Tier
2014
2
felodipine tab sr 24hr 5 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 - isradipine cap 2.5 mg
4
NYMALIZE - nimodipine oral soln 60
mg/20ml
ISRADIPINE - isradipine cap 5 mg
4
PROCARDIA - nifedipine cap 10 mg
4
nicardipine hcl cap 20 mg
2
4
nicardipine hcl cap 30 mg
2
PROCARDIA XL - nifedipine tab sr 24hr
osmotic 30 mg
2
PROCARDIA XL - nifedipine tab sr 24hr
osmotic 60 mg
4
nifedipine cap 10 mg (Procardia)
nifedipine cap 20 mg
2
2
PROCARDIA XL - nifedipine tab sr 24hr
osmotic 90 mg
4
nifedipine tab sr 24hr osmotic 30 mg
(Procardia xl)
SULAR - nisoldipine tab sr 24hr 8.5 mg
4
nifedipine tab sr 24hr osmotic 60 mg
(Procardia xl)
2
SULAR - nisoldipine tab sr 24hr 17 mg
4
nifedipine tab sr 24hr osmotic 90 mg
(Procardia xl)
2
nifedipine tab sr 24hr 30 mg (Adalat
cc)
2
nifedipine tab sr 24hr 60 mg (Adalat
cc)
2
nifedipine tab sr 24hr 90 mg (Adalat
cc)
2
nimodipine cap 30 mg
2
NISOLDIPINE - nisoldipine tab sr 24hr
20 mg
4
NISOLDIPINE - nisoldipine tab sr 24hr
30 mg
4
NISOLDIPINE - nisoldipine tab sr 24hr
40 mg
4
NISOLDIPINE ER - nisoldipine tab sr
24hr 25.5 mg
4
nisoldipine tab sr 24hr 17 mg (Sular)
2
nisoldipine tab sr 24hr 25.5 mg
2
nisoldipine tab sr 24hr 34 mg (Sular)
2
Dispensing Limits
nisoldipine tab sr 24hr 8.5 mg (Sular)
Step Therapy
2
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
felodipine tab sr 24hr 2.5 mg
Prior Authorization
Drug Name
Drug Tier
2014
SULAR - nisoldipine tab sr 24hr 25.5 mg 4
4
SULAR - nisoldipine tab sr 24hr 34 mg
TIAZAC - diltiazem hcl extended release 4
beads cap sr 24hr 120 mg
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)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
43
verapamil hcl cap sr 24hr 180 mg
(Verelan)
2
disopyramide phosphate cap 100 mg
(Norpace)
2
verapamil hcl cap sr 24hr 200 mg
(Verelan pm)
2
disopyramide phosphate cap 150 mg
(Norpace)
2
verapamil hcl cap sr 24hr 240 mg
(Verelan)
2
flecainide acetate tab 100 mg
2
flecainide acetate tab 150 mg
2
verapamil hcl cap sr 24hr 300 mg
(Verelan pm)
2
flecainide acetate tab 50 mg
2
2
mexiletine hcl cap 150 mg
2
verapamil hcl cap sr 24hr 360 mg
(Verelan)
mexiletine hcl cap 200 mg
2
verapamil hcl tab cr 120 mg (Calan
sr)
2
mexiletine hcl cap 250 mg
2
3
verapamil hcl tab cr 180 mg (Calan
sr)
1
MULTAQ - dronedarone hcl tab 400 mg
(base equivalent)
4
verapamil hcl tab cr 240 mg (Calan
sr)
1
NORPACE - disopyramide phosphate
cap 100 mg
4
verapamil hcl tab 120 mg (Calan)
1
NORPACE - disopyramide phosphate
cap 150 mg
verapamil hcl tab 80 mg (Calan)
1
4
VERELAN - verapamil hcl cap sr 24hr
120 mg
4
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
4
VERELAN - verapamil hcl cap sr 24hr
180 mg
4
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
4
VERELAN - verapamil hcl cap sr 24hr
240 mg
4
PACERONE - amiodarone hcl tab 400
mg
2
VERELAN - verapamil hcl cap sr 24hr
360 mg
4
propafenone hcl cap sr 12hr 225 mg
(Rythmol sr)
2
VERELAN PM - verapamil hcl cap sr
24hr 100 mg
4
propafenone hcl cap sr 12hr 325 mg
(Rythmol sr)
2
VERELAN PM - verapamil hcl cap sr
24hr 200 mg
4
propafenone hcl cap sr 12hr 425 mg
(Rythmol sr)
2
VERELAN PM - verapamil hcl cap sr
24hr 300 mg
4
propafenone hcl tab 150 mg
(Rythmol)
propafenone hcl tab 225 mg
(Rythmol)
2
propafenone hcl tab 300 mg
2
quinidine gluconate tab cr 324 mg
2
QUINIDINE SULFATE - quinidine
sulfate tab 200 mg
1
QUINIDINE SULFATE ER - quinidine
sulfate tab cr 300 mg
4
quinidine sulfate tab 200 mg
1
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
44
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
4
RYTHMOL - propafenone hcl tab 150
mg
4
ALTACE - ramipril cap 10 mg
4
RYTHMOL - propafenone hcl tab 225
mg
amlodipine besylate-benazepril hcl
cap 10-20 mg (Lotrel)
2
4
2
RYTHMOL SR - propafenone hcl cap sr
12hr 225 mg
4
amlodipine besylate-benazepril hcl
cap 10-40 mg (Lotrel)
4
amlodipine besylate-benazepril hcl
cap 2.5-10 mg (Lotrel)
2
RYTHMOL SR - propafenone hcl cap sr
12hr 325 mg
RYTHMOL SR - propafenone hcl cap sr
12hr 425 mg
amlodipine besylate-benazepril hcl
cap 5-10 mg (Lotrel)
2
4
TAMBOCOR - flecainide acetate tab 50
mg
amlodipine besylate-benazepril hcl
cap 5-20 mg (Lotrel)
2
4
TAMBOCOR - flecainide acetate tab
100 mg
amlodipine besylate-benazepril hcl
cap 5-40 mg (Lotrel)
2
4
4
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 150-5-12.5
mg
4
TAMBOCOR - flecainide acetate tab
150 mg
TIKOSYN - dofetilide cap 125 mcg
(0.125 mg)
4
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-5-12.5
mg
4
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-5-25 mg
4
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-10-12.5
mg
4
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-10-25
mg
4
4
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
ATACAND - candesartan cilexetil tab 4
mg
4
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5 mg
4
ATACAND - candesartan cilexetil tab 8
mg
4
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
4
ATACAND - candesartan cilexetil tab 16
mg
4
ACEON - perindopril erbumine tab 2 mg
4
ATACAND - candesartan cilexetil tab 32
mg
ACEON - perindopril erbumine tab 4 mg
4
4
ACEON - perindopril erbumine tab 8 mg
4
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
4
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
4
ALTACE - ramipril cap 1.25 mg
ALTACE - ramipril cap 2.5 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
ALTACE - ramipril cap 5 mg
Step Therapy
2
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
quinidine sulfate tab 300 mg
Prior Authorization
Drug Name
Drug Tier
2014
45
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-25 mg
4
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
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
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide tab
20-12.5 mg
3
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide tab
40-12.5 mg
3
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide tab
40-25 mg
3
bisoprolol & hydrochlorothiazide tab
10-6.25 mg (Ziac)
1
bisoprolol & hydrochlorothiazide tab
2.5-6.25 mg (Ziac)
1
AZOR - amlodipine besylate-olmesartan
medoxomil tab 5-20 mg
bisoprolol & hydrochlorothiazide tab
5-6.25 mg (Ziac)
1
4
2
AZOR - amlodipine besylate-olmesartan
medoxomil tab 5-40 mg
4
candesartan cilexetil tab 16 mg
(Atacand)
4
candesartan cilexetil tab 32 mg
(Atacand)
2
AZOR - amlodipine besylate-olmesartan
medoxomil tab 10-20 mg
AZOR - amlodipine besylate-olmesartan
medoxomil tab 10-40 mg
candesartan cilexetil tab 4 mg
(Atacand)
2
4
benazepril & hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
candesartan cilexetil tab 8 mg
(Atacand)
2
1
benazepril & hydrochlorothiazide tab
20-12.5 mg (Lotensin hct)
candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
(Atacand hct)
2
1
benazepril & hydrochlorothiazide tab
20-25 mg (Lotensin hct)
1
2
benazepril & hydrochlorothiazide tab
5-6.25 mg
1
candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
(Atacand hct)
2
benazepril hcl tab 10 mg (Lotensin)
1
benazepril hcl tab 20 mg (Lotensin)
1
candesartan cilexetilhydrochlorothiazide tab 32-25 mg
(Atacand hct)
1
captopril tab 100 mg
1
benazepril hcl tab 40 mg (Lotensin)
1
captopril tab 12.5 mg
1
benazepril hcl tab 5 mg
captopril tab 25 mg
1
captopril tab 50 mg
1
CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab
25-15 mg
4
BENICAR - olmesartan medoxomil tab 5 3
mg
3
BENICAR - olmesartan medoxomil tab
20 mg
3
BENICAR - olmesartan medoxomil tab
40 mg
46
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
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
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
4
COZAAR - losartan potassium tab 50
mg
4
4
COZAAR - losartan potassium tab 100
mg
4
CARDURA - doxazosin mesylate tab 2
mg
4
DEMSER - metyrosine cap 250 mg
4
CARDURA - doxazosin mesylate tab 4
mg
3
CARDURA - doxazosin mesylate tab 8
mg
4
DIBENZYLINE - phenoxybenzamine hcl
cap 10 mg
DIOVAN - valsartan tab 40 mg
4
CATAPRES - clonidine hcl tab 0.1 mg
4
DIOVAN - valsartan tab 80 mg
4
CATAPRES - clonidine hcl tab 0.2 mg
4
DIOVAN - valsartan tab 160 mg
4
CATAPRES - clonidine hcl tab 0.3 mg
4
DIOVAN - valsartan tab 320 mg
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
4
clonidine hcl tab 0.2 mg (Catapres)
1
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-12.5 mg
1
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25 mg
4
clonidine hcl tab 0.3 mg (Catapres)
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
2
doxazosin mesylate tab 1 mg
(Cardura)
1
clonidine hcl td patch weekly
0.2 mg/24hr (Catapres-tts-2)
2
doxazosin mesylate tab 2 mg
(Cardura)
1
clonidine hcl td patch weekly
0.3 mg/24hr (Catapres-tts-3)
2
doxazosin mesylate tab 4 mg
(Cardura)
1
CLORPRES - clonidine & chlorthalidone
tab 0.1-15 mg
4
doxazosin mesylate tab 8 mg
(Cardura)
1
CLORPRES - clonidine & chlorthalidone
tab 0.2-15 mg
4
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
47
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
50-12.5 mg
4
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5
mg
4
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
100-12.5 mg
4
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg
4
4
EDARBI - azilsartan medoxomil tab 40
mg
4
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5
mg
EDARBI - azilsartan medoxomil tab 80
mg
4
4
EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-12.5 mg
4
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-25
mg
4
EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-25 mg
4
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-320-25
mg
enalapril maleate &
hydrochlorothiazide tab 10-25 mg
(Vaseretic)
1
fosinopril sodium &
hydrochlorothiazide tab 10-12.5 mg
2
2
enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg
1
fosinopril sodium &
hydrochlorothiazide tab 20-12.5 mg
fosinopril sodium tab 10 mg
1
fosinopril sodium tab 20 mg
1
fosinopril sodium tab 40 mg
1
guanfacine hcl tab 1 mg (Tenex)
1
guanfacine hcl tab 2 mg (Tenex)
1
hydralazine hcl tab 10 mg
1
hydralazine hcl tab 100 mg
2
hydralazine hcl tab 25 mg
1
hydralazine hcl tab 50 mg
2
enalapril maleate tab 10 mg (Vasotec) 1
1
enalapril maleate tab 2.5 mg
(Vasotec)
enalapril maleate tab 20 mg (Vasotec) 1
enalapril maleate tab 5 mg (Vasotec)
1
EPANED - enalapril maleate for oral
soln 1 mg/ml
4
eplerenone tab 25 mg (Inspra)
2
eplerenone tab 50 mg (Inspra)
2
2
HYZAAR - losartan potassium &
hydrochlorothiazide tab 50-12.5 mg
4
eprosartan mesylate tab 600 mg
(Teveten)
4
HYZAAR - losartan potassium &
hydrochlorothiazide tab 100-12.5 mg
4
EXFORGE - amlodipine besylatevalsartan tab 5-160 mg
4
HYZAAR - losartan potassium &
hydrochlorothiazide tab 100-25 mg
4
EXFORGE - amlodipine besylatevalsartan tab 5-320 mg
4
INSPRA - eplerenone tab 25 mg
4
EXFORGE - amlodipine besylatevalsartan tab 10-160 mg
INSPRA - eplerenone tab 50 mg
4
EXFORGE - amlodipine besylatevalsartan tab 10-320 mg
4
irbesartan tab 150 mg (Avapro)
2
irbesartan tab 300 mg (Avapro)
2
irbesartan tab 75 mg (Avapro)
2
48
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
2
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 10-12.5 mg
4
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
2
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 20-12.5 mg
4
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
1
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 20-25 mg
4
lisinopril & hydrochlorothiazide tab
20-12.5 mg (Zestoretic)
1
LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg
4
lisinopril & hydrochlorothiazide tab
20-25 mg (Zestoretic)
1
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
4
lisinopril tab 10 mg (Prinivil)
1
4
lisinopril tab 2.5 mg (Zestril)
1
LOTREL - amlodipine besylatebenazepril hcl cap 5-20 mg
lisinopril tab 20 mg (Prinivil)
1
4
lisinopril tab 30 mg (Zestril)
1
LOTREL - amlodipine besylatebenazepril hcl cap 5-40 mg
1
LOTREL - amlodipine besylatebenazepril hcl cap 10-20 mg
4
lisinopril tab 40 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
1
4
LOTREL - amlodipine besylatebenazepril hcl cap 10-40 mg
4
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 50-25 mg
MAVIK - trandolapril tab 1 mg
4
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 100-25 mg
4
MAVIK - trandolapril tab 2 mg
4
1
MAVIK - trandolapril tab 4 mg
4
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
methyldopa tab 250 mg
1
methyldopa tab 500 mg
1
losartan potassium &
hydrochlorothiazide tab 100-25 mg
(Hyzaar)
1
METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab
250-15 mg
4
losartan potassium &
hydrochlorothiazide tab 50-12.5 mg
(Hyzaar)
1
METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab
250-25 mg
4
losartan potassium tab 100 mg
(Cozaar)
1
metoprolol & hydrochlorothiazide
tab 100-25 mg (Lopressor hct)
2
losartan potassium tab 25 mg
(Cozaar)
1
metoprolol & hydrochlorothiazide
tab 100-50 mg
2
losartan potassium tab 50 mg
(Cozaar)
1
metoprolol & hydrochlorothiazide
tab 50-25 mg (Lopressor hct)
2
LOTENSIN - benazepril hcl tab 10 mg
4
MICARDIS - telmisartan tab 20 mg
4
LOTENSIN - benazepril hcl tab 20 mg
4
MICARDIS - telmisartan tab 40 mg
4
LOTENSIN - benazepril hcl tab 40 mg
4
MICARDIS - telmisartan tab 80 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
49
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5 mg
4
PRINZIDE - lisinopril &
hydrochlorothiazide tab 10-12.5 mg
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5 mg
4
PRINZIDE - lisinopril &
hydrochlorothiazide tab 20-12.5 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
PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab
80-25 mg
minoxidil tab 10 mg
2
quinapril hcl tab 10 mg (Accupril)
1
minoxidil tab 2.5 mg
1
quinapril hcl tab 20 mg (Accupril)
1
moexipril hcl tab 15 mg (Univasc)
2
quinapril hcl tab 40 mg (Accupril)
1
moexipril hcl tab 7.5 mg (Univasc)
2
quinapril hcl tab 5 mg (Accupril)
1
moexipril-hydrochlorothiazide tab
15-12.5 mg (Uniretic)
2
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
2
moexipril-hydrochlorothiazide tab
15-25 mg
1
quinapril-hydrochlorothiazide tab
20-12.5 mg (Accuretic)
2
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
2
quinapril-hydrochlorothiazide tab
20-25 mg (Accuretic)
2
nadolol & bendroflumethiazide tab
40-5 mg (Corzide)
2
ramipril cap 1.25 mg (Altace)
1
2
ramipril cap 10 mg (Altace)
1
nadolol & bendroflumethiazide tab
80-5 mg (Corzide)
ramipril cap 2.5 mg (Altace)
1
NEXICLON XR - clonidine hcl extended
release susp 0.09 mg/ml (base equiv)
4
ramipril cap 5 mg (Altace)
1
RESERPINE - reserpine tab 0.1 mg
4
NEXICLON XR - clonidine hcl tab sr
24hr 0.17 mg (base equivalent)
4
RESERPINE - reserpine tab 0.25 mg
4
perindopril erbumine tab 2 mg
TARKA - trandolapril-verapamil hcl tab
cr 1-240 mg
4
2
perindopril erbumine tab 4 mg
(Aceon)
2
TARKA - trandolapril-verapamil hcl tab
cr 2-180 mg
4
perindopril erbumine tab 8 mg
(Aceon)
2
TARKA - trandolapril-verapamil hcl tab
cr 2-240 mg
4
prazosin hcl cap 1 mg (Minipress)
1
4
prazosin hcl cap 2 mg (Minipress)
1
TARKA - trandolapril-verapamil hcl tab
cr 4-240 mg
prazosin hcl cap 5 mg (Minipress)
2
4
PRINIVIL - lisinopril tab 5 mg
4
TEKAMLO - aliskiren-amlodipine tab
150-5 mg
4
TEKAMLO - aliskiren-amlodipine tab
150-10 mg
4
PRINIVIL - lisinopril tab 10 mg
PRINIVIL - lisinopril tab 20 mg
4
50
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
terazosin hcl cap 10 mg
1
terazosin hcl cap 2 mg
1
terazosin hcl cap 5 mg
1
TEVETEN - eprosartan mesylate tab
400 mg
4
TEVETEN - eprosartan mesylate tab
600 mg
4
TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-12.5 mg
4
TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-25 mg
4
trandolapril tab 1 mg (Mavik)
2
trandolapril tab 2 mg (Mavik)
1
trandolapril tab 4 mg (Mavik)
1
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg
4
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg
4
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg
4
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5
mg
4
TEKAMLO - aliskiren-amlodipine tab
300-10 mg
4
TEKTURNA - aliskiren fumarate tab 150
mg (base equivalent)
4
TEKTURNA - aliskiren fumarate tab 300
mg (base equivalent)
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5 mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25 mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25 mg
4
telmisartan tab 20 mg (Micardis)
2
telmisartan tab 40 mg (Micardis)
2
telmisartan tab 80 mg (Micardis)
2
telmisartan-amlodipine tab 40-10 mg
(Twynsta)
2
telmisartan-amlodipine tab 40-5 mg
(Twynsta)
2
telmisartan-amlodipine tab 80-10 mg
(Twynsta)
2
2
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg
4
telmisartan-amlodipine tab 80-5 mg
(Twynsta)
2
TWYNSTA - telmisartan-amlodipine tab
40-5 mg
4
telmisartan-hydrochlorothiazide tab
40-12.5 mg (Micardis hct)
2
TWYNSTA - telmisartan-amlodipine tab
40-10 mg
4
telmisartan-hydrochlorothiazide tab
80-12.5 mg (Micardis hct)
2
TWYNSTA - telmisartan-amlodipine tab
80-5 mg
4
telmisartan-hydrochlorothiazide tab
80-25 mg (Micardis hct)
4
TWYNSTA - telmisartan-amlodipine tab
80-10 mg
4
TENEX - guanfacine hcl tab 1 mg
TENEX - guanfacine hcl tab 2 mg
4
4
UNIRETIC - moexiprilhydrochlorothiazide tab 7.5-12.5 mg
4
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25 mg
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
UNIRETIC - moexiprilhydrochlorothiazide tab 15-12.5 mg
4
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
1
4
Step Therapy
terazosin hcl cap 1 mg
TEKAMLO - aliskiren-amlodipine tab
300-5 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
51
ZESTRIL - lisinopril tab 5 mg
4
ZESTRIL - lisinopril tab 10 mg
4
ZESTRIL - lisinopril tab 20 mg
4
ZESTRIL - lisinopril tab 30 mg
4
ZESTRIL - lisinopril tab 40 mg
4
ZIAC - bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg
4
UNIVASC - moexipril hcl tab 7.5 mg
4
UNIVASC - moexipril hcl tab 15 mg
4
valsartan tab 160 mg (Diovan)
2
valsartan tab 320 mg (Diovan)
2
valsartan tab 40 mg (Diovan)
2
valsartan tab 80 mg (Diovan)
2
valsartan-hydrochlorothiazide tab
160-12.5 mg (Diovan hct)
2
ZIAC - bisoprolol & hydrochlorothiazide
tab 5-6.25 mg
4
valsartan-hydrochlorothiazide tab
160-25 mg (Diovan hct)
2
ZIAC - bisoprolol & hydrochlorothiazide
tab 10-6.25 mg
4
valsartan-hydrochlorothiazide tab
320-12.5 mg (Diovan hct)
2
DIURETICS
2
ACETAZOLAMIDE - acetazolamide tab
125 mg
4
valsartan-hydrochlorothiazide tab
320-25 mg (Diovan hct)
2
acetazolamide cap sr 12hr 500 mg
(Diamox)
2
valsartan-hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
acetazolamide tab 250 mg
2
VALTURNA - aliskiren-valsartan tab
150-160 mg
4
ALDACTAZIDE - spironolactone &
hydrochlorothiazide tab 25-25 mg
4
VALTURNA - aliskiren-valsartan tab
300-320 mg
4
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
VASOTEC - enalapril maleate tab 10
mg
ALDACTONE - spironolactone tab 100
mg
4
4
VASOTEC - enalapril maleate tab 20
mg
amiloride & hydrochlorothiazide tab
5-50 mg
1
4
amiloride hcl tab 5 mg
2
VECAMYL - mecamylamine hcl tab 2.5
mg
4
bumetanide tab 0.5 mg
1
4
bumetanide tab 1 mg
1
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 10-12.5 mg
bumetanide tab 2 mg
1
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 20-12.5 mg
4
CHLOROTHIAZIDE - chlorothiazide tab
250 mg
1
ZESTORETIC - lisinopril &
hydrochlorothiazide tab 20-25 mg
4
chlorothiazide tab 250 mg
1
chlorothiazide tab 500 mg
1
52
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
4
4
Step Therapy
ZESTRIL - lisinopril tab 2.5 mg
UNIRETIC - moexiprilhydrochlorothiazide tab 15-25 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
CHLORTHALIDONE - chlorthalidone
tab 25 mg
1
MAXZIDE - triamterene &
hydrochlorothiazide tab 75-50 mg
4
CHLORTHALIDONE - chlorthalidone
tab 50 mg
4
MAXZIDE-25 - triamterene &
hydrochlorothiazide tab 37.5-25 mg
4
CHLORTHALIDONE - chlorthalidone
tab 100 mg
4
methazolamide tab 25 mg
(Neptazane)
2
DEMADEX - torsemide tab 5 mg
4
2
DEMADEX - torsemide tab 10 mg
4
methazolamide tab 50 mg
(Neptazane)
DEMADEX - torsemide tab 20 mg
4
4
DEMADEX - torsemide tab 100 mg
4
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
4
metolazone tab 10 mg
2
DIAMOX - acetazolamide cap sr 12hr
500 mg
metolazone tab 2.5 mg (Zaroxolyn)
1
DIURIL - chlorothiazide susp 250
mg/5ml
4
metolazone tab 5 mg (Zaroxolyn)
2
4
DYAZIDE - triamterene &
hydrochlorothiazide cap 37.5-25 mg
4
MICROZIDE - hydrochlorothiazide cap
12.5 mg
4
DYRENIUM - triamterene cap 50 mg
4
NEPTAZANE - methazolamide tab 25
mg
DYRENIUM - triamterene cap 100 mg
4
4
EDECRIN - ethacrynic acid tab 25 mg
4
NEPTAZANE - methazolamide tab 50
mg
4
spironolactone &
hydrochlorothiazide tab 25-25 mg
(Aldactazide)
1
FUROSEMIDE - furosemide oral soln 8
mg/ml
furosemide oral soln 10 mg/ml
1
2
furosemide tab 20 mg (Lasix)
1
spironolactone tab 100 mg
(Aldactone)
furosemide tab 40 mg (Lasix)
1
spironolactone tab 25 mg (Aldactone)
1
furosemide tab 80 mg (Lasix)
1
spironolactone tab 50 mg (Aldactone)
2
hydrochlorothiazide cap 12.5 mg
(Microzide)
1
THALITONE - chlorthalidone tab 15 mg
4
torsemide tab 10 mg (Demadex)
1
hydrochlorothiazide tab 12.5 mg
1
torsemide tab 100 mg (Demadex)
2
hydrochlorothiazide tab 25 mg
1
torsemide tab 20 mg (Demadex)
1
hydrochlorothiazide tab 50 mg
1
torsemide tab 5 mg (Demadex)
1
indapamide tab 1.25 mg
1
1
triamterene & hydrochlorothiazide
cap 37.5-25 mg (Dyazide)
1
indapamide tab 2.5 mg
INTROL - glycerin soln 75%
4
1
LASIX - furosemide tab 20 mg
4
triamterene & hydrochlorothiazide
tab 37.5-25 mg (Maxzide-25)
LASIX - furosemide tab 40 mg
4
1
LASIX - furosemide tab 80 mg
4
triamterene & hydrochlorothiazide
tab 75-50 mg (Maxzide)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
53
ADVICOR - niacin-lovastatin tab sr 24hr
1000-20 mg
4
•
ADVICOR - niacin-lovastatin tab sr 24hr
1000-40 mg
4
•
4
ALTOPREV - lovastatin tab sr 24hr 20
mg
4
•
ADRENACLICK - epinephrine solution
auto-injector 0.15 mg/0.15ml (1:1000)
4
ALTOPREV - lovastatin tab sr 24hr 40
mg
4
•
ADRENACLICK - epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
4
ALTOPREV - lovastatin tab sr 24hr 60
mg
4
•
AUVI-Q - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000)
4
ANTARA - fenofibrate micronized cap
30 mg
4
AUVI-Q - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
4
ANTARA - fenofibrate micronized cap
43 mg
4
EPINEPHRINE - epinephrine solution
auto-injector 0.15 mg/0.15ml (1:1000)
4
ANTARA - fenofibrate micronized cap
90 mg
4
EPINEPHRINE - epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
4
ANTARA - fenofibrate micronized cap
130 mg
4
EPIPEN 2-PAK - epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
3
atorvastatin calcium tab 10 mg (base
equivalent) (Lipitor)
2
EPIPEN-JR 2-PAK - epinephrine
solution auto-injector 0.15 mg/0.3ml
(1:2000)
3
atorvastatin calcium tab 20 mg (base
equivalent) (Lipitor)
2
2
midodrine hcl tab 10 mg
2
atorvastatin calcium tab 40 mg (base
equivalent) (Lipitor)
midodrine hcl tab 2.5 mg
2
2
midodrine hcl tab 5 mg
2
atorvastatin calcium tab 80 mg (base
equivalent) (Lipitor)
4
cholestyramine light powder packets
4 gm
2
NORTHERA - droxidopa cap 100 mg
NORTHERA - droxidopa cap 200 mg
4
NORTHERA - droxidopa cap 300 mg
cholestyramine light powder 4 gm/
dose (Questran light)
2
4
TWINJECT - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000)
4
cholestyramine powder packets
4 gm (Questran)
2
TWINJECT - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
4
cholestyramine powder 4 gm/dose
(Questran)
2
2
•
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
2
•
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
COLESTID - colestipol hcl tab 1 gm
4
TRIAMTERENE/HYDROCHLOROTH triamterene & hydrochlorothiazide
cap 50-25 mg
4
ZAROXOLYN - metolazone tab 2.5 mg
4
ZAROXOLYN - metolazone tab 5 mg
VASOPRESSORS
ANTIHYPERLIPIDEMICS
ADVICOR - niacin-lovastatin tab sr 24hr
500-20 mg
4
ADVICOR - niacin-lovastatin tab sr 24hr
750-20 mg
4
54
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
COLESTID - colestipol hcl granules 5
gm
4
FENOFIBRIC ACID - fenofibric acid tab
35 mg
4
COLESTID - colestipol hcl granule
packets 5 gm
4
FENOFIBRIC ACID - fenofibric acid tab
105 mg
4
COLESTID FLAVORED - colestipol hcl
granules 5 gm
4
FENOGLIDE - fenofibrate tab 40 mg
4
FENOGLIDE - fenofibrate tab 120 mg
4
COLESTID FLAVORED - colestipol hcl
granule packets 5 gm
4
FIBRICOR - fenofibric acid tab 35 mg
4
2
FIBRICOR - fenofibric acid tab 105 mg
4
colestipol hcl granule packets 5 gm
(Colestid flavored)
fluvastatin sodium cap 20 mg
(Lescol)
2
fluvastatin sodium cap 40 mg
(Lescol)
2
gemfibrozil tab 600 mg (Lopid)
1
JUXTAPID - lomitapide mesylate cap 5
mg (base equiv)
5
•
•
JUXTAPID - lomitapide mesylate cap 10 5
mg (base equiv)
JUXTAPID - lomitapide mesylate cap 20 5
mg (base equiv)
5
KYNAMRO - mipomersen sodium inj
200 mg/ml
LESCOL - fluvastatin sodium cap 20 mg 4
•
•
•
•
•
•
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
LESCOL - fluvastatin sodium cap 40 mg
4
2
LESCOL XL - fluvastatin sodium tab sr
24 hr 80 mg
4
•
•
•
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 micronized cap 43 mg
(Antara)
2
LIPITOR - atorvastatin calcium tab 40
mg (base equivalent)
4
•
fenofibrate micronized cap 67 mg
(Lofibra)
2
LIPITOR - atorvastatin calcium tab 80
mg (base equivalent)
4
•
fenofibrate tab 145 mg (Tricor)
2
LIPOFEN - fenofibrate cap 50 mg
4
fenofibrate tab 160 mg (Lofibra)
2
LIPOFEN - fenofibrate cap 150 mg
4
fenofibrate tab 48 mg (Tricor)
2
4
•
fenofibrate tab 54 mg (Lofibra)
1
LIPTRUZET - ezetimibe-atorvastatin tab
10-10 mg
LIPTRUZET - ezetimibe-atorvastatin tab
10-20 mg
4
•
FENOFIBRATE - fenofibrate cap 150
mg
4
fenofibrate micronized cap 130 mg
(Antara)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
55
LIPTRUZET - ezetimibe-atorvastatin tab
10-40 mg
4
•
NIASPAN - niacin tab cr 1000 mg
(antihyperlipidemic)
4
LIPTRUZET - ezetimibe-atorvastatin tab
10-80 mg
4
•
omega-3-acid ethyl esters cap 1 gm
(Lovaza)
2
LIVALO - pitavastatin calcium tab 1 mg
(base equiv)
4
•
PRAVACHOL - pravastatin sodium tab
20 mg
4
•
LIVALO - pitavastatin calcium tab 2 mg
(base equiv)
4
•
PRAVACHOL - pravastatin sodium tab
40 mg
4
•
LIVALO - pitavastatin calcium tab 4 mg
(base equiv)
4
•
PRAVACHOL - pravastatin sodium tab
80 mg
4
•
LOFIBRA - fenofibrate tab 54 mg
4
pravastatin sodium tab 10 mg
1
LOFIBRA - fenofibrate tab 160 mg
4
1
LOFIBRA - fenofibrate micronized cap
67 mg
4
pravastatin sodium tab 20 mg
(Pravachol)
1
LOFIBRA - fenofibrate micronized cap
134 mg
4
pravastatin sodium tab 40 mg
(Pravachol)
1
LOFIBRA - fenofibrate micronized cap
200 mg
4
pravastatin sodium tab 80 mg
(Pravachol)
4
LOPID - gemfibrozil tab 600 mg
4
QUESTRAN - cholestyramine powder 4
gm/dose
lovastatin tab 10 mg
1
4
lovastatin tab 20 mg (Mevacor)
1
QUESTRAN - cholestyramine powder
packets 4 gm
1
QUESTRAN LIGHT - cholestyramine
light powder 4 gm/dose
4
lovastatin tab 40 mg (Mevacor)
LOVAZA - omega-3-acid ethyl esters
cap 1 gm
4
QUESTRAN LIGHT - cholestyramine
light powder packets 4 gm
4
MEVACOR - lovastatin tab 20 mg
4
MEVACOR - lovastatin tab 40 mg
4
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
2
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
2
niacin tab cr 750 mg
(antihyperlipidemic) (Niaspan)
2
NIACOR - niacin (antihyperlipidemic)
tab 500 mg
4
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
4
NIASPAN - niacin tab cr 750 mg
(antihyperlipidemic)
4
56
•
•
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 10 mg (Zocor)
simvastatin tab 20 mg (Zocor)
1
simvastatin tab 40 mg (Zocor)
1
simvastatin tab 5 mg (Zocor)
1
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
TRIGLIDE - fenofibrate tab 50 mg
4
TRIGLIDE - fenofibrate tab 160 mg
4
TRILIPIX - choline fenofibrate cap dr 45
mg (fenofibric acid equiv)
4
TRILIPIX - choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
4
VASCEPA - icosapent ethyl cap 1 gm
4
VYTORIN - ezetimibe-simvastatin tab
10-10 mg
4
VYTORIN - ezetimibe-simvastatin tab
10-20 mg
4
VYTORIN - ezetimibe-simvastatin tab
10-40 mg
amlodipine besylate-atorvastatin
calcium tab 10-40 mg (Caduet)
2
amlodipine besylate-atorvastatin
calcium tab 10-80 mg (Caduet)
2
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
2
amlodipine besylate-atorvastatin
calcium tab 2.5-20 mg (Caduet)
2
2
•
amlodipine besylate-atorvastatin
calcium tab 2.5-40 mg (Caduet)
2
•
amlodipine besylate-atorvastatin
calcium tab 5-10 mg (Caduet)
2
4
•
amlodipine besylate-atorvastatin
calcium tab 5-20 mg (Caduet)
4
•
amlodipine besylate-atorvastatin
calcium tab 5-40 mg (Caduet)
2
VYTORIN - ezetimibe-simvastatin tab
10-80 mg
WELCHOL - colesevelam hcl tab 625
mg
amlodipine besylate-atorvastatin
calcium tab 5-80 mg (Caduet)
2
3
WELCHOL - colesevelam hcl packet for
susp 3.75 gm
BIDIL - isosorbide dinitrate-hydralazine
hcl tab 20-37.5 mg
4
3
ZETIA - ezetimibe tab 10 mg
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10 mg
4
4
ZOCOR - simvastatin tab 5 mg
4
4
ZOCOR - simvastatin tab 10 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-20 mg
ZOCOR - simvastatin tab 20 mg
4
4
ZOCOR - simvastatin tab 40 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-40 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg
4
ZOCOR - simvastatin tab 80 mg
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
CADUET - amlodipine besylateatorvastatin calcium tab 10-10 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 10-20 mg
4
•
•
•
•
•
•
CARDIOVASCULAR AGENTS - MISC.
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 10-10 mg (Caduet)
2
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
4
2
Step Therapy
TRICOR - fenofibrate tab 145 mg
amlodipine besylate-atorvastatin
calcium tab 10-20 mg (Caduet)
Prior Authorization
4
Drug Name
Drug Tier
TRICOR - fenofibrate tab 48 mg
Dispensing Limits
1
Step Therapy
simvastatin tab 80 mg (Zocor)
Prior Authorization
Drug Name
Drug Tier
2014
57
CADUET - amlodipine besylateatorvastatin calcium tab 10-40 mg
4
brompheniramine maleate tab sr
12hr 6 mg
1
CADUET - amlodipine besylateatorvastatin calcium tab 10-80 mg
4
4
ISOXSUPRINE HCL - isoxsuprine hcl
tab 10 mg
4
BROMPHENIRAMINE TANNATE brompheniramine tannate chew tab
12 mg
2
ISOXSUPRINE HCL - isoxsuprine hcl
tab 20 mg
4
carbinoxamine maleate soln
4 mg/5ml (Palgic)
2
isoxsuprine hcl tab 10 mg
2
carbinoxamine maleate tab 4 mg
(Palgic)
LETAIRIS - ambrisentan tab 5 mg
5
CLARINEX - desloratadine tab 5 mg
4
LETAIRIS - ambrisentan tab 10 mg
5
4
OPSUMIT - macitentan tab 10 mg
5
CLARINEX - desloratadine syrup 0.5
mg/ml
5
CLARINEX REDITABS - desloratadine
tab orally disintegrating 2.5 mg
4
ORENITRAM - treprostinil diolamine tab
cr 0.125 mg (base equiv)
5
CLARINEX REDITABS - desloratadine
tab orally disintegrating 5 mg
4
ORENITRAM - treprostinil diolamine tab
cr 0.25 mg (base equiv)
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
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
RESPIRATORY AGENTS
ANTIHISTAMINES
AEROHIST - chlorpheniraminemethscopolamine tab sr 12hr 8-2.5
mg
58
3
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CLEMASTINE FUMARATE - clemastine 1
fumarate syrup 0.67 mg/5ml (0.5
mg/5ml base eq)
1
clemastine 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
DEXCHLORPHENIRAMINE MALEA dexchlorpheniramine maleate syrup 2
mg/5ml
4
DOXYTEX - doxylamine succinate liquid 4
2.5 mg/2.5ml
4
ED CHLORPED - chlorpheniramine
tannate susp 2 mg/ml
4
ED-CHLOR-TAN - chlorpheniramine
tannate tab 8 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
FEXOFENADINE HCL - fexofenadine
hcl tab 60 mg
4
fexofenadine hcl tab 180 mg
1
fexofenadine hcl tab 30 mg
2
fexofenadine hcl tab 60 mg
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)
PALGIC - carbinoxamine maleate tab 4 4
mg
PALGIC - carbinoxamine maleate soln 4 4
mg/5ml
4
PBZ - tripelennamine hcl tab 50 mg
promethazine hcl suppos 12.5 mg
1
promethazine hcl suppos 25 mg
1
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
XYZAL - levocetirizine dihydrochloride
tab 5 mg
4
XYZAL - levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
4
NASAL AGENTS - SYSTEMIC and TOPICAL
4
ADRENALIN - epinephrine hcl nasal
soln 0.1%
4
ASTELIN - azelastine hcl nasal spray
137 mcg/spray (1 mg/ml)
3
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 0.15%
(205.5 mcg/spray) (Astepro)
2
azelastine hcl nasal spray 137 mcg/
spray (1 mg/ml)
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%)
4
FLUNISOLIDE - flunisolide nasal soln
29 mcg/act (0.025%)
2
flunisolide nasal soln 0.025%
(Flunisolide)
2
fluticasone propionate nasal susp
50 mcg/act (Flonase)
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
4
NASACORT AQ - triamcinolone
acetonide nasal inhal 55 mcg/act
NASONEX - mometasone furoate nasal 3
susp 50 mcg/act
4
OMNARIS - ciclesonide nasal susp 50
mcg/act
PATANASE - olopatadine hcl nasal soln 4
0.6%
QNASL - beclomethasone dipropionate 4
nasal aerosol 80 mcg/act
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
59
RHINOCORT AQUA - budesonide nasal 4
susp 32 mcg/act
2
triamcinolone acetonide nasal inhal
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)
COUGH/COLD/ALLERGY
•
brompheniramine & phenylephrine
susp 6-10 mg/5ml
2
•
brompheniramine &
pseudoephedrine tab sr 12hr
6-45 mg
1
BRONCOPECTOL - phenylephchlorphen w/ dm-gg syrup 5-2-5-75
mg/5ml
4
•
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
acetylcysteine inhal soln 10%
2
acetylcysteine inhal soln 20%
2
ALAHIST AC - phenylephrine w/
codeine liqd 7.5-10 mg/5ml
4
chlorpheniramine w/ codeine liquid
2-10 mg/5ml
1
ALAHIST DHC - phenylephrinedihydrocodeine liqd 7.5-3 mg/5ml
4
4
ALBATUSSIN - phenylephrinecarbetapentane-gg cap 10-25-400 mg
4
CLARINEX-D 12 HOUR - desloratadine
& pseudoephedrine tab sr 12hr
2.5-120 mg
4
ALBATUSSIN NN - phenyleph-dm-pyrilpot guai-sod cit-cit acid liquid
4
CLARINEX-D 24 HOUR - desloratadine
& pseudoephedrine tab sr 24hr 5-240
mg
ALLFEN CD - guaifenesin-codeine tab
400-10 mg
4
CODAR AR - chlorpheniramine w/
codeine liquid 2-8 mg/5ml
4
ALLFEN CDX - guaifenesin-codeine tab
400-20 mg
4
CODAR D - pseudoephedrine w/
codeine liquid 30-8 mg/5ml
4
ALLFEN CDX - guaifenesin-codeine
liquid 200-20 mg/5ml
4
CODAR GF - guaifenesin-codeine liquid
200-8 mg/5ml
4
AMBIFED CD - pseudoephedrine w/
cod-gg tab 30-10-400 mg
4
COTAB A - chlorpheniramine w/
codeine tab 4-10 mg
4
AMBIFED CDX - pseudoephedrine w/
cod-gg tab 30-20-400 mg
4
COTAB AX - chlorpheniramine w/
codeine tab 4-20 mg
4
AMBIFED-G CD - pseudoephedrine w/
cod-gg tab 20-10-400 mg
4
COTABFLU - codeinechlorpheniramine-acetaminophen tab
20-4-500 mg
4
CPB WC - pseudoephedrine-bromphencodeine liq 10-1.3-6.3 mg/5ml
4
DECON-A - brompheniramine &
phenylephrine elixir 2-5 mg/5ml
4
AMBIFED-G CDX - pseudoephedrine w/ 4
cod-gg tab 20-20-400 mg
1
benzonatate cap 100 mg (Tessalon
perles)
1
benzonatate cap 200 mg
60
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
DECON-G - phenylephrinebrompheniramine-guaifenesin liqd
2-1-40 mg/ml
4
hydrocod polst-chlorphen polst
cr susp 10-8 mg/5ml (Tussionex
pennkineti)
2
DESPEC-EXP - pseudoephedrinedihydrocodeine-gg syrup 15-7.5-100
mg/5ml
4
hydrocodone w/ homatropine syrup
5-1.5 mg/5ml
2
2
DESPEC-PDC - phenylephrinechlorphen-dihydrocodeine liqd
7.5-2.5-3 mg/5ml
4
hydrocodone w/ homatropine tab
5-1.5 mg
HYPER-SAL - sodium chloride soln
nebu 7%
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
1
DONATUSS DC - phenylephrinedihydrocodeine-gg syrup 7.5-7.5-50
mg/5ml
4
ENDACOF-DC - pseudoephedrine w/
codeine liquid 30-10 mg/5ml
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
cap 7-14-288 mg
4
GILTUSS TR - phenylephrine w/ dm-gg
tab 10-28-388 mg
4
GILTUSS TR - phenylephrine w/ dm-gg
tab sr 12hr 20-30-600 mg
4
guaifenesin-codeine liquid
225-7.5 mg/5ml
1
guaifenesin-codeine soln
100-10 mg/5ml
1
guaifenesin-codeine soln
100-6.3 mg/5ml
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
HYPERSAL - sodium chloride soln nebu 4
3.5%
HYPERSAL - sodium chloride soln nebu 4
7%
J-COF DHC - pseudoephed-bromphen- 4
dihydrocodeine liqd 15-3-7.5 mg/5ml
4
J-MAX DHC - dihydrocodeineguaifenesin liquid 7.5-100 mg/5ml
LARTUS - phenyleph-chlorphen w/ dm- 4
gg liquid 5-2-15-150 mg/5ml
4
LORTUSS EX - pseudoephedrine w/
cod-gg liqd 22.5-10-100 mg/5ml
4
M-CLEAR - guaifenesin-codeine cap
200-9 mg
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
MAXIFED CD - pseudoephedrine w/
cod-gg tab 60-10-400 mg
4
MAXIFED CDX - pseudoephedrine w/
cod-gg tab 60-20-400 mg
4
MAXIFED-G CD - pseudoephedrine w/
cod-gg tab 40-10-400 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
61
MAXIFED-G CDX - pseudoephedrine w/ 4
cod-gg tab 40-20-400 mg
4
MAXIFLU CD - pseudoephed-codeineguaifenesin-apap tab 40-10-400-500
mg
MAXIFLU CDX - pseudoephed-codeine- 4
guaifenesin-apap tab 60-20-400-500
mg
4
MAXIPHEN CD - phenylephrine w/
codeine-gg tab 10-10-400 mg
4
MAXIPHEN CDX - phenylephrine w/
codeine-gg tab 10-20-400 mg
4
NEBUSAL - sodium chloride soln nebu
6%
NEO AC - pseudoephedrine-pyrilamine- 4
codeine syrup 30-15-10 mg/5ml
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
PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid
5-1-15-100 mg/5ml
4
PEDIATEX TD - triprolidine &
pseudoephedrine liquid 0.938-10 mg/
ml
4
PEDIATEX TDM - pseudoephedtriprolidine-dm susp 10-0.938-4 mg/
ml
PHENFLU CD - phenylephrine-codeine- 4
guaifenesin-apap tab 10-10-400-500
mg
62
PHENFLU CDX - phenylephrinecodeine-guaifenesin-apap tab
10-20-400-500 mg
4
phenylephrine w/ dm-gg liqd
10-15-300 mg/5ml
2
phenylephrine w/ dm-gg liqd
10-30-200 mg/5ml
2
phenylephrine w/ dm-gg liqd
2.5-5-50 mg/ml
2
phenylephrine w/ dm-gg liqd
2.5-7.5-88 mg/ml
2
phenylephrine-bromphen w/ codeine
liqd 7.5-4-10 mg/5ml
1
phenylephrine-brompheniramine-dm
liquid 7.5-4-15 mg/5ml
1
phenylephrine-chlorphen-dm liquid
1.5-1-3 mg/ml
2
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
1
PHENYLHISTINE DH pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml
4
POLY HIST DHC - phenylephrinepyrilamine-dihydrocod liqd 5-7.5-7.5
mg/5ml
4
POLY HIST NC - pseudoephedrinetriprolidine w/ cod liquid 15-1.25-10
mg/5ml
4
POLY-TUSSIN - codeine-chlorcyclizine
liquid 10-9.375 mg/5ml
4
POLY-TUSSIN AC - phenylephrinebromphen w/ codeine liqd 7.5-4-10
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
POLY-TUSSIN DHC - phenylephrinebromphen-dihydrocodeine liqd
7.5-4-3 mg/5ml
4
POLY-TUSSIN EX - phenylephrinedihydrocodeine-gg syrup 5-7.5-50
mg/5ml
4
PRO-CLEAR AC - codeine-pyrilamine
syrup 9-8.33 mg/5ml
4
PRO-RED AC - phenylephrinepyrilamine w/ codeine syrup 5-8.33-9
mg/5ml
4
PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup 5-1-9
mg/5ml
4
promethazine & phenylephrine syrup
6.25-5 mg/5ml
1
PROMETHAZINE VC PLAIN promethazine & phenylephrine syrup
6.25-5 mg/5ml
1
PROMETHAZINE VC/CODEINE phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
RESCON-JR - chlorpheniramine &
phenylephrine tab sr 12hr 4-20 mg
4
RESCON-JR - dexchlorpheniraminephenylephrine tab sr 12hr 3-20 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
4
sodium chloride soln nebu 0.9%
2
sodium chloride soln nebu 10%
2
sodium chloride soln nebu 3%
2
sodium chloride soln nebu 7%
(Hyper-sal)
2
STATUSS GREEN - codeinepseudoephedrine-chlorcyclizine liq
9-30-12.5 mg/5ml
4
1
promethazine w/ codeine syrup
6.25-10 mg/5ml
SUTTAR-SF - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml
4
1
promethazine-dm syrup
6.25-15 mg/5ml
SUTTAR-2 - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml
4
1
4
TEKRAL - diphenhydramine &
pseudoephedrine tab sr 12hr 100-120
mg
4
PROTID - chlorphen-phenylephrine w/
apap tab cr 8-40-500 mg
pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
(Zutripro)
2
TESSALON - benzonatate cap 200 mg
4
pseudoephed-bromphen-dm syrup
30-2-10 mg/5ml
2
pseudoephedrine w/ cod-gg soln
30-10-100 mg/5ml
1
pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml (Suttar-sf)
1
pseudoephedrine-bromphen-codeine
liq 10-1.33-6.33 mg/5ml
1
RELHIST - bromphen tan-phenyleph tan 4
chew tab 6-15 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
TESSALON PERLES - benzonatate cap 4
100 mg
4
TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm syrup
5-2-15 mg/5ml
4
TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup
30-15-150 mg/5ml
4
TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm syrup
30-3-15 mg/5ml
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
63
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm syrup
50-3-30 mg/5ml
1
ZODRYL DAC 35 - pseudoephedrinechlorphen w/codeine susp
3.75-0.25-1 mg/ml
4
TRICODE AR - pseudoephedrinechlorphen w/ codeine liq 30-2-8
mg/5ml
4
ZODRYL DAC 40 - pseudoephedrinechlorphen w/codeine susp
3.333-0.222-1 mg/ml
4
TRICODE GF - pseudoephedrine w/
cod-gg liquid 30-8-200 mg/5ml
4
ZODRYL DEC 25 - pseudoephedrine w/
cod-gg susp 5-1-20 mg/ml
4
TUSNEL - brompheniramine w/ dm-gg
cap 2-15-200 mg
4
ZODRYL DEC 30 - pseudoephedrine w/
cod-gg susp 4.286-1-20 mg/ml
4
TUSSICAPS - hydrocod polst-chlorphen
polst cap sr 12hr 5-4 mg
4
ZODRYL DEC 35 - pseudoephedrine w/
cod-gg susp 3.75-1-20 mg/ml
4
TUSSICAPS - hydrocod polst-chlorphen
polst cap sr 12hr 10-8 mg
4
ZODRYL DEC 40 - pseudoephedrine w/
cod-gg susp 3.333-1-20 mg/ml
4
TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst cr
susp 10-8 mg/5ml
4
ZONATUSS - benzonatate cap 150 mg
4
ZUTRIPRO - pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
4
VANACOF CD - phenylephrinedexchlorphenir-codeine liquid 5-1-10
mg/5ml
4
VITUZ - hydrocodone-chlorpheniramine
soln 5-4 mg/5ml
4
ACCOLATE - zafirlukast tab 20 mg
4
4
•
Z-TUSS AC - chlorpheniramine w/
codeine liquid 2-9 mg/5ml
4
ACCUNEB - albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
4
•
Z-TUSS E - pseudoephedrine w/ cod-gg
liquid 30-9-200 mg/5ml
4
ACCUNEB - albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
3
•
ZODRYL AC 25 - chlorpheniramine w/
codeine susp 0.333-1 mg/ml
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50
mcg/dose
ZODRYL AC 30 - chlorpheniramine w/
codeine susp 0.286-1 mg/ml
4
3
•
ZODRYL AC 35 - chlorpheniramine w/
codeine susp 0.25-1 mg/ml
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 250-50
mcg/dose
3
•
ZODRYL AC 40 - chlorpheniramine w/
codeine susp 0.222-1 mg/ml
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50
mcg/dose
4
ADVAIR HFA - fluticasone-salmeterol
inhal aerosol 45-21 mcg/act
3
ZODRYL DAC 25 - pseudoephedrinechlorphen w/codeine susp 5-0.333-1
mg/ml
•
3
•
ZODRYL DAC 30 - pseudoephedrinechlorphen w/codeine susp
4.286-0.286-1 mg/ml
4
ADVAIR HFA - fluticasone-salmeterol
inhal aerosol 115-21 mcg/act
ADVAIR HFA - fluticasone-salmeterol
inhal aerosol 230-21 mcg/act
3
•
64
ANTIASTHMATIC and BRONCHODILATOR AGENTS
4
ACCOLATE - zafirlukast tab 10 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
4
•
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
1
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
1
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
2
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
2
albuterol sulfate syrup 2 mg/5ml
1
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
2
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
2
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
ALVESCO - ciclesonide inhal aerosol 80 4
mcg/act
4
ALVESCO - ciclesonide inhal aerosol
160 mcg/act
4
AMINOPHYLLINE - aminophylline tab
100 mg
4
AMINOPHYLLINE - aminophylline tab
200 mg
3
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25 mcg/
inh
4
ARCAPTA NEOHALER - indacaterol
maleate inhal powder cap 75 mcg
(base equiv)
3
ASMANEX 120 METERED DOSES mometasone furoate inhal powd 220
mcg/inh (breath activated)
3
ASMANEX 30 METERED DOSES mometasone furoate inhal powd 110
mcg/inh (breath activated)
3
ASMANEX 30 METERED DOSES mometasone furoate inhal powd 220
mcg/inh (breath activated)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
3
•
•
ASMANEX 60 METERED DOSES mometasone furoate inhal powd 220
mcg/inh (breath activated)
3
•
•
ATROVENT HFA - ipratropium bromide
hfa inhal aerosol 17 mcg/act
3
•
•
BREO ELLIPTA - fluticasone furoatevilanterol aero powd ba 100-25 mcg/
inh
•
BRONCOMAR-1 - theophylline-pse-gg
elixir 150-30-150 mg/15ml
4
BRONDIL - dyphylline-guaifenesin liqd
100-100 mg/15ml
4
BROVANA - arformoterol tartrate soln
nebu 15 mcg/2ml (base equiv)
4
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
2
•
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
2
•
COMBIVENT - ipratropium-albuterol
aerosol 18-103 mcg/act (20-120mcg/
act)
3
•
COMBIVENT RESPIMAT - ipratropiumalbuterol inhal aerosol soln 20-100
mcg/act
3
•
cromolyn sodium soln nebu
20 mg/2ml
2
•
•
DALIRESP - roflumilast tab 500 mcg
4
3
•
•
DULERA - mometasone furoateformoterol fumarate aerosol 100-5
mcg/act
3
•
•
DULERA - mometasone furoateformoterol fumarate aerosol 200-5
mcg/act
DUONEB - ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml
4
•
dyphylline-guaifenesin liqd
100-100 mg/5ml
1
dyphylline-guaifenesin tab
200-200 mg
1
dyphylline-guaifenesin tab
200-400 mg
1
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
65
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
2
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
2
FLOVENT DISKUS - fluticasone
propionate aer pow ba 50 mcg/blister
3
FLOVENT DISKUS - fluticasone
propionate aer pow ba 100 mcg/
blister
3
FLOVENT DISKUS - fluticasone
propionate aer pow ba 250 mcg/
blister
3
•
FLOVENT HFA - fluticasone propionate
hfa inhal aero 44 mcg/act (50/valve)
3
•
FLOVENT HFA - fluticasone propionate
hfa inhal aer 110 mcg/act (125/valve)
3
•
FLOVENT HFA - fluticasone propionate
hfa inhal aer 220 mcg/act (250/valve)
3
•
FORADIL AEROLIZER - formoterol
fumarate inhal cap 12 mcg
3
•
ipratropium bromide inhal soln
0.02%
2
•
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml (Duoneb)
2
•
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
2
•
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 200 mg
•
LUFYLLIN - dyphylline tab 400 mg
4
MAXAIR AUTOHALER - pirbuterol
acetate breath activated inhal aerosol
200mcg/inh
4
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
4
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
4
66
•
•
•
2
montelukast sodium oral granules
packet 4 mg (base equiv) (Singulair)
montelukast sodium tab 10 mg (base 2
equiv) (Singulair)
4
PERFOROMIST - formoterol fumarate
soln nebu 20 mcg/2ml
3
PROAIR HFA - albuterol sulfate inhal
aero 108 mcg/act (90mcg 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)
4
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
3
QVAR - beclomethasone dipropionate
inhal aero soln 40 mcg/act
3
QVAR - beclomethasone dipropionate
inhal aero soln 80 mcg/act
4
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/dose
(base equiv)
4
SINGULAIR - montelukast sodium tab
10 mg (base equiv)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
1
•
metaproterenol sulfate syrup
10 mg/5ml
4
Step Therapy
4
•
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10
mg/5ml
ELIXOPHYLLIN - theophylline elixir 80
mg/15ml
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
•
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
SINGULAIR - montelukast sodium chew
tab 4 mg (base equiv)
4
VOSPIRE ER - albuterol sulfate tab sr
12hr 4 mg
4
SINGULAIR - montelukast sodium chew
tab 5 mg (base equiv)
4
VOSPIRE ER - albuterol sulfate tab sr
12hr 8 mg
4
SINGULAIR - montelukast sodium oral
granules packet 4 mg (base equiv)
4
XOPENEX - levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv)
4
•
SPIRIVA HANDIHALER - tiotropium
bromide monohydrate inhal cap 18
mcg (base equiv)
3
XOPENEX - levalbuterol hcl soln nebu
0.63 mg/3ml (base equiv)
4
•
•
STRIVERDI RESPIMAT - olodaterol hcl
inhal aerosol soln 2.5 mcg/act (base
equiv)
XOPENEX - levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv)
4
4
4
•
SYMBICORT - budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/
act
3
XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
XOPENEX HFA - levalbuterol tartrate
inhal aerosol 45 mcg/act (base equiv)
4
•
SYMBICORT - budesonide-formoterol
fumarate dihyd aerosol 160-4.5 mcg/
act
3
zafirlukast tab 10 mg (Accolate)
2
zafirlukast tab 20 mg (Accolate)
2
terbutaline sulfate tab 2.5 mg
1
ZYFLO - zileuton tab 600 mg
4
terbutaline sulfate tab 5 mg
2
ZYFLO CR - zileuton tab sr 12hr 600 mg 4
THEO-24 - theophylline cap sr 24hr 100
mg
4
RESPIRATORY AGENTS - MISC.
4
THEO-24 - theophylline cap sr 24hr 200
mg
4
CUROSURF - poractant alfa
intratracheal susp 80 mg/ml
4
THEO-24 - theophylline cap sr 24hr 300
mg
4
INFASURF - calfactant in nacl 0.9%
intratracheal susp 35 mg/ml
KALYDECO - ivacaftor tab 150 mg
5
THEO-24 - theophylline cap sr 24hr 400
mg
4
PULMOZYME - dornase alfa inhal soln
1 mg/ml
5
theophylline soln 80 mg/15ml
2
4
theophylline tab sr 12hr 100 mg
1
SURFAXIN - lucinactant intratracheal
susp 30 mg/ml
theophylline tab sr 12hr 200 mg
1
4
theophylline tab sr 12hr 300 mg
1
SURVANTA INTRATRACHEAL beractant in nacl 0.9% intratracheal
susp 25 mg/ml
theophylline tab sr 12hr 450 mg
2
theophylline tab sr 24hr 400 mg
2
theophylline tab sr 24hr 600 mg
2
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
•
•
•
•
•
GASTROINTESTINAL AGENTS
LAXATIVES
CASCARA SAGRADA - cascara
sagrada fl ext 1 gm/ml
4
•
4
•
COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln
227.1 gm
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
67
COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln
240 gm
4
SUPREP BOWEL PREP - sodium
sulfate-potassium sulfate-magnesium
sulfate oral soln
4
GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate for soln 236 gm
4
4
GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate packet 227.1 gm
4
VISICOL - sod phos monobasic-sod
phos dibasic-mcc tabs 1.102-0.398
gm
HALFLYTELY BOWEL PREP/FLA bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit
4
KRISTALOSE - lactulose oral crystal
packet 10 gm
4
KRISTALOSE - lactulose oral crystal
packet 20 gm
Dispensing Limits
Step Therapy
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
4
FULYZAQ - crofelemer tab delayed
release 125 mg
4
lactulose solution 10 gm/15ml
1
4
MINERAL OIL HEAVY - mineral oil
4
LOMOTIL - diphenoxylate w/ atropine
tab 2.5-0.025 mg
MOVIPREP - peg 3350-kcl-nacl-na
sulfate-na acorbate-c for soln 100 gm
4
MOTOFEN - difenoxin w/ atropine tab
1-0.025 mg
4
NULYTELY/FLAVOR PACKS - peg
3350-kcl-sod bicarb-nacl for soln 420
gm
4
OPIUM TINCTURE (PAREGORIC paregoric 2 mg/5ml
4
opium tincture 1% (10 mg/ml)
(morphine equiv)
2
RESTORA RX - lactobacillus casei-folic
acid cap 60-1.25 mg
4
OSMOPREP - sod phos mono-sod phos 4
di tabs 1.102-0.398 gm(1.5gm na
phos)
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)
peg 3350-kcl-sod bicarb-nacl for soln 1
420 gm (Nulytely/flavor pack)
polyethylene glycol 3350 oral packet 2
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
polyethylene glycol 3350 oral
powder
1
PREPOPIK - sod picosulfate-mg oxidecitric acid pack 10 mg-3.5 gm-12 gm
4
ANASPAZ - hyoscyamine sulfate tab
disp 0.125 mg
4
SENNA LEAVES - senna leaves
4
AXID - nizatidine cap 150 mg
4
SUCLEAR - na sulf-k sulf-mg sulf & peg
3350-nacl-na bicarb-kcl kit
4
AXID - nizatidine cap 300 mg
4
AXID - nizatidine oral soln 15 mg/ml
4
68
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
BELLADONNA & OPIUM - belladonna
alkaloids & opium suppos 16.2-30 mg
4
DONNATAL - belladonna alkaloidsphenobarbital elixir 16.2 mg/5ml
4
BELLADONNA ALKALOIDS & OP belladonna alkaloids & opium suppos
16.2-60 mg
4
DONNATAL EXTENTABS - belladonna
alkaloids-phenobarbital tab cr 48 mg
4
• •
belladonna alkaloids-phenobarbital
elixir 16.2 mg/5ml (Donnatal)
ESOMEPRAZOLE STRONTIUM esomeprazole strontium cap delayed
release 24.65 mg
4
2
belladonna alkaloids-phenobarbital
tab 16.2 mg (Donnatal)
1
4
• •
BENTYL - dicyclomine hcl cap 10 mg
4
ESOMEPRAZOLE STRONTIUM esomeprazole strontium cap delayed
release 49.3 mg
BENTYL - dicyclomine hcl tab 20 mg
4
2
BENTYL - dicyclomine hcl oral soln 10
mg/5ml
4
famotidine for susp 40 mg/5ml
(Pepcid)
famotidine tab 40 mg (Pepcid)
1
CANTIL - mepenzolate bromide tab 25
mg
4
CARAFATE - sucralfate tab 1 gm
4
FIRST-LANSOPRAZOLE - lansoprazole 4
susp 3 mg/ml (compound kit)
2
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg
4
GLYCATE - glycopyrrolate tab 1.5 mg
CARAFATE - sucralfate susp 1 gm/10ml 4
2
cimetidine hcl soln 300 mg/5ml
cimetidine tab 300 mg
1
cimetidine tab 400 mg
1
cimetidine tab 800 mg
1
clidinium & chlordiazepoxide cap
2.5-5 mg (Librax)
2
CUVPOSA - glycopyrrolate oral soln 1
mg/5ml
4
CYTOTEC - misoprostol tab 100 mcg
4
CYTOTEC - misoprostol tab 200 mcg
4
DEXILANT - dexlansoprazole cap
delayed release 30 mg
4
• •
DEXILANT - dexlansoprazole cap
delayed release 60 mg
4
• •
DICYCLOMINE HCL - dicyclomine hcl
oral soln 10 mg/5ml
4
dicyclomine hcl cap 10 mg (Bentyl)
1
dicyclomine hcl tab 20 mg (Bentyl)
1
DIGEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg
4
DONNATAL - belladonna alkaloidsphenobarbital tab 16.2 mg
4
glycopyrrolate tab 1 mg (Robinul)
2
glycopyrrolate tab 2 mg (Robinul
forte)
2
HELIDAC - metronidaz tab-tetracyc cap- 4
bis subsal chew tab therapy pack
1
hyoscyamine sulfate elixir
0.125 mg/5ml
2
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
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
2
hyoscyamine sulfate tab 0.125 mg
(Levsin)
2
lansoprazole cap delayed release
15 mg (Prevacid)
2
lansoprazole cap delayed release
30 mg (Prevacid)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
69
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
lansoprazole tab delayed release
orally disintegrating 15 mg
2
•
omeprazole cap delayed release
20 mg (Prilosec)
1
•
lansoprazole tab delayed release
orally disintegrating 30 mg
2
•
omeprazole cap delayed release
40 mg (Prilosec)
1
•
LEVBID - hyoscyamine sulfate tab sr
12hr 0.375 mg
4
omeprazole-sodium bicarbonate cap
20-1100 mg (Zegerid)
2
• •
LEVSIN - hyoscyamine sulfate tab 0.125 4
mg
LEVSIN/SL - hyoscyamine sulfate tab sl 4
0.125 mg
4
LIBRAX - clidinium & chlordiazepoxide
cap 2.5-5 mg
2
methscopolamine bromide tab
2.5 mg (Pamine)
2
methscopolamine bromide tab 5 mg
(Pamine forte)
1
misoprostol tab 100 mcg (Cytotec)
omeprazole-sodium bicarbonate cap
40-1100 mg (Zegerid)
2
• •
PAMINE - methscopolamine bromide
tab 2.5 mg
4
PAMINE FORTE - methscopolamine
bromide tab 5 mg
4
PAMINE FQ - methscopolamine tab 5
mg & misc intestinal flora reg cap
4
pantoprazole sodium ec tab 20 mg
(base equiv) (Protonix)
1
•
pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix)
1
•
• •
PEPCID - famotidine tab 40 mg
4
4
• •
PEPCID - famotidine for susp 40
mg/5ml
4
• •
• •
PREVACID - lansoprazole cap delayed
release 15 mg
4
• •
• •
PREVACID - lansoprazole cap delayed
release 30 mg
PREVACID SOLUTAB - lansoprazole
tab delayed release orally
disintegrating 15 mg
4
• •
PREVACID SOLUTAB - lansoprazole
tab delayed release orally
disintegrating 30 mg
4
• •
PREVPAC - amoxicillin cap-clarithro
tab-lansopraz cap dr therapy pack
4
PRILOSEC - omeprazole cap delayed
release 10 mg
4
• •
PRILOSEC - omeprazole cap delayed
release 20 mg
4
• •
PRILOSEC - omeprazole cap delayed
release 40 mg
4
• •
1
misoprostol tab 200 mcg (Cytotec)
NEXIUM - esomeprazole magnesium for 3
delayed release susp pack 2.5 mg
NEXIUM - esomeprazole magnesium for 3
delayed release susp packet 5 mg
NEXIUM - esomeprazole magnesium for 3
delayed release susp packet 10 mg
NEXIUM - esomeprazole magnesium for 3
delayed release susp packet 20 mg
NEXIUM - esomeprazole magnesium for 3
delayed release susp packet 40 mg
3
NEXIUM - esomeprazole magnesium
cap delayed release 20 mg
3
NEXIUM - esomeprazole magnesium
cap delayed release 40 mg
2
nizatidine cap 150 mg
nizatidine cap 300 mg (Axid)
2
nizatidine oral soln 15 mg/ml (Axid)
2
OMECLAMOX-PAK - amoxicillin capclarithro tab w/ omepraz cap dr
therapy pack
4
omeprazole cap delayed release
10 mg (Prilosec)
2
70
• •
• •
• •
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
PRILOSEC - omeprazole magnesium
for delayed release susp packet 2.5
mg
4
• •
ZEGERID - omeprazole-sodium
bicarbonate powd pack for susp
20-1680 mg
4
• •
PRILOSEC - omeprazole magnesium
for delayed release susp packet 10
mg
4
• •
ZEGERID - omeprazole-sodium
bicarbonate powd pack for susp
40-1680 mg
4
• •
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
4
PROTONIX - pantoprazole sodium ec
tab 20 mg (base equiv)
4
• •
PROTONIX - pantoprazole sodium ec
tab 40 mg (base equiv)
4
• •
PROTONIX - pantoprazole sodium for
delayed release susp packet 40 mg
4
• •
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
4
•
rabeprazole sodium ec tab 20 mg
(Aciphex)
2
ranitidine hcl cap 150 mg
ANTIEMETICS
ANTIVERT - meclizine hcl tab 50 mg
4
ANZEMET - dolasetron mesylate tab 50
mg
4
•
ANZEMET - dolasetron mesylate tab
100 mg
4
•
CESAMET - nabilone cap 1 mg
4
COCA COLA SYURP - phosphorated
carbohydrate w/ caffeine syrup
4
DICLEGIS - doxylamine-pyridoxine tab
delayed release 10-10 mg
4
dronabinol cap 10 mg (Marinol)
2
2
dronabinol cap 2.5 mg (Marinol)
2
ranitidine hcl cap 300 mg
2
dronabinol cap 5 mg (Marinol)
2
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
2
EMEND - aprepitant capsule 40 mg
3
EMEND - aprepitant capsule 80 mg
3
ranitidine hcl tab 300 mg (Zantac)
1
EMEND - aprepitant capsule 125 mg
3
ROBINUL - glycopyrrolate tab 1 mg
4
3
ROBINUL FORTE - glycopyrrolate tab 2
mg
4
EMEND - aprepitant capsule therapy
pack 80 & 125 mg
granisetron hcl tab 1 mg
2
sucralfate tab 1 gm (Carafate)
2
GRANISOL - granisetron hcl oral soln 2
mg/10ml (base equivalent)
4
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 24 mg
2
ondansetron hcl tab 4 mg (Zofran)
1
ondansetron hcl tab 8 mg
2
ondansetron hcl tab 8 mg (Zofran)
2
•
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
ZANTAC - ranitidine hcl effer tab 25 mg
4
ZANTAC - ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
4
ZEGERID - omeprazole-sodium
bicarbonate cap 20-1100 mg
4
• •
ZEGERID - omeprazole-sodium
bicarbonate cap 40-1100 mg
4
• •
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
71
ondansetron orally disintegrating tab
4 mg (Zofran odt)
1
•
PANCREAZE - pancrelipase (lip-protamyl) dr cap 16800-40000-70000 unit
4
ondansetron orally disintegrating tab
8 mg (Zofran odt)
1
•
PANCREAZE - pancrelipase (lip-protamyl) dr cap 21000-37000-61000 unit
4
SANCUSO - granisetron td patch 3.1
mg/24hr (contains 34.3 mg)
4
•
PANCRELIPASE - pancrelipase (lipprot-amyl) dr cap 5000-17000-27000
unit
4
PERTZYE - pancrelipase (lip-prot-amyl)
dr cap 8000-28750-30250 unit
4
PERTZYE - pancrelipase (lip-prot-amyl)
dr cap 16000-57500-60500 unit
4
SUCRAID - sacrosidase soln 8500 unit/
ml
5
ULTRESA - pancrelipase (lip-prot-amyl)
dr cap 13800-27600-27600 unit
4
ULTRESA - pancrelipase (lip-prot-amyl)
dr cap 20700-41400-41400 unit
4
ULTRESA - pancrelipase (lip-prot-amyl)
dr cap 23000-46000-46000 unit
4
VIOKACE - pancrelipase (lip-prot-amyl)
tab 10440-39150-39150 unit
4
VIOKACE - pancrelipase (lip-prot-amyl)
tab 20880-78300-78300 unit
4
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 3000-10000-16000 unit
3
TIGAN - trimethobenzamide hcl cap 300 4
mg
4
TRANSDERM-SCOP - scopolamine td
patch 72hr 1.5 mg
2
trimethobenzamide hcl cap 300 mg
(Tigan)
4
ZOFRAN - ondansetron hcl tab 4 mg
ZOFRAN - ondansetron hcl tab 8 mg
4
ZOFRAN - ondansetron hcl oral soln 4
mg/5ml
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
•
•
•
•
•
•
•
3
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 5000-17000-27000 unit
3
CREON - pancrelipase (lip-prot-amyl) dr
cap 3000-9500-15000 unit
3
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 10000-34000-55000 unit
3
CREON - pancrelipase (lip-prot-amyl) dr
cap 6000-19000-30000 unit
3
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 15000-51000-82000 unit
3
CREON - pancrelipase (lip-prot-amyl) dr
cap 12000-38000-60000 unit
3
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 20000-68000-109000 unit
3
CREON - pancrelipase (lip-prot-amyl) dr
cap 24000-76000-120000 unit
3
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 25000-85000-136000 unit
3
CREON - pancrelipase (lip-prot-amyl) dr
cap 36000-114000-180000 unit
PANCREAZE - pancrelipase (lip-protamyl) dr cap 4200-10000-17500 unit
4
PANCREAZE - pancrelipase (lip-protamyl) dr cap 10500-25000-43750 unit
4
72
GASTROINTESTINAL AGENTS- MISC.
mesalamine rectal enema 4 gm &
cleanser wipe kit (Rowasa)
2
ACTIGALL - ursodiol cap 300 mg
4
AMITIZA - lubiprostone cap 8 mcg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
4
4
FOSRENOL - lanthanum carbonate
chew tab 1000 mg
4
ASACOL - mesalamine tab delayed
release 400 mg
3
GASTROCROM - cromolyn sodium oral
conc 100 mg/5ml
5
ASACOL HD - mesalamine tab delayed
release 800 mg
3
GATTEX - teduglutide (rdna) for inj kit 5
mg
4
AZULFIDINE - sulfasalazine tab 500 mg
4
GIAZO - balsalazide disodium tab 1.1
gm
AZULFIDINE EN-TABS - sulfasalazine
tab delayed release 500 mg
4
lactulose (encephalopathy) solution
10 gm/15ml
1
balsalazide disodium cap 750 mg
(Colazal)
2
LIALDA - mesalamine tab delayed
release 1.2 gm
3
calcium acetate (phosphate binder)
cap 667 mg (169 mg ca) (Phoslo)
2
LINZESS - linaclotide cap 145 mcg
3
LINZESS - linaclotide cap 290 mcg
3
calcium acetate (phosphate binder)
tab 667 mg (Eliphos)
2
LOTRONEX - alosetron hcl tab 0.5 mg
(base equiv)
4
CANASA - mesalamine suppos 1000
mg
3
LOTRONEX - alosetron hcl tab 1 mg
(base equiv)
4
CHENODAL - chenodiol tab 250 mg
5
mesalamine enema 4 gm
2
CIMZIA - certolizumab pegol for inj kit 2
x 200 mg
5
•
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
1
CIMZIA - certolizumab pegol inj kit 2 x
200 mg/ml
5
•
metoclopramide hcl tab 10 mg
(Reglan)
1
CIMZIA STARTER KIT - certolizumab
pegol inj kit 6 x 200 mg/ml
5
•
metoclopramide hcl tab 5 mg
(Reglan)
1
COLAZAL - balsalazide disodium cap
750 mg
4
METOZOLV ODT - metoclopramide hcl
orally disintegrating tab 5 mg
4
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
2
METOZOLV ODT - metoclopramide hcl
orally disintegrating tab 10 mg
4
DELZICOL - mesalamine cap dr 400 mg 3
DIPENTUM - olsalazine sodium cap 250 4
mg
ELIPHOS - calcium acetate (phosphate 4
binder) tab 667 mg
4
ENTEREG - alvimopan cap 12 mg
PENTASA - mesalamine cap cr 250 mg
3
PENTASA - mesalamine cap cr 500 mg
3
PHOSLO - calcium acetate (phosphate
binder) cap 667 mg (169 mg ca)
4
PHOSLYRA - calcium acetate
(phosphate binder) oral soln 667
mg/5ml
4
FOSRENOL - lanthanum carbonate
chew tab 500 mg
4
FOSRENOL - lanthanum carbonate
chew tab 750 mg
4
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
APRISO - mesalamine cap sr 24hr
0.375 gm
Dispensing Limits
4
Step Therapy
AMITIZA - lubiprostone cap 24 mcg
Prior Authorization
Drug Name
Drug Tier
2014
•
REGLAN - metoclopramide hcl tab 5 mg 4
4
REGLAN - metoclopramide hcl tab 10
mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
73
RELISTOR - methylnaltrexone bromide
inj 8 mg/0.4ml (20 mg/ml)
4
FURADANTIN - nitrofurantoin susp 25
mg/5ml
4
RELISTOR - methylnaltrexone bromide
inj 12 mg/0.6ml (20 mg/ml)
4
HIPREX - methenamine hippurate tab 1
gm
4
RELISTOR - methylnaltrexone bromide
inj kit 12 mg/0.6ml
4
4
RENAGEL - sevelamer hcl tab 400 mg
4
MACROBID - nitrofurantoin
monohydrate macrocrystalline cap
100 mg
RENAGEL - sevelamer hcl tab 800 mg
4
4
RENVELA - sevelamer carbonate tab
800 mg
3
MACRODANTIN - nitrofurantoin
macrocrystalline cap 25 mg
4
RENVELA - sevelamer carbonate
packet 0.8 gm
3
MACRODANTIN - nitrofurantoin
macrocrystalline cap 50 mg
4
RENVELA - sevelamer carbonate
packet 2.4 gm
3
MACRODANTIN - nitrofurantoin
macrocrystalline cap 100 mg
2
ROWASA - mesalamine rectal enema 4
gm & cleanser wipe kit
4
methenamine hippurate tab 1 gm
(Hiprex)
4
SEVELAMER CARBONATE sevelamer carbonate tab 800 mg
4
METHENAMINE MANDELATE methenamine mandelate tab 0.5 gm
methenamine mandelate tab 1 gm
2
SFROWASA - mesalamine sulfite-free
(sf) enema 4 gm/60ml
4
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
2
sulfasalazine tab 500 mg (Azulfidine)
2
URSO FORTE - ursodiol tab 500 mg
4
URSO 250 - ursodiol tab 250 mg
4
ursodiol cap 300 mg (Actigall)
2
ursodiol tab 250 mg (Urso 250)
2
ursodiol tab 500 mg (Urso forte)
2
VELPHORO - sucroferric oxyhydroxide
chew tab 500 mg
4
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
methenamine-hyos-meth blue-sod
phos-phen sal tab 81.6 mg
2
methenamine-hyosamine-meth bluesod phos tab 81.6 mg (Urogesicblue)
2
methenamine-hyosc-meth blue-sod
phos-phen sal cap 120 mg
2
74
methenamine-hyosc-meth blue-benz 2
acid-phenyl sal tab 81.6mg (Prosed/
ds)
4
MONUROL - fosfomycin tromethamine
powd pack 3 gm (base equivalent)
2
nitrofurantoin macrocrystalline cap
100 mg (Macrodantin)
2
nitrofurantoin macrocrystalline cap
50 mg (Macrodantin)
2
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
2
nitrofurantoin susp 25 mg/5ml
(Furadantin)
4
PROSED/DS - methenamine-hyoscmeth blue-benz acid-phenyl sal tab
81.6mg
4
URELLE - methenamine-hyosc-meth
blue-sod phos-phen sal tab 81 mg
4
URETRON D/S - methenamine-hyoscmeth blue-sod phos-phen sal tab 120
mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
UREX - methenamine hippurate tab 1
gm
4
GELNIQUE - oxybutynin chloride td gel
10%
4
URIBEL - methenamine-hyosc-meth
blue-sod phos-phen sal cap 118 mg
4
MYRBETRIQ - mirabegron tab sr 24 hr
25 mg
4
URIMAR-T - methenamine-hyosc-meth
blue-sod phos-phen sal tab 120 mg
4
MYRBETRIQ - mirabegron tab sr 24 hr
50 mg
4
UROGESIC-BLUE - methenaminehyosamine-meth blue-sod phos tab
81.6 mg
4
oxybutynin chloride syrup 5 mg/5ml
1
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
2
UROQID #2 - methenamine mandelatesod phosphate monobasic tab
500-500 mg
4
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
2
oxybutynin chloride tab sr 24hr 5 mg
(Ditropan xl)
2
oxybutynin chloride tab 5 mg
1
URINARY ANTISPASMODICS
bethanechol chloride tab 10 mg
(Urecholine)
2
2
OXYTROL - oxybutynin td patch
biweekly 3.9 mg/24hr
4
bethanechol chloride tab 25 mg
(Urecholine)
2
phenazopyridine-butabarbitalhyoscyamine tab 150-15-0.3 mg
1
bethanechol chloride tab 5 mg
(Urecholine)
2
SANCTURA - trospium chloride tab 20
mg
4
bethanechol chloride tab 50 mg
(Urecholine)
4
SANCTURA XR - trospium chloride cap
sr 24hr 60 mg
4
DETROL - tolterodine tartrate tab 1 mg
DETROL - tolterodine tartrate tab 2 mg
4
DETROL LA - tolterodine tartrate cap sr
24hr 2 mg
tolterodine tartrate cap sr 24hr 2 mg
(Detrol la)
2
3
3
tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)
2
DETROL LA - tolterodine tartrate cap sr
24hr 4 mg
tolterodine tartrate tab 1 mg (Detrol)
2
DITROPAN XL - oxybutynin chloride tab
sr 24hr 5 mg
4
tolterodine tartrate tab 2 mg (Detrol)
2
4
TOVIAZ - fesoterodine fumarate tab sr
24hr 4 mg
4
DITROPAN XL - oxybutynin chloride tab
sr 24hr 10 mg
4
TOVIAZ - fesoterodine fumarate tab sr
24hr 8 mg
4
DITROPAN XL - oxybutynin chloride tab
sr 24hr 15 mg
4
trospium chloride cap sr 24hr 60 mg
2
ENABLEX - darifenacin hydrobromide
tab sr 24hr 7.5 mg (base equiv)
2
ENABLEX - darifenacin hydrobromide
tab sr 24hr 15 mg (base equiv)
4
trospium chloride tab 20 mg
(Sanctura)
4
flavoxate hcl tab 100 mg
2
URECHOLINE - bethanechol chloride
tab 5 mg
4
URECHOLINE - bethanechol chloride
tab 10 mg
4
GELNIQUE - oxybutynin td gel 3% (28
mg/act metered-dose pump)
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
•
75
URECHOLINE - bethanechol chloride
tab 25 mg
4
miconazole nitrate vaginal supp
200 mg & 2% cream 9 gm kit
1
URECHOLINE - bethanechol chloride
tab 50 mg
4
MICONAZOLE 3 - miconazole nitrate
vaginal suppos 200 mg
4
VESICARE - solifenacin succinate tab 5
mg
3
NYSTATIN VAGINAL - nystatin vaginal
tab 100000 unit
4
VESICARE - solifenacin succinate tab
10 mg
3
PREMARIN - estrogens, conjugated
vaginal cream 0.625 mg/gm
4
RELAGARD - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
4
VAGINAL PRODUCTS
AVC - sulfanilamide vaginal cream 15%
4
CLEOCIN - clindamycin phosphate
vaginal cream 2%
4
TERAZOL 3 - terconazole vaginal
cream 0.8%
4
CLEOCIN - clindamycin phosphate
vaginal suppos 100 mg
3
TERAZOL 3 - terconazole vaginal
suppos 80 mg
4
clindamycin phosphate vaginal
cream 2% (Cleocin)
2
TERAZOL 7 - terconazole vaginal
cream 0.4%
4
CLINDESSE - clindamycin phosphate
(one dose) vaginal cream 2%
4
terconazole vaginal cream 0.4%
(Terazol 7)
1
CRINONE - progesterone vaginal gel
4%
3
•
terconazole vaginal cream 0.8%
(Terazol 3)
1
CRINONE - progesterone vaginal gel
8%
3
•
terconazole vaginal suppos 80 mg
2
ENDOMETRIN - progesterone vaginal
insert 100 mg
4
GENITOURINARY AGENTS - MISC.
1
ESTRACE - estradiol vaginal cream 0.1
mg/gm
3
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
AVODART - dutasteride cap 0.5 mg
3
ESTRING - estradiol vaginal ring 2 mg
(7.5 mcg/24hrs)
4
CARDURA XL - doxazosin mesylate tab
sr 24 hr 4 mg (base equiv)
4
FEM PH - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
4
CARDURA XL - doxazosin mesylate tab
sr 24 hr 8 mg (base equiv)
4
FEMRING - estradiol acetate vaginal
ring 0.05 mg/24hr
4
CIALIS - tadalafil tab 2.5 mg
3
FEMRING - estradiol acetate vaginal
ring 0.1 mg/24hr
4
CIALIS - tadalafil tab 5 mg
3
4
GYNAZOLE-1 - butoconazole nitrate
(one dose) vaginal cream 2%
4
CITROLITH - potassium & sodium
citrates tab 50-950 mg
5
METROGEL-VAGINAL - metronidazole
vaginal gel 0.75%
4
CYSTAGON - cysteamine bitartrate cap
50 mg
5
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
2
CYSTAGON - cysteamine bitartrate cap
150 mg
76
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
VAGIFEM - estradiol vaginal tab 10 mcg 3
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
CYTRA-K - potassium citrate & citric
acid soln 1100-334 mg/5ml
4
CYTRA-3 - pot & sod citrates w/ cit ac
syrup 550-500-334 mg/5ml
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
4
4
SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln
500-334 mg/5ml
4
ELMIRON - pentosan polysulfate
sodium caps 100 mg
4
SODIUM CITRATE - sodium citrate
granules
1
finasteride tab 5 mg (Proscar)
1
FLOMAX - tamsulosin hcl cap 0.4 mg
4
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
4
tamsulosin hcl cap 0.4 mg (Flomax)
1
JALYN - dutasteride-tamsulosin hcl cap
0.5-0.4 mg
THIOLA - tiopronin tab 100 mg
4
K-PHOS NO 2 - potassium & sodium
acid phosphates tab 305-700 mg
4
TRICITRATES - pot & sod citrates w/ cit
ac soln 550-500-334 mg/5ml
4
LITHOSTAT - acetohydroxamic acid tab
250 mg
4
UROCIT-K 10 - potassium citrate tab cr
10 meq (1080 mg)
4
ORACIT - sodium citrate & citric acid
soln 490-640 mg/5ml
4
UROCIT-K 15 - potassium citrate tab cr
15 meq (1620 mg)
4
phenazopyridine hcl tab 100 mg
(Pyridium)
1
UROCIT-K 5 - potassium citrate tab cr 5
meq (540 mg)
4
phenazopyridine hcl tab 200 mg
(Pyridium)
1
UROXATRAL - alfuzosin hcl tab sr 24hr
10 mg
4
POTASSIUM CITRATE - potassium
citrate tab cr 5 meq (540 mg)
3
CENTRAL NERVOUS SYSTEM DRUGS
POTASSIUM CITRATE - potassium
citrate tab cr 10 meq (1080 mg)
3
ALPRAZOLAM INTENSOL - alprazolam
conc 1 mg/ml
4
potassium citrate & citric acid
powder pack 3300-1002 mg
2
alprazolam orally disintegrating tab
0.25 mg (Niravam)
2
POTASSIUM CITRATE ER - potassium
citrate tab cr 15 meq (1620 mg)
4
alprazolam orally disintegrating tab
0.5 mg
2
PROCYSBI - cysteamine bitartrate cap
delayed release 25 mg (base equiv)
5
alprazolam orally disintegrating tab
1 mg
2
PROCYSBI - cysteamine bitartrate cap
delayed release 75 mg (base equiv)
5
alprazolam orally disintegrating tab
2 mg
2
PROSCAR - finasteride tab 5 mg
4
2
PYRIDIUM - phenazopyridine hcl tab
100 mg
4
alprazolam tab sr 24hr 0.5 mg (Xanax
xr)
2
•
PYRIDIUM - phenazopyridine hcl tab
200 mg
4
alprazolam tab sr 24hr 1 mg (Xanax
xr)
2
•
RAPAFLO - silodosin cap 4 mg
4
alprazolam tab sr 24hr 2 mg (Xanax
xr)
RAPAFLO - silodosin cap 8 mg
4
alprazolam tab sr 24hr 3 mg (Xanax
xr)
2
•
ANTIANXIETY AGENTS
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
77
alprazolam tab 2 mg (Xanax)
1
ATIVAN - lorazepam tab 0.5 mg
4
ATIVAN - lorazepam tab 1 mg
4
ATIVAN - lorazepam tab 2 mg
4
buspirone hcl tab 10 mg
1
buspirone hcl tab 15 mg
1
buspirone hcl tab 30 mg
2
buspirone hcl tab 5 mg
1
buspirone hcl tab 7.5 mg
2
chlordiazepoxide hcl cap 10 mg
1
chlordiazepoxide hcl cap 25 mg
1
chlordiazepoxide hcl cap 5 mg
1
clorazepate dipotassium tab 15 mg
(Tranxene t)
2
clorazepate dipotassium tab 3.75 mg
(Tranxene t)
1
clorazepate dipotassium tab 7.5 mg
(Tranxene t)
LORAZEPAM INTENSOL - lorazepam
conc 2 mg/ml
4
lorazepam tab 0.5 mg (Ativan)
1
lorazepam tab 1 mg (Ativan)
1
lorazepam tab 2 mg (Ativan)
1
meprobamate tab 200 mg
2
meprobamate tab 400 mg
2
NIRAVAM - alprazolam orally
disintegrating tab 0.25 mg
4
NIRAVAM - alprazolam orally
disintegrating tab 0.5 mg
4
NIRAVAM - alprazolam orally
disintegrating tab 1 mg
4
NIRAVAM - alprazolam orally
disintegrating tab 2 mg
4
oxazepam cap 10 mg
2
oxazepam cap 15 mg
2
oxazepam cap 30 mg
2
1
TRANXENE T - clorazepate
dipotassium tab 3.75 mg
4
DIAZEPAM - diazepam soln 1 mg/ml
3
4
DIAZEPAM INTENSOL - diazepam
conc 5 mg/ml
4
TRANXENE T - clorazepate
dipotassium tab 7.5 mg
4
diazepam tab 10 mg (Valium)
1
TRANXENE T - clorazepate
dipotassium tab 15 mg
diazepam tab 2 mg (Valium)
1
VALIUM - diazepam tab 2 mg
4
diazepam tab 5 mg (Valium)
1
VALIUM - diazepam tab 5 mg
4
hydroxyzine hcl syrup 10 mg/5ml
1
VALIUM - diazepam tab 10 mg
4
hydroxyzine hcl tab 10 mg
1
4
hydroxyzine hcl tab 25 mg
1
VISTARIL - hydroxyzine pamoate cap
25 mg
1
VISTARIL - hydroxyzine pamoate cap
50 mg
4
hydroxyzine hcl tab 50 mg
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg
4
XANAX - alprazolam tab 0.25 mg
4
1
XANAX - alprazolam tab 0.5 mg
4
hydroxyzine pamoate cap 25 mg
(Vistaril)
XANAX - alprazolam tab 1 mg
4
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
XANAX - alprazolam tab 2 mg
4
78
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
1
2
Step Therapy
alprazolam tab 1 mg (Xanax)
lorazepam conc 2 mg/ml (Lorazepam
intensol)
Prior Authorization
1
Drug Name
Drug Tier
alprazolam tab 0.5 mg (Xanax)
Dispensing Limits
1
Step Therapy
alprazolam tab 0.25 mg (Xanax)
Prior Authorization
Drug Name
Drug Tier
2014
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
1
amitriptyline hcl tab 100 mg
1
amitriptyline hcl tab 150 mg
1
amitriptyline hcl tab 25 mg
1
amitriptyline hcl tab 50 mg
1
amitriptyline hcl tab 75 mg
1
AMOXAPINE - amoxapine tab 25 mg
4
AMOXAPINE - amoxapine tab 50 mg
4
AMOXAPINE - amoxapine tab 100 mg
4
AMOXAPINE - amoxapine tab 150 mg
4
ANAFRANIL - clomipramine hcl cap 25
mg
Dispensing Limits
Step Therapy
bupropion hcl tab 100 mg (Wellbutrin) 2
1
bupropion hcl tab 75 mg (Wellbutrin)
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
CELEXA - citalopram hydrobromide tab
10 mg (base equiv)
4
•
CELEXA - citalopram hydrobromide tab
20 mg (base equiv)
4
•
CELEXA - citalopram hydrobromide tab
40 mg (base equiv)
4
•
citalopram hydrobromide oral soln
10 mg/5ml
2
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
1
4
citalopram hydrobromide tab 20 mg
(base equiv) (Celexa)
1
ANAFRANIL - clomipramine hcl cap 50
mg
4
citalopram hydrobromide tab 40 mg
(base equiv) (Celexa)
1
ANAFRANIL - clomipramine hcl cap 75
mg
4
clomipramine hcl cap 25 mg
(Anafranil)
1
APLENZIN - bupropion hbr tab sr 24hr
174 mg
4
•
clomipramine hcl cap 50 mg
(Anafranil)
2
APLENZIN - bupropion hbr tab sr 24hr
348 mg
4
•
clomipramine hcl cap 75 mg
(Anafranil)
2
APLENZIN - bupropion hbr tab sr 24hr
522 mg
4
•
CYMBALTA - duloxetine hcl enteric
coated pellets cap 20 mg
4
• •
BRINTELLIX - vortioxetine hbr tab 5 mg
(base equiv)
4
•
CYMBALTA - duloxetine hcl enteric
coated pellets cap 30 mg
4
• •
BRINTELLIX - vortioxetine hbr tab 10
mg (base equiv)
4
•
CYMBALTA - duloxetine hcl enteric
coated pellets cap 60 mg
4
• •
BRINTELLIX - vortioxetine hbr tab 20
mg (base equiv)
4
•
desipramine hcl tab 10 mg
(Norpramin)
2
bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr)
2
desipramine hcl tab 100 mg
(Norpramin)
2
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
79
desipramine hcl tab 150 mg
(Norpramin)
2
EMSAM - selegiline td patch 24hr 9
mg/24hr
4
desipramine hcl tab 25 mg
(Norpramin)
2
EMSAM - selegiline td patch 24hr 12
mg/24hr
4
desipramine hcl tab 50 mg
(Norpramin)
2
escitalopram oxalate soln 5 mg/5ml
(base equiv) (Lexapro)
2
desipramine hcl tab 75 mg
(Norpramin)
2
escitalopram oxalate tab 10 mg
(base equiv) (Lexapro)
2
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
4
•
escitalopram oxalate tab 20 mg
(base equiv) (Lexapro)
2
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg
4
•
escitalopram oxalate tab 5 mg (base
equiv) (Lexapro)
2
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr
50 mg (base equiv)
4
•
FETZIMA - levomilnacipran hcl cap sr
24hr 20 mg (base equivalent)
4
•
4
•
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr
100 mg (base equiv)
4
FETZIMA - levomilnacipran hcl cap sr
24hr 40 mg (base equivalent)
FETZIMA - levomilnacipran hcl cap sr
24hr 80 mg (base equivalent)
4
•
DOXEPIN HCL - doxepin hcl cap 75 mg
4
•
doxepin hcl cap 10 mg
FETZIMA - levomilnacipran hcl cap sr
24hr 120 mg (base equivalent)
4
1
doxepin hcl cap 100 mg
1
4
•
doxepin hcl cap 150 mg
2
doxepin hcl cap 25 mg
1
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20 &
40 mg therapy pack
1
FLUOXETINE HCL - fluoxetine hcl tab
60 mg
4
doxepin hcl cap 50 mg
•
doxepin hcl conc 10 mg/ml
1
2
•
fluoxetine hcl cap delayed release
90 mg (Prozac weekly)
2
duloxetine hcl enteric coated pellets
cap 20 mg (Cymbalta)
1
duloxetine hcl enteric coated pellets
cap 30 mg (Cymbalta)
•
fluoxetine hcl cap 10 mg (Prozac)
2
fluoxetine hcl cap 20 mg (Prozac)
1
2
•
fluoxetine hcl cap 40 mg (Prozac)
1
duloxetine hcl enteric coated pellets
cap 60 mg (Cymbalta)
fluoxetine hcl solution 20 mg/5ml
1
EFFEXOR XR - venlafaxine hcl cap sr
24hr 37.5 mg (base equivalent)
4
fluoxetine hcl tab 10 mg
1
fluoxetine hcl tab 20 mg
2
EFFEXOR XR - venlafaxine hcl cap sr
24hr 75 mg (base equivalent)
4
•
fluvoxamine maleate cap sr 24hr
100 mg (Luvox cr)
2
EFFEXOR XR - venlafaxine hcl cap sr
24hr 150 mg (base equivalent)
4
•
fluvoxamine maleate cap sr 24hr
150 mg (Luvox cr)
2
EMSAM - selegiline td patch 24hr 6
mg/24hr
4
fluvoxamine maleate tab 100 mg
2
fluvoxamine maleate tab 25 mg
2
80
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
FORFIVO XL - bupropion hcl tab sr 24hr 4
450 mg
1
imipramine hcl tab 10 mg (Tofranil)
•
mirtazapine orally disintegrating tab
30 mg (Remeron soltab)
2
mirtazapine orally disintegrating tab
45 mg (Remeron soltab)
2
imipramine hcl tab 25 mg (Tofranil)
1
mirtazapine tab 15 mg (Remeron)
1
imipramine hcl tab 50 mg (Tofranil)
2
mirtazapine tab 30 mg (Remeron)
1
imipramine pamoate cap 100 mg
(Tofranil-pm)
2
mirtazapine tab 45 mg (Remeron)
1
mirtazapine tab 7.5 mg
1
imipramine pamoate cap 125 mg
(Tofranil-pm)
2
NARDIL - phenelzine sulfate tab 15 mg
4
imipramine pamoate cap 150 mg
(Tofranil-pm)
NEFAZODONE HCL - nefazodone hcl
tab 50 mg
4
2
imipramine pamoate cap 75 mg
(Tofranil-pm)
NEFAZODONE HCL - nefazodone hcl
tab 100 mg
4
2
4
•
NEFAZODONE HCL - nefazodone hcl
tab 150 mg
NEFAZODONE HCL - nefazodone hcl
tab 200 mg
4
•
nefazodone hcl tab 250 mg
2
NORPRAMIN - desipramine hcl tab 10
mg
4
NORPRAMIN - desipramine hcl tab 25
mg
4
NORPRAMIN - desipramine hcl tab 50
mg
4
NORPRAMIN - desipramine hcl tab 75
mg
4
NORPRAMIN - desipramine hcl tab 100
mg
4
NORPRAMIN - desipramine hcl tab 150
mg
4
KHEDEZLA - desvenlafaxine tab sr 24hr 4
50 mg
KHEDEZLA - desvenlafaxine tab sr 24hr 4
100 mg
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)
LEXAPRO - escitalopram oxalate soln 5 4
mg/5ml (base equiv)
4
LUVOX CR - fluvoxamine maleate cap
sr 24hr 100 mg
4
LUVOX CR - fluvoxamine maleate cap
sr 24hr 150 mg
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
mirtazapine orally disintegrating tab
15 mg (Remeron soltab)
2
•
•
•
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
2
Step Therapy
fluvoxamine maleate tab 50 mg
Prior Authorization
Drug Name
Drug Tier
2014
NORTRIPTYLINE HCL - nortriptyline hcl 4
soln 10 mg/5ml
nortriptyline hcl cap 10 mg (Pamelor) 1
nortriptyline hcl cap 25 mg (Pamelor)
1
nortriptyline hcl cap 50 mg (Pamelor)
1
nortriptyline hcl cap 75 mg (Pamelor)
1
nortriptyline hcl soln 10 mg/5ml
2
OLEPTRO - trazodone hcl tab sr 24hr
150 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
81
phenelzine sulfate tab 15 mg (Nardil)
2
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 50 mg (base equiv)
4
• •
4
• •
OLEPTRO - trazodone hcl tab sr 24hr
300 mg
4
PAMELOR - nortriptyline hcl cap 10 mg
4
PAMELOR - nortriptyline hcl cap 25 mg
4
PAMELOR - nortriptyline hcl cap 50 mg
4
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 100 mg (base equiv)
PAMELOR - nortriptyline hcl cap 75 mg
4
protriptyline hcl tab 10 mg (Vivactil)
2
PARNATE - tranylcypromine sulfate tab
10 mg
4
protriptyline hcl tab 5 mg (Vivactil)
2
PROZAC - fluoxetine hcl cap 10 mg
4
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
2
PROZAC - fluoxetine hcl cap 20 mg
4
PROZAC - fluoxetine hcl cap 40 mg
4
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
2
PROZAC WEEKLY - fluoxetine hcl cap
delayed release 90 mg
4
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
2
REMERON - mirtazapine tab 15 mg
4
1
REMERON - mirtazapine tab 30 mg
4
paroxetine hcl tab 10 mg (Paxil)
1
REMERON - mirtazapine tab 45 mg
4
paroxetine hcl tab 20 mg (Paxil)
1
REMERON SOLTAB - mirtazapine
orally disintegrating tab 15 mg
4
paroxetine hcl tab 30 mg (Paxil)
•
•
•
•
paroxetine hcl tab 40 mg (Paxil)
1
•
PAXIL - paroxetine hcl tab 10 mg
REMERON SOLTAB - mirtazapine
orally disintegrating tab 30 mg
4
4
PAXIL - paroxetine hcl tab 20 mg
4
4
•
PAXIL - paroxetine hcl tab 30 mg
4
REMERON SOLTAB - mirtazapine
orally disintegrating tab 45 mg
PAXIL - paroxetine hcl tab 40 mg
4
2
PAXIL - paroxetine hcl oral susp 10
mg/5ml (base equiv)
4
sertraline hcl oral conc 20 mg/ml
(Zoloft)
sertraline hcl tab 100 mg (Zoloft)
1
PAXIL CR - paroxetine hcl tab sr 24hr
12.5 mg
4
sertraline hcl tab 25 mg (Zoloft)
1
sertraline hcl tab 50 mg (Zoloft)
1
PAXIL CR - paroxetine hcl tab sr 24hr
25 mg
4
•
SURMONTIL - trimipramine maleate
cap 25 mg
4
PAXIL CR - paroxetine hcl tab sr 24hr
37.5 mg
4
•
SURMONTIL - trimipramine maleate
cap 50 mg
4
PEXEVA - paroxetine mesylate tab 10
mg (base equiv)
4
•
SURMONTIL - trimipramine maleate
cap 100 mg
4
PEXEVA - paroxetine mesylate tab 20
mg (base equiv)
4
•
TOFRANIL - imipramine hcl tab 10 mg
4
4
PEXEVA - paroxetine mesylate tab 30
mg (base equiv)
•
TOFRANIL - imipramine hcl tab 25 mg
4
TOFRANIL - imipramine hcl tab 50 mg
4
4
•
TOFRANIL-PM - imipramine pamoate
cap 75 mg
4
PEXEVA - paroxetine mesylate tab 40
mg (base equiv)
82
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
• •
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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 100 mg
1
trazodone hcl tab 150 mg
1
trazodone hcl tab 300 mg
2
trazodone hcl tab 50 mg
1
trimipramine maleate cap 100 mg
2
trimipramine maleate cap 25 mg
2
trimipramine maleate cap 50 mg
2
venlafaxine hcl cap sr 24hr 150 mg
(base equivalent) (Effexor xr)
1
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 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 150 mg
(base equivalent) (Venlafaxine hcl
er)
2
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 100 mg
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
VIIBRYD - vilazodone hcl tab 10 mg
4
VIIBRYD - vilazodone hcl tab 20 mg
4
VIIBRYD - vilazodone hcl tab 40 mg
4
VIIBRYD - vilazodone hcl tab starter kit
10 (7) & 20 (7) & 40 (16) mg
4
VIVACTIL - protriptyline hcl tab 5 mg
4
VIVACTIL - protriptyline hcl tab 10 mg
4
WELLBUTRIN - bupropion hcl tab 75
mg
4
•
WELLBUTRIN - bupropion hcl tab 100
mg
4
•
WELLBUTRIN SR - bupropion hcl tab sr
12hr 100 mg
4
•
WELLBUTRIN SR - bupropion hcl tab sr
12hr 150 mg
4
•
WELLBUTRIN SR - bupropion hcl tab sr
12hr 200 mg
4
•
WELLBUTRIN XL - bupropion hcl tab sr
24hr 150 mg
4
•
WELLBUTRIN XL - bupropion hcl tab sr
24hr 300 mg
4
•
ZOLOFT - sertraline hcl tab 25 mg
4
ZOLOFT - sertraline hcl tab 50 mg
4
ZOLOFT - sertraline hcl tab 100 mg
4
ZOLOFT - sertraline hcl oral conc 20
mg/ml
4
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
•
•
•
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg
4
ABILIFY - aripiprazole tab 5 mg
4
ABILIFY - aripiprazole tab 10 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
83
ABILIFY - aripiprazole tab 20 mg
4
ABILIFY - aripiprazole tab 30 mg
4
ABILIFY - aripiprazole oral solution 1
mg/ml
4
•
•
•
•
ABILIFY DISCMELT - aripiprazole orally
disintegrating tab 10 mg
4
•
ABILIFY DISCMELT - aripiprazole orally
disintegrating tab 15 mg
4
•
ADASUVE - loxapine aerosol powder
breath activated 10 mg
4
chlorpromazine hcl tab 10 mg
2
chlorpromazine hcl tab 100 mg
2
chlorpromazine hcl tab 200 mg
2
chlorpromazine hcl tab 25 mg
2
chlorpromazine hcl tab 50 mg
2
CLOZAPINE ODT - clozapine orally
disintegrating tab 12.5 mg
4
CLOZAPINE ODT - clozapine orally
disintegrating tab 25 mg
Dispensing Limits
4
Step Therapy
ABILIFY - aripiprazole tab 15 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
2014
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 titratration pak
4
•
•
•
•
•
•
•
•
FAZACLO - clozapine orally
disintegrating tab 12.5 mg
4
•
FAZACLO - clozapine orally
disintegrating tab 25 mg
4
•
FAZACLO - clozapine orally
disintegrating tab 100 mg
4
•
•
FAZACLO - clozapine orally
disintegrating tab 150 mg
4
•
4
•
FAZACLO - clozapine orally
disintegrating tab 200 mg
4
•
CLOZAPINE ODT - clozapine orally
disintegrating tab 100 mg
4
•
FLUPHENAZINE HCL - fluphenazine
hcl elixir 2.5 mg/5ml
3
clozapine tab 100 mg (Clozaril)
2
2
FLUPHENAZINE HCL - fluphenazine
hcl oral conc 5 mg/ml
3
clozapine tab 200 mg
2
fluphenazine hcl tab 1 mg
1
clozapine tab 25 mg (Clozaril)
2
fluphenazine hcl tab 10 mg
2
clozapine tab 50 mg
4
fluphenazine hcl tab 2.5 mg
1
CLOZARIL - clozapine tab 25 mg
4
fluphenazine hcl tab 5 mg
1
CLOZARIL - clozapine tab 100 mg
•
•
•
•
•
•
4
GEODON - ziprasidone hcl cap 20 mg
4
COMPAZINE - prochlorperazine
maleate tab 5 mg
GEODON - ziprasidone hcl cap 40 mg
4
COMPAZINE - prochlorperazine
maleate tab 10 mg
4
GEODON - ziprasidone hcl cap 60 mg
4
GEODON - ziprasidone hcl cap 80 mg
4
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100 mg
4
haloperidol lactate oral conc 2 mg/ml
1
haloperidol tab 0.5 mg
1
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 200 mg
4
haloperidol tab 1 mg
1
4
haloperidol tab 10 mg
2
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 300 mg
haloperidol tab 2 mg
1
84
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
•
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
LITHIUM CARBONATE - lithium
carbonate cap 150 mg
4
LITHIUM CARBONATE - lithium
carbonate cap 600 mg
4
lithium carbonate cap 150 mg
(Lithium carbonate)
1
lithium carbonate cap 300 mg
1
lithium carbonate cap 600 mg
(Lithium carbonate)
1
lithium carbonate tab cr 300 mg
(Lithobid)
2
lithium carbonate tab cr 450 mg
2
lithium carbonate tab 300 mg
1
LITHIUM CITRATE - lithium citrate oral
soln 8 meq/5ml
4
Dispensing Limits
4
Step Therapy
INVEGA - paliperidone tab sr 24hr 1.5
mg
Prior Authorization
1
Drug Name
Drug Tier
haloperidol tab 5 mg
Dispensing Limits
2
Step Therapy
haloperidol tab 20 mg
Prior Authorization
Drug Name
Drug Tier
2014
LOXITANE - loxapine succinate cap 25
mg
4
•
LOXITANE - loxapine succinate cap 50
mg
4
•
•
•
•
•
•
•
•
NAVANE - thiothixene cap 20 mg
4
olanzapine orally disintegrating tab
10 mg (Zyprexa zydis)
2
•
olanzapine orally disintegrating tab
15 mg (Zyprexa zydis)
2
•
olanzapine orally disintegrating tab
20 mg (Zyprexa zydis)
2
•
olanzapine orally disintegrating tab
5 mg (Zyprexa zydis)
2
•
olanzapine tab 10 mg (Zyprexa)
2
olanzapine tab 15 mg (Zyprexa)
2
olanzapine tab 2.5 mg (Zyprexa)
2
olanzapine tab 20 mg (Zyprexa)
2
olanzapine tab 5 mg (Zyprexa)
2
olanzapine tab 7.5 mg (Zyprexa)
2
•
•
•
•
•
•
perphenazine tab 16 mg
2
perphenazine tab 2 mg
2
perphenazine tab 4 mg
2
perphenazine tab 8 mg
2
prochlorperazine maleate tab 10 mg
(Compazine)
1
prochlorperazine maleate tab 5 mg
(Compazine)
1
LITHOBID - lithium carbonate tab cr 300 4
mg
2
loxapine succinate cap 10 mg
prochlorperazine suppos 25 mg
2
quetiapine fumarate tab 100 mg
(Seroquel)
2
•
loxapine succinate cap 25 mg
2
2
•
loxapine succinate cap 5 mg
(Loxitane)
2
quetiapine fumarate tab 200 mg
(Seroquel)
2
•
loxapine succinate cap 50 mg
2
quetiapine fumarate tab 25 mg
(Seroquel)
4
quetiapine fumarate tab 300 mg
(Seroquel)
2
LOXITANE - loxapine succinate cap 5
mg
•
4
quetiapine fumarate tab 400 mg
(Seroquel)
2
LOXITANE - loxapine succinate cap 10
mg
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
85
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
quetiapine fumarate tab 50 mg
(Seroquel)
2
•
SAPHRIS - asenapine maleate sl tab 5
mg (base equiv)
4
•
RISPERDAL - risperidone tab 0.25 mg
4
•
4
SAPHRIS - asenapine maleate sl tab 10
mg (base equiv)
4
RISPERDAL - risperidone tab 0.5 mg
RISPERDAL - risperidone tab 1 mg
4
•
4
SEROQUEL - quetiapine fumarate tab
25 mg
4
RISPERDAL - risperidone tab 2 mg
4
SEROQUEL - quetiapine fumarate tab
50 mg
4
RISPERDAL - risperidone tab 3 mg
•
RISPERDAL - risperidone tab 4 mg
4
•
RISPERDAL - risperidone soln 1 mg/ml
SEROQUEL - quetiapine fumarate tab
100 mg
4
4
RISPERDAL M-TAB - risperidone orally
disintegrating tab 0.5 mg
4
•
•
•
•
•
•
•
•
SEROQUEL - quetiapine fumarate tab
200 mg
4
•
RISPERDAL M-TAB - risperidone orally
disintegrating tab 1 mg
4
•
SEROQUEL - quetiapine fumarate tab
300 mg
4
•
RISPERDAL M-TAB - risperidone orally
disintegrating tab 2 mg
4
•
SEROQUEL - quetiapine fumarate tab
400 mg
4
•
RISPERDAL M-TAB - risperidone orally
disintegrating tab 3 mg
4
•
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 50 mg
3
•
RISPERDAL M-TAB - risperidone orally
disintegrating tab 4 mg
4
•
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 150 mg
3
•
risperidone orally disintegrating tab
0.25 mg
2
•
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 200 mg
3
•
risperidone orally disintegrating tab
0.5 mg (Risperdal m-tab)
2
•
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 300 mg
3
•
risperidone orally disintegrating tab
1 mg (Risperdal m-tab)
2
•
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 400 mg
3
•
risperidone orally disintegrating tab
2 mg (Risperdal m-tab)
2
•
thioridazine hcl tab 10 mg
1
2
risperidone orally disintegrating tab
3 mg (Risperdal m-tab)
•
thioridazine hcl tab 100 mg
2
thioridazine hcl tab 25 mg
1
2
•
thioridazine hcl tab 50 mg
1
risperidone orally disintegrating tab
4 mg (Risperdal m-tab)
thiothixene cap 1 mg
1
risperidone soln 1 mg/ml (Risperdal)
2
thiothixene cap 10 mg
2
risperidone tab 0.25 mg (Risperdal)
1
thiothixene cap 2 mg
1
risperidone tab 0.5 mg (Risperdal)
1
thiothixene cap 5 mg
1
risperidone tab 1 mg (Risperdal)
2
trifluoperazine hcl tab 1 mg
1
risperidone tab 2 mg (Risperdal)
1
trifluoperazine hcl tab 10 mg
2
risperidone tab 3 mg (Risperdal)
2
trifluoperazine hcl tab 2 mg
2
risperidone tab 4 mg (Risperdal)
2
•
•
•
•
•
•
•
trifluoperazine hcl tab 5 mg
2
86
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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
ZYPREXA ZYDIS - olanzapine orally
disintegrating tab 10 mg
4
ZYPREXA ZYDIS - olanzapine orally
disintegrating tab 15 mg
4
ZYPREXA ZYDIS - olanzapine orally
disintegrating tab 20 mg
4
Dispensing Limits
Step Therapy
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
VERSACLOZ - clozapine susp 50 mg/ml 4
2
ziprasidone hcl cap 20 mg (Geodon)
Prior Authorization
Drug Name
Drug Tier
2014
•
•
•
•
•
•
•
•
•
•
•
•
eszopiclone tab 1 mg (Lunesta)
2
eszopiclone tab 2 mg (Lunesta)
2
eszopiclone tab 3 mg (Lunesta)
2
flurazepam hcl cap 15 mg
1
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
•
INTERMEZZO - zolpidem tartrate sl tab
3.5 mg
4
•
LUNESTA - eszopiclone tab 1 mg
4
LUNESTA - eszopiclone tab 2 mg
4
•
LUNESTA - eszopiclone tab 3 mg
4
•
•
•
1
•
midazolam hcl syrup 2 mg/ml (base
equivalent)
1
•
PHENOBARBITAL - phenobarbital tab
15 mg
PHENOBARBITAL - phenobarbital tab
30 mg
1
PHENOBARBITAL - phenobarbital tab
60 mg
1
PHENOBARBITAL - phenobarbital tab
64.8 mg
4
PHENOBARBITAL - phenobarbital tab
97.2 mg
4
PHENOBARBITAL - phenobarbital tab
100 mg
1
phenobarbital elixir 20 mg/5ml
1
phenobarbital tab 100 mg
1
phenobarbital tab 15 mg
1
phenobarbital tab 16.2 mg
1
phenobarbital tab 30 mg
1
phenobarbital tab 32.4 mg
1
phenobarbital tab 60 mg
1
QUAZEPAM - quazepam tab 15 mg
4
RESTORIL - temazepam cap 7.5 mg
4
HYPNOTICS
AMBIEN - zolpidem tartrate tab 5 mg
4
AMBIEN - zolpidem tartrate tab 10 mg
4
AMBIEN CR - zolpidem tartrate tab cr
6.25 mg
4
•
•
•
AMBIEN CR - zolpidem tartrate tab cr
12.5 mg
4
•
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
4
BUTISOL SODIUM - butabarbital
sodium tab 50 mg
4
BUTISOL SODIUM - butabarbital
sodium elixir 30 mg/5ml
4
DORAL - quazepam tab 15 mg
4
EDLUAR - zolpidem tartrate sl tab 5 mg
4
EDLUAR - zolpidem tartrate sl tab 10
mg
4
estazolam tab 1 mg
1
estazolam tab 2 mg
1
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
87
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
SOMNOTE - chloral hydrate cap 500
mg
4
SONATA - zaleplon cap 5 mg
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
4
•
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 25
mg
4
•
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 30
mg
4
•
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
cap sr 24hr 5 mg (Adderall xr)
2
•
•
amphetamine-dextroamphetamine
tab 10 mg (Adderall)
2
•
•
amphetamine-dextroamphetamine
tab 12.5 mg (Adderall)
2
•
•
•
•
SONATA - zaleplon cap 10 mg
4
temazepam cap 15 mg (Restoril)
1
temazepam cap 22.5 mg (Restoril)
2
temazepam cap 30 mg (Restoril)
1
temazepam cap 7.5 mg (Restoril)
2
triazolam tab 0.125 mg
1
triazolam tab 0.25 mg (Halcion)
1
zaleplon cap 10 mg (Sonata)
2
zaleplon cap 5 mg (Sonata)
2
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
2
•
•
•
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
2
•
zolpidem tartrate tab 10 mg (Ambien)
1
zolpidem tartrate tab 5 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
88
Dispensing Limits
4
Step Therapy
RESTORIL - temazepam cap 30 mg
Prior Authorization
4
Drug Name
Drug Tier
RESTORIL - temazepam cap 22.5 mg
Dispensing Limits
4
Step Therapy
RESTORIL - temazepam cap 15 mg
Prior Authorization
Drug Name
Drug Tier
2014
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
amphetamine-dextroamphetamine
tab 15 mg (Adderall)
2
•
dexmethylphenidate hcl cap sr 24 hr
15 mg (Focalin xr)
2
•
amphetamine-dextroamphetamine
tab 20 mg (Adderall)
2
•
dexmethylphenidate hcl cap sr 24 hr
30 mg (Focalin xr)
2
•
amphetamine-dextroamphetamine
tab 30 mg (Adderall)
2
•
dexmethylphenidate hcl cap sr 24 hr
40 mg (Focalin xr)
2
•
amphetamine-dextroamphetamine
tab 5 mg (Adderall)
2
•
dexmethylphenidate hcl tab 10 mg
(Focalin)
2
•
amphetamine-dextroamphetamine
tab 7.5 mg (Adderall)
2
•
dexmethylphenidate hcl tab 2.5 mg
(Focalin)
2
•
CAFCIT - caffeine citrate oral soln 60
mg/3ml (10 mg/ml base equiv)
4
dexmethylphenidate hcl tab 5 mg
(Focalin)
2
•
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv) (Cafcit)
2
dextroamphetamine sulfate cap sr
24hr 10 mg (Dexedrine)
2
•
clonidine hcl tab sr 12hr 0.1 mg
2
•
4
dextroamphetamine sulfate cap sr
24hr 15 mg (Dexedrine)
2
CONCERTA - methylphenidate hcl tab
sa osm 18 mg
•
•
2
•
CONCERTA - methylphenidate hcl tab
sa osm 27 mg
4
•
dextroamphetamine sulfate cap sr
24hr 5 mg (Dexedrine)
2
•
CONCERTA - methylphenidate hcl tab
sa osm 36 mg
4
•
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
2
•
CONCERTA - methylphenidate hcl tab
sa osm 54 mg
4
•
dextroamphetamine sulfate tab
10 mg
dextroamphetamine sulfate tab 5 mg
2
DAYTRANA - methylphenidate td patch
10 mg/9hr
4
•
FOCALIN - dexmethylphenidate hcl tab
2.5 mg
4
•
•
DAYTRANA - methylphenidate td patch
15 mg/9hr
4
•
FOCALIN - dexmethylphenidate hcl tab
5 mg
4
•
DAYTRANA - methylphenidate td patch
20 mg/9hr
4
•
FOCALIN - dexmethylphenidate hcl tab
10 mg
4
•
DAYTRANA - methylphenidate td patch
30 mg/9hr
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 5 mg
4
•
DESOXYN - methamphetamine hcl tab
5 mg
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 10 mg
4
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 5 mg
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 15 mg
4
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 10 mg
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 20 mg
4
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 15 mg
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 25 mg
4
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
89
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 30 mg
4
•
METHYLIN - methylphenidate hcl soln
10 mg/5ml
4
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 35 mg
4
•
methylphenidate hcl cap cr 10 mg
(Metadate cd)
2
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 40 mg
4
•
methylphenidate hcl cap cr 20 mg
(Metadate cd)
2
•
INTUNIV - guanfacine hcl tab sr 24hr 1
mg (base equiv)
3
•
methylphenidate hcl cap cr 30 mg
(Metadate cd)
2
•
INTUNIV - guanfacine hcl tab sr 24hr 2
mg (base equiv)
3
•
methylphenidate hcl cap cr 40 mg
(Metadate cd)
2
•
INTUNIV - guanfacine hcl tab sr 24hr 3
mg (base equiv)
3
•
methylphenidate hcl cap cr 50 mg
(Metadate cd)
2
•
INTUNIV - guanfacine hcl tab sr 24hr 4
mg (base equiv)
3
•
methylphenidate hcl cap cr 60 mg
(Metadate cd)
2
•
KAPVAY - clonidine hcl tab sr 12hr 0.1
mg
4
•
methylphenidate hcl cap sr 24hr
20 mg (Ritalin la)
2
•
KAPVAY DOSE PACK - clonidine hcl
tab sr 12hr therapy pack 0.1 & 0.2 mg
4
•
methylphenidate hcl cap sr 24hr
30 mg (Ritalin la)
2
•
METADATE CD - methylphenidate hcl
cap cr 10 mg
4
•
methylphenidate hcl cap sr 24hr
40 mg (Ritalin la)
2
•
METADATE CD - methylphenidate hcl
cap cr 20 mg
4
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab cr 10 mg
4
•
METADATE CD - methylphenidate hcl
cap cr 30 mg
4
•
methylphenidate hcl soln 10 mg/5ml
(Methylin)
2
•
METADATE CD - methylphenidate hcl
cap cr 40 mg
4
•
methylphenidate hcl soln 5 mg/5ml
(Methylin)
2
•
METADATE CD - methylphenidate hcl
cap cr 50 mg
4
•
methylphenidate hcl tab cr 20 mg
(Ritalin sr)
2
•
METADATE CD - methylphenidate hcl
cap cr 60 mg
4
•
methylphenidate hcl tab sa osm
18 mg (Concerta)
2
•
methamphetamine hcl tab 5 mg
(Desoxyn)
2
•
methylphenidate hcl tab sa osm
27 mg (Concerta)
2
•
METHYLIN - methylphenidate hcl chew
tab 2.5 mg
4
•
methylphenidate hcl tab sa osm
36 mg (Concerta)
2
•
METHYLIN - methylphenidate hcl chew
tab 5 mg
4
•
methylphenidate hcl tab sa osm
54 mg (Concerta)
2
•
METHYLIN - methylphenidate hcl chew
tab 10 mg
4
•
methylphenidate hcl tab 10 mg
(Ritalin)
1
•
METHYLIN - methylphenidate hcl soln 5
mg/5ml
4
•
methylphenidate hcl tab 20 mg
(Ritalin)
1
•
90
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
STRATTERA - atomoxetine hcl cap 80
mg (base equiv)
4
•
STRATTERA - atomoxetine hcl cap 100
mg (base equiv)
4
•
VYVANSE - lisdexamfetamine
dimesylate cap 20 mg
3
•
•
VYVANSE - lisdexamfetamine
dimesylate cap 30 mg
3
•
VYVANSE - lisdexamfetamine
dimesylate cap 40 mg
3
•
•
VYVANSE - lisdexamfetamine
dimesylate cap 50 mg
3
•
VYVANSE - lisdexamfetamine
dimesylate cap 60 mg
3
•
VYVANSE - lisdexamfetamine
dimesylate cap 70 mg
3
•
ZENZEDI - dextroamphetamine sulfate
tab 2.5 mg
4
•
•
ZENZEDI - dextroamphetamine sulfate
tab 7.5 mg
4
•
4
•
ZENZEDI - dextroamphetamine sulfate
tab 15 mg
4
•
RITALIN LA - methylphenidate hcl cap
sr 24hr 20 mg
4
•
ZENZEDI - dextroamphetamine sulfate
tab 20 mg
4
•
RITALIN LA - methylphenidate hcl cap
sr 24hr 30 mg
4
•
ZENZEDI - dextroamphetamine sulfate
tab 30 mg
4
•
RITALIN LA - methylphenidate hcl cap
sr 24hr 40 mg
4
•
RITALIN SR - methylphenidate hcl tab
cr 20 mg
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
•
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 40
mg (base equiv)
4
•
ANTABUSE - disulfiram tab 500 mg
4
4
STRATTERA - atomoxetine hcl cap 60
mg (base equiv)
4
•
ARICEPT - donepezil hydrochloride tab
5 mg
methylphenidate hcl tab 5 mg
(Ritalin)
1
modafinil tab 100 mg (Provigil)
2
modafinil tab 200 mg (Provigil)
2
NUVIGIL - armodafinil tab 50 mg
4
NUVIGIL - armodafinil tab 150 mg
4
NUVIGIL - armodafinil tab 200 mg
4
NUVIGIL - armodafinil tab 250 mg
4
PROCENTRA - dextroamphetamine
sulfate oral solution 5 mg/5ml
4
PROVIGIL - modafinil tab 100 mg
4
PROVIGIL - modafinil tab 200 mg
4
QUILLIVANT XR - methylphenidate hcl
for er susp 25 mg/5ml (5 mg/ml)
4
RITALIN - methylphenidate hcl tab 5 mg
4
RITALIN - methylphenidate hcl tab 10
mg
4
•
•
RITALIN - methylphenidate hcl tab 20
mg
4
RITALIN LA - methylphenidate hcl cap
sr 24hr 10 mg
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
91
ARICEPT - donepezil hydrochloride tab
10 mg
4
ARICEPT - donepezil hydrochloride tab
23 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
4
4
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab
10-25 mg
4
ARICEPT ODT - donepezil
hydrochloride orally disintegrating tab
5 mg
4
COMMIT - nicotine polacrilex lozenge 2
mg
COMMIT - nicotine polacrilex lozenge 4
mg
4
ARICEPT ODT - donepezil
hydrochloride orally disintegrating tab
10 mg
4
COPAXONE - glatiramer acetate soln
prefilled syringe 40 mg/ml
5
•
•
AUBAGIO - teriflunomide tab 7 mg
COPAXONE - glatiramer acetate inj kit
20 mg/ml
5
5
AUBAGIO - teriflunomide tab 14 mg
5
disulfiram tab 250 mg (Antabuse)
2
AVONEX - interferon beta-1a for im inj
kit 30mcg (33mcg(6.6 mu)/vial)
5
disulfiram tab 500 mg (Antabuse)
2
AVONEX - interferon beta-1a im inj kit
30 mcg/0.5ml
• •
donepezil hydrochloride orally
disintegrating tab 10 mg (Aricept
odt)
2
5
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)
4
CAMPRAL - acamprosate calcium tab
delayed release 333 mg
3
CHANTIX - varenicline tartrate tab 0.5
mg (base equiv)
CHANTIX - varenicline tartrate tab 1 mg 3
(base equiv)
3
CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base
equiv)
3
CHANTIX STARTING MONTH PA varenicline tartrate tab 0.5 mg x 11 &
tab 1 mg x 42 pack
4
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab
5-12.5 mg
• •
92
• •
• •
• •
•
2
donepezil hydrochloride orally
disintegrating tab 5 mg (Aricept odt)
1
donepezil hydrochloride tab 10 mg
(Aricept)
2
donepezil hydrochloride tab 23 mg
(Aricept)
1
donepezil hydrochloride tab 5 mg
(Aricept)
4
ERGOLOID MESYLATES - ergoloid
mesylates tab 1 mg
3
EXELON - rivastigmine td patch 24hr
4.6 mg/24hr
3
EXELON - rivastigmine td patch 24hr
9.5 mg/24hr
3
EXELON - rivastigmine td patch 24hr
13.3 mg/24hr
4
EXELON - rivastigmine tartrate cap 1.5
mg
4
EXELON - rivastigmine tartrate cap 3
mg
4
EXELON - rivastigmine tartrate cap 4.5
mg
4
EXELON - rivastigmine tartrate cap 6
mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
EXELON - rivastigmine tartrate soln 2
mg/ml
3
EXTAVIA - interferon beta-1b for inj kit
0.3 mg
5
fluoxetine hcl (pmdd) cap 10 mg
2
fluoxetine hcl (pmdd) cap 20 mg
2
galantamine hydrobromide cap sr
24hr 16 mg (Razadyne er)
NAMENDA XR - memantine hcl cap sr
24hr 7 mg
4
NAMENDA XR - memantine hcl cap sr
24hr 14 mg
4
NAMENDA XR - memantine hcl cap sr
24hr 21 mg
4
2
NAMENDA XR - memantine hcl cap sr
24hr 28 mg
4
galantamine hydrobromide cap sr
24hr 24 mg (Razadyne er)
2
4
galantamine hydrobromide cap sr
24hr 8 mg (Razadyne er)
2
NAMENDA XR TITRATION PACK memantine hcl cap sr 24hr 7 mg & 14
mg & 21 mg & 28 mg pack
4
galantamine hydrobromide oral soln
4 mg/ml (Razadyne)
2
NICODERM CQ - nicotine td patch 24hr
7 mg/24hr
4
galantamine hydrobromide tab
12 mg (Razadyne)
2
NICODERM CQ - nicotine td patch 24hr
14 mg/24hr
4
galantamine hydrobromide tab 4 mg
(Razadyne)
2
NICODERM CQ - nicotine td patch 24hr
21 mg/24hr
4
galantamine hydrobromide tab 8 mg
(Razadyne)
2
NICORETTE - nicotine polacrilex gum 2
mg
4
GILENYA - fingolimod hcl cap 0.5 mg
(base equiv)
5
NICORETTE - nicotine polacrilex gum 4
mg
4
GRALISE - gabapentin (phn) tab 300
mg
4
NICORETTE - nicotine polacrilex
lozenge 2 mg
4
GRALISE - gabapentin (phn) tab 600
mg
4
NICORETTE - nicotine polacrilex
lozenge 4 mg
4
GRALISE STARTER - gabapentin (phn)
tab starter pack 300 mg (9) & 600 mg
(69)
4
NICORETTE MINI - nicotine polacrilex
lozenge 2 mg
NICORETTE MINI - nicotine polacrilex
lozenge 4 mg
4
HORIZANT - gabapentin enacarbil tab
sr 24hr 300 mg
4
•
NICORETTE STARTER KIT - nicotine
polacrilex gum 2 mg
4
HORIZANT - gabapentin enacarbil tab
sr 24hr 600 mg
4
•
NICORETTE STARTER KIT - nicotine
polacrilex gum 4 mg
4
NAMENDA - memantine hcl tab 5 mg
4
nicotine polacrilex gum 2 mg
2
NAMENDA - memantine hcl tab 10 mg
4
nicotine polacrilex gum 4 mg
2
NAMENDA - memantine hcl oral
solution 2 mg/ml
4
nicotine polacrilex lozenge 2 mg
2
nicotine polacrilex lozenge 4 mg
2
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak
4
nicotine td patch 24hr 14 mg/24hr
2
nicotine td patch 24hr 21 mg/24hr
2
• •
• •
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
93
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
12-25 mg (Symbyax)
2
olanzapine-fluoxetine hcl cap
12-50 mg (Symbyax)
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)
3
ORAP - pimozide tab 1 mg
ORAP - pimozide tab 2 mg
3
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-10
mg
4
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-25
mg
4
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-10
mg
4
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-25
mg
4
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-50
mg
4
RAZADYNE - galantamine
hydrobromide tab 4 mg
4
RAZADYNE - galantamine
hydrobromide tab 8 mg
4
94
Dispensing Limits
3
Step Therapy
NICOTROL INHALER - nicotine inhaler
system 10 mg (4 mg delivered)
Prior Authorization
4
Drug Name
Drug Tier
NICOTINE TRANSDERMAL SYST nicotine td patch 24 hr kit 21-14-7
mg/24hr
Dispensing Limits
2
Step Therapy
nicotine td patch 24hr 7 mg/24hr
Prior Authorization
Drug Name
Drug Tier
2014
RAZADYNE - galantamine
hydrobromide tab 12 mg
4
RAZADYNE - galantamine
hydrobromide oral soln 4 mg/ml
4
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
4
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 16 mg
4
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 24 mg
4
REBIF - interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/ml)
5
•
REBIF - interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/ml)
5
•
REBIF REBIDOSE - interferon beta-1a
inj 22 mcg/0.5ml (12mu/ml) (44 mcg/
ml)
5
•
REBIF REBIDOSE - interferon beta-1a
inj 44 mcg/0.5ml (24mu/ml) (88 mcg/
ml)
5
•
REBIF REBIDOSE TITRATION interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
5
•
REBIF TITRATION PACK - interferon
beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22
mcg/0.5ml
5
•
rivastigmine tartrate cap 1.5 mg
(Exelon)
2
rivastigmine tartrate cap 3 mg
(Exelon)
2
rivastigmine tartrate cap 4.5 mg
(Exelon)
2
rivastigmine tartrate cap 6 mg
(Exelon)
2
SARAFEM - fluoxetine hcl (pmdd) tab
10 mg
4
SARAFEM - fluoxetine hcl (pmdd) tab
20 mg
4
SAVELLA - milnacipran hcl tab 12.5 mg
4
SAVELLA - milnacipran hcl tab 25 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
4
ASPIRIN LOW DOSE - aspirin tab 81
mg
4
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25
mg (8) & 50 mg (42) pak
4
aspirin tab delayed release 81 mg
1
4
4
BIOREGESIC - phenyltoloxamineacetaminophen tab 50-650 mg
SYMBYAX - olanzapine-fluoxetine hcl
cap 3-25 mg
4
BUPAP - butalbital-acetaminophen tab
50-300 mg
4
SYMBYAX - olanzapine-fluoxetine hcl
cap 6-25 mg
SYMBYAX - olanzapine-fluoxetine hcl
cap 6-50 mg
BUPAP - butalbital-acetaminophen tab
50-650 mg
4
4
SYMBYAX - olanzapine-fluoxetine hcl
cap 12-25 mg
butalbital-acetaminophen tab
50-325 mg
1
4
SYMBYAX - olanzapine-fluoxetine hcl
cap 12-50 mg
butalbital-acetaminophen tab
50-650 mg
2
4
5
•
butalbital-acetaminophen-caffeine
cap 50-300-40 mg (Fioricet)
2
TECFIDERA - dimethyl fumarate
capsule delayed release 120 mg
5
•
butalbital-acetaminophen-caffeine
cap 50-325-40 mg
1
TECFIDERA - dimethyl fumarate
capsule delayed release 240 mg
TECFIDERA STARTER PACK dimethyl fumarate capsule dr starter
pack 120 mg & 240 mg
•
butalbital-acetaminophen-caffeine
cap 50-500-40 mg
2
5
butalbital-acetaminophen-caffeine
tab 50-325-40 mg
1
XENAZINE - tetrabenazine tab 12.5 mg
5
XENAZINE - tetrabenazine tab 25 mg
butalbital-acetaminophen-caffeine
tab 50-500-40 mg
1
5
XYREM - sodium oxybate oral solution
500 mg/ml
5
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
2
ZYBAN - bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
4
butalbital-aspirin-caffeine tab
50-325-40 mg
1
BUTALBITAL/ASPIRIN/CAFFEI butalbital-aspirin-caffeine tab
50-325-40 mg
1
choline & magnesium salicylates liq
500 mg/5ml
2
ANALGESICS AND ANESTHETICS
ANALGESICS - NON-NARCOTIC
•
•
•
•
•
•
acetaminophen-salicylamidephenyltoloxamine cap
300-200-20mg
1
ADULT ASPIRIN LOW STRENGT aspirin dispersible tab 81 mg
4
choline & magnesium salicylates tab
1000 mg
2
ALAGESIC LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
4
diflunisal tab 500 mg
2
4
ALPAIN - phenyltoloxamineacetaminophen tab 60-500 mg
4
DOLGIC PLUS - butalbitalacetaminophen-caffeine tab
50-750-40 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
1
Step Therapy
aspirin chew tab 81 mg
•
•
•
Prior Authorization
Drug Name
Drug Tier
SAVELLA - milnacipran hcl tab 100 mg
Dispensing Limits
4
Step Therapy
SAVELLA - milnacipran hcl tab 50 mg
Prior Authorization
Drug Name
Drug Tier
2014
95
4
EQUAGESIC - meprobamate-aspirin tab 4
200-325 mg
4
ESGIC - butalbital-acetaminophencaffeine cap 50-325-40 mg
4
ESGIC - butalbital-acetaminophencaffeine tab 50-325-40 mg
4
ESGIC-PLUS - butalbitalacetaminophen-caffeine cap
50-500-40 mg
4
ESGIC-PLUS - butalbitalacetaminophen-caffeine tab
50-500-40 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
MST 600 - magnesium salicylate tab
600 mg
4
ORBIVAN - butalbital-acetaminophencaffeine cap 50-300-40 mg
4
ORBIVAN CF - butalbitalacetaminophen tab 50-300 mg
1
phenyltoloxamine-acetaminophen
tab 30-500 mg
1
phenyltoloxamine-acetaminophen
tab 50-500 mg
2
phenyltoloxamine-acetaminophen
tab 55-500 mg
4
PHRENILIN FORTE - butalbitalacetaminophen cap 50-650 mg
4
RELAGESIC - phenyltoloxamineacetaminophen tab 50-650 mg
4
RHINOFLEX-650 - phenyltoloxamineacetaminophen tab 50-650 mg
96
salsalate tab 750 mg
2
STAFLEX - phenyltoloxamineacetaminophen tab 55-500 mg
4
Dispensing Limits
2
Step Therapy
salsalate tab 500 mg
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
DOLOGESIC - phenyltoloxamineacetaminophen liquid 30-500
mg/15ml
Prior Authorization
Drug Name
Drug Tier
2014
TENCON - butalbital-acetaminophen tab 4
50-650 mg
4
ZGESIC - phenyltoloxamineacetaminophen tab cr 66-600 mg
ANALGESICS - NARCOTIC
ABSTRAL - fentanyl citrate sl tab 100
mcg (base equiv)
4
•
•
ABSTRAL - fentanyl citrate sl tab 200
mcg (base equiv)
4
•
•
ABSTRAL - fentanyl citrate sl tab 300
mcg (base equiv)
4
•
•
ABSTRAL - fentanyl citrate sl tab 400
mcg (base equiv)
4
•
•
ABSTRAL - fentanyl citrate sl tab 600
mcg (base equiv)
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)
2
ACETAMINOPHEN/CAFFEINE/
DI - acetaminophen-caffeinedihydrocodeine tab 712.8-60-32 mg
4
•
•
•
•
•
•
•
•
•
•
ACTIQ - fentanyl citrate lollipop 200 mcg 4
ACTIQ - fentanyl citrate lollipop 400 mcg 4
ACTIQ - fentanyl citrate lollipop 600 mcg 4
ACTIQ - fentanyl citrate lollipop 800 mcg 4
ACTIQ - fentanyl citrate lollipop 1200
mcg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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
AVINZA - morphine sulfate beads cap sr 4
24hr 120 mg
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 2
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 10 mcg/hr
4
BUTRANS - buprenorphine td patch
weekly 15 mcg/hr
Dispensing Limits
4
Step Therapy
ASPIRIN-CAFFEINE-DIHYDROC dihydrocodeine compound cap
•
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
ACTIQ - fentanyl citrate lollipop 1600
mcg
Drug Name
Step Therapy
Drug Tier
2014
•
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
3
•
CODEINE SULFATE - codeine sulfate
tab 30 mg
4
•
CODEINE SULFATE - codeine sulfate
tab 60 mg
4
•
CODEINE SULFATE - codeine sulfate
oral soln 30 mg/5ml
4
•
CONZIP - tramadol hcl cap sr 24hr
biphasic release 100 mg
4
•
•
CONZIP - tramadol hcl cap sr 24hr
biphasic release 200 mg
4
•
•
•
CONZIP - tramadol hcl cap sr 24hr
biphasic release 300 mg
4
•
•
•
DEMEROL - meperidine hcl tab 50 mg
4
•
DEMEROL - meperidine hcl tab 100 mg
4
•
4
•
•
DILAUDID - hydromorphone hcl tab 2
mg
DILAUDID - hydromorphone hcl tab 4
mg
4
DILAUDID - hydromorphone hcl tab 8
mg
4
DILAUDID - hydromorphone hcl liqd 1
mg/ml
4
DOLOPHINE - methadone hcl tab 10
mg
4
DOLOPHINE HCL - methadone hcl tab
5 mg
4
•
•
•
•
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
•
97
•
EXALGO - hydromorphone hcl tab er
24hr deter 8 mg
4
•
4
EXALGO - hydromorphone hcl tab er
24hr deter 12 mg
4
•
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-300-40-30 mg
4
EXALGO - hydromorphone hcl tab er
24hr deter 16 mg
4
•
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-325-40-30 mg
EXALGO - hydromorphone hcl tab er
24hr deter 32 mg
4
•
4
fentanyl citrate lollipop 1200 mcg
(Actiq)
2
FIORINAL/CODEINE #3 - butalbitalaspirin-caff w/ codeine cap
50-325-40-30 mg
4
fentanyl citrate lollipop 1600 mcg
(Actiq)
2
HYCET - hydrocodone-acetaminophen
soln 7.5-325 mg/15ml
2
fentanyl citrate lollipop 200 mcg
(Actiq)
•
•
•
•
2
•
•
HYDROCODONE BITARTRATE/AC hydrocodone-acetaminophen tab
10-750 mg
2
•
•
hydrocodone-acetaminophen cap
5-500 mg
1
fentanyl citrate lollipop 400 mcg
(Actiq)
2
•
•
hydrocodone-acetaminophen soln
10-325 mg/15ml
2
fentanyl citrate lollipop 600 mcg
(Actiq)
2
•
•
hydrocodone-acetaminophen soln
7.5-325 mg/15ml (Hycet)
2
fentanyl citrate lollipop 800 mcg
(Actiq)
2
•
hydrocodone-acetaminophen soln
7.5-500 mg/15ml
1
fentanyl td patch 72hr 100 mcg/hr
(Duragesic)
2
•
hydrocodone-acetaminophen tab
10-300 mg (Xodol)
2
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
2
•
hydrocodone-acetaminophen tab
10-325 mg (Norco)
2
fentanyl td patch 72hr 25 mcg/hr
(Duragesic)
2
•
hydrocodone-acetaminophen tab
10-500 mg
1
fentanyl td patch 72hr 50 mcg/hr
(Duragesic)
2
•
hydrocodone-acetaminophen tab
10-650 mg
1
fentanyl td patch 72hr 75 mcg/hr
(Duragesic)
4
•
•
hydrocodone-acetaminophen tab
10-660 mg
2
FENTORA - fentanyl citrate buccal tab
100 mcg (base equiv)
4
•
•
hydrocodone-acetaminophen tab
10-750 mg
2
FENTORA - fentanyl citrate buccal tab
200 mcg (base equiv)
4
•
•
hydrocodone-acetaminophen tab
2.5-325 mg
2
FENTORA - fentanyl citrate buccal tab
400 mcg (base equiv)
4
•
•
hydrocodone-acetaminophen tab
2.5-500 mg
1
FENTORA - fentanyl citrate buccal tab
600 mcg (base equiv)
98
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Prior Authorization
4
Drug Name
Step Therapy
Drug Tier
FENTORA - fentanyl citrate buccal tab
800 mcg (base equiv)
Dispensing Limits
•
Step Therapy
4
Drug Tier
DURAGESIC - fentanyl td patch 72hr
100 mcg/hr
Drug Name
Prior Authorization
2014
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
hydrocodone-acetaminophen tab
5-300 mg (Xodol)
2
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
2
hydrocodone-acetaminophen tab
5-325 mg (Norco)
1
hydromorphone hcl tab er 24hr deter
12 mg (Exalgo)
2
•
hydrocodone-acetaminophen tab
5-500 mg
1
hydromorphone hcl tab er 24hr deter
16 mg (Exalgo)
2
•
hydrocodone-acetaminophen tab
7.5-300 mg (Xodol)
2
hydromorphone hcl tab er 24hr deter
8 mg (Exalgo)
2
•
hydrocodone-acetaminophen tab
7.5-325 mg (Norco)
1
hydromorphone hcl tab 2 mg
(Dilaudid)
1
hydrocodone-acetaminophen tab
7.5-500 mg
1
hydromorphone hcl tab 4 mg
(Dilaudid)
2
hydrocodone-acetaminophen tab
7.5-650 mg
1
hydromorphone hcl tab 8 mg
(Dilaudid)
2
hydrocodone-acetaminophen tab
7.5-750 mg
1
IBUDONE - hydrocodone-ibuprofen tab
10-200 mg
4
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
2
KADIAN - morphine sulfate cap sr 24hr
10 mg
3
•
hydrocodone-ibuprofen tab
2.5-200 mg (Reprexain)
2
KADIAN - morphine sulfate cap sr 24hr
20 mg
3
•
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)
2
KADIAN - morphine sulfate cap sr 24hr
30 mg
3
•
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
1
KADIAN - morphine sulfate cap sr 24hr
40 mg
3
•
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen tab
7.5-500 mg
1
KADIAN - morphine sulfate cap sr 24hr
50 mg
3
•
•
1
KADIAN - morphine sulfate cap sr 24hr
60 mg
3
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen tab
7.5-650 mg
KADIAN - morphine sulfate cap sr 24hr
70 mg
3
•
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen tab
7.5-750 mg
1
KADIAN - morphine sulfate cap sr 24hr
80 mg
3
•
2
KADIAN - morphine sulfate cap sr 24hr
100 mg
3
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen soln
10-325 mg/15ml
•
3
•
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
4
KADIAN - morphine sulfate cap sr 24hr
130 mg
3
•
HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr deter
32 mg
4
KADIAN - morphine sulfate cap sr 24hr
150 mg
KADIAN - morphine sulfate cap sr 24hr
200 mg
3
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
99
4
LAZANDA - fentanyl citrate nasal spray
400 mcg/act (base equiv)
4
•
•
methadone hcl conc 10 mg/ml
(Methadose)
2
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
4
methadone hcl soln 10 mg/5ml
(Methadone hcl)
2
LIQUICET - hydrocodoneacetaminophen soln 10-500 mg/15ml
4
methadone hcl soln 5 mg/5ml
(Methadone hcl)
2
LORCET PLUS - hydrocodoneacetaminophen tab 7.5-650 mg
4
methadone hcl tab for oral susp
40 mg
2
LORCET 10/650 - hydrocodoneacetaminophen tab 10-650 mg
4
methadone hcl tab 10 mg (Dolophine)
1
methadone hcl tab 5 mg (Dolophine
hcl)
1
METHADOSE - methadone hcl conc 10
mg/ml
2
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
2
MORPHINE SULFATE - morphine
sulfate tab 15 mg
3
MORPHINE SULFATE - morphine
sulfate tab 30 mg
3
MORPHINE SULFATE - morphine
sulfate suppos 5 mg
3
MORPHINE SULFATE - morphine
sulfate suppos 10 mg
3
MORPHINE SULFATE - morphine
sulfate suppos 20 mg
3
MORPHINE SULFATE - morphine
sulfate suppos 30 mg
3
morphine sulfate (concentrate) oral
soln 20 mg/ml
2
morphine sulfate beads cap sr 24hr
120 mg (Avinza)
2
•
morphine sulfate beads cap sr 24hr
30 mg (Avinza)
2
•
morphine sulfate beads cap sr 24hr
45 mg (Avinza)
2
•
morphine sulfate beads cap sr 24hr
60 mg (Avinza)
2
•
meperidine hcl tab 50 mg (Demerol)
1
MEPERIDINE HCL/PROMETHAZI meperidine w/ promethazine cap
50-25 mg
4
METHADONE HCL - methadone hcl
soln 5 mg/5ml
4
100
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
METHADONE HCL - methadone hcl
soln 10 mg/5ml
Step Therapy
•
LORTAB - hydrocodone-acetaminophen 4
tab 5-500 mg
LORTAB - hydrocodone-acetaminophen 4
tab 7.5-500 mg
LORTAB - hydrocodone-acetaminophen 4
tab 10-500 mg
LORTAB - hydrocodone-acetaminophen 4
soln 7.5-500 mg/15ml
LORTAB - hydrocodone-acetaminophen 4
soln 10-300 mg/15ml
4
MAGNACET - oxycodone w/
acetaminophen tab 5-400 mg
4
MAGNACET - oxycodone w/
acetaminophen tab 7.5-400 mg
4
MAGNACET - oxycodone w/
acetaminophen tab 10-400 mg
4
MAXIDONE - hydrocodoneacetaminophen tab 10-750 mg
MEPERIDINE HCL - meperidine hcl oral 4
soln 50 mg/5ml
meperidine hcl tab 100 mg (Demerol) 2
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
LAZANDA - fentanyl citrate nasal spray
100 mcg/act (base equiv)
Drug Name
Step Therapy
Drug Tier
2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
morphine sulfate beads cap sr 24hr
75 mg (Avinza)
2
•
NORCO - hydrocodone-acetaminophen
tab 10-325 mg
4
morphine sulfate beads cap sr 24hr
90 mg (Avinza)
2
•
NORCO - hydrocodone-acetaminophen
tab 5-325 mg
4
morphine sulfate cap sr 24hr 10 mg
(Kadian)
2
•
NORCO - hydrocodone-acetaminophen
tab 7.5-325 mg
4
morphine sulfate cap sr 24hr 100 mg
(Kadian)
2
•
NUCYNTA - tapentadol hcl tab 50 mg
4
4
2
•
NUCYNTA - tapentadol hcl tab 75 mg
morphine sulfate cap sr 24hr 20 mg
(Kadian)
NUCYNTA - tapentadol hcl tab 100 mg
4
2
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 50 mg
3
morphine sulfate cap sr 24hr 30 mg
(Kadian)
•
•
•
•
2
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 100 mg
3
morphine sulfate cap sr 24hr 50 mg
(Kadian)
•
2
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 150 mg
3
morphine sulfate cap sr 24hr 60 mg
(Kadian)
•
2
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 200 mg
3
morphine sulfate cap sr 24hr 80 mg
(Kadian)
•
1
NUCYNTA ER - tapentadol hcl tab sr
12hr 250 mg
3
morphine sulfate oral soln 10 mg/5ml
•
morphine sulfate oral soln 20 mg/5ml
2
•
•
morphine sulfate tab cr 100 mg (Ms
contin)
•
ONSOLIS - fentanyl citrate buccal
soluble film 200 mcg
4
2
•
•
•
morphine sulfate tab cr 15 mg (Ms
contin)
ONSOLIS - fentanyl citrate buccal
soluble film 400 mcg
4
2
4
•
2
•
•
morphine sulfate tab cr 200 mg (Ms
contin)
ONSOLIS - fentanyl citrate buccal
soluble film 600 mcg
•
•
•
2
ONSOLIS - fentanyl citrate buccal
soluble film 800 mcg
4
morphine sulfate tab cr 30 mg (Ms
contin)
•
•
morphine sulfate tab cr 60 mg (Ms
contin)
•
ONSOLIS - fentanyl citrate buccal
soluble film 1200 mcg
4
2
4
MS CONTIN - morphine sulfate tab cr
15 mg
•
OPANA - oxymorphone hcl tab 5 mg
4
OPANA - oxymorphone hcl tab 10 mg
4
4
•
OPANA ER - oxymorphone hcl tab sr
12hr 5 mg
4
MS CONTIN - morphine sulfate tab cr
30 mg
•
4
•
OPANA ER - oxymorphone hcl tab sr
12hr 10 mg
4
MS CONTIN - morphine sulfate tab cr
60 mg
•
4
•
OPANA ER - oxymorphone hcl tab sr
12hr 20 mg
4
MS CONTIN - morphine sulfate tab cr
100 mg
•
4
•
OPANA ER - oxymorphone hcl tab sr
12hr 30 mg
4
MS CONTIN - morphine sulfate tab cr
200 mg
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
101
OPANA ER - oxymorphone hcl tab sr
12hr 40 mg
4
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
2
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 5
mg
4
•
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
2
2
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter
7.5 mg
•
oxycodone hcl tab 10 mg
4
oxycodone hcl tab 15 mg
(Roxicodone)
2
4
•
oxycodone hcl tab 20 mg
2
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 10
mg
oxycodone hcl tab 30 mg
(Roxicodone)
2
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 15
mg
4
•
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 20
mg
4
•
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
•
ORAMORPH SR - morphine sulfate tab
cr 15 mg
4
•
ORAMORPH SR - morphine sulfate tab
cr 30 mg
4
•
ORAMORPH SR - morphine sulfate tab
cr 60 mg
4
•
ORAMORPH SR - morphine sulfate tab
cr 100 mg
4
•
oxycodone hcl tab 5 mg (Roxicodone) 1
1
oxycodone w/ acetaminophen cap
5-500 mg
2
oxycodone w/ acetaminophen tab
10-325 mg (Percocet)
2
oxycodone w/ acetaminophen tab
10-650 mg
2
oxycodone w/ acetaminophen tab
2.5-325 mg (Percocet)
1
oxycodone w/ acetaminophen tab
5-325 mg (Percocet)
2
oxycodone w/ acetaminophen tab
7.5-325 mg (Percocet)
2
oxycodone w/ acetaminophen tab
7.5-500 mg
2
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
2
oxycodone-ibuprofen tab 5-400 mg
OXECTA - oxycodone hcl tab abuse
deter 5 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
3
•
4
OXYCONTIN - oxycodone hcl tab er
12hr deter 10 mg
3
•
OXECTA - oxycodone hcl tab abuse
deter 7.5 mg
4
OXYCONTIN - oxycodone hcl tab er
12hr deter 15 mg
3
•
OXYCODONE HCL - oxycodone hcl
conc 100 mg/5ml (20 mg/ml)
4
OXYCONTIN - oxycodone hcl tab er
12hr deter 20 mg
3
•
OXYCODONE HCL - oxycodone hcl
soln 5 mg/5ml
4
OXYCONTIN - oxycodone hcl tab er
12hr deter 30 mg
3
•
oxycodone hcl cap 5 mg
2
OXYCONTIN - oxycodone hcl tab er
12hr deter 40 mg
OXYCONTIN - oxycodone hcl tab er
12hr deter 60 mg
3
•
102
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
OXYCONTIN - oxycodone hcl tab er
12hr deter 80 mg
3
•
ROXICET - oxycodone w/
acetaminophen soln 5-325 mg/5ml
4
oxymorphone hcl tab sr 12hr 10 mg
2
2
ROXICODONE - oxycodone hcl tab 5
mg
4
oxymorphone hcl tab sr 12hr 15 mg
oxymorphone hcl tab sr 12hr 20 mg
2
2
ROXICODONE - oxycodone hcl tab 15
mg
4
oxymorphone hcl tab sr 12hr 30 mg
2
ROXICODONE - oxycodone hcl tab 30
mg
4
oxymorphone hcl tab sr 12hr 40 mg
oxymorphone hcl tab sr 12hr 5 mg
2
•
oxymorphone hcl tab sr 12hr 7.5 mg
RYBIX ODT - tramadol hcl orally
disintegrating tab 50 mg
4
2
•
•
•
•
•
•
•
oxymorphone hcl tab 10 mg (Opana)
2
4
•
oxymorphone hcl tab 5 mg (Opana)
2
RYZOLT - tramadol hcl tab sr 24hr
biphasic release 100 mg
pentazocine w/ naloxone tab
50-0.5 mg
2
RYZOLT - tramadol hcl tab sr 24hr
biphasic release 200 mg
4
•
pentazocine-acetaminophen tab
25-650 mg
2
RYZOLT - tramadol hcl tab sr 24hr
biphasic release 300 mg
4
•
PERCOCET - oxycodone w/
acetaminophen tab 2.5-325 mg
4
4
•
•
PERCOCET - oxycodone w/
acetaminophen tab 5-325 mg
4
SUBOXONE - buprenorphine hclnaloxone hcl sl tab 2-0.5 mg (base
equiv)
4
•
•
PERCOCET - oxycodone w/
acetaminophen tab 7.5-325 mg
4
SUBOXONE - buprenorphine hclnaloxone hcl sl tab 8-2 mg (base
equiv)
4
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base
equiv)
3
PERCOCET - oxycodone w/
acetaminophen tab 7.5-500 mg
•
•
PERCOCET - oxycodone w/
acetaminophen tab 10-325 mg
4
3
•
•
PERCOCET - oxycodone w/
acetaminophen tab 10-650 mg
4
SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
•
•
PERCODAN - oxycodone-aspirin tab
4.8355-325 mg
SUBOXONE - buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
3
4
PRIMLEV - oxycodone w/
acetaminophen tab 5-300 mg
4
3
•
•
PRIMLEV - oxycodone w/
acetaminophen tab 7.5-300 mg
4
SUBOXONE - buprenorphine hclnaloxone hcl sl film 12-3 mg (base
equiv)
•
•
PRIMLEV - oxycodone w/
acetaminophen tab 10-300 mg
4
•
•
REPREXAIN - hydrocodone-ibuprofen
tab 2.5-200 mg
4
•
•
REPREXAIN - hydrocodone-ibuprofen
tab 5-200 mg
4
SUBSYS - fentanyl sublingual spray 100 4
mcg
SUBSYS - fentanyl sublingual spray 200 4
mcg
SUBSYS - fentanyl sublingual spray 400 4
mcg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
103
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)
4
SUBSYS - fentanyl sublingual spray
1600 mcg (800 mcg x 2)
4
SUBUTEX - buprenorphine hcl sl tab 2
mg (base equiv)
4
SUBUTEX - buprenorphine hcl sl tab 8
mg (base equiv)
4
SYNALGOS-DC - dihydrocodeine
compound cap
TRAMADOL HCL ER - tramadol hcl cap 4
sr 24hr biphasic release 150 mg
2
tramadol hcl tab sr 24hr biphasic
release 100 mg
2
tramadol hcl tab sr 24hr biphasic
release 200 mg
2
tramadol hcl tab sr 24hr biphasic
release 300 mg
2
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
2
tramadol hcl tab sr 24hr 200 mg
(Ultram er)
2
tramadol hcl tab sr 24hr 300 mg
(Ultram er)
1
tramadol hcl tab 50 mg (Ultram)
•
•
•
•
•
4
•
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab
300-60 mg
4
•
TYLOX - oxycodone w/ acetaminophen
cap 5-500 mg
4
•
ULTRACET - tramadol-acetaminophen
tab 37.5-325 mg
ULTRAM - tramadol hcl tab 50 mg
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
ULTRAM ER - tramadol hcl tab sr 24hr
100 mg
4
•
•
•
•
ULTRAM ER - tramadol hcl tab sr 24hr
200 mg
4
•
ULTRAM ER - tramadol hcl tab sr 24hr
300 mg
4
•
VICODIN - hydrocodoneacetaminophen tab 5-500 mg
4
•
VICODIN ES - hydrocodoneacetaminophen tab 7.5-750 mg
4
•
VICOPROFEN - hydrocodone-ibuprofen
tab 7.5-200 mg
4
•
XARTEMIS XR - oxycodone w/
acetaminophen tab cr 7.5-325 mg
4
•
XODOL - hydrocodone-acetaminophen
tab 5-300 mg
4
•
XODOL - hydrocodone-acetaminophen
tab 7.5-300 mg
4
•
XODOL - hydrocodone-acetaminophen
tab 10-300 mg
4
•
4
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
2
XOLOX - oxycodone w/ acetaminophen
tab 10-500 mg
4
•
TREZIX - acetaminophen-caffeinedihydrocodeine cap 356.4-30-16 mg
4
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr 10 mg
4
•
TYLENOL/CODEINE - acetaminophen
w/ codeine tab 300-15 mg
4
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr 15 mg
4
•
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab
300-30 mg
4
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr 20 mg
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr 30 mg
4
•
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr 40 mg
4
•
104
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr 50 mg
4
ZOLVIT - hydrocodone-acetaminophen
soln 10-300 mg/15ml
4
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)
4
ZYDONE - hydrocodoneacetaminophen tab 5-400 mg
4
ZYDONE - hydrocodoneacetaminophen tab 7.5-400 mg
4
ZYDONE - hydrocodoneacetaminophen tab 10-400 mg
•
diclofenac potassium tab 50 mg
(Cataflam)
1
diclofenac sodium tab delayed
release 25 mg
2
•
•
diclofenac sodium tab delayed
release 50 mg
2
•
•
diclofenac sodium tab delayed
release 75 mg
2
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
2
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
2
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
2
DUEXIS - ibuprofen-famotidine tab
800-26.6 mg
4
EC-NAPROSYN - naproxen tab ec 375
mg
4
EC-NAPROSYN - naproxen tab ec 500
mg
4
ENBREL - etanercept subcutaneous inj
50 mg/ml
5
•
ENBREL - etanercept subcutaneous inj
25 mg/0.5ml
5
•
ENBREL - etanercept for subcutaneous
inj kit 25 mg
5
•
ENBREL SURECLICK - etanercept
subcutaneous inj 50 mg/ml
5
•
etodolac cap 200 mg
2
etodolac cap 300 mg
2
etodolac tab sr 24hr 400 mg
2
etodolac tab sr 24hr 500 mg
2
etodolac tab sr 24hr 600 mg
2
etodolac tab 400 mg
1
ANALGESICS - ANTI-INFLAMMATORY
•
ACTEMRA - tocilizumab subcutaneous
soln prefilled syringe 162 mg/0.9ml
5
ANAPROX - naproxen sodium tab 275
mg
4
ANAPROX DS - naproxen sodium tab
550 mg
4
ARAVA - leflunomide tab 10 mg
4
ARAVA - leflunomide tab 20 mg
4
ARCALYST - rilonacept for inj 220 mg
5
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
4
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
4
CATAFLAM - diclofenac potassium tab
50 mg
4
CELEBREX - celecoxib cap 50 mg
3
CELEBREX - celecoxib cap 100 mg
3
CELEBREX - celecoxib cap 200 mg
3
CELEBREX - celecoxib cap 400 mg
3
CLINORIL - sulindac tab 200 mg
4
etodolac tab 500 mg
1
DAYPRO - oxaprozin tab 600 mg
4
FELDENE - piroxicam cap 10 mg
4
FELDENE - piroxicam cap 20 mg
4
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
• •
105
FENOPROFEN CALCIUM - fenoprofen
calcium tab 600 mg
4
MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg
4
flurbiprofen tab 100 mg
1
4
flurbiprofen tab 50 mg
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg
HUMIRA - adalimumab inj kit 20
mg/0.4ml
5
•
mefenamic acid cap 250 mg (Ponstel)
2
4
HUMIRA - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
5
•
MELOXICAM - meloxicam susp 7.5
mg/5ml
4
HUMIRA PEN - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
5
•
MELOXICAM COMFORT PAC meloxicam tab 15 mg & liniment
topical gel kit
HUMIRA PEN-CROHNS DISEASE adalimumab inj kit 40 mg/0.8ml (50
mg/ml)
5
•
meloxicam tab 15 mg (Mobic)
1
meloxicam tab 7.5 mg (Mobic)
1
MOBIC - meloxicam tab 7.5 mg
4
HUMIRA PEN-PSORIASIS STAR adalimumab inj kit 40 mg/0.8ml (50
mg/ml)
5
MOBIC - meloxicam tab 15 mg
4
MOBIC - meloxicam susp 7.5 mg/5ml
4
IBUPROFEN COMFORT PAC ibuprofen tab 800 mg & liniment
topical gel kit
4
nabumetone tab 500 mg
2
nabumetone tab 750 mg
2
ibuprofen tab 400 mg
NALFON - fenoprofen calcium cap 200
mg
4
1
ibuprofen tab 600 mg
1
4
ibuprofen tab 800 mg
1
NALFON - fenoprofen calcium cap 400
mg
IC 400 - ibuprofen tab 400 mg &
caffeine-vitamins cap kit
4
NAPRELAN - naproxen sodium tab sr
24hr 375 mg (base equiv)
4
INDOCIN - indomethacin susp 25
mg/5ml
4
NAPRELAN - naproxen sodium tab sr
24hr 500 mg (base equiv)
4
INDOCIN - indomethacin suppos 50 mg
4
4
indomethacin cap cr 75 mg
2
NAPRELAN - naproxen sodium tab sr
24hr 750 mg (base equiv)
1
NAPRELAN - naproxen sodium tab sr
24hr 500 mg (14) & 750 mg (6) pack
4
indomethacin cap 25 mg
indomethacin cap 50 mg
1
NAPROSYN - naproxen tab 250 mg
4
ketoprofen cap 50 mg
1
NAPROSYN - naproxen tab 375 mg
4
ketoprofen cap 75 mg
1
NAPROSYN - naproxen tab 500 mg
4
KETOPROFEN ER - ketoprofen cap sr
24hr 200 mg
4
NAPROSYN - naproxen susp 125
mg/5ml
4
ketorolac tromethamine tab 10 mg
1
KINERET - anakinra subcutaneous inj
100 mg/0.67ml
NAPROXEN COMFORT PAC naproxen tab 500 mg & liniment
topical gel kit
4
5
leflunomide tab 10 mg (Arava)
2
1
leflunomide tab 20 mg (Arava)
1
naproxen sodium tab 275 mg
(Anaprox)
106
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
naproxen sodium tab 550 mg
(Anaprox ds)
1
RASUVO - methotrexate soln pf autoinjector 20 mg/0.4ml
4
naproxen susp 125 mg/5ml
(Naprosyn)
2
RASUVO - methotrexate soln pf autoinjector 22.5 mg/0.45ml
4
naproxen tab ec 375 mg (Ecnaprosyn)
1
RASUVO - methotrexate soln pf autoinjector 25 mg/0.5ml
4
naproxen tab ec 500 mg (Ecnaprosyn)
1
RASUVO - methotrexate soln pf autoinjector 27.5 mg/0.55ml
4
naproxen tab 250 mg (Naprosyn)
1
4
naproxen tab 375 mg (Naprosyn)
1
RASUVO - methotrexate soln pf autoinjector 30 mg/0.6ml
naproxen tab 500 mg (Naprosyn)
1
4
ORENCIA - abatacept subcutaneous inj
125 mg/ml
5
RHEUMATREX - methotrexate sodium
tab 2.5 mg (antirheumatic)
RIDAURA - auranofin cap 3 mg
4
OTEZLA - apremilast tab starter therapy
pack 10 mg & 20 mg & 30 mg
4
•
SIMPONI - golimumab subcutaneous inj
50 mg/0.5ml
5
• •
OTEZLA - apremilast tab 30 mg
4
•
5
• •
OTREXUP - methotrexate soln pf autoinjector 10mg/0.4ml
4
SIMPONI - golimumab subcutaneous inj
100 mg/ml
4
•
OTREXUP - methotrexate soln pf autoinjector 15mg/0.4ml
4
SPRIX - ketorolac tromethamine nasal
spray 15.75 mg/spray
sulindac tab 150 mg
1
OTREXUP - methotrexate soln pf autoinjector 20mg/0.4ml
4
sulindac tab 200 mg
1
4
OTREXUP - methotrexate soln pf autoinjector 25mg/0.4ml
4
TOLMETIN SODIUM - tolmetin sodium
tab 200 mg
4
oxaprozin tab 600 mg (Daypro)
2
TOLMETIN SODIUM - tolmetin sodium
tab 600 mg
piroxicam cap 10 mg (Feldene)
2
tolmetin sodium cap 400 mg
2
piroxicam cap 20 mg (Feldene)
2
4
• •
PONSTEL - mefenamic acid cap 250
mg
4
VIMOVO - naproxen-esomeprazole
magnesium tab dr 375-20 mg
4
• •
RASUVO - methotrexate soln pf autoinjector 7.5 mg/0.15ml
4
VIMOVO - naproxen-esomeprazole
magnesium tab dr 500-20 mg
4
RASUVO - methotrexate soln pf autoinjector 10 mg/0.2ml
4
VOLTAREN-XR - diclofenac sodium tab
sr 24hr 100 mg
5
RASUVO - methotrexate soln pf autoinjector 12.5 mg/0.25ml
4
XELJANZ - tofacitinib citrate tab 5 mg
(base equivalent)
4
RASUVO - methotrexate soln pf autoinjector 15 mg/0.3ml
4
ZIPSOR - diclofenac potassium cap 25
mg
ZORVOLEX - diclofenac cap 18 mg
4
RASUVO - methotrexate soln pf autoinjector 17.5 mg/0.35ml
4
ZORVOLEX - diclofenac cap 35 mg
4
•
•
MIGRAINE PRODUCTS
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
107
acetaminophen-isometheptenecaffeine tab 325-65-20 mg (Prodrin)
2
acetaminophen-isometheptenedichloral cap 325-65-100 mg
2
ALSUMA - sumatriptan succinate
solution auto-injector 6 mg/0.5ml
4
•
AMERGE - naratriptan hcl tab 1 mg
(base equiv)
4
•
AMERGE - naratriptan hcl tab 2.5 mg
(base equiv)
4
•
AXERT - almotriptan malate tab 6.25
mg
4
•
AXERT - almotriptan malate tab 12.5
mg
4
•
CAFERGOT - ergotamine w/ caffeine
tab 1-100 mg
4
CAMBIA - diclofenac potassium packet
50 mg
4
DIHYDROERGOTAMINE MESYLAT dihydroergotamine mesylate nasal
spray 4 mg/ml
4
ERGOMAR - ergotamine tartrate sl tab
2 mg
4
FROVA - frovatriptan succinate tab 2.5
mg (base equivalent)
4
•
IMITREX - sumatriptan nasal spray 5
mg/act
3
•
IMITREX - sumatriptan nasal spray 20
mg/act
3
•
IMITREX - sumatriptan succinate tab 25
mg
4
•
IMITREX - sumatriptan succinate tab 50
mg
4
•
IMITREX - sumatriptan succinate tab
100 mg
4
•
IMITREX - sumatriptan succinate inj 6
mg/0.5ml
4
•
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 4 mg/0.5ml
4
•
108
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 6 mg/0.5ml
4
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 4 mg/0.5ml
4
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 6 mg/0.5ml
4
•
ISOMETHEPTENE/CAFFEINE/AC acetaminophen-isometheptenecaffeine tab 500-130-20 mg
2
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
MIGRAL - isometheptene mucate tab
130 mg
4
MIGRALAM - acetaminophenisometheptene-caffeine cap
325-65-100 mg
3
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 - acetaminophenisometheptene-caffeine tab
325-65-20 mg
4
PRODRIN - acetaminophenisometheptene-caffeine tab
500-130-20 mg
4
RELPAX - eletriptan hydrobromide tab
20 mg (base equivalent)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
RELPAX - eletriptan hydrobromide tab
40 mg (base equivalent)
4
•
sumatriptan succinate tab 50 mg
(Imitrex)
2
•
rizatriptan benzoate orally
disintegrating tab 10 mg (Maxaltmlt)
2
•
SUMAVEL DOSEPRO - sumatriptan
succinate solution jet-injector 6
mg/0.5ml
4
•
rizatriptan benzoate orally
disintegrating tab 5 mg (Maxalt-mlt)
2
•
TREXIMET - sumatriptan-naproxen
sodium tab 85-500 mg
4
•
rizatriptan benzoate tab 10 mg
(Maxalt)
2
•
zolmitriptan orally disintegrating tab
2.5 mg (Zomig zmt)
2
•
rizatriptan benzoate tab 5 mg
(Maxalt)
2
•
zolmitriptan orally disintegrating tab
5 mg (Zomig zmt)
2
•
SUMATRIPTAN - sumatriptan nasal
spray 5 mg/act
4
•
zolmitriptan tab 2.5 mg (Zomig)
2
2
SUMATRIPTAN - sumatriptan nasal
spray 20 mg/act
•
zolmitriptan tab 5 mg (Zomig)
4
ZOMIG - zolmitriptan tab 2.5 mg
4
2
•
ZOMIG - zolmitriptan tab 5 mg
4
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
ZOMIG - zolmitriptan nasal spray 2.5
mg/spray unit
4
•
•
•
•
•
SUMATRIPTAN SUCCINATE sumatriptan succinate inj 4 mg/0.5ml
2
•
ZOMIG - zolmitriptan nasal spray 5 mg/
spray unit
4
•
sumatriptan succinate inj 4 mg/0.5ml
2
•
2
ZOMIG NASAL SPRAY - zolmitriptan
nasal spray 5 mg/spray unit
4
sumatriptan succinate inj 6 mg/0.5ml
(Imitrex)
•
•
ZOMIG ZMT - zolmitriptan orally
disintegrating tab 2.5 mg
4
•
ZOMIG ZMT - zolmitriptan orally
disintegrating tab 5 mg
4
•
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)
2
sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
2
sumatriptan succinate tab 100 mg
(Imitrex)
2
sumatriptan succinate tab 25 mg
(Imitrex)
•
•
•
•
•
•
•
GOUT AGENTS
allopurinol tab 100 mg (Zyloprim)
1
allopurinol tab 300 mg (Zyloprim)
1
colchicine w/ probenecid tab
0.5-500 mg
2
COLCRYS - colchicine tab 0.6 mg
3
probenecid tab 500 mg
2
ULORIC - febuxostat tab 40 mg
4
ULORIC - febuxostat tab 80 mg
4
ZYLOPRIM - allopurinol tab 100 mg
4
ZYLOPRIM - allopurinol tab 300 mg
4
NEUROMUSCULAR DRUGS
ANTICONVULSANTS
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
109
APTIOM - eslicarbazepine acetate tab
200 mg
4
clonazepam orally disintegrating tab
1 mg
2
APTIOM - eslicarbazepine acetate tab
400 mg
4
clonazepam orally disintegrating tab
2 mg
2
APTIOM - eslicarbazepine acetate tab
600 mg
4
clonazepam tab 0.5 mg (Klonopin)
1
clonazepam tab 1 mg (Klonopin)
1
APTIOM - eslicarbazepine acetate tab
800 mg
4
clonazepam tab 2 mg (Klonopin)
1
4
DEPAKENE - valproate sodium syrup
250 mg/5ml (base equiv)
4
BANZEL - rufinamide tab 200 mg
BANZEL - rufinamide tab 400 mg
4
DEPAKENE - valproic acid cap 250 mg
4
BANZEL - rufinamide susp 40 mg/ml
4
carbamazepine cap sr 12hr 100 mg
(Carbatrol)
DEPAKOTE - divalproex sodium tab
delayed release 125 mg
4
2
carbamazepine cap sr 12hr 200 mg
(Carbatrol)
DEPAKOTE - divalproex sodium tab
delayed release 250 mg
4
2
2
DEPAKOTE - divalproex sodium tab
delayed release 500 mg
4
carbamazepine cap sr 12hr 300 mg
(Carbatrol)
1
DEPAKOTE ER - divalproex sodium tab
sr 24 hr 250 mg
4
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
(Tegretol)
2
DEPAKOTE ER - divalproex sodium tab
sr 24 hr 500 mg
4
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
2
DEPAKOTE SPRINKLES - divalproex
sodium cap sprinkle 125 mg
4
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
2
DIASTAT ACUDIAL - diazepam rectal
gel delivery system 10 mg
3
carbamazepine tab 200 mg (Tegretol)
1
3
CARBATROL - carbamazepine cap sr
12hr 100 mg
4
DIASTAT ACUDIAL - diazepam rectal
gel delivery system 20 mg
3
CARBATROL - carbamazepine cap sr
12hr 200 mg
4
DIASTAT PEDIATRIC - diazepam rectal
gel delivery system 2.5 mg
4
CARBATROL - carbamazepine cap sr
12hr 300 mg
4
DIAZEPAM - diazepam rectal gel
delivery system 2.5 mg
4
CELONTIN - methsuximide cap 300 mg
3
DIAZEPAM - diazepam rectal gel
delivery system 10 mg
clonazepam orally disintegrating tab
0.125 mg
2
DIAZEPAM - diazepam rectal gel
delivery system 20 mg
4
clonazepam orally disintegrating tab
0.25 mg
2
DILANTIN - phenytoin susp 125 mg/5ml
4
3
clonazepam orally disintegrating tab
0.5 mg
2
DILANTIN - phenytoin sodium extended
cap 30 mg
DILANTIN - phenytoin sodium extended
cap 100 mg
4
110
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
GABITRIL - tiagabine hcl tab 12 mg
3
GABITRIL - tiagabine hcl tab 16 mg
3
KEPPRA - levetiracetam tab 250 mg
4
KEPPRA - levetiracetam tab 500 mg
4
KEPPRA - levetiracetam tab 750 mg
4
KEPPRA - levetiracetam tab 1000 mg
4
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
2
divalproex sodium tab delayed
release 125 mg (Depakote)
1
divalproex sodium tab delayed
release 250 mg (Depakote)
1
divalproex sodium tab delayed
release 500 mg (Depakote)
2
KEPPRA - levetiracetam oral soln 100
mg/ml
4
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
2
KEPPRA XR - levetiracetam tab sr 24hr
500 mg
4
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
2
KEPPRA XR - levetiracetam tab sr 24hr
750 mg
4
ethosuximide cap 250 mg (Zarontin)
2
KLONOPIN - clonazepam tab 0.5 mg
4
ethosuximide soln 250 mg/5ml
(Zarontin)
2
KLONOPIN - clonazepam tab 1 mg
4
4
2
KLONOPIN - clonazepam tab 2 mg
felbamate susp 600 mg/5ml (Felbatol)
LAMICTAL - lamotrigine tab 25 mg
4
felbamate tab 400 mg (Felbatol)
2
LAMICTAL - lamotrigine tab 100 mg
4
felbamate tab 600 mg (Felbatol)
2
LAMICTAL - lamotrigine tab 150 mg
4
FELBATOL - felbamate tab 400 mg
4
LAMICTAL - lamotrigine tab 200 mg
4
FELBATOL - felbamate tab 600 mg
4
4
LAMICTAL - lamotrigine tab chewable
dispersible 2 mg
4
FELBATOL - felbamate susp 600
mg/5ml
4
FYCOMPA - perampanel tab 4 mg
4
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible
5 mg
4
FYCOMPA - perampanel tab 2 mg
FYCOMPA - perampanel tab 6 mg
4
4
FYCOMPA - perampanel tab 8 mg
4
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible
25 mg
FYCOMPA - perampanel tab 10 mg
4
FYCOMPA - perampanel tab 12 mg
LAMICTAL ODT - lamotrigine tab disp
25 mg (21) & 50 mg (7) titration kit
4
4
gabapentin cap 100 mg (Neurontin)
1
4
gabapentin cap 300 mg (Neurontin)
1
LAMICTAL ODT - lamotrigine tab disp
50 mg (42) & 100 mg (14) titration kit
gabapentin cap 400 mg (Neurontin)
1
4
gabapentin oral soln 250 mg/5ml
(Neurontin)
2
LAMICTAL ODT - lamotrigine tab disp
25 (14) & 50 mg (14) & 100 mg (7) kit
4
gabapentin tab 600 mg (Neurontin)
2
LAMICTAL ODT - lamotrigine orally
disintegrating tab 25 mg
2
LAMICTAL ODT - lamotrigine orally
disintegrating tab 50 mg
4
gabapentin tab 800 mg (Neurontin)
GABITRIL - tiagabine hcl tab 2 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
4
4
Step Therapy
GABITRIL - tiagabine hcl tab 4 mg
DILANTIN INFATABS - phenytoin chew
tab 50 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
111
LAMICTAL ODT - lamotrigine orally
disintegrating tab 100 mg
4
lamotrigine tab sr 24hr 250 mg
(Lamictal xr)
2
LAMICTAL ODT - lamotrigine orally
disintegrating tab 200 mg
4
lamotrigine tab sr 24hr 300 mg
(Lamictal xr)
2
LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100 mg
(7) starter kit
4
lamotrigine tab sr 24hr 50 mg
(Lamictal xr)
2
lamotrigine tab 100 mg (Lamictal)
1
LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100 mg
(14) starter kit
4
lamotrigine tab 150 mg (Lamictal)
1
lamotrigine tab 200 mg (Lamictal)
1
LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter kit
4
lamotrigine tab 25 mg (Lamictal)
1
2
LAMICTAL XR - lamotrigine tab sr 24hr
25 mg (21) & 50 mg (7) titration kit
4
levetiracetam oral soln 100 mg/ml
(Keppra)
2
LAMICTAL XR - lamotrigine tab sr 24hr
25 (14) & 50 mg (14) & 100 mg(7) kit
4
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
2
LAMICTAL XR - lamotrigine tab sr 24hr
50 (14) & 100 mg(14) & 200 mg(7) kit
4
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
levetiracetam tab 1000 mg (Keppra)
2
LAMICTAL XR - lamotrigine tab sr 24hr
25 mg
4
levetiracetam tab 250 mg (Keppra)
2
levetiracetam tab 500 mg (Keppra)
2
LAMICTAL XR - lamotrigine tab sr 24hr
50 mg
4
levetiracetam tab 750 mg (Keppra)
2
4
LYRICA - pregabalin cap 25 mg
3
LAMICTAL XR - lamotrigine tab sr 24hr
100 mg
LYRICA - pregabalin cap 50 mg
3
LAMICTAL XR - lamotrigine tab sr 24hr
200 mg
4
LYRICA - pregabalin cap 75 mg
3
LYRICA - pregabalin cap 100 mg
3
LAMICTAL XR - lamotrigine tab sr 24hr
250 mg
4
LYRICA - pregabalin cap 150 mg
3
3
4
LYRICA - pregabalin cap 200 mg
LAMICTAL XR - lamotrigine tab sr 24hr
300 mg
LYRICA - pregabalin cap 225 mg
3
2
LYRICA - pregabalin cap 300 mg
3
lamotrigine tab chewable dispersible
25 mg (Lamictal chewable di)
LYRICA - pregabalin soln 20 mg/ml
4
lamotrigine tab chewable dispersible
5 mg (Lamictal chewable di)
2
MYSOLINE - primidone tab 50 mg
4
MYSOLINE - primidone tab 250 mg
4
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
2
NEURONTIN - gabapentin cap 100 mg
4
4
2
NEURONTIN - gabapentin cap 300 mg
lamotrigine tab sr 24hr 200 mg
(Lamictal xr)
NEURONTIN - gabapentin cap 400 mg
4
lamotrigine tab sr 24hr 25 mg
(Lamictal xr)
2
NEURONTIN - gabapentin tab 600 mg
4
NEURONTIN - gabapentin tab 800 mg
4
112
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
NEURONTIN - gabapentin oral soln 250
mg/5ml
4
QUDEXY XR - topiramate cap er 24hr
sprinkle 25 mg
4
ONFI - clobazam tab 5 mg
4
4
ONFI - clobazam tab 10 mg
4
QUDEXY XR - topiramate cap er 24hr
sprinkle 50 mg
ONFI - clobazam tab 20 mg
4
4
ONFI - clobazam suspension 2.5 mg/ml
4
QUDEXY XR - topiramate cap er 24hr
sprinkle 100 mg
2
QUDEXY XR - topiramate cap er 24hr
sprinkle 150 mg
4
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
2
QUDEXY XR - topiramate cap er 24hr
sprinkle 200 mg
4
oxcarbazepine tab 150 mg (Trileptal)
oxcarbazepine tab 300 mg (Trileptal)
2
SABRIL - vigabatrin tab 500 mg
3
oxcarbazepine tab 600 mg (Trileptal)
2
SABRIL - vigabatrin powd pack 500 mg
3
OXTELLAR XR - oxcarbazepine tab sr
24hr 150 mg
4
STAVZOR - valproic acid cap delayed
release 125 mg
4
OXTELLAR XR - oxcarbazepine tab sr
24hr 300 mg
4
STAVZOR - valproic acid cap delayed
release 250 mg
4
OXTELLAR XR - oxcarbazepine tab sr
24hr 600 mg
4
STAVZOR - valproic acid cap delayed
release 500 mg
4
PEGANONE - ethotoin tab 250 mg
4
PHENYTEK - phenytoin sodium
extended cap 200 mg
TEGRETOL - carbamazepine tab 200
mg
4
4
PHENYTEK - phenytoin sodium
extended cap 300 mg
TEGRETOL - carbamazepine chew tab
100 mg
4
4
4
phenytoin chew tab 50 mg (Dilantin
infatabs)
2
TEGRETOL - carbamazepine susp 100
mg/5ml
2
TEGRETOL-XR - carbamazepine tab sr
12hr 100 mg
3
phenytoin sodium extended cap
100 mg (Dilantin)
phenytoin sodium extended cap
200 mg (Phenytek)
TEGRETOL-XR - carbamazepine tab sr
12hr 200 mg
4
2
phenytoin sodium extended cap
300 mg (Phenytek)
TEGRETOL-XR - carbamazepine tab sr
12hr 400 mg
4
2
tiagabine hcl tab 2 mg (Gabitril)
2
phenytoin susp 125 mg/5ml (Dilantin)
2
tiagabine hcl tab 4 mg (Gabitril)
2
POTIGA - ezogabine tab 50 mg
4
TOPAMAX - topiramate tab 25 mg
4
POTIGA - ezogabine tab 200 mg
4
TOPAMAX - topiramate tab 50 mg
4
POTIGA - ezogabine tab 300 mg
4
TOPAMAX - topiramate tab 100 mg
4
POTIGA - ezogabine tab 400 mg
4
TOPAMAX - topiramate tab 200 mg
4
primidone tab 250 mg (Mysoline)
1
primidone tab 50 mg (Mysoline)
TOPAMAX SPRINKLE - topiramate
sprinkle cap 15 mg
4
1
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
113
VIMPAT - lacosamide tab 100 mg
4
VIMPAT - lacosamide tab 150 mg
4
VIMPAT - lacosamide tab 200 mg
4
VIMPAT - lacosamide oral solution 10
mg/ml
4
ZARONTIN - ethosuximide cap 250 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 25 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 50 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 100 mg
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 150 mg
4
ZARONTIN - ethosuximide soln 250
mg/5ml
4
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 200 mg
4
ZONEGRAN - zonisamide cap 25 mg
4
ZONEGRAN - zonisamide cap 100 mg
4
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
2
zonisamide cap 100 mg (Zonegran)
2
zonisamide cap 25 mg (Zonegran)
2
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
2
zonisamide cap 50 mg
2
topiramate tab 100 mg (Topamax)
1
ANTIPARKINSON AGENTS
2
topiramate tab 25 mg (Topamax)
1
AMANTADINE HCL - amantadine hcl
tab 100 mg
4
topiramate tab 200 mg (Topamax)
amantadine hcl cap 100 mg
2
topiramate tab 50 mg (Topamax)
1
amantadine hcl syrup 50 mg/5ml
1
TRILEPTAL - oxcarbazepine tab 150
mg
4
5
TRILEPTAL - oxcarbazepine tab 300
mg
4
APOKYN - apomorphine hydrochloride
inj 10 mg/ml
3
TRILEPTAL - oxcarbazepine tab 600
mg
4
AZILECT - rasagiline mesylate tab 0.5
mg (base equiv)
3
TRILEPTAL - oxcarbazepine susp 300
mg/5ml (60 mg/ml)
4
AZILECT - rasagiline mesylate tab 1 mg
(base equiv)
benztropine mesylate tab 0.5 mg
1
4
benztropine mesylate tab 1 mg
1
TROKENDI XR - topiramate cap sr 24hr
25 mg
benztropine mesylate tab 2 mg
1
TROKENDI XR - topiramate cap sr 24hr
50 mg
4
bromocriptine mesylate cap 5 mg
(Parlodel)
2
TROKENDI XR - topiramate cap sr 24hr
100 mg
4
bromocriptine mesylate tab 2.5 mg
(Parlodel)
2
TROKENDI XR - topiramate cap sr 24hr
200 mg
4
carbidopa & levodopa orally
disintegrating tab 10-100 mg
2
valproate sodium syrup 250 mg/5ml
(base equiv) (Depakene)
2
carbidopa & levodopa orally
disintegrating tab 25-100 mg
2
valproic acid cap 250 mg (Depakene)
2
carbidopa & levodopa orally
disintegrating tab 25-250 mg
2
114
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
4
4
Step Therapy
VIMPAT - lacosamide tab 50 mg
TOPAMAX SPRINKLE - topiramate
sprinkle cap 25 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
2
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
2
carbidopa & levodopa tab 10-100 mg
(Sinemet)
1
carbidopa & levodopa tab 25-100 mg
(Sinemet)
2
carbidopa & levodopa tab 25-250 mg
(Sinemet)
2
carbidopa tab 25 mg (Lodosyn)
2
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
12.5-50-200 mg
4
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
18.75-75-200 mg
4
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
ELDEPRYL - selegiline hcl cap 5 mg
4
entacapone tab 200 mg (Comtan)
2
LODOSYN - carbidopa tab 25 mg
4
MIRAPEX - pramipexole dihydrochloride 4
tab 0.125 mg
MIRAPEX - pramipexole dihydrochloride 4
tab 0.25 mg
MIRAPEX - pramipexole dihydrochloride 4
tab 0.5 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
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
PARCOPA - carbidopa & levodopa
orally disintegrating tab 10-100 mg
4
PARCOPA - carbidopa & levodopa
orally disintegrating tab 25-100 mg
4
PARCOPA - carbidopa & levodopa
orally disintegrating tab 25-250 mg
4
PARLODEL - bromocriptine mesylate
cap 5 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
115
PARLODEL - bromocriptine mesylate
tab 2.5 mg
4
ropinirole hydrochloride tab sr 24hr
2 mg (base equivalent) (Requip xl)
2
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
1
ropinirole hydrochloride tab sr 24hr
4 mg (base equivalent) (Requip xl)
2
pramipexole dihydrochloride tab
0.25 mg (Mirapex)
1
ropinirole hydrochloride tab sr 24hr
6 mg (base equivalent) (Requip xl)
2
pramipexole dihydrochloride tab
0.5 mg (Mirapex)
1
ropinirole hydrochloride tab sr 24hr
8 mg (base equivalent) (Requip xl)
2
pramipexole dihydrochloride tab
0.75 mg (Mirapex)
2
ropinirole hydrochloride tab 0.25 mg
(Requip)
2
pramipexole dihydrochloride tab
1 mg (Mirapex)
1
ropinirole hydrochloride tab 0.5 mg
(Requip)
2
pramipexole dihydrochloride tab
1.5 mg (Mirapex)
1
ropinirole hydrochloride tab 1 mg
(Requip)
2
REQUIP - ropinirole hydrochloride tab
0.25 mg
4
ropinirole hydrochloride tab 2 mg
(Requip)
1
REQUIP - ropinirole hydrochloride tab
0.5 mg
4
ropinirole hydrochloride tab 3 mg
(Requip)
1
REQUIP - ropinirole hydrochloride tab 1
mg
4
ropinirole hydrochloride tab 4 mg
(Requip)
2
REQUIP - ropinirole hydrochloride tab 2
mg
4
ropinirole hydrochloride tab 5 mg
(Requip)
2
REQUIP - ropinirole hydrochloride tab 3
mg
4
selegiline hcl cap 5 mg (Eldepryl)
2
selegiline hcl tab 5 mg
2
REQUIP - ropinirole hydrochloride tab 4
mg
4
SINEMET - carbidopa & levodopa tab
10-100 mg
4
REQUIP - ropinirole hydrochloride tab 5
mg
4
SINEMET - carbidopa & levodopa tab
25-100 mg
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 2 mg (base equivalent)
4
SINEMET - carbidopa & levodopa tab
25-250 mg
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 4 mg (base equivalent)
4
SINEMET CR - carbidopa & levodopa
tab cr 25-100 mg
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 6 mg (base equivalent)
4
SINEMET CR - carbidopa & levodopa
tab cr 50-200 mg
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 8 mg (base equivalent)
4
STALEVO 100 - carbidopa-levodopaentacapone tabs 25-100-200 mg
4
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 12 mg (base equivalent)
4
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
116
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
STALEVO 200 - carbidopa-levodopaentacapone tabs 50-200-200 mg
4
DANTRIUM - dantrolene sodium cap 25
mg
4
STALEVO 50 - carbidopa-levodopaentacapone tabs 12.5-50-200 mg
4
DANTRIUM - dantrolene sodium cap 50
mg
4
STALEVO 75 - carbidopa-levodopaentacapone tabs 18.75-75-200 mg
4
DANTRIUM - dantrolene sodium cap
100 mg
4
TASMAR - tolcapone tab 100 mg
4
2
trihexyphenidyl hcl elixir 0.4 mg/ml
2
DANTROLENE SODIUM - dantrolene
sodium cap 100 mg
trihexyphenidyl hcl tab 2 mg
1
2
trihexyphenidyl hcl tab 5 mg
2
dantrolene sodium cap 25 mg
(Dantrium)
4
dantrolene sodium cap 50 mg
(Dantrium)
2
ZELAPAR - selegiline hcl orally
disintegrating tab 1.25 mg
FEXMID - cyclobenzaprine hcl tab 7.5
mg
4
FLEXERIL - cyclobenzaprine hcl tab 5
mg
4
FLEXERIL - cyclobenzaprine hcl tab 10
mg
4
LORZONE - chlorzoxazone tab 375 mg
4
LORZONE - chlorzoxazone tab 750 mg
4
metaxalone tab 800 mg (Skelaxin)
2
NEUROMUSCULAR AGENTS
RILUTEK - riluzole tab 50 mg
3
riluzole tab 50 mg (Rilutek)
2
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
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
methocarbamol tab 500 mg (Robaxin) 1
1
methocarbamol tab 750 mg
(Robaxin-750)
2
orphenadrine citrate tab sr 12hr
100 mg
4
ORPHENADRINE COMPOUND DS orphenadrine w/ aspirin & caffeine tab
50-770-60 mg
2
orphenadrine w/ aspirin & caffeine
tab 25-385-30 mg
4
PARAFON FORTE DSC chlorzoxazone tab 500 mg
ROBAXIN - methocarbamol tab 500 mg 4
baclofen tab 20 mg
1
CARISOPRODOL - carisoprodol tab
250 mg
4
carisoprodol tab 350 mg (Soma)
1
carisoprodol w/ aspirin & codeine
tab 200-325-16 mg
2
carisoprodol w/ aspirin tab
200-325 mg
2
chlorzoxazone tab 500 mg (Parafon
forte dsc)
1
CYCLOBENZAPRINE COMFORT P cyclobenzaprine hcl tab 10 mg &
liniment topical gel kit
4
cyclobenzaprine hcl tab 10 mg
1
cyclobenzaprine hcl tab 5 mg
1
ROBAXIN-750 - methocarbamol tab 750 4
mg
4
SKELAXIN - metaxalone tab 800 mg
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
2
SOMA - carisoprodol tab 250 mg
4
SOMA - carisoprodol tab 350 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
117
TIZANIDINE COMFORT PAC tizanidine tab 4 mg & liniment topical
gel pack
4
tizanidine hcl cap 2 mg (Zanaflex)
2
tizanidine hcl cap 4 mg (Zanaflex)
2
tizanidine hcl cap 6 mg (Zanaflex)
2
tizanidine hcl tab 2 mg
1
tizanidine hcl tab 4 mg (Zanaflex)
1
ZANAFLEX - tizanidine hcl cap 2 mg
4
ZANAFLEX - tizanidine hcl cap 4 mg
4
ZANAFLEX - tizanidine hcl cap 6 mg
4
ZANAFLEX - tizanidine hcl tab 4 mg
4
ANTIMYASTHENIC AGENTS
•
•
•
•
•
•
•
•
•
cholecalciferol drops 400 unit/0.03ml
(per drop)
2
cholecalciferol drops 5000 unit/ml
(1000 unit/0.2ml)
2
cholecalciferol oral liquid 400 unit/ml
1
cholecalciferol tab 1000 unit
1
cholecalciferol tab 400 unit
1
CVS VITAMIN D3 - cholecalciferol cap
400 unit
4
D-VI-SOL - cholecalciferol oral liquid
400 unit/ml
4
DDROPS - cholecalciferol drops 1000
unit/0.03ml (per drop)
4
4
GUANIDINE HCL - guanidine hcl tab
125 mg
4
DECARA - cholecalciferol cap 25000
unit
4
DRISDOL - ergocalciferol cap 50000
unit
4
MESTINON - pyridostigmine bromide
tab 60 mg
D3 - cholecalciferol cap 400 unit
4
MESTINON - pyridostigmine bromide
syrup 60 mg/5ml
3
ergocalciferol cap 50000 unit
(Drisdol)
1
MESTINON TIMESPAN pyridostigmine bromide tab cr 180 mg
3
MEPHYTON - phytonadione tab 5 mg
3
4
phytonadione inj 1 mg/0.5ml (2 mg/
ml)
1
MYTELASE - ambenonium chloride tab
10 mg
4
POTABA - potassium aminobenzoate
cap 500 mg
4
PROSTIGMIN - neostigmine bromide
tab 15 mg
2
POTABA - potassium aminobenzoate
tab 500 mg
4
pyridostigmine bromide tab 60 mg
(Mestinon)
SUPER DAILY D3 - cholecalciferol
drops 1000 unit/0.03ml (per drop)
4
VITAMIN D - cholecalciferol cap 400
unit
4
NUTRITIONAL PRODUCTS
VITAMINS
AMINOBENZOATE POTASSIUM potassium aminobenzoate packet 2
gm
4
BABY DDROPS - cholecalciferol drops
400 unit/0.03ml (per drop)
4
cholecalciferol cap 1000 unit
1
cholecalciferol chew tab 1000 unit
2
cholecalciferol chew tab 400 unit
2
118
VITAMIN D2 - ergocalciferol tab 400 unit 4
4
VITAMIN D3 - cholecalciferol cap 400
unit
4
VITAMIN D3 - cholecalciferol spray
1000 unit/spray
4
VITAMIN D3 400 - cholecalciferol cap
400 unit
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
VITAMIN K1 - phytonadione inj 10 mg/
ml
4
ATABEX EC - prenatal vit w/ dss-iron
carbonyl-fa tab dr 29-1 mg
4
WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000
unit/10ml
4
ATABEX PRENATAL - prenatal vit w/
iron carbonyl-fa tab 65-1 mg
4
B-NEXA - prenatal w/ calcium-vit b6-faginger tab 1.2 mg
4
MULTIVITAMINS
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)
1
B-NEXA - prenatal w/ calcium-vit b6-faginger tab 1.22 mg
4
b-complex w/ c & folic acid tab 1 mg
(Nephro-vite rx)
1
4
b-complex w/ c & folic acid tab 5 mg
1
BAL-CARE DHA - prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr
430mg
b-complex w/ c & folic acid tab
(Strovite)
1
4
b-complex w/ c-biotin-minerals &
folic acid tab 5 mg (Diatx zn)
1
BAL-CARE DHA ESSENTIAL - prenat
w/fe poly-na fered-fa tab 27-1 &
omega cap dr 374mg
4
multiple vitamins w/ minerals & fa
tab 1.25 mg (Corvite)
1
BP FOLINATAL PLUS B - prenatal w/
calcium carbonate-b6-b12-fa tab 1
mg
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
1
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
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
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
C-NATE DHA - prenatal vit w/ fe fum-fa- 4
omega 3 cap 28-1-200 mg
CALCIUM PNV - prenatal w/o vit a w/ fe 4
fum-fa-omega 3 cap 28-1-250 mg
4
CAVAN-ALPHA KIT - prenat w/fe polyna fered-fa tab 27-1 & omega cap dr
300mg
CAVAN-EC SOD DHA - prenatal w/ sod 4
feredetate-fa tab 30-1 & omega 3 cap
dr
4
CHOICE-OB+DHA - prenatal mv w/fe
poly-fa chw 29-1 mg & dha cap 250
mg pak
4
CITRANATAL ASSURE - prenat w/o
a w/fecbn-fegl-dss-fa tab & dha cap
300 mg pack
4
CITRANATAL B-CALM - prenat w/o a
w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab
pak
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
119
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
CITRANATAL HARMONY - prenatal w/
o a w/fe cbn-dss-fa-dha cap 29-1-265
mg
4
CITRANATAL HARMONY - prenatal
w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
4
CITRANATAL HARMONY - prenat w/
o a w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
4
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
COMPLETE-RF PRENATAL - prenatal
without a w/ fe carbonyl-docusate-fa
tab 90-1mg
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
CORVITE - multiple vitamins w/
minerals & fa tab 1.25 mg
4
CRNATAL - prenatal mv w/fecbn-fegldss-fa tab & dha cap 275 mg pack
4
DIALYVITE SUPREME D - multiple
vitamins w/ minerals & fa tab 3 mg
4
120
DIALYVITE 3000 - b-complex w/ cbiotin-e-minerals & folic acid tab 3 mg
4
DIALYVITE 5000 - b-complex w/ cbiotin-e-minerals & folic acid tab 5 mg
4
DIALYVITE/ZINC - b-complex w/ c-zn &
folic acid tab 1 mg
4
DIATX ZN - b-complex w/ c-biotinminerals & folic acid tab 5 mg
4
DUET DHA - prenat w/fe poly-na feredfa tab 25-1 & omega cap 400 mg
4
DUET DHA - prenat w/fe poly-na feredfa tab 25-1 & omega cap 430 mg
4
DUET DHA BALANCED - prenat w/fe
poly-na fered-fa tab 24-1 & omega
cap 272 mg
4
DUET DHA BALANCED - prenat w/fe
poly-na fered-fa tab 25-1 & omega
cap 267 mg
4
DUET DHA BALANCED - prenat w/fe
poly-na fered-fa tab 26-1 & omega
cap 278 mg
4
DUET DHA BALANCED - prenat w/fe
poly-na fered-fa tab 27-1 & omega
cap dr 380mg
4
DUET DHA EC - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap dr
400mg
4
DUET DHA EC - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap dr
430mg
4
DUET DHA 400 - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap 400
mg
4
DUET DHA 400EC - prenat w/fe polyna fered-fa tab 25-1 & omega cap dr
400mg
4
DUET DHA 430 - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap 430
mg
4
DUET DHA 430EC - prenat w/fe polyna fered-fa tab 25-1 & omega cap dr
430mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ELITE OB WITH DHA - prenatal vit w/ fe 4
fum-fa-omega 3 cap 28-1.25-200 mg
ELITE-OB - prenatal vit w/ iron carbonyl- 4
fa tab 50-1.25 mg
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
4
EXTRA-VIRT PLUS DHA - prenatal
w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 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
FOLIVANE-PRX DHA NF - prenatal
w/o vit a w/fe fum-dss-fa-dha cap
30-1.24-265 mg
4
GESTICARE DHA - prenatal w/fe fumfa tab dr 27-1 mg & dha cap 250 mg
pack
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
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
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
L-METHYLFOLATE PNV DHA - prenat
w/fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
4
LACTOCAL-F - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
LEVOMEFOLATE DHA - prenat w/
fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
4
LEVOMEFOLATE PNV - prenatal w/ fe
polycmplx-methylfol-fa pak 29-1.4-0.5
mg
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
4
MAXINATE - prenatal vit w/ fe gluc-fe
fum-fa tab 20-0.8 mg
4
MOMS CHOICE RX - prenat w/fe polyna fered-fa tab 26-1 & omega cap
278 mg
4
MULTICHEW - multiple vitamins w/
minerals & fa chew tab 1 mg
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
121
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
NATA KOMPLETE - prenatal vit w/ fe
fum-fe bisglycinate-fa tab 25-1 mg
4
NATACHEW - prenatal vit w/ fe fum-fe
bisglycin-fa chew tab 28-1 mg
4
NATAFORT - prenatal w/o a vit w/ fe
cbn-fe fum-fa tab 60-1 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
NATELLE ONE - prenatal w/o vit a w/ fe 4
fum-fa-omega 3 cap 28-1-250 mg
4
NEEVO - prenatal w/ fe polycmplxmethylfol-fa pak 29-1.4-0.5 mg
4
NEEVO DHA - prenat w/o a w/fefummethylfol-omegas cap 27-1.13 mg
4
NEEVO DHA - prenat w/o a w/fefummethylfol-fa-omegas cap 27-1.53 mg
4
NEPHPLEX RX - b-complex w/ c-zn &
folic acid tab 1 mg
4
NEPHRO-VITE RX - b-complex w/ c &
folic acid tab 1 mg
NEPHROCAPS - b-complex w/ c & folic 4
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
122
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
NEXA SELECT - prenat w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-337.5 mg
4
niacinamide w/ zinc-copper &folic
acid tab 750-25-1.5-0.5 mg
2
NICOMIDE - niacinamide w/ zn-cumethylfolate tab 750-25-1.5-0.5 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
OB COMPLETE - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
4
OB COMPLETE - prenatal w/o a
w/fecbn-feaspglyc-fa-dha chew
15-5-1-100 mg
4
OB COMPLETE ONE - prenatal w/
o a w/fecbn-fe asp glyc-fa-fish cap
50-1-476 mg
4
OB COMPLETE PETITE - prenat w/o
a w/fecbn-feaspglyc-fa-omega cap
35-5-1-200 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
OB COMPLETE PREMIER - prenatal vit 4
w/ fe cbn-fe asp glyc-fa tab 30-20-1
mg
OB COMPLETE 400 - prenatal w/o a w/ 4
fecbn-fe asp glyc-fa-fish cap 40-10-1
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
4
PAIRE OB - prenat w/ fe poly cmplx-fe
asp-fe gly-fa tab & dha cap pak
4
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/ fe fummethylfol-fa-dha cap 27-0.6-0.4 mg
4
PNV-DHA+DOCUSATE - prenatal
w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
PNV-FIRST - prenatal mv w/ fe polysac 4
cmplx-fa-dha cap 29-1-200 mg
PNV-OB/DHA - prenatal mv w/fe fum-fa 4
tab 65-1 mg & dha cap 250 mg pack
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
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 - ped multiple vit w/
fluoride biphasic susp 0.25 mg/ml
4
POLY-VI-FLOR/IRON - ped multiple vit
w/ fl-fe biphasic chew tab 0.5-10 mg
4
POLY-VI-FLOR/IRON - ped multiple
vitamin w/ fl-fe biphasic susp 0.25-7
mg/ml
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
2014
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 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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
123
PRENAISSANCE - prenatal w/o vit a w/
fe fum-dss-fa-dha cap 29-1.25-325
mg
4
PRENATAL MV & MIN/FE-FA-D prenat-fe poly cmplx-fe hem poly-fadha cap 11-3-0.5-100mg
4
PRENAISSANCE BALANCE - prenatal
w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
4
PRENATAL PLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
PRENATAL PLUS IRON - prenatal vit
w/ iron carbonyl-fa tab 29-1 mg
4
PRENATAL VITAMINS PLUS - prenatal
vit w/ fe fumarate-fa tab 27-1 mg
3
PRENATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
3
PRENATAL 19 - prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
3
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/ fe
fum-methylfol-fa-dha cap 28-0.6-0.4
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/o a w/fecbnmethylf-fa-dha cap 29-0.6-0.4-350 mg
4
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
3
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
3
PRENATABS FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
PRENATABS OBN - prenatal w/o a vit
w/ fe carbonyl-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/ 3
fe fumarate-fa tab 27-1 mg
124
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PRENATE RESTORE - prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew tab
0.5 mg
1
PRENATE STAR - prenatal vit w/ fe
asparto glycinate-fa tab 20-1 mg
4
1
PRENA1 CHEW - prenat w/ b2-b6-b12d3-folic acid chew tab 1.4 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew tab
1 mg
1
PRENA1 CHEW/QUATREFOLIC prenat w/ b2-b6-b12-d3-methylfol-fa
chew tab 0.6-0.4 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride soln 0.25
mg/ml
1
PRENA1 PEARL - prenat w/oa w/fefumna fered-fa-dha cap cr 30-1.4-200 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride soln 0.5
mg/ml
PRENA1 PLUS/QUATREFOLIC prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk
4
R-NATAL OB - prenatal w/o a w/fe cbnfa-dha cap 20-1-320 mg
4
4
PRENA1/QUATREFOLIC - prenat w/
o a w/ fe fum-methylfol-fa-dha cap
30-0.6-0.4 mg
4
REAPHIRM - prenatal mv w/ fe polysac
cmplx-fa-dha cap 29-1-200 mg
RELNATE DHA - prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg
4
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
4
PROMAR - iron & b12 w/ vitamin cap
PROTECTBONE - multiple vit w/ min &
calcium-folic acid wafer 500-1 mg
4
PROTECTNATAL - prenatal vit w/poly
fe-fa-fish oil tab dr 13.5-0.5-700 mg
4
PROVIDA OB - prenatal w/o a w/fe fumfe poly-fa cap 20-20-1.25 mg
4
PUREFE OB PLUS - prenatal w/o a w/fe 4
fum-fe poly-fa cap 162.115.2-1 mg
1
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew tab
0.25 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
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
RENAX - multiple vitamins w/ minerals
& fa tab 2.5 mg
3
SE-NATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
3
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
125
SETONET - prenat-fe bis-fe prot succfa-ca tab & omega 3 cap 430 pk
4
STROVITE - b-complex w/ c & folic acid
tab
4
4
TL-SELECT DHA - prenatal w/o vit a w/
fe fum-doc-fa-dha cap 29-1.25-350
mg
4
STROVITE FORTE - multiple vitamins
w/ minerals & fa syrup 1 mg/15ml
4
TRI RX - prenatal w/o a w/ fe carbonylfe gluc-dss-fa tab 27-1mg
4
SUPERVITE - b-complex w/ lysine-zn &
folic acid liquid
4
TRI-TABS DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
SUPERVITE EC - multiple vitamins w/
minerals & fa tab dr 1 mg
4
TRI-VI-FLOR - ped vit acd & l-methylfol
w/ fl biphasic susp 0.25 mg/ml
4
SYNAGEX - multiple vitamins w/
minerals & fa cap 1.25 mg
4
TRI-VI-FLOR - ped vit acd & l-methylfol
w/ fl biphasic susp 0.5 mg/ml
4
SYNATEK - multiple vitamins w/
minerals & fa cap 1.25 mg
4
4
TANDEM OB - prenatal w/o a w/fe fumfe poly-fa cap 162.115.2-1 mg
4
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25 mg/
ml
4
TARON-BC - prenat w/o a w/ fe cbnyl-fa
tab 20-1 mg & vit b6 tab pak
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
4
TARON-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1 mg
TARON-DUO EC - prenat-fe bis-fe prot
succ-fa-ca tab & omega cap dr 400
pk
4
TRIADVANCE - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
4
TARON-PREX - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 30-1.2-265 mg
4
TL G-FOL OS - multiple vit w/ min &
calcium-folic acid tab 500-1.1 mg
4
TL-ASSURE ONE - prenatal mv w/ fe
polysac cmplx-fa-dha cap 29-1-200
mg
4
TL-ASSURE+DHA - prenatal mv w/fe
poly-fa chw 29-1 mg & dha cap 250
mg pak
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
126
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
4
TRIMESIS RX - prenatal w/ calcium
carbonate-b6-b12-fa tab 1 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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
TRIVEEN-DUO DHA - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3 cap
400 pk
4
VENATAL-FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
TRIVEEN-ONE - prenatal w/o vit a w/ fe
fum-fa-omega 3 cap 27-1-250 mg
VINACAL - prenatal w/o a w/ fe
carbonyl-fe gluc-dss-fa tab 27-1mg
4
4
TRIVEEN-PRX RNF - prenatal w/o vit a
w/ fe fum-dss-fa-dha cap 26-1.2-300
mg
VINACAL B - prenat w/o a w/fecbnfeglu-fa tab 20-1 mg & vit b6 tab pak
4
4
VINATE AZ - prenatal vit w/ fe
bisglycinate chelate-fa tab 27-1 mg
4
TRIVEEN-TEN - prenatal mv & min w/fe
carbonyl-fa-dha tab 15-0.5-50 mg
4
VINATE AZ EXTRA - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1 mg
4
TRIVEEN-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
4
VINATE C - prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg
4
TRUST NATAL DHA - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3 cap
250 pk
4
VINATE CALCIUM - prenatal vit w/ iron
carbonyl-fe gluc-fa tab 27-1 mg
4
4
VINATE CARE - prenatal w/o a vit w/ fe
fum-fa tab chew 40-1 mg
4
UDAMIN - multiple vitamins w/ minerals
& fa tab 2 mg
4
VINATE DHA - prenat w/o a w/fefummethylfol-fa-omegas cap 27-1.53 mg
4
UDAMIN SP - multiple vitamins w/
minerals & fa tab 1 mg
4
VINATE DHA RF - prenat w/o a w/
fefum-methylfol-omegas cap 27-1.13
mg
4
ULTIMATE OB DHA - prenat w/ fe poly
cmplx-fe asp-fe gly-fa tab & dha cap
pak
4
VINATE GT - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
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
VINATE IC - prenatal w/o a w/fe fum-fe
poly-fa cap 162.115.2-1 mg
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1 mg
4
ULTRA TABS - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
4
VINATE M - prenatal vit w/ sel-fe
fumarate-fa tab 27-1 mg
4
V-NATAL - prenatal vit w/o vit a w/ fe
bisglycinate-fa tab 32-1 mg
4
VINATE ONE - prenatal vit w/ fe
fumarate-fa tab 60-1 mg
4
V-NATAL DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
4
VINATE PN CARE - prenatal without a
w/ fe asparto gly-doc-fa tab 30-1mg
4
4
VEMAVITE-PRX 2 - prenatal w/o vit a
w/ fe fum-dss-fa-dha cap 27-1.25-300
mg
4
VINATE ULTRA - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
VENA-BAL DHA - prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr
430mg
4
VIRT-BAL DHA - prenat-fepoly-naferedfa tab 13-13-1 & omega cap dr 374
mg
VIRT-BAL DHA PLUS - prenat w/fe
poly-na fered-fa tab 27-1 & omega
cap dr 380mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
127
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
4
VIRT-PN DHA - prenat w/o a w/ fe fummethylfol-fa-dha cap 27-0.6-0.4 mg
4
4
VITAMEDMD REDICHEW RX/QUA prenat w/ b2-b6-b12-d3-methylfol-fa
chew tab 0.6-0.4 mg
4
VIRT-PN PLUS - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
4
VITAPEARL - prenat w/oa w/fefum-na
fered-fa-dha cap cr 30-1.4-200 mg
VITASPIRE - prenatal w/o a vit w/ fe
carbonyl-fa tab 29-1 mg
4
VIRT-SELECT - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-325 mg
4
VITA-PREN - prenatal vit w/ docusateiron-fa tab 65-1 mg
4
VITAFOL ULTRA - prenat w/fe polymethylfol-fa-dha cap 29-0.6-0.4-200
mg
4
VITAFOL-NANO - prenatal w/o a w/
fefum-l methylfol-fa tab 18-0.6-0.4 mg
4
VITAFOL-OB - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
VITAFOL-OB+DHA - prenatal mv w/fe
fum-fa tab 65-1 mg & dha cap 250
mg pack
4
VITAFOL-ONE - prenatal mv w/ fe
polysac cmplx-fa-dha cap 29-1-200
mg
4
VITAFOL-PLUS - prenatal mv w/ fe
polysac cmplx-fa-dha cap 27-1-200
mg
4
VITAFOL-PN - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
VITAL-D RX - b-complex w/ c-biotin-dzinc & folic acid tab 1 mg
4
VITAMEDMD ONE RX/QUATREFO prenat w/o a w/ fe fum-methylfol-fadha cap 30-0.6-0.4 mg
4
VITAMEDMD PLUS RX/QUATRE prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk
4
VITAMEDMD REDICHEW RX - prenat
w/ b2-b6-b12-d3-folic acid chew tab
1.4 mg
4
128
VIVA CT PRENATAL - prenatal w/o a vit 4
w/ fe fum-fa tab chew 28-1 mg
4
VIVA DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-200 mg
VOL-NATE - prenatal vit w/ fe fumarate- 4
fa tab 28-1 mg
VOL-PLUS - prenatal vit w/ fe fumarate- 4
fa tab 27-1 mg
4
VOL-TAB RX - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
VP CH ULTRA - prenat w/o a w/fe fum- 4
fe cbn-dss-fa-dha cap 27-1-260 mg
VP-CH PLUS - prenatal w/o a w/fe cbn- 4
dss-fa-dha cap 29-1-265 mg
4
VP-CH-PNV - prenatal w/o vit a w/ fe
cbn-dss-fa-dha cap 30-1-260 mg
4
VP-ERA OB PLUS - prenat vit-fe poly
cmplx-fe heme poly-fa tab 22-6-1 mg
4
VP-GGR-B6 PRENATAL - prenatal w/
calcium-vit b6-fa-ginger tab 1.2 mg
VP-HEME OB - prenat vit-fe poly cmplx- 4
fe heme poly-fa tab 28-6-1 mg
4
VP-HEME OB + DHA - prenat-fe poly
cmplx-fe heme poly-fa tab & omega 3
cap pck
4
VP-HEME ONE - prenat-fe poly cmplxfe heme poly-fa-dha cap 22-6-1-200
mg
VP-PNV-DHA - prenatal vit w/ fe fum-fa- 4
omega 3 cap 28-1-215.8 mg
4
ZATEAN-CH - prenatal w/o a w/fe cbndss-fa-dha cap 27-1-250 mg
4
ZATEAN-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ZATEAN-PN DHA - prenat w/o a w/ fe
fum-methylfol-fa-dha cap 27-0.6-0.4
mg
4
K-PHOS NEUTRAL - pot phos
monobasic w/sod phos di & monobas
tab 155-852-130mg
4
ZATEAN-PN PLUS - prenat w/o a w/
fe fumerate-methylfolate-fa-omega 3
cap
4
K-TAB - potassium chloride tab cr 10
meq
4
4
ZINGIBER - prenatal w/ calcium-vit b6fa-ginger tab 1.2 mg
4
K-TAB - potassium chloride tab cr 20
meq (1500 mg)
4
CALCIFOL - ca carb-folic acid-vit d-b6b12-boron-mag wafer 1342-1.6 mg
4
KLOR-CON M15 - potassium chloride
microencapsulated crys cr tab 15
meq
4
CALCIUM-FOLIC ACID PLUS D - ca
carb-folic acid-vit d-b6-b12-boronmag wafer 1342-1 mg
4
KLOR-CON 25 - potassium chloride
powder packet 25 meq
LOZI-FLUR - sodium fluoride lozenge 1
mg f (from 2.2 mg naf)
4
EFFER-K - potassium bicarbonate-citric
acid effer tab 10 meq
4
EFFER-K - potassium bicarbonate-citric
acid effer tab 20 meq
4
FLORICAL - sodium fluoride w/ calcium
carb cap 8.3-364 mg
4
FLORICAL - sodium fluoride w/ calcium
carb tab 8.3-364 mg
4
FLUOR-A-DAY - sodium fluoride-xylitol
chew tab 0.55 (0.25 mg f)-236.79 mg
4
FLUOR-A-DAY - sodium fluoride-xylitol
chew tab 1.1 (0.5 mg f)-236.79 mg
4
FLUOR-A-DAY - sodium fluoride-xylitol
chew tab 2.2 (1 mg f)-236.79 mg
4
FLUORABON - sodium fluoride soln
0.25 mg/0.6ml (from 0.55 mg/0.6ml
naf)
4
FLURA-DROPS - sodium fluoride soln
0.25 mg/drop f (from 0.55 mg/drop
naf)
4
GALZIN - zinc acetate cap 25 mg
4
GALZIN - zinc acetate cap 50 mg
4
IODINE STRONG - iodine solution
strong 5% (lugol's)
4
K-PHOS - potassium phosphate
monobasic tab 500 mg
3
MINERALS and ELECTROLYTES
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
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
MICRO-K - potassium chloride cap cr 8 4
meq
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
1
pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg (Kphos neutral)
1
potassium bicarbonate effer tab 25
meq
2
potassium chloride cap cr 10 meq
(Micro-k)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
129
potassium chloride cap cr 8 meq
(Micro-k)
2
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
4
potassium chloride
microencapsulated crys cr tab 10
meq
1
potassium chloride
microencapsulated crys cr tab 20
meq
2
potassium chloride oral liq 10% (20
meq/15ml)
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
4
1
AVAILNEX - carbocysteine chew tab
750 mg
4
1
CALAFOL RX - fa-hydroxocobalaminpolicosanol-vit b6-vit d-ca tab
4
potassium chloride oral liq 20% (40
meq/15ml)
2
CARDIOTEK-RX - folic acid-b12-b6arginine-black pepper tab
4
potassium chloride powder packet
20 meq
1
CEREFOLIN - l-methylfolate w/ vit b12vit b6-vit b2 tab 6-1-50-5 mg
4
potassium chloride tab cr 10 meq (Ktab)
1
CEREFOLIN NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
4
potassium chloride tab cr 8 meq
(600 mg)
SODIUM FLUORIDE - sodium fluoride
tab 0.5 mg f (from 1.1 mg naf)
4
4
SODIUM FLUORIDE - sodium fluoride
tab 1 mg f (from 2.2 mg naf)
4
CEREFOLIN NAC - l-methylfolatealgae-b12-acetylcyst tab
6-90.314-2-600mg
4
sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) (Luride)
1
CYANOCOBALAMIN/LEVOMEFOLA l-methylfolate w/ vit b6-vit b12 tab
1.13-25-2 mg
sodium fluoride chew tab 0.5 mg f
(from 1.1 mg naf) (Luride)
1
DEPLIN - l-methylfolate tab 7.5 mg
4
DEPLIN - l-methylfolate tab 15 mg
4
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
1
DEPLIN 15 - l-methylfolate-algae cap
15-90.314 mg
4
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
2
DEPLIN 7.5 - l-methylfolate-algae cap
7.5-90.314 mg
4
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
flaxseed oil-evening primrosebilberry cap 1000-500-40 mg (Tears
again hydrate)
2
FOLBEE AR - folic acid-b12-b6arginine-black pepper tab
4
NUTRIENTS
130
2
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
DIETARY PRODUCTS
ALZ-NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
acetylcysteine cap 600 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
FOLBIC RF - l-methylfolate w/ vit b6-vit
b12 tab 1.13-25-2 mg
4
L-METHYLFOLATE FORMULA 15 - lmethylfolate-algae cap 15-90.314 mg
4
folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg
2
L-METHYLFOLATE FORMULA 7. - lmethylfolate-algae cap 7.5-90.314 mg
4
FOLTANX - l-methylfolate w/ vit b6-vit
b12 tab 3-35-2 mg
4
L-METHYLFOLATE FORTE - lmethylfolate-algae cap 7.5-90.314 mg
4
FOLTANX RF - l-methylfolate-algae-vit
b12-b6 cap 3-90.314-2-35 mg
4
L-METHYLFOLATE FORTE - lmethylfolate-algae cap 15-90.314 mg
4
FOLTX - folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg
4
4
FOLTX - l-methylfolate w/ vit b6-vit b12
tab 1.13-25-2 mg
4
LEVOMEFOLATE CALCIUM/ACET - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
4
FOSTEUM - genistein-zinc amino acid
chelate-vitamin d cap
4
LEVOMEFOLATE CALCIUM/ALGA - lmethylfolate-algae cap 7.5-90.314 mg
4
L-METHYL-B6-B12 - l-methylfolate w/
vit b6-vit b12 tab 3-35-2 mg
4
LEVOMEFOLATE CALCIUM/ALGA - lmethylfolate-algae cap 15-90.314 mg
4
L-METHYL-MC - l-methylfolate w/ vit
b12-vit b6-vit b2 tab 6-1-50-5 mg
4
LEVOMEFOLATE CALCIUM/PYRI l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg
L-METHYL-MC NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
4
LIMBREL - flavocoxid cap 250 mg
4
LIMBREL - flavocoxid cap 500 mg
4
L-METHYLFOLATE - l-methylfolate tab
7.5 mg
LIMBREL250 - flavocoxid-citrated zinc
bisglycinate cap 250-50 mg
4
4
L-METHYLFOLATE - l-methylfolate tab
15 mg
LIMBREL500 - flavocoxid-citrated zinc
bisglycinate cap 500-50 mg
4
4
4
LMTHF/PYRIDOXINE HCL/CYAN l-methylfolate w/ vit b6-vit b12 tab
1.13-25-2 mg
4
L-METHYLFOLATE CA ME-CBL - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
4
METAFOLBIC - l-methylfolate w/ vit
b12-vit b6-vit b2 tab 6-1-50-5 mg
4
L-METHYLFOLATE CA/ME-CBL/ l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
4
L-METHYLFOLATE CA/P-5-P/M - lmethylfolate w/ vit b6-vit b12 tab
3-35-2 mg
4
METAFOLBIC PLUS - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
4
L-METHYLFOLATE CA/P-5-P/M - lmethylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg
4
METAFOLBIC PLUS RF - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
METANX - l-methylfolate w/ vit b6-vit
b12 tab 3-35-2 mg
4
L-METHYLFOLATE CALCIUM - lmethylfolate tab 7.5 mg
4
METANX - l-methylfolate-algae-vit b12b6 cap 3-90.314-2-35 mg
4
L-METHYLFOLATE CALCIUM - lmethylfolate tab 15 mg
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
131
METHYLFOL-ALGAE-B12-ACETY - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
4
PKU EASY MICROTABS - nutritional
supplement tabs delayed release
4
PODIAPN - l-methylfolate-b12-b6-alpha
lipoic ac cap 5-2-35-300 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
4
VP-GSTN - genistein-zinc amino acid
chelate-vitamin d cap
4
ZYTAZE - zinc citrate-phytase cap
25-500 mg
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
fe fum-iron polysacch complex-fab cmplx-c-zn-mn-cu cap (Tandem
plus)
1
ferrous fumarate-fa-b complex-c-znmg-mn-cu tab 106-1 mg
2
folic acid-vit b6-vit b12-omega 3phytosterols cap 1 mg
2
iron combination cap
1
iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg (Hematron-af)
1
ACTIVE FE - fe carbonyl-fa-b complexa-c-d-e-min tab 75-1.25 mg
4
132
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 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
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 100 mcg/0.5ml
5
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 150 mcg/0.75ml
5
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
•
•
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 500 mcg/ml
5
B-6 FOLIC ACID - cobalamine
combination cap
•
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 fumarate w/ b12-vit c-fa-ifc cap
110-0.015-75-0.5-240 mg
1
fe fumarate-vit c-vit b12-fa cap 460
(151 fe)-60-0.01-1 mg
1
4
FE 90 PLUS - fe carbonyl-fe gluconatefa-vit b12-vit c-dss tab 90-1 mg
4
BIFERARX - polysacch fe cmplx-fe
heme poly-fa-b12 tab 22-6-1-0.025
mg
4
FER-IN-SOL - ferrous sulfate soln 75
mg/ml (15 mg/ml elemental fe)
4
BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
FERIVA - fe bisglycin-fe carbonyl-c-fab12-biotin-dss cap 75-1 mg
4
2
carbonyl iron chew tab 15 mg
(elemental iron)
1
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
2
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
CORVITE FE - iron combination tab
4
CORVITE 150 - iron combination tab
4
CORVITE 150 - iron-folic acid-vit c-vit
b6-vit b12-zinc tab 150-1.25 mg
4
cyanocobalamin inj 1000 mcg/ml
1
DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg
4
DROXIA - hydroxyurea cap 200 mg
3
DROXIA - hydroxyurea cap 300 mg
3
DROXIA - hydroxyurea cap 400 mg
3
ED CYTE F - ferrous fumarate-folic
acid-docusate sodium tab 324-1-50
mg
4
EPOGEN - epoetin alfa inj 2000 unit/ml
5
EPOGEN - epoetin alfa inj 3000 unit/ml
5
•
•
•
Dispensing Limits
5
5
Step Therapy
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 300 mcg/0.6ml
EPOGEN - epoetin alfa inj 4000 unit/ml
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 300 mcg/ml
Drug Name
Step Therapy
Drug Tier
2014
•
•
•
FERIVAFA - iron-c-fa-b12-biotin-copper- 4
docusate cap 110-1 mg
4
FERRALET 90 - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
FERRAPLUS 90 - iron-folic acid-vit b12- 4
vit c-docusate sod tab 90-1 mg
4
FERRETTS CHEWABLE IRON carbonyl iron chew tab 18 mg
(elemental iron)
4
FERREX 150 FORTE PLUS - fe asp
gly-fe polysacch-succ ac-c-threon acb12-fa cap
FERREX 28 - fe asparto gly-fe fum-b12- 4
fa-c-succinic ac tab ther pack
4
FERRO-PLEX HEMATINIC - fe fumdss-vit c-vit e-vit b12-if-fa tab 115-1
mg
4
FERROTRIN - iron w/ b12-vit c-fa-ifc
cap 36-0.015-75-0.5-240 mg
1
ferrous fumarate-folic acid tab
324-1 mg
4
FERROUS SULFATE - ferrous sulfate
liquid 220 mg/5ml (44 mg/5ml
elemental fe)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
133
FERROUS SULFATE - ferrous sulfate
syrup 300 mg/5ml (60 mg/5ml
elemental fe)
4
HEMETAB - polysacch fe cmplx-fe
heme poly-fa-b12 tab 22-6-1-0.025
mg
4
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
1
4
ferrous sulfate soln 75 mg/ml (15 mg/
ml elemental fe)
1
HEMOCYTE PLUS - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap
106-1 mg
4
ferrous sulfate-vit c-folic acid tab cr
105-500-0.8 mg
1
ICAR - carbonyl iron chew tab 15 mg
(elemental iron)
4
FOLGARD RX - folic acid-vitamin b6vitamin b12 tab 2.2-25-1 mg
4
ICAR PEDIATRIC - carbonyl iron susp
15 mg/1.25ml (elemental iron)
4
folic acid tab 1 mg
1
ICAR-C PLUS - iron-vit c-vit b12-folic
acid tab 100-250-0.025-1 mg
folic acid tab 400 mcg
1
4
folic acid tab 800 mcg
1
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)
1
INTEGRA PLUS - fe fum-iron polysacch
complex-fa-b complex-c-biotin cap
4
folic acid-vitamin b6-vitamin b12 tab
2.2-25-0.5 mg
1
IRON - iron combination tab
4
folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg (Folgard rx)
2
folic acid-vitamin b6-vitamin b12 tab
2.5-25-1 mg
1
IRON ASP GLY/ POLYSACCH C - fe
asp gly-fe polysacch-succ ac-c-threon
ac-b12-fa cap
4
iron polysacch complex-vit b12-fa
cap 150-0.025-1 mg
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
1
FOLPACE RX - folic acid-hydroxocobalvit b6-vit e-mag tab 2.05 mg-425 mcg
4
iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg (Icar-c plus)
4
FUMATINIC - iron combination cap cr
4
IROSPAN 24/6 - fe asp gly-fe polyssucc acd-b cmplx-c-ca-fa tab ther pk
4
IS 24/6 - fe asp gly-fe polys-succ acd-b
cmplx-c-ca-fa tab ther pk
4
FUSION PLUS - fe fum-iron poly cmplxfa-b cmplx-c-biotin-probiotic cap
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
134
LEUKINE - sargramostim inj 500 mcg/ml 5
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
MULTIGEN - fe asparto gly-succ acd-c- 4
threonic acd-b12-des stom tab
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
4
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
4
MV FE ASPARTO GLY/VIT C/V - fe
asparto gly-succ acd-c-threonic acdb12-des stom tab
4
MYKIDZ IRON 10 - iron susp 15
mg/1.5ml
4
NASCOBAL - cyanocobalamin nasal
spray 500 mcg/0.1ml
4
NATALVIRT FLT - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
NEPHRON FA - ferrous fumarate w/ fa- 4
dss-b complex-vit c tab
5
NEULASTA - pegfilgrastim inj 6
mg/0.6ml
5
NEUMEGA - oprelvekin for inj 5 mg
•
Dispensing Limits
Step Therapy
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
MULTIGEN FOLIC - fe asparto glysuccinic acd-vit c-threonic acd-b12-fa
tab
Prior Authorization
Drug Name
Drug Tier
2014
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
•
PROFERRIN-FORTE - iron heme
polypeptide-folic acid tab 12-1 mg (fe
equiv)
4
PROMACTA - eltrombopag olamine tab
12.5 mg (base equiv)
5
•
•
PROMACTA - eltrombopag olamine tab
25 mg (base equiv)
5
•
•
PROMACTA - eltrombopag olamine tab
50 mg (base equiv)
5
•
•
PROMACTA - eltrombopag olamine tab
75 mg (base equiv)
5
•
•
PROTECTIRON - iron polysacch-fa-b
complex-vit c-e & minerals tab 60-1
mg
4
PUREFE PLUS - ferrous fumarate-fab complex-c-zn-mg-mn-cu cap 106-1
mg
4
SPATONE PUR-ABSORB IRON ferrous sulfate liquid 5 mg/20ml
(elemental iron)
4
4
NEUPOGEN - filgrastim inj 300 mcg/ml
5
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
5
•
•
•
NEUPOGEN - filgrastim inj 300
mcg/0.5ml (600 mcg/ml)
5
•
NEUPOGEN - filgrastim inj 480
mcg/0.8ml (600 mcg/ml)
5
•
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg
4
TANDEM F - ferrous fum-iron
polysacch-fa cap 162-115.2-1 mg
(106 mg fe)
4
NIRON KOMPLETE - fe bisglycinate-fe
fum-vit c-vit b12-vit e-fa tab 30-1 mg
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
ZAVESCA - miglustat cap 100 mg
5
PRE-FOLIC - folic acid-vitamin c tab
1-100 mg
4
PROCRIT - epoetin alfa inj 2000 unit/ml
5
•
ANTICOAGULANTS
•
ARIXTRA - fondaparinux sodium inj 2.5
mg/0.5ml
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
4
•
135
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ARIXTRA - fondaparinux sodium inj 5
mg/0.4ml
4
•
fondaparinux sodium inj
2.5 mg/0.5ml (Arixtra)
2
•
ARIXTRA - fondaparinux sodium inj 7.5
mg/0.6ml
4
•
fondaparinux sodium inj 5 mg/0.4ml
(Arixtra)
2
•
ARIXTRA - fondaparinux sodium inj 10
mg/0.8ml
4
•
fondaparinux sodium inj
7.5 mg/0.6ml (Arixtra)
2
•
COUMADIN - warfarin sodium tab 1 mg
4
4
•
COUMADIN - warfarin sodium tab 2 mg
4
FRAGMIN - dalteparin sodium inj 10000
unit/ml
COUMADIN - warfarin sodium tab 2.5
mg
4
FRAGMIN - dalteparin sodium inj 2500
unit/0.2ml
4
•
COUMADIN - warfarin sodium tab 3 mg
4
4
•
COUMADIN - warfarin sodium tab 4 mg
4
FRAGMIN - dalteparin sodium inj 5000
unit/0.2ml
4
FRAGMIN - dalteparin sodium inj 7500
unit/0.3ml
4
COUMADIN - warfarin sodium tab 5 mg
•
COUMADIN - warfarin sodium tab 6 mg
4
4
•
COUMADIN - warfarin sodium tab 7.5
mg
4
FRAGMIN - dalteparin sodium inj 12500
unit/0.5ml
•
4
FRAGMIN - dalteparin sodium inj 15000
unit/0.6ml
4
COUMADIN - warfarin sodium tab 10
mg
•
ELIQUIS - apixaban tab 2.5 mg
FRAGMIN - dalteparin sodium inj 18000
unit/0.72ml
4
4
ELIQUIS - apixaban tab 5 mg
4
4
•
enoxaparin sodium inj 100 mg/ml
(Lovenox)
2
FRAGMIN - dalteparin sodium inj 25000
unit/ml
4
enoxaparin sodium inj 120 mg/0.8ml
(Lovenox)
2
•
HEPARIN SODIUM - heparin sodium
(porcine) inj 2000 unit/ml
4
enoxaparin sodium inj 150 mg/ml
(Lovenox)
2
•
HEPARIN SODIUM - heparin sodium
(porcine) inj 2500 unit/ml
2
enoxaparin sodium inj 30 mg/0.3ml
(Lovenox)
2
•
heparin sodium (porcine) inj 1000
unit/ml
2
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
2
•
heparin sodium (porcine) inj 10000
unit/ml
2
enoxaparin sodium inj 40 mg/0.4ml
(Lovenox)
2
•
heparin sodium (porcine) inj 20000
unit/ml
2
enoxaparin sodium inj 60 mg/0.6ml
(Lovenox)
2
•
heparin sodium (porcine) inj 5000
unit/ml
2
enoxaparin sodium inj 80 mg/0.8ml
(Lovenox)
2
•
heparin sodium (porcine) pf inj 5000
unit/0.5ml
4
•
fondaparinux sodium inj 10 mg/0.8ml
(Arixtra)
2
•
LOVENOX - enoxaparin sodium inj 30
mg/0.3ml
LOVENOX - enoxaparin sodium inj 40
mg/0.4ml
4
•
136
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
LOVENOX - enoxaparin sodium inj 60
mg/0.6ml
4
•
AMINOCAPROIC ACID - aminocaproic
acid tab 1000 mg
4
LOVENOX - enoxaparin sodium inj 80
mg/0.8ml
4
•
aminocaproic acid syrup 25%
(Amicar)
2
LOVENOX - enoxaparin sodium inj 100
mg/ml
4
•
aminocaproic acid tab 500 mg
(Amicar)
2
LOVENOX - enoxaparin sodium inj 120
mg/0.8ml
4
•
LYSTEDA - tranexamic acid tab 650 mg
4
2
4
•
tranexamic acid tab 650 mg (Lysteda)
LOVENOX - enoxaparin sodium inj 150
mg/ml
4
•
ADVATE - antihemophilic factor rahfpfm for inj 250 unit
5
LOVENOX - enoxaparin sodium inj 300
mg/3ml
•
4
•
ADVATE - antihemophilic factor rahfpfm for inj 500 unit
5
PRADAXA - dabigatran etexilate
mesylate cap 75 mg (etexilate base
eq)
•
5
•
PRADAXA - dabigatran etexilate
mesylate cap 150 mg (etexilate base
eq)
4
ADVATE - antihemophilic factor rahfpfm for inj 1000 unit
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
•
5
•
5
•
•
warfarin sodium tab 1 mg (Coumadin) 1
1
warfarin sodium tab 10 mg
(Coumadin)
warfarin sodium tab 2 mg (Coumadin) 1
warfarin sodium tab 2.5 mg
(Coumadin)
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
warfarin sodium tab 7.5 mg
(Coumadin)
1
XARELTO - rivaroxaban tab 10 mg
3
XARELTO - rivaroxaban tab 15 mg
3
XARELTO - rivaroxaban tab 20 mg
3
HEMOSTATICS
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
HEMATOLOGICAL AGENTS - MISC.
AMICAR - aminocaproic acid tab 500
mg
4
AMICAR - aminocaproic acid tab 1000
mg
4
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for
inj 1500 unit
AMICAR - aminocaproic acid syrup 25% 4
ALPHANINE SD - coagulation factor ix
for inj 500 unit
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
137
5
•
EFFIENT - prasugrel hcl tab 5 mg (base
equiv)
4
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 500 unit
5
•
EFFIENT - prasugrel hcl tab 10 mg
(base equiv)
4
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 1000 unit
5
•
FEIBA NF - antiinhibitor coagulant
complex for inj
5
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 2000 unit
5
•
FIRAZYR - icatibant acetate inj 30
mg/3ml (base equivalent)
5
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 3000 unit
2
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 250 unit
5
anagrelide hcl cap 0.5 mg (Agrylin)
•
anagrelide hcl cap 1 mg
2
5
5
•
•
BEBULIN - factor ix complex for inj
200-1200 unit
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 500 unit
•
•
5
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 1000 unit
5
BEBULIN VH - factor ix complex for inj
200-1200 unit
•
BENEFIX - coagulation factor ix
(recombinant) for inj 250 unit
•
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 2000 unit
5
5
•
BENEFIX - coagulation factor ix
(recombinant) for inj 500 unit
•
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 3000 unit
5
5
•
•
BENEFIX - coagulation factor ix
(recombinant) for inj 1000 unit
HEMOFIL M - antihemophilic factor
(human) for inj 220-400 unit
5
5
5
5
•
•
BENEFIX - coagulation factor ix
(recombinant) for inj 2000 unit
HEMOFIL M - antihemophilic factor
(human) for inj 250 unit
•
•
5
HEMOFIL M - antihemophilic factor
(human) for inj 401-800 unit
5
BENEFIX - coagulation factor ix
(recombinant) for inj 3000 unit
•
BERINERT - c1 esterase inhibitor
(human) for iv inj kit 500 unit
HEMOFIL M - antihemophilic factor
(human) for inj 500 unit
5
5
•
BRILINTA - ticagrelor tab 90 mg
HEMOFIL M - antihemophilic factor
(human) for inj 1000 unit
5
4
cilostazol tab 100 mg (Pletal)
1
5
•
cilostazol tab 50 mg (Pletal)
1
HEMOFIL M - antihemophilic factor
(human) for inj 1700 unit
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
2
HEMOFIL M - antihemophilic factor
(human) for inj 801-1500 unit
5
•
clopidogrel bisulfate tab 75 mg (base
equiv) (Plavix)
2
HEMOFIL M - antihemophilic factor
(human) for inj 1501-2000 unit
5
•
CORIFACT - factor xiii concentrate
(human) for inj kit 1000-1600 unit
5
HUMATE-P - antihemophilic factor/vwf
(human) for inj 250-600 unit
5
•
138
•
dipyridamole tab 50 mg (Persantine)
2
dipyridamole tab 75 mg (Persantine)
2
Dispensing Limits
•
1
Step Therapy
ALPHANINE SD - coagulation factor ix
for inj 1500 unit
5
dipyridamole tab 25 mg (Persantine)
Prior Authorization
•
Drug Name
Drug Tier
5
Dispensing Limits
Prior Authorization
ALPHANINE SD - coagulation factor ix
for inj 1000 unit
Drug Name
Step Therapy
Drug Tier
2014
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
MONOCLATE-P - antihemophilic factor
(human) for inj kit 1500 unit
5
•
HUMATE-P - antihemophilic factor/vwf
(human) for inj 1000-2400 unit
5
•
MONONINE - coagulation factor ix for
inj 250 unit
5
•
KOATE-DVI - antihemophilic factor
(human) for inj 250 unit
5
•
MONONINE - coagulation factor ix for
inj 500 unit
5
•
KOATE-DVI - antihemophilic factor
(human) for inj 500 unit
5
•
MONONINE - coagulation factor ix for
inj 1000 unit
5
•
KOATE-DVI - antihemophilic factor
(human) for inj 1000 unit
5
•
NOVOSEVEN - coagulation factor viia
(recomb) for inj 2.4 mg (2400 mcg)
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 250 unit
5
•
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 1 mg (1000 mcg)
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 500 unit
5
•
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 2 mg (2000 mcg)
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 1000 unit
5
•
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 5 mg (5000 mcg)
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 2000 unit
5
•
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 8 mg (8000 mcg)
5
•
KOGENATE FS - antihemophilic factor
(recombinant) for inj kit 3000 unit
5
•
pentoxifylline tab cr 400 mg
1
4
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 250 unit
•
PERSANTINE - dipyridamole tab 25 mg
5
PERSANTINE - dipyridamole tab 50 mg
4
PERSANTINE - dipyridamole tab 75 mg
4
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 500 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 1000 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 2000 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 3000 unit
5
•
MONOCLATE-P - antihemophilic factor
(human) for inj kit 250 unit
5
MONOCLATE-P - antihemophilic factor
(human) for inj kit 500 unit
5
MONOCLATE-P - antihemophilic factor
(human) for inj kit 1000 unit
5
•
•
•
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
Prior Authorization
HUMATE-P - antihemophilic factor/vwf
(human) for inj 500-1200 unit
Drug Name
Step Therapy
Drug Tier
2014
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 SD - factor ix complex for
inj 500 unit
5
•
PROFILNINE SD - factor ix complex for
inj 1000 unit
5
•
PROFILNINE SD - factor ix complex for
inj 1500 unit
5
•
RECOMBINATE - antihemophilic factor
(recombinant) for inj 220-400 unit
5
•
RECOMBINATE - antihemophilic factor
(recombinant) for inj 401-800 unit
5
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
139
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 500
unit
5
•
RECOMBINATE - antihemophilic factor
(recombinant) for inj 1241-1800 unit
5
•
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 1000
unit
5
RECOMBINATE - antihemophilic factor
(recombinant) for inj 1801-2400 unit
5
•
•
RIXUBIS - coagulation factor ix
(recombinant) for inj 250 unit
5
•
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 2000
unit
5
•
RIXUBIS - coagulation factor ix
(recombinant) for inj 500 unit
5
•
5
•
•
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 3000
unit
RIXUBIS - coagulation factor ix
(recombinant) for inj 1000 unit
5
RIXUBIS - coagulation factor ix
(recombinant) for inj 2000 unit
5
•
ZONTIVITY - vorapaxar sulfate tab 2.08
mg (base equivalent)
4
RIXUBIS - coagulation factor ix
(recombinant) for inj 3000 unit
5
•
TOPICAL PRODUCTS
ticlopidine hcl tab 250 mg
2
TRENTAL - pentoxifylline tab cr 400 mg
4
TRETTEN - coagulation factor xiii asubunit for inj 2000-3125 unit
5
WILATE - antihemophilic factor/vwf
(human) for inj 450-450 unit
OPHTHALMIC AGENTS
ACULAR - ketorolac tromethamine
ophth soln 0.5%
4
•
ACULAR LS - ketorolac tromethamine
ophth soln 0.4%
4
5
•
ACUVAIL - ketorolac tromethamine
ophth soln 0.45%
4
5
•
AKTEN - lidocaine hcl ophth gel 3.5%
4
WILATE - antihemophilic factor/vwf
(human) for inj 500-500 unit
4
WILATE - antihemophilic factor/vwf
(human) for inj 900-900 unit
5
ALAMAST - pemirolast potassium ophth
soln 0.1%
4
WILATE - antihemophilic factor/vwf
(human) for inj 1000-1000 unit
5
ALCAINE - proparacaine hcl ophth soln
0.5%
4
XYNTHA - antihemophilic factor
recombinant paf for inj kit 250 unit
5
ALOCRIL - nedocromil sodium ophth
soln 2%
4
XYNTHA - antihemophilic factor
recombinant paf for inj kit 500 unit
5
ALOMIDE - lodoxamide tromethamine
ophth soln 0.1%
3
XYNTHA - antihemophilic factor
recombinant paf for inj kit 1000 unit
5
ALPHAGAN P - brimonidine tartrate
ophth soln 0.1%
4
XYNTHA - antihemophilic factor
recombinant paf for inj kit 2000 unit
5
ALPHAGAN P - brimonidine tartrate
ophth soln 0.15%
4
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 250
unit
5
ALREX - loteprednol etabonate ophth
susp 0.2%
apraclonidine hcl ophth soln 0.5%
(base equivalent) (Iopidine)
2
140
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
5
Dispensing Limits
Prior Authorization
RECOMBINATE - antihemophilic factor
(recombinant) for inj 801-1240 unit
Drug Name
Step Therapy
Drug Tier
2014
ATROPINE SULFATE - atropine sulfate
ophth oint 1%
4
BROMFENAC - bromfenac sodium
ophth soln 0.09% (base equivalent)
4
atropine sulfate ophth soln 1%
(Isopto atropine)
1
bromfenac sodium ophth soln 0.09%
(base equiv) (once-daily)
2
AZASITE - azithromycin ophth soln 1%
4
carteolol hcl ophth soln 1%
1
azelastine hcl ophth soln 0.05%
(Optivar)
2
CILOXAN - ciprofloxacin hcl ophth soln
0.3%
4
AZOPT - brinzolamide ophth susp 1%
3
CILOXAN - ciprofloxacin hcl ophth oint
0.3%
4
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
1
BACITRACIN - bacitracin ophth oint 500 3
unit/gm
2
bacitracin-polymyxin b ophth oint
bacitracin-polymyxin-neomycin-hc
ophth oint 1%
2
COMBIGAN - brimonidine tartratetimolol maleate ophth soln 0.2-0.5%
4
BEPREVE - bepotastine besilate ophth
soln 1.5%
4
COSOPT - dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/ml
4
BESIVANCE - besifloxacin hcl ophth
susp 0.6% (base equiv)
4
COSOPT PF - dorzolamide hcl-timolol
maleate ophth sol 22.3-6.8 mg/ml pf
4
BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5%
4
cromolyn sodium ophth soln 4%
1
4
BETAGAN - levobunolol hcl ophth soln
0.5%
4
CYCLOGYL - cyclopentolate hcl ophth
soln 0.5%
4
betaxolol hcl ophth soln 0.5%
2
CYCLOGYL - cyclopentolate hcl ophth
soln 1%
BETIMOL - timolol ophth soln 0.25%
4
4
BETIMOL - timolol ophth soln 0.5%
4
CYCLOGYL - cyclopentolate hcl ophth
soln 2%
4
CYCLOMYDRIL - cyclopentolate w/
phenylephrine ophth soln 0.2-1%
4
BETOPTIC-S - betaxolol hcl ophth susp
0.25%
4
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
1
BLEPH-10 - sulfacetamide sodium
ophth soln 10%
4
cyclopentolate hcl ophth soln 2%
(Cyclogyl)
2
BLEPHAMIDE - sulfacetamide sodiumprednisolone ophth susp 10-0.2%
BLEPHAMIDE S.O.P. - sulfacetamide
sodium-prednisolone ophth oint
10-0.2%
4
brimonidine tartrate ophth soln
0.15% (Alphagan p)
2
brimonidine tartrate ophth soln 0.2%
1
BROMDAY - bromfenac sodium ophth
soln 0.09% (base equiv) (once-daily)
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
CYSTARAN - cysteamine hcl ophth soln 5
0.44% (base equivalent)
2
dexamethasone sodium phosphate
ophth soln 0.1%
2
diclofenac sodium ophth soln 0.1%
dorzolamide hcl ophth soln 2%
(Trusopt)
2
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml (Cosopt)
2
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
141
DUREZOL - difluprednate ophth
emulsion 0.05%
4
ISOPTO CARBACHOL - carbachol
ophth soln 1.5%
4
ELESTAT - epinastine hcl ophth soln
0.05%
4
ISOPTO CARBACHOL - carbachol
ophth soln 3%
4
EMADINE - emedastine difumarate
ophth soln 0.05% (base equiv)
4
ISOPTO CARPINE - pilocarpine hcl
ophth soln 1%
4
epinastine hcl ophth soln 0.05%
(Elestat)
2
ISOPTO CARPINE - pilocarpine hcl
ophth soln 2%
4
erythromycin ophth oint 5 mg/gm
1
4
FLAREX - fluorometholone acetate
ophth susp 0.1%
4
ISOPTO CARPINE - pilocarpine hcl
ophth soln 4%
fluorometholone ophth susp 0.1%
(Fml liquifilm)
1
flurbiprofen sodium ophth soln
0.03% (Ocufen)
1
FML - fluorometholone ophth oint 0.1%
4
FML FORTE - fluorometholone ophth
susp 0.25%
4
FML LIQUIFILM - fluorometholone
ophth susp 0.1%
4
GARAMYCIN - gentamicin sulfate ophth
soln 0.3%
4
gatifloxacin ophth soln 0.5%
(Zymaxid)
2
GELFILM OP - gelatin adsorbable ophth 4
film
1
gentamicin sulfate ophth oint 0.3%
Dispensing Limits
Step Therapy
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
gentamicin sulfate ophth soln 0.3%
(Garamycin)
1
LEVOBUNOLOL HCL - levobunolol hcl
ophth soln 0.25%
4
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
ILEVRO - nepafenac ophth susp 0.3%
4
levofloxacin ophth soln 0.5%
2
IOPIDINE - apraclonidine hcl ophth soln
0.5% (base equivalent)
4
LOTEMAX - loteprednol etabonate
ophth susp 0.5%
3
IOPIDINE - apraclonidine hcl ophth soln
1% (base equivalent)
4
LOTEMAX - loteprednol etabonate
ophth gel 0.5%
3
IQUIX - levofloxacin ophth soln 1.5%
4
3
ISOPTO ATROPINE - atropine sulfate
ophth soln 1%
4
LOTEMAX - loteprednol etabonate
ophth oint 0.5%
LUMIGAN - bimatoprost ophth soln
0.01%
3
142
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
•
•
ofloxacin ophth soln 0.3% (Ocuflox)
1
3
MAXIDEX - dexamethasone ophth susp
0.1%
OMNIPRED - prednisolone acetate
ophth susp 1%
4
4
MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1%
OPTIPRANOLOL - metipranolol ophth
soln 0.3%
4
4
4
OPTIVAR - azelastine hcl ophth soln
0.05%
4
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
2
PATADAY - olopatadine hcl ophth soln
0.2%
3
METIPRANOLOL - metipranolol ophth
soln 0.3%
MITOSOL - mitomycin for ophth soln kit
0.2 mg
PATANOL - olopatadine hcl ophth soln
0.1%
4
4
phenylephrine hcl ophth soln 10%
1
MOXEZA - moxifloxacin hcl ophth soln
0.5% (base eq) (2 times daily)
4
phenylephrine hcl ophth soln 2.5%
(Mydfrin)
1
MYDFRIN - phenylephrine hcl ophth
soln 2.5%
4
4
MYDRIACYL - tropicamide ophth soln
1%
4
PHOSPHOLINE IODIDE echothiophate iodide ophth for soln
0.125%
4
pilocarpine hcl ophth soln 1% (Isopto
carpine)
2
NAPHAZOLINE HCL - naphazoline hcl
ophth soln 0.1%
NATACYN - natamycin ophth susp 5%
pilocarpine hcl ophth soln 2% (Isopto
carpine)
2
3
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
2
pilocarpine hcl ophth soln 4% (Isopto
carpine)
2
neomycin-polymyxin b-gramicidin
ophth soln (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-polymyxin bgramicidin ophth soln
4
NEVANAC - nepafenac ophth susp
0.1%
4
OCUFEN - flurbiprofen sodium ophth
soln 0.03%
4
PILOPINE HS - pilocarpine hcl ophth gel 4
4%
1
polymyxin b-trimethoprim ophth
soln 10000 unit/ml-0.1% (Polytrim)
4
POLYTRIM - polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
4
PRED FORTE - prednisolone acetate
ophth susp 1%
4
PRED MILD - prednisolone acetate
ophth susp 0.12%
PRED-G - gentamicin-prednisolone ace 4
ophth susp 0.3-1%
4
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6%
prednisolone acetate ophth susp 1% 1
(Pred forte)
OCUFLOX - ofloxacin ophth soln 0.3%
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Drug Tier
•
LUMIGAN - bimatoprost ophth soln
0.03%
Step Therapy
Drug Name
Prior Authorization
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
143
PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate
ophth soln 1%
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
TIMOPTIC-XE - timolol maleate ophth
gel forming soln 0.5%
4
PROLENSA - bromfenac sodium ophth
soln 0.07% (base equivalent)
TOBRADEX - tobramycindexamethasone ophth susp 0.3-0.1%
4
4
proparacaine hcl ophth soln 0.5%
(Alcaine)
TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1%
3
1
4
RESCULA - unoprostone isopropyl
ophth soln 0.15%
4
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
4
QUIXIN - levofloxacin ophth soln 0.5%
tobramycin ophth soln 0.3% (Tobrex)
1
RESTASIS - cyclosporine (ophth)
emulsion 0.05%
4
tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex)
2
SIMBRINZA - brinzolamide-brimonidine
tartrate ophth susp 1-0.2%
3
TOBREX - tobramycin sulfate ophth
soln 0.3%
4
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10%
4
TOBREX - tobramycin sulfate ophth oint
0.3%
4
sulfacetamide sodium ophth soln
10% (Bleph-10)
1
3
•
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
1
TRAVATAN Z - travoprost ophth soln
0.004% (benzalkonium free) (bak
free)
4
•
tetracaine hcl ophth soln 0.5%
1
TRAVOPROST - travoprost ophth soln
0.004%
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
2
trifluridine ophth soln 1% (Viroptic)
2
tropicamide ophth soln 0.5%
2
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
2
tropicamide ophth soln 1%
(Mydriacyl)
2
timolol maleate ophth soln 0.25%
(Timoptic)
1
TRUSOPT - dorzolamide hcl ophth soln
2%
4
timolol maleate ophth soln 0.5%
(Timoptic)
1
VEXOL - rimexolone ophth susp 1%
4
TIMOPTIC - timolol maleate ophth soln
0.25%
VIGAMOX - moxifloxacin hcl ophth soln
0.5% (base equiv)
3
4
VIROPTIC - trifluridine ophth soln 1%
4
TIMOPTIC - timolol maleate ophth soln
0.5%
4
VOLTAREN - diclofenac sodium ophth
soln 0.1%
4
TIMOPTIC OCUDOSE - timolol maleate
preservative free ophth soln 0.25%
4
XALATAN - latanoprost ophth soln
0.005%
4
•
TIMOPTIC OCUDOSE - timolol maleate
preservative free ophth soln 0.5%
4
ZIOPTAN - tafluprost ophth soln
0.0015%
4
•
TIMOPTIC-XE - timolol maleate ophth
gel forming soln 0.25%
4
ZIRGAN - ganciclovir ophth gel 0.15%
4
ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
3
144
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
4
antipyrine-benzocaine-polycosanol
otic sol 5.4-1.4-0.0097% (Treagan
otic)
2
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
2
2
acetic acid otic soln 2%
2
hydrocortisone w/ acetic acid otic
soln 1-2% (Vosol hc)
ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum acetate
otic soln
4
MYOXIN - benzocaine-chloroxylenol-hc
otic soln 15-1-10 mg/ml
4
1
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)
2
antipyrine-benzocaine otic soln
55-14 mg/ml (5.5-1.4%) (Auralgan)
2
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
1
ANTIPYRINE/BENZOCAINE antipyrine-benzocaine otic soln 55-14
mg/ml (5.5-1.4%)
2
OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml
4
4
OTOZIN - antipyrine-benzocaineglycerin-zinc ace otic liqd 5.4-1-2-1%
4
AURALGAN - antipyrine-benzocaine
otic soln 55-14 mg/ml (5.5-1.4%)
4
PINNACAINE OTIC - benzocaine otic
soln 20%
4
CETRAXAL - ciprofloxacin hcl otic soln
0.2% (base equivalent)
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
PRAMOTIC - pramoxine-chloroxylenol
otic liquid 1-0.1%
4
4
CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1%
pramoxine-chloroxylenol otic liquid
1-0.1% (Pramotic)
1
3
1
CIPROFLOXACIN - ciprofloxacin hcl
otic soln 0.2% (base equivalent)
4
pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml
(Cortane-b aqueous)
COLY-MYCIN S - neomycin-colistin-hcthonzonium otic susp 3.3-3-10-0.5
mg/ml
4
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-b-otic)
1
CORTANE-B AQUEOUS - pramoxinehc-chloroxylenol aqueous otic soln
10-10-1 mg/ml
TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
4
4
CORTANE-B-OTIC - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml
TRIOXIN - benzocaine-chloroxylenol-hc
otic soln 15-1-10 mg/ml
4
4
4
CORTISPORIN - neomycin-polymyxinhc otic soln 1%
4
VOSOL HC - hydrocortisone w/ acetic
acid otic soln 1-2%
CORTISPORIN-TC - neomycin-colistinhc-thonzonium otic susp 3.3-3-10-0.5
mg/ml
4
CRESYLATE - cresyl acetate otic soln
25%
4
OTIC AGENTS
Dispensing Limits
DERMOTIC - fluocinolone acetonide
(otic) oil 0.01%
Step Therapy
4
Prior Authorization
ZYMAXID - gatifloxacin ophth soln 0.5%
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
2014
MOUTH/THROAT/DENTAL AGENTS
mouthwashes - liquid
2
ACT TOTAL CARE DRY MOUTH sodium fluoride rinse 0.02%
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
145
APHTHASOL - amlexanox oral paste
5%
4
AQUORAL - artificial saliva - aero soln
4
benzocaine dental soln 20%
1
CAPHOSOL - artificial saliva - solution
4
cevimeline hcl cap 30 mg (Evoxac)
2
chlorhexidine gluconate soln 0.12%
(Peridex)
LISTERINE TOTAL CARE PLUS sodium fluoride rinse 0.0221%
(0.01% f)
4
LISTERINE TOTAL CARE ZERO sodium fluoride rinse 0.02%
4
4
1
LISTERINE WHITENING/RESTO sodium fluoride rinse 0.0221%
(0.01% f)
clotrimazole troche 10 mg
LTA 360 KIT - lidocaine hcl
laryngotracheal soln 4%
4
2
COLGATE DRY MOUTH RELIEF sodium fluoride mouthwash 2.1
mg/10ml
4
FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate gel
1.1-5%
4
GEL-KAM - stannous fluoride gel 0.4%
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
GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63%
4
NUMOISYN - artificial saliva - solution
4
NUMOISYN - artificial saliva - lozenge
4
GELCLAIR - povidone-sodium
hyaluronate-glycyrrhetinic acid gel
4
nystatin susp 100000 unit/ml
2
4
OMNI GEL - stannous fluoride gel 0.4%
4
GELX - oral wound care products - gel
2
ORAFATE - sucralfate-malate paste
10%
4
lidocaine hcl laryngotracheal soln
4% (Lta 360 kit)
1
ORAMAGICRX - oral wound care
products - for susp rinse
4
lidocaine hcl viscous soln 2%
LISTERINE ESSENTIAL CARE - sod
monofluorophosph-eucal-men-methyl
sal-thymol gel 0.76%
4
ORAVIG - miconazole buccal tab 50 mg
(mouth-throat)
4
LISTERINE RESTORING - sodium
fluoride rinse 0.0221% (0.01% f)
4
LISTERINE SMART RINSE - sodium
fluoride rinse 0.0221% (0.01% f)
4
LISTERINE TOOTH DEFENSE sodium fluoride rinse 0.0221%
(0.01% f)
4
LISTERINE TOTAL CARE - sodium
fluoride rinse 0.0221% (0.01% f)
4
DEBACTEROL - sulfuric acid-sulfonated 4
phenolics soln 30-50%
4
EVOXAC - cevimeline hcl cap 30 mg
146
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PREVIDENT FLUORIDE - sodium
fluoride gel 1.1% (0.5% f)
4
sodium fluoride rinse 0.2%
(Prevident)
1
PREVIDENT 5000 BOOSTER - sodium
fluoride paste 1.1%
4
sodium fluoride-potassium nitrate
paste 1.1-5% (Prevident 5000 sensi)
1
PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1%
4
stannous fluoride conc 0.63% (Gelkam oral care ri)
1
PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f)
4
stannous fluoride gel 0.4%
2
4
THERA-FLUR-N - sodium fluoride gel
1.1% (0.5% f)
4
PREVIDENT 5000 ENAMEL PRO sodium fluoride-potassium nitrate
paste 1.1-5%
triamcinolone acetonide dental paste
0.1%
2
PREVIDENT 5000 PLUS - sodium
fluoride cream 1.1%
4
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 DEEPLY WHITE+PE sodium monofluorophosphate paste
0.884%
4
REMBRANDT INTENSE STAIN sodium fluoride paste 0.243%
4
REMBRANDT WHITENING - sodium
fluoride rinse 0.02%
4
SALAGEN - pilocarpine hcl tab 5 mg
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
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
1
sodium fluoride paste 1.1%
(Prevident 5000 boost)
1
sodium fluoride rinse 0.0221%
(0.01% f)
2
sodium fluoride rinse 0.05%
2
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ANORECTAL AGENTS
2
hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit (Analpram e)
4
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
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal cream
1-1%
4
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal cream
2.5-1%
4
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal lotn
2.5-1%
4
ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine
rectal cream 1-1%
4
ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%
4
ANUSOL-HC - hydrocortisone rectal
cream 2.5%
4
ANUSOL-HC - hydrocortisone acetate
suppos 25 mg
4
CORTENEMA - hydrocortisone enema
100 mg/60ml
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
147
CORTIFOAM - hydrocortisone acetate
rectal foam 90 mg/dose
3
Z-PRAM - hydrocortisone acetate w/
pramoxine rectal cream kit 2.35-1%
4
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
ZYPRAM - hydrocortisone acetate w/
pramoxine rectal cream 2.35-1%
4
hydrocortisone acetate suppos
30 mg (Proctocort)
2
DERMATOLOGICALS
hydrocortisone acetate w/ pramoxine
rectal cream 1-1% (Analpram-hc)
2
hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1% (Analpram-hc)
2
hydrocortisone enema 100 mg/60ml
(Cortenema)
2
hydrocortisone rectal cream 1%
(Proctocort)
nystatin topical powder
2
salicylic acid cream 6% & cleanser
liqd kit (Salex cream)
2
salicylic acid lotion 6% & cleanser
liqd kit (Salex lotion)
2
2
2
sulfacetamide sod-sulfur wash
9-4.5% & skin cleanser kit
(Sumadan kit)
hydrocortisone rectal cream 2.5%
(Anusol-hc)
sulfacetamide sodium-sulfur w/
sunscreens cream 10-5%
2
1
wound dressings - cream
2
LIDOCAINE HCL-HYDROCORTIS lidocaine-hydrocortisone acetate
rectal gel 2.8-0.55%
4
ABSORICA - isotretinoin cap 10 mg
4
ABSORICA - isotretinoin cap 20 mg
4
lidocaine-hydrocortisone acetate
rectal cream kit 2-2%
2
ABSORICA - isotretinoin cap 30 mg
4
ABSORICA - isotretinoin cap 40 mg
4
lidocaine-hydrocortisone acetate
rectal cream kit 3-0.5%
2
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
4
lidocaine-hydrocortisone acetate
rectal cream kit 3-1%
2
acitretin cap 10 mg (Soriatane)
2
2
2
acitretin cap 17.5 mg (Soriatane)
lidocaine-hydrocortisone acetate
rectal cream 3-0.5%
acitretin cap 25 mg (Soriatane)
2
2
ACLOVATE - alclometasone
dipropionate cream 0.05%
4
lidocaine-hydrocortisone acetate
rectal gel kit 3-2.5%
4
acyclovir oint 5% (Zovirax)
2
PROCORT - hydrocortisone acetate w/
pramoxine rectal cream 1.85-1.15%
ACZONE - dapsone gel 5%
4
PROCTOCORT - hydrocortisone rectal
cream 1%
4
adapalene cream 0.1% (Differin)
2
adapalene gel 0.1% (Differin)
2
PROCTOCORT - hydrocortisone
acetate suppos 30 mg
4
adapalene gel 0.3% (Differin)
2
4
4
AKNE-MYCIN - erythromycin oint 2%
PROCTOFOAM HC - hydrocortisone
acetate w/ pramoxine rectal foam
1-1%
ALA QUIN - clioquinol-hc cream 3-0.5%
4
ALA SCALP - hydrocortisone lotion 2%
4
RECTIV - nitroglycerin oint 0.4%
4
alclometasone dipropionate cream
0.05% (Aclovate)
2
148
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
alclometasone dipropionate oint
0.05%
2
AURSTAT - emollient cream & wound
dressing gel kit
4
ALCORTIN A - iodoquinolhydrocortisone-aloe polysaccharide
gel 1-2-1%
4
AURSTAT ANTI-ITCH HYDROGE dermatological products misc - kit
4
ALDARA - imiquimod cream 5%
AVAR - sulfacetamide sodium w/ sulfur
cleansing pad 9.5-5%
4
4
ALEVEER - capsaicin-menthol topical
patch 0.0375-5%
4
AVAR LS - sulfacetamide sodium w/
sulfur cleansing pad 10-2%
4
ALLEVYN AG ADHESIVE - wound
dressings - pads
4
AVAR LS CLEANSER - sulfacetamide
sodium w/ sulfur cleanser 10-2%
4
ALLEVYN AG GENTLE BORDER wound dressings - pads
4
AVAR-E LS - sulfacetamide sodium w/
sulfur cream 10-2%
4
AZELEX - azelaic acid cream 20%
4
BACTROBAN - mupirocin oint 2%
4
BACTROBAN - mupirocin calcium
cream 2%
4
BENSAL HP - salicylic acid & benzoic
acid oint 3-6%
4
BENZACLIN - clindamycin phosphatebenzoyl peroxide gel 1-5%
4
ALUMINUM ACETATE - aluminum
acetate soln
BENZACLIN WITH PUMP - clindamycin
phosphate-benzoyl peroxide gel 1-5%
4
4
aluminum chloride soln 20% (Drysol)
BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3%
4
1
ALUVEA - urea cream 39%
4
4
AMCINONIDE - amcinonide lotion 0.1%
4
BENZAMYCINPAK - benzoyl peroxideerythromycin gel pack 5-3%
AMCINONIDE - amcinonide oint 0.1%
4
4
amcinonide cream 0.1%
2
BENZEFOAM - benzoyl peroxide foam
5.3%
ANACAINE - benzocaine oint 10%
4
APEXICON E - diflorasone diacetate
emollient base cream 0.05%
4
ARZOL SILVER NITRATE APP - silver
nitrate-potassium nitrate applicator
75-25%
4
ATOPICLAIR - emollient - cream
ALLEVYN AG NON-ADHESIVE - wound 4
dressings - pads
4
ALLEVYN AG SACRUM - wound
dressings - pads
ALLEVYN GENTLE - wound dressings - 4
pads
4
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
4
ALTABAX - retapamulin oint 1%
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
BENZEFOAMULTRA - benzoyl peroxide 4
foam 9.8%
4
BENZIQ - benzoyl peroxide gel 5.25 %
BENZIQ LS - benzoyl peroxide gel
2.75%
4
benzoyl peroxide cleanser 4.25%
2
4
benzoyl peroxide cloth 3%
2
ATRALIN - tretinoin gel 0.05%
4
benzoyl peroxide cloth 6%
2
ATRAPRO CP - wound dressings - kit
4
benzoyl peroxide cloth 9%
2
ATRAPRO DERMAL SPRAY - wound
cleansers - liquid
4
benzoyl peroxide creamy wash 4% &
cleanser lotion kit
2
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
149
betamethasone valerate lotion 0.1%
2
betamethasone valerate oint 0.1%
2
BPO - benzoyl peroxide gel 4%
4
BPO - benzoyl peroxide gel 8%
4
4
benzoyl peroxide creamy wash 8% &
cleanser lotion 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 CREAMY WASH COMPLETE benzoyl peroxide creamy wash 8%
&benzoyl peroxide bar 5% kit
benzoyl peroxide foam 9.8%
(Benzefoamultra)
2
BPO 3% FOAMING CLOTHS - benzoyl
peroxide cloth 3%
2
benzoyl peroxide gel 10%
1
2
benzoyl peroxide gel 5%
1
BPO 6% FOAMING CLOTHS - benzoyl
peroxide cloth 6%
2
BPO 9% FOAMING CLOTHS - benzoyl
peroxide cloth 9%
2
benzoyl peroxide liq 2.5%
benzoyl peroxide liq 5.25%
2
2
butamben-tetracaine-benzocaine
aerosol spray 2-2-14%
2
benzoyl peroxide liq 7%
benzoyl peroxide lotion 6%
2
2
benzoyl peroxide lotion 9%
2
calcipotriene cream 0.005%
(Dovonex)
benzoyl peroxide pad 3%
2
calcipotriene oint 0.005%
2
benzoyl peroxide pad 6%
2
2
benzoyl peroxide-erythromycin gel
5-3% (Benzamycin)
2
calcipotriene soln 0.005% (50 mcg/
ml)
2
betamethasone dipropionate
augmented cream 0.05% (Diprolene
af)
2
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
CALCITRIOL - calcitriol oint 3 mcg/gm
4
betamethasone dipropionate
augmented gel 0.05%
2
CAPEX - fluocinolone acetonide
shampoo 0.01%
4
CARAC - fluorouracil cream 0.5%
3
CARMOL-HC - urea-hc acetate cream
1%
4
CEM-UREA - urea soln 45%
2
CENTANY - mupirocin oint 2%
1
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
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)
150
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
2
2
Step Therapy
betamethasone valerate cream 0.1%
benzoyl peroxide creamy wash 4%
&benzoyl peroxide bar 5% kit
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
CICLODAN SOLUTION KIT - ciclopirox
solution kit 8%
4
clindamycin phosphate lotion 1%
(Cleocin-t)
2
ciclopirox gel 0.77% (Loprox)
2
1
ciclopirox olamine cream 0.77%
(base equiv)
2
clindamycin phosphate soln 1%
(Cleocin-t)
2
ciclopirox olamine susp 0.77% (base
equiv)
2
clindamycin phosphate swab 1%
(Cleocin-t)
2
ciclopirox shampoo 1% (Loprox
shampoo)
2
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
2
ciclopirox solution kit 8% (Ciclodan
solution ki)
2
clobetasol propionate cream 0.05%
(Temovate)
2
ciclopirox solution 8% (Penlac nail
lacquer)
1
clobetasol propionate emollient base
cream 0.05% (Temovate e)
2
CICLOPIROX TOPICAL SOLUTI ciclopirox solution 8% & vitamin e 5%
topical kit
4
clobetasol propionate emulsion
foam 0.05% (Olux-e)
clobetasol propionate foam 0.05%
(Olux)
2
CLARAVIS - isotretinoin cap 30 mg
4
clobetasol propionate gel 0.05%
(Temovate)
2
clobetasol propionate lotion 0.05%
(Clobex)
2
clobetasol propionate oint 0.05%
(Temovate)
2
clobetasol propionate shampoo
0.05% (Clobex)
2
clobetasol propionate soln 0.05%
(Temovate)
2
CLOBEX - clobetasol propionate spray
0.05%
4
CLOBEX - clobetasol propionate lotion
0.05%
4
CLOBEX - clobetasol propionate
shampoo 0.05%
4
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
4
CLOCORTOLONE PIVALATE PUM clocortolone pivalate cream 0.1%
4
CLODAN KIT - clobetasol propionate
shampoo 0.05% & cleanser kit
4
CLODERM - clocortolone pivalate
cream 0.1%
4
CLARIFOAM EF - sulfacetamide sodium 4
w/ sulfur foam 10-5%
4
CLEOCIN-T - clindamycin phosphate
soln 1%
4
CLEOCIN-T - clindamycin phosphate
gel 1%
4
CLEOCIN-T - clindamycin phosphate
lotion 1%
4
CLEOCIN-T - clindamycin phosphate
swab 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)
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
151
CLODERM PUMP - clocortolone
pivalate cream 0.1%
4
CUTIVATE - fluticasone propionate oint
0.005%
4
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
2
DELOS - benzoyl peroxide lotion 3.5%
4
DENAVIR - penciclovir cream 1%
4
clotrimazole w/ betamethasone
lotion 1-0.05%
2
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%
4
CNL8 NAIL KIT - ciclopirox soln 8% &
lacquer removal pads kit
4
DERMA-SMOOTHE/FS BODY OIL fluocinolone acetonide oil 0.01%
4
COAL TAR - coal tar soln 20%
4
COCAINE HCL - cocaine hcl soln 4%
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%
4
4
COCAINE HCL - cocaine hcl soln 10%
4
4
CONDYLOX - podofilox soln 0.5%
4
DERMA-SMOOTHE/FS SCALP OI fluocinolone acetonide oil 0.01%
CONDYLOX - podofilox gel 0.5%
4
4
CORDRAN - flurandrenolide cream
0.05%
4
DERMASORB AF - clioquinol-hc cream
3-0.5% & emollient liqd kit
4
CORDRAN - flurandrenolide lotion
0.05%
4
DERMASORB HC - hydrocortisone lot
2% & cleanser liq kit
CORDRAN - flurandrenolide oint 0.05%
4
CORDRAN TAPE - flurandrenolide tape
4 mcg/sqcm
4
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
4
CORTISPORIN - neomycin-polymyxinhc cream 0.5%
4
CORTISPORIN - bacitracin-polymyxinneomycin hc oint 1%
4
CURAGEL HYDROGEL ISLAND W hydroactive (sterile) dressing
4
CURAGEL HYDROGEL WOUND DR hydroactive (sterile) dressing
4
CURITY HYPERTONIC SODIUM wound dressings - misc
4
CURITY SODIUM CHLORIDE DR wound dressings - pads
4
CUTIVATE - fluticasone propionate
cream 0.05%
4
CUTIVATE - fluticasone propionate
lotion 0.05%
4
152
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%
DESONATE - desonide gel 0.05%
4
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
DESOWEN CREAM/CETAPHIL
LO - desonide cream 0.05% w/
moisturizing lotion kit
4
DESOWEN LOTION/CETAPHIL C desonide lotion 0.05% w/ moisturizing
cream kit
4
DESOWEN OINTMENT/CETAPHIL desonide ointment 0.05% w/
moisturizing lotion kit
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
DESOXIMETASONE - desoximetasone
cream 0.05%
4
ELENZAPATCH - lidocaine-menthol
patch 4-1%
4
DESOXIMETASONE - desoximetasone
oint 0.05%
4
ELETONE - emollient - cream
4
desoximetasone cream 0.25%
(Topicort)
ELETONE TWINPACK - emollient cream
4
2
ELIDEL - pimecrolimus cream 1%
3
desoximetasone gel 0.05% (Topicort)
2
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
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%
3
DIFFERIN - adapalene lotion 0.1%
4
DIFLORASONE DIACETATE diflorasone diacetate cream 0.05%
4
diflorasone diacetate oint 0.05%
2
4
EPIDUO - adapalene-benzoyl peroxide
gel 0.1-2.5%
4
DIPROLENE - betamethasone
dipropionate augmented lotion 0.05%
4
EPIFOAM - pramoxine-hc aerosol foam
1-1%
4
DIPROLENE - betamethasone
dipropionate augmented oint 0.05%
4
ERTACZO - sertaconazole nitrate
cream 2%
4
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
ERYGEL - erythromycin gel 2%
4
DOVONEX - calcipotriene cream
0.005%
4
erythromycin gel 2% (Erygel)
2
erythromycin pads 2%
2
DOVONEX SCALP - calcipotriene soln
0.005% (50 mcg/ml)
4
erythromycin soln 2%
2
DRITHO-CREME HP - anthralin cream
1%
ETHYL CHLORIDE - ethyl chloride
aerosol spray
4
4
4
DRITHO-SCALP - anthralin cream 0.5%
4
ETHYL CHLORIDE/FINE PINPO - ethyl
chloride aerosol spray
DRYSOL - aluminum chloride soln 20%
4
DUAC - clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
4
econazole nitrate cream 1%
2
ECOZA - econazole nitrate foam 1%
4
EFUDEX - fluorouracil cream 5%
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
153
ETHYL CHLORIDE/MIST - ethyl
chloride aerosol spray
4
fluorouracil soln 5%
2
EURAX - crotamiton cream 10%
fluticasone propionate cream 0.05%
(Cutivate)
2
4
EURAX - crotamiton lotion 10%
4
fluticasone propionate lotion 0.05%
(Cutivate)
2
fluticasone propionate oint 0.005%
(Cutivate)
2
GEBAUERS PAIN EASE pentafluoropropane-tetrafluoroethane
aero spray
4
GEBAUERS SPRAY AND STRETC pentafluoropropane-tetrafluoroethane
aero spray
4
EVOCLIN - clindamycin phosphate foam 4
1%
4
EXELDERM - sulconazole nitrate
solution 1%
EXELDERM - sulconazole nitrate cream 4
1%
4
EXTINA - ketoconazole foam 2%
FABIOR - tazarotene (acne) foam 0.1%
4
FINACEA - azelaic acid gel 15%
3
FINACEA PLUS - azelaic acid gel 15%
w/cleanser & moisturizing lotion kit
GENADUR - dermatological products
misc - liquid
4
4
4
GENADUR KIT - dermatological
products misc topical/oral - kit
4
FIRST-HYDROCORTISONE hydrocortisone gel 10%
FLECTOR - diclofenac epolamine patch
1.3%
GENTAMICIN SULFATE - gentamicin
sulfate cream 0.1%
4
4
fluocinolone acetonide cream 0.01%
GENTAMICIN SULFATE - gentamicin
sulfate oint 0.1%
4
2
fluocinolone acetonide cream
0.025% (Synalar)
2
gentamicin sulfate cream 0.1%
1
gentamicin sulfate oint 0.1%
1
fluocinolone acetonide oil 0.01%
(Derma-smoothe/fs bod)
2
GORDOFILM - salicylic & lactic acids
soln 16.7-16.7%
4
fluocinolone acetonide oint 0.025%
(Synalar)
2
GORDONS UREA - urea ointment 40%
4
2
GRANULEX - trypsin w/ castor oil &
peruvian balsam spray
4
fluocinolone acetonide soln 0.01%
(Synalar)
1
GREEN SOAP - green soap tincture
4
fluocinonide cream 0.05%
2
fluocinonide emulsified base cream
0.05%
1
halobetasol prop oint 0.05% &
ammonium lactate lot 12% kit
(Ultravate pac)
2
fluocinonide cream 0.1% (Vanos)
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)
FLUOROPLEX - fluorouracil cream 1%
3
HALOG - halcinonide cream 0.1%
4
fluorouracil cream 5% (Efudex)
2
HALOG - halcinonide oint 0.1%
4
fluorouracil soln 2%
2
154
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
HYLATOPIC PLUS - emollient - aerosol
foam
4
HYLATOPIC PLUS/AURSTAT emollient foam & wound dressing gel
kit
4
HYLIRA - hyaluronate sodium
(emollient) gel 0.2%
4
HYLIRA - hyaluronate sodium
(emollient) lotion 0.1%
4
imiquimod cream 5% (Aldara)
2
HALOTIN - haloprogin cream 1%
4
HPR - emollient - aerosol foam
4
HPR PLUS - emollient - cream
4
HPR PLUS - emollient - aerosol foam
4
HPR PLUS/MB HYDROGEL - emollient
foam & wound dressing gel kit
4
hyaluronate sodium (emollient) gel
0.2% (Hylira)
2
HYDRO 35 - urea in lactic acid vehicle
foam 35%
4
INOVA - benzoyl peroxide pad 4% &
vitamin e topical 5% kit
4
HYDRO 40 FOAM - urea foam 40%
4
4
hydrocortisone acetate-aloe vera gel
2% (Nuzon)
2
INOVA - benzoyl peroxide pad 8% &
vitamin e topical 5% kit
4
hydrocortisone butyrate cream 0.1%
(Locoid)
2
INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic ac
pad 1% & vit e 5% kit
2
INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic ac
pad 2% & vit e 5% kit
4
hydrocortisone butyrate hydrophilic
lipo base cream 0.1% (Locoid
lipocream)
2
iodoquinol-hc cream 1%
2
hydrocortisone butyrate oint 0.1%
(Locoid)
isotretinoin cap 10 mg
2
hydrocortisone butyrate soln 0.1%
(Locoid)
1
isotretinoin cap 20 mg
2
isotretinoin cap 40 mg
2
hydrocortisone cream 2.5%
1
JUBLIA - efinaconazole soln 10%
4
hydrocortisone lotion 2.5%
2
4
hydrocortisone lotion 2% (Ala scalp)
2
KENALOG - triamcinolone acetonide
aerosol soln
hydrocortisone oint 2.5%
1
4
hydrocortisone valerate cream 0.2%
2
KENDALL HYDROGEL IMPREGNA hydroactive (sterile) dressing
2
KENDALL HYDROGEL WOUND DR hydroactive (sterile) dressing
4
hydrocortisone valerate oint 0.2%
(Westcort)
4
KENDALL ZINC CALCIUM ALGI wound dressings - pads
4
HYDROFERA BLUE FOAM DRESS wound dressings - pads
4
KENDALL ZINC CALCIUM ALGI wound dressings - misc
4
HYDROFERA BLUE 4"X4" - wound
dressings - pads
4
KERAFOAM - urea foam 30%
4
HYLASE WOUND - hyaluronate sodium
gel
KERAFOAM 42 - urea foam 42%
4
HYLATOPIC - emollient - aerosol foam
4
KERALAC - urea cream 47%
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
4
4
Step Therapy
HYLATOPIC PLUS - emollient - cream
HALONATE - halobetasol prop oint
0.05% & ammonium lactate foam
12% kit
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
155
2
KERALYT SCALP - salicylic acid
shampoo 6% & salicylic acid gel 6%
kit
4
lidocaine-prilocaine cream 2.5-2.5%
(Emla)
2
ketoconazole cream 2%
LIDOCAINE/PRILOCAINE - lidocaineprilocaine kit 2.5-2.5%
4
1
ketoconazole foam 2% (Extina)
2
LIDODERM - lidocaine patch 5%
4
ketoconazole shampoo 2% (Nizoral)
1
LIDORX - lidocaine hcl gel 3%
4
KETODAN KIT - ketoconazole foam 2%
& cleanser kit
4
lindane lotion 1%
2
lindane shampoo 1%
2
KLARON - sulfacetamide sodium lotion
10% (acne)
4
LOCOID - hydrocortisone butyrate soln
0.1%
4
LAC-HYDRIN - lactic acid (ammonium
lactate) cream 12%
4
LOCOID - hydrocortisone butyrate
cream 0.1%
4
LAC-HYDRIN - lactic acid (ammonium
lactate) lotion 12%
4
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
1
lactic acid (ammonium lactate) lotion
10%
2
lactic acid (ammonium lactate) lotion
12% (Lac-hydrin)
1
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
1
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%
LEVULAN KERASTICK - aminolevulinic 4
acid hcl for soln 20% (stick applicator)
4
LIDOCAINE HCL - lidocaine hcl lotion
3%
2
lidocaine hcl cream 3%
lidocaine hcl gel 2%
2
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine oint 5%
2
156
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 - ciclopirox gel 0.77%
LOPROX SHAMPOO - ciclopirox
shampoo 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%
4
LYCELLE - nit remover - gel
4
mafenide acetate packet for topical
soln 5% (50 gm) (Sulfamylon)
2
malathion lotion 0.5% (Ovide)
2
MB HYDROGEL - emollient cream &
wound dressing gel kit
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
lidocaine patch 5% (Lidoderm)
Step Therapy
4
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
KERALYT - salicylic acid gel 6%
Prior Authorization
Drug Name
Drug Tier
2014
MEDIHONEY CALCIUM ALGINAT wound dressings - pads
4
NEO-SYNALAR - neomycinfluocinolone cream 0.35-0.025%
4
MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20%
4
4
MENTAX - butenafine hcl cream 1%
4
NEO-SYNALAR KIT - neomycinfluocinolone cream 0.35-0.025% &
emollient cr kit
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
2
NEOSALUS - emollient - cream
4
NEOSALUS - emollient - aerosol foam
4
METROCREAM - metronidazole cream
0.75%
4
NEOSALUS - emollient - lotion
4
NEOSALUS CP - emollient - cream
4
METROGEL - metronidazole gel 1%
4
METROLOTION - metronidazole lotion
0.75%
NEUAC KIT - clindamycin-benzoyl
perox gel 1.2-5% & moisturizer cr kit
4
4
metronidazole cream 0.75%
(Metrocream)
NIVATOPIC PLUS - dermatological
products misc - cream
4
2
NIZORAL - ketoconazole shampoo 2%
4
metronidazole gel 0.75%
2
2
NOBLE MYSTIQUE EMU-LAC - lactic
acid (ammonium lactate) cream 10%
4
metronidazole gel 1% (Metrogel)
metronidazole lotion 0.75%
(Metrolotion)
2
NORITATE - metronidazole cream 1%
4
METVIXIA - methyl aminolevulinate hcl
cream 16.8% (base equiv)
NOVACORT - hydrocortisone acepramoxine-aloe polysacch gel 2-1-1%
4
4
MIMYX - emollient - cream
4
MIRVASO - brimonidine tartrate gel
0.33% (base equivalent)
4
mometasone furoate cream 0.1%
(Elocon)
2
mometasone furoate oint 0.1%
(Elocon)
2
mometasone furoate solution 0.1%
(lotion) (Elocon)
2
MOMEXIN - mometasone furoate cream 4
0.1% & ammon lactate foam 12% kit
2
mupirocin calcium cream 2%
(Bactroban)
1
mupirocin oint 2% (Bactroban)
NAFTIN - naftifine hcl cream 1%
4
NAFTIN - naftifine hcl cream 2%
4
NAFTIN - naftifine hcl gel 1%
4
NAFTIN - naftifine hcl gel 2%
4
NATROBA - spinosad susp 0.9%
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
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
nystatin oint 100000 unit/gm
2
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
2
OLUX - clobetasol propionate foam
0.05%
4
OLUX-E - clobetasol propionate
emulsion foam 0.05%
4
OPTASE - trypsin w/ castor oil &
peruvian balsam gel
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
157
4
OVACE PLUS - sulfacetamide sodium
shampoo 10%
4
OVACE PLUS WASH - sulfacetamide
sodium liquid 10%
4
OVACE PLUS WASH - sulfacetamide
sodium cleansing gel 10%
4
OVACE WASH - sulfacetamide sodium
liquid 10%
4
OVIDE - malathion lotion 0.5%
4
OXISTAT - oxiconazole nitrate cream
1%
4
OXISTAT - oxiconazole nitrate lotion 1% 4
4
OXSORALEN - methoxsalen lotion 1%
PICATO - ingenol mebutate gel 0.05%
4
PICO SINGLE USE NEGATIVE - wound 4
dressings - kit
4
PLEXION - sulfacetamide sodium w/
sulfur cream 9.8-4.8%
4
PLEXION - sulfacetamide sodium w/
sulfur lotion 9.8-4.8%
4
PLEXION CLEANSER - sulfacetamide
sodium w/ sulfur cleanser 9.8-4.8%
4
PLEXION CLEANSING CLOTHS sulfacetamide sodium w/ sulfur
cleansing cloth 9.8-4.8%
4
PLIAGLIS - lidocaine-tetracaine cream
7-7%
4
PODOCON 25 IN BENZOIN TIN podophyllum resin soln 25%
2
podofilox soln 0.5% (Condylox)
PONTOCAINE - tetracaine hcl soln 2%
4
OXSORALEN ULTRA - methoxsalen
rapid cap 10 mg
4
PR CREAM - dermatological products
misc - kit
4
PANDEL - hydrocortisone probutate
cream 0.1%
4
PRAMOSONE - pramoxine-hc cream
1-1%
4
PANRETIN - alitretinoin gel 0.1%
4
4
PEDIADERM AF COMPLETE KIT nystatin cream 100000 unit/gm &
diaper rash cream kit
4
PRAMOSONE - pramoxine-hc cream
1-2.5%
PRAMOSONE - pramoxine-hc lotion
1-1%
4
PEDIADERM HC - hydrocortisone lot
2% & emollient cream kit
4
PRAMOSONE - pramoxine-hc lotion
1-2.5%
4
PEDIADERM TA - triamcinolone cream
0.1% & emollient cream kit
4
PEDIPIROX-4 NAIL - ciclopirox soln 8%
& lacquer removal pads & foot powd
kit
4
PENLAC NAIL LACQUER - ciclopirox
solution 8%
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%
PENNSAID - diclofenac sodium soln
1.5%
4
PENNSAID - diclofenac sodium soln 2% 4
2
permethrin cream 5% (Elimite)
158
pramoxine-hc cream 1-2.5%
(Pramosone)
2
prednicarbate cream 0.1%
(Dermatop)
2
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
OVACE PLUS - sulfacetamide sodium
lotion 9.8%
4
Step Therapy
OVACE PLUS - sulfacetamide sodium
cream 10%
4
PICATO - ingenol mebutate gel 0.015%
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
ORACEA - doxycycline (rosacea) cap
delayed release 40 mg
Drug Name
Step Therapy
Drug Tier
2014
•
•
4
4
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.1%
PROMISEB - antiseborrheic products
misc - cream
4
RIAX - benzoyl peroxide foam 5.5%
4
RIAX - benzoyl peroxide foam 9.5%
4
PROMISEB COMPLETE antiseborrheic products misc - kit
4
ROSADAN KIT - metronidazole gel
0.75% w/ cleanser kit
4
PROTOPIC - tacrolimus oint 0.03%
3
4
PROTOPIC - tacrolimus oint 0.1%
3
ROSADAN KIT - metronidazole cream
0.75% w/ cleanser kit
PRUCLAIR - emollient - cream
4
4
PRUDOXIN - doxepin hcl cream 5%
4
ROSANIL - sulfacetamide sod-sulfur
emul 10-5% & skin cleanser kit
4
RTD WOUND CARE DRESSING wound dressings - pads
4
PRUMYX - emollient - cream
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
4
SALEX - salicylic acid shampoo 6%
4
4
SALEX CREAM - salicylic acid cream
6% & cleanser liqd kit
4
QUTENZA - capsaicin patch 8% &
cleansing gel kit
4
SALEX LOTION - salicylic acid lotion
6% & cleanser liqd kit
4
REGENECARE - lidocaine hcl-collagenaloe vera gel 2%
4
SALICYLIC ACID - salicylic acid soln
26%
4
REGRANEX - becaplermin gel 0.01%
RESTORE SILVER DRESSING 2 wound dressings - pads
4
salicylic acid cream 6%
2
4
salicylic acid film forming liquid
27.5% (Virasal)
2
RESTORE SILVER DRESSING 4 wound dressings - pads
4
salicylic acid foam 6% (Salvax)
2
RESTORE SILVER DRESSING 6 wound dressings - pads
salicylic acid gel 6% (Keralyt)
2
RETIN-A - tretinoin cream 0.025%
4
4
RETIN-A - tretinoin cream 0.05%
4
SALICYLIC ACID IN AMMONIU salicylic acid in ammonium lactate
vehicle foam 6%
RETIN-A - tretinoin cream 0.1%
4
salicylic acid lotion 6%
2
RETIN-A - tretinoin gel 0.01%
4
salicylic acid shampoo 6% (Salex)
2
RETIN-A - tretinoin gel 0.025%
4
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
SANARE SCAR THERAPY - scar
treatment products - cream
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%
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
PRESERA - emollient - aerosol foam
Dispensing Limits
2
Step Therapy
prednicarbate oint 0.1% (Dermatop)
Prior Authorization
Drug Name
Drug Tier
2014
159
SCALACORT DK - hc lot 2% & sal acidsulfur shampoo 2-2% & shampoo kit
4
SKLICE - ivermectin lotion 0.5%
4
SE BPO 7-5.5 WASH KIT - benzoyl
peroxide wash 7% & benzoyl
peroxide cream 5.5% kit
SODIUM SULFACETAMIDE WASH sulfacetamide sodium in bakuchiol
vehicle wash 10%
4
4
SEB-PREV - sulfacetamide sodium
lotion 10%
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium w/ sulfur susp
10-5%
4
4
SELENIUM SULFIDE - selenium
sulfide-pyrithione zinc in urea
shampoo 2.25%
4
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea
emulsion 10-5%
4
selenium sulfide lotion 2.5%
1
4
selenium sulfide-pyrithione zinc in
urea shampoo 2.25%
2
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea
gel 10-5%
SELRX - selenium sulfide-pyrithione
zinc in urea shampoo 2.3%
4
SODIUM SULFACETAMIDE/UREA sulfacetamide sodium-urea pad 10%
4
SELSUN SHAMPOO - selenium sulfide
lotion 2.5%
4
sodium thiosulfate-salicylic acid
lotion 25-1%
2
SILVADENE - silver sulfadiazine cream
1%
4
SOLARAZE - diclofenac sodium (actinic
keratoses) gel 3%
3
SILVER NITRATE - silver nitrate soln
0.5%
4
SORIATANE - acitretin cap 10 mg
4
SORIATANE - acitretin cap 17.5 mg
4
SILVER NITRATE - silver nitrate soln
10%
4
SORIATANE - acitretin cap 25 mg
4
SORILUX - calcipotriene foam 0.005%
4
SILVER NITRATE - silver nitrate soln
25%
4
SPINOSAD - spinosad susp 0.9%
4
4
SSS 10-4 - sulfacetamide sodium w/
sulfur foam 10-4%
4
SILVER NITRATE - silver nitrate soln
50%
4
STELARA - ustekinumab inj 45
mg/0.5ml
5
SILVER NITRATE - silver nitrate oint
10%
•
1
STELARA - ustekinumab inj 90 mg/ml
5
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
•
sulfacetamide sodium cleansing gel
10% (Ovace plus wash)
2
silver sulfadiazine cream 1%
(Silvadene)
1
sulfacetamide sodium liquid 10%
(Ovace wash)
2
SILVERSEAL HYDROGEL DRESS silver - pad 2"x3"
4
sulfacetamide sodium lotion 10%
(acne) (Klaron)
2
SILVERSEAL HYDROGEL DRESS silver - pad 4"x5"
4
sulfacetamide sodium shampoo 10%
(Ovace plus)
2
SILVRSTAT WOUND DRESSING silver - gel
4
sulfacetamide sodium w/ sulfur
cleanser 10-2% (Avar ls cleanser)
2
160
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
sulfacetamide sodium w/ sulfur
cleansing cloth 10-5%
2
SUMAXIN CP KIT - sulfacetamide sodsulfur pad 10-4% & skin cleanser kit
sulfacetamide sodium w/ sulfur
cleansing pad 10-4% (Sumaxin)
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 10-5%
2
sulfacetamide sodium w/ sulfur susp
8-4% (Sumaxin ts)
2
sulfacetamide sodium w/ sulfur wash
9-4.5% (Sumadan wash)
2
sulfacetamide sodium w/ sulfur wash
9-4% (Sumaxin wash)
2
sulfacetamide sodium-sulfur in urea
emulsion 10-4%
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
TACLONEX - calcipotrienebetamethasone dipropionate susp
0.005-0.064%
4
TACLONEX - calcipotrienebetamethasone dipropionate oint
0.005-0.064%
5
TARGRETIN - bexarotene gel 1%
SULFOAM - sulfur shampoo 2%
4
TAZORAC - tazarotene cream 0.05%
3
SULFURATED LIME - sulfurated lime
solution
4
TAZORAC - tazarotene cream 0.1%
3
TAZORAC - tazarotene gel 0.05%
3
SUMADAN KIT - sulfacetamide sodsulfur wash 9-4.5% & skin cleanser
kit
4
TAZORAC - tazarotene gel 0.1%
3
TEGADERM AG MESH DRESSING wound dressings - pads
4
SUMADAN WASH - sulfacetamide
sodium w/ sulfur wash 9-4.5%
4
TEMOVATE - clobetasol propionate
soln 0.05%
4
SUMADAN XLT - sulfacetamide sodsulfur wash 9-4.5% & sunscreen kit
4
TEMOVATE - clobetasol propionate
cream 0.05%
4
SUMAXIN - sulfacetamide sodium w/
sulfur cleansing pad 10-4%
4
TEMOVATE - clobetasol propionate gel
0.05%
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
4
•
161
tretinoin gel 0.01% (Retin-a)
2
tretinoin gel 0.025% (Retin-a)
2
TEMOVATE E - clobetasol propionate
emollient base cream 0.05%
4
4
tretinoin microsphere gel 0.04%
(Retin-a micro)
2
TERSI FOAM - selenium sulfide foam
2.25%
4
tretinoin microsphere gel 0.1%
(Retin-a micro)
2
TETRIX - dermatological products misc
- kit
4
TRI-CHLOR - trichloroacetic acid liqd
80%
4
TEXACORT - hydrocortisone soln 2.5%
TL TRISEB - antiseborrheic products
misc - cream
4
TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint 0.5%
4
TL-CERMIDE - dermatological products
misc - emulsion
4
triamcinolone acetonide cream
0.025%
1
TOPICORT - desoximetasone spray
0.25%
4
triamcinolone acetonide cream 0.1%
1
4
triamcinolone acetonide cream 0.5%
1
TOPICORT - desoximetasone cream
0.05%
3
TOPICORT - desoximetasone cream
0.25%
4
TRIAMCINOLONE ACETONIDE I triamcinolone acetonide oint 0.05%
2
TOPICORT - desoximetasone gel
0.05%
4
triamcinolone acetonide lotion
0.025%
triamcinolone acetonide lotion 0.1%
2
TOPICORT - desoximetasone oint
0.05%
4
triamcinolone acetonide oint 0.025%
1
triamcinolone acetonide oint 0.1%
1
TOPICORT - desoximetasone oint
0.25%
4
TRIANEX - triamcinolone acetonide oint
0.05%
4
TRETIN-X - tretinoin cream 0.0375%
4
TROPAZONE - emollient - lotion
4
TRETIN-X - tretinoin cream 0.075%
4
2
TRETIN-X - tretinoin gel 0.01% w/
cleanser & moisturizer kit
4
trypsin w/ castor oil & peruvian
balsam oint (Xenaderm)
1
TRETIN-X - tretinoin gel 0.025% w/
cleanser & moisturizer kit
4
trypsin w/ castor oil & peruvian
balsam spray (Granulex)
U-CORT - urea-hc acetate cream 1%
2
TRETIN-X - tretinoin cream 0.025% w/
cleanser & moisturizer kit
4
ULESFIA - benzyl alcohol lotion 5%
4
4
ULTRASAL-ER - salicylic acid filmforming soln 28.5%
4
TRETIN-X - tretinoin cream 0.05% w/
cleanser & moisturizer kit
4
ULTRAVATE - halobetasol propionate
cream 0.05%
4
TRETIN-X - tretinoin cream 0.1% w/
cleanser & moisturizer kit
tretinoin cream 0.025% (Retin-a)
ULTRAVATE - halobetasol propionate
oint 0.05%
4
2
tretinoin cream 0.05% (Retin-a)
2
162
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
2
4
Step Therapy
tretinoin cream 0.1% (Retin-a)
TEMOVATE - clobetasol propionate oint
0.05%
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ULTRAVATE PAC - halobetasol prop
cream 0.05% & ammonium lactate lot
12% kit
4
ULTRAVATE PAC - halobetasol prop
oint 0.05% & ammonium lactate lot
12% kit
4
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%
UMECTA NAIL FILM - urea suspension
40%
urea in zinc undecylenate-lactic acid
vehicle emulsion 50%
2
urea lotion 40%
2
urea lotion 45% (Uramaxin)
2
Dispensing Limits
Step Therapy
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)
UTOPIC - urea cream 41%
4
5
4
VALCHLOR - mechlorethamine hcl gel
0.016% (base equivalent)
4
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
4
UMECTA PD - urea-hyaluronate sodium 4
emulsion 40-0.3%
UMECTA PD - urea-hyaluronate sodium 4
susp 40-0.3%
4
URAMAXIN - urea cream 45%
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
URAMAXIN - urea gel 45%
4
VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025%
URAMAXIN - urea lotion 45%
4
VENELEX - balsam peru-castor oil oint
4
URAMAXIN - urea in ammonium lactate
vehicle foam 20%
4
VERDESO - desonide foam 0.05%
4
VEREGEN - sinecatechins oint 15%
4
URAMAXIN GT - urea gel 45%
4
4
URAMAXIN GT KIT - urea soln 45% &
emollient cream kit
4
VEXA - allantoin-lidocaine-petrolatum
patch 2-4-30%
4
urea cream 39% (Aluvea)
2
VIRASAL - salicylic acid film forming
liquid 27.5%
urea cream 40%
2
VOLTAREN - diclofenac sodium gel 1%
3
urea cream 45% (Uramaxin)
2
4
urea cream 50%
2
VUSION - miconazole-zinc oxide-white
petrolatum oint 0.25-15-81.35%
2
VYTONE - iodoquinol-hydrocortisone in
aloe vehicle cream 1-1.9%
4
urea foam 40% (Hydro 40 foam)
urea gel 40%
2
2
WESTCORT - hydrocortisone valerate
oint 0.2%
4
urea gel 45% (Uramaxin)
urea in lactic acid vehicle foam 35%
(Hydro 35)
2
4
urea in lactic acid-salicylic acid
vehicle susp 50%
2
WITCH HAZEL - witch hazel
(hamamelis virginiana) liqd
(hamamelis water)
XCLAIR - dermatological products misc
- cream
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
163
XENADERM - trypsin w/ castor oil &
peruvian balsam oint
4
XERAC AC - aluminum chloride in
alcohol solution 6.25%
4
3
ZACARE 8% KIT - benzoyl peroxide
lotion 8% & hyaluronate sodium gel
0.2% kit
4
XERESE - acyclovir-hydrocortisone
cream 5-1%
4
ZACLIR CLEANSING - benzoyl
peroxide lotion 8%
XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum
dressing pads
4
XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum
dressing - misc
4
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
Dispensing Limits
Step Therapy
ZIANA - clindamycin phosphate-tretinoin 4
gel 1.2-0.025%
4
ZITHRANOL - anthralin shampoo 1%
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%
3
ZYCLARA PUMP - imiquimod cream
2.5%
3
•
•
ZYCLARA PUMP - imiquimod cream
3.75%
3
•
8-MOP - methoxsalen cap 10 mg
4
MISCELLANEOUS PRODUCTS
ANTISEPTICS & DISINFECTANTS
BENZALKONIUM CHLORIDE benzalkonium chloride soln
4
XOLEGEL COREPAK - ketoconazole
gel 2% & hydrocortisone gel 1% kit
BENZALKONIUM CHLORIDE benzalkonium chloride soln 17%
4
4
4
XOLEGEL DUO/HEAD & SHOULD ketoconazole gel 2% & pyrithione
zinc shampoo 1% kit
4
BENZALKONIUM CHLORIDE benzalkonium chloride soln 50%
FORMA-RAY - formaldehyde solution
20%
4
XOLEGEL DUO/XOLEX - ketoconazole
gel 2% & pyrithione zinc shampoo 1%
kit
4
formaldehyde solution 10%
2
4
XYLOCAINE - lidocaine hcl soln 4%
4
GLUTARALDEHYDE - glutaral soln
25%
4
4
IODINE TINCTURE - iodine tincture
XYLOCAINE JELLY - lidocaine hcl gel
2%
4
ZACARE 4% KIT - benzoyl peroxide
lotion 4% & hyaluronate sodium gel
0.2% kit
4
IODINE TINCTURE MILD - iodine
tincture
IODINE TINCTURE STRONG - iodine
tincture strong
4
IODINE TINCTURE STRONG DE iodine tincture strong
4
KERR TRIPLE DYE - triple dye swabs
4
164
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
LUGOLS STRONG IODINE - iodine
solution
4
ACCU-CHEK COMPACT TEST DR glucose blood test strip
3
•
PHISOHEX - hexachlorophene liq 3%
4
3
•
TRIPLE DYE - triple dye solution
4
ACCU-CHEK SMARTVIEW STRIP glucose blood test strip
ACCUTREND GLUCOSE - glucose
blood test strip
3
•
ASCENSIA AUTODISC TEST ST glucose blood test disk
3
•
ANTIDOTES
CHEMET - succimer cap 100 mg
3
CYANIDE ANTIDOTE PKG - cyanide
antidote kit
4
5
•
BAYER BREEZE 2 TEST DISC glucose blood test disk
3
EXJADE - deferasirox tab for oral susp
125 mg
•
5
•
BAYER CONTOUR BLOOD GLUCO glucose blood test strip
3
EXJADE - deferasirox tab for oral susp
250 mg
•
5
•
BAYER CONTOUR NEXT BLOOD glucose blood test strip
3
EXJADE - deferasirox tab for oral susp
500 mg
•
5
GLUCOSE BLOOD TEST STRIPS –
VARIOUS
4
FERRIPROX - deferiprone tab 500 mg
• •
naltrexone hcl tab 50 mg (Revia)
2
4
KETONE BLOOD TEST STRIPS –
VARIOUS
4
PENTETATE CALCIUM TRISODI pentetate calcium trisodium iv or
inhalation soln 200 mg/ml
URINE TEST STRIPS – VARIOUS
4
PENTETATE ZINC TRISODIUM pentetate zinc trisodium iv or
inhalation soln 200 mg/ml
4
RADIOGARDASE - prussian blue
insoluble cap 0.5 gm
4
REVIA - naltrexone hcl tab 50 mg
4
•
ALTERNATIVE MEDICINES
QUINZYME - coenzyme q10 tab disp 90 4
mg
4
RELAMINE - glucosamine-chondroitinpaba-vit e-alpha lipoic acid tab
MEDICAL DEVICES
DIAGNOSTIC PRODUCTS
ACCU-CHEK ACTIVE STRIPS glucose blood test strip
3
ACCU-CHEK AVIVA - glucose blood
test strip
3
ACCU-CHEK AVIVA PLUS - glucose
blood test strip
3
ACCU-CHEK COMFORT CURVE T glucose blood test strip
3
ACCU-CHEK COMPACT PLUS glucose blood test strip
3
ACCU-CHEK COMPACT STRIPS glucose blood test strip
3
•
•
•
•
•
•
ACCU-CHEK FASTCLIX LANCET lancets
3
ACCU-CHEK MULTICLIX LANCE lancets
3
ACCU-CHEK SOFT TOUCH LANC lancets
3
ACCU-CHEK SOFTCLIX LANCET lancets
3
BAYER MICROLET LANCETS - lancets
3
BD LANCET ULTRAFINE 30G - lancets
3
BD LANCET ULTRAFINE 33G - lancets
3
BD MICROTAINER LANCETS - lancets
3
BLOOD GLUCOSE CALIBRATION
LIQUID – VARIOUS
4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
165
LANCETS – VARIOUS
4
MICROLET LANCETS - lancets
3
MICROTAINER SAFETY FLOW L lancets
3
RESPIRATORY THERAPY SUPPLIES
– VARIOUS
3
SINGLE-LET - lancets
3
SPACERS – VARIOUS
3
ASSORTED CLASSES
cyclosporine modified cap 25 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)
2
sodium polystyrene sulfonate
powder (Kayexalate)
2
mycophenolate mofetil tab 500 mg
(Cellcept)
2
ASTAGRAF XL - tacrolimus cap sr 24hr
0.5 mg
5
2
ASTAGRAF XL - tacrolimus cap sr 24hr
1 mg
5
mycophenolate sodium tab dr
180 mg (mycophenolic acid equiv)
(Myfortic)
2
ASTAGRAF XL - tacrolimus cap sr 24hr
5 mg
5
mycophenolate sodium tab dr
360 mg (mycophenolic acid equiv)
(Myfortic)
ATGAM - lymphocyte immune globulin
anti-thymocyte g inj 50 mg/ml(eq)
4
3
AZASAN - azathioprine tab 75 mg
4
MYFORTIC - mycophenolate sodium
tab dr 180 mg (mycophenolic acid
equiv)
4
azathioprine tab 50 mg (Imuran)
2
MYFORTIC - mycophenolate sodium
tab dr 360 mg (mycophenolic acid
equiv)
3
AZASAN - azathioprine tab 100 mg
CELLCEPT - mycophenolate mofetil cap 3
250 mg
CELLCEPT - mycophenolate mofetil tab 3
500 mg
CELLCEPT - mycophenolate mofetil for 3
oral susp 200 mg/ml
CUPRIMINE - penicillamine cap 250 mg 5
cyclosporine cap 100 mg
(Sandimmune)
2
cyclosporine cap 25 mg
(Sandimmune)
2
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
3
166
NEORAL - cyclosporine modified cap 25 4
mg
4
NEORAL - cyclosporine modified cap
100 mg
4
NEORAL - cyclosporine modified oral
soln 100 mg/ml
3
PROGRAF - tacrolimus cap 0.5 mg
PROGRAF - tacrolimus cap 1 mg
3
PROGRAF - tacrolimus cap 5 mg
3
RAPAMUNE - sirolimus tab 0.5 mg
3
RAPAMUNE - sirolimus tab 1 mg
3
RAPAMUNE - sirolimus tab 2 mg
3
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
Dispensing Limits
4
2
Step Therapy
INSULIN SYRINGES – VARIOUS
•
•
cyclosporine modified cap 100 mg
(Neoral)
Prior Authorization
4
Drug Name
Drug Tier
INSULIN PEN NEEDLES – VARIOUS
Dispensing Limits
3
Step Therapy
FINGERSTIX LANCETS - lancets
Prior Authorization
Drug Name
Drug Tier
2014
RAPAMUNE - sirolimus oral soln 1 mg/
ml
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
SANDIMMUNE - cyclosporine cap 25
mg
4
SANDIMMUNE - cyclosporine cap 100
mg
4
SANDIMMUNE - cyclosporine oral soln
100 mg/ml
4
sirolimus tab 0.5 mg (Rapamune)
2
sodium polystyrene sulfonate oral
susp 15 gm/60ml (Sps)
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
3
ZORTRESS - everolimus tab 0.5 mg
3
ZORTRESS - everolimus tab 0.75 mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
167
2014
INDEX
8-MOP -methoxsalen cap 10 mg.....................................164
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................. 7
abacavir sulfate tab 300 mg (base equiv) (Ziagen)......... 7
ABILIFY -aripiprazole oral solution 1 mg/ml...................... 84
ABILIFY -aripiprazole tab 10 mg....................................... 83
ABILIFY -aripiprazole tab 15 mg....................................... 84
ABILIFY -aripiprazole tab 20 mg....................................... 84
ABILIFY -aripiprazole tab 2 mg......................................... 83
ABILIFY -aripiprazole tab 30 mg....................................... 84
ABILIFY -aripiprazole tab 5 mg......................................... 83
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
10 mg............................................................................... 84
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
15 mg............................................................................... 84
ABSORICA -isotretinoin cap 10 mg.................................148
ABSORICA -isotretinoin cap 20 mg.................................148
ABSORICA -isotretinoin cap 30 mg.................................148
ABSORICA -isotretinoin cap 40 mg.................................148
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)................................................................................96
ABSTRAL -fentanyl citrate sl tab 200 mcg (base
equiv)................................................................................96
ABSTRAL -fentanyl citrate sl tab 300 mcg (base
equiv)................................................................................96
ABSTRAL -fentanyl citrate sl tab 400 mcg (base
equiv)................................................................................96
ABSTRAL -fentanyl citrate sl tab 600 mcg (base
equiv)................................................................................96
ABSTRAL -fentanyl citrate sl tab 800 mcg (base
equiv)................................................................................96
acamprosate calcium tab delayed release 333 mg
(Campral).........................................................................91
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%......................................................................... 148
acarbose tab 100 mg (Precose)..................................... 26
acarbose tab 25 mg (Precose)....................................... 26
acarbose tab 50 mg (Precose)....................................... 26
ACCOLATE -zafirlukast tab 10 mg....................................64
ACCOLATE -zafirlukast tab 20 mg....................................64
ACCU-CHEK ACTIVE STRIPS -glucose blood test
strip.................................................................................165
ACCU-CHEK AVIVA -glucose blood test strip.................165
ACCU-CHEK AVIVA PLUS -glucose blood test strip.......165
ACCU-CHEK COMFORT CURVE T -glucose blood test
strip.................................................................................165
ACCU-CHEK COMPACT PLUS -glucose blood test
strip.................................................................................165
ACCU-CHEK COMPACT STRIPS -glucose blood test
strip.................................................................................165
168
ACCU-CHEK COMPACT TEST DR -glucose blood test
strip.................................................................................165
ACCU-CHEK FASTCLIX LANCET - lancets .................. 165
ACCU-CHEK MULTICLIX LANCE - lancets ................... 165
ACCU-CHEK SMARTVIEW STRIP -glucose blood test
strip.................................................................................165
ACCU-CHEK SOFTCLIX LANCET - lancets .................. 165
ACCU-CHEK SOFT TOUCH LANC - lancets .................165
ACCUNEB -albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)................................................................................64
ACCUNEB -albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)................................................................................64
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
ACCUTREND GLUCOSE -glucose blood test strip.........165
acebutolol hcl cap 200 mg (Sectral).............................. 39
acebutolol hcl cap 400 mg (Sectral).............................. 39
ACEON -perindopril erbumine tab 2 mg............................45
ACEON -perindopril erbumine tab 4 mg............................45
ACEON -perindopril erbumine tab 8 mg............................45
ACETAMINOPHEN/CAFFEINE/DI -acetaminophencaffeine-dihydrocodeine tab 712.8-60-32 mg...................96
acetaminophen-isometheptene-caffeine tab 325-65-20
mg (Prodrin)................................................................. 108
acetaminophen-isometheptene-dichloral cap
325-65-100 mg.............................................................. 108
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg..................................................................95
acetaminophen w/ codeine soln 120-12 mg/5ml........... 96
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine)...........................................................................96
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3)..................................................................... 96
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4)..................................................................... 96
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............................................ 145
acetic acid otic soln 2%................................................145
acetylcysteine cap 600 mg........................................... 130
acetylcysteine inhal soln 10%........................................ 60
acetylcysteine inhal soln 20%........................................ 60
ACIPHEX -rabeprazole sodium ec tab 20 mg................... 68
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 10 mg.............................................................68
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 5 mg...............................................................68
acitretin cap 10 mg (Soriatane).................................... 148
acitretin cap 17.5 mg (Soriatane)................................. 148
acitretin cap 25 mg (Soriatane).................................... 148
ACLOVATE -alclometasone dipropionate cream
0.05%............................................................................. 148
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml.................................................... 105
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...................................... 72
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)........................................................ 15
ACTIQ -fentanyl citrate lollipop 1200 mcg......................... 96
ACTIQ -fentanyl citrate lollipop 1600 mcg......................... 97
ACTIQ -fentanyl citrate lollipop 200 mcg........................... 96
ACTIQ -fentanyl citrate lollipop 400 mcg........................... 96
ACTIQ -fentanyl citrate lollipop 600 mcg........................... 96
ACTIQ -fentanyl citrate lollipop 800 mcg........................... 96
ACTIVE FE - fe carbonyl-fa-b complex-a-c-d-e-min tab
75-1.25 mg ................................................................... 132
ACTIVELLA -estradiol & norethindrone acetate tab 0.5-0.1
mg.................................................................................... 21
ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 21
ACTIVE OB - prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg ................................................................................. 119
ACTIVE-PAC/GABAPENTIN -gabapentin oral cap 300 mg
& lidocaine-menthol gel ther pk....................................... 91
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........................................................................26
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-850 mg........................................................................26
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr
24hr 15-1000 mg............................................................. 26
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr
24hr 30-1000 mg............................................................. 26
ACTOS -pioglitazone hcl tab 15 mg (base equiv)..............26
ACTOS -pioglitazone hcl tab 30 mg (base equiv)..............26
ACTOS -pioglitazone hcl tab 45 mg (base equiv)..............26
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
0.02%............................................................................. 145
ACULAR -ketorolac tromethamine ophth soln 0.5%........140
ACULAR LS -ketorolac tromethamine ophth soln
0.4%............................................................................... 140
ACUVAIL -ketorolac tromethamine ophth soln 0.45%..... 140
acyclovir cap 200 mg (Zovirax)........................................ 7
acyclovir oint 5% (Zovirax)........................................... 148
acyclovir susp 200 mg/5ml (Zovirax)...............................7
acyclovir tab 400 mg (Zovirax).........................................7
acyclovir tab 800 mg (Zovirax).........................................7
ACZONE -dapsone gel 5%............................................. 148
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....................... 41
ADALAT CC -nifedipine tab sr 24hr 60 mg....................... 41
ADALAT CC -nifedipine tab sr 24hr 90 mg....................... 41
adapalene cream 0.1% (Differin).................................. 148
adapalene gel 0.1% (Differin)........................................148
adapalene gel 0.3% (Differin)........................................148
ADASUVE -loxapine aerosol powder breath activated 10
mg.................................................................................... 84
ADCIRCA -tadalafil tab 20 mg (pah)................................. 57
ADDERALL -amphetamine-dextroamphetamine tab 10
mg.................................................................................... 88
ADDERALL -amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 88
ADDERALL -amphetamine-dextroamphetamine tab 15
mg.................................................................................... 88
ADDERALL -amphetamine-dextroamphetamine tab 20
mg.................................................................................... 88
ADDERALL -amphetamine-dextroamphetamine tab 30
mg.................................................................................... 88
ADDERALL -amphetamine-dextroamphetamine tab 5
mg.................................................................................... 88
ADDERALL -amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 88
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 10 mg...................................................................... 88
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 15 mg...................................................................... 88
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 20 mg...................................................................... 88
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 25 mg...................................................................... 88
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 30 mg...................................................................... 88
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 5 mg........................................................................ 88
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...................................................................................... 4
ADOXA PAK 1/150 -doxycycline monohydrate tab 150
mg...................................................................................... 4
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
169
2014
ADOXA PAK 2/100 -doxycycline monohydrate tab 100
mg...................................................................................... 4
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 54
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................54
ADRENAL C FORMULA - bioflavonoid products tab ......119
ADRENALIN -epinephrine hcl nasal soln 0.1%................. 59
ADULT ASPIRIN LOW STRENGT -aspirin dispersible tab
81 mg............................................................................... 95
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 64
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
250-50 mcg/dose............................................................. 64
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
500-50 mcg/dose............................................................. 64
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21
mcg/act.............................................................................64
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21
mcg/act.............................................................................64
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act.............................................................................64
ADVANCED AM/PM - multiple vitamins w/ calcium therapy
pack .............................................................................. 119
ADVATE -antihemophilic factor rahf-pfm for inj 1000
unit..................................................................................137
ADVATE -antihemophilic factor rahf-pfm for inj 1500
unit..................................................................................137
ADVATE -antihemophilic factor rahf-pfm for inj 2000
unit..................................................................................137
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit..................................................................................137
ADVATE -antihemophilic factor rahf-pfm for inj 3000
unit..................................................................................137
ADVATE -antihemophilic factor rahf-pfm for inj 4000
unit..................................................................................137
ADVATE -antihemophilic factor rahf-pfm for inj 500
unit..................................................................................137
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
AEROHIST -chlorpheniramine-methscopolamine tab sr
12hr 8-2.5 mg.................................................................. 58
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act....... 65
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
170
AFLURIA 2011-2012 -influenza virus vaccine split inj....... 13
AFLURIA 2012-2013 -influenza virus vaccine split inj....... 13
AFLURIA 2013-2014 -influenza virus vaccine split inj....... 13
AFLURIA 2014-2015 -influenza virus vaccine split inj....... 13
AFLURIA PF 2011-2012 -influenza virus vaccine split
preservative free inj......................................................... 13
AFLURIA PF 2012-2013 -influenza virus vaccine split
preservative free inj......................................................... 13
AFLURIA PF 2013-2014 -influenza virus vaccine split
preservative free inj......................................................... 13
AFLURIA PF 2014-2015 -influenza virus vaccine split
preservative free inj......................................................... 13
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 137
AGRYLIN -anagrelide hcl cap 0.5 mg............................. 137
AKNE-MYCIN -erythromycin oint 2%.............................. 148
AKTEN -lidocaine hcl ophth gel 3.5%............................. 140
ALAGESIC LQ -butalbital-acetaminophen-caffeine soln
50-325-40 mg/15ml.......................................................... 95
ALAHIST AC -phenylephrine w/ codeine liqd 7.5-10
mg/5ml..............................................................................60
ALAHIST DHC -phenylephrine-dihydrocodeine liqd 7.5-3
mg/5ml..............................................................................60
ALAMAST -pemirolast potassium ophth soln 0.1%......... 140
ALA QUIN -clioquinol-hc cream 3-0.5%.......................... 148
ALA SCALP -hydrocortisone lotion 2%........................... 148
ALBATUSSIN NN - phenyleph-dm-pyril-pot guai-sod cit-cit
acid liquid ........................................................................60
ALBATUSSIN -phenylephrine-carbetapentane-gg cap
10-25-400 mg...................................................................60
ALBENZA -albendazole tab 200 mg................................. 12
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 65
albuterol sulfate soln nebu 0.5% (5 mg/ml)...................65
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)...............................................................................65
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)...............................................................................65
albuterol sulfate syrup 2 mg/5ml................................... 65
albuterol sulfate tab 2 mg...............................................65
albuterol sulfate tab 4 mg...............................................65
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............. 65
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............. 65
ALCAINE -proparacaine hcl ophth soln 0.5%..................140
alclometasone dipropionate cream 0.05%
(Aclovate)...................................................................... 148
alclometasone dipropionate oint 0.05%...................... 149
ALCORTIN A - iodoquinol-hydrocortisone-aloe
polysaccharide gel 1-2-1% ........................................... 149
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
ALDARA -imiquimod cream 5%...................................... 149
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%...................................................................... 149
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)...................76
ALINIA -nitazoxanide for susp 100 mg/5ml....................... 12
ALINIA -nitazoxanide tab 500 mg......................................12
ALKERAN -melphalan tab 2 mg........................................16
ALLEVYN AG ADHESIVE - wound dressings - pads ..... 149
ALLEVYN AG GENTLE BORDER - wound dressings pads .............................................................................. 149
ALLEVYN AG NON-ADHESIVE - wound dressings - pads
....................................................................................... 149
ALLEVYN AG SACRUM - wound dressings - pads ........149
ALLEVYN GENTLE - wound dressings - pads ............... 149
ALLFEN CD -guaifenesin-codeine tab 400-10 mg.............60
ALLFEN CDX -guaifenesin-codeine liquid 200-20
mg/5ml..............................................................................60
ALLFEN CDX -guaifenesin-codeine tab 400-20 mg.......... 60
allopurinol tab 100 mg (Zyloprim)................................109
allopurinol tab 300 mg (Zyloprim)................................109
ALOCRIL -nedocromil sodium ophth soln 2%................. 140
ALODOX CONVENIENCE KIT - doxycycline hyclate tab
20 mg w/ eyelid cleansers kit ........................................... 4
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%............................................................................... 140
ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1%
....................................................................................... 149
ALORA -estradiol td patch biweekly 0.025 mg/24hr.......... 21
ALORA -estradiol td patch biweekly 0.05 mg/24hr............ 21
ALORA -estradiol td patch biweekly 0.075 mg/24hr.......... 21
ALORA -estradiol td patch biweekly 0.1 mg/24hr.............. 21
ALPAIN -phenyltoloxamine-acetaminophen tab 60-500
mg.................................................................................... 95
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%...... 140
ALPHAGAN P -brimonidine tartrate ophth soln
0.15%............................................................................. 140
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1000 unit......................................... 137
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1500 unit......................................... 137
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit........................................... 137
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 500 unit........................................... 137
ALPHANINE SD -coagulation factor ix for inj 1000
unit..................................................................................138
ALPHANINE SD -coagulation factor ix for inj 1500
unit..................................................................................138
ALPHANINE SD -coagulation factor ix for inj 500 unit..... 137
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ml......77
alprazolam orally disintegrating tab 0.25 mg
(Niravam).........................................................................77
alprazolam orally disintegrating tab 0.5 mg..................77
alprazolam orally disintegrating tab 1 mg.....................77
alprazolam orally disintegrating tab 2 mg.....................77
alprazolam tab 0.25 mg (Xanax).....................................78
alprazolam tab 0.5 mg (Xanax).......................................78
alprazolam tab 1 mg (Xanax)..........................................78
alprazolam tab 2 mg (Xanax)..........................................78
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 77
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 77
alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 77
alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 77
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
1000 unit........................................................................ 138
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
2000 unit........................................................................ 138
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
3000 unit........................................................................ 138
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
500 unit.......................................................................... 138
ALREX -loteprednol etabonate ophth susp 0.2%............ 140
ALSUMA -sumatriptan succinate solution auto-injector 6
mg/0.5ml.........................................................................108
ALTABAX -retapamulin oint 1%...................................... 149
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.............. 149
aluminum chloride soln 20% (Drysol)......................... 149
ALUVEA -urea cream 39%..............................................149
ALVESCO -ciclesonide inhal aerosol 160 mcg/act............ 65
ALVESCO -ciclesonide inhal aerosol 80 mcg/act.............. 65
ALZ-NAC - l-methylfolate-methylcobalamin-acetylcyst tab
6-2-600 mg ................................................................... 130
AMANTADINE HCL -amantadine hcl tab 100 mg............114
amantadine hcl cap 100 mg......................................... 114
amantadine hcl syrup 50 mg/5ml................................. 114
AMARYL -glimepiride tab 1 mg......................................... 26
AMARYL -glimepiride tab 2 mg......................................... 26
AMARYL -glimepiride tab 4 mg......................................... 26
AMBIEN CR -zolpidem tartrate tab cr 12.5 mg..................87
AMBIEN CR -zolpidem tartrate tab cr 6.25 mg..................87
AMBIEN -zolpidem tartrate tab 10 mg...............................87
AMBIEN -zolpidem tartrate tab 5 mg.................................87
AMBIFED CD -pseudoephedrine w/ cod-gg tab 30-10-400
mg.................................................................................... 60
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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AMBIFED CDX -pseudoephedrine w/ cod-gg tab
30-20-400 mg...................................................................60
AMBIFED-G CD -pseudoephedrine w/ cod-gg tab
20-10-400 mg...................................................................60
AMBIFED-G CDX -pseudoephedrine w/ cod-gg tab
20-20-400 mg...................................................................60
AMCINONIDE -amcinonide lotion 0.1%.......................... 149
AMCINONIDE -amcinonide oint 0.1%............................. 149
amcinonide cream 0.1%................................................149
AMERGE -naratriptan hcl tab 1 mg (base equiv)............ 108
AMERGE -naratriptan hcl tab 2.5 mg (base equiv)..........108
AMETHYST -levonorgestrel-ethinyl estradiol (continuous)
tab 90-20 mcg..................................................................23
AMICAR -aminocaproic acid syrup 25%......................... 137
AMICAR -aminocaproic acid tab 1000 mg...................... 137
AMICAR -aminocaproic acid tab 500 mg........................ 137
amiloride & hydrochlorothiazide tab 5-50 mg............... 52
amiloride hcl tab 5 mg.................................................... 52
AMINOBENZOATE POTASSIUM -potassium
aminobenzoate packet 2 gm..........................................118
AMINOCAPROIC ACID -aminocaproic acid tab 1000
mg.................................................................................. 137
aminocaproic acid syrup 25% (Amicar).......................137
aminocaproic acid tab 500 mg (Amicar)......................137
AMINOPHYLLINE -aminophylline tab 100 mg.................. 65
AMINOPHYLLINE -aminophylline tab 200 mg.................. 65
amiodarone hcl tab 100 mg............................................44
amiodarone hcl tab 200 mg (Cordarone).......................44
amiodarone hcl tab 400 mg............................................44
AMITIZA -lubiprostone cap 24 mcg...................................73
AMITIZA -lubiprostone cap 8 mcg.....................................72
amitriptyline hcl tab 100 mg...........................................79
amitriptyline hcl tab 10 mg.............................................79
amitriptyline hcl tab 150 mg...........................................79
amitriptyline hcl tab 25 mg.............................................79
amitriptyline hcl tab 50 mg.............................................79
amitriptyline hcl tab 75 mg.............................................79
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
172
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)..................... 41
amlodipine besylate tab 2.5 mg (Norvasc).................... 41
amlodipine besylate tab 5 mg (Norvasc).......................41
AMOXAPINE -amoxapine tab 100 mg.............................. 79
AMOXAPINE -amoxapine tab 150 mg.............................. 79
AMOXAPINE -amoxapine tab 25 mg................................ 79
AMOXAPINE -amoxapine tab 50 mg................................ 79
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)............................................................... 68
AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)....................................................................88
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)....................................................................88
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)....................................................................88
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)....................................................................88
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)....................................................................88
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)....................................................................88
amphetamine-dextroamphetamine tab 10 mg
(Adderall).........................................................................88
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall).........................................................................88
amphetamine-dextroamphetamine tab 15 mg
(Adderall).........................................................................89
amphetamine-dextroamphetamine tab 20 mg
(Adderall).........................................................................89
amphetamine-dextroamphetamine tab 30 mg
(Adderall).........................................................................89
amphetamine-dextroamphetamine tab 5 mg
(Adderall).........................................................................89
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall).........................................................................89
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...................... 91
AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg..............117
AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg..............117
AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab
150-5-12.5 mg..................................................................45
AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab
300-10-12.5 mg................................................................45
AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab
300-10-25 mg...................................................................45
AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab
300-5-12.5 mg..................................................................45
AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab
300-5-25 mg.....................................................................45
ANACAINE -benzocaine oint 10%...................................149
ANADROL-50 -oxymetholone tab 50 mg.......................... 20
ANAFRANIL -clomipramine hcl cap 25 mg....................... 79
ANAFRANIL -clomipramine hcl cap 50 mg....................... 79
ANAFRANIL -clomipramine hcl cap 75 mg....................... 79
anagrelide hcl cap 0.5 mg (Agrylin).............................138
anagrelide hcl cap 1 mg............................................... 138
ANALPRAM ADVANCED -hc-pramoxine cr & diet manage
prod tab & cleans wipe kit............................................. 147
ANALPRAM E -hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit...................................................147
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 1-1%..........................................................147
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%.......................................................147
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%...........................................................147
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 1-1%........................................147
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%.....................................147
ANAPROX DS -naproxen sodium tab 550 mg................ 105
ANAPROX -naproxen sodium tab 275 mg...................... 105
ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg..........68
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...... 20
ANDRODERM -testosterone td patch 24hr 4 mg/24hr...... 20
ANDROGEL PUMP -testosterone td gel 12.5 mg/act
(1%)..................................................................................20
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%).............................................................................20
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%).............................................................................20
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)........ 20
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%).............................................................................20
ANDROGEL -testosterone td gel 50 mg/5gm (1%)........... 20
ANDROID -methyltestosterone cap 10 mg........................21
ANDROXY -fluoxymesterone tab 10 mg........................... 21
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg...........21
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg................21
ANIMI-3/VITAMIN D - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg .................................................. 132
ANIMI-3 - folic acid-b6-b12-d-omega 3-phytosterols cap 1
mg ................................................................................. 132
ANIMI-3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 132
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 65
ANTABUSE -disulfiram tab 250 mg.................................. 91
ANTABUSE -disulfiram tab 500 mg.................................. 91
ANTARA -fenofibrate micronized cap 130 mg...................54
ANTARA -fenofibrate micronized cap 30 mg.....................54
ANTARA -fenofibrate micronized cap 43 mg.....................54
ANTARA -fenofibrate micronized cap 90 mg.....................54
ANTIPYRINE/BENZOCAINE -antipyrine-benzocaine otic
soln 55-14 mg/ml (5.5-1.4%)......................................... 145
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%).......................................................................145
antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)
(Auralgan)..................................................................... 145
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)....................................145
ANTIVERT -meclizine hcl tab 50 mg.................................71
ANUSOL-HC -hydrocortisone acetate suppos 25 mg......147
ANUSOL-HC -hydrocortisone rectal cream 2.5%............ 147
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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2014
ANZEMET -dolasetron mesylate tab 100 mg.................... 71
ANZEMET -dolasetron mesylate tab 50 mg...................... 71
APEXICON E -diflorasone diacetate emollient base cream
0.05%............................................................................. 149
APHTHASOL -amlexanox oral paste 5%........................ 146
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................. 79
APLENZIN -bupropion hbr tab sr 24hr 348 mg................. 79
APLENZIN -bupropion hbr tab sr 24hr 522 mg................. 79
APOKYN -apomorphine hydrochloride inj 10 mg/ml........114
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)....................................................................... 140
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 73
APTIOM -eslicarbazepine acetate tab 200 mg................ 110
APTIOM -eslicarbazepine acetate tab 400 mg................ 110
APTIOM -eslicarbazepine acetate tab 600 mg................ 110
APTIOM -eslicarbazepine acetate tab 800 mg................ 110
APTIVUS -tipranavir cap 250 mg........................................ 7
APTIVUS -tipranavir oral soln 100 mg/ml............................7
AQUORAL - artificial saliva - aero soln .......................... 146
ARALEN -chloroquine phosphate tab 500 mg...................11
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 100 mcg/0.5ml..............................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 100 mcg/ml...................................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 150 mcg/0.3ml..............................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 150 mcg/0.75ml............................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 200 mcg/0.4ml..............................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 200 mcg/ml...................................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 25 mcg/0.42ml..............................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 25 mcg/ml.................................................... 132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 300 mcg/0.6ml..............................................133
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 300 mcg/ml...................................................133
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 40 mcg/0.4ml................................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 40 mcg/ml.................................................... 132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 500 mcg/ml...................................................133
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 60 mcg/0.3ml................................................132
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 60 mcg/ml.................................................... 132
ARAVA -leflunomide tab 10 mg.......................................105
ARAVA -leflunomide tab 20 mg.......................................105
174
ARCALYST -rilonacept for inj 220 mg.............................105
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................. 65
ARICEPT -donepezil hydrochloride tab 10 mg.................. 92
ARICEPT -donepezil hydrochloride tab 23 mg.................. 92
ARICEPT -donepezil hydrochloride tab 5 mg.................... 91
ARICEPT ODT -donepezil hydrochloride orally
disintegrating tab 10 mg.................................................. 92
ARICEPT ODT -donepezil hydrochloride orally
disintegrating tab 5 mg.................................................... 92
ARIMIDEX -anastrozole tab 1 mg..................................... 16
ARIXTRA -fondaparinux sodium inj 10 mg/0.8ml............ 136
ARIXTRA -fondaparinux sodium inj 2.5 mg/0.5ml........... 135
ARIXTRA -fondaparinux sodium inj 5 mg/0.4ml.............. 136
ARIXTRA -fondaparinux sodium inj 7.5 mg/0.6ml........... 136
ARMOUR THYROID -thyroid tab 120 mg (2 grain)........... 32
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain).......... 32
ARMOUR THYROID -thyroid tab 180 mg (3 grain)........... 32
ARMOUR THYROID -thyroid tab 240 mg (4 grain)........... 32
ARMOUR THYROID -thyroid tab 300 mg (5 grain)........... 32
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain).......... 32
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............. 32
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)....... 32
AROMASIN -exemestane tab 25 mg.................................16
ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed
release 50-0.2 mg..........................................................105
ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed
release 75-0.2 mg..........................................................105
ARZOL SILVER NITRATE APP -silver nitrate-potassium
nitrate applicator 75-25%............................................... 149
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 73
ASACOL -mesalamine tab delayed release 400 mg......... 73
ASCENSIA AUTODISC TEST ST -glucose blood test
disk................................................................................. 165
ASMANEX 120 METERED DOSES -mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 65
ASMANEX 30 METERED DOSES -mometasone furoate
inhal powd 110 mcg/inh (breath activated)...................... 65
ASMANEX 30 METERED DOSES -mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 65
ASMANEX 60 METERED DOSES -mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 65
ASPIRIN-CAFFEINE-DIHYDROC -dihydrocodeine
compound cap................................................................. 97
aspirin chew tab 81 mg.................................................. 95
ASPIRIN LOW DOSE -aspirin tab 81 mg..........................95
aspirin tab delayed release 81 mg................................. 95
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 166
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 166
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 166
ASTELIN -azelastine hcl nasal spray 137 mcg/spray (1
mg/ml).............................................................................. 59
ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 59
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
ATABEX EC - prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg ........................................................................ 119
ATABEX PRENATAL - prenatal vit w/ iron carbonyl-fa tab
65-1 mg ........................................................................ 119
ATACAND -candesartan cilexetil tab 16 mg......................45
ATACAND -candesartan cilexetil tab 32 mg......................45
ATACAND -candesartan cilexetil tab 4 mg........................45
ATACAND -candesartan cilexetil tab 8 mg........................45
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg................................................................ 45
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 32-12.5 mg................................................................ 45
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 32-25 mg................................................................... 46
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 35
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 46
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 46
atenolol tab 100 mg (Tenormin)..................................... 39
atenolol tab 25 mg (Tenormin)....................................... 39
atenolol tab 50 mg (Tenormin)....................................... 39
ATGAM -lymphocyte immune globulin anti-thymocyte g inj
50 mg/ml(eq)..................................................................166
ATIVAN -lorazepam tab 0.5 mg........................................ 78
ATIVAN -lorazepam tab 1 mg........................................... 78
ATIVAN -lorazepam tab 2 mg........................................... 78
ATOPICLAIR - emollient - cream ................................... 149
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%......................................... 149
ATRAPRO CP - wound dressings - kit ...........................149
ATRAPRO DERMAL SPRAY - wound cleansers - liquid
....................................................................................... 149
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg.................................................................8
ATROPINE SULFATE -atropine sulfate ophth oint
1%.................................................................................. 141
atropine sulfate ophth soln 1% (Isopto atropine)....... 141
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 65
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.................................. 92
AUBAGIO -teriflunomide tab 7 mg.................................... 92
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%).......................................................................145
AURSTAT ANTI-ITCH HYDROGE - dermatological
products misc - kit ........................................................ 149
AURSTAT -emollient cream & wound dressing gel kit.....149
AUVI-Q -epinephrine solution auto-injector 0.15 mg/0.15ml
(1:1000)............................................................................ 54
AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................................ 54
AVAILNEX -carbocysteine chew tab 750 mg.................. 130
AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 46
AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 46
AVANDAMET -rosiglitazone maleate-metformin hcl tab
2-1000 mg........................................................................26
AVANDAMET -rosiglitazone maleate-metformin hcl tab
2-500 mg..........................................................................26
AVANDAMET -rosiglitazone maleate-metformin hcl tab
4-1000 mg........................................................................26
AVANDAMET -rosiglitazone maleate-metformin hcl tab
4-500 mg..........................................................................26
AVANDARYL -rosiglitazone maleate-glimepiride tab 4-1
mg.................................................................................... 26
AVANDARYL -rosiglitazone maleate-glimepiride tab 4-2
mg.................................................................................... 27
AVANDARYL -rosiglitazone maleate-glimepiride tab 4-4
mg.................................................................................... 27
AVANDARYL -rosiglitazone maleate-glimepiride tab 8-2
mg.................................................................................... 27
AVANDARYL -rosiglitazone maleate-glimepiride tab 8-4
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
175
2014
AVAPRO -irbesartan tab 300 mg...................................... 46
AVAPRO -irbesartan tab 75 mg........................................ 46
AVAR-E LS -sulfacetamide sodium w/ sulfur cream
10-2%............................................................................. 149
AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 10-2%.............................................................. 149
AVAR LS -sulfacetamide sodium w/ sulfur cleansing pad
10-2%............................................................................. 149
AVAR -sulfacetamide sodium w/ sulfur cleansing pad
9.5-5%............................................................................ 149
AVC -sulfanilamide vaginal cream 15%............................ 76
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
AVIDOXY DK -doxycycline tab 100 mg & suncreen & sal
acid wash 2% kit................................................................4
AVINZA -morphine sulfate beads cap sr 24hr 120 mg...... 97
AVINZA -morphine sulfate beads cap sr 24hr 30 mg........ 97
AVINZA -morphine sulfate beads cap sr 24hr 45 mg........ 97
AVINZA -morphine sulfate beads cap sr 24hr 60 mg........ 97
AVINZA -morphine sulfate beads cap sr 24hr 75 mg........ 97
AVINZA -morphine sulfate beads cap sr 24hr 90 mg........ 97
AVODART -dutasteride cap 0.5 mg.................................. 76
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)........................................................ 92
AVONEX -interferon beta-1a im inj kit 30 mcg/0.5ml.........92
AVONEX PEN -interferon beta-1a im inj kit 30
mcg/0.5ml.........................................................................92
AXERT -almotriptan malate tab 12.5 mg.........................108
AXERT -almotriptan malate tab 6.25 mg.........................108
AXID -nizatidine cap 150 mg.............................................68
AXID -nizatidine cap 300 mg.............................................68
AXID -nizatidine oral soln 15 mg/ml.................................. 68
AXIRON -testosterone td soln 30 mg/act.......................... 21
AYGESTIN -norethindrone acetate tab 5 mg.................... 26
AZASAN -azathioprine tab 100 mg................................. 166
AZASAN -azathioprine tab 75 mg................................... 166
AZASITE -azithromycin ophth soln 1%........................... 141
azathioprine tab 50 mg (Imuran).................................. 166
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 59
azelastine hcl nasal spray 137 mcg/spray (1 mg/
ml).................................................................................... 59
azelastine hcl ophth soln 0.05% (Optivar)...................141
AZELEX -azelaic acid cream 20%.................................. 149
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)..............................................................................114
AZILECT -rasagiline mesylate tab 1 mg (base equiv)......114
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
176
azithromycin tab 500 mg (Zithromax)..............................2
azithromycin tab 600 mg (Zithromax)..............................3
AZOPT -brinzolamide ophth susp 1%............................. 141
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
AZULFIDINE EN-TABS -sulfasalazine tab delayed release
500 mg............................................................................. 73
AZULFIDINE -sulfasalazine tab 500 mg............................73
B
B-6 FOLIC ACID - cobalamine combination cap ............ 133
BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(per drop)....................................................................... 118
BACITRACIN -bacitracin ophth oint 500 unit/gm............. 141
bacitracin-polymyxin b ophth oint............................... 141
bacitracin-polymyxin-neomycin-hc ophth oint 1%..... 141
baclofen tab 10 mg........................................................117
baclofen tab 20 mg........................................................117
BACTRIM DS -sulfamethoxazole-trimethoprim tab 800-160
mg.................................................................................... 12
BACTRIM -sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 12
BACTROBAN -mupirocin calcium cream 2%.................. 149
BACTROBAN -mupirocin oint 2%................................... 149
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 59
BAL-CARE DHA ESSENTIAL -prenat w/fe poly-na fered-fa
tab 27-1 & omega cap dr 374mg...................................119
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg.....................................................119
balsalazide disodium cap 750 mg (Colazal).................. 73
BANZEL -rufinamide susp 40 mg/ml............................... 110
BANZEL -rufinamide tab 200 mg.................................... 110
BANZEL -rufinamide tab 400 mg.................................... 110
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 8
BARACLUDE -entecavir tab 0.5 mg....................................8
BARACLUDE -entecavir tab 1 mg.......................................8
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................. 165
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip.................................................................................165
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip.................................................................................165
BAYER MICROLET LANCETS - lancets ........................165
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)................................................................ 119
b-complex w/ c & folic acid tab (Strovite)................... 119
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx)...................................................................................119
b-complex w/ c & folic acid tab 5 mg.......................... 119
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
b-complex w/ c-biotin-minerals & folic acid tab 5 mg
(Diatx zn).......................................................................119
BD GLUCOSE -glucose chew tab 5 gm............................27
BD LANCET ULTRAFINE 30G - lancets ........................ 165
BD LANCET ULTRAFINE 33G - lancets ........................ 165
BD MICROTAINER LANCETS - lancets ........................ 165
BEBULIN -factor ix complex for inj 200-1200 unit........... 138
BEBULIN VH -factor ix complex for inj 200-1200 unit......138
BECONASE AQ -beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray.................................................59
BELLADONNA & OPIUM -belladonna alkaloids & opium
suppos 16.2-30 mg.......................................................... 69
BELLADONNA ALKALOIDS & OP -belladonna alkaloids &
opium suppos 16.2-60 mg............................................... 69
belladonna alkaloids-phenobarbital elixir 16.2 mg/5ml
(Donnatal)........................................................................69
belladonna alkaloids-phenobarbital tab 16.2 mg
(Donnatal)........................................................................69
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..................................................................................138
BENEFIX -coagulation factor ix (recombinant) for inj 2000
unit..................................................................................138
BENEFIX -coagulation factor ix (recombinant) for inj 250
unit..................................................................................138
BENEFIX -coagulation factor ix (recombinant) for inj 3000
unit..................................................................................138
BENEFIX -coagulation factor ix (recombinant) for inj 500
unit..................................................................................138
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%...... 149
BENTYL -dicyclomine hcl cap 10 mg................................ 69
BENTYL -dicyclomine hcl oral soln 10 mg/5ml..................69
BENTYL -dicyclomine hcl tab 20 mg.................................69
BENZACLIN -clindamycin phosphate-benzoyl peroxide gel
1-5%............................................................................... 149
BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 149
BENZALKONIUM CHLORIDE -benzalkonium chloride
soln.................................................................................164
BENZALKONIUM CHLORIDE -benzalkonium chloride soln
17%................................................................................ 164
BENZALKONIUM CHLORIDE -benzalkonium chloride soln
50%................................................................................ 164
BENZAMYCIN -benzoyl peroxide-erythromycin gel
5-3%............................................................................... 149
BENZAMYCINPAK -benzoyl peroxide-erythromycin gel
pack 5-3%...................................................................... 149
BENZEFOAM -benzoyl peroxide foam 5.3%...................149
BENZEFOAMULTRA -benzoyl peroxide foam 9.8%....... 149
BENZIQ -benzoyl peroxide gel 5.25 %............................149
BENZIQ LS -benzoyl peroxide gel 2.75%....................... 149
benzocaine dental soln 20%.........................................146
benzonatate cap 100 mg (Tessalon perles)...................60
benzonatate cap 200 mg.................................................60
benzoyl peroxide cleanser 4.25%................................ 149
benzoyl peroxide cloth 3%........................................... 149
benzoyl peroxide cloth 6%........................................... 149
benzoyl peroxide cloth 9%........................................... 149
benzoyl peroxide creamy wash 4% &benzoyl peroxide
bar 5% kit......................................................................150
benzoyl peroxide creamy wash 4% & cleanser lotion
kit................................................................................... 149
benzoyl peroxide creamy wash 8% &benzoyl peroxide
bar 5% kit (Bpo creamy wash comp)......................... 150
benzoyl peroxide creamy wash 8% & cleanser lotion
kit................................................................................... 150
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)................................................................ 150
benzoyl peroxide foam 5.3% (Benzefoam).................. 150
benzoyl peroxide foam 9.8% (Benzefoamultra).......... 150
benzoyl peroxide gel 10%.............................................150
benzoyl peroxide gel 5%...............................................150
benzoyl peroxide liq 2.5%.............................................150
benzoyl peroxide liq 5.25%...........................................150
benzoyl peroxide liq 7%................................................150
benzoyl peroxide lotion 6%.......................................... 150
benzoyl peroxide lotion 9%.......................................... 150
benzoyl peroxide pad 3%............................................. 150
benzoyl peroxide pad 6%............................................. 150
benztropine mesylate tab 0.5 mg................................. 114
benztropine mesylate tab 1 mg....................................114
benztropine mesylate tab 2 mg....................................114
BEPREVE -bepotastine besilate ophth soln 1.5%........... 141
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit..................................................................................138
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)..............................................................................141
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%.......................................................................... 141
BETAGAN -levobunolol hcl ophth soln 0.5%...................141
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
177
2014
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................150
betamethasone dipropionate augmented gel
0.05%............................................................................. 150
betamethasone dipropionate augmented lotion 0.05%
(Diprolene).................................................................... 150
betamethasone dipropionate augmented oint 0.05%
(Diprolene).................................................................... 150
betamethasone dipropionate cream 0.05%................. 150
betamethasone dipropionate lotion 0.05%..................150
betamethasone dipropionate oint 0.05%..................... 150
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 150
betamethasone valerate cream 0.1%........................... 150
betamethasone valerate lotion 0.1%............................150
betamethasone valerate oint 0.1%............................... 150
BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg...............39
BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg...............39
BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg.................39
BETAPACE -sotalol hcl tab 120 mg.................................. 39
BETAPACE -sotalol hcl tab 160 mg.................................. 39
BETAPACE -sotalol hcl tab 80 mg....................................39
BETASERON -interferon beta-1b for inj kit 0.3 mg............92
betaxolol hcl ophth soln 0.5%......................................141
betaxolol hcl tab 10 mg (Kerlone)..................................39
betaxolol hcl tab 20 mg (Kerlone)..................................39
bethanechol chloride tab 10 mg (Urecholine)............... 75
bethanechol chloride tab 25 mg (Urecholine)............... 75
bethanechol chloride tab 50 mg (Urecholine)............... 75
bethanechol chloride tab 5 mg (Urecholine).................75
BETHKIS -tobramycin nebu soln 300 mg/4ml..................... 6
BETIMOL -timolol ophth soln 0.25%............................... 141
BETIMOL -timolol ophth soln 0.5%................................. 141
BETOPTIC-S -betaxolol hcl ophth susp 0.25%............... 141
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg...............................................................23
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............................................................ 133
BILTRICIDE -praziquantel tab 600 mg.............................. 12
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 35
BIOREGESIC -phenyltoloxamine-acetaminophen tab
50-650 mg........................................................................95
BIO-STATIN -nystatin cap 1000000 unit............................. 6
BIO-STATIN -nystatin cap 500000 unit............................... 6
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)................................................................................46
178
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)........................ 39
bisoprolol fumarate tab 5 mg (Zebeta).......................... 39
BLEPH-10 -sulfacetamide sodium ophth soln 10%......... 141
BLEPHAMIDE S.O.P. -sulfacetamide sodium-prednisolone
ophth oint 10-0.2%.........................................................141
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................. 141
BLOOD GLUCOSE CALIBRATION LIQUID –
VARIOUS....................................................................... 165
B-NEXA - prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg
....................................................................................... 119
B-NEXA - prenatal w/ calcium-vit b6-fa-ginger tab 1.2 mg
....................................................................................... 119
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 FOLINATAL PLUS B - prenatal w/ calcium carbonateb6-b12-fa tab 1 mg .......................................................119
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg ...............................................119
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg .........................................................119
BPO 3% FOAMING CLOTHS -benzoyl peroxide cloth
3%.................................................................................. 150
BPO 6% FOAMING CLOTHS -benzoyl peroxide cloth
6%.................................................................................. 150
BPO 9% FOAMING CLOTHS -benzoyl peroxide cloth
9%.................................................................................. 150
BPO -benzoyl peroxide gel 4%....................................... 150
BPO -benzoyl peroxide gel 8%....................................... 150
BPO CREAMY WASH COMPLETE -benzoyl peroxide
creamy wash 8% &benzoyl peroxide bar 5% kit............ 150
BP VIT 3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 133
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh........................................................... 65
BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg....................................................................... 23
BRILINTA -ticagrelor tab 90 mg...................................... 138
brimonidine tartrate ophth soln 0.15% (Alphagan
p).................................................................................... 141
brimonidine tartrate ophth soln 0.2%.......................... 141
BRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)...... 79
BRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)...... 79
BRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)........79
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)................................................................................92
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
BROMDAY -bromfenac sodium ophth soln 0.09% (base
equiv) (once-daily)......................................................... 141
BROMFENAC -bromfenac sodium ophth soln 0.09% (base
equivalent)......................................................................141
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily)................................................................... 141
bromocriptine mesylate cap 5 mg (Parlodel).............. 114
bromocriptine mesylate tab 2.5 mg (Parlodel)............ 114
brompheniramine & phenylephrine susp 6-10
mg/5ml.............................................................................60
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg.................................................................................... 60
brompheniramine maleate tab sr 12hr 6 mg................. 58
BROMPHENIRAMINE TANNATE -brompheniramine
tannate chew tab 12 mg.................................................. 58
BRONCOMAR-1 -theophylline-pse-gg elixir 150-30-150
mg/15ml............................................................................65
BRONCOPECTOL -phenyleph-chlorphen w/ dm-gg syrup
5-2-5-75 mg/5ml...............................................................60
BRONDIL -dyphylline-guaifenesin liqd 100-100
mg/15ml............................................................................65
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv)..................................................................... 65
budesonide cap sr 24hr 3 mg (Entocort ec)..................19
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 65
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 65
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
BUPAP -butalbital-acetaminophen tab 50-300 mg............ 95
BUPAP -butalbital-acetaminophen tab 50-650 mg............ 95
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)...............................................................................97
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)...............................................................................97
buprenorphine hcl sl tab 2 mg (base equiv)................. 97
buprenorphine hcl sl tab 8 mg (base equiv)................. 97
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 92
bupropion hcl tab 100 mg (Wellbutrin)..........................79
bupropion hcl tab 75 mg (Wellbutrin)............................79
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).........79
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr).........79
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr).........79
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 79
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 79
buspirone hcl tab 10 mg.................................................78
buspirone hcl tab 15 mg.................................................78
buspirone hcl tab 30 mg.................................................78
buspirone hcl tab 5 mg...................................................78
buspirone hcl tab 7.5 mg................................................78
BUTALBITAL/ASPIRIN/CAFFEI -butalbital-aspirin-caffeine
tab 50-325-40 mg............................................................ 95
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet).......................................................................... 95
butalbital-acetaminophen-caffeine cap 50-325-40
mg.................................................................................... 95
butalbital-acetaminophen-caffeine cap 50-500-40
mg.................................................................................... 95
butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................... 95
butalbital-acetaminophen-caffeine tab 50-500-40
mg.................................................................................... 95
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine).....................................................97
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg.................................................................................... 97
butalbital-acetaminophen tab 50-325 mg...................... 95
butalbital-acetaminophen tab 50-650 mg...................... 95
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal).......................................................................... 95
butalbital-aspirin-caffeine tab 50-325-40 mg................. 95
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)...................................................... 97
butamben-tetracaine-benzocaine aerosol spray
2-2-14%..........................................................................150
BUTISOL SODIUM -butabarbital sodium elixir 30
mg/5ml..............................................................................87
BUTISOL SODIUM -butabarbital sodium tab 30 mg..........87
BUTISOL SODIUM -butabarbital sodium tab 50 mg..........87
butorphanol tartrate nasal soln 10 mg/ml..................... 97
BUTRANS -buprenorphine td patch weekly 10 mcg/hr......97
BUTRANS -buprenorphine td patch weekly 15 mcg/hr......97
BUTRANS -buprenorphine td patch weekly 20 mcg/hr......97
BUTRANS -buprenorphine td patch weekly 5 mcg/hr........97
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).....39
BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)......40
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent)........39
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..........................................................................58
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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2014
CADUET -amlodipine besylate-atorvastatin calcium tab
10-80 mg..........................................................................58
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
CAFCIT -caffeine citrate oral soln 60 mg/3ml (10 mg/ml
base equiv)...................................................................... 89
CAFERGOT -ergotamine w/ caffeine tab 1-100 mg........ 108
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit)................................................................. 89
CALAFOL RX - fa-hydroxocobalamin-policosanol-vit b6-vit
d-ca tab .........................................................................130
CALAN SR -verapamil hcl tab cr 120 mg.......................... 41
CALAN SR -verapamil hcl tab cr 180 mg.......................... 41
CALAN SR -verapamil hcl tab cr 240 mg.......................... 41
CALAN -verapamil hcl tab 120 mg....................................41
CALAN -verapamil hcl tab 80 mg......................................41
CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag
wafer 1342-1.6 mg.........................................................129
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)..............................................150
calcipotriene cream 0.005% (Dovonex)....................... 150
calcipotriene oint 0.005%..............................................150
calcipotriene soln 0.005% (50 mcg/ml)........................ 150
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin).......................................................................35
CALCITRIOL -calcitriol oint 3 mcg/gm.............................150
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)..............................................................73
calcium acetate (phosphate binder) tab 667 mg
(Eliphos).......................................................................... 73
CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg............................. 129
CALCIUM PNV - prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg .......................................................... 119
CAMBIA -diclofenac potassium packet 50 mg.................108
CAMPRAL -acamprosate calcium tab delayed release 333
mg.................................................................................... 92
CANASA -mesalamine suppos 1000 mg...........................73
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 46
180
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 46
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 46
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........................ 69
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml..................................................................60
capecitabine tab 150 mg (Xeloda)..................................16
capecitabine tab 500 mg (Xeloda)..................................16
CAPEX -fluocinolone acetonide shampoo 0.01%............150
CAPHOSOL - artificial saliva - solution .......................... 146
CAPITAL/CODEINE -acetaminophen w/ codeine susp
120-12 mg/5ml................................................................. 97
CAPRELSA -vandetanib tab 100 mg................................ 16
CAPRELSA -vandetanib tab 300 mg................................ 16
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg................................... 46
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....................................................... 46
captopril tab 12.5 mg...................................................... 46
captopril tab 25 mg......................................................... 46
captopril tab 50 mg......................................................... 46
CARAC -fluorouracil cream 0.5%.................................... 150
CARAFATE -sucralfate susp 1 gm/10ml........................... 69
CARAFATE -sucralfate tab 1 gm...................................... 69
CARBAGLU -carglumic acid tab 200 mg...........................35
carbamazepine cap sr 12hr 100 mg (Carbatrol).......... 110
carbamazepine cap sr 12hr 200 mg (Carbatrol).......... 110
carbamazepine cap sr 12hr 300 mg (Carbatrol).......... 110
carbamazepine chew tab 100 mg.................................110
carbamazepine susp 100 mg/5ml (Tegretol)............... 110
carbamazepine tab 200 mg (Tegretol)......................... 110
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)........ 110
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)........ 110
CARBAPHEN 12 PED -phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml........................ 60
CARBAPHEN 12 -phenyleph-chlorphen-carbetapentane
liqd 10-4-27.5 mg/5ml...................................................... 60
CARBATROL -carbamazepine cap sr 12hr 100 mg........ 110
CARBATROL -carbamazepine cap sr 12hr 200 mg........ 110
CARBATROL -carbamazepine cap sr 12hr 300 mg........ 110
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg.................................. 115
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg................................ 115
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg...................................115
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg.............................. 115
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg................................ 115
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg...................................115
carbidopa & levodopa orally disintegrating tab 10-100
mg.................................................................................. 114
carbidopa & levodopa orally disintegrating tab 25-100
mg.................................................................................. 114
carbidopa & levodopa orally disintegrating tab 25-250
mg.................................................................................. 114
carbidopa & levodopa tab 10-100 mg (Sinemet)......... 115
carbidopa & levodopa tab 25-100 mg (Sinemet)......... 115
carbidopa & levodopa tab 25-250 mg (Sinemet)......... 115
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr)...................................................................................115
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr)...................................................................................115
carbidopa tab 25 mg (Lodosyn)................................... 115
carbinoxamine maleate soln 4 mg/5ml (Palgic)............ 58
carbinoxamine maleate tab 4 mg (Palgic)..................... 58
carbonyl iron chew tab 15 mg (elemental iron)...........133
carbonyl iron susp 15 mg/1.25ml (elemental iron)......133
CARDENE SR -nicardipine hcl cap sr 12hr 30 mg............ 41
CARDENE SR -nicardipine hcl cap sr 12hr 45 mg............ 41
CARDENE SR -nicardipine hcl cap sr 12hr 60 mg............ 41
CARDIOTEK-RX - folic acid-b12-b6-arginine-black pepper
tab ................................................................................. 130
CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg.................................................. 130
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.................................41
CARDIZEM -diltiazem hcl tab 60 mg.................................41
CARDIZEM -diltiazem hcl tab 90 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
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)..................................................................... 76
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv)..................................................................... 76
CARISOPRODOL -carisoprodol tab 250 mg................... 117
carisoprodol tab 350 mg (Soma)..................................117
carisoprodol w/ aspirin & codeine tab 200-325-16
mg.................................................................................. 117
carisoprodol w/ aspirin tab 200-325 mg...................... 117
CARMOL-HC -urea-hc acetate cream 1%.......................150
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%......................................... 141
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......................................................................................67
CASODEX -bicalutamide tab 50 mg................................. 16
CATAFLAM -diclofenac potassium tab 50 mg.................105
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
CAVAN-ALPHA KIT -prenat w/fe poly-na fered-fa tab 27-1
& omega cap dr 300mg................................................. 119
CAVAN-EC SOD DHA -prenatal w/ sod feredetate-fa tab
30-1 & omega 3 cap dr................................................. 119
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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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
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 for susp 125 mg/5ml (Ceftin).............. 2
cefuroxime axetil tab 250 mg (Ceftin)..............................2
cefuroxime axetil tab 500 mg (Ceftin)..............................2
CELEBREX -celecoxib cap 100 mg................................ 105
CELEBREX -celecoxib cap 200 mg................................ 105
CELEBREX -celecoxib cap 400 mg................................ 105
CELEBREX -celecoxib cap 50 mg.................................. 105
CELESTONE -betamethasone soln 0.6 mg/5ml................19
CELEXA -citalopram hydrobromide tab 10 mg (base
equiv)................................................................................79
CELEXA -citalopram hydrobromide tab 20 mg (base
equiv)................................................................................79
CELEXA -citalopram hydrobromide tab 40 mg (base
equiv)................................................................................79
CELLCEPT -mycophenolate mofetil cap 250 mg............ 166
CELLCEPT -mycophenolate mofetil for oral susp 200 mg/
ml....................................................................................166
CELLCEPT -mycophenolate mofetil tab 500 mg............. 166
CELONTIN -methsuximide cap 300 mg.......................... 110
CEM-UREA -urea soln 45%............................................ 150
CENESTIN -estrogens, conjugated synthetic a tab 0.3
mg.................................................................................... 21
CENESTIN -estrogens, conjugated synthetic a tab 0.45
mg.................................................................................... 21
CENESTIN -estrogens, conjugated synthetic a tab 0.625
mg.................................................................................... 21
182
CENESTIN -estrogens, conjugated synthetic a tab 0.9
mg.................................................................................... 21
CENESTIN -estrogens, conjugated synthetic a tab 1.25
mg.................................................................................... 21
CENFOL -folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2
mg.................................................................................. 133
CENTANY AT -mupirocin oint kit 2%.............................. 150
CENTANY -mupirocin oint 2%.........................................150
CENTRATEX - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 133
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
CEREFOLIN - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg .................................................................. 130
CEREFOLIN NAC - l-methylfolate-algae-b12-acetylcyst
tab 6-90.314-2-600mg .................................................. 130
CEREFOLIN NAC - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 130
CERVIDIL -dinoprostone vaginal inserts 10 mg................ 34
CESAMET -nabilone cap 1 mg......................................... 71
CETACAINE -butamben-tetracaine-benzocaine aerosol
spray 2-2-14%................................................................150
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)......................................................................145
cevimeline hcl cap 30 mg (Evoxac)............................. 146
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv)............................................................92
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................. 92
CHANTIX -varenicline tartrate tab 0.5 mg (base equiv).....92
CHANTIX -varenicline tartrate tab 1 mg (base equiv)........92
CHEMET -succimer cap 100 mg.....................................165
CHENODAL -chenodiol tab 250 mg.................................. 73
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg............................................... 92
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg.............................................. 92
chlordiazepoxide hcl cap 10 mg.................................... 78
chlordiazepoxide hcl cap 25 mg.................................... 78
chlordiazepoxide hcl cap 5 mg...................................... 78
chlorhexidine gluconate soln 0.12% (Peridex)............146
chloroquine phosphate tab 250 mg............................... 11
chloroquine phosphate tab 500 mg (Aralen).................11
CHLOROTHIAZIDE -chlorothiazide tab 250 mg................52
chlorothiazide tab 250 mg.............................................. 52
chlorothiazide tab 500 mg.............................................. 52
chlorpheniramine w/ codeine liquid 2-10 mg/5ml......... 60
chlorpromazine hcl tab 100 mg......................................84
chlorpromazine hcl tab 10 mg........................................84
chlorpromazine hcl tab 200 mg......................................84
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
chlorpromazine hcl tab 25 mg........................................84
chlorpromazine hcl tab 50 mg........................................84
CHLORPROPAMIDE -chlorpropamide tab 100 mg...........27
CHLORPROPAMIDE -chlorpropamide tab 250 mg...........27
CHLORTHALIDONE -chlorthalidone tab 100 mg.............. 53
CHLORTHALIDONE -chlorthalidone tab 25 mg................ 53
CHLORTHALIDONE -chlorthalidone tab 50 mg................ 53
chlorzoxazone tab 500 mg (Parafon forte dsc)........... 117
CHOICE-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak .................................................119
cholecalciferol cap 1000 unit........................................118
cholecalciferol chew tab 1000 unit.............................. 118
cholecalciferol chew tab 400 unit................................ 118
cholecalciferol drops 400 unit/0.03ml (per drop)........ 118
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)..................................................................... 118
cholecalciferol oral liquid 400 unit/ml......................... 118
cholecalciferol tab 1000 unit........................................ 118
cholecalciferol tab 400 unit.......................................... 118
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.........95
choline & magnesium salicylates tab 1000 mg.............95
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 54
choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
(Trilipix)........................................................................... 54
CIALIS -tadalafil tab 2.5 mg.............................................. 76
CIALIS -tadalafil tab 5 mg................................................. 76
CICLODAN CREAM KIT -ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit............................................ 150
CICLODAN SOLUTION KIT -ciclopirox solution kit
8%.................................................................................. 151
ciclopirox gel 0.77% (Loprox).......................................151
ciclopirox olamine cream 0.77% (base equiv).............151
ciclopirox olamine susp 0.77% (base equiv)...............151
ciclopirox shampoo 1% (Loprox shampoo)................ 151
ciclopirox solution 8% (Penlac nail lacquer)...............151
ciclopirox solution kit 8% (Ciclodan solution ki)........ 151
CICLOPIROX TOPICAL SOLUTI -ciclopirox solution 8% &
vitamin e 5% topical kit..................................................151
cilostazol tab 100 mg (Pletal)....................................... 138
cilostazol tab 50 mg (Pletal)......................................... 138
CILOXAN -ciprofloxacin hcl ophth oint 0.3%................... 141
CILOXAN -ciprofloxacin hcl ophth soln 0.3%.................. 141
cimetidine hcl soln 300 mg/5ml..................................... 69
cimetidine tab 300 mg.....................................................69
cimetidine tab 400 mg.....................................................69
cimetidine tab 800 mg.....................................................69
CIMZIA -certolizumab pegol for inj kit 2 x 200 mg............. 73
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............. 73
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml................................................................................73
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%......................................................................... 145
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)......................................................................145
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 ophth soln 0.3% (Ciloxan)............... 141
ciprofloxacin hcl tab 100 mg (base equiv)...................... 5
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%............................................................................ 145
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............. 79
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 79
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)........................................................................... 79
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)........................................................................... 79
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak......................................... 120
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack.......................................... 119
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................... 120
CITRANATAL B-CALM -prenat w/o a w/ fe cbnyl-fa tab
20-1 mg & vit b6 tab pak............................................... 119
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack.................................................... 120
CITRANATAL HARMONY - prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg ............................................... 120
CITRANATAL HARMONY - prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg ........................................ 120
CITRANATAL HARMONY - prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg ........................................ 120
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
183
2014
CITRANATAL RX - prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg ........................................................ 120
CITROLITH -potassium & sodium citrates tab 50-950
mg.................................................................................... 76
CLARAVIS -isotretinoin cap 30 mg................................. 151
CLARIFOAM EF -sulfacetamide sodium w/ sulfur foam
10-5%............................................................................. 151
CLARINEX-D 12 HOUR -desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg........................60
CLARINEX-D 24 HOUR -desloratadine &
pseudoephedrine tab sr 24hr 5-240 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 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%.......76
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 76
CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)................................ 12
CLEOCIN-T -clindamycin phosphate gel 1%...................151
CLEOCIN-T -clindamycin phosphate lotion 1%............... 151
CLEOCIN-T -clindamycin phosphate soln 1%................. 151
CLEOCIN-T -clindamycin phosphate swab 1%............... 151
clidinium & chlordiazepoxide cap 2.5-5 mg
(Librax)............................................................................ 69
CLIMARA -estradiol td patch weekly 0.025 mg/24hr......... 21
CLIMARA -estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr)......................................................................... 21
CLIMARA -estradiol td patch weekly 0.05 mg/24hr........... 21
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.....................................................................151
CLINDACIN PAC -clindamycin phosphate swab 1% &
cleanser kit.....................................................................151
CLINDAGEL -clindamycin phosphate gel 1%..................151
184
clindamycin hcl cap 150 mg (Cleocin)...........................12
clindamycin hcl cap 300 mg (Cleocin)...........................12
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).................................................................... 151
clindamycin phosphate foam 1% (Evoclin)................. 151
clindamycin phosphate gel 1% (Cleocin-t)..................151
clindamycin phosphate lotion 1% (Cleocin-t)............. 151
clindamycin phosphate soln 1% (Cleocin-t)................151
clindamycin phosphate swab 1% (Cleocin-t).............. 151
clindamycin phosphate vaginal cream 2%
(Cleocin).......................................................................... 76
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................ 151
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%.........................................................................76
CLINORIL -sulindac tab 200 mg..................................... 105
clobetasol propionate cream 0.05% (Temovate).........151
clobetasol propionate emollient base cream 0.05%
(Temovate e).................................................................151
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 151
clobetasol propionate foam 0.05% (Olux)................... 151
clobetasol propionate gel 0.05% (Temovate).............. 151
clobetasol propionate lotion 0.05% (Clobex).............. 151
clobetasol propionate oint 0.05% (Temovate).............151
clobetasol propionate shampoo 0.05% (Clobex)........ 151
clobetasol propionate soln 0.05% (Temovate)............151
CLOBEX -clobetasol propionate lotion 0.05%................. 151
CLOBEX -clobetasol propionate shampoo 0.05%........... 151
CLOBEX -clobetasol propionate spray 0.05%.................151
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%....................................................................151
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%....................................................................151
CLODAN KIT -clobetasol propionate shampoo 0.05% &
cleanser kit.....................................................................151
CLODERM -clocortolone pivalate cream 0.1%................151
CLODERM PUMP -clocortolone pivalate cream 0.1%.....152
clomipramine hcl cap 25 mg (Anafranil)....................... 79
clomipramine hcl cap 50 mg (Anafranil)....................... 79
clomipramine hcl cap 75 mg (Anafranil)....................... 79
clonazepam orally disintegrating tab 0.125 mg.......... 110
clonazepam orally disintegrating tab 0.25 mg............ 110
clonazepam orally disintegrating tab 0.5 mg.............. 110
clonazepam orally disintegrating tab 1 mg................. 110
clonazepam orally disintegrating tab 2 mg................. 110
clonazepam tab 0.5 mg (Klonopin).............................. 110
clonazepam tab 1 mg (Klonopin)................................. 110
clonazepam tab 2 mg (Klonopin)................................. 110
clonidine hcl tab 0.1 mg (Catapres)...............................47
clonidine hcl tab 0.2 mg (Catapres)...............................47
clonidine hcl tab 0.3 mg (Catapres)...............................47
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
clonidine hcl tab sr 12hr 0.1 mg.................................... 89
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)...........................................................................138
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)...........................................................................138
clorazepate dipotassium tab 15 mg (Tranxene t)..........78
clorazepate dipotassium tab 3.75 mg (Tranxene t).......78
clorazepate dipotassium tab 7.5 mg (Tranxene t).........78
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............................................ 146
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).....................................................................152
clotrimazole w/ betamethasone lotion 1-0.05%...........152
CLOZAPINE ODT -clozapine orally disintegrating tab 100
mg.................................................................................... 84
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 84
CLOZAPINE ODT -clozapine orally disintegrating tab 25
mg.................................................................................... 84
clozapine tab 100 mg (Clozaril)......................................84
clozapine tab 200 mg...................................................... 84
clozapine tab 25 mg (Clozaril)........................................84
clozapine tab 50 mg........................................................ 84
CLOZARIL -clozapine tab 100 mg.................................... 84
CLOZARIL -clozapine tab 25 mg...................................... 84
C-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg ................................................................. 119
CNL8 NAIL KIT -ciclopirox soln 8% & lacquer removal
pads kit...........................................................................152
COAL TAR -coal tar soln 20%........................................ 152
COARTEM -artemether-lumefantrine tab 20-120 mg........ 11
COCA COLA SYURP -phosphorated carbohydrate w/
caffeine syrup...................................................................71
COCAINE HCL -cocaine hcl soln 10%............................ 152
COCAINE HCL -cocaine hcl soln 4%..............................152
CODAR AR -chlorpheniramine w/ codeine liquid 2-8
mg/5ml..............................................................................60
CODAR D -pseudoephedrine w/ codeine liquid 30-8
mg/5ml..............................................................................60
CODAR GF -guaifenesin-codeine liquid 200-8 mg/5ml..... 60
CODEINE SULFATE -codeine sulfate oral soln 30
mg/5ml..............................................................................97
CODEINE SULFATE -codeine sulfate tab 15 mg..............97
CODEINE SULFATE -codeine sulfate tab 30 mg..............97
CODEINE SULFATE -codeine sulfate tab 60 mg..............97
COLAZAL -balsalazide disodium cap 750 mg................... 73
colchicine w/ probenecid tab 0.5-500 mg.................... 109
COLCRYS -colchicine tab 0.6 mg................................... 109
COLESTID -colestipol hcl granule packets 5 gm...............55
COLESTID -colestipol hcl granules 5 gm.......................... 55
COLESTID -colestipol hcl tab 1 gm.................................. 54
COLESTID FLAVORED -colestipol hcl granule packets 5
gm.................................................................................... 55
COLESTID FLAVORED -colestipol hcl granules 5 gm...... 55
colestipol hcl granule packets 5 gm (Colestid
flavored).......................................................................... 55
colestipol hcl granules 5 gm (Colestid flavored).......... 55
colestipol hcl tab 1 gm (Colestid).................................. 55
COLGATE DRY MOUTH RELIEF -sodium fluoride
mouthwash 2.1 mg/10ml................................................146
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................ 145
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................67
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm...............................................68
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................. 141
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 -ipratropium-albuterol aerosol 18-103 mcg/
act (20-120mcg/act)......................................................... 65
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act............................................65
COMBIVIR -lamivudine-zidovudine tab 150-300 mg........... 8
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.......................92
COMMIT -nicotine polacrilex lozenge 4 mg.......................92
COMPAZINE -prochlorperazine maleate tab 10 mg..........84
COMPAZINE -prochlorperazine maleate tab 5 mg............84
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg...................................................................8
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk............................................ 120
COMPLETENATE - prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ........................................................................ 120
COMPLETE-RF PRENATAL - prenatal without a w/ fe
carbonyl-docusate-fa tab 90-1mg ................................. 120
COMTAN -entacapone tab 200 mg................................. 115
CO-NATAL FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg
....................................................................................... 120
CONCEPT DHA - prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg ......................................................... 120
CONCEPT OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 120
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
185
2014
CONCERTA -methylphenidate hcl tab sa osm 18 mg....... 89
CONCERTA -methylphenidate hcl tab sa osm 27 mg....... 89
CONCERTA -methylphenidate hcl tab sa osm 36 mg....... 89
CONCERTA -methylphenidate hcl tab sa osm 54 mg....... 89
CONDYLOX -podofilox gel 0.5%.....................................152
CONDYLOX -podofilox soln 0.5%................................... 152
CONZIP -tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................... 97
CONZIP -tramadol hcl cap sr 24hr biphasic release 200
mg.................................................................................... 97
CONZIP -tramadol hcl cap sr 24hr biphasic release 300
mg.................................................................................... 97
COPAXONE -glatiramer acetate inj kit 20 mg/ml.............. 92
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml................................................................................92
COPEGUS -ribavirin tab 200 mg.........................................8
CORDARONE -amiodarone hcl tab 200 mg..................... 44
CORDRAN -flurandrenolide cream 0.05%...................... 152
CORDRAN -flurandrenolide lotion 0.05%........................152
CORDRAN -flurandrenolide oint 0.05%...........................152
CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm...... 152
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............................................................... 138
CORTANE-B AQUEOUS -pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml.................................. 145
CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................. 152
CORTANE-B-OTIC -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................145
CORTEF -hydrocortisone tab 10 mg................................. 19
CORTEF -hydrocortisone tab 20 mg................................. 19
CORTEF -hydrocortisone tab 5 mg...................................19
CORTENEMA -hydrocortisone enema 100 mg/60ml.......147
CORTIFOAM -hydrocortisone acetate rectal foam 90 mg/
dose................................................................................148
CORTISONE ACETATE -cortisone acetate tab 25 mg......19
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 152
CORTISPORIN -neomycin-polymyxin-hc cream
0.5%............................................................................... 152
CORTISPORIN -neomycin-polymyxin-hc otic soln
1%.................................................................................. 145
CORTISPORIN-TC -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................ 145
186
CORVITE 150 - iron combination tab .............................133
CORVITE 150 -iron-folic acid-vit c-vit b6-vit b12-zinc tab
150-1.25 mg...................................................................133
CORVITE FE - iron combination tab .............................. 133
CORVITE -multiple vitamins w/ minerals & fa tab 1.25
mg.................................................................................. 120
CORZIDE -nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 47
CORZIDE -nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 47
COSOPT -dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml............................................................... 141
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf...........................................................141
COTAB A -chlorpheniramine w/ codeine tab 4-10 mg....... 60
COTAB AX -chlorpheniramine w/ codeine tab 4-20 mg.....60
COTABFLU -codeine-chlorpheniramine-acetaminophen
tab 20-4-500 mg.............................................................. 60
COUMADIN -warfarin sodium tab 10 mg........................ 136
COUMADIN -warfarin sodium tab 1 mg.......................... 136
COUMADIN -warfarin sodium tab 2.5 mg....................... 136
COUMADIN -warfarin sodium tab 2 mg.......................... 136
COUMADIN -warfarin sodium tab 3 mg.......................... 136
COUMADIN -warfarin sodium tab 4 mg.......................... 136
COUMADIN -warfarin sodium tab 5 mg.......................... 136
COUMADIN -warfarin sodium tab 6 mg.......................... 136
COUMADIN -warfarin sodium tab 7.5 mg....................... 136
COVERA-HS -verapamil hcl tab sr 24hr (controlled onset)
180 mg............................................................................. 42
COVERA-HS -verapamil hcl tab sr 24hr (controlled onset)
240 mg............................................................................. 42
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.................................................. 72
CREON -pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit................................................ 72
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit...................................................... 72
CREON -pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit.............................................. 72
CREON -pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit.................................................... 72
CRESTOR -rosuvastatin calcium tab 10 mg..................... 55
CRESTOR -rosuvastatin calcium tab 20 mg..................... 55
CRESTOR -rosuvastatin calcium tab 40 mg..................... 55
CRESTOR -rosuvastatin calcium tab 5 mg....................... 55
CRESYLATE -cresyl acetate otic soln 25%.................... 145
CRINONE -progesterone vaginal gel 4%.......................... 76
CRINONE -progesterone vaginal gel 8%.......................... 76
CRIXIVAN -indinavir sulfate cap 200 mg............................ 8
CRIXIVAN -indinavir sulfate cap 400 mg............................ 8
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
CRNATAL -prenatal mv w/fecbn-fegl-dss-fa tab & dha cap
275 mg pack.................................................................. 120
cromolyn sodium ophth soln 4%................................. 141
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom)...................................................................73
cromolyn sodium soln nebu 20 mg/2ml........................ 65
CUPRIMINE -penicillamine cap 250 mg..........................166
CURAGEL HYDROGEL ISLAND W - hydroactive (sterile)
dressing ........................................................................ 152
CURAGEL HYDROGEL WOUND DR - hydroactive
(sterile) dressing ........................................................... 152
CURITY HYPERTONIC SODIUM - wound dressings misc ...............................................................................152
CURITY SODIUM CHLORIDE DR - wound dressings pads .............................................................................. 152
CUROSURF -poractant alfa intratracheal susp 80 mg/
ml......................................................................................67
CUTIVATE -fluticasone propionate cream 0.05%............152
CUTIVATE -fluticasone propionate lotion 0.05%............. 152
CUTIVATE -fluticasone propionate oint 0.005%..............152
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml.................. 69
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
CVS VITAMIN D3 -cholecalciferol cap 400 unit...............118
CYANIDE ANTIDOTE PKG -cyanide antidote kit............ 165
CYANOCOBALAMIN/LEVOMEFOLA - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg ......................................... 130
cyanocobalamin inj 1000 mcg/ml.................................133
CYCLESSA -desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg.........................23
CYCLOBENZAPRINE COMFORT P -cyclobenzaprine hcl
tab 10 mg & liniment topical gel kit................................117
cyclobenzaprine hcl tab 10 mg.................................... 117
cyclobenzaprine hcl tab 5 mg...................................... 117
cyclobenzaprine hcl tab 7.5 mg (Fexmid)....................117
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%............141
CYCLOGYL -cyclopentolate hcl ophth soln 1%...............141
CYCLOGYL -cyclopentolate hcl ophth soln 2%...............141
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%.................................................................... 141
cyclopentolate hcl ophth soln 1% (Cyclogyl)..............141
cyclopentolate hcl ophth soln 2% (Cyclogyl)..............141
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 16
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 16
CYCLOPHOSPHAMIDE -cyclophosphamide tab 25
mg.................................................................................... 16
CYCLOPHOSPHAMIDE -cyclophosphamide tab 50
mg.................................................................................... 16
CYCLOSERINE -cycloserine cap 250 mg...........................6
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)........................................................................27
cyclosporine cap 100 mg (Sandimmune).................... 166
cyclosporine cap 25 mg (Sandimmune)...................... 166
cyclosporine modified cap 100 mg (Neoral)............... 166
cyclosporine modified cap 25 mg (Neoral)................. 166
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................. 166
cyclosporine modified oral soln 100 mg/ml
(Neoral)..........................................................................166
CYMBALTA -duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 79
CYMBALTA -duloxetine hcl enteric coated pellets cap 30
mg.................................................................................... 79
CYMBALTA -duloxetine hcl enteric coated pellets cap 60
mg.................................................................................... 79
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............... 76
CYSTAGON -cysteamine bitartrate cap 50 mg................. 76
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)......................................................................141
CYTOMEL -liothyronine sodium tab 25 mcg..................... 32
CYTOMEL -liothyronine sodium tab 50 mcg..................... 32
CYTOMEL -liothyronine sodium tab 5 mcg....................... 32
CYTOTEC -misoprostol tab 100 mcg................................ 69
CYTOTEC -misoprostol tab 200 mcg................................ 69
CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml..............................................................................77
CYTRA-K -potassium citrate & citric acid soln 1100-334
mg/5ml..............................................................................77
D
D3 -cholecalciferol cap 400 unit...................................... 118
DALIRESP -roflumilast tab 500 mcg................................. 65
danazol cap 100 mg........................................................ 21
danazol cap 200 mg........................................................ 21
danazol cap 50 mg.......................................................... 21
DANTRIUM -dantrolene sodium cap 100 mg.................. 117
DANTRIUM -dantrolene sodium cap 25 mg.................... 117
DANTRIUM -dantrolene sodium cap 50 mg.................... 117
dantrolene sodium cap 25 mg (Dantrium)...................117
dantrolene sodium cap 50 mg (Dantrium)...................117
DANTROLENE SODIUM -dantrolene sodium cap 100
mg.................................................................................. 117
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.................................... 105
DAYTRANA -methylphenidate td patch 10 mg/9hr............89
DAYTRANA -methylphenidate td patch 15 mg/9hr............89
DAYTRANA -methylphenidate td patch 20 mg/9hr............89
DAYTRANA -methylphenidate td patch 30 mg/9hr............89
DDAVP -desmopressin acetate inj 4 mcg/ml.....................35
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
187
2014
DDAVP -desmopressin acetate nasal soln 0.01%
(refrigerated).....................................................................35
DDAVP -desmopressin acetate nasal spray soln
0.01%............................................................................... 35
DDAVP -desmopressin acetate tab 0.1 mg.......................35
DDAVP -desmopressin acetate tab 0.2 mg.......................35
DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
drop)............................................................................... 118
DEBACTEROL -sulfuric acid-sulfonated phenolics soln
30-50%........................................................................... 146
DECARA -cholecalciferol cap 25000 unit........................ 118
DECAVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu........ 15
DECON-A -brompheniramine & phenylephrine elixir 2-5
mg/5ml..............................................................................60
DECON-G -phenylephrine-brompheniramine-guaifenesin
liqd 2-1-40 mg/ml............................................................. 61
DELATESTRYL -testosterone enanthate im in oil 200 mg/
ml......................................................................................21
DELOS -benzoyl peroxide lotion 3.5%............................ 152
DELZICOL -mesalamine cap dr 400 mg........................... 73
DEMADEX -torsemide tab 100 mg....................................53
DEMADEX -torsemide tab 10 mg......................................53
DEMADEX -torsemide tab 20 mg......................................53
DEMADEX -torsemide tab 5 mg........................................53
demeclocycline hcl tab 150 mg........................................4
demeclocycline hcl tab 300 mg........................................4
DEMEROL -meperidine hcl tab 100 mg............................ 97
DEMEROL -meperidine hcl tab 50 mg.............................. 97
DEMSER -metyrosine cap 250 mg................................... 47
DENAVIR -penciclovir cream 1%.................................... 152
DEPAKENE -valproate sodium syrup 250 mg/5ml (base
equiv)..............................................................................110
DEPAKENE -valproic acid cap 250 mg........................... 110
DEPAKOTE -divalproex sodium tab delayed release 125
mg.................................................................................. 110
DEPAKOTE -divalproex sodium tab delayed release 250
mg.................................................................................. 110
DEPAKOTE -divalproex sodium tab delayed release 500
mg.................................................................................. 110
DEPAKOTE ER -divalproex sodium tab sr 24 hr 250
mg.................................................................................. 110
DEPAKOTE ER -divalproex sodium tab sr 24 hr 500
mg.................................................................................. 110
DEPAKOTE SPRINKLES -divalproex sodium cap sprinkle
125 mg........................................................................... 110
DEPEN TITRATABS -penicillamine tab 250 mg..............166
DEPLIN 15 - l-methylfolate-algae cap 15-90.314 mg ......130
DEPLIN 7.5 - l-methylfolate-algae cap 7.5-90.314 mg
....................................................................................... 130
DEPLIN - l-methylfolate tab 15 mg .................................130
DEPLIN - l-methylfolate tab 7.5 mg ................................130
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml.......... 23
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................... 23
188
DEPO-TESTOSTERONE -testosterone cypionate im in oil
100 mg/ml........................................................................ 21
DEPO-TESTOSTERONE -testosterone cypionate im in oil
200 mg/ml........................................................................ 21
DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil
0.01%............................................................................. 152
DERMA-SMOOTHE/FS BODY OIL -fluocinolone
acetonide oil 0.01%....................................................... 152
DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide oil
0.01%............................................................................. 152
DERMA-SMOOTHE/FS SCALP OI -fluocinolone acetonide
oil 0.01%........................................................................ 152
DERMASORB AF -clioquinol-hc cream 3-0.5% & emollient
liqd kit.............................................................................152
DERMASORB HC -hydrocortisone lot 2% & cleanser liq
kit....................................................................................152
DERMASORB TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................ 152
DERMASORB XM -urea cream 39% & emollient cream
kit....................................................................................152
DERMATOP -prednicarbate cream 0.1%........................ 152
DERMATOP -prednicarbate oint 0.1%............................ 152
DERMOTIC -fluocinolone acetonide (otic) oil 0.01%....... 145
desipramine hcl tab 100 mg (Norpramin)......................79
desipramine hcl tab 10 mg (Norpramin)........................79
desipramine hcl tab 150 mg (Norpramin)......................80
desipramine hcl tab 25 mg (Norpramin)........................80
desipramine hcl tab 50 mg (Norpramin)........................80
desipramine hcl tab 75 mg (Norpramin)........................80
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).................35
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................ 35
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................ 35
desmopressin acetate nasal spray soln 0.01%
(refrigerated)................................................................... 35
desmopressin acetate tab 0.1 mg (Ddavp)....................35
desmopressin acetate tab 0.2 mg (Ddavp)....................35
DESOGEN -desogestrel & ethinyl estradiol tab 0.15 mg-30
mcg...................................................................................23
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)......................................................... 23
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
DESONATE -desonide gel 0.05%................................... 152
desonide cream 0.05% (Desowen)............................... 152
desonide lotion 0.05% (Desowen)................................152
desonide oint 0.05% (Desowen)...................................152
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
DESOWEN CREAM/CETAPHIL LO -desonide cream
0.05% w/ moisturizing lotion kit..................................... 152
DESOWEN -desonide cream 0.05%............................... 152
DESOWEN -desonide lotion 0.05%................................ 152
DESOWEN -desonide oint 0.05%................................... 152
DESOWEN LOTION/CETAPHIL C -desonide lotion 0.05%
w/ moisturizing cream kit............................................... 152
DESOWEN OINTMENT/CETAPHIL -desonide ointment
0.05% w/ moisturizing lotion kit..................................... 152
desoximetasone cream 0.25% (Topicort).................... 153
DESOXIMETASONE -desoximetasone cream 0.05%.....153
DESOXIMETASONE -desoximetasone oint 0.05%......... 153
desoximetasone gel 0.05% (Topicort)......................... 153
desoximetasone oint 0.25% (Topicort)........................ 153
DESOXYN -methamphetamine hcl tab 5 mg.................... 89
DESPEC-EXP -pseudoephedrine-dihydrocodeine-gg syrup
15-7.5-100 mg/5ml........................................................... 61
DESPEC-PDC -phenylephrine-chlorphen-dihydrocodeine
liqd 7.5-2.5-3 mg/5ml....................................................... 61
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)............................................... 80
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................. 80
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 80
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 80
DETROL LA -tolterodine tartrate cap sr 24hr 2 mg........... 75
DETROL LA -tolterodine tartrate cap sr 24hr 4 mg........... 75
DETROL -tolterodine tartrate tab 1 mg............................. 75
DETROL -tolterodine tartrate tab 2 mg............................. 75
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%............................................................................... 141
dexamethasone tab 0.5 mg............................................ 19
dexamethasone tab 0.75 mg.......................................... 19
dexamethasone tab 1.5 mg............................................ 19
dexamethasone tab 4 mg............................................... 19
dexamethasone tab 6 mg............................................... 19
DEXCHLORPHENIRAMINE MALEA -dexchlorpheniramine
maleate syrup 2 mg/5ml.................................................. 58
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 10
mg.................................................................................... 89
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 15
mg.................................................................................... 89
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 5
mg.................................................................................... 89
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 69
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 69
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).....................................................................................89
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr).....................................................................................89
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr).....................................................................................89
dexmethylphenidate hcl tab 10 mg (Focalin)................ 89
dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 89
dexmethylphenidate hcl tab 5 mg (Focalin).................. 89
DEXPAK 10 DAY -dexamethasone tab 1.5 mg taper
pack..................................................................................19
DEXPAK 13 DAY -dexamethasone tab 1.5 mg taper
pack..................................................................................19
DEXPAK 6 DAY -dexamethasone tab 1.5 mg taper
pack..................................................................................19
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)......................................................................89
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)......................................................................89
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)......................................................................89
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)...................................................................... 89
dextroamphetamine sulfate tab 10 mg.......................... 89
dextroamphetamine sulfate tab 5 mg............................ 89
DEXTROMETHORPHAN HBR/CHLO -phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 61
DEX-TUSS -guaifenesin-codeine liquid 300-10
mg/5ml..............................................................................61
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.................................................................................. 120
DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 3 mg.................................................................120
DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 5 mg.................................................................120
DIALYVITE SUPREME D -multiple vitamins w/ minerals &
fa tab 3 mg.................................................................... 120
DIAMOX -acetazolamide cap sr 12hr 500 mg................... 53
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg............................................................................. 110
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
189
2014
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg............................................................................. 110
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg............................................................... 110
DIATX ZN -b-complex w/ c-biotin-minerals & folic acid tab
5 mg............................................................................... 120
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................. 110
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................. 110
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................. 110
DIAZEPAM -diazepam soln 1 mg/ml................................. 78
DIAZEPAM INTENSOL -diazepam conc 5 mg/ml............. 78
diazepam tab 10 mg (Valium)......................................... 78
diazepam tab 2 mg (Valium)...........................................78
diazepam tab 5 mg (Valium)...........................................78
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg...........47
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg..........................................................................71
diclofenac potassium tab 50 mg (Cataflam)................105
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)...................................................................... 153
diclofenac sodium ophth soln 0.1%............................ 141
diclofenac sodium soln 1.5% (Pennsaid).................... 153
diclofenac sodium tab delayed release 25 mg............105
diclofenac sodium tab delayed release 50 mg............105
diclofenac sodium tab delayed release 75 mg............105
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr)...................................................................................105
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50).........................................................105
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75).........................................................105
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 69
DICYCLOMINE HCL -dicyclomine hcl oral soln 10
mg/5ml..............................................................................69
dicyclomine hcl tab 20 mg (Bentyl)............................... 69
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 8
didanosine delayed release capsule 200 mg (Videx
ec)...................................................................................... 8
didanosine delayed release capsule 250 mg (Videx
ec)...................................................................................... 8
didanosine delayed release capsule 400 mg (Videx
ec)...................................................................................... 8
DIDRONEL -etidronate disodium tab 400 mg....................35
DIFFERIN -adapalene cream 0.1%.................................153
DIFFERIN -adapalene gel 0.1%...................................... 153
DIFFERIN -adapalene gel 0.3%...................................... 153
DIFFERIN -adapalene lotion 0.1%.................................. 153
DIFICID -fidaxomicin tab 200 mg........................................ 3
190
DIFLORASONE DIACETATE -diflorasone diacetate cream
0.05%............................................................................. 153
diflorasone diacetate oint 0.05%..................................153
DIFLUCAN -fluconazole for susp 10 mg/ml.........................7
DIFLUCAN -fluconazole for susp 40 mg/ml.........................7
DIFLUCAN -fluconazole tab 100 mg................................... 7
DIFLUCAN -fluconazole tab 150 mg................................... 7
DIFLUCAN -fluconazole tab 200 mg................................... 7
DIFLUCAN -fluconazole tab 50 mg..................................... 6
diflunisal tab 500 mg.......................................................95
DIGEX NF -hyoscyamine-phenyltoloxamine cap 0.0625-15
mg.................................................................................... 69
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 38
digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 38
digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 38
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml....................................... 108
DILACOR XR -diltiazem hcl cap sr 24hr 240 mg...............42
DILANTIN INFATABS -phenytoin chew tab 50 mg..........111
DILANTIN -phenytoin sodium extended cap 100 mg.......110
DILANTIN -phenytoin sodium extended cap 30 mg.........110
DILANTIN -phenytoin susp 125 mg/5ml.......................... 110
DILATRATE SR -isosorbide dinitrate cap cr 40 mg........... 38
DILAUDID -hydromorphone hcl liqd 1 mg/ml.................... 97
DILAUDID -hydromorphone hcl tab 2 mg..........................97
DILAUDID -hydromorphone hcl tab 4 mg..........................97
DILAUDID -hydromorphone hcl tab 8 mg..........................97
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
diltiazem hcl coated beads tab sr 24hr 420 mg
(Cardizem la).................................................................. 42
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac)..................................................................... 42
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
diltiazem hcl extended release beads cap sr 24hr 180
mg (Tiazac)..................................................................... 42
diltiazem hcl extended release beads cap sr 24hr 240
mg (Tiazac)..................................................................... 42
diltiazem hcl extended release beads cap sr 24hr 300
mg (Tiazac)..................................................................... 42
diltiazem hcl extended release beads cap sr 24hr 360
mg (Tiazac)..................................................................... 42
diltiazem hcl extended release beads cap sr 24hr 420
mg (Tiazac)..................................................................... 42
diltiazem hcl tab 120 mg (Cardizem)............................. 42
diltiazem hcl tab 30 mg (Cardizem)............................... 42
diltiazem hcl tab 60 mg (Cardizem)............................... 42
diltiazem hcl tab 90 mg...................................................42
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.................................................................................... 47
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..................... 73
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml........................................................ 68
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil).......................................................................... 68
DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml................................. 15
DIPROLENE AF -betamethasone dipropionate augmented
cream 0.05%..................................................................153
DIPROLENE -betamethasone dipropionate augmented
lotion 0.05%................................................................... 153
DIPROLENE -betamethasone dipropionate augmented
oint 0.05%...................................................................... 153
dipyridamole tab 25 mg (Persantine)...........................138
dipyridamole tab 50 mg (Persantine)...........................138
dipyridamole tab 75 mg (Persantine)...........................138
disopyramide phosphate cap 100 mg (Norpace).......... 44
disopyramide phosphate cap 150 mg (Norpace).......... 44
disulfiram tab 250 mg (Antabuse)..................................92
disulfiram tab 500 mg (Antabuse)..................................92
DITROPAN XL -oxybutynin chloride tab sr 24hr 10 mg..... 75
DITROPAN XL -oxybutynin chloride tab sr 24hr 15 mg..... 75
DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg.......75
DIURIL -chlorothiazide susp 250 mg/5ml.......................... 53
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)...................................................................... 111
divalproex sodium tab delayed release 125 mg
(Depakote).....................................................................111
divalproex sodium tab delayed release 250 mg
(Depakote).....................................................................111
divalproex sodium tab delayed release 500 mg
(Depakote).....................................................................111
divalproex sodium tab sr 24 hr 250 mg (Depakote
er)...................................................................................111
divalproex sodium tab sr 24 hr 500 mg (Depakote
er)...................................................................................111
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 ................................................................................. 133
DOLGIC PLUS -butalbital-acetaminophen-caffeine tab
50-750-40 mg...................................................................95
DOLOGESIC -phenyltoloxamine-acetaminophen liquid
30-500 mg/15ml............................................................... 96
DOLOPHINE HCL -methadone hcl tab 5 mg.................... 97
DOLOPHINE -methadone hcl tab 10 mg...........................97
DONATUSS DC -phenylephrine-dihydrocodeine-gg syrup
7.5-7.5-50 mg/5ml............................................................61
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt)............................................................. 92
donepezil hydrochloride orally disintegrating tab 5 mg
(Aricept odt)....................................................................92
donepezil hydrochloride tab 10 mg (Aricept)................92
donepezil hydrochloride tab 23 mg (Aricept)................92
donepezil hydrochloride tab 5 mg (Aricept)..................92
DONNATAL -belladonna alkaloids-phenobarbital elixir 16.2
mg/5ml..............................................................................69
DONNATAL -belladonna alkaloids-phenobarbital tab 16.2
mg.................................................................................... 69
DONNATAL EXTENTABS -belladonna alkaloidsphenobarbital tab cr 48 mg..............................................69
DORAL -quazepam tab 15 mg.......................................... 87
DORYX -doxycycline hyclate tab delayed release 150
mg...................................................................................... 4
DORYX -doxycycline hyclate tab delayed release 200
mg...................................................................................... 4
dorzolamide hcl ophth soln 2% (Trusopt)................... 141
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................141
DOVONEX -calcipotriene cream 0.005%........................ 153
DOVONEX SCALP -calcipotriene soln 0.005% (50 mcg/
ml).................................................................................. 153
doxazosin mesylate tab 1 mg (Cardura)........................47
doxazosin mesylate tab 2 mg (Cardura)........................47
doxazosin mesylate tab 4 mg (Cardura)........................47
doxazosin mesylate tab 8 mg (Cardura)........................47
doxepin hcl cap 100 mg..................................................80
doxepin hcl cap 10 mg................................................... 80
doxepin hcl cap 150 mg..................................................80
doxepin hcl cap 25 mg................................................... 80
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
191
2014
doxepin hcl cap 50 mg................................................... 80
doxepin hcl conc 10 mg/ml............................................ 80
DOXEPIN HCL -doxepin hcl cap 75 mg............................80
doxercalciferol cap 0.5 mcg (Hectorol)......................... 35
doxercalciferol cap 1 mcg (Hectorol)............................ 35
doxercalciferol cap 2.5 mcg (Hectorol)......................... 35
doxycycline hyclate cap 100 mg (Vibramycin)............... 4
doxycycline hyclate cap 50 mg........................................4
DOXYCYCLINE HYCLATE -doxycycline hyclate cap dr
particles 100 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
DOXYTEX -doxylamine succinate liquid 2.5 mg/2.5ml...... 58
DRISDOL -ergocalciferol cap 50000 unit........................ 118
DRITHO-CREME HP -anthralin cream 1%......................153
DRITHO-SCALP -anthralin cream 0.5%..........................153
dronabinol cap 10 mg (Marinol)..................................... 71
dronabinol cap 2.5 mg (Marinol).................................... 71
dronabinol cap 5 mg (Marinol)....................................... 71
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................................. 133
DROXIA -hydroxyurea cap 300 mg................................. 133
DROXIA -hydroxyurea cap 400 mg................................. 133
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%...........................153
DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%...................................................................... 153
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........ 27
DUET DHA 400EC -prenat w/fe poly-na fered-fa tab 25-1
& omega cap dr 400mg................................................. 120
DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg........................................................120
192
DUET DHA 430EC -prenat w/fe poly-na fered-fa tab 25-1
& omega cap dr 430mg................................................. 120
DUET DHA 430 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 430 mg........................................................120
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
24-1 & omega cap 272 mg............................................120
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg............................................120
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
26-1 & omega cap 278 mg............................................120
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg.........................................120
DUET DHA EC -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap dr 400mg.....................................................120
DUET DHA EC -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap dr 430mg.....................................................120
DUET DHA -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg........................................................120
DUET DHA -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 430 mg........................................................120
DUEXIS -ibuprofen-famotidine tab 800-26.6 mg............. 105
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 65
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 65
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta).......................................................................80
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta).......................................................................80
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta).......................................................................80
DUONEB -ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml..............................................................................65
DURAGESIC -fentanyl td patch 72hr 100 mcg/hr..............98
DURAGESIC -fentanyl td patch 72hr 12 mcg/hr................97
DURAGESIC -fentanyl td patch 72hr 25 mcg/hr................97
DURAGESIC -fentanyl td patch 72hr 50 mcg/hr................97
DURAGESIC -fentanyl td patch 72hr 75 mcg/hr................97
DUREZOL -difluprednate ophth emulsion 0.05%............ 142
DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr
100-12.5 mg.....................................................................48
DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr
25-12.5 mg.......................................................................47
DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr
50-12.5 mg.......................................................................48
D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............. 118
DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 53
DYMISTA -azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act................................................................ 59
DYNACIN -minocycline hcl tab 100 mg...............................4
DYNACIN -minocycline hcl tab 50 mg.................................4
DYNACIN -minocycline hcl tab 75 mg.................................4
DYNACIRC CR -isradipine tab sr 24hr 10 mg...................42
DYNACIRC CR -isradipine tab sr 24hr 5 mg.....................42
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
dyphylline-guaifenesin liqd 100-100 mg/5ml.................65
dyphylline-guaifenesin tab 200-200 mg.........................65
dyphylline-guaifenesin tab 200-400 mg.........................65
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..................... 105
EC-NAPROSYN -naproxen tab ec 500 mg..................... 105
econazole nitrate cream 1%......................................... 153
ECOZA -econazole nitrate foam 1%............................... 153
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 CHLORPED -chlorpheniramine tannate susp 2 mg/
ml......................................................................................58
ED-CHLOR-TAN -chlorpheniramine tannate tab 8 mg...... 58
ED CYTE F -ferrous fumarate-folic acid-docusate sodium
tab 324-1-50 mg............................................................ 133
EDECRIN -ethacrynic acid tab 25 mg............................... 53
EDLUAR -zolpidem tartrate sl tab 10 mg.......................... 87
EDLUAR -zolpidem tartrate sl tab 5 mg............................ 87
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)........ 8
EFFER-K -potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 129
EFFER-K -potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 129
EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)........................................................................80
EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)........................................................................80
EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)........................................................................80
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............. 138
EFFIENT -prasugrel hcl tab 5 mg (base equiv)............... 138
EFUDEX -fluorouracil cream 5%..................................... 153
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)................................................................................35
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)................................................................................35
ELDEPRYL -selegiline hcl cap 5 mg............................... 115
ELENZAPATCH -lidocaine-menthol patch 4-1%............. 153
ELESTAT -epinastine hcl ophth soln 0.05%....................142
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)........................................................22
ELETONE - emollient - cream ........................................153
ELETONE TWINPACK - emollient - cream .................... 153
ELIDEL -pimecrolimus cream 1%....................................153
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..................................................................... 16
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 16
ELIMITE -permethrin cream 5%...................................... 153
ELIPHOS -calcium acetate (phosphate binder) tab 667
mg.................................................................................... 73
ELIQUIS -apixaban tab 2.5 mg....................................... 136
ELIQUIS -apixaban tab 5 mg.......................................... 136
ELITE-OB - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg
....................................................................................... 121
ELITE OB WITH DHA - prenatal vit w/ fe fum-fa-omega 3
cap 28-1.25-200 mg ..................................................... 121
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml................66
ELLA -ulipristal acetate tab 30 mg.................................... 24
ELMIRON -pentosan polysulfate sodium caps 100 mg..... 77
ELOCON -mometasone furoate cream 0.1%.................. 153
ELOCON -mometasone furoate oint 0.1%...................... 153
ELOCON -mometasone furoate solution 0.1%
(lotion)............................................................................ 153
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv)................................................................... 142
EMCYT -estramustine phosphate sodium cap 140 mg......16
EMEND -aprepitant capsule 125 mg................................. 71
EMEND -aprepitant capsule 40 mg...................................71
EMEND -aprepitant capsule 80 mg...................................71
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 71
EMLA -lidocaine-prilocaine cream 2.5-2.5%....................153
EMSAM -selegiline td patch 24hr 12 mg/24hr................... 80
EMSAM -selegiline td patch 24hr 6 mg/24hr..................... 80
EMSAM -selegiline td patch 24hr 9 mg/24hr..................... 80
EMTRIVA -emtricitabine caps 200 mg................................ 8
EMTRIVA -emtricitabine soln 10 mg/ml...............................8
EMULSION SB - dermatological products misc - emulsion
....................................................................................... 153
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv)..................................................................... 75
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv)..................................................................... 75
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
ENBREL -etanercept for subcutaneous inj kit 25 mg.......105
ENBREL -etanercept subcutaneous inj 25 mg/0.5ml.......105
ENBREL -etanercept subcutaneous inj 50 mg/ml............105
ENBREL SURECLICK -etanercept subcutaneous inj 50
mg/ml..............................................................................105
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
193
2014
ENDACOF-DC -pseudoephedrine w/ codeine liquid 30-10
mg/5ml..............................................................................61
ENDOMETRIN -progesterone vaginal insert 100 mg........ 76
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).............. 136
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)......... 136
enoxaparin sodium inj 150 mg/ml (Lovenox).............. 136
enoxaparin sodium inj 300 mg/3ml (Lovenox)............ 136
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)........... 136
enoxaparin sodium inj 40 mg/0.4ml (Lovenox)........... 136
enoxaparin sodium inj 60 mg/0.6ml (Lovenox)........... 136
enoxaparin sodium inj 80 mg/0.8ml (Lovenox)........... 136
entacapone tab 200 mg (Comtan)................................ 115
ENTERAGAM -serum-derived bovine immunoglob/protein
isolate 5 gm packet....................................................... 130
ENTEREG -alvimopan cap 12 mg.....................................73
ENTOCORT EC -budesonide cap sr 24hr 3 mg................19
EPANED -enalapril maleate for oral soln 1 mg/ml.............48
EPICERAM - dermatological products misc - emulsion
....................................................................................... 153
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%.......153
EPIFOAM -pramoxine-hc aerosol foam 1-1%................. 153
epinastine hcl ophth soln 0.05% (Elestat)................... 142
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 54
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........................ 8
EPIVIR HBV -lamivudine tab 100 mg..................................8
EPIVIR -lamivudine oral soln 10 mg/ml...............................8
EPIVIR -lamivudine tab 150 mg.......................................... 8
EPIVIR -lamivudine tab 300 mg.......................................... 8
eplerenone tab 25 mg (Inspra)....................................... 48
eplerenone tab 50 mg (Inspra)....................................... 48
194
EPOGEN -epoetin alfa inj 10000 unit/ml......................... 133
EPOGEN -epoetin alfa inj 20000 unit/ml......................... 133
EPOGEN -epoetin alfa inj 2000 unit/ml........................... 133
EPOGEN -epoetin alfa inj 3000 unit/ml........................... 133
EPOGEN -epoetin alfa inj 4000 unit/ml........................... 133
eprosartan mesylate tab 600 mg (Teveten)................... 48
EPZICOM -abacavir sulfate-lamivudine tab 600-300 mg.....8
EQUAGESIC -meprobamate-aspirin tab 200-325 mg....... 96
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................. 84
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
200 mg............................................................................. 84
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
300 mg............................................................................. 84
ergocalciferol cap 50000 unit (Drisdol)........................118
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................... 92
ERGOMAR -ergotamine tartrate sl tab 2 mg...................108
ERIVEDGE -vismodegib cap 150 mg................................16
ERTACZO -sertaconazole nitrate cream 2%...................153
ERYGEL -erythromycin gel 2%....................................... 153
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 -erythromycin w/ delayed release
particles cap 250 mg......................................................... 3
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg.................................................3
erythromycin ethylsuccinate tab 400 mg........................ 3
erythromycin gel 2% (Erygel)....................................... 153
erythromycin ophth oint 5 mg/gm............................... 142
erythromycin pads 2%.................................................. 153
erythromycin soln 2%................................................... 153
erythromycin-sulfisoxazole for susp 200-600
mg/5ml.............................................................................12
erythromycin w/ delayed release particles cap 250
mg...................................................................................... 3
ESCAVITE D - pediatric multiple vitamins w/ fl-fe chew tab
0.25-6 mg ..................................................................... 121
ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab
0.25-7.5 mg .................................................................. 121
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)......................................................................... 80
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)......................................................................... 80
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)......................................................................... 80
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)......................................................................... 80
ESGIC -butalbital-acetaminophen-caffeine cap 50-325-40
mg.................................................................................... 96
ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................... 96
ESGIC-PLUS -butalbital-acetaminophen-caffeine cap
50-500-40 mg...................................................................96
ESGIC-PLUS -butalbital-acetaminophen-caffeine tab
50-500-40 mg...................................................................96
ESOMEPRAZOLE STRONTIUM -esomeprazole strontium
cap delayed release 24.65 mg........................................ 69
ESOMEPRAZOLE STRONTIUM -esomeprazole strontium
cap delayed release 49.3 mg.......................................... 69
estazolam tab 1 mg......................................................... 87
estazolam tab 2 mg......................................................... 87
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................. 22
esterified estrogens & methyltestosterone tab 1.25-2.5
mg.................................................................................... 22
ESTRACE -estradiol tab 0.5 mg........................................22
ESTRACE -estradiol tab 1 mg.......................................... 22
ESTRACE -estradiol tab 2 mg.......................................... 22
ESTRACE -estradiol vaginal cream 0.1 mg/gm.................76
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................ 22
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................ 22
estradiol tab 0.5 mg (Estrace)........................................ 22
estradiol tab 1 mg (Estrace)........................................... 22
estradiol tab 2 mg (Estrace)........................................... 22
estradiol td patch weekly 0.025 mg/24hr (Climara).......22
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 22
estradiol td patch weekly 0.05 mg/24hr (Climara).........22
estradiol td patch weekly 0.06 mg/24hr (Climara).........22
estradiol td patch weekly 0.075 mg/24hr (Climara).......22
estradiol td patch weekly 0.1 mg/24hr (Climara)...........22
ESTRASORB -estradiol transdermal emulsion 4.35
mg/1.74gm....................................................................... 22
ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).....76
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)........................................................22
ESTROPIPATE -estropipate tab 3 mg.............................. 22
estropipate tab 0.75 mg.................................................. 22
estropipate tab 1.5 mg.................................................... 22
ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg....................................................24
eszopiclone tab 1 mg (Lunesta).....................................87
eszopiclone tab 2 mg (Lunesta).....................................87
eszopiclone tab 3 mg (Lunesta).....................................87
ethambutol hcl tab 100 mg (Myambutol).........................6
ethambutol hcl tab 400 mg (Myambutol).........................6
ethosuximide cap 250 mg (Zarontin)........................... 111
ethosuximide soln 250 mg/5ml (Zarontin)...................111
ETHYL CHLORIDE/FINE PINPO -ethyl chloride aerosol
spray...............................................................................153
ETHYL CHLORIDE/FINE STREA -ethyl chloride aerosol
spray...............................................................................153
ETHYL CHLORIDE/MEDIUM JET -ethyl chloride aerosol
spray...............................................................................153
ETHYL CHLORIDE/MEDIUM STR -ethyl chloride aerosol
spray...............................................................................153
ETHYL CHLORIDE/MIST -ethyl chloride aerosol
spray...............................................................................154
ETHYL CHLORIDE -ethyl chloride aerosol spray............153
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..................................................... 105
etodolac cap 300 mg..................................................... 105
etodolac tab 400 mg......................................................105
etodolac tab 500 mg......................................................105
etodolac tab sr 24hr 400 mg.........................................105
etodolac tab sr 24hr 500 mg.........................................105
etodolac tab sr 24hr 600 mg.........................................105
ETOPOSIDE -etoposide cap 50 mg..................................16
EURAX -crotamiton cream 10%...................................... 154
EURAX -crotamiton lotion 10%....................................... 154
EVAMIST -estradiol transdermal spray 1.53 mg/spray...... 22
EVISTA -raloxifene hcl tab 60 mg..................................... 36
EVOCLIN -clindamycin phosphate foam 1%................... 154
EVOXAC -cevimeline hcl cap 30 mg...............................146
EXACTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml..............................................................................61
EXALGO -hydromorphone hcl tab er 24hr deter 12 mg.....98
EXALGO -hydromorphone hcl tab er 24hr deter 16 mg.....98
EXALGO -hydromorphone hcl tab er 24hr deter 32 mg.....98
EXALGO -hydromorphone hcl tab er 24hr deter 8 mg.......98
EXELDERM -sulconazole nitrate cream 1%....................154
EXELDERM -sulconazole nitrate solution 1%................. 154
EXELON -rivastigmine tartrate cap 1.5 mg....................... 92
EXELON -rivastigmine tartrate cap 3 mg.......................... 92
EXELON -rivastigmine tartrate cap 4.5 mg....................... 92
EXELON -rivastigmine tartrate cap 6 mg.......................... 92
EXELON -rivastigmine tartrate soln 2 mg/ml..................... 93
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr...........92
EXELON -rivastigmine td patch 24hr 4.6 mg/24hr.............92
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr.............92
exemestane tab 25 mg (Aromasin)................................ 16
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
195
2014
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............... 165
EXJADE -deferasirox tab for oral susp 250 mg............... 165
EXJADE -deferasirox tab for oral susp 500 mg............... 165
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 93
EXTINA -ketoconazole foam 2%..................................... 154
EXTRA-VIRT PLUS DHA - prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg ................................... 121
F
FA-8 -folic acid cap 0.8 mg............................................. 133
FABIOR -tazarotene (acne) foam 0.1%...........................154
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)..................................................................................6
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)....................... 69
famotidine tab 40 mg (Pepcid)....................................... 69
FAMVIR -famciclovir tab 125 mg.........................................8
FAMVIR -famciclovir tab 250 mg.........................................8
FAMVIR -famciclovir tab 500 mg.........................................8
FANAPT -iloperidone tab 10 mg....................................... 84
FANAPT -iloperidone tab 12 mg....................................... 84
FANAPT -iloperidone tab 1 mg......................................... 84
FANAPT -iloperidone tab 2 mg......................................... 84
FANAPT -iloperidone tab 4 mg......................................... 84
FANAPT -iloperidone tab 6 mg......................................... 84
FANAPT -iloperidone tab 8 mg......................................... 84
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titratration pak........................................ 84
FARESTON -toremifene citrate tab 60 mg (base
equivalent)........................................................................16
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)........................................................................27
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)........................................................................27
FAZACLO -clozapine orally disintegrating tab 100 mg...... 84
FAZACLO -clozapine orally disintegrating tab 12.5 mg..... 84
FAZACLO -clozapine orally disintegrating tab 150 mg...... 84
FAZACLO -clozapine orally disintegrating tab 200 mg...... 84
FAZACLO -clozapine orally disintegrating tab 25 mg........ 84
196
FE 90 PLUS - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss
tab 90-1 mg .................................................................. 133
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg.................................................................................. 133
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg.................................................................................. 133
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap (Tandem plus)....................................................... 132
FEIBA NF - antiinhibitor coagulant complex for inj ......... 138
felbamate susp 600 mg/5ml (Felbatol).........................111
felbamate tab 400 mg (Felbatol)...................................111
felbamate tab 600 mg (Felbatol)...................................111
FELBATOL -felbamate susp 600 mg/5ml........................ 111
FELBATOL -felbamate tab 400 mg................................. 111
FELBATOL -felbamate tab 600 mg................................. 111
FELDENE -piroxicam cap 10 mg.................................... 105
FELDENE -piroxicam cap 20 mg.................................... 105
felodipine tab sr 24hr 10 mg.......................................... 42
felodipine tab sr 24hr 2.5 mg......................................... 43
felodipine tab sr 24hr 5 mg............................................ 43
FEMARA -letrozole tab 2.5 mg......................................... 16
FEMCON FE -norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg.......................................................... 24
FEMHRT 1/5 -norethindrone acetate-ethinyl estradiol tab 1
mg-5 mcg......................................................................... 22
FEMHRT LOW DOSE -norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg........................................... 22
FEM PH -acetic acid-oxyquinoline vaginal gel
0.9-0.025%....................................................................... 76
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr............................................................................ 76
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr...... 76
FEMTRACE -estradiol acetate tab 0.45 mg...................... 22
FEMTRACE -estradiol acetate tab 0.9 mg........................ 22
FENOFIBRATE -fenofibrate cap 150 mg.......................... 55
FENOFIBRATE -fenofibrate cap 50 mg............................ 55
fenofibrate micronized cap 130 mg (Antara).................55
fenofibrate micronized cap 134 mg (Lofibra)................ 55
fenofibrate micronized cap 200 mg (Lofibra)................ 55
fenofibrate micronized cap 43 mg (Antara)...................55
fenofibrate micronized cap 67 mg (Lofibra).................. 55
fenofibrate tab 145 mg (Tricor)...................................... 55
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 tab 600
mg.................................................................................. 106
fentanyl citrate lollipop 1200 mcg (Actiq)..................... 98
fentanyl citrate lollipop 1600 mcg (Actiq)..................... 98
fentanyl citrate lollipop 200 mcg (Actiq)....................... 98
fentanyl citrate lollipop 400 mcg (Actiq)....................... 98
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
fentanyl citrate lollipop 600 mcg (Actiq)....................... 98
fentanyl citrate lollipop 800 mcg (Actiq)....................... 98
fentanyl td patch 72hr 100 mcg/hr (Duragesic).............98
fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............98
fentanyl td patch 72hr 25 mcg/hr (Duragesic)...............98
fentanyl td patch 72hr 50 mcg/hr (Duragesic)...............98
fentanyl td patch 72hr 75 mcg/hr (Duragesic)...............98
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)................................................................................98
FENTORA -fentanyl citrate buccal tab 200 mcg (base
equiv)................................................................................98
FENTORA -fentanyl citrate buccal tab 400 mcg (base
equiv)................................................................................98
FENTORA -fentanyl citrate buccal tab 600 mcg (base
equiv)................................................................................98
FENTORA -fentanyl citrate buccal tab 800 mcg (base
equiv)................................................................................98
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe).................................................................. 133
FERIVAFA - iron-c-fa-b12-biotin-copper-docusate cap
110-1 mg ...................................................................... 133
FERIVA - fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap
75-1 mg ........................................................................ 133
FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 133
FERRAPLUS 90 - iron-folic acid-vit b12-vit c-docusate sod
tab 90-1 mg .................................................................. 133
FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18
mg (elemental iron)........................................................133
FERREX 150 FORTE PLUS - fe asp gly-fe polysacch-succ
ac-c-threon ac-b12-fa cap ............................................ 133
FERREX 28 - fe asparto gly-fe fum-b12-fa-c-succinic ac
tab ther pack .................................................................133
FERRIPROX -deferiprone tab 500 mg............................ 165
FERRO-PLEX HEMATINIC - fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg ......................................................... 133
FERROTRIN -iron w/ b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg................................................ 133
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab
106-1 mg ...................................................................... 132
ferrous fumarate-folic acid tab 324-1 mg.................... 133
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe)................................................................................... 134
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)...............................................133
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)...............................................134
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe)................................................................................... 134
ferrous sulfate-vit c-folic acid tab cr 105-500-0.8
mg.................................................................................. 134
FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)........................................................................80
FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)........................................................................80
FETZIMA -levomilnacipran hcl cap sr 24hr 40 mg (base
equivalent)........................................................................80
FETZIMA -levomilnacipran hcl cap sr 24hr 80 mg (base
equivalent)........................................................................80
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack........................................ 80
FEXMID -cyclobenzaprine hcl tab 7.5 mg....................... 117
FEXOFENADINE HCL -fexofenadine hcl tab 60 mg......... 59
fexofenadine hcl tab 180 mg.......................................... 59
fexofenadine hcl tab 30 mg............................................ 59
fexofenadine hcl tab 60 mg............................................ 59
FIBRICOR -fenofibric acid tab 105 mg..............................55
FIBRICOR -fenofibric acid tab 35 mg................................55
FINACEA -azelaic acid gel 15%......................................154
FINACEA PLUS -azelaic acid gel 15% w/cleanser &
moisturizing lotion kit..................................................... 154
finasteride tab 5 mg (Proscar)........................................77
FINGERSTIX LANCETS - lancets ..................................166
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................... 98
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg............................................... 98
FIORICET -butalbital-acetaminophen-caffeine cap
50-300-40 mg...................................................................96
FIORICET -butalbital-acetaminophen-caffeine tab
50-325-40 mg...................................................................96
FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg...................................................... 98
FIORINAL -butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................... 96
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)......................................................................138
FIRST-HYDROCORTISONE -hydrocortisone gel
10%................................................................................ 154
FIRST-LANSOPRAZOLE - lansoprazole susp 3 mg/ml
(compound kit) ................................................................ 69
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%...... 142
flavoxate hcl tab 100 mg.................................................75
flaxseed oil-evening primrose-bilberry cap 1000-500-40
mg (Tears again hydrate)............................................ 130
flecainide acetate tab 100 mg.........................................44
flecainide acetate tab 150 mg.........................................44
flecainide acetate tab 50 mg.......................................... 44
FLECTOR -diclofenac epolamine patch 1.3%................. 154
FLEXERIL -cyclobenzaprine hcl tab 10 mg..................... 117
FLEXERIL -cyclobenzaprine hcl tab 5 mg.......................117
FLOMAX -tamsulosin hcl cap 0.4 mg................................77
FLONASE -fluticasone propionate nasal susp 50 mcg/
act.....................................................................................59
FLO-PRED -prednisolone acetate oral susp 16.7 mg/5ml
(15 mg/5ml base).............................................................19
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
197
2014
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 129
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 129
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister.................................................................66
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister.................................................................66
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister........................................................................ 66
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)..........................................................66
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)..........................................................66
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)............................................................66
FLUARIX 2011-2012 -influenza virus vaccine split
preservative free inj......................................................... 13
FLUARIX 2012-2013 -influenza virus vaccine split
preservative free inj......................................................... 13
FLUARIX 2013-2014 -influenza virus vaccine split
preservative free inj......................................................... 13
FLUARIX QUADRIVALENT 2013 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 13
FLUARIX QUADRIVALENT 2014 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 13
FLUBLOK 2013-2014 -influenza virus vac recombinant
hemagglutinin (ha) inj...................................................... 13
FLUCELVAX 2012-2013 -influenza virus vaccine tissuecultured subunit inj...........................................................13
FLUCELVAX 2013-2014 -influenza virus vaccine tissuecultured subunit inj...........................................................13
FLUCELVAX 2014-2015 -influenza virus vaccine tissuecultured subunit inj...........................................................13
fluconazole for susp 10 mg/ml (Diflucan)....................... 7
fluconazole for susp 40 mg/ml (Diflucan)....................... 7
fluconazole tab 100 mg (Diflucan)................................... 7
fluconazole tab 150 mg (Diflucan)................................... 7
fluconazole tab 200 mg (Diflucan)................................... 7
fluconazole tab 50 mg (Diflucan)..................................... 7
flucytosine cap 250 mg (Ancobon).................................. 7
flucytosine cap 500 mg (Ancobon).................................. 7
fludrocortisone acetate tab 0.1 mg................................ 19
FLULAVAL 2011-2012 -influenza virus vaccine split inj.....13
FLULAVAL 2012-2013 -influenza virus vaccine split inj.....13
FLULAVAL 2013-2014 -influenza virus vaccine split inj.....13
FLULAVAL 2014-2015 -influenza virus vaccine split inj.....13
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj.................................................... 13
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 13
FLUMADINE -rimantadine hydrochloride tab 100 mg..........8
FLUMIST NASAL VACCINE 201 -influenza virus vaccine
live intranasal liquid......................................................... 13
198
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp............................................ 13
FLUNISOLIDE -flunisolide nasal soln 25 mcg/act
(0.025%)...........................................................................59
FLUNISOLIDE -flunisolide nasal soln 29 mcg/act
(0.025%)...........................................................................59
flunisolide nasal soln 0.025% (Flunisolide)...................59
fluocinolone acetonide (otic) oil 0.01% (Dermotic).....145
fluocinolone acetonide cream 0.01%...........................154
fluocinolone acetonide cream 0.025% (Synalar).........154
fluocinolone acetonide oil 0.01% (Derma-smoothe/fs
bod)................................................................................154
fluocinolone acetonide oint 0.025% (Synalar).............154
fluocinolone acetonide soln 0.01% (Synalar)..............154
fluocinonide cream 0.05%............................................ 154
fluocinonide cream 0.1% (Vanos)................................ 154
fluocinonide emulsified base cream 0.05%.................154
fluocinonide gel 0.05%..................................................154
fluocinonide oint 0.05%................................................ 154
fluocinonide soln 0.05%................................................154
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf).........................................................129
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25
mg f)-236.79 mg............................................................ 129
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg............................................................ 129
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg...................................................................129
FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%......................................... 146
fluorometholone ophth susp 0.1% (Fml liquifilm).......142
FLUOROPLEX -fluorouracil cream 1%............................154
fluorouracil cream 5% (Efudex)....................................154
fluorouracil soln 2%...................................................... 154
fluorouracil soln 5%...................................................... 154
fluoxetine hcl (pmdd) cap 10 mg................................... 93
fluoxetine hcl (pmdd) cap 20 mg................................... 93
fluoxetine hcl cap 10 mg (Prozac)................................. 80
fluoxetine hcl cap 20 mg (Prozac)................................. 80
fluoxetine hcl cap 40 mg (Prozac)................................. 80
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 80
FLUOXETINE HCL -fluoxetine hcl tab 60 mg....................80
fluoxetine hcl solution 20 mg/5ml..................................80
fluoxetine hcl tab 10 mg................................................. 80
fluoxetine hcl tab 20 mg................................................. 80
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml..............................................................................84
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml......................................................................................84
fluphenazine hcl tab 10 mg............................................ 84
fluphenazine hcl tab 1 mg.............................................. 84
fluphenazine hcl tab 2.5 mg........................................... 84
fluphenazine hcl tab 5 mg.............................................. 84
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from
0.55 mg/drop naf).......................................................... 129
flurazepam hcl cap 15 mg.............................................. 87
flurazepam hcl cap 30 mg.............................................. 87
flurbiprofen sodium ophth soln 0.03% (Ocufen).........142
flurbiprofen tab 100 mg................................................ 106
flurbiprofen tab 50 mg.................................................. 106
flutamide cap 125 mg......................................................16
fluticasone propionate cream 0.05% (Cutivate).......... 154
fluticasone propionate lotion 0.05% (Cutivate)...........154
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 59
fluticasone propionate oint 0.005% (Cutivate)............ 154
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 inj............................................................14
FLUVIRIN 2012-2013 -influenza virus vaccine types a & b
surface antigen inj............................................................14
FLUVIRIN 2013-2014 -influenza virus vaccine types a & b
surface antigen inj............................................................14
FLUVIRIN 2014-2015 -influenza virus vaccine types a & b
surface antigen inj............................................................14
FLUVIRIN PF 2011-2012 -influenza virus vaccine types a
& b preservative free inj...................................................13
FLUVIRIN PF 2012-2013 -influenza virus vaccine types a
& b preservative free inj...................................................13
FLUVIRIN PF 2013-2014 -influenza virus vaccine types a
& b preservative free inj...................................................14
FLUVIRIN PF 2014-2015 -influenza virus vaccine types a
& b preservative free inj...................................................14
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr).....................................................................................80
fluvoxamine maleate cap sr 24hr 150 mg (Luvox
cr).....................................................................................80
fluvoxamine maleate tab 100 mg................................... 80
fluvoxamine maleate tab 25 mg..................................... 80
fluvoxamine maleate tab 50 mg..................................... 81
FLUZONE HIGH-DOSE PF 2012 -influenza virus vac split
high-dose preservative free inj.........................................14
FLUZONE HIGH-DOSE PF 2013 -influenza virus vac split
high-dose preservative free inj.........................................14
FLUZONE HIGH-DOSE PF 2014 -influenza virus vac split
high-dose preservative free inj.........................................14
FLUZONE INTRADERMAL -influenza virus vaccine split
intradermal inj 9 mcg/strain............................................. 14
FLUZONE PEDIATRIC PF 2012 -influenza virus vaccine
split preservative free inj..................................................14
FLUZONE PEDIATRIC PF 2013 -influenza virus vaccine
split preservative free inj..................................................14
FLUZONE PEDIATRIC PF 2014 -influenza virus vaccine
split preservative free inj..................................................14
FLUZONE PF 2012-2013 -influenza virus vaccine split
preservative free inj......................................................... 14
FLUZONE PF 2013-2014 -influenza virus vaccine split
preservative free inj......................................................... 14
FLUZONE QUADRIVALENT 2013 -influenza virus vaccine
split quadrivalent inj 0.25 ml............................................ 14
FLUZONE QUADRIVALENT 2013 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 14
FLUZONE QUADRIVALENT 2014 -influenza virus vaccine
split quadrivalent inj 0.25 ml............................................ 14
FLUZONE QUADRIVALENT 2014 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 14
FLUZONE SPLIT 2012-2013 -influenza virus vaccine split
inj......................................................................................14
FLUZONE SPLIT 2013-2014 -influenza virus vaccine split
inj......................................................................................14
FLUZONE SPLIT 2014-2015 -influenza virus vaccine split
inj......................................................................................14
FML -fluorometholone ophth oint 0.1%........................... 142
FML FORTE -fluorometholone ophth susp 0.25%...........142
FML LIQUIFILM -fluorometholone ophth susp 0.1%....... 142
FOCALGIN-B - prenatal w/ calcium-vit b6-fa-ginger tab
1.22 mg .........................................................................121
FOCALIN -dexmethylphenidate hcl tab 10 mg.................. 89
FOCALIN -dexmethylphenidate hcl tab 2.5 mg................. 89
FOCALIN -dexmethylphenidate hcl tab 5 mg.................... 89
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................... 89
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 15
mg.................................................................................... 89
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 20
mg.................................................................................... 89
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 25
mg.................................................................................... 89
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 30
mg.................................................................................... 90
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 35
mg.................................................................................... 90
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 40
mg.................................................................................... 90
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 5
mg.................................................................................... 89
FOLBECAL - prenatal w/ calcium carbonate-b6-b12-fa tab
1 mg ..............................................................................121
FOLBEE AR - folic acid-b12-b6-arginine-black pepper tab
....................................................................................... 130
FOLBIC RF - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2
mg ................................................................................. 131
FOLCAL DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg ............................................................ 121
FOLCAPS OMEGA 3 - prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg ............................................... 121
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak................................................................... 121
FOLET ONE - prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg .......................................................... 121
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
199
2014
FOLGARD OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.....................................................................121
FOLGARD RX -folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg....................................................................134
folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg.................................................................................. 131
folic acid tab 1 mg.........................................................134
folic acid tab 400 mcg...................................................134
folic acid tab 800 mcg...................................................134
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg.................................................................................. 134
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx)................................................................... 134
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 134
folic acid-vit b6-vit b12-omega 3-phytosterols cap 1
mg .................................................................................132
FOLIVANE-F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ....................................134
FOLIVANE-OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 121
FOLIVANE-PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .....................................................134
FOLIVANE-PRX DHA NF - prenatal w/o vit a w/fe fum-dssfa-dha cap 30-1.24-265 mg .......................................... 121
FOLPACE RX -folic acid-hydroxocobal-vit b6-vit e-mag tab
2.05 mg-425 mcg...........................................................134
FOLTANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg
....................................................................................... 131
FOLTANX RF - l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg ......................................................... 131
FOLTX -folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg.................................................................................. 131
FOLTX - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg
....................................................................................... 131
fondaparinux sodium inj 10 mg/0.8ml (Arixtra)...........136
fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)..........136
fondaparinux sodium inj 5 mg/0.4ml (Arixtra).............136
fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)..........136
FORADIL AEROLIZER -formoterol fumarate inhal cap 12
mcg...................................................................................66
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg.............. 81
formaldehyde solution 10%.......................................... 164
FORMA-RAY -formaldehyde solution 20%......................164
FORTAMET -metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 27
FORTAMET -metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 27
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 10 mg...................... 36
FOSAMAX -alendronate sodium tab 70 mg...................... 36
200
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit.........................................................36
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..... 73
FOSRENOL -lanthanum carbonate chew tab 500 mg....... 73
FOSRENOL -lanthanum carbonate chew tab 750 mg....... 73
FOSTEUM - genistein-zinc amino acid chelate-vitamin d
cap ................................................................................ 131
FRAGMIN -dalteparin sodium inj 10000 unit/ml.............. 136
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml..........136
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml..........136
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml........136
FRAGMIN -dalteparin sodium inj 25000 unit/ml.............. 136
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml............136
FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml............136
FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml............136
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)......................................................................108
FULYZAQ -crofelemer tab delayed release 125 mg..........68
FUMATINIC - iron combination cap cr ........................... 134
FURADANTIN -nitrofurantoin susp 25 mg/5ml.................. 74
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-cbiotin-probiotic cap ........................................................134
FUZEON -enfuvirtide for inj 90 mg......................................8
FYCOMPA -perampanel tab 10 mg.................................111
FYCOMPA -perampanel tab 12 mg.................................111
FYCOMPA -perampanel tab 2 mg.................................. 111
FYCOMPA -perampanel tab 4 mg.................................. 111
FYCOMPA -perampanel tab 6 mg.................................. 111
FYCOMPA -perampanel tab 8 mg.................................. 111
G
gabapentin cap 100 mg (Neurontin)............................ 111
gabapentin cap 300 mg (Neurontin)............................ 111
gabapentin cap 400 mg (Neurontin)............................ 111
gabapentin oral soln 250 mg/5ml (Neurontin).............111
gabapentin tab 600 mg (Neurontin)............................. 111
gabapentin tab 800 mg (Neurontin)............................. 111
GABITRIL -tiagabine hcl tab 12 mg.................................111
GABITRIL -tiagabine hcl tab 16 mg.................................111
GABITRIL -tiagabine hcl tab 2 mg.................................. 111
GABITRIL -tiagabine hcl tab 4 mg.................................. 111
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................. 93
galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er)................................................................. 93
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................. 93
galantamine hydrobromide oral soln 4 mg/ml
(Razadyne)...................................................................... 93
galantamine hydrobromide tab 12 mg (Razadyne)....... 93
galantamine hydrobromide tab 4 mg (Razadyne).........93
galantamine hydrobromide tab 8 mg (Razadyne).........93
GALZIN -zinc acetate cap 25 mg.................................... 129
GALZIN -zinc acetate cap 50 mg.................................... 129
GARAMYCIN -gentamicin sulfate ophth soln 0.3%......... 142
GASTRINEX NF -hyoscyamine-phenyltoloxamine cap
0.0625-15 mg...................................................................69
GASTROCROM -cromolyn sodium oral conc 100
mg/5ml..............................................................................73
gatifloxacin ophth soln 0.5% (Zymaxid)...................... 142
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 73
GEBAUERS PAIN EASE -pentafluoropropanetetrafluoroethane aero spray..........................................154
GEBAUERS SPRAY AND STRETC -pentafluoropropanetetrafluoroethane aero spray..........................................154
GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic
acid gel ......................................................................... 146
GELFILM OP -gelatin adsorbable ophth film................... 142
GEL-KAM ORAL CARE RINSE -stannous fluoride conc
0.63%............................................................................. 146
GEL-KAM -stannous fluoride gel 0.4%............................146
GELNIQUE -oxybutynin chloride td gel 10%..................... 75
GELNIQUE -oxybutynin td gel 3% (28 mg/act metereddose pump)...................................................................... 75
GELX - oral wound care products - gel .......................... 146
gemfibrozil tab 600 mg (Lopid)...................................... 55
GENADUR - dermatological products misc - liquid .........154
GENADUR KIT - dermatological products misc topical/oral
- kit ................................................................................154
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 cream 0.1%.................................... 154
GENTAMICIN SULFATE -gentamicin sulfate cream
0.1%............................................................................... 154
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%............................................................................... 154
gentamicin sulfate oint 0.1%........................................ 154
gentamicin sulfate ophth oint 0.3%............................. 142
gentamicin sulfate ophth soln 0.3% (Garamycin)....... 142
GEODON -ziprasidone hcl cap 20 mg.............................. 84
GEODON -ziprasidone hcl cap 40 mg.............................. 84
GEODON -ziprasidone hcl cap 60 mg.............................. 84
GEODON -ziprasidone hcl cap 80 mg.............................. 84
GESTICARE DHA -prenatal w/fe fum-fa tab dr 27-1 mg &
dha cap 250 mg pack ...................................................121
GIAZO -balsalazide disodium tab 1.1 gm..........................73
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 93
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)........................................................................16
GILOTRIF -afatinib dimaleate tab 30 mg (base
equivalent)........................................................................16
GILOTRIF -afatinib dimaleate tab 40 mg (base
equivalent)........................................................................16
GILPHEX TR -phenylephrine-guaifenesin tab 10-388
mg.................................................................................... 61
GILTUSS PED-C -phenylephrine w/ codeine-gg liquid
2.5-3-50 mg/ml.................................................................61
GILTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml..............................................................................61
GILTUSS TR -phenylephrine w/ dm-gg cap 7-14-288
mg.................................................................................... 61
GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388
mg.................................................................................... 61
GILTUSS TR -phenylephrine w/ dm-gg tab sr 12hr
20-30-600 mg...................................................................61
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)........................................................................16
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)........................................................................16
glimepiride tab 1 mg (Amaryl)........................................27
glimepiride tab 2 mg (Amaryl)........................................27
glimepiride tab 4 mg (Amaryl)........................................27
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).......................................27
glipizide tab 5 mg (Glucotrol).........................................27
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................27
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 27
glipizide tab sr 24hr 5 mg (Glucotrol xl)........................27
GLUCAGEN -glucagon hcl (rdna) for inj 1 mg (base
equiv)................................................................................28
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
201
2014
GLUCOPHAGE -metformin hcl tab 500 mg...................... 28
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............. 165
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%......................... 164
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)......... 28
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............................... 69
glycopyrrolate tab 1 mg (Robinul)................................. 69
glycopyrrolate tab 2 mg (Robinul forte)........................ 69
GLYNASE -glyburide micronized tab 1.5 mg.................... 28
GLYNASE -glyburide micronized tab 3 mg....................... 28
GLYNASE -glyburide micronized tab 6 mg....................... 28
GLYSET -miglitol tab 100 mg............................................28
GLYSET -miglitol tab 25 mg..............................................28
GLYSET -miglitol tab 50 mg..............................................28
GNP GLUCOSE -glucose chew tab 4 gm......................... 28
GNP GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 28
GNP QUICK DISSOLVE GLUCOS -glucose chew tab 4
gm.................................................................................... 28
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm..................................................................... 68
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm.............................................................. 68
GORDOFILM -salicylic & lactic acids soln
16.7-16.7%..................................................................... 154
202
GORDONS UREA -urea ointment 40%...........................154
GRALISE -gabapentin (phn) tab 300 mg...........................93
GRALISE -gabapentin (phn) tab 600 mg...........................93
GRALISE STARTER -gabapentin (phn) tab starter pack
300 mg (9) & 600 mg (69)...............................................93
granisetron hcl tab 1 mg................................................ 71
GRANISOL -granisetron hcl oral soln 2 mg/10ml (base
equivalent)........................................................................71
GRANULEX -trypsin w/ castor oil & peruvian balsam
spray...............................................................................154
GRASTEK -timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 15
GREEN SOAP -green soap tincture................................154
GRIFULVIN V -griseofulvin microsize tab 500 mg...............7
griseofulvin microsize susp 125 mg/5ml.........................7
griseofulvin microsize tab 500 mg (Grifulvin v)..............7
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 7
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 7
GRIS-PEG -griseofulvin ultramicrosize tab 125 mg.............7
GRIS-PEG -griseofulvin ultramicrosize tab 250 mg.............7
guaifenesin-codeine liquid 225-7.5 mg/5ml...................61
guaifenesin-codeine soln 100-10 mg/5ml......................61
guaifenesin-codeine soln 100-6.3 mg/5ml..................... 61
guanfacine hcl tab 1 mg (Tenex)................................... 48
guanfacine hcl tab 2 mg (Tenex)................................... 48
GUANIDINE HCL -guanidine hcl tab 125 mg.................. 118
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%.........................................................................76
H
HALCION -triazolam tab 0.25 mg......................................87
HALFLYTELY BOWEL PREP/FLA -bisacodyl tab & peg
3350-kcl-sod bicarb-nacl for soln kit................................ 68
halobetasol propionate cream 0.05% (Ultravate)........ 154
halobetasol propionate oint 0.05% (Ultravate)............154
halobetasol prop oint 0.05% & ammonium lactate lot
12% kit (Ultravate pac)................................................ 154
HALOG -halcinonide cream 0.1%................................... 154
HALOG -halcinonide oint 0.1%........................................154
HALONATE -halobetasol prop oint 0.05% & ammonium
lactate foam 12% kit...................................................... 155
haloperidol lactate oral conc 2 mg/ml........................... 84
haloperidol tab 0.5 mg.................................................... 84
haloperidol tab 10 mg..................................................... 84
haloperidol tab 1 mg....................................................... 84
haloperidol tab 20 mg..................................................... 85
haloperidol tab 2 mg....................................................... 84
haloperidol tab 5 mg....................................................... 85
HALOTIN -haloprogin cream 1%.....................................155
hc-pramoxine emol cream 2.5-1% & pramoxine wipe
1% kit (Analpram e)..................................................... 147
HECTOROL -doxercalciferol cap 0.5 mcg.........................36
HECTOROL -doxercalciferol cap 1 mcg............................36
HECTOROL -doxercalciferol cap 2.5 mcg.........................36
HELIDAC -metronidaz tab-tetracyc cap-bis subsal chew
tab therapy pack.............................................................. 69
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit................................................................... 138
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 2000 unit................................................................... 138
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit..................................................................... 138
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 3000 unit................................................................... 138
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 500 unit..................................................................... 138
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........................................................ 134
HEMATRON-AF - iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg ...................................................... 134
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck......................................121
HEMENATAL OB - prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg ...........................................................121
HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 134
HEMOCYTE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg .............................................. 134
HEMOFIL M -antihemophilic factor (human) for inj 1000
unit..................................................................................138
HEMOFIL M -antihemophilic factor (human) for inj
1501-2000 unit............................................................... 138
HEMOFIL M -antihemophilic factor (human) for inj 1700
unit..................................................................................138
HEMOFIL M -antihemophilic factor (human) for inj 220-400
unit..................................................................................138
HEMOFIL M -antihemophilic factor (human) for inj 250
unit..................................................................................138
HEMOFIL M -antihemophilic factor (human) for inj 401-800
unit..................................................................................138
HEMOFIL M -antihemophilic factor (human) for inj 500
unit..................................................................................138
HEMOFIL M -antihemophilic factor (human) for inj
801-1500 unit................................................................. 138
HEPAGAM B -hepatitis b immune globulin (human) inj
soln...................................................................................15
heparin sodium (porcine) inj 10000 unit/ml.................136
heparin sodium (porcine) inj 1000 unit/ml...................136
heparin sodium (porcine) inj 20000 unit/ml.................136
heparin sodium (porcine) inj 5000 unit/ml...................136
heparin sodium (porcine) pf inj 5000 unit/0.5ml......... 136
HEPARIN SODIUM -heparin sodium (porcine) inj 2000
unit/ml.............................................................................136
HEPARIN SODIUM -heparin sodium (porcine) inj 2500
unit/ml.............................................................................136
HEPSERA -adefovir dipivoxil tab 10 mg............................. 8
HETLIOZ -tasimelteon capsule 20 mg.............................. 87
HEXALEN -altretamine cap 50 mg....................................16
HIPREX -methenamine hippurate tab 1 gm...................... 74
HIZENTRA -immune globulin (human) subcutaneous inj 10
gm/50ml............................................................................15
HIZENTRA -immune globulin (human) subcutaneous inj 1
gm/5ml..............................................................................15
HIZENTRA -immune globulin (human) subcutaneous inj 2
gm/10ml............................................................................15
HIZENTRA -immune globulin (human) subcutaneous inj 4
gm/20ml............................................................................15
HM GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 29
homatropine hbr ophth soln 5% (Isopto
homatropine)................................................................ 142
HORIZANT -gabapentin enacarbil tab sr 24hr 300 mg...... 93
HORIZANT -gabapentin enacarbil tab sr 24hr 600 mg...... 93
HPR - emollient - aerosol foam ......................................155
HPR PLUS/MB HYDROGEL -emollient foam & wound
dressing gel kit...............................................................155
HPR PLUS - emollient - aerosol foam ............................155
HPR PLUS - emollient - cream ...................................... 155
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 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............................................................... 139
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit................................................................... 138
HUMATE-P -antihemophilic factor/vwf (human) for inj
500-1200 unit................................................................. 139
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 36
HUMATROPE -somatropin for inj 12 mg (36 unit).............36
HUMATROPE -somatropin for inj 24 mg...........................36
HUMATROPE -somatropin for inj 5 mg.............................36
HUMATROPE -somatropin for inj 6 mg (18 unit)...............36
HUMIRA -adalimumab inj kit 20 mg/0.4ml.......................106
HUMIRA -adalimumab inj kit 40 mg/0.8ml (50 mg/ml)..... 106
HUMIRA PEN -adalimumab inj kit 40 mg/0.8ml (50 mg/
ml).................................................................................. 106
HUMIRA PEN-CROHNS DISEASE -adalimumab inj kit 40
mg/0.8ml (50 mg/ml)......................................................106
HUMIRA PEN-PSORIASIS STAR -adalimumab inj kit 40
mg/0.8ml (50 mg/ml)......................................................106
HUMULIN 70/30 -insulin isophane & regular (human) inj
100 unit/ml (70-30)...........................................................32
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
203
2014
HUMULIN 70/30 KWIKPEN -insulin isophane & regular
susp pen-inj 100 unit/ml (70-30)...................................... 32
HUMULIN 70/30 PEN -insulin isophane & regular susp
pen-inj 100 unit/ml (70-30)...............................................32
HUMULIN N -insulin isophane (human) inj 100 unit/ml......32
HUMULIN N KWIKPEN -insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 32
HUMULIN N U-100 PEN -insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 32
HUMULIN R -insulin regular (human) inj 100 unit/ml.........31
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml.................................................................. 31
hyaluronate sodium (emollient) gel 0.2% (Hylira)....... 155
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)....... 16
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)............16
HYCET -hydrocodone-acetaminophen soln 7.5-325
mg/15ml............................................................................98
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..................................16
HYDRO 35 -urea in lactic acid vehicle foam 35%........... 155
HYDRO 40 FOAM -urea foam 40%................................ 155
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..............................99
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen tab 7.5-500 mg....................................... 99
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen tab 7.5-650 mg....................................... 99
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen tab 7.5-750 mg....................................... 99
hydrocodone-acetaminophen cap 5-500 mg.................98
hydrocodone-acetaminophen soln 10-325 mg/15ml.....98
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)............................................................................. 98
hydrocodone-acetaminophen soln 7.5-500
mg/15ml...........................................................................98
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)............................................................................. 98
hydrocodone-acetaminophen tab 10-325 mg
(Norco).............................................................................98
hydrocodone-acetaminophen tab 10-500 mg................98
hydrocodone-acetaminophen tab 10-650 mg................98
hydrocodone-acetaminophen tab 10-660 mg................98
hydrocodone-acetaminophen tab 10-750 mg................98
hydrocodone-acetaminophen tab 2.5-325 mg...............98
hydrocodone-acetaminophen tab 2.5-500 mg...............98
hydrocodone-acetaminophen tab 5-300 mg
(Xodol)............................................................................. 99
204
hydrocodone-acetaminophen tab 5-325 mg
(Norco).............................................................................99
hydrocodone-acetaminophen tab 5-500 mg..................99
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................. 99
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco).............................................................................99
hydrocodone-acetaminophen tab 7.5-500 mg...............99
hydrocodone-acetaminophen tab 7.5-650 mg...............99
hydrocodone-acetaminophen tab 7.5-750 mg...............99
HYDROCODONE BITARTRATE/AC -hydrocodoneacetaminophen tab 10-750 mg........................................ 98
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 99
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)......................................................................99
hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......99
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen).................................................................... 99
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml....... 61
hydrocodone w/ homatropine tab 5-1.5 mg.................. 61
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti).................................................. 61
hydrocortisone acetate-aloe vera gel 2% (Nuzon)...... 155
hydrocortisone acetate suppos 25 mg (Anusolhc).................................................................................. 148
hydrocortisone acetate suppos 30 mg
(Proctocort)...................................................................148
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc)..................................................... 148
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc).................................................. 148
hydrocortisone butyrate cream 0.1% (Locoid)............155
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)..............................................155
hydrocortisone butyrate oint 0.1% (Locoid)................155
hydrocortisone butyrate soln 0.1% (Locoid)...............155
hydrocortisone cream 2.5%..........................................155
hydrocortisone enema 100 mg/60ml (Cortenema)......148
hydrocortisone lotion 2.5%...........................................155
hydrocortisone lotion 2% (Ala scalp).......................... 155
hydrocortisone oint 2.5%..............................................155
hydrocortisone rectal cream 1% (Proctocort).............148
hydrocortisone rectal cream 2.5% (Anusol-hc).......... 148
hydrocortisone tab 10 mg (Cortef).................................19
hydrocortisone tab 20 mg (Cortef).................................19
hydrocortisone tab 5 mg (Cortef).................................. 19
hydrocortisone valerate cream 0.2%........................... 155
hydrocortisone valerate oint 0.2% (Westcort).............155
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc).................................................................................. 145
HYDROFERA BLUE 4"X4" - wound dressings - pads
....................................................................................... 155
HYDROFERA BLUE FOAM DRESS - wound dressings pads .............................................................................. 155
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
HYDROMORPHONE HCL ER -hydromorphone hcl tab er
24hr deter 32 mg............................................................. 99
HYDROMORPHONE HCL -hydromorphone hcl suppos 3
mg.................................................................................... 99
hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 99
hydromorphone hcl tab 2 mg (Dilaudid)....................... 99
hydromorphone hcl tab 4 mg (Dilaudid)....................... 99
hydromorphone hcl tab 8 mg (Dilaudid)....................... 99
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo)........................................................................... 99
hydromorphone hcl tab er 24hr deter 16 mg
(Exalgo)........................................................................... 99
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo)........................................................................... 99
hydroxychloroquine sulfate tab 200 mg (Plaquenil).....11
hydroxyurea cap 500 mg (Hydrea).................................16
hydroxyzine hcl syrup 10 mg/5ml.................................. 78
hydroxyzine hcl tab 10 mg............................................. 78
hydroxyzine hcl tab 25 mg............................................. 78
hydroxyzine hcl tab 50 mg............................................. 78
hydroxyzine pamoate cap 25 mg (Vistaril).................... 78
hydroxyzine pamoate cap 50 mg (Vistaril).................... 78
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................. 78
HYLASE WOUND - hyaluronate sodium gel .................. 155
HYLATOPIC - emollient - aerosol foam ......................... 155
HYLATOPIC PLUS/AURSTAT -emollient foam & wound
dressing gel kit...............................................................155
HYLATOPIC PLUS - emollient - aerosol foam ............... 155
HYLATOPIC PLUS - emollient - cream ..........................155
HYLIRA -hyaluronate sodium (emollient) gel 0.2%..........155
HYLIRA -hyaluronate sodium (emollient) lotion 0.1%...... 155
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 69
hyoscyamine sulfate soln 0.125 mg/ml......................... 69
hyoscyamine sulfate tab 0.125 mg (Levsin)..................69
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 69
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 69
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 69
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%.................. 61
HYPERSAL -sodium chloride soln nebu 7%..................... 61
HYPER-SAL -sodium chloride soln nebu 7%.................... 61
HYPERTET S/D -tetanus immune globulin (human) inj 250
unit/ml...............................................................................15
HY-VEE GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 29
HYZAAR -losartan potassium & hydrochlorothiazide tab
100-12.5 mg.....................................................................48
HYZAAR -losartan potassium & hydrochlorothiazide tab
100-25 mg........................................................................48
HYZAAR -losartan potassium & hydrochlorothiazide tab
50-12.5 mg.......................................................................48
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)........................................................................... 36
IBUDONE -hydrocodone-ibuprofen tab 10-200 mg........... 99
IBUPROFEN COMFORT PAC -ibuprofen tab 800 mg &
liniment topical gel kit.................................................... 106
ibuprofen tab 400 mg.................................................... 106
ibuprofen tab 600 mg.................................................... 106
ibuprofen tab 800 mg.................................................... 106
IC 400 -ibuprofen tab 400 mg & caffeine-vitamins cap
kit....................................................................................106
ICAR -carbonyl iron chew tab 15 mg (elemental iron)..... 134
ICAR-C PLUS -iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg...................................................... 134
ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(elemental iron).............................................................. 134
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)................ 16
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)................ 17
ILEVRO -nepafenac ophth susp 0.3%.............................142
IMBRUVICA -ibrutinib cap 140 mg....................................17
IMDUR -isosorbide mononitrate tab sr 24hr 120 mg......... 38
IMDUR -isosorbide mononitrate tab sr 24hr 30 mg........... 38
IMDUR -isosorbide mononitrate tab sr 24hr 60 mg........... 38
imipramine hcl tab 10 mg (Tofranil)...............................81
imipramine hcl tab 25 mg (Tofranil)...............................81
imipramine hcl tab 50 mg (Tofranil)...............................81
imipramine pamoate cap 100 mg (Tofranil-pm)............ 81
imipramine pamoate cap 125 mg (Tofranil-pm)............ 81
imipramine pamoate cap 150 mg (Tofranil-pm)............ 81
imipramine pamoate cap 75 mg (Tofranil-pm).............. 81
imiquimod cream 5% (Aldara)...................................... 155
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 4 mg/0.5ml.........................................108
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 6 mg/0.5ml.........................................108
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 4 mg/0.5ml...................................108
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 6 mg/0.5ml...................................108
IMITREX -sumatriptan nasal spray 20 mg/act................. 108
IMITREX -sumatriptan nasal spray 5 mg/act................... 108
IMITREX -sumatriptan succinate inj 6 mg/0.5ml..............108
IMITREX -sumatriptan succinate tab 100 mg.................. 108
IMITREX -sumatriptan succinate tab 25 mg.................... 108
IMITREX -sumatriptan succinate tab 50 mg.................... 108
IMOGAM RABIES-HT -rabies immune globulin (human) inj
150 unit/ml....................................................................... 15
IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc
inj......................................................................................14
IMURAN -azathioprine tab 50 mg................................... 166
INATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg .................................................................. 121
INATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg ................................................................................. 121
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
205
2014
INATAL ULTRA - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 121
INCIVEK -telaprevir tab 375 mg.......................................... 8
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)...........36
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.......................... 106
INDOCIN -indomethacin susp 25 mg/5ml........................106
indomethacin cap 25 mg.............................................. 106
indomethacin cap 50 mg.............................................. 106
indomethacin cap cr 75 mg.......................................... 106
INFANATE BALANCE - prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg ................................................... 121
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................................................................................67
INFERGEN -interferon alfacon-1 inj 15 mcg/0.5ml.............. 8
INFERGEN -interferon alfacon-1 inj 9 mcg/0.3ml................8
INFLUENZA A (H1N1) MONOVA -influenza a (h1n1)
monovalent vaccine live intranasal liquid.........................14
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..................................155
INOVA 8/2 ACNE CONTROL TH -benzoyl perox pad 8% &
salicylic ac pad 2% & vit e 5% kit..................................155
INOVA -benzoyl peroxide pad 4% & vitamin e topical 5%
kit....................................................................................155
INOVA -benzoyl peroxide pad 8% & vitamin e topical 5%
kit....................................................................................155
INSPRA -eplerenone tab 25 mg........................................48
INSPRA -eplerenone tab 50 mg........................................48
INSTA-GLUCOSE -glucose gel 77.4%..............................29
INSULIN PEN NEEDLES – VARIOUS............................ 166
INSULIN SYRINGES – VARIOUS...................................166
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ....................................134
INTEGRA PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .....................................................134
INTELENCE -etravirine tab 100 mg.................................... 8
INTELENCE -etravirine tab 200 mg.................................... 8
INTELENCE -etravirine tab 25 mg...................................... 8
206
INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ml
& lidocaine 1% & ammonia inh kit................................... 19
INTERMEZZO -zolpidem tartrate sl tab 1.75 mg...............87
INTERMEZZO -zolpidem tartrate sl tab 3.5 mg.................87
INTROL -glycerin soln 75%...............................................53
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)................................................................................90
INTUNIV -guanfacine hcl tab sr 24hr 2 mg (base
equiv)................................................................................90
INTUNIV -guanfacine hcl tab sr 24hr 3 mg (base
equiv)................................................................................90
INTUNIV -guanfacine hcl tab sr 24hr 4 mg (base
equiv)................................................................................90
INVEGA -paliperidone tab sr 24hr 1.5 mg.........................85
INVEGA -paliperidone tab sr 24hr 3 mg............................85
INVEGA -paliperidone tab sr 24hr 6 mg............................85
INVEGA -paliperidone tab sr 24hr 9 mg............................85
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
INVOKANA -canagliflozin tab 300 mg............................... 29
IODINE STRONG -iodine solution strong 5%
(lugol's)........................................................................... 129
IODINE TINCTURE - iodine tincture .............................. 164
IODINE TINCTURE MILD - iodine tincture .....................164
IODINE TINCTURE STRONG DE - iodine tincture strong
....................................................................................... 164
IODINE TINCTURE STRONG - iodine tincture strong
....................................................................................... 164
iodoquinol-hc cream 1%............................................... 155
IOPIDINE -apraclonidine hcl ophth soln 0.5% (base
equivalent)......................................................................142
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)......................................................................142
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
(Duoneb)..........................................................................66
ipratropium bromide inhal soln 0.02%.......................... 66
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................ 59
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................ 59
IQUIX -levofloxacin ophth soln 1.5%............................... 142
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide).......................................................................... 49
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide).......................................................................... 49
irbesartan tab 150 mg (Avapro)..................................... 48
irbesartan tab 300 mg (Avapro)..................................... 48
irbesartan tab 75 mg (Avapro)....................................... 48
IRON ASP GLY/ POLYSACCH C - fe asp gly-fe
polysacch-succ ac-c-threon ac-b12-fa cap ................... 134
iron combination cap ................................................... 132
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg
(Hematron-af)................................................................132
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................. 134
IRON - iron combination tab .......................................... 134
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg.................................................................................. 134
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
(Icar-c plus)...................................................................134
IROSPAN 24/6 - fe asp gly-fe polys-succ acd-b cmplx-cca-fa tab ther pk ........................................................... 134
IS 24/6 - fe asp gly-fe polys-succ acd-b cmplx-c-ca-fa tab
ther pk ...........................................................................134
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/AC -acetaminophenisometheptene-caffeine tab 500-130-20 mg.................. 108
isoniazid & rifampin cap 150-300 mg.............................. 6
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%......142
ISOPTO CARBACHOL -carbachol ophth soln 1.5%....... 142
ISOPTO CARBACHOL -carbachol ophth soln 3%.......... 142
ISOPTO CARPINE -pilocarpine hcl ophth soln 1%......... 142
ISOPTO CARPINE -pilocarpine hcl ophth soln 2%......... 142
ISOPTO CARPINE -pilocarpine hcl ophth soln 4%......... 142
ISOPTO HOMATROPINE -homatropine hbr ophth soln
2%.................................................................................. 142
ISOPTO HOMATROPINE -homatropine hbr ophth soln
5%.................................................................................. 142
ISOPTO HYOSCINE -scopolamine hbr ophth soln
0.25%............................................................................. 142
ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg......38
ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg........38
ISOSORBIDE DINITRATE -isosorbide dinitrate sl tab 2.5
mg.................................................................................... 38
ISOSORBIDE DINITRATE -isosorbide dinitrate sl tab 5
mg.................................................................................... 38
ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30
mg.................................................................................... 38
isosorbide dinitrate tab 10 mg....................................... 38
isosorbide dinitrate tab 20 mg....................................... 38
isosorbide dinitrate tab 30 mg....................................... 38
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 38
isosorbide dinitrate tab cr 40 mg...................................38
isosorbide mononitrate tab 10 mg.................................39
isosorbide mononitrate tab 20 mg.................................39
isosorbide mononitrate tab sr 24hr 120 mg (Imdur)..... 38
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)....... 38
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)....... 39
isotretinoin cap 10 mg.................................................. 155
isotretinoin cap 20 mg.................................................. 155
isotretinoin cap 40 mg.................................................. 155
ISOXSUPRINE HCL -isoxsuprine hcl tab 10 mg............... 58
ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg............... 58
isoxsuprine hcl tab 10 mg.............................................. 58
ISRADIPINE -isradipine cap 2.5 mg..................................43
ISRADIPINE -isradipine cap 5 mg.....................................43
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily)...............................................................................142
itraconazole cap 100 mg (Sporanox)............................... 7
J
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...........77
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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2014
JARDIANCE -empagliflozin tab 10 mg.............................. 29
JARDIANCE -empagliflozin tab 25 mg.............................. 29
J-COF DHC -pseudoephed-bromphen-dihydrocodeine liqd
15-3-7.5 mg/5ml...............................................................61
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
JINTELI -norethindrone acetate-ethinyl estradiol tab 1
mg-5 mcg......................................................................... 23
J-MAX DHC -dihydrocodeine-guaifenesin liquid 7.5-100
mg/5ml..............................................................................61
JUBLIA -efinaconazole soln 10%.................................... 155
JUVISYNC -sitagliptin-simvastatin tab 100-10 mg.............29
JUVISYNC -sitagliptin-simvastatin tab 100-20 mg.............29
JUVISYNC -sitagliptin-simvastatin tab 100-40 mg.............29
JUVISYNC -sitagliptin-simvastatin tab 50-10 mg...............29
JUVISYNC -sitagliptin-simvastatin tab 50-20 mg...............29
JUVISYNC -sitagliptin-simvastatin tab 50-40 mg...............29
JUXTAPID -lomitapide mesylate cap 10 mg (base
equiv)................................................................................55
JUXTAPID -lomitapide mesylate cap 20 mg (base
equiv)................................................................................55
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)................................................................................55
K
KADIAN -morphine sulfate cap sr 24hr 100 mg................ 99
KADIAN -morphine sulfate cap sr 24hr 10 mg.................. 99
KADIAN -morphine sulfate cap sr 24hr 130 mg................ 99
KADIAN -morphine sulfate cap sr 24hr 150 mg................ 99
KADIAN -morphine sulfate cap sr 24hr 200 mg................ 99
KADIAN -morphine sulfate cap sr 24hr 20 mg.................. 99
KADIAN -morphine sulfate cap sr 24hr 30 mg.................. 99
KADIAN -morphine sulfate cap sr 24hr 40 mg.................. 99
KADIAN -morphine sulfate cap sr 24hr 50 mg.................. 99
KADIAN -morphine sulfate cap sr 24hr 60 mg.................. 99
KADIAN -morphine sulfate cap sr 24hr 70 mg.................. 99
KADIAN -morphine sulfate cap sr 24hr 80 mg.................. 99
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 tab 150 mg.................................... 67
KAPVAY -clonidine hcl tab sr 12hr 0.1 mg........................90
KAPVAY DOSE PACK -clonidine hcl tab sr 12hr therapy
pack 0.1 & 0.2 mg........................................................... 90
KARBINAL ER -carbinoxamine maleate er susp 4
mg/5ml..............................................................................59
KAYEXALATE - sodium polystyrene sulfonate powder
....................................................................................... 166
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
208
KEFLEX -cephalexin cap 500 mg....................................... 2
KEFLEX -cephalexin cap 750 mg....................................... 2
KENALOG -triamcinolone acetonide aerosol soln........... 155
KENDALL HYDROGEL IMPREGNA - hydroactive (sterile)
dressing ........................................................................ 155
KENDALL HYDROGEL WOUND DR - hydroactive (sterile)
dressing ........................................................................ 155
KENDALL ZINC CALCIUM ALGI - wound dressings - misc
....................................................................................... 155
KENDALL ZINC CALCIUM ALGI - wound dressings - pads
....................................................................................... 155
KEPPRA -levetiracetam oral soln 100 mg/ml.................. 111
KEPPRA -levetiracetam tab 1000 mg............................. 111
KEPPRA -levetiracetam tab 250 mg............................... 111
KEPPRA -levetiracetam tab 500 mg............................... 111
KEPPRA -levetiracetam tab 750 mg............................... 111
KEPPRA XR -levetiracetam tab sr 24hr 500 mg............. 111
KEPPRA XR -levetiracetam tab sr 24hr 750 mg............. 111
KERAFOAM 42 -urea foam 42%.....................................155
KERAFOAM -urea foam 30%..........................................155
KERALAC -urea cream 47%........................................... 155
KERALYT -salicylic acid gel 6%......................................156
KERALYT SCALP -salicylic acid shampoo 6% & salicylic
acid gel 6% kit............................................................... 156
KERLONE -betaxolol hcl tab 10 mg.................................. 40
KERLONE -betaxolol hcl tab 20 mg.................................. 40
KERR TRIPLE DYE -triple dye swabs............................ 164
KETEK -telithromycin tab 300 mg..................................... 12
KETEK -telithromycin tab 400 mg..................................... 12
ketoconazole cream 2%................................................ 156
ketoconazole foam 2% (Extina)....................................156
ketoconazole shampoo 2% (Nizoral)........................... 156
ketoconazole tab 200 mg..................................................7
KETODAN KIT -ketoconazole foam 2% & cleanser
kit....................................................................................156
KETONE BLOOD TEST STRIPS – VARIOUS................ 165
ketoprofen cap 50 mg................................................... 106
ketoprofen cap 75 mg................................................... 106
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg....... 106
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 142
ketorolac tromethamine ophth soln 0.5% (Acular)..... 142
ketorolac tromethamine tab 10 mg.............................. 106
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg.............. 81
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg................ 81
KINERET -anakinra subcutaneous inj 100 mg/0.67ml.....106
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj...............................................................................15
KLARON -sulfacetamide sodium lotion 10% (acne)........ 156
KLONOPIN -clonazepam tab 0.5 mg.............................. 111
KLONOPIN -clonazepam tab 1 mg................................. 111
KLONOPIN -clonazepam tab 2 mg................................. 111
KLOR-CON 25 -potassium chloride powder packet 25
meq................................................................................ 129
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq.........................................................129
KOATE-DVI -antihemophilic factor (human) for inj 1000
unit..................................................................................139
KOATE-DVI -antihemophilic factor (human) for inj 250
unit..................................................................................139
KOATE-DVI -antihemophilic factor (human) for inj 500
unit..................................................................................139
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit................................................................... 139
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 2000 unit................................................................... 139
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit..................................................................... 139
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 3000 unit................................................................... 139
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 500 unit..................................................................... 139
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 1000 unit.................................. 139
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 2000 unit.................................. 139
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................... 139
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 3000 unit.................................. 139
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 500 unit.................................... 139
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........................................129
K-PHOS NO 2 -potassium & sodium acid phosphates tab
305-700 mg......................................................................77
K-PHOS -potassium phosphate monobasic tab 500
mg.................................................................................. 129
KRISTALOSE -lactulose oral crystal packet 10 gm........... 68
KRISTALOSE -lactulose oral crystal packet 20 gm........... 68
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.......................129
K-TAB -potassium chloride tab cr 20 meq (1500 mg)...... 129
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 36
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 36
KYNAMRO -mipomersen sodium inj 200 mg/ml................55
L
labetalol hcl tab 200 mg (Trandate)............................... 40
labetalol hcl tab 300 mg (Trandate)............................... 40
LAC-HYDRIN -lactic acid (ammonium lactate) cream
12%................................................................................ 156
LAC-HYDRIN -lactic acid (ammonium lactate) lotion
12%................................................................................ 156
LACRISERT - artificial tear ophth insert .........................142
lactic acid (ammonium lactate) cream 12% (Lachydrin)........................................................................... 156
lactic acid (ammonium lactate) lotion 10%................. 156
lactic acid (ammonium lactate) lotion 12% (Lachydrin)........................................................................... 156
lactic acid w/ vitamin e cream 10%-3500
unit/30gm...................................................................... 156
LACTOCAL-F - prenatal vit w/ fe fumarate-fa tab 65-1 mg
....................................................................................... 121
lactulose (encephalopathy) solution 10 gm/15ml......... 73
lactulose solution 10 gm/15ml....................................... 68
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 25 mg.......................................... 111
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 5 mg............................................ 111
LAMICTAL -lamotrigine tab 100 mg................................ 111
LAMICTAL -lamotrigine tab 150 mg................................ 111
LAMICTAL -lamotrigine tab 200 mg................................ 111
LAMICTAL -lamotrigine tab 25 mg.................................. 111
LAMICTAL -lamotrigine tab chewable dispersible 2
mg.................................................................................. 111
LAMICTAL ODT -lamotrigine orally disintegrating tab 100
mg.................................................................................. 112
LAMICTAL ODT -lamotrigine orally disintegrating tab 200
mg.................................................................................. 112
LAMICTAL ODT -lamotrigine orally disintegrating tab 25
mg.................................................................................. 111
LAMICTAL ODT -lamotrigine orally disintegrating tab 50
mg.................................................................................. 111
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg (14)
& 100 mg (7) kit.............................................................111
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit................................................................. 111
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit.........................................................111
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit.......................................... 112
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit........................................ 112
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit................................................................ 112
LAMICTAL XR -lamotrigine tab sr 24hr 100 mg.............. 112
LAMICTAL XR -lamotrigine tab sr 24hr 200 mg.............. 112
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit...................................................... 112
LAMICTAL XR -lamotrigine tab sr 24hr 250 mg.............. 112
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg................ 112
labetalol hcl tab 100 mg (Trandate)............................... 40
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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2014
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit...........................................................112
LAMICTAL XR -lamotrigine tab sr 24hr 300 mg.............. 112
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit..................................................112
LAMICTAL XR -lamotrigine tab sr 24hr 50 mg................ 112
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................................... 7
lamivudine tab 100 mg (Epivir hbv)................................. 8
lamivudine tab 150 mg (Epivir)........................................ 8
lamivudine tab 300 mg (Epivir)........................................ 8
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 8
lamotrigine tab 100 mg (Lamictal)............................... 112
lamotrigine tab 150 mg (Lamictal)............................... 112
lamotrigine tab 200 mg (Lamictal)............................... 112
lamotrigine tab 25 mg (Lamictal)................................. 112
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................. 112
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................. 112
lamotrigine tab sr 24hr 100 mg (Lamictal xr).............. 112
lamotrigine tab sr 24hr 200 mg (Lamictal xr).............. 112
lamotrigine tab sr 24hr 250 mg (Lamictal xr).............. 112
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................ 112
lamotrigine tab sr 24hr 300 mg (Lamictal xr).............. 112
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................ 112
LANCETS – VARIOUS....................................................166
LANOXIN -digoxin tab 125 mcg (0.125 mg)...................... 38
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................. 38
LANOXIN -digoxin tab 250 mcg (0.25 mg)........................ 38
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg)................... 38
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................ 69
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................ 69
lansoprazole tab delayed release orally disintegrating
15 mg...............................................................................70
lansoprazole tab delayed release orally disintegrating
30 mg...............................................................................70
LANTUS -insulin glargine inj 100 unit/ml........................... 32
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml....................................................................... 32
LARTUS -phenyleph-chlorphen w/ dm-gg liquid 5-2-15-150
mg/5ml..............................................................................61
LASIX -furosemide tab 20 mg........................................... 53
LASIX -furosemide tab 40 mg........................................... 53
LASIX -furosemide tab 80 mg........................................... 53
LASTACAFT -alcaftadine ophth soln 0.25%....................142
latanoprost ophth soln 0.005% (Xalatan).................... 142
LATRIX XM -urea in zinc undecylenate-lactic acid vehicle
emulsion 45%................................................................ 156
LATUDA -lurasidone hcl tab 120 mg.................................85
LATUDA -lurasidone hcl tab 20 mg...................................85
LATUDA -lurasidone hcl tab 40 mg...................................85
210
LATUDA -lurasidone hcl tab 60 mg...................................85
LATUDA -lurasidone hcl tab 80 mg...................................85
LAVARE WOUND WASH - wound cleansers - gel .........156
LAVOCLEN-4 CREAMY WASH -benzoyl peroxide liq
4%.................................................................................. 156
LAVOCLEN-8 CREAMY WASH -benzoyl peroxide liq
8%.................................................................................. 156
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)..............................................................................100
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)..............................................................................100
LEADER GLUCOSE -glucose chew tab 4 gm...................29
LEADER GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 29
LEADER QUICK DISSOLVE GLU -glucose chew tab 4
gm.................................................................................... 29
LECITHIN -lecithin granules............................................ 130
leflunomide tab 10 mg (Arava)..................................... 106
leflunomide tab 20 mg (Arava)..................................... 106
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..................................... 58
letrozole tab 2.5 mg (Femara).........................................17
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 17
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 17
leucovorin calcium tab 25 mg........................................ 17
leucovorin calcium tab 5 mg.......................................... 17
LEUKERAN -chlorambucil tab 2 mg..................................17
LEUKINE -sargramostim inj 500 mcg/ml......................... 134
LEUKINE -sargramostim lyophilized for inj 250 mcg....... 134
leuprolide acetate inj kit 5 mg/ml...................................17
LEVACET -aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg...................................................... 96
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................ 66
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)........................................................................ 66
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex)........................................................................ 66
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate).......................................66
LEVAQUIN -levofloxacin oral soln 25 mg/ml....................... 6
LEVAQUIN -levofloxacin tab 250 mg.................................. 6
LEVAQUIN -levofloxacin tab 500 mg.................................. 6
LEVAQUIN -levofloxacin tab 750 mg.................................. 6
LEVATOL -penbutolol sulfate tab 20 mg........................... 40
LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg......... 70
LEVEMIR FLEXPEN -insulin detemir soln pen-injector 100
unit/ml...............................................................................32
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml....................................................................... 32
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
LEVEMIR -insulin detemir inj 100 unit/ml.......................... 32
levetiracetam oral soln 100 mg/ml (Keppra)............... 112
levetiracetam tab 1000 mg (Keppra)............................ 112
levetiracetam tab 250 mg (Keppra).............................. 112
levetiracetam tab 500 mg (Keppra).............................. 112
levetiracetam tab 750 mg (Keppra).............................. 112
levetiracetam tab sr 24hr 500 mg (Keppra xr).............112
levetiracetam tab sr 24hr 750 mg (Keppra xr).............112
LEVOBUNOLOL HCL -levobunolol hcl ophth soln
0.25%............................................................................. 142
levobunolol hcl ophth soln 0.5% (Betagan)................ 142
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 36
levocarnitine tab 330 mg (Carnitor)............................... 36
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/
ml) (Xyzal)....................................................................... 59
levocetirizine dihydrochloride tab 5 mg (Xyzal)............59
levofloxacin ophth soln 0.5%....................................... 142
levofloxacin oral soln 25 mg/ml (Levaquin).................... 6
levofloxacin tab 250 mg (Levaquin).................................6
levofloxacin tab 500 mg (Levaquin).................................6
levofloxacin tab 750 mg (Levaquin).................................6
LEVOMEFOLATE CALCIUM/ACET - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 131
LEVOMEFOLATE CALCIUM/ALGA - l-methylfolate-algae
cap 15-90.314 mg ........................................................ 131
LEVOMEFOLATE CALCIUM/ALGA - l-methylfolate-algae
cap 7.5-90.314 mg ....................................................... 131
LEVOMEFOLATE CALCIUM/PYRI - l-methylfolate-algaevit b12-b6 cap 3-90.314-2-35 mg ................................. 131
LEVOMEFOLATE DHA - prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg ............................................... 121
LEVOMEFOLATE PNV - prenatal w/ fe polycmplxmethylfol-fa pak 29-1.4-0.5 mg .....................................121
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.................................24
levonorgestrel tab 0.75 mg (Plan b)...............................24
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.................................................................................. 100
levothyroxine sodium tab 100 mcg (Synthroid)............32
levothyroxine sodium tab 112 mcg (Synthroid)............32
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............ 70
LEVSIN -hyoscyamine sulfate tab 0.125 mg..................... 70
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator).................................................... 156
LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base
equiv)................................................................................81
LEXAPRO -escitalopram oxalate tab 10 mg (base
equiv)................................................................................81
LEXAPRO -escitalopram oxalate tab 20 mg (base
equiv)................................................................................81
LEXAPRO -escitalopram oxalate tab 5 mg (base
equiv)................................................................................81
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)..................................................................................9
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)..................................................................................9
LIALDA -mesalamine tab delayed release 1.2 gm............ 73
LIBRAX -clidinium & chlordiazepoxide cap 2.5-5 mg.........70
LIDOCAINE/PRILOCAINE -lidocaine-prilocaine kit
2.5-2.5%......................................................................... 156
lidocaine hcl cream 3%.................................................156
lidocaine hcl gel 2%...................................................... 156
LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%..................148
lidocaine hcl laryngotracheal soln 4% (Lta 360
kit).................................................................................. 146
LIDOCAINE HCL -lidocaine hcl lotion 3%....................... 156
lidocaine hcl soln 4% (Xylocaine)................................ 156
lidocaine hcl viscous soln 2%......................................146
lidocaine-hydrocortisone acetate rectal cream
3-0.5%............................................................................ 148
lidocaine-hydrocortisone acetate rectal cream kit
2-2%............................................................................... 148
lidocaine-hydrocortisone acetate rectal cream kit
3-0.5%............................................................................ 148
lidocaine-hydrocortisone acetate rectal cream kit
3-1%............................................................................... 148
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%............................................................................ 148
lidocaine oint 5%........................................................... 156
lidocaine patch 5% (Lidoderm).................................... 156
lidocaine-prilocaine cream 2.5-2.5% (Emla)................ 156
LIDODERM -lidocaine patch 5%..................................... 156
LIDORX -lidocaine hcl gel 3%......................................... 156
LIMBREL250 -flavocoxid-citrated zinc bisglycinate cap
250-50 mg......................................................................131
LIMBREL500 -flavocoxid-citrated zinc bisglycinate cap
500-50 mg......................................................................131
LIMBREL -flavocoxid cap 250 mg................................... 131
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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LIMBREL -flavocoxid cap 500 mg................................... 131
lindane lotion 1%........................................................... 156
lindane shampoo 1%.....................................................156
LINZESS -linaclotide cap 145 mcg....................................73
LINZESS -linaclotide cap 290 mcg....................................73
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............56
LIPTRUZET -ezetimibe-atorvastatin tab 10-80 mg............56
LIQUICET -hydrocodone-acetaminophen soln 10-500
mg/15ml..........................................................................100
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% ....................... 146
LISTERINE RESTORING -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 146
LISTERINE SMART RINSE -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 146
LISTERINE TOOTH DEFENSE -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 146
LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 146
LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 146
LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
0.02%............................................................................. 146
LISTERINE WHITENING/RESTO -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 146
lithium carbonate cap 150 mg (Lithium carbonate)...... 85
lithium carbonate cap 300 mg........................................85
lithium carbonate cap 600 mg (Lithium carbonate)...... 85
212
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 85
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 85
lithium carbonate tab 300 mg.........................................85
lithium carbonate tab cr 300 mg (Lithobid)................... 85
lithium carbonate tab cr 450 mg.................................... 85
LITHIUM CITRATE -lithium citrate oral soln 8 meq/5ml.....85
LITHOBID -lithium carbonate tab cr 300 mg..................... 85
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 77
LIVALO -pitavastatin calcium tab 1 mg (base equiv)......... 56
LIVALO -pitavastatin calcium tab 2 mg (base equiv)......... 56
LIVALO -pitavastatin calcium tab 4 mg (base equiv)......... 56
L-METHYL-B6-B12 - l-methylfolate w/ vit b6-vit b12 tab
3-35-2 mg ..................................................................... 131
L-METHYLFOLATE CA/ME-CBL/ - l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg .................131
L-METHYLFOLATE CA/P-5-P/M - l-methylfolate-algae-vit
b12-b6 cap 3-90.314-2-35 mg ...................................... 131
L-METHYLFOLATE CA/P-5-P/M - l-methylfolate w/ vit b6vit b12 tab 3-35-2 mg ................................................... 131
L-METHYLFOLATE CALCIUM - l-methylfolate tab 15 mg
....................................................................................... 131
L-METHYLFOLATE CALCIUM - l-methylfolate tab 7.5 mg
....................................................................................... 131
L-METHYLFOLATE CA ME-CBL - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 131
L-METHYLFOLATE FORMULA 15 - l-methylfolate-algae
cap 15-90.314 mg ........................................................ 131
L-METHYLFOLATE FORMULA 7. - l-methylfolate-algae
cap 7.5-90.314 mg ....................................................... 131
L-METHYLFOLATE FORTE - l-methylfolate-algae cap
15-90.314 mg ............................................................... 131
L-METHYLFOLATE FORTE - l-methylfolate-algae cap
7.5-90.314 mg ...............................................................131
L-METHYLFOLATE - l-methylfolate tab 15 mg .............. 131
L-METHYLFOLATE - l-methylfolate tab 7.5 mg ............. 131
L-METHYLFOLATE PNV DHA - prenat w/fe fum-l
methylfolate-fa-dha cap 27-1.13-0.4 mg ....................... 121
L-METHYL-MC - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg .................................................................. 131
L-METHYL-MC NAC - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 131
LMTHF/PYRIDOXINE HCL/CYAN - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg ......................................... 131
LO/OVRAL-28 -norgestrel & ethinyl estradiol tab 0.3
mg-30 mcg....................................................................... 24
LOCOID -hydrocortisone butyrate cream 0.1%............... 156
LOCOID -hydrocortisone butyrate lotion 0.1%................ 156
LOCOID -hydrocortisone butyrate oint 0.1%................... 156
LOCOID -hydrocortisone butyrate soln 0.1%.................. 156
LOCOID LIPOCREAM -hydrocortisone butyrate
hydrophilic lipo base cream 0.1%.................................. 156
LODOSYN -carbidopa tab 25 mg....................................115
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg............................................................. 24
LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg............................................ 24
LOESTRIN 24 FE -norethindrone ace-ethinyl estradiol-fe
tab 1 mg-20 mcg (24)......................................................24
LOESTRIN FE 1/20 -norethindrone ace & ethinyl estradiolfe tab 1 mg-20 mcg......................................................... 24
LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg........................................24
LOFIBRA -fenofibrate micronized cap 134 mg.................. 56
LOFIBRA -fenofibrate micronized cap 200 mg.................. 56
LOFIBRA -fenofibrate micronized cap 67 mg.................... 56
LOFIBRA -fenofibrate tab 160 mg.....................................56
LOFIBRA -fenofibrate tab 54 mg.......................................56
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)........................................................ 24
LOMEDIA 24 FE -norethindrone ace-ethinyl estradiol-fe
tab 1 mg-20 mcg (24)......................................................24
LO MINASTRIN FE -norethin-eth estrad-fe chew/tab 1
mg-10 mcg/10 mcg ther pack.......................................... 24
LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 68
LOMUSTINE -lomustine cap 100 mg................................ 17
LOMUSTINE -lomustine cap 10 mg.................................. 17
LOMUSTINE -lomustine cap 40 mg.................................. 17
LONGS GLUCOSE -glucose chew tab 4 gm.................... 29
LONGS GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 29
LOPID -gemfibrozil tab 600 mg......................................... 56
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
100-25 mg........................................................................49
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
50-25 mg..........................................................................49
LOPRESSOR -metoprolol tartrate tab 100 mg.................. 40
LOPRESSOR -metoprolol tartrate tab 50 mg.................... 40
LOPROX -ciclopirox gel 0.77%....................................... 156
LOPROX SHAMPOO -ciclopirox shampoo 1%............... 156
lorazepam conc 2 mg/ml (Lorazepam intensol)............ 78
LORAZEPAM INTENSOL -lorazepam conc 2 mg/ml........ 78
lorazepam tab 0.5 mg (Ativan)....................................... 78
lorazepam tab 1 mg (Ativan).......................................... 78
lorazepam tab 2 mg (Ativan).......................................... 78
LORCET 10/650 -hydrocodone-acetaminophen tab 10-650
mg.................................................................................. 100
LORCET PLUS -hydrocodone-acetaminophen tab 7.5-650
mg.................................................................................. 100
LORTAB -hydrocodone-acetaminophen soln 10-300
mg/15ml..........................................................................100
LORTAB -hydrocodone-acetaminophen soln 7.5-500
mg/15ml..........................................................................100
LORTAB -hydrocodone-acetaminophen tab 10-500
mg.................................................................................. 100
LORTAB -hydrocodone-acetaminophen tab 5-500
mg.................................................................................. 100
LORTAB -hydrocodone-acetaminophen tab 7.5-500
mg.................................................................................. 100
LORTUSS EX -pseudoephedrine w/ cod-gg liqd
22.5-10-100 mg/5ml......................................................... 61
LORZONE -chlorzoxazone tab 375 mg...........................117
LORZONE -chlorzoxazone tab 750 mg...........................117
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)...................................................... 24
LOTEMAX -loteprednol etabonate ophth gel 0.5%..........142
LOTEMAX -loteprednol etabonate ophth oint 0.5%.........142
LOTEMAX -loteprednol etabonate ophth susp 0.5%....... 142
LOTENSIN -benazepril hcl tab 10 mg............................... 49
LOTENSIN -benazepril hcl tab 20 mg............................... 49
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
LOTREL -amlodipine besylate-benazepril hcl cap 5-40
mg.................................................................................... 49
LOTRIMIN ULTRA -butenafine hcl cream 1%................. 156
LOTRISONE -clotrimazole w/ betamethasone cream
1-0.05%.......................................................................... 156
LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)..........73
LOTRONEX -alosetron hcl tab 1 mg (base equiv).............73
LOUTREX - antiseborrheic products misc - cream .........156
lovastatin tab 10 mg........................................................56
lovastatin tab 20 mg (Mevacor)......................................56
lovastatin tab 40 mg (Mevacor)......................................56
LOVAZA -omega-3-acid ethyl esters cap 1 gm................. 56
LOVENOX -enoxaparin sodium inj 100 mg/ml................ 137
LOVENOX -enoxaparin sodium inj 120 mg/0.8ml............137
LOVENOX -enoxaparin sodium inj 150 mg/ml................ 137
LOVENOX -enoxaparin sodium inj 300 mg/3ml.............. 137
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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2014
LOVENOX -enoxaparin sodium inj 30 mg/0.3ml............. 136
LOVENOX -enoxaparin sodium inj 40 mg/0.4ml............. 136
LOVENOX -enoxaparin sodium inj 60 mg/0.6ml............. 137
LOVENOX -enoxaparin sodium inj 80 mg/0.8ml............. 137
loxapine succinate cap 10 mg........................................85
loxapine succinate cap 25 mg........................................85
loxapine succinate cap 50 mg........................................85
loxapine succinate cap 5 mg (Loxitane)........................85
LOXITANE -loxapine succinate cap 10 mg....................... 85
LOXITANE -loxapine succinate cap 25 mg....................... 85
LOXITANE -loxapine succinate cap 50 mg....................... 85
LOXITANE -loxapine succinate cap 5 mg......................... 85
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 129
LTA 360 KIT -lidocaine hcl laryngotracheal soln 4%....... 146
LUFYLLIN -dyphylline tab 200 mg.................................... 66
LUFYLLIN -dyphylline tab 400 mg.................................... 66
LUGOLS STRONG IODINE - iodine solution ................. 165
LUMIGAN -bimatoprost ophth soln 0.01%.......................142
LUMIGAN -bimatoprost ophth soln 0.03%.......................143
LUNESTA -eszopiclone tab 1 mg......................................87
LUNESTA -eszopiclone tab 2 mg......................................87
LUNESTA -eszopiclone tab 3 mg......................................87
LUPRON DEPOT -leuprolide acetate for inj kit 3.75
mg.................................................................................... 17
LUPRON DEPOT -leuprolide acetate for inj kit 7.5 mg......17
LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf)...........................................................................129
LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................. 129
LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................. 129
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 129
LUVOX CR -fluvoxamine maleate cap sr 24hr 100 mg......81
LUVOX CR -fluvoxamine maleate cap sr 24hr 150 mg......81
LUXIQ -betamethasone valerate aerosol foam 0.12%.....156
LUZU -luliconazole cream 1%......................................... 156
LYCELLE - nit remover - gel ..........................................156
LYRICA -pregabalin cap 100 mg.....................................112
LYRICA -pregabalin cap 150 mg.....................................112
LYRICA -pregabalin cap 200 mg.....................................112
LYRICA -pregabalin cap 225 mg.....................................112
LYRICA -pregabalin cap 25 mg.......................................112
LYRICA -pregabalin cap 300 mg.....................................112
LYRICA -pregabalin cap 50 mg.......................................112
LYRICA -pregabalin cap 75 mg.......................................112
LYRICA -pregabalin soln 20 mg/ml................................. 112
LYSODREN -mitotane tab 500 mg....................................17
LYSTEDA -tranexamic acid tab 650 mg..........................137
M
MACNATAL CN DHA - prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg .......................................................... 121
MACROBID -nitrofurantoin monohydrate macrocrystalline
cap 100 mg......................................................................74
214
MACRODANTIN -nitrofurantoin macrocrystalline cap 100
mg.................................................................................... 74
MACRODANTIN -nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 74
MACRODANTIN -nitrofurantoin macrocrystalline cap 50
mg.................................................................................... 74
mafenide acetate packet for topical soln 5% (50 gm)
(Sulfamylon)..................................................................156
MAGNACET -oxycodone w/ acetaminophen tab 10-400
mg.................................................................................. 100
MAGNACET -oxycodone w/ acetaminophen tab 5-400
mg.................................................................................. 100
MAGNACET -oxycodone w/ acetaminophen tab 7.5-400
mg.................................................................................. 100
MAGNEBIND 400 -magnesium-calcium-folic acid tab
400-200-1 mg.................................................................129
MALARONE -atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 11
MALARONE -atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 11
malathion lotion 0.5% (Ovide)...................................... 156
MAPROTILINE HCL -maprotiline hcl tab 25 mg................81
MAPROTILINE HCL -maprotiline hcl tab 50 mg................81
MAPROTILINE HCL -maprotiline hcl tab 75 mg................81
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml...............................................................61
MAR-COF CG EXPECTORANT -guaifenesin-codeine
liquid 225-7.5 mg/5ml...................................................... 61
MARINOL -dronabinol cap 10 mg..................................... 71
MARINOL -dronabinol cap 2.5 mg.................................... 71
MARINOL -dronabinol cap 5 mg....................................... 71
MARNATAL-F - prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg ................................................................. 121
MARPLAN -isocarboxazid tab 10 mg................................ 81
MATULANE -procarbazine hcl cap 50 mg.........................17
MAVIK -trandolapril tab 1 mg............................................ 49
MAVIK -trandolapril tab 2 mg............................................ 49
MAVIK -trandolapril tab 4 mg............................................ 49
MAXAIR AUTOHALER -pirbuterol acetate breath activated
inhal aerosol 200mcg/inh................................................. 66
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 10 mg.......................................................................108
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 5 mg.........................................................................108
MAXALT -rizatriptan benzoate tab 10 mg....................... 108
MAXALT -rizatriptan benzoate tab 5 mg......................... 108
MAXARON FORTE - fe gly-fe fum-vit c-vit b12methylfolate tab ............................................................ 134
MAXFE - iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab
160-1 mg ...................................................................... 134
MAXIDEX -dexamethasone ophth susp 0.1%................. 143
MAXIDONE -hydrocodone-acetaminophen tab 10-750
mg.................................................................................. 100
MAXIFED CD -pseudoephedrine w/ cod-gg tab 60-10-400
mg.................................................................................... 61
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
MAXIFED CDX -pseudoephedrine w/ cod-gg tab
60-20-400 mg...................................................................61
MAXIFED-G CD -pseudoephedrine w/ cod-gg tab
40-10-400 mg...................................................................61
MAXIFED-G CDX -pseudoephedrine w/ cod-gg tab
40-20-400 mg...................................................................62
MAXIFLU CD -pseudoephed-codeine-guaifenesin-apap
tab 40-10-400-500 mg..................................................... 62
MAXIFLU CDX -pseudoephed-codeine-guaifenesin-apap
tab 60-20-400-500 mg..................................................... 62
MAXINATE - prenatal vit w/ fe gluc-fe fum-fa tab 20-0.8
mg ................................................................................. 121
MAXIPHEN CD -phenylephrine w/ codeine-gg tab
10-10-400 mg...................................................................62
MAXIPHEN CDX -phenylephrine w/ codeine-gg tab
10-20-400 mg...................................................................62
MAXITROL -neomycin-polymyxin-dexamethasone ophth
oint 0.1%........................................................................ 143
MAXITROL -neomycin-polymyxin-dexamethasone ophth
susp 0.1%...................................................................... 143
MAXZIDE-25 -triamterene & hydrochlorothiazide tab
37.5-25 mg.......................................................................53
MAXZIDE -triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 53
MB HYDROGEL -emollient cream & wound dressing gel
kit....................................................................................156
M-CLEAR -guaifenesin-codeine cap 200-9 mg................. 61
MEBENDAZOLE -mebendazole chew tab 100 mg............12
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg....................................................................106
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg......................................................................106
MEDICAL PROVIDER EZ FLU S -influenza virus vaccine
split quadrivalent inj kit 0.5 ml......................................... 14
MEDICAL PROVIDER EZ FLU S -influenza virus vac
types a & b preservative free inj kit................................. 14
MEDICINE SHOPPE GLUCOSE -glucose chew tab 4
gm.................................................................................... 29
MEDIHONEY CALCIUM ALGINAT - wound dressings pads .............................................................................. 157
MEDROL DOSEPAK -methylprednisolone tab 4 mg dose
pack..................................................................................19
MEDROL -methylprednisolone tab 16 mg......................... 19
MEDROL -methylprednisolone tab 2 mg...........................19
MEDROL -methylprednisolone tab 32 mg......................... 19
MEDROL -methylprednisolone tab 4 mg...........................19
MEDROL -methylprednisolone tab 8 mg...........................19
MEDROX-RX -capsaicin-menthol-methyl salicylate oint
0.05-7-20%.....................................................................157
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 24
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).........................106
mefloquine hcl tab 250 mg............................................. 11
MEGACE ES -megestrol acetate susp 625 mg/5ml.......... 26
MEGACE ORAL -megestrol acetate susp 40 mg/ml......... 17
megestrol acetate susp 40 mg/ml (Megace oral).......... 17
megestrol acetate tab 20 mg.......................................... 17
megestrol acetate tab 40 mg.......................................... 17
MEIJER GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 30
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg (base
equivalent)........................................................................17
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)........................................................................17
MELOXICAM COMFORT PAC -meloxicam tab 15 mg &
liniment topical gel kit.................................................... 106
MELOXICAM -meloxicam susp 7.5 mg/5ml.................... 106
meloxicam tab 15 mg (Mobic)...................................... 106
meloxicam tab 7.5 mg (Mobic)..................................... 106
M-END MAX D -pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml.................................................... 61
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml..................................................... 61
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%................................157
MEPERIDINE HCL/PROMETHAZI -meperidine w/
promethazine cap 50-25 mg.......................................... 100
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml............................................................................100
meperidine hcl tab 100 mg (Demerol)..........................100
meperidine hcl tab 50 mg (Demerol)........................... 100
MEPHYTON -phytonadione tab 5 mg............................. 118
meprobamate tab 200 mg............................................... 78
meprobamate tab 400 mg............................................... 78
MEPRON -atovaquone susp 750 mg/5ml......................... 12
mercaptopurine tab 50 mg (Purinethol).........................17
mesalamine enema 4 gm................................................ 73
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa)......................................................................... 72
MESNEX -mesna tab 400 mg........................................... 17
MESTINON -pyridostigmine bromide syrup 60
mg/5ml............................................................................118
MESTINON -pyridostigmine bromide tab 60 mg............. 118
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg........................................................................... 118
METADATE CD -methylphenidate hcl cap cr 10 mg......... 90
METADATE CD -methylphenidate hcl cap cr 20 mg......... 90
METADATE CD -methylphenidate hcl cap cr 30 mg......... 90
METADATE CD -methylphenidate hcl cap cr 40 mg......... 90
METADATE CD -methylphenidate hcl cap cr 50 mg......... 90
METADATE CD -methylphenidate hcl cap cr 60 mg......... 90
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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METAFOLBIC - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg .................................................................. 131
METAFOLBIC PLUS - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 131
METAFOLBIC PLUS RF - l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg ................................. 131
METAGLIP -glipizide-metformin hcl tab 2.5-250 mg..........30
METANX - l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg ......................................................... 131
METANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg
....................................................................................... 131
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml.............................................................. 66
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 10 mg.........................................................................66
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 20 mg.........................................................................66
metaproterenol sulfate syrup 10 mg/5ml.......................66
metaxalone tab 800 mg (Skelaxin)............................... 117
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)............... 100
METHADONE HCL -methadone hcl soln 10 mg/5ml.......100
METHADONE HCL -methadone hcl soln 5 mg/5ml.........100
methadone hcl soln 10 mg/5ml (Methadone hcl)........ 100
methadone hcl soln 5 mg/5ml (Methadone hcl).......... 100
methadone hcl tab 10 mg (Dolophine)........................ 100
methadone hcl tab 5 mg (Dolophine hcl).................... 100
methadone hcl tab for oral susp 40 mg...................... 100
METHADOSE -methadone hcl conc 10 mg/ml................100
METHADOSE SUGAR-FREE -methadone hcl conc 10 mg/
ml....................................................................................100
methamphetamine hcl tab 5 mg (Desoxyn)...................90
methazolamide tab 25 mg (Neptazane)......................... 53
methazolamide tab 50 mg (Neptazane)......................... 53
methenamine hippurate tab 1 gm (Hiprex)....................74
methenamine-hyosamine-meth blue-sod phos tab 81.6
mg (Urogesic-blue)........................................................ 74
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................. 74
methenamine-hyosc-meth blue-sod phos-phen sal cap
120 mg ........................................................................... 74
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg .......................................................................... 74
METHENAMINE MANDELATE -methenamine mandelate
tab 0.5 gm........................................................................74
methenamine mandelate tab 1 gm.................................74
METHERGINE -methylergonovine maleate tab 0.2 mg.....34
216
methimazole tab 10 mg (Tapazole)................................ 33
methimazole tab 5 mg (Tapazole).................................. 33
METHITEST -methyltestosterone oral tab 10 mg.............. 21
methocarbamol tab 500 mg (Robaxin)........................ 117
methocarbamol tab 750 mg (Robaxin-750)................. 117
methotrexate sodium for inj 1 gm..................................17
methotrexate sodium inj 25 mg/ml................................ 17
methotrexate sodium inj pf 25 mg/ml............................ 17
methotrexate sodium tab 2.5 mg (base equiv)..............17
methoxsalen rapid cap 10 mg (Oxsoralen ultra).........157
methscopolamine bromide tab 2.5 mg (Pamine).......... 70
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................ 70
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.......................... 34
METHYLFOL-ALGAE-B12-ACETY - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 132
METHYLIN -methylphenidate hcl chew tab 10 mg............ 90
METHYLIN -methylphenidate hcl chew tab 2.5 mg........... 90
METHYLIN -methylphenidate hcl chew tab 5 mg.............. 90
METHYLIN -methylphenidate hcl soln 10 mg/5ml............. 90
METHYLIN -methylphenidate hcl soln 5 mg/5ml............... 90
methylphenidate hcl cap cr 10 mg (Metadate cd)......... 90
methylphenidate hcl cap cr 20 mg (Metadate cd)......... 90
methylphenidate hcl cap cr 30 mg (Metadate cd)......... 90
methylphenidate hcl cap cr 40 mg (Metadate cd)......... 90
methylphenidate hcl cap cr 50 mg (Metadate cd)......... 90
methylphenidate hcl cap cr 60 mg (Metadate cd)......... 90
methylphenidate hcl cap sr 24hr 20 mg (Ritalin la)...... 90
methylphenidate hcl cap sr 24hr 30 mg (Ritalin la)...... 90
methylphenidate hcl cap sr 24hr 40 mg (Ritalin la)...... 90
METHYLPHENIDATE HCL ER -methylphenidate hcl tab cr
10 mg............................................................................... 90
methylphenidate hcl soln 10 mg/5ml (Methylin)........... 90
methylphenidate hcl soln 5 mg/5ml (Methylin)............. 90
methylphenidate hcl tab 10 mg (Ritalin)........................90
methylphenidate hcl tab 20 mg (Ritalin)........................90
methylphenidate hcl tab 5 mg (Ritalin)..........................91
methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 90
methylphenidate hcl tab sa osm 18 mg (Concerta)...... 90
methylphenidate hcl tab sa osm 27 mg (Concerta)...... 90
methylphenidate hcl tab sa osm 36 mg (Concerta)...... 90
methylphenidate hcl tab sa osm 54 mg (Concerta)...... 90
methylprednisolone tab 16 mg (Medrol)........................19
methylprednisolone tab 32 mg (Medrol)........................19
methylprednisolone tab 4 mg (Medrol)......................... 19
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)..........................................................................19
methylprednisolone tab 8 mg (Medrol)......................... 19
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
METIPRANOLOL -metipranolol ophth soln 0.3%............ 143
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 73
metoclopramide hcl tab 10 mg (Reglan)....................... 73
metoclopramide hcl tab 5 mg (Reglan)......................... 73
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)...............................................................49
metoprolol & hydrochlorothiazide tab 100-50 mg........ 49
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)...............................................................49
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl)..................................................................................... 40
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl)..................................................................................... 40
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)......40
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)......40
metoprolol tartrate tab 100 mg (Lopressor).................. 40
metoprolol tartrate tab 25 mg.........................................40
metoprolol tartrate tab 50 mg (Lopressor).................... 40
METOZOLV ODT -metoclopramide hcl orally disintegrating
tab 10 mg.........................................................................73
METOZOLV ODT -metoclopramide hcl orally disintegrating
tab 5 mg...........................................................................73
METROCREAM -metronidazole cream 0.75%................ 157
METROGEL -metronidazole gel 1%................................157
METROGEL-VAGINAL -metronidazole vaginal gel
0.75%............................................................................... 76
METROLOTION -metronidazole lotion 0.75%................. 157
metronidazole cap 375 mg (Flagyl)................................12
metronidazole cream 0.75% (Metrocream).................. 157
metronidazole gel 0.75%...............................................157
metronidazole gel 1% (Metrogel)................................. 157
metronidazole lotion 0.75% (Metrolotion)....................157
metronidazole tab 250 mg (Flagyl).................................12
metronidazole tab 500 mg (Flagyl).................................12
metronidazole vaginal gel 0.75% (Metrogelvaginal)............................................................................76
METVIXIA -methyl aminolevulinate hcl cream 16.8% (base
equiv)..............................................................................157
MEVACOR -lovastatin tab 20 mg......................................56
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................36
MIACALCIN -calcitonin (salmon) nasal soln 200 unit/
act.....................................................................................36
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.................................... 49
MICARDIS -telmisartan tab 40 mg.................................... 49
MICARDIS -telmisartan tab 80 mg.................................... 49
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 76
miconazole nitrate vaginal supp 200 mg & 2% cream 9
gm kit.............................................................................. 76
MICRO-K -potassium chloride cap cr 10 meq................. 129
MICRO-K -potassium chloride cap cr 8 meq................... 129
MICROLET LANCETS - lancets .....................................166
MICROTAINER SAFETY FLOW L - lancets .................. 166
MICROZIDE -hydrochlorothiazide cap 12.5 mg................ 53
midazolam hcl syrup 2 mg/ml (base equivalent).......... 87
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.................................................................................. 108
MIGRALAM -acetaminophen-isometheptene-caffeine cap
325-65-100 mg...............................................................108
MIGRAL -isometheptene mucate tab 130 mg................. 108
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml..............................................................................108
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..................................19
MIMYX - emollient - cream ............................................ 157
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)............................................ 24
MINERAL OIL HEAVY -mineral oil....................................68
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 biweekly 0.0375
mg/24hr............................................................................ 23
MINIVELLE -estradiol td patch biweekly 0.05 mg/24hr......23
MINIVELLE -estradiol td patch biweekly 0.075
mg/24hr............................................................................ 23
MINIVELLE -estradiol td patch biweekly 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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
217
2014
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........................................................................ 115
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.75 mg.......................................................................... 115
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 1.5
mg.................................................................................. 115
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
2.25 mg.......................................................................... 115
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
3.75 mg.......................................................................... 115
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 115
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 4.5
mg.................................................................................. 115
MIRAPEX -pramipexole dihydrochloride tab 0.125
mg.................................................................................. 115
MIRAPEX -pramipexole dihydrochloride tab 0.25 mg......115
MIRAPEX -pramipexole dihydrochloride tab 0.5 mg........115
MIRAPEX -pramipexole dihydrochloride tab 0.75 mg......115
MIRAPEX -pramipexole dihydrochloride tab 1.5 mg........115
MIRAPEX -pramipexole dihydrochloride tab 1 mg...........115
MIRCETTE -desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)...................................................24
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)..............................................................................81
mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)..............................................................................81
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)..............................................................................81
mirtazapine tab 15 mg (Remeron)..................................81
mirtazapine tab 30 mg (Remeron)..................................81
mirtazapine tab 45 mg (Remeron)..................................81
mirtazapine tab 7.5 mg....................................................81
MIRVASO -brimonidine tartrate gel 0.33% (base
equivalent)......................................................................157
misoprostol tab 100 mcg (Cytotec)................................70
misoprostol tab 200 mcg (Cytotec)................................70
MITOSOL -mitomycin for ophth soln kit 0.2 mg...............143
MOBIC -meloxicam susp 7.5 mg/5ml.............................. 106
MOBIC -meloxicam tab 15 mg........................................ 106
MOBIC -meloxicam tab 7.5 mg....................................... 106
modafinil tab 100 mg (Provigil)...................................... 91
modafinil tab 200 mg (Provigil)...................................... 91
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg......... 9
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg........... 9
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack...........................................................................9
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack...........................................................................9
MODICON -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg....................................................................... 24
moexipril hcl tab 15 mg (Univasc)................................. 50
218
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)................. 157
mometasone furoate oint 0.1% (Elocon)..................... 157
mometasone furoate solution 0.1% (lotion)
(Elocon)......................................................................... 157
MOMEXIN -mometasone furoate cream 0.1% & ammon
lactate foam 12% kit...................................................... 157
MOMS CHOICE RX -prenat w/fe poly-na fered-fa tab 26-1
& omega cap 278 mg.................................................... 121
MONOCAL -sodium monofluorophosphate-calcium carb
tab 22.75-625 mg...........................................................129
MONOCLATE-P -antihemophilic factor (human) for inj kit
1000 unit........................................................................ 139
MONOCLATE-P -antihemophilic factor (human) for inj kit
1500 unit........................................................................ 139
MONOCLATE-P -antihemophilic factor (human) for inj kit
250 unit.......................................................................... 139
MONOCLATE-P -antihemophilic factor (human) for inj kit
500 unit.......................................................................... 139
MONODOX -doxycycline monohydrate cap 100 mg........... 4
MONODOX -doxycycline monohydrate cap 50 mg............. 4
MONODOX -doxycycline monohydrate cap 75 mg............. 4
MONOKET -isosorbide mononitrate tab 10 mg................. 39
MONOKET -isosorbide mononitrate tab 20 mg................. 39
MONONINE -coagulation factor ix for inj 1000 unit......... 139
MONONINE -coagulation factor ix for inj 250 unit........... 139
MONONINE -coagulation factor ix for inj 500 unit........... 139
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)........................................................................66
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)........................................................................66
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)............................................................66
montelukast sodium tab 10 mg (base equiv)
(Singulair)........................................................................66
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................. 74
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 ............................................................ 5
morphine sulfate (concentrate) oral soln 20 mg/
ml................................................................................... 100
morphine sulfate beads cap sr 24hr 120 mg
(Avinza)......................................................................... 100
morphine sulfate beads cap sr 24hr 30 mg
(Avinza)......................................................................... 100
morphine sulfate beads cap sr 24hr 45 mg
(Avinza)......................................................................... 100
morphine sulfate beads cap sr 24hr 60 mg
(Avinza)......................................................................... 100
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
morphine sulfate beads cap sr 24hr 75 mg
(Avinza)......................................................................... 101
morphine sulfate beads cap sr 24hr 90 mg
(Avinza)......................................................................... 101
morphine sulfate cap sr 24hr 100 mg (Kadian)........... 101
morphine sulfate cap sr 24hr 10 mg (Kadian).............101
morphine sulfate cap sr 24hr 20 mg (Kadian).............101
morphine sulfate cap sr 24hr 30 mg (Kadian).............101
morphine sulfate cap sr 24hr 50 mg (Kadian).............101
morphine sulfate cap sr 24hr 60 mg (Kadian).............101
morphine sulfate cap sr 24hr 80 mg (Kadian).............101
MORPHINE SULFATE -morphine sulfate suppos 10
mg.................................................................................. 100
MORPHINE SULFATE -morphine sulfate suppos 20
mg.................................................................................. 100
MORPHINE SULFATE -morphine sulfate suppos 30
mg.................................................................................. 100
MORPHINE SULFATE -morphine sulfate suppos 5
mg.................................................................................. 100
MORPHINE SULFATE -morphine sulfate tab 15 mg.......100
MORPHINE SULFATE -morphine sulfate tab 30 mg.......100
morphine sulfate oral soln 10 mg/5ml......................... 101
morphine sulfate oral soln 20 mg/5ml......................... 101
morphine sulfate tab cr 100 mg (Ms contin)............... 101
morphine sulfate tab cr 15 mg (Ms contin)................. 101
morphine sulfate tab cr 200 mg (Ms contin)............... 101
morphine sulfate tab cr 30 mg (Ms contin)................. 101
morphine sulfate tab cr 60 mg (Ms contin)................. 101
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............ 68
mouthwashes - liquid ...................................................145
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na acorbate-c
for soln 100 gm................................................................68
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg.......1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).....................................................................143
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........6
MS CONTIN -morphine sulfate tab cr 100 mg.................101
MS CONTIN -morphine sulfate tab cr 15 mg...................101
MS CONTIN -morphine sulfate tab cr 200 mg.................101
MS CONTIN -morphine sulfate tab cr 30 mg...................101
MS CONTIN -morphine sulfate tab cr 60 mg...................101
MS QUICK DISSOLVE GLUCOSE -glucose chew tab 4
gm.................................................................................... 30
MST 600 -magnesium salicylate tab 600 mg.................... 96
MUCOTROL - oral wound care products - wafer ............146
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)........................................................................44
MULTICHEW -multiple vitamins w/ minerals & fa chew tab
1 mg............................................................................... 121
MULTIGEN - fe asparto gly-succ acd-c-threonic acd-b12des stom tab .................................................................134
MULTIGEN FOLIC - fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab .................................................135
MULTIGEN PLUS - fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab .................................................135
multiple vitamins w/ minerals & fa tab 1.25 mg
(Corvite).........................................................................119
mupirocin calcium cream 2% (Bactroban).................. 157
mupirocin oint 2% (Bactroban).................................... 157
MV FE ASPARTO GLY/FE FUM/ - fe aspart gly-fe fumsucc acd-c-threonic acd-b12-fa tab .............................. 135
MV FE ASPARTO GLY/VIT C/V - fe asparto gly-succ acdc-threonic acd-b12-des stom tab .................................. 135
M-VIT - prenatal vit w/ fe fumarate-fa tab 27-1 mg ......... 121
MYALEPT -metreleptin for subcutaneous inj 11.3 mg....... 36
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)............166
mycophenolate mofetil tab 500 mg (Cellcept).............166
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)...................................................166
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)...................................................166
MYDFRIN -phenylephrine hcl ophth soln 2.5%............... 143
MYDRIACYL -tropicamide ophth soln 1%....................... 143
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................. 166
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................. 166
MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 135
MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe
susp 0.25-10 mg/2ml..................................................... 121
MYLERAN -busulfan tab 2 mg.......................................... 17
MYNATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg .................................................................. 121
MYNATAL PLUS - prenatal vit w/ fe fumarate-fa tab 65-1
mg ................................................................................. 121
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg........................................................................121
MYNATAL ULTRACAPLET - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg ............................................... 122
MYNATAL-Z - prenatal vit w/ fe fumarate-fa tab 65-1 mg
....................................................................................... 122
MYNATE 90 PLUS - prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg .................................................................... 122
MYOXIN -benzocaine-chloroxylenol-hc otic soln 15-1-10
mg/ml..............................................................................145
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg...................75
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg...................75
MYSOLINE -primidone tab 250 mg................................. 112
MYSOLINE -primidone tab 50 mg...................................112
MYTELASE -ambenonium chloride tab 10 mg................ 118
N
NABI-HB -hepatitis b immune globulin (human) im inj
soln...................................................................................15
nabumetone tab 500 mg............................................... 106
nabumetone tab 750 mg............................................... 106
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)..........................................................................50
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
219
2014
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)..........................................................................50
nadolol tab 20 mg (Corgard).......................................... 40
nadolol tab 40 mg (Corgard).......................................... 40
nadolol tab 80 mg (Corgard).......................................... 40
-NAFARELIN ACETATE NASAL SOLN 2 MG/ML.............38
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................... 146
NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
rinse 0.05%.................................................................... 146
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%............................................................................... 146
NAFTIN -naftifine hcl cream 1%......................................157
NAFTIN -naftifine hcl cream 2%......................................157
NAFTIN -naftifine hcl gel 1%...........................................157
NAFTIN -naftifine hcl gel 2%...........................................157
NALFON -fenoprofen calcium cap 200 mg......................106
NALFON -fenoprofen calcium cap 400 mg......................106
naltrexone hcl tab 50 mg (Revia)................................. 165
NAMENDA -memantine hcl oral solution 2 mg/ml............. 93
NAMENDA -memantine hcl tab 10 mg..............................93
NAMENDA -memantine hcl tab 5 mg................................93
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak........................................ 93
NAMENDA XR -memantine hcl cap sr 24hr 14 mg........... 93
NAMENDA XR -memantine hcl cap sr 24hr 21 mg........... 93
NAMENDA XR -memantine hcl cap sr 24hr 28 mg........... 93
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............. 93
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................... 93
NAPHAZOLINE HCL -naphazoline hcl ophth soln
0.1%............................................................................... 143
NAPRELAN -naproxen sodium tab sr 24hr 375 mg (base
equiv)..............................................................................106
NAPRELAN -naproxen sodium tab sr 24hr 500 mg (14) &
750 mg (6) pack............................................................ 106
NAPRELAN -naproxen sodium tab sr 24hr 500 mg (base
equiv)..............................................................................106
NAPRELAN -naproxen sodium tab sr 24hr 750 mg (base
equiv)..............................................................................106
NAPROSYN -naproxen susp 125 mg/5ml....................... 106
NAPROSYN -naproxen tab 250 mg................................ 106
NAPROSYN -naproxen tab 375 mg................................ 106
NAPROSYN -naproxen tab 500 mg................................ 106
NAPROXEN COMFORT PAC -naproxen tab 500 mg &
liniment topical gel kit.................................................... 106
naproxen sodium tab 275 mg (Anaprox)..................... 106
naproxen sodium tab 550 mg (Anaprox ds)................107
naproxen susp 125 mg/5ml (Naprosyn).......................107
naproxen tab 250 mg (Naprosyn).................................107
naproxen tab 375 mg (Naprosyn).................................107
naproxen tab 500 mg (Naprosyn).................................107
naproxen tab ec 375 mg (Ec-naprosyn)...................... 107
naproxen tab ec 500 mg (Ec-naprosyn)...................... 107
naratriptan hcl tab 1 mg (base equiv) (Amerge)......... 108
220
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 108
NARDIL -phenelzine sulfate tab 15 mg............................. 81
NASACORT AQ -triamcinolone acetonide nasal inhal 55
mcg/act.............................................................................59
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml.......................................................................135
NASONEX -mometasone furoate nasal susp 50 mcg/
act.....................................................................................59
NATACHEW - prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg .................................................................. 122
NATACYN -natamycin ophth susp 5%............................ 143
NATAFORT - prenatal w/o a vit w/ fe cbn-fe fum-fa tab
60-1 mg ........................................................................ 122
NATA KOMPLETE - prenatal vit w/ fe fum-fe bisglycinatefa tab 25-1 mg ..............................................................122
NATALVIRT 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak............................................... 122
NATALVIRT CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack.................................................... 122
NATALVIRT FLT - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 135
NATALVIT - prenatal vit w/ fe fumarate-fa tab 75-1 mg
....................................................................................... 122
NATAL-V RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg
....................................................................................... 122
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg...............................................................24
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 .......................................................... 122
NATROBA -spinosad susp 0.9%.....................................157
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................ 33
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
NAVANE -thiothixene cap 20 mg...................................... 85
NEBUPENT -pentamidine isethionate for nebulization soln
300 mg............................................................................. 12
NEBUSAL -sodium chloride soln nebu 6%........................62
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg...................................................................................24
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)............................................ 25
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
NEEVO DHA - prenat w/o a w/fefum-methylfol-fa-omegas
cap 27-1.53 mg ............................................................ 122
NEEVO DHA - prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg ............................................................ 122
NEEVO - prenatal w/ fe polycmplx-methylfol-fa pak
29-1.4-0.5 mg ............................................................... 122
NEFAZODONE HCL -nefazodone hcl tab 100 mg............ 81
NEFAZODONE HCL -nefazodone hcl tab 150 mg............ 81
NEFAZODONE HCL -nefazodone hcl tab 200 mg............ 81
NEFAZODONE HCL -nefazodone hcl tab 50 mg.............. 81
nefazodone hcl tab 250 mg............................................ 81
NEO AC -pseudoephedrine-pyrilamine-codeine syrup
30-15-10 mg/5ml..............................................................62
NEO-FRADIN -neomycin sulfate soln 25 mg/ml..................6
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp............................................... 143
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................... 143
neomycin-polymyxin b-gramicidin ophth soln
(Neosporin)................................................................... 143
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)....................................................................... 143
neomycin-polymyxin-dexamethasone ophth susp 0.1%
(Maxitrol)....................................................................... 143
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)..................................................................145
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%..................................................................... 145
neomycin sulfate tab 500 mg........................................... 6
NEORAL -cyclosporine modified cap 100 mg................. 166
NEORAL -cyclosporine modified cap 25 mg................... 166
NEORAL -cyclosporine modified oral soln 100 mg/ml..... 166
NEOSALUS CP - emollient - cream ...............................157
NEOSALUS - emollient - aerosol foam .......................... 157
NEOSALUS - emollient - cream .....................................157
NEOSALUS - emollient - lotion ...................................... 157
NEOSPORIN -neomycin-polymyxin b-gramicidin ophth
soln.................................................................................143
NEO-SYNALAR KIT -neomycin-fluocinolone cream
0.35-0.025% & emollient cr kit.......................................157
NEO-SYNALAR -neomycin-fluocinolone cream
0.35-0.025%................................................................... 157
NEOTUSS-D -pseudoephed-chlorphen w/ dm-gg liqd
30-2-30-200 mg/5ml.........................................................62
NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid
7.5-4-30 mg/5ml...............................................................62
NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 122
NEPHROCAPS -b-complex w/ c & folic acid cap 1
mg.................................................................................. 122
NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid
tab disp 1 mg.................................................................122
NEPHRON FA - ferrous fumarate w/ fa-dss-b complex-vit c
tab ................................................................................. 135
NEPHRO-VITE RX -b-complex w/ c & folic acid tab 1
mg.................................................................................. 122
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.............................................................. 122
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.........................................................122
NESTABS - prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg ........................................................................ 122
NEUAC KIT -clindamycin-benzoyl perox gel 1.2-5% &
moisturizer cr kit.............................................................157
NEULASTA -pegfilgrastim inj 6 mg/0.6ml........................135
NEUMEGA -oprelvekin for inj 5 mg.................................135
NEUPOGEN -filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................. 135
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 135
NEUPOGEN -filgrastim inj 480 mcg/0.8ml (600 mcg/
ml).................................................................................. 135
NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................. 135
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................. 115
NEUPRO -rotigotine td patch 24hr 2 mg/24hr................. 115
NEUPRO -rotigotine td patch 24hr 3 mg/24hr................. 115
NEUPRO -rotigotine td patch 24hr 4 mg/24hr................. 115
NEUPRO -rotigotine td patch 24hr 6 mg/24hr................. 115
NEUPRO -rotigotine td patch 24hr 8 mg/24hr................. 115
NEURIN-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg.................................................................. 135
NEURONTIN -gabapentin cap 100 mg........................... 112
NEURONTIN -gabapentin cap 300 mg........................... 112
NEURONTIN -gabapentin cap 400 mg........................... 112
NEURONTIN -gabapentin oral soln 250 mg/5ml............. 113
NEURONTIN -gabapentin tab 600 mg............................ 112
NEURONTIN -gabapentin tab 800 mg............................ 112
NEUTRASAL - artificial saliva - packet .......................... 146
NEVANAC -nepafenac ophth susp 0.1%........................ 143
NEVIRAPINE -nevirapine susp 50 mg/5ml..........................9
nevirapine tab 200 mg (Viramune)...................................9
nevirapine tab sr 24hr 400 mg (Viramune xr)..................9
NEWGEN - prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg ........................................................................ 122
NEXA PLUS - prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg ............................................................ 122
NEXA SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg ..................................................... 122
NEXA SELECT - prenat w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-337.5 mg ......................................................... 122
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)........................................................................17
NEXICLON XR -clonidine hcl extended release susp 0.09
mg/ml (base equiv).......................................................... 50
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
221
2014
NEXICLON XR -clonidine hcl tab sr 24hr 0.17 mg (base
equivalent)........................................................................50
NEXIUM -esomeprazole magnesium cap delayed release
20 mg............................................................................... 70
NEXIUM -esomeprazole magnesium cap delayed release
40 mg............................................................................... 70
NEXIUM -esomeprazole magnesium for delayed release
susp pack 2.5 mg............................................................ 70
NEXIUM -esomeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 70
NEXIUM -esomeprazole magnesium for delayed release
susp packet 20 mg.......................................................... 70
NEXIUM -esomeprazole magnesium for delayed release
susp packet 40 mg.......................................................... 70
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg............................................................ 70
niacinamide w/ zinc-copper &folic acid tab
750-25-1.5-0.5 mg......................................................... 122
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan)......................................................................... 56
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)......................................................................... 56
niacin tab cr 750 mg (antihyperlipidemic)
(Niaspan)......................................................................... 56
NIACOR -niacin (antihyperlipidemic) tab 500 mg.............. 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
NICAZELDOXY 30 KIT -doxycycline monohyd tab 100 mg
&multivit/minerals tab kit.................................................... 5
NICAZELDOXY 60 KIT -doxycycline monohyd tab 100 mg
&multivit/minerals tab kit.................................................... 5
NICODERM CQ -nicotine td patch 24hr 14 mg/24hr......... 93
NICODERM CQ -nicotine td patch 24hr 21 mg/24hr......... 93
NICODERM CQ -nicotine td patch 24hr 7 mg/24hr........... 93
NICOMIDE - niacinamide w/ zn-cu-methylfolate tab
750-25-1.5-0.5 mg ........................................................ 122
NICORETTE MINI -nicotine polacrilex lozenge 2 mg........ 93
NICORETTE MINI -nicotine polacrilex lozenge 4 mg........ 93
NICORETTE -nicotine polacrilex gum 2 mg...................... 93
NICORETTE -nicotine polacrilex gum 4 mg...................... 93
NICORETTE -nicotine polacrilex lozenge 2 mg.................93
NICORETTE -nicotine polacrilex lozenge 4 mg.................93
NICORETTE STARTER KIT -nicotine polacrilex gum 2
mg.................................................................................... 93
NICORETTE STARTER KIT -nicotine polacrilex gum 4
mg.................................................................................... 93
nicotine polacrilex gum 2 mg.........................................93
nicotine polacrilex gum 4 mg.........................................93
nicotine polacrilex lozenge 2 mg................................... 93
nicotine polacrilex lozenge 4 mg................................... 93
nicotine td patch 24hr 14 mg/24hr................................. 93
nicotine td patch 24hr 21 mg/24hr................................. 93
222
nicotine td patch 24hr 7 mg/24hr................................... 94
NICOTINE TRANSDERMAL SYST -nicotine td patch 24 hr
kit 21-14-7 mg/24hr..........................................................94
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered)................................................................... 94
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 94
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................................17
nimodipine cap 30 mg.....................................................43
NIRAVAM -alprazolam orally disintegrating tab 0.25
mg.................................................................................... 78
NIRAVAM -alprazolam orally disintegrating tab 0.5 mg..... 78
NIRAVAM -alprazolam orally disintegrating tab 1 mg........78
NIRAVAM -alprazolam orally disintegrating tab 2 mg........78
NIRON KOMPLETE - fe bisglycinate-fe fum-vit c-vit b12-vit
e-fa tab 30-1 mg ...........................................................135
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 25.5 mg..................................... 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)..................................................................74
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)..................................................................74
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 74
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 74
nitroglycerin cap cr 2.5 mg............................................ 39
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
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........................... 39
NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 39
NIVATOPIC PLUS - dermatological products misc - cream
....................................................................................... 157
nizatidine cap 150 mg..................................................... 70
nizatidine cap 300 mg (Axid).......................................... 70
nizatidine oral soln 15 mg/ml (Axid).............................. 70
NIZORAL -ketoconazole shampoo 2%............................157
NOBLE MYSTIQUE EMU-LAC -lactic acid (ammonium
lactate) cream 10%........................................................157
NORCO -hydrocodone-acetaminophen tab 10-325
mg.................................................................................. 101
NORCO -hydrocodone-acetaminophen tab 5-325 mg.....101
NORCO -hydrocodone-acetaminophen tab 7.5-325
mg.................................................................................. 101
NORDETTE-28 -levonorgestrel & ethinyl estradiol tab 0.15
mg-30 mcg....................................................................... 25
NORDITROPIN CARTRIDGE -somatropin inj 5
mg/1.5ml...........................................................................36
NORDITROPIN FLEXPRO -somatropin inj 10
mg/1.5ml...........................................................................37
NORDITROPIN FLEXPRO -somatropin inj 15
mg/1.5ml...........................................................................37
NORDITROPIN FLEXPRO -somatropin inj 5 mg/1.5ml.....36
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 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 acetate-ethinyl estradiol tab 1 mg-5
mcg.................................................................................. 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.........25
NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1
mg-35 mcg....................................................................... 25
NORINYL 1+50 -norethindrone & mestranol tab 1 mg-50
mcg...................................................................................25
NORITATE -metronidazole cream 1%.............................157
NOROXIN -norfloxacin tab 400 mg..................................... 6
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...................... 81
NORPRAMIN -desipramine hcl tab 10 mg........................ 81
NORPRAMIN -desipramine hcl tab 150 mg...................... 81
NORPRAMIN -desipramine hcl tab 25 mg........................ 81
NORPRAMIN -desipramine hcl tab 50 mg........................ 81
NORPRAMIN -desipramine hcl tab 75 mg........................ 81
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)........................... 81
nortriptyline hcl cap 25 mg (Pamelor)........................... 81
nortriptyline hcl cap 50 mg (Pamelor)........................... 81
nortriptyline hcl cap 75 mg (Pamelor)........................... 81
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml..............................................................................81
nortriptyline hcl soln 10 mg/5ml.................................... 81
NORTUSS-EX -dextromethorphan-guaifenesin liquid
20-200 mg/5ml................................................................. 62
NORVASC -amlodipine besylate tab 10 mg......................43
NORVASC -amlodipine besylate tab 2.5 mg..................... 43
NORVASC -amlodipine besylate tab 5 mg........................43
NORVIR -ritonavir cap 100 mg........................................... 9
NORVIR -ritonavir oral soln 80 mg/ml................................. 9
NORVIR -ritonavir tab 100 mg............................................ 9
NOTUSS-NX -codeine-chlorcyclizine liquid 10-9.375
mg/5ml..............................................................................62
NOTUSS-NXD -codeine-pseudoephedrine-chlorcyclizine
liq 10-30-9.375mg/5ml..................................................... 62
NOVACORT - hydrocortisone ace-pramoxine-aloe
polysacch gel 2-1-1% ................................................... 157
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
223
2014
NOVAFERRUM -polysacch iron complex-vit c-fa for soln
100-60-1 mg/5ml............................................................135
NOVOLIN 70/30 -insulin isophane & regular (human) inj
100 unit/ml (70-30)...........................................................32
NOVOLIN 70/30 RELION -insulin isophane & regular
(human) inj 100 unit/ml (70-30)....................................... 32
NOVOLIN N -insulin isophane (human) inj 100 unit/ml......32
NOVOLIN N RELION -insulin isophane (human) inj 100
unit/ml...............................................................................32
NOVOLIN R -insulin regular (human) inj 100 unit/ml......... 31
NOVOLIN R RELION -insulin regular (human) inj 100 unit/
ml......................................................................................31
NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100
unit/ml...............................................................................31
NOVOLOG -insulin aspart inj 100 unit/ml..........................31
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...........31
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml...............................................................................31
NOVOSEVEN -coagulation factor viia (recomb) for inj 2.4
mg (2400 mcg)...............................................................139
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 1
mg (1000 mcg)...............................................................139
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 2
mg (2000 mcg)...............................................................139
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 5
mg (5000 mcg)...............................................................139
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 8
mg (8000 mcg)...............................................................139
NOXAFIL -posaconazole susp 40 mg/ml............................ 7
NOXAFIL -posaconazole tab delayed release 100 mg........7
NUCORT -hydrocortisone acetate lotion 2%................... 157
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg..........101
NUCYNTA ER -tapentadol hcl tab sr 12hr 150 mg..........101
NUCYNTA ER -tapentadol hcl tab sr 12hr 200 mg..........101
NUCYNTA ER -tapentadol hcl tab sr 12hr 250 mg..........101
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg............101
NUCYNTA -tapentadol hcl tab 100 mg........................... 101
NUCYNTA -tapentadol hcl tab 50 mg............................. 101
NUCYNTA -tapentadol hcl tab 75 mg............................. 101
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg..........................................................................94
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm........................................................68
NUMOISYN - artificial saliva - lozenge ...........................146
NUMOISYN - artificial saliva - solution ...........................146
NUOX -benzoyl peroxide-sulfur gel 6-3%........................157
NUTRESTORE -glutamine powd pack 5 gm................... 130
NUTRIDOX - doxycycline monohyd cap 75 mg w/ omega
3-vit e cap kit ....................................................................5
NUTRI-TAB OB + DHA -prenat w/o a w/ fe bisglyc-fa tab
32-1 mg & omega cap pack.......................................... 122
224
NUTRI-TAB OB - prenatal vit w/o vit a w/ fe bisglycinate-fa
tab 32-1 mg .................................................................. 122
NUTRIVIT -b-complex w/ lysine-min-fe & fa liqd 800-15-1
mg/15ml..........................................................................122
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
NUTROPIN AQ -somatropin inj 10 mg/2ml....................... 37
NUTROPIN -somatropin for inj 10 mg...............................37
NUVAIL - dermatological products misc - solution ..........157
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr........................................................25
NUVIGIL -armodafinil tab 150 mg..................................... 91
NUVIGIL -armodafinil tab 200 mg..................................... 91
NUVIGIL -armodafinil tab 250 mg..................................... 91
NUVIGIL -armodafinil tab 50 mg....................................... 91
NUZON -hydrocortisone acetate-aloe vera gel 2%..........157
NYMALIZE -nimodipine oral soln 60 mg/20ml...................43
nystatin cream 100000 unit/gm.................................... 157
nystatin oint 100000 unit/gm........................................ 157
nystatin oral powder ........................................................ 6
nystatin susp 100000 unit/ml........................................146
nystatin tab 500000 unit....................................................7
nystatin topical powder ............................................... 148
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 157
nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 157
NYSTATIN VAGINAL -nystatin vaginal tab 100000
unit....................................................................................76
O
OB COMPLETE/DHA - prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg ......................................... 123
OB COMPLETE 400 - prenatal w/o a w/fecbn-fe asp glycfa-fish cap 40-10-1 mg ................................................. 123
OB COMPLETE ONE - prenatal w/o a w/fecbn-fe asp glycfa-fish cap 50-1-476 mg ............................................... 122
OB COMPLETE PETITE - prenat w/o a w/fecbn-feaspglycfa-omega cap 35-5-1-200 mg ....................................... 122
OB COMPLETE PREMIER - prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg ................................................. 123
OB COMPLETE - prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg ................................................................... 122
OB COMPLETE - prenatal w/o a w/fecbn-feaspglyc-fa-dha
chew 15-5-1-100 mg .....................................................122
OB-NATAL ONE - prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg ................................................... 123
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak..............................................123
OBSTETRIX EC - prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg ........................................................................ 123
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
O-CAL FA - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 122
O-CAL PRENATAL - prenatal vit w/ fe fumarate-fa tab
15-1 mg ........................................................................ 122
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
OCUDOX -doxycycline hyclate cap 50 mg & eyelid cleans
& spray kit..........................................................................5
OCUFEN -flurbiprofen sodium ophth soln 0.03%............ 143
OCUFLOX -ofloxacin ophth soln 0.3%............................ 143
OFLOXACIN -ofloxacin tab 400 mg.................................... 6
ofloxacin ophth soln 0.3% (Ocuflox)........................... 143
ofloxacin otic soln 0.3%................................................145
ofloxacin tab 200 mg.........................................................6
ofloxacin tab 300 mg.........................................................6
ofloxacin tab 400 mg.........................................................6
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg...................................................................................25
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 94
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 94
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 94
olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)....... 94
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)....... 94
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)............................................................................... 85
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis)............................................................................... 85
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis)............................................................................... 85
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)............................................................................... 85
olanzapine tab 10 mg (Zyprexa).....................................85
olanzapine tab 15 mg (Zyprexa).....................................85
olanzapine tab 2.5 mg (Zyprexa)....................................85
olanzapine tab 20 mg (Zyprexa).....................................85
olanzapine tab 5 mg (Zyprexa).......................................85
olanzapine tab 7.5 mg (Zyprexa)....................................85
OLEPTRO -trazodone hcl tab sr 24hr 150 mg.................. 81
OLEPTRO -trazodone hcl tab sr 24hr 300 mg.................. 82
OLUX -clobetasol propionate foam 0.05%...................... 157
OLUX-E -clobetasol propionate emulsion foam
0.05%............................................................................. 157
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)..........................................................................9
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack.......................................... 70
omega-3-acid ethyl esters cap 1 gm (Lovaza).............. 56
omeprazole cap delayed release 10 mg (Prilosec)....... 70
omeprazole cap delayed release 20 mg (Prilosec)....... 70
omeprazole cap delayed release 40 mg (Prilosec)....... 70
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid).......................................................................... 70
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid).......................................................................... 70
OMNARIS -ciclesonide nasal susp 50 mcg/act................. 59
OMNI GEL -stannous fluoride gel 0.4%.......................... 146
OMNIPRED -prednisolone acetate ophth susp 1%......... 143
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)................71
ondansetron hcl tab 24 mg............................................ 71
ondansetron hcl tab 4 mg (Zofran)................................ 71
ondansetron hcl tab 8 mg.............................................. 71
ondansetron hcl tab 8 mg (Zofran)................................ 71
ondansetron orally disintegrating tab 4 mg (Zofran
odt)...................................................................................72
ondansetron orally disintegrating tab 8 mg (Zofran
odt)...................................................................................72
ONFI -clobazam suspension 2.5 mg/ml.......................... 113
ONFI -clobazam tab 10 mg............................................. 113
ONFI -clobazam tab 20 mg............................................. 113
ONFI -clobazam tab 5 mg............................................... 113
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
ONSOLIS -fentanyl citrate buccal soluble film 1200
mcg.................................................................................101
ONSOLIS -fentanyl citrate buccal soluble film 200
mcg.................................................................................101
ONSOLIS -fentanyl citrate buccal soluble film 400
mcg.................................................................................101
ONSOLIS -fentanyl citrate buccal soluble film 600
mcg.................................................................................101
ONSOLIS -fentanyl citrate buccal soluble film 800
mcg.................................................................................101
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 10 mg.......................................................102
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 15 mg.......................................................102
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 20 mg.......................................................102
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 30 mg.......................................................102
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 40 mg.......................................................102
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg.........................................................102
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 7.5 mg......................................................102
OPANA ER -oxymorphone hcl tab sr 12hr 10 mg........... 101
OPANA ER -oxymorphone hcl tab sr 12hr 20 mg........... 101
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
225
2014
OPANA ER -oxymorphone hcl tab sr 12hr 30 mg........... 101
OPANA ER -oxymorphone hcl tab sr 12hr 40 mg........... 102
OPANA ER -oxymorphone hcl tab sr 12hr 5 mg............. 101
OPANA -oxymorphone hcl tab 10 mg............................. 101
OPANA -oxymorphone hcl tab 5 mg............................... 101
OPIUM TINCTURE (PAREGORIC -paregoric 2
mg/5ml..............................................................................68
opium tincture 1% (10 mg/ml) (morphine equiv)...........68
OPSUMIT -macitentan tab 10 mg..................................... 58
OPTASE -trypsin w/ castor oil & peruvian balsam gel..... 157
OPTIPRANOLOL -metipranolol ophth soln 0.3%............ 143
OPTIVAR -azelastine hcl ophth soln 0.05%.................... 143
ORACEA -doxycycline (rosacea) cap delayed release 40
mg.................................................................................. 158
ORACIT -sodium citrate & citric acid soln 490-640
mg/5ml..............................................................................77
ORAFATE - sucralfate-malate paste 10% ......................146
ORALAIR - grass mixed pollen ext tab sl 300 ir (index of
reactivity) .........................................................................15
ORAMAGICRX - oral wound care products - for susp rinse
....................................................................................... 146
ORAMORPH SR -morphine sulfate tab cr 100 mg.......... 102
ORAMORPH SR -morphine sulfate tab cr 15 mg............102
ORAMORPH SR -morphine sulfate tab cr 30 mg............102
ORAMORPH SR -morphine sulfate tab cr 60 mg............102
ORAP -pimozide tab 1 mg................................................ 94
ORAP -pimozide tab 2 mg................................................ 94
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
ORAPRED -prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)........................................................ 20
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................. 146
ORAXYL -doxycycline hyclate cap 20 mg........................... 5
ORBIVAN -butalbital-acetaminophen-caffeine cap
50-300-40 mg...................................................................96
ORBIVAN CF -butalbital-acetaminophen tab 50-300
mg.................................................................................... 96
ORENCIA -abatacept subcutaneous inj 125 mg/ml.........107
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
ORFADIN -nitisinone cap 2 mg......................................... 37
ORFADIN -nitisinone cap 5 mg......................................... 37
orphenadrine citrate tab sr 12hr 100 mg..................... 117
226
ORPHENADRINE COMPOUND DS -orphenadrine w/
aspirin & caffeine tab 50-770-60 mg..............................117
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg.................................................................................. 117
ORTHO-CEPT -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg....................................................................... 25
ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg...............................................................25
ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr..............................................................25
ORTHO MICRONOR -norethindrone tab 0.35 mg.............25
ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................. 25
ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg............................................25
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg...................................25
ORTHO TRI-CYCLEN -norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg...................................25
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)..................................... 68
OSPHENA -ospemifene tab 60 mg................................... 37
OTEZLA -apremilast tab 30 mg.......................................107
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg................................................................... 107
OTICIN HC NR -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................145
OTOZIN -antipyrine-benzocaine-glycerin-zinc ace otic liqd
5.4-1-2-1%......................................................................145
OTREXUP -methotrexate soln pf auto-injector
10mg/0.4ml.....................................................................107
OTREXUP -methotrexate soln pf auto-injector
15mg/0.4ml.....................................................................107
OTREXUP -methotrexate soln pf auto-injector
20mg/0.4ml.....................................................................107
OTREXUP -methotrexate soln pf auto-injector
25mg/0.4ml.....................................................................107
OVACE PLUS -sulfacetamide sodium cream 10%..........158
OVACE PLUS -sulfacetamide sodium lotion 9.8%.......... 158
OVACE PLUS -sulfacetamide sodium shampoo 10%..... 158
OVACE PLUS WASH -sulfacetamide sodium cleansing gel
10%................................................................................ 158
OVACE PLUS WASH -sulfacetamide sodium liquid
10%................................................................................ 158
OVACE WASH -sulfacetamide sodium liquid 10%.......... 158
OVCON-35 -norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg....................................................................... 25
OVCON-50 28 -norethindrone & ethinyl estradiol tab 1
mg-50 mcg....................................................................... 25
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
OVIDE -malathion lotion 0.5%.........................................158
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)....................................107
oxazepam cap 10 mg...................................................... 78
oxazepam cap 15 mg...................................................... 78
oxazepam cap 30 mg...................................................... 78
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)....................................................................... 113
oxcarbazepine tab 150 mg (Trileptal).......................... 113
oxcarbazepine tab 300 mg (Trileptal).......................... 113
oxcarbazepine tab 600 mg (Trileptal).......................... 113
OXECTA -oxycodone hcl tab abuse deter 5 mg..............102
OXECTA -oxycodone hcl tab abuse deter 7.5 mg........... 102
OXISTAT -oxiconazole nitrate cream 1%........................ 158
OXISTAT -oxiconazole nitrate lotion 1%......................... 158
OXSORALEN -methoxsalen lotion 1%............................ 158
OXSORALEN ULTRA -methoxsalen rapid cap 10 mg.....158
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg....... 113
OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg....... 113
OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg....... 113
oxybutynin chloride syrup 5 mg/5ml............................. 75
oxybutynin chloride tab 5 mg........................................ 75
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 75
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 75
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 75
oxycodone-aspirin tab 4.8355-325 mg (Percodan)..... 102
oxycodone hcl cap 5 mg.............................................. 102
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl)........................................................... 102
OXYCODONE HCL -oxycodone hcl conc 100 mg/5ml (20
mg/ml)............................................................................ 102
OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml.........102
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)..........102
oxycodone hcl tab 10 mg............................................. 102
oxycodone hcl tab 15 mg (Roxicodone)......................102
oxycodone hcl tab 20 mg............................................. 102
oxycodone hcl tab 30 mg (Roxicodone)......................102
oxycodone hcl tab 5 mg (Roxicodone)........................102
oxycodone-ibuprofen tab 5-400 mg............................. 102
oxycodone w/ acetaminophen cap 5-500 mg.............. 102
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)......................................................................102
oxycodone w/ acetaminophen tab 10-650 mg.............102
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)......................................................................102
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)......................................................................102
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)......................................................................102
oxycodone w/ acetaminophen tab 7.5-500 mg............102
OXYCONTIN -oxycodone hcl tab er 12hr deter 10
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 15
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 20
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 30
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 40
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 60
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 80
mg.................................................................................. 103
oxymorphone hcl tab 10 mg (Opana).......................... 103
oxymorphone hcl tab 5 mg (Opana)............................ 103
oxymorphone hcl tab sr 12hr 10 mg............................103
oxymorphone hcl tab sr 12hr 15 mg............................103
oxymorphone hcl tab sr 12hr 20 mg............................103
oxymorphone hcl tab sr 12hr 30 mg............................103
oxymorphone hcl tab sr 12hr 40 mg............................103
oxymorphone hcl tab sr 12hr 5 mg............................. 103
oxymorphone hcl tab sr 12hr 7.5 mg...........................103
OXYTROL -oxybutynin td patch biweekly 3.9 mg/24hr......75
P
PACERONE -amiodarone hcl tab 400 mg.........................44
PAIRE OB -prenat w/ fe poly cmplx-fe asp-fe gly-fa tab &
dha cap pak................................................................... 123
PALGIC -carbinoxamine maleate soln 4 mg/5ml...............59
PALGIC -carbinoxamine maleate tab 4 mg....................... 59
PAMELOR -nortriptyline hcl cap 10 mg.............................82
PAMELOR -nortriptyline hcl cap 25 mg.............................82
PAMELOR -nortriptyline hcl cap 50 mg.............................82
PAMELOR -nortriptyline hcl cap 75 mg.............................82
PAMINE FORTE -methscopolamine bromide tab 5 mg.....70
PAMINE FQ -methscopolamine tab 5 mg & misc intestinal
flora reg cap.....................................................................70
PAMINE -methscopolamine bromide tab 2.5 mg...............70
PANATUSS DXP -phenylephrine-dexbromphen-dm-gg
liquid 5-1-15-100 mg/5ml................................................. 62
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
10500-25000-43750 unit.................................................. 72
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
16800-40000-70000 unit.................................................. 72
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
21000-37000-61000 unit.................................................. 72
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-10000-17500 unit.................................................... 72
PANCRELIPASE -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit.................................................... 72
PANDEL -hydrocortisone probutate cream 0.1%............ 158
PANRETIN -alitretinoin gel 0.1%.....................................158
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 70
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
227
2014
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 70
PARAFON FORTE DSC -chlorzoxazone tab 500 mg......117
PARCOPA -carbidopa & levodopa orally disintegrating tab
10-100 mg......................................................................115
PARCOPA -carbidopa & levodopa orally disintegrating tab
25-100 mg......................................................................115
PARCOPA -carbidopa & levodopa orally disintegrating tab
25-250 mg......................................................................115
paricalcitol cap 1 mcg (Zemplar)................................... 37
paricalcitol cap 2 mcg (Zemplar)................................... 37
paricalcitol cap 4 mcg (Zemplar)................................... 37
PARLODEL -bromocriptine mesylate cap 5 mg.............. 115
PARLODEL -bromocriptine mesylate tab 2.5 mg............ 116
PARNATE -tranylcypromine sulfate tab 10 mg..................82
paromomycin sulfate cap 250 mg....................................6
paroxetine hcl tab 10 mg (Paxil).................................... 82
paroxetine hcl tab 20 mg (Paxil).................................... 82
paroxetine hcl tab 30 mg (Paxil).................................... 82
paroxetine hcl tab 40 mg (Paxil).................................... 82
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 82
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 82
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 82
PASER -aminosalicylic acid cr granules packet 4 gm......... 6
PATADAY -olopatadine hcl ophth soln 0.2%...................143
PATANASE -olopatadine hcl nasal soln 0.6%...................59
PATANOL -olopatadine hcl ophth soln 0.1%...................143
PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 82
PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 82
PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 82
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)................................................................................82
PAXIL -paroxetine hcl tab 10 mg...................................... 82
PAXIL -paroxetine hcl tab 20 mg...................................... 82
PAXIL -paroxetine hcl tab 30 mg...................................... 82
PAXIL -paroxetine hcl tab 40 mg...................................... 82
PBZ -tripelennamine hcl tab 50 mg................................... 59
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 3
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 3
PEDIADERM AF COMPLETE KIT -nystatin cream 100000
unit/gm & diaper rash cream kit.....................................158
PEDIADERM HC -hydrocortisone lot 2% & emollient
cream kit........................................................................ 158
PEDIADERM TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................ 158
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.............................................................62
PEDIATEX TD -triprolidine & pseudoephedrine liquid
0.938-10 mg/ml................................................................ 62
228
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml
....................................................................................... 119
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg .................................................................................119
pediatric multiple vitamins w/ fluoride chew tab 0.5 mg
....................................................................................... 119
pediatric multiple vitamins w/ fluoride chew tab 1 mg
....................................................................................... 119
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
....................................................................................... 119
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml
....................................................................................... 119
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml
....................................................................................... 119
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ..... 119
PEDIPIROX-4 NAIL -ciclopirox soln 8% & lacquer removal
pads & foot powd kit......................................................158
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely).........................................................................68
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)......................................................68
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).....................................................68
PEGANONE -ethotoin tab 250 mg.................................. 113
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml........... 9
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml................ 9
PEGASYS -peginterferon alfa-2a inj kit 180 mcg/0.5ml.......9
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml...........................................................................9
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 150
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml...........................................................................9
PEG-INTRON -peginterferon alfa-2b for inj kit 80
mcg/0.5ml...........................................................................9
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
penicillin v potassium for soln 125 mg/5ml.................... 1
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%.......... 158
PENNSAID -diclofenac sodium soln 1.5%.......................158
PENNSAID -diclofenac sodium soln 2%......................... 158
PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp................................................................ 15
PENTASA -mesalamine cap cr 250 mg............................ 73
PENTASA -mesalamine cap cr 500 mg............................ 73
pentazocine-acetaminophen tab 25-650 mg................103
pentazocine w/ naloxone tab 50-0.5 mg...................... 103
PENTETATE CALCIUM TRISODI -pentetate calcium
trisodium iv or inhalation soln 200 mg/ml.......................165
PENTETATE ZINC TRISODIUM -pentetate zinc trisodium
iv or inhalation soln 200 mg/ml......................................165
pentoxifylline tab cr 400 mg......................................... 139
PEPCID -famotidine for susp 40 mg/5ml...........................70
PEPCID -famotidine tab 40 mg......................................... 70
PERCOCET -oxycodone w/ acetaminophen tab 10-325
mg.................................................................................. 103
PERCOCET -oxycodone w/ acetaminophen tab 10-650
mg.................................................................................. 103
PERCOCET -oxycodone w/ acetaminophen tab 2.5-325
mg.................................................................................. 103
PERCOCET -oxycodone w/ acetaminophen tab 5-325
mg.................................................................................. 103
PERCOCET -oxycodone w/ acetaminophen tab 7.5-325
mg.................................................................................. 103
PERCOCET -oxycodone w/ acetaminophen tab 7.5-500
mg.................................................................................. 103
PERCODAN -oxycodone-aspirin tab 4.8355-325 mg...... 103
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml............................................................................66
PERIDEX -chlorhexidine gluconate soln 0.12%.............. 146
perindopril erbumine tab 2 mg.......................................50
perindopril erbumine tab 4 mg (Aceon)........................ 50
perindopril erbumine tab 8 mg (Aceon)........................ 50
permethrin cream 5% (Elimite).....................................158
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................. 94
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................. 94
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................. 94
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................. 94
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................. 94
perphenazine tab 16 mg................................................. 85
perphenazine tab 2 mg................................................... 85
perphenazine tab 4 mg................................................... 85
perphenazine tab 8 mg................................................... 85
PERSANTINE -dipyridamole tab 25 mg.......................... 139
PERSANTINE -dipyridamole tab 50 mg.......................... 139
PERSANTINE -dipyridamole tab 75 mg.......................... 139
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit.................................................. 72
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit.................................................... 72
PEXEVA -paroxetine mesylate tab 10 mg (base equiv).....82
PEXEVA -paroxetine mesylate tab 20 mg (base equiv).....82
PEXEVA -paroxetine mesylate tab 30 mg (base equiv).....82
PEXEVA -paroxetine mesylate tab 40 mg (base equiv).....82
phenazopyridine-butabarbital-hyoscyamine tab
150-15-0.3 mg................................................................. 75
phenazopyridine hcl tab 100 mg (Pyridium)................. 77
phenazopyridine hcl tab 200 mg (Pyridium)................. 77
phenelzine sulfate tab 15 mg (Nardil)............................ 82
PHENFLU CD -phenylephrine-codeine-guaifenesin-apap
tab 10-10-400-500 mg..................................................... 62
PHENFLU CDX -phenylephrine-codeine-guaifenesin-apap
tab 10-20-400-500 mg..................................................... 62
phenobarbital elixir 20 mg/5ml.......................................87
PHENOBARBITAL -phenobarbital tab 100 mg..................87
PHENOBARBITAL -phenobarbital tab 15 mg....................87
PHENOBARBITAL -phenobarbital tab 30 mg....................87
PHENOBARBITAL -phenobarbital tab 60 mg....................87
PHENOBARBITAL -phenobarbital tab 64.8 mg.................87
PHENOBARBITAL -phenobarbital tab 97.2 mg.................87
phenobarbital tab 100 mg...............................................87
phenobarbital tab 15 mg.................................................87
phenobarbital tab 16.2 mg..............................................87
phenobarbital tab 30 mg.................................................87
phenobarbital tab 32.4 mg..............................................87
phenobarbital tab 60 mg.................................................87
phenylephrine-brompheniramine-dm liquid 7.5-4-15
mg/5ml.............................................................................62
phenylephrine-bromphen w/ codeine liqd 7.5-4-10
mg/5ml.............................................................................62
phenylephrine-chlorphen-dm liquid 1.5-1-3 mg/ml.......62
phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20
mg/ml)..............................................................................62
phenylephrine hcl ophth soln 10%.............................. 143
phenylephrine hcl ophth soln 2.5% (Mydfrin)............. 143
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml............................................................ 62
phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml........... 62
phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml........... 62
phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml................ 62
phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............. 62
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................. 62
phenyltoloxamine-acetaminophen tab 30-500 mg........ 96
phenyltoloxamine-acetaminophen tab 50-500 mg........ 96
phenyltoloxamine-acetaminophen tab 55-500 mg........ 96
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 113
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
229
2014
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 113
phenytoin chew tab 50 mg (Dilantin infatabs)............ 113
phenytoin sodium extended cap 100 mg
(Dilantin)........................................................................113
phenytoin sodium extended cap 200 mg
(Phenytek)..................................................................... 113
phenytoin sodium extended cap 300 mg
(Phenytek)..................................................................... 113
phenytoin susp 125 mg/5ml (Dilantin)......................... 113
PHISOHEX -hexachlorophene liq 3%..............................165
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse
0.044%........................................................................... 146
PHOS FLUR -sodium fluoride rinse 0.044%....................146
PHOSLO -calcium acetate (phosphate binder) cap 667 mg
(169 mg ca)..................................................................... 73
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml...................................................................... 73
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%................................................................... 143
PHRENILIN FORTE -butalbital-acetaminophen cap 50-650
mg.................................................................................... 96
PHYSICIANS EZ USE FLU KIT -influenza virus vaccine
types a & b surface antigen inj kit................................... 14
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)....................... 118
PICATO -ingenol mebutate gel 0.015%.......................... 158
PICATO -ingenol mebutate gel 0.05%............................ 158
PICO SINGLE USE NEGATIVE - wound dressings - kit
....................................................................................... 158
pilocarpine hcl ophth soln 1% (Isopto carpine).......... 143
pilocarpine hcl ophth soln 2% (Isopto carpine).......... 143
pilocarpine hcl ophth soln 4% (Isopto carpine).......... 143
pilocarpine hcl tab 5 mg (Salagen).............................. 146
pilocarpine hcl tab 7.5 mg (Salagen)........................... 146
PILOPINE HS -pilocarpine hcl ophth gel 4%...................143
pindolol tab 10 mg.......................................................... 40
pindolol tab 5 mg............................................................ 40
PINNACAINE OTIC -benzocaine otic soln 20%.............. 145
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)....................................107
piroxicam cap 20 mg (Feldene)....................................107
PKU EASY MICROTABS - nutritional supplement tabs
delayed release ............................................................ 132
PLAN B -levonorgestrel tab 0.75 mg.................................25
PLAN B ONE-STEP -levonorgestrel tab 1.5 mg................25
230
PLAQUENIL -hydroxychloroquine sulfate tab 200 mg....... 11
PLAVIX -clopidogrel bisulfate tab 300 mg (base
equiv)..............................................................................139
PLAVIX -clopidogrel bisulfate tab 75 mg (base equiv).....139
PLETAL -cilostazol tab 100 mg....................................... 139
PLETAL -cilostazol tab 50 mg......................................... 139
PLEXION CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%.......................................................... 158
PLEXION CLEANSING CLOTHS -sulfacetamide sodium
w/ sulfur cleansing cloth 9.8-4.8%................................. 158
PLEXION -sulfacetamide sodium w/ sulfur cream
9.8-4.8%......................................................................... 158
PLEXION -sulfacetamide sodium w/ sulfur lotion
9.8-4.8%......................................................................... 158
PLIAGLIS -lidocaine-tetracaine cream 7-7%................... 158
PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................. 14
PNEUMOVAX 23/5 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................. 15
PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj 25
mcg/0.5ml.........................................................................14
PNV-DHA+DOCUSATE - prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg .......................................... 123
PNV-DHA - prenat w/o a w/ fe fum-methylfol-fa-dha cap
27-0.6-0.4 mg ............................................................... 123
PNV FERROUS FUMARATE/DOCU - prenatal vit w/ dssfe fumarate-fa tab 29-1 mg ...........................................123
PNV-FIRST - prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg ................................................................. 123
PNV FOLIC ACID + IRON MUL - prenatal vit w/ fe
fumarate-fa tab 27-1 mg ...............................................123
PNV-OB/DHA -prenatal mv w/fe fum-fa tab 65-1 mg & dha
cap 250 mg pack ..........................................................123
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack........................................................... 123
PNV-OMEGA - prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap ............................................................ 123
PNV PRENATAL PLUS MULTIVI - prenatal vit w/ fe
fumarate-fa tab 27-1 mg ...............................................123
PNV-SELECT - prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg ............................................................... 123
PNV TABS 29-1 - prenatal vit w/ iron carbonyl-fa tab 29-1
mg ................................................................................. 123
PNV-TOTAL - prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg .................................................................. 123
PODIAPN - l-methylfolate-b12-b6-alpha lipoic ac cap
5-2-35-300 mg .............................................................. 132
PODOCON 25 IN BENZOIN TIN -podophyllum resin soln
25%................................................................................ 158
podofilox soln 0.5% (Condylox)................................... 158
polyethylene glycol 3350 oral packet............................ 68
polyethylene glycol 3350 oral powder...........................68
POLY HIST DHC -phenylephrine-pyrilamine-dihydrocod
liqd 5-7.5-7.5 mg/5ml....................................................... 62
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POLY HIST NC -pseudoephedrine-triprolidine w/ cod liquid
15-1.25-10 mg/5ml...........................................................62
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)........................................................143
POLYTRIM -polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%................................................................... 143
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liqd 7.5-4-10 mg/5ml........................................................ 62
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liquid 10-4-10 mg/5ml...................................................... 62
POLY-TUSSIN -codeine-chlorcyclizine liquid 10-9.375
mg/5ml..............................................................................62
POLY-TUSSIN D -codeine-pseudoephedrinechlorcyclizine liq 10-30-9.375mg/5ml............................... 62
POLY-TUSSIN DHC -phenylephrine-bromphendihydrocodeine liqd 7.5-4-3 mg/5ml.................................63
POLY-TUSSIN EX -phenylephrine-dihydrocodeine-gg
syrup 5-7.5-50 mg/5ml.....................................................63
POLY-VI-FLOR/IRON - ped multiple vitamin w/ fl-fe
biphasic susp 0.25-7 mg/ml ..........................................123
POLY-VI-FLOR/IRON - ped multiple vit w/ fl-fe biphasic
chew tab 0.5-10 mg ......................................................123
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew
tab 0.25 mg .................................................................. 123
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew
tab 0.5 mg .................................................................... 123
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew
tab 1 mg ....................................................................... 123
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic susp
0.25 mg/ml ....................................................................123
POMALYST -pomalidomide cap 1 mg...............................17
POMALYST -pomalidomide cap 2 mg...............................17
POMALYST -pomalidomide cap 3 mg...............................17
POMALYST -pomalidomide cap 4 mg...............................17
PONSTEL -mefenamic acid cap 250 mg.........................107
PONTOCAINE -tetracaine hcl soln 2%........................... 158
POTABA -potassium aminobenzoate cap 500 mg.......... 118
POTABA -potassium aminobenzoate tab 500 mg........... 118
potassium bicarbonate effer tab 25 meq.....................129
potassium chloride cap cr 10 meq (Micro-k)...............129
potassium chloride cap cr 8 meq (Micro-k).................130
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)......................................................... 130
potassium chloride microencapsulated crys cr tab 10
meq................................................................................ 130
potassium chloride microencapsulated crys cr tab 20
meq................................................................................ 130
potassium chloride oral liq 10% (20 meq/15ml).......... 130
potassium chloride oral liq 20% (40 meq/15ml).......... 130
potassium chloride powder packet 20 meq................ 130
potassium chloride tab cr 10 meq (K-tab)................... 130
potassium chloride tab cr 8 meq (600 mg)..................130
potassium citrate & citric acid powder pack 3300-1002
mg.................................................................................... 77
POTASSIUM CITRATE ER -potassium citrate tab cr 15
meq (1620 mg)................................................................ 77
POTASSIUM CITRATE -potassium citrate tab cr 10 meq
(1080 mg).........................................................................77
POTASSIUM CITRATE -potassium citrate tab cr 5 meq
(540 mg)...........................................................................77
pot bicarbonate & chloride effer tab 25 meq...............129
POTIGA -ezogabine tab 200 mg..................................... 113
POTIGA -ezogabine tab 300 mg..................................... 113
POTIGA -ezogabine tab 400 mg..................................... 113
POTIGA -ezogabine tab 50 mg....................................... 113
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)................................ 129
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)......................................................... 137
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)......................................................... 137
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)....................................................................... 116
pramipexole dihydrochloride tab 0.25 mg
(Mirapex)....................................................................... 116
pramipexole dihydrochloride tab 0.5 mg
(Mirapex)....................................................................... 116
pramipexole dihydrochloride tab 0.75 mg
(Mirapex)....................................................................... 116
pramipexole dihydrochloride tab 1.5 mg
(Mirapex)....................................................................... 116
pramipexole dihydrochloride tab 1 mg (Mirapex)....... 116
PRAMOSONE E -pramoxine-hc emollient base cream
1-2.5%............................................................................ 158
PRAMOSONE -pramoxine-hc cream 1-1%..................... 158
PRAMOSONE -pramoxine-hc cream 1-2.5%.................. 158
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 158
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 158
PRAMOSONE -pramoxine-hc oint 1-1%......................... 158
PRAMOSONE -pramoxine-hc oint 1-2.5%...................... 158
PRAMOTIC -pramoxine-chloroxylenol otic liquid
1-0.1%............................................................................ 145
pramoxine-chloroxylenol otic liquid 1-0.1%
(Pramotic)......................................................................145
pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1
mg/ml (Cortane-b aqueous)........................................ 145
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
(Cortane-b-otic)............................................................ 145
pramoxine-hc cream 1-2.5% (Pramosone).................. 158
pramoxine hcl gel 1%....................................................158
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
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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pravastatin sodium tab 20 mg (Pravachol)................... 56
pravastatin sodium tab 40 mg (Pravachol)................... 56
pravastatin sodium tab 80 mg (Pravachol)................... 56
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 ............ 158
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%......143
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%............................................................................ 143
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%......................................................................... 143
PRED MILD -prednisolone acetate ophth susp
0.12%............................................................................. 143
prednicarbate cream 0.1% (Dermatop)........................ 158
prednicarbate oint 0.1% (Dermatop)............................ 159
prednisolone acetate ophth susp 1% (Pred forte)...... 143
PREDNISOLONE SODIUM PHOSP -prednisolone sodium
phosphate ophth soln 1%.............................................. 144
PREDNISOLONE SODIUM PHOSP -prednisolone sodium
phosphate oral soln 25 mg/5ml (base eq)....................... 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)......................................................20
PREDNISONE INTENSOL -prednisone conc 5 mg/ml...... 20
PREDNISONE -prednisone oral soln 5 mg/5ml.................20
PREDNISONE -prednisone tab 10 mg dose pack.............20
PREDNISONE -prednisone tab 50 mg..............................20
PREDNISONE -prednisone tab 5 mg dose pack...............20
prednisone tab 10 mg..................................................... 20
prednisone tab 10 mg dose pack.................................. 20
prednisone tab 1 mg....................................................... 20
prednisone tab 2.5 mg.................................................... 20
prednisone tab 20 mg..................................................... 20
prednisone tab 5 mg....................................................... 20
prednisone tab 5 mg dose pack.................................... 20
PREFERA OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................. 123
PREFERAOB ONE - prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg ................................................ 123
PREFERA OB - prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg ............................................................... 123
PREFERRED PLUS GLUCOSE -glucose chew tab 4
gm.................................................................................... 30
PREFERRED PLUS GLUCOSE -glucose-vitamin c chew
tab 4-0.006 gm................................................................ 30
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab
1-0.09mg(15)....................................................................23
232
PREFOL-DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 26-1.2-300 mg ....................................................... 123
PRE-FOLIC -folic acid-vitamin c tab 1-100 mg................135
PRELONE -prednisolone syrup 15 mg/5ml (usp solution
equivalent)........................................................................20
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.............. 23
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 76
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14)........................................................... 23
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.3-1.5 mg................................................................. 23
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.45-1.5 mg............................................................... 23
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.625-2.5 mg..............................................................23
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.625-5 mg................................................................ 23
PRENA1/QUATREFOLIC - prenat w/o a w/ fe fummethylfol-fa-dha cap 30-0.6-0.4 mg ..............................125
PRENA1 CHEW/QUATREFOLIC - prenat w/ b2-b6-b12d3-methylfol-fa chew tab 0.6-0.4 mg ............................ 125
PRENA1 CHEW - prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg .................................................................... 125
PRENA1 PEARL - prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg ................................................... 125
PRENA1 PLUS/QUATREFOLIC -prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk......................... 125
PRENAISSANCE 90 DHA -prenat w/o a w/fecbn-fegl-dssfa tab 90 &dha cap 300mg pak..................................... 124
PRENAISSANCE BALANCE - prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg ........................................ 124
PRENAISSANCE DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 250 mg pack.......................................... 124
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg......................124
PRENAISSANCE NEXT-B - prenatal w/ calcium-vit b6-faginger tab 1.22 mg ....................................................... 124
PRENAISSANCE NEXT - prenatal w/ calcium-vit b6-faginger tab 1.2 mg ......................................................... 124
PRENAISSANCE PLUS - prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg ................................................... 124
PRENAISSANCE - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg ..................................................... 124
PRENAISSANCE PROMISE -prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack................................124
PRENAPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 124
PRENATABS FA - prenatal vit w/ fe fumarate-fa tab 29-1
mg ................................................................................. 124
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PRENATABS OBN - prenatal w/o a vit w/ fe carbonyl-fa
tab 29-1 mg .................................................................. 124
PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1
mg ................................................................................. 124
PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg ................................................................................. 124
PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ........................................................................ 124
PRENATAL AD - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 124
PRENATAL LOW IRON - prenatal vit w/ fe fumarate-fa tab
27-1 mg ........................................................................ 124
PRENATAL MV & MIN/FE-FA-D -prenat-fe poly cmplx-fe
hem poly-fa-dha cap 11-3-0.5-100mg............................124
PRENATAL PLUS IRON - prenatal vit w/ iron carbonyl-fa
tab 29-1 mg .................................................................. 124
PRENATAL PLUS - prenatal vit w/ fe fumarate-fa tab 27-1
mg ................................................................................. 124
PRENATAL - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 124
PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg ................................................................... 124
PRENATAL VITAMINS PLUS - prenatal vit w/ fe fumaratefa tab 27-1 mg ..............................................................124
PRENATA - prenatal w/o a vit w/ fe fum-fa tab chew 29-1
mg ................................................................................. 124
PRENATE AM - prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg ............................................................ 124
PRENATE DHA - prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg ................................................. 124
PRENATE DHA - prenat w/o a w/ fe fum-methylfol-fa-dha
cap 28-0.6-0.4 mg ........................................................ 124
PRENATE ELITE - prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg ......................................................... 124
PRENATE ELITE - prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg ............................................................... 124
PRENATE ENHANCE - prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg .......................................... 124
PRENATE ESSENTIAL - prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg ...................................... 124
PRENATE ESSENTIAL - prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg ....................................... 124
PRENATE MINI - prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg ........................................................ 124
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg......................................................................124
PRENATE RESTORE - prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg .......................................... 125
PRENATE STAR - prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg .................................................................. 125
PRENEXA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg ............................................................ 125
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm.............34
PREPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 125
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm............................................................ 68
PREQUE 10 - prenatal mv w/fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg ........................................................... 125
PRESERA - emollient - aerosol foam .............................159
PRETAB - prenatal vit w/ fe fumarate-fa tab 29-1 mg .....125
PREVACID -lansoprazole cap delayed release 15 mg...... 70
PREVACID -lansoprazole cap delayed release 30 mg...... 70
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 15 mg...............................................70
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 30 mg...............................................70
PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
1.1%............................................................................... 147
PREVIDENT 5000 BOOSTER -sodium fluoride paste
1.1%............................................................................... 147
PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
1.1% (0.5% f)................................................................. 147
PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%..................................... 147
PREVIDENT 5000 PLUS -sodium fluoride cream
1.1%............................................................................... 147
PREVIDENT 5000 SENSITIVE -sodium fluoride-potassium
nitrate paste 1.1-5%.......................................................147
PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
f)..................................................................................... 147
PREVIDENT -sodium fluoride rinse 0.2%........................146
PREVNAR 13 -pneumococcal 13-valent conjugate vaccine
inj......................................................................................15
PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack.................................................................... 70
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)..................................................................................9
PREZISTA -darunavir ethanolate tab 150 mg (base
equiv)..................................................................................9
PREZISTA -darunavir ethanolate tab 400 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........70
PRILOSEC -omeprazole cap delayed release 20 mg........70
PRILOSEC -omeprazole cap delayed release 40 mg........70
PRILOSEC -omeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 71
PRILOSEC -omeprazole magnesium for delayed release
susp packet 2.5 mg......................................................... 71
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg............................................................................ 11
primidone tab 250 mg (Mysoline).................................113
primidone tab 50 mg (Mysoline).................................. 113
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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PRIMLEV -oxycodone w/ acetaminophen tab 10-300
mg.................................................................................. 103
PRIMLEV -oxycodone w/ acetaminophen tab 5-300
mg.................................................................................. 103
PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300
mg.................................................................................. 103
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
PRINZIDE -lisinopril & hydrochlorothiazide tab 20-12.5
mg.................................................................................... 50
PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg
(base equiv)..................................................................... 82
PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg
(base equiv)..................................................................... 82
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk.................................................... 123
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk......................................................123
PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk.................................................... 123
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk......................................................123
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)......................................................... 66
probenecid tab 500 mg................................................. 109
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..............................................................................91
prochlorperazine maleate tab 10 mg (Compazine)....... 85
prochlorperazine maleate tab 5 mg (Compazine)......... 85
prochlorperazine suppos 25 mg.................................... 85
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33
mg/5ml..............................................................................63
PROCORT -hydrocortisone acetate w/ pramoxine rectal
cream 1.85-1.15%..........................................................148
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 135
PROCRIT -epoetin alfa inj 20000 unit/ml........................ 135
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 135
PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 135
PROCRIT -epoetin alfa inj 40000 unit/ml........................ 135
PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 135
PROCTOCORT -hydrocortisone acetate suppos 30
mg.................................................................................. 148
PROCTOCORT -hydrocortisone rectal cream 1%...........148
234
PROCTOFOAM HC -hydrocortisone acetate w/ pramoxine
rectal foam 1-1%............................................................148
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv)............................................................... 77
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv)............................................................... 77
PRODRIN -acetaminophen-isometheptene-caffeine tab
325-65-20 mg.................................................................108
PRODRIN -acetaminophen-isometheptene-caffeine tab
500-130-20 mg...............................................................108
PROFERRIN-FORTE -iron heme polypeptide-folic acid tab
12-1 mg (fe equiv)......................................................... 135
PROFILNINE SD -factor ix complex for inj 1000 unit.......139
PROFILNINE SD -factor ix complex for inj 1500 unit.......139
PROFILNINE SD -factor ix complex for inj 500 unit.........139
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..........................30
PROGRAF -tacrolimus cap 0.5 mg................................. 166
PROGRAF -tacrolimus cap 1 mg.................................... 166
PROGRAF -tacrolimus cap 5 mg.................................... 166
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)......................................................................144
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)..............................................................................135
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)..............................................................................135
PROMACTA -eltrombopag olamine tab 50 mg (base
equiv)..............................................................................135
PROMACTA -eltrombopag olamine tab 75 mg (base
equiv)..............................................................................135
PROMAR -iron & b12 w/ vitamin cap.............................. 125
promethazine & phenylephrine syrup 6.25-5
mg/5ml.............................................................................63
promethazine-dm syrup 6.25-15 mg/5ml....................... 63
promethazine hcl suppos 12.5 mg.................................59
promethazine hcl suppos 25 mg....................................59
promethazine hcl suppos 50 mg....................................59
promethazine hcl syrup 6.25 mg/5ml.............................59
promethazine hcl tab 12.5 mg........................................ 59
promethazine hcl tab 25 mg...........................................59
promethazine hcl tab 50 mg........................................... 59
PROMETHAZINE VC/CODEINE -phenylephrinepromethazine w/ codeine syrup 5-6.25-10 mg/5ml.......... 63
PROMETHAZINE VC PLAIN -promethazine &
phenylephrine syrup 6.25-5 mg/5ml.................................63
promethazine w/ codeine syrup 6.25-10 mg/5ml...........63
PROMETRIUM -progesterone micronized cap 100 mg..... 26
PROMETRIUM -progesterone micronized cap 200 mg..... 26
PROMISEB - antiseborrheic products misc - cream ....... 159
PROMISEB COMPLETE - antiseborrheic products misc kit .................................................................................. 159
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
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)....... 44
propafenone hcl tab 150 mg (Rythmol)......................... 44
propafenone hcl tab 225 mg (Rythmol)......................... 44
propafenone hcl tab 300 mg.......................................... 44
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg............................................................................... 71
proparacaine hcl ophth soln 0.5% (Alcaine)............... 144
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..............................................................................40
PROPRANOLOL HCL -propranolol hcl oral soln 40
mg/5ml..............................................................................40
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............................................. 33
PRO-RED AC -phenylephrine-dexchlorphenir-codeine
syrup 5-1-9 mg/5ml..........................................................63
PRO-RED AC -phenylephrine-pyrilamine w/ codeine syrup
5-8.33-9 mg/5ml...............................................................63
PROSCAR -finasteride tab 5 mg.......................................77
PROSED/DS -methenamine-hyosc-meth blue-benz acidphenyl sal tab 81.6mg..................................................... 74
PROSTIGMIN -neostigmine bromide tab 15 mg............. 118
PROSTIN E2 -dinoprostone vaginal suppos 20 mg...........34
PROTECTBONE -multiple vit w/ min & calcium-folic acid
wafer 500-1 mg..............................................................125
PROTECTIRON -iron polysacch-fa-b complex-vit c-e &
minerals tab 60-1 mg.....................................................135
PROTECTNATAL - prenatal vit w/poly fe-fa-fish oil tab dr
13.5-0.5-700 mg ........................................................... 125
PROTHELIAL - sucralfate-malate paste 10% .................147
PROTID -chlorphen-phenylephrine w/ apap tab cr
8-40-500 mg.....................................................................63
PROTONIX -pantoprazole sodium ec tab 20 mg (base
equiv)................................................................................71
PROTONIX -pantoprazole sodium ec tab 40 mg (base
equiv)................................................................................71
PROTONIX -pantoprazole sodium for delayed release
susp packet 40 mg.......................................................... 71
PROTOPIC -tacrolimus oint 0.03%................................. 159
PROTOPIC -tacrolimus oint 0.1%................................... 159
protriptyline hcl tab 10 mg (Vivactil)............................. 82
protriptyline hcl tab 5 mg (Vivactil)............................... 82
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)......................................................... 66
PROVERA -medroxyprogesterone acetate tab 10 mg...... 26
PROVERA -medroxyprogesterone acetate tab 2.5 mg......26
PROVERA -medroxyprogesterone acetate tab 5 mg........ 26
PROVIDA OB - prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg .............................................................. 125
PROVIGIL -modafinil tab 100 mg......................................91
PROVIGIL -modafinil tab 200 mg......................................91
PROZAC -fluoxetine hcl cap 10 mg.................................. 82
PROZAC -fluoxetine hcl cap 20 mg.................................. 82
PROZAC -fluoxetine hcl cap 40 mg.................................. 82
PROZAC WEEKLY -fluoxetine hcl cap delayed release 90
mg.................................................................................... 82
PRUCLAIR - emollient - cream ...................................... 159
PRUDOXIN -doxepin hcl cream 5%................................ 159
PRUMYX - emollient - cream ......................................... 159
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro)........................................................... 63
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml.....63
pseudoephedrine-bromphen-codeine liq 10-1.33-6.33
mg/5ml.............................................................................63
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml.............................................................................63
pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml
(Suttar-sf)........................................................................ 63
PULMICORT -budesonide inhalation susp 0.25
mg/2ml..............................................................................66
PULMICORT -budesonide inhalation susp 0.5 mg/2ml..... 66
PULMICORT -budesonide inhalation susp 1 mg/2ml........ 66
PULMICORT FLEXHALER -budesonide inhal aero powd
180 mcg/act (breath activated)........................................ 66
PULMICORT FLEXHALER -budesonide inhal aero powd
90 mcg/act (breath activated).......................................... 66
PULMOZYME -dornase alfa inhal soln 1 mg/ml................ 67
PUREFE OB PLUS - prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg ......................................................125
PUREFE PLUS - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 135
PURINETHOL -mercaptopurine tab 50 mg....................... 17
PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/
ml).................................................................................... 17
PX GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 30
PYLERA -bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg...............................................................71
pyrazinamide tab 500 mg..................................................6
PYRIDIUM -phenazopyridine hcl tab 100 mg.................... 77
PYRIDIUM -phenazopyridine hcl tab 200 mg.................... 77
pyridostigmine bromide tab 60 mg (Mestinon)........... 118
PYROGALLIC ACID -pyrogallol-chlorobutanol oint
25-2%............................................................................. 159
Q
QNASL -beclomethasone dipropionate nasal aerosol 80
mcg/act.............................................................................59
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
235
2014
Q-TABS -levomefolate glucosamine tab 1 mg (folate
equivalent)......................................................................132
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.................................. 87
QUDEXY XR -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 113
QUDEXY XR -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 113
QUDEXY XR -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 113
QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg..... 113
QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg..... 113
QUESTRAN -cholestyramine powder 4 gm/dose.............. 56
QUESTRAN -cholestyramine powder packets 4 gm......... 56
QUESTRAN LIGHT -cholestyramine light powder 4 gm/
dose..................................................................................56
QUESTRAN LIGHT -cholestyramine light powder packets
4 gm................................................................................. 56
quetiapine fumarate tab 100 mg (Seroquel).................. 85
quetiapine fumarate tab 200 mg (Seroquel).................. 85
quetiapine fumarate tab 25 mg (Seroquel).................... 85
quetiapine fumarate tab 300 mg (Seroquel).................. 85
quetiapine fumarate tab 400 mg (Seroquel).................. 85
quetiapine fumarate tab 50 mg (Seroquel).................... 86
QUFLORA PEDIATRIC - pediatric multiple vitamins w/
fluoride chew tab 0.25 mg ............................................ 125
QUFLORA PEDIATRIC - pediatric multiple vitamins w/
fluoride chew tab 0.5 mg .............................................. 125
QUFLORA PEDIATRIC - pediatric multiple vitamins w/
fluoride chew tab 1 mg ................................................. 125
QUFLORA PEDIATRIC - pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml ............................................... 125
QUFLORA PEDIATRIC - pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml ................................................. 125
QUILLIVANT XR -methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml).............................................................91
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
quinidine gluconate tab cr 324 mg................................ 44
QUINIDINE SULFATE ER -quinidine sulfate tab cr 300
mg.................................................................................... 44
QUINIDINE SULFATE -quinidine sulfate tab 200 mg........ 44
quinidine sulfate tab 200 mg.......................................... 44
quinidine sulfate tab 300 mg.......................................... 45
quinine sulfate cap 324 mg (Qualaquin)........................11
236
QUINZYME -coenzyme q10 tab disp 90 mg................... 165
QUIXIN -levofloxacin ophth soln 0.5%............................ 144
QUTENZA -capsaicin patch 8% & cleansing gel kit.........159
QVAR -beclomethasone dipropionate inhal aero soln 40
mcg/act.............................................................................66
QVAR -beclomethasone dipropionate inhal aero soln 80
mcg/act.............................................................................66
R
RABAVERT -rabies vaccine, pcec for inj...........................15
rabeprazole sodium ec tab 20 mg (Aciphex).................71
RADIOGARDASE -prussian blue insoluble cap 0.5
gm.................................................................................. 165
RA GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 30
RAGWITEK -short ragweed pollen allergen extract tab sl
12 amb a 1-u................................................................... 15
raloxifene hcl tab 60 mg (Evista)................................... 37
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........................39
RANEXA -ranolazine tab sr 12hr 500 mg..........................39
ranitidine hcl cap 150 mg............................................... 71
ranitidine hcl cap 300 mg............................................... 71
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)....................71
ranitidine hcl tab 300 mg (Zantac)................................. 71
RAPAFLO -silodosin cap 4 mg......................................... 77
RAPAFLO -silodosin cap 8 mg......................................... 77
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 167
RAPAMUNE -sirolimus tab 0.5 mg..................................166
RAPAMUNE -sirolimus tab 1 mg.....................................166
RAPAMUNE -sirolimus tab 2 mg.....................................166
RASUVO -methotrexate soln pf auto-injector 10
mg/0.2ml.........................................................................107
RASUVO -methotrexate soln pf auto-injector 12.5
mg/0.25ml.......................................................................107
RASUVO -methotrexate soln pf auto-injector 15
mg/0.3ml.........................................................................107
RASUVO -methotrexate soln pf auto-injector 17.5
mg/0.35ml.......................................................................107
RASUVO -methotrexate soln pf auto-injector 20
mg/0.4ml.........................................................................107
RASUVO -methotrexate soln pf auto-injector 22.5
mg/0.45ml.......................................................................107
RASUVO -methotrexate soln pf auto-injector 25
mg/0.5ml.........................................................................107
RASUVO -methotrexate soln pf auto-injector 27.5
mg/0.55ml.......................................................................107
RASUVO -methotrexate soln pf auto-injector 30
mg/0.6ml.........................................................................107
RASUVO -methotrexate soln pf auto-injector 7.5
mg/0.15ml.......................................................................107
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml........... 37
RAYOS -prednisone tab delayed release 1 mg.................20
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
RAYOS -prednisone tab delayed release 2 mg.................20
RAYOS -prednisone tab delayed release 5 mg.................20
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
16 mg............................................................................... 94
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
24 mg............................................................................... 94
RAZADYNE ER -galantamine hydrobromide cap sr 24hr 8
mg.................................................................................... 94
RAZADYNE -galantamine hydrobromide oral soln 4 mg/
ml......................................................................................94
RAZADYNE -galantamine hydrobromide tab 12 mg..........94
RAZADYNE -galantamine hydrobromide tab 4 mg............94
RAZADYNE -galantamine hydrobromide tab 8 mg............94
REACH KIDS -sodium fluoride paste 0.15%................... 147
REAPHIRM - prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg ................................................................. 125
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).............................................................................94
REBIF -interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88
mcg/ml).............................................................................94
REBIF REBIDOSE -interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml).....................................................94
REBIF REBIDOSE -interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml).....................................................94
REBIF REBIDOSE TITRATION -interferon beta-1a inj 6 x
8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml.................................. 94
REBIF TITRATION PACK -interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml........................................ 94
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1241-1800 unit.......................................................... 140
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1801-2400 unit.......................................................... 140
RECOMBINATE -antihemophilic factor (recombinant) for
inj 220-400 unit.............................................................. 139
RECOMBINATE -antihemophilic factor (recombinant) for
inj 401-800 unit.............................................................. 139
RECOMBINATE -antihemophilic factor (recombinant) for
inj 801-1240 unit............................................................ 140
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%......................................148
REGENECARE -lidocaine hcl-collagen-aloe vera gel
2%.................................................................................. 159
REGLAN -metoclopramide hcl tab 10 mg......................... 73
REGLAN -metoclopramide hcl tab 5 mg........................... 73
REGRANEX -becaplermin gel 0.01%..............................159
RELAGARD -acetic acid-oxyquinoline vaginal gel
0.9-0.025%....................................................................... 76
RELAGESIC -phenyltoloxamine-acetaminophen tab
50-650 mg........................................................................96
RELAMINE - glucosamine-chondroitin-paba-vit e-alpha
lipoic acid tab ................................................................165
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister.........................................................9
RELHIST -bromphen tan-phenyleph tan chew tab 6-15
mg.................................................................................... 63
RELION GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
RELION R -insulin regular (human) inj 100 unit/ml............31
RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml (20
mg/ml).............................................................................. 74
RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 74
RELISTOR -methylnaltrexone bromide inj kit 12
mg/0.6ml...........................................................................74
RELNATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg ................................................................. 125
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)......................................................................108
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)......................................................................109
REMBRANDT DEEPLY WHITE+PE -sodium
monofluorophosphate paste 0.884%............................. 147
REMBRANDT INTENSE STAIN -sodium fluoride paste
0.243%........................................................................... 147
REMBRANDT WHITENING -sodium fluoride rinse
0.02%............................................................................. 147
REMERON -mirtazapine tab 15 mg.................................. 82
REMERON -mirtazapine tab 30 mg.................................. 82
REMERON -mirtazapine tab 45 mg.................................. 82
REMERON SOLTAB -mirtazapine orally disintegrating tab
15 mg............................................................................... 82
REMERON SOLTAB -mirtazapine orally disintegrating tab
30 mg............................................................................... 82
REMERON SOLTAB -mirtazapine orally disintegrating tab
45 mg............................................................................... 82
RENAGEL -sevelamer hcl tab 400 mg..............................74
RENAGEL -sevelamer hcl tab 800 mg..............................74
RENATABS -b-complex w/ c-biotin-vit e & folic acid tab 1
mg.................................................................................. 125
RENATABS WITH IRON -b complex-c-biotin-e-fa tab 1mg
& fe cbn tab 100 mg pack............................................. 125
RENAX -multiple vitamins w/ minerals & fa tab 2.5
mg.................................................................................. 125
RENVELA -sevelamer carbonate packet 0.8 gm...............74
RENVELA -sevelamer carbonate packet 2.4 gm...............74
RENVELA -sevelamer carbonate tab 800 mg................... 74
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.................................................................................. 103
REPREXAIN -hydrocodone-ibuprofen tab 5-200 mg....... 103
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
237
2014
REQUIP -ropinirole hydrochloride tab 0.25 mg............... 116
REQUIP -ropinirole hydrochloride tab 0.5 mg................. 116
REQUIP -ropinirole hydrochloride tab 1 mg.................... 116
REQUIP -ropinirole hydrochloride tab 2 mg.................... 116
REQUIP -ropinirole hydrochloride tab 3 mg.................... 116
REQUIP -ropinirole hydrochloride tab 4 mg.................... 116
REQUIP -ropinirole hydrochloride tab 5 mg.................... 116
REQUIP XL -ropinirole hydrochloride tab sr 24hr 12 mg
(base equivalent)........................................................... 116
REQUIP XL -ropinirole hydrochloride tab sr 24hr 2 mg
(base equivalent)........................................................... 116
REQUIP XL -ropinirole hydrochloride tab sr 24hr 4 mg
(base equivalent)........................................................... 116
REQUIP XL -ropinirole hydrochloride tab sr 24hr 6 mg
(base equivalent)........................................................... 116
REQUIP XL -ropinirole hydrochloride tab sr 24hr 8 mg
(base equivalent)........................................................... 116
RESCON-JR -chlorpheniramine & phenylephrine tab sr
12hr 4-20 mg................................................................... 63
RESCON-JR -dexchlorpheniramine-phenylephrine tab sr
12hr 3-20 mg................................................................... 63
RESCON-MX -dexchlorpheniramine-phenylephrine tab sr
12hr 6-40 mg................................................................... 63
RESCRIPTOR -delavirdine mesylate tab 100 mg............... 9
RESCRIPTOR -delavirdine mesylate tab 200 mg............. 10
RESCULA -unoprostone isopropyl ophth soln 0.15%......144
RESERPINE -reserpine tab 0.1 mg.................................. 50
RESERPINE -reserpine tab 0.25 mg.................................50
RESPA-BR -brompheniramine maleate tab sr 12hr 11
mg.................................................................................... 59
RESPIRATORY THERAPY SUPPLIES – VARIOUS.......166
RESTASIS -cyclosporine (ophth) emulsion 0.05%.......... 144
RESTORA RX -lactobacillus casei-folic acid cap 60-1.25
mg.................................................................................... 68
RESTORE SILVER DRESSING 2 - wound dressings pads .............................................................................. 159
RESTORE SILVER DRESSING 4 - wound dressings pads .............................................................................. 159
RESTORE SILVER DRESSING 6 - wound dressings pads .............................................................................. 159
RESTORIL -temazepam cap 15 mg..................................88
RESTORIL -temazepam cap 22.5 mg...............................88
RESTORIL -temazepam cap 30 mg..................................88
RESTORIL -temazepam cap 7.5 mg.................................87
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.04%............................................................................. 159
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.08%............................................................................. 159
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.1%............................................................................... 159
RETIN-A MICRO -tretinoin microsphere gel 0.04%.........159
RETIN-A MICRO -tretinoin microsphere gel 0.1%...........159
RETIN-A -tretinoin cream 0.025%................................... 159
RETIN-A -tretinoin cream 0.05%..................................... 159
RETIN-A -tretinoin cream 0.1%....................................... 159
238
RETIN-A -tretinoin gel 0.01%.......................................... 159
RETIN-A -tretinoin gel 0.025%........................................ 159
RETROVIR -zidovudine cap 100 mg.................................10
RETROVIR -zidovudine syrup 10 mg/ml........................... 10
RETROVIR -zidovudine tab 300 mg................................. 10
REVATIO -sildenafil citrate tab 20 mg...............................58
REVIA -naltrexone hcl tab 50 mg....................................165
REVLIMID -lenalidomide cap 10 mg............................... 167
REVLIMID -lenalidomide cap 15 mg............................... 167
REVLIMID -lenalidomide cap 20 mg............................... 167
REVLIMID -lenalidomide cap 25 mg............................... 167
REVLIMID -lenalidomide cap 5 mg................................. 167
REVLIMID -lenalidomide caps 2.5 mg.............................167
REYATAZ -atazanavir sulfate cap 100 mg (base
equiv)................................................................................10
REYATAZ -atazanavir sulfate cap 150 mg (base
equiv)................................................................................10
REYATAZ -atazanavir sulfate cap 200 mg (base
equiv)................................................................................10
REYATAZ -atazanavir sulfate cap 300 mg (base
equiv)................................................................................10
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml..............................................................................63
RHEUMATREX -methotrexate sodium tab 2.5 mg
(antirheumatic)............................................................... 107
RHINOCORT AQUA -budesonide nasal susp 32 mcg/
act.....................................................................................60
RHINOFLEX-650 -phenyltoloxamine-acetaminophen tab
50-650 mg........................................................................96
RIAX -benzoyl peroxide foam 5.5%................................ 159
RIAX -benzoyl peroxide foam 9.5%................................ 159
RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack..................................................... 10
RIBASPHERE RIBAPAK -ribavirin tab 400 mg................. 10
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack.....................................................10
RIBASPHERE RIBAPAK -ribavirin tab 600 mg................. 10
RIBASPHERE -ribavirin tab 400 mg................................. 10
RIBASPHERE -ribavirin tab 600 mg................................. 10
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....................................... 107
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.......................................... 117
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
riluzole tab 50 mg (Rilutek).......................................... 117
rimantadine hydrochloride tab 100 mg (Flumadine).....10
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 31
risedronate sodium tab 150 mg (Actonel)..................... 37
RISPERDAL M-TAB -risperidone orally disintegrating tab
0.5 mg.............................................................................. 86
RISPERDAL M-TAB -risperidone orally disintegrating tab 1
mg.................................................................................... 86
RISPERDAL M-TAB -risperidone orally disintegrating tab 2
mg.................................................................................... 86
RISPERDAL M-TAB -risperidone orally disintegrating tab 3
mg.................................................................................... 86
RISPERDAL M-TAB -risperidone orally disintegrating tab 4
mg.................................................................................... 86
RISPERDAL -risperidone soln 1 mg/ml.............................86
RISPERDAL -risperidone tab 0.25 mg.............................. 86
RISPERDAL -risperidone tab 0.5 mg................................ 86
RISPERDAL -risperidone tab 1 mg................................... 86
RISPERDAL -risperidone tab 2 mg................................... 86
RISPERDAL -risperidone tab 3 mg................................... 86
RISPERDAL -risperidone tab 4 mg................................... 86
risperidone orally disintegrating tab 0.25 mg............... 86
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 86
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 86
risperidone orally disintegrating tab 2 mg (Risperdal
m-tab).............................................................................. 86
risperidone orally disintegrating tab 3 mg (Risperdal
m-tab).............................................................................. 86
risperidone orally disintegrating tab 4 mg (Risperdal
m-tab).............................................................................. 86
risperidone soln 1 mg/ml (Risperdal)............................ 86
risperidone tab 0.25 mg (Risperdal).............................. 86
risperidone tab 0.5 mg (Risperdal)................................ 86
risperidone tab 1 mg (Risperdal)................................... 86
risperidone tab 2 mg (Risperdal)................................... 86
risperidone tab 3 mg (Risperdal)................................... 86
risperidone tab 4 mg (Risperdal)................................... 86
RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg........91
RITALIN LA -methylphenidate hcl cap sr 24hr 20 mg........91
RITALIN LA -methylphenidate hcl cap sr 24hr 30 mg........91
RITALIN LA -methylphenidate hcl cap sr 24hr 40 mg........91
RITALIN -methylphenidate hcl tab 10 mg..........................91
RITALIN -methylphenidate hcl tab 20 mg..........................91
RITALIN -methylphenidate hcl tab 5 mg........................... 91
RITALIN SR -methylphenidate hcl tab cr 20 mg................91
rivastigmine tartrate cap 1.5 mg (Exelon)..................... 94
rivastigmine tartrate cap 3 mg (Exelon)........................ 94
rivastigmine tartrate cap 4.5 mg (Exelon)..................... 94
rivastigmine tartrate cap 6 mg (Exelon)........................ 94
RIXUBIS -coagulation factor ix (recombinant) for inj 1000
unit..................................................................................140
RIXUBIS -coagulation factor ix (recombinant) for inj 2000
unit..................................................................................140
RIXUBIS -coagulation factor ix (recombinant) for inj 250
unit..................................................................................140
RIXUBIS -coagulation factor ix (recombinant) for inj 3000
unit..................................................................................140
RIXUBIS -coagulation factor ix (recombinant) for inj 500
unit..................................................................................140
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt)................................................................... 109
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt)................................................................... 109
rizatriptan benzoate tab 10 mg (Maxalt)...................... 109
rizatriptan benzoate tab 5 mg (Maxalt)........................ 109
R-NATAL OB - prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg ................................................................. 125
ROBAXIN-750 -methocarbamol tab 750 mg................... 117
ROBAXIN -methocarbamol tab 500 mg.......................... 117
ROBINUL FORTE -glycopyrrolate tab 2 mg......................71
ROBINUL -glycopyrrolate tab 1 mg...................................71
ROCALTROL -calcitriol cap 0.25 mcg...............................37
ROCALTROL -calcitriol cap 0.5 mcg.................................37
ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 37
ropinirole hydrochloride tab 0.25 mg (Requip)........... 116
ropinirole hydrochloride tab 0.5 mg (Requip)............. 116
ropinirole hydrochloride tab 1 mg (Requip)................116
ropinirole hydrochloride tab 2 mg (Requip)................116
ropinirole hydrochloride tab 3 mg (Requip)................116
ropinirole hydrochloride tab 4 mg (Requip)................116
ropinirole hydrochloride tab 5 mg (Requip)................116
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl)................................................ 116
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)................................................ 116
ropinirole hydrochloride tab sr 24hr 4 mg (base
equivalent) (Requip xl)................................................ 116
ropinirole hydrochloride tab sr 24hr 6 mg (base
equivalent) (Requip xl)................................................ 116
ropinirole hydrochloride tab sr 24hr 8 mg (base
equivalent) (Requip xl)................................................ 116
ROSADAN KIT -metronidazole cream 0.75% w/ cleanser
kit....................................................................................159
ROSADAN KIT -metronidazole gel 0.75% w/ cleanser
kit....................................................................................159
ROSANIL -sulfacetamide sod-sulfur emul 10-5% & skin
cleanser kit.....................................................................159
ROWASA -mesalamine rectal enema 4 gm & cleanser
wipe kit............................................................................. 74
ROXICET -oxycodone w/ acetaminophen soln 5-325
mg/5ml............................................................................103
ROXICODONE -oxycodone hcl tab 15 mg......................103
ROXICODONE -oxycodone hcl tab 30 mg......................103
ROXICODONE -oxycodone hcl tab 5 mg........................103
ROZEREM -ramelteon tab 8 mg....................................... 88
RTD WOUND CARE DRESSING - wound dressings pads .............................................................................. 159
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
239
2014
RYBIX ODT -tramadol hcl orally disintegrating tab 50
mg.................................................................................. 103
RYDEX -pseudoephedrine-bromphen-codeine liq
10-1.33-6.33 mg/5ml........................................................ 63
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
RYZOLT -tramadol hcl tab sr 24hr biphasic release 100
mg.................................................................................. 103
RYZOLT -tramadol hcl tab sr 24hr biphasic release 200
mg.................................................................................. 103
RYZOLT -tramadol hcl tab sr 24hr biphasic release 300
mg.................................................................................. 103
S
SABRIL -vigabatrin powd pack 500 mg...........................113
SABRIL -vigabatrin tab 500 mg.......................................113
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg...............................................................26
SAIZEN CLICK.EASY -somatropin (non-refrigerated) for
inj 8.8 mg......................................................................... 37
SAIZEN -somatropin (non-refrigerated) for inj 5 mg.......... 37
SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg....... 37
SALAGEN -pilocarpine hcl tab 5 mg............................... 147
SALAGEN -pilocarpine hcl tab 7.5 mg............................ 147
SALEX CREAM -salicylic acid cream 6% & cleanser liqd
kit....................................................................................159
SALEX LOTION -salicylic acid lotion 6% & cleanser liqd
kit....................................................................................159
SALEX -salicylic acid shampoo 6%.................................159
SALICEPT - oral wound care products - for susp rinse
....................................................................................... 147
salicylic acid cream 6%................................................ 159
salicylic acid cream 6% & cleanser liqd kit (Salex
cream)............................................................................148
salicylic acid film forming liquid 27.5% (Virasal)........ 159
salicylic acid foam 6% (Salvax)....................................159
salicylic acid gel 6% (Keralyt)...................................... 159
SALICYLIC ACID IN AMMONIU -salicylic acid in
ammonium lactate vehicle foam 6%.............................. 159
salicylic acid lotion 6%................................................. 159
salicylic acid lotion 6% & cleanser liqd kit (Salex
lotion)............................................................................ 148
SALICYLIC ACID -salicylic acid soln 26%.......................159
salicylic acid shampoo 6% (Salex).............................. 159
SALKERA -salicylic acid in ammonium lactate vehicle
foam 6%.........................................................................159
salsalate tab 500 mg....................................................... 96
salsalate tab 750 mg....................................................... 96
SALVAX DUO PLUS -salicylic acid foam 6% & urea in
lactic acid foam 35% kit.................................................159
SALVAX -salicylic acid foam 6%..................................... 159
SAMSCA -tolvaptan tab 15 mg......................................... 37
SAMSCA -tolvaptan tab 30 mg......................................... 37
240
SANARE SCAR THERAPY - scar treatment products cream ............................................................................ 159
SANCTURA -trospium chloride tab 20 mg........................ 75
SANCTURA XR -trospium chloride cap sr 24hr 60 mg......75
SANCUSO -granisetron td patch 3.1 mg/24hr (contains
34.3 mg)...........................................................................72
SANDIMMUNE -cyclosporine cap 100 mg...................... 167
SANDIMMUNE -cyclosporine cap 25 mg........................ 167
SANDIMMUNE -cyclosporine oral soln 100 mg/ml..........167
SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1 mg/
ml).................................................................................... 37
SANDOSTATIN -octreotide acetate inj 100 mcg/ml (0.1
mg/ml).............................................................................. 37
SANDOSTATIN -octreotide acetate inj 200 mcg/ml (0.2
mg/ml).............................................................................. 37
SANDOSTATIN -octreotide acetate inj 500 mcg/ml (0.5
mg/ml).............................................................................. 37
SANDOSTATIN -octreotide acetate inj 50 mcg/ml (0.05
mg/ml).............................................................................. 37
SANTYL -collagenase oint 250 unit/gm...........................159
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)................................................................................86
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)................................................................................86
SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.....................94
SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.....................94
SAVELLA -milnacipran hcl tab 100 mg............................. 95
SAVELLA -milnacipran hcl tab 12.5 mg............................ 94
SAVELLA -milnacipran hcl tab 25 mg............................... 94
SAVELLA -milnacipran hcl tab 50 mg............................... 95
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak................................... 95
SCALACORT DK -hc lot 2% & sal acid-sulfur shampoo
2-2% & shampoo kit...................................................... 160
SEASONALE -levonorgestrel & ethinyl estradiol (91-day)
tab 0.15-0.03 mg..............................................................26
SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)...................................................... 26
SE BPO 7-5.5 WASH KIT -benzoyl peroxide wash 7% &
benzoyl peroxide cream 5.5% kit...................................160
SEB-PREV -sulfacetamide sodium lotion 10%................ 160
SECONAL -secobarbital sodium cap 100 mg....................88
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 .................................................125
SELECT-OB - prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg ........................................................................ 125
SELECT-OB - prenat w/ fepolycmplx-methylfol-fa chew tab
29-0.6-0.4 mg ............................................................... 125
selegiline hcl cap 5 mg (Eldepryl)................................116
selegiline hcl tab 5 mg..................................................116
selenium sulfide lotion 2.5%........................................ 160
selenium sulfide-pyrithione zinc in urea shampoo
2.25%............................................................................. 160
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
SELENIUM SULFIDE -selenium sulfide-pyrithione zinc in
urea shampoo 2.25%.....................................................160
SELRX -selenium sulfide-pyrithione zinc in urea shampoo
2.3%............................................................................... 160
SELSUN SHAMPOO -selenium sulfide lotion 2.5%........ 160
SELZENTRY -maraviroc tab 150 mg................................ 10
SELZENTRY -maraviroc tab 300 mg................................ 10
SEMPREX-D -acrivastine & pseudoephedrine cap 8-60
mg.................................................................................... 63
SE-NATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg ................................................................................. 125
SE-NATAL 19 - prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ........................................................................ 125
SENNA LEAVES - senna leaves ..................................... 68
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv)........... 37
SENSIPAR -cinacalcet hcl tab 60 mg (base equiv)........... 37
SENSIPAR -cinacalcet hcl tab 90 mg (base equiv)........... 37
SEPTRA DS -sulfamethoxazole-trimethoprim tab 800-160
mg.................................................................................... 12
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv).................................................... 66
SEROMYCIN -cycloserine cap 250 mg...............................6
SEROQUEL -quetiapine fumarate tab 100 mg..................86
SEROQUEL -quetiapine fumarate tab 200 mg..................86
SEROQUEL -quetiapine fumarate tab 25 mg....................86
SEROQUEL -quetiapine fumarate tab 300 mg..................86
SEROQUEL -quetiapine fumarate tab 400 mg..................86
SEROQUEL -quetiapine fumarate tab 50 mg....................86
SEROQUEL XR -quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 86
SEROQUEL XR -quetiapine fumarate tab sr 24hr 200
mg.................................................................................... 86
SEROQUEL XR -quetiapine fumarate tab sr 24hr 300
mg.................................................................................... 86
SEROQUEL XR -quetiapine fumarate tab sr 24hr 400
mg.................................................................................... 86
SEROQUEL XR -quetiapine fumarate tab sr 24hr 50
mg.................................................................................... 86
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 4 mg.....................................................37
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)..................... 82
sertraline hcl tab 100 mg (Zoloft)...................................82
sertraline hcl tab 25 mg (Zoloft).....................................82
sertraline hcl tab 50 mg (Zoloft).....................................82
SE-TAN DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap
15-15-1 mg ................................................................... 125
SETON ET-EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk.................................................... 125
SETONET -prenat-fe bis-fe prot succ-fa-ca tab & omega 3
cap 430 pk..................................................................... 126
SEVELAMER CARBONATE -sevelamer carbonate tab
800 mg............................................................................. 74
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml............................................................................74
SHOHLS SOLUTION MODIFIED -sodium citrate & citric
acid soln 500-334 mg/5ml............................................... 77
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)....... 88
SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)....... 88
SILVADENE -silver sulfadiazine cream 1%.....................160
silver nitrate-potassium nitrate applicator 75-25%
(Arzol silver nitrate)..................................................... 160
SILVER NITRATE -silver nitrate oint 10%.......................160
SILVER NITRATE -silver nitrate soln 0.5%..................... 160
SILVER NITRATE -silver nitrate soln 10%...................... 160
SILVER NITRATE -silver nitrate soln 25%...................... 160
SILVER NITRATE -silver nitrate soln 50%...................... 160
SILVERSEAL HYDROGEL DRESS - silver - pad 2"x3"
....................................................................................... 160
SILVERSEAL HYDROGEL DRESS - silver - pad 4"x5"
....................................................................................... 160
silver sulfadiazine cream 1% (Silvadene)....................160
SILVRSTAT WOUND DRESSING - silver - gel ..............160
SIMBRINZA -brinzolamide-brimonidine tartrate ophth susp
1-0.2%............................................................................ 144
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 inj 100 mg/ml........ 107
SIMPONI -golimumab subcutaneous inj 50 mg/0.5ml..... 107
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)....................................... 57
SINEMET -carbidopa & levodopa tab 10-100 mg............116
SINEMET -carbidopa & levodopa tab 25-100 mg............116
SINEMET -carbidopa & levodopa tab 25-250 mg............116
SINEMET CR -carbidopa & levodopa tab cr 25-100
mg.................................................................................. 116
SINEMET CR -carbidopa & levodopa tab cr 50-200
mg.................................................................................. 116
SINGLE-LET - lancets ....................................................166
SINGULAIR -montelukast sodium chew tab 4 mg (base
equiv)................................................................................67
SINGULAIR -montelukast sodium chew tab 5 mg (base
equiv)................................................................................67
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
241
2014
SINGULAIR -montelukast sodium oral granules packet 4
mg (base equiv)............................................................... 67
SINGULAIR -montelukast sodium tab 10 mg (base
equiv)................................................................................66
sirolimus tab 0.5 mg (Rapamune)................................ 167
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............................... 117
SKELID -tiludronate disodium tab 200 mg (tiludronic acid
equivalent)........................................................................38
SKLICE -ivermectin lotion 0.5%...................................... 160
SMART SENSE GLUCOSE -glucose-vitamin c chew tab
4-0.006 gm.......................................................................31
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%................................... 63
sodium chloride soln nebu 10%.................................... 63
sodium chloride soln nebu 3%...................................... 63
sodium chloride soln nebu 7% (Hyper-sal)................... 63
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi).................................................. 77
SODIUM CITRATE -sodium citrate granules.....................77
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride).......................................................................... 130
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride).......................................................................... 130
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride).......................................................................... 130
sodium fluoride cream 1.1% (Prevident 5000
plus)...............................................................................147
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)......................................................................... 147
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 147
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi)................................................. 147
sodium fluoride rinse 0.0221% (0.01% f)..................... 147
sodium fluoride rinse 0.05%.........................................147
sodium fluoride rinse 0.2% (Prevident)....................... 147
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf).................................................................... 130
SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from 2.2
mg naf)...........................................................................130
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................130
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride).......................................................................... 130
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl).......................................................................38
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 167
242
sodium polystyrene sulfonate powder
(Kayexalate).................................................................. 166
sodium polystyrene sulfonate rectal susp 30
gm/120ml.......................................................................167
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea emulsion 10-5%.......................... 160
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea gel 10-5%.................................... 160
SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium
w/ sulfur susp 10-5%..................................................... 160
SODIUM SULFACETAMIDE/UREA -sulfacetamide
sodium-urea pad 10%....................................................160
SODIUM SULFACETAMIDE WASH -sulfacetamide
sodium in bakuchiol vehicle wash 10%......................... 160
sodium thiosulfate-salicylic acid lotion 25-1%........... 160
SOLARAZE -diclofenac sodium (actinic keratoses) gel
3%.................................................................................. 160
SOLODYN -minocycline hcl tab sr 24hr 105 mg................. 5
SOLODYN -minocycline hcl tab sr 24hr 115 mg................. 5
SOLODYN -minocycline hcl tab sr 24hr 135 mg................. 5
SOLODYN -minocycline hcl tab sr 24hr 45 mg................... 5
SOLODYN -minocycline hcl tab sr 24hr 55 mg................... 5
SOLODYN -minocycline hcl tab sr 24hr 65 mg................... 5
SOLODYN -minocycline hcl tab sr 24hr 80 mg................... 5
SOLODYN -minocycline hcl tab sr 24hr 90 mg................... 5
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)........................................................................17
SOMA -carisoprodol tab 250 mg..................................... 117
SOMA -carisoprodol tab 350 mg..................................... 117
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
SOMNOTE -chloral hydrate cap 500 mg...........................88
SONATA -zaleplon cap 10 mg.......................................... 88
SONATA -zaleplon cap 5 mg............................................ 88
SORIATANE -acitretin cap 10 mg................................... 160
SORIATANE -acitretin cap 17.5 mg................................ 160
SORIATANE -acitretin cap 25 mg................................... 160
SORILUX -calcipotriene foam 0.005%............................ 160
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
SOVALDI -sofosbuvir tab 400 mg..................................... 10
SPACERS – VARIOUS................................................... 166
SPATONE PUR-ABSORB IRON -ferrous sulfate liquid 5
mg/20ml (elemental iron)............................................... 135
SPECTRACEF -cefditoren pivoxil tab 200 mg (base
equivalent)..........................................................................2
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)..........................................................................2
SPINOSAD -spinosad susp 0.9%....................................160
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)........................................ 67
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...............................................................................107
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..........................................................................167
SSKI -potassium iodide soln 1 gm/ml..............................130
SSS 10-4 -sulfacetamide sodium w/ sulfur foam
10-4%............................................................................. 160
STAFLEX -phenyltoloxamine-acetaminophen tab 55-500
mg.................................................................................... 96
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg...............................................................116
STALEVO 125 -carbidopa-levodopa-entacapone tabs
31.25-125-200 mg..........................................................116
STALEVO 150 -carbidopa-levodopa-entacapone tabs
37.5-150-200 mg............................................................116
STALEVO 200 -carbidopa-levodopa-entacapone tabs
50-200-200 mg...............................................................117
STALEVO 50 -carbidopa-levodopa-entacapone tabs
12.5-50-200 mg..............................................................117
STALEVO 75 -carbidopa-levodopa-entacapone tabs
18.75-75-200 mg............................................................117
stannous fluoride conc 0.63% (Gel-kam oral care
ri)....................................................................................147
stannous fluoride gel 0.4%........................................... 147
STARLIX -nateglinide tab 120 mg.....................................31
STARLIX -nateglinide tab 60 mg.......................................31
STATUSS GREEN -codeine-pseudoephedrinechlorcyclizine liq 9-30-12.5 mg/5ml..................................63
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.................................................................................. 113
STAVZOR -valproic acid cap delayed release 250
mg.................................................................................. 113
STAVZOR -valproic acid cap delayed release 500
mg.................................................................................. 113
STELARA -ustekinumab inj 45 mg/0.5ml........................ 160
STELARA -ustekinumab inj 90 mg/ml............................. 160
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml......................................................................................38
STIVARGA -regorafenib tab 40 mg...................................18
STRATTERA -atomoxetine hcl cap 100 mg (base
equiv)................................................................................91
STRATTERA -atomoxetine hcl cap 10 mg (base
equiv)................................................................................91
STRATTERA -atomoxetine hcl cap 18 mg (base
equiv)................................................................................91
STRATTERA -atomoxetine hcl cap 25 mg (base
equiv)................................................................................91
STRATTERA -atomoxetine hcl cap 40 mg (base
equiv)................................................................................91
STRATTERA -atomoxetine hcl cap 60 mg (base
equiv)................................................................................91
STRATTERA -atomoxetine hcl cap 80 mg (base
equiv)................................................................................91
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)................................................. 67
STROMECTOL -ivermectin tab 3 mg................................ 12
STROVITE -b-complex w/ c & folic acid tab.................... 126
STROVITE FORTE -multiple vitamins w/ minerals & fa
syrup 1 mg/15ml............................................................ 126
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)............................................................. 103
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv)............................................................. 103
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)............................................................. 103
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv)............................................................. 103
SUBOXONE -buprenorphine hcl-naloxone hcl sl tab 2-0.5
mg (base equiv)............................................................. 103
SUBOXONE -buprenorphine hcl-naloxone hcl sl tab 8-2
mg (base equiv)............................................................. 103
SUBSYS -fentanyl sublingual spray 100 mcg..................103
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2).................................................................................... 104
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2).................................................................................... 104
SUBSYS -fentanyl sublingual spray 200 mcg..................103
SUBSYS -fentanyl sublingual spray 400 mcg..................103
SUBSYS -fentanyl sublingual spray 600 mcg..................104
SUBSYS -fentanyl sublingual spray 800 mcg..................104
SUBUTEX -buprenorphine hcl sl tab 2 mg (base
equiv)..............................................................................104
SUBUTEX -buprenorphine hcl sl tab 8 mg (base
equiv)..............................................................................104
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
243
2014
SUCLEAR -na sulf-k sulf-mg sulf & peg 3350-nacl-na
bicarb-kcl kit..................................................................... 68
SUCRAID -sacrosidase soln 8500 unit/ml......................... 72
sucralfate tab 1 gm (Carafate)........................................71
SULAR -nisoldipine tab sr 24hr 17 mg.............................. 43
SULAR -nisoldipine tab sr 24hr 25.5 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)............................................................................. 160
sulfacetamide sodium liquid 10% (Ovace wash)........ 160
sulfacetamide sodium lotion 10% (acne) (Klaron)...... 160
sulfacetamide sodium ophth soln 10% (Bleph-10)..... 144
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%...............................................................144
sulfacetamide sodium shampoo 10% (Ovace
plus)...............................................................................160
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%......................................................................... 144
sulfacetamide sodium-sulfur in urea emulsion
10-4%............................................................................. 161
sulfacetamide sodium-sulfur w/ sunscreens cream
10-5% ............................................................................148
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar
ls cleanser)................................................................... 160
sulfacetamide sodium w/ sulfur cleansing cloth
10-5%............................................................................. 161
sulfacetamide sodium w/ sulfur cleansing pad 10-4%
(Sumaxin)...................................................................... 161
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls)................................................................................... 161
sulfacetamide sodium w/ sulfur cream 10-5%............ 161
sulfacetamide sodium w/ sulfur emulsion 10-1%....... 161
sulfacetamide sodium w/ sulfur emulsion 10-5%....... 161
sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam
ef)................................................................................... 161
sulfacetamide sodium w/ sulfur lotion 10-5%............. 161
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts)................................................................................... 161
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash).......................................................... 161
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash)............................................................................. 161
sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser
kit (Sumadan kit)..........................................................148
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....... 161
SULFAMYLON -mafenide acetate packet for topical soln
5% (50 gm).................................................................... 161
244
sulfasalazine tab 500 mg (Azulfidine)............................74
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 74
SULFOAM -sulfur shampoo 2%...................................... 161
SULFURATED LIME -sulfurated lime solution................ 161
sulindac tab 150 mg...................................................... 107
sulindac tab 200 mg...................................................... 107
SUMADAN KIT -sulfacetamide sod-sulfur wash 9-4.5% &
skin cleanser kit............................................................. 161
SUMADAN WASH -sulfacetamide sodium w/ sulfur wash
9-4.5%............................................................................ 161
SUMADAN XLT -sulfacetamide sod-sulfur wash 9-4.5% &
sunscreen kit..................................................................161
sumatriptan succinate inj 4 mg/0.5ml..........................109
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)...........109
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................. 109
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................. 109
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)................................................... 109
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)................................................... 109
sumatriptan succinate solution prefilled syringe 6
mg/0.5ml........................................................................109
SUMATRIPTAN SUCCINATE -sumatriptan succinate inj 4
mg/0.5ml.........................................................................109
SUMATRIPTAN SUCCINATE -sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml............................. 109
sumatriptan succinate tab 100 mg (Imitrex)................109
sumatriptan succinate tab 25 mg (Imitrex)..................109
sumatriptan succinate tab 50 mg (Imitrex)..................109
SUMATRIPTAN -sumatriptan nasal spray 20 mg/act...... 109
SUMATRIPTAN -sumatriptan nasal spray 5 mg/act........ 109
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml........................................................ 109
SUMAXIN CP KIT -sulfacetamide sod-sulfur pad 10-4% &
skin cleanser kit............................................................. 161
SUMAXIN -sulfacetamide sodium w/ sulfur cleansing pad
10-4%............................................................................. 161
SUMAXIN TS -sulfacetamide sodium w/ sulfur susp
8-4%............................................................................... 161
SUMAXIN WASH -sulfacetamide sodium w/ sulfur wash
9-4%............................................................................... 161
SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml
(per drop)....................................................................... 118
SUPERVITE -b-complex w/ lysine-zn & folic acid
liquid............................................................................... 126
SUPERVITE EC -multiple vitamins w/ minerals & fa tab dr
1 mg............................................................................... 126
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
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
SUPRAX -cefixime for susp 500 mg/5ml.............................2
SUPRAX -cefixime tab 400 mg........................................... 2
SUPREP BOWEL PREP -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln................................ 68
SURFAXIN -lucinactant intratracheal susp 30 mg/ml........ 67
SURMONTIL -trimipramine maleate cap 100 mg.............. 82
SURMONTIL -trimipramine maleate cap 25 mg................ 82
SURMONTIL -trimipramine maleate cap 50 mg................ 82
SURVANTA INTRATRACHEAL -beractant in nacl 0.9%
intratracheal susp 25 mg/ml............................................ 67
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..............................................................................63
SUTTAR-SF -pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml............................................................63
SYLATRON -peginterferon alfa-2b for inj kit 296 mcg....... 18
SYLATRON -peginterferon alfa-2b for inj kit 444 mcg....... 18
SYLATRON -peginterferon alfa-2b for inj kit 4 x 296
mcg...................................................................................18
SYLATRON -peginterferon alfa-2b for inj kit 4 x 444
mcg...................................................................................18
SYLATRON -peginterferon alfa-2b for inj kit 4 x 888
mcg...................................................................................18
SYLATRON -peginterferon alfa-2b for inj kit 888 mcg....... 18
SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg
(0.125 mg ir/0.25 mg cr).................................................. 71
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act.................................................. 67
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.................................................... 67
SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg.........95
SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg.........95
SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg...........95
SYMBYAX -olanzapine-fluoxetine hcl cap 6-25 mg...........95
SYMBYAX -olanzapine-fluoxetine hcl cap 6-50 mg...........95
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
SYMLIN -pramlintide acetate inj 600 mcg/ml (base
equiv)................................................................................31
SYNAGEX -multiple vitamins w/ minerals & fa cap 1.25
mg.................................................................................. 126
SYNALAR CREAM KIT - fluocinolone cream 0.025%emollient cream kit ........................................................161
SYNALAR -fluocinolone acetonide cream 0.025%.......... 161
SYNALAR -fluocinolone acetonide oint 0.025%.............. 161
SYNALAR -fluocinolone acetonide soln 0.01%............... 161
SYNALAR OINTMENT KIT - fluocinolone oint 0.025%emollient cream kit ........................................................161
SYNALAR TS -fluocinolone acetonide soln 0.01% &
cleanser kit.....................................................................161
SYNALGOS-DC -dihydrocodeine compound cap............104
SYNATEK -multiple vitamins w/ minerals & fa cap 1.25
mg.................................................................................. 126
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 161
SYNTHROID -levothyroxine sodium tab 100 mcg............. 33
SYNTHROID -levothyroxine sodium tab 112 mcg............. 33
SYNTHROID -levothyroxine sodium tab 125 mcg............. 33
SYNTHROID -levothyroxine sodium tab 137 mcg............. 33
SYNTHROID -levothyroxine sodium tab 150 mcg............. 33
SYNTHROID -levothyroxine sodium tab 175 mcg............. 33
SYNTHROID -levothyroxine sodium tab 200 mcg............. 33
SYNTHROID -levothyroxine sodium tab 25 mcg...............33
SYNTHROID -levothyroxine sodium tab 300 mcg............. 33
SYNTHROID -levothyroxine sodium tab 50 mcg...............33
SYNTHROID -levothyroxine sodium tab 75 mcg...............33
SYNTHROID -levothyroxine sodium tab 88 mcg...............33
SYPRINE -trientine hcl cap 250 mg................................ 167
T
TABLOID -thioguanine tab 40 mg..................................... 18
TACLONEX -calcipotriene-betamethasone dipropionate
oint 0.005-0.064%.......................................................... 161
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%........................................................ 161
tacrolimus cap 0.5 mg (Prograf).................................. 167
tacrolimus cap 1 mg (Prograf)..................................... 167
tacrolimus cap 5 mg (Prograf)..................................... 167
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)........................................................................18
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)........................................................................18
TAMBOCOR -flecainide acetate tab 100 mg.....................45
TAMBOCOR -flecainide acetate tab 150 mg.....................45
TAMBOCOR -flecainide acetate tab 50 mg.......................45
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)..............18
tamoxifen citrate tab 20 mg (base equivalent)..............18
tamsulosin hcl cap 0.4 mg (Flomax)..............................77
TANDEM F -ferrous fum-iron polysacch-fa cap
162-115.2-1 mg (106 mg fe)..........................................135
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
245
2014
TANDEM OB - prenatal w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg .............................................................126
TANDEM PLUS - fe fum-iron polysacch complex-fa-b
cmplx-c-zn-mn-cu cap .................................................. 135
TANZEUM -albiglutide for soln pen-injector 30 mg............31
TANZEUM -albiglutide for soln pen-injector 50 mg............31
TAPAZOLE -methimazole tab 10 mg................................ 33
TAPAZOLE -methimazole tab 5 mg.................................. 33
TARCEVA -erlotinib tab 100 mg........................................18
TARCEVA -erlotinib tab 150 mg........................................18
TARCEVA -erlotinib tab 25 mg......................................... 18
TARGRETIN -bexarotene cap 75 mg................................18
TARGRETIN -bexarotene gel 1%....................................161
TARKA -trandolapril-verapamil hcl tab cr 1-240 mg.......... 50
TARKA -trandolapril-verapamil hcl tab cr 2-180 mg.......... 50
TARKA -trandolapril-verapamil hcl tab cr 2-240 mg.......... 50
TARKA -trandolapril-verapamil hcl tab cr 4-240 mg.......... 50
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak......................................................................126
TARON-C DHA - prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg ......................................................... 126
TARON-DUO EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk.................................................... 126
TARON FORTE - fe bisglycinate-fe polysacch-vit c-vit b12fa cap ............................................................................135
TARON-PREX - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg ....................................................... 126
TASIGNA -nilotinib cap 150 mg........................................ 18
TASIGNA -nilotinib cap 200 mg........................................ 18
TASMAR -tolcapone tab 100 mg.....................................117
TAZORAC -tazarotene cream 0.05%.............................. 161
TAZORAC -tazarotene cream 0.1%................................ 161
TAZORAC -tazarotene gel 0.05%................................... 161
TAZORAC -tazarotene gel 0.1%..................................... 161
-TBO-FILGRASTIM SOLN PREFILLED SYRINGE 300
MCG/0.5ML.................................................................... 134
-TBO-FILGRASTIM SOLN PREFILLED SYRINGE 480
MCG/0.8ML.................................................................... 134
TEARS AGAIN HYDRATE -flaxseed oil-evening primrosebilberry cap 1000-500-40 mg.........................................132
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg............................................................................. 95
TECFIDERA -dimethyl fumarate capsule delayed release
240 mg............................................................................. 95
TECFIDERA STARTER PACK -dimethyl fumarate capsule
dr starter pack 120 mg & 240 mg....................................95
TEGADERM AG MESH DRESSING - wound dressings pads .............................................................................. 161
TEGRETOL -carbamazepine chew tab 100 mg.............. 113
TEGRETOL -carbamazepine susp 100 mg/5ml.............. 113
TEGRETOL -carbamazepine tab 200 mg........................113
TEGRETOL-XR -carbamazepine tab sr 12hr 100 mg......113
TEGRETOL-XR -carbamazepine tab sr 12hr 200 mg......113
TEGRETOL-XR -carbamazepine tab sr 12hr 400 mg......113
TEKAMLO -aliskiren-amlodipine tab 150-10 mg................50
246
TEKAMLO -aliskiren-amlodipine tab 150-5 mg................. 50
TEKAMLO -aliskiren-amlodipine tab 300-10 mg................51
TEKAMLO -aliskiren-amlodipine tab 300-5 mg................. 51
TEKRAL -diphenhydramine & pseudoephedrine tab sr
12hr 100-120 mg............................................................. 63
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)................................... 88
temazepam cap 22.5 mg (Restoril).................................88
temazepam cap 30 mg (Restoril)................................... 88
temazepam cap 7.5 mg (Restoril).................................. 88
TEMODAR -temozolomide cap 100 mg............................ 18
TEMODAR -temozolomide cap 140 mg............................ 18
TEMODAR -temozolomide cap 180 mg............................ 18
TEMODAR -temozolomide cap 20 mg.............................. 18
TEMODAR -temozolomide cap 250 mg............................ 18
TEMODAR -temozolomide cap 5 mg................................ 18
TEMOVATE -clobetasol propionate cream 0.05%...........161
TEMOVATE -clobetasol propionate gel 0.05%................161
TEMOVATE -clobetasol propionate oint 0.05%...............162
TEMOVATE -clobetasol propionate soln 0.05%.............. 161
TEMOVATE E -clobetasol propionate emollient base
cream 0.05%..................................................................162
temozolomide cap 100 mg (Temodar)........................... 18
temozolomide cap 140 mg (Temodar)........................... 18
temozolomide cap 180 mg (Temodar)........................... 18
temozolomide cap 20 mg (Temodar)............................. 18
temozolomide cap 250 mg (Temodar)........................... 18
temozolomide cap 5 mg (Temodar)............................... 18
TENCON -butalbital-acetaminophen tab 50-650 mg......... 96
TENEX -guanfacine hcl tab 1 mg......................................51
TENEX -guanfacine hcl tab 2 mg......................................51
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
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%..................76
TERAZOL 3 -terconazole vaginal suppos 80 mg.............. 76
TERAZOL 7 -terconazole vaginal cream 0.4%..................76
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
TERBINEX -terbinafine oral tab 250 mg & hydrxyprop
chitosan liq 1% kit..............................................................7
terbutaline sulfate tab 2.5 mg.........................................67
terbutaline sulfate tab 5 mg........................................... 67
terconazole vaginal cream 0.4% (Terazol 7)..................76
terconazole vaginal cream 0.8% (Terazol 3)..................76
terconazole vaginal suppos 80 mg................................ 76
TERSI FOAM -selenium sulfide foam 2.25%...................162
TESSALON -benzonatate cap 200 mg..............................63
TESSALON PERLES -benzonatate cap 100 mg...............63
TESTIM -testosterone td gel 50 mg/5gm (1%).................. 21
testosterone cypionate im in oil 100 mg/ml (Depotestosterone)...................................................................21
testosterone cypionate im in oil 200 mg/ml (Depotestosterone)...................................................................21
testosterone enanthate im in oil 200 mg/ml.................. 21
TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act
(1%)..................................................................................21
TESTOSTERONE -testosterone td gel 50 mg/5gm
(1%)..................................................................................21
TESTRED -methyltestosterone cap 10 mg........................21
TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml............................................... 15
TETANUS TOXOID ADSORBED -tetanus toxoid adsorbed
inj 5 lf............................................................................... 15
tetracaine hcl ophth soln 0.5%.....................................144
tetracycline hcl cap 250 mg............................................. 5
tetracycline hcl cap 500 mg............................................. 5
TETRACYCLINE HCL -tetracycline hcl cap 250 mg............5
TETRACYCLINE HCL -tetracycline hcl cap 500 mg............5
TETRIX - dermatological products misc - kit .................. 162
TEVETEN -eprosartan mesylate tab 400 mg.................... 51
TEVETEN -eprosartan mesylate tab 600 mg.................... 51
TEVETEN HCT -eprosartan mesylate-hydrochlorothiazide
tab 600-12.5 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%...........................162
TGQ 15DM/5PEH/2CPM -phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml........................................................63
TGQ 30PSE/150GFN/15DM -pseudoephedrine w/ dm-gg
syrup 30-15-150 mg/5ml..................................................63
TGQ 30PSE/3BRM/15DM -pseudoephed-bromphen-dm
syrup 30-3-15 mg/5ml......................................................63
TGQ 50PSE/3BRM/30DM -pseudoephed-bromphen-dm
syrup 50-3-30 mg/5ml......................................................64
TGT GLUCOSE -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
THALITONE -chlorthalidone tab 15 mg.............................53
THALOMID -thalidomide cap 100 mg..............................167
THALOMID -thalidomide cap 150 mg..............................167
THALOMID -thalidomide cap 200 mg..............................167
THALOMID -thalidomide cap 50 mg................................167
THEO-24 -theophylline cap sr 24hr 100 mg...................... 67
THEO-24 -theophylline cap sr 24hr 200 mg...................... 67
THEO-24 -theophylline cap sr 24hr 300 mg...................... 67
THEO-24 -theophylline cap sr 24hr 400 mg...................... 67
theophylline soln 80 mg/15ml........................................ 67
theophylline tab sr 12hr 100 mg.................................... 67
theophylline tab sr 12hr 200 mg.................................... 67
theophylline tab sr 12hr 300 mg.................................... 67
theophylline tab sr 12hr 450 mg.................................... 67
theophylline tab sr 24hr 400 mg.................................... 67
theophylline tab sr 24hr 600 mg.................................... 67
THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)....... 147
THIOLA -tiopronin tab 100 mg.......................................... 77
thioridazine hcl tab 100 mg............................................ 86
thioridazine hcl tab 10 mg.............................................. 86
thioridazine hcl tab 25 mg.............................................. 86
thioridazine hcl tab 50 mg.............................................. 86
thiothixene cap 10 mg.....................................................86
thiothixene cap 1 mg...................................................... 86
thiothixene cap 2 mg...................................................... 86
thiothixene cap 5 mg...................................................... 86
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............. 33
thyroid tab 60 mg (1 grain) (Armour thyroid)................ 34
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid).......... 34
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).................................. 113
tiagabine hcl tab 4 mg (Gabitril).................................. 113
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
120 mg............................................................................. 43
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
180 mg............................................................................. 43
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
240 mg............................................................................. 43
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
247
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TIAZAC -diltiazem hcl extended release beads cap sr 24hr
300 mg............................................................................. 43
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
360 mg............................................................................. 43
TIAZAC -diltiazem hcl extended release beads cap sr 24hr
420 mg............................................................................. 43
ticlopidine hcl tab 250 mg............................................ 140
TIGAN -trimethobenzamide hcl cap 300 mg..................... 72
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).................................................................144
timolol maleate ophth gel forming soln 0.5% (Timopticxe).................................................................................. 144
timolol maleate ophth soln 0.25% (Timoptic)..............144
timolol maleate ophth soln 0.5% (Timoptic)................144
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%........................................................... 144
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................. 144
TIMOPTIC -timolol maleate ophth soln 0.25%................ 144
TIMOPTIC -timolol maleate ophth soln 0.5%.................. 144
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.25%............................................................................. 144
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.5%............................................................................... 144
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
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
TIZANIDINE COMFORT PAC -tizanidine tab 4 mg &
liniment topical gel pack................................................ 118
tizanidine hcl cap 2 mg (Zanaflex)............................... 118
tizanidine hcl cap 4 mg (Zanaflex)............................... 118
tizanidine hcl cap 6 mg (Zanaflex)............................... 118
tizanidine hcl tab 2 mg..................................................118
tizanidine hcl tab 4 mg (Zanaflex)................................118
TL-ASSURE+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak .................................................126
248
TL-ASSURE ONE - prenatal mv w/ fe polysac cmplx-fadha cap 29-1-200 mg ................................................... 126
TL-CARE DHA - prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg ................................................................. 126
TL-CERMIDE - dermatological products misc - emulsion
....................................................................................... 162
TL-FLUORIVITE - pediatric multiple vitamins w/ fl-fe chew
tab 0.25-7.5 mg ............................................................ 126
TL G-FOL OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.....................................................................126
TL-SELECT DHA - prenatal w/o vit a w/ fe fum-doc-fa-dha
cap 29-1.25-350 mg ..................................................... 126
TL-SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg ............................................................ 126
TL TRISEB - antiseborrheic products misc - cream ........162
TOBI PODHALER -tobramycin inhal cap 28 mg................. 6
TOBI -tobramycin nebu soln 300 mg/5ml............................ 6
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%....................................................................... 144
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%......................................................................... 144
TOBRADEX -tobramycin-dexamethasone ophth susp
0.3-0.1%......................................................................... 144
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).....................................................................144
tobramycin nebu soln 300 mg/5ml (Tobi)........................6
tobramycin ophth soln 0.3% (Tobrex)......................... 144
TOBREX -tobramycin sulfate ophth oint 0.3%.................144
TOBREX -tobramycin sulfate ophth soln 0.3%................144
TOFRANIL -imipramine hcl tab 10 mg.............................. 82
TOFRANIL -imipramine hcl tab 25 mg.............................. 82
TOFRANIL -imipramine hcl tab 50 mg.............................. 82
TOFRANIL-PM -imipramine pamoate cap 100 mg............ 83
TOFRANIL-PM -imipramine pamoate cap 125 mg............ 83
TOFRANIL-PM -imipramine pamoate cap 150 mg............ 83
TOFRANIL-PM -imipramine pamoate cap 75 mg.............. 82
tolazamide tab 250 mg.................................................... 31
TOLAZAMIDE -tolazamide tab 500 mg............................. 31
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 31
tolmetin sodium cap 400 mg........................................ 107
TOLMETIN SODIUM -tolmetin sodium tab 200 mg......... 107
TOLMETIN SODIUM -tolmetin sodium tab 600 mg......... 107
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 75
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 75
tolterodine tartrate tab 1 mg (Detrol).............................75
tolterodine tartrate tab 2 mg (Detrol).............................75
TOPAMAX SPRINKLE -topiramate sprinkle cap 15
mg.................................................................................. 113
TOPAMAX SPRINKLE -topiramate sprinkle cap 25
mg.................................................................................. 114
TOPAMAX -topiramate tab 100 mg.................................113
TOPAMAX -topiramate tab 200 mg.................................113
TOPAMAX -topiramate tab 25 mg...................................113
TOPAMAX -topiramate tab 50 mg...................................113
TOPICORT -desoximetasone cream 0.05%....................162
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
2014
TOPICORT -desoximetasone cream 0.25%....................162
TOPICORT -desoximetasone gel 0.05%.........................162
TOPICORT -desoximetasone oint 0.05%........................162
TOPICORT -desoximetasone oint 0.25%........................162
TOPICORT -desoximetasone spray 0.25%..................... 162
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 114
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 114
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 114
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 114
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50
mg.................................................................................. 114
topiramate sprinkle cap 15 mg (Topamax
sprinkle)........................................................................ 114
topiramate sprinkle cap 25 mg (Topamax
sprinkle)........................................................................ 114
topiramate tab 100 mg (Topamax)............................... 114
topiramate tab 200 mg (Topamax)............................... 114
topiramate tab 25 mg (Topamax)................................. 114
topiramate tab 50 mg (Topamax)................................. 114
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
TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg............. 75
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg............. 75
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)........................................................................104
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 150 mg.............................................................. 104
tramadol hcl tab 50 mg (Ultram).................................. 104
tramadol hcl tab sr 24hr 100 mg (Ultram er)............... 104
tramadol hcl tab sr 24hr 200 mg (Ultram er)............... 104
tramadol hcl tab sr 24hr 300 mg (Ultram er)............... 104
tramadol hcl tab sr 24hr biphasic release 100 mg...... 104
tramadol hcl tab sr 24hr biphasic release 200 mg...... 104
tramadol hcl tab sr 24hr biphasic release 300 mg...... 104
TRANDATE -labetalol hcl tab 100 mg...............................41
TRANDATE -labetalol hcl tab 200 mg...............................41
TRANDATE -labetalol hcl tab 300 mg...............................41
trandolapril tab 1 mg (Mavik)......................................... 51
trandolapril tab 2 mg (Mavik)......................................... 51
trandolapril tab 4 mg (Mavik)......................................... 51
tranexamic acid tab 650 mg (Lysteda).........................137
TRANSDERM-SCOP -scopolamine td patch 72hr 1.5
mg.................................................................................... 72
TRANXENE T -clorazepate dipotassium tab 15 mg.......... 78
TRANXENE T -clorazepate dipotassium tab 3.75 mg....... 78
TRANXENE T -clorazepate dipotassium tab 7.5 mg......... 78
tranylcypromine sulfate tab 10 mg (Parnate)................83
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free).......................................144
TRAVOPROST -travoprost ophth soln 0.004%............... 144
trazodone hcl tab 100 mg............................................... 83
trazodone hcl tab 150 mg............................................... 83
trazodone hcl tab 300 mg............................................... 83
trazodone hcl tab 50 mg................................................. 83
TREAGAN OTIC - antipyrine-benzocaine-polycosanol otic
sol 5.4-1.4-0.0097% ......................................................145
TRECATOR -ethionamide tab 250 mg................................ 6
TRENTAL -pentoxifylline tab cr 400 mg.......................... 140
tretinoin cap 10 mg......................................................... 18
tretinoin cream 0.025% (Retin-a)..................................162
tretinoin cream 0.05% (Retin-a)....................................162
tretinoin cream 0.1% (Retin-a)......................................162
tretinoin gel 0.01% (Retin-a)......................................... 162
tretinoin gel 0.025% (Retin-a)....................................... 162
tretinoin microsphere gel 0.04% (Retin-a micro)........ 162
tretinoin microsphere gel 0.1% (Retin-a micro).......... 162
TRETIN-X -tretinoin cream 0.025% w/ cleanser &
moisturizer kit.................................................................162
TRETIN-X -tretinoin cream 0.0375%............................... 162
TRETIN-X -tretinoin cream 0.05% w/ cleanser &
moisturizer kit.................................................................162
TRETIN-X -tretinoin cream 0.075%.................................162
TRETIN-X -tretinoin cream 0.1% w/ cleanser & moisturizer
kit....................................................................................162
TRETIN-X -tretinoin gel 0.01% w/ cleanser & moisturizer
kit....................................................................................162
TRETIN-X -tretinoin gel 0.025% w/ cleanser & moisturizer
kit....................................................................................162
TRETTEN -coagulation factor xiii a-subunit for inj
2000-3125 unit............................................................... 140
TREXALL -methotrexate sodium tab 10 mg (base
equiv)................................................................................18
TREXALL -methotrexate sodium tab 15 mg (base
equiv)................................................................................18
TREXALL -methotrexate sodium tab 5 mg (base
equiv)................................................................................18
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)................................................................................18
TREXIMET -sumatriptan-naproxen sodium tab 85-500
mg.................................................................................. 109
TREZIX -acetaminophen-caffeine-dihydrocodeine cap
356.4-30-16 mg..............................................................104
TRIADVANCE - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 126
triamcinolone acetonide cream 0.025%.......................162
triamcinolone acetonide cream 0.1%...........................162
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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triamcinolone acetonide cream 0.5%...........................162
triamcinolone acetonide dental paste 0.1%................ 147
TRIAMCINOLONE ACETONIDE I -triamcinolone
acetonide oint 0.05%..................................................... 162
triamcinolone acetonide lotion 0.025%....................... 162
triamcinolone acetonide lotion 0.1%........................... 162
triamcinolone acetonide nasal inhal 55 mcg/act
(Nasacort aq).................................................................. 60
triamcinolone acetonide oint 0.025%...........................162
triamcinolone acetonide oint 0.1%...............................162
TRIAMCINOLONE ACETONIDE -triamcinolone acetonide
oint 0.5%........................................................................ 162
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg...................................54
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%............... 162
triazolam tab 0.125 mg....................................................88
triazolam tab 0.25 mg (Halcion)..................................... 88
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
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............................. 126
TRICARE PRENATAL DHA ONE - prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg .................................... 126
TRICARE - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 126
TRI-CHLOR -trichloroacetic acid liqd 80%...................... 162
TRICITRATES -pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml........................................................ 77
TRICODE AR -pseudoephedrine-chlorphen w/ codeine liq
30-2-8 mg/5ml..................................................................64
TRICODE GF -pseudoephedrine w/ cod-gg liquid 30-8-200
mg/5ml..............................................................................64
TRICOR -fenofibrate tab 145 mg...................................... 57
TRICOR -fenofibrate tab 48 mg........................................ 57
trifluoperazine hcl tab 10 mg......................................... 86
trifluoperazine hcl tab 1 mg........................................... 86
trifluoperazine hcl tab 2 mg........................................... 86
trifluoperazine hcl tab 5 mg........................................... 86
trifluridine ophth soln 1% (Viroptic)............................ 144
TRIGLIDE -fenofibrate tab 160 mg....................................57
TRIGLIDE -fenofibrate tab 50 mg......................................57
250
trihexyphenidyl hcl elixir 0.4 mg/ml.............................117
trihexyphenidyl hcl tab 2 mg........................................117
trihexyphenidyl hcl tab 5 mg........................................117
TRILEPTAL -oxcarbazepine susp 300 mg/5ml (60 mg/
ml).................................................................................. 114
TRILEPTAL -oxcarbazepine tab 150 mg......................... 114
TRILEPTAL -oxcarbazepine tab 300 mg......................... 114
TRILEPTAL -oxcarbazepine tab 600 mg......................... 114
TRILIPIX -choline fenofibrate cap dr 135 mg (fenofibric
acid equiv)........................................................................57
TRILIPIX -choline fenofibrate cap dr 45 mg (fenofibric acid
equiv)................................................................................57
TRIMESIS RX - prenatal w/ calcium carbonate-b6-b12-fa
tab 1 mg ....................................................................... 126
trimethobenzamide hcl cap 300 mg (Tigan).................. 72
trimethoprim tab 100 mg................................................ 12
trimipramine maleate cap 100 mg..................................83
trimipramine maleate cap 25 mg....................................83
trimipramine maleate cap 50 mg....................................83
TRINATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 126
TRINATAL RX 1 - prenatal vit w/ fe fumarate-fa tab 60-1
mg ................................................................................. 126
TRINATAL ULTRA - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg .................................................................. 126
TRINATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg
....................................................................................... 126
TRI-NORINYL 28 -norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg..............................................26
TRIOXIN -benzocaine-chloroxylenol-hc otic soln 15-1-10
mg/ml..............................................................................145
TRIPEDIA -diph, acellular pert & tet tox inj 6.7 lf-46.8
mcg-5lf/0.5ml....................................................................15
TRIPLE DYE -triple dye solution..................................... 165
TRI RX - prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg ..........................................................................126
TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.........................................................126
TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk.................................................. 127
TRIVEEN-ONE - prenatal w/o vit a w/ fe fum-fa-omega 3
cap 27-1-250 mg .......................................................... 127
TRIVEEN-PRX RNF - prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg ................................................ 127
TRIVEEN-TEN -prenatal mv & min w/fe carbonyl-fa-dha
tab 15-0.5-50 mg........................................................... 127
TRIVEEN-U - prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg ................................................................... 127
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.25 mg/ml............................................................ 126
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.5 mg/ml.............................................................. 126
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.25 mg/ml..................................................................... 126
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.5 mg/ml....................................................................... 126
TRI-VIT/FLUORIDE/IRON -pediatric vitamins acd fluoride
& fe drops 0.25-10 mg/ml.............................................. 126
TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg...............................................................10
TROKENDI XR -topiramate cap sr 24hr 100 mg............. 114
TROKENDI XR -topiramate cap sr 24hr 200 mg............. 114
TROKENDI XR -topiramate cap sr 24hr 25 mg............... 114
TROKENDI XR -topiramate cap sr 24hr 50 mg............... 114
TROPAZONE - emollient - lotion ................................... 162
tropicamide ophth soln 0.5%........................................144
tropicamide ophth soln 1% (Mydriacyl).......................144
trospium chloride cap sr 24hr 60 mg............................ 75
trospium chloride tab 20 mg (Sanctura)........................75
TRUSOPT -dorzolamide hcl ophth soln 2%.................... 144
TRUST NATAL DHA -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 250 pk......................................................127
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg......................................................................10
trypsin w/ castor oil & peruvian balsam oint
(Xenaderm)....................................................................162
trypsin w/ castor oil & peruvian balsam spray
(Granulex)..................................................................... 162
TUDORZA PRESSAIR -aclidinium bromide aerosol powd
breath activated 400 mcg/act...........................................67
TUSNEL -brompheniramine w/ dm-gg cap 2-15-200
mg.................................................................................... 64
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
10-8 mg............................................................................64
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
5-4 mg..............................................................................64
TUSSIONEX PENNKINETIC EXT -hydrocod polstchlorphen polst cr susp 10-8 mg/5ml...............................64
TWINJECT -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 54
TWINJECT -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................54
TWYNSTA -telmisartan-amlodipine tab 40-10 mg.............51
TWYNSTA -telmisartan-amlodipine tab 40-5 mg...............51
TWYNSTA -telmisartan-amlodipine tab 80-10 mg.............51
TWYNSTA -telmisartan-amlodipine tab 80-5 mg...............51
TYKERB -lapatinib ditosylate tab 250 mg (base equiv)..... 18
TYLENOL/CODEINE #3 -acetaminophen w/ codeine tab
300-30 mg......................................................................104
TYLENOL/CODEINE #4 -acetaminophen w/ codeine tab
300-60 mg......................................................................104
TYLENOL/CODEINE -acetaminophen w/ codeine tab
300-15 mg......................................................................104
TYLOX -oxycodone w/ acetaminophen cap 5-500 mg.....104
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 -tetrahydrozoline hcl
nasal soln 0.05%............................................................. 60
TYZINE -tetrahydrozoline hcl nasal soln 0.1%.................. 60
U
UCERIS -budesonide tab sr 24hr 9 mg.............................20
U-CORT -urea-hc acetate cream 1%.............................. 162
UDAMIN -multiple vitamins w/ minerals & fa tab 2 mg.....127
UDAMIN SP -multiple vitamins w/ minerals & fa tab 1
mg.................................................................................. 127
ULESFIA -benzyl alcohol lotion 5%.................................162
ULORIC -febuxostat tab 40 mg....................................... 109
ULORIC -febuxostat tab 80 mg....................................... 109
ULTILET GLUCOSE -glucose chew tab 4 gm...................31
ULTIMATECARE ONE NF - prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap 20-7-1 mg ................................ 127
ULTIMATECARE ONE - prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg ............................................... 127
ULTIMATE OB DHA -prenat w/ fe poly cmplx-fe asp-fe glyfa tab & dha cap pak..................................................... 127
ULTRACET -tramadol-acetaminophen tab 37.5-325
mg.................................................................................. 104
ULTRAM ER -tramadol hcl tab sr 24hr 100 mg............... 104
ULTRAM ER -tramadol hcl tab sr 24hr 200 mg............... 104
ULTRAM ER -tramadol hcl tab sr 24hr 300 mg............... 104
ULTRAM -tramadol hcl tab 50 mg...................................104
ULTRASAL-ER -salicylic acid film-forming soln
28.5%............................................................................. 162
ULTRA TABS - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 127
ULTRAVATE -halobetasol propionate cream 0.05%....... 162
ULTRAVATE -halobetasol propionate oint 0.05%........... 162
ULTRAVATE PAC -halobetasol prop cream 0.05% &
ammonium lactate lot 12% kit........................................163
ULTRAVATE PAC -halobetasol prop oint 0.05% &
ammonium lactate lot 12% kit........................................163
ULTRAVATE X -halobetasol prop cream 0.05% & lactic
acid cream 10% kit........................................................ 163
ULTRAVATE X -halobetasol prop oint 0.05% & lactic acid
cream 10% kit................................................................ 163
ULTRESA -pancrelipase (lip-prot-amyl) dr cap
13800-27600-27600 unit.................................................. 72
ULTRESA -pancrelipase (lip-prot-amyl) dr cap
20700-41400-41400 unit.................................................. 72
ULTRESA -pancrelipase (lip-prot-amyl) dr cap
23000-46000-46000 unit.................................................. 72
UMECTA NAIL FILM -urea suspension 40%...................163
UMECTA PD -urea-hyaluronate sodium emulsion
40-0.3%.......................................................................... 163
UMECTA PD -urea-hyaluronate sodium susp
40-0.3%.......................................................................... 163
UMECTA -urea emulsion 40%........................................ 163
UMECTA -urea suspension 40%.....................................163
UNIRETIC -moexipril-hydrochlorothiazide tab 15-12.5
mg.................................................................................... 51
BCBSTX Health Insurance Marketplace 5 Tier Standard Formulary October 2014
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UNIRETIC -moexipril-hydrochlorothiazide tab 15-25
mg.................................................................................... 52
UNIRETIC -moexipril-hydrochlo