January 2017 (2016 Plan Year)
Health Insurance Marketplace Generics Plus Drug List
Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug list is regularly updated. Please visit bcbstx.com for the most up-to-date information. To find a contracting pharmacy, please access the link below: https://www.myprime.com/en/find-pharmacy.html
Contents
Therapeutic Class Drug List
Introduction ...................................................................... I Anti-Infective Agents ....................................................... 1 How drugs are selected ................................................... I Biologicals ..................................................................... 13 How member payment is determined .............................. I Antineoplastic Agents ................................................... 17 How to use this list .......................................................... II Endocrine and Metabolic Drugs ................................... 22 Drugs used to treat multiple conditions .......................... II Cardiovascular Agents .................................................. 41 Generic drugs ................................................................. II Respiratory Agents ....................................................... 60 Consider talking to your doctor about generic
Gastrointestinal Agents ................................................. 67
drugs ........................................................................... II Genitourinary Agents .................................................... 74 Coverage considerations ............................................... III Central Nervous System Drugs .................................... 77 Specialty drugs ............................................................... V Analgesics and Anesthetics .......................................... 95 Prime Therapeutics Specialty Pharmacy
Neuromuscular Drugs ................................................. 108
program....................................................................... V Nutritional Products .................................................... 118 Abbreviation key ............................................................ VI Hematological Agents ................................................. 148 Topical Products ......................................................... 160 Miscellaneous Products .............................................. 180 Index ........................................................................... 185
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. Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
41722-K TX HIM © Prime Therapeutics LLC 1/17
Introduction Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician. Drug lists updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbstx.com.
How drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list.
How member payment is determined This list shows prescription drug products in tiers. Generally, each drug is placed into one of five member payment tiers: Preferred Generic (Tier 1), Non-preferred Generic (Tier 2), Preferred Brand (Tier 3), Non-preferred Brand (Tier 4) and Specialty (Tier 5). Please refer to the ACA Preventive (ACA) section for drugs marked with an "A" in the drug tier column. To verify your payment amount for a drug, visit bcbstx.com and log in to Blue Access for Members or call the number on the back of your ID card. Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for selfadministration may be available through your medical benefit.
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January 2017 (2016 Plan Year)
I
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.
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January 2017 (2016 Plan Year)
II
Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan materials for details about your particular benefits. Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount. Repackaged medications: Repackaged versions of medications already available on the market are not covered. Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the preferred medications listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the preferred medications listed in this document, if a step therapy is commonly required it will generally be noted next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on additional medications beyond those noted in this document. Dispensing Limits (DL): Drug Dispensing limits are designed to help encourage medication use as intended by the FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered medication in a given time period, coverage only for members within a certain age range, and coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit bcbstx.com. *Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit. Limited Distribution (LD): Medicines marked as "Limited Distribution" have restrictions on where you may obtain a medication. This may include requiring the use of a designated pharmacy to fill a prescription.
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January 2017 (2016 Plan Year)
III
ACA Preventive (ACA): Medicines marked in the ACA column are under the Affordable Care Act coverage of preventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), when meeting the conditions as outlined under the regulation. These are also indicated with an "A" in the drug tier column. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D supplements, and some FDA approved contraceptive methods. To see what contraceptive products may be covered, visit www.bcbstx.com/pdf/rx/contraceptive-list-tx.pdf 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.
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January 2017 (2016 Plan Year)
IV
Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications, visit myprime.com or bcbstx.com and log in to Blue Access for Members. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card. Prime Therapeutics Specialty Pharmacy Program Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at no additional charge the following services: •
Coordination of coverage between you, your doctor and your health plan
•
Educational materials about your particular condition and information about managing potential medication side effects
•
Syringes, sharps containers and other supplies with every shipment for self-injectables
•
24/7/365 phone access to a pharmacist for urgent medication issues
To order through Prime Therapeutics Specialty Pharmacy: •
Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can call 877-627-6337 or fax to 877-828-3939.
•
If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to transfer your prescription.
•
A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.
•
The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging.
If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337, visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card. •
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”). HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January 2017 (2016 Plan Year)
V
Abbreviation key cap ...................................................................... capsules chew .................................................................. chewable
odt ............................................. orally disintegrating tabs oint ..................................................................... ointment
conc ............................................................. concentrate
ophth ................................................................. opthalmic osm .......................................................... osmotic release
cr .......................................................... controlled release dr ............................................................. delayed release ec ................................................................ enteric coated effe................................................................. effervescent equiv ................................................................ equivalent er ...........................................................extended release inhal................................................................... inhalation inj ......................................................................... injection liq .............................................................................. liquid lotn ........................................................................... lotion
powd..................................................................... powder sa ............................................................ sustained action sl ...................................................................... sublingual soln ....................................................................... solution sr .......................................................... sustained release suppos ........................................................ suppositories susp ................................................................ suspension tab ...........................................................................tablets td ................................................................... transdermal
nebu ................................................................... nebulizer You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List (also known as a formulary). To request this exception, you, or your prescriber, can call the number on the back of your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be able to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage decision within 24 hours after they receive your request for an expedited review. If the coverage request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). Call the number on the back of your ID card if you have any questions.
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January 2017 (2016 Plan Year)
VI
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2
1
AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab 400-57 mg
4
1
AMPICILLIN - ampicillin for susp 125 mg/5ml
4
1
AMPICILLIN - ampicillin for susp 250 mg/5ml ampicillin cap 250 mg
1
1 1 1
ampicillin cap 500 mg
1
AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml
4
2
dicloxacillin sodium cap 250 mg
2
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)
2
dicloxacillin sodium cap 500 mg
amoxicillin & k clavulanate for susp 400-57 mg/5ml
2
amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
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
4
penicillin v potassium for soln 125 mg/5ml
1
penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg
Limited Distribution
ACA
Dispensing Limits
2
MOXATAG - amoxicillin (trihydrate) tab sr 24hr 775 mg
penicillin v potassium for soln 250 mg/5ml
Step Therapy
1
1
amoxicillin (trihydrate) tab 500 mg
Prior Authorization
Drug Tier 2
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) for susp 400 mg/5ml
Limited Distribution
AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab 200-28.5 mg
4
amoxicillin (trihydrate) for susp 250 mg/5ml
ACA
2
AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg
amoxicillin (trihydrate) for susp 200 mg/5ml
Dispensing Limits
amoxicillin & k clavulanate tab 875-125 mg (Augmentin)
4
amoxicillin (trihydrate) for susp 125 mg/5ml
Step Therapy
2
AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg
amoxicillin (trihydrate) cap 500 mg
Drug Name amoxicillin & k clavulanate tab 500-125 mg (Augmentin)
ANTI-INFECTIVE AGENTS PENICILLINS
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
1
CEPHALOSPORINS CEDAX - ceftibuten cap 400 mg
4
cefpodoxime proxetil for susp 100 mg/5ml
CEDAX - ceftibuten for susp 180 mg/5ml
4
cefpodoxime proxetil tab 100 mg
CEFACLOR - cefaclor for susp 125 mg/5ml
4
cefpodoxime proxetil tab 200 mg
CEFACLOR - cefaclor for susp 250 mg/5ml
4
cefprozil for susp 125 mg/5ml
CEFACLOR - cefaclor for susp 375 mg/5ml
4
cefprozil for susp 250 mg/5ml
cefaclor cap 250 mg
2
cefaclor cap 500 mg
2
cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml
4
2
CEFTIN - cefuroxime axetil for susp 250 mg/5ml
2
2
cefuroxime axetil tab 250 mg (Ceftin) cefuroxime axetil tab 500 mg (Ceftin)
2
CEPHALEXIN - cephalexin tab 250 mg
4
CEPHALEXIN - cephalexin tab 500 mg
4
cephalexin cap 250 mg (Keflex)
1
cephalexin cap 500 mg (Keflex)
1
cephalexin cap 750 mg (Keflex)
2
cephalexin for susp 125 mg/5ml
2
2 2
CEFDITOREN PIVOXIL cefditoren pivoxil tab 400 mg (base equivalent)
4
cefixime for susp 100 mg/5ml (Suprax)
2 2 2
Limited Distribution
ACA
Dispensing Limits
2
2
2
Step Therapy
2
3
4
cefpodoxime proxetil for susp 50 mg/5ml
2
CEFTIN - cefuroxime axetil for susp 125 mg/5ml
CEFDITOREN PIVOXIL cefditoren pivoxil tab 200 mg (base equivalent)
cefixime for susp 200 mg/5ml (Suprax)
2
4
1
cefdinir cap 300 mg
2
CEFTIBUTEN - ceftibuten for susp 180 mg/5ml
cefadroxil cap 500 mg
cefadroxil tab 1 gm
2
4
4
cefadroxil for susp 500 mg/5ml
cefprozil tab 500 mg
2
CEFTIBUTEN - ceftibuten cap 400 mg
CEFACLOR ER - cefaclor monohydrate tab sr 12hr 500 mg cefadroxil for susp 250 mg/5ml
cefprozil tab 250 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
2
2
clarithromycin tab 250 mg (Biaxin)
2
SPECTRACEF - cefditoren pivoxil tab 400 mg (base equivalent)
4
clarithromycin tab 500 mg (Biaxin)
2
DIFICID - fidaxomicin tab 200 mg
4
SUPRAX - cefixime cap 400 mg
4 4
E.E.S. GRANULES erythromycin ethylsuccinate for susp 200 mg/5ml
4
SUPRAX - cefixime chew tab 100 mg SUPRAX - cefixime chew tab 200 mg
4
E.E.S. 400 - erythromycin ethylsuccinate tab 400 mg
4
SUPRAX - cefixime for susp 100 mg/5ml
4
ERY-TAB - erythromycin tab delayed release 250 mg
4
SUPRAX - cefixime for susp 200 mg/5ml
4
ERY-TAB - erythromycin tab delayed release 333 mg
4
SUPRAX - cefixime for susp 500 mg/5ml
4
ERY-TAB - erythromycin tab delayed release 500 mg
4 4
cephalexin for susp 250 mg/5ml
MACROLIDES AZITHROMYCIN azithromycin powd pack for susp 1 gm
4
ERYPED 200 - erythromycin ethylsuccinate for susp 200 mg/5ml
4
azithromycin for susp 100 mg/5ml (Zithromax)
2
ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml ERYTHROCIN STEARATE erythromycin stearate tab 250 mg
4
ERYTHROMYCIN BASE erythromycin tab 250 mg
4
ERYTHROMYCIN BASE erythromycin tab 500 mg
4
ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate tab 400 mg
4
azithromycin for susp 200 mg/5ml (Zithromax)
2
azithromycin tab 250 mg (Zithromax)
1
•
azithromycin tab 500 mg (Zithromax)
1
•
azithromycin tab 600 mg (Zithromax)
2
•
clarithromycin for susp 125 mg/5ml
2
clarithromycin for susp 250 mg/5ml (Biaxin) clarithromycin tab sr 24hr 500 mg
2 2
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
erythromycin ethylsuccinate 2 for susp 200 mg/5ml (E.e.s. granules)
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
3
erythromycin w/ delayed release particles cap 250 mg
2
doxycycline monohydrate cap 75 mg (Monodox)
2
PCE - erythromycin w/ enteric coated particles tab 333 mg
doxycycline monohydrate cap 100 mg (Monodox)
PCE - erythromycin w/ enteric coated particles tab 500 mg
4
doxycycline monohydrate cap 150 mg (Adoxa)
4
doxycycline monohydrate for susp 25 mg/5ml (Vibramycin)
2
ZITHROMAX - azithromycin powd pack for susp 1 gm ZMAX - azithromycin extended release for oral susp 2 gm
4
doxycycline monohydrate tab 50 mg (Adoxa)
2
demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg (Vibramycin)
doxycycline monohydrate tab 75 mg (Adoxa)
2 2 2 2
2
doxycycline monohydrate tab 100 mg (Adoxa pak 1/100)
2
doxycycline monohydrate tab 150 mg (Adoxa pak 1/150)
2
minocycline hcl cap 50 mg (Minocin)
1
minocycline hcl cap 75 mg (Minocin)
1
doxycycline hyclate tab delayed release 75 mg
2
•
minocycline hcl cap 100 mg (Minocin)
1
2
•
minocycline hcl tab sr 24hr 45 mg
2
•
2
•
minocycline hcl tab sr 24hr 90 mg
2
•
doxycycline hyclate tab delayed release 200 mg (Doryx)
2
•
minocycline hcl tab sr 24hr 135 mg
2
•
doxycycline hyclate tab 20 mg
2
doxycycline hyclate tab 100 mg doxycycline monohydrate cap 50 mg
2 2
minocycline hcl tab 75 mg minocycline hcl tab 100 mg
Limited Distribution
•
•
minocycline hcl tab 50 mg
ACA
2
2
doxycycline hyclate tab delayed release 150 mg
Dispensing Limits
•
doxycycline hyclate tab delayed release 50 mg (Doryx)
doxycycline hyclate tab delayed release 100 mg
Step Therapy
•
2
4
TETRACYCLINES
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2
TETRACYCLINE HCL tetracycline hcl cap 250 mg
4
TETRACYCLINE HCL tetracycline hcl cap 500 mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
4
tetracycline hcl cap 250 mg (Tetracycline hcl)
2
tetracycline hcl cap 500 mg (Tetracycline hcl)
2
FLUOROQUINOLONES ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)
2
2
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg (base equiv)
4
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)
1
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr)
moxifloxacin hcl tab 400 mg (base equiv) (Avelox) AMINOGLYCOSIDES
Limited Distribution
ACA
Dispensing Limits
BETHKIS - tobramycin nebu soln 300 mg/4ml
5
•
•
•
KITABIS PAK - tobramycin nebu soln 300 mg/5ml
5
•
•
•
neomycin sulfate tab 500 mg
1
paromomycin sulfate cap 250 mg
2
TOBI PODHALER - tobramycin inhal cap 28 mg
5
•
•
•
tobramycin nebu soln 300 mg/5ml (Tobi)
5
•
•
•
SULFONAMIDES
4
SULFADIAZINE - sulfadiazine tab 500 mg
1
ANTIMYCOBACTERIAL AGENTS 4 CYCLOSERINE - cycloserine cap 250 mg 2 ethambutol hcl tab 100 mg (Myambutol) 2 ethambutol hcl tab 400 mg (Myambutol) ISONIAZID - isoniazid syrup 50 4 mg/5ml 1 isoniazid tab 100 mg
2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr) 4 FACTIVE - gemifloxacin mesylate tab 320 mg (base equiv) levofloxacin oral soln 25 mg/ 2 ml (Levaquin) 1 levofloxacin tab 250 mg (Levaquin) 1 levofloxacin tab 500 mg (Levaquin) 1 levofloxacin tab 750 mg (Levaquin)
Step Therapy
2
1
2
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
isoniazid tab 300 mg
1
PASER - aminosalicylic acid cr granules packet 4 gm
4
PRIFTIN - rifapentine tab 150 mg
3
pyrazinamide tab 500 mg
2
rifabutin cap 150 mg (Mycobutin)
2
RIFAMATE - isoniazid & rifampin cap 150-300 mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
5
rifampin cap 150 mg (Rifadin) 2 rifampin cap 300 mg (Rifadin) 2 RIFATER - isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg
4
SIRTURO - bedaquiline fumarate tab 100 mg (base equiv)
4
TRECATOR - ethionamide tab 250 mg
4
ANTIFUNGALS BIO-STATIN - nystatin cap 500000 unit
4
BIO-STATIN - nystatin cap 1000000 unit
4
CRESEMBA isavuconazonium sulfate cap 186 mg
4
fluconazole for susp 10 mg/ ml (Diflucan)
griseofulvin ultramicrosize tab 125 mg (Gris-peg) griseofulvin ultramicrosize tab 250 mg (Gris-peg)
•
2
ketoconazole tab 200 mg
1
NOXAFIL - posaconazole susp 40 mg/ml
3
•
NOXAFIL - posaconazole tab delayed release 100 mg
3
•
nystatin oral powder
2
SPORANOX - itraconazole oral soln 10 mg/ml
4
1
terbinafine hcl tab 250 mg (Lamisil)
1
2
voriconazole for susp 40 mg/ml (Vfend)
2
•
fluconazole tab 50 mg (Diflucan)
1
voriconazole tab 50 mg (Vfend)
2
•
fluconazole tab 100 mg (Diflucan)
1
voriconazole tab 200 mg (Vfend)
2
•
fluconazole tab 150 mg (Diflucan)
1
fluconazole tab 200 mg (Diflucan)
2
flucytosine cap 250 mg (Ancobon)
2
flucytosine cap 500 mg (Ancobon)
2
griseofulvin microsize susp 125 mg/5ml
2
acyclovir cap 200 mg (Zovirax)
1
2
acyclovir susp 200 mg/5ml (Zovirax)
2
griseofulvin microsize tab 500 mg (Grifulvin v)
ANTIVIRALS abacavir sulfate tab 300 mg (base equiv) (Ziagen) abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) abacavir sulfatelamivudine-zidovudine tab 300-150-300 mg (Trizivir)
Limited Distribution
2 4
fluconazole for susp 40 mg/ ml (Diflucan)
ACA
2
ONMEL - itraconazole tab 200 mg
•
Dispensing Limits
2
itraconazole cap 100 mg (Sporanox)
nystatin tab 500000 unit
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
•
2
•
2
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
6
•
2
•
EDURANT - rilpivirine hcl tab 25 mg (base equivalent)
4
•
EMTRIVA - emtricitabine caps 200 mg
4
•
EMTRIVA - emtricitabine soln 10 mg/ml
4
•
entecavir tab 0.5 mg (Baraclude)
2
entecavir tab 1 mg (Baraclude)
2
BARACLUDE - entecavir oral soln 0.05 mg/ml
3 4
5
COMPLERA - emtricitabinerilpivirine-tenofovir df tab 200-25-300 mg
EPCLUSA - sofosbuvirvelpatasvir tab 400-100 mg
4
CRIXIVAN - indinavir sulfate cap 200 mg
4
•
EPIVIR - lamivudine oral soln 10 mg/ml
4
CRIXIVAN - indinavir sulfate cap 400 mg
4
•
EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv)
3
•
DAKLINZA - daclatasvir dihydrochloride tab 30 mg (base equivalent)
5
•
•
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
4
•
DAKLINZA - daclatasvir dihydrochloride tab 60 mg (base equivalent)
5
•
•
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg (base equiv) famciclovir tab 125 mg (Famvir)
2
DAKLINZA - daclatasvir dihydrochloride tab 90 mg (base equivalent)
5
•
•
famciclovir tab 250 mg (Famvir)
2 2
DESCOVY - emtricitabinetenofovir alafenamide fumarate tab 200-25 mg
3
•
famciclovir tab 500 mg (Famvir) FUZEON - enfuvirtide for inj 90 mg
5
•
didanosine delayed release capsule 125 mg (Videx ec)
2
•
3
•
2
•
GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab 150-150-200-10 mg HARVONI - ledipasvirsofosbuvir tab 90-400 mg
5
1
acyclovir tab 800 mg (Zovirax)
1
adefovir dipivoxil tab 10 mg (Hepsera)
2
APTIVUS - tipranavir cap 250 mg
4
•
APTIVUS - tipranavir oral soln 100 mg/ml
4
•
ATRIPLA - efavirenzemtricitabine-tenofovir df tab 600-200-300 mg
3
•
didanosine delayed release capsule 200 mg (Videx ec)
didanosine delayed release capsule 250 mg (Videx ec) didanosine delayed release capsule 400 mg (Videx ec)
•
•
Limited Distribution
2
acyclovir tab 400 mg (Zovirax)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
7
3
•
INVIRASE - saquinavir mesylate cap 200 mg
4
•
INVIRASE - saquinavir mesylate tab 500 mg
4
•
ISENTRESS - raltegravir potassium chew tab 25 mg (base equiv)
3
•
ISENTRESS - raltegravir potassium chew tab 100 mg (base equiv)
3
•
ISENTRESS - raltegravir potassium packet for susp 100 mg (base equiv)
3
•
ISENTRESS - raltegravir potassium tab 400 mg (base equiv)
3
•
KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
3
•
KALETRA - lopinavir-ritonavir tab 100-25 mg
3
•
KALETRA - lopinavir-ritonavir tab 200-50 mg
3
•
lamivudine oral soln 10 mg/ ml (Epivir)
2
•
lamivudine tab 100 mg (hbv) (Epivir hbv)
2
lamivudine tab 150 mg (Epivir)
2
•
lamivudine tab 300 mg (Epivir)
2
•
Limited Distribution
INTELENCE - etravirine tab 200 mg
ACA
•
Dispensing Limits
3
Step Therapy
INTELENCE - etravirine tab 100 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
INTELENCE - etravirine tab 25 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
•
LEXIVA - fosamprenavir calcium susp 50 mg/ml (base equiv)
4
•
LEXIVA - fosamprenavir calcium tab 700 mg (base equiv)
4
•
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 - 5 ribavirin tab 400 mg NEVIRAPINE - nevirapine susp 4 50 mg/5ml 2 nevirapine tab sr 24hr 100 mg 2 nevirapine tab sr 24hr 400 mg (Viramune xr) 1 nevirapine tab 200 mg (Viramune) NORVIR - ritonavir cap 100 mg 4
•
•
lamivudine-zidovudine tab 150-300 mg (Combivir)
NORVIR - ritonavir oral soln 80 mg/ml
3
NORVIR - ritonavir tab 100 mg
3
ODEFSEY - emtricitabinerilpivirine-tenofovir af tab 200-25-25 mg
3
OLYSIO - simeprevir sodium cap 150 mg (base equivalent)
5
• • • • • • • • •
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
8
•
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 120 mcg/0.5ml
5
•
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 150 mcg/0.5ml
5
•
•
PEG-INTRON REDIPEN PAK 4 - peginterferon alfa-2b for inj kit 120 mcg/0.5ml
5
•
•
PEGASYS - peginterferon alfa-2a inj 180 mcg/ml
5
•
•
PEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml
5
•
•
PEGASYS PROCLICK peginterferon alfa-2a inj 135 mcg/0.5ml
5
•
•
PEGASYS PROCLICK peginterferon alfa-2a inj 180 mcg/0.5ml
5
•
•
PEGINTRON - peginterferon alfa-2b for inj kit 50 mcg/0.5ml
5
PEGINTRON - peginterferon alfa-2b for inj kit 80 mcg/0.5ml
5
•
•
PEGINTRON - peginterferon alfa-2b for inj kit 120 mcg/0.5ml
5
•
PEGINTRON - peginterferon alfa-2b for inj kit 150 mcg/0.5ml
5
•
PREZCOBIX - darunavircobicistat tab 800-150 mg
4
PREZISTA - darunavir ethanolate susp 100 mg/ml (base equiv)
3
•
PREZISTA - darunavir ethanolate tab 75 mg (base equiv)
3
•
PREZISTA - darunavir ethanolate tab 150 mg (base equiv)
3
•
PREZISTA - darunavir ethanolate tab 600 mg (base equiv)
3
•
PREZISTA - darunavir ethanolate tab 800 mg (base equiv)
3
•
REBETOL - ribavirin soln 40 mg/ml
5
RELENZA DISKHALER zanamivir aero powder breath activated 5 mg/blister
4
•
RESCRIPTOR - delavirdine mesylate tab 100 mg
4
•
RESCRIPTOR - delavirdine mesylate tab 200 mg
4
•
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)
3
•
•
REYATAZ - atazanavir sulfate oral powder packet 50 mg (base equiv)
4
•
•
RIBASPHERE - ribavirin tab 400 mg
5
•
•
RIBASPHERE - ribavirin tab 600 mg
5
•
•
RIBASPHERE RIBAPAK ribavirin tab 400 mg
5
•
•
•
•
Limited Distribution
5
ACA
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 80 mcg/0.5ml
•
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 50 mcg/0.5ml
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
9
5
•
RIBASPHERE RIBAPAK ribavirin tab 400 mg & ribavirin tab 600 mg dose pack
5
ribavirin cap 200 mg (Rebetol)
5
•
•
ribavirin tab 200 mg (Copegus)
5
•
•
rimantadine hydrochloride tab 100 mg (Flumadine)
2
•
•
•
•
3
•
TAMIFLU - oseltamivir phosphate cap 30 mg (base equiv)
4
•
TAMIFLU - oseltamivir phosphate cap 45 mg (base equiv)
4
•
TAMIFLU - oseltamivir phosphate cap 75 mg (base equiv)
4
•
TAMIFLU - oseltamivir phosphate for susp 6 mg/ml (base equiv)
4
•
TECHNIVIE - ombitasvirparitaprevir-ritonavir tab 12.5-75-50 mg
5
TIVICAY - dolutegravir sodium tab 10 mg (base equiv)
3
•
3
•
•
•
SELZENTRY - maraviroc tab 150 mg
4
SELZENTRY - maraviroc tab 300 mg
4
SITAVIG - acyclovir buccal tab 50 mg
4
TIVICAY - dolutegravir sodium tab 25 mg (base equiv)
3
•
SOVALDI - sofosbuvir tab 400 mg
5
TIVICAY - dolutegravir sodium tab 50 mg (base equiv)
4
•
stavudine cap 15 mg (Zerit)
2
TRIUMEQ - abacavirdolutegravir-lamivudine tab 600-50-300 mg TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 100-150 mg
3
•
TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 133-200 mg
3
•
TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 167-250 mg
3
•
TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 200-300 mg
3
•
•
•
•
2
• • • • •
STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab 150-150-200-300 mg
3
•
SUSTIVA - efavirenz cap 50 mg
3
SUSTIVA - efavirenz cap 200 mg
3
stavudine cap 20 mg (Zerit) stavudine cap 30 mg (Zerit) stavudine cap 40 mg (Zerit) stavudine for oral soln 1 mg/ ml (Zerit)
2 2 2
• •
Limited Distribution
RIBASPHERE RIBAPAK ribavirin tab 200 mg & ribavirin tab 400 mg dose pack
SUSTIVA - efavirenz tab 600 mg
ACA
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
RIBASPHERE RIBAPAK ribavirin tab 600 mg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
10
•
4
3
•
valacyclovir hcl tab 500 mg (Valtrex)
2
VIREAD - tenofovir disoproxil fumarate tab 150 mg
3
•
valacyclovir hcl tab 1 gm (Valtrex)
2
VIREAD - tenofovir disoproxil fumarate tab 200 mg
3
•
VALCYTE - valganciclovir hcl for soln 50 mg/ml (base equiv)
3
VIREAD - tenofovir disoproxil fumarate tab 250 mg VIREAD - tenofovir disoproxil fumarate tab 300 mg
3
•
valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte)
2
VITEKTA - elvitegravir tab 85 mg
4
•
VITEKTA - elvitegravir tab 150 mg
4
valganciclovir hcl tab 450 mg (base equivalent) (Valcyte)
2
•
5
VIDEX - didanosine for soln 2 gm
3
•
ZEPATIER - elbasvirgrazoprevir tab 50-100 mg
3
•
VIDEX - didanosine for soln 4 gm
3
•
ZIAGEN - abacavir sulfate soln 20 mg/ml (base equiv)
2
•
VIEKIRA PAK - ombitasparitapre-riton & dasab tab pak 12.5-75-50 & 250 mg
5
•
•
zidovudine cap 100 mg (Retrovir) zidovudine syrup 10 mg/ml (Retrovir)
2
•
VIEKIRA XR - dasab-ombitparitap-riton tab sr 24hr 200-8.33-50-33.33 mg
5
•
•
zidovudine tab 300 mg
2
•
VIRACEPT - nelfinavir mesylate tab 250 mg
4
VIRACEPT - nelfinavir mesylate tab 625 mg
4
VIRAMUNE - nevirapine susp 50 mg/5ml
3
VIRAMUNE XR - nevirapine tab sr 24hr 100 mg
4
VIRAZOLE - ribavirin for inhal soln 6 gm
4
TYZEKA - telbivudine tab 600 mg
• • • •
ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) atovaquone-proguanil hcl tab 250-100 mg (Malarone) chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg (Aralen)
•
Limited Distribution
3
4
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
Drug Name VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/ gm
TYBOST - cobicistat tab 150 mg
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
2 2 1 1
COARTEM - artemetherlumefantrine tab 20-120 mg
4
DARAPRIM - pyrimethamine tab 25 mg
3
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
11
hydroxychloroquine sulfate tab 200 mg (Plaquenil) mefloquine hcl tab 250 mg
dapsone tab 100 mg
2
IMPAVIDO - miltefosine cap 50 mg
3
linezolid for susp 100 mg/5ml (Zyvox)
2
•
2
•
3
quinine sulfate cap 324 mg (Qualaquin)
2
linezolid tab 600 mg (Zyvox)
2
metronidazole tab 250 mg (Flagyl)
1
ALBENZA - albendazole tab 200 mg
3
metronidazole tab 500 mg (Flagyl)
1
BILTRICIDE - praziquantel tab 600 mg
3
NEBUPENT - pentamidine isethionate for nebulization soln 300 mg
4
EMVERM - mebendazole chew tab 100 mg
4
ivermectin tab 3 mg (Stromectol)
2
PRIMSOL - trimethoprim hcl oral soln 50 mg/5ml (base equiv)
4
•
SIVEXTRO - tedizolid phosphate tab 200 mg
4
•
sulfamethoxazoletrimethoprim susp 200-40 mg/5ml
1
•
•
•
sulfamethoxazoletrimethoprim tab 400-80 mg (Bactrim) sulfamethoxazoletrimethoprim tab 800-160 mg (Bactrim ds)
Limited Distribution
2
metronidazole cap 375 mg (Flagyl)
ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 4 100 mg/5ml 4 ALINIA - nitazoxanide tab 500 mg 2 atovaquone susp 750 mg/5ml (Mepron) 5 CAYSTON - aztreonam lysine for inhal soln 75 mg (base equivalent) 1 clindamycin hcl cap 75 mg (Cleocin) 1 clindamycin hcl cap 150 mg (Cleocin) 1 clindamycin hcl cap 300 mg (Cleocin) 2 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) 2 dapsone tab 25 mg
ACA
Dispensing Limits
Step Therapy
1
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg (15 mg base)
ANTHELMINTICS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
tinidazole tab 250 mg (Tindamax)
2
tinidazole tab 500 mg (Tindamax)
2
trimethoprim tab 100 mg
1
vancomycin hcl cap 125 mg (Vancocin hcl)
2
vancomycin hcl cap 250 mg (Vancocin hcl)
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
12
•
ZYVOX - linezolid tab 600 mg
4
•
ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml
A
•
ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml
A
•
ENGERIX-B - hepatitis b vaccine (recombinant) 10 mcg/0.5ml
A
•
•
ENGERIX-B - hepatitis b vaccine (recombinant) 20 mcg/ml
A
•
•
FLUAD 2016-2017 - influenza vac type a&b surface ant adj susp pref syr 0.5 ml
A
•
FLUARIX QUADRIVALENT 2014 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUARIX QUADRIVALENT 2015 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUARIX QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUARIX 2014-2015 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
•
FLUBLOK 2014-2015 influenza virus vac recombinant hemagglutinin (ha) inj
A
•
FLUBLOK 2015-2016 influenza virus vac recombinant hemagglutinin (ha) inj
A
•
BIOLOGICALS VACCINES AFLURIA PF 2012-2013 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
AFLURIA PF 2014-2015 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
AFLURIA PF 2015-2016 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
•
AFLURIA PF 2016-2017 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
•
AFLURIA QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
AFLURIA 2012-2013 influenza virus vaccine split im susp
A
AFLURIA 2014-2015 influenza virus vaccine split im susp
A
AFLURIA 2015-2016 influenza virus vaccine split im susp
A
AFLURIA 2016-2017 influenza virus vaccine split im susp
A
• • • •
Limited Distribution
ZYVOX - linezolid for susp 100 mg/5ml
4
ACA
•
Dispensing Limits
3
Step Therapy
XIFAXAN - rifaximin tab 550 mg
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
XIFAXAN - rifaximin tab 200 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
13
FLUCELVAX 2014-2015 influenza virus vac tiss-cult subunit susp pref syr 0.5 ml
A
•
FLUCELVAX 2015-2016 influenza virus vac tiss-cult subunit susp pref syr 0.5 ml
A
•
FLULAVAL QUADRIVALENT 201 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
FLULAVAL QUADRIVALENT 201 - influenza virus vaccine split quadrivalent im inj
A
FLULAVAL 2014-2015 influenza virus vaccine split im susp
A
•
FLUMIST QUADRIVALENT influenza virus vaccine live quadrivalent intranasal susp
A
•
FLUVIRIN PF 2014-2015 influenza virus vac types a & b pf susp prefilled syr 0.5 ml
A
•
FLUVIRIN 2014-2015 influenza virus vaccine types a & b surface antigen im susp
A
•
FLUVIRIN 2015-2016 influenza vac type a&b surface antigen susp pref syr 0.5 ml
A
•
• •
FLUVIRIN 2015-2016 influenza virus vaccine types a & b surface antigen im susp
A
•
FLUVIRIN 2016-2017 influenza vac type a&b surface antigen susp pref syr 0.5 ml
A
•
FLUVIRIN 2016-2017 influenza virus vaccine types a & b surface antigen im susp
A
•
FLUZONE HIGH-DOSE PF 2014 - influenza virus vac split high-dose pf susp pref syr 0.5ml
A
•
FLUZONE HIGH-DOSE PF 2015 - influenza virus vac split high-dose pf susp pref syr 0.5ml
A
•
FLUZONE HIGH-DOSE PF 2016 - influenza virus vac split high-dose pf susp pref syr 0.5ml
A
•
FLUZONE INTRADERMAL QUADR - influenza virus vac split quad intradermal pen 9 mcg/strain
A
•
FLUZONE PF 2014-2015 influenza virus vaccine split pf susp pref syringe 0.5 ml
A
•
FLUZONE QUADRIVALENT 2014 - influenza virus vac split quadrivalent susp pref syr 0.25 ml
A
•
FLUZONE QUADRIVALENT 2014 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
Limited Distribution
•
ACA
A
Dispensing Limits
FLUCELVAX QUADRIVALENT 20 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
FLUBLOK 2016-2017 influenza virus vac recombinant hemagglutinin (ha) inj
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
14
A
FLUZONE QUADRIVALENT 2014 - influenza virus vaccine split quadrivalent inj 0.5 ml
A
FLUZONE QUADRIVALENT 2015 - influenza virus vac split quadrivalent susp pref syr 0.25 ml
A
•
FLUZONE QUADRIVALENT 2015 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUZONE QUADRIVALENT 2015 - influenza virus vaccine split quadrivalent im inj
A
•
FLUZONE QUADRIVALENT 2015 - influenza virus vaccine split quadrivalent inj 0.5 ml
A
•
FLUZONE QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.25 ml
A
•
FLUZONE QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.5ml
A
•
FLUZONE QUADRIVALENT 2016 - influenza virus vaccine split quadrivalent im inj
A
•
FLUZONE QUADRIVALENT 2016 - influenza virus vaccine split quadrivalent inj 0.5 ml
A
•
•
FLUZONE SPLIT 2014-2015 influenza virus vaccine split im susp
A
•
FLUZONE SPLIT 2015-2016 influenza virus vaccine split im susp
A
•
IMOVAX RABIES (H.D.C.V.) rabies virus vaccine, hdc inj
A
•
MEDICAL PROVIDER EZ FLU S - influenza virus vac tisscult subunit pref syr kit 0.5 ml
A
•
MEDICAL PROVIDER EZ FLU S - influenza virus vac types a & b pf pref syringe kit 0.5 ml
A
•
MEDICAL PROVIDER SINGLE U - influenza vac type a&b surface antigen pref syr kit 0.5 ml
A
•
MEDICAL PROVIDER SINGLE U - influenza virus vac split quad inj prefilled syr kit 0.25 ml
A
•
MEDICAL PROVIDER SINGLE U - influenza virus vac types a & b pf pref syringe kit 0.5 ml
A
•
MEDICAL PROVIDER SINGLE U - influenza virus vaccine split pf susp pref syr kit 0.5 ml
A
•
PNEUMOVAX 23 pneumococcal vaccine polyvalent inj 25 mcg/0.5ml
A
•
PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent inj 25 mcg/0.5ml
A
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
FLUZONE QUADRIVALENT 2014 - influenza virus vaccine split quadrivalent im inj
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
15
RABAVERT - rabies vaccine, pcec for inj
A
•
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml
A
•
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 10 mcg/ml
A
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 40 mcg/ml
A
VIVOTIF - typhoid vaccine cap delayed release
4
ZOSTAVAX - zoster vaccine live for inj 19400 unit/0.65ml
A
•
ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml
A
•
BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
A
•
DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml
4
DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml
4
INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml
4
TOXOIDS
• •
PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio ipv vac inj
4
PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp
4
QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj
4
TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu
4
TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml
4
PASSIVE IMMUNIZING AGENTS 4 HEPAGAM B - hepatitis b immune globulin (human) inj soln HYPERHEP B S/D - hepatitis b 4 immune globulin (human) im inj soln 4 HYPERRAB S/D - rabies immune globulin (human) inj 150 unit/ml 4 HYPERTET S/D - tetanus immune globulin (human) inj 250 unit/ml 4 HYQVIA - immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/1.25 ml kit 4 HYQVIA - immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit 4 HYQVIA - immun glob inj 10 gm/100ml-hyaluron inj 800 unt/5 ml kit
Limited Distribution
•
ACA
A
4
Dispensing Limits
PREVNAR 13 - Pneumococcal 13-valent conjugate vaccine inj
KINRIX - diph-tetanus tox adacell pert & polio virus, ipv vac inj
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
PNEUMOVAX 23/5 DOSE pneumococcal vaccine polyvalent inj 25 mcg/0.5ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
16
4
BIOLOGICALS MISC GRASTEK - timothy grass pollen allergen ext tab sl 2800 bau
4
•
•
ORALAIR - grass mixed pollen ext tab sl 300 ir (index of reactivity)
4
•
•
•
ORALAIR ADULT SAMPLE KIT - grass mixed pollen ext tab sl 300 ir (index of reactivity)
4
•
•
•
ORALAIR ADULT STARTER PAC - grass mixed pollen ext tab sl 300 ir (index of reactivity)
4
•
•
•
ORALAIR CHILDREN/ ADOLESCE - grass mixed pollen ext tab sl 100 ir (index of reactivity)
4
ORALAIR CHILDREN/ ADOLESCE - grass mixed pollen tab sl therpak 100 (3) ir & 300 (6) ir
4
RAGWITEK - short ragweed pollen allergen extract tab sl 12 amb a 1-u
4
ANTINEOPLASTIC AGENTS ANTINEOPLASTICS
•
•
• •
•
•
Limited Distribution
NABI-HB - hepatitis b immune globulin (human) im inj soln
ACA
4
Dispensing Limits
IMOGAM RABIES-HT - rabies immune globulin (human) inj 150 unit/ml
•
Step Therapy
•
Prior Authorization
4
•
Drug Name
Drug Tier
HYQVIA - immun glob inj 30 gm/300ml-hyaluron inj 2400 unt/15 ml kit
Limited Distribution
•
ACA
4
Dispensing Limits
HYQVIA - immun glob inj 20 gm/200ml-hyaluron inj 1600 unt/10 ml kit
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)
5
•
AFINITOR - everolimus tab 2.5 mg
5
•
•
•
AFINITOR - everolimus tab 5 mg
5
•
•
•
AFINITOR - everolimus tab 7.5 mg
5
•
•
•
AFINITOR - everolimus tab 10 mg
5
•
•
•
AFINITOR DISPERZ everolimus tab for oral susp 2 mg
5
•
•
•
AFINITOR DISPERZ everolimus tab for oral susp 3 mg
5
•
•
•
AFINITOR DISPERZ everolimus tab for oral susp 5 mg
5
•
•
•
ALECENSA - alectinib hcl cap 150 mg (base equivalent)
5
•
•
•
ALKERAN - melphalan tab 2 mg
3
anastrozole tab 1 mg (Arimidex)
1
bexarotene cap 75 mg (Targretin)
5
bicalutamide tab 50 mg (Casodex)
1
BOSULIF - bosutinib tab 100 mg
5
•
•
•
BOSULIF - bosutinib tab 500 mg
5
•
•
•
CABOMETYX - cabozantinib s-malate tab 20 mg (base equivalent)
5
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
17
•
capecitabine tab 150 mg (Xeloda)
5
•
•
capecitabine tab 500 mg (Xeloda)
5
•
•
CAPRELSA - vandetanib tab 100 mg
5
CAPRELSA - vandetanib tab 300 mg
5
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit
•
•
•
•
•
•
•
5
•
•
•
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit
5
•
•
•
COMETRIQ - cabozantinib smalate cap 3 x 20 mg (60 mg dose) kit
5
•
•
•
COTELLIC - cobimetinib fumarate tab 20 mg (base equivalent)
5
•
•
•
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg
4
CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
4
ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg
5
ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit 30 mg
5
• •
5
•
ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg
5
•
EMCYT - estramustine phosphate sodium cap 140 mg
4
ERIVEDGE - vismodegib cap 150 mg
5
ETOPOSIDE - etoposide cap 50 mg
4
exemestane tab 25 mg (Aromasin)
2
FARESTON - toremifene citrate 4 tab 60 mg (base equivalent) 5 FARYDAK - panobinostat lactate cap 10 mg (base equivalent) 5 FARYDAK - panobinostat lactate cap 15 mg (base equivalent) 5 FARYDAK - panobinostat lactate cap 20 mg (base equivalent) 2 flutamide cap 125 mg
Limited Distribution
5
ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 mg
ACA
CABOMETYX - cabozantinib s-malate tab 60 mg (base equivalent)
•
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
CABOMETYX - cabozantinib s-malate tab 40 mg (base equivalent)
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
•
•
•
•
•
•
•
•
•
•
•
•
GILOTRIF - afatinib dimaleate tab 20 mg (base equivalent)
5
•
•
•
GILOTRIF - afatinib dimaleate tab 30 mg (base equivalent)
5
•
•
•
•
GILOTRIF - afatinib dimaleate tab 40 mg (base equivalent)
5
•
•
•
5
•
•
•
•
GLEEVEC - imatinib mesylate tab 100 mg (base equivalent) GLEEVEC - imatinib mesylate tab 400 mg (base equivalent)
5
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
18
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
GLEOSTINE - lomustine cap 5 mg
4
INTRON A - interferon alfa-2b inj 10000000 unit/ml
5
•
GLEOSTINE - lomustine cap 10 mg
4
INTRON A - interferon alfa-2b for inj 10000000 unit
5
•
•
GLEOSTINE - lomustine cap 40 mg
4
INTRON A - interferon alfa-2b for inj 18000000 unit
5
•
•
GLEOSTINE - lomustine cap 100 mg
4
5
•
•
HEXALEN - altretamine cap 50 mg
5
•
•
INTRON A - interferon alfa-2b for inj 50000000 unit
5
•
•
HYCAMTIN - topotecan hcl cap 5 0.25 mg (base equiv) HYCAMTIN - topotecan hcl cap 5 1 mg (base equiv) 2 hydroxyurea cap 500 mg (Hydrea) 5 IBRANCE - palbociclib cap 75 mg IBRANCE - palbociclib cap 100 5 mg IBRANCE - palbociclib cap 125 5 mg ICLUSIG - ponatinib hcl tab 15 5 mg (base equiv) ICLUSIG - ponatinib hcl tab 45 5 mg (base equiv) 5 imatinib mesylate tab 100 mg (base equivalent) (Gleevec) 5 imatinib mesylate tab 400 mg (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 140 5 mg 5 INLYTA - axitinib tab 1 mg
•
•
INTRON A W/DILUENT interferon alfa-2b for inj 10000000 unit
•
•
INTRON A W/DILUENT interferon alfa-2b for inj 18000000 unit
5
•
•
INTRON A W/DILUENT interferon alfa-2b for inj 50000000 unit
5
•
•
IRESSA - gefitinib tab 250 mg
5
• •
• •
INLYTA - axitinib tab 5 mg
5
INTRON A - interferon alfa-2b inj 6000000 unit/ml
5
•
•
•
•
•
•
•
JAKAFI - ruxolitinib phosphate tab 5 mg (base equivalent)
5
• •
•
•
•
JAKAFI - ruxolitinib phosphate tab 10 mg (base equivalent)
5
•
•
•
•
•
•
JAKAFI - ruxolitinib phosphate tab 15 mg (base equivalent)
5
•
•
•
•
•
•
JAKAFI - ruxolitinib phosphate tab 20 mg (base equivalent)
5
•
•
•
•
•
•
JAKAFI - ruxolitinib phosphate tab 25 mg (base equivalent)
5
•
•
•
LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack 10 mg (10 mg daily dose)
5
•
•
•
LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose)
5
•
•
•
•
•
•
•
•
•
• • •
• •
• • •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
19
5
LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose)
5
•
•
•
LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose)
5
•
•
•
LENVIMA 8 MG DAILY DOSE - 5 lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose) letrozole tab 2.5 mg (Femara) 1
•
•
•
megestrol acetate susp 40 mg/ml (Megace oral) megestrol acetate tab 20 mg
LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg
3
LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg
3
leucovorin calcium tab 5 mg
2
megestrol acetate tab 40 mg
1
4
METHOTREXATE SODIUM methotrexate sodium inj 250 mg/10ml (25 mg/ml)
1
methotrexate sodium for inj 1 gm
2
methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)
LEUKERAN - chlorambucil tab 2 mg
3
methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)
leuprolide acetate inj kit 5 mg/ml
5
•
LONSURF - trifluridine-tipiracil tab 15-6.14 mg
5
•
LONSURF - trifluridine-tipiracil tab 20-8.19 mg
5
•
LYNPARZA - olaparib cap 50 mg
5
•
LYSODREN - mitotane tab 500 mg
5
•
MATULANE - procarbazine hcl cap 50 mg
5
•
•
methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)
•
•
methotrexate sodium inj 50 mg/2ml (25 mg/ml)
•
•
methotrexate sodium tab 2.5 mg (base equiv)
•
Limited Distribution
ACA
Dispensing Limits
•
•
•
•
•
•
•
•
•
1 1 1 1 1 1 2
MYLERAN - busulfan tab 2 mg
3 5
•
NEXAVAR - sorafenib tosylate tab 200 mg (base equivalent)
•
NILANDRON - nilutamide tab 150 mg
4
•
Step Therapy
1
MESNEX - mesna tab 400 mg
2
leucovorin calcium tab 25 mg
2
MEKINIST - trametinib dimethyl 5 sulfoxide tab 0.5 mg (base equivalent) MEKINIST - trametinib dimethyl 5 sulfoxide tab 2 mg (base equivalent) 2 mercaptopurine tab 50 mg
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)
Prior Authorization
•
LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose)
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
20
nilutamide tab 150 mg (Nilandron)
2
NINLARO - ixazomib citrate cap 2.3 mg (base equivalent)
5
•
•
•
NINLARO - ixazomib citrate cap 3 mg (base equivalent)
5
•
•
•
NINLARO - ixazomib citrate cap 4 mg (base equivalent)
5
•
•
•
ODOMZO - sonidegib phosphate cap 200 mg (base equivalent)
5
•
•
•
POMALYST - pomalidomide cap 1 mg
5
•
•
•
POMALYST - pomalidomide cap 2 mg
5
•
•
•
POMALYST - pomalidomide cap 3 mg
5
•
•
•
POMALYST - pomalidomide cap 4 mg
5
•
•
•
PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)
5
SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml (base equivalent)
4
SPRYCEL - dasatinib tab 20 mg
5
•
•
•
SPRYCEL - dasatinib tab 50 mg
5
•
•
•
SPRYCEL - dasatinib tab 70 mg
5
•
•
•
SPRYCEL - dasatinib tab 80 mg
5
•
•
•
SPRYCEL - dasatinib tab 100 mg
5
•
•
•
SPRYCEL - dasatinib tab 140 mg
5
•
•
•
•
STIVARGA - regorafenib tab 40 5 mg SUTENT - sunitinib malate cap 5 12.5 mg (base equivalent) SUTENT - sunitinib malate cap 5 25 mg (base equivalent) SUTENT - sunitinib malate cap 5 37.5 mg (base equivalent) SUTENT - sunitinib malate cap 5 50 mg (base equivalent) 5 SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 SYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 SYLATRON - peginterferon alfa-2b for inj kit 600 mcg 4 TABLOID - thioguanine tab 40 mg 5 TAFINLAR - dabrafenib mesylate cap 50 mg (base equivalent) 5 TAFINLAR - dabrafenib mesylate cap 75 mg (base equivalent) 5 TAGRISSO - osimertinib mesylate tab 40 mg (base equivalent) 5 TAGRISSO - osimertinib mesylate tab 80 mg (base equivalent) 1 tamoxifen citrate tab 10 mg (base equivalent) 1 tamoxifen citrate tab 20 mg (base equivalent) TARCEVA - erlotinib hcl tab 25 5 mg (base equivalent) 5 TARCEVA - erlotinib hcl tab 100 mg (base equivalent)
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
•
• • •
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
21
5
•
TASIGNA - nilotinib hcl cap 150 5 mg (base equivalent) TASIGNA - nilotinib hcl cap 200 5 mg (base equivalent) 5 temozolomide cap 5 mg (Temodar) 5 temozolomide cap 20 mg (Temodar) 5 temozolomide cap 100 mg (Temodar) 5 temozolomide cap 140 mg (Temodar) 5 temozolomide cap 180 mg (Temodar) 5 temozolomide cap 250 mg (Temodar) 5 tretinoin cap 10 mg
•
•
•
•
•
•
•
Limited Distribution
TARGRETIN - bexarotene cap 75 mg
•
ACA
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
TARCEVA - erlotinib hcl tab 150 mg (base equivalent)
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
VENCLEXTA - venetoclax tab 50 mg
5
•
•
VENCLEXTA - venetoclax tab 100 mg
5
•
•
•
VENCLEXTA STARTING PACK - venetoclax tab therapy starter pack 10 & 50 & 100 mg
5
•
•
•
•
•
VOTRIENT - pazopanib hcl tab 200 mg (base equiv)
5
•
•
•
•
•
XALKORI - crizotinib cap 200 mg
5
•
•
•
•
•
XALKORI - crizotinib cap 250 mg
5
•
•
•
•
•
XTANDI - enzalutamide cap 40 mg
5
•
•
•
•
•
ZELBORAF - vemurafenib tab 240 mg
5
•
•
•
•
•
ZOLINZA - vorinostat cap 100 mg
5
•
•
•
•
•
ZYDELIG - idelalisib tab 100 mg
5
•
•
•
ZYDELIG - idelalisib tab 150 mg
5
•
•
•
ZYKADIA - ceritinib cap 150 mg
5
•
•
•
ZYTIGA - abiraterone acetate tab 250 mg
5
•
•
•
TREXALL - methotrexate sodium tab 5 mg (base equiv)
4
TREXALL - methotrexate sodium tab 7.5 mg (base equiv)
4
TREXALL - methotrexate sodium tab 10 mg (base equiv)
4
TREXALL - methotrexate sodium tab 15 mg (base equiv)
4
TYKERB - lapatinib ditosylate tab 250 mg (base equiv)
5
•
•
•
VENCLEXTA - venetoclax tab 10 mg
5
•
•
•
ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS
ACTIVE INJECTION KIT KL-3 - 4 triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 2 budesonide delayed release particles cap 3 mg (Entocort ec)
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
22
CORTISONE ACETATE cortisone acetate tab 25 mg
3
DEXAMETHASONE dexamethasone soln 0.5 mg/5ml
4
DEXAMETHASONE dexamethasone tab 1 mg
4
DEXAMETHASONE dexamethasone tab 2 mg
4
dexamethasone elixir 0.5 mg/5ml
2
DEXAMETHASONE INTENSOL - dexamethasone conc 1 mg/ml
4
dexamethasone tab 0.5 mg
1
dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 4 mg
1 1 1 1
INTERARTICULAR JOINT KIT - triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit
4
JTT PHYSICIANS KIT triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit
4
MEDROL - methylprednisolone tab 2 mg
4
methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)
2
methylprednisolone tab 4 mg (Medrol)
2
methylprednisolone tab 8 mg (Medrol) methylprednisolone tab 16 mg (Medrol)
4
DEXPAK 13 DAY dexamethasone tab therapy pack 1.5 mg (51)
4
MILLIPRED - prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) MILLIPRED - prednisolone tab 5 mg
4
DEXPAK 6 DAY dexamethasone tab therapy pack 1.5 mg (21)
4
MILLIPRED DP - prednisolone tab therapy pack 5 mg (21)
4
MILLIPRED DP - prednisolone tab therapy pack 5 mg (48)
4
fludrocortisone acetate tab 0.1 mg
2
hydrocortisone tab 10 mg (Cortef)
2
hydrocortisone tab 20 mg (Cortef)
2
Limited Distribution
ACA
2
4
hydrocortisone tab 5 mg (Cortef)
Dispensing Limits
2
DEXPAK 10 DAY dexamethasone tab therapy pack 1.5 mg (35)
2
Step Therapy
2
methylprednisolone tab 32 mg (Medrol)
dexamethasone tab 6 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4 PHYSICIANS EZ USE JOINT T - triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 2 prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt)
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
23
prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt)
2
2
prednisone tab 20 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 4
2
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)
1
VERIPRED 20 - prednisolone sod phosphate oral soln 20 mg/5ml (base equiv)
PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)
4
ANDROGEN-ANABOLIC
prednisolone syrup 15 mg/5ml (usp solution equivalent)
1
ANADROL-50 - oxymetholone tab 50 mg
4
•
ANDROGEL - testosterone td gel 25 mg/2.5gm (1%)
4
•
•
ANDROGEL - testosterone td gel 50 mg/5gm (1%)
4
•
•
4
•
•
PREDNISONE - prednisone oral soln 5 mg/5ml
4
PREDNISONE - prednisone tab therapy pack 5 mg (21)
4
ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%)
4
PREDNISONE - prednisone tab therapy pack 5 mg (48)
4
•
•
4
•
•
PREDNISONE - prednisone tab therapy pack 10 mg (48)
4
ANDROGEL PUMP testosterone td gel 20.25 mg/act (1.62%)
4
PREDNISONE - prednisone tab therapy pack 10 mg (21)
3
•
PREDNISONE - prednisone tab 50 mg
4
ANDROXY - fluoxymesterone tab 10 mg
3
•
•
PREDNISONE INTENSOL prednisone conc 5 mg/ml
4
AXIRON - testosterone td soln 30 mg/act danazol cap 50 mg
2
prednisone tab 1 mg
1
• • • •
•
prednisone tab 2.5 mg prednisone tab 5 mg prednisone tab 10 mg
1 1 1
danazol cap 100 mg danazol cap 200 mg DEPO-TESTOSTERONE testosterone cypionate im inj in oil 100 mg/ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
RAYOS - prednisone tab delayed release 1 mg
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
24
DEPO-TESTOSTERONE testosterone cypionate im inj in oil 200 mg/ml
4
FORTESTA - testosterone td gel 10mg/act (2%)
4
METHITEST methyltestosterone oral tab 10 mg
4
methyltestosterone cap 10 mg (Testred)
ANGELIQ - drospirenoneestradiol tab 0.25-0.5 mg
4
ANGELIQ - drospirenoneestradiol tab 0.5-1 mg
4
•
CLIMARA PRO - estradiollevonorgestrel td patch weekly 0.045-0.015 mg/day
4
2
•
3
oxandrolone tab 2.5 mg (Oxandrin)
2
•
COMBIPATCH - estradiolnorethindrone ace td pttw 0.05-0.14 mg/day
3
oxandrolone tab 10 mg (Oxandrin)
2
•
COMBIPATCH - estradiolnorethindrone ace td pttw 0.05-0.25 mg/day
4
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone)
2
DELESTROGEN - estradiol valerate im in oil 10 mg/ml DELESTROGEN - estradiol valerate im in oil 20 mg/ml
4
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone)
DELESTROGEN - estradiol valerate im in oil 40 mg/ml
4
testosterone enanthate im inj in oil 200 mg/ml
•
•
•
•
2
•
•
2
•
•
DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)
3
•
•
DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)
3
testosterone td gel 25 mg/2.5gm (1%) (Androgel)
2
3
testosterone td gel 50 mg/5gm (1%) (Androgel)
2
•
•
DIVIGEL - estradiol td gel 1 mg/gm (0.1%)
4
2
•
•
DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg
4
•
ELESTRIN - estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump) esterified estrogens & methyltestosterone tab 0.625-1.25 mg
2
testosterone td gel 12.5 mg/ act (1%) (Androgel pump) ESTROGENS ALORA - estradiol td patch twice weekly 0.025 mg/24hr
4
ALORA - estradiol td patch twice weekly 0.05 mg/24hr
4
•
ALORA - estradiol td patch twice weekly 0.075 mg/24hr
4
•
ALORA - estradiol td patch twice weekly 0.1 mg/24hr
4
•
esterified estrogens & methyltestosterone tab 1.25-2.5 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
25
estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)
2
estradiol & norethindrone acetate tab 1-0.5 mg (Activella)
2
1
estradiol valerate im in oil 40 mg/ml (Delestrogen)
•
2
ESTROGEL - estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)
4
ESTROPIPATE - estropipate tab 0.75 mg
1
ESTROPIPATE - estropipate tab 1.5 mg
1
ESTROPIPATE - estropipate tab 3 mg
4
EVAMIST - estradiol transdermal spray 1.53 mg/ spray
4
FEMHRT LOW DOSE norethindrone acetateethinyl estradiol tab 0.5 mg-2.5 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
2
estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot)
2
estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot)
2
estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot)
2
estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot)
2
estradiol td patch weekly 0.025 mg/24hr (Climara)
2
•
2
•
2
•
MENOSTAR - estradiol td patch weekly 14 mcg/24hr
4
•
2
•
MINIVELLE - estradiol td patch twice weekly 0.025 mg/24hr
4
•
2
•
4
•
2
•
MINIVELLE - estradiol td patch twice weekly 0.0375 mg/24hr MINIVELLE - estradiol td patch twice weekly 0.05 mg/24hr
4
•
estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara) estradiol td patch weekly 0.05 mg/24hr (Climara) estradiol td patch weekly 0.06 mg/24hr (Climara) estradiol td patch weekly 0.075 mg/24hr (Climara) estradiol td patch weekly 0.1 mg/24hr (Climara)
• • •
Limited Distribution
2
estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot)
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
Drug Name estradiol valerate im in oil 20 mg/ml (Delestrogen)
estradiol tab 0.5 mg (Estrace) 1 1 estradiol tab 1 mg (Estrace) estradiol tab 2 mg (Estrace)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
26
norethindrone acetateethinyl estradiol tab 1 mg-5 mcg
2
PREFEST - estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15)
4
PREMARIN - estrogens, conjugated tab 0.3 mg
4
PREMARIN - estrogens, conjugated tab 0.45 mg
4
PREMARIN - estrogens, conjugated tab 0.625 mg
4
PREMARIN - estrogens, conjugated tab 0.9 mg
4
PREMARIN - estrogens, conjugated tab 1.25 mg
4
PREMPHASE - conj est 0.625(14)/conj estmedroxypro ac tab 0.625-5mg(14)
4
PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg
4
PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg
4
PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg
4
CONTRACEPTIVES
Limited Distribution
norethindrone acetateethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose)
2
ACA
•
Dispensing Limits
4
Step Therapy
MINIVELLE - estradiol td patch twice weekly 0.1 mg/24hr
PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
MINIVELLE - estradiol td patch twice weekly 0.075 mg/24hr
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
•
BEYAZ - drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg
4
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp prefilled syr 150 mg/ml
A
•
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml
A
•
DEPO-SUBQ PROVERA 104 - medroxyprogesterone acetate susp pref syr 104 mg/0.65ml
A
•
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette)
A
•
2 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa) 1 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) 2 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg (Beyaz) 2 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) 2 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28)
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
27
•
•
MINASTRIN 24 FE norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)
4
•
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2 mg/2-3 mg/1 mg
4
•
NECON 1/50-28 norethindrone & mestranol tab 1 mg-50 mcg
4
•
NECON 10/11-28 norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11)
4
•
2
1
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35)
2
2
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28) norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)
1
norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)
A
FALESSA - levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit GENERESS FE norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg
4
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique)
A
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)
2
•
•
A
2
2 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mgmcg 2 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 4 LO LOESTRIN FE - norethineth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2)
•
•
norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
A
4
levonorgestrel tab 1.5 mg
ACA
•
medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)
2
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg
Dispensing Limits
•
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
Step Therapy
A
A
• •
Drug Name medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depoprovera contrac)
ELLA - ulipristal acetate tab 30 mg
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
Prior Authorization
Drug Name
Drug Tier
2016
•
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
28
norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)
2
NUVARING - etonogestrelethinyl estradiol va ring 0.120-0.015 mg/24hr
A
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)
2
• •
2
OGESTREL - norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg
4
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21)
•
A
• •
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20)
A
ORTHO EVRA norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr
4
•
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)
2
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg
A
norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg (24)
2
PARAGARD INTRAUTERINE COP - copper iud QUARTETTE - levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg
4
•
4
•
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg
•
•
2
• •
norethindrone tab 0.35 mg (Nor-qd)
A
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7)
2
SAFYRAL - drospirenoneethinyl estrad-levomefolate tab 3-0.03-0.451 mg
A
• •
2
XULANE - norelgestrominethinyl estradiol td ptwk 150-35 mcg/24hr
4
•
1
ZOVIA 1/50E - ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Orthocyclen)
2 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mgmcg (Ortho tri-cyclen lo) A norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
PROGESTINS
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
medroxyprogesterone acetate tab 2.5 mg (Provera)
1
medroxyprogesterone acetate tab 5 mg (Provera)
1
1 medroxyprogesterone acetate tab 10 mg (Provera)
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
29
MEGACE ES - megestrol acetate susp 625 mg/5ml
4
megestrol acetate susp 625 mg/5ml (Megace es)
2
norethindrone acetate tab 5 mg (Aygestin) progesterone im in oil 50 mg/ml progesterone micronized cap 100 mg (Prometrium) progesterone micronized cap 200 mg (Prometrium) ANTIDIABETICS
2 2 2 2
4
•
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-15 mg
4
•
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-30 mg
4
•
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-45 mg
4
•
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-15 mg
4
•
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-30 mg
4
•
4
•
acarbose tab 25 mg (Precose)
2
acarbose tab 50 mg (Precose)
2
acarbose tab 100 mg (Precose)
2
ACTOPLUS MET XR pioglitazone hcl-metformin hcl tab sr 24hr 15-1000 mg
4
ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-45 mg
4
ACTOPLUS MET XR pioglitazone hcl-metformin hcl tab sr 24hr 30-1000 mg
4
AVANDIA - rosiglitazone maleate tab 2 mg (base equiv)
4
ALOGLIPTIN - alogliptin benzoate tab 6.25 mg (base equiv)
4
AVANDIA - rosiglitazone maleate tab 4 mg (base equiv)
4
ALOGLIPTIN - alogliptin benzoate tab 12.5 mg (base equiv)
4
•
BD GLUCOSE - glucose chew tab 5 gm BYDUREON - exenatide for inj extended release susp 2 mg
4
• •
•
BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg
4
ALOGLIPTIN - alogliptin benzoate tab 25 mg (base equiv)
4
• •
•
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
4
ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl tab 12.5-500 mg
4
• •
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
4
• •
•
Limited Distribution
ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl tab 12.5-1000 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
30
CHLORPROPAMIDE chlorpropamide tab 100 mg
4
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)
1
CHLORPROPAMIDE chlorpropamide tab 250 mg
4
glipizide tab sr 24hr 5 mg (Glucotrol xl)
1
CVS GLUCOSE - glucose chew tab 4 gm
4
glipizide tab sr 24hr 10 mg (Glucotrol xl)
2
CYCLOSET - bromocriptine mesylate tab 0.8 mg (base equivalent)
4
glipizide tab 5 mg (Glucotrol)
1
DEX4 - glucose-vitamin c chew tab 4-0.006 gm
4
DEX4 FAST ACTING GLUCOSE - glucose gel 15 gm/33gm
4
DEX4 FAST ACTING GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm
4
DEX4 NATURALS - glucosevitamin c chew tab 4-0.006 gm
4
DEX4 POUCH PACK glucose-vitamin c chew tab 4-0.006 gm
4
DEX4 QUICK DISSOLVE GLUCO - glucose chew tab 4 gm
4
FARXIGA - dapagliflozin propanediol tab 5 mg (base equivalent)
4
FARXIGA - dapagliflozin propanediol tab 10 mg (base equivalent)
4
glimepiride tab 1 mg (Amaryl)
1
glimepiride tab 2 mg (Amaryl)
1
glimepiride tab 4 mg (Amaryl)
1
glipizide tab 10 mg (Glucotrol)
1
glipizide-metformin hcl tab 2.5-250 mg
2
glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl tab 5-500 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2 2
GLUCAGEN HYPOKIT glucagon hcl (rdna) for inj 1 mg (base equiv)
4
GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg
3
GLUCOSE - glucose chew tab 4 gm
4
GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm
4
•
glucose gel 40%
1
•
GLUMETZA - metformin hcl tab 4 sr 24hr modified release 500 mg 4 GLUMETZA - metformin hcl tab sr 24hr modified release 1000 mg 1 glyburide micronized tab 1.5 mg (Glynase) 1 glyburide micronized tab 3 mg (Glynase)
glucose oral liquid 15 gm/59ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
31
glyburide micronized tab 6 mg (Glynase) glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg glyburide-metformin tab 1.25-250 mg (Glucovance) glyburide-metformin tab 2.5-500 mg (Glucovance) glyburide-metformin tab 5-500 mg (Glucovance)
1 1 1 1 1 1 1
3
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 50-500 mg
3
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 50-1000 mg
3
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 100-1000 mg
3
•
JANUVIA - sitagliptin phosphate tab 25 mg (base equiv)
3
•
JANUVIA - sitagliptin phosphate tab 50 mg (base equiv)
3
•
3
•
GLYSET - miglitol tab 25 mg
4
GLYSET - miglitol tab 50 mg
4
GLYSET - miglitol tab 100 mg
4
GLYXAMBI - empagliflozinlinagliptin tab 10-5 mg
4
•
GLYXAMBI - empagliflozinlinagliptin tab 25-5 mg
4
•
INSTA-GLUCOSE - glucose gel 77.4%
4
JANUVIA - sitagliptin phosphate tab 100 mg (base equiv)
•
JARDIANCE - empagliflozin tab 10 mg
3
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
3
•
•
JARDIANCE - empagliflozin tab 25 mg
3
INVOKAMET - canagliflozinmetformin hcl tab 50-1000 mg
3
•
4
•
INVOKAMET - canagliflozinmetformin hcl tab 150-500 mg
3
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-500 mg
4
•
INVOKAMET - canagliflozinmetformin hcl tab 150-1000 mg
3
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-850 mg
4
•
INVOKANA - canagliflozin tab 100 mg
3
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-1000 mg
3
•
4
INVOKANA - canagliflozin tab 300 mg
•
JANUMET - sitagliptinmetformin hcl tab 50-500 mg
3
•
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr 2.5-1000 mg
Limited Distribution
JANUMET - sitagliptinmetformin hcl tab 50-1000 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
32
KAZANO - alogliptin-metformin hcl tab 12.5-500 mg
4
KAZANO - alogliptin-metformin hcl tab 12.5-1000 mg
4
•
KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr 2.5-1000 mg
3
•
miglitol tab 100 mg (Glyset) nateglinide tab 60 mg (Starlix)
2
KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr 5-500 mg
3
•
nateglinide tab 120 mg (Starlix)
2 4
•
KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr 5-1000 mg
3
NESINA - alogliptin benzoate tab 6.25 mg (base equiv)
4
•
KORLYM - mifepristone tab 300 mg
5
NESINA - alogliptin benzoate tab 12.5 mg (base equiv)
4
•
KROGER GLUCOSE glucose-vitamin c chew tab 4-0.006 gm
4
NESINA - alogliptin benzoate tab 25 mg (base equiv) ONGLYZA - saxagliptin hcl tab 2.5 mg (base equiv)
3
•
ONGLYZA - saxagliptin hcl tab 5 mg (base equiv)
3
metformin hcl tab sr 24hr 500 mg (Glucophage xr)
1
•
1
OSENI - alogliptin-pioglitazone tab 12.5-15 mg
4
•
2
OSENI - alogliptin-pioglitazone tab 12.5-30 mg
4
•
2
OSENI - alogliptin-pioglitazone tab 12.5-45 mg
4
metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)
•
4
•
metformin hcl tab sr 24hr modified release 500 mg (Glumetza)
2
OSENI - alogliptin-pioglitazone tab 25-15 mg OSENI - alogliptin-pioglitazone tab 25-30 mg
4
•
metformin hcl tab sr 24hr modified release 1000 mg (Glumetza)
2
OSENI - alogliptin-pioglitazone tab 25-45 mg
4
•
1
metformin hcl tab 500 mg (Glucophage)
1
pioglitazone hcl tab 15 mg (base equiv) (Actos)
metformin hcl tab sr 24hr 750 mg (Glucophage xr) metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)
1
miglitol tab 25 mg (Glyset)
2
miglitol tab 50 mg (Glyset)
• •
metformin hcl tab 1000 mg (Glucophage)
•
pioglitazone hcl tab 30 mg (base equiv) (Actos)
Limited Distribution
ACA
Dispensing Limits
4
•
1
Step Therapy
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr 5-1000 mg
•
metformin hcl tab 850 mg (Glucophage)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
33
pioglitazone hcl tab 45 mg (base equiv) (Actos) pioglitazone hcl-glimepiride tab 30-2 mg (Duetact) pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)
•
SYNJARDY - empagliflozinmetformin hcl tab 12.5-1000 mg
4
•
TANZEUM - albiglutide for soln pen-injector 30 mg
4
• •
TANZEUM - albiglutide for soln pen-injector 50 mg
4
• •
TOLAZAMIDE - tolazamide tab 250 mg
2
TOLAZAMIDE - tolazamide tab 500 mg
4
TOLBUTAMIDE - tolbutamide tab 500 mg
4
TRADJENTA - linagliptin tab 5 mg
4
•
TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml
4
• •
TRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml
4
• •
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
3
• •
WALGREENS GLUCOSE glucose chew tab 4 gm
4 4
•
WALGREENS GLUCOSE glucose-vitamin c chew tab 4-0.006 gm
4
•
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-500 mg
4
•
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-1000 mg XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 10-500 mg
4
•
2 2
•
Limited Distribution
4
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
Drug Name SYNJARDY - empagliflozinmetformin hcl tab 12.5-500 mg
1
2 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met) 2 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met) PROGLYCEM - diazoxide susp 4 50 mg/ml 2 repaglinide tab 0.5 mg (Prandin) 2 repaglinide tab 1 mg (Prandin) 2 repaglinide tab 2 mg (Prandin) 2 REPAGLINIDE/METFORMIN HYD - repaglinide-metformin hcl tab 1-500 mg 2 REPAGLINIDE/METFORMIN HYD - repaglinide-metformin hcl tab 2-500 mg 4 RIOMET - metformin hcl oral soln 500 mg/5ml SYMLINPEN 120 - pramlintide 4 acetate pen-inj 2700 mcg/2.7ml (1000 mcg/ml) 4 SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ml) 4 SYNJARDY - empagliflozinmetformin hcl tab 5-500 mg 4 SYNJARDY - empagliflozinmetformin hcl tab 5-1000 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
34
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 10-1000 mg Rapid-Acting Insulins
4
•
•
4
•
•
•
APIDRA SOLOSTAR - insulin glulisine soln pen-injector inj 100 unit/ml
4
•
•
HUMULIN R - insulin regular (human) inj 100 unit/ml
HUMALOG - insulin lispro inj 100 unit/ml
4
•
•
HUMALOG - insulin lispro soln cartridge 100 unit/ml
4
•
•
HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml
4
•
•
HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml
4
NOVOLOG - insulin aspart inj 100 unit/ml
2
•
NOVOLOG FLEXPEN - insulin aspart soln pen-injector 100 unit/ml
2
•
NOVOLOG PENFILL - insulin aspart soln cartridge 100 unit/ml
2
AFREZZA - insulin regular (human) inh powd 8 (60) & 12 (30) unit/cart
4
AFREZZA - insulin regular (human) inhal powd 4 (30) & 8 (60) unit/cart
4
AFREZZA - insulin regular (human) inhal powd 4 (60) & 8 (30) unit/cart
4
• •
• • • •
HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100 unit/ml (50-50)
4
•
•
4
•
•
•
HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro sus pen-inj 100 unit/ ml (50-50)
4
•
•
•
HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml (75-25) HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro sus pen-inj 100 unit/ ml (75-25)
4
•
•
•
•
•
4 HUMULIN R U-500 (CONCENTR - insulin regular (human) inj 500 unit/ml 4 HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml 2 NOVOLIN R - insulin regular (human) inj 100 unit/ml 2 NOVOLIN R RELION - insulin regular (human) inj 100 unit/ ml 3 RELION R - insulin regular (human) inj 100 unit/ml Intermediate-Acting Insulins
•
Limited Distribution
4
•
•
ACA
•
APIDRA - insulin glulisine inj 100 unit/ml
Short-Acting Insulins
Dispensing Limits
4
4
•
Step Therapy
AFREZZA - insulin regular (human) inhal powd 4 (90) & 8 (90) unit/cart AFREZZA - insulin regular (human) inhalation powder 4 unit/cartridge
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
35
•
3
•
•
TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml
3
•
•
TRESIBA FLEXTOUCH insulin degludec soln peninjector 100 unit/ml
3
•
•
TRESIBA FLEXTOUCH insulin degludec soln peninjector 200 unit/ml
HUMULIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30)
4
HUMULIN 70/30 KWIKPEN insulin nph & regular susp pen-inj 100 unit/ml (70-30)
4
NOVOLIN N - insulin nph (human) (isophane) inj 100 unit/ml
2
NOVOLIN N RELION - insulin nph (human) (isophane) inj 100 unit/ml
2
NOVOLIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30)
2
•
NOVOLIN 70/30 RELION insulin nph isophane & regular human inj 100 unit/ ml (70-30)
2
•
NOVOLOG MIX 70/30 - insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)
2
•
NOVOLOG MIX 70/30 PREFILL - insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)
2
•
•
THYROID AGENTS
•
ARMOUR THYROID - thyroid tab 15 mg (1/4 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
levothyroxine sodium tab 25 mcg (Synthroid)
1
levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid)
LANTUS - insulin glargine inj 100 unit/ml
3
•
LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml
3
•
levothyroxine sodium tab 88 mcg (Synthroid) levothyroxine sodium tab 100 mcg (Synthroid) levothyroxine sodium tab 112 mcg (Synthroid)
Limited Distribution
3
ACA
Dispensing Limits
Step Therapy
LEVEMIR FLEXTOUCH insulin detemir soln peninjector 100 unit/ml
HUMULIN N KWIKPEN insulin nph (human) (isophane) susp pen-injector 100 unit/ml
Basal Insulins
Prior Authorization
•
4
•
Drug Tier 3
4
•
Drug Name LEVEMIR - insulin detemir inj 100 unit/ml
HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml
•
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
36
levothyroxine sodium tab 125 mcg (Synthroid) levothyroxine sodium tab 137 mcg (Synthroid) levothyroxine sodium tab 150 mcg (Synthroid) levothyroxine sodium tab 175 mcg (Synthroid) levothyroxine sodium tab 200 mcg (Synthroid) levothyroxine sodium tab 300 mcg (Synthroid)
1
NATURE-THROID - thyroid tab 195 mg
4
1
NATURE-THROID - thyroid tab 260 mg
4
1
NATURE-THROID - thyroid tab 325 mg (5 grain)
4
1
NATURE-THROID - thyroid tab 146.25 mg
4
1
NATURE-THROID NT-2.5 thyroid tab 162.5 mg (2 1/2 grain)
4
propylthiouracil tab 50 mg
2
1
SYNTHROID - levothyroxine sodium tab 25 mcg
4
2
SYNTHROID - levothyroxine sodium tab 50 mcg
4
2
SYNTHROID - levothyroxine sodium tab 75 mcg
4
methimazole tab 5 mg (Tapazole)
1
SYNTHROID - levothyroxine sodium tab 88 mcg
4
methimazole tab 10 mg (Tapazole)
1
SYNTHROID - levothyroxine sodium tab 100 mcg
4
NATURE-THROID - thyroid tab 16.25 mg
4
SYNTHROID - levothyroxine sodium tab 112 mcg
4
NATURE-THROID - thyroid tab 32.5 mg
4
SYNTHROID - levothyroxine sodium tab 125 mcg
4
NATURE-THROID - thyroid tab 48.75 mg (3/4 grain)
4
SYNTHROID - levothyroxine sodium tab 137 mcg
4
NATURE-THROID - thyroid tab 65 mg
4
SYNTHROID - levothyroxine sodium tab 150 mcg
4
NATURE-THROID - thyroid tab 81.25 mg
4
SYNTHROID - levothyroxine sodium tab 175 mcg
4
NATURE-THROID - thyroid tab 97.5 mg
4
SYNTHROID - levothyroxine sodium tab 200 mcg
4
NATURE-THROID - thyroid tab 113.75 mg
4
SYNTHROID - levothyroxine sodium tab 300 mcg
4
NATURE-THROID - thyroid tab 130 mg
4
thyroid tab 30 mg (1/2 grain) (Armour thyroid)
1
liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 25 mcg (Cytomel) liothyronine sodium tab 50 mcg (Cytomel)
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
37
thyroid tab 60 mg (1 grain) (Armour thyroid)
1
WESTHROID - thyroid tab 97.5 mg
4
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)
1
WESTHROID - thyroid tab 130 mg
4
THYROLAR-1 - liotrix (t3-t4) tab 60 mg (12.5-50 mcg)
4
WESTHROID - thyroid tab 195 mg
4
THYROLAR-1/2 - liotrix (t3-t4) tab 30 mg (6.25-25 mcg)
4
WP THYROID - thyroid tab 16.25 mg
4
THYROLAR-1/4 - liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg)
4
WP THYROID - thyroid tab 32.5 mg
4
THYROLAR-2 - liotrix (t3-t4) tab 120 mg (25-100 mcg)
4
WP THYROID - thyroid tab 48.75 mg (3/4 grain)
4
THYROLAR-3 - liotrix (t3-t4) tab 180 mg (37.5-150 mcg)
4
WP THYROID - thyroid tab 65 mg
4
TIROSINT - levothyroxine sodium cap 13 mcg
4
WP THYROID - thyroid tab 81.25 mg
4
TIROSINT - levothyroxine sodium cap 25 mcg
4
WP THYROID - thyroid tab 97.5 mg
4
TIROSINT - levothyroxine sodium cap 50 mcg
4
WP THYROID - thyroid tab 113.75 mg
4
TIROSINT - levothyroxine sodium cap 75 mcg
4
WP THYROID - thyroid tab 130 mg
4
TIROSINT - levothyroxine sodium cap 88 mcg
4
OXYTOCICS
4
4
TIROSINT - levothyroxine sodium cap 100 mcg
CERVIDIL - dinoprostone vaginal inserts 10 mg
4
methylergonovine maleate tab 0.2 mg
2
TIROSINT - levothyroxine sodium cap 112 mcg
PREPIDIL - dinoprostone cervical gel 0.5 mg/3gm
4
TIROSINT - levothyroxine sodium cap 125 mcg
4
PROSTIN E2 - dinoprostone vaginal suppos 20 mg
4
TIROSINT - levothyroxine sodium cap 137 mcg
4
TIROSINT - levothyroxine sodium cap 150 mcg
4
WESTHROID - thyroid tab 32.5 mg
4
WESTHROID - thyroid tab 65 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ENDOCRINE and METABOLIC AGENTS - MISC. 4 • ACTONEL - risedronate sodium tab 5 mg 4 • ACTONEL - risedronate sodium tab 30 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
38
4
•
alendronate sodium tab 5 mg
1
•
1
•
1
•
1
•
ATELVIA - risedronate sodium tab delayed release 35 mg
4
•
BINOSTO - alendronate sodium effervescent tab 70 mg
4
•
BUPHENYL - sodium phenylbutyrate tab 500 mg
5
cabergoline tab 0.5 mg
2
alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 70 mg (Fosamax)
•
2
desmopressin acetate nasal spray soln 0.01% (Ddavp)
2
desmopressin acetate tab 0.1 mg (Ddavp) desmopressin acetate tab 0.2 mg (Ddavp)
•
2
desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)
desmopressin acetate nasal spray soln 0.01% (refrigerated)
2
2 2
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
•
•
calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)
2
ETIDRONATE DISODIUM etidronate disodium tab 200 mg
4
calcitriol cap 0.25 mcg (Rocaltrol)
2
4
calcitriol cap 0.5 mcg (Rocaltrol)
2
ETIDRONATE DISODIUM etidronate disodium tab 400 mg
5
calcitriol oral soln 1 mcg/ml (Rocaltrol)
2
FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml
CARBAGLU - carglumic acid tab 200 mg
5
4
CYSTADANE - betaine powder for oral solution
4
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-2800 mg-unit
•
• •
Limited Distribution
ALENDRONATE SODIUM alendronate sodium tab 40 mg
ACA
•
Dispensing Limits
4
Step Therapy
ALENDRONATE SODIUM alendronate sodium oral soln 70 mg/75ml
desmopressin acetate inj 4 mcg/ml (Ddavp)
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
ACTONEL - risedronate sodium tab 35 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
39
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-5600 mg-unit
4
H.P. ACTHAR - corticotropin inj gel 80 unit/ml
5
ibandronate sodium tab 150 mg (base equivalent) (Boniva)
2
INCRELEX - mecasermin inj 40 5 mg/4ml (10 mg/ml) 5 KUVAN - sapropterin dihydrochloride powder packet 100 mg 5 KUVAN - sapropterin dihydrochloride powder packet 500 mg 5 KUVAN - sapropterin dihydrochloride soluble tab 100 mg 2 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 2 levocarnitine tab 330 mg (Carnitor) 4 MIACALCIN - calcitonin (salmon) inj 200 unit/ml 5 MYALEPT - metreleptin for subcutaneous inj 11.3 mg 5 NATPARA - parathyroid hormone (recombinant) for inj cartridge 25 mcg 5 NATPARA - parathyroid hormone (recombinant) for inj cartridge 50 mcg 5 NATPARA - parathyroid hormone (recombinant) for inj cartridge 75 mcg
•
• •
•
•
•
•
•
•
•
•
•
• • • •
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
NATPARA - parathyroid hormone (recombinant) for inj cartridge 100 mcg
5
octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin)
5
•
•
octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)
5
•
•
octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin)
5
•
•
octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)
5
•
•
octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin)
5
•
•
OMNITROPE - somatropin for inj 5.8 mg
5
•
•
OMNITROPE - somatropin inj 5 5 mg/1.5ml 5 OMNITROPE - somatropin inj 10 mg/1.5ml ORFADIN - nitisinone cap 2 mg 5
•
•
•
•
• • •
• • •
ORFADIN - nitisinone cap 5 mg 5 5 ORFADIN - nitisinone cap 10 mg 5 ORFADIN - nitisinone cap 20 mg 5 ORFADIN - nitisinone susp 4 mg/ml OSPHENA - ospemifene tab 60 4 mg 2 paricalcitol cap 1 mcg (Zemplar) 2 paricalcitol cap 2 mcg (Zemplar)
• •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
40
paricalcitol cap 4 mcg
2
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
SOMAVERT - pegvisomant for inj 10 mg (as protein)
5
•
•
SOMAVERT - pegvisomant for inj 15 mg (as protein)
5
•
•
SOMAVERT - pegvisomant for inj 20 mg (as protein)
5
•
•
SOMAVERT - pegvisomant for inj 25 mg (as protein)
5
•
•
•
•
raloxifene hcl tab 60 mg (Evista)
2
RAVICTI - glycerol phenylbutyrate liquid 1.1 gm/ ml
5
risedronate sodium tab delayed release 35 mg (Atelvia)
2
• •
SOMAVERT - pegvisomant for inj 30 mg (as protein)
5
risedronate sodium tab 5 mg (Actonel)
2
•
STIMATE - desmopressin acetate nasal soln 1.5 mg/ml
3
risedronate sodium tab 30 mg (Actonel)
2 2
•
5
•
2
•
STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml STRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml
5
•
STRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml
5
•
STRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml
5
•
SYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) (base eq)
4
XURIDEN - uridine triacetate oral granules packet 2 gm
5
risedronate sodium tab 35 mg (Actonel) risedronate sodium tab 150 mg (Actonel)
•
• •
•
• •
• •
SAMSCA - tolvaptan tab 15 mg
5
SAMSCA - tolvaptan tab 30 mg
5
SENSIPAR - cinacalcet hcl tab 30 mg (base equiv)
3
SENSIPAR - cinacalcet hcl tab 60 mg (base equiv)
3
SENSIPAR - cinacalcet hcl tab 90 mg (base equiv)
3
SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml (base equiv)
5
•
•
SIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml (base equiv)
5
•
•
SIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml (base equiv)
5
sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)
5
• •
• •
•
CARDIOVASCULAR AGENTS CARDIOTONICS DIGOXIN - digoxin oral soln 0.05 mg/ml
4
digoxin tab 125 mcg (0.125 mg) (Lanoxin)
2
digoxin tab 250 mcg (0.25 mg) (Lanoxin) LANOXIN - digoxin tab 62.5 mcg (0.0625 mg)
2 4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
41
LANOXIN - digoxin tab 125 mcg (0.125 mg)
4
NITRO-DUR - nitroglycerin td patch 24hr 0.3 mg/hr
4
LANOXIN - digoxin tab 187.5 mcg (0.1875 mg)
4
NITRO-DUR - nitroglycerin td patch 24hr 0.8 mg/hr
4
LANOXIN - digoxin tab 250 mcg (0.25 mg)
2
nitroglycerin cap cr 2.5 mg
1
LANOXIN - digoxin tab 250 mcg (0.25 mg)
4
nitroglycerin cap cr 6.5 mg nitroglycerin cap cr 9 mg
4
4
nitroglycerin sl tab 0.3 mg (Nitrostat)
2
ISORDIL TITRADOSE isosorbide dinitrate tab 40 mg
4
nitroglycerin sl tab 0.4 mg (Nitrostat)
2
nitroglycerin sl tab 0.6 mg (Nitrostat)
2
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)
2
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)
Limited Distribution
ACA
Dispensing Limits
2
DILATRATE SR - isosorbide dinitrate cap cr 40 mg
ISOSORBIDE DINITRATE ER - 2 isosorbide dinitrate tab cr 40 mg isosorbide dinitrate tab 5 mg 2 (Isordil titradose) 2 isosorbide dinitrate tab 10 mg 2 isosorbide dinitrate tab 20 mg 2 isosorbide dinitrate tab 30 mg 1 isosorbide mononitrate tab sr 24hr 30 mg 1 isosorbide mononitrate tab sr 24hr 60 mg 2 isosorbide mononitrate tab sr 24hr 120 mg 1 isosorbide mononitrate tab 10 mg 1 isosorbide mononitrate tab 20 mg 4 NITRO-BID - nitroglycerin oint 2%
Step Therapy
2
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/spray
ANTIANGINAL AGENTS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2
nitroglycerin tl soln 0.4 mg/ spray (400 mcg/spray) (Nitrolingual pumpspr)
2
NITROMIST - nitroglycerin lingual aerosol 400 mcg/ spray
4
NITROSTAT - nitroglycerin sl tab 0.3 mg
3
NITROSTAT - nitroglycerin sl tab 0.4 mg
3
NITROSTAT - nitroglycerin sl tab 0.6 mg
3
RANEXA - ranolazine tab sr 12hr 500 mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
42
4
COREG CR - carvedilol phosphate cap sr 24hr 10 mg
4
acebutolol hcl cap 200 mg (Sectral)
1
4
acebutolol hcl cap 400 mg (Sectral)
1
COREG CR - carvedilol phosphate cap sr 24hr 20 mg
4
atenolol tab 25 mg (Tenormin)
1
COREG CR - carvedilol phosphate cap sr 24hr 40 mg
atenolol tab 50 mg (Tenormin)
1
4
atenolol tab 100 mg (Tenormin)
1
COREG CR - carvedilol phosphate cap sr 24hr 80 mg
4
betaxolol hcl tab 10 mg (Kerlone)
2
HEMANGEOL - propranolol hcl oral soln 4.28 mg/ml
4
betaxolol hcl tab 20 mg (Kerlone)
2
INDERAL XL - propranolol hcl sustained-release beads cap sr 24hr 80 mg
1
INDERAL XL - propranolol hcl sustained-release beads cap sr 24hr 120 mg
4
bisoprolol fumarate tab 5 mg (Zebeta) bisoprolol fumarate tab 10 mg (Zebeta)
2
INNOPRAN XL - propranolol hcl sustained-release beads cap sr 24hr 80 mg
4
4
RANEXA - ranolazine tab sr 12hr 1000 mg BETA BLOCKERS
BYSTOLIC - nebivolol hcl tab 2.5 mg (base equivalent)
4
BYSTOLIC - nebivolol hcl tab 5 mg (base equivalent)
4
INNOPRAN XL - propranolol hcl sustained-release beads cap sr 24hr 120 mg
BYSTOLIC - nebivolol hcl tab 10 mg (base equivalent)
4
labetalol hcl tab 100 mg (Trandate)
2
BYSTOLIC - nebivolol hcl tab 20 mg (base equivalent)
4
labetalol hcl tab 200 mg (Trandate)
2
carvedilol tab 3.125 mg (Coreg)
1
labetalol hcl tab 300 mg (Trandate)
2
carvedilol tab 6.25 mg (Coreg)
1
1
carvedilol tab 12.5 mg (Coreg)
1
metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) (Toprol xl)
1
carvedilol tab 25 mg (Coreg)
1
metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) (Toprol xl)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
43
metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) (Toprol xl)
2
propranolol hcl tab 20 mg propranolol hcl tab 40 mg
2
propranolol hcl tab 60 mg
METOPROLOL TARTRATE metoprolol tartrate tab 37.5 mg
4
sotalol hcl (afib/afl) tab 80 mg (Betapace af)
METOPROLOL TARTRATE metoprolol tartrate tab 75 mg
4
metoprolol tartrate tab 25 mg
1
metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) (Toprol xl)
metoprolol tartrate tab 50 mg (Lopressor) metoprolol tartrate tab 100 mg (Lopressor) nadolol tab 20 mg (Corgard) nadolol tab 40 mg (Corgard) nadolol tab 80 mg (Corgard) pindolol tab 5 mg pindolol tab 10 mg
1 1 2 2 2 2 2
PROPRANOLOL HCL propranolol hcl oral soln 20 mg/5ml
4
PROPRANOLOL HCL propranolol hcl oral soln 40 mg/5ml
4
propranolol hcl cap sr 24hr 60 mg (Inderal la)
2
propranolol hcl cap sr 24hr 80 mg (Inderal la) propranolol hcl cap sr 24hr 120 mg (Inderal la) propranolol hcl cap sr 24hr 160 mg (Inderal la) propranolol hcl tab 10 mg
2 2 2 1
propranolol hcl tab 80 mg
sotalol hcl (afib/afl) tab 120 mg (Betapace af) sotalol hcl (afib/afl) tab 160 mg (Betapace af)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 2 1 2 2 2
sotalol hcl tab 80 mg (Betapace)
1
sotalol hcl tab 120 mg (Betapace)
1
sotalol hcl tab 160 mg (Betapace)
1
sotalol hcl tab 240 mg
2
SOTYLIZE - sotalol hcl oral solution 5 mg/ml
4
TIMOLOL MALEATE - timolol maleate tab 5 mg
4
TIMOLOL MALEATE - timolol maleate tab 10 mg
4
TIMOLOL MALEATE - timolol maleate tab 20 mg
4
CALCIUM CHANNEL BLOCKERS 1 amlodipine besylate tab 2.5 mg (Norvasc) 1 amlodipine besylate tab 5 mg (Norvasc) 1 amlodipine besylate tab 10 mg (Norvasc) 4 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 120 mg 2 diltiazem hcl cap sr 12hr 60 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
44
diltiazem hcl cap sr 12hr 90 mg diltiazem hcl cap sr 12hr 120 mg diltiazem hcl cap sr 24hr 120 mg diltiazem hcl cap sr 24hr 180 mg diltiazem hcl cap sr 24hr 240 mg
2 2 1 2 2
diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)
1
diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)
1
diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd)
2
diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd)
2
diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd)
2
diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la)
2
diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la)
2
diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la)
2
diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la)
2
diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la)
2
diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac)
2
diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac) diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac) diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac) diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac) diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac)
2
diltiazem hcl tab 90 mg
1
diltiazem hcl tab 120 mg (Cardizem)
1
felodipine tab sr 24hr 2.5 mg
2
nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nifedipine cap 10 mg (Procardia)
Limited Distribution
2
1
isradipine cap 5 mg
ACA
2
diltiazem hcl tab 60 mg (Cardizem)
isradipine cap 2.5 mg
Dispensing Limits
2
1
felodipine tab sr 24hr 10 mg
Step Therapy
2
diltiazem hcl tab 30 mg (Cardizem)
felodipine tab sr 24hr 5 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2 2 2 2 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
45
nifedipine cap 20 mg
2
nifedipine tab sr 24hr 30 mg (Adalat cc)
1
verapamil hcl cap sr 24hr 180 mg (Verelan)
nifedipine tab sr 24hr 60 mg (Adalat cc)
2
verapamil hcl cap sr 24hr 200 mg (Verelan pm)
nifedipine tab sr 24hr 90 mg (Adalat cc)
2
verapamil hcl cap sr 24hr 240 mg (Verelan)
nifedipine tab sr 24hr osmotic release 30 mg (Procardia xl)
1
verapamil hcl cap sr 24hr 300 mg (Verelan pm)
nifedipine tab sr 24hr osmotic release 60 mg (Procardia xl)
2
nifedipine tab sr 24hr osmotic release 90 mg (Procardia xl)
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 8.5 mg (Sular)
2
verapamil hcl cap sr 24hr 360 mg (Verelan)
1
verapamil hcl tab 40 mg
2
verapamil hcl tab 80 mg (Calan)
1
verapamil hcl tab 120 mg (Calan)
1
1
amiodarone hcl tab 400 mg
2
NYMALIZE - nimodipine oral soln 60 mg/20ml
4
dofetilide cap 125 mcg (0.125 mg) (Tikosyn)
verapamil hcl cap sr 24hr 100 mg (Verelan pm)
2
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)
2
dofetilide cap 500 mcg (0.5 mg) (Tikosyn) flecainide acetate tab 50 mg
Limited Distribution
ACA
2
amiodarone hcl tab 200 mg (Cordarone)
disopyramide phosphate cap 150 mg (Norpace)
Dispensing Limits
2
verapamil hcl tab cr 240 mg (Calan sr)
amiodarone hcl tab 100 mg
Step Therapy
2
1
2
verapamil hcl cap sr 24hr 120 mg (Verelan)
2
verapamil hcl tab cr 180 mg (Calan sr)
disopyramide phosphate cap 100 mg (Norpace)
nisoldipine tab sr 24hr 34 mg (Sular)
2
1
2
nisoldipine tab sr 24hr 17 mg (Sular)
2
verapamil hcl tab cr 120 mg (Calan sr)
ANTIARRHYTHMICS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2 2 2 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
46
2
TIKOSYN - dofetilide cap 125 mcg (0.125 mg)
4
2
TIKOSYN - dofetilide cap 250 mcg (0.25 mg)
4
2
4
2
TIKOSYN - dofetilide cap 500 mcg (0.5 mg)
2
ANTIHYPERTENSIVES
MULTAQ - dronedarone hcl tab 400 mg (base equivalent)
4
NORPACE - disopyramide phosphate cap 100 mg
4
amlodipine besylatebenazepril hcl cap 2.5-10 mg (Lotrel)
NORPACE - disopyramide phosphate cap 150 mg
4
NORPACE CR - disopyramide phosphate cap sr 12hr 100 mg
4
NORPACE CR - disopyramide phosphate cap sr 12hr 150 mg
4
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)
2
flecainide acetate tab 100 mg flecainide acetate tab 150 mg mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg
propafenone hcl cap sr 12hr 325 mg (Rythmol sr) propafenone hcl cap sr 12hr 425 mg (Rythmol sr)
2 2
propafenone hcl tab 150 mg (Rythmol)
2
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
4
QUINIDINE SULFATE quinidine sulfate tab 300 mg
2
2
amlodipine besylatebenazepril hcl cap 5-20 mg (Lotrel)
2
amlodipine besylatebenazepril hcl cap 5-40 mg (Lotrel)
2
amlodipine besylatebenazepril hcl cap 10-20 mg (Lotrel)
2
amlodipine besylateolmesartan medoxomil tab 5-20 mg (Azor) amlodipine besylateolmesartan medoxomil tab 5-40 mg (Azor) amlodipine besylateolmesartan medoxomil tab 10-20 mg (Azor) amlodipine besylateolmesartan medoxomil tab 10-40 mg (Azor)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
amlodipine besylatebenazepril hcl cap 5-10 mg (Lotrel)
amlodipine besylatebenazepril hcl cap 10-40 mg (Lotrel)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
47
amlodipine besylatevalsartan tab 5-160 mg (Exforge)
2
AZOR - amlodipine besylateolmesartan medoxomil tab 10-20 mg
4
amlodipine besylatevalsartan tab 5-320 mg (Exforge)
2
AZOR - amlodipine besylateolmesartan medoxomil tab 10-40 mg
4
amlodipine besylatevalsartan tab 10-160 mg (Exforge)
2
2
amlodipine besylatevalsartan tab 10-320 mg (Exforge)
2
benazepril & hydrochlorothiazide tab 5-6.25 mg
amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg (Exforge hct)
2
benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) benazepril hcl tab 5 mg
Limited Distribution
ACA
2
1
benazepril hcl tab 20 mg (Lotensin)
1
benazepril hcl tab 40 mg (Lotensin)
1
BENICAR - olmesartan medoxomil tab 5 mg
4
1
BENICAR - olmesartan medoxomil tab 20 mg
4
atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100)
1
BENICAR - olmesartan medoxomil tab 40 mg
4 4
AZOR - amlodipine besylateolmesartan medoxomil tab 5-20 mg
4
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg
AZOR - amlodipine besylateolmesartan medoxomil tab 5-40 mg
4
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg
4
atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)
Dispensing Limits
2
1
2
Step Therapy
2
benazepril hcl tab 10 mg (Lotensin)
amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg (Exforge hct)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
48
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab 40-25 mg
4
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)
1
bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)
candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct) candesartan cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct) captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg
CAPTOPRIL/ HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 50-15 mg
4
CAPTOPRIL/ HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 50-25 mg
4
2
clonidine hcl tab 0.1 mg (Catapres)
1
2
clonidine hcl tab 0.2 mg (Catapres)
1
2
clonidine hcl tab 0.3 mg (Catapres)
1
2
clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1)
2
2
clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2)
2
2
clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3)
2
CLORPRES - clonidine & chlorthalidone tab 0.1-15 mg
4
CLORPRES - clonidine & chlorthalidone tab 0.2-15 mg
4
1
1
2
2 2 2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
4
2
candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct)
Dispensing Limits
CAPTOPRIL/ HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 25-25 mg
candesartan cilexetil tab 4 mg (Atacand)
candesartan cilexetil tab 32 mg (Atacand)
Step Therapy
4
4
candesartan cilexetil tab 16 mg (Atacand)
Drug Name CAPTOPRIL/ HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 25-15 mg
BYVALSON - nebivololvalsartan tab 5-80 mg
candesartan cilexetil tab 8 mg (Atacand)
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
49
CLORPRES - clonidine & chlorthalidone tab 0.3-15 mg
4
DEMSER - metyrosine cap 250 mg
4
enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)
1
DIBENZYLINE phenoxybenzamine hcl cap 10 mg
4
enalapril maleate tab 2.5 mg (Vasotec) enalapril maleate tab 5 mg (Vasotec)
1
doxazosin mesylate tab 1 mg (Cardura)
1
enalapril maleate tab 10 mg (Vasotec)
1
1
enalapril maleate tab 20 mg (Vasotec)
1
1
EPANED - enalapril maleate for 4 oral soln 1 mg/ml 2 eplerenone tab 25 mg (Inspra) 2 eplerenone tab 50 mg (Inspra) 2 EPROSARTAN MESYLATE eprosartan mesylate tab 600 mg 2 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 2 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 1 fosinopril sodium tab 10 mg
doxazosin mesylate tab 2 mg (Cardura) doxazosin mesylate tab 4 mg (Cardura) doxazosin mesylate tab 8 mg (Cardura)
1
DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg
4
DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg
4
DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg
4
EDARBI - azilsartan medoxomil 4 tab 40 mg EDARBI - azilsartan medoxomil 4 tab 80 mg 4 EDARBYCLOR - azilsartan medoxomil-chlorthalidone tab 40-12.5 mg 4 EDARBYCLOR - azilsartan medoxomil-chlorthalidone tab 40-25 mg 1 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg
fosinopril sodium tab 20 mg fosinopril sodium tab 40 mg
Limited Distribution
ACA
1
guanfacine hcl tab 2 mg (Tenex)
1
hydralazine hcl tab 10 mg
1
hydralazine hcl tab 100 mg
Dispensing Limits
1 1
hydralazine hcl tab 50 mg
Step Therapy
1
guanfacine hcl tab 1 mg (Tenex)
hydralazine hcl tab 25 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
50
irbesartan tab 75 mg (Avapro)
1
irbesartan tab 150 mg (Avapro)
1
irbesartan tab 300 mg (Avapro)
1
irbesartanhydrochlorothiazide tab 150-12.5 mg (Avalide)
1
irbesartanhydrochlorothiazide tab 300-12.5 mg (Avalide) lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) lisinopril tab 2.5 mg (Zestril) lisinopril tab 5 mg (Prinivil) lisinopril tab 10 mg (Prinivil) lisinopril tab 20 mg (Prinivil) lisinopril tab 30 mg (Zestril) lisinopril tab 40 mg (Zestril) losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar) losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar) losartan potassium tab 25 mg (Cozaar)
losartan potassium tab 50 mg (Cozaar) losartan potassium tab 100 mg (Cozaar) methyldopa tab 250 mg methyldopa tab 500 mg
1
2
1
metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)
1
metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct)
1 1 1 1 1
1
1
1
minoxidil tab 2.5 mg minoxidil tab 10 mg moexipril hcl tab 7.5 mg moexipril hcl tab 15 mg moexiprilhydrochlorothiazide tab 7.5-12.5 mg moexiprilhydrochlorothiazide tab 15-12.5 mg moexiprilhydrochlorothiazide tab 15-25 mg
Limited Distribution
1
4
metoprolol & hydrochlorothiazide tab 100-50 mg
ACA
1
METHYLDOPA/ HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab 250-25 mg
1
Dispensing Limits
1
4
1
Step Therapy
1
METHYLDOPA/ HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab 250-15 mg
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
1 1 2 2 2
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
51
nadolol & bendroflumethiazide tab 40-5 mg (Corzide) nadolol & bendroflumethiazide tab 80-5 mg (Corzide) olmesartan medoxomil tab 5 mg (Benicar) olmesartan medoxomil tab 20 mg (Benicar) olmesartan medoxomil tab 40 mg (Benicar) olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg (Benicar hct) olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg (Benicar hct) olmesartan medoxomilhydrochlorothiazide tab 40-25 mg (Benicar hct) olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg (Tribenzor) olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg (Tribenzor) olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg (Tribenzor) olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5 mg (Tribenzor) olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg (Tribenzor) perindopril erbumine tab 2 mg
2
2
2 2 2 2
2
2
2
2
2
2
2
1
perindopril erbumine tab 4 mg (Aceon) perindopril erbumine tab 8 mg (Aceon) phenoxybenzamine hcl cap 10 mg (Dibenzyline)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2
prazosin hcl cap 1 mg (Minipress)
1
prazosin hcl cap 2 mg (Minipress)
1
prazosin hcl cap 5 mg (Minipress)
2
PRESTALIA - perindopril arginine-amlodipine besylate tab 3.5-2.5 mg
4
PRESTALIA - perindopril arginine-amlodipine besylate tab 7-5 mg
4
PRESTALIA - perindopril arginine-amlodipine besylate tab 14-10 mg
4
PROPRANOLOL/ HYDROCHLOROTH propranolol & hydrochlorothiazide tab 40-25 mg
4
PROPRANOLOL/ HYDROCHLOROTH propranolol & hydrochlorothiazide tab 80-25 mg
4
QBRELIS - lisinopril oral soln 1 mg/ml
4
quinapril hcl tab 5 mg (Accupril)
1
quinapril hcl tab 10 mg (Accupril)
1
quinapril hcl tab 20 mg (Accupril)
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
52
quinapril hcl tab 40 mg (Accupril)
1
quinaprilhydrochlorothiazide tab 10-12.5 mg (Accuretic)
2
quinaprilhydrochlorothiazide tab 20-12.5 mg (Accuretic) quinaprilhydrochlorothiazide tab 20-25 mg (Accuretic) ramipril cap 1.25 mg (Altace) ramipril cap 2.5 mg (Altace) ramipril cap 5 mg (Altace) ramipril cap 10 mg (Altace)
2
2
1 1 1 1
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 40-5 mg (Twynsta)
2
telmisartan-amlodipine tab 40-10 mg (Twynsta) telmisartan-amlodipine tab 80-5 mg (Twynsta)
TARKA - trandolapril-verapamil hcl tab cr 1-240 mg
4
telmisartan-amlodipine tab 80-10 mg (Twynsta)
TARKA - trandolapril-verapamil hcl tab cr 2-180 mg
4
TARKA - trandolapril-verapamil hcl tab cr 2-240 mg
4
telmisartanhydrochlorothiazide tab 40-12.5 mg (Micardis hct)
TARKA - trandolapril-verapamil hcl tab cr 4-240 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
trandolapril tab 2 mg (Mavik)
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg
4
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)
telmisartanhydrochlorothiazide tab 80-12.5 mg (Micardis hct) telmisartanhydrochlorothiazide tab 80-25 mg (Micardis hct) terazosin hcl cap 1 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg terazosin hcl cap 10 mg trandolapril tab 1 mg (Mavik) trandolapril tab 4 mg (Mavik)
trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2 2
2
2
1 1 1 1 1 1 1 2 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
53
trandolapril-verapamil hcl tab cr 2-240 mg (Tarka) trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)
2 2
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
valsartanhydrochlorothiazide tab 320-12.5 mg (Diovan hct) valsartanhydrochlorothiazide tab 320-25 mg (Diovan hct)
VECAMYL - mecamylamine hcl 4 tab 2.5 mg DIURETICS ACETAZOLAMIDE acetazolamide tab 125 mg
4
acetazolamide cap sr 12hr 500 mg (Diamox)
2
acetazolamide tab 250 mg
1
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg
4
amiloride & hydrochlorothiazide tab 5-50 mg
valsartan tab 40 mg (Diovan)
2 2
valsartan tab 160 mg (Diovan)
2
valsartan tab 320 mg (Diovan)
2
valsartanhydrochlorothiazide tab 80-12.5 mg (Diovan hct)
1
valsartanhydrochlorothiazide tab 160-25 mg (Diovan hct)
2
2
bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg
ACA
Limited Distribution
•
2
4
amiloride hcl tab 5 mg
Dispensing Limits
1
4
valsartanhydrochlorothiazide tab 160-12.5 mg (Diovan hct)
Step Therapy
1
ALDACTAZIDE spironolactone & hydrochlorothiazide tab 50-50 mg
valsartan tab 80 mg (Diovan)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 1 1 2
CHLOROTHIAZIDE chlorothiazide tab 250 mg
4
chlorothiazide tab 500 mg
1
CHLORTHALIDONE chlorthalidone tab 100 mg
4
chlorthalidone tab 25 mg
2
DIURIL - chlorothiazide susp 250 mg/5ml
4
DYRENIUM - triamterene cap 50 mg
4
DYRENIUM - triamterene cap 100 mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
54
EDECRIN - ethacrynic acid tab 25 mg
4
spironolactone tab 50 mg (Aldactone)
1
ethacrynic acid tab 25 mg
2
2
FUROSEMIDE - furosemide oral soln 8 mg/ml
4
spironolactone tab 100 mg (Aldactone)
1
furosemide oral soln 10 mg/ ml
1
torsemide tab 5 mg (Demadex)
1
1
torsemide tab 10 mg (Demadex) torsemide tab 20 mg (Demadex)
1
torsemide tab 100 mg (Demadex)
2
triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)
1
furosemide tab 20 mg (Lasix) furosemide tab 40 mg (Lasix) furosemide tab 80 mg (Lasix) hydrochlorothiazide cap 12.5 mg (Microzide) hydrochlorothiazide tab 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg
1 1 1 1 1 1
1 4
methazolamide tab 25 mg (Neptazane)
2
methazolamide tab 50 mg (Neptazane)
2
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
4
metolazone tab 2.5 mg
2
metolazone tab 10 mg spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) spironolactone tab 25 mg (Aldactone)
triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)
1
KEVEYIS - dichlorphenamide tab 50 mg
metolazone tab 5 mg
triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)
•
TRIAMTERENE/ HYDROCHLOROTH triamterene & hydrochlorothiazide cap 50-25 mg VASOPRESSORS
Limited Distribution
ACA
Dispensing Limits
1
4
4
ADRENACLICK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)
4
2
EPINEPHRINE - epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)
4
1
EPINEPHRINE - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)
4
2
Step Therapy
1
ADRENACLICK - epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)
2
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
55
EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)
3
atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)
1
EPIPEN-JR 2-PAK epinephrine solution autoinjector 0.15 mg/0.3ml (1:2000)
3
cholestyramine light powder packets 4 gm
2
midodrine hcl tab 2.5 mg
2
midodrine hcl tab 5 mg midodrine hcl tab 10 mg
cholestyramine light powder 4 gm/dose (Questran light) cholestyramine powder packets 4 gm (Questran)
2 2
•
NORTHERA - droxidopa cap 100 mg
4
NORTHERA - droxidopa cap 200 mg
4
•
NORTHERA - droxidopa cap 300 mg
4
•
ANTIHYPERLIPIDEMICS ALTOPREV - lovastatin tab sr 24hr 20 mg
4
•
ALTOPREV - lovastatin tab sr 24hr 40 mg
4
•
ALTOPREV - lovastatin tab sr 24hr 60 mg
4
•
ANTARA - fenofibrate micronized cap 30 mg
4
• •
ANTARA - fenofibrate micronized cap 90 mg
4
• •
atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)
1
atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)
1
atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)
1
cholestyramine powder 4 gm/dose (Questran) choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2 2
•
2
•
colestipol hcl granule packets 5 gm (Colestid flavored)
2
colestipol hcl granules 5 gm (Colestid flavored)
2
colestipol hcl tab 1 gm (Colestid)
2
CRESTOR - rosuvastatin calcium tab 5 mg
4
CRESTOR - rosuvastatin calcium tab 10 mg
4
CRESTOR - rosuvastatin calcium tab 20 mg
4
CRESTOR - rosuvastatin calcium tab 40 mg
4
FENOFIBRATE - fenofibrate cap 50 mg
4
• •
FENOFIBRATE - fenofibrate cap 150 mg
4
• •
fenofibrate micronized cap 43 mg
2
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
56
fenofibrate micronized cap 67 mg (Lofibra) fenofibrate micronized cap 130 mg fenofibrate micronized cap 134 mg (Lofibra)
2
•
fenofibrate tab 40 mg (Fenoglide)
2
•
fenofibrate tab 48 mg (Tricor)
2
fenofibrate micronized cap 200 mg (Lofibra)
1
JUXTAPID - lomitapide mesylate cap 5 mg (base equiv)
5
•
•
•
JUXTAPID - lomitapide mesylate cap 10 mg (base equiv)
5
•
•
•
JUXTAPID - lomitapide mesylate cap 20 mg (base equiv)
5
•
•
•
JUXTAPID - lomitapide mesylate cap 30 mg (base equiv)
5
•
•
•
JUXTAPID - lomitapide mesylate cap 40 mg (base equiv)
5
•
•
•
JUXTAPID - lomitapide mesylate cap 60 mg (base equiv)
5
•
•
•
KYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml
5
•
•
•
LESCOL XL - fluvastatin sodium tab sr 24 hr 80 mg
4
•
LIPOFEN - fenofibrate cap 50 mg
4
• •
LIPOFEN - fenofibrate cap 150 mg
4
• •
LIVALO - pitavastatin calcium tab 1 mg (base equiv)
4
•
4
• •
fenofibrate tab 54 mg (Lofibra)
1
fenofibrate tab 120 mg (Fenoglide)
2
•
fenofibrate tab 145 mg (Tricor)
2
•
fenofibrate tab 160 mg (Lofibra)
2
•
FENOFIBRIC ACID - fenofibric acid tab 35 mg
4
• •
FENOFIBRIC ACID - fenofibric acid tab 105 mg
4
• •
FENOGLIDE - fenofibrate tab 40 mg
4
FENOGLIDE - fenofibrate tab 120 mg
4
FIBRICOR - fenofibric acid tab 35 mg
4
FIBRICOR - fenofibric acid tab 105 mg
4
fluvastatin sodium cap 20 mg (Lescol)
2
LIVALO - pitavastatin calcium tab 2 mg (base equiv)
4
2
LIVALO - pitavastatin calcium tab 4 mg (base equiv) lovastatin tab 10 mg
1
fluvastatin sodium cap 40 mg (Lescol) fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)
2
• • • • • •
Limited Distribution
gemfibrozil tab 600 mg (Lopid)
• •
• •
•
ACA
•
Dispensing Limits
2
Step Therapy
•
Prior Authorization
2
Drug Name
Drug Tier
•
Limited Distribution
2
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
lovastatin tab 20 mg
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
57
lovastatin tab 40 mg (Mevacor)
1
niacin tab cr 500 mg (antihyperlipidemic) (Niaspan)
2
niacin tab cr 750 mg (antihyperlipidemic) (Niaspan)
2
niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan)
2
omega-3-acid ethyl esters cap 1 gm (Lovaza)
2
rosuvastatin calcium tab 5 mg (Crestor)
2
rosuvastatin calcium tab 40 mg (Crestor) simvastatin tab 5 mg (Zocor)
•
•
•
PRALUENT - alirocumab subcutaneous soln peninjector 150 mg/ml
5
•
•
•
PRALUENT - alirocumab subcutaneous soln prefilled syringe 75 mg/ml
5
•
•
•
pravastatin sodium tab 10 mg
1
pravastatin sodium tab 80 mg (Pravachol)
5
rosuvastatin calcium tab 20 mg (Crestor)
5
pravastatin sodium tab 40 mg (Pravachol)
REPATHA SURECLICK evolocumab subcutaneous soln auto-injector 140 mg/ml
rosuvastatin calcium tab 10 mg (Crestor)
PRALUENT - alirocumab subcutaneous soln peninjector 75 mg/ml
pravastatin sodium tab 20 mg (Pravachol)
1 1 2
REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml
5
•
•
•
REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneous soln cartridge/ infusor 420 mg/3.5ml
5
•
•
•
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
2 2 2 1
simvastatin tab 10 mg (Zocor)
1
simvastatin tab 20 mg (Zocor)
1
simvastatin tab 40 mg (Zocor)
1
simvastatin tab 80 mg (Zocor)
1
TRIGLIDE - fenofibrate tab 160 mg
4
VASCEPA - icosapent ethyl cap 4 0.5 gm VASCEPA - icosapent ethyl cap 4 1 gm 4 VYTORIN - ezetimibesimvastatin tab 10-10 mg 4 VYTORIN - ezetimibesimvastatin tab 10-20 mg 4 VYTORIN - ezetimibesimvastatin tab 10-40 mg 4 VYTORIN - ezetimibesimvastatin tab 10-80 mg 4 WELCHOL - colesevelam hcl packet for susp 3.75 gm 4 WELCHOL - colesevelam hcl tab 625 mg
• •
• • • •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
58
ZETIA - ezetimibe tab 10 mg
4
CARDIOVASCULAR AGENTS - MISC. ADCIRCA - tadalafil tab 20 mg 5 • (pah) 5 • ADEMPAS - riociguat tab 0.5 mg ADEMPAS - riociguat tab 1 mg 5 •
• • •
amlodipine besylateatorvastatin calcium tab 10-80 mg (Caduet)
• •
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5 mg
4
CIALIS - tadalafil tab 2.5 mg
3
CIALIS - tadalafil tab 5 mg
3
CORLANOR - ivabradine hcl tab 5 mg (base equiv)
4
CORLANOR - ivabradine hcl tab 7.5 mg (base equiv)
4
ENTRESTO - sacubitrilvalsartan tab 24-26 mg
ADEMPAS - riociguat tab 2 mg
5
ADEMPAS - riociguat tab 2.5 mg
5
• •
• •
amlodipine besylateatorvastatin calcium tab 2.5-10 mg (Caduet)
2
amlodipine besylateatorvastatin calcium tab 5-10 mg (Caduet) amlodipine besylateatorvastatin calcium tab 5-20 mg (Caduet) amlodipine besylateatorvastatin calcium tab 5-40 mg (Caduet) amlodipine besylateatorvastatin calcium tab 5-80 mg (Caduet) amlodipine besylateatorvastatin calcium tab 10-10 mg (Caduet)
2
2
2
2
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
•
•
2
2
amlodipine besylateatorvastatin calcium tab 10-40 mg (Caduet)
5
amlodipine besylateatorvastatin calcium tab 2.5-40 mg (Caduet)
amlodipine besylateatorvastatin calcium tab 10-20 mg (Caduet)
•
ADEMPAS - riociguat tab 1.5 mg
2
Drug Name
•
• •
amlodipine besylateatorvastatin calcium tab 2.5-20 mg (Caduet)
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
• •
• •
4
•
•
ENTRESTO - sacubitrilvalsartan tab 49-51 mg
4
•
•
ENTRESTO - sacubitrilvalsartan tab 97-103 mg
4
•
•
ISOXSUPRINE HCL isoxsuprine hcl tab 20 mg
4
isoxsuprine hcl tab 10 mg
2
LETAIRIS - ambrisentan tab 5 mg
5
•
•
•
LETAIRIS - ambrisentan tab 10 mg
5
•
•
•
OPSUMIT - macitentan tab 10 mg
5
•
•
•
ORENITRAM - treprostinil diolamine tab cr 0.125 mg (base equiv)
5
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
59
Limited Distribution
5
•
UPTRAVI - selexipag tab 1400 mcg
5
•
•
•
UPTRAVI - selexipag tab 1600 mcg
5
•
•
•
VENTAVIS - iloprost inhalation solution 10 mcg/ml
5
•
•
•
•
VENTAVIS - iloprost inhalation solution 20 mcg/ml
5
•
•
•
•
•
ERECTILE DYSFUNCTION CIALIS - tadalafil tab 2.5 mg
3
•
•
•
CIALIS - tadalafil tab 5 mg
3
• •
• •
•
•
•
•
•
•
brompheniramine maleate tab sr 12hr 6 mg
•
•
•
carbinoxamine maleate soln 4 mg/5ml
•
•
•
carbinoxamine maleate tab 4 mg
1
•
CLEMASTINE FUMARATE clemastine fumarate tab 2.68 mg cyproheptadine hcl syrup 2 mg/5ml
2
5
ORENITRAM - treprostinil diolamine tab cr 1 mg (base equiv)
5
ORENITRAM - treprostinil diolamine tab cr 2.5 mg (base equiv)
5
•
•
•
REVATIO - sildenafil citrate for suspension 10 mg/ml
5
•
•
sildenafil citrate tab 20 mg (Revatio)
5
TRACLEER - bosentan tab 62.5 mg
5
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
ACA
Dispensing Limits
Step Therapy
UPTRAVI - selexipag tab 1200 mcg
ORENITRAM - treprostinil diolamine tab cr 0.25 mg (base equiv)
TRACLEER - bosentan tab 125 5 mg 5 TYVASO - treprostinil inhalation solution 0.6 mg/ml 5 TYVASO REFILL - treprostinil inhalation solution 0.6 mg/ml 5 TYVASO STARTER treprostinil inhalation solution 0.6 mg/ml 5 UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg (60) 5 UPTRAVI - selexipag tab 200 mcg 5 UPTRAVI - selexipag tab 400 mcg 5 UPTRAVI - selexipag tab 600 mcg 5 UPTRAVI - selexipag tab 800 mcg UPTRAVI - selexipag tab 1000 5 mcg
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
RESPIRATORY AGENTS ANTIHISTAMINES
cyproheptadine hcl tab 4 mg
2 2 2
2
DESLORATADINE ODT desloratadine tab orally disintegrating 2.5 mg
2
2
•
DESLORATADINE ODT desloratadine tab orally disintegrating 5 mg
•
desloratadine tab 5 mg (Clarinex)
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
60
KARBINAL ER - carbinoxamine 4 maleate extended release susp 4 mg/5ml 2 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal) 2 levocetirizine dihydrochloride tab 5 mg (Xyzal) 2 promethazine hcl suppos 12.5 mg 2 promethazine hcl suppos 25 mg 2 promethazine hcl suppos 50 mg 1 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 1 promethazine hcl tab 25 mg promethazine hcl tab 50 mg
1
NASAL AGENTS - SYSTEMIC and TOPICAL 4 ADRENALIN - epinephrine hcl nasal soln 0.1% 2 • azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 • azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro) 4 • BACTROBAN NASAL mupirocin calcium nasal oint 2% 2 • budesonide nasal susp 32 mcg/act (Rhinocort aqua)
4
•
flunisolide nasal soln 25 mcg/act (0.025%) (Flunisolide)
2
•
fluticasone propionate nasal susp 50 mcg/act
1
•
ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent)
2
•
ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent)
2
•
mometasone furoate nasal susp 50 mcg/act (Nasonex)
2
•
2
•
OMNARIS - ciclesonide nasal susp 50 mcg/act
4
•
QNASL - beclomethasone dipropionate nasal aerosol 80 mcg/act
4
•
QNASL CHILDRENS beclomethasone dipropionate nasal aerosol 40 mcg/act
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)
4
•
olopatadine hcl nasal soln 0.6% (Patanase)
COUGH/COLD/ALLERGY acetylcysteine inhal soln 10%
Limited Distribution
DYMISTA - azelastine hclfluticasone prop nasal spray 137-50 mcg/act
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
61
acetylcysteine inhal soln 20%
2
BENZONATATE - benzonatate cap 150 mg
2
benzonatate cap 100 mg (Tessalon perles)
1
hydrocodone w/ homatropine tab 5-1.5 mg
4
benzonatate cap 200 mg
1
HYPERSAL - sodium chloride soln nebu 3.5%
1
LEXUSS 210 chlorpheniramine w/ codeine liquid 2-10 mg/5ml
1
CAPCOF - phenylephrinechlorphen w/ codeine syrup 5-2-10 mg/5ml
4
4
CODAR AR - chlorpheniramine w/ codeine liquid 2-8 mg/5ml
4
M-END MAX D pseudoephedrinedexbromphen-codeine liqd 20-0.667-6 mg/5ml
4
FLOWTUSS - hydrocodoneguaifenesin soln 2.5-200 mg/5ml
4
M-END PE - phenylephrinebromphen w/ codeine liqd 3.33-1.33-6.33 mg/5ml
4
GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
4
GILTUSS TR - phenylephrine w/ dm-gg tab 10-28-388 mg
4
MAR-COF BP pseudoephedrinebromphen-codeine liqd 30-2-7.5 mg/5ml
4
guaifenesin-codeine liquid 225-7.5 mg/5ml
2
NEBUSAL - sodium chloride soln nebu 6%
4
1
NEOTUSS PLUS phenylephrine-chlorphen-dm liquid 7.5-4-30 mg/5ml
1
NINJACOF-XG - guaifenesincodeine liquid 200-8 mg/5ml
2
OBREDON - hydrocodoneguaifenesin soln 2.5-200 mg/5ml
4
HISTEX-AC - phenylephrinetriprolidine-codeine syrup 10-2.5-10 mg/5ml
4
phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml
2
HYCOFENIX pseudoephedrine w/ hydrocodone-gg soln 30-2.5-200 mg/5ml
4
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml (Tussionex pennkineti)
2
guaifenesin-codeine soln 100-6.3 mg/5ml guaifenesin-codeine soln 100-10 mg/5ml
phenylephrinebrompheniramine-dm liquid 7.5-4-15 mg/5ml phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml
brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
62
PHENYLEPHRINE/ GUAIFENESIN phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)
2
PHENYLHISTINE DH pseudoephedrine-chlorphen w/ codeine liq 30-2-10 mg/5ml
4
POLY-TUSSIN AC phenylephrine-bromphen w/ codeine liquid 10-4-10 mg/5ml
4
PRO-CLEAR AC - codeinepyrilamine syrup 9-8.33 mg/5ml
SEMPREX-D - acrivastine & pseudoephedrine cap 8-60 mg
4
sodium chloride soln nebu 0.9%
1
sodium chloride soln nebu 3% sodium chloride soln nebu 7% (Hyper-sal) sodium chloride soln nebu 10%
PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup 5-1-9 mg/5ml
4
TUSNEL - brompheniramine w/ dm-gg cap 2-15-200 mg
4 2
promethazine & phenylephrine syrup 6.25-5 mg/5ml
1
TUSNEL C - pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml
4
1
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 5-4 mg TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 10-8 mg
4
TUZISTRA XR - codeine polistchlorphen polist er susp 14.7-2.8 mg/5ml
4
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro) pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml pseudoephedrinebromphen-codeine liq 10-1.33-6.33 mg/5ml REZIRA - pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml
2
2 2 1
4
Limited Distribution
ACA
2
4
1
Dispensing Limits
2
4
promethazine-dm syrup 6.25-15 mg/5ml
Step Therapy
2
STATUSS GREEN - codeinepseudoephedrinechlorcyclizine liq 9-30-12.5 mg/5ml
promethazine w/ codeine syrup 6.25-10 mg/5ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
VANACOF CD - phenylephrine- 4 dexchlorphenir-codeine liquid 5-1-10 mg/5ml 4 VITUZ - hydrocodonechlorpheniramine soln 5-4 mg/5ml Z-TUSS AC - chlorpheniramine 4 w/ codeine liquid 2-9 mg/5ml ANTIASTHMATIC and BRONCHODILATOR AGENTS
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
63
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 250-50 mcg/dose
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50 mcg/dose
4
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 45-21 mcg/act
4
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 115-21 mcg/act
4
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 230-21 mcg/act
4
AEROSPAN - flunisolide hfa inhal aerosol 80 mcg/act
4
•
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
2
•
2
•
2
•
2
•
albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) albuterol sulfate syrup 2 mg/5ml albuterol sulfate tab sr 12hr 4 mg (Vospire er) albuterol sulfate tab sr 12hr 8 mg (Vospire er) albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg ALVESCO - ciclesonide inhal aerosol 80 mcg/act
•
•
1 2 2 2 2 4
•
4
•
ANORO ELLIPTA umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh
4
•
ARCAPTA NEOHALER indacaterol maleate inhal powder cap 75 mcg (base equiv)
4
•
ASMANEX TWISTHALER 120 ME - mometasone furoate inhal powd 220 mcg/inh (breath activated)
4
•
ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd 110 mcg/inh (breath activated)
4
•
ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd 220 mcg/inh (breath activated)
4
•
ASMANEX TWISTHALER 60 MET - mometasone furoate inhal powd 220 mcg/inh (breath activated)
4
•
ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act
4
•
BEVESPI - glycopyrrolateformoterol fumarate aerosol 9-4.8 mcg/act
4
•
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh
4
•
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh
4
•
BROVANA - arformoterol tartrate soln nebu 15 mcg/2ml (base equiv)
4
Limited Distribution
ALVESCO - ciclesonide inhal aerosol 160 mcg/act
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50 mcg/dose
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
64
budesonide inhalation susp 0.25 mg/2ml (Pulmicort) budesonide inhalation susp 0.5 mg/2ml (Pulmicort) budesonide inhalation susp 1 mg/2ml (Pulmicort)
2
COMBIVENT RESPIMAT ipratropium-albuterol inhal aerosol soln 20-100 mcg/act
4
CROMOLYN SODIUM cromolyn sodium soln nebu 20 mg/2ml
4
DALIRESP - roflumilast tab 500 4 mcg 4 DULERA - mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act 4 DULERA - mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act 2 dyphylline-guaifenesin liqd 100-100 mg/5ml 4 ELIXOPHYLLIN - theophylline elixir 80 mg/15ml 3 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
•
ipratropium bromide inhal soln 0.02%
1
•
2
•
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate)
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)
2
•
METAPROTERENOL SULFATE - metaproterenol sulfate syrup 10 mg/5ml
4
4
•
METAPROTERENOL SULFATE - metaproterenol sulfate tab 20 mg
1
•
montelukast sodium chew tab 4 mg (base equiv) (Singulair)
1
•
montelukast sodium chew tab 5 mg (base equiv) (Singulair)
2
•
montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)
•
montelukast sodium tab 10 mg (base equiv) (Singulair)
• • •
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
Limited Distribution
FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
2
Drug Name
Drug Tier
•
Limited Distribution
2
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
65
NUCALA - mepolizumab for inj 100 mg
5
PERFOROMIST - formoterol fumarate soln nebu 20 mcg/2ml
4
PROAIR HFA - albuterol sulfate 3 inhal aero 108 mcg/act (90mcg base equiv) 3 PROAIR RESPICLICK albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv) 4 PROVENTIL HFA - albuterol sulfate inhal aero 108 mcg/ act (90mcg base equiv) 4 PULMICORT - budesonide inhalation susp 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 diprop inhal aero soln 40 mcg/act (50/valve) 3 QVAR - beclomethasone diprop inhal aero soln 80 mcg/act (100/valve) 3 SEREVENT DISKUS salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv) 3 SPIRIVA HANDIHALER tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)
• • • • • •
• • •
•
SPIRIVA RESPIMAT tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act
3
•
STIOLTO RESPIMAT tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act
3
•
STRIVERDI RESPIMAT olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv)
4
•
SYMBICORT - budesonideformoterol fumarate dihyd aerosol 80-4.5 mcg/act
3
•
SYMBICORT - budesonideformoterol fumarate dihyd aerosol 160-4.5 mcg/act
3
•
terbutaline sulfate tab 2.5 mg
2 2
THEO-24 - theophylline cap sr 24hr 100 mg
4
THEO-24 - theophylline cap sr 24hr 200 mg
4
THEO-24 - theophylline cap sr 24hr 300 mg
4
THEO-24 - theophylline cap sr 24hr 400 mg
4
theophylline soln 80 mg/15ml
2
theophylline tab sr 12hr 100 mg theophylline tab sr 12hr 200 mg
Limited Distribution
3
ACA
Dispensing Limits
Step Therapy
SPIRIVA RESPIMAT tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act
terbutaline sulfate tab 5 mg
•
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
66
theophylline tab sr 12hr 300 mg theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600 mg
Limited Distribution
2
KALYDECO - ivacaftor tab 150 mg
5
•
2
OFEV - nintedanib esylate cap 100 mg (base equivalent)
5
•
•
•
2
OFEV - nintedanib esylate cap 150 mg (base equivalent)
5
•
•
•
2
ORKAMBI - lumacaftorivacaftor tab 100-125 mg
5
•
•
•
ORKAMBI - lumacaftorivacaftor tab 200-125 mg
5
•
•
•
PULMOZYME - dornase alfa inhal soln 1 mg/ml
5
•
SURVANTA INTRATRACHEAL beractant in nacl 0.9% intratracheal susp 25 mg/ml
4
•
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
•
XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)
4
•
zafirlukast tab 10 mg (Accolate)
2
zafirlukast tab 20 mg (Accolate)
2
ZYFLO - zileuton tab 600 mg
4
ZYFLO CR - zileuton tab sr 12hr 600 mg
4
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
GASTROINTESTINAL AGENTS
RESPIRATORY AGENTS - MISC. 4 CUROSURF - poractant alfa intratracheal susp 80 mg/ml ESBRIET - pirfenidone cap 267 5 mg 4 INFASURF - calfactant in nacl 0.9% intratracheal susp 35 mg/ml 5 KALYDECO - ivacaftor packet 50 mg 5 KALYDECO - ivacaftor packet 75 mg
LAXATIVES bisacodyl tab & peg 3350kcl-sod bicarb-nacl for soln kit
•
•
•
•
•
•
•
•
•
2
GIALAX - polyethylene glycol 3350 - kit
4
GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm
4
KRISTALOSE - lactulose oral crystal packet 10 gm
4
KRISTALOSE - lactulose oral crystal packet 20 gm
4
lactulose solution 10 gm/15ml
1
MOVIPREP - peg 3350kcl-nacl-na sulfate-na ascorbate-c for soln 100 gm
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
67
OSMOPREP - sod phos mono-sod phos di tabs 1.102-0.398 gm(1.5gm na phos)
4
PCP 100 - mag citbisacodyl-petrolat-pegmetoclopramide-electrol kit
4
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/ flavor pack)
1
•
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm (Golytely)
1
•
peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm (Colyte-flavor packs)
1
•
polyethylene glycol 3350 oral packet
2
polyethylene glycol 3350 oral powder
1
PREPOPIK - sod picosulfatemg oxide-citric acid pack 10 mg-3.5 gm-12 gm
4
SUPREP BOWEL PREP sodium sulfate-potassium sulfate-magnesium sulfate oral soln
4
ANTIDIARRHEALS diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)
2
DIPHENOXYLATE/ ATROPINE - diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml
4
MYTESI - crofelemer tab delayed release 125 mg
4
opium tincture 1% (10 mg/ ml) (morphine equiv)
2
PAREGORIC - paregoric tincture 2 mg/5ml (morphine equivalent)
4
RESTORA RX - lactobacillus casei-folic acid cap 60-1.25 mg
4
RESTORA SPRINKLES lactobacillus casei-folic acid packet 15-0.25 mg
4
ULCER DRUGS ACIPHEX - rabeprazole sodium ec tab 20 mg
4
amoxicillin cap-clarithro tablansopraz cap dr therapy pack (Prevpac)
2
BELLADONNA & OPIUM belladonna alkaloids & opium suppos 16.2-30 mg
4
BELLADONNA ALKALOIDS & OP - belladonna alkaloids & opium suppos 16.2-60 mg
4
CARAFATE - sucralfate susp 1 gm/10ml
4
chlordiazepoxide hclclidinium bromide cap 5-2.5 mg (Librax)
2
cimetidine hcl soln 300 mg/5ml cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
2 1 1 2
CUVPOSA - glycopyrrolate oral 4 soln 1 mg/5ml 4 DEXILANT - dexlansoprazole cap delayed release 30 mg 4 DEXILANT - dexlansoprazole cap delayed release 60 mg
• •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
68
dicyclomine hcl cap 10 mg (Bentyl)
1
dicyclomine hcl oral soln 10 mg/5ml
2
DONNATAL - pb-hyoscyatrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml
4
DONNATAL - pb-hyoscyatrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg
4
esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium)
2
•
2
•
2
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid) hyoscyamine sulfate tab 0.125 mg (Levsin) lansoprazole cap delayed release 15 mg (Prevacid) lansoprazole cap delayed release 30 mg (Prevacid) methscopolamine bromide tab 2.5 mg (Pamine) methscopolamine bromide tab 5 mg (Pamine forte)
2 2 2 2
•
2
•
2 2
misoprostol tab 100 mcg (Cytotec)
1
misoprostol tab 200 mcg (Cytotec)
1
NEXIUM - esomeprazole magnesium for delayed release susp packet 5 mg
4
•
1
FIRST-LANSOPRAZOLE lansoprazole susp 3 mg/ml (compound kit)
4
NEXIUM - esomeprazole magnesium for delayed release susp packet 10 mg
4
•
FIRST-OMEPRAZOLE omeprazole susp 2 mg/ml (compound kit)
4
NEXIUM - esomeprazole magnesium for delayed release susp packet 20 mg
4
•
glycopyrrolate tab 1 mg (Robinul)
2
4
•
glycopyrrolate tab 2 mg (Robinul forte)
2
NEXIUM - esomeprazole magnesium for delayed release susp packet 40 mg
4
•
hyoscyamine sulfate elixir 0.125 mg/5ml
1
NEXIUM - esomeprazole magnesium for delayed release susp pack 2.5 mg NIZATIDINE - nizatidine oral soln 15 mg/ml
2
nizatidine cap 150 mg
1
2
Limited Distribution
2
famotidine tab 40 mg (Pepcid)
hyoscyamine sulfate soln 0.125 mg/ml
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)
1
famotidine for susp 40 mg/5ml (Pepcid)
Drug Name hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)
dicyclomine hcl tab 20 mg (Bentyl)
esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
69
nizatidine cap 300 mg (Axid)
2 4
omeprazole cap delayed release 10 mg (Prilosec)
1
•
1
•
1
•
2
•
2
•
omeprazole cap delayed release 40 mg (Prilosec) omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid) omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid) omeprazole-sodium bicarbonate powd pack for susp 20-1680 mg (Zegerid) omeprazole-sodium bicarbonate powd pack for susp 40-1680 mg (Zegerid)
ranitidine hcl cap 150 mg ranitidine hcl cap 300 mg ranitidine hcl syrup 15 mg/ ml (75 mg/5ml)
2 2 1 1
sucralfate tab 1 gm (Carafate)
2
SYMAX DUOTAB hyoscyamine sulfate tab cr 0.375 mg (0.125 mg ir/0.25 mg cr)
4
2
•
•
AKYNZEO - netupitantpalonosetron cap 300-0.5 mg
4
•
2
•
•
ANZEMET - dolasetron mesylate tab 50 mg
4
•
ANZEMET - dolasetron mesylate tab 100 mg
4
•
CESAMET - nabilone cap 1 mg
4
DICLEGIS - doxylaminepyridoxine tab delayed release 10-10 mg
4
dronabinol cap 2.5 mg (Marinol)
2
•
dronabinol cap 5 mg (Marinol)
2
•
dronabinol cap 10 mg (Marinol)
2
•
EMEND - aprepitant capsule therapy pack 80 & 125 mg
3
•
EMEND - aprepitant capsule 40 mg
3
•
EMEND - aprepitant capsule 80 mg
3
•
pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)
1
pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)
1
2 pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg (Donnatal) 4 PRILOSEC - omeprazole cap delayed release 20 mg PROPANTHELINE BROMIDE - 4 propantheline bromide tab 15 mg 4 PYLERA - bismuth subcitmetronidazole-tetracycline cap 140-125-125 mg
• •
•
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
2
ranitidine hcl tab 300 mg (Zantac)
ANTIEMETICS
Prior Authorization
Drug Tier
Limited Distribution
Drug Name rabeprazole sodium ec tab 20 mg (Aciphex)
OMEPRAZOLE + SYRSPEND SF - omeprazole susp 2 mg/ ml (compound kit)
omeprazole cap delayed release 20 mg (Prilosec)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
70
2 2
• •
ondansetron hcl tab 4 mg (Zofran)
1
•
ondansetron hcl tab 8 mg (Zofran)
2
•
ondansetron hcl tab 24 mg
2
• •
ondansetron hcl oral soln 4 mg/5ml (Zofran)
4
CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit
4
CREON - pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit
4
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 2600-6200-10850 unit
4
4
ondansetron orally disintegrating tab 4 mg (Zofran odt)
1
ondansetron orally disintegrating tab 8 mg (Zofran odt)
2
•
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 4200-10000-17500 unit
•
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 10500-25000-43750 unit
4
SANCUSO - granisetron td patch 3.1 mg/24hr (contains 34.3 mg)
4
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 16800-40000-70000 unit
4
TRANSDERM-SCOP scopolamine td patch 72hr 1 mg/3days
4
PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 21000-37000-61000 unit
4
trimethobenzamide hcl cap 300 mg (Tigan)
2
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
VIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit
4
VARUBI - rolapitant hcl tab 90 mg (base equiv)
4
•
ZUPLENZ - ondansetron oral soluble film 4 mg
4
•
ZUPLENZ - ondansetron oral soluble film 8 mg
4
DIGESTIVE AIDS CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit
4
•
•
•
Limited Distribution
granisetron hcl tab 1 mg
CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit
ACA
•
Dispensing Limits
3
4
Step Therapy
EMEND - aprepitant for oral susp 125 mg (125 mg/5ml)
CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
EMEND - aprepitant capsule 125 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
71
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit
4
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit
3
calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)
3
2
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit
calcium acetate (phosphate binder) tab 667 mg (Eliphos)
3
CANASA - mesalamine suppos 1000 mg
3
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit
5
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit
3
CHENODAL - chenodiol tab 250 mg CHOLBAM - cholic acid cap 50 mg
5
•
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit
3
CHOLBAM - cholic acid cap 250 mg
5
•
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit
3
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit
3
GASTROINTESTINAL AGENTS- MISC. 2 alosetron hcl tab 0.5 mg (base equiv) (Lotronex) alosetron hcl tab 1 mg (base 2 equiv) (Lotronex) 4 AMITIZA - lubiprostone cap 8 mcg AMITIZA - lubiprostone cap 24 4 mcg 4 APRISO - mesalamine cap sr 24hr 0.375 gm ASACOL HD - mesalamine tab 4 delayed release 800 mg 4 AURYXIA - ferric citrate tab 1 gm (210 mg ferric iron)
balsalazide disodium cap 750 mg (Colazal)
2 2
CIMZIA - certolizumab pegol inj 5 kit 2 x 200 mg/ml 5 CIMZIA STARTER KIT certolizumab pegol inj kit 6 x 200 mg/ml 2 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) 4 DELZICOL - mesalamine cap dr 400 mg 4 DIPENTUM - olsalazine sodium cap 250 mg ENTEREG - alvimopan cap 12 4 mg 4 FOSRENOL - lanthanum carbonate chew tab 500 mg (elemental) 4 FOSRENOL - lanthanum carbonate chew tab 750 mg (elemental) 4 FOSRENOL - lanthanum carbonate chew tab 1000 mg (elemental)
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
72
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
FOSRENOL - lanthanum carbonate oral powder pack 750 mg (elemental)
4
MOVANTIK - naloxegol oxalate tab 12.5 mg (base equivalent)
4
FOSRENOL - lanthanum carbonate oral powder pack 1000 mg (elemental)
4
MOVANTIK - naloxegol oxalate tab 25 mg (base equivalent)
4
5
5
GATTEX - teduglutide (rdna) for inj kit 5 mg
OCALIVA - obeticholic acid tab 5 mg
•
•
•
4
OCALIVA - obeticholic acid tab 10 mg
5
GIAZO - balsalazide disodium tab 1.1 gm
•
•
•
PENTASA - mesalamine cap cr 250 mg
4
lactulose (encephalopathy) solution 10 gm/15ml
1
PENTASA - mesalamine cap cr 500 mg
4
LIALDA - mesalamine tab delayed release 1.2 gm
4
PHOSLYRA - calcium acetate (phosphate binder) oral soln 667 mg/5ml
4
LINZESS - linaclotide cap 145 mcg
4
LINZESS - linaclotide cap 290 mcg
4
4
LOTRONEX - alosetron hcl tab 0.5 mg (base equiv)
4
RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml)
4
LOTRONEX - alosetron hcl tab 1 mg (base equiv)
4
RELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml)
MESALAMINE DR mesalamine tab delayed release 800 mg
4
RENAGEL - sevelamer hcl tab 400 mg
4 4
mesalamine enema 4 gm
2
RENAGEL - sevelamer hcl tab 800 mg
1
RENVELA - sevelamer carbonate packet 0.8 gm
4
1
RENVELA - sevelamer carbonate packet 2.4 gm
4
1
RENVELA - sevelamer carbonate tab 800 mg
4
METOCLOPRAMIDE ODT metoclopramide hcl orally disintegrating tab 5 mg
2
SFROWASA - mesalamine sulfite-free (sf) enema 4 gm/60ml
4
METOCLOPRAMIDE ODT metoclopramide hcl orally disintegrating tab 10 mg
4
sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)
2
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg (Reglan) metoclopramide hcl tab 10 mg (Reglan)
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
73
sulfasalazine tab 500 mg (Azulfidine)
2
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
VIBERZI - eluxadoline tab 75 mg
4
VIBERZI - eluxadoline tab 100 mg
4
GENITOURINARY AGENTS URINARY ANTI-INFECTIVES
methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg methenamine-hyosc-meth blue-sod phos-phen sal tab 81 mg methenamine-hyoscaminemeth blue-sod phos cap 120 mg methenamine-hyoscaminemeth blue-sod phos tab 81.6 mg (Urogesic-blue)
2
METHENAMINE MANDELATE - methenamine mandelate tab 0.5 gm
4
nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)
methenamine mandelate tab 1 gm
2
nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)
2
nitrofurantoin susp 25 mg/5ml (Furadantin)
2
URIMAR-T - methenaminehyosc-meth blue-sod phosphen sal tab 120 mg
methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg
URINARY ANTISPASMODICS bethanechol chloride tab 5 mg (Urecholine) bethanechol chloride tab 10 mg (Urecholine) bethanechol chloride tab 25 mg (Urecholine)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
2
methenamine hippurate tab 1 gm (Hiprex)
2
2
nitrofurantoin macrocrystalline cap 25 mg (Macrodantin) nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)
methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg (Prosed/ds)
2
4
4
methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg
2
MONUROL - fosfomycin tromethamine powd pack 3 gm (base equivalent)
MACRODANTIN nitrofurantoin macrocrystalline cap 25 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
2 4
1 2 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
74
bethanechol chloride tab 50 mg (Urecholine) darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) (Enablex) darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) (Enablex)
2
tolterodine tartrate tab 1 mg (Detrol)
2
2
tolterodine tartrate tab 2 mg (Detrol)
2
TOVIAZ - fesoterodine fumarate tab sr 24hr 4 mg
4
TOVIAZ - fesoterodine fumarate tab sr 24hr 8 mg
4
trospium chloride cap sr 24hr 60 mg
2
2
ENABLEX - darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv)
4
ENABLEX - darifenacin hydrobromide tab sr 24hr 15 mg (base equiv)
4
flavoxate hcl tab 100 mg
2
trospium chloride tab 20 mg
4
VESICARE - solifenacin succinate tab 10 mg
4
GELNIQUE - oxybutynin chloride td gel 10%
4
MYRBETRIQ - mirabegron tab sr 24 hr 25 mg
4
AVC - sulfanilamide vaginal cream 15%
4
MYRBETRIQ - mirabegron tab sr 24 hr 50 mg
4
4
oxybutynin chloride syrup 5 mg/5ml
1
CLEOCIN - clindamycin phosphate vaginal suppos 100 mg clindamycin phosphate vaginal cream 2% (Cleocin)
2
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)
2
CLINDESSE - clindamycin phosphate (one dose) vaginal cream 2%
4
2
ESTRACE - estradiol vaginal cream 0.1 mg/gm
3
2
estradiol vaginal tab 10 mcg (Vagifem)
2
OXYTROL - oxybutynin td patch twice weekly 3.9 mg/24hr
4
ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs)
4 4
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)
2
FEM PH - acetic acidoxyquinoline vaginal gel 0.9-0.025% FEMRING - estradiol acetate vaginal ring 0.05 mg/24hr
4
oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl) oxybutynin chloride tab 5 mg
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)
2
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
VESICARE - solifenacin succinate tab 5 mg
VAGINAL PRODUCTS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
75
5
•
GYNAZOLE-1 - butoconazole nitrate (one dose) vaginal cream 2%
4
CYSTAGON - cysteamine bitartrate cap 150 mg
5
•
dutasteride cap 0.5 mg (Avodart)
2
metronidazole vaginal gel 0.75% (Metrogel-vaginal)
2 4
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)
2
MICONAZOLE 3 - miconazole nitrate vaginal suppos 200 mg
4
NUVESSA - metronidazole vaginal gel 1.3%
4
ELMIRON - pentosan polysulfate sodium caps 100 mg finasteride tab 5 mg (Proscar)
1
PREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm
4
RELAGARD - acetic acidoxyquinoline vaginal gel 0.9-0.025%
4
terconazole vaginal cream 0.4% (Terazol 7)
2
terconazole vaginal cream 0.8% (Terazol 3) terconazole vaginal suppos 80 mg VAGIFEM - estradiol vaginal tab 10 mcg
2 2 3
GENITOURINARY AGENTS - MISC. 1 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral) 4 AVODART - dutasteride cap 0.5 mg 4 CARDURA XL - doxazosin mesylate tab sr 24 hr 4 mg (base equiv) 4 CARDURA XL - doxazosin mesylate tab sr 24 hr 8 mg (base equiv)
Limited Distribution
CYSTAGON - cysteamine bitartrate cap 50 mg
ACA
4
Dispensing Limits
FEMRING - estradiol acetate vaginal ring 0.1 mg/24hr
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
JALYN - dutasteride-tamsulosin 4 hcl cap 0.5-0.4 mg 4 K-PHOS NO 2 - potassium & sodium acid phosphates tab 305-700 mg LITHOSTAT - acetohydroxamic 4 acid tab 250 mg 4 ORACIT - sodium citrate & citric acid soln 490-640 mg/5ml 1 phenazopyridine hcl tab 100 mg (Pyridium) 1 phenazopyridine hcl tab 200 mg (Pyridium) 2 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml 2 potassium citrate & citric acid powder pack 3300-1002 mg 2 potassium citrate & citric acid soln 1100-334 mg/5ml 2 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5) 2 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10)
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
76
2 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15) 5 PROCYSBI - cysteamine bitartrate cap delayed release 25 mg (base equiv) 5 PROCYSBI - cysteamine bitartrate cap delayed release 75 mg (base equiv) RAPAFLO - silodosin cap 4 mg 4
• •
• •
alprazolam tab 0.25 mg (Xanax)
1
alprazolam tab 0.5 mg (Xanax)
1
alprazolam tab 1 mg (Xanax)
1
alprazolam tab 2 mg (Xanax) buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg
RAPAFLO - silodosin cap 8 mg
4
buspirone hcl tab 10 mg
sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi)
2
buspirone hcl tab 15 mg
tamsulosin hcl cap 0.4 mg (Flomax)
1
THIOLA - tiopronin tab 100 mg
4
buspirone hcl tab 30 mg
CENTRAL NERVOUS SYSTEM DRUGS ANTIANXIETY AGENTS
chlordiazepoxide hcl cap 5 mg
•
chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg
1 2 1 1 1 1
2
clorazepate dipotassium tab 7.5 mg (Tranxene t)
alprazolam orally disintegrating tab 0.5 mg
2
clorazepate dipotassium tab 15 mg (Tranxene t)
4
2
DIAZEPAM - diazepam oral soln 1 mg/ml diazepam conc 5 mg/ml
2
alprazolam tab sr 24hr 0.5 mg (Xanax xr)
2
diazepam tab 5 mg (Valium) diazepam tab 10 mg (Valium)
alprazolam tab sr 24hr 1 mg (Xanax xr)
2
hydroxyzine hcl syrup 10 mg/5ml
alprazolam tab sr 24hr 2 mg (Xanax xr)
2
hydroxyzine hcl tab 10 mg
alprazolam tab sr 24hr 3 mg (Xanax xr)
2
hydroxyzine hcl tab 50 mg
hydroxyzine hcl tab 25 mg
Limited Distribution
1
alprazolam orally disintegrating tab 0.25 mg (Niravam)
diazepam tab 2 mg (Valium)
ACA
2
clorazepate dipotassium tab 3.75 mg (Tranxene t)
2
Dispensing Limits
1
4
alprazolam orally disintegrating tab 2 mg
Step Therapy
1
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
alprazolam orally disintegrating tab 1 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 2
1 1 1 1 1 1 1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
77
•
1
APLENZIN - bupropion hbr tab sr 24hr 522 mg
4
•
1
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)
1
lorazepam conc 2 mg/ml (Lorazepam intensol)
2
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)
lorazepam tab 0.5 mg (Ativan)
1
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)
lorazepam tab 1 mg (Ativan)
1
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)
hydroxyzine pamoate cap 25 mg (Vistaril) hydroxyzine pamoate cap 50 mg (Vistaril)
lorazepam tab 2 mg (Ativan) meprobamate tab 200 mg meprobamate tab 400 mg oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg ANTIDEPRESSANTS amitriptyline hcl tab 10 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amitriptyline hcl tab 100 mg
1
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)
2 2 2 2 2 1 1 1 1 1 2
1 2 2 2
bupropion hcl tab 75 mg (Wellbutrin)
2
bupropion hcl tab 100 mg (Wellbutrin)
2
citalopram hydrobromide oral soln 10 mg/5ml
2
citalopram hydrobromide tab 10 mg (base equiv) (Celexa)
1
citalopram hydrobromide tab 20 mg (base equiv) (Celexa)
1
1
AMOXAPINE - amoxapine tab 25 mg
4
citalopram hydrobromide tab 40 mg (base equiv) (Celexa)
AMOXAPINE - amoxapine tab 50 mg
4
clomipramine hcl cap 25 mg (Anafranil)
2
AMOXAPINE - amoxapine tab 100 mg
4
clomipramine hcl cap 50 mg (Anafranil)
2
AMOXAPINE - amoxapine tab 150 mg
4
clomipramine hcl cap 75 mg (Anafranil)
2
APLENZIN - bupropion hbr tab sr 24hr 174 mg
4
desipramine hcl tab 10 mg (Norpramin)
2
amitriptyline hcl tab 150 mg
•
Limited Distribution
4
4
ACA
APLENZIN - bupropion hbr tab sr 24hr 348 mg
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
78
2
•
2
•
desipramine hcl tab 75 mg (Norpramin)
2
duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta)
desipramine hcl tab 100 mg (Norpramin)
2
EMSAM - selegiline td patch 24hr 6 mg/24hr
4
desipramine hcl tab 150 mg (Norpramin)
2
EMSAM - selegiline td patch 24hr 9 mg/24hr
4
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr 50 mg (base equiv)
4
•
EMSAM - selegiline td patch 24hr 12 mg/24hr
4
4
•
2
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr 100 mg (base equiv)
escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro)
4
•
1
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
escitalopram oxalate tab 5 mg (base equiv) (Lexapro)
4
•
1
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg
escitalopram oxalate tab 10 mg (base equiv) (Lexapro)
1
DOXEPIN HCL - doxepin hcl cap 75 mg
4
escitalopram oxalate tab 20 mg (base equiv) (Lexapro)
doxepin hcl cap 10 mg
1
FETZIMA - levomilnacipran hcl cap sr 24hr 20 mg (base equivalent)
4
•
FETZIMA - levomilnacipran hcl cap sr 24hr 40 mg (base equivalent)
4
•
FETZIMA - levomilnacipran hcl cap sr 24hr 80 mg (base equivalent)
4
•
FETZIMA - levomilnacipran hcl cap sr 24hr 120 mg (base equivalent)
4
•
2
desipramine hcl tab 50 mg (Norpramin)
2
doxepin hcl cap 25 mg doxepin hcl cap 50 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl conc 10 mg/ml
1 2 2 2 1
DULOXETINE HCL duloxetine hcl enteric coated pellets cap 40 mg
4
duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta)
2
• • •
Limited Distribution
duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta)
desipramine hcl tab 25 mg (Norpramin)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
79
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack
4
FLUOXETINE HCL - fluoxetine hcl tab 60 mg
4
fluoxetine hcl cap delayed release 90 mg (Prozac weekly)
2
fluoxetine hcl cap 10 mg (Prozac)
1
KHEDEZLA - desvenlafaxine tab sr 24hr 50 mg
4
•
fluoxetine hcl cap 20 mg (Prozac)
1
KHEDEZLA - desvenlafaxine tab sr 24hr 100 mg
4
•
fluoxetine hcl cap 40 mg (Prozac)
1
MAPROTILINE HCL maprotiline hcl tab 25 mg
4
•
fluoxetine hcl solution 20 mg/5ml
1
MAPROTILINE HCL maprotiline hcl tab 50 mg
4
•
1
MAPROTILINE HCL maprotiline hcl tab 75 mg
4
•
2
MARPLAN - isocarboxazid tab 10 mg
4
2
mirtazapine orally disintegrating tab 15 mg (Remeron soltab)
2
mirtazapine orally disintegrating tab 30 mg (Remeron soltab)
2
mirtazapine orally disintegrating tab 45 mg (Remeron soltab)
2
mirtazapine tab 7.5 mg
2
fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg fluvoxamine maleate cap sr 24hr 100 mg fluvoxamine maleate cap sr 24hr 150 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg
•
2 2 2 4
imipramine hcl tab 10 mg (Tofranil)
imipramine pamoate cap 100 mg (Tofranil-pm)
•
2
FORFIVO XL - bupropion hcl tab sr 24hr 450 mg
imipramine pamoate cap 75 mg (Tofranil-pm)
•
imipramine pamoate cap 125 mg (Tofranil-pm) imipramine pamoate cap 150 mg (Tofranil-pm)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2 2
1
1
mirtazapine tab 15 mg (Remeron)
1
imipramine hcl tab 25 mg (Tofranil)
1
mirtazapine tab 30 mg (Remeron)
1
imipramine hcl tab 50 mg (Tofranil)
1
mirtazapine tab 45 mg (Remeron) NEFAZODONE HCL nefazodone hcl tab 100 mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
80
PEXEVA - paroxetine mesylate tab 30 mg (base equiv)
4
•
NEFAZODONE HCL nefazodone hcl tab 200 mg
4
PEXEVA - paroxetine mesylate tab 40 mg (base equiv)
4
•
nefazodone hcl tab 50 mg
2
phenelzine sulfate tab 15 mg (Nardil)
2
nefazodone hcl tab 250 mg
2
NORTRIPTYLINE HCL nortriptyline hcl soln 10 mg/5ml
4
PRISTIQ - desvenlafaxine succinate tab sr 24hr 25 mg (base equiv)
4
• •
nortriptyline hcl cap 10 mg (Pamelor)
1
4
• •
nortriptyline hcl cap 25 mg (Pamelor)
1
PRISTIQ - desvenlafaxine succinate tab sr 24hr 50 mg (base equiv)
4
• •
nortriptyline hcl cap 50 mg (Pamelor)
1
PRISTIQ - desvenlafaxine succinate tab sr 24hr 100 mg (base equiv)
nortriptyline hcl cap 75 mg (Pamelor)
1
protriptyline hcl tab 5 mg
2
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)
2
sertraline hcl oral conc 20 mg/ml (Zoloft)
2
sertraline hcl tab 25 mg (Zoloft)
1
2
sertraline hcl tab 50 mg (Zoloft)
1
paroxetine hcl tab 10 mg (Paxil)
1
sertraline hcl tab 100 mg (Zoloft)
1
paroxetine hcl tab 20 mg (Paxil)
1
SURMONTIL - trimipramine maleate cap 25 mg
4
paroxetine hcl tab 30 mg (Paxil)
1
SURMONTIL - trimipramine maleate cap 50 mg
4
paroxetine hcl tab 40 mg (Paxil)
1
SURMONTIL - trimipramine maleate cap 100 mg
4
PAXIL - paroxetine hcl oral susp 10 mg/5ml (base equiv)
4
•
tranylcypromine sulfate tab 10 mg (Parnate)
2
PEXEVA - paroxetine mesylate tab 10 mg (base equiv)
4
•
trazodone hcl tab 50 mg
PEXEVA - paroxetine mesylate tab 20 mg (base equiv)
4
•
trazodone hcl tab 150 mg
paroxetine hcl tab sr 24hr 25 mg (Paxil cr) paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)
protriptyline hcl tab 10 mg
trazodone hcl tab 100 mg trazodone hcl tab 300 mg
Limited Distribution
4
ACA
NEFAZODONE HCL nefazodone hcl tab 150 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2
1 1 1 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
81
1
venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr)
1
venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr)
1
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 225 mg (base equivalent)
4
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)
2
venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er)
2
venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er)
2
venlafaxine hcl tab 25 mg
2
venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab 100 mg
•
ABILIFY - aripiprazole tab 10 mg
4
• • •
ABILIFY - aripiprazole tab 15 mg
4
•
ABILIFY - aripiprazole tab 20 mg
4
•
ABILIFY - aripiprazole tab 30 mg
4
•
ADASUVE - loxapine aerosol powder breath activated 10 mg
4
aripiprazole oral solution 1 mg/ml
2
•
2
•
2
•
2
ABILIFY - aripiprazole tab 2 mg 4 ABILIFY - aripiprazole tab 5 mg 4
aripiprazole orally disintegrating tab 10 mg aripiprazole orally disintegrating tab 15 mg
aripiprazole tab 10 mg (Abilify)
2
• • •
aripiprazole tab 15 mg (Abilify)
2
•
aripiprazole tab 20 mg (Abilify)
2
• •
aripiprazole tab 2 mg (Abilify) aripiprazole tab 5 mg (Abilify)
2 2 2 2
2
VIIBRYD - vilazodone hcl tab 10 mg
4
•
aripiprazole tab 30 mg (Abilify)
2
VIIBRYD - vilazodone hcl tab 20 mg
4
•
chlorpromazine hcl tab 10 mg
2
VIIBRYD - vilazodone hcl tab 40 mg
4
•
chlorpromazine hcl tab 25 mg
Limited Distribution
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr)
•
ANTIPSYCHOTICS
•
ACA
TRINTELLIX - vortioxetine hbr tab 20 mg (base equiv)
4
4
Dispensing Limits
•
Step Therapy
4
VIIBRYD STARTER PACK vilazodone hcl tab starter kit 10 (7) & 20 (23) mg
Prior Authorization
TRINTELLIX - vortioxetine hbr tab 10 mg (base equiv)
Drug Name
Drug Tier
•
Limited Distribution
4
ACA
TRINTELLIX - vortioxetine hbr tab 5 mg (base equiv)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
82
chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg
•
FANAPT - iloperidone tab 12 mg
4
•
4
•
•
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak 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
•
FAZACLO - clozapine orally disintegrating tab 200 mg
4
•
FLUPHENAZINE HCL fluphenazine hcl elixir 2.5 mg/5ml
3
FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/ml
3
fluphenazine hcl tab 1 mg
1
CLOZAPINE ODT - clozapine orally disintegrating tab 200 mg
4
•
clozapine orally disintegrating tab 25 mg (Fazaclo)
2
•
clozapine orally disintegrating tab 100 mg (Fazaclo)
2
clozapine tab 25 mg (Clozaril)
2
•
clozapine tab 50 mg
2
clozapine tab 100 mg (Clozaril)
2
• •
clozapine tab 200 mg
2
•
4
FANAPT - iloperidone tab 2 mg
4
•
fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg fluphenazine hcl tab 10 mg haloperidol lactate oral conc 2 mg/ml haloperidol tab 0.5 mg
• •
haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg
Limited Distribution
4
ACA
FANAPT - iloperidone tab 10 mg
4
FANAPT - iloperidone tab 1 mg
Dispensing Limits
4
CLOZAPINE ODT - clozapine orally disintegrating tab 150 mg
4
Step Therapy
FANAPT - iloperidone tab 8 mg
4
EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 300 mg
Prior Authorization
4
CLOZAPINE ODT - clozapine orally disintegrating tab 12.5 mg
4
Drug Tier
FANAPT - iloperidone tab 6 mg
• • • •
2
EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 200 mg
Limited Distribution
4
2
4
Drug Name FANAPT - iloperidone tab 4 mg
2
EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 100 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1 1 1 1 1 1 1 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
83
haloperidol tab 10 mg haloperidol tab 20 mg
2 2
lithium carbonate tab 300 mg
4
•
LITHOBID - lithium carbonate tab cr 300 mg
4
INVEGA - paliperidone tab sr 24hr 3 mg
4
•
loxapine succinate cap 5 mg
2
INVEGA - paliperidone tab sr 24hr 6 mg
4
INVEGA - paliperidone tab sr 24hr 9 mg
4
LATUDA - lurasidone hcl tab 20 4 mg LATUDA - lurasidone hcl tab 40 4 mg LATUDA - lurasidone hcl tab 60 4 mg LATUDA - lurasidone hcl tab 80 4 mg 4 LATUDA - lurasidone hcl tab 120 mg LITHIUM - lithium oral solution 4 8 meq/5ml 4 LITHIUM CARBONATE lithium carbonate cap 150 mg 4 LITHIUM CARBONATE lithium carbonate cap 600 mg 1 lithium carbonate cap 150 mg (Lithium carbonate) 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg (Lithium carbonate) 2 lithium carbonate tab cr 300 mg (Lithobid) 2 lithium carbonate tab cr 450 mg
• • • • • • •
loxapine succinate cap 25 mg loxapine succinate cap 50 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
INVEGA - paliperidone tab sr 24hr 1.5 mg
loxapine succinate cap 10 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2
MOLINDONE HYDROCHLORIDE molindone hcl tab 5 mg
4
MOLINDONE HYDROCHLORIDE molindone hcl tab 10 mg
4
MOLINDONE HYDROCHLORIDE molindone hcl tab 25 mg
4
NUPLAZID - pimavanserin tartrate tab 17 mg (base equivalent)
4
olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)
2
•
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 tab 2.5 mg (Zyprexa)
1
•
olanzapine tab 5 mg (Zyprexa)
1
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
84
•
olanzapine tab 20 mg (Zyprexa)
2
•
paliperidone tab sr 24hr 1.5 mg (Invega)
2
•
2
•
2
•
2
•
paliperidone tab sr 24hr 3 mg (Invega) paliperidone tab sr 24hr 6 mg (Invega) paliperidone tab sr 24hr 9 mg (Invega) perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg
2 2 2 2
prochlorperazine maleate tab 5 mg (base equivalent) (Compazine)
1
prochlorperazine maleate tab 10 mg (base equivalent) (Compazine)
1
prochlorperazine suppos 25 mg
2
QUETIAPINE FUMARATE ER - 4 quetiapine fumarate tab sr 24hr 50 mg QUETIAPINE FUMARATE ER - 4 quetiapine fumarate tab sr 24hr 150 mg QUETIAPINE FUMARATE ER - 4 quetiapine fumarate tab sr 24hr 200 mg
• • •
Limited Distribution
olanzapine tab 15 mg (Zyprexa)
2
•
ACA
•
QUETIAPINE FUMARATE ER - 4 quetiapine fumarate tab sr 24hr 300 mg 2 quetiapine fumarate tab sr 24hr 400 mg (Seroquel xr) 1 quetiapine fumarate tab 25 mg (Seroquel) 1 quetiapine fumarate tab 50 mg (Seroquel) 1 quetiapine fumarate tab 100 mg (Seroquel) 2 quetiapine fumarate tab 200 mg (Seroquel) 2 quetiapine fumarate tab 300 mg (Seroquel) 2 quetiapine fumarate tab 400 mg (Seroquel) 4 REXULTI - brexpiprazole tab 0.25 mg 4 REXULTI - brexpiprazole tab 0.5 mg REXULTI - brexpiprazole tab 1 4 mg REXULTI - brexpiprazole tab 2 4 mg REXULTI - brexpiprazole tab 3 4 mg REXULTI - brexpiprazole tab 4 4 mg 2 risperidone orally disintegrating tab 0.25 mg 2 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) 2 risperidone orally disintegrating tab 1 mg (Risperdal m-tab)
Dispensing Limits
1
Step Therapy
olanzapine tab 10 mg (Zyprexa)
Prior Authorization
•
Drug Name
Drug Tier
1
Limited Distribution
olanzapine tab 7.5 mg (Zyprexa)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • • • • • • • • • • • • •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
85
3
thioridazine hcl tab 10 mg
2
2
risperidone orally disintegrating tab 3 mg (Risperdal m-tab)
2
risperidone orally disintegrating tab 4 mg (Risperdal m-tab)
2
risperidone soln 1 mg/ml (Risperdal)
2
•
risperidone tab 0.25 mg (Risperdal)
1
•
thiothixene cap 10 mg
risperidone tab 0.5 mg (Risperdal)
1
•
trifluoperazine hcl tab 2 mg
risperidone tab 1 mg (Risperdal)
1
•
1
•
VERSACLOZ - clozapine susp 50 mg/ml
4
risperidone tab 2 mg (Risperdal)
•
•
•
risperidone tab 4 mg (Risperdal)
1
•
VRAYLAR - cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg (6)
4
risperidone tab 3 mg (Risperdal)
1
4
•
SAPHRIS - asenapine maleate sl tab 2.5 mg (base equiv)
4
•
VRAYLAR - cariprazine hcl cap 1.5 mg (base equivalent)
4
•
SAPHRIS - asenapine maleate sl tab 5 mg (base equiv)
4
•
VRAYLAR - cariprazine hcl cap 3 mg (base equivalent)
4
•
SAPHRIS - asenapine maleate sl tab 10 mg (base equiv)
4
•
VRAYLAR - cariprazine hcl cap 4.5 mg (base equivalent)
4
•
SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg
3
•
VRAYLAR - cariprazine hcl cap 6 mg (base equivalent)
2
•
SEROQUEL XR - quetiapine fumarate tab sr 24hr 150 mg
3
•
ziprasidone hcl cap 20 mg (Geodon)
2
•
SEROQUEL XR - quetiapine fumarate tab sr 24hr 200 mg
3
•
ziprasidone hcl cap 40 mg (Geodon)
2
•
SEROQUEL XR - quetiapine fumarate tab sr 24hr 300 mg
3
•
ziprasidone hcl cap 60 mg (Geodon) ziprasidone hcl cap 80 mg (Geodon)
2
•
thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg
•
thioridazine hcl tab 100 mg thiothixene cap 1 mg thiothixene cap 2 mg thiothixene cap 5 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
risperidone orally disintegrating tab 2 mg (Risperdal m-tab)
•
SEROQUEL XR - quetiapine fumarate tab sr 24hr 400 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2 2 2 2 2 2 2 2 2
HYPNOTICS Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
86
BUTISOL SODIUM butabarbital sodium tab 30 mg
4
DORAL - quazepam tab 15 mg
4
estazolam tab 1 mg
1
estazolam tab 2 mg
1
eszopiclone tab 1 mg (Lunesta)
2
•
eszopiclone tab 2 mg (Lunesta)
2
•
eszopiclone tab 3 mg (Lunesta)
2
•
FLURAZEPAM HCL flurazepam hcl cap 15 mg
4
FLURAZEPAM HCL flurazepam hcl cap 30 mg
4
HETLIOZ - tasimelteon capsule 4 20 mg 2 midazolam hcl syrup 2 mg/ ml (base equivalent) 4 PHENOBARBITAL phenobarbital tab 15 mg 4 PHENOBARBITAL phenobarbital tab 30 mg 4 PHENOBARBITAL phenobarbital tab 60 mg 4 PHENOBARBITAL phenobarbital tab 100 mg 2 phenobarbital elixir 20 mg/5ml 1 phenobarbital tab 16.2 mg phenobarbital tab 32.4 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg QUAZEPAM - quazepam tab 15 mg
1 2 2 4
•
•
•
4
SECONAL SODIUM secobarbital sodium cap 100 mg
4
SILENOR - doxepin hcl (sleep) tab 3 mg (base equiv)
4
•
SILENOR - doxepin hcl (sleep) tab 6 mg (base equiv)
4
•
temazepam cap 7.5 mg (Restoril)
2
temazepam cap 15 mg (Restoril)
1
temazepam cap 22.5 mg (Restoril)
2
temazepam cap 30 mg (Restoril)
1
TRIAZOLAM - triazolam tab 0.125 mg
1
triazolam tab 0.25 mg (Halcion)
2
zaleplon cap 5 mg (Sonata)
1 2
• • •
2
•
2
•
2
•
zolpidem tartrate tab 5 mg (Ambien)
1
•
zolpidem tartrate tab 10 mg (Ambien)
1
•
zaleplon cap 10 mg (Sonata) zolpidem tartrate sl tab 1.75 mg (Intermezzo) zolpidem tartrate sl tab 3.5 mg (Intermezzo) zolpidem tartrate tab cr 6.25 mg (Ambien cr) zolpidem tartrate tab cr 12.5 mg (Ambien cr)
1
Limited Distribution
•
ROZEREM - ramelteon tab 8 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
87
amphetaminedextroamphetamine cap sr 24hr 5 mg (Adderall xr) amphetaminedextroamphetamine cap sr 24hr 10 mg (Adderall xr) amphetaminedextroamphetamine cap sr 24hr 15 mg (Adderall xr) amphetaminedextroamphetamine cap sr 24hr 20 mg (Adderall xr) amphetaminedextroamphetamine cap sr 24hr 25 mg (Adderall xr) amphetaminedextroamphetamine cap sr 24hr 30 mg (Adderall xr) amphetaminedextroamphetamine tab 5 mg (Adderall) amphetaminedextroamphetamine tab 7.5 mg (Adderall) amphetaminedextroamphetamine tab 10 mg (Adderall) amphetaminedextroamphetamine tab 12.5 mg (Adderall) amphetaminedextroamphetamine tab 15 mg (Adderall) amphetaminedextroamphetamine tab 20 mg (Adderall) amphetaminedextroamphetamine tab 30 mg (Adderall)
2
2
•
2
•
•
armodafinil tab 150 mg (Nuvigil)
2
•
•
armodafinil tab 250 mg (Nuvigil)
2
•
•
2
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
2
•
clonidine hcl tab sr 12hr 0.1 mg (Kapvay)
•
2
•
2
•
2
•
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr) dexmethylphenidate hcl tab 2.5 mg (Focalin) dexmethylphenidate hcl tab 5 mg (Focalin)
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine)
2
•
2
•
dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine)
2
•
dexmethylphenidate hcl tab 10 mg (Focalin)
Limited Distribution
armodafinil tab 50 mg (Nuvigil)
•
•
ACA
•
2
2
Dispensing Limits
2
•
•
Step Therapy
ARMODAFINIL - armodafinil tab 200 mg
2
2
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
88
2
dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra)
2
dextroamphetamine sulfate tab 5 mg
2
•
2
•
FOCALIN XR dexmethylphenidate hcl cap sr 24 hr 10 mg
4
•
FOCALIN XR dexmethylphenidate hcl cap sr 24 hr 20 mg
4
•
FOCALIN XR dexmethylphenidate hcl cap sr 24 hr 25 mg
4
•
FOCALIN XR dexmethylphenidate hcl cap sr 24 hr 35 mg
4
•
guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv)
2
•
2
•
2
•
2
•
2
•
2
•
dextroamphetamine sulfate tab 10 mg
guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv) guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv) guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv) methamphetamine hcl tab 5 mg (Desoxyn) methylphenidate hcl cap cr 10 mg (cd) (Metadate cd) methylphenidate hcl cap cr 20 mg (cd) (Metadate cd) methylphenidate hcl cap cr 30 mg (cd) (Metadate cd)
•
2
•
2
•
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
METHYLPHENIDATE HCL ER - methylphenidate hcl tab sa osm 18 mg
2
•
METHYLPHENIDATE HCL ER - methylphenidate hcl tab sa osm 27 mg
2
•
METHYLPHENIDATE HCL ER - methylphenidate hcl tab sa osm 36 mg
2
•
METHYLPHENIDATE HCL ER - methylphenidate hcl tab sa osm 54 mg
2
•
METHYLPHENIDATE HCL ER - methylphenidate hcl tab sr 24hr 18 mg
2
•
METHYLPHENIDATE HCL ER - methylphenidate hcl tab sr 24hr 27 mg
2
•
METHYLPHENIDATE HCL ER - methylphenidate hcl tab sr 24hr 36 mg
2
•
methylphenidate hcl cap cr 50 mg (cd) (Metadate cd) methylphenidate hcl cap cr 60 mg (cd) (Metadate cd) methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la) methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la) methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la) methylphenidate hcl chew tab 2.5 mg (Methylin) methylphenidate hcl chew tab 5 mg (Methylin) methylphenidate hcl chew tab 10 mg (Methylin)
Limited Distribution
2
methylphenidate hcl cap cr 40 mg (cd) (Metadate cd)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
89
methylphenidate hcl tab 5 mg (Ritalin) methylphenidate hcl tab 10 mg (Ritalin) methylphenidate hcl tab 20 mg (Ritalin)
•
2
•
STRATTERA - atomoxetine hcl cap 100 mg (base equiv)
4
•
2
•
VYVANSE - lisdexamfetamine dimesylate cap 10 mg
4
•
2
•
VYVANSE - lisdexamfetamine dimesylate cap 20 mg
4
•
2
•
VYVANSE - lisdexamfetamine dimesylate cap 30 mg
4
•
•
VYVANSE - lisdexamfetamine dimesylate cap 40 mg
4
•
•
VYVANSE - lisdexamfetamine dimesylate cap 50 mg
4
•
2 2 2
•
•
VYVANSE - lisdexamfetamine dimesylate cap 60 mg
4
modafinil tab 100 mg (Provigil)
•
•
•
VYVANSE - lisdexamfetamine dimesylate cap 70 mg
4
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
•
•
STRATTERA - atomoxetine hcl cap 10 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl cap 18 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl cap 25 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl cap 40 mg (base equiv)
4
•
PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. 2 acamprosate calcium tab delayed release 333 mg • AMPYRA - dalfampridine tab sr 5 • 12hr 10 mg • AUBAGIO - teriflunomide tab 7 5 mg 5 • AUBAGIO - teriflunomide tab 14 mg 5 • AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial) 5 • AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml
Limited Distribution
4
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
•
STRATTERA - atomoxetine hcl cap 80 mg (base equiv)
methylphenidate hcl soln 5 mg/5ml (Methylin)
methylphenidate hcl tab cr 20 mg
Dispensing Limits
•
2
methylphenidate hcl tab cr 10 mg
Step Therapy
4
2
•
Drug Name STRATTERA - atomoxetine hcl cap 60 mg (base equiv)
METHYLPHENIDATE HCL ER - methylphenidate hcl tab sr 24hr 54 mg
methylphenidate hcl soln 10 mg/5ml (Methylin)
Prior Authorization
Drug Name
Drug Tier
2016
• • • • •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
90
4
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban)
A
2
disulfiram tab 500 mg (Antabuse)
2
•
donepezil hydrochloride orally disintegrating tab 5 mg
2
CHANTIX - varenicline tartrate tab 0.5 mg (base equiv)
A
•
CHANTIX - varenicline tartrate tab 1 mg (base equiv)
A
•
donepezil hydrochloride orally disintegrating tab 10 mg
CHANTIX CONTINUING MONTH - varenicline tartrate tab 1 mg (base equiv)
A
•
CHANTIX STARTING MONTH PA - varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack
A
•
CHLORDIAZEPOXIDE/ AMITRIPT chlordiazepoxideamitriptyline tab 5-12.5 mg
4
CHLORDIAZEPOXIDE/ AMITRIPT chlordiazepoxideamitriptyline tab 10-25 mg
4
COMMIT - nicotine polacrilex lozenge 2 mg
A
•
COMMIT - nicotine polacrilex lozenge 4 mg
A
•
COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml
5
•
donepezil hydrochloride tab 5 mg (Aricept) donepezil hydrochloride tab 10 mg (Aricept) donepezil hydrochloride tab 23 mg (Aricept)
•
Limited Distribution
BRISDELLE - paroxetine mesylate cap 7.5 mg (base equiv)
disulfiram tab 250 mg (Antabuse)
•
•
ACA
•
5
Dispensing Limits
5
COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml
Step Therapy
BETASERON - interferon beta-1b for inj kit 0.3 mg
•
Prior Authorization
•
Drug Name
Drug Tier
5
Limited Distribution
AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
2
1 1 2
ERGOLOID MESYLATES ergoloid mesylates tab 1 mg
2
EXELON - rivastigmine td patch 24hr 4.6 mg/24hr
4
EXELON - rivastigmine td patch 24hr 9.5 mg/24hr
4
EXELON - rivastigmine td patch 24hr 13.3 mg/24hr
4
EXTAVIA - interferon beta-1b for inj kit 0.3 mg
5
FLUOXETINE - fluoxetine hcl (pmdd) cap 10 mg
2
FLUOXETINE - fluoxetine hcl (pmdd) cap 20 mg
2
GALANTAMINE HYDROBROMIDE galantamine hydrobromide oral soln 4 mg/ml
4
• •
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
91
galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)
2
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa)
2
galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)
2
NAMENDA - memantine hcl oral solution 2 mg/ml
4
2
4
galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)
NAMENDA - memantine hcl tab 5 mg
4
galantamine hydrobromide tab 4 mg (Razadyne)
2
NAMENDA - memantine hcl tab 10 mg
4
2
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
2
NAMENDA XR - memantine hcl cap sr 24hr 7 mg
4
•
•
NAMENDA XR - memantine hcl cap sr 24hr 14 mg
4
GILENYA - fingolimod hcl cap 0.5 mg (base equiv)
5 5
•
•
NAMENDA XR - memantine hcl cap sr 24hr 21 mg
4
glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)
4
GRALISE - gabapentin (oncedaily) tab 300 mg
4
•
NAMENDA XR - memantine hcl cap sr 24hr 28 mg
GRALISE - gabapentin (oncedaily) tab 600 mg
4
•
GRALISE STARTER gabapentin (once-daily) tab pack 300 mg (9) & 600 mg (69)
4
•
HORIZANT - gabapentin enacarbil tab cr 300 mg
4
•
HORIZANT - gabapentin enacarbil tab cr 600 mg
4
•
memantine hcl oral solution 2 mg/ml (Namenda)
2
galantamine hydrobromide tab 8 mg (Razadyne) galantamine hydrobromide tab 12 mg (Razadyne)
memantine hcl tab 5 mg (Namenda)
2
memantine hcl tab 10 mg (Namenda)
2
4 NAMENDA XR TITRATION PACK - memantine hcl cap sr 24hr 7 mg & 14 mg & 21 mg & 28 mg pack 4 NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 7-10 mg 4 NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 14-10 mg 4 NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 21-10 mg 4 NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 28-10 mg A NICODERM CQ - nicotine td patch 24hr 7 mg/24hr
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
92
NICOTROL INHALER nicotine inhaler system 10 mg (4 mg delivered)
A
•
NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/ spray)
A
NICORETTE - nicotine polacrilex gum 2 mg
A
•
•
NICORETTE - nicotine polacrilex gum 4 mg
A
•
3
•
NUEDEXTA dextromethorphan hbrquinidine sulfate cap 20-10 mg
NICORETTE - nicotine polacrilex lozenge 2 mg
A
NICORETTE - nicotine polacrilex lozenge 4 mg
A
•
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)
2
NICORETTE MINI - nicotine polacrilex lozenge 2 mg
A
•
olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)
NICORETTE MINI - nicotine polacrilex lozenge 4 mg
A
•
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)
NICORETTE STARTER KIT nicotine polacrilex gum 2 mg
A
•
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)
NICORETTE STARTER KIT nicotine polacrilex gum 4 mg
A
•
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)
nicotine polacrilex gum 2 mg
A
•
ORAP - pimozide tab 1 mg
4
ORAP - pimozide tab 2 mg
4
A
•
4
A
•
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 2-10 mg
A
•
4
A
•
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 2-25 mg
A
•
4
A
•
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-10 mg PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-25 mg
4
nicotine polacrilex gum 4 mg nicotine polacrilex lozenge 2 mg nicotine polacrilex lozenge 4 mg nicotine td patch 24hr 7 mg/24hr nicotine td patch 24hr 14 mg/24hr Nicotine td patch 24hr 21 mg/24hr NICOTINE TRANSDERMAL SYST - nicotine td patch 24 hr kit 21-14-7 mg/24hr
A
•
Limited Distribution
•
ACA
A
Dispensing Limits
NICODERM CQ - nicotine td patch 24hr 21 mg/24hr
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
NICODERM CQ - nicotine td patch 24hr 14 mg/24hr
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
93
PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-50 mg
4
REBIF TITRATION PACK interferon beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
5
pimozide tab 1 mg (Orap)
2
rivastigmine tartrate cap 1.5 mg (Exelon)
2
pimozide tab 2 mg (Orap)
2
•
•
PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml
5
PLEGRIDY - peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml
5
PLEGRIDY STARTER PACK peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack
5
PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack
5
REBIF - interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml)
5
•
•
REBIF - interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml)
5
•
•
REBIF REBIDOSE - interferon beta-1a soln auto-inj 22 mcg/0.5ml (12mu/ml)
5
REBIF REBIDOSE - interferon beta-1a soln auto-inj 44 mcg/0.5ml (24mu/ml) REBIF REBIDOSE TITRATION - interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
•
•
•
•
•
•
•
•
5
•
•
5
•
•
rivastigmine tartrate cap 3 mg (Exelon) rivastigmine tartrate cap 4.5 mg (Exelon) rivastigmine tartrate cap 6 mg (Exelon) rivastigmine td patch 24hr 4.6 mg/24hr (Exelon) rivastigmine td patch 24hr 9.5 mg/24hr (Exelon) rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
2 2 2 2 2 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
•
SAVELLA - milnacipran hcl tab 50 mg
4
•
SAVELLA - milnacipran hcl tab 100 mg
4
•
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak
4
•
TECFIDERA - dimethyl fumarate capsule delayed release 120 mg
5
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
94
5
•
•
tetrabenazine tab 25 mg (Xenazine)
5
•
XENAZINE - tetrabenazine tab 12.5 mg
5
XENAZINE - tetrabenazine tab 25 mg
butalbital-acetaminophen tab 50-325 mg
2 2
•
butalbital-acetaminophencaffeine cap 50-300-40 mg (Fioricet)
•
•
butalbital-acetaminophencaffeine cap 50-325-40 mg
2
•
•
•
2
5
•
•
•
butalbital-acetaminophencaffeine tab 50-325-40 mg (Esgic)
2
XYREM - sodium oxybate oral solution 500 mg/ml
5
•
•
•
butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)
ZINBRYTA - daclizumab soln prefilled syringe 150 mg/ml
5
• •
•
ZYBAN - bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
A
•
ANALGESICS AND ANESTHETICS ANALGESICS - NON-NARCOTIC 2 acetaminophensalicylamidephenyltoloxamine cap 300-200-20mg 4 ALLZITAL - butalbitalacetaminophen tab 25-325 mg A aspirin chew tab 81 mg ASPIRIN LOW DOSE - aspirin tab 81 mg
A
• •
aspirin tab delayed release 81 mg
A
•
choline & magnesium salicylates liq 500 mg/5ml
2
CHOLINE MAGNESIUM TRISALI - choline & magnesium salicylates tab 1000 mg
4
diflunisal tab 500 mg
2
LEVACET - aspirin-apapsalicylamide-caffeine tab 500-250-150-32.5 mg
4
salsalate tab 500 mg (Disalcid)
2
salsalate tab 750 mg (Disalcid)
2
TENCON - butalbitalacetaminophen tab 50-325 mg
2
VANATOL LQ - butalbitalacetaminophen-caffeine soln 50-325-40 mg/15ml
2
ANALGESICS - NARCOTIC ABSTRAL - fentanyl citrate sl tab 100 mcg (base equiv)
Limited Distribution
tetrabenazine tab 12.5 mg (Xenazine)
•
ACA
•
4
Dispensing Limits
5
BUPAP - butalbitalacetaminophen tab 50-300 mg
Step Therapy
TECFIDERA STARTER PACK - dimethyl fumarate capsule dr starter pack 120 mg & 240 mg
•
Prior Authorization
•
Drug Name
Drug Tier
5
Limited Distribution
TECFIDERA - dimethyl fumarate capsule delayed release 240 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
95
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 1
acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3)
1
acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4)
1
acetaminophen-caffeinedihydrocodeine cap 320.5-30-16 mg (Trezix)
2
4
•
BELBUCA - buprenorphine hcl buccal film 600 mcg (base equivalent)
4
•
BELBUCA - buprenorphine hcl buccal film 750 mcg (base equivalent)
4
•
BELBUCA - buprenorphine hcl buccal film 900 mcg (base equivalent)
4
•
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3 mg (base equiv)
4
•
•
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7 mg (base equiv)
4
•
•
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1 mg (base equiv)
4
•
•
buprenorphine hcl sl tab 2 mg (base equiv)
2
•
•
2
•
•
2
•
•
2
•
•
buprenorphine hcl sl tab 8 mg (base equiv)
ASPIRIN-CAFFEINEDIHYDROC - aspirincaffeine-dihydrocodeine cap 356.4-30-16 mg
4
BELBUCA - buprenorphine hcl buccal film 75 mcg (base equivalent)
4
•
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)
BELBUCA - buprenorphine hcl buccal film 150 mcg (base equivalent)
4
•
2
BELBUCA - buprenorphine hcl buccal film 300 mcg (base equivalent)
4
•
butalbital-acetaminophencaff w/ cod cap 50-300-40-30 mg (Fioricet/ codeine) butalbital-acetaminophencaff w/ cod cap 50-325-40-30 mg
2
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)
Limited Distribution
•
BELBUCA - buprenorphine hcl buccal film 450 mcg (base equivalent)
ACA
•
Dispensing Limits
4
Step Therapy
ABSTRAL - fentanyl citrate sl tab 300 mcg (base equiv)
acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine)
•
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
ABSTRAL - fentanyl citrate sl tab 200 mcg (base equiv)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
96
butalbital-aspirincaff w/ codeine cap 50-325-40-30 mg (Fiorinal/ codeine #3)
2
butorphanol tartrate nasal soln 10 mg/ml
2
4
•
•
EMBEDA - morphinenaltrexone cap cr 20-0.8 mg
4
•
4
•
BUTRANS - buprenorphine td patch weekly 5 mcg/hr
4
•
EMBEDA - morphinenaltrexone cap cr 30-1.2 mg
4
•
EMBEDA - morphinenaltrexone cap cr 50-2 mg
4
BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr
•
•
EMBEDA - morphinenaltrexone cap cr 60-2.4 mg
4
BUTRANS - buprenorphine td patch weekly 10 mcg/hr
4
•
•
EMBEDA - morphinenaltrexone cap cr 80-3.2 mg
4
BUTRANS - buprenorphine td patch weekly 15 mcg/hr
4
•
•
EMBEDA - morphinenaltrexone cap cr 100-4 mg
4
BUTRANS - buprenorphine td patch weekly 20 mcg/hr
4
•
4
EXALGO - hydromorphone hcl tab er 24hr deter 32 mg
4
CAPITAL/CODEINE acetaminophen w/ codeine susp 120-12 mg/5ml
•
4
•
CODEINE SULFATE - codeine sulfate tab 15 mg
4
FENTANYL - fentanyl td patch 72hr 37.5 mcg/hr
4
•
CODEINE SULFATE - codeine sulfate tab 30 mg
4
FENTANYL - fentanyl td patch 72hr 62.5 mcg/hr
4
•
CODEINE SULFATE - codeine sulfate tab 60 mg
4
FENTANYL - fentanyl td patch 72hr 87.5 mcg/hr
2
•
•
codeine sulfate tab 15 mg (Codeine sulfate)
2
fentanyl citrate lozenge on a handle 200 mcg (Actiq)
2
•
•
codeine sulfate tab 30 mg (Codeine sulfate)
2
2
•
•
codeine sulfate tab 60 mg (Codeine sulfate)
2
2
•
•
CONZIP - tramadol hcl cap sr 24hr biphasic release 100 mg
4
•
2
•
•
CONZIP - tramadol hcl cap sr 24hr biphasic release 200 mg
4
•
2
•
•
fentanyl citrate lozenge on a handle 400 mcg (Actiq) fentanyl citrate lozenge on a handle 600 mcg (Actiq) fentanyl citrate lozenge on a handle 800 mcg (Actiq) fentanyl citrate lozenge on a handle 1200 mcg (Actiq) fentanyl citrate lozenge on a handle 1600 mcg (Actiq) fentanyl td patch 72hr 12 mcg/hr (Duragesic)
2
Limited Distribution
CONZIP - tramadol hcl cap sr 24hr biphasic release 300 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
97
fentanyl td patch 72hr 25 mcg/hr (Duragesic) fentanyl td patch 72hr 50 mcg/hr (Duragesic) fentanyl td patch 72hr 75 mcg/hr (Duragesic) fentanyl td patch 72hr 100 mcg/hr (Duragesic)
2
•
2
•
FENTORA - fentanyl citrate buccal tab 100 mcg (base equiv)
4
•
•
FENTORA - fentanyl citrate buccal tab 200 mcg (base equiv)
4
•
•
FENTORA - fentanyl citrate buccal tab 400 mcg (base equiv)
4
•
•
FENTORA - fentanyl citrate buccal tab 600 mcg (base equiv)
4
FENTORA - fentanyl citrate buccal tab 800 mcg (base equiv)
4
hydrocodoneacetaminophen soln 7.5-325 mg/15ml (Hycet)
2
hydrocodoneacetaminophen soln 10-325 mg/15ml (Zamicet) hydrocodoneacetaminophen tab 2.5-325 mg hydrocodoneacetaminophen tab 10-325 mg (Norco) hydrocodoneacetaminophen tab 5-300 mg (Xodol)
2
2
1
2
•
•
•
•
hydrocodoneacetaminophen tab 5-325 mg (Norco) hydrocodoneacetaminophen tab 7.5-325 mg (Norco) hydrocodoneacetaminophen tab 10-300 mg (Xodol) hydrocodone-ibuprofen tab 5-200 mg (Reprexain) hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen) hydrocodone-ibuprofen tab 10-200 mg (Ibudone)
2
2 1 2
2
hydromorphone hcl tab er 24hr deter 32 mg (Exalgo) hydromorphone hcl tab 2 mg (Dilaudid) hydromorphone hcl tab 4 mg (Dilaudid) hydromorphone hcl tab 8 mg (Dilaudid)
Limited Distribution
1
hydromorphone hcl liqd 1 mg/ml (Dilaudid)
hydromorphone hcl tab er 24hr deter 16 mg (Exalgo)
ACA
1
4
hydromorphone hcl tab er 24hr deter 12 mg (Exalgo)
Dispensing Limits
2
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
hydromorphone hcl tab er 24hr deter 8 mg (Exalgo)
Step Therapy
•
hydrocodoneacetaminophen tab 7.5-300 mg (Xodol)
Prior Authorization
2
Drug Name
Drug Tier
•
Limited Distribution
2
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
•
2
•
2
•
2
•
1 1 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
98
4
•
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 60 mg
4
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 80 mg
4
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 100 mg
4
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 120 mg
4
IONSYS - fentanyl hcl iontophoretic td system 40 mcg/act (base equiv)
4
KADIAN - morphine sulfate cap sr 24hr 40 mg
4
•
KADIAN - morphine sulfate cap sr 24hr 200 mg
4
•
LAZANDA - fentanyl citrate nasal spray 100 mcg/act (base equiv)
4
LAZANDA - fentanyl citrate nasal spray 300 mcg/act (base equiv)
4
LAZANDA - fentanyl citrate nasal spray 400 mcg/act (base equiv)
4
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
4
4
meperidine hcl tab 50 mg (Demerol)
2
•
meperidine hcl tab 100 mg (Demerol)
2 4
•
MEPERIDINE HCL/ PROMETHAZI - meperidine w/ promethazine cap 50-25 mg
•
methadone hcl conc 10 mg/ ml (Methadose)
2
•
methadone hcl soln 5 mg/5ml (Methadone hcl) methadone hcl soln 10 mg/5ml (Methadone hcl) methadone hcl tab for oral susp 40 mg
• • •
Limited Distribution
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 40 mg
MEPERIDINE HCL meperidine hcl oral soln 50 mg/5ml
ACA
•
Dispensing Limits
4
4
Step Therapy
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 30 mg
LORTAB - hydrocodoneacetaminophen soln 10-300 mg/15ml
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 20 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 1
methadone hcl tab 5 mg (Dolophine hcl)
1
methadone hcl tab 10 mg (Dolophine)
1 3
•
MORPHINE SULFATE morphine sulfate suppos 5 mg
3
•
MORPHINE SULFATE morphine sulfate suppos 10 mg
3
•
MORPHINE SULFATE morphine sulfate suppos 20 mg MORPHINE SULFATE morphine sulfate suppos 30 mg
3
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
99
MORPHINE SULFATE morphine sulfate tab 15 mg
3
MORPHINE SULFATE morphine sulfate tab 30 mg
3
morphine sulfate cap sr 24hr 10 mg (Kadian)
2
•
2
•
2
•
2
•
2
•
2
•
2
•
MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 30 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 45 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 60 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 75 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 90 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 120 mg
2
•
morphine sulfate oral soln 10 mg/5ml
2
morphine sulfate cap sr 24hr 20 mg (Kadian) morphine sulfate cap sr 24hr 30 mg (Kadian) morphine sulfate cap sr 24hr 50 mg (Kadian) morphine sulfate cap sr 24hr 60 mg (Kadian) morphine sulfate cap sr 24hr 80 mg (Kadian) morphine sulfate cap sr 24hr 100 mg (Kadian)
morphine sulfate oral soln 20 mg/5ml morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
2
•
2
•
2
•
2
•
2
•
NUCYNTA - tapentadol hcl tab 50 mg
4
•
NUCYNTA - tapentadol hcl tab 75 mg
4
•
NUCYNTA - tapentadol hcl tab 100 mg
4
•
NUCYNTA ER - tapentadol hcl tab sr 12hr 50 mg
4
•
NUCYNTA ER - tapentadol hcl tab sr 12hr 100 mg
4
•
NUCYNTA ER - tapentadol hcl tab sr 12hr 150 mg
4
•
NUCYNTA ER - tapentadol hcl tab sr 12hr 200 mg
4
•
NUCYNTA ER - tapentadol hcl tab sr 12hr 250 mg
4
•
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 5 mg
4
•
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 7.5 mg
4
•
morphine sulfate tab cr 30 mg (Ms contin) morphine sulfate tab cr 60 mg (Ms contin) morphine sulfate tab cr 100 mg (Ms contin) morphine sulfate tab cr 200 mg (Ms contin)
Limited Distribution
2
2
morphine sulfate tab cr 15 mg (Ms contin)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
100
4
•
4
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 80 mg
4
•
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 20 mg
4
•
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)
2
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
OXAYDO - oxycodone hcl tab abuse deter 5 mg
4
oxycodone hcl tab 30 mg (Roxicodone)
2
OXAYDO - oxycodone hcl tab abuse deter 7.5 mg
4
2
oxycodone hcl cap 5 mg
2
oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)
oxycodone hcl tab 5 mg (Roxicodone)
1
oxycodone hcl tab 10 mg
2
oxycodone hcl tab 15 mg (Roxicodone)
2
oxycodone hcl tab 20 mg
2
oxycodone w/ acetaminophen tab 5-325 mg (Percocet)
oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl)
2
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 10 mg
4
•
oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 15 mg
4
•
oxycodone w/ acetaminophen tab 10-325 mg (Percocet)
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 20 mg
4
•
oxycodone-aspirin tab 4.8355-325 mg (Percodan)
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 30 mg
4
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 40 mg
4
•
Limited Distribution
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 15 mg
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 60 mg
ACA
•
Dispensing Limits
4
Step Therapy
OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 10 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
2
2
2
OXYCODONE/ ACETAMINOPHEN oxycodone w/ acetaminophen soln 5-325 mg/5ml
2
OXYCODONE/IBUPROFEN oxycodone-ibuprofen tab 5-400 mg
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
101
3
•
OXYCONTIN - oxycodone hcl tab er 12hr deter 30 mg
3
OXYCONTIN - oxycodone hcl tab er 12hr deter 40 mg
2
2
•
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 40 mg
3
•
pentazocine w/ naloxone tab 50-0.5 mg
2
OXYCONTIN - oxycodone hcl tab er 12hr deter 60 mg
3
•
4
OXYCONTIN - oxycodone hcl tab er 12hr deter 80 mg
3
•
PRIMLEV - oxycodone w/ acetaminophen tab 5-300 mg
4
oxymorphone hcl tab 5 mg (Opana)
2
PRIMLEV - oxycodone w/ acetaminophen tab 7.5-300 mg
2
4
oxymorphone hcl tab 10 mg (Opana)
PRIMLEV - oxycodone w/ acetaminophen tab 10-300 mg
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 5 mg
2
PROBUPHINE IMPLANT KIT - buprenorphine hcl subdermal implant 74.2 mg (base equiv)
4
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 7.5 mg
2
SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)
4
•
•
2
4
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 10 mg
SUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)
•
•
4
•
•
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 15 mg
2
SUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)
4
•
•
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 20 mg
2
SUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv) SUBSYS - fentanyl sublingual spray 100 mcg
4
•
•
SUBSYS - fentanyl sublingual spray 200 mcg
4
•
•
Limited Distribution
OXYCONTIN - oxycodone hcl tab er 12hr deter 20 mg
OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 30 mg
ACA
•
Dispensing Limits
3
Step Therapy
OXYCONTIN - oxycodone hcl tab er 12hr deter 15 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
OXYCONTIN - oxycodone hcl tab er 12hr deter 10 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
102
SUBSYS - fentanyl sublingual spray 800 mcg
4
•
•
SUBSYS - fentanyl sublingual spray 1200 mcg (600 mcg x 2)
4
•
•
SUBSYS - fentanyl sublingual spray 1600 mcg (800 mcg x 2)
4
•
•
SYNALGOS-DC - aspirincaffeine-dihydrocodeine cap 356.4-30-16 mg
4
TRAMADOL HCL ER tramadol hcl cap sr 24hr biphasic release 100 mg
4
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr biphasic release 150 mg
4
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr biphasic release 200 mg
4
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr biphasic release 300 mg
4
•
tramadol hcl tab sr 24hr 100 mg (Ultram er)
2
•
2
•
2
•
2
•
2
•
2
•
tramadol hcl tab sr 24hr 300 mg (Ultram er) tramadol hcl tab sr 24hr biphasic release 100 mg tramadol hcl tab sr 24hr biphasic release 200 mg tramadol hcl tab sr 24hr biphasic release 300 mg
tramadol-acetaminophen tab 37.5-325 mg (Ultracet)
1
TREZIX - acetaminophencaffeine-dihydrocodeine cap 320.5-30-16 mg
4
XARTEMIS XR - oxycodone w/ acetaminophen tab cr 7.5-325 mg
4
XTAMPZA ER - oxycodone cap 4 er 12hr abuse-deterrent 9 mg XTAMPZA ER - oxycodone cap 4 er 12hr abuse-deterrent 13.5 mg XTAMPZA ER - oxycodone cap 4 er 12hr abuse-deterrent 18 mg XTAMPZA ER - oxycodone cap 4 er 12hr abuse-deterrent 27 mg XTAMPZA ER - oxycodone cap 4 er 12hr abuse-deterrent 36 mg 4 ZAMICET - hydrocodoneacetaminophen soln 10-325 mg/15ml 4 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 10 mg 4 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 15 mg 4 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 20 mg
Limited Distribution
•
•
ACA
•
1
Dispensing Limits
4
tramadol hcl tab 50 mg (Ultram)
Step Therapy
SUBSYS - fentanyl sublingual spray 600 mcg
tramadol hcl tab sr 24hr 200 mg (Ultram er)
•
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
SUBSYS - fentanyl sublingual spray 400 mcg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • •
• • •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
103
4
ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 40 mg
4
ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 50 mg
4
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 1.4-0.36 mg (base eq)
4
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 2.9-0.71 mg (base eq)
4
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 5.7-1.4 mg (base eq)
4
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 8.6-2.1 mg (base eq)
4
•
•
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 11.4-2.9 mg (base eq)
4
•
•
diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 25 mg
•
diclofenac sodium tab delayed release 50 mg
• • • •
ANALGESICS - ANTI-INFLAMMATORY 5 • ACTEMRA - tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml 5 • ARCALYST - rilonacept for inj 220 mg 2 celecoxib cap 50 mg (Celebrex) 2 celecoxib cap 100 mg (Celebrex) 2 celecoxib cap 200 mg (Celebrex) 2 celecoxib cap 400 mg (Celebrex)
diclofenac sodium tab delayed release 75 mg
•
diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr)
•
diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50)
•
diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75)
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2 2 1 1 2 2
2
ENBREL - etanercept for subcutaneous inj 25 mg
5
•
•
•
ENBREL - etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml
5
•
•
•
ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml
5
•
•
•
ENBREL SURECLICK etanercept subcutaneous solution auto-injector 50 mg/ ml
5
•
•
•
etodolac cap 200 mg
2
•
etodolac cap 300 mg
•
etodolac tab sr 24hr 500 mg
•
etodolac tab 400 mg
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 30 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 600 mg etodolac tab 500 mg FENOPROFEN CALCIUM fenoprofen calcium cap 200 mg
2 2 2 2 2 2 4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
104
FENOPROFEN CALCIUM fenoprofen calcium cap 400 mg
4
FENOPROFEN CALCIUM fenoprofen calcium tab 600 mg
4
FENORTHO - fenoprofen calcium cap 200 mg
4
FENORTHO - fenoprofen calcium cap 400 mg
4
flurbiprofen tab 50 mg
1
flurbiprofen tab 100 mg
indomethacin cap 50 mg ketoprofen cap 50 mg
1
ketoprofen cap 75 mg ketorolac tromethamine tab 10 mg
1
KINERET - anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml
5
leflunomide tab 10 mg (Arava)
2
leflunomide tab 20 mg (Arava)
2
MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg
4
MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg
4
mefenamic acid cap 250 mg (Ponstel)
2
meloxicam tab 7.5 mg (Mobic)
1
•
•
HUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml
5
•
•
•
HUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml
5
•
•
•
HUMIRA PEDIATRIC CROHNS D - adalimumab prefilled syringe kit 40 mg/0.8ml
5
•
•
•
HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml
5
•
•
•
5
•
•
•
NALFON - fenoprofen calcium cap 400 mg
4
HUMIRA PEN-CROHNS DISEASE - adalimumab peninjector kit 40 mg/0.8ml
2
HUMIRA PEN-PSORIASIS STAR - adalimumab peninjector kit 40 mg/0.8ml
5
•
naproxen sodium tab sr 24hr 375 mg (base equiv) (Naprelan)
2
ibuprofen tab 400 mg
1
naproxen sodium tab sr 24hr 500 mg (base equiv) (Naprelan) naproxen sodium tab 275 mg (Anaprox)
1
ibuprofen tab 800 mg indomethacin cap cr 75 mg indomethacin cap 25 mg
1 1 2 1
Limited Distribution
ACA
•
1
•
ibuprofen tab 600 mg
Dispensing Limits
1
5
•
Step Therapy
1
HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
meloxicam tab 15 mg (Mobic) 1 1 nabumetone tab 500 mg nabumetone tab 750 mg
naproxen sodium tab 550 mg (Anaprox ds)
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
105
naproxen susp 125 mg/5ml
2
4
naproxen tab ec 375 mg (Ecnaprosyn)
1
OTREXUP - methotrexate soln pf auto-injector 22.5 mg/0.4ml
naproxen tab ec 500 mg (Ecnaprosyn)
1
OTREXUP - methotrexate soln pf auto-injector 25 mg/0.4ml
4
naproxen tab 250 mg (Naprosyn)
1
oxaprozin tab 600 mg (Daypro)
2
naproxen tab 375 mg (Naprosyn)
1
piroxicam cap 10 mg (Feldene)
2
naproxen tab 500 mg (Naprosyn)
1
piroxicam cap 20 mg (Feldene)
2
ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml
5
•
•
•
RASUVO - methotrexate soln pf auto-injector 7.5 mg/0.15ml
4
ORENCIA CLICKJECT abatacept subcutaneous soln auto-injector 125 mg/ml
5
•
•
•
RASUVO - methotrexate soln pf auto-injector 10 mg/0.2ml
4
5
•
4
OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg
RASUVO - methotrexate soln pf auto-injector 12.5 mg/0.25ml
4
OTEZLA - apremilast tab 30 mg
5
RASUVO - methotrexate soln pf auto-injector 15 mg/0.3ml
4
OTREXUP - methotrexate soln pf auto-injector 7.5 mg/0.4ml
4
RASUVO - methotrexate soln pf auto-injector 17.5 mg/0.35ml
OTREXUP - methotrexate soln pf auto-injector 10 mg/0.4ml
4
RASUVO - methotrexate soln pf auto-injector 20 mg/0.4ml
4
OTREXUP - methotrexate soln pf auto-injector 12.5 mg/0.4ml
4
RASUVO - methotrexate soln pf auto-injector 22.5 mg/0.45ml
4
OTREXUP - methotrexate soln pf auto-injector 15 mg/0.4ml
4
RASUVO - methotrexate soln pf auto-injector 25 mg/0.5ml
4
OTREXUP - methotrexate soln pf auto-injector 17.5 mg/0.4ml
4
RASUVO - methotrexate soln pf auto-injector 27.5 mg/0.55ml
4
OTREXUP - methotrexate soln pf auto-injector 20 mg/0.4ml
4
RASUVO - methotrexate soln pf auto-injector 30 mg/0.6ml
4
• •
• •
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
RIDAURA - auranofin cap 3 mg 4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
106
SIMPONI - golimumab subcutaneous soln autoinjector 50 mg/0.5ml
5
SIMPONI - golimumab subcutaneous soln autoinjector 100 mg/ml
5
SIMPONI - golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml
5
SIMPONI - golimumab subcutaneous soln prefilled syringe 100 mg/ml
5
sulindac tab 150 mg
1
sulindac tab 200 mg
• • •
• • •
XELJANZ - tofacitinib citrate tab 5 mg (base equivalent)
5
•
•
XELJANZ XR - tofacitinib citrate tab sr 24hr 11 mg (base equivalent)
5
•
•
•
2
•
AXERT - almotriptan malate tab 6.25 mg
4
•
AXERT - almotriptan malate tab 12.5 mg
4
•
CAMBIA - diclofenac potassium packet 50 mg
4
D.H.E. 45 - dihydroergotamine mesylate inj 1 mg/ml
4
dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45)
2
ERGOMAR - ergotamine tartrate sl tab 2 mg
• •
•
•
frovatriptan succinate tab 2.5 mg (base equivalent) (Frova)
2
•
•
IMITREX - sumatriptan nasal spray 5 mg/act
3
•
IMITREX - sumatriptan nasal spray 20 mg/act
3
•
isometheptene-caffeineacetaminophen tab 65-20-325 mg (Prodrin)
2
•
2
•
MIGRANAL dihydroergotamine mesylate nasal spray 4 mg/ml
4
•
•
naratriptan hcl tab 1 mg (base equiv) (Amerge)
2
•
2
•
RELPAX - eletriptan hydrobromide tab 20 mg (base equivalent)
4
•
RELPAX - eletriptan hydrobromide tab 40 mg (base equivalent)
4
•
rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt)
2
•
2
•
2
•
rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt) rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt)
Limited Distribution
4
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
FROVA - frovatriptan succinate tab 2.5 mg (base equivalent)
naratriptan hcl tab 2.5 mg (base equiv) (Amerge) 2
almotriptan malate tab 12.5 mg (Axert)
Drug Name
isometheptene-dichloralacetaminophen cap 65-100-325 mg
2
almotriptan malate tab 6.25 mg (Axert)
•
1
TOLMETIN SODIUM - tolmetin sodium cap 400 mg
MIGRAINE PRODUCTS
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
107
•
SUMATRIPTAN SUCCINATE sumatriptan succinate solution prefilled syringe 6 mg/0.5ml
4
•
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)
2
•
2 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys) 2 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys) 2 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref) 2 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref) 1 sumatriptan succinate tab 25 mg (Imitrex) 1 sumatriptan succinate tab 50 mg (Imitrex) 1 sumatriptan succinate tab 100 mg (Imitrex) 2 zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt)
•
2
•
zolmitriptan tab 2.5 mg (Zomig)
2
•
zolmitriptan tab 5 mg (Zomig)
2
•
ZOMIG - zolmitriptan nasal spray 2.5 mg/spray unit
4
•
ZOMIG NASAL SPRAY zolmitriptan nasal spray 5 mg/spray unit
4
•
GOUT AGENTS allopurinol tab 100 mg (Zyloprim)
1
allopurinol tab 300 mg (Zyloprim)
1
COLCHICINE - colchicine cap 0.6 mg
4
•
COLCHICINE - colchicine tab 0.6 mg
4
colchicine w/ probenecid tab 0.5-500 mg
2
•
COLCRYS - colchicine tab 0.6 mg
4
MITIGARE - colchicine cap 0.6 mg
4
probenecid tab 500 mg
2
•
• • • •
Limited Distribution
2
sumatriptan nasal spray 20 mg/act (Imitrex)
zolmitriptan orally disintegrating tab 5 mg (Zomig zmt)
ACA
•
Dispensing Limits
2
Step Therapy
sumatriptan nasal spray 5 mg/act (Imitrex)
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ULORIC - febuxostat tab 40 mg 4 ULORIC - febuxostat tab 80 mg 4 NEUROMUSCULAR DRUGS ANTICONVULSANTS APTIOM - eslicarbazepine acetate tab 200 mg
4
APTIOM - eslicarbazepine acetate tab 400 mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
108
APTIOM - eslicarbazepine acetate tab 600 mg
4
carbamazepine tab 200 mg (Tegretol)
2
APTIOM - eslicarbazepine acetate tab 800 mg
4
CARBATROL - carbamazepine cap sr 12hr 100 mg
4
BANZEL - rufinamide susp 40 mg/ml
4
CARBATROL - carbamazepine cap sr 12hr 200 mg
4
BANZEL - rufinamide tab 200 mg
4
CARBATROL - carbamazepine cap sr 12hr 300 mg
4
BANZEL - rufinamide tab 400 mg
4
BRIVIACT - brivaracetam oral soln 10 mg/ml
4
BRIVIACT - brivaracetam tab 10 mg
4
BRIVIACT - brivaracetam tab 25 mg
4
BRIVIACT - brivaracetam tab 50 mg
4
BRIVIACT - brivaracetam tab 75 mg
4
BRIVIACT - brivaracetam tab 100 mg
4
carbamazepine cap sr 12hr 100 mg (Carbatrol)
2
CELONTIN - methsuximide cap 4 300 mg 2 clonazepam orally disintegrating tab 0.125 mg 2 clonazepam orally disintegrating tab 0.25 mg 2 clonazepam orally disintegrating tab 0.5 mg 2 clonazepam orally disintegrating tab 1 mg 2 clonazepam orally disintegrating tab 2 mg 1 clonazepam tab 0.5 mg (Klonopin) 1 clonazepam tab 1 mg (Klonopin) 1 clonazepam tab 2 mg (Klonopin) DEPAKENE - valproate sodium 4 syrup 250 mg/5ml (base equiv) DEPAKENE - valproic acid cap 4 250 mg DIASTAT ACUDIAL - diazepam 3 rectal gel delivery system 10 mg DIASTAT ACUDIAL - diazepam 3 rectal gel delivery system 20 mg
carbamazepine cap sr 12hr 200 mg (Carbatrol) carbamazepine cap sr 12hr 300 mg (Carbatrol) carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml (Tegretol) carbamazepine tab sr 12hr 100 mg (Tegretol-xr) carbamazepine tab sr 12hr 200 mg (Tegretol-xr) carbamazepine tab sr 12hr 400 mg (Tegretol-xr)
2 2 2 2 2 2 2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
109
DIASTAT PEDIATRIC diazepam rectal gel delivery system 2.5 mg
3
felbamate susp 600 mg/5ml (Felbatol)
2
felbamate tab 400 mg (Felbatol)
2
DIAZEPAM - diazepam rectal gel delivery system 2.5 mg
4
felbamate tab 600 mg (Felbatol)
2
DIAZEPAM - diazepam rectal gel delivery system 10 mg
4 4
FYCOMPA - perampanel susp 0.5 mg/ml
4
DIAZEPAM - diazepam rectal gel delivery system 20 mg
FYCOMPA - perampanel tab 2 mg
4
DILANTIN - phenytoin sodium extended cap 30 mg
4
FYCOMPA - perampanel tab 4 mg
4
DILANTIN - phenytoin sodium extended cap 100 mg
4
FYCOMPA - perampanel tab 6 mg
4
DILANTIN INFATABS phenytoin chew tab 50 mg
4 4
4
DILANTIN-125 - phenytoin susp 125 mg/5ml
FYCOMPA - perampanel tab 8 mg
2
FYCOMPA - perampanel tab 10 mg
4
divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles)
FYCOMPA - perampanel tab 12 mg
4
divalproex sodium tab delayed release 125 mg (Depakote)
1
gabapentin cap 100 mg (Neurontin)
1 1
divalproex sodium tab delayed release 250 mg (Depakote)
1
gabapentin cap 300 mg (Neurontin) gabapentin cap 400 mg (Neurontin)
1
divalproex sodium tab delayed release 500 mg (Depakote)
2
gabapentin oral soln 250 mg/5ml (Neurontin)
2
divalproex sodium tab sr 24 hr 250 mg (Depakote er)
2
2
gabapentin tab 600 mg (Neurontin)
2
2
gabapentin tab 800 mg (Neurontin)
4
ethosuximide cap 250 mg (Zarontin)
2
GABITRIL - tiagabine hcl tab 12 mg
4
ethosuximide soln 250 mg/5ml (Zarontin)
2
GABITRIL - tiagabine hcl tab 16 mg
divalproex sodium tab sr 24 hr 500 mg (Depakote er)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
110
LAMICTAL ODT - lamotrigine orally disintegrating tab 25 mg
4
lamotrigine orally disintegrating tab 25 mg (Lamictal odt)
2
LAMICTAL ODT - lamotrigine orally disintegrating tab 50 mg
4
lamotrigine orally disintegrating tab 50 mg (Lamictal odt)
2
LAMICTAL ODT - lamotrigine orally disintegrating tab 100 mg
4
lamotrigine orally disintegrating tab 100 mg (Lamictal odt)
2
LAMICTAL ODT - lamotrigine orally disintegrating tab 200 mg
4
lamotrigine orally disintegrating tab 200 mg (Lamictal odt)
2
LAMICTAL ODT - lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit
4
lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)
2
LAMICTAL ODT - lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit
4
LAMICTAL ODT - lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit
4
LAMICTAL STARTER/NOT TAKI - lamotrigine tab 25 mg (42) & 100 mg (7) starter kit
4
LAMICTAL STARTER/TAKING C - lamotrigine tab 25 mg (84) & 100 mg (14) starter kit
4
LAMICTAL STARTER/TAKING V - lamotrigine tab 25 mg (35) starter kit
4
2 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di) 2 lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit (LAMICTAL ODT) 2 lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit (LAMICTAL ODT) 2 lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit (LAMICTAL ODT) 2 lamotrigine tab sr 24hr 25 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 50 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 100 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 200 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 250 mg (Lamictal xr) 2 lamotrigine tab sr 24hr 300 mg (Lamictal xr)
LAMICTAL XR - lamotrigine tab 4 sr 24hr 25 mg (21) & 50 mg (7) titration kit LAMICTAL XR - lamotrigine tab 4 sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit 4 LAMICTAL XR - lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
111
lamotrigine tab 25 mg (Lamictal)
1
LYRICA - pregabalin soln 20 mg/ml
4
lamotrigine tab 100 mg (Lamictal)
1
ONFI - clobazam suspension 2.5 mg/ml
4
lamotrigine tab 150 mg (Lamictal)
1
ONFI - clobazam tab 10 mg
4
1
ONFI - clobazam tab 20 mg
4
lamotrigine tab 200 mg (Lamictal)
2
levetiracetam oral soln 100 mg/ml (Keppra)
2
oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)
2
oxcarbazepine tab 150 mg (Trileptal)
1
2
oxcarbazepine tab 300 mg (Trileptal)
2
oxcarbazepine tab 600 mg (Trileptal)
2
levetiracetam tab 250 mg (Keppra)
1 2
OXTELLAR XR oxcarbazepine tab sr 24hr 150 mg
4
levetiracetam tab 500 mg (Keppra) levetiracetam tab 750 mg (Keppra)
2
4
levetiracetam tab 1000 mg (Keppra)
2
OXTELLAR XR oxcarbazepine tab sr 24hr 300 mg
4
•
4
LYRICA - pregabalin cap 25 mg
OXTELLAR XR oxcarbazepine tab sr 24hr 600 mg
LYRICA - pregabalin cap 50 mg
4
•
PEGANONE - ethotoin tab 250 mg
4
LYRICA - pregabalin cap 75 mg
4
•
4
LYRICA - pregabalin cap 100 mg
4
•
PHENYTEK - phenytoin sodium extended cap 200 mg
4
LYRICA - pregabalin cap 150 mg
4
•
PHENYTEK - phenytoin sodium extended cap 300 mg
LYRICA - pregabalin cap 200 mg
4
•
phenytoin chew tab 50 mg (Dilantin infatabs)
2
LYRICA - pregabalin cap 225 mg
4
•
phenytoin sodium extended cap 100 mg (Dilantin)
2
LYRICA - pregabalin cap 300 mg
4
•
phenytoin sodium extended cap 200 mg (Phenytek)
levetiracetam tab sr 24hr 500 mg (Keppra xr) levetiracetam tab sr 24hr 750 mg (Keppra xr)
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
112
phenytoin sodium extended cap 300 mg (Phenytek) phenytoin susp 125 mg/5ml (Dilantin-125)
2 2
POTIGA - ezogabine tab 50 mg 4 4 POTIGA - ezogabine tab 200 mg 4 POTIGA - ezogabine tab 300 mg 4 POTIGA - ezogabine tab 400 mg 1 primidone tab 50 mg (Mysoline) 2 primidone tab 250 mg (Mysoline) 4 QUDEXY XR - topiramate cap er 24hr sprinkle 25 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 50 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 100 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 150 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 200 mg SABRIL - vigabatrin powd pack 3 500 mg 3 SABRIL - vigabatrin tab 500 mg 4 SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4 SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4 SPRITAM - levetiracetam tab disintegrating soluble 750 mg
• • • • •
SPRITAM - levetiracetam tab disintegrating soluble 1000 mg
4
TEGRETOL - carbamazepine susp 100 mg/5ml
4
TEGRETOL - carbamazepine tab 200 mg
4
TEGRETOL-XR carbamazepine tab sr 12hr 100 mg
4
TEGRETOL-XR carbamazepine tab sr 12hr 200 mg
4
TEGRETOL-XR carbamazepine tab sr 12hr 400 mg
4
tiagabine hcl tab 2 mg (Gabitril)
2
tiagabine hcl tab 4 mg (Gabitril)
2
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
TOPIRAMATE ER - topiramate cap er 24hr sprinkle 200 mg
4
topiramate sprinkle cap 15 mg (Topamax sprinkle)
2
topiramate sprinkle cap 25 mg (Topamax sprinkle)
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
topiramate tab 25 mg (Topamax)
1
topiramate tab 50 mg (Topamax)
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
113
topiramate tab 100 mg (Topamax)
1
AMANTADINE HCL amantadine hcl tab 100 mg
4
topiramate tab 200 mg (Topamax)
1
amantadine hcl cap 100 mg
2
TROKENDI XR - topiramate cap sr 24hr 25 mg
4
amantadine hcl syrup 50 mg/5ml
4
APOKYN - apomorphine hydrochloride inj 10 mg/ml
5
TROKENDI XR - topiramate cap sr 24hr 50 mg
4
AZILECT - rasagiline mesylate tab 0.5 mg (base equiv)
4
TROKENDI XR - topiramate cap sr 24hr 100 mg
AZILECT - rasagiline mesylate tab 1 mg (base equiv)
4
TROKENDI XR - topiramate cap sr 24hr 200 mg
4
benztropine mesylate tab 0.5 mg
1
valproate sodium syrup 250 mg/5ml (base equiv) (Depakene)
2
valproic acid cap 250 mg (Depakene)
2
VIMPAT - lacosamide oral solution 10 mg/ml
4
VIMPAT - lacosamide tab 50 mg
4
VIMPAT - lacosamide tab 100 mg
4
VIMPAT - lacosamide tab 150 mg
4
VIMPAT - lacosamide tab 200 mg
4
ZARONTIN - ethosuximide cap 250 mg
4
ZARONTIN - ethosuximide soln 4 250 mg/5ml 1 zonisamide cap 25 mg (Zonegran) 2 zonisamide cap 50 mg zonisamide cap 100 mg (Zonegran) ANTIPARKINSON AGENTS
2
benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg
2
carbidopa & levodopa orally disintegrating tab 10-100 mg
2
carbidopa & levodopa tab cr 50-200 mg (Sinemet cr) carbidopa & levodopa tab 10-100 mg (Sinemet)
ACA
Dispensing Limits
Limited Distribution
•
1
bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel)
carbidopa & levodopa tab cr 25-100 mg (Sinemet cr)
•
1
2
carbidopa & levodopa orally disintegrating tab 25-250 mg
Step Therapy
1
bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel)
carbidopa & levodopa orally disintegrating tab 25-100 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2 2 1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
114
carbidopa & levodopa tab 25-100 mg (Sinemet) carbidopa & levodopa tab 25-250 mg (Sinemet)
2 2
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
pramipexole dihydrochloride tab sr 24hr 0.375 mg (Mirapex er)
2
pramipexole dihydrochloride tab sr 24hr 0.75 mg (Mirapex er)
2
carbidopa tab 25 mg (Lodosyn)
2
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 12.5-50-200 mg
4
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 18.75-75-200 mg
4
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 25-100-200 mg
4
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 31.25-125-200 mg
4
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 37.5-150-200 mg
4
CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 50-200-200 mg
4
DUOPA - carbidopa-levodopa enteral susp 4.63-20 mg/ml
4
entacapone tab 200 mg (Comtan)
2
MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 0.375 mg
4
pramipexole dihydrochloride tab sr 24hr 1.5 mg (Mirapex er)
2
MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 0.75 mg
4
pramipexole dihydrochloride tab sr 24hr 2.25 mg (Mirapex er)
2
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
115
pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex er)
2
pramipexole dihydrochloride tab sr 24hr 3.75 mg (Mirapex er)
2
pramipexole dihydrochloride tab sr 24hr 4.5 mg (Mirapex er)
2
pramipexole dihydrochloride tab 0.125 mg (Mirapex)
1
ropinirole hydrochloride tab 4 mg (Requip)
1
ropinirole hydrochloride tab 5 mg (Requip)
pramipexole dihydrochloride tab 0.25 mg (Mirapex) pramipexole dihydrochloride tab 0.5 mg (Mirapex) pramipexole dihydrochloride tab 0.75 mg (Mirapex) pramipexole dihydrochloride tab 1 mg (Mirapex) pramipexole dihydrochloride tab 1.5 mg (Mirapex) ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab 0.25 mg (Requip)
ropinirole hydrochloride tab 0.5 mg (Requip) ropinirole hydrochloride tab 1 mg (Requip) ropinirole hydrochloride tab 2 mg (Requip) ropinirole hydrochloride tab 3 mg (Requip)
1 1
RYTARY - carbidopa & levodopa cap cr 48.75-195 mg
4
2
RYTARY - carbidopa & levodopa cap cr 61.25-245 mg
4
2
selegiline hcl cap 5 mg (Eldepryl)
2
selegiline hcl tab 5 mg
2
2
2
2
1
Limited Distribution
1
4
1
ACA
1
RYTARY - carbidopa & levodopa cap cr 36.25-145 mg
1
Dispensing Limits
1
4
1
Step Therapy
1
RYTARY - carbidopa & levodopa cap cr 23.75-95 mg
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
STALEVO 100 - carbidopalevodopa-entacapone tabs 25-100-200 mg
4
STALEVO 125 - carbidopalevodopa-entacapone tabs 31.25-125-200 mg
4
STALEVO 150 - carbidopalevodopa-entacapone tabs 37.5-150-200 mg
4
STALEVO 200 - carbidopalevodopa-entacapone tabs 50-200-200 mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
116
STALEVO 50 - carbidopalevodopa-entacapone tabs 12.5-50-200 mg
4
STALEVO 75 - carbidopalevodopa-entacapone tabs 18.75-75-200 mg
4
TASMAR - tolcapone tab 100 mg
4
tolcapone tab 100 mg (Tasmar)
2
trihexyphenidyl hcl elixir 0.4 mg/ml
2
trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg ZELAPAR - selegiline hcl orally disintegrating tab 1.25 mg NEUROMUSCULAR AGENTS riluzole tab 50 mg (Rilutek)
1 1 4
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 baclofen tab 20 mg
2
carisoprodol tab 250 mg (Soma)
2
carisoprodol tab 350 mg (Soma)
1
carisoprodol w/ aspirin & codeine tab 200-325-16 mg
2 2
cyclobenzaprine hcl tab 7.5 mg (Fexmid) cyclobenzaprine hcl tab 10 mg dantrolene sodium cap 25 mg (Dantrium) dantrolene sodium cap 50 mg (Dantrium) dantrolene sodium cap 100 mg
2 2 2
LORZONE - chlorzoxazone tab 750 mg
4
METAXALONE - metaxalone tab 400 mg
4
metaxalone tab 800 mg (Skelaxin)
2
methocarbamol tab 500 mg (Robaxin)
1
methocarbamol tab 750 mg (Robaxin-750)
1
orphenadrine citrate tab sr 12hr 100 mg
2
SOMA - carisoprodol tab 250 mg
4
tizanidine hcl cap 2 mg (base equivalent) (Zanaflex)
2
•
tizanidine hcl cap 4 mg (base equivalent) (Zanaflex)
2
•
2
•
1
•
1
cyclobenzaprine hcl tab 5 mg
1
tizanidine hcl tab 2 mg (base equivalent)
Limited Distribution
1
4
chlorzoxazone tab 500 mg (Parafon forte dsc)
ACA
Dispensing Limits
Step Therapy
2
LORZONE - chlorzoxazone tab 375 mg
tizanidine hcl cap 6 mg (base equivalent) (Zanaflex)
carisoprodol w/ aspirin tab 200-325 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
117
tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) ANTIMYASTHENIC AGENTS
1
cholecalciferol tab 50000 unit
A
•
A
•
MESTINON - pyridostigmine bromide syrup 60 mg/5ml
4
DDROPS - cholecalciferol drops 1000 unit/0.03ml (per drop)
MESTINON TIMESPAN pyridostigmine bromide tab cr 180 mg
4
DECARA - cholecalciferol cap 25000 unit
4 1
pyridostigmine bromide tab cr 180 mg (Mestinon timespan)
2
ergocalciferol cap 50000 unit (Drisdol) MEPHYTON - phytonadione tab 5 mg
3
pyridostigmine bromide tab 60 mg (Mestinon)
2
phytonadione inj 1 mg/0.5ml (2 mg/ml)
2
POTABA - potassium aminobenzoate cap 500 mg
4
BABY DDROPS cholecalciferol drops 400 unit/0.03ml (per drop)
A
•
SUPER DAILY D3 cholecalciferol drops 1000 unit/0.03ml (per drop)
A
•
cholecalciferol cap 400 unit
A
• •
VITAMELTS VITAMIN D cholecalciferol orally disintegrating tab 1000 unit
A
•
VITAMIN D2 - ergocalciferol tab 400 unit
A
•
VITAMIN D3 - cholecalciferol oral liquid 1200 unit/15ml
A
•
VITAMIN D3 - cholecalciferol spray 1000 unit/spray
A
•
WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000 unit/10ml
A
•
cholecalciferol cap 1000 unit cholecalciferol cap 50000 unit cholecalciferol chew tab 400 unit cholecalciferol chew tab 1000 unit cholecalciferol drops 5000 unit/ml (1000 unit/0.2ml) cholecalciferol drops 400 unit/0.03ml (per drop) cholecalciferol oral liquid 400 unit/ml cholecalciferol tab 400 unit cholecalciferol tab 1000 unit
A 1 A
•
A
•
A
•
A
•
A
•
A
• •
A
MULTIVITAMINS ACTIVE OB - prenatal w/o a w/ fe cbn-fa-dha cap 20-1-320 mg
Limited Distribution
ACA
Dispensing Limits
D-VI-SOL - cholecalciferol oral liquid 400 unit/ml
4
VITAMINS
Step Therapy
1
GUANIDINE HCL - guanidine hcl tab 125 mg
NUTRITIONAL PRODUCTS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
118
ADVANCED AM/PM - multiple vitamins w/ calcium therapy pack
4
CITRANATAL B-CALM - prenat w/o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak
4
ATABEX EC - prenatal vit w/ dss-iron carbonyl-fa tab dr 29-1 mg
4
CITRANATAL DHA - prenat w/ o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack
4
b-complex w/ c & folic acid cap 1 mg (Nephrocaps)
1
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 glucdss-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-faca tab & omega 3 cap 250 pk
4
b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) b-complex w/ c & folic acid tab 5 mg
1 1
BAL-CARE DHA - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg
4
BP FOLINATAL PLUS B - prenatal w/ calcium carbonate-b6-b12-fa tab 1 mg
4
BP MULTINATAL PLUS prenatal w/o a vit w/ fe fumfa tab chew 40-1 mg
4
BP MULTINATAL PLUS prenatal w/o a vit w/ fe fumarate-fa tab 30-1 mg
4
COMPLETENATE - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg
4
C-BUFF - multiple vitamins w/ minerals powder
4
4
C-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg
4
CONCEPT DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg
4
CALCIUM PNV - prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg
4
CONCEPT OB - prenatal w/ o a w/fe fum-fe poly-fa cap 130-92.4-1 mg
4
CITRANATAL ASSURE prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack
4
DIALYVITE SUPREME D multiple vitamins w/ minerals & fa tab 3 mg DIALYVITE 3000 - b-complex w/ c-biotin-e-minerals & folic acid tab 3 mg
4
DIALYVITE 5000 - b-complex w/ c-biotin-e-minerals & folic acid tab 5 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
119
DIALYVITE/ZINC - b-complex w/ c-zn & folic acid tab 1 mg
4
DOTHELLE DHA - prenatal w/ fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg
4
4
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 1 mg
4
DUET DHA BALANCED prenat w/fe poly-na fered-fa tab 25-1 & omega cap 267 mg
4
FOCALGIN CA - prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack FOCALGIN 90 DHA - prenat w/ o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak
4
DUET DHA 400 - prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg
4
FOLCAL DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg
4
ELITE-OB - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg
4
ENBRACE HR - prenatal vit w/ fe gly cys-fa-omega 3 fatty acids cap
4
END FATIGUE DAILY ENERGY - multiple vitamins w/ minerals powder
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
ESCAVITE LQ - pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml
4
EXTRA-VIRT PLUS DHA prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg
4
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 0.25 mg
4
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 0.5 mg
4
FOLCAPS OMEGA 3 - prenatal 4 vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg 4 FOLET DHA - prenat w/fecbnbisg-methylf-dss tab dr & dha cap pak 4 FOLET ONE - prenat w/o a w/ fecbn-bisg-methylf-dss-dha cap 38-1-225 mg FOLGARD OS - multiple vit w/ 4 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 HEMENATAL OB - prenat vit-fe 4 poly cmplx-fe heme poly-fa tab 28-6-1 mg 4 HEMENATAL OB + DHA prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck 4 INATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 INATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
120
INATAL ULTRA - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg
4
MYNATE 90 PLUS - prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg
4
INFANATE BALANCE prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg
4
NATACHEW - prenatal vit w/ fe fum-fe bisglycin-fa chew tab 28-1 mg
4
M-VIT - prenatal vit w/ fe fumarate-fa tab 27-1 mg
4
NATALVIT - prenatal vit w/ fe fumarate-fa tab 75-1 mg
4
NATELLE ONE - prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg
4
NEEVO DHA - prenat w/o a w/ fefum-methylfol-omegas cap 27-1.13 mg
4
NEPHPLEX RX - b-complex w/ c-zn & folic acid tab 1 mg
4
NESTABS - prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg
4
NESTABS ABC - prenatal w/o vit a w/fe polysac-fa-ca tab & omega 3 cap
4
NESTABS DHA - prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack
4
NEWGEN - prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg
4
NEXA PLUS - prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg
4
NICOMIDE - niacinamide w/ zn-cu-methylfolate tab 750-25-1.5-0.5 mg
4
NIVA-PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg
4
O-CAL FA - prenatal vit w/ fe fumarate-fa tab 27-1 mg
4
MACNATAL CN DHA - prenatal 4 w/o a w/fe cbn-dss-fa-dha cap 28-1-250 mg MARNATAL-F - prenatal w/o vit 4 a w/ fe polysac cmplx-fa cap 60-1 mg 4 MEGA MULTIVITAMIN multiple vitamins w/ minerals powder 1 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) 4 MYKIDZ IRON FL - pediatric vitamins acd fluoride & fe susp 0.25-10 mg/2ml 4 MYNATAL - prenatal multivitamins & minerals w/ iron & fa cap 1 mg 4 MYNATAL ADVANCE prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 MYNATAL PLUS - prenatal vit w/ fe fumarate-fa tab 65-1 mg 4 MYNATAL ULTRACAPLET prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg MYNATAL-Z - prenatal vit w/ fe 4 fumarate-fa tab 65-1 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
121
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 GOLD prenat w/o a w/fecbnmethfol-fa-dha cap 27.5-1-200 mg
4
OB COMPLETE ONE prenatal w/o a w/fecbnfe asp glyc-fa-fish cap 50-1-476 mg
4
OB COMPLETE PETITE prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg
4
OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp glyc-fa tab 30-20-1 mg
pediatric multiple vitamins w/ fluoride chew tab 0.5 mg pediatric multiple vitamins w/ fluoride chew tab 1 mg pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml pediatric vitamins acd w/ fluoride soln 0.25 mg/ml pediatric vitamins acd w/ fluoride soln 0.5 mg/ml
Limited Distribution
ACA
Dispensing Limits
1 1 1 1 1 4 4
4
PNV FERROUS FUMARATE/ DOCU - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg
4
OB COMPLETE/DHA - prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg
4
PNV OB+DHA - prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack
4
OBSTETRIX DHA - prenat w/ fecbn-fa-dss tab 29-1 mg & omega 3 cap 387 mg pak
4
PNV PRENATAL PLUS MULTIVI - prenatal vit w/ fe fumarate-fa tab 27-1 mg
4
OBSTETRIX EC - prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg
4
PNV TABS 29-1 - prenatal vit w/ iron carbonyl-fa tab 29-1 mg
4
OBSTETRIX ONE - prenat w/o a w/fecbn-bisg-methylf-dssdha cap 38-1-225 mg
4
PNV-DHA - prenat w/o a w/ fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg
4
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ ml
1
PNV-DHA+DOCUSATE prenatal w/o vit a w/ fe fumdss-fa-dha cap 27-1.25-300 mg PNV-OMEGA - prenat w/o a w/ fe fumerate-methylfolate-faomega 3 cap
4
1
Step Therapy
1
PHLEXY-VITS - multiple vitamins w/ minerals powder
pediatric multiple vitamins w/ fluoride chew tab 0.25 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
122
PNV-SELECT - prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg
4
PR NATAL 400 EC - prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk
4
PNV-TOTAL - prenat w/ fe cbn-fe bisglyc-fa-fish oil cap 35-5-1.2 mg
4
PR NATAL 430 - prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk
4
PNV-VP-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg
4
PR NATAL 430 EC - prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk
4
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.25 mg
4
PREFERA OB - prenat vit-fe poly cmplx-fe heme poly-fa tab 34-1 mg
4
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.5 mg
4
PREFERAOB +DHA - prenatfe poly cmplx 28mg-fe heme poly-fa tab&dha cap pack
4
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 1 mg
4
PREFERAOB ONE - prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg
4
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic susp 0.25 mg/ml
4
PRENAISSANCE - prenatal w/ o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg
4
POLY-VI-FLOR FS - pediatric multiple vit w/ fluoride oral strip 0.25 mg
4
PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg
4
POLY-VI-FLOR FS - pediatric multiple vit w/ fluoride oral strip 0.5 mg
4
4
POLY-VI-FLOR FS - pediatric multiple vitamins w/ fluoride oral strip 1 mg
4
PRENAISSANCE HARMONY DHA - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg
4
POLY-VI-FLOR/IRON - ped multiple vit w/ fl-fe biphasic chew tab 0.5-10 mg
4
PRENAISSANCE NEXT prenatal w/ calcium-vit b6-faginger tab 1.2 mg
4
POLY-VI-FLOR/IRON - ped multiple vitamin w/ fl-fe biphasic susp 0.25-7 mg/ml
4
PRENAISSANCE NEXT-B prenatal w/ calcium-vit b6-faginger tab 1.22 mg
4
PR NATAL 400 - prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk
4
PRENAISSANCE PLUS prenatal w/o a w/fe cbn-dssfa-dha cap 28-1-250 mg PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
123
PRENATAL - prenatal vit w/ fe fumarate-fa tab 27-1 mg
4
PRENATAL PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg
3
PRENATAL PLUS IRON prenatal vit w/ iron carbonylfa tab 29-1 mg
4
PRENATAL VITAMINS PLUS LO - prenatal vit w/ fe fumarate-fa tab 27-1 mg
3
PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg
PRENATE ENHANCE - prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg
4
PRENATE ESSENTIAL prenat w/o a w/feaspmethylf-fa-omeg cap 29-0.6-0.4-340 mg
4
PRENATE ESSENTIAL prenat w/o a w/feaspgmethfol-fa-dha cap 18-0.6-0.4-300 mg
4
4
PRENATE MINI - prenat w/o a w/fecbn-methylf-fa-dha cap 29-0.6-0.4-350 mg
4
PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg
4
PRENATE MINI - prenat w/oa w/fecb-feasp-meth-fa-dha cap 18-0.6-0.4-350 mg
4
PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg
4
PRENATE PIXIE - prenat w/o a w/feaspg-methfol-fa-dha cap 10-0.6-0.4-200 mg
4
PRENATE - prenat mv & min w/ l-methylfolate-fa chew tab 0.6-0.4 mg
4
PRENATE RESTORE - prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg
4
PRENATE AM - prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg
4
PRENATE STAR - prenatal vit w/ fe asparto glycinate-fa tab 20-1 mg
4
PRENATE DHA - prenat w/o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg
4
PRENA1 CHEW - prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg
4
PRENATE DHA - prenat w/o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-300 mg
4
PRENA1 PEARL - prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg
4
PRENATE ELITE - prenatal vit w/ fe fum-methylfolate-fa tab 26-0.6-0.4 mg
4
PREPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg
4 4
PRENATE ELITE - prenatal w/ fe asp gly-l methylfol-fa tab 20-0.6-0.4 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 tab 29-1 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
124
PROVIDA DHA - prenat w/o a w/fe fum-fe poly-fa-dha cap 16-16-1.25-110 mg
4
SE-NATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg
4
PROVIDA OB - prenatal w/o a w/fe fum-fe poly-fa cap 20-20-1.25 mg
4
SELECT-OB - prenat w/ fepolycmplx-methylfol-fa chew tab 29-0.6-0.4 mg
4
PUREFE OB PLUS - prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg
4
SELECT-OB - prenatal vit w/ fe polysac cmplx-fa chew tab 29-1 mg
4
QUFLORA FE - multi vit w/ min & fluoride-iron-fa chew tab 0.25 mg
4
SELECT-OB+DHA - prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride chew tab 0.25 mg
4
SUPER NU-THERA - multiple vitamins w/ minerals powder
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride chew tab 0.5 mg
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride chew tab 1 mg
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml
4
R-NATAL OB - prenatal w/ o a w/fe cbn-fa-dha cap 20-1-320 mg
4
RELNATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg
4
RULAVITE DHA - prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg
4
SE-NATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
TARON-BC - prenat w/o a w/ fe 4 cbnyl-fa tab 20-1 mg & vit b6 tab pak TARON-C DHA - prenatal w/fe 4 fum-fe poly -fa-omega 3 cap 53.5-38-1 mg 4 TARON-PREX - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 30-1.2-265 mg 4 TEXAVITE LQ - pediatric multivitamins w/fl-fe-zn drops 0.25-7-3 mg/ml 4 THRIVITE RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg 4 THRIVITE 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 4 TL FOLATE - prenatal vit w/ fe fum-methylfolate-fa tab 27-0.5-0.5 mg 4 TL G-FOL OS - multiple vit w/ min & calcium-folic acid tab 500-1.1 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
125
TL-CARE DHA - prenatal w/fe fumarate-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
4
TRI-TABS DHA - prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack
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
4
4
TRINATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg
4
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.25 mg/ml
4
TRINATAL RX 1 - prenatal vit w/ fe fumarate-fa tab 60-1 mg
4
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.5 mg/ml
4
TRINATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg
4
TRI-VI-FLORO - ped vit acd & l-methylfol w/ fl biphasic susp 0.25 mg/ml
4
TRISTART DHA - prenat w/o a w/fecbn-methylf-fa-dha cap 31-0.6-0.4-200 mg
4
TRI-VI-FLORO - ped vit acd & l-methylfol w/ fl biphasic susp 0.5 mg/ml
4
TRIVEEN-DUO DHA - prenatfe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk
4
TRI-VIT/FLUORIDE/IRON pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml
4
TRIVEEN-PRX RNF - prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg UDAMIN SP - multiple vitamins w/ minerals & fa tab 1 mg
4
4
ULTIMATECARE ONE prenatal vit w/ fe cbn-fe asp glyc-fa-omega 3 cap 27-1mg
4
TRIADVANCE - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg
TRICARE PRENATAL - prenat w/o a w/fepyro-mfol chw 4.5-1 mg & dha cap 150 thpk
4
ULTIMATECARE ONE NF prenatal w/fe cbnyl-fe asp glyc-fa-dss-omega cap 20-7-1 mg
4
TRICARE - prenatal vit w/ fe fumarate-fa tab 27-1 mg
4
TRICARE PRENATAL - prenat w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
VEMAVITE-PRX 2 - prenatal w/ 4 o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 4 VENA-BAL DHA - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
126
VINATE DHA RF - prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg
4
VIRTPREX - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg
4
VINATE II - prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg
4
VITA-PREN - prenatal vit w/ docusate-iron-fa tab 65-1 mg
4
4
4
VINATE M - prenatal vit w/ selfe fumarate-fa tab 27-1 mg
VITAFOL FE+ - prenat-fepolymethol-fa-dha cap 90-1-200 mg & dss 50mg cap
VINATE ONE - prenatal vit w/ fe fumarate-fa tab 60-1 mg
4
4
VIRT NATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg
4
VITAFOL GUMMIES - prenat vit w/ fe phos-fa-omega chew tab 3.33-0.333-34.8 mg
VIRT-ADVANCE - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg
4
VITAFOL ULTRA - prenat w/ fe poly-methylfol-fa-dha cap 29-0.6-0.4-200 mg
4
VIRT-C DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg
4
VITAFOL-NANO - prenatal w/o a w/ fefum-l methylfol-fa tab 18-0.6-0.4 mg
4
VIRT-CARE ONE - prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
4
VIRT-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg
4
VIRT-PN - prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg
4
VIRT-PN DHA - prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg
4
VIRT-PN PLUS - prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap
4
VIRT-SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg
4
VIRT-VITE GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg
4
VITAFOL-OB - prenatal vit w/ fe 4 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 VITAFOL-ONE - prenatal mv w/ 4 fe polysac cmplx-fa-dha cap 29-1-200 mg 4 VITAL-D RX - b-complex w/ cbiotin-d-zinc & folic acid tab 1 mg 4 VITAMEDMD ONE RX/ QUATREFO - prenat w/o a w/fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg 4 VITAMEDMD PLUS RX/ QUATRE - prenat w/o a w/ fe chelate-l methylfol-fa tab & dha cap pk VITAMEDMD REDICHEW RX - 4 prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
127
VITAPEARL - prenat w/oa w/ fefum-na fered-fa-dha cap cr 30-1.4-200 mg
4
ZATEAN-PN DHA - prenat w/ o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg
4
VITATRUE - prenat w/o a w/fe chel-fa tab 30-1.4 mg & dha cap 300mg pk
4
ZATEAN-PN PLUS - prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap
4
VIVA DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg
4
VOL-NATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg
4
VOL-PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg
4
VOL-TAB RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg
4
VP-CH PLUS - prenatal w/o a w/fe cbn-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-GGR-B6 PRENATAL prenatal w/ calcium-vit b6-faginger tab 1.2 mg
4
VP-HEME OB - prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg
4
VP-HEME OB + DHA - prenatfe poly cmplx-fe heme polyfa tab & omega 3 cap pck
4
MINERALS and ELECTROLYTES CALCIFOL - ca carb-folic acid- 4 vit d-b6-b12-boron-mag wafer 1342-1.6 mg 4 CALCIUM-FOLIC ACID PLUS D - ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg 4 EFFER-K - potassium bicarbonate-citric acid effer tab 10 meq 4 EFFER-K - potassium bicarbonate-citric acid effer tab 20 meq FLORICAL - sodium fluoride w/ A calcium carb cap 8.3-364 mg FLORICAL - sodium fluoride w/ A calcium carb tab 8.3-364 mg 4 FLORIVA - sodium fluoridevitamin d liqd drops 0.25 mg/ ml-400 unit/ml 4 FLUOR-A-DAY - sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg 4 FLUOR-A-DAY - sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg FLUORABON - sodium fluoride 4 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)
VP-HEME ONE - prenat-fe poly 4 cmplx-fe heme poly-fa-dha cap 22-6-1-200 mg 4 VP-PNV-DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-215.8 mg 4 ZATEAN-CH - prenatal w/o a w/fe cbn-dss-fa-dha cap 27-1-250 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• • • • • • •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
128
GALZIN - zinc acetate cap 25 mg (elemental zinc)
4
GALZIN - zinc acetate cap 50 mg (elemental zinc)
4
GNP VITAMIN D-400 - calcium carbonate-cholecalciferol tab 90 mg-400 unit
4
IODINE STRONG - iodine solution strong 5% (lugol's)
4
potassium chloride cap cr 8 meq (Micro-k)
K-PHOS - potassium phosphate monobasic tab 500 mg
4
potassium chloride cap cr 10 meq (Micro-k)
1
K-TAB - potassium chloride tab cr 8 meq (600 mg)
4
POTASSIUM CHLORIDE ER potassium chloride tab cr 8 meq (600 mg)
4
K-TAB - potassium chloride tab cr 20 meq (1500 mg)
4
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq (1500 mg)
KLOR-CON M15 - potassium chloride microencapsulated crys cr tab 15 meq
4
potassium chloride microencapsulated crys cr tab 10 meq
1
KLOR-CON/25 - potassium chloride powder packet 25 meq
4
potassium chloride microencapsulated crys cr tab 20 meq
LOZI-FLUR - sodium fluoride lozenge 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 magnesium-calcium-folic acid tab 400-200-1 mg
4
MONOCAL - sodium monofluorophosphatecalcium carb tab 22.75-625 mg
A
pot bicarbonate & chloride effer tab 25 meq
2
• •
pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral)
2
potassium bicarbonate effer tab 25 meq
2
potassium chloride oral soln 10% (20 meq/15ml) potassium chloride oral soln 20% (40 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab cr 8 meq (600 mg)
•
potassium chloride tab cr 10 meq (K-tab)
Limited Distribution
ACA
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Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2
1
2 2 2 1 1
SODIUM FLUORIDE - sodium fluoride tab 0.5 mg f (from 1.1 mg naf)
4
•
SODIUM FLUORIDE - sodium fluoride tab 1 mg f (from 2.2 mg naf)
4
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
129
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride)
1
COMPLEX MSUD AMINO ACID B - amino acids bar
4
DEQUASINE - amino acids tab
4
ESSENTIAL AMINO ACID MIX - amino acids oral powder
4
G-PREPROTEIN - amino acids oral liquid
4
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride)
1
•
sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride)
1
•
sodium fluoride soln 0.125 mg/drop f (0.275 mg/ drop naf)
2
•
GLUTARADE AMINO ACID BLEN - amino acids oral powder
4
sodium fluoride soln 0.5 mg/ ml f (from 1.1 mg/ml naf) (Luride)
1
•
GLUTARADE ESSENTIAL GA-1 - amino acids oral powder
4
SSKI - potassium iodide soln 1 gm/ml
4
GLUTARADE JUNIOR GA-1 amino acids oral powder
4
HEPAMENT - amino acids pack
4
L-CARNITINE - amino acids oral liquid
4
LECITHIN - lecithin granules
4
LIQUACEL - amino acids oral liquid
4 4
NUTRIENTS acetylcysteine cap 600 mg
2
ADD-INS COMPLETE - amino acids pack
4
amino acids cap
2
amino acids tab
2
ARGIMENT - amino acids pack
4
ARGIMENT AT - amino acids pack
4
NUTRASENTIALS - amino acids oral powder
4
CARDIOVID PLUS - dha-epavit b6-b12-folic acid cap 240-360-20-0.5-0.8 mg
4
NUTRESTORE - glutamine powd pack 5 gm PERIFLEX LQ PKU - amino acids oral liquid
4
COMPLETE AMINO ACID MIX - amino acids oral powder
4
PHENYLADE - amino acids oral powder
4
PHENYLADE AMINO ACID amino acids bar
4
COMPLEX ESSENTIAL MSD amino acids oral powder
4 4
4
COMPLEX JUNIOR MSD amino acids oral powder
PHENYLADE AMINO ACID BLEN - amino acids pack
4
PHENYLADE MTE - amino acids oral powder
4
COMPLEX MSUD - amino acids oral powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
130
PHENYLADE MTE AMINO ACID - amino acids pack
4
PHENYLADE PHEBLOC amino acids oral powder
4
PHENYLADE PHEBLOC amino acids tab
4
PHENYLADE40 DRINK MIX amino acids pack
4
PHLEXY-10 - amino acids cap
4
PREPROTEIN - amino acids oral liquid
4
PREPROTEIN 20 - amino acids oral liquid
4
SOLVIL - amino acids pack
4
SUPER-AMINO 1600 - amino acids tab
4
TRIAMINO - amino acids tab
4
XPHE MAXAMUM - amino acids oral powder
4
XPHE MAXAMUM - amino acids pack
4
DIETARY PRODUCTS A-SOY - nutritional supplement liquid
4
ACERFLEX - nutritional supplement powder
4
ADVERA - nutritional supplement liquid
4
ALITRAQ - nutritional supplement pack
4
ARGINAID - nutritional supplement pack
4
ARGINAID EXTRA - nutritional supplement liquid
4
BALANCE TOTAL NUTRITIONAL - nutritional supplement liquid
4
Limited Distribution
ACA
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Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
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Drug Name
Drug Tier
2016
4 BALANCED NUTRITIONAL DRIN - nutritional supplement liquid 4 BALANCED NUTRITIONAL SHAK - nutritional supplement liquid 4 BCAD 1 - nutritional supplement powder 4 BCAD 2 - nutritional supplement powder 4 BENECALORIE - nutritional supplement liquid 4 BOOST - nutritional supplement liquid 4 BOOST BREEZE - nutritional supplement liquid 4 BOOST CALORIE SMART nutritional supplement liquid BOOST COMPACT - nutritional 4 supplement liquid 4 BOOST GLUCOSE CONTROL - nutritional supplement liquid 4 BOOST HIGH PROTEIN nutritional supplement liquid 4 BOOST HIGH PROTEIN nutritional supplement powder 4 BOOST KID ESSENTIALS 1.0 - nutritional supplement liquid 4 BOOST KID ESSENTIALS 1.5 - nutritional supplement liquid 4 BOOST KIDS ESSENTIALS nutritional supplement liquid 4 BOOST PLUS - nutritional supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
131
BOOST PUDDING - nutritional supplement pudding
4
BOOST SMOOTHIE nutritional supplement liquid
4
BOOST VHC - nutritional supplement liquid
CARNATION INSTANT BREAKFA - nutritional supplement liquid
4
4
4
CEREFOLIN - l-methylfolate w/ vit b12-vit b6-vit b2 tab 6-1-50-5 mg
BOOST 100 CALORIE SMART - nutritional supplement liquid
4
CHOICE DM - nutritional supplement liquid
4 4
BOOST/BENEFIBER nutritional supplement liquid
4
CHOICE DM TF - nutritional supplement liquid
4
CALCILO XD - infant foods powder
4
CHOLEXTRA - nutritional supplement powder
4
CAMINO PRO BETTERMILK/ GLY - nutritional supplement pack
4
CLICK ESPRESSO PROTEIN DR - nutritional supplement powder
4
CAMINO PRO COMPLETE/ GLYTA - nutritional supplement bar
4
COMPLEAT - nutritional supplement liquid COMPLEAT CLOSED SYSTEM - nutritional supplement liquid
4
COMPLEAT PEDIATRIC nutritional supplement liquid
4
COMPLEAT PEDIATRIC REDUCE - nutritional supplement liquid
4
COMPLETE NUTRITION nutritional supplement liquid
4
COMPLETE NUTRITION PLUS - nutritional supplement liquid
4
COMPLETE PROTEIN & VITAMI - nutritional supplement powder
4
CRITICARE HN - nutritional supplement liquid
4
CRUCIAL - nutritional supplement liquid
4
CVS NUTRITION LIQUID nutritional supplement liquid
4
CAMINO PRO PKU - nutritional 4 supplement liquid 4 CAMINO PRO RESTORE/ GLYTAC - nutritional supplement liquid 4 CAMINO PRO SWIRL nutritional supplement pack 4 CAMINO PRO 15PE nutritional supplement liquid 4 CARDIOTEK-RX - folic acidb12-b6-arginine-black pepper tab 4 CARNATION BREAKFAST ESSEN - nutritional supplement liquid 4 CARNATION BREAKFAST ESSEN - nutritional supplement pack
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
132
CVS NUTRITION PLUS nutritional supplement liquid
4
ENSURE ACTIVE - nutritional supplement liquid
4
CVS NUTRITIONAL SHAKE nutritional supplement liquid
4
4
CYCLINEX-1 - nutritional supplement powder
4
ENSURE ACTIVE HEART HEALT - nutritional supplement liquid
4
CYCLINEX-2 - nutritional supplement powder
4
ENSURE ACTIVE HIGH PROTEI - nutritional supplement liquid
DIABETIC TF - nutritional supplement liquid
4
ENSURE ACTIVE LIGHT nutritional supplement liquid
4
DIABETISHIELD - nutritional supplement liquid
4
4
DIABETISOURCE - nutritional supplement liquid
4
ENSURE BONE HEALTH REVIGO - nutritional supplement liquid
4
DIABETISOURCE AC nutritional supplement liquid
4
ENSURE CLEAR - nutritional supplement liquid
4
DUOCAL - nutritional supplement powder
4
ENSURE CLINICAL STRENGTH - nutritional supplement liquid
EAA SUPPLEMENT nutritional supplement pack
4
ENSURE COMPACT nutritional supplement liquid
4
EGG/PRO - nutritional supplement powder
4
ENSURE COMPLETE nutritional supplement liquid
4
ELECARE - nutritional supplement powder
4
4
ELECARE JR - nutritional supplement powder
4
ENSURE COMPLETE NUTRITION - nutritional supplement liquid
4
ELECARE/DHA/ARA nutritional supplement powder
4
ENSURE ENLIVE - nutritional supplement liquid ENSURE HEALTHY MOM nutritional supplement bar
4
ENLIVE - nutritional supplement liquid
4
ENSURE HEALTHY MOM nutritional supplement liquid
4
ENSURE - nutritional supplement bar
4
ENSURE HIGH CALCIUM nutritional supplement liquid
4
ENSURE - nutritional supplement liquid
4
ENSURE HIGH PROTEIN nutritional supplement liquid
4
ENSURE - nutritional supplement powder
4
ENSURE HIGH PROTEIN nutritional supplement powder
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
133
ENSURE IMMUNE HEALTH nutritional supplement liquid
4
ENSURE MUSCLE HEALTH REVI - nutritional supplement liquid
4
ENSURE NUTRA SHAKE HICAL - nutritional supplement liquid
FALESSA - levomefolate glucosamine tab 1 mg (folate equivalent)
4
FIBER-STAT - nutritional supplement liquid
4
4
FIBERSOURCE CLOSED SYSTEM - nutritional supplement liquid
4
ENSURE NUTRITION SHAKE - nutritional supplement liquid
4
FIBERSOURCE HN nutritional supplement liquid
4
FIBERSOURCE HN CLOSED SYS - nutritional supplement liquid
4
ENSURE PLUS - nutritional supplement liquid
4
ENSURE PLUS HN - nutritional 4 supplement liquid 4 ENSURE PUDDING nutritional supplement pudding 4 ENSURE/FIBER - nutritional supplement liquid 4 ENU NUTRITIONAL SHAKE nutritional supplement liquid 4 EO28 SPLASH - nutritional supplement liquid 4 EQ NUTRITIONAL SHAKE nutritional supplement liquid 4 EQ NUTRITIONAL SHAKE PLUS - nutritional supplement liquid 4 EQ WEIGHT LOSS SHAKE ULTR - nutritional supplement liquid 4 EQUATE - nutritional supplement liquid 4 EQUATE PLUS - nutritional supplement liquid 4 F.A.A. - nutritional supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
FLAVOR PACKETS - nutritional 4 supplement flavor pack 4 FLAVOUR PAC - nutritional supplement flavor pack 2 folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg 4 FORTA DRINK - nutritional supplement powder 4 FORTA SHAKE - nutritional supplement powder 4 FRUITIVITS - nutritional supplement pack 4 GA - nutritional supplement powder 4 GA EXPRESS15 - nutritional supplement pack 4 GA GEL - nutritional supplement pack 4 GA-1 ANAMIX EARLY YEARS - nutritional supplement powder 4 GLUCERNA - nutritional supplement bar
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
134
GLUCERNA - nutritional supplement liquid
4
GLUCERNA 1.0 CAL/FIBER nutritional supplement liquid
4
GLUCERNA ADVANCE SHAKE - nutritional supplement liquid
4
GLUCERNA 1.2 CAL nutritional supplement liquid
4
GLUCERNA 1.5 CAL nutritional supplement liquid
4
GLUCERNA CEREAL CRUNCHY F - nutritional supplement misc
4
4
GLUCERNA CRISPY DELIGHTS - nutritional supplement bar
4
GLUCO BURST - nutritional supplement liquid GLUTAREX-1 - nutritional supplement powder
4
GLUCERNA HUNGER SMART SHA - nutritional supplement liquid
4
GLUTAREX-2 - nutritional supplement powder
4 4
GLUCERNA MEAL - nutritional supplement bar
4
GLYCOSADE - nutritional supplement pack
4
GLUCERNA MEAL REPLACEMENT - nutritional supplement bar
4
GLYTACTIN BETTERMILK DE-L - nutritional supplement pack
GLUCERNA MINI SNACK nutritional supplement bar
4
GLUCERNA MINI SNACKS nutritional supplement bar
4
GLUCERNA OS - nutritional supplement liquid
4
GLUCERNA SELECT nutritional supplement liquid
4
GLUCERNA SHAKE nutritional supplement liquid
4
GLUCERNA SNACK nutritional supplement bar
4
GLUCERNA SNACK SHAKE nutritional supplement liquid
4
GLUCERNA WEIGHT LOSS SHAK - nutritional supplement liquid
4
GLUCERNA 1.0 CAL nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
GLYTACTIN BETTERMILK 15 - 4 nutritional supplement pack 4 GLYTACTIN BUILD 10PE nutritional supplement pack 4 GLYTACTIN COMPLETE 10PE - nutritional supplement bar 4 GLYTACTIN RESTORE LITE 10 - nutritional supplement liquid 4 GLYTACTIN RESTORE LITE 10 - nutritional supplement pack 4 GLYTACTIN RESTORE 10 nutritional supplement liquid 4 GLYTACTIN RESTORE 5 nutritional supplement pack 4 GLYTACTIN RTD 10 nutritional supplement liquid 4 GLYTACTIN RTD 15 nutritional supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
135
GLYTROL - nutritional supplement liquid
4
GLYTROL PREBIO1 nutritional supplement liquid
4
GNP NUTRITIONAL DRINK nutritional supplement liquid
HEALTH SOURCE SOY PROTEIN - nutritional supplement powder
4
4
4
HEALTHY ACCENTS NUTRA FIT - nutritional supplement liquid
GNP NUTRITIONAL DRINK PLU - nutritional supplement liquid
4
HEARTBAR - nutritional supplement bar
4
GOAT MILK - nutritional supplement powder
4
HAELAN HTPI FERMENTED ORG - nutritional supplement liquid
4
HAELAN 951 FERMENTED ORGA - nutritional supplement liquid
4
HCU ANAMIX EARLY YEARS - 4 nutritional supplement powder 4 HCU ANAMIX NEXT nutritional supplement powder 4 HCU COOLER - nutritional supplement liquid 4 HCU EXPRESS - nutritional supplement pack HCU EXPRESS20 - nutritional 4 supplement pack 4 HCU GEL - nutritional supplement pack HCU LOPHLEX LQ - nutritional 4 supplement liquid HCY 1 - nutritional supplement 4 powder HCY 2 - nutritional supplement 4 powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
HI-CAL - nutritional supplement 4 liquid 4 HIGH-PROTEIN NUTRITIONAL - nutritional supplement liquid 4 HM NUTRISURE - nutritional supplement liquid 4 HM NUTRISURE PLUS nutritional supplement liquid HOM 2 - nutritional supplement 4 powder 4 HOMACTIN AA PLUS nutritional supplement liquid 4 HOMINEX-1 - nutritional supplement powder 4 HOMINEX-2 - nutritional supplement powder 4 I-VALEX-1 - nutritional supplement powder 4 I-VALEX-2 - nutritional supplement powder 4 IMMULIFE - nutritional supplement powder 4 IMMUNOPRO RX - nutritional supplement powder 4 IMPACT - nutritional supplement liquid 4 IMPACT ADVANCED RECOVERY - nutritional supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
136
IMPACT GLUTAMINE nutritional supplement liquid
4
JEVITY 1 CAL - nutritional supplement liquid
4
IMPACT PEPTIDE 1.5 nutritional supplement liquid
4
JEVITY 1 CAL/FIBER nutritional supplement liquid
4
IMPACT 1.5 - nutritional supplement liquid
4
JEVITY 1.2 CAL - nutritional supplement liquid
4
IMPACT/FIBER - nutritional supplement liquid
4
JEVITY 1.2 CAL/FIBER nutritional supplement liquid
4
IMUPLUS - nutritional supplement pack
4
JEVITY 1.5 CAL - nutritional supplement liquid
4
INNOVACIN - nutritional supplement liquid
4
JEVITY 1.5 CAL/FIBER nutritional supplement liquid
4
INTROLITE - nutritional supplement liquid
4
JUICE PLUS FIBRE nutritional supplement liquid
4
ISOCAL - nutritional supplement liquid
4
ISOCAL HN - nutritional supplement liquid
4
ISOCAL HN PLUS - nutritional supplement liquid
4
ISOSOURCE - nutritional supplement liquid
4
ISOSOURCE CLOSED SYSTEM - nutritional supplement liquid
4
ISOSOURCE HN - nutritional supplement liquid
4
ISOSOURCE VHN - nutritional supplement liquid
4
ISOSOURCE 1.5 CAL nutritional supplement liquid
4
ISOVACTIN AA PLUS nutritional supplement liquid
4
IVA ANAMIX EARLY YEARS nutritional supplement powder
4
IVA ANAMIX NEXT - nutritional supplement powder
4
JUVEN - nutritional supplement 4 pack JUVEN - nutritional supplement 4 powder 4 JUVEN NUTRIVIGOR nutritional supplement pack 4 JUVEN REVIGOR - nutritional supplement pack 4 K-PAX IMMUNE BOOSTER PROT - nutritional supplement powder 4 KETOCAL 3:1 - nutritional supplement powder 4 KETOCAL 4:1 - nutritional supplement liquid 4 KETOCAL 4:1 - nutritional supplement powder 4 KETOCAL 4:1 LQ MULTI FIBE - nutritional supplement liquid 4 KETOGEN - nutritional supplement powder 4 KETONEX-1 - nutritional supplement powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
137
KETONEX-2 - nutritional supplement powder
4
KETOVIE - nutritional supplement liquid
4
4
META HEALTH BAR/ CRANBERRY - nutritional supplement bar
4
KETOVIE PEPTIDE nutritional supplement liquid
4
METAFORM - nutritional supplement pack
4
KETOVOLVE 4:1 - nutritional supplement powder
4
METHIONAID - nutritional supplement powder
4
KINRAY PREFERRED PLUS nutritional supplement liquid
4
MMA/PA ANAMIX EARLY YEARS - nutritional supplement powder
L-METHYL-MC NAC l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg
4
MMA/PA ANAMIX NEXT nutritional supplement powder
4
4
LANAFLEX - nutritional supplement pack
4
MMA/PA COOLER - nutritional supplement liquid
4
LEU-FREE COOLER nutritional supplement liquid
4
MMA/PA COOLER15 nutritional supplement liquid
4
LIPISTART - nutritional supplement powder
4
MMA/PA GEL - nutritional supplement pack
4
LIQUID HOPE - nutritional supplement liquid
4
MODULEN IBD - nutritional supplement powder
4
LMD - nutritional supplement powder
4
MONOGEN - nutritional supplement powder
4
LOPHLEX - nutritional supplement pack
4
MSUD AID - nutritional supplement powder
4
LOPHLEX LQ 20 - nutritional supplement liquid
4
MSUD ANAMIX EARLY YEARS - nutritional supplement powder
MCT PRO-CAL - nutritional supplement pack
4
MSUD COOLER - nutritional supplement liquid
4
MCT PROCAL - nutritional supplement powder
4
MSUD EXPRESS - nutritional supplement pack
4
MERITENE - nutritional supplement powder
4
MSUD EXPRESS20 nutritional supplement pack
4
META HEALTH BAR/ CINNAMON - nutritional supplement bar
4
MSUD GEL - nutritional supplement pack
4
MSUD LOPHLEX LQ nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
138
MSUD MAXAMAID - nutritional supplement powder
4
MSUD MAXAMUM - nutritional supplement powder
4
MSUD 2 - nutritional supplement powder
4
NEOCATE INFANT DHA/ ARA - nutritional supplement powder
4
NEOCATE JUNIOR - nutritional 4 supplement powder 4 NEOCATE JUNIOR/ PREBIOTICS - nutritional supplement powder NEOCATE NUTRA - nutritional 4 supplement powder 4 NEOCATE SPLASH nutritional supplement liquid 4 NEPRO - nutritional supplement liquid 4 NEPRO WITH CARB STEADY - nutritional supplement liquid 4 NESTLE FLAVOR - nutritional supplement flavor pack 4 NESTLE FLAVOR EXTRA STREN - nutritional supplement flavor pack NESTLE FLAVOR FOR KIDS - 4 nutritional supplement flavor pack 4 NOURISH - nutritional supplement liquid 4 NOVASOURCE PULMONARY - nutritional supplement liquid 4 NOVASOURCE RENAL nutritional supplement liquid
NUTRA BALANCE DIABETIC NU - nutritional supplement bar
4
NUTRA BALANCE FIBER COOKI - nutritional supplement misc
4
NUTRA BALANCE PROTEIN FOR - nutritional supplement misc
4
NUTRA SHAKE - nutritional supplement liquid (frozen)
4
NUTRA SHAKE/SUPREME nutritional supplement liquid (frozen)
4
NUTRA/BALANCE RE/GEN nutritional supplement liquid (frozen)
4
NUTRA/BALANCE RE/ GEN FREE - nutritional supplement liquid (frozen)
4
NUTRA/SHAKE - nutritional supplement liquid (frozen)
4
NUTRA/SHAKE FRUIT PLUS nutritional supplement liquid (frozen)
4
NUTRA/SHAKE SUPREME nutritional supplement liquid (frozen)
4
NUTRA/SHAKE SUPREME nutritional supplement liquid
4
NUTRAMENT - nutritional supplement liquid
4
NUTRAMINE - nutritional supplement pack
4
NUTRAMINE APPLE AMINO BIT - nutritional supplement pack
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
139
NUTRAMINE BANANA AMINO B - nutritional supplement pack
4
NUTREN 1.0/FIBER/ ULTRAPAK - nutritional supplement liquid
4
NUTRAMINE CHOCOLATE AMINO - nutritional supplement pack
4
NUTREN 1.5 - nutritional supplement liquid
4
4
4
NUTRAMINE MANGO AMINO BI - nutritional supplement pack
NUTREN 1.5 CAL - nutritional supplement liquid
4
NUTRAMINE MIXED FLAVORS A - nutritional supplement pack
4
NUTREN 1.5 FIBER nutritional supplement liquid NUTREN 2.0 - nutritional supplement liquid
4
NUTRAMINE PEACHES & CREAM - nutritional supplement pack
4
NUTREN 2.0 CAL - nutritional supplement liquid
4 4
NUTRAMINE PINEAPPLE AMINO - nutritional supplement pack
4
NUTRIFOCUS - nutritional supplement liquid NUTRIHEAL - nutritional supplement liquid
4
NUTREN JR - nutritional supplement liquid
4
NUTRIHEP 1.5 CAL nutritional supplement liquid
4
NUTREN JR FIBER nutritional supplement liquid
4
NUTRIRENAL - nutritional supplement liquid
4
NUTREN JUNIOR - nutritional supplement liquid
4
NUTRITIONAL DRINK nutritional supplement liquid
4
NUTREN JUNIOR 1.0 nutritional supplement liquid
4
4
NUTREN JUNIOR/FIBER nutritional supplement liquid
4
NUTRITIONAL DRINK MIX nutritional supplement powder
4
NUTREN PULMONARY nutritional supplement liquid
4
NUTRITIONAL DRINK PLUS nutritional supplement liquid
4
NUTREN RENAL - nutritional supplement liquid
4
NUTRITIONAL DRINK SHAKE M - nutritional supplement powder
NUTREN 1.0 - nutritional supplement liquid
4
NUTRITIONAL SHAKE nutritional supplement liquid
4
NUTREN 1.0 CAL - nutritional supplement liquid
4
4
NUTREN 1.0/FIBER nutritional supplement liquid
4
NUTRITIONAL SHAKE COMPLET - nutritional supplement liquid NUTRITIONAL SHAKE PLUS nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
140
NUTRITIONAL SHAKE PLUS PR - nutritional supplement liquid
4
NUTRITIONAL SUPPLEMENT - nutritional supplement liquid
4
nutritional supplement liquid
2
OSMOLITE HN - nutritional supplement liquid
4
OSMOLITE 1 CAL - nutritional supplement liquid
4
OSMOLITE 1.2 CAL nutritional supplement liquid
4
OSMOLITE 1.5 CAL nutritional supplement liquid
4
OXEPA - nutritional supplement liquid
4
PEDIASURE - nutritional supplement liquid
4 4
NUTRITIONAL SUPPLEMENT PL - nutritional supplement liquid
4
NUTRIVENT - nutritional supplement liquid
4
NUTRIVENT 1.5 - nutritional supplement liquid
4
NUTRIVIR - nutritional supplement powder
4
PEDIASURE ENTERAL FORMULA - nutritional supplement liquid
4
PEDIASURE GROW & GAIN nutritional supplement liquid
4
NUTRIVIR NSA - nutritional supplement powder
4
PEDIASURE NUTRIPALS nutritional supplement bar
4
OA 1 - nutritional supplement powder
PEDIASURE NUTRIPALS nutritional supplement liquid
4
OA 2 - nutritional supplement powder
4
PEDIASURE PEDIATRIC nutritional supplement liquid
4
OPTIMENTAL - nutritional supplement liquid
4
PEDIASURE PEPTIDE 1.0 CAL - nutritional supplement liquid
4
OPTISOURCE VERY HIGH PROT - nutritional supplement liquid
4
4
PEDIASURE PEPTIDE 1.5 CAL - nutritional supplement liquid
4
ORANGE CHICKEN/ CARROTS/BR - nutritional supplement liquid
PEDIASURE SHAKE MIX nutritional supplement powder
4
ORGANIC PEDIA SMART nutritional supplement powder
4
PEDIASURE SHAKE WITH FIBE - nutritional supplement liquid
4
OS 2 - nutritional supplement powder
4
OSMOLITE - nutritional supplement liquid
4
PEDIASURE SIDEKICKS nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
141
PEDIASURE SIDEKICKS nutritional supplement powder
4
PEPTAMEN JUNIOR nutritional supplement liquid
4
PEPTAMEN JUNIOR nutritional supplement powder
4
PEDIASURE SIDEKICKS CLEAR - nutritional supplement liquid
4
4
4
PEDIASURE SIDEKICKS SHAKE - nutritional supplement liquid
PEPTAMEN JUNIOR FIBER nutritional supplement liquid
4
PEDIASURE WITH FIBER nutritional supplement liquid
4
PEPTAMEN JUNIOR HP nutritional supplement liquid
4
PEDIASURE 1.0 CAL/FIBER nutritional supplement liquid
4
PEPTAMEN JUNIOR 1 CAL nutritional supplement liquid
4
PEDIASURE 1.5 CAL nutritional supplement liquid
4
PEPTAMEN JUNIOR 1 CAL/ PRE - nutritional supplement liquid
PEDIASURE 1.5 CAL WITH FI - nutritional supplement liquid
4
PEDIASURE 1.5 CAL/FIBER nutritional supplement liquid
4
PEDIATRIC DRINK - nutritional supplement liquid
4
PEDIATRIC PEPTINEX DT nutritional supplement liquid
4
PEDIATRIC PEPTINEX DT/ FIB - nutritional supplement liquid
4
PEPDITE JUNIOR - nutritional supplement pack
4
PEPTAMEN - nutritional supplement liquid
4
PEPTAMEN AF - nutritional supplement liquid
4
PEPTAMEN BARIATRIC nutritional supplement liquid
4
PEPTAMEN INTENSE VHP nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PEPTAMEN JUNIOR 1.5 CAL - 4 nutritional supplement liquid 4 PEPTAMEN JUNIOR/ PREBIO1 - nutritional supplement liquid 4 PEPTAMEN OS - nutritional supplement liquid PEPTAMEN OS 1.5 - nutritional 4 supplement liquid 4 PEPTAMEN VHP - nutritional supplement liquid PEPTAMEN 1 CAL - nutritional 4 supplement liquid PEPTAMEN 1 CAL/PREBIO1 - 4 nutritional supplement liquid 4 PEPTAMEN 1.5 - nutritional supplement liquid 4 PEPTAMEN 1.5 CAL nutritional supplement liquid 4 PEPTAMEN 1.5 CAL/ PREBIO1 - nutritional supplement liquid 4 PEPTAMEN/PREBIO1 nutritional supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
142
PEPTINEX DT - nutritional supplement liquid
4
PEPTINEX DT WITH PREBIOTI - nutritional supplement liquid
4
PEPTINEX 1.0 - nutritional supplement liquid
PHENYLADE ESSENTIAL DRINK - nutritional supplement powder
4
PHENYLADE GMP - nutritional supplement pack
4
4
PHENYLADE GMP - nutritional supplement powder
4
PEPTINEX 1.5 - nutritional supplement liquid
4
PHENYLADE RTD PKU 10 nutritional supplement liquid
4
PERATIVE - nutritional supplement liquid
4
PHENYLADE60 DRINK MIX nutritional supplement pack
4
PERIFLEX ADVANCE nutritional supplement powder
4
PHENYLADE60 DRINK MIX nutritional supplement powder
4
PERIFLEX JUNIOR nutritional supplement powder
4
PHLEXY-10 - nutritional supplement pack
4
4
PHYTOFUSION - nutritional supplement pack
4
PFD 1 - nutritional supplement powder
PIVOT 1.5 CAL - nutritional supplement liquid
4
PFD 2 - nutritional supplement powder
4
PKU COOLER 10 - nutritional supplement liquid
4
PHENACTIN AA PLUS nutritional supplement liquid
4
PKU COOLER 15 - nutritional supplement liquid
4
PHENEX-1 - nutritional supplement powder
4 4
4
PHENEX-2 - nutritional supplement powder
PKU COOLER 20 - nutritional supplement liquid
4
PKU EASY MICROTABS nutritional supplement tabs delayed release
4
PHENYL-FREE 2 - nutritional supplement powder PHENYL-FREE 2HP nutritional supplement powder
4
PKU EXPRESS - nutritional supplement pack
4
PKU EXPRESS20 - nutritional supplement pack
4
PHENYLADE DRINK MIX nutritional supplement powder
4
4
PHENYLADE ESSENTIAL DRINK - nutritional supplement pack
4
PKU GEL - nutritional supplement pack PKU LOPHLEX LQ 20 nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
143
PKU PERIFLEX EARLY YEARS - nutritional supplement powder
4
PKU PERIFLEX JUNIOR PLUS - nutritional supplement powder
4
PKU TRIO - nutritional supplement powder
4
PKU 2 - nutritional supplement powder
4
PKU 3 - nutritional supplement powder
4
POLYCAL - nutritional supplement powder
4
PORTAGEN - nutritional supplement powder
4
PPA/MMA EXPRESS nutritional supplement pack
4
PRO-CAL - nutritional supplement pack
4
PRO-CAL - nutritional supplement powder
4
PRO-PHREE - nutritional supplement powder
4
PROBALANCE - nutritional supplement liquid
4
PROMOD - nutritional supplement liquid
4
PROMOD - nutritional supplement powder
4
PROMOTE - nutritional supplement liquid
4
PROMOTE WITH FIBER nutritional supplement liquid
4
PROMOTE/FIBER - nutritional supplement liquid
4
PROPIMEX-1 - nutritional supplement powder
4
PROPIMEX-2 - nutritional supplement powder
4
PROSOURCE - nutritional supplement liquid
4
PROSOURCE - nutritional supplement powder
4
PROSOURCE NO CARB nutritional supplement liquid
4
PROSOURCE PLUS nutritional supplement liquid
4
PROSOURCE TF - nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PROSOURCE ZAC - nutritional 4 supplement liquid 4 PROSURE - nutritional supplement liquid 4 PROTAIN XL - nutritional supplement liquid 4 PROTEIN FORTIFIED COOKIE - nutritional supplement misc 4 PROVIMIN - nutritional supplement powder 4 PULMOCARE - nutritional supplement liquid PX VANILLA PLUS - nutritional 4 supplement liquid 4 QUINOA KALE & HEMP nutritional supplement liquid 4 RA BALANCED NUTRITIONAL - nutritional supplement liquid 4 RA BALANCED NUTRITIONAL P - nutritional supplement liquid 4 RA NUTRITIONAL SUPPLEMENT - nutritional supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
144
RA NUTRITIONAL SUPPORT - 4 nutritional supplement powder 4 RA PEDIATRIC NUTRITIONAL - nutritional supplement liquid 4 RE/GEN PROTEIN FORTIFIED - nutritional supplement misc 4 RE/NEPH - nutritional supplement liquid 4 RE/NEPH HP/HC - nutritional supplement liquid (frozen) 4 RE/NEPH LP/HC - nutritional supplement liquid 4 RE/NEPH REDUCED SUGAR - nutritional supplement liquid 4 RENALCAL - nutritional supplement liquid 4 RENASTART - nutritional supplement powder 4 REPLETE - nutritional supplement liquid 4 REPLETE FIBER - nutritional supplement liquid 4 REPLETE FIBER 1 CAL nutritional supplement liquid REPLETE/FIBER/ULTRAPAK - 4 nutritional supplement liquid 4 RESOURCE ARGINAID nutritional supplement pack 4 RESOURCE DAIRY THICK HONE - nutritional supplement liquid 4 RESOURCE DIABETIC TF nutritional supplement liquid
RESOURCE JUICE DRINK nutritional supplement liquid (frozen)
4
RESOURCE JUST FOR KIDS - nutritional supplement liquid
4
RESOURCE JUST FOR KIDS WI - nutritional supplement liquid
4
RESOURCE JUST FOR KIDS 1. - nutritional supplement liquid
4
RESOURCE SUPPORT nutritional supplement liquid
4
RESOURCE THICKENUP THICKE - nutritional supplement liquid
4
RESOURCE 2.0 - nutritional supplement liquid
4
RESPALOR - nutritional supplement liquid
4
RESURGEX - nutritional supplement pack
4
RESURGEX PLUS - nutritional supplement pack
4
RESURGEX SELECT nutritional supplement pack
4
S.O.S. 15 - nutritional supplement pack
4
S.O.S. 20 - nutritional supplement pack
4
S.O.S. 25 - nutritional supplement pack
4
SALMON/OATS/SQUASH nutritional supplement liquid
4
SB COMPLETE NUTRITION nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
145
SB COMPLETE NUTRITION PLU - nutritional supplement liquid
4
SCANDICAL - nutritional supplement powder
4
SCANDISHAKE - nutritional supplement misc
4
SCANDISHAKE - nutritional supplement pack
4
SCANDISHAKE - nutritional supplement powder
4
SM NUTRI-DRINK - nutritional supplement liquid
4
SM NUTRI-DRINK + nutritional supplement liquid
4
SOL CARB - nutritional supplement powder
4
SOURCE COOKIE BAR nutritional supplement bar
4
SOY PROTEIN SHAKE nutritional supplement powder
4
SOYPRO - nutritional supplement powder
4
SUBDUE - nutritional supplement liquid
4
SUBDUE PLUS - nutritional supplement liquid
4
SUPLENA - nutritional supplement liquid
4
SUPLENA RTU - nutritional supplement liquid
4
SUPLENA WITH CARB STEADY - nutritional supplement liquid
4
THICK-IT BEEF LASAGNA PUR - nutritional supplement misc
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
THICK-IT CHICKEN A LA KIN - 4 nutritional supplement misc THICK-IT MAPLE CINNAMON 4 F - nutritional supplement misc THICK-IT MIXED FRUIT AND - 4 nutritional supplement misc 4 THICK-IT SEASONED CHICKEN - nutritional supplement misc 4 THICK-IT SWEET CORN PUREE - nutritional supplement misc 4 THRIVACIN DETOX nutritional supplement liquid 4 THRIVACIN 30 - nutritional supplement liquid 4 TOLEREX - nutritional supplement pack 4 TWOCAL HN - nutritional supplement liquid 4 TYLACTIN RESTORE 10 nutritional supplement liquid 4 TYLACTIN RESTORE 5PE nutritional supplement pack TYLACTIN RTD 15 - nutritional 4 supplement liquid TYR ANAMIX EARLY YEARS - 4 nutritional supplement powder 4 TYR ANAMIX NEXT nutritional supplement powder 4 TYR COOLER - nutritional supplement liquid 4 TYR COOLER20 - nutritional supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
146
TYR EXPRESS - nutritional supplement pack
4
VITAL AF 1.2 CAL - nutritional supplement liquid
4
TYR EXPRESS20 - nutritional supplement pack
4
VITAL HIGH PROTEIN nutritional supplement liquid
4
TYR GEL - nutritional supplement pack
4
VITAL HN - nutritional supplement pack
4
TYR LOPHLEX LQ - nutritional supplement liquid
4
VITAL JR - nutritional supplement liquid
4
TYREX-1 - nutritional supplement powder
4
VITAL 1.0 CAL - nutritional supplement liquid
4
TYREX-2 - nutritional supplement powder
4
VITAL 1.5 CAL - nutritional supplement liquid
4
TYROS 1 - nutritional supplement powder
4
VITAPRO - nutritional supplement powder
4
TYROS 2 - nutritional supplement powder
4
VITAQUICK - nutritional supplement powder
4
UCD ANAMIX JUNIOR nutritional supplement powder
4
VIVONEX PEDIATRIC nutritional supplement pack
4
VIVONEX PLUS - nutritional supplement powder
4
UCD TRIO - nutritional supplement powder
4
VIVONEX RTF - nutritional supplement liquid
4
UCD 2 - nutritional supplement powder
4
VIVONEX T.E.N. - nutritional supplement pack
4
ULTRACAL - nutritional supplement liquid
4 4
WELLNESS ESSENTIALS nutritional supplement kit
4
ULTRACAL HN PLUS nutritional supplement liquid
4
WELLNESS ESSENTIALS AI nutritional supplement kit
4
ULTRAMINO SOY PROTEIN nutritional supplement powder
4
UTYMAX - nutritional supplement pack
4
WELLNESS ESSENTIALS BLOOD - nutritional supplement kit WELLNESS ESSENTIALS FOR J - nutritional supplement kit
4
VHC 2.25 - nutritional supplement liquid
4
VILACTIN AA PLUS nutritional supplement liquid
4
4
VITAJOULE - nutritional supplement powder
4
WELLNESS ESSENTIALS FOR M - nutritional supplement kit
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
147
WELLNESS ESSENTIALS FOR P - nutritional supplement kit
4
WELLNESS ESSENTIALS FOR W - nutritional supplement kit
4
WND 1 - nutritional supplement powder
4
WND 2 - nutritional supplement powder
4
XAQUIL XR - levomefolate glucosamine tab cr 30 mg
4
XLEU MAXAMAID - nutritional supplement powder
4
XLEU MAXAMUM - nutritional supplement powder
4
XLYS-XTRP MAXAMAID nutritional supplement powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
XYZBAC - dietary management 2 product - tabs 4 ZYTAZE - zinc citrate-phytase cap 25-500 mg HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS ABANEU-SL cyanocobalaminmethylcobalamin tab sl 600-600 mcg
4
ACTIVE FE - fe carbonyl-fab complex-a-c-d-e-min tab 75-1.25 mg
4
ANIMI-3 - folic acid-b6-b12-domega 3-phytosterols cap 1 mg
4
4
ANIMI-3/VITAMIN D - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg
4
XLYS-XTRP MAXAMUM nutritional supplement powder
4
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25 mcg/ml
5
•
•
XMET MAXAMAID - nutritional supplement powder
4
5
•
•
XMET MAXAMUM - nutritional supplement powder
4
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 40 mcg/ml
5
•
•
XMTVI MAXAMAID - nutritional supplement powder
4
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 60 mcg/ml
XMTVI MAXAMUM - nutritional supplement powder
4
5
•
•
XPHE MAXAMAID - nutritional supplement powder
4
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100 mcg/ml
5
•
•
XPHE-XTYR MAXAMAID nutritional supplement powder
4
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200 mcg/ml
5
•
•
XTRACAL PLUS - nutritional supplement liquid
4
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 300 mcg/ml
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
148
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml
5
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml
5
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml
5
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml
5
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml
5
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml
5
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml
• • • •
• • • •
•
•
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 500 mcg/ml
5
B-6 FOLIC ACID - cobalamine combination cap
4
BIFERARX - polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg
4
•
•
BP VIT 3 - folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg
4
carbonyl iron susp 15 mg/1.25ml (elemental iron)
A
CENTRATEX - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
4
CERDELGA - eliglustat tartrate cap 84 mg (base equivalent)
5
CIFEREX - folic acidcholecalciferol cap 1 mg-3775 unit
4
CORVITE FE - iron combination tab
4
CORVITE 150 - iron combination tab
4
cyanocobalamin inj 1000 mcg/ml
1
DERMACINRX PUREFOLIX folic acid-cholecalciferol tab 1 mg-5000 unit
4
DIVISTA - folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1 mg
4
DROXIA - hydroxyurea cap 200 mg
4
DROXIA - hydroxyurea cap 300 mg
4
DROXIA - hydroxyurea cap 400 mg
4
DURACHOL - folic acidcholecalciferol cap 1 mg-3775 unit
4
ED CYTE F - ferrous fumaratefolic acid-docusate sodium tab 324-1-50 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
149
•
•
EPOGEN - epoetin alfa inj 4000 unit/ml
5
•
•
EPOGEN - epoetin alfa inj 10000 unit/ml
5
•
•
EPOGEN - epoetin alfa inj 20000 unit/ml
5
•
•
fe fum-iron polysacch complex-fa-b cmplx-c-znmn-cu cap (Tandem plus)
1
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg
A
FERRO-PLEX HEMATINIC - fe fum-dss-vit c-vit e-vit b12-iffa tab 115-1 mg
4
FERROTRIN - iron w/ b12-vit c-fa-ifc cap 36-0.015-75-0.5-240 mg
4
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg
1
ferrous fumarate-folic acid tab 324-1 mg
1
2
•
•
1
FERROUS SULFATE - ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe)
A
•
FERROUS SULFATE - ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe)
A
•
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
A
•
A
•
FER-IN-SOL - ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)
A
FERIVA - fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap 75-1 mg
4
FERIVA 21/7 - fe asparto glyb12-fa-c-dss-succinic acidzn tab 75-1 mg
4
FOCALGIN DSS - fe carbonylfe gluconate-fa-vit b12-vit cdss tab 90-1 mg
4
FERIVAFA - iron-c-fa-b12biotin-copper-docusate cap 110-1 mg
4
folic acid cap 0.8 mg
A
FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg
4
FERRAPLUS 90 - iron-folic acid-vit b12-vit c-docusate sod tab 90-1 mg
4
ferrous sulfate soln 75 mg/ ml (15 mg/ml elemental fe)
folic acid tab 400 mcg folic acid tab 800 mcg folic acid tab 1 mg folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx)
Limited Distribution
5
FERRETTS CHEWABLE IRON - carbonyl iron chew tab 18 mg (elemental iron)
ACA
EPOGEN - epoetin alfa inj 3000 unit/ml
fe fumarate w/ b12vit c-fa-ifc cap 110-0.015-75-0.5-240 mg
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
EPOGEN - epoetin alfa inj 2000 unit/ml
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
A A
• • •
1 1 1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
150
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg
1
INTEGRA F - fe fumfe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)
4
4
FOLIVANE-F - fe fumfe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)
4
FOLIVANE-PLUS - fe fumiron polysacch complex-fa-b complex-c-biotin cap
4
INTEGRA PLUS - fe fum-iron polysacch complex-fa-b complex-c-biotin cap
A
FOLIXAPURE - folic acidcholecalciferol tab 1 mg-5000 unit
4
IRON CHEWS PEDIATRIC carbonyl iron chew tab 15 mg (elemental iron) iron combination cap
1
FUSION PLUS - fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap
4
iron polysacch complex-vit b12-fa cap 150-0.025-1 mg
1
FUSION SPRINKLES - fe fumfe polys cmplx-fa-c-probiotic pack 7-0.25-50-5 mg
4
iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg (Hematron-af)
2
GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml
5
•
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150)
4
GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml
5
•
IROSPAN 24/6 - fe bisglyc-fe polys-succ acd-b cmplx-cca-fa tab ther pk
4
HEMATOGEN FA - fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg
4
IS 24/6 - fe bisglyc-fe polyssucc acd-b cmplx-c-ca-fa tab ther pk
5
HEMETAB - polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg
4
LEUKINE - sargramostim lyophilized for inj 250 mcg
4
HEMOCYTE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
4
MAXFE - iron-fa-vit b12-biotinvit c-docusate-mg-zn tab 160-1 mg
4
•
ICAR - carbonyl iron chew tab 15 mg (elemental iron)
A
•
MIRCERA - methoxy pegepoetin beta soln prefilled syr 50 mcg/0.3ml
4
•
ICAR PEDIATRIC - carbonyl iron susp 15 mg/1.25ml (elemental iron)
A
•
MIRCERA - methoxy pegepoetin beta soln prefilled syr 75 mcg/0.3ml MIRCERA - methoxy pegepoetin beta soln prefilled syr 100 mcg/0.3ml
4
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
1
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
151
MIRCERA - methoxy pegepoetin beta soln prefilled syr 200 mcg/0.3ml
4
MULTIGEN - fe asparto glysucc acd-c-threonic acdb12-des stom tab
4
MULTIGEN FOLIC - fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab
4
MULTIGEN PLUS - fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab
4
MYKIDZ IRON 10 - iron susp 15 mg/1.5ml
A
NASCOBAL - cyanocobalamin nasal spray 500 mcg/0.1ml
4
NEPHRON FA - ferrous fumarate w/ fa-dss-b complex-vit c tab
4
NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml
5
•
•
NEULASTA ONPRO KIT pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml
5
•
•
NEUPOGEN - filgrastim inj 300 mcg/ml
5
•
•
NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml)
5
•
•
NEUPOGEN - filgrastim soln prefilled syringe 300 mcg/0.5ml
5
•
•
NEUPOGEN - filgrastim soln prefilled syringe 480 mcg/0.8ml (600 mcg/ml)
5
•
•
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg
4
NOXIFOL-D - folic acidcholecalciferol tab 1 mg-2500 unit
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
NUFERA - iron combination tab 4 4 ORTHO D - folic acidcholecalciferol cap 1 mg-3775 unit PRE-FOLIC - folic acid-vitamin 4 c tab 1-100 mg 5 PROCRIT - epoetin alfa inj 2000 unit/ml 5 PROCRIT - epoetin alfa inj 3000 unit/ml 5 PROCRIT - epoetin alfa inj 4000 unit/ml 5 PROCRIT - epoetin alfa inj 10000 unit/ml 5 PROCRIT - epoetin alfa inj 20000 unit/ml 5 PROCRIT - epoetin alfa inj 40000 unit/ml 4 PROFERRIN-FORTE - iron heme polypeptide-folic acid tab 12-1 mg (fe equiv) 5 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) 4 PROTECTIRON - iron polysacch-fa-b complex-vit c-e & minerals tab 60-1 mg
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
152
PUREFE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
4
REVESTA - folic acidcholecalciferol cap 1 mg-5750 unit
4
SPATONE PUR-ABSORB IRON - ferrous sulfate liquid 5 mg/20ml (elemental iron)
4
TANDEM F - ferrous fumiron polysacch-fa cap 162-115.2-1 mg (106 mg fe)
4
TARON FORTE - fe bisglycinate-fe polysacch-vit c-vit b12-fa cap
4
ZARXIO - filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml
5
•
ZARXIO - filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml
5
•
ZAVARA - folic acidcholecalciferol cap 1 mg-5750 unit
4
ZAVESCA - miglustat cap 100 mg
5
ZOLATE - folic acidcholecalciferol cap 1 mg-3775 unit
4
ANTICOAGULANTS
COUMADIN - warfarin sodium tab 5 mg
4
COUMADIN - warfarin sodium tab 6 mg
4
COUMADIN - warfarin sodium tab 7.5 mg
4
COUMADIN - warfarin sodium tab 10 mg
4
ELIQUIS - apixaban tab 2.5 mg
3
ELIQUIS - apixaban tab 5 mg
3
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)
2
• • •
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
enoxaparin sodium inj 40 mg/0.4ml (Lovenox) enoxaparin sodium inj 60 mg/0.6ml (Lovenox)
enoxaparin sodium inj 120 mg/0.8ml (Lovenox) enoxaparin sodium inj 150 mg/ml (Lovenox) enoxaparin sodium inj 300 mg/3ml (Lovenox)
COUMADIN - warfarin sodium tab 1 mg
4
COUMADIN - warfarin sodium tab 2 mg
4
COUMADIN - warfarin sodium tab 2.5 mg
4
COUMADIN - warfarin sodium tab 3 mg
4
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra) fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra) fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra)
Limited Distribution
ACA
Dispensing Limits
4
enoxaparin sodium inj 100 mg/ml (Lovenox)
•
Step Therapy
COUMADIN - warfarin sodium tab 4 mg
enoxaparin sodium inj 80 mg/0.8ml (Lovenox)
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
153
fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra)
2
4
•
•
SAVAYSA - edoxaban tosylate tab 30 mg (base equivalent)
4
•
4
•
FRAGMIN - dalteparin sodium inj 10000 unit/ml
4
FRAGMIN - dalteparin sodium inj 2500 unit/0.2ml
4
•
SAVAYSA - edoxaban tosylate tab 60 mg (base equivalent)
4
•
warfarin sodium tab 1 mg (Coumadin)
1
FRAGMIN - dalteparin sodium inj 5000 unit/0.2ml
•
warfarin sodium tab 2 mg (Coumadin)
1
FRAGMIN - dalteparin sodium inj 7500 unit/0.3ml
4
•
warfarin sodium tab 2.5 mg (Coumadin)
1
FRAGMIN - dalteparin sodium inj 12500 unit/0.5ml
4
•
warfarin sodium tab 3 mg (Coumadin)
1
FRAGMIN - dalteparin sodium inj 15000 unit/0.6ml
4 4
•
1
FRAGMIN - dalteparin sodium inj 18000 unit/0.72ml
warfarin sodium tab 4 mg (Coumadin)
4
•
warfarin sodium tab 5 mg (Coumadin)
1
FRAGMIN - dalteparin sodium inj 95000 unit/3.8ml
warfarin sodium tab 6 mg (Coumadin)
1
heparin sodium (porcine) inj 1000 unit/ml
2 2
warfarin sodium tab 7.5 mg (Coumadin)
1
2
warfarin sodium tab 10 mg (Coumadin)
1
2
XARELTO - rivaroxaban tab 10 mg
3
•
2
XARELTO - rivaroxaban tab 15 mg
3
•
•
XARELTO - rivaroxaban tab 20 mg
3
•
3
•
•
XARELTO STARTER PACK rivaroxaban tab starter therapy pack 15 mg & 20 mg
heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) inj 10000 unit/ml heparin sodium (porcine) inj 20000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml PRADAXA - dabigatran etexilate mesylate cap 75 mg (etexilate base eq)
4
PRADAXA - dabigatran etexilate mesylate cap 110 mg (etexilate base eq)
4
PRADAXA - dabigatran etexilate mesylate cap 150 mg (etexilate base eq)
4
HEMOSTATICS
•
AMICAR - aminocaproic acid oral soln 0.25 gm/ml
4
AMICAR - aminocaproic acid tab 500 mg
4
Limited Distribution
SAVAYSA - edoxaban tosylate tab 15 mg (base equivalent)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
154
AMICAR - aminocaproic acid tab 1000 mg
4
tranexamic acid tab 650 mg (Lysteda)
2
HEMATOLOGICAL AGENTS - MISC. ADVATE - antihemophilic factor 5 • rahf-pfm for inj 250 unit ADVATE - antihemophilic factor 5 • rahf-pfm for inj 500 unit ADVATE - antihemophilic factor 5 • rahf-pfm for inj 1000 unit ADVATE - antihemophilic factor 5 • rahf-pfm for inj 1500 unit ADVATE - antihemophilic factor 5 • rahf-pfm for inj 2000 unit ADVATE - antihemophilic factor 5 • rahf-pfm for inj 3000 unit ADVATE - antihemophilic factor 5 • rahf-pfm for inj 4000 unit 5 ADYNOVATE - antihemophilic factor recomb pegylated for inj 250 unit 5 ADYNOVATE - antihemophilic factor recomb pegylated for inj 500 unit 5 ADYNOVATE - antihemophilic factor recomb pegylated for inj 1000 unit 5 ADYNOVATE - antihemophilic factor recomb pegylated for inj 2000 unit 4 AGGRENOX - aspirindipyridamole cap sr 12hr 25-200 mg 5 • ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 250 unit
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 500 unit
5
•
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 1000 unit
5
•
•
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 1500 unit
5
•
•
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 2000 unit
5
•
•
•
ALPHANINE SD - coagulation factor ix for inj 500 unit
5
•
•
•
ALPHANINE SD - coagulation factor ix for inj 1000 unit
5
•
•
•
ALPHANINE SD - coagulation factor ix for inj 1500 unit
5
•
•
•
ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 250 unit
5
•
•
•
ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 500 unit
5
•
•
•
ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 1000 unit
5
•
•
ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 2000 unit
5
•
•
ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 3000 unit
5
•
•
anagrelide hcl cap 0.5 mg (Agrylin)
2
• • • • •
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
155
anagrelide hcl cap 1 mg
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
5
•
•
•
•
ASPIRIN/DIPYRIDAMOLE aspirin-dipyridamole cap sr 12hr 25-200 mg
4
COAGADEX - coagulation factor x (human) for inj 500 unit
BEBULIN - factor ix complex for inj 200-1200 unit
•
•
5
5
CORIFACT - factor xiii concentrate (human) for inj kit 1000-1600 unit
BENEFIX - coagulation factor ix (recombinant) for inj kit 250 unit
5
•
•
dipyridamole tab 25 mg (Persantine)
1 2
BENEFIX - coagulation factor ix (recombinant) for inj kit 500 unit
5
dipyridamole tab 50 mg (Persantine) dipyridamole tab 75 mg (Persantine)
2
BENEFIX - coagulation factor ix (recombinant) for inj kit 1000 unit
5
EFFIENT - prasugrel hcl tab 5 mg (base equiv)
4
•
EFFIENT - prasugrel hcl tab 10 mg (base equiv)
4
BENEFIX - coagulation factor ix (recombinant) for inj kit 2000 unit
5
5
•
•
BENEFIX - coagulation factor ix (recombinant) for inj kit 3000 unit
5
•
ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 250 unit
5
•
•
BERINERT - c1 esterase inhibitor (human) for iv inj kit 500 unit
5
•
ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 500 unit
5
•
•
BRILINTA - ticagrelor tab 60 mg
3
ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 750 unit
3
5
BRILINTA - ticagrelor tab 90 mg
ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 1000 unit
•
•
cilostazol tab 50 mg (Pletal)
1
ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 1500 unit
5
•
•
ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 2000 unit
5
•
•
ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 3000 unit
5
•
•
FEIBA - antiinhibitor coagulant complex for inj
5
•
•
cilostazol tab 100 mg (Pletal) clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)
•
•
•
•
• • •
1 1
clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)
2
COAGADEX - coagulation factor x (human) for inj 250 unit
5
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
156
5
•
•
HELIXATE FS - antihemophilic factor (recombinant) for inj kit 500 unit
5
•
•
HELIXATE FS - antihemophilic factor (recombinant) for inj kit 1000 unit
5
•
•
HELIXATE FS - antihemophilic factor (recombinant) for inj kit 2000 unit
5
•
•
HELIXATE FS - antihemophilic factor (recombinant) for inj kit 3000 unit
5
•
•
HEMOFIL M - antihemophilic factor (human) for inj 250 unit
5
•
•
HEMOFIL M - antihemophilic factor (human) for inj 500 unit
5
•
•
HEMOFIL M - antihemophilic factor (human) for inj 1000 unit
5
•
•
HEMOFIL M - antihemophilic factor (human) for inj 1700 unit
5
•
•
HUMATE-P - antihemophilic factor/vwf (human) for inj 250-600 unit
5
•
•
HUMATE-P - antihemophilic factor/vwf (human) for inj 500-1200 unit
5
•
•
HUMATE-P - antihemophilic factor/vwf (human) for inj 1000-2400 unit
5
•
•
Limited Distribution
HELIXATE FS - antihemophilic factor (recombinant) for inj kit 250 unit
ACA
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
FIRAZYR - icatibant acetate inj 30 mg/3ml (base equivalent)
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 250 unit
5
•
•
IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 500 unit
5
•
•
IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 1000 unit
5
•
•
IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 2000 unit
5
•
•
IXINITY - coagulation factor ix (recombinant) for inj 500 unit
5
•
•
IXINITY - coagulation factor ix (recombinant) for inj 1000 unit
5
•
•
IXINITY - coagulation factor ix (recombinant) for inj 1500 unit
5
•
•
KCENTRA - prothrombin complex conc human for inj kit 500 unit
4
KCENTRA - prothrombin complex conc human for inj kit 1000 unit
4
KOATE-DVI - antihemophilic factor (human) for inj 250 unit
5
•
•
KOATE-DVI - antihemophilic factor (human) for inj 500 unit
5
•
•
KOATE-DVI - antihemophilic factor (human) for inj 1000 unit
5
•
•
KOGENATE FS antihemophilic factor (recombinant) for inj kit 250 unit
5
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
157
5
KOGENATE FS antihemophilic factor (recombinant) for inj kit 1000 unit
5
KOGENATE FS antihemophilic factor (recombinant) for inj kit 2000 unit
5
KOGENATE FS antihemophilic factor (recombinant) for inj kit 3000 unit
5
•
•
KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 250 unit
5
•
•
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
KOVALTRY - antihemophilic factor (recombinant) for inj 250 unit
5
• •
•
• •
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
KOGENATE FS antihemophilic factor (recombinant) for inj kit 500 unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
KOVALTRY - antihemophilic factor (recombinant) for inj 500 unit
5
•
•
KOVALTRY - antihemophilic factor (recombinant) for inj 1000 unit
5
•
•
KOVALTRY - antihemophilic factor (recombinant) for inj 2000 unit
5
•
•
KOVALTRY - antihemophilic factor (recombinant) for inj 3000 unit
5
•
•
MONOCLATE-P antihemophilic factor (human) for inj kit 1000 unit
5
•
•
MONOCLATE-P antihemophilic factor (human) for inj kit 1500 unit
5
•
•
MONONINE - coagulation factor ix for inj 1000 unit
5
•
•
NOVOEIGHT - antihemophilic factor (recombinant) for inj 250 unit
5
•
•
NOVOEIGHT - antihemophilic factor (recombinant) for inj 500 unit
5
•
•
NOVOEIGHT - antihemophilic factor (recombinant) for inj 1000 unit
5
•
•
NOVOEIGHT - antihemophilic factor (recombinant) for inj 1500 unit
5
•
•
NOVOEIGHT - antihemophilic factor (recombinant) for inj 2000 unit
5
•
•
NOVOEIGHT - antihemophilic factor (recombinant) for inj 3000 unit
5
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
158
NOVOSEVEN RT - coagulation 5 factor viia (recomb) for inj 1 mg (1000 mcg) NOVOSEVEN RT - coagulation 5 factor viia (recomb) for inj 2 mg (2000 mcg) NOVOSEVEN RT - coagulation 5 factor viia (recomb) for inj 5 mg (5000 mcg) NOVOSEVEN RT - coagulation 5 factor viia (recomb) for inj 8 mg (8000 mcg) NUWIQ - antihemophilic factor 5 (recombinant) for inj kit 250 unit NUWIQ - antihemophilic factor 5 (recombinant) for inj kit 500 unit NUWIQ - antihemophilic factor 5 (recombinant) for inj kit 1000 unit NUWIQ - antihemophilic factor 5 (recombinant) for inj kit 2000 unit NUWIQ - antihemophilic factor 5 (recombinant) for inj 250 unit NUWIQ - antihemophilic factor 5 (recombinant) for inj 500 unit NUWIQ - antihemophilic factor 5 (recombinant) for inj 1000 unit NUWIQ - antihemophilic factor 5 (recombinant) for inj 2000 unit OBIZUR - antihemophilic factor 5 (recomb porc) rpfviii for inj 500 unit 1 pentoxifylline tab cr 400 mg
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PROFILNINE - factor ix complex for inj 500 unit
5
•
•
PROFILNINE - factor ix complex for inj 1000 unit
5
•
•
PROFILNINE - factor ix complex for inj 1500 unit
5
•
•
PROFILNINE SD - factor ix complex for inj 500 unit
5
•
•
PROFILNINE SD - factor ix complex for inj 1000 unit
5
•
•
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
•
•
RECOMBINATE antihemophilic factor (recombinant) for inj 801-1240 unit
5
•
•
RECOMBINATE antihemophilic factor (recombinant) for inj 1241-1800 unit
5
•
•
RECOMBINATE antihemophilic factor (recombinant) for inj 1801-2400 unit
5
•
•
RIASTAP - fibrinogen conc (human) inj approximately 1 gm (900-1300 mg)
4
RIXUBIS - coagulation factor ix (recombinant) for inj 250 unit
5
•
•
RIXUBIS - coagulation factor ix (recombinant) for inj 500 unit
5
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
159
5
•
•
RIXUBIS - coagulation factor ix (recombinant) for inj 3000 unit
5
•
•
RUCONEST - c1 esterase inhibitor (recombinant) for iv inj 2100 unit
5
TRETTEN - coagulation factor xiii a-subunit for inj 2000-3125 unit
5
•
•
WILATE - antihemophilic factor/ 5 vwf (human) for inj 500-500 unit kit 5 WILATE - antihemophilic factor/vwf (human) for inj 1000-1000 unit kit 5 XYNTHA - antihemophilic factor recombinant paf for inj kit 250 unit 5 XYNTHA - antihemophilic factor recombinant paf for inj kit 500 unit 5 XYNTHA - antihemophilic factor recombinant paf for inj kit 1000 unit 5 XYNTHA - antihemophilic factor recombinant paf for inj kit 2000 unit 5 XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 250 unit
•
•
•
•
•
•
•
•
•
• • •
XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 500 unit
5
•
XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 1000 unit
5
•
•
XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 2000 unit
5
•
•
XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 3000 unit
5
•
•
ZONTIVITY - vorapaxar sulfate tab 2.08 mg (base equivalent)
4
•
TOPICAL PRODUCTS OPHTHALMIC AGENTS ACUVAIL - ketorolac tromethamine ophth soln 0.45%
4
AKTEN - lidocaine hcl ophth gel 3.5%
4
•
ALOCRIL - nedocromil sodium ophth soln 2%
4 4
•
ALOMIDE - lodoxamide tromethamine ophth soln 0.1% ALPHAGAN P - brimonidine tartrate ophth soln 0.1%
4
ALREX - loteprednol etabonate ophth susp 0.2%
4
apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)
2
•
Limited Distribution
RIXUBIS - coagulation factor ix (recombinant) for inj 2000 unit
ACA
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
RIXUBIS - coagulation factor ix (recombinant) for inj 1000 unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
160
ATROPINE SULFATE atropine sulfate ophth oint 1%
4
BLEPHAMIDE - sulfacetamide sodium-prednisolone ophth susp 10-0.2%
4
ATROPINE SULFATE atropine sulfate ophth soln 1%
1
4
AZASITE - azithromycin ophth soln 1%
4
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint 10-0.2%
2
azelastine hcl ophth soln 0.05%
2
brimonidine tartrate ophth soln 0.15% (Alphagan p)
4
brimonidine tartrate ophth soln 0.2%
AZOPT - brinzolamide ophth susp 1%
BACITRACIN - bacitracin ophth 3 oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 2 bacitracin-polymyxinneomycin-hc ophth oint 1% 4 BEPREVE - bepotastine besilate ophth soln 1.5% 4 BESIVANCE - besifloxacin hcl ophth susp 0.6% (base equiv) 4 BETADINE OPHTHALMIC PREP - povidone-iodine ophth soln 5% 2 betaxolol hcl ophth soln 0.5% 4 BETIMOL - timolol ophth soln 0.25% 4 BETIMOL - timolol ophth soln 0.5% 4 BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4 BIMATOPROST - bimatoprost ophth soln 0.03%
2
bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
CILOXAN - ciprofloxacin hcl ophth oint 0.3%
4
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)
1
COMBIGAN - brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%
• •
1
BROMFENAC - bromfenac sodium ophth soln 0.09% (base equivalent)
carteolol hcl ophth soln 1%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
COSOPT PF - dorzolamide hcl- 4 timolol maleate ophth sol 22.3-6.8 mg/ml pf cromolyn sodium ophth soln 1 4% 4 CYCLOGYL - cyclopentolate hcl ophth soln 0.5% 4 CYCLOMYDRIL cyclopentolate w/ phenylephrine ophth soln 0.2-1% 2 cyclopentolate hcl ophth soln 0.5% (Cyclogyl)
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
161
cyclopentolate hcl ophth soln 1% (Cyclogyl) cyclopentolate hcl ophth soln 2% (Cyclogyl)
2
2
GELFILM OP - gelatin adsorbable ophth film
4
gentamicin sulfate ophth oint 0.3%
1
DEXAMETHASONE SODIUM PHOS - dexamethasone sodium phosphate ophth soln 0.1%
1
diclofenac sodium ophth soln 0.1%
1
•
•
gentamicin sulfate ophth soln 0.3% (Garamycin) homatropine hbr ophth soln 5% (Isopto homatropine)
2 1
IOPIDINE - apraclonidine hcl ophth soln 1% (base equivalent)
4
ISTALOL - timolol maleate ophth soln 0.5% (once-daily)
4 2
ketorolac tromethamine ophth soln 0.4% (Acular ls)
EMADINE - emedastine difumarate ophth soln 0.05% (base equiv)
4
ketorolac tromethamine ophth soln 0.5% (Acular)
epinastine hcl ophth soln 0.05% (Elestat)
2
FLAREX - fluorometholone acetate ophth susp 0.1%
4
fluorometholone ophth susp 0.1% (Fml liquifilm)
2
4
LASTACAFT - alcaftadine ophth soln 0.25%
4
latanoprost ophth soln 0.005% (Xalatan)
1
levofloxacin ophth soln 0.5%
Limited Distribution
ACA
Dispensing Limits
•
1 2
1
LOTEMAX - loteprednol etabonate ophth gel 0.5%
4
FML - fluorometholone ophth oint 0.1%
4
LOTEMAX - loteprednol etabonate ophth oint 0.5%
4
FML FORTE - fluorometholone ophth susp 0.25%
4
LOTEMAX - loteprednol etabonate ophth susp 0.5%
4
LUMIGAN - bimatoprost ophth soln 0.01%
4
flurbiprofen sodium ophth soln 0.03% (Ocufen)
Step Therapy
1
LACRISERT - artificial tear ophth insert
levobunolol hcl ophth soln 0.5% (Betagan)
Prior Authorization
1 4
4
1
1
ILEVRO - nepafenac ophth susp 0.3%
DUREZOL - difluprednate ophth emulsion 0.05%
erythromycin ophth oint 5 mg/gm
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
gatifloxacin ophth soln 0.5% (Zymaxid)
5
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)
Drug Name
1
CYSTARAN - cysteamine hcl ophth soln 0.44% (base equivalent)
dorzolamide hcl ophth soln 2% (Trusopt)
Prior Authorization
Drug Name
Drug Tier
2016
• •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
162
MAXIDEX - dexamethasone ophth susp 0.1%
4
METIPRANOLOL metipranolol ophth soln 0.3%
4
MITOSOL - mitomycin for ophth soln kit 0.2 mg
4
MOXEZA - moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily)
4
NATACYN - natamycin ophth susp 5%
3
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin
2
neomycin-polymygramicid op sol 1.75-10000-0.025mg-untmg/ml (Neosporin) neomycin-polymyxindexamethasone ophth oint 0.1% (Maxitrol) neomycin-polymyxindexamethasone ophth susp 0.1% (Maxitrol)
2
1
1
NEOMYCIN/POLYMYXIN/ HYDROC - neomycinpolymyxin-hc ophth susp
4
NEVANAC - nepafenac ophth susp 0.1%
4
ofloxacin ophth soln 0.3% (Ocuflox)
1
olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol)
2
PATADAY - olopatadine hcl ophth soln 0.2% (base equivalent)
4
PATANOL - olopatadine hcl ophth soln 0.1% (base equivalent)
4
PAZEO - olopatadine hcl ophth soln 0.7% (base equivalent)
4
phenylephrine hcl ophth soln 2.5%
2
phenylephrine hcl ophth soln 10%
4
pilocarpine hcl ophth soln 1% (Isopto carpine)
2
pilocarpine hcl ophth soln 4% (Isopto carpine) polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
PHOSPHOLINE IODIDE echothiophate iodide ophth for soln 0.125%
pilocarpine hcl ophth soln 2% (Isopto carpine)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 1
PRED MILD - prednisolone acetate ophth susp 0.12%
4
PRED-G - gentamicinprednisolone ace ophth susp 0.3-1%
4
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6%
4
prednisolone acetate ophth susp 1% (Pred forte)
2
PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate ophth soln 1%
4
PREDNISOLONE/ MOXIFLOXACIN prednisolone-moxifloxacin opth soln 1-0.5%
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
163
PREDNISOLONE/ MOXIFLOXACIN prednisolone-moxifloxacinbromfenac opth sol 1-0.5-0.09%
4
PREDNISOLONE/ MOXIFLOXACIN prednisolone-moxifloxacinketorolac opth sol 1-0.5-0.5%
4
PROLENSA - bromfenac sodium ophth soln 0.07% (base equivalent)
4
proparacaine hcl ophth soln 0.5% (Alcaine)
1
timolol maleate ophth soln 0.25% (Timoptic) timolol maleate ophth soln 0.5% (Timoptic)
• •
TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.25%
4
TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.5%
4
TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1%
4
TOBRADEX ST - tobramycindexamethasone ophth susp 0.3-0.05%
4
tobramycin ophth soln 0.3% (Tobrex)
1
tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)
2
RESTASIS - cyclosporine (ophth) emulsion 0.05%
4
SIMBRINZA - brinzolamidebrimonidine tartrate ophth susp 1-0.2%
4
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10%
4
TOBREX - tobramycin ophth oint 0.3%
4 4
sulfacetamide sodium ophth soln 10% (Bleph-10)
2
TRAVATAN Z - travoprost ophth soln 0.004% (benzalkonium free) (bak free) trifluridine ophth soln 1% (Viroptic)
2
tropicamide ophth soln 0.5%
1
tetracaine hcl ophth soln 0.5%
1
1
timolol maleate ophth gel forming soln 0.25% (Timoptic-xe)
2
timolol maleate ophth gel forming soln 0.5% (Timoptic-xe)
2
Limited Distribution
ACA
Dispensing Limits
1
4
sulfacetamide sodiumprednisolone ophth soln 10-0.23(0.25)%
Step Therapy
1
RESCULA - unoprostone isopropyl ophth soln 0.15%
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
tropicamide ophth soln 1% (Mydriacyl)
1
VIGAMOX - moxifloxacin hcl ophth soln 0.5% (base equiv)
4
XIIDRA - lifitegrast ophth soln 5%
4
ZIOPTAN - tafluprost ophth soln 0.0015%
4
• •
•
• • •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
164
ZIRGAN - ganciclovir ophth gel 0.15%
4
ZYLET - loteprednol etabonate- 4 tobramycin ophth susp 0.5-0.3% OTIC AGENTS acetic acid otic soln 2%
2
ACETIC ACID/ALUMINUM ACET - acetic acid 2% in aluminum acetate otic soln
4
CETRAXAL - ciprofloxacin hcl otic soln 0.2% (base equivalent)
4
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
4
CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1%
4
CIPROFLOXACIN ciprofloxacin hcl otic soln 0.2% (base equivalent)
4
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml
4
fluocinolone acetonide (otic) oil 0.01% (Dermotic)
2
hydrocortisone w/ acetic acid otic soln 1-2% neomycin-polymyxin-hc otic soln 1% (Cortisporin) neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ ml-1% ofloxacin otic soln 0.3% OTOVEL - ciprofloxacinfluocinolone aceton (pf) otic soln 0.3-0.025%
2 2 2
2 4
MOUTH/THROAT/DENTAL AGENTS A ACT TOTAL CARE DRY MOUTH - sodium fluoride rinse 0.02% 4 AQUORAL - artificial saliva aero soln 1 benzocaine dental soln 20% CAPHOSOL - artificial saliva solution
4
cevimeline hcl cap 30 mg (Evoxac)
2
chlorhexidine gluconate soln 0.12% (Peridex)
1
clotrimazole troche 10 mg
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
COLGATE DRY MOUTH RELIEF - sodium fluoride mouthwash 2.1 mg/10ml
A
•
CREST COMPLETE - sodium fluoride paste 0.243%
A
•
DEBACTEROL - sulfuric acidsulfonated phenolics soln 30-50%
4
FLUORIDEX DAILY DEFENSE S - sodium fluoride-potassium nitrate gel 1.1-5%
4
•
GEL-KAM - stannous fluoride gel 0.4%
A
•
GEL-KAM ORAL CARE RINSE - stannous fluoride conc 0.63%
4
•
GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic acid gel
4
LIDOCAINE HCL - lidocaine hcl laryngotracheal soln 4%
2
lidocaine hcl viscous soln 2%
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
165
A
LISTERINE RESTORING sodium fluoride rinse 0.0221% (0.01% f)
A
LISTERINE SMART RINSE sodium fluoride rinse 0.0221% (0.01% f)
A
LISTERINE TOTAL CARE sodium fluoride rinse 0.0221% (0.01% f)
A
•
LISTERINE TOTAL CARE PLUS - sodium fluoride rinse 0.0221% (0.01% f)
A
•
LISTERINE TOTAL CARE ZERO - sodium fluoride rinse 0.02%
A
•
LISTERINE WHITENING/ RESTO - sodium fluoride rinse 0.0221% (0.01% f)
A
MUCOTROL - oral wound care products - wafer
4
NAFRINSE DAILY/ ACIDULATED - sodium fluoride-phosphoric acid for soln 1 mg/5ml (f equiv)
4
NAFRINSE DAILY/NEUTRAL 7odium fluoride for soln rinse 0.05%
4
•
NAFRINSE WEEKLY - sodium fluoride for soln rinse 0.2%
4
•
NEUTRASAL - artificial saliva packet
4
NUMOISYN - artificial saliva solution
4
nystatin susp 100000 unit/ml
2
•
OMNI GEL - stannous fluoride gel 0.4%
A
ORAFATE - sucralfate-malate paste 10%
4
•
ORAMAGICRX - oral wound care products - for susp rinse
4
•
ORAVIG - miconazole buccal tab 50 mg (mouth-throat)
4
PHOS FLUR - sodium fluoride rinse 0.044%
A
•
PHOS-FLUR ORTHO DEFENSE - sodium fluoride rinse 0.044%
A
•
pilocarpine hcl tab 5 mg (Salagen)
2
pilocarpine hcl tab 7.5 mg (Salagen)
2
PREVIDENT FLUORIDE sodium fluoride gel 1.1% (0.5% f)
4
•
PREVIDENT 5000 BOOSTER - 4 sodium fluoride paste 1.1% 4 PREVIDENT 5000 BOOSTER PL - sodium fluoride paste 1.1% 4 PREVIDENT 5000 DRY MOUTH - sodium fluoride gel 1.1% (0.5% f) 4 PREVIDENT 5000 ENAMEL PRO - sodium fluoridepotassium nitrate paste 1.1-5% 4 PREVIDENT 5000 PLUS sodium fluoride cream 1.1% 4 PREVIDENT 5000 SENSITIVE - sodium fluoride-potassium nitrate paste 1.1-5%
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
LISTERINE ESSENTIAL CARE - sod monofluorophosph-eucalmen-methyl sal-thymol gel 0.76%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
• • • • •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
166
PROTHELIAL - sucralfatemalate paste 10%
4
REMBRANDT DEEPLY WHITE+PE - sodium monofluorophosphate paste 0.884%
A
REMBRANDT INTENSE STAIN - sodium fluoride paste 0.243%
A
REMBRANDT WHITENING sodium fluoride rinse 0.02%
A
SALICEPT - oral wound care products - for susp rinse
4
SALIVAMAX - artificial saliva packet
4
A
•
•
STANNOUS FLUORIDE RINSE - stannous fluoride liq 0.1% THERA-FLUR-N - sodium fluoride gel 1.1% (0.5% f)
4
•
•
triamcinolone acetonide dental paste 0.1%
2
•
ANALPRAM-HC hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1%
4
CORTIFOAM - hydrocortisone acetate rectal foam 10% (90 mg/dose)
3
hydrocortisone acetate suppos 25 mg (Anusol-hc)
2
•
hydrocortisone acetate suppos 30 mg (Proctocort)
•
hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc)
• • • • •
sodium fluoride rinse 0.2% (Prevident)
1
sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi)
1
•
stannous fluoride conc 0.63% (Gel-kam oral care ri)
A
•
A
•
hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc) hydrocortisone enema 100 mg/60ml (Cortenema) hydrocortisone rectal cream 1% (Proctocort) hydrocortisone rectal cream 2.5% (Anusol-hc)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
•
Drug Name
ANORECTAL AGENTS
SALIVATE RX - artificial saliva - 4 packet A SENSODYNE REPAIR & PROTEC - stannous fluoride paste 0.454% 1 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) A sodium fluoride rinse 0.0221% (0.01% f) A sodium fluoride rinse 0.05%
stannous fluoride gel 0.4%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2
2
2 2 1
LIDOCAINE HCLHYDROCORTIS - lidocainehydrocortisone acetate rectal gel 2.8-0.55%
4
lidocaine-hydrocortisone acetate rectal cream 3-0.5%
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
167
PROCORT - hydrocortisone acetate w/ pramoxine rectal cream 1.85-1.15%
4
PROCTOFOAM HC hydrocortisone acetate w/ pramoxine rectal foam 1-1%
4
RECTIV - nitroglycerin oint 0.4%
4
UCERIS - budesonide rectal foam 2 mg/act
ALA-QUIN - clioquinol-hc cream 3-0.5%
4
alclometasone dipropionate cream 0.05% (Aclovate)
2
alclometasone dipropionate oint 0.05%
4
4
4
ABSORICA - isotretinoin cap 10 mg
4
ALEVICYN ANTIPRURITIC SG - dermatological products misc - liquid
4
ABSORICA - isotretinoin cap 20 mg
4
ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1%
4
ABSORICA - isotretinoin cap 25 mg
4
ALTABAX - retapamulin oint 1%
4
ABSORICA - isotretinoin cap 30 mg
4
AMCINONIDE - amcinonide cream 0.1%
4
ABSORICA - isotretinoin cap 35 mg
4
APEXICON E - diflorasone diacetate emollient base cream 0.05%
ABSORICA - isotretinoin cap 40 mg
4
ASTERO - lidocaine hcl gel 4%
4 4
acitretin cap 10 mg (Soriatane)
2
ATOPICLAIR - dermatological products misc - cream
4
acitretin cap 17.5 mg (Soriatane)
2
ATRAPRO CP - wound dressings - kit
4
acitretin cap 25 mg (Soriatane)
2
ATRAPRO DERMAL SPRAY wound cleansers - liquid
4
ACUICYN DAILY EYELID & EY - eyelid cleansers - liquid
4
AVAR - sulfacetamide sodium w/ sulfur cleansing pad 9.5-5%
acyclovir oint 5% (Zovirax)
2
AVENOVA - eyelid cleansers liquid
4
AVENOVA/NEUTROX - eyelid cleansers - liquid
4
BEAU RX - scar treatment products - gel
2
adapalene cream 0.1% (Differin)
2
adapalene gel 0.1% (Differin)
2
adapalene gel 0.3% (Differin)
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
ALCORTIN A - iodoquinolhydrocortisone-aloe polysaccharide gel 1-2-1%
DERMATOLOGICALS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
168
BENSAL HP - salicylic acid & benzoic acid oint 3-6%
4
BENZIQ - benzoyl peroxide gel 5.25 %
4
BENZIQ LS - benzoyl peroxide gel 2.75%
4
benzoyl peroxide cloth 6%
2
betamethasone valerate aerosol foam 0.12% (Luxiq) betamethasone valerate cream 0.1% betamethasone valerate lotion 0.1%
benzoyl peroxide foam 5.3% (Benzefoam)
2
2
benzoyl peroxide foam 9.8% (Benzefoamultra)
2
calcipotriene cream 0.005% (Dovonex)
2
benzoyl peroxide liq 2.5%
2
calcipotriene oint 0.005%
benzoyl peroxide liq 5.25% benzoyl peroxide lotion 6%
2 2
benzoyl peroxideerythromycin gel 5-3% (Benzamycin)
2
betamethasone dipropionate augmented cream 0.05% (Diprolene af)
2
betamethasone dipropionate augmented gel 0.05%
2
calcipotrienebetamethasone dipropionate oint 0.005-0.064% (Taclonex)
CAPEX - fluocinolone acetonide shampoo 0.01%
4
CARAC - fluorouracil cream 0.5%
4
CEM-UREA - urea soln 45%
4
CENTANY - mupirocin oint 2%
4
CERACADE - dermatological products misc - emulsion
4
ciclopirox gel 0.77%
2
betamethasone dipropionate augmented oint 0.05% (Diprolene)
2
betamethasone dipropionate cream 0.05%
2
ciclopirox olamine cream 0.77% (base equiv)
2
ciclopirox olamine susp 0.77% (base equiv)
2
ciclopirox shampoo 1% (Loprox shampoo)
betamethasone dipropionate oint 0.05%
2
4
2
betamethasone dipropionate lotion 0.05%
2
CALCITRIOL - calcitriol oint 3 mcg/gm
betamethasone dipropionate augmented lotion 0.05% (Diprolene)
Limited Distribution
2 2
2
ACA
2
BP CLEANSING WASH sulfacetamide sodium-sulfur in urea emulsion 10-4%
benzoyl peroxide liq 7%
Dispensing Limits
2
2
calcipotriene soln 0.005% (50 mcg/ml)
Step Therapy
2
betamethasone valerate oint 0.1%
benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
169
ciclopirox solution 8% (Penlac Nail Lacquer)
2
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)
2
clindamycin phosphate foam 1% (Evoclin) clindamycin phosphate gel 1% (Cleocin-t) clindamycin phosphate lotion 1% (Cleocin-t) clindamycin phosphate soln 1% (Cleocin-t) clindamycin phosphate swab 1% (Cleocin-t)
clobetasol propionate shampoo 0.05% (Clobex) clobetasol propionate soln 0.05% (Temovate)
2
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
4
4
2
CLOCORTOLONE PIVALATE PUM - clocortolone pivalate cream 0.1%
4
2
CLODERM - clocortolone pivalate cream 0.1%
4
2
clindamycin phosphatebenzoyl peroxide gel 1-5% (Benzaclin)
2
clindamycin phosphatetretinoin gel 1.2-0.025% (Ziana)
2
clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone)
clobetasol propionate cream 0.05% (Temovate)
2
clotrimazole w/ betamethasone lotion 1-0.05%
2
COAL TAR - coal tar soln 20%
4
CONDYLOX - podofilox gel 0.5%
4
COPASIL - emollient - gel
4
CORDRAN - flurandrenolide cream 0.05%
4
CORDRAN - flurandrenolide lotion 0.05%
4
CORDRAN - flurandrenolide oint 0.05%
4
CORDRAN - flurandrenolide tape 4 mcg/sqcm
4
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot 10-10-1mg/ml
4
2
clobetasol propionate foam 0.05% (Olux)
2
clobetasol propionate gel 0.05% (Temovate) clobetasol propionate lotion 0.05% (Clobex) clobetasol propionate oint 0.05% (Temovate)
2 2 2
Limited Distribution
ACA
2
clobetasol propionate spray 0.05% (Clobex)
clobetasol propionate emulsion foam 0.05% (Olux-e)
Dispensing Limits
2
CLODERM PUMP clocortolone pivalate cream 0.1%
clobetasol propionate emollient base cream 0.05% (Temovate e)
Step Therapy
2
2
2
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
170
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint 1%
4
diclofenac sodium soln 1.5% (Pennsaid)
2
DIFFERIN - adapalene lotion 0.1%
4
CORTISPORIN - neomycinpolymyxin-hc crm 3.5 mg/ gm-10000 unt/gm-0.5%
4
4
COSENTYX - secukinumab subcutaneous soln prefilled syringe 150 mg/ml
5
•
DIFLORASONE DIACETATE diflorasone diacetate cream 0.05%
2
COSENTYX SENSOREADY PEN - secukinumab subcutaneous soln autoinjector 150 mg/ml
5
•
DIFLORASONE DIACETATE diflorasone diacetate oint 0.05%
4
DENAVIR - penciclovir cream 1%
4
DOXEPIN HYDROCHLORIDE doxepin hcl cream 5%
4
DESONATE - desonide gel 0.05%
4
DRITHO-CREME HP anthralin cream 1% econazole nitrate cream 1%
2
desonide cream 0.05% (Desowen)
2
ECOZA - econazole nitrate foam 1%
4
desonide lotion 0.05% (Desowen)
2
ELETONE - dermatological products misc - cream
4
desonide oint 0.05% (Desowen)
2
4
DESOXIMETASONE desoximetasone cream 0.05%
4
ELETONE TWINPACK dermatological products misc - cream ELIDEL - pimecrolimus cream 1%
4
DESOXIMETASONE desoximetasone oint 0.05%
4
4
desoximetasone cream 0.25% (Topicort)
2
EMULSION SB dermatological products misc - emulsion ENSTILAR - calcipotrienebetamethasone dipropionate foam 0.005-0.064%
4
ENTTY SPRAY EMULSION dermatological products misc - emulsion
4
EPICERAM - dermatological products misc - emulsion
4
EPIFOAM - pramoxine-hc aerosol foam 1-1%
4
desoximetasone gel 0.05% (Topicort)
2
desoximetasone oint 0.25% (Topicort)
2
diclofenac sodium (actinic keratoses) gel 3% (Solaraze)
2
diclofenac sodium gel 1% (Voltaren)
2
• •
• •
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
171
ERTACZO - sertaconazole nitrate cream 2%
4
erythromycin gel 2% (Erygel)
2
erythromycin pads 2% erythromycin soln 2%
2 2
ESSENTRA WIPES 9X9" CLEAN - isopropyl alcohol wipes 70%
4
EURAX - crotamiton cream 10%
4
EURAX - crotamiton lotion 10% 4 4 EXELDERM - sulconazole nitrate cream 1% 4 EXELDERM - sulconazole nitrate solution 1% 2 EXODERM - sodium thiosulfate-salicylic acid lotion 25-1% 4 FABIOR - tazarotene (acne) foam 0.1% 3 FINACEA - azelaic acid foam 15% 3 FINACEA - azelaic acid gel 15% 4 FLECTOR - diclofenac epolamine patch 1.3% 2 fluocinolone acetonide cream 0.01% 2 fluocinolone acetonide cream 0.025% (Synalar) 2 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod) 2 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca) 2 fluocinolone acetonide oint 0.025% (Synalar)
fluocinolone acetonide soln 0.01% (Synalar) fluocinonide cream 0.05%
fluocinonide emulsified base cream 0.05%
2
fluocinonide soln 0.05%
2
FLUOROURACIL - fluorouracil cream 0.5%
4
fluorouracil cream 5% (Efudex)
2
fluorouracil soln 2%
2 2 2
flurandrenolide lotion 0.05% (Cordran)
2
fluticasone propionate cream 0.05% (Cutivate)
2
fluticasone propionate lotion 0.05% (Cutivate) fluticasone propionate oint 0.005%
Limited Distribution
2 4
flurandrenolide cream 0.05%
ACA
2
FLUOROPLEX - fluorouracil cream 1%
fluorouracil soln 5%
Dispensing Limits
2 2
fluocinonide oint 0.05%
Step Therapy
2
fluocinonide cream 0.1% (Vanos)
fluocinonide gel 0.05%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2
GENADUR - dermatological products misc - liquid
4
GENTAMICIN SULFATE gentamicin sulfate cream 0.1%
4
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
4
halobetasol propionate cream 0.05% (Ultravate)
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
172
halobetasol propionate oint 0.05% (Ultravate)
2
4
HALOG - halcinonide cream 0.1%
4
HYLATOPIC PLUS dermatological products, misc. - aerosol foam
4
HALOG - halcinonide oint 0.1%
4
HYLIRA - hyaluronate sodium (emollient) lotion 0.1%
HALOTIN - haloprogin cream 1%
4
imiquimod cream 5% (Aldara)
2
HPR - dermatological products, misc. - aerosol foam
4
iodoquinol-hc cream 1%
2
HPR PLUS - dermatological products misc - cream
4
iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9% (Vytone)
HPR PLUS - dermatological products, misc. - aerosol foam
4
isotretinoin cap 10 mg
hyaluronate sodium (emollient) gel 0.2% (Hylira)
2
hydrocortisone butyrate cream 0.1% (Locoid)
isotretinoin cap 20 mg
2
isotretinoin cap 30 mg isotretinoin cap 40 mg JUBLIA - efinaconazole soln 10%
4
KENALOG - triamcinolone acetonide aerosol soln 0.147 mg/gm
4
KERYDIN - tavaborole soln 5%
4 2 2
2
ketoconazole foam 2% (Extina)
2
1
ketoconazole shampoo 2% (Nizoral) lactic acid (ammonium lactate) cream 12% (Lachydrin)
1
lactic acid (ammonium lactate) lotion 10%
2
2
hydrocortisone oint 2.5% hydrocortisone valerate cream 0.2% hydrocortisone valerate oint 0.2% (Westcort) HYLATOPIC PLUS dermatological products misc - cream
1 2
Limited Distribution
2
ketoconazole cream 2%
hydrocortisone lotion 2.5%
ACA
2
2
2
Dispensing Limits
2
hydrocortisone butyrate oint 0.1% (Locoid)
hydrocortisone lotion 2% (Ala scalp)
Step Therapy
2
2
hydrocortisone cream 2.5%
•
2
hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream)
hydrocortisone butyrate soln 0.1% (Locoid)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
lactic acid (ammonium lactate) lotion 12% (Lachydrin)
4
lactic acid w/ vitamin e cream 10%-3500 unit/30gm
1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
173
LAVARE WOUND WASH wound cleansers - gel
4
metronidazole lotion 0.75% (Metrolotion)
2
LEVULAN KERASTICK aminolevulinic acid hcl for soln 20% (stick applicator)
4
MICROCYN - wound cleansers - gel
4
MICROCYN - wound cleansers - liquid
4
lidocaine hcl gel 2%
1
MICROCYN SKIN AND WOUND H - wound cleansers - gel
4
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine oint 5%
2
lidocaine patch 5% (Lidoderm)
2
lidocaine-prilocaine cream kit 2.5-2.5%
2
lidocaine-prilocaine cream 2.5-2.5% (Emla) lindane shampoo 1%
2 2
LOCOID - hydrocortisone butyrate lotion 0.1%
4
LOTRIMIN ULTRA - butenafine hcl cream 1%
4
LOUTREX - antiseborrheic products misc - cream
4
LUXAMEND - wound dressings 2 - cream LUZU - luliconazole cream 1% 4 malathion lotion 0.5% (Ovide)
2
MENTAX - butenafine hcl cream 1%
4
methoxsalen rapid cap 10 mg (Oxsoralen ultra)
2
metronidazole cream 0.75% (Metrocream)
2
metronidazole gel 0.75%
2
metronidazole gel 1% (Metrogel)
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
MIRVASO - brimonidine tartrate 4 gel 0.33% (base equivalent) 2 mometasone furoate cream 0.1% (Elocon) 2 mometasone furoate oint 0.1% (Elocon) 2 mometasone furoate solution 0.1% (lotion) (Elocon) 2 mupirocin calcium cream 2% (Bactroban) 1 mupirocin oint 2% (Bactroban) 2 NAFTIFINE HCL - naftifine hcl cream 1% 2 naftifine hcl cream 2% (Naftin) 4 NAFTIN - naftifine hcl cream 2% 4 NAFTIN - naftifine hcl gel 1% NAFTIN - naftifine hcl gel 2%
4
NATROBA - spinosad susp 0.9%
4
NEO-SYNALAR - neomycin sulfate-fluocinolone acetonide cream 0.5-0.025%
4
NEOSALUS - dermatological products misc - cream
4
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
174
NEOSALUS - dermatological products, misc. - aerosol foam
4
NEOSALUS - emollient - lotion
4
NEOSALUS CP dermatological products misc - cream
4
NOBLE MYSTIQUE EMULAC - lactic acid (ammonium lactate) cream 10%
4
NOVACORT - pramoxine-hc gel 1-2%
4
NUCORT - hydrocortisone acetate lotion 2%
4
NUVAIL - dermatological products misc - solution
4
nystatin cream 100000 unit/ gm
2
nystatin oint 100000 unit/gm nystatin topical powder nystatin-triamcinolone cream 100000-0.1 unit/gm% nystatin-triamcinolone oint 100000-0.1 unit/gm-%
2 2 2
2
ONEXTON - clindamycin phosphate-benzoyl peroxide gel 1.2-3.75%
4
OVACE PLUS - sulfacetamide sodium cream 10%
4
OVACE PLUS - sulfacetamide sodium foam 9.8%
4
OVACE PLUS - sulfacetamide sodium lotion 9.8%
4
oxiconazole nitrate cream 1% (Oxistat)
2
OXISTAT - oxiconazole nitrate cream 1%
4
OXISTAT - oxiconazole nitrate lotion 1%
4
PANDEL - hydrocortisone probutate cream 0.1%
4
PANRETIN - alitretinoin gel 0.1%
4
PENNSAID - diclofenac sodium 4 soln 2% 2 permethrin cream 5% (Elimite) PICATO - ingenol mebutate gel 4 0.015% PICATO - ingenol mebutate gel 4 0.05% 4 PLEXION CLEANSING CLOTHS - sulfacetamide sodium w/ sulfur cleansing cloth 9.8-4.8% PLIAGLIS - lidocaine-tetracaine 4 cream 7-7% 4 PODOCON 25 IN BENZOIN TIN - podophyllum resin soln 25% 2 podofilox soln 0.5% (Condylox) PRAMOSONE - pramoxine-hc 4 cream 1-1% PRAMOSONE - pramoxine-hc 4 lotion 1-1% PRAMOSONE - pramoxine-hc 4 lotion 1-2.5% PRAMOSONE - pramoxine-hc 4 oint 1-1% PRAMOSONE - pramoxine-hc 4 oint 1-2.5% 4 PRAMOSONE E - pramoxinehc emollient base cream 1-2.5%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
175
pramoxine-hc cream 1-2.5% (Pramosone)
2
prednicarbate cream 0.1% (Dermatop)
2
prednicarbate oint 0.1% (Dermatop)
2
PROMISEB - antiseborrheic products misc - cream
4
PRUCLAIR - dermatological products misc - cream
4
PRUDOXIN - doxepin hcl cream 5%
4
PRUMYX - dermatological products misc - cream
4
PSORCON - diflorasone diacetate cream 0.05%
4
RECEDO - scar treatment products - gel
2
RECURA - antifungal combination products misc cream
4
REGENECARE - lidocaine hclcollagen-aloe vera gel 2%
4
REGRANEX - becaplermin gel 0.01%
4
RIAX - benzoyl peroxide foam 5.5%
salicylic acid er film-forming soln 28.5% (Ultrasal-er) salicylic acid film forming liquid 27.5% (Virasal) salicylic acid foam 6% (Salvax)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2
salicylic acid gel 6% (Keralyt) 2 2 salicylic acid lotion 6% salicylic acid shampoo 6% (Salex)
2
SANTYL - collagenase oint 250 4 unit/gm 2 scar treatment products - gel 1 selenium sulfide lotion 2.5% selenium sulfide-pyrithione zinc in urea shampoo 2.25%
2
SELRX - selenium sulfidepyrithione zinc in urea shampoo 2.3%
4
SERNIVO - betamethasone dipropionate spray emulsion 0.05% (base equiv)
4
4
SILVER NITRATE - silver nitrate oint 10%
4
4
SILVER NITRATE - silver nitrate soln 0.5%
4
RIAX - benzoyl peroxide foam 9.5%
SILVER NITRATE - silver nitrate soln 10%
4
ROSULA - sulfacetamide sodium w/ sulfur cleansing cloth 10-5%
2
4
RYNODERM - urea cream 37.5%
4
SILVER NITRATE - silver nitrate soln 25%
4
SALICYLIC ACID - salicylic acid soln 26%
4
SILVER NITRATE - silver nitrate soln 50%
1
salicylic acid cream 6%
2
silver sulfadiazine cream 1% (Silvadene) SILVRSTAT WOUND DRESSING - silver - gel
4
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
176
skin protectants misc cream
2
SKLICE - ivermectin lotion 0.5%
4
SODIUM SULFACETAMIDE WASH - sulfacetamide sodium in bakuchiol vehicle wash 10%
4
4 SODIUM SULFACETAMIDE/ SULF - sulfacetamide sodium w/ sulfur susp 10-5% 4 SODIUM SULFACETAMIDE/ SULF - sulfacetamide sodium-sulfur in urea emulsion 10-5% 4 SODIUM SULFACETAMIDE/ SULF - sulfacetamide sodium-sulfur in urea gel 10-5% 4 SOOLANTRA - ivermectin cream 1% 4 SORILUX - calcipotriene foam 0.005% 4 SP SCAR MANAGEMENT scar treatment products - gel 4 SPINOSAD - spinosad susp 0.9% 2 SSS 10-5 - sulfacetamide sodium w/ sulfur foam 10-5% 5 STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 STELARA - ustekinumab soln prefilled syringe 90 mg/ml 2 sulfacetamide sodium cleansing gel 10% (Ovace plus wash) sulfacetamide sodium liquid 2 10% (Ovace wash)
sulfacetamide sodium lotion 10% (acne) (Klaron) sulfacetamide sodium shampoo 10% (Ovace plus)
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2 2
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser)
2
sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin)
2
sulfacetamide sodium w/ sulfur cream 9.8-4.8% (Plexion)
2
sulfacetamide sodium w/ sulfur cream 10-2% (Avare ls)
2
sulfacetamide sodium w/ sulfur cream 10-5%
2
sulfacetamide sodium w/ sulfur emulsion 10-5%
•
2
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion cleanser)
sulfacetamide sodium w/ sulfur emulsion 10-1%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2
sulfacetamide sodium w/ sulfur lotion 9.8-4.8% (Plexion)
2
sulfacetamide sodium w/ sulfur lotion 10-5%
2
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts)
2
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash)
2
sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash)
2
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
177
SULFAMYLON - mafenide acetate cream 85 mg/gm
4
TOPICORT - desoximetasone cream 0.05%
4
SULFOAM - sulfur shampoo 2%
4
TOPICORT - desoximetasone oint 0.05%
4
SYNERA - lidocaine-tetracaine topical patch 70-70 mg
4
TOPICORT - desoximetasone spray 0.25%
4
TACLONEX - calcipotrienebetamethasone dipropionate susp 0.005-0.064%
4
tretinoin cream 0.025% (Retin-a)
2
tretinoin cream 0.05% (Retina)
2
tacrolimus oint 0.03% (Protopic)
2
tretinoin cream 0.1% (Retina)
2
tacrolimus oint 0.1% (Protopic)
2
tretinoin gel 0.01% (Retin-a)
2
TALTZ - ixekizumab subcutaneous soln autoinjector 80 mg/ml
5
TALTZ - ixekizumab subcutaneous soln prefilled syringe 80 mg/ml
5
TARGRETIN - bexarotene gel 1%
5
TAZORAC - tazarotene cream 0.05%
3
TAZORAC - tazarotene cream 0.1%
•
•
•
tretinoin gel 0.025% (Retin-a) tretinoin gel 0.05% (Atralin)
• •
•
• •
tretinoin microsphere gel 0.04% (Retin-a micro) tretinoin microsphere gel 0.1% (Retin-a micro pump)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2 2 2 2
TRI-CHLOR - trichloroacetic acid liqd 80%
4 2
3
triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog)
TAZORAC - tazarotene gel 0.05%
3
triamcinolone acetonide cream 0.025%
1
TAZORAC - tazarotene gel 0.1%
3
triamcinolone acetonide cream 0.1%
TBC - trypsin w/ castor oil & peruvian balsam spray
1
triamcinolone acetonide cream 0.5%
TERSI FOAM - selenium sulfide foam 2.25%
4
triamcinolone acetonide lotion 0.025%
TETRIX - dermatological products misc - cream
2
triamcinolone acetonide lotion 0.1%
TEXACORT - hydrocortisone soln 2.5%
4
triamcinolone acetonide oint 0.025%
TOLAK - fluorouracil cream 4%
4
1 1 2 2 1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
178
triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5%
1
urea suspension 40% (Umecta)
2
2
UREVAZ - urea cream 44%
4
UTOPIC - urea cream 41%
4 5
TRIANEX - triamcinolone acetonide oint 0.05%
4
ULESFIA - benzyl alcohol lotion 5%
4
VALCHLOR - mechlorethamine hcl gel 0.016% (base equivalent)
4
VECTICAL - calcitriol oint 3 mcg/gm
4
ULTRASAL-ER - salicylic acid er film-forming soln 28.5%
VERDESO - desonide foam 0.05%
4
ULTRAVATE - halobetasol propionate lotion 0.05%
4
VEREGEN - sinecatechins oint 15%
4
UMECTA - urea emulsion 40%
4
URAMAXIN - urea in ammonium lactate vehicle foam 20%
4
VOLTAREN - diclofenac sodium gel 1%
4
2
VUSION - miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35%
4
urea cream 39% (Aluvea)
VYTONE - iodoquinolhydrocortisone in aloe vehicle cream 1-1.9%
4
XERESE - acyclovirhydrocortisone cream 5-1%
4
XEROFORM NONOCCLUSIVE OI - bismuth tribromophenate-petrolatum dressing pads
4
XEROFORM OCCLUSIVE PETROL - bismuth tribromophenate-petrolatum dressing - misc
4
XEROFORM OCCLUSIVE PETROL - bismuth tribromophenate-petrolatum dressing pads
4
XEROFORM PETROLATUM DRESS - bismuth tribromophenate-petrolatum dressing - misc
4
urea cream 40% urea cream 45% (Uramaxin) urea cream 47% (Keralac) urea cream 50%
2 2 2 2
urea foam 40% (Hydro 40 foam)
2
urea gel 40%
2
urea gel 45% (Uramaxin) urea in lactic acid vehicle foam 35% (Hydro 35) urea in lactic acid-salicylic acid vehicle susp 50% urea in zinc undecylenatelactic acid vehicle emulsion 50% urea lotion 40% urea lotion 45% (Uramaxin) UREA NAIL - urea in zinc undecylenate-lactic acid vehicle stick 50%
2 2 2 2
2 2 4
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
179
XEROFORM PETROLATUM DRESS - bismuth tribromophenate-petrolatum dressing pads
4
XOLEGEL - ketoconazole gel 2%
4
ZACLIR CLEANSING - benzoyl 4 peroxide lotion 8% 4 ZITHRANOL - anthralin shampoo 1% 4 ZITHRANOL-RR - anthralin cream 1.2% ZONALON - doxepin hcl cream 4 5% ZOVIRAX - acyclovir cream 5% 4
•
•
EXJADE - deferasirox tab for oral susp 250 mg
5
•
•
EXJADE - deferasirox tab for oral susp 500 mg
5
•
•
FERRIPROX - deferiprone oral soln 100 mg/ml
5
•
•
FERRIPROX - deferiprone tab 500 mg
5
•
•
JADENU - deferasirox tab 90 mg
5
•
5
• •
4
•
JADENU - deferasirox tab 360 mg
5
ZYCLARA PUMP - imiquimod cream 2.5%
•
naltrexone hcl tab 50 mg (Revia)
2
ZYCLARA PUMP - imiquimod cream 3.75%
4
NARCAN - naloxone hcl nasal spray 4 mg/0.1ml
3
PENTETATE CALCIUM TRISODI - pentetate calcium trisodium iv or inhalation soln 200 mg/ml
4
PENTETATE ZINC TRISODIUM - pentetate zinc trisodium iv or inhalation soln 200 mg/ml
4
RADIOGARDASE - prussian blue insoluble cap 0.5 gm
4
VISTOGARD - uridine triacetate oral granules packet 10 gm
5
ANTIDOTES CETYLEV - acetylcysteine effervescent tab 500 mg
4
CETYLEV - acetylcysteine effervescent tab 2.5 gm
4
CHEMET - succimer cap 100 mg
3
Limited Distribution
5
•
4
ACA
EXJADE - deferasirox tab for oral susp 125 mg
4
LUGOLS STRONG IODINE iodine solution
Dispensing Limits
4
ZYCLARA - imiquimod cream 3.75%
ANTISEPTICS & DISINFECTANTS 4 ANASEPT - sodium hypochlorite liquid 0.057% 4 FORMA-RAY - formaldehyde solution 20% 1 formaldehyde solution 10%
Step Therapy
EVZIO - naloxone hcl solution auto-injector 0.4 mg/0.4ml
JADENU - deferasirox tab 180 mg
MISCELLANEOUS PRODUCTS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
DIAGNOSTIC PRODUCTS ASCENSIA AUTODISC TEST ST - glucose blood test disk
2
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
180
2
•
GLUCAGEN DIAGNOSTIC glucagon hcl (rdna) diagnostic for inj 1 mg (base equiv)
4
BREATHERITE RIGID SPACER - spacer/aerosolholding chambers - device
3
BREATHERITE VALVED MDI CH - respiratory therapy supplies - devices
3
BREATHERITE W/LARGE MASK - spacer/aerosolholding chambers - device
3
BREATHERITE W/MEDIUM MASK - spacer/aerosolholding chambers - device
3
BREATHERITE W/SMALL MASK - spacer/aerosolholding chambers - device
3
KETONE BLOOD TEST STRIPS-VARIOUS
4
URINE TEST STRIPSVARIOUS
4
CAYA - diaphragm arc-spring
A 4
CITRUS BERGAMOT - citrus bergamot oral powder 250 mg/0.25 gm
4
HURRISEAL - dental desensitizing product solution INSULIN PEN NEEDLESVARIOUS
3
•
CO-BALAMIN - ubiquinolvit b12-resveratrol-fa cap 200-5-400-0.8 mg
4
INSULIN SYRINGESVARIOUS
3
•
LANCETS-VARIOUS
3
CO-VERATROL - ubiquinolvit b12-resveratrol-fa cap 200-5-400-0.8 mg
4
LANCING DEVICE-VARIOUS
4
OMNIFLEX DIAPHRAGM diaphragms
A
•
ORTHO DIAPHRAGM COIL SPRI - diaphragm coil spring kit 50 mm
A
•
ORTHO DIAPHRAGM COIL SPRI - diaphragm coil spring kit 100 mm
A
•
ORTHO DIAPHRAGM COIL SPRI - diaphragm coil spring kit 105 mm
A
•
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 55 mm
A
•
ALTERNATIVE MEDICINES
MEDICAL DEVICES BLOOD GLUCOSE CALIBRATION LIQUIDVARIOUS
4
BREATHERITE - spacer/ aerosol-holding chambers device
3
BREATHERITE COLLAPSIBLE - spacer/ aerosol-holding chambers device
3
Limited Distribution
BAYER CONTOUR NEXT BLOOD - glucose blood test strip
ACA
•
Dispensing Limits
2
Step Therapy
BAYER CONTOUR BLOOD GLUCO - glucose blood test strip
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
BAYER BREEZE 2 TEST DISC - glucose blood test disk
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
181
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 70 mm
A
•
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 75 mm
A
•
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 80 mm
A
•
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 85 mm
A
•
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 90 mm
A
•
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 95 mm
A
•
RESPIRATORY THERAPY SUPPLIES-VARIOUS
WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 80 mm
A
•
WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 85 mm
A
•
WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 90 mm
A
•
WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 95 mm
A
•
Limited Distribution
•
ACA
A
Dispensing Limits
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 65 mm
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
ORTHO DIAPHRAGM FLAT SPRI - diaphragm flat spring kit 60 mm
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PHARMACEUTICAL ADJUVANTS 4 SANARE SCAR THERAPY cream base ASSORTED CLASSES ASTAGRAF XL - tacrolimus cap sr 24hr 0.5 mg
4
•
ASTAGRAF XL - tacrolimus cap sr 24hr 1 mg
4
•
ASTAGRAF XL - tacrolimus cap sr 24hr 5 mg
4
•
4
4
ATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/ml(eq)
SPACERS-VARIOUS
4
4
WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 60 mm
A
•
AZASAN - azathioprine tab 75 mg
WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 65 mm
A
•
WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 70 mm
A
•
WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 75 mm
A
•
AZASAN - azathioprine tab 100 4 mg 2 azathioprine tab 50 mg (Imuran) 5 CUPRIMINE - penicillamine cap 250 mg 2 cyclosporine cap 25 mg (Sandimmune) 2 cyclosporine cap 100 mg (Sandimmune)
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
182
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
3
cyclosporine modified cap 25 mg (Neoral)
2
cyclosporine modified cap 50 mg (Cyclosporine modifie)
2
cyclosporine modified cap 100 mg (Neoral)
2
cyclosporine modified oral soln 100 mg/ml (Neoral)
5
ENVARSUS XR - tacrolimus tab sr 24hr 0.75 mg
4
ENVARSUS XR - tacrolimus tab sr 24hr 1 mg
4
ENVARSUS XR - tacrolimus tab sr 24hr 4 mg
4
mycophenolate mofetil cap 250 mg (Cellcept)
2
mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)
2
mycophenolate mofetil tab 500 mg (Cellcept)
2
mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)
2
2
NEORAL - cyclosporine modified cap 25 mg
4
NEORAL - cyclosporine modified cap 100 mg
4
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Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name NEORAL - cyclosporine modified oral soln 100 mg/ml
2
DEPEN TITRATABS penicillamine tab 250 mg
mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)
Prior Authorization
Drug Name
Drug Tier
2016
4
PROGRAF - tacrolimus cap 0.5 4 mg 4 PROGRAF - tacrolimus cap 1 mg 4 PROGRAF - tacrolimus cap 5 mg 3 RAPAMUNE - sirolimus oral soln 1 mg/ml REVLIMID - lenalidomide caps 5 2.5 mg REVLIMID - lenalidomide cap 5 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 4 SANDIMMUNE - cyclosporine cap 25 mg 4 SANDIMMUNE - cyclosporine cap 100 mg 4 SANDIMMUNE - cyclosporine oral soln 100 mg/ml 2 sirolimus tab 0.5 mg (Rapamune) 2 sirolimus tab 1 mg (Rapamune) 2 sirolimus tab 2 mg (Rapamune) 2 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps)
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Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
183
sodium polystyrene sulfonate powder (Kayexalate)
2
sodium polystyrene sulfonate rectal susp 30 gm/120ml
2
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Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
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
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THALOMID - thalidomide cap 100 mg
5
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THALOMID - thalidomide cap 150 mg
5
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THALOMID - thalidomide cap 200 mg
5
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VELTASSA - patiromer sorbitex 4 calcium for susp packet 8.4 gm (base eq) VELTASSA - patiromer sorbitex 4 calcium for susp packet 16.8 gm (base eq) VELTASSA - patiromer sorbitex 4 calcium for susp packet 25.2 gm (base eq) 4 ZORTRESS - everolimus tab 0.25 mg 4 ZORTRESS - everolimus tab 0.5 mg 4 ZORTRESS - everolimus tab 0.75 mg
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Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
184
2016 INDEX A abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)......................................................................... 6 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir)................................................ 6 abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 6 ABANEU-SL -cyanocobalamin-methylcobalamin tab sl 600-600 mcg................................................................. 148 ABILIFY -aripiprazole tab 2 mg......................................... 82 ABILIFY -aripiprazole tab 5 mg......................................... 82 ABILIFY -aripiprazole tab 10 mg....................................... 82 ABILIFY -aripiprazole tab 15 mg....................................... 82 ABILIFY -aripiprazole tab 20 mg....................................... 82 ABILIFY -aripiprazole tab 30 mg....................................... 82 ABSORICA -isotretinoin cap 10 mg................................ 168 ABSORICA -isotretinoin cap 20 mg................................ 168 ABSORICA -isotretinoin cap 25 mg................................ 168 ABSORICA -isotretinoin cap 30 mg................................ 168 ABSORICA -isotretinoin cap 35 mg................................ 168 ABSORICA -isotretinoin cap 40 mg................................ 168 ABSTRAL -fentanyl citrate sl tab 100 mcg (base equiv)............................................................................... 95 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...... 90 acarbose tab 25 mg (Precose)....................................... 30 acarbose tab 50 mg (Precose)....................................... 30 acarbose tab 100 mg (Precose)..................................... 30 acebutolol hcl cap 200 mg (Sectral).............................. 43 acebutolol hcl cap 400 mg (Sectral).............................. 43 ACERFLEX -nutritional supplement powder................... 131 acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg (Trezix)................................................ 96 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............... 54 acetazolamide cap sr 12hr 500 mg (Diamox)............... 54 acetazolamide tab 250 mg.............................................. 54 ACETIC ACID/ALUMINUM ACET -acetic acid 2% in aluminum acetate otic soln...........................................165 acetic acid otic soln 2%................................................ 165 acetylcysteine cap 600 mg........................................... 130 acetylcysteine inhal soln 10%........................................ 61 acetylcysteine inhal soln 20%........................................ 62 ACIPHEX -rabeprazole sodium ec tab 20 mg.................. 68 acitretin cap 10 mg (Soriatane).................................... 168 acitretin cap 17.5 mg (Soriatane)................................. 168 acitretin cap 25 mg (Soriatane).................................... 168 ACTEMRA -tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml................................................... 104 ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)....................................................... 17 ACTIVE FE -fe carbonyl-fa-b complex-a-c-d-e-min tab 75-1.25 mg.................................................................... 148 ACTIVE INJECTION KIT KL-3 -triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit................................. 22 ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg.................................................................................. 118 ACTONEL -risedronate sodium tab 5 mg......................... 38 ACTONEL -risedronate sodium tab 30 mg....................... 38 ACTONEL -risedronate sodium tab 35 mg....................... 39 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr 24hr 15-1000 mg........................................................ 30 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr 24hr 30-1000 mg........................................................ 30 ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse 0.02%.............................................................................165 ACUICYN DAILY EYELID & EY -eyelid cleansers liquid.............................................................................. 168 ACUVAIL -ketorolac tromethamine ophth soln 0.45%.............................................................................160 acyclovir cap 200 mg (Zovirax)........................................ 6 acyclovir oint 5% (Zovirax)........................................... 168 acyclovir susp 200 mg/5ml (Zovirax).............................. 6 acyclovir tab 400 mg (Zovirax)........................................ 7 acyclovir tab 800 mg (Zovirax)........................................ 7 ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 16 adapalene cream 0.1% (Differin).................................. 168 adapalene gel 0.1% (Differin)....................................... 168 adapalene gel 0.3% (Differin)....................................... 168 ADASUVE -loxapine aerosol powder breath activated 10 mg.................................................................................... 82 ADCIRCA -tadalafil tab 20 mg (pah)................................. 59 ADD-INS COMPLETE -amino acids pack...................... 130
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
185
2016 adefovir dipivoxil tab 10 mg (Hepsera)........................... 7 ADEMPAS -riociguat tab 0.5 mg....................................... 59 ADEMPAS -riociguat tab 1 mg.......................................... 59 ADEMPAS -riociguat tab 1.5 mg....................................... 59 ADEMPAS -riociguat tab 2 mg.......................................... 59 ADEMPAS -riociguat tab 2.5 mg....................................... 59 ADRENACLICK -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)......................................................... 55 ADRENACLICK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................... 55 ADRENALIN -epinephrine hcl nasal soln 0.1%................ 61 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 45-21 mcg/act............................................................................ 64 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21 mcg/act............................................................................ 64 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21 mcg/act............................................................................ 64 ADVANCED AM/PM -multiple vitamins w/ calcium therapy pack............................................................................... 119 ADVATE -antihemophilic factor rahf-pfm for inj 250 unit................................................................................. 155 ADVATE -antihemophilic factor rahf-pfm for inj 500 unit................................................................................. 155 ADVATE -antihemophilic factor rahf-pfm for inj 1000 unit................................................................................. 155 ADVATE -antihemophilic factor rahf-pfm for inj 1500 unit................................................................................. 155 ADVATE -antihemophilic factor rahf-pfm for inj 2000 unit................................................................................. 155 ADVATE -antihemophilic factor rahf-pfm for inj 3000 unit................................................................................. 155 ADVATE -antihemophilic factor rahf-pfm for inj 4000 unit................................................................................. 155 ADVERA -nutritional supplement liquid...........................131 ADYNOVATE -antihemophilic factor recomb pegylated for inj 250 unit.................................................................... 155 ADYNOVATE -antihemophilic factor recomb pegylated for inj 500 unit.................................................................... 155 ADYNOVATE -antihemophilic factor recomb pegylated for inj 1000 unit.................................................................. 155 ADYNOVATE -antihemophilic factor recomb pegylated for inj 2000 unit.................................................................. 155 AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act...... 64 AFINITOR DISPERZ -everolimus tab for oral susp 2 mg.................................................................................... 17
AFINITOR DISPERZ -everolimus tab for oral susp 3 mg.................................................................................... 17 AFINITOR DISPERZ -everolimus tab for oral susp 5 mg.................................................................................... 17 AFINITOR -everolimus tab 2.5 mg.................................... 17 AFINITOR -everolimus tab 5 mg....................................... 17 AFINITOR -everolimus tab 7.5 mg.................................... 17 AFINITOR -everolimus tab 10 mg..................................... 17 AFLURIA 2012-2013 -influenza virus vaccine split im susp................................................................................. 13 AFLURIA 2014-2015 -influenza virus vaccine split im susp................................................................................. 13 AFLURIA 2015-2016 -influenza virus vaccine split im susp................................................................................. 13 AFLURIA 2016-2017 -influenza virus vaccine split im susp................................................................................. 13 AFLURIA PF 2012-2013 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 13 AFLURIA PF 2014-2015 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 13 AFLURIA PF 2015-2016 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 13 AFLURIA PF 2016-2017 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 13 AFLURIA QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 13 AFREZZA -insulin regular (human) inhalation powder 4 unit/cartridge.................................................................... 35 AFREZZA -insulin regular (human) inhal powd 4 (30) & 8 (60) unit/cart.................................................................... 35 AFREZZA -insulin regular (human) inhal powd 4 (60) & 8 (30) unit/cart.................................................................... 35 AFREZZA -insulin regular (human) inhal powd 4 (90) & 8 (90) unit/cart.................................................................... 35 AFREZZA -insulin regular (human) inh powd 8 (60) & 12 (30) unit/cart.................................................................... 35 AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200 mg.................................................................................. 155 AKTEN -lidocaine hcl ophth gel 3.5%............................. 160 AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 70 ALA-QUIN -clioquinol-hc cream 3-0.5%..........................168 ALBENZA -albendazole tab 200 mg................................. 12 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 64 albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 64 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).............................................................................. 64 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).............................................................................. 64 albuterol sulfate syrup 2 mg/5ml................................... 64 albuterol sulfate tab 2 mg...............................................64 albuterol sulfate tab 4 mg...............................................64 albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 64
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
186
2016 albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 64 alclometasone dipropionate cream 0.05% (Aclovate)..................................................................... 168 alclometasone dipropionate oint 0.05%......................168 ALCORTIN A -iodoquinol-hydrocortisone-aloe polysaccharide gel 1-2-1%........................................... 168 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab 50-50 mg......................................................................... 54 ALECENSA -alectinib hcl cap 150 mg (base equivalent)....................................................................... 17 ALENDRONATE SODIUM -alendronate sodium oral soln 70 mg/75ml..................................................................... 39 ALENDRONATE SODIUM -alendronate sodium tab 40 mg.................................................................................... 39 alendronate sodium tab 5 mg........................................ 39 alendronate sodium tab 10 mg...................................... 39 alendronate sodium tab 35 mg...................................... 39 alendronate sodium tab 70 mg (Fosamax)................... 39 ALEVICYN ANTIPRURITIC SG -dermatological products misc - liquid................................................................... 168 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 76 ALINIA -nitazoxanide for susp 100 mg/5ml.......................12 ALINIA -nitazoxanide tab 500 mg..................................... 12 ALITRAQ -nutritional supplement pack........................... 131 ALKERAN -melphalan tab 2 mg....................................... 17 allopurinol tab 100 mg (Zyloprim)............................... 108 allopurinol tab 300 mg (Zyloprim)............................... 108 ALLZITAL -butalbital-acetaminophen tab 25-325 mg....... 95 almotriptan malate tab 6.25 mg (Axert).......................107 almotriptan malate tab 12.5 mg (Axert).......................107 ALOCRIL -nedocromil sodium ophth soln 2%................ 160 ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl tab 12.5-500 mg............................................................. 30 ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl tab 12.5-1000 mg........................................................... 30 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-15 mg...................................................................... 30 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-30 mg...................................................................... 30 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-45 mg...................................................................... 30 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-15 mg......................................................................... 30 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-30 mg......................................................................... 30 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-45 mg......................................................................... 30 ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base equiv)............................................................................... 30 ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base equiv)............................................................................... 30
ALOGLIPTIN -alogliptin benzoate tab 25 mg (base equiv)............................................................................... 30 ALOMIDE -lodoxamide tromethamine ophth soln 0.1%...............................................................................160 ALOQUIN -iodoquinol-aloe polysaccharides gel 1.25-1%......................................................................... 168 ALORA -estradiol td patch twice weekly 0.025 mg/24hr........................................................................... 25 ALORA -estradiol td patch twice weekly 0.05 mg/24hr..... 25 ALORA -estradiol td patch twice weekly 0.075 mg/24hr........................................................................... 25 ALORA -estradiol td patch twice weekly 0.1 mg/24hr....... 25 alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 72 alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 72 ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 160 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 250 unit......................................... 155 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 500 unit......................................... 155 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 1000 unit....................................... 155 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 1500 unit....................................... 155 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 2000 unit....................................... 155 ALPHANINE SD -coagulation factor ix for inj 500 unit................................................................................. 155 ALPHANINE SD -coagulation factor ix for inj 1000 unit................................................................................. 155 ALPHANINE SD -coagulation factor ix for inj 1500 unit................................................................................. 155 ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ ml..................................................................................... 77 alprazolam orally disintegrating tab 0.5 mg................. 77 alprazolam orally disintegrating tab 1 mg.................... 77 alprazolam orally disintegrating tab 2 mg.................... 77 alprazolam orally disintegrating tab 0.25 mg (Niravam)........................................................................ 77 alprazolam tab 0.25 mg (Xanax).................................... 77 alprazolam tab 0.5 mg (Xanax)...................................... 77 alprazolam tab 1 mg (Xanax)..........................................77 alprazolam tab 2 mg (Xanax)..........................................77 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 250 unit......................................................................... 155 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 500 unit......................................................................... 155 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 1000 unit....................................................................... 155
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
187
2016 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 2000 unit....................................................................... 155 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 3000 unit....................................................................... 155 ALREX -loteprednol etabonate ophth susp 0.2%........... 160 ALTABAX -retapamulin oint 1%.......................................168 ALTOPREV -lovastatin tab sr 24hr 20 mg........................ 56 ALTOPREV -lovastatin tab sr 24hr 40 mg........................ 56 ALTOPREV -lovastatin tab sr 24hr 60 mg........................ 56 ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 64 ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 64 AMANTADINE HCL -amantadine hcl tab 100 mg........... 114 amantadine hcl cap 100 mg......................................... 114 amantadine hcl syrup 50 mg/5ml................................ 114 AMCINONIDE -amcinonide cream 0.1%........................ 168 AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 154 AMICAR -aminocaproic acid tab 500 mg........................ 154 AMICAR -aminocaproic acid tab 1000 mg...................... 155 amiloride & hydrochlorothiazide tab 5-50 mg.............. 54 amiloride hcl tab 5 mg.................................................... 54 amino acids cap............................................................. 130 amino acids tab.............................................................. 130 amiodarone hcl tab 100 mg............................................ 46 amiodarone hcl tab 400 mg............................................ 46 amiodarone hcl tab 200 mg (Cordarone)...................... 46 AMITIZA -lubiprostone cap 8 mcg.................................... 72 AMITIZA -lubiprostone cap 24 mcg.................................. 72 amitriptyline hcl tab 10 mg............................................. 78 amitriptyline hcl tab 25 mg............................................. 78 amitriptyline hcl tab 50 mg............................................. 78 amitriptyline hcl tab 75 mg............................................. 78 amitriptyline hcl tab 100 mg........................................... 78 amitriptyline hcl tab 150 mg........................................... 78 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet)................................................................... 59 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet)................................................................... 59 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet)................................................................... 59 amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet).......................................................................... 59 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet).......................................................................... 59 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet).......................................................................... 59 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet).......................................................................... 59 amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet)................................................................... 59 amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet)................................................................... 59
amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet)................................................................... 59 amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet)................................................................... 59 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel)............................................................................ 47 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel)............................................................................ 47 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel)............................................................................ 47 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel)............................................................................ 47 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel)............................................................................ 47 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel)............................................................................ 47 amlodipine besylate-olmesartan medoxomil tab 5-20 mg (Azor)....................................................................... 47 amlodipine besylate-olmesartan medoxomil tab 5-40 mg (Azor)....................................................................... 47 amlodipine besylate-olmesartan medoxomil tab 10-20 mg (Azor)....................................................................... 47 amlodipine besylate-olmesartan medoxomil tab 10-40 mg (Azor)....................................................................... 47 amlodipine besylate tab 2.5 mg (Norvasc)................... 44 amlodipine besylate tab 5 mg (Norvasc)...................... 44 amlodipine besylate tab 10 mg (Norvasc).................... 44 amlodipine besylate-valsartan tab 5-160 mg (Exforge)......................................................................... 48 amlodipine besylate-valsartan tab 5-320 mg (Exforge)......................................................................... 48 amlodipine besylate-valsartan tab 10-160 mg (Exforge)......................................................................... 48 amlodipine besylate-valsartan tab 10-320 mg (Exforge)......................................................................... 48 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)........................................ 48 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg (Exforge hct)........................................... 48 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)...................................... 48 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg (Exforge hct)......................................... 48 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg (Exforge hct)......................................... 48 AMOXAPINE -amoxapine tab 25 mg................................ 78 AMOXAPINE -amoxapine tab 50 mg................................ 78 AMOXAPINE -amoxapine tab 100 mg.............................. 78 AMOXAPINE -amoxapine tab 150 mg.............................. 78 AMOXICILLIN/CLAVULANATE P -amoxicillin & k clavulanate chew tab 200-28.5 mg.................................. 1
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
188
2016 AMOXICILLIN/CLAVULANATE P -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 400-57 mg/5ml..... 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)..................................................................... 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 (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 amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr)................................................................... 88 amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr)................................................................... 88 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 tab 5 mg (Adderall)........................................................................ 88 amphetamine-dextroamphetamine tab 7.5 mg (Adderall)........................................................................ 88 amphetamine-dextroamphetamine tab 10 mg (Adderall)........................................................................ 88 amphetamine-dextroamphetamine tab 12.5 mg (Adderall)........................................................................ 88 amphetamine-dextroamphetamine tab 15 mg (Adderall)........................................................................ 88
amphetamine-dextroamphetamine tab 20 mg (Adderall)........................................................................ 88 amphetamine-dextroamphetamine tab 30 mg (Adderall)........................................................................ 88 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...................... 90 AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg............. 117 AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg............. 117 ANADROL-50 -oxymetholone tab 50 mg.......................... 24 anagrelide hcl cap 1 mg............................................... 156 anagrelide hcl cap 0.5 mg (Agrylin)............................ 155 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1%..........................................................167 ANASEPT -sodium hypochlorite liquid 0.057%.............. 180 anastrozole tab 1 mg (Arimidex)................................... 17 ANDROGEL PUMP -testosterone td gel 20.25 mg/act (1.62%)............................................................................ 24 ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)....... 24 ANDROGEL -testosterone td gel 50 mg/5gm (1%).......... 24 ANDROGEL -testosterone td gel 20.25 mg/1.25gm (1.62%)............................................................................ 24 ANDROGEL -testosterone td gel 40.5 mg/2.5gm (1.62%)............................................................................ 24 ANDROXY -fluoxymesterone tab 10 mg........................... 24 ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 25 ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 25 ANIMI-3/VITAMIN D -folic acid-b6-b12-d-omega 3phytosterols cap 1 mg.................................................. 148 ANIMI-3 -folic acid-b6-b12-d-omega 3-phytosterols cap 1 mg.................................................................................. 148 ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh.............................................................. 64 ANTARA -fenofibrate micronized cap 30 mg.................... 56 ANTARA -fenofibrate micronized cap 90 mg.................... 56 ANZEMET -dolasetron mesylate tab 50 mg..................... 70 ANZEMET -dolasetron mesylate tab 100 mg................... 70 APEXICON E -diflorasone diacetate emollient base cream 0.05%................................................................. 168 APIDRA -insulin glulisine inj 100 unit/ml........................... 35 APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj 100 unit/ml.......................................................................35 APLENZIN -bupropion hbr tab sr 24hr 174 mg.................78 APLENZIN -bupropion hbr tab sr 24hr 348 mg.................78 APLENZIN -bupropion hbr tab sr 24hr 522 mg.................78 APOKYN -apomorphine hydrochloride inj 10 mg/ml....... 114 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)...................................................................... 160 APRISO -mesalamine cap sr 24hr 0.375 gm.................... 72 APTIOM -eslicarbazepine acetate tab 200 mg............... 108
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
189
2016 APTIOM -eslicarbazepine acetate tab 400 mg............... 108 APTIOM -eslicarbazepine acetate tab 600 mg............... 109 APTIOM -eslicarbazepine acetate tab 800 mg............... 109 APTIVUS -tipranavir cap 250 mg........................................ 7 APTIVUS -tipranavir oral soln 100 mg/ml........................... 7 AQUORAL -artificial saliva - aero soln............................ 165 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25 mcg/ml........................................................................... 148 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40 mcg/ml........................................................................... 148 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60 mcg/ml........................................................................... 148 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100 mcg/ml........................................................................... 148 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200 mcg/ml........................................................................... 148 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 300 mcg/ml........................................................................... 148 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml..................................... 149 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml................................... 149 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml..................................... 149 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml..................................... 149 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml................................... 149 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml................................... 149 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml................................... 149 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml................................... 149 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 500 mcg/ml........................................ 149 ARCALYST -rilonacept for inj 220 mg.............................104 ARCAPTA NEOHALER -indacaterol maleate inhal powder cap 75 mcg (base equiv)................................................64 ARGIMENT -amino acids pack....................................... 130 ARGIMENT AT -amino acids pack.................................. 130 ARGINAID EXTRA -nutritional supplement liquid........... 131 ARGINAID -nutritional supplement pack......................... 131 aripiprazole orally disintegrating tab 10 mg.................82 aripiprazole orally disintegrating tab 15 mg.................82 aripiprazole oral solution 1 mg/ml................................. 82 aripiprazole tab 2 mg (Abilify)........................................ 82 aripiprazole tab 5 mg (Abilify)........................................ 82 aripiprazole tab 10 mg (Abilify)...................................... 82 aripiprazole tab 15 mg (Abilify)...................................... 82 aripiprazole tab 20 mg (Abilify)...................................... 82 aripiprazole tab 30 mg (Abilify)...................................... 82
ARMODAFINIL -armodafinil tab 200 mg........................... 88 armodafinil tab 50 mg (Nuvigil)......................................88 armodafinil tab 150 mg (Nuvigil)................................... 88 armodafinil tab 250 mg (Nuvigil)................................... 88 ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 36 ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 36 ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 36 ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 36 ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 36 ASACOL HD -mesalamine tab delayed release 800 mg.................................................................................... 72 ASCENSIA AUTODISC TEST ST -glucose blood test disk................................................................................ 180 ASMANEX TWISTHALER 120 ME -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 64 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 110 mcg/inh (breath activated).................... 64 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 64 ASMANEX TWISTHALER 60 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 64 A-SOY -nutritional supplement liquid.............................. 131 ASPIRIN/DIPYRIDAMOLE -aspirin-dipyridamole cap sr 12hr 25-200 mg............................................................ 156 ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 96 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.............. 182 ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 182 ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 182 ASTERO -lidocaine hcl gel 4%....................................... 168 ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr 29-1 mg......................................................................... 119 ATELVIA -risedronate sodium tab delayed release 35 mg.................................................................................... 39 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50).................................................................................... 48 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100).................................................................................. 48 atenolol tab 25 mg (Tenormin)....................................... 43 atenolol tab 50 mg (Tenormin)....................................... 43 atenolol tab 100 mg (Tenormin)..................................... 43 ATGAM -lymphocyte immune globulin anti-thymocyte g inj 50 mg/ml(eq)................................................................. 182 ATOPICLAIR -dermatological products misc - cream..... 168 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)........................................................................... 56 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)........................................................................... 56
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
190
2016 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)........................................................................... 56 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)........................................................................... 56 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)...................................................................... 11 atovaquone-proguanil hcl tab 250-100 mg (Malarone)...................................................................... 11 atovaquone susp 750 mg/5ml (Mepron)....................... 12 ATRAPRO CP -wound dressings - kit............................. 168 ATRAPRO DERMAL SPRAY -wound cleansers liquid.............................................................................. 168 ATRIPLA -efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg................................................................7 ATROPINE SULFATE -atropine sulfate ophth oint 1%.................................................................................. 161 ATROPINE SULFATE -atropine sulfate ophth soln 1%.................................................................................. 161 ATROVENT HFA -ipratropium bromide hfa inhal aerosol 17 mcg/act.......................................................................64 AUBAGIO -teriflunomide tab 7 mg.................................... 90 AUBAGIO -teriflunomide tab 14 mg.................................. 90 AUGMENTIN -amoxicillin & k clavulanate for susp 125-31.25 mg/5ml............................................................. 1 AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)....... 72 AVANDIA -rosiglitazone maleate tab 2 mg (base equiv)............................................................................... 30 AVANDIA -rosiglitazone maleate tab 4 mg (base equiv)............................................................................... 30 AVAR -sulfacetamide sodium w/ sulfur cleansing pad 9.5-5%........................................................................... 168 AVC -sulfanilamide vaginal cream 15%............................ 75 AVENOVA/NEUTROX -eyelid cleansers - liquid............. 168 AVENOVA -eyelid cleansers - liquid................................168 AVODART -dutasteride cap 0.5 mg.................................. 76 AVONEX -interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial)....................................................... 90 AVONEX -interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml........................................................................ 90 AVONEX PEN -interferon beta-1a im auto-injector kit 30 mcg/0.5ml........................................................................ 91 AXERT -almotriptan malate tab 6.25 mg........................ 107 AXERT -almotriptan malate tab 12.5 mg........................ 107 AXIRON -testosterone td soln 30 mg/act.......................... 24 AZASAN -azathioprine tab 75 mg................................... 182 AZASAN -azathioprine tab 100 mg................................. 182 AZASITE -azithromycin ophth soln 1%........................... 161 azathioprine tab 50 mg (Imuran).................................. 182 azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 61 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro).........................................................................61 azelastine hcl ophth soln 0.05%.................................. 161
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...................................................................................... 3 azithromycin for susp 100 mg/5ml (Zithromax)............. 3 azithromycin for susp 200 mg/5ml (Zithromax)............. 3 azithromycin tab 250 mg (Zithromax)............................. 3 azithromycin tab 500 mg (Zithromax)............................. 3 azithromycin tab 600 mg (Zithromax)............................. 3 AZOPT -brinzolamide ophth susp 1%............................. 161 AZOR -amlodipine besylate-olmesartan medoxomil tab 5-20 mg........................................................................... 48 AZOR -amlodipine besylate-olmesartan medoxomil tab 5-40 mg........................................................................... 48 AZOR -amlodipine besylate-olmesartan medoxomil tab 10-20 mg......................................................................... 48 AZOR -amlodipine besylate-olmesartan medoxomil tab 10-40 mg......................................................................... 48 B BABY DDROPS -cholecalciferol drops 400 unit/0.03ml (per drop)...................................................................... 118 BACITRACIN -bacitracin ophth oint 500 unit/gm............ 161 bacitracin-polymyxin b ophth oint.............................. 161 bacitracin-polymyxin-neomycin-hc ophth oint 1%.................................................................................. 161 baclofen tab 10 mg........................................................ 117 baclofen tab 20 mg........................................................ 117 BACTROBAN NASAL -mupirocin calcium nasal oint 2%.................................................................................... 61 BALANCED NUTRITIONAL DRIN -nutritional supplement liquid.............................................................................. 131 BALANCED NUTRITIONAL SHAK -nutritional supplement liquid.......................................................... 131 BALANCE TOTAL NUTRITIONAL -nutritional supplement liquid.............................................................................. 131 BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg................................................... 119 balsalazide disodium cap 750 mg (Colazal)................. 72 BANZEL -rufinamide susp 40 mg/ml............................... 109 BANZEL -rufinamide tab 200 mg.................................... 109 BANZEL -rufinamide tab 400 mg.................................... 109 BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7 BAYER BREEZE 2 TEST DISC -glucose blood test disk................................................................................ 181 BAYER CONTOUR BLOOD GLUCO -glucose blood test strip................................................................................ 181 BAYER CONTOUR NEXT BLOOD -glucose blood test strip................................................................................ 181 BCAD 1 -nutritional supplement powder......................... 131
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
191
2016 BCAD 2 -nutritional supplement powder......................... 131 b-complex w/ c & folic acid cap 1 mg (Nephrocaps)............................................................... 119 b-complex w/ c & folic acid tab 5 mg.......................... 119 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).................................................................................. 119 BD GLUCOSE -glucose chew tab 5 gm........................... 30 BEAU RX -scar treatment products - gel........................ 168 BEBULIN -factor ix complex for inj 200-1200 unit.......... 156 BELBUCA -buprenorphine hcl buccal film 75 mcg (base equivalent)....................................................................... 96 BELBUCA -buprenorphine hcl buccal film 150 mcg (base equivalent)....................................................................... 96 BELBUCA -buprenorphine hcl buccal film 300 mcg (base equivalent)....................................................................... 96 BELBUCA -buprenorphine hcl buccal film 450 mcg (base equivalent)....................................................................... 96 BELBUCA -buprenorphine hcl buccal film 600 mcg (base equivalent)....................................................................... 96 BELBUCA -buprenorphine hcl buccal film 750 mcg (base equivalent)....................................................................... 96 BELBUCA -buprenorphine hcl buccal film 900 mcg (base equivalent)....................................................................... 96 BELLADONNA & OPIUM -belladonna alkaloids & opium suppos 16.2-30 mg......................................................... 68 BELLADONNA ALKALOIDS & OP -belladonna alkaloids & opium suppos 16.2-60 mg.......................................... 68 benazepril & hydrochlorothiazide tab 5-6.25 mg......... 48 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)................................................................ 48 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)................................................................ 48 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)................................................................ 48 benazepril hcl tab 5 mg.................................................. 48 benazepril hcl tab 10 mg (Lotensin).............................. 48 benazepril hcl tab 20 mg (Lotensin).............................. 48 benazepril hcl tab 40 mg (Lotensin).............................. 48 BENECALORIE -nutritional supplement liquid................ 131 BENEFIX -coagulation factor ix (recombinant) for inj kit 250 unit......................................................................... 156 BENEFIX -coagulation factor ix (recombinant) for inj kit 500 unit......................................................................... 156 BENEFIX -coagulation factor ix (recombinant) for inj kit 1000 unit....................................................................... 156 BENEFIX -coagulation factor ix (recombinant) for inj kit 2000 unit....................................................................... 156 BENEFIX -coagulation factor ix (recombinant) for inj kit 3000 unit....................................................................... 156 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg...............................48
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg...............................48 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................. 49 BENICAR -olmesartan medoxomil tab 5 mg.....................48 BENICAR -olmesartan medoxomil tab 20 mg...................48 BENICAR -olmesartan medoxomil tab 40 mg...................48 BENSAL HP -salicylic acid & benzoic acid oint 3-6%..... 169 BENZIQ -benzoyl peroxide gel 5.25 %........................... 169 BENZIQ LS -benzoyl peroxide gel 2.75%....................... 169 benzocaine dental soln 20%.........................................165 BENZONATATE -benzonatate cap 150 mg...................... 62 benzonatate cap 200 mg................................................. 62 benzonatate cap 100 mg (Tessalon perles).................. 62 benzoyl peroxide cloth 6%........................................... 169 benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit..................................................................... 169 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)............................................................... 169 benzoyl peroxide foam 5.3% (Benzefoam)................. 169 benzoyl peroxide foam 9.8% (Benzefoamultra)......... 169 benzoyl peroxide liq 2.5%.............................................169 benzoyl peroxide liq 5.25%...........................................169 benzoyl peroxide liq 7%................................................169 benzoyl peroxide lotion 6%.......................................... 169 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%.......... 161 BERINERT -c1 esterase inhibitor (human) for iv inj kit 500 unit................................................................................. 156 BESIVANCE -besifloxacin hcl ophth susp 0.6% (base equiv)............................................................................. 161 BETADINE OPHTHALMIC PREP -povidone-iodine ophth soln 5%......................................................................... 161 betamethasone dipropionate augmented cream 0.05% (Diprolene af)............................................................... 169 betamethasone dipropionate augmented gel 0.05%.............................................................................169 betamethasone dipropionate augmented lotion 0.05% (Diprolene)................................................................... 169 betamethasone dipropionate augmented oint 0.05% (Diprolene)................................................................... 169 betamethasone dipropionate cream 0.05%................ 169 betamethasone dipropionate lotion 0.05%................. 169 betamethasone dipropionate oint 0.05%.................... 169 betamethasone valerate aerosol foam 0.12% (Luxiq)........................................................................... 169 betamethasone valerate cream 0.1%.......................... 169 betamethasone valerate lotion 0.1%........................... 169 betamethasone valerate oint 0.1%.............................. 169 BETASERON -interferon beta-1b for inj kit 0.3 mg........... 91
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
192
2016 betaxolol hcl ophth soln 0.5%......................................161 betaxolol hcl tab 10 mg (Kerlone)................................. 43 betaxolol hcl tab 20 mg (Kerlone)................................. 43 bethanechol chloride tab 5 mg (Urecholine)................ 74 bethanechol chloride tab 10 mg (Urecholine).............. 74 bethanechol chloride tab 25 mg (Urecholine).............. 74 bethanechol chloride tab 50 mg (Urecholine).............. 75 BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 5 BETIMOL -timolol ophth soln 0.25%............................... 161 BETIMOL -timolol ophth soln 0.5%................................. 161 BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 161 BEVESPI -glycopyrrolate-formoterol fumarate aerosol 9-4.8 mcg/act.................................................................. 64 bexarotene cap 75 mg (Targretin)..................................17 BEYAZ -drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg..............................................................27 B-6 FOLIC ACID -cobalamine combination cap............. 149 bicalutamide tab 50 mg (Casodex)................................ 17 BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg.................................................................................... 59 BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg........................................................... 149 BILTRICIDE -praziquantel tab 600 mg.............................. 12 BIMATOPROST -bimatoprost ophth soln 0.03%............ 161 BINOSTO -alendronate sodium effervescent tab 70 mg.................................................................................... 39 BIO-STATIN -nystatin cap 500000 unit............................... 6 BIO-STATIN -nystatin cap 1000000 unit............................. 6 bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit..................................................................................... 67 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)............................................................................... 49 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)............................................................................... 49 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)............................................................................... 49 bisoprolol fumarate tab 5 mg (Zebeta)..........................43 bisoprolol fumarate tab 10 mg (Zebeta)........................43 BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 161 BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth susp 10-0.2%................................................................ 161 BLOOD GLUCOSE CALIBRATION LIQUIDVARIOUS....................................................................... 181 BOOST/BENEFIBER -nutritional supplement liquid....... 132 BOOST BREEZE -nutritional supplement liquid............. 131 BOOST CALORIE SMART -nutritional supplement liquid.............................................................................. 131 BOOST 100 CALORIE SMART -nutritional supplement liquid.............................................................................. 132 BOOST COMPACT -nutritional supplement liquid.......... 131
BOOST GLUCOSE CONTROL -nutritional supplement liquid.............................................................................. 131 BOOST HIGH PROTEIN -nutritional supplement liquid.............................................................................. 131 BOOST HIGH PROTEIN -nutritional supplement powder........................................................................... 131 BOOST KID ESSENTIALS 1.0 -nutritional supplement liquid.............................................................................. 131 BOOST KID ESSENTIALS 1.5 -nutritional supplement liquid.............................................................................. 131 BOOST KIDS ESSENTIALS -nutritional supplement liquid.............................................................................. 131 BOOST -nutritional supplement liquid............................. 131 BOOST PLUS -nutritional supplement liquid.................. 131 BOOST PUDDING -nutritional supplement pudding.......132 BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 16 BOOST SMOOTHIE -nutritional supplement liquid........ 132 BOOST VHC -nutritional supplement liquid.................... 132 BOSULIF -bosutinib tab 100 mg....................................... 17 BOSULIF -bosutinib tab 500 mg....................................... 17 BP CLEANSING WASH -sulfacetamide sodium-sulfur in urea emulsion 10-4%................................................... 169 BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg....................................................... 119 BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg.............................................................. 119 BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa tab chew 40-1 mg......................................................... 119 BP VIT 3 -folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg....................................................................... 149 BREATHERITE COLLAPSIBLE -spacer/aerosol-holding chambers - device........................................................ 181 BREATHERITE RIGID SPACER -spacer/aerosol-holding chambers - device........................................................ 181 BREATHERITE -spacer/aerosol-holding chambers device............................................................................ 181 BREATHERITE VALVED MDI CH -respiratory therapy supplies - devices......................................................... 181 BREATHERITE W/LARGE MASK -spacer/aerosol-holding chambers - device........................................................ 181 BREATHERITE W/MEDIUM MASK -spacer/aerosolholding chambers - device........................................... 181 BREATHERITE W/SMALL MASK -spacer/aerosol-holding chambers - device........................................................ 181 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh.......................................................... 64 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh.......................................................... 64 BRILINTA -ticagrelor tab 60 mg...................................... 156 BRILINTA -ticagrelor tab 90 mg...................................... 156 brimonidine tartrate ophth soln 0.2%......................... 161
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
193
2016 brimonidine tartrate ophth soln 0.15% (Alphagan p)................................................................................... 161 BRISDELLE -paroxetine mesylate cap 7.5 mg (base equiv)............................................................................... 91 BRIVIACT -brivaracetam oral soln 10 mg/ml.................. 109 BRIVIACT -brivaracetam tab 10 mg............................... 109 BRIVIACT -brivaracetam tab 25 mg............................... 109 BRIVIACT -brivaracetam tab 50 mg............................... 109 BRIVIACT -brivaracetam tab 75 mg............................... 109 BRIVIACT -brivaracetam tab 100 mg............................. 109 BROMFENAC -bromfenac sodium ophth soln 0.09% (base equivalent).......................................................... 161 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily).................................................................. 161 bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel)...................................................................... 114 bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel)...................................................................... 114 brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg........................................................................... 62 brompheniramine maleate tab sr 12hr 6 mg................ 60 BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml (base equiv).................................................................... 64 budesonide delayed release particles cap 3 mg (Entocort ec).................................................................. 22 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)......................................................................65 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......................................................................65 budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 65 budesonide nasal susp 32 mcg/act (Rhinocort aqua)............................................................................... 61 bumetanide tab 0.5 mg................................................... 54 bumetanide tab 1 mg...................................................... 54 bumetanide tab 2 mg...................................................... 54 BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3 mg (base equiv).............................................................. 96 BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7 mg (base equiv).............................................................. 96 BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg (base equiv).................................................................... 96 BUPAP -butalbital-acetaminophen tab 50-300 mg........... 95 BUPHENYL -sodium phenylbutyrate tab 500 mg............. 39 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv).............................................................................. 96 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv).............................................................................. 96 buprenorphine hcl sl tab 2 mg (base equiv)................ 96 buprenorphine hcl sl tab 8 mg (base equiv)................ 96 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban)............................................................................ 91 bupropion hcl tab 75 mg (Wellbutrin)........................... 78
bupropion hcl tab 100 mg (Wellbutrin)......................... 78 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 78 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 78 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 78 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 78 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 78 buspirone hcl tab 5 mg................................................... 77 buspirone hcl tab 7.5 mg................................................ 77 buspirone hcl tab 10 mg................................................. 77 buspirone hcl tab 15 mg................................................. 77 buspirone hcl tab 30 mg................................................. 77 butalbital-acetaminophen-caffeine cap 50-325-40 mg................................................................................... 95 butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet)......................................................................... 95 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)............................................................................. 95 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg............................................................ 96 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine)............................ 96 butalbital-acetaminophen tab 50-325 mg......................95 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)......................................................................... 95 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)..................................................... 97 BUTISOL SODIUM -butabarbital sodium tab 30 mg.........87 butorphanol tartrate nasal soln 10 mg/ml.................... 97 BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......97 BUTRANS -buprenorphine td patch weekly 7.5 mcg/ hr...................................................................................... 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 BYDUREON -exenatide for inj extended release susp 2 mg.................................................................................... 30 BYDUREON PEN -exenatide extended release for susp pen-injector 2 mg............................................................ 30 BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 30 BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 30 BYSTOLIC -nebivolol hcl tab 2.5 mg (base equivalent)....................................................................... 43 BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......43 BYSTOLIC -nebivolol hcl tab 10 mg (base equivalent)....................................................................... 43 BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)....................................................................... 43 BYVALSON -nebivolol-valsartan tab 5-80 mg.................. 49
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
194
2016 C cabergoline tab 0.5 mg................................................... 39 CABOMETYX -cabozantinib s-malate tab 20 mg (base equivalent)....................................................................... 17 CABOMETYX -cabozantinib s-malate tab 40 mg (base equivalent)....................................................................... 18 CABOMETYX -cabozantinib s-malate tab 60 mg (base equivalent)....................................................................... 18 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv).............................................................................. 88 CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag wafer 1342-1.6 mg........................................................128 CALCILO XD -infant foods powder................................. 132 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex)............................................ 169 calcipotriene cream 0.005% (Dovonex).......................169 calcipotriene oint 0.005%..............................................169 calcipotriene soln 0.005% (50 mcg/ml)....................... 169 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)...................................................................... 39 CALCITRIOL -calcitriol oint 3 mcg/gm............................ 169 calcitriol cap 0.25 mcg (Rocaltrol)................................. 39 calcitriol cap 0.5 mcg (Rocaltrol)................................... 39 calcitriol oral soln 1 mcg/ml (Rocaltrol)........................39 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)............................................................. 72 calcium acetate (phosphate binder) tab 667 mg (Eliphos)......................................................................... 72 CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg........................... 128 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................ 107 CAMINO PRO BETTERMILK/GLY -nutritional supplement pack............................................................................... 132 CAMINO PRO COMPLETE/GLYTA -nutritional supplement bar............................................................. 132 CAMINO PRO 15PE -nutritional supplement liquid........ 132 CAMINO PRO PKU -nutritional supplement liquid..........132 CAMINO PRO RESTORE/GLYTAC -nutritional supplement liquid.......................................................... 132 CAMINO PRO SWIRL -nutritional supplement pack...... 132 CANASA -mesalamine suppos 1000 mg.......................... 72 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand hct).......................................................... 49 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct).......................................................... 49 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand hct).......................................................... 49 candesartan cilexetil tab 4 mg (Atacand)..................... 49 candesartan cilexetil tab 8 mg (Atacand)..................... 49
candesartan cilexetil tab 16 mg (Atacand)................... 49 candesartan cilexetil tab 32 mg (Atacand)................... 49 CAPCOF -phenylephrine-chlorphen w/ codeine syrup 5-2-10 mg/5ml................................................................. 62 capecitabine tab 150 mg (Xeloda)................................. 18 capecitabine tab 500 mg (Xeloda)................................. 18 CAPEX -fluocinolone acetonide shampoo 0.01%........... 169 CAPHOSOL -artificial saliva - solution............................ 165 CAPITAL/CODEINE -acetaminophen w/ codeine susp 120-12 mg/5ml................................................................ 97 CAPRELSA -vandetanib tab 100 mg................................ 18 CAPRELSA -vandetanib tab 300 mg................................ 18 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 25-15 mg.................................. 49 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 25-25 mg.................................. 49 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 50-15 mg.................................. 49 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 50-25 mg.................................. 49 captopril tab 12.5 mg...................................................... 49 captopril tab 25 mg......................................................... 49 captopril tab 50 mg......................................................... 49 captopril tab 100 mg....................................................... 49 CARAC -fluorouracil cream 0.5%.................................... 169 CARAFATE -sucralfate susp 1 gm/10ml........................... 68 CARBAGLU -carglumic acid tab 200 mg.......................... 39 carbamazepine cap sr 12hr 100 mg (Carbatrol)......... 109 carbamazepine cap sr 12hr 200 mg (Carbatrol)......... 109 carbamazepine cap sr 12hr 300 mg (Carbatrol)......... 109 carbamazepine chew tab 100 mg................................ 109 carbamazepine susp 100 mg/5ml (Tegretol)............... 109 carbamazepine tab 200 mg (Tegretol)......................... 109 carbamazepine tab sr 12hr 100 mg (Tegretol-xr)....... 109 carbamazepine tab sr 12hr 200 mg (Tegretol-xr)....... 109 carbamazepine tab sr 12hr 400 mg (Tegretol-xr)....... 109 CARBATROL -carbamazepine cap sr 12hr 100 mg....... 109 CARBATROL -carbamazepine cap sr 12hr 200 mg....... 109 CARBATROL -carbamazepine cap sr 12hr 300 mg....... 109 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 115 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 115 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
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
195
2016 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 cr 25-100 mg (Sinemet cr).................................................................................. 114 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr).................................................................................. 114 carbidopa & levodopa tab 10-100 mg (Sinemet)........ 114 carbidopa & levodopa tab 25-100 mg (Sinemet)........ 115 carbidopa & levodopa tab 25-250 mg (Sinemet)........ 115 carbidopa tab 25 mg (Lodosyn)................................... 115 carbinoxamine maleate soln 4 mg/5ml......................... 60 carbinoxamine maleate tab 4 mg.................................. 60 carbonyl iron susp 15 mg/1.25ml (elemental iron)............................................................................... 149 CARDIOTEK-RX -folic acid-b12-b6-arginine-black pepper tab.................................................................................. 132 CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap 240-360-20-0.5-0.8 mg................................................. 130 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 120 mg............................................................................ 44 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 tab 250 mg (Soma)................................. 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 CARNATION BREAKFAST ESSEN -nutritional supplement liquid.......................................................... 132 CARNATION BREAKFAST ESSEN -nutritional supplement pack........................................................... 132 CARNATION INSTANT BREAKFA -nutritional supplement liquid.............................................................................. 132 carteolol hcl ophth soln 1%......................................... 161 carvedilol tab 3.125 mg (Coreg)..................................... 43 carvedilol tab 6.25 mg (Coreg)....................................... 43 carvedilol tab 12.5 mg (Coreg)....................................... 43 carvedilol tab 25 mg (Coreg).......................................... 43 CAYA -diaphragm arc-spring........................................... 181 CAYSTON -aztreonam lysine for inhal soln 75 mg (base equivalent)....................................................................... 12 C-BUFF -multiple vitamins w/ minerals powder.............. 119 CEDAX -ceftibuten cap 400 mg.......................................... 2 CEDAX -ceftibuten for susp 180 mg/5ml............................ 2 cefaclor cap 250 mg.......................................................... 2 cefaclor cap 500 mg.......................................................... 2
CEFACLOR -cefaclor for susp 125 mg/5ml........................ 2 CEFACLOR -cefaclor for susp 250 mg/5ml........................ 2 CEFACLOR -cefaclor for susp 375 mg/5ml........................ 2 CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500 mg...................................................................................... 2 cefadroxil cap 500 mg....................................................... 2 cefadroxil for susp 250 mg/5ml....................................... 2 cefadroxil for susp 500 mg/5ml....................................... 2 cefadroxil tab 1 gm............................................................ 2 cefdinir cap 300 mg........................................................... 2 cefdinir for susp 125 mg/5ml........................................... 2 cefdinir for susp 250 mg/5ml........................................... 2 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg (base equivalent).............................................................. 2 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg (base equivalent).............................................................. 2 cefixime for susp 100 mg/5ml (Suprax).......................... 2 cefixime for susp 200 mg/5ml (Suprax).......................... 2 cefpodoxime proxetil for susp 50 mg/5ml...................... 2 cefpodoxime proxetil for susp 100 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 cefuroxime axetil tab 250 mg (Ceftin)............................. 2 cefuroxime axetil tab 500 mg (Ceftin)............................. 2 celecoxib cap 50 mg (Celebrex).................................. 104 celecoxib cap 100 mg (Celebrex)................................ 104 celecoxib cap 200 mg (Celebrex)................................ 104 celecoxib cap 400 mg (Celebrex)................................ 104 CELONTIN -methsuximide cap 300 mg.......................... 109 CEM-UREA -urea soln 45%............................................ 169 CENTANY -mupirocin oint 2%.........................................169 CENTRATEX -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg.................................................... 149 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...................................... 3 CERACADE -dermatological products misc emulsion........................................................................ 169 CERDELGA -eliglustat tartrate cap 84 mg (base equivalent)..................................................................... 149
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
196
2016 CEREFOLIN -l-methylfolate w/ vit b12-vit b6-vit b2 tab 6-1-50-5 mg.................................................................. 132 CERVIDIL -dinoprostone vaginal inserts 10 mg............... 38 CESAMET -nabilone cap 1 mg......................................... 70 CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base equivalent)..................................................................... 165 CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 180 CETYLEV -acetylcysteine effervescent tab 500 mg....... 180 cevimeline hcl cap 30 mg (Evoxac)............................. 165 CHANTIX CONTINUING MONTH -varenicline tartrate tab 1 mg (base equiv).......................................................... 91 CHANTIX STARTING MONTH PA -varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack.................................91 CHANTIX -varenicline tartrate tab 0.5 mg (base equiv)............................................................................... 91 CHANTIX -varenicline tartrate tab 1 mg (base equiv).......91 CHEMET -succimer cap 100 mg.................................... 180 CHENODAL -chenodiol tab 250 mg................................. 72 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................. 91 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg.............................................. 91 chlordiazepoxide hcl cap 5 mg...................................... 77 chlordiazepoxide hcl cap 10 mg.................................... 77 chlordiazepoxide hcl cap 25 mg.................................... 77 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg (Librax)........................................................................... 68 chlorhexidine gluconate soln 0.12% (Peridex)...........165 chloroquine phosphate tab 250 mg.............................. 11 chloroquine phosphate tab 500 mg (Aralen)................ 11 CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 54 chlorothiazide tab 500 mg.............................................. 54 chlorpromazine hcl tab 10 mg....................................... 82 chlorpromazine hcl tab 25 mg....................................... 82 chlorpromazine hcl tab 50 mg....................................... 83 chlorpromazine hcl tab 100 mg..................................... 83 chlorpromazine hcl tab 200 mg..................................... 83 CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 31 CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 31 CHLORTHALIDONE -chlorthalidone tab 100 mg............. 54 chlorthalidone tab 25 mg................................................ 54 chlorzoxazone tab 500 mg (Parafon forte dsc).......... 117 CHOICE DM -nutritional supplement liquid.....................132 CHOICE DM TF -nutritional supplement liquid............... 132 CHOLBAM -cholic acid cap 50 mg................................... 72 CHOLBAM -cholic acid cap 250 mg................................. 72 cholecalciferol cap 400 unit......................................... 118 cholecalciferol cap 1000 unit....................................... 118 cholecalciferol cap 50000 unit..................................... 118 cholecalciferol chew tab 400 unit................................ 118 cholecalciferol chew tab 1000 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 400 unit.......................................... 118 cholecalciferol tab 1000 unit........................................ 118 cholecalciferol tab 50000 unit...................................... 118 cholestyramine light powder 4 gm/dose (Questran light)................................................................................ 56 cholestyramine light powder packets 4 gm................. 56 cholestyramine powder 4 gm/dose (Questran)............ 56 cholestyramine powder packets 4 gm (Questran)....... 56 CHOLEXTRA -nutritional supplement powder................ 132 choline & magnesium salicylates liq 500 mg/5ml........ 95 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix).............................................................. 56 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix).............................................................. 56 CHOLINE MAGNESIUM TRISALI -choline & magnesium salicylates tab 1000 mg..................................................95 CIALIS -tadalafil tab 2.5 mg......................................... 59,60 CIALIS -tadalafil tab 5 mg............................................ 59,60 ciclopirox gel 0.77%...................................................... 169 ciclopirox olamine cream 0.77% (base equiv)............169 ciclopirox olamine susp 0.77% (base equiv).............. 169 ciclopirox shampoo 1% (Loprox shampoo)............... 169 ciclopirox solution 8% (Penlac Nail Lacquer)............ 170 CIFEREX -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 149 cilostazol tab 50 mg (Pletal)......................................... 156 cilostazol tab 100 mg (Pletal)....................................... 156 CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 161 cimetidine hcl soln 300 mg/5ml..................................... 68 cimetidine tab 300 mg..................................................... 68 cimetidine tab 400 mg..................................................... 68 cimetidine tab 800 mg..................................................... 68 CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 72 CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200 mg/ml............................................................................... 72 CIPRODEX -ciprofloxacin-dexamethasone otic susp 0.3-0.1%........................................................................ 165 CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base equivalent)..................................................................... 165 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr)................................................... 5 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr)........................................................ 5 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro)........................................................... 5 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)........................................................... 5 CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg (base equiv)...................................................................... 5
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
197
2016 ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 161 ciprofloxacin hcl tab 750 mg (base equiv)..................... 5 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 5 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 5 CIPRO HC -ciprofloxacin-hydrocortisone otic susp 0.2-1%........................................................................... 165 citalopram hydrobromide oral soln 10 mg/5ml............ 78 citalopram hydrobromide tab 10 mg (base equiv) (Celexa)........................................................................... 78 citalopram hydrobromide tab 20 mg (base equiv) (Celexa)........................................................................... 78 citalopram hydrobromide tab 40 mg (base equiv) (Celexa)........................................................................... 78 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............................................. 119 CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack............................................... 119 CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak........................................ 119 CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................ 119 CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg.........................................................119 CITRUS BERGAMOT -citrus bergamot oral powder 250 mg/0.25 gm................................................................... 181 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.................................. 3 CLEMASTINE FUMARATE -clemastine fumarate tab 2.68 mg.................................................................................... 60 CLEOCIN -clindamycin phosphate vaginal suppos 100 mg.................................................................................... 75 CLICK ESPRESSO PROTEIN DR -nutritional supplement powder........................................................................... 132 CLIMARA PRO -estradiol-levonorgestrel td patch weekly 0.045-0.015 mg/day........................................................ 25 clindamycin hcl cap 75 mg (Cleocin)............................ 12 clindamycin hcl cap 150 mg (Cleocin).......................... 12 clindamycin hcl cap 300 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)................................................................... 170 clindamycin phosphate foam 1% (Evoclin)................ 170 clindamycin phosphate gel 1% (Cleocin-t)................. 170 clindamycin phosphate lotion 1% (Cleocin-t)............ 170 clindamycin phosphate soln 1% (Cleocin-t)............... 170 clindamycin phosphate swab 1% (Cleocin-t)............. 170
clindamycin phosphate-tretinoin gel 1.2-0.025% (Ziana)........................................................................... 170 clindamycin phosphate vaginal cream 2% (Cleocin)......................................................................... 75 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)............................................................... 170 CLINDESSE -clindamycin phosphate (one dose) vaginal cream 2%........................................................................ 75 clobetasol propionate cream 0.05% (Temovate)........ 170 clobetasol propionate emollient base cream 0.05% (Temovate e)................................................................ 170 clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 170 clobetasol propionate foam 0.05% (Olux).................. 170 clobetasol propionate gel 0.05% (Temovate)............. 170 clobetasol propionate lotion 0.05% (Clobex)............. 170 clobetasol propionate oint 0.05% (Temovate)............ 170 clobetasol propionate shampoo 0.05% (Clobex)....... 170 clobetasol propionate soln 0.05% (Temovate)........... 170 clobetasol propionate spray 0.05% (Clobex)............. 170 CLOCORTOLONE PIVALATE -clocortolone pivalate cream 0.1%................................................................... 170 CLOCORTOLONE PIVALATE PUM -clocortolone pivalate cream 0.1%................................................................... 170 CLODERM -clocortolone pivalate cream 0.1%............... 170 CLODERM PUMP -clocortolone pivalate cream 0.1%...............................................................................170 clomipramine hcl cap 25 mg (Anafranil)....................... 78 clomipramine hcl cap 50 mg (Anafranil)....................... 78 clomipramine hcl cap 75 mg (Anafranil)....................... 78 clonazepam orally disintegrating tab 0.125 mg......... 109 clonazepam orally disintegrating tab 0.25 mg........... 109 clonazepam orally disintegrating tab 0.5 mg............. 109 clonazepam orally disintegrating tab 1 mg................ 109 clonazepam orally disintegrating tab 2 mg................ 109 clonazepam tab 0.5 mg (Klonopin).............................. 109 clonazepam tab 1 mg (Klonopin)................................. 109 clonazepam tab 2 mg (Klonopin)................................. 109 clonidine hcl tab 0.1 mg (Catapres).............................. 49 clonidine hcl tab 0.2 mg (Catapres).............................. 49 clonidine hcl tab 0.3 mg (Catapres).............................. 49 clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 88 clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 49 clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 49 clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 49 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix).......................................................................... 156 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix).......................................................................... 156
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
198
2016 clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 77 clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 77 clorazepate dipotassium tab 15 mg (Tranxene t)......... 77 CLORPRES -clonidine & chlorthalidone tab 0.1-15 mg.................................................................................... 49 CLORPRES -clonidine & chlorthalidone tab 0.2-15 mg.................................................................................... 49 CLORPRES -clonidine & chlorthalidone tab 0.3-15 mg.................................................................................... 50 clotrimazole troche 10 mg............................................ 165 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone).................................................................... 170 clotrimazole w/ betamethasone lotion 1-0.05%..........170 CLOZAPINE ODT -clozapine orally disintegrating tab 12.5 mg.................................................................................... 83 CLOZAPINE ODT -clozapine orally disintegrating tab 150 mg.................................................................................... 83 CLOZAPINE ODT -clozapine orally disintegrating tab 200 mg.................................................................................... 83 clozapine orally disintegrating tab 25 mg (Fazaclo)......................................................................... 83 clozapine orally disintegrating tab 100 mg (Fazaclo)......................................................................... 83 clozapine tab 50 mg........................................................ 83 clozapine tab 200 mg...................................................... 83 clozapine tab 25 mg (Clozaril)........................................83 clozapine tab 100 mg (Clozaril)..................................... 83 C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................. 119 COAGADEX -coagulation factor x (human) for inj 250 unit................................................................................. 156 COAGADEX -coagulation factor x (human) for inj 500 unit................................................................................. 156 COAL TAR -coal tar soln 20%........................................ 170 COARTEM -artemether-lumefantrine tab 20-120 mg....... 11 CO-BALAMIN -ubiquinol-vit b12-resveratrol-fa cap 200-5-400-0.8 mg......................................................... 181 CODAR AR -chlorpheniramine w/ codeine liquid 2-8 mg/5ml............................................................................. 62 CODEINE SULFATE -codeine sulfate tab 15 mg............. 97 CODEINE SULFATE -codeine sulfate tab 30 mg............. 97 CODEINE SULFATE -codeine sulfate tab 60 mg............. 97 codeine sulfate tab 15 mg (Codeine sulfate)................ 97 codeine sulfate tab 30 mg (Codeine sulfate)................ 97 codeine sulfate tab 60 mg (Codeine sulfate)................ 97 COLCHICINE -colchicine cap 0.6 mg............................. 108 COLCHICINE -colchicine tab 0.6 mg.............................. 108 colchicine w/ probenecid tab 0.5-500 mg................... 108 COLCRYS -colchicine tab 0.6 mg................................... 108 colestipol hcl granule packets 5 gm (Colestid flavored)......................................................................... 56 colestipol hcl granules 5 gm (Colestid flavored)......... 56
colestipol hcl tab 1 gm (Colestid)..................................56 COLGATE DRY MOUTH RELIEF -sodium fluoride mouthwash 2.1 mg/10ml.............................................. 165 COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml.............................................. 165 COMBIGAN -brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%................................................................ 161 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.14 mg/day............................................................ 25 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.25 mg/day............................................................ 25 COMBIVENT RESPIMAT -ipratropium-albuterol inhal aerosol soln 20-100 mcg/act.......................................... 65 COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit........................................................................... 18 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit............................................................18 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit............................................................18 COMMIT -nicotine polacrilex lozenge 2 mg...................... 91 COMMIT -nicotine polacrilex lozenge 4 mg...................... 91 COMPLEAT CLOSED SYSTEM -nutritional supplement liquid.............................................................................. 132 COMPLEAT -nutritional supplement liquid...................... 132 COMPLEAT PEDIATRIC -nutritional supplement liquid.............................................................................. 132 COMPLEAT PEDIATRIC REDUCE -nutritional supplement liquid.......................................................... 132 COMPLERA -emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg.................................................................. 7 COMPLETE AMINO ACID MIX -amino acids oral powder........................................................................... 130 COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 250 pk.......................................... 119 COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab 29-1 mg......................................................................... 119 COMPLETE NUTRITION -nutritional supplement liquid.............................................................................. 132 COMPLETE NUTRITION PLUS -nutritional supplement liquid.............................................................................. 132 COMPLETE PROTEIN & VITAMI -nutritional supplement powder........................................................................... 132 COMPLEX ESSENTIAL MSD -amino acids oral powder........................................................................... 130 COMPLEX JUNIOR MSD -amino acids oral powder...... 130 COMPLEX MSUD AMINO ACID B -amino acids bar..... 130 COMPLEX MSUD -amino acids oral powder..................130 CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................. 119 CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg......................................................... 119
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
199
2016 CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg...............................................................119 CONDYLOX -podofilox gel 0.5%.................................... 170 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 COPASIL -emollient - gel................................................ 170 COPAXONE -glatiramer acetate soln prefilled syringe 20 mg/ml............................................................................... 91 COPAXONE -glatiramer acetate soln prefilled syringe 40 mg/ml............................................................................... 91 CORDRAN -flurandrenolide cream 0.05%...................... 170 CORDRAN -flurandrenolide lotion 0.05%....................... 170 CORDRAN -flurandrenolide oint 0.05%.......................... 170 CORDRAN -flurandrenolide tape 4 mcg/sqcm............... 170 COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 43 COREG CR -carvedilol phosphate cap sr 24hr 20 mg..... 43 COREG CR -carvedilol phosphate cap sr 24hr 40 mg..... 43 COREG CR -carvedilol phosphate cap sr 24hr 80 mg..... 43 CORIFACT -factor xiii concentrate (human) for inj kit 1000-1600 unit.............................................................. 156 CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 59 CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 59 CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot 10-10-1mg/ml................................................................ 170 CORTIFOAM -hydrocortisone acetate rectal foam 10% (90 mg/dose)................................................................. 167 CORTISONE ACETATE -cortisone acetate tab 25 mg..... 23 CORTISPORIN -bacitracin-polymyxin-neomycin hc oint 1%.................................................................................. 171 CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/ gm-10000 unt/gm-0.5%................................................ 171 CORVITE FE -iron combination tab................................ 149 CORVITE 150 -iron combination tab...............................149 COSENTYX -secukinumab subcutaneous soln prefilled syringe 150 mg/ml........................................................ 171 COSENTYX SENSOREADY PEN -secukinumab subcutaneous soln auto-injector 150 mg/ml................ 171 COSOPT PF -dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf..........................................................161 COTELLIC -cobimetinib fumarate tab 20 mg (base equivalent)....................................................................... 18 COUMADIN -warfarin sodium tab 1 mg.......................... 153 COUMADIN -warfarin sodium tab 2 mg.......................... 153 COUMADIN -warfarin sodium tab 2.5 mg....................... 153 COUMADIN -warfarin sodium tab 3 mg.......................... 153 COUMADIN -warfarin sodium tab 4 mg.......................... 153 COUMADIN -warfarin sodium tab 5 mg.......................... 153 COUMADIN -warfarin sodium tab 6 mg.......................... 153
COUMADIN -warfarin sodium tab 7.5 mg....................... 153 COUMADIN -warfarin sodium tab 10 mg........................ 153 CO-VERATROL -ubiquinol-vit b12-resveratrol-fa cap 200-5-400-0.8 mg......................................................... 181 CREON -pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit.....................................................71 CREON -pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit...................................................71 CREON -pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit................................................ 71 CREON -pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit.............................................. 71 CREON -pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit............................................. 71 CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 6 CREST COMPLETE -sodium fluoride paste 0.243%..... 165 CRESTOR -rosuvastatin calcium tab 5 mg.......................56 CRESTOR -rosuvastatin calcium tab 10 mg.....................56 CRESTOR -rosuvastatin calcium tab 20 mg.....................56 CRESTOR -rosuvastatin calcium tab 40 mg.....................56 CRITICARE HN -nutritional supplement liquid................132 CRIXIVAN -indinavir sulfate cap 200 mg............................ 7 CRIXIVAN -indinavir sulfate cap 400 mg............................ 7 CROMOLYN SODIUM -cromolyn sodium soln nebu 20 mg/2ml............................................................................. 65 cromolyn sodium ophth soln 4%................................ 161 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom).................................................................. 72 CRUCIAL -nutritional supplement liquid..........................132 CUPRIMINE -penicillamine cap 250 mg......................... 182 CUROSURF -poractant alfa intratracheal susp 80 mg/ ml..................................................................................... 67 CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 68 CVS GLUCOSE -glucose chew tab 4 gm......................... 31 CVS NUTRITIONAL SHAKE -nutritional supplement liquid.............................................................................. 133 CVS NUTRITION LIQUID -nutritional supplement liquid.............................................................................. 132 CVS NUTRITION PLUS -nutritional supplement liquid.............................................................................. 133 cyanocobalamin inj 1000 mcg/ml................................ 149 CYCLINEX-1 -nutritional supplement powder................. 133 CYCLINEX-2 -nutritional supplement powder................. 133 cyclobenzaprine hcl tab 5 mg...................................... 117 cyclobenzaprine hcl tab 10 mg.................................... 117 cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 117 CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 161 CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth soln 0.2-1%................................................................... 161 cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........161 cyclopentolate hcl ophth soln 1% (Cyclogyl).............162 cyclopentolate hcl ophth soln 2% (Cyclogyl).............162
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
200
2016 CYCLOPHOSPHAMIDE -cyclophosphamide cap 25 mg.................................................................................... 18 CYCLOPHOSPHAMIDE -cyclophosphamide cap 50 mg.................................................................................... 18 CYCLOSERINE -cycloserine cap 250 mg.......................... 5 CYCLOSET -bromocriptine mesylate tab 0.8 mg (base equivalent)....................................................................... 31 cyclosporine cap 25 mg (Sandimmune)..................... 182 cyclosporine cap 100 mg (Sandimmune)................... 182 cyclosporine modified cap 50 mg (Cyclosporine modifie)......................................................................... 183 cyclosporine modified cap 25 mg (Neoral).................183 cyclosporine modified cap 100 mg (Neoral)...............183 CYCLOSPORINE MODIFIED -cyclosporine modified cap 50 mg............................................................................ 183 cyclosporine modified oral soln 100 mg/ml (Neoral)......................................................................... 183 cyproheptadine hcl syrup 2 mg/5ml.............................. 60 cyproheptadine hcl tab 4 mg......................................... 60 CYSTADANE -betaine powder for oral solution................ 39 CYSTAGON -cysteamine bitartrate cap 50 mg.................76 CYSTAGON -cysteamine bitartrate cap 150 mg...............76 CYSTARAN -cysteamine hcl ophth soln 0.44% (base equivalent)..................................................................... 162 D DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base equivalent)......................................................................... 7 DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base equivalent)......................................................................... 7 DAKLINZA -daclatasvir dihydrochloride tab 90 mg (base equivalent)......................................................................... 7 DALIRESP -roflumilast tab 500 mcg................................. 65 danazol cap 50 mg.......................................................... 24 danazol cap 100 mg........................................................ 24 danazol cap 200 mg........................................................ 24 dantrolene sodium cap 100 mg................................... 117 dantrolene sodium cap 25 mg (Dantrium).................. 117 dantrolene sodium cap 50 mg (Dantrium).................. 117 dapsone tab 25 mg.......................................................... 12 dapsone tab 100 mg........................................................ 12 DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml................................................................. 16 DARAPRIM -pyrimethamine tab 25 mg............................ 11 darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) (Enablex)............................................................ 75 darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) (Enablex)............................................................ 75 DDROPS -cholecalciferol drops 1000 unit/0.03ml (per drop).............................................................................. 118 DEBACTEROL -sulfuric acid-sulfonated phenolics soln 30-50%.......................................................................... 165
DECARA -cholecalciferol cap 25000 unit....................... 118 DELESTROGEN -estradiol valerate im in oil 10 mg/ ml..................................................................................... 25 DELESTROGEN -estradiol valerate im in oil 20 mg/ ml..................................................................................... 25 DELESTROGEN -estradiol valerate im in oil 40 mg/ ml..................................................................................... 25 DELZICOL -mesalamine cap dr 400 mg........................... 72 demeclocycline hcl tab 150 mg....................................... 4 demeclocycline hcl tab 300 mg....................................... 4 DEMSER -metyrosine cap 250 mg................................... 50 DENAVIR -penciclovir cream 1%.................................... 171 DEPAKENE -valproate sodium syrup 250 mg/5ml (base equiv)............................................................................. 109 DEPAKENE -valproic acid cap 250 mg...........................109 DEPEN TITRATABS -penicillamine tab 250 mg............. 183 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml........ 27 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp prefilled syr 150 mg/ml............................................................................... 27 DEPO-SUBQ PROVERA 104 -medroxyprogesterone acetate susp pref syr 104 mg/0.65ml.............................27 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 100 mg/ml.................................................................. 24 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 200 mg/ml.................................................................. 25 DEQUASINE -amino acids tab........................................ 130 DERMACINRX PUREFOLIX -folic acid-cholecalciferol tab 1 mg-5000 unit.............................................................. 149 DESCOVY -emtricitabine-tenofovir alafenamide fumarate tab 200-25 mg...................................................................7 desipramine hcl tab 10 mg (Norpramin)....................... 78 desipramine hcl tab 25 mg (Norpramin)....................... 79 desipramine hcl tab 50 mg (Norpramin)....................... 79 desipramine hcl tab 75 mg (Norpramin)....................... 79 desipramine hcl tab 100 mg (Norpramin)..................... 79 desipramine hcl tab 150 mg (Norpramin)..................... 79 DESLORATADINE ODT -desloratadine tab orally disintegrating 2.5 mg...................................................... 60 DESLORATADINE ODT -desloratadine tab orally disintegrating 5 mg......................................................... 60 desloratadine tab 5 mg (Clarinex)................................. 60 desmopressin acetate inj 4 mcg/ml (Ddavp)................ 39 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)........................................................................... 39 desmopressin acetate nasal spray soln 0.01% (Ddavp)........................................................................... 39 desmopressin acetate nasal spray soln 0.01% (refrigerated).................................................................. 39 desmopressin acetate tab 0.1 mg (Ddavp)................... 39 desmopressin acetate tab 0.2 mg (Ddavp)................... 39
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
201
2016 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette)........................................................ 27 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).......................................................................27 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)....................................................................... 27 DESONATE -desonide gel 0.05%................................... 171 desonide cream 0.05% (Desowen).............................. 171 desonide lotion 0.05% (Desowen)............................... 171 desonide oint 0.05% (Desowen).................................. 171 desoximetasone cream 0.25% (Topicort)....................171 DESOXIMETASONE -desoximetasone cream 0.05%.............................................................................171 DESOXIMETASONE -desoximetasone oint 0.05%........ 171 desoximetasone gel 0.05% (Topicort)......................... 171 desoximetasone oint 0.25% (Topicort)........................ 171 DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr 24hr 50 mg (base equiv)................................................ 79 DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr 24hr 100 mg (base equiv).............................................. 79 DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50 mg.................................................................................... 79 DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100 mg.................................................................................... 79 DEXAMETHASONE -dexamethasone soln 0.5 mg/5ml............................................................................. 23 DEXAMETHASONE -dexamethasone tab 1 mg...............23 DEXAMETHASONE -dexamethasone tab 2 mg...............23 dexamethasone elixir 0.5 mg/5ml.................................. 23 DEXAMETHASONE INTENSOL -dexamethasone conc 1 mg/ml............................................................................... 23 DEXAMETHASONE SODIUM PHOS -dexamethasone sodium phosphate ophth soln 0.1%............................. 162 dexamethasone tab 0.5 mg............................................ 23 dexamethasone tab 0.75 mg.......................................... 23 dexamethasone tab 1.5 mg............................................ 23 dexamethasone tab 4 mg............................................... 23 dexamethasone tab 6 mg............................................... 23 DEX4 FAST ACTING GLUCOSE -glucose gel 15 gm/33gm.......................................................................... 31 DEX4 FAST ACTING GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm............................................................... 31 DEX4 -glucose-vitamin c chew tab 4-0.006 gm................ 31 DEXILANT -dexlansoprazole cap delayed release 30 mg.................................................................................... 68 DEXILANT -dexlansoprazole cap delayed release 60 mg.................................................................................... 68 dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin xr).................................................................................... 88 dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin xr).................................................................................... 88
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr).................................................................................... 88 dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin xr).................................................................................... 88 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr).................................................................................... 88 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr).................................................................................... 88 dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 88 dexmethylphenidate hcl tab 5 mg (Focalin)................. 88 dexmethylphenidate hcl tab 10 mg (Focalin)............... 88 DEX4 NATURALS -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 31 DEXPAK 10 DAY -dexamethasone tab therapy pack 1.5 mg (35)............................................................................ 23 DEXPAK 13 DAY -dexamethasone tab therapy pack 1.5 mg (51)............................................................................ 23 DEXPAK 6 DAY -dexamethasone tab therapy pack 1.5 mg (21)............................................................................ 23 DEX4 POUCH PACK -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 31 DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4 gm.................................................................................... 31 dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine)..................................................................... 88 dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine)..................................................................... 88 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine)..................................................................... 89 dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra)..................................................................... 89 dextroamphetamine sulfate tab 5 mg........................... 89 dextroamphetamine sulfate tab 10 mg......................... 89 D.H.E. 45 -dihydroergotamine mesylate inj 1 mg/ml.......107 DIABETIC TF -nutritional supplement liquid................... 133 DIABETISHIELD -nutritional supplement liquid.............. 133 DIABETISOURCE AC -nutritional supplement liquid...... 133 DIABETISOURCE -nutritional supplement liquid............ 133 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................................................................ 119 DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic acid tab 5 mg................................................................ 119 DIALYVITE SUPREME D -multiple vitamins w/ minerals & fa tab 3 mg................................................................... 119 DIASTAT ACUDIAL -diazepam rectal gel delivery system 10 mg............................................................................ 109 DIASTAT ACUDIAL -diazepam rectal gel delivery system 20 mg............................................................................ 109 DIASTAT PEDIATRIC -diazepam rectal gel delivery system 2.5 mg.............................................................. 110
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
202
2016 diazepam conc 5 mg/ml.................................................. 77 DIAZEPAM -diazepam oral soln 1 mg/ml..........................77 DIAZEPAM -diazepam rectal gel delivery system 2.5 mg.................................................................................. 110 DIAZEPAM -diazepam rectal gel delivery system 10 mg.................................................................................. 110 DIAZEPAM -diazepam rectal gel delivery system 20 mg.................................................................................. 110 diazepam tab 2 mg (Valium)........................................... 77 diazepam tab 5 mg (Valium)........................................... 77 diazepam tab 10 mg (Valium)......................................... 77 DIBENZYLINE -phenoxybenzamine hcl cap 10 mg..........50 DICLEGIS -doxylamine-pyridoxine tab delayed release 10-10 mg......................................................................... 70 diclofenac potassium tab 50 mg................................. 104 diclofenac sodium (actinic keratoses) gel 3% (Solaraze)..................................................................... 171 diclofenac sodium gel 1% (Voltaren)...........................171 diclofenac sodium ophth soln 0.1%............................ 162 diclofenac sodium soln 1.5% (Pennsaid)................... 171 diclofenac sodium tab delayed release 25 mg........... 104 diclofenac sodium tab delayed release 50 mg........... 104 diclofenac sodium tab delayed release 75 mg........... 104 diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................. 104 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50)........................................................104 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75)........................................................104 dicloxacillin sodium cap 250 mg..................................... 1 dicloxacillin sodium cap 500 mg..................................... 1 dicyclomine hcl cap 10 mg (Bentyl).............................. 69 dicyclomine hcl oral soln 10 mg/5ml............................ 69 dicyclomine hcl tab 20 mg (Bentyl)............................... 69 didanosine delayed release capsule 125 mg (Videx ec)...................................................................................... 7 didanosine delayed release capsule 200 mg (Videx ec)...................................................................................... 7 didanosine delayed release capsule 250 mg (Videx ec)...................................................................................... 7 didanosine delayed release capsule 400 mg (Videx ec)...................................................................................... 7 DIFFERIN -adapalene lotion 0.1%.................................. 171 DIFICID -fidaxomicin tab 200 mg........................................ 3 DIFLORASONE DIACETATE -diflorasone diacetate cream 0.05%................................................................. 171 DIFLORASONE DIACETATE -diflorasone diacetate oint 0.05%.............................................................................171 diflunisal tab 500 mg....................................................... 95 DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 41 digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 41 digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 41
dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45).................................................................................. 107 DILANTIN INFATABS -phenytoin chew tab 50 mg......... 110 DILANTIN -phenytoin sodium extended cap 30 mg........110 DILANTIN -phenytoin sodium extended cap 100 mg......110 DILANTIN-125 -phenytoin susp 125 mg/5ml.................. 110 DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 42 diltiazem hcl cap sr 12hr 60 mg.....................................44 diltiazem hcl cap sr 12hr 90 mg.....................................45 diltiazem hcl cap sr 12hr 120 mg...................................45 diltiazem hcl cap sr 24hr 120 mg...................................45 diltiazem hcl cap sr 24hr 180 mg...................................45 diltiazem hcl cap sr 24hr 240 mg...................................45 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)................................................................ 45 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)................................................................ 45 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd)................................................................ 45 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd)................................................................ 45 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd)................................................................ 45 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la)................................................................. 45 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la)................................................................. 45 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la)................................................................. 45 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la)................................................................. 45 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la)................................................................. 45 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac).................................................................... 45 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac).................................................................... 45 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac).................................................................... 45 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac).................................................................... 45 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac).................................................................... 45 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac).................................................................... 45 diltiazem hcl tab 90 mg................................................... 45 diltiazem hcl tab 30 mg (Cardizem)............................... 45 diltiazem hcl tab 60 mg (Cardizem)............................... 45 diltiazem hcl tab 120 mg (Cardizem)............................. 45 DIPENTUM -olsalazine sodium cap 250 mg.....................72 DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml....................................................... 68
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
203
2016 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............................... 16 dipyridamole tab 25 mg (Persantine).......................... 156 dipyridamole tab 50 mg (Persantine).......................... 156 dipyridamole tab 75 mg (Persantine).......................... 156 disopyramide phosphate cap 100 mg (Norpace)......... 46 disopyramide phosphate cap 150 mg (Norpace)......... 46 disulfiram tab 250 mg (Antabuse)................................. 91 disulfiram tab 500 mg (Antabuse)................................. 91 DIURIL -chlorothiazide susp 250 mg/5ml......................... 54 divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles)............................................110 divalproex sodium tab delayed release 125 mg (Depakote).................................................................... 110 divalproex sodium tab delayed release 250 mg (Depakote).................................................................... 110 divalproex sodium tab delayed release 500 mg (Depakote).................................................................... 110 divalproex sodium tab sr 24 hr 250 mg (Depakote er).................................................................................. 110 divalproex sodium tab sr 24 hr 500 mg (Depakote er).................................................................................. 110 DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 25 DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 25 DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 25 DIVISTA -folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1 mg.................................................................................. 149 dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................46 dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................46 dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................46 donepezil hydrochloride orally disintegrating tab 5 mg................................................................................... 91 donepezil hydrochloride orally disintegrating tab 10 mg................................................................................... 91 donepezil hydrochloride tab 5 mg (Aricept)................. 91 donepezil hydrochloride tab 10 mg (Aricept)............... 91 donepezil hydrochloride tab 23 mg (Aricept)............... 91 DONNATAL -pb-hyoscy-atrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml............................... 69 DONNATAL -pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg...................................... 69 DORAL -quazepam tab 15 mg.......................................... 87 dorzolamide hcl ophth soln 2% (Trusopt).................. 162 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)............................................................162 DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg......................................................... 120 doxazosin mesylate tab 1 mg (Cardura)....................... 50 doxazosin mesylate tab 2 mg (Cardura)....................... 50 doxazosin mesylate tab 4 mg (Cardura)....................... 50
doxazosin mesylate tab 8 mg (Cardura)....................... 50 doxepin hcl cap 10 mg....................................................79 doxepin hcl cap 25 mg....................................................79 doxepin hcl cap 50 mg....................................................79 doxepin hcl cap 100 mg..................................................79 doxepin hcl cap 150 mg..................................................79 doxepin hcl conc 10 mg/ml............................................ 79 DOXEPIN HCL -doxepin hcl cap 75 mg........................... 79 DOXEPIN HYDROCHLORIDE -doxepin hcl cream 5%.................................................................................. 171 doxercalciferol cap 0.5 mcg (Hectorol)......................... 39 doxercalciferol cap 1 mcg (Hectorol)............................ 39 doxercalciferol cap 2.5 mcg (Hectorol)......................... 39 doxycycline hyclate cap 50 mg....................................... 4 doxycycline hyclate cap 100 mg (Vibramycin)...............4 doxycycline hyclate tab delayed release 75 mg............ 4 doxycycline hyclate tab delayed release 100 mg.......... 4 doxycycline hyclate tab delayed release 150 mg.......... 4 doxycycline hyclate tab delayed release 50 mg (Doryx).............................................................................. 4 doxycycline hyclate tab delayed release 200 mg (Doryx).............................................................................. 4 doxycycline hyclate tab 20 mg........................................ 4 doxycycline hyclate tab 100 mg...................................... 4 doxycycline monohydrate cap 50 mg............................. 4 doxycycline monohydrate cap 150 mg (Adoxa).............4 doxycycline monohydrate cap 75 mg (Monodox)..........4 doxycycline monohydrate cap 100 mg (Monodox)........4 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin)..................................................................... 4 doxycycline monohydrate tab 50 mg (Adoxa)............... 4 doxycycline monohydrate tab 75 mg (Adoxa)............... 4 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100)................................................................................. 4 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150)................................................................................. 4 DRITHO-CREME HP -anthralin cream 1%..................... 171 dronabinol cap 2.5 mg (Marinol).................................... 70 dronabinol cap 5 mg (Marinol)....................................... 70 dronabinol cap 10 mg (Marinol)..................................... 70 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28).................................................................................... 27 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 27 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg (Beyaz)............................................... 27 DROXIA -hydroxyurea cap 200 mg................................ 149 DROXIA -hydroxyurea cap 300 mg................................ 149 DROXIA -hydroxyurea cap 400 mg................................ 149 DUAVEE -conjugated estrogens-bazedoxifene tab 0.45-20 mg...................................................................... 25 DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab 25-1 & omega cap 267 mg.......................................... 120
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
204
2016 DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg...................................................... 120 DULERA -mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act.................................................... 65 DULERA -mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act.................................................... 65 DULOXETINE HCL -duloxetine hcl enteric coated pellets cap 40 mg....................................................................... 79 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta)...................................................................... 79 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta)...................................................................... 79 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta)...................................................................... 79 DUOCAL -nutritional supplement powder....................... 133 DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/ ml................................................................................... 115 DURACHOL -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 149 DUREZOL -difluprednate ophth emulsion 0.05%........... 162 dutasteride cap 0.5 mg (Avodart).................................. 76 dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 76 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg............................................................. 50 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg............................................................. 50 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg........................................................... 50 D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............ 118 DYMISTA -azelastine hcl-fluticasone prop nasal spray 137-50 mcg/act............................................................... 61 dyphylline-guaifenesin liqd 100-100 mg/5ml................ 65 DYRENIUM -triamterene cap 50 mg................................. 54 DYRENIUM -triamterene cap 100 mg............................... 54 E EAA SUPPLEMENT -nutritional supplement pack......... 133 econazole nitrate cream 1%......................................... 171 ECOZA -econazole nitrate foam 1%............................... 171 EDARBI -azilsartan medoxomil tab 40 mg........................50 EDARBI -azilsartan medoxomil tab 80 mg........................50 EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab 40-12.5 mg...................................................................... 50 EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab 40-25 mg......................................................................... 50 ED CYTE F -ferrous fumarate-folic acid-docusate sodium tab 324-1-50 mg........................................................... 149 EDECRIN -ethacrynic acid tab 25 mg.............................. 55 EDURANT -rilpivirine hcl tab 25 mg (base equivalent)....... 7 E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 3 E.E.S. GRANULES -erythromycin ethylsuccinate for susp 200 mg/5ml....................................................................... 3
EFFER-K -potassium bicarbonate-citric acid effer tab 10 meq................................................................................ 128 EFFER-K -potassium bicarbonate-citric acid effer tab 20 meq................................................................................ 128 EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 156 EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 156 EGG/PRO -nutritional supplement powder..................... 133 EGRIFTA -tesamorelin acetate for inj 1 mg (base equiv)............................................................................... 39 EGRIFTA -tesamorelin acetate for inj 2 mg (base equiv)............................................................................... 39 ELECARE/DHA/ARA -nutritional supplement powder........................................................................... 133 ELECARE JR -nutritional supplement powder................133 ELECARE -nutritional supplement powder..................... 133 ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump)...................................................... 25 ELETONE -dermatological products misc - cream......... 171 ELETONE TWINPACK -dermatological products misc cream............................................................................. 171 ELIDEL -pimecrolimus cream 1%................................... 171 ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5 mg.................................................................................... 18 ELIGARD -leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg...................................................................18 ELIGARD -leuprolide acetate (4 month) for subcutaneous inj kit 30 mg.................................................................... 18 ELIGARD -leuprolide acetate (6 month) for subcutaneous inj kit 45 mg.................................................................... 18 ELIQUIS -apixaban tab 2.5 mg....................................... 153 ELIQUIS -apixaban tab 5 mg.......................................... 153 ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg.................................................................................. 120 ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 65 ELLA -ulipristal acetate tab 30 mg.................................... 28 ELMIRON -pentosan polysulfate sodium caps 100 mg.................................................................................... 76 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 250 unit......................................................................... 156 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 500 unit......................................................................... 156 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 750 unit......................................................................... 156 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 1000 unit....................................................................... 156 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 1500 unit....................................................................... 156 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 2000 unit....................................................................... 156 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 3000 unit....................................................................... 156
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
205
2016 EMADINE -emedastine difumarate ophth soln 0.05% (base equiv).................................................................. 162 EMBEDA -morphine-naltrexone cap cr 20-0.8 mg............97 EMBEDA -morphine-naltrexone cap cr 30-1.2 mg............97 EMBEDA -morphine-naltrexone cap cr 50-2 mg...............97 EMBEDA -morphine-naltrexone cap cr 60-2.4 mg............97 EMBEDA -morphine-naltrexone cap cr 80-3.2 mg............97 EMBEDA -morphine-naltrexone cap cr 100-4 mg.............97 EMCYT -estramustine phosphate sodium cap 140 mg.................................................................................... 18 EMEND -aprepitant capsule 40 mg.................................. 70 EMEND -aprepitant capsule 80 mg.................................. 70 EMEND -aprepitant capsule 125 mg................................ 71 EMEND -aprepitant capsule therapy pack 80 & 125 mg.................................................................................... 70 EMEND -aprepitant for oral susp 125 mg (125 mg/5ml)............................................................................ 71 EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 79 EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 79 EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 79 EMTRIVA -emtricitabine caps 200 mg................................ 7 EMTRIVA -emtricitabine soln 10 mg/ml.............................. 7 EMULSION SB -dermatological products misc emulsion........................................................................ 171 EMVERM -mebendazole chew tab 100 mg...................... 12 ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv).................................................................... 75 ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg (base equiv).................................................................... 75 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg................................................................................... 50 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)...................................................................... 50 enalapril maleate tab 2.5 mg (Vasotec)......................... 50 enalapril maleate tab 5 mg (Vasotec)............................ 50 enalapril maleate tab 10 mg (Vasotec).......................... 50 enalapril maleate tab 20 mg (Vasotec).......................... 50 ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty acids cap....................................................................... 120 ENBREL -etanercept for subcutaneous inj 25 mg.......... 104 ENBREL -etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml.................................................................. 104 ENBREL -etanercept subcutaneous soln prefilled syringe 50 mg/ml....................................................................... 104 ENBREL SURECLICK -etanercept subcutaneous solution auto-injector 50 mg/ml.................................................. 104 END FATIGUE DAILY ENERGY -multiple vitamins w/ minerals powder............................................................120 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 ENLIVE -nutritional supplement liquid.............................133 enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 153 enoxaparin sodium inj 40 mg/0.4ml (Lovenox).......... 153 enoxaparin sodium inj 60 mg/0.6ml (Lovenox).......... 153 enoxaparin sodium inj 80 mg/0.8ml (Lovenox).......... 153 enoxaparin sodium inj 100 mg/ml (Lovenox)............. 153 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 153 enoxaparin sodium inj 150 mg/ml (Lovenox)............. 153 enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 153 ENSTILAR -calcipotriene-betamethasone dipropionate foam 0.005-0.064%...................................................... 171 ENSURE/FIBER -nutritional supplement liquid............... 134 ENSURE ACTIVE HEART HEALT -nutritional supplement liquid.............................................................................. 133 ENSURE ACTIVE HIGH PROTEI -nutritional supplement liquid.............................................................................. 133 ENSURE ACTIVE LIGHT -nutritional supplement liquid.............................................................................. 133 ENSURE ACTIVE -nutritional supplement liquid............ 133 ENSURE BONE HEALTH REVIGO -nutritional supplement liquid.......................................................... 133 ENSURE CLEAR -nutritional supplement liquid............. 133 ENSURE CLINICAL STRENGTH -nutritional supplement liquid.............................................................................. 133 ENSURE COMPACT -nutritional supplement liquid....... 133 ENSURE COMPLETE -nutritional supplement liquid..... 133 ENSURE COMPLETE NUTRITION -nutritional supplement liquid.......................................................... 133 ENSURE ENLIVE -nutritional supplement liquid............ 133 ENSURE HEALTHY MOM -nutritional supplement bar.................................................................................. 133 ENSURE HEALTHY MOM -nutritional supplement liquid.............................................................................. 133 ENSURE HIGH CALCIUM -nutritional supplement liquid.............................................................................. 133 ENSURE HIGH PROTEIN -nutritional supplement liquid.............................................................................. 133 ENSURE HIGH PROTEIN -nutritional supplement powder........................................................................... 133 ENSURE IMMUNE HEALTH -nutritional supplement liquid.............................................................................. 134 ENSURE MUSCLE HEALTH REVI -nutritional supplement liquid.......................................................... 134 ENSURE NUTRA SHAKE HI-CAL -nutritional supplement liquid.............................................................................. 134 ENSURE -nutritional supplement bar..............................133 ENSURE -nutritional supplement liquid.......................... 133 ENSURE -nutritional supplement powder....................... 133
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
206
2016 ENSURE NUTRITION SHAKE -nutritional supplement liquid.............................................................................. 134 ENSURE PLUS HN -nutritional supplement liquid..........134 ENSURE PLUS -nutritional supplement liquid................ 134 ENSURE PUDDING -nutritional supplement pudding.......................................................................... 134 entacapone tab 200 mg (Comtan)............................... 115 entecavir tab 0.5 mg (Baraclude)..................................... 7 entecavir tab 1 mg (Baraclude)........................................ 7 ENTEREG -alvimopan cap 12 mg.................................... 72 ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 59 ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 59 ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 59 ENTTY SPRAY EMULSION -dermatological products misc - emulsion............................................................. 171 ENU NUTRITIONAL SHAKE -nutritional supplement liquid.............................................................................. 134 ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............183 ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 183 ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 183 EO28 SPLASH -nutritional supplement liquid................. 134 EPANED -enalapril maleate for oral soln 1 mg/ml............ 50 EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 7 EPICERAM -dermatological products misc emulsion........................................................................ 171 EPIFOAM -pramoxine-hc aerosol foam 1-1%.................171 epinastine hcl ophth soln 0.05% (Elestat).................. 162 EPINEPHRINE -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)......................................................... 55 EPINEPHRINE -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................... 55 EPIPEN-JR 2-PAK -epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000).................................................. 56 EPIPEN 2-PAK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................... 56 EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 7 EPIVIR -lamivudine oral soln 10 mg/ml.............................. 7 eplerenone tab 25 mg (Inspra)....................................... 50 eplerenone tab 50 mg (Inspra)....................................... 50 EPOGEN -epoetin alfa inj 2000 unit/ml...........................150 EPOGEN -epoetin alfa inj 3000 unit/ml...........................150 EPOGEN -epoetin alfa inj 4000 unit/ml...........................150 EPOGEN -epoetin alfa inj 10000 unit/ml.........................150 EPOGEN -epoetin alfa inj 20000 unit/ml.........................150 EPROSARTAN MESYLATE -eprosartan mesylate tab 600 mg.................................................................................... 50 EPZICOM -abacavir sulfate-lamivudine tab 600-300 mg...................................................................................... 7 EQ NUTRITIONAL SHAKE -nutritional supplement liquid.............................................................................. 134 EQ NUTRITIONAL SHAKE PLUS -nutritional supplement liquid.............................................................................. 134
EQUATE -nutritional supplement liquid........................... 134 EQUATE PLUS -nutritional supplement liquid................ 134 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 100 mg............................................................................ 83 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 200 mg............................................................................ 83 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 300 mg............................................................................ 83 EQ WEIGHT LOSS SHAKE ULTR -nutritional supplement liquid.............................................................................. 134 ergocalciferol cap 50000 unit (Drisdol)....................... 118 ERGOLOID MESYLATES -ergoloid mesylates tab 1 mg.................................................................................... 91 ERGOMAR -ergotamine tartrate sl tab 2 mg.................. 107 ERIVEDGE -vismodegib cap 150 mg............................... 18 ERTACZO -sertaconazole nitrate cream 2%.................. 172 ERYPED 200 -erythromycin ethylsuccinate for susp 200 mg/5ml............................................................................... 3 ERYPED 400 -erythromycin ethylsuccinate for susp 400 mg/5ml............................................................................... 3 ERY-TAB -erythromycin tab delayed release 250 mg........ 3 ERY-TAB -erythromycin tab delayed release 333 mg........ 3 ERY-TAB -erythromycin tab delayed release 500 mg........ 3 ERYTHROCIN STEARATE -erythromycin stearate tab 250 mg.............................................................................. 3 ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 3 ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 3 ERYTHROMYCIN ETHYLSUCCINA -erythromycin ethylsuccinate tab 400 mg............................................... 3 erythromycin ethylsuccinate for susp 200 mg/5ml (E.e.s. granules).............................................................. 3 erythromycin gel 2% (Erygel)....................................... 172 erythromycin ophth oint 5 mg/gm............................... 162 erythromycin pads 2%.................................................. 172 erythromycin soln 2%................................................... 172 erythromycin w/ delayed release particles cap 250 mg......................................................................................4 ESBRIET -pirfenidone cap 267 mg................................... 67 ESCAVITE D -pediatric multiple vitamins w/ fl-fe chew tab 0.25-6 mg...................................................................... 120 ESCAVITE LQ -pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml................................................................. 120 ESCAVITE -pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg................................................................... 120 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro)........................................................................ 79 escitalopram oxalate tab 5 mg (base equiv) (Lexapro)........................................................................ 79 escitalopram oxalate tab 10 mg (base equiv) (Lexapro)........................................................................ 79 escitalopram oxalate tab 20 mg (base equiv) (Lexapro)........................................................................ 79
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
207
2016 esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium)....................................................... 69 esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium)....................................................... 69 ESSENTIAL AMINO ACID MIX -amino acids oral powder........................................................................... 130 ESSENTRA WIPES 9X9" CLEAN -isopropyl alcohol wipes 70%..................................................................... 172 estazolam tab 1 mg......................................................... 87 estazolam tab 2 mg......................................................... 87 esterified estrogens & methyltestosterone tab 0.625-1.25 mg................................................................ 25 esterified estrogens & methyltestosterone tab 1.25-2.5 mg.....................................................................25 ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 75 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)....................................................................... 26 estradiol & norethindrone acetate tab 1-0.5 mg (Activella)....................................................................... 26 estradiol tab 0.5 mg (Estrace)........................................ 26 estradiol tab 1 mg (Estrace)........................................... 26 estradiol tab 2 mg (Estrace)........................................... 26 estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 26 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................... 26 estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 26 estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 26 estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 26 estradiol td patch weekly 0.025 mg/24hr (Climara)......26 estradiol td patch weekly 0.05 mg/24hr (Climara)........26 estradiol td patch weekly 0.06 mg/24hr (Climara)........26 estradiol td patch weekly 0.075 mg/24hr (Climara)......26 estradiol td patch weekly 0.1 mg/24hr (Climara)..........26 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)...................................................... 26 estradiol vaginal tab 10 mcg (Vagifem).........................75 estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 26 estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 26 ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).......................................................................75 ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)...................................................... 26 ESTROPIPATE -estropipate tab 0.75 mg......................... 26 ESTROPIPATE -estropipate tab 1.5 mg........................... 26 ESTROPIPATE -estropipate tab 3 mg.............................. 26 eszopiclone tab 1 mg (Lunesta).................................... 87 eszopiclone tab 2 mg (Lunesta).................................... 87 eszopiclone tab 3 mg (Lunesta).................................... 87
ethacrynic acid tab 25 mg.............................................. 55 ethambutol hcl tab 100 mg (Myambutol)........................ 5 ethambutol hcl tab 400 mg (Myambutol)........................ 5 ethosuximide cap 250 mg (Zarontin).......................... 110 ethosuximide soln 250 mg/5ml (Zarontin).................. 110 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg................................................................................. 28 ETIDRONATE DISODIUM -etidronate disodium tab 200 mg.................................................................................... 39 ETIDRONATE DISODIUM -etidronate disodium tab 400 mg.................................................................................... 39 etodolac cap 200 mg..................................................... 104 etodolac cap 300 mg..................................................... 104 etodolac tab 400 mg...................................................... 104 etodolac tab 500 mg...................................................... 104 etodolac tab sr 24hr 400 mg........................................ 104 etodolac tab sr 24hr 500 mg........................................ 104 etodolac tab sr 24hr 600 mg........................................ 104 ETOPOSIDE -etoposide cap 50 mg..................................18 EURAX -crotamiton cream 10%...................................... 172 EURAX -crotamiton lotion 10%....................................... 172 EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 26 EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg (base equiv)...................................................................... 7 EVZIO -naloxone hcl solution auto-injector 0.4 mg/0.4ml........................................................................ 180 EXALGO -hydromorphone hcl tab er 24hr deter 32 mg.................................................................................... 97 EXELDERM -sulconazole nitrate cream 1%................... 172 EXELDERM -sulconazole nitrate solution 1%................ 172 EXELON -rivastigmine td patch 24hr 4.6 mg/24hr............ 91 EXELON -rivastigmine td patch 24hr 9.5 mg/24hr............ 91 EXELON -rivastigmine td patch 24hr 13.3 mg/24hr.......... 91 exemestane tab 25 mg (Aromasin)................................ 18 EXJADE -deferasirox tab for oral susp 125 mg.............. 180 EXJADE -deferasirox tab for oral susp 250 mg.............. 180 EXJADE -deferasirox tab for oral susp 500 mg.............. 180 EXODERM -sodium thiosulfate-salicylic acid lotion 25-1%............................................................................ 172 EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 91 EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg................................... 120 F F.A.A. -nutritional supplement liquid................................ 134 FABIOR -tazarotene (acne) foam 0.1%.......................... 172 FACTIVE -gemifloxacin mesylate tab 320 mg (base equiv)................................................................................. 5 FALESSA -levomefolate glucosamine tab 1 mg (folate equivalent)..................................................................... 134 FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit..................................................................... 28
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
208
2016 famciclovir tab 125 mg (Famvir)...................................... 7 famciclovir tab 250 mg (Famvir)...................................... 7 famciclovir tab 500 mg (Famvir)...................................... 7 famotidine for susp 40 mg/5ml (Pepcid)....................... 69 famotidine tab 40 mg (Pepcid)....................................... 69 FANAPT -iloperidone tab 1 mg......................................... 83 FANAPT -iloperidone tab 2 mg......................................... 83 FANAPT -iloperidone tab 4 mg......................................... 83 FANAPT -iloperidone tab 6 mg......................................... 83 FANAPT -iloperidone tab 8 mg......................................... 83 FANAPT -iloperidone tab 10 mg....................................... 83 FANAPT -iloperidone tab 12 mg....................................... 83 FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak........................................... 83 FARESTON -toremifene citrate tab 60 mg (base equivalent)....................................................................... 18 FARXIGA -dapagliflozin propanediol tab 5 mg (base equivalent)....................................................................... 31 FARXIGA -dapagliflozin propanediol tab 10 mg (base equivalent)....................................................................... 31 FARYDAK -panobinostat lactate cap 10 mg (base equivalent)....................................................................... 18 FARYDAK -panobinostat lactate cap 15 mg (base equivalent)....................................................................... 18 FARYDAK -panobinostat lactate cap 20 mg (base equivalent)....................................................................... 18 FAZACLO -clozapine orally disintegrating tab 12.5 mg.................................................................................... 83 FAZACLO -clozapine orally disintegrating tab 25 mg....... 83 FAZACLO -clozapine orally disintegrating tab 100 mg..... 83 FAZACLO -clozapine orally disintegrating tab 150 mg..... 83 FAZACLO -clozapine orally disintegrating tab 200 mg..... 83 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg................................................................................. 150 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg................................................................................. 150 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mncu cap (Tandem plus)................................................ 150 FEIBA -antiinhibitor coagulant complex for inj................ 156 felbamate susp 600 mg/5ml (Felbatol)........................ 110 felbamate tab 400 mg (Felbatol).................................. 110 felbamate tab 600 mg (Felbatol).................................. 110 felodipine tab sr 24hr 2.5 mg......................................... 45 felodipine tab sr 24hr 5 mg............................................ 45 felodipine tab sr 24hr 10 mg.......................................... 45 FEMHRT LOW DOSE -norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg......................................... 26 FEM PH -acetic acid-oxyquinoline vaginal gel 0.9-0.025%...................................................................... 75 FEMRING -estradiol acetate vaginal ring 0.05 mg/24hr........................................................................... 75 FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 76
FENOFIBRATE -fenofibrate cap 50 mg............................ 56 FENOFIBRATE -fenofibrate cap 150 mg.......................... 56 fenofibrate micronized cap 43 mg................................. 56 fenofibrate micronized cap 130 mg............................... 57 fenofibrate micronized cap 67 mg (Lofibra)................. 57 fenofibrate micronized cap 134 mg (Lofibra)............... 57 fenofibrate micronized cap 200 mg (Lofibra)............... 57 fenofibrate tab 40 mg (Fenoglide)................................. 57 fenofibrate tab 120 mg (Fenoglide)............................... 57 fenofibrate tab 54 mg (Lofibra)...................................... 57 fenofibrate tab 160 mg (Lofibra).................................... 57 fenofibrate tab 48 mg (Tricor)........................................ 57 fenofibrate tab 145 mg (Tricor)...................................... 57 FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 57 FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 57 FENOGLIDE -fenofibrate tab 40 mg................................. 57 FENOGLIDE -fenofibrate tab 120 mg............................... 57 FENOPROFEN CALCIUM -fenoprofen calcium cap 200 mg.................................................................................. 104 FENOPROFEN CALCIUM -fenoprofen calcium cap 400 mg.................................................................................. 105 FENOPROFEN CALCIUM -fenoprofen calcium tab 600 mg.................................................................................. 105 FENORTHO -fenoprofen calcium cap 200 mg............... 105 FENORTHO -fenoprofen calcium cap 400 mg............... 105 fentanyl citrate lozenge on a handle 200 mcg (Actiq)............................................................................. 97 fentanyl citrate lozenge on a handle 400 mcg (Actiq)............................................................................. 97 fentanyl citrate lozenge on a handle 600 mcg (Actiq)............................................................................. 97 fentanyl citrate lozenge on a handle 800 mcg (Actiq)............................................................................. 97 fentanyl citrate lozenge on a handle 1200 mcg (Actiq)............................................................................. 97 fentanyl citrate lozenge on a handle 1600 mcg (Actiq)............................................................................. 97 FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr...............97 FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr...............97 FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr...............97 fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 97 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 fentanyl td patch 72hr 100 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
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
209
2016 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)................................................................. 150 FERIVA 21/7 -fe asparto gly-b12-fa-c-dss-succinic acid-zn tab 75-1 mg...................................................................150 FERIVAFA -iron-c-fa-b12-biotin-copper-docusate cap 110-1 mg....................................................................... 150 FERIVA -fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap 75-1 mg......................................................................... 150 FERRALET 90 -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg........................................................... 150 FERRAPLUS 90 -iron-folic acid-vit b12-vit c-docusate sod tab 90-1 mg...................................................................150 FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18 mg (elemental iron)................................................. 150 FERRIPROX -deferiprone oral soln 100 mg/ml.............. 180 FERRIPROX -deferiprone tab 500 mg............................ 180 FERRO-PLEX HEMATINIC -fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg......................................................... 150 FERROTRIN -iron w/ b12-vit c-fa-ifc cap 36-0.015-75-0.5-240 mg............................................... 150 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg.......................................................................150 ferrous fumarate-folic acid tab 324-1 mg....................150 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe).................................................................................. 150 FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe)............................................. 150 FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe)............................................. 150 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe).................................................................................. 150 FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base equivalent)....................................................................... 79 FETZIMA -levomilnacipran hcl cap sr 24hr 40 mg (base equivalent)....................................................................... 79 FETZIMA -levomilnacipran hcl cap sr 24hr 80 mg (base equivalent)....................................................................... 79 FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base equivalent)....................................................................... 79 FETZIMA TITRATION PACK -levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack...................................... 80 FIBERSOURCE CLOSED SYSTEM -nutritional supplement liquid.......................................................... 134 FIBERSOURCE HN CLOSED SYS -nutritional supplement liquid.......................................................... 134 FIBERSOURCE HN -nutritional supplement liquid......... 134 FIBER-STAT -nutritional supplement liquid..................... 134 FIBRICOR -fenofibric acid tab 35 mg............................... 57
FIBRICOR -fenofibric acid tab 105 mg............................. 57 FINACEA -azelaic acid foam 15%.................................. 172 FINACEA -azelaic acid gel 15%..................................... 172 finasteride tab 5 mg (Proscar)....................................... 76 FIRAZYR -icatibant acetate inj 30 mg/3ml (base equivalent)..................................................................... 157 FIRST-LANSOPRAZOLE -lansoprazole susp 3 mg/ml (compound kit)................................................................ 69 FIRST-OMEPRAZOLE -omeprazole susp 2 mg/ml (compound kit)................................................................ 69 FLAREX -fluorometholone acetate ophth susp 0.1%..... 162 FLAVOR PACKETS -nutritional supplement flavor pack............................................................................... 134 FLAVOUR PAC -nutritional supplement flavor pack....... 134 flavoxate hcl tab 100 mg.................................................75 flecainide acetate tab 50 mg.......................................... 46 flecainide acetate tab 100 mg........................................ 47 flecainide acetate tab 150 mg........................................ 47 FLECTOR -diclofenac epolamine patch 1.3%................ 172 FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364 mg.................................................................................. 128 FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364 mg.................................................................................. 128 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 0.25 mg......................................................................... 120 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 0.5 mg........................................................................... 120 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 1 mg.............................................................................. 120 FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/ ml-400 unit/ml............................................................... 128 FLOVENT DISKUS -fluticasone propionate aer pow ba 50 mcg/blister....................................................................... 65 FLOVENT DISKUS -fluticasone propionate aer pow ba 100 mcg/blister................................................................ 65 FLOVENT DISKUS -fluticasone propionate aer pow ba 250 mcg/blister................................................................ 65 FLOVENT HFA -fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)........................................................ 65 FLOVENT HFA -fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)........................................................ 65 FLOVENT HFA -fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)...........................................................65 FLOWTUSS -hydrocodone-guaifenesin soln 2.5-200 mg/5ml............................................................................. 62 FLUAD 2016-2017 -influenza vac type a&b surface ant adj susp pref syr 0.5 ml................................................. 13 FLUARIX 2014-2015 -influenza virus vaccine split pf susp pref syringe 0.5 ml.......................................................... 13 FLUARIX QUADRIVALENT 2014 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 13
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
210
2016 FLUARIX QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 13 FLUARIX QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 13 FLUBLOK 2014-2015 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 13 FLUBLOK 2015-2016 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 13 FLUBLOK 2016-2017 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 14 FLUCELVAX 2014-2015 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml........................................... 14 FLUCELVAX 2015-2016 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml........................................... 14 FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult subunt quad susp pref syr 0.5 ml.................................. 14 fluconazole for susp 10 mg/ml (Diflucan)....................... 6 fluconazole for susp 40 mg/ml (Diflucan)....................... 6 fluconazole tab 50 mg (Diflucan)..................................... 6 fluconazole tab 100 mg (Diflucan)................................... 6 fluconazole tab 150 mg (Diflucan)................................... 6 fluconazole tab 200 mg (Diflucan)................................... 6 flucytosine cap 250 mg (Ancobon)................................. 6 flucytosine cap 500 mg (Ancobon)................................. 6 fludrocortisone acetate tab 0.1 mg............................... 23 FLULAVAL 2014-2015 -influenza virus vaccine split im susp................................................................................. 14 FLULAVAL QUADRIVALENT 201 -influenza virus vaccine split quadrivalent im inj................................................... 14 FLULAVAL QUADRIVALENT 201 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 14 FLUMIST QUADRIVALENT -influenza virus vaccine live quadrivalent intranasal susp...........................................14 flunisolide nasal soln 25 mcg/act (0.025%) (Flunisolide)................................................................... 61 fluocinolone acetonide cream 0.01%.......................... 172 fluocinolone acetonide cream 0.025% (Synalar)........172 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 172 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................172 fluocinolone acetonide oint 0.025% (Synalar)............ 172 fluocinolone acetonide (otic) oil 0.01% (Dermotic).................................................................... 165 fluocinolone acetonide soln 0.01% (Synalar)............. 172 fluocinonide cream 0.05%............................................ 172 fluocinonide cream 0.1% (Vanos)................................ 172 fluocinonide emulsified base cream 0.05%................ 172 fluocinonide gel 0.05%.................................................. 172 fluocinonide oint 0.05%................................................ 172 fluocinonide soln 0.05%................................................ 172
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf)........................................................128 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg..................................................128 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg.................................................................. 128 FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%........................................165 fluorometholone ophth susp 0.1% (Fml liquifilm)..... 162 FLUOROPLEX -fluorouracil cream 1%........................... 172 fluorouracil cream 5% (Efudex)................................... 172 FLUOROURACIL -fluorouracil cream 0.5%.................... 172 fluorouracil soln 2%...................................................... 172 fluorouracil soln 5%...................................................... 172 FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg.............. 91 FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg.............. 91 fluoxetine hcl cap delayed release 90 mg (Prozac weekly)............................................................................ 80 fluoxetine hcl cap 10 mg (Prozac)................................. 80 fluoxetine hcl cap 20 mg (Prozac)................................. 80 fluoxetine hcl cap 40 mg (Prozac)................................. 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............................................................................. 83 FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/ ml..................................................................................... 83 fluphenazine hcl tab 1 mg.............................................. 83 fluphenazine hcl tab 2.5 mg........................................... 83 fluphenazine hcl tab 5 mg.............................................. 83 fluphenazine hcl tab 10 mg............................................ 83 FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf)............................................... 128 flurandrenolide cream 0.05%....................................... 172 flurandrenolide lotion 0.05% (Cordran).......................172 FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 87 FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 87 flurbiprofen sodium ophth soln 0.03% (Ocufen)........162 flurbiprofen tab 50 mg.................................................. 105 flurbiprofen tab 100 mg................................................ 105 flutamide cap 125 mg...................................................... 18 fluticasone propionate cream 0.05% (Cutivate)......... 172 fluticasone propionate lotion 0.05% (Cutivate).......... 172 fluticasone propionate nasal susp 50 mcg/act............ 61 fluticasone propionate oint 0.005%............................. 172 fluvastatin sodium cap 20 mg (Lescol)......................... 57 fluvastatin sodium cap 40 mg (Lescol)......................... 57 fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........57 FLUVIRIN 2015-2016 -influenza vac type a&b surface antigen susp pref syr 0.5 ml...........................................14
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
211
2016 FLUVIRIN 2016-2017 -influenza vac type a&b surface antigen susp pref syr 0.5 ml...........................................14 FLUVIRIN 2014-2015 -influenza virus vaccine types a & b surface antigen im susp................................................. 14 FLUVIRIN 2015-2016 -influenza virus vaccine types a & b surface antigen im susp................................................. 14 FLUVIRIN 2016-2017 -influenza virus vaccine types a & b surface antigen im susp................................................. 14 FLUVIRIN PF 2014-2015 -influenza virus vac types a & b pf susp prefilled syr 0.5 ml............................................. 14 fluvoxamine maleate cap sr 24hr 100 mg..................... 80 fluvoxamine maleate cap sr 24hr 150 mg..................... 80 fluvoxamine maleate tab 25 mg..................................... 80 fluvoxamine maleate tab 50 mg..................................... 80 fluvoxamine maleate tab 100 mg................................... 80 FLUZONE HIGH-DOSE PF 2014 -influenza virus vac split high-dose pf susp pref syr 0.5ml....................................14 FLUZONE HIGH-DOSE PF 2015 -influenza virus vac split high-dose pf susp pref syr 0.5ml....................................14 FLUZONE HIGH-DOSE PF 2016 -influenza virus vac split high-dose pf susp pref syr 0.5ml....................................14 FLUZONE INTRADERMAL QUADR -influenza virus vac split quad intradermal pen 9 mcg/strain......................... 14 FLUZONE PF 2014-2015 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 14 FLUZONE QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent im inj..................................... 15 FLUZONE QUADRIVALENT 2015 -influenza virus vaccine split quadrivalent im inj..................................... 15 FLUZONE QUADRIVALENT 2016 -influenza virus vaccine split quadrivalent im inj..................................... 15 FLUZONE QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent inj 0.5 ml............................... 15 FLUZONE QUADRIVALENT 2015 -influenza virus vaccine split quadrivalent inj 0.5 ml............................... 15 FLUZONE QUADRIVALENT 2016 -influenza virus vaccine split quadrivalent inj 0.5 ml............................... 15 FLUZONE QUADRIVALENT 2014 -influenza virus vac split quadrivalent susp pref syr 0.25 ml......................... 14 FLUZONE QUADRIVALENT 2014 -influenza virus vac split quadrivalent susp pref syr 0.5ml............................ 14 FLUZONE QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.25 ml......................... 15 FLUZONE QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.5ml............................ 15 FLUZONE QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.25 ml......................... 15 FLUZONE QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.5ml............................ 15 FLUZONE SPLIT 2014-2015 -influenza virus vaccine split im susp............................................................................ 15
FLUZONE SPLIT 2015-2016 -influenza virus vaccine split im susp............................................................................ 15 FML -fluorometholone ophth oint 0.1%........................... 162 FML FORTE -fluorometholone ophth susp 0.25%.......... 162 FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack...................................................120 FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak.............................................. 120 FOCALGIN DSS -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg........................................................... 150 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10 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 35 mg.................................................................................... 89 FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg..................................................... 120 FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 120 FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr & dha cap pak.................................................................. 120 FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha cap 38-1-225 mg.......................................................... 120 FOLGARD OS -multiple vit w/ min & calcium-folic acid tab 500-1.1 mg.................................................................... 120 folic acid cap 0.8 mg..................................................... 150 folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg................................................................................. 134 folic acid tab 400 mcg................................................... 150 folic acid tab 800 mcg................................................... 150 folic acid tab 1 mg......................................................... 150 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg................................................................................. 150 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg..... 151 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx).................................................................. 150 FOLIVANE-F -fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)................................... 151 FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg...............................................................120 FOLIVANE-PLUS -fe fum-iron polysacch complex-fa-b complex-c-biotin cap..................................................... 151 FOLIXAPURE -folic acid-cholecalciferol tab 1 mg-5000 unit................................................................................. 151 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra).........................................................................153 fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra).........................................................................153
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
212
2016 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra).........................................................................153 fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra).........................................................................154 FORFIVO XL -bupropion hcl tab sr 24hr 450 mg............. 80 formaldehyde solution 10%.......................................... 180 FORMA-RAY -formaldehyde solution 20%..................... 180 FORTA DRINK -nutritional supplement powder.............. 134 FORTA SHAKE -nutritional supplement powder............. 134 FORTEO -teriparatide (recombinant) inj 600 mcg/2.4ml........................................................................ 39 FORTESTA -testosterone td gel 10mg/act (2%)............... 25 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-2800 mg-unit....................................................... 39 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-5600 mg-unit....................................................... 40 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg................................................................................... 50 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg................................................................................... 50 fosinopril sodium tab 10 mg.......................................... 50 fosinopril sodium tab 20 mg.......................................... 50 fosinopril sodium tab 40 mg.......................................... 50 FOSRENOL -lanthanum carbonate chew tab 500 mg (elemental).......................................................................72 FOSRENOL -lanthanum carbonate chew tab 750 mg (elemental).......................................................................72 FOSRENOL -lanthanum carbonate chew tab 1000 mg (elemental).......................................................................72 FOSRENOL -lanthanum carbonate oral powder pack 750 mg (elemental)................................................................ 73 FOSRENOL -lanthanum carbonate oral powder pack 1000 mg (elemental).......................................................73 FRAGMIN -dalteparin sodium inj 10000 unit/ml..............154 FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........154 FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml...........154 FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml...........154 FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........154 FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml.........154 FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......154 FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml.........154 FROVA -frovatriptan succinate tab 2.5 mg (base equivalent)..................................................................... 107 frovatriptan succinate tab 2.5 mg (base equivalent) (Frova).......................................................................... 107 FRUITIVITS -nutritional supplement pack.......................134 FUROSEMIDE -furosemide oral soln 8 mg/ml..................55 furosemide oral soln 10 mg/ml...................................... 55 furosemide tab 20 mg (Lasix)........................................ 55 furosemide tab 40 mg (Lasix)........................................ 55 furosemide tab 80 mg (Lasix)........................................ 55
FUSION PLUS -fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap........................................................ 151 FUSION SPRINKLES -fe fum-fe polys cmplx-fa-cprobiotic pack 7-0.25-50-5 mg..................................... 151 FUZEON -enfuvirtide for inj 90 mg..................................... 7 FYCOMPA -perampanel susp 0.5 mg/ml........................ 110 FYCOMPA -perampanel tab 2 mg.................................. 110 FYCOMPA -perampanel tab 4 mg.................................. 110 FYCOMPA -perampanel tab 6 mg.................................. 110 FYCOMPA -perampanel tab 8 mg.................................. 110 FYCOMPA -perampanel tab 10 mg................................ 110 FYCOMPA -perampanel tab 12 mg................................ 110 G GA-1 ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 134 gabapentin cap 100 mg (Neurontin)............................ 110 gabapentin cap 300 mg (Neurontin)............................ 110 gabapentin cap 400 mg (Neurontin)............................ 110 gabapentin oral soln 250 mg/5ml (Neurontin)............ 110 gabapentin tab 600 mg (Neurontin)............................. 110 gabapentin tab 800 mg (Neurontin)............................. 110 GABITRIL -tiagabine hcl tab 12 mg................................ 110 GABITRIL -tiagabine hcl tab 16 mg................................ 110 GA EXPRESS15 -nutritional supplement pack............... 134 GA GEL -nutritional supplement pack............................. 134 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)................................................................ 92 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)................................................................ 92 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)................................................................ 92 GALANTAMINE HYDROBROMIDE -galantamine hydrobromide oral soln 4 mg/ml.................................... 91 galantamine hydrobromide tab 4 mg (Razadyne)........ 92 galantamine hydrobromide tab 8 mg (Razadyne)........ 92 galantamine hydrobromide tab 12 mg (Razadyne)...... 92 GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 129 GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 129 GA -nutritional supplement powder................................. 134 gatifloxacin ophth soln 0.5% (Zymaxid)..................... 162 GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 73 GELCLAIR -povidone-sodium hyaluronate-glycyrrhetinic acid gel.......................................................................... 165 GELFILM OP -gelatin adsorbable ophth film.................. 162 GEL-KAM ORAL CARE RINSE -stannous fluoride conc 0.63%.............................................................................165 GEL-KAM -stannous fluoride gel 0.4%........................... 165 GELNIQUE -oxybutynin chloride td gel 10%.................... 75 gemfibrozil tab 600 mg (Lopid)...................................... 57 GENADUR -dermatological products misc - liquid..........172
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
213
2016 GENERESS FE -norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg................................................28 GENTAMICIN SULFATE -gentamicin sulfate cream 0.1%...............................................................................172 GENTAMICIN SULFATE -gentamicin sulfate oint 0.1%...............................................................................172 gentamicin sulfate ophth oint 0.3%............................. 162 gentamicin sulfate ophth soln 0.3% (Garamycin)...... 162 GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg.......................................................... 7 GIALAX -polyethylene glycol 3350 - kit............................ 67 GIAZO -balsalazide disodium tab 1.1 gm......................... 73 GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 92 GILOTRIF -afatinib dimaleate tab 20 mg (base equivalent)....................................................................... 18 GILOTRIF -afatinib dimaleate tab 30 mg (base equivalent)....................................................................... 18 GILOTRIF -afatinib dimaleate tab 40 mg (base equivalent)....................................................................... 18 GILPHEX TR -phenylephrine-guaifenesin tab 10-388 mg.................................................................................... 62 GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388 mg.................................................................................... 62 glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)..................................................................... 92 GLEEVEC -imatinib mesylate tab 100 mg (base equivalent)....................................................................... 18 GLEEVEC -imatinib mesylate tab 400 mg (base equivalent)....................................................................... 18 GLEOSTINE -lomustine cap 5 mg.................................... 19 GLEOSTINE -lomustine cap 10 mg.................................. 19 GLEOSTINE -lomustine cap 40 mg.................................. 19 GLEOSTINE -lomustine cap 100 mg................................ 19 glimepiride tab 1 mg (Amaryl)........................................31 glimepiride tab 2 mg (Amaryl)........................................31 glimepiride tab 4 mg (Amaryl)........................................31 glipizide-metformin hcl tab 2.5-250 mg......................... 31 glipizide-metformin hcl tab 2.5-500 mg......................... 31 glipizide-metformin hcl tab 5-500 mg............................ 31 glipizide tab 5 mg (Glucotrol).........................................31 glipizide tab 10 mg (Glucotrol).......................................31 glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 31 glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 31 glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 31 GLUCAGEN DIAGNOSTIC -glucagon hcl (rdna) diagnostic for inj 1 mg (base equiv)............................. 181 GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg (base equiv).................................................................... 31 GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj kit 1 mg........................................................................... 31 GLUCERNA ADVANCE SHAKE -nutritional supplement liquid.............................................................................. 135
GLUCERNA 1.0 CAL/FIBER -nutritional supplement liquid.............................................................................. 135 GLUCERNA 1.0 CAL -nutritional supplement liquid....... 135 GLUCERNA 1.2 CAL -nutritional supplement liquid....... 135 GLUCERNA 1.5 CAL -nutritional supplement liquid....... 135 GLUCERNA CEREAL CRUNCHY F -nutritional supplement misc........................................................... 135 GLUCERNA CRISPY DELIGHTS -nutritional supplement bar.................................................................................. 135 GLUCERNA HUNGER SMART SHA -nutritional supplement liquid.......................................................... 135 GLUCERNA MEAL -nutritional supplement bar..............135 GLUCERNA MEAL REPLACEMENT -nutritional supplement bar............................................................. 135 GLUCERNA MINI SNACK -nutritional supplement bar.................................................................................. 135 GLUCERNA MINI SNACKS -nutritional supplement bar.................................................................................. 135 GLUCERNA -nutritional supplement bar.........................134 GLUCERNA -nutritional supplement liquid..................... 135 GLUCERNA OS -nutritional supplement liquid............... 135 GLUCERNA SELECT -nutritional supplement liquid...... 135 GLUCERNA SHAKE -nutritional supplement liquid........ 135 GLUCERNA SNACK -nutritional supplement bar........... 135 GLUCERNA SNACK SHAKE -nutritional supplement liquid.............................................................................. 135 GLUCERNA WEIGHT LOSS SHAK -nutritional supplement liquid.......................................................... 135 GLUCO BURST -nutritional supplement liquid............... 135 glucose gel 40%............................................................... 31 GLUCOSE -glucose chew tab 4 gm................................. 31 GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm........ 31 glucose oral liquid 15 gm/59ml...................................... 31 GLUMETZA -metformin hcl tab sr 24hr modified release 500 mg............................................................................ 31 GLUMETZA -metformin hcl tab sr 24hr modified release 1000 mg.......................................................................... 31 GLUTARADE AMINO ACID BLEN -amino acids oral powder........................................................................... 130 GLUTARADE ESSENTIAL GA-1 -amino acids oral powder........................................................................... 130 GLUTARADE JUNIOR GA-1 -amino acids oral powder........................................................................... 130 GLUTAREX-1 -nutritional supplement powder................135 GLUTAREX-2 -nutritional supplement powder................135 glyburide-metformin tab 1.25-250 mg (Glucovance).................................................................. 32 glyburide-metformin tab 2.5-500 mg (Glucovance)..... 32 glyburide-metformin tab 5-500 mg (Glucovance)........ 32 glyburide micronized tab 1.5 mg (Glynase)..................31 glyburide micronized tab 3 mg (Glynase).....................31 glyburide micronized tab 6 mg (Glynase).....................32
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
214
2016 glyburide tab 1.25 mg..................................................... 32 glyburide tab 2.5 mg....................................................... 32 glyburide tab 5 mg.......................................................... 32 glycopyrrolate tab 1 mg (Robinul)................................. 69 glycopyrrolate tab 2 mg (Robinul forte)........................69 GLYCOSADE -nutritional supplement pack.................... 135 GLYSET -miglitol tab 25 mg.............................................. 32 GLYSET -miglitol tab 50 mg.............................................. 32 GLYSET -miglitol tab 100 mg............................................ 32 GLYTACTIN BETTERMILK DE-L -nutritional supplement pack............................................................................... 135 GLYTACTIN BETTERMILK 15 -nutritional supplement pack............................................................................... 135 GLYTACTIN BUILD 10PE -nutritional supplement pack............................................................................... 135 GLYTACTIN COMPLETE 10PE -nutritional supplement bar.................................................................................. 135 GLYTACTIN RESTORE LITE 10 -nutritional supplement liquid.............................................................................. 135 GLYTACTIN RESTORE LITE 10 -nutritional supplement pack............................................................................... 135 GLYTACTIN RESTORE 10 -nutritional supplement liquid.............................................................................. 135 GLYTACTIN RESTORE 5 -nutritional supplement pack............................................................................... 135 GLYTACTIN RTD 10 -nutritional supplement liquid........ 135 GLYTACTIN RTD 15 -nutritional supplement liquid........ 135 GLYTROL -nutritional supplement liquid......................... 136 GLYTROL PREBIO1 -nutritional supplement liquid........ 136 GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 32 GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 32 GNP NUTRITIONAL DRINK -nutritional supplement liquid.............................................................................. 136 GNP NUTRITIONAL DRINK PLU -nutritional supplement liquid.............................................................................. 136 GNP VITAMIN D-400 -calcium carbonate-cholecalciferol tab 90 mg-400 unit....................................................... 129 GOAT MILK -nutritional supplement powder.................. 136 GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm............................................................. 67 G-PREPROTEIN -amino acids oral liquid....................... 130 GRALISE -gabapentin (once-daily) tab 300 mg................92 GRALISE -gabapentin (once-daily) tab 600 mg................92 GRALISE STARTER -gabapentin (once-daily) tab pack 300 mg (9) & 600 mg (69)............................................. 92 granisetron hcl tab 1 mg................................................ 71 GRANIX -tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml...................................................................... 151 GRANIX -tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml...................................................................... 151 GRASTEK -timothy grass pollen allergen ext tab sl 2800 bau................................................................................... 17
griseofulvin microsize susp 125 mg/5ml........................ 6 griseofulvin microsize tab 500 mg (Grifulvin v)............. 6 griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 6 griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 6 guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 62 guaifenesin-codeine soln 100-6.3 mg/5ml.................... 62 guaifenesin-codeine soln 100-10 mg/5ml..................... 62 guanfacine hcl tab 1 mg (Tenex)................................... 50 guanfacine hcl tab 2 mg (Tenex)................................... 50 guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv).......................................................................... 89 guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv).......................................................................... 89 guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv).......................................................................... 89 guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv).......................................................................... 89 GUANIDINE HCL -guanidine hcl tab 125 mg................. 118 GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal cream 2%........................................................................ 76 H HAELAN 951 FERMENTED ORGA -nutritional supplement liquid.......................................................... 136 HAELAN HTPI FERMENTED ORG -nutritional supplement liquid.......................................................... 136 halobetasol propionate cream 0.05% (Ultravate)....... 172 halobetasol propionate oint 0.05% (Ultravate)........... 173 HALOG -halcinonide cream 0.1%................................... 173 HALOG -halcinonide oint 0.1%....................................... 173 haloperidol lactate oral conc 2 mg/ml...........................83 haloperidol tab 0.5 mg.................................................... 83 haloperidol tab 1 mg....................................................... 83 haloperidol tab 2 mg....................................................... 83 haloperidol tab 5 mg....................................................... 83 haloperidol tab 10 mg..................................................... 84 haloperidol tab 20 mg..................................................... 84 HALOTIN -haloprogin cream 1%.................................... 173 HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 7 HCU ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 136 HCU ANAMIX NEXT -nutritional supplement powder........................................................................... 136 HCU COOLER -nutritional supplement liquid................. 136 HCU EXPRESS -nutritional supplement pack................ 136 HCU EXPRESS20 -nutritional supplement pack............ 136 HCU GEL -nutritional supplement pack.......................... 136 HCU LOPHLEX LQ -nutritional supplement liquid.......... 136 HCY 1 -nutritional supplement powder........................... 136 HCY 2 -nutritional supplement powder........................... 136 HEALTH SOURCE SOY PROTEIN -nutritional supplement powder...................................................... 136
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
215
2016 HEALTHY ACCENTS NUTRA FIT -nutritional supplement liquid.............................................................................. 136 HEARTBAR -nutritional supplement bar......................... 136 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 250 unit.................................................................... 157 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 500 unit.................................................................... 157 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 1000 unit.................................................................. 157 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 2000 unit.................................................................. 157 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 3000 unit.................................................................. 157 HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml........ 43 HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg....................................................... 151 HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck.................................... 120 HEMENATAL OB -prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg........................................................... 120 HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg........................................................... 151 HEMOCYTE PLUS -ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg.............................................. 151 HEMOFIL M -antihemophilic factor (human) for inj 250 unit................................................................................. 157 HEMOFIL M -antihemophilic factor (human) for inj 500 unit................................................................................. 157 HEMOFIL M -antihemophilic factor (human) for inj 1000 unit................................................................................. 157 HEMOFIL M -antihemophilic factor (human) for inj 1700 unit................................................................................. 157 HEPAGAM B -hepatitis b immune globulin (human) inj soln.................................................................................. 16 HEPAMENT -amino acids pack.......................................130 heparin sodium (porcine) inj 1000 unit/ml.................. 154 heparin sodium (porcine) inj 5000 unit/ml.................. 154 heparin sodium (porcine) inj 10000 unit/ml................ 154 heparin sodium (porcine) inj 20000 unit/ml................ 154 heparin sodium (porcine) pf inj 5000 unit/0.5ml........ 154 HETLIOZ -tasimelteon capsule 20 mg.............................. 87 HEXALEN -altretamine cap 50 mg................................... 19 HI-CAL -nutritional supplement liquid..............................136 HIGH-PROTEIN NUTRITIONAL -nutritional supplement liquid.............................................................................. 136 HISTEX-AC -phenylephrine-triprolidine-codeine syrup 10-2.5-10 mg/5ml............................................................ 62 HM NUTRISURE -nutritional supplement liquid..............136 HM NUTRISURE PLUS -nutritional supplement liquid.............................................................................. 136 HOMACTIN AA PLUS -nutritional supplement liquid...... 136
homatropine hbr ophth soln 5% (Isopto homatropine)............................................................... 162 HOMINEX-1 -nutritional supplement powder.................. 136 HOMINEX-2 -nutritional supplement powder.................. 136 HOM 2 -nutritional supplement powder.......................... 136 HORIZANT -gabapentin enacarbil tab cr 300 mg............. 92 HORIZANT -gabapentin enacarbil tab cr 600 mg............. 92 H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 40 HPR -dermatological products, misc. - aerosol foam......173 HPR PLUS -dermatological products, misc. - aerosol foam............................................................................... 173 HPR PLUS -dermatological products misc - cream........ 173 HUMALOG -insulin lispro inj 100 unit/ml...........................35 HUMALOG -insulin lispro soln cartridge 100 unit/ml.........35 HUMALOG KWIKPEN -insulin lispro soln pen-injector 100 unit/ml.............................................................................. 35 HUMALOG KWIKPEN -insulin lispro soln pen-injector 200 unit/ml.............................................................................. 35 HUMALOG MIX 75/25 -insulin lispro prot & lispro inj 100 unit/ml (75-25)................................................................. 35 HUMALOG MIX 50/50 -insulin lispro protamine & lispro inj 100 unit/ml (50-50)......................................................... 35 HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50).............................35 HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25).............................35 HUMATE-P -antihemophilic factor/vwf (human) for inj 250-600 unit.................................................................. 157 HUMATE-P -antihemophilic factor/vwf (human) for inj 500-1200 unit................................................................ 157 HUMATE-P -antihemophilic factor/vwf (human) for inj 1000-2400 unit.............................................................. 157 HUMIRA -adalimumab prefilled syringe kit 10 mg/0.2ml........................................................................ 105 HUMIRA -adalimumab prefilled syringe kit 20 mg/0.4ml........................................................................ 105 HUMIRA -adalimumab prefilled syringe kit 40 mg/0.8ml........................................................................ 105 HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled syringe kit 40 mg/0.8ml................................................ 105 HUMIRA PEN -adalimumab pen-injector kit 40 mg/0.8ml........................................................................ 105 HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml................................................ 105 HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml................................................ 105 HUMULIN 70/30 -insulin nph isophane & regular human inj 100 unit/ml (70-30).................................................... 36 HUMULIN 70/30 KWIKPEN -insulin nph & regular susp pen-inj 100 unit/ml (70-30)............................................. 36 HUMULIN N -insulin nph (human) (isophane) inj 100 unit/ ml..................................................................................... 36
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
216
2016 HUMULIN N KWIKPEN -insulin nph (human) (isophane) susp pen-injector 100 unit/ml......................................... 36 HUMULIN R -insulin regular (human) inj 100 unit/ml........ 35 HUMULIN R U-500 (CONCENTR -insulin regular (human) inj 500 unit/ml..................................................................35 HUMULIN R U-500 KWIKPEN -insulin regular (human) soln pen-injector 500 unit/ml.......................................... 35 HURRISEAL -dental desensitizing product - solution..... 181 hyaluronate sodium (emollient) gel 0.2% (Hylira)...... 173 HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 19 HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 19 HYCOFENIX -pseudoephedrine w/ hydrocodone-gg soln 30-2.5-200 mg/5ml.......................................................... 62 hydralazine hcl tab 10 mg.............................................. 50 hydralazine hcl tab 25 mg.............................................. 50 hydralazine hcl tab 50 mg.............................................. 50 hydralazine hcl tab 100 mg............................................ 50 hydrochlorothiazide cap 12.5 mg (Microzide).............. 55 hydrochlorothiazide tab 12.5 mg................................... 55 hydrochlorothiazide tab 25 mg...................................... 55 hydrochlorothiazide tab 50 mg...................................... 55 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet).............................................................................98 hydrocodone-acetaminophen soln 10-325 mg/15ml (Zamicet).........................................................................98 hydrocodone-acetaminophen tab 2.5-325 mg.............. 98 hydrocodone-acetaminophen tab 7.5-325 mg (Norco)............................................................................ 98 hydrocodone-acetaminophen tab 5-325 mg (Norco)............................................................................ 98 hydrocodone-acetaminophen tab 10-325 mg (Norco)............................................................................ 98 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)............................................................................ 98 hydrocodone-acetaminophen tab 5-300 mg (Xodol)............................................................................ 98 hydrocodone-acetaminophen tab 10-300 mg (Xodol)............................................................................ 98 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 98 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......98 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen)................................................................... 98 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 62 hydrocodone w/ homatropine tab 5-1.5 mg..................62 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml (Tussionex pennkineti)................................................. 62 hydrocortisone acetate suppos 25 mg (Anusolhc)................................................................................. 167 hydrocortisone acetate suppos 30 mg (Proctocort).................................................................. 167 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc).................................................... 167
hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc)................................................. 167 hydrocortisone butyrate cream 0.1% (Locoid)...........173 hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream)............................................ 173 hydrocortisone butyrate oint 0.1% (Locoid)............... 173 hydrocortisone butyrate soln 0.1% (Locoid).............. 173 hydrocortisone cream 2.5%..........................................173 hydrocortisone enema 100 mg/60ml (Cortenema)................................................................. 167 hydrocortisone lotion 2.5%.......................................... 173 hydrocortisone lotion 2% (Ala scalp).......................... 173 hydrocortisone oint 2.5%..............................................173 hydrocortisone rectal cream 2.5% (Anusol-hc)......... 167 hydrocortisone rectal cream 1% (Proctocort)............ 167 hydrocortisone tab 5 mg (Cortef).................................. 23 hydrocortisone tab 10 mg (Cortef)................................ 23 hydrocortisone tab 20 mg (Cortef)................................ 23 hydrocortisone valerate cream 0.2%...........................173 hydrocortisone valerate oint 0.2% (Westcort)............ 173 hydrocortisone w/ acetic acid otic soln 1-2%............ 165 HYDROMORPHONE HCL -hydromorphone hcl suppos 3 mg.................................................................................... 98 hydromorphone hcl liqd 1 mg/ml (Dilaudid).................98 hydromorphone hcl tab er 24hr deter 8 mg (Exalgo).......................................................................... 98 hydromorphone hcl tab er 24hr deter 12 mg (Exalgo).......................................................................... 98 hydromorphone hcl tab er 24hr deter 16 mg (Exalgo).......................................................................... 98 hydromorphone hcl tab er 24hr deter 32 mg (Exalgo).......................................................................... 98 hydromorphone hcl tab 2 mg (Dilaudid)....................... 98 hydromorphone hcl tab 4 mg (Dilaudid)....................... 98 hydromorphone hcl tab 8 mg (Dilaudid)....................... 98 hydroxychloroquine sulfate tab 200 mg (Plaquenil)...................................................................... 12 hydroxyurea cap 500 mg (Hydrea)................................ 19 hydroxyzine hcl syrup 10 mg/5ml................................. 77 hydroxyzine hcl tab 10 mg............................................. 77 hydroxyzine hcl tab 25 mg............................................. 77 hydroxyzine hcl tab 50 mg............................................. 77 hydroxyzine pamoate cap 25 mg (Vistaril)................... 78 hydroxyzine pamoate cap 50 mg (Vistaril)................... 78 HYDROXYZINE PAMOATE -hydroxyzine pamoate cap 100 mg............................................................................ 78 HYLATOPIC PLUS -dermatological products, misc. aerosol foam................................................................. 173 HYLATOPIC PLUS -dermatological products misc cream............................................................................. 173 HYLIRA -hyaluronate sodium (emollient) lotion 0.1%..... 173 hyoscyamine sulfate elixir 0.125 mg/5ml...................... 69
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
217
2016 hyoscyamine sulfate soln 0.125 mg/ml......................... 69 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)..... 69 hyoscyamine sulfate tab 0.125 mg (Levsin)................. 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........................................................................ 16 HYPERRAB S/D -rabies immune globulin (human) inj 150 unit/ml.............................................................................. 16 HYPERSAL -sodium chloride soln nebu 3.5%..................62 HYPERTET S/D -tetanus immune globulin (human) inj 250 unit/ml.......................................................................16 HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/1.25 ml kit................................................................. 16 HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit................................................................... 16 HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800 unt/5 ml kit...................................................................... 16 HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600 unt/10 ml kit.................................................................... 17 HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400 unt/15 ml kit.................................................................... 17 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 20 mg.............................................................................. 99 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 30 mg.............................................................................. 99 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 40 mg.............................................................................. 99 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 60 mg.............................................................................. 99 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 80 mg.............................................................................. 99 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 100 mg............................................................................ 99 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 120 mg............................................................................ 99 I ibandronate sodium tab 150 mg (base equivalent) (Boniva).......................................................................... 40 IBRANCE -palbociclib cap 75 mg..................................... 19 IBRANCE -palbociclib cap 100 mg................................... 19 IBRANCE -palbociclib cap 125 mg................................... 19 ibuprofen tab 400 mg.................................................... 105 ibuprofen tab 600 mg.................................................... 105 ibuprofen tab 800 mg.................................................... 105 ICAR -carbonyl iron chew tab 15 mg (elemental iron)................................................................................151 ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml (elemental iron)............................................................. 151 ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 19
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 19 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj 250 unit......................................................................... 157 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj 500 unit......................................................................... 157 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj 1000 unit....................................................................... 157 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj 2000 unit....................................................................... 157 ILEVRO -nepafenac ophth susp 0.3%............................ 162 imatinib mesylate tab 100 mg (base equivalent) (Gleevec)........................................................................ 19 imatinib mesylate tab 400 mg (base equivalent) (Gleevec)........................................................................ 19 IMBRUVICA -ibrutinib cap 140 mg................................... 19 imipramine hcl tab 10 mg (Tofranil).............................. 80 imipramine hcl tab 25 mg (Tofranil).............................. 80 imipramine hcl tab 50 mg (Tofranil).............................. 80 imipramine pamoate cap 75 mg (Tofranil-pm)............. 80 imipramine pamoate cap 100 mg (Tofranil-pm)........... 80 imipramine pamoate cap 125 mg (Tofranil-pm)........... 80 imipramine pamoate cap 150 mg (Tofranil-pm)........... 80 imiquimod cream 5% (Aldara)...................................... 173 IMITREX -sumatriptan nasal spray 5 mg/act.................. 107 IMITREX -sumatriptan nasal spray 20 mg/act................ 107 IMMULIFE -nutritional supplement powder..................... 136 IMMUNOPRO RX -nutritional supplement powder......... 136 IMOGAM RABIES-HT -rabies immune globulin (human) inj 150 unit/ml..................................................................17 IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc inj..................................................................................... 15 IMPACT/FIBER -nutritional supplement liquid................ 137 IMPACT ADVANCED RECOVERY -nutritional supplement liquid.......................................................... 136 IMPACT GLUTAMINE -nutritional supplement liquid...... 137 IMPACT -nutritional supplement liquid............................ 136 IMPACT 1.5 -nutritional supplement liquid...................... 137 IMPACT PEPTIDE 1.5 -nutritional supplement liquid..... 137 IMPAVIDO -miltefosine cap 50 mg.................................... 12 IMUPLUS -nutritional supplement pack.......................... 137 INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg...................................................................120 INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg.................................................................................. 120 INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg......................................................................... 121 INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........40 indapamide tab 1.25 mg..................................................55 indapamide tab 2.5 mg.................................................... 55 INDERAL XL -propranolol hcl sustained-release beads cap sr 24hr 80 mg.......................................................... 43
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
218
2016 INDERAL XL -propranolol hcl sustained-release beads cap sr 24hr 120 mg........................................................ 43 indomethacin cap cr 75 mg.......................................... 105 indomethacin cap 25 mg.............................................. 105 indomethacin cap 50 mg.............................................. 105 INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg.......................................................... 121 INFANRIX -diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml............................................................... 16 INFASURF -calfactant in nacl 0.9% intratracheal susp 35 mg/ml............................................................................... 67 INLYTA -axitinib tab 1 mg.................................................. 19 INLYTA -axitinib tab 5 mg.................................................. 19 INNOPRAN XL -propranolol hcl sustained-release beads cap sr 24hr 80 mg.......................................................... 43 INNOPRAN XL -propranolol hcl sustained-release beads cap sr 24hr 120 mg........................................................ 43 INNOVACIN -nutritional supplement liquid......................137 INSTA-GLUCOSE -glucose gel 77.4%............................. 32 INSULIN PEN NEEDLES-VARIOUS............................... 181 INSULIN SYRINGES-VARIOUS...................................... 181 INTEGRA F -fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe)................................... 151 INTEGRA PLUS -fe fum-iron polysacch complex-fa-b complex-c-biotin cap..................................................... 151 INTELENCE -etravirine tab 25 mg...................................... 8 INTELENCE -etravirine tab 100 mg.................................... 8 INTELENCE -etravirine tab 200 mg.................................... 8 INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ ml & lidocaine 1% & ammonia inh kit............................ 23 INTROLITE -nutritional supplement liquid.......................137 INTRON A -interferon alfa-2b for inj 10000000 unit.......... 19 INTRON A -interferon alfa-2b for inj 18000000 unit.......... 19 INTRON A -interferon alfa-2b for inj 50000000 unit.......... 19 INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 19 INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 19 INTRON A W/DILUENT -interferon alfa-2b for inj 10000000 unit................................................................. 19 INTRON A W/DILUENT -interferon alfa-2b for inj 18000000 unit................................................................. 19 INTRON A W/DILUENT -interferon alfa-2b for inj 50000000 unit................................................................. 19 INVEGA -paliperidone tab sr 24hr 1.5 mg........................ 84 INVEGA -paliperidone tab sr 24hr 3 mg........................... 84 INVEGA -paliperidone tab sr 24hr 6 mg........................... 84 INVEGA -paliperidone tab sr 24hr 9 mg........................... 84 INVIRASE -saquinavir mesylate cap 200 mg..................... 8 INVIRASE -saquinavir mesylate tab 500 mg...................... 8 INVOKAMET -canagliflozin-metformin hcl tab 50-500 mg.................................................................................... 32 INVOKAMET -canagliflozin-metformin hcl tab 150-500 mg.................................................................................... 32
INVOKAMET -canagliflozin-metformin hcl tab 50-1000 mg.................................................................................... 32 INVOKAMET -canagliflozin-metformin hcl tab 150-1000 mg.................................................................................... 32 INVOKANA -canagliflozin tab 100 mg.............................. 32 INVOKANA -canagliflozin tab 300 mg.............................. 32 IODINE STRONG -iodine solution strong 5% (lugol's).......................................................................... 129 iodoquinol-hc cream 1%............................................... 173 iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9% (Vytone)........................................................... 173 IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act (base equiv).................................................................... 99 IOPIDINE -apraclonidine hcl ophth soln 1% (base equivalent)..................................................................... 162 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 65 ipratropium bromide inhal soln 0.02%.......................... 65 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent)....................................................................... 61 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent)....................................................................... 61 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide)..........................................................................51 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide)..........................................................................51 irbesartan tab 75 mg (Avapro)....................................... 51 irbesartan tab 150 mg (Avapro)..................................... 51 irbesartan tab 300 mg (Avapro)..................................... 51 IRESSA -gefitinib tab 250 mg........................................... 19 IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg (elemental iron)............................................................. 151 iron combination cap.................................................... 151 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg (Hematron-af)........................................................ 151 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150)................................................................ 151 iron polysacch complex-vit b12-fa cap 150-0.025-1 mg................................................................................. 151 IROSPAN 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-cca-fa tab ther pk........................................................... 151 IS 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-c-ca-fa tab ther pk........................................................................... 151 ISENTRESS -raltegravir potassium chew tab 25 mg (base equiv)................................................................................. 8 ISENTRESS -raltegravir potassium chew tab 100 mg (base equiv)...................................................................... 8 ISENTRESS -raltegravir potassium packet for susp 100 mg (base equiv)................................................................ 8 ISENTRESS -raltegravir potassium tab 400 mg (base equiv)................................................................................. 8 ISOCAL HN -nutritional supplement liquid...................... 137 ISOCAL HN PLUS -nutritional supplement liquid........... 137
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
219
2016 ISOCAL -nutritional supplement liquid............................ 137 isometheptene-caffeine-acetaminophen tab 65-20-325 mg (Prodrin)................................................................ 107 isometheptene-dichloral-acetaminophen cap 65-100-325 mg............................................................. 107 ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 5 isoniazid tab 100 mg......................................................... 5 isoniazid tab 300 mg......................................................... 5 ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg.................................................................................... 42 ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr 40 mg.............................................................................. 42 isosorbide dinitrate tab 10 mg....................................... 42 isosorbide dinitrate tab 20 mg....................................... 42 isosorbide dinitrate tab 30 mg....................................... 42 isosorbide dinitrate tab 5 mg (Isordil titradose).......... 42 isosorbide mononitrate tab 10 mg................................ 42 isosorbide mononitrate tab 20 mg................................ 42 isosorbide mononitrate tab sr 24hr 30 mg................... 42 isosorbide mononitrate tab sr 24hr 60 mg................... 42 isosorbide mononitrate tab sr 24hr 120 mg................. 42 ISOSOURCE 1.5 CAL -nutritional supplement liquid......137 ISOSOURCE CLOSED SYSTEM -nutritional supplement liquid.............................................................................. 137 ISOSOURCE HN -nutritional supplement liquid............. 137 ISOSOURCE -nutritional supplement liquid.................... 137 ISOSOURCE VHN -nutritional supplement liquid........... 137 isotretinoin cap 10 mg.................................................. 173 isotretinoin cap 20 mg.................................................. 173 isotretinoin cap 30 mg.................................................. 173 isotretinoin cap 40 mg.................................................. 173 ISOVACTIN AA PLUS -nutritional supplement liquid...... 137 ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg.............. 59 isoxsuprine hcl tab 10 mg.............................................. 59 isradipine cap 2.5 mg...................................................... 45 isradipine cap 5 mg......................................................... 45 ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 162 itraconazole cap 100 mg (Sporanox).............................. 6 IVA ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 137 IVA ANAMIX NEXT -nutritional supplement powder....... 137 I-VALEX-1 -nutritional supplement powder..................... 136 I-VALEX-2 -nutritional supplement powder..................... 136 ivermectin tab 3 mg (Stromectol).................................. 12 IXINITY -coagulation factor ix (recombinant) for inj 500 unit................................................................................. 157 IXINITY -coagulation factor ix (recombinant) for inj 1000 unit................................................................................. 157 IXINITY -coagulation factor ix (recombinant) for inj 1500 unit................................................................................. 157
J JADENU -deferasirox tab 90 mg..................................... 180 JADENU -deferasirox tab 180 mg................................... 180 JADENU -deferasirox tab 360 mg................................... 180 JAKAFI -ruxolitinib phosphate tab 5 mg (base equivalent)....................................................................... 19 JAKAFI -ruxolitinib phosphate tab 10 mg (base equivalent)....................................................................... 19 JAKAFI -ruxolitinib phosphate tab 15 mg (base equivalent)....................................................................... 19 JAKAFI -ruxolitinib phosphate tab 20 mg (base equivalent)....................................................................... 19 JAKAFI -ruxolitinib phosphate tab 25 mg (base equivalent)....................................................................... 19 JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg.......... 76 JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 32 JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 32 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-500 mg....................................................................... 32 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-1000 mg..................................................................... 32 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 100-1000 mg................................................................... 32 JANUVIA -sitagliptin phosphate tab 25 mg (base equiv)............................................................................... 32 JANUVIA -sitagliptin phosphate tab 50 mg (base equiv)............................................................................... 32 JANUVIA -sitagliptin phosphate tab 100 mg (base equiv)............................................................................... 32 JARDIANCE -empagliflozin tab 10 mg............................. 32 JARDIANCE -empagliflozin tab 25 mg............................. 32 JENTADUETO -linagliptin-metformin hcl tab 2.5-1000 mg.................................................................................... 32 JENTADUETO -linagliptin-metformin hcl tab 2.5-500 mg.................................................................................... 32 JENTADUETO -linagliptin-metformin hcl tab 2.5-850 mg.................................................................................... 32 JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr 2.5-1000 mg.................................................................... 32 JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr 5-1000 mg....................................................................... 33 JEVITY 1 CAL/FIBER -nutritional supplement liquid...... 137 JEVITY 1.2 CAL/FIBER -nutritional supplement liquid.............................................................................. 137 JEVITY 1.5 CAL/FIBER -nutritional supplement liquid.............................................................................. 137 JEVITY 1 CAL -nutritional supplement liquid.................. 137 JEVITY 1.2 CAL -nutritional supplement liquid............... 137 JEVITY 1.5 CAL -nutritional supplement liquid............... 137 JTT PHYSICIANS KIT -triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit..................................... 23
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
220
2016 JUBLIA -efinaconazole soln 10%.................................... 173 JUICE PLUS FIBRE -nutritional supplement liquid......... 137 JUVEN -nutritional supplement pack.............................. 137 JUVEN -nutritional supplement powder.......................... 137 JUVEN NUTRIVIGOR -nutritional supplement pack.......137 JUVEN REVIGOR -nutritional supplement pack.............137 JUXTAPID -lomitapide mesylate cap 5 mg (base equiv)............................................................................... 57 JUXTAPID -lomitapide mesylate cap 10 mg (base equiv)............................................................................... 57 JUXTAPID -lomitapide mesylate cap 20 mg (base equiv)............................................................................... 57 JUXTAPID -lomitapide mesylate cap 30 mg (base equiv)............................................................................... 57 JUXTAPID -lomitapide mesylate cap 40 mg (base equiv)............................................................................... 57 JUXTAPID -lomitapide mesylate cap 60 mg (base equiv)............................................................................... 57 K KADIAN -morphine sulfate cap sr 24hr 40 mg..................99 KADIAN -morphine sulfate cap sr 24hr 200 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 packet 50 mg................................ 67 KALYDECO -ivacaftor packet 75 mg................................ 67 KALYDECO -ivacaftor tab 150 mg.................................... 67 KARBINAL ER -carbinoxamine maleate extended release susp 4 mg/5ml................................................................ 61 KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 33 KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 33 KCENTRA -prothrombin complex conc human for inj kit 500 unit......................................................................... 157 KCENTRA -prothrombin complex conc human for inj kit 1000 unit....................................................................... 157 KENALOG -triamcinolone acetonide aerosol soln 0.147 mg/gm............................................................................ 173 KERYDIN -tavaborole soln 5%........................................173 KETOCAL 4:1 LQ MULTI FIBE -nutritional supplement liquid.............................................................................. 137 KETOCAL 4:1 -nutritional supplement liquid.................. 137 KETOCAL 3:1 -nutritional supplement powder............... 137 KETOCAL 4:1 -nutritional supplement powder............... 137 ketoconazole cream 2%................................................ 173 ketoconazole foam 2% (Extina)................................... 173 ketoconazole shampoo 2% (Nizoral)........................... 173 ketoconazole tab 200 mg.................................................. 6 KETOGEN -nutritional supplement powder.................... 137 KETONE BLOOD TEST STRIPS-VARIOUS.................. 181 KETONEX-1 -nutritional supplement powder..................137
KETONEX-2 -nutritional supplement powder..................138 ketoprofen cap 50 mg................................................... 105 ketoprofen cap 75 mg................................................... 105 ketorolac tromethamine ophth soln 0.5% (Acular)......................................................................... 162 ketorolac tromethamine ophth soln 0.4% (Acular ls)................................................................................... 162 ketorolac tromethamine tab 10 mg............................. 105 KETOVIE -nutritional supplement liquid.......................... 138 KETOVIE PEPTIDE -nutritional supplement liquid......... 138 KETOVOLVE 4:1 -nutritional supplement powder.......... 138 KEVEYIS -dichlorphenamide tab 50 mg........................... 55 KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg............... 80 KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg............. 80 KINERET -anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml.............................................................. 105 KINRAY PREFERRED PLUS -nutritional supplement liquid.............................................................................. 138 KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv vac inj.............................................................................. 16 KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 5 KLOR-CON/25 -potassium chloride powder packet 25 meq................................................................................ 129 KLOR-CON M15 -potassium chloride microencapsulated crys cr tab 15 meq....................................................... 129 KOATE-DVI -antihemophilic factor (human) for inj 250 unit................................................................................. 157 KOATE-DVI -antihemophilic factor (human) for inj 500 unit................................................................................. 157 KOATE-DVI -antihemophilic factor (human) for inj 1000 unit................................................................................. 157 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 250 unit............................................................... 157 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 500 unit............................................................... 158 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 1000 unit............................................................. 158 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 2000 unit............................................................. 158 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 3000 unit............................................................. 158 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 250 unit.................................. 158 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 500 unit.................................. 158 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 1000 unit................................ 158 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 2000 unit................................ 158 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 3000 unit................................ 158
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
221
2016 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 2.5-1000 mg.................................................................... 33 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 5-500 mg......................................................................... 33 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 5-1000 mg....................................................................... 33 KORLYM -mifepristone tab 300 mg.................................. 33 KOVALTRY -antihemophilic factor (recombinant) for inj 250 unit......................................................................... 158 KOVALTRY -antihemophilic factor (recombinant) for inj 500 unit......................................................................... 158 KOVALTRY -antihemophilic factor (recombinant) for inj 1000 unit....................................................................... 158 KOVALTRY -antihemophilic factor (recombinant) for inj 2000 unit....................................................................... 158 KOVALTRY -antihemophilic factor (recombinant) for inj 3000 unit....................................................................... 158 K-PAX IMMUNE BOOSTER PROT -nutritional supplement powder...................................................... 137 K-PHOS NO 2 -potassium & sodium acid phosphates tab 305-700 mg..................................................................... 76 K-PHOS -potassium phosphate monobasic tab 500 mg.................................................................................. 129 KRISTALOSE -lactulose oral crystal packet 10 gm.......... 67 KRISTALOSE -lactulose oral crystal packet 20 gm.......... 67 KROGER GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm...................................................................... 33 K-TAB -potassium chloride tab cr 8 meq (600 mg)......... 129 K-TAB -potassium chloride tab cr 20 meq (1500 mg)..... 129 KUVAN -sapropterin dihydrochloride powder packet 100 mg.................................................................................... 40 KUVAN -sapropterin dihydrochloride powder packet 500 mg.................................................................................... 40 KUVAN -sapropterin dihydrochloride soluble tab 100 mg.................................................................................... 40 KYNAMRO -mipomersen sodium soln prefilled syringe 200 mg/ml....................................................................... 57 L labetalol hcl tab 100 mg (Trandate)............................... 43 labetalol hcl tab 200 mg (Trandate)............................... 43 labetalol hcl tab 300 mg (Trandate)............................... 43 LACRISERT -artificial tear ophth insert...........................162 lactic acid (ammonium lactate) cream 12% (Lachydrin).......................................................................... 173 lactic acid (ammonium lactate) lotion 10%.................173 lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 173 lactic acid w/ vitamin e cream 10%-3500 unit/30gm......................................................................173 lactulose (encephalopathy) solution 10 gm/15ml........ 73 lactulose solution 10 gm/15ml....................................... 67
LAMICTAL ODT -lamotrigine orally disintegrating tab 25 mg.................................................................................. 111 LAMICTAL ODT -lamotrigine orally disintegrating tab 50 mg.................................................................................. 111 LAMICTAL ODT -lamotrigine orally disintegrating tab 100 mg.................................................................................. 111 LAMICTAL ODT -lamotrigine orally disintegrating tab 200 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.........................................111 LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg (84) & 100 mg (14) starter kit.......................................111 LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg (35) starter kit............................................................... 111 LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit..................................................... 111 LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit................................................ 111 LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50 mg (7) titration kit......................................................... 111 lamivudine oral soln 10 mg/ml (Epivir)........................... 8 lamivudine tab 150 mg (Epivir)........................................ 8 lamivudine tab 300 mg (Epivir)........................................ 8 lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 8 lamivudine-zidovudine tab 150-300 mg (Combivir)....... 8 lamotrigine orally disintegrating tab 25 mg (Lamictal odt)................................................................................ 111 lamotrigine orally disintegrating tab 50 mg (Lamictal odt)................................................................................ 111 lamotrigine orally disintegrating tab 100 mg (Lamictal odt)................................................................................ 111 lamotrigine orally disintegrating tab 200 mg (Lamictal odt)................................................................................ 111 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)................................................................ 111 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)................................................................ 111 lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit (LAMICTAL ODT)................................................... 111 lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit (LAMICTAL ODT)................................................... 111 lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit (LAMICTAL ODT)................................................... 111 lamotrigine tab 25 mg (Lamictal)................................. 112 lamotrigine tab 100 mg (Lamictal)............................... 112 lamotrigine tab 150 mg (Lamictal)............................... 112
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
222
2016 lamotrigine tab 200 mg (Lamictal)............................... 112 lamotrigine tab sr 24hr 25 mg (Lamictal xr)............... 111 lamotrigine tab sr 24hr 50 mg (Lamictal xr)............... 111 lamotrigine tab sr 24hr 100 mg (Lamictal xr)............. 111 lamotrigine tab sr 24hr 200 mg (Lamictal xr)............. 111 lamotrigine tab sr 24hr 250 mg (Lamictal xr)............. 111 lamotrigine tab sr 24hr 300 mg (Lamictal xr)............. 111 LANAFLEX -nutritional supplement pack........................ 138 LANCETS-VARIOUS........................................................181 LANCING DEVICE-VARIOUS......................................... 181 LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 41 LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 42 LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 42 LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 42 lansoprazole cap delayed release 15 mg (Prevacid)....................................................................... 69 lansoprazole cap delayed release 30 mg (Prevacid)....................................................................... 69 LANTUS -insulin glargine inj 100 unit/ml.......................... 36 LANTUS SOLOSTAR -insulin glargine soln pen-injector 100 unit/ml.......................................................................36 LASTACAFT -alcaftadine ophth soln 0.25%................... 162 latanoprost ophth soln 0.005% (Xalatan).................... 162 LATUDA -lurasidone hcl tab 20 mg...................................84 LATUDA -lurasidone hcl tab 40 mg...................................84 LATUDA -lurasidone hcl tab 60 mg...................................84 LATUDA -lurasidone hcl tab 80 mg...................................84 LATUDA -lurasidone hcl tab 120 mg.................................84 LAVARE WOUND WASH -wound cleansers - gel.......... 174 LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base equiv)............................................................................... 99 LAZANDA -fentanyl citrate nasal spray 300 mcg/act (base equiv)............................................................................... 99 LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base equiv)............................................................................... 99 L-CARNITINE -amino acids oral liquid............................ 130 LECITHIN -lecithin granules............................................ 130 leflunomide tab 10 mg (Arava)..................................... 105 leflunomide tab 20 mg (Arava)..................................... 105 LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose)............................... 19 LENVIMA 18 MG DAILY DOSE -lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose)......................... 20 LENVIMA 24 MG DAILY DOSE -lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose)......................... 20 LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapy pack 10 mg (10 mg daily dose)..................................... 19 LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose)................................ 20 LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose).................................... 20 LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg......... 57
LETAIRIS -ambrisentan tab 5 mg..................................... 59 LETAIRIS -ambrisentan tab 10 mg................................... 59 letrozole tab 2.5 mg (Femara)........................................ 20 LEUCOVORIN CALCIUM -leucovorin calcium tab 10 mg.................................................................................... 20 LEUCOVORIN CALCIUM -leucovorin calcium tab 15 mg.................................................................................... 20 leucovorin calcium tab 5 mg.......................................... 20 leucovorin calcium tab 25 mg........................................ 20 LEU-FREE COOLER -nutritional supplement liquid....... 138 LEUKERAN -chlorambucil tab 2 mg................................. 20 LEUKINE -sargramostim lyophilized for inj 250 mcg...... 151 leuprolide acetate inj kit 5 mg/ml.................................. 20 LEVACET -aspirin-apap-salicylamide-caffeine tab 500-250-150-32.5 mg..................................................... 95 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex concentrate)..................................... 65 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex)....................................................................... 65 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex)....................................................................... 65 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)....................................................................... 65 LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector 100 unit/ml.......................................................................36 LEVEMIR -insulin detemir inj 100 unit/ml..........................36 levetiracetam oral soln 100 mg/ml (Keppra)...............112 levetiracetam tab 250 mg (Keppra)............................. 112 levetiracetam tab 500 mg (Keppra)............................. 112 levetiracetam tab 750 mg (Keppra)............................. 112 levetiracetam tab 1000 mg (Keppra)........................... 112 levetiracetam tab sr 24hr 500 mg (Keppra xr)............ 112 levetiracetam tab sr 24hr 750 mg (Keppra xr)............ 112 levobunolol hcl ophth soln 0.5% (Betagan)............... 162 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 40 levocarnitine tab 330 mg (Carnitor)............................... 40 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal)................................................................ 61 levocetirizine dihydrochloride tab 5 mg (Xyzal)...........61 levofloxacin ophth soln 0.5%....................................... 162 levofloxacin oral soln 25 mg/ml (Levaquin)................... 5 levofloxacin tab 250 mg (Levaquin)................................ 5 levofloxacin tab 500 mg (Levaquin)................................ 5 levofloxacin tab 750 mg (Levaquin)................................ 5 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg.................................................................. 28 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg................................................................................. 28 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg................................................................................. 28 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg............................... 28
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
223
2016 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg.......................................................................28 levonorgestrel tab 1.5 mg............................................... 28 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique)........................................... 28 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)............................................... 28 LEVORPHANOL TARTRATE -levorphanol tartrate tab 2 mg.................................................................................... 99 levothyroxine sodium tab 25 mcg (Synthroid)............. 36 levothyroxine sodium tab 50 mcg (Synthroid)............. 36 levothyroxine sodium tab 75 mcg (Synthroid)............. 36 levothyroxine sodium tab 88 mcg (Synthroid)............. 36 levothyroxine sodium tab 100 mcg (Synthroid)........... 36 levothyroxine sodium tab 112 mcg (Synthroid)........... 36 levothyroxine sodium tab 125 mcg (Synthroid)........... 37 levothyroxine sodium tab 137 mcg (Synthroid)........... 37 levothyroxine sodium tab 150 mcg (Synthroid)........... 37 levothyroxine sodium tab 175 mcg (Synthroid)........... 37 levothyroxine sodium tab 200 mcg (Synthroid)........... 37 levothyroxine sodium tab 300 mcg (Synthroid)........... 37 LEVULAN KERASTICK -aminolevulinic acid hcl for soln 20% (stick applicator)................................................... 174 LEXIVA -fosamprenavir calcium susp 50 mg/ml (base equiv)................................................................................. 8 LEXIVA -fosamprenavir calcium tab 700 mg (base equiv)................................................................................. 8 LEXUSS 210 -chlorpheniramine w/ codeine liquid 2-10 mg/5ml............................................................................. 62 LIALDA -mesalamine tab delayed release 1.2 gm........... 73 lidocaine hcl gel 2%...................................................... 174 LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%............... 167 LIDOCAINE HCL -lidocaine hcl laryngotracheal soln 4%.................................................................................. 165 lidocaine hcl soln 4% (Xylocaine)............................... 174 lidocaine hcl viscous soln 2%..................................... 165 lidocaine-hydrocortisone acetate rectal cream 3-0.5%........................................................................... 167 lidocaine oint 5%........................................................... 174 lidocaine patch 5% (Lidoderm).................................... 174 lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 174 lidocaine-prilocaine cream kit 2.5-2.5%...................... 174 lindane shampoo 1%..................................................... 174 linezolid for susp 100 mg/5ml (Zyvox).......................... 12 linezolid tab 600 mg (Zyvox).......................................... 12 LINZESS -linaclotide cap 145 mcg................................... 73 LINZESS -linaclotide cap 290 mcg................................... 73 liothyronine sodium tab 5 mcg (Cytomel).................... 37 liothyronine sodium tab 25 mcg (Cytomel).................. 37 liothyronine sodium tab 50 mcg (Cytomel).................. 37 LIPISTART -nutritional supplement powder.................... 138
LIPOFEN -fenofibrate cap 50 mg...................................... 57 LIPOFEN -fenofibrate cap 150 mg.................................... 57 LIQUACEL -amino acids oral liquid................................ 130 LIQUID HOPE -nutritional supplement liquid.................. 138 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)..................................................................... 51 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)..................................................................... 51 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic)..................................................................... 51 lisinopril tab 5 mg (Prinivil)............................................ 51 lisinopril tab 10 mg (Prinivil).......................................... 51 lisinopril tab 20 mg (Prinivil).......................................... 51 lisinopril tab 2.5 mg (Zestril).......................................... 51 lisinopril tab 30 mg (Zestril)........................................... 51 lisinopril tab 40 mg (Zestril)........................................... 51 LISTERINE ESSENTIAL CARE -sod monofluorophospheucal-men-methyl sal-thymol gel 0.76%...................... 166 LISTERINE RESTORING -sodium fluoride rinse 0.0221% (0.01% f)........................................................................166 LISTERINE SMART RINSE -sodium fluoride rinse 0.0221% (0.01% f)........................................................ 166 LISTERINE TOTAL CARE PLUS -sodium fluoride rinse 0.0221% (0.01% f)........................................................ 166 LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221% (0.01% f)........................................................................166 LISTERINE TOTAL CARE ZERO -sodium fluoride rinse 0.02%.............................................................................166 LISTERINE WHITENING/RESTO -sodium fluoride rinse 0.0221% (0.01% f)........................................................ 166 lithium carbonate cap 300 mg....................................... 84 lithium carbonate cap 150 mg (Lithium carbonate)..... 84 lithium carbonate cap 600 mg (Lithium carbonate)..... 84 LITHIUM CARBONATE -lithium carbonate cap 150 mg.................................................................................... 84 LITHIUM CARBONATE -lithium carbonate cap 600 mg.................................................................................... 84 lithium carbonate tab cr 450 mg.................................... 84 lithium carbonate tab cr 300 mg (Lithobid).................. 84 lithium carbonate tab 300 mg........................................ 84 LITHIUM -lithium oral solution 8 meq/5ml......................... 84 LITHOBID -lithium carbonate tab cr 300 mg..................... 84 LITHOSTAT -acetohydroxamic acid tab 250 mg............... 76 LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 57 LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 57 LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 57 LMD -nutritional supplement powder.............................. 138 L-METHYL-MC NAC -l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg............................................ 138 LOCOID -hydrocortisone butyrate lotion 0.1%................174 LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2)....................................................... 28
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
224
2016 LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 20 LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 20 LOPHLEX LQ 20 -nutritional supplement liquid.............. 138 LOPHLEX -nutritional supplement pack..........................138 lorazepam conc 2 mg/ml (Lorazepam intensol)........... 78 lorazepam tab 0.5 mg (Ativan)....................................... 78 lorazepam tab 1 mg (Ativan).......................................... 78 lorazepam tab 2 mg (Ativan).......................................... 78 LORTAB -hydrocodone-acetaminophen soln 10-300 mg/15ml........................................................................... 99 LORZONE -chlorzoxazone tab 375 mg.......................... 117 LORZONE -chlorzoxazone tab 750 mg.......................... 117 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar)....................................................................51 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar).................................................... 51 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar)....................................................................51 losartan potassium tab 25 mg (Cozaar)........................ 51 losartan potassium tab 50 mg (Cozaar)........................ 51 losartan potassium tab 100 mg (Cozaar)...................... 51 LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 162 LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 162 LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 162 LOTRIMIN ULTRA -butenafine hcl cream 1%................ 174 LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)......... 73 LOTRONEX -alosetron hcl tab 1 mg (base equiv)............ 73 LOUTREX -antiseborrheic products misc - cream.......... 174 lovastatin tab 10 mg........................................................ 57 lovastatin tab 20 mg........................................................ 57 lovastatin tab 40 mg (Mevacor)..................................... 58 loxapine succinate cap 5 mg......................................... 84 loxapine succinate cap 10 mg....................................... 84 loxapine succinate cap 25 mg....................................... 84 loxapine succinate cap 50 mg....................................... 84 LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg naf)................................................................................. 129 LUGOLS STRONG IODINE -iodine solution.................. 180 LUMIGAN -bimatoprost ophth soln 0.01%...................... 162 LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)................................................................................. 129 LUXAMEND -wound dressings - cream.......................... 174 LUZU -luliconazole cream 1%......................................... 174 LYNPARZA -olaparib cap 50 mg....................................... 20 LYRICA -pregabalin cap 25 mg.......................................112 LYRICA -pregabalin cap 50 mg.......................................112 LYRICA -pregabalin cap 75 mg.......................................112 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 300 mg.....................................112
LYRICA -pregabalin soln 20 mg/ml................................. 112 LYSODREN -mitotane tab 500 mg....................................20 M MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha cap 28-1-250 mg.......................................................... 121 MACRODANTIN -nitrofurantoin macrocrystalline cap 25 mg.................................................................................... 74 MAGNEBIND 400 -magnesium-calcium-folic acid tab 400-200-1 mg................................................................129 malathion lotion 0.5% (Ovide)...................................... 174 MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 80 MAPROTILINE HCL -maprotiline hcl tab 50 mg............... 80 MAPROTILINE HCL -maprotiline hcl tab 75 mg............... 80 MAR-COF BP -pseudoephedrine-bromphen-codeine liqd 30-2-7.5 mg/5ml.............................................................. 62 MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa cap 60-1 mg.................................................................. 121 MARPLAN -isocarboxazid tab 10 mg............................... 80 MATULANE -procarbazine hcl cap 50 mg........................ 20 MAXFE -iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab 160-1 mg....................................................................... 151 MAXIDEX -dexamethasone ophth susp 0.1%................ 163 MCT PRO-CAL -nutritional supplement pack................. 138 MCT PROCAL -nutritional supplement powder.............. 138 MECLOFENAMATE SODIUM -meclofenamate sodium cap 50 mg..................................................................... 105 MECLOFENAMATE SODIUM -meclofenamate sodium cap 100 mg................................................................... 105 MEDICAL PROVIDER EZ FLU S -influenza virus vac tisscult subunit pref syr kit 0.5 ml........................................ 15 MEDICAL PROVIDER EZ FLU S -influenza virus vac types a & b pf pref syringe kit 0.5 ml............................. 15 MEDICAL PROVIDER SINGLE U -influenza vac type a&b surface antigen pref syr kit 0.5 ml..................................15 MEDICAL PROVIDER SINGLE U -influenza virus vaccine split pf susp pref syr kit 0.5 ml....................................... 15 MEDICAL PROVIDER SINGLE U -influenza virus vac split quad inj prefilled syr kit 0.25 ml.............................. 15 MEDICAL PROVIDER SINGLE U -influenza virus vac types a & b pf pref syringe kit 0.5 ml............................. 15 MEDROL -methylprednisolone tab 2 mg.......................... 23 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)................................................ 28 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depo-provera contrac)............................. 28 medroxyprogesterone acetate tab 2.5 mg (Provera)......................................................................... 29 medroxyprogesterone acetate tab 5 mg (Provera)...... 29 medroxyprogesterone acetate tab 10 mg (Provera)......................................................................... 29 mefenamic acid cap 250 mg (Ponstel)........................ 105
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
225
2016 mefloquine hcl tab 250 mg............................................. 12 MEGACE ES -megestrol acetate susp 625 mg/5ml......... 30 MEGA MULTIVITAMIN -multiple vitamins w/ minerals powder........................................................................... 121 megestrol acetate susp 625 mg/5ml (Megace es)........ 30 megestrol acetate susp 40 mg/ml (Megace oral)......... 20 megestrol acetate tab 20 mg.......................................... 20 megestrol acetate tab 40 mg.......................................... 20 MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent)............................................................ 20 MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base equivalent)....................................................................... 20 meloxicam tab 7.5 mg (Mobic)..................................... 105 meloxicam tab 15 mg (Mobic)...................................... 105 memantine hcl oral solution 2 mg/ml (Namenda)........ 92 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa)................................................. 92 memantine hcl tab 5 mg (Namenda)............................. 92 memantine hcl tab 10 mg (Namenda)........................... 92 M-END MAX D -pseudoephedrine-dexbromphen-codeine liqd 20-0.667-6 mg/5ml................................................... 62 M-END PE -phenylephrine-bromphen w/ codeine liqd 3.33-1.33-6.33 mg/5ml....................................................62 MENEST -esterified estrogens tab 0.3 mg....................... 26 MENEST -esterified estrogens tab 0.625 mg................... 26 MENEST -esterified estrogens tab 1.25 mg..................... 26 MENEST -esterified estrogens tab 2.5 mg....................... 26 MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 26 MENTAX -butenafine hcl cream 1%................................174 MEPERIDINE HCL/PROMETHAZI -meperidine w/ promethazine cap 50-25 mg.......................................... 99 MEPERIDINE HCL -meperidine hcl oral soln 50 mg/5ml............................................................................. 99 meperidine hcl tab 50 mg (Demerol)............................. 99 meperidine hcl tab 100 mg (Demerol)........................... 99 MEPHYTON -phytonadione tab 5 mg............................. 118 meprobamate tab 200 mg............................................... 78 meprobamate tab 400 mg............................................... 78 mercaptopurine tab 50 mg............................................. 20 MERITENE -nutritional supplement powder................... 138 MESALAMINE DR -mesalamine tab delayed release 800 mg.................................................................................... 73 mesalamine enema 4 gm................................................ 73 MESNEX -mesna tab 400 mg........................................... 20 MESTINON -pyridostigmine bromide syrup 60 mg/5ml........................................................................... 118 MESTINON TIMESPAN -pyridostigmine bromide tab cr 180 mg.......................................................................... 118 METAFORM -nutritional supplement pack...................... 138 META HEALTH BAR/CINNAMON -nutritional supplement bar.................................................................................. 138
META HEALTH BAR/CRANBERRY -nutritional supplement bar............................................................. 138 METAPROTERENOL SULFATE -metaproterenol sulfate syrup 10 mg/5ml............................................................. 65 METAPROTERENOL SULFATE -metaproterenol sulfate tab 20 mg........................................................................ 65 METAXALONE -metaxalone tab 400 mg........................ 117 metaxalone tab 800 mg (Skelaxin).............................. 117 metformin hcl tab 500 mg (Glucophage)...................... 33 metformin hcl tab 850 mg (Glucophage)...................... 33 metformin hcl tab 1000 mg (Glucophage).................... 33 metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 33 metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 33 metformin hcl tab sr 24hr modified release 500 mg (Glumetza)...................................................................... 33 metformin hcl tab sr 24hr modified release 1000 mg (Glumetza)...................................................................... 33 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)....................................................................... 33 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)....................................................................... 33 methadone hcl conc 10 mg/ml (Methadose)................ 99 methadone hcl soln 5 mg/5ml (Methadone hcl)........... 99 methadone hcl soln 10 mg/5ml (Methadone hcl)......... 99 methadone hcl tab for oral susp 40 mg........................ 99 methadone hcl tab 10 mg (Dolophine).......................... 99 methadone hcl tab 5 mg (Dolophine hcl)..................... 99 methamphetamine hcl tab 5 mg (Desoxyn).................. 89 methazolamide tab 25 mg (Neptazane)......................... 55 methazolamide tab 50 mg (Neptazane)......................... 55 methenamine hippurate tab 1 gm (Hiprex)................... 74 methenamine-hyoscamine-meth blue-sod phos cap 120 mg............................................................................ 74 methenamine-hyoscamine-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 118 mg.................................................................... 74 methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg.................................................................... 74 methenamine-hyosc-meth blue-sod phos-phen sal tab 81 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 methimazole tab 5 mg (Tapazole).................................. 37 methimazole tab 10 mg (Tapazole)................................ 37 METHIONAID -nutritional supplement powder............... 138 METHITEST -methyltestosterone oral tab 10 mg............. 25
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
226
2016 methocarbamol tab 750 mg (Robaxin-750).................117 methocarbamol tab 500 mg (Robaxin)........................ 117 methotrexate sodium for inj 1 gm................................. 20 methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 20 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 20 methotrexate sodium inj pf 100 mg/4ml (25 mg/ ml)................................................................................... 20 methotrexate sodium inj pf 200 mg/8ml (25 mg/ ml)................................................................................... 20 methotrexate sodium inj pf 250 mg/10ml (25 mg/ ml)................................................................................... 20 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ ml)................................................................................... 20 METHOTREXATE SODIUM -methotrexate sodium inj 250 mg/10ml (25 mg/ml)........................................................20 methotrexate sodium tab 2.5 mg (base equiv)............. 20 methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 174 methscopolamine bromide tab 2.5 mg (Pamine)......... 69 methscopolamine bromide tab 5 mg (Pamine forte)................................................................................69 METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........55 METHYLDOPA/HYDROCHLOROTHI -methyldopa & hydrochlorothiazide tab 250-15 mg................................ 51 METHYLDOPA/HYDROCHLOROTHI -methyldopa & hydrochlorothiazide tab 250-25 mg................................ 51 methyldopa tab 250 mg.................................................. 51 methyldopa tab 500 mg.................................................. 51 methylergonovine maleate tab 0.2 mg.......................... 38 methylphenidate hcl cap cr 10 mg (cd) (Metadate cd)................................................................................... 89 methylphenidate hcl cap cr 20 mg (cd) (Metadate cd)................................................................................... 89 methylphenidate hcl cap cr 30 mg (cd) (Metadate cd)................................................................................... 89 methylphenidate hcl cap cr 40 mg (cd) (Metadate cd)................................................................................... 89 methylphenidate hcl cap cr 50 mg (cd) (Metadate cd)................................................................................... 89 methylphenidate hcl cap cr 60 mg (cd) (Metadate cd)................................................................................... 89 methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la)..................................................................................... 89 methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la)..................................................................................... 89 methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la)..................................................................................... 89 methylphenidate hcl chew tab 2.5 mg (Methylin)........ 89 methylphenidate hcl chew tab 5 mg (Methylin)........... 89 methylphenidate hcl chew tab 10 mg (Methylin)......... 89 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sa osm 18 mg................................................................. 89
METHYLPHENIDATE HCL ER -methylphenidate hcl tab sa osm 27 mg................................................................. 89 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sa osm 36 mg................................................................. 89 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sa osm 54 mg................................................................. 89 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sr 24hr 18 mg................................................................. 89 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sr 24hr 27 mg................................................................. 89 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sr 24hr 36 mg................................................................. 89 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sr 24hr 54 mg................................................................. 90 methylphenidate hcl soln 5 mg/5ml (Methylin)............ 90 methylphenidate hcl soln 10 mg/5ml (Methylin).......... 90 methylphenidate hcl tab cr 10 mg................................. 90 methylphenidate hcl tab cr 20 mg................................. 90 methylphenidate hcl tab 5 mg (Ritalin)......................... 90 methylphenidate hcl tab 10 mg (Ritalin)....................... 90 methylphenidate hcl tab 20 mg (Ritalin)....................... 90 methylprednisolone tab 4 mg (Medrol)......................... 23 methylprednisolone tab 8 mg (Medrol)......................... 23 methylprednisolone tab 16 mg (Medrol)....................... 23 methylprednisolone tab 32 mg (Medrol)....................... 23 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak).......................................................... 23 methyltestosterone cap 10 mg (Testred)...................... 25 METIPRANOLOL -metipranolol ophth soln 0.3%........... 163 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 73 metoclopramide hcl tab 5 mg (Reglan)......................... 73 metoclopramide hcl tab 10 mg (Reglan)....................... 73 METOCLOPRAMIDE ODT -metoclopramide hcl orally disintegrating tab 5 mg................................................... 73 METOCLOPRAMIDE ODT -metoclopramide hcl orally disintegrating tab 10 mg................................................. 73 metolazone tab 2.5 mg.................................................... 55 metolazone tab 5 mg....................................................... 55 metolazone tab 10 mg..................................................... 55 metoprolol & hydrochlorothiazide tab 100-50 mg....... 51 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)..............................................................51 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct)..............................................................51 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) (Toprol xl)........................................................... 43 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) (Toprol xl)........................................................... 43 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) (Toprol xl)........................................................... 44 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) (Toprol xl)........................................................... 44
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
227
2016 METOPROLOL TARTRATE -metoprolol tartrate tab 37.5 mg.................................................................................... 44 METOPROLOL TARTRATE -metoprolol tartrate tab 75 mg.................................................................................... 44 metoprolol tartrate tab 25 mg........................................ 44 metoprolol tartrate tab 50 mg (Lopressor)................... 44 metoprolol tartrate tab 100 mg (Lopressor)................. 44 metronidazole cap 375 mg (Flagyl)............................... 12 metronidazole cream 0.75% (Metrocream)................. 174 metronidazole gel 0.75%............................................... 174 metronidazole gel 1% (Metrogel)................................. 174 metronidazole lotion 0.75% (Metrolotion)................... 174 metronidazole tab 250 mg (Flagyl)................................ 12 metronidazole tab 500 mg (Flagyl)................................ 12 metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 76 mexiletine hcl cap 150 mg.............................................. 47 mexiletine hcl cap 200 mg.............................................. 47 mexiletine hcl cap 250 mg.............................................. 47 MIACALCIN -calcitonin (salmon) inj 200 unit/ml............... 40 MICONAZOLE 3 -miconazole nitrate vaginal suppos 200 mg.................................................................................... 76 MICROCYN SKIN AND WOUND H -wound cleansers gel.................................................................................. 174 MICROCYN -wound cleansers - gel............................... 174 MICROCYN -wound cleansers - liquid............................ 174 midazolam hcl syrup 2 mg/ml (base equivalent)......... 87 midodrine hcl tab 2.5 mg................................................ 56 midodrine hcl tab 5 mg................................................... 56 midodrine hcl tab 10 mg................................................. 56 miglitol tab 25 mg (Glyset)............................................. 33 miglitol tab 50 mg (Glyset)............................................. 33 miglitol tab 100 mg (Glyset)........................................... 33 MIGRANAL -dihydroergotamine mesylate nasal spray 4 mg/ml............................................................................. 107 MILLIPRED DP -prednisolone tab therapy pack 5 mg (21).................................................................................. 23 MILLIPRED DP -prednisolone tab therapy pack 5 mg (48).................................................................................. 23 MILLIPRED -prednisolone sod phosphate oral soln 10 mg/5ml (base equiv)....................................................... 23 MILLIPRED -prednisolone tab 5 mg................................. 23 MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)........................................... 28 MINIVELLE -estradiol td patch twice weekly 0.025 mg/24hr........................................................................... 26 MINIVELLE -estradiol td patch twice weekly 0.0375 mg/24hr........................................................................... 26 MINIVELLE -estradiol td patch twice weekly 0.05 mg/24hr........................................................................... 26 MINIVELLE -estradiol td patch twice weekly 0.075 mg/24hr........................................................................... 27
MINIVELLE -estradiol td patch twice weekly 0.1 mg/24hr........................................................................... 27 minocycline hcl cap 50 mg (Minocin)............................. 4 minocycline hcl cap 75 mg (Minocin)............................. 4 minocycline hcl cap 100 mg (Minocin)........................... 4 minocycline hcl tab 50 mg............................................... 4 minocycline hcl tab 75 mg............................................... 4 minocycline hcl tab 100 mg............................................. 4 minocycline hcl tab sr 24hr 45 mg.................................. 4 minocycline hcl tab sr 24hr 90 mg.................................. 4 minocycline hcl tab sr 24hr 135 mg................................ 4 minoxidil tab 2.5 mg........................................................ 51 minoxidil tab 10 mg......................................................... 51 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 mg.................................................................................. 115 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3.75 mg......................................................................... 115 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 4.5 mg........................................................................... 115 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50 mcg/0.3ml...................................................................... 151 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75 mcg/0.3ml...................................................................... 151 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 100 mcg/0.3ml.............................................................. 151 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 200 mcg/0.3ml.............................................................. 152 mirtazapine orally disintegrating tab 15 mg (Remeron soltab)............................................................................. 80 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)............................................................................. 80 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)............................................................................. 80 mirtazapine tab 7.5 mg....................................................80 mirtazapine tab 15 mg (Remeron)................................. 80 mirtazapine tab 30 mg (Remeron)................................. 80 mirtazapine tab 45 mg (Remeron)................................. 80 MIRVASO -brimonidine tartrate gel 0.33% (base equivalent)..................................................................... 174 misoprostol tab 100 mcg (Cytotec)............................... 69 misoprostol tab 200 mcg (Cytotec)............................... 69 MITIGARE -colchicine cap 0.6 mg.................................. 108 MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 163
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
228
2016 MMA/PA ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 138 MMA/PA ANAMIX NEXT -nutritional supplement powder........................................................................... 138 MMA/PA COOLER -nutritional supplement liquid........... 138 MMA/PA COOLER15 -nutritional supplement liquid....... 138 MMA/PA GEL -nutritional supplement pack.................... 138 modafinil tab 100 mg (Provigil)...................................... 90 modafinil tab 200 mg (Provigil)...................................... 90 MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg........ 8 MODERIBA 800 DOSE PACK -ribavirin tab 400 mg.......... 8 MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg dose pack.......................................................................... 8 MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack.......................................................................... 8 MODULEN IBD -nutritional supplement powder............. 138 moexipril hcl tab 7.5 mg................................................. 51 moexipril hcl tab 15 mg.................................................. 51 moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 51 moexipril-hydrochlorothiazide tab 15-12.5 mg............ 51 moexipril-hydrochlorothiazide tab 15-25 mg............... 51 MOLINDONE HYDROCHLORIDE -molindone hcl tab 5 mg.................................................................................... 84 MOLINDONE HYDROCHLORIDE -molindone hcl tab 10 mg.................................................................................... 84 MOLINDONE HYDROCHLORIDE -molindone hcl tab 25 mg.................................................................................... 84 mometasone furoate cream 0.1% (Elocon)................ 174 mometasone furoate nasal susp 50 mcg/act (Nasonex)....................................................................... 61 mometasone furoate oint 0.1% (Elocon).................... 174 mometasone furoate solution 0.1% (lotion) (Elocon)........................................................................ 174 MONOCAL -sodium monofluorophosphate-calcium carb tab 22.75-625 mg......................................................... 129 MONOCLATE-P -antihemophilic factor (human) for inj kit 1000 unit....................................................................... 158 MONOCLATE-P -antihemophilic factor (human) for inj kit 1500 unit....................................................................... 158 MONOGEN -nutritional supplement powder................... 138 MONONINE -coagulation factor ix for inj 1000 unit........ 158 montelukast sodium chew tab 4 mg (base equiv) (Singulair)....................................................................... 65 montelukast sodium chew tab 5 mg (base equiv) (Singulair)....................................................................... 65 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)...........................................................65 montelukast sodium tab 10 mg (base equiv) (Singulair)....................................................................... 65 MONUROL -fosfomycin tromethamine powd pack 3 gm (base equivalent)............................................................ 74 morphine sulfate cap sr 24hr 10 mg (Kadian)............ 100
morphine sulfate cap sr 24hr 20 mg (Kadian)............ 100 morphine sulfate cap sr 24hr 30 mg (Kadian)............ 100 morphine sulfate cap sr 24hr 50 mg (Kadian)............ 100 morphine sulfate cap sr 24hr 60 mg (Kadian)............ 100 morphine sulfate cap sr 24hr 80 mg (Kadian)............ 100 morphine sulfate cap sr 24hr 100 mg (Kadian).......... 100 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 30 mg....................................................................100 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 45 mg....................................................................100 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 60 mg....................................................................100 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 75 mg....................................................................100 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 90 mg....................................................................100 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 120 mg..................................................................100 MORPHINE SULFATE -morphine sulfate suppos 5 mg.................................................................................... 99 MORPHINE SULFATE -morphine sulfate suppos 10 mg.................................................................................... 99 MORPHINE SULFATE -morphine sulfate suppos 20 mg.................................................................................... 99 MORPHINE SULFATE -morphine sulfate suppos 30 mg.................................................................................... 99 MORPHINE SULFATE -morphine sulfate tab 15 mg...... 100 MORPHINE SULFATE -morphine sulfate tab 30 mg...... 100 morphine sulfate oral soln 10 mg/5ml........................ 100 morphine sulfate oral soln 20 mg/5ml........................ 100 morphine sulfate oral soln 100 mg/5ml (20 mg/ ml)................................................................................. 100 morphine sulfate tab cr 15 mg (Ms contin)................ 100 morphine sulfate tab cr 30 mg (Ms contin)................ 100 morphine sulfate tab cr 60 mg (Ms contin)................ 100 morphine sulfate tab cr 100 mg (Ms contin).............. 100 morphine sulfate tab cr 200 mg (Ms contin).............. 100 MOVANTIK -naloxegol oxalate tab 12.5 mg (base equivalent)....................................................................... 73 MOVANTIK -naloxegol oxalate tab 25 mg (base equivalent)....................................................................... 73 MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln 100 gm...............................................................67 MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 1 MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily).................................................................... 163 moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 5 MSUD AID -nutritional supplement powder.................... 138 MSUD ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 138 MSUD COOLER -nutritional supplement liquid.............. 138 MSUD EXPRESS -nutritional supplement pack............. 138
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
229
2016 MSUD EXPRESS20 -nutritional supplement pack......... 138 MSUD GEL -nutritional supplement pack....................... 138 MSUD LOPHLEX LQ -nutritional supplement liquid....... 138 MSUD MAXAMAID -nutritional supplement powder....... 139 MSUD MAXAMUM -nutritional supplement powder....... 139 MSUD 2 -nutritional supplement powder........................ 139 MUCOTROL -oral wound care products - wafer............. 166 MULTAQ -dronedarone hcl tab 400 mg (base equivalent)....................................................................... 47 MULTIGEN -fe asparto gly-succ acd-c-threonic acd-b12des stom tab................................................................. 152 MULTIGEN FOLIC -fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab................................................ 152 MULTIGEN PLUS -fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab................................................ 152 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite)........................................................................ 121 mupirocin calcium cream 2% (Bactroban)................. 174 mupirocin oint 2% (Bactroban).................................... 174 M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 121 MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 40 mycophenolate mofetil cap 250 mg (Cellcept)........... 183 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)...................................................................... 183 mycophenolate mofetil tab 500 mg (Cellcept)............183 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)................................................. 183 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)................................................. 183 MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe susp 0.25-10 mg/2ml.................................................... 121 MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 152 MYLERAN -busulfan tab 2 mg.......................................... 20 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............................................... 121 MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................. 121 MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg.....................................................................121 MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 75 MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 75 MYTESI -crofelemer tab delayed release 125 mg............ 68 N NABI-HB -hepatitis b immune globulin (human) im inj soln.................................................................................. 17
nabumetone tab 500 mg............................................... 105 nabumetone tab 750 mg............................................... 105 nadolol & bendroflumethiazide tab 40-5 mg (Corzide)......................................................................... 52 nadolol & bendroflumethiazide tab 80-5 mg (Corzide)......................................................................... 52 nadolol tab 20 mg (Corgard).......................................... 44 nadolol tab 40 mg (Corgard).......................................... 44 nadolol tab 80 mg (Corgard).......................................... 44 NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................. 166 NAFRINSE DAILY/NEUTRAL -7odium fluoride for soln rinse 0.05%................................................................... 166 NAFRINSE WEEKLY -sodium fluoride for soln rinse 0.2%...............................................................................166 naftifine hcl cream 2% (Naftin).................................... 174 NAFTIFINE HCL -naftifine hcl cream 1%........................174 NAFTIN -naftifine hcl cream 2%..................................... 174 NAFTIN -naftifine hcl gel 1%........................................... 174 NAFTIN -naftifine hcl gel 2%........................................... 174 NALFON -fenoprofen calcium cap 400 mg..................... 105 naltrexone hcl tab 50 mg (Revia)................................. 180 NAMENDA -memantine hcl oral solution 2 mg/ml............ 92 NAMENDA -memantine hcl tab 5 mg............................... 92 NAMENDA -memantine hcl tab 10 mg............................. 92 NAMENDA TITRATION PAK -memantine hcl tab 5 mg (28) & 10 mg (21) titration pak....................................... 92 NAMENDA XR -memantine hcl cap sr 24hr 7 mg............ 92 NAMENDA XR -memantine hcl cap sr 24hr 14 mg.......... 92 NAMENDA XR -memantine hcl cap sr 24hr 21 mg.......... 92 NAMENDA XR -memantine hcl cap sr 24hr 28 mg.......... 92 NAMENDA XR TITRATION PACK -memantine hcl cap sr 24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 92 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 7-10 mg........................................................................... 92 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 14-10 mg......................................................................... 92 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 21-10 mg......................................................................... 92 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 28-10 mg......................................................................... 92 naproxen sodium tab 275 mg (Anaprox).................... 105 naproxen sodium tab 550 mg (Anaprox ds)............... 105 naproxen sodium tab sr 24hr 375 mg (base equiv) (Naprelan)..................................................................... 105 naproxen sodium tab sr 24hr 500 mg (base equiv) (Naprelan)..................................................................... 105 naproxen susp 125 mg/5ml.......................................... 106 naproxen tab ec 375 mg (Ec-naprosyn)...................... 106 naproxen tab ec 500 mg (Ec-naprosyn)...................... 106 naproxen tab 250 mg (Naprosyn)................................ 106 naproxen tab 375 mg (Naprosyn)................................ 106
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
230
2016 naproxen tab 500 mg (Naprosyn)................................ 106 naratriptan hcl tab 1 mg (base equiv) (Amerge)........ 107 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)..... 107 NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 180 NASCOBAL -cyanocobalamin nasal spray 500 mcg/0.1ml...................................................................... 152 NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew tab 28-1 mg...................................................................121 NATACYN -natamycin ophth susp 5%............................ 163 NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1 mg.................................................................................. 121 NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2 mg/2-3 mg/1 mg............................................................. 28 nateglinide tab 60 mg (Starlix)....................................... 33 nateglinide tab 120 mg (Starlix)..................................... 33 NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg.......................................................... 121 NATPARA -parathyroid hormone (recombinant) for inj cartridge 25 mcg............................................................. 40 NATPARA -parathyroid hormone (recombinant) for inj cartridge 50 mcg............................................................. 40 NATPARA -parathyroid hormone (recombinant) for inj cartridge 75 mcg............................................................. 40 NATPARA -parathyroid hormone (recombinant) for inj cartridge 100 mcg........................................................... 40 NATROBA -spinosad susp 0.9%..................................... 174 NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2 grain)................................................................................37 NATURE-THROID -thyroid tab 16.25 mg..........................37 NATURE-THROID -thyroid tab 32.5 mg............................37 NATURE-THROID -thyroid tab 65 mg...............................37 NATURE-THROID -thyroid tab 81.25 mg..........................37 NATURE-THROID -thyroid tab 97.5 mg............................37 NATURE-THROID -thyroid tab 113.75 mg........................ 37 NATURE-THROID -thyroid tab 130 mg.............................37 NATURE-THROID -thyroid tab 146.25 mg....................... 37 NATURE-THROID -thyroid tab 195 mg.............................37 NATURE-THROID -thyroid tab 260 mg.............................37 NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 37 NATURE-THROID -thyroid tab 325 mg (5 grain).............. 37 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.................................................................................. 28 NECON 10/11-28 -norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11)........................................... 28 NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg............................................................. 121 NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 80 NEFAZODONE HCL -nefazodone hcl tab 150 mg........... 81 NEFAZODONE HCL -nefazodone hcl tab 200 mg........... 81
nefazodone hcl tab 50 mg.............................................. 81 nefazodone hcl tab 250 mg............................................ 81 NEOCATE INFANT DHA/ARA -nutritional supplement powder........................................................................... 139 NEOCATE JUNIOR/PREBIOTICS -nutritional supplement powder........................................................................... 139 NEOCATE JUNIOR -nutritional supplement powder...... 139 NEOCATE NUTRA -nutritional supplement powder....... 139 NEOCATE SPLASH -nutritional supplement liquid......... 139 NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 163 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin............................. 163 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 163 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)...................................................................... 163 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol).............................................................163 neomycin-polymyxin-hc otic soln 1% (Cortisporin).................................................................165 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%.................................................................... 165 neomycin sulfate tab 500 mg........................................... 5 NEORAL -cyclosporine modified cap 25 mg...................183 NEORAL -cyclosporine modified cap 100 mg.................183 NEORAL -cyclosporine modified oral soln 100 mg/ ml................................................................................... 183 NEOSALUS CP -dermatological products misc cream............................................................................. 175 NEOSALUS -dermatological products, misc. - aerosol foam............................................................................... 175 NEOSALUS -dermatological products misc - cream...... 174 NEOSALUS -emollient - lotion........................................ 175 NEO-SYNALAR -neomycin sulfate-fluocinolone acetonide cream 0.5-0.025%........................................................ 174 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.................................................................................. 121 NEPHRON FA -ferrous fumarate w/ fa-dss-b complex-vit c tab...............................................................................152 NEPRO -nutritional supplement liquid.............................139 NEPRO WITH CARB STEADY -nutritional supplement liquid.............................................................................. 139 NESINA -alogliptin benzoate tab 6.25 mg (base equiv)............................................................................... 33 NESINA -alogliptin benzoate tab 12.5 mg (base equiv)............................................................................... 33 NESINA -alogliptin benzoate tab 25 mg (base equiv).......33 NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab & omega 3 cap............................................................. 121
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
231
2016 NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack....................................................... 121 NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg......................................................................... 121 NESTLE FLAVOR EXTRA STREN -nutritional supplement flavor pack................................................ 139 NESTLE FLAVOR FOR KIDS -nutritional supplement flavor pack..................................................................... 139 NESTLE FLAVOR -nutritional supplement flavor pack............................................................................... 139 NEULASTA ONPRO KIT -pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml.................................................. 152 NEULASTA -pegfilgrastim soln prefilled syringe 6 mg/0.6ml........................................................................ 152 NEUPOGEN -filgrastim inj 300 mcg/ml........................... 152 NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/ ml).................................................................................. 152 NEUPOGEN -filgrastim soln prefilled syringe 300 mcg/0.5ml...................................................................... 152 NEUPOGEN -filgrastim soln prefilled syringe 480 mcg/0.8ml (600 mcg/ml)............................................... 152 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................................................................. 152 NEUTRASAL -artificial saliva - packet............................ 166 NEVANAC -nepafenac ophth susp 0.1%........................ 163 NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 8 nevirapine tab 200 mg (Viramune)...................................8 nevirapine tab sr 24hr 100 mg......................................... 8 nevirapine tab sr 24hr 400 mg (Viramune xr)................. 8 NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg......................................................................... 121 NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg.............................................................121 NEXAVAR -sorafenib tosylate tab 200 mg (base equivalent)....................................................................... 20 NEXIUM -esomeprazole magnesium for delayed release susp packet 5 mg........................................................... 69 NEXIUM -esomeprazole magnesium for delayed release susp packet 10 mg......................................................... 69 NEXIUM -esomeprazole magnesium for delayed release susp packet 20 mg......................................................... 69 NEXIUM -esomeprazole magnesium for delayed release susp packet 40 mg......................................................... 69 NEXIUM -esomeprazole magnesium for delayed release susp pack 2.5 mg........................................................... 69
niacin tab cr 500 mg (antihyperlipidemic) (Niaspan)........................................................................ 58 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan)........................................................................ 58 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan)........................................................................ 58 nicardipine hcl cap 20 mg.............................................. 45 nicardipine hcl cap 30 mg.............................................. 45 NICODERM CQ -nicotine td patch 24hr 7 mg/24hr.......... 92 NICODERM CQ -nicotine td patch 24hr 14 mg/24hr........ 93 NICODERM CQ -nicotine td patch 24hr 21 mg/24hr........ 93 NICOMIDE -niacinamide w/ zn-cu-methylfolate tab 750-25-1.5-0.5 mg........................................................ 121 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 7 mg/24hr...................................93 nicotine td patch 24hr 14 mg/24hr.................................93 nicotine td patch 24hr 21 mg/24hr.................................93 NICOTINE TRANSDERMAL SYST -nicotine td patch 24 hr kit 21-14-7 mg/24hr.................................................... 93 NICOTROL INHALER -nicotine inhaler system 10 mg (4 mg delivered).................................................................. 93 NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/ spray)............................................................................... 93 nifedipine cap 20 mg....................................................... 46 nifedipine cap 10 mg (Procardia).................................. 45 nifedipine tab sr 24hr 30 mg (Adalat cc).......................46 nifedipine tab sr 24hr 60 mg (Adalat cc).......................46 nifedipine tab sr 24hr 90 mg (Adalat cc).......................46 nifedipine tab sr 24hr osmotic release 30 mg (Procardia xl)................................................................. 46 nifedipine tab sr 24hr osmotic release 60 mg (Procardia xl)................................................................. 46 nifedipine tab sr 24hr osmotic release 90 mg (Procardia xl)................................................................. 46 NILANDRON -nilutamide tab 150 mg............................... 20 nilutamide tab 150 mg (Nilandron)................................ 21 nimodipine cap 30 mg..................................................... 46 NINJACOF-XG -guaifenesin-codeine liquid 200-8 mg/5ml............................................................................. 62
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
232
2016 NINLARO -ixazomib citrate cap 2.3 mg (base equivalent)....................................................................... 21 NINLARO -ixazomib citrate cap 3 mg (base equivalent)....................................................................... 21 NINLARO -ixazomib citrate cap 4 mg (base equivalent)....................................................................... 21 NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 46 NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 46 NISOLDIPINE -nisoldipine tab sr 24hr 30 mg................... 46 NISOLDIPINE -nisoldipine tab sr 24hr 40 mg................... 46 nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 46 nisoldipine tab sr 24hr 17 mg (Sular)............................46 nisoldipine tab sr 24hr 34 mg (Sular)............................46 NITRO-BID -nitroglycerin oint 2%..................................... 42 NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 42 NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 42 nitrofurantoin macrocrystalline cap 25 mg (Macrodantin).................................................................74 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin).................................................................74 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin).................................................................74 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)............................................................... 74 nitrofurantoin susp 25 mg/5ml (Furadantin)................ 74 nitroglycerin cap cr 2.5 mg............................................ 42 nitroglycerin cap cr 6.5 mg............................................ 42 nitroglycerin cap cr 9 mg............................................... 42 NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol 400 mcg/spray................................................................ 42 nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 42 nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 42 nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 42 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 42 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 42 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 42 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 42 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr)................................................. 42 NITROMIST -nitroglycerin lingual aerosol 400 mcg/ spray................................................................................ 42 NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 42 NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 42 NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 42 NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 121 nizatidine cap 150 mg..................................................... 69 nizatidine cap 300 mg (Axid).......................................... 70 NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 69 NOBLE MYSTIQUE EMU-LAC -lactic acid (ammonium lactate) cream 10%.......................................................175
norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)............................................... 28 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe)............................................ 28 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28)................................................................. 28 norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)................................................................ 28 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35)...................................................................... 28 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20).................................................. 29 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)............................................... 29 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)................................................. 29 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21).............................................. 29 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)......................................................................... 29 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg................................................................................. 27 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose)................................................ 27 norethindrone acetate tab 5 mg (Aygestin).................. 30 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)................................................. 29 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)...................................... 29 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 29 norethindrone tab 0.35 mg (Nor-qd).............................. 29 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen)................................................................ 29 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen)........................................... 29 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg (Ortho tri-cyclen lo)....................................... 29 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 29 NORPACE CR -disopyramide phosphate cap sr 12hr 100 mg.................................................................................... 47 NORPACE CR -disopyramide phosphate cap sr 12hr 150 mg.................................................................................... 47 NORPACE -disopyramide phosphate cap 100 mg........... 47 NORPACE -disopyramide phosphate cap 150 mg........... 47 NORTHERA -droxidopa cap 100 mg................................ 56 NORTHERA -droxidopa cap 200 mg................................ 56 NORTHERA -droxidopa cap 300 mg................................ 56 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
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
233
2016 NORTRIPTYLINE HCL -nortriptyline hcl soln 10 mg/5ml............................................................................. 81 NORVIR -ritonavir cap 100 mg........................................... 8 NORVIR -ritonavir oral soln 80 mg/ml.................................8 NORVIR -ritonavir tab 100 mg............................................ 8 NOURISH -nutritional supplement liquid......................... 139 NOVACORT -pramoxine-hc gel 1-2%............................. 175 NOVASOURCE PULMONARY -nutritional supplement liquid.............................................................................. 139 NOVASOURCE RENAL -nutritional supplement liquid.............................................................................. 139 NOVOEIGHT -antihemophilic factor (recombinant) for inj 250 unit......................................................................... 158 NOVOEIGHT -antihemophilic factor (recombinant) for inj 500 unit......................................................................... 158 NOVOEIGHT -antihemophilic factor (recombinant) for inj 1000 unit....................................................................... 158 NOVOEIGHT -antihemophilic factor (recombinant) for inj 1500 unit....................................................................... 158 NOVOEIGHT -antihemophilic factor (recombinant) for inj 2000 unit....................................................................... 158 NOVOEIGHT -antihemophilic factor (recombinant) for inj 3000 unit....................................................................... 158 NOVOLIN 70/30 -insulin nph isophane & regular human inj 100 unit/ml (70-30).................................................... 36 NOVOLIN 70/30 RELION -insulin nph isophane & regular human inj 100 unit/ml (70-30)........................................ 36 NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/ ml..................................................................................... 36 NOVOLIN N RELION -insulin nph (human) (isophane) inj 100 unit/ml.......................................................................36 NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 35 NOVOLIN R RELION -insulin regular (human) inj 100 unit/ml.............................................................................. 35 NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100 unit/ml.......................................................................35 NOVOLOG -insulin aspart inj 100 unit/ml......................... 35 NOVOLOG MIX 70/30 -insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)...................................... 36 NOVOLOG MIX 70/30 PREFILL -insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)........................... 36 NOVOLOG PENFILL -insulin aspart soln cartridge 100 unit/ml.............................................................................. 35 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 1 mg (1000 mcg).......................................................... 159 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 2 mg (2000 mcg).......................................................... 159 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 5 mg (5000 mcg).......................................................... 159 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 8 mg (8000 mcg).......................................................... 159 NOXAFIL -posaconazole susp 40 mg/ml............................ 6
NOXAFIL -posaconazole tab delayed release 100 mg....... 6 NOXIFOL-D -folic acid-cholecalciferol tab 1 mg-2500 unit................................................................................. 152 NUCALA -mepolizumab for inj 100 mg............................. 66 NUCORT -hydrocortisone acetate lotion 2%.................. 175 NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg........... 100 NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg......... 100 NUCYNTA ER -tapentadol hcl tab sr 12hr 150 mg......... 100 NUCYNTA ER -tapentadol hcl tab sr 12hr 200 mg......... 100 NUCYNTA ER -tapentadol hcl tab sr 12hr 250 mg......... 100 NUCYNTA -tapentadol hcl tab 50 mg............................. 100 NUCYNTA -tapentadol hcl tab 75 mg............................. 100 NUCYNTA -tapentadol hcl tab 100 mg........................... 100 NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap 20-10 mg......................................................................... 93 NUFERA -iron combination tab....................................... 152 NUMOISYN -artificial saliva - solution............................ 166 NUPLAZID -pimavanserin tartrate tab 17 mg (base equivalent)....................................................................... 84 NUTRA/BALANCE RE/GEN FREE -nutritional supplement liquid (frozen)............................................ 139 NUTRA/BALANCE RE/GEN -nutritional supplement liquid (frozen).......................................................................... 139 NUTRA/SHAKE FRUIT PLUS -nutritional supplement liquid (frozen)................................................................ 139 NUTRA/SHAKE -nutritional supplement liquid (frozen).......................................................................... 139 NUTRA/SHAKE SUPREME -nutritional supplement liquid.............................................................................. 139 NUTRA/SHAKE SUPREME -nutritional supplement liquid (frozen).......................................................................... 139 NUTRA BALANCE DIABETIC NU -nutritional supplement bar.................................................................................. 139 NUTRA BALANCE FIBER COOKI -nutritional supplement misc............................................................................... 139 NUTRA BALANCE PROTEIN FOR -nutritional supplement misc........................................................... 139 NUTRAMENT -nutritional supplement liquid................... 139 NUTRAMINE APPLE AMINO BIT -nutritional supplement pack............................................................................... 139 NUTRAMINE BANANA AMINO B -nutritional supplement pack............................................................................... 140 NUTRAMINE CHOCOLATE AMINO -nutritional supplement pack........................................................... 140 NUTRAMINE MANGO AMINO BI -nutritional supplement pack............................................................................... 140 NUTRAMINE MIXED FLAVORS A -nutritional supplement pack............................................................................... 140 NUTRAMINE -nutritional supplement pack..................... 139 NUTRAMINE PEACHES & CREAM -nutritional supplement pack........................................................... 140
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
234
2016 NUTRAMINE PINEAPPLE AMINO -nutritional supplement pack........................................................... 140 NUTRASENTIALS -amino acids oral powder................. 130 NUTRA SHAKE/SUPREME -nutritional supplement liquid (frozen).......................................................................... 139 NUTRA SHAKE -nutritional supplement liquid (frozen).......................................................................... 139 NUTREN 1.0/FIBER/ULTRAPAK -nutritional supplement liquid.............................................................................. 140 NUTREN 1.0/FIBER -nutritional supplement liquid.........140 NUTREN 1.0 CAL -nutritional supplement liquid............ 140 NUTREN 1.5 CAL -nutritional supplement liquid............ 140 NUTREN 2.0 CAL -nutritional supplement liquid............ 140 NUTREN 1.5 FIBER -nutritional supplement liquid.........140 NUTREN JR FIBER -nutritional supplement liquid......... 140 NUTREN JR -nutritional supplement liquid..................... 140 NUTREN JUNIOR/FIBER -nutritional supplement liquid.............................................................................. 140 NUTREN JUNIOR -nutritional supplement liquid............ 140 NUTREN JUNIOR 1.0 -nutritional supplement liquid...... 140 NUTREN 1.0 -nutritional supplement liquid.................... 140 NUTREN 1.5 -nutritional supplement liquid.................... 140 NUTREN 2.0 -nutritional supplement liquid.................... 140 NUTREN PULMONARY -nutritional supplement liquid.............................................................................. 140 NUTREN RENAL -nutritional supplement liquid............. 140 NUTRESTORE -glutamine powd pack 5 gm.................. 130 NUTRIFOCUS -nutritional supplement liquid.................. 140 NUTRIHEAL -nutritional supplement liquid..................... 140 NUTRIHEP 1.5 CAL -nutritional supplement liquid......... 140 NUTRIRENAL -nutritional supplement liquid.................. 140 NUTRITIONAL DRINK MIX -nutritional supplement powder........................................................................... 140 NUTRITIONAL DRINK -nutritional supplement liquid..... 140 NUTRITIONAL DRINK PLUS -nutritional supplement liquid.............................................................................. 140 NUTRITIONAL DRINK SHAKE M -nutritional supplement powder........................................................................... 140 NUTRITIONAL SHAKE COMPLET -nutritional supplement liquid.......................................................... 140 NUTRITIONAL SHAKE -nutritional supplement liquid.............................................................................. 140 NUTRITIONAL SHAKE PLUS -nutritional supplement liquid.............................................................................. 140 NUTRITIONAL SHAKE PLUS PR -nutritional supplement liquid.............................................................................. 141 nutritional supplement liquid....................................... 141 NUTRITIONAL SUPPLEMENT -nutritional supplement liquid.............................................................................. 141 NUTRITIONAL SUPPLEMENT PL -nutritional supplement liquid.............................................................................. 141 NUTRIVENT -nutritional supplement liquid..................... 141
NUTRIVENT 1.5 -nutritional supplement liquid...............141 NUTRIVIR NSA -nutritional supplement powder............ 141 NUTRIVIR -nutritional supplement powder..................... 141 NUVAIL -dermatological products misc - solution........... 175 NUVARING -etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr...................................................... 29 NUVESSA -metronidazole vaginal gel 1.3%.....................76 NUVIGIL -armodafinil tab 50 mg....................................... 90 NUVIGIL -armodafinil tab 150 mg..................................... 90 NUVIGIL -armodafinil tab 200 mg..................................... 90 NUVIGIL -armodafinil tab 250 mg..................................... 90 NUWIQ -antihemophilic factor (recombinant) for inj kit 250 unit................................................................................. 159 NUWIQ -antihemophilic factor (recombinant) for inj kit 500 unit................................................................................. 159 NUWIQ -antihemophilic factor (recombinant) for inj kit 1000 unit....................................................................... 159 NUWIQ -antihemophilic factor (recombinant) for inj kit 2000 unit....................................................................... 159 NUWIQ -antihemophilic factor (recombinant) for inj 250 unit................................................................................. 159 NUWIQ -antihemophilic factor (recombinant) for inj 500 unit................................................................................. 159 NUWIQ -antihemophilic factor (recombinant) for inj 1000 unit................................................................................. 159 NUWIQ -antihemophilic factor (recombinant) for inj 2000 unit................................................................................. 159 NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 46 nystatin cream 100000 unit/gm.................................... 175 nystatin oint 100000 unit/gm........................................ 175 nystatin oral powder..........................................................6 nystatin susp 100000 unit/ml....................................... 166 nystatin tab 500000 unit....................................................6 nystatin topical powder................................................ 175 nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 175 nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 175 O OA 1 -nutritional supplement powder.............................. 141 OA 2 -nutritional supplement powder.............................. 141 OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg......................................... 122 OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fadha cap 27.5-1-200 mg................................................ 122 OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp glyc-fa-fish cap 50-1-476 mg........................................122 OB COMPLETE PETITE -prenat w/o a w/fecbnfeaspglyc-fa-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................................................. 122
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
235
2016 OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg.................................................................... 122 OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj 500 unit......................................................................... 159 OBREDON -hydrocodone-guaifenesin soln 2.5-200 mg/5ml............................................................................. 62 OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg & omega 3 cap 387 mg pak............................................ 122 OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg......................................................................... 122 OBSTETRIX ONE -prenat w/o a w/fecbn-bisg-methylfdss-dha cap 38-1-225 mg............................................ 122 O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 121 OCALIVA -obeticholic acid tab 5 mg................................. 73 OCALIVA -obeticholic acid tab 10 mg............................... 73 O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1 mg.................................................................................. 122 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin)................................................................. 40 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)................................................................. 40 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin)................................................................. 40 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)................................................................. 40 octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin)................................................................. 40 ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg.................................................................... 8 ODOMZO -sonidegib phosphate cap 200 mg (base equivalent)....................................................................... 21 OFEV -nintedanib esylate cap 100 mg (base equivalent)....................................................................... 67 OFEV -nintedanib esylate cap 150 mg (base equivalent)....................................................................... 67 ofloxacin ophth soln 0.3% (Ocuflox)........................... 163 ofloxacin otic soln 0.3%................................................165 OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg.................................................................................. 29 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 93 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)...... 93 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)...... 93 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)...................................................................... 93 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)...................................................................... 93 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)...............................................................................84 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)...............................................................................84
olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)...............................................................................84 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)...............................................................................84 olanzapine tab 2.5 mg (Zyprexa)................................... 84 olanzapine tab 5 mg (Zyprexa)...................................... 84 olanzapine tab 7.5 mg (Zyprexa)................................... 85 olanzapine tab 10 mg (Zyprexa).................................... 85 olanzapine tab 15 mg (Zyprexa).................................... 85 olanzapine tab 20 mg (Zyprexa).................................... 85 olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg (Tribenzor).............................................. 52 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg (Tribenzor).............................................. 52 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg (Tribenzor)................................................. 52 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg (Tribenzor)............................................ 52 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg (Tribenzor)............................................... 52 olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg (Benicar hct)..............................................52 olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg (Benicar hct)..............................................52 olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg (Benicar hct)........................................................... 52 olmesartan medoxomil tab 5 mg (Benicar).................. 52 olmesartan medoxomil tab 20 mg (Benicar)................ 52 olmesartan medoxomil tab 40 mg (Benicar)................ 52 olopatadine hcl nasal soln 0.6% (Patanase).................61 olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol)....................................................................... 163 OLYSIO -simeprevir sodium cap 150 mg (base equivalent)......................................................................... 8 omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 58 OMEPRAZOLE + SYRSPEND SF -omeprazole susp 2 mg/ml (compound kit)..................................................... 70 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 omeprazole-sodium bicarbonate powd pack for susp 20-1680 mg (Zegerid)....................................................70 omeprazole-sodium bicarbonate powd pack for susp 40-1680 mg (Zegerid)....................................................70 OMNARIS -ciclesonide nasal susp 50 mcg/act................ 61 OMNIFLEX DIAPHRAGM -diaphragms.......................... 181 OMNI GEL -stannous fluoride gel 0.4%.......................... 166 OMNITROPE -somatropin for inj 5.8 mg.......................... 40
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
236
2016 OMNITROPE -somatropin inj 5 mg/1.5ml......................... 40 OMNITROPE -somatropin inj 10 mg/1.5ml....................... 40 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 (Zofran)................................71 ondansetron orally disintegrating tab 4 mg (Zofran odt).................................................................................. 71 ondansetron orally disintegrating tab 8 mg (Zofran odt).................................................................................. 71 ONEXTON -clindamycin phosphate-benzoyl peroxide gel 1.2-3.75%...................................................................... 175 ONFI -clobazam suspension 2.5 mg/ml.......................... 112 ONFI -clobazam tab 10 mg............................................. 112 ONFI -clobazam tab 20 mg............................................. 112 ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 33 ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 33 ONMEL -itraconazole tab 200 mg....................................... 6 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 5 mg....................................................... 100 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 7.5 mg.................................................... 100 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 10 mg..................................................... 101 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 15 mg..................................................... 101 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 20 mg..................................................... 101 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 30 mg..................................................... 101 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 40 mg..................................................... 101 opium tincture 1% (10 mg/ml) (morphine equiv)..........68 OPSUMIT -macitentan tab 10 mg..................................... 59 OPTIMENTAL -nutritional supplement liquid...................141 OPTISOURCE VERY HIGH PROT -nutritional supplement liquid.......................................................... 141 ORACIT -sodium citrate & citric acid soln 490-640 mg/5ml............................................................................. 76 ORAFATE -sucralfate-malate paste 10%........................ 166 ORALAIR ADULT SAMPLE KIT -grass mixed pollen ext tab sl 300 ir (index of reactivity)..................................... 17 ORALAIR ADULT STARTER PAC -grass mixed pollen ext tab sl 300 ir (index of reactivity)..................................... 17 ORALAIR CHILDREN/ADOLESCE -grass mixed pollen ext tab sl 100 ir (index of reactivity)............................... 17 ORALAIR CHILDREN/ADOLESCE -grass mixed pollen tab sl therpak 100 (3) ir & 300 (6) ir.............................. 17 ORALAIR -grass mixed pollen ext tab sl 300 ir (index of reactivity)......................................................................... 17 ORAMAGICRX -oral wound care products - for susp rinse............................................................................... 166
ORANGE CHICKEN/CARROTS/BR -nutritional supplement liquid.......................................................... 141 ORAP -pimozide tab 1 mg................................................ 93 ORAP -pimozide tab 2 mg................................................ 93 ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 166 ORENCIA -abatacept subcutaneous soln prefilled syringe 125 mg/ml..................................................................... 106 ORENCIA CLICKJECT -abatacept subcutaneous soln auto-injector 125 mg/ml................................................ 106 ORENITRAM -treprostinil diolamine tab cr 0.125 mg (base equiv).................................................................... 59 ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base equiv)............................................................................... 60 ORENITRAM -treprostinil diolamine tab cr 1 mg (base equiv)............................................................................... 60 ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base equiv)............................................................................... 60 ORFADIN -nitisinone cap 2 mg......................................... 40 ORFADIN -nitisinone cap 5 mg......................................... 40 ORFADIN -nitisinone cap 10 mg....................................... 40 ORFADIN -nitisinone cap 20 mg....................................... 40 ORFADIN -nitisinone susp 4 mg/ml.................................. 40 ORGANIC PEDIA SMART -nutritional supplement powder........................................................................... 141 ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 67 ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 67 orphenadrine citrate tab sr 12hr 100 mg.................... 117 ORTHO D -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 152 ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring kit 50 mm...................................................................... 181 ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring kit 100 mm.................................................................... 181 ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring kit 105 mm.................................................................... 181 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 55 mm...................................................................... 181 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 60 mm...................................................................... 182 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 65 mm...................................................................... 182 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 70 mm...................................................................... 182 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 75 mm...................................................................... 182 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 80 mm...................................................................... 182 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 85 mm...................................................................... 182 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 90 mm...................................................................... 182
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
237
2016 ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring kit 95 mm...................................................................... 182 ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr............................................................. 29 ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg................................. 29 OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 33 OSENI -alogliptin-pioglitazone tab 12.5-30 mg................. 33 OSENI -alogliptin-pioglitazone tab 12.5-45 mg................. 33 OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 33 OSENI -alogliptin-pioglitazone tab 25-30 mg.................... 33 OSENI -alogliptin-pioglitazone tab 25-45 mg.................... 33 OSMOLITE 1 CAL -nutritional supplement liquid............141 OSMOLITE 1.2 CAL -nutritional supplement liquid.........141 OSMOLITE 1.5 CAL -nutritional supplement liquid.........141 OSMOLITE HN -nutritional supplement liquid................ 141 OSMOLITE -nutritional supplement liquid....................... 141 OSMOPREP -sod phos mono-sod phos di tabs 1.102-0.398 gm(1.5gm na phos).................................... 68 OS 2 -nutritional supplement powder.............................. 141 OSPHENA -ospemifene tab 60 mg................................... 40 OTEZLA -apremilast tab 30 mg...................................... 106 OTEZLA -apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg.................................................................. 106 OTOVEL -ciprofloxacin-fluocinolone aceton (pf) otic soln 0.3-0.025%.................................................................... 165 OTREXUP -methotrexate soln pf auto-injector 7.5 mg/0.4ml........................................................................ 106 OTREXUP -methotrexate soln pf auto-injector 10 mg/0.4ml........................................................................ 106 OTREXUP -methotrexate soln pf auto-injector 12.5 mg/0.4ml........................................................................ 106 OTREXUP -methotrexate soln pf auto-injector 15 mg/0.4ml........................................................................ 106 OTREXUP -methotrexate soln pf auto-injector 17.5 mg/0.4ml........................................................................ 106 OTREXUP -methotrexate soln pf auto-injector 20 mg/0.4ml........................................................................ 106 OTREXUP -methotrexate soln pf auto-injector 22.5 mg/0.4ml........................................................................ 106 OTREXUP -methotrexate soln pf auto-injector 25 mg/0.4ml........................................................................ 106 OVACE PLUS -sulfacetamide sodium cream 10%......... 175 OVACE PLUS -sulfacetamide sodium foam 9.8%.......... 175 OVACE PLUS -sulfacetamide sodium lotion 9.8%......... 175 oxandrolone tab 2.5 mg (Oxandrin).............................. 25 oxandrolone tab 10 mg (Oxandrin)............................... 25 oxaprozin tab 600 mg (Daypro)................................... 106 OXAYDO -oxycodone hcl tab abuse deter 5 mg............ 101 OXAYDO -oxycodone hcl tab abuse deter 7.5 mg..........101 oxazepam cap 10 mg...................................................... 78 oxazepam cap 15 mg...................................................... 78
oxazepam cap 30 mg...................................................... 78 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)...................................................................... 112 oxcarbazepine tab 150 mg (Trileptal).......................... 112 oxcarbazepine tab 300 mg (Trileptal).......................... 112 oxcarbazepine tab 600 mg (Trileptal).......................... 112 OXEPA -nutritional supplement liquid............................. 141 oxiconazole nitrate cream 1% (Oxistat)...................... 175 OXISTAT -oxiconazole nitrate cream 1%........................ 175 OXISTAT -oxiconazole nitrate lotion 1%......................... 175 OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg...... 112 OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg...... 112 OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg...... 112 oxybutynin chloride syrup 5 mg/5ml............................ 75 oxybutynin chloride tab 5 mg........................................ 75 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 75 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl)..................................................................................... 75 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl)..................................................................................... 75 OXYCODONE/ACETAMINOPHEN -oxycodone w/ acetaminophen soln 5-325 mg/5ml.............................. 101 OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab 5-400 mg....................................................................... 101 oxycodone-aspirin tab 4.8355-325 mg (Percodan).................................................................... 101 oxycodone hcl cap 5 mg.............................................. 101 oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl).......................................................... 101 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 10 mg............................................................................ 101 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 15 mg............................................................................ 101 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 20 mg............................................................................ 101 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 30 mg............................................................................ 101 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 40 mg............................................................................ 101 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 60 mg............................................................................ 101 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 80 mg............................................................................ 101 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl).........101 oxycodone hcl tab 10 mg............................................. 101 oxycodone hcl tab 20 mg............................................. 101 oxycodone hcl tab 5 mg (Roxicodone)....................... 101 oxycodone hcl tab 15 mg (Roxicodone)..................... 101 oxycodone hcl tab 30 mg (Roxicodone)..................... 101 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)..................................................................... 101
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
238
2016 oxycodone w/ acetaminophen tab 5-325 mg (Percocet)..................................................................... 101 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)..................................................................... 101 oxycodone w/ acetaminophen tab 10-325 mg (Percocet)..................................................................... 101 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.................................................................................. 102 oxymorphone hcl tab 5 mg (Opana)............................102 oxymorphone hcl tab 10 mg (Opana)..........................102 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 5 mg........................................................... 102 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 7.5 mg........................................................ 102 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 10 mg......................................................... 102 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 15 mg......................................................... 102 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 20 mg......................................................... 102 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 30 mg......................................................... 102 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 40 mg......................................................... 102 OXYTROL -oxybutynin td patch twice weekly 3.9 mg/24hr........................................................................... 75 P paliperidone tab sr 24hr 1.5 mg (Invega)...................... 85 paliperidone tab sr 24hr 3 mg (Invega)......................... 85 paliperidone tab sr 24hr 6 mg (Invega)......................... 85 paliperidone tab sr 24hr 9 mg (Invega)......................... 85 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 2600-6200-10850 unit.....................................................71 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 4200-10000-17500 unit...................................................71 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 10500-25000-43750 unit................................................ 71 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 16800-40000-70000 unit................................................ 71
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 21000-37000-61000 unit................................................ 71 PANDEL -hydrocortisone probutate cream 0.1%............ 175 PANRETIN -alitretinoin gel 0.1%..................................... 175 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)........................................................................70 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)........................................................................70 PARAGARD INTRAUTERINE COP -copper iud............... 29 PAREGORIC -paregoric tincture 2 mg/5ml (morphine equivalent)....................................................................... 68 paricalcitol cap 4 mcg..................................................... 41 paricalcitol cap 1 mcg (Zemplar)................................... 40 paricalcitol cap 2 mcg (Zemplar)................................... 40 paromomycin sulfate cap 250 mg................................... 5 paroxetine hcl tab 10 mg (Paxil).................................... 81 paroxetine hcl tab 20 mg (Paxil).................................... 81 paroxetine hcl tab 30 mg (Paxil).................................... 81 paroxetine hcl tab 40 mg (Paxil).................................... 81 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)............... 81 paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 81 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)............... 81 PASER -aminosalicylic acid cr granules packet 4 gm.........5 PATADAY -olopatadine hcl ophth soln 0.2% (base equivalent)..................................................................... 163 PATANOL -olopatadine hcl ophth soln 0.1% (base equivalent)..................................................................... 163 PAXIL -paroxetine hcl oral susp 10 mg/5ml (base equiv)............................................................................... 81 PAZEO -olopatadine hcl ophth soln 0.7% (base equivalent)..................................................................... 163 pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg (Donnatal)................................................................ 70 PCE -erythromycin w/ enteric coated particles tab 333 mg...................................................................................... 4 PCE -erythromycin w/ enteric coated particles tab 500 mg...................................................................................... 4 PCP 100 -mag cit-bisacodyl-petrolat-pegmetoclopramide-electrol kit............................................. 68 PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj.............................................................................. 16 PEDIASURE 1.0 CAL/FIBER -nutritional supplement liquid.............................................................................. 142 PEDIASURE 1.5 CAL/FIBER -nutritional supplement liquid.............................................................................. 142 PEDIASURE 1.5 CAL -nutritional supplement liquid...... 142 PEDIASURE 1.5 CAL WITH FI -nutritional supplement liquid.............................................................................. 142 PEDIASURE ENTERAL FORMULA -nutritional supplement liquid.......................................................... 141 PEDIASURE GROW & GAIN -nutritional supplement liquid.............................................................................. 141
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
239
2016 PEDIASURE NUTRIPALS -nutritional supplement bar.................................................................................. 141 PEDIASURE NUTRIPALS -nutritional supplement liquid.............................................................................. 141 PEDIASURE -nutritional supplement liquid.................... 141 PEDIASURE PEDIATRIC -nutritional supplement liquid.............................................................................. 141 PEDIASURE PEPTIDE 1.0 CAL -nutritional supplement liquid.............................................................................. 141 PEDIASURE PEPTIDE 1.5 CAL -nutritional supplement liquid.............................................................................. 141 PEDIASURE SHAKE MIX -nutritional supplement powder........................................................................... 141 PEDIASURE SHAKE WITH FIBE -nutritional supplement liquid.............................................................................. 141 PEDIASURE SIDEKICKS CLEAR -nutritional supplement liquid.............................................................................. 142 PEDIASURE SIDEKICKS -nutritional supplement liquid.............................................................................. 141 PEDIASURE SIDEKICKS -nutritional supplement powder........................................................................... 142 PEDIASURE SIDEKICKS SHAKE -nutritional supplement liquid.............................................................................. 142 PEDIASURE WITH FIBER -nutritional supplement liquid.............................................................................. 142 PEDIATRIC DRINK -nutritional supplement liquid.......... 142 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ ml................................................................................... 122 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg................................................................................. 122 pediatric multiple vitamins w/ fluoride chew tab 0.5 mg................................................................................. 122 pediatric multiple vitamins w/ fluoride chew tab 1 mg................................................................................. 122 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ ml................................................................................... 122 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ ml................................................................................... 122 PEDIATRIC PEPTINEX DT/FIB -nutritional supplement liquid.............................................................................. 142 PEDIATRIC PEPTINEX DT -nutritional supplement liquid.............................................................................. 142 pediatric vitamins acd w/ fluoride soln 0.25 mg/ ml................................................................................... 122 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml..... 122 PEGANONE -ethotoin tab 250 mg.................................. 112 PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 9 PEGASYS -peginterferon alfa-2a inj 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
PEGINTRON -peginterferon alfa-2b for inj kit 50 mcg/0.5ml.......................................................................... 9 PEGINTRON -peginterferon alfa-2b for inj kit 80 mcg/0.5ml.......................................................................... 9 PEGINTRON -peginterferon alfa-2b for inj kit 120 mcg/0.5ml.......................................................................... 9 PEGINTRON -peginterferon alfa-2b for inj kit 150 mcg/0.5ml.......................................................................... 9 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 120 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 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 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)............................................. 68 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)................................................................. 68 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)................................................... 68 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 PENNSAID -diclofenac sodium soln 2%......................... 175 PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp............................................................... 16 PENTASA -mesalamine cap cr 250 mg............................ 73 PENTASA -mesalamine cap cr 500 mg............................ 73 pentazocine w/ naloxone tab 50-0.5 mg......................102 PENTETATE CALCIUM TRISODI -pentetate calcium trisodium iv or inhalation soln 200 mg/ml.................... 180 PENTETATE ZINC TRISODIUM -pentetate zinc trisodium iv or inhalation soln 200 mg/ml.................................... 180 pentoxifylline tab cr 400 mg......................................... 159 PEPDITE JUNIOR -nutritional supplement pack............ 142 PEPTAMEN/PREBIO1 -nutritional supplement liquid..... 142 PEPTAMEN AF -nutritional supplement liquid................ 142 PEPTAMEN BARIATRIC -nutritional supplement liquid.............................................................................. 142 PEPTAMEN 1 CAL/PREBIO1 -nutritional supplement liquid.............................................................................. 142 PEPTAMEN 1.5 CAL/PREBIO1 -nutritional supplement liquid.............................................................................. 142 PEPTAMEN 1 CAL -nutritional supplement liquid...........142 PEPTAMEN 1.5 CAL -nutritional supplement liquid........142 PEPTAMEN INTENSE VHP -nutritional supplement liquid.............................................................................. 142
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
240
2016 PEPTAMEN JUNIOR/PREBIO1 -nutritional supplement liquid.............................................................................. 142 PEPTAMEN JUNIOR 1 CAL/PRE -nutritional supplement liquid.............................................................................. 142 PEPTAMEN JUNIOR 1 CAL -nutritional supplement liquid.............................................................................. 142 PEPTAMEN JUNIOR 1.5 CAL -nutritional supplement liquid.............................................................................. 142 PEPTAMEN JUNIOR FIBER -nutritional supplement liquid.............................................................................. 142 PEPTAMEN JUNIOR HP -nutritional supplement liquid.............................................................................. 142 PEPTAMEN JUNIOR -nutritional supplement liquid....... 142 PEPTAMEN JUNIOR -nutritional supplement powder........................................................................... 142 PEPTAMEN -nutritional supplement liquid...................... 142 PEPTAMEN 1.5 -nutritional supplement liquid................ 142 PEPTAMEN OS -nutritional supplement liquid............... 142 PEPTAMEN OS 1.5 -nutritional supplement liquid......... 142 PEPTAMEN VHP -nutritional supplement liquid............. 142 PEPTINEX DT -nutritional supplement liquid..................143 PEPTINEX DT WITH PREBIOTI -nutritional supplement liquid.............................................................................. 143 PEPTINEX 1.0 -nutritional supplement liquid................. 143 PEPTINEX 1.5 -nutritional supplement liquid................. 143 PERATIVE -nutritional supplement liquid........................ 143 PERFOROMIST -formoterol fumarate soln nebu 20 mcg/2ml........................................................................... 66 PERIFLEX ADVANCE -nutritional supplement powder........................................................................... 143 PERIFLEX JUNIOR -nutritional supplement powder...... 143 PERIFLEX LQ PKU -amino acids oral liquid.................. 130 perindopril erbumine tab 2 mg...................................... 52 perindopril erbumine tab 4 mg (Aceon)........................ 52 perindopril erbumine tab 8 mg (Aceon)........................ 52 permethrin cream 5% (Elimite).................................... 175 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................ 93 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................ 93 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................ 93 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................ 93 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................ 94 perphenazine tab 2 mg................................................... 85 perphenazine tab 4 mg................................................... 85 perphenazine tab 8 mg................................................... 85 perphenazine tab 16 mg................................................. 85 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit...................................................71
PERTZYE -pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit................................................ 71 PEXEVA -paroxetine mesylate tab 10 mg (base equiv)............................................................................... 81 PEXEVA -paroxetine mesylate tab 20 mg (base equiv)............................................................................... 81 PEXEVA -paroxetine mesylate tab 30 mg (base equiv)............................................................................... 81 PEXEVA -paroxetine mesylate tab 40 mg (base equiv)............................................................................... 81 PFD 1 -nutritional supplement powder............................ 143 PFD 2 -nutritional supplement powder............................ 143 PHENACTIN AA PLUS -nutritional supplement liquid.............................................................................. 143 phenazopyridine hcl tab 100 mg (Pyridium).................76 phenazopyridine hcl tab 200 mg (Pyridium).................76 phenelzine sulfate tab 15 mg (Nardil)........................... 81 PHENEX-1 -nutritional supplement powder.................... 143 PHENEX-2 -nutritional supplement powder.................... 143 phenobarbital elixir 20 mg/5ml...................................... 87 PHENOBARBITAL -phenobarbital tab 15 mg................... 87 PHENOBARBITAL -phenobarbital tab 30 mg................... 87 PHENOBARBITAL -phenobarbital tab 60 mg................... 87 PHENOBARBITAL -phenobarbital tab 100 mg................. 87 phenobarbital tab 16.2 mg.............................................. 87 phenobarbital tab 32.4 mg.............................................. 87 phenobarbital tab 64.8 mg.............................................. 87 phenobarbital tab 97.2 mg.............................................. 87 phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 52 PHENYLADE AMINO ACID -amino acids bar................ 130 PHENYLADE AMINO ACID BLEN -amino acids pack............................................................................... 130 PHENYLADE -amino acids oral powder......................... 130 PHENYLADE40 DRINK MIX -amino acids pack.............131 PHENYLADE60 DRINK MIX -nutritional supplement pack............................................................................... 143 PHENYLADE DRINK MIX -nutritional supplement powder........................................................................... 143 PHENYLADE60 DRINK MIX -nutritional supplement powder........................................................................... 143 PHENYLADE ESSENTIAL DRINK -nutritional supplement pack............................................................................... 143 PHENYLADE ESSENTIAL DRINK -nutritional supplement powder........................................................................... 143 PHENYLADE GMP -nutritional supplement pack........... 143 PHENYLADE GMP -nutritional supplement powder....... 143 PHENYLADE MTE AMINO ACID -amino acids pack..... 131 PHENYLADE MTE -amino acids oral powder................ 130 PHENYLADE PHEBLOC -amino acids oral powder....... 131 PHENYLADE PHEBLOC -amino acids tab..................... 131 PHENYLADE RTD PKU 10 -nutritional supplement liquid.............................................................................. 143
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
241
2016 PHENYLEPHRINE/GUAIFENESIN -phenylephrineguaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)........... 63 phenylephrine-brompheniramine-dm liquid 7.5-4-15 mg/5ml............................................................................ 62 phenylephrine hcl ophth soln 2.5%............................. 163 phenylephrine hcl ophth soln 10%.............................. 163 phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml........................................................... 62 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............ 62 PHENYL-FREE 2HP -nutritional supplement powder........................................................................... 143 PHENYL-FREE 2 -nutritional supplement powder..........143 PHENYLHISTINE DH -pseudoephedrine-chlorphen w/ codeine liq 30-2-10 mg/5ml............................................ 63 PHENYTEK -phenytoin sodium extended cap 200 mg.................................................................................. 112 PHENYTEK -phenytoin sodium extended cap 300 mg.................................................................................. 112 phenytoin chew tab 50 mg (Dilantin infatabs)............112 phenytoin sodium extended cap 100 mg (Dilantin)....................................................................... 112 phenytoin sodium extended cap 200 mg (Phenytek).................................................................... 112 phenytoin sodium extended cap 300 mg (Phenytek).................................................................... 113 phenytoin susp 125 mg/5ml (Dilantin-125)................. 113 PHLEXY-10 -amino acids cap......................................... 131 PHLEXY-10 -nutritional supplement pack....................... 143 PHLEXY-VITS -multiple vitamins w/ minerals powder........................................................................... 122 PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse 0.044%.......................................................................... 166 PHOS FLUR -sodium fluoride rinse 0.044%................... 166 PHOSLYRA -calcium acetate (phosphate binder) oral soln 667 mg/5ml..................................................................... 73 PHOSPHOLINE IODIDE -echothiophate iodide ophth for soln 0.125%.................................................................. 163 PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/ ml & lidocaine 1% & ammonia inh kit............................ 23 PHYTOFUSION -nutritional supplement pack................ 143 phytonadione inj 1 mg/0.5ml (2 mg/ml).......................118 PICATO -ingenol mebutate gel 0.015%.......................... 175 PICATO -ingenol mebutate gel 0.05%............................ 175 pilocarpine hcl ophth soln 1% (Isopto carpine)......... 163 pilocarpine hcl ophth soln 2% (Isopto carpine)......... 163 pilocarpine hcl ophth soln 4% (Isopto carpine)......... 163 pilocarpine hcl tab 5 mg (Salagen)..............................166 pilocarpine hcl tab 7.5 mg (Salagen)...........................166 pimozide tab 1 mg (Orap)............................................... 94 pimozide tab 2 mg (Orap)............................................... 94 pindolol tab 5 mg............................................................. 44 pindolol tab 10 mg........................................................... 44
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)..... 34 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)..... 34 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met)............................................................... 34 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)............................................................... 34 pioglitazone hcl tab 15 mg (base equiv) (Actos)..........33 pioglitazone hcl tab 30 mg (base equiv) (Actos)..........33 pioglitazone hcl tab 45 mg (base equiv) (Actos)..........34 piroxicam cap 10 mg (Feldene)................................... 106 piroxicam cap 20 mg (Feldene)................................... 106 PIVOT 1.5 CAL -nutritional supplement liquid................ 143 PKU COOLER 10 -nutritional supplement liquid.............143 PKU COOLER 15 -nutritional supplement liquid.............143 PKU COOLER 20 -nutritional supplement liquid.............143 PKU EASY MICROTABS -nutritional supplement tabs delayed release.............................................................143 PKU EXPRESS -nutritional supplement pack.................143 PKU EXPRESS20 -nutritional supplement pack.............143 PKU GEL -nutritional supplement pack.......................... 143 PKU LOPHLEX LQ 20 -nutritional supplement liquid..... 143 PKU 2 -nutritional supplement powder........................... 144 PKU 3 -nutritional supplement powder........................... 144 PKU PERIFLEX EARLY YEARS -nutritional supplement powder........................................................................... 144 PKU PERIFLEX JUNIOR PLUS -nutritional supplement powder........................................................................... 144 PKU TRIO -nutritional supplement powder..................... 144 PLEGRIDY -peginterferon beta-1a soln pen-injector 125 mcg/0.5ml........................................................................ 94 PLEGRIDY -peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml................................................................ 94 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack.................................... 94 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack................................... 94 PLEXION CLEANSING CLOTHS -sulfacetamide sodium w/ sulfur cleansing cloth 9.8-4.8%............................... 175 PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 175 PNEUMOVAX 23/1 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................ 15 PNEUMOVAX 23/5 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................ 16 PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml.................................................................. 15 PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg.......................................... 122 PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg........................................................ 122 PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dssfe fumarate-fa tab 29-1 mg.......................................... 122
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
242
2016 PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack...................................................122 PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 122 PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe fumarate-fa tab 27-1 mg...............................................122 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.................................................................................. 122 PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap 35-5-1.2 mg................................................................... 123 PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg.................................................................... 123 PODOCON 25 IN BENZOIN TIN -podophyllum resin soln 25%................................................................................175 podofilox soln 0.5% (Condylox)................................... 175 POLYCAL -nutritional supplement powder......................144 polyethylene glycol 3350 oral packet............................ 68 polyethylene glycol 3350 oral powder.......................... 68 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)...................................................... 163 POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine liquid 10-4-10 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 FS -pediatric multiple vitamins w/ fluoride oral strip 1 mg...............................................................123 POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral strip 0.25 mg................................................................. 123 POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral strip 0.5 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.............................. 21 POMALYST -pomalidomide cap 2 mg.............................. 21 POMALYST -pomalidomide cap 3 mg.............................. 21 POMALYST -pomalidomide cap 4 mg.............................. 21 PORTAGEN -nutritional supplement powder.................. 144 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml............................................................................ 76 POTABA -potassium aminobenzoate cap 500 mg..........118 potassium bicarbonate effer tab 25 meq.................... 129 potassium chloride cap cr 8 meq (Micro-k)................ 129
potassium chloride cap cr 10 meq (Micro-k).............. 129 POTASSIUM CHLORIDE ER -potassium chloride tab cr 8 meq (600 mg)............................................................... 129 POTASSIUM CHLORIDE ER -potassium chloride tab cr 20 meq (1500 mg)........................................................ 129 potassium chloride microencapsulated crys cr tab 10 meq............................................................................... 129 potassium chloride microencapsulated crys cr tab 20 meq............................................................................... 129 potassium chloride oral soln 10% (20 meq/15ml)...... 129 potassium chloride oral soln 20% (40 meq/15ml)...... 129 potassium chloride powder packet 20 meq............... 129 potassium chloride tab cr 10 meq (K-tab).................. 129 potassium chloride tab cr 8 meq (600 mg)................. 129 potassium citrate & citric acid powder pack 3300-1002 mg................................................................................... 76 potassium citrate & citric acid soln 1100-334 mg/5ml............................................................................ 76 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)...................................................................................... 76 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10).................................................................................... 76 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15).................................................................................... 77 pot bicarbonate & chloride effer tab 25 meq.............. 129 POTIGA -ezogabine tab 50 mg....................................... 113 POTIGA -ezogabine tab 200 mg..................................... 113 POTIGA -ezogabine tab 300 mg..................................... 113 POTIGA -ezogabine tab 400 mg..................................... 113 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral)...............................129 PPA/MMA EXPRESS -nutritional supplement pack........ 144 PRADAXA -dabigatran etexilate mesylate cap 75 mg (etexilate base eq)........................................................ 154 PRADAXA -dabigatran etexilate mesylate cap 110 mg (etexilate base eq)........................................................ 154 PRADAXA -dabigatran etexilate mesylate cap 150 mg (etexilate base eq)........................................................ 154 PRALUENT -alirocumab subcutaneous soln pen-injector 75 mg/ml......................................................................... 58 PRALUENT -alirocumab subcutaneous soln pen-injector 150 mg/ml....................................................................... 58 PRALUENT -alirocumab subcutaneous soln prefilled syringe 75 mg/ml............................................................ 58 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
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
243
2016 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 116 pramipexole dihydrochloride tab 1.5 mg (Mirapex).......................................................................116 pramipexole dihydrochloride tab sr 24hr 0.375 mg (Mirapex er).................................................................. 115 pramipexole dihydrochloride tab sr 24hr 0.75 mg (Mirapex er).................................................................. 115 pramipexole dihydrochloride tab sr 24hr 1.5 mg (Mirapex er).................................................................. 115 pramipexole dihydrochloride tab sr 24hr 2.25 mg (Mirapex er).................................................................. 115 pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex er).................................................................. 116 pramipexole dihydrochloride tab sr 24hr 3.75 mg (Mirapex er).................................................................. 116 pramipexole dihydrochloride tab sr 24hr 4.5 mg (Mirapex er).................................................................. 116 PRAMOSONE E -pramoxine-hc emollient base cream 1-2.5%........................................................................... 175 PRAMOSONE -pramoxine-hc cream 1-1%.................... 175 PRAMOSONE -pramoxine-hc lotion 1-1%...................... 175 PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 175 PRAMOSONE -pramoxine-hc oint 1-1%.........................175 PRAMOSONE -pramoxine-hc oint 1-2.5%......................175 pramoxine-hc cream 1-2.5% (Pramosone)................. 176 pravastatin sodium tab 10 mg....................................... 58 pravastatin sodium tab 20 mg (Pravachol)...................58 pravastatin sodium tab 40 mg (Pravachol)...................58 pravastatin sodium tab 80 mg (Pravachol)...................58 prazosin hcl cap 1 mg (Minipress)................................ 52 prazosin hcl cap 2 mg (Minipress)................................ 52 prazosin hcl cap 5 mg (Minipress)................................ 52 PRED-G -gentamicin-prednisolone ace ophth susp 0.3-1%........................................................................... 163 PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint 0.3-0.6%........................................................................ 163 PRED MILD -prednisolone acetate ophth susp 0.12%.............................................................................163 prednicarbate cream 0.1% (Dermatop)....................... 176 prednicarbate oint 0.1% (Dermatop)........................... 176 PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin-bromfenac opth sol 1-0.5-0.09%............. 164 PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin-ketorolac opth sol 1-0.5-0.5%................. 164 PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin opth soln 1-0.5%..................................... 163 prednisolone acetate ophth susp 1% (Pred forte)..... 163 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate ophth soln 1%................................ 163 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)......... 24
prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt)............................................... 23 prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt)............................................... 24 prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt)............................................... 24 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)................................................................... 24 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)............................................24 prednisolone syrup 15 mg/5ml (usp solution equivalent)......................................................................24 PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 24 PREDNISONE -prednisone oral soln 5 mg/5ml................ 24 PREDNISONE -prednisone tab 50 mg............................. 24 PREDNISONE -prednisone tab therapy pack 5 mg (21).................................................................................. 24 PREDNISONE -prednisone tab therapy pack 5 mg (48).................................................................................. 24 PREDNISONE -prednisone tab therapy pack 10 mg (21).................................................................................. 24 PREDNISONE -prednisone tab therapy pack 10 mg (48).................................................................................. 24 prednisone tab 1 mg....................................................... 24 prednisone tab 2.5 mg.................................................... 24 prednisone tab 5 mg....................................................... 24 prednisone tab 10 mg..................................................... 24 prednisone tab 20 mg..................................................... 24 PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme poly-fa tab&dha cap pack.............................................123 PREFERAOB ONE -prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg............................................123 PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa tab 34-1 mg...................................................................123 PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15)............................................................ 27 PRE-FOLIC -folic acid-vitamin c tab 1-100 mg............... 152 PREMARIN -estrogens, conjugated tab 0.3 mg............... 27 PREMARIN -estrogens, conjugated tab 0.45 mg............. 27 PREMARIN -estrogens, conjugated tab 0.625 mg........... 27 PREMARIN -estrogens, conjugated tab 0.9 mg............... 27 PREMARIN -estrogens, conjugated tab 1.25 mg............. 27 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).......................................................... 27 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg................................................... 27 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg................................................. 27 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg............................................... 27
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
244
2016 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg.................................................. 27 PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg..................................................................... 124 PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg........................................ 123 PRENAISSANCE HARMONY DHA -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg....................123 PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg....................................................... 123 PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 123 PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg................................................... 123 PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg..................................................... 123 PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg................................................... 124 PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 123 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 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 -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 LO -prenatal vit w/ fe fumarate-fa tab 27-1 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/fefum-methfol-fa-dha cap 28-0.6-0.4-300 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/oa w/fecb-feasp-meth-fa-dha cap 18-0.6-0.4-350 mg................................................. 124
PRENATE MINI -prenat w/o a w/fecbn-methylf-fa-dha cap 29-0.6-0.4-350 mg........................................................ 124 PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha cap 10-0.6-0.4-200 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.......................................... 124 PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa tab 20-1 mg...................................................................124 PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............38 PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 124 PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10 mg-3.5 gm-12 gm........................................................... 68 PREPROTEIN -amino acids oral liquid........................... 131 PREPROTEIN 20 -amino acids oral liquid...................... 131 PREQUE 10 -prenatal mv w/fe carbonyl-dss-fa-dha tab 15-25-0.5-50 mg........................................................... 124 PRESTALIA -perindopril arginine-amlodipine besylate tab 3.5-2.5 mg....................................................................... 52 PRESTALIA -perindopril arginine-amlodipine besylate tab 7-5 mg............................................................................. 52 PRESTALIA -perindopril arginine-amlodipine besylate tab 14-10 mg......................................................................... 52 PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg...... 124 PREVIDENT 5000 BOOSTER PL -sodium fluoride paste 1.1%...............................................................................166 PREVIDENT 5000 BOOSTER -sodium fluoride paste 1.1%...............................................................................166 PREVIDENT 5000 DRY MOUTH -sodium fluoride gel 1.1% (0.5% f)................................................................ 166 PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%................................... 166 PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5% f)..................................................................................... 166 PREVIDENT 5000 PLUS -sodium fluoride cream 1.1%...............................................................................166 PREVIDENT 5000 SENSITIVE -sodium fluoridepotassium nitrate paste 1.1-5%................................... 166 PREVNAR 13 -Pneumococcal 13-valent conjugate vaccine inj....................................................................... 16 PREZCOBIX -darunavir-cobicistat tab 800-150 mg............9 PREZISTA -darunavir ethanolate susp 100 mg/ml (base equiv)................................................................................. 9 PREZISTA -darunavir ethanolate tab 75 mg (base equiv)................................................................................. 9 PREZISTA -darunavir ethanolate tab 150 mg (base equiv)................................................................................. 9 PREZISTA -darunavir ethanolate tab 600 mg (base equiv)................................................................................. 9
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
245
2016 PREZISTA -darunavir ethanolate tab 800 mg (base equiv)................................................................................. 9 PRIFTIN -rifapentine tab 150 mg........................................ 5 PRILOSEC -omeprazole cap delayed release 20 mg.......70 PRIMAQUINE PHOSPHATE -primaquine phosphate tab 26.3 mg (15 mg base).................................................... 12 primidone tab 50 mg (Mysoline).................................. 113 primidone tab 250 mg (Mysoline)................................ 113 PRIMLEV -oxycodone w/ acetaminophen tab 5-300 mg.................................................................................. 102 PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300 mg.................................................................................. 102 PRIMLEV -oxycodone w/ acetaminophen tab 10-300 mg.................................................................................. 102 PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base equiv)............................................................................... 12 PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg (base equiv).................................................................... 81 PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg (base equiv).................................................................... 81 PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg (base equiv).................................................................... 81 PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk................................................... 123 PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk................................................... 123 PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 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 PROAIR RESPICLICK -albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv)......................................... 66 PROBALANCE -nutritional supplement liquid................. 144 probenecid tab 500 mg................................................. 108 PROBUPHINE IMPLANT KIT -buprenorphine hcl subdermal implant 74.2 mg (base equiv).....................102 PRO-CAL -nutritional supplement pack.......................... 144 PRO-CAL -nutritional supplement powder...................... 144 prochlorperazine maleate tab 5 mg (base equivalent) (Compazine)................................................................... 85 prochlorperazine maleate tab 10 mg (base equivalent) (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%........................................................ 168 PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 152 PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 152 PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 152
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 152 PROCRIT -epoetin alfa inj 20000 unit/ml........................ 152 PROCRIT -epoetin alfa inj 40000 unit/ml........................ 152 PROCTOFOAM HC -hydrocortisone acetate w/ pramoxine rectal foam 1-1%........................................ 168 PROCYSBI -cysteamine bitartrate cap delayed release 25 mg (base equiv).............................................................. 77 PROCYSBI -cysteamine bitartrate cap delayed release 75 mg (base equiv).............................................................. 77 PROFERRIN-FORTE -iron heme polypeptide-folic acid tab 12-1 mg (fe equiv).................................................. 152 PROFILNINE -factor ix complex for inj 500 unit............. 159 PROFILNINE -factor ix complex for inj 1000 unit........... 159 PROFILNINE -factor ix complex for inj 1500 unit........... 159 PROFILNINE SD -factor ix complex for inj 500 unit........159 PROFILNINE SD -factor ix complex for inj 1000 unit......159 PROFILNINE SD -factor ix complex for inj 1500 unit......159 progesterone im in oil 50 mg/ml.................................... 30 progesterone micronized cap 100 mg (Prometrium).................................................................. 30 progesterone micronized cap 200 mg (Prometrium).................................................................. 30 PROGLYCEM -diazoxide susp 50 mg/ml......................... 34 PROGRAF -tacrolimus cap 0.5 mg................................. 183 PROGRAF -tacrolimus cap 1 mg.................................... 183 PROGRAF -tacrolimus cap 5 mg.................................... 183 PROLENSA -bromfenac sodium ophth soln 0.07% (base equivalent)..................................................................... 164 PROMACTA -eltrombopag olamine tab 12.5 mg (base equiv)............................................................................. 152 PROMACTA -eltrombopag olamine tab 25 mg (base equiv)............................................................................. 152 PROMACTA -eltrombopag olamine tab 50 mg (base equiv)............................................................................. 152 PROMACTA -eltrombopag olamine tab 75 mg (base equiv)............................................................................. 152 promethazine & phenylephrine syrup 6.25-5 mg/5ml............................................................................ 63 promethazine-dm syrup 6.25-15 mg/5ml.......................63 promethazine hcl suppos 12.5 mg................................ 61 promethazine hcl suppos 25 mg................................... 61 promethazine hcl suppos 50 mg................................... 61 promethazine hcl syrup 6.25 mg/5ml............................ 61 promethazine hcl tab 12.5 mg........................................ 61 promethazine hcl tab 25 mg........................................... 61 promethazine hcl tab 50 mg........................................... 61 promethazine w/ codeine syrup 6.25-10 mg/5ml..........63 PROMISEB -antiseborrheic products misc - cream........ 176 PROMOD -nutritional supplement liquid......................... 144 PROMOD -nutritional supplement powder...................... 144 PROMOTE/FIBER -nutritional supplement liquid........... 144 PROMOTE -nutritional supplement liquid....................... 144
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
246
2016 PROMOTE WITH FIBER -nutritional supplement liquid.............................................................................. 144 propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 47 propafenone hcl cap sr 12hr 325 mg (Rythmol sr)...... 47 propafenone hcl cap sr 12hr 425 mg (Rythmol sr)...... 47 propafenone hcl tab 300 mg.......................................... 47 propafenone hcl tab 150 mg (Rythmol)........................ 47 propafenone hcl tab 225 mg (Rythmol)........................ 47 PROPANTHELINE BROMIDE -propantheline bromide tab 15 mg.............................................................................. 70 proparacaine hcl ophth soln 0.5% (Alcaine).............. 164 PRO-PHREE -nutritional supplement powder................ 144 PROPIMEX-1 -nutritional supplement powder................ 144 PROPIMEX-2 -nutritional supplement powder................ 144 PROPRANOLOL/HYDROCHLOROTH -propranolol & hydrochlorothiazide tab 40-25 mg.................................. 52 PROPRANOLOL/HYDROCHLOROTH -propranolol & hydrochlorothiazide tab 80-25 mg.................................. 52 propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 44 propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 44 propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 44 propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 44 PROPRANOLOL HCL -propranolol hcl oral soln 20 mg/5ml............................................................................. 44 PROPRANOLOL HCL -propranolol hcl oral soln 40 mg/5ml............................................................................. 44 propranolol hcl tab 10 mg.............................................. 44 propranolol hcl tab 20 mg.............................................. 44 propranolol hcl tab 40 mg.............................................. 44 propranolol hcl tab 60 mg.............................................. 44 propranolol hcl tab 80 mg.............................................. 44 propylthiouracil tab 50 mg............................................. 37 PRO-RED AC -phenylephrine-dexchlorphenir-codeine syrup 5-1-9 mg/5ml.........................................................63 PROSOURCE NO CARB -nutritional supplement liquid.............................................................................. 144 PROSOURCE -nutritional supplement liquid.................. 144 PROSOURCE -nutritional supplement powder............... 144 PROSOURCE PLUS -nutritional supplement liquid........144 PROSOURCE TF -nutritional supplement liquid.............144 PROSOURCE ZAC -nutritional supplement liquid.......... 144 PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 38 PROSURE -nutritional supplement liquid........................144 PROTAIN XL -nutritional supplement liquid.................... 144 PROTECTIRON -iron polysacch-fa-b complex-vit c-e & minerals tab 60-1 mg................................................... 152 PROTEIN FORTIFIED COOKIE -nutritional supplement misc............................................................................... 144 PROTHELIAL -sucralfate-malate paste 10%.................. 167 protriptyline hcl tab 5 mg............................................... 81 protriptyline hcl tab 10 mg............................................. 81
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/ act (90mcg base equiv).................................................. 66 PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap 16-16-1.25-110 mg........................................................125 PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap 20-20-1.25 mg...............................................................125 PROVIMIN -nutritional supplement powder.................... 144 PRUCLAIR -dermatological products misc - cream........ 176 PRUDOXIN -doxepin hcl cream 5%............................... 176 PRUMYX -dermatological products misc - cream...........176 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 PSORCON -diflorasone diacetate cream 0.05%............ 176 PULMICORT -budesonide inhalation susp 1 mg/2ml....... 66 PULMICORT FLEXHALER -budesonide inhal aero powd 90 mcg/act (breath activated).........................................66 PULMICORT FLEXHALER -budesonide inhal aero powd 180 mcg/act (breath activated)...................................... 66 PULMOCARE -nutritional supplement liquid.................. 144 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.................................................... 153 PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/ ml).................................................................................... 21 PX VANILLA PLUS -nutritional supplement liquid.......... 144 PYLERA -bismuth subcit-metronidazole-tetracycline cap 140-125-125 mg..............................................................70 pyrazinamide tab 500 mg..................................................5 pyridostigmine bromide tab cr 180 mg (Mestinon timespan)......................................................................118 pyridostigmine bromide tab 60 mg (Mestinon).......... 118 Q QBRELIS -lisinopril oral soln 1 mg/ml............................... 52 QNASL -beclomethasone dipropionate nasal aerosol 80 mcg/act............................................................................ 61 QNASL CHILDRENS -beclomethasone dipropionate nasal aerosol 40 mcg/act............................................... 61 QUADRACEL -diph-tetanus tox ad-acell pert & polio virus, ipv vac inj.............................................................. 16 QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg...................................................... 29 QUAZEPAM -quazepam tab 15 mg.................................. 87
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
247
2016 QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg.................................................................................. 113 QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg.................................................................................. 113 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 QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr 24hr 50 mg......................................................................85 QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr 24hr 150 mg....................................................................85 QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr 24hr 200 mg....................................................................85 QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr 24hr 300 mg....................................................................85 quetiapine fumarate tab 25 mg (Seroquel)................... 85 quetiapine fumarate tab 50 mg (Seroquel)................... 85 quetiapine fumarate tab 100 mg (Seroquel)................. 85 quetiapine fumarate tab 200 mg (Seroquel)................. 85 quetiapine fumarate tab 300 mg (Seroquel)................. 85 quetiapine fumarate tab 400 mg (Seroquel)................. 85 quetiapine fumarate tab sr 24hr 400 mg (Seroquel xr).................................................................................... 85 QUFLORA FE -multi vit w/ min & fluoride-iron-fa chew tab 0.25 mg......................................................................... 125 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 quinapril hcl tab 5 mg (Accupril)................................... 52 quinapril hcl tab 10 mg (Accupril)................................. 52 quinapril hcl tab 20 mg (Accupril)................................. 52 quinapril hcl tab 40 mg (Accupril)................................. 53 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic)...................................................................... 53 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic)...................................................................... 53 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic)...................................................................... 53 quinidine gluconate tab cr 324 mg................................ 47 QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 47 QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 47 quinine sulfate cap 324 mg (Qualaquin)....................... 12
QUINOA KALE & HEMP -nutritional supplement liquid.............................................................................. 144 QVAR -beclomethasone diprop inhal aero soln 40 mcg/act (50/valve)......................................................................... 66 QVAR -beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)....................................................................... 66 R RA BALANCED NUTRITIONAL -nutritional supplement liquid.............................................................................. 144 RA BALANCED NUTRITIONAL P -nutritional supplement liquid.............................................................................. 144 RABAVERT -rabies vaccine, pcec for inj.......................... 16 rabeprazole sodium ec tab 20 mg (Aciphex)................ 70 RADIOGARDASE -prussian blue insoluble cap 0.5 gm.................................................................................. 180 RAGWITEK -short ragweed pollen allergen extract tab sl 12 amb a 1-u.................................................................. 17 raloxifene hcl tab 60 mg (Evista)................................... 41 ramipril cap 1.25 mg (Altace)......................................... 53 ramipril cap 2.5 mg (Altace)........................................... 53 ramipril cap 5 mg (Altace).............................................. 53 ramipril cap 10 mg (Altace)............................................ 53 RANEXA -ranolazine tab sr 12hr 500 mg......................... 42 RANEXA -ranolazine tab sr 12hr 1000 mg....................... 43 ranitidine hcl cap 150 mg............................................... 70 ranitidine hcl cap 300 mg............................................... 70 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 70 ranitidine hcl tab 300 mg (Zantac)................................. 70 RA NUTRITIONAL SUPPLEMENT -nutritional supplement liquid.......................................................... 144 RA NUTRITIONAL SUPPORT -nutritional supplement powder........................................................................... 145 RAPAFLO -silodosin cap 4 mg..........................................77 RAPAFLO -silodosin cap 8 mg..........................................77 RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 183 RA PEDIATRIC NUTRITIONAL -nutritional supplement liquid.............................................................................. 145 RASUVO -methotrexate soln pf auto-injector 7.5 mg/0.15ml...................................................................... 106 RASUVO -methotrexate soln pf auto-injector 10 mg/0.2ml........................................................................ 106 RASUVO -methotrexate soln pf auto-injector 12.5 mg/0.25ml...................................................................... 106 RASUVO -methotrexate soln pf auto-injector 15 mg/0.3ml........................................................................ 106 RASUVO -methotrexate soln pf auto-injector 17.5 mg/0.35ml...................................................................... 106 RASUVO -methotrexate soln pf auto-injector 20 mg/0.4ml........................................................................ 106 RASUVO -methotrexate soln pf auto-injector 22.5 mg/0.45ml...................................................................... 106
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
248
2016 RASUVO -methotrexate soln pf auto-injector 25 mg/0.5ml........................................................................ 106 RASUVO -methotrexate soln pf auto-injector 27.5 mg/0.55ml...................................................................... 106 RASUVO -methotrexate soln pf auto-injector 30 mg/0.6ml........................................................................ 106 RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........41 RAYOS -prednisone tab delayed release 1 mg................ 24 RAYOS -prednisone tab delayed release 2 mg................ 24 RAYOS -prednisone tab delayed release 5 mg................ 24 RE/GEN PROTEIN FORTIFIED -nutritional supplement misc............................................................................... 145 RE/NEPH HP/HC -nutritional supplement liquid (frozen).......................................................................... 145 RE/NEPH LP/HC -nutritional supplement liquid..............145 RE/NEPH -nutritional supplement liquid......................... 145 RE/NEPH REDUCED SUGAR -nutritional supplement liquid.............................................................................. 145 REBETOL -ribavirin soln 40 mg/ml..................................... 9 REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml)........................................................................ 94 REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml)........................................................................ 94 REBIF REBIDOSE -interferon beta-1a soln auto-inj 22 mcg/0.5ml (12mu/ml)...................................................... 94 REBIF REBIDOSE -interferon beta-1a soln auto-inj 44 mcg/0.5ml (24mu/ml)...................................................... 94 REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 94 REBIF TITRATION PACK -interferon beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................... 94 RECEDO -scar treatment products - gel.........................176 RECOMBINATE -antihemophilic factor (recombinant) for inj 220-400 unit............................................................. 159 RECOMBINATE -antihemophilic factor (recombinant) for inj 401-800 unit............................................................. 159 RECOMBINATE -antihemophilic factor (recombinant) for inj 801-1240 unit........................................................... 159 RECOMBINATE -antihemophilic factor (recombinant) for inj 1241-1800 unit......................................................... 159 RECOMBINATE -antihemophilic factor (recombinant) for inj 1801-2400 unit......................................................... 159 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml........................................................... 16 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 10 mcg/ml.............................................................. 16 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 40 mcg/ml.............................................................. 16 RECTIV -nitroglycerin oint 0.4%..................................... 168 RECURA -antifungal combination products misc cream............................................................................. 176
REGENECARE -lidocaine hcl-collagen-aloe vera gel 2%.................................................................................. 176 REGRANEX -becaplermin gel 0.01%............................. 176 RELAGARD -acetic acid-oxyquinoline vaginal gel 0.9-0.025%...................................................................... 76 RELENZA DISKHALER -zanamivir aero powder breath activated 5 mg/blister........................................................9 RELION R -insulin regular (human) inj 100 unit/ml........... 35 RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml).............................................................................. 73 RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml)....................................................................... 73 RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................. 125 RELPAX -eletriptan hydrobromide tab 20 mg (base equivalent)..................................................................... 107 RELPAX -eletriptan hydrobromide tab 40 mg (base equivalent)..................................................................... 107 REMBRANDT DEEPLY WHITE+PE -sodium monofluorophosphate paste 0.884%........................... 167 REMBRANDT INTENSE STAIN -sodium fluoride paste 0.243%.......................................................................... 167 REMBRANDT WHITENING -sodium fluoride rinse 0.02%.............................................................................167 RENAGEL -sevelamer hcl tab 400 mg............................. 73 RENAGEL -sevelamer hcl tab 800 mg............................. 73 RENALCAL -nutritional supplement liquid...................... 145 RENASTART -nutritional supplement powder................ 145 RENVELA -sevelamer carbonate packet 0.8 gm.............. 73 RENVELA -sevelamer carbonate packet 2.4 gm.............. 73 RENVELA -sevelamer carbonate tab 800 mg.................. 73 REPAGLINIDE/METFORMIN HYD -repaglinide-metformin hcl tab 1-500 mg.............................................................34 REPAGLINIDE/METFORMIN HYD -repaglinide-metformin hcl tab 2-500 mg.............................................................34 repaglinide tab 0.5 mg (Prandin)................................... 34 repaglinide tab 1 mg (Prandin)...................................... 34 repaglinide tab 2 mg (Prandin)...................................... 34 REPATHA -evolocumab subcutaneous soln prefilled syringe 140 mg/ml.......................................................... 58 REPATHA PUSHTRONEX SYSTEM -evolocumab subcutaneous soln cartridge/infusor 420 mg/3.5ml....... 58 REPATHA SURECLICK -evolocumab subcutaneous soln auto-injector 140 mg/ml.................................................. 58 REPLETE/FIBER/ULTRAPAK -nutritional supplement liquid.............................................................................. 145 REPLETE FIBER 1 CAL -nutritional supplement liquid.............................................................................. 145 REPLETE FIBER -nutritional supplement liquid............. 145 REPLETE -nutritional supplement liquid......................... 145 RESCRIPTOR -delavirdine mesylate tab 100 mg.............. 9 RESCRIPTOR -delavirdine mesylate tab 200 mg.............. 9
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
249
2016 RESCULA -unoprostone isopropyl ophth soln 0.15%.............................................................................164 RESOURCE ARGINAID -nutritional supplement pack............................................................................... 145 RESOURCE DAIRY THICK HONE -nutritional supplement liquid.......................................................... 145 RESOURCE DIABETIC TF -nutritional supplement liquid.............................................................................. 145 RESOURCE JUICE DRINK -nutritional supplement liquid (frozen).......................................................................... 145 RESOURCE JUST FOR KIDS -nutritional supplement liquid.............................................................................. 145 RESOURCE JUST FOR KIDS 1. -nutritional supplement liquid.............................................................................. 145 RESOURCE JUST FOR KIDS WI -nutritional supplement liquid.............................................................................. 145 RESOURCE 2.0 -nutritional supplement liquid............... 145 RESOURCE SUPPORT -nutritional supplement liquid.............................................................................. 145 RESOURCE THICKENUP THICKE -nutritional supplement liquid.......................................................... 145 RESPALOR -nutritional supplement liquid...................... 145 RESPIRATORY THERAPY SUPPLIES-VARIOUS......... 182 RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 164 RESTORA RX -lactobacillus casei-folic acid cap 60-1.25 mg.................................................................................... 68 RESTORA SPRINKLES -lactobacillus casei-folic acid packet 15-0.25 mg.......................................................... 68 RESURGEX -nutritional supplement pack...................... 145 RESURGEX PLUS -nutritional supplement pack........... 145 RESURGEX SELECT -nutritional supplement pack....... 145 REVATIO -sildenafil citrate for suspension 10 mg/ml....... 60 REVESTA -folic acid-cholecalciferol cap 1 mg-5750 unit................................................................................. 153 REVLIMID -lenalidomide cap 5 mg................................. 183 REVLIMID -lenalidomide cap 10 mg............................... 183 REVLIMID -lenalidomide cap 15 mg............................... 183 REVLIMID -lenalidomide cap 20 mg............................... 183 REVLIMID -lenalidomide cap 25 mg............................... 183 REVLIMID -lenalidomide caps 2.5 mg............................ 183 REXULTI -brexpiprazole tab 0.25 mg............................... 85 REXULTI -brexpiprazole tab 0.5 mg................................. 85 REXULTI -brexpiprazole tab 1 mg.................................... 85 REXULTI -brexpiprazole tab 2 mg.................................... 85 REXULTI -brexpiprazole tab 3 mg.................................... 85 REXULTI -brexpiprazole tab 4 mg.................................... 85 REYATAZ -atazanavir sulfate cap 150 mg (base equiv)..... 9 REYATAZ -atazanavir sulfate cap 200 mg (base equiv)..... 9 REYATAZ -atazanavir sulfate cap 300 mg (base equiv)..... 9 REYATAZ -atazanavir sulfate oral powder packet 50 mg (base equiv)...................................................................... 9
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml............................................................................. 63 RIASTAP -fibrinogen conc (human) inj approximately 1 gm (900-1300 mg)........................................................ 159 RIAX -benzoyl peroxide foam 5.5%................................ 176 RIAX -benzoyl peroxide foam 9.5%................................ 176 RIBASPHERE RIBAPAK -ribavirin tab 400 mg................... 9 RIBASPHERE RIBAPAK -ribavirin tab 600 mg................. 10 RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin tab 400 mg dose pack....................................................10 RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack....................................................10 RIBASPHERE -ribavirin tab 400 mg................................... 9 RIBASPHERE -ribavirin tab 600 mg................................... 9 ribavirin cap 200 mg (Rebetol)....................................... 10 ribavirin tab 200 mg (Copegus)..................................... 10 RIDAURA -auranofin cap 3 mg....................................... 106 rifabutin cap 150 mg (Mycobutin).................................... 5 RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 5 rifampin cap 150 mg (Rifadin).......................................... 6 rifampin cap 300 mg (Rifadin).......................................... 6 RIFATER -isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg.................................................................. 6 riluzole tab 50 mg (Rilutek).......................................... 117 rimantadine hydrochloride tab 100 mg (Flumadine).................................................................... 10 RIOMET -metformin hcl oral soln 500 mg/5ml.................. 34 risedronate sodium tab delayed release 35 mg (Atelvia).......................................................................... 41 risedronate sodium tab 5 mg (Actonel)........................ 41 risedronate sodium tab 30 mg (Actonel)...................... 41 risedronate sodium tab 35 mg (Actonel)...................... 41 risedronate sodium tab 150 mg (Actonel).................... 41 risperidone orally disintegrating tab 0.25 mg.............. 85 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).............................................................................. 85 risperidone orally disintegrating tab 1 mg (Risperdal m-tab).............................................................................. 85 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 rivastigmine tartrate cap 1.5 mg (Exelon).....................94
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
250
2016 rivastigmine tartrate cap 3 mg (Exelon)........................94 rivastigmine tartrate cap 4.5 mg (Exelon).....................94 rivastigmine tartrate cap 6 mg (Exelon)........................94 rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 94 rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 94 rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 94 RIXUBIS -coagulation factor ix (recombinant) for inj 250 unit................................................................................. 159 RIXUBIS -coagulation factor ix (recombinant) for inj 500 unit................................................................................. 159 RIXUBIS -coagulation factor ix (recombinant) for inj 1000 unit................................................................................. 160 RIXUBIS -coagulation factor ix (recombinant) for inj 2000 unit................................................................................. 160 RIXUBIS -coagulation factor ix (recombinant) for inj 3000 unit................................................................................. 160 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt)........................................................... 107 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt)................................................ 107 rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt)......................................................................... 107 rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)......................................................................... 108 R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg.................................................................. 125 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 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 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl)............................................... 116 ROSULA -sulfacetamide sodium w/ sulfur cleansing cloth 10-5%............................................................................ 176 rosuvastatin calcium tab 5 mg (Crestor)...................... 58 rosuvastatin calcium tab 10 mg (Crestor).................... 58 rosuvastatin calcium tab 20 mg (Crestor).................... 58 rosuvastatin calcium tab 40 mg (Crestor).................... 58 ROZEREM -ramelteon tab 8 mg....................................... 87 RUCONEST -c1 esterase inhibitor (recombinant) for iv inj 2100 unit....................................................................... 160
RULAVITE DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg................................................. 125 RYNODERM -urea cream 37.5%.................................... 176 RYTARY -carbidopa & levodopa cap cr 23.75-95 mg..... 116 RYTARY -carbidopa & levodopa cap cr 36.25-145 mg.................................................................................. 116 RYTARY -carbidopa & levodopa cap cr 48.75-195 mg.................................................................................. 116 RYTARY -carbidopa & levodopa cap cr 61.25-245 mg.................................................................................. 116 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..............................................................29 SALICEPT -oral wound care products - for susp rinse............................................................................... 167 salicylic acid cream 6%................................................ 176 salicylic acid er film-forming soln 28.5% (Ultrasaler).................................................................................. 176 salicylic acid film forming liquid 27.5% (Virasal)....... 176 salicylic acid foam 6% (Salvax)................................... 176 salicylic acid gel 6% (Keralyt)...................................... 176 salicylic acid lotion 6%................................................. 176 SALICYLIC ACID -salicylic acid soln 26%...................... 176 salicylic acid shampoo 6% (Salex).............................. 176 SALIVAMAX -artificial saliva - packet..............................167 SALIVATE RX -artificial saliva - packet........................... 167 SALMON/OATS/SQUASH -nutritional supplement liquid.............................................................................. 145 salsalate tab 500 mg (Disalcid)...................................... 95 salsalate tab 750 mg (Disalcid)...................................... 95 SAMSCA -tolvaptan tab 15 mg......................................... 41 SAMSCA -tolvaptan tab 30 mg......................................... 41 SANARE SCAR THERAPY -cream base....................... 182 SANCUSO -granisetron td patch 3.1 mg/24hr (contains 34.3 mg).......................................................................... 71 SANDIMMUNE -cyclosporine cap 25 mg....................... 183 SANDIMMUNE -cyclosporine cap 100 mg..................... 183 SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 183 SANTYL -collagenase oint 250 unit/gm.......................... 176 SAPHRIS -asenapine maleate sl tab 2.5 mg (base equiv)............................................................................... 86 SAPHRIS -asenapine maleate sl tab 5 mg (base equiv)............................................................................... 86 SAPHRIS -asenapine maleate sl tab 10 mg (base equiv)............................................................................... 86 SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.................... 94 SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.................... 94 SAVAYSA -edoxaban tosylate tab 15 mg (base equivalent)..................................................................... 154
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
251
2016 SAVAYSA -edoxaban tosylate tab 30 mg (base equivalent)..................................................................... 154 SAVAYSA -edoxaban tosylate tab 60 mg (base equivalent)..................................................................... 154 SAVELLA -milnacipran hcl tab 12.5 mg............................ 94 SAVELLA -milnacipran hcl tab 25 mg............................... 94 SAVELLA -milnacipran hcl tab 50 mg............................... 94 SAVELLA -milnacipran hcl tab 100 mg............................. 94 SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak................................. 94 SB COMPLETE NUTRITION -nutritional supplement liquid.............................................................................. 145 SB COMPLETE NUTRITION PLU -nutritional supplement liquid.............................................................................. 146 SCANDICAL -nutritional supplement powder................. 146 SCANDISHAKE -nutritional supplement misc................ 146 SCANDISHAKE -nutritional supplement pack................ 146 SCANDISHAKE -nutritional supplement powder............ 146 scar treatment products - gel...................................... 176 SECONAL SODIUM -secobarbital sodium cap 100 mg.................................................................................... 87 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%........................................ 176 selenium sulfide-pyrithione zinc in urea shampoo 2.25%.............................................................................176 SELRX -selenium sulfide-pyrithione zinc in urea shampoo 2.3%...............................................................................176 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 SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 41 SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 41 SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 41 SENSODYNE REPAIR & PROTEC -stannous fluoride paste 0.454%................................................................ 167 SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)................................................... 66 SERNIVO -betamethasone dipropionate spray emulsion 0.05% (base equiv).......................................................176
SEROQUEL XR -quetiapine fumarate tab sr 24hr 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 sertraline hcl oral conc 20 mg/ml (Zoloft).................... 81 sertraline hcl tab 25 mg (Zoloft).................................... 81 sertraline hcl tab 50 mg (Zoloft).................................... 81 sertraline hcl tab 100 mg (Zoloft).................................. 81 SFROWASA -mesalamine sulfite-free (sf) enema 4 gm/60ml........................................................................... 73 SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base equiv)............................................................................... 41 SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base equiv)............................................................................... 41 SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base equiv)............................................................................... 41 sildenafil citrate tab 20 mg (Revatio)............................ 60 SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)...... 87 SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)...... 87 SILVER NITRATE -silver nitrate oint 10%....................... 176 SILVER NITRATE -silver nitrate soln 0.5%..................... 176 SILVER NITRATE -silver nitrate soln 10%...................... 176 SILVER NITRATE -silver nitrate soln 25%...................... 176 SILVER NITRATE -silver nitrate soln 50%...................... 176 silver sulfadiazine cream 1% (Silvadene)................... 176 SILVRSTAT WOUND DRESSING -silver - gel................ 176 SIMBRINZA -brinzolamide-brimonidine tartrate ophth susp 1-0.2%.................................................................. 164 SIMPONI -golimumab subcutaneous soln auto-injector 50 mg/0.5ml........................................................................ 107 SIMPONI -golimumab subcutaneous soln auto-injector 100 mg/ml..................................................................... 107 SIMPONI -golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml.................................................................. 107 SIMPONI -golimumab subcutaneous soln prefilled syringe 100 mg/ml..................................................................... 107 simvastatin tab 5 mg (Zocor)......................................... 58 simvastatin tab 10 mg (Zocor)....................................... 58 simvastatin tab 20 mg (Zocor)....................................... 58 simvastatin tab 40 mg (Zocor)....................................... 58 simvastatin tab 80 mg (Zocor)....................................... 58 sirolimus tab 0.5 mg (Rapamune)............................... 183 sirolimus tab 1 mg (Rapamune).................................. 183 sirolimus tab 2 mg (Rapamune).................................. 183 SIRTURO -bedaquiline fumarate tab 100 mg (base equiv)................................................................................. 6
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
252
2016 SITAVIG -acyclovir buccal tab 50 mg................................ 10 SIVEXTRO -tedizolid phosphate tab 200 mg....................12 skin protectants misc - cream..................................... 177 SKLICE -ivermectin lotion 0.5%...................................... 177 SM NUTRI-DRINK + -nutritional supplement liquid........ 146 SM NUTRI-DRINK -nutritional supplement liquid........... 146 sodium chloride soln nebu 0.9%................................... 63 sodium chloride soln nebu 3%...................................... 63 sodium chloride soln nebu 10%.................................... 63 sodium chloride soln nebu 7% (Hyper-sal).................. 63 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi)................................................ 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).............................................................................. 167 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)........................................................................ 167 sodium fluoride paste 1.1% (Prevident 5000 boost)............................................................................ 167 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi)............................................... 167 sodium fluoride rinse 0.05%.........................................167 sodium fluoride rinse 0.0221% (0.01% f).................... 167 sodium fluoride rinse 0.2% (Prevident)...................... 167 SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from 1.1 mg naf)....................................................................129 SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from 2.2 mg naf)....................................................................129 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)...................................................................... 41 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps).............................................................................. 183 sodium polystyrene sulfonate powder (Kayexalate)................................................................. 184 sodium polystyrene sulfonate rectal susp 30 gm/120ml...................................................................... 184 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium-sulfur in urea emulsion 10-5%........................ 177 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium-sulfur in urea gel 10-5%.................................. 177 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium w/ sulfur susp 10-5%.................................................... 177
SODIUM SULFACETAMIDE WASH -sulfacetamide sodium in bakuchiol vehicle wash 10%....................... 177 SOL CARB -nutritional supplement powder....................146 SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base equivalent)....................................................................... 21 SOLVIL -amino acids pack.............................................. 131 SOMA -carisoprodol tab 250 mg..................................... 117 SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 41 SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 41 SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 41 SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 41 SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 41 SOOLANTRA -ivermectin cream 1%.............................. 177 SORILUX -calcipotriene foam 0.005%............................ 177 S.O.S. 15 -nutritional supplement pack.......................... 145 S.O.S. 20 -nutritional supplement pack.......................... 145 S.O.S. 25 -nutritional supplement pack.......................... 145 sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 44 sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 44 sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 44 sotalol hcl tab 240 mg.....................................................44 sotalol hcl tab 80 mg (Betapace)................................... 44 sotalol hcl tab 120 mg (Betapace)................................. 44 sotalol hcl tab 160 mg (Betapace)................................. 44 SOTYLIZE -sotalol hcl oral solution 5 mg/ml.................... 44 SOURCE COOKIE BAR -nutritional supplement bar......146 SOVALDI -sofosbuvir tab 400 mg..................................... 10 SOYPRO -nutritional supplement powder.......................146 SOY PROTEIN SHAKE -nutritional supplement powder........................................................................... 146 SPACERS-VARIOUS....................................................... 182 SPATONE PUR-ABSORB IRON -ferrous sulfate liquid 5 mg/20ml (elemental iron)..............................................153 SPECTRACEF -cefditoren pivoxil tab 400 mg (base equivalent)......................................................................... 3 SPINOSAD -spinosad susp 0.9%................................... 177 SPIRIVA HANDIHALER -tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)....................................... 66 SPIRIVA RESPIMAT -tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act............................................. 66 SPIRIVA RESPIMAT -tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act............................................... 66 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide).................................................................. 55 spironolactone tab 25 mg (Aldactone).......................... 55 spironolactone tab 50 mg (Aldactone).......................... 55 spironolactone tab 100 mg (Aldactone)........................ 55 SPORANOX -itraconazole oral soln 10 mg/ml....................6 SPRITAM -levetiracetam tab disintegrating soluble 250 mg.................................................................................. 113 SPRITAM -levetiracetam tab disintegrating soluble 500 mg.................................................................................. 113
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
253
2016 SPRITAM -levetiracetam tab disintegrating soluble 750 mg.................................................................................. 113 SPRITAM -levetiracetam tab disintegrating soluble 1000 mg.................................................................................. 113 SPRYCEL -dasatinib tab 20 mg........................................ 21 SPRYCEL -dasatinib tab 50 mg........................................ 21 SPRYCEL -dasatinib tab 70 mg........................................ 21 SPRYCEL -dasatinib tab 80 mg........................................ 21 SPRYCEL -dasatinib tab 100 mg...................................... 21 SPRYCEL -dasatinib tab 140 mg...................................... 21 SP SCAR MANAGEMENT -scar treatment products gel.................................................................................. 177 SSKI -potassium iodide soln 1 gm/ml............................. 130 SSS 10-5 -sulfacetamide sodium w/ sulfur foam 10-5%............................................................................ 177 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..............................................................116 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)................................................................................... 167 stannous fluoride gel 0.4%........................................... 167 STANNOUS FLUORIDE RINSE -stannous fluoride liq 0.1%...............................................................................167 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 STELARA -ustekinumab soln prefilled syringe 45 mg/0.5ml........................................................................ 177 STELARA -ustekinumab soln prefilled syringe 90 mg/ ml................................................................................... 177 STIMATE -desmopressin acetate nasal soln 1.5 mg/ ml..................................................................................... 41 STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act....................................................... 66 STIVARGA -regorafenib tab 40 mg................................... 21 STRATTERA -atomoxetine hcl cap 10 mg (base equiv)............................................................................... 90 STRATTERA -atomoxetine hcl cap 18 mg (base equiv)............................................................................... 90
STRATTERA -atomoxetine hcl cap 25 mg (base equiv)............................................................................... 90 STRATTERA -atomoxetine hcl cap 40 mg (base equiv)............................................................................... 90 STRATTERA -atomoxetine hcl cap 60 mg (base equiv)............................................................................... 90 STRATTERA -atomoxetine hcl cap 80 mg (base equiv)............................................................................... 90 STRATTERA -atomoxetine hcl cap 100 mg (base equiv)............................................................................... 90 STRENSIQ -asfotase alfa subcutaneous inj 18 mg/0.45ml........................................................................ 41 STRENSIQ -asfotase alfa subcutaneous inj 28 mg/0.7ml.......................................................................... 41 STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 41 STRENSIQ -asfotase alfa subcutaneous inj 80 mg/0.8ml.......................................................................... 41 STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg...................................................... 10 STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv)................................................ 66 SUBDUE -nutritional supplement liquid.......................... 146 SUBDUE PLUS -nutritional supplement liquid................ 146 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)............................................................ 102 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)............................................................ 102 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)............................................................ 102 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)............................................................ 102 SUBSYS -fentanyl sublingual spray 100 mcg................. 102 SUBSYS -fentanyl sublingual spray 200 mcg................. 102 SUBSYS -fentanyl sublingual spray 400 mcg................. 103 SUBSYS -fentanyl sublingual spray 600 mcg................. 103 SUBSYS -fentanyl sublingual spray 800 mcg................. 103 SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x 2).................................................................................... 103 SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x 2).................................................................................... 103 SUCRAID -sacrosidase soln 8500 unit/ml........................ 71 sucralfate tab 1 gm (Carafate)....................................... 70 sulfacetamide sodium cleansing gel 10% (Ovace plus wash).............................................................................177 sulfacetamide sodium liquid 10% (Ovace wash)....... 177 sulfacetamide sodium lotion 10% (acne) (Klaron)..... 177 sulfacetamide sodium ophth soln 10% (Bleph-10)..................................................................... 164 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%............................................................. 164 sulfacetamide sodium shampoo 10% (Ovace plus).............................................................................. 177
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
254
2016 SULFACETAMIDE SODIUM -sulfacetamide sodium ophth oint 10%........................................................................ 164 sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser).................................................................. 177 sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion cleanser)....................................................... 177 sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin)..................................................................... 177 sulfacetamide sodium w/ sulfur cream 10-5%........... 177 sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls)................................................................................... 177 sulfacetamide sodium w/ sulfur cream 9.8-4.8% (Plexion)....................................................................... 177 sulfacetamide sodium w/ sulfur emulsion 10-1%...... 177 sulfacetamide sodium w/ sulfur emulsion 10-5%...... 177 sulfacetamide sodium w/ sulfur lotion 10-5%............ 177 sulfacetamide sodium w/ sulfur lotion 9.8-4.8% (Plexion)....................................................................... 177 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts).................................................................................. 177 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash)......................................................... 177 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash).............................................................................177 SULFADIAZINE -sulfadiazine tab 500 mg.......................... 5 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...... 178 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)........................................................................... 73 sulfasalazine tab 500 mg (Azulfidine)........................... 74 SULFOAM -sulfur shampoo 2%...................................... 178 sulindac tab 150 mg...................................................... 107 sulindac tab 200 mg...................................................... 107 sumatriptan nasal spray 5 mg/act (Imitrex)................ 108 sumatriptan nasal spray 20 mg/act (Imitrex).............. 108 sumatriptan succinate inj 6 mg/0.5ml (Imitrex).......... 108 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys)............................... 108 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)............................... 108 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref).................................................. 108 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref).................................................. 108 SUMATRIPTAN SUCCINATE -sumatriptan succinate solution prefilled syringe 6 mg/0.5ml........................... 108 sumatriptan succinate tab 25 mg (Imitrex)................. 108
sumatriptan succinate tab 50 mg (Imitrex)................. 108 sumatriptan succinate tab 100 mg (Imitrex)............... 108 SUPER-AMINO 1600 -amino acids tab.......................... 131 SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml (per drop)...................................................................... 118 SUPER NU-THERA -multiple vitamins w/ minerals powder........................................................................... 125 SUPLENA -nutritional supplement liquid.........................146 SUPLENA RTU -nutritional supplement liquid................ 146 SUPLENA WITH CARB STEADY -nutritional supplement liquid.............................................................................. 146 SUPRAX -cefixime cap 400 mg.......................................... 3 SUPRAX -cefixime chew tab 100 mg................................. 3 SUPRAX -cefixime chew tab 200 mg................................. 3 SUPRAX -cefixime for susp 100 mg/5ml............................ 3 SUPRAX -cefixime for susp 200 mg/5ml............................ 3 SUPRAX -cefixime for susp 500 mg/5ml............................ 3 SUPREP BOWEL PREP -sodium sulfate-potassium sulfate-magnesium sulfate oral soln.............................. 68 SURMONTIL -trimipramine maleate cap 25 mg............... 81 SURMONTIL -trimipramine maleate cap 50 mg............... 81 SURMONTIL -trimipramine maleate cap 100 mg............. 81 SURVANTA INTRATRACHEAL -beractant in nacl 0.9% intratracheal susp 25 mg/ml........................................... 67 SUSTIVA -efavirenz cap 50 mg........................................ 10 SUSTIVA -efavirenz cap 200 mg...................................... 10 SUSTIVA -efavirenz tab 600 mg....................................... 10 SUTENT -sunitinib malate cap 12.5 mg (base equivalent)....................................................................... 21 SUTENT -sunitinib malate cap 25 mg (base equivalent)....................................................................... 21 SUTENT -sunitinib malate cap 37.5 mg (base equivalent)....................................................................... 21 SUTENT -sunitinib malate cap 50 mg (base equivalent)....................................................................... 21 SYLATRON -peginterferon alfa-2b for inj kit 200 mcg...... 21 SYLATRON -peginterferon alfa-2b for inj kit 300 mcg...... 21 SYLATRON -peginterferon alfa-2b for inj kit 600 mcg...... 21 SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg (0.125 mg ir/0.25 mg cr).................................................70 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act................................................... 66 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act................................................. 66 SYMLINPEN 120 -pramlintide acetate pen-inj 2700 mcg/2.7ml (1000 mcg/ml)............................................... 34 SYMLINPEN 60 -pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ml)............................................... 34 SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg.............................................................103 SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) (base eq)..........................................................41
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
255
2016 SYNERA -lidocaine-tetracaine topical patch 70-70 mg.................................................................................. 178 SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000 mg.................................................................................... 34 SYNJARDY -empagliflozin-metformin hcl tab 12.5-500 mg.................................................................................... 34 SYNJARDY -empagliflozin-metformin hcl tab 5-500 mg.................................................................................... 34 SYNJARDY -empagliflozin-metformin hcl tab 5-1000 mg.................................................................................... 34 SYNTHROID -levothyroxine sodium tab 25 mcg.............. 37 SYNTHROID -levothyroxine sodium tab 50 mcg.............. 37 SYNTHROID -levothyroxine sodium tab 75 mcg.............. 37 SYNTHROID -levothyroxine sodium tab 88 mcg.............. 37 SYNTHROID -levothyroxine sodium tab 100 mcg............ 37 SYNTHROID -levothyroxine sodium tab 112 mcg............ 37 SYNTHROID -levothyroxine sodium tab 125 mcg............ 37 SYNTHROID -levothyroxine sodium tab 137 mcg............ 37 SYNTHROID -levothyroxine sodium tab 150 mcg............ 37 SYNTHROID -levothyroxine sodium tab 175 mcg............ 37 SYNTHROID -levothyroxine sodium tab 200 mcg............ 37 SYNTHROID -levothyroxine sodium tab 300 mcg............ 37 SYPRINE -trientine hcl cap 250 mg................................ 184 T TABLOID -thioguanine tab 40 mg..................................... 21 TACLONEX -calcipotriene-betamethasone dipropionate susp 0.005-0.064%....................................................... 178 tacrolimus cap 0.5 mg (Prograf).................................. 184 tacrolimus cap 1 mg (Prograf)..................................... 184 tacrolimus cap 5 mg (Prograf)..................................... 184 tacrolimus oint 0.03% (Protopic)................................. 178 tacrolimus oint 0.1% (Protopic)................................... 178 TAFINLAR -dabrafenib mesylate cap 50 mg (base equivalent)....................................................................... 21 TAFINLAR -dabrafenib mesylate cap 75 mg (base equivalent)....................................................................... 21 TAGRISSO -osimertinib mesylate tab 40 mg (base equivalent)....................................................................... 21 TAGRISSO -osimertinib mesylate tab 80 mg (base equivalent)....................................................................... 21 TALTZ -ixekizumab subcutaneous soln auto-injector 80 mg/ml............................................................................. 178 TALTZ -ixekizumab subcutaneous soln prefilled syringe 80 mg/ml....................................................................... 178 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)............. 21 tamoxifen citrate tab 20 mg (base equivalent)............. 21 tamsulosin hcl cap 0.4 mg (Flomax)............................. 77 TANDEM F -ferrous fum-iron polysacch-fa cap 162-115.2-1 mg (106 mg fe)........................................ 153 TANZEUM -albiglutide for soln pen-injector 30 mg........... 34 TANZEUM -albiglutide for soln pen-injector 50 mg........... 34 TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 21 TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 21 TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 22 TARGRETIN -bexarotene cap 75 mg................................22 TARGRETIN -bexarotene gel 1%....................................178 TARKA -trandolapril-verapamil hcl tab cr 1-240 mg..........53 TARKA -trandolapril-verapamil hcl tab cr 2-180 mg..........53 TARKA -trandolapril-verapamil hcl tab cr 2-240 mg..........53 TARKA -trandolapril-verapamil hcl tab cr 4-240 mg..........53 TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab pak..................................................................... 125 TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg......................................................... 125 TARON FORTE -fe bisglycinate-fe polysacch-vit c-vit b12fa cap............................................................................ 153 TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 30-1.2-265 mg....................................................... 125 TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 22 TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 22 TASMAR -tolcapone tab 100 mg.....................................117 TAZORAC -tazarotene cream 0.05%.............................. 178 TAZORAC -tazarotene cream 0.1%................................ 178 TAZORAC -tazarotene gel 0.05%................................... 178 TAZORAC -tazarotene gel 0.1%..................................... 178 TBC -trypsin w/ castor oil & peruvian balsam spray....... 178 TECFIDERA -dimethyl fumarate capsule delayed release 120 mg............................................................................ 94 TECFIDERA -dimethyl fumarate capsule delayed release 240 mg............................................................................ 95 TECFIDERA STARTER PACK -dimethyl fumarate capsule dr starter pack 120 mg & 240 mg..................... 95 TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg................................................................. 10 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 TEKTURNA -aliskiren fumarate tab 150 mg (base equivalent)....................................................................... 53
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
256
2016 TEKTURNA -aliskiren fumarate tab 300 mg (base equivalent)....................................................................... 53 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-12.5 mg.................................................................... 53 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-25 mg....................................................................... 53 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-12.5 mg.................................................................... 53 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-25 mg....................................................................... 53 telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 53 telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 53 telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 53 telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 53 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)................................................................. 53 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)................................................................. 53 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)................................................................. 53 telmisartan tab 20 mg (Micardis)................................... 53 telmisartan tab 40 mg (Micardis)................................... 53 telmisartan tab 80 mg (Micardis)................................... 53 temazepam cap 7.5 mg (Restoril).................................. 87 temazepam cap 15 mg (Restoril)................................... 87 temazepam cap 22.5 mg (Restoril)................................ 87 temazepam cap 30 mg (Restoril)................................... 87 temozolomide cap 5 mg (Temodar)............................... 22 temozolomide cap 20 mg (Temodar)............................. 22 temozolomide cap 100 mg (Temodar)........................... 22 temozolomide cap 140 mg (Temodar)........................... 22 temozolomide cap 180 mg (Temodar)........................... 22 temozolomide cap 250 mg (Temodar)........................... 22 TENCON -butalbital-acetaminophen tab 50-325 mg........ 95 TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 16 terazosin hcl cap 1 mg....................................................53 terazosin hcl cap 2 mg....................................................53 terazosin hcl cap 5 mg....................................................53 terazosin hcl cap 10 mg..................................................53 terbinafine hcl tab 250 mg (Lamisil)................................ 6 terbutaline sulfate tab 2.5 mg........................................ 66 terbutaline sulfate tab 5 mg........................................... 66 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%.................. 178 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 25 testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 25 testosterone enanthate im inj in oil 200 mg/ml............ 25
testosterone td gel 12.5 mg/act (1%) (Androgel pump).............................................................................. 25 testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 25 testosterone td gel 50 mg/5gm (1%) (Androgel).......... 25 TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml.............................................. 16 tetrabenazine tab 12.5 mg (Xenazine)........................... 95 tetrabenazine tab 25 mg (Xenazine).............................. 95 tetracaine hcl ophth soln 0.5%.................................... 164 tetracycline hcl cap 250 mg (Tetracycline hcl)............... 5 tetracycline hcl cap 500 mg (Tetracycline hcl)............... 5 TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........4 TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........4 TETRIX -dermatological products misc - cream............. 178 TEXACORT -hydrocortisone soln 2.5%.......................... 178 TEXAVITE LQ -pediatric multivitamins w/fl-fe-zn drops 0.25-7-3 mg/ml.............................................................. 125 THALOMID -thalidomide cap 50 mg............................... 184 THALOMID -thalidomide cap 100 mg............................. 184 THALOMID -thalidomide cap 150 mg............................. 184 THALOMID -thalidomide cap 200 mg............................. 184 theophylline soln 80 mg/15ml........................................ 66 theophylline tab sr 12hr 100 mg.................................... 66 theophylline tab sr 12hr 200 mg.................................... 66 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 THEO-24 -theophylline cap sr 24hr 100 mg..................... 66 THEO-24 -theophylline cap sr 24hr 200 mg..................... 66 THEO-24 -theophylline cap sr 24hr 300 mg..................... 66 THEO-24 -theophylline cap sr 24hr 400 mg..................... 66 THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)...... 167 THICK-IT BEEF LASAGNA PUR -nutritional supplement misc............................................................................... 146 THICK-IT CHICKEN A LA KIN -nutritional supplement misc............................................................................... 146 THICK-IT MAPLE CINNAMON F -nutritional supplement misc............................................................................... 146 THICK-IT MIXED FRUIT AND -nutritional supplement misc............................................................................... 146 THICK-IT SEASONED CHICKEN -nutritional supplement misc............................................................................... 146 THICK-IT SWEET CORN PUREE -nutritional supplement misc............................................................................... 146 THIOLA -tiopronin tab 100 mg.......................................... 77 thioridazine hcl tab 10 mg.............................................. 86 thioridazine hcl tab 25 mg.............................................. 86 thioridazine hcl tab 50 mg.............................................. 86 thioridazine hcl tab 100 mg............................................ 86 thiothixene cap 1 mg....................................................... 86 thiothixene cap 2 mg....................................................... 86
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
257
2016 thiothixene cap 5 mg....................................................... 86 thiothixene cap 10 mg..................................................... 86 THRIVACIN DETOX -nutritional supplement liquid......... 146 THRIVACIN 30 -nutritional supplement liquid................. 146 THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................. 125 THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 125 thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 37 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 38 thyroid tab 60 mg (1 grain) (Armour thyroid)............... 38 THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25 mcg)................................................................................. 38 THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg)................................................................................. 38 THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......38 THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100 mcg)................................................................................. 38 THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150 mcg)................................................................................. 38 tiagabine hcl tab 2 mg (Gabitril).................................. 113 tiagabine hcl tab 4 mg (Gabitril).................................. 113 TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 47 TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 47 TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 47 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe)................................................................ 164 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe)................................................................ 164 timolol maleate ophth soln 0.25% (Timoptic)............. 164 timolol maleate ophth soln 0.5% (Timoptic)............... 164 TIMOLOL MALEATE -timolol maleate tab 5 mg............... 44 TIMOLOL MALEATE -timolol maleate tab 10 mg............. 44 TIMOLOL MALEATE -timolol maleate tab 20 mg............. 44 TIMOPTIC OCUDOSE -timolol maleate preservative free ophth soln 0.25%.......................................................... 164 TIMOPTIC OCUDOSE -timolol maleate preservative free ophth soln 0.5%............................................................ 164 tinidazole tab 250 mg (Tindamax)..................................12 tinidazole tab 500 mg (Tindamax)..................................12 TIROSINT -levothyroxine sodium cap 13 mcg..................38 TIROSINT -levothyroxine sodium cap 25 mcg..................38 TIROSINT -levothyroxine sodium cap 50 mcg..................38 TIROSINT -levothyroxine sodium cap 75 mcg..................38 TIROSINT -levothyroxine sodium cap 88 mcg..................38 TIROSINT -levothyroxine sodium cap 100 mcg................38 TIROSINT -levothyroxine sodium cap 112 mcg................ 38 TIROSINT -levothyroxine sodium cap 125 mcg................38 TIROSINT -levothyroxine sodium cap 137 mcg................38 TIROSINT -levothyroxine sodium cap 150 mcg................38 TIVICAY -dolutegravir sodium tab 10 mg (base equiv)..... 10 TIVICAY -dolutegravir sodium tab 25 mg (base equiv)..... 10
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)..... 10 tizanidine hcl cap 2 mg (base equivalent) (Zanaflex)......................................................................117 tizanidine hcl cap 4 mg (base equivalent) (Zanaflex)......................................................................117 tizanidine hcl cap 6 mg (base equivalent) (Zanaflex)......................................................................117 tizanidine hcl tab 2 mg (base equivalent)................... 117 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)......................................................................118 TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg.................................................................. 126 TL-FLUORIVITE -pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg............................................................ 126 TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab 27-0.5-0.5 mg................................................................ 125 TL G-FOL OS -multiple vit w/ min & calcium-folic acid tab 500-1.1 mg.................................................................... 125 TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg.............................................................126 TOBI PODHALER -tobramycin inhal cap 28 mg.................5 TOBRADEX ST -tobramycin-dexamethasone ophth susp 0.3-0.05%...................................................................... 164 TOBRADEX -tobramycin-dexamethasone ophth oint 0.3-0.1%........................................................................ 164 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex).................................................................... 164 tobramycin nebu soln 300 mg/5ml (Tobi)....................... 5 tobramycin ophth soln 0.3% (Tobrex)......................... 164 TOBREX -tobramycin ophth oint 0.3%........................... 164 TOLAK -fluorouracil cream 4%........................................178 TOLAZAMIDE -tolazamide tab 250 mg.............................34 TOLAZAMIDE -tolazamide tab 500 mg.............................34 TOLBUTAMIDE -tolbutamide tab 500 mg......................... 34 tolcapone tab 100 mg (Tasmar)................................... 117 TOLEREX -nutritional supplement pack......................... 146 TOLMETIN SODIUM -tolmetin sodium cap 400 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 TOPICORT -desoximetasone cream 0.05%................... 178 TOPICORT -desoximetasone oint 0.05%....................... 178 TOPICORT -desoximetasone spray 0.25%.................... 178 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25 mg.................................................................................. 113 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50 mg.................................................................................. 113 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100 mg.................................................................................. 113 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150 mg.................................................................................. 113
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
258
2016 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200 mg.................................................................................. 113 topiramate sprinkle cap 15 mg (Topamax sprinkle)........................................................................113 topiramate sprinkle cap 25 mg (Topamax sprinkle)........................................................................113 topiramate tab 25 mg (Topamax)................................. 113 topiramate tab 50 mg (Topamax)................................. 113 topiramate tab 100 mg (Topamax)............................... 114 topiramate tab 200 mg (Topamax)............................... 114 torsemide tab 5 mg (Demadex)...................................... 55 torsemide tab 10 mg (Demadex).................................... 55 torsemide tab 20 mg (Demadex).................................... 55 torsemide tab 100 mg (Demadex).................................. 55 TOUJEO SOLOSTAR -insulin glargine soln pen-injector 300 unit/ml.......................................................................36 TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg.............75 TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg.............75 TRACLEER -bosentan tab 62.5 mg.................................. 60 TRACLEER -bosentan tab 125 mg................................... 60 TRADJENTA -linagliptin tab 5 mg..................................... 34 tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....................................................................... 103 TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic release 100 mg............................................................. 103 TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic release 150 mg............................................................. 103 TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic release 200 mg............................................................. 103 TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic release 300 mg............................................................. 103 tramadol hcl tab 50 mg (Ultram).................................. 103 tramadol hcl tab sr 24hr biphasic release 100 mg..... 103 tramadol hcl tab sr 24hr biphasic release 200 mg..... 103 tramadol hcl tab sr 24hr biphasic release 300 mg..... 103 tramadol hcl tab sr 24hr 100 mg (Ultram er).............. 103 tramadol hcl tab sr 24hr 200 mg (Ultram er).............. 103 tramadol hcl tab sr 24hr 300 mg (Ultram er).............. 103 trandolapril tab 1 mg (Mavik)......................................... 53 trandolapril tab 2 mg (Mavik)......................................... 53 trandolapril tab 4 mg (Mavik)......................................... 53 trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 53 trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)...... 53 trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)...... 54 trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)...... 54 tranexamic acid tab 650 mg (Lysteda)........................ 155 TRANSDERM-SCOP -scopolamine td patch 72hr 1 mg/3days......................................................................... 71 tranylcypromine sulfate tab 10 mg (Parnate)............... 81 TRAVATAN Z -travoprost ophth soln 0.004% (benzalkonium free) (bak free)..................................... 164 trazodone hcl tab 50 mg................................................. 81
trazodone hcl tab 100 mg............................................... 81 trazodone hcl tab 150 mg............................................... 81 trazodone hcl tab 300 mg............................................... 81 TRECATOR -ethionamide tab 250 mg................................ 6 TRESIBA FLEXTOUCH -insulin degludec soln peninjector 100 unit/ml......................................................... 36 TRESIBA FLEXTOUCH -insulin degludec soln peninjector 200 unit/ml......................................................... 36 tretinoin cap 10 mg......................................................... 22 tretinoin cream 0.025% (Retin-a)................................. 178 tretinoin cream 0.05% (Retin-a)................................... 178 tretinoin cream 0.1% (Retin-a)..................................... 178 tretinoin gel 0.05% (Atralin).......................................... 178 tretinoin gel 0.01% (Retin-a)......................................... 178 tretinoin gel 0.025% (Retin-a)....................................... 178 tretinoin microsphere gel 0.04% (Retin-a micro)....... 178 tretinoin microsphere gel 0.1% (Retin-a micro pump)............................................................................ 178 TRETTEN -coagulation factor xiii a-subunit for inj 2000-3125 unit.............................................................. 160 TREXALL -methotrexate sodium tab 5 mg (base equiv)............................................................................... 22 TREXALL -methotrexate sodium tab 7.5 mg (base equiv)............................................................................... 22 TREXALL -methotrexate sodium tab 10 mg (base equiv)............................................................................... 22 TREXALL -methotrexate sodium tab 15 mg (base equiv)............................................................................... 22 TREZIX -acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg.............................................................103 TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg......................................................................... 126 triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog)...................................................................... 178 triamcinolone acetonide cream 0.025%...................... 178 triamcinolone acetonide cream 0.1%.......................... 178 triamcinolone acetonide cream 0.5%.......................... 178 triamcinolone acetonide dental paste 0.1%............... 167 triamcinolone acetonide lotion 0.025%....................... 178 triamcinolone acetonide lotion 0.1%........................... 178 triamcinolone acetonide oint 0.025%.......................... 178 triamcinolone acetonide oint 0.1%.............................. 179 triamcinolone acetonide oint 0.5%.............................. 179 TRIAMINO -amino acids tab........................................... 131 TRIAMTERENE/HYDROCHLOROTH -triamterene & hydrochlorothiazide cap 50-25 mg................................. 55 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide).........................................................................55 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)................................................................... 55 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)........................................................................ 55
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
259
2016 TRIANEX -triamcinolone acetonide oint 0.05%.............. 179 triazolam tab 0.25 mg (Halcion)..................................... 87 TRIAZOLAM -triazolam tab 0.125 mg............................... 87 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg............................................................ 54 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg............................................................ 54 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg............................................................... 54 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg.......................................................... 54 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg............................................................. 54 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 -prenat w/o a w/fepyro-mfol chw 4.5-1 mg & dha cap 150 thpk...................................... 126 TRICARE PRENATAL -prenat w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg........................................... 126 TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 126 TRI-CHLOR -trichloroacetic acid liqd 80%......................178 trifluoperazine hcl tab 1 mg........................................... 86 trifluoperazine hcl tab 2 mg........................................... 86 trifluoperazine hcl tab 5 mg........................................... 86 trifluoperazine hcl tab 10 mg......................................... 86 trifluridine ophth soln 1% (Viroptic)............................ 164 TRIGLIDE -fenofibrate tab 160 mg................................... 58 trihexyphenidyl hcl elixir 0.4 mg/ml............................ 117 trihexyphenidyl hcl tab 2 mg........................................117 trihexyphenidyl hcl tab 5 mg........................................117 trimethobenzamide hcl cap 300 mg (Tigan)................. 71 trimethoprim tab 100 mg................................................ 12 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 TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg..... 126 TRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)....... 82 TRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)..... 82 TRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)..... 82 TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap 31-0.6-0.4-200 mg........................................................ 126 TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack....................................................... 126 TRIUMEQ -abacavir-dolutegravir-lamivudine tab 600-50-300 mg................................................................10 TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk................................................. 126
TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................ 126 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 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 TROKENDI XR -topiramate cap sr 24hr 25 mg.............. 114 TROKENDI XR -topiramate cap sr 24hr 50 mg.............. 114 TROKENDI XR -topiramate cap sr 24hr 100 mg............ 114 TROKENDI XR -topiramate cap sr 24hr 200 mg............ 114 tropicamide ophth soln 0.5%....................................... 164 tropicamide ophth soln 1% (Mydriacyl)...................... 164 trospium chloride cap sr 24hr 60 mg............................ 75 trospium chloride tab 20 mg.......................................... 75 TRULICITY -dulaglutide soln pen-injector 0.75 mg/0.5ml.......................................................................... 34 TRULICITY -dulaglutide soln pen-injector 1.5 mg/0.5ml.......................................................................... 34 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg..................................................................... 10 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg..................................................................... 10 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 167-250 mg..................................................................... 10 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg..................................................................... 10 TUDORZA PRESSAIR -aclidinium bromide aerosol powd breath activated 400 mcg/act......................................... 67 TUSNEL -brompheniramine w/ dm-gg cap 2-15-200 mg.................................................................................... 63 TUSNEL C -pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml............................................................................. 63 TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr 5-4 mg............................................................................. 63 TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr 10-8 mg........................................................................... 63 TUZISTRA XR -codeine polist-chlorphen polist er susp 14.7-2.8 mg/5ml.............................................................. 63 TWOCAL HN -nutritional supplement liquid....................146 TYBOST -cobicistat tab 150 mg....................................... 11 TYKERB -lapatinib ditosylate tab 250 mg (base equiv)............................................................................... 22 TYLACTIN RESTORE 10 -nutritional supplement liquid.............................................................................. 146 TYLACTIN RESTORE 5PE -nutritional supplement pack............................................................................... 146
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
260
2016 TYLACTIN RTD 15 -nutritional supplement liquid.......... 146 TYR ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 146 TYR ANAMIX NEXT -nutritional supplement powder..... 146 TYR COOLER -nutritional supplement liquid.................. 146 TYR COOLER20 -nutritional supplement liquid.............. 146 TYREX-1 -nutritional supplement powder....................... 147 TYREX-2 -nutritional supplement powder....................... 147 TYR EXPRESS -nutritional supplement pack................. 147 TYR EXPRESS20 -nutritional supplement pack............. 147 TYR GEL -nutritional supplement pack........................... 147 TYR LOPHLEX LQ -nutritional supplement liquid...........147 TYROS 1 -nutritional supplement powder...................... 147 TYROS 2 -nutritional supplement powder...................... 147 TYVASO REFILL -treprostinil inhalation solution 0.6 mg/ ml..................................................................................... 60 TYVASO STARTER -treprostinil inhalation solution 0.6 mg/ml............................................................................... 60 TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 60 TYZEKA -telbivudine tab 600 mg...................................... 11 TYZINE PEDIATRIC NASAL DR -tetrahydrozoline hcl nasal soln 0.05%............................................................ 61 U UCD ANAMIX JUNIOR -nutritional supplement powder........................................................................... 147 UCD 2 -nutritional supplement powder........................... 147 UCD TRIO -nutritional supplement powder.................... 147 UCERIS -budesonide rectal foam 2 mg/act.................... 168 UCERIS -budesonide tab sr 24hr 9 mg............................ 24 UDAMIN SP -multiple vitamins w/ minerals & fa tab 1 mg.................................................................................. 126 ULESFIA -benzyl alcohol lotion 5%................................ 179 ULORIC -febuxostat tab 40 mg....................................... 108 ULORIC -febuxostat tab 80 mg....................................... 108 ULTIMATECARE ONE NF -prenatal w/fe cbnyl-fe asp glyc-fa-dss-omega cap 20-7-1 mg............................... 126 ULTIMATECARE ONE -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 126 ULTRACAL HN PLUS -nutritional supplement liquid...... 147 ULTRACAL -nutritional supplement liquid....................... 147 ULTRAMINO SOY PROTEIN -nutritional supplement powder........................................................................... 147 ULTRASAL-ER -salicylic acid er film-forming soln 28.5%.............................................................................179 ULTRAVATE -halobetasol propionate lotion 0.05%........ 179 UMECTA -urea emulsion 40%........................................ 179 UPTRAVI -selexipag tab 200 mcg.....................................60 UPTRAVI -selexipag tab 400 mcg.....................................60 UPTRAVI -selexipag tab 600 mcg.....................................60 UPTRAVI -selexipag tab 800 mcg.....................................60 UPTRAVI -selexipag tab 1000 mcg...................................60
UPTRAVI -selexipag tab 1200 mcg...................................60 UPTRAVI -selexipag tab 1400 mcg...................................60 UPTRAVI -selexipag tab 1600 mcg...................................60 UPTRAVI -selexipag tab therapy pack 200 mcg (140) & 800 mcg (60)...................................................................60 URAMAXIN -urea in ammonium lactate vehicle foam 20%................................................................................179 urea cream 40%............................................................. 179 urea cream 50%............................................................. 179 urea cream 39% (Aluvea).............................................. 179 urea cream 47% (Keralac).............................................179 urea cream 45% (Uramaxin)......................................... 179 urea foam 40% (Hydro 40 foam).................................. 179 urea gel 40%................................................................... 179 urea gel 45% (Uramaxin)...............................................179 urea in lactic acid-salicylic acid vehicle susp 50%................................................................................179 urea in lactic acid vehicle foam 35% (Hydro 35)........ 179 urea in zinc undecylenate-lactic acid vehicle emulsion 50%................................................................................179 urea lotion 40%.............................................................. 179 urea lotion 45% (Uramaxin).......................................... 179 UREA NAIL -urea in zinc undecylenate-lactic acid vehicle stick 50%....................................................................... 179 urea suspension 40% (Umecta)................................... 179 UREVAZ -urea cream 44%............................................. 179 URIMAR-T -methenamine-hyosc-meth blue-sod phosphen sal tab 120 mg...................................................... 74 URINE TEST STRIPS-VARIOUS.................................... 181 ursodiol cap 300 mg (Actigall)....................................... 74 ursodiol tab 250 mg (Urso 250)..................................... 74 ursodiol tab 500 mg (Urso forte)................................... 74 UTOPIC -urea cream 41%.............................................. 179 UTYMAX -nutritional supplement pack........................... 147 V VAGIFEM -estradiol vaginal tab 10 mcg........................... 76 valacyclovir hcl tab 1 gm (Valtrex)................................ 11 valacyclovir hcl tab 500 mg (Valtrex)............................ 11 VALCHLOR -mechlorethamine hcl gel 0.016% (base equivalent)..................................................................... 179 VALCYTE -valganciclovir hcl for soln 50 mg/ml (base equiv)............................................................................... 11 valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte).......................................................................... 11 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte).......................................................................... 11 valproate sodium syrup 250 mg/5ml (base equiv) (Depakene)................................................................... 114 valproic acid cap 250 mg (Depakene)......................... 114 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct).................................................................................. 54
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
261
2016 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct)................................................................... 54 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct).................................................................................. 54 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct)................................................................... 54 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct).................................................................................. 54 valsartan tab 40 mg (Diovan)......................................... 54 valsartan tab 80 mg (Diovan)......................................... 54 valsartan tab 160 mg (Diovan)....................................... 54 valsartan tab 320 mg (Diovan)....................................... 54 VANACOF CD -phenylephrine-dexchlorphenir-codeine liquid 5-1-10 mg/5ml....................................................... 63 VANATOL LQ -butalbital-acetaminophen-caffeine soln 50-325-40 mg/15ml......................................................... 95 vancomycin hcl cap 125 mg (Vancocin hcl)................. 12 vancomycin hcl cap 250 mg (Vancocin hcl)................. 12 VARUBI -rolapitant hcl tab 90 mg (base equiv)................ 71 VASCEPA -icosapent ethyl cap 0.5 gm............................ 58 VASCEPA -icosapent ethyl cap 1 gm............................... 58 VECAMYL -mecamylamine hcl tab 2.5 mg....................... 54 VECTICAL -calcitriol oint 3 mcg/gm................................ 179 VELPHORO -sucroferric oxyhydroxide chew tab 500 mg.................................................................................... 74 VELTASSA -patiromer sorbitex calcium for susp packet 8.4 gm (base eq).......................................................... 184 VELTASSA -patiromer sorbitex calcium for susp packet 16.8 gm (base eq)........................................................ 184 VELTASSA -patiromer sorbitex calcium for susp packet 25.2 gm (base eq)........................................................ 184 VEMAVITE-PRX 2 -prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg.............................................. 126 VENA-BAL DHA -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg................................................... 126 VENCLEXTA STARTING PACK -venetoclax tab therapy starter pack 10 & 50 & 100 mg...................................... 22 VENCLEXTA -venetoclax tab 10 mg.................................22 VENCLEXTA -venetoclax tab 50 mg.................................22 VENCLEXTA -venetoclax tab 100 mg...............................22 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr)..................................................................... 82 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr)..................................................................... 82 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr)..................................................................... 82 VENLAFAXINE HCL ER -venlafaxine hcl tab sr 24hr 225 mg (base equivalent)...................................................... 82 venlafaxine hcl tab 25 mg...............................................82 venlafaxine hcl tab 37.5 mg............................................82 venlafaxine hcl tab 50 mg...............................................82 venlafaxine hcl tab 75 mg...............................................82
venlafaxine hcl tab 100 mg.............................................82 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)....................................................... 82 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er)....................................................... 82 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er)....................................................... 82 VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 60 VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 60 VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)........................................................ 67 VERAMYST -fluticasone furoate nasal susp 27.5 mcg/ spray................................................................................ 61 verapamil hcl cap sr 24hr 120 mg (Verelan)................. 46 verapamil hcl cap sr 24hr 180 mg (Verelan)................. 46 verapamil hcl cap sr 24hr 240 mg (Verelan)................. 46 verapamil hcl cap sr 24hr 360 mg (Verelan)................. 46 verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 46 verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 46 verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 46 verapamil hcl tab cr 120 mg (Calan sr)......................... 46 verapamil hcl tab cr 180 mg (Calan sr)......................... 46 verapamil hcl tab cr 240 mg (Calan sr)......................... 46 verapamil hcl tab 40 mg................................................. 46 verapamil hcl tab 80 mg (Calan).................................... 46 verapamil hcl tab 120 mg (Calan).................................. 46 VERDESO -desonide foam 0.05%.................................. 179 VEREGEN -sinecatechins oint 15%................................179 VERIPRED 20 -prednisolone sod phosphate oral soln 20 mg/5ml (base equiv)....................................................... 24 VERSACLOZ -clozapine susp 50 mg/ml.......................... 86 VESICARE -solifenacin succinate tab 5 mg..................... 75 VESICARE -solifenacin succinate tab 10 mg................... 75 VHC 2.25 -nutritional supplement liquid.......................... 147 VIBERZI -eluxadoline tab 75 mg....................................... 74 VIBERZI -eluxadoline tab 100 mg..................................... 74 VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/ ml).................................................................................... 34 VIDEX -didanosine for soln 2 gm...................................... 11 VIDEX -didanosine for soln 4 gm...................................... 11 VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak 12.5-75-50 & 250 mg..................................................... 11 VIEKIRA XR -dasab-ombit-paritap-riton tab sr 24hr 200-8.33-50-33.33 mg.................................................... 11 VIGAMOX -moxifloxacin hcl ophth soln 0.5% (base equiv)............................................................................. 164 VIIBRYD STARTER PACK -vilazodone hcl tab starter kit 10 (7) & 20 (23) mg....................................................... 82 VIIBRYD -vilazodone hcl tab 10 mg..................................82 VIIBRYD -vilazodone hcl tab 20 mg..................................82 VIIBRYD -vilazodone hcl tab 40 mg..................................82 VILACTIN AA PLUS -nutritional supplement liquid......... 147
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
262
2016 VIMPAT -lacosamide oral solution 10 mg/ml.................. 114 VIMPAT -lacosamide tab 50 mg...................................... 114 VIMPAT -lacosamide tab 100 mg.................................... 114 VIMPAT -lacosamide tab 150 mg.................................... 114 VIMPAT -lacosamide tab 200 mg.................................... 114 VINATE DHA RF -prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg............................................................. 127 VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg......................................................................... 127 VINATE M -prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg.................................................................................. 127 VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1 mg.................................................................................. 127 VIOKACE -pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit................................................ 71 VIOKACE -pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit................................................ 72 VIRACEPT -nelfinavir mesylate tab 250 mg..................... 11 VIRACEPT -nelfinavir mesylate tab 625 mg..................... 11 VIRAMUNE -nevirapine susp 50 mg/5ml.......................... 11 VIRAMUNE XR -nevirapine tab sr 24hr 100 mg............... 11 VIRAZOLE -ribavirin for inhal soln 6 gm........................... 11 VIREAD -tenofovir disoproxil fumarate oral powder 40 mg/gm.............................................................................. 11 VIREAD -tenofovir disoproxil fumarate tab 150 mg.......... 11 VIREAD -tenofovir disoproxil fumarate tab 200 mg.......... 11 VIREAD -tenofovir disoproxil fumarate tab 250 mg.......... 11 VIREAD -tenofovir disoproxil fumarate tab 300 mg.......... 11 VIRT-ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg......................................................................... 127 VIRT-CARE ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg................................................... 127 VIRT-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg................................................................. 127 VIRT-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................. 127 VIRT NATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg.................................................................................. 127 VIRT-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg........................................................ 127 VIRT-PN PLUS -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 127 VIRT-PN -prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg................................................................ 127 VIRTPREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg...............................................................127 VIRT-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg..................................................... 127 VIRT-VITE GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg......................................................................... 127 VISTOGARD -uridine triacetate oral granules packet 10 gm.................................................................................. 180
VITAFOL FE+ -prenat-fepoly-methol-fa-dha cap 90-1-200 mg & dss 50mg cap..................................................... 127 VITAFOL GUMMIES -prenat vit w/ fe phos-fa-omega chew tab 3.33-0.333-34.8 mg...................................... 127 VITAFOL-NANO -prenatal w/o a w/ fefum-l methylfol-fa tab 18-0.6-0.4 mg......................................................... 127 VITAFOL-OB+DHA -prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack............................................... 127 VITAFOL-OB -prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................. 127 VITAFOL-ONE -prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg.......................................................... 127 VITAFOL ULTRA -prenat w/fe poly-methylfol-fa-dha cap 29-0.6-0.4-200 mg........................................................ 127 VITAJOULE -nutritional supplement powder...................147 VITAL AF 1.2 CAL -nutritional supplement liquid............ 147 VITAL 1.0 CAL -nutritional supplement liquid................. 147 VITAL 1.5 CAL -nutritional supplement liquid................. 147 VITAL-D RX -b-complex w/ c-biotin-d-zinc & folic acid tab 1 mg.............................................................................. 127 VITAL HIGH PROTEIN -nutritional supplement liquid.............................................................................. 147 VITAL HN -nutritional supplement pack.......................... 147 VITAL JR -nutritional supplement liquid.......................... 147 VITAMEDMD ONE RX/QUATREFO -prenat w/o a w/ fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.............. 127 VITAMEDMD PLUS RX/QUATRE -prenat w/o a w/ fe chelate-l methylfol-fa tab & dha cap pk....................... 127 VITAMEDMD REDICHEW RX -prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg........................................... 127 VITAMELTS VITAMIN D -cholecalciferol orally disintegrating tab 1000 unit.......................................... 118 VITAMIN D3 -cholecalciferol oral liquid 1200 unit/15ml........................................................................ 118 VITAMIN D3 -cholecalciferol spray 1000 unit/spray........118 VITAMIN D2 -ergocalciferol tab 400 unit.........................118 VITAPEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg...............................................................128 VITA-PREN -prenatal vit w/ docusate-iron-fa tab 65-1 mg.................................................................................. 127 VITAPRO -nutritional supplement powder...................... 147 VITAQUICK -nutritional supplement powder................... 147 VITATRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg & dha cap 300mg pk............................................................... 128 VITEKTA -elvitegravir tab 85 mg....................................... 11 VITEKTA -elvitegravir tab 150 mg..................................... 11 VITUZ -hydrocodone-chlorpheniramine soln 5-4 mg/5ml............................................................................. 63 VIVA DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................. 128 VIVONEX PEDIATRIC -nutritional supplement pack...... 147 VIVONEX PLUS -nutritional supplement powder........... 147
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
263
2016 VIVONEX RTF -nutritional supplement liquid................. 147 VIVONEX T.E.N. -nutritional supplement pack............... 147 VIVOTIF -typhoid vaccine cap delayed release................ 16 VOL-NATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg.................................................................................. 128 VOL-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 128 VOL-TAB RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 128 VOLTAREN -diclofenac sodium gel 1%.......................... 179 voriconazole for susp 40 mg/ml (Vfend)......................... 6 voriconazole tab 50 mg (Vfend)....................................... 6 voriconazole tab 200 mg (Vfend)..................................... 6 VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 22 VP-CH PLUS -prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg.................................................................. 128 VP-CH-PNV -prenatal w/o vit a w/ fe cbn-dss-fa-dha cap 30-1-260 mg.................................................................. 128 VP-GGR-B6 PRENATAL -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 128 VP-HEME OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................ 128 VP-HEME OB -prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg............................................................... 128 VP-HEME ONE -prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg................................................ 128 VP-PNV-DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-215.8 mg...............................................................128 VRAYLAR -cariprazine hcl cap 1.5 mg (base equivalent)....................................................................... 86 VRAYLAR -cariprazine hcl cap 3 mg (base equivalent)....................................................................... 86 VRAYLAR -cariprazine hcl cap 4.5 mg (base equivalent)....................................................................... 86 VRAYLAR -cariprazine hcl cap 6 mg (base equivalent)....................................................................... 86 VRAYLAR -cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg (6).......................................................................... 86 VUSION -miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35%............................................................. 179 VYTONE -iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9%................................................................ 179 VYTORIN -ezetimibe-simvastatin tab 10-10 mg............... 58 VYTORIN -ezetimibe-simvastatin tab 10-20 mg............... 58 VYTORIN -ezetimibe-simvastatin tab 10-40 mg............... 58 VYTORIN -ezetimibe-simvastatin tab 10-80 mg............... 58 VYVANSE -lisdexamfetamine dimesylate cap 10 mg....... 90 VYVANSE -lisdexamfetamine dimesylate cap 20 mg....... 90 VYVANSE -lisdexamfetamine dimesylate cap 30 mg....... 90 VYVANSE -lisdexamfetamine dimesylate cap 40 mg....... 90 VYVANSE -lisdexamfetamine dimesylate cap 50 mg....... 90 VYVANSE -lisdexamfetamine dimesylate cap 60 mg....... 90
VYVANSE -lisdexamfetamine dimesylate cap 70 mg....... 90 W WALGREENS GLUCOSE -glucose chew tab 4 gm......... 34 WALGREENS GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm...................................................................... 34 warfarin sodium tab 1 mg (Coumadin)....................... 154 warfarin sodium tab 2 mg (Coumadin)....................... 154 warfarin sodium tab 2.5 mg (Coumadin).................... 154 warfarin sodium tab 3 mg (Coumadin)....................... 154 warfarin sodium tab 4 mg (Coumadin)....................... 154 warfarin sodium tab 5 mg (Coumadin)....................... 154 warfarin sodium tab 6 mg (Coumadin)....................... 154 warfarin sodium tab 7.5 mg (Coumadin).................... 154 warfarin sodium tab 10 mg (Coumadin)..................... 154 WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 58 WELCHOL -colesevelam hcl tab 625 mg......................... 58 WELLESSE VITAMIN D3 -cholecalciferol oral liquid 1000 unit/10ml........................................................................ 118 WELLNESS ESSENTIALS AI -nutritional supplement kit................................................................................... 147 WELLNESS ESSENTIALS BLOOD -nutritional supplement kit............................................................... 147 WELLNESS ESSENTIALS FOR J -nutritional supplement kit................................................................................... 147 WELLNESS ESSENTIALS FOR M -nutritional supplement kit............................................................... 147 WELLNESS ESSENTIALS FOR P -nutritional supplement kit................................................................................... 148 WELLNESS ESSENTIALS FOR W -nutritional supplement kit............................................................... 148 WELLNESS ESSENTIALS -nutritional supplement kit................................................................................... 147 WESTHROID -thyroid tab 32.5 mg................................... 38 WESTHROID -thyroid tab 65 mg...................................... 38 WESTHROID -thyroid tab 97.5 mg................................... 38 WESTHROID -thyroid tab 130 mg.................................... 38 WESTHROID -thyroid tab 195 mg.................................... 38 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60 mm................................................................................. 182 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65 mm................................................................................. 182 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 70 mm................................................................................. 182 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 75 mm................................................................................. 182 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 80 mm................................................................................. 182 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 85 mm................................................................................. 182 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 90 mm................................................................................. 182
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
264
2016 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 95 mm................................................................................. 182 WILATE -antihemophilic factor/vwf (human) for inj 500-500 unit kit............................................................. 160 WILATE -antihemophilic factor/vwf (human) for inj 1000-1000 unit kit......................................................... 160 WND 1 -nutritional supplement powder.......................... 148 WND 2 -nutritional supplement powder.......................... 148 WP THYROID -thyroid tab 16.25 mg................................ 38 WP THYROID -thyroid tab 32.5 mg.................................. 38 WP THYROID -thyroid tab 65 mg..................................... 38 WP THYROID -thyroid tab 81.25 mg................................ 38 WP THYROID -thyroid tab 97.5 mg.................................. 38 WP THYROID -thyroid tab 113.75 mg.............................. 38 WP THYROID -thyroid tab 130 mg................................... 38 WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 38 X XALKORI -crizotinib cap 200 mg...................................... 22 XALKORI -crizotinib cap 250 mg...................................... 22 XAQUIL XR -levomefolate glucosamine tab cr 30 mg.................................................................................. 148 XARELTO -rivaroxaban tab 10 mg..................................154 XARELTO -rivaroxaban tab 15 mg..................................154 XARELTO -rivaroxaban tab 20 mg..................................154 XARELTO STARTER PACK -rivaroxaban tab starter therapy pack 15 mg & 20 mg.......................................154 XARTEMIS XR -oxycodone w/ acetaminophen tab cr 7.5-325 mg.................................................................... 103 XELJANZ -tofacitinib citrate tab 5 mg (base equivalent)..................................................................... 107 XELJANZ XR -tofacitinib citrate tab sr 24hr 11 mg (base equivalent)..................................................................... 107 XENAZINE -tetrabenazine tab 12.5 mg............................ 95 XENAZINE -tetrabenazine tab 25 mg............................... 95 XERESE -acyclovir-hydrocortisone cream 5-1%............ 179 XEROFORM NON-OCCLUSIVE OI -bismuth tribromophenate-petrolatum dressing pads................. 179 XEROFORM OCCLUSIVE PETROL -bismuth tribromophenate-petrolatum dressing - misc............... 179 XEROFORM OCCLUSIVE PETROL -bismuth tribromophenate-petrolatum dressing pads................. 179 XEROFORM PETROLATUM DRESS -bismuth tribromophenate-petrolatum dressing - misc............... 179 XEROFORM PETROLATUM DRESS -bismuth tribromophenate-petrolatum dressing pads................. 180 XIFAXAN -rifaximin tab 200 mg........................................ 13 XIFAXAN -rifaximin tab 550 mg........................................ 13 XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr 5-500 mg......................................................................... 34 XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr 5-1000 mg....................................................................... 34
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr 10-500 mg....................................................................... 34 XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr 10-1000 mg..................................................................... 35 XIIDRA -lifitegrast ophth soln 5%.................................... 164 XLEU MAXAMAID -nutritional supplement powder........ 148 XLEU MAXAMUM -nutritional supplement powder.........148 XLYS-XTRP MAXAMAID -nutritional supplement powder........................................................................... 148 XLYS-XTRP MAXAMUM -nutritional supplement powder........................................................................... 148 XMET MAXAMAID -nutritional supplement powder........148 XMET MAXAMUM -nutritional supplement powder........ 148 XMTVI MAXAMAID -nutritional supplement powder.......148 XMTVI MAXAMUM -nutritional supplement powder....... 148 XOLEGEL -ketoconazole gel 2%.................................... 180 XOPENEX HFA -levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)...................................................... 67 XPHE MAXAMAID -nutritional supplement powder........ 148 XPHE MAXAMUM -amino acids oral powder................. 131 XPHE MAXAMUM -amino acids pack............................ 131 XPHE-XTYR MAXAMAID -nutritional supplement powder........................................................................... 148 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9 mg.................................................................................. 103 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 13.5 mg......................................................................... 103 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 18 mg............................................................................ 103 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 27 mg............................................................................ 103 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 36 mg............................................................................ 103 XTANDI -enzalutamide cap 40 mg.................................... 22 XTRACAL PLUS -nutritional supplement liquid.............. 148 XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr.......................................................................... 29 XURIDEN -uridine triacetate oral granules packet 2 gm.................................................................................... 41 XYNTHA -antihemophilic factor recombinant paf for inj kit 250 unit......................................................................... 160 XYNTHA -antihemophilic factor recombinant paf for inj kit 500 unit......................................................................... 160 XYNTHA -antihemophilic factor recombinant paf for inj kit 1000 unit....................................................................... 160 XYNTHA -antihemophilic factor recombinant paf for inj kit 2000 unit....................................................................... 160 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 250 unit................................................... 160 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 500 unit................................................... 160
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
265
2016 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 1000 unit................................................. 160 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 2000 unit................................................. 160 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 3000 unit................................................. 160 XYREM -sodium oxybate oral solution 500 mg/ml........... 95 XYZBAC -dietary management product - tabs................148 Y Z ZACLIR CLEANSING -benzoyl peroxide lotion 8%........ 180 zafirlukast tab 10 mg (Accolate).................................... 67 zafirlukast tab 20 mg (Accolate).................................... 67 zaleplon cap 5 mg (Sonata)............................................ 87 zaleplon cap 10 mg (Sonata).......................................... 87 ZAMICET -hydrocodone-acetaminophen soln 10-325 mg/15ml......................................................................... 103 ZARONTIN -ethosuximide cap 250 mg.......................... 114 ZARONTIN -ethosuximide soln 250 mg/5ml................... 114 ZARXIO -filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml...................................................................... 153 ZARXIO -filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml...................................................................... 153 ZATEAN-CH -prenatal w/o a w/fe cbn-dss-fa-dha cap 27-1-250 mg.................................................................. 128 ZATEAN-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg................................................. 128 ZATEAN-PN PLUS -prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................ 128 ZAVARA -folic acid-cholecalciferol cap 1 mg-5750 unit................................................................................. 153 ZAVESCA -miglustat cap 100 mg................................... 153 ZELAPAR -selegiline hcl orally disintegrating tab 1.25 mg.................................................................................. 117 ZELBORAF -vemurafenib tab 240 mg.............................. 22 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit...................................................72 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit...................................................72 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit................................................ 72 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit................................................ 72 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit.............................................. 72 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit.............................................. 72 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit............................................ 72 ZEPATIER -elbasvir-grazoprevir tab 50-100 mg............... 11 ZETIA -ezetimibe tab 10 mg............................................. 59
ZETONNA -ciclesonide nasal aerosol soln 37 mcg/act (50 mcg/valve)....................................................................... 61 ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)..... 11 zidovudine cap 100 mg (Retrovir)................................. 11 zidovudine syrup 10 mg/ml (Retrovir)........................... 11 zidovudine tab 300 mg.................................................... 11 ZINBRYTA -daclizumab soln prefilled syringe 150 mg/ ml..................................................................................... 95 ZIOPTAN -tafluprost ophth soln 0.0015%....................... 164 ziprasidone hcl cap 20 mg (Geodon)............................ 86 ziprasidone hcl cap 40 mg (Geodon)............................ 86 ziprasidone hcl cap 60 mg (Geodon)............................ 86 ziprasidone hcl cap 80 mg (Geodon)............................ 86 ZIRGAN -ganciclovir ophth gel 0.15%............................ 165 ZITHRANOL -anthralin shampoo 1%.............................. 180 ZITHRANOL-RR -anthralin cream 1.2%......................... 180 ZITHROMAX -azithromycin powd pack for susp 1 gm....... 4 ZMAX -azithromycin extended release for oral susp 2 gm...................................................................................... 4 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 10 mg................................................. 103 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 15 mg................................................. 103 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 20 mg................................................. 103 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 30 mg................................................. 104 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 40 mg................................................. 104 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 50 mg................................................. 104 ZOLATE -folic acid-cholecalciferol cap 1 mg-3775 unit................................................................................. 153 ZOLINZA -vorinostat cap 100 mg..................................... 22 zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt)............................................................................... 108 zolmitriptan orally disintegrating tab 5 mg (Zomig zmt)............................................................................... 108 zolmitriptan tab 2.5 mg (Zomig)................................... 108 zolmitriptan tab 5 mg (Zomig)...................................... 108 zolpidem tartrate sl tab 1.75 mg (Intermezzo).............. 87 zolpidem tartrate sl tab 3.5 mg (Intermezzo)................ 87 zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 87 zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 87 zolpidem tartrate tab 5 mg (Ambien).............................87 zolpidem tartrate tab 10 mg (Ambien)...........................87 ZOMIG NASAL SPRAY -zolmitriptan nasal spray 5 mg/ spray unit.......................................................................108 ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit........108 ZONALON -doxepin hcl cream 5%................................. 180 zonisamide cap 50 mg.................................................. 114 zonisamide cap 25 mg (Zonegran).............................. 114
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
266
2016 zonisamide cap 100 mg (Zonegran)............................ 114 ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base equivalent)..................................................................... 160 ZORTRESS -everolimus tab 0.25 mg............................. 184 ZORTRESS -everolimus tab 0.5 mg............................... 184 ZORTRESS -everolimus tab 0.75 mg............................. 184 ZOSTAVAX -zoster vaccine live for inj 19400 unit/0.65ml....................................................................... 16 ZOVIA 1/50E -ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg................................................................... 29 ZOVIRAX -acyclovir cream 5%....................................... 180 Z-TUSS AC -chlorpheniramine w/ codeine liquid 2-9 mg/5ml............................................................................. 63 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 1.4-0.36 mg (base eq).................................................. 104 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 2.9-0.71 mg (base eq).................................................. 104 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4 mg (base eq)................................................................ 104 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 8.6-2.1 mg (base eq)................................................................ 104 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 11.4-2.9 mg (base eq)................................................................ 104 ZUPLENZ -ondansetron oral soluble film 4 mg................ 71 ZUPLENZ -ondansetron oral soluble film 8 mg................ 71 ZYBAN -bupropion hcl (smoking deterrent) tab sr 12hr 150 mg............................................................................ 95 ZYCLARA -imiquimod cream 3.75%............................... 180 ZYCLARA PUMP -imiquimod cream 2.5%..................... 180 ZYCLARA PUMP -imiquimod cream 3.75%................... 180 ZYDELIG -idelalisib tab 100 mg........................................ 22 ZYDELIG -idelalisib tab 150 mg........................................ 22 ZYFLO CR -zileuton tab sr 12hr 600 mg.......................... 67 ZYFLO -zileuton tab 600 mg............................................. 67 ZYKADIA -ceritinib cap 150 mg........................................ 22 ZYLET -loteprednol etabonate-tobramycin ophth susp 0.5-0.3%........................................................................ 165 ZYTAZE -zinc citrate-phytase cap 25-500 mg................ 148 ZYTIGA -abiraterone acetate tab 250 mg......................... 22 ZYVOX -linezolid for susp 100 mg/5ml............................. 13 ZYVOX -linezolid tab 600 mg............................................ 13
Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List January (2016 Plan Year)
267
