generic drug list - Blue Cross and Blue Shield of Texas
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Health Insurance Marketplace Generics Plus Drug List October 2015 Contents Introduction .................................................................... I Therapeutic Class Drug List ........................................ 1 How drugs are selected ................................................... I Anti-Infective Agents ....................................................... 1 How member payment is determined .............................. I Biologicals ..................................................................... 12 How to use this list .......................................................... II Antineoplastic Agents ................................................... 16 Drugs used to treat multiple conditions .......................... II Endocrine and Metabolic Drugs ................................... 19 Generic drugs ................................................................. II Cardiovascular Agents .................................................. 39 Consider talking to your doctor about generic Respiratory Agents ....................................................... 58 drugs ........................................................................... II Gastrointestinal Agents ................................................. 65 Coverage considerations ............................................... III Genitourinary Agents .................................................... 72 Specialty drugs .............................................................. IV Central Nervous System Drugs .................................... 75 Prime Therapeutics Specialty Pharmacy Analgesics and Anesthetics .......................................... 93 program...................................................................... IV Neuromuscular Drugs ................................................. 106 Abbreviation key ............................................................. V Nutritional Products .................................................... 115 Hematological Agents ................................................. 128 Topical Products ......................................................... 137 Miscellaneous Products .............................................. 162 Index........................................................................... 166 Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug list is regularly updated. Please visit bcbstx.com for the most up-to-date information. To find a contracting pharmacy, please access the link below: https://www.myprime.com/content/myprime/en/find-pharmacy/find-pharmacy-results.html To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. 41722-K TX HIM © Prime Therapeutics LLC 10/15 Introduction Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician. Drug lists updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbstx.com. How drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. How member payment is determined This list shows prescription drug products in tiers. Generally, each drug is placed into one of five member payment tiers: Preferred Generic (Tier 1), Non-preferred Generic (Tier 2), Preferred Brand (Tier 3), Non-preferred Brand (Tier 4) and Specialty (Tier 5). To verify your payment amount for a drug, visit bcbstx.com and log in to Blue Access for Members or call the number on the back of your ID card. Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for selfadministration may be available through your medical benefit. Some drugs may have limited or $0 member cost-sharing (co-pay or co-insurance) under the Affordable Care Act. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D supplements, and some contraceptive drugs and devices. Call the customer service number on the back of your ID card to find out if the drug is available over-the-counter or is covered under your medical benefit. I BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Example: atorvastatin (Lipitor – brand is NF) Brand prescription drugs are shown in capital letters followed by the generic name. Drugs used to treat multiple conditions Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use. Generic drugs Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same standards. There are two types of generic drugs: • A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. • A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. According to the FDA, compared to its brand counterpart, an FDA-approved generic drug: • Is chemically the same • Works just as well in the body • Is as safe and effective • Meets the same standards set by the FDA The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less. Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available. You may be responsible for the brand member payment amount plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount. Consider talking to your doctor about generic drugs If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication. BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 II Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan materials for details about your particular benefits. Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount. Repackaged medications: Repackaged versions of medications already available on the market are not covered. Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the preferred medications listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the preferred medications listed in this document, if a step therapy is commonly required it will generally be noted next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on additional medications beyond those noted in this document. Dispensing Limits (DL): Drug Dispensing limits are designed to help encourage medication use as intended by the FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered medication in a given time period, coverage only for members within a certain age range, and coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit bcbstx.com. *Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit. Remember, medication decisions are between you and your doctor. Only you and your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor. BCBSTX does not provide health care services and, therefore, cannot guarantee any results or outcomes. III BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications, visit myprime.com or bcbstx.com and log in to Blue Access for Members. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card. Prime Therapeutics Specialty Pharmacy Program Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at no additional charge the following services: • Coordination of coverage between you, your doctor and your health plan • Educational materials about your particular condition and information about managing potential medication side effects • Syringes, sharps containers and other supplies with every shipment for self-injectables • 24/7/365 phone access to a pharmacist for urgent medication issues To order through Prime Therapeutics Specialty Pharmacy: • Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can call 877-627-6337 or fax to 877-828-3939. • If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to transfer your prescription. • A Prime Therapeutics coordinator will contact you to arrange delivery of your medication. • The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging. If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337, visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card. • Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”). HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC. BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 IV Abbreviation key cap ...................................................................... capsules chew .................................................................. chewable odt ............................................. orally disintegrating tabs oint ..................................................................... ointment conc ............................................................. concentrate ophth ................................................................. opthalmic osm .......................................................... osmotic release cr .......................................................... controlled release dr ............................................................. delayed release ec ................................................................ enteric coated effe................................................................. effervescent equiv ................................................................ equivalent er ...........................................................extended release inhal................................................................... inhalation inj ......................................................................... injection liq .............................................................................. liquid lotn ........................................................................... lotion powd..................................................................... powder sa ............................................................ sustained action sl ...................................................................... sublingual soln ....................................................................... solution sr .......................................................... sustained release suppos ........................................................ suppositories susp ................................................................ suspension tab ...........................................................................tablets td ................................................................... transdermal nebu ................................................................... nebulizer You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List (also known as a formulary). To request this exception, you, or your prescriber, can call the number on the back of your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be able to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage decision within 24 hours after they receive your request for an expedited review. If the coverage request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). Call the number on the back of your ID card if you have any questions. V BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN ER - amoxicillin (trihydrate) tab sr 24hr 775 mg 4 AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg 4 AMPICILLIN - ampicillin for susp 125 mg/5ml 4 AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg 4 AMPICILLIN - ampicillin for susp 250 mg/5ml 4 amoxicillin (trihydrate) cap 250 mg 1 ampicillin cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 ampicillin cap 500 mg 1 amoxicillin (trihydrate) for susp 125 mg/5ml 1 AUGMENTIN - amoxicillin & k clavulanate tab 500-125 mg 4 amoxicillin (trihydrate) for susp 200 mg/5ml 1 AUGMENTIN - amoxicillin & k clavulanate tab 875-125 mg 4 amoxicillin (trihydrate) for susp 250 mg/5ml 1 4 amoxicillin (trihydrate) for susp 400 mg/5ml 1 AUGMENTIN - amoxicillin & k clavulanate for susp 125-31.25 mg/5ml 4 amoxicillin (trihydrate) tab 500 mg 1 AUGMENTIN - amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 1 AUGMENTIN ES-600 - amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 4 amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate chew tab 200-28.5 mg 2 AUGMENTIN XR - amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg 4 amoxicillin & k clavulanate chew tab 400-57 mg 2 dicloxacillin sodium cap 250 mg 1 2 dicloxacillin sodium cap 500 mg 2 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 4 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin) 2 MOXATAG - amoxicillin (trihydrate) tab sr 24hr 775 mg 1 amoxicillin & k clavulanate for susp 400-57 mg/5ml 2 penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 2 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) 2 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr) 2 amoxicillin & k clavulanate tab 250-125 mg 2 amoxicillin & k clavulanate tab 500-125 mg (Augmentin) 2 amoxicillin & k clavulanate tab 875-125 mg (Augmentin) Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 CEPHALOSPORINS CEDAX - ceftibuten cap 400 mg 4 CEDAX - ceftibuten for susp 90 mg/5ml 4 CEDAX - ceftibuten for susp 180 mg/5ml 4 CEFACLOR - cefaclor for susp 125 mg/5ml 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 1 CEFACLOR - cefaclor for susp 250 mg/5ml 4 CEFTIN - cefuroxime axetil for susp 125 mg/5ml 3 CEFACLOR - cefaclor for susp 375 mg/5ml 4 CEFTIN - cefuroxime axetil for susp 250 mg/5ml 4 cefaclor cap 250 mg 2 cefuroxime axetil tab 250 mg (Ceftin) 1 cefaclor cap 500 mg 2 cefuroxime axetil tab 500 mg (Ceftin) 1 CEFACLOR ER - cefaclor monohydrate tab sr 12hr 500 mg 4 CEPHALEXIN - cephalexin tab 250 mg 4 CEPHALEXIN - cephalexin tab 500 mg 4 cefadroxil cap 500 mg 1 cephalexin cap 250 mg (Keflex) 1 cefadroxil for susp 250 mg/5ml 2 cephalexin cap 500 mg (Keflex) 1 cefadroxil for susp 500 mg/5ml 2 cephalexin cap 750 mg (Keflex) 2 cefadroxil tab 1 gm 2 cephalexin for susp 125 mg/5ml 1 cefdinir cap 300 mg 2 cephalexin for susp 250 mg/5ml 1 cefdinir for susp 125 mg/5ml 2 KEFLEX - cephalexin cap 250 mg 4 cefdinir for susp 250 mg/5ml 2 KEFLEX - cephalexin cap 500 mg 4 CEFDITOREN PIVOXIL - cefditoren pivoxil tab 200 mg (base equivalent) 4 KEFLEX - cephalexin cap 750 mg 4 4 SPECTRACEF - cefditoren pivoxil tab 200 mg (base equivalent) 4 CEFDITOREN PIVOXIL - cefditoren pivoxil tab 400 mg (base equivalent) 2 SPECTRACEF - cefditoren pivoxil tab 400 mg (base equivalent) 4 cefixime for susp 100 mg/5ml (Suprax) 2 SUPRAX - cefixime cap 400 mg 4 cefixime for susp 200 mg/5ml (Suprax) SUPRAX - cefixime chew tab 100 mg 4 cefpodoxime proxetil for susp 50 mg/5ml 2 SUPRAX - cefixime chew tab 200 mg 4 4 cefpodoxime proxetil for susp 100 mg/5ml 2 SUPRAX - cefixime for susp 100 mg/5ml 4 cefpodoxime proxetil tab 100 mg 2 SUPRAX - cefixime for susp 200 mg/5ml cefpodoxime proxetil tab 200 mg 2 4 cefprozil for susp 125 mg/5ml 2 SUPRAX - cefixime for susp 500 mg/5ml cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 CEFTIBUTEN - ceftibuten cap 400 mg 4 CEFTIBUTEN - ceftibuten for susp 180 mg/5ml Dispensing Limits Step Therapy MACROLIDES AZITHROMYCIN - azithromycin powd pack for susp 1 gm 4 azithromycin for susp 100 mg/5ml (Zithromax) 2 4 azithromycin for susp 200 mg/5ml (Zithromax) 1 CEFTIN - cefuroxime axetil tab 250 mg 4 azithromycin tab 250 mg (Zithromax) 1 CEFTIN - cefuroxime axetil tab 500 mg 4 azithromycin tab 500 mg (Zithromax) 1 2 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier BIAXIN - clarithromycin for susp 250 mg/5ml Dispensing Limits 2 Step Therapy azithromycin tab 600 mg (Zithromax) Prior Authorization Drug Name Drug Tier 2015 4 4 ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate tab 400 mg BIAXIN - clarithromycin tab 250 mg 4 2 BIAXIN - clarithromycin tab 500 mg 4 erythromycin w/ delayed release particles cap 250 mg 4 • PCE - erythromycin w/ enteric coated particles tab 333 mg 4 BIAXIN XL - clarithromycin tab sr 24hr 500 mg 4 • PCE - erythromycin w/ enteric coated particles tab 500 mg 4 BIAXIN XL PAC - clarithromycin tab sr 24hr 500 mg 2 ZITHROMAX - azithromycin tab 250 mg 4 clarithromycin for susp 125 mg/5ml 2 ZITHROMAX - azithromycin tab 500 mg 4 clarithromycin for susp 250 mg/5ml (Biaxin) ZITHROMAX - azithromycin tab 600 mg 4 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac) 2 ZITHROMAX - azithromycin for susp 100 mg/5ml 4 clarithromycin tab 250 mg (Biaxin) 2 4 clarithromycin tab 500 mg (Biaxin) 2 ZITHROMAX - azithromycin for susp 200 mg/5ml 4 ZITHROMAX - azithromycin powd pack for susp 1 gm 4 DIFICID - fidaxomicin tab 200 mg E.E.S. GRANULES - erythromycin ethylsuccinate for susp 200 mg/5ml 4 ZITHROMAX TRI-PAK - azithromycin tab 500 mg 4 • E.E.S. 400 - erythromycin ethylsuccinate tab 400 mg 4 ZITHROMAX Z-PAK - azithromycin tab 250 mg 4 • ERY-TAB - erythromycin tab delayed release 250 mg 4 ZMAX - azithromycin extended release for oral susp 2 gm 4 ERY-TAB - erythromycin tab delayed release 333 mg 4 4 ACTICLATE - doxycycline hyclate tab 75 mg 4 ERY-TAB - erythromycin tab delayed release 500 mg • 4 ACTICLATE - doxycycline hyclate tab 150 mg 4 ERYPED 200 - erythromycin ethylsuccinate for susp 200 mg/5ml • 4 ADOXA - doxycycline monohydrate cap 150 mg 4 ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml • 4 ADOXA - doxycycline monohydrate tab 50 mg 4 ERYTHROCIN STEARATE erythromycin stearate tab 250 mg • 4 ADOXA - doxycycline monohydrate tab 75 mg 4 ERYTHROMYCIN BASE - erythromycin tab 250 mg • 4 ADOXA - doxycycline monohydrate tab 100 mg 4 ERYTHROMYCIN BASE - erythromycin tab 500 mg • ADOXA PAK 1/100 - doxycycline monohydrate tab 100 mg 4 • • • • • TETRACYCLINES BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 3 ADOXA PAK 2/100 - doxycycline monohydrate tab 100 mg 4 • MINOCIN - minocycline hcl cap 50 mg 4 MINOCIN - minocycline hcl cap 75 mg 4 AVIDOXY DK - doxycycline tab 100 mg & suncreen & sal acid wash 2% kit 4 MINOCIN - minocycline hcl cap 100 mg 4 2 MINOCIN KIT - minocycline hcl cap 50 mg w/ acne care products kit 4 demeclocycline hcl tab 150 mg • • • • demeclocycline hcl tab 300 mg 2 • • 4 MINOCIN KIT - minocycline hcl cap 100 mg w/ acne care products kit 4 DORYX - doxycycline hyclate tab delayed release 50 mg 1 DORYX - doxycycline hyclate tab delayed release 200 mg • minocycline hcl cap 50 mg (Minocin) 4 minocycline hcl cap 75 mg (Minocin) 1 doxycycline hyclate cap 50 mg 2 doxycycline hyclate cap 100 mg (Vibramycin) 2 doxycycline hyclate tab delayed release 75 mg 2 doxycycline hyclate tab delayed release 100 mg 2 • doxycycline hyclate tab delayed release 150 mg (Doryx) 2 • doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 2 doxycycline monohydrate cap 50 mg 2 doxycycline monohydrate cap 75 mg (Monodox) 2 doxycycline monohydrate cap 100 mg (Monodox) 2 doxycycline monohydrate cap 150 mg (Adoxa) 2 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) 2 doxycycline monohydrate tab 50 mg (Adoxa) 2 doxycycline monohydrate tab 75 mg (Adoxa) 2 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) 2 4 minocycline hcl cap 100 mg (Minocin) 1 2 minocycline hcl tab sr 24hr 45 mg • Dispensing Limits 2 Step Therapy doxycycline monohydrate tab 150 mg (Adoxa pak 1/150) • Prior Authorization • Drug Name Drug Tier 4 Dispensing Limits Prior Authorization ADOXA PAK 1/150 - doxycycline monohydrate tab 150 mg Drug Name Step Therapy Drug Tier 2015 • • • minocycline hcl tab sr 24hr 90 mg 2 minocycline hcl tab sr 24hr 135 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 MONODOX - doxycycline monohydrate cap 75 mg 4 • MONODOX - doxycycline monohydrate cap 100 mg 4 • MORGIDOX 1X100MG - doxycycline hyclate cap 1 x 100 mg w/ cleanser kit 4 • MORGIDOX 2X100MG - doxycycline hyclate cap 2 x 100 mg w/ cleanser kit 4 • NUTRIDOX - doxycycline monohyd cap 75 mg w/ omega 3-vit e cap kit 4 • SOLODYN - minocycline hcl tab sr 24hr 55 mg 4 • SOLODYN - minocycline hcl tab sr 24hr 65 mg 4 • SOLODYN - minocycline hcl tab sr 24hr 80 mg 4 • SOLODYN - minocycline hcl tab sr 24hr 105 mg 4 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 TARGADOX - doxycycline hyclate tab 50 mg 4 • ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) 1 TETRACYCLINE HCL - tetracycline hcl cap 250 mg 4 ciprofloxacin hcl tab 750 mg (base equiv) 1 TETRACYCLINE HCL - tetracycline hcl cap 500 mg 4 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr) 2 VIBRAMYCIN - doxycycline monohydrate for susp 25 mg/5ml 4 • ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr) 2 VIBRAMYCIN - doxycycline calcium syrup 50 mg/5ml 4 • FACTIVE - gemifloxacin mesylate tab 320 mg (base equiv) 4 VIBRAMYCIN - doxycycline hyclate cap 100 mg 4 • LEVAQUIN - levofloxacin oral soln 25 mg/ml 4 LEVAQUIN - levofloxacin tab 250 mg 4 LEVAQUIN - levofloxacin tab 500 mg 4 LEVAQUIN - levofloxacin tab 750 mg 4 levofloxacin oral soln 25 mg/ml (Levaquin) 2 levofloxacin tab 250 mg (Levaquin) 1 levofloxacin tab 500 mg (Levaquin) 1 levofloxacin tab 750 mg (Levaquin) 1 FLUOROQUINOLONES Dispensing Limits 1 Step Therapy ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) Prior Authorization • Drug Name Drug Tier 4 Dispensing Limits Prior Authorization SOLODYN - minocycline hcl tab sr 24hr 115 mg Drug Name Step Therapy Drug Tier 2015 AVELOX - moxifloxacin hcl tab 400 mg (base equiv) 4 AVELOX ABC PACK - moxifloxacin hcl tab 400 mg (base equiv) 4 CIPRO - ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) 4 CIPRO - ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 4 CIPRO - ciprofloxacin hcl tab 250 mg (base equiv) 4 moxifloxacin hcl tab 400 mg (base equiv) (Avelox) 2 CIPRO - ciprofloxacin hcl tab 500 mg (base equiv) 4 OFLOXACIN - ofloxacin tab 400 mg 4 CIPRO XR - ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) 4 BETHKIS - tobramycin nebu soln 300 mg/4ml 5 • • CIPRO XR - ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) 4 KITABIS PAK - tobramycin nebu soln 300 mg/5ml 5 • • ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) 2 neomycin sulfate tab 500 mg 1 paromomycin sulfate cap 250 mg 2 2 TOBI - tobramycin nebu soln 300 mg/5ml 5 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro) • • 5 • • CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg (base equiv) 2 TOBI PODHALER - tobramycin inhal cap 28 mg tobramycin nebu soln 300 mg/5ml (Tobi) 5 • • AMINOGLYCOSIDES SULFONAMIDES BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 5 SULFADIAZINE - sulfadiazine tab 500 mg 4 ANTIMYCOBACTERIAL AGENTS CYCLOSERINE - cycloserine cap 250 mg 4 ethambutol hcl tab 100 mg (Myambutol) 2 ethambutol hcl tab 400 mg (Myambutol) 2 ISONIAZID - isoniazid syrup 50 mg/5ml 4 isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 4 DIFLUCAN - fluconazole tab 150 mg 4 DIFLUCAN - fluconazole tab 200 mg 4 DIFLUCAN - fluconazole for susp 10 mg/ml 4 DIFLUCAN - fluconazole for susp 40 mg/ml 4 MYAMBUTOL - ethambutol hcl tab 100 mg fluconazole for susp 10 mg/ml (Diflucan) 1 4 2 MYAMBUTOL - ethambutol hcl tab 400 mg 4 fluconazole for susp 40 mg/ml (Diflucan) fluconazole tab 50 mg (Diflucan) 1 MYCOBUTIN - rifabutin cap 150 mg 4 fluconazole tab 100 mg (Diflucan) 1 PASER - aminosalicylic acid cr granules packet 4 gm 4 fluconazole tab 150 mg (Diflucan) 1 3 fluconazole tab 200 mg (Diflucan) 1 PRIFTIN - rifapentine tab 150 mg 2 flucytosine cap 250 mg (Ancobon) 2 pyrazinamide tab 500 mg 2 flucytosine cap 500 mg (Ancobon) 2 rifabutin cap 150 mg (Mycobutin) 4 GRIFULVIN V - griseofulvin microsize tab 500 mg 4 RIFADIN - rifampin cap 150 mg RIFADIN - rifampin cap 300 mg 4 4 GRIS-PEG - griseofulvin ultramicrosize tab 125 mg 4 RIFAMATE - isoniazid & rifampin cap 150-300 mg rifampin cap 150 mg (Rifadin) GRIS-PEG - griseofulvin ultramicrosize tab 250 mg 4 2 rifampin cap 300 mg (Rifadin) 2 2 RIFATER - isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg 4 griseofulvin microsize susp 125 mg/5ml 2 SEROMYCIN - cycloserine cap 250 mg 4 griseofulvin microsize tab 500 mg (Grifulvin v) SIRTURO - bedaquiline fumarate tab 100 mg (base equiv) 4 griseofulvin ultramicrosize tab 125 mg (Gris-peg) 2 TRECATOR - ethionamide tab 250 mg 4 griseofulvin ultramicrosize tab 250 mg (Gris-peg) 2 itraconazole cap 100 mg (Sporanox) 2 ketoconazole tab 200 mg 1 LAMISIL - terbinafine hcl tab 250 mg 4 ANCOBON - flucytosine cap 250 mg 4 ANCOBON - flucytosine cap 500 mg 4 BIO-STATIN - nystatin cap 500000 unit 4 6 Dispensing Limits Step Therapy BIO-STATIN - nystatin cap 1000000 unit 4 CRESEMBA - isavuconazonium sulfate 4 cap 186 mg 4 DIFLUCAN - fluconazole tab 50 mg DIFLUCAN - fluconazole tab 100 mg ANTIFUNGALS Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 LAMISIL - terbinafine hcl oral granules packet 125 mg 4 APTIVUS - tipranavir oral soln 100 mg/ ml 3 • LAMISIL - terbinafine hcl oral granules packet 187.5 mg 4 ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg 3 • NOXAFIL - posaconazole tab delayed release 100 mg 4 • BARACLUDE - entecavir oral soln 0.05 mg/ml 3 NOXAFIL - posaconazole susp 40 mg/ ml 3 • BARACLUDE - entecavir tab 0.5 mg 3 BARACLUDE - entecavir tab 1 mg 3 nystatin oral powder 2 • nystatin tab 500000 unit COMBIVIR - lamivudine-zidovudine tab 150-300 mg 4 2 ONMEL - itraconazole tab 200 mg 4 4 • SPORANOX - itraconazole oral soln 10 mg/ml 4 COMPLERA - emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg COPEGUS - ribavirin tab 200 mg 5 SPORANOX - itraconazole cap 100 mg 4 • SPORANOX PULSEPAK - itraconazole cap 100 mg 4 CRIXIVAN - indinavir sulfate cap 200 mg 3 3 • terbinafine hcl tab 250 mg (Lamisil) 1 CRIXIVAN - indinavir sulfate cap 400 mg VFEND - voriconazole for susp 40 mg/ ml 4 • DAKLINZA - daclatasvir dihydrochloride tab 30 mg (base equivalent) 5 • VFEND - voriconazole tab 50 mg 4 • 4 DAKLINZA - daclatasvir dihydrochloride tab 60 mg (base equivalent) 5 VFEND - voriconazole tab 200 mg 2 didanosine delayed release capsule 125 mg (Videx ec) 2 voriconazole for susp 40 mg/ml (Vfend) • • • • 2 didanosine delayed release capsule 200 mg (Videx ec) • voriconazole tab 200 mg (Vfend) 2 • • 2 voriconazole tab 50 mg (Vfend) didanosine delayed release capsule 250 mg (Videx ec) 2 • ANTIVIRALS • abacavir sulfate tab 300 mg (base equiv) (Ziagen) 2 • didanosine delayed release capsule 400 mg (Videx ec) 2 • abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg (Trizivir) 2 • EDURANT - rilpivirine hcl tab 25 mg (base equivalent) 4 • EMTRIVA - emtricitabine caps 200 mg 3 acyclovir cap 200 mg (Zovirax) 1 EMTRIVA - emtricitabine soln 10 mg/ml 3 • • acyclovir susp 200 mg/5ml (Zovirax) 2 entecavir tab 0.5 mg (Baraclude) 2 acyclovir tab 400 mg (Zovirax) 1 entecavir tab 1 mg (Baraclude) 2 acyclovir tab 800 mg (Zovirax) 1 EPIVIR - lamivudine tab 150 mg 4 adefovir dipivoxil tab 10 mg (Hepsera) 2 EPIVIR - lamivudine tab 300 mg 4 3 EPIVIR - lamivudine oral soln 10 mg/ml 3 APTIVUS - tipranavir cap 250 mg • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • 7 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 EPIVIR HBV - lamivudine tab 100 mg (hbv) 4 KALETRA - lopinavir-ritonavir tab 200-50 mg 3 • EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 4 lamivudine oral soln 10 mg/ml (Epivir) 2 • EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg 3 • lamivudine tab 100 mg (hbv) (Epivir hbv) 2 EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg (base equiv) 5 • lamivudine tab 150 mg (Epivir) 2 lamivudine tab 300 mg (Epivir) 2 famciclovir tab 125 mg (Famvir) 2 2 famciclovir tab 250 mg (Famvir) 2 lamivudine-zidovudine tab 150-300 mg (Combivir) • • • famciclovir tab 500 mg (Famvir) 2 3 • FAMVIR - famciclovir tab 125 mg 4 LEXIVA - fosamprenavir calcium tab 700 mg (base equiv) FAMVIR - famciclovir tab 250 mg 4 3 • FAMVIR - famciclovir tab 500 mg 4 LEXIVA - fosamprenavir calcium susp 50 mg/ml (base equiv) 4 MODERIBA - ribavirin tab 200 mg & ribavirin tab 400 mg dose pack 5 FLUMADINE - rimantadine hydrochloride tab 100 mg • 5 MODERIBA - ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 5 FUZEON - enfuvirtide for inj 90 mg • HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 MODERIBA 1200 DOSE PACK ribavirin tab 600 mg 5 • HEPSERA - adefovir dipivoxil tab 10 mg 4 INTELENCE - etravirine tab 100 mg 3 • 3 NEVIRAPINE - nevirapine susp 50 mg/5ml 4 INTELENCE - etravirine tab 200 mg INVIRASE - saquinavir mesylate cap 200 mg 3 • • • • • INTELENCE - etravirine tab 25 mg MODERIBA 800 DOSE PACK - ribavirin tab 400 mg 5 3 nevirapine tab sr 24hr 400 mg (Viramune xr) 2 • INVIRASE - saquinavir mesylate tab 500 mg 3 • nevirapine tab 200 mg (Viramune) 2 NORVIR - ritonavir cap 100 mg 3 ISENTRESS - raltegravir potassium tab 400 mg (base equiv) 3 NORVIR - ritonavir tab 100 mg 3 3 ISENTRESS - raltegravir potassium packet for susp 100 mg (base equiv) 3 • NORVIR - ritonavir oral soln 80 mg/ml • • • • 5 • ISENTRESS - raltegravir potassium chew tab 25 mg (base equiv) 3 • OLYSIO - simeprevir sodium cap 150 mg (base equivalent) • ISENTRESS - raltegravir potassium chew tab 100 mg (base equiv) 3 • KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 3 • KALETRA - lopinavir-ritonavir tab 100-25 mg 3 • PEG-INTRON - peginterferon alfa-2b for 5 inj kit 50 mcg/0.5ml PEG-INTRON - peginterferon alfa-2b for 5 inj kit 80 mcg/0.5ml PEG-INTRON - peginterferon alfa-2b for 5 inj kit 120 mcg/0.5ml 8 • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 PEG-INTRON - peginterferon alfa-2b for 5 inj kit 150 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon 5 alfa-2b for inj kit 50 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon 5 alfa-2b for inj kit 80 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon 5 alfa-2b for inj kit 120 mcg/0.5ml PEG-INTRON REDIPEN - peginterferon 5 alfa-2b for inj kit 150 mcg/0.5ml 5 PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 50 mcg/0.5ml 5 PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 80 mcg/0.5ml 5 PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 120 mcg/0.5ml 5 PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 150 mcg/0.5ml 5 PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PEGASYS PROCLICK - peginterferon alfa-2a inj 135 mcg/0.5ml 5 PEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml PEGINTRON - peginterferon alfa-2b for 5 inj kit 50 mcg/0.5ml PEGINTRON - peginterferon alfa-2b for 5 inj kit 80 mcg/0.5ml PEGINTRON - peginterferon alfa-2b for 5 inj kit 120 mcg/0.5ml PEGINTRON - peginterferon alfa-2b for 5 inj kit 150 mcg/0.5ml 5 PREZCOBIX - darunavir-cobicistat tab 800-150 mg Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 • PREZISTA - darunavir ethanolate susp 100 mg/ml (base equiv) 3 • • PREZISTA - darunavir ethanolate tab 75 3 mg (base equiv) 3 PREZISTA - darunavir ethanolate tab 150 mg (base equiv) 3 PREZISTA - darunavir ethanolate tab 600 mg (base equiv) 3 PREZISTA - darunavir ethanolate tab 800 mg (base equiv) 5 REBETOL - ribavirin cap 200 mg • • • • • • • • • • REBETOL - ribavirin soln 40 mg/ml 5 • RELENZA DISKHALER - zanamivir aero powder breath activated 5 mg/ blister 4 • • RESCRIPTOR - delavirdine mesylate tab 100 mg 3 • RESCRIPTOR - delavirdine mesylate tab 200 mg 3 • RETROVIR - zidovudine cap 100 mg 4 • • • • RETROVIR - zidovudine syrup 10 mg/ml 4 3 REYATAZ - atazanavir sulfate oral powder packet 50 mg (base equiv) 3 REYATAZ - atazanavir sulfate cap 150 mg (base equiv) 3 REYATAZ - atazanavir sulfate cap 200 mg (base equiv) 3 REYATAZ - atazanavir sulfate cap 300 mg (base equiv) 5 RIBASPHERE - ribavirin tab 400 mg • • • • • • • • • • • • RIBASPHERE - ribavirin tab 600 mg 5 RIBASPHERE RIBAPAK - ribavirin tab 400 mg 5 • • • RIBASPHERE RIBAPAK - ribavirin tab 600 mg 5 • RIBASPHERE RIBAPAK - ribavirin tab 200 mg & ribavirin tab 400 mg dose pack 5 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 9 RIBATAB - ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 5 ribavirin cap 200 mg (Rebetol) 5 ribavirin tab 200 mg (Copegus) 5 rimantadine hydrochloride tab 100 mg (Flumadine) 2 SELZENTRY - maraviroc tab 150 mg 3 SELZENTRY - maraviroc tab 300 mg 3 SITAVIG - acyclovir buccal tab 50 mg 4 SOVALDI - sofosbuvir tab 400 mg 5 stavudine cap 15 mg (Zerit) 2 stavudine cap 20 mg (Zerit) 2 stavudine cap 30 mg (Zerit) 2 stavudine cap 40 mg (Zerit) 2 stavudine for oral soln 1 mg/ml (Zerit) 2 STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab 150-150-200-300 mg 3 SUSTIVA - efavirenz tab 600 mg 3 SUSTIVA - efavirenz cap 50 mg 3 SUSTIVA - efavirenz cap 200 mg 3 TAMIFLU - oseltamivir phosphate for susp 6 mg/ml (base equiv) 4 • • • • TAMIFLU - oseltamivir phosphate cap 30 mg (base equiv) 4 TAMIFLU - oseltamivir phosphate cap 45 mg (base equiv) • • • • • • • • • • • • • Dispensing Limits RIBATAB - ribavirin tab 600 mg 5 Step Therapy RIBATAB - ribavirin tab 400 mg 5 Prior Authorization • Drug Name Drug Tier 5 Dispensing Limits Prior Authorization RIBASPHERE RIBAPAK - ribavirin tab 400 mg & ribavirin tab 600 mg dose pack Drug Name Step Therapy Drug Tier 2015 TIVICAY - dolutegravir sodium tab 50 mg (base equiv) 3 • TRIUMEQ - abacavir-dolutegravirlamivudine tab 600-50-300 mg 4 • TRIZIVIR - abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg 4 • TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg 3 • TYBOST - cobicistat tab 150 mg 5 • TYZEKA - telbivudine tab 600 mg 4 valacyclovir hcl tab 500 mg (Valtrex) 2 valacyclovir hcl tab 1 gm (Valtrex) 2 VALCYTE - valganciclovir hcl for soln 50 3 mg/ml (base equiv) 2 VALCYTE - valganciclovir hcl tab 450 mg (base equivalent) 2 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) VALTREX - valacyclovir hcl tab 500 mg 4 VALTREX - valacyclovir hcl tab 1 gm 4 VICTRELIS - boceprevir cap 200 mg 5 VIDEX - didanosine for soln 2 gm 3 VIDEX - didanosine for soln 4 gm 3 VIDEX EC - didanosine delayed release capsule 125 mg 4 • • • VIDEX EC - didanosine delayed release capsule 200 mg 4 • VIDEX EC - didanosine delayed release capsule 250 mg 4 • • VIDEX EC - didanosine delayed release capsule 400 mg 4 • 4 • 5 TAMIFLU - oseltamivir phosphate cap 75 mg (base equiv) 4 • VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak 12.5-75-50 & 250 mg VIRACEPT - nelfinavir mesylate tab 250 mg 3 • TECHNIVIE - ombitasvir-paritaprevirritonavir tab 12.5-75-50 mg 5 VIRACEPT - nelfinavir mesylate tab 625 mg 3 • VIRAMUNE - nevirapine tab 200 mg 4 • 10 • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 VIRAMUNE - nevirapine susp 50 mg/5ml 3 • atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) 2 VIRAMUNE XR - nevirapine tab sr 24hr 100 mg 3 • atovaquone-proguanil hcl tab 250-100 mg (Malarone) 2 VIRAMUNE XR - nevirapine tab sr 24hr 400 mg 4 • chloroquine phosphate tab 250 mg 2 4 chloroquine phosphate tab 500 mg (Aralen) 1 VIRAZOLE - ribavirin for inhal soln 6 gm VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 3 • COARTEM - artemether-lumefantrine tab 20-120 mg 4 VIREAD - tenofovir disoproxil fumarate tab 150 mg 3 • DARAPRIM - pyrimethamine tab 25 mg 3 VIREAD - tenofovir disoproxil fumarate tab 200 mg • hydroxychloroquine sulfate tab 200 mg (Plaquenil) 1 3 VIREAD - tenofovir disoproxil fumarate tab 250 mg • MALARONE - atovaquone-proguanil hcl tab 62.5-25 mg 4 3 3 • MALARONE - atovaquone-proguanil hcl tab 250-100 mg 4 VIREAD - tenofovir disoproxil fumarate tab 300 mg 2 4 VITEKTA - elvitegravir tab 150 mg PLAQUENIL - hydroxychloroquine sulfate tab 200 mg 4 4 ZERIT - stavudine for oral soln 1 mg/ml 4 4 ZERIT - stavudine cap 20 mg 4 PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg (15 mg base) 3 ZERIT - stavudine cap 15 mg 4 QUALAQUIN - quinine sulfate cap 324 mg 4 ZERIT - stavudine cap 30 mg ZERIT - stavudine cap 40 mg 4 4 quinine sulfate cap 324 mg (Qualaquin) 2 ZIAGEN - abacavir sulfate tab 300 mg (base equiv) • • • • • • • • mefloquine hcl tab 250 mg VITEKTA - elvitegravir tab 85 mg ZIAGEN - abacavir sulfate soln 20 mg/ ml (base equiv) 3 • zidovudine cap 100 mg (Retrovir) 2 zidovudine syrup 10 mg/ml (Retrovir) 2 zidovudine tab 300 mg 2 • • • ZOVIRAX - acyclovir cap 200 mg 4 ZOVIRAX - acyclovir susp 200 mg/5ml 4 ZOVIRAX - acyclovir tab 400 mg 4 ZOVIRAX - acyclovir tab 800 mg 4 ANTIMALARIALS ARALEN - chloroquine phosphate tab 500 mg 4 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 AMEBICIDES YODOXIN - iodoquinol tab 210 mg 4 YODOXIN - iodoquinol tab 650 mg 4 ANTHELMINTICS ALBENZA - albendazole tab 200 mg 3 BILTRICIDE - praziquantel tab 600 mg 3 ivermectin tab 3 mg (Stromectol) 2 STROMECTOL - ivermectin tab 3 mg 3 ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide tab 500 mg 4 ALINIA - nitazoxanide for susp 100 mg/5ml 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • 11 atovaquone susp 750 mg/5ml (Mepron) 2 BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg 4 BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg 4 CAYSTON - aztreonam lysine for inhal soln 75 mg (base equivalent) 5 CLEOCIN - clindamycin hcl cap 75 mg 4 CLEOCIN - clindamycin hcl cap 150 mg 4 CLEOCIN - clindamycin hcl cap 300 mg 4 PRIMSOL - trimethoprim hcl oral soln 50 4 mg/5ml (base equiv) 4 SIVEXTRO - tedizolid phosphate tab 200 mg sulfamethoxazole-trimethoprim susp 1 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) 1 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) 4 TINDAMAX - tinidazole tab 250 mg CLEOCIN PEDIATRIC GRANULE clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) 4 TINDAMAX - tinidazole tab 500 mg 4 tinidazole tab 250 mg (Tindamax) 2 tinidazole tab 500 mg (Tindamax) 2 clindamycin hcl cap 75 mg (Cleocin) 1 trimethoprim tab 100 mg 1 clindamycin hcl cap 150 mg (Cleocin) 1 1 VANCOCIN HCL - vancomycin hcl cap 125 mg 4 clindamycin hcl cap 300 mg (Cleocin) clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) 2 VANCOCIN HCL - vancomycin hcl cap 250 mg 4 DAPSONE - dapsone tab 25 mg vancomycin hcl cap 125 mg (Vancocin hcl) 2 3 DAPSONE - dapsone tab 100 mg 3 2 FLAGYL - metronidazole cap 375 mg 4 vancomycin hcl cap 250 mg (Vancocin hcl) FLAGYL - metronidazole tab 250 mg 4 XIFAXAN - rifaximin tab 200 mg 4 FLAGYL - metronidazole tab 500 mg 4 XIFAXAN - rifaximin tab 550 mg 3 FLAGYL ER - metronidazole tab sr 24hr 750 mg 4 ZYVOX - linezolid tab 600 mg 3 ZYVOX - linezolid for susp 100 mg/5ml 3 KETEK - telithromycin tab 300 mg 4 BIOLOGICALS KETEK - telithromycin tab 400 mg 4 VACCINES linezolid tab 600 mg (Zyvox) 2 MEPRON - atovaquone susp 750 mg/5ml 4 metronidazole cap 375 mg (Flagyl) 2 metronidazole tab 250 mg (Flagyl) 1 metronidazole tab 500 mg (Flagyl) 1 NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 12 • • • AFLURIA PF 2011-2012 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 AFLURIA PF 2012-2013 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 AFLURIA PF 2013-2014 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • AFLURIA PF 2014-2015 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 FLUARIX 2013-2014 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 AFLURIA PF 2015-2016 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 FLUARIX 2014-2015 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 AFLURIA 2011-2012 - influenza virus vaccine split im susp 4 4 AFLURIA 2012-2013 - influenza virus vaccine split im susp 4 FLUBLOK 2013-2014 - influenza virus vac recombinant hemagglutinin (ha) inj 4 AFLURIA 2013-2014 - influenza virus vaccine split im susp 4 FLUBLOK 2014-2015 - influenza virus vac recombinant hemagglutinin (ha) inj AFLURIA 2014-2015 - influenza virus vaccine split im susp 4 4 AFLURIA 2015-2016 - influenza virus vaccine split im susp 4 FLUBLOK 2015-2016 - influenza virus vac recombinant hemagglutinin (ha) inj 4 ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 4 FLUCELVAX 2012-2013 - influenza virus vac tiss-cult subunit susp pref syr 0.5 ml 4 FLUCELVAX 2013-2014 - influenza virus vac tiss-cult subunit susp pref syr 0.5 ml 4 ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml ENGERIX-B - hepatitis b vaccine (recombinant) 10 mcg/0.5ml 4 4 ENGERIX-B - hepatitis b vaccine (recombinant) 20 mcg/ml 4 FLUCELVAX 2014-2015 - influenza virus vac tiss-cult subunit susp pref syr 0.5 ml FLUARIX QUADRIVALENT 2013 influenza virus vac split quadrivalent susp pref syr 0.5ml FLUCELVAX 2015-2016 - influenza virus vac tiss-cult subunit susp pref syr 0.5 ml 4 4 4 FLULAVAL QUADRIVALENT 201 influenza virus vac split quadrivalent susp pref syr 0.5ml 4 FLUARIX QUADRIVALENT 2014 influenza virus vac split quadrivalent susp pref syr 0.5ml FLUARIX QUADRIVALENT 2015 influenza virus vac split quadrivalent susp pref syr 0.5ml FLULAVAL QUADRIVALENT 201 - influenza virus vaccine split quadrivalent im inj 4 4 FLUARIX 2011-2012 - influenza virus vaccine split pf susp pref syringe 0.5 ml FLULAVAL 2011-2012 - influenza virus vaccine split im susp 4 4 FLULAVAL 2012-2013 - influenza virus vaccine split im susp 4 FLUARIX 2012-2013 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 FLULAVAL 2013-2014 - influenza virus vaccine split im susp 4 FLULAVAL 2014-2015 - influenza virus vaccine split im susp 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 13 FLUMIST QUADRIVALENT - influenza virus vaccine live quadrivalent intranasal susp 4 FLUZONE INTRADERMAL QUADR influenza virus vac split quad intradermal pen 9 mcg/strain 4 FLUVIRIN PF 2011-2012 - influenza virus vac types a & b pf susp prefilled syr 0.5 ml 4 FLUZONE PF 2012-2013 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 FLUVIRIN PF 2012-2013 - influenza virus vac types a & b pf susp prefilled syr 0.5 ml 4 FLUZONE PF 2013-2014 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 FLUVIRIN PF 2013-2014 - influenza virus vac types a & b pf susp prefilled syr 0.5 ml 4 FLUZONE PF 2014-2015 - influenza virus vaccine split pf susp pref syringe 0.5 ml 4 FLUVIRIN PF 2014-2015 - influenza virus vac types a & b pf susp prefilled syr 0.5 ml 4 FLUZONE QUADRIVALENT 2013 influenza virus vac split quadrivalent susp pref syr 0.25 ml 4 FLUVIRIN 2011-2012 - influenza virus vaccine types a & b surface antigen im susp 4 FLUZONE QUADRIVALENT 2013 influenza virus vac split quadrivalent susp pref syr 0.5ml 4 FLUVIRIN 2012-2013 - influenza virus vaccine types a & b surface antigen im susp 4 FLUZONE QUADRIVALENT 2013 influenza virus vaccine split quadrivalent inj 0.5 ml 4 FLUVIRIN 2013-2014 - influenza virus vaccine types a & b surface antigen im susp 4 FLUZONE QUADRIVALENT 2014 influenza virus vac split quadrivalent susp pref syr 0.25 ml 4 FLUVIRIN 2014-2015 - influenza virus vaccine types a & b surface antigen im susp 4 FLUZONE QUADRIVALENT 2014 influenza virus vac split quadrivalent susp pref syr 0.5ml 4 FLUVIRIN 2015-2016 - influenza virus vaccine types a & b surface antigen im susp 4 FLUZONE QUADRIVALENT 2014 influenza virus vaccine split quadrivalent im inj 4 FLUZONE HIGH-DOSE PF 2012 influenza virus vac split high-dose pf susp pref syr 0.5ml 4 FLUZONE QUADRIVALENT 2014 influenza virus vaccine split quadrivalent inj 0.5 ml 4 FLUZONE HIGH-DOSE PF 2013 influenza virus vac split high-dose pf susp pref syr 0.5ml 4 FLUZONE QUADRIVALENT 2015 influenza virus vac split quadrivalent susp pref syr 0.25 ml 4 FLUZONE HIGH-DOSE PF 2014 influenza virus vac split high-dose pf susp pref syr 0.5ml 4 FLUZONE QUADRIVALENT 2015 influenza virus vac split quadrivalent susp pref syr 0.5ml 4 FLUZONE HIGH-DOSE PF 2015 influenza virus vac split high-dose pf susp pref syr 0.5ml 4 FLUZONE QUADRIVALENT 2015 influenza virus vaccine split quadrivalent im inj 4 14 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 FLUZONE QUADRIVALENT 2015 influenza virus vaccine split quadrivalent inj 0.5 ml 4 FLUZONE SPLIT 2012-2013 - influenza virus vaccine split im susp 4 FLUZONE SPLIT 2013-2014 - influenza virus vaccine split im susp 4 FLUZONE SPLIT 2014-2015 - influenza virus vaccine split im susp 4 FLUZONE SPLIT 2015-2016 - influenza virus vaccine split im susp Dispensing Limits Step Therapy TOXOIDS ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 4 BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml 4 DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml 4 4 4 DIPHTHERIA/TETANUS TOXOID diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 4 4 MEDICAL PROVIDER EZ FLU S influenza virus vac types a & b pf pref syringe kit 0.5 ml KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4 4 PEDIARIX - diph-tetanus tox-acell perthepatitis b-polio ipv vac inj 4 MEDICAL PROVIDER EZ FLU S influenza virus vac tiss-cult subunit pref syr kit 0.5 ml 4 PENTACEL - diph-ac per-tet tox adpoliov-haemoph b poly vac for im susp 4 PNEUMOVAX 23 - pneumococcal vaccine polyvalent inj 25 mcg/0.5ml 4 QUADRACEL - diph-tetanus tox adacell pert & polio virus, ipv vac inj 4 PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent inj 25 mcg/0.5ml 4 TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 4 4 TETANUS/DIPHTHERIA TOXOID tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 4 PNEUMOVAX 23/5 DOSE pneumococcal vaccine polyvalent inj 25 mcg/0.5ml PREVNAR 13 - pneumococcal 13-valent 4 conjugate vaccine inj 4 RABAVERT - rabies vaccine, pcec for inj RECOMBIVAX HB - hepatitis b vaccine 4 (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB - hepatitis b vaccine 4 (recombinant) susp 10 mcg/ml RECOMBIVAX HB - hepatitis b vaccine 4 (recombinant) susp 40 mcg/ml 4 VIVOTIF BERNA - typhoid vaccine cap delayed release 4 ZOSTAVAX - zoster vaccine live for inj 19400 unit/0.65ml Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 PASSIVE IMMUNIZING AGENTS HEPAGAM B - hepatitis b immune globulin (human) inj soln 4 HYPERHEP B S/D - hepatitis b immune globulin (human) im inj soln 4 HYPERRAB S/D - rabies immune globulin (human) inj 150 unit/ml 4 HYPERTET S/D - tetanus immune globulin (human) inj 250 unit/ml 4 HYQVIA - immun glob inj 2.5 gm/25mlhyaluron inj 200 unt/1.25 ml kit 5 HYQVIA - immun glob inj 5 gm/50mlhyaluron inj 400 unt/2.5 ml kit 5 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 15 • HYQVIA - immun glob inj 20 gm/200mlhyaluron inj 1600 unt/10 ml kit 5 AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 • • HYQVIA - immun glob inj 30 gm/300mlhyaluron inj 2400 unt/15 ml kit 5 AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 • • IMOGAM RABIES-HT - rabies immune globulin (human) inj 150 unit/ml 4 ALKERAN - melphalan tab 2 mg 3 anastrozole tab 1 mg (Arimidex) 1 NABI-HB - hepatitis b immune globulin (human) im inj soln 4 ARIMIDEX - anastrozole tab 1 mg 4 4 AROMASIN - exemestane tab 25 mg 4 VARIZIG - varicella-zoster immune glob (human) for im inj 125 unit bexarotene cap 75 mg (Targretin) 5 bicalutamide tab 50 mg (Casodex) 2 BOSULIF - bosutinib tab 100 mg 5 BOSULIF - bosutinib tab 500 mg 5 capecitabine tab 150 mg (Xeloda) 5 capecitabine tab 500 mg (Xeloda) 5 CAPRELSA - vandetanib tab 100 mg 5 CAPRELSA - vandetanib tab 300 mg 5 CASODEX - bicalutamide tab 50 mg 4 CEENU - lomustine cap 10 mg 3 CEENU - lomustine cap 40 mg 3 CEENU - lomustine cap 100 mg 3 BIOLOGICALS MISC GRASTEK - timothy grass pollen allergen ext tab sl 2800 bau 4 ORALAIR - grass mixed pollen ext tab sl 4 300 ir (index of reactivity) ORALAIR ADULT SAMPLE KIT - grass 4 mixed pollen ext tab sl 300 ir (index of reactivity) 4 ORALAIR ADULT STARTER PAC grass mixed pollen ext tab sl 300 ir (index of reactivity) 4 ORALAIR CHILDREN/ADOLESCE grass mixed pollen tab sl therpak 100 (3) ir & 300 (6) ir 4 ORALAIR CHILDREN/ADOLESCE grass mixed pollen ext tab sl 100 ir (index of reactivity) 4 RAGWITEK - short ragweed pollen allergen extract tab sl 12 amb a 1-u • • ANTINEOPLASTIC AGENTS ANTINEOPLASTICS ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml) 5 • AFINITOR - everolimus tab 2.5 mg 5 AFINITOR - everolimus tab 5 mg 5 AFINITOR - everolimus tab 7.5 mg 5 AFINITOR - everolimus tab 10 mg 5 • • • • 16 • • • • COMETRIQ - cabozantinib s-malate cap 5 3 x 20 mg (60 mg dose) kit COMETRIQ - cabozantinib s-mal cap 1 5 x 80 mg & 1 x 20 mg (100 dose) kit COMETRIQ - cabozantinib s-mal cap 1 5 x 80 mg & 3 x 20 mg (140 dose) kit 4 CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg 4 CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg 5 ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg ELIGARD - leuprolide acetate (3 month) 5 for subcutaneous inj kit 22.5mg ELIGARD - leuprolide acetate (4 month) 5 for subcutaneous inj kit 30 mg Dispensing Limits Prior Authorization • Drug Name Step Therapy Drug Tier 5 Dispensing Limits AFINITOR DISPERZ - everolimus tab for oral susp 2 mg Step Therapy 5 Drug Tier HYQVIA - immun glob inj 10 gm/100mlhyaluron inj 800 unt/5 ml kit Drug Name Prior Authorization 2015 • • • • • • • • • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • 5 ETOPOSIDE - etoposide cap 50 mg IBRANCE - palbociclib cap 125 mg 5 ICLUSIG - ponatinib hcl tab 15 mg (base equiv) Dispensing Limits ERIVEDGE - vismodegib cap 150 mg 5 Step Therapy EMCYT - estramustine phosphate sodium cap 140 mg 4 IBRANCE - palbociclib cap 100 mg Prior Authorization • Drug Name Drug Tier 5 Dispensing Limits Prior Authorization ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 mg Drug Name Step Therapy Drug Tier 2015 5 • • • • • • 5 • • 4 ICLUSIG - ponatinib hcl tab 45 mg (base equiv) exemestane tab 25 mg (Aromasin) 2 IMBRUVICA - ibrutinib cap 140 mg 5 FARESTON - toremifene citrate tab 60 mg (base equivalent) 4 INLYTA - axitinib tab 1 mg 5 INLYTA - axitinib tab 5 mg 5 • • • INTRON A - interferon alfa-2b inj 6000000 unit/ml 5 • • • • INTRON A - interferon alfa-2b inj 10000000 unit/ml 5 • INTRON A - interferon alfa-2b for inj 10000000 unit 5 • INTRON A - interferon alfa-2b for inj 18000000 unit 5 • FARYDAK - panobinostat lactate cap 10 5 mg (base equivalent) FARYDAK - panobinostat lactate cap 15 5 mg (base equivalent) FARYDAK - panobinostat lactate cap 20 5 mg (base equivalent) 4 FEMARA - letrozole tab 2.5 mg • • • • • • • • flutamide cap 125 mg 2 GILOTRIF - afatinib dimaleate tab 20 mg (base equivalent) 5 • • INTRON A - interferon alfa-2b for inj 50000000 unit 5 • GILOTRIF - afatinib dimaleate tab 30 mg (base equivalent) 5 • • INTRON A W/DILUENT - interferon alfa-2b for inj 10000000 unit 5 • GILOTRIF - afatinib dimaleate tab 40 mg (base equivalent) 5 • • INTRON A W/DILUENT - interferon alfa-2b for inj 18000000 unit 5 • GLEEVEC - imatinib mesylate tab 100 mg (base equivalent) 5 • • INTRON A W/DILUENT - interferon alfa-2b for inj 50000000 unit 5 • GLEEVEC - imatinib mesylate tab 400 mg (base equivalent) 5 • • IRESSA - gefitinib tab 250 mg 5 5 • • GLEOSTINE - lomustine cap 10 mg 4 JAKAFI - ruxolitinib phosphate tab 5 mg (base equivalent) • • GLEOSTINE - lomustine cap 40 mg 4 5 • • GLEOSTINE - lomustine cap 100 mg 4 JAKAFI - ruxolitinib phosphate tab 10 mg (base equivalent) HEXALEN - altretamine cap 50 mg 5 JAKAFI - ruxolitinib phosphate tab 15 mg (base equivalent) 5 • • JAKAFI - ruxolitinib phosphate tab 20 mg (base equivalent) 5 • • JAKAFI - ruxolitinib phosphate tab 25 mg (base equivalent) 5 • • LENVIMA 10MG DAILY DOSE lenvatinib cap therapy pack 10 mg (10 mg daily dose) 5 • • HYCAMTIN - topotecan hcl cap 0.25 mg 5 (base equiv) 5 HYCAMTIN - topotecan hcl cap 1 mg (base equiv) 4 HYDREA - hydroxyurea cap 500 mg hydroxyurea cap 500 mg (Hydrea) 2 IBRANCE - palbociclib cap 75 mg 5 • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 17 LENVIMA 24MG DAILY DOSE lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose) 5 letrozole tab 2.5 mg (Femara) 2 methotrexate sodium inj pf 25 mg/ml 1 • • methotrexate sodium inj 25 mg/ml 1 methotrexate sodium tab 2.5 mg (base equiv) 2 • • MYLERAN - busulfan tab 2 mg 3 NEXAVAR - sorafenib tosylate tab 200 mg (base equivalent) 5 1 NILANDRON - nilutamide tab 150 mg 4 LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3 POMALYST - pomalidomide cap 1 mg 5 POMALYST - pomalidomide cap 2 mg 5 LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 3 POMALYST - pomalidomide cap 3 mg 5 2 POMALYST - pomalidomide cap 4 mg 5 leucovorin calcium tab 5 mg 2 LEUKERAN - chlorambucil tab 2 mg 3 PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml) 4 leucovorin calcium tab 25 mg leuprolide acetate inj kit 5 mg/ml 5 LOMUSTINE - lomustine cap 10 mg 4 SOLTAMOX - tamoxifen citrate oral soln 4 10 mg/5ml (base equivalent) 5 SPRYCEL - dasatinib tab 20 mg LOMUSTINE - lomustine cap 40 mg 4 SPRYCEL - dasatinib tab 50 mg 5 LOMUSTINE - lomustine cap 100 mg 4 SPRYCEL - dasatinib tab 70 mg 5 LYNPARZA - olaparib cap 50 mg 5 SPRYCEL - dasatinib tab 80 mg 5 LYSODREN - mitotane tab 500 mg 5 SPRYCEL - dasatinib tab 100 mg 5 MATULANE - procarbazine hcl cap 50 mg 5 SPRYCEL - dasatinib tab 140 mg 5 5 4 STIVARGA - regorafenib tab 40 mg MEGACE ORAL - megestrol acetate susp 40 mg/ml megestrol acetate susp 40 mg/ml (Megace oral) 2 SUTENT - sunitinib malate cap 12.5 mg (base equivalent) megestrol acetate tab 20 mg 1 megestrol acetate tab 40 mg 1 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) 5 • • MEKINIST - trametinib dimethyl sulfoxide tab 2 mg (base equivalent) 5 • • Dispensing Limits 5 methotrexate sodium for inj 1 gm Step Therapy LENVIMA 20MG DAILY DOSE lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose) • Prior Authorization • Drug Name Drug Tier 5 Dispensing Limits Prior Authorization LENVIMA 14MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose) Drug Name Step Therapy Drug Tier 2015 • • • • • • • • • • 5 • • • • • • • • • • • • • • • • SUTENT - sunitinib malate cap 25 mg (base equivalent) 5 • • SUTENT - sunitinib malate cap 37.5 mg (base equivalent) 5 • • SUTENT - sunitinib malate cap 50 mg (base equivalent) 5 • • SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 • • mercaptopurine tab 50 mg (Purinethol) SYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 2 • MESNEX - mesna tab 400 mg SYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 4 18 • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • 5 • • tamoxifen citrate tab 20 mg (base equivalent) 1 VOTRIENT - pazopanib hcl tab 200 mg (base equiv) XALKORI - crizotinib cap 200 mg 5 TARCEVA - erlotinib hcl tab 25 mg (base equivalent) 5 • • XALKORI - crizotinib cap 250 mg 5 • • 5 TARCEVA - erlotinib hcl tab 100 mg (base equivalent) • • XELODA - capecitabine tab 150 mg 5 XELODA - capecitabine tab 500 mg 5 5 • • XTANDI - enzalutamide cap 40 mg 5 TARCEVA - erlotinib hcl tab 150 mg (base equivalent) ZELBORAF - vemurafenib tab 240 mg 5 TARGRETIN - bexarotene cap 75 mg 5 ZOLINZA - vorinostat cap 100 mg 5 TASIGNA - nilotinib hcl cap 150 mg (base equivalent) 5 ZYDELIG - idelalisib tab 100 mg 5 ZYDELIG - idelalisib tab 150 mg 5 TASIGNA - nilotinib hcl cap 200 mg (base equivalent) 5 • ZYKADIA - ceritinib cap 150 mg 5 TEMODAR - temozolomide cap 5 mg ZYTIGA - abiraterone acetate tab 250 mg 5 5 TEMODAR - temozolomide cap 20 mg 5 TEMODAR - temozolomide cap 100 mg 5 TEMODAR - temozolomide cap 140 mg 5 TEMODAR - temozolomide cap 180 mg 5 TEMODAR - temozolomide cap 250 mg 5 temozolomide cap 5 mg (Temodar) 5 temozolomide cap 20 mg (Temodar) 5 temozolomide cap 100 mg (Temodar) 5 temozolomide cap 140 mg (Temodar) 5 temozolomide cap 180 mg (Temodar) 5 temozolomide cap 250 mg (Temodar) 5 tretinoin cap 10 mg 5 • • • • • • • • • • • • • • • • • • • • • • • • TREXALL - methotrexate sodium tab 5 mg (base equiv) TREXALL - methotrexate sodium tab 7.5 mg (base equiv) 5 TAFINLAR - dabrafenib mesylate cap 75 mg (base equivalent) 5 tamoxifen citrate tab 10 mg (base equivalent) • • • • • Step Therapy 5 1 TYKERB - lapatinib ditosylate tab 250 mg (base equiv) TAFINLAR - dabrafenib mesylate cap 50 mg (base equivalent) • • Dispensing Limits Prior Authorization 4 • TREXALL - methotrexate sodium tab 15 mg (base equiv) 4 Drug Tier 4 • TREXALL - methotrexate sodium tab 10 mg (base equiv) TABLOID - thioguanine tab 40 mg Step Therapy Drug Name Drug Name Drug Tier Dispensing Limits Prior Authorization 2015 • • • • • • • ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide cap sr 24hr 3 mg (Entocort ec) 2 CORTEF - hydrocortisone tab 5 mg 4 CORTEF - hydrocortisone tab 10 mg 4 CORTEF - hydrocortisone tab 20 mg 4 CORTISONE ACETATE - cortisone acetate tab 25 mg 3 DEXAMETHASONE - dexamethasone soln 0.5 mg/5ml 4 DEXAMETHASONE - dexamethasone tab 1 mg 4 4 DEXAMETHASONE - dexamethasone tab 2 mg 4 4 dexamethasone elixir 0.5 mg/5ml 2 DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 19 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 DEXPAK 10 DAY - dexamethasone tab 1.5 mg taper pack 4 DEXPAK 13 DAY - dexamethasone tab 1.5 mg taper pack 4 DEXPAK 6 DAY - dexamethasone tab 1.5 mg taper pack 4 ENTOCORT EC - budesonide cap sr 24hr 3 mg 4 FLO-PRED - prednisolone acetate oral susp 16.7 mg/5ml (15 mg/5ml base) 4 fludrocortisone acetate tab 0.1 mg 2 hydrocortisone tab 5 mg (Cortef) 2 hydrocortisone tab 10 mg (Cortef) 2 hydrocortisone tab 20 mg (Cortef) 2 INTERARTICULAR JOINT KIT triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 4 MEDROL - methylprednisolone tab 2 mg 4 MEDROL - methylprednisolone tab 4 mg 4 MEDROL - methylprednisolone tab 8 mg 4 MEDROL - methylprednisolone tab 16 mg 4 MEDROL - methylprednisolone tab 32 mg 4 MEDROL DOSEPAK methylprednisolone tab 4 mg dose pack 4 methylprednisolone tab 4 mg dose pack (Medrol dosepak) 2 methylprednisolone tab 4 mg (Medrol) 2 20 methylprednisolone tab 16 mg (Medrol) 2 methylprednisolone tab 32 mg (Medrol) 2 MILLIPRED - prednisolone tab 5 mg 4 MILLIPRED - prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) 4 MILLIPRED DP - prednisolone tab 5 mg dose pack 4 ORAPRED ODT - prednisolone sod phos orally disintegr tab 10 mg (base eq) 4 ORAPRED ODT - prednisolone sod phos orally disintegr tab 15 mg (base eq) 4 ORAPRED ODT - prednisolone sod phos orally disintegr tab 30 mg (base eq) 4 Dispensing Limits 1 2 Step Therapy dexamethasone tab 1.5 mg methylprednisolone tab 8 mg (Medrol) Prior Authorization 1 Drug Name Drug Tier dexamethasone tab 0.75 mg Dispensing Limits 1 Step Therapy dexamethasone tab 0.5 mg Prior Authorization Drug Name Drug Tier 2015 PEDIAPRED - prednisolone sod phosph 4 oral soln 6.7 mg/5ml (5 mg/5ml base) 4 PHYSICIANS EZ USE JOINT T triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 2 prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt) 2 prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt) 2 prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt) 2 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred) 1 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • PREDNISONE - prednisone tab 50 mg ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 4 4 PREDNISONE - prednisone oral soln 5 mg/5ml 4 • • PREDNISONE - prednisone tab 5 mg dose pack 4 • • PREDNISONE - prednisone tab 10 mg dose pack 4 PREDNISONE INTENSOL - prednisone conc 5 mg/ml 4 prednisone tab 1 mg 1 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 ANDROGEL PUMP - testosterone td gel 4 12.5 mg/act (1%) ANDROGEL PUMP - testosterone td gel 4 20.25 mg/act (1.62%) 4 ANDROID - methyltestosterone cap 10 mg 4 AVEED - testosterone undecanoate im inj in oil 750 mg/3ml (250mg/ml) 4 AXIRON - testosterone td soln 30 mg/ act 2 danazol cap 50 mg prednisone tab 10 mg 1 danazol cap 100 mg 2 prednisone tab 20 mg 1 danazol cap 200 mg 2 RAYOS - prednisone tab delayed release 1 mg 4 DEPO-TESTOSTERONE - testosterone cypionate im inj in oil 100 mg/ml RAYOS - prednisone tab delayed release 2 mg 4 RAYOS - prednisone tab delayed release 5 mg Dispensing Limits Prior Authorization • prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone) ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) 4 1 Drug Name Step Therapy Drug Tier • 4 Dispensing Limits • PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) Step Therapy 4 Drug Tier ANDROGEL - testosterone td gel 50 mg/5gm (1%) Drug Name Prior Authorization 2015 • • • • • 4 • • • • • DEPO-TESTOSTERONE - testosterone cypionate im inj in oil 200 mg/ml 4 • • 4 FORTESTA - testosterone td gel 10mg/ act (2%) 4 • • UCERIS - budesonide tab sr 24hr 9 mg 4 4 • VERIPRED 20 - prednisolone sod phosphate oral soln 20 mg/5ml (base equiv) 4 METHITEST - methyltestosterone oral tab 10 mg NATESTO - testosterone nasal gel 5.5 mg/act 4 • • OXANDRIN - oxandrolone tab 2.5 mg 4 OXANDRIN - oxandrolone tab 10 mg 4 oxandrolone tab 2.5 mg (Oxandrin) 2 • ANADROL-50 - oxymetholone tab 50 mg 4 ANDRODERM - testosterone td patch 24hr 2 mg/24hr 4 • • oxandrolone tab 10 mg (Oxandrin) 2 4 • STRIANT - testosterone buccal mucoadhesive system 30 mg 4 ANDRODERM - testosterone td patch 24hr 4 mg/24hr • • • • • • • • • ANDROGEL - testosterone td gel 25 mg/2.5gm (1%) • TESTIM - testosterone td gel 50 mg/5gm (1%) 4 4 TESTOSTERONE - testosterone td gel 25 mg/2.5gm (1%) 4 • • ANDROGEN-ANABOLIC • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 21 4 • TESTOSTERONE - testosterone td gel 10mg/act (2%) 4 • • CLIMARA - estradiol td patch weekly 0.05 mg/24hr 4 • TESTOSTERONE - testosterone cypionate im inj in oil 250 mg/ml 4 CLIMARA - estradiol td patch weekly 0.06 mg/24hr 4 • testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone) 2 • • CLIMARA - estradiol td patch weekly 0.075 mg/24hr 4 • testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone) 2 • • • testosterone enanthate im inj in oil 200 mg/ml 2 • • TESTOSTERONE PUMP - testosterone td gel 12.5 mg/act (1%) 4 • • TESTRED - methyltestosterone cap 10 mg 4 • VOGELXO - testosterone td gel 50 mg/5gm (1%) 4 • • VOGELXO PUMP - testosterone td gel 12.5 mg/act (1%) 4 • • CLIMARA - estradiol td patch weekly 0.1 4 mg/24hr 4 CLIMARA PRO - estradiollevonorgestrel td patch weekly 0.045-0.015 mg/day COMBIPATCH - estradiol-norethindrone 3 ace td pttw 0.05-0.14 mg/day COMBIPATCH - estradiol-norethindrone 3 ace td pttw 0.05-0.25 mg/day 3 DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%) DIVIGEL - estradiol td gel 0.5 mg/0.5gm 3 (0.1%) 3 DIVIGEL - estradiol td gel 1 mg/gm (0.1%) 4 DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg 4 ELESTRIN - estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump) 4 ENJUVIA - estrogens, conjugated synthetic b tab 0.3 mg 4 ENJUVIA - estrogens, conjugated synthetic b tab 0.45 mg 4 ENJUVIA - estrogens, conjugated synthetic b tab 0.625 mg 4 ENJUVIA - estrogens, conjugated synthetic b tab 0.9 mg 4 ENJUVIA - estrogens, conjugated synthetic b tab 1.25 mg 2 esterified estrogens & methyltestosterone tab 0.625-1.25 mg ACTIVELLA - estradiol & norethindrone acetate tab 0.5-0.1 mg 4 ACTIVELLA - estradiol & norethindrone acetate tab 1-0.5 mg 4 ALORA - estradiol td patch twice weekly 0.025 mg/24hr 4 • ALORA - estradiol td patch twice weekly 0.05 mg/24hr 4 • ALORA - estradiol td patch twice weekly 0.075 mg/24hr 4 • ALORA - estradiol td patch twice weekly 0.1 mg/24hr 4 • ANGELIQ - drospirenone-estradiol tab 0.25-0.5 mg 4 ANGELIQ - drospirenone-estradiol tab 0.5-1 mg 4 CLIMARA - estradiol td patch weekly 0.025 mg/24hr 4 22 • Dispensing Limits CLIMARA - estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) Step Therapy • ESTROGENS Prior Authorization • Drug Name Drug Tier 4 Dispensing Limits Prior Authorization TESTOSTERONE - testosterone td gel 50 mg/5gm (1%) Drug Name Step Therapy Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 esterified estrogens & methyltestosterone tab 1.25-2.5 mg 2 estropipate tab 1.5 mg 1 ESTRACE - estradiol tab 0.5 mg EVAMIST - estradiol transdermal spray 1.53 mg/spray 4 4 ESTRACE - estradiol tab 1 mg 4 4 ESTRACE - estradiol tab 2 mg 4 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) 2 FEMHRT LOW DOSE - norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg 4 estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 2 MENEST - esterified estrogens tab 0.3 mg 4 estradiol tab 0.5 mg (Estrace) 1 MENEST - esterified estrogens tab 0.625 mg 1 MENEST - esterified estrogens tab 1.25 mg 4 estradiol tab 1 mg (Estrace) estradiol tab 2 mg (Estrace) 1 estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) • MENEST - esterified estrogens tab 2.5 mg 4 2 4 2 • • estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) MENOSTAR - estradiol td patch weekly 14 mcg/24hr • • 2 MINIVELLE - estradiol td patch twice weekly 0.025 mg/24hr 4 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) • estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot) • MINIVELLE - estradiol td patch twice weekly 0.0375 mg/24hr 4 2 • • estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) MINIVELLE - estradiol td patch twice weekly 0.05 mg/24hr 4 2 • • estradiol td patch weekly 0.025 mg/24hr (Climara) MINIVELLE - estradiol td patch twice weekly 0.075 mg/24hr 4 2 • • 2 MINIVELLE - estradiol td patch twice weekly 0.1 mg/24hr 4 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara) 2 estradiol td patch weekly 0.05 mg/24hr (Climara) 2 • norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose) estradiol td patch weekly 0.06 mg/24hr (Climara) • PREFEST - estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15) 4 2 estradiol td patch weekly 0.075 mg/24hr (Climara) 2 • PREMARIN - estrogens, conjugated tab 0.3 mg 4 estradiol td patch weekly 0.1 mg/24hr (Climara) 2 • PREMARIN - estrogens, conjugated tab 0.45 mg 4 ESTROGEL - estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump) 4 PREMARIN - estrogens, conjugated tab 0.625 mg 4 ESTROPIPATE - estropipate tab 3 mg 4 4 estropipate tab 0.75 mg 1 PREMARIN - estrogens, conjugated tab 0.9 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 23 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 PREMARIN - estrogens, conjugated tab 1.25 mg 4 DESOGEN - desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 4 • PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14) 4 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette) 2 • PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.3-1.5 mg 4 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa) 2 • PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.45-1.5 mg 4 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) 1 • • PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.625-2.5 mg drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) 2 4 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) 2 • PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.625-5 mg 4 ELLA - ulipristal acetate tab 30 mg 3 • • VIVELLE-DOT - estradiol td patch twice weekly 0.025 mg/24hr 4 • ESTROSTEP FE - norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 4 4 • ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 2 VIVELLE-DOT - estradiol td patch twice weekly 0.0375 mg/24hr • 4 • FALESSA - levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit 4 VIVELLE-DOT - estradiol td patch twice weekly 0.05 mg/24hr • 4 • FEMCON FE - norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 4 VIVELLE-DOT - estradiol td patch twice weekly 0.075 mg/24hr • 4 • GENERESS FE - norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 4 VIVELLE-DOT - estradiol td patch twice weekly 0.1 mg/24hr • • levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique) 2 • 4 BREVICON-28 - norethindrone & ethinyl 4 estradiol tab 0.5 mg-35 mcg 4 CYCLESSA - desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mgmg 4 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml 4 DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate subcutaneous susp 104 mg/0.65ml • levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique) 2 • levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 2 • levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 1 • levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 2 • levonorgestrel tab 1.5 mg (Plan b one-step) 2 • CONTRACEPTIVES BEYAZ - drospirenone-ethinyl estradlevomefolate tab 3-0.02-0.451 mg 24 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 2 • norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35) 2 • levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 2 • norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28) 2 • LO LOESTRIN FE - norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2) 4 • norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35) 2 • • • 4 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe) 2 LOESTRIN FE 1.5/30 - norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg • LOESTRIN FE 1/20 - norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg • norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe) 2 4 • • LOESTRIN 1.5/30-21 - norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe) 2 4 2 4 • • LOESTRIN 1/20-21 - norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) • • 4 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) 2 LOSEASONIQUE - levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) • medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20) 2 1 • • MINASTRIN 24 FE - norethindrone aceeth estradiol-fe chew tab 1 mg-20 mcg (24) norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30) 2 4 • • 4 norethindrone ace-ethinyl estradiolfe tab 1 mg-20 mcg (24) (Lomedia 24 fe) 2 MIRCETTE - desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) MODICON - norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 4 • norethindrone tab 0.35 mg (Nor-qd) 2 NATAZIA - estradiol valerate-dienogest tab 3 mg /2-2 mg/2-3 mg/1 mg norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7) 2 4 • • • NECON 1/50-28 - norethindrone & mestranol tab 1 mg-50 mcg 4 • 2 • NECON 10/11-28 - norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11) 4 • norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen) 1 • NOR-QD - norethindrone tab 0.35 mg 4 1 • norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr (Ortho evra) 2 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen) • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 25 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 2 • NORINYL 1+35 - norethindrone & ethinyl estradiol tab 1 mg-35 mcg 4 NORINYL 1+50 - norethindrone & mestranol tab 1 mg-50 mcg 4 NUVARING - etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr 3 OGESTREL - norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 4 • • TRI-NORINYL 28 - norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg 4 • • YASMIN 28 - drospirenone-ethinyl estradiol tab 3-0.03 mg 4 • • YAZ - drospirenone-ethinyl estradiol tab 3-0.02 mg 4 • 4 • ZOVIA 1/50E - ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg ORTHO EVRA - norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr 4 • AYGESTIN - norethindrone acetate tab 5 mg 4 ORTHO MICRONOR - norethindrone tab 0.35 mg 4 • medroxyprogesterone acetate tab 2.5 mg (Provera) 1 ORTHO TRI-CYCLEN norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 4 • medroxyprogesterone acetate tab 5 mg (Provera) 1 4 • medroxyprogesterone acetate tab 10 mg (Provera) 1 ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 4 ORTHO-CEPT - desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 4 • MEGACE ES - megestrol acetate susp 625 mg/5ml 4 ORTHO-CYCLEN - norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 4 • megestrol acetate susp 625 mg/5ml (Megace es) 2 ORTHO-NOVUM 1/35 - norethindrone & 4 ethinyl estradiol tab 1 mg-35 mcg ORTHO-NOVUM 7/7/7 - norethindrone- 4 eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 4 OVCON-35 - norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg PLAN B ONE-STEP - levonorgestrel tab 4 1.5 mg 4 QUARTETTE - levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg SAFYRAL - drospirenone-ethinyl estrad- 4 levomefolate tab 3-0.03-0.451 mg 4 SEASONIQUE - levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) • norethindrone acetate tab 5 mg (Aygestin) progesterone im in oil 50 mg/ml 2 progesterone micronized cap 100 mg (Prometrium) 2 progesterone micronized cap 200 mg (Prometrium) 2 PROMETRIUM - progesterone micronized cap 100 mg 4 PROMETRIUM - progesterone micronized cap 200 mg 4 PROVERA - medroxyprogesterone acetate tab 2.5 mg 4 • PROVERA - medroxyprogesterone acetate tab 5 mg 4 • PROVERA - medroxyprogesterone acetate tab 10 mg 4 26 PROGESTINS • • • • ANTIDIABETICS BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-500 mg 4 ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-850 mg 4 ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 15-1000 mg 4 ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 30-1000 mg 4 ACTOS - pioglitazone hcl tab 15 mg (base equiv) CVS GLUCOSE - glucose chew tab 4 gm 4 CVS GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 CVS GLUCOSE BITS - glucose chew tab 1 gm 4 CYCLOSET - bromocriptine mesylate tab 0.8 mg (base equivalent) 4 DEX4 - glucose chew tab 1 gm 4 4 DEX4 - glucose-vitamin c chew tab 4-0.006 gm 4 ACTOS - pioglitazone hcl tab 30 mg (base equiv) 4 DEX4 FAST ACTING GLUCOSE glucose oral liquid 15 gm/59ml 4 ACTOS - pioglitazone hcl tab 45 mg (base equiv) 4 DEX4 FAST ACTING GLUCOSE glucose gel 15 gm/33gm 4 AMARYL - glimepiride tab 1 mg 4 4 AMARYL - glimepiride tab 2 mg 4 DEX4 FAST ACTING GLUCOSE glucose-vitamin c chew tab 4-0.006 gm AMARYL - glimepiride tab 4 mg 4 AVANDAMET - rosiglitazone maleatemetformin hcl tab 2-1000 mg DEX4 GLUCOSE - glucose chew tab 4 gm 4 4 AVANDIA - rosiglitazone maleate tab 2 mg (base equiv) DEX4 GLUCOSE - glucose oral liquid 15 gm/59ml 4 4 4 DEX4 NATURALS - glucose-vitamin c chew tab 4-0.006 gm 4 AVANDIA - rosiglitazone maleate tab 4 mg (base equiv) AVANDIA - rosiglitazone maleate tab 8 mg (base equiv) DEX4 POUCH PACK - glucose-vitamin c chew tab 4-0.006 gm 4 4 BD GLUCOSE - glucose chew tab 5 gm DEX4 QUICK DISSOLVE GLUCO glucose chew tab 4 gm 4 4 BYDUREON - exenatide extended release for susp pen-injector 2 mg 4 DIABETA - glyburide tab 1.25 mg 4 4 BYDUREON - exenatide extended release for inj susp 2 mg • • DIABETA - glyburide tab 2.5 mg 4 DIABETA - glyburide tab 5 mg 4 4 • • DRUG MART GLUCOSE - glucose chew tab 4 gm 4 BYETTA - exenatide soln pen-injector 5 mcg/0.02ml 4 • • DRUG MART GLUCOSE - glucosevitamin c chew tab 4-0.006 gm 4 BYETTA - exenatide soln pen-injector 10 mcg/0.04ml 4 DUETACT - pioglitazone hcl-glimepiride tab 30-2 mg 4 CHLORPROPAMIDE - chlorpropamide tab 100 mg • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits 2 4 Step Therapy acarbose tab 100 mg (Precose) CHLORPROPAMIDE - chlorpropamide tab 250 mg Prior Authorization 2 Drug Name Drug Tier acarbose tab 50 mg (Precose) Dispensing Limits 2 Step Therapy acarbose tab 25 mg (Precose) Prior Authorization Drug Name Drug Tier 2015 27 DUETACT - pioglitazone hcl-glimepiride tab 30-4 mg 4 FARXIGA - dapagliflozin propanediol tab 10 mg (base equivalent) 4 FORTAMET - metformin hcl tab sr 24hr osmotic 500 mg 4 FORTAMET - metformin hcl tab sr 24hr osmotic 1000 mg 4 glimepiride tab 1 mg (Amaryl) 1 glimepiride tab 2 mg (Amaryl) 1 glimepiride tab 4 mg (Amaryl) 1 GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 glucose gel 40% 1 glucose oral liquid 15 gm/59ml 2 GLUCOTROL - glipizide tab 5 mg 4 GLUCOTROL - glipizide tab 10 mg 4 GLUCOTROL XL - glipizide tab sr 24hr 2.5 mg 4 GLUCOTROL XL - glipizide tab sr 24hr 5 mg 4 glipizide tab sr 24hr 2.5 mg (Glucotrol xl) GLUCOTROL XL - glipizide tab sr 24hr 10 mg 4 1 glipizide tab sr 24hr 5 mg (Glucotrol xl) GLUCOVANCE - glyburide-metformin tab 1.25-250 mg 4 1 1 GLUCOVANCE - glyburide-metformin tab 2.5-500 mg 4 glipizide tab sr 24hr 10 mg (Glucotrol xl) 1 GLUCOVANCE - glyburide-metformin tab 5-500 mg 4 glipizide tab 5 mg (Glucotrol) glipizide tab 10 mg (Glucotrol) 1 4 glipizide-metformin hcl tab 2.5-250 mg 2 GLUMETZA - metformin hcl tab sr 24hr modified release 500 mg 4 glipizide-metformin hcl tab 2.5-500 mg 2 GLUMETZA - metformin hcl tab sr 24hr modified release 1000 mg GLYBURIDE - glyburide tab 1.25 mg 4 glipizide-metformin hcl tab 5-500 mg 2 GLYBURIDE - glyburide tab 2.5 mg 4 GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg (base equiv) 4 GLYBURIDE - glyburide tab 5 mg 4 GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg glyburide micronized tab 1.5 mg (Glynase) 1 3 GLUCOPHAGE - metformin hcl tab 500 mg glyburide micronized tab 3 mg (Glynase) 1 4 GLUCOPHAGE - metformin hcl tab 850 mg glyburide micronized tab 6 mg (Glynase) 1 4 glyburide tab 1.25 mg 1 GLUCOPHAGE - metformin hcl tab 1000 mg 4 glyburide tab 2.5 mg 1 4 glyburide tab 5 mg 1 GLUCOPHAGE XR - metformin hcl tab sr 24hr 500 mg 1 GLUCOPHAGE XR - metformin hcl tab sr 24hr 750 mg 4 glyburide-metformin tab 1.25-250 mg (Glucovance) 1 GLUCOSE - glucose chew tab 4 gm 4 glyburide-metformin tab 2.5-500 mg (Glucovance) 28 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 glyburide-metformin tab 5-500 mg (Glucovance) 1 JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 4 • GLYNASE - glyburide micronized tab 1.5 mg 4 JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 50-500 mg 4 • GLYNASE - glyburide micronized tab 3 mg 4 JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 50-1000 mg 4 • GLYNASE - glyburide micronized tab 6 mg 4 JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 100-1000 mg 4 • GLYSET - miglitol tab 25 mg 4 4 • GLYSET - miglitol tab 50 mg 4 JANUVIA - sitagliptin phosphate tab 25 mg (base equiv) GLYSET - miglitol tab 100 mg 4 4 • GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg 4 • JANUVIA - sitagliptin phosphate tab 50 mg (base equiv) • GLYXAMBI - empagliflozin-linagliptin tab 25-5 mg 4 • JANUVIA - sitagliptin phosphate tab 100 4 mg (base equiv) 3 JARDIANCE - empagliflozin tab 10 mg GNP GLUCOSE - glucose chew tab 4 gm 4 JARDIANCE - empagliflozin tab 25 mg 3 4 GNP GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg • • • 4 • GNP QUICK DISSOLVE GLUCOS glucose chew tab 4 gm 4 JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 • KAZANO - alogliptin-metformin hcl tab 12.5-500 mg 4 • KAZANO - alogliptin-metformin hcl tab 12.5-1000 mg 4 • KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 2.5-1000 mg 4 • KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500 mg 4 • KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000 mg 4 • KORLYM - mifepristone tab 300 mg 5 KROGER GLUCOSE - glucose chew tab 4 gm 4 KROGER GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 LEADER GLUCOSE - glucose chew tab 4 gm 4 HM GLUCOSE - glucose-vitamin c chew 4 tab 4-0.006 gm HY-VEE GLUCOSE - glucose-vitamin c 4 chew tab 4-0.006 gm 4 INSTA-GLUCOSE - glucose gel 77.4% INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 4 • INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 4 • INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 4 INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 4 INVOKANA - canagliflozin tab 100 mg 4 INVOKANA - canagliflozin tab 300 mg 4 JANUMET - sitagliptin-metformin hcl tab 50-500 mg 4 • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • 29 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 LEADER GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 OSENI - alogliptin-pioglitazone tab 12.5-15 mg 4 • LEADER QUICK DISSOLVE GLU glucose chew tab 4 gm 4 OSENI - alogliptin-pioglitazone tab 12.5-30 mg 4 • LONGS GLUCOSE - glucose chew tab 4 gm 4 OSENI - alogliptin-pioglitazone tab 12.5-45 mg 4 • LONGS GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 OSENI - alogliptin-pioglitazone tab 25-15 mg 4 • MEDICINE SHOPPE GLUCOSE glucose chew tab 4 gm 4 OSENI - alogliptin-pioglitazone tab 25-30 mg 4 • MEIJER GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 OSENI - alogliptin-pioglitazone tab 25-45 mg 4 • metformin hcl tab sr 24hr 500 mg (Glucophage xr) 1 pioglitazone hcl tab 15 mg (base equiv) (Actos) 1 metformin hcl tab sr 24hr 750 mg (Glucophage xr) 1 pioglitazone hcl tab 30 mg (base equiv) (Actos) 1 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet) 2 pioglitazone hcl tab 45 mg (base equiv) (Actos) 1 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet) 2 pioglitazone hcl-glimepiride tab 30-2 mg (Duetact) 2 metformin hcl tab 500 mg (Glucophage) 1 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact) 2 metformin hcl tab 850 mg (Glucophage) 1 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met) 2 metformin hcl tab 1000 mg (Glucophage) 1 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met) 2 MS QUICK DISSOLVE GLUCOSE glucose chew tab 4 gm 4 PRANDIMET - repaglinide-metformin hcl tab 1-500 mg 4 nateglinide tab 60 mg (Starlix) 2 4 nateglinide tab 120 mg (Starlix) 2 PRANDIMET - repaglinide-metformin hcl tab 2-500 mg NESINA - alogliptin benzoate tab 6.25 mg (base equiv) 4 PRANDIN - repaglinide tab 0.5 mg 4 PRANDIN - repaglinide tab 1 mg 4 NESINA - alogliptin benzoate tab 12.5 mg (base equiv) 4 • PRANDIN - repaglinide tab 2 mg 4 4 4 • PRECOSE - acarbose tab 25 mg NESINA - alogliptin benzoate tab 25 mg (base equiv) PRECOSE - acarbose tab 50 mg 4 4 • PRECOSE - acarbose tab 100 mg 4 ONGLYZA - saxagliptin hcl tab 2.5 mg (base equiv) 4 ONGLYZA - saxagliptin hcl tab 5 mg (base equiv) 4 PREFERRED PLUS GLUCOSE glucose chew tab 4 gm 30 • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 TRADJENTA - linagliptin tab 5 mg 4 TRULICITY - dulaglutide soln peninjector 0.75 mg/0.5ml 4 • • • TRULICITY - dulaglutide soln peninjector 1.5 mg/0.5ml 4 • • ULTILET GLUCOSE - glucose chew tab 4 gm 4 UP & UP GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 VALUE PLUS GLUCOSE - glucose chew tab 4 gm 4 VALUE PLUS GLUCOSE - glucosevitamin c chew tab 4-0.006 gm 4 3 PREFERRED PLUS GLUCOSE glucose-vitamin c chew tab 4-0.006 gm 4 PROGLYCEM - diazoxide susp 50 mg/ ml 4 PX GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 RA GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 RELION GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm 4 repaglinide tab 0.5 mg (Prandin) 2 repaglinide tab 1 mg (Prandin) 2 repaglinide tab 2 mg (Prandin) 2 RIOMET - metformin hcl oral soln 500 mg/5ml 4 VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 4 SM GLUCOSE - glucose chew tab 4 gm 4 WALGREENS GLUCOSE - glucose chew tab 4 gm WALGREENS GLUCOSE - glucosevitamin c chew tab 4-0.006 gm 4 XIGDUO XR - dapagliflozin-metformin hcl tab sr 24hr 5-500 mg 4 • XIGDUO XR - dapagliflozin-metformin hcl tab sr 24hr 5-1000 mg 4 • XIGDUO XR - dapagliflozin-metformin hcl tab sr 24hr 10-500 mg 4 • XIGDUO XR - dapagliflozin-metformin hcl tab sr 24hr 10-1000 mg 4 • SM GLUCOSE - glucose-vitamin c chew 4 tab 4-0.006 gm 4 SMART SENSE GLUCOSE - glucosevitamin c chew tab 4-0.006 gm 4 STARLIX - nateglinide tab 60 mg STARLIX - nateglinide tab 120 mg 4 SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml (1000 mcg/ ml) 4 SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ ml) 4 TANZEUM - albiglutide for soln peninjector 30 mg 4 TANZEUM - albiglutide for soln peninjector 50 mg 4 TGT GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm • • • • Rapid-Acting Insulins 4 • • • • HUMALOG - insulin lispro (human) soln cartridge 100 unit/ml 4 • • 4 HUMALOG - insulin lispro (human) inj 100 unit/ml 4 • • TOLAZAMIDE - tolazamide tab 500 mg 4 4 • • tolazamide tab 250 mg 2 HUMALOG KWIKPEN - insulin lispro (human) soln pen-injector 100 unit/ml TOLBUTAMIDE - tolbutamide tab 500 mg 4 HUMALOG KWIKPEN - insulin lispro (human) soln pen-injector 200 unit/ml 4 • • APIDRA - insulin glulisine inj 100 unit/ml 4 • • APIDRA SOLOSTAR - insulin glulisine soln pen-injector inj 100 unit/ml • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 31 • • NOVOLOG FLEXPEN - insulin aspart soln pen-injector 100 unit/ml 2 • 4 • • NOVOLOG PENFILL - insulin aspart soln cartridge 100 unit/ml 2 • HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-injector 100 unit/ml 4 • • NOVOLOG PENFILL - insulin aspart inj 100 unit/ml 2 HUMULIN N U-100 PEN - insulin nph (human) (isophane) susp pen-injector 100 unit/ml HUMULIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30) 4 • • HUMULIN 70/30 KWIKPEN - insulin nph 4 & regular susp pen-inj 100 unit/ml (70-30) 4 HUMULIN 70/30 PEN - insulin nph & regular susp pen-inj 100 unit/ml (70-30) 2 NOVOLIN N - insulin nph (human) (isophane) inj 100 unit/ml 2 NOVOLIN N RELION - insulin nph (human) (isophane) inj 100 unit/ml 2 NOVOLIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30) 2 NOVOLIN 70/30 RELION - insulin nph isophane & regular human inj 100 unit/ml (70-30) 2 NOVOLOG MIX 70/30 - insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL - insulin 2 aspart prot & aspart sus pen-inj 100 unit/ml (70-30) • • • • • Short-Acting Insulins AFREZZA - insulin regular (human) inhalation powder 4 unit/cartridge 4 • • AFREZZA - insulin regular (human) inhal powd 4 (30) & 8 (60) unit/cart 4 • • AFREZZA - insulin regular (human) inhal powd 4 (60) & 8 (30) unit/cart 4 • • AFREZZA - insulin regular (human) inh powd 8 (60) & 12 (30) unit/cart 4 • • HUMULIN R - insulin regular (human) inj 4 100 unit/ml 4 HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500 unit/ml NOVOLIN R - insulin regular (human) inj 2 100 unit/ml 2 NOVOLIN R RELION - insulin regular (human) inj 100 unit/ml 3 RELION R - insulin regular (human) inj 100 unit/ml • • • • • • Intermediate-Acting Insulins HUMALOG MIX 50/50 - insulin lispro prot & lispro (human) inj 100 unit/ml (50-50) 4 • • HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50) 4 • • HUMALOG MIX 75/25 - insulin lispro prot & lispro (human) inj 100 unit/ml (75-25) 4 • • HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25) 4 • • 32 Dispensing Limits Prior Authorization 4 Drug Name Step Therapy Drug Tier HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml Dispensing Limits • Step Therapy 2 Drug Tier NOVOLOG - insulin aspart inj 100 unit/ ml Drug Name Prior Authorization 2015 • • • • • • Basal Insulins LANTUS - insulin glargine inj 100 unit/ml 3 3 LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 3 LEVEMIR - insulin detemir inj 100 unit/ ml 3 LEVEMIR FLEXPEN - insulin detemir soln pen-injector 100 unit/ml BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/ml 3 • levothyroxine sodium tab 125 mcg (Synthroid) 1 TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml 3 • levothyroxine sodium tab 137 mcg (Synthroid) 1 levothyroxine sodium tab 150 mcg (Synthroid) 1 levothyroxine sodium tab 175 mcg (Synthroid) 1 levothyroxine sodium tab 200 mcg (Synthroid) 1 levothyroxine sodium tab 300 mcg (Synthroid) 1 liothyronine sodium tab 5 mcg (Cytomel) 2 liothyronine sodium tab 25 mcg (Cytomel) 2 liothyronine sodium tab 50 mcg (Cytomel) 2 methimazole tab 5 mg (Tapazole) 1 methimazole tab 10 mg (Tapazole) 1 NATURE-THROID - thyroid tab 16.25 mg 4 NATURE-THROID - thyroid tab 32.5 mg 4 NATURE-THROID - thyroid tab 48.75 mg (3/4 grain) 4 NATURE-THROID - thyroid tab 65 mg 4 NATURE-THROID - thyroid tab 81.25 mg 4 NATURE-THROID - thyroid tab 97.5 mg 4 NATURE-THROID - thyroid tab 113.75 mg 4 NATURE-THROID - thyroid tab 130 mg 4 NATURE-THROID - thyroid tab 195 mg 4 NATURE-THROID - thyroid tab 260 mg 4 NATURE-THROID - thyroid tab 325 mg (5 grain) 4 NATURE-THROID - thyroid tab 146.25 mg 4 THYROID AGENTS ARMOUR THYROID - thyroid tab 15 mg 4 (1/4 grain) ARMOUR THYROID - thyroid tab 30 mg 4 (1/2 grain) ARMOUR THYROID - thyroid tab 60 mg 4 (1 grain) ARMOUR THYROID - thyroid tab 90 mg 4 (1 1/2 grain) 4 ARMOUR THYROID - thyroid tab 120 mg (2 grain) 4 ARMOUR THYROID - thyroid tab 180 mg (3 grain) 4 ARMOUR THYROID - thyroid tab 240 mg (4 grain) 4 ARMOUR THYROID - thyroid tab 300 mg (5 grain) 4 CYTOMEL - liothyronine sodium tab 5 mcg CYTOMEL - liothyronine sodium tab 25 4 mcg CYTOMEL - liothyronine sodium tab 50 4 mcg 1 levothyroxine sodium tab 25 mcg (Synthroid) 1 levothyroxine sodium tab 50 mcg (Synthroid) 1 levothyroxine sodium tab 75 mcg (Synthroid) 1 levothyroxine sodium tab 88 mcg (Synthroid) 1 levothyroxine sodium tab 100 mcg (Synthroid) 1 levothyroxine sodium tab 112 mcg (Synthroid) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 33 NATURE-THROID NT-2.5 - thyroid tab 162.5 mg (2 1/2 grain) 4 THYROLAR-1/4 - liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg) 4 propylthiouracil tab 50 mg 2 THYROLAR-2 - liotrix (t3-t4) tab 120 mg (25-100 mcg) 4 THYROLAR-3 - liotrix (t3-t4) tab 180 mg (37.5-150 mcg) 4 TIROSINT - levothyroxine sodium cap 13 mcg 4 TIROSINT - levothyroxine sodium cap 25 mcg 4 TIROSINT - levothyroxine sodium cap 50 mcg 4 TIROSINT - levothyroxine sodium cap 75 mcg 4 TIROSINT - levothyroxine sodium cap 88 mcg 4 TIROSINT - levothyroxine sodium cap 100 mcg 4 TIROSINT - levothyroxine sodium cap 112 mcg 4 TIROSINT - levothyroxine sodium cap 125 mcg 4 TIROSINT - levothyroxine sodium cap 137 mcg 4 TIROSINT - levothyroxine sodium cap 150 mcg 4 WESTHROID - thyroid tab 16.25 mg 4 WESTHROID - thyroid tab 32.5 mg 4 WESTHROID - thyroid tab 48.75 mg (3/4 grain) 4 WESTHROID - thyroid tab 65 mg 4 WESTHROID - thyroid tab 81.25 mg 4 WESTHROID - thyroid tab 97.5 mg 4 WESTHROID - thyroid tab 113.75 mg 4 WESTHROID - thyroid tab 130 mg 4 WESTHROID - thyroid tab 162.5 mg (2 1/2 grain) 4 WESTHROID - thyroid tab 195 mg 4 WESTHROID - thyroid tab 260 mg 4 SYNTHROID - levothyroxine sodium tab 4 25 mcg SYNTHROID - levothyroxine sodium tab 4 50 mcg SYNTHROID - levothyroxine sodium tab 4 75 mcg SYNTHROID - levothyroxine sodium tab 4 88 mcg SYNTHROID - levothyroxine sodium tab 4 100 mcg SYNTHROID - levothyroxine sodium tab 4 112 mcg SYNTHROID - levothyroxine sodium tab 4 125 mcg SYNTHROID - levothyroxine sodium tab 4 137 mcg SYNTHROID - levothyroxine sodium tab 4 150 mcg SYNTHROID - levothyroxine sodium tab 4 175 mcg SYNTHROID - levothyroxine sodium tab 4 200 mcg SYNTHROID - levothyroxine sodium tab 4 300 mcg 4 TAPAZOLE - methimazole tab 5 mg TAPAZOLE - methimazole tab 10 mg 4 thyroid tab 30 mg (1/2 grain) (Armour thyroid) 1 thyroid tab 60 mg (1 grain) (Armour thyroid) 1 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) 1 THYROLAR-1 - liotrix (t3-t4) tab 60 mg (12.5-50 mcg) 4 THYROLAR-1/2 - liotrix (t3-t4) tab 30 mg (6.25-25 mcg) 4 34 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 WESTHROID - thyroid tab 325 mg (5 grain) 4 ACTONEL - risedronate sodium tab 150 mg 4 • WESTHROID - thyroid tab 146.25 mg 4 • WESTHROID-P - thyroid tab 16.25 mg 4 WESTHROID-P - thyroid tab 32.5 mg 4 WESTHROID-P - thyroid tab 48.75 mg (3/4 grain) 4 ALENDRONATE SODIUM - alendronate 4 sodium oral soln 70 mg/75ml ALENDRONATE SODIUM - alendronate 4 sodium tab 40 mg 1 alendronate sodium tab 5 mg WESTHROID-P - thyroid tab 65 mg 4 alendronate sodium tab 10 mg 1 WESTHROID-P - thyroid tab 97.5 mg 4 alendronate sodium tab 35 mg 1 WESTHROID-P - thyroid tab 130 mg 4 1 WP THYROID - thyroid tab 16.25 mg 4 alendronate sodium tab 70 mg (Fosamax) • • • • 4 ATELVIA - risedronate sodium tab delayed release 35 mg 4 WP THYROID - thyroid tab 32.5 mg • WP THYROID - thyroid tab 48.75 mg (3/4 grain) 4 BINOSTO - alendronate sodium effervescent tab 70 mg 4 • WP THYROID - thyroid tab 65 mg 4 • 4 BONIVA - ibandronate sodium tab 150 mg (base equivalent) 4 WP THYROID - thyroid tab 81.25 mg WP THYROID - thyroid tab 97.5 mg 4 5 • WP THYROID - thyroid tab 113.75 mg 4 BUPHENYL - sodium phenylbutyrate tab 500 mg WP THYROID - thyroid tab 130 mg 4 BUPHENYL - sodium phenylbutyrate oral powder 3 gm/teaspoonful 5 • cabergoline tab 0.5 mg 2 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) 2 calcitriol cap 0.25 mcg (Rocaltrol) 2 calcitriol cap 0.5 mcg (Rocaltrol) 2 calcitriol oral soln 1 mcg/ml (Rocaltrol) 2 CARBAGLU - carglumic acid tab 200 mg 5 CARNITOR - levocarnitine tab 330 mg 4 4 • CARNITOR - levocarnitine oral soln 1 gm/10ml (10%) 4 • CARNITOR SF - levocarnitine oral soln 1 gm/10ml (10%) 4 • CYSTADANE - betaine powder for oral solution DDAVP - desmopressin acetate nasal soln 0.01% (refrigerated) 4 OXYTOCICS CERVIDIL - dinoprostone vaginal inserts 4 10 mg 2 methylergonovine maleate tab 0.2 mg 4 PREPIDIL - dinoprostone cervical gel 0.5 mg/3gm 4 PROSTIN E2 - dinoprostone vaginal suppos 20 mg ENDOCRINE and METABOLIC AGENTS - MISC. 5 • ACTHAR HP - corticotropin inj gel 80 unit/ml 4 ACTONEL - risedronate sodium tab 5 mg 4 ACTONEL - risedronate sodium tab 30 mg 4 ACTONEL - risedronate sodium tab 35 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • 35 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 DDAVP - desmopressin acetate nasal spray soln 0.01% 4 FOSAMAX - alendronate sodium tab 70 mg 4 • DDAVP - desmopressin acetate tab 0.1 mg 4 4 • DDAVP - desmopressin acetate tab 0.2 mg 4 FOSAMAX PLUS D - alendronate sodium-cholecalciferol tab 70-2800 mg-unit 4 • DDAVP - desmopressin acetate inj 4 mcg/ml 4 FOSAMAX PLUS D - alendronate sodium-cholecalciferol tab 70-5600 mg-unit desmopressin acetate inj 4 mcg/ml (Ddavp) 2 GENOTROPIN - somatropin for subcutaneous inj 5 mg 5 • desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) 2 GENOTROPIN - somatropin for inj 12 mg (13.8 mg overfill) 5 • desmopressin acetate nasal spray soln 0.01% (Ddavp) 2 GENOTROPIN MINIQUICK somatropin for inj 0.2 mg 5 • desmopressin acetate nasal spray soln 0.01% (refrigerated) 2 GENOTROPIN MINIQUICK somatropin for inj 0.4 mg 5 • desmopressin acetate tab 0.1 mg (Ddavp) 2 GENOTROPIN MINIQUICK somatropin for inj 0.6 mg 5 • desmopressin acetate tab 0.2 mg (Ddavp) 2 GENOTROPIN MINIQUICK somatropin for inj 0.8 mg 5 • DIDRONEL - etidronate disodium tab 400 mg 4 GENOTROPIN MINIQUICK somatropin for inj 1 mg 5 • doxercalciferol cap 0.5 mcg (Hectorol) 2 GENOTROPIN MINIQUICK somatropin for inj 1.2 mg 5 • doxercalciferol cap 1 mcg (Hectorol) 2 5 • doxercalciferol cap 2.5 mcg (Hectorol) 2 GENOTROPIN MINIQUICK somatropin for inj 1.4 mg 5 • EGRIFTA - tesamorelin acetate for inj 1 mg (base equiv) 5 GENOTROPIN MINIQUICK somatropin for inj 1.6 mg 5 • EGRIFTA - tesamorelin acetate for inj 2 mg (base equiv) 5 GENOTROPIN MINIQUICK somatropin for inj 1.8 mg 5 • ETIDRONATE DISODIUM - etidronate disodium tab 200 mg 4 GENOTROPIN MINIQUICK somatropin for inj 2 mg 5 • ETIDRONATE DISODIUM - etidronate disodium tab 400 mg 4 H.P. ACTHAR - corticotropin inj gel 80 unit/ml 4 EVISTA - raloxifene hcl tab 60 mg 4 HECTOROL - doxercalciferol cap 0.5 mcg 5 HECTOROL - doxercalciferol cap 1 mcg 4 FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 4 FORTICAL - calcitonin (salmon) nasal soln 200 unit/act 4 HECTOROL - doxercalciferol cap 2.5 mcg HUMATROPE - somatropin for inj 5 mg 5 36 • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 NORDITROPIN FLEXPRO - somatropin inj 10 mg/1.5ml 5 • HUMATROPE - somatropin for inj 12 mg (36 unit) 5 • NORDITROPIN FLEXPRO - somatropin inj 15 mg/1.5ml 5 • HUMATROPE - somatropin for inj 24 mg 5 • NORDITROPIN FLEXPRO - somatropin inj 30 mg/3ml 5 • HUMATROPE COMBO PACK somatropin for inj 5 mg 5 • NORDITROPIN NORDIFLEX PEN somatropin inj 30 mg/3ml 5 • ibandronate sodium tab 150 mg (base equivalent) (Boniva) 2 NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml 5 • INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml) 5 • NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml 5 • KUVAN - sapropterin dihydrochloride soluble tab 100 mg 5 • NUTROPIN AQ NUSPIN 5 - somatropin inj 5 mg/2ml 5 • KUVAN - sapropterin dihydrochloride powder packet 100 mg 5 • NUTROPIN AQ PEN - somatropin inj 10 mg/2ml 5 • KUVAN - sapropterin dihydrochloride powder packet 500 mg 5 • NUTROPIN AQ PEN - somatropin inj 20 mg/2ml 5 • levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 2 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) 5 • levocarnitine tab 330 mg (Carnitor) 2 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) 5 • octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) 5 • octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) 5 • octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) 5 • OMNITROPE - somatropin inj 5 mg/1.5ml 5 • OMNITROPE - somatropin inj 10 mg/1.5ml 5 • OMNITROPE - somatropin for inj 5.8 mg 5 5 ORFADIN - nitisinone cap 2 mg • • • • MIACALCIN - calcitonin (salmon) inj 200 4 unit/ml MIACALCIN - calcitonin (salmon) nasal 4 soln 200 unit/act 5 MYALEPT - metreleptin for subcutaneous inj 11.3 mg 5 NATPARA - parathyroid hormone (recombinant) for inj cartridge 25 mcg 5 NATPARA - parathyroid hormone (recombinant) for inj cartridge 50 mcg 5 NATPARA - parathyroid hormone (recombinant) for inj cartridge 75 mcg 5 NATPARA - parathyroid hormone (recombinant) for inj cartridge 100 mcg 5 NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml NORDITROPIN FLEXPRO - somatropin 5 inj 5 mg/1.5ml • ORFADIN - nitisinone cap 5 mg 5 • ORFADIN - nitisinone cap 10 mg 5 OSPHENA - ospemifene tab 60 mg 4 • paricalcitol cap 1 mcg (Zemplar) 2 paricalcitol cap 2 mcg (Zemplar) 2 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Prior Authorization • Drug Name Step Therapy Drug Tier 5 Dispensing Limits Prior Authorization HUMATROPE - somatropin for inj 6 mg (18 unit) Drug Name Step Therapy Drug Tier 2015 37 2 RAVICTI - glycerol phenylbutyrate liquid 1.1 gm/ml 5 risedronate sodium tab delayed release 35 mg (Atelvia) 2 • risedronate sodium tab 5 mg (Actonel) 2 • risedronate sodium tab 30 mg (Actonel) 2 • risedronate sodium tab 35 mg (Actonel) 2 • risedronate sodium tab 150 mg (Actonel) 2 • • ROCALTROL - calcitriol oral soln 1 mcg/ 4 ml 4 ROCALTROL - calcitriol cap 0.25 mcg SENSIPAR - cinacalcet hcl tab 60 mg (base equiv) 3 SENSIPAR - cinacalcet hcl tab 90 mg (base equiv) 3 SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 4 mg 5 • SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 5 mg 5 • SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 6 mg 5 • SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml (base equiv) 5 • • SIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml (base equiv) 5 • • SIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml (base equiv) 5 • • ROCALTROL - calcitriol cap 0.5 mcg 4 SAIZEN - somatropin (non-refrigerated) for inj 5 mg 5 • sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl) 5 • SAIZEN - somatropin (non-refrigerated) for inj 8.8 mg 5 • • SAIZEN CLICK.EASY - somatropin (non-refrigerated) for inj 8.8 mg 5 • SAMSCA - tolvaptan tab 15 mg 5 SAMSCA - tolvaptan tab 30 mg 5 SANDOSTATIN - octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 5 • • • SANDOSTATIN - octreotide acetate inj 100 mcg/ml (0.1 mg/ml) 5 • SANDOSTATIN - octreotide acetate inj 200 mcg/ml (0.2 mg/ml) 5 • SANDOSTATIN - octreotide acetate inj 500 mcg/ml (0.5 mg/ml) 5 • SANDOSTATIN - octreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 • SENSIPAR - cinacalcet hcl tab 30 mg (base equiv) 3 SOMAVERT - pegvisomant for inj 10 mg 5 (as protein) SOMAVERT - pegvisomant for inj 15 mg 5 (as protein) SOMAVERT - pegvisomant for inj 20 mg 5 (as protein) SOMAVERT - pegvisomant for inj 25 mg 5 (as protein) SOMAVERT - pegvisomant for inj 30 mg 5 (as protein) STIMATE - desmopressin acetate nasal 3 soln 1.5 mg/ml SYNAREL - nafarelin acetate nasal soln 3 2 mg/ml 5 TEV-TROPIN - somatropin for subcutaneous inj 5 mg 4 ZEMPLAR - paricalcitol cap 1 mcg 38 • • Dispensing Limits raloxifene hcl tab 60 mg (Evista) Step Therapy 2 Prior Authorization paricalcitol cap 4 mcg (Zemplar) Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Drug Tier Prior Authorization 2015 ZEMPLAR - paricalcitol cap 2 mcg • • • 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 ZOMACTON - somatropin for inj 10 mg 5 isosorbide mononitrate tab 10 mg 1 ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj 8.8 mg 5 • • isosorbide mononitrate tab 20 mg 1 NITRO-BID - nitroglycerin oint 2% 4 NITRO-DUR - nitroglycerin td patch 24hr 0.1 mg/hr 4 NITRO-DUR - nitroglycerin td patch 24hr 0.2 mg/hr 4 CARDIOVASCULAR AGENTS CARDIOTONICS DIGOXIN - digoxin oral soln 0.05 mg/ml 4 digoxin tab 125 mcg (0.125 mg) (Lanoxin) 1 NITRO-DUR - nitroglycerin td patch 24hr 0.3 mg/hr 4 digoxin tab 250 mcg (0.25 mg) (Lanoxin) 1 NITRO-DUR - nitroglycerin td patch 24hr 0.4 mg/hr 4 LANOXIN - digoxin tab 62.5 mcg (0.0625 mg) 4 NITRO-DUR - nitroglycerin td patch 24hr 0.6 mg/hr 4 LANOXIN - digoxin tab 125 mcg (0.125 mg) 4 NITRO-DUR - nitroglycerin td patch 24hr 0.8 mg/hr 4 LANOXIN - digoxin tab 187.5 mcg (0.1875 mg) 4 nitroglycerin cap cr 2.5 mg 1 nitroglycerin cap cr 6.5 mg 2 LANOXIN - digoxin tab 250 mcg (0.25 mg) 4 nitroglycerin cap cr 9 mg 2 4 DILATRATE SR - isosorbide dinitrate cap cr 40 mg 4 NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/ spray 4 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 2 ISORDIL TITRADOSE - isosorbide dinitrate tab 5 mg 4 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) 2 ISORDIL TITRADOSE - isosorbide dinitrate tab 40 mg ISOSORBIDE DINITRATE - isosorbide dinitrate tab 30 mg nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur) 2 4 isosorbide dinitrate tab cr 40 mg nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur) 2 2 isosorbide dinitrate tab 5 mg (Isordil titradose) 2 2 isosorbide dinitrate tab 10 mg 2 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr) isosorbide dinitrate tab 20 mg 2 4 isosorbide mononitrate tab sr 24hr 30 mg (Imdur) 1 NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 1 NITROMIST - nitroglycerin lingual aerosol 400 mcg/spray 4 isosorbide mononitrate tab sr 24hr 60 mg (Imdur) ANTIANGINAL AGENTS Dispensing Limits 1 Step Therapy isosorbide mononitrate tab sr 24hr 120 mg (Imdur) Prior Authorization • Drug Name Drug Tier 5 Dispensing Limits Prior Authorization ZOMACTON - somatropin for subcutaneous inj 5 mg Drug Name Step Therapy Drug Tier 2015 NITROSTAT - nitroglycerin sl tab 0.3 mg 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 39 RANEXA - ranolazine tab sr 12hr 500 mg 4 RANEXA - ranolazine tab sr 12hr 1000 mg 4 BETA BLOCKERS acebutolol hcl cap 200 mg (Sectral) 1 acebutolol hcl cap 400 mg (Sectral) 1 atenolol tab 25 mg (Tenormin) 1 atenolol tab 50 mg (Tenormin) 1 atenolol tab 100 mg (Tenormin) 1 BETAPACE - sotalol hcl tab 80 mg 4 BETAPACE - sotalol hcl tab 120 mg 4 BETAPACE - sotalol hcl tab 160 mg 4 BETAPACE AF - sotalol hcl (afib/afl) tab 80 mg 4 BETAPACE AF - sotalol hcl (afib/afl) tab 120 mg 4 BETAPACE AF - sotalol hcl (afib/afl) tab 160 mg 4 betaxolol hcl tab 10 mg (Kerlone) 2 betaxolol hcl tab 20 mg (Kerlone) 2 bisoprolol fumarate tab 5 mg (Zebeta) 2 bisoprolol fumarate tab 10 mg (Zebeta) 2 BYSTOLIC - nebivolol hcl tab 2.5 mg (base equivalent) 4 BYSTOLIC - nebivolol hcl tab 5 mg (base equivalent) 4 BYSTOLIC - nebivolol hcl tab 10 mg (base equivalent) 4 BYSTOLIC - nebivolol hcl tab 20 mg (base equivalent) 4 carvedilol tab 3.125 mg (Coreg) 1 carvedilol tab 6.25 mg (Coreg) 1 carvedilol tab 12.5 mg (Coreg) 1 40 COREG - carvedilol tab 3.125 mg 4 COREG - carvedilol tab 6.25 mg 4 COREG - carvedilol tab 12.5 mg 4 COREG - carvedilol tab 25 mg 4 COREG CR - carvedilol phosphate cap sr 24hr 10 mg 4 COREG CR - carvedilol phosphate cap sr 24hr 20 mg 4 COREG CR - carvedilol phosphate cap sr 24hr 40 mg 4 COREG CR - carvedilol phosphate cap sr 24hr 80 mg 4 CORGARD - nadolol tab 20 mg 4 CORGARD - nadolol tab 40 mg 4 CORGARD - nadolol tab 80 mg 4 Dispensing Limits 1 Step Therapy carvedilol tab 25 mg (Coreg) Prior Authorization Dispensing Limits Drug Name Drug Tier NITROSTAT - nitroglycerin sl tab 0.4 mg 3 NITROSTAT - nitroglycerin sl tab 0.6 mg 3 Step Therapy Drug Name Prior Authorization Drug Tier 2015 HEMANGEOL - propranolol hcl oral soln 4 4.28 mg/ml 4 INDERAL LA - propranolol hcl cap sr 24hr 60 mg 4 INDERAL LA - propranolol hcl cap sr 24hr 80 mg 4 INDERAL LA - propranolol hcl cap sr 24hr 120 mg 4 INDERAL LA - propranolol hcl cap sr 24hr 160 mg 4 INDERAL XL - propranolol hcl sustained-release beads cap sr 24hr 80 mg 4 INDERAL XL - propranolol hcl sustained-release beads cap sr 24hr 120 mg 4 INNOPRAN XL - propranolol hcl sustained-release beads cap sr 24hr 80 mg 4 INNOPRAN XL - propranolol hcl sustained-release beads cap sr 24hr 120 mg 4 KERLONE - betaxolol hcl tab 10 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 1 labetalol hcl tab 100 mg (Trandate) 2 propranolol hcl tab 20 mg 1 labetalol hcl tab 200 mg (Trandate) 2 propranolol hcl tab 40 mg 1 labetalol hcl tab 300 mg (Trandate) 2 propranolol hcl tab 60 mg 2 LEVATOL - penbutolol sulfate tab 20 mg 4 4 LOPRESSOR - metoprolol tartrate tab 50 mg 4 LOPRESSOR - metoprolol tartrate tab 100 mg 2 metoprolol succinate tab sr 24hr 25 mg (Toprol xl) 2 metoprolol succinate tab sr 24hr 50 mg (Toprol xl) 2 metoprolol succinate tab sr 24hr 100 mg (Toprol xl) 2 metoprolol succinate tab sr 24hr 200 mg (Toprol xl) 1 metoprolol tartrate tab 25 mg propranolol hcl tab 80 mg 1 SECTRAL - acebutolol hcl cap 200 mg 4 SECTRAL - acebutolol hcl cap 400 mg 4 sotalol hcl (afib/afl) tab 80 mg (Betapace af) 2 sotalol hcl (afib/afl) tab 120 mg (Betapace af) 2 sotalol hcl (afib/afl) tab 160 mg (Betapace af) 2 sotalol hcl tab 80 mg (Betapace) 1 sotalol hcl tab 120 mg (Betapace) 1 sotalol hcl tab 160 mg (Betapace) 1 sotalol hcl tab 240 mg 2 metoprolol tartrate tab 50 mg (Lopressor) 1 SOTYLIZE - sotalol hcl oral solution 5 mg/ml 4 metoprolol tartrate tab 100 mg (Lopressor) 1 TENORMIN - atenolol tab 25 mg 4 TENORMIN - atenolol tab 50 mg 4 nadolol tab 20 mg (Corgard) 2 TENORMIN - atenolol tab 100 mg 4 nadolol tab 40 mg (Corgard) 2 4 nadolol tab 80 mg (Corgard) 2 TIMOLOL MALEATE - timolol maleate tab 5 mg pindolol tab 5 mg 2 4 pindolol tab 10 mg 2 TIMOLOL MALEATE - timolol maleate tab 10 mg 4 TIMOLOL MALEATE - timolol maleate tab 20 mg 4 PROPRANOLOL HCL - propranolol hcl oral soln 20 mg/5ml 4 TOPROL XL - metoprolol succinate tab sr 24hr 25 mg 4 PROPRANOLOL HCL - propranolol hcl oral soln 40 mg/5ml 2 TOPROL XL - metoprolol succinate tab sr 24hr 50 mg 4 propranolol hcl cap sr 24hr 60 mg (Inderal la) 2 TOPROL XL - metoprolol succinate tab sr 24hr 100 mg 4 propranolol hcl cap sr 24hr 80 mg (Inderal la) 2 TOPROL XL - metoprolol succinate tab sr 24hr 200 mg 4 propranolol hcl cap sr 24hr 120 mg (Inderal la) 2 TRANDATE - labetalol hcl tab 100 mg 4 propranolol hcl cap sr 24hr 160 mg (Inderal la) TRANDATE - labetalol hcl tab 200 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits propranolol hcl tab 10 mg Step Therapy 4 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy KERLONE - betaxolol hcl tab 20 mg Prior Authorization Drug Name Drug Tier 2015 41 CALCIUM CHANNEL BLOCKERS CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 180 mg 4 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 240 mg 4 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 300 mg 4 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 360 mg 4 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 420 mg 4 diltiazem hcl cap sr 12hr 60 mg 2 diltiazem hcl cap sr 12hr 90 mg 2 diltiazem hcl cap sr 12hr 120 mg 2 diltiazem hcl cap sr 24hr 120 mg 2 diltiazem hcl cap sr 24hr 180 mg 2 diltiazem hcl cap sr 24hr 240 mg 2 ADALAT CC - nifedipine tab sr 24hr 30 mg 4 ADALAT CC - nifedipine tab sr 24hr 60 mg 4 ADALAT CC - nifedipine tab sr 24hr 90 mg 4 amlodipine besylate tab 2.5 mg (Norvasc) 1 amlodipine besylate tab 5 mg (Norvasc) 1 amlodipine besylate tab 10 mg (Norvasc) 1 CALAN - verapamil hcl tab 80 mg 4 CALAN - verapamil hcl tab 120 mg 4 CALAN SR - verapamil hcl tab cr 120 mg diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd) 1 4 CALAN SR - verapamil hcl tab cr 180 mg diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd) 1 4 2 CALAN SR - verapamil hcl tab cr 240 mg 4 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd) 4 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd) 2 CARDIZEM - diltiazem hcl tab 30 mg CARDIZEM - diltiazem hcl tab 60 mg 4 2 CARDIZEM - diltiazem hcl tab 120 mg 4 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd) CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 120 mg 4 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la) 2 CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 180 mg 4 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la) 2 CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 240 mg 4 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la) 2 CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 300 mg 4 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la) 2 CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr 360 mg 4 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la) 2 42 Dispensing Limits 4 4 Step Therapy ZEBETA - bisoprolol fumarate tab 10 mg CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 120 mg Prior Authorization 4 Drug Name Drug Tier ZEBETA - bisoprolol fumarate tab 5 mg Dispensing Limits 4 Step Therapy TRANDATE - labetalol hcl tab 300 mg Prior Authorization Drug Name Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac) 2 nifedipine tab sr 24hr osmotic 30 mg (Procardia xl) 2 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac) 2 nifedipine tab sr 24hr osmotic 60 mg (Procardia xl) 2 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac) 2 nifedipine tab sr 24hr osmotic 90 mg (Procardia xl) 2 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac) 2 nimodipine cap 30 mg 2 2 NISOLDIPINE - nisoldipine tab sr 24hr 20 mg 4 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac) diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac) NISOLDIPINE - nisoldipine tab sr 24hr 30 mg 4 2 diltiazem hcl tab 30 mg (Cardizem) NISOLDIPINE - nisoldipine tab sr 24hr 40 mg 4 1 diltiazem hcl tab 60 mg (Cardizem) 1 4 diltiazem hcl tab 90 mg 1 NISOLDIPINE ER - nisoldipine tab sr 24hr 25.5 mg diltiazem hcl tab 120 mg (Cardizem) 1 nisoldipine tab sr 24hr 8.5 mg (Sular) 2 felodipine tab sr 24hr 2.5 mg 2 nisoldipine tab sr 24hr 17 mg (Sular) 2 felodipine tab sr 24hr 5 mg 2 nisoldipine tab sr 24hr 34 mg (Sular) 2 felodipine tab sr 24hr 10 mg 2 4 ISOPTIN SR - verapamil hcl tab cr 120 mg 4 NORVASC - amlodipine besylate tab 2.5 mg 4 ISOPTIN SR - verapamil hcl tab cr 180 mg 4 NORVASC - amlodipine besylate tab 5 mg 4 ISOPTIN SR - verapamil hcl tab cr 240 mg 4 NORVASC - amlodipine besylate tab 10 mg 4 isradipine cap 2.5 mg 2 NYMALIZE - nimodipine oral soln 60 mg/20ml 2 PROCARDIA - nifedipine cap 10 mg 4 isradipine cap 5 mg 2 PROCARDIA XL - nifedipine tab sr 24hr osmotic 30 mg 4 nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg 2 nifedipine cap 10 mg (Procardia) PROCARDIA XL - nifedipine tab sr 24hr osmotic 60 mg 4 2 nifedipine cap 20 mg 2 4 nifedipine tab sr 24hr 30 mg (Adalat cc) 2 PROCARDIA XL - nifedipine tab sr 24hr osmotic 90 mg SULAR - nisoldipine tab sr 24hr 8.5 mg 4 nifedipine tab sr 24hr 60 mg (Adalat cc) 2 SULAR - nisoldipine tab sr 24hr 17 mg 4 SULAR - nisoldipine tab sr 24hr 34 mg 4 nifedipine tab sr 24hr 90 mg (Adalat cc) 2 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 TIAZAC - diltiazem hcl extended release 4 beads cap sr 24hr 120 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 43 TIAZAC - diltiazem hcl extended release 4 beads cap sr 24hr 180 mg TIAZAC - diltiazem hcl extended release 4 beads cap sr 24hr 240 mg TIAZAC - diltiazem hcl extended release 4 beads cap sr 24hr 300 mg TIAZAC - diltiazem hcl extended release 4 beads cap sr 24hr 360 mg TIAZAC - diltiazem hcl extended release 4 beads cap sr 24hr 420 mg VERAPAMIL HCL - verapamil hcl tab 40 4 mg 2 verapamil hcl cap sr 24hr 100 mg (Verelan pm) 2 verapamil hcl cap sr 24hr 120 mg (Verelan) 2 verapamil hcl cap sr 24hr 180 mg (Verelan) 2 verapamil hcl cap sr 24hr 200 mg (Verelan pm) 2 verapamil hcl cap sr 24hr 240 mg (Verelan) 2 verapamil hcl cap sr 24hr 300 mg (Verelan pm) 2 verapamil hcl cap sr 24hr 360 mg (Verelan) 1 verapamil hcl tab cr 120 mg (Calan sr) 1 verapamil hcl tab cr 180 mg (Calan sr) 1 verapamil hcl tab cr 240 mg (Calan sr) 1 verapamil hcl tab 80 mg (Calan) VERELAN - verapamil hcl cap sr 24hr 360 mg 4 VERELAN PM - verapamil hcl cap sr 24hr 100 mg 4 VERELAN PM - verapamil hcl cap sr 24hr 200 mg 4 VERELAN PM - verapamil hcl cap sr 24hr 300 mg 4 Dispensing Limits Step Therapy ANTIARRHYTHMICS amiodarone hcl tab 100 mg 2 amiodarone hcl tab 200 mg (Cordarone) 1 amiodarone hcl tab 400 mg 2 CORDARONE - amiodarone hcl tab 200 4 mg disopyramide phosphate cap 100 mg 2 (Norpace) disopyramide phosphate cap 150 mg 2 (Norpace) 2 flecainide acetate tab 50 mg flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 MULTAQ - dronedarone hcl tab 400 mg (base equivalent) 4 NORPACE - disopyramide phosphate cap 100 mg 4 NORPACE - disopyramide phosphate cap 150 mg 4 NORPACE CR - disopyramide phosphate cap sr 12hr 100 mg 4 verapamil hcl tab 120 mg (Calan) 1 VERELAN - verapamil hcl cap sr 24hr 120 mg 4 NORPACE CR - disopyramide phosphate cap sr 12hr 150 mg 4 VERELAN - verapamil hcl cap sr 24hr 180 mg 4 propafenone hcl cap sr 12hr 225 mg (Rythmol sr) 2 VERELAN - verapamil hcl cap sr 24hr 240 mg 4 propafenone hcl cap sr 12hr 325 mg (Rythmol sr) 2 44 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 propafenone hcl cap sr 12hr 425 mg (Rythmol sr) 2 ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg 4 propafenone hcl tab 150 mg (Rythmol) 2 ACEON - perindopril erbumine tab 4 mg 4 ACEON - perindopril erbumine tab 8 mg 4 propafenone hcl tab 225 mg (Rythmol) 2 ALTACE - ramipril cap 1.25 mg 4 2 ALTACE - ramipril cap 2.5 mg 4 propafenone hcl tab 300 mg 2 ALTACE - ramipril cap 5 mg 4 quinidine gluconate tab cr 324 mg 4 ALTACE - ramipril cap 10 mg 4 QUINIDINE SULFATE - quinidine sulfate tab 200 mg 2 QUINIDINE SULFATE ER - quinidine sulfate tab cr 300 mg 4 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel) 2 quinidine sulfate tab 300 mg 2 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) 4 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) 2 RYTHMOL - propafenone hcl tab 150 mg 4 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel) 2 RYTHMOL - propafenone hcl tab 225 mg 4 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel) 2 RYTHMOL SR - propafenone hcl cap sr 12hr 225 mg 4 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel) 2 RYTHMOL SR - propafenone hcl cap sr 12hr 325 mg 4 amlodipine besylate-valsartan tab 5-160 mg (Exforge) 2 RYTHMOL SR - propafenone hcl cap sr 12hr 425 mg 4 amlodipine besylate-valsartan tab 5-320 mg (Exforge) 2 TIKOSYN - dofetilide cap 125 mcg (0.125 mg) amlodipine besylate-valsartan tab 10-160 mg (Exforge) 2 amlodipine besylate-valsartan tab 10-320 mg (Exforge) 2 amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg (Exforge hct) 2 amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg (Exforge hct) 2 amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg (Exforge hct) 2 amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg (Exforge hct) 2 TIKOSYN - dofetilide cap 250 mcg (0.25 4 mg) 4 TIKOSYN - dofetilide cap 500 mcg (0.5 mg) ANTIHYPERTENSIVES ACCUPRIL - quinapril hcl tab 5 mg 4 ACCUPRIL - quinapril hcl tab 10 mg 4 ACCUPRIL - quinapril hcl tab 20 mg 4 ACCUPRIL - quinapril hcl tab 40 mg 4 ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5 mg 4 ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 45 amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg (Exforge hct) 2 ATACAND - candesartan cilexetil tab 4 mg 4 ATACAND - candesartan cilexetil tab 8 mg 4 ATACAND - candesartan cilexetil tab 16 mg 4 ATACAND - candesartan cilexetil tab 32 mg 4 ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg 4 ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg 4 ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-25 mg 4 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) 1 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) 1 AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5 mg 4 AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5 mg 4 AVAPRO - irbesartan tab 75 mg 4 AVAPRO - irbesartan tab 150 mg 4 AVAPRO - irbesartan tab 300 mg 4 AZOR - amlodipine besylate-olmesartan medoxomil tab 5-20 mg 4 AZOR - amlodipine besylate-olmesartan medoxomil tab 5-40 mg 4 AZOR - amlodipine besylate-olmesartan medoxomil tab 10-20 mg 4 AZOR - amlodipine besylate-olmesartan medoxomil tab 10-40 mg 4 benazepril & hydrochlorothiazide tab 5-6.25 mg 2 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) 2 46 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) 2 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) 2 benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg (Lotensin) 1 benazepril hcl tab 20 mg (Lotensin) 1 benazepril hcl tab 40 mg (Lotensin) 1 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BENICAR - olmesartan medoxomil tab 5 4 mg 4 BENICAR - olmesartan medoxomil tab 20 mg 4 BENICAR - olmesartan medoxomil tab 40 mg 4 BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg 4 BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg 4 BENICAR HCT - olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg bisoprolol & hydrochlorothiazide tab 1 2.5-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 1 5-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 1 10-6.25 mg (Ziac) 2 candesartan cilexetil tab 4 mg (Atacand) 2 candesartan cilexetil tab 8 mg (Atacand) 2 candesartan cilexetil tab 16 mg (Atacand) 2 candesartan cilexetil tab 32 mg (Atacand) 2 candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 clonidine hcl tab 0.3 mg (Catapres) 1 clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) 2 clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) 2 clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) 2 CLORPRES - clonidine & chlorthalidone tab 0.1-15 mg 4 CLORPRES - clonidine & chlorthalidone tab 0.2-15 mg 4 CLORPRES - clonidine & chlorthalidone tab 0.3-15 mg 4 CORZIDE - nadolol & bendroflumethiazide tab 40-5 mg 4 CORZIDE - nadolol & bendroflumethiazide tab 80-5 mg 4 COZAAR - losartan potassium tab 25 mg 4 COZAAR - losartan potassium tab 50 mg 4 COZAAR - losartan potassium tab 100 mg 4 DEMSER - metyrosine cap 250 mg 4 candesartan cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct) 2 captopril tab 12.5 mg 1 captopril tab 25 mg 1 captopril tab 50 mg 2 captopril tab 100 mg 2 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 25-15 mg 4 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 25-25 mg 4 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 50-15 mg 4 CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab 50-25 mg 4 CARDURA - doxazosin mesylate tab 1 mg 4 CARDURA - doxazosin mesylate tab 2 mg 4 CARDURA - doxazosin mesylate tab 4 mg 4 DIBENZYLINE - phenoxybenzamine hcl cap 10 mg 3 CARDURA - doxazosin mesylate tab 8 mg 4 DIOVAN - valsartan tab 40 mg 4 DIOVAN - valsartan tab 80 mg 4 CATAPRES - clonidine hcl tab 0.1 mg 4 DIOVAN - valsartan tab 160 mg 4 CATAPRES - clonidine hcl tab 0.2 mg 4 DIOVAN - valsartan tab 320 mg 4 CATAPRES - clonidine hcl tab 0.3 mg 4 4 CATAPRES-TTS-1 - clonidine hcl td patch weekly 0.1 mg/24hr 4 DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5 mg 4 CATAPRES-TTS-2 - clonidine hcl td patch weekly 0.2 mg/24hr 4 DIOVAN HCT - valsartanhydrochlorothiazide tab 160-12.5 mg 4 CATAPRES-TTS-3 - clonidine hcl td patch weekly 0.3 mg/24hr 4 DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25 mg 4 clonidine hcl tab 0.1 mg (Catapres) 1 DIOVAN HCT - valsartanhydrochlorothiazide tab 320-12.5 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits 1 2 Step Therapy clonidine hcl tab 0.2 mg (Catapres) candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct) Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 47 DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25 mg 4 eplerenone tab 50 mg (Inspra) 2 doxazosin mesylate tab 1 mg (Cardura) EPROSARTAN MESYLATE eprosartan mesylate tab 600 mg 2 1 doxazosin mesylate tab 2 mg (Cardura) EXFORGE - amlodipine besylatevalsartan tab 5-160 mg 4 1 1 EXFORGE - amlodipine besylatevalsartan tab 5-320 mg 4 doxazosin mesylate tab 4 mg (Cardura) 1 EXFORGE - amlodipine besylatevalsartan tab 10-160 mg 4 doxazosin mesylate tab 8 mg (Cardura) DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg EXFORGE - amlodipine besylatevalsartan tab 10-320 mg 4 4 4 DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg 4 EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg 4 DUTOPROL - metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg 4 EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg 4 EDARBI - azilsartan medoxomil tab 40 mg 4 4 EDARBI - azilsartan medoxomil tab 80 mg 4 EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-12.5 mg EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg 4 4 EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-25 mg 4 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 2 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 2 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 fosinopril sodium tab 10 mg 1 fosinopril sodium tab 20 mg 1 1 fosinopril sodium tab 40 mg 1 enalapril maleate tab 2.5 mg (Vasotec) guanfacine hcl tab 1 mg (Tenex) 1 enalapril maleate tab 5 mg (Vasotec) 1 guanfacine hcl tab 2 mg (Tenex) 1 enalapril maleate tab 10 mg (Vasotec) 1 enalapril maleate tab 20 mg (Vasotec) 1 hydralazine hcl tab 10 mg 1 hydralazine hcl tab 25 mg 1 EPANED - enalapril maleate for oral soln 1 mg/ml 4 hydralazine hcl tab 50 mg 1 hydralazine hcl tab 100 mg 2 eplerenone tab 25 mg (Inspra) 2 48 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 HYZAAR - losartan potassium & hydrochlorothiazide tab 50-12.5 mg 4 HYZAAR - losartan potassium & hydrochlorothiazide tab 100-12.5 mg 1 4 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar) 1 HYZAAR - losartan potassium & hydrochlorothiazide tab 100-25 mg 4 losartan potassium tab 25 mg (Cozaar) 1 INSPRA - eplerenone tab 25 mg 4 losartan potassium tab 50 mg (Cozaar) INSPRA - eplerenone tab 50 mg 4 1 irbesartan tab 75 mg (Avapro) 1 losartan potassium tab 100 mg (Cozaar) 1 LOTENSIN - benazepril hcl tab 10 mg 4 irbesartan tab 150 mg (Avapro) 1 LOTENSIN - benazepril hcl tab 20 mg 4 irbesartan tab 300 mg (Avapro) 1 LOTENSIN - benazepril hcl tab 40 mg 4 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) 4 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) 1 LOTENSIN HCT - benazepril & hydrochlorothiazide tab 10-12.5 mg 4 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) 1 LOTENSIN HCT - benazepril & hydrochlorothiazide tab 20-12.5 mg 4 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) 1 LOTENSIN HCT - benazepril & hydrochlorothiazide tab 20-25 mg 4 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) 1 LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg 4 lisinopril tab 2.5 mg (Zestril) 1 LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg 1 LOTREL - amlodipine besylatebenazepril hcl cap 5-20 mg 4 lisinopril tab 5 mg (Prinivil) lisinopril tab 10 mg (Prinivil) 1 1 LOTREL - amlodipine besylatebenazepril hcl cap 10-20 mg 4 lisinopril tab 20 mg (Prinivil) lisinopril tab 30 mg (Zestril) 1 4 lisinopril tab 40 mg (Zestril) 1 LOTREL - amlodipine besylatebenazepril hcl cap 10-40 mg LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab 50-25 mg 4 MAVIK - trandolapril tab 1 mg 4 MAVIK - trandolapril tab 2 mg 4 LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab 100-25 mg 4 MAVIK - trandolapril tab 4 mg 4 methyldopa tab 250 mg 1 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar) 1 methyldopa tab 500 mg 1 4 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) 1 METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab 250-15 mg METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab 250-25 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 49 prazosin hcl cap 5 mg (Minipress) 2 PRESTALIA - perindopril arginineamlodipine besylate tab 3.5-2.5 mg 4 PRESTALIA - perindopril arginineamlodipine besylate tab 7-5 mg 4 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) 2 metoprolol & hydrochlorothiazide tab 100-50 mg 2 MICARDIS - telmisartan tab 20 mg 4 4 PRESTALIA - perindopril arginineamlodipine besylate tab 14-10 mg 4 MICARDIS - telmisartan tab 40 mg MICARDIS - telmisartan tab 80 mg 4 PRINIVIL - lisinopril tab 5 mg 4 MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5 mg 4 PRINIVIL - lisinopril tab 10 mg 4 PRINIVIL - lisinopril tab 20 mg 4 MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5 mg 4 PRINZIDE - lisinopril & hydrochlorothiazide tab 10-12.5 mg 4 MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg 4 4 MINIPRESS - prazosin hcl cap 1 mg 4 PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab 40-25 mg MINIPRESS - prazosin hcl cap 2 mg 4 4 MINIPRESS - prazosin hcl cap 5 mg 4 minoxidil tab 2.5 mg 1 PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab 80-25 mg 1 quinapril hcl tab 5 mg (Accupril) 1 minoxidil tab 10 mg 2 quinapril hcl tab 10 mg (Accupril) 1 moexipril hcl tab 7.5 mg (Univasc) 2 quinapril hcl tab 20 mg (Accupril) 1 moexipril hcl tab 15 mg (Univasc) 2 quinapril hcl tab 40 mg (Accupril) 1 moexipril-hydrochlorothiazide tab 7.5-12.5 mg 2 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic) 2 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) 2 moexipril-hydrochlorothiazide tab 15-25 mg 2 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) 2 nadolol & bendroflumethiazide tab 40-5 mg (Corzide) 2 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) ramipril cap 1.25 mg (Altace) 1 nadolol & bendroflumethiazide tab 80-5 mg (Corzide) 2 ramipril cap 2.5 mg (Altace) 1 ramipril cap 5 mg (Altace) 1 perindopril erbumine tab 2 mg 2 ramipril cap 10 mg (Altace) 1 perindopril erbumine tab 4 mg (Aceon) 2 RESERPINE - reserpine tab 0.1 mg 4 RESERPINE - reserpine tab 0.25 mg 4 perindopril erbumine tab 8 mg (Aceon) 2 TARKA - trandolapril-verapamil hcl tab cr 1-240 mg 4 prazosin hcl cap 1 mg (Minipress) 1 50 Dispensing Limits 1 2 Step Therapy prazosin hcl cap 2 mg (Minipress) metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 TARKA - trandolapril-verapamil hcl tab cr 2-180 mg 4 TENORETIC 50 - atenolol & chlorthalidone tab 50-25 mg 4 TARKA - trandolapril-verapamil hcl tab cr 2-240 mg 4 terazosin hcl cap 1 mg 1 terazosin hcl cap 2 mg 1 TARKA - trandolapril-verapamil hcl tab cr 4-240 mg 4 terazosin hcl cap 5 mg 1 4 terazosin hcl cap 10 mg 1 TEKTURNA - aliskiren fumarate tab 150 mg (base equivalent) 4 TEKTURNA - aliskiren fumarate tab 300 mg (base equivalent) 4 TEVETEN - eprosartan mesylate tab 600 mg 4 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5 mg 4 TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-25 mg trandolapril tab 1 mg (Mavik) 1 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25 mg 4 trandolapril tab 2 mg (Mavik) 1 trandolapril tab 4 mg (Mavik) 1 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg 4 trandolapril-verapamil hcl tab cr 1-240 mg (Tarka) 2 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25 mg 4 trandolapril-verapamil hcl tab cr 2-180 mg (Tarka) 2 telmisartan tab 20 mg (Micardis) 2 2 telmisartan tab 40 mg (Micardis) 2 trandolapril-verapamil hcl tab cr 2-240 mg (Tarka) telmisartan tab 80 mg (Micardis) 2 2 telmisartan-amlodipine tab 40-5 mg (Twynsta) 2 trandolapril-verapamil hcl tab cr 4-240 mg (Tarka) 4 telmisartan-amlodipine tab 40-10 mg (Twynsta) 2 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg 4 telmisartan-amlodipine tab 80-5 mg (Twynsta) 2 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg 4 telmisartan-amlodipine tab 80-10 mg (Twynsta) 2 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg 4 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct) 2 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5 mg 2 TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg 4 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct) 2 TWYNSTA - telmisartan-amlodipine tab 40-5 mg 4 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct) 4 TWYNSTA - telmisartan-amlodipine tab 40-10 mg 4 TENEX - guanfacine hcl tab 1 mg TENEX - guanfacine hcl tab 2 mg 4 TENORETIC 100 - atenolol & chlorthalidone tab 100-25 mg TWYNSTA - telmisartan-amlodipine tab 80-5 mg 4 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 51 TWYNSTA - telmisartan-amlodipine tab 80-10 mg 4 ZIAC - bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 4 valsartan tab 40 mg (Diovan) 2 4 valsartan tab 80 mg (Diovan) 2 ZIAC - bisoprolol & hydrochlorothiazide tab 5-6.25 mg valsartan tab 160 mg (Diovan) 2 4 valsartan tab 320 mg (Diovan) 2 ZIAC - bisoprolol & hydrochlorothiazide tab 10-6.25 mg valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) 2 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct) 2 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) 2 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct) Dispensing Limits Step Therapy DIURETICS ACETAZOLAMIDE - acetazolamide tab 125 mg 4 acetazolamide cap sr 12hr 500 mg (Diamox) 2 acetazolamide tab 250 mg 2 2 ALDACTAZIDE - spironolactone & hydrochlorothiazide tab 25-25 mg 4 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) 2 ALDACTAZIDE - spironolactone & hydrochlorothiazide tab 50-50 mg 4 VASERETIC - enalapril maleate & hydrochlorothiazide tab 10-25 mg 4 ALDACTONE - spironolactone tab 25 mg 4 VASOTEC - enalapril maleate tab 2.5 mg 4 ALDACTONE - spironolactone tab 50 mg 4 VASOTEC - enalapril maleate tab 5 mg 4 4 VASOTEC - enalapril maleate tab 10 mg 4 ALDACTONE - spironolactone tab 100 mg 1 VASOTEC - enalapril maleate tab 20 mg 4 amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg 2 VECAMYL - mecamylamine hcl tab 2.5 mg 4 bumetanide tab 0.5 mg 1 bumetanide tab 1 mg 1 ZESTORETIC - lisinopril & hydrochlorothiazide tab 10-12.5 mg 4 bumetanide tab 2 mg 1 ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-12.5 mg CHLOROTHIAZIDE - chlorothiazide tab 250 mg 4 4 chlorothiazide tab 500 mg 1 ZESTORETIC - lisinopril & hydrochlorothiazide tab 20-25 mg 4 CHLORTHALIDONE - chlorthalidone tab 25 mg 4 ZESTRIL - lisinopril tab 2.5 mg 4 4 CHLORTHALIDONE - chlorthalidone tab 50 mg 4 ZESTRIL - lisinopril tab 5 mg ZESTRIL - lisinopril tab 10 mg 4 4 ZESTRIL - lisinopril tab 20 mg 4 CHLORTHALIDONE - chlorthalidone tab 100 mg ZESTRIL - lisinopril tab 30 mg 4 DEMADEX - torsemide tab 5 mg 4 ZESTRIL - lisinopril tab 40 mg 4 DEMADEX - torsemide tab 10 mg 4 52 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2 DIAMOX - acetazolamide cap sr 12hr 500 mg 4 metolazone tab 10 mg 2 DIURIL - chlorothiazide susp 250 mg/5ml MICROZIDE - hydrochlorothiazide cap 12.5 mg 4 4 4 DYAZIDE - triamterene & hydrochlorothiazide cap 37.5-25 mg 4 NEPTAZANE - methazolamide tab 25 mg 4 NEPTAZANE - methazolamide tab 50 mg 4 DYRENIUM - triamterene cap 50 mg DYRENIUM - triamterene cap 100 mg 4 2 EDECRIN - ethacrynic acid tab 25 mg 4 FUROSEMIDE - furosemide oral soln 8 mg/ml 4 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) spironolactone tab 25 mg (Aldactone) 1 furosemide oral soln 10 mg/ml 1 spironolactone tab 50 mg (Aldactone) 1 furosemide tab 20 mg (Lasix) 1 2 furosemide tab 40 mg (Lasix) 1 spironolactone tab 100 mg (Aldactone) 1 torsemide tab 5 mg (Demadex) 1 furosemide tab 80 mg (Lasix) 1 torsemide tab 10 mg (Demadex) 1 hydrochlorothiazide cap 12.5 mg (Microzide) torsemide tab 20 mg (Demadex) 1 hydrochlorothiazide tab 12.5 mg 1 torsemide tab 100 mg (Demadex) 2 hydrochlorothiazide tab 25 mg 1 1 hydrochlorothiazide tab 50 mg 1 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) 1 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) 1 indapamide tab 1.25 mg indapamide tab 2.5 mg 1 4 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) 1 INTROL - glycerin soln 75% LASIX - furosemide tab 20 mg 4 4 LASIX - furosemide tab 40 mg 4 LASIX - furosemide tab 80 mg 4 TRIAMTERENE/HYDROCHLOROTH triamterene & hydrochlorothiazide cap 50-25 mg MAXZIDE - triamterene & hydrochlorothiazide tab 75-50 mg 4 MAXZIDE-25 - triamterene & hydrochlorothiazide tab 37.5-25 mg 4 methazolamide tab 25 mg (Neptazane) 2 methazolamide tab 50 mg (Neptazane) 2 METHYCLOTHIAZIDE methyclothiazide tab 5 mg 4 metolazone tab 2.5 mg (Zaroxolyn) 2 Dispensing Limits metolazone tab 5 mg (Zaroxolyn) Step Therapy 4 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy DEMADEX - torsemide tab 20 mg Prior Authorization Drug Name Drug Tier 2015 VASOPRESSORS ADRENACLICK - epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) 4 ADRENACLICK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 4 AUVI-Q - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000) 4 AUVI-Q - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000) 4 EPINEPHRINE - epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 53 EPINEPHRINE - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 4 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) 1 EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 3 cholestyramine light powder packets 4 gm 2 EPIPEN-JR 2-PAK - epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 3 cholestyramine light powder 4 gm/ dose (Questran light) 2 2 cholestyramine powder packets 4 gm (Questran) 2 midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg 2 2 midodrine hcl tab 10 mg 2 cholestyramine powder 4 gm/dose (Questran) NORTHERA - droxidopa cap 100 mg 4 2 NORTHERA - droxidopa cap 200 mg 4 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) 4 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) 2 NORTHERA - droxidopa cap 300 mg COLESTID - colestipol hcl tab 1 gm 4 COLESTID - colestipol hcl granules 5 gm 4 COLESTID - colestipol hcl granule packets 5 gm 4 COLESTID FLAVORED - colestipol hcl granules 5 gm 4 COLESTID FLAVORED - colestipol hcl granule packets 5 gm 4 colestipol hcl granule packets 5 gm (Colestid flavored) 2 ANTIHYPERLIPIDEMICS ADVICOR - niacin-lovastatin tab sr 24hr 500-20 mg 4 • ADVICOR - niacin-lovastatin tab sr 24hr 750-20 mg 4 • ADVICOR - niacin-lovastatin tab sr 24hr 1000-20 mg 4 • ADVICOR - niacin-lovastatin tab sr 24hr 1000-40 mg 4 • ALTOPREV - lovastatin tab sr 24hr 20 mg 4 • ALTOPREV - lovastatin tab sr 24hr 40 mg 4 • ALTOPREV - lovastatin tab sr 24hr 60 mg 4 • ANTARA - fenofibrate micronized cap 30 mg 4 ANTARA - fenofibrate micronized cap 90 mg 4 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) 1 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) 1 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) 1 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 colestipol hcl granules 5 gm (Colestid 2 flavored) 2 colestipol hcl tab 1 gm (Colestid) CRESTOR - rosuvastatin calcium tab 5 mg 3 CRESTOR - rosuvastatin calcium tab 10 3 mg CRESTOR - rosuvastatin calcium tab 20 3 mg CRESTOR - rosuvastatin calcium tab 40 3 mg FENOFIBRATE - fenofibrate cap 50 mg 4 FENOFIBRATE - fenofibrate cap 150 mg 4 FENOFIBRATE - fenofibrate tab 120 mg 4 54 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2 LESCOL - fluvastatin sodium cap 20 mg 4 fenofibrate micronized cap 67 mg (Lofibra) 2 LESCOL - fluvastatin sodium cap 40 mg 4 4 fenofibrate micronized cap 130 mg 2 LESCOL XL - fluvastatin sodium tab sr 24 hr 80 mg • • • fenofibrate micronized cap 134 mg (Lofibra) 2 LIPITOR - atorvastatin calcium tab 10 mg (base equivalent) 4 • fenofibrate micronized cap 200 mg (Lofibra) 2 LIPITOR - atorvastatin calcium tab 20 mg (base equivalent) 4 • fenofibrate tab 48 mg (Tricor) 2 4 • fenofibrate tab 54 mg (Lofibra) 1 LIPITOR - atorvastatin calcium tab 40 mg (base equivalent) fenofibrate tab 145 mg (Tricor) 2 4 • fenofibrate tab 160 mg (Lofibra) 2 LIPITOR - atorvastatin calcium tab 80 mg (base equivalent) 4 LIPOFEN - fenofibrate cap 50 mg 4 FENOFIBRIC ACID - fenofibric acid tab 35 mg LIPOFEN - fenofibrate cap 150 mg 4 FENOFIBRIC ACID - fenofibric acid tab 105 mg 4 LIPTRUZET - ezetimibe-atorvastatin tab 10-10 mg 4 • FENOGLIDE - fenofibrate tab 40 mg 4 4 • FENOGLIDE - fenofibrate tab 120 mg 4 LIPTRUZET - ezetimibe-atorvastatin tab 10-20 mg 4 LIPTRUZET - ezetimibe-atorvastatin tab 10-40 mg 4 FIBRICOR - fenofibric acid tab 35 mg • FIBRICOR - fenofibric acid tab 105 mg 4 • fluvastatin sodium cap 20 mg (Lescol) LIPTRUZET - ezetimibe-atorvastatin tab 10-80 mg 4 2 4 • fluvastatin sodium cap 40 mg (Lescol) 2 LIVALO - pitavastatin calcium tab 1 mg (base equiv) • 1 LIVALO - pitavastatin calcium tab 2 mg (base equiv) 4 gemfibrozil tab 600 mg (Lopid) JUXTAPID - lomitapide mesylate cap 5 mg (base equiv) 5 • • LIVALO - pitavastatin calcium tab 4 mg (base equiv) 4 • JUXTAPID - lomitapide mesylate cap 10 5 mg (base equiv) JUXTAPID - lomitapide mesylate cap 20 5 mg (base equiv) JUXTAPID - lomitapide mesylate cap 30 5 mg (base equiv) JUXTAPID - lomitapide mesylate cap 40 5 mg (base equiv) JUXTAPID - lomitapide mesylate cap 60 5 mg (base equiv) 5 KYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml • • LOFIBRA - fenofibrate tab 54 mg 4 LOFIBRA - fenofibrate tab 160 mg 4 LOFIBRA - fenofibrate micronized cap 67 mg 4 LOFIBRA - fenofibrate micronized cap 134 mg 4 LOFIBRA - fenofibrate micronized cap 200 mg 4 LOPID - gemfibrozil tab 600 mg 4 lovastatin tab 10 mg 1 lovastatin tab 20 mg (Mevacor) 1 • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy fenofibrate micronized cap 43 mg Prior Authorization Drug Name Drug Tier 2015 55 4 4 QUESTRAN - cholestyramine powder 4 gm/dose 4 MEVACOR - lovastatin tab 40 mg 4 QUESTRAN - cholestyramine powder packets 4 gm niacin tab cr 500 mg (antihyperlipidemic) (Niaspan) 2 QUESTRAN LIGHT - cholestyramine light powder 4 gm/dose 4 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan) 2 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan) 2 NIASPAN - niacin tab cr 500 mg (antihyperlipidemic) 4 NIASPAN - niacin tab cr 750 mg (antihyperlipidemic) 4 NIASPAN - niacin tab cr 1000 mg (antihyperlipidemic) 4 omega-3-acid ethyl esters cap 1 gm (Lovaza) 2 SIMCOR - niacin-simvastatin tab sr 24hr 4 500-20 mg SIMCOR - niacin-simvastatin tab sr 24hr 4 500-40 mg SIMCOR - niacin-simvastatin tab sr 24hr 4 750-20 mg SIMCOR - niacin-simvastatin tab sr 24hr 4 1000-20 mg SIMCOR - niacin-simvastatin tab sr 24hr 4 1000-40 mg 1 simvastatin tab 5 mg (Zocor) PRALUENT - alirocumab subcutaneous soln pen-injector 75 mg/ml 5 • • PRALUENT - alirocumab subcutaneous soln pen-injector 150 mg/ml 5 • • PRALUENT - alirocumab subcutaneous soln prefilled syringe 75 mg/ml 5 • PRALUENT - alirocumab subcutaneous soln prefilled syringe 150 mg/ml 5 • PRAVACHOL - pravastatin sodium tab 20 mg 4 PRAVACHOL - pravastatin sodium tab 40 mg 4 PRAVACHOL - pravastatin sodium tab 80 mg 4 pravastatin sodium tab 10 mg 1 pravastatin sodium tab 20 mg (Pravachol) • • • • • • simvastatin tab 10 mg (Zocor) 1 simvastatin tab 20 mg (Zocor) 1 simvastatin tab 40 mg (Zocor) 1 simvastatin tab 80 mg (Zocor) 1 • TRICOR - fenofibrate tab 48 mg 4 TRICOR - fenofibrate tab 145 mg 4 • TRIGLIDE - fenofibrate tab 160 mg 4 4 • TRILIPIX - choline fenofibrate cap dr 45 mg (fenofibric acid equiv) 4 • TRILIPIX - choline fenofibrate cap dr 135 mg (fenofibric acid equiv) VASCEPA - icosapent ethyl cap 1 gm 4 VYTORIN - ezetimibe-simvastatin tab 10-10 mg 4 • 4 • 1 VYTORIN - ezetimibe-simvastatin tab 10-20 mg 4 • pravastatin sodium tab 40 mg (Pravachol) 1 VYTORIN - ezetimibe-simvastatin tab 10-40 mg 4 • pravastatin sodium tab 80 mg (Pravachol) 1 VYTORIN - ezetimibe-simvastatin tab 10-80 mg WELCHOL - colesevelam hcl tab 625 mg 4 56 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier LOVAZA - omega-3-acid ethyl esters cap 1 gm Dispensing Limits 1 Step Therapy lovastatin tab 40 mg (Mevacor) Prior Authorization Drug Name Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 WELCHOL - colesevelam hcl packet for susp 3.75 gm 4 ZETIA - ezetimibe tab 10 mg 4 ZOCOR - simvastatin tab 5 mg 4 ZOCOR - simvastatin tab 10 mg 4 ZOCOR - simvastatin tab 20 mg 4 ZOCOR - simvastatin tab 40 mg 4 ZOCOR - simvastatin tab 80 mg 4 • • • • • • CARDIOVASCULAR AGENTS - MISC. • • • • • • • • • • • • BIDIL - isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg 4 CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10 mg 4 CADUET - amlodipine besylateatorvastatin calcium tab 2.5-20 mg 4 CADUET - amlodipine besylateatorvastatin calcium tab 2.5-40 mg 4 CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg 4 CADUET - amlodipine besylateatorvastatin calcium tab 5-20 mg 4 CADUET - amlodipine besylateatorvastatin calcium tab 5-40 mg 4 CADUET - amlodipine besylateatorvastatin calcium tab 5-80 mg 4 ADCIRCA - tadalafil tab 20 mg (pah) 5 ADEMPAS - riociguat tab 0.5 mg 5 ADEMPAS - riociguat tab 1 mg 5 ADEMPAS - riociguat tab 1.5 mg 5 ADEMPAS - riociguat tab 2 mg 5 ADEMPAS - riociguat tab 2.5 mg 5 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet) CADUET - amlodipine besylateatorvastatin calcium tab 10-10 mg 4 2 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet) CADUET - amlodipine besylateatorvastatin calcium tab 10-20 mg 4 2 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet) CADUET - amlodipine besylateatorvastatin calcium tab 10-40 mg 4 2 4 amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet) 2 CADUET - amlodipine besylateatorvastatin calcium tab 10-80 mg CIALIS - tadalafil tab 2.5 mg 3 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet) 2 CIALIS - tadalafil tab 5 mg 3 2 CORLANOR - ivabradine hcl tab 5 mg (base equiv) 4 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet) 2 CORLANOR - ivabradine hcl tab 7.5 mg (base equiv) 4 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet) amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet) 2 ENTRESTO - sacubitril-valsartan tab 24-26 mg amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet) 2 amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet) amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet) Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 • • • • 4 • • ENTRESTO - sacubitril-valsartan tab 49-51 mg 4 • • 2 ENTRESTO - sacubitril-valsartan tab 97-103 mg 4 • • 2 ISOXSUPRINE HCL - isoxsuprine hcl tab 20 mg 4 isoxsuprine hcl tab 10 mg 2 LETAIRIS - ambrisentan tab 5 mg 5 • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 57 5 ORENITRAM - treprostinil diolamine tab cr 0.125 mg (base equiv) 5 ORENITRAM - treprostinil diolamine tab cr 0.25 mg (base equiv) 5 ORENITRAM - treprostinil diolamine tab cr 1 mg (base equiv) 5 ORENITRAM - treprostinil diolamine tab cr 2.5 mg (base equiv) 5 • • REVATIO - sildenafil citrate tab 20 mg 5 REVATIO - sildenafil citrate for suspension 10 mg/ml 5 • • • • sildenafil citrate tab 20 mg (Revatio) 5 TRACLEER - bosentan tab 62.5 mg 5 TRACLEER - bosentan tab 125 mg 5 TYVASO - treprostinil inhalation solution 5 0.6 mg/ml TYVASO REFILL - treprostinil inhalation 5 solution 0.6 mg/ml 5 TYVASO STARTER - treprostinil inhalation solution 0.6 mg/ml VENTAVIS - iloprost inhalation solution 5 10 mcg/ml VENTAVIS - iloprost inhalation solution 5 20 mcg/ml • • • • • 4 CLARINEX - desloratadine syrup 0.5 mg/ml 4 4 • CLARINEX REDITABS - desloratadine tab orally disintegrating 2.5 mg 4 • CLARINEX REDITABS - desloratadine tab orally disintegrating 5 mg • • • 3 • • CIALIS - tadalafil tab 5 mg 3 RESPIRATORY AGENTS ANTIHISTAMINES • • CLEMASTINE FUMARATE - clemastine 4 fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq) 1 clemastine fumarate tab 2.68 mg cyproheptadine hcl syrup 2 mg/5ml 2 cyproheptadine hcl tab 4 mg 1 desloratadine tab orally disintegrating 2.5 mg (Clarinex reditabs) 2 desloratadine tab orally disintegrating 5 mg (Clarinex reditabs) 2 desloratadine tab 5 mg (Clarinex) 2 KARBINAL ER - carbinoxamine maleate 4 er susp 4 mg/5ml 2 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal) 2 levocetirizine dihydrochloride tab 5 mg (Xyzal) 2 promethazine hcl suppos 12.5 mg • ERECTLIE DYSFUNCTION CIALIS - tadalafil tab 2.5 mg • • promethazine hcl suppos 25 mg 2 promethazine hcl suppos 50 mg 2 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 1 promethazine hcl tab 25 mg 1 promethazine hcl tab 50 mg 1 RESPA-BR - brompheniramine maleate tab sr 12hr 11 mg 4 4 4 brompheniramine maleate tab sr 12hr 6 mg 1 BROMPHENIRAMINE TANNATE brompheniramine tannate chew tab 12 mg 4 carbinoxamine maleate soln 4 mg/5ml 1 XYZAL - levocetirizine dihydrochloride tab 5 mg carbinoxamine maleate tab 4 mg 2 XYZAL - levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) 58 Dispensing Limits OPSUMIT - macitentan tab 10 mg • CLARINEX - desloratadine tab 5 mg • • • Step Therapy 5 Prior Authorization LETAIRIS - ambrisentan tab 10 mg • • • Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Drug Tier Prior Authorization 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 NASAL AGENTS - SYSTEMIC and TOPICAL 4 ADRENALIN - epinephrine hcl nasal soln 0.1% 4 ASTEPRO - azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ATROVENT - ipratropium bromide nasal 4 soln 0.03% (21 mcg/spray) ATROVENT - ipratropium bromide nasal 4 soln 0.06% (42 mcg/spray) 2 azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro) 4 BACTROBAN NASAL - mupirocin calcium nasal oint 2% 4 BECONASE AQ - beclomethasone dipropionate monohyd nasal susp 42 mcg/spray 2 budesonide nasal susp 32 mcg/act (Rhinocort aqua) 4 DYMISTA - azelastine hcl-fluticasone prop nasal spray 137-50 mcg/act 4 FLONASE - fluticasone propionate nasal susp 50 mcg/act 4 FLUNISOLIDE - flunisolide nasal soln 25 mcg/act (0.025%) 2 flunisolide nasal soln 25 mcg/act (0.025%) (Flunisolide) 1 fluticasone propionate nasal susp 50 mcg/act (Flonase) 2 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent) 2 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent) NASONEX - mometasone furoate nasal 4 susp 50 mcg/act 2 olopatadine hcl nasal soln 0.6% (Patanase) 4 OMNARIS - ciclesonide nasal susp 50 mcg/act • • • • • • • • • • QNASL - beclomethasone dipropionate nasal aerosol 80 mcg/act 4 • QNASL CHILDRENS - beclomethasone dipropionate nasal aerosol 40 mcg/ act 4 • RHINOCORT AQUA - budesonide nasal 4 susp 32 mcg/act 2 triamcinolone acetonide nasal aerosol suspension 55 mcg/act (Nasacort aq) TYZINE - tetrahydrozoline hcl nasal soln 4 0.1% 4 TYZINE PEDIATRIC NASAL DR tetrahydrozoline hcl nasal soln 0.05% 4 VERAMYST - fluticasone furoate nasal susp 27.5 mcg/spray 4 ZETONNA - ciclesonide nasal aerosol soln 37 mcg/act (50 mcg/valve) • acetylcysteine inhal soln 20% 2 1 • benzonatate cap 100 mg (Tessalon perles) benzonatate cap 150 mg (Zonatuss) 2 benzonatate cap 200 mg 1 brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg 1 CAPCOF - phenylephrine-chlorphen w/ codeine syrup 5-2-10 mg/5ml 4 CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd 10-4-27.5 mg/5ml 4 CARBAPHEN 12 PED - phenylephchlorphen-carbetapentane susp 2.5-1.25-7.5 mg/ml 4 • • • • • • COUGH/COLD/ALLERGY • • Dispensing Limits 4 2 • Step Therapy PATANASE - olopatadine hcl nasal soln 0.6% acetylcysteine inhal soln 10% • Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 59 CLARINEX-D 12 HOUR - desloratadine & pseudoephedrine tab sr 12hr 2.5-120 mg 4 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml 2 CODAR AR - chlorpheniramine w/ codeine liquid 2-8 mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg 2 4 CODAR D - pseudoephedrine w/ codeine liquid 30-8 mg/5ml HYPER-SAL - sodium chloride soln nebu 7% 4 4 CPB WC - pseudoephedrine-bromphencodeine liq 10-1.3-6.3 mg/5ml 4 DECON-A - brompheniramine & phenylephrine elixir 2-5 mg/5ml 4 DECON-G - phenylephrinebrompheniramine-guaifenesin liqd 2-1-40 mg/ml 4 DEX-TUSS - guaifenesin-codeine liquid 300-10 mg/5ml 4 DEXTROMETHORPHAN HBR/CHLO phenylephrine-chlorphen-dm liquid 1.75-0.75-2.75 mg/ml 4 EXACTUSS - phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml 4 GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg 4 GILTUSS - phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml 4 GILTUSS PED-C - phenylephrine w/ codeine-gg liquid 2.5-3-50 mg/ml 4 GILTUSS TR - phenylephrine w/ dm-gg tab 10-28-388 mg 4 guaifenesin-codeine liquid 200-8 mg/5ml 2 guaifenesin-codeine liquid 225-7.5 mg/5ml 1 guaifenesin-codeine soln 100-6.3 mg/5ml 1 guaifenesin-codeine soln 100-10 mg/5ml 1 hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml (Tussionex pennkineti) 2 60 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 HYPERSAL - sodium chloride soln nebu 4 3.5% HYPERSAL - sodium chloride soln nebu 4 7% 1 LEXUSS 210 - chlorpheniramine w/ codeine liquid 2-10 mg/5ml 4 LORTUSS EX - pseudoephedrine w/ cod-gg liquid 30-10-100 mg/5ml 4 M-END MAX D - pseudoephedrinedexbromphen-codeine liqd 20-0.667-6 mg/5ml 4 M-END PE - phenylephrine-bromphen w/ codeine liqd 3.33-1.33-6.33 mg/5ml 4 MAR-COF BP - pseudoephedrinebromphen-codeine liqd 30-2-7.5 mg/5ml 4 MAR-COF CG EXPECTORANT guaifenesin-codeine liquid 225-7.5 mg/5ml 4 NEBUSAL - sodium chloride soln nebu 6% 4 NEOTUSS PLUS - phenylephrinechlorphen-dm liquid 7.5-4-30 mg/5ml NEOTUSS-D - pseudoephed-chlorphen 4 w/ dm-gg liqd 30-2-30-200 mg/5ml 4 NORTUSS-EX - dextromethorphanguaifenesin liquid 20-200 mg/5ml 4 NOTUSS-NX - codeine-chlorcyclizine liquid 10-9.375 mg/5ml 4 NOTUSS-NXD - codeinepseudoephedrine-chlorcyclizine liq 10-30-9.375mg/5ml 4 OBREDON - hydrocodone-guaifenesin soln 2.5-200 mg/5ml BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid 5-1-15-100 mg/5ml 4 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro) 2 PEDIATEX TDM - pseudoephedtriprolidine-dm susp 10-0.938-4 mg/ ml 4 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml 2 1 phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml 2 pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml 2 pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml (Suttar-sf) 1 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml phenylephrine-brompheniramine-dm liquid 7.5-4-15 mg/5ml pseudoephedrine-bromphen-codeine liq 10-1.33-6.33 mg/5ml 1 1 phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml) 2 phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml 4 PHENYLHISTINE DH pseudoephedrine-chlorphen w/ codeine liq 30-2-10 mg/5ml 4 POLY-TUSSIN - codeine-chlorcyclizine liquid 10-9.375 mg/5ml 4 POLY-TUSSIN AC - phenylephrinebromphen w/ codeine liquid 10-4-10 mg/5ml 4 POLY-TUSSIN D - codeinepseudoephedrine-chlorcyclizine liq 10-30-9.375mg/5ml 4 PRO-CLEAR AC - codeine-pyrilamine syrup 9-8.33 mg/5ml 4 PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup 5-1-9 mg/5ml 4 PROMETHAZINE VC PLAIN promethazine & phenylephrine syrup 6.25-5 mg/5ml 4 promethazine w/ codeine syrup 6.25-10 mg/5ml 1 promethazine-dm syrup 6.25-15 mg/5ml 1 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 RELHIST - bromphen tan-phenyleph tan 4 chew tab 6-15 mg 4 RESCON-MX - dexchlorpheniraminephenylephrine tab sr 12hr 6-40 mg 4 REZIRA - pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml 4 RYDEX - pseudoephedrine-bromphencodeine liq 10-1.33-6.33 mg/5ml 4 SEMPREX-D - acrivastine & pseudoephedrine cap 8-60 mg 2 sodium chloride soln nebu 0.9% sodium chloride soln nebu 3% 2 sodium chloride soln nebu 7% (Hyper-sal) 2 sodium chloride soln nebu 10% 2 STATUSS GREEN - codeinepseudoephedrine-chlorcyclizine liq 9-30-12.5 mg/5ml 4 SUTTAR-SF - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml 4 SUTTAR-2 - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml 4 TESSALON PERLES - benzonatate cap 4 100 mg 4 TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm syrup 5-2-15 mg/5ml BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 61 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup 30-15-150 mg/5ml 4 ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50 mcg/dose 4 • TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm syrup 30-3-15 mg/5ml 4 ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 250-50 mcg/dose 4 • TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm syrup 50-3-30 mg/5ml 4 ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50 mcg/dose 4 • TRICODE AR - pseudoephedrinechlorphen w/ codeine liq 30-2-8 mg/5ml 4 ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 4 • • TRICODE GF - pseudoephedrine w/ cod-gg liquid 30-8-200 mg/5ml ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 4 4 • TUSNEL - brompheniramine w/ dm-gg cap 2-15-200 mg ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 4 4 4 • TUSSICAPS - hydrocod polst-chlorphen polst cap sr 12hr 5-4 mg 4 AEROSPAN - flunisolide hfa inhal aerosol 80 mcg/act • 4 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2 TUSSICAPS - hydrocod polst-chlorphen polst cap sr 12hr 10-8 mg • TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml albuterol sulfate soln nebu 0.5% (5 mg/ml) 2 4 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 2 • TUZISTRA XR - codeine polistchlorphen polist er susp 14.7-2.8 mg/5ml 4 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 2 • 4 albuterol sulfate syrup 2 mg/5ml 1 VANACOF CD - phenylephrinedexchlorphenir-codeine liquid 5-1-10 mg/5ml albuterol sulfate tab sr 12hr 4 mg (Vospire er) 2 VITUZ - hydrocodone-chlorpheniramine soln 5-4 mg/5ml 4 albuterol sulfate tab sr 12hr 8 mg (Vospire er) 2 Z-TUSS AC - chlorpheniramine w/ codeine liquid 2-9 mg/5ml 4 albuterol sulfate tab 2 mg 2 albuterol sulfate tab 4 mg 2 ZONATUSS - benzonatate cap 150 mg 4 ZUTRIPRO - pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml 4 ANTIASTHMATIC and BRONCHODILATOR AGENTS 4 ACCOLATE - zafirlukast tab 10 mg ACCOLATE - zafirlukast tab 20 mg 62 4 ALVESCO - ciclesonide inhal aerosol 80 4 mcg/act 4 ALVESCO - ciclesonide inhal aerosol 160 mcg/act 4 ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25 mcg/ inh BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ARCAPTA NEOHALER - indacaterol maleate inhal powder cap 75 mcg (base equiv) 4 • COMBIVENT RESPIMAT - ipratropiumalbuterol inhal aerosol soln 20-100 mcg/act 4 • ARNUITY ELLIPTA - fluticasone furoate aerosol powder breath activ 100 mcg/ act 3 • CROMOLYN SODIUM - cromolyn sodium soln nebu 20 mg/2ml 2 • 4 ARNUITY ELLIPTA - fluticasone furoate aerosol powder breath activ 200 mcg/ act 3 • DALIRESP - roflumilast tab 500 mcg 4 • ASMANEX HFA - mometasone furoate inhal aerosol suspension 100 mcg/act 4 • DULERA - mometasone furoateformoterol fumarate aerosol 100-5 mcg/act 4 • ASMANEX HFA - mometasone furoate inhal aerosol suspension 200 mcg/act 4 • DULERA - mometasone furoateformoterol fumarate aerosol 200-5 mcg/act ASMANEX TWISTHALER 120 ME mometasone furoate inhal powd 220 mcg/inh (breath activated) • dyphylline-guaifenesin liqd 100-100 mg/5ml 1 4 4 ASMANEX TWISTHALER 30 MET mometasone furoate inhal powd 110 mcg/inh (breath activated) 4 • ELIXOPHYLLIN - theophylline elixir 80 mg/15ml FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/blister 3 • 4 • FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/ blister 3 ASMANEX TWISTHALER 30 MET mometasone furoate inhal powd 220 mcg/inh (breath activated) • 4 • FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/ blister 3 ASMANEX TWISTHALER 60 MET mometasone furoate inhal powd 220 mcg/inh (breath activated) • 4 • FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act (50/valve) 3 ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act • 4 • FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act (125/valve) 3 BREO ELLIPTA - fluticasone furoatevilanterol aero powd ba 100-25 mcg/ inh • 3 • BREO ELLIPTA - fluticasone furoatevilanterol aero powd ba 200-25 mcg/ inh 4 FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act (250/valve) FORADIL AEROLIZER - formoterol fumarate inhal cap 12 mcg 3 • BROVANA - arformoterol tartrate soln nebu 15 mcg/2ml (base equiv) 4 3 • budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 2 INCRUSE ELLIPTA - umeclidinium br aero powd breath act 62.5 mcg/inh (base eq) 1 • budesonide inhalation susp 0.5 mg/2ml (Pulmicort) 2 ipratropium bromide inhal soln 0.02% 2 • budesonide inhalation susp 1 mg/2ml (Pulmicort) 2 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) 2 • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 63 2 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex) 2 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex) 2 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex) 4 LUFYLLIN - dyphylline tab 400 mg • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 4 • • PULMICORT FLEXHALER budesonide inhal aero powd 180 mcg/act (breath activated) 3 • • QVAR - beclomethasone dipropionate inhal aero soln 40 mcg/act QVAR - beclomethasone dipropionate inhal aero soln 80 mcg/act 3 • • METAPROTERENOL SULFATE metaproterenol sulfate syrup 10 mg/5ml 4 SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv) 4 METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg 4 SINGULAIR - montelukast sodium tab 10 mg (base equiv) 4 METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg 4 SINGULAIR - montelukast sodium oral granules packet 4 mg (base equiv) 4 montelukast sodium chew tab 4 mg (base equiv) (Singulair) 1 SINGULAIR - montelukast sodium chew tab 4 mg (base equiv) 4 montelukast sodium chew tab 5 mg (base equiv) (Singulair) 1 SINGULAIR - montelukast sodium chew tab 5 mg (base equiv) 4 SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal cap 18 mcg (base equiv) 3 • SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act 3 • STIOLTO RESPIMAT - tiotropium brolodaterol inhal aero soln 2.5-2.5 mcg/act 4 • STRIVERDI RESPIMAT - olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv) 4 • SYMBICORT - budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/ act 3 • SYMBICORT - budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/ act 3 • terbutaline sulfate tab 2.5 mg 2 terbutaline sulfate tab 5 mg 2 THEO-24 - theophylline cap sr 24hr 100 mg 4 2 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair) montelukast sodium tab 10 mg (base 1 equiv) (Singulair) 4 PERFOROMIST - formoterol fumarate soln nebu 20 mcg/2ml 3 PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) 3 PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv) 4 PROVENTIL HFA - albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) 4 PULMICORT - budesonide inhalation susp 0.25 mg/2ml 4 PULMICORT - budesonide inhalation susp 0.5 mg/2ml 4 PULMICORT - budesonide inhalation susp 1 mg/2ml 4 PULMICORT FLEXHALER budesonide inhal aero powd 90 mcg/ act (breath activated) 64 • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • THEO-24 - theophylline cap sr 24hr 300 mg 4 OFEV - nintedanib esylate cap 150 mg (base equivalent) 5 • • THEO-24 - theophylline cap sr 24hr 400 mg 4 ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg 5 • • theophylline soln 80 mg/15ml 2 5 • theophylline tab sr 12hr 100 mg 1 PULMOZYME - dornase alfa inhal soln 1 mg/ml theophylline tab sr 12hr 200 mg 1 4 theophylline tab sr 12hr 300 mg 1 SURFAXIN - lucinactant intratracheal susp 30 mg/ml 2 theophylline tab sr 24hr 400 mg 2 SURVANTA INTRATRACHEAL beractant in nacl 0.9% intratracheal susp 25 mg/ml 4 theophylline tab sr 12hr 450 mg theophylline tab sr 24hr 600 mg 2 GASTROINTESTINAL AGENTS TUDORZA PRESSAIR - aclidinium bromide aerosol powd breath activated 400 mcg/act 4 VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) 3 VOSPIRE ER - albuterol sulfate tab sr 12hr 4 mg 4 VOSPIRE ER - albuterol sulfate tab sr 12hr 8 mg 4 XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) 4 zafirlukast tab 10 mg (Accolate) 2 zafirlukast tab 20 mg (Accolate) 2 ZYFLO - zileuton tab 600 mg 4 • • • ZYFLO CR - zileuton tab sr 12hr 600 mg 4 RESPIRATORY AGENTS - MISC. CUROSURF - poractant alfa intratracheal susp 80 mg/ml 4 ESBRIET - pirfenidone cap 267 mg 5 INFASURF - calfactant in nacl 0.9% intratracheal susp 35 mg/ml 4 KALYDECO - ivacaftor tab 150 mg 5 KALYDECO - ivacaftor packet 50 mg 5 KALYDECO - ivacaftor packet 75 mg 5 • • • • • Dispensing Limits Prior Authorization • Drug Name Step Therapy Drug Tier 5 Dispensing Limits OFEV - nintedanib esylate cap 100 mg (base equivalent) Step Therapy 4 Drug Tier THEO-24 - theophylline cap sr 24hr 200 mg Drug Name Prior Authorization 2015 LAXATIVES bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit 2 CASCARA SAGRADA - cascara sagrada fl ext 1 gm/ml 4 COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln 227.1 gm 4 COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln 240 gm 4 GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate packet 227.1 gm 4 GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate for soln 236 gm 4 KRISTALOSE - lactulose oral crystal packet 10 gm 4 KRISTALOSE - lactulose oral crystal packet 20 gm 4 lactulose solution 10 gm/15ml 1 MINERAL OIL HEAVY - mineral oil 4 MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln 100 gm 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 65 NULYTELY/FLAVOR PACKS - peg 3350-kcl-sod bicarb-nacl for soln 420 gm 4 OSMOPREP - sod phos mono-sod phos 4 di tabs 1.102-0.398 gm(1.5gm na phos) 4 PCP 100 - mag cit-bisacodyl-petrolatpeg-metoclopramide-electrol kit peg 3350-kcl-sod bicarb-nacl for soln 1 420 gm (Nulytely/flavor pack) 1 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) 1 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyteflavor packs) polyethylene glycol 3350 oral packet 2 polyethylene glycol 3350 oral powder 1 PREPOPIK - sod picosulfate-mg oxidecitric acid pack 10 mg-3.5 gm-12 gm 4 SENNA LEAVES - senna leaves 4 SUPREP BOWEL PREP - sodium sulfate-potassium sulfate-magnesium sulfate oral soln 4 ANTIDIARRHEALS diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) 1 DIPHENOXYLATE/ATROPINE diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml 4 FULYZAQ - crofelemer tab delayed release 125 mg 4 LOMOTIL - diphenoxylate w/ atropine tab 2.5-0.025 mg Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ULCER DRUGS ACIPHEX - rabeprazole sodium ec tab 20 mg 4 • ACIPHEX SPRINKLE - rabeprazole sodium capsule sprinkle dr 5 mg 4 • ACIPHEX SPRINKLE - rabeprazole sodium capsule sprinkle dr 10 mg 4 • amoxicillin cap-clarithro tablansopraz cap dr therapy pack (Prevpac) 2 ANASPAZ - hyoscyamine sulfate tab disp 0.125 mg 4 AXID - nizatidine cap 300 mg 4 BELLADONNA & OPIUM - belladonna alkaloids & opium suppos 16.2-30 mg 4 BELLADONNA ALKALOIDS & OP belladonna alkaloids & opium suppos 16.2-60 mg 4 BENTYL - dicyclomine hcl cap 10 mg 4 BENTYL - dicyclomine hcl tab 20 mg 4 CANTIL - mepenzolate bromide tab 25 mg 4 CARAFATE - sucralfate tab 1 gm 4 CARAFATE - sucralfate susp 1 gm/10ml 4 2 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg (Librax) 1 cimetidine hcl soln 300 mg/5ml cimetidine tab 300 mg 1 cimetidine tab 400 mg 1 cimetidine tab 800 mg 2 4 CUVPOSA - glycopyrrolate oral soln 1 mg/5ml 4 4 CYTOTEC - misoprostol tab 100 mcg 4 MOTOFEN - difenoxin w/ atropine tab 1-0.025 mg CYTOTEC - misoprostol tab 200 mcg 4 opium tincture 1% (10 mg/ml) (morphine equiv) 2 DEXILANT - dexlansoprazole cap delayed release 30 mg 4 • RESTORA RX - lactobacillus casei-folic acid cap 60-1.25 mg 4 DEXILANT - dexlansoprazole cap delayed release 60 mg 4 • dicyclomine hcl cap 10 mg (Bentyl) 1 66 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy DIGEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg Prior Authorization 1 Drug Name Drug Tier dicyclomine hcl tab 20 mg (Bentyl) Dispensing Limits 4 Step Therapy dicyclomine hcl oral soln 10 mg/5ml Prior Authorization Drug Name Drug Tier 2015 hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid) 2 4 hyoscyamine sulfate tab 0.125 mg (Levsin) 2 DONNATAL - pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg 3 lansoprazole cap delayed release 15 mg (Prevacid) 2 • DONNATAL - pb-hyoscy-atrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml 4 lansoprazole cap delayed release 30 mg (Prevacid) 2 • 4 DONNATAL EXTENTABS - pbhyoscy-atrop-scopol tab cr 48.6-0.3111-0.0582-0.0195 mg 4 LEVBID - hyoscyamine sulfate tab sr 12hr 0.375 mg esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium) 2 • esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium) 2 • famotidine for susp 40 mg/5ml (Pepcid) 2 famotidine tab 40 mg (Pepcid) 1 FIRST-LANSOPRAZOLE - lansoprazole 4 susp 3 mg/ml (compound kit) 4 FIRST-OMEPRAZOLE - omeprazole susp 2 mg/ml (compound kit) 4 GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg 4 GLYCATE - glycopyrrolate tab 1.5 mg glycopyrrolate tab 1 mg (Robinul) 2 glycopyrrolate tab 2 mg (Robinul forte) 2 hyoscyamine sulfate elixir 0.125 mg/5ml 1 hyoscyamine sulfate soln 0.125 mg/ ml 2 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz) 2 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) 2 LEVSIN - hyoscyamine sulfate tab 0.125 4 mg LEVSIN/SL - hyoscyamine sulfate tab sl 4 0.125 mg LIBRAX - chlordiazepoxide hcl-clidinium 4 bromide cap 5-2.5 mg 2 methscopolamine bromide tab 2.5 mg (Pamine) 2 methscopolamine bromide tab 5 mg (Pamine forte) 1 misoprostol tab 100 mcg (Cytotec) misoprostol tab 200 mcg (Cytotec) 1 NEXIUM - esomeprazole magnesium for 4 delayed release susp pack 2.5 mg NEXIUM - esomeprazole magnesium for 4 delayed release susp packet 5 mg NEXIUM - esomeprazole magnesium for 4 delayed release susp packet 10 mg NEXIUM - esomeprazole magnesium for 4 delayed release susp packet 20 mg NEXIUM - esomeprazole magnesium for 4 delayed release susp packet 40 mg 4 NEXIUM - esomeprazole magnesium cap delayed release 20 mg (base eq) 4 NEXIUM - esomeprazole magnesium cap delayed release 40 mg (base eq) 2 nizatidine cap 150 mg nizatidine cap 300 mg (Axid) 2 nizatidine oral soln 15 mg/ml (Axid) 2 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • • • • 67 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 PRILOSEC - omeprazole cap delayed release 10 mg 4 • PRILOSEC - omeprazole cap delayed release 20 mg 4 • PRILOSEC - omeprazole cap delayed release 40 mg 4 • PRILOSEC - omeprazole magnesium for delayed release susp packet 2.5 mg 4 • PRILOSEC - omeprazole magnesium for delayed release susp packet 10 mg 4 • • PROPANTHELINE BROMIDE propantheline bromide tab 15 mg 4 • PROTONIX - pantoprazole sodium for delayed release susp packet 40 mg 4 • 4 PROTONIX - pantoprazole sodium ec tab 20 mg (base equiv) 4 • PAMINE FORTE - methscopolamine bromide tab 5 mg 4 PROTONIX - pantoprazole sodium ec tab 40 mg (base equiv) 4 • PAMINE FQ - methscopolamine tab 5 mg & misc intestinal flora reg cap 4 4 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) 1 • PYLERA - bismuth subcitmetronidazole-tetracycline cap 140-125-125 mg 2 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) 1 • rabeprazole sodium ec tab 20 mg (Aciphex) ranitidine hcl cap 150 mg 2 PEPCID - famotidine tab 40 mg 4 ranitidine hcl cap 300 mg 2 PEPCID - famotidine for susp 40 mg/5ml 4 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 PREVACID - lansoprazole cap delayed release 15 mg 4 ranitidine hcl tab 300 mg (Zantac) 1 4 PREVACID - lansoprazole cap delayed release 30 mg • ROBINUL - glycopyrrolate tab 1 mg 4 4 PREVACID SOLUTAB - lansoprazole tab delayed release orally disintegrating 15 mg 4 • ROBINUL FORTE - glycopyrrolate tab 2 mg sucralfate tab 1 gm (Carafate) 2 PREVACID SOLUTAB - lansoprazole tab delayed release orally disintegrating 30 mg 4 PREVPAC - amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack 4 OMECLAMOX-PAK - amoxicillin capclarithro tab w/ omepraz cap dr therapy pack 4 OMEPRAZOLE + SYRSPEND SF omeprazole susp 2 mg/ml (compound kit) 4 omeprazole cap delayed release 10 mg (Prilosec) 2 • omeprazole cap delayed release 20 mg (Prilosec) 1 • omeprazole cap delayed release 40 mg (Prilosec) 1 • omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid) 2 omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid) 2 PAMINE - methscopolamine bromide tab 2.5 mg 68 • • • SYMAX DUOTAB - hyoscyamine sulfate 4 tab cr 0.375 mg (0.125 mg ir/0.25 mg cr) 4 ZANTAC - ranitidine hcl tab 300 mg ZEGERID - omeprazole-sodium bicarbonate cap 20-1100 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ZEGERID - omeprazole-sodium bicarbonate cap 40-1100 mg 4 • ondansetron orally disintegrating tab 8 mg (Zofran odt) 2 • ZEGERID - omeprazole-sodium bicarbonate powd pack for susp 20-1680 mg 4 • SANCUSO - granisetron td patch 3.1 mg/24hr (contains 34.3 mg) 4 • ZEGERID - omeprazole-sodium bicarbonate powd pack for susp 40-1680 mg 4 • AKYNZEO - netupitant-palonosetron cap 300-0.5 mg 4 • ANZEMET - dolasetron mesylate tab 50 mg 4 • ANZEMET - dolasetron mesylate tab 100 mg 4 • CESAMET - nabilone cap 1 mg 4 DICLEGIS - doxylamine-pyridoxine tab delayed release 10-10 mg 4 dronabinol cap 2.5 mg (Marinol) 2 dronabinol cap 5 mg (Marinol) 2 dronabinol cap 10 mg (Marinol) 2 EMEND - aprepitant capsule therapy pack 80 & 125 mg 3 EMEND - aprepitant capsule 40 mg 3 EMEND - aprepitant capsule 80 mg 3 EMEND - aprepitant capsule 125 mg 3 granisetron hcl tab 1 mg 2 MARINOL - dronabinol cap 2.5 mg 4 MARINOL - dronabinol cap 5 mg 4 MARINOL - dronabinol cap 10 mg 4 ondansetron hcl oral soln 4 mg/5ml (Zofran) 2 ondansetron hcl tab 4 mg (Zofran) 1 ondansetron hcl tab 8 mg (Zofran) 2 ondansetron hcl tab 24 mg 2 ondansetron orally disintegrating tab 4 mg (Zofran odt) 2 ANTIEMETICS • • • • TIGAN - trimethobenzamide hcl cap 300 4 mg 4 TRANSDERM-SCOP - scopolamine td patch 72hr 1 mg/3days 2 trimethobenzamide hcl cap 300 mg (Tigan) 4 ZOFRAN - ondansetron hcl oral soln 4 mg/5ml 4 ZOFRAN - ondansetron hcl tab 4 mg • ZOFRAN - ondansetron hcl tab 8 mg 4 ZOFRAN ODT - ondansetron orally disintegrating tab 4 mg 4 • • • ZOFRAN ODT - ondansetron orally disintegrating tab 8 mg 4 • ZUPLENZ - ondansetron oral soluble film 4 mg 4 • ZUPLENZ - ondansetron oral soluble film 8 mg 4 • DIGESTIVE AIDS • • • • • • • • CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 4 CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit 4 CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit 4 CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit 4 CREON - pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit 4 • • • • PANCREAZE - pancrelipase (lip-protamyl) dr cap 4200-10000-17500 unit 4 PANCREAZE - pancrelipase (lip-protamyl) dr cap 10500-25000-43750 unit 4 PANCREAZE - pancrelipase (lip-protamyl) dr cap 16800-40000-70000 unit 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 69 PANCREAZE - pancrelipase (lip-protamyl) dr cap 21000-37000-61000 unit 4 alosetron hcl tab 1 mg (base equiv) (Lotronex) 2 PANCRELIPASE - pancrelipase (lipprot-amyl) dr cap 5000-17000-27000 unit 4 AMITIZA - lubiprostone cap 8 mcg 4 AMITIZA - lubiprostone cap 24 mcg 4 4 APRISO - mesalamine cap sr 24hr 0.375 gm 4 PERTZYE - pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit 4 ASACOL HD - mesalamine tab delayed release 800 mg 4 PERTZYE - pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit 5 AURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) 4 SUCRAID - sacrosidase soln 8500 unit/ ml 4 AZULFIDINE - sulfasalazine tab 500 mg 4 ULTRESA - pancrelipase (lip-prot-amyl) dr cap 13800-27600-27600 unit 4 ULTRESA - pancrelipase (lip-prot-amyl) dr cap 20700-41400-41400 unit 4 AZULFIDINE EN-TABS - sulfasalazine tab delayed release 500 mg 2 ULTRESA - pancrelipase (lip-prot-amyl) dr cap 23000-46000-46000 unit 4 balsalazide disodium cap 750 mg (Colazal) 2 VIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit 4 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo) 2 VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit 4 calcium acetate (phosphate binder) tab 667 mg (Eliphos) 3 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit 3 CANASA - mesalamine suppos 1000 mg CHENODAL - chenodiol tab 250 mg 5 CHOLBAM - cholic acid cap 50 mg 5 CHOLBAM - cholic acid cap 250 mg 5 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 • ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit 3 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit 3 CIMZIA - certolizumab pegol inj kit 2 x 200 mg/ml 5 • • ZENPEP - pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit 3 CIMZIA STARTER KIT - certolizumab pegol inj kit 6 x 200 mg/ml 5 • • ZENPEP - pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit 3 COLAZAL - balsalazide disodium cap 750 mg 4 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit 3 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) 2 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit 3 DELZICOL - mesalamine cap dr 400 mg 4 DIPENTUM - olsalazine sodium cap 250 4 mg ELIPHOS - calcium acetate (phosphate 4 binder) tab 667 mg 4 ENTEREG - alvimopan cap 12 mg GASTROINTESTINAL AGENTS- MISC. ACTIGALL - ursodiol cap 300 mg 4 alosetron hcl tab 0.5 mg (base equiv) (Lotronex) 2 70 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 FOSRENOL - lanthanum carbonate chew tab 500 mg (elemental) 4 MOVANTIK - naloxegol oxalate tab 12.5 mg (base equivalent) 4 FOSRENOL - lanthanum carbonate chew tab 750 mg (elemental) 4 MOVANTIK - naloxegol oxalate tab 25 mg (base equivalent) 4 FOSRENOL - lanthanum carbonate chew tab 1000 mg (elemental) 4 PENTASA - mesalamine cap cr 250 mg 4 PENTASA - mesalamine cap cr 500 mg 4 FOSRENOL - lanthanum carbonate oral powder pack 750 mg (elemental) 4 PHOSLO - calcium acetate (phosphate binder) cap 667 mg (169 mg ca) 4 FOSRENOL - lanthanum carbonate oral powder pack 1000 mg (elemental) 4 4 GASTROCROM - cromolyn sodium oral conc 100 mg/5ml 4 PHOSLYRA - calcium acetate (phosphate binder) oral soln 667 mg/5ml GATTEX - teduglutide (rdna) for inj kit 5 mg 5 GIAZO - balsalazide disodium tab 1.1 gm 4 lactulose (encephalopathy) solution 10 gm/15ml 1 LIALDA - mesalamine tab delayed release 1.2 gm 4 LINZESS - linaclotide cap 145 mcg 4 LINZESS - linaclotide cap 290 mcg 4 LOTRONEX - alosetron hcl tab 0.5 mg (base equiv) 4 LOTRONEX - alosetron hcl tab 1 mg (base equiv) 4 mesalamine enema 4 gm 2 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 REGLAN - metoclopramide hcl tab 5 mg 4 4 REGLAN - metoclopramide hcl tab 10 mg RELISTOR - methylnaltrexone bromide 4 inj 8 mg/0.4ml (20 mg/ml) RELISTOR - methylnaltrexone bromide 4 inj 12 mg/0.6ml (20 mg/ml) 4 RENAGEL - sevelamer hcl tab 400 mg RENAGEL - sevelamer hcl tab 800 mg 4 RENVELA - sevelamer carbonate tab 800 mg 4 RENVELA - sevelamer carbonate packet 0.8 gm 4 RENVELA - sevelamer carbonate packet 2.4 gm 4 mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa) ROWASA - mesalamine rectal enema 4 gm & cleanser wipe kit 4 2 metoclopramide hcl orally disintegrating tab 5 mg (Metozolv odt) SEVELAMER CARBONATE sevelamer carbonate tab 800 mg 4 2 SFROWASA - mesalamine sulfite-free (sf) enema 4 gm/60ml 4 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 1 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) 2 metoclopramide hcl tab 5 mg (Reglan) 1 sulfasalazine tab 500 mg (Azulfidine) 2 1 URSO FORTE - ursodiol tab 500 mg 4 metoclopramide hcl tab 10 mg (Reglan) URSO 250 - ursodiol tab 250 mg 4 METOZOLV ODT - metoclopramide hcl orally disintegrating tab 5 mg 4 ursodiol cap 300 mg (Actigall) 2 ursodiol tab 250 mg (Urso 250) 2 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 71 GENITOURINARY AGENTS URINARY ANTI-INFECTIVES FURADANTIN - nitrofurantoin susp 25 mg/5ml 4 HIPREX - methenamine hippurate tab 1 gm 4 MACROBID - nitrofurantoin monohydrate macrocrystalline cap 100 mg 4 MACRODANTIN - nitrofurantoin macrocrystalline cap 25 mg 4 MACRODANTIN - nitrofurantoin macrocrystalline cap 50 mg 4 MACRODANTIN - nitrofurantoin macrocrystalline cap 100 mg 4 methenamine hippurate tab 1 gm (Hiprex) 2 METHENAMINE MANDELATE methenamine mandelate tab 0.5 gm 4 methenamine mandelate tab 1 gm 2 methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg 2 methenamine-hyosc-meth blue-benz 2 acid-phenyl sal tab 81.6mg (Prosed/ ds) 2 methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg 2 methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg 2 methenamine-hyosc-meth blue-sod phos-phen sal tab 81 mg 2 methenamine-hyoscamine-meth blue-sod phos tab 81.6 mg (Urogesic-blue) 4 MONUROL - fosfomycin tromethamine powd pack 3 gm (base equivalent) 72 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) 2 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) 2 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid) 2 nitrofurantoin susp 25 mg/5ml (Furadantin) 2 PROSED/DS - methenamine-hyoscmeth blue-benz acid-phenyl sal tab 81.6mg 4 URETRON D/S - methenamine-hyoscmeth blue-sod phos-phen sal tab 120 mg 4 UREX - methenamine hippurate tab 1 gm 4 URIMAR-T - methenamine-hyosc-meth blue-sod phos-phen sal tab 120 mg 4 UROGESIC-BLUE - methenaminehyoscamine-meth blue-sod phos tab 81.6 mg 4 UROQID #2 - methenamine mandelatesod phosphate monobasic tab 500-500 mg 4 UTA - methenamine-hyoscamine-meth blue-sod phos cap 120 mg 4 Dispensing Limits Step Therapy Prior Authorization 4 Drug Name Drug Tier VELPHORO - sucroferric oxyhydroxide chew tab 500 mg Dispensing Limits 2 Step Therapy ursodiol tab 500 mg (Urso forte) Prior Authorization Drug Name Drug Tier 2015 URINARY ANTISPASMODICS bethanechol chloride tab 5 mg (Urecholine) 2 bethanechol chloride tab 10 mg (Urecholine) 2 bethanechol chloride tab 25 mg (Urecholine) 2 bethanechol chloride tab 50 mg (Urecholine) 2 DETROL - tolterodine tartrate tab 1 mg 4 DETROL - tolterodine tartrate tab 2 mg 4 DETROL LA - tolterodine tartrate cap sr 24hr 2 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 DETROL LA - tolterodine tartrate cap sr 24hr 4 mg 4 TOVIAZ - fesoterodine fumarate tab sr 24hr 8 mg 4 DITROPAN XL - oxybutynin chloride tab sr 24hr 5 mg 4 trospium chloride cap sr 24hr 60 mg 2 trospium chloride tab 20 mg 2 DITROPAN XL - oxybutynin chloride tab sr 24hr 10 mg 4 URECHOLINE - bethanechol chloride tab 5 mg 4 DITROPAN XL - oxybutynin chloride tab sr 24hr 15 mg 4 URECHOLINE - bethanechol chloride tab 10 mg 4 ENABLEX - darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) 4 URECHOLINE - bethanechol chloride tab 25 mg 4 ENABLEX - darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) 4 URECHOLINE - bethanechol chloride tab 50 mg 4 flavoxate hcl tab 100 mg 2 GELNIQUE - oxybutynin td gel 3% (28 mg/act metered-dose pump) • VESICARE - solifenacin succinate tab 5 mg 4 4 4 • VESICARE - solifenacin succinate tab 10 mg 4 GELNIQUE - oxybutynin chloride td gel 10% MYRBETRIQ - mirabegron tab sr 24 hr 25 mg 4 MYRBETRIQ - mirabegron tab sr 24 hr 50 mg Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 VAGINAL PRODUCTS AVC - sulfanilamide vaginal cream 15% 4 4 CLEOCIN - clindamycin phosphate vaginal cream 2% 4 1 CLEOCIN - clindamycin phosphate vaginal suppos 100 mg 4 oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl) 2 clindamycin phosphate vaginal cream 2% (Cleocin) 2 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) 2 CLINDESSE - clindamycin phosphate (one dose) vaginal cream 2% 4 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl) 2 ESTRACE - estradiol vaginal cream 0.1 mg/gm 3 oxybutynin chloride tab 5 mg 2 OXYTROL - oxybutynin td patch twice weekly 3.9 mg/24hr ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs) 4 4 tolterodine tartrate cap sr 24hr 2 mg (Detrol la) FEM PH - acetic acid-oxyquinoline vaginal gel 0.9-0.025% 4 2 4 tolterodine tartrate cap sr 24hr 4 mg (Detrol la) 2 FEMRING - estradiol acetate vaginal ring 0.05 mg/24hr 2 FEMRING - estradiol acetate vaginal ring 0.1 mg/24hr 4 tolterodine tartrate tab 1 mg (Detrol) tolterodine tartrate tab 2 mg (Detrol) 2 4 TOVIAZ - fesoterodine fumarate tab sr 24hr 4 mg 4 GYNAZOLE-1 - butoconazole nitrate (one dose) vaginal cream 2% METROGEL-VAGINAL - metronidazole vaginal gel 0.75% 4 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 73 metronidazole vaginal gel 0.75% (Metrogel-vaginal) 2 FLOMAX - tamsulosin hcl cap 0.4 mg 4 miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit JALYN - dutasteride-tamsulosin hcl cap 0.5-0.4 mg 4 1 MICONAZOLE 3 - miconazole nitrate vaginal suppos 200 mg K-PHOS NO 2 - potassium & sodium acid phosphates tab 305-700 mg 4 4 4 LITHOSTAT - acetohydroxamic acid tab 250 mg 4 NUVESSA - metronidazole vaginal gel 1.3% 4 ORACIT - sodium citrate & citric acid soln 490-640 mg/5ml 4 PREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm RELAGARD - acetic acid-oxyquinoline vaginal gel 0.9-0.025% phenazopyridine hcl tab 100 mg (Pyridium) 1 4 TERAZOL 3 - terconazole vaginal cream 0.8% phenazopyridine hcl tab 200 mg (Pyridium) 1 4 TERAZOL 7 - terconazole vaginal cream 0.4% pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml 2 4 2 potassium citrate & citric acid powder pack 3300-1002 mg 2 terconazole vaginal cream 0.4% (Terazol 7) 2 potassium citrate & citric acid soln 1100-334 mg/5ml 2 terconazole vaginal cream 0.8% (Terazol 3) terconazole vaginal suppos 80 mg potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5) 2 2 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10) 2 VAGIFEM - estradiol vaginal tab 10 mcg 3 GENITOURINARY AGENTS - MISC. alfuzosin hcl tab sr 24hr 10 mg (Uroxatral) 1 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15) 2 AVODART - dutasteride cap 0.5 mg 4 5 • CARDURA XL - doxazosin mesylate tab sr 24 hr 4 mg (base equiv) 4 PROCYSBI - cysteamine bitartrate cap delayed release 25 mg (base equiv) 5 • CARDURA XL - doxazosin mesylate tab sr 24 hr 8 mg (base equiv) 4 PROCYSBI - cysteamine bitartrate cap delayed release 75 mg (base equiv) PROSCAR - finasteride tab 5 mg 4 CYSTAGON - cysteamine bitartrate cap 50 mg 5 • PYRIDIUM - phenazopyridine hcl tab 100 mg 4 CYSTAGON - cysteamine bitartrate cap 150 mg 5 • PYRIDIUM - phenazopyridine hcl tab 200 mg 4 CYTRA-3 - pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml 4 RAPAFLO - silodosin cap 4 mg 4 RAPAFLO - silodosin cap 8 mg 4 ELMIRON - pentosan polysulfate sodium caps 100 mg 4 4 finasteride tab 5 mg (Proscar) 1 SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln 500-334 mg/5ml 74 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 buspirone hcl tab 5 mg 1 buspirone hcl tab 7.5 mg 2 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 2 chlordiazepoxide hcl cap 5 mg 1 chlordiazepoxide hcl cap 10 mg 1 tamsulosin hcl cap 0.4 mg (Flomax) 1 THIOLA - tiopronin tab 100 mg 4 UROCIT-K 10 - potassium citrate tab cr 10 meq (1080 mg) 4 UROCIT-K 15 - potassium citrate tab cr 15 meq (1620 mg) 4 UROCIT-K 5 - potassium citrate tab cr 5 meq (540 mg) 4 chlordiazepoxide hcl cap 25 mg 1 UROXATRAL - alfuzosin hcl tab sr 24hr 10 mg clorazepate dipotassium tab 3.75 mg (Tranxene t) 1 4 clorazepate dipotassium tab 7.5 mg (Tranxene t) 1 clorazepate dipotassium tab 15 mg (Tranxene t) 2 DIAZEPAM - diazepam soln 1 mg/ml 4 diazepam conc 5 mg/ml 2 diazepam tab 2 mg (Valium) 1 diazepam tab 5 mg (Valium) 1 diazepam tab 10 mg (Valium) 1 hydroxyzine hcl syrup 10 mg/5ml 1 hydroxyzine hcl tab 10 mg 1 hydroxyzine hcl tab 25 mg 1 CENTRAL NERVOUS SYSTEM DRUGS ANTIANXIETY AGENTS ALPRAZOLAM INTENSOL - alprazolam conc 1 mg/ml 4 alprazolam orally disintegrating tab 0.25 mg (Niravam) 2 alprazolam orally disintegrating tab 0.5 mg 2 alprazolam orally disintegrating tab 1 mg 2 alprazolam orally disintegrating tab 2 mg 2 alprazolam tab sr 24hr 0.5 mg (Xanax xr) 2 hydroxyzine hcl tab 50 mg 1 alprazolam tab sr 24hr 1 mg (Xanax xr) HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg 4 2 alprazolam tab sr 24hr 2 mg (Xanax xr) hydroxyzine pamoate cap 25 mg (Vistaril) 1 2 alprazolam tab sr 24hr 3 mg (Xanax xr) hydroxyzine pamoate cap 50 mg (Vistaril) 1 2 1 lorazepam conc 2 mg/ml (Lorazepam intensol) 2 alprazolam tab 0.25 mg (Xanax) alprazolam tab 0.5 mg (Xanax) 1 4 alprazolam tab 1 mg (Xanax) 1 LORAZEPAM INTENSOL - lorazepam conc 2 mg/ml alprazolam tab 2 mg (Xanax) 1 lorazepam tab 0.5 mg (Ativan) 1 ATIVAN - lorazepam tab 0.5 mg 4 lorazepam tab 1 mg (Ativan) 1 ATIVAN - lorazepam tab 1 mg 4 lorazepam tab 2 mg (Ativan) 1 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits 4 1 Step Therapy ATIVAN - lorazepam tab 2 mg sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi) Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 75 2 amitriptyline hcl tab 150 mg 1 meprobamate tab 400 mg 2 AMOXAPINE - amoxapine tab 25 mg 4 NIRAVAM - alprazolam orally disintegrating tab 0.25 mg 4 AMOXAPINE - amoxapine tab 50 mg 4 AMOXAPINE - amoxapine tab 100 mg 4 oxazepam cap 10 mg 2 AMOXAPINE - amoxapine tab 150 mg 4 oxazepam cap 15 mg 2 2 ANAFRANIL - clomipramine hcl cap 25 mg 4 oxazepam cap 30 mg TRANXENE T - clorazepate dipotassium tab 3.75 mg 4 ANAFRANIL - clomipramine hcl cap 50 mg 4 TRANXENE T - clorazepate dipotassium tab 7.5 mg 4 ANAFRANIL - clomipramine hcl cap 75 mg 4 TRANXENE T - clorazepate dipotassium tab 15 mg 4 APLENZIN - bupropion hbr tab sr 24hr 174 mg 4 • VALIUM - diazepam tab 2 mg 4 4 • VALIUM - diazepam tab 5 mg 4 APLENZIN - bupropion hbr tab sr 24hr 348 mg VALIUM - diazepam tab 10 mg 4 4 • VISTARIL - hydroxyzine pamoate cap 25 mg 4 APLENZIN - bupropion hbr tab sr 24hr 522 mg 4 • VISTARIL - hydroxyzine pamoate cap 50 mg 4 BRINTELLIX - vortioxetine hbr tab 5 mg (base equiv) 4 • XANAX - alprazolam tab 0.25 mg 4 BRINTELLIX - vortioxetine hbr tab 10 mg (base equiv) 4 BRINTELLIX - vortioxetine hbr tab 20 mg (base equiv) 4 XANAX - alprazolam tab 0.5 mg • XANAX - alprazolam tab 1 mg 4 4 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr) 2 XANAX - alprazolam tab 2 mg XANAX XR - alprazolam tab sr 24hr 0.5 mg 4 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr) 2 XANAX XR - alprazolam tab sr 24hr 1 mg 4 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr) 2 XANAX XR - alprazolam tab sr 24hr 2 mg 4 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl) 2 XANAX XR - alprazolam tab sr 24hr 3 mg 4 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl) 2 bupropion hcl tab 75 mg (Wellbutrin) 2 ANTIDEPRESSANTS amitriptyline hcl tab 10 mg 1 amitriptyline hcl tab 25 mg 1 amitriptyline hcl tab 50 mg 1 amitriptyline hcl tab 75 mg 1 amitriptyline hcl tab 100 mg 1 76 bupropion hcl tab 100 mg (Wellbutrin) 2 CELEXA - citalopram hydrobromide tab 4 10 mg (base equiv) CELEXA - citalopram hydrobromide tab 4 20 mg (base equiv) Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy meprobamate tab 200 mg Prior Authorization Drug Name Drug Tier 2015 • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr 50 mg (base equiv) 4 • 4 • citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr 100 mg (base equiv) citalopram hydrobromide tab 20 mg (base equiv) (Celexa) 1 DOXEPIN HCL - doxepin hcl cap 75 mg 4 doxepin hcl cap 10 mg 1 citalopram hydrobromide tab 40 mg (base equiv) (Celexa) 1 doxepin hcl cap 25 mg 1 doxepin hcl cap 50 mg 1 clomipramine hcl cap 25 mg (Anafranil) 2 doxepin hcl cap 100 mg 1 2 doxepin hcl cap 150 mg 1 clomipramine hcl cap 50 mg (Anafranil) doxepin hcl conc 10 mg/ml 1 clomipramine hcl cap 75 mg (Anafranil) 2 DULOXETINE HCL - duloxetine hcl enteric coated pellets cap 40 mg 4 • • CYMBALTA - duloxetine hcl enteric coated pellets cap 20 mg 4 • • duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta) 2 • CYMBALTA - duloxetine hcl enteric coated pellets cap 30 mg 4 • • duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta) 2 • CYMBALTA - duloxetine hcl enteric coated pellets cap 60 mg 4 • • duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta) 2 • desipramine hcl tab 10 mg (Norpramin) 2 EFFEXOR XR - venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) 4 • desipramine hcl tab 25 mg (Norpramin) 2 EFFEXOR XR - venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 4 • desipramine hcl tab 50 mg (Norpramin) 2 EFFEXOR XR - venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 4 • desipramine hcl tab 75 mg (Norpramin) 2 EMSAM - selegiline td patch 24hr 6 mg/24hr 4 desipramine hcl tab 100 mg (Norpramin) 2 EMSAM - selegiline td patch 24hr 9 mg/24hr 4 desipramine hcl tab 150 mg (Norpramin) 2 EMSAM - selegiline td patch 24hr 12 mg/24hr 4 DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg 4 • escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) 2 DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg 4 • escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 1 escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 1 CELEXA - citalopram hydrobromide tab 40 mg (base equiv) 4 citalopram hydrobromide oral soln 10 mg/5ml 2 • Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 77 escitalopram oxalate tab 20 mg (base equiv) (Lexapro) 1 FETZIMA - levomilnacipran hcl cap sr 24hr 20 mg (base equivalent) 4 FETZIMA - levomilnacipran hcl cap sr 24hr 40 mg (base equivalent) imipramine pamoate cap 125 mg (Tofranil-pm) 2 • imipramine pamoate cap 150 mg (Tofranil-pm) 2 4 • IRENKA - duloxetine hcl enteric coated pellets cap 40 mg 4 FETZIMA - levomilnacipran hcl cap sr 24hr 80 mg (base equivalent) 4 • FETZIMA - levomilnacipran hcl cap sr 24hr 120 mg (base equivalent) 4 • FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack 4 • FLUOXETINE HCL - fluoxetine hcl tab 60 mg 4 • fluoxetine hcl cap delayed release 90 mg (Prozac weekly) 2 fluoxetine hcl cap 10 mg (Prozac) 1 fluoxetine hcl cap 20 mg (Prozac) 1 fluoxetine hcl cap 40 mg (Prozac) 1 fluoxetine hcl solution 20 mg/5ml 1 fluoxetine hcl tab 10 mg 1 fluoxetine hcl tab 20 mg 2 fluvoxamine maleate cap sr 24hr 100 mg (Luvox cr) 2 KHEDEZLA - desvenlafaxine tab sr 24hr 4 50 mg KHEDEZLA - desvenlafaxine tab sr 24hr 4 100 mg LEXAPRO - escitalopram oxalate soln 5 4 mg/5ml (base equiv) 4 LEXAPRO - escitalopram oxalate tab 5 mg (base equiv) LEXAPRO - escitalopram oxalate tab 10 4 mg (base equiv) LEXAPRO - escitalopram oxalate tab 20 4 mg (base equiv) 4 MAPROTILINE HCL - maprotiline hcl tab 25 mg 4 MAPROTILINE HCL - maprotiline hcl tab 50 mg 4 MAPROTILINE HCL - maprotiline hcl tab 75 mg 4 MARPLAN - isocarboxazid tab 10 mg 2 mirtazapine orally disintegrating tab 15 mg (Remeron soltab) 2 fluvoxamine maleate cap sr 24hr 150 mg (Luvox cr) 2 mirtazapine orally disintegrating tab 30 mg (Remeron soltab) 2 fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg 2 fluvoxamine maleate tab 100 mg mirtazapine orally disintegrating tab 45 mg (Remeron soltab) 2 2 mirtazapine tab 7.5 mg 2 mirtazapine tab 15 mg (Remeron) 1 mirtazapine tab 30 mg (Remeron) 1 mirtazapine tab 45 mg (Remeron) 1 NARDIL - phenelzine sulfate tab 15 mg 4 NEFAZODONE HCL - nefazodone hcl tab 50 mg 4 FORFIVO XL - bupropion hcl tab sr 24hr 4 450 mg 1 imipramine hcl tab 10 mg (Tofranil) imipramine hcl tab 25 mg (Tofranil) 1 imipramine hcl tab 50 mg (Tofranil) 1 imipramine pamoate cap 75 mg (Tofranil-pm) 2 imipramine pamoate cap 100 mg (Tofranil-pm) 2 78 • • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 • • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 NEFAZODONE HCL - nefazodone hcl tab 100 mg 4 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr) 2 NEFAZODONE HCL - nefazodone hcl tab 150 mg 4 paroxetine hcl tab 10 mg (Paxil) 1 paroxetine hcl tab 20 mg (Paxil) 1 NEFAZODONE HCL - nefazodone hcl tab 200 mg 4 paroxetine hcl tab 30 mg (Paxil) 1 2 paroxetine hcl tab 40 mg (Paxil) 1 nefazodone hcl tab 250 mg 4 PAXIL - paroxetine hcl oral susp 10 mg/5ml (base equiv) 4 NORPRAMIN - desipramine hcl tab 10 mg • 4 PAXIL - paroxetine hcl tab 10 mg 4 NORPRAMIN - desipramine hcl tab 25 mg PAXIL - paroxetine hcl tab 20 mg 4 NORPRAMIN - desipramine hcl tab 50 mg 4 PAXIL - paroxetine hcl tab 30 mg 4 PAXIL - paroxetine hcl tab 40 mg 4 NORPRAMIN - desipramine hcl tab 75 mg 4 PAXIL CR - paroxetine hcl tab sr 24hr 12.5 mg 4 • • • • • NORPRAMIN - desipramine hcl tab 100 mg 4 PAXIL CR - paroxetine hcl tab sr 24hr 25 mg 4 • NORPRAMIN - desipramine hcl tab 150 mg 4 PAXIL CR - paroxetine hcl tab sr 24hr 37.5 mg 4 • NORTRIPTYLINE HCL - nortriptyline hcl 4 soln 10 mg/5ml nortriptyline hcl cap 10 mg (Pamelor) 1 PEXEVA - paroxetine mesylate tab 10 mg (base equiv) 4 • PEXEVA - paroxetine mesylate tab 20 mg (base equiv) 4 • PEXEVA - paroxetine mesylate tab 30 mg (base equiv) 4 • • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 nortriptyline hcl cap 25 mg (Pamelor) 1 nortriptyline hcl cap 50 mg (Pamelor) 1 nortriptyline hcl cap 75 mg (Pamelor) 1 4 • PEXEVA - paroxetine mesylate tab 40 mg (base equiv) 4 OLEPTRO - trazodone hcl tab sr 24hr 150 mg 4 • phenelzine sulfate tab 15 mg (Nardil) 2 OLEPTRO - trazodone hcl tab sr 24hr 300 mg 4 • • PAMELOR - nortriptyline hcl cap 10 mg 4 PRISTIQ - desvenlafaxine succinate tab sr 24hr 25 mg (base equiv) 4 PRISTIQ - desvenlafaxine succinate tab sr 24hr 50 mg (base equiv) 4 PAMELOR - nortriptyline hcl cap 25 mg • • PAMELOR - nortriptyline hcl cap 50 mg 4 • • 4 PRISTIQ - desvenlafaxine succinate tab sr 24hr 100 mg (base equiv) 4 PAMELOR - nortriptyline hcl cap 75 mg PARNATE - tranylcypromine sulfate tab 10 mg 4 protriptyline hcl tab 5 mg (Vivactil) 2 protriptyline hcl tab 10 mg (Vivactil) 2 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr) 2 PROZAC - fluoxetine hcl cap 10 mg 4 2 PROZAC - fluoxetine hcl cap 20 mg 4 paroxetine hcl tab sr 24hr 25 mg (Paxil cr) PROZAC - fluoxetine hcl cap 40 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • 79 2 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr) 1 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr) 1 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr) 1 VENLAFAXINE HCL ER - venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) 4 • VENLAFAXINE HCL ER - venlafaxine hcl tab sr 24hr 75 mg (base equivalent) 4 • VENLAFAXINE HCL ER - venlafaxine hcl tab sr 24hr 150 mg (base equivalent) 4 • VENLAFAXINE HCL ER - venlafaxine hcl tab sr 24hr 225 mg (base equivalent) 4 • venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er) 2 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er) 2 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er) 2 venlafaxine hcl tab 25 mg 2 venlafaxine hcl tab 37.5 mg 2 venlafaxine hcl tab 50 mg 2 venlafaxine hcl tab 75 mg 2 venlafaxine hcl tab 100 mg 2 VIIBRYD - vilazodone hcl tab starter kit 10 (7) & 20 (7) & 40 (16) mg 4 • VIIBRYD - vilazodone hcl tab 10 mg 4 • • • • 4 • • REMERON - mirtazapine tab 15 mg 4 REMERON - mirtazapine tab 30 mg 4 REMERON - mirtazapine tab 45 mg 4 REMERON SOLTAB - mirtazapine orally disintegrating tab 15 mg 4 • • • • REMERON SOLTAB - mirtazapine orally disintegrating tab 30 mg 4 • REMERON SOLTAB - mirtazapine orally disintegrating tab 45 mg 4 • sertraline hcl oral conc 20 mg/ml (Zoloft) 2 sertraline hcl tab 25 mg (Zoloft) 1 sertraline hcl tab 50 mg (Zoloft) 1 sertraline hcl tab 100 mg (Zoloft) 1 SURMONTIL - trimipramine maleate cap 25 mg 4 SURMONTIL - trimipramine maleate cap 50 mg 4 SURMONTIL - trimipramine maleate cap 100 mg 4 TOFRANIL - imipramine hcl tab 10 mg 4 TOFRANIL - imipramine hcl tab 25 mg 4 TOFRANIL - imipramine hcl tab 50 mg 4 TOFRANIL-PM - imipramine pamoate cap 75 mg 4 TOFRANIL-PM - imipramine pamoate cap 100 mg 4 TOFRANIL-PM - imipramine pamoate cap 125 mg 4 TOFRANIL-PM - imipramine pamoate cap 150 mg 4 tranylcypromine sulfate tab 10 mg (Parnate) 2 trazodone hcl tab 50 mg 1 VIIBRYD - vilazodone hcl tab 20 mg 4 trazodone hcl tab 100 mg 1 VIIBRYD - vilazodone hcl tab 40 mg 4 trazodone hcl tab 150 mg 1 WELLBUTRIN - bupropion hcl tab 75 mg 4 Dispensing Limits Step Therapy trazodone hcl tab 300 mg PROZAC WEEKLY - fluoxetine hcl cap delayed release 90 mg 80 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 WELLBUTRIN - bupropion hcl tab 100 mg 4 • CLOZAPINE ODT - clozapine orally disintegrating tab 12.5 mg 4 • WELLBUTRIN SR - bupropion hcl tab sr 12hr 100 mg 4 • CLOZAPINE ODT - clozapine orally disintegrating tab 25 mg 4 • WELLBUTRIN SR - bupropion hcl tab sr 12hr 150 mg 4 • CLOZAPINE ODT - clozapine orally disintegrating tab 100 mg 4 • WELLBUTRIN SR - bupropion hcl tab sr 12hr 200 mg 4 • CLOZAPINE ODT - clozapine orally disintegrating tab 150 mg 4 • WELLBUTRIN XL - bupropion hcl tab sr 24hr 150 mg 4 • CLOZAPINE ODT - clozapine orally disintegrating tab 200 mg 4 • WELLBUTRIN XL - bupropion hcl tab sr 24hr 300 mg 4 • clozapine tab 25 mg (Clozaril) 2 2 ZOLOFT - sertraline hcl oral conc 20 mg/ml • clozapine tab 50 mg 4 clozapine tab 100 mg (Clozaril) 2 4 clozapine tab 200 mg 4 CLOZARIL - clozapine tab 25 mg 4 ZOLOFT - sertraline hcl tab 50 mg 4 CLOZARIL - clozapine tab 100 mg 4 ZOLOFT - sertraline hcl tab 100 mg • • • 2 ZOLOFT - sertraline hcl tab 25 mg • • • • • • COMPAZINE - prochlorperazine maleate tab 5 mg (base equivalent) 4 COMPAZINE - prochlorperazine maleate tab 10 mg (base equivalent) 4 EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 100 mg 4 EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 200 mg 4 EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 300 mg 4 FANAPT - iloperidone tab 1 mg 4 FANAPT - iloperidone tab 2 mg 4 FANAPT - iloperidone tab 4 mg 4 FANAPT - iloperidone tab 6 mg 4 FANAPT - iloperidone tab 8 mg 4 FANAPT - iloperidone tab 10 mg 4 FANAPT - iloperidone tab 12 mg 4 FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak 4 • • • • • • • • FAZACLO - clozapine orally disintegrating tab 12.5 mg 4 • ANTIPSYCHOTICS ABILIFY - aripiprazole tab 2 mg 4 ABILIFY - aripiprazole tab 5 mg 4 ABILIFY - aripiprazole tab 10 mg 4 ABILIFY - aripiprazole tab 15 mg 4 ABILIFY - aripiprazole tab 20 mg 4 ABILIFY - aripiprazole tab 30 mg 4 ADASUVE - loxapine aerosol powder breath activated 10 mg 4 aripiprazole tab 2 mg (Abilify) 2 aripiprazole tab 5 mg (Abilify) 2 aripiprazole tab 10 mg (Abilify) 2 aripiprazole tab 15 mg (Abilify) 2 aripiprazole tab 20 mg (Abilify) 2 aripiprazole tab 30 mg (Abilify) 2 chlorpromazine hcl tab 10 mg 2 chlorpromazine hcl tab 25 mg 2 chlorpromazine hcl tab 50 mg 2 chlorpromazine hcl tab 100 mg 2 chlorpromazine hcl tab 200 mg 2 • • • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 81 FAZACLO - clozapine orally disintegrating tab 25 mg 4 • LITHIUM - lithium oral solution 8 meq/5ml 4 FAZACLO - clozapine orally disintegrating tab 100 mg 4 • LITHIUM CARBONATE - lithium carbonate cap 150 mg 4 FAZACLO - clozapine orally disintegrating tab 150 mg 4 • LITHIUM CARBONATE - lithium carbonate cap 600 mg 4 FAZACLO - clozapine orally disintegrating tab 200 mg 4 • lithium carbonate cap 150 mg (Lithium carbonate) 1 FLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml 3 lithium carbonate cap 300 mg 1 FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml lithium carbonate cap 600 mg (Lithium carbonate) 1 3 fluphenazine hcl tab 1 mg lithium carbonate tab cr 300 mg (Lithobid) 2 1 fluphenazine hcl tab 2.5 mg 1 lithium carbonate tab cr 450 mg 2 fluphenazine hcl tab 5 mg 1 lithium carbonate tab 300 mg 1 fluphenazine hcl tab 10 mg 1 GEODON - ziprasidone hcl cap 20 mg 4 GEODON - ziprasidone hcl cap 40 mg 4 LITHOBID - lithium carbonate tab cr 300 4 mg 2 loxapine succinate cap 5 mg GEODON - ziprasidone hcl cap 60 mg 4 GEODON - ziprasidone hcl cap 80 mg 4 haloperidol lactate oral conc 2 mg/ml • • • • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 loxapine succinate cap 10 mg 2 loxapine succinate cap 25 mg 2 1 loxapine succinate cap 50 mg 2 haloperidol tab 0.5 mg 1 2 • haloperidol tab 1 mg 1 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) 1 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) 2 haloperidol tab 2 mg • haloperidol tab 5 mg 2 • haloperidol tab 10 mg olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) 2 2 haloperidol tab 20 mg 2 2 • INVEGA - paliperidone tab sr 24hr 1.5 mg 4 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) olanzapine tab 2.5 mg (Zyprexa) 1 olanzapine tab 5 mg (Zyprexa) 1 olanzapine tab 7.5 mg (Zyprexa) 1 olanzapine tab 10 mg (Zyprexa) 2 olanzapine tab 15 mg (Zyprexa) 2 olanzapine tab 20 mg (Zyprexa) 2 • • • • • • perphenazine tab 2 mg 2 perphenazine tab 4 mg 2 perphenazine tab 8 mg 2 INVEGA - paliperidone tab sr 24hr 3 mg 4 INVEGA - paliperidone tab sr 24hr 6 mg 4 INVEGA - paliperidone tab sr 24hr 9 mg 4 LATUDA - lurasidone hcl tab 20 mg 4 LATUDA - lurasidone hcl tab 40 mg 4 LATUDA - lurasidone hcl tab 60 mg 4 LATUDA - lurasidone hcl tab 80 mg 4 LATUDA - lurasidone hcl tab 120 mg 4 82 • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier prochlorperazine maleate tab 5 mg (base equivalent) (Compazine) Dispensing Limits 2 Step Therapy perphenazine tab 16 mg Prior Authorization Drug Name Drug Tier 2015 4 • 1 RISPERDAL M-TAB - risperidone orally disintegrating tab 3 mg 4 • prochlorperazine maleate tab 10 mg (base equivalent) (Compazine) 1 RISPERDAL M-TAB - risperidone orally disintegrating tab 4 mg 2 • prochlorperazine suppos 25 mg 2 risperidone orally disintegrating tab 0.25 mg quetiapine fumarate tab 25 mg (Seroquel) 1 • risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) 2 • quetiapine fumarate tab 50 mg (Seroquel) 1 • risperidone orally disintegrating tab 1 mg (Risperdal m-tab) 2 • quetiapine fumarate tab 100 mg (Seroquel) 1 • risperidone orally disintegrating tab 2 mg (Risperdal m-tab) 2 • quetiapine fumarate tab 200 mg (Seroquel) 2 • risperidone orally disintegrating tab 3 mg (Risperdal m-tab) 2 • quetiapine fumarate tab 300 mg (Seroquel) 2 • risperidone orally disintegrating tab 4 mg (Risperdal m-tab) 2 • quetiapine fumarate tab 400 mg (Seroquel) 2 • risperidone soln 1 mg/ml (Risperdal) 2 risperidone tab 0.25 mg (Risperdal) 1 REXULTI - brexpiprazole tab 0.25 mg 4 risperidone tab 0.5 mg (Risperdal) 1 REXULTI - brexpiprazole tab 0.5 mg 4 risperidone tab 1 mg (Risperdal) 1 REXULTI - brexpiprazole tab 1 mg 4 risperidone tab 2 mg (Risperdal) 1 REXULTI - brexpiprazole tab 2 mg 4 risperidone tab 3 mg (Risperdal) 1 REXULTI - brexpiprazole tab 3 mg 4 risperidone tab 4 mg (Risperdal) 1 REXULTI - brexpiprazole tab 4 mg 4 4 RISPERDAL - risperidone soln 1 mg/ml 4 SAPHRIS - asenapine maleate sl tab 2.5 mg (base equiv) • • • • • • • • RISPERDAL - risperidone tab 0.25 mg 4 4 • RISPERDAL - risperidone tab 0.5 mg 4 SAPHRIS - asenapine maleate sl tab 5 mg (base equiv) 4 SAPHRIS - asenapine maleate sl tab 10 mg (base equiv) 4 RISPERDAL - risperidone tab 1 mg • RISPERDAL - risperidone tab 2 mg 4 • RISPERDAL - risperidone tab 3 mg SEROQUEL - quetiapine fumarate tab 25 mg 4 4 RISPERDAL - risperidone tab 4 mg 4 4 • RISPERDAL M-TAB - risperidone orally disintegrating tab 0.5 mg 4 SEROQUEL - quetiapine fumarate tab 50 mg 4 • RISPERDAL M-TAB - risperidone orally disintegrating tab 1 mg 4 • SEROQUEL - quetiapine fumarate tab 100 mg 4 • RISPERDAL M-TAB - risperidone orally disintegrating tab 2 mg 4 • SEROQUEL - quetiapine fumarate tab 200 mg SEROQUEL - quetiapine fumarate tab 300 mg 4 • • • • • • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 83 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 SEROQUEL - quetiapine fumarate tab 400 mg 4 • ZYPREXA ZYDIS - olanzapine orally disintegrating tab 10 mg 4 • SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg 3 • ZYPREXA ZYDIS - olanzapine orally disintegrating tab 15 mg 4 • SEROQUEL XR - quetiapine fumarate tab sr 24hr 150 mg 3 • ZYPREXA ZYDIS - olanzapine orally disintegrating tab 20 mg 4 • SEROQUEL XR - quetiapine fumarate tab sr 24hr 200 mg 3 • HYPNOTICS 4 3 • AMBIEN - zolpidem tartrate tab 5 mg SEROQUEL XR - quetiapine fumarate tab sr 24hr 300 mg AMBIEN - zolpidem tartrate tab 10 mg 4 3 • AMBIEN CR - zolpidem tartrate tab cr 6.25 mg 4 SEROQUEL XR - quetiapine fumarate tab sr 24hr 400 mg • • • 1 AMBIEN CR - zolpidem tartrate tab cr 12.5 mg 4 thioridazine hcl tab 10 mg • thioridazine hcl tab 25 mg 2 BELSOMRA - suvorexant tab 5 mg 4 thioridazine hcl tab 50 mg 2 BELSOMRA - suvorexant tab 10 mg 4 thioridazine hcl tab 100 mg 2 BELSOMRA - suvorexant tab 15 mg 4 thiothixene cap 1 mg 1 BELSOMRA - suvorexant tab 20 mg 4 • • • • thiothixene cap 2 mg 1 thiothixene cap 5 mg BUTISOL SODIUM - butabarbital sodium tab 30 mg 4 1 thiothixene cap 10 mg 2 4 trifluoperazine hcl tab 1 mg 2 BUTISOL SODIUM - butabarbital sodium tab 50 mg trifluoperazine hcl tab 2 mg 2 DORAL - quazepam tab 15 mg 4 trifluoperazine hcl tab 5 mg 2 EDLUAR - zolpidem tartrate sl tab 5 mg 4 trifluoperazine hcl tab 10 mg 2 EDLUAR - zolpidem tartrate sl tab 10 mg 4 estazolam tab 1 mg 1 estazolam tab 2 mg 1 eszopiclone tab 1 mg (Lunesta) 2 eszopiclone tab 2 mg (Lunesta) 2 eszopiclone tab 3 mg (Lunesta) 2 FLURAZEPAM HCL - flurazepam hcl cap 15 mg 1 FLURAZEPAM HCL - flurazepam hcl cap 30 mg 1 HALCION - triazolam tab 0.25 mg 4 HETLIOZ - tasimelteon capsule 20 mg 4 INTERMEZZO - zolpidem tartrate sl tab 1.75 mg 4 VERSACLOZ - clozapine susp 50 mg/ml 4 2 ziprasidone hcl cap 20 mg (Geodon) ziprasidone hcl cap 40 mg (Geodon) 2 ziprasidone hcl cap 60 mg (Geodon) 2 ziprasidone hcl cap 80 mg (Geodon) 2 ZYPREXA - olanzapine tab 2.5 mg 4 ZYPREXA - olanzapine tab 5 mg 4 ZYPREXA - olanzapine tab 7.5 mg 4 ZYPREXA - olanzapine tab 10 mg 4 ZYPREXA - olanzapine tab 15 mg 4 ZYPREXA - olanzapine tab 20 mg 4 ZYPREXA ZYDIS - olanzapine orally disintegrating tab 5 mg 4 84 • • • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • • • LUNESTA - eszopiclone tab 1 mg 4 LUNESTA - eszopiclone tab 2 mg 4 LUNESTA - eszopiclone tab 3 mg 4 • • • midazolam hcl syrup 2 mg/ml (base equivalent) 1 PHENOBARBITAL - phenobarbital tab 15 mg 4 PHENOBARBITAL - phenobarbital tab 30 mg 4 PHENOBARBITAL - phenobarbital tab 60 mg 4 PHENOBARBITAL - phenobarbital tab 100 mg 4 phenobarbital elixir 20 mg/5ml 2 phenobarbital tab 16.2 mg 1 phenobarbital tab 32.4 mg 1 phenobarbital tab 64.8 mg 2 phenobarbital tab 97.2 mg 2 QUAZEPAM - quazepam tab 15 mg 4 RESTORIL - temazepam cap 7.5 mg 4 RESTORIL - temazepam cap 15 mg 4 RESTORIL - temazepam cap 22.5 mg 4 RESTORIL - temazepam cap 30 mg 4 ROZEREM - ramelteon tab 8 mg 4 SECONAL - secobarbital sodium cap 100 mg 4 SILENOR - doxepin hcl (sleep) tab 3 mg 4 (base equiv) SILENOR - doxepin hcl (sleep) tab 6 mg 4 (base equiv) 4 SONATA - zaleplon cap 5 mg SONATA - zaleplon cap 10 mg 4 temazepam cap 7.5 mg (Restoril) 2 temazepam cap 15 mg (Restoril) 1 temazepam cap 22.5 mg (Restoril) 2 • • • • • Dispensing Limits temazepam cap 30 mg (Restoril) Step Therapy • Prior Authorization 4 Drug Tier INTERMEZZO - zolpidem tartrate sl tab 3.5 mg Step Therapy Drug Name Drug Name Drug Tier Dispensing Limits Prior Authorization 2015 1 triazolam tab 0.125 mg 1 triazolam tab 0.25 mg (Halcion) 1 zaleplon cap 5 mg (Sonata) 1 zaleplon cap 10 mg (Sonata) 1 zolpidem tartrate tab cr 6.25 mg (Ambien cr) 2 • • • zolpidem tartrate tab cr 12.5 mg (Ambien cr) 2 • zolpidem tartrate tab 5 mg (Ambien) 1 zolpidem tartrate tab 10 mg (Ambien) 1 ZOLPIMIST - zolpidem tartrate oral spray 5 mg/act 4 • • • ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS 4 ADDERALL - amphetaminedextroamphetamine tab 5 mg 4 ADDERALL - amphetaminedextroamphetamine tab 7.5 mg 4 ADDERALL - amphetaminedextroamphetamine tab 10 mg 4 ADDERALL - amphetaminedextroamphetamine tab 12.5 mg 4 ADDERALL - amphetaminedextroamphetamine tab 15 mg 4 ADDERALL - amphetaminedextroamphetamine tab 20 mg 4 ADDERALL - amphetaminedextroamphetamine tab 30 mg 4 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 5 mg 4 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 10 mg 4 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 15 mg 4 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 20 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • • • • • • • • 85 • ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 25 mg 4 ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 30 mg 4 amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr) 2 • amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr) 2 • amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr) 2 • amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr) 2 • amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr) 2 • amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr) 2 • amphetamine-dextroamphetamine tab 5 mg (Adderall) 2 • amphetamine-dextroamphetamine tab 7.5 mg (Adderall) 2 • amphetamine-dextroamphetamine tab 10 mg (Adderall) 2 • amphetamine-dextroamphetamine tab 12.5 mg (Adderall) 2 • amphetamine-dextroamphetamine tab 15 mg (Adderall) 2 • amphetamine-dextroamphetamine tab 20 mg (Adderall) 2 • amphetamine-dextroamphetamine tab 30 mg (Adderall) 2 • APTENSIO XR - methylphenidate hcl cap er 24hr 10 mg (xr) 4 • APTENSIO XR - methylphenidate hcl cap er 24hr 15 mg (xr) 4 • APTENSIO XR - methylphenidate hcl cap er 24hr 20 mg (xr) 4 • APTENSIO XR - methylphenidate hcl cap er 24hr 30 mg (xr) 4 • 86 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 APTENSIO XR - methylphenidate hcl cap er 24hr 40 mg (xr) 4 • APTENSIO XR - methylphenidate hcl cap er 24hr 50 mg (xr) 4 • APTENSIO XR - methylphenidate hcl cap er 24hr 60 mg (xr) 4 • caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit) 2 clonidine hcl tab sr 12hr 0.1 mg (Kapvay) 2 • CONCERTA - methylphenidate hcl tab sa osm 18 mg 4 • CONCERTA - methylphenidate hcl tab sa osm 27 mg 4 • CONCERTA - methylphenidate hcl tab sa osm 36 mg 4 • CONCERTA - methylphenidate hcl tab sa osm 54 mg 4 • DAYTRANA - methylphenidate td patch 10 mg/9hr 4 • DAYTRANA - methylphenidate td patch 15 mg/9hr 4 • DAYTRANA - methylphenidate td patch 20 mg/9hr 4 • DAYTRANA - methylphenidate td patch 30 mg/9hr 4 • DESOXYN - methamphetamine hcl tab 5 mg 4 • DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 5 mg 4 • DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 10 mg 4 • DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 15 mg 4 • dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin xr) 2 • dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin xr) 2 • dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr) 2 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin xr) 2 • FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 20 mg 4 • dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr) 2 • FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 25 mg 4 • dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr) 2 • FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 30 mg 4 • dexmethylphenidate hcl tab 2.5 mg (Focalin) 2 • FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 35 mg 4 • dexmethylphenidate hcl tab 5 mg (Focalin) 2 • FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 40 mg 4 • dexmethylphenidate hcl tab 10 mg (Focalin) 2 • guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv) 2 • dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine) 2 • guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv) 2 • dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine) 2 • guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv) 2 • dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine) 2 • guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv) 2 • dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) 2 • INTUNIV - guanfacine hcl tab sr 24hr 1 mg (base equiv) 3 • dextroamphetamine sulfate tab 5 mg 2 • 2 INTUNIV - guanfacine hcl tab sr 24hr 2 mg (base equiv) 3 dextroamphetamine sulfate tab 10 mg • • 3 • EVEKEO - amphetamine sulfate tab 5 mg 4 • INTUNIV - guanfacine hcl tab sr 24hr 3 mg (base equiv) 3 • EVEKEO - amphetamine sulfate tab 10 mg 4 • INTUNIV - guanfacine hcl tab sr 24hr 4 mg (base equiv) 4 • FOCALIN - dexmethylphenidate hcl tab 2.5 mg 4 • KAPVAY - clonidine hcl tab sr 12hr 0.1 mg 4 • FOCALIN - dexmethylphenidate hcl tab 5 mg 4 • METADATE CD - methylphenidate hcl cap cr 10 mg 4 • FOCALIN - dexmethylphenidate hcl tab 10 mg 4 • METADATE CD - methylphenidate hcl cap cr 20 mg 4 • FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 5 mg 4 • METADATE CD - methylphenidate hcl cap cr 30 mg 4 • FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 10 mg 4 • METADATE CD - methylphenidate hcl cap cr 40 mg 4 • FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 15 mg 4 • METADATE CD - methylphenidate hcl cap cr 50 mg METADATE CD - methylphenidate hcl cap cr 60 mg 4 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 87 methamphetamine hcl tab 5 mg (Desoxyn) 2 • METHYLIN - methylphenidate hcl chew tab 2.5 mg 4 • METHYLIN - methylphenidate hcl chew tab 5 mg 4 • METHYLIN - methylphenidate hcl chew tab 10 mg 4 • METHYLIN - methylphenidate hcl soln 5 mg/5ml 4 • METHYLIN - methylphenidate hcl soln 10 mg/5ml 4 methylphenidate hcl cap cr 10 mg (Metadate cd) 2 methylphenidate hcl cap cr 20 mg (Metadate cd) 2 methylphenidate hcl cap cr 30 mg (Metadate cd) Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm 27 mg 2 • METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm 36 mg 2 • METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm 54 mg 2 • methylphenidate hcl soln 5 mg/5ml (Methylin) 2 • methylphenidate hcl soln 10 mg/5ml (Methylin) 2 • methylphenidate hcl tab cr 10 mg 4 • methylphenidate hcl tab cr 20 mg (Ritalin sr) 2 • 2 • methylphenidate hcl tab 5 mg (Ritalin) 2 • methylphenidate hcl cap cr 40 mg (Metadate cd) 2 • methylphenidate hcl tab 10 mg (Ritalin) 2 • methylphenidate hcl cap cr 50 mg (Metadate cd) 2 • methylphenidate hcl tab 20 mg (Ritalin) 2 • methylphenidate hcl cap cr 60 mg (Metadate cd) 2 • modafinil tab 100 mg (Provigil) 2 modafinil tab 200 mg (Provigil) 2 methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la) 2 • NUVIGIL - armodafinil tab 50 mg 4 4 2 • NUVIGIL - armodafinil tab 150 mg methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la) NUVIGIL - armodafinil tab 200 mg 4 2 • NUVIGIL - armodafinil tab 250 mg 4 methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la) 4 methylphenidate hcl chew tab 2.5 mg (Methylin) 2 PROCENTRA - dextroamphetamine sulfate oral solution 5 mg/5ml PROVIGIL - modafinil tab 100 mg 4 • PROVIGIL - modafinil tab 200 mg 4 4 • • QUILLIVANT XR - methylphenidate hcl for er susp 25 mg/5ml (5 mg/ml) RITALIN - methylphenidate hcl tab 5 mg 4 RITALIN - methylphenidate hcl tab 10 mg 4 • • RITALIN - methylphenidate hcl tab 20 mg 4 • methylphenidate hcl chew tab 5 mg (Methylin) 2 methylphenidate hcl chew tab 10 mg (Methylin) 2 METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm 18 mg 2 88 • • • • • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 RITALIN LA - methylphenidate hcl cap sr 24hr 10 mg (la) 4 • ZENZEDI - dextroamphetamine sulfate tab 7.5 mg 4 • RITALIN LA - methylphenidate hcl cap sr 24hr 20 mg (la) 4 • ZENZEDI - dextroamphetamine sulfate tab 15 mg 4 • RITALIN LA - methylphenidate hcl cap sr 24hr 30 mg (la) 4 • ZENZEDI - dextroamphetamine sulfate tab 20 mg 4 • RITALIN LA - methylphenidate hcl cap sr 24hr 40 mg (la) 4 • ZENZEDI - dextroamphetamine sulfate tab 30 mg 4 • RITALIN LA - methylphenidate hcl cap sr 24hr 60 mg (la) 4 • STRATTERA - atomoxetine hcl cap 10 mg (base equiv) 4 • STRATTERA - atomoxetine hcl cap 18 mg (base equiv) 4 • STRATTERA - atomoxetine hcl cap 25 mg (base equiv) 4 • STRATTERA - atomoxetine hcl cap 40 mg (base equiv) 4 • PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. 2 acamprosate calcium tab delayed release 333 mg (Campral) 4 ACTIVE-PAC/GABAPENTIN gabapentin oral cap 300 mg & lidocaine-menthol gel ther pk AMPYRA - dalfampridine tab sr 12hr 10 5 • mg 4 ANTABUSE - disulfiram tab 250 mg STRATTERA - atomoxetine hcl cap 60 mg (base equiv) 4 • ANTABUSE - disulfiram tab 500 mg 4 STRATTERA - atomoxetine hcl cap 80 mg (base equiv) • ARICEPT - donepezil hydrochloride tab 5 mg 4 4 STRATTERA - atomoxetine hcl cap 100 mg (base equiv) • ARICEPT - donepezil hydrochloride tab 10 mg 4 4 4 VYVANSE - lisdexamfetamine dimesylate cap 10 mg 4 • ARICEPT - donepezil hydrochloride tab 23 mg 5 4 • AUBAGIO - teriflunomide tab 7 mg VYVANSE - lisdexamfetamine dimesylate cap 20 mg AUBAGIO - teriflunomide tab 14 mg 5 4 • AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial) 5 VYVANSE - lisdexamfetamine dimesylate cap 30 mg • • • • • • 4 • AVONEX - interferon beta-1a im inj kit 30 mcg/0.5ml 5 VYVANSE - lisdexamfetamine dimesylate cap 40 mg • • VYVANSE - lisdexamfetamine dimesylate cap 50 mg 4 • • • VYVANSE - lisdexamfetamine dimesylate cap 60 mg 4 • VYVANSE - lisdexamfetamine dimesylate cap 70 mg 4 • ZENZEDI - dextroamphetamine sulfate tab 2.5 mg 4 • AVONEX PEN - interferon beta-1a im inj 5 kit 30 mcg/0.5ml BETASERON - interferon beta-1b for inj 5 kit 0.3 mg 4 BRISDELLE - paroxetine mesylate cap 7.5 mg (base equiv) 2 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • 89 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 CHANTIX - varenicline tartrate tab 0.5 mg (base equiv) 3 EXELON - rivastigmine td patch 24hr 9.5 mg/24hr 4 CHANTIX - varenicline tartrate tab 1 mg (base equiv) 3 EXELON - rivastigmine td patch 24hr 13.3 mg/24hr 4 CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base equiv) 3 EXELON - rivastigmine tartrate cap 1.5 mg 4 3 EXELON - rivastigmine tartrate cap 3 mg 4 CHANTIX STARTING MONTH PA varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack EXELON - rivastigmine tartrate cap 4.5 mg 4 CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab 5-12.5 mg 4 EXELON - rivastigmine tartrate cap 6 mg 4 4 EXTAVIA - interferon beta-1b for inj kit 0.3 mg 5 CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab 10-25 mg fluoxetine hcl (pmdd) cap 10 mg 2 COMMIT - nicotine polacrilex lozenge 2 mg 4 fluoxetine hcl (pmdd) cap 20 mg 2 2 COMMIT - nicotine polacrilex lozenge 4 mg 4 GALANTAMINE HYDROBROMIDE galantamine hydrobromide oral soln 4 mg/ml COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 5 • galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er) 2 COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 • galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er) 2 disulfiram tab 250 mg (Antabuse) 2 2 disulfiram tab 500 mg (Antabuse) 2 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er) 2 galantamine hydrobromide tab 4 mg (Razadyne) 2 donepezil hydrochloride orally disintegrating tab 5 mg 2 galantamine hydrobromide tab 8 mg (Razadyne) 2 donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt) 2 donepezil hydrochloride tab 5 mg (Aricept) 1 galantamine hydrobromide tab 12 mg (Razadyne) 5 • • donepezil hydrochloride tab 10 mg (Aricept) 1 GILENYA - fingolimod hcl cap 0.5 mg (base equiv) 5 • donepezil hydrochloride tab 23 mg (Aricept) 2 glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone) 4 • ergoloid mesylates tab 1 mg 2 GRALISE - gabapentin (phn) tab 300 mg 4 GRALISE - gabapentin (phn) tab 600 mg 4 EXELON - rivastigmine td patch 24hr 4.6 mg/24hr • 90 • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 GRALISE STARTER - gabapentin (phn) tab starter pack 300 mg (9) & 600 mg (69) 4 HORIZANT - gabapentin enacarbil tab cr 300 mg 4 HORIZANT - gabapentin enacarbil tab cr 600 mg 4 memantine hcl tab 5 mg (Namenda) 2 memantine hcl tab 10 mg (Namenda) 2 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa) 2 NAMENDA - memantine hcl oral solution 2 mg/ml • NICORETTE - nicotine polacrilex gum 2 mg 4 4 • NICORETTE - nicotine polacrilex gum 4 mg 4 • NICORETTE - nicotine polacrilex lozenge 2 mg NICORETTE - nicotine polacrilex lozenge 4 mg 4 NICORETTE MINI - nicotine polacrilex lozenge 2 mg 4 NICORETTE MINI - nicotine polacrilex lozenge 4 mg 4 4 NICORETTE STARTER KIT - nicotine polacrilex gum 2 mg 4 NAMENDA - memantine hcl tab 5 mg 4 4 NAMENDA - memantine hcl tab 10 mg 4 NICORETTE STARTER KIT - nicotine polacrilex gum 4 mg NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 4 nicotine polacrilex gum 2 mg 2 nicotine polacrilex gum 4 mg 2 nicotine polacrilex lozenge 2 mg 2 NAMENDA XR - memantine hcl cap sr 24hr 7 mg 4 nicotine polacrilex lozenge 4 mg 2 4 nicotine td patch 24hr 7 mg/24hr 2 NAMENDA XR - memantine hcl cap sr 24hr 14 mg nicotine td patch 24hr 14 mg/24hr 2 NAMENDA XR - memantine hcl cap sr 24hr 21 mg 4 nicotine td patch 24hr 21 mg/24hr 2 4 NAMENDA XR - memantine hcl cap sr 24hr 28 mg 4 NICOTINE TRANSDERMAL SYST nicotine td patch 24 hr kit 21-14-7 mg/24hr NAMENDA XR TITRATION PACK memantine hcl cap sr 24hr 7 mg & 14 mg & 21 mg & 28 mg pack 4 NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg delivered) 3 NAMZARIC - memantine hcl-donepezil hcl cap sr 24hr 14-10 mg 4 NAMZARIC - memantine hcl-donepezil hcl cap sr 24hr 28-10 mg 4 NICODERM CQ - nicotine td patch 24hr 7 mg/24hr 4 NICODERM CQ - nicotine td patch 24hr 14 mg/24hr 4 NICODERM CQ - nicotine td patch 24hr 21 mg/24hr 4 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 NICOTROL NS - nicotine nasal spray 10 3 mg/ml (0.5 mg/spray) 3 NUEDEXTA - dextromethorphan hbrquinidine sulfate cap 20-10 mg 2 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax) 2 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax) 2 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 91 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax) 2 RAZADYNE ER - galantamine hydrobromide cap sr 24hr 16 mg 4 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax) 2 RAZADYNE ER - galantamine hydrobromide cap sr 24hr 24 mg 4 ORAP - pimozide tab 1 mg 4 5 • ORAP - pimozide tab 2 mg 4 REBIF - interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml) PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-10 mg 4 REBIF - interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml) 5 • 5 • PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 2-25 mg 4 REBIF REBIDOSE - interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ ml) 5 • PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-10 mg 4 REBIF REBIDOSE - interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ ml) 5 • PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-25 mg 4 REBIF REBIDOSE TITRATION interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml 5 • PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-50 mg 4 REBIF TITRATION PACK - interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml 2 PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 • rivastigmine tartrate cap 1.5 mg (Exelon) 2 PLEGRIDY - peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml 5 • rivastigmine tartrate cap 3 mg (Exelon) 2 PLEGRIDY STARTER PACK peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack 5 • rivastigmine tartrate cap 4.5 mg (Exelon) rivastigmine tartrate cap 6 mg (Exelon) 2 PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack 5 SARAFEM - fluoxetine hcl (pmdd) tab 10 mg 4 RAZADYNE - galantamine hydrobromide tab 4 mg SARAFEM - fluoxetine hcl (pmdd) tab 20 mg 4 4 SAVELLA - milnacipran hcl tab 12.5 mg 4 RAZADYNE - galantamine hydrobromide tab 8 mg 4 SAVELLA - milnacipran hcl tab 25 mg 4 4 SAVELLA - milnacipran hcl tab 50 mg 4 RAZADYNE - galantamine hydrobromide tab 12 mg SAVELLA - milnacipran hcl tab 100 mg 4 RAZADYNE - galantamine hydrobromide oral soln 4 mg/ml 4 4 RAZADYNE ER - galantamine hydrobromide cap sr 24hr 8 mg 4 SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak 92 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • • SYMBYAX - olanzapine-fluoxetine hcl cap 3-25 mg 4 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) 1 SYMBYAX - olanzapine-fluoxetine hcl cap 6-25 mg 4 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) 2 SYMBYAX - olanzapine-fluoxetine hcl cap 6-50 mg 4 choline & magnesium salicylates liq 500 mg/5ml 2 SYMBYAX - olanzapine-fluoxetine hcl cap 12-25 mg 4 2 SYMBYAX - olanzapine-fluoxetine hcl cap 12-50 mg 4 CHOLINE MAGNESIUM TRISALI choline & magnesium salicylates tab 1000 mg diflunisal tab 500 mg 2 TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 DISALCID - salsalate tab 500 mg 4 4 TECFIDERA - dimethyl fumarate capsule delayed release 240 mg • DISALCID - salsalate tab 750 mg 5 TECFIDERA STARTER PACK dimethyl fumarate capsule dr starter pack 120 mg & 240 mg 5 • XENAZINE - tetrabenazine tab 12.5 mg 5 XENAZINE - tetrabenazine tab 25 mg 5 XYREM - sodium oxybate oral solution 500 mg/ml 5 ZYBAN - bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 4 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 acetaminophen-salicylamidephenyltoloxamine cap 300-200-20mg 1 aspirin chew tab 81 mg 1 EQUAGESIC - meprobamate-aspirin tab 4 200-325 mg 4 ESGIC - butalbital-acetaminophencaffeine tab 50-325-40 mg 4 FIORICET - butalbital-acetaminophencaffeine cap 50-300-40 mg 4 FIORICET - butalbital-acetaminophencaffeine tab 50-325-40 mg 4 FIORINAL - butalbital-aspirin-caffeine cap 50-325-40 mg 4 LEVACET - aspirin-apap-salicylamidecaffeine tab 500-250-150-32.5 mg 4 ORBIVAN - butalbital-acetaminophencaffeine cap 50-300-40 mg 4 ORBIVAN CF - butalbitalacetaminophen tab 50-300 mg 2 salsalate tab 500 mg ASPIRIN LOW DOSE - aspirin tab 81 mg 4 salsalate tab 750 mg 2 aspirin tab delayed release 81 mg BUPAP - butalbital-acetaminophen tab 50-300 mg 4 VANATOL LQ - butalbitalacetaminophen-caffeine soln 50-325-40 mg/15ml 2 1 butalbital-acetaminophen tab 50-325 mg 1 ABSTRAL - fentanyl citrate sl tab 100 mcg (base equiv) 4 • • butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) 2 ABSTRAL - fentanyl citrate sl tab 200 mcg (base equiv) 4 • • butalbital-acetaminophen-caffeine cap 50-325-40 mg 2 ABSTRAL - fentanyl citrate sl tab 300 mcg (base equiv) 4 • • ANALGESICS AND ANESTHETICS ANALGESICS - NON-NARCOTIC • • • • • • ANALGESICS - NARCOTIC BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 93 4 • • ABSTRAL - fentanyl citrate sl tab 800 mcg (base equiv) 4 • • acetaminophen w/ codeine soln 120-12 mg/5ml 1 acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) 1 acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) 1 acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) 1 ACTIQ - fentanyl citrate lozenge on a handle 200 mcg 4 • • ACTIQ - fentanyl citrate lozenge on a handle 400 mcg 4 • • ACTIQ - fentanyl citrate lozenge on a handle 600 mcg 4 • • ACTIQ - fentanyl citrate lozenge on a handle 800 mcg 4 • • ACTIQ - fentanyl citrate lozenge on a handle 1200 mcg 4 • • ACTIQ - fentanyl citrate lozenge on a handle 1600 mcg 4 • • ASPIRIN-CAFFEINE-DIHYDROC aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg 4 AVINZA - morphine sulfate beads cap sr 4 24hr 30 mg AVINZA - morphine sulfate beads cap sr 4 24hr 45 mg AVINZA - morphine sulfate beads cap sr 4 24hr 60 mg AVINZA - morphine sulfate beads cap sr 4 24hr 75 mg AVINZA - morphine sulfate beads cap sr 4 24hr 90 mg 94 • • • • • Dispensing Limits ABSTRAL - fentanyl citrate sl tab 600 mcg (base equiv) AVINZA - morphine sulfate beads cap sr 4 24hr 120 mg 4 BUNAVAIL - buprenorphine-naloxone buccal film 2.1-0.3 mg (base equiv) 4 BUNAVAIL - buprenorphine-naloxone buccal film 4.2-0.7 mg (base equiv) 4 BUNAVAIL - buprenorphine-naloxone buccal film 6.3-1 mg (base equiv) 2 buprenorphine hcl sl tab 2 mg (base equiv) 2 buprenorphine hcl sl tab 8 mg (base equiv) 2 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 2 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 2 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/ codeine) butalbital-acetaminophen-caff w/ cod 1 cap 50-325-40-30 mg butalbital-aspirin-caff w/ codeine cap 2 50-325-40-30 mg (Fiorinal/codeine #3) 2 butorphanol tartrate nasal soln 10 mg/ml 4 BUTRANS - buprenorphine td patch weekly 5 mcg/hr 4 BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr 4 BUTRANS - buprenorphine td patch weekly 10 mcg/hr 4 BUTRANS - buprenorphine td patch weekly 15 mcg/hr 4 BUTRANS - buprenorphine td patch weekly 20 mcg/hr 4 CAPITAL/CODEINE - acetaminophen w/ codeine susp 120-12 mg/5ml 4 CODEINE SULFATE - codeine sulfate tab 15 mg Step Therapy • Prior Authorization • Drug Name Drug Tier 4 Dispensing Limits Prior Authorization ABSTRAL - fentanyl citrate sl tab 400 mcg (base equiv) Drug Name Step Therapy Drug Tier 2015 • • • • • • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • • • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 CODEINE SULFATE - codeine sulfate tab 30 mg 2 EMBEDA - morphine-naltrexone cap cr 30-1.2 mg 4 • CODEINE SULFATE - codeine sulfate tab 60 mg 2 EMBEDA - morphine-naltrexone cap cr 50-2 mg 4 • codeine sulfate tab 15 mg (Codeine sulfate) 2 EMBEDA - morphine-naltrexone cap cr 60-2.4 mg 4 • codeine sulfate tab 30 mg 2 4 • codeine sulfate tab 60 mg 2 EMBEDA - morphine-naltrexone cap cr 80-3.2 mg CONZIP - tramadol hcl cap sr 24hr biphasic release 100 mg 4 • EMBEDA - morphine-naltrexone cap cr 100-4 mg 4 • CONZIP - tramadol hcl cap sr 24hr biphasic release 200 mg 4 • EXALGO - hydromorphone hcl tab er 24hr deter 8 mg 4 • CONZIP - tramadol hcl cap sr 24hr biphasic release 300 mg 4 • EXALGO - hydromorphone hcl tab er 24hr deter 12 mg 4 • DEMEROL - meperidine hcl tab 50 mg 4 4 • DEMEROL - meperidine hcl tab 100 mg 4 EXALGO - hydromorphone hcl tab er 24hr deter 16 mg 4 EXALGO - hydromorphone hcl tab er 24hr deter 32 mg 4 DILAUDID - hydromorphone hcl liqd 1 mg/ml • DILAUDID - hydromorphone hcl tab 2 mg 4 • DILAUDID - hydromorphone hcl tab 4 mg 4 DILAUDID - hydromorphone hcl tab 8 mg 4 DOLOPHINE - methadone hcl tab 10 mg 4 DOLOPHINE HCL - methadone hcl tab 5 mg 4 FENTANYL - fentanyl td patch 72hr 37.5 4 mcg/hr FENTANYL - fentanyl td patch 72hr 62.5 4 mcg/hr FENTANYL - fentanyl td patch 72hr 87.5 4 mcg/hr 2 fentanyl citrate lozenge on a handle 200 mcg (Actiq) 2 fentanyl citrate lozenge on a handle 400 mcg (Actiq) 2 fentanyl citrate lozenge on a handle 600 mcg (Actiq) 2 fentanyl citrate lozenge on a handle 800 mcg (Actiq) 2 fentanyl citrate lozenge on a handle 1200 mcg (Actiq) 2 fentanyl citrate lozenge on a handle 1600 mcg (Actiq) 2 fentanyl td patch 72hr 12 mcg/hr (Duragesic) 2 fentanyl td patch 72hr 25 mcg/hr (Duragesic) DURAGESIC - fentanyl td patch 72hr 12 4 mcg/hr DURAGESIC - fentanyl td patch 72hr 25 4 mcg/hr DURAGESIC - fentanyl td patch 72hr 50 4 mcg/hr DURAGESIC - fentanyl td patch 72hr 75 4 mcg/hr 4 DURAGESIC - fentanyl td patch 72hr 100 mcg/hr 4 EMBEDA - morphine-naltrexone cap cr 20-0.8 mg • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • • • • • • • • • • • • • 95 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 fentanyl td patch 72hr 50 mcg/hr (Duragesic) 2 • hydrocodone-ibuprofen tab 2.5-200 mg (Reprexain) 2 fentanyl td patch 72hr 75 mcg/hr (Duragesic) 2 • hydrocodone-ibuprofen tab 5-200 mg (Reprexain) 2 fentanyl td patch 72hr 100 mcg/hr (Duragesic) 2 • hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen) 1 FENTORA - fentanyl citrate buccal tab 100 mcg (base equiv) 4 • • hydrocodone-ibuprofen tab 10-200 mg (Ibudone) 2 FENTORA - fentanyl citrate buccal tab 200 mcg (base equiv) 4 • • 4 FENTORA - fentanyl citrate buccal tab 400 mcg (base equiv) 4 • • HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen soln 10-325 mg/15ml 4 FENTORA - fentanyl citrate buccal tab 600 mcg (base equiv) 4 • HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg 4 FENTORA - fentanyl citrate buccal tab 800 mcg (base equiv) 4 HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr deter 32 mg FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap 50-300-40-30 mg 4 hydromorphone hcl liqd 1 mg/ml (Dilaudid) 2 2 • FIORINAL/CODEINE #3 - butalbitalaspirin-caff w/ codeine cap 50-325-40-30 mg 4 hydromorphone hcl tab er 24hr deter 8 mg (Exalgo) hydromorphone hcl tab er 24hr deter 12 mg (Exalgo) 2 • HYCET - hydrocodone-acetaminophen soln 7.5-325 mg/15ml 4 hydromorphone hcl tab er 24hr deter 16 mg (Exalgo) 2 • hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) 2 hydromorphone hcl tab 2 mg (Dilaudid) 1 hydrocodone-acetaminophen tab 2.5-325 mg 2 hydromorphone hcl tab 4 mg (Dilaudid) 1 hydrocodone-acetaminophen tab 10-325 mg (Norco) 1 hydromorphone hcl tab 8 mg (Dilaudid) 2 hydrocodone-acetaminophen tab 5-300 mg (Xodol) 2 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 20 mg 4 • hydrocodone-acetaminophen tab 7.5-300 mg (Xodol) 2 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 30 mg 4 • hydrocodone-acetaminophen tab 5-325 mg (Norco) 1 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 40 mg 4 • hydrocodone-acetaminophen tab 7.5-325 mg (Norco) 1 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 60 mg 4 • hydrocodone-acetaminophen tab 10-300 mg (Xodol) 2 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 80 mg 4 • 96 • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 100 mg 4 • METHADONE HCL - methadone hcl soln 5 mg/5ml 4 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 120 mg 4 • METHADONE HCL - methadone hcl soln 10 mg/5ml 4 IBUDONE - hydrocodone-ibuprofen tab 10-200 mg 4 methadone hcl conc 10 mg/ml (Methadose) 2 IONSYS - fentanyl hcl iontophoretic td system 40 mcg/act (base equiv) 4 methadone hcl soln 5 mg/5ml (Methadone hcl) 2 KADIAN - morphine sulfate cap sr 24hr 10 mg 4 • methadone hcl soln 10 mg/5ml (Methadone hcl) 2 KADIAN - morphine sulfate cap sr 24hr 20 mg 4 • methadone hcl tab for oral susp 40 mg 2 KADIAN - morphine sulfate cap sr 24hr 30 mg 4 • methadone hcl tab 5 mg (Dolophine hcl) 1 KADIAN - morphine sulfate cap sr 24hr 40 mg 4 • methadone hcl tab 10 mg (Dolophine) 1 4 • METHADOSE - methadone hcl conc 10 mg/ml 4 KADIAN - morphine sulfate cap sr 24hr 50 mg 4 • METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml 4 KADIAN - morphine sulfate cap sr 24hr 60 mg KADIAN - morphine sulfate cap sr 24hr 80 mg • MORPHINE SULFATE - morphine sulfate tab 15 mg 3 4 KADIAN - morphine sulfate cap sr 24hr 100 mg • MORPHINE SULFATE - morphine sulfate tab 30 mg 3 4 3 KADIAN - morphine sulfate cap sr 24hr 200 mg 4 • MORPHINE SULFATE - morphine sulfate suppos 5 mg 4 • • MORPHINE SULFATE - morphine sulfate suppos 10 mg 3 LAZANDA - fentanyl citrate nasal spray 100 mcg/act (base equiv) LAZANDA - fentanyl citrate nasal spray 400 mcg/act (base equiv) • • MORPHINE SULFATE - morphine sulfate suppos 20 mg 3 4 LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg MORPHINE SULFATE - morphine sulfate suppos 30 mg 3 4 morphine sulfate (concentrate) oral soln 20 mg/ml 2 morphine sulfate cap sr 24hr 10 mg (Kadian) 2 • morphine sulfate cap sr 24hr 20 mg (Kadian) 2 • morphine sulfate cap sr 24hr 30 mg (Kadian) 2 • MEPERIDINE HCL - meperidine hcl oral 4 soln 50 mg/5ml 1 meperidine hcl tab 50 mg (Demerol) meperidine hcl tab 100 mg (Demerol) 2 MEPERIDINE HCL/PROMETHAZI meperidine w/ promethazine cap 50-25 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 97 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 morphine sulfate cap sr 24hr 50 mg (Kadian) 2 • MS CONTIN - morphine sulfate tab cr 200 mg 4 morphine sulfate cap sr 24hr 60 mg (Kadian) 2 • NORCO - hydrocodone-acetaminophen tab 10-325 mg 4 morphine sulfate cap sr 24hr 80 mg (Kadian) 2 • NORCO - hydrocodone-acetaminophen tab 5-325 mg 4 morphine sulfate cap sr 24hr 100 mg (Kadian) 2 • NORCO - hydrocodone-acetaminophen tab 7.5-325 mg 4 MORPHINE SULFATE ER - morphine sulfate beads cap sr 24hr 30 mg 2 • NUCYNTA - tapentadol hcl tab 50 mg 4 4 MORPHINE SULFATE ER - morphine sulfate beads cap sr 24hr 45 mg • NUCYNTA - tapentadol hcl tab 75 mg 2 NUCYNTA - tapentadol hcl tab 100 mg 4 2 • NUCYNTA ER - tapentadol hcl tab sr 12hr 50 mg 4 MORPHINE SULFATE ER - morphine sulfate beads cap sr 24hr 60 mg • • • • 2 • NUCYNTA ER - tapentadol hcl tab sr 12hr 100 mg 4 MORPHINE SULFATE ER - morphine sulfate beads cap sr 24hr 75 mg • 2 • NUCYNTA ER - tapentadol hcl tab sr 12hr 150 mg 4 MORPHINE SULFATE ER - morphine sulfate beads cap sr 24hr 90 mg • 2 • NUCYNTA ER - tapentadol hcl tab sr 12hr 200 mg 4 MORPHINE SULFATE ER - morphine sulfate beads cap sr 24hr 120 mg • 1 NUCYNTA ER - tapentadol hcl tab sr 12hr 250 mg 4 morphine sulfate oral soln 10 mg/5ml • morphine sulfate oral soln 20 mg/5ml 2 4 morphine sulfate tab cr 15 mg (Ms contin) • OPANA - oxymorphone hcl tab 5 mg 2 OPANA - oxymorphone hcl tab 10 mg 4 2 • • morphine sulfate tab cr 60 mg (Ms contin) 2 • OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 5 mg 4 morphine sulfate tab cr 30 mg (Ms contin) 4 • morphine sulfate tab cr 100 mg (Ms contin) 2 • OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 7.5 mg • • morphine sulfate tab cr 200 mg (Ms contin) OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 10 mg 4 2 MS CONTIN - morphine sulfate tab cr 15 mg 4 • 4 • MS CONTIN - morphine sulfate tab cr 30 mg 4 • OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 15 mg 4 • MS CONTIN - morphine sulfate tab cr 60 mg 4 • OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 20 mg MS CONTIN - morphine sulfate tab cr 100 mg 4 • 98 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • Dispensing Limits • oxycodone-ibuprofen tab 5-400 mg 2 OXYCONTIN - oxycodone hcl tab er 12hr deter 10 mg 3 • OXYCONTIN - oxycodone hcl tab er 12hr deter 15 mg 3 • Step Therapy Drug Name Drug Tier Prior Authorization Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 30 mg 4 OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 40 mg 4 4 OXYCONTIN - oxycodone hcl tab er 12hr deter 20 mg 3 OXYCODONE HCL - oxycodone hcl conc 100 mg/5ml (20 mg/ml) • 4 OXYCONTIN - oxycodone hcl tab er 12hr deter 30 mg 3 OXYCODONE HCL - oxycodone hcl soln 5 mg/5ml • 2 OXYCONTIN - oxycodone hcl tab er 12hr deter 40 mg 3 oxycodone hcl cap 5 mg • oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl) 2 3 • OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 10 mg 4 • OXYCONTIN - oxycodone hcl tab er 12hr deter 60 mg 3 • OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 20 mg 4 • OXYCONTIN - oxycodone hcl tab er 12hr deter 80 mg oxymorphone hcl tab sr 12hr 5 mg 2 4 • oxymorphone hcl tab sr 12hr 7.5 mg 2 OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 40 mg oxymorphone hcl tab sr 12hr 10 mg 2 OXYCODONE HCL ER - oxycodone hcl tab er 12hr deter 80 mg 4 • oxymorphone hcl tab sr 12hr 15 mg 2 oxymorphone hcl tab sr 12hr 20 mg 2 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl) 2 oxymorphone hcl tab sr 12hr 30 mg 2 oxymorphone hcl tab sr 12hr 40 mg 2 • • • • • • • oxymorphone hcl tab 5 mg (Opana) 2 oxymorphone hcl tab 10 mg (Opana) 2 pentazocine w/ naloxone tab 50-0.5 mg 2 oxycodone hcl tab 5 mg (Roxicodone) 1 2 oxycodone hcl tab 10 mg • oxycodone hcl tab 15 mg (Roxicodone) 2 oxycodone hcl tab 20 mg 2 oxycodone hcl tab 30 mg (Roxicodone) PERCOCET - oxycodone w/ acetaminophen tab 2.5-325 mg 4 2 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) PERCOCET - oxycodone w/ acetaminophen tab 5-325 mg 4 2 oxycodone w/ acetaminophen tab 5-325 mg (Percocet) PERCOCET - oxycodone w/ acetaminophen tab 7.5-325 mg 4 1 2 PERCOCET - oxycodone w/ acetaminophen tab 10-325 mg 4 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) 2 PERCODAN - oxycodone-aspirin tab 4.8355-325 mg 4 oxycodone w/ acetaminophen tab 10-325 mg (Percocet) oxycodone-aspirin tab 4.8355-325 mg (Percodan) PRIMLEV - oxycodone w/ acetaminophen tab 5-300 mg 4 2 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 99 PRIMLEV - oxycodone w/ acetaminophen tab 10-300 mg 4 SYNALGOS-DC - aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg 4 REPREXAIN - hydrocodone-ibuprofen tab 2.5-200 mg 4 TRAMADOL HCL ER - tramadol hcl cap sr 24hr biphasic release 100 mg 4 • REPREXAIN - hydrocodone-ibuprofen tab 5-200 mg 4 TRAMADOL HCL ER - tramadol hcl cap sr 24hr biphasic release 150 mg 4 • ROXICET - oxycodone w/ acetaminophen soln 5-325 mg/5ml 4 TRAMADOL HCL ER - tramadol hcl cap sr 24hr biphasic release 200 mg 4 • ROXICODONE - oxycodone hcl tab 5 mg 4 TRAMADOL HCL ER - tramadol hcl cap sr 24hr biphasic release 300 mg 4 • ROXICODONE - oxycodone hcl tab 15 mg 4 tramadol hcl tab sr 24hr 100 mg (Ultram er) 2 • ROXICODONE - oxycodone hcl tab 30 mg 4 tramadol hcl tab sr 24hr 200 mg (Ultram er) 2 • SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base equiv) 4 • • tramadol hcl tab sr 24hr 300 mg (Ultram er) 2 • • • SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base equiv) • tramadol hcl tab sr 24hr biphasic release 100 mg 2 4 2 • SUBOXONE - buprenorphine hclnaloxone hcl sl film 8-2 mg (base equiv) 4 • • tramadol hcl tab sr 24hr biphasic release 200 mg tramadol hcl tab sr 24hr biphasic release 300 mg 2 • 4 • • tramadol hcl tab 50 mg (Ultram) 1 SUBOXONE - buprenorphine hclnaloxone hcl sl film 12-3 mg (base equiv) • tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 • • TREZIX - acetaminophen-caffeinedihydrocodeine cap 320.5-30-16 mg 4 • • TYLENOL/CODEINE - acetaminophen w/ codeine tab 300-15 mg 4 • • 4 • • TYLENOL/CODEINE #3 acetaminophen w/ codeine tab 300-30 mg 4 • • TYLENOL/CODEINE #4 acetaminophen w/ codeine tab 300-60 mg • • ULTRACET - tramadol-acetaminophen tab 37.5-325 mg 4 ULTRAM - tramadol hcl tab 50 mg 4 SUBSYS - fentanyl sublingual spray 100 4 mcg SUBSYS - fentanyl sublingual spray 200 4 mcg SUBSYS - fentanyl sublingual spray 400 4 mcg SUBSYS - fentanyl sublingual spray 600 4 mcg SUBSYS - fentanyl sublingual spray 800 4 mcg 4 SUBSYS - fentanyl sublingual spray 1200 mcg (600 mcg x 2) 100 Dispensing Limits Prior Authorization • Drug Name Step Therapy Drug Tier 4 Dispensing Limits SUBSYS - fentanyl sublingual spray 1600 mcg (800 mcg x 2) Step Therapy 4 Drug Tier PRIMLEV - oxycodone w/ acetaminophen tab 7.5-300 mg Drug Name Prior Authorization 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • ULTRAM ER - tramadol hcl tab sr 24hr 100 mg 4 • ANAPROX - naproxen sodium tab 275 mg 4 ULTRAM ER - tramadol hcl tab sr 24hr 200 mg 4 • ANAPROX DS - naproxen sodium tab 550 mg 4 ULTRAM ER - tramadol hcl tab sr 24hr 300 mg 4 • ARAVA - leflunomide tab 10 mg 4 ARAVA - leflunomide tab 20 mg 4 VICOPROFEN - hydrocodone-ibuprofen tab 7.5-200 mg 4 ARCALYST - rilonacept for inj 220 mg 5 4 ARTHROTEC 50 - diclofenac w/ misoprostol tab delayed release 50-0.2 mg 4 XARTEMIS XR - oxycodone w/ acetaminophen tab cr 7.5-325 mg XODOL - hydrocodone-acetaminophen tab 5-300 mg 4 4 XODOL - hydrocodone-acetaminophen tab 7.5-300 mg 4 ARTHROTEC 75 - diclofenac w/ misoprostol tab delayed release 75-0.2 mg CELEBREX - celecoxib cap 50 mg 4 XODOL - hydrocodone-acetaminophen tab 10-300 mg 4 CELEBREX - celecoxib cap 100 mg 4 4 CELEBREX - celecoxib cap 200 mg 4 ZAMICET - hydrocodoneacetaminophen soln 10-325 mg/15ml CELEBREX - celecoxib cap 400 mg 4 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abuse-deterrent 10 mg 4 celecoxib cap 50 mg (Celebrex) 2 celecoxib cap 100 mg (Celebrex) 2 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abuse-deterrent 15 mg 4 celecoxib cap 200 mg (Celebrex) 2 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abuse-deterrent 20 mg • celecoxib cap 400 mg (Celebrex) 2 4 DAYPRO - oxaprozin tab 600 mg 4 4 • ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abuse-deterrent 40 mg 4 • DERMA SILKRX ANODYNEXA PA diclofen dr tab 75mg-ranitidine tab 150mg-capsaicin cr thpk 4 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abuse-deterrent 30 mg 4 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abuse-deterrent 50 mg 4 • DERMACINRX ANALGESIC COMB diclofenac sod tab dr 75 mg & lidomen-methyl sal ptch kit DERMACINRX INFLAMMATRAL P diclofen dr tab 75mg-ranitidine tab 150mg-capsaicin cr thpk 4 diclofenac potassium tab 50 mg (Cataflam) 2 diclofenac sodium tab delayed release 25 mg 2 diclofenac sodium tab delayed release 50 mg 2 diclofenac sodium tab delayed release 75 mg 2 ZUBSOLV - buprenorphine hcl-naloxone 4 hcl sl tab 1.4-0.36 mg (base eq) ZUBSOLV - buprenorphine hcl-naloxone 4 hcl sl tab 5.7-1.4 mg (base eq) ZUBSOLV - buprenorphine hcl-naloxone 4 hcl sl tab 8.6-2.1 mg (base eq) • • • • • • • • ANALGESICS - ANTI-INFLAMMATORY ACTEMRA - tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml 5 • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 • • • • • • • • • • • • • 101 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr) 2 HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 • • diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50) 2 HUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 • • • • diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75) HUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 2 5 • • DUEXIS - ibuprofen-famotidine tab 800-26.6 mg 4 HUMIRA PEDIATRIC CROHNS D adalimumab prefilled syringe kit 40 mg/0.8ml • • EC-NAPROSYN - naproxen tab ec 375 mg HUMIRA PEN - adalimumab peninjector kit 40 mg/0.8ml 5 4 • • EC-NAPROSYN - naproxen tab ec 500 mg HUMIRA PEN-CROHNS DISEASE adalimumab pen-injector kit 40 mg/0.8ml 5 4 ENBREL - etanercept for subcutaneous inj kit 25 mg 5 • • 5 • • ENBREL - etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml 5 • • HUMIRA PEN-PSORIASIS STAR adalimumab pen-injector kit 40 mg/0.8ml 4 ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 • • IBUPROFEN COMFORT PAC ibuprofen tab 800 mg & liniment topical gel kit ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml 5 • • ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 etodolac cap 200 mg 2 etodolac cap 300 mg IC 400 - ibuprofen tab 400 mg & caffeine-vitamins cap kit 4 2 etodolac tab sr 24hr 400 mg 2 4 etodolac tab sr 24hr 500 mg 2 IC 800 - ibuprofen tab 800 mg & caffeine-vitamins cap kit etodolac tab sr 24hr 600 mg 2 4 etodolac tab 400 mg 2 INDOCIN - indomethacin susp 25 mg/5ml 2 INDOCIN - indomethacin suppos 50 mg 4 etodolac tab 500 mg 4 indomethacin cap cr 75 mg 2 FELDENE - piroxicam cap 10 mg 4 indomethacin cap 25 mg 1 FELDENE - piroxicam cap 20 mg 4 indomethacin cap 50 mg 1 FENOPROFEN CALCIUM - fenoprofen calcium tab 600 mg ketoprofen cap 50 mg 1 FENOPROFEN CALCIUM - fenoprofen calcium cap 400 mg 4 ketoprofen cap 75 mg 1 4 flurbiprofen tab 50 mg 1 KETOPROFEN ER - ketoprofen cap sr 24hr 200 mg flurbiprofen tab 100 mg 1 ketorolac tromethamine tab 10 mg 1 102 • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • KINERET - anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml 5 leflunomide tab 10 mg (Arava) 1 leflunomide tab 20 mg (Arava) 1 MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg • • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 naproxen sodium tab sr 24hr 500 mg (base equiv) (Naprelan) 2 naproxen sodium tab 275 mg (Anaprox) 1 4 naproxen sodium tab 550 mg (Anaprox ds) 1 MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg 4 naproxen tab ec 375 mg (Ecnaprosyn) 1 mefenamic acid cap 250 mg (Ponstel) 2 1 MELOXICAM - meloxicam susp 7.5 mg/5ml 4 naproxen tab ec 500 mg (Ecnaprosyn) naproxen tab 250 mg (Naprosyn) 1 MELOXICAM COMFORT PAC meloxicam tab 15 mg & liniment topical gel kit 4 naproxen tab 375 mg (Naprosyn) 1 naproxen tab 500 mg (Naprosyn) 1 5 • • meloxicam tab 7.5 mg (Mobic) 1 ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml meloxicam tab 15 mg (Mobic) 1 5 • • MOBIC - meloxicam tab 7.5 mg 4 OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg MOBIC - meloxicam tab 15 mg 4 OTEZLA - apremilast tab 30 mg 5 • • MOBIC - meloxicam susp 7.5 mg/5ml 4 4 nabumetone tab 500 mg 1 OTREXUP - methotrexate soln pf autoinjector 10 mg/0.4ml 1 OTREXUP - methotrexate soln pf autoinjector 15 mg/0.4ml 4 nabumetone tab 750 mg NALFON - fenoprofen calcium cap 400 mg 4 OTREXUP - methotrexate soln pf autoinjector 20 mg/0.4ml 4 NAPRELAN - naproxen sodium tab sr 24hr 375 mg (base equiv) 4 OTREXUP - methotrexate soln pf autoinjector 25 mg/0.4ml 4 NAPRELAN - naproxen sodium tab sr 24hr 500 mg (base equiv) 4 oxaprozin tab 600 mg (Daypro) 2 4 piroxicam cap 10 mg (Feldene) 2 NAPRELAN - naproxen sodium tab sr 24hr 750 mg (base equiv) piroxicam cap 20 mg (Feldene) 2 NAPROSYN - naproxen tab 250 mg 4 4 NAPROSYN - naproxen tab 375 mg 4 PONSTEL - mefenamic acid cap 250 mg 4 PRASTERA - prasterone cap 200 mg & ibuprofen tab 400 mg kit 4 NAPROSYN - naproxen tab 500 mg NAPROSYN - naproxen susp 125 mg/5ml 4 RASUVO - methotrexate soln pf autoinjector 7.5 mg/0.15ml 4 NAPROXEN - naproxen susp 125 mg/5ml 2 RASUVO - methotrexate soln pf autoinjector 10 mg/0.2ml 4 NAPROXEN COMFORT PAC naproxen tab 500 mg & liniment topical gel kit 4 RASUVO - methotrexate soln pf autoinjector 12.5 mg/0.25ml 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 103 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 RASUVO - methotrexate soln pf autoinjector 15 mg/0.3ml 4 VIMOVO - naproxen-esomeprazole magnesium tab dr 500-20 mg 4 • • RASUVO - methotrexate soln pf autoinjector 17.5 mg/0.35ml 4 XELJANZ - tofacitinib citrate tab 5 mg (base equivalent) 5 • • RASUVO - methotrexate soln pf autoinjector 20 mg/0.4ml 4 ZIPSOR - diclofenac potassium cap 25 mg 4 RASUVO - methotrexate soln pf autoinjector 22.5 mg/0.45ml 4 ZORVOLEX - diclofenac cap 18 mg 4 ZORVOLEX - diclofenac cap 35 mg 4 RASUVO - methotrexate soln pf autoinjector 25 mg/0.5ml 4 4 acetaminophen-isometheptenedichloral cap 325-65-100 mg 2 RASUVO - methotrexate soln pf autoinjector 27.5 mg/0.55ml 4 almotriptan malate tab 6.25 mg (Axert) 2 RASUVO - methotrexate soln pf autoinjector 30 mg/0.6ml • 4 almotriptan malate tab 12.5 mg (Axert) 2 RHEUMATREX - methotrexate sodium tab 2.5 mg (antirheumatic) • 4 • SIMPONI - golimumab subcutaneous soln auto-injector 50 mg/0.5ml 5 • • ALSUMA - sumatriptan succinate solution auto-injector 6 mg/0.5ml 4 RIDAURA - auranofin cap 3 mg 4 • SIMPONI - golimumab subcutaneous soln auto-injector 100 mg/ml 5 • • AMERGE - naratriptan hcl tab 1 mg (base equiv) 4 • SIMPONI - golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml 5 • • AMERGE - naratriptan hcl tab 2.5 mg (base equiv) 4 • SIMPONI - golimumab subcutaneous soln prefilled syringe 100 mg/ml 5 • • AXERT - almotriptan malate tab 6.25 mg 4 • SPRIX - ketorolac tromethamine nasal spray 15.75 mg/spray 4 • AXERT - almotriptan malate tab 12.5 mg CAFERGOT - ergotamine w/ caffeine tab 1-100 mg 4 sulindac tab 150 mg 1 sulindac tab 200 mg CAMBIA - diclofenac potassium packet 50 mg 4 1 TIVORBEX - indomethacin cap 20 mg 4 4 TIVORBEX - indomethacin cap 40 mg 4 TOLMETIN SODIUM - tolmetin sodium tab 200 mg 4 DIHYDROERGOTAMINE MESYLAT dihydroergotamine mesylate nasal spray 4 mg/ml 4 TOLMETIN SODIUM - tolmetin sodium tab 600 mg 4 ERGOMAR - ergotamine tartrate sl tab 2 mg 4 • tolmetin sodium cap 400 mg 2 FROVA - frovatriptan succinate tab 2.5 mg (base equivalent) 4 IMITREX - sumatriptan nasal spray 5 mg/act 3 VIMOVO - naproxen-esomeprazole magnesium tab dr 375-20 mg • IMITREX - sumatriptan nasal spray 20 mg/act 3 • 104 MIGRAINE PRODUCTS • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 IMITREX - sumatriptan succinate tab 25 mg 4 • RELPAX - eletriptan hydrobromide tab 20 mg (base equivalent) 4 • IMITREX - sumatriptan succinate tab 50 mg 4 • RELPAX - eletriptan hydrobromide tab 40 mg (base equivalent) 4 • IMITREX - sumatriptan succinate tab 100 mg 4 • rizatriptan benzoate orally disintegrating tab 5 mg (Maxalt-mlt) 2 • IMITREX - sumatriptan succinate inj 6 mg/0.5ml 4 • 2 • IMITREX STATDOSE REFILL sumatriptan succinate solution cartridge 4 mg/0.5ml 4 • rizatriptan benzoate orally disintegrating tab 10 mg (Maxaltmlt) rizatriptan benzoate tab 5 mg (Maxalt) 2 • IMITREX STATDOSE REFILL sumatriptan succinate solution cartridge 6 mg/0.5ml 4 rizatriptan benzoate tab 10 mg (Maxalt) 2 • • IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 4 mg/0.5ml SUMATRIPTAN - sumatriptan nasal spray 5 mg/act 4 4 SUMATRIPTAN - sumatriptan nasal spray 20 mg/act 4 • IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 6 mg/0.5ml 4 SUMATRIPTAN SUCCINATE sumatriptan succinate solution prefilled syringe 6 mg/0.5ml 4 • isometheptene-caffeineacetaminophen tab 65-20-325 mg (Prodrin) 2 SUMATRIPTAN SUCCINATE sumatriptan succinate inj 4 mg/0.5ml 4 • sumatriptan succinate inj 6 mg/0.5ml (Imitrex) 2 • sumatriptan succinate solution auto- 2 injector 4 mg/0.5ml (Imitrex statdose sys) sumatriptan succinate solution auto- 2 injector 6 mg/0.5ml (Imitrex statdose sys) 2 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref) 2 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref) 1 sumatriptan succinate tab 25 mg (Imitrex) 1 sumatriptan succinate tab 50 mg (Imitrex) • MAXALT - rizatriptan benzoate tab 5 mg 4 4 MAXALT - rizatriptan benzoate tab 10 mg 4 MAXALT-MLT - rizatriptan benzoate orally disintegrating tab 5 mg 4 MAXALT-MLT - rizatriptan benzoate orally disintegrating tab 10 mg 4 MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 4 MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml naratriptan hcl tab 1 mg (base equiv) 2 (Amerge) 2 naratriptan hcl tab 2.5 mg (base equiv) (Amerge) 4 PRODRIN - isometheptene-caffeineacetaminophen tab 65-20-325 mg • • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • • 105 SUMAVEL DOSEPRO - sumatriptan succinate solution jet-injector 4 mg/0.5ml 4 • SUMAVEL DOSEPRO - sumatriptan succinate solution jet-injector 6 mg/0.5ml 4 TREXIMET - sumatriptan-naproxen sodium tab 85-500 mg 4 • zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt) 2 • zolmitriptan orally disintegrating tab 5 mg (Zomig zmt) 2 • zolmitriptan tab 2.5 mg (Zomig) 2 zolmitriptan tab 5 mg (Zomig) 2 ZOMIG - zolmitriptan tab 2.5 mg 4 ZOMIG - zolmitriptan tab 5 mg 4 ZOMIG - zolmitriptan nasal spray 2.5 mg/spray unit 4 • • • • • ZOMIG - zolmitriptan nasal spray 5 mg/ spray unit 4 ZOMIG NASAL SPRAY - zolmitriptan nasal spray 5 mg/spray unit 4 ZOMIG ZMT - zolmitriptan orally disintegrating tab 2.5 mg 4 • ZOMIG ZMT - zolmitriptan orally disintegrating tab 5 mg 4 • 4 ZYLOPRIM - allopurinol tab 100 mg 4 ZYLOPRIM - allopurinol tab 300 mg 4 NEUROMUSCULAR DRUGS GOUT AGENTS • ANTICONVULSANTS APTIOM - eslicarbazepine acetate tab 200 mg 4 APTIOM - eslicarbazepine acetate tab 400 mg 4 APTIOM - eslicarbazepine acetate tab 600 mg 4 APTIOM - eslicarbazepine acetate tab 800 mg 4 BANZEL - rufinamide susp 40 mg/ml 4 BANZEL - rufinamide tab 200 mg 4 BANZEL - rufinamide tab 400 mg 4 carbamazepine cap sr 12hr 100 mg (Carbatrol) 2 2 • carbamazepine cap sr 12hr 200 mg (Carbatrol) 2 • carbamazepine cap sr 12hr 300 mg (Carbatrol) carbamazepine chew tab 100 mg 1 carbamazepine susp 100 mg/5ml (Tegretol) 2 carbamazepine tab sr 12hr 200 mg (Tegretol-xr) 2 2 allopurinol tab 100 mg (Zyloprim) 1 carbamazepine tab sr 12hr 400 mg (Tegretol-xr) allopurinol tab 300 mg (Zyloprim) 1 carbamazepine tab 200 mg (Tegretol) 1 COLCHICINE - colchicine cap 0.6 mg 4 4 COLCHICINE - colchicine tab 0.6 mg 4 CARBATROL - carbamazepine cap sr 12hr 100 mg 2 CARBATROL - carbamazepine cap sr 12hr 200 mg 4 colchicine w/ probenecid tab 0.5-500 mg 4 CARBATROL - carbamazepine cap sr 12hr 300 mg 4 COLCRYS - colchicine tab 0.6 mg MITIGARE - colchicine cap 0.6 mg 4 CELONTIN - methsuximide cap 300 mg 4 probenecid tab 500 mg 2 ULORIC - febuxostat tab 40 mg clonazepam orally disintegrating tab 0.125 mg 2 4 106 Dispensing Limits ULORIC - febuxostat tab 80 mg Step Therapy • Prior Authorization 1 Drug Tier sumatriptan succinate tab 100 mg (Imitrex) Drug Name Step Therapy Drug Name Drug Tier Dispensing Limits Prior Authorization 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 clonazepam orally disintegrating tab 0.25 mg 2 DILANTIN - phenytoin sodium extended cap 100 mg 4 clonazepam orally disintegrating tab 0.5 mg 2 DILANTIN INFATABS - phenytoin chew tab 50 mg 4 clonazepam orally disintegrating tab 1 mg 2 DILANTIN-125 - phenytoin susp 125 mg/5ml 4 clonazepam orally disintegrating tab 2 mg 2 divalproex sodium cap sprinkle 125 mg (Depakote sprinkles) 2 clonazepam tab 0.5 mg (Klonopin) 1 1 clonazepam tab 1 mg (Klonopin) 1 divalproex sodium tab delayed release 125 mg (Depakote) clonazepam tab 2 mg (Klonopin) 1 1 DEPAKENE - valproate sodium syrup 250 mg/5ml (base equiv) 4 divalproex sodium tab delayed release 250 mg (Depakote) 2 DEPAKENE - valproic acid cap 250 mg 4 divalproex sodium tab delayed release 500 mg (Depakote) 4 divalproex sodium tab sr 24 hr 250 mg (Depakote er) 2 DEPAKOTE - divalproex sodium tab delayed release 125 mg 4 divalproex sodium tab sr 24 hr 500 mg (Depakote er) 2 DEPAKOTE - divalproex sodium tab delayed release 250 mg 4 ethosuximide cap 250 mg (Zarontin) 2 DEPAKOTE - divalproex sodium tab delayed release 500 mg 2 DEPAKOTE ER - divalproex sodium tab sr 24 hr 250 mg 4 ethosuximide soln 250 mg/5ml (Zarontin) felbamate susp 600 mg/5ml (Felbatol) 2 DEPAKOTE ER - divalproex sodium tab sr 24 hr 500 mg 4 felbamate tab 400 mg (Felbatol) 2 felbamate tab 600 mg (Felbatol) 2 DEPAKOTE SPRINKLES - divalproex sodium cap sprinkle 125 mg 4 FELBATOL - felbamate susp 600 mg/5ml 4 DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 3 FELBATOL - felbamate tab 400 mg 4 FELBATOL - felbamate tab 600 mg 4 DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 3 FYCOMPA - perampanel tab 2 mg 4 3 FYCOMPA - perampanel tab 4 mg 4 DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg FYCOMPA - perampanel tab 6 mg 4 DIAZEPAM - diazepam rectal gel delivery system 2.5 mg 4 FYCOMPA - perampanel tab 8 mg 4 FYCOMPA - perampanel tab 10 mg 4 DIAZEPAM - diazepam rectal gel delivery system 10 mg 4 FYCOMPA - perampanel tab 12 mg 4 gabapentin cap 100 mg (Neurontin) 1 DIAZEPAM - diazepam rectal gel delivery system 20 mg 4 gabapentin cap 300 mg (Neurontin) 1 4 gabapentin cap 400 mg (Neurontin) 1 DILANTIN - phenytoin sodium extended cap 30 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 107 gabapentin oral soln 250 mg/5ml (Neurontin) 2 LAMICTAL ODT - lamotrigine orally disintegrating tab 25 mg 4 gabapentin tab 600 mg (Neurontin) 2 4 gabapentin tab 800 mg (Neurontin) 2 LAMICTAL ODT - lamotrigine orally disintegrating tab 50 mg GABITRIL - tiagabine hcl tab 2 mg 4 4 GABITRIL - tiagabine hcl tab 4 mg 4 LAMICTAL ODT - lamotrigine orally disintegrating tab 100 mg 4 LAMICTAL ODT - lamotrigine orally disintegrating tab 200 mg 4 GABITRIL - tiagabine hcl tab 12 mg GABITRIL - tiagabine hcl tab 16 mg 4 KEPPRA - levetiracetam oral soln 100 mg/ml LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100 mg (7) starter kit 4 4 KEPPRA - levetiracetam tab 250 mg 4 4 KEPPRA - levetiracetam tab 500 mg 4 KEPPRA - levetiracetam tab 750 mg 4 LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100 mg (14) starter kit 4 LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter kit 4 KEPPRA - levetiracetam tab 1000 mg KEPPRA XR - levetiracetam tab sr 24hr 500 mg 4 LAMICTAL XR - lamotrigine tab sr 24hr 25 mg (21) & 50 mg (7) titration kit 4 KEPPRA XR - levetiracetam tab sr 24hr 750 mg 4 LAMICTAL XR - lamotrigine tab sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit 4 KLONOPIN - clonazepam tab 0.5 mg 4 KLONOPIN - clonazepam tab 1 mg LAMICTAL XR - lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit 4 4 KLONOPIN - clonazepam tab 2 mg 4 4 LAMICTAL - lamotrigine tab 25 mg 4 LAMICTAL XR - lamotrigine tab sr 24hr 25 mg LAMICTAL - lamotrigine tab 100 mg 4 4 LAMICTAL - lamotrigine tab 150 mg 4 LAMICTAL XR - lamotrigine tab sr 24hr 50 mg 4 LAMICTAL XR - lamotrigine tab sr 24hr 100 mg 4 LAMICTAL - lamotrigine tab 200 mg LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible 5 mg 4 LAMICTAL XR - lamotrigine tab sr 24hr 200 mg 4 4 LAMICTAL XR - lamotrigine tab sr 24hr 250 mg 4 LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible 25 mg 4 LAMICTAL ODT - lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit 4 LAMICTAL XR - lamotrigine tab sr 24hr 300 mg 2 LAMICTAL ODT - lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit 4 lamotrigine orally disintegrating tab 25 mg (Lamictal odt) 2 LAMICTAL ODT - lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit 4 lamotrigine orally disintegrating tab 50 mg (Lamictal odt) lamotrigine orally disintegrating tab 100 mg (Lamictal odt) 2 108 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 LYRICA - pregabalin cap 225 mg 4 LYRICA - pregabalin cap 300 mg 4 MYSOLINE - primidone tab 50 mg 4 MYSOLINE - primidone tab 250 mg 4 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 2 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di) 2 lamotrigine tab sr 24hr 25 mg (Lamictal xr) 2 NEURONTIN - gabapentin oral soln 250 mg/5ml 4 lamotrigine tab sr 24hr 50 mg (Lamictal xr) 2 NEURONTIN - gabapentin cap 100 mg 4 NEURONTIN - gabapentin cap 300 mg 4 lamotrigine tab sr 24hr 100 mg (Lamictal xr) 2 NEURONTIN - gabapentin cap 400 mg 4 NEURONTIN - gabapentin tab 600 mg 4 lamotrigine tab sr 24hr 200 mg (Lamictal xr) 2 NEURONTIN - gabapentin tab 800 mg 4 2 ONFI - clobazam suspension 2.5 mg/ml 4 lamotrigine tab sr 24hr 250 mg (Lamictal xr) ONFI - clobazam tab 10 mg 4 lamotrigine tab sr 24hr 300 mg (Lamictal xr) 2 ONFI - clobazam tab 20 mg 4 2 lamotrigine tab 25 mg (Lamictal) 1 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) lamotrigine tab 100 mg (Lamictal) 1 oxcarbazepine tab 150 mg (Trileptal) 2 lamotrigine tab 150 mg (Lamictal) 1 oxcarbazepine tab 300 mg (Trileptal) 2 lamotrigine tab 200 mg (Lamictal) 1 oxcarbazepine tab 600 mg (Trileptal) 2 levetiracetam oral soln 100 mg/ml (Keppra) 2 OXTELLAR XR - oxcarbazepine tab sr 24hr 150 mg 4 levetiracetam tab sr 24hr 500 mg (Keppra xr) 2 OXTELLAR XR - oxcarbazepine tab sr 24hr 300 mg 4 levetiracetam tab sr 24hr 750 mg (Keppra xr) 2 OXTELLAR XR - oxcarbazepine tab sr 24hr 600 mg 4 levetiracetam tab 250 mg (Keppra) 2 PEGANONE - ethotoin tab 250 mg 4 levetiracetam tab 500 mg (Keppra) 2 4 levetiracetam tab 750 mg (Keppra) 2 PHENYTEK - phenytoin sodium extended cap 200 mg 2 LYRICA - pregabalin soln 20 mg/ml 4 PHENYTEK - phenytoin sodium extended cap 300 mg 4 levetiracetam tab 1000 mg (Keppra) 4 phenytoin chew tab 50 mg (Dilantin infatabs) 2 LYRICA - pregabalin cap 25 mg LYRICA - pregabalin cap 50 mg 4 2 LYRICA - pregabalin cap 75 mg 4 phenytoin sodium extended cap 100 mg (Dilantin) LYRICA - pregabalin cap 100 mg 4 phenytoin susp 125 mg/5ml (Dilantin) 2 LYRICA - pregabalin cap 150 mg 4 POTIGA - ezogabine tab 50 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits 4 2 Step Therapy LYRICA - pregabalin cap 200 mg lamotrigine orally disintegrating tab 200 mg (Lamictal odt) Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 109 4 POTIGA - ezogabine tab 300 mg 4 4 POTIGA - ezogabine tab 400 mg 4 TOPAMAX SPRINKLE - topiramate sprinkle cap 15 mg primidone tab 50 mg (Mysoline) 1 4 primidone tab 250 mg (Mysoline) 1 TOPAMAX SPRINKLE - topiramate sprinkle cap 25 mg 4 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 25 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 25 mg 4 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 50 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 50 mg 4 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 100 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 100 mg 4 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 150 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 150 mg 4 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 200 mg 4 QUDEXY XR - topiramate cap er 24hr sprinkle 200 mg 3 topiramate sprinkle cap 15 mg (Topamax sprinkle) 2 SABRIL - vigabatrin tab 500 mg SABRIL - vigabatrin powd pack 500 mg 3 STAVZOR - valproic acid cap delayed release 125 mg topiramate sprinkle cap 25 mg (Topamax sprinkle) 2 4 topiramate tab 25 mg (Topamax) 1 STAVZOR - valproic acid cap delayed release 250 mg 4 topiramate tab 50 mg (Topamax) 1 4 topiramate tab 100 mg (Topamax) 1 STAVZOR - valproic acid cap delayed release 500 mg topiramate tab 200 mg (Topamax) 1 TEGRETOL - carbamazepine tab 200 mg 4 TRILEPTAL - oxcarbazepine susp 300 mg/5ml (60 mg/ml) 4 TEGRETOL - carbamazepine susp 100 mg/5ml 4 TRILEPTAL - oxcarbazepine tab 150 mg 4 TEGRETOL-XR - carbamazepine tab sr 12hr 100 mg 4 TRILEPTAL - oxcarbazepine tab 300 mg 4 TEGRETOL-XR - carbamazepine tab sr 12hr 200 mg 4 TRILEPTAL - oxcarbazepine tab 600 mg 4 TEGRETOL-XR - carbamazepine tab sr 12hr 400 mg 4 TROKENDI XR - topiramate cap sr 24hr 25 mg 4 tiagabine hcl tab 2 mg (Gabitril) 2 4 tiagabine hcl tab 4 mg (Gabitril) 2 TROKENDI XR - topiramate cap sr 24hr 50 mg 4 TROKENDI XR - topiramate cap sr 24hr 100 mg 4 TOPAMAX - topiramate tab 25 mg TOPAMAX - topiramate tab 50 mg 4 TOPAMAX - topiramate tab 100 mg TROKENDI XR - topiramate cap sr 24hr 200 mg 4 4 110 Dispensing Limits TOPAMAX - topiramate tab 200 mg Step Therapy 4 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy POTIGA - ezogabine tab 200 mg Prior Authorization Drug Name Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 valproate sodium syrup 250 mg/5ml (base equiv) (Depakene) 2 carbidopa & levodopa orally disintegrating tab 25-250 mg 2 valproic acid cap 250 mg (Depakene) 2 2 VIMPAT - lacosamide oral solution 10 mg/ml 4 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr) 2 VIMPAT - lacosamide tab 50 mg 4 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr) VIMPAT - lacosamide tab 100 mg 4 1 VIMPAT - lacosamide tab 150 mg 4 carbidopa & levodopa tab 10-100 mg (Sinemet) 4 carbidopa & levodopa tab 25-100 mg (Sinemet) 2 VIMPAT - lacosamide tab 200 mg ZARONTIN - ethosuximide cap 250 mg 4 ZARONTIN - ethosuximide soln 250 mg/5ml carbidopa & levodopa tab 25-250 mg (Sinemet) 2 4 carbidopa tab 25 mg (Lodosyn) 2 ZONEGRAN - zonisamide cap 25 mg 4 4 ZONEGRAN - zonisamide cap 100 mg 4 zonisamide cap 25 mg (Zonegran) 2 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 12.5-50-200 mg zonisamide cap 50 mg 2 4 zonisamide cap 100 mg (Zonegran) 2 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 18.75-75-200 mg CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 25-100-200 mg 4 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 31.25-125-200 mg 4 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 37.5-150-200 mg 4 CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs 50-200-200 mg 4 COMTAN - entacapone tab 200 mg 4 4 ANTIPARKINSON AGENTS AMANTADINE HCL - amantadine hcl tab 100 mg 4 amantadine hcl cap 100 mg 2 amantadine hcl syrup 50 mg/5ml 1 APOKYN - apomorphine hydrochloride inj 10 mg/ml 5 AZILECT - rasagiline mesylate tab 0.5 mg (base equiv) 4 AZILECT - rasagiline mesylate tab 1 mg (base equiv) 4 benztropine mesylate tab 0.5 mg 1 benztropine mesylate tab 1 mg 1 benztropine mesylate tab 2 mg 1 DUOPA - carbidopa-levodopa enteral susp 4.63-20 mg/ml bromocriptine mesylate cap 5 mg (Parlodel) 2 ELDEPRYL - selegiline hcl cap 5 mg 4 entacapone tab 200 mg (Comtan) 2 bromocriptine mesylate tab 2.5 mg 2 LODOSYN - carbidopa tab 25 mg 4 carbidopa & levodopa orally disintegrating tab 10-100 mg 2 carbidopa & levodopa orally disintegrating tab 25-100 mg 2 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 MIRAPEX - pramipexole dihydrochloride 4 tab 0.125 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 111 MIRAPEX - pramipexole dihydrochloride 4 tab 0.25 mg MIRAPEX - pramipexole dihydrochloride 4 tab 0.5 mg MIRAPEX - pramipexole dihydrochloride 4 tab 0.75 mg MIRAPEX - pramipexole dihydrochloride 4 tab 1 mg MIRAPEX - pramipexole dihydrochloride 4 tab 1.5 mg 4 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 0.375 mg 4 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 0.75 mg 4 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 1.5 mg 4 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 2.25 mg 4 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 3 mg 4 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 3.75 mg 4 MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 4.5 mg 4 NEUPRO - rotigotine td patch 24hr 1 mg/24hr 4 NEUPRO - rotigotine td patch 24hr 2 mg/24hr 4 NEUPRO - rotigotine td patch 24hr 3 mg/24hr 4 NEUPRO - rotigotine td patch 24hr 4 mg/24hr 4 NEUPRO - rotigotine td patch 24hr 6 mg/24hr 4 NEUPRO - rotigotine td patch 24hr 8 mg/24hr 4 PARLODEL - bromocriptine mesylate cap 5 mg 2 pramipexole dihydrochloride tab sr 24hr 0.375 mg (Mirapex er) 112 pramipexole dihydrochloride tab sr 24hr 0.75 mg (Mirapex er) 2 pramipexole dihydrochloride tab sr 24hr 1.5 mg (Mirapex er) 2 pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex er) 2 pramipexole dihydrochloride tab 0.125 mg (Mirapex) 1 pramipexole dihydrochloride tab 0.25 mg (Mirapex) 1 pramipexole dihydrochloride tab 0.5 mg (Mirapex) 1 pramipexole dihydrochloride tab 0.75 mg (Mirapex) 1 pramipexole dihydrochloride tab 1 mg (Mirapex) 1 pramipexole dihydrochloride tab 1.5 mg (Mirapex) 1 REQUIP - ropinirole hydrochloride tab 0.25 mg 4 REQUIP - ropinirole hydrochloride tab 0.5 mg 4 REQUIP - ropinirole hydrochloride tab 1 mg 4 REQUIP - ropinirole hydrochloride tab 2 mg 4 REQUIP - ropinirole hydrochloride tab 3 mg 4 REQUIP - ropinirole hydrochloride tab 4 mg 4 REQUIP - ropinirole hydrochloride tab 5 mg 4 REQUIP XL - ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) 4 REQUIP XL - ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) 4 REQUIP XL - ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) 4 REQUIP XL - ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) 4 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 REQUIP XL - ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) 4 SINEMET - carbidopa & levodopa tab 25-250 mg 4 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl) 2 SINEMET CR - carbidopa & levodopa tab cr 25-100 mg 4 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl) 2 SINEMET CR - carbidopa & levodopa tab cr 50-200 mg 4 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl) 2 STALEVO 100 - carbidopa-levodopaentacapone tabs 25-100-200 mg 4 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl) 2 STALEVO 125 - carbidopa-levodopaentacapone tabs 31.25-125-200 mg 4 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl) 2 STALEVO 150 - carbidopa-levodopaentacapone tabs 37.5-150-200 mg 4 ropinirole hydrochloride tab 0.25 mg (Requip) 1 STALEVO 200 - carbidopa-levodopaentacapone tabs 50-200-200 mg 4 ropinirole hydrochloride tab 0.5 mg (Requip) 1 STALEVO 50 - carbidopa-levodopaentacapone tabs 12.5-50-200 mg 4 ropinirole hydrochloride tab 1 mg (Requip) 1 STALEVO 75 - carbidopa-levodopaentacapone tabs 18.75-75-200 mg 4 ropinirole hydrochloride tab 2 mg (Requip) 1 TASMAR - tolcapone tab 100 mg 4 tolcapone tab 100 mg (Tasmar) 2 ropinirole hydrochloride tab 3 mg (Requip) 1 trihexyphenidyl hcl elixir 0.4 mg/ml 2 1 trihexyphenidyl hcl tab 2 mg 1 ropinirole hydrochloride tab 4 mg (Requip) trihexyphenidyl hcl tab 5 mg 1 ropinirole hydrochloride tab 5 mg (Requip) 1 ZELAPAR - selegiline hcl orally disintegrating tab 1.25 mg 4 RYTARY - carbidopa & levodopa cap cr 23.75-95 mg 4 NEUROMUSCULAR AGENTS RYTARY - carbidopa & levodopa cap cr 36.25-145 mg 4 RYTARY - carbidopa & levodopa cap cr 48.75-195 mg 4 RYTARY - carbidopa & levodopa cap cr 61.25-245 mg 4 selegiline hcl cap 5 mg (Eldepryl) 2 selegiline hcl tab 5 mg 2 SINEMET - carbidopa & levodopa tab 10-100 mg 4 SINEMET - carbidopa & levodopa tab 25-100 mg 4 RILUTEK - riluzole tab 50 mg 4 riluzole tab 50 mg (Rilutek) 2 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 MUSCULOSKELETAL THERAPY AGENTS 4 AMRIX - cyclobenzaprine hcl cap sr 24hr 15 mg 4 AMRIX - cyclobenzaprine hcl cap sr 24hr 30 mg 1 baclofen tab 10 mg baclofen tab 20 mg 1 CARISOPRODOL - carisoprodol tab 250 mg 4 carisoprodol tab 350 mg (Soma) 1 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 113 carisoprodol w/ aspirin & codeine tab 200-325-16 mg 2 PARAFON FORTE DSC chlorzoxazone tab 500 mg 4 carisoprodol w/ aspirin tab 200-325 mg 2 ROBAXIN - methocarbamol tab 500 mg 4 chlorzoxazone tab 500 mg (Parafon forte dsc) 1 ROBAXIN-750 - methocarbamol tab 750 4 mg 4 SKELAXIN - metaxalone tab 800 mg CYCLOBENZAPRINE COMFORT P cyclobenzaprine hcl tab 10 mg & liniment topical gel kit 4 cyclobenzaprine hcl tab 5 mg 1 cyclobenzaprine hcl tab 7.5 mg (Fexmid) 2 cyclobenzaprine hcl tab 10 mg 1 DANTRIUM - dantrolene sodium cap 25 mg 4 DANTRIUM - dantrolene sodium cap 50 mg 4 DANTRIUM - dantrolene sodium cap 100 mg 4 DANTROLENE SODIUM - dantrolene sodium cap 100 mg 4 dantrolene sodium cap 25 mg (Dantrium) 2 dantrolene sodium cap 50 mg (Dantrium) 2 FEXMID - cyclobenzaprine hcl tab 7.5 mg 4 LORZONE - chlorzoxazone tab 375 mg 4 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 SOMA - carisoprodol tab 250 mg 4 SOMA - carisoprodol tab 350 mg 4 TIZANIDINE COMFORT PAC tizanidine tab 4 mg & liniment topical gel pack 4 tizanidine hcl cap 2 mg (base equivalent) (Zanaflex) 2 • tizanidine hcl cap 4 mg (base equivalent) (Zanaflex) 2 • tizanidine hcl cap 6 mg (base equivalent) (Zanaflex) 2 • tizanidine hcl tab 2 mg (base equivalent) 1 • tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) 1 • ZANAFLEX - tizanidine hcl tab 4 mg (base equivalent) 4 • ZANAFLEX - tizanidine hcl cap 2 mg (base equivalent) 4 • ZANAFLEX - tizanidine hcl cap 4 mg (base equivalent) 4 • • LORZONE - chlorzoxazone tab 750 mg ZANAFLEX - tizanidine hcl cap 6 mg (base equivalent) 4 4 METAXALONE - metaxalone tab 400 mg 4 ANTIMYASTHENIC AGENTS metaxalone tab 800 mg (Skelaxin) GUANIDINE HCL - guanidine hcl tab 125 mg 4 2 MESTINON - pyridostigmine bromide tab 60 mg 4 MESTINON - pyridostigmine bromide syrup 60 mg/5ml 4 MESTINON TIMESPAN pyridostigmine bromide tab cr 180 mg 4 pyridostigmine bromide tab cr 180 mg (Mestinon timespan) 2 methocarbamol tab 500 mg (Robaxin) 1 1 methocarbamol tab 750 mg (Robaxin-750) 2 orphenadrine citrate tab sr 12hr 100 mg 2 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg 114 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 pyridostigmine bromide tab 60 mg (Mestinon) 2 NUTRITIONAL PRODUCTS VITAMINS AMINOBENZOATE POTASSIUM potassium aminobenzoate packet 2 gm 4 BABY DDROPS - cholecalciferol drops 400 unit/0.03ml (per drop) 4 cholecalciferol cap 400 unit 2 cholecalciferol cap 1000 unit 1 cholecalciferol cap 50000 unit 1 cholecalciferol chew tab 400 unit 2 cholecalciferol chew tab 1000 unit 1 cholecalciferol drops 5000 unit/ml (1000 unit/0.2ml) 2 cholecalciferol drops 400 unit/0.03ml (per drop) 2 cholecalciferol oral liquid 400 unit/ml 1 cholecalciferol tab 400 unit 1 cholecalciferol tab 1000 unit 1 D-VI-SOL - cholecalciferol oral liquid 400 unit/ml SUPER DAILY D3 - cholecalciferol drops 1000 unit/0.03ml (per drop) 4 VITAMIN D - cholecalciferol cap 400 unit 4 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 VITAMIN D2 - ergocalciferol tab 400 unit 4 4 VITAMIN D3 - cholecalciferol spray 1000 unit/spray 4 VITAMIN K1 - phytonadione inj 10 mg/ ml 4 WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000 unit/10ml MULTIVITAMINS ACTIVE OB - prenatal w/o a w/fe cbnfa-dha cap 20-1-320 mg 4 ADRENAL C FORMULA - bioflavonoid products tab 4 ADVANCED AM/PM - multiple vitamins w/ calcium therapy pack 4 ATABEX EC - prenatal vit w/ dss-iron carbonyl-fa tab dr 29-1 mg 4 1 4 b-complex w/ c & folic acid cap 1 mg (Nephrocaps) 1 DDROPS - cholecalciferol drops 1000 unit/0.03ml (per drop) 4 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) b-complex w/ c & folic acid tab 5 mg 1 DECARA - cholecalciferol cap 25000 unit 4 b-complex w/ c-biotin-minerals & folic acid tab 5 mg (Diatx zn) 1 DRISDOL - ergocalciferol cap 50000 unit 4 B-NEXA - prenatal w/ calcium-vit b6-faginger tab 1.22 mg 4 ergocalciferol cap 50000 unit (Drisdol) 1 4 MEPHYTON - phytonadione tab 5 mg 3 BAL-CARE DHA - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg phytonadione inj 1 mg/0.5ml (2 mg/ ml) 2 4 POTABA - potassium aminobenzoate cap 500 mg 4 BP FOLINATAL PLUS B - prenatal w/ calcium carbonate-b6-b12-fa tab 1 mg POTABA - potassium aminobenzoate tab 500 mg 4 BP MULTINATAL PLUS - prenatal w/o a 4 vit w/ fe fumarate-fa tab 30-1 mg BP MULTINATAL PLUS - prenatal w/o a 4 vit w/ fe fum-fa tab chew 40-1 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 115 C-NATE DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-200 mg 4 CORVITE - multiple vitamins w/ minerals & fa tab 1.25 mg 4 CALCIUM PNV - prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg 4 DIALYVITE SUPREME D - multiple vitamins w/ minerals & fa tab 3 mg 4 CHOICE-OB+DHA - prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak 4 DIALYVITE 3000 - b-complex w/ cbiotin-e-minerals & folic acid tab 3 mg 4 4 DIALYVITE 5000 - b-complex w/ cbiotin-e-minerals & folic acid tab 5 mg 4 CITRANATAL ASSURE - prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack DIALYVITE/ZINC - b-complex w/ c-zn & folic acid tab 1 mg 4 CITRANATAL B-CALM - prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab pak 4 DIATX ZN - b-complex w/ c-biotinminerals & folic acid tab 5 mg 4 4 DUET DHA - prenat w/fe poly-na feredfa tab 25-1 & omega cap 400 mg 4 CITRANATAL B-CALM - prenat w/o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak 4 CITRANATAL DHA - prenat w/o a w/ fecbn-fegl-dss-fa tab & dha cap 250 mg pack 4 DUET DHA BALANCED - prenat w/fe poly-na fered-fa tab 25-1 & omega cap 267 mg 4 CITRANATAL HARMONY - prenatal w/ o a w/fe cbn-dss-fa-dha cap 29-1-265 mg 4 DUET DHA BALANCED - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg 4 CITRANATAL HARMONY - prenat w/ o a w/fe fum-fe cbn-dss-fa-dha cap 27-1-260 mg 4 DUET DHA 400 - prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg CITRANATAL RX - prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa tab 27-1mg 4 CITRANATAL 90 DHA - prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak 4 CO-NATAL FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg 4 COMPLETE NATAL DHA - prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 250 pk 4 COMPLETENATE - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 4 CONCEPT DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg 4 CONCEPT OB - prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg 4 116 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ELITE-OB - prenatal vit w/ iron carbonyl- 4 fa tab 50-1.25 mg 4 ENBRACE HR - prenatal vit w/ fe gly cys-fa-omega 3 fatty acids cap 4 ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg 4 ESCAVITE D - pediatric multiple vitamins w/ fl-fe chew tab 0.25-6 mg 1 ESCAVITE LQ - pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml 4 EXTRA-VIRT PLUS DHA - prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg 4 FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 0.5 mg 4 FLORIVA - ped multiple vitamins & minerals w/ fl chew tab 1 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 FOCALGIN CA - prenat w/o a w/fecbnfegl-dss-fa tab & dha cap 300 mg pack 4 L-METHYLFOLATE PNV DHA - prenat w/fe fum-l methylfolate-fa-dha cap 27-1.13-0.4 mg 4 FOCALGIN 90 DHA - prenat w/o a w/ fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak 4 LEVOMEFOLATE DHA - prenat w/ fe fum-l methylfolate-fa-dha cap 27-1.13-0.4 mg 4 FOCALGIN-B - prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg 4 FOLBECAL - prenatal w/ calcium carbonate-b6-b12-fa tab 1 mg 4 FOLCAL DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 4 FOLCAPS OMEGA 3 - prenatal vit w/ fe cbn-fe asp glyc-fa-omega 3 cap 27-1mg 4 FOLET DHA - prenat w/fecbn-bisgmethylf-dss tab dr & dha cap pak 4 FOLET ONE - prenat w/o a w/fecbnbisg-methylf-dss-dha cap 38-1-225 mg 4 FOLGARD OS - multiple vit w/ min & calcium-folic acid tab 500-1.1 mg 4 FOLIVANE-OB - prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg 4 HEMENATAL OB - prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg 4 HEMENATAL OB + DHA - prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck 4 M-VIT - prenatal vit w/ fe fumarate-fa tab 4 27-1 mg 4 MACNATAL CN DHA - prenatal w/o a w/fe cbn-dss-fa-dha cap 28-1-250 mg 4 MARNATAL-F - prenatal w/o vit a w/ fe polysac cmplx-fa cap 60-1 mg 1 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) 4 MYKIDZ IRON FL - pediatric vitamins acd fluoride & fe susp 0.25-10 mg/2ml 4 MYNATAL - prenatal multivitamins & minerals w/ iron & fa cap 1 mg 4 MYNATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 MYNATAL PLUS - prenatal vit w/ fe fumarate-fa tab 65-1 mg MYNATAL ULTRACAPLET - prenatal vit 4 w/ dss-iron carbonyl-fa tab 90-1 mg 4 MYNATAL-Z - prenatal vit w/ fe fumarate-fa tab 65-1 mg MYNATE 90 PLUS - prenatal vit w/ dss- 4 fe fumarate-fa tab cr 90-1 mg 4 NATACHEW - prenatal vit w/ fe fum-fe bisglycin-fa chew tab 28-1 mg 4 NATAL-V RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg NATALVIRT CA - prenat w/o a w/fecbn- 4 fegl-dss-fa tab & dha cap 300 mg pack 4 NATALVIRT 90 DHA - prenat w/o a w/ fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak NATALVIT - prenatal vit w/ fe fumarate- 4 fa tab 75-1 mg INATAL ADVANCE - prenatal vit w/ dss- 4 iron carbonyl-fa tab 90-1 mg 4 INATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg INATAL ULTRA - prenatal vit w/ dss-iron 4 carbonyl-fa tab 90-1 mg 4 INFANATE BALANCE - prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg 4 INFANATE PLUS - prenat w/o a w/fe fum-fe cbn-dss-fa-dha cap 27-1-260 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 117 NATELLE ONE - prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg 4 OB COMPLETE - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg 4 NEEVO DHA - prenat w/o a w/fefummethylfol-omegas cap 27-1.13 mg 4 4 NEPHPLEX RX - b-complex w/ c-zn & folic acid tab 1 mg 4 OB COMPLETE ONE - prenatal w/ o a w/fecbn-fe asp glyc-fa-fish cap 50-1-476 mg 4 NEPHRO-VITE RX - b-complex w/ c & folic acid tab 1 mg 4 OB COMPLETE PETITE - prenat w/o a w/fecbn-feaspglyc-fa-omega cap 35-5-1-200 mg NEPHROCAPS - b-complex w/ c & folic acid cap 1 mg 4 NEPHROCAPS QT - b-complex w/ cbiotin-d & folic acid tab disp 1 mg 4 NESTABS - prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg 4 NESTABS ABC - prenatal w/o vit a w/fe polysac-fa-ca tab & omega 3 cap 4 NESTABS DHA - prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack 4 NEWGEN - prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg 4 NEXA PLUS - prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg 4 NEXA SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg 4 NICOMIDE - niacinamide w/ zn-cumethylfol-se-cr tab 750-27-2-0.5 mg 4 NIVA-PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg 4 NUTRI-TAB OB - prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg 4 NUTRI-TAB OB + DHA - prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack 4 NUTRIVIT - b-complex w/ lysine-min-fe & fa liqd 800-15-1 mg/15ml 4 O-CAL FA - prenatal vit w/ fe fumaratefa tab 27-1 mg 4 O-CAL PRENATAL - prenatal vit w/ fe fumarate-fa tab 15-1 mg 4 118 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 OB COMPLETE PREMIER - prenatal vit 4 w/ fe cbn-fe asp glyc-fa tab 30-20-1 mg 4 OB COMPLETE/DHA - prenat w/ iron cbn-fe asp glyc-fa-omega cap 30-10-1-200 mg OB-NATAL ONE - prenatal vit w/ fe cbn- 4 fe asp glyc-fa-omega 3 cap 27-1mg 4 OBSTETRIX DHA - prenat w/fecbn-fadss tab 29-1 mg & omega 3 cap 387 mg pak 4 OBSTETRIX EC - prenatal vit w/ dssiron carbonyl-fa tab 29-1 mg OCUVEL - multiple vitamins w/ minerals 4 & fa cap 0.5 mg 4 PAIRE OB - prenat w/ fe poly cmplx-fe asp-fe gly-fa tab & dha cap pak 1 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml 1 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg 1 pediatric multiple vitamins w/ fluoride chew tab 0.5 mg 1 pediatric multiple vitamins w/ fluoride chew tab 1 mg 1 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml 1 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml 1 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml 1 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 PNV FERROUS FUMARATE/DOCU prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 4 PNV FOLIC ACID + IRON MUL prenatal vit w/ fe fumarate-fa tab 27-1 mg 4 PNV OB+DHA - prenat w/o a w/fecbnfegl-dss-fa tab & dha cap 250 mg pack 4 PNV PRENATAL PLUS MULTIVI prenatal vit w/ fe fumarate-fa tab 27-1 mg 4 PNV TABS 29-1 - prenatal vit w/ iron carbonyl-fa tab 29-1 mg 4 PNV-DHA - prenat w/o a w/fefummethfol-fa-dha cap 27-0.6-0.4-300 mg 4 PNV-DHA+DOCUSATE - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 4 PNV-FIRST - prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg 4 PNV-OB/DHA - prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack 4 PNV-OMEGA - prenat w/o a w/ fe fumerate-methylfolate-fa-omega 3 cap 4 PNV-SELECT - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg 4 PNV-TOTAL - prenat w/ fe cbn-fe bisglyc-fa-fish oil cap 35-5-1.2 mg 4 PNV-VP-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg 4 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic susp 0.25 mg/ml 4 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.25 mg 4 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 0.5 mg 4 POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew tab 1 mg 4 POLY-VI-FLOR FS - pediatric multiple vit w/ fluoride oral strip 0.25 mg 4 POLY-VI-FLOR FS - pediatric multiple vit w/ fluoride oral strip 0.5 mg 4 POLY-VI-FLOR FS - pediatric multiple vitamins w/ fluoride oral strip 1 mg 4 POLY-VI-FLOR/IRON - ped multiple vitamin w/ fl-fe biphasic susp 0.25-7 mg/ml 4 POLY-VI-FLOR/IRON - ped multiple vit w/ fl-fe biphasic chew tab 0.5-10 mg 4 PR NATAL 400 - prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk 4 PR NATAL 400 EC - prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk 4 PR NATAL 430 - prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk 4 PR NATAL 430 EC - prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk 4 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 PREFERA OB - prenat vit-fe poly cmplx- 4 fe heme poly-fa tab 28-6-1 mg 4 PREFERA OB + DHA - prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck 4 PREFERAOB +DHA - prenat-fe poly cmplx 28mg-fe heme poly-fa tab&dha cap pack 4 PREFERAOB ONE - prenat-fe poly cmplx-fe heme poly-fa-dha cap 22-6-1-200 mg 4 PREFOL-DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg PRENAISSANCE - prenatal w/o vit a w/ 4 fe fum-dss-fa-dha cap 29-1.25-325 mg 4 PRENAISSANCE BALANCE - prenatal w/o vit a w/ fe cbn-dss-fa-dha cap 30-1-260 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 119 PRENAISSANCE DHA - prenat w/o a w/ 4 fecbn-fegl-dss-fa tab & dha cap 250 mg pack 4 PRENAISSANCE HARMONY DHA prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg 4 PRENAISSANCE NEXT - prenatal w/ calcium-vit b6-fa-ginger tab 1.2 mg PRENAISSANCE NEXT-B - prenatal w/ 4 calcium-vit b6-fa-ginger tab 1.22 mg PRENAISSANCE PLUS - prenatal w/o a 4 w/fe cbn-dss-fa-dha cap 28-1-250 mg PRENAISSANCE PROMISE - prenat w/ 4 o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack 4 PRENAISSANCE 90 DHA - prenat w/ o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak 4 PRENAPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg PRENATA - prenatal w/o a vit w/ fe fum- 4 fa tab chew 29-1 mg 4 PRENATABS FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg 4 PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg 4 PRENATAL - prenatal vit w/ fe fumarate-fa tab 27-1 mg PRENATAL AD - prenatal vit w/ dss-iron 4 carbonyl-fa tab 90-1 mg PRENATAL LOW IRON - prenatal vit w/ 4 fe fumarate-fa tab 27-1 mg 3 PRENATAL PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg 4 PRENATAL PLUS IRON - prenatal vit w/ iron carbonyl-fa tab 29-1 mg PRENATAL VITAMINS PLUS - prenatal 3 vit w/ fe fumarate-fa tab 27-1 mg 4 PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 120 PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 4 PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg 4 PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4 mg 4 PRENATE AM - prenatal w/ calcium-vit b6-vit b12-fa-ginger tab 1 mg 4 PRENATE DHA - prenat w/o a w/fefummethfol-fa-dha cap 28-0.6-0.4-300 mg 4 PRENATE DHA - prenat w/o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg 4 PRENATE ELITE - prenatal w/ fe asp gly-l methylfol-fa tab 20-0.6-0.4 mg 4 PRENATE ELITE - prenatal vit w/ fe fum-methylfolate-fa tab 26-0.6-0.4 mg 4 PRENATE ENHANCE - prenat w/ o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-400 mg 4 PRENATE ESSENTIAL - prenat w/ o a w/feasp-methylf-fa-omeg cap 29-0.6-0.4-340 mg 4 PRENATE ESSENTIAL - prenat w/ o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg 4 PRENATE MINI - prenat w/oa w/ fecb-feasp-meth-fa-dha cap 18-0.6-0.4-350 mg 4 PRENATE PIXIE - prenat w/o a w/feaspg-methfol-fa-dha cap 10-0.6-0.4-200 mg 4 PRENATE RESTORE - prenat w/ o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-400 mg 4 PRENATE STAR - prenatal vit w/ fe asparto glycinate-fa tab 20-1 mg 4 PRENA1 CHEW - prenat w/ b2-b6-b12d3-folic acid chew tab 1.4 mg 4 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 PRENA1 PEARL - prenat w/oa w/fefumna fered-fa-dha cap cr 30-1.4-200 mg 4 RELNATE DHA - prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg PRENA1 PLUS/QUATREFOLIC prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk 4 PRENA1/QUATREFOLIC - prenat w/o a w/fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg 4 RENATABS - b-complex w/ c-biotin-vit e 4 & folic acid tab 1 mg RENATABS WITH IRON - b complex-c- 4 biotin-e-fa tab 1mg & fe cbn tab 100 mg pack 4 SE-NATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 4 SE-NATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg SE-TAN DHA - prenatal w/fe fum-fe poly 4 -fa-omega 3 cap 15-15-1 mg SELECT-OB - prenatal vit w/ fe polysac 4 cmplx-fa chew tab 29-1 mg 4 SELECT-OB - prenat w/ fepolycmplxmethylfol-fa chew tab 29-0.6-0.4 mg 4 SELECT-OB+DHA - prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak 4 SETON ET-EC - prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk 4 SETONET - prenat-fe bis-fe prot succfa-ca tab & omega 3 cap 430 pk 4 STROVITE FORTE - multiple vitamins w/ minerals & fa syrup 1 mg/15ml SUPERVITE - b-complex w/ lysine-zn & 4 folic acid liquid 4 SUPERVITE EC - multiple vitamins w/ minerals & fa tab dr 1 mg 4 SYNAGEX - multiple vitamins w/ minerals & fa cap 1.25 mg 4 SYNATEK - multiple vitamins w/ minerals & fa cap 1.25 mg TARON-BC - prenat w/o a w/ fe cbnyl-fa 4 tab 20-1 mg & vit b6 tab pak 4 TARON-C DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg PRENEXA - prenatal w/o vit a w/ fe fum- 4 dss-fa-dha cap 27-1.25-300 mg PREPLUS - prenatal vit w/ fe fumarate- 4 fa tab 27-1 mg 4 PREQUE 10 - prenatal mv w/fe carbonyl-dss-fa-dha tab 15-25-0.5-50 mg PRETAB - prenatal vit w/ fe fumarate-fa 4 tab 29-1 mg PROVIDA DHA - prenat w/o a w/fe fum- 4 fe poly-fa-dha cap 16-16-1.25-110 mg PROVIDA OB - prenatal w/o a w/fe fum- 4 fe poly-fa cap 20-20-1.25 mg PUREFE OB PLUS - prenatal w/o a w/fe 4 fum-fe poly-fa cap 162.115.2-1 mg 4 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 0.25 mg 4 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 0.5 mg 4 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride chew tab 1 mg 4 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml 4 QUFLORA PEDIATRIC - pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml R-NATAL OB - prenatal w/o a w/fe cbn- 4 fa-dha cap 20-1-320 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 4 121 TARON-DUO EC - prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk 4 TARON-PREX - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 30-1.2-265 mg 4 TEXAVITE LQ - pediatric multivitamins w/fl-fe-zn drops 0.25-7-3 mg/ml 4 THRIVITE 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 4 TL FOLATE - prenatal vit w/ fe fummethylfolate-fa tab 27-0.5-0.5 mg 4 TL G-FOL OS - multiple vit w/ min & calcium-folic acid tab 500-1.1 mg 4 TL-CARE DHA - prenatal w/fe fumarate- 4 fa-dss-fish oil cap 27-1-500 mg 4 TL-FLUORIVITE - pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg 4 TL-SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg TL-SELECT DHA - prenatal w/o vit a w/ 4 fe fum-doc-fa-dha cap 29-1.25-350 mg 4 TRI-TABS DHA - prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack TRI-VI-FLOR - ped vit acd & l-methylfol 4 w/ fl biphasic susp 0.25 mg/ml TRI-VI-FLOR - ped vit acd & l-methylfol 4 w/ fl biphasic susp 0.5 mg/ml 4 TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25 mg/ ml 4 TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.5 mg/ ml 4 TRI-VIT/FLUORIDE/IRON - pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml TRIADVANCE - prenatal vit w/ dss-iron 4 carbonyl-fa tab 90-1 mg 122 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 TRICARE - prenatal vit w/ fe fumarate-fa 4 tab 27-1 mg 4 TRICARE PRENATAL COMPLEAT prenat w/o a fefum-fa tab 27-1 mg & fish oil chew cap pak 4 TRICARE PRENATAL DHA ONE prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg TRINATAL GT - prenatal vit w/ dss-iron 4 carbonyl-fa tab 90-1 mg 4 TRINATAL RX 1 - prenatal vit w/ fe fumarate-fa tab 60-1 mg TRINATAL ULTRA - prenatal vit w/ dss- 4 iron carbonyl-fa tab 90-1 mg TRINATE - prenatal vit w/ fe fumarate-fa 4 tab 28-1 mg TRISTART DHA - prenat w/o a w/fecbn- 4 methylf-fa-dha cap 31-0.6-0.4-200 mg 4 TRIVEEN-DUO DHA - prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk TRIVEEN-PRX RNF - prenatal w/o vit a 4 w/ fe fum-dss-fa-dha cap 26-1.2-300 mg 4 UDAMIN SP - multiple vitamins w/ minerals & fa tab 1 mg 4 ULTIMATE OB DHA - prenat w/ fe poly cmplx-fe asp-fe gly-fa tab & dha cap pak 4 ULTIMATECARE ONE - prenatal vit w/ fe cbn-fe asp glyc-fa-omega 3 cap 27-1mg 4 ULTIMATECARE ONE NF - prenatal w/fe cbnyl-fe asp glyc-fa-dss-omega cap 20-7-1 mg 4 ULTRA TABS - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 V-NATAL - prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 V-NATAL DHA - prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack 4 VIRT-ADVANCE - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg 4 VEMAVITE-PRX 2 - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg VIRT-BAL DHA PLUS - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg 4 4 4 VENA-BAL DHA - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg 4 VIRT-C DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg 4 VENATAL-FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg 4 VIRT-CARE ONE - prenatal vit w/ fe cbn-fe asp glyc-fa-omega 3 cap 27-1mg VINACAL - prenatal w/o a w/ fe carbonyl-fe gluc-dss-fa tab 27-1mg VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg 4 4 VINACAL B - prenat w/o a w/fecbnfeglu-fa tab 20-1 mg & vit b6 tab pak VIRT-PN DHA - prenat w/o a w/fefummethfol-fa-dha cap 27-0.6-0.4-300 mg 4 4 VINATE AZ EXTRA - prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg 4 4 VINATE C - prenatal w/o a vit w/ fe fumarate-fa tab 30-1 mg 4 VIRT-PN PLUS - prenat w/o a w/ fe fumerate-methylfolate-fa-omega 3 cap 4 VINATE CALCIUM - prenatal vit w/ iron carbonyl-fe gluc-fa tab 27-1 mg 4 VIRT-SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg 4 VINATE CARE - prenatal w/o a vit w/ fe fum-fa tab chew 40-1 mg 4 VIRT-VITE GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 VINATE DHA RF - prenat w/o a w/ fefum-methylfol-omegas cap 27-1.13 mg 4 VIRTPREX - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg VITA-PREN - prenatal vit w/ docusateiron-fa tab 65-1 mg 4 VINATE GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 4 4 VINATE IC - prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg 4 VITAFOL ULTRA - prenat w/fe polymethylfol-fa-dha cap 29-0.6-0.4-200 mg 4 VINATE II - prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg 4 VITAFOL-NANO - prenatal w/o a w/ fefum-l methylfol-fa tab 18-0.6-0.4 mg 4 VINATE M - prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg 4 VITAFOL-OB - prenatal vit w/ fe fumarate-fa tab 65-1 mg 4 VINATE ONE - prenatal vit w/ fe fumarate-fa tab 60-1 mg 4 VITAFOL-OB+DHA - prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack VINATE ULTRA - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg 4 VITAFOL-ONE - prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg 4 VITAFOL-PN - prenatal vit w/ fe fumarate-fa tab 65-1 mg 4 VIRT NATE - prenatal vit w/ fe fumarate- 4 fa tab 28-1 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 123 VITAL-D RX - b-complex w/ c-biotin-dzinc & folic acid tab 1 mg 4 ZATEAN-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg 4 VITAMEDMD ONE RX/QUATREFO prenat w/o a w/fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg 4 ZATEAN-PN DHA - prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg 4 VITAMEDMD PLUS RX/QUATRE prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk 4 ZATEAN-PN PLUS - prenat w/o a w/ fe fumerate-methylfolate-fa-omega 3 cap 4 VITAMEDMD REDICHEW RX - prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg 4 ZINGIBER - prenatal w/ calcium-vit b6fa-ginger tab 1.2 mg 4 VITAPEARL - prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg 4 VIVA DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-200 mg 4 VOL-NATE - prenatal vit w/ fe fumaratefa tab 28-1 mg Dispensing Limits Step Therapy MINERALS and ELECTROLYTES CALCIFOL - ca carb-folic acid-vit d-b6b12-boron-mag wafer 1342-1.6 mg 4 4 4 CALCIUM-FOLIC ACID PLUS D - ca carb-folic acid-vit d-b6-b12-boronmag wafer 1342-1 mg 4 EFFER-K - potassium bicarbonate-citric acid effer tab 10 meq 4 VOL-PLUS - prenatal vit w/ fe fumaratefa tab 27-1 mg VOL-TAB RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg EFFER-K - potassium bicarbonate-citric acid effer tab 20 meq 4 4 VP CH ULTRA - prenat w/o a w/fe fumfe cbn-dss-fa-dha cap 27-1-260 mg FLORICAL - sodium fluoride w/ calcium carb cap 8.3-364 mg 4 4 VP-CH PLUS - prenatal w/o a w/fe cbndss-fa-dha cap 29-1-265 mg FLORICAL - sodium fluoride w/ calcium carb tab 8.3-364 mg 4 4 4 VP-CH-PNV - prenatal w/o vit a w/ fe cbn-dss-fa-dha cap 30-1-260 mg 4 FLORIVA - sodium fluoride-vitamin d liqd drops 0.25 mg/ml-400 unit/ml 4 FLUOR-A-DAY - sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg 4 VP-GGR-B6 PRENATAL - prenatal w/ calcium-vit b6-fa-ginger tab 1.2 mg VP-HEME OB - prenat vit-fe poly cmplxfe heme poly-fa tab 28-6-1 mg FLUOR-A-DAY - sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79 mg 4 4 VP-HEME OB + DHA - prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck FLUOR-A-DAY - sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg 4 4 4 VP-HEME ONE - prenat-fe poly cmplxfe heme poly-fa-dha cap 22-6-1-200 mg 4 FLUORABON - sodium fluoride soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf) 4 VP-PNV-DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-215.8 mg 4 FLURA-DROPS - sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) ZATEAN-CH - prenatal w/o a w/fe cbndss-fa-dha cap 27-1-250 mg GALZIN - zinc acetate cap 25 mg (elemental zinc) 4 4 124 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 GALZIN - zinc acetate cap 50 mg (elemental zinc) 4 MICRO-K - potassium chloride cap cr 8 meq GNP VITAMIN D-400 - calcium carbonate-cholecalciferol tab 90 mg-400 unit 1 GNP VITAMIN D-400 - calcium carbonate-cholecalciferol tab 90 mg-400 unit 4 IODINE STRONG - iodine solution strong 5% (lugol's) 4 K-PHOS - potassium phosphate monobasic tab 500 mg 4 K-PHOS NEUTRAL - pot phos monobasic w/sod phos di & monobas tab 155-852-130mg 4 K-TAB - potassium chloride tab cr 8 meq (600 mg) 4 K-TAB - potassium chloride tab cr 10 meq 4 K-TAB - potassium chloride tab cr 20 meq (1500 mg) 4 KLOR-CON M15 - potassium chloride microencapsulated crys cr tab 15 meq 4 KLOR-CON 25 - potassium chloride powder packet 25 meq 4 KLOR-CON/25 - potassium chloride powder packet 25 meq 4 LOZI-FLUR - sodium fluoride lozenge 1 mg f (from 2.2 mg naf) 4 MICRO-K - potassium chloride cap cr 10 4 meq 4 MONOCAL - sodium monofluorophosphate-calcium carb tab 22.75-625 mg 2 pot bicarbonate & chloride effer tab 25 meq 2 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (Kphos neutral) 2 potassium bicarbonate effer tab 25 meq 2 potassium chloride cap cr 8 meq (Micro-k) 2 potassium chloride cap cr 10 meq (Micro-k) 1 POTASSIUM CHLORIDE ER potassium chloride tab cr 8 meq (600 mg) 4 POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq (1500 mg) 1 potassium chloride microencapsulated crys cr tab 10 meq 1 potassium chloride microencapsulated crys cr tab 20 meq 1 potassium chloride oral liq 10% (20 meq/15ml) 1 potassium chloride oral liq 20% (40 meq/15ml) 2 potassium chloride powder packet 20 meq 1 potassium chloride tab cr 8 meq (600 mg) potassium chloride tab cr 10 meq (K- 1 tab) LURIDE - sodium fluoride chew tab 0.25 4 mg f (from 0.55 mg naf) 4 LURIDE - sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) 4 LURIDE - sodium fluoride chew tab 1 mg f (from 2.2 mg naf) 4 LURIDE - sodium fluoride soln 0.5 mg/ ml f (from 1.1 mg/ml naf) 4 MAGNEBIND 400 - magnesiumcalcium-folic acid tab 400-200-1 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 4 125 SODIUM FLUORIDE - sodium fluoride tab 0.5 mg f (from 1.1 mg naf) 4 SODIUM FLUORIDE - sodium fluoride tab 1 mg f (from 2.2 mg naf) 4 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) CYANOCOBALAMIN/LEVOMEFOLA l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg 4 DEPLIN - l-methylfolate tab 7.5 mg 4 1 DEPLIN - l-methylfolate tab 15 mg 4 1 DEPLIN 15 - l-methylfolate-algae cap 15-90.314 mg 4 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) 1 DEPLIN 7.5 - l-methylfolate-algae cap 7.5-90.314 mg 4 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) ELIGEN B12 - cyanocobalaminsalcaprozate sodium tab 1000 mcg-100 mg 4 2 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride) 1 4 SSKI - potassium iodide soln 1 gm/ml 4 ENTERAGAM - serum-derived bovine immunoglob/protein isolate 5 gm packet FALESSA - levomefolate glucosamine tab 1 mg (folate equivalent) 4 flaxseed oil-evening primrosebilberry cap 1000-500-40 mg (Tears again hydrate) 2 FOLBEE AR - folic acid-b12-b6arginine-black pepper tab 4 FOLBIC RF - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg 4 folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg 2 FOLTANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg 4 FOLTANX RF - l-methylfolate-algae-vit b12-b6 cap 3-90.314-2-35 mg 4 FOLTX - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg 4 FOSTEUM - genistein-zinc amino acid chelate-vitamin d cap 4 L-METHYL-B6-B12 - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg 4 L-METHYL-MC - l-methylfolate w/ vit b12-vit b6-vit b2 tab 6-1-50-5 mg 4 L-METHYL-MC NAC - l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg 4 NUTRIENTS acetylcysteine cap 600 mg 2 CARDIOVID PLUS - dha-epa-vit b6b12-folic acid cap 240-360-20-0.5-0.8 mg 4 LECITHIN - lecithin granules 4 NUTRESTORE - glutamine powd pack 5 gm 4 DIETARY PRODUCTS ALZ-NAC - l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg 4 AVAILNEX - carbocysteine chew tab 750 mg 4 CARDIOTEK-RX - folic acid-b12-b6arginine-black pepper tab 4 CEREFOLIN - l-methylfolate w/ vit b12vit b6-vit b2 tab 6-1-50-5 mg 4 CEREFOLIN NAC - l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg 4 CEREFOLIN NAC - l-methylfolatealgae-b12-acetylcyst tab 6-90.314-2-600mg 4 126 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 L-METHYLFOLATE - l-methylfolate tab 7.5 mg 4 LIMBREL250 - flavocoxid-citrated zinc bisglycinate cap 250-50 mg 4 L-METHYLFOLATE - l-methylfolate tab 15 mg 4 LIMBREL500 - flavocoxid-citrated zinc bisglycinate cap 500-50 mg 4 L-METHYLFOLATE CA ME-CBL - lmethylfolate-algae-b12-acetylcyst tab 6-90.314-2-600mg 4 LMTHF/PYRIDOXINE HCL/CYAN l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg 4 L-METHYLFOLATE CA/ME-CBL/ l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg 4 METAFOLBIC - l-methylfolate w/ vit b12-vit b6-vit b2 tab 6-1-50-5 mg 4 L-METHYLFOLATE CA/P-5-P/M - lmethylfolate w/ vit b6-vit b12 tab 3-35-2 mg METAFOLBIC PLUS - l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg 4 4 L-METHYLFOLATE CA/P-5-P/M - lmethylfolate-algae-vit b12-b6 cap 3-90.314-2-35 mg METAFOLBIC PLUS RF - lmethylfolate-algae-b12-acetylcyst tab 6-90.314-2-600mg 4 4 4 L-METHYLFOLATE CALCIUM - lmethylfolate tab 7.5 mg 4 METANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg 4 METANX - l-methylfolate-algae-vit b12b6 cap 3-90.314-2-35 mg 4 L-METHYLFOLATE CALCIUM - lmethylfolate tab 15 mg L-METHYLFOLATE FORMULA 15 - lmethylfolate-algae cap 15-90.314 mg METHYLFOL-ALGAE-B12-ACETY - lmethylfolate-algae-b12-acetylcyst tab 6-90.314-2-600mg 4 4 L-METHYLFOLATE FORMULA 7. - lmethylfolate-algae cap 7.5-90.314 mg 4 PKU EASY MICROTABS - nutritional supplement tabs delayed release 4 L-METHYLFOLATE FORTE - lmethylfolate-algae cap 7.5-90.314 mg 4 PODIAPN - l-methylfolate-b12-b6-alpha lipoic ac cap 5-2-35-300 mg 4 L-METHYLFOLATE FORTE - lmethylfolate-algae cap 15-90.314 mg 4 LEVOMEFOLATE CALCIUM/ACET - lmethylfolate-algae-b12-acetylcyst tab 6-90.314-2-600mg 4 LEVOMEFOLATE CALCIUM/ALGA - lmethylfolate-algae cap 7.5-90.314 mg 4 LEVOMEFOLATE CALCIUM/ALGA - lmethylfolate-algae cap 15-90.314 mg 4 LEVOMEFOLATE CALCIUM/PYRI l-methylfolate-algae-vit b12-b6 cap 3-90.314-2-35 mg 4 LIMBREL - flavocoxid cap 250 mg 4 LIMBREL - flavocoxid cap 500 mg 4 Q-TABS - levomefolate glucosamine tab 4 1 mg (folate equivalent) 4 TEARS AGAIN HYDRATE - flaxseed oil-evening primrose-bilberry cap 1000-500-40 mg 4 VAYACOG - phosphatidylserine-dhaepa cap 100-19.5-6.5 mg VAYARIN - phosphatidylserine-dha-epa 4 cap 75-21.5-8.5 mg VAYAROL - phytosterol esters-dha-epa 4 cap 630-232.5-92.5 mg 4 VITA-RESPA - folic acid-pyridoxinecyanocobalamin tab 2.2-25-1.3 mg VITACIRC-B - l-methylfolate w/ vit b6-vit 4 b12 tab 3-35-2 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 127 ZYTAZE - zinc citrate-phytase cap 25-500 mg 4 • ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.3ml 5 • ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 200 mcg/ml 5 • ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 200 mcg/0.4ml 5 • ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 300 mcg/ml 5 • 5 • • ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 300 mcg/0.6ml 5 • • ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 500 mcg/ml B-6 FOLIC ACID - cobalamine combination cap 4 • BIFERARX - polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg 4 • BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg 4 BP VIT 3 PLUS - folic acid-b6-b12-domega 3-phytosterols cap 1 mg 4 carbonyl iron susp 15 mg/1.25ml (elemental iron) 1 CENFOL - folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2 mg 4 • CENTRATEX - ferrous fumarate-fa-b complex-c-zn-mg-mn-cu cap 106-1 mg 4 • CERDELGA - eliglustat tartrate cap 84 mg (base equivalent) 5 CIFEREX - folic acid-cholecalciferol cap 1 mg-3775 unit 4 HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS ABANEU-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg 4 ACTIVE FE - fe carbonyl-fa-b complexa-c-d-e-min tab 75-1.25 mg 4 ANIMI-3 - folic acid-vit b6-vit b12-omega 4 3-phytosterols cap 1 mg ANIMI-3 - folic acid-b6-b12-d-omega 3- 4 phytosterols cap 1 mg ANIMI-3/VITAMIN D - folic acid-b6-b12- 4 d-omega 3-phytosterols cap 1 mg 5 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 10 mcg/0.4ml 5 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 25 mcg/ml 5 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 25 mcg/0.42ml 5 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 40 mcg/ml 5 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 40 mcg/0.4ml 5 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 60 mcg/ml 5 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 60 mcg/0.3ml 5 ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 100 mcg/ml 128 • • Dispensing Limits 5 Drug Name Step Therapy ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln inj 100 mcg/0.5ml Dispensing Limits Prior Authorization 4 Drug Tier VP-GSTN - genistein-zinc amino acid chelate-vitamin d cap Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 4 4 FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg CORVITE 150 - iron combination tab 4 4 cyanocobalamin inj 1000 mcg/ml 1 FERRAPLUS 90 - iron-folic acid-vit b12vit c-docusate sod tab 90-1 mg 4 FERRETTS CHEWABLE IRON carbonyl iron chew tab 18 mg (elemental iron) 4 DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg DROXIA - hydroxyurea cap 200 mg 4 DROXIA - hydroxyurea cap 300 mg DROXIA - hydroxyurea cap 400 mg 4 FERREX 150 FORTE PLUS - fe asp gly-fe polysacch-succ ac-c-threon acb12-fa cap 4 4 DURACHOL - folic acid-cholecalciferol cap 1 mg-3775 unit 4 FERREX 28 - fe asparto gly-fe fum-b12fa-c-succinic ac tab ther pack 4 ED CYTE F - ferrous fumarate-folic acid-docusate sodium tab 324-1-50 mg 4 FERRO-PLEX HEMATINIC - fe fumdss-vit c-vit e-vit b12-if-fa tab 115-1 mg 4 EPOGEN - epoetin alfa inj 2000 unit/ml 5 4 EPOGEN - epoetin alfa inj 3000 unit/ml 5 FERROTRIN - iron w/ b12-vit c-fa-ifc cap 36-0.015-75-0.5-240 mg 5 ferrous fumarate-fa-b complex-c-znmg-mn-cu tab 106-1 mg 1 EPOGEN - epoetin alfa inj 4000 unit/ml ferrous fumarate-folic acid tab 324-1 mg 1 4 EPOGEN - epoetin alfa inj 10000 unit/ml 5 EPOGEN - epoetin alfa inj 20000 unit/ml 5 • • • • • FA-8 - folic acid cap 0.8 mg 4 fe fum-iron polysacch complex-fab cmplx-c-zn-mn-cu cap (Tandem plus) 1 FERROUS SULFATE - ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe) 4 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg 1 FERROUS SULFATE - ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe) fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg 1 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) 1 FE 90 PLUS - fe carbonyl-fe gluconatefa-vit b12-vit c-dss tab 90-1 mg 4 ferrous sulfate soln 75 mg/ml (15 mg/ ml elemental fe) 1 FER-IN-SOL - ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) 4 4 FERIVA - fe bisglycin-fe carbonyl-c-fab12-biotin-dss cap 75-1 mg 4 FOCALGIN DSS - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg 4 FERIVA 21/7 - fe asparto gly-b12-fa-cdss-succinic acid-zn tab 75-1 mg 4 FOLGARD RX - folic acid-vitamin b6vitamin b12 tab 2.2-25-1 mg folic acid tab 400 mcg 1 folic acid tab 800 mcg 1 folic acid tab 1 mg 1 FERIVAFA - iron-c-fa-b12-biotin-copper- 4 docusate cap 110-1 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier CORVITE 150 - iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg Dispensing Limits 4 Step Therapy CORVITE FE - iron combination tab Prior Authorization Drug Name Drug Tier 2015 129 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg 1 IRON CHEWS PEDIATRIC - carbonyl iron chew tab 15 mg (elemental iron) 2 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) 1 iron combination cap 1 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg iron polysacch complex-vit b12-fa cap 150-0.025-1 mg 1 1 4 iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg (Hematron-af) 1 FOLIVANE-F - fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe) 4 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150) 2 FOLIVANE-PLUS - fe fum-iron polysacch complex-fa-b complex-cbiotin cap iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c plus) 1 FUSION PLUS - fe fum-iron poly cmplxfa-b cmplx-c-biotin-probiotic cap 4 GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 4 GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 4 HEMATOGEN FA - fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg 4 HEMATRON-AF - iron-docusate-b12folic acid-c-e-cu-biotin tab 150-1 mg 4 HEMETAB - polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg 4 HEMOCYTE PLUS - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap 106-1 mg 4 ICAR - carbonyl iron chew tab 15 mg (elemental iron) 4 ICAR PEDIATRIC - carbonyl iron susp 15 mg/1.25ml (elemental iron) 4 ICAR-C PLUS - iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg 4 INTEGRA F - fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe) 4 INTEGRA PLUS - fe fum-iron polysacch complex-fa-b complex-c-biotin cap 4 IRON ASP GLY/ POLYSACCH C - fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap 4 130 IROSPAN 24/6 - fe bisglyc-fe polys-succ 4 acd-b cmplx-c-ca-fa tab ther pk 4 IS 24/6 - fe bisglyc-fe polys-succ acd-b cmplx-c-ca-fa tab ther pk LEUKINE - sargramostim lyophilized for 5 inj 250 mcg MAXARON FORTE - fe gly-fe fum-vit c- 4 vit b12-methylfolate tab 4 MAXFE - iron-fa-vit b12-biotin-vit cdocusate-mg-zn tab 160-1 mg 4 MIRCERA - methoxy polyethylene glycol-epoetin beta inj 50 mcg/0.3ml 4 MIRCERA - methoxy polyethylene glycol-epoetin beta inj 75 mcg/0.3ml 4 MIRCERA - methoxy polyethylene glycol-epoetin beta inj 100 mcg/0.3ml 4 MIRCERA - methoxy polyethylene glycol-epoetin beta inj 200 mcg/0.3ml MULTIGEN - fe asparto gly-succ acd-c- 4 threonic acd-b12-des stom tab 4 MULTIGEN FOLIC - fe asparto glysuccinic acd-vit c-threonic acd-b12-fa tab MULTIGEN PLUS - fe aspart gly-fe fum- 4 succ acd-c-threonic acd-b12-fa tab 4 MV FE ASPARTO GLY/FE FUM/ - fe aspart gly-fe fum-succ acd-c-threonic acd-b12-fa tab Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 MV FE ASPARTO GLY/VIT C/V - fe asparto gly-succ acd-c-threonic acdb12-des stom tab 4 PROFERRIN-FORTE - iron heme polypeptide-folic acid tab 12-1 mg (fe equiv) 4 MYKIDZ IRON 10 - iron susp 15 mg/1.5ml 4 PROMACTA - eltrombopag olamine tab 12.5 mg (base equiv) 5 • • NASCOBAL - cyanocobalamin nasal spray 500 mcg/0.1ml 4 PROMACTA - eltrombopag olamine tab 25 mg (base equiv) 5 • • NATALVIRT FLT - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg 4 PROMACTA - eltrombopag olamine tab 50 mg (base equiv) 5 • • • • NEPHRON FA - ferrous fumarate w/ fadss-b complex-vit c tab PROMACTA - eltrombopag olamine tab 75 mg (base equiv) 5 4 NEULASTA - pegfilgrastim inj 6 mg/0.6ml • PROTECTIRON - iron polysacch-fa-b complex-vit c-e & minerals tab 60-1 mg 4 5 NEULASTA DELIVERY KIT pegfilgrastim inj 6 mg/0.6ml 5 • 4 NEUMEGA - oprelvekin for inj 5 mg 5 NEUPOGEN - filgrastim inj 300 mcg/ml 5 5 REVESTA - folic acid-cholecalciferol cap 1 mg-5750 unit 4 NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml) • • • PUREFE PLUS - ferrous fumarate-fab complex-c-zn-mg-mn-cu cap 106-1 mg 4 NEUPOGEN - filgrastim inj 300 mcg/0.5ml (600 mcg/ml) 5 • SPATONE PUR-ABSORB IRON ferrous sulfate liquid 5 mg/20ml (elemental iron) 5 • TANDEM F - ferrous fum-iron polysacch-fa cap 162-115.2-1 mg (106 mg fe) 4 NEUPOGEN - filgrastim inj 480 mcg/0.8ml (600 mcg/ml) NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg 4 TANDEM PLUS - fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap 4 NOVAFERRUM - polysacch iron complex-vit c-fa for soln 100-60-1 mg/5ml 4 TARON FORTE - fe bisglycinate-fe polysacch-vit c-vit b12-fa cap 4 4 ZAVESCA - miglustat cap 100 mg 5 PRE-FOLIC - folic acid-vitamin c tab 1-100 mg PROCRIT - epoetin alfa inj 2000 unit/ml 5 PROCRIT - epoetin alfa inj 3000 unit/ml 5 PROCRIT - epoetin alfa inj 4000 unit/ml 5 PROCRIT - epoetin alfa inj 10000 unit/ ml 5 • • • • PROCRIT - epoetin alfa inj 20000 unit/ ml 5 • PROCRIT - epoetin alfa inj 40000 unit/ ml 5 • • ANTICOAGULANTS ARIXTRA - fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 • ARIXTRA - fondaparinux sodium subcutaneous inj 5 mg/0.4ml 4 • ARIXTRA - fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 4 • ARIXTRA - fondaparinux sodium subcutaneous inj 10 mg/0.8ml 4 • COUMADIN - warfarin sodium tab 1 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 131 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier COUMADIN - warfarin sodium tab 2.5 mg Dispensing Limits 4 Step Therapy COUMADIN - warfarin sodium tab 2 mg Prior Authorization Drug Name Drug Tier 2015 4 • 4 FRAGMIN - dalteparin sodium inj 2500 unit/0.2ml 4 • COUMADIN - warfarin sodium tab 3 mg 4 FRAGMIN - dalteparin sodium inj 5000 unit/0.2ml COUMADIN - warfarin sodium tab 4 mg 4 4 • COUMADIN - warfarin sodium tab 5 mg 4 FRAGMIN - dalteparin sodium inj 7500 unit/0.3ml 4 FRAGMIN - dalteparin sodium inj 12500 unit/0.5ml 4 COUMADIN - warfarin sodium tab 6 mg • COUMADIN - warfarin sodium tab 7.5 mg 4 FRAGMIN - dalteparin sodium inj 15000 unit/0.6ml 4 • COUMADIN - warfarin sodium tab 10 mg 4 4 • ELIQUIS - apixaban tab 2.5 mg 4 • ELIQUIS - apixaban tab 5 mg FRAGMIN - dalteparin sodium inj 95000 unit/3.8ml 4 4 enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 2 • • • FRAGMIN - dalteparin sodium inj 18000 unit/0.72ml HEPARIN SODIUM - heparin sodium (porcine) inj 2000 unit/ml 4 enoxaparin sodium inj 40 mg/0.4ml (Lovenox) 2 • HEPARIN SODIUM - heparin sodium (porcine) inj 2500 unit/ml 4 enoxaparin sodium inj 60 mg/0.6ml (Lovenox) 2 • heparin sodium (porcine) inj 1000 unit/ml 2 enoxaparin sodium inj 80 mg/0.8ml (Lovenox) 2 • heparin sodium (porcine) inj 5000 unit/ml 2 enoxaparin sodium inj 100 mg/ml (Lovenox) 2 • heparin sodium (porcine) inj 10000 unit/ml 2 enoxaparin sodium inj 120 mg/0.8ml (Lovenox) 2 • heparin sodium (porcine) inj 20000 unit/ml 2 enoxaparin sodium inj 150 mg/ml (Lovenox) 2 • heparin sodium (porcine) pf inj 5000 unit/0.5ml 2 enoxaparin sodium inj 300 mg/3ml (Lovenox) 2 • LOVENOX - enoxaparin sodium inj 30 mg/0.3ml 4 • fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra) 2 • LOVENOX - enoxaparin sodium inj 40 mg/0.4ml 4 • fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra) 2 • LOVENOX - enoxaparin sodium inj 60 mg/0.6ml 4 • fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra) 2 • LOVENOX - enoxaparin sodium inj 80 mg/0.8ml 4 • fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra) 2 • LOVENOX - enoxaparin sodium inj 100 mg/ml 4 • FRAGMIN - dalteparin sodium inj 10000 unit/ml 4 • LOVENOX - enoxaparin sodium inj 120 mg/0.8ml 4 • 132 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 LOVENOX - enoxaparin sodium inj 150 mg/ml 4 • AMICAR - aminocaproic acid tab 500 mg 4 LOVENOX - enoxaparin sodium inj 300 mg/3ml 4 • AMICAR - aminocaproic acid tab 1000 mg 4 PRADAXA - dabigatran etexilate mesylate cap 75 mg (etexilate base eq) 4 • AMINOCAPROIC ACID - aminocaproic acid tab 1000 mg 4 4 4 • LYSTEDA - tranexamic acid tab 650 mg PRADAXA - dabigatran etexilate mesylate cap 150 mg (etexilate base eq) tranexamic acid tab 650 mg (Lysteda) 2 SAVAYSA - edoxaban tosylate tab 15 mg (base equivalent) 4 • ADVATE - antihemophilic factor rahfpfm for inj 250 unit 5 • SAVAYSA - edoxaban tosylate tab 30 mg (base equivalent) 4 • ADVATE - antihemophilic factor rahfpfm for inj 500 unit 5 • SAVAYSA - edoxaban tosylate tab 60 mg (base equivalent) 4 • ADVATE - antihemophilic factor rahfpfm for inj 1000 unit 5 • ADVATE - antihemophilic factor rahfpfm for inj 1500 unit 5 • ADVATE - antihemophilic factor rahfpfm for inj 2000 unit 5 • ADVATE - antihemophilic factor rahfpfm for inj 3000 unit 5 • ADVATE - antihemophilic factor rahfpfm for inj 4000 unit 5 • AGGRENOX - aspirin-dipyridamole cap sr 12hr 25-200 mg 4 AGRYLIN - anagrelide hcl cap 0.5 mg 4 ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 250 unit 5 • ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 500 unit 5 • ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 1000 unit 5 • ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 1500 unit 5 • Dispensing Limits HEMATOLOGICAL AGENTS - MISC. warfarin sodium tab 1 mg (Coumadin) 1 warfarin sodium tab 2 mg (Coumadin) 1 warfarin sodium tab 2.5 mg (Coumadin) Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 1 warfarin sodium tab 3 mg (Coumadin) 1 warfarin sodium tab 4 mg (Coumadin) 1 warfarin sodium tab 5 mg (Coumadin) 1 warfarin sodium tab 6 mg (Coumadin) 1 1 warfarin sodium tab 7.5 mg (Coumadin) 1 warfarin sodium tab 10 mg (Coumadin) 4 XARELTO - rivaroxaban tab 10 mg XARELTO - rivaroxaban tab 15 mg 4 XARELTO - rivaroxaban tab 20 mg 4 XARELTO STARTER PACK rivaroxaban tab starter therapy pack 15 mg & 20 mg 4 HEMOSTATICS AMICAR - aminocaproic acid syrup 25% 4 4 AMICAR - aminocaproic acid oral soln 0.25 gm/ml • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 133 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1 2 • clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) ALPHANINE SD - coagulation factor ix for inj 1000 unit • CORIFACT - factor xiii concentrate (human) for inj kit 1000-1600 unit 5 5 1 5 • dipyridamole tab 25 mg (Persantine) ALPHANINE SD - coagulation factor ix for inj 1500 unit dipyridamole tab 50 mg (Persantine) 2 5 • dipyridamole tab 75 mg (Persantine) 2 ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 500 unit 4 ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 1000 unit 5 EFFIENT - prasugrel hcl tab 5 mg (base equiv) 4 ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 2000 unit 5 EFFIENT - prasugrel hcl tab 10 mg (base equiv) 5 • ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 3000 unit 5 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 250 unit 5 • anagrelide hcl cap 0.5 mg (Agrylin) 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 500 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 750 unit 5 anagrelide hcl cap 1 mg • ASPIRIN/DIPYRIDAMOLE - aspirindipyridamole cap sr 12hr 25-200 mg 4 5 • BEBULIN - factor ix complex for inj 200-1200 unit 5 • ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 1000 unit 5 • BEBULIN VH - factor ix complex for inj 200-1200 unit 5 • ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 1500 unit 5 • BENEFIX - coagulation factor ix (recombinant) for inj 250 unit 5 • ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 2000 unit 5 • BENEFIX - coagulation factor ix (recombinant) for inj 500 unit 5 • ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 3000 unit 5 • BENEFIX - coagulation factor ix (recombinant) for inj 1000 unit 5 • FEIBA - antiinhibitor coagulant complex for inj 5 • BENEFIX - coagulation factor ix (recombinant) for inj 2000 unit 5 • FEIBA NF - antiinhibitor coagulant complex for inj 5 • BENEFIX - coagulation factor ix (recombinant) for inj 3000 unit 5 • FIRAZYR - icatibant acetate inj 30 mg/3ml (base equivalent) 5 • BERINERT - c1 esterase inhibitor (human) for iv inj kit 500 unit 5 • HELIXATE FS - antihemophilic factor (recombinant) for inj kit 250 unit HELIXATE FS - antihemophilic factor (recombinant) for inj kit 500 unit 5 • BRILINTA - ticagrelor tab 90 mg 4 • cilostazol tab 50 mg (Pletal) HELIXATE FS - antihemophilic factor (recombinant) for inj kit 1000 unit 5 1 cilostazol tab 100 mg (Pletal) 1 134 • • • Dispensing Limits Step Therapy ALPHANINE SD - coagulation factor ix for inj 500 unit 5 Prior Authorization • Drug Name Drug Tier 5 Dispensing Limits Prior Authorization ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 2000 unit Drug Name Step Therapy Drug Tier 2015 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • KOGENATE FS - antihemophilic factor (recombinant) for inj kit 500 unit 5 • HELIXATE FS - antihemophilic factor (recombinant) for inj kit 3000 unit 5 • KOGENATE FS - antihemophilic factor (recombinant) for inj kit 1000 unit 5 • HEMOFIL M - antihemophilic factor (human) for inj 220-400 unit 5 • KOGENATE FS - antihemophilic factor (recombinant) for inj kit 2000 unit 5 • HEMOFIL M - antihemophilic factor (human) for inj 250 unit 5 • KOGENATE FS - antihemophilic factor (recombinant) for inj kit 3000 unit 5 • HEMOFIL M - antihemophilic factor (human) for inj 401-800 unit 5 • 5 • HEMOFIL M - antihemophilic factor (human) for inj 500 unit 5 • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 250 unit 5 • HEMOFIL M - antihemophilic factor (human) for inj 1000 unit 5 • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 500 unit HEMOFIL M - antihemophilic factor (human) for inj 1700 unit 5 • 5 • HEMOFIL M - antihemophilic factor (human) for inj 801-1500 unit 5 • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 1000 unit 5 • HEMOFIL M - antihemophilic factor (human) for inj 1501-2000 unit 5 • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 2000 unit 5 • • HUMATE-P - antihemophilic factor/vwf (human) for inj 500-1200 unit 5 • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 3000 unit 5 HUMATE-P - antihemophilic factor/vwf (human) for inj 250-600 unit 5 • HUMATE-P - antihemophilic factor/vwf (human) for inj 1000-2400 unit 5 • MONOCLATE-P - antihemophilic factor (human) for inj kit 250 unit 5 • IXINITY - coagulation factor ix (recombinant) for inj 500 unit 5 • MONOCLATE-P - antihemophilic factor (human) for inj kit 500 unit 5 • IXINITY - coagulation factor ix (recombinant) for inj 1000 unit 5 • MONOCLATE-P - antihemophilic factor (human) for inj kit 1000 unit 5 • IXINITY - coagulation factor ix (recombinant) for inj 1500 unit 5 • MONOCLATE-P - antihemophilic factor (human) for inj kit 1500 unit 5 • KOATE-DVI - antihemophilic factor (human) for inj 250 unit 5 • MONONINE - coagulation factor ix for inj 250 unit 5 • KOATE-DVI - antihemophilic factor (human) for inj 500 unit 5 • MONONINE - coagulation factor ix for inj 500 unit 5 • KOATE-DVI - antihemophilic factor (human) for inj 1000 unit 5 • MONONINE - coagulation factor ix for inj 1000 unit 5 • KOGENATE FS - antihemophilic factor (recombinant) for inj kit 250 unit 5 • NOVOEIGHT - antihemophilic factor (recombinant) for inj 250 unit NOVOEIGHT - antihemophilic factor (recombinant) for inj 500 unit 5 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Prior Authorization • Drug Name Step Therapy Drug Tier 5 Dispensing Limits Prior Authorization HELIXATE FS - antihemophilic factor (recombinant) for inj kit 2000 unit Drug Name Step Therapy Drug Tier 2015 135 PROFILNINE SD - factor ix complex for inj 1500 unit 5 • NOVOEIGHT - antihemophilic factor (recombinant) for inj 1500 unit 5 • RECOMBINATE - antihemophilic factor (recombinant) for inj 220-400 unit 5 • NOVOEIGHT - antihemophilic factor (recombinant) for inj 2000 unit 5 • RECOMBINATE - antihemophilic factor (recombinant) for inj 401-800 unit 5 • NOVOEIGHT - antihemophilic factor (recombinant) for inj 3000 unit 5 • RECOMBINATE - antihemophilic factor (recombinant) for inj 801-1240 unit 5 • NOVOSEVEN - coagulation factor viia (recomb) for inj 2.4 mg (2400 mcg) 5 • RECOMBINATE - antihemophilic factor (recombinant) for inj 1241-1800 unit 5 • NOVOSEVEN RT - coagulation factor viia (recomb) for inj 1 mg (1000 mcg) 5 • RECOMBINATE - antihemophilic factor (recombinant) for inj 1801-2400 unit 5 • NOVOSEVEN RT - coagulation factor viia (recomb) for inj 2 mg (2000 mcg) 5 • RIXUBIS - coagulation factor ix (recombinant) for inj 250 unit 5 • NOVOSEVEN RT - coagulation factor viia (recomb) for inj 5 mg (5000 mcg) 5 • RIXUBIS - coagulation factor ix (recombinant) for inj 500 unit 5 • NOVOSEVEN RT - coagulation factor viia (recomb) for inj 8 mg (8000 mcg) 5 • RIXUBIS - coagulation factor ix (recombinant) for inj 1000 unit 5 • pentoxifylline tab cr 400 mg 1 5 • PERSANTINE - dipyridamole tab 25 mg 4 RIXUBIS - coagulation factor ix (recombinant) for inj 2000 unit PERSANTINE - dipyridamole tab 50 mg 4 5 • PERSANTINE - dipyridamole tab 75 mg 4 RIXUBIS - coagulation factor ix (recombinant) for inj 3000 unit ticlopidine hcl tab 250 mg 2 TRETTEN - coagulation factor xiii asubunit for inj 2000-3125 unit 5 • WILATE - antihemophilic factor/vwf (human) for inj 500-500 unit 5 • WILATE - antihemophilic factor/vwf (human) for inj 1000-1000 unit 5 • XYNTHA - antihemophilic factor recombinant paf for inj kit 250 unit 5 • XYNTHA - antihemophilic factor recombinant paf for inj kit 500 unit 5 • XYNTHA - antihemophilic factor recombinant paf for inj kit 1000 unit 5 • XYNTHA - antihemophilic factor recombinant paf for inj kit 2000 unit 5 • XYNTHA SOLOFUSE - antihemophilic factor recombinant paf for inj kit 250 unit 5 • PLAVIX - clopidogrel bisulfate tab 75 mg 4 (base equiv) 4 PLAVIX - clopidogrel bisulfate tab 300 mg (base equiv) 4 PLETAL - cilostazol tab 50 mg PLETAL - cilostazol tab 100 mg 4 PROFILNINE - factor ix complex for inj 500 unit 5 • PROFILNINE - factor ix complex for inj 1000 unit 5 • PROFILNINE - factor ix complex for inj 1500 unit 5 • PROFILNINE SD - factor ix complex for inj 500 unit 5 • PROFILNINE SD - factor ix complex for inj 1000 unit 5 • 136 Dispensing Limits Prior Authorization • Drug Name Step Therapy Drug Tier 5 Dispensing Limits Prior Authorization NOVOEIGHT - antihemophilic factor (recombinant) for inj 1000 unit Drug Name Step Therapy Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 XYNTHA SOLOFUSE - antihemophilic factor recombinant paf for inj kit 2000 unit 5 • XYNTHA SOLOFUSE - antihemophilic factor recombinant paf for inj kit 3000 unit 5 • ZONTIVITY - vorapaxar sulfate tab 2.08 mg (base equivalent) 4 TOPICAL PRODUCTS OPHTHALMIC AGENTS AZASITE - azithromycin ophth soln 1% 4 azelastine hcl ophth soln 0.05% (Optivar) 2 AZOPT - brinzolamide ophth susp 1% 4 Dispensing Limits • 1 Step Therapy XYNTHA SOLOFUSE - antihemophilic factor recombinant paf for inj kit 1000 unit 5 atropine sulfate ophth soln 1% (Isopto atropine) Prior Authorization • Drug Name Drug Tier 5 Dispensing Limits Prior Authorization XYNTHA SOLOFUSE - antihemophilic factor recombinant paf for inj kit 500 unit Drug Name Step Therapy Drug Tier 2015 BACITRACIN - bacitracin ophth oint 500 3 unit/gm 1 bacitracin-polymyxin b ophth oint bacitracin-polymyxin-neomycin-hc ophth oint 1% 2 BEPREVE - bepotastine besilate ophth soln 1.5% 4 BESIVANCE - besifloxacin hcl ophth susp 0.6% (base equiv) 4 ACULAR - ketorolac tromethamine ophth soln 0.5% 4 BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5% 4 ACULAR LS - ketorolac tromethamine ophth soln 0.4% 4 BETAGAN - levobunolol hcl ophth soln 0.5% 4 ACUVAIL - ketorolac tromethamine ophth soln 0.45% 4 betaxolol hcl ophth soln 0.5% 2 BETIMOL - timolol ophth soln 0.25% 4 AKTEN - lidocaine hcl ophth gel 3.5% 4 BETIMOL - timolol ophth soln 0.5% 4 ALCAINE - proparacaine hcl ophth soln 0.5% 4 BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4 ALOCRIL - nedocromil sodium ophth soln 2% 4 BIMATOPROST - bimatoprost ophth soln 0.03% 4 ALOMIDE - lodoxamide tromethamine ophth soln 0.1% 4 BLEPH-10 - sulfacetamide sodium ophth soln 10% 4 ALPHAGAN P - brimonidine tartrate ophth soln 0.1% 4 BLEPHAMIDE - sulfacetamide sodiumprednisolone ophth susp 10-0.2% 4 ALPHAGAN P - brimonidine tartrate ophth soln 0.15% 4 4 ALREX - loteprednol etabonate ophth susp 0.2% 4 BLEPHAMIDE S.O.P. - sulfacetamide sodium-prednisolone ophth oint 10-0.2% 2 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) 2 brimonidine tartrate ophth soln 0.15% (Alphagan p) brimonidine tartrate ophth soln 0.2% 1 ATROPINE SULFATE - atropine sulfate ophth oint 1% 4 bromfenac sodium ophth soln 0.09% (base equivalent) 2 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • 137 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) 2 ELESTAT - epinastine hcl ophth soln 0.05% 4 carteolol hcl ophth soln 1% 1 4 CILOXAN - ciprofloxacin hcl ophth soln 0.3% 4 EMADINE - emedastine difumarate ophth soln 0.05% (base equiv) 2 CILOXAN - ciprofloxacin hcl ophth oint 0.3% 4 epinastine hcl ophth soln 0.05% (Elestat) erythromycin ophth oint 5 mg/gm 1 ciprofloxacin hcl ophth soln 0.3% (Ciloxan) 1 FLAREX - fluorometholone acetate ophth susp 0.1% 4 COMBIGAN - brimonidine tartratetimolol maleate ophth soln 0.2-0.5% 4 fluorometholone ophth susp 0.1% (Fml liquifilm) 1 COSOPT - dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 4 flurbiprofen sodium ophth soln 0.03% (Ocufen) 1 COSOPT PF - dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf 4 FML - fluorometholone ophth oint 0.1% 4 1 FML FORTE - fluorometholone ophth susp 0.25% 4 cromolyn sodium ophth soln 4% CYCLOGYL - cyclopentolate hcl ophth soln 0.5% 4 FML LIQUIFILM - fluorometholone ophth susp 0.1% 4 CYCLOGYL - cyclopentolate hcl ophth soln 1% 4 GARAMYCIN - gentamicin sulfate ophth soln 0.3% 4 CYCLOGYL - cyclopentolate hcl ophth soln 2% 4 gatifloxacin ophth soln 0.5% (Zymaxid) 2 CYCLOMYDRIL - cyclopentolate w/ phenylephrine ophth soln 0.2-1% 4 cyclopentolate hcl ophth soln 1% (Cyclogyl) 1 GELFILM OP - gelatin adsorbable ophth 4 film 1 gentamicin sulfate ophth oint 0.3% 2 gentamicin sulfate ophth soln 0.3% (Garamycin) 1 cyclopentolate hcl ophth soln 2% (Cyclogyl) homatropine hbr ophth soln 5% (Isopto homatropine) 1 ILEVRO - nepafenac ophth susp 0.3% 4 IOPIDINE - apraclonidine hcl ophth soln 0.5% (base equivalent) 4 4 CYSTARAN - cysteamine hcl ophth soln 5 0.44% (base equivalent) 1 dexamethasone sodium phosphate ophth soln 0.1% 1 diclofenac sodium ophth soln 0.1% • dorzolamide hcl ophth soln 2% (Trusopt) 2 IOPIDINE - apraclonidine hcl ophth soln 1% (base equivalent) 1 ISOPTO ATROPINE - atropine sulfate ophth soln 1% 4 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt) DUREZOL - difluprednate ophth emulsion 0.05% ISOPTO CARBACHOL - carbachol ophth soln 1.5% 4 4 ISOPTO CARBACHOL - carbachol ophth soln 3% 4 138 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 ISOPTO CARPINE - pilocarpine hcl ophth soln 1% 4 MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1% 4 ISOPTO CARPINE - pilocarpine hcl ophth soln 2% 4 METIPRANOLOL - metipranolol ophth soln 0.3% 4 ISOPTO CARPINE - pilocarpine hcl ophth soln 4% 4 MITOSOL - mitomycin for ophth soln kit 0.2 mg 4 MOXEZA - moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily) 4 MYDRIACYL - tropicamide ophth soln 1% 4 NAPHAZOLINE HCL - naphazoline hcl ophth soln 0.1% 4 NATACYN - natamycin ophth susp 5% 3 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 2 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin) 2 neomycin-polymyxindexamethasone ophth oint 0.1% (Maxitrol) 1 neomycin-polymyxindexamethasone ophth susp 0.1% (Maxitrol) 1 NEOMYCIN/POLYMYXIN/HYDROC neomycin-polymyxin-hc ophth susp 4 NEOSPORIN - neomycin-polymygramicid op sol 1.75-10000-0.025mgunt-mg/ml 4 NEVANAC - nepafenac ophth susp 0.1% 4 OCUFEN - flurbiprofen sodium ophth soln 0.03% 4 OCUFLOX - ofloxacin ophth soln 0.3% 4 ofloxacin ophth soln 0.3% (Ocuflox) 1 OMNIPRED - prednisolone acetate ophth susp 1% 4 PATADAY - olopatadine hcl ophth soln 0.2% 4 ISOPTO HOMATROPINE - homatropine 4 hbr ophth soln 2% ISOPTO HOMATROPINE - homatropine 4 hbr ophth soln 5% ISOPTO HYOSCINE - scopolamine hbr 4 ophth soln 0.25% 4 ISTALOL - timolol maleate ophth soln 0.5% (once-daily) 2 ketorolac tromethamine ophth soln 0.4% (Acular ls) 2 ketorolac tromethamine ophth soln 0.5% (Acular) LACRISERT - artificial tear ophth insert 4 LASTACAFT - alcaftadine ophth soln 0.25% 4 latanoprost ophth soln 0.005% (Xalatan) 1 LEVOBUNOLOL HCL - levobunolol hcl ophth soln 0.25% 4 levobunolol hcl ophth soln 0.5% (Betagan) 1 levofloxacin ophth soln 0.5% 2 LOTEMAX - loteprednol etabonate ophth gel 0.5% 4 LOTEMAX - loteprednol etabonate ophth oint 0.5% 4 LOTEMAX - loteprednol etabonate ophth susp 0.5% 4 LUMIGAN - bimatoprost ophth soln 0.01% 4 MAXIDEX - dexamethasone ophth susp 0.1% 4 MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1% 4 • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 139 PATANOL - olopatadine hcl ophth soln 0.1% 4 SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 4 PAZEO - olopatadine hcl ophth soln 0.7% (base equivalent) 4 SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10% 4 phenylephrine hcl ophth soln 2.5% 1 2 phenylephrine hcl ophth soln 10% 1 sulfacetamide sodium ophth soln 10% (Bleph-10) PHOSPHOLINE IODIDE echothiophate iodide ophth for soln 0.125% 4 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 1 tetracaine hcl ophth soln 0.5% 1 pilocarpine hcl ophth soln 1% (Isopto carpine) 2 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe) 2 pilocarpine hcl ophth soln 2% (Isopto carpine) 2 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe) 2 pilocarpine hcl ophth soln 4% (Isopto carpine) 2 timolol maleate ophth soln 0.25% (Timoptic) 1 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim) 1 timolol maleate ophth soln 0.5% (Timoptic) 1 POLYTRIM - polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 4 TIMOPTIC - timolol maleate ophth soln 0.25% 4 PRED FORTE - prednisolone acetate ophth susp 1% 4 TIMOPTIC - timolol maleate ophth soln 0.5% 4 PRED MILD - prednisolone acetate ophth susp 0.12% 4 TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.25% 4 PRED-G - gentamicin-prednisolone ace ophth susp 0.3-1% 4 TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.5% 4 PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6% 4 TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.25% 4 prednisolone acetate ophth susp 1% (Pred forte) 2 TIMOPTIC-XE - timolol maleate ophth gel forming soln 0.5% 4 PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate ophth soln 1% 4 TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1% 4 PROLENSA - bromfenac sodium ophth soln 0.07% (base equivalent) TOBRADEX - tobramycindexamethasone ophth susp 0.3-0.1% 4 4 4 proparacaine hcl ophth soln 0.5% (Alcaine) 1 TOBRADEX ST - tobramycindexamethasone ophth susp 0.3-0.05% RESCULA - unoprostone isopropyl ophth soln 0.15% 4 tobramycin ophth soln 0.3% (Tobrex) 1 RESTASIS - cyclosporine (ophth) emulsion 0.05% tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) 2 4 TOBREX - tobramycin ophth soln 0.3% 4 140 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 4 CIPROFLOXACIN - ciprofloxacin hcl otic soln 0.2% (base equivalent) 4 COLY-MYCIN S - neomycin-colistin-hcthonzonium otic susp 3.3-3-10-0.5 mg/ml 4 CORTANE-B AQUEOUS - pramoxinehc-chloroxylenol aqueous otic soln 10-10-1 mg/ml 4 CORTANE-B-OTIC - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml 4 CORTISPORIN - neomycin-polymyxinhc otic soln 1% 4 • CORTISPORIN-TC - neomycin-colistinhc-thonzonium otic susp 3.3-3-10-0.5 mg/ml 4 • 4 4 DERMOTIC - fluocinolone acetonide (otic) oil 0.01% 2 4 fluocinolone acetonide (otic) oil 0.01% (Dermotic) hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc) 2 MYOXIN - benzocaine-chloroxylenol-hc otic susp 15-1-10 mg/ml 4 neomycin-polymyxin-hc otic soln 1% (Cortisporin) 2 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 2 ofloxacin otic soln 0.3% 2 OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml 4 OTOZIN - antipyrine-benzocaineglycerin-zinc ace otic liqd 5.4-1-2-1% 4 PINNACAINE OTIC - benzocaine otic soln 20% 4 TRAVOPROST - travoprost ophth soln 0.004% 4 trifluridine ophth soln 1% (Viroptic) 2 tropicamide ophth soln 0.5% 1 tropicamide ophth soln 1% (Mydriacyl) 1 TRUSOPT - dorzolamide hcl ophth soln 2% 4 VEXOL - rimexolone ophth susp 1% 4 VIGAMOX - moxifloxacin hcl ophth soln 0.5% (base equiv) 4 VIROPTIC - trifluridine ophth soln 1% 4 XALATAN - latanoprost ophth soln 0.005% 4 ZIOPTAN - tafluprost ophth soln 0.0015% 4 ZIRGAN - ganciclovir ophth gel 0.15% 4 ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3% ZYMAXID - gatifloxacin ophth soln 0.5% OTIC AGENTS acetic acid otic soln 2% 2 ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum acetate otic soln 4 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) 1 antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097% (Treagan otic) 2 ANTIPYRINE/BENZOCAINE antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) 4 AURALGAN - antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%) 4 • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1% 4 Step Therapy 4 TRAVATAN Z - travoprost ophth soln 0.004% (benzalkonium free) (bak free) Prior Authorization CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1% 4 Drug Tier 4 • CETRAXAL - ciprofloxacin hcl otic soln 0.2% (base equivalent) TOBREX - tobramycin ophth oint 0.3% Step Therapy Drug Name Drug Name Drug Tier Dispensing Limits Prior Authorization 2015 141 PRAMOTIC - pramoxine-chloroxylenol otic liquid 1-0.1% 4 pramoxine-chloroxylenol otic liquid 1-0.1% (Pramotic) 4 2 LISTERINE ESSENTIAL CARE - sod monofluorophosph-eucal-men-methyl sal-thymol gel 0.76% 4 pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml (Cortane-b-otic) 1 LISTERINE RESTORING - sodium fluoride rinse 0.0221% (0.01% f) 4 TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol 5.4-1.4-0.0097% 4 LISTERINE SMART RINSE - sodium fluoride rinse 0.0221% (0.01% f) LISTERINE SMART RINSE ANT sodium fluoride rinse 0.02% 4 4 MOUTH/THROAT/DENTAL AGENTS ACT TOTAL CARE DRY MOUTH sodium fluoride rinse 0.02% 4 LISTERINE TOOTH DEFENSE sodium fluoride rinse 0.0221% (0.01% f) AQUORAL - artificial saliva - aero soln 4 4 benzocaine dental soln 20% 1 LISTERINE TOTAL CARE - sodium fluoride rinse 0.0221% (0.01% f) 4 cevimeline hcl cap 30 mg (Evoxac) 2 LISTERINE TOTAL CARE PLUS sodium fluoride rinse 0.0221% (0.01% f) 4 CAPHOSOL - artificial saliva - solution chlorhexidine gluconate soln 0.12% (Peridex) 1 LISTERINE TOTAL CARE ZERO sodium fluoride rinse 0.02% 4 clotrimazole troche 10 mg 2 4 COLGATE DRY MOUTH RELIEF sodium fluoride mouthwash 2.1 mg/10ml 4 LISTERINE WHITENING/RESTO sodium fluoride rinse 0.0221% (0.01% f) LTA 360 KIT - lidocaine hcl laryngotracheal soln 4% 4 mouthwashes - liquid 2 DEBACTEROL - sulfuric acid-sulfonated 4 phenolics soln 30-50% 4 EVOXAC - cevimeline hcl cap 30 mg FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate gel 1.1-5% 4 GEL-KAM - stannous fluoride gel 0.4% 4 GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63% 4 GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic acid gel 4 GELX - oral wound care products - gel 4 MUCOTROL - oral wound care products 4 - wafer 4 NAFRINSE DAILY/ACIDULATED sodium fluoride-phosphoric acid for soln 1 mg/5ml (f equiv) 4 NAFRINSE DAILY/NEUTRAL - sodium fluoride for soln rinse 0.05% 4 NAFRINSE WEEKLY - sodium fluoride for soln rinse 0.2% 4 NEUTRASAL - artificial saliva - packet lidocaine hcl laryngotracheal soln 4% (Lta 360 kit) 2 NUMOISYN - artificial saliva - lozenge 4 NUMOISYN - artificial saliva - solution 4 lidocaine hcl viscous soln 2% 1 nystatin susp 100000 unit/ml 2 OMNI GEL - stannous fluoride gel 0.4% 4 142 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 ORAFATE - sucralfate-malate paste 10% 4 ORAMAGICRX - oral wound care products - for susp rinse ORAVIG - miconazole buccal tab 50 mg (mouth-throat) 4 4 REMBRANDT DEEPLY WHITE+PE sodium monofluorophosphate paste 0.884% 4 4 REMBRANDT INTENSE STAIN sodium fluoride paste 0.243% REMBRANDT WHITENING - sodium fluoride rinse 0.02% 4 SALAGEN - pilocarpine hcl tab 5 mg 4 SALAGEN - pilocarpine hcl tab 7.5 mg 4 SALICEPT - oral wound care products for susp rinse 4 sodium fluoride cream 1.1% (Prevident 5000 plus) 1 1 PERIDEX - chlorhexidine gluconate soln 4 0.12% 4 PHOS FLUR - sodium fluoride rinse 0.044% 4 PHOS-FLUR ORTHO DEFENSE sodium fluoride rinse 0.044% 2 pilocarpine hcl tab 5 mg (Salagen) pilocarpine hcl tab 7.5 mg (Salagen) 2 PREVIDENT - sodium fluoride rinse 0.2% 4 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1 PREVIDENT FLUORIDE - sodium fluoride gel 1.1% (0.5% f) 4 sodium fluoride paste 1.1% (Prevident 5000 boost) 2 PREVIDENT 5000 BOOSTER - sodium fluoride paste 1.1% 4 sodium fluoride rinse 0.0221% (0.01% f) sodium fluoride rinse 0.05% 2 PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1% 4 sodium fluoride rinse 0.2% (Prevident) 1 PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f) 4 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi) 1 PREVIDENT 5000 ENAMEL PRO sodium fluoride-potassium nitrate paste 1.1-5% 4 stannous fluoride conc 0.63% (Gelkam oral care ri) 1 stannous fluoride gel 0.4% 2 PREVIDENT 5000 PLUS - sodium fluoride cream 1.1% 4 STANNOUS FLUORIDE RINSE stannous fluoride liq 0.1% 4 THERA-FLUR-N - sodium fluoride gel 1.1% (0.5% f) 4 triamcinolone acetonide dental paste 0.1% 2 PREVIDENT 5000 SENSITIVE - sodium 4 fluoride-potassium nitrate paste 1.1-5% PROTHELIAL - sucralfate-malate paste 4 10% 4 REACH KIDS - sodium fluoride paste 0.15% 4 REMBRANDT CANKER SORE sodium fluoride paste 0.243% Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 ANORECTAL AGENTS ANALPRAM ADVANCED - hcpramoxine cr & diet manage prod tab & cleans wipe kit 4 ANALPRAM E - hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 143 ANALPRAM-HC - hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1% 4 LIDOCAINE HCL-HYDROCORTIS lidocaine-hydrocortisone acetate rectal gel 2.8-0.55% 4 ANALPRAM-HC - hydrocortisone acetate w/ pramoxine rectal cream 1-1% 4 lidocaine-hydrocortisone acetate rectal cream kit 2-2% 2 2 ANALPRAM-HC - hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% 4 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% lidocaine-hydrocortisone acetate rectal cream kit 3-1% 2 ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine rectal cream 1-1% 4 lidocaine-hydrocortisone acetate rectal cream 3-0.5% 2 4 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% 2 ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% 4 ANUSOL-HC - hydrocortisone rectal cream 2.5% 4 PROCORT - hydrocortisone acetate w/ pramoxine rectal cream 1.85-1.15% 4 ANUSOL-HC - hydrocortisone acetate suppos 25 mg 4 PROCTOCORT - hydrocortisone rectal cream 1% 4 CORTENEMA - hydrocortisone enema 100 mg/60ml 4 PROCTOCORT - hydrocortisone acetate suppos 30 mg 4 CORTIFOAM - hydrocortisone acetate rectal foam 90 mg/dose 3 PROCTOFOAM HC - hydrocortisone acetate w/ pramoxine rectal foam 1-1% RECTIV - nitroglycerin oint 0.4% 4 2 hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit (Analpram e) 2 hydrocortisone acetate suppos 25 mg (Anusol-hc) 2 hydrocortisone acetate suppos 30 mg (Proctocort) hydrocortisone acetate w/ pramoxine 2 rectal cream 1-1% (Analpram-hc) hydrocortisone acetate w/ pramoxine 2 rectal cream 2.5-1% (Analpram-hc) 2 hydrocortisone enema 100 mg/60ml (Cortenema) 2 hydrocortisone rectal cream 1% (Proctocort) 1 hydrocortisone rectal cream 2.5% (Anusol-hc) 144 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 UCERIS - budesonide rectal foam 2 mg/ 4 act DERMATOLOGICALS ABSORICA - isotretinoin cap 10 mg 4 ABSORICA - isotretinoin cap 20 mg 4 ABSORICA - isotretinoin cap 25 mg 4 ABSORICA - isotretinoin cap 30 mg 4 ABSORICA - isotretinoin cap 35 mg 4 ABSORICA - isotretinoin cap 40 mg 4 ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5% 4 acitretin cap 10 mg (Soriatane) 2 acitretin cap 17.5 mg (Soriatane) 2 acitretin cap 25 mg (Soriatane) 2 ACLOVATE - alclometasone dipropionate cream 0.05% 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 ACUICYN DAILY EYELID & EY - eyelid cleansers - liquid 4 ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1% 4 acyclovir oint 5% (Zovirax) 2 ALTABAX - retapamulin oint 1% 4 ACZONE - dapsone gel 5% 4 4 ADAPALENE - adapalene lotion 0.1% 4 ALUMINUM ACETATE - aluminum acetate soln adapalene cream 0.1% (Differin) 2 ALUVEA - urea cream 39% 4 adapalene gel 0.1% (Differin) 2 2 adapalene gel 0.3% (Differin) 2 AMCINONIDE - amcinonide cream 0.1% 4 AMCINONIDE - amcinonide lotion 0.1% 4 ADAZIN - benzo-capsaicin-lido-methyl salicylate cream 2-0.035-2-10% AMCINONIDE - amcinonide oint 0.1% 4 ADVANCED ALLERGY COLLECTI hydrocortisone cream kit 2.5% 4 ANACAINE - benzocaine oint 10% 4 4 ALA QUIN - clioquinol-hc cream 3-0.5% 4 ANODYNERX - capsaicin-lidocainementhol patch 0.05-2.5-5% ALA SCALP - hydrocortisone lotion 2% 4 4 alclometasone dipropionate cream 0.05% (Aclovate) 2 ANODYNZ - capsaicin-menthol disk 0.0375-5% 4 alclometasone dipropionate oint 0.05% 2 APEXICON E - diflorasone diacetate emollient base cream 0.05% 4 ALCORTIN A - iodoquinolhydrocortisone-aloe polysaccharide gel 1-2-1% 4 ARZOL SILVER NITRATE APP - silver nitrate-potassium nitrate applicator 75-25% 4 ALDARA - imiquimod cream 5% 4 ATENDIA - lidocaine-menthol patch 4-3% 4 ATOPICLAIR - dermatological products misc - cream 4 ALEGENIX - capsaicin-menthol disk 0.0375-5% 4 ATRALIN - tretinoin gel 0.05% 4 ALEVEER - capsaicin-menthol topical patch 0.0375-5% ATRAPRO CP - wound dressings - kit 4 ALEVICYN DERMAL SPRAY - wound dressings - soln 4 ATRAPRO DERMAL SPRAY - wound cleansers - liquid 4 ALLEVYN AG ADHESIVE - wound dressings - pads 4 AURSTAT - dermatological products misc - kit 4 ALLEVYN AG GENTLE BORDER wound dressings - pads 4 AURSTAT ANTI-ITCH HYDROGE dermatological products misc - kit 4 AVALIN-RX - lidocaine-menthol patch 4-1% 4 AVAR - sulfacetamide sodium w/ sulfur foam 9.5-5% 4 AVAR - sulfacetamide sodium w/ sulfur cleansing pad 9.5-5% 4 ALLEVYN AG NON-ADHESIVE - wound 4 dressings - pads 4 ALLEVYN AG SACRUM - wound dressings - pads ALLEVYN GENTLE - wound dressings - 4 pads • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 145 4 AVAR LS - sulfacetamide sodium w/ sulfur cleansing pad 10-2% 4 AVAR LS CLEANSER - sulfacetamide sodium w/ sulfur cleanser 10-2% 4 AVAR-E LS - sulfacetamide sodium w/ sulfur cream 10-2% 4 AVENOVA - hypochlorous acid cleanser 4 soln 0.01% 4 AZELEX - azelaic acid cream 20% BACTROBAN - mupirocin calcium cream 2% 4 BACTROBAN - mupirocin oint 2% 4 BENSAL HP - salicylic acid & benzoic acid oint 3-6% 4 BENZACLIN - clindamycin phosphatebenzoyl peroxide gel 1-5% 4 BENZACLIN WITH PUMP - clindamycin phosphate-benzoyl peroxide gel 1-5% 4 BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3% 4 BENZAMYCINPAK - benzoyl peroxideerythromycin gel pack 5-3% 4 BENZEFOAM - benzoyl peroxide foam 5.3% 4 BENZEFOAMULTRA - benzoyl peroxide 4 foam 9.8% 4 BENZIQ - benzoyl peroxide gel 5.25 % benzoyl peroxide liq 7% 2 benzoyl peroxide liq 5.25% 2 benzoyl peroxide lotion 6% 2 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin) 2 betamethasone dipropionate augmented cream 0.05% (Diprolene af) 2 betamethasone dipropionate augmented gel 0.05% 2 2 betamethasone dipropionate augmented lotion 0.05% (Diprolene) 2 betamethasone dipropionate augmented oint 0.05% (Diprolene) 2 betamethasone dipropionate cream 0.05% 2 betamethasone dipropionate lotion 0.05% 2 betamethasone dipropionate oint 0.05% 2 betamethasone valerate aerosol foam 0.12% (Luxiq) 2 betamethasone valerate cream 0.1% betamethasone valerate lotion 0.1% 2 betamethasone valerate oint 0.1% 2 BP CLEANSING WASH - sulfacetamide sodium-sulfur in urea emulsion 10-4% 2 BPO - benzoyl peroxide gel 4% 4 BPO - benzoyl peroxide gel 8% 4 BPO CREAMY WASH COMPLETE benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit 4 BPO 3% FOAMING CLOTHS - benzoyl peroxide cloth 3% 4 BENZIQ LS - benzoyl peroxide gel 2.75% 4 benzoyl peroxide creamy wash 4% &benzoyl peroxide bar 5% kit 2 benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit (Bpo creamy wash comp) 2 benzoyl peroxide foam 5.3% (Benzefoam) 2 BPO 9% FOAMING CLOTHS - benzoyl peroxide cloth 9% 4 benzoyl peroxide foam 9.8% (Benzefoamultra) 2 calcipotriene cream 0.005% (Dovonex) 2 146 Dispensing Limits 2 Step Therapy benzoyl peroxide liq 2.5% Prior Authorization Dispensing Limits Drug Name Drug Tier AVAR LS - sulfacetamide sodium w/ sulfur foam 10-2% Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 4 calcipotriene soln 0.005% (50 mcg/ ml) 2 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex) 2 CALCITRIOL - calcitriol oint 3 mcg/gm 4 CAMPHOMEX - camphor-histaminementhol liqd spray 4-0.025-10% 4 CAPEX - fluocinolone acetonide shampoo 0.01% 4 CAPSIDERM - capsaicin-menthol topical patch 0.0375-5% 4 CLARIFOAM EF - sulfacetamide sodium 4 w/ sulfur foam 10-5% 4 CLEOCIN-T - clindamycin phosphate soln 1% 4 CLEOCIN-T - clindamycin phosphate lotion 1% 4 CLEOCIN-T - clindamycin phosphate swab 1% 4 CLEOCIN-T - clindamycin phosphate gel 1% 4 CLEVER CHOICE COMFORT EZ methyl salicylate-lidocaine-menthol patch 2-4-1% 4 CLEVER CHOICE COMFORT EZ methyl salicylate-lidocaine-menthol patch 20-4-1% 4 CLINDACIN ETZ - clindamycin phosphate swab 1% & cleanser kit 4 CLINDACIN PAC - clindamycin phosphate swab 1% & cleanser kit 4 CLINDAGEL - clindamycin phosphate gel 1% 2 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac) 2 clindamycin phosphate foam 1% (Evoclin) 2 clindamycin phosphate gel 1% (Cleocin-t) 2 clindamycin phosphate lotion 1% (Cleocin-t) 2 clindamycin phosphate soln 1% (Cleocin-t) 2 clindamycin phosphate swab 1% (Cleocin-t) 2 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin) 2 clobetasol propionate cream 0.05% (Temovate) CAPTRACIN - capsaicin-menthol topical 4 patch 0.0375-5% 4 CARAC - fluorouracil cream 0.5% CEM-UREA - urea soln 45% 4 CENTANY - mupirocin oint 2% 4 CENTANY AT - mupirocin oint kit 2% 4 CETACAINE - butamben-tetracainebenzocaine aerosol spray 2-2-14% 4 CICLODAN CREAM KIT - ciclopirox olamine cream 0.77% (base equiv) & cleanser kit 4 CICLODAN SOLUTION KIT - ciclopirox solution kit 8% 4 ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base equiv) 2 ciclopirox olamine susp 0.77% (base equiv) 2 ciclopirox shampoo 1% (Loprox shampoo) 2 ciclopirox solution kit 8% (Ciclodan solution ki) 2 ciclopirox solution 8% (Penlac Nail Lacquer) 2 CICLOPIROX TOPICAL SOLUTI ciclopirox solution 8% & vitamin e 5% topical kit 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits CLARAVIS - isotretinoin cap 30 mg Step Therapy 2 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy calcipotriene oint 0.005% Prior Authorization Drug Name Drug Tier 2015 147 COCAINE HCL - cocaine hcl soln 4% 4 COCAINE HCL - cocaine hcl soln 10% 4 CONDYLOX - podofilox soln 0.5% 4 CONDYLOX - podofilox gel 0.5% 4 Dispensing Limits 4 Step Therapy COAL TAR - coal tar soln 20% Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 clobetasol propionate emollient base cream 0.05% (Temovate e) 2 clobetasol propionate emulsion foam 0.05% (Olux-e) 2 clobetasol propionate foam 0.05% (Olux) 2 clobetasol propionate gel 0.05% (Temovate) 2 COPASIL - emollient - gel 4 4 clobetasol propionate lotion 0.05% (Clobex) 2 CORDRAN - flurandrenolide cream 0.05% 4 clobetasol propionate oint 0.05% (Temovate) 2 CORDRAN - flurandrenolide lotion 0.05% CORDRAN - flurandrenolide oint 0.05% 4 clobetasol propionate shampoo 0.05% (Clobex) 2 CORDRAN TAPE - flurandrenolide tape 4 mcg/sqcm 4 clobetasol propionate soln 0.05% (Temovate) 2 CORTALO - hydrocortisone acetatealoe vera gel 2% 2 clobetasol propionate spray 0.05% (Clobex) 2 4 CLOBEX - clobetasol propionate spray 0.05% 4 CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot 10-10-1mg/ml 4 CLOBEX - clobetasol propionate lotion 0.05% 4 CORTISPORIN - neomycin-polymyxinhc cream 0.5% 4 CLOBEX - clobetasol propionate shampoo 0.05% 4 CORTISPORIN - bacitracin-polymyxinneomycin hc oint 1% 4 • • CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1% 4 COSENTYX - secukinumab subcutaneous soln prefilled syringe 150 mg/ml CLOCORTOLONE PIVALATE PUM clocortolone pivalate cream 0.1% 4 4 • • CLODAN KIT - clobetasol propionate shampoo 0.05% & cleanser kit 4 COSENTYX SENSOREADY PEN secukinumab subcutaneous soln auto-injector 150 mg/ml 4 CLODERM - clocortolone pivalate cream 0.1% 4 CURITY HYPERTONIC SODIUM wound dressings - misc 4 CLODERM PUMP - clocortolone pivalate cream 0.1% 4 CURITY SODIUM CHLORIDE DR wound dressings - pads 4 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) 2 CUTIVATE - fluticasone propionate cream 0.05% 4 clotrimazole w/ betamethasone lotion 1-0.05% 2 CUTIVATE - fluticasone propionate lotion 0.05% DENAVIR - penciclovir cream 1% 4 CNL8 NAIL KIT - ciclopirox soln 8% & lacquer removal pads kit 4 DERMA SILKRX SDS PAK triamcinolone acet cr 0.1% & dimeth cr 5% & silicone tape 4 148 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 4 DERMA-SMOOTHE/FS BODY OIL fluocinolone acetonide oil 0.01% (body oil) 4 DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01% (scalp oil) 4 DERMA-SMOOTHE/FS SCALP OI fluocinolone acetonide oil 0.01% (scalp oil) 4 DERMACINRX DUOPATCH PHARM lidocaine patch 5% & menthol-methyl sal patch 3-10% ther pak 4 DERMACINRX LEXITRAL PHARM diclofenac sod soln 1.5% & capsaicin cream 0.025% ther pack 4 DERMACINRX NEUROTRAL PHAR lidocaine patch 5% & capsaicin cream 0.025% therapy pack 4 DERMACINRX SILAPAK triamcinolone acet cr 0.1% & dimeth cr 5% & silicone tape 4 DERMACINRX SURGICAL COMBO chlorhexidine soln-dimeth cr-silicone tape-homeopathic kit 4 DERMACINRX SURGICAL PHARM chlorhexidine sol-mupirocin cr-dimeth cr-silicone tape kit 4 DERMASORB AF - clioquinol-hc cream 3-0.5% & emollient liqd kit 4 DERMASORB HC - hydrocortisone lot 2% & cleanser liq kit 4 DERMASORB TA - triamcinolone cream 4 0.1% & emollient cream kit DERMASORB XM - urea cream 39% & 4 emollient cream kit 4 DERMATOP - prednicarbate cream 0.1% 4 DERMATOP - prednicarbate oint 0.1% desonide cream 0.05% (Desowen) 2 desonide lotion 0.05% (Desowen) 2 desonide oint 0.05% (Desowen) 2 DESOWEN - desonide cream 0.05% 4 DESOWEN - desonide lotion 0.05% 4 DESOWEN - desonide oint 0.05% 4 DESOXIMETASONE - desoximetasone cream 0.05% 4 DESOXIMETASONE - desoximetasone oint 0.05% 4 desoximetasone cream 0.25% (Topicort) 2 desoximetasone gel 0.05% (Topicort) 2 Dispensing Limits 4 Step Therapy DESONATE - desonide gel 0.05% Prior Authorization Dispensing Limits Step Therapy Drug Name Drug Tier DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01% (body oil) Prior Authorization Drug Name Drug Tier 2015 desoximetasone oint 0.25% (Topicort) 2 2 diclofenac sodium (actinic keratoses) gel 3% (Solaraze) 2 diclofenac sodium soln 1.5% (Pennsaid) 4 DIFFERIN - adapalene cream 0.1% DIFFERIN - adapalene gel 0.1% 4 DIFFERIN - adapalene gel 0.3% 4 DIFFERIN - adapalene lotion 0.1% 4 DIFLORASONE DIACETATE diflorasone diacetate oint 0.05% 2 DIFLORASONE DIACETATE diflorasone diacetate cream 0.05% 4 DIPROLENE - betamethasone dipropionate augmented lotion 0.05% 4 DIPROLENE - betamethasone dipropionate augmented oint 0.05% 4 DIPROLENE AF - betamethasone dipropionate augmented cream 0.05% 4 DOVONEX - calcipotriene cream 0.005% 4 DOXYCYCLINE - doxycycline (rosacea) cap delayed release 40 mg 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • 149 DRITHO-CREME HP - anthralin cream 1% 4 erythromycin soln 2% 2 DRYSOL - aluminum chloride soln 20% ESSENTRA WIPES 9X9" CLEAN isopropyl alcohol wipes 70% 4 4 DUAC - clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 4 ETHYL CHLORIDE - ethyl chloride aerosol spray 4 econazole nitrate cream 1% 2 4 ECOZA - econazole nitrate foam 1% 4 ETHYL CHLORIDE/FINE PINPO - ethyl chloride aerosol spray EFUDEX - fluorouracil cream 5% 4 ELENZAPATCH - lidocaine-menthol patch 4-1% 4 ELETONE - dermatological products misc - cream 4 ELETONE TWINPACK - dermatological products misc - cream 4 ELIDEL - pimecrolimus cream 1% 4 ELIMITE - permethrin cream 5% 4 ELOCON - mometasone furoate solution 0.1% (lotion) 4 ELOCON - mometasone furoate cream 0.1% 4 ELOCON - mometasone furoate oint 0.1% 4 EMLA - lidocaine-prilocaine cream 2.5-2.5% 4 EMULSION SB - dermatological products misc - emulsion 4 EPICERAM - dermatological products misc - emulsion 4 EPIDUO - adapalene-benzoyl peroxide gel 0.1-2.5% Dispensing Limits Step Therapy ETHYL CHLORIDE/FINE STREA - ethyl 4 chloride aerosol spray 4 ETHYL CHLORIDE/MEDIUM JET ethyl chloride aerosol spray 4 ETHYL CHLORIDE/MEDIUM STR ethyl chloride aerosol spray 4 ETHYL CHLORIDE/MIST - ethyl chloride aerosol spray 4 EURAX - crotamiton cream 10% EURAX - crotamiton lotion 10% 4 EVOCLIN - clindamycin phosphate foam 4 1% 4 EXELDERM - sulconazole nitrate solution 1% EXELDERM - sulconazole nitrate cream 4 1% EXODERM - sodium thiosulfate-salicylic 2 acid lotion 25-1% 4 EXTINA - ketoconazole foam 2% FABIOR - tazarotene (acne) foam 0.1% 4 FINACEA - azelaic acid gel 15% 3 4 FIRST-HYDROCORTISONE hydrocortisone gel 10% (cmpd kit) 4 EPIDUO FORTE - adapalene-benzoyl peroxide gel 0.3-2.5% 4 FLECTOR - diclofenac epolamine patch 1.3% 4 EPIFOAM - pramoxine-hc aerosol foam 1-1% 4 FLEXIN - capsaicin-menthol topical patch 0.0375-5% 4 ERTACZO - sertaconazole nitrate cream 2% 4 fluocinolone acetonide cream 0.01% 2 ERYGEL - erythromycin gel 2% fluocinolone acetonide cream 0.025% (Synalar) 2 4 erythromycin gel 2% (Erygel) 2 2 erythromycin pads 2% 2 fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod) 150 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca) 2 GENTAMICIN SULFATE - gentamicin sulfate oint 0.1% 4 fluocinolone acetonide oint 0.025% (Synalar) 2 GORDOFILM - salicylic & lactic acids soln 16.7-16.7% 4 fluocinolone acetonide soln 0.01% (Synalar) 2 GORDONS UREA - urea ointment 40% 4 2 GRANULEX - trypsin w/ castor oil & peruvian balsam spray 4 fluocinonide cream 0.05% fluocinonide cream 0.1% (Vanos) 2 2 fluocinonide emulsified base cream 0.05% 2 HALAC - halobetasol prop oint 0.05% & ammonium lactate lot 12% kit 2 fluocinonide gel 0.05% 2 halobetasol propionate cream 0.05% (Ultravate) fluocinonide oint 0.05% 2 2 fluocinonide soln 0.05% 2 halobetasol propionate oint 0.05% (Ultravate) 4 HALOG - halcinonide cream 0.1% 4 FLUORAC - fluorouracil-diclofenac sodium cream 5-1% HALOG - halcinonide oint 0.1% 4 FLUOROPLEX - fluorouracil cream 1% 4 HALOTIN - haloprogin cream 1% 4 FLUOROURACIL - fluorouracil cream 0.5% 4 HPR - emollient - aerosol foam 4 HPR PLUS - emollient - aerosol foam 4 fluorouracil cream 5% (Efudex) 2 4 fluorouracil soln 2% 2 HPR PLUS - dermatological products misc - cream fluorouracil soln 5% 2 4 fluticasone propionate cream 0.05% (Cutivate) 2 HPR PLUS HYDROGEL KIT dermatological products misc - kit 4 fluticasone propionate lotion 0.05% (Cutivate) 2 HPR PLUS/MB HYDROGEL - emollient foam & wound dressing gel kit 2 fluticasone propionate oint 0.005% (Cutivate) 2 hyaluronate sodium (emollient) gel 0.2% (Hylira) 4 GEBAUERS PAIN EASE pentafluoropropane-tetrafluoroethane aero spray 4 HYDRO 35 - urea in lactic acid vehicle foam 35% HYDRO 40 FOAM - urea foam 40% 4 2 GEBAUERS SPRAY AND STRETC pentafluoropropane-tetrafluoroethane aero spray 4 hydrocortisone butyrate cream 0.1% (Locoid) 2 GENADUR - dermatological products misc - liquid 4 hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream) 2 GENADUR KIT - dermatological products misc topical/oral - kit 4 hydrocortisone butyrate oint 0.1% (Locoid) 1 GENTAMICIN SULFATE - gentamicin sulfate cream 0.1% 4 hydrocortisone butyrate soln 0.1% (Locoid) hydrocortisone cream 2.5% 1 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 151 2 hydrocortisone lotion 2.5% 2 isotretinoin cap 20 mg 2 hydrocortisone oint 2.5% 1 isotretinoin cap 40 mg 2 hydrocortisone valerate cream 0.2% 2 JUBLIA - efinaconazole soln 10% 4 hydrocortisone valerate oint 0.2% (Westcort) 2 KENALOG - triamcinolone acetonide aerosol soln 4 HYDROFERA BLUE FOAM DRESS wound dressings - pads 4 KENDALL HYDROGEL IMPREGNA hydroactive (sterile) dressing 4 HYDROFERA BLUE HEAVY DRAI wound dressings - pads 4 KENDALL HYDROGEL WOUND DR hydroactive (sterile) dressing 4 HYDROFERA BLUE READY FOAM wound dressings - pads 4 KENDALL ZINC CALCIUM ALGI wound dressings - pads 4 HYDROFERA BLUE 4"X4" - wound dressings - pads 4 KENDALL ZINC CALCIUM ALGI wound dressings - misc 4 HYLASE WOUND - hyaluronate sodium gel 4 KERAFOAM - urea foam 30% 4 KERAFOAM 42 - urea foam 42% 4 HYLATOPIC - emollient - aerosol foam 4 KERALAC - urea cream 47% 4 HYLATOPIC PLUS - emollient - aerosol foam 4 KERALYT - salicylic acid gel 6% 4 4 KERALYT SCALP - salicylic acid shampoo 6% & salicylic acid gel 6% kit 4 HYLATOPIC PLUS - dermatological products misc - cream HYLIRA - hyaluronate sodium (emollient) gel 0.2% 4 KERYDIN - tavaborole soln 5% 4 4 ketoconazole cream 2% 1 HYLIRA - hyaluronate sodium (emollient) lotion 0.1% ketoconazole foam 2% (Extina) 2 imiquimod cream 5% (Aldara) 2 ketoconazole shampoo 2% (Nizoral) 2 INOVA - benzoyl peroxide pad 4% & vitamin e topical 5% kit 4 KETODAN KIT - ketoconazole foam 2% & cleanser kit 4 INOVA - benzoyl peroxide pad 8% & vitamin e topical 5% kit 4 KLARON - sulfacetamide sodium lotion 10% (acne) 4 INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic ac pad 1% & vit e 5% kit 4 K2K PAIN RELIEVING PATCH lidocaine-menthol patch 4-4% 4 4 INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic ac pad 2% & vit e 5% kit 4 LAC-HYDRIN - lactic acid (ammonium lactate) lotion 12% LAC-HYDRIN - lactic acid (ammonium lactate) cream 12% 4 iodoquinol-hc cream 1% 2 1 iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9% (Vytone) 2 lactic acid (ammonium lactate) cream 12% (Lac-hydrin) lactic acid (ammonium lactate) lotion 10% 1 152 • Dispensing Limits isotretinoin cap 10 mg Step Therapy 2 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy hydrocortisone lotion 2% (Ala scalp) Prior Authorization Drug Name Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 lactic acid (ammonium lactate) lotion 12% (Lac-hydrin) 1 LIDORX - lidocaine hcl gel 3% 4 lactic acid w/ vitamin e cream 10%-3500 unit/30gm LIDOTHOL - lidocaine-menthol patch 4.5-5% 4 1 LIDOVEX - lidocaine cream 3.75% 4 LIDOVIN - lidocaine hcl cream 3.95% 4 LIDOZOL - lidocaine hcl cream 3.75% 4 lindane lotion 1% 2 lindane shampoo 1% 2 LOCOID - hydrocortisone butyrate soln 0.1% 4 LOCOID - hydrocortisone butyrate cream 0.1% 4 LATRIX XM - urea in zinc undecylenate- 4 lactic acid vehicle emulsion 45% 4 LAVARE WOUND WASH - wound cleansers - gel 4 LAVOCLEN-4 CREAMY WASH benzoyl peroxide liq 4% 4 LAVOCLEN-8 CREAMY WASH benzoyl peroxide liq 8% 4 LEVATIO PATCH - capsaicin-menthol topical patch 0.03-5% LEVULAN KERASTICK - aminolevulinic 4 acid hcl for soln 20% (stick applicator) 4 LIDENZA PATCH - lidocaine-menthol patch 4-1% 4 LIDOCAINE AND TETRACAINE lidocaine-tetracaine cream 7-7% 4 LIDOCAINE HCL - lidocaine hcl lotion 3% 2 lidocaine hcl cream 3% lidocaine hcl gel 2% 1 lidocaine hcl soln 4% (Xylocaine) 1 lidocaine oint 5% 2 lidocaine patch 5% (700 mg) (Lidoderm) 2 lidocaine-menthol patch 4-5% 2 lidocaine-prilocaine cream 2.5-2.5% (Emla) 2 lidocaine-prilocaine kit 2.5-2.5% 2 LOCOID - hydrocortisone butyrate lotion 4 0.1% 4 LOCOID - hydrocortisone butyrate oint 0.1% LOCOID LIPOCREAM - hydrocortisone 4 butyrate hydrophilic lipo base cream 0.1% 4 LOPROX SHAMPOO - ciclopirox shampoo 1% 4 LORENZA - lidocaine-menthol patch 4-1% 4 LOTRIMIN ULTRA - butenafine hcl cream 1% 4 LOTRISONE - clotrimazole w/ betamethasone cream 1-0.05% 4 LOUTREX - antiseborrheic products misc - cream 4 LUXIQ - betamethasone valerate aerosol foam 0.12% 4 LUZU - luliconazole cream 1% lidocaine-prilocaine kit 2.5-2.5% 4 LYCELLE - nit remover - gel 4 LIDOCIN - lidocaine hcl gel 3% 4 4 LIDODERM - lidocaine patch 5% (700 mg) 4 MAC PATCH - capsaicin-menthol topical patch 0.0375-5% malathion lotion 0.5% (Ovide) 2 LIDODEXTRAPINE - lidocaine-menthol patch 4-1% 4 MB HYDROGEL - dermatological products misc - kit 4 LIDOPIN - lidocaine hcl cream 3.25% 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 153 MEDI-DERM-RX - capsaicin-mentholmethyl salicylate cream 0.035-5-20% 4 MIGRYL - capsaicin-menthol disk 0.0375-5% 4 MEDI-DERM/L-RX - lidocainecapsaicin-menthol-methyl sal cream 2-0.035-5-20% 4 MIRVASO - brimonidine tartrate gel 0.33% (base equivalent) 4 MEDI-PATCH RX - lidocainecapsaicin-menthol-methyl sal patch 0.5-0.035-5-20% mometasone furoate cream 0.1% (Elocon) 2 4 mometasone furoate oint 0.1% (Elocon) 2 MEDIHONEY CALCIUM ALGINAT wound dressings - pads 4 mometasone furoate solution 0.1% (lotion) (Elocon) 2 MEDIHONEY WOUND & BURN DR wound dressings - pads 4 mupirocin calcium cream 2% (Bactroban) 2 MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20% 4 mupirocin oint 2% (Bactroban) 1 4 naftifine hcl cream 1% (Naftin) 2 MEGRIX - capsaicin-menthol disk 0.0375-5% NAFTIN - naftifine hcl cream 1% 4 MENTAX - butenafine hcl cream 1% 4 NAFTIN - naftifine hcl cream 2% 4 MENTHOCIN PATCH/LIDOCAINE lidocaine-capsaicin-menthol-methyl sal patch 0.5-0.035-5-20% 4 NAFTIN - naftifine hcl gel 1% 4 NAFTIN - naftifine hcl gel 2% 4 NATROBA - spinosad susp 0.9% 4 MENTHOCIN PATCH/LIDOCAINE lidocaine-capsaicin-men-methyl sal patch 0.5-0.0375-5-20% 4 NEO-SYNALAR - neomycinfluocinolone cream 0.35-0.025% 4 4 methoxsalen rapid cap 10 mg (Oxsoralen ultra) 2 NEO-SYNALAR KIT - neomycinfluocinolone cream 0.35-0.025% & emollient cr kit 4 MENTHOLIX - lidocaine-menthol liquid spray 4-1% NEOSALUS - emollient - aerosol foam 4 4 NEOSALUS - emollient - lotion 4 METROCREAM - metronidazole cream 0.75% 4 METROGEL - metronidazole gel 1% 4 NEOSALUS - dermatological products misc - cream 4 NEOSALUS CP - dermatological products misc - cream 4 METROLOTION - metronidazole lotion 0.75% 2 NEUAC KIT - clindamycin-benzoyl perox gel 1.2-5% & moisturizer cr kit 4 metronidazole cream 0.75% (Metrocream) 2 metronidazole gel 1% (Metrogel) 2 NEUVAXIN - capsaicin-menthol topical patch 0.0375-5% 4 metronidazole gel 0.75% 2 NIVATOPIC PLUS - dermatological products misc - cream 4 metronidazole lotion 0.75% (Metrolotion) NIZORAL - ketoconazole shampoo 2% 4 METVIXIA - methyl aminolevulinate hcl cream 16.8% (base equiv) 4 NOBLE MYSTIQUE EMU-LAC - lactic acid (ammonium lactate) cream 10% 4 154 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 NUCORT - hydrocortisone acetate lotion 4 2% 4 NUOX - benzoyl peroxide-sulfur gel 6-3% NUVAIL - dermatological products misc 4 - solution 4 NUZON - hydrocortisone acetate-aloe vera gel 2% 2 nystatin cream 100000 unit/gm OVACE WASH - sulfacetamide sodium liquid 10% 4 OVIDE - malathion lotion 0.5% 4 OXISTAT - oxiconazole nitrate cream 1% 4 Dispensing Limits Step Therapy Prior Authorization 4 Drug Name Drug Tier NOVACORT - hydrocortisone acepramoxine-aloe polysacch gel 2-1-1% Dispensing Limits 4 Step Therapy NORITATE - metronidazole cream 1% Prior Authorization Drug Name Drug Tier 2015 OXISTAT - oxiconazole nitrate lotion 1% 4 4 OXSORALEN - methoxsalen lotion 1% OXSORALEN ULTRA - methoxsalen rapid cap 10 mg 4 PAIN RELIEF PATCH - capsaicinmenthol topical patch 0.0375-5% 4 PAIN RELIEF PATCH - lidocainementhol patch 5-1% 4 PANDEL - hydrocortisone probutate cream 0.1% 4 PANRETIN - alitretinoin gel 0.1% 4 4 nystatin oint 100000 unit/gm 2 nystatin topical powder 2 nystatin-triamcinolone cream 100000-0.1 unit/gm-% 2 nystatin-triamcinolone oint 100000-0.1 unit/gm-% 2 OLUX - clobetasol propionate foam 0.05% 4 PEDIADERM AF COMPLETE KIT nystatin cream 100000 unit/gm & diaper rash cream kit 4 OLUX-E - clobetasol propionate emulsion foam 0.05% 4 PEDIADERM HC - hydrocortisone lot 2% & emollient cream kit 4 ONEXTON - clindamycin phosphatebenzoyl peroxide gel 1.2-3.75% 4 PEDIADERM TA - triamcinolone cream 0.1% & emollient cream kit 4 OPTASE - trypsin w/ castor oil & peruvian balsam gel 4 PENLAC NAIL LACQUER - ciclopirox solution 8% ORACEA - doxycycline (rosacea) cap delayed release 40 mg 4 OVACE PLUS - sulfacetamide sodium cream 10% 4 OVACE PLUS - sulfacetamide sodium foam 9.8% 4 OVACE PLUS - sulfacetamide sodium shampoo 10% 4 OVACE PLUS - sulfacetamide sodium lotion 9.8% 4 OVACE PLUS WASH - sulfacetamide sodium cleansing gel 10% 4 OVACE PLUS WASH - sulfacetamide sodium liquid 10% 4 • PENNSAID - diclofenac sodium soln 2% 4 4 PERMAVAN EXTERNAL PATCH lidocaine-dm-trolamine salicylate patch 4-4-10% 2 permethrin cream 5% (Elimite) PHARMACIST CHOICE TSX PAT methyl salicylate-lidocaine-menthol patch 2-4-1% 4 PICATO - ingenol mebutate gel 0.015% 4 PICATO - ingenol mebutate gel 0.05% 4 • • PICO SINGLE USE NEGATIVE - wound 4 dressings - kit 4 PLEXION - sulfacetamide sodium w/ sulfur lotion 9.8-4.8% BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 155 PLEXION - sulfacetamide sodium w/ sulfur cream 9.8-4.8% 4 PROLIDA - lidocaine-menthol patch 4-1% 4 PLEXION CLEANSER - sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% 4 PROMISEB - antiseborrheic products misc - cream 4 PLEXION CLEANSING CLOTHS sulfacetamide sodium w/ sulfur cleansing cloth 9.8-4.8% 4 PROMISEB COMPLETE antiseborrheic products misc - kit 4 PROTOPIC - tacrolimus oint 0.03% 4 PLIAGLIS - lidocaine-tetracaine cream 7-7% 4 PROTOPIC - tacrolimus oint 0.1% 4 4 PROVENZA - lidocaine-menthol patch 4-1% 4 PODOCON 25 IN BENZOIN TIN podophyllum resin soln 25% 2 PROZENA - lidocaine patch 4% 4 podofilox soln 0.5% (Condylox) 4 PRUCLAIR - dermatological products misc - cream 4 PR CREAM - dermatological products misc - kit 4 PRUDOXIN - doxepin hcl cream 5% 4 PRAMOSONE - pramoxine-hc cream 1-1% 4 PRAMOSONE - pramoxine-hc cream 1-2.5% 4 PRUMYX - dermatological products misc - cream 4 PRAMOSONE - pramoxine-hc lotion 1-1% 4 PSORCON - diflorasone diacetate cream 0.05% 4 PRAMOSONE - pramoxine-hc lotion 1-2.5% 4 PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2% QROXIN - capsaicin-menthol topical patch 0.0375-5% 4 QUTENZA - capsaicin patch 8% & cleansing gel kit 4 RECIPHEXAMINE - lidocaine-menthol patch 4-1% 4 REGENECARE - lidocaine hcl-collagenaloe vera gel 2% 4 REGRANEX - becaplermin gel 0.01% 4 RELEEVIA - capsaicin-menthol topical patch 0.0375-5% 4 RELEEVIA MC - capsaicin-menthol topical patch 0.0375-5% 4 RELEEVIA ML - lidocaine-menthol patch 4-1% 4 PRAMOSONE - pramoxine-hc oint 1-1% 4 4 PRAMOSONE - pramoxine-hc oint 1-2.5% 4 PRAMOSONE E - pramoxine-hc emollient base cream 1-2.5% 1 pramoxine hcl gel 1% pramoxine-hc cream 1-2.5% (Pramosone) 2 PRASCION RA WITH SUNSCREE sulfacetamide sodium-sulfursunscreen cream 10-5% 2 prednicarbate cream 0.1% (Dermatop) 2 prednicarbate oint 0.1% (Dermatop) 2 4 RELYYT - capsaicin-menthol topical patch 0.025-5% 4 PREMIUM SCAR PATCH - allantoinlidocaine-petrolatum patch 2-4-30% 4 REMATEX - capsaicin-menthol-methyl salicylate cream 0.035-6-30% 4 PRESERA - emollient - aerosol foam 156 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • REMAXAZON EXTERNAL PATCH lidocaine-capsaicin-chondroitinglucos patch 4-0.0285-3-5% 4 ROSADAN KIT - metronidazole cream 0.75% w/ cleanser kit 4 RENOVO - capsaicin-menthol topical patch 0.0375-5% ROSANIL - sulfacetamide sod-sulfur emul 10-5% & skin cleanser kit 4 4 RENOVO LIDO 5 - lidocaine-capsaicin cream 5-0.05% ROSULA - sulfacetamide sodium w/ sulfur wash 10-4.5% 4 4 4 RTD WOUND CARE DRESSING wound dressings - pads 4 RENUU NL - allantoin-petrolatum patch 2-30% SALEX - salicylic acid shampoo 6% 4 RENUU PATCH - allantoin-lidocainepetrolatum patch 2-5-30% 4 SALEX CREAM - salicylic acid cream 6% & cleanser liqd kit 4 RESTORE SILVER DRESSING 2 wound dressings - pads 4 SALEX LOTION - salicylic acid lotion 6% & cleanser liqd kit 4 RESTORE SILVER DRESSING 4 wound dressings - pads 4 SALICYLIC ACID - salicylic acid soln 26% 4 RESTORE SILVER DRESSING 6 wound dressings - pads 4 salicylic acid cream 6% 2 4 salicylic acid cream 6% & cleanser liqd kit (Salex cream) 2 RETIN-A - tretinoin cream 0.025% RETIN-A - tretinoin cream 0.05% 4 RETIN-A - tretinoin cream 0.1% salicylic acid film forming liquid 27.5% (Virasal) 2 4 RETIN-A - tretinoin gel 0.01% 4 2 RETIN-A - tretinoin gel 0.025% 4 salicylic acid film-forming soln 28.5% (Ultrasal-er) salicylic acid foam 6% (Salvax) 2 salicylic acid gel 6% (Keralyt) 2 SALICYLIC ACID IN AMMONIU salicylic acid in ammonium lactate vehicle foam 6% 4 salicylic acid lotion 6% 2 salicylic acid lotion 6% & cleanser liqd kit (Salex lotion) 2 salicylic acid shampoo 6% (Salex) 2 SALKERA - salicylic acid in ammonium lactate vehicle foam 6% 4 SALVAX - salicylic acid foam 6% 4 SALVAX DUO PLUS - salicylic acid foam 6% & urea in lactic acid foam 35% kit 4 SANTYL - collagenase oint 250 unit/gm 4 RETIN-A MICRO - tretinoin microsphere 4 gel 0.04% RETIN-A MICRO - tretinoin microsphere 4 gel 0.1% 4 RETIN-A MICRO PUMP - tretinoin microsphere gel 0.04% 4 RETIN-A MICRO PUMP - tretinoin microsphere gel 0.08% 4 RETIN-A MICRO PUMP - tretinoin microsphere gel 0.1% 4 REXAPHENAC - diclofenac sodium cream 1% 4 RIAX - benzoyl peroxide foam 5.5% RIAX - benzoyl peroxide foam 9.5% 4 ROSADAN KIT - metronidazole gel 0.75% w/ cleanser kit 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 157 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 SCALACORT DK - hc lot 2% & sal acidsulfur shampoo 2-2% & shampoo kit 4 SINELEE - capsaicin-menthol topical patch 0.05-5% 4 SCAR PATCH - allantoin-lidocainepetrolatum patch 2-4-30% 4 SKLICE - ivermectin lotion 0.5% 4 SCAR PATCH - allantoin-lidocainepetrolatum patch 2-5-30% SODIUM SULFACETAMIDE WASH sulfacetamide sodium in bakuchiol vehicle wash 10% 4 4 scar treatment products - gel 2 4 selenium sulfide lotion 2.5% 1 SELRX - selenium sulfide-pyrithione zinc in urea shampoo 2.3% 4 SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea gel 10-5% 4 SILMANIX PAIN RELIEIVING capsaicin-menthol-histamine cream 0.0375-3-0.035% 4 SODIUM SULFACETAMIDE/SULF sulfacetamide sodium w/ sulfur susp 10-5% 4 SILVADENE - silver sulfadiazine cream 1% 4 SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea emulsion 10-5% 4 SOLAICE - capsaicin-menthol topical patch 0.05-5% 4 SILVER NITRATE - silver nitrate oint 10% 4 SOLARAZE - diclofenac sodium (actinic keratoses) gel 3% 4 SILVER NITRATE - silver nitrate soln 0.5% 4 SOOLANTRA - ivermectin cream 1% 4 SILVER NITRATE - silver nitrate soln 10% 4 SILVER NITRATE - silver nitrate soln 25% 4 SOOTHEE - lidocaine-capsaicin-menmethyl sal patch 0.5-0.0375-5-20% SORIATANE - acitretin cap 10 mg 4 SILVER NITRATE - silver nitrate soln 50% 4 SORIATANE - acitretin cap 17.5 mg 4 SORIATANE - acitretin cap 25 mg 4 silver nitrate-potassium nitrate applicator 75-25% (Arzol silver nitrate) 1 SORILUX - calcipotriene foam 0.005% 4 SPINOSAD - spinosad susp 0.9% 4 1 STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 silver sulfadiazine cream 1% (Silvadene) • • 4 STELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 SILVERA PAIN RELIEF - capsaicinlidocaine-menthol patch 0.0375-1-5% • • 4 sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit (Sumadan kit) 2 SILVERSEAL HYDROGEL DRESS silver - pad 2"x3" SILVERSEAL HYDROGEL DRESS silver - pad 4"x5" 4 2 SILVRSTAT WOUND DRESSING silver - gel 4 sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit (Sumadan xlt) SINELEE - capsaicin-menthol topical patch 0.0375-5% sulfacetamide sodium cleansing gel 10% (Ovace plus wash) 2 4 158 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 sulfacetamide sodium liquid 10% (Ovace wash) 2 SULFOAM - sulfur shampoo 2% 4 sulfacetamide sodium lotion 10% (acne) (Klaron) SULFURATED LIME - sulfurated lime solution 4 2 sulfacetamide sodium shampoo 10% (Ovace plus) SUMADAN KIT - sulfacetamide sodsulfur wash 9-4.5% & skin cleanser kit 4 2 sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion cleanser) 2 SUMADAN WASH - sulfacetamide sodium w/ sulfur wash 9-4.5% 4 sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser) 2 SUMADAN XLT - sulfacetamide sodsulfur wash 9-4.5% & sunscreen kit 4 sulfacetamide sodium w/ sulfur cleansing cloth 10-5% 2 SUMAXIN - sulfacetamide sodium w/ sulfur cleansing pad 10-4% 4 sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin) 2 SUMAXIN CP KIT - sulfacetamide sodsulfur pad 10-4% & skin cleanser kit 4 sulfacetamide sodium w/ sulfur cream 9.8-4.8% (Plexion) 2 sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls) 2 sulfacetamide sodium w/ sulfur cream 10-5% 2 sulfacetamide sodium w/ sulfur emulsion 10-1% 2 sulfacetamide sodium w/ sulfur emulsion 10-5% 2 sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam ef) 2 sulfacetamide sodium w/ sulfur lotion 9.8-4.8% (Plexion) 2 sulfacetamide sodium w/ sulfur lotion 10-5% 2 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts) 2 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash) 2 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash) 2 SULFAMYLON - mafenide acetate packet for topical soln 5% (50 gm) 4 SULFAMYLON - mafenide acetate cream 85 mg/gm 4 SUMAXIN TS - sulfacetamide sodium w/ 4 sulfur susp 8-4% 4 SUMAXIN WASH - sulfacetamide sodium w/ sulfur wash 9-4% SYNALAR - fluocinolone acetonide soln 4 0.01% 4 SYNALAR - fluocinolone acetonide cream 0.025% SYNALAR - fluocinolone acetonide oint 4 0.025% 4 SYNALAR CREAM KIT - fluocinolone cream 0.025%-emollient cream kit 4 SYNALAR OINTMENT KIT fluocinolone oint 0.025%-emollient cream kit 4 SYNALAR TS - fluocinolone acetonide soln 0.01% & cleanser kit 4 SYNERA - lidocaine-tetracaine topical patch 70-70 mg 4 SYNVEXIA - lidocaine-menthol patch 4-1% 4 SYNVEXIA TC - lidocaine-menthol cream 4-1% 4 TACLONEX - calcipotrienebetamethasone dipropionate susp 0.005-0.064% BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 159 TACLONEX - calcipotrienebetamethasone dipropionate oint 0.005-0.064% 4 tacrolimus oint 0.03% (Protopic) 2 tacrolimus oint 0.1% (Protopic) 2 TARGRETIN - bexarotene gel 1% 5 TAZORAC - tazarotene cream 0.05% TOPICORT - desoximetasone cream 0.25% 4 TOPICORT - desoximetasone oint 0.05% 4 TOPICORT - desoximetasone oint 0.25% 4 3 TRETIN-X - tretinoin cream 0.075% 4 TAZORAC - tazarotene cream 0.1% 3 4 TAZORAC - tazarotene gel 0.05% 3 TRETIN-X - tretinoin cream 0.025% w/ cleanser & moisturizer kit 3 TRETIN-X - tretinoin cream 0.05% w/ cleanser & moisturizer kit 4 TAZORAC - tazarotene gel 0.1% TEGADERM AG MESH DRESSING wound dressings - pads 4 TRETIN-X - tretinoin cream 0.1% w/ cleanser & moisturizer kit 4 TEMOVATE - clobetasol propionate soln 0.05% 4 tretinoin cream 0.025% (Retin-a) 2 4 tretinoin cream 0.05% (Retin-a) 2 TEMOVATE - clobetasol propionate cream 0.05% tretinoin cream 0.1% (Retin-a) 2 TEMOVATE - clobetasol propionate gel 0.05% 4 tretinoin gel 0.01% (Retin-a) 2 tretinoin gel 0.025% (Retin-a) 2 TEMOVATE - clobetasol propionate oint 0.05% 4 tretinoin microsphere gel 0.04% (Retin-a micro) 2 TEMOVATE E - clobetasol propionate emollient base cream 0.05% 4 tretinoin microsphere gel 0.1% (Retin-a micro) 2 TERSI FOAM - selenium sulfide foam 2.25% 4 TRI-CHLOR - trichloroacetic acid liqd 80% 4 TETRAMEX - tetracaine-mentholcamphor liqd spray 2-1-3% 4 TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint 0.5% 4 TETRIX - dermatological products misc - kit 4 triamcinolone acetonide aerosol soln (Kenalog) 2 TEXACORT - hydrocortisone soln 2.5% 4 1 TL TRISEB - antiseborrheic products misc - cream 4 triamcinolone acetonide cream 0.025% triamcinolone acetonide cream 0.1% 1 TL-CERMIDE - dermatological products misc - emulsion 4 triamcinolone acetonide cream 0.5% 1 4 triamcinolone acetonide lotion 0.025% 2 TOPICORT - desoximetasone spray 0.25% triamcinolone acetonide lotion 0.1% 2 TOPICORT - desoximetasone gel 0.05% 4 triamcinolone acetonide oint 0.025% 1 4 triamcinolone acetonide oint 0.1% 1 TOPICORT - desoximetasone cream 0.05% TRIANEX - triamcinolone acetonide oint 0.05% 4 160 • Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2 trypsin w/ castor oil & peruvian balsam spray (Granulex) 1 urea in lactic acid vehicle foam 35% (Hydro 35) 2 ULESFIA - benzyl alcohol lotion 5% 4 2 ULTRASAL-ER - salicylic acid filmforming soln 28.5% 4 urea in lactic acid-salicylic acid vehicle susp 50% 2 ULTRAVATE - halobetasol propionate cream 0.05% 4 urea in zinc undecylenate-lactic acid vehicle emulsion 50% urea lotion 40% 2 ULTRAVATE - halobetasol propionate oint 0.05% 4 urea lotion 45% (Uramaxin) 2 ULTRAVATE X - halobetasol prop cream 0.05% & lactic acid cream 10% kit 4 ULTRAVATE X - halobetasol prop oint 0.05% & lactic acid cream 10% kit 4 UMECTA - urea emulsion 40% 4 UMECTA - urea suspension 40% 4 UMECTA NAIL FILM - urea suspension 40% 4 UMECTA PD - urea-hyaluronate sodium 4 emulsion 40-0.3% UMECTA PD - urea-hyaluronate sodium 4 susp 40-0.3% 4 URAMAXIN - urea lotion 45% Dispensing Limits urea gel 45% (Uramaxin) Step Therapy 4 Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy TROPAZONE - emollient - lotion Prior Authorization Drug Name Drug Tier 2015 UREA NAIL - urea in zinc undecylenate- 4 lactic acid vehicle stick 50% 4 UREA NAIL KIT - urea susp 40% & hyaluronate sodium gel 0.2% kit 2 urea suspension 40% (Umecta) UREVAZ - urea cream 44% 4 UTOPIC - urea cream 41% 4 VALCHLOR - mechlorethamine hcl gel 0.016% (base equivalent) 5 VANOS - fluocinonide cream 0.1% 4 VANOXIDE-HC - benzoyl peroxide-hc lotion 5-0.5% 4 VASCUDERM STASIS KIT - wound dressings - kit 4 VECTICAL - calcitriol oint 3 mcg/gm 4 VELMA PAIN RELIEF - methyl salicylate-lidocaine-menthol patch 16-4-2% 4 URAMAXIN - urea in ammonium lactate vehicle foam 20% 4 URAMAXIN - urea cream 45% 4 URAMAXIN - urea gel 45% 4 URAMAXIN GT - urea gel 45% VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025% 4 4 URAMAXIN GT KIT - urea gel 45% & emollient cream kit 4 VENELEX - balsam peru-castor oil oint 4 VERDESO - desonide foam 0.05% 4 urea cream 39% (Aluvea) 2 VEREGEN - sinecatechins oint 15% 4 urea cream 40% 2 2 VEXA - allantoin-lidocaine-petrolatum patch 2-4-30% 4 urea cream 45% (Uramaxin) urea cream 47% (Keralac) 2 4 urea cream 50% 2 VIRASAL - salicylic acid film forming liquid 27.5% urea foam 40% (Hydro 40 foam) 2 VOLTAREN - diclofenac sodium gel 1% 4 urea gel 40% 2 VUSION - miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35% 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • 161 VYTONE - iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9% 4 WESTCORT - hydrocortisone valerate oint 0.2% 4 WITCH HAZEL - witch hazel (hamamelis virginiana) liqd (hamamelis water) 4 wound dressings - cream 2 XCLAIR - dermatological products misc - cream 4 XENADERM - trypsin w/ castor oil & peruvian balsam oint XOLEGEL DUO/XOLEX - ketoconazole gel 2% & pyrithione zinc shampoo 1% kit 4 XYLOCAINE - lidocaine hcl soln 4% 4 XYPHEX - capsaicin-menthol disk 0.0375-5% 4 ZACARE 4% KIT - benzoyl peroxide lotion 4% & hyaluronate sodium gel 0.2% kit 4 4 4 ZACARE 8% KIT - benzoyl peroxide lotion 8% & hyaluronate sodium gel 0.2% kit XERAC AC - aluminum chloride in alcohol solution 6.25% 4 ZACLIR CLEANSING - benzoyl peroxide lotion 8% 4 XERESE - acyclovir-hydrocortisone cream 5-1% 4 ZENATANE - isotretinoin cap 30 mg 4 4 XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum dressing pads 4 ZERUVIA - lidocaine-menthol patch 4-1% XEROFORM NON-OCCLUSIVE OI bismuth tribromophenate-petrolatum dressing - misc 4 ZIANA - clindamycin phosphate-tretinoin 4 gel 1.2-0.025% 4 ZITHRANOL - anthralin shampoo 1% XEROFORM OCCLUSIVE PETROL bismuth tribromophenate-petrolatum dressing pads 4 XEROFORM OCCLUSIVE PETROL bismuth tribromophenate-petrolatum dressing - misc 4 XEROFORM PETROLATUM DRESS bismuth tribromophenate-petrolatum dressing pads 4 XEROFORM PETROLATUM DRESS bismuth tribromophenate-petrolatum dressing - misc 4 XOLEGEL - ketoconazole gel 2% 4 XOLEGEL COREPAK - ketoconazole gel 2% & hydrocortisone gel 1% kit XOLEGEL DUO/HEAD & SHOULD ketoconazole gel 2% & pyrithione zinc shampoo 1% kit 162 Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Drug Name Prior Authorization Drug Tier 2015 ZITHRANOL-RR - anthralin cream 1.2% 4 ZONALON - doxepin hcl cream 5% 4 ZOVIRAX - acyclovir cream 5% 4 ZOVIRAX - acyclovir oint 5% 4 ZYCLARA - imiquimod cream 3.75% 4 ZYCLARA PUMP - imiquimod cream 2.5% 4 • • ZYCLARA PUMP - imiquimod cream 3.75% 4 • 8-MOP - methoxsalen cap 10 mg 4 MISCELLANEOUS PRODUCTS ANTISEPTICS & DISINFECTANTS 4 4 ANASEPT - sodium hypochlorite liquid 0.057% 4 4 BENZALKONIUM CHLORIDE benzalkonium chloride soln BENZALKONIUM CHLORIDE benzalkonium chloride soln 50% 4 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 Dispensing Limits 4 Step Therapy REVIA - naltrexone hcl tab 50 mg Prior Authorization Drug Name Drug Tier Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2015 FORMA-RAY - formaldehyde solution 20% 4 formaldehyde solution 10% 2 • GLUTARALDEHYDE - glutaral soln 25% ASCENSIA AUTODISC TEST ST glucose blood test disk 2 4 2 • IODINE TINCTURE - iodine tincture 4 BAYER BREEZE 2 TEST DISC glucose blood test disk IODINE TINCTURE MILD - iodine tincture 4 BAYER CONTOUR BLOOD GLUCO glucose blood test strip 2 • IODINE TINCTURE STRONG - iodine tincture strong 4 BAYER CONTOUR NEXT BLOOD glucose blood test strip 2 • IODINE TINCTURE STRONG DE iodine tincture strong 4 4 KERR TRIPLE DYE - triple dye swabs 4 GLUCAGEN DIAGNOSTIC - glucagon hcl (rdna) diagnostic for inj 1 mg (base equiv) LUGOLS STRONG IODINE - iodine solution 4 GLUCOSE BLOOD TEST STRIPS – VARIOUS 4 TRIPLE DYE - triple dye solution 4 KETONE BLOOD TEST STRIPS – VARIOUS 4 URINE TEST STRIPS – VARIOUS 4 DIAGNOSTIC PRODUCTS ANTIDOTES CHEMET - succimer cap 100 mg 3 EVZIO - naloxone hcl solution autoinjector 0.4 mg/0.4ml 4 EXJADE - deferasirox tab for oral susp 125 mg 5 • EXJADE - deferasirox tab for oral susp 250 mg 5 • EXJADE - deferasirox tab for oral susp 500 mg 5 FERRIPROX - deferiprone tab 500 mg 5 JADENU - deferasirox tab 90 mg 5 JADENU - deferasirox tab 180 mg 5 JADENU - deferasirox tab 360 mg 5 naltrexone hcl tab 50 mg (Revia) 2 PENTETATE CALCIUM TRISODI pentetate calcium trisodium iv or inhalation soln 200 mg/ml 4 PENTETATE ZINC TRISODIUM pentetate zinc trisodium iv or inhalation soln 200 mg/ml 4 RADIOGARDASE - prussian blue insoluble cap 0.5 gm 4 • • ALTERNATIVE MEDICINES CITRUS BERGAMOT - citrus bergamot oral powder 250 mg/0.25 gm 4 QUINZYME - coenzyme q10 tab disp 90 4 mg MEDICAL DEVICES • • BLOOD GLUCOSE CALIBRATION LIQUID – VARIOUS 4 HURRISEAL - dental desensitizing product - solution 4 INSULIN PEN NEEDLES-VARIOUS 3 INSULIN SYRINGES-VARIOUS 4 LANCETS-VARIOUS 3 RESPIRATORY THERAPY SUPPLIES – VARIOUS 4 SPACERS – VARIOUS 4 SANARE SCAR THERAPY - cream base 4 • • ASSORTED CLASSES ASTAGRAF XL - tacrolimus cap sr 24hr 0.5 mg BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 4 • 163 • ATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/ml(eq) 4 AZASAN - azathioprine tab 75 mg 4 AZASAN - azathioprine tab 100 mg 4 azathioprine tab 50 mg (Imuran) 2 CELLCEPT - mycophenolate mofetil cap 4 250 mg CELLCEPT - mycophenolate mofetil tab 4 500 mg CELLCEPT - mycophenolate mofetil for 3 oral susp 200 mg/ml CUPRIMINE - penicillamine cap 250 mg 5 cyclosporine cap 25 mg (Sandimmune) 2 cyclosporine cap 100 mg (Sandimmune) 2 CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg 3 cyclosporine modified cap 25 mg (Neoral) 2 cyclosporine modified cap 100 mg (Neoral) 2 cyclosporine modified oral soln 100 mg/ml (Neoral) 2 DEPEN TITRATABS - penicillamine tab 250 mg 5 IMURAN - azathioprine tab 50 mg 4 KAYEXALATE - sodium polystyrene sulfonate powder 4 mycophenolate mofetil cap 250 mg (Cellcept) • mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic) 2 MYFORTIC - mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) 4 MYFORTIC - mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) 4 NEORAL - cyclosporine modified oral soln 100 mg/ml 4 NEORAL - cyclosporine modified cap 25 4 mg 4 NEORAL - cyclosporine modified cap 100 mg 4 PROGRAF - tacrolimus cap 0.5 mg PROGRAF - tacrolimus cap 1 mg 4 PROGRAF - tacrolimus cap 5 mg 4 RAPAMUNE - sirolimus oral soln 1 mg/ ml 3 RAPAMUNE - sirolimus tab 0.5 mg 4 RAPAMUNE - sirolimus tab 1 mg 3 RAPAMUNE - sirolimus tab 2 mg 3 REVLIMID - lenalidomide caps 2.5 mg 5 REVLIMID - lenalidomide cap 5 mg 5 REVLIMID - lenalidomide cap 10 mg 5 REVLIMID - lenalidomide cap 15 mg 5 REVLIMID - lenalidomide cap 20 mg 5 REVLIMID - lenalidomide cap 25 mg 5 2 SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 2 SANDIMMUNE - cyclosporine cap 25 mg 4 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 2 SANDIMMUNE - cyclosporine cap 100 mg 4 mycophenolate mofetil tab 500 mg (Cellcept) sirolimus tab 0.5 mg (Rapamune) 2 164 • Dispensing Limits 4 2 Step Therapy ASTAGRAF XL - tacrolimus cap sr 24hr 5 mg mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic) Prior Authorization • Drug Name Drug Tier 4 Dispensing Limits Prior Authorization ASTAGRAF XL - tacrolimus cap sr 24hr 1 mg Drug Name Step Therapy Drug Tier 2015 • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 • • • • • • sirolimus tab 2 mg (Rapamune) 2 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps) 2 sodium polystyrene sulfonate powder (Kayexalate) 2 sodium polystyrene sulfonate rectal susp 30 gm/120ml 2 SPS - sodium polystyrene sulfonate oral susp 15 gm/60ml 4 SYPRINE - trientine hcl cap 250 mg 5 tacrolimus cap 0.5 mg (Prograf) 2 tacrolimus cap 1 mg (Prograf) 2 tacrolimus cap 5 mg (Prograf) 2 THALOMID - thalidomide cap 50 mg 5 THALOMID - thalidomide cap 100 mg 5 THALOMID - thalidomide cap 150 mg 5 THALOMID - thalidomide cap 200 mg 5 ZORTRESS - everolimus tab 0.25 mg 4 ZORTRESS - everolimus tab 0.5 mg 4 ZORTRESS - everolimus tab 0.75 mg 4 Dispensing Limits 2 Step Therapy sirolimus tab 1 mg (Rapamune) Prior Authorization Drug Name Drug Tier 2015 • • • • • • • • • BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 165 2015 INDEX 8-MOP -methoxsalen cap 10 mg.....................................162 A abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir)................................................. 7 abacavir sulfate tab 300 mg (base equiv) (Ziagen)......... 7 ABANEU-SL -cyanocobalamin-methylcobalamin tab sl 600-600 mcg.................................................................. 128 ABILIFY -aripiprazole tab 10 mg....................................... 81 ABILIFY -aripiprazole tab 15 mg....................................... 81 ABILIFY -aripiprazole tab 20 mg....................................... 81 ABILIFY -aripiprazole tab 2 mg......................................... 81 ABILIFY -aripiprazole tab 30 mg....................................... 81 ABILIFY -aripiprazole tab 5 mg......................................... 81 ABSORICA -isotretinoin cap 10 mg.................................144 ABSORICA -isotretinoin cap 20 mg.................................144 ABSORICA -isotretinoin cap 25 mg.................................144 ABSORICA -isotretinoin cap 30 mg.................................144 ABSORICA -isotretinoin cap 35 mg.................................144 ABSORICA -isotretinoin cap 40 mg.................................144 ABSTRAL -fentanyl citrate sl tab 100 mcg (base equiv)................................................................................93 ABSTRAL -fentanyl citrate sl tab 200 mcg (base equiv)................................................................................93 ABSTRAL -fentanyl citrate sl tab 300 mcg (base equiv)................................................................................93 ABSTRAL -fentanyl citrate sl tab 400 mcg (base equiv)................................................................................94 ABSTRAL -fentanyl citrate sl tab 600 mcg (base equiv)................................................................................94 ABSTRAL -fentanyl citrate sl tab 800 mcg (base equiv)................................................................................94 acamprosate calcium tab delayed release 333 mg (Campral).........................................................................89 ACANYA -clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%......................................................................... 144 acarbose tab 100 mg (Precose)..................................... 27 acarbose tab 25 mg (Precose)....................................... 27 acarbose tab 50 mg (Precose)....................................... 27 ACCOLATE -zafirlukast tab 10 mg....................................62 ACCOLATE -zafirlukast tab 20 mg....................................62 ACCUPRIL -quinapril hcl tab 10 mg..................................45 ACCUPRIL -quinapril hcl tab 20 mg..................................45 ACCUPRIL -quinapril hcl tab 40 mg..................................45 ACCUPRIL -quinapril hcl tab 5 mg....................................45 ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5 mg.................................................................................... 45 ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5 mg.................................................................................... 45 ACCURETIC -quinapril-hydrochlorothiazide tab 20-25 mg.................................................................................... 45 acebutolol hcl cap 200 mg (Sectral).............................. 40 acebutolol hcl cap 400 mg (Sectral).............................. 40 166 ACEON -perindopril erbumine tab 4 mg............................45 ACEON -perindopril erbumine tab 8 mg............................45 acetaminophen-isometheptene-dichloral cap 325-65-100 mg.............................................................. 104 acetaminophen-salicylamide-phenyltoloxamine cap 300-200-20mg..................................................................93 acetaminophen w/ codeine soln 120-12 mg/5ml........... 94 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine)...........................................................................94 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3)..................................................................... 94 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4)..................................................................... 94 ACETAZOLAMIDE -acetazolamide tab 125 mg................ 52 acetazolamide cap sr 12hr 500 mg (Diamox)................ 52 acetazolamide tab 250 mg.............................................. 52 ACETIC ACID/ALUMINUM ACET -acetic acid 2% in aluminum acetate otic soln............................................ 141 acetic acid otic soln 2%................................................141 acetylcysteine cap 600 mg........................................... 126 acetylcysteine inhal soln 10%........................................ 59 acetylcysteine inhal soln 20%........................................ 59 ACIPHEX -rabeprazole sodium ec tab 20 mg................... 66 ACIPHEX SPRINKLE -rabeprazole sodium capsule sprinkle dr 10 mg.............................................................66 ACIPHEX SPRINKLE -rabeprazole sodium capsule sprinkle dr 5 mg...............................................................66 acitretin cap 10 mg (Soriatane).................................... 144 acitretin cap 17.5 mg (Soriatane)................................. 144 acitretin cap 25 mg (Soriatane).................................... 144 ACLOVATE -alclometasone dipropionate cream 0.05%............................................................................. 144 ACTEMRA -tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml.................................................... 101 ACTHAR HP -corticotropin inj gel 80 unit/ml..................... 35 ACTICLATE -doxycycline hyclate tab 150 mg.....................3 ACTICLATE -doxycycline hyclate tab 75 mg.......................3 ACTIGALL -ursodiol cap 300 mg...................................... 70 ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)........................................................ 16 ACTIQ -fentanyl citrate lozenge on a handle 1200 mcg...................................................................................94 ACTIQ -fentanyl citrate lozenge on a handle 1600 mcg...................................................................................94 ACTIQ -fentanyl citrate lozenge on a handle 200 mcg...... 94 ACTIQ -fentanyl citrate lozenge on a handle 400 mcg...... 94 ACTIQ -fentanyl citrate lozenge on a handle 600 mcg...... 94 ACTIQ -fentanyl citrate lozenge on a handle 800 mcg...... 94 ACTIVE FE -fe carbonyl-fa-b complex-a-c-d-e-min tab 75-1.25 mg.....................................................................128 ACTIVELLA -estradiol & norethindrone acetate tab 0.5-0.1 mg.................................................................................... 22 ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5 mg.................................................................................... 22 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg.................................................................................. 115 ACTIVE-PAC/GABAPENTIN -gabapentin oral cap 300 mg & lidocaine-menthol gel ther pk....................................... 89 ACTONEL -risedronate sodium tab 150 mg......................35 ACTONEL -risedronate sodium tab 30 mg........................35 ACTONEL -risedronate sodium tab 35 mg........................35 ACTONEL -risedronate sodium tab 5 mg..........................35 ACTOPLUS MET -pioglitazone hcl-metformin hcl tab 15-500 mg........................................................................27 ACTOPLUS MET -pioglitazone hcl-metformin hcl tab 15-850 mg........................................................................27 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr 24hr 15-1000 mg............................................................. 27 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr 24hr 30-1000 mg............................................................. 27 ACTOS -pioglitazone hcl tab 15 mg (base equiv)..............27 ACTOS -pioglitazone hcl tab 30 mg (base equiv)..............27 ACTOS -pioglitazone hcl tab 45 mg (base equiv)..............27 ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse 0.02%............................................................................. 142 ACUICYN DAILY EYELID & EY -eyelid cleansers liquid............................................................................... 145 ACULAR -ketorolac tromethamine ophth soln 0.5%........137 ACULAR LS -ketorolac tromethamine ophth soln 0.4%............................................................................... 137 ACUVAIL -ketorolac tromethamine ophth soln 0.45%..... 137 acyclovir cap 200 mg (Zovirax)........................................ 7 acyclovir oint 5% (Zovirax)........................................... 145 acyclovir susp 200 mg/5ml (Zovirax)...............................7 acyclovir tab 400 mg (Zovirax).........................................7 acyclovir tab 800 mg (Zovirax).........................................7 ACZONE -dapsone gel 5%............................................. 145 ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml.........................................................................15 ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 42 ADALAT CC -nifedipine tab sr 24hr 60 mg....................... 42 ADALAT CC -nifedipine tab sr 24hr 90 mg....................... 42 ADAPALENE -adapalene lotion 0.1%............................. 145 adapalene cream 0.1% (Differin).................................. 145 adapalene gel 0.1% (Differin)........................................145 adapalene gel 0.3% (Differin)........................................145 ADASUVE -loxapine aerosol powder breath activated 10 mg.................................................................................... 81 ADAZIN -benzo-capsaicin-lido-methyl salicylate cream 2-0.035-2-10%................................................................145 ADCIRCA -tadalafil tab 20 mg (pah)................................. 57 ADDERALL -amphetamine-dextroamphetamine tab 10 mg.................................................................................... 85 ADDERALL -amphetamine-dextroamphetamine tab 12.5 mg.................................................................................... 85 ADDERALL -amphetamine-dextroamphetamine tab 15 mg.................................................................................... 85 ADDERALL -amphetamine-dextroamphetamine tab 20 mg.................................................................................... 85 ADDERALL -amphetamine-dextroamphetamine tab 30 mg.................................................................................... 85 ADDERALL -amphetamine-dextroamphetamine tab 5 mg.................................................................................... 85 ADDERALL -amphetamine-dextroamphetamine tab 7.5 mg.................................................................................... 85 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 10 mg...................................................................... 85 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 15 mg...................................................................... 85 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 20 mg...................................................................... 85 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 25 mg...................................................................... 86 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 30 mg...................................................................... 86 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 5 mg........................................................................ 85 adefovir dipivoxil tab 10 mg (Hepsera)........................... 7 ADEMPAS -riociguat tab 0.5 mg....................................... 57 ADEMPAS -riociguat tab 1.5 mg....................................... 57 ADEMPAS -riociguat tab 1 mg.......................................... 57 ADEMPAS -riociguat tab 2.5 mg....................................... 57 ADEMPAS -riociguat tab 2 mg.......................................... 57 ADOXA -doxycycline monohydrate cap 150 mg..................3 ADOXA -doxycycline monohydrate tab 100 mg.................. 3 ADOXA -doxycycline monohydrate tab 50 mg.................... 3 ADOXA -doxycycline monohydrate tab 75 mg.................... 3 ADOXA PAK 1/100 -doxycycline monohydrate tab 100 mg...................................................................................... 3 ADOXA PAK 1/150 -doxycycline monohydrate tab 150 mg...................................................................................... 4 ADOXA PAK 2/100 -doxycycline monohydrate tab 100 mg...................................................................................... 4 ADRENACLICK -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000).......................................................... 53 ADRENACLICK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................53 ADRENAL C FORMULA -bioflavonoid products tab........115 ADRENALIN -epinephrine hcl nasal soln 0.1%................. 59 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 100-50 mcg/dose............................................................. 62 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 250-50 mcg/dose............................................................. 62 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 500-50 mcg/dose............................................................. 62 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21 mcg/act.............................................................................62 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21 mcg/act.............................................................................62 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21 mcg/act.............................................................................62 ADVANCED ALLERGY COLLECTI -hydrocortisone cream kit 2.5%.......................................................................... 145 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 167 2015 ADVANCED AM/PM -multiple vitamins w/ calcium therapy pack................................................................................115 ADVATE -antihemophilic factor rahf-pfm for inj 1000 unit..................................................................................133 ADVATE -antihemophilic factor rahf-pfm for inj 1500 unit..................................................................................133 ADVATE -antihemophilic factor rahf-pfm for inj 2000 unit..................................................................................133 ADVATE -antihemophilic factor rahf-pfm for inj 250 unit..................................................................................133 ADVATE -antihemophilic factor rahf-pfm for inj 3000 unit..................................................................................133 ADVATE -antihemophilic factor rahf-pfm for inj 4000 unit..................................................................................133 ADVATE -antihemophilic factor rahf-pfm for inj 500 unit..................................................................................133 ADVICOR -niacin-lovastatin tab sr 24hr 1000-20 mg........ 54 ADVICOR -niacin-lovastatin tab sr 24hr 1000-40 mg........ 54 ADVICOR -niacin-lovastatin tab sr 24hr 500-20 mg.......... 54 ADVICOR -niacin-lovastatin tab sr 24hr 750-20 mg.......... 54 AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act....... 62 AFINITOR DISPERZ -everolimus tab for oral susp 2 mg.................................................................................... 16 AFINITOR DISPERZ -everolimus tab for oral susp 3 mg.................................................................................... 16 AFINITOR DISPERZ -everolimus tab for oral susp 5 mg.................................................................................... 16 AFINITOR -everolimus tab 10 mg..................................... 16 AFINITOR -everolimus tab 2.5 mg.................................... 16 AFINITOR -everolimus tab 5 mg....................................... 16 AFINITOR -everolimus tab 7.5 mg.................................... 16 AFLURIA 2011-2012 -influenza virus vaccine split im susp..................................................................................13 AFLURIA 2012-2013 -influenza virus vaccine split im susp..................................................................................13 AFLURIA 2013-2014 -influenza virus vaccine split im susp..................................................................................13 AFLURIA 2014-2015 -influenza virus vaccine split im susp..................................................................................13 AFLURIA 2015-2016 -influenza virus vaccine split im susp..................................................................................13 AFLURIA PF 2011-2012 -influenza virus vaccine split pf susp pref syringe 0.5 ml.................................................. 12 AFLURIA PF 2012-2013 -influenza virus vaccine split pf susp pref syringe 0.5 ml.................................................. 12 AFLURIA PF 2013-2014 -influenza virus vaccine split pf susp pref syringe 0.5 ml.................................................. 12 AFLURIA PF 2014-2015 -influenza virus vaccine split pf susp pref syringe 0.5 ml.................................................. 13 AFLURIA PF 2015-2016 -influenza virus vaccine split pf susp pref syringe 0.5 ml.................................................. 13 AFREZZA -insulin regular (human) inhalation powder 4 unit/cartridge.....................................................................32 AFREZZA -insulin regular (human) inhal powd 4 (30) & 8 (60) unit/cart.....................................................................32 168 AFREZZA -insulin regular (human) inhal powd 4 (60) & 8 (30) unit/cart.....................................................................32 AFREZZA -insulin regular (human) inh powd 8 (60) & 12 (30) unit/cart.....................................................................32 AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200 mg.................................................................................. 133 AGRYLIN -anagrelide hcl cap 0.5 mg............................. 133 AKTEN -lidocaine hcl ophth gel 3.5%............................. 137 AKYNZEO -netupitant-palonosetron cap 300-0.5 mg........ 69 ALA QUIN -clioquinol-hc cream 3-0.5%.......................... 145 ALA SCALP -hydrocortisone lotion 2%........................... 145 ALBENZA -albendazole tab 200 mg................................. 11 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 62 albuterol sulfate soln nebu 0.5% (5 mg/ml)...................62 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)...............................................................................62 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)...............................................................................62 albuterol sulfate syrup 2 mg/5ml................................... 62 albuterol sulfate tab 2 mg...............................................62 albuterol sulfate tab 4 mg...............................................62 albuterol sulfate tab sr 12hr 4 mg (Vospire er)............. 62 albuterol sulfate tab sr 12hr 8 mg (Vospire er)............. 62 ALCAINE -proparacaine hcl ophth soln 0.5%..................137 alclometasone dipropionate cream 0.05% (Aclovate)...................................................................... 145 alclometasone dipropionate oint 0.05%...................... 145 ALCORTIN A -iodoquinol-hydrocortisone-aloe polysaccharide gel 1-2-1%.............................................145 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab 25-25 mg..........................................................................52 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab 50-50 mg..........................................................................52 ALDACTONE -spironolactone tab 100 mg........................ 52 ALDACTONE -spironolactone tab 25 mg.......................... 52 ALDACTONE -spironolactone tab 50 mg.......................... 52 ALDARA -imiquimod cream 5%...................................... 145 ALEGENIX -capsaicin-menthol disk 0.0375-5%.............. 145 ALENDRONATE SODIUM -alendronate sodium oral soln 70 mg/75ml...................................................................... 35 ALENDRONATE SODIUM -alendronate sodium tab 40 mg.................................................................................... 35 alendronate sodium tab 10 mg...................................... 35 alendronate sodium tab 35 mg...................................... 35 alendronate sodium tab 5 mg........................................ 35 alendronate sodium tab 70 mg (Fosamax)....................35 ALEVEER -capsaicin-menthol topical patch 0.0375-5%...................................................................... 145 ALEVICYN DERMAL SPRAY -wound dressings soln.................................................................................145 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)...................74 ALINIA -nitazoxanide for susp 100 mg/5ml....................... 11 ALINIA -nitazoxanide tab 500 mg......................................11 ALKERAN -melphalan tab 2 mg........................................16 ALLEVYN AG ADHESIVE -wound dressings - pads....... 145 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 ALLEVYN AG GENTLE BORDER -wound dressings pads................................................................................145 ALLEVYN AG NON-ADHESIVE -wound dressings pads................................................................................145 ALLEVYN AG SACRUM -wound dressings - pads..........145 ALLEVYN GENTLE -wound dressings - pads................. 145 allopurinol tab 100 mg (Zyloprim)................................106 allopurinol tab 300 mg (Zyloprim)................................106 almotriptan malate tab 12.5 mg (Axert)....................... 104 almotriptan malate tab 6.25 mg (Axert)....................... 104 ALOCRIL -nedocromil sodium ophth soln 2%................. 137 ALOMIDE -lodoxamide tromethamine ophth soln 0.1%............................................................................... 137 ALOQUIN -iodoquinol-aloe polysaccharides gel 1.25-1%.......................................................................... 145 ALORA -estradiol td patch twice weekly 0.025 mg/24hr............................................................................ 22 ALORA -estradiol td patch twice weekly 0.05 mg/24hr...... 22 ALORA -estradiol td patch twice weekly 0.075 mg/24hr............................................................................ 22 ALORA -estradiol td patch twice weekly 0.1 mg/24hr........22 alosetron hcl tab 0.5 mg (base equiv) (Lotronex)......... 70 alosetron hcl tab 1 mg (base equiv) (Lotronex)............ 70 ALPHAGAN P -brimonidine tartrate ophth soln 0.1%...... 137 ALPHAGAN P -brimonidine tartrate ophth soln 0.15%............................................................................. 137 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 1000 unit......................................... 133 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 1500 unit......................................... 133 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 2000 unit......................................... 134 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 250 unit........................................... 133 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 500 unit........................................... 133 ALPHANINE SD -coagulation factor ix for inj 1000 unit..................................................................................134 ALPHANINE SD -coagulation factor ix for inj 1500 unit..................................................................................134 ALPHANINE SD -coagulation factor ix for inj 500 unit..... 134 ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ml......75 alprazolam orally disintegrating tab 0.25 mg (Niravam).........................................................................75 alprazolam orally disintegrating tab 0.5 mg..................75 alprazolam orally disintegrating tab 1 mg.....................75 alprazolam orally disintegrating tab 2 mg.....................75 alprazolam tab 0.25 mg (Xanax).....................................75 alprazolam tab 0.5 mg (Xanax).......................................75 alprazolam tab 1 mg (Xanax)..........................................75 alprazolam tab 2 mg (Xanax)..........................................75 alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 75 alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 75 alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 75 alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 75 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 1000 unit........................................................................ 134 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 2000 unit........................................................................ 134 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 3000 unit........................................................................ 134 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 500 unit.......................................................................... 134 ALREX -loteprednol etabonate ophth susp 0.2%............ 137 ALSUMA -sumatriptan succinate solution auto-injector 6 mg/0.5ml.........................................................................104 ALTABAX -retapamulin oint 1%...................................... 145 ALTACE -ramipril cap 1.25 mg......................................... 45 ALTACE -ramipril cap 10 mg............................................ 45 ALTACE -ramipril cap 2.5 mg........................................... 45 ALTACE -ramipril cap 5 mg.............................................. 45 ALTOPREV -lovastatin tab sr 24hr 20 mg.........................54 ALTOPREV -lovastatin tab sr 24hr 40 mg.........................54 ALTOPREV -lovastatin tab sr 24hr 60 mg.........................54 ALUMINUM ACETATE -aluminum acetate soln.............. 145 ALUVEA -urea cream 39%..............................................145 ALVESCO -ciclesonide inhal aerosol 160 mcg/act............ 62 ALVESCO -ciclesonide inhal aerosol 80 mcg/act.............. 62 ALZ-NAC -l-methylfolate-methylcobalamin-acetylcyst tab 6-2-600 mg.....................................................................126 AMANTADINE HCL -amantadine hcl tab 100 mg............111 amantadine hcl cap 100 mg......................................... 111 amantadine hcl syrup 50 mg/5ml................................. 111 AMARYL -glimepiride tab 1 mg......................................... 27 AMARYL -glimepiride tab 2 mg......................................... 27 AMARYL -glimepiride tab 4 mg......................................... 27 AMBIEN CR -zolpidem tartrate tab cr 12.5 mg..................84 AMBIEN CR -zolpidem tartrate tab cr 6.25 mg..................84 AMBIEN -zolpidem tartrate tab 10 mg...............................84 AMBIEN -zolpidem tartrate tab 5 mg.................................84 AMCINONIDE -amcinonide cream 0.1%......................... 145 AMCINONIDE -amcinonide lotion 0.1%.......................... 145 AMCINONIDE -amcinonide oint 0.1%............................. 145 AMERGE -naratriptan hcl tab 1 mg (base equiv)............ 104 AMERGE -naratriptan hcl tab 2.5 mg (base equiv)..........104 AMICAR -aminocaproic acid oral soln 0.25 gm/ml.......... 133 AMICAR -aminocaproic acid syrup 25%......................... 133 AMICAR -aminocaproic acid tab 1000 mg...................... 133 AMICAR -aminocaproic acid tab 500 mg........................ 133 amiloride & hydrochlorothiazide tab 5-50 mg............... 52 amiloride hcl tab 5 mg.................................................... 52 AMINOBENZOATE POTASSIUM -potassium aminobenzoate packet 2 gm..........................................115 AMINOCAPROIC ACID -aminocaproic acid tab 1000 mg.................................................................................. 133 amiodarone hcl tab 100 mg............................................44 amiodarone hcl tab 200 mg (Cordarone).......................44 amiodarone hcl tab 400 mg............................................44 AMITIZA -lubiprostone cap 24 mcg...................................70 AMITIZA -lubiprostone cap 8 mcg.....................................70 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 169 2015 amitriptyline hcl tab 100 mg...........................................76 amitriptyline hcl tab 10 mg.............................................76 amitriptyline hcl tab 150 mg........................................... 76 amitriptyline hcl tab 25 mg.............................................76 amitriptyline hcl tab 50 mg.............................................76 amitriptyline hcl tab 75 mg.............................................76 amlodipine besylate-atorvastatin calcium tab 10-10 mg (Caduet)...........................................................................57 amlodipine besylate-atorvastatin calcium tab 10-20 mg (Caduet)...........................................................................57 amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet)...........................................................................57 amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet)...........................................................................57 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet).................................................................... 57 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet).................................................................... 57 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg (Caduet).................................................................... 57 amlodipine besylate-atorvastatin calcium tab 5-10 mg (Caduet)...........................................................................57 amlodipine besylate-atorvastatin calcium tab 5-20 mg (Caduet)...........................................................................57 amlodipine besylate-atorvastatin calcium tab 5-40 mg (Caduet)...........................................................................57 amlodipine besylate-atorvastatin calcium tab 5-80 mg (Caduet)...........................................................................57 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel)............................................................................. 45 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel)............................................................................. 45 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel)............................................................................. 45 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel)............................................................................. 45 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel)............................................................................. 45 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel)............................................................................. 45 amlodipine besylate tab 10 mg (Norvasc)..................... 42 amlodipine besylate tab 2.5 mg (Norvasc).................... 42 amlodipine besylate tab 5 mg (Norvasc).......................42 amlodipine besylate-valsartan tab 10-160 mg (Exforge)..........................................................................45 amlodipine besylate-valsartan tab 10-320 mg (Exforge)..........................................................................45 amlodipine besylate-valsartan tab 5-160 mg (Exforge)..........................................................................45 amlodipine besylate-valsartan tab 5-320 mg (Exforge)..........................................................................45 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)........................................45 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg (Exforge hct)...........................................45 170 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg (Exforge hct)...........................................46 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)..........................................45 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg (Exforge hct)............................................................ 45 AMOXAPINE -amoxapine tab 100 mg.............................. 76 AMOXAPINE -amoxapine tab 150 mg.............................. 76 AMOXAPINE -amoxapine tab 25 mg................................ 76 AMOXAPINE -amoxapine tab 50 mg................................ 76 amoxicillin (trihydrate) cap 250 mg................................. 1 amoxicillin (trihydrate) cap 500 mg................................. 1 amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 200 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 250 mg/5ml.................. 1 amoxicillin (trihydrate) for susp 400 mg/5ml.................. 1 amoxicillin (trihydrate) tab 500 mg.................................. 1 amoxicillin (trihydrate) tab 875 mg.................................. 1 amoxicillin & k clavulanate chew tab 200-28.5 mg......... 1 amoxicillin & k clavulanate chew tab 400-57 mg............ 1 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml...............................................................................1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)...................................................................... 1 amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)..........................................................1 amoxicillin & k clavulanate tab 250-125 mg....................1 amoxicillin & k clavulanate tab 500-125 mg (Augmentin)...................................................................... 1 amoxicillin & k clavulanate tab 875-125 mg (Augmentin)...................................................................... 1 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr)................................................................. 1 AMOXICILLIN -amoxicillin (trihydrate) chew tab 125 mg.....1 AMOXICILLIN -amoxicillin (trihydrate) chew tab 250 mg.....1 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack (Prevpac)............................................................... 66 AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775 mg...................................................................................... 1 amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr)....................................................................86 amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr)....................................................................86 amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr)....................................................................86 amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr)....................................................................86 amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr)....................................................................86 amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr)....................................................................86 amphetamine-dextroamphetamine tab 10 mg (Adderall).........................................................................86 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 amphetamine-dextroamphetamine tab 12.5 mg (Adderall).........................................................................86 amphetamine-dextroamphetamine tab 15 mg (Adderall).........................................................................86 amphetamine-dextroamphetamine tab 20 mg (Adderall).........................................................................86 amphetamine-dextroamphetamine tab 30 mg (Adderall).........................................................................86 amphetamine-dextroamphetamine tab 5 mg (Adderall).........................................................................86 amphetamine-dextroamphetamine tab 7.5 mg (Adderall).........................................................................86 AMPICILLIN -ampicillin for susp 125 mg/5ml...................... 1 AMPICILLIN -ampicillin for susp 250 mg/5ml...................... 1 ampicillin cap 250 mg....................................................... 1 ampicillin cap 500 mg....................................................... 1 AMPYRA -dalfampridine tab sr 12hr 10 mg...................... 89 AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg..............113 AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg..............113 ANACAINE -benzocaine oint 10%...................................145 ANADROL-50 -oxymetholone tab 50 mg.......................... 21 ANAFRANIL -clomipramine hcl cap 25 mg....................... 76 ANAFRANIL -clomipramine hcl cap 50 mg....................... 76 ANAFRANIL -clomipramine hcl cap 75 mg....................... 76 anagrelide hcl cap 0.5 mg (Agrylin).............................134 anagrelide hcl cap 1 mg............................................... 134 ANALPRAM ADVANCED -hc-pramoxine cr & diet manage prod tab & cleans wipe kit............................................. 143 ANALPRAM E -hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit...................................................143 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal cream 1-1%..........................................................144 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%.......................................................144 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1%...........................................................144 ANALPRAM-HC SINGLES -hydrocortisone acetate w/ pramoxine rectal cream 1-1%........................................144 ANALPRAM-HC SINGLES -hydrocortisone acetate w/ pramoxine rectal cream 2.5-1%.....................................144 ANAPROX DS -naproxen sodium tab 550 mg................ 101 ANAPROX -naproxen sodium tab 275 mg...................... 101 ANASEPT -sodium hypochlorite liquid 0.057%............... 162 ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg..........66 anastrozole tab 1 mg (Arimidex)....................................16 ANCOBON -flucytosine cap 250 mg................................... 6 ANCOBON -flucytosine cap 500 mg................................... 6 ANDRODERM -testosterone td patch 24hr 2 mg/24hr...... 21 ANDRODERM -testosterone td patch 24hr 4 mg/24hr...... 21 ANDROGEL PUMP -testosterone td gel 12.5 mg/act (1%)..................................................................................21 ANDROGEL PUMP -testosterone td gel 20.25 mg/act (1.62%).............................................................................21 ANDROGEL -testosterone td gel 20.25 mg/1.25gm (1.62%).............................................................................21 ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)........ 21 ANDROGEL -testosterone td gel 40.5 mg/2.5gm (1.62%).............................................................................21 ANDROGEL -testosterone td gel 50 mg/5gm (1%)........... 21 ANDROID -methyltestosterone cap 10 mg........................21 ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg...........22 ANGELIQ -drospirenone-estradiol tab 0.5-1 mg................22 ANIMI-3/VITAMIN D -folic acid-b6-b12-d-omega 3phytosterols cap 1 mg................................................... 128 ANIMI-3 -folic acid-b6-b12-d-omega 3-phytosterols cap 1 mg.................................................................................. 128 ANIMI-3 -folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg............................................................................... 128 ANODYNERX -capsaicin-lidocaine-menthol patch 0.05-2.5-5%....................................................................145 ANODYNZ -capsaicin-menthol disk 0.0375-5%.............. 145 ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh............................................................... 62 ANTABUSE -disulfiram tab 250 mg.................................. 89 ANTABUSE -disulfiram tab 500 mg.................................. 89 ANTARA -fenofibrate micronized cap 30 mg.....................54 ANTARA -fenofibrate micronized cap 90 mg.....................54 ANTIPYRINE/BENZOCAINE -antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)......................................... 141 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%).......................................................................141 antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097% (Treagan otic)....................................141 ANUSOL-HC -hydrocortisone acetate suppos 25 mg......144 ANUSOL-HC -hydrocortisone rectal cream 2.5%............ 144 ANZEMET -dolasetron mesylate tab 100 mg.................... 69 ANZEMET -dolasetron mesylate tab 50 mg...................... 69 APEXICON E -diflorasone diacetate emollient base cream 0.05%............................................................................. 145 APIDRA -insulin glulisine inj 100 unit/ml........................... 31 APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj 100 unit/ml....................................................................... 31 APLENZIN -bupropion hbr tab sr 24hr 174 mg................. 76 APLENZIN -bupropion hbr tab sr 24hr 348 mg................. 76 APLENZIN -bupropion hbr tab sr 24hr 522 mg................. 76 APOKYN -apomorphine hydrochloride inj 10 mg/ml........111 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)....................................................................... 137 APRISO -mesalamine cap sr 24hr 0.375 gm.................... 70 APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg (xr).................................................................................... 86 APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg (xr).................................................................................... 86 APTENSIO XR -methylphenidate hcl cap er 24hr 20 mg (xr).................................................................................... 86 APTENSIO XR -methylphenidate hcl cap er 24hr 30 mg (xr).................................................................................... 86 APTENSIO XR -methylphenidate hcl cap er 24hr 40 mg (xr).................................................................................... 86 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 171 2015 APTENSIO XR -methylphenidate hcl cap er 24hr 50 mg (xr).................................................................................... 86 APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg (xr).................................................................................... 86 APTIOM -eslicarbazepine acetate tab 200 mg................ 106 APTIOM -eslicarbazepine acetate tab 400 mg................ 106 APTIOM -eslicarbazepine acetate tab 600 mg................ 106 APTIOM -eslicarbazepine acetate tab 800 mg................ 106 APTIVUS -tipranavir cap 250 mg........................................ 7 APTIVUS -tipranavir oral soln 100 mg/ml............................7 AQUORAL -artificial saliva - aero soln............................ 142 ARALEN -chloroquine phosphate tab 500 mg...................11 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 100 mcg/0.5ml..............................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 100 mcg/ml...................................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 10 mcg/0.4ml................................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 150 mcg/0.3ml..............................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 200 mcg/0.4ml..............................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 200 mcg/ml...................................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 25 mcg/0.42ml..............................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 25 mcg/ml.................................................... 128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 300 mcg/0.6ml..............................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 300 mcg/ml...................................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 40 mcg/0.4ml................................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 40 mcg/ml.................................................... 128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 500 mcg/ml...................................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 60 mcg/0.3ml................................................128 ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate 80 soln inj 60 mcg/ml.................................................... 128 ARAVA -leflunomide tab 10 mg.......................................101 ARAVA -leflunomide tab 20 mg.......................................101 ARCALYST -rilonacept for inj 220 mg.............................101 ARCAPTA NEOHALER -indacaterol maleate inhal powder cap 75 mcg (base equiv)................................................. 63 ARICEPT -donepezil hydrochloride tab 10 mg.................. 89 ARICEPT -donepezil hydrochloride tab 23 mg.................. 89 ARICEPT -donepezil hydrochloride tab 5 mg.................... 89 ARIMIDEX -anastrozole tab 1 mg..................................... 16 aripiprazole tab 10 mg (Abilify)...................................... 81 aripiprazole tab 15 mg (Abilify)...................................... 81 aripiprazole tab 20 mg (Abilify)...................................... 81 aripiprazole tab 2 mg (Abilify)........................................ 81 172 aripiprazole tab 30 mg (Abilify)...................................... 81 aripiprazole tab 5 mg (Abilify)........................................ 81 ARIXTRA -fondaparinux sodium subcutaneous inj 10 mg/0.8ml.........................................................................131 ARIXTRA -fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml.........................................................................131 ARIXTRA -fondaparinux sodium subcutaneous inj 5 mg/0.4ml.........................................................................131 ARIXTRA -fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml.........................................................................131 ARMOUR THYROID -thyroid tab 120 mg (2 grain)........... 33 ARMOUR THYROID -thyroid tab 15 mg (1/4 grain).......... 33 ARMOUR THYROID -thyroid tab 180 mg (3 grain)........... 33 ARMOUR THYROID -thyroid tab 240 mg (4 grain)........... 33 ARMOUR THYROID -thyroid tab 300 mg (5 grain)........... 33 ARMOUR THYROID -thyroid tab 30 mg (1/2 grain).......... 33 ARMOUR THYROID -thyroid tab 60 mg (1 grain)............. 33 ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)....... 33 ARNUITY ELLIPTA -fluticasone furoate aerosol powder breath activ 100 mcg/act................................................. 63 ARNUITY ELLIPTA -fluticasone furoate aerosol powder breath activ 200 mcg/act................................................. 63 AROMASIN -exemestane tab 25 mg.................................16 ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed release 50-0.2 mg..........................................................101 ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed release 75-0.2 mg..........................................................101 ARZOL SILVER NITRATE APP -silver nitrate-potassium nitrate applicator 75-25%............................................... 145 ASACOL HD -mesalamine tab delayed release 800 mg.................................................................................... 70 ASCENSIA AUTODISC TEST ST -glucose blood test disk................................................................................. 163 ASMANEX HFA -mometasone furoate inhal aerosol suspension 100 mcg/act.................................................. 63 ASMANEX HFA -mometasone furoate inhal aerosol suspension 200 mcg/act.................................................. 63 ASMANEX TWISTHALER 120 ME -mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 63 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 110 mcg/inh (breath activated)...................... 63 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 63 ASMANEX TWISTHALER 60 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated)...................... 63 ASPIRIN/DIPYRIDAMOLE -aspirin-dipyridamole cap sr 12hr 25-200 mg............................................................. 134 ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................... 94 aspirin chew tab 81 mg.................................................. 93 ASPIRIN LOW DOSE -aspirin tab 81 mg..........................93 aspirin tab delayed release 81 mg................................. 93 ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 163 ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 164 ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 164 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/ spray)............................................................................... 59 ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr 29-1 mg..........................................................................115 ATACAND -candesartan cilexetil tab 16 mg......................46 ATACAND -candesartan cilexetil tab 32 mg......................46 ATACAND -candesartan cilexetil tab 4 mg........................46 ATACAND -candesartan cilexetil tab 8 mg........................46 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg................................................................ 46 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg................................................................ 46 ATACAND HCT -candesartan cilexetil-hydrochlorothiazide tab 32-25 mg................................................................... 46 ATELVIA -risedronate sodium tab delayed release 35 mg.................................................................................... 35 ATENDIA -lidocaine-menthol patch 4-3%........................145 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100).................................................................................. 46 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50).................................................................................... 46 atenolol tab 100 mg (Tenormin)..................................... 40 atenolol tab 25 mg (Tenormin)....................................... 40 atenolol tab 50 mg (Tenormin)....................................... 40 ATGAM -lymphocyte immune globulin anti-thymocyte g inj 50 mg/ml(eq)..................................................................164 ATIVAN -lorazepam tab 0.5 mg........................................ 75 ATIVAN -lorazepam tab 1 mg........................................... 75 ATIVAN -lorazepam tab 2 mg........................................... 75 ATOPICLAIR -dermatological products misc - cream......145 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)............................................................................54 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)............................................................................54 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)............................................................................54 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)............................................................................54 atovaquone-proguanil hcl tab 250-100 mg (Malarone)....................................................................... 11 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)....................................................................... 11 atovaquone susp 750 mg/5ml (Mepron)........................ 12 ATRALIN -tretinoin gel 0.05%......................................... 145 ATRAPRO CP -wound dressings - kit............................. 145 ATRAPRO DERMAL SPRAY -wound cleansers liquid............................................................................... 145 ATRIPLA -efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg.................................................................7 ATROPINE SULFATE -atropine sulfate ophth oint 1%.................................................................................. 137 atropine sulfate ophth soln 1% (Isopto atropine)....... 137 ATROVENT HFA -ipratropium bromide hfa inhal aerosol 17 mcg/act....................................................................... 63 ATROVENT -ipratropium bromide nasal soln 0.03% (21 mcg/spray)........................................................................59 ATROVENT -ipratropium bromide nasal soln 0.06% (42 mcg/spray)........................................................................59 AUBAGIO -teriflunomide tab 14 mg.................................. 89 AUBAGIO -teriflunomide tab 7 mg.................................... 89 AUGMENTIN -amoxicillin & k clavulanate for susp 125-31.25 mg/5ml.............................................................. 1 AUGMENTIN -amoxicillin & k clavulanate for susp 250-62.5 mg/5ml................................................................ 1 AUGMENTIN -amoxicillin & k clavulanate tab 500-125 mg...................................................................................... 1 AUGMENTIN -amoxicillin & k clavulanate tab 875-125 mg...................................................................................... 1 AUGMENTIN ES-600 -amoxicillin & k clavulanate for susp 600-42.9 mg/5ml................................................................ 1 AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg.....................................................................1 AURALGAN -antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%).......................................................................141 AURSTAT ANTI-ITCH HYDROGE -dermatological products misc - kit......................................................... 145 AURSTAT -dermatological products misc - kit................ 145 AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)........70 AUVI-Q -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)............................................................................ 53 AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................................ 53 AVAILNEX -carbocysteine chew tab 750 mg.................. 126 AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5 mg.................................................................................... 46 AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5 mg.................................................................................... 46 AVALIN-RX -lidocaine-menthol patch 4-1%.................... 145 AVANDAMET -rosiglitazone maleate-metformin hcl tab 2-1000 mg........................................................................27 AVANDIA -rosiglitazone maleate tab 2 mg (base equiv)................................................................................27 AVANDIA -rosiglitazone maleate tab 4 mg (base equiv)................................................................................27 AVANDIA -rosiglitazone maleate tab 8 mg (base equiv)................................................................................27 AVAPRO -irbesartan tab 150 mg...................................... 46 AVAPRO -irbesartan tab 300 mg...................................... 46 AVAPRO -irbesartan tab 75 mg........................................ 46 AVAR-E LS -sulfacetamide sodium w/ sulfur cream 10-2%............................................................................. 146 AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur cleanser 10-2%.............................................................. 146 AVAR LS -sulfacetamide sodium w/ sulfur cleansing pad 10-2%............................................................................. 146 AVAR LS -sulfacetamide sodium w/ sulfur foam 10-2%............................................................................. 146 AVAR -sulfacetamide sodium w/ sulfur cleansing pad 9.5-5%............................................................................ 145 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 173 2015 AVAR -sulfacetamide sodium w/ sulfur foam 9.5-5%...... 145 AVC -sulfanilamide vaginal cream 15%............................ 73 AVEED -testosterone undecanoate im inj in oil 750 mg/3ml (250mg/ml)....................................................................... 21 AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base equiv)..................................................................................5 AVELOX -moxifloxacin hcl tab 400 mg (base equiv)........... 5 AVENOVA -hypochlorous acid cleanser soln 0.01%....... 146 AVIDOXY DK -doxycycline tab 100 mg & suncreen & sal acid wash 2% kit................................................................4 AVINZA -morphine sulfate beads cap sr 24hr 120 mg...... 94 AVINZA -morphine sulfate beads cap sr 24hr 30 mg........ 94 AVINZA -morphine sulfate beads cap sr 24hr 45 mg........ 94 AVINZA -morphine sulfate beads cap sr 24hr 60 mg........ 94 AVINZA -morphine sulfate beads cap sr 24hr 75 mg........ 94 AVINZA -morphine sulfate beads cap sr 24hr 90 mg........ 94 AVODART -dutasteride cap 0.5 mg.................................. 74 AVONEX -interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial)........................................................ 89 AVONEX -interferon beta-1a im inj kit 30 mcg/0.5ml.........89 AVONEX PEN -interferon beta-1a im inj kit 30 mcg/0.5ml.........................................................................89 AXERT -almotriptan malate tab 12.5 mg.........................104 AXERT -almotriptan malate tab 6.25 mg.........................104 AXID -nizatidine cap 300 mg.............................................66 AXIRON -testosterone td soln 30 mg/act.......................... 21 AYGESTIN -norethindrone acetate tab 5 mg.................... 26 AZASAN -azathioprine tab 100 mg................................. 164 AZASAN -azathioprine tab 75 mg................................... 164 AZASITE -azithromycin ophth soln 1%........................... 137 azathioprine tab 50 mg (Imuran).................................. 164 azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 59 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro)......................................................................... 59 azelastine hcl ophth soln 0.05% (Optivar)...................137 AZELEX -azelaic acid cream 20%.................................. 146 AZILECT -rasagiline mesylate tab 0.5 mg (base equiv)..............................................................................111 AZILECT -rasagiline mesylate tab 1 mg (base equiv)......111 AZITHROMYCIN -azithromycin powd pack for susp 1 gm...................................................................................... 2 azithromycin for susp 100 mg/5ml (Zithromax).............. 2 azithromycin for susp 200 mg/5ml (Zithromax).............. 2 azithromycin tab 250 mg (Zithromax)..............................2 azithromycin tab 500 mg (Zithromax)..............................2 azithromycin tab 600 mg (Zithromax)..............................3 AZOPT -brinzolamide ophth susp 1%............................. 137 AZOR -amlodipine besylate-olmesartan medoxomil tab 10-20 mg..........................................................................46 AZOR -amlodipine besylate-olmesartan medoxomil tab 10-40 mg..........................................................................46 AZOR -amlodipine besylate-olmesartan medoxomil tab 5-20 mg............................................................................46 AZOR -amlodipine besylate-olmesartan medoxomil tab 5-40 mg............................................................................46 174 AZULFIDINE EN-TABS -sulfasalazine tab delayed release 500 mg............................................................................. 70 AZULFIDINE -sulfasalazine tab 500 mg............................70 B B-6 FOLIC ACID -cobalamine combination cap.............. 128 BABY DDROPS -cholecalciferol drops 400 unit/0.03ml (per drop)....................................................................... 115 BACITRACIN -bacitracin ophth oint 500 unit/gm............. 137 bacitracin-polymyxin b ophth oint............................... 137 bacitracin-polymyxin-neomycin-hc ophth oint 1%..... 137 baclofen tab 10 mg........................................................113 baclofen tab 20 mg........................................................113 BACTRIM DS -sulfamethoxazole-trimethoprim tab 800-160 mg.................................................................................... 12 BACTRIM -sulfamethoxazole-trimethoprim tab 400-80 mg.................................................................................... 12 BACTROBAN -mupirocin calcium cream 2%.................. 146 BACTROBAN -mupirocin oint 2%................................... 146 BACTROBAN NASAL -mupirocin calcium nasal oint 2%.................................................................................... 59 BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg.....................................................115 balsalazide disodium cap 750 mg (Colazal).................. 70 BANZEL -rufinamide susp 40 mg/ml............................... 106 BANZEL -rufinamide tab 200 mg.................................... 106 BANZEL -rufinamide tab 400 mg.................................... 106 BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7 BARACLUDE -entecavir tab 0.5 mg....................................7 BARACLUDE -entecavir tab 1 mg.......................................7 BAYER BREEZE 2 TEST DISC -glucose blood test disk................................................................................. 163 BAYER CONTOUR BLOOD GLUCO -glucose blood test strip.................................................................................163 BAYER CONTOUR NEXT BLOOD -glucose blood test strip.................................................................................163 b-complex w/ c & folic acid cap 1 mg (Nephrocaps)................................................................ 115 b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)...................................................................................115 b-complex w/ c & folic acid tab 5 mg.......................... 115 b-complex w/ c-biotin-minerals & folic acid tab 5 mg (Diatx zn).......................................................................115 BD GLUCOSE -glucose chew tab 5 gm............................27 BEBULIN -factor ix complex for inj 200-1200 unit........... 134 BEBULIN VH -factor ix complex for inj 200-1200 unit......134 BECONASE AQ -beclomethasone dipropionate monohyd nasal susp 42 mcg/spray.................................................59 BELLADONNA & OPIUM -belladonna alkaloids & opium suppos 16.2-30 mg.......................................................... 66 BELLADONNA ALKALOIDS & OP -belladonna alkaloids & opium suppos 16.2-60 mg............................................... 66 BELSOMRA -suvorexant tab 10 mg..................................84 BELSOMRA -suvorexant tab 15 mg..................................84 BELSOMRA -suvorexant tab 20 mg..................................84 BELSOMRA -suvorexant tab 5 mg....................................84 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)................................................................. 46 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)................................................................. 46 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)................................................................. 46 benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 46 benazepril hcl tab 10 mg (Lotensin).............................. 46 benazepril hcl tab 20 mg (Lotensin).............................. 46 benazepril hcl tab 40 mg (Lotensin).............................. 46 benazepril hcl tab 5 mg.................................................. 46 BENEFIX -coagulation factor ix (recombinant) for inj 1000 unit..................................................................................134 BENEFIX -coagulation factor ix (recombinant) for inj 2000 unit..................................................................................134 BENEFIX -coagulation factor ix (recombinant) for inj 250 unit..................................................................................134 BENEFIX -coagulation factor ix (recombinant) for inj 3000 unit..................................................................................134 BENEFIX -coagulation factor ix (recombinant) for inj 500 unit..................................................................................134 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 46 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 46 BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 46 BENICAR -olmesartan medoxomil tab 20 mg................... 46 BENICAR -olmesartan medoxomil tab 40 mg................... 46 BENICAR -olmesartan medoxomil tab 5 mg..................... 46 BENSAL HP -salicylic acid & benzoic acid oint 3-6%...... 146 BENTYL -dicyclomine hcl cap 10 mg................................ 66 BENTYL -dicyclomine hcl tab 20 mg.................................66 BENZACLIN -clindamycin phosphate-benzoyl peroxide gel 1-5%............................................................................... 146 BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 146 BENZALKONIUM CHLORIDE -benzalkonium chloride soln.................................................................................162 BENZALKONIUM CHLORIDE -benzalkonium chloride soln 50%................................................................................ 162 BENZAMYCIN -benzoyl peroxide-erythromycin gel 5-3%............................................................................... 146 BENZAMYCINPAK -benzoyl peroxide-erythromycin gel pack 5-3%...................................................................... 146 BENZEFOAM -benzoyl peroxide foam 5.3%...................146 BENZEFOAMULTRA -benzoyl peroxide foam 9.8%....... 146 BENZIQ -benzoyl peroxide gel 5.25 %............................146 BENZIQ LS -benzoyl peroxide gel 2.75%....................... 146 benzocaine dental soln 20%.........................................142 benzonatate cap 100 mg (Tessalon perles)...................59 benzonatate cap 150 mg (Zonatuss)..............................59 benzonatate cap 200 mg.................................................59 benzoyl peroxide creamy wash 4% &benzoyl peroxide bar 5% kit......................................................................146 benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit (Bpo creamy wash comp)......................... 146 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)................................................................ 146 benzoyl peroxide foam 5.3% (Benzefoam).................. 146 benzoyl peroxide foam 9.8% (Benzefoamultra).......... 146 benzoyl peroxide liq 2.5%.............................................146 benzoyl peroxide liq 5.25%...........................................146 benzoyl peroxide liq 7%................................................146 benzoyl peroxide lotion 6%.......................................... 146 benztropine mesylate tab 0.5 mg................................. 111 benztropine mesylate tab 1 mg....................................111 benztropine mesylate tab 2 mg....................................111 BEPREVE -bepotastine besilate ophth soln 1.5%........... 137 BERINERT -c1 esterase inhibitor (human) for iv inj kit 500 unit..................................................................................134 BESIVANCE -besifloxacin hcl ophth susp 0.6% (base equiv)..............................................................................137 BETADINE OPHTHALMIC PREP -povidone-iodine ophth soln 5%.......................................................................... 137 BETAGAN -levobunolol hcl ophth soln 0.5%...................137 betamethasone dipropionate augmented cream 0.05% (Diprolene af)................................................................146 betamethasone dipropionate augmented gel 0.05%............................................................................. 146 betamethasone dipropionate augmented lotion 0.05% (Diprolene).................................................................... 146 betamethasone dipropionate augmented oint 0.05% (Diprolene).................................................................... 146 betamethasone dipropionate cream 0.05%................. 146 betamethasone dipropionate lotion 0.05%..................146 betamethasone dipropionate oint 0.05%..................... 146 betamethasone valerate aerosol foam 0.12% (Luxiq)........................................................................... 146 betamethasone valerate cream 0.1%........................... 146 betamethasone valerate lotion 0.1%............................146 betamethasone valerate oint 0.1%............................... 146 BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg...............40 BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg...............40 BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg.................40 BETAPACE -sotalol hcl tab 120 mg.................................. 40 BETAPACE -sotalol hcl tab 160 mg.................................. 40 BETAPACE -sotalol hcl tab 80 mg....................................40 BETASERON -interferon beta-1b for inj kit 0.3 mg............89 betaxolol hcl ophth soln 0.5%......................................137 betaxolol hcl tab 10 mg (Kerlone)..................................40 betaxolol hcl tab 20 mg (Kerlone)..................................40 bethanechol chloride tab 10 mg (Urecholine)............... 72 bethanechol chloride tab 25 mg (Urecholine)............... 72 bethanechol chloride tab 50 mg (Urecholine)............... 72 bethanechol chloride tab 5 mg (Urecholine).................72 BETHKIS -tobramycin nebu soln 300 mg/4ml..................... 5 BETIMOL -timolol ophth soln 0.25%............................... 137 BETIMOL -timolol ophth soln 0.5%................................. 137 BETOPTIC-S -betaxolol hcl ophth susp 0.25%............... 137 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 175 2015 bexarotene cap 75 mg (Targretin)..................................16 BEYAZ -drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg...............................................................24 BIAXIN -clarithromycin for susp 250 mg/5ml.......................3 BIAXIN -clarithromycin tab 250 mg..................................... 3 BIAXIN -clarithromycin tab 500 mg..................................... 3 BIAXIN XL -clarithromycin tab sr 24hr 500 mg....................3 BIAXIN XL PAC -clarithromycin tab sr 24hr 500 mg............3 bicalutamide tab 50 mg (Casodex)................................ 16 BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg.................................................................................... 57 BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg............................................................ 128 BILTRICIDE -praziquantel tab 600 mg.............................. 11 BIMATOPROST -bimatoprost ophth soln 0.03%............. 137 BINOSTO -alendronate sodium effervescent tab 70 mg.................................................................................... 35 BIO-STATIN -nystatin cap 1000000 unit............................. 6 BIO-STATIN -nystatin cap 500000 unit............................... 6 bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit..................................................................................... 65 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)................................................................................46 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)................................................................................46 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)................................................................................46 bisoprolol fumarate tab 10 mg (Zebeta)........................ 40 bisoprolol fumarate tab 5 mg (Zebeta).......................... 40 BLEPH-10 -sulfacetamide sodium ophth soln 10%......... 137 BLEPHAMIDE S.O.P. -sulfacetamide sodium-prednisolone ophth oint 10-0.2%.........................................................137 BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth susp 10-0.2%................................................................. 137 BLOOD GLUCOSE CALIBRATION LIQUID – VARIOUS....................................................................... 163 B-NEXA -prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg.................................................................................. 115 BONIVA -ibandronate sodium tab 150 mg (base equivalent)........................................................................35 BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml......................................................................15 BOSULIF -bosutinib tab 100 mg....................................... 16 BOSULIF -bosutinib tab 500 mg....................................... 16 BP CLEANSING WASH -sulfacetamide sodium-sulfur in urea emulsion 10-4%.....................................................146 BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg........................................................ 115 BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg............................................................... 115 BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa tab chew 40-1 mg................................................................ 115 BPO 3% FOAMING CLOTHS -benzoyl peroxide cloth 3%.................................................................................. 146 176 BPO 9% FOAMING CLOTHS -benzoyl peroxide cloth 9%.................................................................................. 146 BPO -benzoyl peroxide gel 4%....................................... 146 BPO -benzoyl peroxide gel 8%....................................... 146 BPO CREAMY WASH COMPLETE -benzoyl peroxide creamy wash 8% &benzoyl peroxide bar 5% kit............ 146 BP VIT 3 -folic acid-vit b6-vit b12-omega 3-phytosterols cap 1 mg........................................................................128 BP VIT 3 PLUS -folic acid-b6-b12-d-omega 3-phytosterols cap 1 mg........................................................................128 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh........................................................... 63 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh........................................................... 63 BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg....................................................................... 24 BRILINTA -ticagrelor tab 90 mg...................................... 134 brimonidine tartrate ophth soln 0.15% (Alphagan p).................................................................................... 137 brimonidine tartrate ophth soln 0.2%.......................... 137 BRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)...... 76 BRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)...... 76 BRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)........76 BRISDELLE -paroxetine mesylate cap 7.5 mg (base equiv)................................................................................89 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)................................................................... 138 bromfenac sodium ophth soln 0.09% (base equivalent).................................................................... 137 bromocriptine mesylate cap 5 mg (Parlodel).............. 111 bromocriptine mesylate tab 2.5 mg............................. 111 brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg.................................................................................... 59 brompheniramine maleate tab sr 12hr 6 mg................. 58 BROMPHENIRAMINE TANNATE -brompheniramine tannate chew tab 12 mg.................................................. 58 BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml (base equiv)..................................................................... 63 budesonide cap sr 24hr 3 mg (Entocort ec)..................19 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)...................................................................... 63 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)...................................................................... 63 budesonide inhalation susp 1 mg/2ml (Pulmicort)....... 63 budesonide nasal susp 32 mcg/act (Rhinocort aqua)................................................................................59 bumetanide tab 0.5 mg................................................... 52 bumetanide tab 1 mg...................................................... 52 bumetanide tab 2 mg...................................................... 52 BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3 mg (base equiv)............................................................... 94 BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7 mg (base equiv)............................................................... 94 BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg (base equiv)..................................................................... 94 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 BUPAP -butalbital-acetaminophen tab 50-300 mg............ 93 BUPHENYL -sodium phenylbutyrate oral powder 3 gm/ teaspoonful.......................................................................35 BUPHENYL -sodium phenylbutyrate tab 500 mg.............. 35 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)...............................................................................94 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)...............................................................................94 buprenorphine hcl sl tab 2 mg (base equiv)................. 94 buprenorphine hcl sl tab 8 mg (base equiv)................. 94 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban)............................................................................ 89 bupropion hcl tab 100 mg (Wellbutrin)..........................76 bupropion hcl tab 75 mg (Wellbutrin)............................76 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).........76 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr).........76 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr).........76 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 76 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 76 buspirone hcl tab 10 mg.................................................75 buspirone hcl tab 15 mg.................................................75 buspirone hcl tab 30 mg.................................................75 buspirone hcl tab 5 mg...................................................75 buspirone hcl tab 7.5 mg................................................75 butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet).......................................................................... 93 butalbital-acetaminophen-caffeine cap 50-325-40 mg.................................................................................... 93 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)............................................................................. 93 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine).....................................................94 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg.................................................................................... 94 butalbital-acetaminophen tab 50-325 mg...................... 93 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).......................................................................... 93 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)...................................................... 94 BUTISOL SODIUM -butabarbital sodium tab 30 mg..........84 BUTISOL SODIUM -butabarbital sodium tab 50 mg..........84 butorphanol tartrate nasal soln 10 mg/ml..................... 94 BUTRANS -buprenorphine td patch weekly 10 mcg/hr......94 BUTRANS -buprenorphine td patch weekly 15 mcg/hr......94 BUTRANS -buprenorphine td patch weekly 20 mcg/hr......94 BUTRANS -buprenorphine td patch weekly 5 mcg/hr........94 BUTRANS -buprenorphine td patch weekly 7.5 mcg/hr.....94 BYDUREON -exenatide extended release for inj susp 2 mg.................................................................................... 27 BYDUREON -exenatide extended release for susp peninjector 2 mg.................................................................... 27 BYETTA -exenatide soln pen-injector 10 mcg/0.04ml....... 27 BYETTA -exenatide soln pen-injector 5 mcg/0.02ml......... 27 BYSTOLIC -nebivolol hcl tab 10 mg (base equivalent)......40 BYSTOLIC -nebivolol hcl tab 2.5 mg (base equivalent).....40 BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)......40 BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent)........40 C cabergoline tab 0.5 mg................................................... 35 CADUET -amlodipine besylate-atorvastatin calcium tab 10-10 mg..........................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 10-20 mg..........................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 10-40 mg..........................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 10-80 mg..........................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 2.5-10 mg.........................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 2.5-20 mg.........................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 2.5-40 mg.........................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 5-10 mg............................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 5-20 mg............................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 5-40 mg............................................................................57 CADUET -amlodipine besylate-atorvastatin calcium tab 5-80 mg............................................................................57 CAFERGOT -ergotamine w/ caffeine tab 1-100 mg........ 104 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit)................................................................. 86 CALAN SR -verapamil hcl tab cr 120 mg.......................... 42 CALAN SR -verapamil hcl tab cr 180 mg.......................... 42 CALAN SR -verapamil hcl tab cr 240 mg.......................... 42 CALAN -verapamil hcl tab 120 mg....................................42 CALAN -verapamil hcl tab 80 mg......................................42 CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag wafer 1342-1.6 mg.........................................................124 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex)..............................................147 calcipotriene cream 0.005% (Dovonex)....................... 146 calcipotriene oint 0.005%..............................................147 calcipotriene soln 0.005% (50 mcg/ml)........................ 147 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin).......................................................................35 CALCITRIOL -calcitriol oint 3 mcg/gm.............................147 calcitriol cap 0.25 mcg (Rocaltrol)................................. 35 calcitriol cap 0.5 mcg (Rocaltrol)................................... 35 calcitriol oral soln 1 mcg/ml (Rocaltrol)........................ 35 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)..............................................................70 calcium acetate (phosphate binder) tab 667 mg (Eliphos).......................................................................... 70 CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg............................. 124 CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg............................................................116 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 177 2015 CAMBIA -diclofenac potassium packet 50 mg.................104 CAMPHOMEX -camphor-histamine-menthol liqd spray 4-0.025-10%...................................................................147 CANASA -mesalamine suppos 1000 mg...........................70 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand hct)........................................................... 46 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct)........................................................... 47 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand hct)........................................................... 47 candesartan cilexetil tab 16 mg (Atacand).................... 46 candesartan cilexetil tab 32 mg (Atacand).................... 46 candesartan cilexetil tab 4 mg (Atacand)......................46 candesartan cilexetil tab 8 mg (Atacand)......................46 CANTIL -mepenzolate bromide tab 25 mg........................ 66 CAPCOF -phenylephrine-chlorphen w/ codeine syrup 5-2-10 mg/5ml..................................................................59 capecitabine tab 150 mg (Xeloda)..................................16 capecitabine tab 500 mg (Xeloda)..................................16 CAPEX -fluocinolone acetonide shampoo 0.01%............147 CAPHOSOL -artificial saliva - solution............................ 142 CAPITAL/CODEINE -acetaminophen w/ codeine susp 120-12 mg/5ml................................................................. 94 CAPRELSA -vandetanib tab 100 mg................................ 16 CAPRELSA -vandetanib tab 300 mg................................ 16 CAPSIDERM -capsaicin-menthol topical patch 0.0375-5%...................................................................... 147 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 25-15 mg................................... 47 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 25-25 mg................................... 47 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 50-15 mg................................... 47 CAPTOPRIL/HYDROCHLOROTHIA -captopril & hydrochlorothiazide tab 50-25 mg................................... 47 captopril tab 100 mg....................................................... 47 captopril tab 12.5 mg...................................................... 47 captopril tab 25 mg......................................................... 47 captopril tab 50 mg......................................................... 47 CAPTRACIN -capsaicin-menthol topical patch 0.0375-5%...................................................................... 147 CARAC -fluorouracil cream 0.5%.................................... 147 CARAFATE -sucralfate susp 1 gm/10ml........................... 66 CARAFATE -sucralfate tab 1 gm...................................... 66 CARBAGLU -carglumic acid tab 200 mg...........................35 carbamazepine cap sr 12hr 100 mg (Carbatrol).......... 106 carbamazepine cap sr 12hr 200 mg (Carbatrol).......... 106 carbamazepine cap sr 12hr 300 mg (Carbatrol).......... 106 carbamazepine chew tab 100 mg.................................106 carbamazepine susp 100 mg/5ml (Tegretol)............... 106 carbamazepine tab 200 mg (Tegretol)......................... 106 carbamazepine tab sr 12hr 200 mg (Tegretol-xr)........ 106 carbamazepine tab sr 12hr 400 mg (Tegretol-xr)........ 106 CARBAPHEN 12 PED -phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml........................ 59 178 CARBAPHEN 12 -phenyleph-chlorphen-carbetapentane liqd 10-4-27.5 mg/5ml...................................................... 59 CARBATROL -carbamazepine cap sr 12hr 100 mg........ 106 CARBATROL -carbamazepine cap sr 12hr 200 mg........ 106 CARBATROL -carbamazepine cap sr 12hr 300 mg........ 106 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg.................................. 111 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg................................ 111 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg...................................111 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg.............................. 111 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg................................ 111 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg...................................111 carbidopa & levodopa orally disintegrating tab 10-100 mg.................................................................................. 111 carbidopa & levodopa orally disintegrating tab 25-100 mg.................................................................................. 111 carbidopa & levodopa orally disintegrating tab 25-250 mg.................................................................................. 111 carbidopa & levodopa tab 10-100 mg (Sinemet)......... 111 carbidopa & levodopa tab 25-100 mg (Sinemet)......... 111 carbidopa & levodopa tab 25-250 mg (Sinemet)......... 111 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr)...................................................................................111 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr)...................................................................................111 carbidopa tab 25 mg (Lodosyn)................................... 111 carbinoxamine maleate soln 4 mg/5ml..........................58 carbinoxamine maleate tab 4 mg...................................58 carbonyl iron susp 15 mg/1.25ml (elemental iron)......128 CARDIOTEK-RX -folic acid-b12-b6-arginine-black pepper tab.................................................................................. 126 CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap 240-360-20-0.5-0.8 mg.................................................. 126 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 120 mg............................................................................. 42 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 180 mg............................................................................. 42 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 240 mg............................................................................. 42 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 300 mg............................................................................. 42 CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr 360 mg............................................................................. 42 CARDIZEM -diltiazem hcl tab 120 mg...............................42 CARDIZEM -diltiazem hcl tab 30 mg.................................42 CARDIZEM -diltiazem hcl tab 60 mg.................................42 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 120 mg............................................................................. 42 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 180 mg............................................................................. 42 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 240 mg............................................................................. 42 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 300 mg............................................................................. 42 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 360 mg............................................................................. 42 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 420 mg............................................................................. 42 CARDURA -doxazosin mesylate tab 1 mg........................ 47 CARDURA -doxazosin mesylate tab 2 mg........................ 47 CARDURA -doxazosin mesylate tab 4 mg........................ 47 CARDURA -doxazosin mesylate tab 8 mg........................ 47 CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg (base equiv)..................................................................... 74 CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg (base equiv)..................................................................... 74 CARISOPRODOL -carisoprodol tab 250 mg................... 113 carisoprodol tab 350 mg (Soma)..................................113 carisoprodol w/ aspirin & codeine tab 200-325-16 mg.................................................................................. 114 carisoprodol w/ aspirin tab 200-325 mg...................... 114 CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)....... 35 CARNITOR -levocarnitine tab 330 mg.............................. 35 CARNITOR SF -levocarnitine oral soln 1 gm/10ml (10%)................................................................................35 carteolol hcl ophth soln 1%......................................... 138 carvedilol tab 12.5 mg (Coreg)....................................... 40 carvedilol tab 25 mg (Coreg).......................................... 40 carvedilol tab 3.125 mg (Coreg)..................................... 40 carvedilol tab 6.25 mg (Coreg)....................................... 40 CASCARA SAGRADA -cascara sagrada fl ext 1 gm/ ml......................................................................................65 CASODEX -bicalutamide tab 50 mg................................. 16 CATAPRES -clonidine hcl tab 0.1 mg............................... 47 CATAPRES -clonidine hcl tab 0.2 mg............................... 47 CATAPRES -clonidine hcl tab 0.3 mg............................... 47 CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1 mg/24hr............................................................................ 47 CATAPRES-TTS-2 -clonidine hcl td patch weekly 0.2 mg/24hr............................................................................ 47 CATAPRES-TTS-3 -clonidine hcl td patch weekly 0.3 mg/24hr............................................................................ 47 CAYSTON -aztreonam lysine for inhal soln 75 mg (base equivalent)........................................................................12 CEDAX -ceftibuten cap 400 mg.......................................... 1 CEDAX -ceftibuten for susp 180 mg/5ml.............................1 CEDAX -ceftibuten for susp 90 mg/5ml...............................1 CEENU -lomustine cap 100 mg........................................ 16 CEENU -lomustine cap 10 mg.......................................... 16 CEENU -lomustine cap 40 mg.......................................... 16 cefaclor cap 250 mg..........................................................2 cefaclor cap 500 mg..........................................................2 CEFACLOR -cefaclor for susp 125 mg/5ml.........................1 CEFACLOR -cefaclor for susp 250 mg/5ml.........................2 CEFACLOR -cefaclor for susp 375 mg/5ml.........................2 CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500 mg...................................................................................... 2 cefadroxil cap 500 mg.......................................................2 cefadroxil for susp 250 mg/5ml........................................2 cefadroxil for susp 500 mg/5ml........................................2 cefadroxil tab 1 gm........................................................... 2 cefdinir cap 300 mg...........................................................2 cefdinir for susp 125 mg/5ml........................................... 2 cefdinir for susp 250 mg/5ml........................................... 2 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg (base equivalent)............................................................... 2 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg (base equivalent)............................................................... 2 cefixime for susp 100 mg/5ml (Suprax)...........................2 cefixime for susp 200 mg/5ml (Suprax)...........................2 cefpodoxime proxetil for susp 100 mg/5ml.....................2 cefpodoxime proxetil for susp 50 mg/5ml.......................2 cefpodoxime proxetil tab 100 mg.................................... 2 cefpodoxime proxetil tab 200 mg.................................... 2 cefprozil for susp 125 mg/5ml..........................................2 cefprozil for susp 250 mg/5ml..........................................2 cefprozil tab 250 mg..........................................................2 cefprozil tab 500 mg..........................................................2 CEFTIBUTEN -ceftibuten cap 400 mg................................ 2 CEFTIBUTEN -ceftibuten for susp 180 mg/5ml...................2 CEFTIN -cefuroxime axetil for susp 125 mg/5ml................. 2 CEFTIN -cefuroxime axetil for susp 250 mg/5ml................. 2 CEFTIN -cefuroxime axetil tab 250 mg............................... 2 CEFTIN -cefuroxime axetil tab 500 mg............................... 2 cefuroxime axetil tab 250 mg (Ceftin)..............................2 cefuroxime axetil tab 500 mg (Ceftin)..............................2 CELEBREX -celecoxib cap 100 mg................................ 101 CELEBREX -celecoxib cap 200 mg................................ 101 CELEBREX -celecoxib cap 400 mg................................ 101 CELEBREX -celecoxib cap 50 mg.................................. 101 celecoxib cap 100 mg (Celebrex)................................. 101 celecoxib cap 200 mg (Celebrex)................................. 101 celecoxib cap 400 mg (Celebrex)................................. 101 celecoxib cap 50 mg (Celebrex)...................................101 CELEXA -citalopram hydrobromide tab 10 mg (base equiv)................................................................................76 CELEXA -citalopram hydrobromide tab 20 mg (base equiv)................................................................................76 CELEXA -citalopram hydrobromide tab 40 mg (base equiv)................................................................................77 CELLCEPT -mycophenolate mofetil cap 250 mg............ 164 CELLCEPT -mycophenolate mofetil for oral susp 200 mg/ ml....................................................................................164 CELLCEPT -mycophenolate mofetil tab 500 mg............. 164 CELONTIN -methsuximide cap 300 mg.......................... 106 CEM-UREA -urea soln 45%............................................ 147 CENFOL -folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2 mg.................................................................................. 128 CENTANY AT -mupirocin oint kit 2%.............................. 147 CENTANY -mupirocin oint 2%.........................................147 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 179 2015 CENTRATEX -ferrous fumarate-fa-b complex-c-zn-mg-mncu cap 106-1 mg............................................................128 cephalexin cap 250 mg (Keflex)....................................... 2 cephalexin cap 500 mg (Keflex)....................................... 2 cephalexin cap 750 mg (Keflex)....................................... 2 CEPHALEXIN -cephalexin tab 250 mg............................... 2 CEPHALEXIN -cephalexin tab 500 mg............................... 2 cephalexin for susp 125 mg/5ml...................................... 2 cephalexin for susp 250 mg/5ml...................................... 2 CERDELGA -eliglustat tartrate cap 84 mg (base equivalent)......................................................................128 CEREFOLIN -l-methylfolate w/ vit b12-vit b6-vit b2 tab 6-1-50-5 mg................................................................... 126 CEREFOLIN NAC -l-methylfolate-algae-b12-acetylcyst tab 6-90.314-2-600mg..........................................................126 CEREFOLIN NAC -l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg............................................. 126 CERVIDIL -dinoprostone vaginal inserts 10 mg................ 35 CESAMET -nabilone cap 1 mg......................................... 69 CETACAINE -butamben-tetracaine-benzocaine aerosol spray 2-2-14%................................................................147 CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base equivalent)......................................................................141 cevimeline hcl cap 30 mg (Evoxac)............................. 142 CHANTIX CONTINUING MONTH -varenicline tartrate tab 1 mg (base equiv)............................................................90 CHANTIX STARTING MONTH PA -varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack.................................. 90 CHANTIX -varenicline tartrate tab 0.5 mg (base equiv).....90 CHANTIX -varenicline tartrate tab 1 mg (base equiv)........90 CHEMET -succimer cap 100 mg.....................................163 CHENODAL -chenodiol tab 250 mg.................................. 70 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg............................................... 90 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg.............................................. 90 chlordiazepoxide hcl cap 10 mg.................................... 75 chlordiazepoxide hcl cap 25 mg.................................... 75 chlordiazepoxide hcl cap 5 mg...................................... 75 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg (Librax)............................................................................ 66 chlorhexidine gluconate soln 0.12% (Peridex)............142 chloroquine phosphate tab 250 mg............................... 11 chloroquine phosphate tab 500 mg (Aralen).................11 CHLOROTHIAZIDE -chlorothiazide tab 250 mg................52 chlorothiazide tab 500 mg.............................................. 52 chlorpromazine hcl tab 100 mg......................................81 chlorpromazine hcl tab 10 mg........................................81 chlorpromazine hcl tab 200 mg......................................81 chlorpromazine hcl tab 25 mg........................................81 chlorpromazine hcl tab 50 mg........................................81 CHLORPROPAMIDE -chlorpropamide tab 100 mg...........27 CHLORPROPAMIDE -chlorpropamide tab 250 mg...........27 CHLORTHALIDONE -chlorthalidone tab 100 mg.............. 52 CHLORTHALIDONE -chlorthalidone tab 25 mg................ 52 180 CHLORTHALIDONE -chlorthalidone tab 50 mg................ 52 chlorzoxazone tab 500 mg (Parafon forte dsc)........... 114 CHOICE-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak.................................................. 116 CHOLBAM -cholic acid cap 250 mg..................................70 CHOLBAM -cholic acid cap 50 mg....................................70 cholecalciferol cap 1000 unit........................................115 cholecalciferol cap 400 unit..........................................115 cholecalciferol cap 50000 unit......................................115 cholecalciferol chew tab 1000 unit.............................. 115 cholecalciferol chew tab 400 unit................................ 115 cholecalciferol drops 400 unit/0.03ml (per drop)........ 115 cholecalciferol drops 5000 unit/ml (1000 unit/0.2ml)..................................................................... 115 cholecalciferol oral liquid 400 unit/ml......................... 115 cholecalciferol tab 1000 unit........................................ 115 cholecalciferol tab 400 unit.......................................... 115 cholestyramine light powder 4 gm/dose (Questran light).................................................................................54 cholestyramine light powder packets 4 gm.................. 54 cholestyramine powder 4 gm/dose (Questran).............54 cholestyramine powder packets 4 gm (Questran)........54 choline & magnesium salicylates liq 500 mg/5ml.........93 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)............................................................... 54 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)........................................................................... 54 CHOLINE MAGNESIUM TRISALI -choline & magnesium salicylates tab 1000 mg................................................... 93 CIALIS -tadalafil tab 2.5 mg.............................................. 57 CIALIS -tadalafil tab 2.5 mg.............................................. 58 CIALIS -tadalafil tab 5 mg................................................. 57 CIALIS -tadalafil tab 5 mg................................................. 58 CICLODAN CREAM KIT -ciclopirox olamine cream 0.77% (base equiv) & cleanser kit............................................ 147 CICLODAN SOLUTION KIT -ciclopirox solution kit 8%.................................................................................. 147 ciclopirox gel 0.77%...................................................... 147 ciclopirox olamine cream 0.77% (base equiv).............147 ciclopirox olamine susp 0.77% (base equiv)...............147 ciclopirox shampoo 1% (Loprox shampoo)................ 147 ciclopirox solution 8% (Penlac Nail Lacquer)............. 147 ciclopirox solution kit 8% (Ciclodan solution ki)........ 147 CICLOPIROX TOPICAL SOLUTI -ciclopirox solution 8% & vitamin e 5% topical kit..................................................147 CIFEREX -folic acid-cholecalciferol cap 1 mg-3775 unit..................................................................................128 cilostazol tab 100 mg (Pletal)....................................... 134 cilostazol tab 50 mg (Pletal)......................................... 134 CILOXAN -ciprofloxacin hcl ophth oint 0.3%................... 138 CILOXAN -ciprofloxacin hcl ophth soln 0.3%.................. 138 cimetidine hcl soln 300 mg/5ml..................................... 66 cimetidine tab 300 mg.....................................................66 cimetidine tab 400 mg.....................................................66 cimetidine tab 800 mg.....................................................66 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............. 70 CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200 mg/ml................................................................................70 CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml).......................................................................... 5 CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml).......................................................................... 5 CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)..............5 CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)..............5 CIPRODEX -ciprofloxacin-dexamethasone otic susp 0.3-0.1%......................................................................... 141 CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base equivalent)......................................................................141 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr).................................................... 5 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro xr)......................................................... 5 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro)............................................................ 5 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)............................................................ 5 CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg (base equiv)....................................................................... 5 ciprofloxacin hcl ophth soln 0.3% (Ciloxan)............... 138 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........5 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........5 ciprofloxacin hcl tab 750 mg (base equiv)...................... 5 CIPRO HC -ciprofloxacin-hydrocortisone otic susp 0.2-1%............................................................................ 141 CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq).......................................................................5 CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq)..................................................................... 5 citalopram hydrobromide oral soln 10 mg/5ml............. 77 citalopram hydrobromide tab 10 mg (base equiv) (Celexa)........................................................................... 77 citalopram hydrobromide tab 20 mg (base equiv) (Celexa)........................................................................... 77 citalopram hydrobromide tab 40 mg (base equiv) (Celexa)........................................................................... 77 CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak......................................... 116 CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack.......................................... 116 CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak............................................... 116 CITRANATAL B-CALM -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab pak............................................... 116 CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack.................................................... 116 CITRANATAL HARMONY -prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg.................................................... 116 CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg..........................................116 CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg..........................................................116 CITRUS BERGAMOT -citrus bergamot oral powder 250 mg/0.25 gm.................................................................... 163 CLARAVIS -isotretinoin cap 30 mg................................. 147 CLARIFOAM EF -sulfacetamide sodium w/ sulfur foam 10-5%............................................................................. 147 CLARINEX-D 12 HOUR -desloratadine & pseudoephedrine tab sr 12hr 2.5-120 mg........................60 CLARINEX -desloratadine syrup 0.5 mg/ml...................... 58 CLARINEX -desloratadine tab 5 mg..................................58 CLARINEX REDITABS -desloratadine tab orally disintegrating 2.5 mg....................................................... 58 CLARINEX REDITABS -desloratadine tab orally disintegrating 5 mg.......................................................... 58 clarithromycin for susp 125 mg/5ml................................ 3 clarithromycin for susp 250 mg/5ml (Biaxin).................. 3 clarithromycin tab 250 mg (Biaxin)..................................3 clarithromycin tab 500 mg (Biaxin)..................................3 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac).......... 3 CLEMASTINE FUMARATE -clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq)..................................58 clemastine fumarate tab 2.68 mg...................................58 CLEOCIN -clindamycin hcl cap 150 mg............................ 12 CLEOCIN -clindamycin hcl cap 300 mg............................ 12 CLEOCIN -clindamycin hcl cap 75 mg.............................. 12 CLEOCIN -clindamycin phosphate vaginal cream 2%.......73 CLEOCIN -clindamycin phosphate vaginal suppos 100 mg.................................................................................... 73 CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)................................ 12 CLEOCIN-T -clindamycin phosphate gel 1%...................147 CLEOCIN-T -clindamycin phosphate lotion 1%............... 147 CLEOCIN-T -clindamycin phosphate soln 1%................. 147 CLEOCIN-T -clindamycin phosphate swab 1%............... 147 CLEVER CHOICE COMFORT EZ -methyl salicylatelidocaine-menthol patch 20-4-1%.................................. 147 CLEVER CHOICE COMFORT EZ -methyl salicylatelidocaine-menthol patch 2-4-1%.................................... 147 CLIMARA -estradiol td patch weekly 0.025 mg/24hr......... 22 CLIMARA -estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)......................................................................... 22 CLIMARA -estradiol td patch weekly 0.05 mg/24hr........... 22 CLIMARA -estradiol td patch weekly 0.06 mg/24hr........... 22 CLIMARA -estradiol td patch weekly 0.075 mg/24hr......... 22 CLIMARA -estradiol td patch weekly 0.1 mg/24hr............. 22 CLIMARA PRO -estradiol-levonorgestrel td patch weekly 0.045-0.015 mg/day......................................................... 22 CLINDACIN ETZ -clindamycin phosphate swab 1% & cleanser kit.....................................................................147 CLINDACIN PAC -clindamycin phosphate swab 1% & cleanser kit.....................................................................147 CLINDAGEL -clindamycin phosphate gel 1%..................147 clindamycin hcl cap 150 mg (Cleocin)...........................12 clindamycin hcl cap 300 mg (Cleocin)...........................12 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 181 2015 clindamycin hcl cap 75 mg (Cleocin)............................ 12 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr)......................................... 12 clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin).................................................................... 147 clindamycin phosphate foam 1% (Evoclin)................. 147 clindamycin phosphate gel 1% (Cleocin-t)..................147 clindamycin phosphate lotion 1% (Cleocin-t)............. 147 clindamycin phosphate soln 1% (Cleocin-t)................147 clindamycin phosphate swab 1% (Cleocin-t).............. 147 clindamycin phosphate vaginal cream 2% (Cleocin).......................................................................... 73 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)................................................................ 147 CLINDESSE -clindamycin phosphate (one dose) vaginal cream 2%.........................................................................73 clobetasol propionate cream 0.05% (Temovate).........147 clobetasol propionate emollient base cream 0.05% (Temovate e).................................................................148 clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 148 clobetasol propionate foam 0.05% (Olux)................... 148 clobetasol propionate gel 0.05% (Temovate).............. 148 clobetasol propionate lotion 0.05% (Clobex).............. 148 clobetasol propionate oint 0.05% (Temovate).............148 clobetasol propionate shampoo 0.05% (Clobex)........ 148 clobetasol propionate soln 0.05% (Temovate)............148 clobetasol propionate spray 0.05% (Clobex).............. 148 CLOBEX -clobetasol propionate lotion 0.05%................. 148 CLOBEX -clobetasol propionate shampoo 0.05%........... 148 CLOBEX -clobetasol propionate spray 0.05%.................148 CLOCORTOLONE PIVALATE -clocortolone pivalate cream 0.1%....................................................................148 CLOCORTOLONE PIVALATE PUM -clocortolone pivalate cream 0.1%....................................................................148 CLODAN KIT -clobetasol propionate shampoo 0.05% & cleanser kit.....................................................................148 CLODERM -clocortolone pivalate cream 0.1%................148 CLODERM PUMP -clocortolone pivalate cream 0.1%.....148 clomipramine hcl cap 25 mg (Anafranil)....................... 77 clomipramine hcl cap 50 mg (Anafranil)....................... 77 clomipramine hcl cap 75 mg (Anafranil)....................... 77 clonazepam orally disintegrating tab 0.125 mg.......... 106 clonazepam orally disintegrating tab 0.25 mg............ 107 clonazepam orally disintegrating tab 0.5 mg.............. 107 clonazepam orally disintegrating tab 1 mg................. 107 clonazepam orally disintegrating tab 2 mg................. 107 clonazepam tab 0.5 mg (Klonopin).............................. 107 clonazepam tab 1 mg (Klonopin)................................. 107 clonazepam tab 2 mg (Klonopin)................................. 107 clonidine hcl tab 0.1 mg (Catapres)...............................47 clonidine hcl tab 0.2 mg (Catapres)...............................47 clonidine hcl tab 0.3 mg (Catapres)...............................47 clonidine hcl tab sr 12hr 0.1 mg (Kapvay).....................86 182 clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1).................................................................................47 clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2).................................................................................47 clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3).................................................................................47 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix)...........................................................................134 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)...........................................................................134 clorazepate dipotassium tab 15 mg (Tranxene t)..........75 clorazepate dipotassium tab 3.75 mg (Tranxene t).......75 clorazepate dipotassium tab 7.5 mg (Tranxene t).........75 CLORPRES -clonidine & chlorthalidone tab 0.1-15 mg..... 47 CLORPRES -clonidine & chlorthalidone tab 0.2-15 mg..... 47 CLORPRES -clonidine & chlorthalidone tab 0.3-15 mg..... 47 clotrimazole troche 10 mg............................................ 142 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone).....................................................................148 clotrimazole w/ betamethasone lotion 1-0.05%...........148 CLOZAPINE ODT -clozapine orally disintegrating tab 100 mg.................................................................................... 81 CLOZAPINE ODT -clozapine orally disintegrating tab 12.5 mg.................................................................................... 81 CLOZAPINE ODT -clozapine orally disintegrating tab 150 mg.................................................................................... 81 CLOZAPINE ODT -clozapine orally disintegrating tab 200 mg.................................................................................... 81 CLOZAPINE ODT -clozapine orally disintegrating tab 25 mg.................................................................................... 81 clozapine tab 100 mg (Clozaril)......................................81 clozapine tab 200 mg...................................................... 81 clozapine tab 25 mg (Clozaril)........................................81 clozapine tab 50 mg........................................................ 81 CLOZARIL -clozapine tab 100 mg.................................... 81 CLOZARIL -clozapine tab 25 mg...................................... 81 C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg...................................................................116 CNL8 NAIL KIT -ciclopirox soln 8% & lacquer removal pads kit...........................................................................148 COAL TAR -coal tar soln 20%........................................ 148 COARTEM -artemether-lumefantrine tab 20-120 mg........ 11 COCAINE HCL -cocaine hcl soln 10%............................ 148 COCAINE HCL -cocaine hcl soln 4%..............................148 CODAR AR -chlorpheniramine w/ codeine liquid 2-8 mg/5ml..............................................................................60 CODAR D -pseudoephedrine w/ codeine liquid 30-8 mg/5ml..............................................................................60 CODEINE SULFATE -codeine sulfate tab 15 mg..............94 CODEINE SULFATE -codeine sulfate tab 30 mg..............95 CODEINE SULFATE -codeine sulfate tab 60 mg..............95 codeine sulfate tab 15 mg (Codeine sulfate).................95 codeine sulfate tab 30 mg.............................................. 95 codeine sulfate tab 60 mg.............................................. 95 COLAZAL -balsalazide disodium cap 750 mg................... 70 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 COLCHICINE -colchicine cap 0.6 mg..............................106 COLCHICINE -colchicine tab 0.6 mg.............................. 106 colchicine w/ probenecid tab 0.5-500 mg.................... 106 COLCRYS -colchicine tab 0.6 mg................................... 106 COLESTID -colestipol hcl granule packets 5 gm...............54 COLESTID -colestipol hcl granules 5 gm.......................... 54 COLESTID -colestipol hcl tab 1 gm.................................. 54 COLESTID FLAVORED -colestipol hcl granule packets 5 gm.................................................................................... 54 COLESTID FLAVORED -colestipol hcl granules 5 gm...... 54 colestipol hcl granule packets 5 gm (Colestid flavored).......................................................................... 54 colestipol hcl granules 5 gm (Colestid flavored).......... 54 colestipol hcl tab 1 gm (Colestid).................................. 54 COLGATE DRY MOUTH RELIEF -sodium fluoride mouthwash 2.1 mg/10ml................................................142 COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml................................................ 141 COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................65 COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm...............................................65 COMBIGAN -brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%................................................................. 138 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.14 mg/day............................................................. 22 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.25 mg/day............................................................. 22 COMBIVENT RESPIMAT -ipratropium-albuterol inhal aerosol soln 20-100 mcg/act............................................63 COMBIVIR -lamivudine-zidovudine tab 150-300 mg........... 7 COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit........................................................................... 16 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit.............................................................16 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit.............................................................16 COMMIT -nicotine polacrilex lozenge 2 mg.......................90 COMMIT -nicotine polacrilex lozenge 4 mg.......................90 COMPAZINE -prochlorperazine maleate tab 10 mg (base equivalent)........................................................................81 COMPAZINE -prochlorperazine maleate tab 5 mg (base equivalent)........................................................................81 COMPLERA -emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg...................................................................7 COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 250 pk............................................ 116 COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab 29-1 mg..........................................................................116 COMTAN -entacapone tab 200 mg................................. 111 CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................. 116 CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg...........................................................116 CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg................................................................116 CONCERTA -methylphenidate hcl tab sa osm 18 mg....... 86 CONCERTA -methylphenidate hcl tab sa osm 27 mg....... 86 CONCERTA -methylphenidate hcl tab sa osm 36 mg....... 86 CONCERTA -methylphenidate hcl tab sa osm 54 mg....... 86 CONDYLOX -podofilox gel 0.5%.....................................148 CONDYLOX -podofilox soln 0.5%................................... 148 CONZIP -tramadol hcl cap sr 24hr biphasic release 100 mg.................................................................................... 95 CONZIP -tramadol hcl cap sr 24hr biphasic release 200 mg.................................................................................... 95 CONZIP -tramadol hcl cap sr 24hr biphasic release 300 mg.................................................................................... 95 COPASIL -emollient - gel................................................ 148 COPAXONE -glatiramer acetate soln prefilled syringe 20 mg/ml................................................................................90 COPAXONE -glatiramer acetate soln prefilled syringe 40 mg/ml................................................................................90 COPEGUS -ribavirin tab 200 mg.........................................7 CORDARONE -amiodarone hcl tab 200 mg..................... 44 CORDRAN -flurandrenolide cream 0.05%...................... 148 CORDRAN -flurandrenolide lotion 0.05%........................148 CORDRAN -flurandrenolide oint 0.05%...........................148 CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm...... 148 COREG -carvedilol tab 12.5 mg........................................40 COREG -carvedilol tab 25 mg...........................................40 COREG -carvedilol tab 3.125 mg......................................40 COREG -carvedilol tab 6.25 mg........................................40 COREG CR -carvedilol phosphate cap sr 24hr 10 mg...... 40 COREG CR -carvedilol phosphate cap sr 24hr 20 mg...... 40 COREG CR -carvedilol phosphate cap sr 24hr 40 mg...... 40 COREG CR -carvedilol phosphate cap sr 24hr 80 mg...... 40 CORGARD -nadolol tab 20 mg......................................... 40 CORGARD -nadolol tab 40 mg......................................... 40 CORGARD -nadolol tab 80 mg......................................... 40 CORIFACT -factor xiii concentrate (human) for inj kit 1000-1600 unit............................................................... 134 CORLANOR -ivabradine hcl tab 5 mg (base equiv).......... 57 CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)....... 57 CORTALO -hydrocortisone acetate-aloe vera gel 2%..... 148 CORTANE-B AQUEOUS -pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1 mg/ml.................................. 141 CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot 10-10-1mg/ml................................................................. 148 CORTANE-B-OTIC -pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml................................................................141 CORTEF -hydrocortisone tab 10 mg................................. 19 CORTEF -hydrocortisone tab 20 mg................................. 19 CORTEF -hydrocortisone tab 5 mg...................................19 CORTENEMA -hydrocortisone enema 100 mg/60ml.......144 CORTIFOAM -hydrocortisone acetate rectal foam 90 mg/ dose................................................................................144 CORTISONE ACETATE -cortisone acetate tab 25 mg......19 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 183 2015 CORTISPORIN -bacitracin-polymyxin-neomycin hc oint 1%.................................................................................. 148 CORTISPORIN -neomycin-polymyxin-hc cream 0.5%............................................................................... 148 CORTISPORIN -neomycin-polymyxin-hc otic soln 1%.................................................................................. 141 CORTISPORIN-TC -neomycin-colistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml................................................ 141 CORVITE 150 -iron combination tab............................... 129 CORVITE 150 -iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg...................................................................129 CORVITE FE -iron combination tab................................ 129 CORVITE -multiple vitamins w/ minerals & fa tab 1.25 mg.................................................................................. 116 CORZIDE -nadolol & bendroflumethiazide tab 40-5 mg.................................................................................... 47 CORZIDE -nadolol & bendroflumethiazide tab 80-5 mg.................................................................................... 47 COSENTYX -secukinumab subcutaneous soln prefilled syringe 150 mg/ml......................................................... 148 COSENTYX SENSOREADY PEN -secukinumab subcutaneous soln auto-injector 150 mg/ml.................. 148 COSOPT -dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml............................................................... 138 COSOPT PF -dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf...........................................................138 COUMADIN -warfarin sodium tab 10 mg........................ 132 COUMADIN -warfarin sodium tab 1 mg.......................... 131 COUMADIN -warfarin sodium tab 2.5 mg....................... 132 COUMADIN -warfarin sodium tab 2 mg.......................... 132 COUMADIN -warfarin sodium tab 3 mg.......................... 132 COUMADIN -warfarin sodium tab 4 mg.......................... 132 COUMADIN -warfarin sodium tab 5 mg.......................... 132 COUMADIN -warfarin sodium tab 6 mg.......................... 132 COUMADIN -warfarin sodium tab 7.5 mg....................... 132 COZAAR -losartan potassium tab 100 mg........................ 47 COZAAR -losartan potassium tab 25 mg.......................... 47 COZAAR -losartan potassium tab 50 mg.......................... 47 CPB WC -pseudoephedrine-bromphen-codeine liq 10-1.3-6.3 mg/5ml............................................................60 CREON -pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit.................................................. 69 CREON -pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit................................................ 69 CREON -pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit...................................................... 69 CREON -pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit.............................................. 69 CREON -pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit.................................................... 69 CRESEMBA -isavuconazonium sulfate cap 186 mg........... 6 CRESTOR -rosuvastatin calcium tab 10 mg..................... 54 CRESTOR -rosuvastatin calcium tab 20 mg..................... 54 CRESTOR -rosuvastatin calcium tab 40 mg..................... 54 CRESTOR -rosuvastatin calcium tab 5 mg....................... 54 184 CRIXIVAN -indinavir sulfate cap 200 mg............................ 7 CRIXIVAN -indinavir sulfate cap 400 mg............................ 7 CROMOLYN SODIUM -cromolyn sodium soln nebu 20 mg/2ml..............................................................................63 cromolyn sodium ophth soln 4%................................. 138 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)...................................................................70 CUPRIMINE -penicillamine cap 250 mg..........................164 CURITY HYPERTONIC SODIUM -wound dressings misc................................................................................ 148 CURITY SODIUM CHLORIDE DR -wound dressings pads................................................................................148 CUROSURF -poractant alfa intratracheal susp 80 mg/ ml......................................................................................65 CUTIVATE -fluticasone propionate cream 0.05%............148 CUTIVATE -fluticasone propionate lotion 0.05%............. 148 CUVPOSA -glycopyrrolate oral soln 1 mg/5ml.................. 66 CVS GLUCOSE BITS -glucose chew tab 1 gm.................27 CVS GLUCOSE -glucose chew tab 4 gm......................... 27 CVS GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 27 CYANOCOBALAMIN/LEVOMEFOLA -l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg.......................................... 126 cyanocobalamin inj 1000 mcg/ml.................................129 CYCLESSA -desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg.........................24 CYCLOBENZAPRINE COMFORT P -cyclobenzaprine hcl tab 10 mg & liniment topical gel kit................................114 cyclobenzaprine hcl tab 10 mg.................................... 114 cyclobenzaprine hcl tab 5 mg...................................... 114 cyclobenzaprine hcl tab 7.5 mg (Fexmid)....................114 CYCLOGYL -cyclopentolate hcl ophth soln 0.5%............138 CYCLOGYL -cyclopentolate hcl ophth soln 1%...............138 CYCLOGYL -cyclopentolate hcl ophth soln 2%...............138 CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth soln 0.2-1%.................................................................... 138 cyclopentolate hcl ophth soln 1% (Cyclogyl)..............138 cyclopentolate hcl ophth soln 2% (Cyclogyl)..............138 CYCLOPHOSPHAMIDE -cyclophosphamide cap 25 mg.................................................................................... 16 CYCLOPHOSPHAMIDE -cyclophosphamide cap 50 mg.................................................................................... 16 CYCLOSERINE -cycloserine cap 250 mg...........................6 CYCLOSET -bromocriptine mesylate tab 0.8 mg (base equivalent)........................................................................27 cyclosporine cap 100 mg (Sandimmune).................... 164 cyclosporine cap 25 mg (Sandimmune)...................... 164 cyclosporine modified cap 100 mg (Neoral)............... 164 cyclosporine modified cap 25 mg (Neoral)................. 164 CYCLOSPORINE MODIFIED -cyclosporine modified cap 50 mg............................................................................. 164 cyclosporine modified oral soln 100 mg/ml (Neoral)..........................................................................164 CYMBALTA -duloxetine hcl enteric coated pellets cap 20 mg.................................................................................... 77 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 CYMBALTA -duloxetine hcl enteric coated pellets cap 30 mg.................................................................................... 77 CYMBALTA -duloxetine hcl enteric coated pellets cap 60 mg.................................................................................... 77 cyproheptadine hcl syrup 2 mg/5ml.............................. 58 cyproheptadine hcl tab 4 mg......................................... 58 CYSTADANE -betaine powder for oral solution................ 35 CYSTAGON -cysteamine bitartrate cap 150 mg............... 74 CYSTAGON -cysteamine bitartrate cap 50 mg................. 74 CYSTARAN -cysteamine hcl ophth soln 0.44% (base equivalent)......................................................................138 CYTOMEL -liothyronine sodium tab 25 mcg..................... 33 CYTOMEL -liothyronine sodium tab 50 mcg..................... 33 CYTOMEL -liothyronine sodium tab 5 mcg....................... 33 CYTOTEC -misoprostol tab 100 mcg................................ 66 CYTOTEC -misoprostol tab 200 mcg................................ 66 CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml..............................................................................74 D DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base equivalent)..........................................................................7 DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base equivalent)..........................................................................7 DALIRESP -roflumilast tab 500 mcg................................. 63 danazol cap 100 mg........................................................ 21 danazol cap 200 mg........................................................ 21 danazol cap 50 mg.......................................................... 21 DANTRIUM -dantrolene sodium cap 100 mg.................. 114 DANTRIUM -dantrolene sodium cap 25 mg.................... 114 DANTRIUM -dantrolene sodium cap 50 mg.................... 114 dantrolene sodium cap 25 mg (Dantrium)...................114 dantrolene sodium cap 50 mg (Dantrium)...................114 DANTROLENE SODIUM -dantrolene sodium cap 100 mg.................................................................................. 114 DAPSONE -dapsone tab 100 mg......................................12 DAPSONE -dapsone tab 25 mg........................................12 DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml..............................................................................15 DARAPRIM -pyrimethamine tab 25 mg.............................11 DAYPRO -oxaprozin tab 600 mg.................................... 101 DAYTRANA -methylphenidate td patch 10 mg/9hr............86 DAYTRANA -methylphenidate td patch 15 mg/9hr............86 DAYTRANA -methylphenidate td patch 20 mg/9hr............86 DAYTRANA -methylphenidate td patch 30 mg/9hr............86 DDAVP -desmopressin acetate inj 4 mcg/ml.....................36 DDAVP -desmopressin acetate nasal soln 0.01% (refrigerated).....................................................................35 DDAVP -desmopressin acetate nasal spray soln 0.01%............................................................................... 36 DDAVP -desmopressin acetate tab 0.1 mg.......................36 DDAVP -desmopressin acetate tab 0.2 mg.......................36 DDROPS -cholecalciferol drops 1000 unit/0.03ml (per drop)............................................................................... 115 DEBACTEROL -sulfuric acid-sulfonated phenolics soln 30-50%........................................................................... 142 DECARA -cholecalciferol cap 25000 unit........................ 115 DECON-A -brompheniramine & phenylephrine elixir 2-5 mg/5ml..............................................................................60 DECON-G -phenylephrine-brompheniramine-guaifenesin liqd 2-1-40 mg/ml............................................................. 60 DELZICOL -mesalamine cap dr 400 mg........................... 70 DEMADEX -torsemide tab 10 mg......................................52 DEMADEX -torsemide tab 20 mg......................................53 DEMADEX -torsemide tab 5 mg........................................52 demeclocycline hcl tab 150 mg........................................4 demeclocycline hcl tab 300 mg........................................4 DEMEROL -meperidine hcl tab 100 mg............................ 95 DEMEROL -meperidine hcl tab 50 mg.............................. 95 DEMSER -metyrosine cap 250 mg................................... 47 DENAVIR -penciclovir cream 1%.................................... 148 DEPAKENE -valproate sodium syrup 250 mg/5ml (base equiv)..............................................................................107 DEPAKENE -valproic acid cap 250 mg........................... 107 DEPAKOTE -divalproex sodium tab delayed release 125 mg.................................................................................. 107 DEPAKOTE -divalproex sodium tab delayed release 250 mg.................................................................................. 107 DEPAKOTE -divalproex sodium tab delayed release 500 mg.................................................................................. 107 DEPAKOTE ER -divalproex sodium tab sr 24 hr 250 mg.................................................................................. 107 DEPAKOTE ER -divalproex sodium tab sr 24 hr 500 mg.................................................................................. 107 DEPAKOTE SPRINKLES -divalproex sodium cap sprinkle 125 mg........................................................................... 107 DEPEN TITRATABS -penicillamine tab 250 mg..............164 DEPLIN 15 -l-methylfolate-algae cap 15-90.314 mg....... 126 DEPLIN 7.5 -l-methylfolate-algae cap 7.5-90.314 mg......126 DEPLIN -l-methylfolate tab 15 mg...................................126 DEPLIN -l-methylfolate tab 7.5 mg.................................. 126 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml.......... 24 DEPO-SUBQ PROVERA 104 -medroxyprogesterone acetate subcutaneous susp 104 mg/0.65ml.................... 24 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 100 mg/ml................................................................... 21 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 200 mg/ml................................................................... 21 DERMACINRX ANALGESIC COMB -diclofenac sod tab dr 75 mg & lido-men-methyl sal ptch kit.............................101 DERMACINRX DUOPATCH PHARM -lidocaine patch 5% & menthol-methyl sal patch 3-10% ther pak.................. 149 DERMACINRX INFLAMMATRAL P -diclofen dr tab 75mgranitidine tab 150mg-capsaicin cr thpk.......................... 101 DERMACINRX LEXITRAL PHARM -diclofenac sod soln 1.5% & capsaicin cream 0.025% ther pack................... 149 DERMACINRX NEUROTRAL PHAR -lidocaine patch 5% & capsaicin cream 0.025% therapy pack.......................149 DERMACINRX SILAPAK -triamcinolone acet cr 0.1% & dimeth cr 5% & silicone tape......................................... 149 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 185 2015 DERMACINRX SURGICAL COMBO -chlorhexidine solndimeth cr-silicone tape-homeopathic kit.........................149 DERMACINRX SURGICAL PHARM -chlorhexidine solmupirocin cr-dimeth cr-silicone tape kit..........................149 DERMA SILKRX ANODYNEXA PA -diclofen dr tab 75mgranitidine tab 150mg-capsaicin cr thpk.......................... 101 DERMA SILKRX SDS PAK -triamcinolone acet cr 0.1% & dimeth cr 5% & silicone tape......................................... 148 DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil 0.01% (body oil).............................................................149 DERMA-SMOOTHE/FS BODY OIL -fluocinolone acetonide oil 0.01% (body oil)....................................... 149 DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide oil 0.01% (scalp oil)............................................................ 149 DERMA-SMOOTHE/FS SCALP OI -fluocinolone acetonide oil 0.01% (scalp oil)....................................................... 149 DERMASORB AF -clioquinol-hc cream 3-0.5% & emollient liqd kit.............................................................................149 DERMASORB HC -hydrocortisone lot 2% & cleanser liq kit....................................................................................149 DERMASORB TA -triamcinolone cream 0.1% & emollient cream kit........................................................................ 149 DERMASORB XM -urea cream 39% & emollient cream kit....................................................................................149 DERMATOP -prednicarbate cream 0.1%........................ 149 DERMATOP -prednicarbate oint 0.1%............................ 149 DERMOTIC -fluocinolone acetonide (otic) oil 0.01%....... 141 desipramine hcl tab 100 mg (Norpramin)......................77 desipramine hcl tab 10 mg (Norpramin)........................77 desipramine hcl tab 150 mg (Norpramin)......................77 desipramine hcl tab 25 mg (Norpramin)........................77 desipramine hcl tab 50 mg (Norpramin)........................77 desipramine hcl tab 75 mg (Norpramin)........................77 desloratadine tab 5 mg (Clarinex)..................................58 desloratadine tab orally disintegrating 2.5 mg (Clarinex reditabs)......................................................... 58 desloratadine tab orally disintegrating 5 mg (Clarinex reditabs).......................................................................... 58 desmopressin acetate inj 4 mcg/ml (Ddavp).................36 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)............................................................................ 36 desmopressin acetate nasal spray soln 0.01% (Ddavp)............................................................................ 36 desmopressin acetate nasal spray soln 0.01% (refrigerated)................................................................... 36 desmopressin acetate tab 0.1 mg (Ddavp)....................36 desmopressin acetate tab 0.2 mg (Ddavp)....................36 DESOGEN -desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg...................................................................................24 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette)......................................................... 24 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....24 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)........................................................................24 186 DESONATE -desonide gel 0.05%................................... 149 desonide cream 0.05% (Desowen)............................... 149 desonide lotion 0.05% (Desowen)................................149 desonide oint 0.05% (Desowen)...................................149 DESOWEN -desonide cream 0.05%............................... 149 DESOWEN -desonide lotion 0.05%................................ 149 DESOWEN -desonide oint 0.05%................................... 149 desoximetasone cream 0.25% (Topicort).................... 149 DESOXIMETASONE -desoximetasone cream 0.05%.....149 DESOXIMETASONE -desoximetasone oint 0.05%......... 149 desoximetasone gel 0.05% (Topicort)......................... 149 desoximetasone oint 0.25% (Topicort)........................ 149 DESOXYN -methamphetamine hcl tab 5 mg.................... 86 DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr 24hr 100 mg (base equiv)............................................... 77 DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr 24hr 50 mg (base equiv)................................................. 77 DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100 mg.................................................................................... 77 DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50 mg.................................................................................... 77 DETROL LA -tolterodine tartrate cap sr 24hr 2 mg........... 72 DETROL LA -tolterodine tartrate cap sr 24hr 4 mg........... 73 DETROL -tolterodine tartrate tab 1 mg............................. 72 DETROL -tolterodine tartrate tab 2 mg............................. 72 DEX4 FAST ACTING GLUCOSE -glucose gel 15 gm/33gm.......................................................................... 27 DEX4 FAST ACTING GLUCOSE -glucose oral liquid 15 gm/59ml............................................................................27 DEX4 FAST ACTING GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm................................................................ 27 DEX4 -glucose chew tab 1 gm..........................................27 DEX4 GLUCOSE -glucose chew tab 4 gm....................... 27 DEX4 GLUCOSE -glucose oral liquid 15 gm/59ml............ 27 DEX4 -glucose-vitamin c chew tab 4-0.006 gm.................27 DEX4 NATURALS -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 27 DEX4 POUCH PACK -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 27 DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4 gm.................................................................................... 27 DEXAMETHASONE -dexamethasone soln 0.5 mg/5ml..............................................................................19 DEXAMETHASONE -dexamethasone tab 1 mg............... 19 DEXAMETHASONE -dexamethasone tab 2 mg............... 19 dexamethasone elixir 0.5 mg/5ml.................................. 19 DEXAMETHASONE INTENSOL -dexamethasone conc 1 mg/ml................................................................................19 dexamethasone sodium phosphate ophth soln 0.1%............................................................................... 138 dexamethasone tab 0.5 mg............................................ 20 dexamethasone tab 0.75 mg.......................................... 20 dexamethasone tab 1.5 mg............................................ 20 dexamethasone tab 4 mg............................................... 20 dexamethasone tab 6 mg............................................... 20 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 10 mg.................................................................................... 86 DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 15 mg.................................................................................... 86 DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 5 mg.................................................................................... 86 DEXILANT -dexlansoprazole cap delayed release 30 mg.................................................................................... 66 DEXILANT -dexlansoprazole cap delayed release 60 mg.................................................................................... 66 dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin xr).....................................................................................86 dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr).....................................................................................86 dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin xr).....................................................................................87 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr).....................................................................................87 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr).....................................................................................87 dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin xr).....................................................................................86 dexmethylphenidate hcl tab 10 mg (Focalin)................ 87 dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 87 dexmethylphenidate hcl tab 5 mg (Focalin).................. 87 DEXPAK 10 DAY -dexamethasone tab 1.5 mg taper pack..................................................................................20 DEXPAK 13 DAY -dexamethasone tab 1.5 mg taper pack..................................................................................20 DEXPAK 6 DAY -dexamethasone tab 1.5 mg taper pack..................................................................................20 dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine)......................................................................87 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine)......................................................................87 dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine)......................................................................87 dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra)...................................................................... 87 dextroamphetamine sulfate tab 10 mg.......................... 87 dextroamphetamine sulfate tab 5 mg............................ 87 DEXTROMETHORPHAN HBR/CHLO -phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 60 DEX-TUSS -guaifenesin-codeine liquid 300-10 mg/5ml..............................................................................60 DIABETA -glyburide tab 1.25 mg...................................... 27 DIABETA -glyburide tab 2.5 mg........................................ 27 DIABETA -glyburide tab 5 mg........................................... 27 DIALYVITE/ZINC -b-complex w/ c-zn & folic acid tab 1 mg.................................................................................. 116 DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic acid tab 3 mg.................................................................116 DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic acid tab 5 mg.................................................................116 DIALYVITE SUPREME D -multiple vitamins w/ minerals & fa tab 3 mg.................................................................... 116 DIAMOX -acetazolamide cap sr 12hr 500 mg................... 53 DIASTAT ACUDIAL -diazepam rectal gel delivery system 10 mg............................................................................. 107 DIASTAT ACUDIAL -diazepam rectal gel delivery system 20 mg............................................................................. 107 DIASTAT PEDIATRIC -diazepam rectal gel delivery system 2.5 mg............................................................... 107 DIATX ZN -b-complex w/ c-biotin-minerals & folic acid tab 5 mg............................................................................... 116 diazepam conc 5 mg/ml.................................................. 75 DIAZEPAM -diazepam rectal gel delivery system 10 mg.................................................................................. 107 DIAZEPAM -diazepam rectal gel delivery system 2.5 mg.................................................................................. 107 DIAZEPAM -diazepam rectal gel delivery system 20 mg.................................................................................. 107 DIAZEPAM -diazepam soln 1 mg/ml................................. 75 diazepam tab 10 mg (Valium)......................................... 75 diazepam tab 2 mg (Valium)...........................................75 diazepam tab 5 mg (Valium)........................................... 75 DIBENZYLINE -phenoxybenzamine hcl cap 10 mg...........47 DICLEGIS -doxylamine-pyridoxine tab delayed release 10-10 mg..........................................................................69 diclofenac potassium tab 50 mg (Cataflam)................101 diclofenac sodium (actinic keratoses) gel 3% (Solaraze)...................................................................... 149 diclofenac sodium ophth soln 0.1%............................ 138 diclofenac sodium soln 1.5% (Pennsaid).................... 149 diclofenac sodium tab delayed release 25 mg............101 diclofenac sodium tab delayed release 50 mg............101 diclofenac sodium tab delayed release 75 mg............101 diclofenac sodium tab sr 24hr 100 mg (Voltarenxr)...................................................................................102 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50).........................................................102 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75).........................................................102 dicloxacillin sodium cap 250 mg..................................... 1 dicloxacillin sodium cap 500 mg..................................... 1 dicyclomine hcl cap 10 mg (Bentyl).............................. 66 dicyclomine hcl oral soln 10 mg/5ml.............................67 dicyclomine hcl tab 20 mg (Bentyl)............................... 67 didanosine delayed release capsule 125 mg (Videx ec)...................................................................................... 7 didanosine delayed release capsule 200 mg (Videx ec)...................................................................................... 7 didanosine delayed release capsule 250 mg (Videx ec)...................................................................................... 7 didanosine delayed release capsule 400 mg (Videx ec)...................................................................................... 7 DIDRONEL -etidronate disodium tab 400 mg....................36 DIFFERIN -adapalene cream 0.1%.................................149 DIFFERIN -adapalene gel 0.1%...................................... 149 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 187 2015 DIFFERIN -adapalene gel 0.3%...................................... 149 DIFFERIN -adapalene lotion 0.1%.................................. 149 DIFICID -fidaxomicin tab 200 mg........................................ 3 DIFLORASONE DIACETATE -diflorasone diacetate cream 0.05%............................................................................. 149 DIFLORASONE DIACETATE -diflorasone diacetate oint 0.05%............................................................................. 149 DIFLUCAN -fluconazole for susp 10 mg/ml.........................6 DIFLUCAN -fluconazole for susp 40 mg/ml.........................6 DIFLUCAN -fluconazole tab 100 mg................................... 6 DIFLUCAN -fluconazole tab 150 mg................................... 6 DIFLUCAN -fluconazole tab 200 mg................................... 6 DIFLUCAN -fluconazole tab 50 mg..................................... 6 diflunisal tab 500 mg.......................................................93 DIGEX NF -hyoscyamine-phenyltoloxamine cap 0.0625-15 mg.................................................................................... 67 DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 39 digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 39 digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 39 DIHYDROERGOTAMINE MESYLAT -dihydroergotamine mesylate nasal spray 4 mg/ml....................................... 104 DILANTIN-125 -phenytoin susp 125 mg/5ml................... 107 DILANTIN INFATABS -phenytoin chew tab 50 mg..........107 DILANTIN -phenytoin sodium extended cap 100 mg.......107 DILANTIN -phenytoin sodium extended cap 30 mg.........107 DILATRATE SR -isosorbide dinitrate cap cr 40 mg........... 39 DILAUDID -hydromorphone hcl liqd 1 mg/ml.................... 95 DILAUDID -hydromorphone hcl tab 2 mg..........................95 DILAUDID -hydromorphone hcl tab 4 mg..........................95 DILAUDID -hydromorphone hcl tab 8 mg..........................95 diltiazem hcl cap sr 12hr 120 mg................................... 42 diltiazem hcl cap sr 12hr 60 mg.....................................42 diltiazem hcl cap sr 12hr 90 mg.....................................42 diltiazem hcl cap sr 24hr 120 mg................................... 42 diltiazem hcl cap sr 24hr 180 mg................................... 42 diltiazem hcl cap sr 24hr 240 mg................................... 42 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)................................................................. 42 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)................................................................. 42 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd)................................................................. 42 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd)................................................................. 42 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd)................................................................. 42 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la).................................................................. 42 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la).................................................................. 42 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la).................................................................. 42 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la).................................................................. 42 188 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la).................................................................. 42 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac)..................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac)..................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac)..................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac)..................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac)..................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac)..................................................................... 43 diltiazem hcl tab 120 mg (Cardizem)............................. 43 diltiazem hcl tab 30 mg (Cardizem)............................... 43 diltiazem hcl tab 60 mg (Cardizem)............................... 43 diltiazem hcl tab 90 mg...................................................43 DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-12.5 mg.................................................................................... 47 DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25 mg.................................................................................... 47 DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-12.5 mg.................................................................................... 47 DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25 mg.................................................................................... 48 DIOVAN HCT -valsartan-hydrochlorothiazide tab 80-12.5 mg.................................................................................... 47 DIOVAN -valsartan tab 160 mg.........................................47 DIOVAN -valsartan tab 320 mg.........................................47 DIOVAN -valsartan tab 40 mg...........................................47 DIOVAN -valsartan tab 80 mg...........................................47 DIPENTUM -olsalazine sodium cap 250 mg..................... 70 DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml........................................................ 66 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil).......................................................................... 66 DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml................................. 15 DIPROLENE AF -betamethasone dipropionate augmented cream 0.05%..................................................................149 DIPROLENE -betamethasone dipropionate augmented lotion 0.05%................................................................... 149 DIPROLENE -betamethasone dipropionate augmented oint 0.05%...................................................................... 149 dipyridamole tab 25 mg (Persantine)...........................134 dipyridamole tab 50 mg (Persantine)...........................134 dipyridamole tab 75 mg (Persantine)...........................134 DISALCID -salsalate tab 500 mg...................................... 93 DISALCID -salsalate tab 750 mg...................................... 93 disopyramide phosphate cap 100 mg (Norpace).......... 44 disopyramide phosphate cap 150 mg (Norpace).......... 44 disulfiram tab 250 mg (Antabuse)..................................90 disulfiram tab 500 mg (Antabuse)..................................90 DITROPAN XL -oxybutynin chloride tab sr 24hr 10 mg..... 73 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 DITROPAN XL -oxybutynin chloride tab sr 24hr 15 mg..... 73 DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg.......73 DIURIL -chlorothiazide susp 250 mg/5ml.......................... 53 divalproex sodium cap sprinkle 125 mg (Depakote sprinkles)...................................................................... 107 divalproex sodium tab delayed release 125 mg (Depakote).....................................................................107 divalproex sodium tab delayed release 250 mg (Depakote).....................................................................107 divalproex sodium tab delayed release 500 mg (Depakote).....................................................................107 divalproex sodium tab sr 24 hr 250 mg (Depakote er)...................................................................................107 divalproex sodium tab sr 24 hr 500 mg (Depakote er)...................................................................................107 DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)............ 22 DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)................ 22 DIVIGEL -estradiol td gel 1 mg/gm (0.1%)........................ 22 DIVISTA -folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1 mg.................................................................................. 129 DOLOPHINE HCL -methadone hcl tab 5 mg.................... 95 DOLOPHINE -methadone hcl tab 10 mg...........................95 donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt)............................................................. 90 donepezil hydrochloride orally disintegrating tab 5 mg.................................................................................... 90 donepezil hydrochloride tab 10 mg (Aricept)................90 donepezil hydrochloride tab 23 mg (Aricept)................90 donepezil hydrochloride tab 5 mg (Aricept)..................90 DONNATAL EXTENTABS -pb-hyoscy-atrop-scopol tab cr 48.6-0.3111-0.0582-0.0195 mg........................................67 DONNATAL -pb-hyoscy-atrop-scopol elix 16.2-0.1037-0.0194-0.0065 mg/5ml.................................67 DONNATAL -pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg........................................67 DORAL -quazepam tab 15 mg.......................................... 84 DORYX -doxycycline hyclate tab delayed release 200 mg...................................................................................... 4 DORYX -doxycycline hyclate tab delayed release 50 mg...................................................................................... 4 dorzolamide hcl ophth soln 2% (Trusopt)................... 138 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt).............................................................138 DOVONEX -calcipotriene cream 0.005%........................ 149 doxazosin mesylate tab 1 mg (Cardura)........................48 doxazosin mesylate tab 2 mg (Cardura)........................48 doxazosin mesylate tab 4 mg (Cardura)........................48 doxazosin mesylate tab 8 mg (Cardura)........................48 doxepin hcl cap 100 mg..................................................77 doxepin hcl cap 10 mg................................................... 77 doxepin hcl cap 150 mg..................................................77 doxepin hcl cap 25 mg................................................... 77 doxepin hcl cap 50 mg................................................... 77 doxepin hcl conc 10 mg/ml............................................ 77 DOXEPIN HCL -doxepin hcl cap 75 mg............................77 doxercalciferol cap 0.5 mcg (Hectorol)......................... 36 doxercalciferol cap 1 mcg (Hectorol)............................ 36 doxercalciferol cap 2.5 mcg (Hectorol)......................... 36 DOXYCYCLINE -doxycycline (rosacea) cap delayed release 40 mg................................................................ 149 doxycycline hyclate cap 100 mg (Vibramycin)............... 4 doxycycline hyclate cap 50 mg........................................4 doxycycline hyclate tab 100 mg.......................................4 doxycycline hyclate tab 20 mg.........................................4 doxycycline hyclate tab delayed release 100 mg........... 4 doxycycline hyclate tab delayed release 150 mg (Doryx)...............................................................................4 doxycycline hyclate tab delayed release 75 mg............. 4 doxycycline monohydrate cap 100 mg (Monodox).........4 doxycycline monohydrate cap 150 mg (Adoxa)............. 4 doxycycline monohydrate cap 50 mg..............................4 doxycycline monohydrate cap 75 mg (Monodox)...........4 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin)......................................................................4 doxycycline monohydrate tab 100 mg (Adoxa pak 1/100)................................................................................. 4 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150)................................................................................. 4 doxycycline monohydrate tab 50 mg (Adoxa)................ 4 doxycycline monohydrate tab 75 mg (Adoxa)................ 4 DRISDOL -ergocalciferol cap 50000 unit........................ 115 DRITHO-CREME HP -anthralin cream 1%......................150 dronabinol cap 10 mg (Marinol)..................................... 69 dronabinol cap 2.5 mg (Marinol).................................... 69 dronabinol cap 5 mg (Marinol)....................................... 69 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......24 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28).................................................................................... 24 DROXIA -hydroxyurea cap 200 mg................................. 129 DROXIA -hydroxyurea cap 300 mg................................. 129 DROXIA -hydroxyurea cap 400 mg................................. 129 DRUG MART GLUCOSE -glucose chew tab 4 gm........... 27 DRUG MART GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.......................................................................27 DRYSOL -aluminum chloride soln 20%...........................150 DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%...................................................................... 150 DUAVEE -conjugated estrogens-bazedoxifene tab 0.45-20 mg.................................................................................... 22 DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg........ 27 DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg........ 28 DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg........................................................116 DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab 25-1 & omega cap 267 mg............................................116 DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg.........................................116 DUET DHA -prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg........................................................116 DUEXIS -ibuprofen-famotidine tab 800-26.6 mg............. 102 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 189 2015 DULERA -mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act..................................................... 63 DULERA -mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act..................................................... 63 DULOXETINE HCL -duloxetine hcl enteric coated pellets cap 40 mg........................................................................77 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta).......................................................................77 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta).......................................................................77 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta).......................................................................77 DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/ ml....................................................................................111 DURACHOL -folic acid-cholecalciferol cap 1 mg-3775 unit..................................................................................129 DURAGESIC -fentanyl td patch 72hr 100 mcg/hr..............95 DURAGESIC -fentanyl td patch 72hr 12 mcg/hr................95 DURAGESIC -fentanyl td patch 72hr 25 mcg/hr................95 DURAGESIC -fentanyl td patch 72hr 50 mcg/hr................95 DURAGESIC -fentanyl td patch 72hr 75 mcg/hr................95 DUREZOL -difluprednate ophth emulsion 0.05%............ 138 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 100-12.5 mg.....................................................................48 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 25-12.5 mg.......................................................................48 DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr 50-12.5 mg.......................................................................48 D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............. 115 DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25 mg.................................................................................... 53 DYMISTA -azelastine hcl-fluticasone prop nasal spray 137-50 mcg/act................................................................ 59 dyphylline-guaifenesin liqd 100-100 mg/5ml.................63 DYRENIUM -triamterene cap 100 mg............................... 53 DYRENIUM -triamterene cap 50 mg................................. 53 E E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg.......... 3 E.E.S. GRANULES -erythromycin ethylsuccinate for susp 200 mg/5ml........................................................................ 3 EC-NAPROSYN -naproxen tab ec 375 mg..................... 102 EC-NAPROSYN -naproxen tab ec 500 mg..................... 102 econazole nitrate cream 1%......................................... 150 ECOZA -econazole nitrate foam 1%............................... 150 EDARBI -azilsartan medoxomil tab 40 mg........................ 48 EDARBI -azilsartan medoxomil tab 80 mg........................ 48 EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab 40-12.5 mg.......................................................................48 EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab 40-25 mg..........................................................................48 ED CYTE F -ferrous fumarate-folic acid-docusate sodium tab 324-1-50 mg............................................................ 129 EDECRIN -ethacrynic acid tab 25 mg............................... 53 EDLUAR -zolpidem tartrate sl tab 10 mg.......................... 84 EDLUAR -zolpidem tartrate sl tab 5 mg............................ 84 190 EDURANT -rilpivirine hcl tab 25 mg (base equivalent)........ 7 EFFER-K -potassium bicarbonate-citric acid effer tab 10 meq................................................................................ 124 EFFER-K -potassium bicarbonate-citric acid effer tab 20 meq................................................................................ 124 EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base equivalent)........................................................................77 EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)........................................................................77 EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base equivalent)........................................................................77 EFFIENT -prasugrel hcl tab 10 mg (base equiv)............. 134 EFFIENT -prasugrel hcl tab 5 mg (base equiv)............... 134 EFUDEX -fluorouracil cream 5%..................................... 150 EGRIFTA -tesamorelin acetate for inj 1 mg (base equiv)................................................................................36 EGRIFTA -tesamorelin acetate for inj 2 mg (base equiv)................................................................................36 ELDEPRYL -selegiline hcl cap 5 mg............................... 111 ELENZAPATCH -lidocaine-menthol patch 4-1%............. 150 ELESTAT -epinastine hcl ophth soln 0.05%....................138 ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump)........................................................22 ELETONE -dermatological products misc - cream.......... 150 ELETONE TWINPACK -dermatological products misc cream............................................................................. 150 ELIDEL -pimecrolimus cream 1%....................................150 ELIGARD -leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg................................................................... 16 ELIGARD -leuprolide acetate (4 month) for subcutaneous inj kit 30 mg..................................................................... 16 ELIGARD -leuprolide acetate (6 month) for subcutaneous inj kit 45 mg..................................................................... 17 ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5 mg.................................................................................... 16 ELIGEN B12 -cyanocobalamin-salcaprozate sodium tab 1000 mcg-100 mg..........................................................126 ELIMITE -permethrin cream 5%...................................... 150 ELIPHOS -calcium acetate (phosphate binder) tab 667 mg.................................................................................... 70 ELIQUIS -apixaban tab 2.5 mg....................................... 132 ELIQUIS -apixaban tab 5 mg.......................................... 132 ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg.................................................................................. 116 ELIXOPHYLLIN -theophylline elixir 80 mg/15ml................63 ELLA -ulipristal acetate tab 30 mg.................................... 24 ELMIRON -pentosan polysulfate sodium caps 100 mg..... 74 ELOCON -mometasone furoate cream 0.1%.................. 150 ELOCON -mometasone furoate oint 0.1%...................... 150 ELOCON -mometasone furoate solution 0.1% (lotion)............................................................................ 150 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 1000 unit........................................................................ 134 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 1500 unit........................................................................ 134 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 2000 unit........................................................................ 134 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 250 unit.......................................................................... 134 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 3000 unit........................................................................ 134 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 500 unit.......................................................................... 134 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 750 unit.......................................................................... 134 EMADINE -emedastine difumarate ophth soln 0.05% (base equiv)................................................................... 138 EMBEDA -morphine-naltrexone cap cr 100-4 mg............. 95 EMBEDA -morphine-naltrexone cap cr 20-0.8 mg.............95 EMBEDA -morphine-naltrexone cap cr 30-1.2 mg.............95 EMBEDA -morphine-naltrexone cap cr 50-2 mg............... 95 EMBEDA -morphine-naltrexone cap cr 60-2.4 mg.............95 EMBEDA -morphine-naltrexone cap cr 80-3.2 mg.............95 EMCYT -estramustine phosphate sodium cap 140 mg......17 EMEND -aprepitant capsule 125 mg................................. 69 EMEND -aprepitant capsule 40 mg...................................69 EMEND -aprepitant capsule 80 mg...................................69 EMEND -aprepitant capsule therapy pack 80 & 125 mg.................................................................................... 69 EMLA -lidocaine-prilocaine cream 2.5-2.5%....................150 EMSAM -selegiline td patch 24hr 12 mg/24hr................... 77 EMSAM -selegiline td patch 24hr 6 mg/24hr..................... 77 EMSAM -selegiline td patch 24hr 9 mg/24hr..................... 77 EMTRIVA -emtricitabine caps 200 mg................................ 7 EMTRIVA -emtricitabine soln 10 mg/ml...............................7 EMULSION SB -dermatological products misc emulsion......................................................................... 150 ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg (base equiv)..................................................................... 73 ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv)..................................................................... 73 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)....................................................................... 48 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg.................................................................................... 48 enalapril maleate tab 10 mg (Vasotec).......................... 48 enalapril maleate tab 2.5 mg (Vasotec)......................... 48 enalapril maleate tab 20 mg (Vasotec).......................... 48 enalapril maleate tab 5 mg (Vasotec)............................ 48 ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty acids cap........................................................................116 ENBREL -etanercept for subcutaneous inj kit 25 mg.......102 ENBREL -etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml................................................................... 102 ENBREL -etanercept subcutaneous soln prefilled syringe 50 mg/ml........................................................................ 102 ENBREL SURECLICK -etanercept subcutaneous solution auto-injector 50 mg/ml................................................... 102 ENGERIX-B -hepatitis b vaccine (recombinant) 10 mcg/0.5ml.........................................................................13 ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/ ml......................................................................................13 ENGERIX-B -hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml.........................................................................13 ENGERIX-B -hepatitis b vaccine (recombinant) susp 20 mcg/ml..............................................................................13 ENJUVIA -estrogens, conjugated synthetic b tab 0.3 mg.................................................................................... 22 ENJUVIA -estrogens, conjugated synthetic b tab 0.45 mg.................................................................................... 22 ENJUVIA -estrogens, conjugated synthetic b tab 0.625 mg.................................................................................... 22 ENJUVIA -estrogens, conjugated synthetic b tab 0.9 mg.................................................................................... 22 ENJUVIA -estrogens, conjugated synthetic b tab 1.25 mg.................................................................................... 22 enoxaparin sodium inj 100 mg/ml (Lovenox).............. 132 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)......... 132 enoxaparin sodium inj 150 mg/ml (Lovenox).............. 132 enoxaparin sodium inj 300 mg/3ml (Lovenox)............ 132 enoxaparin sodium inj 30 mg/0.3ml (Lovenox)........... 132 enoxaparin sodium inj 40 mg/0.4ml (Lovenox)........... 132 enoxaparin sodium inj 60 mg/0.6ml (Lovenox)........... 132 enoxaparin sodium inj 80 mg/0.8ml (Lovenox)........... 132 entacapone tab 200 mg (Comtan)................................ 111 entecavir tab 0.5 mg (Baraclude)..................................... 7 entecavir tab 1 mg (Baraclude)........................................ 7 ENTERAGAM -serum-derived bovine immunoglob/protein isolate 5 gm packet....................................................... 126 ENTEREG -alvimopan cap 12 mg.....................................70 ENTOCORT EC -budesonide cap sr 24hr 3 mg................20 ENTRESTO -sacubitril-valsartan tab 24-26 mg................. 57 ENTRESTO -sacubitril-valsartan tab 49-51 mg................. 57 ENTRESTO -sacubitril-valsartan tab 97-103 mg............... 57 EPANED -enalapril maleate for oral soln 1 mg/ml.............48 EPICERAM -dermatological products misc emulsion......................................................................... 150 EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%.......150 EPIDUO FORTE -adapalene-benzoyl peroxide gel 0.3-2.5%......................................................................... 150 EPIFOAM -pramoxine-hc aerosol foam 1-1%................. 150 epinastine hcl ophth soln 0.05% (Elestat)................... 138 EPINEPHRINE -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000).......................................................... 53 EPINEPHRINE -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................54 EPIPEN 2-PAK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)............................................................54 EPIPEN-JR 2-PAK -epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)............................................................54 EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)................8 EPIVIR HBV -lamivudine tab 100 mg (hbv).........................8 EPIVIR -lamivudine oral soln 10 mg/ml...............................7 EPIVIR -lamivudine tab 150 mg.......................................... 7 EPIVIR -lamivudine tab 300 mg.......................................... 7 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 191 2015 eplerenone tab 25 mg (Inspra)....................................... 48 eplerenone tab 50 mg (Inspra)....................................... 48 EPOGEN -epoetin alfa inj 10000 unit/ml......................... 129 EPOGEN -epoetin alfa inj 20000 unit/ml......................... 129 EPOGEN -epoetin alfa inj 2000 unit/ml........................... 129 EPOGEN -epoetin alfa inj 3000 unit/ml........................... 129 EPOGEN -epoetin alfa inj 4000 unit/ml........................... 129 EPROSARTAN MESYLATE -eprosartan mesylate tab 600 mg.................................................................................... 48 EPZICOM -abacavir sulfate-lamivudine tab 600-300 mg.....8 EQUAGESIC -meprobamate-aspirin tab 200-325 mg....... 93 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 100 mg............................................................................. 81 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 200 mg............................................................................. 81 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 300 mg............................................................................. 81 ergocalciferol cap 50000 unit (Drisdol)........................115 ergoloid mesylates tab 1 mg.......................................... 90 ERGOMAR -ergotamine tartrate sl tab 2 mg...................104 ERIVEDGE -vismodegib cap 150 mg................................17 ERTACZO -sertaconazole nitrate cream 2%...................150 ERYGEL -erythromycin gel 2%....................................... 150 ERYPED 200 -erythromycin ethylsuccinate for susp 200 mg/5ml................................................................................3 ERYPED 400 -erythromycin ethylsuccinate for susp 400 mg/5ml................................................................................3 ERY-TAB -erythromycin tab delayed release 250 mg......... 3 ERY-TAB -erythromycin tab delayed release 333 mg......... 3 ERY-TAB -erythromycin tab delayed release 500 mg......... 3 ERYTHROCIN STEARATE -erythromycin stearate tab 250 mg...................................................................................... 3 ERYTHROMYCIN BASE -erythromycin tab 250 mg........... 3 ERYTHROMYCIN BASE -erythromycin tab 500 mg........... 3 ERYTHROMYCIN ETHYLSUCCINA -erythromycin ethylsuccinate tab 400 mg.................................................3 erythromycin gel 2% (Erygel)....................................... 150 erythromycin ophth oint 5 mg/gm............................... 138 erythromycin pads 2%.................................................. 150 erythromycin soln 2%................................................... 150 erythromycin w/ delayed release particles cap 250 mg...................................................................................... 3 ESBRIET -pirfenidone cap 267 mg................................... 65 ESCAVITE D -pediatric multiple vitamins w/ fl-fe chew tab 0.25-6 mg.......................................................................116 ESCAVITE LQ -pediatric multiple vitamins w/ fl-fe drops 0.25-6 mg/ml.................................................................. 116 ESCAVITE -pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg....................................................................116 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro)......................................................................... 77 escitalopram oxalate tab 10 mg (base equiv) (Lexapro)......................................................................... 77 escitalopram oxalate tab 20 mg (base equiv) (Lexapro)......................................................................... 78 192 escitalopram oxalate tab 5 mg (base equiv) (Lexapro)......................................................................... 77 ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40 mg.................................................................................... 93 esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium).........................................................67 esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium).........................................................67 ESSENTRA WIPES 9X9" CLEAN -isopropyl alcohol wipes 70%................................................................................ 150 estazolam tab 1 mg......................................................... 84 estazolam tab 2 mg......................................................... 84 esterified estrogens & methyltestosterone tab 0.625-1.25 mg................................................................. 22 esterified estrogens & methyltestosterone tab 1.25-2.5 mg.................................................................................... 23 ESTRACE -estradiol tab 0.5 mg........................................23 ESTRACE -estradiol tab 1 mg.......................................... 23 ESTRACE -estradiol tab 2 mg.......................................... 23 ESTRACE -estradiol vaginal cream 0.1 mg/gm.................73 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)........................................................................ 23 estradiol & norethindrone acetate tab 1-0.5 mg (Activella)........................................................................ 23 estradiol tab 0.5 mg (Estrace)........................................ 23 estradiol tab 1 mg (Estrace)........................................... 23 estradiol tab 2 mg (Estrace)........................................... 23 estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot)...................................................................................23 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).....................................................................23 estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot)...................................................................................23 estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot)...................................................................................23 estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot)...................................................................................23 estradiol td patch weekly 0.025 mg/24hr (Climara).......23 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)....................................................... 23 estradiol td patch weekly 0.05 mg/24hr (Climara).........23 estradiol td patch weekly 0.06 mg/24hr (Climara).........23 estradiol td patch weekly 0.075 mg/24hr (Climara).......23 estradiol td patch weekly 0.1 mg/24hr (Climara)...........23 ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).....73 ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)........................................................23 ESTROPIPATE -estropipate tab 3 mg.............................. 23 estropipate tab 0.75 mg.................................................. 23 estropipate tab 1.5 mg.................................................... 23 ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg....................................................24 eszopiclone tab 1 mg (Lunesta).....................................84 eszopiclone tab 2 mg (Lunesta).....................................84 eszopiclone tab 3 mg (Lunesta).....................................84 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 ethambutol hcl tab 100 mg (Myambutol).........................6 ethambutol hcl tab 400 mg (Myambutol).........................6 ethosuximide cap 250 mg (Zarontin)........................... 107 ethosuximide soln 250 mg/5ml (Zarontin)...................107 ETHYL CHLORIDE/FINE PINPO -ethyl chloride aerosol spray...............................................................................150 ETHYL CHLORIDE/FINE STREA -ethyl chloride aerosol spray...............................................................................150 ETHYL CHLORIDE/MEDIUM JET -ethyl chloride aerosol spray...............................................................................150 ETHYL CHLORIDE/MEDIUM STR -ethyl chloride aerosol spray...............................................................................150 ETHYL CHLORIDE/MIST -ethyl chloride aerosol spray...............................................................................150 ETHYL CHLORIDE -ethyl chloride aerosol spray............150 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg.................................................................................. 24 ETIDRONATE DISODIUM -etidronate disodium tab 200 mg.................................................................................... 36 ETIDRONATE DISODIUM -etidronate disodium tab 400 mg.................................................................................... 36 etodolac cap 200 mg..................................................... 102 etodolac cap 300 mg..................................................... 102 etodolac tab 400 mg......................................................102 etodolac tab 500 mg......................................................102 etodolac tab sr 24hr 400 mg.........................................102 etodolac tab sr 24hr 500 mg.........................................102 etodolac tab sr 24hr 600 mg.........................................102 ETOPOSIDE -etoposide cap 50 mg..................................17 EURAX -crotamiton cream 10%...................................... 150 EURAX -crotamiton lotion 10%....................................... 150 EVAMIST -estradiol transdermal spray 1.53 mg/spray...... 23 EVEKEO -amphetamine sulfate tab 10 mg....................... 87 EVEKEO -amphetamine sulfate tab 5 mg......................... 87 EVISTA -raloxifene hcl tab 60 mg..................................... 36 EVOCLIN -clindamycin phosphate foam 1%................... 150 EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg (base equiv)....................................................................... 8 EVOXAC -cevimeline hcl cap 30 mg...............................142 EVZIO -naloxone hcl solution auto-injector 0.4 mg/0.4ml.........................................................................163 EXACTUSS -phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml..............................................................................60 EXALGO -hydromorphone hcl tab er 24hr deter 12 mg.....95 EXALGO -hydromorphone hcl tab er 24hr deter 16 mg.....95 EXALGO -hydromorphone hcl tab er 24hr deter 32 mg.....95 EXALGO -hydromorphone hcl tab er 24hr deter 8 mg.......95 EXELDERM -sulconazole nitrate cream 1%....................150 EXELDERM -sulconazole nitrate solution 1%................. 150 EXELON -rivastigmine tartrate cap 1.5 mg....................... 90 EXELON -rivastigmine tartrate cap 3 mg.......................... 90 EXELON -rivastigmine tartrate cap 4.5 mg....................... 90 EXELON -rivastigmine tartrate cap 6 mg.......................... 90 EXELON -rivastigmine td patch 24hr 13.3 mg/24hr...........90 EXELON -rivastigmine td patch 24hr 4.6 mg/24hr.............90 EXELON -rivastigmine td patch 24hr 9.5 mg/24hr.............90 exemestane tab 25 mg (Aromasin)................................ 17 EXFORGE -amlodipine besylate-valsartan tab 10-160 mg.................................................................................... 48 EXFORGE -amlodipine besylate-valsartan tab 10-320 mg.................................................................................... 48 EXFORGE -amlodipine besylate-valsartan tab 5-160 mg.................................................................................... 48 EXFORGE -amlodipine besylate-valsartan tab 5-320 mg.................................................................................... 48 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg......................................................... 48 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg............................................................ 48 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg............................................................ 48 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg........................................................... 48 EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg.............................................................. 48 EXJADE -deferasirox tab for oral susp 125 mg............... 163 EXJADE -deferasirox tab for oral susp 250 mg............... 163 EXJADE -deferasirox tab for oral susp 500 mg............... 163 EXODERM -sodium thiosulfate-salicylic acid lotion 25-1%............................................................................. 150 EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 90 EXTINA -ketoconazole foam 2%..................................... 150 EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fum-docfa-dha cap 29-1.25-350 mg........................................... 116 F FA-8 -folic acid cap 0.8 mg............................................. 129 FABIOR -tazarotene (acne) foam 0.1%...........................150 FACTIVE -gemifloxacin mesylate tab 320 mg (base equiv)..................................................................................5 FALESSA -levomefolate glucosamine tab 1 mg (folate equivalent)......................................................................126 FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit......................................................................24 famciclovir tab 125 mg (Famvir)...................................... 8 famciclovir tab 250 mg (Famvir)...................................... 8 famciclovir tab 500 mg (Famvir)...................................... 8 famotidine for susp 40 mg/5ml (Pepcid)....................... 67 famotidine tab 40 mg (Pepcid)....................................... 67 FAMVIR -famciclovir tab 125 mg.........................................8 FAMVIR -famciclovir tab 250 mg.........................................8 FAMVIR -famciclovir tab 500 mg.........................................8 FANAPT -iloperidone tab 10 mg....................................... 81 FANAPT -iloperidone tab 12 mg....................................... 81 FANAPT -iloperidone tab 1 mg......................................... 81 FANAPT -iloperidone tab 2 mg......................................... 81 FANAPT -iloperidone tab 4 mg......................................... 81 FANAPT -iloperidone tab 6 mg......................................... 81 FANAPT -iloperidone tab 8 mg......................................... 81 FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak............................................ 81 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 193 2015 FARESTON -toremifene citrate tab 60 mg (base equivalent)........................................................................17 FARXIGA -dapagliflozin propanediol tab 10 mg (base equivalent)........................................................................28 FARYDAK -panobinostat lactate cap 10 mg (base equivalent)........................................................................17 FARYDAK -panobinostat lactate cap 15 mg (base equivalent)........................................................................17 FARYDAK -panobinostat lactate cap 20 mg (base equivalent)........................................................................17 FAZACLO -clozapine orally disintegrating tab 100 mg...... 82 FAZACLO -clozapine orally disintegrating tab 12.5 mg..... 81 FAZACLO -clozapine orally disintegrating tab 150 mg...... 82 FAZACLO -clozapine orally disintegrating tab 200 mg...... 82 FAZACLO -clozapine orally disintegrating tab 25 mg........ 82 FE 90 PLUS -fe carbonyl-fe gluconate-fa-vit b12-vit c-dss tab 90-1 mg................................................................... 129 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg.................................................................................. 129 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg.................................................................................. 129 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap (Tandem plus)....................................................... 129 FEIBA -antiinhibitor coagulant complex for inj................. 134 FEIBA NF -antiinhibitor coagulant complex for inj........... 134 felbamate susp 600 mg/5ml (Felbatol).........................107 felbamate tab 400 mg (Felbatol)...................................107 felbamate tab 600 mg (Felbatol)...................................107 FELBATOL -felbamate susp 600 mg/5ml........................ 107 FELBATOL -felbamate tab 400 mg................................. 107 FELBATOL -felbamate tab 600 mg................................. 107 FELDENE -piroxicam cap 10 mg.................................... 102 FELDENE -piroxicam cap 20 mg.................................... 102 felodipine tab sr 24hr 10 mg.......................................... 43 felodipine tab sr 24hr 2.5 mg......................................... 43 felodipine tab sr 24hr 5 mg............................................ 43 FEMARA -letrozole tab 2.5 mg......................................... 17 FEMCON FE -norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg.......................................................... 24 FEMHRT LOW DOSE -norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg........................................... 23 FEM PH -acetic acid-oxyquinoline vaginal gel 0.9-0.025%....................................................................... 73 FEMRING -estradiol acetate vaginal ring 0.05 mg/24hr............................................................................ 73 FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr...... 73 FENOFIBRATE -fenofibrate cap 150 mg.......................... 54 FENOFIBRATE -fenofibrate cap 50 mg............................ 54 FENOFIBRATE -fenofibrate tab 120 mg........................... 54 fenofibrate micronized cap 130 mg............................... 55 fenofibrate micronized cap 134 mg (Lofibra)................ 55 fenofibrate micronized cap 200 mg (Lofibra)................ 55 fenofibrate micronized cap 43 mg................................. 55 fenofibrate micronized cap 67 mg (Lofibra).................. 55 fenofibrate tab 145 mg (Tricor)...................................... 55 194 fenofibrate tab 160 mg (Lofibra).................................... 55 fenofibrate tab 48 mg (Tricor)........................................ 55 fenofibrate tab 54 mg (Lofibra)...................................... 55 FENOFIBRIC ACID -fenofibric acid tab 105 mg................ 55 FENOFIBRIC ACID -fenofibric acid tab 35 mg.................. 55 FENOGLIDE -fenofibrate tab 120 mg................................55 FENOGLIDE -fenofibrate tab 40 mg................................. 55 FENOPROFEN CALCIUM -fenoprofen calcium cap 400 mg.................................................................................. 102 FENOPROFEN CALCIUM -fenoprofen calcium tab 600 mg.................................................................................. 102 fentanyl citrate lozenge on a handle 1200 mcg (Actiq).............................................................................. 95 fentanyl citrate lozenge on a handle 1600 mcg (Actiq).............................................................................. 95 fentanyl citrate lozenge on a handle 200 mcg (Actiq).............................................................................. 95 fentanyl citrate lozenge on a handle 400 mcg (Actiq).............................................................................. 95 fentanyl citrate lozenge on a handle 600 mcg (Actiq).............................................................................. 95 fentanyl citrate lozenge on a handle 800 mcg (Actiq).............................................................................. 95 FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr............... 95 FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr............... 95 FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr............... 95 fentanyl td patch 72hr 100 mcg/hr (Duragesic).............96 fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............95 fentanyl td patch 72hr 25 mcg/hr (Duragesic)...............95 fentanyl td patch 72hr 50 mcg/hr (Duragesic)...............96 fentanyl td patch 72hr 75 mcg/hr (Duragesic)...............96 FENTORA -fentanyl citrate buccal tab 100 mcg (base equiv)................................................................................96 FENTORA -fentanyl citrate buccal tab 200 mcg (base equiv)................................................................................96 FENTORA -fentanyl citrate buccal tab 400 mcg (base equiv)................................................................................96 FENTORA -fentanyl citrate buccal tab 600 mcg (base equiv)................................................................................96 FENTORA -fentanyl citrate buccal tab 800 mcg (base equiv)................................................................................96 FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe).................................................................. 129 FERIVA 21/7 -fe asparto gly-b12-fa-c-dss-succinic acid-zn tab 75-1 mg................................................................... 129 FERIVAFA -iron-c-fa-b12-biotin-copper-docusate cap 110-1 mg........................................................................129 FERIVA -fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap 75-1 mg..........................................................................129 FERRALET 90 -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg.............................................................129 FERRAPLUS 90 -iron-folic acid-vit b12-vit c-docusate sod tab 90-1 mg................................................................... 129 FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18 mg (elemental iron)........................................................129 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 FERREX 150 FORTE PLUS -fe asp gly-fe polysacch-succ ac-c-threon ac-b12-fa cap..............................................129 FERREX 28 -fe asparto gly-fe fum-b12-fa-c-succinic ac tab ther pack........................................................................ 129 FERRIPROX -deferiprone tab 500 mg............................ 163 FERRO-PLEX HEMATINIC -fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg.......................................................... 129 FERROTRIN -iron w/ b12-vit c-fa-ifc cap 36-0.015-75-0.5-240 mg................................................ 129 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg....................................................................... 129 ferrous fumarate-folic acid tab 324-1 mg.................... 129 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)................................................................................... 129 FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe)...............................................129 FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe)...............................................129 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)................................................................................... 129 FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base equivalent)........................................................................78 FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base equivalent)........................................................................78 FETZIMA -levomilnacipran hcl cap sr 24hr 40 mg (base equivalent)........................................................................78 FETZIMA -levomilnacipran hcl cap sr 24hr 80 mg (base equivalent)........................................................................78 FETZIMA TITRATION PACK -levomilnacipran hcl cap sr 24hr 20 & 40 mg therapy pack........................................ 78 FEXMID -cyclobenzaprine hcl tab 7.5 mg....................... 114 FIBRICOR -fenofibric acid tab 105 mg..............................55 FIBRICOR -fenofibric acid tab 35 mg................................55 FINACEA -azelaic acid gel 15%......................................150 finasteride tab 5 mg (Proscar)........................................74 FIORICET/CODEINE -butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg............................................... 96 FIORICET -butalbital-acetaminophen-caffeine cap 50-300-40 mg...................................................................93 FIORICET -butalbital-acetaminophen-caffeine tab 50-325-40 mg...................................................................93 FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg...................................................... 96 FIORINAL -butalbital-aspirin-caffeine cap 50-325-40 mg.................................................................................... 93 FIRAZYR -icatibant acetate inj 30 mg/3ml (base equivalent)......................................................................134 FIRST-HYDROCORTISONE -hydrocortisone gel 10% (cmpd kit)....................................................................... 150 FIRST-LANSOPRAZOLE -lansoprazole susp 3 mg/ml (compound kit)................................................................. 67 FIRST-OMEPRAZOLE -omeprazole susp 2 mg/ml (compound kit)................................................................. 67 FLAGYL ER -metronidazole tab sr 24hr 750 mg............... 12 FLAGYL -metronidazole cap 375 mg................................ 12 FLAGYL -metronidazole tab 250 mg................................. 12 FLAGYL -metronidazole tab 500 mg................................. 12 FLAREX -fluorometholone acetate ophth susp 0.1%...... 138 flavoxate hcl tab 100 mg.................................................73 flaxseed oil-evening primrose-bilberry cap 1000-500-40 mg (Tears again hydrate)............................................ 126 flecainide acetate tab 100 mg.........................................44 flecainide acetate tab 150 mg.........................................44 flecainide acetate tab 50 mg.......................................... 44 FLECTOR -diclofenac epolamine patch 1.3%................. 150 FLEXIN -capsaicin-menthol topical patch 0.0375-5%......150 FLOMAX -tamsulosin hcl cap 0.4 mg................................74 FLONASE -fluticasone propionate nasal susp 50 mcg/ act.....................................................................................59 FLO-PRED -prednisolone acetate oral susp 16.7 mg/5ml (15 mg/5ml base).............................................................20 FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364 mg.................................................................................. 124 FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364 mg.................................................................................. 124 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 0.5 mg............................................................................ 116 FLORIVA -ped multiple vitamins & minerals w/ fl chew tab 1 mg............................................................................... 116 FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/ ml-400 unit/ml................................................................ 124 FLOVENT DISKUS -fluticasone propionate aer pow ba 100 mcg/blister.................................................................63 FLOVENT DISKUS -fluticasone propionate aer pow ba 250 mcg/blister.................................................................63 FLOVENT DISKUS -fluticasone propionate aer pow ba 50 mcg/blister........................................................................ 63 FLOVENT HFA -fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)..........................................................63 FLOVENT HFA -fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)..........................................................63 FLOVENT HFA -fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)............................................................63 FLUARIX 2011-2012 -influenza virus vaccine split pf susp pref syringe 0.5 ml...........................................................13 FLUARIX 2012-2013 -influenza virus vaccine split pf susp pref syringe 0.5 ml...........................................................13 FLUARIX 2013-2014 -influenza virus vaccine split pf susp pref syringe 0.5 ml...........................................................13 FLUARIX 2014-2015 -influenza virus vaccine split pf susp pref syringe 0.5 ml...........................................................13 FLUARIX QUADRIVALENT 2013 -influenza virus vac split quadrivalent susp pref syr 0.5ml......................................13 FLUARIX QUADRIVALENT 2014 -influenza virus vac split quadrivalent susp pref syr 0.5ml......................................13 FLUARIX QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.5ml......................................13 FLUBLOK 2013-2014 -influenza virus vac recombinant hemagglutinin (ha) inj...................................................... 13 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 195 2015 FLUBLOK 2014-2015 -influenza virus vac recombinant hemagglutinin (ha) inj...................................................... 13 FLUBLOK 2015-2016 -influenza virus vac recombinant hemagglutinin (ha) inj...................................................... 13 FLUCELVAX 2012-2013 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml............................................ 13 FLUCELVAX 2013-2014 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml............................................ 13 FLUCELVAX 2014-2015 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml............................................ 13 FLUCELVAX 2015-2016 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml............................................ 13 fluconazole for susp 10 mg/ml (Diflucan)....................... 6 fluconazole for susp 40 mg/ml (Diflucan)....................... 6 fluconazole tab 100 mg (Diflucan)................................... 6 fluconazole tab 150 mg (Diflucan)................................... 6 fluconazole tab 200 mg (Diflucan)................................... 6 fluconazole tab 50 mg (Diflucan)..................................... 6 flucytosine cap 250 mg (Ancobon).................................. 6 flucytosine cap 500 mg (Ancobon).................................. 6 fludrocortisone acetate tab 0.1 mg................................ 20 FLULAVAL 2011-2012 -influenza virus vaccine split im susp..................................................................................13 FLULAVAL 2012-2013 -influenza virus vaccine split im susp..................................................................................13 FLULAVAL 2013-2014 -influenza virus vaccine split im susp..................................................................................13 FLULAVAL 2014-2015 -influenza virus vaccine split im susp..................................................................................13 FLULAVAL QUADRIVALENT 201 -influenza virus vaccine split quadrivalent im inj.................................................... 13 FLULAVAL QUADRIVALENT 201 -influenza virus vac split quadrivalent susp pref syr 0.5ml......................................13 FLUMADINE -rimantadine hydrochloride tab 100 mg..........8 FLUMIST QUADRIVALENT -influenza virus vaccine live quadrivalent intranasal susp............................................ 14 FLUNISOLIDE -flunisolide nasal soln 25 mcg/act (0.025%)...........................................................................59 flunisolide nasal soln 25 mcg/act (0.025%) (Flunisolide).................................................................... 59 fluocinolone acetonide (otic) oil 0.01% (Dermotic).....141 fluocinolone acetonide cream 0.01%...........................150 fluocinolone acetonide cream 0.025% (Synalar).........150 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod)........................................................... 150 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)............................................................151 fluocinolone acetonide oint 0.025% (Synalar).............151 fluocinolone acetonide soln 0.01% (Synalar)..............151 fluocinonide cream 0.05%............................................ 151 fluocinonide cream 0.1% (Vanos)................................ 151 fluocinonide emulsified base cream 0.05%.................151 fluocinonide gel 0.05%..................................................151 fluocinonide oint 0.05%................................................ 151 fluocinonide soln 0.05%................................................151 196 FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf).........................................................124 FLUORAC -fluorouracil-diclofenac sodium cream 5-1%............................................................................... 151 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg............................................................ 124 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79 mg............................................................ 124 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg...................................................................124 FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%......................................... 142 fluorometholone ophth susp 0.1% (Fml liquifilm).......138 FLUOROPLEX -fluorouracil cream 1%............................151 fluorouracil cream 5% (Efudex)....................................151 FLUOROURACIL -fluorouracil cream 0.5%.....................151 fluorouracil soln 2%...................................................... 151 fluorouracil soln 5%...................................................... 151 fluoxetine hcl (pmdd) cap 10 mg................................... 90 fluoxetine hcl (pmdd) cap 20 mg................................... 90 fluoxetine hcl cap 10 mg (Prozac)................................. 78 fluoxetine hcl cap 20 mg (Prozac)................................. 78 fluoxetine hcl cap 40 mg (Prozac)................................. 78 fluoxetine hcl cap delayed release 90 mg (Prozac weekly)............................................................................ 78 FLUOXETINE HCL -fluoxetine hcl tab 60 mg....................78 fluoxetine hcl solution 20 mg/5ml..................................78 fluoxetine hcl tab 10 mg................................................. 78 fluoxetine hcl tab 20 mg................................................. 78 FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5 mg/5ml..............................................................................82 FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/ ml......................................................................................82 fluphenazine hcl tab 10 mg............................................ 82 fluphenazine hcl tab 1 mg.............................................. 82 fluphenazine hcl tab 2.5 mg........................................... 82 fluphenazine hcl tab 5 mg.............................................. 82 FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf).......................................................... 124 FLURAZEPAM HCL -flurazepam hcl cap 15 mg............... 84 FLURAZEPAM HCL -flurazepam hcl cap 30 mg............... 84 flurbiprofen sodium ophth soln 0.03% (Ocufen).........138 flurbiprofen tab 100 mg................................................ 102 flurbiprofen tab 50 mg.................................................. 102 flutamide cap 125 mg......................................................17 fluticasone propionate cream 0.05% (Cutivate).......... 151 fluticasone propionate lotion 0.05% (Cutivate)...........151 fluticasone propionate nasal susp 50 mcg/act (Flonase)......................................................................... 59 fluticasone propionate oint 0.005% (Cutivate)............ 151 fluvastatin sodium cap 20 mg (Lescol)......................... 55 fluvastatin sodium cap 40 mg (Lescol)......................... 55 FLUVIRIN 2011-2012 -influenza virus vaccine types a & b surface antigen im susp...................................................14 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 FLUVIRIN 2012-2013 -influenza virus vaccine types a & b surface antigen im susp...................................................14 FLUVIRIN 2013-2014 -influenza virus vaccine types a & b surface antigen im susp...................................................14 FLUVIRIN 2014-2015 -influenza virus vaccine types a & b surface antigen im susp...................................................14 FLUVIRIN 2015-2016 -influenza virus vaccine types a & b surface antigen im susp...................................................14 FLUVIRIN PF 2011-2012 -influenza virus vac types a & b pf susp prefilled syr 0.5 ml.............................................. 14 FLUVIRIN PF 2012-2013 -influenza virus vac types a & b pf susp prefilled syr 0.5 ml.............................................. 14 FLUVIRIN PF 2013-2014 -influenza virus vac types a & b pf susp prefilled syr 0.5 ml.............................................. 14 FLUVIRIN PF 2014-2015 -influenza virus vac types a & b pf susp prefilled syr 0.5 ml.............................................. 14 fluvoxamine maleate cap sr 24hr 100 mg (Luvox cr).....................................................................................78 fluvoxamine maleate cap sr 24hr 150 mg (Luvox cr).....................................................................................78 fluvoxamine maleate tab 100 mg................................... 78 fluvoxamine maleate tab 25 mg..................................... 78 fluvoxamine maleate tab 50 mg..................................... 78 FLUZONE HIGH-DOSE PF 2012 -influenza virus vac split high-dose pf susp pref syr 0.5ml..................................... 14 FLUZONE HIGH-DOSE PF 2013 -influenza virus vac split high-dose pf susp pref syr 0.5ml..................................... 14 FLUZONE HIGH-DOSE PF 2014 -influenza virus vac split high-dose pf susp pref syr 0.5ml..................................... 14 FLUZONE HIGH-DOSE PF 2015 -influenza virus vac split high-dose pf susp pref syr 0.5ml..................................... 14 FLUZONE INTRADERMAL QUADR -influenza virus vac split quad intradermal pen 9 mcg/strain...........................14 FLUZONE PF 2012-2013 -influenza virus vaccine split pf susp pref syringe 0.5 ml.................................................. 14 FLUZONE PF 2013-2014 -influenza virus vaccine split pf susp pref syringe 0.5 ml.................................................. 14 FLUZONE PF 2014-2015 -influenza virus vaccine split pf susp pref syringe 0.5 ml.................................................. 14 FLUZONE QUADRIVALENT 2013 -influenza virus vaccine split quadrivalent inj 0.5 ml.............................................. 14 FLUZONE QUADRIVALENT 2013 -influenza virus vac split quadrivalent susp pref syr 0.25 ml........................... 14 FLUZONE QUADRIVALENT 2013 -influenza virus vac split quadrivalent susp pref syr 0.5ml.............................. 14 FLUZONE QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent im inj.................................................... 14 FLUZONE QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent inj 0.5 ml.............................................. 14 FLUZONE QUADRIVALENT 2014 -influenza virus vac split quadrivalent susp pref syr 0.25 ml........................... 14 FLUZONE QUADRIVALENT 2014 -influenza virus vac split quadrivalent susp pref syr 0.5ml.............................. 14 FLUZONE QUADRIVALENT 2015 -influenza virus vaccine split quadrivalent im inj.................................................... 14 FLUZONE QUADRIVALENT 2015 -influenza virus vaccine split quadrivalent inj 0.5 ml.............................................. 15 FLUZONE QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.25 ml........................... 14 FLUZONE QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.5ml.............................. 14 FLUZONE SPLIT 2012-2013 -influenza virus vaccine split im susp.............................................................................15 FLUZONE SPLIT 2013-2014 -influenza virus vaccine split im susp.............................................................................15 FLUZONE SPLIT 2014-2015 -influenza virus vaccine split im susp.............................................................................15 FLUZONE SPLIT 2015-2016 -influenza virus vaccine split im susp.............................................................................15 FML -fluorometholone ophth oint 0.1%........................... 138 FML FORTE -fluorometholone ophth susp 0.25%...........138 FML LIQUIFILM -fluorometholone ophth susp 0.1%....... 138 FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak............................................... 117 FOCALGIN-B -prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg.......................................................................... 117 FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack.................................................... 117 FOCALGIN DSS -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg.............................................................129 FOCALIN -dexmethylphenidate hcl tab 10 mg.................. 87 FOCALIN -dexmethylphenidate hcl tab 2.5 mg................. 87 FOCALIN -dexmethylphenidate hcl tab 5 mg.................... 87 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10 mg.................................................................................... 87 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 15 mg.................................................................................... 87 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 20 mg.................................................................................... 87 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 25 mg.................................................................................... 87 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 30 mg.................................................................................... 87 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 35 mg.................................................................................... 87 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 40 mg.................................................................................... 87 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 5 mg.................................................................................... 87 FOLBECAL -prenatal w/ calcium carbonate-b6-b12-fa tab 1 mg............................................................................... 117 FOLBEE AR -folic acid-b12-b6-arginine-black pepper tab.................................................................................. 126 FOLBIC RF -l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg.................................................................................. 126 FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg..............................................................117 FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg.....................................................117 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 197 2015 FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr & dha cap pak................................................................... 117 FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha cap 38-1-225 mg............................................................117 FOLGARD OS -multiple vit w/ min & calcium-folic acid tab 500-1.1 mg.....................................................................117 FOLGARD RX -folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg....................................................................129 folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg.................................................................................. 126 folic acid tab 1 mg.........................................................129 folic acid tab 400 mcg...................................................129 folic acid tab 800 mcg...................................................129 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg.................................................................................. 130 folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx)................................................................... 130 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 130 FOLIVANE-F -fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe).....................................130 FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg................................................................117 FOLIVANE-PLUS -fe fum-iron polysacch complex-fa-b complex-c-biotin cap...................................................... 130 FOLTANX -l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg.................................................................................. 126 FOLTANX RF -l-methylfolate-algae-vit b12-b6 cap 3-90.314-2-35 mg.......................................................... 126 FOLTX -l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg.................................................................................. 126 fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra)......................................................................... 132 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra)......................................................................... 132 fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra)......................................................................... 132 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra)......................................................................... 132 FORADIL AEROLIZER -formoterol fumarate inhal cap 12 mcg...................................................................................63 FORFIVO XL -bupropion hcl tab sr 24hr 450 mg.............. 78 formaldehyde solution 10%.......................................... 163 FORMA-RAY -formaldehyde solution 20%......................163 FORTAMET -metformin hcl tab sr 24hr osmotic 1000 mg.................................................................................... 28 FORTAMET -metformin hcl tab sr 24hr osmotic 500 mg.................................................................................... 28 FORTEO -teriparatide (recombinant) inj 600 mcg/2.4ml.........................................................................36 FORTESTA -testosterone td gel 10mg/act (2%)............... 21 FORTICAL -calcitonin (salmon) nasal soln 200 unit/ act.....................................................................................36 FOSAMAX -alendronate sodium tab 70 mg...................... 36 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-2800 mg-unit.........................................................36 198 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-5600 mg-unit.........................................................36 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg.................................................................................... 48 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg.................................................................................... 48 fosinopril sodium tab 10 mg.......................................... 48 fosinopril sodium tab 20 mg.......................................... 48 fosinopril sodium tab 40 mg.......................................... 48 FOSRENOL -lanthanum carbonate chew tab 1000 mg (elemental)....................................................................... 71 FOSRENOL -lanthanum carbonate chew tab 500 mg (elemental)....................................................................... 71 FOSRENOL -lanthanum carbonate chew tab 750 mg (elemental)....................................................................... 71 FOSRENOL -lanthanum carbonate oral powder pack 1000 mg (elemental)................................................................. 71 FOSRENOL -lanthanum carbonate oral powder pack 750 mg (elemental)................................................................. 71 FOSTEUM -genistein-zinc amino acid chelate-vitamin d cap..................................................................................126 FRAGMIN -dalteparin sodium inj 10000 unit/ml.............. 132 FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml..........132 FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml..........132 FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml........132 FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml............132 FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml............132 FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml............132 FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml..........132 FROVA -frovatriptan succinate tab 2.5 mg (base equivalent)......................................................................104 FULYZAQ -crofelemer tab delayed release 125 mg..........66 FURADANTIN -nitrofurantoin susp 25 mg/5ml.................. 72 FUROSEMIDE -furosemide oral soln 8 mg/ml.................. 53 furosemide oral soln 10 mg/ml...................................... 53 furosemide tab 20 mg (Lasix).........................................53 furosemide tab 40 mg (Lasix).........................................53 furosemide tab 80 mg (Lasix).........................................53 FUSION PLUS -fe fum-iron poly cmplx-fa-b cmplx-c-biotinprobiotic cap...................................................................130 FUZEON -enfuvirtide for inj 90 mg......................................8 FYCOMPA -perampanel tab 10 mg.................................107 FYCOMPA -perampanel tab 12 mg.................................107 FYCOMPA -perampanel tab 2 mg.................................. 107 FYCOMPA -perampanel tab 4 mg.................................. 107 FYCOMPA -perampanel tab 6 mg.................................. 107 FYCOMPA -perampanel tab 8 mg.................................. 107 G gabapentin cap 100 mg (Neurontin)............................ 107 gabapentin cap 300 mg (Neurontin)............................ 107 gabapentin cap 400 mg (Neurontin)............................ 107 gabapentin oral soln 250 mg/5ml (Neurontin).............108 gabapentin tab 600 mg (Neurontin)............................. 108 gabapentin tab 800 mg (Neurontin)............................. 108 GABITRIL -tiagabine hcl tab 12 mg.................................108 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 GABITRIL -tiagabine hcl tab 16 mg.................................108 GABITRIL -tiagabine hcl tab 2 mg.................................. 108 GABITRIL -tiagabine hcl tab 4 mg.................................. 108 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)................................................................. 90 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)................................................................. 90 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)................................................................. 90 GALANTAMINE HYDROBROMIDE -galantamine hydrobromide oral soln 4 mg/ml...................................... 90 galantamine hydrobromide tab 12 mg (Razadyne)....... 90 galantamine hydrobromide tab 4 mg (Razadyne).........90 galantamine hydrobromide tab 8 mg (Razadyne).........90 GALZIN -zinc acetate cap 25 mg (elemental zinc).......... 124 GALZIN -zinc acetate cap 50 mg (elemental zinc).......... 125 GARAMYCIN -gentamicin sulfate ophth soln 0.3%......... 138 GASTRINEX NF -hyoscyamine-phenyltoloxamine cap 0.0625-15 mg...................................................................67 GASTROCROM -cromolyn sodium oral conc 100 mg/5ml..............................................................................71 gatifloxacin ophth soln 0.5% (Zymaxid)...................... 138 GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 71 GEBAUERS PAIN EASE -pentafluoropropanetetrafluoroethane aero spray..........................................151 GEBAUERS SPRAY AND STRETC -pentafluoropropanetetrafluoroethane aero spray..........................................151 GELCLAIR -povidone-sodium hyaluronate-glycyrrhetinic acid gel...........................................................................142 GELFILM OP -gelatin adsorbable ophth film................... 138 GEL-KAM ORAL CARE RINSE -stannous fluoride conc 0.63%............................................................................. 142 GEL-KAM -stannous fluoride gel 0.4%............................142 GELNIQUE -oxybutynin chloride td gel 10%..................... 73 GELNIQUE -oxybutynin td gel 3% (28 mg/act metereddose pump)...................................................................... 73 GELX -oral wound care products - gel............................ 142 gemfibrozil tab 600 mg (Lopid)...................................... 55 GENADUR -dermatological products misc - liquid...........151 GENADUR KIT -dermatological products misc topical/oral - kit................................................................................. 151 GENERESS FE -norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg.......................................................... 24 GENOTROPIN MINIQUICK -somatropin for inj 0.2 mg..... 36 GENOTROPIN MINIQUICK -somatropin for inj 0.4 mg..... 36 GENOTROPIN MINIQUICK -somatropin for inj 0.6 mg..... 36 GENOTROPIN MINIQUICK -somatropin for inj 0.8 mg..... 36 GENOTROPIN MINIQUICK -somatropin for inj 1.2 mg..... 36 GENOTROPIN MINIQUICK -somatropin for inj 1.4 mg..... 36 GENOTROPIN MINIQUICK -somatropin for inj 1.6 mg..... 36 GENOTROPIN MINIQUICK -somatropin for inj 1.8 mg..... 36 GENOTROPIN MINIQUICK -somatropin for inj 1 mg........ 36 GENOTROPIN MINIQUICK -somatropin for inj 2 mg........ 36 GENOTROPIN -somatropin for inj 12 mg (13.8 mg overfill)..............................................................................36 GENOTROPIN -somatropin for subcutaneous inj 5 mg.....36 GENTAMICIN SULFATE -gentamicin sulfate cream 0.1%............................................................................... 151 GENTAMICIN SULFATE -gentamicin sulfate oint 0.1%............................................................................... 151 gentamicin sulfate ophth oint 0.3%............................. 138 gentamicin sulfate ophth soln 0.3% (Garamycin)....... 138 GEODON -ziprasidone hcl cap 20 mg.............................. 82 GEODON -ziprasidone hcl cap 40 mg.............................. 82 GEODON -ziprasidone hcl cap 60 mg.............................. 82 GEODON -ziprasidone hcl cap 80 mg.............................. 82 GIAZO -balsalazide disodium tab 1.1 gm..........................71 GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 90 GILOTRIF -afatinib dimaleate tab 20 mg (base equivalent)........................................................................17 GILOTRIF -afatinib dimaleate tab 30 mg (base equivalent)........................................................................17 GILOTRIF -afatinib dimaleate tab 40 mg (base equivalent)........................................................................17 GILPHEX TR -phenylephrine-guaifenesin tab 10-388 mg.................................................................................... 60 GILTUSS PED-C -phenylephrine w/ codeine-gg liquid 2.5-3-50 mg/ml.................................................................60 GILTUSS -phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml..............................................................................60 GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388 mg.................................................................................... 60 glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)......................................................................90 GLEEVEC -imatinib mesylate tab 100 mg (base equivalent)........................................................................17 GLEEVEC -imatinib mesylate tab 400 mg (base equivalent)........................................................................17 GLEOSTINE -lomustine cap 100 mg.................................17 GLEOSTINE -lomustine cap 10 mg.................................. 17 GLEOSTINE -lomustine cap 40 mg.................................. 17 glimepiride tab 1 mg (Amaryl)........................................28 glimepiride tab 2 mg (Amaryl)........................................28 glimepiride tab 4 mg (Amaryl)........................................28 glipizide-metformin hcl tab 2.5-250 mg......................... 28 glipizide-metformin hcl tab 2.5-500 mg......................... 28 glipizide-metformin hcl tab 5-500 mg............................ 28 glipizide tab 10 mg (Glucotrol).......................................28 glipizide tab 5 mg (Glucotrol).........................................28 glipizide tab sr 24hr 10 mg (Glucotrol xl)......................28 glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 28 glipizide tab sr 24hr 5 mg (Glucotrol xl)........................28 GLUCAGEN DIAGNOSTIC -glucagon hcl (rdna) diagnostic for inj 1 mg (base equiv)................................................163 GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg (base equiv)..................................................................... 28 GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj kit 1 mg................................................................................. 28 GLUCOPHAGE -metformin hcl tab 1000 mg.................... 28 GLUCOPHAGE -metformin hcl tab 500 mg...................... 28 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 199 2015 GLUCOPHAGE -metformin hcl tab 850 mg...................... 28 GLUCOPHAGE XR -metformin hcl tab sr 24hr 500 mg.....28 GLUCOPHAGE XR -metformin hcl tab sr 24hr 750 mg.....28 GLUCOSE BLOOD TEST STRIPS – VARIOUS............. 163 glucose gel 40%.............................................................. 28 GLUCOSE -glucose chew tab 4 gm..................................28 GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.........28 glucose oral liquid 15 gm/59ml...................................... 28 GLUCOTROL -glipizide tab 10 mg....................................28 GLUCOTROL -glipizide tab 5 mg......................................28 GLUCOTROL XL -glipizide tab sr 24hr 10 mg.................. 28 GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg................. 28 GLUCOTROL XL -glipizide tab sr 24hr 5 mg.................... 28 GLUCOVANCE -glyburide-metformin tab 1.25-250 mg.....28 GLUCOVANCE -glyburide-metformin tab 2.5-500 mg.......28 GLUCOVANCE -glyburide-metformin tab 5-500 mg..........28 GLUMETZA -metformin hcl tab sr 24hr modified release 1000 mg........................................................................... 28 GLUMETZA -metformin hcl tab sr 24hr modified release 500 mg............................................................................. 28 GLUTARALDEHYDE -glutaral soln 25%......................... 163 GLYBURIDE -glyburide tab 1.25 mg................................. 28 GLYBURIDE -glyburide tab 2.5 mg...................................28 GLYBURIDE -glyburide tab 5 mg......................................28 glyburide-metformin tab 1.25-250 mg (Glucovance)...................................................................28 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 28 glyburide-metformin tab 5-500 mg (Glucovance)......... 29 glyburide micronized tab 1.5 mg (Glynase).................. 28 glyburide micronized tab 3 mg (Glynase)..................... 28 glyburide micronized tab 6 mg (Glynase)..................... 28 glyburide tab 1.25 mg..................................................... 28 glyburide tab 2.5 mg....................................................... 28 glyburide tab 5 mg.......................................................... 28 GLYCATE -glycopyrrolate tab 1.5 mg............................... 67 glycopyrrolate tab 1 mg (Robinul)................................. 67 glycopyrrolate tab 2 mg (Robinul forte)........................ 67 GLYNASE -glyburide micronized tab 1.5 mg.................... 29 GLYNASE -glyburide micronized tab 3 mg....................... 29 GLYNASE -glyburide micronized tab 6 mg....................... 29 GLYSET -miglitol tab 100 mg............................................29 GLYSET -miglitol tab 25 mg..............................................29 GLYSET -miglitol tab 50 mg..............................................29 GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............. 29 GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............. 29 GNP GLUCOSE -glucose chew tab 4 gm......................... 29 GNP GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 29 GNP QUICK DISSOLVE GLUCOS -glucose chew tab 4 gm.................................................................................... 29 GNP VITAMIN D-400 -calcium carbonate-cholecalciferol tab 90 mg-400 unit........................................................ 125 GNP VITAMIN D-400 -calcium carbonate-cholecalciferol tab 90 mg-400 unit........................................................ 125 200 GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm..................................................................... 65 GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm.............................................................. 65 GORDOFILM -salicylic & lactic acids soln 16.7-16.7%..................................................................... 151 GORDONS UREA -urea ointment 40%...........................151 GRALISE -gabapentin (phn) tab 300 mg...........................90 GRALISE -gabapentin (phn) tab 600 mg...........................90 GRALISE STARTER -gabapentin (phn) tab starter pack 300 mg (9) & 600 mg (69)...............................................91 granisetron hcl tab 1 mg................................................ 69 GRANIX -tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml.......................................................................130 GRANIX -tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml.......................................................................130 GRANULEX -trypsin w/ castor oil & peruvian balsam spray...............................................................................151 GRASTEK -timothy grass pollen allergen ext tab sl 2800 bau................................................................................... 16 GRIFULVIN V -griseofulvin microsize tab 500 mg...............6 griseofulvin microsize susp 125 mg/5ml.........................6 griseofulvin microsize tab 500 mg (Grifulvin v)..............6 griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 6 griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 6 GRIS-PEG -griseofulvin ultramicrosize tab 125 mg.............6 GRIS-PEG -griseofulvin ultramicrosize tab 250 mg.............6 guaifenesin-codeine liquid 200-8 mg/5ml......................60 guaifenesin-codeine liquid 225-7.5 mg/5ml...................60 guaifenesin-codeine soln 100-10 mg/5ml......................60 guaifenesin-codeine soln 100-6.3 mg/5ml..................... 60 guanfacine hcl tab 1 mg (Tenex)................................... 48 guanfacine hcl tab 2 mg (Tenex)................................... 48 guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv)........................................................................... 87 guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv)........................................................................... 87 guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv)........................................................................... 87 guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv)........................................................................... 87 GUANIDINE HCL -guanidine hcl tab 125 mg.................. 114 GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal cream 2%.........................................................................73 H H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 36 HALAC -halobetasol prop oint 0.05% & ammonium lactate lot 12% kit...................................................................... 151 HALCION -triazolam tab 0.25 mg......................................84 halobetasol propionate cream 0.05% (Ultravate)........ 151 halobetasol propionate oint 0.05% (Ultravate)............151 HALOG -halcinonide cream 0.1%................................... 151 HALOG -halcinonide oint 0.1%........................................151 haloperidol lactate oral conc 2 mg/ml........................... 82 haloperidol tab 0.5 mg.................................................... 82 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 haloperidol tab 10 mg..................................................... 82 haloperidol tab 1 mg....................................................... 82 haloperidol tab 20 mg..................................................... 82 haloperidol tab 2 mg....................................................... 82 haloperidol tab 5 mg....................................................... 82 HALOTIN -haloprogin cream 1%.....................................151 HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................. 8 hc-pramoxine emol cream 2.5-1% & pramoxine wipe 1% kit (Analpram e)..................................................... 144 HECTOROL -doxercalciferol cap 0.5 mcg.........................36 HECTOROL -doxercalciferol cap 1 mcg............................36 HECTOROL -doxercalciferol cap 2.5 mcg.........................36 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 1000 unit................................................................... 134 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 2000 unit................................................................... 135 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 250 unit..................................................................... 134 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 3000 unit................................................................... 135 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 500 unit..................................................................... 134 HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml.........40 HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg........................................................ 130 HEMATRON-AF -iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg................................................................. 130 HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck......................................117 HEMENATAL OB -prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg................................................................ 117 HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab 22-6-1-0.025 mg............................................................ 130 HEMOCYTE PLUS -ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg............................................... 130 HEMOFIL M -antihemophilic factor (human) for inj 1000 unit..................................................................................135 HEMOFIL M -antihemophilic factor (human) for inj 1501-2000 unit............................................................... 135 HEMOFIL M -antihemophilic factor (human) for inj 1700 unit..................................................................................135 HEMOFIL M -antihemophilic factor (human) for inj 220-400 unit..................................................................................135 HEMOFIL M -antihemophilic factor (human) for inj 250 unit..................................................................................135 HEMOFIL M -antihemophilic factor (human) for inj 401-800 unit..................................................................................135 HEMOFIL M -antihemophilic factor (human) for inj 500 unit..................................................................................135 HEMOFIL M -antihemophilic factor (human) for inj 801-1500 unit................................................................. 135 HEPAGAM B -hepatitis b immune globulin (human) inj soln...................................................................................15 heparin sodium (porcine) inj 10000 unit/ml.................132 heparin sodium (porcine) inj 1000 unit/ml...................132 heparin sodium (porcine) inj 20000 unit/ml.................132 heparin sodium (porcine) inj 5000 unit/ml...................132 heparin sodium (porcine) pf inj 5000 unit/0.5ml......... 132 HEPARIN SODIUM -heparin sodium (porcine) inj 2000 unit/ml.............................................................................132 HEPARIN SODIUM -heparin sodium (porcine) inj 2500 unit/ml.............................................................................132 HEPSERA -adefovir dipivoxil tab 10 mg............................. 8 HETLIOZ -tasimelteon capsule 20 mg.............................. 84 HEXALEN -altretamine cap 50 mg....................................17 HIPREX -methenamine hippurate tab 1 gm...................... 72 HM GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 29 homatropine hbr ophth soln 5% (Isopto homatropine)................................................................ 138 HORIZANT -gabapentin enacarbil tab cr 300 mg..............91 HORIZANT -gabapentin enacarbil tab cr 600 mg..............91 HPR -emollient - aerosol foam........................................ 151 HPR PLUS/MB HYDROGEL -emollient foam & wound dressing gel kit...............................................................151 HPR PLUS -dermatological products misc - cream......... 151 HPR PLUS -emollient - aerosol foam..............................151 HPR PLUS HYDROGEL KIT -dermatological products misc - kit........................................................................ 151 HUMALOG -insulin lispro (human) inj 100 unit/ml............. 31 HUMALOG -insulin lispro (human) soln cartridge 100 unit/ ml......................................................................................31 HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 100 unit/ml...........................................................31 HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 200 unit/ml...........................................................31 HUMALOG MIX 50/50 -insulin lispro prot & lispro (human) inj 100 unit/ml (50-50)......................................................32 HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50).............................. 32 HUMALOG MIX 75/25 -insulin lispro prot & lispro (human) inj 100 unit/ml (75-25)......................................................32 HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25).............................. 32 HUMATE-P -antihemophilic factor/vwf (human) for inj 1000-2400 unit............................................................... 135 HUMATE-P -antihemophilic factor/vwf (human) for inj 250-600 unit................................................................... 135 HUMATE-P -antihemophilic factor/vwf (human) for inj 500-1200 unit................................................................. 135 HUMATROPE COMBO PACK -somatropin for inj 5 mg.................................................................................... 37 HUMATROPE -somatropin for inj 12 mg (36 unit).............37 HUMATROPE -somatropin for inj 24 mg...........................37 HUMATROPE -somatropin for inj 5 mg.............................36 HUMATROPE -somatropin for inj 6 mg (18 unit)...............37 HUMIRA -adalimumab prefilled syringe kit 10 mg/0.2ml.........................................................................102 HUMIRA -adalimumab prefilled syringe kit 20 mg/0.4ml.........................................................................102 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 201 2015 HUMIRA -adalimumab prefilled syringe kit 40 mg/0.8ml.........................................................................102 HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled syringe kit 40 mg/0.8ml..................................................102 HUMIRA PEN -adalimumab pen-injector kit 40 mg/0.8ml.........................................................................102 HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml..................................................102 HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml..................................................102 HUMULIN 70/30 -insulin nph isophane & regular human inj 100 unit/ml (70-30)...........................................................32 HUMULIN 70/30 KWIKPEN -insulin nph & regular susp pen-inj 100 unit/ml (70-30)...............................................32 HUMULIN 70/30 PEN -insulin nph & regular susp pen-inj 100 unit/ml (70-30)...........................................................32 HUMULIN N -insulin nph (human) (isophane) inj 100 unit/ ml......................................................................................32 HUMULIN N KWIKPEN -insulin nph (human) (isophane) susp pen-injector 100 unit/ml...........................................32 HUMULIN N U-100 PEN -insulin nph (human) (isophane) susp pen-injector 100 unit/ml...........................................32 HUMULIN R -insulin regular (human) inj 100 unit/ml.........32 HUMULIN R U-500 (CONCENTR -insulin regular (human) inj 500 unit/ml.................................................................. 32 HURRISEAL -dental desensitizing product - solution...... 163 hyaluronate sodium (emollient) gel 0.2% (Hylira)....... 151 HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)....... 17 HYCAMTIN -topotecan hcl cap 1 mg (base equiv)............17 HYCET -hydrocodone-acetaminophen soln 7.5-325 mg/15ml............................................................................96 hydralazine hcl tab 100 mg............................................ 48 hydralazine hcl tab 10 mg.............................................. 48 hydralazine hcl tab 25 mg.............................................. 48 hydralazine hcl tab 50 mg.............................................. 48 HYDREA -hydroxyurea cap 500 mg..................................17 HYDRO 35 -urea in lactic acid vehicle foam 35%........... 151 HYDRO 40 FOAM -urea foam 40%................................ 151 hydrochlorothiazide cap 12.5 mg (Microzide)............... 53 hydrochlorothiazide tab 12.5 mg................................... 53 hydrochlorothiazide tab 25 mg...................................... 53 hydrochlorothiazide tab 50 mg...................................... 53 HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen soln 10-325 mg/15ml..............................96 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet)............................................................................. 96 hydrocodone-acetaminophen tab 10-300 mg (Xodol)............................................................................. 96 hydrocodone-acetaminophen tab 10-325 mg (Norco).............................................................................96 hydrocodone-acetaminophen tab 2.5-325 mg...............96 hydrocodone-acetaminophen tab 5-300 mg (Xodol)............................................................................. 96 hydrocodone-acetaminophen tab 5-325 mg (Norco).............................................................................96 202 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)............................................................................. 96 hydrocodone-acetaminophen tab 7.5-325 mg (Norco).............................................................................96 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 96 hydrocodone-ibuprofen tab 2.5-200 mg (Reprexain)......................................................................96 hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......96 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen).................................................................... 96 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml....... 60 hydrocodone w/ homatropine tab 5-1.5 mg.................. 60 hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml (Tussionex pennkineti).................................................. 60 hydrocortisone acetate suppos 25 mg (Anusolhc).................................................................................. 144 hydrocortisone acetate suppos 30 mg (Proctocort)...................................................................144 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc)..................................................... 144 hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% (Analpram-hc).................................................. 144 hydrocortisone butyrate cream 0.1% (Locoid)............151 hydrocortisone butyrate hydrophilic lipo base cream 0.1% (Locoid lipocream)..............................................151 hydrocortisone butyrate oint 0.1% (Locoid)................151 hydrocortisone butyrate soln 0.1% (Locoid)...............151 hydrocortisone cream 2.5%..........................................151 hydrocortisone enema 100 mg/60ml (Cortenema)......144 hydrocortisone lotion 2.5%...........................................152 hydrocortisone lotion 2% (Ala scalp).......................... 152 hydrocortisone oint 2.5%..............................................152 hydrocortisone rectal cream 1% (Proctocort).............144 hydrocortisone rectal cream 2.5% (Anusol-hc).......... 144 hydrocortisone tab 10 mg (Cortef).................................20 hydrocortisone tab 20 mg (Cortef).................................20 hydrocortisone tab 5 mg (Cortef).................................. 20 hydrocortisone valerate cream 0.2%........................... 152 hydrocortisone valerate oint 0.2% (Westcort).............152 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc).................................................................................. 141 HYDROFERA BLUE 4"X4" -wound dressings - pads...... 152 HYDROFERA BLUE FOAM DRESS -wound dressings pads................................................................................152 HYDROFERA BLUE HEAVY DRAI -wound dressings pads................................................................................152 HYDROFERA BLUE READY FOAM -wound dressings pads................................................................................152 HYDROMORPHONE HCL ER -hydromorphone hcl tab er 24hr deter 32 mg............................................................. 96 HYDROMORPHONE HCL -hydromorphone hcl suppos 3 mg.................................................................................... 96 hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 96 hydromorphone hcl tab 2 mg (Dilaudid)....................... 96 hydromorphone hcl tab 4 mg (Dilaudid)....................... 96 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 hydromorphone hcl tab 8 mg (Dilaudid)....................... 96 hydromorphone hcl tab er 24hr deter 12 mg (Exalgo)........................................................................... 96 hydromorphone hcl tab er 24hr deter 16 mg (Exalgo)........................................................................... 96 hydromorphone hcl tab er 24hr deter 8 mg (Exalgo)........................................................................... 96 hydroxychloroquine sulfate tab 200 mg (Plaquenil).....11 hydroxyurea cap 500 mg (Hydrea).................................17 hydroxyzine hcl syrup 10 mg/5ml.................................. 75 hydroxyzine hcl tab 10 mg............................................. 75 hydroxyzine hcl tab 25 mg............................................. 75 hydroxyzine hcl tab 50 mg............................................. 75 hydroxyzine pamoate cap 25 mg (Vistaril).................... 75 hydroxyzine pamoate cap 50 mg (Vistaril).................... 75 HYDROXYZINE PAMOATE -hydroxyzine pamoate cap 100 mg............................................................................. 75 HYLASE WOUND -hyaluronate sodium gel.................... 152 HYLATOPIC -emollient - aerosol foam............................152 HYLATOPIC PLUS -dermatological products misc cream............................................................................. 152 HYLATOPIC PLUS -emollient - aerosol foam................. 152 HYLIRA -hyaluronate sodium (emollient) gel 0.2%..........152 HYLIRA -hyaluronate sodium (emollient) lotion 0.1%...... 152 hyoscyamine sulfate elixir 0.125 mg/5ml...................... 67 hyoscyamine sulfate soln 0.125 mg/ml......................... 67 hyoscyamine sulfate tab 0.125 mg (Levsin)..................67 hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 67 hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 67 hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 67 HYPERHEP B S/D -hepatitis b immune globulin (human) im inj soln.........................................................................15 HYPERRAB S/D -rabies immune globulin (human) inj 150 unit/ml...............................................................................15 HYPERSAL -sodium chloride soln nebu 3.5%.................. 60 HYPERSAL -sodium chloride soln nebu 7%..................... 60 HYPER-SAL -sodium chloride soln nebu 7%.................... 60 HYPERTET S/D -tetanus immune globulin (human) inj 250 unit/ml...............................................................................15 HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800 unt/5 ml kit....................................................................... 16 HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/1.25 ml kit.................................................................. 15 HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600 unt/10 ml kit..................................................................... 16 HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400 unt/15 ml kit..................................................................... 16 HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit.................................................................... 15 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 100 mg............................................................................. 97 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 120 mg............................................................................. 97 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 20 mg............................................................................... 96 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 30 mg............................................................................... 96 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 40 mg............................................................................... 96 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 60 mg............................................................................... 96 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 80 mg............................................................................... 96 HY-VEE GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 29 HYZAAR -losartan potassium & hydrochlorothiazide tab 100-12.5 mg.....................................................................49 HYZAAR -losartan potassium & hydrochlorothiazide tab 100-25 mg........................................................................49 HYZAAR -losartan potassium & hydrochlorothiazide tab 50-12.5 mg.......................................................................49 I ibandronate sodium tab 150 mg (base equivalent) (Boniva)........................................................................... 37 IBRANCE -palbociclib cap 100 mg....................................17 IBRANCE -palbociclib cap 125 mg....................................17 IBRANCE -palbociclib cap 75 mg......................................17 IBUDONE -hydrocodone-ibuprofen tab 10-200 mg........... 97 IBUPROFEN COMFORT PAC -ibuprofen tab 800 mg & liniment topical gel kit.................................................... 102 ibuprofen tab 400 mg.................................................... 102 ibuprofen tab 600 mg.................................................... 102 ibuprofen tab 800 mg.................................................... 102 IC 400 -ibuprofen tab 400 mg & caffeine-vitamins cap kit....................................................................................102 IC 800 -ibuprofen tab 800 mg & caffeine-vitamins cap kit....................................................................................102 ICAR -carbonyl iron chew tab 15 mg (elemental iron)..... 130 ICAR-C PLUS -iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg...................................................... 130 ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml (elemental iron).............................................................. 130 ICLUSIG -ponatinib hcl tab 15 mg (base equiv)................ 17 ICLUSIG -ponatinib hcl tab 45 mg (base equiv)................ 17 ILEVRO -nepafenac ophth susp 0.3%.............................138 IMBRUVICA -ibrutinib cap 140 mg....................................17 imipramine hcl tab 10 mg (Tofranil)...............................78 imipramine hcl tab 25 mg (Tofranil)...............................78 imipramine hcl tab 50 mg (Tofranil)...............................78 imipramine pamoate cap 100 mg (Tofranil-pm)............ 78 imipramine pamoate cap 125 mg (Tofranil-pm)............ 78 imipramine pamoate cap 150 mg (Tofranil-pm)............ 78 imipramine pamoate cap 75 mg (Tofranil-pm).............. 78 imiquimod cream 5% (Aldara)...................................... 152 IMITREX STATDOSE REFILL -sumatriptan succinate solution cartridge 4 mg/0.5ml.........................................105 IMITREX STATDOSE REFILL -sumatriptan succinate solution cartridge 6 mg/0.5ml.........................................105 IMITREX STATDOSE SYSTEM -sumatriptan succinate solution auto-injector 4 mg/0.5ml...................................105 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 203 2015 IMITREX STATDOSE SYSTEM -sumatriptan succinate solution auto-injector 6 mg/0.5ml...................................105 IMITREX -sumatriptan nasal spray 20 mg/act................. 104 IMITREX -sumatriptan nasal spray 5 mg/act................... 104 IMITREX -sumatriptan succinate inj 6 mg/0.5ml..............105 IMITREX -sumatriptan succinate tab 100 mg.................. 105 IMITREX -sumatriptan succinate tab 25 mg.................... 105 IMITREX -sumatriptan succinate tab 50 mg.................... 105 IMOGAM RABIES-HT -rabies immune globulin (human) inj 150 unit/ml....................................................................... 16 IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc inj......................................................................................15 IMURAN -azathioprine tab 50 mg................................... 164 INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg................................................................... 117 INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg.................................................................................. 117 INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg..........................................................................117 INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)...........37 INCRUSE ELLIPTA -umeclidinium br aero powd breath act 62.5 mcg/inh (base eq)....................................................63 indapamide tab 1.25 mg..................................................53 indapamide tab 2.5 mg....................................................53 INDERAL LA -propranolol hcl cap sr 24hr 120 mg............ 40 INDERAL LA -propranolol hcl cap sr 24hr 160 mg............ 40 INDERAL LA -propranolol hcl cap sr 24hr 60 mg.............. 40 INDERAL LA -propranolol hcl cap sr 24hr 80 mg.............. 40 INDERAL XL -propranolol hcl sustained-release beads cap sr 24hr 120 mg................................................................ 40 INDERAL XL -propranolol hcl sustained-release beads cap sr 24hr 80 mg.................................................................. 40 INDOCIN -indomethacin suppos 50 mg.......................... 102 INDOCIN -indomethacin susp 25 mg/5ml........................102 indomethacin cap 25 mg.............................................. 102 indomethacin cap 50 mg.............................................. 102 indomethacin cap cr 75 mg.......................................... 102 INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg............................................................117 INFANATE PLUS -prenat w/o a w/fe fum-fe cbn-dss-fadha cap 27-1-260 mg.................................................... 117 INFANRIX -diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml..............................................................................15 INFASURF -calfactant in nacl 0.9% intratracheal susp 35 mg/ml................................................................................65 INLYTA -axitinib tab 1 mg................................................. 17 INLYTA -axitinib tab 5 mg................................................. 17 INNOPRAN XL -propranolol hcl sustained-release beads cap sr 24hr 120 mg......................................................... 40 INNOPRAN XL -propranolol hcl sustained-release beads cap sr 24hr 80 mg........................................................... 40 INOVA 4/1 ACNE CONTROL TH -benzoyl perox pad 4% & salicylic ac pad 1% & vit e 5% kit..................................152 INOVA 8/2 ACNE CONTROL TH -benzoyl perox pad 8% & salicylic ac pad 2% & vit e 5% kit..................................152 204 INOVA -benzoyl peroxide pad 4% & vitamin e topical 5% kit....................................................................................152 INOVA -benzoyl peroxide pad 8% & vitamin e topical 5% kit....................................................................................152 INSPRA -eplerenone tab 25 mg........................................49 INSPRA -eplerenone tab 50 mg........................................49 INSTA-GLUCOSE -glucose gel 77.4%..............................29 INSULIN PEN NEEDLES-VARIOUS............................... 163 INSULIN SYRINGES-VARIOUS......................................163 INTEGRA F -fe fum-fe poly-fa-c-b3 cap 62.5-62.5-1-40-3mg(125 mg fe).....................................130 INTEGRA PLUS -fe fum-iron polysacch complex-fa-b complex-c-biotin cap...................................................... 130 INTELENCE -etravirine tab 100 mg.................................... 8 INTELENCE -etravirine tab 200 mg.................................... 8 INTELENCE -etravirine tab 25 mg...................................... 8 INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit................................... 20 INTERMEZZO -zolpidem tartrate sl tab 1.75 mg...............84 INTERMEZZO -zolpidem tartrate sl tab 3.5 mg.................85 INTROL -glycerin soln 75%...............................................53 INTRON A -interferon alfa-2b for inj 10000000 unit...........17 INTRON A -interferon alfa-2b for inj 18000000 unit...........17 INTRON A -interferon alfa-2b for inj 50000000 unit...........17 INTRON A -interferon alfa-2b inj 10000000 unit/ml........... 17 INTRON A -interferon alfa-2b inj 6000000 unit/ml............. 17 INTRON A W/DILUENT -interferon alfa-2b for inj 10000000 unit.................................................................. 17 INTRON A W/DILUENT -interferon alfa-2b for inj 18000000 unit.................................................................. 17 INTRON A W/DILUENT -interferon alfa-2b for inj 50000000 unit.................................................................. 17 INTUNIV -guanfacine hcl tab sr 24hr 1 mg (base equiv)................................................................................87 INTUNIV -guanfacine hcl tab sr 24hr 2 mg (base equiv)................................................................................87 INTUNIV -guanfacine hcl tab sr 24hr 3 mg (base equiv)................................................................................87 INTUNIV -guanfacine hcl tab sr 24hr 4 mg (base equiv)................................................................................87 INVEGA -paliperidone tab sr 24hr 1.5 mg.........................82 INVEGA -paliperidone tab sr 24hr 3 mg............................82 INVEGA -paliperidone tab sr 24hr 6 mg............................82 INVEGA -paliperidone tab sr 24hr 9 mg............................82 INVIRASE -saquinavir mesylate cap 200 mg...................... 8 INVIRASE -saquinavir mesylate tab 500 mg.......................8 INVOKAMET -canagliflozin-metformin hcl tab 150-1000 mg.................................................................................... 29 INVOKAMET -canagliflozin-metformin hcl tab 150-500 mg.................................................................................... 29 INVOKAMET -canagliflozin-metformin hcl tab 50-1000 mg.................................................................................... 29 INVOKAMET -canagliflozin-metformin hcl tab 50-500 mg.................................................................................... 29 INVOKANA -canagliflozin tab 100 mg............................... 29 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 INVOKANA -canagliflozin tab 300 mg............................... 29 IODINE STRONG -iodine solution strong 5% (lugol's)........................................................................... 125 IODINE TINCTURE -iodine tincture................................ 163 IODINE TINCTURE MILD -iodine tincture....................... 163 IODINE TINCTURE STRONG DE -iodine tincture strong............................................................................. 163 IODINE TINCTURE STRONG -iodine tincture strong......163 iodoquinol-hc cream 1%............................................... 152 iodoquinol-hydrocortisone in aloe vehicle cream 1-1.9% (Vytone)............................................................ 152 IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act (base equiv)..................................................................... 97 IOPIDINE -apraclonidine hcl ophth soln 0.5% (base equivalent)......................................................................138 IOPIDINE -apraclonidine hcl ophth soln 1% (base equivalent)......................................................................138 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml.......63 ipratropium bromide inhal soln 0.02%.......................... 63 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent)........................................................................ 59 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent)........................................................................ 59 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide).......................................................................... 49 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide).......................................................................... 49 irbesartan tab 150 mg (Avapro)..................................... 49 irbesartan tab 300 mg (Avapro)..................................... 49 irbesartan tab 75 mg (Avapro)....................................... 49 IRENKA -duloxetine hcl enteric coated pellets cap 40 mg.................................................................................... 78 IRESSA -gefitinib tab 250 mg........................................... 17 IRON ASP GLY/ POLYSACCH C -fe asp gly-fe polysacchsucc ac-c-threon ac-b12-fa cap..................................... 130 IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg (elemental iron).............................................................. 130 iron combination cap.................................................... 130 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg (Hematron-af)................................................................130 iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite 150)................................................................. 130 iron polysacch complex-vit b12-fa cap 150-0.025-1 mg.................................................................................. 130 iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg (Icar-c plus)...................................................................130 IROSPAN 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-c-cafa tab ther pk................................................................. 130 IS 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-c-ca-fa tab ther pk............................................................................ 130 ISENTRESS -raltegravir potassium chew tab 100 mg (base equiv)....................................................................... 8 ISENTRESS -raltegravir potassium chew tab 25 mg (base equiv)..................................................................................8 ISENTRESS -raltegravir potassium packet for susp 100 mg (base equiv)................................................................. 8 ISENTRESS -raltegravir potassium tab 400 mg (base equiv)..................................................................................8 isometheptene-caffeine-acetaminophen tab 65-20-325 mg (Prodrin)................................................................. 105 ISONIAZID -isoniazid syrup 50 mg/5ml...............................6 isoniazid tab 100 mg......................................................... 6 isoniazid tab 300 mg......................................................... 6 ISOPTIN SR -verapamil hcl tab cr 120 mg........................43 ISOPTIN SR -verapamil hcl tab cr 180 mg........................43 ISOPTIN SR -verapamil hcl tab cr 240 mg........................43 ISOPTO ATROPINE -atropine sulfate ophth soln 1%......138 ISOPTO CARBACHOL -carbachol ophth soln 1.5%....... 138 ISOPTO CARBACHOL -carbachol ophth soln 3%.......... 138 ISOPTO CARPINE -pilocarpine hcl ophth soln 1%......... 139 ISOPTO CARPINE -pilocarpine hcl ophth soln 2%......... 139 ISOPTO CARPINE -pilocarpine hcl ophth soln 4%......... 139 ISOPTO HOMATROPINE -homatropine hbr ophth soln 2%.................................................................................. 139 ISOPTO HOMATROPINE -homatropine hbr ophth soln 5%.................................................................................. 139 ISOPTO HYOSCINE -scopolamine hbr ophth soln 0.25%............................................................................. 139 ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg......39 ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg........39 ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30 mg.................................................................................... 39 isosorbide dinitrate tab 10 mg....................................... 39 isosorbide dinitrate tab 20 mg....................................... 39 isosorbide dinitrate tab 5 mg (Isordil titradose)........... 39 isosorbide dinitrate tab cr 40 mg...................................39 isosorbide mononitrate tab 10 mg.................................39 isosorbide mononitrate tab 20 mg.................................39 isosorbide mononitrate tab sr 24hr 120 mg (Imdur)..... 39 isosorbide mononitrate tab sr 24hr 30 mg (Imdur)....... 39 isosorbide mononitrate tab sr 24hr 60 mg (Imdur)....... 39 isotretinoin cap 10 mg.................................................. 152 isotretinoin cap 20 mg.................................................. 152 isotretinoin cap 40 mg.................................................. 152 ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg............... 57 isoxsuprine hcl tab 10 mg.............................................. 57 isradipine cap 2.5 mg......................................................43 isradipine cap 5 mg.........................................................43 ISTALOL -timolol maleate ophth soln 0.5% (oncedaily)...............................................................................139 itraconazole cap 100 mg (Sporanox)............................... 6 ivermectin tab 3 mg (Stromectol).................................. 11 IXINITY -coagulation factor ix (recombinant) for inj 1000 unit..................................................................................135 IXINITY -coagulation factor ix (recombinant) for inj 1500 unit..................................................................................135 IXINITY -coagulation factor ix (recombinant) for inj 500 unit..................................................................................135 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 205 2015 J JADENU -deferasirox tab 180 mg................................... 163 JADENU -deferasirox tab 360 mg................................... 163 JADENU -deferasirox tab 90 mg..................................... 163 JAKAFI -ruxolitinib phosphate tab 10 mg (base equivalent)........................................................................17 JAKAFI -ruxolitinib phosphate tab 15 mg (base equivalent)........................................................................17 JAKAFI -ruxolitinib phosphate tab 20 mg (base equivalent)........................................................................17 JAKAFI -ruxolitinib phosphate tab 25 mg (base equivalent)........................................................................17 JAKAFI -ruxolitinib phosphate tab 5 mg (base equivalent)........................................................................17 JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg...........74 JANUMET -sitagliptin-metformin hcl tab 50-1000 mg........ 29 JANUMET -sitagliptin-metformin hcl tab 50-500 mg..........29 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 100-1000 mg....................................................................29 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-1000 mg......................................................................29 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-500 mg.................................................................................... 29 JANUVIA -sitagliptin phosphate tab 100 mg (base equiv)................................................................................29 JANUVIA -sitagliptin phosphate tab 25 mg (base equiv)................................................................................29 JANUVIA -sitagliptin phosphate tab 50 mg (base equiv)................................................................................29 JARDIANCE -empagliflozin tab 10 mg.............................. 29 JARDIANCE -empagliflozin tab 25 mg.............................. 29 JENTADUETO -linagliptin-metformin hcl tab 2.5-1000 mg.................................................................................... 29 JENTADUETO -linagliptin-metformin hcl tab 2.5-500 mg.................................................................................... 29 JENTADUETO -linagliptin-metformin hcl tab 2.5-850 mg.................................................................................... 29 JUBLIA -efinaconazole soln 10%.................................... 152 JUXTAPID -lomitapide mesylate cap 10 mg (base equiv)................................................................................55 JUXTAPID -lomitapide mesylate cap 20 mg (base equiv)................................................................................55 JUXTAPID -lomitapide mesylate cap 30 mg (base equiv)................................................................................55 JUXTAPID -lomitapide mesylate cap 40 mg (base equiv)................................................................................55 JUXTAPID -lomitapide mesylate cap 5 mg (base equiv)................................................................................55 JUXTAPID -lomitapide mesylate cap 60 mg (base equiv)................................................................................55 K K2K PAIN RELIEVING PATCH -lidocaine-menthol patch 4-4%............................................................................... 152 KADIAN -morphine sulfate cap sr 24hr 100 mg................ 97 206 KADIAN -morphine sulfate cap sr 24hr 10 mg.................. 97 KADIAN -morphine sulfate cap sr 24hr 200 mg................ 97 KADIAN -morphine sulfate cap sr 24hr 20 mg.................. 97 KADIAN -morphine sulfate cap sr 24hr 30 mg.................. 97 KADIAN -morphine sulfate cap sr 24hr 40 mg.................. 97 KADIAN -morphine sulfate cap sr 24hr 50 mg.................. 97 KADIAN -morphine sulfate cap sr 24hr 60 mg.................. 97 KADIAN -morphine sulfate cap sr 24hr 80 mg.................. 97 KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)................................................................................ 8 KALETRA -lopinavir-ritonavir tab 100-25 mg.......................8 KALETRA -lopinavir-ritonavir tab 200-50 mg.......................8 KALYDECO -ivacaftor packet 50 mg.................................65 KALYDECO -ivacaftor packet 75 mg.................................65 KALYDECO -ivacaftor tab 150 mg.................................... 65 KAPVAY -clonidine hcl tab sr 12hr 0.1 mg........................87 KARBINAL ER -carbinoxamine maleate er susp 4 mg/5ml..............................................................................58 KAYEXALATE -sodium polystyrene sulfonate powder............................................................................164 KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg........29 KAZANO -alogliptin-metformin hcl tab 12.5-500 mg..........29 KEFLEX -cephalexin cap 250 mg....................................... 2 KEFLEX -cephalexin cap 500 mg....................................... 2 KEFLEX -cephalexin cap 750 mg....................................... 2 KENALOG -triamcinolone acetonide aerosol soln........... 152 KENDALL HYDROGEL IMPREGNA -hydroactive (sterile) dressing..........................................................................152 KENDALL HYDROGEL WOUND DR -hydroactive (sterile) dressing..........................................................................152 KENDALL ZINC CALCIUM ALGI -wound dressings misc................................................................................ 152 KENDALL ZINC CALCIUM ALGI -wound dressings pads................................................................................152 KEPPRA -levetiracetam oral soln 100 mg/ml.................. 108 KEPPRA -levetiracetam tab 1000 mg............................. 108 KEPPRA -levetiracetam tab 250 mg............................... 108 KEPPRA -levetiracetam tab 500 mg............................... 108 KEPPRA -levetiracetam tab 750 mg............................... 108 KEPPRA XR -levetiracetam tab sr 24hr 500 mg............. 108 KEPPRA XR -levetiracetam tab sr 24hr 750 mg............. 108 KERAFOAM 42 -urea foam 42%.....................................152 KERAFOAM -urea foam 30%..........................................152 KERALAC -urea cream 47%........................................... 152 KERALYT -salicylic acid gel 6%......................................152 KERALYT SCALP -salicylic acid shampoo 6% & salicylic acid gel 6% kit............................................................... 152 KERLONE -betaxolol hcl tab 10 mg.................................. 40 KERLONE -betaxolol hcl tab 20 mg.................................. 41 KERR TRIPLE DYE -triple dye swabs............................ 163 KERYDIN -tavaborole soln 5%........................................152 KETEK -telithromycin tab 300 mg..................................... 12 KETEK -telithromycin tab 400 mg..................................... 12 ketoconazole cream 2%................................................ 152 ketoconazole foam 2% (Extina)....................................152 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 ketoconazole shampoo 2% (Nizoral)........................... 152 ketoconazole tab 200 mg..................................................6 KETODAN KIT -ketoconazole foam 2% & cleanser kit....................................................................................152 KETONE BLOOD TEST STRIPS – VARIOUS................ 163 ketoprofen cap 50 mg................................................... 102 ketoprofen cap 75 mg................................................... 102 KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg....... 102 ketorolac tromethamine ophth soln 0.4% (Acular ls)................................................................................... 139 ketorolac tromethamine ophth soln 0.5% (Acular)..... 139 ketorolac tromethamine tab 10 mg.............................. 102 KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg.............. 78 KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg................ 78 KINERET -anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml............................................................... 103 KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv vac inj...............................................................................15 KITABIS PAK -tobramycin nebu soln 300 mg/5ml...............5 KLARON -sulfacetamide sodium lotion 10% (acne)........ 152 KLONOPIN -clonazepam tab 0.5 mg.............................. 108 KLONOPIN -clonazepam tab 1 mg................................. 108 KLONOPIN -clonazepam tab 2 mg................................. 108 KLOR-CON/25 -potassium chloride powder packet 25 meq................................................................................ 125 KLOR-CON 25 -potassium chloride powder packet 25 meq................................................................................ 125 KLOR-CON M15 -potassium chloride microencapsulated crys cr tab 15 meq.........................................................125 KOATE-DVI -antihemophilic factor (human) for inj 1000 unit..................................................................................135 KOATE-DVI -antihemophilic factor (human) for inj 250 unit..................................................................................135 KOATE-DVI -antihemophilic factor (human) for inj 500 unit..................................................................................135 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 1000 unit................................................................... 135 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 2000 unit................................................................... 135 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 250 unit..................................................................... 135 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 3000 unit................................................................... 135 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 500 unit..................................................................... 135 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 1000 unit.................................. 135 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 2000 unit.................................. 135 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 250 unit.................................... 135 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 3000 unit.................................. 135 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 500 unit.................................... 135 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 2.5-1000 mg.....................................................................29 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 5-1000 mg........................................................................29 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 5-500 mg..........................................................................29 KORLYM -mifepristone tab 300 mg.................................. 29 K-PHOS NEUTRAL -pot phos monobasic w/sod phos di & monobas tab 155-852-130mg........................................125 K-PHOS NO 2 -potassium & sodium acid phosphates tab 305-700 mg......................................................................74 K-PHOS -potassium phosphate monobasic tab 500 mg.................................................................................. 125 KRISTALOSE -lactulose oral crystal packet 10 gm........... 65 KRISTALOSE -lactulose oral crystal packet 20 gm........... 65 KROGER GLUCOSE -glucose chew tab 4 gm..................29 KROGER GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 29 K-TAB -potassium chloride tab cr 10 meq.......................125 K-TAB -potassium chloride tab cr 20 meq (1500 mg)...... 125 K-TAB -potassium chloride tab cr 8 meq (600 mg)..........125 KUVAN -sapropterin dihydrochloride powder packet 100 mg.................................................................................... 37 KUVAN -sapropterin dihydrochloride powder packet 500 mg.................................................................................... 37 KUVAN -sapropterin dihydrochloride soluble tab 100 mg.................................................................................... 37 KYNAMRO -mipomersen sodium soln prefilled syringe 200 mg/ml................................................................................55 L labetalol hcl tab 100 mg (Trandate)............................... 41 labetalol hcl tab 200 mg (Trandate)............................... 41 labetalol hcl tab 300 mg (Trandate)............................... 41 LAC-HYDRIN -lactic acid (ammonium lactate) cream 12%................................................................................ 152 LAC-HYDRIN -lactic acid (ammonium lactate) lotion 12%................................................................................ 152 LACRISERT -artificial tear ophth insert........................... 139 lactic acid (ammonium lactate) cream 12% (Lachydrin)........................................................................... 152 lactic acid (ammonium lactate) lotion 10%................. 152 lactic acid (ammonium lactate) lotion 12% (Lachydrin)........................................................................... 153 lactic acid w/ vitamin e cream 10%-3500 unit/30gm...................................................................... 153 lactulose (encephalopathy) solution 10 gm/15ml......... 71 lactulose solution 10 gm/15ml....................................... 65 LAMICTAL CHEWABLE DISPERS -lamotrigine tab chewable dispersible 25 mg.......................................... 108 LAMICTAL CHEWABLE DISPERS -lamotrigine tab chewable dispersible 5 mg............................................ 108 LAMICTAL -lamotrigine tab 100 mg................................ 108 LAMICTAL -lamotrigine tab 150 mg................................ 108 LAMICTAL -lamotrigine tab 200 mg................................ 108 LAMICTAL -lamotrigine tab 25 mg.................................. 108 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 207 2015 LAMICTAL ODT -lamotrigine orally disintegrating tab 100 mg.................................................................................. 108 LAMICTAL ODT -lamotrigine orally disintegrating tab 200 mg.................................................................................. 108 LAMICTAL ODT -lamotrigine orally disintegrating tab 25 mg.................................................................................. 108 LAMICTAL ODT -lamotrigine orally disintegrating tab 50 mg.................................................................................. 108 LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit.............................................................108 LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit................................................................. 108 LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit.........................................................108 LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg (42) & 100 mg (7) starter kit.......................................... 108 LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg (84) & 100 mg (14) starter kit........................................ 108 LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg (35) starter kit................................................................ 108 LAMICTAL XR -lamotrigine tab sr 24hr 100 mg.............. 108 LAMICTAL XR -lamotrigine tab sr 24hr 200 mg.............. 108 LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit...................................................... 108 LAMICTAL XR -lamotrigine tab sr 24hr 250 mg.............. 108 LAMICTAL XR -lamotrigine tab sr 24hr 25 mg................ 108 LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50 mg (7) titration kit...........................................................108 LAMICTAL XR -lamotrigine tab sr 24hr 300 mg.............. 108 LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit..................................................108 LAMICTAL XR -lamotrigine tab sr 24hr 50 mg................ 108 LAMISIL -terbinafine hcl oral granules packet 125 mg........ 7 LAMISIL -terbinafine hcl oral granules packet 187.5 mg..... 7 LAMISIL -terbinafine hcl tab 250 mg................................... 6 lamivudine oral soln 10 mg/ml (Epivir)............................8 lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 8 lamivudine tab 150 mg (Epivir)........................................ 8 lamivudine tab 300 mg (Epivir)........................................ 8 lamivudine-zidovudine tab 150-300 mg (Combivir)........ 8 lamotrigine orally disintegrating tab 100 mg (Lamictal odt).................................................................................108 lamotrigine orally disintegrating tab 200 mg (Lamictal odt).................................................................................109 lamotrigine orally disintegrating tab 25 mg (Lamictal odt).................................................................................108 lamotrigine orally disintegrating tab 50 mg (Lamictal odt).................................................................................108 lamotrigine tab 100 mg (Lamictal)............................... 109 lamotrigine tab 150 mg (Lamictal)............................... 109 lamotrigine tab 200 mg (Lamictal)............................... 109 lamotrigine tab 25 mg (Lamictal)................................. 109 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di)................................................................. 109 208 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di)................................................................. 109 lamotrigine tab sr 24hr 100 mg (Lamictal xr).............. 109 lamotrigine tab sr 24hr 200 mg (Lamictal xr).............. 109 lamotrigine tab sr 24hr 250 mg (Lamictal xr).............. 109 lamotrigine tab sr 24hr 25 mg (Lamictal xr)................ 109 lamotrigine tab sr 24hr 300 mg (Lamictal xr).............. 109 lamotrigine tab sr 24hr 50 mg (Lamictal xr)................ 109 LANCETS-VARIOUS....................................................... 163 LANOXIN -digoxin tab 125 mcg (0.125 mg)...................... 39 LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................. 39 LANOXIN -digoxin tab 250 mcg (0.25 mg)........................ 39 LANOXIN -digoxin tab 62.5 mcg (0.0625 mg)................... 39 lansoprazole cap delayed release 15 mg (Prevacid)........................................................................ 67 lansoprazole cap delayed release 30 mg (Prevacid)........................................................................ 67 LANTUS -insulin glargine inj 100 unit/ml........................... 32 LANTUS SOLOSTAR -insulin glargine soln pen-injector 100 unit/ml....................................................................... 32 LASIX -furosemide tab 20 mg........................................... 53 LASIX -furosemide tab 40 mg........................................... 53 LASIX -furosemide tab 80 mg........................................... 53 LASTACAFT -alcaftadine ophth soln 0.25%....................139 latanoprost ophth soln 0.005% (Xalatan).................... 139 LATRIX XM -urea in zinc undecylenate-lactic acid vehicle emulsion 45%................................................................ 153 LATUDA -lurasidone hcl tab 120 mg.................................82 LATUDA -lurasidone hcl tab 20 mg...................................82 LATUDA -lurasidone hcl tab 40 mg...................................82 LATUDA -lurasidone hcl tab 60 mg...................................82 LATUDA -lurasidone hcl tab 80 mg...................................82 LAVARE WOUND WASH -wound cleansers - gel...........153 LAVOCLEN-4 CREAMY WASH -benzoyl peroxide liq 4%.................................................................................. 153 LAVOCLEN-8 CREAMY WASH -benzoyl peroxide liq 8%.................................................................................. 153 LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base equiv)................................................................................97 LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base equiv)................................................................................97 LEADER GLUCOSE -glucose chew tab 4 gm...................29 LEADER GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 30 LEADER QUICK DISSOLVE GLU -glucose chew tab 4 gm.................................................................................... 30 LECITHIN -lecithin granules............................................ 126 leflunomide tab 10 mg (Arava)..................................... 103 leflunomide tab 20 mg (Arava)..................................... 103 LENVIMA 10MG DAILY DOSE -lenvatinib cap therapy pack 10 mg (10 mg daily dose)....................................... 17 LENVIMA 14MG DAILY DOSE -lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose)................................ 18 LENVIMA 20MG DAILY DOSE -lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose)..................................18 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 LENVIMA 24MG DAILY DOSE -lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose)........................... 18 LESCOL -fluvastatin sodium cap 20 mg........................... 55 LESCOL -fluvastatin sodium cap 40 mg........................... 55 LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg.......... 55 LETAIRIS -ambrisentan tab 10 mg................................... 58 LETAIRIS -ambrisentan tab 5 mg..................................... 57 letrozole tab 2.5 mg (Femara).........................................18 LEUCOVORIN CALCIUM -leucovorin calcium tab 10 mg.................................................................................... 18 LEUCOVORIN CALCIUM -leucovorin calcium tab 15 mg.................................................................................... 18 leucovorin calcium tab 25 mg........................................ 18 leucovorin calcium tab 5 mg.......................................... 18 LEUKERAN -chlorambucil tab 2 mg..................................18 LEUKINE -sargramostim lyophilized for inj 250 mcg....... 130 leuprolide acetate inj kit 5 mg/ml...................................18 LEVACET -aspirin-apap-salicylamide-caffeine tab 500-250-150-32.5 mg...................................................... 93 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex)........................................................................ 64 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex)........................................................................ 64 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)........................................................................ 64 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)...............................................................................63 LEVAQUIN -levofloxacin oral soln 25 mg/ml....................... 5 LEVAQUIN -levofloxacin tab 250 mg.................................. 5 LEVAQUIN -levofloxacin tab 500 mg.................................. 5 LEVAQUIN -levofloxacin tab 750 mg.................................. 5 LEVATIO PATCH -capsaicin-menthol topical patch 0.03-5%.......................................................................... 153 LEVATOL -penbutolol sulfate tab 20 mg........................... 41 LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg......... 67 LEVEMIR FLEXPEN -insulin detemir soln pen-injector 100 unit/ml...............................................................................32 LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector 100 unit/ml....................................................................... 33 LEVEMIR -insulin detemir inj 100 unit/ml.......................... 32 levetiracetam oral soln 100 mg/ml (Keppra)............... 109 levetiracetam tab 1000 mg (Keppra)............................ 109 levetiracetam tab 250 mg (Keppra).............................. 109 levetiracetam tab 500 mg (Keppra).............................. 109 levetiracetam tab 750 mg (Keppra).............................. 109 levetiracetam tab sr 24hr 500 mg (Keppra xr).............109 levetiracetam tab sr 24hr 750 mg (Keppra xr).............109 LEVOBUNOLOL HCL -levobunolol hcl ophth soln 0.25%............................................................................. 139 levobunolol hcl ophth soln 0.5% (Betagan)................ 139 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 37 levocarnitine tab 330 mg (Carnitor)............................... 37 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ ml) (Xyzal)....................................................................... 58 levocetirizine dihydrochloride tab 5 mg (Xyzal)............58 levofloxacin ophth soln 0.5%....................................... 139 levofloxacin oral soln 25 mg/ml (Levaquin).................... 5 levofloxacin tab 250 mg (Levaquin).................................5 levofloxacin tab 500 mg (Levaquin).................................5 levofloxacin tab 750 mg (Levaquin).................................5 LEVOMEFOLATE CALCIUM/ACET -l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg............................127 LEVOMEFOLATE CALCIUM/ALGA -l-methylfolate-algae cap 15-90.314 mg..........................................................127 LEVOMEFOLATE CALCIUM/ALGA -l-methylfolate-algae cap 7.5-90.314 mg.........................................................127 LEVOMEFOLATE CALCIUM/PYRI -l-methylfolate-algaevit b12-b6 cap 3-90.314-2-35 mg.................................. 127 LEVOMEFOLATE DHA -prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg................................................ 117 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg................................................................... 24 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg.................................................................................. 24 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg.................................................................................. 24 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg.................................25 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg.................................................................................. 25 levonorgestrel tab 1.5 mg (Plan b one-step)................. 24 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique).............................................24 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique).................................................24 LEVORPHANOL TARTRATE -levorphanol tartrate tab 2 mg.................................................................................... 97 levothyroxine sodium tab 100 mcg (Synthroid)............33 levothyroxine sodium tab 112 mcg (Synthroid)............33 levothyroxine sodium tab 125 mcg (Synthroid)............33 levothyroxine sodium tab 137 mcg (Synthroid)............33 levothyroxine sodium tab 150 mcg (Synthroid)............33 levothyroxine sodium tab 175 mcg (Synthroid)............33 levothyroxine sodium tab 200 mcg (Synthroid)............33 levothyroxine sodium tab 25 mcg (Synthroid)..............33 levothyroxine sodium tab 300 mcg (Synthroid)............33 levothyroxine sodium tab 50 mcg (Synthroid)..............33 levothyroxine sodium tab 75 mcg (Synthroid)..............33 levothyroxine sodium tab 88 mcg (Synthroid)..............33 LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg............ 67 LEVSIN -hyoscyamine sulfate tab 0.125 mg..................... 67 LEVULAN KERASTICK -aminolevulinic acid hcl for soln 20% (stick applicator).................................................... 153 LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base equiv)................................................................................78 LEXAPRO -escitalopram oxalate tab 10 mg (base equiv)................................................................................78 LEXAPRO -escitalopram oxalate tab 20 mg (base equiv)................................................................................78 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 209 2015 LEXAPRO -escitalopram oxalate tab 5 mg (base equiv)................................................................................78 LEXIVA -fosamprenavir calcium susp 50 mg/ml (base equiv)..................................................................................8 LEXIVA -fosamprenavir calcium tab 700 mg (base equiv)..................................................................................8 LEXUSS 210 -chlorpheniramine w/ codeine liquid 2-10 mg/5ml..............................................................................60 LIALDA -mesalamine tab delayed release 1.2 gm............ 71 LIBRAX -chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg.................................................................................... 67 LIDENZA PATCH -lidocaine-menthol patch 4-1%........... 153 LIDOCAINE AND TETRACAINE -lidocaine-tetracaine cream 7-7%....................................................................153 lidocaine hcl cream 3%.................................................153 lidocaine hcl gel 2%...................................................... 153 LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%..................144 lidocaine hcl laryngotracheal soln 4% (Lta 360 kit).................................................................................. 142 LIDOCAINE HCL -lidocaine hcl lotion 3%....................... 153 lidocaine hcl soln 4% (Xylocaine)................................ 153 lidocaine hcl viscous soln 2%......................................142 lidocaine-hydrocortisone acetate rectal cream 3-0.5%............................................................................ 144 lidocaine-hydrocortisone acetate rectal cream kit 2-2%............................................................................... 144 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%............................................................................ 144 lidocaine-hydrocortisone acetate rectal cream kit 3-1%............................................................................... 144 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%............................................................................ 144 lidocaine-menthol patch 4-5%...................................... 153 lidocaine oint 5%........................................................... 153 lidocaine patch 5% (700 mg) (Lidoderm).....................153 lidocaine-prilocaine cream 2.5-2.5% (Emla)................ 153 lidocaine-prilocaine kit 2.5-2.5%.................................. 153 lidocaine-prilocaine kit 2.5-2.5%.................................. 153 LIDOCIN -lidocaine hcl gel 3%........................................153 LIDODERM -lidocaine patch 5% (700 mg)......................153 LIDODEXTRAPINE -lidocaine-menthol patch 4-1%........ 153 LIDOPIN -lidocaine hcl cream 3.25%.............................. 153 LIDORX -lidocaine hcl gel 3%......................................... 153 LIDOTHOL -lidocaine-menthol patch 4.5-5%.................. 153 LIDOVEX -lidocaine cream 3.75%.................................. 153 LIDOVIN -lidocaine hcl cream 3.95%.............................. 153 LIDOZOL -lidocaine hcl cream 3.75%............................. 153 LIMBREL250 -flavocoxid-citrated zinc bisglycinate cap 250-50 mg......................................................................127 LIMBREL500 -flavocoxid-citrated zinc bisglycinate cap 500-50 mg......................................................................127 LIMBREL -flavocoxid cap 250 mg................................... 127 LIMBREL -flavocoxid cap 500 mg................................... 127 lindane lotion 1%........................................................... 153 210 lindane shampoo 1%.....................................................153 linezolid tab 600 mg (Zyvox).......................................... 12 LINZESS -linaclotide cap 145 mcg....................................71 LINZESS -linaclotide cap 290 mcg....................................71 liothyronine sodium tab 25 mcg (Cytomel)................... 33 liothyronine sodium tab 50 mcg (Cytomel)................... 33 liothyronine sodium tab 5 mcg (Cytomel)..................... 33 LIPITOR -atorvastatin calcium tab 10 mg (base equivalent)........................................................................55 LIPITOR -atorvastatin calcium tab 20 mg (base equivalent)........................................................................55 LIPITOR -atorvastatin calcium tab 40 mg (base equivalent)........................................................................55 LIPITOR -atorvastatin calcium tab 80 mg (base equivalent)........................................................................55 LIPOFEN -fenofibrate cap 150 mg.................................... 55 LIPOFEN -fenofibrate cap 50 mg...................................... 55 LIPTRUZET -ezetimibe-atorvastatin tab 10-10 mg............55 LIPTRUZET -ezetimibe-atorvastatin tab 10-20 mg............55 LIPTRUZET -ezetimibe-atorvastatin tab 10-40 mg............55 LIPTRUZET -ezetimibe-atorvastatin tab 10-80 mg............55 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)......................................................................49 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)......................................................................49 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic)......................................................................49 lisinopril tab 10 mg (Prinivil).......................................... 49 lisinopril tab 2.5 mg (Zestril).......................................... 49 lisinopril tab 20 mg (Prinivil).......................................... 49 lisinopril tab 30 mg (Zestril)........................................... 49 lisinopril tab 40 mg (Zestril)........................................... 49 lisinopril tab 5 mg (Prinivil)............................................ 49 LISTERINE ESSENTIAL CARE -sod monofluorophospheucal-men-methyl sal-thymol gel 0.76%........................ 142 LISTERINE RESTORING -sodium fluoride rinse 0.0221% (0.01% f)........................................................................ 142 LISTERINE SMART RINSE ANT -sodium fluoride rinse 0.02%............................................................................. 142 LISTERINE SMART RINSE -sodium fluoride rinse 0.0221% (0.01% f)......................................................... 142 LISTERINE TOOTH DEFENSE -sodium fluoride rinse 0.0221% (0.01% f)......................................................... 142 LISTERINE TOTAL CARE PLUS -sodium fluoride rinse 0.0221% (0.01% f)......................................................... 142 LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221% (0.01% f)........................................................................ 142 LISTERINE TOTAL CARE ZERO -sodium fluoride rinse 0.02%............................................................................. 142 LISTERINE WHITENING/RESTO -sodium fluoride rinse 0.0221% (0.01% f)......................................................... 142 lithium carbonate cap 150 mg (Lithium carbonate)...... 82 lithium carbonate cap 300 mg........................................82 lithium carbonate cap 600 mg (Lithium carbonate)...... 82 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 LITHIUM CARBONATE -lithium carbonate cap 150 mg.................................................................................... 82 LITHIUM CARBONATE -lithium carbonate cap 600 mg.................................................................................... 82 lithium carbonate tab 300 mg.........................................82 lithium carbonate tab cr 300 mg (Lithobid)................... 82 lithium carbonate tab cr 450 mg.................................... 82 LITHIUM -lithium oral solution 8 meq/5ml......................... 82 LITHOBID -lithium carbonate tab cr 300 mg..................... 82 LITHOSTAT -acetohydroxamic acid tab 250 mg............... 74 LIVALO -pitavastatin calcium tab 1 mg (base equiv)......... 55 LIVALO -pitavastatin calcium tab 2 mg (base equiv)......... 55 LIVALO -pitavastatin calcium tab 4 mg (base equiv)......... 55 L-METHYL-B6-B12 -l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg.......................................................................126 L-METHYLFOLATE CA/ME-CBL/ -l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg..................127 L-METHYLFOLATE CA/P-5-P/M -l-methylfolate-algae-vit b12-b6 cap 3-90.314-2-35 mg....................................... 127 L-METHYLFOLATE CA/P-5-P/M -l-methylfolate w/ vit b6vit b12 tab 3-35-2 mg.................................................... 127 L-METHYLFOLATE CALCIUM -l-methylfolate tab 15 mg.................................................................................. 127 L-METHYLFOLATE CALCIUM -l-methylfolate tab 7.5 mg.................................................................................. 127 L-METHYLFOLATE CA ME-CBL -l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg............................127 L-METHYLFOLATE FORMULA 15 -l-methylfolate-algae cap 15-90.314 mg..........................................................127 L-METHYLFOLATE FORMULA 7. -l-methylfolate-algae cap 7.5-90.314 mg.........................................................127 L-METHYLFOLATE FORTE -l-methylfolate-algae cap 15-90.314 mg.................................................................127 L-METHYLFOLATE FORTE -l-methylfolate-algae cap 7.5-90.314 mg................................................................127 L-METHYLFOLATE -l-methylfolate tab 15 mg................ 127 L-METHYLFOLATE -l-methylfolate tab 7.5 mg................127 L-METHYLFOLATE PNV DHA -prenat w/fe fum-l methylfolate-fa-dha cap 27-1.13-0.4 mg........................ 117 L-METHYL-MC -l-methylfolate w/ vit b12-vit b6-vit b2 tab 6-1-50-5 mg................................................................... 126 L-METHYL-MC NAC -l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg............................................. 126 LMTHF/PYRIDOXINE HCL/CYAN -l-methylfolate w/ vit b6vit b12 tab 1.13-25-2 mg............................................... 127 LOCOID -hydrocortisone butyrate cream 0.1%............... 153 LOCOID -hydrocortisone butyrate lotion 0.1%................ 153 LOCOID -hydrocortisone butyrate oint 0.1%................... 153 LOCOID -hydrocortisone butyrate soln 0.1%.................. 153 LOCOID LIPOCREAM -hydrocortisone butyrate hydrophilic lipo base cream 0.1%.................................. 153 LODOSYN -carbidopa tab 25 mg....................................111 LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg............................................................. 25 LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg............................................ 25 LOESTRIN FE 1/20 -norethindrone ace & ethinyl estradiolfe tab 1 mg-20 mcg......................................................... 25 LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg........................................25 LOFIBRA -fenofibrate micronized cap 134 mg.................. 55 LOFIBRA -fenofibrate micronized cap 200 mg.................. 55 LOFIBRA -fenofibrate micronized cap 67 mg.................... 55 LOFIBRA -fenofibrate tab 160 mg.....................................55 LOFIBRA -fenofibrate tab 54 mg.......................................55 LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2)........................................................ 25 LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025 mg.................................................................................... 66 LOMUSTINE -lomustine cap 100 mg................................ 18 LOMUSTINE -lomustine cap 10 mg.................................. 18 LOMUSTINE -lomustine cap 40 mg.................................. 18 LONGS GLUCOSE -glucose chew tab 4 gm.................... 30 LONGS GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 30 LOPID -gemfibrozil tab 600 mg......................................... 55 LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab 100-25 mg........................................................................49 LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab 50-25 mg..........................................................................49 LOPRESSOR -metoprolol tartrate tab 100 mg.................. 41 LOPRESSOR -metoprolol tartrate tab 50 mg.................... 41 LOPROX SHAMPOO -ciclopirox shampoo 1%............... 153 lorazepam conc 2 mg/ml (Lorazepam intensol)............ 75 LORAZEPAM INTENSOL -lorazepam conc 2 mg/ml........ 75 lorazepam tab 0.5 mg (Ativan)....................................... 75 lorazepam tab 1 mg (Ativan).......................................... 75 lorazepam tab 2 mg (Ativan).......................................... 75 LORENZA -lidocaine-menthol patch 4-1%...................... 153 LORTUSS EX -pseudoephedrine w/ cod-gg liquid 30-10-100 mg/5ml............................................................60 LORZONE -chlorzoxazone tab 375 mg...........................114 LORZONE -chlorzoxazone tab 750 mg...........................114 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar).................................................................... 49 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar).................................................................... 49 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar).................................................................... 49 losartan potassium tab 100 mg (Cozaar)...................... 49 losartan potassium tab 25 mg (Cozaar)........................ 49 losartan potassium tab 50 mg (Cozaar)........................ 49 LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)...................................................... 25 LOTEMAX -loteprednol etabonate ophth gel 0.5%..........139 LOTEMAX -loteprednol etabonate ophth oint 0.5%.........139 LOTEMAX -loteprednol etabonate ophth susp 0.5%....... 139 LOTENSIN -benazepril hcl tab 10 mg............................... 49 LOTENSIN -benazepril hcl tab 20 mg............................... 49 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 211 2015 LOTENSIN -benazepril hcl tab 40 mg............................... 49 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 10-12.5 mg.......................................................................49 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 20-12.5 mg.......................................................................49 LOTENSIN HCT -benazepril & hydrochlorothiazide tab 20-25 mg..........................................................................49 LOTREL -amlodipine besylate-benazepril hcl cap 10-20 mg.................................................................................... 49 LOTREL -amlodipine besylate-benazepril hcl cap 10-40 mg.................................................................................... 49 LOTREL -amlodipine besylate-benazepril hcl cap 2.5-10 mg.................................................................................... 49 LOTREL -amlodipine besylate-benazepril hcl cap 5-10 mg.................................................................................... 49 LOTREL -amlodipine besylate-benazepril hcl cap 5-20 mg.................................................................................... 49 LOTRIMIN ULTRA -butenafine hcl cream 1%................. 153 LOTRISONE -clotrimazole w/ betamethasone cream 1-0.05%.......................................................................... 153 LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)..........71 LOTRONEX -alosetron hcl tab 1 mg (base equiv).............71 LOUTREX -antiseborrheic products misc - cream...........153 lovastatin tab 10 mg........................................................55 lovastatin tab 20 mg (Mevacor)......................................55 lovastatin tab 40 mg (Mevacor)......................................56 LOVAZA -omega-3-acid ethyl esters cap 1 gm................. 56 LOVENOX -enoxaparin sodium inj 100 mg/ml................ 132 LOVENOX -enoxaparin sodium inj 120 mg/0.8ml............132 LOVENOX -enoxaparin sodium inj 150 mg/ml................ 133 LOVENOX -enoxaparin sodium inj 300 mg/3ml.............. 133 LOVENOX -enoxaparin sodium inj 30 mg/0.3ml............. 132 LOVENOX -enoxaparin sodium inj 40 mg/0.4ml............. 132 LOVENOX -enoxaparin sodium inj 60 mg/0.6ml............. 132 LOVENOX -enoxaparin sodium inj 80 mg/0.8ml............. 132 loxapine succinate cap 10 mg........................................82 loxapine succinate cap 25 mg........................................82 loxapine succinate cap 50 mg........................................82 loxapine succinate cap 5 mg......................................... 82 LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg naf)................................................................................. 125 LTA 360 KIT -lidocaine hcl laryngotracheal soln 4%....... 142 LUFYLLIN -dyphylline tab 400 mg.................................... 64 LUGOLS STRONG IODINE -iodine solution................... 163 LUMIGAN -bimatoprost ophth soln 0.01%.......................139 LUNESTA -eszopiclone tab 1 mg......................................85 LUNESTA -eszopiclone tab 2 mg......................................85 LUNESTA -eszopiclone tab 3 mg......................................85 LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)...........................................................................125 LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)................................................................................. 125 LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg naf)................................................................................. 125 212 LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)................................................................................. 125 LUXIQ -betamethasone valerate aerosol foam 0.12%.....153 LUZU -luliconazole cream 1%......................................... 153 LYCELLE -nit remover - gel............................................ 153 LYNPARZA -olaparib cap 50 mg.......................................18 LYRICA -pregabalin cap 100 mg.....................................109 LYRICA -pregabalin cap 150 mg.....................................109 LYRICA -pregabalin cap 200 mg.....................................109 LYRICA -pregabalin cap 225 mg.....................................109 LYRICA -pregabalin cap 25 mg.......................................109 LYRICA -pregabalin cap 300 mg.....................................109 LYRICA -pregabalin cap 50 mg.......................................109 LYRICA -pregabalin cap 75 mg.......................................109 LYRICA -pregabalin soln 20 mg/ml................................. 109 LYSODREN -mitotane tab 500 mg....................................18 LYSTEDA -tranexamic acid tab 650 mg..........................133 M MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha cap 28-1-250 mg............................................................117 MAC PATCH -capsaicin-menthol topical patch 0.0375-5%...................................................................... 153 MACROBID -nitrofurantoin monohydrate macrocrystalline cap 100 mg......................................................................72 MACRODANTIN -nitrofurantoin macrocrystalline cap 100 mg.................................................................................... 72 MACRODANTIN -nitrofurantoin macrocrystalline cap 25 mg.................................................................................... 72 MACRODANTIN -nitrofurantoin macrocrystalline cap 50 mg.................................................................................... 72 MAGNEBIND 400 -magnesium-calcium-folic acid tab 400-200-1 mg.................................................................125 MALARONE -atovaquone-proguanil hcl tab 250-100 mg.................................................................................... 11 MALARONE -atovaquone-proguanil hcl tab 62.5-25 mg.................................................................................... 11 malathion lotion 0.5% (Ovide)...................................... 153 MAPROTILINE HCL -maprotiline hcl tab 25 mg................78 MAPROTILINE HCL -maprotiline hcl tab 50 mg................78 MAPROTILINE HCL -maprotiline hcl tab 75 mg................78 MAR-COF BP -pseudoephedrine-bromphen-codeine liqd 30-2-7.5 mg/5ml...............................................................60 MAR-COF CG EXPECTORANT -guaifenesin-codeine liquid 225-7.5 mg/5ml...................................................... 60 MARINOL -dronabinol cap 10 mg..................................... 69 MARINOL -dronabinol cap 2.5 mg.................................... 69 MARINOL -dronabinol cap 5 mg....................................... 69 MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa cap 60-1 mg...................................................................117 MARPLAN -isocarboxazid tab 10 mg................................ 78 MATULANE -procarbazine hcl cap 50 mg.........................18 MAVIK -trandolapril tab 1 mg............................................ 49 MAVIK -trandolapril tab 2 mg............................................ 49 MAVIK -trandolapril tab 4 mg............................................ 49 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 MAXALT-MLT -rizatriptan benzoate orally disintegrating tab 10 mg.......................................................................105 MAXALT-MLT -rizatriptan benzoate orally disintegrating tab 5 mg.........................................................................105 MAXALT -rizatriptan benzoate tab 10 mg....................... 105 MAXALT -rizatriptan benzoate tab 5 mg......................... 105 MAXARON FORTE -fe gly-fe fum-vit c-vit b12-methylfolate tab.................................................................................. 130 MAXFE -iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab 160-1 mg........................................................................130 MAXIDEX -dexamethasone ophth susp 0.1%................. 139 MAXITROL -neomycin-polymyxin-dexamethasone ophth oint 0.1%........................................................................ 139 MAXITROL -neomycin-polymyxin-dexamethasone ophth susp 0.1%...................................................................... 139 MAXZIDE-25 -triamterene & hydrochlorothiazide tab 37.5-25 mg.......................................................................53 MAXZIDE -triamterene & hydrochlorothiazide tab 75-50 mg.................................................................................... 53 MB HYDROGEL -dermatological products misc - kit....... 153 MECLOFENAMATE SODIUM -meclofenamate sodium cap 100 mg....................................................................103 MECLOFENAMATE SODIUM -meclofenamate sodium cap 50 mg......................................................................103 MEDICAL PROVIDER EZ FLU S -influenza virus vac tisscult subunit pref syr kit 0.5 ml..........................................15 MEDICAL PROVIDER EZ FLU S -influenza virus vac types a & b pf pref syringe kit 0.5 ml...............................15 MEDICINE SHOPPE GLUCOSE -glucose chew tab 4 gm.................................................................................... 30 MEDI-DERM/L-RX -lidocaine-capsaicin-menthol-methyl sal cream 2-0.035-5-20%...............................................154 MEDI-DERM-RX -capsaicin-menthol-methyl salicylate cream 0.035-5-20%....................................................... 154 MEDIHONEY CALCIUM ALGINAT -wound dressings pads................................................................................154 MEDIHONEY WOUND & BURN DR -wound dressings pads................................................................................154 MEDI-PATCH RX -lidocaine-capsaicin-menthol-methyl sal patch 0.5-0.035-5-20%...................................................154 MEDROL DOSEPAK -methylprednisolone tab 4 mg dose pack..................................................................................20 MEDROL -methylprednisolone tab 16 mg......................... 20 MEDROL -methylprednisolone tab 2 mg...........................20 MEDROL -methylprednisolone tab 32 mg......................... 20 MEDROL -methylprednisolone tab 4 mg...........................20 MEDROL -methylprednisolone tab 8 mg...........................20 MEDROX-RX -capsaicin-menthol-methyl salicylate oint 0.05-7-20%.....................................................................154 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)................................................. 25 medroxyprogesterone acetate tab 10 mg (Provera)..... 26 medroxyprogesterone acetate tab 2.5 mg (Provera)..........................................................................26 medroxyprogesterone acetate tab 5 mg (Provera)....... 26 mefenamic acid cap 250 mg (Ponstel).........................103 mefloquine hcl tab 250 mg............................................. 11 MEGACE ES -megestrol acetate susp 625 mg/5ml.......... 26 MEGACE ORAL -megestrol acetate susp 40 mg/ml......... 18 megestrol acetate susp 40 mg/ml (Megace oral).......... 18 megestrol acetate susp 625 mg/5ml (Megace es).........26 megestrol acetate tab 20 mg.......................................... 18 megestrol acetate tab 40 mg.......................................... 18 MEGRIX -capsaicin-menthol disk 0.0375-5%..................154 MEIJER GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 30 MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent)........................................................................18 MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base equivalent)........................................................................18 MELOXICAM COMFORT PAC -meloxicam tab 15 mg & liniment topical gel kit.................................................... 103 MELOXICAM -meloxicam susp 7.5 mg/5ml.................... 103 meloxicam tab 15 mg (Mobic)...................................... 103 meloxicam tab 7.5 mg (Mobic)..................................... 103 memantine hcl tab 10 mg (Namenda)............................ 91 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa)...................................................91 memantine hcl tab 5 mg (Namenda)..............................91 M-END MAX D -pseudoephedrine-dexbromphen-codeine liqd 20-0.667-6 mg/5ml.................................................... 60 M-END PE -phenylephrine-bromphen w/ codeine liqd 3.33-1.33-6.33 mg/5ml..................................................... 60 MENEST -esterified estrogens tab 0.3 mg........................ 23 MENEST -esterified estrogens tab 0.625 mg.................... 23 MENEST -esterified estrogens tab 1.25 mg...................... 23 MENEST -esterified estrogens tab 2.5 mg........................ 23 MENOSTAR -estradiol td patch weekly 14 mcg/24hr........ 23 MENTAX -butenafine hcl cream 1%................................154 MENTHOCIN PATCH/LIDOCAINE -lidocaine-capsaicinmen-methyl sal patch 0.5-0.0375-5-20%....................... 154 MENTHOCIN PATCH/LIDOCAINE -lidocaine-capsaicinmenthol-methyl sal patch 0.5-0.035-5-20%................... 154 MENTHOLIX -lidocaine-menthol liquid spray 4-1%......... 154 MEPERIDINE HCL/PROMETHAZI -meperidine w/ promethazine cap 50-25 mg............................................ 97 MEPERIDINE HCL -meperidine hcl oral soln 50 mg/5ml..............................................................................97 meperidine hcl tab 100 mg (Demerol)........................... 97 meperidine hcl tab 50 mg (Demerol)............................. 97 MEPHYTON -phytonadione tab 5 mg............................. 115 meprobamate tab 200 mg............................................... 76 meprobamate tab 400 mg............................................... 76 MEPRON -atovaquone susp 750 mg/5ml......................... 12 mercaptopurine tab 50 mg (Purinethol).........................18 mesalamine enema 4 gm................................................ 71 mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa)......................................................................... 71 MESNEX -mesna tab 400 mg........................................... 18 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 213 2015 MESTINON -pyridostigmine bromide syrup 60 mg/5ml............................................................................114 MESTINON -pyridostigmine bromide tab 60 mg............. 114 MESTINON TIMESPAN -pyridostigmine bromide tab cr 180 mg........................................................................... 114 METADATE CD -methylphenidate hcl cap cr 10 mg......... 87 METADATE CD -methylphenidate hcl cap cr 20 mg......... 87 METADATE CD -methylphenidate hcl cap cr 30 mg......... 87 METADATE CD -methylphenidate hcl cap cr 40 mg......... 87 METADATE CD -methylphenidate hcl cap cr 50 mg......... 87 METADATE CD -methylphenidate hcl cap cr 60 mg......... 87 METAFOLBIC -l-methylfolate w/ vit b12-vit b6-vit b2 tab 6-1-50-5 mg................................................................... 127 METAFOLBIC PLUS -l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg............................................. 127 METAFOLBIC PLUS RF -l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg...................................127 METANX -l-methylfolate-algae-vit b12-b6 cap 3-90.314-2-35 mg.......................................................... 127 METANX -l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg.................................................................................. 127 METAPROTERENOL SULFATE -metaproterenol sulfate syrup 10 mg/5ml.............................................................. 64 METAPROTERENOL SULFATE -metaproterenol sulfate tab 10 mg.........................................................................64 METAPROTERENOL SULFATE -metaproterenol sulfate tab 20 mg.........................................................................64 METAXALONE -metaxalone tab 400 mg........................ 114 metaxalone tab 800 mg (Skelaxin)............................... 114 metformin hcl tab 1000 mg (Glucophage)..................... 30 metformin hcl tab 500 mg (Glucophage).......................30 metformin hcl tab 850 mg (Glucophage).......................30 metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 30 metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 30 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)........................................................................30 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)........................................................................30 methadone hcl conc 10 mg/ml (Methadose)................. 97 METHADONE HCL -methadone hcl soln 10 mg/5ml.........97 METHADONE HCL -methadone hcl soln 5 mg/5ml...........97 methadone hcl soln 10 mg/5ml (Methadone hcl).......... 97 methadone hcl soln 5 mg/5ml (Methadone hcl)............ 97 methadone hcl tab 10 mg (Dolophine).......................... 97 methadone hcl tab 5 mg (Dolophine hcl)...................... 97 methadone hcl tab for oral susp 40 mg........................ 97 METHADOSE -methadone hcl conc 10 mg/ml..................97 METHADOSE SUGAR-FREE -methadone hcl conc 10 mg/ ml......................................................................................97 methamphetamine hcl tab 5 mg (Desoxyn)...................88 methazolamide tab 25 mg (Neptazane)......................... 53 methazolamide tab 50 mg (Neptazane)......................... 53 methenamine hippurate tab 1 gm (Hiprex)....................72 methenamine-hyoscamine-meth blue-sod phos tab 81.6 mg (Urogesic-blue)................................................ 72 214 methenamine-hyosc-meth blue-benz acid-phenyl sal tab 81.6mg (Prosed/ds)................................................. 72 methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg.............................................................................72 methenamine-hyosc-meth blue-sod phos-phen sal cap 120 mg.............................................................................72 methenamine-hyosc-meth blue-sod phos-phen sal tab 81 mg...............................................................................72 methenamine-hyos-meth blue-sod phos-phen sal tab 81.6 mg............................................................................72 METHENAMINE MANDELATE -methenamine mandelate tab 0.5 gm........................................................................72 methenamine mandelate tab 1 gm.................................72 methimazole tab 10 mg (Tapazole)................................ 33 methimazole tab 5 mg (Tapazole).................................. 33 METHITEST -methyltestosterone oral tab 10 mg.............. 21 methocarbamol tab 500 mg (Robaxin)........................ 114 methocarbamol tab 750 mg (Robaxin-750)................. 114 methotrexate sodium for inj 1 gm..................................18 methotrexate sodium inj 25 mg/ml................................ 18 methotrexate sodium inj pf 25 mg/ml............................ 18 methotrexate sodium tab 2.5 mg (base equiv)..............18 methoxsalen rapid cap 10 mg (Oxsoralen ultra).........154 methscopolamine bromide tab 2.5 mg (Pamine).......... 67 methscopolamine bromide tab 5 mg (Pamine forte)................................................................................ 67 METHYCLOTHIAZIDE -methyclothiazide tab 5 mg...........53 METHYLDOPA/HYDROCHLOROTHI -methyldopa & hydrochlorothiazide tab 250-15 mg................................. 49 METHYLDOPA/HYDROCHLOROTHI -methyldopa & hydrochlorothiazide tab 250-25 mg................................. 49 methyldopa tab 250 mg.................................................. 49 methyldopa tab 500 mg.................................................. 49 methylergonovine maleate tab 0.2 mg.......................... 35 METHYLFOL-ALGAE-B12-ACETY -l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg............................127 METHYLIN -methylphenidate hcl chew tab 10 mg............ 88 METHYLIN -methylphenidate hcl chew tab 2.5 mg........... 88 METHYLIN -methylphenidate hcl chew tab 5 mg.............. 88 METHYLIN -methylphenidate hcl soln 10 mg/5ml............. 88 METHYLIN -methylphenidate hcl soln 5 mg/5ml............... 88 methylphenidate hcl cap cr 10 mg (Metadate cd)......... 88 methylphenidate hcl cap cr 20 mg (Metadate cd)......... 88 methylphenidate hcl cap cr 30 mg (Metadate cd)......... 88 methylphenidate hcl cap cr 40 mg (Metadate cd)......... 88 methylphenidate hcl cap cr 50 mg (Metadate cd)......... 88 methylphenidate hcl cap cr 60 mg (Metadate cd)......... 88 methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la)..................................................................................... 88 methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la)..................................................................................... 88 methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la)..................................................................................... 88 methylphenidate hcl chew tab 10 mg (Methylin).......... 88 methylphenidate hcl chew tab 2.5 mg (Methylin)......... 88 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 methylphenidate hcl chew tab 5 mg (Methylin)............ 88 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sa osm 18 mg..................................................................88 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sa osm 27 mg..................................................................88 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sa osm 36 mg..................................................................88 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sa osm 54 mg..................................................................88 methylphenidate hcl soln 10 mg/5ml (Methylin)........... 88 methylphenidate hcl soln 5 mg/5ml (Methylin)............. 88 methylphenidate hcl tab 10 mg (Ritalin)........................88 methylphenidate hcl tab 20 mg (Ritalin)........................88 methylphenidate hcl tab 5 mg (Ritalin)..........................88 methylphenidate hcl tab cr 10 mg................................. 88 methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 88 methylprednisolone tab 16 mg (Medrol)........................20 methylprednisolone tab 32 mg (Medrol)........................20 methylprednisolone tab 4 mg (Medrol)......................... 20 methylprednisolone tab 4 mg dose pack (Medrol dosepak)..........................................................................20 methylprednisolone tab 8 mg (Medrol)......................... 20 METIPRANOLOL -metipranolol ophth soln 0.3%............ 139 metoclopramide hcl orally disintegrating tab 5 mg (Metozolv odt).................................................................71 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 71 metoclopramide hcl tab 10 mg (Reglan)....................... 71 metoclopramide hcl tab 5 mg (Reglan)......................... 71 metolazone tab 10 mg.....................................................53 metolazone tab 2.5 mg (Zaroxolyn)............................... 53 metolazone tab 5 mg (Zaroxolyn).................................. 53 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct)...............................................................50 metoprolol & hydrochlorothiazide tab 100-50 mg........ 50 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)...............................................................50 metoprolol succinate tab sr 24hr 100 mg (Toprol xl)..................................................................................... 41 metoprolol succinate tab sr 24hr 200 mg (Toprol xl)..................................................................................... 41 metoprolol succinate tab sr 24hr 25 mg (Toprol xl)......41 metoprolol succinate tab sr 24hr 50 mg (Toprol xl)......41 metoprolol tartrate tab 100 mg (Lopressor).................. 41 metoprolol tartrate tab 25 mg.........................................41 metoprolol tartrate tab 50 mg (Lopressor).................... 41 METOZOLV ODT -metoclopramide hcl orally disintegrating tab 5 mg...........................................................................71 METROCREAM -metronidazole cream 0.75%................ 154 METROGEL -metronidazole gel 1%................................154 METROGEL-VAGINAL -metronidazole vaginal gel 0.75%............................................................................... 73 METROLOTION -metronidazole lotion 0.75%................. 154 metronidazole cap 375 mg (Flagyl)................................12 metronidazole cream 0.75% (Metrocream).................. 154 metronidazole gel 0.75%...............................................154 metronidazole gel 1% (Metrogel)................................. 154 metronidazole lotion 0.75% (Metrolotion)....................154 metronidazole tab 250 mg (Flagyl).................................12 metronidazole tab 500 mg (Flagyl).................................12 metronidazole vaginal gel 0.75% (Metrogelvaginal)............................................................................74 METVIXIA -methyl aminolevulinate hcl cream 16.8% (base equiv)..............................................................................154 MEVACOR -lovastatin tab 40 mg......................................56 mexiletine hcl cap 150 mg..............................................44 mexiletine hcl cap 200 mg..............................................44 mexiletine hcl cap 250 mg..............................................44 MIACALCIN -calcitonin (salmon) inj 200 unit/ml................37 MIACALCIN -calcitonin (salmon) nasal soln 200 unit/ act.....................................................................................37 MICARDIS HCT -telmisartan-hydrochlorothiazide tab 40-12.5 mg.......................................................................50 MICARDIS HCT -telmisartan-hydrochlorothiazide tab 80-12.5 mg.......................................................................50 MICARDIS HCT -telmisartan-hydrochlorothiazide tab 80-25 mg..........................................................................50 MICARDIS -telmisartan tab 20 mg.................................... 50 MICARDIS -telmisartan tab 40 mg.................................... 50 MICARDIS -telmisartan tab 80 mg.................................... 50 MICONAZOLE 3 -miconazole nitrate vaginal suppos 200 mg.................................................................................... 74 miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit.............................................................................. 74 MICRO-K -potassium chloride cap cr 10 meq................. 125 MICRO-K -potassium chloride cap cr 8 meq................... 125 MICROZIDE -hydrochlorothiazide cap 12.5 mg................ 53 midazolam hcl syrup 2 mg/ml (base equivalent).......... 85 midodrine hcl tab 10 mg.................................................54 midodrine hcl tab 2.5 mg................................................54 midodrine hcl tab 5 mg...................................................54 MIGERGOT -ergotamine w/ caffeine suppos 2-100 mg.................................................................................. 105 MIGRANAL -dihydroergotamine mesylate nasal spray 4 mg/ml..............................................................................105 MIGRYL -capsaicin-menthol disk 0.0375-5%.................. 154 MILLIPRED DP -prednisolone tab 5 mg dose pack...........20 MILLIPRED -prednisolone sod phosphate oral soln 10 mg/5ml (base equiv)........................................................ 20 MILLIPRED -prednisolone tab 5 mg..................................20 MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)............................................ 25 MINERAL OIL HEAVY -mineral oil....................................65 MINIPRESS -prazosin hcl cap 1 mg................................. 50 MINIPRESS -prazosin hcl cap 2 mg................................. 50 MINIPRESS -prazosin hcl cap 5 mg................................. 50 MINIVELLE -estradiol td patch twice weekly 0.025 mg/24hr............................................................................ 23 MINIVELLE -estradiol td patch twice weekly 0.0375 mg/24hr............................................................................ 23 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 215 2015 MINIVELLE -estradiol td patch twice weekly 0.05 mg/24hr............................................................................ 23 MINIVELLE -estradiol td patch twice weekly 0.075 mg/24hr............................................................................ 23 MINIVELLE -estradiol td patch twice weekly 0.1 mg/24hr............................................................................ 23 MINOCIN KIT -minocycline hcl cap 100 mg w/ acne care products kit.........................................................................4 MINOCIN KIT -minocycline hcl cap 50 mg w/ acne care products kit.........................................................................4 MINOCIN -minocycline hcl cap 100 mg.............................. 4 MINOCIN -minocycline hcl cap 50 mg................................ 4 MINOCIN -minocycline hcl cap 75 mg................................ 4 minocycline hcl cap 100 mg (Minocin)............................ 4 minocycline hcl cap 50 mg (Minocin)..............................4 minocycline hcl cap 75 mg (Minocin)..............................4 minocycline hcl tab 100 mg............................................. 4 minocycline hcl tab 50 mg............................................... 4 minocycline hcl tab 75 mg............................................... 4 minocycline hcl tab sr 24hr 135 mg................................ 4 minocycline hcl tab sr 24hr 45 mg.................................. 4 minocycline hcl tab sr 24hr 90 mg.................................. 4 minoxidil tab 10 mg.........................................................50 minoxidil tab 2.5 mg........................................................50 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 0.375 mg........................................................................ 112 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 0.75 mg.......................................................................... 112 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 1.5 mg.................................................................................. 112 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 2.25 mg.......................................................................... 112 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3.75 mg.......................................................................... 112 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3 mg.................................................................................. 112 MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 4.5 mg.................................................................................. 112 MIRAPEX -pramipexole dihydrochloride tab 0.125 mg.................................................................................. 111 MIRAPEX -pramipexole dihydrochloride tab 0.25 mg......112 MIRAPEX -pramipexole dihydrochloride tab 0.5 mg........112 MIRAPEX -pramipexole dihydrochloride tab 0.75 mg......112 MIRAPEX -pramipexole dihydrochloride tab 1.5 mg........112 MIRAPEX -pramipexole dihydrochloride tab 1 mg...........112 MIRCERA -methoxy polyethylene glycol-epoetin beta inj 100 mcg/0.3ml............................................................... 130 MIRCERA -methoxy polyethylene glycol-epoetin beta inj 200 mcg/0.3ml............................................................... 130 MIRCERA -methoxy polyethylene glycol-epoetin beta inj 50 mcg/0.3ml................................................................. 130 MIRCERA -methoxy polyethylene glycol-epoetin beta inj 75 mcg/0.3ml................................................................. 130 MIRCETTE -desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)...................................................25 216 mirtazapine orally disintegrating tab 15 mg (Remeron soltab)..............................................................................78 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)..............................................................................78 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)..............................................................................78 mirtazapine tab 15 mg (Remeron)..................................78 mirtazapine tab 30 mg (Remeron)..................................78 mirtazapine tab 45 mg (Remeron)..................................78 mirtazapine tab 7.5 mg....................................................78 MIRVASO -brimonidine tartrate gel 0.33% (base equivalent)......................................................................154 misoprostol tab 100 mcg (Cytotec)................................67 misoprostol tab 200 mcg (Cytotec)................................67 MITIGARE -colchicine cap 0.6 mg.................................. 106 MITOSOL -mitomycin for ophth soln kit 0.2 mg...............139 MOBIC -meloxicam susp 7.5 mg/5ml.............................. 103 MOBIC -meloxicam tab 15 mg........................................ 103 MOBIC -meloxicam tab 7.5 mg....................................... 103 modafinil tab 100 mg (Provigil)...................................... 88 modafinil tab 200 mg (Provigil)...................................... 88 MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg......... 8 MODERIBA 800 DOSE PACK -ribavirin tab 400 mg........... 8 MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg dose pack...........................................................................8 MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack...........................................................................8 MODICON -norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg....................................................................... 25 moexipril hcl tab 15 mg (Univasc)................................. 50 moexipril hcl tab 7.5 mg (Univasc)................................ 50 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic)..........................................................................50 moexipril-hydrochlorothiazide tab 15-25 mg................ 50 moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 50 mometasone furoate cream 0.1% (Elocon)................. 154 mometasone furoate oint 0.1% (Elocon)..................... 154 mometasone furoate solution 0.1% (lotion) (Elocon)......................................................................... 154 MONOCAL -sodium monofluorophosphate-calcium carb tab 22.75-625 mg...........................................................125 MONOCLATE-P -antihemophilic factor (human) for inj kit 1000 unit........................................................................ 135 MONOCLATE-P -antihemophilic factor (human) for inj kit 1500 unit........................................................................ 135 MONOCLATE-P -antihemophilic factor (human) for inj kit 250 unit.......................................................................... 135 MONOCLATE-P -antihemophilic factor (human) for inj kit 500 unit.......................................................................... 135 MONODOX -doxycycline monohydrate cap 100 mg........... 4 MONODOX -doxycycline monohydrate cap 75 mg............. 4 MONONINE -coagulation factor ix for inj 1000 unit......... 135 MONONINE -coagulation factor ix for inj 250 unit........... 135 MONONINE -coagulation factor ix for inj 500 unit........... 135 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 montelukast sodium chew tab 4 mg (base equiv) (Singulair)........................................................................64 montelukast sodium chew tab 5 mg (base equiv) (Singulair)........................................................................64 montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)............................................................64 montelukast sodium tab 10 mg (base equiv) (Singulair)........................................................................64 MONUROL -fosfomycin tromethamine powd pack 3 gm (base equivalent)............................................................. 72 MORGIDOX 1X100MG -doxycycline hyclate cap 1 x 100 mg w/ cleanser kit..............................................................4 MORGIDOX 2X100MG -doxycycline hyclate cap 2 x 100 mg w/ cleanser kit..............................................................4 morphine sulfate (concentrate) oral soln 20 mg/ml......97 morphine sulfate cap sr 24hr 100 mg (Kadian).............98 morphine sulfate cap sr 24hr 10 mg (Kadian)...............97 morphine sulfate cap sr 24hr 20 mg (Kadian)...............97 morphine sulfate cap sr 24hr 30 mg (Kadian)...............97 morphine sulfate cap sr 24hr 50 mg (Kadian)...............98 morphine sulfate cap sr 24hr 60 mg (Kadian)...............98 morphine sulfate cap sr 24hr 80 mg (Kadian)...............98 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 120 mg.................................................................... 98 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 30 mg...................................................................... 98 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 45 mg...................................................................... 98 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 60 mg...................................................................... 98 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 75 mg...................................................................... 98 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 90 mg...................................................................... 98 MORPHINE SULFATE -morphine sulfate suppos 10 mg.................................................................................... 97 MORPHINE SULFATE -morphine sulfate suppos 20 mg.................................................................................... 97 MORPHINE SULFATE -morphine sulfate suppos 30 mg.................................................................................... 97 MORPHINE SULFATE -morphine sulfate suppos 5 mg.................................................................................... 97 MORPHINE SULFATE -morphine sulfate tab 15 mg.........97 MORPHINE SULFATE -morphine sulfate tab 30 mg.........97 morphine sulfate oral soln 10 mg/5ml........................... 98 morphine sulfate oral soln 20 mg/5ml........................... 98 morphine sulfate tab cr 100 mg (Ms contin)................. 98 morphine sulfate tab cr 15 mg (Ms contin)................... 98 morphine sulfate tab cr 200 mg (Ms contin)................. 98 morphine sulfate tab cr 30 mg (Ms contin)................... 98 morphine sulfate tab cr 60 mg (Ms contin)................... 98 MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............ 66 mouthwashes - liquid....................................................142 MOVANTIK -naloxegol oxalate tab 12.5 mg (base equivalent)........................................................................71 MOVANTIK -naloxegol oxalate tab 25 mg (base equivalent)........................................................................71 MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln 100 gm................................................................65 MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg.......1 MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily).....................................................................139 moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........5 MS CONTIN -morphine sulfate tab cr 100 mg...................98 MS CONTIN -morphine sulfate tab cr 15 mg.....................98 MS CONTIN -morphine sulfate tab cr 200 mg...................98 MS CONTIN -morphine sulfate tab cr 30 mg.....................98 MS CONTIN -morphine sulfate tab cr 60 mg.....................98 MS QUICK DISSOLVE GLUCOSE -glucose chew tab 4 gm.................................................................................... 30 MUCOTROL -oral wound care products - wafer..............142 MULTAQ -dronedarone hcl tab 400 mg (base equivalent)........................................................................44 MULTIGEN -fe asparto gly-succ acd-c-threonic acd-b12des stom tab.................................................................. 130 MULTIGEN FOLIC -fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab..................................................130 MULTIGEN PLUS -fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab..................................................130 multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite).........................................................................117 mupirocin calcium cream 2% (Bactroban).................. 154 mupirocin oint 2% (Bactroban).................................... 154 MV FE ASPARTO GLY/FE FUM/ -fe aspart gly-fe fumsucc acd-c-threonic acd-b12-fa tab................................130 MV FE ASPARTO GLY/VIT C/V -fe asparto gly-succ acdc-threonic acd-b12-des stom tab................................... 131 M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg........... 117 MYALEPT -metreleptin for subcutaneous inj 11.3 mg....... 37 MYAMBUTOL -ethambutol hcl tab 100 mg......................... 6 MYAMBUTOL -ethambutol hcl tab 400 mg......................... 6 MYCOBUTIN -rifabutin cap 150 mg.................................... 6 mycophenolate mofetil cap 250 mg (Cellcept)............164 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)....................................................................... 164 mycophenolate mofetil tab 500 mg (Cellcept).............164 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)...................................................164 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)...................................................164 MYDRIACYL -tropicamide ophth soln 1%....................... 139 MYFORTIC -mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)............................................. 164 MYFORTIC -mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)............................................. 164 MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 131 MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe susp 0.25-10 mg/2ml..................................................... 117 MYLERAN -busulfan tab 2 mg.......................................... 18 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 217 2015 MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg................................................................... 117 MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................. 117 MYNATAL -prenatal multivitamins & minerals w/ iron & fa cap 1 mg........................................................................117 MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg.................................................117 MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................. 117 MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg..................................................................... 117 MYOXIN -benzocaine-chloroxylenol-hc otic susp 15-1-10 mg/ml..............................................................................141 MYRBETRIQ -mirabegron tab sr 24 hr 25 mg...................73 MYRBETRIQ -mirabegron tab sr 24 hr 50 mg...................73 MYSOLINE -primidone tab 250 mg................................. 109 MYSOLINE -primidone tab 50 mg...................................109 N NABI-HB -hepatitis b immune globulin (human) im inj soln...................................................................................16 nabumetone tab 500 mg............................................... 103 nabumetone tab 750 mg............................................... 103 nadolol & bendroflumethiazide tab 40-5 mg (Corzide)..........................................................................50 nadolol & bendroflumethiazide tab 80-5 mg (Corzide)..........................................................................50 nadolol tab 20 mg (Corgard).......................................... 41 nadolol tab 40 mg (Corgard).......................................... 41 nadolol tab 80 mg (Corgard).......................................... 41 NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................... 142 NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln rinse 0.05%.................................................................... 142 NAFRINSE WEEKLY -sodium fluoride for soln rinse 0.2%............................................................................... 142 naftifine hcl cream 1% (Naftin).....................................154 NAFTIN -naftifine hcl cream 1%......................................154 NAFTIN -naftifine hcl cream 2%......................................154 NAFTIN -naftifine hcl gel 1%...........................................154 NAFTIN -naftifine hcl gel 2%...........................................154 NALFON -fenoprofen calcium cap 400 mg......................103 naltrexone hcl tab 50 mg (Revia)................................. 163 NAMENDA -memantine hcl oral solution 2 mg/ml............. 91 NAMENDA -memantine hcl tab 10 mg..............................91 NAMENDA -memantine hcl tab 5 mg................................91 NAMENDA TITRATION PAK -memantine hcl tab 5 mg (28) & 10 mg (21) titration pak........................................ 91 NAMENDA XR -memantine hcl cap sr 24hr 14 mg........... 91 NAMENDA XR -memantine hcl cap sr 24hr 21 mg........... 91 NAMENDA XR -memantine hcl cap sr 24hr 28 mg........... 91 NAMENDA XR -memantine hcl cap sr 24hr 7 mg............. 91 NAMENDA XR TITRATION PACK -memantine hcl cap sr 24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................... 91 218 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 14-10 mg..........................................................................91 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 28-10 mg..........................................................................91 NAPHAZOLINE HCL -naphazoline hcl ophth soln 0.1%............................................................................... 139 NAPRELAN -naproxen sodium tab sr 24hr 375 mg (base equiv)..............................................................................103 NAPRELAN -naproxen sodium tab sr 24hr 500 mg (base equiv)..............................................................................103 NAPRELAN -naproxen sodium tab sr 24hr 750 mg (base equiv)..............................................................................103 NAPROSYN -naproxen susp 125 mg/5ml....................... 103 NAPROSYN -naproxen tab 250 mg................................ 103 NAPROSYN -naproxen tab 375 mg................................ 103 NAPROSYN -naproxen tab 500 mg................................ 103 NAPROXEN COMFORT PAC -naproxen tab 500 mg & liniment topical gel kit.................................................... 103 NAPROXEN -naproxen susp 125 mg/5ml....................... 103 naproxen sodium tab 275 mg (Anaprox)..................... 103 naproxen sodium tab 550 mg (Anaprox ds)................103 naproxen sodium tab sr 24hr 500 mg (base equiv) (Naprelan)......................................................................103 naproxen tab 250 mg (Naprosyn).................................103 naproxen tab 375 mg (Naprosyn).................................103 naproxen tab 500 mg (Naprosyn).................................103 naproxen tab ec 375 mg (Ec-naprosyn)...................... 103 naproxen tab ec 500 mg (Ec-naprosyn)...................... 103 naratriptan hcl tab 1 mg (base equiv) (Amerge)......... 105 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 105 NARDIL -phenelzine sulfate tab 15 mg............................. 78 NASCOBAL -cyanocobalamin nasal spray 500 mcg/0.1ml.......................................................................131 NASONEX -mometasone furoate nasal susp 50 mcg/ act.....................................................................................59 NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew tab 28-1 mg................................................................... 117 NATACYN -natamycin ophth susp 5%............................ 139 NATALVIRT 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak............................................... 117 NATALVIRT CA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack.................................................... 117 NATALVIRT FLT -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg.............................................................131 NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1 mg.................................................................................. 117 NATAL-V RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 117 NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2 mg/2-3 mg/1 mg...............................................................25 nateglinide tab 120 mg (Starlix)..................................... 30 nateglinide tab 60 mg (Starlix)....................................... 30 NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg............................................................118 NATESTO -testosterone nasal gel 5.5 mg/act...................21 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 NATPARA -parathyroid hormone (recombinant) for inj cartridge 100 mcg............................................................ 37 NATPARA -parathyroid hormone (recombinant) for inj cartridge 25 mcg.............................................................. 37 NATPARA -parathyroid hormone (recombinant) for inj cartridge 50 mcg.............................................................. 37 NATPARA -parathyroid hormone (recombinant) for inj cartridge 75 mcg.............................................................. 37 NATROBA -spinosad susp 0.9%.....................................154 NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2 grain)................................................................................ 34 NATURE-THROID -thyroid tab 113.75 mg........................ 33 NATURE-THROID -thyroid tab 130 mg.............................33 NATURE-THROID -thyroid tab 146.25 mg........................ 33 NATURE-THROID -thyroid tab 16.25 mg.......................... 33 NATURE-THROID -thyroid tab 195 mg.............................33 NATURE-THROID -thyroid tab 260 mg.............................33 NATURE-THROID -thyroid tab 32.5 mg............................33 NATURE-THROID -thyroid tab 325 mg (5 grain)...............33 NATURE-THROID -thyroid tab 48.75 mg (3/4 grain).........33 NATURE-THROID -thyroid tab 65 mg...............................33 NATURE-THROID -thyroid tab 81.25 mg.......................... 33 NATURE-THROID -thyroid tab 97.5 mg............................33 NEBUPENT -pentamidine isethionate for nebulization soln 300 mg............................................................................. 12 NEBUSAL -sodium chloride soln nebu 6%........................60 NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50 mcg...................................................................................25 NECON 10/11-28 -norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11)............................................ 25 NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg.....................................................................118 NEFAZODONE HCL -nefazodone hcl tab 100 mg............ 79 NEFAZODONE HCL -nefazodone hcl tab 150 mg............ 79 NEFAZODONE HCL -nefazodone hcl tab 200 mg............ 79 NEFAZODONE HCL -nefazodone hcl tab 50 mg.............. 78 nefazodone hcl tab 250 mg............................................ 79 NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp............................................... 139 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin............................... 139 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)..............139 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)....................................................................... 139 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)....................................................................... 139 neomycin-polymyxin-hc otic soln 1% (Cortisporin)..................................................................141 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%..................................................................... 141 neomycin sulfate tab 500 mg........................................... 5 NEORAL -cyclosporine modified cap 100 mg................. 164 NEORAL -cyclosporine modified cap 25 mg................... 164 NEORAL -cyclosporine modified oral soln 100 mg/ml..... 164 NEOSALUS CP -dermatological products misc cream............................................................................. 154 NEOSALUS -dermatological products misc - cream....... 154 NEOSALUS -emollient - aerosol foam............................ 154 NEOSALUS -emollient - lotion.........................................154 NEOSPORIN -neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml.....................................139 NEO-SYNALAR KIT -neomycin-fluocinolone cream 0.35-0.025% & emollient cr kit.......................................154 NEO-SYNALAR -neomycin-fluocinolone cream 0.35-0.025%................................................................... 154 NEOTUSS-D -pseudoephed-chlorphen w/ dm-gg liqd 30-2-30-200 mg/5ml.........................................................60 NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid 7.5-4-30 mg/5ml...............................................................60 NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1 mg.................................................................................. 118 NEPHROCAPS -b-complex w/ c & folic acid cap 1 mg.................................................................................. 118 NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid tab disp 1 mg.................................................................118 NEPHRON FA -ferrous fumarate w/ fa-dss-b complex-vit c tab.................................................................................. 131 NEPHRO-VITE RX -b-complex w/ c & folic acid tab 1 mg.................................................................................. 118 NEPTAZANE -methazolamide tab 25 mg......................... 53 NEPTAZANE -methazolamide tab 50 mg......................... 53 NESINA -alogliptin benzoate tab 12.5 mg (base equiv).....30 NESINA -alogliptin benzoate tab 25 mg (base equiv)........30 NESINA -alogliptin benzoate tab 6.25 mg (base equiv).....30 NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab & omega 3 cap.............................................................. 118 NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack.........................................................118 NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg..........................................................................118 NEUAC KIT -clindamycin-benzoyl perox gel 1.2-5% & moisturizer cr kit.............................................................154 NEULASTA DELIVERY KIT -pegfilgrastim inj 6 mg/0.6ml.........................................................................131 NEULASTA -pegfilgrastim inj 6 mg/0.6ml........................131 NEUMEGA -oprelvekin for inj 5 mg.................................131 NEUPOGEN -filgrastim inj 300 mcg/0.5ml (600 mcg/ ml).................................................................................. 131 NEUPOGEN -filgrastim inj 300 mcg/ml........................... 131 NEUPOGEN -filgrastim inj 480 mcg/0.8ml (600 mcg/ ml).................................................................................. 131 NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/ ml).................................................................................. 131 NEUPRO -rotigotine td patch 24hr 1 mg/24hr................. 112 NEUPRO -rotigotine td patch 24hr 2 mg/24hr................. 112 NEUPRO -rotigotine td patch 24hr 3 mg/24hr................. 112 NEUPRO -rotigotine td patch 24hr 4 mg/24hr................. 112 NEUPRO -rotigotine td patch 24hr 6 mg/24hr................. 112 NEUPRO -rotigotine td patch 24hr 8 mg/24hr................. 112 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 219 2015 NEURIN-SL -cyanocobalamin-methylcobalamin tab sl 600-600 mcg.................................................................. 131 NEURONTIN -gabapentin cap 100 mg........................... 109 NEURONTIN -gabapentin cap 300 mg........................... 109 NEURONTIN -gabapentin cap 400 mg........................... 109 NEURONTIN -gabapentin oral soln 250 mg/5ml............. 109 NEURONTIN -gabapentin tab 600 mg............................ 109 NEURONTIN -gabapentin tab 800 mg............................ 109 NEUTRASAL -artificial saliva - packet.............................142 NEUVAXIN -capsaicin-menthol topical patch 0.0375-5%...................................................................... 154 NEVANAC -nepafenac ophth susp 0.1%........................ 139 NEVIRAPINE -nevirapine susp 50 mg/5ml..........................8 nevirapine tab 200 mg (Viramune)...................................8 nevirapine tab sr 24hr 400 mg (Viramune xr)..................8 NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg..........................................................................118 NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg..............................................................118 NEXA SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg.......................................................118 NEXAVAR -sorafenib tosylate tab 200 mg (base equivalent)........................................................................18 NEXIUM -esomeprazole magnesium cap delayed release 20 mg (base eq).............................................................. 67 NEXIUM -esomeprazole magnesium cap delayed release 40 mg (base eq).............................................................. 67 NEXIUM -esomeprazole magnesium for delayed release susp pack 2.5 mg............................................................ 67 NEXIUM -esomeprazole magnesium for delayed release susp packet 10 mg.......................................................... 67 NEXIUM -esomeprazole magnesium for delayed release susp packet 20 mg.......................................................... 67 NEXIUM -esomeprazole magnesium for delayed release susp packet 40 mg.......................................................... 67 NEXIUM -esomeprazole magnesium for delayed release susp packet 5 mg............................................................ 67 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan)......................................................................... 56 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan)......................................................................... 56 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan)......................................................................... 56 NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)...... 56 NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........ 56 NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........ 56 nicardipine hcl cap 20 mg.............................................. 43 nicardipine hcl cap 30 mg.............................................. 43 NICODERM CQ -nicotine td patch 24hr 14 mg/24hr......... 91 NICODERM CQ -nicotine td patch 24hr 21 mg/24hr......... 91 NICODERM CQ -nicotine td patch 24hr 7 mg/24hr........... 91 NICOMIDE -niacinamide w/ zn-cu-methylfol-se-cr tab 750-27-2-0.5 mg............................................................ 118 NICORETTE MINI -nicotine polacrilex lozenge 2 mg........ 91 NICORETTE MINI -nicotine polacrilex lozenge 4 mg........ 91 220 NICORETTE -nicotine polacrilex gum 2 mg...................... 91 NICORETTE -nicotine polacrilex gum 4 mg...................... 91 NICORETTE -nicotine polacrilex lozenge 2 mg.................91 NICORETTE -nicotine polacrilex lozenge 4 mg.................91 NICORETTE STARTER KIT -nicotine polacrilex gum 2 mg.................................................................................... 91 NICORETTE STARTER KIT -nicotine polacrilex gum 4 mg.................................................................................... 91 nicotine polacrilex gum 2 mg.........................................91 nicotine polacrilex gum 4 mg.........................................91 nicotine polacrilex lozenge 2 mg................................... 91 nicotine polacrilex lozenge 4 mg................................... 91 nicotine td patch 24hr 14 mg/24hr................................. 91 nicotine td patch 24hr 21 mg/24hr................................. 91 nicotine td patch 24hr 7 mg/24hr................................... 91 NICOTINE TRANSDERMAL SYST -nicotine td patch 24 hr kit 21-14-7 mg/24hr..........................................................91 NICOTROL INHALER -nicotine inhaler system 10 mg (4 mg delivered)................................................................... 91 NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/ spray)............................................................................... 91 nifedipine cap 10 mg (Procardia)...................................43 nifedipine cap 20 mg.......................................................43 nifedipine tab sr 24hr 30 mg (Adalat cc)....................... 43 nifedipine tab sr 24hr 60 mg (Adalat cc)....................... 43 nifedipine tab sr 24hr 90 mg (Adalat cc)....................... 43 nifedipine tab sr 24hr osmotic 30 mg (Procardia xl).....43 nifedipine tab sr 24hr osmotic 60 mg (Procardia xl).....43 nifedipine tab sr 24hr osmotic 90 mg (Procardia xl).....43 NILANDRON -nilutamide tab 150 mg................................18 nimodipine cap 30 mg.....................................................43 NIRAVAM -alprazolam orally disintegrating tab 0.25 mg.................................................................................... 76 NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg...........43 NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 43 NISOLDIPINE -nisoldipine tab sr 24hr 30 mg................... 43 NISOLDIPINE -nisoldipine tab sr 24hr 40 mg................... 43 nisoldipine tab sr 24hr 17 mg (Sular)............................ 43 nisoldipine tab sr 24hr 34 mg (Sular)............................ 43 nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 43 NITRO-BID -nitroglycerin oint 2%......................................39 NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr........... 39 NITRO-DUR -nitroglycerin td patch 24hr 0.2 mg/hr........... 39 NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr........... 39 NITRO-DUR -nitroglycerin td patch 24hr 0.4 mg/hr........... 39 NITRO-DUR -nitroglycerin td patch 24hr 0.6 mg/hr........... 39 NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr........... 39 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin)..................................................................72 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)..................................................................72 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)................................................................ 72 nitrofurantoin susp 25 mg/5ml (Furadantin)................. 72 nitroglycerin cap cr 2.5 mg............................................ 39 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 nitroglycerin cap cr 6.5 mg............................................ 39 nitroglycerin cap cr 9 mg............................................... 39 NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol 400 mcg/spray................................................................. 39 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........39 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........39 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........39 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........39 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr).................................................. 39 NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)............................................... 39 NITROMIST -nitroglycerin lingual aerosol 400 mcg/ spray.................................................................................39 NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 39 NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 40 NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 40 NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 118 NIVATOPIC PLUS -dermatological products misc cream............................................................................. 154 nizatidine cap 150 mg..................................................... 67 nizatidine cap 300 mg (Axid).......................................... 67 nizatidine oral soln 15 mg/ml (Axid).............................. 67 NIZORAL -ketoconazole shampoo 2%............................154 NOBLE MYSTIQUE EMU-LAC -lactic acid (ammonium lactate) cream 10%........................................................154 NORCO -hydrocodone-acetaminophen tab 10-325 mg.....98 NORCO -hydrocodone-acetaminophen tab 5-325 mg.......98 NORCO -hydrocodone-acetaminophen tab 7.5-325 mg.................................................................................... 98 NORDITROPIN CARTRIDGE -somatropin inj 5 mg/1.5ml...........................................................................37 NORDITROPIN FLEXPRO -somatropin inj 10 mg/1.5ml...........................................................................37 NORDITROPIN FLEXPRO -somatropin inj 15 mg/1.5ml...........................................................................37 NORDITROPIN FLEXPRO -somatropin inj 30 mg/3ml......37 NORDITROPIN FLEXPRO -somatropin inj 5 mg/1.5ml.....37 NORDITROPIN NORDIFLEX PEN -somatropin inj 30 mg/3ml..............................................................................37 norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr (Ortho evra)................................................... 25 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)................................................ 25 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe)..............................................25 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35).......................................................................25 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28).................................................................. 25 norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)................................................................. 25 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)................................................ 25 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20)................................................... 25 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21)................................................25 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)........................................................... 25 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) (Lomedia 24 fe).............................................. 25 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose)................................................. 23 norethindrone acetate tab 5 mg (Aygestin)...................26 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)...................................................25 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7).............................................. 25 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)....................................................... 25 norethindrone tab 0.35 mg (Nor-qd).............................. 25 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen).................................................................25 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen).............................................25 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........26 NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1 mg-35 mcg....................................................................... 26 NORINYL 1+50 -norethindrone & mestranol tab 1 mg-50 mcg...................................................................................26 NORITATE -metronidazole cream 1%.............................155 NORPACE CR -disopyramide phosphate cap sr 12hr 100 mg.................................................................................... 44 NORPACE CR -disopyramide phosphate cap sr 12hr 150 mg.................................................................................... 44 NORPACE -disopyramide phosphate cap 100 mg............ 44 NORPACE -disopyramide phosphate cap 150 mg............ 44 NORPRAMIN -desipramine hcl tab 100 mg...................... 79 NORPRAMIN -desipramine hcl tab 10 mg........................ 79 NORPRAMIN -desipramine hcl tab 150 mg...................... 79 NORPRAMIN -desipramine hcl tab 25 mg........................ 79 NORPRAMIN -desipramine hcl tab 50 mg........................ 79 NORPRAMIN -desipramine hcl tab 75 mg........................ 79 NOR-QD -norethindrone tab 0.35 mg................................25 NORTHERA -droxidopa cap 100 mg.................................54 NORTHERA -droxidopa cap 200 mg.................................54 NORTHERA -droxidopa cap 300 mg.................................54 nortriptyline hcl cap 10 mg (Pamelor)........................... 79 nortriptyline hcl cap 25 mg (Pamelor)........................... 79 nortriptyline hcl cap 50 mg (Pamelor)........................... 79 nortriptyline hcl cap 75 mg (Pamelor)........................... 79 NORTRIPTYLINE HCL -nortriptyline hcl soln 10 mg/5ml..............................................................................79 NORTUSS-EX -dextromethorphan-guaifenesin liquid 20-200 mg/5ml................................................................. 60 NORVASC -amlodipine besylate tab 10 mg......................43 NORVASC -amlodipine besylate tab 2.5 mg..................... 43 NORVASC -amlodipine besylate tab 5 mg........................43 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 221 2015 NORVIR -ritonavir cap 100 mg........................................... 8 NORVIR -ritonavir oral soln 80 mg/ml................................. 8 NORVIR -ritonavir tab 100 mg............................................ 8 NOTUSS-NX -codeine-chlorcyclizine liquid 10-9.375 mg/5ml..............................................................................60 NOTUSS-NXD -codeine-pseudoephedrine-chlorcyclizine liq 10-30-9.375mg/5ml..................................................... 60 NOVACORT -hydrocortisone ace-pramoxine-aloe polysacch gel 2-1-1%.................................................... 155 NOVAFERRUM -polysacch iron complex-vit c-fa for soln 100-60-1 mg/5ml............................................................131 NOVOEIGHT -antihemophilic factor (recombinant) for inj 1000 unit........................................................................ 136 NOVOEIGHT -antihemophilic factor (recombinant) for inj 1500 unit........................................................................ 136 NOVOEIGHT -antihemophilic factor (recombinant) for inj 2000 unit........................................................................ 136 NOVOEIGHT -antihemophilic factor (recombinant) for inj 250 unit.......................................................................... 135 NOVOEIGHT -antihemophilic factor (recombinant) for inj 3000 unit........................................................................ 136 NOVOEIGHT -antihemophilic factor (recombinant) for inj 500 unit.......................................................................... 135 NOVOLIN 70/30 -insulin nph isophane & regular human inj 100 unit/ml (70-30)...........................................................32 NOVOLIN 70/30 RELION -insulin nph isophane & regular human inj 100 unit/ml (70-30)..........................................32 NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/ ml......................................................................................32 NOVOLIN N RELION -insulin nph (human) (isophane) inj 100 unit/ml....................................................................... 32 NOVOLIN R -insulin regular (human) inj 100 unit/ml......... 32 NOVOLIN R RELION -insulin regular (human) inj 100 unit/ ml......................................................................................32 NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100 unit/ml...............................................................................32 NOVOLOG -insulin aspart inj 100 unit/ml..........................32 NOVOLOG MIX 70/30 -insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)....................................... 32 NOVOLOG MIX 70/30 PREFILL -insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)............................. 32 NOVOLOG PENFILL -insulin aspart inj 100 unit/ml...........32 NOVOLOG PENFILL -insulin aspart soln cartridge 100 unit/ml...............................................................................32 NOVOSEVEN -coagulation factor viia (recomb) for inj 2.4 mg (2400 mcg)...............................................................136 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 1 mg (1000 mcg)...............................................................136 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 2 mg (2000 mcg)...............................................................136 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 5 mg (5000 mcg)...............................................................136 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 8 mg (8000 mcg)...............................................................136 NOXAFIL -posaconazole susp 40 mg/ml............................ 7 222 NOXAFIL -posaconazole tab delayed release 100 mg........7 NUCORT -hydrocortisone acetate lotion 2%................... 155 NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg............98 NUCYNTA ER -tapentadol hcl tab sr 12hr 150 mg............98 NUCYNTA ER -tapentadol hcl tab sr 12hr 200 mg............98 NUCYNTA ER -tapentadol hcl tab sr 12hr 250 mg............98 NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg..............98 NUCYNTA -tapentadol hcl tab 100 mg............................. 98 NUCYNTA -tapentadol hcl tab 50 mg............................... 98 NUCYNTA -tapentadol hcl tab 75 mg............................... 98 NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap 20-10 mg..........................................................................91 NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm........................................................66 NUMOISYN -artificial saliva - lozenge.............................142 NUMOISYN -artificial saliva - solution............................. 142 NUOX -benzoyl peroxide-sulfur gel 6-3%........................155 NUTRESTORE -glutamine powd pack 5 gm................... 126 NUTRIDOX -doxycycline monohyd cap 75 mg w/ omega 3-vit e cap kit..................................................................... 4 NUTRI-TAB OB + DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack.......................................... 118 NUTRI-TAB OB -prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg................................................................... 118 NUTRIVIT -b-complex w/ lysine-min-fe & fa liqd 800-15-1 mg/15ml..........................................................................118 NUTROPIN AQ NUSPIN 10 -somatropin inj 10 mg/2ml..............................................................................37 NUTROPIN AQ NUSPIN 20 -somatropin inj 20 mg/2ml..............................................................................37 NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml........ 37 NUTROPIN AQ PEN -somatropin inj 10 mg/2ml............... 37 NUTROPIN AQ PEN -somatropin inj 20 mg/2ml............... 37 NUVAIL -dermatological products misc - solution............155 NUVARING -etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr........................................................26 NUVESSA -metronidazole vaginal gel 1.3%..................... 74 NUVIGIL -armodafinil tab 150 mg..................................... 88 NUVIGIL -armodafinil tab 200 mg..................................... 88 NUVIGIL -armodafinil tab 250 mg..................................... 88 NUVIGIL -armodafinil tab 50 mg....................................... 88 NUZON -hydrocortisone acetate-aloe vera gel 2%..........155 NYMALIZE -nimodipine oral soln 60 mg/20ml...................43 nystatin cream 100000 unit/gm.................................... 155 nystatin oint 100000 unit/gm........................................ 155 nystatin oral powder......................................................... 7 nystatin susp 100000 unit/ml........................................142 nystatin tab 500000 unit....................................................7 nystatin topical powder................................................ 155 nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 155 nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 155 O OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg.......................................... 118 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp glycfa-fish cap 50-1-476 mg.................................................118 OB COMPLETE PETITE -prenat w/o a w/fecbn-feaspglycfa-omega cap 35-5-1-200 mg........................................ 118 OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp glyc-fa tab 30-20-1 mg...................................................118 OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg.....................................................................118 OB-NATAL ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg.....................................................118 OBREDON -hydrocodone-guaifenesin soln 2.5-200 mg/5ml..............................................................................60 OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg & omega 3 cap 387 mg pak..............................................118 OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg..........................................................................118 O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1 mg.....118 O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1 mg.................................................................................. 118 octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin).................................................................. 37 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin).................................................................. 37 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin).................................................................. 37 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin).................................................................. 37 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin).................................................................. 37 OCUFEN -flurbiprofen sodium ophth soln 0.03%............ 139 OCUFLOX -ofloxacin ophth soln 0.3%............................ 139 OCUVEL -multiple vitamins w/ minerals & fa cap 0.5 mg.................................................................................. 118 OFEV -nintedanib esylate cap 100 mg (base equivalent)........................................................................65 OFEV -nintedanib esylate cap 150 mg (base equivalent)........................................................................65 OFLOXACIN -ofloxacin tab 400 mg.................................... 5 ofloxacin ophth soln 0.3% (Ocuflox)........................... 139 ofloxacin otic soln 0.3%................................................141 OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg...................................................................................26 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 92 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 92 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 91 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)....... 91 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)....... 91 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)............................................................................... 82 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)............................................................................... 82 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)............................................................................... 82 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)............................................................................... 82 olanzapine tab 10 mg (Zyprexa).....................................82 olanzapine tab 15 mg (Zyprexa).....................................82 olanzapine tab 2.5 mg (Zyprexa)....................................82 olanzapine tab 20 mg (Zyprexa).....................................82 olanzapine tab 5 mg (Zyprexa).......................................82 olanzapine tab 7.5 mg (Zyprexa)....................................82 OLEPTRO -trazodone hcl tab sr 24hr 150 mg.................. 79 OLEPTRO -trazodone hcl tab sr 24hr 300 mg.................. 79 olopatadine hcl nasal soln 0.6% (Patanase)................. 59 OLUX -clobetasol propionate foam 0.05%...................... 155 OLUX-E -clobetasol propionate emulsion foam 0.05%............................................................................. 155 OLYSIO -simeprevir sodium cap 150 mg (base equivalent)..........................................................................8 OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/ omepraz cap dr therapy pack.......................................... 68 omega-3-acid ethyl esters cap 1 gm (Lovaza).............. 56 OMEPRAZOLE + SYRSPEND SF -omeprazole susp 2 mg/ml (compound kit)...................................................... 68 omeprazole cap delayed release 10 mg (Prilosec)....... 68 omeprazole cap delayed release 20 mg (Prilosec)....... 68 omeprazole cap delayed release 40 mg (Prilosec)....... 68 omeprazole-sodium bicarbonate cap 20-1100 mg (Zegerid).......................................................................... 68 omeprazole-sodium bicarbonate cap 40-1100 mg (Zegerid).......................................................................... 68 OMNARIS -ciclesonide nasal susp 50 mcg/act................. 59 OMNI GEL -stannous fluoride gel 0.4%.......................... 142 OMNIPRED -prednisolone acetate ophth susp 1%......... 139 OMNITROPE -somatropin for inj 5.8 mg........................... 37 OMNITROPE -somatropin inj 10 mg/1.5ml........................37 OMNITROPE -somatropin inj 5 mg/1.5ml......................... 37 ondansetron hcl oral soln 4 mg/5ml (Zofran)................69 ondansetron hcl tab 24 mg............................................ 69 ondansetron hcl tab 4 mg (Zofran)................................ 69 ondansetron hcl tab 8 mg (Zofran)................................ 69 ondansetron orally disintegrating tab 4 mg (Zofran odt)...................................................................................69 ondansetron orally disintegrating tab 8 mg (Zofran odt)...................................................................................69 ONEXTON -clindamycin phosphate-benzoyl peroxide gel 1.2-3.75%....................................................................... 155 ONFI -clobazam suspension 2.5 mg/ml.......................... 109 ONFI -clobazam tab 10 mg............................................. 109 ONFI -clobazam tab 20 mg............................................. 109 ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv).......... 30 ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............. 30 ONMEL -itraconazole tab 200 mg....................................... 7 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 10 mg.........................................................98 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 15 mg.........................................................98 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 20 mg.........................................................98 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 223 2015 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 30 mg.........................................................99 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 40 mg.........................................................99 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 5 mg...........................................................98 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 7.5 mg........................................................98 OPANA -oxymorphone hcl tab 10 mg............................... 98 OPANA -oxymorphone hcl tab 5 mg................................. 98 opium tincture 1% (10 mg/ml) (morphine equiv)...........66 OPSUMIT -macitentan tab 10 mg..................................... 58 OPTASE -trypsin w/ castor oil & peruvian balsam gel..... 155 ORACEA -doxycycline (rosacea) cap delayed release 40 mg.................................................................................. 155 ORACIT -sodium citrate & citric acid soln 490-640 mg/5ml..............................................................................74 ORAFATE -sucralfate-malate paste 10%........................ 143 ORALAIR ADULT SAMPLE KIT -grass mixed pollen ext tab sl 300 ir (index of reactivity)...................................... 16 ORALAIR ADULT STARTER PAC -grass mixed pollen ext tab sl 300 ir (index of reactivity)...................................... 16 ORALAIR CHILDREN/ADOLESCE -grass mixed pollen ext tab sl 100 ir (index of reactivity)...................................... 16 ORALAIR CHILDREN/ADOLESCE -grass mixed pollen tab sl therpak 100 (3) ir & 300 (6) ir................................ 16 ORALAIR -grass mixed pollen ext tab sl 300 ir (index of reactivity).......................................................................... 16 ORAMAGICRX -oral wound care products - for susp rinse................................................................................143 ORAP -pimozide tab 1 mg................................................ 92 ORAP -pimozide tab 2 mg................................................ 92 ORAPRED ODT -prednisolone sod phos orally disintegr tab 10 mg (base eq)........................................................ 20 ORAPRED ODT -prednisolone sod phos orally disintegr tab 15 mg (base eq)........................................................ 20 ORAPRED ODT -prednisolone sod phos orally disintegr tab 30 mg (base eq)........................................................ 20 ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................. 143 ORBIVAN -butalbital-acetaminophen-caffeine cap 50-300-40 mg...................................................................93 ORBIVAN CF -butalbital-acetaminophen tab 50-300 mg.................................................................................... 93 ORENCIA -abatacept subcutaneous soln prefilled syringe 125 mg/ml...................................................................... 103 ORENITRAM -treprostinil diolamine tab cr 0.125 mg (base equiv)................................................................................58 ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base equiv)................................................................................58 ORENITRAM -treprostinil diolamine tab cr 1 mg (base equiv)................................................................................58 ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base equiv)................................................................................58 ORFADIN -nitisinone cap 10 mg....................................... 37 224 ORFADIN -nitisinone cap 2 mg......................................... 37 ORFADIN -nitisinone cap 5 mg......................................... 37 ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg.............. 65 orphenadrine citrate tab sr 12hr 100 mg..................... 114 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg.................................................................................. 114 ORTHO-CEPT -desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg....................................................................... 26 ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg...............................................................26 ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr..............................................................26 ORTHO MICRONOR -norethindrone tab 0.35 mg.............26 ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol tab 1 mg-35 mcg............................................................. 26 ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg............................................26 ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg...................................26 ORTHO TRI-CYCLEN -norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg...................................26 OSENI -alogliptin-pioglitazone tab 12.5-15 mg..................30 OSENI -alogliptin-pioglitazone tab 12.5-30 mg..................30 OSENI -alogliptin-pioglitazone tab 12.5-45 mg..................30 OSENI -alogliptin-pioglitazone tab 25-15 mg.....................30 OSENI -alogliptin-pioglitazone tab 25-30 mg.....................30 OSENI -alogliptin-pioglitazone tab 25-45 mg.....................30 OSMOPREP -sod phos mono-sod phos di tabs 1.102-0.398 gm(1.5gm na phos)..................................... 66 OSPHENA -ospemifene tab 60 mg................................... 37 OTEZLA -apremilast tab 30 mg.......................................103 OTEZLA -apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg................................................................... 103 OTICIN HC NR -pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml................................................................141 OTOZIN -antipyrine-benzocaine-glycerin-zinc ace otic liqd 5.4-1-2-1%......................................................................141 OTREXUP -methotrexate soln pf auto-injector 10 mg/0.4ml.........................................................................103 OTREXUP -methotrexate soln pf auto-injector 15 mg/0.4ml.........................................................................103 OTREXUP -methotrexate soln pf auto-injector 20 mg/0.4ml.........................................................................103 OTREXUP -methotrexate soln pf auto-injector 25 mg/0.4ml.........................................................................103 OVACE PLUS -sulfacetamide sodium cream 10%..........155 OVACE PLUS -sulfacetamide sodium foam 9.8%...........155 OVACE PLUS -sulfacetamide sodium lotion 9.8%.......... 155 OVACE PLUS -sulfacetamide sodium shampoo 10%..... 155 OVACE PLUS WASH -sulfacetamide sodium cleansing gel 10%................................................................................ 155 OVACE PLUS WASH -sulfacetamide sodium liquid 10%................................................................................ 155 OVACE WASH -sulfacetamide sodium liquid 10%.......... 155 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 OVCON-35 -norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg....................................................................... 26 OVIDE -malathion lotion 0.5%.........................................155 OXANDRIN -oxandrolone tab 10 mg.................................21 OXANDRIN -oxandrolone tab 2.5 mg................................21 oxandrolone tab 10 mg (Oxandrin)................................ 21 oxandrolone tab 2.5 mg (Oxandrin)............................... 21 oxaprozin tab 600 mg (Daypro)....................................103 oxazepam cap 10 mg...................................................... 76 oxazepam cap 15 mg...................................................... 76 oxazepam cap 30 mg...................................................... 76 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)....................................................................... 109 oxcarbazepine tab 150 mg (Trileptal).......................... 109 oxcarbazepine tab 300 mg (Trileptal).......................... 109 oxcarbazepine tab 600 mg (Trileptal).......................... 109 OXISTAT -oxiconazole nitrate cream 1%........................ 155 OXISTAT -oxiconazole nitrate lotion 1%......................... 155 OXSORALEN -methoxsalen lotion 1%............................ 155 OXSORALEN ULTRA -methoxsalen rapid cap 10 mg.....155 OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg....... 109 OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg....... 109 OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg....... 109 oxybutynin chloride syrup 5 mg/5ml............................. 73 oxybutynin chloride tab 5 mg........................................ 73 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl)..................................................................................... 73 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl)..................................................................................... 73 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 73 oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 99 oxycodone hcl cap 5 mg................................................ 99 oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl).............................................................99 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 10 mg............................................................................... 99 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 20 mg............................................................................... 99 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 40 mg............................................................................... 99 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 80 mg............................................................................... 99 OXYCODONE HCL -oxycodone hcl conc 100 mg/5ml (20 mg/ml).............................................................................. 99 OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml...........99 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)............99 oxycodone hcl tab 10 mg............................................... 99 oxycodone hcl tab 15 mg (Roxicodone)........................99 oxycodone hcl tab 20 mg............................................... 99 oxycodone hcl tab 30 mg (Roxicodone)........................99 oxycodone hcl tab 5 mg (Roxicodone)..........................99 oxycodone-ibuprofen tab 5-400 mg............................... 99 oxycodone w/ acetaminophen tab 10-325 mg (Percocet)........................................................................99 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)........................................................................99 oxycodone w/ acetaminophen tab 5-325 mg (Percocet)........................................................................99 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)........................................................................99 OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg...... 99 OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg...... 99 OXYCONTIN -oxycodone hcl tab er 12hr deter 20 mg...... 99 OXYCONTIN -oxycodone hcl tab er 12hr deter 30 mg...... 99 OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg...... 99 OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg...... 99 OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg...... 99 oxymorphone hcl tab 10 mg (Opana)............................ 99 oxymorphone hcl tab 5 mg (Opana).............................. 99 oxymorphone hcl tab sr 12hr 10 mg............................. 99 oxymorphone hcl tab sr 12hr 15 mg............................. 99 oxymorphone hcl tab sr 12hr 20 mg............................. 99 oxymorphone hcl tab sr 12hr 30 mg............................. 99 oxymorphone hcl tab sr 12hr 40 mg............................. 99 oxymorphone hcl tab sr 12hr 5 mg............................... 99 oxymorphone hcl tab sr 12hr 7.5 mg.............................99 OXYTROL -oxybutynin td patch twice weekly 3.9 mg/24hr............................................................................ 73 P PAIN RELIEF PATCH -capsaicin-menthol topical patch 0.0375-5%...................................................................... 155 PAIN RELIEF PATCH -lidocaine-menthol patch 5-1%............................................................................... 155 PAIRE OB -prenat w/ fe poly cmplx-fe asp-fe gly-fa tab & dha cap pak................................................................... 118 PAMELOR -nortriptyline hcl cap 10 mg.............................79 PAMELOR -nortriptyline hcl cap 25 mg.............................79 PAMELOR -nortriptyline hcl cap 50 mg.............................79 PAMELOR -nortriptyline hcl cap 75 mg.............................79 PAMINE FORTE -methscopolamine bromide tab 5 mg.....68 PAMINE FQ -methscopolamine tab 5 mg & misc intestinal flora reg cap.....................................................................68 PAMINE -methscopolamine bromide tab 2.5 mg...............68 PANATUSS DXP -phenylephrine-dexbromphen-dm-gg liquid 5-1-15-100 mg/5ml................................................. 61 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 10500-25000-43750 unit.................................................. 69 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 16800-40000-70000 unit.................................................. 69 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 21000-37000-61000 unit.................................................. 70 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 4200-10000-17500 unit.................................................... 69 PANCRELIPASE -pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit.................................................... 70 PANDEL -hydrocortisone probutate cream 0.1%............ 155 PANRETIN -alitretinoin gel 0.1%.....................................155 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)........................................................................ 68 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 225 2015 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)........................................................................ 68 PARAFON FORTE DSC -chlorzoxazone tab 500 mg......114 paricalcitol cap 1 mcg (Zemplar)................................... 37 paricalcitol cap 2 mcg (Zemplar)................................... 37 paricalcitol cap 4 mcg (Zemplar)................................... 38 PARLODEL -bromocriptine mesylate cap 5 mg.............. 112 PARNATE -tranylcypromine sulfate tab 10 mg..................79 paromomycin sulfate cap 250 mg....................................5 paroxetine hcl tab 10 mg (Paxil).................................... 79 paroxetine hcl tab 20 mg (Paxil).................................... 79 paroxetine hcl tab 30 mg (Paxil).................................... 79 paroxetine hcl tab 40 mg (Paxil).................................... 79 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 79 paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 79 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 79 PASER -aminosalicylic acid cr granules packet 4 gm......... 6 PATADAY -olopatadine hcl ophth soln 0.2%...................139 PATANASE -olopatadine hcl nasal soln 0.6%...................59 PATANOL -olopatadine hcl ophth soln 0.1%...................140 PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 79 PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 79 PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 79 PAXIL -paroxetine hcl oral susp 10 mg/5ml (base equiv)................................................................................79 PAXIL -paroxetine hcl tab 10 mg...................................... 79 PAXIL -paroxetine hcl tab 20 mg...................................... 79 PAXIL -paroxetine hcl tab 30 mg...................................... 79 PAXIL -paroxetine hcl tab 40 mg...................................... 79 PAZEO -olopatadine hcl ophth soln 0.7% (base equivalent)......................................................................140 PCE -erythromycin w/ enteric coated particles tab 333 mg...................................................................................... 3 PCE -erythromycin w/ enteric coated particles tab 500 mg...................................................................................... 3 PCP 100 -mag cit-bisacodyl-petrolat-peg-metoclopramideelectrol kit.........................................................................66 PEDIADERM AF COMPLETE KIT -nystatin cream 100000 unit/gm & diaper rash cream kit.....................................155 PEDIADERM HC -hydrocortisone lot 2% & emollient cream kit........................................................................ 155 PEDIADERM TA -triamcinolone cream 0.1% & emollient cream kit........................................................................ 155 PEDIAPRED -prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)..................................................20 PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj...............................................................................15 PEDIATEX TDM -pseudoephed-triprolidine-dm susp 10-0.938-4 mg/ml.............................................................61 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ ml................................................................................... 118 pediatric multiple vitamins w/ fluoride chew tab 0.25 mg.................................................................................. 118 pediatric multiple vitamins w/ fluoride chew tab 0.5 mg.................................................................................. 118 226 pediatric multiple vitamins w/ fluoride chew tab 1 mg.................................................................................. 118 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ ml................................................................................... 118 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ ml................................................................................... 118 pediatric vitamins acd w/ fluoride soln 0.25 mg/ ml................................................................................... 118 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml...... 118 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely).........................................................................66 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor packs)......................................................66 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack).....................................................66 PEGANONE -ethotoin tab 250 mg.................................. 109 PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml........... 9 PEGASYS -peginterferon alfa-2a inj 180 mcg/ml................ 9 PEGASYS PROCLICK -peginterferon alfa-2a inj 135 mcg/0.5ml...........................................................................9 PEGASYS PROCLICK -peginterferon alfa-2a inj 180 mcg/0.5ml...........................................................................9 PEGINTRON -peginterferon alfa-2b for inj kit 120 mcg/0.5ml...........................................................................9 PEG-INTRON -peginterferon alfa-2b for inj kit 120 mcg/0.5ml...........................................................................8 PEGINTRON -peginterferon alfa-2b for inj kit 150 mcg/0.5ml...........................................................................9 PEG-INTRON -peginterferon alfa-2b for inj kit 150 mcg/0.5ml...........................................................................9 PEGINTRON -peginterferon alfa-2b for inj kit 50 mcg/0.5ml...........................................................................9 PEG-INTRON -peginterferon alfa-2b for inj kit 50 mcg/0.5ml...........................................................................8 PEGINTRON -peginterferon alfa-2b for inj kit 80 mcg/0.5ml...........................................................................9 PEG-INTRON -peginterferon alfa-2b for inj kit 80 mcg/0.5ml...........................................................................8 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 120 mcg/0.5ml..........................................................9 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 150 mcg/0.5ml..........................................................9 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 50 mcg/0.5ml............................................................9 PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit 80 mcg/0.5ml............................................................9 PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit 120 mcg/0.5ml................................................................... 9 PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit 150 mcg/0.5ml................................................................... 9 PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit 50 mcg/0.5ml..................................................................... 9 PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit 80 mcg/0.5ml..................................................................... 9 penicillin v potassium for soln 125 mg/5ml.................... 1 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 penicillin v potassium for soln 250 mg/5ml.................... 1 penicillin v potassium tab 250 mg................................... 1 penicillin v potassium tab 500 mg................................... 1 PENLAC NAIL LACQUER -ciclopirox solution 8%.......... 155 PENNSAID -diclofenac sodium soln 2%......................... 155 PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp................................................................ 15 PENTASA -mesalamine cap cr 250 mg............................ 71 PENTASA -mesalamine cap cr 500 mg............................ 71 pentazocine w/ naloxone tab 50-0.5 mg........................ 99 PENTETATE CALCIUM TRISODI -pentetate calcium trisodium iv or inhalation soln 200 mg/ml.......................163 PENTETATE ZINC TRISODIUM -pentetate zinc trisodium iv or inhalation soln 200 mg/ml......................................163 pentoxifylline tab cr 400 mg......................................... 136 PEPCID -famotidine for susp 40 mg/5ml...........................68 PEPCID -famotidine tab 40 mg......................................... 68 PERCOCET -oxycodone w/ acetaminophen tab 10-325 mg.................................................................................... 99 PERCOCET -oxycodone w/ acetaminophen tab 2.5-325 mg.................................................................................... 99 PERCOCET -oxycodone w/ acetaminophen tab 5-325 mg.................................................................................... 99 PERCOCET -oxycodone w/ acetaminophen tab 7.5-325 mg.................................................................................... 99 PERCODAN -oxycodone-aspirin tab 4.8355-325 mg........ 99 PERFOROMIST -formoterol fumarate soln nebu 20 mcg/2ml............................................................................64 PERIDEX -chlorhexidine gluconate soln 0.12%.............. 143 perindopril erbumine tab 2 mg.......................................50 perindopril erbumine tab 4 mg (Aceon)........................ 50 perindopril erbumine tab 8 mg (Aceon)........................ 50 PERMAVAN EXTERNAL PATCH -lidocaine-dm-trolamine salicylate patch 4-4-10%................................................155 permethrin cream 5% (Elimite).....................................155 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................. 92 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................. 92 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................. 92 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................. 92 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................. 92 perphenazine tab 16 mg................................................. 83 perphenazine tab 2 mg................................................... 82 perphenazine tab 4 mg................................................... 82 perphenazine tab 8 mg................................................... 82 PERSANTINE -dipyridamole tab 25 mg.......................... 136 PERSANTINE -dipyridamole tab 50 mg.......................... 136 PERSANTINE -dipyridamole tab 75 mg.......................... 136 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit.................................................. 70 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit.................................................... 70 PEXEVA -paroxetine mesylate tab 10 mg (base equiv).....79 PEXEVA -paroxetine mesylate tab 20 mg (base equiv).....79 PEXEVA -paroxetine mesylate tab 30 mg (base equiv).....79 PEXEVA -paroxetine mesylate tab 40 mg (base equiv).....79 PHARMACIST CHOICE TSX PAT -methyl salicylatelidocaine-menthol patch 2-4-1%.................................... 155 phenazopyridine hcl tab 100 mg (Pyridium)................. 74 phenazopyridine hcl tab 200 mg (Pyridium)................. 74 phenelzine sulfate tab 15 mg (Nardil)............................ 79 phenobarbital elixir 20 mg/5ml.......................................85 PHENOBARBITAL -phenobarbital tab 100 mg..................85 PHENOBARBITAL -phenobarbital tab 15 mg....................85 PHENOBARBITAL -phenobarbital tab 30 mg....................85 PHENOBARBITAL -phenobarbital tab 60 mg....................85 phenobarbital tab 16.2 mg..............................................85 phenobarbital tab 32.4 mg..............................................85 phenobarbital tab 64.8 mg..............................................85 phenobarbital tab 97.2 mg..............................................85 phenylephrine-brompheniramine-dm liquid 7.5-4-15 mg/5ml.............................................................................61 phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)..............................................................................61 phenylephrine hcl ophth soln 10%.............................. 140 phenylephrine hcl ophth soln 2.5%............................. 140 phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml............................................................ 61 phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml........... 61 phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............. 61 PHENYLHISTINE DH -pseudoephedrine-chlorphen w/ codeine liq 30-2-10 mg/5ml............................................. 61 PHENYTEK -phenytoin sodium extended cap 200 mg.................................................................................. 109 PHENYTEK -phenytoin sodium extended cap 300 mg.................................................................................. 109 phenytoin chew tab 50 mg (Dilantin infatabs)............ 109 phenytoin sodium extended cap 100 mg (Dilantin)........................................................................109 phenytoin susp 125 mg/5ml (Dilantin)......................... 109 PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse 0.044%........................................................................... 143 PHOS FLUR -sodium fluoride rinse 0.044%....................143 PHOSLO -calcium acetate (phosphate binder) cap 667 mg (169 mg ca)..................................................................... 71 PHOSLYRA -calcium acetate (phosphate binder) oral soln 667 mg/5ml...................................................................... 71 PHOSPHOLINE IODIDE -echothiophate iodide ophth for soln 0.125%................................................................... 140 PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/ ml & lidocaine 1% & ammonia inh kit.............................. 20 phytonadione inj 1 mg/0.5ml (2 mg/ml)....................... 115 PICATO -ingenol mebutate gel 0.015%.......................... 155 PICATO -ingenol mebutate gel 0.05%............................ 155 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 227 2015 PICO SINGLE USE NEGATIVE -wound dressings kit....................................................................................155 pilocarpine hcl ophth soln 1% (Isopto carpine).......... 140 pilocarpine hcl ophth soln 2% (Isopto carpine).......... 140 pilocarpine hcl ophth soln 4% (Isopto carpine).......... 140 pilocarpine hcl tab 5 mg (Salagen).............................. 143 pilocarpine hcl tab 7.5 mg (Salagen)........................... 143 pindolol tab 10 mg.......................................................... 41 pindolol tab 5 mg............................................................ 41 PINNACAINE OTIC -benzocaine otic soln 20%.............. 141 pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)...... 30 pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)...... 30 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met)................................................................30 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)................................................................30 pioglitazone hcl tab 15 mg (base equiv) (Actos)...........30 pioglitazone hcl tab 30 mg (base equiv) (Actos)...........30 pioglitazone hcl tab 45 mg (base equiv) (Actos)...........30 piroxicam cap 10 mg (Feldene)....................................103 piroxicam cap 20 mg (Feldene)....................................103 PKU EASY MICROTABS -nutritional supplement tabs delayed release..............................................................127 PLAN B ONE-STEP -levonorgestrel tab 1.5 mg................26 PLAQUENIL -hydroxychloroquine sulfate tab 200 mg....... 11 PLAVIX -clopidogrel bisulfate tab 300 mg (base equiv)..............................................................................136 PLAVIX -clopidogrel bisulfate tab 75 mg (base equiv).....136 PLEGRIDY -peginterferon beta-1a soln pen-injector 125 mcg/0.5ml.........................................................................92 PLEGRIDY -peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml................................................................. 92 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack...................................... 92 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack.....................................92 PLETAL -cilostazol tab 100 mg....................................... 136 PLETAL -cilostazol tab 50 mg......................................... 136 PLEXION CLEANSER -sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%.......................................................... 156 PLEXION CLEANSING CLOTHS -sulfacetamide sodium w/ sulfur cleansing cloth 9.8-4.8%................................. 156 PLEXION -sulfacetamide sodium w/ sulfur cream 9.8-4.8%......................................................................... 156 PLEXION -sulfacetamide sodium w/ sulfur lotion 9.8-4.8%......................................................................... 155 PLIAGLIS -lidocaine-tetracaine cream 7-7%................... 156 PNEUMOVAX 23/1 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................. 15 PNEUMOVAX 23/5 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................. 15 PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml.........................................................................15 PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg........................................... 119 228 PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg......................................................... 119 PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg................................................ 119 PNV-FIRST -prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg...................................................................119 PNV FOLIC ACID + IRON MUL -prenatal vit w/ fe fumarate-fa tab 27-1 mg................................................ 119 PNV-OB/DHA -prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack........................................................... 119 PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack........................................................... 119 PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolate-faomega 3 cap..................................................................119 PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe fumarate-fa tab 27-1 mg................................................ 119 PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg.................................................................119 PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 119 PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap 35-5-1.2 mg....................................................................119 PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg.....................................................................119 PODIAPN -l-methylfolate-b12-b6-alpha lipoic ac cap 5-2-35-300 mg............................................................... 127 PODOCON 25 IN BENZOIN TIN -podophyllum resin soln 25%................................................................................ 156 podofilox soln 0.5% (Condylox)................................... 156 polyethylene glycol 3350 oral packet............................ 66 polyethylene glycol 3350 oral powder...........................66 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)........................................................140 POLYTRIM -polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%................................................................... 140 POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine liquid 10-4-10 mg/5ml...................................................... 61 POLY-TUSSIN -codeine-chlorcyclizine liquid 10-9.375 mg/5ml..............................................................................61 POLY-TUSSIN D -codeine-pseudoephedrinechlorcyclizine liq 10-30-9.375mg/5ml............................... 61 POLY-VI-FLOR/IRON -ped multiple vitamin w/ fl-fe biphasic susp 0.25-7 mg/ml........................................... 119 POLY-VI-FLOR/IRON -ped multiple vit w/ fl-fe biphasic chew tab 0.5-10 mg....................................................... 119 POLY-VI-FLOR FS -pediatric multiple vitamins w/ fluoride oral strip 1 mg................................................................119 POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral strip 0.25 mg.................................................................. 119 POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral strip 0.5 mg....................................................................119 POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew tab 0.25 mg....................................................................119 POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew tab 0.5 mg......................................................................119 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew tab 1 mg.........................................................................119 POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic susp 0.25 mg/ml..................................................................... 119 POMALYST -pomalidomide cap 1 mg...............................18 POMALYST -pomalidomide cap 2 mg...............................18 POMALYST -pomalidomide cap 3 mg...............................18 POMALYST -pomalidomide cap 4 mg...............................18 PONSTEL -mefenamic acid cap 250 mg.........................103 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml.............................................................................74 POTABA -potassium aminobenzoate cap 500 mg.......... 115 POTABA -potassium aminobenzoate tab 500 mg........... 115 potassium bicarbonate effer tab 25 meq.....................125 potassium chloride cap cr 10 meq (Micro-k)...............125 potassium chloride cap cr 8 meq (Micro-k).................125 POTASSIUM CHLORIDE ER -potassium chloride tab cr 20 meq (1500 mg)......................................................... 125 POTASSIUM CHLORIDE ER -potassium chloride tab cr 8 meq (600 mg)................................................................ 125 potassium chloride microencapsulated crys cr tab 10 meq................................................................................ 125 potassium chloride microencapsulated crys cr tab 20 meq................................................................................ 125 potassium chloride oral liq 10% (20 meq/15ml).......... 125 potassium chloride oral liq 20% (40 meq/15ml).......... 125 potassium chloride powder packet 20 meq................ 125 potassium chloride tab cr 10 meq (K-tab)................... 125 potassium chloride tab cr 8 meq (600 mg)..................125 potassium citrate & citric acid powder pack 3300-1002 mg.................................................................................... 74 potassium citrate & citric acid soln 1100-334 mg/5ml.............................................................................74 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10).................................................................................... 74 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15).................................................................................... 74 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)...................................................................................... 74 pot bicarbonate & chloride effer tab 25 meq...............125 POTIGA -ezogabine tab 200 mg..................................... 110 POTIGA -ezogabine tab 300 mg..................................... 110 POTIGA -ezogabine tab 400 mg..................................... 110 POTIGA -ezogabine tab 50 mg....................................... 109 pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral)................................ 125 PRADAXA -dabigatran etexilate mesylate cap 150 mg (etexilate base eq)......................................................... 133 PRADAXA -dabigatran etexilate mesylate cap 75 mg (etexilate base eq)......................................................... 133 PRALUENT -alirocumab subcutaneous soln pen-injector 150 mg/ml........................................................................ 56 PRALUENT -alirocumab subcutaneous soln pen-injector 75 mg/ml.......................................................................... 56 PRALUENT -alirocumab subcutaneous soln prefilled syringe 150 mg/ml........................................................... 56 PRALUENT -alirocumab subcutaneous soln prefilled syringe 75 mg/ml............................................................. 56 pramipexole dihydrochloride tab 0.125 mg (Mirapex)....................................................................... 112 pramipexole dihydrochloride tab 0.25 mg (Mirapex)....................................................................... 112 pramipexole dihydrochloride tab 0.5 mg (Mirapex)....................................................................... 112 pramipexole dihydrochloride tab 0.75 mg (Mirapex)....................................................................... 112 pramipexole dihydrochloride tab 1.5 mg (Mirapex)....................................................................... 112 pramipexole dihydrochloride tab 1 mg (Mirapex)....... 112 pramipexole dihydrochloride tab sr 24hr 0.375 mg (Mirapex er)...................................................................112 pramipexole dihydrochloride tab sr 24hr 0.75 mg (Mirapex er)...................................................................112 pramipexole dihydrochloride tab sr 24hr 1.5 mg (Mirapex er)...................................................................112 pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex er)...................................................................112 PRAMOSONE E -pramoxine-hc emollient base cream 1-2.5%............................................................................ 156 PRAMOSONE -pramoxine-hc cream 1-1%..................... 156 PRAMOSONE -pramoxine-hc cream 1-2.5%.................. 156 PRAMOSONE -pramoxine-hc lotion 1-1%...................... 156 PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 156 PRAMOSONE -pramoxine-hc oint 1-1%......................... 156 PRAMOSONE -pramoxine-hc oint 1-2.5%...................... 156 PRAMOTIC -pramoxine-chloroxylenol otic liquid 1-0.1%............................................................................ 142 pramoxine-chloroxylenol otic liquid 1-0.1% (Pramotic)......................................................................142 pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml (Cortane-b-otic)............................................................ 142 pramoxine-hc cream 1-2.5% (Pramosone).................. 156 pramoxine hcl gel 1%....................................................156 PRANDIMET -repaglinide-metformin hcl tab 1-500 mg..... 30 PRANDIMET -repaglinide-metformin hcl tab 2-500 mg..... 30 PRANDIN -repaglinide tab 0.5 mg.................................... 30 PRANDIN -repaglinide tab 1 mg....................................... 30 PRANDIN -repaglinide tab 2 mg....................................... 30 PRASCION RA WITH SUNSCREE -sulfacetamide sodium-sulfur-sunscreen cream 10-5%......................... 156 PRASTERA -prasterone cap 200 mg & ibuprofen tab 400 mg kit............................................................................. 103 PRAVACHOL -pravastatin sodium tab 20 mg................... 56 PRAVACHOL -pravastatin sodium tab 40 mg................... 56 PRAVACHOL -pravastatin sodium tab 80 mg................... 56 pravastatin sodium tab 10 mg........................................56 pravastatin sodium tab 20 mg (Pravachol)................... 56 pravastatin sodium tab 40 mg (Pravachol)................... 56 pravastatin sodium tab 80 mg (Pravachol)................... 56 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 229 2015 prazosin hcl cap 1 mg (Minipress).................................50 prazosin hcl cap 2 mg (Minipress).................................50 prazosin hcl cap 5 mg (Minipress).................................50 PR CREAM -dermatological products misc - kit.............. 156 PRECOSE -acarbose tab 100 mg.....................................30 PRECOSE -acarbose tab 25 mg.......................................30 PRECOSE -acarbose tab 50 mg.......................................30 PRED FORTE -prednisolone acetate ophth susp 1%......140 PRED-G -gentamicin-prednisolone ace ophth susp 0.3-1%............................................................................ 140 PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint 0.3-0.6%......................................................................... 140 PRED MILD -prednisolone acetate ophth susp 0.12%............................................................................. 140 prednicarbate cream 0.1% (Dermatop)........................ 156 prednicarbate oint 0.1% (Dermatop)............................ 156 prednisolone acetate ophth susp 1% (Pred forte)...... 140 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate ophth soln 1%.............................................. 140 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)....................... 21 prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt).................................................20 prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt).................................................20 prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt).................................................20 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv).................................................................... 20 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)............................................. 20 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone)......................................................21 PREDNISONE INTENSOL -prednisone conc 5 mg/ml...... 21 PREDNISONE -prednisone oral soln 5 mg/5ml.................21 PREDNISONE -prednisone tab 10 mg dose pack.............21 PREDNISONE -prednisone tab 50 mg..............................21 PREDNISONE -prednisone tab 5 mg dose pack...............21 prednisone tab 10 mg..................................................... 21 prednisone tab 1 mg....................................................... 21 prednisone tab 2.5 mg.................................................... 21 prednisone tab 20 mg..................................................... 21 prednisone tab 5 mg....................................................... 21 PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme poly-fa tab&dha cap pack.............................................. 119 PREFERA OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................. 119 PREFERAOB ONE -prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg................................................. 119 PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg................................................................ 119 PREFERRED PLUS GLUCOSE -glucose chew tab 4 gm.................................................................................... 30 PREFERRED PLUS GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm................................................................ 31 230 PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15)....................................................................23 PREFOL-DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg................................................................119 PRE-FOLIC -folic acid-vitamin c tab 1-100 mg................131 PREMARIN -estrogens, conjugated tab 0.3 mg................ 23 PREMARIN -estrogens, conjugated tab 0.45 mg.............. 23 PREMARIN -estrogens, conjugated tab 0.625 mg............ 23 PREMARIN -estrogens, conjugated tab 0.9 mg................ 23 PREMARIN -estrogens, conjugated tab 1.25 mg.............. 24 PREMARIN -estrogens, conjugated vaginal cream 0.625 mg/gm.............................................................................. 74 PREMIUM SCAR PATCH -allantoin-lidocaine-petrolatum patch 2-4-30%................................................................156 PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14)........................................................... 24 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg................................................................. 24 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg............................................................... 24 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg..............................................................24 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg................................................................ 24 PRENA1/QUATREFOLIC -prenat w/o a w/fefum-methfolfa-dha cap 30-0.6-0.4-200 mg....................................... 121 PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg......................................................................120 PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg.................................................... 121 PRENA1 PLUS/QUATREFOLIC -prenat w/o a w/ fe chelate-l methylfol-fa tab & dha cap pk......................... 121 PRENAISSANCE 90 DHA -prenat w/o a w/fecbn-fegl-dssfa tab 90 &dha cap 300mg pak..................................... 120 PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg..........................................119 PRENAISSANCE DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack.......................................... 120 PRENAISSANCE HARMONY DHA -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg......................120 PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg........................................................ 120 PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg.......................................................... 120 PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg.................................................... 120 PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg.......................................................119 PRENAISSANCE PROMISE -prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack................................120 PRENAPLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 120 PRENATABS FA -prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................. 120 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 120 PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................. 120 PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab 29-1 mg..........................................................................120 PRENATAL AD -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg..........................................................................120 PRENATAL LOW IRON -prenatal vit w/ fe fumarate-fa tab 27-1 mg..........................................................................120 PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa tab 29-1 mg................................................................... 120 PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 120 PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 120 PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg.....................................................................120 PRENATAL VITAMINS PLUS -prenatal vit w/ fe fumaratefa tab 27-1 mg............................................................... 120 PRENATA -prenatal w/o a vit w/ fe fum-fa tab chew 29-1 mg.................................................................................. 120 PRENATE AM -prenatal w/ calcium-vit b6-vit b12-fa-ginger tab 1 mg.........................................................................120 PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg.................................................. 120 PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-300 mg......................................................... 120 PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa tab 26-0.6-0.4 mg.......................................................... 120 PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab 20-0.6-0.4 mg.................................................................120 PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg........................................... 120 PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfol-fadha cap 18-0.6-0.4-300 mg........................................... 120 PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg........................................ 120 PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha cap 18-0.6-0.4-350 mg.................................................. 120 PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha cap 10-0.6-0.4-200 mg.................................................. 120 PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab 0.6-0.4 mg......................................................................120 PRENATE RESTORE -prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg........................................... 120 PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa tab 20-1 mg................................................................... 120 PRENEXA -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg..............................................................121 PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm.............35 PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 121 PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10 mg-3.5 gm-12 gm............................................................ 66 PREQUE 10 -prenatal mv w/fe carbonyl-dss-fa-dha tab 15-25-0.5-50 mg............................................................ 121 PRESERA -emollient - aerosol foam...............................156 PRESTALIA -perindopril arginine-amlodipine besylate tab 14-10 mg..........................................................................50 PRESTALIA -perindopril arginine-amlodipine besylate tab 3.5-2.5 mg........................................................................50 PRESTALIA -perindopril arginine-amlodipine besylate tab 7-5 mg..............................................................................50 PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg.......121 PREVACID -lansoprazole cap delayed release 15 mg...... 68 PREVACID -lansoprazole cap delayed release 30 mg...... 68 PREVACID SOLUTAB -lansoprazole tab delayed release orally disintegrating 15 mg...............................................68 PREVACID SOLUTAB -lansoprazole tab delayed release orally disintegrating 30 mg...............................................68 PREVIDENT 5000 BOOSTER PL -sodium fluoride paste 1.1%............................................................................... 143 PREVIDENT 5000 BOOSTER -sodium fluoride paste 1.1%............................................................................... 143 PREVIDENT 5000 DRY MOUTH -sodium fluoride gel 1.1% (0.5% f)................................................................. 143 PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%..................................... 143 PREVIDENT 5000 PLUS -sodium fluoride cream 1.1%............................................................................... 143 PREVIDENT 5000 SENSITIVE -sodium fluoride-potassium nitrate paste 1.1-5%.......................................................143 PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5% f)..................................................................................... 143 PREVIDENT -sodium fluoride rinse 0.2%........................143 PREVNAR 13 -pneumococcal 13-valent conjugate vaccine inj......................................................................................15 PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack.................................................................... 68 PREZCOBIX -darunavir-cobicistat tab 800-150 mg.............9 PREZISTA -darunavir ethanolate susp 100 mg/ml (base equiv)..................................................................................9 PREZISTA -darunavir ethanolate tab 150 mg (base equiv)..................................................................................9 PREZISTA -darunavir ethanolate tab 600 mg (base equiv)..................................................................................9 PREZISTA -darunavir ethanolate tab 75 mg (base equiv)..................................................................................9 PREZISTA -darunavir ethanolate tab 800 mg (base equiv)..................................................................................9 PRIFTIN -rifapentine tab 150 mg........................................ 6 PRILOSEC -omeprazole cap delayed release 10 mg........68 PRILOSEC -omeprazole cap delayed release 20 mg........68 PRILOSEC -omeprazole cap delayed release 40 mg........68 PRILOSEC -omeprazole magnesium for delayed release susp packet 10 mg.......................................................... 68 PRILOSEC -omeprazole magnesium for delayed release susp packet 2.5 mg......................................................... 68 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 231 2015 PRIMAQUINE PHOSPHATE -primaquine phosphate tab 26.3 mg (15 mg base)..................................................... 11 primidone tab 250 mg (Mysoline).................................110 primidone tab 50 mg (Mysoline).................................. 110 PRIMLEV -oxycodone w/ acetaminophen tab 10-300 mg.................................................................................. 100 PRIMLEV -oxycodone w/ acetaminophen tab 5-300 mg.................................................................................... 99 PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300 mg.................................................................................. 100 PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base equiv)................................................................................12 PRINIVIL -lisinopril tab 10 mg........................................... 50 PRINIVIL -lisinopril tab 20 mg........................................... 50 PRINIVIL -lisinopril tab 5 mg............................................. 50 PRINZIDE -lisinopril & hydrochlorothiazide tab 10-12.5 mg.................................................................................... 50 PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg (base equiv)..................................................................... 79 PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg (base equiv)..................................................................... 79 PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg (base equiv)..................................................................... 79 PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk.................................................... 119 PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk......................................................119 PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk.................................................... 119 PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk......................................................119 PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)......................................................... 64 PROAIR RESPICLICK -albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv).......................................... 64 probenecid tab 500 mg................................................. 106 PROCARDIA -nifedipine cap 10 mg..................................43 PROCARDIA XL -nifedipine tab sr 24hr osmotic 30 mg.................................................................................... 43 PROCARDIA XL -nifedipine tab sr 24hr osmotic 60 mg.................................................................................... 43 PROCARDIA XL -nifedipine tab sr 24hr osmotic 90 mg.................................................................................... 43 PROCENTRA -dextroamphetamine sulfate oral solution 5 mg/5ml..............................................................................88 prochlorperazine maleate tab 10 mg (base equivalent) (Compazine)....................................................................83 prochlorperazine maleate tab 5 mg (base equivalent) (Compazine)....................................................................83 prochlorperazine suppos 25 mg.................................... 83 PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33 mg/5ml..............................................................................61 PROCORT -hydrocortisone acetate w/ pramoxine rectal cream 1.85-1.15%..........................................................144 PROCRIT -epoetin alfa inj 10000 unit/ml........................ 131 232 PROCRIT -epoetin alfa inj 20000 unit/ml........................ 131 PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 131 PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 131 PROCRIT -epoetin alfa inj 40000 unit/ml........................ 131 PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 131 PROCTOCORT -hydrocortisone acetate suppos 30 mg.................................................................................. 144 PROCTOCORT -hydrocortisone rectal cream 1%...........144 PROCTOFOAM HC -hydrocortisone acetate w/ pramoxine rectal foam 1-1%............................................................144 PROCYSBI -cysteamine bitartrate cap delayed release 25 mg (base equiv)............................................................... 74 PROCYSBI -cysteamine bitartrate cap delayed release 75 mg (base equiv)............................................................... 74 PRODRIN -isometheptene-caffeine-acetaminophen tab 65-20-325 mg.................................................................105 PROFERRIN-FORTE -iron heme polypeptide-folic acid tab 12-1 mg (fe equiv)......................................................... 131 PROFILNINE -factor ix complex for inj 1000 unit............ 136 PROFILNINE -factor ix complex for inj 1500 unit............ 136 PROFILNINE -factor ix complex for inj 500 unit.............. 136 PROFILNINE SD -factor ix complex for inj 1000 unit.......136 PROFILNINE SD -factor ix complex for inj 1500 unit.......136 PROFILNINE SD -factor ix complex for inj 500 unit.........136 progesterone im in oil 50 mg/ml.................................... 26 progesterone micronized cap 100 mg (Prometrium)...................................................................26 progesterone micronized cap 200 mg (Prometrium)...................................................................26 PROGLYCEM -diazoxide susp 50 mg/ml..........................31 PROGRAF -tacrolimus cap 0.5 mg................................. 164 PROGRAF -tacrolimus cap 1 mg.................................... 164 PROGRAF -tacrolimus cap 5 mg.................................... 164 PROLENSA -bromfenac sodium ophth soln 0.07% (base equivalent)......................................................................140 PROLIDA -lidocaine-menthol patch 4-1%....................... 156 PROMACTA -eltrombopag olamine tab 12.5 mg (base equiv)..............................................................................131 PROMACTA -eltrombopag olamine tab 25 mg (base equiv)..............................................................................131 PROMACTA -eltrombopag olamine tab 50 mg (base equiv)..............................................................................131 PROMACTA -eltrombopag olamine tab 75 mg (base equiv)..............................................................................131 promethazine-dm syrup 6.25-15 mg/5ml....................... 61 promethazine hcl suppos 12.5 mg.................................58 promethazine hcl suppos 25 mg....................................58 promethazine hcl suppos 50 mg....................................58 promethazine hcl syrup 6.25 mg/5ml.............................58 promethazine hcl tab 12.5 mg........................................ 58 promethazine hcl tab 25 mg........................................... 58 promethazine hcl tab 50 mg...........................................58 PROMETHAZINE VC PLAIN -promethazine & phenylephrine syrup 6.25-5 mg/5ml.................................61 promethazine w/ codeine syrup 6.25-10 mg/5ml...........61 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 PROMETRIUM -progesterone micronized cap 100 mg..... 26 PROMETRIUM -progesterone micronized cap 200 mg..... 26 PROMISEB -antiseborrheic products misc - cream.........156 PROMISEB COMPLETE -antiseborrheic products misc kit....................................................................................156 propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 44 propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 44 propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 45 propafenone hcl tab 150 mg (Rythmol)......................... 45 propafenone hcl tab 225 mg (Rythmol)......................... 45 propafenone hcl tab 300 mg.......................................... 45 PROPANTHELINE BROMIDE -propantheline bromide tab 15 mg............................................................................... 68 proparacaine hcl ophth soln 0.5% (Alcaine)............... 140 PROPRANOLOL/HYDROCHLOROTH -propranolol & hydrochlorothiazide tab 40-25 mg................................... 50 PROPRANOLOL/HYDROCHLOROTH -propranolol & hydrochlorothiazide tab 80-25 mg................................... 50 propranolol hcl cap sr 24hr 120 mg (Inderal la)............41 propranolol hcl cap sr 24hr 160 mg (Inderal la)............41 propranolol hcl cap sr 24hr 60 mg (Inderal la)..............41 propranolol hcl cap sr 24hr 80 mg (Inderal la)..............41 PROPRANOLOL HCL -propranolol hcl oral soln 20 mg/5ml..............................................................................41 PROPRANOLOL HCL -propranolol hcl oral soln 40 mg/5ml..............................................................................41 propranolol hcl tab 10 mg.............................................. 41 propranolol hcl tab 20 mg.............................................. 41 propranolol hcl tab 40 mg.............................................. 41 propranolol hcl tab 60 mg.............................................. 41 propranolol hcl tab 80 mg.............................................. 41 propylthiouracil tab 50 mg............................................. 34 PRO-RED AC -phenylephrine-dexchlorphenir-codeine syrup 5-1-9 mg/5ml..........................................................61 PROSCAR -finasteride tab 5 mg.......................................74 PROSED/DS -methenamine-hyosc-meth blue-benz acidphenyl sal tab 81.6mg..................................................... 72 PROSTIN E2 -dinoprostone vaginal suppos 20 mg...........35 PROTECTIRON -iron polysacch-fa-b complex-vit c-e & minerals tab 60-1 mg.....................................................131 PROTHELIAL -sucralfate-malate paste 10%...................143 PROTONIX -pantoprazole sodium ec tab 20 mg (base equiv)................................................................................68 PROTONIX -pantoprazole sodium ec tab 40 mg (base equiv)................................................................................68 PROTONIX -pantoprazole sodium for delayed release susp packet 40 mg.......................................................... 68 PROTOPIC -tacrolimus oint 0.03%................................. 156 PROTOPIC -tacrolimus oint 0.1%................................... 156 protriptyline hcl tab 10 mg (Vivactil)............................. 79 protriptyline hcl tab 5 mg (Vivactil)............................... 79 PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)......................................................... 64 PROVENZA -lidocaine-menthol patch 4-1%................... 156 PROVERA -medroxyprogesterone acetate tab 10 mg...... 26 PROVERA -medroxyprogesterone acetate tab 2.5 mg......26 PROVERA -medroxyprogesterone acetate tab 5 mg........ 26 PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap 16-16-1.25-110 mg........................................................ 121 PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap 20-20-1.25 mg................................................................121 PROVIGIL -modafinil tab 100 mg......................................88 PROVIGIL -modafinil tab 200 mg......................................88 PROZAC -fluoxetine hcl cap 10 mg.................................. 79 PROZAC -fluoxetine hcl cap 20 mg.................................. 79 PROZAC -fluoxetine hcl cap 40 mg.................................. 79 PROZAC WEEKLY -fluoxetine hcl cap delayed release 90 mg.................................................................................... 80 PROZENA -lidocaine patch 4%.......................................156 PRUCLAIR -dermatological products misc - cream.........156 PRUDOXIN -doxepin hcl cream 5%................................ 156 PRUMYX -dermatological products misc - cream............156 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro)........................................................... 61 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml.....61 pseudoephedrine-bromphen-codeine liq 10-1.33-6.33 mg/5ml.............................................................................61 pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml.............................................................................61 pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml (Suttar-sf)........................................................................ 61 PSORCON -diflorasone diacetate cream 0.05%............. 156 PULMICORT -budesonide inhalation susp 0.25 mg/2ml..............................................................................64 PULMICORT -budesonide inhalation susp 0.5 mg/2ml..... 64 PULMICORT -budesonide inhalation susp 1 mg/2ml........ 64 PULMICORT FLEXHALER -budesonide inhal aero powd 180 mcg/act (breath activated)........................................ 64 PULMICORT FLEXHALER -budesonide inhal aero powd 90 mcg/act (breath activated).......................................... 64 PULMOZYME -dornase alfa inhal soln 1 mg/ml................ 65 PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg..............................................................121 PUREFE PLUS -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg......................................................131 PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/ ml).................................................................................... 18 PX GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 31 PYLERA -bismuth subcit-metronidazole-tetracycline cap 140-125-125 mg...............................................................68 pyrazinamide tab 500 mg..................................................6 PYRIDIUM -phenazopyridine hcl tab 100 mg.................... 74 PYRIDIUM -phenazopyridine hcl tab 200 mg.................... 74 pyridostigmine bromide tab 60 mg (Mestinon)........... 115 pyridostigmine bromide tab cr 180 mg (Mestinon timespan)...................................................................... 114 PYROGALLIC ACID -pyrogallol-chlorobutanol oint 25-2%............................................................................. 156 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 233 2015 Q QNASL -beclomethasone dipropionate nasal aerosol 80 mcg/act.............................................................................59 QNASL CHILDRENS -beclomethasone dipropionate nasal aerosol 40 mcg/act.......................................................... 59 QROXIN -capsaicin-menthol topical patch 0.0375-5%...................................................................... 156 Q-TABS -levomefolate glucosamine tab 1 mg (folate equivalent)......................................................................127 QUADRACEL -diph-tetanus tox ad-acell pert & polio virus, ipv vac inj.........................................................................15 QUALAQUIN -quinine sulfate cap 324 mg........................ 11 QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg....................................................... 26 QUAZEPAM -quazepam tab 15 mg.................................. 85 QUDEXY XR -topiramate cap er 24hr sprinkle 100 mg.................................................................................. 110 QUDEXY XR -topiramate cap er 24hr sprinkle 150 mg.................................................................................. 110 QUDEXY XR -topiramate cap er 24hr sprinkle 200 mg.................................................................................. 110 QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg..... 110 QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg..... 110 QUESTRAN -cholestyramine powder 4 gm/dose.............. 56 QUESTRAN -cholestyramine powder packets 4 gm......... 56 QUESTRAN LIGHT -cholestyramine light powder 4 gm/ dose..................................................................................56 quetiapine fumarate tab 100 mg (Seroquel).................. 83 quetiapine fumarate tab 200 mg (Seroquel).................. 83 quetiapine fumarate tab 25 mg (Seroquel).................... 83 quetiapine fumarate tab 300 mg (Seroquel).................. 83 quetiapine fumarate tab 400 mg (Seroquel).................. 83 quetiapine fumarate tab 50 mg (Seroquel).................... 83 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride chew tab 0.25 mg............................................. 121 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride chew tab 0.5 mg............................................... 121 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride chew tab 1 mg.................................................. 121 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml................................................ 121 QUFLORA PEDIATRIC -pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml.................................................. 121 QUILLIVANT XR -methylphenidate hcl for er susp 25 mg/5ml (5 mg/ml).............................................................88 quinapril hcl tab 10 mg (Accupril)................................. 50 quinapril hcl tab 20 mg (Accupril)................................. 50 quinapril hcl tab 40 mg (Accupril)................................. 50 quinapril hcl tab 5 mg (Accupril)................................... 50 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic).......................................................................50 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic).......................................................................50 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic).......................................................................50 234 quinidine gluconate tab cr 324 mg................................ 45 QUINIDINE SULFATE ER -quinidine sulfate tab cr 300 mg.................................................................................... 45 QUINIDINE SULFATE -quinidine sulfate tab 200 mg........ 45 quinidine sulfate tab 300 mg.......................................... 45 quinine sulfate cap 324 mg (Qualaquin)........................11 QUINZYME -coenzyme q10 tab disp 90 mg................... 163 QUTENZA -capsaicin patch 8% & cleansing gel kit.........156 QVAR -beclomethasone dipropionate inhal aero soln 40 mcg/act.............................................................................64 QVAR -beclomethasone dipropionate inhal aero soln 80 mcg/act.............................................................................64 R RABAVERT -rabies vaccine, pcec for inj...........................15 rabeprazole sodium ec tab 20 mg (Aciphex).................68 RADIOGARDASE -prussian blue insoluble cap 0.5 gm.................................................................................. 163 RA GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 31 RAGWITEK -short ragweed pollen allergen extract tab sl 12 amb a 1-u................................................................... 16 raloxifene hcl tab 60 mg (Evista)................................... 38 ramipril cap 1.25 mg (Altace)......................................... 50 ramipril cap 10 mg (Altace)............................................ 50 ramipril cap 2.5 mg (Altace)........................................... 50 ramipril cap 5 mg (Altace).............................................. 50 RANEXA -ranolazine tab sr 12hr 1000 mg........................40 RANEXA -ranolazine tab sr 12hr 500 mg..........................40 ranitidine hcl cap 150 mg............................................... 68 ranitidine hcl cap 300 mg............................................... 68 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)....................68 ranitidine hcl tab 300 mg (Zantac)................................. 68 RAPAFLO -silodosin cap 4 mg......................................... 74 RAPAFLO -silodosin cap 8 mg......................................... 74 RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 164 RAPAMUNE -sirolimus tab 0.5 mg..................................164 RAPAMUNE -sirolimus tab 1 mg.....................................164 RAPAMUNE -sirolimus tab 2 mg.....................................164 RASUVO -methotrexate soln pf auto-injector 10 mg/0.2ml.........................................................................103 RASUVO -methotrexate soln pf auto-injector 12.5 mg/0.25ml.......................................................................103 RASUVO -methotrexate soln pf auto-injector 15 mg/0.3ml.........................................................................104 RASUVO -methotrexate soln pf auto-injector 17.5 mg/0.35ml.......................................................................104 RASUVO -methotrexate soln pf auto-injector 20 mg/0.4ml.........................................................................104 RASUVO -methotrexate soln pf auto-injector 22.5 mg/0.45ml.......................................................................104 RASUVO -methotrexate soln pf auto-injector 25 mg/0.5ml.........................................................................104 RASUVO -methotrexate soln pf auto-injector 27.5 mg/0.55ml.......................................................................104 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 RASUVO -methotrexate soln pf auto-injector 30 mg/0.6ml.........................................................................104 RASUVO -methotrexate soln pf auto-injector 7.5 mg/0.15ml.......................................................................103 RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml........... 38 RAYOS -prednisone tab delayed release 1 mg.................21 RAYOS -prednisone tab delayed release 2 mg.................21 RAYOS -prednisone tab delayed release 5 mg.................21 RAZADYNE ER -galantamine hydrobromide cap sr 24hr 16 mg............................................................................... 92 RAZADYNE ER -galantamine hydrobromide cap sr 24hr 24 mg............................................................................... 92 RAZADYNE ER -galantamine hydrobromide cap sr 24hr 8 mg.................................................................................... 92 RAZADYNE -galantamine hydrobromide oral soln 4 mg/ ml......................................................................................92 RAZADYNE -galantamine hydrobromide tab 12 mg..........92 RAZADYNE -galantamine hydrobromide tab 4 mg............92 RAZADYNE -galantamine hydrobromide tab 8 mg............92 REACH KIDS -sodium fluoride paste 0.15%................... 143 REBETOL -ribavirin cap 200 mg......................................... 9 REBETOL -ribavirin soln 40 mg/ml..................................... 9 REBIF -interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml).............................................................................92 REBIF -interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml).............................................................................92 REBIF REBIDOSE -interferon beta-1a inj 22 mcg/0.5ml (12mu/ml) (44 mcg/ml).....................................................92 REBIF REBIDOSE -interferon beta-1a inj 44 mcg/0.5ml (24mu/ml) (88 mcg/ml).....................................................92 REBIF REBIDOSE TITRATION -interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml.................................. 92 REBIF TITRATION PACK -interferon beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml........................................ 92 RECIPHEXAMINE -lidocaine-menthol patch 4-1%..........156 RECOMBINATE -antihemophilic factor (recombinant) for inj 1241-1800 unit.......................................................... 136 RECOMBINATE -antihemophilic factor (recombinant) for inj 1801-2400 unit.......................................................... 136 RECOMBINATE -antihemophilic factor (recombinant) for inj 220-400 unit.............................................................. 136 RECOMBINATE -antihemophilic factor (recombinant) for inj 401-800 unit.............................................................. 136 RECOMBINATE -antihemophilic factor (recombinant) for inj 801-1240 unit............................................................ 136 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 10 mcg/ml........................................................................ 15 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 40 mcg/ml........................................................................ 15 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml..................................................................... 15 RECTIV -nitroglycerin oint 0.4%......................................144 REGENECARE -lidocaine hcl-collagen-aloe vera gel 2%.................................................................................. 156 REGLAN -metoclopramide hcl tab 10 mg......................... 71 REGLAN -metoclopramide hcl tab 5 mg........................... 71 REGRANEX -becaplermin gel 0.01%..............................156 RELAGARD -acetic acid-oxyquinoline vaginal gel 0.9-0.025%....................................................................... 74 RELEEVIA -capsaicin-menthol topical patch 0.0375-5%...................................................................... 156 RELEEVIA MC -capsaicin-menthol topical patch 0.0375-5%...................................................................... 156 RELEEVIA ML -lidocaine-menthol patch 4-1%................156 RELENZA DISKHALER -zanamivir aero powder breath activated 5 mg/blister.........................................................9 RELHIST -bromphen tan-phenyleph tan chew tab 6-15 mg.................................................................................... 61 RELION GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 31 RELION R -insulin regular (human) inj 100 unit/ml............32 RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml).............................................................................. 71 RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml).............................................................................. 71 RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg...................................................................121 RELPAX -eletriptan hydrobromide tab 20 mg (base equivalent)......................................................................105 RELPAX -eletriptan hydrobromide tab 40 mg (base equivalent)......................................................................105 RELYYT -capsaicin-menthol topical patch 0.025-5%...... 156 REMATEX -capsaicin-menthol-methyl salicylate cream 0.035-6-30%...................................................................156 REMAXAZON EXTERNAL PATCH -lidocaine-capsaicinchondroitin-glucos patch 4-0.0285-3-5%....................... 157 REMBRANDT CANKER SORE -sodium fluoride paste 0.243%........................................................................... 143 REMBRANDT DEEPLY WHITE+PE -sodium monofluorophosphate paste 0.884%............................. 143 REMBRANDT INTENSE STAIN -sodium fluoride paste 0.243%........................................................................... 143 REMBRANDT WHITENING -sodium fluoride rinse 0.02%............................................................................. 143 REMERON -mirtazapine tab 15 mg.................................. 80 REMERON -mirtazapine tab 30 mg.................................. 80 REMERON -mirtazapine tab 45 mg.................................. 80 REMERON SOLTAB -mirtazapine orally disintegrating tab 15 mg............................................................................... 80 REMERON SOLTAB -mirtazapine orally disintegrating tab 30 mg............................................................................... 80 REMERON SOLTAB -mirtazapine orally disintegrating tab 45 mg............................................................................... 80 RENAGEL -sevelamer hcl tab 400 mg..............................71 RENAGEL -sevelamer hcl tab 800 mg..............................71 RENATABS -b-complex w/ c-biotin-vit e & folic acid tab 1 mg.................................................................................. 121 RENATABS WITH IRON -b complex-c-biotin-e-fa tab 1mg & fe cbn tab 100 mg pack............................................. 121 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 235 2015 RENOVO -capsaicin-menthol topical patch 0.0375-5%...................................................................... 157 RENOVO LIDO 5 -lidocaine-capsaicin cream 5-0.05%.......................................................................... 157 RENUU NL -allantoin-petrolatum patch 2-30%................157 RENUU PATCH -allantoin-lidocaine-petrolatum patch 2-5-30%..........................................................................157 RENVELA -sevelamer carbonate packet 0.8 gm...............71 RENVELA -sevelamer carbonate packet 2.4 gm...............71 RENVELA -sevelamer carbonate tab 800 mg................... 71 repaglinide tab 0.5 mg (Prandin)....................................31 repaglinide tab 1 mg (Prandin).......................................31 repaglinide tab 2 mg (Prandin).......................................31 REPREXAIN -hydrocodone-ibuprofen tab 2.5-200 mg.................................................................................. 100 REPREXAIN -hydrocodone-ibuprofen tab 5-200 mg....... 100 REQUIP -ropinirole hydrochloride tab 0.25 mg............... 112 REQUIP -ropinirole hydrochloride tab 0.5 mg................. 112 REQUIP -ropinirole hydrochloride tab 1 mg.................... 112 REQUIP -ropinirole hydrochloride tab 2 mg.................... 112 REQUIP -ropinirole hydrochloride tab 3 mg.................... 112 REQUIP -ropinirole hydrochloride tab 4 mg.................... 112 REQUIP -ropinirole hydrochloride tab 5 mg.................... 112 REQUIP XL -ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent)........................................................... 113 REQUIP XL -ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent)........................................................... 112 REQUIP XL -ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent)........................................................... 112 REQUIP XL -ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent)........................................................... 112 REQUIP XL -ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent)........................................................... 112 RESCON-MX -dexchlorpheniramine-phenylephrine tab sr 12hr 6-40 mg................................................................... 61 RESCRIPTOR -delavirdine mesylate tab 100 mg............... 9 RESCRIPTOR -delavirdine mesylate tab 200 mg............... 9 RESCULA -unoprostone isopropyl ophth soln 0.15%......140 RESERPINE -reserpine tab 0.1 mg.................................. 50 RESERPINE -reserpine tab 0.25 mg.................................50 RESPA-BR -brompheniramine maleate tab sr 12hr 11 mg.................................................................................... 58 RESPIRATORY THERAPY SUPPLIES – VARIOUS.......163 RESTASIS -cyclosporine (ophth) emulsion 0.05%.......... 140 RESTORA RX -lactobacillus casei-folic acid cap 60-1.25 mg.................................................................................... 66 RESTORE SILVER DRESSING 2 -wound dressings pads................................................................................157 RESTORE SILVER DRESSING 4 -wound dressings pads................................................................................157 RESTORE SILVER DRESSING 6 -wound dressings pads................................................................................157 RESTORIL -temazepam cap 15 mg..................................85 RESTORIL -temazepam cap 22.5 mg...............................85 RESTORIL -temazepam cap 30 mg..................................85 236 RESTORIL -temazepam cap 7.5 mg.................................85 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.04%............................................................................. 157 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.08%............................................................................. 157 RETIN-A MICRO PUMP -tretinoin microsphere gel 0.1%............................................................................... 157 RETIN-A MICRO -tretinoin microsphere gel 0.04%.........157 RETIN-A MICRO -tretinoin microsphere gel 0.1%...........157 RETIN-A -tretinoin cream 0.025%................................... 157 RETIN-A -tretinoin cream 0.05%..................................... 157 RETIN-A -tretinoin cream 0.1%....................................... 157 RETIN-A -tretinoin gel 0.01%.......................................... 157 RETIN-A -tretinoin gel 0.025%........................................ 157 RETROVIR -zidovudine cap 100 mg...................................9 RETROVIR -zidovudine syrup 10 mg/ml............................. 9 REVATIO -sildenafil citrate for suspension 10 mg/ml........ 58 REVATIO -sildenafil citrate tab 20 mg...............................58 REVESTA -folic acid-cholecalciferol cap 1 mg-5750 unit..................................................................................131 REVIA -naltrexone hcl tab 50 mg....................................163 REVLIMID -lenalidomide cap 10 mg............................... 164 REVLIMID -lenalidomide cap 15 mg............................... 164 REVLIMID -lenalidomide cap 20 mg............................... 164 REVLIMID -lenalidomide cap 25 mg............................... 164 REVLIMID -lenalidomide cap 5 mg................................. 164 REVLIMID -lenalidomide caps 2.5 mg.............................164 REXAPHENAC -diclofenac sodium cream 1%................ 157 REXULTI -brexpiprazole tab 0.25 mg................................83 REXULTI -brexpiprazole tab 0.5 mg................................. 83 REXULTI -brexpiprazole tab 1 mg.................................... 83 REXULTI -brexpiprazole tab 2 mg.................................... 83 REXULTI -brexpiprazole tab 3 mg.................................... 83 REXULTI -brexpiprazole tab 4 mg.................................... 83 REYATAZ -atazanavir sulfate cap 150 mg (base equiv)......9 REYATAZ -atazanavir sulfate cap 200 mg (base equiv)......9 REYATAZ -atazanavir sulfate cap 300 mg (base equiv)......9 REYATAZ -atazanavir sulfate oral powder packet 50 mg (base equiv)....................................................................... 9 REZIRA -pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml..............................................................................61 RHEUMATREX -methotrexate sodium tab 2.5 mg (antirheumatic)............................................................... 104 RHINOCORT AQUA -budesonide nasal susp 32 mcg/ act.....................................................................................59 RIAX -benzoyl peroxide foam 5.5%................................ 157 RIAX -benzoyl peroxide foam 9.5%................................ 157 RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin tab 400 mg dose pack.......................................................9 RIBASPHERE RIBAPAK -ribavirin tab 400 mg................... 9 RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack.....................................................10 RIBASPHERE RIBAPAK -ribavirin tab 600 mg................... 9 RIBASPHERE -ribavirin tab 400 mg................................... 9 RIBASPHERE -ribavirin tab 600 mg................................... 9 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 RIBATAB -ribavirin tab 400 mg......................................... 10 RIBATAB -ribavirin tab 400 mg & ribavirin tab 600 mg dose pack.........................................................................10 RIBATAB -ribavirin tab 600 mg......................................... 10 ribavirin cap 200 mg (Rebetol)....................................... 10 ribavirin tab 200 mg (Copegus)......................................10 RIDAURA -auranofin cap 3 mg....................................... 104 rifabutin cap 150 mg (Mycobutin).................................... 6 RIFADIN -rifampin cap 150 mg........................................... 6 RIFADIN -rifampin cap 300 mg........................................... 6 RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 6 rifampin cap 150 mg (Rifadin).......................................... 6 rifampin cap 300 mg (Rifadin).......................................... 6 RIFATER -isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg...................................................................6 RILUTEK -riluzole tab 50 mg.......................................... 113 riluzole tab 50 mg (Rilutek).......................................... 113 rimantadine hydrochloride tab 100 mg (Flumadine).....10 RIOMET -metformin hcl oral soln 500 mg/5ml.................. 31 risedronate sodium tab 150 mg (Actonel)..................... 38 risedronate sodium tab 30 mg (Actonel).......................38 risedronate sodium tab 35 mg (Actonel).......................38 risedronate sodium tab 5 mg (Actonel).........................38 risedronate sodium tab delayed release 35 mg (Atelvia)........................................................................... 38 RISPERDAL M-TAB -risperidone orally disintegrating tab 0.5 mg.............................................................................. 83 RISPERDAL M-TAB -risperidone orally disintegrating tab 1 mg.................................................................................... 83 RISPERDAL M-TAB -risperidone orally disintegrating tab 2 mg.................................................................................... 83 RISPERDAL M-TAB -risperidone orally disintegrating tab 3 mg.................................................................................... 83 RISPERDAL M-TAB -risperidone orally disintegrating tab 4 mg.................................................................................... 83 RISPERDAL -risperidone soln 1 mg/ml.............................83 RISPERDAL -risperidone tab 0.25 mg.............................. 83 RISPERDAL -risperidone tab 0.5 mg................................ 83 RISPERDAL -risperidone tab 1 mg................................... 83 RISPERDAL -risperidone tab 2 mg................................... 83 RISPERDAL -risperidone tab 3 mg................................... 83 RISPERDAL -risperidone tab 4 mg................................... 83 risperidone orally disintegrating tab 0.25 mg............... 83 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).............................................................................. 83 risperidone orally disintegrating tab 1 mg (Risperdal m-tab).............................................................................. 83 risperidone orally disintegrating tab 2 mg (Risperdal m-tab).............................................................................. 83 risperidone orally disintegrating tab 3 mg (Risperdal m-tab).............................................................................. 83 risperidone orally disintegrating tab 4 mg (Risperdal m-tab).............................................................................. 83 risperidone soln 1 mg/ml (Risperdal)............................ 83 risperidone tab 0.25 mg (Risperdal).............................. 83 risperidone tab 0.5 mg (Risperdal)................................ 83 risperidone tab 1 mg (Risperdal)................................... 83 risperidone tab 2 mg (Risperdal)................................... 83 risperidone tab 3 mg (Risperdal)................................... 83 risperidone tab 4 mg (Risperdal)................................... 83 RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg (la).................................................................................... 89 RITALIN LA -methylphenidate hcl cap sr 24hr 20 mg (la).................................................................................... 89 RITALIN LA -methylphenidate hcl cap sr 24hr 30 mg (la).................................................................................... 89 RITALIN LA -methylphenidate hcl cap sr 24hr 40 mg (la).................................................................................... 89 RITALIN LA -methylphenidate hcl cap sr 24hr 60 mg (la).................................................................................... 89 RITALIN -methylphenidate hcl tab 10 mg..........................88 RITALIN -methylphenidate hcl tab 20 mg..........................88 RITALIN -methylphenidate hcl tab 5 mg........................... 88 rivastigmine tartrate cap 1.5 mg (Exelon)..................... 92 rivastigmine tartrate cap 3 mg (Exelon)........................ 92 rivastigmine tartrate cap 4.5 mg (Exelon)..................... 92 rivastigmine tartrate cap 6 mg (Exelon)........................ 92 RIXUBIS -coagulation factor ix (recombinant) for inj 1000 unit..................................................................................136 RIXUBIS -coagulation factor ix (recombinant) for inj 2000 unit..................................................................................136 RIXUBIS -coagulation factor ix (recombinant) for inj 250 unit..................................................................................136 RIXUBIS -coagulation factor ix (recombinant) for inj 3000 unit..................................................................................136 RIXUBIS -coagulation factor ix (recombinant) for inj 500 unit..................................................................................136 rizatriptan benzoate orally disintegrating tab 10 mg (Maxalt-mlt)................................................................... 105 rizatriptan benzoate orally disintegrating tab 5 mg (Maxalt-mlt)................................................................... 105 rizatriptan benzoate tab 10 mg (Maxalt)...................... 105 rizatriptan benzoate tab 5 mg (Maxalt)........................ 105 R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg...................................................................121 ROBAXIN-750 -methocarbamol tab 750 mg................... 114 ROBAXIN -methocarbamol tab 500 mg.......................... 114 ROBINUL FORTE -glycopyrrolate tab 2 mg......................68 ROBINUL -glycopyrrolate tab 1 mg...................................68 ROCALTROL -calcitriol cap 0.25 mcg...............................38 ROCALTROL -calcitriol cap 0.5 mcg.................................38 ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 38 ropinirole hydrochloride tab 0.25 mg (Requip)........... 113 ropinirole hydrochloride tab 0.5 mg (Requip)............. 113 ropinirole hydrochloride tab 1 mg (Requip)................113 ropinirole hydrochloride tab 2 mg (Requip)................113 ropinirole hydrochloride tab 3 mg (Requip)................113 ropinirole hydrochloride tab 4 mg (Requip)................113 ropinirole hydrochloride tab 5 mg (Requip)................113 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 237 2015 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl)................................................ 113 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl)................................................ 113 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl)................................................ 113 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl)................................................ 113 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl)................................................ 113 ROSADAN KIT -metronidazole cream 0.75% w/ cleanser kit....................................................................................157 ROSADAN KIT -metronidazole gel 0.75% w/ cleanser kit....................................................................................157 ROSANIL -sulfacetamide sod-sulfur emul 10-5% & skin cleanser kit.....................................................................157 ROSULA -sulfacetamide sodium w/ sulfur wash 10-4.5%.......................................................................... 157 ROWASA -mesalamine rectal enema 4 gm & cleanser wipe kit............................................................................. 71 ROXICET -oxycodone w/ acetaminophen soln 5-325 mg/5ml............................................................................100 ROXICODONE -oxycodone hcl tab 15 mg......................100 ROXICODONE -oxycodone hcl tab 30 mg......................100 ROXICODONE -oxycodone hcl tab 5 mg........................100 ROZEREM -ramelteon tab 8 mg....................................... 85 RTD WOUND CARE DRESSING -wound dressings pads................................................................................157 RYDEX -pseudoephedrine-bromphen-codeine liq 10-1.33-6.33 mg/5ml........................................................ 61 RYTARY -carbidopa & levodopa cap cr 23.75-95 mg......113 RYTARY -carbidopa & levodopa cap cr 36.25-145 mg.................................................................................. 113 RYTARY -carbidopa & levodopa cap cr 48.75-195 mg.................................................................................. 113 RYTARY -carbidopa & levodopa cap cr 61.25-245 mg.................................................................................. 113 RYTHMOL -propafenone hcl tab 150 mg.......................... 45 RYTHMOL -propafenone hcl tab 225 mg.......................... 45 RYTHMOL SR -propafenone hcl cap sr 12hr 225 mg....... 45 RYTHMOL SR -propafenone hcl cap sr 12hr 325 mg....... 45 RYTHMOL SR -propafenone hcl cap sr 12hr 425 mg....... 45 S SABRIL -vigabatrin powd pack 500 mg...........................110 SABRIL -vigabatrin tab 500 mg.......................................110 SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg...............................................................26 SAIZEN CLICK.EASY -somatropin (non-refrigerated) for inj 8.8 mg......................................................................... 38 SAIZEN -somatropin (non-refrigerated) for inj 5 mg.......... 38 SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg....... 38 SALAGEN -pilocarpine hcl tab 5 mg............................... 143 SALAGEN -pilocarpine hcl tab 7.5 mg............................ 143 SALEX CREAM -salicylic acid cream 6% & cleanser liqd kit....................................................................................157 238 SALEX LOTION -salicylic acid lotion 6% & cleanser liqd kit....................................................................................157 SALEX -salicylic acid shampoo 6%.................................157 SALICEPT -oral wound care products - for susp rinse................................................................................143 salicylic acid cream 6%................................................ 157 salicylic acid cream 6% & cleanser liqd kit (Salex cream)............................................................................157 salicylic acid film forming liquid 27.5% (Virasal)........ 157 salicylic acid film-forming soln 28.5% (Ultrasaler)...................................................................................157 salicylic acid foam 6% (Salvax)....................................157 salicylic acid gel 6% (Keralyt)...................................... 157 SALICYLIC ACID IN AMMONIU -salicylic acid in ammonium lactate vehicle foam 6%.............................. 157 salicylic acid lotion 6%................................................. 157 salicylic acid lotion 6% & cleanser liqd kit (Salex lotion)............................................................................ 157 SALICYLIC ACID -salicylic acid soln 26%.......................157 salicylic acid shampoo 6% (Salex).............................. 157 SALKERA -salicylic acid in ammonium lactate vehicle foam 6%.........................................................................157 salsalate tab 500 mg....................................................... 93 salsalate tab 750 mg....................................................... 93 SALVAX DUO PLUS -salicylic acid foam 6% & urea in lactic acid foam 35% kit.................................................157 SALVAX -salicylic acid foam 6%..................................... 157 SAMSCA -tolvaptan tab 15 mg......................................... 38 SAMSCA -tolvaptan tab 30 mg......................................... 38 SANARE SCAR THERAPY -cream base........................ 163 SANCUSO -granisetron td patch 3.1 mg/24hr (contains 34.3 mg)...........................................................................69 SANDIMMUNE -cyclosporine cap 100 mg...................... 164 SANDIMMUNE -cyclosporine cap 25 mg........................ 164 SANDIMMUNE -cyclosporine oral soln 100 mg/ml..........164 SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1 mg/ ml).................................................................................... 38 SANDOSTATIN -octreotide acetate inj 100 mcg/ml (0.1 mg/ml).............................................................................. 38 SANDOSTATIN -octreotide acetate inj 200 mcg/ml (0.2 mg/ml).............................................................................. 38 SANDOSTATIN -octreotide acetate inj 500 mcg/ml (0.5 mg/ml).............................................................................. 38 SANDOSTATIN -octreotide acetate inj 50 mcg/ml (0.05 mg/ml).............................................................................. 38 SANTYL -collagenase oint 250 unit/gm...........................157 SAPHRIS -asenapine maleate sl tab 10 mg (base equiv)................................................................................83 SAPHRIS -asenapine maleate sl tab 2.5 mg (base equiv)................................................................................83 SAPHRIS -asenapine maleate sl tab 5 mg (base equiv)................................................................................83 SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.....................92 SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.....................92 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 SAVAYSA -edoxaban tosylate tab 15 mg (base equivalent)......................................................................133 SAVAYSA -edoxaban tosylate tab 30 mg (base equivalent)......................................................................133 SAVAYSA -edoxaban tosylate tab 60 mg (base equivalent)......................................................................133 SAVELLA -milnacipran hcl tab 100 mg............................. 92 SAVELLA -milnacipran hcl tab 12.5 mg............................ 92 SAVELLA -milnacipran hcl tab 25 mg............................... 92 SAVELLA -milnacipran hcl tab 50 mg............................... 92 SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak................................... 92 SCALACORT DK -hc lot 2% & sal acid-sulfur shampoo 2-2% & shampoo kit...................................................... 158 SCAR PATCH -allantoin-lidocaine-petrolatum patch 2-4-30%..........................................................................158 SCAR PATCH -allantoin-lidocaine-petrolatum patch 2-5-30%..........................................................................158 scar treatment products - gel.......................................158 SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)...................................................... 26 SECONAL -secobarbital sodium cap 100 mg....................85 SECTRAL -acebutolol hcl cap 200 mg..............................41 SECTRAL -acebutolol hcl cap 400 mg..............................41 SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak.................................................. 121 SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab 29-1 mg..........................................................................121 SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew tab 29-0.6-0.4 mg.................................................................121 selegiline hcl cap 5 mg (Eldepryl)................................113 selegiline hcl tab 5 mg..................................................113 selenium sulfide lotion 2.5%........................................ 158 SELRX -selenium sulfide-pyrithione zinc in urea shampoo 2.3%............................................................................... 158 SELZENTRY -maraviroc tab 150 mg................................ 10 SELZENTRY -maraviroc tab 300 mg................................ 10 SEMPREX-D -acrivastine & pseudoephedrine cap 8-60 mg.................................................................................... 61 SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................. 121 SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab 29-1 mg..........................................................................121 SENNA LEAVES -senna leaves........................................66 SENSIPAR -cinacalcet hcl tab 30 mg (base equiv)........... 38 SENSIPAR -cinacalcet hcl tab 60 mg (base equiv)........... 38 SENSIPAR -cinacalcet hcl tab 90 mg (base equiv)........... 38 SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv).................................................... 64 SEROMYCIN -cycloserine cap 250 mg...............................6 SEROQUEL -quetiapine fumarate tab 100 mg..................83 SEROQUEL -quetiapine fumarate tab 200 mg..................83 SEROQUEL -quetiapine fumarate tab 25 mg....................83 SEROQUEL -quetiapine fumarate tab 300 mg..................83 SEROQUEL -quetiapine fumarate tab 400 mg..................84 SEROQUEL -quetiapine fumarate tab 50 mg....................83 SEROQUEL XR -quetiapine fumarate tab sr 24hr 150 mg.................................................................................... 84 SEROQUEL XR -quetiapine fumarate tab sr 24hr 200 mg.................................................................................... 84 SEROQUEL XR -quetiapine fumarate tab sr 24hr 300 mg.................................................................................... 84 SEROQUEL XR -quetiapine fumarate tab sr 24hr 400 mg.................................................................................... 84 SEROQUEL XR -quetiapine fumarate tab sr 24hr 50 mg.................................................................................... 84 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 4 mg.....................................................38 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 5 mg.....................................................38 SEROSTIM -somatropin (non-refrigerated) for subcutaneous inj 6 mg.....................................................38 sertraline hcl oral conc 20 mg/ml (Zoloft)..................... 80 sertraline hcl tab 100 mg (Zoloft)...................................80 sertraline hcl tab 25 mg (Zoloft).....................................80 sertraline hcl tab 50 mg (Zoloft).....................................80 SE-TAN DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 15-15-1 mg.....................................................................121 SETON ET-EC -prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk.................................................... 121 SETONET -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk..................................................................... 121 SEVELAMER CARBONATE -sevelamer carbonate tab 800 mg............................................................................. 71 SFROWASA -mesalamine sulfite-free (sf) enema 4 gm/60ml............................................................................71 SHOHLS SOLUTION MODIFIED -sodium citrate & citric acid soln 500-334 mg/5ml............................................... 74 SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base equiv)................................................................................38 SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base equiv)................................................................................38 SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base equiv)................................................................................38 sildenafil citrate tab 20 mg (Revatio).............................58 SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)....... 85 SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)....... 85 SILMANIX PAIN RELIEIVING -capsaicin-mentholhistamine cream 0.0375-3-0.035%................................ 158 SILVADENE -silver sulfadiazine cream 1%.....................158 SILVERA PAIN RELIEF -capsaicin-lidocaine-menthol patch 0.0375-1-5%.........................................................158 silver nitrate-potassium nitrate applicator 75-25% (Arzol silver nitrate)..................................................... 158 SILVER NITRATE -silver nitrate oint 10%.......................158 SILVER NITRATE -silver nitrate soln 0.5%..................... 158 SILVER NITRATE -silver nitrate soln 10%...................... 158 SILVER NITRATE -silver nitrate soln 25%...................... 158 SILVER NITRATE -silver nitrate soln 50%...................... 158 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 239 2015 SILVERSEAL HYDROGEL DRESS -silver - pad 2"x3"............................................................................... 158 SILVERSEAL HYDROGEL DRESS -silver - pad 4"x5"............................................................................... 158 silver sulfadiazine cream 1% (Silvadene)....................158 SILVRSTAT WOUND DRESSING -silver - gel................158 SIMBRINZA -brinzolamide-brimonidine tartrate ophth susp 1-0.2%............................................................................ 140 SIMCOR -niacin-simvastatin tab sr 24hr 1000-20 mg....... 56 SIMCOR -niacin-simvastatin tab sr 24hr 1000-40 mg....... 56 SIMCOR -niacin-simvastatin tab sr 24hr 500-20 mg......... 56 SIMCOR -niacin-simvastatin tab sr 24hr 500-40 mg......... 56 SIMCOR -niacin-simvastatin tab sr 24hr 750-20 mg......... 56 SIMPONI -golimumab subcutaneous soln auto-injector 100 mg/ml..............................................................................104 SIMPONI -golimumab subcutaneous soln auto-injector 50 mg/0.5ml.........................................................................104 SIMPONI -golimumab subcutaneous soln prefilled syringe 100 mg/ml...................................................................... 104 SIMPONI -golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml................................................................... 104 simvastatin tab 10 mg (Zocor)....................................... 56 simvastatin tab 20 mg (Zocor)....................................... 56 simvastatin tab 40 mg (Zocor)....................................... 56 simvastatin tab 5 mg (Zocor)......................................... 56 simvastatin tab 80 mg (Zocor)....................................... 56 SINELEE -capsaicin-menthol topical patch 0.0375-5%...................................................................... 158 SINELEE -capsaicin-menthol topical patch 0.05-5%....... 158 SINEMET -carbidopa & levodopa tab 10-100 mg............113 SINEMET -carbidopa & levodopa tab 25-100 mg............113 SINEMET -carbidopa & levodopa tab 25-250 mg............113 SINEMET CR -carbidopa & levodopa tab cr 25-100 mg.................................................................................. 113 SINEMET CR -carbidopa & levodopa tab cr 50-200 mg.................................................................................. 113 SINGULAIR -montelukast sodium chew tab 4 mg (base equiv)................................................................................64 SINGULAIR -montelukast sodium chew tab 5 mg (base equiv)................................................................................64 SINGULAIR -montelukast sodium oral granules packet 4 mg (base equiv)............................................................... 64 SINGULAIR -montelukast sodium tab 10 mg (base equiv)................................................................................64 sirolimus tab 0.5 mg (Rapamune)................................ 164 sirolimus tab 1 mg (Rapamune)...................................165 sirolimus tab 2 mg (Rapamune)...................................165 SIRTURO -bedaquiline fumarate tab 100 mg (base equiv)..................................................................................6 SITAVIG -acyclovir buccal tab 50 mg................................10 SIVEXTRO -tedizolid phosphate tab 200 mg.................... 12 SKELAXIN -metaxalone tab 800 mg............................... 114 SKLICE -ivermectin lotion 0.5%...................................... 158 SMART SENSE GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.......................................................................31 240 SM GLUCOSE -glucose chew tab 4 gm........................... 31 SM GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 31 sodium chloride soln nebu 0.9%................................... 61 sodium chloride soln nebu 10%.................................... 61 sodium chloride soln nebu 3%...................................... 61 sodium chloride soln nebu 7% (Hyper-sal)................... 61 sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution modi).................................................. 75 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride).......................................................................... 126 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride).......................................................................... 126 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride).......................................................................... 126 sodium fluoride cream 1.1% (Prevident 5000 plus)...............................................................................143 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)......................................................................... 143 sodium fluoride paste 1.1% (Prevident 5000 boost)............................................................................ 143 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi)................................................. 143 sodium fluoride rinse 0.0221% (0.01% f)..................... 143 sodium fluoride rinse 0.05%.........................................143 sodium fluoride rinse 0.2% (Prevident)....................... 143 SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from 1.1 mg naf).................................................................... 126 SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from 2.2 mg naf)...........................................................................126 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf).................................................................................126 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride).......................................................................... 126 sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl).......................................................................38 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps).............................................................................. 165 sodium polystyrene sulfonate powder (Kayexalate).................................................................. 165 sodium polystyrene sulfonate rectal susp 30 gm/120ml.......................................................................165 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium-sulfur in urea emulsion 10-5%.......................... 158 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium-sulfur in urea gel 10-5%....................................158 SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium w/ sulfur susp 10-5%..................................................... 158 SODIUM SULFACETAMIDE WASH -sulfacetamide sodium in bakuchiol vehicle wash 10%......................... 158 SOLAICE -capsaicin-menthol topical patch 0.05-5%.......158 SOLARAZE -diclofenac sodium (actinic keratoses) gel 3%.................................................................................. 158 SOLODYN -minocycline hcl tab sr 24hr 105 mg................. 4 SOLODYN -minocycline hcl tab sr 24hr 115 mg................. 5 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 SOLODYN -minocycline hcl tab sr 24hr 55 mg................... 4 SOLODYN -minocycline hcl tab sr 24hr 65 mg................... 4 SOLODYN -minocycline hcl tab sr 24hr 80 mg................... 4 SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base equivalent)........................................................................18 SOMA -carisoprodol tab 250 mg..................................... 114 SOMA -carisoprodol tab 350 mg..................................... 114 SOMAVERT -pegvisomant for inj 10 mg (as protein)........ 38 SOMAVERT -pegvisomant for inj 15 mg (as protein)........ 38 SOMAVERT -pegvisomant for inj 20 mg (as protein)........ 38 SOMAVERT -pegvisomant for inj 25 mg (as protein)........ 38 SOMAVERT -pegvisomant for inj 30 mg (as protein)........ 38 SONATA -zaleplon cap 10 mg.......................................... 85 SONATA -zaleplon cap 5 mg............................................ 85 SOOLANTRA -ivermectin cream 1%...............................158 SOOTHEE -lidocaine-capsaicin-men-methyl sal patch 0.5-0.0375-5-20%...........................................................158 SORIATANE -acitretin cap 10 mg................................... 158 SORIATANE -acitretin cap 17.5 mg................................ 158 SORIATANE -acitretin cap 25 mg................................... 158 SORILUX -calcipotriene foam 0.005%............................ 158 sotalol hcl (afib/afl) tab 120 mg (Betapace af)...............41 sotalol hcl (afib/afl) tab 160 mg (Betapace af)...............41 sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 41 sotalol hcl tab 120 mg (Betapace)................................. 41 sotalol hcl tab 160 mg (Betapace)................................. 41 sotalol hcl tab 240 mg.................................................... 41 sotalol hcl tab 80 mg (Betapace)................................... 41 SOTYLIZE -sotalol hcl oral solution 5 mg/ml.....................41 SOVALDI -sofosbuvir tab 400 mg..................................... 10 SPACERS – VARIOUS................................................... 163 SPATONE PUR-ABSORB IRON -ferrous sulfate liquid 5 mg/20ml (elemental iron)............................................... 131 SPECTRACEF -cefditoren pivoxil tab 200 mg (base equivalent)..........................................................................2 SPECTRACEF -cefditoren pivoxil tab 400 mg (base equivalent)..........................................................................2 SPINOSAD -spinosad susp 0.9%....................................158 SPIRIVA HANDIHALER -tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)........................................ 64 SPIRIVA RESPIMAT -tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act.................................................64 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)................................................................... 53 spironolactone tab 100 mg (Aldactone)........................ 53 spironolactone tab 25 mg (Aldactone).......................... 53 spironolactone tab 50 mg (Aldactone).......................... 53 SPORANOX -itraconazole cap 100 mg...............................7 SPORANOX -itraconazole oral soln 10 mg/ml.................... 7 SPORANOX PULSEPAK -itraconazole cap 100 mg........... 7 SPRIX -ketorolac tromethamine nasal spray 15.75 mg/ spray...............................................................................104 SPRYCEL -dasatinib tab 100 mg...................................... 18 SPRYCEL -dasatinib tab 140 mg...................................... 18 SPRYCEL -dasatinib tab 20 mg........................................ 18 SPRYCEL -dasatinib tab 50 mg........................................ 18 SPRYCEL -dasatinib tab 70 mg........................................ 18 SPRYCEL -dasatinib tab 80 mg........................................ 18 SPS -sodium polystyrene sulfonate oral susp 15 gm/60ml..........................................................................165 SSKI -potassium iodide soln 1 gm/ml..............................126 STALEVO 100 -carbidopa-levodopa-entacapone tabs 25-100-200 mg...............................................................113 STALEVO 125 -carbidopa-levodopa-entacapone tabs 31.25-125-200 mg..........................................................113 STALEVO 150 -carbidopa-levodopa-entacapone tabs 37.5-150-200 mg............................................................113 STALEVO 200 -carbidopa-levodopa-entacapone tabs 50-200-200 mg...............................................................113 STALEVO 50 -carbidopa-levodopa-entacapone tabs 12.5-50-200 mg..............................................................113 STALEVO 75 -carbidopa-levodopa-entacapone tabs 18.75-75-200 mg............................................................113 stannous fluoride conc 0.63% (Gel-kam oral care ri)....................................................................................143 stannous fluoride gel 0.4%........................................... 143 STANNOUS FLUORIDE RINSE -stannous fluoride liq 0.1%............................................................................... 143 STARLIX -nateglinide tab 120 mg.....................................31 STARLIX -nateglinide tab 60 mg.......................................31 STATUSS GREEN -codeine-pseudoephedrinechlorcyclizine liq 9-30-12.5 mg/5ml..................................61 stavudine cap 15 mg (Zerit)............................................10 stavudine cap 20 mg (Zerit)............................................10 stavudine cap 30 mg (Zerit)............................................10 stavudine cap 40 mg (Zerit)............................................10 stavudine for oral soln 1 mg/ml (Zerit).......................... 10 STAVZOR -valproic acid cap delayed release 125 mg.................................................................................. 110 STAVZOR -valproic acid cap delayed release 250 mg.................................................................................. 110 STAVZOR -valproic acid cap delayed release 500 mg.................................................................................. 110 STELARA -ustekinumab soln prefilled syringe 45 mg/0.5ml.........................................................................158 STELARA -ustekinumab soln prefilled syringe 90 mg/ ml....................................................................................158 STIMATE -desmopressin acetate nasal soln 1.5 mg/ ml......................................................................................38 STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act........................................................ 64 STIVARGA -regorafenib tab 40 mg...................................18 STRATTERA -atomoxetine hcl cap 100 mg (base equiv)................................................................................89 STRATTERA -atomoxetine hcl cap 10 mg (base equiv)................................................................................89 STRATTERA -atomoxetine hcl cap 18 mg (base equiv)................................................................................89 STRATTERA -atomoxetine hcl cap 25 mg (base equiv)................................................................................89 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 241 2015 STRATTERA -atomoxetine hcl cap 40 mg (base equiv)................................................................................89 STRATTERA -atomoxetine hcl cap 60 mg (base equiv)................................................................................89 STRATTERA -atomoxetine hcl cap 80 mg (base equiv)................................................................................89 STRIANT -testosterone buccal mucoadhesive system 30 mg.................................................................................... 21 STRIBILD -elvitegrav-cobicis-emtricitab-tenofov tab 150-150-200-300 mg....................................................... 10 STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv)................................................. 64 STROMECTOL -ivermectin tab 3 mg................................ 11 STROVITE FORTE -multiple vitamins w/ minerals & fa syrup 1 mg/15ml............................................................ 121 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)............................................................. 100 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)............................................................. 100 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)............................................................. 100 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)............................................................. 100 SUBSYS -fentanyl sublingual spray 100 mcg..................100 SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x 2).................................................................................... 100 SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x 2).................................................................................... 100 SUBSYS -fentanyl sublingual spray 200 mcg..................100 SUBSYS -fentanyl sublingual spray 400 mcg..................100 SUBSYS -fentanyl sublingual spray 600 mcg..................100 SUBSYS -fentanyl sublingual spray 800 mcg..................100 SUCRAID -sacrosidase soln 8500 unit/ml......................... 70 sucralfate tab 1 gm (Carafate)........................................68 SULAR -nisoldipine tab sr 24hr 17 mg.............................. 43 SULAR -nisoldipine tab sr 24hr 34 mg.............................. 43 SULAR -nisoldipine tab sr 24hr 8.5 mg............................. 43 sulfacetamide sodium cleansing gel 10% (Ovace plus wash)............................................................................. 158 sulfacetamide sodium liquid 10% (Ovace wash)........ 159 sulfacetamide sodium lotion 10% (acne) (Klaron)...... 159 sulfacetamide sodium ophth soln 10% (Bleph-10)..... 140 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%...............................................................140 sulfacetamide sodium shampoo 10% (Ovace plus)...............................................................................159 SULFACETAMIDE SODIUM -sulfacetamide sodium ophth oint 10%......................................................................... 140 sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser)................................................................... 159 sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion cleanser)........................................................ 159 sulfacetamide sodium w/ sulfur cleansing cloth 10-5%............................................................................. 159 242 sulfacetamide sodium w/ sulfur cleansing pad 10-4% (Sumaxin)...................................................................... 159 sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls)................................................................................... 159 sulfacetamide sodium w/ sulfur cream 10-5%............ 159 sulfacetamide sodium w/ sulfur cream 9.8-4.8% (Plexion)........................................................................ 159 sulfacetamide sodium w/ sulfur emulsion 10-1%....... 159 sulfacetamide sodium w/ sulfur emulsion 10-5%....... 159 sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam ef)................................................................................... 159 sulfacetamide sodium w/ sulfur lotion 10-5%............. 159 sulfacetamide sodium w/ sulfur lotion 9.8-4.8% (Plexion)........................................................................ 159 sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin ts)................................................................................... 159 sulfacetamide sodium w/ sulfur wash 9-4.5% (Sumadan wash).......................................................... 159 sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin wash)............................................................................. 159 sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit (Sumadan kit)..........................................................158 sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit (Sumadan xlt)............................................................... 158 SULFADIAZINE -sulfadiazine tab 500 mg...........................6 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml.............................................................................12 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)..........................................................................12 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds).................................................................... 12 SULFAMYLON -mafenide acetate cream 85 mg/gm....... 159 SULFAMYLON -mafenide acetate packet for topical soln 5% (50 gm).................................................................... 159 sulfasalazine tab 500 mg (Azulfidine)............................71 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)........................................................................... 71 SULFOAM -sulfur shampoo 2%...................................... 159 SULFURATED LIME -sulfurated lime solution................ 159 sulindac tab 150 mg...................................................... 104 sulindac tab 200 mg...................................................... 104 SUMADAN KIT -sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit............................................................. 159 SUMADAN WASH -sulfacetamide sodium w/ sulfur wash 9-4.5%............................................................................ 159 SUMADAN XLT -sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit..................................................................159 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)...........105 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys)................................. 105 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)................................. 105 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref)................................................... 105 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref)................................................... 105 SUMATRIPTAN SUCCINATE -sumatriptan succinate inj 4 mg/0.5ml.........................................................................105 SUMATRIPTAN SUCCINATE -sumatriptan succinate solution prefilled syringe 6 mg/0.5ml............................. 105 sumatriptan succinate tab 100 mg (Imitrex)................106 sumatriptan succinate tab 25 mg (Imitrex)..................105 sumatriptan succinate tab 50 mg (Imitrex)..................105 SUMATRIPTAN -sumatriptan nasal spray 20 mg/act...... 105 SUMATRIPTAN -sumatriptan nasal spray 5 mg/act........ 105 SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 4 mg/0.5ml........................................................ 106 SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml........................................................ 106 SUMAXIN CP KIT -sulfacetamide sod-sulfur pad 10-4% & skin cleanser kit............................................................. 159 SUMAXIN -sulfacetamide sodium w/ sulfur cleansing pad 10-4%............................................................................. 159 SUMAXIN TS -sulfacetamide sodium w/ sulfur susp 8-4%............................................................................... 159 SUMAXIN WASH -sulfacetamide sodium w/ sulfur wash 9-4%............................................................................... 159 SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml (per drop)....................................................................... 115 SUPERVITE -b-complex w/ lysine-zn & folic acid liquid............................................................................... 121 SUPERVITE EC -multiple vitamins w/ minerals & fa tab dr 1 mg............................................................................... 121 SUPRAX -cefixime cap 400 mg.......................................... 2 SUPRAX -cefixime chew tab 100 mg..................................2 SUPRAX -cefixime chew tab 200 mg..................................2 SUPRAX -cefixime for susp 100 mg/5ml.............................2 SUPRAX -cefixime for susp 200 mg/5ml.............................2 SUPRAX -cefixime for susp 500 mg/5ml.............................2 SUPREP BOWEL PREP -sodium sulfate-potassium sulfate-magnesium sulfate oral soln................................ 66 SURFAXIN -lucinactant intratracheal susp 30 mg/ml........ 65 SURMONTIL -trimipramine maleate cap 100 mg.............. 80 SURMONTIL -trimipramine maleate cap 25 mg................ 80 SURMONTIL -trimipramine maleate cap 50 mg................ 80 SURVANTA INTRATRACHEAL -beractant in nacl 0.9% intratracheal susp 25 mg/ml............................................ 65 SUSTIVA -efavirenz cap 200 mg...................................... 10 SUSTIVA -efavirenz cap 50 mg........................................ 10 SUSTIVA -efavirenz tab 600 mg....................................... 10 SUTENT -sunitinib malate cap 12.5 mg (base equivalent)........................................................................18 SUTENT -sunitinib malate cap 25 mg (base equivalent)........................................................................18 SUTENT -sunitinib malate cap 37.5 mg (base equivalent)........................................................................18 SUTENT -sunitinib malate cap 50 mg (base equivalent)........................................................................18 SUTTAR-2 -pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml..............................................................................61 SUTTAR-SF -pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml............................................................61 SYLATRON -peginterferon alfa-2b for inj kit 200 mcg....... 18 SYLATRON -peginterferon alfa-2b for inj kit 300 mcg....... 18 SYLATRON -peginterferon alfa-2b for inj kit 600 mcg....... 18 SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg (0.125 mg ir/0.25 mg cr).................................................. 68 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act.................................................. 64 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act.................................................... 64 SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg.........93 SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg.........93 SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg...........93 SYMBYAX -olanzapine-fluoxetine hcl cap 6-25 mg...........93 SYMBYAX -olanzapine-fluoxetine hcl cap 6-50 mg...........93 SYMLINPEN 120 -pramlintide acetate pen-inj 2700 mcg/2.7ml (1000 mcg/ml)................................................ 31 SYMLINPEN 60 -pramlintide acetate pen-inj 1500 mcg/1.5ml (1000 mcg/ml)................................................ 31 SYNAGEX -multiple vitamins w/ minerals & fa cap 1.25 mg.................................................................................. 121 SYNALAR CREAM KIT -fluocinolone cream 0.025%emollient cream kit.........................................................159 SYNALAR -fluocinolone acetonide cream 0.025%.......... 159 SYNALAR -fluocinolone acetonide oint 0.025%.............. 159 SYNALAR -fluocinolone acetonide soln 0.01%............... 159 SYNALAR OINTMENT KIT -fluocinolone oint 0.025%emollient cream kit.........................................................159 SYNALAR TS -fluocinolone acetonide soln 0.01% & cleanser kit.....................................................................159 SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg..............................................................100 SYNAREL -nafarelin acetate nasal soln 2 mg/ml.............. 38 SYNATEK -multiple vitamins w/ minerals & fa cap 1.25 mg.................................................................................. 121 SYNERA -lidocaine-tetracaine topical patch 70-70 mg.................................................................................. 159 SYNTHROID -levothyroxine sodium tab 100 mcg............. 34 SYNTHROID -levothyroxine sodium tab 112 mcg............. 34 SYNTHROID -levothyroxine sodium tab 125 mcg............. 34 SYNTHROID -levothyroxine sodium tab 137 mcg............. 34 SYNTHROID -levothyroxine sodium tab 150 mcg............. 34 SYNTHROID -levothyroxine sodium tab 175 mcg............. 34 SYNTHROID -levothyroxine sodium tab 200 mcg............. 34 SYNTHROID -levothyroxine sodium tab 25 mcg...............34 SYNTHROID -levothyroxine sodium tab 300 mcg............. 34 SYNTHROID -levothyroxine sodium tab 50 mcg...............34 SYNTHROID -levothyroxine sodium tab 75 mcg...............34 SYNTHROID -levothyroxine sodium tab 88 mcg...............34 SYNVEXIA -lidocaine-menthol patch 4-1%..................... 159 SYNVEXIA TC -lidocaine-menthol cream 4-1%.............. 159 SYPRINE -trientine hcl cap 250 mg................................ 165 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 243 2015 T TABLOID -thioguanine tab 40 mg..................................... 19 TACLONEX -calcipotriene-betamethasone dipropionate oint 0.005-0.064%..........................................................160 TACLONEX -calcipotriene-betamethasone dipropionate susp 0.005-0.064%........................................................ 159 tacrolimus cap 0.5 mg (Prograf).................................. 165 tacrolimus cap 1 mg (Prograf)..................................... 165 tacrolimus cap 5 mg (Prograf)..................................... 165 tacrolimus oint 0.03% (Protopic)..................................160 tacrolimus oint 0.1% (Protopic)....................................160 TAFINLAR -dabrafenib mesylate cap 50 mg (base equivalent)........................................................................19 TAFINLAR -dabrafenib mesylate cap 75 mg (base equivalent)........................................................................19 TAMIFLU -oseltamivir phosphate cap 30 mg (base equiv)................................................................................10 TAMIFLU -oseltamivir phosphate cap 45 mg (base equiv)................................................................................10 TAMIFLU -oseltamivir phosphate cap 75 mg (base equiv)................................................................................10 TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base equiv)................................................................................10 tamoxifen citrate tab 10 mg (base equivalent)..............19 tamoxifen citrate tab 20 mg (base equivalent)..............19 tamsulosin hcl cap 0.4 mg (Flomax)..............................75 TANDEM F -ferrous fum-iron polysacch-fa cap 162-115.2-1 mg (106 mg fe)..........................................131 TANDEM PLUS -fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap....................................................131 TANZEUM -albiglutide for soln pen-injector 30 mg............31 TANZEUM -albiglutide for soln pen-injector 50 mg............31 TAPAZOLE -methimazole tab 10 mg................................ 34 TAPAZOLE -methimazole tab 5 mg.................................. 34 TARCEVA -erlotinib hcl tab 100 mg (base equivalent)...... 19 TARCEVA -erlotinib hcl tab 150 mg (base equivalent)...... 19 TARCEVA -erlotinib hcl tab 25 mg (base equivalent)........ 19 TARGADOX -doxycycline hyclate tab 50 mg...................... 5 TARGRETIN -bexarotene cap 75 mg................................19 TARGRETIN -bexarotene gel 1%....................................160 TARKA -trandolapril-verapamil hcl tab cr 1-240 mg.......... 50 TARKA -trandolapril-verapamil hcl tab cr 2-180 mg.......... 51 TARKA -trandolapril-verapamil hcl tab cr 2-240 mg.......... 51 TARKA -trandolapril-verapamil hcl tab cr 4-240 mg.......... 51 TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab pak......................................................................121 TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg..................................................................121 TARON-DUO EC -prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk.................................................... 122 TARON FORTE -fe bisglycinate-fe polysacch-vit c-vit b12fa cap............................................................................. 131 TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 30-1.2-265 mg................................................................122 TASIGNA -nilotinib hcl cap 150 mg (base equivalent).......19 244 TASIGNA -nilotinib hcl cap 200 mg (base equivalent).......19 TASMAR -tolcapone tab 100 mg.....................................113 TAZORAC -tazarotene cream 0.05%.............................. 160 TAZORAC -tazarotene cream 0.1%................................ 160 TAZORAC -tazarotene gel 0.05%................................... 160 TAZORAC -tazarotene gel 0.1%..................................... 160 TEARS AGAIN HYDRATE -flaxseed oil-evening primrosebilberry cap 1000-500-40 mg.........................................127 TECFIDERA -dimethyl fumarate capsule delayed release 120 mg............................................................................. 93 TECFIDERA -dimethyl fumarate capsule delayed release 240 mg............................................................................. 93 TECFIDERA STARTER PACK -dimethyl fumarate capsule dr starter pack 120 mg & 240 mg....................................93 TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg..................................................................10 TEGADERM AG MESH DRESSING -wound dressings pads................................................................................160 TEGRETOL -carbamazepine susp 100 mg/5ml.............. 110 TEGRETOL -carbamazepine tab 200 mg........................110 TEGRETOL-XR -carbamazepine tab sr 12hr 100 mg......110 TEGRETOL-XR -carbamazepine tab sr 12hr 200 mg......110 TEGRETOL-XR -carbamazepine tab sr 12hr 400 mg......110 TEKTURNA -aliskiren fumarate tab 150 mg (base equivalent)........................................................................51 TEKTURNA -aliskiren fumarate tab 300 mg (base equivalent)........................................................................51 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-12.5 mg.....................................................................51 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-25 mg.................................................................................... 51 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-12.5 mg.....................................................................51 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-25 mg.................................................................................... 51 telmisartan-amlodipine tab 40-10 mg (Twynsta)...........51 telmisartan-amlodipine tab 40-5 mg (Twynsta).............51 telmisartan-amlodipine tab 80-10 mg (Twynsta)...........51 telmisartan-amlodipine tab 80-5 mg (Twynsta).............51 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)..................................................................51 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)..................................................................51 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)..................................................................51 telmisartan tab 20 mg (Micardis)................................... 51 telmisartan tab 40 mg (Micardis)................................... 51 telmisartan tab 80 mg (Micardis)................................... 51 temazepam cap 15 mg (Restoril)................................... 85 temazepam cap 22.5 mg (Restoril).................................85 temazepam cap 30 mg (Restoril)................................... 85 temazepam cap 7.5 mg (Restoril).................................. 85 TEMODAR -temozolomide cap 100 mg............................ 19 TEMODAR -temozolomide cap 140 mg............................ 19 TEMODAR -temozolomide cap 180 mg............................ 19 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 TEMODAR -temozolomide cap 20 mg.............................. 19 TEMODAR -temozolomide cap 250 mg............................ 19 TEMODAR -temozolomide cap 5 mg................................ 19 TEMOVATE -clobetasol propionate cream 0.05%...........160 TEMOVATE -clobetasol propionate gel 0.05%................160 TEMOVATE -clobetasol propionate oint 0.05%...............160 TEMOVATE -clobetasol propionate soln 0.05%.............. 160 TEMOVATE E -clobetasol propionate emollient base cream 0.05%..................................................................160 temozolomide cap 100 mg (Temodar)........................... 19 temozolomide cap 140 mg (Temodar)........................... 19 temozolomide cap 180 mg (Temodar)........................... 19 temozolomide cap 20 mg (Temodar)............................. 19 temozolomide cap 250 mg (Temodar)........................... 19 temozolomide cap 5 mg (Temodar)............................... 19 TENEX -guanfacine hcl tab 1 mg......................................51 TENEX -guanfacine hcl tab 2 mg......................................51 TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu.......... 15 TENORETIC 100 -atenolol & chlorthalidone tab 100-25 mg.................................................................................... 51 TENORETIC 50 -atenolol & chlorthalidone tab 50-25 mg.................................................................................... 51 TENORMIN -atenolol tab 100 mg..................................... 41 TENORMIN -atenolol tab 25 mg....................................... 41 TENORMIN -atenolol tab 50 mg....................................... 41 TERAZOL 3 -terconazole vaginal cream 0.8%..................74 TERAZOL 7 -terconazole vaginal cream 0.4%..................74 terazosin hcl cap 10 mg..................................................51 terazosin hcl cap 1 mg................................................... 51 terazosin hcl cap 2 mg................................................... 51 terazosin hcl cap 5 mg................................................... 51 terbinafine hcl tab 250 mg (Lamisil)................................ 7 terbutaline sulfate tab 2.5 mg.........................................64 terbutaline sulfate tab 5 mg........................................... 64 terconazole vaginal cream 0.4% (Terazol 7)..................74 terconazole vaginal cream 0.8% (Terazol 3)..................74 terconazole vaginal suppos 80 mg................................ 74 TERSI FOAM -selenium sulfide foam 2.25%...................160 TESSALON PERLES -benzonatate cap 100 mg...............61 TESTIM -testosterone td gel 50 mg/5gm (1%).................. 21 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone)...................................................................22 testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone)...................................................................22 testosterone enanthate im inj in oil 200 mg/ml.............22 TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act (1%)..................................................................................22 TESTOSTERONE -testosterone cypionate im inj in oil 250 mg/ml................................................................................22 TESTOSTERONE -testosterone td gel 10mg/act (2%)......22 TESTOSTERONE -testosterone td gel 25 mg/2.5gm (1%)..................................................................................21 TESTOSTERONE -testosterone td gel 50 mg/5gm (1%)..................................................................................22 TESTRED -methyltestosterone cap 10 mg........................22 TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml............................................... 15 tetracaine hcl ophth soln 0.5%.....................................140 TETRACYCLINE HCL -tetracycline hcl cap 250 mg............5 TETRACYCLINE HCL -tetracycline hcl cap 500 mg............5 TETRAMEX -tetracaine-menthol-camphor liqd spray 2-1-3%............................................................................160 TETRIX -dermatological products misc - kit.................... 160 TEVETEN -eprosartan mesylate tab 600 mg.................... 51 TEVETEN HCT -eprosartan mesylate-hydrochlorothiazide tab 600-25 mg................................................................. 51 TEV-TROPIN -somatropin for subcutaneous inj 5 mg....... 38 TEXACORT -hydrocortisone soln 2.5%...........................160 TEXAVITE LQ -pediatric multivitamins w/fl-fe-zn drops 0.25-7-3 mg/ml...............................................................122 TGQ 15DM/5PEH/2CPM -phenylephrine-chlorphen-dm syrup 5-2-15 mg/5ml........................................................61 TGQ 30PSE/150GFN/15DM -pseudoephedrine w/ dm-gg syrup 30-15-150 mg/5ml..................................................62 TGQ 30PSE/3BRM/15DM -pseudoephed-bromphen-dm syrup 30-3-15 mg/5ml......................................................62 TGQ 50PSE/3BRM/30DM -pseudoephed-bromphen-dm syrup 50-3-30 mg/5ml......................................................62 TGT GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm.................................................................................... 31 THALOMID -thalidomide cap 100 mg..............................165 THALOMID -thalidomide cap 150 mg..............................165 THALOMID -thalidomide cap 200 mg..............................165 THALOMID -thalidomide cap 50 mg................................165 THEO-24 -theophylline cap sr 24hr 100 mg...................... 64 THEO-24 -theophylline cap sr 24hr 200 mg...................... 65 THEO-24 -theophylline cap sr 24hr 300 mg...................... 65 THEO-24 -theophylline cap sr 24hr 400 mg...................... 65 theophylline soln 80 mg/15ml........................................ 65 theophylline tab sr 12hr 100 mg.................................... 65 theophylline tab sr 12hr 200 mg.................................... 65 theophylline tab sr 12hr 300 mg.................................... 65 theophylline tab sr 12hr 450 mg.................................... 65 theophylline tab sr 24hr 400 mg.................................... 65 theophylline tab sr 24hr 600 mg.................................... 65 THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)....... 143 THIOLA -tiopronin tab 100 mg.......................................... 75 thioridazine hcl tab 100 mg............................................ 84 thioridazine hcl tab 10 mg.............................................. 84 thioridazine hcl tab 25 mg.............................................. 84 thioridazine hcl tab 50 mg.............................................. 84 thiothixene cap 10 mg.....................................................84 thiothixene cap 1 mg...................................................... 84 thiothixene cap 2 mg...................................................... 84 thiothixene cap 5 mg...................................................... 84 THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................. 122 thyroid tab 30 mg (1/2 grain) (Armour thyroid)............. 34 thyroid tab 60 mg (1 grain) (Armour thyroid)................ 34 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid).......... 34 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 245 2015 THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25 mcg)................................................................................. 34 THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg)................................................................................. 34 THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg).......34 THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100 mcg)......34 THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150 mcg)................................................................................. 34 tiagabine hcl tab 2 mg (Gabitril).................................. 110 tiagabine hcl tab 4 mg (Gabitril).................................. 110 TIAZAC -diltiazem hcl extended release beads cap sr 24hr 120 mg............................................................................. 43 TIAZAC -diltiazem hcl extended release beads cap sr 24hr 180 mg............................................................................. 44 TIAZAC -diltiazem hcl extended release beads cap sr 24hr 240 mg............................................................................. 44 TIAZAC -diltiazem hcl extended release beads cap sr 24hr 300 mg............................................................................. 44 TIAZAC -diltiazem hcl extended release beads cap sr 24hr 360 mg............................................................................. 44 TIAZAC -diltiazem hcl extended release beads cap sr 24hr 420 mg............................................................................. 44 ticlopidine hcl tab 250 mg............................................ 136 TIGAN -trimethobenzamide hcl cap 300 mg..................... 69 TIKOSYN -dofetilide cap 125 mcg (0.125 mg).................. 45 TIKOSYN -dofetilide cap 250 mcg (0.25 mg).................... 45 TIKOSYN -dofetilide cap 500 mcg (0.5 mg)...................... 45 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe).................................................................140 timolol maleate ophth gel forming soln 0.5% (Timopticxe).................................................................................. 140 timolol maleate ophth soln 0.25% (Timoptic)..............140 timolol maleate ophth soln 0.5% (Timoptic)................140 TIMOLOL MALEATE -timolol maleate tab 10 mg..............41 TIMOLOL MALEATE -timolol maleate tab 20 mg..............41 TIMOLOL MALEATE -timolol maleate tab 5 mg................41 TIMOPTIC OCUDOSE -timolol maleate preservative free ophth soln 0.25%........................................................... 140 TIMOPTIC OCUDOSE -timolol maleate preservative free ophth soln 0.5%............................................................. 140 TIMOPTIC -timolol maleate ophth soln 0.25%................ 140 TIMOPTIC -timolol maleate ophth soln 0.5%.................. 140 TIMOPTIC-XE -timolol maleate ophth gel forming soln 0.25%............................................................................. 140 TIMOPTIC-XE -timolol maleate ophth gel forming soln 0.5%............................................................................... 140 TINDAMAX -tinidazole tab 250 mg................................... 12 TINDAMAX -tinidazole tab 500 mg................................... 12 tinidazole tab 250 mg (Tindamax).................................. 12 tinidazole tab 500 mg (Tindamax).................................. 12 TIROSINT -levothyroxine sodium cap 100 mcg................ 34 TIROSINT -levothyroxine sodium cap 112 mcg................ 34 TIROSINT -levothyroxine sodium cap 125 mcg................ 34 TIROSINT -levothyroxine sodium cap 137 mcg................ 34 TIROSINT -levothyroxine sodium cap 13 mcg.................. 34 246 TIROSINT -levothyroxine sodium cap 150 mcg................ 34 TIROSINT -levothyroxine sodium cap 25 mcg.................. 34 TIROSINT -levothyroxine sodium cap 50 mcg.................. 34 TIROSINT -levothyroxine sodium cap 75 mcg.................. 34 TIROSINT -levothyroxine sodium cap 88 mcg.................. 34 TIVICAY -dolutegravir sodium tab 50 mg (base equiv)......10 TIVORBEX -indomethacin cap 20 mg............................. 104 TIVORBEX -indomethacin cap 40 mg............................. 104 TIZANIDINE COMFORT PAC -tizanidine tab 4 mg & liniment topical gel pack................................................ 114 tizanidine hcl cap 2 mg (base equivalent) (Zanaflex)...................................................................... 114 tizanidine hcl cap 4 mg (base equivalent) (Zanaflex)...................................................................... 114 tizanidine hcl cap 6 mg (base equivalent) (Zanaflex)...................................................................... 114 tizanidine hcl tab 2 mg (base equivalent)....................114 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)...................................................................... 114 TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg...................................................................122 TL-CERMIDE -dermatological products misc emulsion......................................................................... 160 TL-FLUORIVITE -pediatric multiple vitamins w/ fl-fe chew tab 0.25-7.5 mg..............................................................122 TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab 27-0.5-0.5 mg.................................................................122 TL G-FOL OS -multiple vit w/ min & calcium-folic acid tab 500-1.1 mg.....................................................................122 TL-SELECT DHA -prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg.......................................................122 TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg..............................................................122 TL TRISEB -antiseborrheic products misc - cream..........160 TOBI PODHALER -tobramycin inhal cap 28 mg................. 5 TOBI -tobramycin nebu soln 300 mg/5ml............................ 5 TOBRADEX ST -tobramycin-dexamethasone ophth susp 0.3-0.05%....................................................................... 140 TOBRADEX -tobramycin-dexamethasone ophth oint 0.3-0.1%......................................................................... 140 TOBRADEX -tobramycin-dexamethasone ophth susp 0.3-0.1%......................................................................... 140 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex).....................................................................140 tobramycin nebu soln 300 mg/5ml (Tobi)........................5 tobramycin ophth soln 0.3% (Tobrex)......................... 140 TOBREX -tobramycin ophth oint 0.3%............................ 141 TOBREX -tobramycin ophth soln 0.3%........................... 140 TOFRANIL -imipramine hcl tab 10 mg.............................. 80 TOFRANIL -imipramine hcl tab 25 mg.............................. 80 TOFRANIL -imipramine hcl tab 50 mg.............................. 80 TOFRANIL-PM -imipramine pamoate cap 100 mg............ 80 TOFRANIL-PM -imipramine pamoate cap 125 mg............ 80 TOFRANIL-PM -imipramine pamoate cap 150 mg............ 80 TOFRANIL-PM -imipramine pamoate cap 75 mg.............. 80 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 tolazamide tab 250 mg.................................................... 31 TOLAZAMIDE -tolazamide tab 500 mg............................. 31 TOLBUTAMIDE -tolbutamide tab 500 mg......................... 31 tolcapone tab 100 mg (Tasmar)................................... 113 tolmetin sodium cap 400 mg........................................ 104 TOLMETIN SODIUM -tolmetin sodium tab 200 mg......... 104 TOLMETIN SODIUM -tolmetin sodium tab 600 mg......... 104 tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 73 tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 73 tolterodine tartrate tab 1 mg (Detrol)............................. 73 tolterodine tartrate tab 2 mg (Detrol).............................73 TOPAMAX SPRINKLE -topiramate sprinkle cap 15 mg.................................................................................. 110 TOPAMAX SPRINKLE -topiramate sprinkle cap 25 mg.................................................................................. 110 TOPAMAX -topiramate tab 100 mg.................................110 TOPAMAX -topiramate tab 200 mg.................................110 TOPAMAX -topiramate tab 25 mg...................................110 TOPAMAX -topiramate tab 50 mg...................................110 TOPICORT -desoximetasone cream 0.05%....................160 TOPICORT -desoximetasone cream 0.25%....................160 TOPICORT -desoximetasone gel 0.05%.........................160 TOPICORT -desoximetasone oint 0.05%........................160 TOPICORT -desoximetasone oint 0.25%........................160 TOPICORT -desoximetasone spray 0.25%..................... 160 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100 mg.................................................................................. 110 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150 mg.................................................................................. 110 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200 mg.................................................................................. 110 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25 mg.................................................................................. 110 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50 mg.................................................................................. 110 topiramate sprinkle cap 15 mg (Topamax sprinkle)........................................................................ 110 topiramate sprinkle cap 25 mg (Topamax sprinkle)........................................................................ 110 topiramate tab 100 mg (Topamax)............................... 110 topiramate tab 200 mg (Topamax)............................... 110 topiramate tab 25 mg (Topamax)................................. 110 topiramate tab 50 mg (Topamax)................................. 110 TOPROL XL -metoprolol succinate tab sr 24hr 100 mg.....41 TOPROL XL -metoprolol succinate tab sr 24hr 200 mg.....41 TOPROL XL -metoprolol succinate tab sr 24hr 25 mg...... 41 TOPROL XL -metoprolol succinate tab sr 24hr 50 mg...... 41 torsemide tab 100 mg (Demadex).................................. 53 torsemide tab 10 mg (Demadex).................................... 53 torsemide tab 20 mg (Demadex).................................... 53 torsemide tab 5 mg (Demadex)...................................... 53 TOUJEO SOLOSTAR -insulin glargine soln pen-injector 300 unit/ml....................................................................... 33 TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg............. 73 TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg............. 73 TRACLEER -bosentan tab 125 mg................................... 58 TRACLEER -bosentan tab 62.5 mg.................................. 58 TRADJENTA -linagliptin tab 5 mg..................................... 31 tramadol-acetaminophen tab 37.5-325 mg (Ultracet)........................................................................100 TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic release 100 mg.............................................................. 100 TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic release 150 mg.............................................................. 100 TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic release 200 mg.............................................................. 100 TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic release 300 mg.............................................................. 100 tramadol hcl tab 50 mg (Ultram).................................. 100 tramadol hcl tab sr 24hr 100 mg (Ultram er)............... 100 tramadol hcl tab sr 24hr 200 mg (Ultram er)............... 100 tramadol hcl tab sr 24hr 300 mg (Ultram er)............... 100 tramadol hcl tab sr 24hr biphasic release 100 mg...... 100 tramadol hcl tab sr 24hr biphasic release 200 mg...... 100 tramadol hcl tab sr 24hr biphasic release 300 mg...... 100 TRANDATE -labetalol hcl tab 100 mg...............................41 TRANDATE -labetalol hcl tab 200 mg...............................41 TRANDATE -labetalol hcl tab 300 mg...............................42 trandolapril tab 1 mg (Mavik)......................................... 51 trandolapril tab 2 mg (Mavik)......................................... 51 trandolapril tab 4 mg (Mavik)......................................... 51 trandolapril-verapamil hcl tab cr 1-240 mg (Tarka).......51 trandolapril-verapamil hcl tab cr 2-180 mg (Tarka).......51 trandolapril-verapamil hcl tab cr 2-240 mg (Tarka).......51 trandolapril-verapamil hcl tab cr 4-240 mg (Tarka).......51 tranexamic acid tab 650 mg (Lysteda).........................133 TRANSDERM-SCOP -scopolamine td patch 72hr 1 mg/3days..........................................................................69 TRANXENE T -clorazepate dipotassium tab 15 mg.......... 76 TRANXENE T -clorazepate dipotassium tab 3.75 mg....... 76 TRANXENE T -clorazepate dipotassium tab 7.5 mg......... 76 tranylcypromine sulfate tab 10 mg (Parnate)................80 TRAVATAN Z -travoprost ophth soln 0.004% (benzalkonium free) (bak free).......................................141 TRAVOPROST -travoprost ophth soln 0.004%............... 141 trazodone hcl tab 100 mg............................................... 80 trazodone hcl tab 150 mg............................................... 80 trazodone hcl tab 300 mg............................................... 80 trazodone hcl tab 50 mg................................................. 80 TREAGAN OTIC -antipyrine-benzocaine-polycosanol otic sol 5.4-1.4-0.0097%....................................................... 142 TRECATOR -ethionamide tab 250 mg................................ 6 tretinoin cap 10 mg......................................................... 19 tretinoin cream 0.025% (Retin-a)..................................160 tretinoin cream 0.05% (Retin-a)....................................160 tretinoin cream 0.1% (Retin-a)......................................160 tretinoin gel 0.01% (Retin-a)......................................... 160 tretinoin gel 0.025% (Retin-a)....................................... 160 tretinoin microsphere gel 0.04% (Retin-a micro)........ 160 tretinoin microsphere gel 0.1% (Retin-a micro).......... 160 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 247 2015 TRETIN-X -tretinoin cream 0.025% w/ cleanser & moisturizer kit.................................................................160 TRETIN-X -tretinoin cream 0.05% w/ cleanser & moisturizer kit.................................................................160 TRETIN-X -tretinoin cream 0.075%.................................160 TRETIN-X -tretinoin cream 0.1% w/ cleanser & moisturizer kit....................................................................................160 TRETTEN -coagulation factor xiii a-subunit for inj 2000-3125 unit............................................................... 136 TREXALL -methotrexate sodium tab 10 mg (base equiv)................................................................................19 TREXALL -methotrexate sodium tab 15 mg (base equiv)................................................................................19 TREXALL -methotrexate sodium tab 5 mg (base equiv)................................................................................19 TREXALL -methotrexate sodium tab 7.5 mg (base equiv)................................................................................19 TREXIMET -sumatriptan-naproxen sodium tab 85-500 mg.................................................................................. 106 TREZIX -acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg..............................................................100 TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg..........................................................................122 triamcinolone acetonide aerosol soln (Kenalog)........ 160 triamcinolone acetonide cream 0.025%.......................160 triamcinolone acetonide cream 0.1%...........................160 triamcinolone acetonide cream 0.5%...........................160 triamcinolone acetonide dental paste 0.1%................ 143 triamcinolone acetonide lotion 0.025%....................... 160 triamcinolone acetonide lotion 0.1%........................... 160 triamcinolone acetonide nasal aerosol suspension 55 mcg/act (Nasacort aq)................................................... 59 triamcinolone acetonide oint 0.025%...........................160 triamcinolone acetonide oint 0.1%...............................160 TRIAMCINOLONE ACETONIDE -triamcinolone acetonide oint 0.5%........................................................................ 160 TRIAMTERENE/HYDROCHLOROTH -triamterene & hydrochlorothiazide cap 50-25 mg...................................53 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)......................................................................... 53 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)....................................................................53 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)......................................................................... 53 TRIANEX -triamcinolone acetonide oint 0.05%............... 160 triazolam tab 0.125 mg....................................................85 triazolam tab 0.25 mg (Halcion)..................................... 85 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg............................................................. 51 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg........................................................... 51 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg.............................................................. 51 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg............................................................. 51 248 TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg................................................................ 51 TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa tab 27-1 mg & fish oil chew cap pak............................. 122 TRICARE PRENATAL DHA ONE -prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg..................................... 122 TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1 mg..... 122 TRI-CHLOR -trichloroacetic acid liqd 80%...................... 160 TRICODE AR -pseudoephedrine-chlorphen w/ codeine liq 30-2-8 mg/5ml..................................................................62 TRICODE GF -pseudoephedrine w/ cod-gg liquid 30-8-200 mg/5ml..............................................................................62 TRICOR -fenofibrate tab 145 mg...................................... 56 TRICOR -fenofibrate tab 48 mg........................................ 56 trifluoperazine hcl tab 10 mg......................................... 84 trifluoperazine hcl tab 1 mg........................................... 84 trifluoperazine hcl tab 2 mg........................................... 84 trifluoperazine hcl tab 5 mg........................................... 84 trifluridine ophth soln 1% (Viroptic)............................ 141 TRIGLIDE -fenofibrate tab 160 mg....................................56 trihexyphenidyl hcl elixir 0.4 mg/ml.............................113 trihexyphenidyl hcl tab 2 mg........................................113 trihexyphenidyl hcl tab 5 mg........................................113 TRILEPTAL -oxcarbazepine susp 300 mg/5ml (60 mg/ ml).................................................................................. 110 TRILEPTAL -oxcarbazepine tab 150 mg......................... 110 TRILEPTAL -oxcarbazepine tab 300 mg......................... 110 TRILEPTAL -oxcarbazepine tab 600 mg......................... 110 TRILIPIX -choline fenofibrate cap dr 135 mg (fenofibric acid equiv)........................................................................56 TRILIPIX -choline fenofibrate cap dr 45 mg (fenofibric acid equiv)................................................................................56 trimethobenzamide hcl cap 300 mg (Tigan).................. 69 trimethoprim tab 100 mg................................................ 12 TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg..........................................................................122 TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1 mg.................................................................................. 122 TRINATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg..........................................................................122 TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg......122 TRI-NORINYL 28 -norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg..............................................26 TRIPLE DYE -triple dye solution..................................... 163 TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap 31-0.6-0.4-200 mg......................................................... 122 TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack.........................................................122 TRIUMEQ -abacavir-dolutegravir-lamivudine tab 600-50-300 mg.................................................................10 TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk.................................................. 122 TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................. 122 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List October 2015 2015 TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic susp 0.25 mg/ml............................................................ 122 TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic susp 0.5 mg/ml.............................................................. 122 TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp 0.25 mg/ml..................................................................... 122 TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp 0.5 mg/ml....................................................................... 122 TRI-VIT/FLUORIDE/IRON -pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml.............................................. 122 TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg...............................................................10 TROKENDI XR -topiramate cap sr 24hr 100 mg............. 110 TROKENDI XR -topiramate cap sr 24hr 200 mg............. 110 TROKENDI XR -topiramate cap sr 24hr 25 mg............... 110 TROKENDI XR -topiramate cap sr 24hr 50 mg............... 110 TROPAZONE -emollient - lotion......................................161 tropicamide ophth soln 0.5%........................................141 tropicamide ophth soln 1% (Mydriacyl).......................141 trospium chloride cap sr 24hr 60 mg............................ 73 trospium chloride tab 20 mg.......................................... 73 TRULICITY -dulaglutide soln pen-injector 0.75 mg/0.5ml...........................................................................31 TRULICITY -dulaglutide soln pen-injector 1.5 mg/0.5ml...........................................................................31 TRUSOPT -dorzolamide hcl ophth soln 2%.................... 141 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg......................................................................10 trypsin w/ castor oil & peruvian balsam spray (Granulex)..................................................................... 161 TUDORZA PRESSAIR -aclidinium bromide aerosol powd breath activated 400 mcg/act...........................................65 TUSNEL -brompheniramine w/ dm-gg cap 2-15-200 mg.................................................................................... 62 TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr 10-8 mg............................................................................62 TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr 5-4 mg..............................................................................62 TUSSIONEX PENNKINETIC EXT -hydrocod polstchlorphen polst cr susp 10-8 mg/5ml...............................62 TUZISTRA XR -codeine polist-chlorphen polist er susp 14.7-2.8 mg/5ml............................................................... 62 TWYNSTA -telmisartan-amlodipine tab 40-10 mg.............51 TWYNSTA -telmisartan-amlodipine tab 40-5 mg...............51 TWYNSTA -telmisartan-amlodipine tab 80-10 mg.............52 TWYNSTA -telmisartan-amlodipine tab 80-5 mg...............51 TYBOST -cobicistat tab 150 mg........................................10 TYKERB -lapatinib ditosylate tab 250 mg (base equiv)..... 19 TYLENOL/CODEINE #3 -acetaminophen w/ codeine tab 300-30 mg......................................................................100 TYLENOL/CODEINE #4 -acetaminophen w/ codeine tab 300-60 mg......................................................................100 TYLENOL/CODEINE -acetaminophen w/ codeine tab 300-15 mg......................................................................100 TYVASO REFILL -treprostinil inhalation solution 0.6 mg/ ml......................................................................................58 TYVASO STARTER -treprostinil inhalation solution 0.6 mg/ml................................................................................58 TYVASO -treprostinil inhalation solution 0.6 mg/ml........... 58 TYZEKA -telbivudine tab 600 mg...................................... 10 TYZINE PEDIATRIC NASAL DR -
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