July 2017
Basic Drug List
Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug list, also known as a formulary, is regularly updated. Please visit bcbstx.com for the most up-to-date information.
Contents Therapeutic Class Drug List Introduction ...... I Anti-Infective Agents ...... 1 How drugs are selected ...... I Cancer Drugs ...... 6 How member payment is determined ...... I Hormones, Diabetes and Related Drugs ...... 8 How to use this list ...... I Heart and Circulatory Drugs ...... 14 Generic drugs ...... II Respiratory Agents ...... 24 Coverage considerations ...... III Gastrointestinal Drugs ...... 27 Specialty drugs ...... IV Genitourinary Drugs ...... 29 Abbreviation key ...... V Central Nervous System Drugs ...... 30 Pain Relief Drugs ...... 37 Neuromuscular Drugs ...... 42 Supplements ...... 45 Blood Modifying Drugs ...... 45 Topical Products ...... 51 Miscellaneous Categories (includes Supplies and Devices) ...... 56 Index ...... 58
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.
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
41722-A TX © Prime Therapeutics LLC 07/17
Introduction Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to present the 2017 Drug List. This is a list of preferred drugs which includes Brand drugs and a partial listing of generic drugs. 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 List updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbstx.com.
How 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 three or four member payment tiers: generic, Preferred Brand or Non-Preferred Brand (not listed in this document). Specialty drugs can either be within the previous three tiers or can be a separate fourth tier depending on your benefit design. 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. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Prescription products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA- approved for self-administration may be available through your medical benefit.
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List I
How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand drug is a non-preferred (NP) brand and is only included as a reference to the brand. Some generic products have no reference brand. Example: atorvastatin (Lipitor) Brand drugs are listed in all CAPITAL letters. Example: PROAIR HFA 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.
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 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. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction or weight loss. Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan material for details about your particular benefits. Compounded medications: Your benefit plan may 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 generally 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. Refer to your benefit plan materials for details about your particular benefits. 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. Refer to your benefit plan materials for details about your particular benefits. Dispensing Limits (DL): Drug Dispensing limits help encourage medication use as intended by the FDA. Dispensing 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. Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List III
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 self- administered 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 (BCBSTX) is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. BCBSTX contracts with Prime Therapeutics to provide pharmacy benefit management, home delivery pharmacy and specialty pharmacy services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC.
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List IV
Abbreviation key cap ...... capsules odt ...... orally disintegrating tabs chew ...... chewable oint ...... ointment conc ...... concentrate ophth ...... ophthalmic cr ...... controlled release osm ...... osmotic release dr ...... delayed release powd ...... powder ec ...... enteric coated sa ...... sustained action effe...... effervescent sl ...... sublingual equiv ...... equivalent soln ...... solution er ...... extended release sr ...... sustained release inhal...... inhalation suppos ...... suppositories inj ...... injection susp ...... suspension liq ...... liquid tab ...... tablets lotn ...... lotion td ...... transdermal nebu ...... nebulizer
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List V 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ANTI-INFECTIVE AGENTS penicillin v potassium for soln PENICILLINS 250 mg/5ml amoxicillin (trihydrate) cap 250 mg penicillin v potassium tab 250 mg amoxicillin (trihydrate) cap 500 mg penicillin v potassium tab 500 mg amoxicillin (trihydrate) for susp CEPHALOSPORINS 125 mg/5ml cefaclor cap 250 mg amoxicillin (trihydrate) for susp cefaclor cap 500 mg 200 mg/5ml cefadroxil cap 500 mg amoxicillin (trihydrate) for susp cefadroxil for susp 250 mg/5ml 250 mg/5ml cefadroxil for susp 500 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml cefadroxil tab 1 gm amoxicillin (trihydrate) tab 500 mg cefdinir cap 300 mg amoxicillin (trihydrate) tab 875 mg cefdinir for susp 125 mg/5ml amoxicillin & k clavulanate for susp cefdinir for susp 250 mg/5ml 200-28.5 mg/5ml cefixime for susp 100 mg/5ml amoxicillin & k clavulanate for susp (Suprax) 250-62.5 mg/5ml (Augmentin) cefixime for susp 200 mg/5ml amoxicillin & k clavulanate for susp (Suprax) 400-57 mg/5ml cefpodoxime proxetil for susp amoxicillin & k clavulanate for susp 50 mg/5ml 600-42.9 mg/5ml (Augmentin es-600) cefpodoxime proxetil for susp amoxicillin & k clavulanate tab sr 100 mg/5ml 12hr 1000-62.5 mg (Augmentin xr) cefpodoxime proxetil tab 100 mg amoxicillin & k clavulanate tab cefpodoxime proxetil tab 200 mg 250-125 mg cefprozil for susp 125 mg/5ml amoxicillin & k clavulanate tab cefprozil for susp 250 mg/5ml 500-125 mg (Augmentin) cefprozil tab 250 mg amoxicillin & k clavulanate tab 875-125 mg (Augmentin) cefprozil tab 500 mg ampicillin cap 250 mg CEFTIN – cefuroxime axetil for susp 125 mg/5ml ampicillin cap 500 mg ceftriaxone sodium for inj 250 mg dicloxacillin sodium cap 250 mg ceftriaxone sodium for inj 500 mg dicloxacillin sodium cap 500 mg (Rocephin) penicillin v potassium for soln ceftriaxone sodium for inj 1 gm 125 mg/5ml (Rocephin)
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 1 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ceftriaxone sodium for inj 2 gm doxycycline monohydrate cap 50 mg cefuroxime axetil tab 250 mg (Ceftin) doxycycline monohydrate cap 75 mg • cefuroxime axetil tab 500 mg (Ceftin) (Monodox) cephalexin cap 250 mg (Keflex) doxycycline monohydrate cap 100 mg (Monodox) cephalexin cap 500 mg (Keflex) doxycycline monohydrate cap • cephalexin for susp 125 mg/5ml 150 mg (Adoxa) cephalexin for susp 250 mg/5ml doxycycline monohydrate tab 50 mg MACROLIDES (Adoxa) AZITHROMYCIN – azithromycin powd doxycycline monohydrate tab 75 mg pack for susp 1 gm (Adoxa) azithromycin for susp 100 mg/5ml doxycycline monohydrate tab (Zithromax) 100 mg (Adoxa pak 1/100) azithromycin for susp 200 mg/5ml doxycycline monohydrate tab • (Zithromax) 150 mg (Adoxa pak 1/150) azithromycin tab 250 mg (Zithromax) • minocycline hcl cap 50 mg (Minocin) azithromycin tab 500 mg (Zithromax) • minocycline hcl cap 75 mg (Minocin) azithromycin tab 600 mg (Zithromax) • minocycline hcl cap 100 mg (Minocin) clarithromycin for susp 125 mg/5ml minocycline hcl tab 50 mg clarithromycin for susp 250 mg/5ml minocycline hcl tab 75 mg (Biaxin) minocycline hcl tab 100 mg clarithromycin tab sr 24hr 500 mg • tetracycline hcl cap 250 mg (Biaxin xl pac) (Tetracycline hcl) clarithromycin tab 250 mg (Biaxin) tetracycline hcl cap 500 mg clarithromycin tab 500 mg (Biaxin) (Tetracycline hcl) erythromycin w/ delayed release FLUOROQUINOLONES particles cap 250 mg ciprofloxacin for oral susp TETRACYCLINES 250 mg/5ml (5%) (5 gm/100ml) (Cipro) demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) doxycycline hyclate cap 50 mg (Cipro) doxycycline hyclate cap 100 mg ciprofloxacin hcl tab 250 mg (base (Vibramycin) equiv) (Cipro) doxycycline hyclate tab 20 mg ciprofloxacin hcl tab 500 mg (base doxycycline hyclate tab 100 mg equiv) (Cipro)
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 2 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ciprofloxacin hcl tab 750 mg (base fluconazole tab 200 mg (Diflucan) equiv) flucytosine cap 250 mg (Ancobon) ciprofloxacin-ciprofloxacin hcl tab sr flucytosine cap 500 mg (Ancobon) 24hr 500 mg (base eq) (Cipro xr) griseofulvin microsize susp ciprofloxacin-ciprofloxacin hcl tab sr 125 mg/5ml 24hr 1000 mg(base eq) (Cipro xr) griseofulvin microsize tab 500 mg levofloxacin tab 250 mg (Levaquin) (Grifulvin v) levofloxacin tab 500 mg (Levaquin) itraconazole cap 100 mg (Sporanox) • levofloxacin tab 750 mg (Levaquin) NOXAFIL – posaconazole tab delayed • ofloxacin tab 400 mg release 100 mg AMINOGLYCOSIDES NOXAFIL – posaconazole susp 40 mg/ • neomycin sulfate tab 500 mg ml paromomycin sulfate cap 250 mg nystatin tab 500000 unit tobramycin nebu soln 300 mg/5ml • • terbinafine hcl tab 250 mg (Lamisil) (Tobi) voriconazole for susp 40 mg/ml • TUBERCULOSIS (Vfend) ethambutol hcl tab 100 mg voriconazole tab 50 mg (Vfend) • (Myambutol) voriconazole tab 200 mg (Vfend) • ethambutol hcl tab 400 mg VIRAL INFECTIONS (Myambutol) Cytomegalovirus isoniazid tab 100 mg VALCYTE – valganciclovir hcl for soln isoniazid tab 300 mg 50 mg/ml (base equiv) PRIFTIN – rifapentine tab 150 mg valganciclovir hcl for soln 50 mg/ml pyrazinamide tab 500 mg (base equiv) (Valcyte) rifabutin cap 150 mg (Mycobutin) valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) rifampin cap 150 mg (Rifadin) Hepatitis rifampin cap 300 mg (Rifadin) adefovir dipivoxil tab 10 mg FUNGAL INFECTIONS (Hepsera) fluconazole for susp 10 mg/ml BARACLUDE – entecavir oral soln 0.05 (Diflucan) mg/ml fluconazole for susp 40 mg/ml DAKLINZA – daclatasvir • • (Diflucan) dihydrochloride tab 30 mg (base fluconazole tab 50 mg (Diflucan) equivalent) fluconazole tab 100 mg (Diflucan) fluconazole tab 150 mg (Diflucan)
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 3 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy DAKLINZA – daclatasvir • • HIV/AIDS dihydrochloride tab 60 mg (base abacavir sulfate tab 300 mg (base • equivalent) equiv) (Ziagen) DAKLINZA – daclatasvir • • abacavir sulfate-lamivudine tab • dihydrochloride tab 90 mg (base 600-300 mg (Epzicom) equivalent) abacavir sulfate-lamivudine- • entecavir tab 0.5 mg (Baraclude) zidovudine tab 300-150-300 mg entecavir tab 1 mg (Baraclude) (Trizivir) EPCLUSA – sofosbuvir-velpatasvir tab • • ATRIPLA – efavirenz-emtricitabine- • 400-100 mg tenofovir df tab 600-200-300 mg HARVONI – ledipasvir-sofosbuvir tab • • DESCOVY – emtricitabine-tenofovir • 90-400 mg alafenamide fumarate tab 200-25 mg lamivudine tab 100 mg (hbv) (Epivir didanosine delayed release capsule • hbv) 125 mg (Videx ec) PEGASYS – peginterferon alfa-2a inj • • didanosine delayed release capsule • 180 mcg/ml 200 mg (Videx ec) PEGASYS – peginterferon alfa-2a inj • • didanosine delayed release capsule • 180 mcg/0.5ml 250 mg (Videx ec) PEGASYS PROCLICK – peginterferon • • didanosine delayed release capsule • alfa-2a inj 135 mcg/0.5ml 400 mg (Videx ec) PEGASYS PROCLICK – peginterferon • • EPZICOM – abacavir sulfate- • alfa-2a inj 180 mcg/0.5ml lamivudine tab 600-300 mg ribavirin cap 200 mg (Rebetol) • GENVOYA – elvitegrav-cobic- • ribavirin tab 200 mg (Copegus) • emtricitab-tenofov af tab 150-150-200-10 mg SOVALDI – sofosbuvir tab 400 mg • • INTELENCE – etravirine tab 25 mg • Herpes INTELENCE – etravirine tab 100 mg • acyclovir cap 200 mg (Zovirax) INTELENCE – etravirine tab 200 mg • acyclovir susp 200 mg/5ml (Zovirax) ISENTRESS – raltegravir potassium • acyclovir tab 400 mg (Zovirax) tab 400 mg (base equiv) acyclovir tab 800 mg (Zovirax) ISENTRESS – raltegravir potassium • famciclovir tab 125 mg (Famvir) packet for susp 100 mg (base equiv) famciclovir tab 250 mg (Famvir) ISENTRESS – raltegravir potassium • chew tab 25 mg (base equiv) famciclovir tab 500 mg (Famvir) ISENTRESS – raltegravir potassium valacyclovir hcl tab 500 mg (Valtrex) • chew tab 100 mg (base equiv) valacyclovir hcl tab 1 gm (Valtrex)
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 4 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy KALETRA – lopinavir-ritonavir soln • REYATAZ – atazanavir sulfate cap 200 • 400-100 mg/5ml (80-20 mg/ml) mg (base equiv) KALETRA – lopinavir-ritonavir tab • REYATAZ – atazanavir sulfate cap 300 • 100-25 mg mg (base equiv) KALETRA – lopinavir-ritonavir tab • stavudine cap 15 mg (Zerit) • 200-50 mg stavudine cap 20 mg (Zerit) • lamivudine oral soln 10 mg/ml • stavudine cap 30 mg (Zerit) • (Epivir) stavudine cap 40 mg (Zerit) • lamivudine tab 150 mg (Epivir) • STRIBILD – elvitegrav-cobic-emtricitab- • lamivudine tab 300 mg (Epivir) • tenofovdf tab 150-150-200-300 mg lamivudine-zidovudine tab • SUSTIVA – efavirenz tab 600 mg • 150-300 mg (Combivir) SUSTIVA – efavirenz cap 50 mg • lopinavir-ritonavir soln • 400-100 mg/5ml (80-20 mg/ml) SUSTIVA – efavirenz cap 200 mg • (Kaletra) TIVICAY – dolutegravir sodium tab 10 • nevirapine tab sr 24hr 100 mg • mg (base equiv) (Viramune xr) TIVICAY – dolutegravir sodium tab 25 • nevirapine tab sr 24hr 400 mg • mg (base equiv) (Viramune xr) TIVICAY – dolutegravir sodium tab 50 • nevirapine tab 200 mg (Viramune) • mg (base equiv) NORVIR – ritonavir tab 100 mg • TRUVADA – emtricitabine-tenofovir • disoproxil fumarate tab 100-150 mg NORVIR – ritonavir oral soln 80 mg/ml • TRUVADA – emtricitabine-tenofovir • ODEFSEY – emtricitabine-rilpivirine- • disoproxil fumarate tab 133-200 mg tenofovir af tab 200-25-25 mg TRUVADA – emtricitabine-tenofovir • PREZISTA – darunavir ethanolate susp • disoproxil fumarate tab 167-250 mg 100 mg/ml (base equiv) TRUVADA – emtricitabine-tenofovir • PREZISTA – darunavir ethanolate tab • disoproxil fumarate tab 200-300 mg 75 mg (base equiv) VIDEX – didanosine for soln 2 gm • PREZISTA – darunavir ethanolate tab • 150 mg (base equiv) VIDEX – didanosine for soln 4 gm • PREZISTA – darunavir ethanolate tab • VIRAMUNE – nevirapine susp 50 • 600 mg (base equiv) mg/5ml PREZISTA – darunavir ethanolate tab • VIREAD – tenofovir disoproxil fumarate • 800 mg (base equiv) oral powder 40 mg/gm REYATAZ – atazanavir sulfate cap 150 • VIREAD – tenofovir disoproxil fumarate • mg (base equiv) tab 150 mg
Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 5 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy VIREAD – tenofovir disoproxil fumarate • clindamycin hcl cap 75 mg (Cleocin) tab 200 mg clindamycin hcl cap 150 mg (Cleocin) VIREAD – tenofovir disoproxil fumarate • clindamycin hcl cap 300 mg (Cleocin) tab 250 mg clindamycin palmitate hcl for soln VIREAD – tenofovir disoproxil fumarate • 75 mg/5ml (base equiv) (Cleocin tab 300 mg pediatric gr) ZIAGEN – abacavir sulfate soln 20 mg/ • dapsone tab 25 mg ml (base equiv) dapsone tab 100 mg zidovudine cap 100 mg (Retrovir) • IMPAVIDO – miltefosine cap 50 mg zidovudine syrup 10 mg/ml (Retrovir) • linezolid for susp 100 mg/5ml (Zyvox) • zidovudine tab 300 mg • linezolid tab 600 mg (Zyvox) • oseltamivir phosphate cap 30 mg • (base equiv) (Tamiflu) metronidazole tab 250 mg (Flagyl) oseltamivir phosphate cap 45 mg • metronidazole tab 500 mg (Flagyl) (base equiv) (Tamiflu) SIVEXTRO – tedizolid phosphate tab • oseltamivir phosphate cap 75 mg • 200 mg (base equiv) (Tamiflu) sulfamethoxazole-trimethoprim susp MALARIA 200-40 mg/5ml atovaquone-proguanil hcl tab sulfamethoxazole-trimethoprim tab 62.5-25 mg (Malarone) 400-80 mg (Bactrim) atovaquone-proguanil hcl tab sulfamethoxazole-trimethoprim tab 250-100 mg (Malarone) 800-160 mg (Bactrim ds) chloroquine phosphate tab 500 mg trimethoprim tab 100 mg (Aralen) vancomycin hcl cap 125 mg DARAPRIM – pyrimethamine tab 25 mg • • (Vancocin hcl) hydroxychloroquine sulfate tab vancomycin hcl cap 250 mg 200 mg (Plaquenil) (Vancocin hcl) mefloquine hcl tab 250 mg XIFAXAN – rifaximin tab 550 mg • PRIMAQUINE PHOSPHATE – CANCER DRUGS primaquine phosphate tab 26.3 mg ACTIMMUNE – interferon gamma-1b • (15 mg base) inj 100 mcg/0.5ml (2000000 WORM INFECTIONS unit/0.5ml) ALBENZA – albendazole tab 200 mg AFINITOR – everolimus tab 2.5 mg • • • BILTRICIDE – praziquantel tab 600 mg AFINITOR – everolimus tab 5 mg • • • ivermectin tab 3 mg (Stromectol) AFINITOR – everolimus tab 7.5 mg • • • OTHER ANTI-INFECTIVES AFINITOR – everolimus tab 10 mg • • •
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 6 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ALKERAN – melphalan tab 2 mg megestrol acetate tab 40 mg anastrozole tab 1 mg (Arimidex) MEKINIST – trametinib dimethyl • • • bexarotene cap 75 mg (Targretin) • • • sulfoxide tab 0.5 mg (base equivalent) bicalutamide tab 50 mg (Casodex) MEKINIST – trametinib dimethyl • • • capecitabine tab 150 mg (Xeloda) • • sulfoxide tab 2 mg (base equivalent) capecitabine tab 500 mg (Xeloda) • • mercaptopurine tab 50 mg COTELLIC – cobimetinib fumarate tab • • • (Purinethol) 20 mg (base equivalent) MESNEX – mesna tab 400 mg EMCYT – estramustine phosphate methotrexate sodium tab 2.5 mg sodium cap 140 mg (base equiv) exemestane tab 25 mg (Aromasin) MYLERAN – busulfan tab 2 mg FARESTON – toremifene citrate tab 60 NEXAVAR – sorafenib tosylate tab 200 • • • mg (base equivalent) mg (base equivalent) flutamide cap 125 mg NILANDRON – nilutamide tab 150 mg hydroxyurea cap 500 mg (Hydrea) nilutamide tab 150 mg (Nilandron) IBRANCE – palbociclib cap 75 mg • • • PURIXAN – mercaptopurine susp 2000 • IBRANCE – palbociclib cap 100 mg • • • mg/100ml (20 mg/ml) IBRANCE – palbociclib cap 125 mg • • • SPRYCEL – dasatinib tab 20 mg • • • imatinib mesylate tab 100 mg (base • • • SPRYCEL – dasatinib tab 50 mg • • • equivalent) (Gleevec) SPRYCEL – dasatinib tab 70 mg • • • imatinib mesylate tab 400 mg (base • • • SPRYCEL – dasatinib tab 80 mg • • • equivalent) (Gleevec) SPRYCEL – dasatinib tab 100 mg • • • KISQALI – ribociclib succinate tab 200 • • • mg (base equiv) SPRYCEL – dasatinib tab 140 mg • • • letrozole tab 2.5 mg (Femara) SUTENT – sunitinib malate cap 12.5 • • • mg (base equivalent) LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg SUTENT – sunitinib malate cap 25 mg • • • (base equivalent) LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg SUTENT – sunitinib malate cap 37.5 • • • mg (base equivalent) leucovorin calcium tab 5 mg SUTENT – sunitinib malate cap 50 mg • • • leucovorin calcium tab 25 mg (base equivalent) LEUKERAN – chlorambucil tab 2 mg SYLATRON – peginterferon alfa-2b for • • • megestrol acetate susp 40 mg/ml inj kit 200 mcg (Megace oral) SYLATRON – peginterferon alfa-2b for • • • megestrol acetate tab 20 mg inj kit 300 mcg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 7 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy SYLATRON – peginterferon alfa-2b for • • • VOTRIENT – pazopanib hcl tab 200 mg • • • inj kit 600 mcg (base equiv) TABLOID – thioguanine tab 40 mg XALKORI – crizotinib cap 200 mg • • • TAFINLAR – dabrafenib mesylate cap • • • XALKORI – crizotinib cap 250 mg • • • 50 mg (base equivalent) XTANDI – enzalutamide cap 40 mg • • • TAFINLAR – dabrafenib mesylate cap • • • ZELBORAF – vemurafenib tab 240 mg • • • 75 mg (base equivalent) ZYTIGA – abiraterone acetate tab 250 • • • tamoxifen citrate tab 10 mg (base mg equivalent) ZYTIGA – abiraterone acetate tab 500 • • • tamoxifen citrate tab 20 mg (base mg equivalent) HORMONES, DIABETES AND RELATED DRUGS TARCEVA – erlotinib hcl tab 25 mg • • • (base equivalent) CORTICOSTEROIDS TARCEVA – erlotinib hcl tab 100 mg • • • budesonide delayed release (base equivalent) particles cap 3 mg (Entocort ec) TARCEVA – erlotinib hcl tab 150 mg • • • CORTISONE ACETATE – cortisone (base equivalent) acetate tab 25 mg TASIGNA – nilotinib hcl cap 150 mg • • • DEXAMETHASONE – dexamethasone (base equivalent) soln 0.5 mg/5ml TASIGNA – nilotinib hcl cap 200 mg • • • dexamethasone elixir 0.5 mg/5ml (base equivalent) dexamethasone tab 0.5 mg temozolomide cap 5 mg (Temodar) • • dexamethasone tab 0.75 mg temozolomide cap 20 mg (Temodar) • • dexamethasone tab 1.5 mg temozolomide cap 100 mg (Temodar) • • dexamethasone tab 4 mg temozolomide cap 140 mg (Temodar) • • dexamethasone tab 6 mg temozolomide cap 180 mg (Temodar) • • fludrocortisone acetate tab 0.1 mg temozolomide cap 250 mg (Temodar) • • hydrocortisone tab 5 mg (Cortef) tretinoin cap 10 mg • • hydrocortisone tab 10 mg (Cortef) TREXALL – methotrexate sodium tab 5 hydrocortisone tab 20 mg (Cortef) mg (base equiv) methylprednisolone tab therapy TREXALL – methotrexate sodium tab pack 4 mg (21) (Medrol dosepak) 7.5 mg (base equiv) methylprednisolone tab 4 mg TREXALL – methotrexate sodium tab (Medrol) 10 mg (base equiv) methylprednisolone tab 8 mg TREXALL – methotrexate sodium tab (Medrol) 15 mg (base equiv)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 8 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy methylprednisolone tab 16 mg testosterone cypionate im inj in oil • • (Medrol) 100 mg/ml (Depo-testosterone) methylprednisolone tab 32 mg testosterone cypionate im inj in oil • • (Medrol) 200 mg/ml (Depo-testosterone) prednisolone sod phosph oral testosterone enanthate im inj in oil • • soln 6.7 mg/5ml (5 mg/5ml base) 200 mg/ml (Pediapred) testosterone td gel 25 mg/2.5gm (1%) • • prednisolone sod phosphate oral (Androgel) soln 15 mg/5ml (base equiv) testosterone td gel 50 mg/5gm (1%) • • prednisolone syrup 15 mg/5ml (usp (Androgel) solution equivalent) (Prelone) testosterone td gel 12.5 mg/act (1%) • • PREDNISONE – prednisone tab 50 mg (Androgel pump) PREDNISONE – prednisone oral soln 5 ESTROGENS mg/5ml COMBIPATCH – estradiol- PREDNISONE INTENSOL – norethindrone ace td pttw 0.05-0.14 prednisone conc 5 mg/ml mg/day prednisone tab 1 mg COMBIPATCH – estradiol- prednisone tab 2.5 mg norethindrone ace td pttw 0.05-0.25 mg/day prednisone tab 5 mg DIVIGEL – estradiol td gel 0.25 prednisone tab 10 mg mg/0.25gm (0.1%) prednisone tab 20 mg DIVIGEL – estradiol td gel 0.5 MALE HORMONES mg/0.5gm (0.1%) ANDROGEL – testosterone td gel • • DIVIGEL – estradiol td gel 1 mg/gm 20.25 mg/1.25gm (1.62%) (0.1%) ANDROGEL – testosterone td gel 40.5 • • estradiol & norethindrone acetate mg/2.5gm (1.62%) tab 0.5-0.1 mg (Activella) ANDROGEL PUMP – testosterone td • • estradiol & norethindrone acetate gel 20.25 mg/act (1.62%) tab 1-0.5 mg (Activella) ANDROXY – fluoxymesterone tab 10 • estradiol tab 0.5 mg (Estrace) mg estradiol tab 1 mg (Estrace) AXIRON – testosterone td soln 30 mg/ • • estradiol tab 2 mg (Estrace) act estradiol td patch twice weekly • danazol cap 50 mg • 0.025 mg/24hr (Vivelle-dot) danazol cap 100 mg • estradiol td patch twice weekly • danazol cap 200 mg • 0.0375 mg/24hr (Vivelle-dot)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 9 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy estradiol td patch twice weekly • BIRTH CONTROL 0.05 mg/24hr (Vivelle-dot) ELLA – ulipristal acetate tab 30 mg • estradiol td patch twice weekly • MIRENA – levonorgestrel releasing iud 0.075 mg/24hr (Vivelle-dot) 20 mcg/day (52 mg total) estradiol td patch twice weekly • NUVARING – etonogestrel-ethinyl • 0.1 mg/24hr (Vivelle-dot) estradiol va ring 0.120-0.015 mg/24hr estradiol td patch weekly • oral contraceptives– all generics • 0.025 mg/24hr (Climara) SKYLA – levonorgestrel releasing iud estradiol td patch weekly • 14 mcg/day (13.5 mg total) 0.0375 mg/24hr (37.5 mcg/24hr) (Climara) INFERTILITY estradiol td patch weekly • chorionic gonadotropin for inj 10000 • • 0.05 mg/24hr (Climara) unit estradiol td patch weekly • FOLLISTIM AQ – follitropin beta inj 75 • • 0.06 mg/24hr (Climara) unit/0.5ml estradiol td patch weekly • FOLLISTIM AQ – follitropin beta inj 300 • • 0.075 mg/24hr (Climara) unit/0.36ml estradiol td patch weekly • FOLLISTIM AQ – follitropin beta inj 600 • • 0.1 mg/24hr (Climara) unit/0.72ml norethindrone acetate-ethinyl FOLLISTIM AQ – follitropin beta inj 900 • • estradiol tab 0.5 mg-2.5 mcg unit/1.08ml (Femhrt low dose) GANIRELIX ACETATE – ganirelix • • norethindrone acetate-ethinyl acetate inj 250 mcg/0.5ml estradiol tab 1 mg-5 mcg DIABETES PROGESTINS acarbose tab 25 mg (Precose) medroxyprogesterone acetate tab acarbose tab 50 mg (Precose) (Provera) 2.5 mg acarbose tab 100 mg (Precose) medroxyprogesterone acetate tab BYDUREON – exenatide for inj • • 5 mg (Provera) extended release susp 2 mg medroxyprogesterone acetate tab BYDUREON PEN – exenatide • • 10 mg (Provera) extended release for susp pen- norethindrone acetate tab 5 mg injector 2 mg (Aygestin) glimepiride tab 1 mg (Amaryl) progesterone micronized cap 100 mg glimepiride tab 2 mg (Amaryl) (Prometrium) glimepiride tab 4 mg (Amaryl) progesterone micronized cap 200 mg (Prometrium) glipizide tab sr 24hr 2.5 mg (Glucotrol xl)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 10 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy glipizide tab sr 24hr 5 mg (Glucotrol INVOKAMET XR – canagliflozin- • xl) metformin hcl tab sr 24hr 50-500 mg glipizide tab sr 24hr 10 mg (Glucotrol INVOKAMET XR – canagliflozin- • xl) metformin hcl tab sr 24hr 50-1000 mg glipizide tab 5 mg (Glucotrol) INVOKAMET XR – canagliflozin- • glipizide tab 10 mg (Glucotrol) metformin hcl tab sr 24hr 150-500 mg glipizide-metformin hcl tab INVOKAMET XR – canagliflozin- • 2.5-250 mg metformin hcl tab sr 24hr 150-1000 mg glipizide-metformin hcl tab 2.5-500 mg INVOKANA – canagliflozin tab 100 mg • glipizide-metformin hcl tab 5-500 mg INVOKANA – canagliflozin tab 300 mg • GLUCAGON EMERGENCY KIT – JANUMET – sitagliptin-metformin hcl • glucagon (rdna) for inj kit 1 mg tab 50-500 mg glyburide micronized tab 1.5 mg JANUMET – sitagliptin-metformin hcl • (Glynase) tab 50-1000 mg glyburide micronized tab 3 mg JANUMET XR – sitagliptin-metformin • (Glynase) hcl tab sr 24hr 50-500 mg glyburide micronized tab 6 mg JANUMET XR – sitagliptin-metformin • (Glynase) hcl tab sr 24hr 50-1000 mg glyburide tab 1.25 mg JANUMET XR – sitagliptin-metformin • hcl tab sr 24hr 100-1000 mg glyburide tab 2.5 mg JANUVIA – sitagliptin phosphate tab 25 • glyburide tab 5 mg mg (base equiv) glyburide-metformin tab 1.25-250 mg JANUVIA – sitagliptin phosphate tab 50 • (Glucovance) mg (base equiv) glyburide-metformin tab 2.5-500 mg JANUVIA – sitagliptin phosphate tab • (Glucovance) 100 mg (base equiv) glyburide-metformin tab 5-500 mg JARDIANCE – empagliflozin tab 10 mg • (Glucovance) JARDIANCE – empagliflozin tab 25 mg • INVOKAMET – canagliflozin-metformin • hcl tab 50-500 mg KOMBIGLYZE XR – saxagliptin- • metformin hcl tab sr 24hr 2.5-1000 INVOKAMET – canagliflozin-metformin • mg hcl tab 50-1000 mg KOMBIGLYZE XR – saxagliptin- • INVOKAMET – canagliflozin-metformin • metformin hcl tab sr 24hr 5-500 mg hcl tab 150-500 mg KOMBIGLYZE XR – saxagliptin- • INVOKAMET – canagliflozin-metformin • metformin hcl tab sr 24hr 5-1000 mg hcl tab 150-1000 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 11 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy metformin hcl tab sr 24hr 500 mg VICTOZA – liraglutide soln pen-injector • • (Glucophage xr) 18 mg/3ml (6 mg/ml) metformin hcl tab sr 24hr 750 mg DIABETES - INSULINS (Glucophage xr) Rapid-Acting Insulins metformin hcl tab 500 mg NOVOLOG – insulin aspart inj 100 unit/ • (Glucophage) ml metformin hcl tab 850 mg NOVOLOG FLEXPEN – insulin aspart • (Glucophage) soln pen-injector 100 unit/ml metformin hcl tab 1000 mg NOVOLOG PENFILL – insulin aspart • (Glucophage) soln cartridge 100 unit/ml nateglinide tab 60 mg (Starlix) Short-Acting Insulins nateglinide tab 120 mg (Starlix) HUMULIN R U-500 (CONCENTR – • ONGLYZA – saxagliptin hcl tab 2.5 mg • insulin regular (human) inj 500 unit/ml (base equiv) HUMULIN R U-500 KWIKPEN – insulin • ONGLYZA – saxagliptin hcl tab 5 mg • regular (human) soln pen-injector 500 (base equiv) unit/ml pioglitazone hcl tab 15 mg (base NOVOLIN R – insulin regular (human) • equiv) (Actos) inj 100 unit/ml pioglitazone hcl tab 30 mg (base Intermediate-Acting Insulins equiv) (Actos) NOVOLIN N – insulin nph (human) • pioglitazone hcl tab 45 mg (base (isophane) inj 100 unit/ml equiv) (Actos) NOVOLIN 70/30 – insulin nph isophane • pioglitazone hcl-metformin hcl tab & regular human inj 100 unit/ml 15-500 mg (Actoplus met) (70-30) pioglitazone hcl-metformin hcl tab NOVOLOG MIX 70/30 – insulin aspart • 15-850 mg (Actoplus met) prot & aspart (human) inj 100 unit/ml repaglinide tab 0.5 mg (Prandin) (70-30) repaglinide tab 1 mg (Prandin) NOVOLOG MIX 70/30 PREFILL – • insulin aspart prot & aspart sus pen- repaglinide tab 2 mg (Prandin) inj 100 unit/ml (70-30) SYNJARDY – empagliflozin-metformin • Basal Insulins hcl tab 5-500 mg LANTUS – insulin glargine inj 100 unit/ • SYNJARDY – empagliflozin-metformin • ml hcl tab 5-1000 mg LANTUS SOLOSTAR – insulin glargine • SYNJARDY – empagliflozin-metformin • soln pen-injector 100 unit/ml hcl tab 12.5-500 mg LEVEMIR – insulin detemir inj 100 unit/ • SYNJARDY – empagliflozin-metformin • ml hcl tab 12.5-1000 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 12 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy LEVEMIR FLEXTOUCH – insulin • liothyronine sodium tab 25 mcg detemir soln pen-injector 100 unit/ml (Cytomel) TOUJEO SOLOSTAR – insulin glargine • liothyronine sodium tab 50 mcg soln pen-injector 300 unit/ml (Cytomel) TRESIBA FLEXTOUCH – insulin • methimazole tab 5 mg (Tapazole) degludec soln pen-injector 100 unit/ methimazole tab 10 mg (Tapazole) ml propylthiouracil tab 50 mg TRESIBA FLEXTOUCH – insulin • degludec soln pen-injector 200 unit/ GROWTH HORMONE ml INCRELEX – mecasermin inj 40 • THYROID REGULATION mg/4ml (10 mg/ml) levothyroxine sodium tab 25 mcg OMNITROPE – somatropin for inj 5.8 • • (Synthroid) mg levothyroxine sodium tab 50 mcg OMNITROPE – somatropin inj 5 • • (Synthroid) mg/1.5ml levothyroxine sodium tab 75 mcg OMNITROPE – somatropin inj 10 • • (Synthroid) mg/1.5ml levothyroxine sodium tab 88 mcg OTHER HORMONES AND RELATED DRUGS (Synthroid) alendronate sodium tab 5 mg • levothyroxine sodium tab 100 mcg alendronate sodium tab 10 mg • (Synthroid) alendronate sodium tab 35 mg • levothyroxine sodium tab 112 mcg alendronate sodium tab 70 mg • (Synthroid) (Fosamax) levothyroxine sodium tab 125 mcg cabergoline tab 0.5 mg (Synthroid) calcitonin (salmon) nasal soln 200 levothyroxine sodium tab 137 mcg unit/act (Miacalcin) (Synthroid) calcitriol cap 0.25 mcg (Rocaltrol) levothyroxine sodium tab 150 mcg (Synthroid) calcitriol cap 0.5 mcg (Rocaltrol) levothyroxine sodium tab 175 mcg calcitriol oral soln 1 mcg/ml (Synthroid) (Rocaltrol) levothyroxine sodium tab 200 mcg desmopressin acetate inj 4 mcg/ml (Synthroid) (Ddavp) levothyroxine sodium tab 300 mcg desmopressin acetate nasal soln (Synthroid) 0.01% (refrigerated) (Ddavp) liothyronine sodium tab 5 mcg desmopressin acetate nasal spray (Cytomel) soln 0.01% (Ddavp)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 13 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy desmopressin acetate nasal spray risedronate sodium tab 35 mg • soln 0.01% (refrigerated) (Actonel) desmopressin acetate tab 0.1 mg risedronate sodium tab 150 mg • (Ddavp) (Actonel) desmopressin acetate tab 0.2 mg SENSIPAR – cinacalcet hcl tab 30 mg (Ddavp) (base equiv) FORTEO – teriparatide (recombinant) • • • SENSIPAR – cinacalcet hcl tab 60 mg inj 600 mcg/2.4ml (base equiv) ibandronate sodium tab 150 mg • SENSIPAR – cinacalcet hcl tab 90 mg (base equivalent) (Boniva) (base equiv) levocarnitine oral soln 1 gm/10ml STIMATE – desmopressin acetate (10%) (Carnitor) nasal soln 1.5 mg/ml levocarnitine tab 330 mg (Carnitor) STRENSIQ – asfotase alfa • • octreotide acetate inj 50 mcg/ml • subcutaneous inj 18 mg/0.45ml (0.05 mg/ml) (Sandostatin) STRENSIQ – asfotase alfa • • octreotide acetate inj 100 mcg/ml • subcutaneous inj 28 mg/0.7ml (0.1 mg/ml) (Sandostatin) STRENSIQ – asfotase alfa • • octreotide acetate inj 200 mcg/ml • subcutaneous inj 40 mg/ml (0.2 mg/ml) (Sandostatin) STRENSIQ – asfotase alfa • • octreotide acetate inj 500 mcg/ml • subcutaneous inj 80 mg/0.8ml (0.5 mg/ml) (Sandostatin) HEART AND CIRCULATORY DRUGS octreotide acetate inj 1000 mcg/ml • ANGIOTENSIN CONVERTING ENZYME (ACE) (1 mg/ml) (Sandostatin) INHIBITORS AND COMBINATI ORFADIN – nitisinone susp 4 mg/ml • benazepril & hydrochlorothiazide tab ORFADIN – nitisinone cap 2 mg • 5-6.25 mg ORFADIN – nitisinone cap 5 mg • benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) ORFADIN – nitisinone cap 10 mg • benazepril & hydrochlorothiazide tab ORFADIN – nitisinone cap 20 mg • 20-12.5 mg (Lotensin hct) paricalcitol cap 1 mcg (Zemplar) benazepril & hydrochlorothiazide tab paricalcitol cap 2 mcg (Zemplar) 20-25 mg (Lotensin hct) paricalcitol cap 4 mcg (Zemplar) benazepril hcl tab 5 mg raloxifene hcl tab 60 mg (Evista) benazepril hcl tab 10 mg (Lotensin) risedronate sodium tab 5 mg • benazepril hcl tab 20 mg (Lotensin) (Actonel) benazepril hcl tab 40 mg (Lotensin) risedronate sodium tab 30 mg • captopril tab 12.5 mg (Actonel)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 14 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy captopril tab 25 mg moexipril-hydrochlorothiazide tab captopril tab 50 mg 7.5-12.5 mg captopril tab 100 mg moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic) enalapril maleate & hydrochlorothiazide tab 5-12.5 mg moexipril-hydrochlorothiazide tab 15-25 mg enalapril maleate & hydrochlorothiazide tab 10-25 mg perindopril erbumine tab 2 mg (Vaseretic) perindopril erbumine tab 4 mg enalapril maleate tab 2.5 mg (Aceon) (Vasotec) perindopril erbumine tab 8 mg enalapril maleate tab 5 mg (Vasotec) (Aceon) enalapril maleate tab 10 mg (Vasotec) quinapril hcl tab 5 mg (Accupril) enalapril maleate tab 20 mg (Vasotec) quinapril hcl tab 10 mg (Accupril) fosinopril sodium & quinapril hcl tab 20 mg (Accupril) hydrochlorothiazide tab 10-12.5 mg quinapril hcl tab 40 mg (Accupril) fosinopril sodium & quinapril-hydrochlorothiazide tab hydrochlorothiazide tab 20-12.5 mg 10-12.5 mg (Accuretic) fosinopril sodium tab 10 mg quinapril-hydrochlorothiazide tab fosinopril sodium tab 20 mg 20-12.5 mg (Accuretic) fosinopril sodium tab 40 mg quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) ramipril cap 1.25 mg (Altace) lisinopril & hydrochlorothiazide tab ramipril cap 2.5 mg (Altace) 20-12.5 mg (Zestoretic) ramipril cap 5 mg (Altace) lisinopril & hydrochlorothiazide tab ramipril cap 10 mg (Altace) 20-25 mg (Zestoretic) trandolapril tab 1 mg (Mavik) lisinopril tab 2.5 mg (Zestril) trandolapril tab 2 mg (Mavik) lisinopril tab 5 mg (Prinivil) trandolapril tab 4 mg (Mavik) lisinopril tab 10 mg (Prinivil) ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) lisinopril tab 20 mg (Prinivil) AND COMBINATIONS lisinopril tab 30 mg (Zestril) amlodipine-valsartan- lisinopril tab 40 mg (Zestril) hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct) moexipril hcl tab 7.5 mg (Univasc) amlodipine-valsartan- moexipril hcl tab 15 mg (Univasc) hydrochlorothiazide tab 5-160-25 mg (Exforge hct)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 15 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy amlodipine-valsartan- candesartan cilexetil- hydrochlorothiazide tab hydrochlorothiazide tab 32-25 mg 10-160-12.5 mg (Exforge hct) (Atacand hct) amlodipine-valsartan- irbesartan tab 75 mg (Avapro) hydrochlorothiazide tab irbesartan tab 150 mg (Avapro) 10-160-25 mg (Exforge hct) irbesartan tab 300 mg (Avapro) amlodipine-valsartan- hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab 10-320-25 mg (Exforge hct) 150-12.5 mg (Avalide) BENICAR – olmesartan medoxomil tab irbesartan-hydrochlorothiazide tab 5 mg 300-12.5 mg (Avalide) BENICAR – olmesartan medoxomil tab losartan potassium & 20 mg hydrochlorothiazide tab 50-12.5 mg (Hyzaar) BENICAR – olmesartan medoxomil tab 40 mg losartan potassium & hydrochlorothiazide tab BENICAR HCT – olmesartan 100-12.5 mg (Hyzaar) medoxomil-hydrochlorothiazide tab 20-12.5 mg losartan potassium & hydrochlorothiazide tab 100-25 mg BENICAR HCT – olmesartan (Hyzaar) medoxomil-hydrochlorothiazide tab 40-12.5 mg losartan potassium tab 25 mg (Cozaar) BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab losartan potassium tab 50 mg 40-25 mg (Cozaar) candesartan cilexetil tab 4 mg losartan potassium tab 100 mg (Atacand) (Cozaar) candesartan cilexetil tab 8 mg olmesartan medoxomil tab 5 mg (Atacand) (Benicar) candesartan cilexetil tab 16 mg olmesartan medoxomil tab 20 mg (Atacand) (Benicar) candesartan cilexetil tab 32 mg olmesartan medoxomil tab 40 mg (Atacand) (Benicar) candesartan cilexetil- olmesartan medoxomil- hydrochlorothiazide tab 16-12.5 mg hydrochlorothiazide tab 20-12.5 mg (Atacand hct) (Benicar hct) candesartan cilexetil- olmesartan medoxomil- hydrochlorothiazide tab 32-12.5 mg hydrochlorothiazide tab 40-12.5 mg (Atacand hct) (Benicar hct)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 16 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy olmesartan medoxomil- bisoprolol & hydrochlorothiazide tab hydrochlorothiazide tab 40-25 mg 2.5-6.25 mg (Ziac) (Benicar hct) bisoprolol & hydrochlorothiazide tab telmisartan tab 20 mg (Micardis) 5-6.25 mg (Ziac) telmisartan tab 40 mg (Micardis) bisoprolol & hydrochlorothiazide tab telmisartan tab 80 mg (Micardis) 10-6.25 mg (Ziac) telmisartan-hydrochlorothiazide tab bisoprolol fumarate tab 5 mg 40-12.5 mg (Micardis hct) (Zebeta) telmisartan-hydrochlorothiazide tab bisoprolol fumarate tab 10 mg 80-12.5 mg (Micardis hct) (Zebeta) telmisartan-hydrochlorothiazide tab carvedilol tab 3.125 mg (Coreg) 80-25 mg (Micardis hct) carvedilol tab 6.25 mg (Coreg) valsartan tab 40 mg (Diovan) carvedilol tab 12.5 mg (Coreg) valsartan tab 80 mg (Diovan) carvedilol tab 25 mg (Coreg) valsartan tab 160 mg (Diovan) INNOPRAN XL – propranolol hcl valsartan tab 320 mg (Diovan) sustained-release beads cap sr 24hr 80 mg valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) INNOPRAN XL – propranolol hcl sustained-release beads cap sr 24hr valsartan-hydrochlorothiazide tab 120 mg 160-12.5 mg (Diovan hct) labetalol hcl tab 100 mg (Trandate) valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) labetalol hcl tab 200 mg (Trandate) valsartan-hydrochlorothiazide tab labetalol hcl tab 300 mg (Trandate) 320-12.5 mg (Diovan hct) metoprolol & hydrochlorothiazide valsartan-hydrochlorothiazide tab tab 50-25 mg (Lopressor hct) 320-25 mg (Diovan hct) metoprolol & hydrochlorothiazide BETA BLOCKERS AND COMBINATIONS tab 100-25 mg (Lopressor hct) acebutolol hcl cap 200 mg (Sectral) metoprolol & hydrochlorothiazide tab 100-50 mg acebutolol hcl cap 400 mg (Sectral) metoprolol succinate tab sr 24hr atenolol & chlorthalidone tab 25 mg (tartrate equiv) (Toprol xl) 50-25 mg (Tenoretic 50) metoprolol succinate tab sr 24hr atenolol & chlorthalidone tab 50 mg (tartrate equiv) (Toprol xl) 100-25 mg (Tenoretic 100) metoprolol succinate tab sr 24hr atenolol tab 25 mg (Tenormin) 100 mg (tartrate equiv) (Toprol xl) atenolol tab 50 mg (Tenormin) metoprolol succinate tab sr 24hr atenolol tab 100 mg (Tenormin) 200 mg (tartrate equiv) (Toprol xl)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 17 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy metoprolol tartrate tab 25 mg amlodipine besylate tab 2.5 mg metoprolol tartrate tab 50 mg (Norvasc) (Lopressor) amlodipine besylate tab 5 mg metoprolol tartrate tab 100 mg (Norvasc) (Lopressor) amlodipine besylate tab 10 mg nadolol tab 20 mg (Corgard) (Norvasc) nadolol tab 40 mg (Corgard) amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet) nadolol tab 80 mg (Corgard) amlodipine besylate-atorvastatin pindolol tab 5 mg calcium tab 2.5-20 mg (Caduet) pindolol tab 10 mg amlodipine besylate-atorvastatin PROPRANOLOL HCL – propranolol hcl calcium tab 2.5-40 mg (Caduet) oral soln 20 mg/5ml amlodipine besylate-atorvastatin PROPRANOLOL HCL – propranolol hcl calcium tab 5-10 mg (Caduet) oral soln 40 mg/5ml amlodipine besylate-atorvastatin propranolol hcl cap sr 24hr 60 mg calcium tab 5-20 mg (Caduet) (Inderal la) amlodipine besylate-atorvastatin propranolol hcl cap sr 24hr 80 mg calcium tab 5-40 mg (Caduet) (Inderal la) amlodipine besylate-atorvastatin propranolol hcl cap sr 24hr 120 mg calcium tab 5-80 mg (Caduet) (Inderal la) amlodipine besylate-atorvastatin propranolol hcl cap sr 24hr 160 mg calcium tab 10-10 mg (Caduet) (Inderal la) amlodipine besylate-atorvastatin propranolol hcl tab 10 mg calcium tab 10-20 mg (Caduet) propranolol hcl tab 20 mg amlodipine besylate-atorvastatin (Caduet) propranolol hcl tab 40 mg calcium tab 10-40 mg propranolol hcl tab 60 mg amlodipine besylate-atorvastatin calcium tab 10-80 mg (Caduet) propranolol hcl tab 80 mg amlodipine besylate-benazepril hcl TIMOLOL MALEATE – timolol maleate cap 2.5-10 mg (Lotrel) tab 5 mg amlodipine besylate-benazepril hcl TIMOLOL MALEATE – timolol maleate cap 5-10 mg (Lotrel) tab 10 mg amlodipine besylate-benazepril hcl TIMOLOL MALEATE – timolol maleate cap 5-20 mg (Lotrel) tab 20 mg amlodipine besylate-benazepril hcl CALCIUM CHANNEL BLOCKERS AND cap 5-40 mg (Lotrel) COMBINATIONS
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 18 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy amlodipine besylate-benazepril hcl diltiazem hcl tab 30 mg (Cardizem) cap 10-20 mg (Lotrel) diltiazem hcl tab 60 mg (Cardizem) amlodipine besylate-benazepril hcl diltiazem hcl tab 90 mg cap 10-40 mg (Lotrel) diltiazem hcl tab 120 mg (Cardizem) amlodipine besylate-valsartan tab 5-160 mg (Exforge) ENTRESTO – sacubitril-valsartan tab • • 24-26 mg amlodipine besylate-valsartan tab 5-320 mg (Exforge) ENTRESTO – sacubitril-valsartan tab • • 49-51 mg amlodipine besylate-valsartan tab 10-160 mg (Exforge) ENTRESTO – sacubitril-valsartan tab • • 97-103 mg amlodipine besylate-valsartan tab 10-320 mg (Exforge) felodipine tab sr 24hr 2.5 mg diltiazem hcl cap sr 24hr 120 mg felodipine tab sr 24hr 5 mg diltiazem hcl cap sr 24hr 180 mg felodipine tab sr 24hr 10 mg diltiazem hcl cap sr 24hr 240 mg nifedipine tab sr 24hr 30 mg (Adalat cc) diltiazem hcl coated beads cap sr • 24hr 120 mg (Cardizem cd) nifedipine tab sr 24hr 60 mg (Adalat cc) diltiazem hcl coated beads cap sr • 24hr 180 mg (Cardizem cd) nifedipine tab sr 24hr 90 mg (Adalat cc) diltiazem hcl coated beads cap sr • 24hr 240 mg (Cardizem cd) nifedipine tab sr 24hr osmotic release 30 mg (Procardia xl) diltiazem hcl coated beads cap sr • 24hr 300 mg (Cardizem cd) nifedipine tab sr 24hr osmotic release 60 mg (Procardia xl) diltiazem hcl coated beads cap sr • 24hr 360 mg (Cardizem cd) nifedipine tab sr 24hr osmotic release 90 mg (Procardia xl) diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac) verapamil hcl cap sr 24hr 120 mg (Verelan) diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac) verapamil hcl cap sr 24hr 180 mg (Verelan) diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac) verapamil hcl cap sr 24hr 240 mg (Verelan) diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac) verapamil hcl cap sr 24hr 360 mg (Verelan) diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac) verapamil hcl tab cr 120 mg (Calan sr) diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 19 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy verapamil hcl tab cr 180 mg (Calan NITROSTAT – nitroglycerin sl tab 0.6 sr) mg verapamil hcl tab cr 240 mg (Calan CHOLESTEROL LOWERING sr) atorvastatin calcium tab 10 mg (base verapamil hcl tab 40 mg equivalent) (Lipitor) verapamil hcl tab 80 mg (Calan) atorvastatin calcium tab 20 mg (base verapamil hcl tab 120 mg (Calan) equivalent) (Lipitor) CHEST PAIN atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) isosorbide dinitrate tab 5 mg (Isordil titradose) atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) isosorbide dinitrate tab 10 mg cholestyramine light powder packets isosorbide dinitrate tab 20 mg 4 gm isosorbide dinitrate tab 30 mg cholestyramine light powder 4 gm/ isosorbide mononitrate tab sr 24hr dose (Questran light) 30 mg (Imdur) cholestyramine powder packets isosorbide mononitrate tab sr 24hr 4 gm (Questran) 60 mg (Imdur) cholestyramine powder 4 gm/dose isosorbide mononitrate tab sr 24hr (Questran) 120 mg (Imdur) choline fenofibrate cap dr 45 mg • isosorbide mononitrate tab 10 mg (fenofibric acid equiv) (Trilipix) isosorbide mononitrate tab 20 mg choline fenofibrate cap dr 135 mg • (Trilipix) nitroglycerin sl tab 0.3 mg (Nitrostat) (fenofibric acid equiv) nitroglycerin sl tab 0.4 mg (Nitrostat) colestipol hcl granule packets 5 gm (Colestid flavored) nitroglycerin sl tab 0.6 mg (Nitrostat) colestipol hcl granules 5 gm (Colestid nitroglycerin td patch 24hr 0.1 mg/hr flavored) (Nitro-dur) colestipol hcl tab 1 gm (Colestid) nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) ezetimibe tab 10 mg (Zetia) • nitroglycerin td patch 24hr 0.4 mg/hr fenofibrate micronized cap 67 mg • (Nitro-dur) (Lofibra) nitroglycerin td patch 24hr 0.6 mg/hr fenofibrate micronized cap 134 mg • (Nitro-dur) (Lofibra) NITROSTAT – nitroglycerin sl tab 0.3 fenofibrate micronized cap 200 mg • mg (Lofibra) NITROSTAT – nitroglycerin sl tab 0.4 fenofibrate tab 48 mg (Tricor) • mg fenofibrate tab 54 mg (Lofibra) •
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 20 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy fenofibrate tab 145 mg (Tricor) • rosuvastatin calcium tab 20 mg fenofibrate tab 160 mg (Lofibra) • (Crestor) gemfibrozil tab 600 mg (Lopid) • rosuvastatin calcium tab 40 mg (Crestor) lovastatin tab 10 mg simvastatin tab 5 mg (Zocor) lovastatin tab 20 mg (Mevacor) simvastatin tab 10 mg (Zocor) lovastatin tab 40 mg (Mevacor) simvastatin tab 20 mg (Zocor) niacin tab cr 500 mg (antihyperlipidemic) (Niaspan) simvastatin tab 40 mg (Zocor) niacin tab cr 750 mg simvastatin tab 80 mg (Zocor) (antihyperlipidemic) (Niaspan) WELCHOL – colesevelam hcl tab 625 niacin tab cr 1000 mg mg (antihyperlipidemic) (Niaspan) WELCHOL – colesevelam hcl packet PRALUENT – alirocumab • • • for susp 3.75 gm subcutaneous soln pen-injector 75 FLUID RETENTION mg/ml acetazolamide cap sr 12hr 500 mg PRALUENT – alirocumab • • • (Diamox) subcutaneous soln pen-injector 150 acetazolamide tab 125 mg mg/ml acetazolamide tab 250 mg pravastatin sodium tab 10 mg amiloride & hydrochlorothiazide tab pravastatin sodium tab 20 mg 5-50 mg (Pravachol) amiloride hcl tab 5 mg pravastatin sodium tab 40 mg (Pravachol) bumetanide tab 0.5 mg pravastatin sodium tab 80 mg bumetanide tab 1 mg (Pravachol) bumetanide tab 2 mg REPATHA – evolocumab subcutaneous • • • chlorothiazide tab 500 mg soln prefilled syringe 140 mg/ml chlorthalidone tab 25 mg REPATHA PUSHTRONEX SYSTEM • • • chlorthalidone tab 50 mg – evolocumab subcutaneous soln cartridge/infusor 420 mg/3.5ml furosemide oral soln 10 mg/ml REPATHA SURECLICK – evolocumab • • • furosemide tab 20 mg (Lasix) subcutaneous soln auto-injector 140 furosemide tab 40 mg (Lasix) mg/ml furosemide tab 80 mg (Lasix) rosuvastatin calcium tab 5 mg hydrochlorothiazide cap 12.5 mg (Crestor) (Microzide) rosuvastatin calcium tab 10 mg hydrochlorothiazide tab 12.5 mg (Crestor)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 21 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy hydrochlorothiazide tab 25 mg disopyramide phosphate cap 150 mg hydrochlorothiazide tab 50 mg (Norpace) indapamide tab 1.25 mg flecainide acetate tab 50 mg indapamide tab 2.5 mg flecainide acetate tab 100 mg methazolamide tab 25 mg flecainide acetate tab 150 mg (Neptazane) mexiletine hcl cap 150 mg methazolamide tab 50 mg mexiletine hcl cap 200 mg (Neptazane) mexiletine hcl cap 250 mg metolazone tab 2.5 mg (Zaroxolyn) MULTAQ – dronedarone hcl tab 400 mg metolazone tab 5 mg (Zaroxolyn) (base equivalent) metolazone tab 10 mg propafenone hcl cap sr 12hr 225 mg spironolactone & (Rythmol sr) hydrochlorothiazide tab 25-25 mg propafenone hcl cap sr 12hr 325 mg (Aldactazide) (Rythmol sr) spironolactone tab 25 mg (Aldactone) propafenone hcl cap sr 12hr 425 mg spironolactone tab 50 mg (Aldactone) (Rythmol sr) spironolactone tab 100 mg propafenone hcl tab 150 mg (Aldactone) (Rythmol) torsemide tab 5 mg (Demadex) propafenone hcl tab 225 mg (Rythmol) torsemide tab 10 mg (Demadex) propafenone hcl tab 300 mg torsemide tab 20 mg (Demadex) quinidine gluconate tab cr 324 mg torsemide tab 100 mg (Demadex) sotalol hcl (afib/afl) tab 80 mg triamterene & hydrochlorothiazide (Betapace af) cap 37.5-25 mg (Dyazide) sotalol hcl (afib/afl) tab 120 mg triamterene & hydrochlorothiazide (Betapace af) tab 37.5-25 mg (Maxzide-25) sotalol hcl (afib/afl) tab 160 mg triamterene & hydrochlorothiazide (Betapace af) tab 75-50 mg (Maxzide) sotalol hcl tab 80 mg (Betapace) HEART RHYTHM sotalol hcl tab 120 mg (Betapace) amiodarone hcl tab 100 mg sotalol hcl tab 160 mg (Betapace) amiodarone hcl tab 200 mg (Cordarone) sotalol hcl tab 240 mg amiodarone hcl tab 400 mg OTHER HEART RELATED DRUGS disopyramide phosphate cap 100 mg ADCIRCA – tadalafil tab 20 mg (pah) • • • (Norpace) clonidine hcl tab 0.1 mg (Catapres)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 22 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy clonidine hcl tab 0.2 mg (Catapres) minoxidil tab 2.5 mg clonidine hcl tab 0.3 mg (Catapres) minoxidil tab 10 mg clonidine hcl td patch weekly OPSUMIT – macitentan tab 10 mg • • • 0.1 mg/24hr (Catapres-tts-1) phenoxybenzamine hcl cap 10 mg clonidine hcl td patch weekly (Dibenzyline) 0.2 mg/24hr (Catapres-tts-2) prazosin hcl cap 1 mg (Minipress) clonidine hcl td patch weekly prazosin hcl cap 2 mg (Minipress) 0.3 mg/24hr (Catapres-tts-3) prazosin hcl cap 5 mg (Minipress) digoxin tab 125 mcg (0.125 mg) (Lanoxin) sildenafil citrate tab 20 mg (Revatio) • • digoxin tab 250 mcg (0.25 mg) terazosin hcl cap 1 mg (Lanoxin) terazosin hcl cap 2 mg doxazosin mesylate tab 1 mg terazosin hcl cap 5 mg (Cardura) terazosin hcl cap 10 mg doxazosin mesylate tab 2 mg TRACLEER – bosentan tab 62.5 mg • • • (Cardura) TRACLEER – bosentan tab 125 mg • • • doxazosin mesylate tab 4 mg (Cardura) UPTRAVI – selexipag tab therapy pack • • • 200 mcg (140) & 800 mcg (60) doxazosin mesylate tab 8 mg (Cardura) UPTRAVI – selexipag tab 200 mcg • • • eplerenone tab 25 mg (Inspra) UPTRAVI – selexipag tab 400 mcg • • • eplerenone tab 50 mg (Inspra) UPTRAVI – selexipag tab 600 mcg • • • guanfacine hcl tab 1 mg (Tenex) UPTRAVI – selexipag tab 800 mcg • • • guanfacine hcl tab 2 mg (Tenex) UPTRAVI – selexipag tab 1000 mcg • • • hydralazine hcl tab 10 mg UPTRAVI – selexipag tab 1200 mcg • • • hydralazine hcl tab 25 mg UPTRAVI – selexipag tab 1400 mcg • • • hydralazine hcl tab 50 mg UPTRAVI – selexipag tab 1600 mcg • • • hydralazine hcl tab 100 mg ERECTILE DYSFUNCTION LETAIRIS – ambrisentan tab 5 mg • • • CIALIS – tadalafil tab 2.5 mg • • LETAIRIS – ambrisentan tab 10 mg • • • CIALIS – tadalafil tab 5 mg • • methyldopa tab 250 mg CIALIS – tadalafil tab 10 mg • • methyldopa tab 500 mg CIALIS – tadalafil tab 20 mg • • midodrine hcl tab 2.5 mg BEE STING KITS midodrine hcl tab 5 mg EPINEPHRINE (Mylan Products) – epinephrine solution auto-injector midodrine hcl tab 10 mg 0.15 mg/0.3ml (1:2000)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 23 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy EPINEPHRINE (Mylan Products) – ipratropium bromide nasal soln • epinephrine solution auto-injector 0.3 0.03% (21 mcg/spray) (Atrovent) mg/0.3ml (1:1000) ipratropium bromide nasal soln • EPIPEN 2-PAK – epinephrine solution 0.06% (42 mcg/spray) (Atrovent) auto-injector 0.3 mg/0.3ml (1:1000) mometasone furoate nasal susp • EPIPEN-JR 2-PAK – epinephrine 50 mcg/act (Nasonex) solution auto-injector 0.15 mg/0.3ml NASONEX – mometasone furoate • (1:2000) nasal susp 50 mcg/act RESPIRATORY AGENTS triamcinolone acetonide nasal • ANTIHISTAMINES aerosol suspension 55 mcg/act cetirizine hcl oral soln 1 mg/ml (Nasacort aq) (5 mg/5ml) COUGH/COLD/ALLERGY cyproheptadine hcl syrup 2 mg/5ml acetylcysteine inhal soln 10% cyproheptadine hcl tab 4 mg acetylcysteine inhal soln 20% desloratadine tab 5 mg (Clarinex) ASTHMA/COPD levocetirizine dihydrochloride soln ADVAIR DISKUS – fluticasone- • 2.5 mg/5ml (0.5 mg/ml) (Xyzal) salmeterol aer powder ba 100-50 levocetirizine dihydrochloride tab mcg/dose 5 mg (Xyzal) ADVAIR DISKUS – fluticasone- • promethazine hcl suppos 12.5 mg salmeterol aer powder ba 250-50 mcg/dose promethazine hcl suppos 25 mg ADVAIR DISKUS – fluticasone- • promethazine hcl suppos 50 mg salmeterol aer powder ba 500-50 promethazine hcl syrup 6.25 mg/5ml mcg/dose promethazine hcl tab 12.5 mg ADVAIR HFA – fluticasone-salmeterol • inhal aerosol 45-21 mcg/act promethazine hcl tab 25 mg ADVAIR HFA – fluticasone-salmeterol promethazine hcl tab 50 mg • inhal aerosol 115-21 mcg/act NASAL PRODUCTS ADVAIR HFA – fluticasone-salmeterol • azelastine hcl nasal spray 0.1% • inhal aerosol 230-21 mcg/act (137 mcg/spray) albuterol sulfate soln nebu 0.083% • azelastine hcl nasal spray 0.15% • (2.5 mg/3ml) (205.5 mcg/spray) (Astepro) albuterol sulfate soln nebu 0.5% • flunisolide nasal soln 25 mcg/act • (5 mg/ml) (0.025%) albuterol sulfate soln nebu • fluticasone propionate nasal susp • 0.63 mg/3ml (base equiv) 50 mcg/act (Flonase)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 24 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy albuterol sulfate soln nebu • BREO ELLIPTA – fluticasone furoate- • 1.25 mg/3ml (base equiv) vilanterol aero powd ba 100-25 mcg/ albuterol sulfate syrup 2 mg/5ml inh albuterol sulfate tab 2 mg BREO ELLIPTA – fluticasone furoate- • vilanterol aero powd ba 200-25 mcg/ albuterol sulfate tab 4 mg inh ANORO ELLIPTA – umeclidinium- • budesonide inhalation susp • vilanterol aero powd ba 62.5-25 mcg/ 0.25 mg/2ml (Pulmicort) inh budesonide inhalation susp • ARNUITY ELLIPTA – fluticasone • 0.5 mg/2ml (Pulmicort) furoate aerosol powder breath activ 100 mcg/act budesonide inhalation susp • 1 mg/2ml (Pulmicort) ARNUITY ELLIPTA – fluticasone • furoate aerosol powder breath activ COMBIVENT RESPIMAT – • 200 mcg/act ipratropium-albuterol inhal aerosol soln 20-100 mcg/act ASMANEX HFA – mometasone furoate • inhal aerosol suspension 100 mcg/act DULERA – mometasone furoate- • formoterol fumarate aerosol 100-5 ASMANEX HFA – mometasone furoate • mcg/act inhal aerosol suspension 200 mcg/act DULERA – mometasone furoate- • ASMANEX TWISTHALER 120 ME – • formoterol fumarate aerosol 200-5 mometasone furoate inhal powd 220 mcg/act mcg/inh (breath activated) FLOVENT DISKUS – fluticasone • ASMANEX TWISTHALER 14 MET – • propionate aer pow ba 50 mcg/blister mometasone furoate inhal powd 220 mcg/inh (breath activated) FLOVENT DISKUS – fluticasone • propionate aer pow ba 100 mcg/ ASMANEX TWISTHALER 30 MET – • blister mometasone furoate inhal powd 110 mcg/inh (breath activated) FLOVENT DISKUS – fluticasone • propionate aer pow ba 250 mcg/ ASMANEX TWISTHALER 30 MET – • blister mometasone furoate inhal powd 220 mcg/inh (breath activated) FLOVENT HFA – fluticasone • propionate hfa inhal aero 44 mcg/act ASMANEX TWISTHALER 60 MET – • (50/valve) mometasone furoate inhal powd 220 mcg/inh (breath activated) FLOVENT HFA – fluticasone • propionate hfa inhal aer 110 mcg/act ASMANEX TWISTHALER 7 METE – • (125/valve) mometasone furoate inhal powd 110 mcg/inh (breath activated) FLOVENT HFA – fluticasone • propionate hfa inhal aer 220 mcg/act ATROVENT HFA – ipratropium bromide • (250/valve) hfa inhal aerosol 17 mcg/act
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 25 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy INCRUSE ELLIPTA – umeclidinium br • SPIRIVA RESPIMAT – tiotropium • aero powd breath act 62.5 mcg/inh bromide monohydrate inhal aerosol (base eq) 1.25 mcg/act ipratropium bromide inhal soln • SPIRIVA RESPIMAT – tiotropium • 0.02% bromide monohydrate inhal aerosol ipratropium-albuterol nebu soln • 2.5 mcg/act 0.5-2.5(3) mg/3ml (Duoneb) STIOLTO RESPIMAT – tiotropium br- • levalbuterol hcl soln nebu conc • olodaterol inhal aero soln 2.5-2.5 1.25 mg/0.5ml (base equiv) mcg/act levalbuterol hcl soln nebu • STRIVERDI RESPIMAT – olodaterol • 0.31 mg/3ml (base equiv) (Xopenex) hcl inhal aerosol soln 2.5 mcg/act (base equiv) levalbuterol hcl soln nebu • 0.63 mg/3ml (base equiv) (Xopenex) SYMBICORT – budesonide-formoterol • fumarate dihyd aerosol 80-4.5 mcg/ levalbuterol hcl soln nebu • act 1.25 mg/3ml (base equiv) (Xopenex) SYMBICORT – budesonide-formoterol • montelukast sodium chew tab 4 mg fumarate dihyd aerosol 160-4.5 mcg/ (base equiv) (Singulair) act montelukast sodium chew tab 5 mg terbutaline sulfate tab 2.5 mg (base equiv) (Singulair) terbutaline sulfate tab 5 mg montelukast sodium oral granules packet 4 mg (base equiv) (Singulair) theophylline tab sr 12hr 100 mg montelukast sodium tab 10 mg (base theophylline tab sr 12hr 200 mg equiv) (Singulair) theophylline tab sr 12hr 300 mg PROAIR HFA – albuterol sulfate inhal • theophylline tab sr 12hr 450 mg aero 108 mcg/act (90mcg base equiv) theophylline tab sr 24hr 400 mg PROAIR RESPICLICK – albuterol • theophylline tab sr 24hr 600 mg sulfate aer pow ba 108 mcg/act (90 mcg base equiv) VENTOLIN HFA – albuterol sulfate • inhal aero 108 mcg/act (90mcg base QVAR – beclomethasone diprop inhal • equiv) aero soln 40 mcg/act (50/valve) zafirlukast tab 10 mg (Accolate) QVAR – beclomethasone diprop inhal • aero soln 80 mcg/act (100/valve) zafirlukast tab 20 mg (Accolate) SEREVENT DISKUS – salmeterol • OTHER RESPIRATORY DRUGS xinafoate aer pow ba 50 mcg/dose KALYDECO – ivacaftor tab 150 mg • • • (base equiv) KALYDECO – ivacaftor packet 50 mg • • • SPIRIVA HANDIHALER – tiotropium • KALYDECO – ivacaftor packet 75 mg • • • bromide monohydrate inhal cap 18 mcg (base equiv)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 26 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy PULMOZYME – dornase alfa inhal soln • lansoprazole cap delayed release • 1 mg/ml 15 mg (Prevacid) GASTROINTESTINAL DRUGS lansoprazole cap delayed release • LAXATIVES 30 mg (Prevacid) lactulose solution 10 gm/15ml methscopolamine bromide tab 2.5 mg (Pamine) peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack) methscopolamine bromide tab 5 mg (Pamine forte) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) misoprostol tab 100 mcg (Cytotec) peg 3350-kcl-na bicarb-nacl-na misoprostol tab 200 mcg (Cytotec) sulfate for soln 240 gm (Colyte- NEXIUM – esomeprazole magnesium • flavor packs) for delayed release susp pack 2.5 mg ANTIDIARRHEALS NEXIUM – esomeprazole magnesium • diphenoxylate w/ atropine tab for delayed release susp packet 5 mg 2.5-0.025 mg (Lomotil) NEXIUM – esomeprazole magnesium • loperamide hcl cap 2 mg for delayed release susp packet 10 mg ULCER/GERD NEXIUM – esomeprazole magnesium • cimetidine hcl soln 300 mg/5ml for delayed release susp packet 20 cimetidine tab 300 mg mg cimetidine tab 400 mg NEXIUM – esomeprazole magnesium • for delayed release susp packet 40 cimetidine tab 800 mg mg dicyclomine hcl cap 10 mg (Bentyl) omeprazole cap delayed release • dicyclomine hcl oral soln 10 mg/5ml 10 mg (Prilosec) dicyclomine hcl tab 20 mg (Bentyl) omeprazole cap delayed release • esomeprazole magnesium cap • 20 mg (Prilosec) delayed release 20 mg (base eq) omeprazole cap delayed release • (Nexium) 40 mg (Prilosec) esomeprazole magnesium cap • pantoprazole sodium ec tab 20 mg • delayed release 40 mg (base eq) (base equiv) (Protonix) (Nexium) pantoprazole sodium ec tab 40 mg • famotidine tab 20 mg (Pepcid) (base equiv) (Protonix) famotidine tab 40 mg (Pepcid) ranitidine hcl cap 150 mg glycopyrrolate tab 1 mg (Robinul) ranitidine hcl cap 300 mg glycopyrrolate tab 2 mg (Robinul ranitidine hcl syrup 15 mg/ml forte) (75 mg/5ml)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 27 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ranitidine hcl tab 150 mg (Zantac) CREON – pancrelipase (lip-prot-amyl) ranitidine hcl tab 300 mg (Zantac) dr cap 6000-19000-30000 unit sucralfate tab 1 gm (Carafate) CREON – pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit NAUSEA AND VOMITING CREON – pancrelipase (lip-prot-amyl) aprepitant capsule therapy pack 80 & • dr cap 24000-76000-120000 unit 125 mg (Emend) CREON – pancrelipase (lip-prot-amyl) aprepitant capsule 80 mg (Emend) • dr cap 36000-114000-180000 unit EMEND – aprepitant for oral susp 125 • ZENPEP – pancrelipase (lip-prot-amyl) mg (125 mg/5ml) dr cap 3000-10000-16000 unit EMEND – aprepitant capsule therapy • ZENPEP – pancrelipase (lip-prot-amyl) pack 80 & 125 mg dr cap 5000-17000-27000 unit EMEND – aprepitant capsule 40 mg • ZENPEP – pancrelipase (lip-prot-amyl) EMEND – aprepitant capsule 80 mg • dr cap 10000-34000-55000 unit EMEND – aprepitant capsule 125 mg • ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit granisetron hcl tab 1 mg • ZENPEP – pancrelipase (lip-prot-amyl) meclizine hcl tab 12.5 mg dr cap 20000-68000-109000 unit meclizine hcl tab 25 mg ZENPEP – pancrelipase (lip-prot-amyl) ondansetron hcl inj 4 mg/2ml (2 mg/ dr cap 25000-85000-136000 unit ml) ZENPEP – pancrelipase (lip-prot-amyl) ondansetron hcl inj 40 mg/20ml dr cap 40000-136000-218000 unit (2 mg/ml) (Zofran) OTHER GASTROINTESTINAL DRUGS ondansetron hcl oral soln 4 mg/5ml • (Zofran) ASACOL HD – mesalamine tab delayed release 800 mg ondansetron hcl tab 4 mg (Zofran) • balsalazide disodium cap 750 mg ondansetron hcl tab 8 mg (Zofran) • (Colazal) ondansetron hcl tab 24 mg • calcium acetate (phosphate binder) ondansetron orally disintegrating tab • cap 667 mg (169 mg ca) (Phoslo) 4 mg (Zofran odt) calcium acetate (phosphate binder) ondansetron orally disintegrating tab • tab 667 mg (Eliphos) 8 mg (Zofran odt) CANASA – mesalamine suppos 1000 trimethobenzamide hcl cap 300 mg mg (Tigan) CHENODAL – chenodiol tab 250 mg • DIGESTIVE ENZYMES DELZICOL – mesalamine cap dr 400 CREON – pancrelipase (lip-prot-amyl) mg dr cap 3000-9500-15000 unit
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 28 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy lactulose (encephalopathy) solution nitrofurantoin monohydrate 10 gm/15ml macrocrystalline cap 100 mg LIALDA – mesalamine tab delayed (Macrobid) release 1.2 gm nitrofurantoin susp 25 mg/5ml LINZESS – linaclotide cap 72 mcg (Furadantin) LINZESS – linaclotide cap 145 mcg URINARY TRACT SPASMS LINZESS – linaclotide cap 290 mcg oxybutynin chloride syrup 5 mg/5ml mesalamine enema 4 gm oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl) metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) metoclopramide hcl tab 5 mg (Reglan) oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl) metoclopramide hcl tab 10 mg (Reglan) oxybutynin chloride tab 5 mg PENTASA – mesalamine cap cr 250 tolterodine tartrate cap sr 24hr 2 mg mg (Detrol la) PENTASA – mesalamine cap cr 500 tolterodine tartrate cap sr 24hr 4 mg mg (Detrol la) sulfasalazine tab delayed release tolterodine tartrate tab 1 mg (Detrol) 500 mg (Azulfidine en-tabs) tolterodine tartrate tab 2 mg (Detrol) sulfasalazine tab 500 mg (Azulfidine) VESICARE – solifenacin succinate tab ursodiol cap 300 mg (Actigall) 5 mg ursodiol tab 250 mg (Urso 250) VESICARE – solifenacin succinate tab 10 mg ursodiol tab 500 mg (Urso forte) VAGINAL PRODUCTS VELPHORO – sucroferric oxyhydroxide chew tab 500 mg CLEOCIN – clindamycin phosphate vaginal suppos 100 mg GENITOURINARY DRUGS clindamycin phosphate vaginal URINARY TRACT INFECTIONS cream 2% (Cleocin) nitrofurantoin macrocrystalline cap CRINONE – progesterone vaginal gel • 25 mg (Macrodantin) 4% nitrofurantoin macrocrystalline cap CRINONE – progesterone vaginal gel • 50 mg (Macrodantin) 8% nitrofurantoin macrocrystalline cap ESTRACE – estradiol vaginal cream 100 mg (Macrodantin) 0.1 mg/gm estradiol vaginal tab 10 mcg (Vagifem)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 29 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy metronidazole vaginal gel 0.75% alprazolam tab 0.5 mg (Xanax) (Metrogel-vaginal) alprazolam tab 1 mg (Xanax) terconazole vaginal cream 0.4% alprazolam tab 2 mg (Xanax) (Terazol 7) buspirone hcl tab 5 mg terconazole vaginal cream 0.8% (Terazol 3) buspirone hcl tab 10 mg terconazole vaginal suppos 80 mg buspirone hcl tab 15 mg VAGIFEM – estradiol vaginal tab 10 buspirone hcl tab 30 mg mcg DIAZEPAM – diazepam oral soln 1 mg/ OTHER GENITOURINARY DRUGS ml alfuzosin hcl tab sr 24hr 10 mg diazepam tab 2 mg (Valium) (Uroxatral) diazepam tab 5 mg (Valium) CYSTAGON – cysteamine bitartrate • diazepam tab 10 mg (Valium) cap 50 mg hydroxyzine hcl syrup 10 mg/5ml CYSTAGON – cysteamine bitartrate • hydroxyzine hcl tab 10 mg cap 150 mg hydroxyzine hcl tab 25 mg dutasteride cap 0.5 mg (Avodart) hydroxyzine hcl tab 50 mg finasteride tab 5 mg (Proscar) hydroxyzine pamoate cap 25 mg potassium citrate tab cr 5 meq (Vistaril) (540 mg) (Urocit-k 5) hydroxyzine pamoate cap 50 mg potassium citrate tab cr 10 meq (Vistaril) (1080 mg) (Urocit-k 10) lorazepam conc 2 mg/ml (Lorazepam potassium citrate tab cr 15 meq intensol) (1620 mg) (Urocit-k 15) lorazepam tab 0.5 mg (Ativan) • tamsulosin hcl cap 0.4 mg (Flomax) lorazepam tab 1 mg (Ativan) • CENTRAL NERVOUS SYSTEM DRUGS lorazepam tab 2 mg (Ativan) • ANXIETY DEPRESSION alprazolam tab sr 24hr 0.5 mg (Xanax xr) amitriptyline hcl tab 10 mg alprazolam tab sr 24hr 1 mg (Xanax amitriptyline hcl tab 25 mg xr) amitriptyline hcl tab 50 mg alprazolam tab sr 24hr 2 mg (Xanax amitriptyline hcl tab 75 mg xr) amitriptyline hcl tab 100 mg alprazolam tab sr 24hr 3 mg (Xanax amitriptyline hcl tab 150 mg xr) bupropion hcl tab sr 12hr 100 mg (Xanax) alprazolam tab 0.25 mg (Wellbutrin sr)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 30 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy bupropion hcl tab sr 12hr 150 mg doxepin hcl cap 25 mg (Wellbutrin sr) doxepin hcl cap 50 mg bupropion hcl tab sr 12hr 200 mg doxepin hcl cap 100 mg (Wellbutrin sr) doxepin hcl conc 10 mg/ml bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl) duloxetine hcl enteric coated pellets • cap 20 mg (Cymbalta) bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl) duloxetine hcl enteric coated pellets • cap 30 mg (Cymbalta) bupropion hcl tab 75 mg (Wellbutrin) duloxetine hcl enteric coated pellets • bupropion hcl tab 100 mg (Wellbutrin) cap 60 mg (Cymbalta) citalopram hydrobromide oral soln escitalopram oxalate soln 5 mg/5ml 10 mg/5ml (base equiv) (Lexapro) citalopram hydrobromide tab 10 mg escitalopram oxalate tab 5 mg (base (base equiv) (Celexa) equiv) (Lexapro) citalopram hydrobromide tab 20 mg escitalopram oxalate tab 10 mg (base equiv) (Celexa) (base equiv) (Lexapro) citalopram hydrobromide tab 40 mg escitalopram oxalate tab 20 mg (base equiv) (Celexa) (base equiv) (Lexapro) clomipramine hcl cap 25 mg fluoxetine hcl cap 10 mg (Prozac) (Anafranil) fluoxetine hcl cap 20 mg (Prozac) clomipramine hcl cap 50 mg (Anafranil) fluoxetine hcl cap 40 mg (Prozac) clomipramine hcl cap 75 mg fluoxetine hcl solution 20 mg/5ml (Anafranil) fluoxetine hcl tab 10 mg desipramine hcl tab 10 mg fluoxetine hcl tab 20 mg (Norpramin) fluvoxamine maleate tab 25 mg desipramine hcl tab 25 mg fluvoxamine maleate tab 50 mg (Norpramin) fluvoxamine maleate tab 100 mg desipramine hcl tab 50 mg (Norpramin) imipramine hcl tab 10 mg (Tofranil) desipramine hcl tab 75 mg imipramine hcl tab 25 mg (Tofranil) (Norpramin) imipramine hcl tab 50 mg (Tofranil) desipramine hcl tab 100 mg mirtazapine tab 7.5 mg (Norpramin) mirtazapine tab 15 mg (Remeron) desipramine hcl tab 150 mg mirtazapine tab 30 mg (Remeron) (Norpramin) mirtazapine tab 45 mg (Remeron) doxepin hcl cap 10 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 31 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy nortriptyline hcl cap 10 mg (Pamelor) venlafaxine hcl tab sr 24hr 75 mg nortriptyline hcl cap 25 mg (Pamelor) (base equivalent) (Venlafaxine hcl er) nortriptyline hcl cap 50 mg (Pamelor) venlafaxine hcl tab sr 24hr 150 mg nortriptyline hcl cap 75 mg (Pamelor) (base equivalent) (Venlafaxine hcl paroxetine hcl tab sr 24hr 12.5 mg er) (Paxil cr) venlafaxine hcl tab 25 mg paroxetine hcl tab sr 24hr 25 mg venlafaxine hcl tab 37.5 mg (Paxil cr) venlafaxine hcl tab 50 mg paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr) venlafaxine hcl tab 75 mg paroxetine hcl tab 10 mg (Paxil) venlafaxine hcl tab 100 mg paroxetine hcl tab 20 mg (Paxil) PSYCHOTIC AND BIPOLAR DISORDERS paroxetine hcl tab 30 mg (Paxil) aripiprazole tab 2 mg (Abilify) • paroxetine hcl tab 40 mg (Paxil) aripiprazole tab 5 mg (Abilify) • phenelzine sulfate tab 15 mg (Nardil) aripiprazole tab 10 mg (Abilify) • sertraline hcl oral conc 20 mg/ml aripiprazole tab 15 mg (Abilify) • (Zoloft) aripiprazole tab 20 mg (Abilify) • sertraline hcl tab 25 mg (Zoloft) aripiprazole tab 30 mg (Abilify) • sertraline hcl tab 50 mg (Zoloft) chlorpromazine hcl tab 10 mg sertraline hcl tab 100 mg (Zoloft) chlorpromazine hcl tab 25 mg tranylcypromine sulfate tab 10 mg chlorpromazine hcl tab 50 mg (Parnate) chlorpromazine hcl tab 100 mg trazodone hcl tab 50 mg chlorpromazine hcl tab 200 mg trazodone hcl tab 100 mg clozapine tab 25 mg (Clozaril) • trazodone hcl tab 150 mg clozapine tab 50 mg • trazodone hcl tab 300 mg clozapine tab 100 mg (Clozaril) • venlafaxine hcl cap sr 24hr 37.5 mg clozapine tab 200 mg • (base equivalent) (Effexor xr) fluphenazine decanoate inj 25 mg/ml venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr) FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr) FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl fluphenazine hcl tab 1 mg er) fluphenazine hcl tab 2.5 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 32 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy fluphenazine hcl tab 5 mg olanzapine tab 2.5 mg (Zyprexa) • fluphenazine hcl tab 10 mg olanzapine tab 5 mg (Zyprexa) • haloperidol decanoate im soln olanzapine tab 7.5 mg (Zyprexa) • 50 mg/ml (Haldol decanoate 50) olanzapine tab 10 mg (Zyprexa) • haloperidol decanoate im soln olanzapine tab 15 mg (Zyprexa) • 100 mg/ml (Haldol decanoate 100) olanzapine tab 20 mg (Zyprexa) • haloperidol lactate oral conc 2 mg/ml perphenazine tab 2 mg haloperidol tab 0.5 mg perphenazine tab 4 mg haloperidol tab 1 mg perphenazine tab 8 mg haloperidol tab 2 mg perphenazine tab 16 mg haloperidol tab 5 mg prochlorperazine maleate tab 5 mg haloperidol tab 10 mg (base equivalent) (Compazine) haloperidol tab 20 mg prochlorperazine maleate tab 10 mg lithium carbonate cap 150 mg (base equivalent) (Compazine) (Lithium carbonate) prochlorperazine suppos 25 mg lithium carbonate cap 300 mg quetiapine fumarate tab sr 24hr • lithium carbonate cap 600 mg 50 mg (Seroquel xr) (Lithium carbonate) quetiapine fumarate tab sr 24hr • lithium carbonate tab cr 300 mg 150 mg (Seroquel xr) (Lithobid) quetiapine fumarate tab sr 24hr • lithium carbonate tab cr 450 mg 200 mg (Seroquel xr) lithium carbonate tab 300 mg quetiapine fumarate tab sr 24hr • loxapine succinate cap 5 mg 300 mg (Seroquel xr) (Loxitane) quetiapine fumarate tab sr 24hr • loxapine succinate cap 10 mg 400 mg (Seroquel xr) loxapine succinate cap 25 mg quetiapine fumarate tab 25 mg • (Seroquel) loxapine succinate cap 50 mg quetiapine fumarate tab 50 mg • olanzapine orally disintegrating tab • (Seroquel) 5 mg (Zyprexa zydis) quetiapine fumarate tab 100 mg • olanzapine orally disintegrating tab • (Seroquel) 10 mg (Zyprexa zydis) quetiapine fumarate tab 200 mg • olanzapine orally disintegrating tab • (Seroquel) 15 mg (Zyprexa zydis) quetiapine fumarate tab 300 mg • olanzapine orally disintegrating tab • (Seroquel) 20 mg (Zyprexa zydis)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 33 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy quetiapine fumarate tab 400 mg • trifluoperazine hcl tab 2 mg (Seroquel) trifluoperazine hcl tab 5 mg risperidone orally disintegrating tab • trifluoperazine hcl tab 10 mg 0.25 mg ziprasidone hcl cap 20 mg (Geodon) • risperidone orally disintegrating tab • 0.5 mg (Risperdal m-tab) ziprasidone hcl cap 40 mg (Geodon) • risperidone orally disintegrating tab • ziprasidone hcl cap 60 mg (Geodon) • 1 mg (Risperdal m-tab) ziprasidone hcl cap 80 mg (Geodon) • risperidone orally disintegrating tab • SLEEP AIDS (Risperdal m-tab) 2 mg estazolam tab 1 mg risperidone orally disintegrating tab • estazolam tab 2 mg 3 mg (Risperdal m-tab) eszopiclone tab 1 mg (Lunesta) • risperidone orally disintegrating tab • 4 mg (Risperdal m-tab) eszopiclone tab 2 mg (Lunesta) • risperidone soln 1 mg/ml (Risperdal) • eszopiclone tab 3 mg (Lunesta) • risperidone tab 0.25 mg (Risperdal) • phenobarbital elixir 20 mg/5ml risperidone tab 0.5 mg (Risperdal) • phenobarbital tab 16.2 mg risperidone tab 1 mg (Risperdal) • phenobarbital tab 32.4 mg risperidone tab 2 mg (Risperdal) • temazepam cap 7.5 mg (Restoril) risperidone tab 3 mg (Risperdal) • temazepam cap 15 mg (Restoril) risperidone tab 4 mg (Risperdal) • temazepam cap 22.5 mg (Restoril) SEROQUEL XR – quetiapine fumarate • • temazepam cap 30 mg (Restoril) tab sr 24hr 50 mg zaleplon cap 5 mg (Sonata) • SEROQUEL XR – quetiapine fumarate • • zaleplon cap 10 mg (Sonata) • tab sr 24hr 150 mg zolpidem tartrate tab cr 6.25 mg • SEROQUEL XR – quetiapine fumarate • • (Ambien cr) tab sr 24hr 200 mg zolpidem tartrate tab cr 12.5 mg • SEROQUEL XR – quetiapine fumarate • • (Ambien cr) tab sr 24hr 300 mg zolpidem tartrate tab 5 mg (Ambien) • SEROQUEL XR – quetiapine fumarate • • zolpidem tartrate tab 10 mg (Ambien) • tab sr 24hr 400 mg HYPERACTIVITY/NARCOLEPSY thiothixene cap 1 mg amphetamine-dextroamphetamine • thiothixene cap 2 mg cap sr 24hr 5 mg (Adderall xr) thiothixene cap 5 mg amphetamine-dextroamphetamine • thiothixene cap 10 mg cap sr 24hr 10 mg (Adderall xr) trifluoperazine hcl tab 1 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 34 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy amphetamine-dextroamphetamine • dextroamphetamine sulfate cap sr • cap sr 24hr 15 mg (Adderall xr) 24hr 5 mg (Dexedrine) amphetamine-dextroamphetamine • dextroamphetamine sulfate cap sr • cap sr 24hr 20 mg (Adderall xr) 24hr 10 mg (Dexedrine) amphetamine-dextroamphetamine • dextroamphetamine sulfate cap sr • cap sr 24hr 25 mg (Adderall xr) 24hr 15 mg (Dexedrine) amphetamine-dextroamphetamine • dextroamphetamine sulfate tab 5 mg • cap sr 24hr 30 mg (Adderall xr) dextroamphetamine sulfate tab • amphetamine-dextroamphetamine • 10 mg tab 5 mg (Adderall) guanfacine hcl tab sr 24hr 1 mg • amphetamine-dextroamphetamine • (base equiv) (Intuniv) tab 7.5 mg (Adderall) guanfacine hcl tab sr 24hr 2 mg • amphetamine-dextroamphetamine • (base equiv) (Intuniv) tab 10 mg (Adderall) guanfacine hcl tab sr 24hr 3 mg • amphetamine-dextroamphetamine • (base equiv) (Intuniv) tab 12.5 mg (Adderall) guanfacine hcl tab sr 24hr 4 mg • amphetamine-dextroamphetamine • (base equiv) (Intuniv) tab 15 mg (Adderall) methylphenidate hcl tab cr 10 mg • amphetamine-dextroamphetamine • methylphenidate hcl tab cr 20 mg • tab 20 mg (Adderall) (Ritalin sr) amphetamine-dextroamphetamine • methylphenidate hcl tab sa osm • tab 30 mg (Adderall) 18 mg (Concerta) caffeine citrate oral soln 60 mg/3ml methylphenidate hcl tab sa osm • (10 mg/ml base equiv) (Cafcit) 27 mg (Concerta) dexmethylphenidate hcl cap sr 24 hr • methylphenidate hcl tab sa osm • 5 mg (Focalin xr) 36 mg (Concerta) dexmethylphenidate hcl cap sr 24 hr • methylphenidate hcl tab sa osm • 10 mg (Focalin xr) 54 mg (Concerta) dexmethylphenidate hcl cap sr 24 hr • methylphenidate hcl tab 5 mg • 15 mg (Focalin xr) (Ritalin) dexmethylphenidate hcl cap sr 24 hr • methylphenidate hcl tab 10 mg • 20 mg (Focalin xr) (Ritalin) dexmethylphenidate hcl cap sr 24 hr • methylphenidate hcl tab 20 mg • 30 mg (Focalin xr) (Ritalin) dexmethylphenidate hcl cap sr 24 hr • modafinil tab 100 mg (Provigil) • • 40 mg (Focalin xr) modafinil tab 200 mg (Provigil) • •
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 35 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy VYVANSE – lisdexamfetamine • COPAXONE – glatiramer acetate soln • • dimesylate cap 10 mg prefilled syringe 20 mg/ml VYVANSE – lisdexamfetamine • COPAXONE – glatiramer acetate soln • • dimesylate cap 20 mg prefilled syringe 40 mg/ml VYVANSE – lisdexamfetamine • GILENYA – fingolimod hcl cap 0.5 mg • • dimesylate cap 30 mg (base equiv) VYVANSE – lisdexamfetamine • glatiramer acetate soln prefilled • • dimesylate cap 40 mg syringe 20 mg/ml (Copaxone) VYVANSE – lisdexamfetamine • PLEGRIDY – peginterferon beta-1a • • dimesylate cap 50 mg soln pen-injector 125 mcg/0.5ml VYVANSE – lisdexamfetamine • PLEGRIDY – peginterferon beta-1a • • dimesylate cap 60 mg soln prefilled syringe 125 mcg/0.5ml VYVANSE – lisdexamfetamine • PLEGRIDY STARTER PACK – • • dimesylate cap 70 mg peginterferon beta-1a soln pen-inj 63 VYVANSE – lisdexamfetamine • & 94 mcg/0.5ml pack dimesylate chew tab 10 mg PLEGRIDY STARTER PACK – • • VYVANSE – lisdexamfetamine • peginterferon beta-1a soln pref syr 63 dimesylate chew tab 20 mg & 94 mcg/0.5ml pack VYVANSE – lisdexamfetamine • REBIF – interferon beta-1a soln pref syr • • dimesylate chew tab 30 mg 22 mcg/0.5ml (12mu/ml) VYVANSE – lisdexamfetamine • REBIF – interferon beta-1a soln pref syr • • dimesylate chew tab 40 mg 44 mcg/0.5ml (24mu/ml) VYVANSE – lisdexamfetamine • REBIF REBIDOSE – interferon beta-1a • • dimesylate chew tab 50 mg soln auto-inj 22 mcg/0.5ml (12mu/ml) VYVANSE – lisdexamfetamine • REBIF REBIDOSE – interferon beta-1a • • dimesylate chew tab 60 mg soln auto-inj 44 mcg/0.5ml (24mu/ml) MULTIPLE SCLEROSIS REBIF REBIDOSE TITRATION – • • interferon beta-1a auto-inj 6x8.8 AUBAGIO – teriflunomide tab 7 mg • • mcg/0.2ml & 6x22 mcg/0.5ml AUBAGIO – teriflunomide tab 14 mg • • REBIF TITRATION PACK – interferon • • AVONEX – interferon beta-1a im • • beta-1a pref syr 6x8.8 mcg/0.2ml & prefilled syringe kit 30 mcg/0.5ml 6x22 mcg/0.5ml AVONEX – interferon beta-1a for im inj • • TECFIDERA – dimethyl fumarate • • kit 30mcg (33mcg(6.6 mu)/vial) capsule delayed release 120 mg AVONEX PEN – interferon beta-1a im • • TECFIDERA – dimethyl fumarate • • auto-injector kit 30 mcg/0.5ml capsule delayed release 240 mg BETASERON – interferon beta-1b for • • inj kit 0.3 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 36 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy TECFIDERA STARTER PACK – • • galantamine hydrobromide tab 8 mg dimethyl fumarate capsule dr starter (Razadyne) pack 120 mg & 240 mg galantamine hydrobromide tab OTHER CENTRAL NERVOUS SYSTEM DRUGS 12 mg (Razadyne) acamprosate calcium tab delayed memantine hcl oral solution 2 mg/ml release 333 mg (Campral) (Namenda) bupropion hcl (smoking deterrent) memantine hcl tab 5 mg (Namenda) tab sr 12hr 150 mg (Zyban) memantine hcl tab 10 mg (Namenda) CHANTIX – varenicline tartrate tab 0.5 memantine hcl tab 5 mg (28) & 10 mg mg (base equiv) (21) titration pak (Namenda titration CHANTIX – varenicline tartrate tab 1 pa) mg (base equiv) NICOTROL INHALER – nicotine inhaler CHANTIX CONTINUING MONTH – system 10 mg (4 mg delivered) varenicline tartrate tab 1 mg (base NICOTROL NS – nicotine nasal spray equiv) 10 mg/ml (0.5 mg/spray) CHANTIX STARTING MONTH PA – NUEDEXTA – dextromethorphan hbr- varenicline tartrate tab 0.5 mg x 11 & quinidine sulfate cap 20-10 mg tab 1 mg x 42 pack pimozide tab 1 mg (Orap) disulfiram tab 250 mg (Antabuse) pimozide tab 2 mg (Orap) disulfiram tab 500 mg (Antabuse) rivastigmine tartrate cap 1.5 mg donepezil hydrochloride orally (Exelon) disintegrating tab 5 mg (Aricept odt) rivastigmine tartrate cap 3 mg donepezil hydrochloride orally (Exelon) disintegrating tab 10 mg (Aricept odt) rivastigmine tartrate cap 4.5 mg (Exelon) donepezil hydrochloride tab 5 mg (Aricept) rivastigmine tartrate cap 6 mg (Exelon) donepezil hydrochloride tab 10 mg (Aricept) tetrabenazine tab 12.5 mg (Xenazine) • • • galantamine hydrobromide cap sr tetrabenazine tab 25 mg (Xenazine) • • • 24hr 8 mg (Razadyne er) PAIN RELIEF DRUGS galantamine hydrobromide cap sr NON-NARCOTIC DRUGS (Razadyne er) 24hr 16 mg butalbital-acetaminophen tab galantamine hydrobromide cap sr 50-325 mg (Razadyne er) 24hr 24 mg butalbital-acetaminophen-caffeine galantamine hydrobromide tab 4 mg cap 50-325-40 mg (Razadyne)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 37 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy butalbital-acetaminophen-caffeine fentanyl td patch 72hr 12 mcg/hr • tab 50-325-40 mg (Duragesic) butalbital-aspirin-caffeine cap fentanyl td patch 72hr 25 mcg/hr • 50-325-40 mg (Fiorinal) (Duragesic) NARCOTIC DRUGS fentanyl td patch 72hr 50 mcg/hr • acetaminophen w/ codeine soln (Duragesic) 120-12 mg/5ml fentanyl td patch 72hr 75 mcg/hr • acetaminophen w/ codeine tab (Duragesic) 300-15 mg (Tylenol/codeine) fentanyl td patch 72hr 100 mcg/hr • acetaminophen w/ codeine tab (Duragesic) 300-30 mg (Tylenol/codeine #3) hydrocodone-acetaminophen soln acetaminophen w/ codeine tab 7.5-325 mg/15ml (Hycet) 300-60 mg (Tylenol/codeine #4) hydrocodone-acetaminophen tab buprenorphine hcl sl tab 2 mg (base • 10-325 mg (Norco) equiv) hydrocodone-acetaminophen tab buprenorphine hcl sl tab 8 mg (base • 5-325 mg (Norco) equiv) hydrocodone-acetaminophen tab butalbital-aspirin-caff w/ codeine cap 7.5-325 mg (Norco) 50-325-40-30 mg (Fiorinal/codeine hydrocodone-ibuprofen tab 5-200 mg #3) (Reprexain) codeine sulfate tab 15 mg (Codeine hydrocodone-ibuprofen tab sulfate) 7.5-200 mg (Vicoprofen) codeine sulfate tab 30 mg hydrocodone-ibuprofen tab codeine sulfate tab 60 mg 10-200 mg (Ibudone) fentanyl citrate lozenge on a handle • • hydromorphone hcl liqd 1 mg/ml 200 mcg (Actiq) (Dilaudid) fentanyl citrate lozenge on a handle • • hydromorphone hcl tab 2 mg 400 mcg (Actiq) (Dilaudid) fentanyl citrate lozenge on a handle • • hydromorphone hcl tab 4 mg 600 mcg (Actiq) (Dilaudid) fentanyl citrate lozenge on a handle • • hydromorphone hcl tab 8 mg 800 mcg (Actiq) (Dilaudid) fentanyl citrate lozenge on a handle • • KADIAN – morphine sulfate cap sr 24hr • • 1200 mcg (Actiq) 40 mg fentanyl citrate lozenge on a handle • • KADIAN – morphine sulfate cap sr 24hr • • 1600 mcg (Actiq) 200 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 38 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy methadone hcl conc 10 mg/ml NUCYNTA ER – tapentadol hcl tab sr • (Methadose) 12hr 250 mg methadone hcl soln 5 mg/5ml oxycodone hcl cap 5 mg (Methadone hcl) oxycodone hcl conc 100 mg/5ml methadone hcl soln 10 mg/5ml (20 mg/ml) (Oxycodone hcl) (Methadone hcl) oxycodone hcl soln 5 mg/5ml methadone hcl tab for oral susp (Oxycodone hcl) 40 mg oxycodone hcl tab 5 mg (Roxicodone) methadone hcl tab 5 mg (Dolophine oxycodone hcl tab 10 mg hcl) oxycodone hcl tab 15 mg methadone hcl tab 10 mg (Dolophine) (Roxicodone) MORPHINE SULFATE – morphine oxycodone hcl tab 20 mg sulfate tab 15 mg oxycodone hcl tab 30 mg MORPHINE SULFATE – morphine (Roxicodone) sulfate tab 30 mg oxycodone w/ acetaminophen tab morphine sulfate oral soln 10 mg/5ml 5-325 mg (Percocet) morphine sulfate oral soln 20 mg/5ml oxycodone w/ acetaminophen tab morphine sulfate oral soln 7.5-325 mg (Percocet) 100 mg/5ml (20 mg/ml) oxycodone w/ acetaminophen tab morphine sulfate tab cr 15 mg (Ms • 10-325 mg (Percocet) contin) oxycodone-aspirin tab morphine sulfate tab cr 30 mg (Ms • 4.8355-325 mg (Percodan) contin) OXYCONTIN – oxycodone hcl tab er • morphine sulfate tab cr 60 mg (Ms • 12hr deter 10 mg contin) OXYCONTIN – oxycodone hcl tab er • morphine sulfate tab cr 100 mg (Ms • 12hr deter 15 mg contin) OXYCONTIN – oxycodone hcl tab er • morphine sulfate tab cr 200 mg (Ms • 12hr deter 20 mg contin) OXYCONTIN – oxycodone hcl tab er • NUCYNTA ER – tapentadol hcl tab sr • 12hr deter 30 mg 12hr 50 mg OXYCONTIN – oxycodone hcl tab er • NUCYNTA ER – tapentadol hcl tab sr • 12hr deter 40 mg 12hr 100 mg OXYCONTIN – oxycodone hcl tab er • NUCYNTA ER – tapentadol hcl tab sr • 12hr deter 60 mg 12hr 150 mg OXYCONTIN – oxycodone hcl tab er • NUCYNTA ER – tapentadol hcl tab sr • 12hr deter 80 mg 12hr 200 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 39 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy tramadol hcl tab sr 24hr 100 mg • etodolac tab sr 24hr 500 mg (Ultram er) etodolac tab sr 24hr 600 mg tramadol hcl tab sr 24hr 200 mg • etodolac tab 400 mg (Ultram er) etodolac tab 500 mg tramadol hcl tab sr 24hr 300 mg • (Ultram er) flurbiprofen tab 50 mg tramadol hcl tab 50 mg (Ultram) • flurbiprofen tab 100 mg tramadol-acetaminophen tab HUMIRA – adalimumab prefilled • • • 37.5-325 mg (Ultracet) syringe kit 10 mg/0.2ml RHEUMATOID AND OSTEOARTHRITIS HUMIRA – adalimumab prefilled • • • syringe kit 20 mg/0.4ml celecoxib cap 50 mg (Celebrex) • HUMIRA – adalimumab prefilled • • • celecoxib cap 100 mg (Celebrex) • syringe kit 40 mg/0.8ml celecoxib cap 200 mg (Celebrex) • HUMIRA PEDIATRIC CROHNS D – • • • celecoxib cap 400 mg (Celebrex) • adalimumab prefilled syringe kit 40 diclofenac potassium tab 50 mg mg/0.8ml (Cataflam) HUMIRA PEN – adalimumab pen- • • • diclofenac sodium tab delayed injector kit 40 mg/0.8ml release 25 mg HUMIRA PEN-CROHNS DISEASE • • • diclofenac sodium tab delayed – adalimumab pen-injector kit 40 release 50 mg mg/0.8ml diclofenac sodium tab delayed HUMIRA PEN-PSORIASIS STAR • • • release 75 mg – adalimumab pen-injector kit 40 mg/0.8ml diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr) ibuprofen susp 100 mg/5ml ENBREL – etanercept for • • • ibuprofen tab 400 mg subcutaneous inj 25 mg ibuprofen tab 600 mg ENBREL – etanercept subcutaneous • • • ibuprofen tab 800 mg soln prefilled syringe 25 mg/0.5ml indomethacin cap 25 mg ENBREL – etanercept subcutaneous • • • indomethacin cap 50 mg soln prefilled syringe 50 mg/ml ketoprofen cap 50 mg ENBREL SURECLICK – etanercept • • • subcutaneous solution auto-injector ketoprofen cap 75 mg 50 mg/ml leflunomide tab 10 mg (Arava) etodolac cap 200 mg leflunomide tab 20 mg (Arava) etodolac cap 300 mg meloxicam tab 7.5 mg (Mobic) etodolac tab sr 24hr 400 mg meloxicam tab 15 mg (Mobic)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 40 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy nabumetone tab 500 mg MIGRANAL – dihydroergotamine • nabumetone tab 750 mg mesylate nasal spray 4 mg/ml naproxen sodium tab 275 mg naratriptan hcl tab 1 mg (base equiv) • (Anaprox) (Amerge) naproxen sodium tab 550 mg naratriptan hcl tab 2.5 mg (base • (Anaprox ds) equiv) (Amerge) naproxen susp 125 mg/5ml rizatriptan benzoate oral • (Naprosyn) disintegrating tab 5 mg (base eq) (Maxalt-mlt) naproxen tab ec 375 mg (Ec- naprosyn) rizatriptan benzoate oral • disintegrating tab 10 mg (base eq) naproxen tab ec 500 mg (Ec- (Maxalt-mlt) naprosyn) rizatriptan benzoate tab 5 mg (base • naproxen tab 250 mg (Naprosyn) equivalent) (Maxalt) naproxen tab 375 mg (Naprosyn) rizatriptan benzoate tab 10 mg (base • naproxen tab 500 mg (Naprosyn) equivalent) (Maxalt) OTEZLA – apremilast tab starter • • • sumatriptan nasal spray 5 mg/act • therapy pack 10 mg & 20 mg & 30 mg (Imitrex) OTEZLA – apremilast tab 30 mg • • • sumatriptan nasal spray 20 mg/act • (Imitrex) oxaprozin tab 600 mg (Daypro) piroxicam cap 10 mg (Feldene) sumatriptan succinate inj 6 mg/0.5ml • (Imitrex) piroxicam cap 20 mg (Feldene) sumatriptan succinate solution auto- • SIMPONI – golimumab subcutaneous • • • injector 4 mg/0.5ml (Imitrex statdose soln auto-injector 50 mg/0.5ml sys) SIMPONI – golimumab subcutaneous • • • sumatriptan succinate solution auto- • soln auto-injector 100 mg/ml injector 6 mg/0.5ml (Imitrex statdose SIMPONI – golimumab subcutaneous • • • sys) soln prefilled syringe 50 mg/0.5ml sumatriptan succinate solution • SIMPONI – golimumab subcutaneous • • • cartridge 4 mg/0.5ml (Imitrex soln prefilled syringe 100 mg/ml statdose ref) sulindac tab 150 mg sumatriptan succinate solution • cartridge 6 mg/0.5ml (Imitrex sulindac tab 200 mg statdose ref) MIGRAINE HEADACHES sumatriptan succinate tab 25 mg • IMITREX – sumatriptan nasal spray 5 • (Imitrex) mg/act sumatriptan succinate tab 50 mg • IMITREX – sumatriptan nasal spray 20 • (Imitrex) mg/act
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 41 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy sumatriptan succinate tab 100 mg • clonazepam tab 2 mg (Klonopin) (Imitrex) DIASTAT ACUDIAL – diazepam rectal GOUT gel delivery system 10 mg allopurinol tab 100 mg (Zyloprim) DIASTAT ACUDIAL – diazepam rectal allopurinol tab 300 mg (Zyloprim) gel delivery system 20 mg colchicine w/ probenecid tab DIASTAT PEDIATRIC – diazepam 0.5-500 mg rectal gel delivery system 2.5 mg COLCRYS – colchicine tab 0.6 mg DILANTIN – phenytoin sodium extended cap 30 mg probenecid tab 500 mg divalproex sodium cap delayed LOCAL ANESTHETICS INJECTABLE release sprinkle 125 mg (Depakote lidocaine hcl local inj 1% (Xylocaine) sprinkles) lidocaine hcl local preservative free divalproex sodium tab delayed (pf) inj 1% (Xylocaine-mpf) release 125 mg (Depakote) NEUROMUSCULAR DRUGS divalproex sodium tab delayed (Depakote) SEIZURES release 250 mg carbamazepine cap sr 12hr 100 mg divalproex sodium tab delayed (Carbatrol) release 500 mg (Depakote) carbamazepine cap sr 12hr 200 mg divalproex sodium tab sr 24 hr (Carbatrol) 250 mg (Depakote er) carbamazepine cap sr 12hr 300 mg divalproex sodium tab sr 24 hr (Carbatrol) 500 mg (Depakote er) (Zarontin) carbamazepine chew tab 100 mg ethosuximide cap 250 mg carbamazepine susp 100 mg/5ml ethosuximide soln 250 mg/5ml (Tegretol) (Zarontin) (Neurontin) carbamazepine tab sr 12hr 100 mg gabapentin cap 100 mg (Tegretol-xr) gabapentin cap 300 mg (Neurontin) carbamazepine tab sr 12hr 200 mg gabapentin cap 400 mg (Neurontin) (Tegretol-xr) gabapentin oral soln 250 mg/5ml carbamazepine tab sr 12hr 400 mg (Neurontin) (Tegretol-xr) gabapentin tab 600 mg (Neurontin) carbamazepine tab 200 mg (Tegretol) gabapentin tab 800 mg (Neurontin) CELONTIN – methsuximide cap 300 GABITRIL – tiagabine hcl tab 12 mg mg GABITRIL – tiagabine hcl tab 16 mg clonazepam tab 0.5 mg (Klonopin) lamotrigine tab chewable dispersible clonazepam tab 1 mg (Klonopin) 5 mg (Lamictal chewable di)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 42 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy lamotrigine tab chewable dispersible phenytoin sodium extended cap 25 mg (Lamictal chewable di) 300 mg (Phenytek) lamotrigine tab 25 mg (Lamictal) phenytoin susp 125 mg/5ml (Dilantin) lamotrigine tab 100 mg (Lamictal) primidone tab 50 mg (Mysoline) lamotrigine tab 150 mg (Lamictal) primidone tab 250 mg (Mysoline) lamotrigine tab 200 mg (Lamictal) SABRIL – vigabatrin tab 500 mg levetiracetam oral soln 100 mg/ml SABRIL – vigabatrin powd pack 500 mg (Keppra) topiramate sprinkle cap 15 mg levetiracetam tab sr 24hr 500 mg (Topamax sprinkle) (Keppra xr) topiramate sprinkle cap 25 mg levetiracetam tab sr 24hr 750 mg (Topamax sprinkle) (Keppra xr) topiramate tab 25 mg (Topamax) levetiracetam tab 250 mg (Keppra) topiramate tab 50 mg (Topamax) levetiracetam tab 500 mg (Keppra) topiramate tab 100 mg (Topamax) levetiracetam tab 750 mg (Keppra) topiramate tab 200 mg (Topamax) levetiracetam tab 1000 mg (Keppra) valproate sodium oral soln LYRICA – pregabalin cap 25 mg • 250 mg/5ml (base equiv) LYRICA – pregabalin cap 50 mg • (Depakene) LYRICA – pregabalin cap 75 mg • valproic acid cap 250 mg (Depakene) LYRICA – pregabalin cap 100 mg • zonisamide cap 25 mg (Zonegran) LYRICA – pregabalin cap 150 mg • zonisamide cap 50 mg LYRICA – pregabalin cap 200 mg • zonisamide cap 100 mg (Zonegran) LYRICA – pregabalin cap 225 mg • PARKINSON'S DISEASE LYRICA – pregabalin cap 300 mg • amantadine hcl cap 100 mg oxcarbazepine susp 300 mg/5ml amantadine hcl syrup 50 mg/5ml (60 mg/ml) (Trileptal) AZILECT – rasagiline mesylate tab 0.5 oxcarbazepine tab 150 mg (Trileptal) mg (base equiv) oxcarbazepine tab 300 mg (Trileptal) AZILECT – rasagiline mesylate tab 1 mg (base equiv) oxcarbazepine tab 600 mg (Trileptal) benztropine mesylate tab 0.5 mg phenytoin chew tab 50 mg (Dilantin infatabs) benztropine mesylate tab 1 mg phenytoin sodium extended cap benztropine mesylate tab 2 mg 100 mg (Dilantin) bromocriptine mesylate cap 5 mg phenytoin sodium extended cap (base equivalent) 200 mg (Phenytek)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 43 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy bromocriptine mesylate tab 2.5 mg ropinirole hydrochloride tab 0.5 mg (base equivalent) (Parlodel) (Requip) carbidopa & levodopa orally ropinirole hydrochloride tab 1 mg disintegrating tab 10-100 mg (Requip) carbidopa & levodopa orally ropinirole hydrochloride tab 2 mg disintegrating tab 25-100 mg (Requip) carbidopa & levodopa orally ropinirole hydrochloride tab 3 mg disintegrating tab 25-250 mg (Requip) carbidopa & levodopa tab cr ropinirole hydrochloride tab 4 mg 25-100 mg (Sinemet cr) (Requip) carbidopa & levodopa tab cr ropinirole hydrochloride tab 5 mg 50-200 mg (Sinemet cr) (Requip) carbidopa & levodopa tab 10-100 mg selegiline hcl cap 5 mg (Eldepryl) (Sinemet) selegiline hcl tab 5 mg carbidopa & levodopa tab 25-100 mg trihexyphenidyl hcl elixir 0.4 mg/ml (Sinemet) trihexyphenidyl hcl tab 2 mg carbidopa & levodopa tab 25-250 mg (Sinemet) trihexyphenidyl hcl tab 5 mg entacapone tab 200 mg (Comtan) MUSCLE RELAXANTS pramipexole dihydrochloride tab baclofen tab 10 mg 0.125 mg (Mirapex) baclofen tab 20 mg pramipexole dihydrochloride tab chlorzoxazone tab 500 mg (Parafon 0.25 mg (Mirapex) forte dsc) pramipexole dihydrochloride tab cyclobenzaprine hcl tab 5 mg (Mirapex) 0.5 mg cyclobenzaprine hcl tab 10 mg pramipexole dihydrochloride tab dantrolene sodium cap 25 mg 0.75 mg (Mirapex) (Dantrium) pramipexole dihydrochloride tab dantrolene sodium cap 50 mg 1 mg (Mirapex) (Dantrium) pramipexole dihydrochloride tab dantrolene sodium cap 100 mg 1.5 mg (Mirapex) (Dantrolene sodium) rasagiline mesylate tab 0.5 mg (base metaxalone tab 800 mg (Skelaxin) equiv) (Azilect) methocarbamol tab 500 mg (Robaxin) rasagiline mesylate tab 1 mg (base equiv) (Azilect) methocarbamol tab 750 mg (Robaxin-750) ropinirole hydrochloride tab 0.25 mg (Requip) orphenadrine citrate tab sr 12hr 100 mg
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 44 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy tizanidine hcl tab 2 mg (base • potassium chloride cap cr 10 meq equivalent) (Micro-k) tizanidine hcl tab 4 mg (base • potassium chloride equivalent) (Zanaflex) microencapsulated crys cr tab 10 OTHER NEUROMUSCULAR DRUGS meq pyridostigmine bromide tab 60 mg potassium chloride (Mestinon) microencapsulated crys cr tab 20 meq riluzole tab 50 mg (Rilutek) potassium chloride oral soln 10% (20 SUPPLEMENTS meq/15ml) VITAMINS potassium chloride powder packet ergocalciferol cap 50000 unit 20 meq (Drisdol) potassium chloride tab cr 8 meq MEPHYTON – phytonadione tab 5 mg (600 mg) MULTIVITAMINS potassium chloride tab cr 10 meq (K- KOSHER PRENATAL PLUS IRON – tab) prenatal vit w/ iron carbonyl-fa tab BLOOD MODIFYING DRUGS 30-1 mg ADVATE – antihemophilic factor rahf- • PRENATAL LOW IRON – prenatal vit pfm for inj 250 unit w/ fe fumarate-fa tab 27-1 mg ADVATE – antihemophilic factor rahf- • PRENATAL PLUS – prenatal vit w/ fe pfm for inj 500 unit fumarate-fa tab 27-1 mg ADVATE – antihemophilic factor rahf- • PRENATAL PLUS/IRON – prenatal vit pfm for inj 1000 unit w/ fe fumarate-fa tab 27-1 mg ADVATE – antihemophilic factor rahf- • PRENATAL VITAMINS PLUS LO – pfm for inj 1500 unit prenatal vit w/ fe fumarate-fa tab 27-1 ADVATE – antihemophilic factor rahf- • mg pfm for inj 2000 unit PRENATAL 19 – prenatal vit w/ fe ADVATE – antihemophilic factor rahf- • fumarate-fa chew tab 29-1 mg pfm for inj 3000 unit PRENATAL 19 – prenatal vit w/ dss-fe ADVATE – antihemophilic factor rahf- • fumarate-fa tab 29-1 mg pfm for inj 4000 unit SE-NATAL 19 – prenatal vit w/ fe ADYNOVATE – antihemophilic factor • fumarate-fa chew tab 29-1 mg recomb pegylated for inj 250 unit SE-NATAL 19 – prenatal vit w/ dss-fe ADYNOVATE – antihemophilic factor • fumarate-fa tab 29-1 mg recomb pegylated for inj 500 unit MINERALS AND ELECTROLYTES ADYNOVATE – antihemophilic factor • potassium chloride cap cr 8 meq recomb pegylated for inj 750 unit (Micro-k)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 45 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ADYNOVATE – antihemophilic factor • ALPROLIX – coagulation factor ix • recomb pegylated for inj 1000 unit (recomb) (rfixfc) for inj 250 unit ADYNOVATE – antihemophilic factor • ALPROLIX – coagulation factor ix • recomb pegylated for inj 1500 unit (recomb) (rfixfc) for inj 500 unit ADYNOVATE – antihemophilic factor • ALPROLIX – coagulation factor ix • recomb pegylated for inj 2000 unit (recomb) (rfixfc) for inj 1000 unit AFSTYLA – antihemophilic fact rcmb • ALPROLIX – coagulation factor ix • single chain for inj kit 250 unit (recomb) (rfixfc) for inj 2000 unit AFSTYLA – antihemophilic fact rcmb • ALPROLIX – coagulation factor ix • single chain for inj kit 500 unit (recomb) (rfixfc) for inj 3000 unit AFSTYLA – antihemophilic fact rcmb • ALPROLIX – coagulation factor ix • single chain for inj kit 1000 unit (recomb) (rfixfc) for inj 4000 unit AFSTYLA – antihemophilic fact rcmb • anagrelide hcl cap 0.5 mg (Agrylin) single chain for inj kit 2000 unit anagrelide hcl cap 1 mg AFSTYLA – antihemophilic fact rcmb • ARANESP ALBUMIN FREE – • • single chain for inj kit 3000 unit darbepoetin alfa soln prefilled syringe ALPHANATE/VON WILLEBRAND – • 10 mcg/0.4ml antihemophilic factor/vwf (human) for ARANESP ALBUMIN FREE – • • inj 250 unit darbepoetin alfa soln prefilled syringe ALPHANATE/VON WILLEBRAND – • 25 mcg/0.42ml antihemophilic factor/vwf (human) for ARANESP ALBUMIN FREE – • • inj 500 unit darbepoetin alfa soln prefilled syringe ALPHANATE/VON WILLEBRAND – • 40 mcg/0.4ml antihemophilic factor/vwf (human) for ARANESP ALBUMIN FREE – • • inj 1000 unit darbepoetin alfa soln prefilled syringe ALPHANATE/VON WILLEBRAND – • 60 mcg/0.3ml antihemophilic factor/vwf (human) for ARANESP ALBUMIN FREE – • • inj 1500 unit darbepoetin alfa soln prefilled syringe ALPHANATE/VON WILLEBRAND – • 100 mcg/0.5ml antihemophilic factor/vwf (human) for ARANESP ALBUMIN FREE – • • inj 2000 unit darbepoetin alfa soln prefilled syringe ALPHANINE SD – coagulation factor ix • 150 mcg/0.3ml for inj 500 unit ARANESP ALBUMIN FREE – • • ALPHANINE SD – coagulation factor ix • darbepoetin alfa soln prefilled syringe for inj 1000 unit 200 mcg/0.4ml ALPHANINE SD – coagulation factor ix • ARANESP ALBUMIN FREE – • • for inj 1500 unit darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 46 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ARANESP ALBUMIN FREE – • • CORIFACT – factor xiii concentrate • darbepoetin alfa soln prefilled syringe (human) for inj kit 1000-1600 unit 500 mcg/ml cyanocobalamin inj 1000 mcg/ml ARANESP ALBUMIN FREE – • • dipyridamole tab 25 mg (Persantine) darbepoetin alfa soln inj 25 mcg/ml dipyridamole tab 50 mg (Persantine) ARANESP ALBUMIN FREE – • • darbepoetin alfa soln inj 40 mcg/ml dipyridamole tab 75 mg (Persantine) ARANESP ALBUMIN FREE – • • DROXIA – hydroxyurea cap 200 mg darbepoetin alfa soln inj 60 mcg/ml DROXIA – hydroxyurea cap 300 mg ARANESP ALBUMIN FREE – • • DROXIA – hydroxyurea cap 400 mg darbepoetin alfa soln inj 100 mcg/ml ELIQUIS – apixaban tab 2.5 mg • ARANESP ALBUMIN FREE – • • ELIQUIS – apixaban tab 5 mg • darbepoetin alfa soln inj 200 mcg/ml ELOCTATE – antihemophilic factor • ARANESP ALBUMIN FREE – • • (recomb) rfviiifc for inj 250 unit darbepoetin alfa soln inj 300 mcg/ml ELOCTATE – antihemophilic factor • BEBULIN – factor ix complex for inj • (recomb) rfviiifc for inj 500 unit 200-1200 unit ELOCTATE – antihemophilic factor • BENEFIX – coagulation factor ix • (recomb) rfviiifc for inj 750 unit (recombinant) for inj kit 250 unit ELOCTATE – antihemophilic factor • BENEFIX – coagulation factor ix • (recomb) rfviiifc for inj 1000 unit (recombinant) for inj kit 500 unit ELOCTATE – antihemophilic factor • BENEFIX – coagulation factor ix • (recomb) rfviiifc for inj 1500 unit (recombinant) for inj kit 1000 unit ELOCTATE – antihemophilic factor • BENEFIX – coagulation factor ix • (recomb) rfviiifc for inj 2000 unit (recombinant) for inj kit 2000 unit ELOCTATE – antihemophilic factor • BENEFIX – coagulation factor ix • (recomb) rfviiifc for inj 3000 unit (recombinant) for inj kit 3000 unit ELOCTATE – antihemophilic factor • BRILINTA – ticagrelor tab 60 mg (recomb) rfviiifc for inj 4000 unit BRILINTA – ticagrelor tab 90 mg ELOCTATE – antihemophilic factor • cilostazol tab 50 mg (Pletal) (recomb) rfviiifc for inj 5000 unit cilostazol tab 100 mg (Pletal) ELOCTATE – antihemophilic factor • clopidogrel bisulfate tab 75 mg (base (recomb) rfviiifc for inj 6000 unit equiv) (Plavix) enoxaparin sodium inj 30 mg/0.3ml • COAGADEX – coagulation factor x • (Lovenox) (human) for inj 250 unit enoxaparin sodium inj 40 mg/0.4ml • COAGADEX – coagulation factor x • (Lovenox) (human) for inj 500 unit
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 47 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy enoxaparin sodium inj 60 mg/0.6ml • HEMOFIL M – antihemophilic factor • (Lovenox) (human) for inj 500 unit enoxaparin sodium inj 80 mg/0.8ml • HEMOFIL M – antihemophilic factor • (Lovenox) (human) for inj 1000 unit enoxaparin sodium inj 100 mg/ml • HEMOFIL M – antihemophilic factor • (Lovenox) (human) for inj 1700 unit enoxaparin sodium inj 120 mg/0.8ml • HUMATE-P – antihemophilic factor/vwf • (Lovenox) (human) for inj 250-600 unit enoxaparin sodium inj 150 mg/ml • HUMATE-P – antihemophilic factor/vwf • (Lovenox) (human) for inj 500-1200 unit enoxaparin sodium inj 300 mg/3ml • HUMATE-P – antihemophilic factor/vwf • (Lovenox) (human) for inj 1000-2400 unit EPOGEN – epoetin alfa inj 2000 unit/ml • • IDELVION – coagulation factor ix • EPOGEN – epoetin alfa inj 3000 unit/ml • • (recomb) (rix-fp) for inj 250 unit EPOGEN – epoetin alfa inj 4000 unit/ml • • IDELVION – coagulation factor ix • (recomb) (rix-fp) for inj 500 unit EPOGEN – epoetin alfa inj 10000 unit/ • • ml IDELVION – coagulation factor ix • (recomb) (rix-fp) for inj 1000 unit EPOGEN – epoetin alfa inj 20000 unit/ • • ml IDELVION – coagulation factor ix • (recomb) (rix-fp) for inj 2000 unit FEIBA – antiinhibitor coagulant • complex for inj KOATE – antihemophilic factor (human) • for inj 250 unit FIRAZYR – icatibant acetate inj 30 • • mg/3ml (base equivalent) KOATE – antihemophilic factor (human) • for inj 500 unit folic acid tab 1 mg KOATE – antihemophilic factor (human) • HELIXATE FS – antihemophilic factor • for inj 1000 unit (recombinant) for inj kit 250 unit KOATE-DVI – antihemophilic factor • HELIXATE FS – antihemophilic factor • (human) for inj 250 unit (recombinant) for inj kit 500 unit KOATE-DVI – antihemophilic factor • HELIXATE FS – antihemophilic factor • (human) for inj 500 unit (recombinant) for inj kit 1000 unit KOATE-DVI – antihemophilic factor • HELIXATE FS – antihemophilic factor • (human) for inj 1000 unit (recombinant) for inj kit 2000 unit KOGENATE FS – antihemophilic factor • HELIXATE FS – antihemophilic factor • (recombinant) for inj kit 250 unit (recombinant) for inj kit 3000 unit KOGENATE FS – antihemophilic factor • HEMOFIL M – antihemophilic factor • (recombinant) for inj kit 500 unit (human) for inj 250 unit
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 48 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy KOGENATE FS – antihemophilic factor • NEULASTA – pegfilgrastim soln • (recombinant) for inj kit 1000 unit prefilled syringe 6 mg/0.6ml KOGENATE FS – antihemophilic factor • NEULASTA ONPRO KIT – • (recombinant) for inj kit 2000 unit pegfilgrastim soln prefilled syringe kit KOGENATE FS – antihemophilic factor • 6 mg/0.6ml (recombinant) for inj kit 3000 unit NEUPOGEN – filgrastim soln prefilled • KOGENATE FS BIO-SET – • syringe 300 mcg/0.5ml antihemophilic factor (recombinant) NEUPOGEN – filgrastim soln prefilled • for inj kit 250 unit syringe 480 mcg/0.8ml (600 mcg/ml) KOGENATE FS BIO-SET – • NEUPOGEN – filgrastim inj 300 mcg/ml • antihemophilic factor (recombinant) NEUPOGEN – filgrastim inj 480 • for inj kit 500 unit mcg/1.6ml (300 mcg/ml) KOGENATE FS BIO-SET – • NOVOEIGHT – antihemophilic factor • antihemophilic factor (recombinant) (recombinant) for inj 250 unit for inj kit 1000 unit NOVOEIGHT – antihemophilic factor • KOGENATE FS BIO-SET – • (recombinant) for inj 500 unit antihemophilic factor (recombinant) for inj kit 2000 unit NOVOEIGHT – antihemophilic factor • (recombinant) for inj 1000 unit KOGENATE FS BIO-SET – • antihemophilic factor (recombinant) NOVOEIGHT – antihemophilic factor • for inj kit 3000 unit (recombinant) for inj 1500 unit KOVALTRY – antihemophilic factor • NOVOEIGHT – antihemophilic factor • (recombinant) for inj 250 unit (recombinant) for inj 2000 unit KOVALTRY – antihemophilic factor • NOVOEIGHT – antihemophilic factor • (recombinant) for inj 500 unit (recombinant) for inj 3000 unit KOVALTRY – antihemophilic factor • NOVOSEVEN RT – coagulation factor • (recombinant) for inj 1000 unit viia (recomb) for inj 1 mg (1000 mcg) KOVALTRY – antihemophilic factor • NOVOSEVEN RT – coagulation factor • (recombinant) for inj 2000 unit viia (recomb) for inj 2 mg (2000 mcg) KOVALTRY – antihemophilic factor • NOVOSEVEN RT – coagulation factor • (recombinant) for inj 3000 unit viia (recomb) for inj 5 mg (5000 mcg) MONOCLATE-P – antihemophilic factor • NOVOSEVEN RT – coagulation factor • (human) for inj kit 1000 unit viia (recomb) for inj 8 mg (8000 mcg) MONOCLATE-P – antihemophilic factor • NUWIQ – antihemophilic factor (bdd- • (human) for inj kit 1500 unit rfviii) for inj 250 unit MONONINE – coagulation factor ix for • NUWIQ – antihemophilic factor (bdd- • inj 1000 unit rfviii) for inj 500 unit
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 49 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy NUWIQ – antihemophilic factor (bdd- • PROFILNINE SD – factor ix complex • rfviii) for inj 1000 unit for inj 1500 unit NUWIQ – antihemophilic factor (bdd- • RECOMBINATE – antihemophilic factor • rfviii) for inj 2000 unit (recombinant) for inj 220-400 unit NUWIQ – antihemophilic factor (bdd- • RECOMBINATE – antihemophilic factor • rfviii) for inj kit 250 unit (recombinant) for inj 401-800 unit NUWIQ – antihemophilic factor (bdd- • RECOMBINATE – antihemophilic factor • rfviii) for inj kit 500 unit (recombinant) for inj 801-1240 unit NUWIQ – antihemophilic factor (bdd- • RECOMBINATE – antihemophilic factor • rfviii) for inj kit 1000 unit (recombinant) for inj 1241-1800 unit NUWIQ – antihemophilic factor (bdd- • RECOMBINATE – antihemophilic factor • rfviii) for inj kit 2000 unit (recombinant) for inj 1801-2400 unit OBIZUR – antihemophilic factor • RIXUBIS – coagulation factor ix • (recomb porc) rpfviii for inj 500 unit (recombinant) for inj 250 unit pentoxifylline tab cr 400 mg RIXUBIS – coagulation factor ix • PROCRIT – epoetin alfa inj 2000 unit/ • • (recombinant) for inj 500 unit ml RIXUBIS – coagulation factor ix • PROCRIT – epoetin alfa inj 3000 unit/ • • (recombinant) for inj 1000 unit ml RIXUBIS – coagulation factor ix • PROCRIT – epoetin alfa inj 4000 unit/ • • (recombinant) for inj 2000 unit ml RIXUBIS – coagulation factor ix • PROCRIT – epoetin alfa inj 10000 unit/ • • (recombinant) for inj 3000 unit ml TRETTEN – coagulation factor xiii a- • PROCRIT – epoetin alfa inj 20000 unit/ • • subunit for inj 2000-3125 unit ml VONVENDI – von willebrand factor • PROCRIT – epoetin alfa inj 40000 unit/ • • (recombinant) for inj 650 unit ml VONVENDI – von willebrand factor • PROFILNINE – factor ix complex for inj • (recombinant) for inj 1300 unit 500 unit warfarin sodium tab 1 mg (Coumadin) PROFILNINE – factor ix complex for inj • warfarin sodium tab 2 mg (Coumadin) 1000 unit warfarin sodium tab 2.5 mg PROFILNINE – factor ix complex for inj • (Coumadin) 1500 unit warfarin sodium tab 3 mg (Coumadin) PROFILNINE SD – factor ix complex • warfarin sodium tab 4 mg (Coumadin) for inj 500 unit warfarin sodium tab 5 mg (Coumadin) PROFILNINE SD – factor ix complex • for inj 1000 unit warfarin sodium tab 6 mg (Coumadin)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 50 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy warfarin sodium tab 7.5 mg ZARXIO – filgrastim-sndz soln prefilled • (Coumadin) syringe 300 mcg/0.5ml warfarin sodium tab 10 mg ZARXIO – filgrastim-sndz soln prefilled • (Coumadin) syringe 480 mcg/0.8ml WILATE – antihemophilic factor/vwf • TOPICAL PRODUCTS (human) for inj 500-500 unit kit EYE WILATE – antihemophilic factor/vwf • Anti-infectives (human) for inj 1000-1000 unit kit BACITRACIN – bacitracin ophth oint XARELTO – rivaroxaban tab 10 mg • 500 unit/gm XARELTO – rivaroxaban tab 15 mg • bacitracin-polymyxin b ophth oint XARELTO – rivaroxaban tab 20 mg • ciprofloxacin hcl ophth soln 0.3% XARELTO STARTER PACK – • (Ciloxan) rivaroxaban tab starter therapy pack erythromycin ophth oint 5 mg/gm 15 mg & 20 mg gentamicin sulfate ophth oint 0.3% XYNTHA – antihemophilic factor • recombinant paf for inj kit 250 unit gentamicin sulfate ophth soln 0.3% (Garamycin) XYNTHA – antihemophilic factor • recombinant paf for inj kit 500 unit NATACYN – natamycin ophth susp 5% XYNTHA – antihemophilic factor • neomycin-bacitrac zn-polymyx recombinant paf for inj kit 1000 unit 5(3.5)mg-400unt-10000unt op oin XYNTHA – antihemophilic factor • neomycin-polymy-gramicid op sol recombinant paf for inj kit 2000 unit 1.75-10000-0.025mg-unt-mg/ml (Neosporin) XYNTHA SOLOFUSE – antihemophilic • factor recombinant paf for inj kit 250 ofloxacin ophth soln 0.3% (Ocuflox) unit polymyxin b-trimethoprim ophth XYNTHA SOLOFUSE – antihemophilic • soln 10000 unit/ml-0.1% (Polytrim) factor recombinant paf for inj kit 500 sulfacetamide sodium ophth soln unit 10% (Bleph-10) XYNTHA SOLOFUSE – antihemophilic • tobramycin ophth soln 0.3% (Tobrex) factor recombinant paf for inj kit 1000 trifluridine ophth soln 1% (Viroptic) unit VIGAMOX – moxifloxacin hcl ophth XYNTHA SOLOFUSE – antihemophilic • soln 0.5% (base equiv) factor recombinant paf for inj kit 2000 unit Steroids and Combination Products XYNTHA SOLOFUSE – antihemophilic • bacitracin-polymyxin-neomycin-hc factor recombinant paf for inj kit 3000 ophth oint 1% unit fluorometholone ophth susp 0.1% (Fml liquifilm)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 51 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy LOTEMAX – loteprednol etabonate levobunolol hcl ophth soln 0.5% ophth susp 0.5% (Betagan) LOTEMAX – loteprednol etabonate LUMIGAN – bimatoprost ophth soln • • ophth gel 0.5% 0.01% LOTEMAX – loteprednol etabonate pilocarpine hcl ophth soln 1% (Isopto ophth oint 0.5% carpine) neomycin-polymyxin- pilocarpine hcl ophth soln 2% (Isopto dexamethasone ophth oint 0.1% carpine) (Maxitrol) pilocarpine hcl ophth soln 4% (Isopto neomycin-polymyxin- carpine) dexamethasone ophth susp 0.1% SIMBRINZA – brinzolamide- (Maxitrol) brimonidine tartrate ophth susp prednisolone acetate ophth susp 1% 1-0.2% (Pred forte) timolol maleate ophth gel forming PREDNISOLONE SODIUM PHOSP soln 0.25% (Timoptic-xe) – prednisolone sodium phosphate timolol maleate ophth gel forming ophth soln 1% soln 0.5% (Timoptic-xe) sulfacetamide sodium-prednisolone timolol maleate ophth soln 0.25% ophth soln 10-0.23(0.25)% (Timoptic) tobramycin-dexamethasone ophth timolol maleate ophth soln 0.5% susp 0.3-0.1% (Tobradex) (Timoptic) ZYLET – loteprednol etabonate- TRAVATAN Z – travoprost ophth soln • • tobramycin ophth susp 0.5-0.3% 0.004% (benzalkonium free) (bak Glaucoma free) ALPHAGAN P – brimonidine tartrate Other Eye Products ophth soln 0.1% azelastine hcl ophth soln 0.05% AZOPT – brinzolamide ophth susp 1% (Optivar) brimonidine tartrate ophth soln cromolyn sodium ophth soln 4% 0.15% (Alphagan p) cyclopentolate hcl ophth soln 1% brimonidine tartrate ophth soln 0.2% (Cyclogyl) carteolol hcl ophth soln 1% diclofenac sodium ophth soln 0.1% dorzolamide hcl ophth soln 2% flurbiprofen sodium ophth soln (Trusopt) 0.03% (Ocufen) dorzolamide hcl-timolol maleate ketorolac tromethamine ophth soln ophth soln 22.3-6.8 mg/ml (Cosopt) 0.4% (Acular ls) latanoprost ophth soln 0.005% • ketorolac tromethamine ophth soln (Xalatan) 0.5% (Acular)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 52 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy olopatadine hcl ophth soln 0.1% hydrocortisone rectal cream 2.5% (base equivalent) (Patanol) (Anusol-hc) PATADAY – olopatadine hcl ophth soln SKIN CONDITIONS/PRODUCTS 0.2% (base equivalent) Acne PAZEO – olopatadine hcl ophth soln adapalene cream 0.1% (Differin) 0.7% (base equivalent) adapalene gel 0.1% (Differin) tropicamide ophth soln 0.5% adapalene gel 0.3% (Differin) tropicamide ophth soln 1% (Mydriacyl) benzoyl peroxide-erythromycin gel 5-3% (Benzamycin) EAR clindamycin phosph-benzoyl acetic acid otic soln 2% peroxide (refrig) gel 1.2 (1)-5% CIPRODEX – ciprofloxacin- (Duac) dexamethasone otic susp 0.3-0.1% clindamycin phosphate gel 1% hydrocortisone w/ acetic acid otic (Cleocin-t) soln 1-2% (Vosol hc) clindamycin phosphate lotion 1% neomycin-polymyxin-hc otic soln 1% (Cleocin-t) (Cortisporin) clindamycin phosphate soln 1% neomycin-polymyxin-hc otic susp (Cleocin-t) 3.5 mg/ml-10000 unit/ml-1% clindamycin phosphate swab 1% ofloxacin otic soln 0.3% (Cleocin-t) MOUTH AND THROAT (LOCAL) clindamycin phosphate-benzoyl cevimeline hcl cap 30 mg (Evoxac) peroxide gel 1-5% (Benzaclin) chlorhexidine gluconate soln 0.12% erythromycin gel 2% (Erygel) (Peridex) erythromycin pads 2% clotrimazole troche 10 mg erythromycin soln 2% lidocaine hcl viscous soln 2% FINACEA – azelaic acid foam 15% nystatin susp 100000 unit/ml FINACEA – azelaic acid gel 15% pilocarpine hcl tab 5 mg (Salagen) isotretinoin cap 10 mg • pilocarpine hcl tab 7.5 mg (Salagen) isotretinoin cap 20 mg • triamcinolone acetonide dental paste isotretinoin cap 30 mg (Claravis) • 0.1% isotretinoin cap 40 mg • ANORECTAL AGENTS metronidazole cream 0.75% CORTIFOAM – hydrocortisone acetate (Metrocream) rectal foam 10% (90 mg/dose) metronidazole gel 0.75% hydrocortisone enema 100 mg/60ml metronidazole gel 1% (Metrogel) (Cortenema)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 53 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy metronidazole lotion 0.75% mupirocin oint 2% (Bactroban) (Metrolotion) nystatin cream 100000 unit/gm SOOLANTRA – ivermectin cream 1% nystatin oint 100000 unit/gm sulfacetamide sodium lotion 10% nystatin topical powder 100000 unit/ (acne) (Klaron) gm tazarotene cream 0.1% (Tazorac) silver sulfadiazine cream 1% TAZORAC – tazarotene cream 0.05% (Silvadene) TAZORAC – tazarotene cream 0.1% Corticosteroids TAZORAC – tazarotene gel 0.05% alclometasone dipropionate cream TAZORAC – tazarotene gel 0.1% 0.05% (Aclovate) tretinoin cream 0.025% (Retin-a) alclometasone dipropionate oint 0.05% tretinoin cream 0.05% (Retin-a) betamethasone dipropionate tretinoin cream 0.1% (Retin-a) augmented cream 0.05% (Diprolene tretinoin gel 0.01% (Retin-a) af) tretinoin gel 0.025% (Retin-a) betamethasone dipropionate tretinoin microsphere gel 0.04% augmented gel 0.05% (Retin-a micro) betamethasone dipropionate (Diprolene) tretinoin microsphere gel 0.1% augmented lotion 0.05% (Retin-a micro) betamethasone dipropionate (Diprolene) Anti-infectives augmented oint 0.05% ciclopirox gel 0.77% (Loprox) betamethasone dipropionate cream 0.05% ciclopirox olamine cream 0.77% (base equiv) betamethasone dipropionate lotion 0.05% ciclopirox olamine susp 0.77% (base equiv) betamethasone dipropionate oint 0.05% ciclopirox shampoo 1% (Loprox shampoo) betamethasone valerate cream 0.1% ciclopirox solution 8% (Penlac nail • • betamethasone valerate lotion 0.1% lacquer) betamethasone valerate oint 0.1% econazole nitrate cream 1% clobetasol propionate cream 0.05% (Temovate) gentamicin sulfate cream 0.1% ketoconazole cream 2% clobetasol propionate emollient base cream 0.05% (Temovate e) ketoconazole shampoo 2% (Nizoral) clobetasol propionate foam 0.05% mupirocin calcium cream 2% (Olux) (Bactroban)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 54 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy clobetasol propionate gel 0.05% halobetasol propionate oint 0.05% (Temovate) (Ultravate) clobetasol propionate oint 0.05% hydrocortisone cream 2.5% (Temovate) hydrocortisone lotion 2.5% clobetasol propionate soln 0.05% hydrocortisone oint 2.5% (Temovate) hydrocortisone valerate cream 0.2% desonide cream 0.05% (Desowen) hydrocortisone valerate oint 0.2% desonide lotion 0.05% (Desowen) (Westcort) desonide oint 0.05% (Desowen) mometasone furoate cream 0.1% desoximetasone cream 0.25% (Elocon) (Topicort) mometasone furoate oint 0.1% desoximetasone gel 0.05% (Topicort) (Elocon) desoximetasone oint 0.25% (Topicort) mometasone furoate solution 0.1% fluocinolone acetonide cream 0.01% (lotion) (Elocon) fluocinolone acetonide cream nystatin-triamcinolone cream 0.025% (Synalar) 100000-0.1 unit/gm-% fluocinolone acetonide oil 0.01% nystatin-triamcinolone oint (body oil) (Derma-smoothe/fs bod) 100000-0.1 unit/gm-% fluocinolone acetonide oil 0.01% triamcinolone acetonide cream (scalp oil) (Derma-smoothe/fs sca) 0.025% fluocinolone acetonide oint 0.025% triamcinolone acetonide cream 0.1% (Synalar) triamcinolone acetonide cream 0.5% fluocinolone acetonide soln 0.01% triamcinolone acetonide lotion (Synalar) 0.025% fluocinonide cream 0.05% triamcinolone acetonide lotion 0.1% fluocinonide emulsified base cream triamcinolone acetonide oint 0.025% 0.05% triamcinolone acetonide oint 0.1% fluocinonide gel 0.05% triamcinolone acetonide oint 0.5% fluocinonide oint 0.05% Other Skin Products fluocinonide soln 0.05% acitretin cap 10 mg (Soriatane) fluticasone propionate cream 0.05% acitretin cap 17.5 mg (Soriatane) (Cutivate) acitretin cap 25 mg (Soriatane) fluticasone propionate oint 0.005% (Cutivate) calcipotriene cream 0.005% (Dovonex) halobetasol propionate cream 0.05% (Ultravate) calcipotriene oint 0.005%
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 55 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy calcipotriene soln 0.005% (50 mcg/ MISCELLANEOUS CATEGORIES ml) DIABETIC SUPPLIES CARAC – fluorouracil cream 0.5% • • TEST STRIPS – ASCENSIA BREEZE • diclofenac sodium (actinic • • 2, CONTOUR, CONTOUR NEXT keratoses) gel 3% (Solaraze) INSULIN PEN NEEDLES – BD • diclofenac sodium gel 1% (Voltaren) • • ULTRAFINE, NOVOFINE, ELIDEL – pimecrolimus cream 1% • NOVOTWIST FLUOROPLEX – fluorouracil cream 1% • • INSULIN SYRINGES – BD • fluorouracil cream 5% (Efudex) • LANCETS – BAYER FINGERSTIX, MICROLET, SINGLE-LET fluorouracil soln 2% LANCETS – BD MICROTAINER, fluorouracil soln 5% ULTRAFINE imiquimod cream 5% (Aldara) • RESPIRATORY INHALER-ASSIST DEVICES lidocaine hcl gel 2% • • BREATHERITE – spacer/aerosol- lidocaine hcl soln 4% (Xylocaine) • • holding chambers - device lidocaine oint 5% • • MISCELLANEOUS DRUGS lidocaine patch 5% (Lidoderm) • • azathioprine tab 50 mg (Imuran) malathion lotion 0.5% (Ovide) buprenorphine hcl-naloxone hcl sl • permethrin cream 5% (Elimite) tab 2-0.5 mg (base equiv) podofilox soln 0.5% (Condylox) buprenorphine hcl-naloxone hcl sl • tab 8-2 mg (base equiv) selenium sulfide lotion 2.5% CHEMET – succimer cap 100 mg STELARA – ustekinumab inj 45 • • • mg/0.5ml cyclosporine cap 25 mg (Sandimmune) STELARA – ustekinumab soln prefilled • • • syringe 45 mg/0.5ml cyclosporine cap 100 mg (Sandimmune) STELARA – ustekinumab soln prefilled • • • syringe 90 mg/ml CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg tacrolimus oint 0.03% (Protopic) • cyclosporine modified cap 25 mg tacrolimus oint 0.1% (Protopic) • (Neoral) VALCHLOR – mechlorethamine hcl gel • cyclosporine modified cap 50 mg 0.016% (base equivalent) (Cyclosporine modifie) ZYCLARA – imiquimod cream 3.75% • • cyclosporine modified cap 100 mg ZYCLARA PUMP – imiquimod cream • • (Neoral) 2.5% cyclosporine modified oral soln ZYCLARA PUMP – imiquimod cream • • 100 mg/ml (Neoral) 3.75%
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 56 2017
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy DEPEN TITRATABS – penicillamine tab • SUBOXONE – buprenorphine hcl- • 250 mg naloxone hcl sl film 2-0.5 mg (base mycophenolate mofetil cap 250 mg equiv) (Cellcept) SUBOXONE – buprenorphine hcl- • mycophenolate mofetil for oral susp naloxone hcl sl film 4-1 mg (base 200 mg/ml (Cellcept) equiv) mycophenolate mofetil tab 500 mg SUBOXONE – buprenorphine hcl- • (Cellcept) naloxone hcl sl film 8-2 mg (base equiv) mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) SUBOXONE – buprenorphine hcl- • (Myfortic) naloxone hcl sl film 12-3 mg (base equiv) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) tacrolimus cap 0.5 mg (Prograf) (Myfortic) tacrolimus cap 1 mg (Prograf) naloxone hcl inj 0.4 mg/ml tacrolimus cap 5 mg (Prograf) naloxone hcl inj 4 mg/10ml THALOMID – thalidomide cap 50 mg • • • naltrexone hcl tab 50 mg (Revia) THALOMID – thalidomide cap 100 mg • • • NARCAN – naloxone hcl nasal spray 4 THALOMID – thalidomide cap 150 mg • • • mg/0.1ml THALOMID – thalidomide cap 200 mg • • • RAPAMUNE – sirolimus oral soln 1 mg/ ZORTRESS – everolimus tab 0.25 mg ml ZORTRESS – everolimus tab 0.5 mg REVLIMID – lenalidomide caps 2.5 mg • • • ZORTRESS – everolimus tab 0.75 mg REVLIMID – lenalidomide cap 5 mg • • • REVLIMID – lenalidomide cap 10 mg • • • REVLIMID – lenalidomide cap 15 mg • • • REVLIMID – lenalidomide cap 20 mg • • • REVLIMID – lenalidomide cap 25 mg • • • sirolimus tab 0.5 mg (Rapamune) sirolimus tab 1 mg (Rapamune) sirolimus tab 2 mg (Rapamune) sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps) sodium polystyrene sulfonate powder (Kayexalate)
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 57 2017
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 INDEX mcg/act...... 24 ADVAIR HFA – fluticasone-salmeterol inhal aerosol A 230-21 mcg/act...... 24 ADVATE – antihemophilic factor rahf-pfm for inj 250 abacavir sulfate-lamivudine tab 600-300 mg unit...... 45 (Epzicom)...... 4 ADVATE – antihemophilic factor rahf-pfm for inj 500 abacavir sulfate-lamivudine-zidovudine tab unit...... 45 300-150-300 mg (Trizivir)...... 4 ADVATE – antihemophilic factor rahf-pfm for inj 1000 abacavir sulfate tab 300 mg (base equiv) (Ziagen)...... 4 unit...... 45 acamprosate calcium tab delayed release 333 mg ADVATE – antihemophilic factor rahf-pfm for inj 1500 (Campral)...... 37 unit...... 45 acarbose tab 25 mg (Precose)...... 10 ADVATE – antihemophilic factor rahf-pfm for inj 2000 acarbose tab 50 mg (Precose)...... 10 unit...... 45 acarbose tab 100 mg (Precose)...... 10 ADVATE – antihemophilic factor rahf-pfm for inj 3000 acebutolol hcl cap 200 mg (Sectral)...... 17 unit...... 45 acebutolol hcl cap 400 mg (Sectral)...... 17 ADVATE – antihemophilic factor rahf-pfm for inj 4000 acetaminophen w/ codeine soln 120-12 mg/5ml...... 38 unit...... 45 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ ADYNOVATE – antihemophilic factor recomb pegylated for codeine)...... 38 inj 250 unit...... 45 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ ADYNOVATE – antihemophilic factor recomb pegylated for codeine #3)...... 38 inj 500 unit...... 45 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ ADYNOVATE – antihemophilic factor recomb pegylated for codeine #4)...... 38 inj 750 unit...... 45 acetazolamide cap sr 12hr 500 mg (Diamox)...... 21 ADYNOVATE – antihemophilic factor recomb pegylated for acetazolamide tab 125 mg...... 21 inj 1000 unit...... 46 acetazolamide tab 250 mg...... 21 ADYNOVATE – antihemophilic factor recomb pegylated for acetic acid otic soln 2%...... 53 inj 1500 unit...... 46 acetylcysteine inhal soln 10%...... 24 ADYNOVATE – antihemophilic factor recomb pegylated for acetylcysteine inhal soln 20%...... 24 inj 2000 unit...... 46 acitretin cap 10 mg (Soriatane)...... 55 AFINITOR – everolimus tab 2.5 mg...... 6 acitretin cap 17.5 mg (Soriatane)...... 55 AFINITOR – everolimus tab 5 mg...... 6 acitretin cap 25 mg (Soriatane)...... 55 AFINITOR – everolimus tab 7.5 mg...... 6 ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml AFINITOR – everolimus tab 10 mg...... 6 (2000000 unit/0.5ml)...... 6 AFSTYLA – antihemophilic fact rcmb single chain for inj kit acyclovir cap 200 mg (Zovirax)...... 4 250 unit...... 46 acyclovir susp 200 mg/5ml (Zovirax)...... 4 AFSTYLA – antihemophilic fact rcmb single chain for inj kit acyclovir tab 400 mg (Zovirax)...... 4 500 unit...... 46 acyclovir tab 800 mg (Zovirax)...... 4 AFSTYLA – antihemophilic fact rcmb single chain for inj kit adapalene cream 0.1% (Differin)...... 53 1000 unit...... 46 adapalene gel 0.1% (Differin)...... 53 AFSTYLA – antihemophilic fact rcmb single chain for inj kit adapalene gel 0.3% (Differin)...... 53 2000 unit...... 46 ADCIRCA – tadalafil tab 20 mg (pah)...... 22 AFSTYLA – antihemophilic fact rcmb single chain for inj kit adefovir dipivoxil tab 10 mg (Hepsera)...... 3 3000 unit...... 46 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba ALBENZA – albendazole tab 200 mg...... 6 100-50 mcg/dose...... 24 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)...... 24 250-50 mcg/dose...... 24 albuterol sulfate soln nebu 0.5% (5 mg/ml)...... 24 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba albuterol sulfate soln nebu 0.63 mg/3ml (base 500-50 mcg/dose...... 24 equiv)...... 24 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 albuterol sulfate soln nebu 1.25 mg/3ml (base mcg/act...... 24 equiv)...... 25 albuterol sulfate syrup 2 mg/5ml...... 25 albuterol sulfate tab 2 mg...... 25
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 58 2017 albuterol sulfate tab 4 mg...... 25 amiodarone hcl tab 400 mg...... 22 alclometasone dipropionate cream 0.05% amiodarone hcl tab 200 mg (Cordarone)...... 22 (Aclovate)...... 54 amitriptyline hcl tab 10 mg...... 30 alclometasone dipropionate oint 0.05%...... 54 amitriptyline hcl tab 25 mg...... 30 alendronate sodium tab 5 mg...... 13 amitriptyline hcl tab 50 mg...... 30 alendronate sodium tab 10 mg...... 13 amitriptyline hcl tab 75 mg...... 30 alendronate sodium tab 35 mg...... 13 amitriptyline hcl tab 100 mg...... 30 alendronate sodium tab 70 mg (Fosamax)...... 13 amitriptyline hcl tab 150 mg...... 30 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)...... 30 amlodipine besylate-atorvastatin calcium tab 2.5-10 ALKERAN – melphalan tab 2 mg...... 7 mg (Caduet)...... 18 allopurinol tab 100 mg (Zyloprim)...... 42 amlodipine besylate-atorvastatin calcium tab 2.5-20 allopurinol tab 300 mg (Zyloprim)...... 42 mg (Caduet)...... 18 ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 52 amlodipine besylate-atorvastatin calcium tab 2.5-40 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ mg (Caduet)...... 18 vwf (human) for inj 250 unit...... 46 amlodipine besylate-atorvastatin calcium tab 5-10 mg ALPHANATE/VON WILLEBRAND – antihemophilic factor/ (Caduet)...... 18 vwf (human) for inj 500 unit...... 46 amlodipine besylate-atorvastatin calcium tab 5-20 mg ALPHANATE/VON WILLEBRAND – antihemophilic factor/ (Caduet)...... 18 vwf (human) for inj 1000 unit...... 46 amlodipine besylate-atorvastatin calcium tab 5-40 mg ALPHANATE/VON WILLEBRAND – antihemophilic factor/ (Caduet)...... 18 vwf (human) for inj 1500 unit...... 46 amlodipine besylate-atorvastatin calcium tab 5-80 mg ALPHANATE/VON WILLEBRAND – antihemophilic factor/ (Caduet)...... 18 vwf (human) for inj 2000 unit...... 46 amlodipine besylate-atorvastatin calcium tab 10-10 mg ALPHANINE SD – coagulation factor ix for inj 500 unit..... 46 (Caduet)...... 18 ALPHANINE SD – coagulation factor ix for inj 1000 amlodipine besylate-atorvastatin calcium tab 10-20 mg unit...... 46 (Caduet)...... 18 ALPHANINE SD – coagulation factor ix for inj 1500 amlodipine besylate-atorvastatin calcium tab 10-40 mg unit...... 46 (Caduet)...... 18 alprazolam tab 0.25 mg (Xanax)...... 30 amlodipine besylate-atorvastatin calcium tab 10-80 mg alprazolam tab 0.5 mg (Xanax)...... 30 (Caduet)...... 18 alprazolam tab 1 mg (Xanax)...... 30 amlodipine besylate-benazepril hcl cap 2.5-10 mg alprazolam tab 2 mg (Xanax)...... 30 (Lotrel)...... 18 alprazolam tab sr 24hr 0.5 mg (Xanax xr)...... 30 amlodipine besylate-benazepril hcl cap 5-10 mg alprazolam tab sr 24hr 1 mg (Xanax xr)...... 30 (Lotrel)...... 18 alprazolam tab sr 24hr 2 mg (Xanax xr)...... 30 amlodipine besylate-benazepril hcl cap 5-20 mg alprazolam tab sr 24hr 3 mg (Xanax xr)...... 30 (Lotrel)...... 18 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj amlodipine besylate-benazepril hcl cap 5-40 mg 250 unit...... 46 (Lotrel)...... 18 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj amlodipine besylate-benazepril hcl cap 10-20 mg 500 unit...... 46 (Lotrel)...... 19 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj amlodipine besylate-benazepril hcl cap 10-40 mg 1000 unit...... 46 (Lotrel)...... 19 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj amlodipine besylate tab 2.5 mg (Norvasc)...... 18 2000 unit...... 46 amlodipine besylate tab 5 mg (Norvasc)...... 18 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj amlodipine besylate tab 10 mg (Norvasc)...... 18 3000 unit...... 46 amlodipine besylate-valsartan tab 5-160 mg ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj (Exforge)...... 19 4000 unit...... 46 amlodipine besylate-valsartan tab 5-320 mg amantadine hcl cap 100 mg...... 43 (Exforge)...... 19 amantadine hcl syrup 50 mg/5ml...... 43 amlodipine besylate-valsartan tab 10-160 mg amiloride & hydrochlorothiazide tab 5-50 mg...... 21 (Exforge)...... 19 amiloride hcl tab 5 mg...... 21 amlodipine besylate-valsartan tab 10-320 mg amiodarone hcl tab 100 mg...... 22 (Exforge)...... 19
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 59 2017 amlodipine-valsartan-hydrochlorothiazide tab amphetamine-dextroamphetamine tab 15 mg 5-160-12.5 mg (Exforge hct)...... 15 (Adderall)...... 35 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 amphetamine-dextroamphetamine tab 20 mg mg (Exforge hct)...... 15 (Adderall)...... 35 amlodipine-valsartan-hydrochlorothiazide tab amphetamine-dextroamphetamine tab 30 mg 10-160-12.5 mg (Exforge hct)...... 16 (Adderall)...... 35 amlodipine-valsartan-hydrochlorothiazide tab ampicillin cap 250 mg...... 1 10-160-25 mg (Exforge hct)...... 16 ampicillin cap 500 mg...... 1 amlodipine-valsartan-hydrochlorothiazide tab anagrelide hcl cap 1 mg...... 46 10-320-25 mg (Exforge hct)...... 16 anagrelide hcl cap 0.5 mg (Agrylin)...... 46 amoxicillin & k clavulanate for susp 200-28.5 anastrozole tab 1 mg (Arimidex)...... 7 mg/5ml...... 1 ANDROGEL PUMP – testosterone td gel 20.25 mg/act amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1 (1.62%)...... 9 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ANDROGEL – testosterone td gel 20.25 mg/1.25gm (Augmentin)...... 1 (1.62%)...... 9 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ANDROGEL – testosterone td gel 40.5 mg/2.5gm (Augmentin es-600)...... 1 (1.62%)...... 9 amoxicillin & k clavulanate tab 250-125 mg...... 1 ANDROXY – fluoxymesterone tab 10 mg...... 9 amoxicillin & k clavulanate tab 500-125 mg ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba (Augmentin)...... 1 62.5-25 mcg/inh...... 25 amoxicillin & k clavulanate tab 875-125 mg aprepitant capsule 80 mg (Emend)...... 28 (Augmentin)...... 1 aprepitant capsule therapy pack 80 & 125 mg amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Emend)...... 28 (Augmentin xr)...... 1 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 amoxicillin (trihydrate) cap 250 mg...... 1 mcg/ml...... 47 amoxicillin (trihydrate) cap 500 mg...... 1 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40 amoxicillin (trihydrate) for susp 125 mg/5ml...... 1 mcg/ml...... 47 amoxicillin (trihydrate) for susp 200 mg/5ml...... 1 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60 amoxicillin (trihydrate) for susp 250 mg/5ml...... 1 mcg/ml...... 47 amoxicillin (trihydrate) for susp 400 mg/5ml...... 1 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj amoxicillin (trihydrate) tab 500 mg...... 1 100 mcg/ml...... 47 amoxicillin (trihydrate) tab 875 mg...... 1 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj amphetamine-dextroamphetamine cap sr 24hr 5 mg 200 mcg/ml...... 47 (Adderall xr)...... 34 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj amphetamine-dextroamphetamine cap sr 24hr 10 mg 300 mcg/ml...... 47 (Adderall xr)...... 34 ARANESP ALBUMIN FREE – darbepoetin alfa soln amphetamine-dextroamphetamine cap sr 24hr 15 mg prefilled syringe 10 mcg/0.4ml...... 46 (Adderall xr)...... 35 ARANESP ALBUMIN FREE – darbepoetin alfa soln amphetamine-dextroamphetamine cap sr 24hr 20 mg prefilled syringe 25 mcg/0.42ml...... 46 (Adderall xr)...... 35 ARANESP ALBUMIN FREE – darbepoetin alfa soln amphetamine-dextroamphetamine cap sr 24hr 25 mg prefilled syringe 40 mcg/0.4ml...... 46 (Adderall xr)...... 35 ARANESP ALBUMIN FREE – darbepoetin alfa soln amphetamine-dextroamphetamine cap sr 24hr 30 mg prefilled syringe 60 mcg/0.3ml...... 46 (Adderall xr)...... 35 ARANESP ALBUMIN FREE – darbepoetin alfa soln amphetamine-dextroamphetamine tab 5 mg prefilled syringe 100 mcg/0.5ml...... 46 (Adderall)...... 35 ARANESP ALBUMIN FREE – darbepoetin alfa soln amphetamine-dextroamphetamine tab 7.5 mg prefilled syringe 150 mcg/0.3ml...... 46 (Adderall)...... 35 ARANESP ALBUMIN FREE – darbepoetin alfa soln amphetamine-dextroamphetamine tab 10 mg prefilled syringe 200 mcg/0.4ml...... 46 (Adderall)...... 35 ARANESP ALBUMIN FREE – darbepoetin alfa soln amphetamine-dextroamphetamine tab 12.5 mg prefilled syringe 300 mcg/0.6ml...... 46 (Adderall)...... 35 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 500 mcg/ml...... 47
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 60 2017 aripiprazole tab 2 mg (Abilify)...... 32 AVONEX – interferon beta-1a for im inj kit 30mcg aripiprazole tab 5 mg (Abilify)...... 32 (33mcg(6.6 mu)/vial)...... 36 aripiprazole tab 10 mg (Abilify)...... 32 AVONEX – interferon beta-1a im prefilled syringe kit 30 aripiprazole tab 15 mg (Abilify)...... 32 mcg/0.5ml...... 36 aripiprazole tab 20 mg (Abilify)...... 32 AVONEX PEN – interferon beta-1a im auto-injector kit 30 aripiprazole tab 30 mg (Abilify)...... 32 mcg/0.5ml...... 36 ARNUITY ELLIPTA – fluticasone furoate aerosol powder AXIRON – testosterone td soln 30 mg/act...... 9 breath activ 100 mcg/act...... 25 azathioprine tab 50 mg (Imuran)...... 56 ARNUITY ELLIPTA – fluticasone furoate aerosol powder azelastine hcl nasal spray 0.1% (137 mcg/spray)...... 24 breath activ 200 mcg/act...... 25 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ASACOL HD – mesalamine tab delayed release 800 (Astepro)...... 24 mg...... 28 azelastine hcl ophth soln 0.05% (Optivar)...... 52 ASMANEX HFA – mometasone furoate inhal aerosol AZILECT – rasagiline mesylate tab 0.5 mg (base suspension 100 mcg/act...... 25 equiv)...... 43 ASMANEX HFA – mometasone furoate inhal aerosol AZILECT – rasagiline mesylate tab 1 mg (base equiv)...... 43 suspension 200 mcg/act...... 25 AZITHROMYCIN – azithromycin powd pack for susp 1 ASMANEX TWISTHALER 120 ME – mometasone furoate gm...... 2 inhal powd 220 mcg/inh (breath activated)...... 25 azithromycin for susp 100 mg/5ml (Zithromax)...... 2 ASMANEX TWISTHALER 7 METE – mometasone furoate azithromycin for susp 200 mg/5ml (Zithromax)...... 2 inhal powd 110 mcg/inh (breath activated)...... 25 azithromycin tab 250 mg (Zithromax)...... 2 ASMANEX TWISTHALER 14 MET – mometasone furoate azithromycin tab 500 mg (Zithromax)...... 2 inhal powd 220 mcg/inh (breath activated)...... 25 azithromycin tab 600 mg (Zithromax)...... 2 ASMANEX TWISTHALER 30 MET – mometasone furoate AZOPT – brinzolamide ophth susp 1%...... 52 inhal powd 110 mcg/inh (breath activated)...... 25 B ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 220 mcg/inh (breath activated)...... 25 BACITRACIN – bacitracin ophth oint 500 unit/gm...... 51 ASMANEX TWISTHALER 60 MET – mometasone furoate bacitracin-polymyxin b ophth oint...... 51 inhal powd 220 mcg/inh (breath activated)...... 25 bacitracin-polymyxin-neomycin-hc ophth oint 1%...... 51 atenolol & chlorthalidone tab 50-25 mg (Tenoretic baclofen tab 10 mg...... 44 50)...... 17 baclofen tab 20 mg...... 44 atenolol & chlorthalidone tab 100-25 mg (Tenoretic balsalazide disodium cap 750 mg (Colazal)...... 28 100)...... 17 BARACLUDE – entecavir oral soln 0.05 mg/ml...... 3 atenolol tab 25 mg (Tenormin)...... 17 BEBULIN – factor ix complex for inj 200-1200 unit...... 47 atenolol tab 50 mg (Tenormin)...... 17 benazepril & hydrochlorothiazide tab 5-6.25 mg...... 14 atenolol tab 100 mg (Tenormin)...... 17 benazepril & hydrochlorothiazide tab 10-12.5 mg atorvastatin calcium tab 10 mg (base equivalent) (Lotensin hct)...... 14 (Lipitor)...... 20 benazepril & hydrochlorothiazide tab 20-12.5 mg atorvastatin calcium tab 20 mg (base equivalent) (Lotensin hct)...... 14 (Lipitor)...... 20 benazepril & hydrochlorothiazide tab 20-25 mg atorvastatin calcium tab 40 mg (base equivalent) (Lotensin hct)...... 14 (Lipitor)...... 20 benazepril hcl tab 5 mg...... 14 atorvastatin calcium tab 80 mg (base equivalent) benazepril hcl tab 10 mg (Lotensin)...... 14 (Lipitor)...... 20 benazepril hcl tab 20 mg (Lotensin)...... 14 atovaquone-proguanil hcl tab 62.5-25 mg benazepril hcl tab 40 mg (Lotensin)...... 14 (Malarone)...... 6 BENEFIX – coagulation factor ix (recombinant) for inj kit atovaquone-proguanil hcl tab 250-100 mg 250 unit...... 47 (Malarone)...... 6 BENEFIX – coagulation factor ix (recombinant) for inj kit ATRIPLA – efavirenz-emtricitabine-tenofovir df tab 500 unit...... 47 600-200-300 mg...... 4 BENEFIX – coagulation factor ix (recombinant) for inj kit ATROVENT HFA – ipratropium bromide hfa inhal aerosol 1000 unit...... 47 17 mcg/act...... 25 BENEFIX – coagulation factor ix (recombinant) for inj kit AUBAGIO – teriflunomide tab 7 mg...... 36 2000 unit...... 47 AUBAGIO – teriflunomide tab 14 mg...... 36
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 61 2017
BENEFIX – coagulation factor ix (recombinant) for inj kit bromocriptine mesylate cap 5 mg (base 3000 unit...... 47 equivalent)...... 43 BENICAR HCT – olmesartan medoxomil- bromocriptine mesylate tab 2.5 mg (base equivalent) hydrochlorothiazide tab 20-12.5 mg...... 16 (Parlodel)...... 44 BENICAR HCT – olmesartan medoxomil- budesonide delayed release particles cap 3 mg hydrochlorothiazide tab 40-12.5 mg...... 16 (Entocort ec)...... 8 BENICAR HCT – olmesartan medoxomil- budesonide inhalation susp 0.25 mg/2ml hydrochlorothiazide tab 40-25 mg...... 16 (Pulmicort)...... 25 BENICAR – olmesartan medoxomil tab 5 mg...... 16 budesonide inhalation susp 0.5 mg/2ml BENICAR – olmesartan medoxomil tab 20 mg...... 16 (Pulmicort)...... 25 BENICAR – olmesartan medoxomil tab 40 mg...... 16 budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 25 benzoyl peroxide-erythromycin gel 5-3% bumetanide tab 0.5 mg...... 21 (Benzamycin)...... 53 bumetanide tab 1 mg...... 21 benztropine mesylate tab 0.5 mg...... 43 bumetanide tab 2 mg...... 21 benztropine mesylate tab 1 mg...... 43 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base benztropine mesylate tab 2 mg...... 43 equiv)...... 56 betamethasone dipropionate augmented cream 0.05% buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base (Diprolene af)...... 54 equiv)...... 56 betamethasone dipropionate augmented gel buprenorphine hcl sl tab 2 mg (base equiv)...... 38 0.05%...... 54 buprenorphine hcl sl tab 8 mg (base equiv)...... 38 betamethasone dipropionate augmented lotion 0.05% bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Diprolene)...... 54 (Zyban)...... 37 betamethasone dipropionate augmented oint 0.05% bupropion hcl tab 75 mg (Wellbutrin)...... 31 (Diprolene)...... 54 bupropion hcl tab 100 mg (Wellbutrin)...... 31 betamethasone dipropionate cream 0.05%...... 54 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)...... 30 betamethasone dipropionate lotion 0.05%...... 54 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)...... 31 betamethasone dipropionate oint 0.05%...... 54 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)...... 31 betamethasone valerate cream 0.1%...... 54 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)...... 31 betamethasone valerate lotion 0.1%...... 54 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)...... 31 betamethasone valerate oint 0.1%...... 54 buspirone hcl tab 5 mg...... 30 BETASERON – interferon beta-1b for inj kit 0.3 mg...... 36 buspirone hcl tab 10 mg...... 30 bexarotene cap 75 mg (Targretin)...... 7 buspirone hcl tab 15 mg...... 30 bicalutamide tab 50 mg (Casodex)...... 7 buspirone hcl tab 30 mg...... 30 BILTRICIDE – praziquantel tab 600 mg...... 6 butalbital-acetaminophen-caffeine cap 50-325-40 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg mg...... 37 (Ziac)...... 17 butalbital-acetaminophen-caffeine tab 50-325-40 bisoprolol & hydrochlorothiazide tab 5-6.25 mg mg...... 38 (Ziac)...... 17 butalbital-acetaminophen tab 50-325 mg...... 37 bisoprolol & hydrochlorothiazide tab 10-6.25 mg butalbital-aspirin-caffeine cap 50-325-40 mg (Ziac)...... 17 (Fiorinal)...... 38 bisoprolol fumarate tab 5 mg (Zebeta)...... 17 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg bisoprolol fumarate tab 10 mg (Zebeta)...... 17 (Fiorinal/codeine #3)...... 38 BREATHERITE – spacer/aerosol-holding chambers - BYDUREON – exenatide for inj extended release susp 2 device...... 56 mg...... 10 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd BYDUREON PEN – exenatide extended release for susp ba 100-25 mcg/inh...... 25 pen-injector 2 mg...... 10 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd C ba 200-25 mcg/inh...... 25 BRILINTA – ticagrelor tab 60 mg...... 47 cabergoline tab 0.5 mg...... 13 BRILINTA – ticagrelor tab 90 mg...... 47 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base brimonidine tartrate ophth soln 0.2%...... 52 equiv) (Cafcit)...... 35 brimonidine tartrate ophth soln 0.15% (Alphagan calcipotriene cream 0.005% (Dovonex)...... 55 p)...... 52 calcipotriene oint 0.005%...... 55
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 62 2017 calcipotriene soln 0.005% (50 mcg/ml)...... 56 carvedilol tab 12.5 mg (Coreg)...... 17 calcitonin (salmon) nasal soln 200 unit/act carvedilol tab 25 mg (Coreg)...... 17 (Miacalcin)...... 13 cefaclor cap 250 mg...... 1 calcitriol cap 0.25 mcg (Rocaltrol)...... 13 cefaclor cap 500 mg...... 1 calcitriol cap 0.5 mcg (Rocaltrol)...... 13 cefadroxil cap 500 mg...... 1 calcitriol oral soln 1 mcg/ml (Rocaltrol)...... 13 cefadroxil for susp 250 mg/5ml...... 1 calcium acetate (phosphate binder) cap 667 mg (169 cefadroxil for susp 500 mg/5ml...... 1 mg ca) (Phoslo)...... 28 cefadroxil tab 1 gm...... 1 calcium acetate (phosphate binder) tab 667 mg cefdinir cap 300 mg...... 1 (Eliphos)...... 28 cefdinir for susp 125 mg/5ml...... 1 CANASA – mesalamine suppos 1000 mg...... 28 cefdinir for susp 250 mg/5ml...... 1 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 cefixime for susp 100 mg/5ml (Suprax)...... 1 mg (Atacand hct)...... 16 cefixime for susp 200 mg/5ml (Suprax)...... 1 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 cefpodoxime proxetil for susp 50 mg/5ml...... 1 mg (Atacand hct)...... 16 cefpodoxime proxetil for susp 100 mg/5ml...... 1 candesartan cilexetil-hydrochlorothiazide tab 32-25 cefpodoxime proxetil tab 100 mg...... 1 mg (Atacand hct)...... 16 cefpodoxime proxetil tab 200 mg...... 1 candesartan cilexetil tab 4 mg (Atacand)...... 16 cefprozil for susp 125 mg/5ml...... 1 candesartan cilexetil tab 8 mg (Atacand)...... 16 cefprozil for susp 250 mg/5ml...... 1 candesartan cilexetil tab 16 mg (Atacand)...... 16 cefprozil tab 250 mg...... 1 candesartan cilexetil tab 32 mg (Atacand)...... 16 cefprozil tab 500 mg...... 1 capecitabine tab 150 mg (Xeloda)...... 7 CEFTIN – cefuroxime axetil for susp 125 mg/5ml...... 1 capecitabine tab 500 mg (Xeloda)...... 7 ceftriaxone sodium for inj 2 gm...... 2 captopril tab 12.5 mg...... 14 ceftriaxone sodium for inj 1 gm (Rocephin)...... 1 captopril tab 25 mg...... 15 ceftriaxone sodium for inj 250 mg...... 1 captopril tab 50 mg...... 15 ceftriaxone sodium for inj 500 mg (Rocephin)...... 1 captopril tab 100 mg...... 15 cefuroxime axetil tab 250 mg (Ceftin)...... 2 CARAC – fluorouracil cream 0.5%...... 56 cefuroxime axetil tab 500 mg (Ceftin)...... 2 carbamazepine cap sr 12hr 100 mg (Carbatrol)...... 42 celecoxib cap 50 mg (Celebrex)...... 40 carbamazepine cap sr 12hr 200 mg (Carbatrol)...... 42 celecoxib cap 100 mg (Celebrex)...... 40 carbamazepine cap sr 12hr 300 mg (Carbatrol)...... 42 celecoxib cap 200 mg (Celebrex)...... 40 carbamazepine chew tab 100 mg...... 42 celecoxib cap 400 mg (Celebrex)...... 40 carbamazepine susp 100 mg/5ml (Tegretol)...... 42 CELONTIN – methsuximide cap 300 mg...... 42 carbamazepine tab 200 mg (Tegretol)...... 42 cephalexin cap 250 mg (Keflex)...... 2 carbamazepine tab sr 12hr 100 mg (Tegretol-xr)...... 42 cephalexin cap 500 mg (Keflex)...... 2 carbamazepine tab sr 12hr 200 mg (Tegretol-xr)...... 42 cephalexin for susp 125 mg/5ml...... 2 carbamazepine tab sr 12hr 400 mg (Tegretol-xr)...... 42 cephalexin for susp 250 mg/5ml...... 2 carbidopa & levodopa orally disintegrating tab 10-100 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...... 24 mg...... 44 cevimeline hcl cap 30 mg (Evoxac)...... 53 carbidopa & levodopa orally disintegrating tab 25-100 CHANTIX CONTINUING MONTH – varenicline tartrate tab mg...... 44 1 mg (base equiv)...... 37 carbidopa & levodopa orally disintegrating tab 25-250 CHANTIX STARTING MONTH PA – varenicline tartrate mg...... 44 tab 0.5 mg x 11 & tab 1 mg x 42 pack...... 37 carbidopa & levodopa tab cr 25-100 mg (Sinemet CHANTIX – varenicline tartrate tab 0.5 mg (base cr)...... 44 equiv)...... 37 carbidopa & levodopa tab cr 50-200 mg (Sinemet CHANTIX – varenicline tartrate tab 1 mg (base equiv)...... 37 cr)...... 44 CHEMET – succimer cap 100 mg...... 56 carbidopa & levodopa tab 10-100 mg (Sinemet)...... 44 CHENODAL – chenodiol tab 250 mg...... 28 carbidopa & levodopa tab 25-100 mg (Sinemet)...... 44 chlorhexidine gluconate soln 0.12% (Peridex)...... 53 carbidopa & levodopa tab 25-250 mg (Sinemet)...... 44 chloroquine phosphate tab 500 mg (Aralen)...... 6 carteolol hcl ophth soln 1%...... 52 chlorothiazide tab 500 mg...... 21 carvedilol tab 3.125 mg (Coreg)...... 17 chlorpromazine hcl tab 10 mg...... 32 carvedilol tab 6.25 mg (Coreg)...... 17 chlorpromazine hcl tab 25 mg...... 32
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 63 2017 chlorpromazine hcl tab 50 mg...... 32 clarithromycin for susp 250 mg/5ml (Biaxin)...... 2 chlorpromazine hcl tab 100 mg...... 32 clarithromycin tab 250 mg (Biaxin)...... 2 chlorpromazine hcl tab 200 mg...... 32 clarithromycin tab 500 mg (Biaxin)...... 2 chlorthalidone tab 25 mg...... 21 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)...... 2 chlorthalidone tab 50 mg...... 21 CLEOCIN – clindamycin phosphate vaginal suppos 100 chlorzoxazone tab 500 mg (Parafon forte dsc)...... 44 mg...... 29 cholestyramine light powder 4 gm/dose (Questran clindamycin hcl cap 75 mg (Cleocin)...... 6 light)...... 20 clindamycin hcl cap 150 mg (Cleocin)...... 6 cholestyramine light powder packets 4 gm...... 20 clindamycin hcl cap 300 mg (Cleocin)...... 6 cholestyramine powder 4 gm/dose (Questran)...... 20 clindamycin palmitate hcl for soln 75 mg/5ml (base cholestyramine powder packets 4 gm (Questran)...... 20 equiv) (Cleocin pediatric gr)...... 6 choline fenofibrate cap dr 45 mg (fenofibric acid clindamycin phosphate-benzoyl peroxide gel 1-5% equiv) (Trilipix)...... 20 (Benzaclin)...... 53 choline fenofibrate cap dr 135 mg (fenofibric acid clindamycin phosphate gel 1% (Cleocin-t)...... 53 equiv) (Trilipix)...... 20 clindamycin phosphate lotion 1% (Cleocin-t)...... 53 chorionic gonadotropin for inj 10000 unit...... 10 clindamycin phosphate soln 1% (Cleocin-t)...... 53 CIALIS – tadalafil tab 2.5 mg...... 23 clindamycin phosphate swab 1% (Cleocin-t)...... 53 CIALIS – tadalafil tab 5 mg...... 23 clindamycin phosphate vaginal cream 2% CIALIS – tadalafil tab 10 mg...... 23 (Cleocin)...... 29 CIALIS – tadalafil tab 20 mg...... 23 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 ciclopirox gel 0.77% (Loprox)...... 54 (1)-5% (Duac)...... 53 ciclopirox olamine cream 0.77% (base equiv)...... 54 clobetasol propionate cream 0.05% (Temovate)...... 54 ciclopirox olamine susp 0.77% (base equiv)...... 54 clobetasol propionate emollient base cream 0.05% ciclopirox shampoo 1% (Loprox shampoo)...... 54 (Temovate e)...... 54 ciclopirox solution 8% (Penlac nail lacquer)...... 54 clobetasol propionate foam 0.05% (Olux)...... 54 cilostazol tab 50 mg (Pletal)...... 47 clobetasol propionate gel 0.05% (Temovate)...... 55 cilostazol tab 100 mg (Pletal)...... 47 clobetasol propionate oint 0.05% (Temovate)...... 55 cimetidine hcl soln 300 mg/5ml...... 27 clobetasol propionate soln 0.05% (Temovate)...... 55 cimetidine tab 300 mg...... 27 clomipramine hcl cap 25 mg (Anafranil)...... 31 cimetidine tab 400 mg...... 27 clomipramine hcl cap 50 mg (Anafranil)...... 31 cimetidine tab 800 mg...... 27 clomipramine hcl cap 75 mg (Anafranil)...... 31 CIPRODEX – ciprofloxacin-dexamethasone otic susp clonazepam tab 0.5 mg (Klonopin)...... 42 0.3-0.1%...... 53 clonazepam tab 1 mg (Klonopin)...... 42 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 clonazepam tab 2 mg (Klonopin)...... 42 mg(base eq) (Cipro xr)...... 3 clonidine hcl tab 0.1 mg (Catapres)...... 22 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg clonidine hcl tab 0.2 mg (Catapres)...... 23 (base eq) (Cipro xr)...... 3 clonidine hcl tab 0.3 mg (Catapres)...... 23 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 clonidine hcl td patch weekly 0.1 mg/24hr (Catapres- gm/100ml) (Cipro)...... 2 tts-1)...... 23 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 clonidine hcl td patch weekly 0.2 mg/24hr (Catapres- gm/100ml) (Cipro)...... 2 tts-2)...... 23 ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...... 51 clonidine hcl td patch weekly 0.3 mg/24hr (Catapres- ciprofloxacin hcl tab 750 mg (base equiv)...... 3 tts-3)...... 23 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...... 2 clopidogrel bisulfate tab 75 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...... 2 (Plavix)...... 47 citalopram hydrobromide oral soln 10 mg/5ml...... 31 clotrimazole troche 10 mg...... 53 citalopram hydrobromide tab 10 mg (base equiv) clozapine tab 50 mg...... 32 (Celexa)...... 31 clozapine tab 200 mg...... 32 citalopram hydrobromide tab 20 mg (base equiv) clozapine tab 25 mg (Clozaril)...... 32 (Celexa)...... 31 clozapine tab 100 mg (Clozaril)...... 32 citalopram hydrobromide tab 40 mg (base equiv) COAGADEX – coagulation factor x (human) for inj 250 (Celexa)...... 31 unit...... 47 clarithromycin for susp 125 mg/5ml...... 2
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 64 2017
COAGADEX – coagulation factor x (human) for inj 500 cyclosporine modified oral soln 100 mg/ml unit...... 47 (Neoral)...... 56 codeine sulfate tab 30 mg...... 38 cyproheptadine hcl syrup 2 mg/5ml...... 24 codeine sulfate tab 60 mg...... 38 cyproheptadine hcl tab 4 mg...... 24 codeine sulfate tab 15 mg (Codeine sulfate)...... 38 CYSTAGON – cysteamine bitartrate cap 50 mg...... 30 colchicine w/ probenecid tab 0.5-500 mg...... 42 CYSTAGON – cysteamine bitartrate cap 150 mg...... 30 COLCRYS – colchicine tab 0.6 mg...... 42 D colestipol hcl granule packets 5 gm (Colestid flavored)...... 20 DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base colestipol hcl granules 5 gm (Colestid flavored)...... 20 equivalent)...... 3 colestipol hcl tab 1 gm (Colestid)...... 20 DAKLINZA – daclatasvir dihydrochloride tab 60 mg (base COMBIPATCH – estradiol-norethindrone ace td pttw equivalent)...... 4 0.05-0.14 mg/day...... 9 DAKLINZA – daclatasvir dihydrochloride tab 90 mg (base COMBIPATCH – estradiol-norethindrone ace td pttw equivalent)...... 4 0.05-0.25 mg/day...... 9 danazol cap 50 mg...... 9 COMBIVENT RESPIMAT – ipratropium-albuterol inhal danazol cap 100 mg...... 9 aerosol soln 20-100 mcg/act...... 25 danazol cap 200 mg...... 9 COPAXONE – glatiramer acetate soln prefilled syringe 20 dantrolene sodium cap 25 mg (Dantrium)...... 44 mg/ml...... 36 dantrolene sodium cap 50 mg (Dantrium)...... 44 COPAXONE – glatiramer acetate soln prefilled syringe 40 dantrolene sodium cap 100 mg (Dantrolene mg/ml...... 36 sodium)...... 44 CORIFACT – factor xiii concentrate (human) for inj kit dapsone tab 25 mg...... 6 1000-1600 unit...... 47 dapsone tab 100 mg...... 6 CORTIFOAM – hydrocortisone acetate rectal foam 10% DARAPRIM – pyrimethamine tab 25 mg...... 6 (90 mg/dose)...... 53 DELZICOL – mesalamine cap dr 400 mg...... 28 CORTISONE ACETATE – cortisone acetate tab 25 mg...... 8 demeclocycline hcl tab 150 mg...... 2 COTELLIC – cobimetinib fumarate tab 20 mg (base demeclocycline hcl tab 300 mg...... 2 equivalent)...... 7 DEPEN TITRATABS – penicillamine tab 250 mg...... 57 CREON – pancrelipase (lip-prot-amyl) dr cap DESCOVY – emtricitabine-tenofovir alafenamide fumarate 3000-9500-15000 unit...... 28 tab 200-25 mg...... 4 CREON – pancrelipase (lip-prot-amyl) dr cap desipramine hcl tab 10 mg (Norpramin)...... 31 6000-19000-30000 unit...... 28 desipramine hcl tab 25 mg (Norpramin)...... 31 CREON – pancrelipase (lip-prot-amyl) dr cap desipramine hcl tab 50 mg (Norpramin)...... 31 12000-38000-60000 unit...... 28 desipramine hcl tab 75 mg (Norpramin)...... 31 CREON – pancrelipase (lip-prot-amyl) dr cap desipramine hcl tab 100 mg (Norpramin)...... 31 24000-76000-120000 unit...... 28 desipramine hcl tab 150 mg (Norpramin)...... 31 CREON – pancrelipase (lip-prot-amyl) dr cap desloratadine tab 5 mg (Clarinex)...... 24 36000-114000-180000 unit...... 28 desmopressin acetate inj 4 mcg/ml (Ddavp)...... 13 CRINONE – progesterone vaginal gel 4%...... 29 desmopressin acetate nasal soln 0.01% (refrigerated) CRINONE – progesterone vaginal gel 8%...... 29 (Ddavp)...... 13 cromolyn sodium ophth soln 4%...... 52 desmopressin acetate nasal spray soln 0.01% cyanocobalamin inj 1000 mcg/ml...... 47 (Ddavp)...... 13 cyclobenzaprine hcl tab 5 mg...... 44 desmopressin acetate nasal spray soln 0.01% cyclobenzaprine hcl tab 10 mg...... 44 (refrigerated)...... 14 cyclopentolate hcl ophth soln 1% (Cyclogyl)...... 52 desmopressin acetate tab 0.1 mg (Ddavp)...... 14 cyclosporine cap 25 mg (Sandimmune)...... 56 desmopressin acetate tab 0.2 mg (Ddavp)...... 14 cyclosporine cap 100 mg (Sandimmune)...... 56 desonide cream 0.05% (Desowen)...... 55 cyclosporine modified cap 50 mg (Cyclosporine desonide lotion 0.05% (Desowen)...... 55 modifie)...... 56 desonide oint 0.05% (Desowen)...... 55 cyclosporine modified cap 25 mg (Neoral)...... 56 desoximetasone cream 0.25% (Topicort)...... 55 cyclosporine modified cap 100 mg (Neoral)...... 56 desoximetasone gel 0.05% (Topicort)...... 55 CYCLOSPORINE MODIFIED – cyclosporine modified cap desoximetasone oint 0.25% (Topicort)...... 55 50 mg...... 56
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 65 2017
DEXAMETHASONE – dexamethasone soln 0.5 didanosine delayed release capsule 125 mg (Videx mg/5ml...... 8 ec)...... 4 dexamethasone elixir 0.5 mg/5ml...... 8 didanosine delayed release capsule 200 mg (Videx dexamethasone tab 0.5 mg...... 8 ec)...... 4 dexamethasone tab 0.75 mg...... 8 didanosine delayed release capsule 250 mg (Videx dexamethasone tab 1.5 mg...... 8 ec)...... 4 dexamethasone tab 4 mg...... 8 didanosine delayed release capsule 400 mg (Videx dexamethasone tab 6 mg...... 8 ec)...... 4 dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin digoxin tab 125 mcg (0.125 mg) (Lanoxin)...... 23 xr)...... 35 digoxin tab 250 mcg (0.25 mg) (Lanoxin)...... 23 dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin DILANTIN – phenytoin sodium extended cap 30 mg...... 42 xr)...... 35 diltiazem hcl cap sr 24hr 120 mg...... 19 dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin diltiazem hcl cap sr 24hr 180 mg...... 19 xr)...... 35 diltiazem hcl cap sr 24hr 240 mg...... 19 dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin diltiazem hcl coated beads cap sr 24hr 120 mg xr)...... 35 (Cardizem cd)...... 19 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin diltiazem hcl coated beads cap sr 24hr 180 mg xr)...... 35 (Cardizem cd)...... 19 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin diltiazem hcl coated beads cap sr 24hr 240 mg xr)...... 35 (Cardizem cd)...... 19 dextroamphetamine sulfate cap sr 24hr 5 mg diltiazem hcl coated beads cap sr 24hr 300 mg (Dexedrine)...... 35 (Cardizem cd)...... 19 dextroamphetamine sulfate cap sr 24hr 10 mg diltiazem hcl coated beads cap sr 24hr 360 mg (Dexedrine)...... 35 (Cardizem cd)...... 19 dextroamphetamine sulfate cap sr 24hr 15 mg diltiazem hcl extended release beads cap sr 24hr 120 (Dexedrine)...... 35 mg (Tiazac)...... 19 dextroamphetamine sulfate tab 5 mg...... 35 diltiazem hcl extended release beads cap sr 24hr 180 dextroamphetamine sulfate tab 10 mg...... 35 mg (Tiazac)...... 19 DIASTAT ACUDIAL – diazepam rectal gel delivery system diltiazem hcl extended release beads cap sr 24hr 240 10 mg...... 42 mg (Tiazac)...... 19 DIASTAT ACUDIAL – diazepam rectal gel delivery system diltiazem hcl extended release beads cap sr 24hr 300 20 mg...... 42 mg (Tiazac)...... 19 DIASTAT PEDIATRIC – diazepam rectal gel delivery diltiazem hcl extended release beads cap sr 24hr 360 system 2.5 mg...... 42 mg (Tiazac)...... 19 DIAZEPAM – diazepam oral soln 1 mg/ml...... 30 diltiazem hcl extended release beads cap sr 24hr 420 diazepam tab 2 mg (Valium)...... 30 mg (Tiazac)...... 19 diazepam tab 5 mg (Valium)...... 30 diltiazem hcl tab 90 mg...... 19 diazepam tab 10 mg (Valium)...... 30 diltiazem hcl tab 30 mg (Cardizem)...... 19 diclofenac potassium tab 50 mg (Cataflam)...... 40 diltiazem hcl tab 60 mg (Cardizem)...... 19 diclofenac sodium (actinic keratoses) gel 3% diltiazem hcl tab 120 mg (Cardizem)...... 19 (Solaraze)...... 56 diphenoxylate w/ atropine tab 2.5-0.025 mg diclofenac sodium gel 1% (Voltaren)...... 56 (Lomotil)...... 27 diclofenac sodium ophth soln 0.1%...... 52 dipyridamole tab 25 mg (Persantine)...... 47 diclofenac sodium tab delayed release 25 mg...... 40 dipyridamole tab 50 mg (Persantine)...... 47 diclofenac sodium tab delayed release 50 mg...... 40 dipyridamole tab 75 mg (Persantine)...... 47 diclofenac sodium tab delayed release 75 mg...... 40 disopyramide phosphate cap 100 mg (Norpace)...... 22 diclofenac sodium tab sr 24hr 100 mg (Voltaren- disopyramide phosphate cap 150 mg (Norpace)...... 22 xr)...... 40 disulfiram tab 250 mg (Antabuse)...... 37 dicloxacillin sodium cap 250 mg...... 1 disulfiram tab 500 mg (Antabuse)...... 37 dicloxacillin sodium cap 500 mg...... 1 divalproex sodium cap delayed release sprinkle 125 dicyclomine hcl cap 10 mg (Bentyl)...... 27 mg (Depakote sprinkles)...... 42 dicyclomine hcl oral soln 10 mg/5ml...... 27 divalproex sodium tab delayed release 125 mg dicyclomine hcl tab 20 mg (Bentyl)...... 27 (Depakote)...... 42
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 66 2017 divalproex sodium tab delayed release 250 mg duloxetine hcl enteric coated pellets cap 30 mg (Depakote)...... 42 (Cymbalta)...... 31 divalproex sodium tab delayed release 500 mg duloxetine hcl enteric coated pellets cap 60 mg (Depakote)...... 42 (Cymbalta)...... 31 divalproex sodium tab sr 24 hr 250 mg (Depakote dutasteride cap 0.5 mg (Avodart)...... 30 er)...... 42 E divalproex sodium tab sr 24 hr 500 mg (Depakote er)...... 42 econazole nitrate cream 1%...... 54 DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)...... 9 ELIDEL – pimecrolimus cream 1%...... 56 DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)...... 9 ELIQUIS – apixaban tab 2.5 mg...... 47 DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...... 9 ELIQUIS – apixaban tab 5 mg...... 47 donepezil hydrochloride orally disintegrating tab 5 mg ELLA – ulipristal acetate tab 30 mg...... 10 (Aricept odt)...... 37 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj donepezil hydrochloride orally disintegrating tab 10 250 unit...... 47 mg (Aricept odt)...... 37 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj donepezil hydrochloride tab 5 mg (Aricept)...... 37 500 unit...... 47 donepezil hydrochloride tab 10 mg (Aricept)...... 37 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj dorzolamide hcl ophth soln 2% (Trusopt)...... 52 750 unit...... 47 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj mg/ml (Cosopt)...... 52 1000 unit...... 47 doxazosin mesylate tab 1 mg (Cardura)...... 23 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj doxazosin mesylate tab 2 mg (Cardura)...... 23 1500 unit...... 47 doxazosin mesylate tab 4 mg (Cardura)...... 23 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj doxazosin mesylate tab 8 mg (Cardura)...... 23 2000 unit...... 47 doxepin hcl cap 10 mg...... 31 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj doxepin hcl cap 25 mg...... 31 3000 unit...... 47 doxepin hcl cap 50 mg...... 31 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj doxepin hcl cap 100 mg...... 31 4000 unit...... 47 doxepin hcl conc 10 mg/ml...... 31 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj doxycycline hyclate cap 50 mg...... 2 5000 unit...... 47 doxycycline hyclate cap 100 mg (Vibramycin)...... 2 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj doxycycline hyclate tab 20 mg...... 2 6000 unit...... 47 doxycycline hyclate tab 100 mg...... 2 EMCYT – estramustine phosphate sodium cap 140 mg...... 7 doxycycline monohydrate cap 50 mg...... 2 EMEND – aprepitant capsule 40 mg...... 28 doxycycline monohydrate cap 150 mg (Adoxa)...... 2 EMEND – aprepitant capsule 80 mg...... 28 doxycycline monohydrate cap 75 mg (Monodox)...... 2 EMEND – aprepitant capsule 125 mg...... 28 doxycycline monohydrate cap 100 mg (Monodox)...... 2 EMEND – aprepitant capsule therapy pack 80 & 125 doxycycline monohydrate tab 50 mg (Adoxa)...... 2 mg...... 28 doxycycline monohydrate tab 75 mg (Adoxa)...... 2 EMEND – aprepitant for oral susp 125 mg (125 doxycycline monohydrate tab 100 mg (Adoxa pak mg/5ml)...... 28 1/100)...... 2 enalapril maleate & hydrochlorothiazide tab 5-12.5 doxycycline monohydrate tab 150 mg (Adoxa pak mg...... 15 1/150)...... 2 enalapril maleate & hydrochlorothiazide tab 10-25 mg DROXIA – hydroxyurea cap 200 mg...... 47 (Vaseretic)...... 15 DROXIA – hydroxyurea cap 300 mg...... 47 enalapril maleate tab 2.5 mg (Vasotec)...... 15 DROXIA – hydroxyurea cap 400 mg...... 47 enalapril maleate tab 5 mg (Vasotec)...... 15 DULERA – mometasone furoate-formoterol fumarate enalapril maleate tab 10 mg (Vasotec)...... 15 aerosol 100-5 mcg/act...... 25 enalapril maleate tab 20 mg (Vasotec)...... 15 DULERA – mometasone furoate-formoterol fumarate ENBREL – etanercept for subcutaneous inj 25 mg...... 40 aerosol 200-5 mcg/act...... 25 ENBREL – etanercept subcutaneous soln prefilled syringe duloxetine hcl enteric coated pellets cap 20 mg 25 mg/0.5ml...... 40 (Cymbalta)...... 31 ENBREL – etanercept subcutaneous soln prefilled syringe 50 mg/ml...... 40
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 67 2017
ENBREL SURECLICK – etanercept subcutaneous estazolam tab 1 mg...... 34 solution auto-injector 50 mg/ml...... 40 estazolam tab 2 mg...... 34 enoxaparin sodium inj 30 mg/0.3ml (Lovenox)...... 47 ESTRACE – estradiol vaginal cream 0.1 mg/gm...... 29 enoxaparin sodium inj 40 mg/0.4ml (Lovenox)...... 47 estradiol & norethindrone acetate tab 0.5-0.1 mg enoxaparin sodium inj 60 mg/0.6ml (Lovenox)...... 48 (Activella)...... 9 enoxaparin sodium inj 80 mg/0.8ml (Lovenox)...... 48 estradiol & norethindrone acetate tab 1-0.5 mg enoxaparin sodium inj 100 mg/ml (Lovenox)...... 48 (Activella)...... 9 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...... 48 estradiol tab 0.5 mg (Estrace)...... 9 enoxaparin sodium inj 150 mg/ml (Lovenox)...... 48 estradiol tab 1 mg (Estrace)...... 9 enoxaparin sodium inj 300 mg/3ml (Lovenox)...... 48 estradiol tab 2 mg (Estrace)...... 9 entacapone tab 200 mg (Comtan)...... 44 estradiol td patch twice weekly 0.025 mg/24hr (Vivelle- entecavir tab 0.5 mg (Baraclude)...... 4 dot)...... 9 entecavir tab 1 mg (Baraclude)...... 4 estradiol td patch twice weekly 0.0375 mg/24hr ENTRESTO – sacubitril-valsartan tab 24-26 mg...... 19 (Vivelle-dot)...... 9 ENTRESTO – sacubitril-valsartan tab 49-51 mg...... 19 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle- ENTRESTO – sacubitril-valsartan tab 97-103 mg...... 19 dot)...... 10 EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg...... 4 estradiol td patch twice weekly 0.075 mg/24hr (Vivelle- EPINEPHRINE (Mylan Products) – epinephrine solution dot)...... 10 auto-injector 0.15 mg/0.3ml (1:2000)...... 23 estradiol td patch twice weekly 0.1 mg/24hr (Vivelle- EPINEPHRINE (Mylan Products) – epinephrine solution dot)...... 10 auto-injector 0.3 mg/0.3ml (1:1000)...... 24 estradiol td patch weekly 0.025 mg/24hr (Climara)...... 10 EPIPEN-JR 2-PAK – epinephrine solution auto-injector estradiol td patch weekly 0.05 mg/24hr (Climara)...... 10 0.15 mg/0.3ml (1:2000)...... 24 estradiol td patch weekly 0.06 mg/24hr (Climara)...... 10 EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 estradiol td patch weekly 0.075 mg/24hr (Climara)...... 10 mg/0.3ml (1:1000)...... 24 estradiol td patch weekly 0.1 mg/24hr (Climara)...... 10 eplerenone tab 25 mg (Inspra)...... 23 estradiol td patch weekly 0.0375 mg/24hr (37.5 eplerenone tab 50 mg (Inspra)...... 23 mcg/24hr) (Climara)...... 10 EPOGEN – epoetin alfa inj 2000 unit/ml...... 48 estradiol vaginal tab 10 mcg (Vagifem)...... 29 EPOGEN – epoetin alfa inj 3000 unit/ml...... 48 eszopiclone tab 1 mg (Lunesta)...... 34 EPOGEN – epoetin alfa inj 4000 unit/ml...... 48 eszopiclone tab 2 mg (Lunesta)...... 34 EPOGEN – epoetin alfa inj 10000 unit/ml...... 48 eszopiclone tab 3 mg (Lunesta)...... 34 EPOGEN – epoetin alfa inj 20000 unit/ml...... 48 ethambutol hcl tab 100 mg (Myambutol)...... 3 EPZICOM – abacavir sulfate-lamivudine tab 600-300 ethambutol hcl tab 400 mg (Myambutol)...... 3 mg...... 4 ethosuximide cap 250 mg (Zarontin)...... 42 ergocalciferol cap 50000 unit (Drisdol)...... 45 ethosuximide soln 250 mg/5ml (Zarontin)...... 42 erythromycin gel 2% (Erygel)...... 53 etodolac cap 200 mg...... 40 erythromycin ophth oint 5 mg/gm...... 51 etodolac cap 300 mg...... 40 erythromycin pads 2%...... 53 etodolac tab 400 mg...... 40 erythromycin soln 2%...... 53 etodolac tab 500 mg...... 40 erythromycin w/ delayed release particles cap 250 etodolac tab sr 24hr 400 mg...... 40 mg...... 2 etodolac tab sr 24hr 500 mg...... 40 escitalopram oxalate soln 5 mg/5ml (base equiv) etodolac tab sr 24hr 600 mg...... 40 (Lexapro)...... 31 exemestane tab 25 mg (Aromasin)...... 7 escitalopram oxalate tab 5 mg (base equiv) ezetimibe tab 10 mg (Zetia)...... 20 (Lexapro)...... 31 F escitalopram oxalate tab 10 mg (base equiv) (Lexapro)...... 31 famciclovir tab 125 mg (Famvir)...... 4 escitalopram oxalate tab 20 mg (base equiv) famciclovir tab 250 mg (Famvir)...... 4 (Lexapro)...... 31 famciclovir tab 500 mg (Famvir)...... 4 esomeprazole magnesium cap delayed release 20 mg famotidine tab 20 mg (Pepcid)...... 27 (base eq) (Nexium)...... 27 famotidine tab 40 mg (Pepcid)...... 27 esomeprazole magnesium cap delayed release 40 mg FARESTON – toremifene citrate tab 60 mg (base (base eq) (Nexium)...... 27 equivalent)...... 7
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 68 2017
FEIBA – antiinhibitor coagulant complex for inj...... 48 fluconazole tab 200 mg (Diflucan)...... 3 felodipine tab sr 24hr 2.5 mg...... 19 flucytosine cap 250 mg (Ancobon)...... 3 felodipine tab sr 24hr 5 mg...... 19 flucytosine cap 500 mg (Ancobon)...... 3 felodipine tab sr 24hr 10 mg...... 19 fludrocortisone acetate tab 0.1 mg...... 8 fenofibrate micronized cap 67 mg (Lofibra)...... 20 flunisolide nasal soln 25 mcg/act (0.025%)...... 24 fenofibrate micronized cap 134 mg (Lofibra)...... 20 fluocinolone acetonide cream 0.01%...... 55 fenofibrate micronized cap 200 mg (Lofibra)...... 20 fluocinolone acetonide cream 0.025% (Synalar)...... 55 fenofibrate tab 54 mg (Lofibra)...... 20 fluocinolone acetonide oil 0.01% (body oil) (Derma- fenofibrate tab 160 mg (Lofibra)...... 21 smoothe/fs bod)...... 55 fenofibrate tab 48 mg (Tricor)...... 20 fluocinolone acetonide oil 0.01% (scalp oil) (Derma- fenofibrate tab 145 mg (Tricor)...... 21 smoothe/fs sca)...... 55 fentanyl citrate lozenge on a handle 200 mcg fluocinolone acetonide oint 0.025% (Synalar)...... 55 (Actiq)...... 38 fluocinolone acetonide soln 0.01% (Synalar)...... 55 fentanyl citrate lozenge on a handle 400 mcg fluocinonide cream 0.05%...... 55 (Actiq)...... 38 fluocinonide emulsified base cream 0.05%...... 55 fentanyl citrate lozenge on a handle 600 mcg fluocinonide gel 0.05%...... 55 (Actiq)...... 38 fluocinonide oint 0.05%...... 55 fentanyl citrate lozenge on a handle 800 mcg fluocinonide soln 0.05%...... 55 (Actiq)...... 38 fluorometholone ophth susp 0.1% (Fml liquifilm)...... 51 fentanyl citrate lozenge on a handle 1200 mcg FLUOROPLEX – fluorouracil cream 1%...... 56 (Actiq)...... 38 fluorouracil cream 5% (Efudex)...... 56 fentanyl citrate lozenge on a handle 1600 mcg fluorouracil soln 2%...... 56 (Actiq)...... 38 fluorouracil soln 5%...... 56 fentanyl td patch 72hr 12 mcg/hr (Duragesic)...... 38 fluoxetine hcl cap 10 mg (Prozac)...... 31 fentanyl td patch 72hr 25 mcg/hr (Duragesic)...... 38 fluoxetine hcl cap 20 mg (Prozac)...... 31 fentanyl td patch 72hr 50 mcg/hr (Duragesic)...... 38 fluoxetine hcl cap 40 mg (Prozac)...... 31 fentanyl td patch 72hr 75 mcg/hr (Duragesic)...... 38 fluoxetine hcl solution 20 mg/5ml...... 31 fentanyl td patch 72hr 100 mcg/hr (Duragesic)...... 38 fluoxetine hcl tab 10 mg...... 31 FINACEA – azelaic acid foam 15%...... 53 fluoxetine hcl tab 20 mg...... 31 FINACEA – azelaic acid gel 15%...... 53 fluphenazine decanoate inj 25 mg/ml...... 32 finasteride tab 5 mg (Proscar)...... 30 FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 FIRAZYR – icatibant acetate inj 30 mg/3ml (base mg/5ml...... 32 equivalent)...... 48 FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ flecainide acetate tab 50 mg...... 22 ml...... 32 flecainide acetate tab 100 mg...... 22 fluphenazine hcl tab 1 mg...... 32 flecainide acetate tab 150 mg...... 22 fluphenazine hcl tab 2.5 mg...... 32 FLOVENT DISKUS – fluticasone propionate aer pow ba fluphenazine hcl tab 5 mg...... 33 50 mcg/blister...... 25 fluphenazine hcl tab 10 mg...... 33 FLOVENT DISKUS – fluticasone propionate aer pow ba flurbiprofen sodium ophth soln 0.03% (Ocufen)...... 52 100 mcg/blister...... 25 flurbiprofen tab 50 mg...... 40 FLOVENT DISKUS – fluticasone propionate aer pow ba flurbiprofen tab 100 mg...... 40 250 mcg/blister...... 25 flutamide cap 125 mg...... 7 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 fluticasone propionate cream 0.05% (Cutivate)...... 55 mcg/act (125/valve)...... 25 fluticasone propionate nasal susp 50 mcg/act FLOVENT HFA – fluticasone propionate hfa inhal aer 220 (Flonase)...... 24 mcg/act (250/valve)...... 25 fluticasone propionate oint 0.005% (Cutivate)...... 55 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 fluvoxamine maleate tab 25 mg...... 31 mcg/act (50/valve)...... 25 fluvoxamine maleate tab 50 mg...... 31 fluconazole for susp 10 mg/ml (Diflucan)...... 3 fluvoxamine maleate tab 100 mg...... 31 fluconazole for susp 40 mg/ml (Diflucan)...... 3 folic acid tab 1 mg...... 48 fluconazole tab 50 mg (Diflucan)...... 3 FOLLISTIM AQ – follitropin beta inj 75 unit/0.5ml...... 10 fluconazole tab 100 mg (Diflucan)...... 3 FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml...... 10 fluconazole tab 150 mg (Diflucan)...... 3 FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml...... 10
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 69 2017
FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml...... 10 glipizide tab sr 24hr 5 mg (Glucotrol xl)...... 11 FORTEO – teriparatide (recombinant) inj 600 glipizide tab sr 24hr 10 mg (Glucotrol xl)...... 11 mcg/2.4ml...... 14 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj fosinopril sodium & hydrochlorothiazide tab 10-12.5 kit 1 mg...... 11 mg...... 15 glyburide-metformin tab 1.25-250 mg fosinopril sodium & hydrochlorothiazide tab 20-12.5 (Glucovance)...... 11 mg...... 15 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 11 fosinopril sodium tab 10 mg...... 15 glyburide-metformin tab 5-500 mg (Glucovance)...... 11 fosinopril sodium tab 20 mg...... 15 glyburide micronized tab 1.5 mg (Glynase)...... 11 fosinopril sodium tab 40 mg...... 15 glyburide micronized tab 3 mg (Glynase)...... 11 furosemide oral soln 10 mg/ml...... 21 glyburide micronized tab 6 mg (Glynase)...... 11 furosemide tab 20 mg (Lasix)...... 21 glyburide tab 1.25 mg...... 11 furosemide tab 40 mg (Lasix)...... 21 glyburide tab 2.5 mg...... 11 furosemide tab 80 mg (Lasix)...... 21 glyburide tab 5 mg...... 11 G glycopyrrolate tab 1 mg (Robinul)...... 27 glycopyrrolate tab 2 mg (Robinul forte)...... 27 gabapentin cap 100 mg (Neurontin)...... 42 granisetron hcl tab 1 mg...... 28 gabapentin cap 300 mg (Neurontin)...... 42 griseofulvin microsize susp 125 mg/5ml...... 3 gabapentin cap 400 mg (Neurontin)...... 42 griseofulvin microsize tab 500 mg (Grifulvin v)...... 3 gabapentin oral soln 250 mg/5ml (Neurontin)...... 42 guanfacine hcl tab 1 mg (Tenex)...... 23 gabapentin tab 600 mg (Neurontin)...... 42 guanfacine hcl tab 2 mg (Tenex)...... 23 gabapentin tab 800 mg (Neurontin)...... 42 guanfacine hcl tab sr 24hr 1 mg (base equiv) GABITRIL – tiagabine hcl tab 12 mg...... 42 (Intuniv)...... 35 GABITRIL – tiagabine hcl tab 16 mg...... 42 guanfacine hcl tab sr 24hr 2 mg (base equiv) galantamine hydrobromide cap sr 24hr 8 mg (Intuniv)...... 35 (Razadyne er)...... 37 guanfacine hcl tab sr 24hr 3 mg (base equiv) galantamine hydrobromide cap sr 24hr 16 mg (Intuniv)...... 35 (Razadyne er)...... 37 guanfacine hcl tab sr 24hr 4 mg (base equiv) galantamine hydrobromide cap sr 24hr 24 mg (Intuniv)...... 35 (Razadyne er)...... 37 galantamine hydrobromide tab 4 mg (Razadyne)...... 37 H galantamine hydrobromide tab 8 mg (Razadyne)...... 37 halobetasol propionate cream 0.05% (Ultravate)...... 55 galantamine hydrobromide tab 12 mg (Razadyne)...... 37 halobetasol propionate oint 0.05% (Ultravate)...... 55 GANIRELIX ACETATE – ganirelix acetate inj 250 haloperidol decanoate im soln 50 mg/ml (Haldol mcg/0.5ml...... 10 decanoate 50)...... 33 gemfibrozil tab 600 mg (Lopid)...... 21 haloperidol decanoate im soln 100 mg/ml (Haldol gentamicin sulfate cream 0.1%...... 54 decanoate 100)...... 33 gentamicin sulfate ophth oint 0.3%...... 51 haloperidol lactate oral conc 2 mg/ml...... 33 gentamicin sulfate ophth soln 0.3% (Garamycin)...... 51 haloperidol tab 0.5 mg...... 33 GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab haloperidol tab 1 mg...... 33 150-150-200-10 mg...... 4 haloperidol tab 2 mg...... 33 GILENYA – fingolimod hcl cap 0.5 mg (base equiv)...... 36 haloperidol tab 5 mg...... 33 glatiramer acetate soln prefilled syringe 20 mg/ml haloperidol tab 10 mg...... 33 (Copaxone)...... 36 haloperidol tab 20 mg...... 33 glimepiride tab 1 mg (Amaryl)...... 10 HARVONI – ledipasvir-sofosbuvir tab 90-400 mg...... 4 glimepiride tab 2 mg (Amaryl)...... 10 HELIXATE FS – antihemophilic factor (recombinant) for inj glimepiride tab 4 mg (Amaryl)...... 10 kit 250 unit...... 48 glipizide-metformin hcl tab 2.5-250 mg...... 11 HELIXATE FS – antihemophilic factor (recombinant) for inj glipizide-metformin hcl tab 2.5-500 mg...... 11 kit 500 unit...... 48 glipizide-metformin hcl tab 5-500 mg...... 11 HELIXATE FS – antihemophilic factor (recombinant) for inj glipizide tab 5 mg (Glucotrol)...... 11 kit 1000 unit...... 48 glipizide tab 10 mg (Glucotrol)...... 11 HELIXATE FS – antihemophilic factor (recombinant) for inj glipizide tab sr 24hr 2.5 mg (Glucotrol xl)...... 10 kit 2000 unit...... 48
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 70 2017
HELIXATE FS – antihemophilic factor (recombinant) for inj hydrocodone-ibuprofen tab 7.5-200 mg kit 3000 unit...... 48 (Vicoprofen)...... 38 HEMOFIL M – antihemophilic factor (human) for inj 250 hydrocortisone cream 2.5%...... 55 unit...... 48 hydrocortisone enema 100 mg/60ml (Cortenema)...... 53 HEMOFIL M – antihemophilic factor (human) for inj 500 hydrocortisone lotion 2.5%...... 55 unit...... 48 hydrocortisone oint 2.5%...... 55 HEMOFIL M – antihemophilic factor (human) for inj 1000 hydrocortisone rectal cream 2.5% (Anusol-hc)...... 53 unit...... 48 hydrocortisone tab 5 mg (Cortef)...... 8 HEMOFIL M – antihemophilic factor (human) for inj 1700 hydrocortisone tab 10 mg (Cortef)...... 8 unit...... 48 hydrocortisone tab 20 mg (Cortef)...... 8 HUMATE-P – antihemophilic factor/vwf (human) for inj hydrocortisone valerate cream 0.2%...... 55 250-600 unit...... 48 hydrocortisone valerate oint 0.2% (Westcort)...... 55 HUMATE-P – antihemophilic factor/vwf (human) for inj hydrocortisone w/ acetic acid otic soln 1-2% (Vosol 500-1200 unit...... 48 hc)...... 53 HUMATE-P – antihemophilic factor/vwf (human) for inj hydromorphone hcl liqd 1 mg/ml (Dilaudid)...... 38 1000-2400 unit...... 48 hydromorphone hcl tab 2 mg (Dilaudid)...... 38 HUMIRA – adalimumab prefilled syringe kit 10 hydromorphone hcl tab 4 mg (Dilaudid)...... 38 mg/0.2ml...... 40 hydromorphone hcl tab 8 mg (Dilaudid)...... 38 HUMIRA – adalimumab prefilled syringe kit 20 hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 6 mg/0.4ml...... 40 hydroxyurea cap 500 mg (Hydrea)...... 7 HUMIRA – adalimumab prefilled syringe kit 40 hydroxyzine hcl syrup 10 mg/5ml...... 30 mg/0.8ml...... 40 hydroxyzine hcl tab 10 mg...... 30 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled hydroxyzine hcl tab 25 mg...... 30 syringe kit 40 mg/0.8ml...... 40 hydroxyzine hcl tab 50 mg...... 30 HUMIRA PEN – adalimumab pen-injector kit 40 hydroxyzine pamoate cap 25 mg (Vistaril)...... 30 mg/0.8ml...... 40 hydroxyzine pamoate cap 50 mg (Vistaril)...... 30 HUMIRA PEN-CROHNS DISEASE – adalimumab pen- I injector kit 40 mg/0.8ml...... 40 HUMIRA PEN-PSORIASIS STAR – adalimumab pen- ibandronate sodium tab 150 mg (base equivalent) injector kit 40 mg/0.8ml...... 40 (Boniva)...... 14 HUMULIN R U-500 (CONCENTR – insulin regular IBRANCE – palbociclib cap 75 mg...... 7 (human) inj 500 unit/ml...... 12 IBRANCE – palbociclib cap 100 mg...... 7 HUMULIN R U-500 KWIKPEN – insulin regular (human) IBRANCE – palbociclib cap 125 mg...... 7 soln pen-injector 500 unit/ml...... 12 ibuprofen susp 100 mg/5ml...... 40 hydralazine hcl tab 10 mg...... 23 ibuprofen tab 400 mg...... 40 hydralazine hcl tab 25 mg...... 23 ibuprofen tab 600 mg...... 40 hydralazine hcl tab 50 mg...... 23 ibuprofen tab 800 mg...... 40 hydralazine hcl tab 100 mg...... 23 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj hydrochlorothiazide cap 12.5 mg (Microzide)...... 21 250 unit...... 48 hydrochlorothiazide tab 12.5 mg...... 21 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj hydrochlorothiazide tab 25 mg...... 22 500 unit...... 48 hydrochlorothiazide tab 50 mg...... 22 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj hydrocodone-acetaminophen soln 7.5-325 mg/15ml 1000 unit...... 48 (Hycet)...... 38 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj hydrocodone-acetaminophen tab 7.5-325 mg 2000 unit...... 48 (Norco)...... 38 imatinib mesylate tab 100 mg (base equivalent) hydrocodone-acetaminophen tab 5-325 mg (Gleevec)...... 7 (Norco)...... 38 imatinib mesylate tab 400 mg (base equivalent) hydrocodone-acetaminophen tab 10-325 mg (Gleevec)...... 7 (Norco)...... 38 imipramine hcl tab 10 mg (Tofranil)...... 31 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)...... 38 imipramine hcl tab 25 mg (Tofranil)...... 31 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 38 imipramine hcl tab 50 mg (Tofranil)...... 31 imiquimod cream 5% (Aldara)...... 56
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 71 2017
IMITREX – sumatriptan nasal spray 5 mg/act...... 41 ISENTRESS – raltegravir potassium chew tab 25 mg IMITREX – sumatriptan nasal spray 20 mg/act...... 41 (base equiv)...... 4 IMPAVIDO – miltefosine cap 50 mg...... 6 ISENTRESS – raltegravir potassium chew tab 100 mg INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)...... 13 (base equiv)...... 4 INCRUSE ELLIPTA – umeclidinium br aero powd breath ISENTRESS – raltegravir potassium packet for susp 100 act 62.5 mcg/inh (base eq)...... 26 mg (base equiv)...... 4 indapamide tab 1.25 mg...... 22 ISENTRESS – raltegravir potassium tab 400 mg (base indapamide tab 2.5 mg...... 22 equiv)...... 4 indomethacin cap 25 mg...... 40 isoniazid tab 100 mg...... 3 indomethacin cap 50 mg...... 40 isoniazid tab 300 mg...... 3 INNOPRAN XL – propranolol hcl sustained-release beads isosorbide dinitrate tab 10 mg...... 20 cap sr 24hr 80 mg...... 17 isosorbide dinitrate tab 20 mg...... 20 INNOPRAN XL – propranolol hcl sustained-release beads isosorbide dinitrate tab 30 mg...... 20 cap sr 24hr 120 mg...... 17 isosorbide dinitrate tab 5 mg (Isordil titradose)...... 20 INSULIN PEN NEEDLES – BD ULTRAFINE, NOVOFINE, isosorbide mononitrate tab 10 mg...... 20 NOVOTWIST...... 56 isosorbide mononitrate tab 20 mg...... 20 INSULIN SYRINGES – BD...... 56 isosorbide mononitrate tab sr 24hr 30 mg (Imdur)...... 20 INTELENCE – etravirine tab 25 mg...... 4 isosorbide mononitrate tab sr 24hr 60 mg (Imdur)...... 20 INTELENCE – etravirine tab 100 mg...... 4 isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....20 INTELENCE – etravirine tab 200 mg...... 4 isotretinoin cap 10 mg...... 53 INVOKAMET – canagliflozin-metformin hcl tab 50-500 isotretinoin cap 20 mg...... 53 mg...... 11 isotretinoin cap 40 mg...... 53 INVOKAMET – canagliflozin-metformin hcl tab 50-1000 isotretinoin cap 30 mg (Claravis)...... 53 mg...... 11 itraconazole cap 100 mg (Sporanox)...... 3 INVOKAMET – canagliflozin-metformin hcl tab 150-500 ivermectin tab 3 mg (Stromectol)...... 6 mg...... 11 J INVOKAMET – canagliflozin-metformin hcl tab 150-1000 mg...... 11 JANUMET – sitagliptin-metformin hcl tab 50-500 mg...... 11 INVOKAMET XR – canagliflozin-metformin hcl tab sr 24hr JANUMET – sitagliptin-metformin hcl tab 50-1000 mg...... 11 50-500 mg...... 11 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr INVOKAMET XR – canagliflozin-metformin hcl tab sr 24hr 50-500 mg...... 11 50-1000 mg...... 11 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr INVOKAMET XR – canagliflozin-metformin hcl tab sr 24hr 50-1000 mg...... 11 150-500 mg...... 11 JANUMET XR – sitagliptin-metformin hcl tab sr 24hr INVOKAMET XR – canagliflozin-metformin hcl tab sr 24hr 100-1000 mg...... 11 150-1000 mg...... 11 JANUVIA – sitagliptin phosphate tab 25 mg (base INVOKANA – canagliflozin tab 100 mg...... 11 equiv)...... 11 INVOKANA – canagliflozin tab 300 mg...... 11 JANUVIA – sitagliptin phosphate tab 50 mg (base ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml equiv)...... 11 (Duoneb)...... 26 JANUVIA – sitagliptin phosphate tab 100 mg (base ipratropium bromide inhal soln 0.02%...... 26 equiv)...... 11 ipratropium bromide nasal soln 0.03% (21 mcg/spray) JARDIANCE – empagliflozin tab 10 mg...... 11 (Atrovent)...... 24 JARDIANCE – empagliflozin tab 25 mg...... 11 ipratropium bromide nasal soln 0.06% (42 mcg/spray) K (Atrovent)...... 24 KADIAN – morphine sulfate cap sr 24hr 40 mg...... 38 irbesartan-hydrochlorothiazide tab 150-12.5 mg KADIAN – morphine sulfate cap sr 24hr 200 mg...... 38 (Avalide)...... 16 KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml irbesartan-hydrochlorothiazide tab 300-12.5 mg (80-20 mg/ml)...... 5 (Avalide)...... 16 KALETRA – lopinavir-ritonavir tab 100-25 mg...... 5 irbesartan tab 75 mg (Avapro)...... 16 KALETRA – lopinavir-ritonavir tab 200-50 mg...... 5 irbesartan tab 150 mg (Avapro)...... 16 KALYDECO – ivacaftor packet 50 mg...... 26 irbesartan tab 300 mg (Avapro)...... 16 KALYDECO – ivacaftor packet 75 mg...... 26
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 72 2017
KALYDECO – ivacaftor tab 150 mg...... 26 KOVALTRY – antihemophilic factor (recombinant) for inj ketoconazole cream 2%...... 54 1000 unit...... 49 ketoconazole shampoo 2% (Nizoral)...... 54 KOVALTRY – antihemophilic factor (recombinant) for inj ketoprofen cap 50 mg...... 40 2000 unit...... 49 ketoprofen cap 75 mg...... 40 KOVALTRY – antihemophilic factor (recombinant) for inj ketorolac tromethamine ophth soln 0.5% (Acular)...... 52 3000 unit...... 49 ketorolac tromethamine ophth soln 0.4% (Acular L ls)...... 52 KISQALI – ribociclib succinate tab 200 mg (base equiv)..... 7 labetalol hcl tab 100 mg (Trandate)...... 17 KOATE – antihemophilic factor (human) for inj 250 labetalol hcl tab 200 mg (Trandate)...... 17 unit...... 48 labetalol hcl tab 300 mg (Trandate)...... 17 KOATE – antihemophilic factor (human) for inj 500 lactulose (encephalopathy) solution 10 gm/15ml...... 29 unit...... 48 lactulose solution 10 gm/15ml...... 27 KOATE – antihemophilic factor (human) for inj 1000 lamivudine oral soln 10 mg/ml (Epivir)...... 5 unit...... 48 lamivudine tab 150 mg (Epivir)...... 5 KOATE-DVI – antihemophilic factor (human) for inj 250 lamivudine tab 300 mg (Epivir)...... 5 unit...... 48 lamivudine tab 100 mg (hbv) (Epivir hbv)...... 4 KOATE-DVI – antihemophilic factor (human) for inj 500 lamivudine-zidovudine tab 150-300 mg (Combivir)...... 5 unit...... 48 lamotrigine tab chewable dispersible 5 mg (Lamictal KOATE-DVI – antihemophilic factor (human) for inj 1000 chewable di)...... 42 unit...... 48 lamotrigine tab chewable dispersible 25 mg (Lamictal KOGENATE FS – antihemophilic factor (recombinant) for chewable di)...... 43 inj kit 250 unit...... 48 lamotrigine tab 25 mg (Lamictal)...... 43 KOGENATE FS – antihemophilic factor (recombinant) for lamotrigine tab 100 mg (Lamictal)...... 43 inj kit 500 unit...... 48 lamotrigine tab 150 mg (Lamictal)...... 43 KOGENATE FS – antihemophilic factor (recombinant) for lamotrigine tab 200 mg (Lamictal)...... 43 inj kit 1000 unit...... 49 LANCETS – BAYER FINGERSTIX, MICROLET, SINGLE- KOGENATE FS – antihemophilic factor (recombinant) for LET...... 56 inj kit 2000 unit...... 49 LANCETS – BD MICROTAINER, ULTRAFINE...... 56 KOGENATE FS – antihemophilic factor (recombinant) for lansoprazole cap delayed release 15 mg inj kit 3000 unit...... 49 (Prevacid)...... 27 KOGENATE FS BIO-SET – antihemophilic factor lansoprazole cap delayed release 30 mg (recombinant) for inj kit 250 unit...... 49 (Prevacid)...... 27 KOGENATE FS BIO-SET – antihemophilic factor LANTUS – insulin glargine inj 100 unit/ml...... 12 (recombinant) for inj kit 500 unit...... 49 LANTUS SOLOSTAR – insulin glargine soln pen-injector KOGENATE FS BIO-SET – antihemophilic factor 100 unit/ml...... 12 (recombinant) for inj kit 1000 unit...... 49 latanoprost ophth soln 0.005% (Xalatan)...... 52 KOGENATE FS BIO-SET – antihemophilic factor leflunomide tab 10 mg (Arava)...... 40 (recombinant) for inj kit 2000 unit...... 49 leflunomide tab 20 mg (Arava)...... 40 KOGENATE FS BIO-SET – antihemophilic factor LETAIRIS – ambrisentan tab 5 mg...... 23 (recombinant) for inj kit 3000 unit...... 49 LETAIRIS – ambrisentan tab 10 mg...... 23 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr letrozole tab 2.5 mg (Femara)...... 7 2.5-1000 mg...... 11 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr mg...... 7 5-500 mg...... 11 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr mg...... 7 5-1000 mg...... 11 leucovorin calcium tab 5 mg...... 7 KOSHER PRENATAL PLUS IRON – prenatal vit w/ iron leucovorin calcium tab 25 mg...... 7 carbonyl-fa tab 30-1 mg...... 45 LEUKERAN – chlorambucil tab 2 mg...... 7 KOVALTRY – antihemophilic factor (recombinant) for inj levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base 250 unit...... 49 equiv)...... 26 KOVALTRY – antihemophilic factor (recombinant) for inj levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) 500 unit...... 49 (Xopenex)...... 26
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 73 2017 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) lisinopril & hydrochlorothiazide tab 10-12.5 mg (Xopenex)...... 26 (Zestoretic)...... 15 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) lisinopril & hydrochlorothiazide tab 20-12.5 mg (Xopenex)...... 26 (Zestoretic)...... 15 LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector lisinopril & hydrochlorothiazide tab 20-25 mg 100 unit/ml...... 13 (Zestoretic)...... 15 LEVEMIR – insulin detemir inj 100 unit/ml...... 12 lisinopril tab 5 mg (Prinivil)...... 15 levetiracetam oral soln 100 mg/ml (Keppra)...... 43 lisinopril tab 10 mg (Prinivil)...... 15 levetiracetam tab 250 mg (Keppra)...... 43 lisinopril tab 20 mg (Prinivil)...... 15 levetiracetam tab 500 mg (Keppra)...... 43 lisinopril tab 2.5 mg (Zestril)...... 15 levetiracetam tab 750 mg (Keppra)...... 43 lisinopril tab 30 mg (Zestril)...... 15 levetiracetam tab 1000 mg (Keppra)...... 43 lisinopril tab 40 mg (Zestril)...... 15 levetiracetam tab sr 24hr 500 mg (Keppra xr)...... 43 lithium carbonate cap 300 mg...... 33 levetiracetam tab sr 24hr 750 mg (Keppra xr)...... 43 lithium carbonate cap 150 mg (Lithium carbonate)...... 33 levobunolol hcl ophth soln 0.5% (Betagan)...... 52 lithium carbonate cap 600 mg (Lithium carbonate)...... 33 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 14 lithium carbonate tab cr 450 mg...... 33 levocarnitine tab 330 mg (Carnitor)...... 14 lithium carbonate tab cr 300 mg (Lithobid)...... 33 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ lithium carbonate tab 300 mg...... 33 ml) (Xyzal)...... 24 loperamide hcl cap 2 mg...... 27 levocetirizine dihydrochloride tab 5 mg (Xyzal)...... 24 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) levofloxacin tab 250 mg (Levaquin)...... 3 (Kaletra)...... 5 levofloxacin tab 500 mg (Levaquin)...... 3 lorazepam conc 2 mg/ml (Lorazepam intensol)...... 30 levofloxacin tab 750 mg (Levaquin)...... 3 lorazepam tab 0.5 mg (Ativan)...... 30 levothyroxine sodium tab 25 mcg (Synthroid)...... 13 lorazepam tab 1 mg (Ativan)...... 30 levothyroxine sodium tab 50 mcg (Synthroid)...... 13 lorazepam tab 2 mg (Ativan)...... 30 levothyroxine sodium tab 75 mcg (Synthroid)...... 13 losartan potassium & hydrochlorothiazide tab 50-12.5 levothyroxine sodium tab 88 mcg (Synthroid)...... 13 mg (Hyzaar)...... 16 levothyroxine sodium tab 100 mcg (Synthroid)...... 13 losartan potassium & hydrochlorothiazide tab 100-12.5 levothyroxine sodium tab 112 mcg (Synthroid)...... 13 mg (Hyzaar)...... 16 levothyroxine sodium tab 125 mcg (Synthroid)...... 13 losartan potassium & hydrochlorothiazide tab 100-25 levothyroxine sodium tab 137 mcg (Synthroid)...... 13 mg (Hyzaar)...... 16 levothyroxine sodium tab 150 mcg (Synthroid)...... 13 losartan potassium tab 25 mg (Cozaar)...... 16 levothyroxine sodium tab 175 mcg (Synthroid)...... 13 losartan potassium tab 50 mg (Cozaar)...... 16 levothyroxine sodium tab 200 mcg (Synthroid)...... 13 losartan potassium tab 100 mg (Cozaar)...... 16 levothyroxine sodium tab 300 mcg (Synthroid)...... 13 LOTEMAX – loteprednol etabonate ophth gel 0.5%...... 52 LIALDA – mesalamine tab delayed release 1.2 gm...... 29 LOTEMAX – loteprednol etabonate ophth oint 0.5%...... 52 lidocaine hcl gel 2%...... 56 LOTEMAX – loteprednol etabonate ophth susp 0.5%...... 52 lidocaine hcl local inj 1% (Xylocaine)...... 42 lovastatin tab 10 mg...... 21 lidocaine hcl local preservative free (pf) inj 1% lovastatin tab 20 mg (Mevacor)...... 21 (Xylocaine-mpf)...... 42 lovastatin tab 40 mg (Mevacor)...... 21 lidocaine hcl soln 4% (Xylocaine)...... 56 loxapine succinate cap 10 mg...... 33 lidocaine hcl viscous soln 2%...... 53 loxapine succinate cap 25 mg...... 33 lidocaine oint 5%...... 56 loxapine succinate cap 50 mg...... 33 lidocaine patch 5% (Lidoderm)...... 56 loxapine succinate cap 5 mg (Loxitane)...... 33 linezolid for susp 100 mg/5ml (Zyvox)...... 6 LUMIGAN – bimatoprost ophth soln 0.01%...... 52 linezolid tab 600 mg (Zyvox)...... 6 LYRICA – pregabalin cap 25 mg...... 43 LINZESS – linaclotide cap 72 mcg...... 29 LYRICA – pregabalin cap 50 mg...... 43 LINZESS – linaclotide cap 145 mcg...... 29 LYRICA – pregabalin cap 75 mg...... 43 LINZESS – linaclotide cap 290 mcg...... 29 LYRICA – pregabalin cap 100 mg...... 43 liothyronine sodium tab 5 mcg (Cytomel)...... 13 LYRICA – pregabalin cap 150 mg...... 43 liothyronine sodium tab 25 mcg (Cytomel)...... 13 LYRICA – pregabalin cap 200 mg...... 43 liothyronine sodium tab 50 mcg (Cytomel)...... 13 LYRICA – pregabalin cap 225 mg...... 43 LYRICA – pregabalin cap 300 mg...... 43
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 74 2017
M methylphenidate hcl tab cr 20 mg (Ritalin sr)...... 35 methylphenidate hcl tab 5 mg (Ritalin)...... 35 malathion lotion 0.5% (Ovide)...... 56 methylphenidate hcl tab 10 mg (Ritalin)...... 35 meclizine hcl tab 12.5 mg...... 28 methylphenidate hcl tab 20 mg (Ritalin)...... 35 meclizine hcl tab 25 mg...... 28 methylphenidate hcl tab sa osm 18 mg (Concerta)...... 35 medroxyprogesterone acetate tab 2.5 mg methylphenidate hcl tab sa osm 27 mg (Concerta)...... 35 (Provera)...... 10 methylphenidate hcl tab sa osm 36 mg (Concerta)...... 35 medroxyprogesterone acetate tab 5 mg (Provera)...... 10 methylphenidate hcl tab sa osm 54 mg (Concerta)...... 35 medroxyprogesterone acetate tab 10 mg (Provera)..... 10 methylprednisolone tab 4 mg (Medrol)...... 8 mefloquine hcl tab 250 mg...... 6 methylprednisolone tab 8 mg (Medrol)...... 8 megestrol acetate susp 40 mg/ml (Megace oral)...... 7 methylprednisolone tab 16 mg (Medrol)...... 9 megestrol acetate tab 20 mg...... 7 methylprednisolone tab 32 mg (Medrol)...... 9 megestrol acetate tab 40 mg...... 7 methylprednisolone tab therapy pack 4 mg (21) MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (Medrol dosepak)...... 8 (base equivalent)...... 7 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)...... 29 MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base metoclopramide hcl tab 5 mg (Reglan)...... 29 equivalent)...... 7 metoclopramide hcl tab 10 mg (Reglan)...... 29 meloxicam tab 7.5 mg (Mobic)...... 40 metolazone tab 10 mg...... 22 meloxicam tab 15 mg (Mobic)...... 40 metolazone tab 2.5 mg (Zaroxolyn)...... 22 memantine hcl oral solution 2 mg/ml (Namenda)...... 37 metolazone tab 5 mg (Zaroxolyn)...... 22 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak metoprolol & hydrochlorothiazide tab 100-50 mg...... 17 (Namenda titration pa)...... 37 metoprolol & hydrochlorothiazide tab 50-25 mg memantine hcl tab 5 mg (Namenda)...... 37 (Lopressor hct)...... 17 memantine hcl tab 10 mg (Namenda)...... 37 metoprolol & hydrochlorothiazide tab 100-25 mg MEPHYTON – phytonadione tab 5 mg...... 45 (Lopressor hct)...... 17 mercaptopurine tab 50 mg (Purinethol)...... 7 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) mesalamine enema 4 gm...... 29 (Toprol xl)...... 17 MESNEX – mesna tab 400 mg...... 7 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) metaxalone tab 800 mg (Skelaxin)...... 44 (Toprol xl)...... 17 metformin hcl tab 500 mg (Glucophage)...... 12 metoprolol succinate tab sr 24hr 100 mg (tartrate metformin hcl tab 850 mg (Glucophage)...... 12 equiv) (Toprol xl)...... 17 metformin hcl tab 1000 mg (Glucophage)...... 12 metoprolol succinate tab sr 24hr 200 mg (tartrate metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 12 equiv) (Toprol xl)...... 17 metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 12 metoprolol tartrate tab 25 mg...... 18 methadone hcl conc 10 mg/ml (Methadose)...... 39 metoprolol tartrate tab 50 mg (Lopressor)...... 18 methadone hcl soln 5 mg/5ml (Methadone hcl)...... 39 metoprolol tartrate tab 100 mg (Lopressor)...... 18 methadone hcl soln 10 mg/5ml (Methadone hcl)...... 39 metronidazole cream 0.75% (Metrocream)...... 53 methadone hcl tab for oral susp 40 mg...... 39 metronidazole gel 0.75%...... 53 methadone hcl tab 10 mg (Dolophine)...... 39 metronidazole gel 1% (Metrogel)...... 53 methadone hcl tab 5 mg (Dolophine hcl)...... 39 metronidazole lotion 0.75% (Metrolotion)...... 54 methazolamide tab 25 mg (Neptazane)...... 22 metronidazole tab 250 mg (Flagyl)...... 6 methazolamide tab 50 mg (Neptazane)...... 22 metronidazole tab 500 mg (Flagyl)...... 6 methimazole tab 5 mg (Tapazole)...... 13 metronidazole vaginal gel 0.75% (Metrogel- methimazole tab 10 mg (Tapazole)...... 13 vaginal)...... 30 methocarbamol tab 750 mg (Robaxin-750)...... 44 mexiletine hcl cap 150 mg...... 22 methocarbamol tab 500 mg (Robaxin)...... 44 mexiletine hcl cap 200 mg...... 22 methotrexate sodium tab 2.5 mg (base equiv)...... 7 mexiletine hcl cap 250 mg...... 22 methscopolamine bromide tab 2.5 mg (Pamine)...... 27 midodrine hcl tab 2.5 mg...... 23 methscopolamine bromide tab 5 mg (Pamine midodrine hcl tab 5 mg...... 23 forte)...... 27 midodrine hcl tab 10 mg...... 23 methyldopa tab 250 mg...... 23 MIGRANAL – dihydroergotamine mesylate nasal spray 4 methyldopa tab 500 mg...... 23 mg/ml...... 41 methylphenidate hcl tab cr 10 mg...... 35 minocycline hcl cap 50 mg (Minocin)...... 2
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 75 2017 minocycline hcl cap 75 mg (Minocin)...... 2 MULTAQ – dronedarone hcl tab 400 mg (base minocycline hcl cap 100 mg (Minocin)...... 2 equivalent)...... 22 minocycline hcl tab 50 mg...... 2 mupirocin calcium cream 2% (Bactroban)...... 54 minocycline hcl tab 75 mg...... 2 mupirocin oint 2% (Bactroban)...... 54 minocycline hcl tab 100 mg...... 2 mycophenolate mofetil cap 250 mg (Cellcept)...... 57 minoxidil tab 2.5 mg...... 23 mycophenolate mofetil for oral susp 200 mg/ml minoxidil tab 10 mg...... 23 (Cellcept)...... 57 MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mycophenolate mofetil tab 500 mg (Cellcept)...... 57 mg total)...... 10 mycophenolate sodium tab dr 180 mg (mycophenolic mirtazapine tab 7.5 mg...... 31 acid equiv) (Myfortic)...... 57 mirtazapine tab 15 mg (Remeron)...... 31 mycophenolate sodium tab dr 360 mg (mycophenolic mirtazapine tab 30 mg (Remeron)...... 31 acid equiv) (Myfortic)...... 57 mirtazapine tab 45 mg (Remeron)...... 31 MYLERAN – busulfan tab 2 mg...... 7 misoprostol tab 100 mcg (Cytotec)...... 27 N misoprostol tab 200 mcg (Cytotec)...... 27 modafinil tab 100 mg (Provigil)...... 35 nabumetone tab 500 mg...... 41 modafinil tab 200 mg (Provigil)...... 35 nabumetone tab 750 mg...... 41 moexipril hcl tab 7.5 mg (Univasc)...... 15 nadolol tab 20 mg (Corgard)...... 18 moexipril hcl tab 15 mg (Univasc)...... 15 nadolol tab 40 mg (Corgard)...... 18 moexipril-hydrochlorothiazide tab 7.5-12.5 mg...... 15 nadolol tab 80 mg (Corgard)...... 18 moexipril-hydrochlorothiazide tab 15-25 mg...... 15 naloxone hcl inj 0.4 mg/ml...... 57 moexipril-hydrochlorothiazide tab 15-12.5 mg naloxone hcl inj 4 mg/10ml...... 57 (Uniretic)...... 15 naltrexone hcl tab 50 mg (Revia)...... 57 mometasone furoate cream 0.1% (Elocon)...... 55 naproxen sodium tab 275 mg (Anaprox)...... 41 mometasone furoate nasal susp 50 mcg/act naproxen sodium tab 550 mg (Anaprox ds)...... 41 (Nasonex)...... 24 naproxen susp 125 mg/5ml (Naprosyn)...... 41 mometasone furoate oint 0.1% (Elocon)...... 55 naproxen tab ec 375 mg (Ec-naprosyn)...... 41 mometasone furoate solution 0.1% (lotion) naproxen tab ec 500 mg (Ec-naprosyn)...... 41 (Elocon)...... 55 naproxen tab 250 mg (Naprosyn)...... 41 MONOCLATE-P – antihemophilic factor (human) for inj kit naproxen tab 375 mg (Naprosyn)...... 41 1000 unit...... 49 naproxen tab 500 mg (Naprosyn)...... 41 MONOCLATE-P – antihemophilic factor (human) for inj kit naratriptan hcl tab 1 mg (base equiv) (Amerge)...... 41 1500 unit...... 49 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 41 MONONINE – coagulation factor ix for inj 1000 unit...... 49 NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...... 57 montelukast sodium chew tab 4 mg (base equiv) NASONEX – mometasone furoate nasal susp 50 mcg/ (Singulair)...... 26 act...... 24 montelukast sodium chew tab 5 mg (base equiv) NATACYN – natamycin ophth susp 5%...... 51 (Singulair)...... 26 nateglinide tab 60 mg (Starlix)...... 12 montelukast sodium oral granules packet 4 mg (base nateglinide tab 120 mg (Starlix)...... 12 equiv) (Singulair)...... 26 neomycin-bacitrac zn-polymyx montelukast sodium tab 10 mg (base equiv) 5(3.5)mg-400unt-10000unt op oin...... 51 (Singulair)...... 26 neomycin-polymy-gramicid op sol MORPHINE SULFATE – morphine sulfate tab 15 mg...... 39 1.75-10000-0.025mg-unt-mg/ml (Neosporin)...... 51 MORPHINE SULFATE – morphine sulfate tab 30 mg...... 39 neomycin-polymyxin-dexamethasone ophth oint 0.1% morphine sulfate oral soln 10 mg/5ml...... 39 (Maxitrol)...... 52 morphine sulfate oral soln 20 mg/5ml...... 39 neomycin-polymyxin-dexamethasone ophth susp morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 39 0.1% (Maxitrol)...... 52 morphine sulfate tab cr 15 mg (Ms contin)...... 39 neomycin-polymyxin-hc otic soln 1% (Cortisporin)..... 53 morphine sulfate tab cr 30 mg (Ms contin)...... 39 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 morphine sulfate tab cr 60 mg (Ms contin)...... 39 unit/ml-1%...... 53 morphine sulfate tab cr 100 mg (Ms contin)...... 39 neomycin sulfate tab 500 mg...... 3 morphine sulfate tab cr 200 mg (Ms contin)...... 39 NEULASTA ONPRO KIT – pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml...... 49
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 76 2017
NEULASTA – pegfilgrastim soln prefilled syringe 6 nitrofurantoin susp 25 mg/5ml (Furadantin)...... 29 mg/0.6ml...... 49 nitroglycerin sl tab 0.3 mg (Nitrostat)...... 20 NEUPOGEN – filgrastim inj 300 mcg/ml...... 49 nitroglycerin sl tab 0.4 mg (Nitrostat)...... 20 NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ nitroglycerin sl tab 0.6 mg (Nitrostat)...... 20 ml)...... 49 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)...... 20 NEUPOGEN – filgrastim soln prefilled syringe 300 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)...... 20 mcg/0.5ml...... 49 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)...... 20 NEUPOGEN – filgrastim soln prefilled syringe 480 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)...... 20 mcg/0.8ml (600 mcg/ml)...... 49 NITROSTAT – nitroglycerin sl tab 0.3 mg...... 20 nevirapine tab 200 mg (Viramune)...... 5 NITROSTAT – nitroglycerin sl tab 0.4 mg...... 20 nevirapine tab sr 24hr 100 mg (Viramune xr)...... 5 NITROSTAT – nitroglycerin sl tab 0.6 mg...... 20 nevirapine tab sr 24hr 400 mg (Viramune xr)...... 5 norethindrone acetate-ethinyl estradiol tab 1 mg-5 NEXAVAR – sorafenib tosylate tab 200 mg (base mcg...... 10 equivalent)...... 7 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 NEXIUM – esomeprazole magnesium for delayed release mcg (Femhrt low dose)...... 10 susp packet 5 mg...... 27 norethindrone acetate tab 5 mg (Aygestin)...... 10 NEXIUM – esomeprazole magnesium for delayed release nortriptyline hcl cap 10 mg (Pamelor)...... 32 susp packet 10 mg...... 27 nortriptyline hcl cap 25 mg (Pamelor)...... 32 NEXIUM – esomeprazole magnesium for delayed release nortriptyline hcl cap 50 mg (Pamelor)...... 32 susp packet 20 mg...... 27 nortriptyline hcl cap 75 mg (Pamelor)...... 32 NEXIUM – esomeprazole magnesium for delayed release NORVIR – ritonavir oral soln 80 mg/ml...... 5 susp packet 40 mg...... 27 NORVIR – ritonavir tab 100 mg...... 5 NEXIUM – esomeprazole magnesium for delayed release NOVOEIGHT – antihemophilic factor (recombinant) for inj susp pack 2.5 mg...... 27 250 unit...... 49 niacin tab cr 500 mg (antihyperlipidemic) NOVOEIGHT – antihemophilic factor (recombinant) for inj (Niaspan)...... 21 500 unit...... 49 niacin tab cr 750 mg (antihyperlipidemic) NOVOEIGHT – antihemophilic factor (recombinant) for inj (Niaspan)...... 21 1000 unit...... 49 niacin tab cr 1000 mg (antihyperlipidemic) NOVOEIGHT – antihemophilic factor (recombinant) for inj (Niaspan)...... 21 1500 unit...... 49 NICOTROL INHALER – nicotine inhaler system 10 mg (4 NOVOEIGHT – antihemophilic factor (recombinant) for inj mg delivered)...... 37 2000 unit...... 49 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ NOVOEIGHT – antihemophilic factor (recombinant) for inj spray)...... 37 3000 unit...... 49 nifedipine tab sr 24hr 30 mg (Adalat cc)...... 19 NOVOLIN 70/30 – insulin nph isophane & regular human nifedipine tab sr 24hr 60 mg (Adalat cc)...... 19 inj 100 unit/ml (70-30)...... 12 nifedipine tab sr 24hr 90 mg (Adalat cc)...... 19 NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ nifedipine tab sr 24hr osmotic release 30 mg ml...... 12 (Procardia xl)...... 19 NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 12 nifedipine tab sr 24hr osmotic release 60 mg NOVOLOG FLEXPEN – insulin aspart soln pen-injector (Procardia xl)...... 19 100 unit/ml...... 12 nifedipine tab sr 24hr osmotic release 90 mg NOVOLOG – insulin aspart inj 100 unit/ml...... 12 (Procardia xl)...... 19 NOVOLOG MIX 70/30 – insulin aspart prot & aspart NILANDRON – nilutamide tab 150 mg...... 7 (human) inj 100 unit/ml (70-30)...... 12 nilutamide tab 150 mg (Nilandron)...... 7 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & nitrofurantoin macrocrystalline cap 25 mg aspart sus pen-inj 100 unit/ml (70-30)...... 12 (Macrodantin)...... 29 NOVOLOG PENFILL – insulin aspart soln cartridge 100 nitrofurantoin macrocrystalline cap 50 mg unit/ml...... 12 (Macrodantin)...... 29 NOVOSEVEN RT – coagulation factor viia (recomb) for inj nitrofurantoin macrocrystalline cap 100 mg 1 mg (1000 mcg)...... 49 (Macrodantin)...... 29 NOVOSEVEN RT – coagulation factor viia (recomb) for inj nitrofurantoin monohydrate macrocrystalline cap 100 2 mg (2000 mcg)...... 49 mg (Macrobid)...... 29
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 77 2017
NOVOSEVEN RT – coagulation factor viia (recomb) for inj ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab 5 mg (5000 mcg)...... 49 200-25-25 mg...... 5 NOVOSEVEN RT – coagulation factor viia (recomb) for inj ofloxacin ophth soln 0.3% (Ocuflox)...... 51 8 mg (8000 mcg)...... 49 ofloxacin otic soln 0.3%...... 53 NOXAFIL – posaconazole susp 40 mg/ml...... 3 ofloxacin tab 400 mg...... 3 NOXAFIL – posaconazole tab delayed release 100 mg...... 3 olanzapine orally disintegrating tab 5 mg (Zyprexa NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg...... 39 zydis)...... 33 NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg...... 39 olanzapine orally disintegrating tab 10 mg (Zyprexa NUCYNTA ER – tapentadol hcl tab sr 12hr 150 mg...... 39 zydis)...... 33 NUCYNTA ER – tapentadol hcl tab sr 12hr 200 mg...... 39 olanzapine orally disintegrating tab 15 mg (Zyprexa NUCYNTA ER – tapentadol hcl tab sr 12hr 250 mg...... 39 zydis)...... 33 NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap olanzapine orally disintegrating tab 20 mg (Zyprexa 20-10 mg...... 37 zydis)...... 33 NUVARING – etonogestrel-ethinyl estradiol va ring olanzapine tab 2.5 mg (Zyprexa)...... 33 0.120-0.015 mg/24hr...... 10 olanzapine tab 5 mg (Zyprexa)...... 33 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 250 olanzapine tab 7.5 mg (Zyprexa)...... 33 unit...... 50 olanzapine tab 10 mg (Zyprexa)...... 33 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 500 olanzapine tab 15 mg (Zyprexa)...... 33 unit...... 50 olanzapine tab 20 mg (Zyprexa)...... 33 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 1000 olmesartan medoxomil-hydrochlorothiazide tab unit...... 50 20-12.5 mg (Benicar hct)...... 16 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 2000 olmesartan medoxomil-hydrochlorothiazide tab unit...... 50 40-12.5 mg (Benicar hct)...... 16 NUWIQ – antihemophilic factor (bdd-rfviii) for inj 250 olmesartan medoxomil-hydrochlorothiazide tab 40-25 unit...... 49 mg (Benicar hct)...... 17 NUWIQ – antihemophilic factor (bdd-rfviii) for inj 500 olmesartan medoxomil tab 5 mg (Benicar)...... 16 unit...... 49 olmesartan medoxomil tab 20 mg (Benicar)...... 16 NUWIQ – antihemophilic factor (bdd-rfviii) for inj 1000 olmesartan medoxomil tab 40 mg (Benicar)...... 16 unit...... 50 olopatadine hcl ophth soln 0.1% (base equivalent) NUWIQ – antihemophilic factor (bdd-rfviii) for inj 2000 (Patanol)...... 53 unit...... 50 omeprazole cap delayed release 10 mg (Prilosec)...... 27 nystatin cream 100000 unit/gm...... 54 omeprazole cap delayed release 20 mg (Prilosec)...... 27 nystatin oint 100000 unit/gm...... 54 omeprazole cap delayed release 40 mg (Prilosec)...... 27 nystatin susp 100000 unit/ml...... 53 OMNITROPE – somatropin for inj 5.8 mg...... 13 nystatin tab 500000 unit...... 3 OMNITROPE – somatropin inj 5 mg/1.5ml...... 13 nystatin topical powder 100000 unit/gm...... 54 OMNITROPE – somatropin inj 10 mg/1.5ml...... 13 nystatin-triamcinolone cream 100000-0.1 unit/gm- ondansetron hcl inj 4 mg/2ml (2 mg/ml)...... 28 %...... 55 ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)...... 28 nystatin-triamcinolone oint 100000-0.1 unit/gm-%...... 55 ondansetron hcl oral soln 4 mg/5ml (Zofran)...... 28 O ondansetron hcl tab 24 mg...... 28 ondansetron hcl tab 4 mg (Zofran)...... 28 OBIZUR – antihemophilic factor (recomb porc) rpfviii for inj ondansetron hcl tab 8 mg (Zofran)...... 28 500 unit...... 50 ondansetron orally disintegrating tab 4 mg (Zofran octreotide acetate inj 50 mcg/ml (0.05 mg/ml) odt)...... 28 (Sandostatin)...... 14 ondansetron orally disintegrating tab 8 mg (Zofran octreotide acetate inj 100 mcg/ml (0.1 mg/ml) odt)...... 28 (Sandostatin)...... 14 ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)...... 12 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)...... 12 (Sandostatin)...... 14 OPSUMIT – macitentan tab 10 mg...... 23 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) oral contraceptives– all generics...... 10 (Sandostatin)...... 14 ORFADIN – nitisinone cap 2 mg...... 14 octreotide acetate inj 1000 mcg/ml (1 mg/ml) ORFADIN – nitisinone cap 5 mg...... 14 (Sandostatin)...... 14 ORFADIN – nitisinone cap 10 mg...... 14
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 78 2017
ORFADIN – nitisinone cap 20 mg...... 14 OXYCONTIN – oxycodone hcl tab er 12hr deter 80 ORFADIN – nitisinone susp 4 mg/ml...... 14 mg...... 39 orphenadrine citrate tab sr 12hr 100 mg...... 44 P oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu)...... 6 pantoprazole sodium ec tab 20 mg (base equiv) oseltamivir phosphate cap 45 mg (base equiv) (Protonix)...... 27 (Tamiflu)...... 6 pantoprazole sodium ec tab 40 mg (base equiv) oseltamivir phosphate cap 75 mg (base equiv) (Protonix)...... 27 (Tamiflu)...... 6 paricalcitol cap 1 mcg (Zemplar)...... 14 OTEZLA – apremilast tab 30 mg...... 41 paricalcitol cap 2 mcg (Zemplar)...... 14 OTEZLA – apremilast tab starter therapy pack 10 mg & 20 paricalcitol cap 4 mcg (Zemplar)...... 14 mg & 30 mg...... 41 paromomycin sulfate cap 250 mg...... 3 oxaprozin tab 600 mg (Daypro)...... 41 paroxetine hcl tab 10 mg (Paxil)...... 32 oxcarbazepine susp 300 mg/5ml (60 mg/ml) paroxetine hcl tab 20 mg (Paxil)...... 32 (Trileptal)...... 43 paroxetine hcl tab 30 mg (Paxil)...... 32 oxcarbazepine tab 150 mg (Trileptal)...... 43 paroxetine hcl tab 40 mg (Paxil)...... 32 oxcarbazepine tab 300 mg (Trileptal)...... 43 paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)...... 32 oxcarbazepine tab 600 mg (Trileptal)...... 43 paroxetine hcl tab sr 24hr 25 mg (Paxil cr)...... 32 oxybutynin chloride syrup 5 mg/5ml...... 29 paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)...... 32 oxybutynin chloride tab 5 mg...... 29 PATADAY – olopatadine hcl ophth soln 0.2% (base oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 29 equivalent)...... 53 oxybutynin chloride tab sr 24hr 10 mg (Ditropan PAZEO – olopatadine hcl ophth soln 0.7% (base xl)...... 29 equivalent)...... 53 oxybutynin chloride tab sr 24hr 15 mg (Ditropan PEGASYS – peginterferon alfa-2a inj 180 mcg/ml...... 4 xl)...... 29 PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml...... 4 oxycodone-aspirin tab 4.8355-325 mg (Percodan)...... 39 PEGASYS PROCLICK – peginterferon alfa-2a inj 135 oxycodone hcl cap 5 mg...... 39 mcg/0.5ml...... 4 oxycodone hcl conc 100 mg/5ml (20 mg/ml) PEGASYS PROCLICK – peginterferon alfa-2a inj 180 (Oxycodone hcl)...... 39 mcg/0.5ml...... 4 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)...... 39 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm oxycodone hcl tab 10 mg...... 39 (Colyte-flavor packs)...... 27 oxycodone hcl tab 20 mg...... 39 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm oxycodone hcl tab 5 mg (Roxicodone)...... 39 (Golytely)...... 27 oxycodone hcl tab 15 mg (Roxicodone)...... 39 peg 3350-kcl-sod bicarb-nacl for soln 420 gm oxycodone hcl tab 30 mg (Roxicodone)...... 39 (Nulytely/flavor pack)...... 27 oxycodone w/ acetaminophen tab 5-325 mg penicillin v potassium for soln 125 mg/5ml...... 1 (Percocet)...... 39 penicillin v potassium for soln 250 mg/5ml...... 1 oxycodone w/ acetaminophen tab 7.5-325 mg penicillin v potassium tab 250 mg...... 1 (Percocet)...... 39 penicillin v potassium tab 500 mg...... 1 oxycodone w/ acetaminophen tab 10-325 mg PENTASA – mesalamine cap cr 250 mg...... 29 (Percocet)...... 39 PENTASA – mesalamine cap cr 500 mg...... 29 OXYCONTIN – oxycodone hcl tab er 12hr deter 10 pentoxifylline tab cr 400 mg...... 50 mg...... 39 perindopril erbumine tab 2 mg...... 15 OXYCONTIN – oxycodone hcl tab er 12hr deter 15 perindopril erbumine tab 4 mg (Aceon)...... 15 mg...... 39 perindopril erbumine tab 8 mg (Aceon)...... 15 OXYCONTIN – oxycodone hcl tab er 12hr deter 20 permethrin cream 5% (Elimite)...... 56 mg...... 39 perphenazine tab 2 mg...... 33 OXYCONTIN – oxycodone hcl tab er 12hr deter 30 perphenazine tab 4 mg...... 33 mg...... 39 perphenazine tab 8 mg...... 33 OXYCONTIN – oxycodone hcl tab er 12hr deter 40 perphenazine tab 16 mg...... 33 mg...... 39 phenelzine sulfate tab 15 mg (Nardil)...... 32 OXYCONTIN – oxycodone hcl tab er 12hr deter 60 phenobarbital elixir 20 mg/5ml...... 34 mg...... 39 phenobarbital tab 16.2 mg...... 34
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 79 2017 phenobarbital tab 32.4 mg...... 34 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k phenoxybenzamine hcl cap 10 mg (Dibenzyline)...... 23 15)...... 30 phenytoin chew tab 50 mg (Dilantin infatabs)...... 43 PRALUENT – alirocumab subcutaneous soln pen-injector phenytoin sodium extended cap 100 mg (Dilantin)...... 43 75 mg/ml...... 21 phenytoin sodium extended cap 200 mg PRALUENT – alirocumab subcutaneous soln pen-injector (Phenytek)...... 43 150 mg/ml...... 21 phenytoin sodium extended cap 300 mg pramipexole dihydrochloride tab 0.125 mg (Phenytek)...... 43 (Mirapex)...... 44 phenytoin susp 125 mg/5ml (Dilantin)...... 43 pramipexole dihydrochloride tab 0.25 mg pilocarpine hcl ophth soln 1% (Isopto carpine)...... 52 (Mirapex)...... 44 pilocarpine hcl ophth soln 2% (Isopto carpine)...... 52 pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 44 pilocarpine hcl ophth soln 4% (Isopto carpine)...... 52 pramipexole dihydrochloride tab 0.75 mg pilocarpine hcl tab 5 mg (Salagen)...... 53 (Mirapex)...... 44 pilocarpine hcl tab 7.5 mg (Salagen)...... 53 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 44 pimozide tab 1 mg (Orap)...... 37 pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 44 pimozide tab 2 mg (Orap)...... 37 pravastatin sodium tab 10 mg...... 21 pindolol tab 5 mg...... 18 pravastatin sodium tab 20 mg (Pravachol)...... 21 pindolol tab 10 mg...... 18 pravastatin sodium tab 40 mg (Pravachol)...... 21 pioglitazone hcl-metformin hcl tab 15-500 mg pravastatin sodium tab 80 mg (Pravachol)...... 21 (Actoplus met)...... 12 prazosin hcl cap 1 mg (Minipress)...... 23 pioglitazone hcl-metformin hcl tab 15-850 mg prazosin hcl cap 2 mg (Minipress)...... 23 (Actoplus met)...... 12 prazosin hcl cap 5 mg (Minipress)...... 23 pioglitazone hcl tab 15 mg (base equiv) (Actos)...... 12 prednisolone acetate ophth susp 1% (Pred forte)...... 52 pioglitazone hcl tab 30 mg (base equiv) (Actos)...... 12 PREDNISOLONE SODIUM PHOSP – prednisolone pioglitazone hcl tab 45 mg (base equiv) (Actos)...... 12 sodium phosphate ophth soln 1%...... 52 piroxicam cap 10 mg (Feldene)...... 41 prednisolone sod phosphate oral soln 15 mg/5ml piroxicam cap 20 mg (Feldene)...... 41 (base equiv)...... 9 PLEGRIDY – peginterferon beta-1a soln pen-injector 125 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mcg/0.5ml...... 36 mg/5ml base) (Pediapred)...... 9 PLEGRIDY – peginterferon beta-1a soln prefilled syringe prednisolone syrup 15 mg/5ml (usp solution 125 mcg/0.5ml...... 36 equivalent) (Prelone)...... 9 PLEGRIDY STARTER PACK – peginterferon beta-1a soln PREDNISONE INTENSOL – prednisone conc 5 mg/ml...... 9 pen-inj 63 & 94 mcg/0.5ml pack...... 36 PREDNISONE – prednisone oral soln 5 mg/5ml...... 9 PLEGRIDY STARTER PACK – peginterferon beta-1a soln PREDNISONE – prednisone tab 50 mg...... 9 pref syr 63 & 94 mcg/0.5ml pack...... 36 prednisone tab 1 mg...... 9 podofilox soln 0.5% (Condylox)...... 56 prednisone tab 2.5 mg...... 9 polymyxin b-trimethoprim ophth soln 10000 unit/ prednisone tab 5 mg...... 9 ml-0.1% (Polytrim)...... 51 prednisone tab 10 mg...... 9 potassium chloride cap cr 8 meq (Micro-k)...... 45 prednisone tab 20 mg...... 9 potassium chloride cap cr 10 meq (Micro-k)...... 45 PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa tab potassium chloride microencapsulated crys cr tab 10 27-1 mg...... 45 meq...... 45 PRENATAL PLUS/IRON – prenatal vit w/ fe fumarate-fa potassium chloride microencapsulated crys cr tab 20 tab 27-1 mg...... 45 meq...... 45 PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 potassium chloride oral soln 10% (20 meq/15ml)...... 45 mg...... 45 potassium chloride powder packet 20 meq...... 45 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab potassium chloride tab cr 10 meq (K-tab)...... 45 29-1 mg...... 45 potassium chloride tab cr 8 meq (600 mg)...... 45 PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab potassium citrate tab cr 5 meq (540 mg) (Urocit-k 29-1 mg...... 45 5)...... 30 PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe potassium citrate tab cr 10 meq (1080 mg) (Urocit-k fumarate-fa tab 27-1 mg...... 45 10)...... 30 PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv)...... 5
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 80 2017
PREZISTA – darunavir ethanolate tab 75 mg (base propranolol hcl cap sr 24hr 80 mg (Inderal la)...... 18 equiv)...... 5 propranolol hcl cap sr 24hr 120 mg (Inderal la)...... 18 PREZISTA – darunavir ethanolate tab 150 mg (base propranolol hcl cap sr 24hr 160 mg (Inderal la)...... 18 equiv)...... 5 PROPRANOLOL HCL – propranolol hcl oral soln 20 PREZISTA – darunavir ethanolate tab 600 mg (base mg/5ml...... 18 equiv)...... 5 PROPRANOLOL HCL – propranolol hcl oral soln 40 PREZISTA – darunavir ethanolate tab 800 mg (base mg/5ml...... 18 equiv)...... 5 propranolol hcl tab 10 mg...... 18 PRIFTIN – rifapentine tab 150 mg...... 3 propranolol hcl tab 20 mg...... 18 PRIMAQUINE PHOSPHATE – primaquine phosphate tab propranolol hcl tab 40 mg...... 18 26.3 mg (15 mg base)...... 6 propranolol hcl tab 60 mg...... 18 primidone tab 50 mg (Mysoline)...... 43 propranolol hcl tab 80 mg...... 18 primidone tab 250 mg (Mysoline)...... 43 propylthiouracil tab 50 mg...... 13 PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act PULMOZYME – dornase alfa inhal soln 1 mg/ml...... 27 (90mcg base equiv)...... 26 PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ PROAIR RESPICLICK – albuterol sulfate aer pow ba 108 ml)...... 7 mcg/act (90 mcg base equiv)...... 26 pyrazinamide tab 500 mg...... 3 probenecid tab 500 mg...... 42 pyridostigmine bromide tab 60 mg (Mestinon)...... 45 prochlorperazine maleate tab 5 mg (base equivalent) Q (Compazine)...... 33 prochlorperazine maleate tab 10 mg (base equivalent) quetiapine fumarate tab 25 mg (Seroquel)...... 33 (Compazine)...... 33 quetiapine fumarate tab 50 mg (Seroquel)...... 33 prochlorperazine suppos 25 mg...... 33 quetiapine fumarate tab 100 mg (Seroquel)...... 33 PROCRIT – epoetin alfa inj 2000 unit/ml...... 50 quetiapine fumarate tab 200 mg (Seroquel)...... 33 PROCRIT – epoetin alfa inj 3000 unit/ml...... 50 quetiapine fumarate tab 300 mg (Seroquel)...... 33 PROCRIT – epoetin alfa inj 4000 unit/ml...... 50 quetiapine fumarate tab 400 mg (Seroquel)...... 34 PROCRIT – epoetin alfa inj 10000 unit/ml...... 50 quetiapine fumarate tab sr 24hr 50 mg (Seroquel PROCRIT – epoetin alfa inj 20000 unit/ml...... 50 xr)...... 33 PROCRIT – epoetin alfa inj 40000 unit/ml...... 50 quetiapine fumarate tab sr 24hr 150 mg (Seroquel PROFILNINE – factor ix complex for inj 500 unit...... 50 xr)...... 33 PROFILNINE – factor ix complex for inj 1000 unit...... 50 quetiapine fumarate tab sr 24hr 200 mg (Seroquel PROFILNINE – factor ix complex for inj 1500 unit...... 50 xr)...... 33 PROFILNINE SD – factor ix complex for inj 500 unit...... 50 quetiapine fumarate tab sr 24hr 300 mg (Seroquel PROFILNINE SD – factor ix complex for inj 1000 unit...... 50 xr)...... 33 PROFILNINE SD – factor ix complex for inj 1500 unit...... 50 quetiapine fumarate tab sr 24hr 400 mg (Seroquel progesterone micronized cap 100 mg xr)...... 33 (Prometrium)...... 10 quinapril hcl tab 5 mg (Accupril)...... 15 progesterone micronized cap 200 mg quinapril hcl tab 10 mg (Accupril)...... 15 (Prometrium)...... 10 quinapril hcl tab 20 mg (Accupril)...... 15 promethazine hcl suppos 12.5 mg...... 24 quinapril hcl tab 40 mg (Accupril)...... 15 promethazine hcl suppos 25 mg...... 24 quinapril-hydrochlorothiazide tab 10-12.5 mg promethazine hcl suppos 50 mg...... 24 (Accuretic)...... 15 promethazine hcl syrup 6.25 mg/5ml...... 24 quinapril-hydrochlorothiazide tab 20-12.5 mg promethazine hcl tab 12.5 mg...... 24 (Accuretic)...... 15 promethazine hcl tab 25 mg...... 24 quinapril-hydrochlorothiazide tab 20-25 mg promethazine hcl tab 50 mg...... 24 (Accuretic)...... 15 propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 22 quinidine gluconate tab cr 324 mg...... 22 propafenone hcl cap sr 12hr 325 mg (Rythmol sr)...... 22 QVAR – beclomethasone diprop inhal aero soln 40 mcg/ propafenone hcl cap sr 12hr 425 mg (Rythmol sr)...... 22 act (50/valve)...... 26 propafenone hcl tab 300 mg...... 22 QVAR – beclomethasone diprop inhal aero soln 80 mcg/ propafenone hcl tab 150 mg (Rythmol)...... 22 act (100/valve)...... 26 propafenone hcl tab 225 mg (Rythmol)...... 22 propranolol hcl cap sr 24hr 60 mg (Inderal la)...... 18
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 81 2017
REYATAZ – atazanavir sulfate cap 150 mg (base R equiv)...... 5 raloxifene hcl tab 60 mg (Evista)...... 14 REYATAZ – atazanavir sulfate cap 200 mg (base ramipril cap 1.25 mg (Altace)...... 15 equiv)...... 5 ramipril cap 2.5 mg (Altace)...... 15 REYATAZ – atazanavir sulfate cap 300 mg (base ramipril cap 5 mg (Altace)...... 15 equiv)...... 5 ramipril cap 10 mg (Altace)...... 15 ribavirin cap 200 mg (Rebetol)...... 4 ranitidine hcl cap 150 mg...... 27 ribavirin tab 200 mg (Copegus)...... 4 ranitidine hcl cap 300 mg...... 27 rifabutin cap 150 mg (Mycobutin)...... 3 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)...... 27 rifampin cap 150 mg (Rifadin)...... 3 ranitidine hcl tab 150 mg (Zantac)...... 28 rifampin cap 300 mg (Rifadin)...... 3 ranitidine hcl tab 300 mg (Zantac)...... 28 riluzole tab 50 mg (Rilutek)...... 45 RAPAMUNE – sirolimus oral soln 1 mg/ml...... 57 risedronate sodium tab 5 mg (Actonel)...... 14 rasagiline mesylate tab 0.5 mg (base equiv) risedronate sodium tab 30 mg (Actonel)...... 14 (Azilect)...... 44 risedronate sodium tab 35 mg (Actonel)...... 14 rasagiline mesylate tab 1 mg (base equiv) (Azilect)..... 44 risedronate sodium tab 150 mg (Actonel)...... 14 REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml risperidone orally disintegrating tab 0.25 mg...... 34 (12mu/ml)...... 36 risperidone orally disintegrating tab 0.5 mg (Risperdal REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml m-tab)...... 34 (24mu/ml)...... 36 risperidone orally disintegrating tab 1 mg (Risperdal REBIF REBIDOSE – interferon beta-1a soln auto-inj 22 m-tab)...... 34 mcg/0.5ml (12mu/ml)...... 36 risperidone orally disintegrating tab 2 mg (Risperdal REBIF REBIDOSE – interferon beta-1a soln auto-inj 44 m-tab)...... 34 mcg/0.5ml (24mu/ml)...... 36 risperidone orally disintegrating tab 3 mg (Risperdal REBIF REBIDOSE TITRATION – interferon beta-1a auto- m-tab)...... 34 inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 36 risperidone orally disintegrating tab 4 mg (Risperdal REBIF TITRATION PACK – interferon beta-1a pref syr m-tab)...... 34 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 36 risperidone soln 1 mg/ml (Risperdal)...... 34 RECOMBINATE – antihemophilic factor (recombinant) for risperidone tab 0.25 mg (Risperdal)...... 34 inj 220-400 unit...... 50 risperidone tab 0.5 mg (Risperdal)...... 34 RECOMBINATE – antihemophilic factor (recombinant) for risperidone tab 1 mg (Risperdal)...... 34 inj 401-800 unit...... 50 risperidone tab 2 mg (Risperdal)...... 34 RECOMBINATE – antihemophilic factor (recombinant) for risperidone tab 3 mg (Risperdal)...... 34 inj 801-1240 unit...... 50 risperidone tab 4 mg (Risperdal)...... 34 RECOMBINATE – antihemophilic factor (recombinant) for rivastigmine tartrate cap 1.5 mg (Exelon)...... 37 inj 1241-1800 unit...... 50 rivastigmine tartrate cap 3 mg (Exelon)...... 37 RECOMBINATE – antihemophilic factor (recombinant) for rivastigmine tartrate cap 4.5 mg (Exelon)...... 37 inj 1801-2400 unit...... 50 rivastigmine tartrate cap 6 mg (Exelon)...... 37 repaglinide tab 0.5 mg (Prandin)...... 12 RIXUBIS – coagulation factor ix (recombinant) for inj 250 repaglinide tab 1 mg (Prandin)...... 12 unit...... 50 repaglinide tab 2 mg (Prandin)...... 12 RIXUBIS – coagulation factor ix (recombinant) for inj 500 REPATHA – evolocumab subcutaneous soln prefilled unit...... 50 syringe 140 mg/ml...... 21 RIXUBIS – coagulation factor ix (recombinant) for inj 1000 REPATHA PUSHTRONEX SYSTEM – evolocumab unit...... 50 subcutaneous soln cartridge/infusor 420 mg/3.5ml...... 21 RIXUBIS – coagulation factor ix (recombinant) for inj 2000 REPATHA SURECLICK – evolocumab subcutaneous soln unit...... 50 auto-injector 140 mg/ml...... 21 RIXUBIS – coagulation factor ix (recombinant) for inj 3000 REVLIMID – lenalidomide cap 5 mg...... 57 unit...... 50 REVLIMID – lenalidomide cap 10 mg...... 57 rizatriptan benzoate oral disintegrating tab 5 mg (base REVLIMID – lenalidomide cap 15 mg...... 57 eq) (Maxalt-mlt)...... 41 REVLIMID – lenalidomide cap 20 mg...... 57 rizatriptan benzoate oral disintegrating tab 10 mg REVLIMID – lenalidomide cap 25 mg...... 57 (base eq) (Maxalt-mlt)...... 41 REVLIMID – lenalidomide caps 2.5 mg...... 57
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 82 2017 rizatriptan benzoate tab 5 mg (base equivalent) SIMPONI – golimumab subcutaneous soln prefilled (Maxalt)...... 41 syringe 50 mg/0.5ml...... 41 rizatriptan benzoate tab 10 mg (base equivalent) SIMPONI – golimumab subcutaneous soln prefilled (Maxalt)...... 41 syringe 100 mg/ml...... 41 ropinirole hydrochloride tab 0.25 mg (Requip)...... 44 simvastatin tab 5 mg (Zocor)...... 21 ropinirole hydrochloride tab 0.5 mg (Requip)...... 44 simvastatin tab 10 mg (Zocor)...... 21 ropinirole hydrochloride tab 1 mg (Requip)...... 44 simvastatin tab 20 mg (Zocor)...... 21 ropinirole hydrochloride tab 2 mg (Requip)...... 44 simvastatin tab 40 mg (Zocor)...... 21 ropinirole hydrochloride tab 3 mg (Requip)...... 44 simvastatin tab 80 mg (Zocor)...... 21 ropinirole hydrochloride tab 4 mg (Requip)...... 44 sirolimus tab 0.5 mg (Rapamune)...... 57 ropinirole hydrochloride tab 5 mg (Requip)...... 44 sirolimus tab 1 mg (Rapamune)...... 57 rosuvastatin calcium tab 5 mg (Crestor)...... 21 sirolimus tab 2 mg (Rapamune)...... 57 rosuvastatin calcium tab 10 mg (Crestor)...... 21 SIVEXTRO – tedizolid phosphate tab 200 mg...... 6 rosuvastatin calcium tab 20 mg (Crestor)...... 21 SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 rosuvastatin calcium tab 40 mg (Crestor)...... 21 mg total)...... 10 S sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps)...... 57 SABRIL – vigabatrin powd pack 500 mg...... 43 sodium polystyrene sulfonate powder SABRIL – vigabatrin tab 500 mg...... 43 (Kayexalate)...... 57 selegiline hcl cap 5 mg (Eldepryl)...... 44 SOOLANTRA – ivermectin cream 1%...... 54 selegiline hcl tab 5 mg...... 44 sotalol hcl (afib/afl) tab 80 mg (Betapace af)...... 22 selenium sulfide lotion 2.5%...... 56 sotalol hcl (afib/afl) tab 120 mg (Betapace af)...... 22 SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 sotalol hcl (afib/afl) tab 160 mg (Betapace af)...... 22 mg...... 45 sotalol hcl tab 240 mg...... 22 SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab sotalol hcl tab 80 mg (Betapace)...... 22 29-1 mg...... 45 sotalol hcl tab 120 mg (Betapace)...... 22 SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)...... 14 sotalol hcl tab 160 mg (Betapace)...... 22 SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)...... 14 SOVALDI – sofosbuvir tab 400 mg...... 4 SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)...... 14 SPIRIVA HANDIHALER – tiotropium bromide SEREVENT DISKUS – salmeterol xinafoate aer pow ba monohydrate inhal cap 18 mcg (base equiv)...... 26 50 mcg/dose (base equiv)...... 26 SPIRIVA RESPIMAT – tiotropium bromide monohydrate SEROQUEL XR – quetiapine fumarate tab sr 24hr 50 inhal aerosol 1.25 mcg/act...... 26 mg...... 34 SPIRIVA RESPIMAT – tiotropium bromide monohydrate SEROQUEL XR – quetiapine fumarate tab sr 24hr 150 inhal aerosol 2.5 mcg/act...... 26 mg...... 34 spironolactone & hydrochlorothiazide tab 25-25 mg SEROQUEL XR – quetiapine fumarate tab sr 24hr 200 (Aldactazide)...... 22 mg...... 34 spironolactone tab 25 mg (Aldactone)...... 22 SEROQUEL XR – quetiapine fumarate tab sr 24hr 300 spironolactone tab 50 mg (Aldactone)...... 22 mg...... 34 spironolactone tab 100 mg (Aldactone)...... 22 SEROQUEL XR – quetiapine fumarate tab sr 24hr 400 SPRYCEL – dasatinib tab 20 mg...... 7 mg...... 34 SPRYCEL – dasatinib tab 50 mg...... 7 sertraline hcl oral conc 20 mg/ml (Zoloft)...... 32 SPRYCEL – dasatinib tab 70 mg...... 7 sertraline hcl tab 25 mg (Zoloft)...... 32 SPRYCEL – dasatinib tab 80 mg...... 7 sertraline hcl tab 50 mg (Zoloft)...... 32 SPRYCEL – dasatinib tab 100 mg...... 7 sertraline hcl tab 100 mg (Zoloft)...... 32 SPRYCEL – dasatinib tab 140 mg...... 7 sildenafil citrate tab 20 mg (Revatio)...... 23 stavudine cap 15 mg (Zerit)...... 5 silver sulfadiazine cream 1% (Silvadene)...... 54 stavudine cap 20 mg (Zerit)...... 5 SIMBRINZA – brinzolamide-brimonidine tartrate ophth stavudine cap 30 mg (Zerit)...... 5 susp 1-0.2%...... 52 stavudine cap 40 mg (Zerit)...... 5 SIMPONI – golimumab subcutaneous soln auto-injector STELARA – ustekinumab inj 45 mg/0.5ml...... 56 50 mg/0.5ml...... 41 STELARA – ustekinumab soln prefilled syringe 45 SIMPONI – golimumab subcutaneous soln auto-injector mg/0.5ml...... 56 100 mg/ml...... 41
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 83 2017
STELARA – ustekinumab soln prefilled syringe 90 mg/ sumatriptan succinate tab 25 mg (Imitrex)...... 41 ml...... 56 sumatriptan succinate tab 50 mg (Imitrex)...... 41 STIMATE – desmopressin acetate nasal soln 1.5 mg/ sumatriptan succinate tab 100 mg (Imitrex)...... 42 ml...... 14 SUSTIVA – efavirenz cap 50 mg...... 5 STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero SUSTIVA – efavirenz cap 200 mg...... 5 soln 2.5-2.5 mcg/act...... 26 SUSTIVA – efavirenz tab 600 mg...... 5 STRENSIQ – asfotase alfa subcutaneous inj 18 SUTENT – sunitinib malate cap 12.5 mg (base mg/0.45ml...... 14 equivalent)...... 7 STRENSIQ – asfotase alfa subcutaneous inj 28 SUTENT – sunitinib malate cap 25 mg (base mg/0.7ml...... 14 equivalent)...... 7 STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ SUTENT – sunitinib malate cap 37.5 mg (base ml...... 14 equivalent)...... 7 STRENSIQ – asfotase alfa subcutaneous inj 80 SUTENT – sunitinib malate cap 50 mg (base mg/0.8ml...... 14 equivalent)...... 7 STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab SYLATRON – peginterferon alfa-2b for inj kit 200 mcg...... 7 150-150-200-300 mg...... 5 SYLATRON – peginterferon alfa-2b for inj kit 300 mcg...... 7 STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln SYLATRON – peginterferon alfa-2b for inj kit 600 mcg...... 8 2.5 mcg/act (base equiv)...... 26 SYMBICORT – budesonide-formoterol fumarate dihyd SUBOXONE – buprenorphine hcl-naloxone hcl sl film aerosol 80-4.5 mcg/act...... 26 2-0.5 mg (base equiv)...... 57 SYMBICORT – budesonide-formoterol fumarate dihyd SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 aerosol 160-4.5 mcg/act...... 26 mg (base equiv)...... 57 SYNJARDY – empagliflozin-metformin hcl tab 5-500 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 mg...... 12 mg (base equiv)...... 57 SYNJARDY – empagliflozin-metformin hcl tab 5-1000 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 mg...... 12 mg (base equiv)...... 57 SYNJARDY – empagliflozin-metformin hcl tab 12.5-500 sucralfate tab 1 gm (Carafate)...... 28 mg...... 12 sulfacetamide sodium lotion 10% (acne) (Klaron)...... 54 SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000 sulfacetamide sodium ophth soln 10% (Bleph-10)...... 51 mg...... 12 sulfacetamide sodium-prednisolone ophth soln T 10-0.23(0.25)%...... 52 sulfamethoxazole-trimethoprim susp 200-40 TABLOID – thioguanine tab 40 mg...... 8 mg/5ml...... 6 tacrolimus cap 0.5 mg (Prograf)...... 57 sulfamethoxazole-trimethoprim tab 400-80 mg tacrolimus cap 1 mg (Prograf)...... 57 (Bactrim)...... 6 tacrolimus cap 5 mg (Prograf)...... 57 sulfamethoxazole-trimethoprim tab 800-160 mg tacrolimus oint 0.03% (Protopic)...... 56 (Bactrim ds)...... 6 tacrolimus oint 0.1% (Protopic)...... 56 sulfasalazine tab delayed release 500 mg (Azulfidine TAFINLAR – dabrafenib mesylate cap 50 mg (base en-tabs)...... 29 equivalent)...... 8 sulfasalazine tab 500 mg (Azulfidine)...... 29 TAFINLAR – dabrafenib mesylate cap 75 mg (base sulindac tab 150 mg...... 41 equivalent)...... 8 sulindac tab 200 mg...... 41 tamoxifen citrate tab 10 mg (base equivalent)...... 8 sumatriptan nasal spray 5 mg/act (Imitrex)...... 41 tamoxifen citrate tab 20 mg (base equivalent)...... 8 sumatriptan nasal spray 20 mg/act (Imitrex)...... 41 tamsulosin hcl cap 0.4 mg (Flomax)...... 30 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)...... 41 TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 8 sumatriptan succinate solution auto-injector 4 TARCEVA – erlotinib hcl tab 100 mg (base equivalent)...... 8 mg/0.5ml (Imitrex statdose sys)...... 41 TARCEVA – erlotinib hcl tab 150 mg (base equivalent)...... 8 sumatriptan succinate solution auto-injector 6 TASIGNA – nilotinib hcl cap 150 mg (base equivalent)...... 8 mg/0.5ml (Imitrex statdose sys)...... 41 TASIGNA – nilotinib hcl cap 200 mg (base equivalent)...... 8 sumatriptan succinate solution cartridge 4 mg/0.5ml tazarotene cream 0.1% (Tazorac)...... 54 (Imitrex statdose ref)...... 41 TAZORAC – tazarotene cream 0.05%...... 54 sumatriptan succinate solution cartridge 6 mg/0.5ml TAZORAC – tazarotene cream 0.1%...... 54 (Imitrex statdose ref)...... 41 TAZORAC – tazarotene gel 0.05%...... 54
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 84 2017
TAZORAC – tazarotene gel 0.1%...... 54 THALOMID – thalidomide cap 150 mg...... 57 TECFIDERA – dimethyl fumarate capsule delayed release THALOMID – thalidomide cap 200 mg...... 57 120 mg...... 36 theophylline tab sr 12hr 100 mg...... 26 TECFIDERA – dimethyl fumarate capsule delayed release theophylline tab sr 12hr 200 mg...... 26 240 mg...... 36 theophylline tab sr 12hr 300 mg...... 26 TECFIDERA STARTER PACK – dimethyl fumarate theophylline tab sr 12hr 450 mg...... 26 capsule dr starter pack 120 mg & 240 mg...... 37 theophylline tab sr 24hr 400 mg...... 26 telmisartan-hydrochlorothiazide tab 40-12.5 mg theophylline tab sr 24hr 600 mg...... 26 (Micardis hct)...... 17 thiothixene cap 1 mg...... 34 telmisartan-hydrochlorothiazide tab 80-12.5 mg thiothixene cap 2 mg...... 34 (Micardis hct)...... 17 thiothixene cap 5 mg...... 34 telmisartan-hydrochlorothiazide tab 80-25 mg thiothixene cap 10 mg...... 34 (Micardis hct)...... 17 timolol maleate ophth gel forming soln 0.25% telmisartan tab 20 mg (Micardis)...... 17 (Timoptic-xe)...... 52 telmisartan tab 40 mg (Micardis)...... 17 timolol maleate ophth gel forming soln 0.5% telmisartan tab 80 mg (Micardis)...... 17 (Timoptic-xe)...... 52 temazepam cap 7.5 mg (Restoril)...... 34 timolol maleate ophth soln 0.25% (Timoptic)...... 52 temazepam cap 15 mg (Restoril)...... 34 timolol maleate ophth soln 0.5% (Timoptic)...... 52 temazepam cap 22.5 mg (Restoril)...... 34 TIMOLOL MALEATE – timolol maleate tab 5 mg...... 18 temazepam cap 30 mg (Restoril)...... 34 TIMOLOL MALEATE – timolol maleate tab 10 mg...... 18 temozolomide cap 5 mg (Temodar)...... 8 TIMOLOL MALEATE – timolol maleate tab 20 mg...... 18 temozolomide cap 20 mg (Temodar)...... 8 TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 5 temozolomide cap 100 mg (Temodar)...... 8 TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 5 temozolomide cap 140 mg (Temodar)...... 8 TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 5 temozolomide cap 180 mg (Temodar)...... 8 tizanidine hcl tab 2 mg (base equivalent)...... 45 temozolomide cap 250 mg (Temodar)...... 8 tizanidine hcl tab 4 mg (base equivalent) terazosin hcl cap 1 mg...... 23 (Zanaflex)...... 45 terazosin hcl cap 2 mg...... 23 tobramycin-dexamethasone ophth susp 0.3-0.1% terazosin hcl cap 5 mg...... 23 (Tobradex)...... 52 terazosin hcl cap 10 mg...... 23 tobramycin nebu soln 300 mg/5ml (Tobi)...... 3 terbinafine hcl tab 250 mg (Lamisil)...... 3 tobramycin ophth soln 0.3% (Tobrex)...... 51 terbutaline sulfate tab 2.5 mg...... 26 tolterodine tartrate cap sr 24hr 2 mg (Detrol la)...... 29 terbutaline sulfate tab 5 mg...... 26 tolterodine tartrate cap sr 24hr 4 mg (Detrol la)...... 29 terconazole vaginal cream 0.4% (Terazol 7)...... 30 tolterodine tartrate tab 1 mg (Detrol)...... 29 terconazole vaginal cream 0.8% (Terazol 3)...... 30 tolterodine tartrate tab 2 mg (Detrol)...... 29 terconazole vaginal suppos 80 mg...... 30 topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 43 testosterone cypionate im inj in oil 100 mg/ml (Depo- topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 43 testosterone)...... 9 topiramate tab 25 mg (Topamax)...... 43 testosterone cypionate im inj in oil 200 mg/ml (Depo- topiramate tab 50 mg (Topamax)...... 43 testosterone)...... 9 topiramate tab 100 mg (Topamax)...... 43 testosterone enanthate im inj in oil 200 mg/ml...... 9 topiramate tab 200 mg (Topamax)...... 43 testosterone td gel 12.5 mg/act (1%) (Androgel torsemide tab 5 mg (Demadex)...... 22 pump)...... 9 torsemide tab 10 mg (Demadex)...... 22 testosterone td gel 25 mg/2.5gm (1%) (Androgel)...... 9 torsemide tab 20 mg (Demadex)...... 22 testosterone td gel 50 mg/5gm (1%) (Androgel)...... 9 torsemide tab 100 mg (Demadex)...... 22 TEST STRIPS – ASCENSIA BREEZE 2, CONTOUR, TOUJEO SOLOSTAR – insulin glargine soln pen-injector CONTOUR NEXT...... 56 300 unit/ml...... 13 tetrabenazine tab 12.5 mg (Xenazine)...... 37 TRACLEER – bosentan tab 62.5 mg...... 23 tetrabenazine tab 25 mg (Xenazine)...... 37 TRACLEER – bosentan tab 125 mg...... 23 tetracycline hcl cap 250 mg (Tetracycline hcl)...... 2 tramadol-acetaminophen tab 37.5-325 mg tetracycline hcl cap 500 mg (Tetracycline hcl)...... 2 (Ultracet)...... 40 THALOMID – thalidomide cap 50 mg...... 57 tramadol hcl tab 50 mg (Ultram)...... 40 THALOMID – thalidomide cap 100 mg...... 57 tramadol hcl tab sr 24hr 100 mg (Ultram er)...... 40
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 85 2017 tramadol hcl tab sr 24hr 200 mg (Ultram er)...... 40 trifluoperazine hcl tab 5 mg...... 34 tramadol hcl tab sr 24hr 300 mg (Ultram er)...... 40 trifluoperazine hcl tab 10 mg...... 34 trandolapril tab 1 mg (Mavik)...... 15 trifluridine ophth soln 1% (Viroptic)...... 51 trandolapril tab 2 mg (Mavik)...... 15 trihexyphenidyl hcl elixir 0.4 mg/ml...... 44 trandolapril tab 4 mg (Mavik)...... 15 trihexyphenidyl hcl tab 2 mg...... 44 tranylcypromine sulfate tab 10 mg (Parnate)...... 32 trihexyphenidyl hcl tab 5 mg...... 44 TRAVATAN Z – travoprost ophth soln 0.004% trimethobenzamide hcl cap 300 mg (Tigan)...... 28 (benzalkonium free) (bak free)...... 52 trimethoprim tab 100 mg...... 6 trazodone hcl tab 50 mg...... 32 tropicamide ophth soln 0.5%...... 53 trazodone hcl tab 100 mg...... 32 tropicamide ophth soln 1% (Mydriacyl)...... 53 trazodone hcl tab 150 mg...... 32 TRUVADA – emtricitabine-tenofovir disoproxil fumarate trazodone hcl tab 300 mg...... 32 tab 100-150 mg...... 5 TRESIBA FLEXTOUCH – insulin degludec soln pen- TRUVADA – emtricitabine-tenofovir disoproxil fumarate injector 100 unit/ml...... 13 tab 133-200 mg...... 5 TRESIBA FLEXTOUCH – insulin degludec soln pen- TRUVADA – emtricitabine-tenofovir disoproxil fumarate injector 200 unit/ml...... 13 tab 167-250 mg...... 5 tretinoin cap 10 mg...... 8 TRUVADA – emtricitabine-tenofovir disoproxil fumarate tretinoin cream 0.025% (Retin-a)...... 54 tab 200-300 mg...... 5 tretinoin cream 0.05% (Retin-a)...... 54 U tretinoin cream 0.1% (Retin-a)...... 54 tretinoin gel 0.01% (Retin-a)...... 54 UPTRAVI – selexipag tab 200 mcg...... 23 tretinoin gel 0.025% (Retin-a)...... 54 UPTRAVI – selexipag tab 400 mcg...... 23 tretinoin microsphere gel 0.04% (Retin-a micro)...... 54 UPTRAVI – selexipag tab 600 mcg...... 23 tretinoin microsphere gel 0.1% (Retin-a micro)...... 54 UPTRAVI – selexipag tab 800 mcg...... 23 TRETTEN – coagulation factor xiii a-subunit for inj UPTRAVI – selexipag tab 1000 mcg...... 23 2000-3125 unit...... 50 UPTRAVI – selexipag tab 1200 mcg...... 23 TREXALL – methotrexate sodium tab 5 mg (base UPTRAVI – selexipag tab 1400 mcg...... 23 equiv)...... 8 UPTRAVI – selexipag tab 1600 mcg...... 23 TREXALL – methotrexate sodium tab 7.5 mg (base UPTRAVI – selexipag tab therapy pack 200 mcg (140) & equiv)...... 8 800 mcg (60)...... 23 TREXALL – methotrexate sodium tab 10 mg (base ursodiol cap 300 mg (Actigall)...... 29 equiv)...... 8 ursodiol tab 250 mg (Urso 250)...... 29 TREXALL – methotrexate sodium tab 15 mg (base ursodiol tab 500 mg (Urso forte)...... 29 equiv)...... 8 V triamcinolone acetonide cream 0.025%...... 55 VAGIFEM – estradiol vaginal tab 10 mcg...... 30 triamcinolone acetonide cream 0.1%...... 55 triamcinolone acetonide cream 0.5%...... 55 valacyclovir hcl tab 1 gm (Valtrex)...... 4 triamcinolone acetonide dental paste 0.1%...... 53 valacyclovir hcl tab 500 mg (Valtrex)...... 4 VALCHLOR – mechlorethamine hcl gel 0.016% (base triamcinolone acetonide lotion 0.025%...... 55 equivalent)...... 56 triamcinolone acetonide lotion 0.1%...... 55 VALCYTE – valganciclovir hcl for soln 50 mg/ml (base triamcinolone acetonide nasal aerosol suspension 55 equiv)...... 3 mcg/act (Nasacort aq)...... 24 triamcinolone acetonide oint 0.025%...... 55 valganciclovir hcl for soln 50 mg/ml (base equiv) triamcinolone acetonide oint 0.1%...... 55 (Valcyte)...... 3 triamcinolone acetonide oint 0.5%...... 55 valganciclovir hcl tab 450 mg (base equivalent) triamterene & hydrochlorothiazide cap 37.5-25 mg (Valcyte)...... 3 (Dyazide)...... 22 valproate sodium oral soln 250 mg/5ml (base equiv) triamterene & hydrochlorothiazide tab 37.5-25 mg (Depakene)...... 43 (Maxzide-25)...... 22 valproic acid cap 250 mg (Depakene)...... 43 triamterene & hydrochlorothiazide tab 75-50 mg valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan (Maxzide)...... 22 hct)...... 17 trifluoperazine hcl tab 1 mg...... 34 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan trifluoperazine hcl tab 2 mg...... 34 hct)...... 17
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 86 2017 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan VIREAD – tenofovir disoproxil fumarate oral powder 40 hct)...... 17 mg/gm...... 5 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan VIREAD – tenofovir disoproxil fumarate tab 150 mg...... 5 hct)...... 17 VIREAD – tenofovir disoproxil fumarate tab 200 mg...... 6 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan VIREAD – tenofovir disoproxil fumarate tab 250 mg...... 6 hct)...... 17 VIREAD – tenofovir disoproxil fumarate tab 300 mg...... 6 valsartan tab 40 mg (Diovan)...... 17 VONVENDI – von willebrand factor (recombinant) for inj valsartan tab 80 mg (Diovan)...... 17 650 unit...... 50 valsartan tab 160 mg (Diovan)...... 17 VONVENDI – von willebrand factor (recombinant) for inj valsartan tab 320 mg (Diovan)...... 17 1300 unit...... 50 vancomycin hcl cap 125 mg (Vancocin hcl)...... 6 voriconazole for susp 40 mg/ml (Vfend)...... 3 vancomycin hcl cap 250 mg (Vancocin hcl)...... 6 voriconazole tab 50 mg (Vfend)...... 3 VELPHORO – sucroferric oxyhydroxide chew tab 500 voriconazole tab 200 mg (Vfend)...... 3 mg...... 29 VOTRIENT – pazopanib hcl tab 200 mg (base equiv)...... 8 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 36 (Effexor xr)...... 32 VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 36 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) VYVANSE – lisdexamfetamine dimesylate cap 30 mg...... 36 (Effexor xr)...... 32 VYVANSE – lisdexamfetamine dimesylate cap 40 mg...... 36 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) VYVANSE – lisdexamfetamine dimesylate cap 50 mg...... 36 (Effexor xr)...... 32 VYVANSE – lisdexamfetamine dimesylate cap 60 mg...... 36 venlafaxine hcl tab 25 mg...... 32 VYVANSE – lisdexamfetamine dimesylate cap 70 mg...... 36 venlafaxine hcl tab 37.5 mg...... 32 VYVANSE – lisdexamfetamine dimesylate chew tab 10 venlafaxine hcl tab 50 mg...... 32 mg...... 36 venlafaxine hcl tab 75 mg...... 32 VYVANSE – lisdexamfetamine dimesylate chew tab 20 venlafaxine hcl tab 100 mg...... 32 mg...... 36 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) VYVANSE – lisdexamfetamine dimesylate chew tab 30 (Venlafaxine hcl er)...... 32 mg...... 36 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) VYVANSE – lisdexamfetamine dimesylate chew tab 40 (Venlafaxine hcl er)...... 32 mg...... 36 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) VYVANSE – lisdexamfetamine dimesylate chew tab 50 (Venlafaxine hcl er)...... 32 mg...... 36 VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act VYVANSE – lisdexamfetamine dimesylate chew tab 60 (90mcg base equiv)...... 26 mg...... 36 verapamil hcl cap sr 24hr 120 mg (Verelan)...... 19 W verapamil hcl cap sr 24hr 180 mg (Verelan)...... 19 verapamil hcl cap sr 24hr 240 mg (Verelan)...... 19 warfarin sodium tab 1 mg (Coumadin)...... 50 verapamil hcl cap sr 24hr 360 mg (Verelan)...... 19 warfarin sodium tab 2 mg (Coumadin)...... 50 verapamil hcl tab cr 120 mg (Calan sr)...... 19 warfarin sodium tab 2.5 mg (Coumadin)...... 50 verapamil hcl tab cr 180 mg (Calan sr)...... 20 warfarin sodium tab 3 mg (Coumadin)...... 50 verapamil hcl tab cr 240 mg (Calan sr)...... 20 warfarin sodium tab 4 mg (Coumadin)...... 50 verapamil hcl tab 40 mg...... 20 warfarin sodium tab 5 mg (Coumadin)...... 50 verapamil hcl tab 80 mg (Calan)...... 20 warfarin sodium tab 6 mg (Coumadin)...... 50 verapamil hcl tab 120 mg (Calan)...... 20 warfarin sodium tab 7.5 mg (Coumadin)...... 51 VESICARE – solifenacin succinate tab 5 mg...... 29 warfarin sodium tab 10 mg (Coumadin)...... 51 VESICARE – solifenacin succinate tab 10 mg...... 29 WELCHOL – colesevelam hcl packet for susp 3.75 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ gm...... 21 ml)...... 12 WELCHOL – colesevelam hcl tab 625 mg...... 21 VIDEX – didanosine for soln 2 gm...... 5 WILATE – antihemophilic factor/vwf (human) for inj VIDEX – didanosine for soln 4 gm...... 5 500-500 unit kit...... 51 VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base WILATE – antihemophilic factor/vwf (human) for inj equiv)...... 51 1000-1000 unit kit...... 51 VIRAMUNE – nevirapine susp 50 mg/5ml...... 5
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 87 2017
ZENPEP – pancrelipase (lip-prot-amyl) dr cap X 25000-85000-136000 unit...... 28 XALKORI – crizotinib cap 200 mg...... 8 ZENPEP – pancrelipase (lip-prot-amyl) dr cap XALKORI – crizotinib cap 250 mg...... 8 40000-136000-218000 unit...... 28 XARELTO – rivaroxaban tab 10 mg...... 51 ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 6 XARELTO – rivaroxaban tab 15 mg...... 51 zidovudine cap 100 mg (Retrovir)...... 6 XARELTO – rivaroxaban tab 20 mg...... 51 zidovudine syrup 10 mg/ml (Retrovir)...... 6 XARELTO STARTER PACK – rivaroxaban tab starter zidovudine tab 300 mg...... 6 therapy pack 15 mg & 20 mg...... 51 ziprasidone hcl cap 20 mg (Geodon)...... 34 XIFAXAN – rifaximin tab 550 mg...... 6 ziprasidone hcl cap 40 mg (Geodon)...... 34 XTANDI – enzalutamide cap 40 mg...... 8 ziprasidone hcl cap 60 mg (Geodon)...... 34 XYNTHA – antihemophilic factor recombinant paf for inj kit ziprasidone hcl cap 80 mg (Geodon)...... 34 250 unit...... 51 zolpidem tartrate tab cr 6.25 mg (Ambien cr)...... 34 XYNTHA – antihemophilic factor recombinant paf for inj kit zolpidem tartrate tab cr 12.5 mg (Ambien cr)...... 34 500 unit...... 51 zolpidem tartrate tab 5 mg (Ambien)...... 34 XYNTHA – antihemophilic factor recombinant paf for inj kit zolpidem tartrate tab 10 mg (Ambien)...... 34 1000 unit...... 51 zonisamide cap 50 mg...... 43 XYNTHA – antihemophilic factor recombinant paf for inj kit zonisamide cap 25 mg (Zonegran)...... 43 2000 unit...... 51 zonisamide cap 100 mg (Zonegran)...... 43 XYNTHA SOLOFUSE – antihemophilic factor recombinant ZORTRESS – everolimus tab 0.25 mg...... 57 paf for inj kit 250 unit...... 51 ZORTRESS – everolimus tab 0.5 mg...... 57 XYNTHA SOLOFUSE – antihemophilic factor recombinant ZORTRESS – everolimus tab 0.75 mg...... 57 paf for inj kit 500 unit...... 51 ZYCLARA – imiquimod cream 3.75%...... 56 XYNTHA SOLOFUSE – antihemophilic factor recombinant ZYCLARA PUMP – imiquimod cream 2.5%...... 56 paf for inj kit 1000 unit...... 51 ZYCLARA PUMP – imiquimod cream 3.75%...... 56 XYNTHA SOLOFUSE – antihemophilic factor recombinant ZYLET – loteprednol etabonate-tobramycin ophth susp paf for inj kit 2000 unit...... 51 0.5-0.3%...... 52 XYNTHA SOLOFUSE – antihemophilic factor recombinant ZYTIGA – abiraterone acetate tab 250 mg...... 8 paf for inj kit 3000 unit...... 51 ZYTIGA – abiraterone acetate tab 500 mg...... 8 Y
Z zafirlukast tab 10 mg (Accolate)...... 26 zafirlukast tab 20 mg (Accolate)...... 26 zaleplon cap 5 mg (Sonata)...... 34 zaleplon cap 10 mg (Sonata)...... 34 ZARXIO – filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml...... 51 ZARXIO – filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml...... 51 ZELBORAF – vemurafenib tab 240 mg...... 8 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit...... 28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit...... 28
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 88