TWO-TIER Generic Medications Benefit Design

What is a two-tiered generic medications benefit design?

A two-tiered generic medication benefit design features a list of generic drugs with two levels of member cost-share amounts for generic prescription medications. This gives an incentive to request lower-cost generic medications whenever possible. Your cost share amount depends on which tier of the list your medication is In.

Tier I: Lower-cost generic drugs. Tier II: Higher-cost generic drugs

Generic drugs deliver a better value than brand-name drugs. They work the same way as brand-name drugs, but can cost between 30 and 80 percent less. 1 The medications in the list below are the lower-cost generic medications that are in Tier I of your plan. You may use the higher-cost generic medications in Tier II, but those medications will cost you more than Tier I generics. Generic medications not listed below would follow your benefit plan out-of-pocket for Tier II. NOTE: This is a list of two-tiered generic medications. Drugs may appear on the list that may or may not be covered under your plan. This list is subject to change. If you have questions, please contact Blue Cross and Blue Shield of Nebraska’s Member Services department at the number on the back of your member ID card.

1http://www.healthsmart.com/SmarterHealth/GenericVsBrandDrugs. aspx, accessed 12 March 2013.

2021

Drug Name Drug Name ANTI-INFECTIVE AGENTS levofloxacin tab 250 mg (Levaquin) levofloxacin tab 500 mg (Levaquin) amoxicillin (trihydrate) cap 250 mg levofloxacin tab 750 mg (Levaquin) amoxicillin (trihydrate) cap 500 mg AMINOGLYCOSIDES amoxicillin (trihydrate) for susp 125 mg/5ml sulfate inj 40 mg/ml amoxicillin (trihydrate) for susp 200 mg/5ml neomycin sulfate tab 500 mg amoxicillin (trihydrate) for susp 250 mg/5ml ANTIMYCOBACTERIAL AGENTS amoxicillin (trihydrate) for susp 400 mg/5ml tab 100 mg amoxicillin (trihydrate) tab 500 mg isoniazid tab 300 mg amoxicillin (trihydrate) tab 875 mg ANTIFUNGALS amoxicillin & k clavulanate for susp 200-28.5 mg/5ml fluconazole tab 50 mg (Diflucan) amoxicillin & k clavulanate tab 500-125 mg fluconazole tab 100 mg (Diflucan) (Augmentin) fluconazole tab 150 mg (Diflucan) amoxicillin & k clavulanate tab 875-125 mg fluconazole tab 200 mg (Diflucan) (Augmentin) terbinafine hcl tab 250 mg (Lamisil) v potassium tab 250 mg ANTIVIRALS penicillin v potassium tab 500 mg acyclovir cap 200 mg (Zovirax) acyclovir tab 400 mg (Zovirax) cap 500 mg acyclovir tab 800 mg (Zovirax) sodium for inj 500 mg famciclovir tab 125 mg cefazolin sodium for inj 10 gm nevirapine tab 200 mg (Viramune) cap 300 mg valacyclovir hcl tab 500 mg (Valtrex) sodium for inj 250 mg valacyclovir hcl tab 1 gm (Valtrex) ceftriaxone sodium for inj 1 gm ANTI-INFECTIVE AGENTS - MISC. ceftriaxone sodium for iv soln 2 gm intramuscular for soln 50000 unit cephalexin cap 250 mg (Keflex) clindamycin hcl cap 150 mg (Cleocin) cephalexin cap 500 mg (Keflex) clindamycin hcl cap 300 mg (Cleocin) clindamycin phosphate inj 9 gm/60ml (Cleocin tab 250 mg (Zithromax) phosphate) azithromycin tab 500 mg (Zithromax) metronidazole tab 250 mg (Flagyl) TETRACYCLINES metronidazole tab 500 mg (Flagyl) hyclate cap 100 mg (Vibramycin) nitrofurantoin monohydrate macrocrystalline cap doxycycline hyclate tab 100 mg 100 mg (Macrobid) doxycycline monohydrate cap 50 mg b sulfate for inj 500000 unit doxycycline monohydrate cap 100 mg (Monodox) sulfamethoxazole-trimethoprim tab 400-80 mg hcl cap 50 mg (Minocin) (Bactrim) FLUOROQUINOLONES sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) trimethoprim tab 100 mg ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) ANTINEOPLASTIC AGENTS ciprofloxacin hcl tab 750 mg (base equiv)

BCBSNE Preferred Generics (Lower Cost Generics), 2021 1 2021

Drug Name Drug Name ANTINEOPLASTICS prednisone tab 10 mg anastrozole tab 1 mg (Arimidex) prednisone tab 20 mg bicalutamide tab 50 mg (Casodex) prednisone tab 50 mg cytarabine inj pf 100 mg/ml triamcinolone acetonide inj susp 40 mg/ml fluorouracil iv soln 5 gm/100ml (50 mg/ml) (Kenalog-40) letrozole tab 2.5 mg (Femara) ESTROGENS megestrol acetate tab 20 mg estradiol tab 0.5 mg (Estrace) megestrol acetate tab 40 mg estradiol tab 1 mg (Estrace) sodium inj pf 50 mg/2ml (25 mg/ml) estradiol tab 2 mg (Estrace) methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) CONTRACEPTIVES methotrexate sodium inj 50 mg/2ml (25 mg/ml) desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) tamoxifen citrate tab 10 mg (base equivalent) levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ENDOCRINE AND METABOLIC DRUGS levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg CORTICOSTEROIDS levonorgestrel-eth estra tab dexamethasone sod phosphate preservative free inj 0.05-30/0.075-40/0.125-30mg-mcg 10 mg/ml (Dexamethasone sodium) norethindrone & ethinyl estradiol tab 1 mg-35 mcg dexamethasone sodium phosphate inj 4 mg/ml (Ortho-novum 1/35) dexamethasone sodium phosphate inj 20 mg/5ml norethindrone ace & ethinyl estradiol tab dexamethasone sodium phosphate inj 120 mg/30ml 1 mg-20 mcg (Loestrin 1/20-21) dexamethasone sodium phosphate inj 100 mg/10ml norethindrone ace & ethinyl estradiol-fe tab (Loestrin fe 1/20) dexamethasone tab 0.5 mg 1 mg-20 mcg dexamethasone tab 0.75 mg norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30) dexamethasone tab 1.5 mg norethindrone tab 0.35 mg (Ortho micronor) dexamethasone tab 4 mg norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg dexamethasone tab 6 mg (Ortho-cyclen) fludrocortisone acetate tab 0.1 mg norgestimate-eth estrad tab methylprednisolone acetate inj susp 80 mg/ml (Depo- 0.18-25/0.215-25/0.25-25 mg-mcg (Ortho tri-cyclen lo) medrol) norgestimate-eth estrad tab methylprednisolone tab therapy pack 4 mg (21) 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen) (Medrol dosepak) PROGESTINS methylprednisolone tab 4 mg (Medrol) medroxyprogesterone acetate tab 2.5 mg (Provera) methylprednisolone tab 16 mg (Medrol) medroxyprogesterone acetate tab 5 mg (Provera) methylprednisolone tab 32 mg (Medrol) medroxyprogesterone acetate tab 10 mg (Provera) prednisolone sod phosphate oral soln 15 mg/5ml ANTIDIABETICS (base equiv) glimepiride tab 1 mg (Amaryl) prednisone tab therapy pack 5 mg (21) glimepiride tab 2 mg (Amaryl) prednisone tab therapy pack 5 mg (48) glimepiride tab 4 mg (Amaryl) prednisone tab 1 mg glipizide tab er 24hr 2.5 mg (Glucotrol xl) prednisone tab 2.5 mg glipizide tab er 24hr 5 mg (Glucotrol xl) prednisone tab 5 mg glipizide tab er 24hr 10 mg (Glucotrol xl)

2 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021

Drug Name Drug Name glipizide tab 5 mg (Glucotrol) ENDOCRINE and METABOLIC AGENTS - MISC. glipizide tab 10 mg (Glucotrol) alendronate sodium tab 10 mg glucose gel 40% alendronate sodium tab 35 mg glyburide micronized tab 1.5 mg (Glynase) alendronate sodium tab 70 mg (Fosamax) glyburide micronized tab 3 mg (Glynase) calcitriol cap 0.25 mcg (Rocaltrol) glyburide micronized tab 6 mg (Glynase) ibandronate sodium tab 150 mg (base equivalent) glyburide tab 1.25 mg (Boniva) glyburide tab 2.5 mg CARDIOVASCULAR AGENTS glyburide tab 5 mg CARDIOTONICS glyburide-metformin tab 1.25-250 mg digoxin tab 125 mcg (0.125 mg) (Lanoxin) glyburide-metformin tab 2.5-500 mg (Glucovance) digoxin tab 250 mcg (0.25 mg) (Lanoxin) glyburide-metformin tab 5-500 mg (Glucovance) ANTIANGINAL AGENTS metformin hcl tab er 24hr 500 mg (Glucophage xr) isosorbide mononitrate tab er 24hr 30 mg metformin hcl tab er 24hr 750 mg (Glucophage xr) isosorbide mononitrate tab er 24hr 60 mg metformin hcl tab 500 mg (Glucophage) isosorbide mononitrate tab 10 mg metformin hcl tab 850 mg (Glucophage) isosorbide mononitrate tab 20 mg metformin hcl tab 1000 mg (Glucophage) nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur) pioglitazone hcl tab 15 mg (base equiv) (Actos) BETA BLOCKERS pioglitazone hcl tab 30 mg (base equiv) (Actos) atenolol tab 25 mg (Tenormin) pioglitazone hcl tab 45 mg (base equiv) (Actos) atenolol tab 50 mg (Tenormin) THYROID AGENTS atenolol tab 100 mg (Tenormin) levothyroxine sodium tab 25 mcg (Synthroid) carvedilol tab 3.125 mg (Coreg) levothyroxine sodium tab 50 mcg (Synthroid) carvedilol tab 6.25 mg (Coreg) levothyroxine sodium tab 75 mcg (Synthroid) carvedilol tab 12.5 mg (Coreg) levothyroxine sodium tab 88 mcg (Synthroid) carvedilol tab 25 mg (Coreg) levothyroxine sodium tab 100 mcg (Synthroid) labetalol hcl iv soln 5 mg/ml levothyroxine sodium tab 112 mcg (Synthroid) labetalol hcl tab 100 mg levothyroxine sodium tab 125 mcg (Synthroid) metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) levothyroxine sodium tab 137 mcg (Synthroid) metoprolol succinate tab er 24hr 50 mg (tartrate levothyroxine sodium tab 150 mcg (Synthroid) equiv) (Toprol xl) levothyroxine sodium tab 175 mcg (Synthroid) metoprolol succinate tab er 24hr 100 mg (tartrate levothyroxine sodium tab 200 mcg (Synthroid) equiv) (Toprol xl) levothyroxine sodium tab 300 mcg (Synthroid) metoprolol tartrate tab 25 mg methimazole tab 5 mg (Tapazole) metoprolol tartrate tab 50 mg (Lopressor) methimazole tab 10 mg (Tapazole) metoprolol tartrate tab 100 mg (Lopressor) thyroid tab 15 mg (1/4 grain) (Armour thyroid) propranolol hcl tab 10 mg thyroid tab 30 mg (1/2 grain) (Armour thyroid) propranolol hcl tab 20 mg OXYTOCICS propranolol hcl tab 40 mg oxytocin inj 10 unit/ml (Pitocin) sotalol hcl (afib/afl) tab 80 mg (Betapace af)

BCBSNE Preferred Generics (Lower Cost Generics), 2021 3 2021

Drug Name Drug Name sotalol hcl (afib/afl) tab 120 mg (Betapace af) amlodipine besylate-benazepril hcl cap 5-10 mg sotalol hcl (afib/afl) tab 160 mg (Betapace af) (Lotrel) sotalol hcl tab 80 mg (Betapace) amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel) sotalol hcl tab 120 mg (Betapace) amlodipine besylate-benazepril hcl cap 5-40 mg sotalol hcl tab 160 mg (Betapace) amlodipine besylate-benazepril hcl cap 10-20 mg sotalol hcl tab 240 mg (Lotrel) CALCIUM CHANNEL BLOCKERS amlodipine besylate-benazepril hcl cap 10-40 mg amlodipine besylate tab 2.5 mg (Norvasc) (Lotrel) amlodipine besylate tab 5 mg (Norvasc) amlodipine besylate-valsartan tab 5-160 mg (Exforge) amlodipine besylate tab 10 mg (Norvasc) amlodipine besylate-valsartan tab 5-320 mg (Exforge) diltiazem hcl coated beads cap er 24hr 120 mg amlodipine besylate-valsartan tab 10-160 mg (Cardizem cd) (Exforge) diltiazem hcl coated beads cap er 24hr 180 mg atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) (Cardizem cd) benazepril hcl tab 5 mg diltiazem hcl coated beads cap er 24hr 240 mg benazepril hcl tab 10 mg (Cardizem cd) benazepril hcl tab 20 mg (Lotensin) diltiazem hcl extended release beads cap er 24hr 120 mg (Tiazac) benazepril hcl tab 40 mg (Lotensin) diltiazem hcl tab 30 mg (Cardizem) bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) diltiazem hcl tab 60 mg (Cardizem) bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) felodipine tab er 24hr 2.5 mg bisoprolol & hydrochlorothiazide tab 10-6.25 mg felodipine tab er 24hr 5 mg (Ziac) felodipine tab er 24hr 10 mg clonidine hcl tab 0.1 mg (Catapres) nifedipine tab er 24hr 30 mg (Adalat cc) clonidine hcl tab 0.2 mg (Catapres) nifedipine tab er 24hr osmotic release 30 mg clonidine hcl tab 0.3 mg (Catapres) (Procardia xl) doxazosin mesylate tab 1 mg (Cardura) nifedipine tab er 24hr osmotic release 60 mg (Procardia xl) doxazosin mesylate tab 2 mg (Cardura) verapamil hcl tab er 120 mg (Calan sr) doxazosin mesylate tab 4 mg (Cardura) verapamil hcl tab er 180 mg (Calan sr) doxazosin mesylate tab 8 mg (Cardura) verapamil hcl tab er 240 mg (Calan sr) enalapril maleate & hydrochlorothiazide tab 5-12.5 mg verapamil hcl tab 40 mg enalapril maleate & hydrochlorothiazide tab 10-25 mg verapamil hcl tab 80 mg (Calan) (Vaseretic) verapamil hcl tab 120 mg (Calan) enalapril maleate tab 2.5 mg (Vasotec) ANTIARRHYTHMICS enalapril maleate tab 5 mg (Vasotec) amiodarone hcl inj 150 mg/3ml (50 mg/ml) enalapril maleate tab 10 mg (Vasotec) amiodarone hcl tab 200 mg enalapril maleate tab 20 mg (Vasotec) propafenone hcl tab 150 mg fosinopril sodium tab 10 mg ANTIHYPERTENSIVES fosinopril sodium tab 20 mg amlodipine besylate-benazepril hcl cap 2.5-10 mg fosinopril sodium tab 40 mg hydralazine hcl tab 10 mg

4 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021

Drug Name Drug Name hydralazine hcl tab 25 mg olmesartan medoxomil-hydrochlorothiazide tab hydralazine hcl tab 50 mg 40-25 mg (Benicar hct) hydralazine hcl tab 100 mg perindopril erbumine tab 2 mg irbesartan tab 75 mg (Avapro) perindopril erbumine tab 4 mg irbesartan tab 150 mg (Avapro) quinapril hcl tab 5 mg (Accupril) irbesartan tab 300 mg (Avapro) quinapril hcl tab 10 mg (Accupril) irbesartan-hydrochlorothiazide tab 150-12.5 mg quinapril hcl tab 20 mg (Accupril) (Avalide) quinapril hcl tab 40 mg (Accupril) irbesartan-hydrochlorothiazide tab 300-12.5 mg ramipril cap 1.25 mg (Altace) (Avalide) ramipril cap 2.5 mg (Altace) lisinopril & hydrochlorothiazide tab 10-12.5 mg ramipril cap 5 mg (Altace) (Zestoretic) ramipril cap 10 mg (Altace) lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) telmisartan tab 80 mg (Micardis) lisinopril & hydrochlorothiazide tab 20-25 mg terazosin hcl cap 1 mg (Zestoretic) terazosin hcl cap 2 mg lisinopril tab 2.5 mg (Zestril) terazosin hcl cap 5 mg lisinopril tab 5 mg (Prinivil) terazosin hcl cap 10 mg lisinopril tab 10 mg (Prinivil) trandolapril tab 1 mg lisinopril tab 20 mg (Prinivil) trandolapril tab 2 mg lisinopril tab 30 mg (Zestril) trandolapril tab 4 mg lisinopril tab 40 mg (Zestril) valsartan tab 40 mg (Diovan) losartan potassium & hydrochlorothiazide tab valsartan tab 80 mg (Diovan) (Hyzaar) 50-12.5 mg valsartan tab 160 mg (Diovan) losartan potassium & hydrochlorothiazide tab valsartan tab 320 mg (Diovan) 100-12.5 mg (Hyzaar) valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan losartan potassium & hydrochlorothiazide tab hct) 100-25 mg (Hyzaar) valsartan-hydrochlorothiazide tab 160-12.5 mg losartan potassium tab 25 mg (Cozaar) (Diovan hct) (Cozaar) losartan potassium tab 50 mg valsartan-hydrochlorothiazide tab 160-25 mg (Diovan losartan potassium tab 100 mg (Cozaar) hct) tab 250 mg valsartan-hydrochlorothiazide tab 320-12.5 mg minoxidil tab 2.5 mg (Diovan hct) minoxidil tab 10 mg valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) olmesartan medoxomil tab 5 mg (Benicar) DIURETICS olmesartan medoxomil tab 20 mg (Benicar) amiloride & hydrochlorothiazide tab 5-50 mg olmesartan medoxomil tab 40 mg (Benicar) amiloride hcl tab 5 mg olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg (Benicar hct) chlorthalidone tab 25 mg olmesartan medoxomil-hydrochlorothiazide tab furosemide inj 10 mg/ml 40-12.5 mg (Benicar hct) furosemide oral soln 10 mg/ml furosemide tab 20 mg (Lasix)

BCBSNE Preferred Generics (Lower Cost Generics), 2021 5 2021

Drug Name Drug Name furosemide tab 40 mg (Lasix) pravastatin sodium tab 10 mg furosemide tab 80 mg (Lasix) pravastatin sodium tab 20 mg (Pravachol) hydrochlorothiazide cap 12.5 mg (Microzide) pravastatin sodium tab 40 mg (Pravachol) hydrochlorothiazide tab 12.5 mg pravastatin sodium tab 80 mg (Pravachol) hydrochlorothiazide tab 25 mg rosuvastatin calcium tab 5 mg (Crestor) hydrochlorothiazide tab 50 mg rosuvastatin calcium tab 10 mg (Crestor) indapamide tab 1.25 mg rosuvastatin calcium tab 20 mg (Crestor) indapamide tab 2.5 mg rosuvastatin calcium tab 40 mg (Crestor) spironolactone tab 25 mg (Aldactone) simvastatin tab 5 mg (Zocor) spironolactone tab 50 mg (Aldactone) simvastatin tab 10 mg (Zocor) spironolactone tab 100 mg (Aldactone) simvastatin tab 20 mg (Zocor) torsemide tab 5 mg simvastatin tab 40 mg (Zocor) torsemide tab 10 mg (Demadex) simvastatin tab 80 mg (Zocor) torsemide tab 20 mg (Demadex) RESPIRATORY AGENTS torsemide tab 100 mg ANTIHISTAMINES triamterene & hydrochlorothiazide cap 37.5-25 mg cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) (Dyazide) cetirizine hcl tab 5 mg triamterene & hydrochlorothiazide tab 37.5-25 mg cetirizine hcl tab 10 mg (Maxzide-25) cyproheptadine hcl tab 4 mg triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) diphenhydramine hcl cap 25 mg VASOPRESSORS diphenhydramine hcl cap 50 mg epinephrine pf inj 1 mg/ml diphenhydramine hcl liquid 12.5 mg/5ml epinephrine soln prefilled syringe 1 mg/10ml (0.1 mg/ diphenhydramine hcl tab disint 12.5 mg ml) diphenhydramine hcl tab 25 mg ANTIHYPERLIPIDEMICS fexofenadine hcl susp 30 mg/5ml (6 mg/ml) atorvastatin calcium tab 10 mg (base equivalent) fexofenadine hcl tab 180 mg (Lipitor) levocetirizine dihydrochloride tab 5 mg atorvastatin calcium tab 20 mg (base equivalent) loratadine chew tab 5 mg (Lipitor) loratadine rapidly-disintegrating tab 10 mg (Claritin) atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) loratadine syrup 5 mg/5ml atorvastatin calcium tab 80 mg (base equivalent) loratadine tab 10 mg (Lipitor) promethazine hcl syrup 6.25 mg/5ml fenofibrate tab 48 mg (Tricor) promethazine hcl tab 12.5 mg fenofibrate tab 54 mg (Lofibra) promethazine hcl tab 25 mg fenofibrate tab 145 mg (Tricor) promethazine hcl tab 50 mg fenofibrate tab 160 mg NASAL AGENTS - SYSTEMIC and TOPICAL gemfibrozil tab 600 mg (Lopid) azelastine hcl nasal spray 0.1% (137 mcg/spray) lovastatin tab 10 mg cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) lovastatin tab 20 mg nasal susp 50 mcg/act lovastatin tab 40 mg

6 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021

Drug Name Drug Name oxymetazoline hcl nasal soln 0.05% sodium chloride soln nebu 0.9% hcl liq 15 mg/5ml sodium chloride soln nebu 3% pseudoephedrine hcl tab er 12hr 120 mg sodium chloride soln nebu 7% (Hypersal) pseudoephedrine hcl tab 30 mg triprolidine & pseudoephedrine tab 2.5-60 mg pseudoephedrine hcl tab 60 mg ANTIASTHMATIC and BRONCHODILATOR AGENTS saline nasal spray 0.65% albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) triamcinolone acetonide nasal aerosol suspension albuterol sulfate syrup 2 mg/5ml 55 mcg/act ipratropium bromide inhal soln 0.02% COUGH/COLD/ALLERGY montelukast sodium chew tab 4 mg (base equiv) benzonatate cap 100 mg (Tessalon perles) (Singulair) benzonatate cap 200 mg montelukast sodium chew tab 5 mg (base equiv) brompheniramine & elixir 1-2.5 mg/5ml (Singulair) brompheniramine & pseudoephedrine elixir montelukast sodium tab 10 mg (base equiv) 1-15 mg/5ml (Singulair) cetirizine-pseudoephedrine tab er 12hr 5-120 mg terbutaline sulfate inj 1 mg/ml chlorpheniramine & phenylephrine tab 4-10 mg GASTROINTESTINAL AGENTS chlorpheniramine & pseudoephedrine tab 4-60 mg LAXATIVES dextromethorphan polistirex extended release susp bisacodyl suppos 10 mg 30 mg/5ml bisacodyl tab delayed release 5 mg dextromethorphan-guaifenesin cap 10-200 mg docusate sodium cap 100 mg dextromethorphan-guaifenesin liquid 10-100 mg/5ml docusate sodium cap 250 mg dextromethorphan-guaifenesin syrup 10-100 mg/5ml docusate sodium liquid 150 mg/15ml dextromethorphan-guaifenesin tab er 12hr 30-600 mg docusate sodium syrup 60 mg/15ml fexofenadine-pseudoephedrine tab er 12hr 60-120 mg glycerin suppos 1 gm guaifenesin liquid 100 mg/5ml magnesium citrate soln guaifenesin syrup 100 mg/5ml peg 3350-kcl-sod bicarb-nacl for soln 420 gm guaifenesin tab er 12hr 600 mg (Nulytely/flavor pack) guaifenesin-codeine soln 100-10 mg/5ml peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) hydrocodone w/ homatropine syrup 5-1.5 mg/5ml polyethylene glycol 3350 oral powder loratadine & pseudoephedrine tab er 12hr 5-120 mg psyllium cap 0.52 gm loratadine & pseudoephedrine tab er 24hr 10-240 mg sennosides syrup 8.8 mg/5ml phenylephrine w/ dm-gg liqd 10-18-200 mg/15ml sennosides tab 8.6 mg phenylephrine-brompheniramine-dm liquid 2.5-1-5 mg/5ml sennosides-docusate sodium tab 8.6-50 mg promethazine w/ codeine syrup 6.25-10 mg/5ml ANTIDIARRHEALS promethazine-dm syrup 6.25-15 mg/5ml lactobacillus cap pseudoephedrine-guaifenesin tab er 12hr 60-600 mg loperamide hcl liq 1 mg/7.5ml pseudoephedrine-guaifenesin tab 40-400 mg loperamide hcl liq 1 mg/5ml (0.2 mg/ml) pseudoephedrine-ibuprofen tab 30-200 mg loperamide hcl tab 2 mg pseudoephedrine-naproxen sodium tab er 12hr ANTACIDS 120-220 mg

BCBSNE Preferred Generics (Lower Cost Generics), 2021 7 2021

Drug Name Drug Name alum & mag hydroxide-simethicone susp ondansetron hcl inj 4 mg/2ml (2 mg/ml) 200-200-20 mg/5ml ondansetron hcl inj 40 mg/20ml (2 mg/ml) alum & mag hydroxide-simethicone susp ondansetron hcl tab 4 mg (Zofran) 400-400-40 mg/5ml ondansetron hcl tab 8 mg (Zofran) aluminum hydroxide-magnesium carbonate susp 95-358 mg/15ml ondansetron orally disintegrating tab 4 mg (Zofran odt) aluminum hydroxide-magnesium carbonate susp 508-475 mg/10ml ondansetron orally disintegrating tab 8 mg (Zofran odt) calcium carbonate (antacid) chew tab 500 mg GASTROINTESTINAL AGENTS- MISC. calcium carbonate (antacid) chew tab 750 mg metoclopramide hcl tab 5 mg (Reglan) calcium carbonate (antacid) susp 1250 mg/5ml metoclopramide hcl tab 10 mg (Reglan) magnesium oxide tab 400 mg simethicone susp 40 mg/0.6ml sodium bicarbonate tab 650 mg GENITOURINARY AGENTS ULCER DRUGS URINARY ANTISPASMODICS atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ml) oxybutynin chloride syrup 5 mg/5ml dicyclomine hcl cap 10 mg (Bentyl) oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) dicyclomine hcl tab 20 mg oxybutynin chloride tab er 24hr 10 mg (Ditropan xl) famotidine inj 40 mg/4ml oxybutynin chloride tab er 24hr 15 mg famotidine tab 20 mg (Pepcid) oxybutynin chloride tab 5 mg famotidine tab 40 mg (Pepcid) VAGINAL PRODUCTS hyoscyamine sulfate elixir 0.125 mg/5ml clotrimazole vaginal cream 1% hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl) clotrimazole vaginal cream 2% hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) miconazole nitrate vaginal cream 2% cap delayed release 30 mg (Prevacid) GENITOURINARY AGENTS - MISC. misoprostol tab 100 mcg (Cytotec) acetic acid irrigation soln 0.25% misoprostol tab 200 mcg (Cytotec) alfuzosin hcl tab er 24hr 10 mg (Uroxatral) cap delayed release 10 mg dutasteride cap 0.5 mg (Avodart) omeprazole cap delayed release 20 mg finasteride tab 5 mg (Proscar) omeprazole cap delayed release 40 mg phenazopyridine hcl tab 100 mg (Pyridium) omeprazole delayed release tab 20 mg phenazopyridine hcl tab 200 mg (Pyridium) omeprazole magnesium cap dr 20.6 mg (20 mg base equiv) sodium chloride irrigation soln 0.9% sodium ec tab 20 mg (base equiv) tamsulosin hcl cap 0.4 mg (Flomax) (Protonix) CENTRAL NERVOUS SYSTEM DRUGS pantoprazole sodium ec tab 40 mg (base equiv) ANTIANXIETY AGENTS (Protonix) alprazolam tab er 24hr 0.5 mg (Xanax xr) hcl tab 75 mg alprazolam tab er 24hr 1 mg (Xanax xr) (Zantac) ranitidine hcl tab 150 mg alprazolam tab 0.25 mg (Xanax) ANTIEMETICS alprazolam tab 0.5 mg (Xanax) meclizine hcl tab 12.5 mg alprazolam tab 1 mg (Xanax) meclizine hcl tab 25 mg alprazolam tab 2 mg (Xanax)

8 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021

Drug Name Drug Name buspirone hcl tab 5 mg duloxetine hcl enteric coated pellets cap 60 mg (base buspirone hcl tab 10 mg eq) (Cymbalta) buspirone hcl tab 15 mg escitalopram oxalate tab 5 mg (base equiv) (Lexapro) chlordiazepoxide hcl cap 5 mg escitalopram oxalate tab 10 mg (base equiv) (Lexapro) chlordiazepoxide hcl cap 10 mg escitalopram oxalate tab 20 mg (base equiv) (Lexapro) chlordiazepoxide hcl cap 25 mg fluoxetine hcl cap 10 mg (Prozac) diazepam tab 2 mg (Valium) fluoxetine hcl cap 20 mg (Prozac) diazepam tab 5 mg (Valium) fluoxetine hcl cap 40 mg (Prozac) diazepam tab 10 mg (Valium) imipramine hcl tab 10 mg (Tofranil) hydroxyzine hcl syrup 10 mg/5ml imipramine hcl tab 25 mg (Tofranil) hydroxyzine hcl tab 10 mg imipramine hcl tab 50 mg (Tofranil) hydroxyzine hcl tab 25 mg mirtazapine tab 15 mg (Remeron) hydroxyzine hcl tab 50 mg mirtazapine tab 30 mg (Remeron) hydroxyzine pamoate cap 25 mg (Vistaril) mirtazapine tab 45 mg (Remeron) hydroxyzine pamoate cap 50 mg (Vistaril) nortriptyline hcl cap 10 mg (Pamelor) lorazepam inj 2 mg/ml (Ativan) nortriptyline hcl cap 25 mg (Pamelor) lorazepam tab 0.5 mg (Ativan) nortriptyline hcl cap 50 mg (Pamelor) lorazepam tab 1 mg (Ativan) nortriptyline hcl cap 75 mg (Pamelor) lorazepam tab 2 mg (Ativan) hcl tab 10 mg (Paxil) ANTIDEPRESSANTS paroxetine hcl tab 20 mg (Paxil) amitriptyline hcl tab 10 mg paroxetine hcl tab 30 mg (Paxil) amitriptyline hcl tab 25 mg (Elavil) paroxetine hcl tab 40 mg (Paxil) amitriptyline hcl tab 50 mg sertraline hcl tab 25 mg (Zoloft) hcl tab er 12hr 100 mg (Wellbutrin sr) sertraline hcl tab 50 mg (Zoloft) bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) sertraline hcl tab 100 mg (Zoloft) bupropion hcl tab er 12hr 200 mg (Wellbutrin sr) trazodone hcl tab 50 mg bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) trazodone hcl tab 100 mg bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) trazodone hcl tab 150 mg citalopram hydrobromide tab 10 mg (base equiv) hcl cap er 24hr 37.5 mg (base equivalent) (Celexa) (Effexor xr) citalopram hydrobromide tab 20 mg (base equiv) venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Celexa) (Effexor xr) citalopram hydrobromide tab 40 mg (base equiv) venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Celexa) (Effexor xr) doxepin hcl cap 10 mg venlafaxine hcl tab 25 mg doxepin hcl conc 10 mg/ml venlafaxine hcl tab 37.5 mg duloxetine hcl enteric coated pellets cap 20 mg (base venlafaxine hcl tab 50 mg eq) (Cymbalta) venlafaxine hcl tab 75 mg duloxetine hcl enteric coated pellets cap 30 mg (base venlafaxine hcl tab 100 mg eq) (Cymbalta) ANTIPSYCHOTICS

BCBSNE Preferred Generics (Lower Cost Generics), 2021 9 2021

Drug Name Drug Name haloperidol lactate inj 5 mg/ml (Haldol) midazolam hcl inj pf 10 mg/2ml (base equivalent) haloperidol lactate oral conc 2 mg/ml midazolam hcl inj 2 mg/2ml (base equivalent) haloperidol tab 0.5 mg midazolam hcl inj 5 mg/ml (base equivalent) haloperidol tab 1 mg midazolam hcl inj 10 mg/2ml (base equivalent) haloperidol tab 2 mg midazolam hcl inj 50 mg/10ml (base equivalent) lithium carbonate cap 150 mg (Lithium carbonate) midazolam hcl syrup 2 mg/ml (base equivalent) lithium carbonate cap 300 mg phenobarbital tab 15 mg lithium carbonate cap 600 mg (Lithium carbonate) phenobarbital tab 30 mg lithium carbonate tab er 300 mg (Lithobid) phenobarbital tab 60 mg lithium carbonate tab er 450 mg phenobarbital tab 100 mg lithium carbonate tab 300 mg temazepam cap 15 mg (Restoril) olanzapine tab 2.5 mg (Zyprexa) temazepam cap 30 mg (Restoril) olanzapine tab 5 mg (Zyprexa) zaleplon cap 5 mg (Sonata) olanzapine tab 7.5 mg (Zyprexa) zaleplon cap 10 mg (Sonata) olanzapine tab 10 mg (Zyprexa) zolpidem tartrate tab 5 mg (Ambien) olanzapine tab 15 mg (Zyprexa) zolpidem tartrate tab 10 mg (Ambien) olanzapine tab 20 mg (Zyprexa) ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ prochlorperazine maleate tab 5 mg (base equivalent) ANOREXIANTS prochlorperazine maleate tab 10 mg (base equivalent) dexmethylphenidate hcl tab 2.5 mg (Focalin) quetiapine fumarate tab 25 mg (Seroquel) diethylpropion hcl tab 25 mg (Diethylpropion hcl) quetiapine fumarate tab 50 mg (Seroquel) hcl tab 5 mg (Ritalin) quetiapine fumarate tab 100 mg (Seroquel) phendimetrazine tartrate tab 35 mg quetiapine fumarate tab 200 mg (Seroquel) hcl cap 15 mg quetiapine fumarate tab 300 mg (Seroquel) phentermine hcl cap 30 mg quetiapine fumarate tab 400 mg (Seroquel) phentermine hcl cap 37.5 mg (Adipex-p) risperidone tab 0.25 mg (Risperdal) phentermine hcl tab 37.5 mg (Adipex-p) risperidone tab 0.5 mg (Risperdal) PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. risperidone tab 1 mg (Risperdal) donepezil hydrochloride orally disintegrating tab risperidone tab 2 mg (Risperdal) 5 mg risperidone tab 3 mg (Risperdal) donepezil hydrochloride orally disintegrating tab risperidone tab 4 mg (Risperdal) 10 mg HYPNOTICS donepezil hydrochloride tab 5 mg (Aricept) diphenhydramine hcl (sleep) tab 25 mg donepezil hydrochloride tab 10 mg (Aricept) doxylamine succinate (sleep) tab 25 mg memantine hcl tab 5 mg (Namenda) eszopiclone tab 1 mg (Lunesta) memantine hcl tab 10 mg (Namenda) eszopiclone tab 2 mg (Lunesta) ANALGESICS AND ANESTHETICS eszopiclone tab 3 mg (Lunesta) ANALGESICS - NON-NARCOTIC midazolam hcl inj pf 5 mg/ml (base equivalent) acetaminophen cap 500 mg midazolam hcl inj pf 2 mg/2ml (base equivalent) acetaminophen chew tab 160 mg

10 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021

Drug Name Drug Name acetaminophen disintegrating tab 80 mg oxycodone w/ acetaminophen tab 5-325 mg (Percocet) acetaminophen liquid 160 mg/5ml tramadol hcl tab 50 mg (Ultram) acetaminophen soln 160 mg/5ml tramadol-acetaminophen tab 37.5-325 mg (Ultracet) acetaminophen suppos 120 mg ANALGESICS - ANTI-INFLAMMATORY acetaminophen suppos 650 mg celecoxib cap 50 mg (Celebrex) acetaminophen susp 160 mg/5ml celecoxib cap 100 mg (Celebrex) acetaminophen tab er 650 mg celecoxib cap 200 mg (Celebrex) acetaminophen tab 325 mg diclofenac sodium tab delayed release 50 mg acetaminophen tab 500 mg diclofenac sodium tab delayed release 75 mg aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg ibuprofen susp 100 mg/5ml aspirin chew tab 81 mg ibuprofen tab 200 mg aspirin tab delayed release 81 mg ibuprofen tab 400 mg aspirin tab delayed release 325 mg ibuprofen tab 600 mg aspirin tab 325 mg ibuprofen tab 800 mg aspirin-acetaminophen-caffeine tab 250-250-65 mg indomethacin cap 25 mg ANALGESICS - NARCOTIC indomethacin cap 50 mg acetaminophen w/ codeine soln 120-12 mg/5ml ketorolac tromethamine im inj 60 mg/2ml (30 mg/ml) acetaminophen w/ codeine tab 300-15 mg (Tylenol/ ketorolac tromethamine inj 15 mg/ml codeine) ketorolac tromethamine inj 30 mg/ml acetaminophen w/ codeine tab 300-30 mg (Tylenol/ meloxicam tab 7.5 mg (Mobic) codeine #3) meloxicam tab 15 mg (Mobic) fentanyl citrate preservative free (pf) inj 250 mcg/5ml (Fentanyl citrate) nabumetone tab 500 mg hydrocodone-acetaminophen tab 10-325 mg nabumetone tab 750 mg hydrocodone-acetaminophen tab 5-325 mg (Norco) naproxen tab ec 375 mg (Ec-naprosyn) hydrocodone-acetaminophen tab 7.5-325 mg (Norco) naproxen tab ec 500 mg (Ec-naprosyn) hydromorphone hcl tab 2 mg (Dilaudid) naproxen tab 250 mg hydromorphone hcl tab 4 mg (Dilaudid) naproxen tab 375 mg meperidine hcl inj 25 mg/ml (Demerol) naproxen tab 500 mg (Naprosyn) meperidine hcl inj 50 mg/ml (Demerol) sulindac tab 150 mg meperidine hcl inj 100 mg/ml (Demerol) sulindac tab 200 mg methadone hcl tab 5 mg (Dolophine) MIGRAINE PRODUCTS methadone hcl tab 10 mg (Dolophine) rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt) morphine sulfate iv soln pf 4 mg/ml (Morphine sulfate) rizatriptan benzoate oral disintegrating tab 10 mg morphine sulfate iv soln pf 10 mg/ml (Morphine (base eq) (Maxalt-mlt) sulfate) rizatriptan benzoate tab 5 mg (base equivalent) morphine sulfate oral soln 10 mg/5ml (Maxalt) morphine sulfate tab er 15 mg (Ms contin) rizatriptan benzoate tab 10 mg (base equivalent) oxycodone hcl tab 5 mg (Roxicodone) (Maxalt) oxycodone hcl tab 10 mg sumatriptan succinate tab 25 mg (Imitrex)

BCBSNE Preferred Generics (Lower Cost Generics), 2021 11 2021

Drug Name Drug Name sumatriptan succinate tab 50 mg (Imitrex) tab 25 mg (Lamictal) sumatriptan succinate tab 100 mg (Imitrex) lamotrigine tab 100 mg (Lamictal) GOUT AGENTS lamotrigine tab 150 mg (Lamictal) tab 100 mg (Zyloprim) lamotrigine tab 200 mg (Lamictal) allopurinol tab 300 mg (Zyloprim) levetiracetam inj 500 mg/5ml (100 mg/ml) (Keppra) LOCAL ANESTHETICS - PARENTERAL levetiracetam tab 250 mg (Keppra) bupivacaine hcl inj 0.5% (Marcaine) levetiracetam tab 500 mg (Keppra) bupivacaine hcl preservative free (pf) inj 0.25% oxcarbazepine tab 150 mg (Trileptal) (Marcaine) primidone tab 50 mg (Mysoline) bupivacaine hcl preservative free (pf) inj 0.5% primidone tab 250 mg (Mysoline) (Marcaine) topiramate tab 25 mg (Topamax) lidocaine hcl local inj 0.5% (Xylocaine) topiramate tab 50 mg (Topamax) lidocaine hcl local inj 1% (Xylocaine) topiramate tab 100 mg (Topamax) lidocaine hcl local inj 2% (Xylocaine) topiramate tab 200 mg (Topamax) lidocaine hcl local preservative free (pf) inj 0.5% (Xylocaine-mpf) zonisamide cap 25 mg (Zonegran) lidocaine hcl local preservative free (pf) inj 1% zonisamide cap 50 mg (Xylocaine-mpf) ANTIPARKINSON AGENTS lidocaine inj 1% w/ epinephrine-1:100000 (Xylocaine/ amantadine hcl syrup 50 mg/5ml epinephrin) benztropine mesylate tab 0.5 mg (Xylocaine- lidocaine inj 1.5% w/ epinephrine-1:200000 benztropine mesylate tab 1 mg mpf/epinep) benztropine mesylate tab 2 mg lidocaine inj 2% w/ epinephrine-1:200000 (Xylocaine- mpf/epinep) carbidopa & levodopa tab 10-100 mg (Sinemet) lidocaine inj 2% w/ epinephrine-1:100000 (Xylocaine/ carbidopa & levodopa tab 25-100 mg (Sinemet) epinephrin) pramipexole dihydrochloride tab 0.125 mg (Mirapex) NEUROMUSCULAR DRUGS pramipexole dihydrochloride tab 0.25 mg (Mirapex) ANTICONVULSANTS pramipexole dihydrochloride tab 0.5 mg (Mirapex) clonazepam tab 0.5 mg (Klonopin) pramipexole dihydrochloride tab 0.75 mg (Mirapex) clonazepam tab 1 mg (Klonopin) pramipexole dihydrochloride tab 1 mg (Mirapex) clonazepam tab 2 mg (Klonopin) pramipexole dihydrochloride tab 1.5 mg (Mirapex) divalproex sodium tab delayed release 125 mg ropinirole hydrochloride tab 0.25 mg (Requip) (Depakote) ropinirole hydrochloride tab 0.5 mg (Requip) divalproex sodium tab delayed release 250 mg ropinirole hydrochloride tab 1 mg (Requip) (Depakote) ropinirole hydrochloride tab 2 mg (Requip) divalproex sodium tab delayed release 500 mg (Depakote) ropinirole hydrochloride tab 3 mg (Requip) gabapentin cap 100 mg (Neurontin) ropinirole hydrochloride tab 4 mg (Requip) gabapentin cap 300 mg (Neurontin) ropinirole hydrochloride tab 5 mg (Requip) gabapentin cap 400 mg (Neurontin) trihexyphenidyl hcl tab 2 mg gabapentin tab 600 mg (Neurontin) trihexyphenidyl hcl tab 5 mg gabapentin tab 800 mg (Neurontin) MUSCULOSKELETAL THERAPY AGENTS

12 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021

Drug Name Drug Name baclofen tab 10 mg pyridoxine hcl tab 25 mg carisoprodol tab 350 mg (Soma) pyridoxine hcl tab 50 mg cyclobenzaprine hcl tab 5 mg pyridoxine hcl tab 100 mg cyclobenzaprine hcl tab 10 mg riboflavin tab 25 mg methocarbamol tab 500 mg (Robaxin) riboflavin tab 100 mg methocarbamol tab 750 mg (Robaxin-750) thiamine hcl tab 50 mg orphenadrine citrate tab er 12hr 100 mg thiamine hcl tab 100 mg tizanidine hcl tab 2 mg (base equivalent) vitamin a cap 2400 mcg (8000 unit) tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) vitamin a cap 3 mg (10000 unit) NUTRITIONAL PRODUCTS vitamin e cap 400 unit VITAMINS vitamin e cap 1000 unit ascorbic acid chew tab 250 mg vitamin e cap 180 mg ascorbic acid tab 250 mg MULTIVITAMINS ascorbic acid tab 500 mg b-complex vitamin cap ascorbic acid tab 1000 mg b-complex vitamin tab biotin cap 2.5 mg b-complex w/ c & folic acid cap 1 mg biotin cap 5 mg b-complex w/ c & folic acid tab 0.8 mg biotin tab 1000 mcg b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) cholecalciferol cap 10 mcg (400 unit) b-complex w/ c & folic acid tab 5 mg cholecalciferol cap 25 mcg (1000 unit) b-complex w/ folic acid tab cholecalciferol cap 50 mcg (2000 unit) multiple vitamin tab cholecalciferol cap 125 mcg (5000 unit) multiple vitamins w/ minerals cap cholecalciferol cap 250 mcg (10000 unit) multiple vitamins w/ minerals chew tab cholecalciferol cap 1.25 mg (50000 unit) multiple vitamins w/ minerals tab (Strovite forte) cholecalciferol chew tab 10 mcg (400 unit) pediatric multiple vitamin w/ c & fa chew tab cholecalciferol chew tab 25 mcg (1000 unit) pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ cholecalciferol drops 5000 unit/ml (1000 unit/0.2ml) ml cholecalciferol oral liquid 400 unit/ml pediatric multiple vitamins w/ fluoride chew tab 0.5 mg cholecalciferol tab 10 mcg (400 unit) pediatric multiple vitamins w/ fluoride chew tab 1 mg cholecalciferol tab 25 mcg (1000 unit) pediatric multiple vitamins w/ fluoride soln 0.25 mg/ cholecalciferol tab 50 mcg (2000 unit) ml cholecalciferol tab 125 mcg (5000 unit) pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml cholecalciferol tab 1.25 mg (50000 unit) pediatric multiple vitamins w/ iron chew tab 15 mg ergocalciferol cap 1.25 mg (50000 unit) (Drisdol) pediatric multiple vitamins w/ iron chew tab 18 mg niacin cap er 500 mg pediatric vitamins acd w/ fluoride soln 0.25 mg/ml niacin tab er 500 mg pediatric vitamins acd w/ fluoride soln 0.5 mg/ml niacin tab 100 mg MINERALS and ELECTROLYTES niacin tab 500 mg calcium carbonate tab 600 mg phytonadione inj 1 mg/0.5ml (2 mg/ml) calcium carbonate tab 1500 mg (600 mg elemental ca)

BCBSNE Preferred Generics (Lower Cost Generics), 2021 13 2021

Drug Name Drug Name calcium carbonate-cholecalciferol chew tab potassium chloride microencapsulated crys er tab 10 500 mg-400 unit meq calcium carbonate-cholecalciferol tab 500 mg-125 potassium chloride microencapsulated crys er tab 20 unit meq calcium carbonate-cholecalciferol tab 500 mg-200 potassium chloride tab er 8 meq (600 mg) unit potassium chloride tab er 10 meq (K-tab) calcium carbonate-cholecalciferol tab 500 mg-400 sodium chloride flush iv soln 0.9% unit sodium chloride inj 2.5 meq/ml (14.6%) calcium carbonate-cholecalciferol tab 600 mg-200 unit sodium chloride iv soln 0.45% calcium carbonate-cholecalciferol tab 600 mg-400 sodium chloride iv soln 0.9% unit sodium chloride tab 1 gm calcium carbonate-cholecalciferol tab 600 mg-800 sodium fluoride chew tab 0.25 mg f (from 0.55 mg unit naf) calcium carbonate-vitamin d chew tab 600 mg-400 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) unit sodium fluoride chew tab 1 mg f (from 2.2 mg naf) calcium carbonate-vitamin d tab 500 mg-200 unit sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) calcium carbonate-vitamin d tab 500 mg-400 unit zinc gluconate tab 50 mg (elemental zn) calcium carbonate-vitamin d tab 600 mg-200 unit zinc sulfate cap 220 mg (50 mg elemental zn) calcium chloride inj 10% NUTRIENTS calcium citrate tab 950 mg (200 mg elemental ca) dextrose inj 5% calcium citrate-vitamin d tab 200 mg-250 unit omega-3 fatty acids cap 1000 mg (elemental ca) HEMATOLOGICAL AGENTS calcium citrate-vitamin d tab 315 mg-200 unit (elemental ca) HEMATOPOIETIC AGENTS calcium citrate-vitamin d tab 315 mg-250 unit carbonyl iron susp 15 mg/1.25ml (elemental iron) (elemental ca) cobalamin combination sl tab dextrose 5% w/ sodium chloride 0.45% cyanocobalamin inj 1000 mcg/ml dextrose 5% w/ sodium chloride 0.9% cyanocobalamin sl tab 500 mcg lactated ringer's solution cyanocobalamin sl tab 1000 mcg magnesium chloride tab dr 64 mg (elemental mg) cyanocobalamin sl tab 2500 mcg magnesium oxide cap 500 mg (elemental mg) cyanocobalamin tab er 1000 mcg magnesium oxide tab 400 mg (240 mg elemental mg) cyanocobalamin tab 100 mcg magnesium oxide tab 400 mg (241.3 mg cyanocobalamin tab 250 mcg elemental mg) cyanocobalamin tab 500 mcg magnesium oxide tab 250 mg (mg supplement) cyanocobalamin tab 1000 mcg magnesium oxide tab 500 mg (mg supplement) fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn- magnesium tab 250 mg cu cap oral electrolyte solution fe fumarate w/ b12-vit c-fa-ifc cap oyster shell calcium tab 500 mg 110-0.015-75-0.5-240 mg potassium & sodium phosphates powder pack fe fumarate-vit c-vit b12-fa cap 460 (151 280-160-250 mg fe)-60-0.01-1 mg potassium bicarbonate effer tab 25 meq ferrous fumarate tab 324 mg (106 mg elemental fe)

14 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021

Drug Name Drug Name ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab sodium tab 10 mg (Coumadin) 106-1 mg HEMATOLOGICAL AGENTS - MISC. ferrous fumarate-folic acid tab 324-1 mg albumin, human inj 5% ferrous gluconate tab 240 mg (27 mg elemental fe) cilostazol tab 50 mg ferrous gluconate tab 324 mg (37.5 mg elemental cilostazol tab 100 mg iron) clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) TOPICAL PRODUCTS ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) OPHTHALMIC AGENTS ferrous sulfate tab ec 325 mg (65 mg fe equivalent) azelastine hcl ophth soln 0.05% ferrous sulfate tab er 142 mg (45 mg fe equivalent) bacitracin- ophth oint ferrous sulfate tab er 143 mg (45 mg fe equivalent) brimonidine tartrate ophth soln 0.2% ferrous sulfate tab 325 mg (65 mg elemental fe) ciprofloxacin hcl ophth soln 0.3% (Ciloxan) folic acid cap 0.8 mg cromolyn sodium ophth soln 4% folic acid tab 400 mcg cyclopentolate hcl ophth soln 1% (Cyclogyl) folic acid tab 800 mcg dextran 70-hypromellose ophth soln 0.1-0.3% folic acid tab 1 mg diclofenac sodium ophth soln 0.1% folic acid-vitamin b6- tab 2.2-25-0.5 mg dorzolamide hcl ophth soln 2% (Trusopt) folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg dorzolamide hcl-timolol maleate ophth soln (Folgard rx) 22.3-6.8 mg/ml (Cosopt) folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg erythromycin ophth oint 5 mg/gm iron polysacch complex-vit b12-fa cap gentamicin sulfate ophth soln 0.3% 150-0.025-1 mg glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1% iron-docusate-b12-folic acid-c-e-cu-biotin tab ketorolac tromethamine ophth soln 0.5% (Acular) (Hematron-af) 150-1 mg ketotifen fumarate ophth soln 0.025% (base equiv) iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg latanoprost ophth soln 0.005% (Xalatan) (Icar-c plus) neomycin-polymyxin-dexamethasone ophth oint iron-vitamin c tab 100-250 mg 0.1% (Maxitrol) polysaccharide iron complex cap 150 mg (iron neomycin-polymyxin-dexamethasone ophth susp equivalent) 0.1% (Maxitrol) polymyxin b-trimethoprim ophth soln 10000 unit/ heparin sodium (porcine) lock flush iv soln 10 unit/ml ml-0.1% (Polytrim) heparin sodium (porcine) lock flush iv soln 100 unit/ tetracaine hcl ophth soln 0.5% ml timolol maleate ophth soln 0.25% (Timoptic) (Coumadin) warfarin sodium tab 1 mg timolol maleate ophth soln 0.5% (Timoptic) (Coumadin) warfarin sodium tab 2 mg tobramycin ophth soln 0.3% (Tobrex) (Coumadin) warfarin sodium tab 2.5 mg tropicamide ophth soln 0.5% (Coumadin) warfarin sodium tab 3 mg tropicamide ophth soln 1% (Mydriacyl) (Coumadin) warfarin sodium tab 4 mg white petrolatum-mineral oil ophth ointment (Coumadin) warfarin sodium tab 5 mg OTIC AGENTS (Coumadin) warfarin sodium tab 6 mg carbamide peroxide 6.5% otic soln warfarin sodium tab 7.5 mg (Coumadin)

BCBSNE Preferred Generics (Lower Cost Generics), 2021 15 2021

Drug Name Drug Name MOUTH/THROAT/DENTAL AGENTS permethrin lotion 1% chlorhexidine gluconate soln 0.12% (Peridex) salicylic acid soln 17% lidocaine hcl viscous soln 2% selenium sulfide lotion 2.5% sodium fluoride cream 1.1% (Prevident 5000 plus) silver sulfadiazine cream 1% (Silvadene) sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) skin protectants misc - liquid sodium fluoride paste 1.1% (Prevident 5000 boost) skin protectants misc - lotion sodium fluoride-potassium nitrate paste 1.1-5% terbinafine hcl cream 1% (Prevident 5000 sensi) triamcinolone acetonide cream 0.025% ANORECTAL AGENTS triamcinolone acetonide cream 0.1% phenylephrine-mineral oil-petrolatum oint triamcinolone acetonide cream 0.5% 0.25-14-74.9% triamcinolone acetonide oint 0.025% DERMATOLOGICALS triamcinolone acetonide oint 0.1% bacitracin oint 500 unit/gm triamcinolone acetonide oint 0.5% bacitracin zinc oint 500 unit/gm trolamine salicylate cream 10% bacitracin-polymyxin b oint urea cream 20% benzoyl peroxide gel 5% urea lotion 10% benzoyl peroxide gel 10% zinc oxide oint 20% benzoyl peroxide liq 10% MISCELLANEOUS PRODUCTS betamethasone dipropionate augmented cream 0.05% (Diprolene af) ANTISEPTICS & DISINFECTANTS clotrimazole cream 1% povidone-iodine soln 10% emollient - cream ANTIDOTES emollient - ointment deferoxamine mesylate for inj 500 mg (Desferal) finasteride tab 1 mg (Propecia) ALTERNATIVE MEDICINES glycerin topical liquid melatonin tab 3 mg hydrocortisone cream 1% melatonin tab 5 mg hydrocortisone cream 2.5% prasterone (dhea) tab 25 mg hydrocortisone oint 1% CHEMICALS hydrocortisone oint 2.5% alcohol, rubbing 70% ketoconazole shampoo 1% isopropyl alcohol, rubbing 70% ketoconazole shampoo 2% (Nizoral) PHARMACEUTICAL ADJUVANTS lidocaine hcl cream 4% lanolin ointment lubricant gels - gel water for injection menthol gel 4% water for iv injection miconazole nitrate cream 2% white petrolatum gel mometasone furoate oint 0.1% (Elocon) white petrolatum topical gel mupirocin oint 2% ASSORTED CLASSES neomycin-bacitracin-polymyxin oint cyclosporine iv soln 50 mg/ml (Sandimmune) nystatin cream 100000 unit/gm water for irrigation, sterile irrigation soln nystatin oint 100000 unit/gm

16 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021

amitriptyline hcl tab 50 mg...... 9 INDEX amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel)...... 4 A amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel)...... 4 acetaminophen cap 500 mg...... 10 amlodipine besylate-benazepril hcl cap 2.5-10 mg...... 4 acetaminophen chew tab 160 mg...... 10 amlodipine besylate-benazepril hcl cap 5-10 mg acetaminophen disintegrating tab 80 mg...... 11 (Lotrel)...... 4 acetaminophen liquid 160 mg/5ml...... 11 amlodipine besylate-benazepril hcl cap 5-20 mg acetaminophen soln 160 mg/5ml...... 11 (Lotrel)...... 4 acetaminophen suppos 120 mg...... 11 amlodipine besylate-benazepril hcl cap 5-40 mg...... 4 acetaminophen suppos 650 mg...... 11 amlodipine besylate tab 10 mg (Norvasc)...... 4 acetaminophen susp 160 mg/5ml...... 11 amlodipine besylate tab 2.5 mg (Norvasc)...... 4 acetaminophen tab 325 mg...... 11 amlodipine besylate tab 5 mg (Norvasc)...... 4 acetaminophen tab 500 mg...... 11 amlodipine besylate-valsartan tab 10-160 mg acetaminophen tab er 650 mg...... 11 (Exforge)...... 4 acetaminophen w/ codeine soln 120-12 mg/5ml...... 11 amlodipine besylate-valsartan tab 5-160 mg acetaminophen w/ codeine tab 300-15 mg (Tylenol/ (Exforge)...... 4 codeine)...... 11 amlodipine besylate-valsartan tab 5-320 mg acetaminophen w/ codeine tab 300-30 mg (Tylenol/ (Exforge)...... 4 codeine #3)...... 11 amoxicillin (trihydrate) cap 250 mg...... 1 acetic acid irrigation soln 0.25%...... 8 amoxicillin (trihydrate) cap 500 mg...... 1 acyclovir cap 200 mg (Zovirax)...... 1 amoxicillin (trihydrate) for susp 125 mg/5ml...... 1 acyclovir tab 400 mg (Zovirax)...... 1 amoxicillin (trihydrate) for susp 200 mg/5ml...... 1 acyclovir tab 800 mg (Zovirax)...... 1 amoxicillin (trihydrate) for susp 250 mg/5ml...... 1 albumin, human inj 5%...... 15 amoxicillin (trihydrate) for susp 400 mg/5ml...... 1 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)...... 7 amoxicillin (trihydrate) tab 500 mg...... 1 albuterol sulfate syrup 2 mg/5ml...... 7 amoxicillin (trihydrate) tab 875 mg...... 1 alcohol, rubbing 70%...... 16 amoxicillin & k clavulanate for susp 200-28.5 alendronate sodium tab 10 mg...... 3 mg/5ml...... 1 alendronate sodium tab 35 mg...... 3 amoxicillin & k clavulanate tab 500-125 mg alendronate sodium tab 70 mg (Fosamax)...... 3 (Augmentin)...... 1 alfuzosin hcl tab er 24hr 10 mg (Uroxatral)...... 8 amoxicillin & k clavulanate tab 875-125 mg allopurinol tab 100 mg (Zyloprim)...... 12 (Augmentin)...... 1 allopurinol tab 300 mg (Zyloprim)...... 12 anastrozole tab 1 mg (Arimidex)...... 2 alprazolam tab 0.25 mg (Xanax)...... 8 ascorbic acid chew tab 250 mg...... 13 alprazolam tab 0.5 mg (Xanax)...... 8 ascorbic acid tab 1000 mg...... 13 alprazolam tab 1 mg (Xanax)...... 8 ascorbic acid tab 250 mg...... 13 alprazolam tab 2 mg (Xanax)...... 8 ascorbic acid tab 500 mg...... 13 alprazolam tab er 24hr 0.5 mg (Xanax xr)...... 8 aspirin-acetaminophen-caffeine tab 250-250-65 alprazolam tab er 24hr 1 mg (Xanax xr)...... 8 mg...... 11 alum & mag hydroxide-simethicone susp 200-200-20 aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg/5ml...... 8 mg...... 11 alum & mag hydroxide-simethicone susp 400-400-40 aspirin chew tab 81 mg...... 11 mg/5ml...... 8 aspirin tab 325 mg...... 11 aluminum hydroxide-magnesium carbonate susp aspirin tab delayed release 325 mg...... 11 508-475 mg/10ml...... 8 aspirin tab delayed release 81 mg...... 11 aluminum hydroxide-magnesium carbonate susp atenolol & chlorthalidone tab 50-25 mg (Tenoretic 95-358 mg/15ml...... 8 50)...... 4 amantadine hcl syrup 50 mg/5ml...... 12 atenolol tab 100 mg (Tenormin)...... 3 amiloride & hydrochlorothiazide tab 5-50 mg...... 5 atenolol tab 25 mg (Tenormin)...... 3 amiloride hcl tab 5 mg...... 5 atenolol tab 50 mg (Tenormin)...... 3 amiodarone hcl inj 150 mg/3ml (50 mg/ml)...... 4 atorvastatin calcium tab 10 mg (base equivalent) amiodarone hcl tab 200 mg...... 4 (Lipitor)...... 6 amitriptyline hcl tab 10 mg...... 9 atorvastatin calcium tab 20 mg (base equivalent) amitriptyline hcl tab 25 mg (Elavil)...... 9 (Lipitor)...... 6

BCBSNE Preferred Generics (Lower Cost Generics), 2021 17 2021 atorvastatin calcium tab 40 mg (base equivalent) brompheniramine & pseudoephedrine elixir 1-15 (Lipitor)...... 6 mg/5ml...... 7 atorvastatin calcium tab 80 mg (base equivalent) bupivacaine hcl inj 0.5% (Marcaine)...... 12 (Lipitor)...... 6 bupivacaine hcl preservative free (pf) inj 0.25% atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ (Marcaine)...... 12 ml)...... 8 bupivacaine hcl preservative free (pf) inj 0.5% azelastine hcl nasal spray 0.1% (137 mcg/spray)...... 6 (Marcaine)...... 12 azelastine hcl ophth soln 0.05%...... 15 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)...... 9 azithromycin tab 250 mg (Zithromax)...... 1 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)...... 9 azithromycin tab 500 mg (Zithromax)...... 1 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)...... 9 ...... 9 B bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)...... 9 bacitracin intramuscular for soln 50000 unit...... 1 buspirone hcl tab 10 mg...... 9 bacitracin oint 500 unit/gm...... 16 buspirone hcl tab 15 mg...... 9 bacitracin-polymyxin b oint...... 16 buspirone hcl tab 5 mg...... 9 bacitracin-polymyxin b ophth oint...... 15 bacitracin zinc oint 500 unit/gm...... 16 C baclofen tab 10 mg...... 13 calcitriol cap 0.25 mcg (Rocaltrol)...... 3 b-complex vitamin cap...... 13 calcium carbonate (antacid) chew tab 500 mg...... 8 b-complex vitamin tab...... 13 calcium carbonate (antacid) chew tab 750 mg...... 8 b-complex w/ c & folic acid cap 1 mg...... 13 calcium carbonate (antacid) susp 1250 mg/5ml...... 8 b-complex w/ c & folic acid tab 0.8 mg...... 13 calcium carbonate-cholecalciferol chew tab 500 b-complex w/ c & folic acid tab 1 mg (Nephro-vite mg-400 unit...... 14 rx)...... 13 calcium carbonate-cholecalciferol tab 500 mg-125 b-complex w/ c & folic acid tab 5 mg...... 13 unit...... 14 b-complex w/ folic acid tab...... 13 calcium carbonate-cholecalciferol tab 500 mg-200 benazepril hcl tab 10 mg...... 4 unit...... 14 benazepril hcl tab 20 mg (Lotensin)...... 4 calcium carbonate-cholecalciferol tab 500 mg-400 benazepril hcl tab 40 mg (Lotensin)...... 4 unit...... 14 benazepril hcl tab 5 mg...... 4 calcium carbonate-cholecalciferol tab 600 mg-200 benzonatate cap 100 mg (Tessalon perles)...... 7 unit...... 14 benzonatate cap 200 mg...... 7 calcium carbonate-cholecalciferol tab 600 mg-400 benzoyl peroxide gel 10%...... 16 unit...... 14 benzoyl peroxide gel 5%...... 16 calcium carbonate-cholecalciferol tab 600 mg-800 benzoyl peroxide liq 10%...... 16 unit...... 14 benztropine mesylate tab 0.5 mg...... 12 calcium carbonate tab 1500 mg (600 mg elemental benztropine mesylate tab 1 mg...... 12 ca)...... 13 benztropine mesylate tab 2 mg...... 12 calcium carbonate tab 600 mg...... 13 betamethasone dipropionate augmented cream 0.05% calcium carbonate-vitamin d chew tab 600 mg-400 (Diprolene af)...... 16 unit...... 14 bicalutamide tab 50 mg (Casodex)...... 2 calcium carbonate-vitamin d tab 500 mg-200 unit...... 14 biotin cap 2.5 mg...... 13 calcium carbonate-vitamin d tab 500 mg-400 unit...... 14 biotin cap 5 mg...... 13 calcium carbonate-vitamin d tab 600 mg-200 unit...... 14 biotin tab 1000 mcg...... 13 calcium chloride inj 10%...... 14 bisacodyl suppos 10 mg...... 7 calcium citrate tab 950 mg (200 mg elemental ca)...... 14 bisacodyl tab delayed release 5 mg...... 7 calcium citrate-vitamin d tab 200 mg-250 unit bisoprolol & hydrochlorothiazide tab 10-6.25 mg (elemental ca)...... 14 (Ziac)...... 4 calcium citrate-vitamin d tab 315 mg-200 unit bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (elemental ca)...... 14 (Ziac)...... 4 calcium citrate-vitamin d tab 315 mg-250 unit bisoprolol & hydrochlorothiazide tab 5-6.25 mg (elemental ca)...... 14 (Ziac)...... 4 carbamide peroxide 6.5% otic soln...... 15 brimonidine tartrate ophth soln 0.2%...... 15 carbidopa & levodopa tab 10-100 mg (Sinemet)...... 12 brompheniramine & phenylephrine elixir 1-2.5 carbidopa & levodopa tab 25-100 mg (Sinemet)...... 12 mg/5ml...... 7 carbonyl iron susp 15 mg/1.25ml (elemental iron)...... 14 carisoprodol tab 350 mg (Soma)...... 13

18 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021 carvedilol tab 12.5 mg (Coreg)...... 3 clindamycin hcl cap 300 mg (Cleocin)...... 1 carvedilol tab 25 mg (Coreg)...... 3 clindamycin phosphate inj 9 gm/60ml (Cleocin carvedilol tab 3.125 mg (Coreg)...... 3 phosphate)...... 1 carvedilol tab 6.25 mg (Coreg)...... 3 clonazepam tab 0.5 mg (Klonopin)...... 12 cefadroxil cap 500 mg...... 1 clonazepam tab 1 mg (Klonopin)...... 12 cefazolin sodium for inj 10 gm...... 1 clonazepam tab 2 mg (Klonopin)...... 12 cefazolin sodium for inj 500 mg...... 1 clonidine hcl tab 0.1 mg (Catapres)...... 4 cefdinir cap 300 mg...... 1 clonidine hcl tab 0.2 mg (Catapres)...... 4 ceftriaxone sodium for inj 1 gm...... 1 clonidine hcl tab 0.3 mg (Catapres)...... 4 ceftriaxone sodium for inj 250 mg...... 1 clopidogrel bisulfate tab 75 mg (base equiv) ceftriaxone sodium for iv soln 2 gm...... 1 (Plavix)...... 15 celecoxib cap 100 mg (Celebrex)...... 11 clotrimazole cream 1%...... 16 celecoxib cap 200 mg (Celebrex)...... 11 clotrimazole vaginal cream 1%...... 8 celecoxib cap 50 mg (Celebrex)...... 11 clotrimazole vaginal cream 2%...... 8 cephalexin cap 250 mg (Keflex)...... 1 cobalamin combination sl tab...... 14 cephalexin cap 500 mg (Keflex)...... 1 cromolyn sodium nasal aerosol soln 5.2 mg/act cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...... 6 (4%)...... 6 cetirizine hcl tab 10 mg...... 6 cromolyn sodium ophth soln 4%...... 15 cetirizine hcl tab 5 mg...... 6 cyanocobalamin inj 1000 mcg/ml...... 14 cetirizine-pseudoephedrine tab er 12hr 5-120 mg...... 7 cyanocobalamin sl tab 1000 mcg...... 14 chlordiazepoxide hcl cap 10 mg...... 9 cyanocobalamin sl tab 2500 mcg...... 14 chlordiazepoxide hcl cap 25 mg...... 9 cyanocobalamin sl tab 500 mcg...... 14 chlordiazepoxide hcl cap 5 mg...... 9 cyanocobalamin tab 1000 mcg...... 14 chlorhexidine gluconate soln 0.12% (Peridex)...... 16 cyanocobalamin tab 100 mcg...... 14 chlorpheniramine & phenylephrine tab 4-10 mg...... 7 cyanocobalamin tab 250 mcg...... 14 chlorpheniramine & pseudoephedrine tab 4-60 mg...... 7 cyanocobalamin tab 500 mcg...... 14 chlorthalidone tab 25 mg...... 5 cyanocobalamin tab er 1000 mcg...... 14 cholecalciferol cap 1.25 mg (50000 unit)...... 13 cyclobenzaprine hcl tab 10 mg...... 13 cholecalciferol cap 10 mcg (400 unit)...... 13 cyclobenzaprine hcl tab 5 mg...... 13 cholecalciferol cap 125 mcg (5000 unit)...... 13 cyclopentolate hcl ophth soln 1% (Cyclogyl)...... 15 cholecalciferol cap 250 mcg (10000 unit)...... 13 cyclosporine iv soln 50 mg/ml (Sandimmune)...... 16 cholecalciferol cap 25 mcg (1000 unit)...... 13 cyproheptadine hcl tab 4 mg...... 6 cholecalciferol cap 50 mcg (2000 unit)...... 13 cytarabine inj pf 100 mg/ml...... 2 ...... 13 cholecalciferol chew tab 10 mcg (400 unit) D cholecalciferol chew tab 25 mcg (1000 unit)...... 13 cholecalciferol drops 5000 unit/ml (1000 deferoxamine mesylate for inj 500 mg (Desferal)...... 16 unit/0.2ml)...... 13 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg cholecalciferol oral liquid 400 unit/ml...... 13 (Desogen)...... 2 cholecalciferol tab 1.25 mg (50000 unit)...... 13 dexamethasone sodium phosphate inj 100 mg/10ml..... 2 cholecalciferol tab 10 mcg (400 unit)...... 13 dexamethasone sodium phosphate inj 120 mg/30ml..... 2 cholecalciferol tab 125 mcg (5000 unit)...... 13 dexamethasone sodium phosphate inj 20 mg/5ml...... 2 cholecalciferol tab 25 mcg (1000 unit)...... 13 dexamethasone sodium phosphate inj 4 mg/ml...... 2 cholecalciferol tab 50 mcg (2000 unit)...... 13 dexamethasone sod phosphate preservative free inj cilostazol tab 100 mg...... 15 10 mg/ml (Dexamethasone sodium)...... 2 cilostazol tab 50 mg...... 15 dexamethasone tab 0.5 mg...... 2 ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...... 15 dexamethasone tab 0.75 mg...... 2 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...... 1 dexamethasone tab 1.5 mg...... 2 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...... 1 dexamethasone tab 4 mg...... 2 ciprofloxacin hcl tab 750 mg (base equiv)...... 1 dexamethasone tab 6 mg...... 2 citalopram hydrobromide tab 10 mg (base equiv) dexmethylphenidate hcl tab 2.5 mg (Focalin)...... 10 (Celexa)...... 9 dextran 70-hypromellose ophth soln 0.1-0.3%...... 15 citalopram hydrobromide tab 20 mg (base equiv) dextromethorphan-guaifenesin cap 10-200 mg...... 7 (Celexa)...... 9 dextromethorphan-guaifenesin liquid 10-100 citalopram hydrobromide tab 40 mg (base equiv) mg/5ml...... 7 (Celexa)...... 9 dextromethorphan-guaifenesin syrup 10-100 clindamycin hcl cap 150 mg (Cleocin)...... 1 mg/5ml...... 7

BCBSNE Preferred Generics (Lower Cost Generics), 2021 19 2021 dextromethorphan-guaifenesin tab er 12hr 30-600 doxazosin mesylate tab 8 mg (Cardura)...... 4 mg...... 7 doxepin hcl cap 10 mg...... 9 dextromethorphan polistirex extended release susp 30 doxepin hcl conc 10 mg/ml...... 9 mg/5ml...... 7 doxycycline hyclate cap 100 mg (Vibramycin)...... 1 dextrose 5% w/ sodium chloride 0.45%...... 14 doxycycline hyclate tab 100 mg...... 1 dextrose 5% w/ sodium chloride 0.9%...... 14 doxycycline monohydrate cap 100 mg (Monodox)...... 1 dextrose inj 5%...... 14 doxycycline monohydrate cap 50 mg...... 1 diazepam tab 10 mg (Valium)...... 9 doxylamine succinate (sleep) tab 25 mg...... 10 diazepam tab 2 mg (Valium)...... 9 duloxetine hcl enteric coated pellets cap 20 mg (base diazepam tab 5 mg (Valium)...... 9 eq) (Cymbalta)...... 9 diclofenac sodium ophth soln 0.1%...... 15 duloxetine hcl enteric coated pellets cap 30 mg (base diclofenac sodium tab delayed release 50 mg...... 11 eq) (Cymbalta)...... 9 diclofenac sodium tab delayed release 75 mg...... 11 duloxetine hcl enteric coated pellets cap 60 mg (base dicyclomine hcl cap 10 mg (Bentyl)...... 8 eq) (Cymbalta)...... 9 dicyclomine hcl tab 20 mg...... 8 dutasteride cap 0.5 mg (Avodart)...... 8 ...... 10 diethylpropion hcl tab 25 mg (Diethylpropion hcl) E digoxin tab 125 mcg (0.125 mg) (Lanoxin)...... 3 digoxin tab 250 mcg (0.25 mg) (Lanoxin)...... 3 emollient - cream...... 16 diltiazem hcl coated beads cap er 24hr 120 mg emollient - ointment...... 16 (Cardizem cd)...... 4 enalapril maleate & hydrochlorothiazide tab 10-25 mg diltiazem hcl coated beads cap er 24hr 180 mg (Vaseretic)...... 4 (Cardizem cd)...... 4 enalapril maleate & hydrochlorothiazide tab 5-12.5 diltiazem hcl coated beads cap er 24hr 240 mg mg...... 4 (Cardizem cd)...... 4 enalapril maleate tab 10 mg (Vasotec)...... 4 diltiazem hcl extended release beads cap er 24hr 120 enalapril maleate tab 2.5 mg (Vasotec)...... 4 mg (Tiazac)...... 4 enalapril maleate tab 20 mg (Vasotec)...... 4 diltiazem hcl tab 30 mg (Cardizem)...... 4 enalapril maleate tab 5 mg (Vasotec)...... 4 diltiazem hcl tab 60 mg (Cardizem)...... 4 epinephrine pf inj 1 mg/ml...... 6 diphenhydramine hcl (sleep) tab 25 mg...... 10 epinephrine soln prefilled syringe 1 mg/10ml (0.1 mg/ diphenhydramine hcl cap 25 mg...... 6 ml)...... 6 diphenhydramine hcl cap 50 mg...... 6 ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)...... 13 diphenhydramine hcl liquid 12.5 mg/5ml...... 6 erythromycin ophth oint 5 mg/gm...... 15 diphenhydramine hcl tab 25 mg...... 6 escitalopram oxalate tab 10 mg (base equiv) diphenhydramine hcl tab disint 12.5 mg...... 6 (Lexapro)...... 9 divalproex sodium tab delayed release 125 mg escitalopram oxalate tab 20 mg (base equiv) (Depakote)...... 12 (Lexapro)...... 9 divalproex sodium tab delayed release 250 mg escitalopram oxalate tab 5 mg (base equiv) (Depakote)...... 12 (Lexapro)...... 9 divalproex sodium tab delayed release 500 mg estradiol tab 0.5 mg (Estrace)...... 2 (Depakote)...... 12 estradiol tab 1 mg (Estrace)...... 2 docusate sodium cap 100 mg...... 7 estradiol tab 2 mg (Estrace)...... 2 docusate sodium cap 250 mg...... 7 eszopiclone tab 1 mg (Lunesta)...... 10 docusate sodium liquid 150 mg/15ml...... 7 eszopiclone tab 2 mg (Lunesta)...... 10 docusate sodium syrup 60 mg/15ml...... 7 eszopiclone tab 3 mg (Lunesta)...... 10 donepezil hydrochloride orally disintegrating tab 10 F mg...... 10 ...... 1 donepezil hydrochloride orally disintegrating tab 5 famciclovir tab 125 mg ...... 8 mg...... 10 famotidine inj 40 mg/4ml ...... 8 donepezil hydrochloride tab 10 mg (Aricept)...... 10 famotidine tab 20 mg (Pepcid) ...... 8 donepezil hydrochloride tab 5 mg (Aricept)...... 10 famotidine tab 40 mg (Pepcid) dorzolamide hcl ophth soln 2% (Trusopt)...... 15 fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 ...... 14 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg mg/ml (Cosopt)...... 15 fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 ...... 14 doxazosin mesylate tab 1 mg (Cardura)...... 4 mg doxazosin mesylate tab 2 mg (Cardura)...... 4 fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu ...... 14 doxazosin mesylate tab 4 mg (Cardura)...... 4 cap

20 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021 felodipine tab er 24hr 10 mg...... 4 furosemide tab 80 mg (Lasix)...... 6 ...... 4 felodipine tab er 24hr 2.5 mg G felodipine tab er 24hr 5 mg...... 4 fenofibrate tab 145 mg (Tricor)...... 6 gabapentin cap 100 mg (Neurontin)...... 12 fenofibrate tab 160 mg...... 6 gabapentin cap 300 mg (Neurontin)...... 12 fenofibrate tab 48 mg (Tricor)...... 6 gabapentin cap 400 mg (Neurontin)...... 12 fenofibrate tab 54 mg (Lofibra)...... 6 gabapentin tab 600 mg (Neurontin)...... 12 fentanyl citrate preservative free (pf) inj 250 mcg/5ml gabapentin tab 800 mg (Neurontin)...... 12 (Fentanyl citrate)...... 11 gemfibrozil tab 600 mg (Lopid)...... 6 ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab gentamicin sulfate inj 40 mg/ml...... 1 106-1 mg...... 15 gentamicin sulfate ophth soln 0.3%...... 15 ferrous fumarate-folic acid tab 324-1 mg...... 15 glimepiride tab 1 mg (Amaryl)...... 2 ferrous fumarate tab 324 mg (106 mg elemental fe)..... 14 glimepiride tab 2 mg (Amaryl)...... 2 ferrous gluconate tab 240 mg (27 mg elemental fe)..... 15 glimepiride tab 4 mg (Amaryl)...... 2 ferrous gluconate tab 324 mg (37.5 mg elemental glipizide tab 10 mg (Glucotrol)...... 3 iron)...... 15 glipizide tab 5 mg (Glucotrol)...... 3 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental glipizide tab er 24hr 10 mg (Glucotrol xl)...... 2 fe)...... 15 glipizide tab er 24hr 2.5 mg (Glucotrol xl)...... 2 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental glipizide tab er 24hr 5 mg (Glucotrol xl)...... 2 fe)...... 15 glucose gel 40%...... 3 ferrous sulfate tab 325 mg (65 mg elemental fe)...... 15 glyburide-metformin tab 1.25-250 mg...... 3 ferrous sulfate tab ec 325 mg (65 mg fe glyburide-metformin tab 2.5-500 mg (Glucovance)...... 3 equivalent)...... 15 glyburide-metformin tab 5-500 mg (Glucovance)...... 3 ferrous sulfate tab er 142 mg (45 mg fe equivalent)..... 15 glyburide micronized tab 1.5 mg (Glynase)...... 3 ferrous sulfate tab er 143 mg (45 mg fe equivalent)..... 15 glyburide micronized tab 3 mg (Glynase)...... 3 fexofenadine hcl susp 30 mg/5ml (6 mg/ml)...... 6 glyburide micronized tab 6 mg (Glynase)...... 3 fexofenadine hcl tab 180 mg...... 6 glyburide tab 1.25 mg...... 3 fexofenadine-pseudoephedrine tab er 12hr 60-120 glyburide tab 2.5 mg...... 3 mg...... 7 glyburide tab 5 mg...... 3 finasteride tab 1 mg (Propecia)...... 16 glycerin-hypromellose-peg 400 ophth soln finasteride tab 5 mg (Proscar)...... 8 0.2-0.2-1%...... 15 fluconazole tab 100 mg (Diflucan)...... 1 glycerin suppos 1 gm...... 7 fluconazole tab 150 mg (Diflucan)...... 1 glycerin topical liquid...... 16 fluconazole tab 200 mg (Diflucan)...... 1 guaifenesin-codeine soln 100-10 mg/5ml...... 7 fluconazole tab 50 mg (Diflucan)...... 1 guaifenesin liquid 100 mg/5ml...... 7 fludrocortisone acetate tab 0.1 mg...... 2 guaifenesin syrup 100 mg/5ml...... 7 fluorouracil iv soln 5 gm/100ml (50 mg/ml)...... 2 guaifenesin tab er 12hr 600 mg...... 7 fluoxetine hcl cap 10 mg (Prozac)...... 9 H fluoxetine hcl cap 20 mg (Prozac)...... 9 ...... 10 fluoxetine hcl cap 40 mg (Prozac)...... 9 haloperidol lactate inj 5 mg/ml (Haldol) ...... 10 fluticasone propionate nasal susp 50 mcg/act...... 6 haloperidol lactate oral conc 2 mg/ml ...... 10 folic acid cap 0.8 mg...... 15 haloperidol tab 0.5 mg ...... 10 folic acid tab 1 mg...... 15 haloperidol tab 1 mg ...... 10 folic acid tab 400 mcg...... 15 haloperidol tab 2 mg folic acid tab 800 mcg...... 15 heparin sodium (porcine) lock flush iv soln 100 unit/ ...... 15 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..... 15 ml folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg heparin sodium (porcine) lock flush iv soln 10 unit/ ...... 15 (Folgard rx)...... 15 ml ...... 5 folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 15 hydralazine hcl tab 100 mg ...... 4 fosinopril sodium tab 10 mg...... 4 hydralazine hcl tab 10 mg ...... 5 fosinopril sodium tab 20 mg...... 4 hydralazine hcl tab 25 mg ...... 5 fosinopril sodium tab 40 mg...... 4 hydralazine hcl tab 50 mg ...... 6 furosemide inj 10 mg/ml...... 5 hydrochlorothiazide cap 12.5 mg (Microzide) ...... 6 furosemide oral soln 10 mg/ml...... 5 hydrochlorothiazide tab 12.5 mg ...... 6 furosemide tab 20 mg (Lasix)...... 5 hydrochlorothiazide tab 25 mg ...... 6 furosemide tab 40 mg (Lasix)...... 6 hydrochlorothiazide tab 50 mg

BCBSNE Preferred Generics (Lower Cost Generics), 2021 21 2021 hydrocodone-acetaminophen tab 10-325 mg...... 11 isosorbide mononitrate tab 20 mg...... 3 hydrocodone-acetaminophen tab 5-325 mg isosorbide mononitrate tab er 24hr 30 mg...... 3 (Norco)...... 11 isosorbide mononitrate tab er 24hr 60 mg...... 3 hydrocodone-acetaminophen tab 7.5-325 mg J (Norco)...... 11 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 7 K hydrocortisone cream 1%...... 16 ...... 16 hydrocortisone cream 2.5%...... 16 ketoconazole shampoo 1% ...... 16 hydrocortisone oint 1%...... 16 ketoconazole shampoo 2% (Nizoral) hydrocortisone oint 2.5%...... 16 ketorolac tromethamine im inj 60 mg/2ml (30 mg/ ...... 11 hydromorphone hcl tab 2 mg (Dilaudid)...... 11 ml) ...... 11 hydromorphone hcl tab 4 mg (Dilaudid)...... 11 ketorolac tromethamine inj 15 mg/ml ...... 11 hydroxyzine hcl syrup 10 mg/5ml...... 9 ketorolac tromethamine inj 30 mg/ml ...... 15 hydroxyzine hcl tab 10 mg...... 9 ketorolac tromethamine ophth soln 0.5% (Acular) ..... 15 hydroxyzine hcl tab 25 mg...... 9 ketotifen fumarate ophth soln 0.025% (base equiv) hydroxyzine hcl tab 50 mg...... 9 L hydroxyzine pamoate cap 25 mg (Vistaril)...... 9 labetalol hcl iv soln 5 mg/ml...... 3 hydroxyzine pamoate cap 50 mg (Vistaril)...... 9 labetalol hcl tab 100 mg...... 3 hyoscyamine sulfate elixir 0.125 mg/5ml...... 8 lactated ringer's solution...... 14 hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl)...... 8 lactobacillus cap...... 7 hyoscyamine sulfate tab disint 0.125 mg (Anaspaz)...... 8 lamotrigine tab 100 mg (Lamictal)...... 12 I lamotrigine tab 150 mg (Lamictal)...... 12 ...... 12 ibandronate sodium tab 150 mg (base equivalent) lamotrigine tab 200 mg (Lamictal) ...... 12 (Boniva)...... 3 lamotrigine tab 25 mg (Lamictal) ...... 16 ibuprofen susp 100 mg/5ml...... 11 lanolin ointment ...... 8 ibuprofen tab 200 mg...... 11 lansoprazole cap delayed release 30 mg (Prevacid) ...... 15 ibuprofen tab 400 mg...... 11 latanoprost ophth soln 0.005% (Xalatan) ...... 2 ibuprofen tab 600 mg...... 11 letrozole tab 2.5 mg (Femara) ..... 12 ibuprofen tab 800 mg...... 11 levetiracetam inj 500 mg/5ml (100 mg/ml) (Keppra) ...... 12 imipramine hcl tab 10 mg (Tofranil)...... 9 levetiracetam tab 250 mg (Keppra) ...... 12 imipramine hcl tab 25 mg (Tofranil)...... 9 levetiracetam tab 500 mg (Keppra) ...... 6 imipramine hcl tab 50 mg (Tofranil)...... 9 levocetirizine dihydrochloride tab 5 mg ...... 1 indapamide tab 1.25 mg...... 6 levofloxacin tab 250 mg (Levaquin) ...... 1 indapamide tab 2.5 mg...... 6 levofloxacin tab 500 mg (Levaquin) ...... 1 indomethacin cap 25 mg...... 11 levofloxacin tab 750 mg (Levaquin) indomethacin cap 50 mg...... 11 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 ...... 2 ipratropium bromide inhal soln 0.02%...... 7 mcg irbesartan-hydrochlorothiazide tab 150-12.5 mg levonorgestrel & ethinyl estradiol tab 0.1 mg-20 ...... 2 (Avalide)...... 5 mcg irbesartan-hydrochlorothiazide tab 300-12.5 mg levonorgestrel-eth estra tab ...... 2 (Avalide)...... 5 0.05-30/0.075-40/0.125-30mg-mcg ...... 3 irbesartan tab 150 mg (Avapro)...... 5 levothyroxine sodium tab 100 mcg (Synthroid) ...... 3 irbesartan tab 300 mg (Avapro)...... 5 levothyroxine sodium tab 112 mcg (Synthroid) ...... 3 irbesartan tab 75 mg (Avapro)...... 5 levothyroxine sodium tab 125 mcg (Synthroid) ...... 3 iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 levothyroxine sodium tab 137 mcg (Synthroid) ...... 3 mg (Hematron-af)...... 15 levothyroxine sodium tab 150 mcg (Synthroid) ...... 3 iron polysacch complex-vit b12-fa cap 150-0.025-1 levothyroxine sodium tab 175 mcg (Synthroid) ...... 3 mg...... 15 levothyroxine sodium tab 200 mcg (Synthroid) ...... 3 iron-vitamin c tab 100-250 mg...... 15 levothyroxine sodium tab 25 mcg (Synthroid) ...... 3 iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg levothyroxine sodium tab 300 mcg (Synthroid) ...... 3 (Icar-c plus)...... 15 levothyroxine sodium tab 50 mcg (Synthroid) ...... 3 isoniazid tab 100 mg...... 1 levothyroxine sodium tab 75 mcg (Synthroid) ...... 3 isoniazid tab 300 mg...... 1 levothyroxine sodium tab 88 mcg (Synthroid) ...... 16 isopropyl alcohol, rubbing 70%...... 16 lidocaine hcl cream 4% ...... 12 isosorbide mononitrate tab 10 mg...... 3 lidocaine hcl local inj 0.5% (Xylocaine)

22 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021 lidocaine hcl local inj 1% (Xylocaine)...... 12 losartan potassium tab 50 mg (Cozaar)...... 5 lidocaine hcl local inj 2% (Xylocaine)...... 12 lovastatin tab 10 mg...... 6 lidocaine hcl local preservative free (pf) inj 0.5% lovastatin tab 20 mg...... 6 (Xylocaine-mpf)...... 12 lovastatin tab 40 mg...... 6 lidocaine hcl local preservative free (pf) inj 1% lubricant gels - gel...... 16 ...... 12 (Xylocaine-mpf) M lidocaine hcl viscous soln 2%...... 16 lidocaine inj 1.5% w/ epinephrine-1:200000 (Xylocaine- magnesium chloride tab dr 64 mg (elemental mg)...... 14 mpf/epinep)...... 12 magnesium citrate soln...... 7 lidocaine inj 1% w/ epinephrine-1:100000 (Xylocaine/ magnesium oxide cap 500 mg (elemental mg)...... 14 epinephrin)...... 12 magnesium oxide tab 250 mg (mg supplement)...... 14 lidocaine inj 2% w/ epinephrine-1:100000 (Xylocaine/ magnesium oxide tab 400 mg...... 8 epinephrin)...... 12 magnesium oxide tab 400 mg (240 mg elemental lidocaine inj 2% w/ epinephrine-1:200000 (Xylocaine- mg)...... 14 mpf/epinep)...... 12 magnesium oxide tab 400 mg (241.3 mg elemental lisinopril & hydrochlorothiazide tab 10-12.5 mg mg)...... 14 (Zestoretic)...... 5 magnesium oxide tab 500 mg (mg supplement)...... 14 lisinopril & hydrochlorothiazide tab 20-12.5 mg magnesium tab 250 mg...... 14 (Zestoretic)...... 5 meclizine hcl tab 12.5 mg...... 8 lisinopril & hydrochlorothiazide tab 20-25 mg meclizine hcl tab 25 mg...... 8 (Zestoretic)...... 5 medroxyprogesterone acetate tab 10 mg (Provera)...... 2 lisinopril tab 10 mg (Prinivil)...... 5 medroxyprogesterone acetate tab 2.5 mg (Provera)...... 2 lisinopril tab 2.5 mg (Zestril)...... 5 medroxyprogesterone acetate tab 5 mg (Provera)...... 2 lisinopril tab 20 mg (Prinivil)...... 5 megestrol acetate tab 20 mg...... 2 lisinopril tab 30 mg (Zestril)...... 5 megestrol acetate tab 40 mg...... 2 lisinopril tab 40 mg (Zestril)...... 5 melatonin tab 3 mg...... 16 lisinopril tab 5 mg (Prinivil)...... 5 melatonin tab 5 mg...... 16 lithium carbonate cap 150 mg (Lithium carbonate)...... 10 meloxicam tab 15 mg (Mobic)...... 11 lithium carbonate cap 300 mg...... 10 meloxicam tab 7.5 mg (Mobic)...... 11 lithium carbonate cap 600 mg (Lithium carbonate)...... 10 memantine hcl tab 10 mg (Namenda)...... 10 lithium carbonate tab 300 mg...... 10 memantine hcl tab 5 mg (Namenda)...... 10 lithium carbonate tab er 300 mg (Lithobid)...... 10 menthol gel 4%...... 16 lithium carbonate tab er 450 mg...... 10 meperidine hcl inj 100 mg/ml (Demerol)...... 11 loperamide hcl liq 1 mg/5ml (0.2 mg/ml)...... 7 meperidine hcl inj 25 mg/ml (Demerol)...... 11 loperamide hcl liq 1 mg/7.5ml...... 7 meperidine hcl inj 50 mg/ml (Demerol)...... 11 loperamide hcl tab 2 mg...... 7 metformin hcl tab 1000 mg (Glucophage)...... 3 loratadine & pseudoephedrine tab er 12hr 5-120 mg..... 7 metformin hcl tab 500 mg (Glucophage)...... 3 loratadine & pseudoephedrine tab er 24hr 10-240 metformin hcl tab 850 mg (Glucophage)...... 3 mg...... 7 metformin hcl tab er 24hr 500 mg (Glucophage xr)...... 3 loratadine chew tab 5 mg...... 6 metformin hcl tab er 24hr 750 mg (Glucophage xr)...... 3 loratadine rapidly-disintegrating tab 10 mg methadone hcl tab 10 mg (Dolophine)...... 11 (Claritin)...... 6 methadone hcl tab 5 mg (Dolophine)...... 11 loratadine syrup 5 mg/5ml...... 6 methimazole tab 10 mg (Tapazole)...... 3 loratadine tab 10 mg...... 6 methimazole tab 5 mg (Tapazole)...... 3 lorazepam inj 2 mg/ml (Ativan)...... 9 methocarbamol tab 500 mg (Robaxin)...... 13 lorazepam tab 0.5 mg (Ativan)...... 9 methocarbamol tab 750 mg (Robaxin-750)...... 13 lorazepam tab 1 mg (Ativan)...... 9 methotrexate sodium inj 50 mg/2ml (25 mg/ml)...... 2 lorazepam tab 2 mg (Ativan)...... 9 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)..... 2 losartan potassium & hydrochlorothiazide tab 100-12.5 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 2 mg (Hyzaar)...... 5 methyldopa tab 250 mg...... 5 losartan potassium & hydrochlorothiazide tab 100-25 methylphenidate hcl tab 5 mg (Ritalin)...... 10 mg (Hyzaar)...... 5 methylprednisolone acetate inj susp 80 mg/ml (Depo- losartan potassium & hydrochlorothiazide tab 50-12.5 medrol)...... 2 mg (Hyzaar)...... 5 methylprednisolone tab 16 mg (Medrol)...... 2 losartan potassium tab 100 mg (Cozaar)...... 5 methylprednisolone tab 32 mg (Medrol)...... 2 losartan potassium tab 25 mg (Cozaar)...... 5 methylprednisolone tab 4 mg (Medrol)...... 2

BCBSNE Preferred Generics (Lower Cost Generics), 2021 23 2021 methylprednisolone tab therapy pack 4 mg (21) naproxen tab 375 mg...... 11 (Medrol dosepak)...... 2 naproxen tab 500 mg (Naprosyn)...... 11 metoclopramide hcl tab 10 mg (Reglan)...... 8 naproxen tab ec 375 mg (Ec-naprosyn)...... 11 metoclopramide hcl tab 5 mg (Reglan)...... 8 naproxen tab ec 500 mg (Ec-naprosyn)...... 11 metoprolol succinate tab er 24hr 100 mg (tartrate neomycin-bacitracin-polymyxin oint...... 16 equiv) (Toprol xl)...... 3 neomycin-polymyxin-dexamethasone ophth oint 0.1% metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Maxitrol)...... 15 (Toprol xl)...... 3 neomycin-polymyxin-dexamethasone ophth susp metoprolol succinate tab er 24hr 50 mg (tartrate equiv) 0.1% (Maxitrol)...... 15 (Toprol xl)...... 3 neomycin sulfate tab 500 mg...... 1 metoprolol tartrate tab 100 mg (Lopressor)...... 3 nevirapine tab 200 mg (Viramune)...... 1 metoprolol tartrate tab 25 mg...... 3 niacin cap er 500 mg...... 13 metoprolol tartrate tab 50 mg (Lopressor)...... 3 niacin tab 100 mg...... 13 metronidazole tab 250 mg (Flagyl)...... 1 niacin tab 500 mg...... 13 metronidazole tab 500 mg (Flagyl)...... 1 niacin tab er 500 mg...... 13 miconazole nitrate cream 2%...... 16 nifedipine tab er 24hr 30 mg (Adalat cc)...... 4 miconazole nitrate vaginal cream 2%...... 8 nifedipine tab er 24hr osmotic release 30 mg midazolam hcl inj 10 mg/2ml (base equivalent)...... 10 (Procardia xl)...... 4 midazolam hcl inj 2 mg/2ml (base equivalent)...... 10 nifedipine tab er 24hr osmotic release 60 mg midazolam hcl inj 50 mg/10ml (base equivalent)...... 10 (Procardia xl)...... 4 midazolam hcl inj 5 mg/ml (base equivalent)...... 10 nitrofurantoin monohydrate macrocrystalline cap 100 midazolam hcl inj pf 10 mg/2ml (base equivalent)...... 10 mg (Macrobid)...... 1 midazolam hcl inj pf 2 mg/2ml (base equivalent)...... 10 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)...... 3 midazolam hcl inj pf 5 mg/ml (base equivalent)...... 10 norethindrone & ethinyl estradiol tab 1 mg-35 mcg midazolam hcl syrup 2 mg/ml (base equivalent)...... 10 (Ortho-novum 1/35)...... 2 minocycline hcl cap 50 mg (Minocin)...... 1 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 minoxidil tab 10 mg...... 5 mcg (Loestrin fe 1.5/30)...... 2 minoxidil tab 2.5 mg...... 5 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mirtazapine tab 15 mg (Remeron)...... 9 mcg (Loestrin fe 1/20)...... 2 mirtazapine tab 30 mg (Remeron)...... 9 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg mirtazapine tab 45 mg (Remeron)...... 9 (Loestrin 1/20-21)...... 2 misoprostol tab 100 mcg (Cytotec)...... 8 norethindrone tab 0.35 mg (Ortho micronor)...... 2 misoprostol tab 200 mcg (Cytotec)...... 8 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg mometasone furoate oint 0.1% (Elocon)...... 16 (Ortho-cyclen)...... 2 montelukast sodium chew tab 4 mg (base equiv) norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 (Singulair)...... 7 mg-mcg (Ortho tri-cyclen lo)...... 2 montelukast sodium chew tab 5 mg (base equiv) norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 (Singulair)...... 7 mg-mcg (Ortho tri-cyclen)...... 2 montelukast sodium tab 10 mg (base equiv) nortriptyline hcl cap 10 mg (Pamelor)...... 9 (Singulair)...... 7 nortriptyline hcl cap 25 mg (Pamelor)...... 9 morphine sulfate iv soln pf 10 mg/ml (Morphine nortriptyline hcl cap 50 mg (Pamelor)...... 9 sulfate)...... 11 nortriptyline hcl cap 75 mg (Pamelor)...... 9 morphine sulfate iv soln pf 4 mg/ml (Morphine nystatin cream 100000 unit/gm...... 16 sulfate)...... 11 nystatin oint 100000 unit/gm...... 16 ...... 11 morphine sulfate oral soln 10 mg/5ml O morphine sulfate tab er 15 mg (Ms contin)...... 11 multiple vitamins w/ minerals cap...... 13 olanzapine tab 10 mg (Zyprexa)...... 10 multiple vitamins w/ minerals chew tab...... 13 olanzapine tab 15 mg (Zyprexa)...... 10 multiple vitamins w/ minerals tab (Strovite forte)...... 13 olanzapine tab 2.5 mg (Zyprexa)...... 10 multiple vitamin tab...... 13 olanzapine tab 20 mg (Zyprexa)...... 10 mupirocin oint 2%...... 16 olanzapine tab 5 mg (Zyprexa)...... 10 olanzapine tab 7.5 mg (Zyprexa)...... 10 N olmesartan medoxomil-hydrochlorothiazide tab nabumetone tab 500 mg...... 11 20-12.5 mg (Benicar hct)...... 5 nabumetone tab 750 mg...... 11 olmesartan medoxomil-hydrochlorothiazide tab naproxen tab 250 mg...... 11 40-12.5 mg (Benicar hct)...... 5

24 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021 olmesartan medoxomil-hydrochlorothiazide tab 40-25 pediatric multiple vitamins w/ iron chew tab 18 mg..... 13 mg (Benicar hct)...... 5 pediatric multiple vitamin w/ c & fa chew tab...... 13 olmesartan medoxomil tab 20 mg (Benicar)...... 5 pediatric vitamins acd w/ fluoride soln 0.25 mg/ml...... 13 olmesartan medoxomil tab 40 mg (Benicar)...... 5 pediatric vitamins acd w/ fluoride soln 0.5 mg/ml...... 13 olmesartan medoxomil tab 5 mg (Benicar)...... 5 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm omega-3 fatty acids cap 1000 mg...... 14 (Golytely)...... 7 omeprazole cap delayed release 10 mg...... 8 peg 3350-kcl-sod bicarb-nacl for soln 420 gm omeprazole cap delayed release 20 mg...... 8 (Nulytely/flavor pack)...... 7 omeprazole cap delayed release 40 mg...... 8 penicillin v potassium tab 250 mg...... 1 omeprazole delayed release tab 20 mg...... 8 penicillin v potassium tab 500 mg...... 1 omeprazole magnesium cap dr 20.6 mg (20 mg base perindopril erbumine tab 2 mg...... 5 equiv)...... 8 perindopril erbumine tab 4 mg...... 5 ondansetron hcl inj 40 mg/20ml (2 mg/ml)...... 8 permethrin lotion 1%...... 16 ondansetron hcl inj 4 mg/2ml (2 mg/ml)...... 8 phenazopyridine hcl tab 100 mg (Pyridium)...... 8 ondansetron hcl tab 4 mg (Zofran)...... 8 phenazopyridine hcl tab 200 mg (Pyridium)...... 8 ondansetron hcl tab 8 mg (Zofran)...... 8 phendimetrazine tartrate tab 35 mg...... 10 ondansetron orally disintegrating tab 4 mg (Zofran phenobarbital tab 100 mg...... 10 odt)...... 8 phenobarbital tab 15 mg...... 10 ondansetron orally disintegrating tab 8 mg (Zofran phenobarbital tab 30 mg...... 10 odt)...... 8 phenobarbital tab 60 mg...... 10 oral electrolyte solution...... 14 phentermine hcl cap 15 mg...... 10 orphenadrine citrate tab er 12hr 100 mg...... 13 phentermine hcl cap 30 mg...... 10 oxcarbazepine tab 150 mg (Trileptal)...... 12 phentermine hcl cap 37.5 mg (Adipex-p)...... 10 oxybutynin chloride syrup 5 mg/5ml...... 8 phentermine hcl tab 37.5 mg (Adipex-p)...... 10 oxybutynin chloride tab 5 mg...... 8 phenylephrine-brompheniramine-dm liquid 2.5-1-5 oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)...... 8 mg/5ml...... 7 oxybutynin chloride tab er 24hr 15 mg...... 8 phenylephrine-mineral oil-petrolatum oint oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)...... 8 0.25-14-74.9%...... 16 oxycodone hcl tab 10 mg...... 11 phenylephrine w/ dm-gg liqd 10-18-200 mg/15ml...... 7 oxycodone hcl tab 5 mg (Roxicodone)...... 11 phytonadione inj 1 mg/0.5ml (2 mg/ml)...... 13 oxycodone w/ acetaminophen tab 5-325 mg pioglitazone hcl tab 15 mg (base equiv) (Actos)...... 3 (Percocet)...... 11 pioglitazone hcl tab 30 mg (base equiv) (Actos)...... 3 oxymetazoline hcl nasal soln 0.05%...... 7 pioglitazone hcl tab 45 mg (base equiv) (Actos)...... 3 oxytocin inj 10 unit/ml (Pitocin)...... 3 polyethylene glycol 3350 oral powder...... 7 oyster shell calcium tab 500 mg...... 14 polymyxin b sulfate for inj 500000 unit...... 1 P polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)...... 15 pantoprazole sodium ec tab 20 mg (base equiv) polysaccharide iron complex cap 150 mg (iron (Protonix)...... 8 equivalent)...... 15 pantoprazole sodium ec tab 40 mg (base equiv) potassium & sodium phosphates powder pack (Protonix)...... 8 280-160-250 mg...... 14 paroxetine hcl tab 10 mg (Paxil)...... 9 potassium bicarbonate effer tab 25 meq...... 14 paroxetine hcl tab 20 mg (Paxil)...... 9 potassium chloride microencapsulated crys er tab 10 paroxetine hcl tab 30 mg (Paxil)...... 9 meq...... 14 paroxetine hcl tab 40 mg (Paxil)...... 9 potassium chloride microencapsulated crys er tab 20 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ meq...... 14 ml...... 13 potassium chloride tab er 10 meq (K-tab)...... 14 pediatric multiple vitamins w/ fluoride chew tab 0.5 potassium chloride tab er 8 meq (600 mg)...... 14 mg...... 13 povidone-iodine soln 10%...... 16 pediatric multiple vitamins w/ fluoride chew tab 1 pramipexole dihydrochloride tab 0.125 mg mg...... 13 (Mirapex)...... 12 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ pramipexole dihydrochloride tab 0.25 mg ml...... 13 (Mirapex)...... 12 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 12 ml...... 13 pramipexole dihydrochloride tab 0.75 mg pediatric multiple vitamins w/ iron chew tab 15 mg..... 13 (Mirapex)...... 12

BCBSNE Preferred Generics (Lower Cost Generics), 2021 25 2021 pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 12 quinapril hcl tab 20 mg (Accupril)...... 5 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 12 quinapril hcl tab 40 mg (Accupril)...... 5 prasterone (dhea) tab 25 mg...... 16 quinapril hcl tab 5 mg (Accupril)...... 5 ...... 6 pravastatin sodium tab 10 mg R pravastatin sodium tab 20 mg (Pravachol)...... 6 pravastatin sodium tab 40 mg (Pravachol)...... 6 ramipril cap 1.25 mg (Altace)...... 5 pravastatin sodium tab 80 mg (Pravachol)...... 6 ramipril cap 10 mg (Altace)...... 5 prednisolone sod phosphate oral soln 15 mg/5ml ramipril cap 2.5 mg (Altace)...... 5 (base equiv)...... 2 ramipril cap 5 mg (Altace)...... 5 prednisone tab 10 mg...... 2 ranitidine hcl tab 150 mg (Zantac)...... 8 prednisone tab 1 mg...... 2 ranitidine hcl tab 75 mg...... 8 prednisone tab 2.5 mg...... 2 riboflavin tab 100 mg...... 13 prednisone tab 20 mg...... 2 riboflavin tab 25 mg...... 13 prednisone tab 50 mg...... 2 risperidone tab 0.25 mg (Risperdal)...... 10 prednisone tab 5 mg...... 2 risperidone tab 0.5 mg (Risperdal)...... 10 prednisone tab therapy pack 5 mg (21)...... 2 risperidone tab 1 mg (Risperdal)...... 10 prednisone tab therapy pack 5 mg (48)...... 2 risperidone tab 2 mg (Risperdal)...... 10 primidone tab 250 mg (Mysoline)...... 12 risperidone tab 3 mg (Risperdal)...... 10 primidone tab 50 mg (Mysoline)...... 12 risperidone tab 4 mg (Risperdal)...... 10 prochlorperazine maleate tab 10 mg (base rizatriptan benzoate oral disintegrating tab 10 mg equivalent)...... 10 (base eq) (Maxalt-mlt)...... 11 prochlorperazine maleate tab 5 mg (base rizatriptan benzoate oral disintegrating tab 5 mg (base equivalent)...... 10 eq) (Maxalt-mlt)...... 11 promethazine-dm syrup 6.25-15 mg/5ml...... 7 rizatriptan benzoate tab 10 mg (base equivalent) promethazine hcl syrup 6.25 mg/5ml...... 6 (Maxalt)...... 11 promethazine hcl tab 12.5 mg...... 6 rizatriptan benzoate tab 5 mg (base equivalent) promethazine hcl tab 25 mg...... 6 (Maxalt)...... 11 promethazine hcl tab 50 mg...... 6 ropinirole hydrochloride tab 0.25 mg (Requip)...... 12 promethazine w/ codeine syrup 6.25-10 mg/5ml...... 7 ropinirole hydrochloride tab 0.5 mg (Requip)...... 12 propafenone hcl tab 150 mg...... 4 ropinirole hydrochloride tab 1 mg (Requip)...... 12 propranolol hcl tab 10 mg...... 3 ropinirole hydrochloride tab 2 mg (Requip)...... 12 propranolol hcl tab 20 mg...... 3 ropinirole hydrochloride tab 3 mg (Requip)...... 12 propranolol hcl tab 40 mg...... 3 ropinirole hydrochloride tab 4 mg (Requip)...... 12 pseudoephedrine-guaifenesin tab 40-400 mg...... 7 ropinirole hydrochloride tab 5 mg (Requip)...... 12 pseudoephedrine-guaifenesin tab er 12hr 60-600 rosuvastatin calcium tab 10 mg (Crestor)...... 6 mg...... 7 rosuvastatin calcium tab 20 mg (Crestor)...... 6 pseudoephedrine hcl liq 15 mg/5ml...... 7 rosuvastatin calcium tab 40 mg (Crestor)...... 6 pseudoephedrine hcl tab 30 mg...... 7 rosuvastatin calcium tab 5 mg (Crestor)...... 6 pseudoephedrine hcl tab 60 mg...... 7 S pseudoephedrine hcl tab er 12hr 120 mg...... 7 ...... 16 pseudoephedrine-ibuprofen tab 30-200 mg...... 7 salicylic acid soln 17% ...... 7 pseudoephedrine-naproxen sodium tab er 12hr saline nasal spray 0.65% ...... 16 120-220 mg...... 7 selenium sulfide lotion 2.5% ...... 7 psyllium cap 0.52 gm...... 7 sennosides-docusate sodium tab 8.6-50 mg ...... 7 pyridoxine hcl tab 100 mg...... 13 sennosides syrup 8.8 mg/5ml ...... 7 pyridoxine hcl tab 25 mg...... 13 sennosides tab 8.6 mg ...... 9 pyridoxine hcl tab 50 mg...... 13 sertraline hcl tab 100 mg (Zoloft) sertraline hcl tab 25 mg (Zoloft)...... 9 Q sertraline hcl tab 50 mg (Zoloft)...... 9 quetiapine fumarate tab 100 mg (Seroquel)...... 10 silver sulfadiazine cream 1% (Silvadene)...... 16 quetiapine fumarate tab 200 mg (Seroquel)...... 10 simethicone susp 40 mg/0.6ml...... 8 quetiapine fumarate tab 25 mg (Seroquel)...... 10 simvastatin tab 10 mg (Zocor)...... 6 quetiapine fumarate tab 300 mg (Seroquel)...... 10 simvastatin tab 20 mg (Zocor)...... 6 quetiapine fumarate tab 400 mg (Seroquel)...... 10 simvastatin tab 40 mg (Zocor)...... 6 quetiapine fumarate tab 50 mg (Seroquel)...... 10 simvastatin tab 5 mg (Zocor)...... 6 quinapril hcl tab 10 mg (Accupril)...... 5 simvastatin tab 80 mg (Zocor)...... 6

26 BCBSNE Preferred Generics (Lower Cost Generics), 2021 2021 skin protectants misc - liquid...... 16 terbinafine hcl tab 250 mg (Lamisil)...... 1 skin protectants misc - lotion...... 16 terbutaline sulfate inj 1 mg/ml...... 7 sodium bicarbonate tab 650 mg...... 8 tetracaine hcl ophth soln 0.5%...... 15 sodium chloride flush iv soln 0.9%...... 14 thiamine hcl tab 100 mg...... 13 sodium chloride inj 2.5 meq/ml (14.6%)...... 14 thiamine hcl tab 50 mg...... 13 sodium chloride irrigation soln 0.9%...... 8 thyroid tab 15 mg (1/4 grain) (Armour thyroid)...... 3 sodium chloride iv soln 0.45%...... 14 thyroid tab 30 mg (1/2 grain) (Armour thyroid)...... 3 sodium chloride iv soln 0.9%...... 14 timolol maleate ophth soln 0.25% (Timoptic)...... 15 sodium chloride soln nebu 0.9%...... 7 timolol maleate ophth soln 0.5% (Timoptic)...... 15 sodium chloride soln nebu 3%...... 7 tizanidine hcl tab 2 mg (base equivalent)...... 13 sodium chloride soln nebu 7% (Hypersal)...... 7 tizanidine hcl tab 4 mg (base equivalent) sodium chloride tab 1 gm...... 14 (Zanaflex)...... 13 sodium fluoride chew tab 0.25 mg f (from 0.55 mg tobramycin ophth soln 0.3% (Tobrex)...... 15 naf)...... 14 topiramate tab 100 mg (Topamax)...... 12 sodium fluoride chew tab 0.5 mg f (from 1.1 mg topiramate tab 200 mg (Topamax)...... 12 naf)...... 14 topiramate tab 25 mg (Topamax)...... 12 sodium fluoride chew tab 1 mg f (from 2.2 mg naf)...... 14 topiramate tab 50 mg (Topamax)...... 12 sodium fluoride cream 1.1% (Prevident 5000 plus)...... 16 torsemide tab 100 mg...... 6 sodium fluoride gel 1.1% (0.5% f) (Prevident torsemide tab 10 mg (Demadex)...... 6 fluoride)...... 16 torsemide tab 20 mg (Demadex)...... 6 sodium fluoride paste 1.1% (Prevident 5000 boost).....16 torsemide tab 5 mg...... 6 sodium fluoride-potassium nitrate paste 1.1-5% tramadol-acetaminophen tab 37.5-325 mg (Prevident 5000 sensi)...... 16 (Ultracet)...... 11 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml tramadol hcl tab 50 mg (Ultram)...... 11 naf)...... 14 trandolapril tab 1 mg...... 5 sotalol hcl (afib/afl) tab 120 mg (Betapace af)...... 4 trandolapril tab 2 mg...... 5 sotalol hcl (afib/afl) tab 160 mg (Betapace af)...... 4 trandolapril tab 4 mg...... 5 sotalol hcl (afib/afl) tab 80 mg (Betapace af)...... 3 trazodone hcl tab 100 mg...... 9 sotalol hcl tab 120 mg (Betapace)...... 4 trazodone hcl tab 150 mg...... 9 sotalol hcl tab 160 mg (Betapace)...... 4 trazodone hcl tab 50 mg...... 9 sotalol hcl tab 240 mg...... 4 triamcinolone acetonide cream 0.025%...... 16 sotalol hcl tab 80 mg (Betapace)...... 4 triamcinolone acetonide cream 0.1%...... 16 spironolactone tab 100 mg (Aldactone)...... 6 triamcinolone acetonide cream 0.5%...... 16 spironolactone tab 25 mg (Aldactone)...... 6 triamcinolone acetonide inj susp 40 mg/ml spironolactone tab 50 mg (Aldactone)...... 6 (Kenalog-40)...... 2 sulfamethoxazole-trimethoprim tab 400-80 mg triamcinolone acetonide nasal aerosol suspension 55 (Bactrim)...... 1 mcg/act...... 7 sulfamethoxazole-trimethoprim tab 800-160 mg triamcinolone acetonide oint 0.025%...... 16 (Bactrim ds)...... 1 triamcinolone acetonide oint 0.1%...... 16 sulindac tab 150 mg...... 11 triamcinolone acetonide oint 0.5%...... 16 sulindac tab 200 mg...... 11 triamterene & hydrochlorothiazide cap 37.5-25 mg sumatriptan succinate tab 100 mg (Imitrex)...... 12 (Dyazide)...... 6 sumatriptan succinate tab 25 mg (Imitrex)...... 11 triamterene & hydrochlorothiazide tab 37.5-25 mg sumatriptan succinate tab 50 mg (Imitrex)...... 12 (Maxzide-25)...... 6 T triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)...... 6 tamoxifen citrate tab 10 mg (base equivalent)...... 2 trihexyphenidyl hcl tab 2 mg...... 12 tamsulosin hcl cap 0.4 mg (Flomax)...... 8 trihexyphenidyl hcl tab 5 mg...... 12 telmisartan tab 80 mg (Micardis)...... 5 trimethoprim tab 100 mg...... 1 temazepam cap 15 mg (Restoril)...... 10 triprolidine & pseudoephedrine tab 2.5-60 mg...... 7 temazepam cap 30 mg (Restoril)...... 10 trolamine salicylate cream 10%...... 16 terazosin hcl cap 10 mg...... 5 tropicamide ophth soln 0.5%...... 15 terazosin hcl cap 1 mg...... 5 tropicamide ophth soln 1% (Mydriacyl)...... 15 terazosin hcl cap 2 mg...... 5 terazosin hcl cap 5 mg...... 5 U terbinafine hcl cream 1%...... 16 urea cream 20%...... 16

BCBSNE Preferred Generics (Lower Cost Generics), 2021 27 2021 urea lotion 10%...... 16 white petrolatum-mineral oil ophth ointment...... 15 ...... 16 V white petrolatum topical gel valacyclovir hcl tab 1 gm (Valtrex)...... 1 X ...... 1 valacyclovir hcl tab 500 mg (Valtrex) Y valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct)...... 5 Z valsartan-hydrochlorothiazide tab 160-25 mg (Diovan ...... 10 hct)...... 5 zaleplon cap 10 mg (Sonata) ...... 10 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan zaleplon cap 5 mg (Sonata) ...... 14 hct)...... 5 zinc gluconate tab 50 mg (elemental zn) ...... 16 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan zinc oxide oint 20% ...... 14 hct)...... 5 zinc sulfate cap 220 mg (50 mg elemental zn) ...... 10 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan zolpidem tartrate tab 10 mg (Ambien) ...... 10 hct)...... 5 zolpidem tartrate tab 5 mg (Ambien) ...... 12 valsartan tab 160 mg (Diovan)...... 5 zonisamide cap 25 mg (Zonegran) ...... 12 valsartan tab 320 mg (Diovan)...... 5 zonisamide cap 50 mg valsartan tab 40 mg (Diovan)...... 5 valsartan tab 80 mg (Diovan)...... 5 venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr)...... 9 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor xr)...... 9 venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr)...... 9 venlafaxine hcl tab 100 mg...... 9 venlafaxine hcl tab 25 mg...... 9 venlafaxine hcl tab 37.5 mg...... 9 venlafaxine hcl tab 50 mg...... 9 venlafaxine hcl tab 75 mg...... 9 verapamil hcl tab 120 mg (Calan)...... 4 verapamil hcl tab 40 mg...... 4 verapamil hcl tab 80 mg (Calan)...... 4 verapamil hcl tab er 120 mg (Calan sr)...... 4 verapamil hcl tab er 180 mg (Calan sr)...... 4 verapamil hcl tab er 240 mg (Calan sr)...... 4 vitamin a cap 2400 mcg (8000 unit)...... 13 vitamin a cap 3 mg (10000 unit)...... 13 vitamin e cap 1000 unit...... 13 vitamin e cap 180 mg...... 13 vitamin e cap 400 unit...... 13 W warfarin sodium tab 10 mg (Coumadin)...... 15 warfarin sodium tab 1 mg (Coumadin)...... 15 warfarin sodium tab 2.5 mg (Coumadin)...... 15 warfarin sodium tab 2 mg (Coumadin)...... 15 warfarin sodium tab 3 mg (Coumadin)...... 15 warfarin sodium tab 4 mg (Coumadin)...... 15 warfarin sodium tab 5 mg (Coumadin)...... 15 warfarin sodium tab 6 mg (Coumadin)...... 15 warfarin sodium tab 7.5 mg (Coumadin)...... 15 water for injection...... 16 water for irrigation, sterile irrigation soln...... 16 water for iv injection...... 16 white petrolatum gel...... 16

28 BCBSNE Preferred Generics (Lower Cost Generics), 2021