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Two-Tier Generic Drugs

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Two-Tier Generic Drugs 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 generic drug 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 prescription drug 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) PENICILLINS 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 gentamicin 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 isoniazid 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) penicillin v potassium tab 250 mg ANTIVIRALS penicillin v potassium tab 500 mg acyclovir cap 200 mg (Zovirax) CEPHALOSPORINS acyclovir tab 400 mg (Zovirax) cefadroxil cap 500 mg acyclovir tab 800 mg (Zovirax) cefazolin sodium for inj 500 mg famciclovir tab 125 mg cefazolin sodium for inj 10 gm nevirapine tab 200 mg (Viramune) cefdinir cap 300 mg valacyclovir hcl tab 500 mg (Valtrex) ceftriaxone 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 bacitracin 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) MACROLIDES clindamycin phosphate inj 9 gm/60ml (Cleocin azithromycin tab 250 mg (Zithromax) phosphate) azithromycin tab 500 mg (Zithromax) metronidazole tab 250 mg (Flagyl) TETRACYCLINES metronidazole tab 500 mg (Flagyl) doxycycline hyclate cap 100 mg (Vibramycin) nitrofurantoin monohydrate macrocrystalline cap doxycycline hyclate tab 100 mg 100 mg (Macrobid) doxycycline monohydrate cap 50 mg polymyxin b sulfate for inj 500000 unit doxycycline monohydrate cap 100 mg (Monodox) sulfamethoxazole-trimethoprim tab 400-80 mg minocycline 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) methotrexate 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
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