Download 5-tier Generics Plus drug list

June 2017
(2016 Plan Year)
Health Insurance Marketplace Generics Plus Drug List
Please consider talking to your doctor about prescribing preferred medications, which may
help reduce your out-of-pocket costs. This list may help guide you and your doctor in
selecting an appropriate medication for you.
The drug list is regularly updated. Please visit bcbstx.com for the most up-to-date
information.
To find a contracting pharmacy, please access the link below:
https://www.myprime.com/en/find-pharmacy.html
Contents
Therapeutic Class Drug List
Introduction ...................................................................... I Anti-Infective Agents ....................................................... 1
How drugs are selected ................................................... I Biologicals ..................................................................... 13
How member payment is determined .............................. I Antineoplastic Agents ................................................... 17
How to use this list .......................................................... II Endocrine and Metabolic Drugs ................................... 23
Drugs used to treat multiple conditions .......................... II Cardiovascular Agents .................................................. 42
Generic drugs ................................................................. II Respiratory Agents ....................................................... 61
Consider talking to your doctor about generic
Gastrointestinal Agents ................................................. 68
drugs ........................................................................... II Genitourinary Agents .................................................... 74
Coverage considerations ............................................... III Central Nervous System Drugs .................................... 77
Specialty drugs ............................................................... V Analgesics and Anesthetics .......................................... 96
Prime Therapeutics Specialty Pharmacy
Neuromuscular Drugs ................................................. 109
program....................................................................... V Nutritional Products .................................................... 119
Abbreviation key ............................................................ VI Hematological Agents ................................................. 149
Topical Products ......................................................... 162
Miscellaneous Products .............................................. 182
Index ........................................................................... 187
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or
go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking
for and click on Search.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
41722-K TX HIM © Prime Therapeutics LLC 06/17
Introduction
Members are encouraged to show this list to their physicians and pharmacists. Physicians are
encouraged to prescribe drugs on this list, when right for the member. However decisions regarding
therapy and treatment are always between members and their physician.
Drug lists updates – This list is regularly updated as generic drugs become available and changes take place in
the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to
Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from
the provider portal at bcbstx.com.
How drugs are selected
Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least one representative from
BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).
Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are
considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on
the list.
How member payment is determined
This list shows prescription drug products in tiers. Generally, each drug is placed into one of five member
payment tiers: Preferred Generic (Tier 1), Non-preferred Generic (Tier 2), Preferred Brand (Tier 3),
Non-preferred Brand (Tier 4) and Specialty (Tier 5). Please refer to the ACA Preventive (ACA) section for drugs
marked with an "A" in the drug tier column. To verify your payment amount for a drug, visit bcbstx.com and log in
to Blue Access for Members or call the number on the back of your ID card.
Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply.
Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic
purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for selfadministration may be available through your medical benefit.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June 2017
(2016 Plan Year)
I
How to use this list
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). Some generic products have no reference brand.
Example: atorvastatin (Lipitor – brand is NF)
Brand prescription drugs are shown in capital letters followed by the generic name.
Drugs used to treat multiple conditions
Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,
each medication is classified according to its first FDA-approved use. Please check the index if you do not find
your particular medication in the class/condition section that corresponds to your use.
Generic drugs
Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs
must be approved by the FDA just as brand drugs are, and must meet the same standards.
There are two types of generic drugs:
•
A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.
•
A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s)
differs from the brand drug.
According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:
•
Is chemically the same
•
Works just as well in the body
•
Is as safe and effective
•
Meets the same standards set by the FDA
The main difference between the reference brand drug and the generic equivalent is that the generic often costs
much less.
Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.
You may be responsible for the brand member payment amount plus the difference in cost between the brand
and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs
have the lowest member payment amount.
Consider talking to your doctor about generic drugs
If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an
appropriate generic alternative is available.
You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is
available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new
prescription from your doctor.
Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June 2017
(2016 Plan Year)
II
Coverage considerations
Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.
Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood
pressure, diabetes or high cholesterol.
Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that
have an over-the-counter version. You should refer to your benefit plan materials for details about your particular
benefits.
Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please
see your plan materials or call the number on the back of your ID card to determine whether compounded
medications are covered and/or verify your payment amount.
Repackaged medications: Repackaged versions of medications already available on the market are not covered.
Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that
your doctor will need to submit a prior authorization request for coverage of these medications, and the request
will need to be approved, before the medication will be covered under your plan. For the preferred medications
listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a
dot under the prior authorization column. Some plans may have prior authorization on additional medications
beyond those noted in this document.
Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try
another proven, cost-effective medication before coverage may be available for the drug included in the program.
Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the
preferred medications listed in this document, if a step therapy is commonly required it will generally be noted
next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on
additional medications beyond those noted in this document.
Dispensing Limits (DL): Drug Dispensing limits are designed to help encourage medication use as intended by
the FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications
listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot
under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity
of covered medication in a given time period, coverage only for members within a certain age range, and
coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than
what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost
of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit
bcbstx.com.
*Please note: For certain controlled substance medications, some state laws may not allow coverage by a health
benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be
responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the
dispensing limit.
Limited Distribution (LD): Medicines marked as "Limited Distribution" have restrictions on where you may obtain
a medication. This may include requiring the use of a designated pharmacy to fill a prescription.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June 2017
(2016 Plan Year)
III
ACA Preventive (ACA): Medicines marked in the ACA column are under the Affordable Care Act coverage of
preventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), when
meeting the conditions as outlined under the regulation. These are also indicated with an "A" in the drug tier
column. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic
acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D
supplements, and some FDA approved contraceptive methods. To see what contraceptive products may be
covered, visit www.bcbstx.com/pdf/rx/contraceptive-list-tx.pdf
Remember, medication decisions are between you and your doctor. Only you and your doctor can determine
which medication is right for you. Discuss any questions or concerns you have about medications you are taking
or are prescribed with your doctor. BCBSTX does not provide health care services and, therefore, cannot
guarantee any results or outcomes.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June 2017
(2016 Plan Year)
IV
Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbstx.com and log in to Blue Access for Members.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you
have questions about your coverage for specialty medications or your prescription drug benefit, call the
number on the back of your ID card.
Prime Therapeutics Specialty Pharmacy Program
Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered
directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at
no additional charge the following services:
•
Coordination of coverage between you, your doctor and your health plan
•
Educational materials about your particular condition and information about managing potential
medication side effects
•
Syringes, sharps containers and other supplies with every shipment for self-injectables
•
24/7/365 phone access to a pharmacist for urgent medication issues
To order through Prime Therapeutics Specialty Pharmacy:
•
Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can
call 877-627-6337 or fax to 877-828-3939.
•
If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to
transfer your prescription.
•
A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.
•
The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is
individually marked for each member. Refrigerated drugs are shipped in temperature-controlled
packaging.
If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337,
visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.
•
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”).
HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide
pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as
well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June 2017
(2016 Plan Year)
V
Abbreviation key
cap ...................................................................... capsules
chew .................................................................. chewable
odt ............................................. orally disintegrating tabs
oint ..................................................................... ointment
conc ............................................................. concentrate
ophth ................................................................. opthalmic
osm .......................................................... osmotic release
cr .......................................................... controlled release
dr ............................................................. delayed release
ec ................................................................ enteric coated
effe................................................................. effervescent
equiv ................................................................ equivalent
er ...........................................................extended release
inhal................................................................... inhalation
inj ......................................................................... injection
liq .............................................................................. liquid
lotn ........................................................................... lotion
powd..................................................................... powder
sa ............................................................ sustained action
sl ...................................................................... sublingual
soln ....................................................................... solution
sr .......................................................... sustained release
suppos ........................................................ suppositories
susp ................................................................ suspension
tab ...........................................................................tablets
td ................................................................... transdermal
nebu ................................................................... nebulizer
You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List
(also known as a formulary). To request this exception, you, or your prescriber, can call the number on the back
of your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you
from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be
able to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage
decision within 24 hours after they receive your request for an expedited review. If the coverage request is
denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative
drug (if applicable). Call the number on the back of your ID card if you have any questions.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June 2017
(2016 Plan Year)
VI
bcbstx.com
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language assistance.
We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator
Phone:
855-664-7270 (voicemail)
300 E. Randolph St.
TTY/TDD: 855-661-6965
35th Floor
Fax:
855-661-6960
Chicago, Illinois 60601
Email:
[email protected]
You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:
U.S. Dept. of Health & Human Services
Phone:
800-368-1019
200 Independence Avenue SW
TTY/TDD:
800-537-7697
Room 509F, HHH Building 1019
Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201
Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
bcbstx.com
2
1
AMOXICILLIN/CLAVULANATE
P - amoxicillin & k
clavulanate chew tab 400-57
mg
4
1
AMPICILLIN - ampicillin for
susp 125 mg/5ml
4
1
AMPICILLIN - ampicillin for
susp 250 mg/5ml
ampicillin cap 250 mg
1
1
1
1
ampicillin cap 500 mg
1
AUGMENTIN - amoxicillin
& k clavulanate for susp
125-31.25 mg/5ml
4
2
dicloxacillin sodium cap
250 mg
2
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
2
dicloxacillin sodium cap
500 mg
amoxicillin & k clavulanate
for susp 400-57 mg/5ml
2
amoxicillin (trihydrate) tab
875 mg
amoxicillin & k clavulanate
for susp 200-28.5 mg/5ml
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
2
amoxicillin & k clavulanate
tab sr 12hr 1000-62.5 mg
(Augmentin xr)
2
amoxicillin & k clavulanate
tab 250-125 mg
2
4
penicillin v potassium for
soln 125 mg/5ml
1
penicillin v potassium tab
250 mg
penicillin v potassium tab
500 mg
Limited Distribution
ACA
Dispensing Limits
2
MOXATAG - amoxicillin
(trihydrate) tab sr 24hr 775
mg
penicillin v potassium for
soln 250 mg/5ml
Step Therapy
1
1
amoxicillin (trihydrate) tab
500 mg
Prior Authorization
Drug Tier
2
amoxicillin (trihydrate) cap
250 mg
amoxicillin (trihydrate) for
susp 400 mg/5ml
Limited Distribution
AMOXICILLIN/CLAVULANATE
P - amoxicillin & k
clavulanate chew tab
200-28.5 mg
4
amoxicillin (trihydrate) for
susp 250 mg/5ml
ACA
2
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 250 mg
amoxicillin (trihydrate) for
susp 200 mg/5ml
Dispensing Limits
amoxicillin & k clavulanate
tab 875-125 mg
(Augmentin)
4
amoxicillin (trihydrate) for
susp 125 mg/5ml
Step Therapy
2
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg
amoxicillin (trihydrate) cap
500 mg
Drug Name
amoxicillin & k clavulanate
tab 500-125 mg
(Augmentin)
ANTI-INFECTIVE AGENTS
PENICILLINS
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
1
CEPHALOSPORINS
CEDAX - ceftibuten cap 400
mg
4
cefpodoxime proxetil for
susp 100 mg/5ml
CEDAX - ceftibuten for susp
180 mg/5ml
4
cefpodoxime proxetil tab
100 mg
CEFACLOR - cefaclor for susp
125 mg/5ml
4
cefpodoxime proxetil tab
200 mg
CEFACLOR - cefaclor for susp
250 mg/5ml
4
cefprozil for susp
125 mg/5ml
CEFACLOR - cefaclor for susp
375 mg/5ml
4
cefprozil for susp
250 mg/5ml
cefaclor cap 250 mg
2
cefaclor cap 500 mg
2
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
4
2
CEFTIN - cefuroxime axetil for
susp 250 mg/5ml
2
2
cefuroxime axetil tab 250 mg
(Ceftin)
cefuroxime axetil tab 500 mg
(Ceftin)
2
CEPHALEXIN - cephalexin tab
250 mg
4
CEPHALEXIN - cephalexin tab
500 mg
4
cephalexin cap 250 mg
(Keflex)
1
cephalexin cap 500 mg
(Keflex)
1
cephalexin cap 750 mg
(Keflex)
2
cephalexin for susp
125 mg/5ml
2
2
2
CEFDITOREN PIVOXIL cefditoren pivoxil tab 400 mg
(base equivalent)
4
cefixime for susp
100 mg/5ml (Suprax)
2
2
2
Limited Distribution
ACA
Dispensing Limits
2
2
2
Step Therapy
2
3
4
cefpodoxime proxetil for
susp 50 mg/5ml
2
CEFTIN - cefuroxime axetil for
susp 125 mg/5ml
CEFDITOREN PIVOXIL cefditoren pivoxil tab 200 mg
(base equivalent)
cefixime for susp
200 mg/5ml (Suprax)
2
4
1
cefdinir cap 300 mg
2
CEFTIBUTEN - ceftibuten for
susp 180 mg/5ml
cefadroxil cap 500 mg
cefadroxil tab 1 gm
2
4
4
cefadroxil for susp
500 mg/5ml
cefprozil tab 500 mg
2
CEFTIBUTEN - ceftibuten cap
400 mg
CEFACLOR ER - cefaclor
monohydrate tab sr 12hr 500
mg
cefadroxil for susp
250 mg/5ml
cefprozil tab 250 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
2
2
clarithromycin tab 250 mg
(Biaxin)
2
SPECTRACEF - cefditoren
pivoxil tab 400 mg (base
equivalent)
4
clarithromycin tab 500 mg
(Biaxin)
2
DIFICID - fidaxomicin tab 200
mg
4
SUPRAX - cefixime cap 400
mg
4
4
E.E.S. GRANULES erythromycin ethylsuccinate
for susp 200 mg/5ml
4
SUPRAX - cefixime chew tab
100 mg
SUPRAX - cefixime chew tab
200 mg
4
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
4
SUPRAX - cefixime for susp
100 mg/5ml
4
ERY-TAB - erythromycin tab
delayed release 250 mg
4
SUPRAX - cefixime for susp
200 mg/5ml
4
ERY-TAB - erythromycin tab
delayed release 333 mg
4
SUPRAX - cefixime for susp
500 mg/5ml
4
ERY-TAB - erythromycin tab
delayed release 500 mg
4
4
cephalexin for susp
250 mg/5ml
MACROLIDES
AZITHROMYCIN azithromycin powd pack for
susp 1 gm
4
ERYPED 200 - erythromycin
ethylsuccinate for susp 200
mg/5ml
4
azithromycin for susp
100 mg/5ml (Zithromax)
2
ERYPED 400 - erythromycin
ethylsuccinate for susp 400
mg/5ml
ERYTHROCIN STEARATE erythromycin stearate tab
250 mg
4
ERYTHROMYCIN BASE erythromycin tab 250 mg
4
ERYTHROMYCIN BASE erythromycin tab 500 mg
4
ERYTHROMYCIN
ETHYLSUCCINA erythromycin ethylsuccinate
tab 400 mg
4
azithromycin for susp
200 mg/5ml (Zithromax)
2
azithromycin tab 250 mg
(Zithromax)
1
•
azithromycin tab 500 mg
(Zithromax)
1
•
azithromycin tab 600 mg
(Zithromax)
2
•
clarithromycin for susp
125 mg/5ml
2
clarithromycin for susp
250 mg/5ml (Biaxin)
clarithromycin tab sr 24hr
500 mg
2
2
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
erythromycin ethylsuccinate 2
for susp 200 mg/5ml (E.e.s.
granules)
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
3
erythromycin w/ delayed
release particles cap
250 mg
2
doxycycline monohydrate
cap 75 mg (Monodox)
2
PCE - erythromycin w/ enteric
coated particles tab 333 mg
doxycycline monohydrate
cap 100 mg (Monodox)
PCE - erythromycin w/ enteric
coated particles tab 500 mg
4
doxycycline monohydrate
cap 150 mg (Adoxa)
4
doxycycline monohydrate
for susp 25 mg/5ml
(Vibramycin)
2
ZITHROMAX - azithromycin
powd pack for susp 1 gm
ZMAX - azithromycin extended
release for oral susp 2 gm
4
doxycycline monohydrate
tab 50 mg (Adoxa)
2
demeclocycline hcl tab
150 mg
demeclocycline hcl tab
300 mg
doxycycline hyclate cap
50 mg
doxycycline hyclate cap
100 mg (Vibramycin)
doxycycline monohydrate
tab 75 mg (Adoxa)
2
2
2
2
2
doxycycline monohydrate
tab 100 mg (Adoxa pak
1/100)
2
doxycycline monohydrate
tab 150 mg (Adoxa pak
1/150)
2
minocycline hcl cap 50 mg
(Minocin)
1
minocycline hcl cap 75 mg
(Minocin)
1
doxycycline hyclate tab
delayed release 75 mg
2
•
minocycline hcl cap 100 mg
(Minocin)
1
2
•
minocycline hcl tab sr 24hr
45 mg
2
•
2
•
minocycline hcl tab sr 24hr
90 mg
2
•
doxycycline hyclate tab
delayed release 200 mg
(Doryx)
2
•
minocycline hcl tab sr 24hr
135 mg
2
•
doxycycline hyclate tab
20 mg
2
doxycycline hyclate tab
100 mg
doxycycline monohydrate
cap 50 mg
2
2
minocycline hcl tab 75 mg
minocycline hcl tab 100 mg
Limited Distribution
•
•
minocycline hcl tab 50 mg
ACA
2
2
doxycycline hyclate tab
delayed release 150 mg
Dispensing Limits
•
doxycycline hyclate tab
delayed release 50 mg
(Doryx)
doxycycline hyclate tab
delayed release 100 mg
Step Therapy
•
2
4
TETRACYCLINES
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
TETRACYCLINE HCL tetracycline hcl cap 250 mg
4
TETRACYCLINE HCL tetracycline hcl cap 500 mg
4
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4
tetracycline hcl cap 250 mg
(Tetracycline hcl)
2
tetracycline hcl cap 500 mg
(Tetracycline hcl)
2
FLUOROQUINOLONES
ciprofloxacin for oral
susp 250 mg/5ml (5%)
(5 gm/100ml) (Cipro)
ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
2
2
moxifloxacin hcl tab 400 mg
(base equiv) (Avelox)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
OFLOXACIN - ofloxacin tab
300 mg
4
ofloxacin tab 400 mg
2
AMINOGLYCOSIDES
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
BETHKIS - tobramycin nebu
soln 300 mg/4ml
5
•
•
•
KITABIS PAK - tobramycin
nebu soln 300 mg/5ml
5
•
•
•
neomycin sulfate tab 500 mg
1
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg
(base equiv)
4
ciprofloxacin hcl tab 250 mg
(base equiv) (Cipro)
1
TOBI PODHALER - tobramycin
inhal cap 28 mg
5
•
•
•
1
TOBRAMYCIN - tobramycin
nebu soln 300 mg/5ml
5
•
•
•
1
tobramycin nebu soln
300 mg/5ml (Tobi)
5
•
•
•
2
SULFONAMIDES
ciprofloxacin hcl tab 500 mg
(base equiv) (Cipro)
ciprofloxacin hcl tab 750 mg
(base equiv)
ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)
2
ciprofloxacin-ciprofloxacin
hcl tab sr 24hr
1000 mg(base eq) (Cipro xr)
4
FACTIVE - gemifloxacin
mesylate tab 320 mg (base
equiv)
LEVOFLOXACIN - levofloxacin 2
oral soln 25 mg/ml
1
levofloxacin tab 250 mg
(Levaquin)
1
levofloxacin tab 500 mg
(Levaquin)
1
levofloxacin tab 750 mg
(Levaquin)
paromomycin sulfate cap
250 mg
SULFADIAZINE - sulfadiazine
tab 500 mg
2
4
ANTIMYCOBACTERIAL AGENTS
4
CYCLOSERINE - cycloserine
cap 250 mg
2
ethambutol hcl tab 100 mg
(Myambutol)
2
ethambutol hcl tab 400 mg
(Myambutol)
ISONIAZID - isoniazid syrup 50 4
mg/5ml
1
isoniazid tab 100 mg
isoniazid tab 300 mg
1
PASER - aminosalicylic acid cr
granules packet 4 gm
4
PRIFTIN - rifapentine tab 150
mg
3
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
5
pyrazinamide tab 500 mg
2
rifabutin cap 150 mg
(Mycobutin)
2
flucytosine cap 500 mg
(Ancobon)
RIFAMATE - isoniazid &
rifampin cap 150-300 mg
4
griseofulvin microsize susp
125 mg/5ml
griseofulvin microsize tab
500 mg (Grifulvin v)
rifampin cap 150 mg (Rifadin) 2
rifampin cap 300 mg (Rifadin) 2
RIFATER - isoniazid-rifampin
w/ pyrazinamide tab
50-120-300 mg
4
SIRTURO - bedaquiline
fumarate tab 100 mg (base
equiv)
4
TRECATOR - ethionamide tab
250 mg
4
ANTIFUNGALS
BIO-STATIN - nystatin cap
500000 unit
4
BIO-STATIN - nystatin cap
1000000 unit
4
CRESEMBA isavuconazonium sulfate cap
186 mg
4
fluconazole for susp 10 mg/
ml (Diflucan)
1
fluconazole for susp 40 mg/
ml (Diflucan)
2
griseofulvin ultramicrosize
tab 125 mg (Gris-peg)
griseofulvin ultramicrosize
tab 250 mg (Gris-peg)
•
2
1
NOXAFIL - posaconazole susp
40 mg/ml
3
•
NOXAFIL - posaconazole tab
delayed release 100 mg
3
•
nystatin oral powder
2
4
SPORANOX - itraconazole oral
soln 10 mg/ml
4
terbinafine hcl tab 250 mg
(Lamisil)
1
voriconazole for susp
40 mg/ml (Vfend)
2
•
voriconazole tab 50 mg
(Vfend)
2
•
voriconazole tab 200 mg
(Vfend)
2
•
1
fluconazole tab 150 mg
(Diflucan)
1
fluconazole tab 200 mg
(Diflucan)
2
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
flucytosine cap 250 mg
(Ancobon)
2
abacavir sulfate-lamivudine
tab 600-300 mg (Epzicom)
ANTIVIRALS
Limited Distribution
2
ONMEL - itraconazole tab 200
mg
fluconazole tab 100 mg
(Diflucan)
ACA
2
ketoconazole tab 200 mg
1
Dispensing Limits
2
2
fluconazole tab 50 mg
(Diflucan)
Step Therapy
2
itraconazole cap 100 mg
(Sporanox)
nystatin tab 500000 unit
•
2
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
•
2
•
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6
abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg (Trizivir)
2
3
•
didanosine delayed release
capsule 125 mg (Videx ec)
2
•
2
•
2
•
2
•
EDURANT - rilpivirine hcl tab
25 mg (base equivalent)
4
•
EMTRIVA - emtricitabine caps
200 mg
4
•
EMTRIVA - emtricitabine soln
10 mg/ml
4
•
entecavir tab 0.5 mg
(Baraclude)
2
acyclovir cap 200 mg
(Zovirax)
1
acyclovir susp 200 mg/5ml
(Zovirax)
2
acyclovir tab 400 mg
(Zovirax)
1
acyclovir tab 800 mg
(Zovirax)
1
adefovir dipivoxil tab 10 mg
(Hepsera)
2
APTIVUS - tipranavir cap 250
mg
4
•
APTIVUS - tipranavir oral soln
100 mg/ml
4
•
ATRIPLA - efavirenzemtricitabine-tenofovir df tab
600-200-300 mg
3
•
entecavir tab 1 mg
(Baraclude)
2
BARACLUDE - entecavir oral
soln 0.05 mg/ml
3
EPCLUSA - sofosbuvirvelpatasvir tab 400-100 mg
5
COMPLERA - emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
4
4
CRIXIVAN - indinavir sulfate
cap 200 mg
4
•
EPIVIR - lamivudine oral soln
10 mg/ml
4
CRIXIVAN - indinavir sulfate
cap 400 mg
4
•
EPIVIR HBV - lamivudine oral
soln 5 mg/ml (hbv)
3
•
DAKLINZA - daclatasvir
dihydrochloride tab 30 mg
(base equivalent)
5
•
•
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
4
•
DAKLINZA - daclatasvir
dihydrochloride tab 60 mg
(base equivalent)
5
•
•
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg
(base equiv)
famciclovir tab 125 mg
(Famvir)
2
DAKLINZA - daclatasvir
dihydrochloride tab 90 mg
(base equivalent)
5
•
•
famciclovir tab 250 mg
(Famvir)
2
famciclovir tab 500 mg
(Famvir)
2
didanosine delayed release
capsule 200 mg (Videx ec)
didanosine delayed release
capsule 250 mg (Videx ec)
didanosine delayed release
capsule 400 mg (Videx ec)
•
•
Limited Distribution
DESCOVY - emtricitabinetenofovir alafenamide
fumarate tab 200-25 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
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7
INTELENCE - etravirine tab 25
mg
3
Limited Distribution
HARVONI - ledipasvirsofosbuvir tab 90-400 mg
5
ACA
•
Dispensing Limits
3
Step Therapy
GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab
150-150-200-10 mg
•
Prior Authorization
•
Drug Name
Drug Tier
5
Limited Distribution
FUZEON - enfuvirtide for inj 90
mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
lamivudine tab 100 mg (hbv)
(Epivir hbv)
2
lamivudine tab 150 mg
(Epivir)
2
•
lamivudine tab 300 mg
(Epivir)
2
•
•
lamivudine-zidovudine tab
150-300 mg (Combivir)
2
•
•
•
INTELENCE - etravirine tab
200 mg
3
•
LEXIVA - fosamprenavir
calcium susp 50 mg/ml
(base equiv)
4
INTELENCE - etravirine tab
100 mg
3
4
•
INVIRASE - saquinavir
mesylate cap 200 mg
4
•
LEXIVA - fosamprenavir
calcium tab 700 mg (base
equiv)
•
4
•
2
INVIRASE - saquinavir
mesylate tab 500 mg
lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/
ml) (Kaletra)
ISENTRESS - raltegravir
potassium chew tab 25 mg
(base equiv)
3
•
MODERIBA - ribavirin tab 200
mg & ribavirin tab 400 mg
dose pack
5
•
•
ISENTRESS - raltegravir
potassium chew tab 100 mg
(base equiv)
3
•
MODERIBA - ribavirin tab 400
mg & ribavirin tab 600 mg
dose pack
5
•
•
ISENTRESS - raltegravir
potassium packet for susp
100 mg (base equiv)
3
•
MODERIBA 1200 DOSE
PACK - ribavirin tab 600 mg
5
•
•
•
3
•
•
ISENTRESS - raltegravir
potassium tab 400 mg (base
equiv)
KALETRA - lopinavir-ritonavir
soln 400-100 mg/5ml (80-20
mg/ml)
3
•
KALETRA - lopinavir-ritonavir
tab 100-25 mg
3
•
KALETRA - lopinavir-ritonavir
tab 200-50 mg
3
•
lamivudine oral soln 10 mg/
ml (Epivir)
2
•
MODERIBA 800 DOSE PACK - 5
ribavirin tab 400 mg
NEVIRAPINE - nevirapine susp 4
50 mg/5ml
2
nevirapine tab sr 24hr
100 mg
2
nevirapine tab sr 24hr
400 mg (Viramune xr)
1
nevirapine tab 200 mg
(Viramune)
NORVIR - ritonavir cap 100 mg 4
•
•
NORVIR - ritonavir oral soln 80
mg/ml
3
•
•
•
•
•
•
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8
NORVIR - ritonavir tab 100 mg
3
ODEFSEY - emtricitabinerilpivirine-tenofovir af tab
200-25-25 mg
3
OLYSIO - simeprevir sodium
cap 150 mg (base
equivalent)
5
oseltamivir phosphate
cap 30 mg (base equiv)
(Tamiflu)
2
oseltamivir phosphate
cap 45 mg (base equiv)
(Tamiflu)
2
oseltamivir phosphate
cap 75 mg (base equiv)
(Tamiflu)
2
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 50 mcg/0.5ml
5
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 80 mcg/0.5ml
5
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 120 mcg/0.5ml
5
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 150 mcg/0.5ml
5
PEG-INTRON REDIPEN PAK
4 - peginterferon alfa-2b for
inj kit 120 mcg/0.5ml
5
PEGASYS - peginterferon
alfa-2a inj 180 mcg/ml
5
PEGASYS - peginterferon
alfa-2a inj 180 mcg/0.5ml
5
PEGASYS PROCLICK peginterferon alfa-2a inj 135
mcg/0.5ml
5
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PEGASYS PROCLICK peginterferon alfa-2a inj 180
mcg/0.5ml
5
•
PEGINTRON - peginterferon
alfa-2b for inj kit 50
mcg/0.5ml
5
•
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 80
mcg/0.5ml
5
•
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 120
mcg/0.5ml
5
•
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 150
mcg/0.5ml
5
•
•
PREZCOBIX - darunavircobicistat tab 800-150 mg
4
•
PREZISTA - darunavir
ethanolate susp 100 mg/ml
(base equiv)
3
•
PREZISTA - darunavir
ethanolate tab 75 mg (base
equiv)
3
•
PREZISTA - darunavir
ethanolate tab 150 mg (base
equiv)
3
•
PREZISTA - darunavir
ethanolate tab 600 mg (base
equiv)
3
•
PREZISTA - darunavir
ethanolate tab 800 mg (base
equiv)
3
•
REBETOL - ribavirin soln 40
mg/ml
5
RELENZA DISKHALER zanamivir aero powder
breath activated 5 mg/blister
4
•
RESCRIPTOR - delavirdine
mesylate tab 100 mg
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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9
4
•
REYATAZ - atazanavir sulfate
cap 150 mg (base equiv)
3
•
REYATAZ - atazanavir sulfate
cap 200 mg (base equiv)
3
•
REYATAZ - atazanavir sulfate
cap 300 mg (base equiv)
3
•
REYATAZ - atazanavir sulfate
oral powder packet 50 mg
(base equiv)
4
•
RIBASPHERE - ribavirin tab
400 mg
5
•
•
RIBASPHERE - ribavirin tab
600 mg
5
•
•
stavudine cap 30 mg (Zerit)
RIBASPHERE RIBAPAK ribavirin tab 400 mg
5
•
•
3
RIBASPHERE RIBAPAK ribavirin tab 600 mg
5
•
•
STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab
150-150-200-300 mg
•
•
•
•
•
3
•
RIBASPHERE RIBAPAK ribavirin tab 200 mg &
ribavirin tab 400 mg dose
pack
5
•
•
SUSTIVA - efavirenz cap 50
mg
SUSTIVA - efavirenz cap 200
mg
3
•
3
•
RIBASPHERE RIBAPAK ribavirin tab 400 mg &
ribavirin tab 600 mg dose
pack
5
SUSTIVA - efavirenz tab 600
mg
4
•
ribavirin cap 200 mg
(Rebetol)
5
TAMIFLU - oseltamivir
phosphate cap 30 mg (base
equiv)
4
•
ribavirin for inhal soln 6 gm
(Virazole)
2
TAMIFLU - oseltamivir
phosphate cap 45 mg (base
equiv)
4
5
•
ribavirin tab 200 mg
(Copegus)
TAMIFLU - oseltamivir
phosphate cap 75 mg (base
equiv)
rimantadine hydrochloride
tab 100 mg (Flumadine)
2
TAMIFLU - oseltamivir
phosphate for susp 6 mg/ml
(base equiv)
4
•
TECHNIVIE - ombitasvirparitaprevir-ritonavir tab
12.5-75-50 mg
5
SELZENTRY - maraviroc tab
25 mg
4
•
•
•
•
•
•
•
SELZENTRY - maraviroc tab
75 mg
4
•
SELZENTRY - maraviroc tab
150 mg
4
•
SELZENTRY - maraviroc tab
300 mg
4
•
SITAVIG - acyclovir buccal tab
50 mg
4
SOVALDI - sofosbuvir tab 400
mg
5
stavudine cap 15 mg (Zerit)
2
stavudine cap 20 mg (Zerit)
stavudine cap 40 mg (Zerit)
•
2
2
2
•
Limited Distribution
RESCRIPTOR - delavirdine
mesylate tab 200 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
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10
3
•
TRIUMEQ - abacavirdolutegravir-lamivudine tab
600-50-300 mg
4
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 100-150 mg
3
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 133-200 mg
3
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 167-250 mg
3
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 200-300 mg
3
•
TYBOST - cobicistat tab 150
mg
4
•
valacyclovir hcl tab 500 mg
(Valtrex)
2
valacyclovir hcl tab 1 gm
(Valtrex)
2
VALCYTE - valganciclovir hcl
for soln 50 mg/ml (base
equiv)
3
valganciclovir hcl for soln
50 mg/ml (base equiv)
(Valcyte)
2
valganciclovir hcl tab
450 mg (base equivalent)
(Valcyte)
2
VIDEX - didanosine for soln 2
gm
3
•
•
•
•
•
Limited Distribution
TIVICAY - dolutegravir sodium
tab 50 mg (base equiv)
•
ACA
•
Dispensing Limits
3
Step Therapy
TIVICAY - dolutegravir sodium
tab 25 mg (base equiv)
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
TIVICAY - dolutegravir sodium
tab 10 mg (base equiv)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
VIDEX - didanosine for soln 4
gm
3
VIEKIRA PAK - ombitasparitapre-riton & dasab tab
pak 12.5-75-50 & 250 mg
5
•
•
VIEKIRA XR - dasab-ombitparitap-riton tab sr 24hr
200-8.33-50-33.33 mg
5
•
•
VIRACEPT - nelfinavir
mesylate tab 250 mg
4
•
VIRACEPT - nelfinavir
mesylate tab 625 mg
4
•
VIRAMUNE - nevirapine susp
50 mg/5ml
3
•
VIRAMUNE XR - nevirapine
tab sr 24hr 100 mg
4
•
VIRAZOLE - ribavirin for inhal
soln 6 gm
4
VIREAD - tenofovir disoproxil
fumarate oral powder 40 mg/
gm
3
•
VIREAD - tenofovir disoproxil
fumarate tab 150 mg
3
•
VIREAD - tenofovir disoproxil
fumarate tab 200 mg
3
•
VIREAD - tenofovir disoproxil
fumarate tab 250 mg
3
•
VIREAD - tenofovir disoproxil
fumarate tab 300 mg
3
•
ZEPATIER - elbasvirgrazoprevir tab 50-100 mg
5
ZERIT - stavudine for oral soln
1 mg/ml
4
•
ZIAGEN - abacavir sulfate soln
20 mg/ml (base equiv)
3
•
zidovudine cap 100 mg
(Retrovir)
2
•
•
•
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11
ANTIMALARIALS
atovaquone-proguanil hcl
tab 62.5-25 mg (Malarone)
atovaquone-proguanil hcl
tab 250-100 mg (Malarone)
2
2
atovaquone susp
750 mg/5ml (Mepron)
2
CAYSTON - aztreonam lysine
for inhal soln 75 mg (base
equivalent)
5
clindamycin hcl cap 75 mg
(Cleocin)
1
clindamycin hcl cap 150 mg
(Cleocin)
1
•
•
CHLOROQUINE
PHOSPHATE - chloroquine
phosphate tab 250 mg
1
chloroquine phosphate tab
500 mg (Aralen)
1
clindamycin hcl cap 300 mg
(Cleocin)
1
COARTEM - artemetherlumefantrine tab 20-120 mg
4
2
DARAPRIM - pyrimethamine
tab 25 mg
3
clindamycin palmitate hcl
for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)
hydroxychloroquine sulfate
tab 200 mg (Plaquenil)
1
dapsone tab 100 mg
3
2
IMPAVIDO - miltefosine cap 50
mg
linezolid for susp
100 mg/5ml (Zyvox)
2
•
2
•
mefloquine hcl tab 250 mg
PRIMAQUINE PHOSPHATE primaquine phosphate tab
26.3 mg (15 mg base)
3
quinine sulfate cap 324 mg
(Qualaquin)
2
ANTHELMINTICS
•
dapsone tab 25 mg
linezolid tab 600 mg (Zyvox)
2
metronidazole cap 375 mg
(Flagyl)
2
1
ALBENZA - albendazole tab
200 mg
3
1
BILTRICIDE - praziquantel tab
600 mg
3
metronidazole tab 500 mg
(Flagyl)
4
EMVERM - mebendazole chew
tab 100 mg
4
NEBUPENT - pentamidine
isethionate for nebulization
soln 300 mg
ivermectin tab 3 mg
(Stromectol)
2
PRIMSOL - trimethoprim hcl
oral soln 50 mg/5ml (base
equiv)
4
SIVEXTRO - tedizolid
phosphate tab 200 mg
4
•
•
2
metronidazole tab 250 mg
(Flagyl)
ANTI-INFECTIVE AGENTS - MISC.
ALINIA - nitazoxanide for susp 4
100 mg/5ml
Limited Distribution
•
ACA
•
Dispensing Limits
2
4
Step Therapy
zidovudine tab 300 mg
ALINIA - nitazoxanide tab 500
mg
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
zidovudine syrup 10 mg/ml
(Retrovir)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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1
AFLURIA PF 2016-2017 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
1
A
•
1
AFLURIA QUADRIVALENT
2016 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
tinidazole tab 250 mg
(Tindamax)
2
AFLURIA 2012-2013 influenza virus vaccine split
im susp
A
•
tinidazole tab 500 mg
(Tindamax)
2
AFLURIA 2014-2015 influenza virus vaccine split
im susp
trimethoprim tab 100 mg
1
AFLURIA 2015-2016 influenza virus vaccine split
im susp
A
•
AFLURIA 2016-2017 influenza virus vaccine split
im susp
A
•
ENGERIX-B - hepatitis b
vaccine (recombinant) susp
10 mcg/0.5ml
A
•
ENGERIX-B - hepatitis b
vaccine (recombinant) susp
20 mcg/ml
A
•
ENGERIX-B - hepatitis b
vaccine (recombinant) 10
mcg/0.5ml
A
•
sulfamethoxazoletrimethoprim susp
200-40 mg/5ml
sulfamethoxazoletrimethoprim tab
400-80 mg (Bactrim)
sulfamethoxazoletrimethoprim tab
800-160 mg (Bactrim ds)
vancomycin hcl cap 125 mg
(Vancocin hcl)
2
vancomycin hcl cap 250 mg
(Vancocin hcl)
2
XIFAXAN - rifaximin tab 200
mg
4
•
XIFAXAN - rifaximin tab 550
mg
3
•
ZYVOX - linezolid for susp 100
mg/5ml
4
•
ZYVOX - linezolid tab 600 mg
4
•
BIOLOGICALS
VACCINES
AFLURIA PF 2012-2013 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
ENGERIX-B - hepatitis b
vaccine (recombinant) 20
mcg/ml
A
•
AFLURIA PF 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
FLUAD 2016-2017 - influenza
vac type a&b surface ant adj
susp pref syr 0.5 ml
A
•
AFLURIA PF 2015-2016 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
FLUARIX QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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A
•
FLUMIST QUADRIVALENT influenza virus vaccine live
quadrivalent intranasal susp
A
•
FLUVIRIN PF 2014-2015 influenza virus vac types a &
b pf susp prefilled syr 0.5 ml
A
•
A
•
•
FLUVIRIN 2014-2015 influenza virus vaccine types
a & b surface antigen im
susp
A
•
•
FLUVIRIN 2015-2016 influenza vac type a&b
surface antigen susp pref syr
0.5 ml
A
•
•
FLUVIRIN 2015-2016 influenza virus vaccine types
a & b surface antigen im
susp
A
•
•
FLUVIRIN 2016-2017 influenza vac type a&b
surface antigen susp pref syr
0.5 ml
A
•
A
•
FLUVIRIN 2016-2017 influenza virus vaccine types
a & b surface antigen im
susp
A
•
•
FLULAVAL QUADRIVALENT
201 - influenza virus vac split
quadrivalent susp pref syr
0.5ml
A
•
FLUZONE HIGH-DOSE PF
2014 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
A
FLUCELVAX 2015-2016 influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml
A
•
FLULAVAL QUADRIVALENT
201 - influenza virus vaccine
split quadrivalent im inj
A
•
FLUZONE HIGH-DOSE PF
2015 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
A
FLUARIX QUADRIVALENT
2016 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
FLUARIX 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
FLUBLOK 2014-2015 influenza virus vac
recombinant hemagglutinin
(ha) inj
A
FLUBLOK 2015-2016 influenza virus vac
recombinant hemagglutinin
(ha) inj
A
FLUBLOK 2016-2017 influenza virus vac
recombinant hemagglutinin
(ha) inj
A
FLUCELVAX QUADRIVALENT
20 - influenza vac tiss-cult
subunt quad susp pref syr
0.5 ml
A
FLUCELVAX 2014-2015 influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Drug Name
FLULAVAL 2014-2015 influenza virus vaccine split
im susp
FLUARIX QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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FLUZONE QUADRIVALENT
2015 - influenza virus
vaccine split quadrivalent inj
0.5 ml
A
•
FLUZONE QUADRIVALENT
2016 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
A
•
FLUZONE PF 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
FLUZONE QUADRIVALENT
2016 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
FLUZONE QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
A
•
FLUZONE QUADRIVALENT
2016 - influenza virus
vaccine split quadrivalent im
inj
A
•
FLUZONE QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
FLUZONE QUADRIVALENT
2016 - influenza virus
vaccine split quadrivalent inj
0.5 ml
A
•
FLUZONE QUADRIVALENT
2014 - influenza virus
vaccine split quadrivalent im
inj
A
FLUZONE SPLIT 2014-2015 influenza virus vaccine split
im susp
A
•
FLUZONE QUADRIVALENT
2014 - influenza virus
vaccine split quadrivalent inj
0.5 ml
A
FLUZONE SPLIT 2015-2016 influenza virus vaccine split
im susp
A
•
FLUZONE QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
A
•
IMOVAX RABIES (H.D.C.V.) rabies virus vaccine, hdc inj
A
•
A
•
•
MEDICAL PROVIDER EZ FLU
S - influenza virus vac tisscult subunit pref syr kit 0.5
ml
FLUZONE QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
A
•
•
MEDICAL PROVIDER EZ FLU
S - influenza virus vac types
a & b pf pref syringe kit 0.5
ml
FLUZONE QUADRIVALENT
2015 - influenza virus
vaccine split quadrivalent im
inj
A
MEDICAL PROVIDER
SINGLE U - influenza vac
type a&b surface antigen
pref syr kit 0.5 ml
A
•
•
•
•
Limited Distribution
•
ACA
A
Dispensing Limits
FLUZONE INTRADERMAL
QUADR - influenza virus vac
split quad intradermal pen 9
mcg/strain
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
FLUZONE HIGH-DOSE PF
2016 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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A
MEDICAL PROVIDER
SINGLE U - influenza virus
vac types a & b pf pref
syringe kit 0.5 ml
A
•
MEDICAL PROVIDER
SINGLE U - influenza virus
vaccine split pf susp pref syr
kit 0.5 ml
A
•
PNEUMOVAX 23 pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
A
•
PNEUMOVAX 23/1 DOSE pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
A
PNEUMOVAX 23/5 DOSE pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
TOXOIDS
ADACEL - tet tox-diph-acell
pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml
A
•
BOOSTRIX - tet tox-diph-acell
pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
A
•
DAPTACEL - diph, acellular
pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml
4
DIPHTHERIA/TETANUS
TOXOID - diphtheria-tetanus
tox adsorbed (dt) im inj 25-5
unit/0.5ml
4
•
INFANRIX - diph, acellular pert
& tet tox inj 25 lf-58 mcg-10
lf/0.5ml
4
A
•
KINRIX - diph-tetanus tox adacell pert & polio virus, ipv
vac inj
4
PREVNAR 13 - Pneumococcal
13-valent conjugate vaccine
inj
A
•
PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio
ipv vac inj
4
RABAVERT - rabies vaccine,
pcec for inj
A
•
4
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
5 mcg/0.5ml
A
•
PENTACEL - diph-ac per-tet
tox ad-poliov-haemoph b
poly vac for im susp
4
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
10 mcg/ml
A
•
QUADRACEL - diph-tetanus
tox ad-acell pert & polio
virus, ipv vac inj
TENIVAC - tetanus-diphtheria
toxoids (td) inj 5-2 lfu
4
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
40 mcg/ml
A
•
TETANUS/DIPHTHERIA
TOXOID - tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml
4
VIVOTIF - typhoid vaccine cap
delayed release
4
ZOSTAVAX - zoster vaccine
live for subcutaneous susp
19400 unit/0.65ml
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
MEDICAL PROVIDER
SINGLE U - influenza virus
vac split quad inj prefilled syr
kit 0.25 ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PASSIVE IMMUNIZING AGENTS
4
HEPAGAM B - hepatitis b
immune globulin (human) inj
soln
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
16
Limited Distribution
4
•
ORALAIR ADULT STARTER
PAC - grass mixed pollen
ext tab sl 300 ir (index of
reactivity)
4
•
•
•
ORALAIR CHILDREN/
ADOLESCE - grass mixed
pollen ext tab sl 100 ir (index
of reactivity)
4
•
•
•
ORALAIR CHILDREN/
ADOLESCE - grass mixed
pollen tab sl therpak 100 (3)
ir & 300 (6) ir
4
RAGWITEK - short ragweed
pollen allergen extract tab sl
12 amb a 1-u
4
•
ACTIMMUNE - interferon
gamma-1b inj 100
mcg/0.5ml (2000000
unit/0.5ml)
5
•
AFINITOR - everolimus tab 2.5
mg
5
•
•
•
4
AFINITOR - everolimus tab 5
mg
5
•
•
•
4
AFINITOR - everolimus tab 7.5
mg
5
•
•
•
AFINITOR - everolimus tab 10
mg
5
•
•
•
AFINITOR DISPERZ everolimus tab for oral susp
2 mg
5
•
•
•
AFINITOR DISPERZ everolimus tab for oral susp
3 mg
5
•
•
•
4
HYPERRAB S/D - rabies
immune globulin (human) inj
150 unit/ml
4
HYPERTET S/D - tetanus
immune globulin (human) inj
250 unit/ml
4
HYQVIA - immun glob inj 2.5
gm/25ml-hyaluron inj 200
unt/1.25 ml kit
4
•
•
HYQVIA - immun glob inj 5
gm/50ml-hyaluron inj 400
unt/2.5 ml kit
4
•
•
HYQVIA - immun glob inj 10
gm/100ml-hyaluron inj 800
unt/5 ml kit
4
•
•
HYQVIA - immun glob inj 20
gm/200ml-hyaluron inj 1600
unt/10 ml kit
4
•
•
HYQVIA - immun glob inj 30
gm/300ml-hyaluron inj 2400
unt/15 ml kit
4
IMOGAM RABIES-HT - rabies
immune globulin (human) inj
150 unit/ml
4
NABI-HB - hepatitis b immune
globulin (human) im inj soln
VARIZIG - varicella-zoster
immune glob (human) im inj
125 unit/1.2ml
•
•
GRASTEK - timothy grass
pollen allergen ext tab sl
2800 bau
4
•
•
ORALAIR - grass mixed pollen
ext tab sl 300 ir (index of
reactivity)
4
•
•
•
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
ORALAIR ADULT SAMPLE
KIT - grass mixed pollen
ext tab sl 300 ir (index of
reactivity)
HYPERHEP B S/D - hepatitis b
immune globulin (human) im
inj soln
BIOLOGICALS MISC
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS
•
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•
ALKERAN - melphalan tab 2
mg
3
anastrozole tab 1 mg
(Arimidex)
1
bexarotene cap 75 mg
(Targretin)
5
bicalutamide tab 50 mg
(Casodex)
1
BOSULIF - bosutinib tab 100
mg
5
•
•
•
BOSULIF - bosutinib tab 500
mg
5
•
•
•
CABOMETYX - cabozantinib
s-malate tab 20 mg (base
equivalent)
5
•
•
•
CABOMETYX - cabozantinib
s-malate tab 40 mg (base
equivalent)
5
•
•
•
CABOMETYX - cabozantinib
s-malate tab 60 mg (base
equivalent)
5
•
•
•
capecitabine tab 150 mg
(Xeloda)
5
•
•
capecitabine tab 500 mg
(Xeloda)
5
•
CAPRELSA - vandetanib tab
100 mg
5
•
CAPRELSA - vandetanib tab
300 mg
5
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit
5
•
•
•
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit
5
•
COMETRIQ - cabozantinib smalate cap 3 x 20 mg (60
mg dose) kit
5
•
•
•
COTELLIC - cobimetinib
fumarate tab 20 mg (base
equivalent)
5
•
•
•
CYCLOPHOSPHAMIDE cyclophosphamide cap 25
mg
4
CYCLOPHOSPHAMIDE cyclophosphamide cap 50
mg
4
ELIGARD - leuprolide acetate
(3 month) for subcutaneous
inj kit 22.5mg
5
•
•
ELIGARD - leuprolide acetate
(4 month) for subcutaneous
inj kit 30 mg
5
•
•
ELIGARD - leuprolide acetate
(6 month) for subcutaneous
inj kit 45 mg
5
•
•
ELIGARD - leuprolide acetate
for subcutaneous inj kit 7.5
mg
5
•
•
4
•
EMCYT - estramustine
phosphate sodium cap 140
mg
•
ERIVEDGE - vismodegib cap
150 mg
5
•
ETOPOSIDE - etoposide cap
50 mg
4
•
exemestane tab 25 mg
(Aromasin)
2
•
•
•
•
•
Limited Distribution
5
•
•
ACA
ALECENSA - alectinib hcl cap
150 mg (base equivalent)
•
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
AFINITOR DISPERZ everolimus tab for oral susp
5 mg
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
FARESTON - toremifene citrate 4
tab 60 mg (base equivalent)
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FARYDAK - panobinostat
lactate cap 10 mg (base
equivalent)
5
FARYDAK - panobinostat
lactate cap 15 mg (base
equivalent)
5
FARYDAK - panobinostat
lactate cap 20 mg (base
equivalent)
5
flutamide cap 125 mg
2
•
•
•
•
•
•
GILOTRIF - afatinib dimaleate
tab 20 mg (base equivalent)
5
•
•
•
GILOTRIF - afatinib dimaleate
tab 30 mg (base equivalent)
5
•
•
•
GILOTRIF - afatinib dimaleate
tab 40 mg (base equivalent)
5
•
•
•
GLEEVEC - imatinib
mesylate tab 100 mg (base
equivalent)
5
•
•
•
GLEEVEC - imatinib
mesylate tab 400 mg (base
equivalent)
5
•
•
•
GLEOSTINE - lomustine cap 5
mg
4
GLEOSTINE - lomustine cap
10 mg
4
GLEOSTINE - lomustine cap
40 mg
4
GLEOSTINE - lomustine cap
100 mg
4
HEXALEN - altretamine cap 50
mg
5
•
•
HYCAMTIN - topotecan hcl cap 5
0.25 mg (base equiv)
HYCAMTIN - topotecan hcl cap 5
1 mg (base equiv)
2
hydroxyurea cap 500 mg
(Hydrea)
•
•
•
•
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
IBRANCE - palbociclib cap 75
mg
5
•
•
IBRANCE - palbociclib cap 100
mg
5
•
•
•
IBRANCE - palbociclib cap 125
mg
5
•
•
•
ICLUSIG - ponatinib hcl tab 15
mg (base equiv)
5
•
•
•
ICLUSIG - ponatinib hcl tab 45
mg (base equiv)
5
•
•
•
imatinib mesylate tab
100 mg (base equivalent)
(Gleevec)
5
•
•
•
imatinib mesylate tab
400 mg (base equivalent)
(Gleevec)
5
•
•
•
IMBRUVICA - ibrutinib cap 140
mg
5
•
•
•
INLYTA - axitinib tab 1 mg
5
INLYTA - axitinib tab 5 mg
5
•
•
INTRON A - interferon alfa-2b
inj 6000000 unit/ml
5
•
•
•
•
•
•
INTRON A - interferon alfa-2b
inj 10000000 unit/ml
5
•
•
INTRON A - interferon alfa-2b
for inj 10000000 unit
5
•
•
INTRON A - interferon alfa-2b
for inj 18000000 unit
5
•
•
INTRON A - interferon alfa-2b
for inj 50000000 unit
5
•
•
INTRON A W/DILUENT interferon alfa-2b for inj
10000000 unit
5
•
•
INTRON A W/DILUENT interferon alfa-2b for inj
18000000 unit
5
•
•
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19
JAKAFI - ruxolitinib phosphate
tab 5 mg (base equivalent)
5
•
•
•
•
•
•
JAKAFI - ruxolitinib phosphate
tab 10 mg (base equivalent)
5
•
•
•
JAKAFI - ruxolitinib phosphate
tab 15 mg (base equivalent)
5
•
•
•
JAKAFI - ruxolitinib phosphate
tab 20 mg (base equivalent)
5
•
•
•
JAKAFI - ruxolitinib phosphate
tab 25 mg (base equivalent)
5
•
•
•
LENVIMA 10 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 mg (10 mg
daily dose)
5
•
•
LENVIMA 14 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 & 4 mg (14
mg daily dose)
5
•
•
LENVIMA 18 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 & 4 (2) mg
(18 mg daily dose)
5
LENVIMA 20 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 (2) mg (20
mg daily dose)
5
LENVIMA 24 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 (2) & 4 mg
(24 mg daily dose)
5
•
•
•
LENVIMA 8 MG DAILY DOSE - 5
lenvatinib cap therapy pack
4 (2) mg (8 mg daily dose)
letrozole tab 2.5 mg (Femara) 1
•
•
•
•
•
•
3
LEUCOVORIN CALCIUM leucovorin calcium tab 15
mg
3
leucovorin calcium tab 5 mg
2
leucovorin calcium tab
25 mg
Limited Distribution
5
LEUCOVORIN CALCIUM leucovorin calcium tab 10
mg
ACA
IRESSA - gefitinib tab 250 mg
•
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
INTRON A W/DILUENT interferon alfa-2b for inj
50000000 unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
LEUKERAN - chlorambucil tab
2 mg
3
leuprolide acetate inj kit
5 mg/ml
5
•
•
LONSURF - trifluridine-tipiracil
tab 15-6.14 mg
5
•
•
•
LONSURF - trifluridine-tipiracil
tab 20-8.19 mg
5
•
•
•
•
LYNPARZA - olaparib cap 50
mg
5
•
•
•
LYSODREN - mitotane tab 500
mg
5
•
•
MATULANE - procarbazine hcl
cap 50 mg
5
•
•
megestrol acetate susp
40 mg/ml (Megace oral)
2
•
•
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
•
1
1
MEKINIST - trametinib dimethyl 5
sulfoxide tab 0.5 mg (base
equivalent)
MEKINIST - trametinib dimethyl 5
sulfoxide tab 2 mg (base
equivalent)
2
mercaptopurine tab 50 mg
MESNEX - mesna tab 400 mg
4
METHOTREXATE SODIUM methotrexate sodium inj 250
mg/10ml (25 mg/ml)
1
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
20
methotrexate sodium for inj
1 gm
methotrexate sodium inj pf
50 mg/2ml (25 mg/ml)
methotrexate sodium inj pf
100 mg/4ml (25 mg/ml)
methotrexate sodium inj pf
200 mg/8ml (25 mg/ml)
methotrexate sodium inj pf
250 mg/10ml (25 mg/ml)
methotrexate sodium inj pf
1000 mg/40ml (25 mg/ml)
methotrexate sodium inj
50 mg/2ml (25 mg/ml)
methotrexate sodium tab
2.5 mg (base equiv)
Limited Distribution
2
POMALYST - pomalidomide
cap 3 mg
5
•
1
POMALYST - pomalidomide
cap 4 mg
5
•
1
PURIXAN - mercaptopurine
susp 2000 mg/100ml (20
mg/ml)
5
RUBRACA - rucaparib
camsylate tab 200 mg (base
equivalent)
5
•
•
•
RUBRACA - rucaparib
camsylate tab 300 mg (base
equivalent)
5
•
•
•
SOLTAMOX - tamoxifen citrate
oral soln 10 mg/5ml (base
equivalent)
4
SPRYCEL - dasatinib tab 20
mg
5
•
•
•
SPRYCEL - dasatinib tab 50
mg
5
•
•
•
1
1
1
1
2
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
MYLERAN - busulfan tab 2 mg
3
NEXAVAR - sorafenib
tosylate tab 200 mg (base
equivalent)
5
NILANDRON - nilutamide tab
150 mg
4
SPRYCEL - dasatinib tab 70
mg
5
•
•
•
nilutamide tab 150 mg
(Nilandron)
2
SPRYCEL - dasatinib tab 80
mg
5
•
•
•
NINLARO - ixazomib
citrate cap 2.3 mg (base
equivalent)
5
SPRYCEL - dasatinib tab 100
mg
5
•
•
•
5
•
•
•
NINLARO - ixazomib citrate
cap 3 mg (base equivalent)
5
•
•
•
SPRYCEL - dasatinib tab 140
mg
•
•
•
NINLARO - ixazomib citrate
cap 4 mg (base equivalent)
5
•
•
•
•
•
•
ODOMZO - sonidegib
phosphate cap 200 mg
(base equivalent)
5
•
•
•
•
•
•
POMALYST - pomalidomide
cap 1 mg
5
•
•
•
•
•
•
POMALYST - pomalidomide
cap 2 mg
5
•
•
•
STIVARGA - regorafenib tab 40 5
mg
SUTENT - sunitinib malate cap 5
12.5 mg (base equivalent)
SUTENT - sunitinib malate cap 5
25 mg (base equivalent)
SUTENT - sunitinib malate cap 5
37.5 mg (base equivalent)
SUTENT - sunitinib malate cap 5
50 mg (base equivalent)
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
21
•
•
SYLATRON - peginterferon
alfa-2b for inj kit 600 mcg
5
•
•
TABLOID - thioguanine tab 40
mg
4
•
TAFINLAR - dabrafenib
mesylate cap 50 mg (base
equivalent)
5
•
•
•
TAFINLAR - dabrafenib
mesylate cap 75 mg (base
equivalent)
5
•
•
•
TAGRISSO - osimertinib
mesylate tab 40 mg (base
equivalent)
5
•
•
•
TAGRISSO - osimertinib
mesylate tab 80 mg (base
equivalent)
5
•
•
•
tamoxifen citrate tab 10 mg
(base equivalent)
1
•
1
•
Limited Distribution
5
ACA
SYLATRON - peginterferon
alfa-2b for inj kit 300 mcg
tamoxifen citrate tab 20 mg
(base equivalent)
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
SYLATRON - peginterferon
alfa-2b for inj kit 200 mcg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
temozolomide cap 20 mg
(Temodar)
5
•
•
temozolomide cap 100 mg
(Temodar)
5
•
•
temozolomide cap 140 mg
(Temodar)
5
•
•
temozolomide cap 180 mg
(Temodar)
5
•
•
temozolomide cap 250 mg
(Temodar)
5
•
•
tretinoin cap 10 mg
5
•
•
TREXALL - methotrexate
sodium tab 5 mg (base
equiv)
4
TREXALL - methotrexate
sodium tab 7.5 mg (base
equiv)
4
TREXALL - methotrexate
sodium tab 10 mg (base
equiv)
4
TREXALL - methotrexate
sodium tab 15 mg (base
equiv)
4
5
•
•
•
TARCEVA - erlotinib hcl tab 25
mg (base equivalent)
5
•
•
•
TYKERB - lapatinib ditosylate
tab 250 mg (base equiv)
5
•
•
•
VENCLEXTA - venetoclax tab
10 mg
5
TARCEVA - erlotinib hcl tab
100 mg (base equivalent)
•
•
•
5
•
•
•
VENCLEXTA - venetoclax tab
50 mg
5
TARCEVA - erlotinib hcl tab
150 mg (base equivalent)
•
•
•
•
•
VENCLEXTA - venetoclax tab
100 mg
5
TARGRETIN - bexarotene cap
75 mg
5
•
•
•
VENCLEXTA STARTING
PACK - venetoclax tab
therapy starter pack 10 & 50
& 100 mg
5
•
•
•
VOTRIENT - pazopanib hcl tab
200 mg (base equiv)
5
•
•
•
TASIGNA - nilotinib hcl cap 150 5
mg (base equivalent)
TASIGNA - nilotinib hcl cap 200 5
mg (base equivalent)
5
temozolomide cap 5 mg
(Temodar)
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
22
•
XTANDI - enzalutamide cap 40
mg
5
•
ZELBORAF - vemurafenib tab
240 mg
5
ZOLINZA - vorinostat cap 100
mg
•
•
•
dexamethasone tab 0.5 mg
1
dexamethasone tab 0.75 mg
•
•
•
5
•
•
•
ZYDELIG - idelalisib tab 100
mg
5
•
•
•
ZYDELIG - idelalisib tab 150
mg
5
•
•
•
ZYKADIA - ceritinib cap 150
mg
5
•
•
•
ZYTIGA - abiraterone acetate
tab 250 mg
5
•
•
•
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
ACTIVE INJECTION KIT KL-3 - 4
triamcinolone inj 40 mg/ml &
lidocaine 1% & ammonia inh
kit
2
budesonide delayed
release particles cap 3 mg
(Entocort ec)
3
CORTISONE ACETATE cortisone acetate tab 25 mg
4
DEXAMETHASONE dexamethasone soln 0.5
mg/5ml
4
DEXAMETHASONE dexamethasone tab 1 mg
4
DEXAMETHASONE dexamethasone tab 2 mg
2
dexamethasone elixir
0.5 mg/5ml
dexamethasone tab 1.5 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
Limited Distribution
•
4
ACA
5
DEXAMETHASONE
INTENSOL - dexamethasone
conc 1 mg/ml
Dispensing Limits
XALKORI - crizotinib cap 250
mg
•
Step Therapy
•
Prior Authorization
•
Drug Name
Drug Tier
5
Limited Distribution
XALKORI - crizotinib cap 200
mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
DEXPAK 10 DAY dexamethasone tab therapy
pack 1.5 mg (35)
4
DEXPAK 13 DAY dexamethasone tab therapy
pack 1.5 mg (51)
4
DEXPAK 6 DAY dexamethasone tab therapy
pack 1.5 mg (21)
4
fludrocortisone acetate tab
0.1 mg
2
hydrocortisone tab 5 mg
(Cortef)
2
hydrocortisone tab 10 mg
(Cortef)
2
hydrocortisone tab 20 mg
(Cortef)
2
INTERARTICULAR JOINT
KIT - triamcinolone inj 40
mg/ml & lidocaine 1% &
ammonia inh kit
4
JTT PHYSICIANS KIT triamcinolone inj 40 mg/ml &
lidocaine 1% & ammonia inh
kit
4
MEDROL - methylprednisolone
tab 2 mg
4
methylprednisolone tab
therapy pack 4 mg (21)
(Medrol dosepak)
2
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
23
methylprednisolone tab
4 mg (Medrol)
methylprednisolone tab
8 mg (Medrol)
methylprednisolone tab
16 mg (Medrol)
methylprednisolone tab
32 mg (Medrol)
2
2
2
2
prednisolone sod phosphate
oral soln 10 mg/5ml (base
equiv) (Millipred)
prednisolone sod phosphate
oral soln 20 mg/5ml (base
equiv) (Veripred 20)
4
prednisolone syrup
15 mg/5ml (usp solution
equivalent)
1
4
MILLIPRED - prednisolone tab
5 mg
4
MILLIPRED DP - prednisolone
tab therapy pack 5 mg (21)
4
PREDNISONE - prednisone
oral soln 5 mg/5ml
4
MILLIPRED DP - prednisolone
tab therapy pack 5 mg (48)
4
PREDNISONE - prednisone
tab therapy pack 5 mg (21)
4
PREDNISONE - prednisone
tab therapy pack 5 mg (48)
4
PREDNISONE - prednisone
tab therapy pack 10 mg (21)
4
PREDNISONE - prednisone
tab therapy pack 10 mg (48)
4
PREDNISONE - prednisone
tab 50 mg
4
PREDNISONE INTENSOL prednisone conc 5 mg/ml
4
prednisone tab 1 mg
1
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
Limited Distribution
ACA
Dispensing Limits
2
PREDNISOLONE SODIUM
PHOSP - prednisolone
sodium phosphate oral soln
25 mg/5ml (base eq)
prednisone tab 2.5 mg
Step Therapy
2
MILLIPRED - prednisolone
sod phosphate oral soln 10
mg/5ml (base equiv)
4
PHYSICIANS EZ USE JOINT
T - triamcinolone inj 40 mg/ml
& lidocaine 1% & ammonia
inh kit
2
prednisolone sod phos
orally disintegr tab 10 mg
(base eq) (Orapred odt)
2
prednisolone sod phos
orally disintegr tab 15 mg
(base eq) (Orapred odt)
2
prednisolone sod phos
orally disintegr tab 30 mg
(base eq) (Orapred odt)
2
prednisolone sod phosph
oral soln 6.7 mg/5ml
(5 mg/5ml base)
(Pediapred)
prednisolone sod phosphate 1
oral soln 15 mg/5ml (base
equiv)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
RAYOS - prednisone tab
delayed release 1 mg
4
RAYOS - prednisone tab
delayed release 2 mg
4
RAYOS - prednisone tab
delayed release 5 mg
4
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
24
UCERIS - budesonide tab sr
24hr 9 mg
4
VERIPRED 20 - prednisolone
sod phosphate oral soln 20
mg/5ml (base equiv)
4
ANDROGEN-ANABOLIC
•
oxandrolone tab 2.5 mg
(Oxandrin)
2
•
oxandrolone tab 10 mg
(Oxandrin)
2
•
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
2
•
•
2
•
•
2
•
•
ANADROL-50 - oxymetholone
tab 50 mg
4
•
ANDROGEL - testosterone td
gel 25 mg/2.5gm (1%)
4
•
•
ANDROGEL - testosterone td
gel 50 mg/5gm (1%)
4
•
•
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
ANDROGEL - testosterone
td gel 20.25 mg/1.25gm
(1.62%)
4
•
•
testosterone enanthate im
inj in oil 200 mg/ml
•
•
•
4
•
2
ANDROGEL - testosterone td
gel 40.5 mg/2.5gm (1.62%)
testosterone td gel
25 mg/2.5gm (1%)
(Androgel)
ANDROGEL PUMP testosterone td gel 20.25
mg/act (1.62%)
4
•
•
testosterone td gel
50 mg/5gm (1%) (Androgel)
2
•
•
2
•
•
ANDROXY - fluoxymesterone
tab 10 mg
3
AXIRON - testosterone td soln
30 mg/act
3
•
danazol cap 50 mg
2
•
•
•
DEPO-TESTOSTERONE testosterone cypionate im inj
in oil 100 mg/ml
4
•
•
•
•
DEPO-TESTOSTERONE testosterone cypionate im inj
in oil 200 mg/ml
4
•
FORTESTA - testosterone td
gel 10mg/act (2%)
4
METHITEST methyltestosterone oral tab
10 mg
4
danazol cap 100 mg
danazol cap 200 mg
2
2
testosterone td gel 12.5 mg/
act (1%) (Androgel pump)
•
•
•
•
ESTROGENS
ALORA - estradiol td patch
twice weekly 0.025 mg/24hr
4
•
ALORA - estradiol td patch
twice weekly 0.05 mg/24hr
4
•
ALORA - estradiol td patch
twice weekly 0.075 mg/24hr
4
•
ALORA - estradiol td patch
twice weekly 0.1 mg/24hr
4
•
ANGELIQ - drospirenoneestradiol tab 0.25-0.5 mg
4
ANGELIQ - drospirenoneestradiol tab 0.5-1 mg
4
CLIMARA PRO - estradiollevonorgestrel td patch
weekly 0.045-0.015 mg/day
4
Limited Distribution
2
methyltestosterone cap
10 mg (Testred)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
25
3
estradiol tab 2 mg (Estrace)
2
•
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
3
estradiol td patch twice
weekly 0.025 mg/24hr
(Vivelle-dot)
2
•
DELESTROGEN - estradiol
valerate im in oil 10 mg/ml
4
estradiol td patch twice
weekly 0.0375 mg/24hr
(Vivelle-dot)
4
estradiol td patch twice
weekly 0.05 mg/24hr
(Vivelle-dot)
2
DELESTROGEN - estradiol
valerate im in oil 20 mg/ml
•
DELESTROGEN - estradiol
valerate im in oil 40 mg/ml
4
2
•
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
3
estradiol td patch twice
weekly 0.075 mg/24hr
(Vivelle-dot)
2
•
DIVIGEL - estradiol td gel 0.5
mg/0.5gm (0.1%)
3
estradiol td patch twice
weekly 0.1 mg/24hr
(Vivelle-dot)
DIVIGEL - estradiol td gel 1
mg/gm (0.1%)
3
estradiol td patch weekly
0.025 mg/24hr (Climara)
2
•
DUAVEE - conjugated
estrogens-bazedoxifene tab
0.45-20 mg
4
estradiol td patch
weekly 0.0375 mg/24hr
(37.5 mcg/24hr) (Climara)
2
•
ELESTRIN - estradiol gel
0.06% (0.52 mg/0.87 gm
metered-dose pump)
4
estradiol td patch weekly
0.05 mg/24hr (Climara)
2
•
2
•
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
2
2
•
2
•
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
2
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
2
estradiol & norethindrone
acetate tab 1-0.5 mg
(Activella)
2
estradiol tab 0.5 mg (Estrace) 1
1
estradiol tab 1 mg (Estrace)
estradiol td patch weekly
0.075 mg/24hr (Climara)
estradiol td patch weekly
0.1 mg/24hr (Climara)
estradiol valerate im in oil
20 mg/ml (Delestrogen)
estradiol valerate im in oil
40 mg/ml (Delestrogen)
Limited Distribution
ACA
Dispensing Limits
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
estradiol td patch weekly
0.06 mg/24hr (Climara)
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
ESTROGEL - estradiol gel
0.06% (0.75 mg/1.25 gm
metered-dose pump)
4
ESTROPIPATE - estropipate
tab 0.75 mg
1
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
26
ESTROPIPATE - estropipate
tab 1.5 mg
1
ESTROPIPATE - estropipate
tab 3 mg
4
4
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate
tab 1-0.09mg(15)
4
EVAMIST - estradiol
transdermal spray 1.53 mg/
spray
4
PREMARIN - estrogens,
conjugated tab 0.3 mg
PREMARIN - estrogens,
conjugated tab 0.45 mg
4
FEMHRT LOW DOSE norethindrone acetateethinyl estradiol tab 0.5
mg-2.5 mcg
4
PREMARIN - estrogens,
conjugated tab 0.625 mg
4
4
MENEST - esterified estrogens
tab 0.3 mg
4
PREMARIN - estrogens,
conjugated tab 0.9 mg
4
MENEST - esterified estrogens
tab 0.625 mg
4
PREMARIN - estrogens,
conjugated tab 1.25 mg
4
MENEST - esterified estrogens
tab 1.25 mg
4
MENOSTAR - estradiol td
patch weekly 14 mcg/24hr
4
•
PREMPHASE - conj est
0.625(14)/conj estmedroxypro ac tab
0.625-5mg(14)
4
MINIVELLE - estradiol td patch
twice weekly 0.025 mg/24hr
4
•
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.3-1.5 mg
4
•
4
MINIVELLE - estradiol td
patch twice weekly 0.0375
mg/24hr
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.45-1.5 mg
4
•
4
MINIVELLE - estradiol td patch
twice weekly 0.05 mg/24hr
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.625-2.5 mg
MINIVELLE - estradiol td patch
twice weekly 0.075 mg/24hr
4
•
4
MINIVELLE - estradiol td patch
twice weekly 0.1 mg/24hr
4
•
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.625-5 mg
2
norethindrone acetateethinyl estradiol tab
0.5 mg-2.5 mcg (Femhrt low
dose)
2
norethindrone acetateethinyl estradiol tab
1 mg-5 mcg
CONTRACEPTIVES
BEYAZ - drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
4
DEPO-PROVERA
CONTRACEPTIV medroxyprogesterone
acetate im susp prefilled syr
150 mg/ml
A
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
27
desogest-eth estrad
& eth estrad tab
0.15-0.02/0.01 mg(21/5)
(Mircette)
A
•
2
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
1
desogestrel & ethinyl
estradiol tab
0.15 mg-30 mcg (Desogen)
2
drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg (Beyaz)
2
drospirenone-ethinyl
estradiol tab 3-0.02 mg
(Yaz)
2
drospirenone-ethinyl
estradiol tab 3-0.03 mg
(Yasmin 28)
ELLA - ulipristal acetate tab 30 A
mg
2
ethynodiol diacetate &
ethinyl estradiol tab
1 mg-35 mcg
2
ethynodiol diacetate &
ethinyl estradiol tab
1 mg-50 mcg (Zovia 1/50e)
4
FALESSA - levonorgest-eth
estrad tab 0.1 mg-20 mcg &
fa tab 1 mg kit
•
4
•
levonor-eth est tab
0.15-0.02/0.025/0.03 mg
&eth est 0.01 mg
(Quartette)
2
•
levonorg-eth est tab
0.1-0.02mg(84) & eth
est tab 0.01mg(7)
(Loseasonique)
A
levonorg-eth est tab
0.15-0.03mg(84) & eth est
tab 0.01mg(7) (Seasonique)
2
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg
levonorgestrel &
ethinyl estradiol tab
0.1 mg-20 mcg
levonorgestrel &
ethinyl estradiol tab
0.15 mg-30 mcg
levonorgestrel tab 1.5 mg
• •
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
levonorgestrel-ethinyl
estradiol (continuous) tab
90-20 mcg
•
•
Limited Distribution
•
GENERESS FE norethindrone & ethinyl
estradiol-fe chew tab 0.8
mg-25 mcg
ACA
A
Dispensing Limits
DEPO-SUBQ PROVERA
104 - medroxyprogesterone
acetate susp pref syr 104
mg/0.65ml
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
DEPO-PROVERA
CONTRACEPTIV medroxyprogesterone
acetate im susp 150 mg/ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
A
1
2
2
•
2
2
LO LOESTRIN FE - norethineth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)
4
medroxyprogesterone
acetate im susp prefilled
syr 150 mg/ml (Depoprovera contrac)
A
•
•
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medroxyprogesterone
acetate im susp 150 mg/ml
(Depo-provera contrac)
A
MINASTRIN 24 FE norethindrone ace-eth
estradiol-fe chew tab 1
mg-20 mcg (24)
4
•
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2
mg/2-3 mg/1 mg
4
•
NECON 1/50-28 norethindrone & mestranol
tab 1 mg-50 mcg
4
•
NECON 10/11-28 norethindrone-eth estradiol
tab 0.5-35/1-35 mg-mcg
(10/11)
4
norethindrone &
ethinyl estradiol tab
0.4 mg-35 mcg (Ovcon-35)
2
norethindrone &
ethinyl estradiol
tab 0.5 mg-35 mcg
(Brevicon-28)
2
norethindrone & ethinyl
estradiol tab 1 mg-35 mcg
(Norinyl 1+35)
1
norethindrone & ethinyl
estradiol-fe chew tab
0.4 mg-35 mcg (Femcon fe)
A
norethindrone & ethinyl
estradiol-fe chew tab
0.8 mg-25 mcg (Generess
fe)
2
norethindrone acethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
(Estrostep fe)
2
•
•
norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)
2
norethindrone ace &
ethinyl estradiol tab
1.5 mg-30 mcg (Loestrin
1.5/30-21)
2
norethindrone ace &
ethinyl estradiol-fe tab
1 mg-20 mcg (Loestrin fe
1/20)
A
norethindrone ace &
ethinyl estradiol-fe tab
1.5 mg-30 mcg (Loestrin fe
1.5/30)
2
2
norethindrone ace-eth
estradiol-fe chew tab
1 mg-20 mcg (24) (Minastrin
24 fe)
2
norethindrone aceethinyl estradiol-fe tab
1 mg-20 mcg (24)
A
norethindrone tab 0.35 mg
(Nor-qd)
2
norethindrone-eth estradiol
tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7)
2
norethindrone-eth estradiol
tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)
1
norgestimate &
ethinyl estradiol tab
0.25 mg-35 mcg (Orthocyclen)
2
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg (Ortho tri-cyclen lo)
A
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
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norgestrel & ethinyl
estradiol tab
0.3 mg-30 mcg
2
megestrol acetate susp
625 mg/5ml (Megace es)
• •
NUVARING - etonogestrelethinyl estradiol va ring
0.120-0.015 mg/24hr
A
OGESTREL - norgestrel &
ethinyl estradiol tab 0.5
mg-50 mcg
4
•
ORTHO EVRA norelgestromin-ethinyl
estradiol td ptwk 150-35
mcg/24hr
A
• •
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25
mg-mcg
4
PARAGARD INTRAUTERINE
COP - copper iud
A
QUARTETTE - levonor-eth est
tab 0.15-0.02/0.025/0.03 mg
&eth est 0.01 mg
4
SAFYRAL - drospirenoneethinyl estrad-levomefolate
tab 3-0.03-0.451 mg
4
XULANE - norelgestrominethinyl estradiol td ptwk
150-35 mcg/24hr
A
norethindrone acetate tab
5 mg (Aygestin)
progesterone im in oil
50 mg/ml
progesterone micronized
cap 100 mg (Prometrium)
progesterone micronized
cap 200 mg (Prometrium)
ANTIDIABETICS
2
2
2
2
2
acarbose tab 50 mg
(Precose)
2
acarbose tab 100 mg
(Precose)
2
•
ACTOPLUS MET XR pioglitazone hcl-metformin
hcl tab sr 24hr 15-1000 mg
4
•
ACTOPLUS MET XR pioglitazone hcl-metformin
hcl tab sr 24hr 30-1000 mg
4
• •
ALOGLIPTIN - alogliptin
benzoate tab 6.25 mg (base
equiv)
4
•
4
•
• •
medroxyprogesterone
acetate tab 2.5 mg
(Provera)
1
ALOGLIPTIN - alogliptin
benzoate tab 12.5 mg (base
equiv)
4
•
medroxyprogesterone
acetate tab 5 mg (Provera)
1
ALOGLIPTIN - alogliptin
benzoate tab 25 mg (base
equiv)
ALOGLIPTIN/METFORMIN
HCL - alogliptin-metformin
hcl tab 12.5-500 mg
4
•
ALOGLIPTIN/METFORMIN
HCL - alogliptin-metformin
hcl tab 12.5-1000 mg
4
•
PROGESTINS
medroxyprogesterone
acetate tab 10 mg (Provera)
MEGACE ES - megestrol
acetate susp 625 mg/5ml
1
4
Limited Distribution
2
acarbose tab 25 mg
(Precose)
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 12.5-15 mg
4
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 12.5-30 mg
4
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 12.5-45 mg
4
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 25-15 mg
4
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 25-30 mg
4
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 25-45 mg
4
AVANDIA - rosiglitazone
maleate tab 2 mg (base
equiv)
CVS GLUCOSE - glucose
chew tab 4 gm
4
•
CYCLOSET - bromocriptine
mesylate tab 0.8 mg (base
equivalent)
4
•
DEX4 - glucose-vitamin c chew
tab 4-0.006 gm
4
4
•
DEX4 FAST ACTING
GLUCOSE - glucose gel 15
gm/33gm
4
•
DEX4 FAST ACTING
GLUCOSE - glucose-vitamin
c chew tab 4-0.006 gm
4
•
DEX4 NATURALS - glucosevitamin c chew tab 4-0.006
gm
4
4
DEX4 POUCH PACK glucose-vitamin c chew tab
4-0.006 gm
4
AVANDIA - rosiglitazone
maleate tab 4 mg (base
equiv)
4
DEX4 QUICK DISSOLVE
GLUCO - glucose chew tab 4
gm
4
•
BD GLUCOSE - glucose chew
tab 5 gm
4
FARXIGA - dapagliflozin
propanediol tab 5 mg (base
equivalent)
• •
•
BYDUREON PEN - exenatide
extended release for susp
pen-injector 2 mg
4
• •
FARXIGA - dapagliflozin
propanediol tab 10 mg (base
equivalent)
4
BYDUREON - exenatide for inj
extended release susp 2 mg
4
glimepiride tab 1 mg
(Amaryl)
1
• •
glimepiride tab 2 mg
(Amaryl)
1
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
4
• •
glimepiride tab 4 mg
(Amaryl)
1
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
4
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
CHLORPROPAMIDE chlorpropamide tab 100 mg
4
4
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
CHLORPROPAMIDE chlorpropamide tab 250 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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glipizide tab sr 24hr 10 mg
(Glucotrol xl)
2
glyburide tab 5 mg
glipizide tab 5 mg (Glucotrol)
1
glyburide-metformin tab
1.25-250 mg (Glucovance)
glipizide tab 10 mg
(Glucotrol)
1
glipizide-metformin hcl tab
2.5-250 mg
2
glipizide-metformin hcl tab
2.5-500 mg
glipizide-metformin hcl tab
5-500 mg
2
2
glyburide-metformin tab
2.5-500 mg (Glucovance)
glyburide-metformin tab
5-500 mg (Glucovance)
1
1
1
GLYSET - miglitol tab 25 mg
4
GLYSET - miglitol tab 50 mg
4
GLYSET - miglitol tab 100 mg
4
GLYXAMBI - empagliflozinlinagliptin tab 10-5 mg
4
•
GLYXAMBI - empagliflozinlinagliptin tab 25-5 mg
4
•
INSTA-GLUCOSE - glucose
gel 77.4%
4
4
GLUCAGON EMERGENCY
KIT - glucagon (rdna) for inj
kit 1 mg
3
GLUCOSE - glucose chew tab
4 gm
4
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
3
•
GLUCOSE - glucose-vitamin c
chew tab 4-0.006 gm
4
3
•
glucose gel 40%
1
INVOKAMET - canagliflozinmetformin hcl tab 50-1000
mg
INVOKAMET - canagliflozinmetformin hcl tab 150-500
mg
3
•
INVOKAMET - canagliflozinmetformin hcl tab 150-1000
mg
3
•
INVOKAMET XR canagliflozin-metformin hcl
tab sr 24hr 50-500 mg
3
•
INVOKAMET XR canagliflozin-metformin hcl
tab sr 24hr 50-1000 mg
3
•
INVOKAMET XR canagliflozin-metformin hcl
tab sr 24hr 150-500 mg
3
•
2
GLUMETZA - metformin hcl tab 4
sr 24hr modified release 500
mg
4
GLUMETZA - metformin hcl
tab sr 24hr modified release
1000 mg
1
glyburide micronized tab
1.5 mg (Glynase)
1
glyburide micronized tab
3 mg (Glynase)
1
glyburide micronized tab
6 mg (Glynase)
1
glyburide tab 1.25 mg
glyburide tab 2.5 mg
Limited Distribution
1
GLUCAGEN HYPOKIT glucagon hcl (rdna) for inj 1
mg (base equiv)
glucose oral liquid
15 gm/59ml
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
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4
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-1000
mg
4
•
INVOKANA - canagliflozin tab
300 mg
3
•
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
4
•
JANUMET - sitagliptinmetformin hcl tab 50-500 mg
3
•
JANUMET - sitagliptinmetformin hcl tab 50-1000
mg
3
•
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr
5-1000 mg
4
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-500 mg
3
•
KAZANO - alogliptin-metformin
hcl tab 12.5-500 mg
4
•
KAZANO - alogliptin-metformin
hcl tab 12.5-1000 mg
4
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-1000 mg
3
•
KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 2.5-1000 mg
3
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
100-1000 mg
3
KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 5-500 mg
3
•
JANUVIA - sitagliptin
phosphate tab 25 mg (base
equiv)
3
KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 5-1000 mg
3
•
JANUVIA - sitagliptin
phosphate tab 50 mg (base
equiv)
3
KORLYM - mifepristone tab
300 mg
5
JANUVIA - sitagliptin
phosphate tab 100 mg (base
equiv)
3
•
KROGER GLUCOSE glucose-vitamin c chew tab
4-0.006 gm
4
JARDIANCE - empagliflozin
tab 10 mg
3
•
metformin hcl tab sr 24hr
500 mg (Glucophage xr)
1
JARDIANCE - empagliflozin
tab 25 mg
3
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-500
mg
4
•
•
•
•
•
metformin hcl tab sr 24hr
750 mg (Glucophage xr)
metformin hcl tab sr 24hr
osmotic 500 mg (Fortamet)
metformin hcl tab sr
24hr osmotic 1000 mg
(Fortamet)
•
•
Limited Distribution
JENTADUETO - linagliptinmetformin hcl tab 2.5-850
mg
ACA
•
Dispensing Limits
3
Step Therapy
INVOKANA - canagliflozin tab
100 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
INVOKAMET XR canagliflozin-metformin hcl
tab sr 24hr 150-1000 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
1
2
2
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metformin hcl tab sr 24hr
modified release 500 mg
(Glumetza)
2
metformin hcl tab sr 24hr
modified release 1000 mg
(Glumetza)
2
metformin hcl tab 500 mg
(Glucophage)
1
metformin hcl tab 850 mg
(Glucophage)
1
metformin hcl tab 1000 mg
(Glucophage)
1
miglitol tab 25 mg (Glyset)
2
miglitol tab 50 mg (Glyset)
miglitol tab 100 mg (Glyset)
4
•
pioglitazone hcl tab 15 mg
(base equiv) (Actos)
1
pioglitazone hcl-glimepiride
tab 30-4 mg (Duetact)
2
nateglinide tab 120 mg
(Starlix)
2
NESINA - alogliptin benzoate
tab 6.25 mg (base equiv)
4
•
NESINA - alogliptin benzoate
tab 12.5 mg (base equiv)
4
•
NESINA - alogliptin benzoate
tab 25 mg (base equiv)
4
•
ONGLYZA - saxagliptin hcl tab
2.5 mg (base equiv)
3
•
ONGLYZA - saxagliptin hcl tab
5 mg (base equiv)
3
•
OSENI - alogliptin-pioglitazone
tab 12.5-15 mg
4
•
OSENI - alogliptin-pioglitazone
tab 12.5-30 mg
4
•
OSENI - alogliptin-pioglitazone
tab 12.5-45 mg
4
•
OSENI - alogliptin-pioglitazone
tab 25-15 mg
4
•
Limited Distribution
OSENI - alogliptin-pioglitazone
tab 25-45 mg
ACA
•
pioglitazone hcl-glimepiride
tab 30-2 mg (Duetact)
nateglinide tab 60 mg
(Starlix)
Dispensing Limits
4
pioglitazone hcl tab 45 mg
(base equiv) (Actos)
2
Step Therapy
OSENI - alogliptin-pioglitazone
tab 25-30 mg
pioglitazone hcl tab 30 mg
(base equiv) (Actos)
2
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
2
2
2
pioglitazone hcl-metformin
hcl tab 15-500 mg (Actoplus
met)
2
pioglitazone hcl-metformin
hcl tab 15-850 mg (Actoplus
met)
PROGLYCEM - diazoxide susp 4
50 mg/ml
2
repaglinide tab 0.5 mg
(Prandin)
2
repaglinide tab 1 mg
(Prandin)
2
repaglinide tab 2 mg
(Prandin)
2
REPAGLINIDE/METFORMIN
HYD - repaglinide-metformin
hcl tab 1-500 mg
2
REPAGLINIDE/METFORMIN
HYD - repaglinide-metformin
hcl tab 2-500 mg
4
RIOMET - metformin hcl oral
soln 500 mg/5ml
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4
•
SYNJARDY - empagliflozinmetformin hcl tab 5-1000 mg
4
•
SYNJARDY - empagliflozinmetformin hcl tab 12.5-500
mg
4
SYNJARDY - empagliflozinmetformin hcl tab 12.5-1000
mg
4
TANZEUM - albiglutide for soln
pen-injector 30 mg
4
• •
TANZEUM - albiglutide for soln
pen-injector 50 mg
4
• •
TOLAZAMIDE - tolazamide tab
250 mg
4
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
5-500 mg
4
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
5-1000 mg
4
•
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-500 mg
4
•
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-1000 mg
4
•
Rapid-Acting Insulins
APIDRA - insulin glulisine inj
100 unit/ml
4
•
•
4
•
•
2
APIDRA SOLOSTAR - insulin
glulisine soln pen-injector inj
100 unit/ml
4
•
•
TOLAZAMIDE - tolazamide tab
500 mg
4
HUMALOG - insulin lispro inj
100 unit/ml
4
•
•
TOLBUTAMIDE - tolbutamide
tab 500 mg
4
HUMALOG - insulin lispro soln
cartridge 100 unit/ml
•
•
4
•
4
TRADJENTA - linagliptin tab 5
mg
HUMALOG KWIKPEN - insulin
lispro soln pen-injector 100
unit/ml
TRULICITY - dulaglutide soln
pen-injector 0.75 mg/0.5ml
4
• •
4
•
•
TRULICITY - dulaglutide soln
pen-injector 1.5 mg/0.5ml
4
• •
HUMALOG KWIKPEN - insulin
lispro soln pen-injector 200
unit/ml
2
•
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
3
• •
NOVOLOG - insulin aspart inj
100 unit/ml
2
•
WALGREENS GLUCOSE glucose chew tab 4 gm
4
NOVOLOG FLEXPEN - insulin
aspart soln pen-injector 100
unit/ml
NOVOLOG PENFILL - insulin
aspart soln cartridge 100
unit/ml
2
•
Limited Distribution
SYNJARDY - empagliflozinmetformin hcl tab 5-500 mg
WALGREENS GLUCOSE glucose-vitamin c chew tab
4-0.006 gm
ACA
•
Dispensing Limits
4
Step Therapy
SYMLINPEN 60 - pramlintide
acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
SYMLINPEN 120 - pramlintide
acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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Short-Acting Insulins
•
AFREZZA - insulin regular
(human) inh powd 8 (60) &
12 (30) unit/cart
4
•
•
AFREZZA - insulin regular
(human) inh powd 4 & 8 &
12 unit/cart (60)
4
•
•
HUMALOG MIX 75/25 - insulin
lispro prot & lispro inj 100
unit/ml (75-25)
4
•
•
AFREZZA - insulin regular
(human) inhal powd 4 (30) &
8 (60) unit/cart
4
•
•
4
•
•
AFREZZA - insulin regular
(human) inhal powd 4 (60) &
8 (30) unit/cart
4
•
•
HUMALOG MIX 75/25
KWIKPEN - insulin lispro prot
& lispro sus pen-inj 100 unit/
ml (75-25)
4
•
•
AFREZZA - insulin regular
(human) inhal powd 4 (90) &
8 (90) unit/cart
4
•
•
HUMULIN N - insulin nph
(human) (isophane) inj 100
unit/ml
4
•
•
AFREZZA - insulin regular
(human) inhalation powder 4
unit/cartridge
4
•
•
HUMULIN N KWIKPEN insulin nph (human)
(isophane) susp pen-injector
100 unit/ml
4
•
•
HUMULIN R - insulin regular
(human) inj 100 unit/ml
4
•
HUMULIN 70/30 - insulin nph
isophane & regular human
inj 100 unit/ml (70-30)
•
HUMULIN 70/30 KWIKPEN insulin nph & regular susp
pen-inj 100 unit/ml (70-30)
4
•
•
•
NOVOLIN N - insulin nph
(human) (isophane) inj 100
unit/ml
2
•
NOVOLIN N RELION - insulin
nph (human) (isophane) inj
100 unit/ml
2
•
•
NOVOLIN 70/30 - insulin nph
isophane & regular human
inj 100 unit/ml (70-30)
2
•
•
NOVOLIN 70/30 RELION insulin nph isophane &
regular human inj 100 unit/
ml (70-30)
2
•
NOVOLOG MIX 70/30 - insulin
aspart prot & aspart (human)
inj 100 unit/ml (70-30)
2
•
•
4
HUMULIN R U-500
(CONCENTR - insulin regular
(human) inj 500 unit/ml
4
HUMULIN R U-500
KWIKPEN - insulin regular
(human) soln pen-injector
500 unit/ml
2
NOVOLIN R - insulin regular
(human) inj 100 unit/ml
2
NOVOLIN R RELION - insulin
regular (human) inj 100 unit/
ml
3
RELION R - insulin regular
(human) inj 100 unit/ml
Intermediate-Acting Insulins
HUMALOG MIX 50/50 - insulin
lispro protamine & lispro inj
100 unit/ml (50-50)
4
•
•
•
Limited Distribution
•
ACA
4
Dispensing Limits
HUMALOG MIX 50/50
KWIKPEN - insulin lispro prot
& lispro sus pen-inj 100 unit/
ml (50-50)
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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NOVOLOG MIX 70/30
PREFILL - insulin aspart prot
& aspart sus pen-inj 100
unit/ml (70-30)
Basal Insulins
2
levothyroxine sodium tab
50 mcg (Synthroid)
levothyroxine sodium tab
75 mcg (Synthroid)
LANTUS - insulin glargine inj
100 unit/ml
3
•
levothyroxine sodium tab
88 mcg (Synthroid)
LANTUS SOLOSTAR - insulin
glargine soln pen-injector
100 unit/ml
3
•
levothyroxine sodium tab
100 mcg (Synthroid)
LEVEMIR - insulin detemir inj
100 unit/ml
3
•
LEVEMIR FLEXTOUCH insulin detemir soln peninjector 100 unit/ml
3
•
TOUJEO SOLOSTAR - insulin
glargine soln pen-injector
300 unit/ml
3
•
TRESIBA FLEXTOUCH insulin degludec soln peninjector 100 unit/ml
3
•
TRESIBA FLEXTOUCH insulin degludec soln peninjector 200 unit/ml
3
•
THYROID AGENTS
levothyroxine sodium tab
112 mcg (Synthroid)
levothyroxine sodium tab
125 mcg (Synthroid)
levothyroxine sodium tab
137 mcg (Synthroid)
levothyroxine sodium tab
150 mcg (Synthroid)
levothyroxine sodium tab
175 mcg (Synthroid)
levothyroxine sodium tab
200 mcg (Synthroid)
levothyroxine sodium tab
300 mcg (Synthroid)
liothyronine sodium tab
5 mcg (Cytomel)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
1
1
1
1
2
2
ARMOUR THYROID - thyroid
tab 15 mg (1/4 grain)
4
liothyronine sodium tab
25 mcg (Cytomel)
ARMOUR THYROID - thyroid
tab 120 mg (2 grain)
4
liothyronine sodium tab
50 mcg (Cytomel)
ARMOUR THYROID - thyroid
tab 180 mg (3 grain)
4
methimazole tab 5 mg
(Tapazole)
1
ARMOUR THYROID - thyroid
tab 240 mg (4 grain)
4
methimazole tab 10 mg
(Tapazole)
1
ARMOUR THYROID - thyroid
tab 300 mg (5 grain)
4
NATURE-THROID - thyroid tab
16.25 mg
4
levothyroxine sodium tab
25 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
32.5 mg
4
NATURE-THROID - thyroid tab
48.75 mg (3/4 grain)
4
2
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NATURE-THROID - thyroid tab
65 mg
4
SYNTHROID - levothyroxine
sodium tab 150 mcg
4
NATURE-THROID - thyroid tab
81.25 mg
4
SYNTHROID - levothyroxine
sodium tab 175 mcg
4
NATURE-THROID - thyroid tab
97.5 mg
4
SYNTHROID - levothyroxine
sodium tab 200 mcg
4
NATURE-THROID - thyroid tab
113.75 mg
4
SYNTHROID - levothyroxine
sodium tab 300 mcg
4
NATURE-THROID - thyroid tab
130 mg
4
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
NATURE-THROID - thyroid tab
195 mg
4
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
NATURE-THROID - thyroid tab
260 mg
4
1
NATURE-THROID - thyroid tab
325 mg (5 grain)
4
thyroid tab 90 mg (1
1/2 grain) (Armour thyroid)
NATURE-THROID - thyroid tab
146.25 mg
THYROLAR-1 - liotrix (t3-t4)
tab 60 mg (12.5-50 mcg)
4
4
THYROLAR-1/2 - liotrix (t3-t4)
tab 30 mg (6.25-25 mcg)
4
NATURE-THROID NT-2.5 thyroid tab 162.5 mg (2 1/2
grain)
4
THYROLAR-1/4 - liotrix (t3-t4)
tab 15 mg (3.1-12.5 mcg)
4
THYROLAR-2 - liotrix (t3-t4)
tab 120 mg (25-100 mcg)
4
propylthiouracil tab 50 mg
2
SYNTHROID - levothyroxine
sodium tab 25 mcg
4
THYROLAR-3 - liotrix (t3-t4)
tab 180 mg (37.5-150 mcg)
4
SYNTHROID - levothyroxine
sodium tab 50 mcg
4
TIROSINT - levothyroxine
sodium cap 13 mcg
4
SYNTHROID - levothyroxine
sodium tab 75 mcg
4
TIROSINT - levothyroxine
sodium cap 25 mcg
4
SYNTHROID - levothyroxine
sodium tab 88 mcg
4
TIROSINT - levothyroxine
sodium cap 50 mcg
4
SYNTHROID - levothyroxine
sodium tab 100 mcg
4
TIROSINT - levothyroxine
sodium cap 75 mcg
4
SYNTHROID - levothyroxine
sodium tab 112 mcg
4
TIROSINT - levothyroxine
sodium cap 88 mcg
4
SYNTHROID - levothyroxine
sodium tab 125 mcg
4
TIROSINT - levothyroxine
sodium cap 100 mcg
4
SYNTHROID - levothyroxine
sodium tab 137 mcg
4
TIROSINT - levothyroxine
sodium cap 112 mcg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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TIROSINT - levothyroxine
sodium cap 125 mcg
4
PREPIDIL - dinoprostone
cervical gel 0.5 mg/3gm
4
TIROSINT - levothyroxine
sodium cap 137 mcg
4
PROSTIN E2 - dinoprostone
vaginal suppos 20 mg
4
TIROSINT - levothyroxine
sodium cap 150 mcg
4
WESTHROID - thyroid tab 32.5
mg
4
WESTHROID - thyroid tab 65
mg
4
WESTHROID - thyroid tab 97.5
mg
4
WESTHROID - thyroid tab 130
mg
4
WESTHROID - thyroid tab 195
mg
4
WP THYROID - thyroid tab
16.25 mg
4
WP THYROID - thyroid tab
32.5 mg
4
WP THYROID - thyroid tab
48.75 mg (3/4 grain)
4
WP THYROID - thyroid tab 65
mg
4
WP THYROID - thyroid tab
81.25 mg
4
WP THYROID - thyroid tab
97.5 mg
4
WP THYROID - thyroid tab
113.75 mg
4
WP THYROID - thyroid tab 130
mg
4
ENDOCRINE and METABOLIC AGENTS - MISC.
4
•
ACTONEL - risedronate
sodium tab 5 mg
4
•
ACTONEL - risedronate
sodium tab 30 mg
4
•
ACTONEL - risedronate
sodium tab 35 mg
4
•
ALENDRONATE SODIUM alendronate sodium oral soln
70 mg/75ml
4
•
ALENDRONATE SODIUM alendronate sodium tab 40
mg
1
•
alendronate sodium tab
5 mg
1
•
alendronate sodium tab
10 mg
1
•
alendronate sodium tab
35 mg
1
•
alendronate sodium tab
70 mg (Fosamax)
4
•
ATELVIA - risedronate sodium
tab delayed release 35 mg
4
•
BINOSTO - alendronate
sodium effervescent tab 70
mg
5 •
BUPHENYL - sodium
phenylbutyrate tab 500 mg
2
cabergoline tab 0.5 mg
OXYTOCICS
CERVIDIL - dinoprostone
vaginal inserts 10 mg
4
METHERGINE methylergonovine maleate
tab 0.2 mg
2
calcitonin (salmon)
nasal soln 200 unit/act
(Miacalcin)
2
calcitriol cap 0.25 mcg
(Rocaltrol)
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
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39
calcitriol cap 0.5 mcg
(Rocaltrol)
2
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
2
CARBAGLU - carglumic acid
tab 200 mg
5
desmopressin acetate inj
4 mcg/ml (Ddavp)
2
•
•
•
4
•
2
H.P. ACTHAR - corticotropin inj
gel 80 unit/ml
5
ibandronate sodium tab
150 mg (base equivalent)
(Boniva)
2
desmopressin acetate tab
0.2 mg (Ddavp)
2
doxercalciferol cap 0.5 mcg
(Hectorol)
2
doxercalciferol cap 1 mcg
(Hectorol)
2
doxercalciferol cap 2.5 mcg
(Hectorol)
2
EGRIFTA - tesamorelin acetate
for inj 1 mg (base equiv)
5
•
•
EGRIFTA - tesamorelin acetate
for inj 2 mg (base equiv)
5
•
•
ETIDRONATE DISODIUM etidronate disodium tab 200
mg
4
ETIDRONATE DISODIUM etidronate disodium tab 400
mg
4
INCRELEX - mecasermin inj 40 5
mg/4ml (10 mg/ml)
5
KUVAN - sapropterin
dihydrochloride powder
packet 100 mg
5
KUVAN - sapropterin
dihydrochloride powder
packet 500 mg
5
KUVAN - sapropterin
dihydrochloride soluble tab
100 mg
2
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
2
levocarnitine tab 330 mg
(Carnitor)
4
MIACALCIN - calcitonin
(salmon) inj 200 unit/ml
5
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
5
NATPARA - parathyroid
hormone (recombinant) for
inj cartridge 25 mcg
•
Limited Distribution
ACA
Dispensing Limits
4
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
2
Step Therapy
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-2800
mg-unit
2
desmopressin acetate tab
0.1 mg (Ddavp)
•
5
desmopressin acetate nasal
soln 0.01% (refrigerated)
(Ddavp)
2
•
FORTEO - teriparatide
(recombinant) inj 600
mcg/2.4ml
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-5600
mg-unit
desmopressin acetate
nasal spray soln 0.01%
(refrigerated)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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40
•
NATPARA - parathyroid
hormone (recombinant) for
inj cartridge 100 mcg
5
•
octreotide acetate inj
50 mcg/ml (0.05 mg/ml)
(Sandostatin)
5
•
•
octreotide acetate inj
100 mcg/ml (0.1 mg/ml)
(Sandostatin)
5
•
•
octreotide acetate inj
200 mcg/ml (0.2 mg/ml)
(Sandostatin)
5
•
•
octreotide acetate inj
500 mcg/ml (0.5 mg/ml)
(Sandostatin)
5
•
•
octreotide acetate inj
1000 mcg/ml (1 mg/ml)
(Sandostatin)
5
OMNITROPE - somatropin for
inj 5.8 mg
2
RAVICTI - glycerol
phenylbutyrate liquid 1.1 gm/
ml
5
risedronate sodium tab
delayed release 35 mg
(Atelvia)
2
•
risedronate sodium tab 5 mg
(Actonel)
2
•
risedronate sodium tab
30 mg (Actonel)
2
•
2
•
2
•
•
•
5
•
•
SAMSCA - tolvaptan tab 15 mg
5
OMNITROPE - somatropin inj 5 5
mg/1.5ml
5
OMNITROPE - somatropin inj
10 mg/1.5ml
ORFADIN - nitisinone cap 2 mg 5
•
•
SAMSCA - tolvaptan tab 30 mg
5
3
•
•
SENSIPAR - cinacalcet hcl tab
30 mg (base equiv)
3
•
•
•
•
•
•
SENSIPAR - cinacalcet hcl tab
60 mg (base equiv)
SENSIPAR - cinacalcet hcl tab
90 mg (base equiv)
3
SIGNIFOR - pasireotide
diaspartate inj 0.3 mg/ml
(base equiv)
SIGNIFOR - pasireotide
diaspartate inj 0.6 mg/ml
(base equiv)
ORFADIN - nitisinone cap 5 mg 5
5
ORFADIN - nitisinone cap 10
mg
5
ORFADIN - nitisinone cap 20
mg
5
ORFADIN - nitisinone susp 4
mg/ml
•
•
•
raloxifene hcl tab 60 mg
(Evista)
risedronate sodium tab
35 mg (Actonel)
risedronate sodium tab
150 mg (Actonel)
Limited Distribution
5
OSPHENA - ospemifene tab 60 4
mg
2
paricalcitol cap 1 mcg
(Zemplar)
2
paricalcitol cap 2 mcg
(Zemplar)
2
paricalcitol cap 4 mcg
ACA
NATPARA - parathyroid
hormone (recombinant) for
inj cartridge 75 mcg
Dispensing Limits
•
Step Therapy
5
Prior Authorization
NATPARA - parathyroid
hormone (recombinant) for
inj cartridge 50 mcg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
5
•
•
5
•
•
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5
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
5
SOMAVERT - pegvisomant for
inj 10 mg (as protein)
5
•
•
SOMAVERT - pegvisomant for
inj 15 mg (as protein)
5
•
•
SOMAVERT - pegvisomant for
inj 20 mg (as protein)
5
•
•
SOMAVERT - pegvisomant for
inj 25 mg (as protein)
5
•
•
SOMAVERT - pegvisomant for
inj 30 mg (as protein)
5
•
•
STIMATE - desmopressin
acetate nasal soln 1.5 mg/ml
3
STRENSIQ - asfotase alfa
subcutaneous inj 18
mg/0.45ml
5
STRENSIQ - asfotase alfa
subcutaneous inj 28
mg/0.7ml
•
•
digoxin tab 125 mcg
(0.125 mg) (Lanoxin)
digoxin tab 250 mcg
(0.25 mg) (Lanoxin)
4
LANOXIN - digoxin tab 125
mcg (0.125 mg)
4
LANOXIN - digoxin tab 187.5
mcg (0.1875 mg)
4
LANOXIN - digoxin tab 250
mcg (0.25 mg)
2
LANOXIN - digoxin tab 250
mcg (0.25 mg)
4
4
•
ISORDIL TITRADOSE isosorbide dinitrate tab 40
mg
4
5
•
STRENSIQ - asfotase alfa
subcutaneous inj 40 mg/ml
5
•
STRENSIQ - asfotase alfa
subcutaneous inj 80
mg/0.8ml
5
•
SYNAREL - nafarelin acetate
nasal soln 2 mg/ml (200
mcg/act) (base eq)
4
XURIDEN - uridine triacetate
oral granules packet 2 gm
5
ISOSORBIDE DINITRATE ER - 2
isosorbide dinitrate tab cr 40
mg
isosorbide dinitrate tab 5 mg 2
(Isordil titradose)
2
isosorbide dinitrate tab
10 mg
2
isosorbide dinitrate tab
20 mg
2
isosorbide dinitrate tab
30 mg
1
isosorbide mononitrate tab
sr 24hr 30 mg
1
isosorbide mononitrate tab
sr 24hr 60 mg
2
isosorbide mononitrate tab
sr 24hr 120 mg
CARDIOVASCULAR AGENTS
CARDIOTONICS
DIGOXIN - digoxin oral soln
0.05 mg/ml
4
Limited Distribution
ACA
Dispensing Limits
2
DILATRATE SR - isosorbide
dinitrate cap cr 40 mg
•
Step Therapy
2
LANOXIN - digoxin tab 62.5
mcg (0.0625 mg)
ANTIANGINAL AGENTS
Prior Authorization
•
SIGNIFOR - pasireotide
diaspartate inj 0.9 mg/ml
(base equiv)
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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42
1
NITROSTAT - nitroglycerin sl
tab 0.4 mg
3
1
NITROSTAT - nitroglycerin sl
tab 0.6 mg
3
NITRO-BID - nitroglycerin oint
2%
4
RANEXA - ranolazine tab sr
12hr 500 mg
4
NITRO-DUR - nitroglycerin td
patch 24hr 0.3 mg/hr
4
RANEXA - ranolazine tab sr
12hr 1000 mg
4
NITRO-DUR - nitroglycerin td
patch 24hr 0.8 mg/hr
4
BETA BLOCKERS
acebutolol hcl cap 200 mg
(Sectral)
1
nitroglycerin cap cr 2.5 mg
1
acebutolol hcl cap 400 mg
(Sectral)
1
atenolol tab 25 mg
(Tenormin)
1
1
isosorbide mononitrate tab
10 mg
isosorbide mononitrate tab
20 mg
nitroglycerin cap cr 6.5 mg
nitroglycerin cap cr 9 mg
2
2
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol
400 mcg/spray
4
nitroglycerin sl tab 0.3 mg
(Nitrostat)
2
atenolol tab 50 mg
(Tenormin)
1
nitroglycerin sl tab 0.4 mg
(Nitrostat)
2
atenolol tab 100 mg
(Tenormin)
2
nitroglycerin sl tab 0.6 mg
(Nitrostat)
2
betaxolol hcl tab 10 mg
(Kerlone)
2
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
2
betaxolol hcl tab 20 mg
(Kerlone)
1
2
bisoprolol fumarate tab 5 mg
(Zebeta)
2
2
bisoprolol fumarate tab
10 mg (Zebeta)
4
2
BYSTOLIC - nebivolol hcl tab
2.5 mg (base equivalent)
4
nitroglycerin tl soln 0.4 mg/
spray (400 mcg/spray)
(Nitrolingual pumpspr)
2
BYSTOLIC - nebivolol hcl tab 5
mg (base equivalent)
BYSTOLIC - nebivolol hcl tab
10 mg (base equivalent)
4
NITROMIST - nitroglycerin
lingual aerosol 400 mcg/
spray
4
BYSTOLIC - nebivolol hcl tab
20 mg (base equivalent)
4
3
carvedilol tab 3.125 mg
(Coreg)
1
NITROSTAT - nitroglycerin sl
tab 0.3 mg
nitroglycerin td patch 24hr
0.2 mg/hr (Nitro-dur)
nitroglycerin td patch 24hr
0.4 mg/hr (Nitro-dur)
nitroglycerin td patch 24hr
0.6 mg/hr (Nitro-dur)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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carvedilol tab 6.25 mg
(Coreg)
1
carvedilol tab 12.5 mg
(Coreg)
1
carvedilol tab 25 mg (Coreg)
1
COREG CR - carvedilol
phosphate cap sr 24hr 10
mg
4
COREG CR - carvedilol
phosphate cap sr 24hr 20
mg
4
COREG CR - carvedilol
phosphate cap sr 24hr 40
mg
4
COREG CR - carvedilol
phosphate cap sr 24hr 80
mg
4
HEMANGEOL - propranolol hcl
oral soln 4.28 mg/ml (3.75
mg/ml base equiv)
4
INDERAL XL - propranolol hcl
sustained-release beads cap
sr 24hr 80 mg
4
INDERAL XL - propranolol hcl
sustained-release beads cap
sr 24hr 120 mg
4
INNOPRAN XL - propranolol
hcl sustained-release beads
cap sr 24hr 80 mg
4
INNOPRAN XL - propranolol
hcl sustained-release beads
cap sr 24hr 120 mg
4
labetalol hcl tab 100 mg
(Trandate)
2
labetalol hcl tab 200 mg
(Trandate)
labetalol hcl tab 300 mg
(Trandate)
metoprolol succinate tab sr
24hr 25 mg (tartrate equiv)
(Toprol xl)
1
metoprolol succinate tab sr
24hr 50 mg (tartrate equiv)
(Toprol xl)
1
metoprolol succinate tab
sr 24hr 100 mg (tartrate
equiv) (Toprol xl)
2
metoprolol succinate tab
sr 24hr 200 mg (tartrate
equiv) (Toprol xl)
•
4
METOPROLOL TARTRATE metoprolol tartrate tab 75 mg
4
metoprolol tartrate tab
25 mg
1
metoprolol tartrate tab
100 mg (Lopressor)
nadolol tab 20 mg (Corgard)
nadolol tab 40 mg (Corgard)
nadolol tab 80 mg (Corgard)
pindolol tab 5 mg
pindolol tab 10 mg
Limited Distribution
ACA
Dispensing Limits
1
1
2
2
2
2
2
PROPRANOLOL HCL propranolol hcl oral soln 20
mg/5ml
4
4
2
PROPRANOLOL HCL propranolol hcl oral soln 40
mg/5ml
2
2
propranolol hcl cap sr 24hr
60 mg (Inderal la)
propranolol hcl cap sr 24hr
80 mg (Inderal la)
Step Therapy
2
METOPROLOL TARTRATE metoprolol tartrate tab 37.5
mg
metoprolol tartrate tab
50 mg (Lopressor)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
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propranolol hcl cap sr 24hr
120 mg (Inderal la)
propranolol hcl cap sr 24hr
160 mg (Inderal la)
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
2
4
2
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr
120 mg
2
1
diltiazem hcl cap sr 12hr
60 mg
1
1
2
1
diltiazem hcl cap sr 12hr
90 mg
diltiazem hcl cap sr 12hr
120 mg
diltiazem hcl cap sr 24hr
180 mg
2
diltiazem hcl cap sr 24hr
240 mg
1
diltiazem hcl coated beads
cap sr 24hr 120 mg
(Cardizem cd)
1
sotalol hcl tab 80 mg
(Betapace)
sotalol hcl tab 120 mg
(Betapace)
1
1
sotalol hcl tab 160 mg
(Betapace)
1
diltiazem hcl coated beads
cap sr 24hr 180 mg
(Cardizem cd)
2
sotalol hcl tab 240 mg
2
diltiazem hcl coated beads
cap sr 24hr 240 mg
(Cardizem cd)
diltiazem hcl coated beads
cap sr 24hr 300 mg
(Cardizem cd)
2
diltiazem hcl coated beads
cap sr 24hr 360 mg
(Cardizem cd)
2
diltiazem hcl coated beads
tab sr 24hr 180 mg
(Cardizem la)
2
diltiazem hcl coated beads
tab sr 24hr 240 mg
(Cardizem la)
2
diltiazem hcl coated beads
tab sr 24hr 300 mg
(Cardizem la)
2
SOTYLIZE - sotalol hcl oral
solution 5 mg/ml
4
TIMOLOL MALEATE - timolol
maleate tab 5 mg
4
TIMOLOL MALEATE - timolol
maleate tab 10 mg
4
TIMOLOL MALEATE - timolol
maleate tab 20 mg
4
CALCIUM CHANNEL BLOCKERS
1
amlodipine besylate tab
2.5 mg (Norvasc)
1
amlodipine besylate tab
5 mg (Norvasc)
1
amlodipine besylate tab
10 mg (Norvasc)
Limited Distribution
ACA
1
2
sotalol hcl (afib/afl) tab
160 mg (Betapace af)
Dispensing Limits
2
diltiazem hcl cap sr 24hr
120 mg
sotalol hcl (afib/afl) tab
120 mg (Betapace af)
Step Therapy
2
2
sotalol hcl (afib/afl) tab
80 mg (Betapace af)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
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diltiazem hcl coated beads
tab sr 24hr 360 mg
(Cardizem la)
2
diltiazem hcl coated beads
tab sr 24hr 420 mg
(Cardizem la)
2
diltiazem hcl extended
release beads cap sr 24hr
120 mg (Tiazac)
2
diltiazem hcl extended
release beads cap sr 24hr
180 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
240 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
300 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
360 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
420 mg (Tiazac)
2
2
2
2
2
diltiazem hcl tab 30 mg
(Cardizem)
1
diltiazem hcl tab 60 mg
(Cardizem)
1
diltiazem hcl tab 90 mg
1
nifedipine cap 10 mg
(Procardia)
2
nifedipine cap 20 mg
2
nifedipine tab sr 24hr 30 mg
(Adalat cc)
1
nifedipine tab sr 24hr 60 mg
(Adalat cc)
2
nifedipine tab sr 24hr 90 mg
(Adalat cc)
2
nifedipine tab sr 24hr
osmotic release 30 mg
(Procardia xl)
1
nifedipine tab sr 24hr
osmotic release 60 mg
(Procardia xl)
2
nifedipine tab sr 24hr
osmotic release 90 mg
(Procardia xl)
2
nimodipine cap 30 mg
2
NISOLDIPINE ER - nisoldipine
tab sr 24hr 20 mg
4
NISOLDIPINE ER - nisoldipine
tab sr 24hr 25.5 mg
4
NISOLDIPINE ER - nisoldipine
tab sr 24hr 30 mg
4
NISOLDIPINE ER - nisoldipine
tab sr 24hr 40 mg
4
2
diltiazem hcl tab 120 mg
(Cardizem)
1
nisoldipine tab sr 24hr
8.5 mg (Sular)
felodipine tab sr 24hr 2.5 mg
2
nisoldipine tab sr 24hr
17 mg (Sular)
felodipine tab sr 24hr 5 mg
felodipine tab sr 24hr 10 mg
isradipine cap 2.5 mg
isradipine cap 5 mg
nicardipine hcl cap 20 mg
nicardipine hcl cap 30 mg
2
2
2
2
2
2
nisoldipine tab sr 24hr
34 mg (Sular)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
NYMALIZE - nimodipine oral
soln 60 mg/20ml
4
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
2
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verapamil hcl cap sr 24hr
120 mg (Verelan)
verapamil hcl cap sr 24hr
180 mg (Verelan)
verapamil hcl cap sr 24hr
200 mg (Verelan pm)
verapamil hcl cap sr 24hr
240 mg (Verelan)
verapamil hcl cap sr 24hr
300 mg (Verelan pm)
verapamil hcl cap sr 24hr
360 mg (Verelan)
2
2
dofetilide cap 500 mcg
(0.5 mg) (Tikosyn)
flecainide acetate tab 50 mg
2
flecainide acetate tab
150 mg
2
2
verapamil hcl tab cr 180 mg
(Calan sr)
1
verapamil hcl tab cr 240 mg
(Calan sr)
1
verapamil hcl tab 40 mg
2
verapamil hcl tab 80 mg
(Calan)
1
verapamil hcl tab 120 mg
(Calan)
1
2
mexiletine hcl cap 150 mg
mexiletine hcl cap 200 mg
mexiletine hcl cap 250 mg
Limited Distribution
ACA
2
NORPACE CR - disopyramide
phosphate cap sr 12hr 100
mg
4
NORPACE CR - disopyramide
phosphate cap sr 12hr 150
mg
4
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
2
2
2
2
propafenone hcl tab 150 mg
(Rythmol)
2
2
propafenone hcl tab 225 mg
(Rythmol)
2
2
propafenone hcl tab 300 mg
2
2
quinidine gluconate tab cr
324 mg
QUINIDINE SULFATE quinidine sulfate tab 200 mg
Dispensing Limits
2
4
2
Step Therapy
2
NORPACE - disopyramide
phosphate cap 150 mg
amiodarone hcl tab 400 mg
Prior Authorization
2
4
propafenone hcl cap sr 12hr
425 mg (Rythmol sr)
dofetilide cap 250 mcg
(0.25 mg) (Tikosyn)
2
NORPACE - disopyramide
phosphate cap 100 mg
1
dofetilide cap 125 mcg
(0.125 mg) (Tikosyn)
2
4
amiodarone hcl tab 200 mg
(Cordarone)
disopyramide phosphate
cap 150 mg (Norpace)
2
MULTAQ - dronedarone hcl tab
400 mg (base equivalent)
propafenone hcl cap sr 12hr
325 mg (Rythmol sr)
disopyramide phosphate
cap 100 mg (Norpace)
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
flecainide acetate tab
100 mg
1
amiodarone hcl tab 100 mg
Drug Name
2
verapamil hcl tab cr 120 mg
(Calan sr)
ANTIARRHYTHMICS
Prior Authorization
Drug Name
Drug Tier
2016
2
4
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QUINIDINE SULFATE quinidine sulfate tab 300 mg
2
TIKOSYN - dofetilide cap 125
mcg (0.125 mg)
4
TIKOSYN - dofetilide cap 250
mcg (0.25 mg)
4
TIKOSYN - dofetilide cap 500
mcg (0.5 mg)
4
ANTIHYPERTENSIVES
amlodipine besylatebenazepril hcl cap
2.5-10 mg (Lotrel)
2
amlodipine besylatebenazepril hcl cap 5-10 mg
(Lotrel)
2
amlodipine besylatebenazepril hcl cap 5-20 mg
(Lotrel)
2
amlodipine besylatebenazepril hcl cap 5-40 mg
(Lotrel)
2
amlodipine besylatebenazepril hcl cap
10-20 mg (Lotrel)
2
amlodipine besylatebenazepril hcl cap
10-40 mg (Lotrel)
amlodipine besylateolmesartan medoxomil tab
5-20 mg (Azor)
amlodipine besylateolmesartan medoxomil tab
5-40 mg (Azor)
amlodipine besylateolmesartan medoxomil tab
10-20 mg (Azor)
amlodipine besylateolmesartan medoxomil tab
10-40 mg (Azor)
2
2
2
2
2
amlodipine besylatevalsartan tab 5-160 mg
(Exforge)
2
amlodipine besylatevalsartan tab 5-320 mg
(Exforge)
2
amlodipine besylatevalsartan tab 10-160 mg
(Exforge)
2
amlodipine besylatevalsartan tab 10-320 mg
(Exforge)
2
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg (Exforge hct)
2
amlodipine-valsartanhydrochlorothiazide tab
10-160-25 mg (Exforge hct)
2
atenolol & chlorthalidone
tab 50-25 mg (Tenoretic 50)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge
hct)
amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg (Exforge hct)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
1
atenolol & chlorthalidone
tab 100-25 mg (Tenoretic
100)
1
AZOR - amlodipine besylateolmesartan medoxomil tab
5-20 mg
4
AZOR - amlodipine besylateolmesartan medoxomil tab
5-40 mg
4
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AZOR - amlodipine besylateolmesartan medoxomil tab
10-20 mg
4
AZOR - amlodipine besylateolmesartan medoxomil tab
10-40 mg
benazepril &
hydrochlorothiazide tab
5-6.25 mg
benazepril &
hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
benazepril &
hydrochlorothiazide tab
20-12.5 mg (Lotensin hct)
benazepril &
hydrochlorothiazide tab
20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
4
4
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab
40-25 mg
1
2
bisoprolol &
hydrochlorothiazide tab
2.5-6.25 mg (Ziac)
2
bisoprolol &
hydrochlorothiazide tab
5-6.25 mg (Ziac)
2
bisoprolol &
hydrochlorothiazide tab
10-6.25 mg (Ziac)
2
1
benazepril hcl tab 10 mg
(Lotensin)
1
benazepril hcl tab 20 mg
(Lotensin)
1
benazepril hcl tab 40 mg
(Lotensin)
1
BENICAR - olmesartan
medoxomil tab 5 mg
4
BENICAR - olmesartan
medoxomil tab 20 mg
4
BENICAR - olmesartan
medoxomil tab 40 mg
4
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab
20-12.5 mg
4
BENICAR HCT olmesartan medoxomilhydrochlorothiazide tab
40-12.5 mg
4
candesartan cilexetil tab
4 mg (Atacand)
2
candesartan cilexetil tab
32 mg (Atacand)
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand hct)
candesartan cilexetilhydrochlorothiazide tab
32-25 mg (Atacand hct)
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
Limited Distribution
ACA
Dispensing Limits
1
4
candesartan cilexetil tab
16 mg (Atacand)
Step Therapy
1
BYVALSON - nebivololvalsartan tab 5-80 mg
candesartan cilexetil tab
8 mg (Atacand)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
2
2
2
2
2
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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CAPTOPRIL/
HYDROCHLOROTHIA captopril &
hydrochlorothiazide tab
25-15 mg
4
CAPTOPRIL/
HYDROCHLOROTHIA captopril &
hydrochlorothiazide tab
25-25 mg
4
CAPTOPRIL/
HYDROCHLOROTHIA captopril &
hydrochlorothiazide tab
50-15 mg
4
CAPTOPRIL/
HYDROCHLOROTHIA captopril &
hydrochlorothiazide tab
50-25 mg
4
clonidine hcl tab 0.1 mg
(Catapres)
1
clonidine hcl tab 0.2 mg
(Catapres)
1
clonidine hcl tab 0.3 mg
(Catapres)
1
clonidine hcl td patch
weekly 0.1 mg/24hr
(Catapres-tts-1)
2
clonidine hcl td patch
weekly 0.2 mg/24hr
(Catapres-tts-2)
2
clonidine hcl td patch
weekly 0.3 mg/24hr
(Catapres-tts-3)
2
CLORPRES - clonidine &
chlorthalidone tab 0.1-15 mg
4
CLORPRES - clonidine &
chlorthalidone tab 0.2-15 mg
4
CLORPRES - clonidine &
chlorthalidone tab 0.3-15 mg
4
DEMSER - metyrosine cap 250
mg
4
DIBENZYLINE phenoxybenzamine hcl cap
10 mg
4
doxazosin mesylate tab
1 mg (Cardura)
1
doxazosin mesylate tab
2 mg (Cardura)
doxazosin mesylate tab
4 mg (Cardura)
doxazosin mesylate tab
8 mg (Cardura)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr
24hr 25-12.5 mg
4
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr
24hr 50-12.5 mg
4
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr
24hr 100-12.5 mg
4
EDARBI - azilsartan medoxomil 4
tab 40 mg
EDARBI - azilsartan medoxomil 4
tab 80 mg
4
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone
tab 40-12.5 mg
4
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone
tab 40-25 mg
1
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg
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1
irbesartan tab 150 mg
(Avapro)
1
enalapril maleate tab 2.5 mg
(Vasotec)
1
irbesartan tab 300 mg
(Avapro)
1
enalapril maleate tab 5 mg
(Vasotec)
1
1
enalapril maleate tab 20 mg
(Vasotec)
1
irbesartanhydrochlorothiazide tab
150-12.5 mg (Avalide)
1
enalapril maleate tab 10 mg
(Vasotec)
EPANED - enalapril maleate
oral soln 1 mg/ml
4
eplerenone tab 25 mg
(Inspra)
2
eplerenone tab 50 mg
(Inspra)
2
EPROSARTAN MESYLATE eprosartan mesylate tab 600
mg
2
fosinopril sodium &
hydrochlorothiazide tab
10-12.5 mg
2
fosinopril sodium &
hydrochlorothiazide tab
20-12.5 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
2
1
1
1
1
guanfacine hcl tab 2 mg
(Tenex)
1
hydralazine hcl tab 10 mg
1
hydralazine hcl tab 50 mg
hydralazine hcl tab 100 mg
lisinopril &
hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
lisinopril &
hydrochlorothiazide tab
20-12.5 mg (Zestoretic)
lisinopril &
hydrochlorothiazide tab
20-25 mg (Zestoretic)
lisinopril tab 2.5 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
lisinopril tab 10 mg (Prinivil)
lisinopril tab 20 mg (Prinivil)
guanfacine hcl tab 1 mg
(Tenex)
hydralazine hcl tab 25 mg
irbesartanhydrochlorothiazide tab
300-12.5 mg (Avalide)
1
1
2
lisinopril tab 30 mg (Zestril)
lisinopril tab 40 mg (Zestril)
losartan potassium &
hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
losartan potassium &
hydrochlorothiazide tab
100-25 mg (Hyzaar)
losartan potassium tab
25 mg (Cozaar)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name
irbesartan tab 75 mg
(Avapro)
enalapril maleate &
hydrochlorothiazide tab
10-25 mg (Vaseretic)
1
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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losartan potassium tab
50 mg (Cozaar)
losartan potassium tab
100 mg (Cozaar)
methyldopa tab 250 mg
methyldopa tab 500 mg
1
1
1
1
nadolol &
bendroflumethiazide tab
40-5 mg (Corzide)
nadolol &
bendroflumethiazide tab
80-5 mg (Corzide)
olmesartan medoxomil tab
5 mg (Benicar)
METHYLDOPA/
HYDROCHLOROTHI methyldopa &
hydrochlorothiazide tab
250-15 mg
4
METHYLDOPA/
HYDROCHLOROTHI methyldopa &
hydrochlorothiazide tab
250-25 mg
4
metoprolol &
hydrochlorothiazide tab
50-25 mg (Lopressor hct)
2
olmesartan medoxomilhydrochlorothiazide tab
40-12.5 mg (Benicar hct)
2
olmesartan medoxomilhydrochlorothiazide tab
40-25 mg (Benicar hct)
2
olmesartan-amlodipinehydrochlorothiazide tab
20-5-12.5 mg (Tribenzor)
1
olmesartan-amlodipinehydrochlorothiazide tab
40-5-12.5 mg (Tribenzor)
metoprolol &
hydrochlorothiazide tab
100-25 mg (Lopressor hct)
metoprolol &
hydrochlorothiazide tab
100-50 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
moexiprilhydrochlorothiazide tab
7.5-12.5 mg
moexiprilhydrochlorothiazide tab
15-12.5 mg
moexiprilhydrochlorothiazide tab
15-25 mg
olmesartan medoxomil tab
20 mg (Benicar)
olmesartan medoxomil tab
40 mg (Benicar)
olmesartan medoxomilhydrochlorothiazide tab
20-12.5 mg (Benicar hct)
1
2
2
2
2
2
olmesartan-amlodipinehydrochlorothiazide tab
40-5-25 mg (Tribenzor)
olmesartan-amlodipinehydrochlorothiazide tab
40-10-12.5 mg (Tribenzor)
olmesartan-amlodipinehydrochlorothiazide tab
40-10-25 mg (Tribenzor)
perindopril erbumine tab
2 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
2
2
2
2
2
2
2
2
2
2
1
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perindopril erbumine tab
4 mg (Aceon)
perindopril erbumine tab
8 mg (Aceon)
phenoxybenzamine hcl cap
10 mg (Dibenzyline)
2
quinapril hcl tab 40 mg
(Accupril)
1
2
quinaprilhydrochlorothiazide tab
10-12.5 mg (Accuretic)
2
2
prazosin hcl cap 1 mg
(Minipress)
1
prazosin hcl cap 2 mg
(Minipress)
1
prazosin hcl cap 5 mg
(Minipress)
2
PRESTALIA - perindopril
arginine-amlodipine besylate
tab 3.5-2.5 mg
4
PRESTALIA - perindopril
arginine-amlodipine besylate
tab 7-5 mg
4
PRESTALIA - perindopril
arginine-amlodipine besylate
tab 14-10 mg
4
PROPRANOLOL/
HYDROCHLOROTH propranolol &
hydrochlorothiazide tab
40-25 mg
4
PROPRANOLOL/
HYDROCHLOROTH propranolol &
hydrochlorothiazide tab
80-25 mg
4
QBRELIS - lisinopril oral soln 1
mg/ml
4
quinapril hcl tab 5 mg
(Accupril)
1
quinapril hcl tab 10 mg
(Accupril)
1
quinapril hcl tab 20 mg
(Accupril)
1
quinaprilhydrochlorothiazide tab
20-12.5 mg (Accuretic)
quinaprilhydrochlorothiazide tab
20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
ramipril cap 10 mg (Altace)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
1
1
1
1
TARKA - trandolapril-verapamil
hcl tab cr 1-240 mg
4
TARKA - trandolapril-verapamil
hcl tab cr 2-180 mg
4
TARKA - trandolapril-verapamil
hcl tab cr 2-240 mg
4
TARKA - trandolapril-verapamil
hcl tab cr 4-240 mg
4
TEKTURNA - aliskiren
fumarate tab 150 mg (base
equivalent)
4
TEKTURNA - aliskiren
fumarate tab 300 mg (base
equivalent)
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
150-12.5 mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
150-25 mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
300-12.5 mg
4
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TEKTURNA HCT - aliskirenhydrochlorothiazide tab
300-25 mg
4
telmisartan tab 20 mg
(Micardis)
2
telmisartan tab 40 mg
(Micardis)
2
telmisartan tab 80 mg
(Micardis)
2
telmisartan-amlodipine tab
40-5 mg (Twynsta)
2
telmisartan-amlodipine tab
40-10 mg (Twynsta)
telmisartan-amlodipine tab
80-5 mg (Twynsta)
telmisartan-amlodipine tab
80-10 mg (Twynsta)
telmisartanhydrochlorothiazide tab
40-12.5 mg (Micardis hct)
telmisartanhydrochlorothiazide tab
80-12.5 mg (Micardis hct)
telmisartanhydrochlorothiazide tab
80-25 mg (Micardis hct)
terazosin hcl cap 1 mg
terazosin hcl cap 2 mg
terazosin hcl cap 5 mg
terazosin hcl cap 10 mg
trandolapril tab 1 mg (Mavik)
trandolapril tab 2 mg (Mavik)
trandolapril tab 4 mg (Mavik)
trandolapril-verapamil hcl
tab cr 1-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 2-180 mg (Tarka)
2
2
2
2
2
2
trandolapril-verapamil hcl
tab cr 2-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 4-240 mg (Tarka)
1
1
1
1
1
1
1
2
2
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
40-5-12.5 mg
4
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
40-5-25 mg
4
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
40-10-12.5 mg
4
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
40-10-25 mg
4
valsartan tab 40 mg (Diovan)
2
Limited Distribution
ACA
2
valsartan tab 160 mg
(Diovan)
2
valsartan tab 320 mg
(Diovan)
2
valsartanhydrochlorothiazide tab
80-12.5 mg (Diovan hct)
1
valsartanhydrochlorothiazide tab
160-25 mg (Diovan hct)
Dispensing Limits
2
4
valsartanhydrochlorothiazide tab
160-12.5 mg (Diovan hct)
Step Therapy
2
TRIBENZOR olmesartan-amlodipinehydrochlorothiazide tab
20-5-12.5 mg
valsartan tab 80 mg (Diovan)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
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54
valsartanhydrochlorothiazide tab
320-12.5 mg (Diovan hct)
valsartanhydrochlorothiazide tab
320-25 mg (Diovan hct)
acetazolamide cap sr 12hr
500 mg (Diamox)
acetazolamide tab 125 mg
acetazolamide tab 250 mg
2
2
2
4
amiloride &
hydrochlorothiazide tab
5-50 mg
1
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
2
1
1
2
4
chlorothiazide tab 500 mg
1
CHLORTHALIDONE chlorthalidone tab 100 mg
4
chlorthalidone tab 25 mg
2
2
DIURIL - chlorothiazide susp
250 mg/5ml
4
DYRENIUM - triamterene cap
50 mg
4
DYRENIUM - triamterene cap
100 mg
4
EDECRIN - ethacrynic acid tab
25 mg
4
ethacrynic acid tab 25 mg
2
FUROSEMIDE - furosemide
oral soln 8 mg/ml
4
furosemide oral soln 10 mg/
ml
1
furosemide tab 20 mg (Lasix)
furosemide tab 40 mg (Lasix)
furosemide tab 80 mg (Lasix)
hydrochlorothiazide cap
12.5 mg (Microzide)
hydrochlorothiazide tab
12.5 mg
hydrochlorothiazide tab
50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
Limited Distribution
1
1
1
1
1
1
2
methazolamide tab 50 mg
(Neptazane)
2
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
4
metolazone tab 2.5 mg
2
spironolactone tab 25 mg
(Aldactone)
ACA
1
methazolamide tab 25 mg
(Neptazane)
spironolactone &
hydrochlorothiazide tab
25-25 mg (Aldactazide)
Dispensing Limits
1
4
metolazone tab 10 mg
Step Therapy
1
KEVEYIS - dichlorphenamide
tab 50 mg
metolazone tab 5 mg
Prior Authorization
Drug Tier
ACA
Limited Distribution
•
Drug Name
hydrochlorothiazide tab
25 mg
CHLOROTHIAZIDE chlorothiazide tab 250 mg
chlorthalidone tab 50 mg
Dispensing Limits
1
ALDACTAZIDE spironolactone &
hydrochlorothiazide tab
50-50 mg
amiloride hcl tab 5 mg
Step Therapy
1
VECAMYL - mecamylamine hcl 4
tab 2.5 mg
DIURETICS
Prior Authorization
Drug Name
Drug Tier
2016
•
2
2
2
1
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55
spironolactone tab 50 mg
(Aldactone)
1
spironolactone tab 100 mg
(Aldactone)
2
torsemide tab 5 mg
(Demadex)
1
torsemide tab 10 mg
(Demadex)
1
torsemide tab 20 mg
(Demadex)
1
torsemide tab 100 mg
(Demadex)
2
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
1
triamterene &
hydrochlorothiazide tab
37.5-25 mg (Maxzide-25)
triamterene &
hydrochlorothiazide tab
75-50 mg (Maxzide)
TRIAMTERENE/
HYDROCHLOROTH triamterene &
hydrochlorothiazide cap
50-25 mg
VASOPRESSORS
1
1
4
ADRENACLICK - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
4
ADRENACLICK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
4
EPINEPHRINE - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
4
EPINEPHRINE - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
4
EPINEPHRINE AUTHORIZED GENERIC
TO EPIPEN - epinephrine
solution auto-injector 0.15
mg/0.3ml (1:2000)
3
EPINEPHRINE AUTHORIZED GENERIC
TO EPIPEN - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
EPIPEN 2-PAK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
EPIPEN-JR 2-PAK epinephrine solution autoinjector 0.15 mg/0.3ml
(1:2000)
3
midodrine hcl tab 2.5 mg
2
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
NORTHERA - droxidopa cap
100 mg
4
•
NORTHERA - droxidopa cap
200 mg
4
•
NORTHERA - droxidopa cap
300 mg
4
•
ANTIHYPERLIPIDEMICS
ALTOPREV - lovastatin tab sr
24hr 20 mg
4
•
ALTOPREV - lovastatin tab sr
24hr 40 mg
4
•
ALTOPREV - lovastatin tab sr
24hr 60 mg
4
•
ANTARA - fenofibrate
micronized cap 30 mg
4
• •
ANTARA - fenofibrate
micronized cap 90 mg
4
• •
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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atorvastatin calcium tab
10 mg (base equivalent)
(Lipitor)
1
atorvastatin calcium tab
20 mg (base equivalent)
(Lipitor)
1
atorvastatin calcium tab
40 mg (base equivalent)
(Lipitor)
1
atorvastatin calcium tab
80 mg (base equivalent)
(Lipitor)
1
cholestyramine light powder
packets 4 gm
2
fenofibrate micronized cap
130 mg
2
fenofibrate micronized cap
134 mg (Lofibra)
2
fenofibrate micronized cap
200 mg (Lofibra)
2
cholestyramine light powder
4 gm/dose (Questran light)
cholestyramine powder
packets 4 gm (Questran)
cholestyramine powder
4 gm/dose (Questran)
choline fenofibrate cap dr
45 mg (fenofibric acid
equiv) (Trilipix)
choline fenofibrate cap dr
135 mg (fenofibric acid
equiv) (Trilipix)
2
2
colestipol hcl granule
packets 5 gm (Colestid
flavored)
2
colestipol hcl granules 5 gm
(Colestid flavored)
2
colestipol hcl tab 1 gm
(Colestid)
2
CRESTOR - rosuvastatin
calcium tab 5 mg
4
CRESTOR - rosuvastatin
calcium tab 10 mg
4
CRESTOR - rosuvastatin
calcium tab 20 mg
4
CRESTOR - rosuvastatin
calcium tab 40 mg
4
ezetimibe tab 10 mg (Zetia)
2
•
4
FENOFIBRATE - fenofibrate
cap 150 mg
4
• •
fenofibrate micronized cap
43 mg
2
•
2
•
2
•
2
•
2
•
fenofibrate tab 40 mg
(Fenoglide)
2
•
fenofibrate tab 48 mg (Tricor)
2
fenofibrate tab 54 mg
(Lofibra)
1
•
•
fenofibrate tab 120 mg
(Fenoglide)
2
•
fenofibrate tab 145 mg
(Tricor)
2
•
fenofibrate tab 160 mg
(Lofibra)
2
•
FENOFIBRIC ACID - fenofibric
acid tab 35 mg
4
• •
FENOFIBRIC ACID - fenofibric
acid tab 105 mg
4
• •
FENOGLIDE - fenofibrate tab
40 mg
4
• •
FENOGLIDE - fenofibrate tab
120 mg
4
• •
Limited Distribution
ACA
Dispensing Limits
Step Therapy
FENOFIBRATE - fenofibrate
cap 50 mg
•
• •
fenofibrate micronized cap
67 mg (Lofibra)
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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•
LIVALO - pitavastatin calcium
tab 2 mg (base equiv)
4
•
2
LIVALO - pitavastatin calcium
tab 4 mg (base equiv)
4
•
2
lovastatin tab 10 mg
1
lovastatin tab 20 mg
2
1
2
•
niacin tab cr 500 mg
(antihyperlipidemic)
(Niaspan)
2
•
niacin tab cr 750 mg
(antihyperlipidemic)
(Niaspan)
2
•
niacin tab cr 1000 mg
(antihyperlipidemic)
(Niaspan)
omega-3-acid ethyl esters
cap 1 gm (Lovaza)
2
•
1
JUXTAPID - lomitapide
mesylate cap 5 mg (base
equiv)
5
JUXTAPID - lomitapide
mesylate cap 10 mg (base
equiv)
5
JUXTAPID - lomitapide
mesylate cap 20 mg (base
equiv)
5
JUXTAPID - lomitapide
mesylate cap 30 mg (base
equiv)
5
•
•
•
JUXTAPID - lomitapide
mesylate cap 40 mg (base
equiv)
5
•
•
•
JUXTAPID - lomitapide
mesylate cap 60 mg (base
equiv)
5
•
•
•
KYNAMRO - mipomersen
sodium soln prefilled syringe
200 mg/ml
5
•
•
•
LESCOL XL - fluvastatin
sodium tab sr 24 hr 80 mg
4
•
LIPOFEN - fenofibrate cap 50
mg
4
• •
LIPOFEN - fenofibrate cap 150
mg
4
• •
•
•
•
•
•
•
1
lovastatin tab 40 mg
(Mevacor)
gemfibrozil tab 600 mg
(Lopid)
Limited Distribution
fluvastatin sodium cap
20 mg (Lescol)
fluvastatin sodium tab sr 24
hr 80 mg (Lescol xl)
4
ACA
• •
fluvastatin sodium cap
40 mg (Lescol)
LIVALO - pitavastatin calcium
tab 1 mg (base equiv)
Dispensing Limits
4
Step Therapy
FIBRICOR - fenofibric acid tab
105 mg
Prior Authorization
• •
Drug Name
Drug Tier
4
Limited Distribution
FIBRICOR - fenofibric acid tab
35 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PRALUENT - alirocumab
subcutaneous soln peninjector 75 mg/ml
5
•
•
•
PRALUENT - alirocumab
subcutaneous soln peninjector 150 mg/ml
5
•
•
•
pravastatin sodium tab
10 mg
1
•
•
•
pravastatin sodium tab
20 mg (Pravachol)
pravastatin sodium tab
40 mg (Pravachol)
pravastatin sodium tab
80 mg (Pravachol)
REPATHA - evolocumab
subcutaneous soln prefilled
syringe 140 mg/ml
1
1
2
5
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REPATHA PUSHTRONEX
SYSTEM - evolocumab
subcutaneous soln cartridge/
infusor 420 mg/3.5ml
5
REPATHA SURECLICK evolocumab subcutaneous
soln auto-injector 140 mg/ml
5
rosuvastatin calcium tab
5 mg (Crestor)
2
rosuvastatin calcium tab
10 mg (Crestor)
rosuvastatin calcium tab
20 mg (Crestor)
rosuvastatin calcium tab
40 mg (Crestor)
simvastatin tab 5 mg (Zocor)
•
•
•
WELCHOL - colesevelam hcl
packet for susp 3.75 gm
4
WELCHOL - colesevelam hcl
tab 625 mg
4
ZETIA - ezetimibe tab 10 mg
4
2
5
2
ADEMPAS - riociguat tab 1.5
mg
•
•
•
ADEMPAS - riociguat tab 2 mg
5
ADEMPAS - riociguat tab 2.5
mg
5
•
•
•
•
amlodipine besylateatorvastatin calcium tab
2.5-10 mg (Caduet)
2
1
simvastatin tab 10 mg
(Zocor)
1
simvastatin tab 20 mg
(Zocor)
1
simvastatin tab 40 mg
(Zocor)
1
simvastatin tab 80 mg
(Zocor)
1
TRIGLIDE - fenofibrate tab 160
mg
4
VASCEPA - icosapent ethyl cap 4
0.5 gm
VASCEPA - icosapent ethyl cap 4
1 gm
4
VYTORIN - ezetimibesimvastatin tab 10-10 mg
4
VYTORIN - ezetimibesimvastatin tab 10-20 mg
4
VYTORIN - ezetimibesimvastatin tab 10-40 mg
4
VYTORIN - ezetimibesimvastatin tab 10-80 mg
amlodipine besylateatorvastatin calcium tab
2.5-20 mg (Caduet)
• •
amlodipine besylateatorvastatin calcium tab
2.5-40 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
5-10 mg (Caduet)
•
•
•
•
amlodipine besylateatorvastatin calcium tab
5-20 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
5-40 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
5-80 mg (Caduet)
Limited Distribution
•
CARDIOVASCULAR AGENTS - MISC.
ADCIRCA - tadalafil tab 20 mg 5 •
(pah)
5 •
ADEMPAS - riociguat tab 0.5
mg
ADEMPAS - riociguat tab 1 mg 5 •
2
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
2
2
2
2
2
2
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Limited Distribution
2
ORENITRAM - treprostinil
diolamine tab cr 0.125 mg
(base equiv)
5
•
2
ORENITRAM - treprostinil
diolamine tab cr 0.25 mg
(base equiv)
5
•
•
•
2
ORENITRAM - treprostinil
diolamine tab cr 1 mg (base
equiv)
5
•
•
•
2
ORENITRAM - treprostinil
diolamine tab cr 2.5 mg
(base equiv)
5
•
•
•
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5
mg
4
REVATIO - sildenafil citrate for
suspension 10 mg/ml
5
•
•
•
sildenafil citrate tab 20 mg
(Revatio)
5
CIALIS - tadalafil tab 2.5 mg
3
•
•
CIALIS - tadalafil tab 5 mg
3
5
•
•
•
CORLANOR - ivabradine hcl
tab 5 mg (base equiv)
4
TRACLEER - bosentan tab
62.5 mg
•
•
•
CORLANOR - ivabradine hcl
tab 7.5 mg (base equiv)
4
•
•
•
4
•
•
ENTRESTO - sacubitrilvalsartan tab 24-26 mg
•
•
•
4
•
•
ENTRESTO - sacubitrilvalsartan tab 49-51 mg
•
•
•
4
•
•
ENTRESTO - sacubitrilvalsartan tab 97-103 mg
ISOXSUPRINE HCL isoxsuprine hcl tab 20 mg
4
•
•
•
isoxsuprine hcl tab 10 mg
2
TRACLEER - bosentan tab 125 5
mg
5
TYVASO - treprostinil
inhalation solution 0.6 mg/ml
5
TYVASO REFILL - treprostinil
inhalation solution 0.6 mg/ml
5
TYVASO STARTER treprostinil inhalation
solution 0.6 mg/ml
5
UPTRAVI - selexipag tab
therapy pack 200 mcg (140)
& 800 mcg (60)
5
UPTRAVI - selexipag tab 200
mcg
5
UPTRAVI - selexipag tab 400
mcg
5
UPTRAVI - selexipag tab 600
mcg
5
UPTRAVI - selexipag tab 800
mcg
•
•
•
•
•
•
•
•
•
•
•
•
amlodipine besylateatorvastatin calcium tab
10-10 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
10-20 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
10-40 mg (Caduet)
amlodipine besylateatorvastatin calcium tab
10-80 mg (Caduet)
•
•
•
•
LETAIRIS - ambrisentan tab 5
mg
5
•
•
•
LETAIRIS - ambrisentan tab 10
mg
5
•
•
•
OPSUMIT - macitentan tab 10
mg
5
•
•
•
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
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•
•
UPTRAVI - selexipag tab 1400
mcg
5
•
•
•
UPTRAVI - selexipag tab 1600
mcg
5
•
•
•
VENTAVIS - iloprost inhalation
solution 10 mcg/ml
5
•
•
•
VENTAVIS - iloprost inhalation
solution 20 mcg/ml
5
•
•
•
CIALIS - tadalafil tab 2.5 mg
3
CIALIS - tadalafil tab 5 mg
3
•
•
•
•
ANTIHISTAMINES
brompheniramine maleate
tab sr 12hr 6 mg
carbinoxamine maleate soln
4 mg/5ml
carbinoxamine maleate tab
4 mg
2
2
CLEMASTINE FUMARATE clemastine fumarate tab
2.68 mg
1
cyproheptadine hcl syrup
2 mg/5ml
2
cyproheptadine hcl tab 4 mg
KARBINAL ER - carbinoxamine 4
maleate extended release
susp 4 mg/5ml
2
levocetirizine
dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
2
levocetirizine
dihydrochloride tab 5 mg
(Xyzal)
2
promethazine hcl suppos
12.5 mg
2
promethazine hcl suppos
25 mg
2
promethazine hcl suppos
50 mg
1
promethazine hcl syrup
6.25 mg/5ml
1
promethazine hcl tab
12.5 mg
1
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
2
2
DESLORATADINE ODT desloratadine tab orally
disintegrating 2.5 mg
2
DESLORATADINE ODT desloratadine tab orally
disintegrating 5 mg
2
desloratadine tab 5 mg
(Clarinex)
2
Limited Distribution
•
ACA
5
Dispensing Limits
UPTRAVI - selexipag tab 1200
mcg
RESPIRATORY AGENTS
•
Step Therapy
•
Prior Authorization
5
Drug Name
Drug Tier
Limited Distribution
UPTRAVI - selexipag tab 1000
mcg
ERECTILE DYSFUNCTION
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
NASAL AGENTS - SYSTEMIC and TOPICAL
4
ADRENALIN - epinephrine hcl
nasal soln 0.1%
2
•
azelastine hcl nasal spray
0.1% (137 mcg/spray)
2
•
azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
(Astepro)
4
•
BACTROBAN NASAL mupirocin calcium nasal oint
2%
2
•
budesonide nasal susp
32 mcg/act (Rhinocort
aqua)
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DYMISTA - azelastine hclfluticasone prop nasal spray
137-50 mcg/act
4
flunisolide nasal soln
25 mcg/act (0.025%)
(Flunisolide)
2
fluticasone propionate nasal
susp 50 mcg/act
benzonatate cap 200 mg
4
1
•
CAPCOF - phenylephrinechlorphen w/ codeine syrup
5-2-10 mg/5ml
2
•
CODAR AR - chlorpheniramine
w/ codeine liquid 2-8 mg/5ml
4
ipratropium bromide nasal
soln 0.03% (21 mcg/spray)
(Atrovent)
4
ipratropium bromide nasal
soln 0.06% (42 mcg/spray)
(Atrovent)
2
•
FLOWTUSS - hydrocodoneguaifenesin soln 2.5-200
mg/5ml
4
mometasone furoate nasal
susp 50 mcg/act (Nasonex)
2
•
GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
4
2
•
GILTUSS TR - phenylephrine
w/ dm-gg tab 10-28-388 mg
2
OMNARIS - ciclesonide nasal
susp 50 mcg/act
4
•
guaifenesin-codeine liquid
225-7.5 mg/5ml
QNASL - beclomethasone
dipropionate nasal aerosol
80 mcg/act
4
•
QNASL CHILDRENS beclomethasone
dipropionate nasal aerosol
40 mcg/act
4
•
ZETONNA - ciclesonide nasal
aerosol soln 37 mcg/act (50
mcg/valve)
4
COUGH/COLD/ALLERGY
acetylcysteine inhal soln
10%
acetylcysteine inhal soln
20%
2
2
BENZONATATE - benzonatate
cap 150 mg
2
benzonatate cap 100 mg
(Tessalon perles)
1
•
guaifenesin-codeine soln
100-10 mg/5ml
Limited Distribution
1
4
HYCOFENIX pseudoephedrine w/
hydrocodone-gg soln
30-2.5-200 mg/5ml
4
hydrocod polst-chlorphen
polst er susp 10-8 mg/5ml
(Tussionex pennkineti)
2
hydrocodone w/
homatropine syrup
5-1.5 mg/5ml
2
HYPERSAL - sodium chloride
soln nebu 3.5%
ACA
1
HISTEX-AC - phenylephrinetriprolidine-codeine syrup
10-2.5-10 mg/5ml
hydrocodone w/
homatropine tab 5-1.5 mg
Dispensing Limits
1
•
guaifenesin-codeine soln
100-6.3 mg/5ml
Step Therapy
1
brompheniramine &
pseudoephedrine tab sr
12hr 6-45 mg
olopatadine hcl nasal soln
0.6% (Patanase)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
4
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LEXUSS 210 chlorpheniramine w/ codeine
liquid 2-10 mg/5ml
1
M-END MAX D pseudoephedrinedexbromphen-codeine liqd
20-0.667-6 mg/5ml
4
M-END PE - phenylephrinebromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml
POLY-TUSSIN AC phenylephrine-bromphen
w/ codeine liquid 10-4-10
mg/5ml
4
PRO-CLEAR AC - codeinepyrilamine syrup 9-8.33
mg/5ml
4
4
PRO-RED AC - phenylephrinedexchlorphenir-codeine
syrup 5-1-9 mg/5ml
4
MAR-COF BP pseudoephedrinebromphen-codeine liqd
30-2-7.5 mg/5ml
4
promethazine &
phenylephrine syrup
6.25-5 mg/5ml
1
NEBUSAL - sodium chloride
soln nebu 6%
4
promethazine w/ codeine
syrup 6.25-10 mg/5ml
NEOTUSS PLUS phenylephrine-chlorphen-dm
liquid 7.5-4-30 mg/5ml
4
promethazine-dm syrup
6.25-15 mg/5ml
NINJACOF-XG - guaifenesincodeine liquid 200-8 mg/5ml
2
promethazinephenylephrine-codeine
syrup 6.25-5-10 mg/5ml
OBREDON - hydrocodoneguaifenesin soln 2.5-200
mg/5ml
4
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
phenylephrine w/ dm-gg liqd
2.5-7.5-88 mg/ml
2
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
2
pseudoephedrine w/ cod-gg
soln 30-10-100 mg/5ml
4
PHENYLEPHRINE/
GUAIFENESIN phenylephrine-guaifenesin
liqd 7.5-100 mg/5ml (1.5-20
mg/ml)
2
REZIRA - pseudoephedrine
w/ hydrocodone soln 60-5
mg/5ml
SEMPREX-D - acrivastine &
pseudoephedrine cap 8-60
mg
4
PHENYLHISTINE DH pseudoephedrine-chlorphen
w/ codeine liq 30-2-10
mg/5ml
4
sodium chloride soln nebu
0.9%
1
phenylephrinebrompheniramine-dm
liquid 7.5-4-15 mg/5ml
sodium chloride soln nebu
3%
sodium chloride soln nebu
7% (Hyper-sal)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
2
2
2
2
2
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sodium chloride soln nebu
10%
2
•
TUSNEL - brompheniramine w/
dm-gg cap 2-15-200 mg
4
4
•
TUSNEL C - pseudoephedrine
w/ cod-gg syrup 30-10-100
mg/5ml
2
AEROSPAN - flunisolide hfa
inhal aerosol 80 mcg/act
2
•
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr
5-4 mg
4
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
2
•
2
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr
10-8 mg
4
•
2
•
TUZISTRA XR - codeine polistchlorphen polist er susp
14.7-2.8 mg/5ml
4
VITUZ - hydrocodonechlorpheniramine soln 5-4
mg/5ml
4
Z-TUSS AC - chlorpheniramine
w/ codeine liquid 2-9 mg/5ml
4
ANTIASTHMATIC and BRONCHODILATOR AGENTS
•
ADVAIR DISKUS - fluticasone- 4
salmeterol aer powder ba
100-50 mcg/dose
•
ADVAIR DISKUS - fluticasone- 4
salmeterol aer powder ba
250-50 mcg/dose
•
ADVAIR DISKUS - fluticasone- 4
salmeterol aer powder ba
500-50 mcg/dose
4
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
45-21 mcg/act
4
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
115-21 mcg/act
albuterol sulfate soln nebu
0.5% (5 mg/ml)
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
albuterol sulfate syrup
2 mg/5ml
albuterol sulfate tab sr 12hr
4 mg (Vospire er)
albuterol sulfate tab sr 12hr
8 mg (Vospire er)
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
Limited Distribution
4
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
230-21 mcg/act
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
2
2
2
2
ALVESCO - ciclesonide inhal
aerosol 80 mcg/act
4
•
ALVESCO - ciclesonide inhal
aerosol 160 mcg/act
4
•
ANORO ELLIPTA umeclidinium-vilanterol aero
powd ba 62.5-25 mcg/inh
4
•
ARCAPTA NEOHALER indacaterol maleate inhal
powder cap 75 mcg (base
equiv)
4
•
ASMANEX TWISTHALER 120
ME - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
4
•
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4
ASMANEX TWISTHALER 30
MET - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
4
•
ASMANEX TWISTHALER 60
MET - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
4
•
ATROVENT HFA - ipratropium
bromide hfa inhal aerosol 17
mcg/act
4
•
BEVESPI AEROSPHERE glycopyrrolate-formoterol
fumarate aerosol 9-4.8 mcg/
act
4
•
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd
ba 100-25 mcg/inh
4
•
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd
ba 200-25 mcg/inh
4
•
BROVANA - arformoterol
tartrate soln nebu 15
mcg/2ml (base equiv)
4
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
2
•
2
•
2
•
COMBIVENT RESPIMAT ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
4
•
CROMOLYN SODIUM cromolyn sodium soln nebu
20 mg/2ml
4
•
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
budesonide inhalation susp
1 mg/2ml (Pulmicort)
DALIRESP - roflumilast tab 500 4
mcg
4
DULERA - mometasone
furoate-formoterol fumarate
aerosol 100-5 mcg/act
4
DULERA - mometasone
furoate-formoterol fumarate
aerosol 200-5 mcg/act
2
dyphylline-guaifenesin liqd
100-100 mg/5ml
4
ELIXOPHYLLIN - theophylline
elixir 80 mg/15ml
3
FLOVENT DISKUS fluticasone propionate aer
pow ba 50 mcg/blister
3
FLOVENT DISKUS fluticasone propionate aer
pow ba 100 mcg/blister
3
FLOVENT DISKUS fluticasone propionate aer
pow ba 250 mcg/blister
3
FLOVENT HFA - fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
3
FLOVENT HFA - fluticasone
propionate hfa inhal aer 110
mcg/act (125/valve)
3
FLOVENT HFA - fluticasone
propionate hfa inhal aer 220
mcg/act (250/valve)
1
ipratropium bromide inhal
soln 0.02%
2
ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml
2
levalbuterol hcl soln nebu
conc 1.25 mg/0.5ml
(base equiv) (Xopenex
concentrate)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ASMANEX TWISTHALER 30
MET - mometasone furoate
inhal powd 110 mcg/inh
(breath activated)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
•
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4
•
PULMICORT - budesonide
inhalation susp 1 mg/2ml
4
•
PULMICORT FLEXHALER budesonide inhal aero
powd 90 mcg/act (breath
activated)
4
levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv)
(Xopenex)
2
•
METAPROTERENOL
SULFATE - metaproterenol
sulfate syrup 10 mg/5ml
4
4
•
4
PULMICORT FLEXHALER budesonide inhal aero
powd 180 mcg/act (breath
activated)
METAPROTERENOL
SULFATE - metaproterenol
sulfate tab 20 mg
3
•
montelukast sodium chew
tab 4 mg (base equiv)
(Singulair)
1
QVAR - beclomethasone
diprop inhal aero soln 40
mcg/act (50/valve)
3
•
montelukast sodium chew
tab 5 mg (base equiv)
(Singulair)
1
QVAR - beclomethasone
diprop inhal aero soln 80
mcg/act (100/valve)
4
•
montelukast sodium
oral granules packet 4 mg
(base equiv) (Singulair)
2
SEEBRI NEOHALER glycopyrrolate inhal cap 15.6
mcg
SEREVENT DISKUS salmeterol xinafoate aer
pow ba 50 mcg/dose (base
equiv)
3
•
SPIRIVA HANDIHALER tiotropium bromide
monohydrate inhal cap 18
mcg (base equiv)
3
•
SPIRIVA RESPIMAT tiotropium bromide
monohydrate inhal aerosol
1.25 mcg/act
3
•
SPIRIVA RESPIMAT tiotropium bromide
monohydrate inhal aerosol
2.5 mcg/act
3
•
montelukast sodium tab
10 mg (base equiv)
(Singulair)
1
NUCALA - mepolizumab for inj
100 mg
5
PERFOROMIST - formoterol
fumarate soln nebu 20
mcg/2ml
4
PROAIR HFA - albuterol sulfate 3
inhal aero 108 mcg/act
(90mcg base equiv)
3
PROAIR RESPICLICK albuterol sulfate aer pow ba
108 mcg/act (90 mcg base
equiv)
•
•
•
•
Limited Distribution
PROVENTIL HFA - albuterol
sulfate inhal aero 108 mcg/
act (90mcg base equiv)
ACA
•
Dispensing Limits
2
Step Therapy
levalbuterol hcl soln nebu
0.63 mg/3ml (base equiv)
(Xopenex)
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv)
(Xopenex)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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4
•
UTIBRON NEOHALER indacaterol-glycopyrrolate
inhal cap 27.5-15.6 mcg
4
•
3
•
VENTOLIN HFA - albuterol
sulfate inhal aero 108 mcg/
act (90mcg base equiv)
3
•
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
3
•
XOPENEX HFA - levalbuterol
tartrate inhal aerosol 45
mcg/act (base equiv)
4
•
terbutaline sulfate tab
2.5 mg
2
zafirlukast tab 10 mg
(Accolate)
2
2
2
THEO-24 - theophylline cap sr
24hr 100 mg
4
zafirlukast tab 20 mg
(Accolate)
2
THEO-24 - theophylline cap sr
24hr 200 mg
4
zileuton tab sr 12hr 600 mg
(Zyflo cr)
ZYFLO - zileuton tab 600 mg
4
THEO-24 - theophylline cap sr
24hr 300 mg
4
ZYFLO CR - zileuton tab sr
12hr 600 mg
4
THEO-24 - theophylline cap sr
24hr 400 mg
4
theophylline soln
80 mg/15ml
2
RESPIRATORY AGENTS - MISC.
4
CUROSURF - poractant alfa
intratracheal susp 120
mg/1.5ml
4
CUROSURF - poractant alfa
intratracheal susp 240
mg/3ml
ESBRIET - pirfenidone cap 267 5
mg
4
INFASURF - calfactant in nacl
0.9% intratracheal susp 35
mg/ml
5
KALYDECO - ivacaftor packet
50 mg
5
KALYDECO - ivacaftor packet
75 mg
theophylline tab sr 12hr
100 mg
theophylline tab sr 12hr
200 mg
theophylline tab sr 12hr
300 mg
theophylline tab sr 12hr
450 mg
theophylline tab sr 24hr
400 mg
theophylline tab sr 24hr
600 mg
1
2
2
2
2
2
Limited Distribution
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
terbutaline sulfate tab 5 mg
TUDORZA PRESSAIR aclidinium bromide aerosol
powd breath activated 400
mcg/act
ACA
•
Dispensing Limits
4
Step Therapy
STRIVERDI RESPIMAT olodaterol hcl inhal aerosol
soln 2.5 mcg/act (base
equiv)
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
STIOLTO RESPIMAT tiotropium br-olodaterol inhal
aero soln 2.5-2.5 mcg/act
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
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•
•
OFEV - nintedanib esylate cap
150 mg (base equivalent)
5
•
•
•
ORKAMBI - lumacaftorivacaftor tab 100-125 mg
5
•
•
•
ORKAMBI - lumacaftorivacaftor tab 200-125 mg
5
•
•
•
PULMOZYME - dornase alfa
inhal soln 1 mg/ml
5
•
SURVANTA
INTRATRACHEAL beractant in nacl 0.9%
intratracheal susp 25 mg/ml
4
•
OSMOPREP - sod phos
mono-sod phos di tabs
1.102-0.398 gm(1.5gm na
phos)
4
PCP 100 - mag citbisacodyl-petrolat-pegmetoclopramide-electrol kit
4
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/
flavor pack)
1
•
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
1
•
peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm
(Colyte-flavor packs)
1
•
polyethylene glycol 3350
oral packet
2
1
2
polyethylene glycol 3350
oral powder
4
GIALAX - polyethylene glycol
3350 - kit
4
PREPOPIK - sod picosulfatemg oxide-citric acid pack 10
mg-3.5 gm-12 gm
SUPREP BOWEL PREP KIT sodium sulfate-potassium
sulfate-magnesium sulfate
oral soln
4
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
4
KRISTALOSE - lactulose oral
crystal packet 10 gm
4
ANTIDIARRHEALS
KRISTALOSE - lactulose oral
crystal packet 20 gm
4
diphenoxylate w/ atropine
tab 2.5-0.025 mg (Lomotil)
lactulose solution
10 gm/15ml
1
bisacodyl tab & peg 3350kcl-sod bicarb-nacl for
soln kit
MOVIPREP - peg 3350kcl-nacl-na sulfate-na
ascorbate-c for soln 100 gm
4
Limited Distribution
•
ACA
5
Dispensing Limits
OFEV - nintedanib esylate cap
100 mg (base equivalent)
LAXATIVES
•
Step Therapy
•
Prior Authorization
5
Drug Name
Drug Tier
Limited Distribution
KALYDECO - ivacaftor tab 150
mg
GASTROINTESTINAL AGENTS
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
DIPHENOXYLATE/
ATROPINE - diphenoxylate
w/ atropine liq 2.5-0.025
mg/5ml
4
MOTOFEN - difenoxin w/
atropine tab 1-0.025 mg
4
MYTESI - crofelemer tab
delayed release 125 mg
4
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2
DEXILANT - dexlansoprazole
cap delayed release 60 mg
4
PAREGORIC - paregoric
tincture 2 mg/5ml (morphine
equivalent)
4
dicyclomine hcl cap 10 mg
(Bentyl)
1
dicyclomine hcl oral soln
10 mg/5ml
2
RESTORA RX - lactobacillus
casei-folic acid cap 60-1.25
mg
4
RESTORA SPRINKLES lactobacillus casei-folic acid
packet 15-0.25 mg
4
opium tincture 1% (10 mg/
ml) (morphine equiv)
ULCER DRUGS
ACIPHEX - rabeprazole
sodium ec tab 20 mg
4
amoxicillin cap-clarithro tablansopraz cap dr therapy
pack (Prevpac)
2
•
4
DONNATAL - pb-hyoscyatrop-scopol tab
16.2-0.1037-0.0194-0.0065
mg
4
2
•
2
•
BELLADONNA ALKALOIDS &
OP - belladonna alkaloids &
opium suppos 16.2-60 mg
4
esomeprazole magnesium
cap delayed release 40 mg
(base eq) (Nexium)
CARAFATE - sucralfate susp 1
gm/10ml
4
famotidine for susp
40 mg/5ml (Pepcid)
1
chlordiazepoxide hclclidinium bromide cap
5-2.5 mg (Librax)
2
famotidine tab 40 mg
(Pepcid)
4
2
FIRST-LANSOPRAZOLE lansoprazole susp 3 mg/ml
(compound kit)
FIRST-OMEPRAZOLE omeprazole susp 2 mg/ml
(compound kit)
4
glycopyrrolate tab 1 mg
(Robinul)
2
glycopyrrolate tab 2 mg
(Robinul forte)
2
hyoscyamine sulfate elixir
0.125 mg/5ml
1
cimetidine tab 400 mg
cimetidine tab 800 mg
1
2
CUVPOSA - glycopyrrolate oral 4
soln 1 mg/5ml
4
DEXILANT - dexlansoprazole
cap delayed release 30 mg
•
Limited Distribution
ACA
Dispensing Limits
DONNATAL - pb-hyoscyatrop-scopol elix
16.2-0.1037-0.0194-0.0065
mg/5ml
4
1
Step Therapy
1
BELLADONNA & OPIUM belladonna alkaloids &
opium suppos 16.2-30 mg
cimetidine tab 300 mg
•
dicyclomine hcl tab 20 mg
(Bentyl)
esomeprazole magnesium
cap delayed release 20 mg
(base eq) (Nexium)
cimetidine hcl soln
300 mg/5ml
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
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hyoscyamine sulfate soln
0.125 mg/ml
hyoscyamine sulfate tab
disp 0.125 mg (Anaspaz)
hyoscyamine sulfate tab sl
0.125 mg (Levsin/sl)
hyoscyamine sulfate tab sr
12hr 0.375 mg (Levbid)
hyoscyamine sulfate tab
0.125 mg (Levsin)
lansoprazole cap delayed
release 15 mg (Prevacid)
lansoprazole cap delayed
release 30 mg (Prevacid)
methscopolamine bromide
tab 2.5 mg (Pamine)
methscopolamine bromide
tab 5 mg (Pamine forte)
2
NIZATIDINE - nizatidine oral
soln 15 mg/ml
2
2
nizatidine cap 150 mg
1
nizatidine cap 300 mg (Axid)
2
2
2
2
2
•
•
4
omeprazole cap delayed
release 10 mg (Prilosec)
1
•
1
•
1
•
2
•
2
•
2
omeprazole-sodium
bicarbonate cap
20-1100 mg (Zegerid)
1
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 5 mg
4
•
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 10 mg
4
•
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 20 mg
4
•
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 40 mg
4
•
NEXIUM - esomeprazole
magnesium for delayed
release susp pack 2.5 mg
4
•
omeprazole-sodium
bicarbonate cap
40-1100 mg (Zegerid)
omeprazole-sodium
bicarbonate powd pack for
susp 20-1680 mg (Zegerid)
omeprazole-sodium
bicarbonate powd pack for
susp 40-1680 mg (Zegerid)
Limited Distribution
ACA
Dispensing Limits
OMEPRAZOLE + SYRSPEND
SF - omeprazole susp 2 mg/
ml (compound kit)
omeprazole cap delayed
release 40 mg (Prilosec)
misoprostol tab 200 mcg
(Cytotec)
Step Therapy
4
2
1
2
OMECLAMOX-PAK amoxicillin cap-clarithro tab
w/ omepraz cap dr therapy
pack
omeprazole cap delayed
release 20 mg (Prilosec)
misoprostol tab 100 mcg
(Cytotec)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
•
•
2
•
•
pantoprazole sodium ec
tab 20 mg (base equiv)
(Protonix)
1
•
pantoprazole sodium ec
tab 40 mg (base equiv)
(Protonix)
1
•
2
pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg
(Donnatal)
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2
•
dronabinol cap 10 mg
(Marinol)
2
•
EMEND - aprepitant capsule
therapy pack 80 & 125 mg
3
•
EMEND - aprepitant capsule
40 mg
3
•
EMEND - aprepitant capsule
80 mg
3
•
1
EMEND - aprepitant capsule
125 mg
3
•
ranitidine hcl tab 300 mg
(Zantac)
1
EMEND - aprepitant for oral
susp 125 mg (125 mg/5ml)
3
•
sucralfate tab 1 gm
(Carafate)
2
granisetron hcl tab 1 mg
2
4
ondansetron hcl oral soln
4 mg/5ml (Zofran)
2
SYMAX DUOTAB hyoscyamine sulfate tab cr
0.375 mg (0.125 mg ir/0.25
mg cr)
•
•
ondansetron hcl tab 4 mg
(Zofran)
1
•
ondansetron hcl tab 8 mg
(Zofran)
2
•
ondansetron hcl tab 24 mg
2
ondansetron orally
disintegrating tab 4 mg
(Zofran odt)
1
•
•
ondansetron orally
disintegrating tab 8 mg
(Zofran odt)
2
•
SANCUSO - granisetron td
patch 3.1 mg/24hr (contains
34.3 mg)
4
•
TRANSDERM-SCOP scopolamine td patch 72hr 1
mg/3days
4
trimethobenzamide hcl cap
300 mg (Tigan)
2
ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/
ml (75 mg/5ml)
ANTIEMETICS
•
2
•
AKYNZEO - netupitantpalonosetron cap 300-0.5
mg
4
ANZEMET - dolasetron
mesylate tab 50 mg
4
•
ANZEMET - dolasetron
mesylate tab 100 mg
4
•
aprepitant capsule therapy
pack 80 & 125 mg (Emend)
2
•
aprepitant capsule 80 mg
(Emend)
2
•
CESAMET - nabilone cap 1 mg
4
DICLEGIS - doxylaminepyridoxine tab delayed
release 10-10 mg
4
dronabinol cap 2.5 mg
(Marinol)
2
•
VARUBI - rolapitant hcl tab 90
mg (base equiv)
4
•
Limited Distribution
dronabinol cap 5 mg
(Marinol)
PROPANTHELINE BROMIDE - 4
propantheline bromide tab
15 mg
4
PYLERA - bismuth subcitmetronidazole-tetracycline
cap 140-125-125 mg
2
rabeprazole sodium ec tab
20 mg (Aciphex)
2
ranitidine hcl cap 150 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
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DIGESTIVE AIDS
PERTZYE - pancrelipase
(lip-prot-amyl) dr cap
16000-57500-60500 unit
4
SUCRAID - sacrosidase soln
8500 unit/ml
5
CREON - pancrelipase
(lip-prot-amyl) dr cap
3000-9500-15000 unit
3
CREON - pancrelipase
(lip-prot-amyl) dr cap
6000-19000-30000 unit
3
VIOKACE - pancrelipase
(lip-prot-amyl) tab
10440-39150-39150 unit
4
CREON - pancrelipase
(lip-prot-amyl) dr cap
12000-38000-60000 unit
3
VIOKACE - pancrelipase
(lip-prot-amyl) tab
20880-78300-78300 unit
4
CREON - pancrelipase
(lip-prot-amyl) dr cap
24000-76000-120000 unit
3
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
3000-10000-16000 unit
3
CREON - pancrelipase
(lip-prot-amyl) dr cap
36000-114000-180000 unit
3
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
5000-17000-27000 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
2600-6200-10850 unit
4
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
10000-34000-55000 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
4200-14200-24600 unit
4
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
15000-51000-82000 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
10500-35500-61500 unit
4
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
20000-68000-109000 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
16800-56800-98400 unit
4
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
25000-85000-136000 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
21000-54700-83900 unit
4
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
40000-136000-218000 unit
3
PERTZYE - pancrelipase
(lip-prot-amyl) dr cap
4000-14375-15125 unit
4
GASTROINTESTINAL AGENTS- MISC.
2
alosetron hcl tab 0.5 mg
(base equiv) (Lotronex)
•
Limited Distribution
ACA
•
Dispensing Limits
4
4
Step Therapy
ZUPLENZ - ondansetron oral
soluble film 8 mg
PERTZYE - pancrelipase
(lip-prot-amyl) dr cap
8000-28750-30250 unit
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
ZUPLENZ - ondansetron oral
soluble film 4 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
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2
DIPENTUM - olsalazine
sodium cap 250 mg
4
AMITIZA - lubiprostone cap 8
mcg
4
ENTEREG - alvimopan cap 12
mg
4
AMITIZA - lubiprostone cap 24
mcg
4
4
APRISO - mesalamine cap sr
24hr 0.375 gm
4
FOSRENOL - lanthanum
carbonate chew tab 500 mg
(elemental)
4
ASACOL HD - mesalamine tab
delayed release 800 mg
4
FOSRENOL - lanthanum
carbonate chew tab 750 mg
(elemental)
AURYXIA - ferric citrate tab 1
gm (210 mg ferric iron)
4
4
balsalazide disodium cap
750 mg (Colazal)
2
FOSRENOL - lanthanum
carbonate chew tab 1000
mg (elemental)
FOSRENOL - lanthanum
carbonate oral powder pack
750 mg (elemental)
4
FOSRENOL - lanthanum
carbonate oral powder pack
1000 mg (elemental)
4
GATTEX - teduglutide (rdna)
for inj kit 5 mg
5
GIAZO - balsalazide disodium
tab 1.1 gm
4
lactulose (encephalopathy)
solution 10 gm/15ml
1
alosetron hcl tab 1 mg (base
equiv) (Lotronex)
calcium acetate (phosphate
binder) cap 667 mg
(169 mg ca) (Phoslo)
2
calcium acetate (phosphate
binder) tab 667 mg
(Eliphos)
2
CANASA - mesalamine suppos
1000 mg
3
CHENODAL - chenodiol tab
250 mg
5
CHOLBAM - cholic acid cap 50
mg
5
•
CHOLBAM - cholic acid cap
250 mg
5
•
CIMZIA - certolizumab pegol inj 5
kit 2 x 200 mg/ml
5
CIMZIA STARTER KIT certolizumab pegol inj kit 6 x
200 mg/ml
2
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
4
DELZICOL - mesalamine cap
dr 400 mg
•
•
•
•
•
•
•
•
LIALDA - mesalamine tab
delayed release 1.2 gm
4
LINZESS - linaclotide cap 72
mcg
4
LINZESS - linaclotide cap 145
mcg
4
LINZESS - linaclotide cap 290
mcg
4
LOTRONEX - alosetron hcl tab
0.5 mg (base equiv)
4
LOTRONEX - alosetron hcl tab
1 mg (base equiv)
4
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
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MESALAMINE DR mesalamine tab delayed
release 800 mg
4
mesalamine enema 4 gm
2
RENAGEL - sevelamer hcl tab
400 mg
4
RENAGEL - sevelamer hcl tab
800 mg
4
1
RENVELA - sevelamer
carbonate packet 0.8 gm
3
1
RENVELA - sevelamer
carbonate packet 2.4 gm
3
1
RENVELA - sevelamer
carbonate tab 800 mg
3
METOCLOPRAMIDE ODT metoclopramide hcl orally
disintegrating tab 5 mg
2
SFROWASA - mesalamine
sulfite-free (sf) enema 4
gm/60ml
4
METOCLOPRAMIDE ODT metoclopramide hcl orally
disintegrating tab 10 mg
4
sulfasalazine tab delayed
release 500 mg (Azulfidine
en-tabs)
2
MOVANTIK - naloxegol
oxalate tab 12.5 mg (base
equivalent)
4
sulfasalazine tab 500 mg
(Azulfidine)
2
ursodiol cap 300 mg
(Actigall)
2
MOVANTIK - naloxegol oxalate
tab 25 mg (base equivalent)
4
•
ursodiol tab 250 mg (Urso
250)
2
OCALIVA - obeticholic acid tab
5 mg
5
•
ursodiol tab 500 mg (Urso
forte)
2
OCALIVA - obeticholic acid tab
10 mg
5
4
3
PENTASA - mesalamine cap cr
250 mg
VELPHORO - sucroferric
oxyhydroxide chew tab 500
mg
PENTASA - mesalamine cap cr
500 mg
4
VIBERZI - eluxadoline tab 75
mg
4
PHOSLYRA - calcium acetate
(phosphate binder) oral soln
667 mg/5ml
4
VIBERZI - eluxadoline tab 100
mg
4
RELISTOR - methylnaltrexone
bromide inj 8 mg/0.4ml (20
mg/ml)
4
RELISTOR - methylnaltrexone
bromide inj 12 mg/0.6ml (20
mg/ml)
4
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
metoclopramide hcl tab
5 mg (Reglan)
metoclopramide hcl tab
10 mg (Reglan)
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
MACRODANTIN nitrofurantoin
macrocrystalline cap 25 mg
4
methenamine hippurate tab
1 gm (Hiprex)
2
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METHENAMINE
MANDELATE - methenamine
mandelate tab 0.5 gm
4
methenamine mandelate tab
1 gm
2
methenamine-hyos-meth
blue-sod phos-phen sal
tab 81.6 mg
methenamine-hyosc-meth
blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)
methenamine-hyosc-meth
blue-sod phos-phen sal
cap 118 mg
methenamine-hyosc-meth
blue-sod phos-phen sal
cap 120 mg
methenamine-hyosc-meth
blue-sod phos-phen sal
tab 81 mg
methenamine-hyoscaminemeth blue-sod phos cap
120 mg
methenamine-hyoscaminemeth blue-sod phos tab
81.6 mg (Urogesic-blue)
2
2
2
2
2
2
2
MONUROL - fosfomycin
tromethamine powd pack 3
gm (base equivalent)
4
nitrofurantoin
macrocrystalline cap
25 mg (Macrodantin)
2
nitrofurantoin
macrocrystalline cap
50 mg (Macrodantin)
nitrofurantoin
macrocrystalline cap
100 mg (Macrodantin)
2
2
nitrofurantoin monohydrate
macrocrystalline cap
100 mg (Macrobid)
nitrofurantoin susp
25 mg/5ml (Furadantin)
URIMAR-T - methenaminehyosc-meth blue-sod phosphen sal tab 120 mg
URINARY ANTISPASMODICS
bethanechol chloride tab
5 mg (Urecholine)
bethanechol chloride tab
10 mg (Urecholine)
bethanechol chloride tab
25 mg (Urecholine)
bethanechol chloride tab
50 mg (Urecholine)
darifenacin hydrobromide
tab sr 24hr 7.5 mg (base
equiv) (Enablex)
darifenacin hydrobromide
tab sr 24hr 15 mg (base
equiv) (Enablex)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
4
1
2
2
2
2
2
ENABLEX - darifenacin
hydrobromide tab sr 24hr 7.5
mg (base equiv)
4
ENABLEX - darifenacin
hydrobromide tab sr 24hr 15
mg (base equiv)
4
flavoxate hcl tab 100 mg
2
GELNIQUE - oxybutynin
chloride td gel 10%
4
MYRBETRIQ - mirabegron tab
sr 24 hr 25 mg
3
MYRBETRIQ - mirabegron tab
sr 24 hr 50 mg
3
oxybutynin chloride syrup
5 mg/5ml
1
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4
2
3
2
ESTRACE - estradiol vaginal
cream 0.1 mg/gm
2
2
estradiol vaginal tab 10 mcg
(Vagifem)
4
OXYTROL - oxybutynin td
patch twice weekly 3.9
mg/24hr
4
ESTRING - estradiol vaginal
ring 2 mg (7.5 mcg/24hrs)
4
tolterodine tartrate cap sr
24hr 2 mg (Detrol la)
2
FEM PH - acetic acidoxyquinoline vaginal gel
0.9-0.025%
4
2
FEMRING - estradiol acetate
vaginal ring 0.05 mg/24hr
4
tolterodine tartrate tab 1 mg
(Detrol)
2
FEMRING - estradiol acetate
vaginal ring 0.1 mg/24hr
4
tolterodine tartrate tab 2 mg
(Detrol)
2
GYNAZOLE-1 - butoconazole
nitrate (one dose) vaginal
cream 2%
TOVIAZ - fesoterodine
fumarate tab sr 24hr 4 mg
4
metronidazole vaginal gel
0.75% (Metrogel-vaginal)
2
TOVIAZ - fesoterodine
fumarate tab sr 24hr 8 mg
4
4
trospium chloride cap sr
24hr 60 mg
2
MICONAZOLE 3 - miconazole
nitrate vaginal suppos 200
mg
NUVESSA - metronidazole
vaginal gel 1.3%
4
PREMARIN - estrogens,
conjugated vaginal cream
0.625 mg/gm
4
RELAGARD - acetic acidoxyquinoline vaginal gel
0.9-0.025%
4
2
oxybutynin chloride tab sr
24hr 10 mg (Ditropan xl)
oxybutynin chloride tab sr
24hr 15 mg (Ditropan xl)
oxybutynin chloride tab
5 mg
tolterodine tartrate cap sr
24hr 4 mg (Detrol la)
trospium chloride tab 20 mg
2
VESICARE - solifenacin
succinate tab 5 mg
3
VESICARE - solifenacin
succinate tab 10 mg
3
VAGINAL PRODUCTS
AVC - sulfanilamide vaginal
cream 15%
4
terconazole vaginal cream
0.4% (Terazol 7)
CLEOCIN - clindamycin
phosphate vaginal suppos
100 mg
4
terconazole vaginal cream
0.8% (Terazol 3)
clindamycin phosphate
vaginal cream 2% (Cleocin)
2
terconazole vaginal suppos
80 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name
CLINDESSE - clindamycin
phosphate (one dose)
vaginal cream 2%
oxybutynin chloride tab sr
24hr 5 mg (Ditropan xl)
2
Prior Authorization
Drug Name
Drug Tier
2016
2
2
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VAGIFEM - estradiol vaginal
tab 10 mcg
3
GENITOURINARY AGENTS - MISC.
1
alfuzosin hcl tab sr 24hr
10 mg (Uroxatral)
4
AVODART - dutasteride cap
0.5 mg
4
CARDURA XL - doxazosin
mesylate tab sr 24 hr 4 mg
(base equiv)
4
CARDURA XL - doxazosin
mesylate tab sr 24 hr 8 mg
(base equiv)
5
CYSTAGON - cysteamine
bitartrate cap 50 mg
5
CYSTAGON - cysteamine
bitartrate cap 150 mg
2
dutasteride cap 0.5 mg
(Avodart)
2
dutasteride-tamsulosin hcl
cap 0.5-0.4 mg (Jalyn)
4
ELMIRON - pentosan
polysulfate sodium caps 100
mg
1
finasteride tab 5 mg
(Proscar)
JALYN - dutasteride-tamsulosin 4
hcl cap 0.5-0.4 mg
4
K-PHOS NO 2 - potassium &
sodium acid phosphates tab
305-700 mg
LITHOSTAT - acetohydroxamic 4
acid tab 250 mg
4
ORACIT - sodium citrate &
citric acid soln 490-640
mg/5ml
1
phenazopyridine hcl tab
100 mg (Pyridium)
phenazopyridine hcl tab
200 mg (Pyridium)
pot & sod citrates w/ cit ac
soln 550-500-334 mg/5ml
potassium citrate &
citric acid powder pack
3300-1002 mg
potassium citrate & citric
acid soln 1100-334 mg/5ml
potassium citrate tab cr 5
meq (540 mg) (Urocit-k 5)
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
2
2
2
2
2
potassium citrate tab cr 10
meq (1080 mg) (Urocit-k 10)
2
potassium citrate tab cr 15
meq (1620 mg) (Urocit-k 15)
5
PROCYSBI - cysteamine
bitartrate cap delayed
release 25 mg (base equiv)
5
PROCYSBI - cysteamine
bitartrate cap delayed
release 75 mg (base equiv)
RAPAFLO - silodosin cap 4 mg 4
RAPAFLO - silodosin cap 8 mg
4
sodium citrate & citric acid
soln 500-334 mg/5ml
(Shohls solution modi)
2
tamsulosin hcl cap 0.4 mg
(Flomax)
1
THIOLA - tiopronin tab 100 mg
4
•
•
•
•
•
CENTRAL NERVOUS SYSTEM DRUGS
ANTIANXIETY AGENTS
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
4
alprazolam orally
disintegrating tab 0.25 mg
(Niravam)
2
alprazolam orally
disintegrating tab 0.5 mg
2
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alprazolam orally
disintegrating tab 1 mg
alprazolam orally
disintegrating tab 2 mg
alprazolam tab sr 24hr
0.5 mg (Xanax xr)
2
2
2
diazepam conc 5 mg/ml
diazepam tab 2 mg (Valium)
diazepam tab 5 mg (Valium)
diazepam tab 10 mg (Valium)
alprazolam tab sr 24hr 1 mg
(Xanax xr)
2
hydroxyzine hcl syrup
10 mg/5ml
alprazolam tab sr 24hr 2 mg
(Xanax xr)
2
hydroxyzine hcl tab 25 mg
alprazolam tab sr 24hr 3 mg
(Xanax xr)
2
alprazolam tab 0.25 mg
(Xanax)
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 50 mg
1
1
1
1
1
alprazolam tab 0.5 mg
(Xanax)
1
alprazolam tab 1 mg (Xanax)
1
hydroxyzine pamoate cap
50 mg (Vistaril)
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
chlordiazepoxide hcl cap
5 mg
chlordiazepoxide hcl cap
10 mg
chlordiazepoxide hcl cap
25 mg
clorazepate dipotassium tab
3.75 mg (Tranxene t)
clorazepate dipotassium tab
7.5 mg (Tranxene t)
clorazepate dipotassium tab
15 mg (Tranxene t)
DIAZEPAM - diazepam oral
soln 1 mg/ml
2
1
1
2
1
2
lorazepam tab 0.5 mg
(Ativan)
1
lorazepam tab 1 mg (Ativan)
1
meprobamate tab 200 mg
meprobamate tab 400 mg
1
oxazepam cap 10 mg
1
oxazepam cap 30 mg
1
1
1
lorazepam conc 2 mg/ml
(Lorazepam intensol)
lorazepam tab 2 mg (Ativan)
oxazepam cap 15 mg
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
amitriptyline hcl tab 25 mg
amitriptyline hcl tab 50 mg
2
amitriptyline hcl tab 75 mg
4
amitriptyline hcl tab 150 mg
amitriptyline hcl tab 100 mg
Limited Distribution
1
hydroxyzine pamoate cap
25 mg (Vistaril)
1
ACA
1
1
buspirone hcl tab 5 mg
Dispensing Limits
1
4
1
Step Therapy
2
HYDROXYZINE PAMOATE hydroxyzine pamoate cap
100 mg
alprazolam tab 2 mg (Xanax)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
2
2
2
2
2
1
1
1
1
1
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
78
AMOXAPINE - amoxapine tab
25 mg
4
AMOXAPINE - amoxapine tab
50 mg
1
4
citalopram hydrobromide
tab 40 mg (base equiv)
(Celexa)
2
AMOXAPINE - amoxapine tab
100 mg
4
clomipramine hcl cap 25 mg
(Anafranil)
2
AMOXAPINE - amoxapine tab
150 mg
4
clomipramine hcl cap 50 mg
(Anafranil)
2
APLENZIN - bupropion hbr tab
sr 24hr 174 mg
4
clomipramine hcl cap 75 mg
(Anafranil)
2
APLENZIN - bupropion hbr tab
sr 24hr 348 mg
4
desipramine hcl tab 10 mg
(Norpramin)
2
APLENZIN - bupropion hbr tab
sr 24hr 522 mg
4
desipramine hcl tab 25 mg
(Norpramin)
2
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
desipramine hcl tab 50 mg
(Norpramin)
2
1
desipramine hcl tab 75 mg
(Norpramin)
2
2
desipramine hcl tab 100 mg
(Norpramin)
2
2
desipramine hcl tab 150 mg
(Norpramin)
DESVENLAFAXINE ER desvenlafaxine fumarate tab
sr 24hr 50 mg (base equiv)
4
•
DESVENLAFAXINE ER desvenlafaxine fumarate tab
sr 24hr 100 mg (base equiv)
4
•
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr
50 mg
4
•
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr
100 mg
4
•
desvenlafaxine succinate
tab sr 24hr 25 mg (base
equiv) (Pristiq)
2
•
2
•
bupropion hcl tab sr 12hr
150 mg (Wellbutrin sr)
bupropion hcl tab sr 12hr
200 mg (Wellbutrin sr)
bupropion hcl tab sr 24hr
150 mg (Wellbutrin xl)
bupropion hcl tab sr 24hr
300 mg (Wellbutrin xl)
2
bupropion hcl tab 75 mg
(Wellbutrin)
2
bupropion hcl tab 100 mg
(Wellbutrin)
2
citalopram hydrobromide
oral soln 10 mg/5ml
2
citalopram hydrobromide
tab 10 mg (base equiv)
(Celexa)
1
citalopram hydrobromide
tab 20 mg (base equiv)
(Celexa)
1
•
•
•
desvenlafaxine succinate
tab sr 24hr 50 mg (base
equiv) (Pristiq)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
79
desvenlafaxine succinate
tab sr 24hr 100 mg (base
equiv) (Pristiq)
2
DOXEPIN HCL - doxepin hcl
cap 75 mg
4
doxepin hcl cap 10 mg
1
doxepin hcl cap 25 mg
doxepin hcl cap 50 mg
doxepin hcl cap 100 mg
doxepin hcl cap 150 mg
doxepin hcl conc 10 mg/ml
1
2
2
2
1
escitalopram oxalate
tab 20 mg (base equiv)
(Lexapro)
1
FETZIMA - levomilnacipran
hcl cap sr 24hr 20 mg (base
equivalent)
4
•
FETZIMA - levomilnacipran
hcl cap sr 24hr 40 mg (base
equivalent)
4
•
FETZIMA - levomilnacipran
hcl cap sr 24hr 80 mg (base
equivalent)
4
•
FETZIMA - levomilnacipran hcl
cap sr 24hr 120 mg (base
equivalent)
4
•
FETZIMA TITRATION PACK levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy
pack
4
•
FLUOXETINE DR - fluoxetine
hcl cap delayed release 90
mg
2
• •
FLUOXETINE HCL - fluoxetine
hcl tab 60 mg
4
•
DULOXETINE HCL duloxetine hcl enteric coated
pellets cap 40 mg
4
• •
duloxetine hcl enteric
coated pellets cap 20 mg
(Cymbalta)
2
•
duloxetine hcl enteric
coated pellets cap 30 mg
(Cymbalta)
2
•
duloxetine hcl enteric
coated pellets cap 60 mg
(Cymbalta)
2
•
EMSAM - selegiline td patch
24hr 6 mg/24hr
4
fluoxetine hcl cap 10 mg
(Prozac)
1
EMSAM - selegiline td patch
24hr 9 mg/24hr
4
fluoxetine hcl cap 20 mg
(Prozac)
1
EMSAM - selegiline td patch
24hr 12 mg/24hr
4
fluoxetine hcl cap 40 mg
(Prozac)
1
escitalopram oxalate soln
5 mg/5ml (base equiv)
(Lexapro)
2
fluoxetine hcl solution
20 mg/5ml
1
escitalopram oxalate
tab 5 mg (base equiv)
(Lexapro)
1
escitalopram oxalate
tab 10 mg (base equiv)
(Lexapro)
1
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate cap sr
24hr 100 mg
fluvoxamine maleate cap sr
24hr 150 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
2
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
80
fluvoxamine maleate tab
25 mg
fluvoxamine maleate tab
50 mg
fluvoxamine maleate tab
100 mg
2
2
2
FORFIVO XL - bupropion hcl
tab sr 24hr 450 mg
4
imipramine hcl tab 10 mg
(Tofranil)
•
mirtazapine orally
disintegrating tab 30 mg
(Remeron soltab)
2
mirtazapine orally
disintegrating tab 45 mg
(Remeron soltab)
2
mirtazapine tab 7.5 mg
2
1
1
mirtazapine tab 15 mg
(Remeron)
1
imipramine hcl tab 25 mg
(Tofranil)
1
mirtazapine tab 30 mg
(Remeron)
1
imipramine hcl tab 50 mg
(Tofranil)
1
mirtazapine tab 45 mg
(Remeron)
4
imipramine pamoate cap
75 mg (Tofranil-pm)
2
NEFAZODONE HCL nefazodone hcl tab 100 mg
4
2
NEFAZODONE HCL nefazodone hcl tab 150 mg
4
2
NEFAZODONE HCL nefazodone hcl tab 200 mg
nefazodone hcl tab 50 mg
2
imipramine pamoate cap
100 mg (Tofranil-pm)
imipramine pamoate cap
125 mg (Tofranil-pm)
imipramine pamoate cap
150 mg (Tofranil-pm)
2
nefazodone hcl tab 250 mg
KHEDEZLA - desvenlafaxine
tab sr 24hr 50 mg
4
•
KHEDEZLA - desvenlafaxine
tab sr 24hr 100 mg
4
•
MAPROTILINE HCL maprotiline hcl tab 25 mg
4
•
MAPROTILINE HCL maprotiline hcl tab 50 mg
4
•
MAPROTILINE HCL maprotiline hcl tab 75 mg
4
•
MARPLAN - isocarboxazid tab
10 mg
4
mirtazapine orally
disintegrating tab 15 mg
(Remeron soltab)
2
4
nortriptyline hcl cap 10 mg
(Pamelor)
1
nortriptyline hcl cap 25 mg
(Pamelor)
1
nortriptyline hcl cap 50 mg
(Pamelor)
1
nortriptyline hcl cap 75 mg
(Pamelor)
1
paroxetine hcl tab sr 24hr
12.5 mg (Paxil cr)
2
paroxetine hcl tab sr 24hr
37.5 mg (Paxil cr)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
NORTRIPTYLINE HCL nortriptyline hcl soln 10
mg/5ml
paroxetine hcl tab sr 24hr
25 mg (Paxil cr)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
81
paroxetine hcl tab 10 mg
(Paxil)
1
sertraline hcl tab 100 mg
(Zoloft)
1
paroxetine hcl tab 20 mg
(Paxil)
1
SURMONTIL - trimipramine
maleate cap 25 mg
4
paroxetine hcl tab 30 mg
(Paxil)
1
SURMONTIL - trimipramine
maleate cap 50 mg
4
paroxetine hcl tab 40 mg
(Paxil)
1
4
PAXIL - paroxetine hcl oral
susp 10 mg/5ml (base equiv)
4
•
SURMONTIL - trimipramine
maleate cap 100 mg
2
PEXEVA - paroxetine mesylate
tab 10 mg (base equiv)
4
•
tranylcypromine sulfate tab
10 mg (Parnate)
PEXEVA - paroxetine mesylate
tab 20 mg (base equiv)
4
•
PEXEVA - paroxetine mesylate
tab 30 mg (base equiv)
4
•
PEXEVA - paroxetine mesylate
tab 40 mg (base equiv)
4
•
phenelzine sulfate tab 15 mg
(Nardil)
2
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 25 mg
(base equiv)
4
• •
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 50 mg
(base equiv)
4
• •
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 100
mg (base equiv)
4
• •
protriptyline hcl tab 5 mg
2
protriptyline hcl tab 10 mg
sertraline hcl oral conc
20 mg/ml (Zoloft)
2
2
sertraline hcl tab 25 mg
(Zoloft)
1
sertraline hcl tab 50 mg
(Zoloft)
1
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
2
TRINTELLIX - vortioxetine hbr
tab 5 mg (base equiv)
4
•
TRINTELLIX - vortioxetine hbr
tab 10 mg (base equiv)
4
•
TRINTELLIX - vortioxetine hbr
tab 20 mg (base equiv)
4
•
venlafaxine hcl cap sr 24hr
37.5 mg (base equivalent)
(Effexor xr)
1
venlafaxine hcl cap sr 24hr
75 mg (base equivalent)
(Effexor xr)
1
venlafaxine hcl cap sr 24hr
150 mg (base equivalent)
(Effexor xr)
1
venlafaxine hcl tab sr 24hr
37.5 mg (base equivalent)
(Venlafaxine hcl er)
2
venlafaxine hcl tab sr 24hr
75 mg (base equivalent)
(Venlafaxine hcl er)
2
venlafaxine hcl tab sr 24hr
150 mg (base equivalent)
(Venlafaxine hcl er)
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
82
venlafaxine hcl tab sr 24hr
225 mg (base equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
2
aripiprazole tab 15 mg
(Abilify)
2
•
aripiprazole tab 20 mg
(Abilify)
2
•
•
2
2
2
2
aripiprazole tab 30 mg
(Abilify)
2
VIIBRYD - vilazodone hcl tab
20 mg
4
•
chlorpromazine hcl tab
10 mg
2
VIIBRYD - vilazodone hcl tab
40 mg
4
•
chlorpromazine hcl tab
25 mg
VIIBRYD STARTER PACK vilazodone hcl tab starter kit
10 (7) & 20 (23) mg
4
•
chlorpromazine hcl tab
50 mg
chlorpromazine hcl tab
100 mg
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 10
mg
4
•
•
•
ABILIFY - aripiprazole tab 15
mg
4
•
ABILIFY - aripiprazole tab 20
mg
4
•
ABILIFY - aripiprazole tab 30
mg
4
ADASUVE - loxapine aerosol
powder breath activated 10
mg
4
aripiprazole oral solution
1 mg/ml
2
•
2
•
2
•
2
•
ABILIFY - aripiprazole tab 2 mg 4
ABILIFY - aripiprazole tab 5 mg 4
•
chlorpromazine hcl tab
200 mg
Limited Distribution
aripiprazole tab 10 mg
(Abilify)
ACA
2
•
•
2
•
aripiprazole tab 2 mg (Abilify)
Dispensing Limits
aripiprazole tab 5 mg (Abilify)
4
aripiprazole orally
disintegrating tab 15 mg
Step Therapy
2
VIIBRYD - vilazodone hcl tab
10 mg
aripiprazole orally
disintegrating tab 10 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
2
CLOZAPINE ODT - clozapine
orally disintegrating tab 12.5
mg
4
•
CLOZAPINE ODT - clozapine
orally disintegrating tab 150
mg
4
•
CLOZAPINE ODT - clozapine
orally disintegrating tab 200
mg
4
•
clozapine orally
disintegrating tab 25 mg
(Fazaclo)
2
•
clozapine orally
disintegrating tab 100 mg
(Fazaclo)
2
•
clozapine tab 25 mg
(Clozaril)
2
•
clozapine tab 50 mg
2
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
83
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
100 mg
4
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
200 mg
4
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
300 mg
4
FANAPT - iloperidone tab 1 mg
4
FANAPT - iloperidone tab 2 mg
4
FANAPT - iloperidone tab 4 mg
4
FANAPT - iloperidone tab 6 mg
4
FANAPT - iloperidone tab 8 mg
4
FANAPT - iloperidone tab 10
mg
4
FANAPT - iloperidone tab 12
mg
4
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak
4
FAZACLO - clozapine orally
disintegrating tab 12.5 mg
4
•
FAZACLO - clozapine orally
disintegrating tab 25 mg
4
•
FAZACLO - clozapine orally
disintegrating tab 100 mg
4
•
FAZACLO - clozapine orally
disintegrating tab 150 mg
4
•
FAZACLO - clozapine orally
disintegrating tab 200 mg
4
•
FLUPHENAZINE HCL fluphenazine hcl elixir 2.5
mg/5ml
3
fluphenazine hcl tab 1 mg
1
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 5 mg
fluphenazine hcl tab 10 mg
haloperidol lactate oral conc
2 mg/ml
haloperidol tab 0.5 mg
•
•
•
•
•
•
•
•
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
Limited Distribution
ACA
•
Dispensing Limits
2
3
Step Therapy
clozapine tab 200 mg
FLUPHENAZINE HCL fluphenazine hcl oral conc 5
mg/ml
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
clozapine tab 100 mg
(Clozaril)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
2
2
2
INVEGA - paliperidone tab sr
24hr 1.5 mg
4
•
INVEGA - paliperidone tab sr
24hr 3 mg
4
•
INVEGA - paliperidone tab sr
24hr 6 mg
4
•
INVEGA - paliperidone tab sr
24hr 9 mg
4
•
LATUDA - lurasidone hcl tab 20 4
mg
LATUDA - lurasidone hcl tab 40 4
mg
LATUDA - lurasidone hcl tab 60 4
mg
LATUDA - lurasidone hcl tab 80 4
mg
4
LATUDA - lurasidone hcl tab
120 mg
LITHIUM - lithium oral solution 4
8 meq/5ml
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
84
LITHIUM CARBONATE lithium carbonate cap 150
mg
4
NUPLAZID - pimavanserin
tartrate tab 17 mg (base
equivalent)
4
LITHIUM CARBONATE lithium carbonate cap 600
mg
4
olanzapine orally
disintegrating tab 5 mg
(Zyprexa zydis)
2
•
lithium carbonate cap
150 mg (Lithium carbonate)
1
olanzapine orally
disintegrating tab 10 mg
(Zyprexa zydis)
2
•
olanzapine orally
disintegrating tab 15 mg
(Zyprexa zydis)
2
•
olanzapine orally
disintegrating tab 20 mg
(Zyprexa zydis)
2
•
olanzapine tab 2.5 mg
(Zyprexa)
1
•
olanzapine tab 5 mg
(Zyprexa)
1
•
olanzapine tab 7.5 mg
(Zyprexa)
1
•
2
olanzapine tab 10 mg
(Zyprexa)
1
•
2
olanzapine tab 15 mg
(Zyprexa)
2
•
2
olanzapine tab 20 mg
(Zyprexa)
2
•
MOLINDONE
HYDROCHLORIDE molindone hcl tab 5 mg
4
paliperidone tab sr 24hr
1.5 mg (Invega)
2
•
2
•
MOLINDONE
HYDROCHLORIDE molindone hcl tab 10 mg
4
2
•
MOLINDONE
HYDROCHLORIDE molindone hcl tab 25 mg
4
2
•
lithium carbonate cap
300 mg
lithium carbonate cap
600 mg (Lithium carbonate)
lithium carbonate tab cr
300 mg (Lithobid)
lithium carbonate tab cr
450 mg
lithium carbonate tab
300 mg
1
1
2
2
1
LITHOBID - lithium carbonate
tab cr 300 mg
4
loxapine succinate cap 5 mg
2
loxapine succinate cap
10 mg
loxapine succinate cap
25 mg
loxapine succinate cap
50 mg
paliperidone tab sr 24hr
3 mg (Invega)
paliperidone tab sr 24hr
6 mg (Invega)
paliperidone tab sr 24hr
9 mg (Invega)
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
2
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
85
perphenazine tab 16 mg
1
prochlorperazine maleate
tab 10 mg (base
equivalent) (Compazine)
1
2
QUETIAPINE FUMARATE ER - 4
quetiapine fumarate tab sr
24hr 50 mg
QUETIAPINE FUMARATE ER - 4
quetiapine fumarate tab sr
24hr 150 mg
QUETIAPINE FUMARATE ER - 4
quetiapine fumarate tab sr
24hr 200 mg
QUETIAPINE FUMARATE ER - 4
quetiapine fumarate tab sr
24hr 300 mg
2
quetiapine fumarate tab sr
24hr 400 mg (Seroquel xr)
1
quetiapine fumarate tab
25 mg (Seroquel)
1
quetiapine fumarate tab
50 mg (Seroquel)
1
quetiapine fumarate tab
100 mg (Seroquel)
2
quetiapine fumarate tab
200 mg (Seroquel)
2
quetiapine fumarate tab
300 mg (Seroquel)
2
quetiapine fumarate tab
400 mg (Seroquel)
4
REXULTI - brexpiprazole tab
0.25 mg
•
•
•
•
•
•
•
•
•
•
•
•
4
•
REXULTI - brexpiprazole tab 1
mg
4
•
REXULTI - brexpiprazole tab 2
mg
4
•
REXULTI - brexpiprazole tab 3
mg
4
•
REXULTI - brexpiprazole tab 4
mg
4
•
risperidone orally
disintegrating tab 0.25 mg
2
•
risperidone orally
disintegrating tab 0.5 mg
(Risperdal m-tab)
2
•
risperidone orally
disintegrating tab 1 mg
(Risperdal m-tab)
2
•
risperidone orally
disintegrating tab 2 mg
(Risperdal m-tab)
2
•
risperidone orally
disintegrating tab 3 mg
(Risperdal m-tab)
2
•
risperidone orally
disintegrating tab 4 mg
(Risperdal m-tab)
2
•
risperidone soln 1 mg/ml
(Risperdal)
2
•
risperidone tab 0.25 mg
(Risperdal)
1
•
risperidone tab 0.5 mg
(Risperdal)
1
•
risperidone tab 1 mg
(Risperdal)
1
•
risperidone tab 2 mg
(Risperdal)
1
•
Limited Distribution
REXULTI - brexpiprazole tab
0.5 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
prochlorperazine maleate
tab 5 mg (base equivalent)
(Compazine)
prochlorperazine suppos
25 mg
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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86
SAPHRIS - asenapine maleate
sl tab 5 mg (base equiv)
4
SAPHRIS - asenapine maleate
sl tab 10 mg (base equiv)
4
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 50 mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 150 mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 200 mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 300 mg
3
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 400 mg
3
thioridazine hcl tab 10 mg
2
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
thiothixene cap 1 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
thiothixene cap 10 mg
trifluoperazine hcl tab 1 mg
trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 5 mg
trifluoperazine hcl tab 10 mg
VERSACLOZ - clozapine susp
50 mg/ml
•
•
•
•
•
•
•
•
2
2
2
2
2
2
2
2
2
4
•
VRAYLAR - cariprazine hcl cap
1.5 mg (base equivalent)
4
•
VRAYLAR - cariprazine hcl cap
3 mg (base equivalent)
4
•
VRAYLAR - cariprazine hcl cap
4.5 mg (base equivalent)
4
•
VRAYLAR - cariprazine hcl cap
6 mg (base equivalent)
4
•
ziprasidone hcl cap 20 mg
(Geodon)
2
•
ziprasidone hcl cap 40 mg
(Geodon)
2
•
ziprasidone hcl cap 60 mg
(Geodon)
2
•
ziprasidone hcl cap 80 mg
(Geodon)
2
•
HYPNOTICS
BUTISOL SODIUM butabarbital sodium tab 30
mg
4
DORAL - quazepam tab 15 mg
4
estazolam tab 1 mg
1
estazolam tab 2 mg
2
2
4
•
1
eszopiclone tab 1 mg
(Lunesta)
2
•
eszopiclone tab 2 mg
(Lunesta)
2
•
eszopiclone tab 3 mg
(Lunesta)
2
•
FLURAZEPAM HCL flurazepam hcl cap 15 mg
4
FLURAZEPAM HCL flurazepam hcl cap 30 mg
4
Limited Distribution
SAPHRIS - asenapine maleate
sl tab 2.5 mg (base equiv)
4
VRAYLAR - cariprazine hcl cap
therapy pack 1.5 mg (1) & 3
mg (6)
ACA
•
Dispensing Limits
1
Step Therapy
risperidone tab 4 mg
(Risperdal)
Prior Authorization
•
Drug Name
Drug Tier
1
Limited Distribution
risperidone tab 3 mg
(Risperdal)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
87
HETLIOZ - tasimelteon capsule 4
20 mg
2
midazolam hcl syrup 2 mg/
ml (base equivalent)
4
PHENOBARBITAL phenobarbital tab 15 mg
4
PHENOBARBITAL phenobarbital tab 30 mg
4
PHENOBARBITAL phenobarbital tab 60 mg
4
PHENOBARBITAL phenobarbital tab 100 mg
2
phenobarbital elixir
20 mg/5ml
1
phenobarbital tab 16.2 mg
phenobarbital tab 32.4 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
TRIAZOLAM - triazolam tab
0.125 mg
1
triazolam tab 0.25 mg
(Halcion)
2
zaleplon cap 5 mg (Sonata)
1
•
2
•
2
•
zolpidem tartrate tab 5 mg
(Ambien)
1
•
zolpidem tartrate tab 10 mg
(Ambien)
1
•
zolpidem tartrate sl tab
3.5 mg (Intermezzo)
zolpidem tartrate tab cr
6.25 mg (Ambien cr)
zolpidem tartrate tab cr
12.5 mg (Ambien cr)
2
QUAZEPAM - quazepam tab
15 mg
4
ROZEREM - ramelteon tab 8
mg
4
SECONAL SODIUM secobarbital sodium cap 100
mg
4
SILENOR - doxepin hcl (sleep)
tab 3 mg (base equiv)
4
•
SILENOR - doxepin hcl (sleep)
tab 6 mg (base equiv)
4
•
temazepam cap 7.5 mg
(Restoril)
2
temazepam cap 15 mg
(Restoril)
1
temazepam cap 22.5 mg
(Restoril)
2
temazepam cap 30 mg
(Restoril)
1
•
1
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
2
amphetaminedextroamphetamine cap sr
24hr 5 mg (Adderall xr)
2
amphetaminedextroamphetamine cap sr
24hr 10 mg (Adderall xr)
2
amphetaminedextroamphetamine cap sr
24hr 15 mg (Adderall xr)
2
amphetaminedextroamphetamine cap sr
24hr 20 mg (Adderall xr)
2
amphetaminedextroamphetamine cap sr
24hr 25 mg (Adderall xr)
2
amphetaminedextroamphetamine cap sr
24hr 30 mg (Adderall xr)
Limited Distribution
ACA
Dispensing Limits
2
zolpidem tartrate sl tab
1.75 mg (Intermezzo)
2
Step Therapy
2
•
•
•
zaleplon cap 10 mg (Sonata)
1
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
88
amphetaminedextroamphetamine tab
5 mg (Adderall)
amphetaminedextroamphetamine tab
7.5 mg (Adderall)
amphetaminedextroamphetamine tab
10 mg (Adderall)
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
amphetaminedextroamphetamine tab
15 mg (Adderall)
amphetaminedextroamphetamine tab
20 mg (Adderall)
amphetaminedextroamphetamine tab
30 mg (Adderall)
2
•
2
2
•
2
•
2
•
2
•
•
2
•
•
2
•
•
armodafinil tab 200 mg
(Nuvigil)
2
•
•
armodafinil tab 250 mg
(Nuvigil)
2
•
•
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv)
2
armodafinil tab 50 mg
(Nuvigil)
2
armodafinil tab 150 mg
(Nuvigil)
clonidine hcl tab sr 12hr
0.1 mg (Kapvay)
dexmethylphenidate hcl cap
sr 24 hr 5 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 10 mg (Focalin xr)
2
•
2
•
2
•
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
dextroamphetamine
sulfate cap sr 24hr 5 mg
(Dexedrine)
2
•
dextroamphetamine
sulfate cap sr 24hr 10 mg
(Dexedrine)
2
•
dextroamphetamine
sulfate cap sr 24hr 15 mg
(Dexedrine)
2
•
dextroamphetamine sulfate
oral solution 5 mg/5ml
(Procentra)
2
•
dextroamphetamine sulfate
tab 5 mg
2
•
2
•
4
•
dexmethylphenidate hcl cap
sr 24 hr 20 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 25 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 30 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 35 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 40 mg (Focalin xr)
dexmethylphenidate hcl tab
2.5 mg (Focalin)
dexmethylphenidate hcl tab
5 mg (Focalin)
dexmethylphenidate hcl tab
10 mg (Focalin)
dextroamphetamine sulfate
tab 10 mg
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 10 mg
Limited Distribution
2
dexmethylphenidate hcl cap
sr 24 hr 15 mg (Focalin xr)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
89
4
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 25 mg
4
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 35 mg
4
•
guanfacine hcl tab sr 24hr
1 mg (base equiv) (Intuniv)
2
•
2
•
guanfacine hcl tab sr 24hr
2 mg (base equiv) (Intuniv)
guanfacine hcl tab sr 24hr
3 mg (base equiv) (Intuniv)
guanfacine hcl tab sr 24hr
4 mg (base equiv) (Intuniv)
methamphetamine hcl tab
5 mg (Desoxyn)
methylphenidate hcl cap cr
10 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
20 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
30 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
40 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
50 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
60 mg (cd) (Metadate cd)
methylphenidate hcl cap sr
24hr 20 mg (la) (Ritalin la)
methylphenidate hcl cap sr
24hr 30 mg (la) (Ritalin la)
methylphenidate hcl cap sr
24hr 40 mg (la) (Ritalin la)
•
2
•
2
•
2
•
2
2
2
2
2
2
2
2
2
•
•
•
•
•
•
•
•
•
•
2
•
2
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 18 mg
2
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 27 mg
2
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 36 mg
2
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 54 mg
2
•
methylphenidate hcl soln
5 mg/5ml (Methylin)
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
methylphenidate hcl chew
tab 5 mg (Methylin)
methylphenidate hcl chew
tab 10 mg (Methylin)
methylphenidate hcl soln
10 mg/5ml (Methylin)
methylphenidate hcl tab cr
10 mg
methylphenidate hcl tab cr
20 mg
methylphenidate hcl tab sa
osm 18 mg (Concerta)
methylphenidate hcl tab sa
osm 27 mg (Concerta)
methylphenidate hcl tab sa
osm 36 mg (Concerta)
methylphenidate hcl tab sa
osm 54 mg (Concerta)
methylphenidate hcl tab
5 mg (Ritalin)
methylphenidate hcl tab
10 mg (Ritalin)
Limited Distribution
2
methylphenidate hcl chew
tab 2.5 mg (Methylin)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 20 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
90
methylphenidate hcl tab
20 mg (Ritalin)
2
modafinil tab 100 mg
(Provigil)
2
•
•
modafinil tab 200 mg
(Provigil)
2
•
•
NUVIGIL - armodafinil tab 50
mg
4
•
•
NUVIGIL - armodafinil tab 150
mg
4
•
•
NUVIGIL - armodafinil tab 200
mg
4
•
•
NUVIGIL - armodafinil tab 250
mg
4
•
•
STRATTERA - atomoxetine hcl
cap 10 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl
cap 18 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl
cap 25 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl
cap 40 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl
cap 60 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl
cap 80 mg (base equiv)
4
•
STRATTERA - atomoxetine hcl
cap 100 mg (base equiv)
4
•
VYVANSE - lisdexamfetamine
dimesylate cap 10 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate cap 20 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate cap 30 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate cap 40 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate cap 50 mg
4
•
4
•
VYVANSE - lisdexamfetamine
dimesylate cap 70 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 10 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 20 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 30 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 40 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 50 mg
4
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 60 mg
4
•
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
2
acamprosate calcium tab
delayed release 333 mg
•
AMPYRA - dalfampridine tab sr 5 •
12hr 10 mg
•
AUBAGIO - teriflunomide tab 7 5
mg
5
•
AUBAGIO - teriflunomide tab
14 mg
5
•
AVONEX - interferon beta-1a
for im inj kit 30mcg
(33mcg(6.6 mu)/vial)
5
•
AVONEX - interferon beta-1a
im prefilled syringe kit 30
mcg/0.5ml
5
•
AVONEX PEN - interferon
beta-1a im auto-injector kit
30 mcg/0.5ml
5
•
BETASERON - interferon
beta-1b for inj kit 0.3 mg
Limited Distribution
VYVANSE - lisdexamfetamine
dimesylate cap 60 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
91
BRISDELLE - paroxetine
mesylate cap 7.5 mg (base
equiv)
4
bupropion hcl (smoking
deterrent) tab sr 12hr
150 mg (Zyban)
A
•
CHANTIX - varenicline tartrate
tab 0.5 mg (base equiv)
A
•
CHANTIX - varenicline tartrate
tab 1 mg (base equiv)
A
•
CHANTIX CONTINUING
MONTH - varenicline tartrate
tab 1 mg (base equiv)
A
•
CHANTIX STARTING MONTH
PA - varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42
pack
A
CHLORDIAZEPOXIDE/
AMITRIPT chlordiazepoxideamitriptyline tab 5-12.5 mg
4
CHLORDIAZEPOXIDE/
AMITRIPT chlordiazepoxideamitriptyline tab 10-25 mg
4
COMMIT - nicotine polacrilex
lozenge 2 mg
A
•
COMMIT - nicotine polacrilex
lozenge 4 mg
A
•
COPAXONE - glatiramer
acetate soln prefilled syringe
20 mg/ml
5
•
•
COPAXONE - glatiramer
acetate soln prefilled syringe
40 mg/ml
5
•
•
disulfiram tab 250 mg
(Antabuse)
2
disulfiram tab 500 mg
(Antabuse)
2
donepezil hydrochloride
orally disintegrating tab
5 mg
donepezil hydrochloride
orally disintegrating tab
10 mg
donepezil hydrochloride tab
5 mg (Aricept)
donepezil hydrochloride tab
10 mg (Aricept)
donepezil hydrochloride tab
23 mg (Aricept)
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
2
1
1
2
ERGOLOID MESYLATES ergoloid mesylates tab 1 mg
2
EXELON - rivastigmine td
patch 24hr 4.6 mg/24hr
4
EXELON - rivastigmine td
patch 24hr 9.5 mg/24hr
4
EXELON - rivastigmine td
patch 24hr 13.3 mg/24hr
4
EXTAVIA - interferon beta-1b
for inj kit 0.3 mg
5
FLUOXETINE - fluoxetine hcl
(pmdd) cap 10 mg
2
FLUOXETINE - fluoxetine hcl
(pmdd) cap 20 mg
2
fluoxetine hcl (pmdd) tab
10 mg (Sarafem)
2
fluoxetine hcl (pmdd) tab
20 mg (Sarafem)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
•
2
GALANTAMINE
HYDROBROMIDE galantamine hydrobromide
oral soln 4 mg/ml
4
galantamine hydrobromide
cap sr 24hr 8 mg
(Razadyne er)
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
92
galantamine hydrobromide
cap sr 24hr 16 mg
(Razadyne er)
2
galantamine hydrobromide
cap sr 24hr 24 mg
(Razadyne er)
2
galantamine hydrobromide
tab 4 mg (Razadyne)
2
galantamine hydrobromide
tab 8 mg (Razadyne)
galantamine hydrobromide
tab 12 mg (Razadyne)
NAMENDA - memantine hcl
oral solution 2 mg/ml
4
NAMENDA - memantine hcl
tab 5 mg
4
NAMENDA - memantine hcl
tab 10 mg
4
4
2
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
2
NAMENDA XR - memantine
hcl cap sr 24hr 7 mg
4
•
NAMENDA XR - memantine
hcl cap sr 24hr 14 mg
4
•
NAMENDA XR - memantine
hcl cap sr 24hr 21 mg
4
NAMENDA XR - memantine
hcl cap sr 24hr 28 mg
4
•
GILENYA - fingolimod hcl cap
0.5 mg (base equiv)
5
glatiramer acetate soln
prefilled syringe 20 mg/ml
(Copaxone)
5
GRALISE - gabapentin (oncedaily) tab 300 mg
4
•
GRALISE - gabapentin (oncedaily) tab 600 mg
4
•
GRALISE STARTER gabapentin (once-daily) tab
pack 300 mg (9) & 600 mg
(69)
4
•
HORIZANT - gabapentin
enacarbil tab cr 300 mg
4
•
HORIZANT - gabapentin
enacarbil tab cr 600 mg
4
•
memantine hcl oral solution
2 mg/ml (Namenda)
2
memantine hcl tab 5 mg
(Namenda)
2
memantine hcl tab 10 mg
(Namenda)
2
memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
(Namenda titration pa)
2
•
4
NAMENDA XR TITRATION
PACK - memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg
& 28 mg pack
4
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
7-10 mg
4
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
14-10 mg
4
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
21-10 mg
4
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
28-10 mg
4
NAMZARIC - memantinedonepezil cap er 24hr 7 & 14
& 21 & 28-10 mg pack
A
NICODERM CQ - nicotine td
patch 24hr 7 mg/24hr
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
93
NICOTROL INHALER nicotine inhaler system 10
mg (4 mg delivered)
A
•
NICOTROL NS - nicotine nasal
spray 10 mg/ml (0.5 mg/
spray)
A
NICORETTE - nicotine
polacrilex gum 2 mg
A
•
•
NICORETTE - nicotine
polacrilex gum 4 mg
A
•
3
•
NUEDEXTA dextromethorphan hbrquinidine sulfate cap 20-10
mg
NICORETTE - nicotine
polacrilex lozenge 2 mg
A
NICORETTE - nicotine
polacrilex lozenge 4 mg
A
•
olanzapine-fluoxetine hcl
cap 3-25 mg (Symbyax)
2
NICORETTE MINI - nicotine
polacrilex lozenge 2 mg
A
•
olanzapine-fluoxetine hcl
cap 6-25 mg (Symbyax)
NICORETTE MINI - nicotine
polacrilex lozenge 4 mg
A
•
olanzapine-fluoxetine hcl
cap 6-50 mg (Symbyax)
NICORETTE STARTER KIT nicotine polacrilex gum 2 mg
A
•
olanzapine-fluoxetine hcl
cap 12-25 mg (Symbyax)
NICORETTE STARTER KIT nicotine polacrilex gum 4 mg
A
•
olanzapine-fluoxetine hcl
cap 12-50 mg (Symbyax)
nicotine polacrilex gum
2 mg
A
•
ORAP - pimozide tab 1 mg
4
ORAP - pimozide tab 2 mg
4
A
•
4
A
•
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 2-10 mg
A
•
4
A
•
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 2-25 mg
A
•
4
A
•
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-10 mg
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-25 mg
4
nicotine polacrilex gum
4 mg
nicotine polacrilex lozenge
2 mg
nicotine polacrilex lozenge
4 mg
nicotine td patch 24hr
7 mg/24hr
nicotine td patch 24hr
14 mg/24hr
Nicotine td patch 24hr
21 mg/24hr
NICOTINE TRANSDERMAL
SYST - nicotine td patch 24
hr kit 21-14-7 mg/24hr
A
•
Limited Distribution
•
ACA
A
Dispensing Limits
NICODERM CQ - nicotine td
patch 24hr 21 mg/24hr
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
NICODERM CQ - nicotine td
patch 24hr 14 mg/24hr
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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94
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-50 mg
4
REBIF TITRATION PACK interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22
mcg/0.5ml
5
pimozide tab 1 mg (Orap)
2
rivastigmine tartrate cap
1.5 mg (Exelon)
2
pimozide tab 2 mg (Orap)
2
•
•
PLEGRIDY - peginterferon
beta-1a soln pen-injector
125 mcg/0.5ml
5
PLEGRIDY - peginterferon
beta-1a soln prefilled syringe
125 mcg/0.5ml
5
PLEGRIDY STARTER PACK peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml
pack
5
PLEGRIDY STARTER PACK peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml
pack
5
REBIF - interferon beta-1a
soln pref syr 22 mcg/0.5ml
(12mu/ml)
5
•
•
REBIF - interferon beta-1a
soln pref syr 44 mcg/0.5ml
(24mu/ml)
5
•
•
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)
5
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)
REBIF REBIDOSE
TITRATION - interferon
beta-1a auto-inj 6x8.8
mcg/0.2ml & 6x22
mcg/0.5ml
•
•
•
•
•
•
•
•
5
•
•
5
•
•
rivastigmine tartrate cap
3 mg (Exelon)
rivastigmine tartrate cap
4.5 mg (Exelon)
rivastigmine tartrate cap
6 mg (Exelon)
rivastigmine td patch 24hr
4.6 mg/24hr (Exelon)
rivastigmine td patch 24hr
9.5 mg/24hr (Exelon)
rivastigmine td patch 24hr
13.3 mg/24hr (Exelon)
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
2
2
2
2
2
2
SARAFEM - fluoxetine hcl
(pmdd) tab 10 mg
4
SARAFEM - fluoxetine hcl
(pmdd) tab 20 mg
4
SAVELLA - milnacipran hcl tab
12.5 mg
4
•
SAVELLA - milnacipran hcl tab
25 mg
4
•
SAVELLA - milnacipran hcl tab
50 mg
4
•
SAVELLA - milnacipran hcl tab
100 mg
4
•
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42)
pak
4
•
TECFIDERA - dimethyl
fumarate capsule delayed
release 120 mg
5
•
•
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95
5
TECFIDERA STARTER
PACK - dimethyl fumarate
capsule dr starter pack 120
mg & 240 mg
5
tetrabenazine tab 12.5 mg
(Xenazine)
5
•
•
•
tetrabenazine tab 25 mg
(Xenazine)
5
•
•
XENAZINE - tetrabenazine tab
12.5 mg
5
•
•
XENAZINE - tetrabenazine tab
25 mg
5
XYREM - sodium oxybate oral
solution 500 mg/ml
5
ZINBRYTA - daclizumab soln
prefilled syringe 150 mg/ml
5
ZYBAN - bupropion hcl
(smoking deterrent) tab sr
12hr 150 mg
A
•
•
•
•
•
ANALGESICS - NON-NARCOTIC
2
acetaminophensalicylamidephenyltoloxamine cap
300-200-20mg
4
ALLZITAL - butalbitalacetaminophen tab 25-325
mg
A
aspirin chew tab 81 mg
ASPIRIN LOW DOSE - aspirin
tab 81 mg
A
aspirin tab delayed release
81 mg
A
butalbital-acetaminophen
tab 50-300 mg
2
butalbital-acetaminophencaffeine cap 50-325-40 mg
2
•
butalbital-aspirin-caffeine
cap 50-325-40 mg (Fiorinal)
2
•
choline & magnesium
salicylates liq 500 mg/5ml
•
•
2
•
• •
•
•
butalbital-acetaminophencaffeine cap 50-300-40 mg
(Fioricet)
2
•
ANALGESICS AND ANESTHETICS
Limited Distribution
ACA
Dispensing Limits
2
CHOLINE MAGNESIUM
TRISALI - choline &
magnesium salicylates tab
1000 mg
4
diflunisal tab 500 mg
2
LEVACET - aspirin-apapsalicylamide-caffeine tab
500-250-150-32.5 mg
4
salsalate tab 500 mg
(Disalcid)
2
salsalate tab 750 mg
(Disalcid)
2
TENCON - butalbitalacetaminophen tab 50-325
mg
2
VANATOL LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
2
ANALGESICS - NARCOTIC
Step Therapy
2
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
•
•
butalbital-acetaminophen
tab 50-325 mg
Prior Authorization
•
TECFIDERA - dimethyl
fumarate capsule delayed
release 240 mg
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ABSTRAL - fentanyl citrate sl
tab 100 mcg (base equiv)
4
•
•
ABSTRAL - fentanyl citrate sl
tab 200 mcg (base equiv)
4
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
96
ABSTRAL - fentanyl citrate sl
tab 600 mcg (base equiv)
4
•
•
ABSTRAL - fentanyl citrate sl
tab 800 mcg (base equiv)
4
•
•
acetaminophen w/ codeine
soln 120-12 mg/5ml
1
1
acetaminophen w/ codeine
tab 300-30 mg (Tylenol/
codeine #3)
1
acetaminophen w/ codeine
tab 300-60 mg (Tylenol/
codeine #4)
1
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
2
ASPIRIN-CAFFEINEDIHYDROC - aspirincaffeine-dihydrocodeine cap
356.4-30-16 mg
4
BELBUCA - buprenorphine hcl
buccal film 75 mcg (base
equivalent)
4
BELBUCA - buprenorphine hcl
buccal film 150 mcg (base
equivalent)
4
•
BELBUCA - buprenorphine hcl
buccal film 750 mcg (base
equivalent)
4
•
BELBUCA - buprenorphine hcl
buccal film 900 mcg (base
equivalent)
4
•
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3
mg (base equiv)
4
•
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7
mg (base equiv)
4
•
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1
mg (base equiv)
4
•
buprenorphine hcl sl tab
2 mg (base equiv)
2
•
2
•
2
•
2
•
buprenorphine hcl sl tab
8 mg (base equiv)
buprenorphine hcl-naloxone
hcl sl tab 2-0.5 mg (base
equiv)
•
buprenorphine hcl-naloxone
hcl sl tab 8-2 mg (base
equiv)
•
2
4
butalbital-acetaminophencaff w/ cod cap
50-300-40-30 mg (Fioricet/
codeine)
BELBUCA - buprenorphine hcl
buccal film 300 mcg (base
equivalent)
4
•
butalbital-acetaminophencaff w/ cod cap
50-325-40-30 mg
2
BELBUCA - buprenorphine hcl
buccal film 450 mcg (base
equivalent)
4
•
butalbital-aspirincaff w/ codeine cap
50-325-40-30 mg (Fiorinal/
codeine #3)
Limited Distribution
•
BELBUCA - buprenorphine hcl
buccal film 600 mcg (base
equivalent)
ACA
•
Dispensing Limits
4
Step Therapy
ABSTRAL - fentanyl citrate sl
tab 400 mcg (base equiv)
acetaminophen w/ codeine
tab 300-15 mg (Tylenol/
codeine)
•
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
ABSTRAL - fentanyl citrate sl
tab 300 mcg (base equiv)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
97
4
•
EMBEDA - morphinenaltrexone cap cr 60-2.4 mg
4
•
4
•
EMBEDA - morphinenaltrexone cap cr 80-3.2 mg
4
•
BUTRANS - buprenorphine td
patch weekly 10 mcg/hr
4
•
EMBEDA - morphinenaltrexone cap cr 100-4 mg
4
•
BUTRANS - buprenorphine td
patch weekly 15 mcg/hr
4
•
EXALGO - hydromorphone hcl
tab er 24hr deter 32 mg
4
•
BUTRANS - buprenorphine td
patch weekly 20 mcg/hr
4
•
FENTANYL - fentanyl td patch
72hr 37.5 mcg/hr
4
•
CODEINE SULFATE - codeine
sulfate tab 15 mg
4
FENTANYL - fentanyl td patch
72hr 62.5 mcg/hr
4
•
CODEINE SULFATE - codeine
sulfate tab 30 mg
4
FENTANYL - fentanyl td patch
72hr 87.5 mcg/hr
4
•
CODEINE SULFATE - codeine
sulfate tab 60 mg
4
2
•
•
codeine sulfate tab 15 mg
(Codeine sulfate)
2
fentanyl citrate lozenge on a
handle 200 mcg (Actiq)
2
•
•
codeine sulfate tab 30 mg
(Codeine sulfate)
2
2
•
•
codeine sulfate tab 60 mg
(Codeine sulfate)
2
2
•
•
CONZIP - tramadol hcl cap sr
24hr biphasic release 100
mg
4
•
2
•
•
4
•
2
CONZIP - tramadol hcl cap sr
24hr biphasic release 200
mg
•
•
CONZIP - tramadol hcl cap sr
24hr biphasic release 300
mg
4
•
EMBEDA - morphinenaltrexone cap cr 20-0.8 mg
4
•
fentanyl td patch 72hr
50 mcg/hr (Duragesic)
EMBEDA - morphinenaltrexone cap cr 30-1.2 mg
4
•
fentanyl td patch 72hr
75 mcg/hr (Duragesic)
fentanyl citrate lozenge on a
handle 400 mcg (Actiq)
fentanyl citrate lozenge on a
handle 600 mcg (Actiq)
fentanyl citrate lozenge on a
handle 800 mcg (Actiq)
fentanyl citrate lozenge on a
handle 1200 mcg (Actiq)
fentanyl citrate lozenge on a
handle 1600 mcg (Actiq)
fentanyl td patch 72hr
12 mcg/hr (Duragesic)
fentanyl td patch 72hr
25 mcg/hr (Duragesic)
fentanyl td patch 72hr
100 mcg/hr (Duragesic)
2
•
2
•
2
•
2
•
2
•
Limited Distribution
EMBEDA - morphinenaltrexone cap cr 50-2 mg
butorphanol tartrate nasal
soln 10 mg/ml
ACA
BUTRANS - buprenorphine td
patch weekly 7.5 mcg/hr
Dispensing Limits
•
Step Therapy
4
Prior Authorization
BUTRANS - buprenorphine td
patch weekly 5 mcg/hr
Drug Name
Drug Tier
•
Limited Distribution
2
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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98
4
FENTORA - fentanyl citrate
buccal tab 600 mcg (base
equiv)
4
•
•
FENTORA - fentanyl citrate
buccal tab 800 mcg (base
equiv)
4
•
•
hydrocodoneacetaminophen soln
7.5-325 mg/15ml (Hycet)
2
hydrocodoneacetaminophen soln
10-325 mg/15ml (Zamicet)
hydrocodoneacetaminophen tab
2.5-325 mg
hydrocodoneacetaminophen tab
10-325 mg (Norco)
hydrocodoneacetaminophen tab
5-300 mg (Xodol)
hydrocodoneacetaminophen tab
7.5-300 mg (Xodol)
hydrocodoneacetaminophen tab
5-325 mg (Norco)
hydrocodoneacetaminophen tab
7.5-325 mg (Norco)
2
2
1
2
•
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
2
2
1
2
HYDROMORPHONE HCL hydromorphone hcl suppos
3 mg
4
hydromorphone hcl liqd
1 mg/ml (Dilaudid)
2
hydromorphone hcl tab er
24hr deter 8 mg (Exalgo)
hydromorphone hcl tab er
24hr deter 12 mg (Exalgo)
hydromorphone hcl tab er
24hr deter 16 mg (Exalgo)
hydromorphone hcl tab er
24hr deter 32 mg (Exalgo)
hydromorphone hcl tab
2 mg (Dilaudid)
hydromorphone hcl tab
4 mg (Dilaudid)
hydromorphone hcl tab
8 mg (Dilaudid)
Limited Distribution
FENTORA - fentanyl citrate
buccal tab 400 mcg (base
equiv)
•
ACA
•
Dispensing Limits
4
hydrocodoneacetaminophen tab
10-300 mg (Xodol)
Step Therapy
FENTORA - fentanyl citrate
buccal tab 200 mcg (base
equiv)
•
•
Prior Authorization
•
Drug Name
Drug Tier
4
Limited Distribution
FENTORA - fentanyl citrate
buccal tab 100 mcg (base
equiv)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
•
2
•
2
•
2
•
1
1
2
2
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
20 mg
4
•
1
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
30 mg
4
•
1
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
40 mg
4
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
99
meperidine hcl tab 100 mg
(Demerol)
2
MEPERIDINE HCL/
PROMETHAZI - meperidine
w/ promethazine cap 50-25
mg
4
methadone hcl conc 10 mg/
ml (Methadose)
2
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
60 mg
4
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
80 mg
4
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
100 mg
4
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
120 mg
4
•
IONSYS - fentanyl hcl
iontophoretic td system 40
mcg/act (base equiv)
4
KADIAN - morphine sulfate cap
sr 24hr 40 mg
4
•
methadone hcl tab 5 mg
(Dolophine hcl)
1
KADIAN - morphine sulfate cap
sr 24hr 200 mg
4
•
methadone hcl tab 10 mg
(Dolophine)
1
LAZANDA - fentanyl citrate
nasal spray 100 mcg/act
(base equiv)
4
•
•
MORPHINE SULFATE morphine sulfate suppos 5
mg
3
LAZANDA - fentanyl citrate
nasal spray 300 mcg/act
(base equiv)
4
•
•
MORPHINE SULFATE morphine sulfate suppos 10
mg
3
LAZANDA - fentanyl citrate
nasal spray 400 mcg/act
(base equiv)
4
•
•
MORPHINE SULFATE morphine sulfate suppos 20
mg
3
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
4
3
LORTAB - hydrocodoneacetaminophen soln 10-300
mg/15ml
4
MORPHINE SULFATE morphine sulfate suppos 30
mg
MORPHINE SULFATE morphine sulfate tab 15 mg
3
MEPERIDINE HCL meperidine hcl oral soln 50
mg/5ml
4
MORPHINE SULFATE morphine sulfate tab 30 mg
3
2
•
meperidine hcl tab 50 mg
(Demerol)
2
morphine sulfate cap sr 24hr
10 mg (Kadian)
2
•
methadone hcl soln
5 mg/5ml (Methadone hcl)
methadone hcl soln
10 mg/5ml (Methadone hcl)
methadone hcl tab for oral
susp 40 mg
morphine sulfate cap sr 24hr
20 mg (Kadian)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
100
•
2
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 30 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 45 mg
2
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 60 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 75 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 90 mg
2
•
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 120 mg
2
•
morphine sulfate oral soln
10 mg/5ml
2
morphine sulfate cap sr 24hr
100 mg (Kadian)
morphine sulfate oral soln
20 mg/5ml
morphine sulfate oral soln
100 mg/5ml (20 mg/ml)
morphine sulfate tab cr
15 mg (Ms contin)
morphine sulfate tab cr
30 mg (Ms contin)
•
2
2
2
•
2
•
•
2
•
2
•
NUCYNTA - tapentadol hcl tab
50 mg
4
•
NUCYNTA - tapentadol hcl tab
75 mg
4
•
NUCYNTA - tapentadol hcl tab
100 mg
4
•
NUCYNTA ER - tapentadol hcl
tab sr 12hr 50 mg
4
•
NUCYNTA ER - tapentadol hcl
tab sr 12hr 100 mg
4
•
NUCYNTA ER - tapentadol hcl
tab sr 12hr 150 mg
4
•
NUCYNTA ER - tapentadol hcl
tab sr 12hr 200 mg
4
•
NUCYNTA ER - tapentadol hcl
tab sr 12hr 250 mg
4
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 5 mg
4
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 7.5 mg
4
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 10 mg
4
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 15 mg
4
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 20 mg
4
•
morphine sulfate tab cr
100 mg (Ms contin)
morphine sulfate tab cr
200 mg (Ms contin)
Limited Distribution
2
morphine sulfate cap sr 24hr
80 mg (Kadian)
2
morphine sulfate tab cr
60 mg (Ms contin)
ACA
•
Dispensing Limits
2
morphine sulfate cap sr 24hr
60 mg (Kadian)
Step Therapy
•
Prior Authorization
2
morphine sulfate cap sr 24hr
50 mg (Kadian)
Drug Name
Drug Tier
•
Limited Distribution
2
morphine sulfate cap sr 24hr
30 mg (Kadian)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
101
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 30 mg
4
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 40 mg
4
OXAYDO - oxycodone hcl tab
abuse deter 5 mg
4
OXAYDO - oxycodone hcl tab
abuse deter 7.5 mg
4
oxycodone hcl cap 5 mg
2
•
oxycodone hcl tab 10 mg
2
oxycodone hcl tab 20 mg
2
oxycodone hcl tab 30 mg
(Roxicodone)
2
oxycodone w/
acetaminophen tab
2.5-325 mg (Percocet)
2
oxycodone hcl conc
100 mg/5ml (20 mg/ml)
(Oxycodone hcl)
2
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 10 mg
4
•
oxycodone w/
acetaminophen tab
7.5-325 mg (Percocet)
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 15 mg
4
•
oxycodone w/
acetaminophen tab
10-325 mg (Percocet)
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 20 mg
4
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 30 mg
4
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 40 mg
4
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 60 mg
4
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 80 mg
4
oxycodone hcl soln
5 mg/5ml (Oxycodone hcl)
oxycodone hcl tab 5 mg
(Roxicodone)
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
Limited Distribution
1
2
2
2
OXYCODONE/
ACETAMINOPHEN oxycodone w/
acetaminophen soln 5-325
mg/5ml
2
•
OXYCODONE/IBUPROFEN oxycodone-ibuprofen tab
5-400 mg
2
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 10 mg
3
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 15 mg
3
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 20 mg
3
•
2
OXYCONTIN - oxycodone hcl
tab er 12hr deter 30 mg
3
•
1
OXYCONTIN - oxycodone hcl
tab er 12hr deter 40 mg
3
•
•
ACA
Dispensing Limits
Step Therapy
2
oxycodone hcl tab 15 mg
(Roxicodone)
oxycodone w/
acetaminophen tab
5-325 mg (Percocet)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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102
2
oxymorphone hcl tab 10 mg
(Opana)
2
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
5 mg
2
•
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
7.5 mg
2
•
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
10 mg
2
•
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
15 mg
2
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
20 mg
2
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
30 mg
2
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
40 mg
2
pentazocine w/ naloxone tab
50-0.5 mg
2
4
PRIMLEV - oxycodone w/
acetaminophen tab 7.5-300
mg
4
PRIMLEV - oxycodone w/
acetaminophen tab 10-300
mg
4
PROBUPHINE IMPLANT
KIT - buprenorphine hcl
subdermal implant 74.2 mg
(base equiv)
4
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 2-0.5
mg (base equiv)
4
•
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 4-1
mg (base equiv)
4
•
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 8-2
mg (base equiv)
4
•
4
•
•
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 12-3
mg (base equiv)
SUBSYS - fentanyl sublingual
spray 100 mcg
4
•
•
•
SUBSYS - fentanyl sublingual
spray 200 mcg
4
•
•
SUBSYS - fentanyl sublingual
spray 400 mcg
4
•
•
SUBSYS - fentanyl sublingual
spray 600 mcg
4
•
•
SUBSYS - fentanyl sublingual
spray 800 mcg
4
•
•
SUBSYS - fentanyl sublingual
spray 1200 mcg (600 mcg x
2)
4
•
•
•
•
Limited Distribution
oxymorphone hcl tab 5 mg
(Opana)
PRIMLEV - oxycodone w/
acetaminophen tab 5-300
mg
ACA
•
Dispensing Limits
3
Step Therapy
OXYCONTIN - oxycodone hcl
tab er 12hr deter 80 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
OXYCONTIN - oxycodone hcl
tab er 12hr deter 60 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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103
4
SYNALGOS-DC - aspirincaffeine-dihydrocodeine cap
356.4-30-16 mg
4
TRAMADOL HCL ER tramadol hcl cap sr 24hr
biphasic release 100 mg
4
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr
biphasic release 150 mg
4
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr
biphasic release 200 mg
4
•
TRAMADOL HCL ER tramadol hcl cap sr 24hr
biphasic release 300 mg
4
•
tramadol hcl tab sr 24hr
100 mg (Ultram er)
2
•
2
•
2
•
2
•
2
•
2
•
tramadol hcl tab 50 mg
(Ultram)
1
•
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
tramadol hcl tab sr 24hr
200 mg (Ultram er)
tramadol hcl tab sr 24hr
300 mg (Ultram er)
tramadol hcl tab sr 24hr
biphasic release 100 mg
tramadol hcl tab sr 24hr
biphasic release 200 mg
tramadol hcl tab sr 24hr
biphasic release 300 mg
TREZIX - acetaminophencaffeine-dihydrocodeine cap
320.5-30-16 mg
4
XARTEMIS XR - oxycodone
w/ acetaminophen tab cr
7.5-325 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
SUBSYS - fentanyl sublingual
spray 1600 mcg (800 mcg x
2)
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
XTAMPZA ER - oxycodone cap 4
er 12hr abuse-deterrent 9
mg
XTAMPZA ER - oxycodone cap 4
er 12hr abuse-deterrent 13.5
mg
XTAMPZA ER - oxycodone cap 4
er 12hr abuse-deterrent 18
mg
XTAMPZA ER - oxycodone cap 4
er 12hr abuse-deterrent 27
mg
XTAMPZA ER - oxycodone cap 4
er 12hr abuse-deterrent 36
mg
4
ZAMICET - hydrocodoneacetaminophen soln 10-325
mg/15ml
4
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 10 mg
4
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 15 mg
4
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 20 mg
4
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 30 mg
4
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 40 mg
4
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 50 mg
•
•
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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104
4
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 1.4-0.36
mg (base eq)
4
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 2.9-0.71
mg (base eq)
4
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 5.7-1.4
mg (base eq)
4
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 8.6-2.1
mg (base eq)
4
•
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 11.4-2.9
mg (base eq)
4
•
ANALGESICS - ANTI-INFLAMMATORY
5 •
ACTEMRA - tocilizumab
subcutaneous soln prefilled
syringe 162 mg/0.9ml
5 •
ARCALYST - rilonacept for inj
220 mg
2
celecoxib cap 50 mg
(Celebrex)
2
celecoxib cap 100 mg
(Celebrex)
2
celecoxib cap 200 mg
(Celebrex)
2
celecoxib cap 400 mg
(Celebrex)
2
diclofenac potassium tab
50 mg
2
diclofenac sodium tab
delayed release 25 mg
1
diclofenac sodium tab
delayed release 50 mg
diclofenac sodium tab
delayed release 75 mg
•
diclofenac sodium tab sr
24hr 100 mg (Voltaren-xr)
•
diclofenac w/ misoprostol
tab delayed release
50-0.2 mg (Arthrotec 50)
•
diclofenac w/ misoprostol
tab delayed release
75-0.2 mg (Arthrotec 75)
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
2
2
2
ENBREL - etanercept for
subcutaneous inj 25 mg
5
•
•
•
ENBREL - etanercept
subcutaneous soln prefilled
syringe 25 mg/0.5ml
5
•
•
•
ENBREL - etanercept
subcutaneous soln prefilled
syringe 50 mg/ml
5
•
•
•
ENBREL SURECLICK etanercept subcutaneous
solution auto-injector 50 mg/
ml
5
•
•
•
etodolac cap 200 mg
2
etodolac cap 300 mg
etodolac tab sr 24hr 400 mg
•
etodolac tab sr 24hr 500 mg
•
etodolac tab 400 mg
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 0.7-0.18
mg (base eq)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
etodolac tab sr 24hr 600 mg
etodolac tab 500 mg
2
2
2
2
2
2
FENOPROFEN CALCIUM fenoprofen calcium cap 200
mg
4
FENOPROFEN CALCIUM fenoprofen calcium cap 400
mg
4
FENOPROFEN CALCIUM fenoprofen calcium tab 600
mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
105
FENORTHO - fenoprofen
calcium cap 200 mg
4
FENORTHO - fenoprofen
calcium cap 400 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
5
4
KINERET - anakinra
subcutaneous soln prefilled
syringe 100 mg/0.67ml
2
1
leflunomide tab 10 mg
(Arava)
leflunomide tab 20 mg
(Arava)
2
MECLOFENAMATE SODIUM meclofenamate sodium cap
50 mg
4
MECLOFENAMATE SODIUM meclofenamate sodium cap
100 mg
4
mefenamic acid cap 250 mg
(Ponstel)
2
meloxicam tab 7.5 mg
(Mobic)
1
1
HUMIRA - adalimumab
prefilled syringe kit 10
mg/0.2ml
5
•
•
•
HUMIRA - adalimumab
prefilled syringe kit 20
mg/0.4ml
5
•
•
•
HUMIRA - adalimumab
prefilled syringe kit 40
mg/0.8ml
5
•
•
•
HUMIRA PEDIATRIC
CROHNS D - adalimumab
prefilled syringe kit 40
mg/0.8ml
5
•
•
•
HUMIRA PEN - adalimumab
pen-injector kit 40 mg/0.8ml
5
•
•
•
HUMIRA PEN-CROHNS
DISEASE - adalimumab peninjector kit 40 mg/0.8ml
5
•
•
•
NALFON - fenoprofen calcium
cap 400 mg
4
2
HUMIRA PEN-PSORIASIS
STAR - adalimumab peninjector kit 40 mg/0.8ml
5
•
naproxen sodium tab sr
24hr 375 mg (base equiv)
(Naprelan)
2
ibuprofen tab 400 mg
1
naproxen sodium tab sr
24hr 500 mg (base equiv)
(Naprelan)
naproxen sodium tab
275 mg (Anaprox)
1
ibuprofen tab 600 mg
ibuprofen tab 800 mg
indomethacin cap cr 75 mg
indomethacin cap 25 mg
indomethacin cap 50 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
ketorolac tromethamine tab
10 mg
•
•
1
1
2
nabumetone tab 750 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
1
1
naproxen susp 125 mg/5ml
1
naproxen tab ec 375 mg (Ecnaprosyn)
1
naproxen tab ec 500 mg (Ecnaprosyn)
1
•
•
1
1
1
•
meloxicam tab 15 mg (Mobic) 1
1
nabumetone tab 500 mg
naproxen sodium tab
550 mg (Anaprox ds)
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
106
naproxen tab 250 mg
(Naprosyn)
1
piroxicam cap 10 mg
(Feldene)
2
naproxen tab 375 mg
(Naprosyn)
1
piroxicam cap 20 mg
(Feldene)
2
naproxen tab 500 mg
(Naprosyn)
1
4
ORENCIA - abatacept
subcutaneous soln prefilled
syringe 125 mg/ml
5
RASUVO - methotrexate
soln pf auto-injector 7.5
mg/0.15ml
RASUVO - methotrexate soln
pf auto-injector 10 mg/0.2ml
4
ORENCIA CLICKJECT abatacept subcutaneous
soln auto-injector 125 mg/ml
RASUVO - methotrexate
soln pf auto-injector 12.5
mg/0.25ml
4
RASUVO - methotrexate soln
pf auto-injector 15 mg/0.3ml
4
RASUVO - methotrexate
soln pf auto-injector 17.5
mg/0.35ml
4
•
•
•
5
•
•
•
OTEZLA - apremilast tab
starter therapy pack 10 mg &
20 mg & 30 mg
5
•
•
•
OTEZLA - apremilast tab 30
mg
5
OTREXUP - methotrexate soln
pf auto-injector 7.5 mg/0.4ml
4
RASUVO - methotrexate soln
pf auto-injector 20 mg/0.4ml
4
OTREXUP - methotrexate soln
pf auto-injector 10 mg/0.4ml
4
4
OTREXUP - methotrexate
soln pf auto-injector 12.5
mg/0.4ml
4
RASUVO - methotrexate
soln pf auto-injector 22.5
mg/0.45ml
RASUVO - methotrexate soln
pf auto-injector 25 mg/0.5ml
4
OTREXUP - methotrexate soln
pf auto-injector 15 mg/0.4ml
4
4
OTREXUP - methotrexate
soln pf auto-injector 17.5
mg/0.4ml
4
RASUVO - methotrexate
soln pf auto-injector 27.5
mg/0.55ml
RASUVO - methotrexate soln
pf auto-injector 30 mg/0.6ml
4
OTREXUP - methotrexate soln
pf auto-injector 20 mg/0.4ml
4
OTREXUP - methotrexate
soln pf auto-injector 22.5
mg/0.4ml
4
OTREXUP - methotrexate soln
pf auto-injector 25 mg/0.4ml
4
oxaprozin tab 600 mg
(Daypro)
2
•
•
•
RIDAURA - auranofin cap 3 mg 4
5
SIMPONI - golimumab
subcutaneous soln autoinjector 50 mg/0.5ml
5
SIMPONI - golimumab
subcutaneous soln autoinjector 100 mg/ml
5
SIMPONI - golimumab
subcutaneous soln prefilled
syringe 50 mg/0.5ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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107
SIMPONI - golimumab
subcutaneous soln prefilled
syringe 100 mg/ml
5
sulindac tab 150 mg
1
sulindac tab 200 mg
1
TOLMETIN SODIUM - tolmetin
sodium cap 400 mg
2
XELJANZ - tofacitinib citrate
tab 5 mg (base equivalent)
5
•
•
•
XELJANZ XR - tofacitinib
citrate tab sr 24hr 11 mg
(base equivalent)
5
•
•
•
MIGRAINE PRODUCTS
IMITREX - sumatriptan nasal
spray 20 mg/act
3
isometheptene-caffeineacetaminophen tab
65-20-325 mg (Prodrin)
2
isometheptene-dichloralacetaminophen cap
65-100-325 mg
2
MIGRANAL dihydroergotamine mesylate
nasal spray 4 mg/ml
4
•
naratriptan hcl tab 1 mg
(base equiv) (Amerge)
2
•
2
•
2
•
naratriptan hcl tab 2.5 mg
(base equiv) (Amerge)
2
•
4
•
AXERT - almotriptan malate
tab 6.25 mg
4
•
RELPAX - eletriptan
hydrobromide tab 20 mg
(base equivalent)
4
•
AXERT - almotriptan malate
tab 12.5 mg
4
•
RELPAX - eletriptan
hydrobromide tab 40 mg
(base equivalent)
•
D.H.E. 45 - dihydroergotamine
mesylate inj 1 mg/ml
4
•
rizatriptan benzoate oral
disintegrating tab 5 mg
(base eq) (Maxalt-mlt)
2
CAMBIA - diclofenac
potassium packet 50 mg
4
2
•
dihydroergotamine mesylate
inj 1 mg/ml (D.h.e. 45)
2
•
rizatriptan benzoate tab
5 mg (base equivalent)
(Maxalt)
2
•
rizatriptan benzoate tab
10 mg (base equivalent)
(Maxalt)
2
•
sumatriptan nasal spray
5 mg/act (Imitrex)
2
•
2
•
almotriptan malate tab
6.25 mg (Axert)
almotriptan malate tab
12.5 mg (Axert)
ERGOMAR - ergotamine
tartrate sl tab 2 mg
4
ergotamine w/ caffeine tab
1-100 mg (Cafergot)
2
FROVA - frovatriptan succinate
tab 2.5 mg (base equivalent)
4
•
frovatriptan succinate tab
2.5 mg (base equivalent)
(Frova)
2
•
IMITREX - sumatriptan nasal
spray 5 mg/act
3
•
rizatriptan benzoate oral
disintegrating tab 10 mg
(base eq) (Maxalt-mlt)
sumatriptan nasal spray
20 mg/act (Imitrex)
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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108
4
•
2
•
GOUT AGENTS
2
sumatriptan succinate
solution auto-injector
4 mg/0.5ml (Imitrex statdose
sys)
2
sumatriptan succinate
solution auto-injector
6 mg/0.5ml (Imitrex statdose
sys)
2
sumatriptan succinate
solution cartridge
4 mg/0.5ml (Imitrex statdose
ref)
2
sumatriptan succinate
solution cartridge
6 mg/0.5ml (Imitrex statdose
ref)
1
sumatriptan succinate tab
25 mg (Imitrex)
1
sumatriptan succinate tab
50 mg (Imitrex)
1
sumatriptan succinate tab
100 mg (Imitrex)
2
zolmitriptan orally
disintegrating tab 2.5 mg
(Zomig zmt)
2
zolmitriptan orally
disintegrating tab 5 mg
(Zomig zmt)
2
zolmitriptan tab 2.5 mg
(Zomig)
2
zolmitriptan tab 5 mg
(Zomig)
•
allopurinol tab 100 mg
(Zyloprim)
1
allopurinol tab 300 mg
(Zyloprim)
1
COLCHICINE - colchicine cap
0.6 mg
4
COLCHICINE - colchicine tab
0.6 mg
4
colchicine w/ probenecid tab
0.5-500 mg
2
•
•
•
•
•
•
•
COLCRYS - colchicine tab 0.6
mg
4
MITIGARE - colchicine cap 0.6
mg
4
probenecid tab 500 mg
2
Limited Distribution
ZOMIG - zolmitriptan nasal
spray 5 mg/spray unit
ACA
•
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
•
Dispensing Limits
4
4
•
Step Therapy
ZOMIG - zolmitriptan nasal
spray 2.5 mg/spray unit
SUMATRIPTAN SUCCINATE sumatriptan succinate
solution prefilled syringe 6
mg/0.5ml
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ULORIC - febuxostat tab 40 mg 4
ULORIC - febuxostat tab 80 mg 4
NEUROMUSCULAR DRUGS
ANTICONVULSANTS
APTIOM - eslicarbazepine
acetate tab 200 mg
4
APTIOM - eslicarbazepine
acetate tab 400 mg
4
APTIOM - eslicarbazepine
acetate tab 600 mg
4
APTIOM - eslicarbazepine
acetate tab 800 mg
4
BANZEL - rufinamide susp 40
mg/ml
4
BANZEL - rufinamide tab 200
mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
109
BANZEL - rufinamide tab 400
mg
4
BRIVIACT - brivaracetam oral
soln 10 mg/ml
4
BRIVIACT - brivaracetam tab
10 mg
4
BRIVIACT - brivaracetam tab
25 mg
4
BRIVIACT - brivaracetam tab
50 mg
4
BRIVIACT - brivaracetam tab
75 mg
4
BRIVIACT - brivaracetam tab
100 mg
4
carbamazepine cap sr 12hr
100 mg (Carbatrol)
2
carbamazepine cap sr 12hr
200 mg (Carbatrol)
carbamazepine cap sr 12hr
300 mg (Carbatrol)
carbamazepine chew tab
100 mg
carbamazepine susp
100 mg/5ml (Tegretol)
carbamazepine tab sr 12hr
100 mg (Tegretol-xr)
carbamazepine tab sr 12hr
200 mg (Tegretol-xr)
carbamazepine tab sr 12hr
400 mg (Tegretol-xr)
2
2
2
2
2
2
2
carbamazepine tab 200 mg
(Tegretol)
2
CARBATROL - carbamazepine
cap sr 12hr 100 mg
4
CARBATROL - carbamazepine
cap sr 12hr 200 mg
4
CARBATROL - carbamazepine
cap sr 12hr 300 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
CELONTIN - methsuximide cap 4
300 mg
2
clonazepam orally
disintegrating tab
0.125 mg
2
clonazepam orally
disintegrating tab 0.25 mg
2
clonazepam orally
disintegrating tab 0.5 mg
2
clonazepam orally
disintegrating tab 1 mg
2
clonazepam orally
disintegrating tab 2 mg
1
clonazepam tab 0.5 mg
(Klonopin)
1
clonazepam tab 1 mg
(Klonopin)
1
clonazepam tab 2 mg
(Klonopin)
DEPAKENE - valproate sodium 4
oral soln 250 mg/5ml (base
equiv)
DEPAKENE - valproic acid cap 4
250 mg
DIASTAT ACUDIAL - diazepam 3
rectal gel delivery system 10
mg
DIASTAT ACUDIAL - diazepam 3
rectal gel delivery system 20
mg
3
DIASTAT PEDIATRIC diazepam rectal gel delivery
system 2.5 mg
4
DIAZEPAM - diazepam rectal
gel delivery system 2.5 mg
4
DIAZEPAM - diazepam rectal
gel delivery system 10 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
110
DIAZEPAM - diazepam rectal
gel delivery system 20 mg
4
FYCOMPA - perampanel susp
0.5 mg/ml
4
DILANTIN - phenytoin sodium
extended cap 30 mg
4
FYCOMPA - perampanel tab 2
mg
4
DILANTIN - phenytoin sodium
extended cap 100 mg
4
FYCOMPA - perampanel tab 4
mg
4
DILANTIN INFATABS phenytoin chew tab 50 mg
4
FYCOMPA - perampanel tab 6
mg
4
DILANTIN-125 - phenytoin
susp 125 mg/5ml
4
FYCOMPA - perampanel tab 8
mg
4
divalproex sodium cap
delayed release sprinkle
125 mg (Depakote
sprinkles)
2
FYCOMPA - perampanel tab
10 mg
4
4
divalproex sodium tab
delayed release 125 mg
(Depakote)
1
FYCOMPA - perampanel tab
12 mg
gabapentin cap 100 mg
(Neurontin)
1
divalproex sodium tab
delayed release 250 mg
(Depakote)
1
gabapentin cap 300 mg
(Neurontin)
1
1
divalproex sodium tab
delayed release 500 mg
(Depakote)
2
gabapentin cap 400 mg
(Neurontin)
gabapentin oral soln
250 mg/5ml (Neurontin)
2
divalproex sodium tab sr 24
hr 250 mg (Depakote er)
2
gabapentin tab 600 mg
(Neurontin)
2
2
gabapentin tab 800 mg
(Neurontin)
2
ethosuximide cap 250 mg
(Zarontin)
2
GABITRIL - tiagabine hcl tab
12 mg
4
ethosuximide soln
250 mg/5ml (Zarontin)
2
GABITRIL - tiagabine hcl tab
16 mg
4
felbamate susp 600 mg/5ml
(Felbatol)
2
4
felbamate tab 400 mg
(Felbatol)
2
LAMICTAL ODT - lamotrigine
orally disintegrating tab 25
mg
4
felbamate tab 600 mg
(Felbatol)
2
LAMICTAL ODT - lamotrigine
orally disintegrating tab 50
mg
divalproex sodium tab sr 24
hr 500 mg (Depakote er)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
111
LAMICTAL ODT - lamotrigine
orally disintegrating tab 100
mg
4
lamotrigine orally
disintegrating tab 100 mg
(Lamictal odt)
2
LAMICTAL ODT - lamotrigine
orally disintegrating tab 200
mg
4
lamotrigine orally
disintegrating tab 200 mg
(Lamictal odt)
2
LAMICTAL ODT - lamotrigine
tab disp 25 mg (21) & 50 mg
(7) titration kit
4
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
2
LAMICTAL ODT - lamotrigine
tab disp 50 mg (42) & 100
mg (14) titration kit
4
LAMICTAL ODT - lamotrigine
tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit
4
LAMICTAL STARTER/NOT
TAKI - lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit
4
LAMICTAL STARTER/TAKING
C - lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit
4
LAMICTAL STARTER/TAKING
V - lamotrigine tab 25 mg
(35) starter kit
4
2
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
2
lamotrigine tab disp 25 mg
(21) & 50 mg (7) titration
kit (LAMICTAL ODT)
2
lamotrigine tab disp 50 mg
(42) & 100 mg (14) titration
kit (LAMICTAL ODT)
2
lamotrigine tab disp 25 (14)
& 50 mg (14) & 100 mg (7)
kit (LAMICTAL ODT)
2
lamotrigine tab sr 24hr
25 mg (Lamictal xr)
2
lamotrigine tab sr 24hr
50 mg (Lamictal xr)
2
lamotrigine tab sr 24hr
100 mg (Lamictal xr)
2
lamotrigine tab sr 24hr
200 mg (Lamictal xr)
2
lamotrigine tab sr 24hr
250 mg (Lamictal xr)
2
lamotrigine tab sr 24hr
300 mg (Lamictal xr)
1
lamotrigine tab 25 mg
(Lamictal)
1
lamotrigine tab 100 mg
(Lamictal)
1
lamotrigine tab 150 mg
(Lamictal)
LAMICTAL XR - lamotrigine tab 4
sr 24hr 25 mg (21) & 50 mg
(7) titration kit
LAMICTAL XR - lamotrigine tab 4
sr 24hr 25 (14) & 50 mg (14)
& 100 mg(7) kit
4
LAMICTAL XR - lamotrigine
tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit
2
lamotrigine orally
disintegrating tab 25 mg
(Lamictal odt)
2
lamotrigine orally
disintegrating tab 50 mg
(Lamictal odt)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
112
lamotrigine tab 200 mg
(Lamictal)
1
ONFI - clobazam tab 20 mg
4
oxcarbazepine susp
300 mg/5ml (60 mg/ml)
(Trileptal)
2
levetiracetam oral soln
100 mg/ml (Keppra)
2
2
oxcarbazepine tab 150 mg
(Trileptal)
1
2
oxcarbazepine tab 300 mg
(Trileptal)
2
levetiracetam tab 250 mg
(Keppra)
1
oxcarbazepine tab 600 mg
(Trileptal)
2
levetiracetam tab 500 mg
(Keppra)
2
4
levetiracetam tab 750 mg
(Keppra)
2
OXTELLAR XR oxcarbazepine tab sr 24hr
150 mg
4
levetiracetam tab 1000 mg
(Keppra)
2
OXTELLAR XR oxcarbazepine tab sr 24hr
300 mg
LYRICA - pregabalin cap 25
mg
4
•
4
LYRICA - pregabalin cap 50
mg
4
•
OXTELLAR XR oxcarbazepine tab sr 24hr
600 mg
4
LYRICA - pregabalin cap 75
mg
4
•
PEGANONE - ethotoin tab 250
mg
4
LYRICA - pregabalin cap 100
mg
4
•
PHENYTEK - phenytoin
sodium extended cap 200
mg
LYRICA - pregabalin cap 150
mg
4
•
4
LYRICA - pregabalin cap 200
mg
4
•
PHENYTEK - phenytoin
sodium extended cap 300
mg
2
LYRICA - pregabalin cap 225
mg
4
•
phenytoin chew tab 50 mg
(Dilantin infatabs)
2
LYRICA - pregabalin cap 300
mg
4
•
phenytoin sodium extended
cap 100 mg (Dilantin)
LYRICA - pregabalin soln 20
mg/ml
4
•
ONFI - clobazam suspension
2.5 mg/ml
4
ONFI - clobazam tab 10 mg
4
levetiracetam tab sr 24hr
500 mg (Keppra xr)
levetiracetam tab sr 24hr
750 mg (Keppra xr)
phenytoin sodium extended
cap 200 mg (Phenytek)
phenytoin sodium extended
cap 300 mg (Phenytek)
phenytoin susp 125 mg/5ml
(Dilantin-125)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
POTIGA - ezogabine tab 50 mg 4
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
113
POTIGA - ezogabine tab 200
mg
4
TEGRETOL - carbamazepine
tab 200 mg
4
POTIGA - ezogabine tab 300
mg
4
4
POTIGA - ezogabine tab 400
mg
4
TEGRETOL-XR carbamazepine tab sr 12hr
100 mg
4
primidone tab 50 mg
(Mysoline)
1
TEGRETOL-XR carbamazepine tab sr 12hr
200 mg
primidone tab 250 mg
(Mysoline)
2
4
QUDEXY XR - topiramate cap
er 24hr sprinkle 25 mg
4
TEGRETOL-XR carbamazepine tab sr 12hr
400 mg
2
QUDEXY XR - topiramate cap
er 24hr sprinkle 50 mg
4
tiagabine hcl tab 2 mg
(Gabitril)
2
QUDEXY XR - topiramate cap
er 24hr sprinkle 100 mg
4
tiagabine hcl tab 4 mg
(Gabitril)
4
QUDEXY XR - topiramate cap
er 24hr sprinkle 150 mg
4
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 25 mg
4
QUDEXY XR - topiramate cap
er 24hr sprinkle 200 mg
4
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 50 mg
4
SABRIL - vigabatrin powd pack
500 mg
3
•
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 100 mg
4
SABRIL - vigabatrin tab 500
mg
3
•
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 150 mg
4
SPRITAM - levetiracetam tab
disintegrating soluble 250
mg
4
•
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 200 mg
topiramate sprinkle cap
15 mg (Topamax sprinkle)
2
SPRITAM - levetiracetam tab
disintegrating soluble 500
mg
4
•
SPRITAM - levetiracetam tab
disintegrating soluble 750
mg
4
SPRITAM - levetiracetam tab
disintegrating soluble 1000
mg
4
TEGRETOL - carbamazepine
susp 100 mg/5ml
4
•
•
topiramate sprinkle cap
25 mg (Topamax sprinkle)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
topiramate tab 25 mg
(Topamax)
1
topiramate tab 50 mg
(Topamax)
1
topiramate tab 100 mg
(Topamax)
1
topiramate tab 200 mg
(Topamax)
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
114
TROKENDI XR - topiramate
cap sr 24hr 25 mg
4
APOKYN - apomorphine hcl
soln cartridge 30 mg/3ml
5
TROKENDI XR - topiramate
cap sr 24hr 50 mg
4
AZILECT - rasagiline mesylate
tab 0.5 mg (base equiv)
4
TROKENDI XR - topiramate
cap sr 24hr 100 mg
4
AZILECT - rasagiline mesylate
tab 1 mg (base equiv)
4
TROKENDI XR - topiramate
cap sr 24hr 200 mg
4
1
valproate sodium oral soln
250 mg/5ml (base equiv)
(Depakene)
2
benztropine mesylate tab
0.5 mg
valproic acid cap 250 mg
(Depakene)
2
benztropine mesylate tab
2 mg
bromocriptine mesylate cap
5 mg (base equivalent)
(Parlodel)
2
VIMPAT - lacosamide oral
solution 10 mg/ml
4
VIMPAT - lacosamide tab 50
mg
4
2
VIMPAT - lacosamide tab 100
mg
4
bromocriptine mesylate tab
2.5 mg (base equivalent)
(Parlodel)
2
VIMPAT - lacosamide tab 150
mg
4
carbidopa & levodopa
orally disintegrating tab
10-100 mg
VIMPAT - lacosamide tab 200
mg
4
ZARONTIN - ethosuximide cap
250 mg
4
ZARONTIN - ethosuximide soln 4
250 mg/5ml
1
zonisamide cap 25 mg
(Zonegran)
2
zonisamide cap 50 mg
zonisamide cap 100 mg
(Zonegran)
ANTIPARKINSON AGENTS
amantadine hcl cap 100 mg
amantadine hcl syrup
50 mg/5ml
amantadine hcl tab 100 mg
2
2
1
benztropine mesylate tab
1 mg
carbidopa & levodopa
orally disintegrating tab
25-100 mg
carbidopa & levodopa
orally disintegrating tab
25-250 mg
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
carbidopa & levodopa tab
10-100 mg (Sinemet)
carbidopa & levodopa tab
25-100 mg (Sinemet)
carbidopa & levodopa tab
25-250 mg (Sinemet)
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
1
1
2
2
2
2
1
2
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
115
carbidopa tab 25 mg
(Lodosyn)
2
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
12.5-50-200 mg
4
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
18.75-75-200 mg
4
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
25-100-200 mg
4
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
31.25-125-200 mg
4
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
37.5-150-200 mg
4
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
50-200-200 mg
4
DUOPA - carbidopa-levodopa
enteral susp 4.63-20 mg/ml
4
entacapone tab 200 mg
(Comtan)
2
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
0.375 mg
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
2.25 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 3
mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
3.75 mg
4
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
4.5 mg
4
NEUPRO - rotigotine td patch
24hr 1 mg/24hr
4
NEUPRO - rotigotine td patch
24hr 2 mg/24hr
4
NEUPRO - rotigotine td patch
24hr 3 mg/24hr
4
NEUPRO - rotigotine td patch
24hr 4 mg/24hr
4
NEUPRO - rotigotine td patch
24hr 6 mg/24hr
4
NEUPRO - rotigotine td patch
24hr 8 mg/24hr
4
pramipexole dihydrochloride
tab sr 24hr 0.375 mg
(Mirapex er)
2
2
4
pramipexole dihydrochloride
tab sr 24hr 0.75 mg
(Mirapex er)
2
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
0.75 mg
4
pramipexole dihydrochloride
tab sr 24hr 1.5 mg (Mirapex
er)
2
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr
1.5 mg
4
pramipexole dihydrochloride
tab sr 24hr 2.25 mg
(Mirapex er)
pramipexole dihydrochloride
tab sr 24hr 3 mg (Mirapex
er)
2
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
116
pramipexole dihydrochloride
tab sr 24hr 3.75 mg
(Mirapex er)
2
pramipexole dihydrochloride
tab sr 24hr 4.5 mg (Mirapex
er)
2
pramipexole dihydrochloride
tab 0.125 mg (Mirapex)
1
pramipexole dihydrochloride
tab 0.25 mg (Mirapex)
pramipexole dihydrochloride
tab 0.5 mg (Mirapex)
pramipexole dihydrochloride
tab 0.75 mg (Mirapex)
pramipexole dihydrochloride
tab 1 mg (Mirapex)
pramipexole dihydrochloride
tab 1.5 mg (Mirapex)
1
1
1
1
1
ropinirole hydrochloride tab
0.25 mg (Requip)
ropinirole hydrochloride tab
0.5 mg (Requip)
ropinirole hydrochloride tab
1 mg (Requip)
ropinirole hydrochloride tab
2 mg (Requip)
ropinirole hydrochloride tab
3 mg (Requip)
ropinirole hydrochloride tab
4 mg (Requip)
ropinirole hydrochloride tab
5 mg (Requip)
1
1
1
RYTARY - carbidopa &
levodopa cap cr 23.75-95
mg
4
RYTARY - carbidopa &
levodopa cap cr 48.75-195
mg
4
rasagiline mesylate tab 1 mg
(base equiv) (Azilect)
2
2
RYTARY - carbidopa &
levodopa cap cr 61.25-245
mg
4
2
selegiline hcl cap 5 mg
(Eldepryl)
2
selegiline hcl tab 5 mg
2
ropinirole hydrochloride
tab sr 24hr 8 mg (base
equivalent) (Requip xl)
ropinirole hydrochloride
tab sr 24hr 12 mg (base
equivalent) (Requip xl)
2
2
Limited Distribution
1
4
ropinirole hydrochloride
tab sr 24hr 6 mg (base
equivalent) (Requip xl)
ACA
1
RYTARY - carbidopa &
levodopa cap cr 36.25-145
mg
2
Dispensing Limits
1
2
ropinirole hydrochloride
tab sr 24hr 4 mg (base
equivalent) (Requip xl)
Step Therapy
1
rasagiline mesylate tab
0.5 mg (base equiv)
(Azilect)
ropinirole hydrochloride
tab sr 24hr 2 mg (base
equivalent) (Requip xl)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
STALEVO 100 - carbidopalevodopa-entacapone tabs
25-100-200 mg
4
STALEVO 125 - carbidopalevodopa-entacapone tabs
31.25-125-200 mg
4
STALEVO 150 - carbidopalevodopa-entacapone tabs
37.5-150-200 mg
4
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
117
STALEVO 200 - carbidopalevodopa-entacapone tabs
50-200-200 mg
4
STALEVO 50 - carbidopalevodopa-entacapone tabs
12.5-50-200 mg
4
STALEVO 75 - carbidopalevodopa-entacapone tabs
18.75-75-200 mg
4
TASMAR - tolcapone tab 100
mg
4
dantrolene sodium cap
25 mg (Dantrium)
tolcapone tab 100 mg
(Tasmar)
2
dantrolene sodium cap
50 mg (Dantrium)
trihexyphenidyl hcl elixir
0.4 mg/ml
2
dantrolene sodium cap
100 mg
1
LORZONE - chlorzoxazone tab
375 mg
4
LORZONE - chlorzoxazone tab
750 mg
4
METAXALONE - metaxalone
tab 400 mg
4
metaxalone tab 800 mg
(Skelaxin)
2
methocarbamol tab 500 mg
(Robaxin)
1
methocarbamol tab 750 mg
(Robaxin-750)
1
orphenadrine citrate tab sr
12hr 100 mg
2
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
ZELAPAR - selegiline hcl orally
disintegrating tab 1.25 mg
NEUROMUSCULAR AGENTS
riluzole tab 50 mg (Rilutek)
1
4
2
MUSCULOSKELETAL THERAPY AGENTS
4
AMRIX - cyclobenzaprine hcl
cap sr 24hr 15 mg
4
AMRIX - cyclobenzaprine hcl
cap sr 24hr 30 mg
1
baclofen tab 10 mg
baclofen tab 20 mg
2
carisoprodol tab 250 mg
(Soma)
2
carisoprodol tab 350 mg
(Soma)
1
carisoprodol w/ aspirin &
codeine tab 200-325-16 mg
2
carisoprodol w/ aspirin tab
200-325 mg
2
chlorzoxazone tab 500 mg
(Parafon forte dsc)
1
cyclobenzaprine hcl tab
5 mg
1
cyclobenzaprine hcl tab
7.5 mg (Fexmid)
cyclobenzaprine hcl tab
10 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
1
2
2
2
SOMA - carisoprodol tab 250
mg
4
tizanidine hcl cap 2 mg
(base equivalent)
(Zanaflex)
2
•
tizanidine hcl cap 4 mg
(base equivalent)
(Zanaflex)
2
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
118
2
tizanidine hcl tab 2 mg (base
equivalent)
1
•
1
•
tizanidine hcl tab 4 mg (base
equivalent) (Zanaflex)
ANTIMYASTHENIC AGENTS
cholecalciferol oral liquid
400 unit/ml
cholecalciferol tab 400 unit
cholecalciferol tab 1000 unit
cholecalciferol tab 50000
unit
A
1
D-VI-SOL - cholecalciferol oral
liquid 400 unit/ml
A
•
A
•
4
DECARA - cholecalciferol cap
25000 unit
4
MESTINON TIMESPAN pyridostigmine bromide tab
cr 180 mg
4
1
pyridostigmine bromide
tab cr 180 mg (Mestinon
timespan)
2
ergocalciferol cap 50000 unit
(Drisdol)
MEPHYTON - phytonadione
tab 5 mg
3
pyridostigmine bromide tab
60 mg (Mestinon)
2
phytonadione inj 1 mg/0.5ml
(2 mg/ml)
2
•
cholecalciferol cap 400 unit
A
•
•
cholecalciferol cap 1000 unit
cholecalciferol cap 50000
unit
cholecalciferol chew tab 400
unit
cholecalciferol chew tab
1000 unit
cholecalciferol drops 5000
unit/ml (1000 unit/0.2ml)
cholecalciferol drops 400
unit/0.03ml (per drop)
A
1
Limited Distribution
•
•
MESTINON - pyridostigmine
bromide syrup 60 mg/5ml
BABY DDROPS cholecalciferol drops 400
unit/0.03ml (per drop)
ACA
A
DDROPS - cholecalciferol
drops 1000 unit/0.03ml (per
drop)
A
Dispensing Limits
•
4
VITAMINS
Step Therapy
A
GUANIDINE HCL - guanidine
hcl tab 125 mg
NUTRITIONAL PRODUCTS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
tizanidine hcl cap 6 mg
(base equivalent)
(Zanaflex)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
POTABA - potassium
aminobenzoate cap 500 mg
4
SUPER DAILY D3 cholecalciferol drops 1000
unit/0.03ml (per drop)
A
•
VITAMELTS VITAMIN D cholecalciferol orally
disintegrating tab 1000 unit
A
•
VITAMIN D2 - ergocalciferol
tab 400 unit
A
•
A
•
VITAMIN D3 - cholecalciferol
oral liquid 1200 unit/15ml
A
•
A
•
VITAMIN D3 - cholecalciferol
spray 1000 unit/spray
A
•
A
•
A
•
A
•
WELLESSE VITAMIN D3 cholecalciferol oral liquid
1000 unit/10ml
MULTIVITAMINS
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
119
ACTIVE OB - prenatal w/o a w/
fe cbn-fa-dha cap 20-1-320
mg
4
ADVANCED AM/PM - multiple
vitamins w/ calcium therapy
pack
4
4
CITRANATAL ASSURE prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg
pack
4
ATABEX EC - prenatal vit w/
dss-iron carbonyl-fa tab dr
29-1 mg
4
CITRANATAL B-CALM - prenat
w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak
4
b-complex w/ c & folic acid
cap 1 mg (Nephrocaps)
1
CITRANATAL DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack
CITRANATAL HARMONY prenat w/o a w/fe fum-fe
cbn-dss-fa-dha cap 27-1-260
mg
4
CITRANATAL RX - prenatal w/
o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg
4
CITRANATAL 90 DHA - prenat
w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak
4
CO-NATAL FA - prenatal vit w/
fe fumarate-fa tab 29-1 mg
4
COMPLETE NATAL DHA prenat-fe bis-fe prot succ-faca tab & omega 3 cap 250
pk
4
COMPLETENATE - prenatal vit
w/ fe fumarate-fa chew tab
29-1 mg
4
CONCEPT DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
4
CONCEPT OB - prenatal w/
o a w/fe fum-fe poly-fa cap
130-92.4-1 mg
4
DIALYVITE SUPREME D multiple vitamins w/ minerals
& fa tab 3 mg
4
b-complex w/ c & folic acid
tab 1 mg (Nephro-vite rx)
b-complex w/ c & folic acid
tab 5 mg
1
1
BAL-CARE DHA - prenat w/fe
poly-na fered-fa tab 27-1 &
omega cap dr 430mg
4
BP FOLINATAL PLUS
B - prenatal w/ calcium
carbonate-b6-b12-fa tab 1
mg
4
BP MULTINATAL PLUS prenatal w/o a vit w/ fe fumfa tab chew 40-1 mg
4
BP MULTINATAL PLUS prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg
4
C-BUFF - multiple vitamins w/
minerals powder
4
C-NATE DHA - prenatal vit
w/ fe fum-fa-omega 3 cap
28-1-200 mg
4
CALCIUM PNV - prenatal w/o
vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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120
DIALYVITE 3000 - b-complex
w/ c-biotin-e-minerals & folic
acid tab 3 mg
4
FLORIVA - ped multiple
vitamins & minerals w/ fl
chew tab 0.25 mg
4
DIALYVITE 5000 - b-complex
w/ c-biotin-e-minerals & folic
acid tab 5 mg
4
FLORIVA - ped multiple
vitamins & minerals w/ fl
chew tab 0.5 mg
4
DIALYVITE/ZINC - b-complex
w/ c-zn & folic acid tab 1 mg
4
4
DOTHELLE DHA - prenatal w/
fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg
4
FLORIVA - ped multiple
vitamins & minerals w/ fl
chew tab 1 mg
1
DUET DHA BALANCED prenat w/fe poly-na fered-fa
tab 25-1 & omega cap 267
mg
4
FLORIVA PLUS - pediatric
multiple vitamins w/ fluoride
soln 0.25 mg/ml
FOCALGIN CA - prenat w/o
a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack
4
DUET DHA 400 - prenat w/fe
poly-na fered-fa tab 25-1 &
omega cap 400 mg
4
FOCALGIN 90 DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak
4
ELITE-OB - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
4
4
ENBRACE HR - prenatal vit w/
fe gly cys-fa-omega 3 fatty
acids cap
4
FOLCAL DHA - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
END FATIGUE DAILY
ENERGY - multiple vitamins
w/ minerals powder
4
ESCAVITE - pediatric multiple
vitamins w/ fl-fe chew tab
0.25-7.5 mg
4
ESCAVITE D - pediatric
multiple vitamins w/ fl-fe
chew tab 0.25-6 mg
4
ESCAVITE LQ - pediatric
multiple vitamins w/ fl-fe
drops 0.25-6 mg/ml
4
EXTRA-VIRT PLUS DHA prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350
mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
FOLCAPS OMEGA 3 - prenatal 4
vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
4
FOLET DHA - prenat w/fecbnbisg-methylf-dss tab dr &
dha cap pak
4
FOLET ONE - prenat w/o a w/
fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg
FOLGARD OS - multiple vit w/ 4
min & calcium-folic acid tab
500-1.1 mg
4
FOLIVANE-OB - prenatal w/
o a w/fe fum-fe poly-fa cap
130-92.4-1 mg
HEMENATAL OB - prenat vit-fe 4
poly cmplx-fe heme poly-fa
tab 28-6-1 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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121
HEMENATAL OB + DHA prenat-fe poly cmplx-fe
heme poly-fa tab & omega 3
cap pck
4
MYNATAL PLUS - prenatal vit
w/ fe fumarate-fa tab 65-1
mg
4
MYNATAL ULTRACAPLET prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
4
INATAL ADVANCE - prenatal
vit w/ dss-iron carbonyl-fa
tab 90-1 mg
4
4
MYNATAL-Z - prenatal vit w/ fe
fumarate-fa tab 65-1 mg
4
INATAL GT - prenatal vit w/
dss-iron carbonyl-fa tab 90-1
mg
4
INATAL ULTRA - prenatal vit w/
dss-iron carbonyl-fa tab 90-1
mg
4
MYNATE 90 PLUS - prenatal
vit w/ dss-fe fumarate-fa tab
cr 90-1 mg
4
INFANATE BALANCE prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg
4
NATACHEW - prenatal vit w/ fe
fum-fe bisglycin-fa chew tab
28-1 mg
4
M-VIT - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
NATALVIT - prenatal vit w/ fe
fumarate-fa tab 75-1 mg
NATELLE ONE - prenatal w/o
vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg
4
NEEVO DHA - prenat w/o a w/
fefum-methylfol-omegas cap
27-1.13 mg
4
NEPHPLEX RX - b-complex w/
c-zn & folic acid tab 1 mg
4
NESTABS - prenatal vit w/o vit
a w/ fe bisglycinate-fa tab
32-1 mg
4
NESTABS ABC - prenatal w/o
vit a w/fe polysac-fa-ca tab &
omega 3 cap
4
NESTABS DHA - prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack
4
NEWGEN - prenatal vit w/o vit
a w/ fe bisglycinate-fa tab
32-1 mg
4
NEXA PLUS - prenatal w/o vit
a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
4
MACNATAL CN DHA - prenatal 4
w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg
MARNATAL-F - prenatal w/o vit 4
a w/ fe polysac cmplx-fa cap
60-1 mg
4
MEGA MULTIVITAMIN multiple vitamins w/ minerals
powder
1
multiple vitamins w/
minerals & fa tab 1.25 mg
(Corvite)
4
MYKIDZ IRON FL - pediatric
vitamins acd fluoride & fe
susp 0.25-10 mg/2ml
4
MYNATAL - prenatal
multivitamins & minerals w/
iron & fa cap 1 mg
4
MYNATAL ADVANCE prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
122
NICOMIDE - niacinamide
w/ zn-cu-methylfolate tab
750-25-1.5-0.5 mg
4
NIVA-PLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
O-CAL FA - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
O-CAL PRENATAL - prenatal
vit w/ fe fumarate-fa tab 15-1
mg
4
OB COMPLETE - prenatal
vit w/ iron carbonyl-fa tab
50-1.25 mg
4
OB COMPLETE GOLD prenat w/o a w/fecbnmethfol-fa-dha cap
27.5-1-200 mg
4
OB COMPLETE ONE prenatal w/o a w/fecbnfe asp glyc-fa-fish cap
50-1-476 mg
4
OB COMPLETE PETITE prenat w/o a w/fecbnfeaspglyc-fa-omega cap
35-5-1-200 mg
4
OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg
pediatric multiple vitamins
w/ fl-fe drops 0.25-10 mg/
ml
pediatric multiple vitamins
w/ fluoride chew tab
0.25 mg
pediatric multiple vitamins
w/ fluoride chew tab
0.5 mg
pediatric multiple vitamins
w/ fluoride chew tab 1 mg
pediatric multiple vitamins
w/ fluoride soln 0.25 mg/ml
pediatric multiple vitamins
w/ fluoride soln 0.5 mg/ml
pediatric vitamins acd w/
fluoride soln 0.25 mg/ml
pediatric vitamins acd w/
fluoride soln 0.5 mg/ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
1
PHLEXY-VITS - multiple
vitamins w/ minerals powder
4
PNV FERROUS FUMARATE/
DOCU - prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
4
4
PNV OB+DHA - prenat w/o a
w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack
4
OB COMPLETE/DHA - prenat
w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg
4
PNV PRENATAL PLUS
MULTIVI - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
OBSTETRIX DHA - prenat w/
fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak
4
PNV TABS 29-1 - prenatal vit
w/ iron carbonyl-fa tab 29-1
mg
4
OBSTETRIX EC - prenatal vit
w/ dss-iron carbonyl-fa tab
29-1 mg
4
PNV-DHA - prenat w/o a w/
fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
OBSTETRIX ONE - prenat w/o
a w/fecbn-bisg-methylf-dssdha cap 38-1-225 mg
4
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
123
PNV-DHA+DOCUSATE prenatal w/o vit a w/ fe fumdss-fa-dha cap 27-1.25-300
mg
4
POLY-VI-FLOR/IRON - ped
multiple vitamin w/ fl-fe
biphasic susp 0.25-7 mg/ml
4
PR NATAL 400 - prenat-fe
bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk
4
PNV-OMEGA - prenat w/o a w/
fe fumerate-methylfolate-faomega 3 cap
4
4
PR NATAL 400 EC - prenat-fe
bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk
4
PNV-SELECT - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.6-0.4 mg
PR NATAL 430 - prenat-fe
bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk
4
PNV-TOTAL - prenat w/ fe
cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg
4
PR NATAL 430 EC - prenat-fe
bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk
4
PNV-VP-U - prenatal w/o a
vit w/ fe fumarate-fa cap
106.5-1 mg
4
PREFERA OB - prenat vit-fe
poly cmplx-fe heme poly-fa
tab 34-1 mg
4
POLY-VI-FLOR - ped multiple
vit w/ fluoride biphasic chew
tab 0.25 mg
4
4
PREFERAOB +DHA - prenatfe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack
4
POLY-VI-FLOR - ped multiple
vit w/ fluoride biphasic chew
tab 0.5 mg
PREFERAOB ONE - prenat-fe
poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg
4
POLY-VI-FLOR - ped multiple
vit w/ fluoride biphasic chew
tab 1 mg
4
PRENAISSANCE - prenatal w/
o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg
4
POLY-VI-FLOR - ped multiple
vit w/ fluoride biphasic susp
0.25 mg/ml
4
4
PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg
4
POLY-VI-FLOR FS - pediatric
multiple vit w/ fluoride oral
strip 0.25 mg
PRENAISSANCE HARMONY
DHA - prenat w/fe poly-na
fered-fa tab 27-1 & omega
cap dr 380mg
4
POLY-VI-FLOR FS - pediatric
multiple vit w/ fluoride oral
strip 0.5 mg
4
POLY-VI-FLOR FS - pediatric
multiple vitamins w/ fluoride
oral strip 1 mg
4
PRENAISSANCE NEXT prenatal w/ calcium-vit b6-faginger tab 1.2 mg
4
POLY-VI-FLOR/IRON - ped
multiple vit w/ fl-fe biphasic
chew tab 0.5-10 mg
4
PRENAISSANCE NEXT-B prenatal w/ calcium-vit b6-faginger tab 1.22 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
124
PRENAISSANCE PLUS prenatal w/o a w/fe cbn-dssfa-dha cap 28-1-250 mg
4
PRENATE ELITE - prenatal vit
w/ fe fum-methylfolate-fa tab
26-0.6-0.4 mg
4
PRENATABS RX - prenatal vit
w/ iron carbonyl-fa tab 29-1
mg
4
PRENATE ELITE - prenatal w/
fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
4
PRENATAL - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
4
PRENATAL PLUS - prenatal vit
w/ fe fumarate-fa tab 27-1
mg
3
PRENATE ENHANCE - prenat
w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg
4
PRENATAL PLUS IRON prenatal vit w/ iron carbonylfa tab 29-1 mg
4
PRENATE ESSENTIAL prenat w/o a w/feaspmethylf-fa-omeg cap
29-0.6-0.4-340 mg
4
PRENATAL VITAMINS PLUS
LO - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
PRENATE ESSENTIAL prenat w/o a w/feaspgmethfol-fa-dha cap
18-0.6-0.4-300 mg
PRENATAL 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1
mg
4
PRENATE MINI - prenat w/o a
w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg
4
PRENATAL 19 - prenatal vit w/
fe fumarate-fa chew tab 29-1
mg
4
PRENATE MINI - prenat w/oa
w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg
4
PRENATAL-U - prenatal w/o
a vit w/ fe fumarate-fa cap
106.5-1 mg
4
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
4
PRENATE - prenat mv & min
w/ l-methylfolate-fa chew tab
0.6-0.4 mg
4
PRENATE RESTORE - prenat
w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg
4
PRENATE AM - prenatal w/
calcium-vit b6-vit b12-faginger tab 1 mg
4
PRENATE STAR - prenatal vit
w/ fe asparto glycinate-fa tab
20-1 mg
4
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
4
PRENA1 CHEW - prenat w/
b2-b6-b12-d3-folic acid chew
tab 1.4 mg
4
PRENATE DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
4
PRENA1 PEARL - prenat w/oa
w/fefum-na fered-fa-dha cap
cr 30-1.4-200 mg
4
PREPLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
125
PRETAB - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
PROVIDA DHA - prenat w/o a
w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg
4
4
SE-NATAL 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1
mg
4
PROVIDA OB - prenatal w/o
a w/fe fum-fe poly-fa cap
20-20-1.25 mg
4
SE-NATAL 19 - prenatal vit w/
fe fumarate-fa chew tab 29-1
mg
4
PUREFE OB PLUS - prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
4
SELECT-OB - prenat w/
fepolycmplx-methylfol-fa
chew tab 29-0.6-0.4 mg
4
QUFLORA FE - multi vit w/ min
& fluoride-iron-fa chew tab
0.25 mg
4
SELECT-OB - prenatal vit w/ fe
polysac cmplx-fa chew tab
29-1 mg
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
4
SELECT-OB+DHA - prenatal
mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak
SUPER NU-THERA - multiple
vitamins w/ minerals powder
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/
fluoride chew tab 0.5 mg
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/
fluoride chew tab 1 mg
4
QUFLORA PEDIATRIC pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml
1
QUFLORA PEDIATRIC pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml
1
R-NATAL OB - prenatal w/
o a w/fe cbn-fa-dha cap
20-1-320 mg
4
RELNATE DHA - prenatal vit
w/ fe fum-fa-omega 3 cap
28-1-200 mg
4
RULAVITE DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
TARON-BC - prenat w/o a w/ fe 4
cbnyl-fa tab 20-1 mg & vit b6
tab pak
TARON-C DHA - prenatal w/fe 4
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
4
TARON-PREX - prenatal w/o
vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg
4
TEXAVITE LQ - pediatric
multivitamins w/fl-fe-zn
drops 0.25-7-3 mg/ml
4
THRIVITE RX - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
4
THRIVITE 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1
mg
4
TL FOLATE - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.5-0.5 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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126
TL G-FOL OS - multiple vit w/
min & calcium-folic acid tab
500-1.1 mg
4
TRICARE PRENATAL - prenat
w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg
4
TL-CARE DHA - prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
4
4
TL-FLUORIVITE - pediatric
multiple vitamins w/ fl-fe
chew tab 0.25-7.5 mg
4
TRICARE PRENATAL
COMPLEAT - prenat w/o a
fefum-fa tab 27-1 mg & fish
oil chew cap pak
4
TL-SELECT - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
4
TRICARE PRENATAL
DHA ONE - prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
4
TRI-TABS DHA - prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack
4
TRINATAL GT - prenatal vit w/
dss-iron carbonyl-fa tab 90-1
mg
4
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp
0.25 mg/ml
4
TRINATAL RX 1 - prenatal vit
w/ fe fumarate-fa tab 60-1
mg
4
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp
0.5 mg/ml
4
TRINATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
4
TRI-VI-FLORO - ped vit acd
& l-methylfol w/ fl biphasic
susp 0.25 mg/ml
4
TRISTART DHA - prenat w/o a
w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
4
TRI-VI-FLORO - ped vit acd
& l-methylfol w/ fl biphasic
susp 0.5 mg/ml
4
TRIVEEN-DUO DHA - prenatfe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk
4
TRI-VIT/FLUORIDE/IRON pediatric vitamins acd
fluoride & fe drops 0.25-10
mg/ml
4
TRIVEEN-PRX RNF - prenatal
w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg
UDAMIN SP - multiple vitamins
w/ minerals & fa tab 1 mg
4
ULTIMATECARE ONE prenatal vit w/ fe cbn-fe asp
glyc-fa-omega 3 cap 27-1mg
4
TRIADVANCE - prenatal vit w/
dss-iron carbonyl-fa tab 90-1
mg
4
TRICARE PRENATAL - prenat
w/o a w/fepyro-mfol chw
4.5-1 mg & dha cap 150 thpk
4
ULTIMATECARE ONE NF prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap
20-7-1 mg
4
TRICARE - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
VEMAVITE-PRX 2 - prenatal w/ 4
o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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VENA-BAL DHA - prenat w/fe
poly-na fered-fa tab 27-1 &
omega cap dr 430mg
4
VIRT-VITE GT - prenatal vit w/
dss-iron carbonyl-fa tab 90-1
mg
4
VINATE DHA RF - prenat w/o
a w/fefum-methylfol-omegas
cap 27-1.13 mg
4
VIRTPREX - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
4
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab
29-1 mg
4
VITA-PREN - prenatal vit w/
docusate-iron-fa tab 65-1 mg
4
4
VITAFOL FE+ - prenat-fepolymethol-fa-dha cap 90-1-200
mg & dss 50mg cap
4
VINATE M - prenatal vit w/ selfe fumarate-fa tab 27-1 mg
VINATE ONE - prenatal vit w/
fe fumarate-fa tab 60-1 mg
4
4
VIRT NATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
4
VITAFOL GUMMIES - prenat
vit w/ fe phos-fa-omega
chew tab 3.33-0.333-34.8
mg
VIRT-ADVANCE - prenatal vit
w/ dss-iron carbonyl-fa tab
90-1 mg
4
VITAFOL ULTRA - prenat w/
fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
4
VIRT-C DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
4
VITAFOL-NANO - prenatal w/o
a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
4
VIRT-CARE ONE - prenatal
vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
4
VIRT-NATE DHA - prenatal vit
w/ fe fum-fa-omega 3 cap
28-1-200 mg
4
VIRT-PN - prenatal vit w/ fe
fum-methylfolate-fa tab
27-0.6-0.4 mg
4
VIRT-PN DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
VIRT-PN PLUS - prenat w/o a
w/ fe fumerate-methylfolatefa-omega 3 cap
4
VIRT-SELECT - prenatal w/o
vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg
4
VITAFOL-OB - prenatal vit w/ fe 4
fumarate-fa tab 65-1 mg
4
VITAFOL-OB+DHA - prenatal
mv w/fe fum-fa tab 65-1 mg
& dha cap 250 mg pack
VITAFOL-ONE - prenatal mv w/ 4
fe polysac cmplx-fa-dha cap
29-1-200 mg
4
VITAL-D RX - b-complex w/ cbiotin-d-zinc & folic acid tab
1 mg
4
VITAMEDMD ONE RX/
QUATREFO - prenat w/o a
w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
VITAMEDMD REDICHEW RX - 4
prenat w/ b2-b6-b12-d3-folic
acid chew tab 1.4 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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VITAPEARL - prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
4
ZATEAN-PN DHA - prenat w/
o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg
4
VITATRUE - prenat w/o a w/fe
chel-fa tab 30-1.4 mg & dha
cap 300mg pk
4
ZATEAN-PN PLUS - prenat
w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap
4
VIVA DHA - prenatal vit w/
fe fum-fa-omega 3 cap
28-1-200 mg
4
VOL-NATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
4
VOL-PLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
4
VOL-TAB RX - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
4
VP-CH PLUS - prenatal w/o
a w/fe cbn-dss-fa-dha cap
29-1-265 mg
4
VP-CH-PNV - prenatal w/o vit
a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
4
VP-GGR-B6 PRENATAL prenatal w/ calcium-vit b6-faginger tab 1.2 mg
4
VP-HEME OB - prenat vit-fe
poly cmplx-fe heme poly-fa
tab 28-6-1 mg
4
VP-HEME OB + DHA - prenatfe poly cmplx-fe heme polyfa tab & omega 3 cap pck
4
MINERALS and ELECTROLYTES
CALCIFOL - ca carb-folic acid- 4
vit d-b6-b12-boron-mag
wafer 1342-1.6 mg
4
CALCIUM-FOLIC ACID PLUS
D - ca carb-folic acid-vit db6-b12-boron-mag wafer
1342-1 mg
4
EFFER-K - potassium
bicarbonate-citric acid effer
tab 10 meq
4
EFFER-K - potassium
bicarbonate-citric acid effer
tab 20 meq
FLORICAL - sodium fluoride w/ A
calcium carb cap 8.3-364 mg
FLORICAL - sodium fluoride w/ A
calcium carb tab 8.3-364 mg
4
FLORIVA - sodium fluoridevitamin d liqd drops 0.25 mg/
ml-400 unit/ml
4
FLUOR-A-DAY - sodium
fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg
4
FLUOR-A-DAY - sodium
fluoride-xylitol chew tab 2.2
(1 mg f)-236.79 mg
FLUORABON - sodium fluoride 4
soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)
4
FLURA-DROPS - sodium
fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)
VP-HEME ONE - prenat-fe poly 4
cmplx-fe heme poly-fa-dha
cap 22-6-1-200 mg
4
VP-PNV-DHA - prenatal vit
w/ fe fum-fa-omega 3 cap
28-1-215.8 mg
4
ZATEAN-CH - prenatal w/o
a w/fe cbn-dss-fa-dha cap
27-1-250 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
129
GALZIN - zinc acetate cap 25
mg (elemental zinc)
4
GALZIN - zinc acetate cap 50
mg (elemental zinc)
4
GNP VITAMIN D-400 - calcium
carbonate-cholecalciferol tab
90 mg-400 unit
4
IODINE STRONG - iodine
solution strong 5% (lugol's)
4
K-PHOS - potassium
phosphate monobasic tab
500 mg
4
K-TAB - potassium chloride tab
cr 8 meq (600 mg)
4
K-TAB - potassium chloride tab
cr 20 meq (1500 mg)
4
KLOR-CON M15 - potassium
chloride microencapsulated
crys cr tab 15 meq
potassium bicarbonate effer
tab 25 meq
2
potassium chloride cap cr 8
meq (Micro-k)
2
1
POTASSIUM CHLORIDE ER potassium chloride tab cr 20
meq (1500 mg)
4
1
4
potassium chloride
microencapsulated crys cr
tab 10 meq
KLOR-CON/25 - potassium
chloride powder packet 25
meq
4
potassium chloride
microencapsulated crys cr
tab 20 meq
LOZI-FLUR - sodium fluoride
lozenge 1 mg f (from 2.2 mg
naf)
4
MAGNEBIND 400 magnesium-calcium-folic
acid tab 400-200-1 mg
4
MONOCAL - sodium
monofluorophosphatecalcium carb tab 22.75-625
mg
A
pot bicarbonate & chloride
effer tab 25 meq
2
pot phos monobasic w/sod
phos di & monobas tab
155-852-130mg (K-phos
neutral)
2
•
potassium chloride powder
packet 20 meq
potassium chloride tab cr 8
meq (600 mg)
•
potassium chloride tab cr 10
meq (K-tab)
Limited Distribution
ACA
Dispensing Limits
2
POTASSIUM CHLORIDE ER potassium chloride tab cr 8
meq (600 mg)
potassium chloride oral soln
10% (20 meq/15ml)
Step Therapy
2
POTASSIUM CHLORIDE potassium chloride oral soln
20% (40 meq/15ml)
potassium chloride cap cr
10 meq (Micro-k)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
2
2
1
1
SODIUM FLUORIDE - sodium
fluoride tab 0.5 mg f (from
1.1 mg naf)
4
•
SODIUM FLUORIDE - sodium
fluoride tab 1 mg f (from 2.2
mg naf)
4
•
sodium fluoride chew tab
0.25 mg f (from 0.55 mg
naf) (Luride)
1
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
130
sodium fluoride soln
0.125 mg/drop f (0.275 mg/
drop naf)
2
sodium fluoride soln 0.5 mg/
ml f (from 1.1 mg/ml naf)
(Luride)
1
SSKI - potassium iodide soln 1
gm/ml
4
NUTRIENTS
acetylcysteine cap 600 mg
2
ADD-INS COMPLETE - amino
acids pack
4
amino acids cap
2
amino acids tab
2
G-PREPROTEIN - amino acids
oral liquid
4
•
GLUTARADE AMINO ACID
BLEN - amino acids oral
powder
4
•
GLUTARADE ESSENTIAL
GA-1 - amino acids oral
powder
4
GLUTARADE JUNIOR GA-1 amino acids oral powder
4
HEPAMENT - amino acids
pack
4
L-CARNITINE - amino acids
oral liquid
4
LECITHIN - lecithin granules
4
LIQUACEL - amino acids oral
liquid
4
LIQUACEL PUMP + GO amino acids oral liquid
4
NUTRASENTIALS - amino
acids oral powder
4
NUTRESTORE - glutamine
powd pack 5 gm
4
PERIFLEX LQ PKU - amino
acids oral liquid
4
4
ARGIMENT - amino acids pack
4
ARGIMENT AT - amino acids
pack
4
CARDIOVID PLUS - dha-epavit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg
4
COMPLETE AMINO ACID
MIX - amino acids oral
powder
4
COMPLEX ESSENTIAL MSD amino acids oral powder
4
PHENYLADE - amino acids
oral powder
4
COMPLEX JUNIOR MSD amino acids oral powder
4
PHENYLADE AMINO ACID amino acids bar
4
COMPLEX MSUD - amino
acids oral powder
4
PHENYLADE AMINO ACID
BLEN - amino acids pack
4
COMPLEX MSUD AMINO
ACID B - amino acids bar
4
PHENYLADE MTE - amino
acids oral powder
4
DEQUASINE - amino acids tab
4
PHENYLADE MTE AMINO
ACID - amino acids pack
Limited Distribution
•
ACA
1
4
Dispensing Limits
sodium fluoride chew tab
1 mg f (from 2.2 mg naf)
(Luride)
ESSENTIAL AMINO ACID
MIX - amino acids oral
powder
Step Therapy
•
Prior Authorization
1
Drug Name
Drug Tier
sodium fluoride chew tab
0.5 mg f (from 1.1 mg naf)
(Luride)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
131
PHENYLADE PHEBLOC amino acids oral powder
4
PHENYLADE PHEBLOC amino acids tab
4
PHENYLADE40 DRINK MIX amino acids pack
4
PHLEXY-10 - amino acids cap
4
PREPROTEIN - amino acids
oral liquid
4
PREPROTEIN 20 - amino
acids oral liquid
4
SOLVIL - amino acids pack
4
SUPER-AMINO 1600 - amino
acids tab
4
TRIAMINO - amino acids tab
4
XPHE MAXAMUM - amino
acids oral powder
4
XPHE MAXAMUM - amino
acids pack
4
DIETARY PRODUCTS
A-SOY - nutritional supplement
liquid
4
ACERFLEX - nutritional
supplement powder
4
ADVERA - nutritional
supplement liquid
4
ALITRAQ - nutritional
supplement pack
4
ARGINAID - nutritional
supplement pack
4
ARGINAID EXTRA - nutritional
supplement liquid
4
BALANCE TOTAL
NUTRITIONAL - nutritional
supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
BALANCED NUTRITIONAL
DRIN - nutritional supplement
liquid
4
BALANCED NUTRITIONAL
SHAK - nutritional
supplement liquid
4
BCAD 1 - nutritional
supplement powder
4
BCAD 2 - nutritional
supplement powder
4
BEEF/POTATOES/PEAS nutritional supplement liquid
4
BENECALORIE - nutritional
supplement liquid
4
BOOST - nutritional
supplement liquid
4
BOOST BREEZE - nutritional
supplement liquid
4
BOOST CALORIE SMART nutritional supplement liquid
BOOST COMPACT - nutritional 4
supplement liquid
4
BOOST GLUCOSE
CONTROL - nutritional
supplement liquid
4
BOOST HIGH PROTEIN nutritional supplement liquid
4
BOOST HIGH PROTEIN nutritional supplement
powder
4
BOOST KID ESSENTIALS
1.0 - nutritional supplement
liquid
4
BOOST KID ESSENTIALS
1.5 - nutritional supplement
liquid
4
BOOST KIDS ESSENTIALS nutritional supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
132
BOOST PLUS - nutritional
supplement liquid
4
BOOST PUDDING - nutritional
supplement pudding
4
BOOST SMOOTHIE nutritional supplement liquid
CARNATION INSTANT
BREAKFA - nutritional
supplement liquid
4
4
4
CEREFOLIN - l-methylfolate
w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg
BOOST VHC - nutritional
supplement liquid
4
CHOICE DM - nutritional
supplement liquid
4
BOOST 100 CALORIE
SMART - nutritional
supplement liquid
4
CHOICE DM TF - nutritional
supplement liquid
4
4
BOOST/BENEFIBER nutritional supplement liquid
4
CHOLEXTRA - nutritional
supplement powder
4
CALCILO XD - infant foods
powder
4
CLICK ESPRESSO PROTEIN
DR - nutritional supplement
powder
CAMINO PRO BETTERMILK/
GLY - nutritional supplement
pack
4
COMPLEAT - nutritional
supplement liquid
4
4
CAMINO PRO COMPLETE/
GLYTA - nutritional
supplement bar
4
COMPLEAT CLOSED
SYSTEM - nutritional
supplement liquid
COMPLEAT PEDIATRIC nutritional supplement liquid
4
COMPLEAT PEDIATRIC
REDUCE - nutritional
supplement liquid
4
COMPLETE NUTRITION nutritional supplement liquid
4
COMPLETE NUTRITION
PLUS - nutritional
supplement liquid
4
COMPLETE PROTEIN
& VITAMI - nutritional
supplement powder
4
CRITICARE HN - nutritional
supplement liquid
4
CRUCIAL - nutritional
supplement liquid
4
CVS NUTRITION LIQUID nutritional supplement liquid
4
CAMINO PRO PKU - nutritional 4
supplement liquid
4
CAMINO PRO RESTORE/
GLYTAC - nutritional
supplement liquid
4
CAMINO PRO SWIRL nutritional supplement pack
4
CAMINO PRO 15PE nutritional supplement liquid
4
CARDIOTEK-RX - folic acidb12-b6-arginine-black
pepper tab
4
CARNATION BREAKFAST
ESSEN - nutritional
supplement liquid
4
CARNATION BREAKFAST
ESSEN - nutritional
supplement pack
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
133
CVS NUTRITION PLUS nutritional supplement liquid
4
ENSURE ACTIVE - nutritional
supplement liquid
4
CVS NUTRITIONAL SHAKE nutritional supplement liquid
4
4
CYCLINEX-1 - nutritional
supplement powder
4
ENSURE ACTIVE HEART
HEALT - nutritional
supplement liquid
4
CYCLINEX-2 - nutritional
supplement powder
4
ENSURE ACTIVE HIGH
PROTEI - nutritional
supplement liquid
DIABETIC TF - nutritional
supplement liquid
4
ENSURE ACTIVE LIGHT nutritional supplement liquid
4
DIABETISHIELD - nutritional
supplement liquid
4
4
DIABETISOURCE - nutritional
supplement liquid
4
ENSURE BONE HEALTH
REVIGO - nutritional
supplement liquid
4
DIABETISOURCE AC nutritional supplement liquid
4
ENSURE CLEAR - nutritional
supplement liquid
4
DUOCAL - nutritional
supplement powder
4
ENSURE CLINICAL
STRENGTH - nutritional
supplement liquid
EAA SUPPLEMENT nutritional supplement pack
4
ENSURE COMPACT nutritional supplement liquid
4
EGG/PRO - nutritional
supplement powder
4
ENSURE COMPLETE nutritional supplement liquid
4
ELECARE - nutritional
supplement powder
4
4
ELECARE JR - nutritional
supplement powder
4
ENSURE COMPLETE
NUTRITION - nutritional
supplement liquid
4
ELECARE/DHA/ARA nutritional supplement
powder
4
ENSURE ENLIVE - nutritional
supplement liquid
ENSURE HEALTHY MOM nutritional supplement bar
4
ENLIVE - nutritional
supplement liquid
4
ENSURE HEALTHY MOM nutritional supplement liquid
4
ENSURE - nutritional
supplement bar
4
ENSURE HIGH CALCIUM nutritional supplement liquid
4
ENSURE - nutritional
supplement liquid
4
ENSURE HIGH PROTEIN nutritional supplement liquid
4
ENSURE - nutritional
supplement powder
4
ENSURE HIGH PROTEIN nutritional supplement
powder
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
134
ENSURE IMMUNE HEALTH nutritional supplement liquid
4
EQUATE PLUS - nutritional
supplement liquid
4
ENSURE MUSCLE HEALTH
REVI - nutritional supplement
liquid
4
F.A.A. - nutritional supplement
liquid
4
FALESSA - levomefolate
glucosamine tab 1 mg (folate
equivalent)
4
ENSURE NUTRA SHAKE HICAL - nutritional supplement
liquid
4
4
FIBER FLOW - nutritional
supplement liquid
4
ENSURE NUTRITION
SHAKE - nutritional
supplement liquid
4
ENSURE PLUS - nutritional
supplement liquid
4
FIBER-STAT - nutritional
supplement liquid
FIBERSOURCE CLOSED
SYSTEM - nutritional
supplement liquid
4
FIBERSOURCE HN nutritional supplement liquid
4
FIBERSOURCE HN CLOSED
SYS - nutritional supplement
liquid
4
ENSURE PLUS HN - nutritional 4
supplement liquid
4
ENSURE PRE-SURGERY nutritional supplement liquid
4
ENSURE PUDDING nutritional supplement
pudding
4
ENSURE SURGERY
IMMUNONUTR - nutritional
supplement liquid
4
ENSURE/FIBER - nutritional
supplement liquid
4
ENU NUTRITIONAL SHAKE nutritional supplement liquid
4
EO28 SPLASH - nutritional
supplement liquid
4
EQ NUTRITIONAL SHAKE nutritional supplement liquid
4
EQ NUTRITIONAL SHAKE
PLUS - nutritional
supplement liquid
4
EQ WEIGHT LOSS
SHAKE ULTR - nutritional
supplement liquid
4
EQUATE - nutritional
supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
FLAVOR PACKETS - nutritional 4
supplement flavor pack
4
FLAVOUR PAC - nutritional
supplement flavor pack
2
folic acid-pyridoxinecyanocobalamin tab
2.5-25-2 mg
4
FORTA DRINK - nutritional
supplement powder
4
FORTA SHAKE - nutritional
supplement powder
4
FRUITIVITS - nutritional
supplement pack
4
GA - nutritional supplement
powder
4
GA EXPRESS15 - nutritional
supplement pack
4
GA GEL - nutritional
supplement pack
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
135
GA-1 ANAMIX EARLY
YEARS - nutritional
supplement powder
4
GLUCERNA - nutritional
supplement bar
4
GLUCERNA - nutritional
supplement liquid
GLUCERNA SNACK SHAKE nutritional supplement liquid
4
GLUCERNA WEIGHT
LOSS SHAK - nutritional
supplement liquid
4
4
GLUCERNA 1.0 CAL nutritional supplement liquid
4
GLUCERNA ADVANCE
SHAKE - nutritional
supplement liquid
4
GLUCERNA 1.0 CAL/FIBER nutritional supplement liquid
4
GLUCERNA 1.0 WITH
CARBSTE - nutritional
supplement liquid
4
GLUCERNA CARBSTEADY nutritional supplement liquid
4
GLUCERNA CEREAL
CRUNCHY F - nutritional
supplement misc
4
GLUCERNA 1.2 CAL nutritional supplement liquid
4
GLUCERNA 1.5 CAL nutritional supplement liquid
4
GLUCERNA CRISPY
DELIGHTS - nutritional
supplement bar
4
4
GLUCERNA HUNGER
SMART SHA - nutritional
supplement liquid
4
GLUCO BURST - nutritional
supplement liquid
GLUTAREX-1 - nutritional
supplement powder
4
GLUCERNA MEAL - nutritional
supplement bar
4
GLUTAREX-2 - nutritional
supplement powder
4
GLUCERNA MEAL
REPLACEMENT - nutritional
supplement bar
4
GLYCOSADE - nutritional
supplement pack
4
4
GLUCERNA MINI SNACK nutritional supplement bar
4
GLYTACTIN BETTERMILK
DE-L - nutritional supplement
pack
GLUCERNA MINI SNACKS nutritional supplement bar
4
GLUCERNA OS - nutritional
supplement liquid
4
GLUCERNA SELECT nutritional supplement liquid
4
GLUCERNA SHAKE nutritional supplement liquid
4
GLUCERNA SNACK nutritional supplement bar
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
GLYTACTIN BETTERMILK 15 - 4
nutritional supplement pack
4
GLYTACTIN BUILD 10PE nutritional supplement pack
4
GLYTACTIN COMPLETE
10PE - nutritional supplement
bar
4
GLYTACTIN RESTORE LITE
10 - nutritional supplement
liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
136
GLYTACTIN RESTORE LITE
10 - nutritional supplement
pack
4
HCU EXPRESS20 - nutritional
supplement pack
4
HCU GEL - nutritional
supplement pack
4
GLYTACTIN RESTORE 10 nutritional supplement liquid
4
HCU LOPHLEX LQ - nutritional
supplement liquid
4
GLYTACTIN RESTORE 5 nutritional supplement pack
4
4
HCY 1 - nutritional supplement
powder
4
GLYTACTIN RTD 10 nutritional supplement liquid
HCY 2 - nutritional supplement
powder
4
GLYTACTIN RTD 15 nutritional supplement liquid
4
HEALTH SOURCE SOY
PROTEIN - nutritional
supplement powder
4
GLYTROL - nutritional
supplement liquid
4
GLYTROL PREBIO1 nutritional supplement liquid
4
4
GNP NUTRITIONAL DRINK nutritional supplement liquid
4
HEALTHY ACCENTS NUTRA
FIT - nutritional supplement
liquid
4
GNP NUTRITIONAL DRINK
PLU - nutritional supplement
liquid
4
HEARTBAR - nutritional
supplement bar
GOAT MILK - nutritional
supplement powder
4
HAELAN HTPI FERMENTED
ORG - nutritional supplement
liquid
4
HAELAN 951 FERMENTED
ORGA - nutritional
supplement liquid
4
HCU ANAMIX EARLY YEARS - 4
nutritional supplement
powder
4
HCU ANAMIX NEXT nutritional supplement
powder
4
HCU COOLER - nutritional
supplement liquid
4
HCU EXPRESS - nutritional
supplement pack
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
HI-CAL - nutritional supplement 4
liquid
4
HIGH-PROTEIN
NUTRITIONAL - nutritional
supplement liquid
4
HM NUTRISURE - nutritional
supplement liquid
4
HM NUTRISURE PLUS nutritional supplement liquid
HOM 2 - nutritional supplement 4
powder
4
HOMACTIN AA PLUS nutritional supplement liquid
4
HOMINEX-1 - nutritional
supplement powder
4
HOMINEX-2 - nutritional
supplement powder
4
I-VALEX-1 - nutritional
supplement powder
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
137
I-VALEX-2 - nutritional
supplement powder
4
ISOSOURCE VHN - nutritional
supplement liquid
4
IMMULIFE - nutritional
supplement powder
4
ISOSOURCE 1.5 CAL nutritional supplement liquid
4
IMMUNOPRO RX - nutritional
supplement powder
4
ISOVACTIN AA PLUS nutritional supplement liquid
4
IMPACT - nutritional
supplement liquid
4
4
IMPACT ADVANCED
RECOVERY - nutritional
supplement liquid
4
IVA ANAMIX EARLY YEARS nutritional supplement
powder
IVA ANAMIX NEXT - nutritional
supplement powder
4
IMPACT GLUTAMINE nutritional supplement liquid
4
JEVITY 1 CAL - nutritional
supplement liquid
4
IMPACT PEPTIDE 1.5 nutritional supplement liquid
4
JEVITY 1 CAL/FIBER nutritional supplement liquid
4
IMPACT 1.5 - nutritional
supplement liquid
4
JEVITY 1.2 CAL - nutritional
supplement liquid
4
IMPACT/FIBER - nutritional
supplement liquid
4
JEVITY 1.2 CAL/FIBER nutritional supplement liquid
4
IMUPLUS - nutritional
supplement pack
4
JEVITY 1.5 CAL - nutritional
supplement liquid
4
INNOVACIN - nutritional
supplement liquid
4
JEVITY 1.5 CAL/FIBER nutritional supplement liquid
4
INTROLITE - nutritional
supplement liquid
4
JUICE PLUS FIBRE nutritional supplement liquid
4
ISOCAL - nutritional
supplement liquid
4
ISOCAL HN - nutritional
supplement liquid
4
ISOCAL HN PLUS - nutritional
supplement liquid
4
ISOSOURCE - nutritional
supplement liquid
4
ISOSOURCE CLOSED
SYSTEM - nutritional
supplement liquid
4
ISOSOURCE HN - nutritional
supplement liquid
4
JUVEN - nutritional supplement 4
pack
JUVEN - nutritional supplement 4
powder
4
JUVEN NUTRIVIGOR nutritional supplement pack
4
JUVEN REVIGOR - nutritional
supplement pack
4
K-PAX IMMUNE BOOSTER
PROT - nutritional
supplement powder
4
KETOCAL 3:1 - nutritional
supplement powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
138
KETOCAL 4:1 - nutritional
supplement liquid
4
LOPHLEX LQ 20 - nutritional
supplement liquid
4
KETOCAL 4:1 - nutritional
supplement powder
4
4
KETOCAL 4:1 LQ MULTI
FIBE - nutritional supplement
liquid
4
LPS CRITICAL CARE SUGAR
F - nutritional supplement
liquid
LPS SUGAR FREE - nutritional
supplement liquid
4
KETOGEN - nutritional
supplement powder
4
MCT PRO-CAL - nutritional
supplement pack
4
KETONEX-1 - nutritional
supplement powder
4
MCT PROCAL - nutritional
supplement powder
4
KETONEX-2 - nutritional
supplement powder
4
MERITENE - nutritional
supplement powder
4
KETOVIE - nutritional
supplement liquid
4
METAFORM - nutritional
supplement pack
4
KETOVIE PEPTIDE nutritional supplement liquid
4
METHIONAID - nutritional
supplement powder
4
KETOVOLVE 4:1 - nutritional
supplement powder
4
4
KINRAY PREFERRED PLUS nutritional supplement liquid
4
MMA/PA ANAMIX EARLY
YEARS - nutritional
supplement powder
4
L-METHYL-MC NAC l-methylfolatemethylcobalamin-acetylcyst
tab 6-2-600 mg
4
MMA/PA ANAMIX NEXT nutritional supplement
powder
MMA/PA COOLER - nutritional
supplement liquid
4
LANAFLEX - nutritional
supplement pack
4
MMA/PA COOLER15 nutritional supplement liquid
4
LEU-FREE COOLER nutritional supplement liquid
4
MMA/PA GEL - nutritional
supplement pack
4
LIPISTART - nutritional
supplement powder
4
MODULEN IBD - nutritional
supplement powder
4
LIQUID HOPE - nutritional
supplement liquid
4
MONOGEN - nutritional
supplement powder
4
LMD - nutritional supplement
powder
4
MSUD AID - nutritional
supplement powder
4
LOPHLEX - nutritional
supplement pack
4
MSUD ANAMIX EARLY
YEARS - nutritional
supplement powder
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
139
MSUD COOLER - nutritional
supplement liquid
4
MSUD EXPRESS - nutritional
supplement pack
4
MSUD EXPRESS20 nutritional supplement pack
NESTLE FLAVOR EXTRA
STREN - nutritional
supplement flavor pack
4
4
4
NESTLE FLAVOR FOR KIDS nutritional supplement flavor
pack
MSUD GEL - nutritional
supplement pack
4
NOURISH - nutritional
supplement liquid
4
MSUD LOPHLEX LQ nutritional supplement liquid
4
4
MSUD MAXAMAID - nutritional
supplement powder
4
NOVASOURCE
PULMONARY - nutritional
supplement liquid
4
MSUD MAXAMUM - nutritional
supplement powder
4
NOVASOURCE RENAL nutritional supplement liquid
4
MSUD 2 - nutritional
supplement powder
4
NUTRA BALANCE DIABETIC
NU - nutritional supplement
bar
NEOCATE INFANT DHA/
ARA - nutritional supplement
powder
4
NUTRA BALANCE FIBER
COOKI - nutritional
supplement misc
4
NUTRA BALANCE PROTEIN
FOR - nutritional supplement
misc
4
NUTRA SHAKE - nutritional
supplement liquid (frozen)
4
NUTRA SHAKE/SUPREME nutritional supplement liquid
(frozen)
4
NUTRA/BALANCE RE/GEN nutritional supplement liquid
(frozen)
4
NUTRA/BALANCE RE/
GEN FREE - nutritional
supplement liquid (frozen)
4
NUTRA/SHAKE - nutritional
supplement liquid (frozen)
4
NUTRA/SHAKE FRUIT PLUS nutritional supplement liquid
(frozen)
4
NEOCATE JUNIOR - nutritional 4
supplement powder
4
NEOCATE JUNIOR/
PREBIOTICS - nutritional
supplement powder
NEOCATE NUTRA - nutritional 4
supplement powder
4
NEOCATE SPLASH nutritional supplement liquid
4
NEPRO - nutritional
supplement liquid
4
NEPRO WITH CARB
STEADY - nutritional
supplement liquid
4
NEPRO WITH
CARBSTEADY - nutritional
supplement liquid
4
NESTLE FLAVOR - nutritional
supplement flavor pack
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
140
NUTRA/SHAKE SUPREME nutritional supplement liquid
(frozen)
4
NUTREN JUNIOR/FIBER nutritional supplement liquid
4
NUTREN PULMONARY nutritional supplement liquid
4
NUTRA/SHAKE SUPREME nutritional supplement liquid
4
NUTREN RENAL - nutritional
supplement liquid
4
NUTRAMENT - nutritional
supplement liquid
4
4
NUTREN 1.0 - nutritional
supplement liquid
4
NUTRAMINE - nutritional
supplement pack
NUTREN 1.0 CAL - nutritional
supplement liquid
4
NUTRAMINE APPLE AMINO
BIT - nutritional supplement
pack
4
4
NUTRAMINE BANANA
AMINO B - nutritional
supplement pack
4
NUTREN 1.0/FIBER nutritional supplement liquid
4
NUTRAMINE CHOCOLATE
AMINO - nutritional
supplement pack
4
NUTREN 1.0/FIBER/
ULTRAPAK - nutritional
supplement liquid
NUTREN 1.5 - nutritional
supplement liquid
4
NUTRAMINE MANGO AMINO
BI - nutritional supplement
pack
4
NUTREN 1.5 CAL - nutritional
supplement liquid
4
4
NUTRAMINE MIXED
FLAVORS A - nutritional
supplement pack
4
NUTREN 1.5 FIBER nutritional supplement liquid
NUTREN 2.0 - nutritional
supplement liquid
4
NUTRAMINE PEACHES
& CREAM - nutritional
supplement pack
4
NUTREN 2.0 CAL - nutritional
supplement liquid
4
4
NUTRAMINE PINEAPPLE
AMINO - nutritional
supplement pack
4
NUTRICIA PREOP - nutritional
supplement pack
4
NUTREN JR - nutritional
supplement liquid
4
NUTRIFOCUS - nutritional
supplement liquid
4
NUTREN JR FIBER nutritional supplement liquid
4
NUTRIHEAL - nutritional
supplement liquid
4
NUTREN JUNIOR - nutritional
supplement liquid
4
NUTRIHEP 1.5 CAL nutritional supplement liquid
4
NUTREN JUNIOR 1.0 nutritional supplement liquid
4
NUTRIRENAL - nutritional
supplement liquid
NUTRITIONAL DRINK nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
141
NUTRITIONAL DRINK MIX nutritional supplement
powder
4
NUTRITIONAL DRINK PLUS nutritional supplement liquid
4
NUTRITIONAL DRINK SHAKE
M - nutritional supplement
powder
OPTIMENTAL - nutritional
supplement liquid
4
OPTISOURCE VERY
HIGH PROT - nutritional
supplement liquid
4
4
ORANGE CHICKEN/
CARROTS/BR - nutritional
supplement liquid
4
NUTRITIONAL SHAKE nutritional supplement liquid
4
4
NUTRITIONAL SHAKE
COMPLET - nutritional
supplement liquid
4
ORGANIC PEDIA SMART nutritional supplement
powder
OS 2 - nutritional supplement
powder
4
NUTRITIONAL SHAKE PLUS nutritional supplement liquid
4
OSMOLITE - nutritional
supplement liquid
4
NUTRITIONAL SHAKE PLUS
PR - nutritional supplement
liquid
4
OSMOLITE HN - nutritional
supplement liquid
4
4
OSMOLITE 1 CAL - nutritional
supplement liquid
4
NUTRITIONAL
SUPPLEMENT - nutritional
supplement liquid
4
nutritional supplement liquid
2
OSMOLITE 1.2 CAL nutritional supplement liquid
OSMOLITE 1.5 CAL nutritional supplement liquid
4
OXEPA - nutritional
supplement liquid
4
OXEPA 1.5 - nutritional
supplement liquid
4
PEDIASURE - nutritional
supplement liquid
4
4
NUTRITIONAL SUPPLEMENT
PL - nutritional supplement
liquid
4
NUTRIVENT - nutritional
supplement liquid
4
NUTRIVENT 1.5 - nutritional
supplement liquid
4
NUTRIVIR - nutritional
supplement powder
4
NUTRIVIR NSA - nutritional
supplement powder
4
PEDIASURE ENTERAL
FORMULA - nutritional
supplement liquid
PEDIASURE GROW & GAIN nutritional supplement liquid
4
OA 1 - nutritional supplement
powder
4
4
4
OA 2 - nutritional supplement
powder
PEDIASURE NUTRIPALS nutritional supplement bar
PEDIASURE NUTRIPALS nutritional supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
142
PEDIASURE PEDIATRIC nutritional supplement liquid
4
PEDIATRIC PEPTINEX DT nutritional supplement liquid
4
PEDIASURE PEPTIDE 1.0
CAL - nutritional supplement
liquid
4
PEDIATRIC PEPTINEX DT/
FIB - nutritional supplement
liquid
4
PEDIASURE PEPTIDE 1.5
CAL - nutritional supplement
liquid
4
PEPDITE JUNIOR - nutritional
supplement pack
4
4
PEPTAMEN - nutritional
supplement liquid
4
PEDIASURE SHAKE MIX nutritional supplement
powder
4
PEDIASURE SHAKE WITH
FIBE - nutritional supplement
liquid
4
PEPTAMEN AF - nutritional
supplement liquid
PEPTAMEN BARIATRIC nutritional supplement liquid
4
PEDIASURE SIDEKICKS nutritional supplement liquid
4
PEPTAMEN INTENSE VHP nutritional supplement liquid
4
PEDIASURE SIDEKICKS nutritional supplement
powder
4
PEPTAMEN JUNIOR nutritional supplement liquid
4
4
PEDIASURE SIDEKICKS
CLEAR - nutritional
supplement liquid
4
PEPTAMEN JUNIOR nutritional supplement
powder
4
PEDIASURE SIDEKICKS
SHAKE - nutritional
supplement liquid
4
PEPTAMEN JUNIOR FIBER nutritional supplement liquid
PEPTAMEN JUNIOR HP nutritional supplement liquid
4
PEDIASURE WITH FIBER nutritional supplement liquid
4
PEPTAMEN JUNIOR 1 CAL nutritional supplement liquid
4
PEDIASURE 1.0 CAL/FIBER nutritional supplement liquid
4
4
PEDIASURE 1.5 CAL nutritional supplement liquid
4
PEPTAMEN JUNIOR 1 CAL/
PRE - nutritional supplement
liquid
PEDIASURE 1.5 CAL WITH
FI - nutritional supplement
liquid
4
PEDIASURE 1.5 CAL/FIBER nutritional supplement liquid
4
PEDIATRIC DRINK - nutritional
supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PEPTAMEN JUNIOR 1.5 CAL - 4
nutritional supplement liquid
4
PEPTAMEN JUNIOR/
PREBIO1 - nutritional
supplement liquid
4
PEPTAMEN OS - nutritional
supplement liquid
PEPTAMEN OS 1.5 - nutritional 4
supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
143
PEPTAMEN VHP - nutritional
supplement liquid
4
PHENEX-1 - nutritional
supplement powder
4
PEPTAMEN 1 CAL - nutritional
supplement liquid
4
PHENEX-2 - nutritional
supplement powder
4
PEPTAMEN 1 CAL/PREBIO1 nutritional supplement liquid
4
PHENYL-FREE 2 - nutritional
supplement powder
4
PEPTAMEN 1.5 - nutritional
supplement liquid
4
4
PEPTAMEN 1.5 CAL nutritional supplement liquid
4
PHENYL-FREE 2HP nutritional supplement
powder
4
PEPTAMEN 1.5 CAL/
PREBIO1 - nutritional
supplement liquid
4
PHENYLADE DRINK MIX nutritional supplement
powder
4
PEPTAMEN/PREBIO1 nutritional supplement liquid
4
PHENYLADE ESSENTIAL
DRINK - nutritional
supplement pack
PEPTINEX DT - nutritional
supplement liquid
4
4
PEPTINEX DT WITH
PREBIOTI - nutritional
supplement liquid
4
PHENYLADE ESSENTIAL
DRINK - nutritional
supplement powder
PHENYLADE GMP - nutritional
supplement pack
4
PEPTINEX 1.0 - nutritional
supplement liquid
4
PHENYLADE GMP - nutritional
supplement powder
4
PEPTINEX 1.5 - nutritional
supplement liquid
4
PHENYLADE GMP MIX-IN nutritional supplement pack
4
PERATIVE - nutritional
supplement liquid
4
PHENYLADE RTD PKU 10 nutritional supplement liquid
4
PERIFLEX ADVANCE nutritional supplement
powder
4
PHENYLADE60 DRINK MIX nutritional supplement pack
4
4
PERIFLEX JUNIOR nutritional supplement
powder
4
PHENYLADE60 DRINK MIX nutritional supplement
powder
4
PFD 1 - nutritional supplement
powder
4
PHLEXY-10 - nutritional
supplement pack
4
PFD 2 - nutritional supplement
powder
4
PHYTOFUSION - nutritional
supplement pack
4
PHENACTIN AA PLUS nutritional supplement liquid
4
PIVOT 1.5 CAL - nutritional
supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
144
PKU COOLER 10 - nutritional
supplement liquid
4
PRO-CAL - nutritional
supplement pack
4
PKU COOLER 15 - nutritional
supplement liquid
4
PRO-CAL - nutritional
supplement powder
4
PKU COOLER 20 - nutritional
supplement liquid
4
PRO-PHREE - nutritional
supplement powder
4
PKU EASY MICROTABS nutritional supplement tabs
delayed release
4
PROBALANCE - nutritional
supplement liquid
4
PROMACTIN AA PLUS nutritional supplement liquid
4
PKU EXPRESS - nutritional
supplement pack
4
PROMOD - nutritional
supplement liquid
4
PKU EXPRESS20 - nutritional
supplement pack
4
PROMOD - nutritional
supplement powder
4
PKU GEL - nutritional
supplement pack
4
4
4
PKU LOPHLEX LQ 20 nutritional supplement liquid
PROMOTE - nutritional
supplement liquid
4
PROMOTE WITH FIBER nutritional supplement liquid
4
PKU PERIFLEX EARLY
YEARS - nutritional
supplement powder
4
PKU PERIFLEX JUNIOR
PLUS - nutritional
supplement powder
4
PROMOTE 1.0 - nutritional
supplement liquid
PROMOTE 1.0 WITH FIBER nutritional supplement liquid
4
PKU SPHERE 20 - nutritional
supplement pack
4
PROMOTE/FIBER - nutritional
supplement liquid
4
PKU TRIO - nutritional
supplement powder
4
PROPIMEX-1 - nutritional
supplement powder
4
PKU 2 - nutritional supplement
powder
4
PROPIMEX-2 - nutritional
supplement powder
4
PKU 3 - nutritional supplement
powder
4
PROSOURCE - nutritional
supplement liquid
4
POLYCAL - nutritional
supplement powder
4
PROSOURCE - nutritional
supplement powder
4
PORTAGEN - nutritional
supplement powder
4
PROSOURCE NO CARB nutritional supplement liquid
4
PPA/MMA EXPRESS nutritional supplement pack
4
PROSOURCE PLUS nutritional supplement liquid
4
PROSOURCE TF - nutritional
supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
145
PROSOURCE ZAC - nutritional 4
supplement liquid
4
PROSURE - nutritional
supplement liquid
4
PROTAIN XL - nutritional
supplement liquid
4
PROTEIN FORTIFIED
COOKIE - nutritional
supplement misc
4
PROVIMIN - nutritional
supplement powder
4
PULMOCARE - nutritional
supplement liquid
4
PULMOCARE 1.5 - nutritional
supplement liquid
PX VANILLA PLUS - nutritional 4
supplement liquid
4
QUINOA KALE & HEMP nutritional supplement liquid
4
RA BALANCED
NUTRITIONAL - nutritional
supplement liquid
4
RA BALANCED
NUTRITIONAL P - nutritional
supplement liquid
4
RA NUTRITIONAL
SUPPLEMENT - nutritional
supplement liquid
RA NUTRITIONAL SUPPORT - 4
nutritional supplement
powder
4
RA PEDIATRIC
NUTRITIONAL - nutritional
supplement liquid
4
RE/GEN PROTEIN
FORTIFIED - nutritional
supplement misc
4
RE/NEPH - nutritional
supplement liquid
RE/NEPH HP/HC - nutritional
supplement liquid (frozen)
4
RE/NEPH LP/HC - nutritional
supplement liquid
4
RE/NEPH REDUCED
SUGAR - nutritional
supplement liquid
4
RENALCAL - nutritional
supplement liquid
4
RENASTART - nutritional
supplement powder
4
REPLETE - nutritional
supplement liquid
4
REPLETE FIBER - nutritional
supplement liquid
4
REPLETE FIBER 1 CAL nutritional supplement liquid
4
REPLETE/FIBER/ULTRAPAK nutritional supplement liquid
4
RESOURCE ARGINAID nutritional supplement pack
4
RESOURCE DAIRY
THICK HONE - nutritional
supplement liquid
4
RESOURCE DIABETIC TF nutritional supplement liquid
4
RESOURCE JUICE DRINK nutritional supplement liquid
(frozen)
4
RESOURCE JUST FOR
KIDS - nutritional supplement
liquid
4
RESOURCE JUST FOR KIDS
WI - nutritional supplement
liquid
4
RESOURCE JUST FOR KIDS
1. - nutritional supplement
liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
146
RESOURCE SUPPORT nutritional supplement liquid
4
SM NUTRI-DRINK + nutritional supplement liquid
4
RESOURCE THICKENUP
THICKE - nutritional
supplement liquid
4
SOL CARB - nutritional
supplement powder
4
SOURCE COOKIE BAR nutritional supplement bar
4
RESOURCE 2.0 - nutritional
supplement liquid
4
4
SOY PROTEIN SHAKE nutritional supplement
powder
4
RESPALOR - nutritional
supplement liquid
RESURGEX - nutritional
supplement pack
4
SUBDUE - nutritional
supplement liquid
4
RESURGEX PLUS - nutritional
supplement pack
4
SUBDUE PLUS - nutritional
supplement liquid
4
RESURGEX SELECT nutritional supplement pack
4
SUPLENA - nutritional
supplement liquid
4
S.O.S. 15 - nutritional
supplement pack
4
SUPLENA RTU - nutritional
supplement liquid
4
S.O.S. 20 - nutritional
supplement pack
4
4
S.O.S. 25 - nutritional
supplement pack
4
SUPLENA WITH CARB
STEADY - nutritional
supplement liquid
4
SALMON/OATS/SQUASH nutritional supplement liquid
4
SUPLENA 1.8 WITH
CARBSTEA - nutritional
supplement liquid
SB COMPLETE NUTRITION nutritional supplement liquid
4
4
SB COMPLETE NUTRITION
PLU - nutritional supplement
liquid
4
THICK-IT BEEF LASAGNA
PUR - nutritional supplement
misc
SCANDICAL - nutritional
supplement powder
4
SCANDISHAKE - nutritional
supplement misc
4
SCANDISHAKE - nutritional
supplement pack
4
SCANDISHAKE - nutritional
supplement powder
4
SM NUTRI-DRINK - nutritional
supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
THICK-IT CHICKEN A LA KIN - 4
nutritional supplement misc
THICK-IT MAPLE CINNAMON 4
F - nutritional supplement
misc
THICK-IT MIXED FRUIT AND - 4
nutritional supplement misc
4
THICK-IT SEASONED
CHICKEN - nutritional
supplement misc
4
THICK-IT SWEET CORN
PUREE - nutritional
supplement misc
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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147
THICK-IT THICKENED
CRANBE - nutritional
supplement liquid
4
TYREX-1 - nutritional
supplement powder
4
TYREX-2 - nutritional
supplement powder
4
THRIVACIN DETOX nutritional supplement liquid
4
TYROS 1 - nutritional
supplement powder
4
THRIVACIN 30 - nutritional
supplement liquid
4
4
TYROS 2 - nutritional
supplement powder
4
TOLEREX - nutritional
supplement pack
UCD ANAMIX JUNIOR nutritional supplement
powder
4
TWOCAL HN - nutritional
supplement liquid
4
TWOCAL HN 2.0 - nutritional
supplement liquid
4
UCD TRIO - nutritional
supplement powder
4
TYLACTIN RESTORE 10 nutritional supplement liquid
4
UCD 2 - nutritional supplement
powder
4
TYLACTIN RESTORE 5PE nutritional supplement pack
4
ULTRACAL - nutritional
supplement liquid
4
TYLACTIN RTD 15 - nutritional
supplement liquid
4
ULTRACAL HN PLUS nutritional supplement liquid
4
TYR ANAMIX EARLY YEARS nutritional supplement
powder
4
ULTRAMINO SOY PROTEIN nutritional supplement
powder
4
TYR ANAMIX NEXT nutritional supplement
powder
4
UTYMAX - nutritional
supplement pack
4
4
4
TYR COOLER - nutritional
supplement liquid
VHC 2.25 - nutritional
supplement liquid
4
VILACTIN AA PLUS nutritional supplement liquid
4
TYR COOLER20 - nutritional
supplement liquid
VITAJOULE - nutritional
supplement powder
4
TYR EXPRESS - nutritional
supplement pack
4
VITAL AF 1.2 CAL - nutritional
supplement liquid
4
TYR EXPRESS20 - nutritional
supplement pack
4
VITAL HIGH PROTEIN nutritional supplement liquid
4
TYR GEL - nutritional
supplement pack
4
4
VITAL HN - nutritional
supplement pack
4
TYR LOPHLEX LQ - nutritional
supplement liquid
VITAL JR - nutritional
supplement liquid
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
148
VITAL PEPTIDE 1.5 CAL nutritional supplement liquid
4
WND 1 - nutritional supplement
powder
4
VITAL 1.0 CAL - nutritional
supplement liquid
4
WND 2 - nutritional supplement
powder
4
VITAL 1.5 CAL - nutritional
supplement liquid
4
XAQUIL XR - levomefolate
glucosamine tab cr 30 mg
4
VITAPRO - nutritional
supplement powder
4
XLEU MAXAMAID - nutritional
supplement powder
4
VITAQUICK - nutritional
supplement powder
4
XLEU MAXAMUM - nutritional
supplement powder
4
VIVONEX PEDIATRIC nutritional supplement pack
4
4
VIVONEX PLUS - nutritional
supplement powder
4
XLYS-XTRP MAXAMAID nutritional supplement
powder
4
VIVONEX RTF - nutritional
supplement liquid
4
XLYS-XTRP MAXAMUM nutritional supplement
powder
VIVONEX T.E.N. - nutritional
supplement pack
4
XMET MAXAMAID - nutritional
supplement powder
4
WELLNESS ESSENTIALS nutritional supplement kit
4
XMET MAXAMUM - nutritional
supplement powder
4
WELLNESS ESSENTIALS AI nutritional supplement kit
4
XMTVI MAXAMAID - nutritional
supplement powder
4
WELLNESS ESSENTIALS
BLOOD - nutritional
supplement kit
4
XMTVI MAXAMUM - nutritional
supplement powder
4
4
WELLNESS ESSENTIALS
FOR J - nutritional
supplement kit
4
XPHE MAXAMAID - nutritional
supplement powder
4
WELLNESS ESSENTIALS
FOR M - nutritional
supplement kit
4
XPHE-XTYR MAXAMAID nutritional supplement
powder
XTRACAL PLUS - nutritional
supplement liquid
4
WELLNESS ESSENTIALS
FOR P - nutritional
supplement kit
4
WELLNESS ESSENTIALS
FOR W - nutritional
supplement kit
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
XYZBAC - dietary management 2
product - tabs
4
ZYTAZE - zinc citrate-phytase
cap 25-500 mg
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ABANEU-SL cyanocobalaminmethylcobalamin tab sl
600-600 mcg
4
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 40
mcg/0.4ml
5
•
ACTIVE FE - fe carbonyl-fab complex-a-c-d-e-min tab
75-1.25 mg
4
5
•
•
ANIMI-3 - folic acid-b6-b12-domega 3-phytosterols cap 1
mg
4
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 60
mcg/0.3ml
5
•
•
ANIMI-3/VITAMIN D - folic
acid-b6-b12-d-omega 3phytosterols cap 1 mg
4
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 100
mcg/0.5ml
•
•
•
5
•
5
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25
mcg/ml
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 150
mcg/0.3ml
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 40
mcg/ml
5
•
•
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 60
mcg/ml
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 200
mcg/0.4ml
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100
mcg/ml
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 300
mcg/0.6ml
5
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200
mcg/ml
5
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 500 mcg/ml
4
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 300
mcg/ml
5
•
•
B-6 FOLIC ACID - cobalamine
combination cap
4
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 10
mcg/0.4ml
5
•
•
BIFERARX - polysacch fe
cmplx-fe heme poly-fa-b12
tab 22-6-1-0.025 mg
BP VIT 3 - folic acid-vit b6-vit
b12-omega 3-phytosterols
cap 1 mg
4
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 25
mcg/0.42ml
5
•
•
carbonyl iron susp
15 mg/1.25ml (elemental
iron)
A
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
150
CENTRATEX - ferrous
fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
4
CERDELGA - eliglustat tartrate
cap 84 mg (base equivalent)
5
CIFEREX - folic acidcholecalciferol cap 1
mg-3775 unit
4
CORVITE FE - iron
combination tab
4
CORVITE 150 - iron
combination tab
4
cyanocobalamin inj
1000 mcg/ml
1
•
•
•
EPOGEN - epoetin alfa inj
20000 unit/ml
5
fe fum-iron polysacch
complex-fa-b cmplx-c-znmn-cu cap (Tandem plus)
1
fe fumarate w/ b12vit c-fa-ifc cap
110-0.015-75-0.5-240 mg
fe fumarate-vit c-vit
b12-fa cap 460 (151
fe)-60-0.01-1 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
2
FER-IN-SOL - ferrous sulfate
soln 75 mg/ml (15 mg/ml
elemental fe)
A
4
FERIVA - fe bisglycin-fe
carbonyl-c-fa-b12-biotin-dss
cap 75-1 mg
4
DIVISTA - folic acid-vit b6-vit
b12-omega 3-biotin-cr cap 1
mg
4
FERIVA 21/7 - fe asparto glyb12-fa-c-dss-succinic acidzn tab 75-1 mg
4
DROXIA - hydroxyurea cap
200 mg
4
4
DROXIA - hydroxyurea cap
300 mg
4
FERIVAFA - iron-c-fa-b12biotin-copper-docusate cap
110-1 mg
4
DROXIA - hydroxyurea cap
400 mg
4
FERRALET 90 - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss
tab 90-1 mg
DURACHOL - folic acidcholecalciferol cap 1
mg-3775 unit
4
FERRAPLUS 90 - iron-folic
acid-vit b12-vit c-docusate
sod tab 90-1 mg
4
EPOGEN - epoetin alfa inj
2000 unit/ml
5
•
•
A
EPOGEN - epoetin alfa inj
3000 unit/ml
5
•
•
FERRETTS CHEWABLE
IRON - carbonyl iron chew
tab 18 mg (elemental iron)
4
EPOGEN - epoetin alfa inj
4000 unit/ml
5
•
•
FERRO-PLEX HEMATINIC - fe
fum-dss-vit c-vit e-vit b12-iffa tab 115-1 mg
5
4
EPOGEN - epoetin alfa inj
10000 unit/ml
FERROTRIN - iron w/
b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg
•
•
1
DERMACINRX PUREFOLIX folic acid-cholecalciferol tab
1 mg-5000 unit
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
151
ferrous fumarate-fa-b
complex-c-zn-mg-mn-cu
tab 106-1 mg
ferrous fumarate-folic acid
tab 324-1 mg
Limited Distribution
FUSION PLUS - fe fum-iron
poly cmplx-fa-b cmplx-cbiotin-probiotic cap
4
FUSION SPRINKLES - fe fumfe polys cmplx-fa-c-probiotic
pack 7-0.25-50-5 mg
4
GRANIX - tbo-filgrastim
soln prefilled syringe 300
mcg/0.5ml
5
•
GRANIX - tbo-filgrastim
soln prefilled syringe 480
mcg/0.8ml
5
•
4
ferrous sulfate elixir
220 mg/5ml (44 mg/5ml
elemental fe)
A
A
•
•
•
•
FOCALGIN DSS - fe carbonylfe gluconate-fa-vit b12-vit cdss tab 90-1 mg
4
HEMATOGEN FA - fe
fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg
4
folic acid cap 0.8 mg
A
HEMETAB - polysacch fe
cmplx-fe heme poly-fa-b12
tab 22-6-1-0.025 mg
HEMOCYTE PLUS - ferrous
fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
4
ICAR PEDIATRIC - carbonyl
iron susp 15 mg/1.25ml
(elemental iron)
A
INTEGRA F - fe fumfe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg
fe)
4
INTEGRA PLUS - fe fum-iron
polysacch complex-fa-b
complex-c-biotin cap
4
IRON CHEWS PEDIATRIC carbonyl iron chew tab 15
mg (elemental iron)
A
iron combination cap
1
folic acid-vitamin b6-vitamin
b12 tab 2.2-25-0.5 mg
ACA
1
A
folic acid tab 1 mg
Dispensing Limits
4
FERROUS SULFATE - ferrous
sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)
folic acid tab 800 mcg
Step Therapy
FOLIXAPURE - folic acidcholecalciferol tab 1
mg-5000 unit
A
folic acid tab 400 mcg
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name
1
FERROUS SULFATE - ferrous
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
ferrous sulfate soln 75 mg/
ml (15 mg/ml elemental fe)
Prior Authorization
Drug Name
Drug Tier
2016
A
A
1
1
folic acid-vitamin b6-vitamin
b12 tab 2.2-25-1 mg
(Folgard rx)
1
folic acid-vitamin b6-vitamin
b12 tab 2.5-25-1 mg
1
FOLIVANE-F - fe fumfe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg
fe)
4
FOLIVANE-PLUS - fe fumiron polysacch complex-fa-b
complex-c-biotin cap
4
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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152
iron polysacch complex-vit
b12-fa cap 150-0.025-1 mg
1
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg
(Hematron-af)
1
MULTIGEN - fe asparto glysucc acd-c-threonic acdb12-des stom tab
4
iron-folic acid-vit c-vit b6-vit
b12-zinc tab 150-1.25 mg
(Corvite 150)
2
MULTIGEN FOLIC - fe asparto
gly-succinic acd-vit cthreonic acd-b12-fa tab
4
IROSPAN 24/6 - fe bisglyc-fe
polys-succ acd-b cmplx-cca-fa tab ther pk
4
MULTIGEN PLUS - fe aspart
gly-fe fum-succ acd-cthreonic acd-b12-fa tab
MYKIDZ IRON 10 - iron susp
15 mg/1.5ml
A
IS 24/6 - fe bisglyc-fe polyssucc acd-b cmplx-c-ca-fa tab
ther pk
4
NASCOBAL - cyanocobalamin
nasal spray 500 mcg/0.1ml
4
NEPHRON FA - ferrous
fumarate w/ fa-dss-b
complex-vit c tab
4
LEUKINE - sargramostim
lyophilized for inj 250 mcg
5
MAXFE - iron-fa-vit b12-biotinvit c-docusate-mg-zn tab
160-1 mg
4
NEULASTA - pegfilgrastim soln
prefilled syringe 6 mg/0.6ml
5
•
•
4
•
NEULASTA ONPRO KIT pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml
5
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 30 mcg/0.3ml
•
•
•
NEUPOGEN - filgrastim inj 300
mcg/ml
5
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 50 mcg/0.3ml
4
•
•
5
•
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 75 mcg/0.3ml
4
•
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
5
•
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 100 mcg/0.3ml
4
•
NEUPOGEN - filgrastim
soln prefilled syringe 300
mcg/0.5ml
5
•
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 150 mcg/0.3ml
4
•
NEUPOGEN - filgrastim
soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)
4
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 200 mcg/0.3ml
4
•
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl
600-600 mcg
NOXIFOL-D - folic acidcholecalciferol tab 1
mg-2500 unit
4
•
•
•
NUFERA - iron combination tab 4
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
153
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
ORTHO D - folic acidcholecalciferol cap 1
mg-3775 unit
4
REVESTA - folic acidcholecalciferol cap 1
mg-5750 unit
4
PRE-FOLIC - folic acid-vitamin
c tab 1-100 mg
4
4
PROCRIT - epoetin alfa inj
2000 unit/ml
5
SPATONE PUR-ABSORB
IRON - ferrous sulfate liquid
5 mg/20ml (elemental iron)
4
PROCRIT - epoetin alfa inj
3000 unit/ml
TANDEM F - ferrous fumiron polysacch-fa cap
162-115.2-1 mg (106 mg fe)
TARON FORTE - fe
bisglycinate-fe polysacch-vit
c-vit b12-fa cap
4
ZARXIO - filgrastim-sndz
soln prefilled syringe 300
mcg/0.5ml
5
•
ZARXIO - filgrastim-sndz
soln prefilled syringe 480
mcg/0.8ml
5
•
ZAVARA - folic acidcholecalciferol cap 1
mg-5750 unit
4
ZAVESCA - miglustat cap 100
mg
5
4
•
•
5
•
•
PROCRIT - epoetin alfa inj
4000 unit/ml
5
•
•
PROCRIT - epoetin alfa inj
10000 unit/ml
5
•
•
PROCRIT - epoetin alfa inj
20000 unit/ml
5
•
•
PROCRIT - epoetin alfa inj
40000 unit/ml
5
•
•
PROFERRIN-FORTE - iron
heme polypeptide-folic acid
tab 12-1 mg (fe equiv)
4
PROMACTA - eltrombopag
olamine tab 12.5 mg (base
equiv)
5
•
•
•
PROMACTA - eltrombopag
olamine tab 25 mg (base
equiv)
5
•
•
•
ZOLATE - folic acidcholecalciferol cap 1
mg-3775 unit
PROMACTA - eltrombopag
olamine tab 50 mg (base
equiv)
5
•
•
•
ANTICOAGULANTS
COUMADIN - warfarin sodium
tab 1 mg
4
PROMACTA - eltrombopag
olamine tab 75 mg (base
equiv)
5
•
•
•
COUMADIN - warfarin sodium
tab 2 mg
4
4
PROTECTIRON - iron
polysacch-fa-b complex-vit
c-e & minerals tab 60-1 mg
4
COUMADIN - warfarin sodium
tab 2.5 mg
COUMADIN - warfarin sodium
tab 3 mg
4
PUREFE PLUS - ferrous
fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg
4
COUMADIN - warfarin sodium
tab 4 mg
4
COUMADIN - warfarin sodium
tab 5 mg
4
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
154
4
FRAGMIN - dalteparin sodium
inj 2500 unit/0.2ml
4
•
COUMADIN - warfarin sodium
tab 7.5 mg
4
FRAGMIN - dalteparin sodium
inj 5000 unit/0.2ml
4
•
COUMADIN - warfarin sodium
tab 10 mg
4
4
•
ELIQUIS - apixaban tab 2.5 mg
3
•
3
FRAGMIN - dalteparin sodium
inj 12500 unit/0.5ml
4
ELIQUIS - apixaban tab 5 mg
enoxaparin sodium inj
30 mg/0.3ml (Lovenox)
2
•
•
•
FRAGMIN - dalteparin sodium
inj 7500 unit/0.3ml
FRAGMIN - dalteparin sodium
inj 15000 unit/0.6ml
4
•
2
•
FRAGMIN - dalteparin sodium
inj 18000 unit/0.72ml
4
•
2
•
FRAGMIN - dalteparin sodium
inj 95000 unit/3.8ml
4
•
2
•
heparin sodium (porcine) inj
1000 unit/ml
2
2
•
heparin sodium (porcine) inj
5000 unit/ml
2
•
heparin sodium (porcine) inj
10000 unit/ml
2
•
heparin sodium (porcine) inj
20000 unit/ml
2
•
heparin sodium (porcine) pf
inj 5000 unit/0.5ml
2
•
PRADAXA - dabigatran
etexilate mesylate cap 75
mg (etexilate base eq)
4
•
2
•
PRADAXA - dabigatran
etexilate mesylate cap 110
mg (etexilate base eq)
4
•
2
•
PRADAXA - dabigatran
etexilate mesylate cap 150
mg (etexilate base eq)
4
•
2
•
SAVAYSA - edoxaban tosylate
tab 15 mg (base equivalent)
4
•
SAVAYSA - edoxaban tosylate
tab 30 mg (base equivalent)
4
•
enoxaparin sodium inj
40 mg/0.4ml (Lovenox)
enoxaparin sodium inj
60 mg/0.6ml (Lovenox)
enoxaparin sodium inj
80 mg/0.8ml (Lovenox)
enoxaparin sodium inj
100 mg/ml (Lovenox)
enoxaparin sodium inj
120 mg/0.8ml (Lovenox)
enoxaparin sodium inj
150 mg/ml (Lovenox)
enoxaparin sodium inj
300 mg/3ml (Lovenox)
fondaparinux sodium
subcutaneous inj
2.5 mg/0.5ml (Arixtra)
fondaparinux sodium
subcutaneous inj
5 mg/0.4ml (Arixtra)
fondaparinux sodium
subcutaneous inj
7.5 mg/0.6ml (Arixtra)
fondaparinux sodium
subcutaneous inj
10 mg/0.8ml (Arixtra)
FRAGMIN - dalteparin sodium
inj 10000 unit/ml
4
•
Limited Distribution
COUMADIN - warfarin sodium
tab 6 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
2
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4
warfarin sodium tab 1 mg
(Coumadin)
1
warfarin sodium tab 2 mg
(Coumadin)
1
warfarin sodium tab 2.5 mg
(Coumadin)
1
warfarin sodium tab 3 mg
(Coumadin)
1
warfarin sodium tab 4 mg
(Coumadin)
1
warfarin sodium tab 5 mg
(Coumadin)
1
warfarin sodium tab 6 mg
(Coumadin)
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
warfarin sodium tab 10 mg
(Coumadin)
1
XARELTO - rivaroxaban tab 10
mg
3
•
XARELTO - rivaroxaban tab 15
mg
3
•
XARELTO - rivaroxaban tab 20
mg
3
•
XARELTO STARTER PACK rivaroxaban tab starter
therapy pack 15 mg & 20 mg
3
•
HEMOSTATICS
AMICAR - aminocaproic acid
oral soln 0.25 gm/ml
4
AMICAR - aminocaproic acid
tab 500 mg
4
AMICAR - aminocaproic acid
tab 1000 mg
4
tranexamic acid tab 650 mg
(Lysteda)
2
HEMATOLOGICAL AGENTS - MISC.
ADVATE - antihemophilic factor 5 •
rahf-pfm for inj 250 unit
ADVATE - antihemophilic factor 5 •
rahf-pfm for inj 500 unit
ADVATE - antihemophilic factor 5 •
rahf-pfm for inj 1000 unit
ADVATE - antihemophilic factor 5 •
rahf-pfm for inj 1500 unit
ADVATE - antihemophilic factor 5 •
rahf-pfm for inj 2000 unit
ADVATE - antihemophilic factor 5 •
rahf-pfm for inj 3000 unit
ADVATE - antihemophilic factor 5 •
rahf-pfm for inj 4000 unit
5
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 250 unit
5
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 500 unit
5 •
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 750 unit
5
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 1000 unit
5 •
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 1500 unit
5
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 2000 unit
4
AGGRENOX - aspirindipyridamole cap sr 12hr
25-200 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
SAVAYSA - edoxaban tosylate
tab 60 mg (base equivalent)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 250 unit
5
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 500 unit
5
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 1000 unit
5
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 1500 unit
5
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 2000 unit
5
ALPHANINE SD - coagulation
factor ix for inj 500 unit
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
3000 unit
5
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
4000 unit
5
•
•
anagrelide hcl cap 0.5 mg
(Agrylin)
2
anagrelide hcl cap 1 mg
2
aspirin-dipyridamole cap sr
12hr 25-200 mg (Aggrenox)
•
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
2
BEBULIN - factor ix complex
for inj 200-1200 unit
5
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
250 unit
5
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
500 unit
5
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
1000 unit
5
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
2000 unit
5
•
•
•
•
5
•
•
ALPHANINE SD - coagulation
factor ix for inj 1000 unit
5
•
•
ALPHANINE SD - coagulation
factor ix for inj 1500 unit
5
•
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj 250
unit
5
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
3000 unit
5
•
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj 500
unit
5
•
•
BERINERT - c1 esterase
inhibitor (human) for iv inj kit
500 unit
5
•
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
1000 unit
5
•
•
BRILINTA - ticagrelor tab 60
mg
3
3
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
2000 unit
5
BRILINTA - ticagrelor tab 90
mg
cilostazol tab 50 mg (Pletal)
1
•
•
cilostazol tab 100 mg (Pletal)
1
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157
clopidogrel bisulfate tab
75 mg (base equiv) (Plavix)
1
Limited Distribution
ACA
•
Dispensing Limits
5
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
clopidogrel bisulfate tab
300 mg (base equiv)
(Plavix)
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
2000 unit
5
•
•
COAGADEX - coagulation
factor x (human) for inj 250
unit
5
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
3000 unit
5
•
•
COAGADEX - coagulation
factor x (human) for inj 500
unit
5
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
4000 unit
5
•
•
CORIFACT - factor xiii
concentrate (human) for inj
kit 1000-1600 unit
5
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
5000 unit
5
•
•
dipyridamole tab 25 mg
(Persantine)
1
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
6000 unit
5
•
•
dipyridamole tab 50 mg
(Persantine)
2
FEIBA - antiinhibitor coagulant
complex for inj
5
•
dipyridamole tab 75 mg
(Persantine)
2
FIRAZYR - icatibant acetate inj
30 mg/3ml (base equivalent)
5
•
•
EFFIENT - prasugrel hcl tab 5
mg (base equiv)
4
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 250 unit
EFFIENT - prasugrel hcl tab 10
mg (base equiv)
4
5
•
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
250 unit
5
•
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 500 unit
5
•
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
500 unit
5
•
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 1000 unit
5
•
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
750 unit
5
•
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 2000 unit
5
•
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
1000 unit
5
•
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 3000 unit
5
•
•
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
1500 unit
5
•
•
HEMOFIL M - antihemophilic
factor (human) for inj 250
unit
•
•
•
•
•
•
•
•
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158
5
•
•
HEMOFIL M - antihemophilic
factor (human) for inj 1700
unit
5
•
•
HUMATE-P - antihemophilic
factor/vwf (human) for inj
250-600 unit
5
•
•
HUMATE-P - antihemophilic
factor/vwf (human) for inj
500-1200 unit
5
•
•
HUMATE-P - antihemophilic
factor/vwf (human) for inj
1000-2400 unit
5
•
•
IDELVION - coagulation factor
ix (recomb) (rix-fp) for inj 250
unit
5
•
•
IDELVION - coagulation factor
ix (recomb) (rix-fp) for inj 500
unit
5
•
•
IDELVION - coagulation factor
ix (recomb) (rix-fp) for inj
1000 unit
5
•
•
IDELVION - coagulation factor
ix (recomb) (rix-fp) for inj
2000 unit
5
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 250 unit
5
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 500 unit
5
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 1000
unit
5
•
•
Limited Distribution
HEMOFIL M - antihemophilic
factor (human) for inj 1000
unit
ACA
•
Dispensing Limits
•
Step Therapy
5
Prior Authorization
HEMOFIL M - antihemophilic
factor (human) for inj 500
unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
IXINITY - coagulation factor ix
(recombinant) for inj 1500
unit
5
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 2000
unit
5
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 3000
unit
5
•
•
KCENTRA - prothrombin
complex conc human for inj
kit 500 unit
4
KCENTRA - prothrombin
complex conc human for inj
kit 1000 unit
4
KOATE - antihemophilic factor
(human) for inj 250 unit
5
•
•
KOATE - antihemophilic factor
(human) for inj 500 unit
5
•
•
KOATE - antihemophilic factor
(human) for inj 1000 unit
5
•
•
KOATE-DVI - antihemophilic
factor (human) for inj 250
unit
5
•
•
KOATE-DVI - antihemophilic
factor (human) for inj 500
unit
5
•
•
KOATE-DVI - antihemophilic
factor (human) for inj 1000
unit
5
•
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 250
unit
5
•
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 500
unit
5
•
•
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159
5
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 2000
unit
5
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 3000
unit
5
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 250
unit
5
•
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 500
unit
5
•
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 1000
unit
5
•
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 2000
unit
5
•
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 3000
unit
5
KOVALTRY - antihemophilic
factor (recombinant) for inj
250 unit
5
KOVALTRY - antihemophilic
factor (recombinant) for inj
500 unit
5
•
•
•
•
•
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 1000
unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
KOVALTRY - antihemophilic
factor (recombinant) for inj
1000 unit
5
•
•
KOVALTRY - antihemophilic
factor (recombinant) for inj
2000 unit
5
•
•
KOVALTRY - antihemophilic
factor (recombinant) for inj
3000 unit
5
•
•
MONOCLATE-P antihemophilic factor
(human) for inj kit 1000 unit
5
•
•
MONOCLATE-P antihemophilic factor
(human) for inj kit 1500 unit
5
•
•
MONONINE - coagulation
factor ix for inj 1000 unit
5
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
250 unit
5
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
500 unit
5
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
1000 unit
5
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
1500 unit
5
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
2000 unit
5
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
3000 unit
5
•
•
NOVOSEVEN RT - coagulation 5
factor viia (recomb) for inj 1
mg (1000 mcg)
•
•
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NOVOSEVEN RT - coagulation 5
factor viia (recomb) for inj 2
mg (2000 mcg)
NOVOSEVEN RT - coagulation 5
factor viia (recomb) for inj 5
mg (5000 mcg)
NOVOSEVEN RT - coagulation 5
factor viia (recomb) for inj 8
mg (8000 mcg)
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj kit 250 unit
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj kit 500 unit
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj kit 1000 unit
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj kit 2000 unit
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj 250 unit
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj 500 unit
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj 1000 unit
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj 2000 unit
OBIZUR - antihemophilic factor 5
(recomb porc) rpfviii for inj
500 unit
1
pentoxifylline tab cr 400 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
PROFILNINE SD - factor ix
complex for inj 1000 unit
5
•
•
PROFILNINE SD - factor ix
complex for inj 1500 unit
5
•
•
5
•
•
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj 220-400
unit
•
•
5
•
•
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj 401-800
unit
•
•
5
•
•
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj
801-1240 unit
5
•
•
•
•
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj
1241-1800 unit
5
•
•
•
•
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj
1801-2400 unit
4
•
•
RIASTAP - fibrinogen conc
(human) inj approximately 1
gm (900-1300 mg)
RIXUBIS - coagulation factor ix
(recombinant) for inj 250 unit
5
•
•
•
•
RIXUBIS - coagulation factor ix
(recombinant) for inj 500 unit
5
•
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 1000
unit
5
•
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 2000
unit
5
•
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 3000
unit
5
•
•
•
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
PROFILNINE - factor ix
complex for inj 500 unit
5
PROFILNINE - factor ix
complex for inj 1000 unit
5
•
•
PROFILNINE - factor ix
complex for inj 1500 unit
5
•
•
PROFILNINE SD - factor ix
complex for inj 500 unit
5
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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RUCONEST - c1 esterase
inhibitor (recombinant) for iv
inj 2100 unit
5
TRETTEN - coagulation
factor xiii a-subunit for inj
2000-3125 unit
5
WILATE - antihemophilic factor/ 5
vwf (human) for inj 500-500
unit kit
5
WILATE - antihemophilic
factor/vwf (human) for inj
1000-1000 unit kit
5
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 250 unit
5
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 500 unit
5
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 1000 unit
5
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 2000 unit
5
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
250 unit
5
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
500 unit
5
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
1000 unit
5
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
2000 unit
•
•
•
•
•
•
•
•
•
•
4
OPHTHALMIC AGENTS
4
•
ALOCRIL - nedocromil sodium
ophth soln 2%
4
4
•
ALOMIDE - lodoxamide
tromethamine ophth soln
0.1%
ALPHAGAN P - brimonidine
tartrate ophth soln 0.1%
4
ALREX - loteprednol etabonate
ophth susp 0.2%
4
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
2
ATROPINE SULFATE atropine sulfate ophth oint
1%
4
1
•
ATROPINE SULFATE atropine sulfate ophth soln
1%
AZASITE - azithromycin ophth
soln 1%
4
•
azelastine hcl ophth soln
0.05%
2
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
•
TOPICAL PRODUCTS
AKTEN - lidocaine hcl ophth
gel 3.5%
•
•
ZONTIVITY - vorapaxar
sulfate tab 2.08 mg (base
equivalent)
4
•
•
5
ACUVAIL - ketorolac
tromethamine ophth soln
0.45%
•
•
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
3000 unit
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
AZOPT - brinzolamide ophth
susp 1%
4
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BACITRACIN - bacitracin ophth 3
oint 500 unit/gm
1
bacitracin-polymyxin b
ophth oint
2
bacitracin-polymyxinneomycin-hc ophth oint
1%
4
BEPREVE - bepotastine
besilate ophth soln 1.5%
4
BESIVANCE - besifloxacin
hcl ophth susp 0.6% (base
equiv)
4
BETADINE OPHTHALMIC
PREP - povidone-iodine
ophth soln 5%
2
betaxolol hcl ophth soln
0.5%
4
BETIMOL - timolol ophth soln
0.25%
4
BETIMOL - timolol ophth soln
0.5%
4
BETOPTIC-S - betaxolol hcl
ophth susp 0.25%
4
BIMATOPROST - bimatoprost
ophth soln 0.03%
BLEPHAMIDE - sulfacetamide 4
sodium-prednisolone ophth
susp 10-0.2%
4
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint
10-0.2%
2
brimonidine tartrate ophth
soln 0.15% (Alphagan p)
1
brimonidine tartrate ophth
soln 0.2%
2
BROMFENAC - bromfenac
sodium ophth soln 0.09%
(base equivalent)
bromfenac sodium ophth
soln 0.09% (base equiv)
(once-daily)
carteolol hcl ophth soln 1%
• •
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
1
CILOXAN - ciprofloxacin hcl
ophth oint 0.3%
4
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
COMBIGAN - brimonidine
tartrate-timolol maleate
ophth soln 0.2-0.5%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
COSOPT PF - dorzolamide hcl- 4
timolol maleate ophth sol
22.3-6.8 mg/ml pf
cromolyn sodium ophth soln 1
4%
4
CYCLOGYL - cyclopentolate
hcl ophth soln 0.5%
4
CYCLOMYDRIL cyclopentolate w/
phenylephrine ophth soln
0.2-1%
2
cyclopentolate hcl ophth
soln 0.5% (Cyclogyl)
1
cyclopentolate hcl ophth
soln 1% (Cyclogyl)
2
cyclopentolate hcl ophth
soln 2% (Cyclogyl)
5
CYSTARAN - cysteamine hcl
ophth soln 0.44% (base
equivalent)
1
DEXAMETHASONE SODIUM
PHOS - dexamethasone
sodium phosphate ophth
soln 0.1%
1
diclofenac sodium ophth
soln 0.1%
2
dorzolamide hcl ophth soln
2% (Trusopt)
•
•
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4
ketorolac tromethamine
ophth soln 0.4% (Acular ls)
2
DUREZOL - difluprednate
ophth emulsion 0.05%
4
EMADINE - emedastine
difumarate ophth soln 0.05%
(base equiv)
4
ketorolac tromethamine
ophth soln 0.5% (Acular)
epinastine hcl ophth soln
0.05% (Elestat)
2
erythromycin ophth oint
5 mg/gm
1
FLAREX - fluorometholone
acetate ophth susp 0.1%
4
fluorometholone ophth susp
0.1% (Fml liquifilm)
2
4
LASTACAFT - alcaftadine
ophth soln 0.25%
4
latanoprost ophth soln
0.005% (Xalatan)
1
levofloxacin ophth soln 0.5%
4
FML - fluorometholone ophth
oint 0.1%
4
LOTEMAX - loteprednol
etabonate ophth oint 0.5%
4
FML FORTE - fluorometholone
ophth susp 0.25%
4
LOTEMAX - loteprednol
etabonate ophth susp 0.5%
4
gatifloxacin ophth soln 0.5%
(Zymaxid)
2
LUMIGAN - bimatoprost ophth
soln 0.01%
4
GELFILM OP - gelatin
adsorbable ophth film
4
MAXIDEX - dexamethasone
ophth susp 0.1%
4
gentamicin sulfate ophth
oint 0.3%
1
METIPRANOLOL metipranolol ophth soln
0.3%
4
MITOSOL - mitomycin for
ophth soln kit 0.2 mg
4
4
3
homatropine hbr ophth soln
5% (Isopto homatropine)
1
1
ILEVRO - nepafenac ophth
susp 0.3%
4
MOXEZA - moxifloxacin hcl
ophth soln 0.5% (base eq) (2
times daily)
IOPIDINE - apraclonidine
hcl ophth soln 1% (base
equivalent)
4
NATACYN - natamycin ophth
susp 5%
Limited Distribution
ACA
Dispensing Limits
2
LOTEMAX - loteprednol
etabonate ophth gel 0.5%
gentamicin sulfate ophth
soln 0.3% (Garamycin)
•
1
1
flurbiprofen sodium ophth
soln 0.03% (Ocufen)
Step Therapy
1
LACRISERT - artificial tear
ophth insert
levobunolol hcl ophth soln
0.5% (Betagan)
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name
ISTALOL - timolol maleate
ophth soln 0.5% (once-daily)
dorzolamide hcl-timolol
maleate ophth soln
22.3-6.8 mg/ml (Cosopt)
1
Prior Authorization
Drug Name
Drug Tier
2016
• •
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neomycin-bacitrac
zn-polymyx
5(3.5)mg-400unt-10000unt
op oin
neomycin-polymygramicid op sol
1.75-10000-0.025mg-untmg/ml (Neosporin)
neomycin-polymyxindexamethasone ophth oint
0.1% (Maxitrol)
neomycin-polymyxindexamethasone ophth
susp 0.1% (Maxitrol)
2
2
1
1
NEOMYCIN/POLYMYXIN/
HYDROC - neomycinpolymyxin-hc ophth susp
4
NEVANAC - nepafenac ophth
susp 0.1%
4
ofloxacin ophth soln 0.3%
(Ocuflox)
1
olopatadine hcl ophth soln
0.1% (base equivalent)
(Patanol)
2
PATADAY - olopatadine hcl
ophth soln 0.2% (base
equivalent)
4
PATANOL - olopatadine hcl
ophth soln 0.1% (base
equivalent)
4
PAZEO - olopatadine hcl ophth
soln 0.7% (base equivalent)
4
phenylephrine hcl ophth
soln 2.5%
2
phenylephrine hcl ophth
soln 10%
PHOSPHOLINE IODIDE echothiophate iodide ophth
for soln 0.125%
2
4
pilocarpine hcl ophth soln
1% (Isopto carpine)
pilocarpine hcl ophth soln
2% (Isopto carpine)
pilocarpine hcl ophth soln
4% (Isopto carpine)
polymyxin b-trimethoprim
ophth soln 10000 unit/
ml-0.1% (Polytrim)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
1
PRED MILD - prednisolone
acetate ophth susp 0.12%
4
PRED-G - gentamicinprednisolone ace ophth susp
0.3-1%
4
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint
0.3-0.6%
4
prednisolone acetate ophth
susp 1% (Pred forte)
2
PREDNISOLONE SODIUM
PHOSP - prednisolone
sodium phosphate ophth
soln 1%
4
PREDNISOLONE/
MOXIFLOXACIN prednisolone-moxifloxacin
opth soln 1-0.5%
4
PREDNISOLONE/
MOXIFLOXACIN prednisolone-moxifloxacinbromfenac opth sol
1-0.5-0.09%
4
PREDNISOLONE/
MOXIFLOXACIN prednisolone-moxifloxacinketorolac opth sol
1-0.5-0.5%
4
PROLENSA - bromfenac
sodium ophth soln 0.07%
(base equivalent)
4
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proparacaine hcl ophth soln
0.5% (Alcaine)
1
• •
TOBRADEX - tobramycindexamethasone ophth oint
0.3-0.1%
4
4
RESCULA - unoprostone
isopropyl ophth soln 0.15%
4
RESTASIS - cyclosporine
(ophth) emulsion 0.05%
4
•
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
RESTASIS MULTIDOSE cyclosporine (ophth)
emulsion 0.05%
4
•
tobramycin ophth soln 0.3%
(Tobrex)
1
2
SIMBRINZA - brinzolamidebrimonidine tartrate ophth
susp 1-0.2%
4
tobramycin-dexamethasone
ophth susp 0.3-0.1%
(Tobradex)
4
SULFACETAMIDE SODIUM sulfacetamide sodium ophth
oint 10%
4
TOBREX - tobramycin ophth
oint 0.3%
4
sulfacetamide sodium ophth
soln 10% (Bleph-10)
2
TRAVATAN Z - travoprost
ophth soln 0.004%
(benzalkonium free) (bak
free)
trifluridine ophth soln 1%
(Viroptic)
2
tropicamide ophth soln 0.5%
1
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
tetracaine hcl ophth soln
0.5%
1
1
tropicamide ophth soln 1%
(Mydriacyl)
1
timolol maleate ophth gel
forming soln 0.25%
(Timoptic-xe)
2
VIGAMOX - moxifloxacin hcl
ophth soln 0.5% (base
equiv)
4
timolol maleate ophth gel
forming soln 0.5%
(Timoptic-xe)
2
XIIDRA - lifitegrast ophth soln
5%
4
1
ZIOPTAN - tafluprost ophth
soln 0.0015%
4
timolol maleate ophth soln
0.25% (Timoptic)
1
ZIRGAN - ganciclovir ophth gel
0.15%
4
TIMOPTIC OCUDOSE - timolol
maleate preservative free
ophth soln 0.25%
4
ZYLET - loteprednol etabonate- 4
tobramycin ophth susp
0.5-0.3%
TIMOPTIC OCUDOSE - timolol
maleate preservative free
ophth soln 0.5%
4
timolol maleate ophth soln
0.5% (Timoptic)
OTIC AGENTS
acetic acid otic soln 2%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
• •
•
•
• •
2
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ACETIC ACID/ALUMINUM
ACET - acetic acid 2% in
aluminum acetate otic soln
4
CETRAXAL - ciprofloxacin
hcl otic soln 0.2% (base
equivalent)
4
CIPRO HC - ciprofloxacinhydrocortisone otic susp
0.2-1%
4
CIPRODEX - ciprofloxacindexamethasone otic susp
0.3-0.1%
4
CIPROFLOXACIN ciprofloxacin hcl otic soln
0.2% (base equivalent)
4
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml
4
fluocinolone acetonide (otic)
oil 0.01% (Dermotic)
2
hydrocortisone w/ acetic
acid otic soln 1-2%
neomycin-polymyxin-hc otic
soln 1% (Cortisporin)
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
ofloxacin otic soln 0.3%
OTOVEL - ciprofloxacinfluocinolone aceton (pf) otic
soln 0.3-0.025%
cevimeline hcl cap 30 mg
(Evoxac)
2
chlorhexidine gluconate
soln 0.12% (Peridex)
1
clotrimazole troche 10 mg
2
COLGATE DRY MOUTH
RELIEF - sodium fluoride
mouthwash 2.1 mg/10ml
A
•
CREST COMPLETE - sodium
fluoride paste 0.243%
A
•
DEBACTEROL - sulfuric acidsulfonated phenolics soln
30-50%
4
EQL DENTAL TRAVEL PACK sodium fluoride paste
0.243% & mouthwash kit
A
•
EQL TRAVEL TOOTHBRUSH/
TOO - sodium
monofluorophosphate paste
0.15%
A
•
GEL-KAM - stannous fluoride
gel 0.4%
A
•
4
•
2
GEL-KAM ORAL CARE
RINSE - stannous fluoride
conc 0.63%
4
2
GELCLAIR - povidone-sodium
hyaluronate-glycyrrhetinic
acid gel
LIDOCAINE HCL - lidocaine
hcl laryngotracheal soln 4%
2
lidocaine hcl viscous soln
2%
1
2
2
4
MOUTH/THROAT/DENTAL AGENTS
A
ACT TOTAL CARE DRY
MOUTH - sodium fluoride
rinse 0.02%
1
benzocaine mouth/throat
aerosol 20%
4
CAPHOSOL - artificial saliva solution
•
LISTERINE ESSENTIAL
CARE - sod
monofluorophosph-eucalmen-methyl sal-thymol gel
0.76%
A
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
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4
LISTERINE RESTORING sodium fluoride rinse
0.0221% (0.01% f)
A
LISTERINE SMART RINSE sodium fluoride rinse
0.0221% (0.01% f)
A
LISTERINE TOTAL CARE sodium fluoride rinse
0.0221% (0.01% f)
A
•
LISTERINE TOTAL CARE
PLUS - sodium fluoride rinse
0.0221% (0.01% f)
A
LISTERINE TOTAL CARE
ZERO - sodium fluoride rinse
0.02%
A
LISTERINE WHITENING/
RESTO - sodium fluoride
rinse 0.0221% (0.01% f)
A
MUCOTROL - oral wound care
products - wafer
4
NAFRINSE DAILY/
ACIDULATED - sodium
fluoride-phosphoric acid for
soln 1 mg/5ml (f equiv)
4
•
NAFRINSE DAILY/NEUTRAL 7odium fluoride for soln rinse
0.05%
4
•
NAFRINSE WEEKLY - sodium
fluoride for soln rinse 0.2%
4
•
NEUTRASAL - artificial saliva packet
4
NUMOISYN - artificial saliva solution
4
nystatin susp 100000 unit/ml
2
OMNI GEL - stannous fluoride
gel 0.4%
A
ORAFATE - sucralfate-malate
paste 10%
4
•
ORAMAGICRX - oral wound
care products - for susp
rinse
4
•
ORAVIG - miconazole buccal
tab 50 mg (mouth-throat)
4
PARODONTAX - stannous
fluoride paste 0.454%
A
•
PHOS FLUR - sodium fluoride
rinse 0.044%
A
•
•
PHOS-FLUR ORTHO
DEFENSE - sodium fluoride
rinse 0.044%
A
•
•
pilocarpine hcl tab 5 mg
(Salagen)
2
pilocarpine hcl tab 7.5 mg
(Salagen)
2
PREVIDENT FLUORIDE sodium fluoride gel 1.1%
(0.5% f)
4
•
PREVIDENT 5000 BOOSTER - 4
sodium fluoride paste 1.1%
4
PREVIDENT 5000 BOOSTER
PL - sodium fluoride paste
1.1%
4
PREVIDENT 5000 DRY
MOUTH - sodium fluoride gel
1.1% (0.5% f)
4
PREVIDENT 5000 ENAMEL
PRO - sodium fluoridepotassium nitrate paste
1.1-5%
4
PREVIDENT 5000 PLUS sodium fluoride cream 1.1%
4
PREVIDENT 5000
SENSITIVE - sodium
fluoride-potassium nitrate
paste 1.1-5%
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
•
LISTERINE NATURALS WITH
F - sodium fluoride rinse
0.02%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
•
•
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PROTHELIAL - sucralfatemalate paste 10%
4
REMBRANDT DEEPLY
WHITE+PE - sodium
monofluorophosphate paste
0.884%
A
REMBRANDT INTENSE
STAIN - sodium fluoride
paste 0.243%
A
REMBRANDT WHITENING sodium fluoride rinse 0.02%
A
SALICEPT - oral wound care
products - for susp rinse
4
SALIVAMAX - artificial saliva packet
4
A
•
•
STANNOUS FLUORIDE
RINSE - stannous fluoride liq
0.1%
THERA-FLUR-N - sodium
fluoride gel 1.1% (0.5% f)
4
•
•
triamcinolone acetonide
dental paste 0.1%
2
•
ANALPRAM-HC hydrocortisone acetate w/
pramoxine rectal lotn 2.5-1%
4
CORTIFOAM - hydrocortisone
acetate rectal foam 10% (90
mg/dose)
3
hydrocortisone acetate
suppos 25 mg (Anusol-hc)
2
•
hydrocortisone acetate
suppos 30 mg (Proctocort)
•
hydrocortisone acetate w/
pramoxine rectal cream
1-1% (Analpram-hc)
•
•
•
•
•
sodium fluoride rinse 0.2%
(Prevident)
1
sodium fluoride-potassium
nitrate paste 1.1-5%
(Prevident 5000 sensi)
1
•
stannous fluoride conc
0.63% (Gel-kam oral care ri)
A
•
A
•
hydrocortisone acetate w/
pramoxine rectal cream
2.5-1% (Analpram-hc)
hydrocortisone enema
100 mg/60ml (Cortenema)
hydrocortisone rectal cream
1% (Proctocort)
hydrocortisone rectal cream
2.5% (Anusol-hc)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
•
Drug Name
ANORECTAL AGENTS
SALIVATE RX - artificial saliva - 4
packet
A
SENSODYNE REPAIR &
PROTEC - stannous fluoride
paste 0.454%
1
sodium fluoride cream 1.1%
(Prevident 5000 plus)
1
sodium fluoride gel 1.1%
(0.5% f) (Prevident fluoride)
1
sodium fluoride paste 1.1%
(Prevident 5000 boost)
A
sodium fluoride rinse
0.0221% (0.01% f)
A
sodium fluoride rinse 0.05%
stannous fluoride gel 0.4%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
2
2
1
LIDOCAINE HCLHYDROCORTIS - lidocainehydrocortisone acetate rectal
gel 2.8-0.55%
4
lidocaine-hydrocortisone
acetate rectal cream
3-0.5%
2
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PROCORT - hydrocortisone
acetate w/ pramoxine rectal
cream 1.85-1.15%
4
PROCTOFOAM HC hydrocortisone acetate w/
pramoxine rectal foam 1-1%
4
RECTIV - nitroglycerin oint
0.4%
4
UCERIS - budesonide rectal
foam 2 mg/act
ALA-QUIN - clioquinol-hc
cream 3-0.5%
4
alclometasone dipropionate
cream 0.05% (Aclovate)
2
alclometasone dipropionate
oint 0.05%
4
4
4
ABSORICA - isotretinoin cap
10 mg
4
ALEVICYN ANTIPRURITIC
SG - dermatological products
misc - liquid
4
ABSORICA - isotretinoin cap
20 mg
4
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
4
ABSORICA - isotretinoin cap
25 mg
4
ALTABAX - retapamulin oint
1%
4
ABSORICA - isotretinoin cap
30 mg
4
AMCINONIDE - amcinonide
cream 0.1%
4
ABSORICA - isotretinoin cap
35 mg
4
APEXICON E - diflorasone
diacetate emollient base
cream 0.05%
ABSORICA - isotretinoin cap
40 mg
4
ASTERO - lidocaine hcl gel 4%
4
4
acitretin cap 10 mg
(Soriatane)
2
ATOPICLAIR - dermatological
products misc - cream
4
acitretin cap 17.5 mg
(Soriatane)
2
ATRAPRO CP - wound
dressings - kit
4
acitretin cap 25 mg
(Soriatane)
2
ATRAPRO DERMAL SPRAY wound cleansers - liquid
4
ACUICYN DAILY EYELID &
EY - eyelid cleansers - liquid
4
AVAR - sulfacetamide sodium
w/ sulfur cleansing pad
9.5-5%
acyclovir oint 5% (Zovirax)
2
AVENOVA - eyelid cleansers liquid
4
AVENOVA/NEUTROX - eyelid
cleansers - liquid
4
BEAU RX - scar treatment
products - gel
2
adapalene cream 0.1%
(Differin)
2
adapalene gel 0.1% (Differin)
2
adapalene gel 0.3% (Differin)
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
ALCORTIN A - iodoquinolhydrocortisone-aloe
polysaccharide gel 1-2-1%
DERMATOLOGICALS
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
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BENSAL HP - salicylic acid &
benzoic acid oint 3-6%
4
BENZIQ - benzoyl peroxide gel
5.25 %
4
BENZIQ LS - benzoyl peroxide
gel 2.75%
4
BENZIQ WASH - benzoyl
peroxide liq 5.25%
2
benzoyl peroxide cloth 6%
2
betamethasone valerate
cream 0.1%
betamethasone valerate
lotion 0.1%
betamethasone valerate oint
0.1%
2
calcipotriene cream 0.005%
(Dovonex)
2
benzoyl peroxide foam 9.8%
(Benzefoamultra)
2
calcipotriene oint 0.005%
2
benzoyl peroxide liq 2.5%
2
calcipotriene soln 0.005%
(50 mcg/ml)
benzoyl peroxide lotion 6%
2
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
2
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
2
betamethasone dipropionate
augmented gel 0.05%
2
2
CALCITRIOL - calcitriol oint 3
mcg/gm
4
CAPEX - fluocinolone
acetonide shampoo 0.01%
4
CARAC - fluorouracil cream
0.5%
4
CEM-UREA - urea soln 45%
4
CENTANY - mupirocin oint 2%
4
CERACADE - dermatological
products misc - emulsion
4
ciclopirox gel 0.77%
2
2
betamethasone dipropionate
augmented oint 0.05%
(Diprolene)
2
betamethasone dipropionate
cream 0.05%
2
ciclopirox olamine cream
0.77% (base equiv)
2
ciclopirox olamine susp
0.77% (base equiv)
2
ciclopirox shampoo 1%
(Loprox shampoo)
2
2
ciclopirox solution 8%
(Penlac Nail Lacquer)
2
betamethasone dipropionate
oint 0.05%
betamethasone valerate
aerosol foam 0.12% (Luxiq)
Limited Distribution
2
betamethasone dipropionate
augmented lotion 0.05%
(Diprolene)
betamethasone dipropionate
lotion 0.05%
ACA
2
BP CLEANSING WASH sulfacetamide sodium-sulfur
in urea emulsion 10-4%
calcipotrienebetamethasone
dipropionate oint
0.005-0.064% (Taclonex)
Dispensing Limits
2
2
2
Step Therapy
2
benzoyl peroxide foam 5.3%
(Benzefoam)
benzoyl peroxide liq 7%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
171
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2
(1)-5% (Duac)
clindamycin phosphate
foam 1% (Evoclin)
clindamycin phosphate gel
1% (Cleocin-t)
clindamycin phosphate
lotion 1% (Cleocin-t)
clindamycin phosphate soln
1% (Cleocin-t)
clindamycin phosphate
swab 1% (Cleocin-t)
2
clobetasol propionate soln
0.05% (Temovate)
2
CLOCORTOLONE PIVALATE clocortolone pivalate cream
0.1%
4
4
2
CLOCORTOLONE PIVALATE
PUM - clocortolone pivalate
cream 0.1%
4
2
CLODERM - clocortolone
pivalate cream 0.1%
4
2
clindamycin phosphatebenzoyl peroxide gel 1-5%
(Benzaclin)
2
clindamycin phosphatetretinoin gel 1.2-0.025%
(Ziana)
2
clotrimazole w/
betamethasone cream
1-0.05% (Lotrisone)
clobetasol propionate cream
0.05% (Temovate)
2
clotrimazole w/
betamethasone lotion
1-0.05%
2
COAL TAR - coal tar soln 20%
4
CONDYLOX - podofilox gel
0.5%
4
COPASIL - emollient - gel
4
CORDRAN - flurandrenolide
cream 0.05%
4
CORDRAN - flurandrenolide
lotion 0.05%
4
CORDRAN - flurandrenolide
oint 0.05%
4
CORDRAN - flurandrenolide
tape 4 mcg/sqcm
4
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
4
clobetasol propionate
emulsion foam 0.05%
(Olux-e)
2
clobetasol propionate foam
0.05% (Olux)
2
clobetasol propionate gel
0.05% (Temovate)
clobetasol propionate lotion
0.05% (Clobex)
clobetasol propionate oint
0.05% (Temovate)
clobetasol propionate
shampoo 0.05% (Clobex)
2
2
2
2
Limited Distribution
ACA
Dispensing Limits
2
clobetasol propionate spray
0.05% (Clobex)
CLODERM PUMP clocortolone pivalate cream
0.1%
clobetasol propionate
emollient base cream
0.05% (Temovate e)
Step Therapy
2
2
2
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
172
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint
1%
4
diclofenac sodium soln 1.5%
(Pennsaid)
2
DIFFERIN - adapalene lotion
0.1%
4
CORTISPORIN - neomycinpolymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%
4
4
COSENTYX - secukinumab
subcutaneous soln prefilled
syringe 150 mg/ml
5
•
DIFLORASONE DIACETATE diflorasone diacetate cream
0.05%
2
COSENTYX SENSOREADY
PEN - secukinumab
subcutaneous soln autoinjector 150 mg/ml
5
•
DIFLORASONE DIACETATE diflorasone diacetate oint
0.05%
4
DENAVIR - penciclovir cream
1%
4
DOXEPIN
HYDROCHLORIDE doxepin hcl cream 5%
4
DESONATE - desonide gel
0.05%
4
DRITHO-CREME HP anthralin cream 1%
econazole nitrate cream 1%
2
desonide cream 0.05%
(Desowen)
2
ECOZA - econazole nitrate
foam 1%
4
desonide lotion 0.05%
(Desowen)
2
ELETONE - dermatological
products misc - cream
4
desonide oint 0.05%
(Desowen)
2
4
DESOXIMETASONE desoximetasone cream
0.05%
4
ELETONE TWINPACK dermatological products
misc - cream
ELIDEL - pimecrolimus cream
1%
4
desoximetasone cream
0.25% (Topicort)
2
EMULSION SB dermatological products
misc - emulsion
4
ENSTILAR - calcipotrienebetamethasone dipropionate
foam 0.005-0.064%
4
ENTTY SPRAY EMULSION dermatological products
misc - emulsion
4
EPICERAM - dermatological
products misc - emulsion
4
EPIFOAM - pramoxine-hc
aerosol foam 1-1%
4
desoximetasone gel 0.05%
(Topicort)
2
desoximetasone oint 0.05%
(Topicort)
4
desoximetasone oint 0.25%
(Topicort)
2
diclofenac sodium (actinic
keratoses) gel 3%
(Solaraze)
2
diclofenac sodium gel 1%
(Voltaren)
2
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
173
ERTACZO - sertaconazole
nitrate cream 2%
4
erythromycin gel 2% (Erygel)
2
erythromycin pads 2%
erythromycin soln 2%
2
2
ESSENTRA WIPES 9X9"
CLEAN - isopropyl alcohol
wipes 70%
4
EURAX - crotamiton cream
10%
4
EURAX - crotamiton lotion 10% 4
4
EXELDERM - sulconazole
nitrate cream 1%
4
EXELDERM - sulconazole
nitrate solution 1%
2
EXODERM - sodium
thiosulfate-salicylic acid
lotion 25-1%
4
FABIOR - tazarotene (acne)
foam 0.1%
3
FINACEA - azelaic acid foam
15%
3
FINACEA - azelaic acid gel
15%
4
FLECTOR - diclofenac
epolamine patch 1.3%
2
fluocinolone acetonide
cream 0.01%
2
fluocinolone acetonide
cream 0.025% (Synalar)
2
fluocinolone acetonide oil
0.01% (body oil) (Dermasmoothe/fs bod)
2
fluocinolone acetonide oil
0.01% (scalp oil) (Dermasmoothe/fs sca)
2
fluocinolone acetonide oint
0.025% (Synalar)
fluocinolone acetonide soln
0.01% (Synalar)
fluocinonide cream 0.05%
2
2
fluocinonide emulsified base
cream 0.05%
2
fluocinonide oint 0.05%
fluocinonide soln 0.05%
4
fluorouracil cream 5%
(Efudex)
2
fluorouracil soln 2%
2
2
2
flurandrenolide oint 0.05%
(Cordran)
2
fluticasone propionate
cream 0.05% (Cutivate)
2
2
2
GENADUR - dermatological
products misc - liquid
4
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
4
gentamicin sulfate cream
0.1%
2
halobetasol propionate
cream 0.05% (Ultravate)
Limited Distribution
2
flurandrenolide lotion 0.05%
(Cordran)
fluticasone propionate oint
0.005%
ACA
2
FLUOROURACIL - fluorouracil
cream 0.5%
fluticasone propionate lotion
0.05% (Cutivate)
Dispensing Limits
2
4
flurandrenolide cream 0.05%
•
2
FLUOROPLEX - fluorouracil
cream 1%
fluorouracil soln 5%
Step Therapy
2
fluocinonide cream 0.1%
(Vanos)
fluocinonide gel 0.05%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
174
halobetasol propionate oint
0.05% (Ultravate)
2
4
HALOG - halcinonide cream
0.1%
4
HYLATOPIC PLUS dermatological products,
misc. - aerosol foam
4
HALOG - halcinonide oint 0.1%
4
HYLIRA - hyaluronate sodium
(emollient) lotion 0.1%
HALOTIN - haloprogin cream
1%
4
imiquimod cream 5%
(Aldara)
2
HPR - dermatological products,
misc. - aerosol foam
4
iodoquinol-hc cream 1%
2
HPR PLUS - dermatological
products misc - cream
4
iodoquinol-hydrocortisone
in aloe vehicle cream
1-1.9% (Vytone)
HPR PLUS - dermatological
products, misc. - aerosol
foam
4
isotretinoin cap 10 mg
hyaluronate sodium
(emollient) gel 0.2% (Hylira)
2
hydrocortisone butyrate
cream 0.1% (Locoid)
isotretinoin cap 20 mg
2
isotretinoin cap 30 mg
isotretinoin cap 40 mg
JUBLIA - efinaconazole soln
10%
4
KENALOG - triamcinolone
acetonide aerosol soln 0.147
mg/gm
4
KERYDIN - tavaborole soln 5%
4
2
2
2
ketoconazole foam 2%
(Extina)
2
1
ketoconazole shampoo 2%
(Nizoral)
lactic acid (ammonium
lactate) cream 12% (Lachydrin)
1
lactic acid (ammonium
lactate) lotion 10%
2
2
hydrocortisone oint 2.5%
hydrocortisone valerate
cream 0.2%
hydrocortisone valerate oint
0.2% (Westcort)
HYLATOPIC PLUS dermatological products
misc - cream
1
2
Limited Distribution
2
ketoconazole cream 2%
hydrocortisone lotion 2.5%
ACA
2
2
2
Dispensing Limits
2
hydrocortisone butyrate oint
0.1% (Locoid)
hydrocortisone lotion 2%
(Ala scalp)
Step Therapy
2
2
hydrocortisone cream 2.5%
•
2
hydrocortisone butyrate
hydrophilic lipo base
cream 0.1% (Locoid
lipocream)
hydrocortisone butyrate
soln 0.1% (Locoid)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
lactic acid (ammonium
lactate) lotion 12% (Lachydrin)
4
lactic acid w/ vitamin e
cream 10%-3500 unit/30gm
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
175
LAVARE WOUND WASH wound cleansers - gel
4
metronidazole lotion 0.75%
(Metrolotion)
2
LEVULAN KERASTICK aminolevulinic acid hcl for
soln 20% (stick applicator)
4
MICROCYN - wound cleansers
- gel
4
MICROCYN - wound cleansers
- liquid
4
lidocaine hcl gel 2%
1
MICROCYN SKIN AND
WOUND H - wound
cleansers - gel
4
lidocaine hcl soln 4%
(Xylocaine)
1
lidocaine oint 5%
2
lidocaine patch 5%
(Lidoderm)
2
lidocaine-prilocaine cream
kit 2.5-2.5%
2
lidocaine-prilocaine cream
2.5-2.5% (Emla)
2
LINDANE - lindane shampoo
1%
2
LOCOID - hydrocortisone
butyrate lotion 0.1%
4
LOTRIMIN ULTRA - butenafine
hcl cream 1%
4
LOUTREX - antiseborrheic
products misc - cream
4
LUXAMEND - wound dressings 2
- cream
LUZU - luliconazole cream 1% 4
naftifine hcl cream 2%
(Naftin)
2
NAFTIN - naftifine hcl cream
2%
4
NAFTIN - naftifine hcl gel 1%
4
2
MENTAX - butenafine hcl
cream 1%
4
NAFTIN - naftifine hcl gel 2%
4
4
methoxsalen rapid cap
10 mg (Oxsoralen ultra)
2
NATROBA - spinosad susp
0.9%
4
4
metronidazole cream 0.75%
(Metrocream)
2
NEO-SYNALAR - neomycin
sulfate-fluocinolone
acetonide cream 0.5-0.025%
metronidazole gel 0.75%
2
NEOSALUS - dermatological
products misc - cream
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
MIRVASO - brimonidine tartrate 4
gel 0.33% (base equivalent)
2
mometasone furoate cream
0.1% (Elocon)
2
mometasone furoate oint
0.1% (Elocon)
2
mometasone furoate
solution 0.1% (lotion)
(Elocon)
2
mupirocin calcium cream
2% (Bactroban)
1
mupirocin oint 2%
(Bactroban)
2
naftifine hcl cream 1%
malathion lotion 0.5%
(Ovide)
metronidazole gel 1%
(Metrogel)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
176
NEOSALUS - dermatological
products, misc. - aerosol
foam
4
NEOSALUS - emollient - lotion
4
NEOSALUS CP dermatological products
misc - cream
4
NOBLE MYSTIQUE EMULAC - lactic acid (ammonium
lactate) cream 10%
4
NOVACORT - pramoxine-hc
gel 1-2%
4
NUCORT - hydrocortisone
acetate lotion 2%
4
NUVAIL - dermatological
products misc - solution
4
nystatin cream 100000 unit/
gm
2
nystatin oint 100000 unit/gm
nystatin topical powder
100000 unit/gm
nystatin-triamcinolone
cream 100000-0.1 unit/gm%
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
2
2
2
2
ONEXTON - clindamycin
phosphate-benzoyl peroxide
gel 1.2-3.75%
4
OVACE PLUS - sulfacetamide
sodium cream 10%
4
OVACE PLUS - sulfacetamide
sodium foam 9.8%
4
OVACE PLUS - sulfacetamide
sodium lotion 9.8%
4
oxiconazole nitrate cream
1% (Oxistat)
2
OXISTAT - oxiconazole nitrate
cream 1%
4
OXISTAT - oxiconazole nitrate
lotion 1%
4
PANDEL - hydrocortisone
probutate cream 0.1%
4
PANRETIN - alitretinoin gel
0.1%
4
PENNSAID - diclofenac sodium 4
soln 2%
2
permethrin cream 5%
(Elimite)
PICATO - ingenol mebutate gel 4
0.015%
PICATO - ingenol mebutate gel 4
0.05%
4
PLEXION CLEANSING
CLOTHS - sulfacetamide
sodium w/ sulfur cleansing
cloth 9.8-4.8%
PLIAGLIS - lidocaine-tetracaine 4
cream 7-7%
4
PODOCON 25 IN BENZOIN
TIN - podophyllum resin soln
25%
2
podofilox soln 0.5%
(Condylox)
PRAMOSONE - pramoxine-hc 4
cream 1-1%
PRAMOSONE - pramoxine-hc 4
lotion 1-1%
PRAMOSONE - pramoxine-hc 4
lotion 1-2.5%
PRAMOSONE - pramoxine-hc 4
oint 1-1%
PRAMOSONE - pramoxine-hc 4
oint 1-2.5%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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177
PRAMOSONE E - pramoxinehc emollient base cream
1-2.5%
4
pramoxine-hc cream 1-2.5%
(Pramosone)
2
salicylic acid film forming
liquid 27.5% (Virasal)
prednicarbate cream 0.1%
(Dermatop)
2
salicylic acid foam 6%
(Salvax)
prednicarbate oint 0.1%
(Dermatop)
2
salicylic acid gel 6% (Keralyt) 2
2
salicylic acid lotion 6%
PROMISEB - antiseborrheic
products misc - cream
4
salicylic acid shampoo 6%
(Salex)
2
PRUCLAIR - dermatological
products misc - cream
4
salicylic acid soln 26%
2
PRUDOXIN - doxepin hcl
cream 5%
4
PRUMYX - dermatological
products misc - cream
4
PSORCON - diflorasone
diacetate cream 0.05%
4
2
RECEDO - scar treatment
products - gel
2
selenium sulfide-pyrithione
zinc in urea shampoo
2.25%
RECURA - antifungal
combination products misc cream
4
REGENECARE - lidocaine hclcollagen-aloe vera gel 2%
4
REGRANEX - becaplermin gel
0.01%
4
RIAX - benzoyl peroxide foam
5.5%
salicylic acid er film-forming
soln 28.5% (Ultrasal-er)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
2
SANTYL - collagenase oint 250 4
unit/gm
2
scar treatment products
- gel
1
selenium sulfide lotion 2.5%
SELRX - selenium sulfidepyrithione zinc in urea
shampoo 2.3%
4
SERNIVO - betamethasone
dipropionate spray emulsion
0.05% (base equiv)
4
SILVER NITRATE - silver
nitrate oint 10%
4
4
SILVER NITRATE - silver
nitrate soln 0.5%
4
RIAX - benzoyl peroxide foam
9.5%
4
SILVER NITRATE - silver
nitrate soln 10%
4
ROSULA - sulfacetamide
sodium w/ sulfur cleansing
cloth 10-5%
2
SILVER NITRATE - silver
nitrate soln 25%
4
4
RYNODERM - urea cream
37.5%
4
SILVER NITRATE - silver
nitrate soln 50%
1
salicylic acid cream 6%
2
silver sulfadiazine cream 1%
(Silvadene)
•
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SILVRSTAT WOUND
DRESSING - silver - gel
4
STELARA - ustekinumab soln
prefilled syringe 90 mg/ml
5
skin protectants misc cream
2
2
2
SKLICE - ivermectin lotion
0.5%
4
sulfacetamide sodium
cleansing gel 10% (Ovace
plus wash)
SODIUM SULFACETAMIDE
WASH - sulfacetamide
sodium in bakuchiol vehicle
wash 10%
4
sulfacetamide sodium liquid
10% (Ovace wash)
SODIUM SULFACETAMIDE/
SULF - sulfacetamide sodium
w/ sulfur lotion 10-5%
2
sulfacetamide sodium lotion
10% (acne) (Klaron)
4
SODIUM SULFACETAMIDE/
SULF - sulfacetamide sodium
w/ sulfur susp 10-5%
4
SODIUM SULFACETAMIDE/
SULF - sulfacetamide
sodium-sulfur in urea
emulsion 10-5%
4
SODIUM SULFACETAMIDE/
SULF - sulfacetamide
sodium-sulfur in urea gel
10-5%
3
SOOLANTRA - ivermectin
cream 1%
4
SORILUX - calcipotriene foam
0.005%
4
SP SCAR MANAGEMENT scar treatment products - gel
4
SPINOSAD - spinosad susp
0.9%
2
SSS 10-5 - sulfacetamide
sodium w/ sulfur foam
10-5%
STELARA - ustekinumab inj 45 5
mg/0.5ml
5
STELARA - ustekinumab soln
prefilled syringe 45 mg/0.5ml
sulfacetamide sodium
shampoo 10% (Ovace plus)
•
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
•
2
2
sulfacetamide sodium w/
sulfur cleanser 10-2%
(Avar ls cleanser)
2
sulfacetamide sodium w/
sulfur cleansing pad
10-4% (Sumaxin)
2
sulfacetamide sodium w/
sulfur cream 9.8-4.8%
(Plexion)
2
sulfacetamide sodium w/
sulfur cream 10-2% (Avare ls)
2
sulfacetamide sodium w/
sulfur cream 10-5%
2
sulfacetamide sodium w/
sulfur emulsion 10-5%
•
2
sulfacetamide sodium w/
sulfur cleanser 9.8-4.8%
(Plexion cleanser)
sulfacetamide sodium w/
sulfur emulsion 10-1%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
2
2
sulfacetamide sodium w/
sulfur lotion 9.8-4.8%
(Plexion)
2
sulfacetamide sodium w/
sulfur susp 8-4% (Sumaxin
ts)
2
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
179
sulfacetamide sodium w/
sulfur wash 9-4% (Sumaxin
wash)
2
sulfacetamide sodium
w/ sulfur wash 9-4.5%
(Sumadan wash)
2
SULFAMYLON - mafenide
acetate cream 85 mg/gm
TETRIX - dermatological
products misc - cream
2
TEXACORT - hydrocortisone
soln 2.5%
4
TOLAK - fluorouracil cream 4%
4
4
TOPICORT - desoximetasone
cream 0.05%
4
SYNERA - lidocaine-tetracaine
topical patch 70-70 mg
4
TOPICORT - desoximetasone
oint 0.05%
4
TACLONEX - calcipotrienebetamethasone dipropionate
susp 0.005-0.064%
4
TOPICORT - desoximetasone
spray 0.25%
4
2
tacrolimus oint 0.03%
(Protopic)
2
tretinoin cream 0.025%
(Retin-a)
2
tacrolimus oint 0.1%
(Protopic)
2
tretinoin cream 0.05% (Retina)
2
TALTZ - ixekizumab
subcutaneous soln autoinjector 80 mg/ml
5
tretinoin cream 0.1% (Retina)
tretinoin gel 0.01% (Retin-a)
2
TALTZ - ixekizumab
subcutaneous soln prefilled
syringe 80 mg/ml
5
TARGRETIN - bexarotene gel
1%
5
tazarotene cream 0.1%
(Tazorac)
2
TAZORAC - tazarotene cream
0.05%
3
TAZORAC - tazarotene cream
0.1%
•
•
•
•
•
•
•
•
tretinoin gel 0.025% (Retin-a)
tretinoin gel 0.05% (Atralin)
tretinoin microsphere gel
0.04% (Retin-a micro)
tretinoin microsphere gel
0.1% (Retin-a micro pump)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
2
2
2
2
TRI-CHLOR - trichloroacetic
acid liqd 80%
4
2
3
triamcinolone acetonide
aerosol soln 0.147 mg/gm
(Kenalog)
triamcinolone acetonide
cream 0.025%
1
TAZORAC - tazarotene gel
0.05%
3
TAZORAC - tazarotene gel
0.1%
3
triamcinolone acetonide
cream 0.1%
TBC - trypsin w/ castor oil &
peruvian balsam spray
1
triamcinolone acetonide
cream 0.5%
triamcinolone acetonide
lotion 0.025%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
1
1
2
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triamcinolone acetonide
lotion 0.1%
triamcinolone acetonide oint
0.025%
triamcinolone acetonide oint
0.1%
triamcinolone acetonide oint
0.5%
TRIANEX - triamcinolone
acetonide oint 0.05%
2
1
1
4
UTOPIC - urea cream 41%
4
VALCHLOR - mechlorethamine
hcl gel 0.016% (base
equivalent)
5
VECTICAL - calcitriol oint 3
mcg/gm
4
VENELEX - balsam perucastor oil oint
4
VERDESO - desonide foam
0.05%
4
VEREGEN - sinecatechins oint
15%
4
VOLTAREN - diclofenac
sodium gel 1%
4
VUSION - miconazole-zinc
oxide-white petrolatum oint
0.25-15-81.35%
4
VYTONE - iodoquinolhydrocortisone in aloe
vehicle cream 1-1.9%
4
XERESE - acyclovirhydrocortisone cream 5-1%
4
XEROFORM NONOCCLUSIVE OI - bismuth
tribromophenate-petrolatum
dressing pads
4
2
2
2
2
urea gel 40%
2
2
2
2
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
UREVAZ - urea cream 44%
urea foam 40% (Hydro 40
foam)
urea in lactic acid-salicylic
acid vehicle susp 50%
Dispensing Limits
4
2
urea in lactic acid vehicle
foam 35% (Hydro 35)
Step Therapy
2
2
urea gel 45% (Uramaxin)
2
urea suspension 40%
(Umecta)
urea cream 39% (Aluvea)
urea cream 50%
urea lotion 40%
2
2
4
urea cream 47% (Keralac)
urea in zinc undecylenatelactic acid vehicle
emulsion 50%
4
URAMAXIN - urea in
ammonium lactate vehicle
foam 20%
urea cream 45% (Uramaxin)
Drug Name
UREA NAIL - urea in zinc
undecylenate-lactic acid
vehicle stick 50%
TRIDESILON - desonide cream 2
0.05%
4
ULESFIA - benzyl alcohol
lotion 5%
4
ULTRASAL-ER - salicylic acid
er film-forming soln 28.5%
4
ULTRAVATE - halobetasol
propionate lotion 0.05%
UMECTA - urea emulsion 40% 4
urea cream 40%
Prior Authorization
Drug Name
Drug Tier
2016
•
•
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XEROFORM OCCLUSIVE
PETROL - bismuth
tribromophenate-petrolatum
dressing - misc
4
XEROFORM OCCLUSIVE
PETROL - bismuth
tribromophenate-petrolatum
dressing pads
4
XEROFORM PETROLATUM
DRESS - bismuth
tribromophenate-petrolatum
dressing - misc
4
XEROFORM PETROLATUM
DRESS - bismuth
tribromophenate-petrolatum
dressing pads
4
XOLEGEL - ketoconazole gel
2%
4
LUGOLS STRONG IODINE iodine solution
ANTIDOTES
ZACLIR CLEANSING - benzoyl 4
peroxide lotion 8%
4
ZITHRANOL - anthralin
shampoo 1%
ZONALON - doxepin hcl cream 4
5%
ZOVIRAX - acyclovir cream 5% 4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
4
CETYLEV - acetylcysteine
effervescent tab 500 mg
4
CETYLEV - acetylcysteine
effervescent tab 2.5 gm
4
CHEMET - succimer cap 100
mg
3
EVZIO - naloxone hcl solution
auto-injector 0.4 mg/0.4ml
4
EVZIO - naloxone hcl solution
auto-injector 2 mg/0.4ml
4
EXJADE - deferasirox tab for
oral susp 125 mg
5
•
•
EXJADE - deferasirox tab for
oral susp 250 mg
5
•
•
EXJADE - deferasirox tab for
oral susp 500 mg
5
•
•
FERRIPROX - deferiprone oral
soln 100 mg/ml
5
•
•
FERRIPROX - deferiprone tab
500 mg
5
•
•
5
•
ZYCLARA - imiquimod cream
3.75%
4
•
JADENU - deferasirox tab 90
mg
4
•
JADENU - deferasirox tab 180
mg
5
ZYCLARA PUMP - imiquimod
cream 2.5%
•
4
•
JADENU - deferasirox tab 360
mg
5
ZYCLARA PUMP - imiquimod
cream 3.75%
•
NALOXONE HCL - naloxone
hcl soln prefilled syringe 2
mg/2ml
4
naloxone hcl inj 0.4 mg/ml
2
MISCELLANEOUS PRODUCTS
ANTISEPTICS & DISINFECTANTS
4
ANASEPT - sodium
hypochlorite liquid 0.057%
4
FORMA-RAY - formaldehyde
solution 20%
1
formaldehyde solution 10%
naltrexone hcl tab 50 mg
(Revia)
2
NARCAN - naloxone hcl nasal
spray 4 mg/0.1ml
3
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RADIOGARDASE - prussian
blue insoluble cap 0.5 gm
4
VISTOGARD - uridine
triacetate oral granules
packet 10 gm
5
DIAGNOSTIC PRODUCTS
2
•
BAYER CONTOUR BLOOD
GLUCO - glucose blood test
strip
2
•
BAYER CONTOUR NEXT
BLOOD - glucose blood test
strip
2
•
GLUCAGEN DIAGNOSTIC glucagon hcl (rdna)
diagnostic for inj 1 mg (base
equiv)
4
KETONE BLOOD TEST
STRIPS-VARIOUS
4
URINE TEST STRIPSVARIOUS
4
CITRUS BERGAMOT - citrus
bergamot oral powder 250
mg/0.25 gm
4
CO-BALAMIN - ubiquinolvit b12-resveratrol-fa cap
200-5-400-0.8 mg
4
CO-VERATROL - ubiquinolvit b12-resveratrol-fa cap
200-5-400-0.8 mg
4
MEDICAL DEVICES
BLOOD GLUCOSE
CALIBRATION LIQUIDVARIOUS
4
BREATHERITE - spacer/
aerosol-holding chambers device
3
BREATHERITE
COLLAPSIBLE - spacer/
aerosol-holding chambers device
3
BREATHERITE RIGID
SPACER - spacer/aerosolholding chambers - device
3
BREATHERITE VALVED MDI
CH - respiratory therapy
supplies - devices
3
BREATHERITE W/LARGE
MASK - spacer/aerosolholding chambers - device
3
BREATHERITE W/MEDIUM
MASK - spacer/aerosolholding chambers - device
3
BREATHERITE W/SMALL
MASK - spacer/aerosolholding chambers - device
3
CAYA - diaphragm arc-spring
A
HURRISEAL - dental
desensitizing product solution
4
INSULIN PEN NEEDLESVARIOUS
3
•
INSULIN SYRINGESVARIOUS
3
•
LANCETS-VARIOUS
3
LANCING DEVICE-VARIOUS
4
OMNIFLEX DIAPHRAGM diaphragms
A
RESPIRATORY THERAPY
SUPPLIES-VARIOUS
4
SPACERS-VARIOUS
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
BAYER BREEZE 2 TEST
DISC - glucose blood test
disk
ALTERNATIVE MEDICINES
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
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WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 70 mm
A
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 75 mm
A
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 80 mm
A
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 85 mm
A
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 90 mm
A
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 95 mm
A
•
PHARMACEUTICAL ADJUVANTS
4
SANARE SCAR THERAPY cream base
ASSORTED CLASSES
ASTAGRAF XL - tacrolimus
cap sr 24hr 0.5 mg
4
•
ASTAGRAF XL - tacrolimus
cap sr 24hr 1 mg
4
•
ASTAGRAF XL - tacrolimus
cap sr 24hr 5 mg
4
•
ATGAM - lymphocyte immune
globulin anti-thymocyte g inj
50 mg/ml(eq)
4
AZASAN - azathioprine tab 75
mg
4
Limited Distribution
•
ACA
A
Dispensing Limits
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 65 mm
AZASAN - azathioprine tab 100 4
mg
2
azathioprine tab 50 mg
(Imuran)
5
CUPRIMINE - penicillamine
cap 250 mg
2
cyclosporine cap 25 mg
(Sandimmune)
2
cyclosporine cap 100 mg
(Sandimmune)
CYCLOSPORINE MODIFIED - 3
cyclosporine modified cap
50 mg
2
cyclosporine modified cap
25 mg (Neoral)
2
cyclosporine modified
cap 50 mg (Cyclosporine
modifie)
2
cyclosporine modified cap
100 mg (Neoral)
2
cyclosporine modified oral
soln 100 mg/ml (Neoral)
5
DEPEN TITRATABS penicillamine tab 250 mg
4
ENVARSUS XR - tacrolimus
tab sr 24hr 0.75 mg
4
ENVARSUS XR - tacrolimus
tab sr 24hr 1 mg
4
ENVARSUS XR - tacrolimus
tab sr 24hr 4 mg
2
mycophenolate mofetil cap
250 mg (Cellcept)
2
mycophenolate mofetil
for oral susp 200 mg/ml
(Cellcept)
2
mycophenolate mofetil tab
500 mg (Cellcept)
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 60 mm
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
•
•
•
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184
mycophenolate sodium tab
dr 180 mg (mycophenolic
acid equiv) (Myfortic)
mycophenolate sodium tab
dr 360 mg (mycophenolic
acid equiv) (Myfortic)
2
2
NEORAL - cyclosporine
modified cap 25 mg
4
NEORAL - cyclosporine
modified cap 100 mg
4
NEORAL - cyclosporine
modified oral soln 100 mg/ml
4
PROGRAF - tacrolimus cap 0.5 4
mg
4
PROGRAF - tacrolimus cap 1
mg
4
PROGRAF - tacrolimus cap 5
mg
3
RAPAMUNE - sirolimus oral
soln 1 mg/ml
REVLIMID - lenalidomide caps 5
2.5 mg
REVLIMID - lenalidomide cap 5 5
mg
5
REVLIMID - lenalidomide cap
10 mg
5
REVLIMID - lenalidomide cap
15 mg
5
REVLIMID - lenalidomide cap
20 mg
5
REVLIMID - lenalidomide cap
25 mg
4
SANDIMMUNE - cyclosporine
cap 25 mg
4
SANDIMMUNE - cyclosporine
cap 100 mg
4
SANDIMMUNE - cyclosporine
oral soln 100 mg/ml
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
sirolimus tab 0.5 mg
(Rapamune)
2
sirolimus tab 1 mg
(Rapamune)
2
sirolimus tab 2 mg
(Rapamune)
2
sodium polystyrene
sulfonate oral susp
15 gm/60ml (Sps)
2
sodium polystyrene
sulfonate powder
(Kayexalate)
2
sodium polystyrene
sulfonate rectal susp
30 gm/120ml
2
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
SYPRINE - trientine hcl cap
250 mg
5
tacrolimus cap 0.5 mg
(Prograf)
2
tacrolimus cap 1 mg
(Prograf)
2
tacrolimus cap 5 mg
(Prograf)
2
THALOMID - thalidomide cap
50 mg
5
•
•
•
THALOMID - thalidomide cap
100 mg
5
•
•
•
THALOMID - thalidomide cap
150 mg
5
•
•
•
THALOMID - thalidomide cap
200 mg
5
•
•
•
VELTASSA - patiromer sorbitex 4
calcium for susp packet 8.4
gm (base eq)
VELTASSA - patiromer sorbitex 4
calcium for susp packet 16.8
gm (base eq)
•
•
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VELTASSA - patiromer sorbitex 4
calcium for susp packet 25.2
gm (base eq)
4
ZORTRESS - everolimus tab
0.25 mg
4
ZORTRESS - everolimus tab
0.5 mg
4
ZORTRESS - everolimus tab
0.75 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2016
•
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2016
INDEX
A
abacavir sulfate-lamivudine tab 600-300 mg
(Epzicom)......................................................................... 6
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................ 7
abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 6
ABANEU-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg................................................................. 150
ABILIFY -aripiprazole tab 2 mg......................................... 83
ABILIFY -aripiprazole tab 5 mg......................................... 83
ABILIFY -aripiprazole tab 10 mg....................................... 83
ABILIFY -aripiprazole tab 15 mg....................................... 83
ABILIFY -aripiprazole tab 20 mg....................................... 83
ABILIFY -aripiprazole tab 30 mg....................................... 83
ABSORICA -isotretinoin cap 10 mg................................ 170
ABSORICA -isotretinoin cap 20 mg................................ 170
ABSORICA -isotretinoin cap 25 mg................................ 170
ABSORICA -isotretinoin cap 30 mg................................ 170
ABSORICA -isotretinoin cap 35 mg................................ 170
ABSORICA -isotretinoin cap 40 mg................................ 170
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................... 96
ABSTRAL -fentanyl citrate sl tab 200 mcg (base
equiv)............................................................................... 96
ABSTRAL -fentanyl citrate sl tab 300 mcg (base
equiv)............................................................................... 97
ABSTRAL -fentanyl citrate sl tab 400 mcg (base
equiv)............................................................................... 97
ABSTRAL -fentanyl citrate sl tab 600 mcg (base
equiv)............................................................................... 97
ABSTRAL -fentanyl citrate sl tab 800 mcg (base
equiv)............................................................................... 97
acamprosate calcium tab delayed release 333 mg...... 91
acarbose tab 25 mg (Precose)....................................... 30
acarbose tab 50 mg (Precose)....................................... 30
acarbose tab 100 mg (Precose)..................................... 30
acebutolol hcl cap 200 mg (Sectral).............................. 43
acebutolol hcl cap 400 mg (Sectral).............................. 43
ACERFLEX -nutritional supplement powder................... 132
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix)................................................ 97
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg.................................................................96
acetaminophen w/ codeine soln 120-12 mg/5ml.......... 97
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 97
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3).................................................................... 97
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4).................................................................... 97
acetazolamide cap sr 12hr 500 mg (Diamox)............... 55
acetazolamide tab 125 mg.............................................. 55
acetazolamide tab 250 mg.............................................. 55
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln...........................................167
acetic acid otic soln 2%................................................ 166
acetylcysteine cap 600 mg........................................... 131
acetylcysteine inhal soln 10%........................................ 62
acetylcysteine inhal soln 20%........................................ 62
ACIPHEX -rabeprazole sodium ec tab 20 mg.................. 69
acitretin cap 10 mg (Soriatane).................................... 170
acitretin cap 17.5 mg (Soriatane)................................. 170
acitretin cap 25 mg (Soriatane).................................... 170
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml................................................... 105
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)....................................................... 17
ACTIVE FE -fe carbonyl-fa-b complex-a-c-d-e-min tab
75-1.25 mg.................................................................... 150
ACTIVE INJECTION KIT KL-3 -triamcinolone inj 40 mg/ml
& lidocaine 1% & ammonia inh kit................................. 23
ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg.................................................................................. 120
ACTONEL -risedronate sodium tab 5 mg......................... 39
ACTONEL -risedronate sodium tab 30 mg....................... 39
ACTONEL -risedronate sodium tab 35 mg....................... 39
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg........................................................ 30
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg........................................................ 30
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
0.02%.............................................................................167
ACUICYN DAILY EYELID & EY -eyelid cleansers liquid.............................................................................. 170
ACUVAIL -ketorolac tromethamine ophth soln
0.45%.............................................................................162
acyclovir cap 200 mg (Zovirax)........................................ 7
acyclovir oint 5% (Zovirax)........................................... 170
acyclovir susp 200 mg/5ml (Zovirax).............................. 7
acyclovir tab 400 mg (Zovirax)........................................ 7
acyclovir tab 800 mg (Zovirax)........................................ 7
ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 16
adapalene cream 0.1% (Differin).................................. 170
adapalene gel 0.1% (Differin)....................................... 170
adapalene gel 0.3% (Differin)....................................... 170
ADASUVE -loxapine aerosol powder breath activated 10
mg.................................................................................... 83
ADCIRCA -tadalafil tab 20 mg (pah)................................. 59
ADD-INS COMPLETE -amino acids pack...................... 131
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2016
adefovir dipivoxil tab 10 mg (Hepsera)........................... 7
ADEMPAS -riociguat tab 0.5 mg....................................... 59
ADEMPAS -riociguat tab 1 mg.......................................... 59
ADEMPAS -riociguat tab 1.5 mg....................................... 59
ADEMPAS -riociguat tab 2 mg.......................................... 59
ADEMPAS -riociguat tab 2.5 mg....................................... 59
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 56
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 56
ADRENALIN -epinephrine hcl nasal soln 0.1%................ 61
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................ 64
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
250-50 mcg/dose............................................................ 64
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
500-50 mcg/dose............................................................ 64
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 64
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21
mcg/act............................................................................ 64
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21
mcg/act............................................................................ 64
ADVANCED AM/PM -multiple vitamins w/ calcium therapy
pack............................................................................... 120
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit................................................................................. 156
ADVATE -antihemophilic factor rahf-pfm for inj 500
unit................................................................................. 156
ADVATE -antihemophilic factor rahf-pfm for inj 1000
unit................................................................................. 156
ADVATE -antihemophilic factor rahf-pfm for inj 1500
unit................................................................................. 156
ADVATE -antihemophilic factor rahf-pfm for inj 2000
unit................................................................................. 156
ADVATE -antihemophilic factor rahf-pfm for inj 3000
unit................................................................................. 156
ADVATE -antihemophilic factor rahf-pfm for inj 4000
unit................................................................................. 156
ADVERA -nutritional supplement liquid...........................132
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 250 unit.................................................................... 156
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 500 unit.................................................................... 156
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 750 unit.................................................................... 156
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 1000 unit.................................................................. 156
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 1500 unit.................................................................. 156
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 2000 unit.................................................................. 156
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act...... 64
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 17
AFINITOR DISPERZ -everolimus tab for oral susp 3
mg.................................................................................... 17
AFINITOR DISPERZ -everolimus tab for oral susp 5
mg.................................................................................... 18
AFINITOR -everolimus tab 2.5 mg.................................... 17
AFINITOR -everolimus tab 5 mg....................................... 17
AFINITOR -everolimus tab 7.5 mg.................................... 17
AFINITOR -everolimus tab 10 mg..................................... 17
AFLURIA 2012-2013 -influenza virus vaccine split im
susp................................................................................. 13
AFLURIA 2014-2015 -influenza virus vaccine split im
susp................................................................................. 13
AFLURIA 2015-2016 -influenza virus vaccine split im
susp................................................................................. 13
AFLURIA 2016-2017 -influenza virus vaccine split im
susp................................................................................. 13
AFLURIA PF 2012-2013 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 13
AFLURIA PF 2014-2015 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 13
AFLURIA PF 2015-2016 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 13
AFLURIA PF 2016-2017 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 13
AFLURIA QUADRIVALENT 2016 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
AFREZZA -insulin regular (human) inhalation powder 4
unit/cartridge.................................................................... 36
AFREZZA -insulin regular (human) inhal powd 4 (30) & 8
(60) unit/cart.................................................................... 36
AFREZZA -insulin regular (human) inhal powd 4 (60) & 8
(30) unit/cart.................................................................... 36
AFREZZA -insulin regular (human) inhal powd 4 (90) & 8
(90) unit/cart.................................................................... 36
AFREZZA -insulin regular (human) inh powd 4 & 8 & 12
unit/cart (60).................................................................... 36
AFREZZA -insulin regular (human) inh powd 8 (60) & 12
(30) unit/cart.................................................................... 36
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 156
AKTEN -lidocaine hcl ophth gel 3.5%............................. 162
AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 71
ALA-QUIN -clioquinol-hc cream 3-0.5%..........................170
ALBENZA -albendazole tab 200 mg................................. 12
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 64
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 64
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 64
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
188
2016
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 64
albuterol sulfate syrup 2 mg/5ml................................... 64
albuterol sulfate tab 2 mg...............................................64
albuterol sulfate tab 4 mg...............................................64
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 64
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 64
alclometasone dipropionate cream 0.05%
(Aclovate)..................................................................... 170
alclometasone dipropionate oint 0.05%......................170
ALCORTIN A -iodoquinol-hydrocortisone-aloe
polysaccharide gel 1-2-1%........................................... 170
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 55
ALECENSA -alectinib hcl cap 150 mg (base
equivalent)....................................................................... 18
ALENDRONATE SODIUM -alendronate sodium oral soln
70 mg/75ml..................................................................... 39
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 39
alendronate sodium tab 5 mg........................................ 39
alendronate sodium tab 10 mg...................................... 39
alendronate sodium tab 35 mg...................................... 39
alendronate sodium tab 70 mg (Fosamax)................... 39
ALEVICYN ANTIPRURITIC SG -dermatological products
misc - liquid................................................................... 170
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 77
ALINIA -nitazoxanide for susp 100 mg/5ml.......................12
ALINIA -nitazoxanide tab 500 mg..................................... 12
ALITRAQ -nutritional supplement pack........................... 132
ALKERAN -melphalan tab 2 mg....................................... 18
allopurinol tab 100 mg (Zyloprim)............................... 109
allopurinol tab 300 mg (Zyloprim)............................... 109
ALLZITAL -butalbital-acetaminophen tab 25-325 mg....... 96
almotriptan malate tab 6.25 mg (Axert).......................108
almotriptan malate tab 12.5 mg (Axert).......................108
ALOCRIL -nedocromil sodium ophth soln 2%................ 162
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-500 mg............................................................. 30
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-1000 mg........................................................... 30
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-15 mg...................................................................... 31
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-30 mg...................................................................... 31
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-45 mg...................................................................... 31
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-15 mg......................................................................... 31
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-30 mg......................................................................... 31
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-45 mg......................................................................... 31
ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 30
ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 30
ALOGLIPTIN -alogliptin benzoate tab 25 mg (base
equiv)............................................................................... 30
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%...............................................................................162
ALOQUIN -iodoquinol-aloe polysaccharides gel
1.25-1%......................................................................... 170
ALORA -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 25
ALORA -estradiol td patch twice weekly 0.05 mg/24hr..... 25
ALORA -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 25
ALORA -estradiol td patch twice weekly 0.1 mg/24hr....... 25
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 72
alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 73
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 162
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit......................................... 157
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 500 unit......................................... 157
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1000 unit....................................... 157
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1500 unit....................................... 157
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 2000 unit....................................... 157
ALPHANINE SD -coagulation factor ix for inj 500
unit................................................................................. 157
ALPHANINE SD -coagulation factor ix for inj 1000
unit................................................................................. 157
ALPHANINE SD -coagulation factor ix for inj 1500
unit................................................................................. 157
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/
ml..................................................................................... 77
alprazolam orally disintegrating tab 0.5 mg................. 77
alprazolam orally disintegrating tab 1 mg.................... 78
alprazolam orally disintegrating tab 2 mg.................... 78
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 77
alprazolam tab 0.25 mg (Xanax).................................... 78
alprazolam tab 0.5 mg (Xanax)...................................... 78
alprazolam tab 1 mg (Xanax)..........................................78
alprazolam tab 2 mg (Xanax)..........................................78
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 78
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 78
alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 78
alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 78
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
189
2016
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
250 unit......................................................................... 157
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
500 unit......................................................................... 157
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
1000 unit....................................................................... 157
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
2000 unit....................................................................... 157
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
3000 unit....................................................................... 157
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
4000 unit....................................................................... 157
ALREX -loteprednol etabonate ophth susp 0.2%........... 162
ALTABAX -retapamulin oint 1%.......................................170
ALTOPREV -lovastatin tab sr 24hr 20 mg........................ 56
ALTOPREV -lovastatin tab sr 24hr 40 mg........................ 56
ALTOPREV -lovastatin tab sr 24hr 60 mg........................ 56
ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 64
ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 64
amantadine hcl cap 100 mg......................................... 115
amantadine hcl syrup 50 mg/5ml................................ 115
amantadine hcl tab 100 mg.......................................... 115
AMCINONIDE -amcinonide cream 0.1%........................ 170
AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 156
AMICAR -aminocaproic acid tab 500 mg........................ 156
AMICAR -aminocaproic acid tab 1000 mg...................... 156
amiloride & hydrochlorothiazide tab 5-50 mg.............. 55
amiloride hcl tab 5 mg.................................................... 55
amino acids cap............................................................. 131
amino acids tab.............................................................. 131
amiodarone hcl tab 100 mg............................................ 47
amiodarone hcl tab 400 mg............................................ 47
amiodarone hcl tab 200 mg (Cordarone)...................... 47
AMITIZA -lubiprostone cap 8 mcg.................................... 73
AMITIZA -lubiprostone cap 24 mcg.................................. 73
amitriptyline hcl tab 10 mg............................................. 78
amitriptyline hcl tab 25 mg............................................. 78
amitriptyline hcl tab 50 mg............................................. 78
amitriptyline hcl tab 75 mg............................................. 78
amitriptyline hcl tab 100 mg........................................... 78
amitriptyline hcl tab 150 mg........................................... 78
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)................................................................... 59
amlodipine besylate-atorvastatin calcium tab 2.5-20
mg (Caduet)................................................................... 59
amlodipine besylate-atorvastatin calcium tab 2.5-40
mg (Caduet)................................................................... 59
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).......................................................................... 59
amlodipine besylate-atorvastatin calcium tab 5-20 mg
(Caduet).......................................................................... 59
amlodipine besylate-atorvastatin calcium tab 5-40 mg
(Caduet).......................................................................... 59
amlodipine besylate-atorvastatin calcium tab 5-80 mg
(Caduet).......................................................................... 59
amlodipine besylate-atorvastatin calcium tab 10-10
mg (Caduet)................................................................... 60
amlodipine besylate-atorvastatin calcium tab 10-20
mg (Caduet)................................................................... 60
amlodipine besylate-atorvastatin calcium tab 10-40
mg (Caduet)................................................................... 60
amlodipine besylate-atorvastatin calcium tab 10-80
mg (Caduet)................................................................... 60
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................ 48
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................ 48
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel)............................................................................ 48
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel)............................................................................ 48
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................ 48
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel)............................................................................ 48
amlodipine besylate-olmesartan medoxomil tab 5-20
mg (Azor)....................................................................... 48
amlodipine besylate-olmesartan medoxomil tab 5-40
mg (Azor)....................................................................... 48
amlodipine besylate-olmesartan medoxomil tab 10-20
mg (Azor)....................................................................... 48
amlodipine besylate-olmesartan medoxomil tab 10-40
mg (Azor)....................................................................... 48
amlodipine besylate tab 2.5 mg (Norvasc)................... 45
amlodipine besylate tab 5 mg (Norvasc)...................... 45
amlodipine besylate tab 10 mg (Norvasc).................... 45
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 48
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)......................................................................... 48
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 48
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)......................................................................... 48
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................ 48
amlodipine-valsartan-hydrochlorothiazide tab
5-160-25 mg (Exforge hct)........................................... 48
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)...................................... 48
amlodipine-valsartan-hydrochlorothiazide tab
10-160-25 mg (Exforge hct)......................................... 48
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
190
2016
amlodipine-valsartan-hydrochlorothiazide tab
10-320-25 mg (Exforge hct)......................................... 48
AMOXAPINE -amoxapine tab 25 mg................................ 79
AMOXAPINE -amoxapine tab 50 mg................................ 79
AMOXAPINE -amoxapine tab 100 mg.............................. 79
AMOXAPINE -amoxapine tab 150 mg.............................. 79
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 200-28.5 mg.................................. 1
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 400-57 mg..................................... 1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)........................................................ 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................ 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac).............................................................. 69
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml..................1
amoxicillin (trihydrate) for susp 200 mg/5ml..................1
amoxicillin (trihydrate) for susp 250 mg/5ml..................1
amoxicillin (trihydrate) for susp 400 mg/5ml..................1
amoxicillin (trihydrate) tab 500 mg.................................. 1
amoxicillin (trihydrate) tab 875 mg.................................. 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)................................................................... 88
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 88
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)................................................................... 88
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)................................................................... 88
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)................................................................... 88
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)................................................................... 88
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................ 89
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 89
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 89
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 89
amphetamine-dextroamphetamine tab 15 mg
(Adderall)........................................................................ 89
amphetamine-dextroamphetamine tab 20 mg
(Adderall)........................................................................ 89
amphetamine-dextroamphetamine tab 30 mg
(Adderall)........................................................................ 89
AMPICILLIN -ampicillin for susp 125 mg/5ml..................... 1
AMPICILLIN -ampicillin for susp 250 mg/5ml..................... 1
ampicillin cap 250 mg....................................................... 1
ampicillin cap 500 mg....................................................... 1
AMPYRA -dalfampridine tab sr 12hr 10 mg...................... 91
AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg............. 118
AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg............. 118
ANADROL-50 -oxymetholone tab 50 mg.......................... 25
anagrelide hcl cap 1 mg............................................... 157
anagrelide hcl cap 0.5 mg (Agrylin)............................ 157
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%..........................................................169
ANASEPT -sodium hypochlorite liquid 0.057%.............. 182
anastrozole tab 1 mg (Arimidex)................................... 18
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 25
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)....... 25
ANDROGEL -testosterone td gel 50 mg/5gm (1%).......... 25
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 25
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 25
ANDROXY -fluoxymesterone tab 10 mg........................... 25
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 25
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 25
ANIMI-3/VITAMIN D -folic acid-b6-b12-d-omega 3phytosterols cap 1 mg.................................................. 150
ANIMI-3 -folic acid-b6-b12-d-omega 3-phytosterols cap 1
mg.................................................................................. 150
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh.............................................................. 64
ANTARA -fenofibrate micronized cap 30 mg.................... 56
ANTARA -fenofibrate micronized cap 90 mg.................... 56
ANZEMET -dolasetron mesylate tab 50 mg..................... 71
ANZEMET -dolasetron mesylate tab 100 mg................... 71
APEXICON E -diflorasone diacetate emollient base
cream 0.05%................................................................. 170
APIDRA -insulin glulisine inj 100 unit/ml........................... 35
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml.......................................................................35
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
191
2016
APLENZIN -bupropion hbr tab sr 24hr 174 mg.................79
APLENZIN -bupropion hbr tab sr 24hr 348 mg.................79
APLENZIN -bupropion hbr tab sr 24hr 522 mg.................79
APOKYN -apomorphine hcl soln cartridge 30
mg/3ml........................................................................... 115
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)...................................................................... 162
aprepitant capsule 80 mg (Emend)............................... 71
aprepitant capsule therapy pack 80 & 125 mg
(Emend).......................................................................... 71
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 73
APTIOM -eslicarbazepine acetate tab 200 mg............... 109
APTIOM -eslicarbazepine acetate tab 400 mg............... 109
APTIOM -eslicarbazepine acetate tab 600 mg............... 109
APTIOM -eslicarbazepine acetate tab 800 mg............... 109
APTIVUS -tipranavir cap 250 mg........................................ 7
APTIVUS -tipranavir oral soln 100 mg/ml........................... 7
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25
mcg/ml........................................................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40
mcg/ml........................................................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60
mcg/ml........................................................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100
mcg/ml........................................................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200
mcg/ml........................................................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 300
mcg/ml........................................................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml..................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 25 mcg/0.42ml................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 40 mcg/0.4ml..................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 60 mcg/0.3ml..................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 100 mcg/0.5ml................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 150 mcg/0.3ml................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 200 mcg/0.4ml................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 300 mcg/0.6ml................................... 150
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 500 mcg/ml........................................ 150
ARCALYST -rilonacept for inj 220 mg.............................105
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................64
ARGIMENT -amino acids pack....................................... 131
ARGIMENT AT -amino acids pack.................................. 131
ARGINAID EXTRA -nutritional supplement liquid........... 132
ARGINAID -nutritional supplement pack......................... 132
aripiprazole orally disintegrating tab 10 mg.................83
aripiprazole orally disintegrating tab 15 mg.................83
aripiprazole oral solution 1 mg/ml................................. 83
aripiprazole tab 2 mg (Abilify)........................................ 83
aripiprazole tab 5 mg (Abilify)........................................ 83
aripiprazole tab 10 mg (Abilify)...................................... 83
aripiprazole tab 15 mg (Abilify)...................................... 83
aripiprazole tab 20 mg (Abilify)...................................... 83
aripiprazole tab 30 mg (Abilify)...................................... 83
armodafinil tab 50 mg (Nuvigil)......................................89
armodafinil tab 150 mg (Nuvigil)................................... 89
armodafinil tab 200 mg (Nuvigil)................................... 89
armodafinil tab 250 mg (Nuvigil)................................... 89
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 37
ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 37
ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 37
ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 37
ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 37
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 73
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 64
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 110 mcg/inh (breath activated).................... 65
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 65
ASMANEX TWISTHALER 60 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 65
A-SOY -nutritional supplement liquid.............................. 132
ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 97
aspirin chew tab 81 mg...................................................96
aspirin-dipyridamole cap sr 12hr 25-200 mg
(Aggrenox)................................................................... 157
ASPIRIN LOW DOSE -aspirin tab 81 mg......................... 96
aspirin tab delayed release 81 mg.................................96
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 184
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 184
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 184
ASTERO -lidocaine hcl gel 4%....................................... 170
ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg......................................................................... 120
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 39
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 48
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 48
atenolol tab 25 mg (Tenormin)....................................... 43
atenolol tab 50 mg (Tenormin)....................................... 43
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
192
2016
atenolol tab 100 mg (Tenormin)..................................... 43
ATGAM -lymphocyte immune globulin anti-thymocyte g inj
50 mg/ml(eq)................................................................. 184
ATOPICLAIR -dermatological products misc - cream..... 170
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 57
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor)........................................................................... 57
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor)........................................................................... 57
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor)........................................................................... 57
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)...................................................................... 12
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)...................................................................... 12
atovaquone susp 750 mg/5ml (Mepron)....................... 12
ATRAPRO CP -wound dressings - kit............................. 170
ATRAPRO DERMAL SPRAY -wound cleansers liquid.............................................................................. 170
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................7
ATROPINE SULFATE -atropine sulfate ophth oint
1%.................................................................................. 162
ATROPINE SULFATE -atropine sulfate ophth soln
1%.................................................................................. 162
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act.......................................................................65
AUBAGIO -teriflunomide tab 7 mg.................................... 91
AUBAGIO -teriflunomide tab 14 mg.................................. 91
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................. 1
AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)....... 73
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 31
AVANDIA -rosiglitazone maleate tab 4 mg (base
equiv)............................................................................... 31
AVAR -sulfacetamide sodium w/ sulfur cleansing pad
9.5-5%........................................................................... 170
AVC -sulfanilamide vaginal cream 15%............................ 76
AVENOVA/NEUTROX -eyelid cleansers - liquid............. 170
AVENOVA -eyelid cleansers - liquid................................170
AVODART -dutasteride cap 0.5 mg.................................. 77
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)....................................................... 91
AVONEX -interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml........................................................................ 91
AVONEX PEN -interferon beta-1a im auto-injector kit 30
mcg/0.5ml........................................................................ 91
AXERT -almotriptan malate tab 6.25 mg........................ 108
AXERT -almotriptan malate tab 12.5 mg........................ 108
AXIRON -testosterone td soln 30 mg/act.......................... 25
AZASAN -azathioprine tab 75 mg................................... 184
AZASAN -azathioprine tab 100 mg................................. 184
AZASITE -azithromycin ophth soln 1%........................... 162
azathioprine tab 50 mg (Imuran).................................. 184
azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 61
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro).........................................................................61
azelastine hcl ophth soln 0.05%.................................. 162
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................. 115
AZILECT -rasagiline mesylate tab 1 mg (base
equiv)............................................................................. 115
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 3
azithromycin for susp 100 mg/5ml (Zithromax)............. 3
azithromycin for susp 200 mg/5ml (Zithromax)............. 3
azithromycin tab 250 mg (Zithromax)............................. 3
azithromycin tab 500 mg (Zithromax)............................. 3
azithromycin tab 600 mg (Zithromax)............................. 3
AZOPT -brinzolamide ophth susp 1%............................. 162
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-20 mg........................................................................... 48
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-40 mg........................................................................... 48
AZOR -amlodipine besylate-olmesartan medoxomil tab
10-20 mg......................................................................... 49
AZOR -amlodipine besylate-olmesartan medoxomil tab
10-40 mg......................................................................... 49
B
BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(per drop)...................................................................... 119
BACITRACIN -bacitracin ophth oint 500 unit/gm............ 163
bacitracin-polymyxin b ophth oint.............................. 163
bacitracin-polymyxin-neomycin-hc ophth oint
1%.................................................................................. 163
baclofen tab 10 mg........................................................ 118
baclofen tab 20 mg........................................................ 118
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 61
BALANCED NUTRITIONAL DRIN -nutritional supplement
liquid.............................................................................. 132
BALANCED NUTRITIONAL SHAK -nutritional
supplement liquid.......................................................... 132
BALANCE TOTAL NUTRITIONAL -nutritional supplement
liquid.............................................................................. 132
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg................................................... 120
balsalazide disodium cap 750 mg (Colazal)................. 73
BANZEL -rufinamide susp 40 mg/ml............................... 109
BANZEL -rufinamide tab 200 mg.................................... 109
BANZEL -rufinamide tab 400 mg.................................... 110
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................ 183
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip................................................................................ 183
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip................................................................................ 183
BCAD 1 -nutritional supplement powder......................... 132
BCAD 2 -nutritional supplement powder......................... 132
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)............................................................... 120
b-complex w/ c & folic acid tab 5 mg.......................... 120
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx).................................................................................. 120
BD GLUCOSE -glucose chew tab 5 gm........................... 31
BEAU RX -scar treatment products - gel........................ 170
BEBULIN -factor ix complex for inj 200-1200 unit.......... 157
BEEF/POTATOES/PEAS -nutritional supplement
liquid.............................................................................. 132
BELBUCA -buprenorphine hcl buccal film 75 mcg (base
equivalent)....................................................................... 97
BELBUCA -buprenorphine hcl buccal film 150 mcg (base
equivalent)....................................................................... 97
BELBUCA -buprenorphine hcl buccal film 300 mcg (base
equivalent)....................................................................... 97
BELBUCA -buprenorphine hcl buccal film 450 mcg (base
equivalent)....................................................................... 97
BELBUCA -buprenorphine hcl buccal film 600 mcg (base
equivalent)....................................................................... 97
BELBUCA -buprenorphine hcl buccal film 750 mcg (base
equivalent)....................................................................... 97
BELBUCA -buprenorphine hcl buccal film 900 mcg (base
equivalent)....................................................................... 97
BELLADONNA & OPIUM -belladonna alkaloids & opium
suppos 16.2-30 mg......................................................... 69
BELLADONNA ALKALOIDS & OP -belladonna alkaloids
& opium suppos 16.2-60 mg.......................................... 69
benazepril & hydrochlorothiazide tab 5-6.25 mg......... 49
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................ 49
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................ 49
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................ 49
benazepril hcl tab 5 mg.................................................. 49
benazepril hcl tab 10 mg (Lotensin).............................. 49
benazepril hcl tab 20 mg (Lotensin).............................. 49
benazepril hcl tab 40 mg (Lotensin).............................. 49
BENECALORIE -nutritional supplement liquid................ 132
BENEFIX -coagulation factor ix (recombinant) for inj kit
250 unit......................................................................... 157
BENEFIX -coagulation factor ix (recombinant) for inj kit
500 unit......................................................................... 157
BENEFIX -coagulation factor ix (recombinant) for inj kit
1000 unit....................................................................... 157
BENEFIX -coagulation factor ix (recombinant) for inj kit
2000 unit....................................................................... 157
BENEFIX -coagulation factor ix (recombinant) for inj kit
3000 unit....................................................................... 157
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg...............................49
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg...............................49
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................. 49
BENICAR -olmesartan medoxomil tab 5 mg.....................49
BENICAR -olmesartan medoxomil tab 20 mg...................49
BENICAR -olmesartan medoxomil tab 40 mg...................49
BENSAL HP -salicylic acid & benzoic acid oint 3-6%..... 171
BENZIQ -benzoyl peroxide gel 5.25 %........................... 171
BENZIQ LS -benzoyl peroxide gel 2.75%....................... 171
BENZIQ WASH -benzoyl peroxide liq 5.25%.................. 171
benzocaine mouth/throat aerosol 20%....................... 167
BENZONATATE -benzonatate cap 150 mg...................... 62
benzonatate cap 200 mg................................................. 62
benzonatate cap 100 mg (Tessalon perles).................. 62
benzoyl peroxide cloth 6%........................................... 171
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)............................................................... 171
benzoyl peroxide foam 5.3% (Benzefoam)................. 171
benzoyl peroxide foam 9.8% (Benzefoamultra)......... 171
benzoyl peroxide liq 2.5%.............................................171
benzoyl peroxide liq 7%................................................171
benzoyl peroxide lotion 6%.......................................... 171
benztropine mesylate tab 0.5 mg................................ 115
benztropine mesylate tab 1 mg................................... 115
benztropine mesylate tab 2 mg................................... 115
BEPREVE -bepotastine besilate ophth soln 1.5%.......... 163
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit................................................................................. 157
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 163
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%......................................................................... 163
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 171
betamethasone dipropionate augmented gel
0.05%.............................................................................171
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)................................................................... 171
betamethasone dipropionate augmented oint 0.05%
(Diprolene)................................................................... 171
betamethasone dipropionate cream 0.05%................ 171
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
betamethasone dipropionate lotion 0.05%................. 171
betamethasone dipropionate oint 0.05%.................... 171
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 171
betamethasone valerate cream 0.1%.......................... 171
betamethasone valerate lotion 0.1%........................... 171
betamethasone valerate oint 0.1%.............................. 171
BETASERON -interferon beta-1b for inj kit 0.3 mg........... 91
betaxolol hcl ophth soln 0.5%......................................163
betaxolol hcl tab 10 mg (Kerlone)................................. 43
betaxolol hcl tab 20 mg (Kerlone)................................. 43
bethanechol chloride tab 5 mg (Urecholine)................ 75
bethanechol chloride tab 10 mg (Urecholine).............. 75
bethanechol chloride tab 25 mg (Urecholine).............. 75
bethanechol chloride tab 50 mg (Urecholine).............. 75
BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 5
BETIMOL -timolol ophth soln 0.25%............................... 163
BETIMOL -timolol ophth soln 0.5%................................. 163
BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 163
BEVESPI AEROSPHERE -glycopyrrolate-formoterol
fumarate aerosol 9-4.8 mcg/act..................................... 65
bexarotene cap 75 mg (Targretin)..................................18
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg..............................................................27
B-6 FOLIC ACID -cobalamine combination cap............. 150
bicalutamide tab 50 mg (Casodex)................................ 18
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 60
BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg........................................................... 150
BILTRICIDE -praziquantel tab 600 mg.............................. 12
BIMATOPROST -bimatoprost ophth soln 0.03%............ 163
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 39
BIO-STATIN -nystatin cap 500000 unit............................... 6
BIO-STATIN -nystatin cap 1000000 unit............................. 6
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit..................................................................................... 68
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 49
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 49
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 49
bisoprolol fumarate tab 5 mg (Zebeta)..........................43
bisoprolol fumarate tab 10 mg (Zebeta)........................43
BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 163
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................ 163
BLOOD GLUCOSE CALIBRATION LIQUIDVARIOUS....................................................................... 183
BOOST/BENEFIBER -nutritional supplement liquid....... 133
BOOST BREEZE -nutritional supplement liquid............. 132
BOOST CALORIE SMART -nutritional supplement
liquid.............................................................................. 132
BOOST 100 CALORIE SMART -nutritional supplement
liquid.............................................................................. 133
BOOST COMPACT -nutritional supplement liquid.......... 132
BOOST GLUCOSE CONTROL -nutritional supplement
liquid.............................................................................. 132
BOOST HIGH PROTEIN -nutritional supplement
liquid.............................................................................. 132
BOOST HIGH PROTEIN -nutritional supplement
powder........................................................................... 132
BOOST KID ESSENTIALS 1.0 -nutritional supplement
liquid.............................................................................. 132
BOOST KID ESSENTIALS 1.5 -nutritional supplement
liquid.............................................................................. 132
BOOST KIDS ESSENTIALS -nutritional supplement
liquid.............................................................................. 132
BOOST -nutritional supplement liquid............................. 132
BOOST PLUS -nutritional supplement liquid.................. 133
BOOST PUDDING -nutritional supplement pudding.......133
BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 16
BOOST SMOOTHIE -nutritional supplement liquid........ 133
BOOST VHC -nutritional supplement liquid.................... 133
BOSULIF -bosutinib tab 100 mg....................................... 18
BOSULIF -bosutinib tab 500 mg....................................... 18
BP CLEANSING WASH -sulfacetamide sodium-sulfur in
urea emulsion 10-4%................................................... 171
BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg....................................................... 120
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg.............................................................. 120
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg......................................................... 120
BP VIT 3 -folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg....................................................................... 150
BREATHERITE COLLAPSIBLE -spacer/aerosol-holding
chambers - device........................................................ 183
BREATHERITE RIGID SPACER -spacer/aerosol-holding
chambers - device........................................................ 183
BREATHERITE -spacer/aerosol-holding chambers device............................................................................ 183
BREATHERITE VALVED MDI CH -respiratory therapy
supplies - devices......................................................... 183
BREATHERITE W/LARGE MASK -spacer/aerosol-holding
chambers - device........................................................ 183
BREATHERITE W/MEDIUM MASK -spacer/aerosolholding chambers - device........................................... 183
BREATHERITE W/SMALL MASK -spacer/aerosol-holding
chambers - device........................................................ 183
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh.......................................................... 65
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh.......................................................... 65
BRILINTA -ticagrelor tab 60 mg...................................... 157
BRILINTA -ticagrelor tab 90 mg...................................... 157
brimonidine tartrate ophth soln 0.2%......................... 163
brimonidine tartrate ophth soln 0.15% (Alphagan
p)................................................................................... 163
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)............................................................................... 92
BRIVIACT -brivaracetam oral soln 10 mg/ml.................. 110
BRIVIACT -brivaracetam tab 10 mg............................... 110
BRIVIACT -brivaracetam tab 25 mg............................... 110
BRIVIACT -brivaracetam tab 50 mg............................... 110
BRIVIACT -brivaracetam tab 75 mg............................... 110
BRIVIACT -brivaracetam tab 100 mg............................. 110
BROMFENAC -bromfenac sodium ophth soln 0.09%
(base equivalent).......................................................... 163
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily).................................................................. 163
bromocriptine mesylate cap 5 mg (base equivalent)
(Parlodel)...................................................................... 115
bromocriptine mesylate tab 2.5 mg (base equivalent)
(Parlodel)...................................................................... 115
brompheniramine & pseudoephedrine tab sr 12hr
6-45 mg........................................................................... 62
brompheniramine maleate tab sr 12hr 6 mg................ 61
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).................................................................... 65
budesonide delayed release particles cap 3 mg
(Entocort ec).................................................................. 23
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)......................................................................65
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)......................................................................65
budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 65
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 61
bumetanide tab 0.5 mg................................................... 55
bumetanide tab 1 mg...................................................... 55
bumetanide tab 2 mg...................................................... 55
BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv).............................................................. 97
BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv).............................................................. 97
BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv).................................................................... 97
BUPHENYL -sodium phenylbutyrate tab 500 mg............. 39
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 97
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 97
buprenorphine hcl sl tab 2 mg (base equiv)................ 97
buprenorphine hcl sl tab 8 mg (base equiv)................ 97
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 92
bupropion hcl tab 75 mg (Wellbutrin)........................... 79
bupropion hcl tab 100 mg (Wellbutrin)......................... 79
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 79
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 79
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 79
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 79
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 79
buspirone hcl tab 5 mg................................................... 78
buspirone hcl tab 7.5 mg................................................ 78
buspirone hcl tab 10 mg................................................. 78
buspirone hcl tab 15 mg................................................. 78
buspirone hcl tab 30 mg................................................. 78
butalbital-acetaminophen-caffeine cap 50-325-40
mg................................................................................... 96
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)......................................................................... 96
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 96
butalbital-acetaminophen-caff w/ cod cap
50-325-40-30 mg............................................................ 97
butalbital-acetaminophen-caff w/ cod cap
50-300-40-30 mg (Fioricet/codeine)............................ 97
butalbital-acetaminophen tab 50-300 mg......................96
butalbital-acetaminophen tab 50-325 mg......................96
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)......................................................................... 96
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)..................................................... 97
BUTISOL SODIUM -butabarbital sodium tab 30 mg.........87
butorphanol tartrate nasal soln 10 mg/ml.................... 98
BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......98
BUTRANS -buprenorphine td patch weekly 7.5 mcg/
hr...................................................................................... 98
BUTRANS -buprenorphine td patch weekly 10 mcg/
hr...................................................................................... 98
BUTRANS -buprenorphine td patch weekly 15 mcg/
hr...................................................................................... 98
BUTRANS -buprenorphine td patch weekly 20 mcg/
hr...................................................................................... 98
BYDUREON -exenatide for inj extended release susp 2
mg.................................................................................... 31
BYDUREON PEN -exenatide extended release for susp
pen-injector 2 mg............................................................ 31
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 31
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 31
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
BYSTOLIC -nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 43
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......43
BYSTOLIC -nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 43
BYSTOLIC -nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 43
BYVALSON -nebivolol-valsartan tab 5-80 mg.................. 49
C
cabergoline tab 0.5 mg................................................... 39
CABOMETYX -cabozantinib s-malate tab 20 mg (base
equivalent)....................................................................... 18
CABOMETYX -cabozantinib s-malate tab 40 mg (base
equivalent)....................................................................... 18
CABOMETYX -cabozantinib s-malate tab 60 mg (base
equivalent)....................................................................... 18
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv).............................................................................. 89
CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag
wafer 1342-1.6 mg........................................................129
CALCILO XD -infant foods powder................................. 133
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................ 171
calcipotriene cream 0.005% (Dovonex).......................171
calcipotriene oint 0.005%..............................................171
calcipotriene soln 0.005% (50 mcg/ml)....................... 171
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 39
CALCITRIOL -calcitriol oint 3 mcg/gm............................ 171
calcitriol cap 0.25 mcg (Rocaltrol)................................. 39
calcitriol cap 0.5 mcg (Rocaltrol)................................... 40
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................40
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 73
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)......................................................................... 73
CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg........................... 129
CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 120
CAMBIA -diclofenac potassium packet 50 mg................ 108
CAMINO PRO BETTERMILK/GLY -nutritional supplement
pack............................................................................... 133
CAMINO PRO COMPLETE/GLYTA -nutritional
supplement bar............................................................. 133
CAMINO PRO 15PE -nutritional supplement liquid........ 133
CAMINO PRO PKU -nutritional supplement liquid..........133
CAMINO PRO RESTORE/GLYTAC -nutritional
supplement liquid.......................................................... 133
CAMINO PRO SWIRL -nutritional supplement pack...... 133
CANASA -mesalamine suppos 1000 mg.......................... 73
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct).......................................................... 49
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct).......................................................... 49
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct).......................................................... 49
candesartan cilexetil tab 4 mg (Atacand)..................... 49
candesartan cilexetil tab 8 mg (Atacand)..................... 49
candesartan cilexetil tab 16 mg (Atacand)................... 49
candesartan cilexetil tab 32 mg (Atacand)................... 49
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml................................................................. 62
capecitabine tab 150 mg (Xeloda)................................. 18
capecitabine tab 500 mg (Xeloda)................................. 18
CAPEX -fluocinolone acetonide shampoo 0.01%........... 171
CAPHOSOL -artificial saliva - solution............................ 167
CAPRELSA -vandetanib tab 100 mg................................ 18
CAPRELSA -vandetanib tab 300 mg................................ 18
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg.................................. 50
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-25 mg.................................. 50
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 50-15 mg.................................. 50
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 50-25 mg.................................. 50
captopril tab 12.5 mg...................................................... 49
captopril tab 25 mg......................................................... 49
captopril tab 50 mg......................................................... 49
captopril tab 100 mg....................................................... 49
CARAC -fluorouracil cream 0.5%.................................... 171
CARAFATE -sucralfate susp 1 gm/10ml........................... 69
CARBAGLU -carglumic acid tab 200 mg.......................... 40
carbamazepine cap sr 12hr 100 mg (Carbatrol)......... 110
carbamazepine cap sr 12hr 200 mg (Carbatrol)......... 110
carbamazepine cap sr 12hr 300 mg (Carbatrol)......... 110
carbamazepine chew tab 100 mg................................ 110
carbamazepine susp 100 mg/5ml (Tegretol)............... 110
carbamazepine tab 200 mg (Tegretol)......................... 110
carbamazepine tab sr 12hr 100 mg (Tegretol-xr)....... 110
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)....... 110
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)....... 110
CARBATROL -carbamazepine cap sr 12hr 100 mg....... 110
CARBATROL -carbamazepine cap sr 12hr 200 mg....... 110
CARBATROL -carbamazepine cap sr 12hr 300 mg....... 110
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 116
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 116
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................. 116
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg............................ 116
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg.............................. 116
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................. 116
carbidopa & levodopa orally disintegrating tab 10-100
mg................................................................................. 115
carbidopa & levodopa orally disintegrating tab 25-100
mg................................................................................. 115
carbidopa & levodopa orally disintegrating tab 25-250
mg................................................................................. 115
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................. 115
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................. 115
carbidopa & levodopa tab 10-100 mg (Sinemet)........ 115
carbidopa & levodopa tab 25-100 mg (Sinemet)........ 115
carbidopa & levodopa tab 25-250 mg (Sinemet)........ 115
carbidopa tab 25 mg (Lodosyn)................................... 116
carbinoxamine maleate soln 4 mg/5ml......................... 61
carbinoxamine maleate tab 4 mg.................................. 61
carbonyl iron susp 15 mg/1.25ml (elemental
iron)............................................................................... 150
CARDIOTEK-RX -folic acid-b12-b6-arginine-black pepper
tab.................................................................................. 133
CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg................................................. 131
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................ 45
CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).................................................................... 77
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).................................................................... 77
carisoprodol tab 250 mg (Soma)................................. 118
carisoprodol tab 350 mg (Soma)................................. 118
carisoprodol w/ aspirin & codeine tab 200-325-16
mg................................................................................. 118
carisoprodol w/ aspirin tab 200-325 mg......................118
CARNATION BREAKFAST ESSEN -nutritional
supplement liquid.......................................................... 133
CARNATION BREAKFAST ESSEN -nutritional
supplement pack........................................................... 133
CARNATION INSTANT BREAKFA -nutritional supplement
liquid.............................................................................. 133
carteolol hcl ophth soln 1%......................................... 163
carvedilol tab 3.125 mg (Coreg)..................................... 43
carvedilol tab 6.25 mg (Coreg)....................................... 44
carvedilol tab 12.5 mg (Coreg)....................................... 44
carvedilol tab 25 mg (Coreg).......................................... 44
CAYA -diaphragm arc-spring........................................... 183
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 12
C-BUFF -multiple vitamins w/ minerals powder.............. 120
CEDAX -ceftibuten cap 400 mg.......................................... 2
CEDAX -ceftibuten for susp 180 mg/5ml............................ 2
cefaclor cap 250 mg.......................................................... 2
cefaclor cap 500 mg.......................................................... 2
CEFACLOR -cefaclor for susp 125 mg/5ml........................ 2
CEFACLOR -cefaclor for susp 250 mg/5ml........................ 2
CEFACLOR -cefaclor for susp 375 mg/5ml........................ 2
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg....................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm............................................................ 2
cefdinir cap 300 mg........................................................... 2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
(base equivalent).............................................................. 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
(base equivalent).............................................................. 2
cefixime for susp 100 mg/5ml (Suprax).......................... 2
cefixime for susp 200 mg/5ml (Suprax).......................... 2
cefpodoxime proxetil for susp 50 mg/5ml...................... 2
cefpodoxime proxetil for susp 100 mg/5ml.................... 2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml..........................................2
cefprozil for susp 250 mg/5ml..........................................2
cefprozil tab 250 mg.......................................................... 2
cefprozil tab 500 mg.......................................................... 2
CEFTIBUTEN -ceftibuten cap 400 mg................................ 2
CEFTIBUTEN -ceftibuten for susp 180 mg/5ml.................. 2
CEFTIN -cefuroxime axetil for susp 125 mg/5ml................ 2
CEFTIN -cefuroxime axetil for susp 250 mg/5ml................ 2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
celecoxib cap 50 mg (Celebrex).................................. 105
celecoxib cap 100 mg (Celebrex)................................ 105
celecoxib cap 200 mg (Celebrex)................................ 105
celecoxib cap 400 mg (Celebrex)................................ 105
CELONTIN -methsuximide cap 300 mg.......................... 110
CEM-UREA -urea soln 45%............................................ 171
CENTANY -mupirocin oint 2%.........................................171
CENTRATEX -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg.................................................... 151
cephalexin cap 250 mg (Keflex)....................................... 2
cephalexin cap 500 mg (Keflex)....................................... 2
cephalexin cap 750 mg (Keflex)....................................... 2
CEPHALEXIN -cephalexin tab 250 mg............................... 2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
CEPHALEXIN -cephalexin tab 500 mg............................... 2
cephalexin for susp 125 mg/5ml...................................... 2
cephalexin for susp 250 mg/5ml...................................... 3
CERACADE -dermatological products misc emulsion........................................................................ 171
CERDELGA -eliglustat tartrate cap 84 mg (base
equivalent)..................................................................... 151
CEREFOLIN -l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg.................................................................. 133
CERVIDIL -dinoprostone vaginal inserts 10 mg............... 39
CESAMET -nabilone cap 1 mg......................................... 71
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 167
CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 182
CETYLEV -acetylcysteine effervescent tab 500 mg....... 182
cevimeline hcl cap 30 mg (Evoxac)............................. 167
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv).......................................................... 92
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................92
CHANTIX -varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 92
CHANTIX -varenicline tartrate tab 1 mg (base equiv).......92
CHEMET -succimer cap 100 mg.................................... 182
CHENODAL -chenodiol tab 250 mg................................. 73
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................. 92
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg.............................................. 92
chlordiazepoxide hcl cap 5 mg...................................... 78
chlordiazepoxide hcl cap 10 mg.................................... 78
chlordiazepoxide hcl cap 25 mg.................................... 78
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)........................................................................... 69
chlorhexidine gluconate soln 0.12% (Peridex)...........167
CHLOROQUINE PHOSPHATE -chloroquine phosphate
tab 250 mg...................................................................... 12
chloroquine phosphate tab 500 mg (Aralen)................ 12
CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 55
chlorothiazide tab 500 mg.............................................. 55
chlorpromazine hcl tab 10 mg....................................... 83
chlorpromazine hcl tab 25 mg....................................... 83
chlorpromazine hcl tab 50 mg....................................... 83
chlorpromazine hcl tab 100 mg..................................... 83
chlorpromazine hcl tab 200 mg..................................... 83
CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 31
CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 31
CHLORTHALIDONE -chlorthalidone tab 100 mg............. 55
chlorthalidone tab 25 mg................................................ 55
chlorthalidone tab 50 mg................................................ 55
chlorzoxazone tab 500 mg (Parafon forte dsc).......... 118
CHOICE DM -nutritional supplement liquid.....................133
CHOICE DM TF -nutritional supplement liquid............... 133
CHOLBAM -cholic acid cap 50 mg................................... 73
CHOLBAM -cholic acid cap 250 mg................................. 73
cholecalciferol cap 400 unit......................................... 119
cholecalciferol cap 1000 unit....................................... 119
cholecalciferol cap 50000 unit..................................... 119
cholecalciferol chew tab 400 unit................................ 119
cholecalciferol chew tab 1000 unit.............................. 119
cholecalciferol drops 400 unit/0.03ml (per drop)....... 119
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml).....................................................................119
cholecalciferol oral liquid 400 unit/ml......................... 119
cholecalciferol tab 400 unit.......................................... 119
cholecalciferol tab 1000 unit........................................ 119
cholecalciferol tab 50000 unit...................................... 119
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 57
cholestyramine light powder packets 4 gm................. 57
cholestyramine powder 4 gm/dose (Questran)............ 57
cholestyramine powder packets 4 gm (Questran)....... 57
CHOLEXTRA -nutritional supplement powder................ 133
choline & magnesium salicylates liq 500 mg/5ml........ 96
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix).............................................................. 57
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix).............................................................. 57
CHOLINE MAGNESIUM TRISALI -choline & magnesium
salicylates tab 1000 mg..................................................96
CIALIS -tadalafil tab 2.5 mg......................................... 60,61
CIALIS -tadalafil tab 5 mg............................................ 60,61
ciclopirox gel 0.77%...................................................... 171
ciclopirox olamine cream 0.77% (base equiv)............171
ciclopirox olamine susp 0.77% (base equiv).............. 171
ciclopirox shampoo 1% (Loprox shampoo)............... 171
ciclopirox solution 8% (Penlac Nail Lacquer)............ 171
CIFEREX -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 151
cilostazol tab 50 mg (Pletal)......................................... 157
cilostazol tab 100 mg (Pletal)....................................... 157
CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 163
cimetidine hcl soln 300 mg/5ml..................................... 69
cimetidine tab 300 mg..................................................... 69
cimetidine tab 400 mg..................................................... 69
cimetidine tab 800 mg..................................................... 69
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 73
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 73
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%........................................................................ 167
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 167
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)................................................... 5
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)........................................................ 5
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)........................................................... 5
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)........................................................... 5
CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg
(base equiv)...................................................................... 5
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 163
ciprofloxacin hcl tab 750 mg (base equiv)..................... 5
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 5
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 5
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%........................................................................... 167
citalopram hydrobromide oral soln 10 mg/5ml............ 79
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 79
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)........................................................................... 79
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)........................................................................... 79
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack......................................... 120
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................. 120
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack............................................... 120
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak........................................ 120
CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................ 120
CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg.........................................................120
CITRUS BERGAMOT -citrus bergamot oral powder 250
mg/0.25 gm................................................................... 183
clarithromycin for susp 125 mg/5ml............................... 3
clarithromycin for susp 250 mg/5ml (Biaxin)................. 3
clarithromycin tab 250 mg (Biaxin)................................. 3
clarithromycin tab 500 mg (Biaxin)................................. 3
clarithromycin tab sr 24hr 500 mg.................................. 3
CLEMASTINE FUMARATE -clemastine fumarate tab 2.68
mg.................................................................................... 61
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 76
CLICK ESPRESSO PROTEIN DR -nutritional supplement
powder........................................................................... 133
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day........................................................ 25
clindamycin hcl cap 75 mg (Cleocin)............................ 12
clindamycin hcl cap 150 mg (Cleocin).......................... 12
clindamycin hcl cap 300 mg (Cleocin).......................... 12
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)........................................12
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)................................................................... 172
clindamycin phosphate foam 1% (Evoclin)................ 172
clindamycin phosphate gel 1% (Cleocin-t)................. 172
clindamycin phosphate lotion 1% (Cleocin-t)............ 172
clindamycin phosphate soln 1% (Cleocin-t)............... 172
clindamycin phosphate swab 1% (Cleocin-t)............. 172
clindamycin phosphate-tretinoin gel 1.2-0.025%
(Ziana)........................................................................... 172
clindamycin phosphate vaginal cream 2%
(Cleocin)......................................................................... 76
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)............................................................... 172
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 76
clobetasol propionate cream 0.05% (Temovate)........ 172
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 172
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 172
clobetasol propionate foam 0.05% (Olux).................. 172
clobetasol propionate gel 0.05% (Temovate)............. 172
clobetasol propionate lotion 0.05% (Clobex)............. 172
clobetasol propionate oint 0.05% (Temovate)............ 172
clobetasol propionate shampoo 0.05% (Clobex)....... 172
clobetasol propionate soln 0.05% (Temovate)........... 172
clobetasol propionate spray 0.05% (Clobex)............. 172
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%................................................................... 172
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%................................................................... 172
CLODERM -clocortolone pivalate cream 0.1%............... 172
CLODERM PUMP -clocortolone pivalate cream
0.1%...............................................................................172
clomipramine hcl cap 25 mg (Anafranil)....................... 79
clomipramine hcl cap 50 mg (Anafranil)....................... 79
clomipramine hcl cap 75 mg (Anafranil)....................... 79
clonazepam orally disintegrating tab 0.125 mg......... 110
clonazepam orally disintegrating tab 0.25 mg........... 110
clonazepam orally disintegrating tab 0.5 mg............. 110
clonazepam orally disintegrating tab 1 mg................ 110
clonazepam orally disintegrating tab 2 mg................ 110
clonazepam tab 0.5 mg (Klonopin).............................. 110
clonazepam tab 1 mg (Klonopin)................................. 110
clonazepam tab 2 mg (Klonopin)................................. 110
clonidine hcl tab 0.1 mg (Catapres).............................. 50
clonidine hcl tab 0.2 mg (Catapres).............................. 50
clonidine hcl tab 0.3 mg (Catapres).............................. 50
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 89
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 50
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 50
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 50
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 158
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 158
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 78
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 78
clorazepate dipotassium tab 15 mg (Tranxene t)......... 78
CLORPRES -clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 50
CLORPRES -clonidine & chlorthalidone tab 0.2-15
mg.................................................................................... 50
CLORPRES -clonidine & chlorthalidone tab 0.3-15
mg.................................................................................... 50
clotrimazole troche 10 mg............................................ 167
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 172
clotrimazole w/ betamethasone lotion 1-0.05%..........172
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 83
CLOZAPINE ODT -clozapine orally disintegrating tab 150
mg.................................................................................... 83
CLOZAPINE ODT -clozapine orally disintegrating tab 200
mg.................................................................................... 83
clozapine orally disintegrating tab 25 mg
(Fazaclo)......................................................................... 83
clozapine orally disintegrating tab 100 mg
(Fazaclo)......................................................................... 83
clozapine tab 50 mg........................................................ 83
clozapine tab 200 mg...................................................... 84
clozapine tab 25 mg (Clozaril)........................................83
clozapine tab 100 mg (Clozaril)..................................... 84
C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 120
COAGADEX -coagulation factor x (human) for inj 250
unit................................................................................. 158
COAGADEX -coagulation factor x (human) for inj 500
unit................................................................................. 158
COAL TAR -coal tar soln 20%........................................ 172
COARTEM -artemether-lumefantrine tab 20-120 mg....... 12
CO-BALAMIN -ubiquinol-vit b12-resveratrol-fa cap
200-5-400-0.8 mg......................................................... 183
CODAR AR -chlorpheniramine w/ codeine liquid 2-8
mg/5ml............................................................................. 62
CODEINE SULFATE -codeine sulfate tab 15 mg............. 98
CODEINE SULFATE -codeine sulfate tab 30 mg............. 98
CODEINE SULFATE -codeine sulfate tab 60 mg............. 98
codeine sulfate tab 15 mg (Codeine sulfate)................ 98
codeine sulfate tab 30 mg (Codeine sulfate)................ 98
codeine sulfate tab 60 mg (Codeine sulfate)................ 98
COLCHICINE -colchicine cap 0.6 mg............................. 109
COLCHICINE -colchicine tab 0.6 mg.............................. 109
colchicine w/ probenecid tab 0.5-500 mg................... 109
COLCRYS -colchicine tab 0.6 mg................................... 109
colestipol hcl granule packets 5 gm (Colestid
flavored)......................................................................... 57
colestipol hcl granules 5 gm (Colestid flavored)......... 57
colestipol hcl tab 1 gm (Colestid)..................................57
COLGATE DRY MOUTH RELIEF -sodium fluoride
mouthwash 2.1 mg/10ml.............................................. 167
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 167
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................ 163
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................ 26
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................ 26
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act.......................................... 65
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 18
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................18
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................18
COMMIT -nicotine polacrilex lozenge 2 mg...................... 92
COMMIT -nicotine polacrilex lozenge 4 mg...................... 92
COMPLEAT CLOSED SYSTEM -nutritional supplement
liquid.............................................................................. 133
COMPLEAT -nutritional supplement liquid...................... 133
COMPLEAT PEDIATRIC -nutritional supplement
liquid.............................................................................. 133
COMPLEAT PEDIATRIC REDUCE -nutritional
supplement liquid.......................................................... 133
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 7
COMPLETE AMINO ACID MIX -amino acids oral
powder........................................................................... 131
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk.......................................... 120
COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 120
COMPLETE NUTRITION -nutritional supplement
liquid.............................................................................. 133
COMPLETE NUTRITION PLUS -nutritional supplement
liquid.............................................................................. 133
COMPLETE PROTEIN & VITAMI -nutritional supplement
powder........................................................................... 133
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
COMPLEX ESSENTIAL MSD -amino acids oral
powder........................................................................... 131
COMPLEX JUNIOR MSD -amino acids oral powder...... 131
COMPLEX MSUD AMINO ACID B -amino acids bar..... 131
COMPLEX MSUD -amino acids oral powder..................131
CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 120
CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 120
CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................120
CONDYLOX -podofilox gel 0.5%.................................... 172
CONZIP -tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................... 98
CONZIP -tramadol hcl cap sr 24hr biphasic release 200
mg.................................................................................... 98
CONZIP -tramadol hcl cap sr 24hr biphasic release 300
mg.................................................................................... 98
COPASIL -emollient - gel................................................ 172
COPAXONE -glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 92
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 92
CORDRAN -flurandrenolide cream 0.05%...................... 172
CORDRAN -flurandrenolide lotion 0.05%....................... 172
CORDRAN -flurandrenolide oint 0.05%.......................... 172
CORDRAN -flurandrenolide tape 4 mcg/sqcm............... 172
COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 44
COREG CR -carvedilol phosphate cap sr 24hr 20 mg..... 44
COREG CR -carvedilol phosphate cap sr 24hr 40 mg..... 44
COREG CR -carvedilol phosphate cap sr 24hr 80 mg..... 44
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit.............................................................. 158
CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 60
CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 60
CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................ 172
CORTIFOAM -hydrocortisone acetate rectal foam 10%
(90 mg/dose)................................................................. 169
CORTISONE ACETATE -cortisone acetate tab 25 mg..... 23
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 173
CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%................................................ 173
CORVITE FE -iron combination tab................................ 151
CORVITE 150 -iron combination tab...............................151
COSENTYX -secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................ 173
COSENTYX SENSOREADY PEN -secukinumab
subcutaneous soln auto-injector 150 mg/ml................ 173
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf..........................................................163
COTELLIC -cobimetinib fumarate tab 20 mg (base
equivalent)....................................................................... 18
COUMADIN -warfarin sodium tab 1 mg.......................... 154
COUMADIN -warfarin sodium tab 2 mg.......................... 154
COUMADIN -warfarin sodium tab 2.5 mg....................... 154
COUMADIN -warfarin sodium tab 3 mg.......................... 154
COUMADIN -warfarin sodium tab 4 mg.......................... 154
COUMADIN -warfarin sodium tab 5 mg.......................... 154
COUMADIN -warfarin sodium tab 6 mg.......................... 155
COUMADIN -warfarin sodium tab 7.5 mg....................... 155
COUMADIN -warfarin sodium tab 10 mg........................ 155
CO-VERATROL -ubiquinol-vit b12-resveratrol-fa cap
200-5-400-0.8 mg......................................................... 183
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit.....................................................72
CREON -pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit...................................................72
CREON -pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit................................................ 72
CREON -pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit.............................................. 72
CREON -pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit............................................. 72
CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 6
CREST COMPLETE -sodium fluoride paste 0.243%..... 167
CRESTOR -rosuvastatin calcium tab 5 mg.......................57
CRESTOR -rosuvastatin calcium tab 10 mg.....................57
CRESTOR -rosuvastatin calcium tab 20 mg.....................57
CRESTOR -rosuvastatin calcium tab 40 mg.....................57
CRITICARE HN -nutritional supplement liquid................133
CRIXIVAN -indinavir sulfate cap 200 mg............................ 7
CRIXIVAN -indinavir sulfate cap 400 mg............................ 7
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml............................................................................. 65
cromolyn sodium ophth soln 4%................................ 163
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 73
CRUCIAL -nutritional supplement liquid..........................133
CUPRIMINE -penicillamine cap 250 mg......................... 184
CUROSURF -poractant alfa intratracheal susp 120
mg/1.5ml.......................................................................... 67
CUROSURF -poractant alfa intratracheal susp 240
mg/3ml............................................................................. 67
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 69
CVS GLUCOSE -glucose chew tab 4 gm......................... 31
CVS NUTRITIONAL SHAKE -nutritional supplement
liquid.............................................................................. 134
CVS NUTRITION LIQUID -nutritional supplement
liquid.............................................................................. 133
CVS NUTRITION PLUS -nutritional supplement
liquid.............................................................................. 134
cyanocobalamin inj 1000 mcg/ml................................ 151
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
CYCLINEX-1 -nutritional supplement powder................. 134
CYCLINEX-2 -nutritional supplement powder................. 134
cyclobenzaprine hcl tab 5 mg...................................... 118
cyclobenzaprine hcl tab 10 mg.................................... 118
cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 118
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 163
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%................................................................... 163
cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........163
cyclopentolate hcl ophth soln 1% (Cyclogyl).............163
cyclopentolate hcl ophth soln 2% (Cyclogyl).............163
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 18
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 18
CYCLOSERINE -cycloserine cap 250 mg.......................... 5
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 31
cyclosporine cap 25 mg (Sandimmune)..................... 184
cyclosporine cap 100 mg (Sandimmune)................... 184
cyclosporine modified cap 50 mg (Cyclosporine
modifie)......................................................................... 184
cyclosporine modified cap 25 mg (Neoral).................184
cyclosporine modified cap 100 mg (Neoral)...............184
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................ 184
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 184
cyproheptadine hcl syrup 2 mg/5ml.............................. 61
cyproheptadine hcl tab 4 mg......................................... 61
CYSTAGON -cysteamine bitartrate cap 50 mg.................77
CYSTAGON -cysteamine bitartrate cap 150 mg...............77
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 163
D
DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
equivalent)......................................................................... 7
DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base
equivalent)......................................................................... 7
DAKLINZA -daclatasvir dihydrochloride tab 90 mg (base
equivalent)......................................................................... 7
DALIRESP -roflumilast tab 500 mcg................................. 65
danazol cap 50 mg.......................................................... 25
danazol cap 100 mg........................................................ 25
danazol cap 200 mg........................................................ 25
dantrolene sodium cap 100 mg................................... 118
dantrolene sodium cap 25 mg (Dantrium).................. 118
dantrolene sodium cap 50 mg (Dantrium).................. 118
dapsone tab 25 mg.......................................................... 12
dapsone tab 100 mg........................................................ 12
DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml................................................................. 16
DARAPRIM -pyrimethamine tab 25 mg............................ 12
darifenacin hydrobromide tab sr 24hr 7.5 mg (base
equiv) (Enablex)............................................................ 75
darifenacin hydrobromide tab sr 24hr 15 mg (base
equiv) (Enablex)............................................................ 75
DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
drop).............................................................................. 119
DEBACTEROL -sulfuric acid-sulfonated phenolics soln
30-50%.......................................................................... 167
DECARA -cholecalciferol cap 25000 unit....................... 119
DELESTROGEN -estradiol valerate im in oil 10 mg/
ml..................................................................................... 26
DELESTROGEN -estradiol valerate im in oil 20 mg/
ml..................................................................................... 26
DELESTROGEN -estradiol valerate im in oil 40 mg/
ml..................................................................................... 26
DELZICOL -mesalamine cap dr 400 mg........................... 73
demeclocycline hcl tab 150 mg....................................... 4
demeclocycline hcl tab 300 mg....................................... 4
DEMSER -metyrosine cap 250 mg................................... 50
DENAVIR -penciclovir cream 1%.................................... 173
DEPAKENE -valproate sodium oral soln 250 mg/5ml
(base equiv).................................................................. 110
DEPAKENE -valproic acid cap 250 mg...........................110
DEPEN TITRATABS -penicillamine tab 250 mg............. 184
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml........ 28
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp prefilled syr 150
mg/ml............................................................................... 27
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate susp pref syr 104 mg/0.65ml.............................28
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 100 mg/ml.................................................................. 25
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 200 mg/ml.................................................................. 25
DEQUASINE -amino acids tab........................................ 131
DERMACINRX PUREFOLIX -folic acid-cholecalciferol tab
1 mg-5000 unit.............................................................. 151
DESCOVY -emtricitabine-tenofovir alafenamide fumarate
tab 200-25 mg...................................................................7
desipramine hcl tab 10 mg (Norpramin)....................... 79
desipramine hcl tab 25 mg (Norpramin)....................... 79
desipramine hcl tab 50 mg (Norpramin)....................... 79
desipramine hcl tab 75 mg (Norpramin)....................... 79
desipramine hcl tab 100 mg (Norpramin)..................... 79
desipramine hcl tab 150 mg (Norpramin)..................... 79
DESLORATADINE ODT -desloratadine tab orally
disintegrating 2.5 mg...................................................... 61
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
DESLORATADINE ODT -desloratadine tab orally
disintegrating 5 mg......................................................... 61
desloratadine tab 5 mg (Clarinex)................................. 61
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 40
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)........................................................................... 40
desmopressin acetate nasal spray soln 0.01%
(Ddavp)........................................................................... 40
desmopressin acetate nasal spray soln 0.01%
(refrigerated).................................................................. 40
desmopressin acetate tab 0.1 mg (Ddavp)................... 40
desmopressin acetate tab 0.2 mg (Ddavp)................... 40
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)........................................................ 28
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa).......................................................................28
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 28
DESONATE -desonide gel 0.05%................................... 173
desonide cream 0.05% (Desowen).............................. 173
desonide lotion 0.05% (Desowen)............................... 173
desonide oint 0.05% (Desowen).................................. 173
desoximetasone cream 0.25% (Topicort)....................173
DESOXIMETASONE -desoximetasone cream
0.05%.............................................................................173
desoximetasone gel 0.05% (Topicort)......................... 173
desoximetasone oint 0.05% (Topicort)........................ 173
desoximetasone oint 0.25% (Topicort)........................ 173
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................ 79
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv).............................................. 79
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 79
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 79
desvenlafaxine succinate tab sr 24hr 25 mg (base
equiv) (Pristiq)............................................................... 79
desvenlafaxine succinate tab sr 24hr 50 mg (base
equiv) (Pristiq)............................................................... 79
desvenlafaxine succinate tab sr 24hr 100 mg (base
equiv) (Pristiq)............................................................... 80
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml............................................................................. 23
DEXAMETHASONE -dexamethasone tab 1 mg...............23
DEXAMETHASONE -dexamethasone tab 2 mg...............23
dexamethasone elixir 0.5 mg/5ml.................................. 23
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml............................................................................... 23
DEXAMETHASONE SODIUM PHOS -dexamethasone
sodium phosphate ophth soln 0.1%............................. 163
dexamethasone tab 0.5 mg............................................ 23
dexamethasone tab 0.75 mg.......................................... 23
dexamethasone tab 1.5 mg............................................ 23
dexamethasone tab 4 mg............................................... 23
dexamethasone tab 6 mg............................................... 23
DEX4 FAST ACTING GLUCOSE -glucose gel 15
gm/33gm.......................................................................... 31
DEX4 FAST ACTING GLUCOSE -glucose-vitamin c chew
tab 4-0.006 gm............................................................... 31
DEX4 -glucose-vitamin c chew tab 4-0.006 gm................ 31
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 69
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 69
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).................................................................................... 89
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr).................................................................................... 89
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).................................................................................... 89
dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin
xr).................................................................................... 89
dexmethylphenidate hcl cap sr 24 hr 25 mg (Focalin
xr).................................................................................... 89
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr).................................................................................... 89
dexmethylphenidate hcl cap sr 24 hr 35 mg (Focalin
xr).................................................................................... 89
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr).................................................................................... 89
dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 89
dexmethylphenidate hcl tab 5 mg (Focalin)................. 89
dexmethylphenidate hcl tab 10 mg (Focalin)............... 89
DEX4 NATURALS -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
DEXPAK 10 DAY -dexamethasone tab therapy pack 1.5
mg (35)............................................................................ 23
DEXPAK 13 DAY -dexamethasone tab therapy pack 1.5
mg (51)............................................................................ 23
DEXPAK 6 DAY -dexamethasone tab therapy pack 1.5
mg (21)............................................................................ 23
DEX4 POUCH PACK -glucose-vitamin c chew tab 4-0.006
gm.................................................................................... 31
DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4
gm.................................................................................... 31
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)..................................................................... 89
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 89
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)..................................................................... 89
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
204
2016
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)..................................................................... 89
dextroamphetamine sulfate tab 5 mg........................... 89
dextroamphetamine sulfate tab 10 mg......................... 89
D.H.E. 45 -dihydroergotamine mesylate inj 1 mg/ml.......108
DIABETIC TF -nutritional supplement liquid................... 134
DIABETISHIELD -nutritional supplement liquid.............. 134
DIABETISOURCE AC -nutritional supplement liquid...... 134
DIABETISOURCE -nutritional supplement liquid............ 134
DIALYVITE/ZINC -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 121
DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 3 mg................................................................ 121
DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 5 mg................................................................ 121
DIALYVITE SUPREME D -multiple vitamins w/ minerals &
fa tab 3 mg................................................................... 120
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg............................................................................ 110
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg............................................................................ 110
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg.............................................................. 110
diazepam conc 5 mg/ml.................................................. 78
DIAZEPAM -diazepam oral soln 1 mg/ml..........................78
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................. 110
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................. 110
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................. 111
diazepam tab 2 mg (Valium)........................................... 78
diazepam tab 5 mg (Valium)........................................... 78
diazepam tab 10 mg (Valium)......................................... 78
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg..........50
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 71
diclofenac potassium tab 50 mg................................. 105
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)..................................................................... 173
diclofenac sodium gel 1% (Voltaren)...........................173
diclofenac sodium ophth soln 0.1%............................ 163
diclofenac sodium soln 1.5% (Pennsaid)................... 173
diclofenac sodium tab delayed release 25 mg........... 105
diclofenac sodium tab delayed release 50 mg........... 105
diclofenac sodium tab delayed release 75 mg........... 105
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................. 105
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)........................................................105
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)........................................................105
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 69
dicyclomine hcl oral soln 10 mg/5ml............................ 69
dicyclomine hcl tab 20 mg (Bentyl)............................... 69
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 7
didanosine delayed release capsule 200 mg (Videx
ec)...................................................................................... 7
didanosine delayed release capsule 250 mg (Videx
ec)...................................................................................... 7
didanosine delayed release capsule 400 mg (Videx
ec)...................................................................................... 7
DIFFERIN -adapalene lotion 0.1%.................................. 173
DIFICID -fidaxomicin tab 200 mg........................................ 3
DIFLORASONE DIACETATE -diflorasone diacetate
cream 0.05%................................................................. 173
DIFLORASONE DIACETATE -diflorasone diacetate oint
0.05%.............................................................................173
diflunisal tab 500 mg....................................................... 96
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 42
digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 42
digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 42
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................. 108
DILANTIN INFATABS -phenytoin chew tab 50 mg......... 111
DILANTIN -phenytoin sodium extended cap 30 mg........111
DILANTIN -phenytoin sodium extended cap 100 mg......111
DILANTIN-125 -phenytoin susp 125 mg/5ml.................. 111
DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 42
diltiazem hcl cap sr 12hr 60 mg.....................................45
diltiazem hcl cap sr 12hr 90 mg.....................................45
diltiazem hcl cap sr 12hr 120 mg...................................45
diltiazem hcl cap sr 24hr 120 mg...................................45
diltiazem hcl cap sr 24hr 180 mg...................................45
diltiazem hcl cap sr 24hr 240 mg...................................45
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................ 45
diltiazem hcl coated beads cap sr 24hr 180 mg
(Cardizem cd)................................................................ 45
diltiazem hcl coated beads cap sr 24hr 240 mg
(Cardizem cd)................................................................ 45
diltiazem hcl coated beads cap sr 24hr 300 mg
(Cardizem cd)................................................................ 45
diltiazem hcl coated beads cap sr 24hr 360 mg
(Cardizem cd)................................................................ 45
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la)................................................................. 45
diltiazem hcl coated beads tab sr 24hr 240 mg
(Cardizem la)................................................................. 45
diltiazem hcl coated beads tab sr 24hr 300 mg
(Cardizem la)................................................................. 45
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
diltiazem hcl coated beads tab sr 24hr 360 mg
(Cardizem la)................................................................. 46
diltiazem hcl coated beads tab sr 24hr 420 mg
(Cardizem la)................................................................. 46
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).................................................................... 46
diltiazem hcl extended release beads cap sr 24hr 180
mg (Tiazac).................................................................... 46
diltiazem hcl extended release beads cap sr 24hr 240
mg (Tiazac).................................................................... 46
diltiazem hcl extended release beads cap sr 24hr 300
mg (Tiazac).................................................................... 46
diltiazem hcl extended release beads cap sr 24hr 360
mg (Tiazac).................................................................... 46
diltiazem hcl extended release beads cap sr 24hr 420
mg (Tiazac).................................................................... 46
diltiazem hcl tab 90 mg................................................... 46
diltiazem hcl tab 30 mg (Cardizem)............................... 46
diltiazem hcl tab 60 mg (Cardizem)............................... 46
diltiazem hcl tab 120 mg (Cardizem)............................. 46
DIPENTUM -olsalazine sodium cap 250 mg.....................73
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml....................................................... 68
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)......................................................................... 68
DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml............................... 16
dipyridamole tab 25 mg (Persantine).......................... 158
dipyridamole tab 50 mg (Persantine).......................... 158
dipyridamole tab 75 mg (Persantine).......................... 158
disopyramide phosphate cap 100 mg (Norpace)......... 47
disopyramide phosphate cap 150 mg (Norpace)......... 47
disulfiram tab 250 mg (Antabuse)................................. 92
disulfiram tab 500 mg (Antabuse)................................. 92
DIURIL -chlorothiazide susp 250 mg/5ml......................... 55
divalproex sodium cap delayed release sprinkle 125
mg (Depakote sprinkles)............................................111
divalproex sodium tab delayed release 125 mg
(Depakote).................................................................... 111
divalproex sodium tab delayed release 250 mg
(Depakote).................................................................... 111
divalproex sodium tab delayed release 500 mg
(Depakote).................................................................... 111
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................. 111
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................. 111
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 26
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 26
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 26
DIVISTA -folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1
mg.................................................................................. 151
dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................47
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................47
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................47
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................... 92
donepezil hydrochloride orally disintegrating tab 10
mg................................................................................... 92
donepezil hydrochloride tab 5 mg (Aricept)................. 92
donepezil hydrochloride tab 10 mg (Aricept)............... 92
donepezil hydrochloride tab 23 mg (Aricept)............... 92
DONNATAL -pb-hyoscy-atrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml............................... 69
DONNATAL -pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg...................................... 69
DORAL -quazepam tab 15 mg.......................................... 87
dorzolamide hcl ophth soln 2% (Trusopt).................. 163
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................164
DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 121
doxazosin mesylate tab 1 mg (Cardura)....................... 50
doxazosin mesylate tab 2 mg (Cardura)....................... 50
doxazosin mesylate tab 4 mg (Cardura)....................... 50
doxazosin mesylate tab 8 mg (Cardura)....................... 50
doxepin hcl cap 10 mg....................................................80
doxepin hcl cap 25 mg....................................................80
doxepin hcl cap 50 mg....................................................80
doxepin hcl cap 100 mg..................................................80
doxepin hcl cap 150 mg..................................................80
doxepin hcl conc 10 mg/ml............................................ 80
DOXEPIN HCL -doxepin hcl cap 75 mg........................... 80
DOXEPIN HYDROCHLORIDE -doxepin hcl cream
5%.................................................................................. 173
doxercalciferol cap 0.5 mcg (Hectorol)......................... 40
doxercalciferol cap 1 mcg (Hectorol)............................ 40
doxercalciferol cap 2.5 mcg (Hectorol)......................... 40
doxycycline hyclate cap 50 mg....................................... 4
doxycycline hyclate cap 100 mg (Vibramycin)...............4
doxycycline hyclate tab delayed release 75 mg............ 4
doxycycline hyclate tab delayed release 100 mg.......... 4
doxycycline hyclate tab delayed release 150 mg.......... 4
doxycycline hyclate tab delayed release 50 mg
(Doryx).............................................................................. 4
doxycycline hyclate tab delayed release 200 mg
(Doryx).............................................................................. 4
doxycycline hyclate tab 20 mg........................................ 4
doxycycline hyclate tab 100 mg...................................... 4
doxycycline monohydrate cap 50 mg............................. 4
doxycycline monohydrate cap 150 mg (Adoxa).............4
doxycycline monohydrate cap 75 mg (Monodox)..........4
doxycycline monohydrate cap 100 mg (Monodox)........4
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 4
doxycycline monohydrate tab 50 mg (Adoxa)............... 4
doxycycline monohydrate tab 75 mg (Adoxa)............... 4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................. 4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................. 4
DRITHO-CREME HP -anthralin cream 1%..................... 173
dronabinol cap 2.5 mg (Marinol).................................... 71
dronabinol cap 5 mg (Marinol)....................................... 71
dronabinol cap 10 mg (Marinol)..................................... 71
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 28
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 28
drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg (Beyaz)............................................... 28
DROXIA -hydroxyurea cap 200 mg................................ 151
DROXIA -hydroxyurea cap 300 mg................................ 151
DROXIA -hydroxyurea cap 400 mg................................ 151
DUAVEE -conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 26
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg.......................................... 121
DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg...................................................... 121
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act.................................................... 65
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act.................................................... 65
DULOXETINE HCL -duloxetine hcl enteric coated pellets
cap 40 mg....................................................................... 80
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 80
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)...................................................................... 80
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)...................................................................... 80
DUOCAL -nutritional supplement powder....................... 134
DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/
ml................................................................................... 116
DURACHOL -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 151
DUREZOL -difluprednate ophth emulsion 0.05%........... 164
dutasteride cap 0.5 mg (Avodart).................................. 77
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 77
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg............................................................. 50
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 50-12.5 mg............................................................. 50
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 100-12.5 mg........................................................... 50
D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............ 119
DYMISTA -azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act............................................................... 62
dyphylline-guaifenesin liqd 100-100 mg/5ml................ 65
DYRENIUM -triamterene cap 50 mg................................. 55
DYRENIUM -triamterene cap 100 mg............................... 55
E
EAA SUPPLEMENT -nutritional supplement pack......... 134
econazole nitrate cream 1%......................................... 173
ECOZA -econazole nitrate foam 1%............................... 173
EDARBI -azilsartan medoxomil tab 40 mg........................50
EDARBI -azilsartan medoxomil tab 80 mg........................50
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 50
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 50
EDECRIN -ethacrynic acid tab 25 mg.............................. 55
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)....... 7
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 3
E.E.S. GRANULES -erythromycin ethylsuccinate for susp
200 mg/5ml....................................................................... 3
EFFER-K -potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 129
EFFER-K -potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 129
EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 158
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 158
EGG/PRO -nutritional supplement powder..................... 134
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 40
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 40
ELECARE/DHA/ARA -nutritional supplement
powder........................................................................... 134
ELECARE JR -nutritional supplement powder................134
ELECARE -nutritional supplement powder..................... 134
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)...................................................... 26
ELETONE -dermatological products misc - cream......... 173
ELETONE TWINPACK -dermatological products misc cream............................................................................. 173
ELIDEL -pimecrolimus cream 1%................................... 173
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 18
ELIGARD -leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg...................................................................18
ELIGARD -leuprolide acetate (4 month) for subcutaneous
inj kit 30 mg.................................................................... 18
ELIGARD -leuprolide acetate (6 month) for subcutaneous
inj kit 45 mg.................................................................... 18
ELIQUIS -apixaban tab 2.5 mg....................................... 155
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
ELIQUIS -apixaban tab 5 mg.......................................... 155
ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................. 121
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 65
ELLA -ulipristal acetate tab 30 mg.................................... 28
ELMIRON -pentosan polysulfate sodium caps 100
mg.................................................................................... 77
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
250 unit......................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
500 unit......................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
750 unit......................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1000 unit....................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1500 unit....................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
2000 unit....................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
3000 unit....................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
4000 unit....................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
5000 unit....................................................................... 158
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
6000 unit....................................................................... 158
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv).................................................................. 164
EMBEDA -morphine-naltrexone cap cr 20-0.8 mg............98
EMBEDA -morphine-naltrexone cap cr 30-1.2 mg............98
EMBEDA -morphine-naltrexone cap cr 50-2 mg...............98
EMBEDA -morphine-naltrexone cap cr 60-2.4 mg............98
EMBEDA -morphine-naltrexone cap cr 80-3.2 mg............98
EMBEDA -morphine-naltrexone cap cr 100-4 mg.............98
EMCYT -estramustine phosphate sodium cap 140
mg.................................................................................... 18
EMEND -aprepitant capsule 40 mg.................................. 71
EMEND -aprepitant capsule 80 mg.................................. 71
EMEND -aprepitant capsule 125 mg................................ 71
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 71
EMEND -aprepitant for oral susp 125 mg (125
mg/5ml)............................................................................ 71
EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 80
EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 80
EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 80
EMTRIVA -emtricitabine caps 200 mg................................ 7
EMTRIVA -emtricitabine soln 10 mg/ml.............................. 7
EMULSION SB -dermatological products misc emulsion........................................................................ 173
EMVERM -mebendazole chew tab 100 mg...................... 12
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).................................................................... 75
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).................................................................... 75
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg................................................................................... 50
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)...................................................................... 51
enalapril maleate tab 2.5 mg (Vasotec)......................... 51
enalapril maleate tab 5 mg (Vasotec)............................ 51
enalapril maleate tab 10 mg (Vasotec).......................... 51
enalapril maleate tab 20 mg (Vasotec).......................... 51
ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty
acids cap....................................................................... 121
ENBREL -etanercept for subcutaneous inj 25 mg.......... 105
ENBREL -etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.................................................................. 105
ENBREL -etanercept subcutaneous soln prefilled syringe
50 mg/ml....................................................................... 105
ENBREL SURECLICK -etanercept subcutaneous solution
auto-injector 50 mg/ml.................................................. 105
END FATIGUE DAILY ENERGY -multiple vitamins w/
minerals powder............................................................121
ENGERIX-B -hepatitis b vaccine (recombinant) 10
mcg/0.5ml........................................................................ 13
ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/
ml..................................................................................... 13
ENGERIX-B -hepatitis b vaccine (recombinant) susp 10
mcg/0.5ml........................................................................ 13
ENGERIX-B -hepatitis b vaccine (recombinant) susp 20
mcg/ml............................................................................. 13
ENLIVE -nutritional supplement liquid.............................134
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 155
enoxaparin sodium inj 40 mg/0.4ml (Lovenox).......... 155
enoxaparin sodium inj 60 mg/0.6ml (Lovenox).......... 155
enoxaparin sodium inj 80 mg/0.8ml (Lovenox).......... 155
enoxaparin sodium inj 100 mg/ml (Lovenox)............. 155
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 155
enoxaparin sodium inj 150 mg/ml (Lovenox)............. 155
enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 155
ENSTILAR -calcipotriene-betamethasone dipropionate
foam 0.005-0.064%...................................................... 173
ENSURE/FIBER -nutritional supplement liquid............... 135
ENSURE ACTIVE HEART HEALT -nutritional supplement
liquid.............................................................................. 134
ENSURE ACTIVE HIGH PROTEI -nutritional supplement
liquid.............................................................................. 134
ENSURE ACTIVE LIGHT -nutritional supplement
liquid.............................................................................. 134
ENSURE ACTIVE -nutritional supplement liquid............ 134
ENSURE BONE HEALTH REVIGO -nutritional
supplement liquid.......................................................... 134
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
ENSURE CLEAR -nutritional supplement liquid............. 134
ENSURE CLINICAL STRENGTH -nutritional supplement
liquid.............................................................................. 134
ENSURE COMPACT -nutritional supplement liquid....... 134
ENSURE COMPLETE -nutritional supplement liquid..... 134
ENSURE COMPLETE NUTRITION -nutritional
supplement liquid.......................................................... 134
ENSURE ENLIVE -nutritional supplement liquid............ 134
ENSURE HEALTHY MOM -nutritional supplement
bar.................................................................................. 134
ENSURE HEALTHY MOM -nutritional supplement
liquid.............................................................................. 134
ENSURE HIGH CALCIUM -nutritional supplement
liquid.............................................................................. 134
ENSURE HIGH PROTEIN -nutritional supplement
liquid.............................................................................. 134
ENSURE HIGH PROTEIN -nutritional supplement
powder........................................................................... 134
ENSURE IMMUNE HEALTH -nutritional supplement
liquid.............................................................................. 135
ENSURE MUSCLE HEALTH REVI -nutritional
supplement liquid.......................................................... 135
ENSURE NUTRA SHAKE HI-CAL -nutritional supplement
liquid.............................................................................. 135
ENSURE -nutritional supplement bar..............................134
ENSURE -nutritional supplement liquid.......................... 134
ENSURE -nutritional supplement powder....................... 134
ENSURE NUTRITION SHAKE -nutritional supplement
liquid.............................................................................. 135
ENSURE PLUS HN -nutritional supplement liquid..........135
ENSURE PLUS -nutritional supplement liquid................ 135
ENSURE PRE-SURGERY -nutritional supplement
liquid.............................................................................. 135
ENSURE PUDDING -nutritional supplement
pudding.......................................................................... 135
ENSURE SURGERY IMMUNONUTR -nutritional
supplement liquid.......................................................... 135
entacapone tab 200 mg (Comtan)............................... 116
entecavir tab 0.5 mg (Baraclude)..................................... 7
entecavir tab 1 mg (Baraclude)........................................ 7
ENTEREG -alvimopan cap 12 mg.................................... 73
ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 60
ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 60
ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 60
ENTTY SPRAY EMULSION -dermatological products
misc - emulsion............................................................. 173
ENU NUTRITIONAL SHAKE -nutritional supplement
liquid.............................................................................. 135
ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............184
ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 184
ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 184
EO28 SPLASH -nutritional supplement liquid................. 135
EPANED -enalapril maleate oral soln 1 mg/ml................. 51
EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 7
EPICERAM -dermatological products misc emulsion........................................................................ 173
EPIFOAM -pramoxine-hc aerosol foam 1-1%.................173
epinastine hcl ophth soln 0.05% (Elestat).................. 164
EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN
-epinephrine solution auto-injector 0.15 mg/0.3ml
(1:2000)........................................................................... 56
EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN
-epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)........................................................................... 56
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 56
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 56
EPIPEN-JR 2-PAK -epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................. 56
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 56
EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 7
EPIVIR -lamivudine oral soln 10 mg/ml.............................. 7
eplerenone tab 25 mg (Inspra)....................................... 51
eplerenone tab 50 mg (Inspra)....................................... 51
EPOGEN -epoetin alfa inj 2000 unit/ml...........................151
EPOGEN -epoetin alfa inj 3000 unit/ml...........................151
EPOGEN -epoetin alfa inj 4000 unit/ml...........................151
EPOGEN -epoetin alfa inj 10000 unit/ml.........................151
EPOGEN -epoetin alfa inj 20000 unit/ml.........................151
EPROSARTAN MESYLATE -eprosartan mesylate tab 600
mg.................................................................................... 51
EPZICOM -abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 7
EQL DENTAL TRAVEL PACK -sodium fluoride paste
0.243% & mouthwash kit..............................................167
EQL TRAVEL TOOTHBRUSH/TOO -sodium
monofluorophosphate paste 0.15%............................. 167
EQ NUTRITIONAL SHAKE -nutritional supplement
liquid.............................................................................. 135
EQ NUTRITIONAL SHAKE PLUS -nutritional supplement
liquid.............................................................................. 135
EQUATE -nutritional supplement liquid........................... 135
EQUATE PLUS -nutritional supplement liquid................ 135
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................ 84
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
200 mg............................................................................ 84
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
300 mg............................................................................ 84
EQ WEIGHT LOSS SHAKE ULTR -nutritional supplement
liquid.............................................................................. 135
ergocalciferol cap 50000 unit (Drisdol)....................... 119
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................... 92
ERGOMAR -ergotamine tartrate sl tab 2 mg.................. 108
ergotamine w/ caffeine tab 1-100 mg (Cafergot)........ 108
ERIVEDGE -vismodegib cap 150 mg............................... 18
ERTACZO -sertaconazole nitrate cream 2%.................. 174
ERYPED 200 -erythromycin ethylsuccinate for susp 200
mg/5ml............................................................................... 3
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml............................................................................... 3
ERY-TAB -erythromycin tab delayed release 250 mg........ 3
ERY-TAB -erythromycin tab delayed release 333 mg........ 3
ERY-TAB -erythromycin tab delayed release 500 mg........ 3
ERYTHROCIN STEARATE -erythromycin stearate tab
250 mg.............................................................................. 3
ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 3
ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 3
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg............................................... 3
erythromycin ethylsuccinate for susp 200 mg/5ml
(E.e.s. granules).............................................................. 3
erythromycin gel 2% (Erygel)....................................... 174
erythromycin ophth oint 5 mg/gm............................... 164
erythromycin pads 2%.................................................. 174
erythromycin soln 2%................................................... 174
erythromycin w/ delayed release particles cap 250
mg......................................................................................4
ESBRIET -pirfenidone cap 267 mg................................... 67
ESCAVITE D -pediatric multiple vitamins w/ fl-fe chew tab
0.25-6 mg...................................................................... 121
ESCAVITE LQ -pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml................................................................. 121
ESCAVITE -pediatric multiple vitamins w/ fl-fe chew tab
0.25-7.5 mg................................................................... 121
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................ 80
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................ 80
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)........................................................................ 80
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)........................................................................ 80
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)....................................................... 69
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)....................................................... 69
ESSENTIAL AMINO ACID MIX -amino acids oral
powder........................................................................... 131
ESSENTRA WIPES 9X9" CLEAN -isopropyl alcohol
wipes 70%..................................................................... 174
estazolam tab 1 mg......................................................... 87
estazolam tab 2 mg......................................................... 87
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................ 26
esterified estrogens & methyltestosterone tab
1.25-2.5 mg.....................................................................26
ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 76
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)....................................................................... 26
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)....................................................................... 26
estradiol tab 0.5 mg (Estrace)........................................ 26
estradiol tab 1 mg (Estrace)........................................... 26
estradiol tab 2 mg (Estrace)........................................... 26
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 26
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 26
estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 26
estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 26
estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 26
estradiol td patch weekly 0.025 mg/24hr (Climara)......26
estradiol td patch weekly 0.05 mg/24hr (Climara)........26
estradiol td patch weekly 0.06 mg/24hr (Climara)........26
estradiol td patch weekly 0.075 mg/24hr (Climara)......26
estradiol td patch weekly 0.1 mg/24hr (Climara)..........26
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)...................................................... 26
estradiol vaginal tab 10 mcg (Vagifem).........................76
estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 26
estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 26
ESTRING -estradiol vaginal ring 2 mg (7.5
mcg/24hrs).......................................................................76
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)...................................................... 26
ESTROPIPATE -estropipate tab 0.75 mg......................... 26
ESTROPIPATE -estropipate tab 1.5 mg........................... 27
ESTROPIPATE -estropipate tab 3 mg.............................. 27
eszopiclone tab 1 mg (Lunesta).................................... 87
eszopiclone tab 2 mg (Lunesta).................................... 87
eszopiclone tab 3 mg (Lunesta).................................... 87
ethacrynic acid tab 25 mg.............................................. 55
ethambutol hcl tab 100 mg (Myambutol)........................ 5
ethambutol hcl tab 400 mg (Myambutol)........................ 5
ethosuximide cap 250 mg (Zarontin).......................... 111
ethosuximide soln 250 mg/5ml (Zarontin).................. 111
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg................................................................................. 28
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50
mcg (Zovia 1/50e)......................................................... 28
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 40
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 40
etodolac cap 200 mg..................................................... 105
etodolac cap 300 mg..................................................... 105
etodolac tab 400 mg...................................................... 105
etodolac tab 500 mg...................................................... 105
etodolac tab sr 24hr 400 mg........................................ 105
etodolac tab sr 24hr 500 mg........................................ 105
etodolac tab sr 24hr 600 mg........................................ 105
ETOPOSIDE -etoposide cap 50 mg..................................18
EURAX -crotamiton cream 10%...................................... 174
EURAX -crotamiton lotion 10%....................................... 174
EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 27
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)...................................................................... 7
EVZIO -naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 182
EVZIO -naloxone hcl solution auto-injector 2
mg/0.4ml........................................................................ 182
EXALGO -hydromorphone hcl tab er 24hr deter 32
mg.................................................................................... 98
EXELDERM -sulconazole nitrate cream 1%................... 174
EXELDERM -sulconazole nitrate solution 1%................ 174
EXELON -rivastigmine td patch 24hr 4.6 mg/24hr............ 92
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr............ 92
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr.......... 92
exemestane tab 25 mg (Aromasin)................................ 18
EXJADE -deferasirox tab for oral susp 125 mg.............. 182
EXJADE -deferasirox tab for oral susp 250 mg.............. 182
EXJADE -deferasirox tab for oral susp 500 mg.............. 182
EXODERM -sodium thiosulfate-salicylic acid lotion
25-1%............................................................................ 174
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 92
EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg................................... 121
ezetimibe tab 10 mg (Zetia)............................................ 57
F
F.A.A. -nutritional supplement liquid................................ 135
FABIOR -tazarotene (acne) foam 0.1%.......................... 174
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 5
FALESSA -levomefolate glucosamine tab 1 mg (folate
equivalent)..................................................................... 135
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa
tab 1 mg kit..................................................................... 28
famciclovir tab 125 mg (Famvir)...................................... 7
famciclovir tab 250 mg (Famvir)...................................... 7
famciclovir tab 500 mg (Famvir)...................................... 7
famotidine for susp 40 mg/5ml (Pepcid)....................... 69
famotidine tab 40 mg (Pepcid)....................................... 69
FANAPT -iloperidone tab 1 mg......................................... 84
FANAPT -iloperidone tab 2 mg......................................... 84
FANAPT -iloperidone tab 4 mg......................................... 84
FANAPT -iloperidone tab 6 mg......................................... 84
FANAPT -iloperidone tab 8 mg......................................... 84
FANAPT -iloperidone tab 10 mg....................................... 84
FANAPT -iloperidone tab 12 mg....................................... 84
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak........................................... 84
FARESTON -toremifene citrate tab 60 mg (base
equivalent)....................................................................... 18
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)....................................................................... 31
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 31
FARYDAK -panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 19
FARYDAK -panobinostat lactate cap 15 mg (base
equivalent)....................................................................... 19
FARYDAK -panobinostat lactate cap 20 mg (base
equivalent)....................................................................... 19
FAZACLO -clozapine orally disintegrating tab 12.5
mg.................................................................................... 84
FAZACLO -clozapine orally disintegrating tab 25 mg....... 84
FAZACLO -clozapine orally disintegrating tab 100 mg..... 84
FAZACLO -clozapine orally disintegrating tab 150 mg..... 84
FAZACLO -clozapine orally disintegrating tab 200 mg..... 84
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg................................................................................. 151
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg................................................................................. 151
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mncu cap (Tandem plus)................................................ 151
FEIBA -antiinhibitor coagulant complex for inj................ 158
felbamate susp 600 mg/5ml (Felbatol)........................ 111
felbamate tab 400 mg (Felbatol).................................. 111
felbamate tab 600 mg (Felbatol).................................. 111
felodipine tab sr 24hr 2.5 mg......................................... 46
felodipine tab sr 24hr 5 mg............................................ 46
felodipine tab sr 24hr 10 mg.......................................... 46
FEMHRT LOW DOSE -norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg......................................... 27
FEM PH -acetic acid-oxyquinoline vaginal gel
0.9-0.025%...................................................................... 76
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr........................................................................... 76
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 76
FENOFIBRATE -fenofibrate cap 50 mg............................ 57
FENOFIBRATE -fenofibrate cap 150 mg.......................... 57
fenofibrate micronized cap 43 mg................................. 57
fenofibrate micronized cap 130 mg............................... 57
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
fenofibrate micronized cap 67 mg (Lofibra)................. 57
fenofibrate micronized cap 134 mg (Lofibra)............... 57
fenofibrate micronized cap 200 mg (Lofibra)............... 57
fenofibrate tab 40 mg (Fenoglide)................................. 57
fenofibrate tab 120 mg (Fenoglide)............................... 57
fenofibrate tab 54 mg (Lofibra)...................................... 57
fenofibrate tab 160 mg (Lofibra).................................... 57
fenofibrate tab 48 mg (Tricor)........................................ 57
fenofibrate tab 145 mg (Tricor)...................................... 57
FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 57
FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 57
FENOGLIDE -fenofibrate tab 40 mg................................. 57
FENOGLIDE -fenofibrate tab 120 mg............................... 57
FENOPROFEN CALCIUM -fenoprofen calcium cap 200
mg.................................................................................. 105
FENOPROFEN CALCIUM -fenoprofen calcium cap 400
mg.................................................................................. 105
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................. 105
FENORTHO -fenoprofen calcium cap 200 mg............... 106
FENORTHO -fenoprofen calcium cap 400 mg............... 106
fentanyl citrate lozenge on a handle 200 mcg
(Actiq)............................................................................. 98
fentanyl citrate lozenge on a handle 400 mcg
(Actiq)............................................................................. 98
fentanyl citrate lozenge on a handle 600 mcg
(Actiq)............................................................................. 98
fentanyl citrate lozenge on a handle 800 mcg
(Actiq)............................................................................. 98
fentanyl citrate lozenge on a handle 1200 mcg
(Actiq)............................................................................. 98
fentanyl citrate lozenge on a handle 1600 mcg
(Actiq)............................................................................. 98
FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr...............98
FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr...............98
FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr...............98
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 98
fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. 98
fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. 98
fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. 98
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 98
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................... 99
FENTORA -fentanyl citrate buccal tab 200 mcg (base
equiv)............................................................................... 99
FENTORA -fentanyl citrate buccal tab 400 mcg (base
equiv)............................................................................... 99
FENTORA -fentanyl citrate buccal tab 600 mcg (base
equiv)............................................................................... 99
FENTORA -fentanyl citrate buccal tab 800 mcg (base
equiv)............................................................................... 99
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)................................................................. 151
FERIVA 21/7 -fe asparto gly-b12-fa-c-dss-succinic acid-zn
tab 75-1 mg...................................................................151
FERIVAFA -iron-c-fa-b12-biotin-copper-docusate cap
110-1 mg....................................................................... 151
FERIVA -fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap
75-1 mg......................................................................... 151
FERRALET 90 -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg........................................................... 151
FERRAPLUS 90 -iron-folic acid-vit b12-vit c-docusate sod
tab 90-1 mg...................................................................151
FERRETTS CHEWABLE IRON -carbonyl iron chew tab
18 mg (elemental iron)................................................. 151
FERRIPROX -deferiprone oral soln 100 mg/ml.............. 182
FERRIPROX -deferiprone tab 500 mg............................ 182
FERRO-PLEX HEMATINIC -fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg......................................................... 151
FERROTRIN -iron w/ b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg............................................... 151
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab
106-1 mg.......................................................................152
ferrous fumarate-folic acid tab 324-1 mg....................152
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe).................................................................................. 152
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)............................................. 152
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)............................................. 152
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe).................................................................................. 152
FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)....................................................................... 80
FETZIMA -levomilnacipran hcl cap sr 24hr 40 mg (base
equivalent)....................................................................... 80
FETZIMA -levomilnacipran hcl cap sr 24hr 80 mg (base
equivalent)....................................................................... 80
FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)....................................................................... 80
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack...................................... 80
FIBER FLOW -nutritional supplement liquid................... 135
FIBERSOURCE CLOSED SYSTEM -nutritional
supplement liquid.......................................................... 135
FIBERSOURCE HN CLOSED SYS -nutritional
supplement liquid.......................................................... 135
FIBERSOURCE HN -nutritional supplement liquid......... 135
FIBER-STAT -nutritional supplement liquid..................... 135
FIBRICOR -fenofibric acid tab 35 mg............................... 58
FIBRICOR -fenofibric acid tab 105 mg............................. 58
FINACEA -azelaic acid foam 15%.................................. 174
FINACEA -azelaic acid gel 15%..................................... 174
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
finasteride tab 5 mg (Proscar)....................................... 77
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 158
FIRST-LANSOPRAZOLE -lansoprazole susp 3 mg/ml
(compound kit)................................................................ 69
FIRST-OMEPRAZOLE -omeprazole susp 2 mg/ml
(compound kit)................................................................ 69
FLAREX -fluorometholone acetate ophth susp 0.1%..... 164
FLAVOR PACKETS -nutritional supplement flavor
pack............................................................................... 135
FLAVOUR PAC -nutritional supplement flavor pack....... 135
flavoxate hcl tab 100 mg.................................................75
flecainide acetate tab 50 mg.......................................... 47
flecainide acetate tab 100 mg........................................ 47
flecainide acetate tab 150 mg........................................ 47
FLECTOR -diclofenac epolamine patch 1.3%................ 174
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 129
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 129
FLORIVA -ped multiple vitamins & minerals w/ fl chew tab
0.25 mg......................................................................... 121
FLORIVA -ped multiple vitamins & minerals w/ fl chew tab
0.5 mg........................................................................... 121
FLORIVA -ped multiple vitamins & minerals w/ fl chew tab
1 mg.............................................................................. 121
FLORIVA PLUS -pediatric multiple vitamins w/ fluoride
soln 0.25 mg/ml............................................................ 121
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml............................................................... 129
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister....................................................................... 65
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister................................................................ 65
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister................................................................ 65
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................ 65
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................ 65
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)...........................................................65
FLOWTUSS -hydrocodone-guaifenesin soln 2.5-200
mg/5ml............................................................................. 62
FLUAD 2016-2017 -influenza vac type a&b surface ant
adj susp pref syr 0.5 ml................................................. 13
FLUARIX 2014-2015 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 14
FLUARIX QUADRIVALENT 2014 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
FLUARIX QUADRIVALENT 2015 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 14
FLUARIX QUADRIVALENT 2016 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 14
FLUBLOK 2014-2015 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 14
FLUBLOK 2015-2016 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 14
FLUBLOK 2016-2017 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 14
FLUCELVAX 2014-2015 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml........................................... 14
FLUCELVAX 2015-2016 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml........................................... 14
FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult
subunt quad susp pref syr 0.5 ml.................................. 14
fluconazole for susp 10 mg/ml (Diflucan)....................... 6
fluconazole for susp 40 mg/ml (Diflucan)....................... 6
fluconazole tab 50 mg (Diflucan)..................................... 6
fluconazole tab 100 mg (Diflucan)................................... 6
fluconazole tab 150 mg (Diflucan)................................... 6
fluconazole tab 200 mg (Diflucan)................................... 6
flucytosine cap 250 mg (Ancobon)................................. 6
flucytosine cap 500 mg (Ancobon)................................. 6
fludrocortisone acetate tab 0.1 mg............................... 23
FLULAVAL 2014-2015 -influenza virus vaccine split im
susp................................................................................. 14
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj................................................... 14
FLULAVAL QUADRIVALENT 201 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 14
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp...........................................14
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)................................................................... 62
fluocinolone acetonide cream 0.01%.......................... 174
fluocinolone acetonide cream 0.025% (Synalar)........174
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 174
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................174
fluocinolone acetonide oint 0.025% (Synalar)............ 174
fluocinolone acetonide (otic) oil 0.01%
(Dermotic).................................................................... 167
fluocinolone acetonide soln 0.01% (Synalar)............. 174
fluocinonide cream 0.05%............................................ 174
fluocinonide cream 0.1% (Vanos)................................ 174
fluocinonide emulsified base cream 0.05%................ 174
fluocinonide gel 0.05%.................................................. 174
fluocinonide oint 0.05%................................................ 174
fluocinonide soln 0.05%................................................ 174
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)........................................................129
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg..................................................129
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg.................................................................. 129
fluorometholone ophth susp 0.1% (Fml liquifilm)..... 164
FLUOROPLEX -fluorouracil cream 1%........................... 174
fluorouracil cream 5% (Efudex)................................... 174
FLUOROURACIL -fluorouracil cream 0.5%.................... 174
fluorouracil soln 2%...................................................... 174
fluorouracil soln 5%...................................................... 174
FLUOXETINE DR -fluoxetine hcl cap delayed release 90
mg.................................................................................... 80
FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg.............. 92
FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg.............. 92
fluoxetine hcl cap 10 mg (Prozac)................................. 80
fluoxetine hcl cap 20 mg (Prozac)................................. 80
fluoxetine hcl cap 40 mg (Prozac)................................. 80
FLUOXETINE HCL -fluoxetine hcl tab 60 mg................... 80
fluoxetine hcl (pmdd) tab 10 mg (Sarafem).................. 92
fluoxetine hcl (pmdd) tab 20 mg (Sarafem).................. 92
fluoxetine hcl solution 20 mg/5ml................................. 80
fluoxetine hcl tab 10 mg................................................. 80
fluoxetine hcl tab 20 mg................................................. 80
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 84
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 84
fluphenazine hcl tab 1 mg.............................................. 84
fluphenazine hcl tab 2.5 mg........................................... 84
fluphenazine hcl tab 5 mg.............................................. 84
fluphenazine hcl tab 10 mg............................................ 84
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)............................................... 129
flurandrenolide cream 0.05%....................................... 174
flurandrenolide lotion 0.05% (Cordran).......................174
flurandrenolide oint 0.05% (Cordran).......................... 174
FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 87
FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 87
flurbiprofen sodium ophth soln 0.03% (Ocufen)........164
flurbiprofen tab 50 mg.................................................. 106
flurbiprofen tab 100 mg................................................ 106
flutamide cap 125 mg...................................................... 19
fluticasone propionate cream 0.05% (Cutivate)......... 174
fluticasone propionate lotion 0.05% (Cutivate).......... 174
fluticasone propionate nasal susp 50 mcg/act............ 62
fluticasone propionate oint 0.005%............................. 174
fluvastatin sodium cap 20 mg (Lescol)......................... 58
fluvastatin sodium cap 40 mg (Lescol)......................... 58
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........58
FLUVIRIN 2015-2016 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................14
FLUVIRIN 2016-2017 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................14
FLUVIRIN 2014-2015 -influenza virus vaccine types a & b
surface antigen im susp................................................. 14
FLUVIRIN 2015-2016 -influenza virus vaccine types a & b
surface antigen im susp................................................. 14
FLUVIRIN 2016-2017 -influenza virus vaccine types a & b
surface antigen im susp................................................. 14
FLUVIRIN PF 2014-2015 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 14
fluvoxamine maleate cap sr 24hr 100 mg..................... 80
fluvoxamine maleate cap sr 24hr 150 mg..................... 80
fluvoxamine maleate tab 25 mg..................................... 81
fluvoxamine maleate tab 50 mg..................................... 81
fluvoxamine maleate tab 100 mg................................... 81
FLUZONE HIGH-DOSE PF 2014 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................14
FLUZONE HIGH-DOSE PF 2015 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................14
FLUZONE HIGH-DOSE PF 2016 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................15
FLUZONE INTRADERMAL QUADR -influenza virus vac
split quad intradermal pen 9 mcg/strain......................... 15
FLUZONE PF 2014-2015 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 15
FLUZONE QUADRIVALENT 2014 -influenza virus
vaccine split quadrivalent im inj..................................... 15
FLUZONE QUADRIVALENT 2015 -influenza virus
vaccine split quadrivalent im inj..................................... 15
FLUZONE QUADRIVALENT 2016 -influenza virus
vaccine split quadrivalent im inj..................................... 15
FLUZONE QUADRIVALENT 2014 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 15
FLUZONE QUADRIVALENT 2015 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 15
FLUZONE QUADRIVALENT 2016 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 15
FLUZONE QUADRIVALENT 2014 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 15
FLUZONE QUADRIVALENT 2014 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 15
FLUZONE QUADRIVALENT 2015 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 15
FLUZONE QUADRIVALENT 2015 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 15
FLUZONE QUADRIVALENT 2016 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 15
FLUZONE QUADRIVALENT 2016 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 15
FLUZONE SPLIT 2014-2015 -influenza virus vaccine split
im susp............................................................................ 15
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
FLUZONE SPLIT 2015-2016 -influenza virus vaccine split
im susp............................................................................ 15
FML -fluorometholone ophth oint 0.1%........................... 164
FML FORTE -fluorometholone ophth susp 0.25%.......... 164
FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack...................................................121
FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak.............................................. 121
FOCALGIN DSS -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg........................................................... 152
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................... 89
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 20
mg.................................................................................... 90
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 25
mg.................................................................................... 90
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 35
mg.................................................................................... 90
FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg..................................................... 121
FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 121
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak.................................................................. 121
FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg.......................................................... 121
FOLGARD OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.................................................................... 121
folic acid cap 0.8 mg..................................................... 152
folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg................................................................................. 135
folic acid tab 400 mcg................................................... 152
folic acid tab 800 mcg................................................... 152
folic acid tab 1 mg......................................................... 152
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg................................................................................. 152
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg..... 152
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx).................................................................. 152
FOLIVANE-F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)................................... 152
FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................121
FOLIVANE-PLUS -fe fum-iron polysacch complex-fa-b
complex-c-biotin cap..................................................... 152
FOLIXAPURE -folic acid-cholecalciferol tab 1 mg-5000
unit................................................................................. 152
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra).........................................................................155
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).........................................................................155
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra).........................................................................155
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra).........................................................................155
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg............. 81
formaldehyde solution 10%.......................................... 182
FORMA-RAY -formaldehyde solution 20%..................... 182
FORTA DRINK -nutritional supplement powder.............. 135
FORTA SHAKE -nutritional supplement powder............. 135
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 40
FORTESTA -testosterone td gel 10mg/act (2%)............... 25
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit....................................................... 40
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit....................................................... 40
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................... 51
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................... 51
fosinopril sodium tab 10 mg.......................................... 51
fosinopril sodium tab 20 mg.......................................... 51
fosinopril sodium tab 40 mg.......................................... 51
FOSRENOL -lanthanum carbonate chew tab 500 mg
(elemental).......................................................................73
FOSRENOL -lanthanum carbonate chew tab 750 mg
(elemental).......................................................................73
FOSRENOL -lanthanum carbonate chew tab 1000 mg
(elemental).......................................................................73
FOSRENOL -lanthanum carbonate oral powder pack 750
mg (elemental)................................................................ 73
FOSRENOL -lanthanum carbonate oral powder pack
1000 mg (elemental).......................................................73
FRAGMIN -dalteparin sodium inj 10000 unit/ml..............155
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........155
FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml...........155
FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml...........155
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........155
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml.........155
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......155
FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml.........155
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)..................................................................... 108
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova).......................................................................... 108
FRUITIVITS -nutritional supplement pack.......................135
FUROSEMIDE -furosemide oral soln 8 mg/ml..................55
furosemide oral soln 10 mg/ml...................................... 55
furosemide tab 20 mg (Lasix)........................................ 55
furosemide tab 40 mg (Lasix)........................................ 55
furosemide tab 80 mg (Lasix)........................................ 55
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
FUSION PLUS -fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap........................................................ 152
FUSION SPRINKLES -fe fum-fe polys cmplx-fa-cprobiotic pack 7-0.25-50-5 mg..................................... 152
FUZEON -enfuvirtide for inj 90 mg..................................... 8
FYCOMPA -perampanel susp 0.5 mg/ml........................ 111
FYCOMPA -perampanel tab 2 mg.................................. 111
FYCOMPA -perampanel tab 4 mg.................................. 111
FYCOMPA -perampanel tab 6 mg.................................. 111
FYCOMPA -perampanel tab 8 mg.................................. 111
FYCOMPA -perampanel tab 10 mg................................ 111
FYCOMPA -perampanel tab 12 mg................................ 111
G
GA-1 ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 136
gabapentin cap 100 mg (Neurontin)............................ 111
gabapentin cap 300 mg (Neurontin)............................ 111
gabapentin cap 400 mg (Neurontin)............................ 111
gabapentin oral soln 250 mg/5ml (Neurontin)............ 111
gabapentin tab 600 mg (Neurontin)............................. 111
gabapentin tab 800 mg (Neurontin)............................. 111
GABITRIL -tiagabine hcl tab 12 mg................................ 111
GABITRIL -tiagabine hcl tab 16 mg................................ 111
GA EXPRESS15 -nutritional supplement pack............... 135
GA GEL -nutritional supplement pack............................. 135
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................ 92
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................ 93
galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er)................................................................ 93
GALANTAMINE HYDROBROMIDE -galantamine
hydrobromide oral soln 4 mg/ml.................................... 92
galantamine hydrobromide tab 4 mg (Razadyne)........ 93
galantamine hydrobromide tab 8 mg (Razadyne)........ 93
galantamine hydrobromide tab 12 mg (Razadyne)...... 93
GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 130
GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 130
GA -nutritional supplement powder................................. 135
gatifloxacin ophth soln 0.5% (Zymaxid)..................... 164
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 73
GELCLAIR -povidone-sodium hyaluronate-glycyrrhetinic
acid gel.......................................................................... 167
GELFILM OP -gelatin adsorbable ophth film.................. 164
GEL-KAM ORAL CARE RINSE -stannous fluoride conc
0.63%.............................................................................167
GEL-KAM -stannous fluoride gel 0.4%........................... 167
GELNIQUE -oxybutynin chloride td gel 10%.................... 75
gemfibrozil tab 600 mg (Lopid)...................................... 58
GENADUR -dermatological products misc - liquid..........174
GENERESS FE -norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg................................................28
gentamicin sulfate cream 0.1%.................................... 174
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%...............................................................................174
gentamicin sulfate ophth oint 0.3%............................. 164
gentamicin sulfate ophth soln 0.3% (Garamycin)...... 164
GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg.......................................................... 8
GIALAX -polyethylene glycol 3350 - kit............................ 68
GIAZO -balsalazide disodium tab 1.1 gm......................... 73
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 93
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 19
GILOTRIF -afatinib dimaleate tab 30 mg (base
equivalent)....................................................................... 19
GILOTRIF -afatinib dimaleate tab 40 mg (base
equivalent)....................................................................... 19
GILPHEX TR -phenylephrine-guaifenesin tab 10-388
mg.................................................................................... 62
GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388
mg.................................................................................... 62
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 93
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 19
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 19
GLEOSTINE -lomustine cap 5 mg.................................... 19
GLEOSTINE -lomustine cap 10 mg.................................. 19
GLEOSTINE -lomustine cap 40 mg.................................. 19
GLEOSTINE -lomustine cap 100 mg................................ 19
glimepiride tab 1 mg (Amaryl)........................................31
glimepiride tab 2 mg (Amaryl)........................................31
glimepiride tab 4 mg (Amaryl)........................................31
glipizide-metformin hcl tab 2.5-250 mg......................... 32
glipizide-metformin hcl tab 2.5-500 mg......................... 32
glipizide-metformin hcl tab 5-500 mg............................ 32
glipizide tab 5 mg (Glucotrol).........................................32
glipizide tab 10 mg (Glucotrol).......................................32
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 31
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 31
glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 32
GLUCAGEN DIAGNOSTIC -glucagon hcl (rdna)
diagnostic for inj 1 mg (base equiv)............................. 183
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv).................................................................... 32
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj
kit 1 mg........................................................................... 32
GLUCERNA ADVANCE SHAKE -nutritional supplement
liquid.............................................................................. 136
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
GLUCERNA 1.0 CAL/FIBER -nutritional supplement
liquid.............................................................................. 136
GLUCERNA 1.0 CAL -nutritional supplement liquid....... 136
GLUCERNA 1.2 CAL -nutritional supplement liquid....... 136
GLUCERNA 1.5 CAL -nutritional supplement liquid....... 136
GLUCERNA CARBSTEADY -nutritional supplement
liquid.............................................................................. 136
GLUCERNA CEREAL CRUNCHY F -nutritional
supplement misc........................................................... 136
GLUCERNA CRISPY DELIGHTS -nutritional supplement
bar.................................................................................. 136
GLUCERNA HUNGER SMART SHA -nutritional
supplement liquid.......................................................... 136
GLUCERNA MEAL -nutritional supplement bar..............136
GLUCERNA MEAL REPLACEMENT -nutritional
supplement bar............................................................. 136
GLUCERNA MINI SNACK -nutritional supplement
bar.................................................................................. 136
GLUCERNA MINI SNACKS -nutritional supplement
bar.................................................................................. 136
GLUCERNA -nutritional supplement bar.........................136
GLUCERNA -nutritional supplement liquid..................... 136
GLUCERNA OS -nutritional supplement liquid............... 136
GLUCERNA SELECT -nutritional supplement liquid...... 136
GLUCERNA SHAKE -nutritional supplement liquid........ 136
GLUCERNA SNACK -nutritional supplement bar........... 136
GLUCERNA SNACK SHAKE -nutritional supplement
liquid.............................................................................. 136
GLUCERNA WEIGHT LOSS SHAK -nutritional
supplement liquid.......................................................... 136
GLUCERNA 1.0 WITH CARBSTE -nutritional supplement
liquid.............................................................................. 136
GLUCO BURST -nutritional supplement liquid............... 136
glucose gel 40%............................................................... 32
GLUCOSE -glucose chew tab 4 gm................................. 32
GLUCOSE -glucose-vitamin c chew tab 4-0.006 gm........ 32
glucose oral liquid 15 gm/59ml...................................... 32
GLUMETZA -metformin hcl tab sr 24hr modified release
500 mg............................................................................ 32
GLUMETZA -metformin hcl tab sr 24hr modified release
1000 mg.......................................................................... 32
GLUTARADE AMINO ACID BLEN -amino acids oral
powder........................................................................... 131
GLUTARADE ESSENTIAL GA-1 -amino acids oral
powder........................................................................... 131
GLUTARADE JUNIOR GA-1 -amino acids oral
powder........................................................................... 131
GLUTAREX-1 -nutritional supplement powder................136
GLUTAREX-2 -nutritional supplement powder................136
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 32
glyburide-metformin tab 2.5-500 mg (Glucovance)..... 32
glyburide-metformin tab 5-500 mg (Glucovance)........ 32
glyburide micronized tab 1.5 mg (Glynase)..................32
glyburide micronized tab 3 mg (Glynase).....................32
glyburide micronized tab 6 mg (Glynase).....................32
glyburide tab 1.25 mg..................................................... 32
glyburide tab 2.5 mg....................................................... 32
glyburide tab 5 mg.......................................................... 32
glycopyrrolate tab 1 mg (Robinul)................................. 69
glycopyrrolate tab 2 mg (Robinul forte)........................69
GLYCOSADE -nutritional supplement pack.................... 136
GLYSET -miglitol tab 25 mg.............................................. 32
GLYSET -miglitol tab 50 mg.............................................. 32
GLYSET -miglitol tab 100 mg............................................ 32
GLYTACTIN BETTERMILK DE-L -nutritional supplement
pack............................................................................... 136
GLYTACTIN BETTERMILK 15 -nutritional supplement
pack............................................................................... 136
GLYTACTIN BUILD 10PE -nutritional supplement
pack............................................................................... 136
GLYTACTIN COMPLETE 10PE -nutritional supplement
bar.................................................................................. 136
GLYTACTIN RESTORE LITE 10 -nutritional supplement
liquid.............................................................................. 136
GLYTACTIN RESTORE LITE 10 -nutritional supplement
pack............................................................................... 137
GLYTACTIN RESTORE 10 -nutritional supplement
liquid.............................................................................. 137
GLYTACTIN RESTORE 5 -nutritional supplement
pack............................................................................... 137
GLYTACTIN RTD 10 -nutritional supplement liquid........ 137
GLYTACTIN RTD 15 -nutritional supplement liquid........ 137
GLYTROL -nutritional supplement liquid......................... 137
GLYTROL PREBIO1 -nutritional supplement liquid........ 137
GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 32
GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 32
GNP NUTRITIONAL DRINK -nutritional supplement
liquid.............................................................................. 137
GNP NUTRITIONAL DRINK PLU -nutritional supplement
liquid.............................................................................. 137
GNP VITAMIN D-400 -calcium carbonate-cholecalciferol
tab 90 mg-400 unit....................................................... 130
GOAT MILK -nutritional supplement powder.................. 137
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm............................................................. 68
G-PREPROTEIN -amino acids oral liquid....................... 131
GRALISE -gabapentin (once-daily) tab 300 mg................93
GRALISE -gabapentin (once-daily) tab 600 mg................93
GRALISE STARTER -gabapentin (once-daily) tab pack
300 mg (9) & 600 mg (69)............................................. 93
granisetron hcl tab 1 mg................................................ 71
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 152
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml...................................................................... 152
GRASTEK -timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 17
griseofulvin microsize susp 125 mg/5ml........................ 6
griseofulvin microsize tab 500 mg (Grifulvin v)............. 6
griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 6
griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 6
guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 62
guaifenesin-codeine soln 100-6.3 mg/5ml.................... 62
guaifenesin-codeine soln 100-10 mg/5ml..................... 62
guanfacine hcl tab 1 mg (Tenex)................................... 51
guanfacine hcl tab 2 mg (Tenex)................................... 51
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv).......................................................................... 90
guanfacine hcl tab sr 24hr 2 mg (base equiv)
(Intuniv).......................................................................... 90
guanfacine hcl tab sr 24hr 3 mg (base equiv)
(Intuniv).......................................................................... 90
guanfacine hcl tab sr 24hr 4 mg (base equiv)
(Intuniv).......................................................................... 90
GUANIDINE HCL -guanidine hcl tab 125 mg................. 119
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 76
H
HAELAN 951 FERMENTED ORGA -nutritional
supplement liquid.......................................................... 137
HAELAN HTPI FERMENTED ORG -nutritional
supplement liquid.......................................................... 137
halobetasol propionate cream 0.05% (Ultravate)....... 174
halobetasol propionate oint 0.05% (Ultravate)........... 175
HALOG -halcinonide cream 0.1%................................... 175
HALOG -halcinonide oint 0.1%....................................... 175
haloperidol lactate oral conc 2 mg/ml...........................84
haloperidol tab 0.5 mg.................................................... 84
haloperidol tab 1 mg....................................................... 84
haloperidol tab 2 mg....................................................... 84
haloperidol tab 5 mg....................................................... 84
haloperidol tab 10 mg..................................................... 84
haloperidol tab 20 mg..................................................... 84
HALOTIN -haloprogin cream 1%.................................... 175
HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 8
HCU ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 137
HCU ANAMIX NEXT -nutritional supplement
powder........................................................................... 137
HCU COOLER -nutritional supplement liquid................. 137
HCU EXPRESS -nutritional supplement pack................ 137
HCU EXPRESS20 -nutritional supplement pack............ 137
HCU GEL -nutritional supplement pack.......................... 137
HCU LOPHLEX LQ -nutritional supplement liquid.......... 137
HCY 1 -nutritional supplement powder........................... 137
HCY 2 -nutritional supplement powder........................... 137
HEALTH SOURCE SOY PROTEIN -nutritional
supplement powder...................................................... 137
HEALTHY ACCENTS NUTRA FIT -nutritional supplement
liquid.............................................................................. 137
HEARTBAR -nutritional supplement bar......................... 137
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit.................................................................... 158
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 500 unit.................................................................... 158
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit.................................................................. 158
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 2000 unit.................................................................. 158
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 3000 unit.................................................................. 158
HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml (3.75
mg/ml base equiv).......................................................... 44
HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg....................................................... 152
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck.................................... 122
HEMENATAL OB -prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg........................................................... 121
HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg........................................................... 152
HEMOCYTE PLUS -ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg.............................................. 152
HEMOFIL M -antihemophilic factor (human) for inj 250
unit................................................................................. 158
HEMOFIL M -antihemophilic factor (human) for inj 500
unit................................................................................. 159
HEMOFIL M -antihemophilic factor (human) for inj 1000
unit................................................................................. 159
HEMOFIL M -antihemophilic factor (human) for inj 1700
unit................................................................................. 159
HEPAGAM B -hepatitis b immune globulin (human) inj
soln.................................................................................. 16
HEPAMENT -amino acids pack.......................................131
heparin sodium (porcine) inj 1000 unit/ml.................. 155
heparin sodium (porcine) inj 5000 unit/ml.................. 155
heparin sodium (porcine) inj 10000 unit/ml................ 155
heparin sodium (porcine) inj 20000 unit/ml................ 155
heparin sodium (porcine) pf inj 5000 unit/0.5ml........ 155
HETLIOZ -tasimelteon capsule 20 mg.............................. 88
HEXALEN -altretamine cap 50 mg................................... 19
HI-CAL -nutritional supplement liquid..............................137
HIGH-PROTEIN NUTRITIONAL -nutritional supplement
liquid.............................................................................. 137
HISTEX-AC -phenylephrine-triprolidine-codeine syrup
10-2.5-10 mg/5ml............................................................ 62
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
HM NUTRISURE -nutritional supplement liquid..............137
HM NUTRISURE PLUS -nutritional supplement
liquid.............................................................................. 137
HOMACTIN AA PLUS -nutritional supplement liquid...... 137
homatropine hbr ophth soln 5% (Isopto
homatropine)............................................................... 164
HOMINEX-1 -nutritional supplement powder.................. 137
HOMINEX-2 -nutritional supplement powder.................. 137
HOM 2 -nutritional supplement powder.......................... 137
HORIZANT -gabapentin enacarbil tab cr 300 mg............. 93
HORIZANT -gabapentin enacarbil tab cr 600 mg............. 93
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 40
HPR -dermatological products, misc. - aerosol foam......175
HPR PLUS -dermatological products, misc. - aerosol
foam............................................................................... 175
HPR PLUS -dermatological products misc - cream........ 175
HUMALOG -insulin lispro inj 100 unit/ml...........................35
HUMALOG -insulin lispro soln cartridge 100 unit/ml.........35
HUMALOG KWIKPEN -insulin lispro soln pen-injector 100
unit/ml.............................................................................. 35
HUMALOG KWIKPEN -insulin lispro soln pen-injector 200
unit/ml.............................................................................. 35
HUMALOG MIX 75/25 -insulin lispro prot & lispro inj 100
unit/ml (75-25)................................................................. 36
HUMALOG MIX 50/50 -insulin lispro protamine & lispro inj
100 unit/ml (50-50)......................................................... 36
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................36
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................36
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit.................................................................. 159
HUMATE-P -antihemophilic factor/vwf (human) for inj
500-1200 unit................................................................ 159
HUMATE-P -antihemophilic factor/vwf (human) for inj
1000-2400 unit.............................................................. 159
HUMIRA -adalimumab prefilled syringe kit 10
mg/0.2ml........................................................................ 106
HUMIRA -adalimumab prefilled syringe kit 20
mg/0.4ml........................................................................ 106
HUMIRA -adalimumab prefilled syringe kit 40
mg/0.8ml........................................................................ 106
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled
syringe kit 40 mg/0.8ml................................................ 106
HUMIRA PEN -adalimumab pen-injector kit 40
mg/0.8ml........................................................................ 106
HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml................................................ 106
HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml................................................ 106
HUMULIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 36
HUMULIN 70/30 KWIKPEN -insulin nph & regular susp
pen-inj 100 unit/ml (70-30)............................................. 36
HUMULIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 36
HUMULIN N KWIKPEN -insulin nph (human) (isophane)
susp pen-injector 100 unit/ml......................................... 36
HUMULIN R -insulin regular (human) inj 100 unit/ml........ 36
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml..................................................................36
HUMULIN R U-500 KWIKPEN -insulin regular (human)
soln pen-injector 500 unit/ml.......................................... 36
HURRISEAL -dental desensitizing product - solution..... 183
hyaluronate sodium (emollient) gel 0.2% (Hylira)...... 175
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 19
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 19
HYCOFENIX -pseudoephedrine w/ hydrocodone-gg soln
30-2.5-200 mg/5ml.......................................................... 62
hydralazine hcl tab 10 mg.............................................. 51
hydralazine hcl tab 25 mg.............................................. 51
hydralazine hcl tab 50 mg.............................................. 51
hydralazine hcl tab 100 mg............................................ 51
hydrochlorothiazide cap 12.5 mg (Microzide).............. 55
hydrochlorothiazide tab 12.5 mg................................... 55
hydrochlorothiazide tab 25 mg...................................... 55
hydrochlorothiazide tab 50 mg...................................... 55
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................99
hydrocodone-acetaminophen soln 10-325 mg/15ml
(Zamicet).........................................................................99
hydrocodone-acetaminophen tab 2.5-325 mg.............. 99
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 99
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 99
hydrocodone-acetaminophen tab 10-325 mg
(Norco)............................................................................ 99
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................ 99
hydrocodone-acetaminophen tab 5-300 mg
(Xodol)............................................................................ 99
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)............................................................................ 99
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 99
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......99
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)................................................................... 99
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 62
hydrocodone w/ homatropine tab 5-1.5 mg..................62
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
(Tussionex pennkineti)................................................. 62
hydrocortisone acetate suppos 25 mg (Anusolhc)................................................................................. 169
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
hydrocortisone acetate suppos 30 mg
(Proctocort).................................................................. 169
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc).................................................... 169
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc)................................................. 169
hydrocortisone butyrate cream 0.1% (Locoid)...........175
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................ 175
hydrocortisone butyrate oint 0.1% (Locoid)............... 175
hydrocortisone butyrate soln 0.1% (Locoid).............. 175
hydrocortisone cream 2.5%..........................................175
hydrocortisone enema 100 mg/60ml
(Cortenema)................................................................. 169
hydrocortisone lotion 2.5%.......................................... 175
hydrocortisone lotion 2% (Ala scalp).......................... 175
hydrocortisone oint 2.5%..............................................175
hydrocortisone rectal cream 2.5% (Anusol-hc)......... 169
hydrocortisone rectal cream 1% (Proctocort)............ 169
hydrocortisone tab 5 mg (Cortef).................................. 23
hydrocortisone tab 10 mg (Cortef)................................ 23
hydrocortisone tab 20 mg (Cortef)................................ 23
hydrocortisone valerate cream 0.2%...........................175
hydrocortisone valerate oint 0.2% (Westcort)............ 175
hydrocortisone w/ acetic acid otic soln 1-2%............ 167
HYDROMORPHONE HCL -hydromorphone hcl suppos 3
mg.................................................................................... 99
hydromorphone hcl liqd 1 mg/ml (Dilaudid).................99
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo).......................................................................... 99
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo).......................................................................... 99
hydromorphone hcl tab er 24hr deter 16 mg
(Exalgo).......................................................................... 99
hydromorphone hcl tab er 24hr deter 32 mg
(Exalgo).......................................................................... 99
hydromorphone hcl tab 2 mg (Dilaudid)....................... 99
hydromorphone hcl tab 4 mg (Dilaudid)....................... 99
hydromorphone hcl tab 8 mg (Dilaudid)....................... 99
hydroxychloroquine sulfate tab 200 mg
(Plaquenil)...................................................................... 12
hydroxyurea cap 500 mg (Hydrea)................................ 19
hydroxyzine hcl syrup 10 mg/5ml................................. 78
hydroxyzine hcl tab 10 mg............................................. 78
hydroxyzine hcl tab 25 mg............................................. 78
hydroxyzine hcl tab 50 mg............................................. 78
hydroxyzine pamoate cap 25 mg (Vistaril)................... 78
hydroxyzine pamoate cap 50 mg (Vistaril)................... 78
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................ 78
HYLATOPIC PLUS -dermatological products, misc. aerosol foam................................................................. 175
HYLATOPIC PLUS -dermatological products misc cream............................................................................. 175
HYLIRA -hyaluronate sodium (emollient) lotion 0.1%..... 175
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 69
hyoscyamine sulfate soln 0.125 mg/ml......................... 70
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)..... 70
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 70
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)......... 70
hyoscyamine sulfate tab sr 12hr 0.375 mg
(Levbid)........................................................................... 70
HYPERHEP B S/D -hepatitis b immune globulin (human)
im inj soln........................................................................ 17
HYPERRAB S/D -rabies immune globulin (human) inj 150
unit/ml.............................................................................. 17
HYPERSAL -sodium chloride soln nebu 3.5%..................62
HYPERTET S/D -tetanus immune globulin (human) inj
250 unit/ml.......................................................................17
HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200
unt/1.25 ml kit................................................................. 17
HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400
unt/2.5 ml kit................................................................... 17
HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800
unt/5 ml kit...................................................................... 17
HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600
unt/10 ml kit.................................................................... 17
HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400
unt/15 ml kit.................................................................... 17
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
20 mg.............................................................................. 99
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
30 mg.............................................................................. 99
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
40 mg.............................................................................. 99
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
60 mg............................................................................ 100
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
80 mg............................................................................ 100
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
100 mg.......................................................................... 100
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
120 mg.......................................................................... 100
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva).......................................................................... 40
IBRANCE -palbociclib cap 75 mg..................................... 19
IBRANCE -palbociclib cap 100 mg................................... 19
IBRANCE -palbociclib cap 125 mg................................... 19
ibuprofen tab 400 mg.................................................... 106
ibuprofen tab 600 mg.................................................... 106
ibuprofen tab 800 mg.................................................... 106
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(elemental iron)............................................................. 152
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 19
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 19
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
250 unit......................................................................... 159
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
500 unit......................................................................... 159
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
1000 unit....................................................................... 159
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
2000 unit....................................................................... 159
ILEVRO -nepafenac ophth susp 0.3%............................ 164
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)........................................................................ 19
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)........................................................................ 19
IMBRUVICA -ibrutinib cap 140 mg................................... 19
imipramine hcl tab 10 mg (Tofranil).............................. 81
imipramine hcl tab 25 mg (Tofranil).............................. 81
imipramine hcl tab 50 mg (Tofranil).............................. 81
imipramine pamoate cap 75 mg (Tofranil-pm)............. 81
imipramine pamoate cap 100 mg (Tofranil-pm)........... 81
imipramine pamoate cap 125 mg (Tofranil-pm)........... 81
imipramine pamoate cap 150 mg (Tofranil-pm)........... 81
imiquimod cream 5% (Aldara)...................................... 175
IMITREX -sumatriptan nasal spray 5 mg/act.................. 108
IMITREX -sumatriptan nasal spray 20 mg/act................ 108
IMMULIFE -nutritional supplement powder..................... 138
IMMUNOPRO RX -nutritional supplement powder......... 138
IMOGAM RABIES-HT -rabies immune globulin (human)
inj 150 unit/ml..................................................................17
IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc
inj..................................................................................... 15
IMPACT/FIBER -nutritional supplement liquid................ 138
IMPACT ADVANCED RECOVERY -nutritional
supplement liquid.......................................................... 138
IMPACT GLUTAMINE -nutritional supplement liquid...... 138
IMPACT -nutritional supplement liquid............................ 138
IMPACT 1.5 -nutritional supplement liquid...................... 138
IMPACT PEPTIDE 1.5 -nutritional supplement liquid..... 138
IMPAVIDO -miltefosine cap 50 mg.................................... 12
IMUPLUS -nutritional supplement pack.......................... 138
INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................122
INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................. 122
INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 122
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........40
indapamide tab 1.25 mg..................................................55
indapamide tab 2.5 mg.................................................... 55
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 44
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 44
indomethacin cap cr 75 mg.......................................... 106
indomethacin cap 25 mg.............................................. 106
indomethacin cap 50 mg.............................................. 106
INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha
cap 29-1-265 mg.......................................................... 122
INFANRIX -diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml............................................................... 16
INFASURF -calfactant in nacl 0.9% intratracheal susp 35
mg/ml............................................................................... 67
INLYTA -axitinib tab 1 mg.................................................. 19
INLYTA -axitinib tab 5 mg.................................................. 19
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 44
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 44
INNOVACIN -nutritional supplement liquid......................138
INSTA-GLUCOSE -glucose gel 77.4%............................. 32
INSULIN PEN NEEDLES-VARIOUS............................... 183
INSULIN SYRINGES-VARIOUS...................................... 183
INTEGRA F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)................................... 152
INTEGRA PLUS -fe fum-iron polysacch complex-fa-b
complex-c-biotin cap..................................................... 152
INTELENCE -etravirine tab 25 mg...................................... 8
INTELENCE -etravirine tab 100 mg.................................... 8
INTELENCE -etravirine tab 200 mg.................................... 8
INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/
ml & lidocaine 1% & ammonia inh kit............................ 23
INTROLITE -nutritional supplement liquid.......................138
INTRON A -interferon alfa-2b for inj 10000000 unit.......... 19
INTRON A -interferon alfa-2b for inj 18000000 unit.......... 19
INTRON A -interferon alfa-2b for inj 50000000 unit.......... 19
INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 19
INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 19
INTRON A W/DILUENT -interferon alfa-2b for inj
10000000 unit................................................................. 19
INTRON A W/DILUENT -interferon alfa-2b for inj
18000000 unit................................................................. 19
INTRON A W/DILUENT -interferon alfa-2b for inj
50000000 unit................................................................. 20
INVEGA -paliperidone tab sr 24hr 1.5 mg........................ 84
INVEGA -paliperidone tab sr 24hr 3 mg........................... 84
INVEGA -paliperidone tab sr 24hr 6 mg........................... 84
INVEGA -paliperidone tab sr 24hr 9 mg........................... 84
INVIRASE -saquinavir mesylate cap 200 mg..................... 8
INVIRASE -saquinavir mesylate tab 500 mg...................... 8
INVOKAMET -canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 32
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
INVOKAMET -canagliflozin-metformin hcl tab 150-500
mg.................................................................................... 32
INVOKAMET -canagliflozin-metformin hcl tab 50-1000
mg.................................................................................... 32
INVOKAMET -canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 32
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 32
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
50-1000 mg..................................................................... 32
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
150-500 mg..................................................................... 32
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
150-1000 mg................................................................... 33
INVOKANA -canagliflozin tab 100 mg.............................. 33
INVOKANA -canagliflozin tab 300 mg.............................. 33
IODINE STRONG -iodine solution strong 5%
(lugol's).......................................................................... 130
iodoquinol-hc cream 1%............................................... 175
iodoquinol-hydrocortisone in aloe vehicle cream
1-1.9% (Vytone)........................................................... 175
IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act
(base equiv).................................................................. 100
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 164
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 65
ipratropium bromide inhal soln 0.02%.......................... 65
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)....................................................................... 62
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)....................................................................... 62
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................51
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................51
irbesartan tab 75 mg (Avapro)....................................... 51
irbesartan tab 150 mg (Avapro)..................................... 51
irbesartan tab 300 mg (Avapro)..................................... 51
IRESSA -gefitinib tab 250 mg........................................... 20
IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg
(elemental iron)............................................................. 152
iron combination cap.................................................... 152
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1
mg (Hematron-af)........................................................ 153
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................ 153
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg................................................................................. 153
IROSPAN 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-cca-fa tab ther pk........................................................... 153
IS 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-c-ca-fa tab
ther pk........................................................................... 153
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)................................................................................. 8
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv)...................................................................... 8
ISENTRESS -raltegravir potassium packet for susp 100
mg (base equiv)................................................................ 8
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)................................................................................. 8
ISOCAL HN -nutritional supplement liquid...................... 138
ISOCAL HN PLUS -nutritional supplement liquid........... 138
ISOCAL -nutritional supplement liquid............................ 138
isometheptene-caffeine-acetaminophen tab 65-20-325
mg (Prodrin)................................................................ 108
isometheptene-dichloral-acetaminophen cap
65-100-325 mg............................................................. 108
ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 5
isoniazid tab 100 mg......................................................... 5
isoniazid tab 300 mg......................................................... 5
ISORDIL TITRADOSE -isosorbide dinitrate tab 40
mg.................................................................................... 42
ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr
40 mg.............................................................................. 42
isosorbide dinitrate tab 10 mg....................................... 42
isosorbide dinitrate tab 20 mg....................................... 42
isosorbide dinitrate tab 30 mg....................................... 42
isosorbide dinitrate tab 5 mg (Isordil titradose).......... 42
isosorbide mononitrate tab 10 mg................................ 43
isosorbide mononitrate tab 20 mg................................ 43
isosorbide mononitrate tab sr 24hr 30 mg................... 42
isosorbide mononitrate tab sr 24hr 60 mg................... 42
isosorbide mononitrate tab sr 24hr 120 mg................. 42
ISOSOURCE 1.5 CAL -nutritional supplement liquid......138
ISOSOURCE CLOSED SYSTEM -nutritional supplement
liquid.............................................................................. 138
ISOSOURCE HN -nutritional supplement liquid............. 138
ISOSOURCE -nutritional supplement liquid.................... 138
ISOSOURCE VHN -nutritional supplement liquid........... 138
isotretinoin cap 10 mg.................................................. 175
isotretinoin cap 20 mg.................................................. 175
isotretinoin cap 30 mg.................................................. 175
isotretinoin cap 40 mg.................................................. 175
ISOVACTIN AA PLUS -nutritional supplement liquid...... 138
ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg.............. 60
isoxsuprine hcl tab 10 mg.............................................. 60
isradipine cap 2.5 mg...................................................... 46
isradipine cap 5 mg......................................................... 46
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 164
itraconazole cap 100 mg (Sporanox).............................. 6
IVA ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 138
IVA ANAMIX NEXT -nutritional supplement powder....... 138
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
I-VALEX-1 -nutritional supplement powder..................... 137
I-VALEX-2 -nutritional supplement powder..................... 138
ivermectin tab 3 mg (Stromectol).................................. 12
IXINITY -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 159
IXINITY -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 159
IXINITY -coagulation factor ix (recombinant) for inj 1000
unit................................................................................. 159
IXINITY -coagulation factor ix (recombinant) for inj 1500
unit................................................................................. 159
IXINITY -coagulation factor ix (recombinant) for inj 2000
unit................................................................................. 159
IXINITY -coagulation factor ix (recombinant) for inj 3000
unit................................................................................. 159
J
JADENU -deferasirox tab 90 mg..................................... 182
JADENU -deferasirox tab 180 mg................................... 182
JADENU -deferasirox tab 360 mg................................... 182
JAKAFI -ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 20
JAKAFI -ruxolitinib phosphate tab 10 mg (base
equivalent)....................................................................... 20
JAKAFI -ruxolitinib phosphate tab 15 mg (base
equivalent)....................................................................... 20
JAKAFI -ruxolitinib phosphate tab 20 mg (base
equivalent)....................................................................... 20
JAKAFI -ruxolitinib phosphate tab 25 mg (base
equivalent)....................................................................... 20
JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg.......... 77
JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 33
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 33
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 33
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-1000 mg..................................................................... 33
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 33
JANUVIA -sitagliptin phosphate tab 25 mg (base
equiv)............................................................................... 33
JANUVIA -sitagliptin phosphate tab 50 mg (base
equiv)............................................................................... 33
JANUVIA -sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 33
JARDIANCE -empagliflozin tab 10 mg............................. 33
JARDIANCE -empagliflozin tab 25 mg............................. 33
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 33
JENTADUETO -linagliptin-metformin hcl tab 2.5-500
mg.................................................................................... 33
JENTADUETO -linagliptin-metformin hcl tab 2.5-850
mg.................................................................................... 33
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 33
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 33
JEVITY 1 CAL/FIBER -nutritional supplement liquid...... 138
JEVITY 1.2 CAL/FIBER -nutritional supplement
liquid.............................................................................. 138
JEVITY 1.5 CAL/FIBER -nutritional supplement
liquid.............................................................................. 138
JEVITY 1 CAL -nutritional supplement liquid.................. 138
JEVITY 1.2 CAL -nutritional supplement liquid............... 138
JEVITY 1.5 CAL -nutritional supplement liquid............... 138
JTT PHYSICIANS KIT -triamcinolone inj 40 mg/ml &
lidocaine 1% & ammonia inh kit..................................... 23
JUBLIA -efinaconazole soln 10%.................................... 175
JUICE PLUS FIBRE -nutritional supplement liquid......... 138
JUVEN -nutritional supplement pack.............................. 138
JUVEN -nutritional supplement powder.......................... 138
JUVEN NUTRIVIGOR -nutritional supplement pack.......138
JUVEN REVIGOR -nutritional supplement pack.............138
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)............................................................................... 58
JUXTAPID -lomitapide mesylate cap 10 mg (base
equiv)............................................................................... 58
JUXTAPID -lomitapide mesylate cap 20 mg (base
equiv)............................................................................... 58
JUXTAPID -lomitapide mesylate cap 30 mg (base
equiv)............................................................................... 58
JUXTAPID -lomitapide mesylate cap 40 mg (base
equiv)............................................................................... 58
JUXTAPID -lomitapide mesylate cap 60 mg (base
equiv)............................................................................... 58
K
KADIAN -morphine sulfate cap sr 24hr 40 mg................100
KADIAN -morphine sulfate cap sr 24hr 200 mg.............. 100
KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)................................................................................ 8
KALETRA -lopinavir-ritonavir tab 100-25 mg...................... 8
KALETRA -lopinavir-ritonavir tab 200-50 mg...................... 8
KALYDECO -ivacaftor packet 50 mg................................ 67
KALYDECO -ivacaftor packet 75 mg................................ 67
KALYDECO -ivacaftor tab 150 mg.................................... 68
KARBINAL ER -carbinoxamine maleate extended release
susp 4 mg/5ml................................................................ 61
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 33
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 33
KCENTRA -prothrombin complex conc human for inj kit
500 unit......................................................................... 159
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
KCENTRA -prothrombin complex conc human for inj kit
1000 unit....................................................................... 159
KENALOG -triamcinolone acetonide aerosol soln 0.147
mg/gm............................................................................ 175
KERYDIN -tavaborole soln 5%........................................175
KETOCAL 4:1 LQ MULTI FIBE -nutritional supplement
liquid.............................................................................. 139
KETOCAL 4:1 -nutritional supplement liquid.................. 139
KETOCAL 3:1 -nutritional supplement powder............... 138
KETOCAL 4:1 -nutritional supplement powder............... 139
ketoconazole cream 2%................................................ 175
ketoconazole foam 2% (Extina)................................... 175
ketoconazole shampoo 2% (Nizoral)........................... 175
ketoconazole tab 200 mg.................................................. 6
KETOGEN -nutritional supplement powder.................... 139
KETONE BLOOD TEST STRIPS-VARIOUS.................. 183
KETONEX-1 -nutritional supplement powder..................139
KETONEX-2 -nutritional supplement powder..................139
ketoprofen cap 50 mg................................................... 106
ketoprofen cap 75 mg................................................... 106
ketorolac tromethamine ophth soln 0.5%
(Acular)......................................................................... 164
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 164
ketorolac tromethamine tab 10 mg............................. 106
KETOVIE -nutritional supplement liquid.......................... 139
KETOVIE PEPTIDE -nutritional supplement liquid......... 139
KETOVOLVE 4:1 -nutritional supplement powder.......... 139
KEVEYIS -dichlorphenamide tab 50 mg........................... 55
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg............... 81
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg............. 81
KINERET -anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml.............................................................. 106
KINRAY PREFERRED PLUS -nutritional supplement
liquid.............................................................................. 139
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj.............................................................................. 16
KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 5
KLOR-CON/25 -potassium chloride powder packet 25
meq................................................................................ 130
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq....................................................... 130
KOATE -antihemophilic factor (human) for inj 250
unit................................................................................. 159
KOATE -antihemophilic factor (human) for inj 500
unit................................................................................. 159
KOATE -antihemophilic factor (human) for inj 1000
unit................................................................................. 159
KOATE-DVI -antihemophilic factor (human) for inj 250
unit................................................................................. 159
KOATE-DVI -antihemophilic factor (human) for inj 500
unit................................................................................. 159
KOATE-DVI -antihemophilic factor (human) for inj 1000
unit................................................................................. 159
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 250 unit............................................................... 159
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 500 unit............................................................... 159
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 1000 unit............................................................. 160
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 2000 unit............................................................. 160
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 3000 unit............................................................. 160
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................. 160
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 500 unit.................................. 160
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 1000 unit................................ 160
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 2000 unit................................ 160
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 3000 unit................................ 160
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 33
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 33
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 33
KORLYM -mifepristone tab 300 mg.................................. 33
KOVALTRY -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 160
KOVALTRY -antihemophilic factor (recombinant) for inj
500 unit......................................................................... 160
KOVALTRY -antihemophilic factor (recombinant) for inj
1000 unit....................................................................... 160
KOVALTRY -antihemophilic factor (recombinant) for inj
2000 unit....................................................................... 160
KOVALTRY -antihemophilic factor (recombinant) for inj
3000 unit....................................................................... 160
K-PAX IMMUNE BOOSTER PROT -nutritional
supplement powder...................................................... 138
K-PHOS NO 2 -potassium & sodium acid phosphates tab
305-700 mg..................................................................... 77
K-PHOS -potassium phosphate monobasic tab 500
mg.................................................................................. 130
KRISTALOSE -lactulose oral crystal packet 10 gm.......... 68
KRISTALOSE -lactulose oral crystal packet 20 gm.......... 68
KROGER GLUCOSE -glucose-vitamin c chew tab
4-0.006 gm...................................................................... 33
K-TAB -potassium chloride tab cr 8 meq (600 mg)......... 130
K-TAB -potassium chloride tab cr 20 meq (1500 mg)..... 130
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 40
KUVAN -sapropterin dihydrochloride powder packet 500
mg.................................................................................... 40
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 40
KYNAMRO -mipomersen sodium soln prefilled syringe
200 mg/ml....................................................................... 58
L
labetalol hcl tab 100 mg (Trandate)............................... 44
labetalol hcl tab 200 mg (Trandate)............................... 44
labetalol hcl tab 300 mg (Trandate)............................... 44
LACRISERT -artificial tear ophth insert...........................164
lactic acid (ammonium lactate) cream 12% (Lachydrin).......................................................................... 175
lactic acid (ammonium lactate) lotion 10%.................175
lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 175
lactic acid w/ vitamin e cream 10%-3500
unit/30gm......................................................................175
lactulose (encephalopathy) solution 10 gm/15ml........ 73
lactulose solution 10 gm/15ml....................................... 68
LAMICTAL ODT -lamotrigine orally disintegrating tab 25
mg.................................................................................. 111
LAMICTAL ODT -lamotrigine orally disintegrating tab 50
mg.................................................................................. 111
LAMICTAL ODT -lamotrigine orally disintegrating tab 100
mg.................................................................................. 112
LAMICTAL ODT -lamotrigine orally disintegrating tab 200
mg.................................................................................. 112
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit.................................................... 112
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit................................................................ 112
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit....................................................... 112
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit.........................................112
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit.......................................112
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit............................................................... 112
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit..................................................... 112
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit................................................ 112
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit......................................................... 112
lamivudine oral soln 10 mg/ml (Epivir)........................... 8
lamivudine tab 150 mg (Epivir)........................................ 8
lamivudine tab 300 mg (Epivir)........................................ 8
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 8
lamivudine-zidovudine tab 150-300 mg (Combivir)....... 8
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt)................................................................................ 112
lamotrigine orally disintegrating tab 50 mg (Lamictal
odt)................................................................................ 112
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt)................................................................................ 112
lamotrigine orally disintegrating tab 200 mg (Lamictal
odt)................................................................................ 112
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................ 112
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................ 112
lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7)
kit (LAMICTAL ODT)................................................... 112
lamotrigine tab disp 25 mg (21) & 50 mg (7) titration
kit (LAMICTAL ODT)................................................... 112
lamotrigine tab disp 50 mg (42) & 100 mg (14) titration
kit (LAMICTAL ODT)................................................... 112
lamotrigine tab 25 mg (Lamictal)................................. 112
lamotrigine tab 100 mg (Lamictal)............................... 112
lamotrigine tab 150 mg (Lamictal)............................... 112
lamotrigine tab 200 mg (Lamictal)............................... 113
lamotrigine tab sr 24hr 25 mg (Lamictal xr)............... 112
lamotrigine tab sr 24hr 50 mg (Lamictal xr)............... 112
lamotrigine tab sr 24hr 100 mg (Lamictal xr)............. 112
lamotrigine tab sr 24hr 200 mg (Lamictal xr)............. 112
lamotrigine tab sr 24hr 250 mg (Lamictal xr)............. 112
lamotrigine tab sr 24hr 300 mg (Lamictal xr)............. 112
LANAFLEX -nutritional supplement pack........................ 139
LANCETS-VARIOUS........................................................183
LANCING DEVICE-VARIOUS......................................... 183
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 42
LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 42
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 42
LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 42
lansoprazole cap delayed release 15 mg
(Prevacid)....................................................................... 70
lansoprazole cap delayed release 30 mg
(Prevacid)....................................................................... 70
LANTUS -insulin glargine inj 100 unit/ml.......................... 37
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml.......................................................................37
LASTACAFT -alcaftadine ophth soln 0.25%................... 164
latanoprost ophth soln 0.005% (Xalatan).................... 164
LATUDA -lurasidone hcl tab 20 mg...................................84
LATUDA -lurasidone hcl tab 40 mg...................................84
LATUDA -lurasidone hcl tab 60 mg...................................84
LATUDA -lurasidone hcl tab 80 mg...................................84
LATUDA -lurasidone hcl tab 120 mg.................................84
LAVARE WOUND WASH -wound cleansers - gel.......... 176
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LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)............................................................................. 100
LAZANDA -fentanyl citrate nasal spray 300 mcg/act (base
equiv)............................................................................. 100
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)............................................................................. 100
L-CARNITINE -amino acids oral liquid............................ 131
LECITHIN -lecithin granules............................................ 131
leflunomide tab 10 mg (Arava)..................................... 106
leflunomide tab 20 mg (Arava)..................................... 106
LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)............................... 20
LENVIMA 18 MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 (2) mg (18 mg daily dose)......................... 20
LENVIMA 24 MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) & 4 mg (24 mg daily dose)......................... 20
LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapy
pack 10 mg (10 mg daily dose)..................................... 20
LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) mg (20 mg daily dose)................................ 20
LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapy
pack 4 (2) mg (8 mg daily dose).................................... 20
LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg......... 58
LETAIRIS -ambrisentan tab 5 mg..................................... 60
LETAIRIS -ambrisentan tab 10 mg................................... 60
letrozole tab 2.5 mg (Femara)........................................ 20
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 20
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 20
leucovorin calcium tab 5 mg.......................................... 20
leucovorin calcium tab 25 mg........................................ 20
LEU-FREE COOLER -nutritional supplement liquid....... 139
LEUKERAN -chlorambucil tab 2 mg................................. 20
LEUKINE -sargramostim lyophilized for inj 250 mcg...... 153
leuprolide acetate inj kit 5 mg/ml.................................. 20
LEVACET -aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg..................................................... 96
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)..................................... 65
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)....................................................................... 66
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)....................................................................... 66
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex)....................................................................... 66
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml.......................................................................37
LEVEMIR -insulin detemir inj 100 unit/ml..........................37
levetiracetam oral soln 100 mg/ml (Keppra)...............113
levetiracetam tab 250 mg (Keppra)............................. 113
levetiracetam tab 500 mg (Keppra)............................. 113
levetiracetam tab 750 mg (Keppra)............................. 113
levetiracetam tab 1000 mg (Keppra)........................... 113
levetiracetam tab sr 24hr 500 mg (Keppra xr)............ 113
levetiracetam tab sr 24hr 750 mg (Keppra xr)............ 113
levobunolol hcl ophth soln 0.5% (Betagan)............... 164
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 40
levocarnitine tab 330 mg (Carnitor)............................... 40
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 61
levocetirizine dihydrochloride tab 5 mg (Xyzal)...........61
LEVOFLOXACIN -levofloxacin oral soln 25 mg/ml............. 5
levofloxacin ophth soln 0.5%....................................... 164
levofloxacin tab 250 mg (Levaquin)................................ 5
levofloxacin tab 500 mg (Levaquin)................................ 5
levofloxacin tab 750 mg (Levaquin)................................ 5
levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est
0.01 mg (Quartette)....................................................... 28
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg.................................................................. 28
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg................................................................................. 28
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg................................................................................. 28
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg............................... 28
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.......................................................................28
levonorgestrel tab 1.5 mg............................................... 28
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)........................................... 28
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)............................................... 28
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................. 100
levothyroxine sodium tab 25 mcg (Synthroid)............. 37
levothyroxine sodium tab 50 mcg (Synthroid)............. 37
levothyroxine sodium tab 75 mcg (Synthroid)............. 37
levothyroxine sodium tab 88 mcg (Synthroid)............. 37
levothyroxine sodium tab 100 mcg (Synthroid)........... 37
levothyroxine sodium tab 112 mcg (Synthroid)........... 37
levothyroxine sodium tab 125 mcg (Synthroid)........... 37
levothyroxine sodium tab 137 mcg (Synthroid)........... 37
levothyroxine sodium tab 150 mcg (Synthroid)........... 37
levothyroxine sodium tab 175 mcg (Synthroid)........... 37
levothyroxine sodium tab 200 mcg (Synthroid)........... 37
levothyroxine sodium tab 300 mcg (Synthroid)........... 37
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator)................................................... 176
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 8
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 8
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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LEXUSS 210 -chlorpheniramine w/ codeine liquid 2-10
mg/5ml............................................................................. 63
LIALDA -mesalamine tab delayed release 1.2 gm........... 73
lidocaine hcl gel 2%...................................................... 176
LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%............... 169
LIDOCAINE HCL -lidocaine hcl laryngotracheal soln
4%.................................................................................. 167
lidocaine hcl soln 4% (Xylocaine)............................... 176
lidocaine hcl viscous soln 2%..................................... 167
lidocaine-hydrocortisone acetate rectal cream
3-0.5%........................................................................... 169
lidocaine oint 5%........................................................... 176
lidocaine patch 5% (Lidoderm).................................... 176
lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 176
lidocaine-prilocaine cream kit 2.5-2.5%...................... 176
LINDANE -lindane shampoo 1%..................................... 176
linezolid for susp 100 mg/5ml (Zyvox).......................... 12
linezolid tab 600 mg (Zyvox).......................................... 12
LINZESS -linaclotide cap 72 mcg..................................... 73
LINZESS -linaclotide cap 145 mcg................................... 73
LINZESS -linaclotide cap 290 mcg................................... 73
liothyronine sodium tab 5 mcg (Cytomel).................... 37
liothyronine sodium tab 25 mcg (Cytomel).................. 37
liothyronine sodium tab 50 mcg (Cytomel).................. 37
LIPISTART -nutritional supplement powder.................... 139
LIPOFEN -fenofibrate cap 50 mg...................................... 58
LIPOFEN -fenofibrate cap 150 mg.................................... 58
LIQUACEL -amino acids oral liquid................................ 131
LIQUACEL PUMP + GO -amino acids oral liquid........... 131
LIQUID HOPE -nutritional supplement liquid.................. 139
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 51
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 51
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 51
lisinopril tab 5 mg (Prinivil)............................................ 51
lisinopril tab 10 mg (Prinivil).......................................... 51
lisinopril tab 20 mg (Prinivil).......................................... 51
lisinopril tab 2.5 mg (Zestril).......................................... 51
lisinopril tab 30 mg (Zestril)........................................... 51
lisinopril tab 40 mg (Zestril)........................................... 51
LISTERINE ESSENTIAL CARE -sod monofluorophospheucal-men-methyl sal-thymol gel 0.76%...................... 167
LISTERINE NATURALS WITH F -sodium fluoride rinse
0.02%.............................................................................168
LISTERINE RESTORING -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................168
LISTERINE SMART RINSE -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 168
LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 168
LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................168
LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
0.02%.............................................................................168
LISTERINE WHITENING/RESTO -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 168
lithium carbonate cap 300 mg....................................... 85
lithium carbonate cap 150 mg (Lithium carbonate)..... 85
lithium carbonate cap 600 mg (Lithium carbonate)..... 85
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 85
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 85
lithium carbonate tab cr 450 mg.................................... 85
lithium carbonate tab cr 300 mg (Lithobid).................. 85
lithium carbonate tab 300 mg........................................ 85
LITHIUM -lithium oral solution 8 meq/5ml......................... 84
LITHOBID -lithium carbonate tab cr 300 mg..................... 85
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 77
LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 58
LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 58
LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 58
LMD -nutritional supplement powder.............................. 139
L-METHYL-MC NAC -l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg............................................ 139
LOCOID -hydrocortisone butyrate lotion 0.1%................176
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)....................................................... 28
LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 20
LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 20
LOPHLEX LQ 20 -nutritional supplement liquid.............. 139
LOPHLEX -nutritional supplement pack..........................139
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
(Kaletra)............................................................................ 8
lorazepam conc 2 mg/ml (Lorazepam intensol)........... 78
lorazepam tab 0.5 mg (Ativan)....................................... 78
lorazepam tab 1 mg (Ativan).......................................... 78
lorazepam tab 2 mg (Ativan).......................................... 78
LORTAB -hydrocodone-acetaminophen soln 10-300
mg/15ml......................................................................... 100
LORZONE -chlorzoxazone tab 375 mg.......................... 118
LORZONE -chlorzoxazone tab 750 mg.......................... 118
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)....................................................................51
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).................................................... 51
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar)....................................................................51
losartan potassium tab 25 mg (Cozaar)........................ 51
losartan potassium tab 50 mg (Cozaar)........................ 52
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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losartan potassium tab 100 mg (Cozaar)...................... 52
LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 164
LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 164
LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 164
LOTRIMIN ULTRA -butenafine hcl cream 1%................ 176
LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)......... 73
LOTRONEX -alosetron hcl tab 1 mg (base equiv)............ 73
LOUTREX -antiseborrheic products misc - cream.......... 176
lovastatin tab 10 mg........................................................ 58
lovastatin tab 20 mg........................................................ 58
lovastatin tab 40 mg (Mevacor)..................................... 58
loxapine succinate cap 5 mg......................................... 85
loxapine succinate cap 10 mg....................................... 85
loxapine succinate cap 25 mg....................................... 85
loxapine succinate cap 50 mg....................................... 85
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 130
LPS CRITICAL CARE SUGAR F -nutritional supplement
liquid.............................................................................. 139
LPS SUGAR FREE -nutritional supplement liquid.......... 139
LUGOLS STRONG IODINE -iodine solution.................. 182
LUMIGAN -bimatoprost ophth soln 0.01%...................... 164
LUXAMEND -wound dressings - cream.......................... 176
LUZU -luliconazole cream 1%......................................... 176
LYNPARZA -olaparib cap 50 mg....................................... 20
LYRICA -pregabalin cap 25 mg.......................................113
LYRICA -pregabalin cap 50 mg.......................................113
LYRICA -pregabalin cap 75 mg.......................................113
LYRICA -pregabalin cap 100 mg.....................................113
LYRICA -pregabalin cap 150 mg.....................................113
LYRICA -pregabalin cap 200 mg.....................................113
LYRICA -pregabalin cap 225 mg.....................................113
LYRICA -pregabalin cap 300 mg.....................................113
LYRICA -pregabalin soln 20 mg/ml................................. 113
LYSODREN -mitotane tab 500 mg....................................20
M
MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg.......................................................... 122
MACRODANTIN -nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 74
MAGNEBIND 400 -magnesium-calcium-folic acid tab
400-200-1 mg................................................................130
malathion lotion 0.5% (Ovide)...................................... 176
MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 81
MAPROTILINE HCL -maprotiline hcl tab 50 mg............... 81
MAPROTILINE HCL -maprotiline hcl tab 75 mg............... 81
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml.............................................................. 63
MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg.................................................................. 122
MARPLAN -isocarboxazid tab 10 mg............................... 81
MATULANE -procarbazine hcl cap 50 mg........................ 20
MAXFE -iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab
160-1 mg....................................................................... 153
MAXIDEX -dexamethasone ophth susp 0.1%................ 164
MCT PRO-CAL -nutritional supplement pack................. 139
MCT PROCAL -nutritional supplement powder.............. 139
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg..................................................................... 106
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg................................................................... 106
MEDICAL PROVIDER EZ FLU S -influenza virus vac tisscult subunit pref syr kit 0.5 ml........................................ 15
MEDICAL PROVIDER EZ FLU S -influenza virus vac
types a & b pf pref syringe kit 0.5 ml............................. 15
MEDICAL PROVIDER SINGLE U -influenza vac type a&b
surface antigen pref syr kit 0.5 ml..................................15
MEDICAL PROVIDER SINGLE U -influenza virus vaccine
split pf susp pref syr kit 0.5 ml....................................... 16
MEDICAL PROVIDER SINGLE U -influenza virus vac
split quad inj prefilled syr kit 0.25 ml.............................. 16
MEDICAL PROVIDER SINGLE U -influenza virus vac
types a & b pf pref syringe kit 0.5 ml............................. 16
MEDROL -methylprednisolone tab 2 mg.......................... 23
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................ 29
medroxyprogesterone acetate im susp prefilled syr
150 mg/ml (Depo-provera contrac)............................. 28
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 30
medroxyprogesterone acetate tab 5 mg (Provera)...... 30
medroxyprogesterone acetate tab 10 mg
(Provera)......................................................................... 30
mefenamic acid cap 250 mg (Ponstel)........................ 106
mefloquine hcl tab 250 mg............................................. 12
MEGACE ES -megestrol acetate susp 625 mg/5ml......... 30
MEGA MULTIVITAMIN -multiple vitamins w/ minerals
powder........................................................................... 122
megestrol acetate susp 625 mg/5ml (Megace es)........ 30
megestrol acetate susp 40 mg/ml (Megace oral)......... 20
megestrol acetate tab 20 mg.......................................... 20
megestrol acetate tab 40 mg.......................................... 20
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................ 20
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 20
meloxicam tab 7.5 mg (Mobic)..................................... 106
meloxicam tab 15 mg (Mobic)...................................... 106
memantine hcl oral solution 2 mg/ml (Namenda)........ 93
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa)................................................. 93
memantine hcl tab 5 mg (Namenda)............................. 93
memantine hcl tab 10 mg (Namenda)........................... 93
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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M-END MAX D -pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml................................................... 63
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml....................................................63
MENEST -esterified estrogens tab 0.3 mg....................... 27
MENEST -esterified estrogens tab 0.625 mg................... 27
MENEST -esterified estrogens tab 1.25 mg..................... 27
MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 27
MENTAX -butenafine hcl cream 1%................................176
MEPERIDINE HCL/PROMETHAZI -meperidine w/
promethazine cap 50-25 mg........................................ 100
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml........................................................................... 100
meperidine hcl tab 50 mg (Demerol)........................... 100
meperidine hcl tab 100 mg (Demerol)......................... 100
MEPHYTON -phytonadione tab 5 mg............................. 119
meprobamate tab 200 mg............................................... 78
meprobamate tab 400 mg............................................... 78
mercaptopurine tab 50 mg............................................. 20
MERITENE -nutritional supplement powder................... 139
MESALAMINE DR -mesalamine tab delayed release 800
mg.................................................................................... 74
mesalamine enema 4 gm................................................ 74
MESNEX -mesna tab 400 mg........................................... 20
MESTINON -pyridostigmine bromide syrup 60
mg/5ml........................................................................... 119
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg.......................................................................... 119
METAFORM -nutritional supplement pack...................... 139
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml............................................................. 66
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 20 mg........................................................................ 66
METAXALONE -metaxalone tab 400 mg........................ 118
metaxalone tab 800 mg (Skelaxin).............................. 118
metformin hcl tab 500 mg (Glucophage)...................... 34
metformin hcl tab 850 mg (Glucophage)...................... 34
metformin hcl tab 1000 mg (Glucophage).................... 34
metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 33
metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 33
metformin hcl tab sr 24hr modified release 500 mg
(Glumetza)...................................................................... 34
metformin hcl tab sr 24hr modified release 1000 mg
(Glumetza)...................................................................... 34
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)....................................................................... 33
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)....................................................................... 33
methadone hcl conc 10 mg/ml (Methadose).............. 100
methadone hcl soln 5 mg/5ml (Methadone hcl)......... 100
methadone hcl soln 10 mg/5ml (Methadone hcl)....... 100
methadone hcl tab for oral susp 40 mg...................... 100
methadone hcl tab 10 mg (Dolophine)........................ 100
methadone hcl tab 5 mg (Dolophine hcl)................... 100
methamphetamine hcl tab 5 mg (Desoxyn).................. 90
methazolamide tab 25 mg (Neptazane)......................... 55
methazolamide tab 50 mg (Neptazane)......................... 55
methenamine hippurate tab 1 gm (Hiprex)................... 74
methenamine-hyoscamine-meth blue-sod phos cap
120 mg............................................................................ 75
methenamine-hyoscamine-meth blue-sod phos tab
81.6 mg (Urogesic-blue)............................................... 75
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................ 75
methenamine-hyosc-meth blue-sod phos-phen sal
cap 118 mg.................................................................... 75
methenamine-hyosc-meth blue-sod phos-phen sal
cap 120 mg.................................................................... 75
methenamine-hyosc-meth blue-sod phos-phen sal tab
81 mg.............................................................................. 75
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg........................................................................... 75
METHENAMINE MANDELATE -methenamine mandelate
tab 0.5 gm....................................................................... 75
methenamine mandelate tab 1 gm................................ 75
METHERGINE -methylergonovine maleate tab 0.2
mg.................................................................................... 39
methimazole tab 5 mg (Tapazole).................................. 37
methimazole tab 10 mg (Tapazole)................................ 37
METHIONAID -nutritional supplement powder............... 139
METHITEST -methyltestosterone oral tab 10 mg............. 25
methocarbamol tab 750 mg (Robaxin-750).................118
methocarbamol tab 500 mg (Robaxin)........................ 118
methotrexate sodium for inj 1 gm................................. 21
methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 21
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 21
methotrexate sodium inj pf 100 mg/4ml (25 mg/
ml)................................................................................... 21
methotrexate sodium inj pf 200 mg/8ml (25 mg/
ml)................................................................................... 21
methotrexate sodium inj pf 250 mg/10ml (25 mg/
ml)................................................................................... 21
methotrexate sodium inj pf 1000 mg/40ml (25 mg/
ml)................................................................................... 21
METHOTREXATE SODIUM -methotrexate sodium inj 250
mg/10ml (25 mg/ml)........................................................20
methotrexate sodium tab 2.5 mg (base equiv)............. 21
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 176
methscopolamine bromide tab 2.5 mg (Pamine)......... 70
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................70
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........55
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................ 52
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2016
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................ 52
methyldopa tab 250 mg.................................................. 52
methyldopa tab 500 mg.................................................. 52
methylphenidate hcl cap cr 10 mg (cd) (Metadate
cd)................................................................................... 90
methylphenidate hcl cap cr 20 mg (cd) (Metadate
cd)................................................................................... 90
methylphenidate hcl cap cr 30 mg (cd) (Metadate
cd)................................................................................... 90
methylphenidate hcl cap cr 40 mg (cd) (Metadate
cd)................................................................................... 90
methylphenidate hcl cap cr 50 mg (cd) (Metadate
cd)................................................................................... 90
methylphenidate hcl cap cr 60 mg (cd) (Metadate
cd)................................................................................... 90
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)..................................................................................... 90
methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin
la)..................................................................................... 90
methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin
la)..................................................................................... 90
methylphenidate hcl chew tab 2.5 mg (Methylin)........ 90
methylphenidate hcl chew tab 5 mg (Methylin)........... 90
methylphenidate hcl chew tab 10 mg (Methylin)......... 90
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 18 mg................................................................. 90
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 27 mg................................................................. 90
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 36 mg................................................................. 90
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 54 mg................................................................. 90
methylphenidate hcl soln 5 mg/5ml (Methylin)............ 90
methylphenidate hcl soln 10 mg/5ml (Methylin).......... 90
methylphenidate hcl tab cr 10 mg................................. 90
methylphenidate hcl tab cr 20 mg................................. 90
methylphenidate hcl tab 5 mg (Ritalin)......................... 90
methylphenidate hcl tab 10 mg (Ritalin)....................... 90
methylphenidate hcl tab 20 mg (Ritalin)....................... 91
methylphenidate hcl tab sa osm 18 mg (Concerta)..... 90
methylphenidate hcl tab sa osm 27 mg (Concerta)..... 90
methylphenidate hcl tab sa osm 36 mg (Concerta)..... 90
methylphenidate hcl tab sa osm 54 mg (Concerta)..... 90
methylprednisolone tab 4 mg (Medrol)......................... 24
methylprednisolone tab 8 mg (Medrol)......................... 24
methylprednisolone tab 16 mg (Medrol)....................... 24
methylprednisolone tab 32 mg (Medrol)....................... 24
methylprednisolone tab therapy pack 4 mg (21)
(Medrol dosepak).......................................................... 23
methyltestosterone cap 10 mg (Testred)...................... 25
METIPRANOLOL -metipranolol ophth soln 0.3%........... 164
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 74
metoclopramide hcl tab 5 mg (Reglan)......................... 74
metoclopramide hcl tab 10 mg (Reglan)....................... 74
METOCLOPRAMIDE ODT -metoclopramide hcl orally
disintegrating tab 5 mg................................................... 74
METOCLOPRAMIDE ODT -metoclopramide hcl orally
disintegrating tab 10 mg................................................. 74
metolazone tab 2.5 mg.................................................... 55
metolazone tab 5 mg....................................................... 55
metolazone tab 10 mg..................................................... 55
metoprolol & hydrochlorothiazide tab 100-50 mg....... 52
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..............................................................52
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)..............................................................52
metoprolol succinate tab sr 24hr 25 mg (tartrate
equiv) (Toprol xl)........................................................... 44
metoprolol succinate tab sr 24hr 50 mg (tartrate
equiv) (Toprol xl)........................................................... 44
metoprolol succinate tab sr 24hr 100 mg (tartrate
equiv) (Toprol xl)........................................................... 44
metoprolol succinate tab sr 24hr 200 mg (tartrate
equiv) (Toprol xl)........................................................... 44
METOPROLOL TARTRATE -metoprolol tartrate tab 37.5
mg.................................................................................... 44
METOPROLOL TARTRATE -metoprolol tartrate tab 75
mg.................................................................................... 44
metoprolol tartrate tab 25 mg........................................ 44
metoprolol tartrate tab 50 mg (Lopressor)................... 44
metoprolol tartrate tab 100 mg (Lopressor)................. 44
metronidazole cap 375 mg (Flagyl)............................... 12
metronidazole cream 0.75% (Metrocream)................. 176
metronidazole gel 0.75%............................................... 176
metronidazole gel 1% (Metrogel)................................. 176
metronidazole lotion 0.75% (Metrolotion)................... 176
metronidazole tab 250 mg (Flagyl)................................ 12
metronidazole tab 500 mg (Flagyl)................................ 12
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 76
mexiletine hcl cap 150 mg.............................................. 47
mexiletine hcl cap 200 mg.............................................. 47
mexiletine hcl cap 250 mg.............................................. 47
MIACALCIN -calcitonin (salmon) inj 200 unit/ml............... 40
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 76
MICROCYN SKIN AND WOUND H -wound cleansers gel.................................................................................. 176
MICROCYN -wound cleansers - gel............................... 176
MICROCYN -wound cleansers - liquid............................ 176
midazolam hcl syrup 2 mg/ml (base equivalent)......... 88
midodrine hcl tab 2.5 mg................................................ 56
midodrine hcl tab 5 mg................................................... 56
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
midodrine hcl tab 10 mg................................................. 56
miglitol tab 25 mg (Glyset)............................................. 34
miglitol tab 50 mg (Glyset)............................................. 34
miglitol tab 100 mg (Glyset)........................................... 34
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................. 108
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(21).................................................................................. 24
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(48).................................................................................. 24
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)....................................................... 24
MILLIPRED -prednisolone tab 5 mg................................. 24
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)........................................... 29
MINIVELLE -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 27
MINIVELLE -estradiol td patch twice weekly 0.0375
mg/24hr........................................................................... 27
MINIVELLE -estradiol td patch twice weekly 0.05
mg/24hr........................................................................... 27
MINIVELLE -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 27
MINIVELLE -estradiol td patch twice weekly 0.1
mg/24hr........................................................................... 27
minocycline hcl cap 50 mg (Minocin)............................. 4
minocycline hcl cap 75 mg (Minocin)............................. 4
minocycline hcl cap 100 mg (Minocin)........................... 4
minocycline hcl tab 50 mg............................................... 4
minocycline hcl tab 75 mg............................................... 4
minocycline hcl tab 100 mg............................................. 4
minocycline hcl tab sr 24hr 45 mg.................................. 4
minocycline hcl tab sr 24hr 90 mg.................................. 4
minocycline hcl tab sr 24hr 135 mg................................ 4
minoxidil tab 2.5 mg........................................................ 52
minoxidil tab 10 mg......................................................... 52
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.375 mg....................................................................... 116
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.75 mg......................................................................... 116
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
1.5 mg........................................................................... 116
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
2.25 mg......................................................................... 116
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 116
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
3.75 mg......................................................................... 116
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
4.5 mg........................................................................... 116
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 30
mcg/0.3ml...................................................................... 153
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50
mcg/0.3ml...................................................................... 153
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75
mcg/0.3ml...................................................................... 153
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
100 mcg/0.3ml.............................................................. 153
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
150 mcg/0.3ml.............................................................. 153
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
200 mcg/0.3ml.............................................................. 153
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 81
mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)............................................................................. 81
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)............................................................................. 81
mirtazapine tab 7.5 mg....................................................81
mirtazapine tab 15 mg (Remeron)................................. 81
mirtazapine tab 30 mg (Remeron)................................. 81
mirtazapine tab 45 mg (Remeron)................................. 81
MIRVASO -brimonidine tartrate gel 0.33% (base
equivalent)..................................................................... 176
misoprostol tab 100 mcg (Cytotec)............................... 70
misoprostol tab 200 mcg (Cytotec)............................... 70
MITIGARE -colchicine cap 0.6 mg.................................. 109
MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 164
MMA/PA ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 139
MMA/PA ANAMIX NEXT -nutritional supplement
powder........................................................................... 139
MMA/PA COOLER -nutritional supplement liquid........... 139
MMA/PA COOLER15 -nutritional supplement liquid....... 139
MMA/PA GEL -nutritional supplement pack.................... 139
modafinil tab 100 mg (Provigil)...................................... 91
modafinil tab 200 mg (Provigil)...................................... 91
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg........ 8
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg.......... 8
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack.......................................................................... 8
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 8
MODULEN IBD -nutritional supplement powder............. 139
moexipril hcl tab 7.5 mg................................................. 52
moexipril hcl tab 15 mg.................................................. 52
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 52
moexipril-hydrochlorothiazide tab 15-12.5 mg............ 52
moexipril-hydrochlorothiazide tab 15-25 mg............... 52
MOLINDONE HYDROCHLORIDE -molindone hcl tab 5
mg.................................................................................... 85
MOLINDONE HYDROCHLORIDE -molindone hcl tab 10
mg.................................................................................... 85
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
MOLINDONE HYDROCHLORIDE -molindone hcl tab 25
mg.................................................................................... 85
mometasone furoate cream 0.1% (Elocon)................ 176
mometasone furoate nasal susp 50 mcg/act
(Nasonex)....................................................................... 62
mometasone furoate oint 0.1% (Elocon).................... 176
mometasone furoate solution 0.1% (lotion)
(Elocon)........................................................................ 176
MONOCAL -sodium monofluorophosphate-calcium carb
tab 22.75-625 mg......................................................... 130
MONOCLATE-P -antihemophilic factor (human) for inj kit
1000 unit....................................................................... 160
MONOCLATE-P -antihemophilic factor (human) for inj kit
1500 unit....................................................................... 160
MONOGEN -nutritional supplement powder................... 139
MONONINE -coagulation factor ix for inj 1000 unit........ 160
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 66
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 66
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)...........................................................66
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 66
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................ 75
morphine sulfate cap sr 24hr 10 mg (Kadian)............ 100
morphine sulfate cap sr 24hr 20 mg (Kadian)............ 100
morphine sulfate cap sr 24hr 30 mg (Kadian)............ 101
morphine sulfate cap sr 24hr 50 mg (Kadian)............ 101
morphine sulfate cap sr 24hr 60 mg (Kadian)............ 101
morphine sulfate cap sr 24hr 80 mg (Kadian)............ 101
morphine sulfate cap sr 24hr 100 mg (Kadian).......... 101
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 30 mg....................................................................101
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 45 mg....................................................................101
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 60 mg....................................................................101
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 75 mg....................................................................101
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 90 mg....................................................................101
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 120 mg..................................................................101
MORPHINE SULFATE -morphine sulfate suppos 5
mg.................................................................................. 100
MORPHINE SULFATE -morphine sulfate suppos 10
mg.................................................................................. 100
MORPHINE SULFATE -morphine sulfate suppos 20
mg.................................................................................. 100
MORPHINE SULFATE -morphine sulfate suppos 30
mg.................................................................................. 100
MORPHINE SULFATE -morphine sulfate tab 15 mg...... 100
MORPHINE SULFATE -morphine sulfate tab 30 mg...... 100
morphine sulfate oral soln 10 mg/5ml........................ 101
morphine sulfate oral soln 20 mg/5ml........................ 101
morphine sulfate oral soln 100 mg/5ml (20 mg/
ml)................................................................................. 101
morphine sulfate tab cr 15 mg (Ms contin)................ 101
morphine sulfate tab cr 30 mg (Ms contin)................ 101
morphine sulfate tab cr 60 mg (Ms contin)................ 101
morphine sulfate tab cr 100 mg (Ms contin).............. 101
morphine sulfate tab cr 200 mg (Ms contin).............. 101
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............68
MOVANTIK -naloxegol oxalate tab 12.5 mg (base
equivalent)....................................................................... 74
MOVANTIK -naloxegol oxalate tab 25 mg (base
equivalent)....................................................................... 74
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm...............................................................68
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).................................................................... 164
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 5
MSUD AID -nutritional supplement powder.................... 139
MSUD ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 139
MSUD COOLER -nutritional supplement liquid.............. 140
MSUD EXPRESS -nutritional supplement pack............. 140
MSUD EXPRESS20 -nutritional supplement pack......... 140
MSUD GEL -nutritional supplement pack....................... 140
MSUD LOPHLEX LQ -nutritional supplement liquid....... 140
MSUD MAXAMAID -nutritional supplement powder....... 140
MSUD MAXAMUM -nutritional supplement powder....... 140
MSUD 2 -nutritional supplement powder........................ 140
MUCOTROL -oral wound care products - wafer............. 168
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 47
MULTIGEN -fe asparto gly-succ acd-c-threonic acd-b12des stom tab................................................................. 153
MULTIGEN FOLIC -fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab................................................ 153
MULTIGEN PLUS -fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab................................................ 153
multiple vitamins w/ minerals & fa tab 1.25 mg
(Corvite)........................................................................ 122
mupirocin calcium cream 2% (Bactroban)................. 176
mupirocin oint 2% (Bactroban).................................... 176
M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 122
MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 40
mycophenolate mofetil cap 250 mg (Cellcept)........... 184
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)...................................................................... 184
mycophenolate mofetil tab 500 mg (Cellcept)............184
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)................................................. 185
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)................................................. 185
MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe
susp 0.25-10 mg/2ml.................................................... 122
MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 153
MYLERAN -busulfan tab 2 mg.......................................... 21
MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................122
MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 122
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg....................................................................... 122
MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg............................................... 122
MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 122
MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg.....................................................................122
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 75
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 75
MYTESI -crofelemer tab delayed release 125 mg............ 68
N
NABI-HB -hepatitis b immune globulin (human) im inj
soln.................................................................................. 17
nabumetone tab 500 mg............................................... 106
nabumetone tab 750 mg............................................... 106
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 52
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 52
nadolol tab 20 mg (Corgard).......................................... 44
nadolol tab 40 mg (Corgard).......................................... 44
nadolol tab 80 mg (Corgard).......................................... 44
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................. 168
NAFRINSE DAILY/NEUTRAL -7odium fluoride for soln
rinse 0.05%................................................................... 168
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%...............................................................................168
naftifine hcl cream 1%.................................................. 176
naftifine hcl cream 2% (Naftin).................................... 176
NAFTIN -naftifine hcl cream 2%..................................... 176
NAFTIN -naftifine hcl gel 1%........................................... 176
NAFTIN -naftifine hcl gel 2%........................................... 176
NALFON -fenoprofen calcium cap 400 mg..................... 106
naloxone hcl inj 0.4 mg/ml........................................... 182
NALOXONE HCL -naloxone hcl soln prefilled syringe 2
mg/2ml........................................................................... 182
naltrexone hcl tab 50 mg (Revia)................................. 182
NAMENDA -memantine hcl oral solution 2 mg/ml............ 93
NAMENDA -memantine hcl tab 5 mg............................... 93
NAMENDA -memantine hcl tab 10 mg............................. 93
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak....................................... 93
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............ 93
NAMENDA XR -memantine hcl cap sr 24hr 14 mg.......... 93
NAMENDA XR -memantine hcl cap sr 24hr 21 mg.......... 93
NAMENDA XR -memantine hcl cap sr 24hr 28 mg.......... 93
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 93
NAMZARIC -memantine-donepezil cap er 24hr 7 & 14 &
21 & 28-10 mg pack....................................................... 93
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
7-10 mg........................................................................... 93
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
14-10 mg......................................................................... 93
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
21-10 mg......................................................................... 93
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
28-10 mg......................................................................... 93
naproxen sodium tab 275 mg (Anaprox).................... 106
naproxen sodium tab 550 mg (Anaprox ds)............... 106
naproxen sodium tab sr 24hr 375 mg (base equiv)
(Naprelan)..................................................................... 106
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)..................................................................... 106
naproxen susp 125 mg/5ml.......................................... 106
naproxen tab ec 375 mg (Ec-naprosyn)...................... 106
naproxen tab ec 500 mg (Ec-naprosyn)...................... 106
naproxen tab 250 mg (Naprosyn)................................ 107
naproxen tab 375 mg (Naprosyn)................................ 107
naproxen tab 500 mg (Naprosyn)................................ 107
naratriptan hcl tab 1 mg (base equiv) (Amerge)........ 108
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)..... 108
NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 182
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml...................................................................... 153
NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg...................................................................122
NATACYN -natamycin ophth susp 5%............................ 164
NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1
mg.................................................................................. 122
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg............................................................. 29
nateglinide tab 60 mg (Starlix)....................................... 34
nateglinide tab 120 mg (Starlix)..................................... 34
NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 122
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 25 mcg............................................................. 40
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 50 mcg............................................................. 41
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 75 mcg............................................................. 41
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 100 mcg........................................................... 41
NATROBA -spinosad susp 0.9%..................................... 176
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................38
NATURE-THROID -thyroid tab 16.25 mg..........................37
NATURE-THROID -thyroid tab 32.5 mg............................37
NATURE-THROID -thyroid tab 65 mg...............................38
NATURE-THROID -thyroid tab 81.25 mg..........................38
NATURE-THROID -thyroid tab 97.5 mg............................38
NATURE-THROID -thyroid tab 113.75 mg........................ 38
NATURE-THROID -thyroid tab 130 mg.............................38
NATURE-THROID -thyroid tab 146.25 mg....................... 38
NATURE-THROID -thyroid tab 195 mg.............................38
NATURE-THROID -thyroid tab 260 mg.............................38
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 37
NATURE-THROID -thyroid tab 325 mg (5 grain).............. 38
NEBUPENT -pentamidine isethionate for nebulization
soln 300 mg.................................................................... 12
NEBUSAL -sodium chloride soln nebu 6%....................... 63
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 29
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)........................................... 29
NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................. 122
NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 81
NEFAZODONE HCL -nefazodone hcl tab 150 mg........... 81
NEFAZODONE HCL -nefazodone hcl tab 200 mg........... 81
nefazodone hcl tab 50 mg.............................................. 81
nefazodone hcl tab 250 mg............................................ 81
NEOCATE INFANT DHA/ARA -nutritional supplement
powder........................................................................... 140
NEOCATE JUNIOR/PREBIOTICS -nutritional supplement
powder........................................................................... 140
NEOCATE JUNIOR -nutritional supplement powder...... 140
NEOCATE NUTRA -nutritional supplement powder....... 140
NEOCATE SPLASH -nutritional supplement liquid......... 140
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 165
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................. 165
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 165
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)...................................................................... 165
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol).............................................................165
neomycin-polymyxin-hc otic soln 1%
(Cortisporin).................................................................167
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.................................................................... 167
neomycin sulfate tab 500 mg........................................... 5
NEORAL -cyclosporine modified cap 25 mg...................185
NEORAL -cyclosporine modified cap 100 mg.................185
NEORAL -cyclosporine modified oral soln 100 mg/
ml................................................................................... 185
NEOSALUS CP -dermatological products misc cream............................................................................. 177
NEOSALUS -dermatological products, misc. - aerosol
foam............................................................................... 177
NEOSALUS -dermatological products misc - cream...... 176
NEOSALUS -emollient - lotion........................................ 177
NEO-SYNALAR -neomycin sulfate-fluocinolone acetonide
cream 0.5-0.025%........................................................ 176
NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid
7.5-4-30 mg/5ml.............................................................. 63
NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 122
NEPHRON FA -ferrous fumarate w/ fa-dss-b complex-vit
c tab...............................................................................153
NEPRO -nutritional supplement liquid.............................140
NEPRO WITH CARBSTEADY -nutritional supplement
liquid.............................................................................. 140
NEPRO WITH CARB STEADY -nutritional supplement
liquid.............................................................................. 140
NESINA -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 34
NESINA -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 34
NESINA -alogliptin benzoate tab 25 mg (base equiv).......34
NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap............................................................. 122
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 122
NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 122
NESTLE FLAVOR EXTRA STREN -nutritional
supplement flavor pack................................................ 140
NESTLE FLAVOR FOR KIDS -nutritional supplement
flavor pack..................................................................... 140
NESTLE FLAVOR -nutritional supplement flavor
pack............................................................................... 140
NEULASTA ONPRO KIT -pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml.................................................. 153
NEULASTA -pegfilgrastim soln prefilled syringe 6
mg/0.6ml........................................................................ 153
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 153
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................. 153
NEUPOGEN -filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 153
NEUPOGEN -filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)............................................... 153
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................ 116
NEUPRO -rotigotine td patch 24hr 2 mg/24hr................ 116
NEUPRO -rotigotine td patch 24hr 3 mg/24hr................ 116
NEUPRO -rotigotine td patch 24hr 4 mg/24hr................ 116
NEUPRO -rotigotine td patch 24hr 6 mg/24hr................ 116
NEUPRO -rotigotine td patch 24hr 8 mg/24hr................ 116
NEURIN-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg................................................................. 153
NEUTRASAL -artificial saliva - packet............................ 168
NEVANAC -nepafenac ophth susp 0.1%........................ 165
NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 8
nevirapine tab 200 mg (Viramune)...................................8
nevirapine tab sr 24hr 100 mg......................................... 8
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 8
NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 122
NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg.............................................................122
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 21
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg........................................................... 70
NEXIUM -esomeprazole magnesium for delayed release
susp packet 10 mg......................................................... 70
NEXIUM -esomeprazole magnesium for delayed release
susp packet 20 mg......................................................... 70
NEXIUM -esomeprazole magnesium for delayed release
susp packet 40 mg......................................................... 70
NEXIUM -esomeprazole magnesium for delayed release
susp pack 2.5 mg........................................................... 70
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................ 58
niacin tab cr 750 mg (antihyperlipidemic)
(Niaspan)........................................................................ 58
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan)........................................................................ 58
nicardipine hcl cap 20 mg.............................................. 46
nicardipine hcl cap 30 mg.............................................. 46
NICODERM CQ -nicotine td patch 24hr 7 mg/24hr.......... 93
NICODERM CQ -nicotine td patch 24hr 14 mg/24hr........ 94
NICODERM CQ -nicotine td patch 24hr 21 mg/24hr........ 94
NICOMIDE -niacinamide w/ zn-cu-methylfolate tab
750-25-1.5-0.5 mg........................................................ 123
NICORETTE MINI -nicotine polacrilex lozenge 2 mg....... 94
NICORETTE MINI -nicotine polacrilex lozenge 4 mg....... 94
NICORETTE -nicotine polacrilex gum 2 mg..................... 94
NICORETTE -nicotine polacrilex gum 4 mg..................... 94
NICORETTE -nicotine polacrilex lozenge 2 mg................ 94
NICORETTE -nicotine polacrilex lozenge 4 mg................ 94
NICORETTE STARTER KIT -nicotine polacrilex gum 2
mg.................................................................................... 94
NICORETTE STARTER KIT -nicotine polacrilex gum 4
mg.................................................................................... 94
nicotine polacrilex gum 2 mg.........................................94
nicotine polacrilex gum 4 mg.........................................94
nicotine polacrilex lozenge 2 mg................................... 94
nicotine polacrilex lozenge 4 mg................................... 94
nicotine td patch 24hr 7 mg/24hr...................................94
nicotine td patch 24hr 14 mg/24hr.................................94
nicotine td patch 24hr 21 mg/24hr.................................94
NICOTINE TRANSDERMAL SYST -nicotine td patch 24
hr kit 21-14-7 mg/24hr.................................................... 94
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered).................................................................. 94
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 94
nifedipine cap 20 mg....................................................... 46
nifedipine cap 10 mg (Procardia).................................. 46
nifedipine tab sr 24hr 30 mg (Adalat cc).......................46
nifedipine tab sr 24hr 60 mg (Adalat cc).......................46
nifedipine tab sr 24hr 90 mg (Adalat cc).......................46
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)................................................................. 46
nifedipine tab sr 24hr osmotic release 60 mg
(Procardia xl)................................................................. 46
nifedipine tab sr 24hr osmotic release 90 mg
(Procardia xl)................................................................. 46
NILANDRON -nilutamide tab 150 mg............................... 21
nilutamide tab 150 mg (Nilandron)................................ 21
nimodipine cap 30 mg..................................................... 46
NINJACOF-XG -guaifenesin-codeine liquid 200-8
mg/5ml............................................................................. 63
NINLARO -ixazomib citrate cap 2.3 mg (base
equivalent)....................................................................... 21
NINLARO -ixazomib citrate cap 3 mg (base
equivalent)....................................................................... 21
NINLARO -ixazomib citrate cap 4 mg (base
equivalent)....................................................................... 21
NISOLDIPINE ER -nisoldipine tab sr 24hr 20 mg............. 46
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 46
NISOLDIPINE ER -nisoldipine tab sr 24hr 30 mg............. 46
NISOLDIPINE ER -nisoldipine tab sr 24hr 40 mg............. 46
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 46
nisoldipine tab sr 24hr 17 mg (Sular)............................46
nisoldipine tab sr 24hr 34 mg (Sular)............................46
NITRO-BID -nitroglycerin oint 2%..................................... 43
NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 43
NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 43
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nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................75
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin).................................................................75
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin).................................................................75
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)............................................................... 75
nitrofurantoin susp 25 mg/5ml (Furadantin)................ 75
nitroglycerin cap cr 2.5 mg............................................ 43
nitroglycerin cap cr 6.5 mg............................................ 43
nitroglycerin cap cr 9 mg............................................... 43
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................ 43
nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 43
nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 43
nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 43
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 43
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 43
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 43
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 43
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr)................................................. 43
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray................................................................................ 43
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 43
NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 43
NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 43
NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 123
nizatidine cap 150 mg..................................................... 70
nizatidine cap 300 mg (Axid).......................................... 70
NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 70
NOBLE MYSTIQUE EMU-LAC -lactic acid (ammonium
lactate) cream 10%.......................................................177
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)............................................... 29
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)............................................ 29
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28)................................................................. 29
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................ 29
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 29
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20).................................................. 29
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)............................................... 29
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg (Loestrin 1/20-21)................................................. 29
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21).............................................. 29
norethindrone ace-eth estradiol-fe chew tab 1 mg-20
mcg (24) (Minastrin 24 fe)............................................29
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)......................................................................... 29
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg................................................................................. 27
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................ 27
norethindrone acetate tab 5 mg (Aygestin).................. 30
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)................................................. 29
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)...................................... 29
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 29
norethindrone tab 0.35 mg (Nor-qd).............................. 29
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 29
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)........................................... 29
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25
mg-mcg (Ortho tri-cyclen lo)....................................... 29
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 30
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 47
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 47
NORPACE -disopyramide phosphate cap 100 mg........... 47
NORPACE -disopyramide phosphate cap 150 mg........... 47
NORTHERA -droxidopa cap 100 mg................................ 56
NORTHERA -droxidopa cap 200 mg................................ 56
NORTHERA -droxidopa cap 300 mg................................ 56
nortriptyline hcl cap 10 mg (Pamelor)...........................81
nortriptyline hcl cap 25 mg (Pamelor)...........................81
nortriptyline hcl cap 50 mg (Pamelor)...........................81
nortriptyline hcl cap 75 mg (Pamelor)...........................81
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml............................................................................. 81
NORVIR -ritonavir cap 100 mg........................................... 8
NORVIR -ritonavir oral soln 80 mg/ml.................................8
NORVIR -ritonavir tab 100 mg............................................ 9
NOURISH -nutritional supplement liquid......................... 140
NOVACORT -pramoxine-hc gel 1-2%............................. 177
NOVASOURCE PULMONARY -nutritional supplement
liquid.............................................................................. 140
NOVASOURCE RENAL -nutritional supplement
liquid.............................................................................. 140
NOVOEIGHT -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 160
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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NOVOEIGHT -antihemophilic factor (recombinant) for inj
500 unit......................................................................... 160
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1000 unit....................................................................... 160
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1500 unit....................................................................... 160
NOVOEIGHT -antihemophilic factor (recombinant) for inj
2000 unit....................................................................... 160
NOVOEIGHT -antihemophilic factor (recombinant) for inj
3000 unit....................................................................... 160
NOVOLIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 36
NOVOLIN 70/30 RELION -insulin nph isophane & regular
human inj 100 unit/ml (70-30)........................................ 36
NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 36
NOVOLIN N RELION -insulin nph (human) (isophane) inj
100 unit/ml.......................................................................36
NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 36
NOVOLIN R RELION -insulin regular (human) inj 100
unit/ml.............................................................................. 36
NOVOLOG FLEXPEN -insulin aspart soln pen-injector
100 unit/ml.......................................................................35
NOVOLOG -insulin aspart inj 100 unit/ml......................... 35
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)...................................... 36
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)........................... 37
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml.............................................................................. 35
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
1 mg (1000 mcg).......................................................... 160
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
2 mg (2000 mcg).......................................................... 161
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
5 mg (5000 mcg).......................................................... 161
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
8 mg (8000 mcg).......................................................... 161
NOXAFIL -posaconazole susp 40 mg/ml............................ 6
NOXAFIL -posaconazole tab delayed release 100 mg....... 6
NOXIFOL-D -folic acid-cholecalciferol tab 1 mg-2500
unit................................................................................. 153
NUCALA -mepolizumab for inj 100 mg............................. 66
NUCORT -hydrocortisone acetate lotion 2%.................. 177
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg........... 101
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg......... 101
NUCYNTA ER -tapentadol hcl tab sr 12hr 150 mg......... 101
NUCYNTA ER -tapentadol hcl tab sr 12hr 200 mg......... 101
NUCYNTA ER -tapentadol hcl tab sr 12hr 250 mg......... 101
NUCYNTA -tapentadol hcl tab 50 mg............................. 101
NUCYNTA -tapentadol hcl tab 75 mg............................. 101
NUCYNTA -tapentadol hcl tab 100 mg........................... 101
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg......................................................................... 94
NUFERA -iron combination tab....................................... 153
NUMOISYN -artificial saliva - solution............................ 168
NUPLAZID -pimavanserin tartrate tab 17 mg (base
equivalent)....................................................................... 85
NUTRA/BALANCE RE/GEN FREE -nutritional
supplement liquid (frozen)............................................ 140
NUTRA/BALANCE RE/GEN -nutritional supplement liquid
(frozen).......................................................................... 140
NUTRA/SHAKE FRUIT PLUS -nutritional supplement
liquid (frozen)................................................................ 140
NUTRA/SHAKE -nutritional supplement liquid
(frozen).......................................................................... 140
NUTRA/SHAKE SUPREME -nutritional supplement
liquid.............................................................................. 141
NUTRA/SHAKE SUPREME -nutritional supplement liquid
(frozen).......................................................................... 141
NUTRA BALANCE DIABETIC NU -nutritional supplement
bar.................................................................................. 140
NUTRA BALANCE FIBER COOKI -nutritional supplement
misc............................................................................... 140
NUTRA BALANCE PROTEIN FOR -nutritional
supplement misc........................................................... 140
NUTRAMENT -nutritional supplement liquid................... 141
NUTRAMINE APPLE AMINO BIT -nutritional supplement
pack............................................................................... 141
NUTRAMINE BANANA AMINO B -nutritional supplement
pack............................................................................... 141
NUTRAMINE CHOCOLATE AMINO -nutritional
supplement pack........................................................... 141
NUTRAMINE MANGO AMINO BI -nutritional supplement
pack............................................................................... 141
NUTRAMINE MIXED FLAVORS A -nutritional supplement
pack............................................................................... 141
NUTRAMINE -nutritional supplement pack..................... 141
NUTRAMINE PEACHES & CREAM -nutritional
supplement pack........................................................... 141
NUTRAMINE PINEAPPLE AMINO -nutritional
supplement pack........................................................... 141
NUTRASENTIALS -amino acids oral powder................. 131
NUTRA SHAKE/SUPREME -nutritional supplement liquid
(frozen).......................................................................... 140
NUTRA SHAKE -nutritional supplement liquid
(frozen).......................................................................... 140
NUTREN 1.0/FIBER/ULTRAPAK -nutritional supplement
liquid.............................................................................. 141
NUTREN 1.0/FIBER -nutritional supplement liquid.........141
NUTREN 1.0 CAL -nutritional supplement liquid............ 141
NUTREN 1.5 CAL -nutritional supplement liquid............ 141
NUTREN 2.0 CAL -nutritional supplement liquid............ 141
NUTREN 1.5 FIBER -nutritional supplement liquid.........141
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NUTREN JR FIBER -nutritional supplement liquid......... 141
NUTREN JR -nutritional supplement liquid..................... 141
NUTREN JUNIOR/FIBER -nutritional supplement
liquid.............................................................................. 141
NUTREN JUNIOR -nutritional supplement liquid............ 141
NUTREN JUNIOR 1.0 -nutritional supplement liquid...... 141
NUTREN 1.0 -nutritional supplement liquid.................... 141
NUTREN 1.5 -nutritional supplement liquid.................... 141
NUTREN 2.0 -nutritional supplement liquid.................... 141
NUTREN PULMONARY -nutritional supplement
liquid.............................................................................. 141
NUTREN RENAL -nutritional supplement liquid............. 141
NUTRESTORE -glutamine powd pack 5 gm.................. 131
NUTRICIA PREOP -nutritional supplement pack........... 141
NUTRIFOCUS -nutritional supplement liquid.................. 141
NUTRIHEAL -nutritional supplement liquid..................... 141
NUTRIHEP 1.5 CAL -nutritional supplement liquid......... 141
NUTRIRENAL -nutritional supplement liquid.................. 141
NUTRITIONAL DRINK MIX -nutritional supplement
powder........................................................................... 142
NUTRITIONAL DRINK -nutritional supplement liquid..... 141
NUTRITIONAL DRINK PLUS -nutritional supplement
liquid.............................................................................. 142
NUTRITIONAL DRINK SHAKE M -nutritional supplement
powder........................................................................... 142
NUTRITIONAL SHAKE COMPLET -nutritional
supplement liquid.......................................................... 142
NUTRITIONAL SHAKE -nutritional supplement
liquid.............................................................................. 142
NUTRITIONAL SHAKE PLUS -nutritional supplement
liquid.............................................................................. 142
NUTRITIONAL SHAKE PLUS PR -nutritional supplement
liquid.............................................................................. 142
nutritional supplement liquid....................................... 142
NUTRITIONAL SUPPLEMENT -nutritional supplement
liquid.............................................................................. 142
NUTRITIONAL SUPPLEMENT PL -nutritional supplement
liquid.............................................................................. 142
NUTRIVENT -nutritional supplement liquid..................... 142
NUTRIVENT 1.5 -nutritional supplement liquid...............142
NUTRIVIR NSA -nutritional supplement powder............ 142
NUTRIVIR -nutritional supplement powder..................... 142
NUVAIL -dermatological products misc - solution........... 177
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr...................................................... 30
NUVESSA -metronidazole vaginal gel 1.3%.....................76
NUVIGIL -armodafinil tab 50 mg....................................... 91
NUVIGIL -armodafinil tab 150 mg..................................... 91
NUVIGIL -armodafinil tab 200 mg..................................... 91
NUVIGIL -armodafinil tab 250 mg..................................... 91
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 250
unit................................................................................. 161
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 500
unit................................................................................. 161
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 1000
unit................................................................................. 161
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 2000
unit................................................................................. 161
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 250
unit................................................................................. 161
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 500
unit................................................................................. 161
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 1000
unit................................................................................. 161
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 2000
unit................................................................................. 161
NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 46
nystatin cream 100000 unit/gm.................................... 177
nystatin oint 100000 unit/gm........................................ 177
nystatin oral powder..........................................................6
nystatin susp 100000 unit/ml....................................... 168
nystatin tab 500000 unit....................................................6
nystatin topical powder 100000 unit/gm..................... 177
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 177
nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 177
O
OA 1 -nutritional supplement powder.............................. 142
OA 2 -nutritional supplement powder.............................. 142
OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg......................................... 123
OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fadha cap 27.5-1-200 mg................................................ 123
OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp
glyc-fa-fish cap 50-1-476 mg........................................123
OB COMPLETE PETITE -prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg...................... 123
OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg................................................. 123
OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg.................................................................... 123
OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj
500 unit......................................................................... 161
OBREDON -hydrocodone-guaifenesin soln 2.5-200
mg/5ml............................................................................. 63
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak............................................ 123
OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg......................................................................... 123
OBSTETRIX ONE -prenat w/o a w/fecbn-bisg-methylfdss-dha cap 38-1-225 mg............................................ 123
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 123
OCALIVA -obeticholic acid tab 5 mg................................. 74
OCALIVA -obeticholic acid tab 10 mg............................... 74
O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1
mg.................................................................................. 123
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)................................................................. 41
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin)................................................................. 41
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin)................................................................. 41
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin)................................................................. 41
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)................................................................. 41
ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab
200-25-25 mg.................................................................... 9
ODOMZO -sonidegib phosphate cap 200 mg (base
equivalent)....................................................................... 21
OFEV -nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 68
OFEV -nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 68
OFLOXACIN -ofloxacin tab 300 mg.................................... 5
ofloxacin ophth soln 0.3% (Ocuflox)........................... 165
ofloxacin otic soln 0.3%................................................167
ofloxacin tab 400 mg......................................................... 5
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 30
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 94
olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)...... 94
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)...... 94
olanzapine-fluoxetine hcl cap 12-25 mg
(Symbyax)...................................................................... 94
olanzapine-fluoxetine hcl cap 12-50 mg
(Symbyax)...................................................................... 94
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)...............................................................................85
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)...............................................................................85
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis)...............................................................................85
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis)...............................................................................85
olanzapine tab 2.5 mg (Zyprexa)................................... 85
olanzapine tab 5 mg (Zyprexa)...................................... 85
olanzapine tab 7.5 mg (Zyprexa)................................... 85
olanzapine tab 10 mg (Zyprexa).................................... 85
olanzapine tab 15 mg (Zyprexa).................................... 85
olanzapine tab 20 mg (Zyprexa).................................... 85
olmesartan-amlodipine-hydrochlorothiazide tab
20-5-12.5 mg (Tribenzor).............................................. 52
olmesartan-amlodipine-hydrochlorothiazide tab
40-5-12.5 mg (Tribenzor).............................................. 52
olmesartan-amlodipine-hydrochlorothiazide tab
40-5-25 mg (Tribenzor)................................................. 52
olmesartan-amlodipine-hydrochlorothiazide tab
40-10-12.5 mg (Tribenzor)............................................ 52
olmesartan-amlodipine-hydrochlorothiazide tab
40-10-25 mg (Tribenzor)............................................... 52
olmesartan medoxomil-hydrochlorothiazide tab
20-12.5 mg (Benicar hct)..............................................52
olmesartan medoxomil-hydrochlorothiazide tab
40-12.5 mg (Benicar hct)..............................................52
olmesartan medoxomil-hydrochlorothiazide tab 40-25
mg (Benicar hct)........................................................... 52
olmesartan medoxomil tab 5 mg (Benicar).................. 52
olmesartan medoxomil tab 20 mg (Benicar)................ 52
olmesartan medoxomil tab 40 mg (Benicar)................ 52
olopatadine hcl nasal soln 0.6% (Patanase).................62
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)....................................................................... 165
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 9
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack........................................ 70
omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 58
OMEPRAZOLE + SYRSPEND SF -omeprazole susp 2
mg/ml (compound kit)..................................................... 70
omeprazole cap delayed release 10 mg (Prilosec)...... 70
omeprazole cap delayed release 20 mg (Prilosec)...... 70
omeprazole cap delayed release 40 mg (Prilosec)...... 70
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid)......................................................................... 70
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid)......................................................................... 70
omeprazole-sodium bicarbonate powd pack for susp
20-1680 mg (Zegerid)....................................................70
omeprazole-sodium bicarbonate powd pack for susp
40-1680 mg (Zegerid)....................................................70
OMNARIS -ciclesonide nasal susp 50 mcg/act................ 62
OMNIFLEX DIAPHRAGM -diaphragms.......................... 183
OMNI GEL -stannous fluoride gel 0.4%.......................... 168
OMNITROPE -somatropin for inj 5.8 mg.......................... 41
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 41
OMNITROPE -somatropin inj 10 mg/1.5ml....................... 41
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 71
ondansetron hcl tab 24 mg............................................ 71
ondansetron hcl tab 4 mg (Zofran)................................71
ondansetron hcl tab 8 mg (Zofran)................................71
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 71
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 71
ONEXTON -clindamycin phosphate-benzoyl peroxide gel
1.2-3.75%...................................................................... 177
ONFI -clobazam suspension 2.5 mg/ml.......................... 113
ONFI -clobazam tab 10 mg............................................. 113
ONFI -clobazam tab 20 mg............................................. 113
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 34
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 34
ONMEL -itraconazole tab 200 mg....................................... 6
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg....................................................... 101
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 7.5 mg.................................................... 101
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 10 mg..................................................... 101
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 15 mg..................................................... 101
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 20 mg..................................................... 101
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 30 mg..................................................... 102
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 40 mg..................................................... 102
opium tincture 1% (10 mg/ml) (morphine equiv)..........69
OPSUMIT -macitentan tab 10 mg..................................... 60
OPTIMENTAL -nutritional supplement liquid...................142
OPTISOURCE VERY HIGH PROT -nutritional
supplement liquid.......................................................... 142
ORACIT -sodium citrate & citric acid soln 490-640
mg/5ml............................................................................. 77
ORAFATE -sucralfate-malate paste 10%........................ 168
ORALAIR ADULT SAMPLE KIT -grass mixed pollen ext
tab sl 300 ir (index of reactivity)..................................... 17
ORALAIR ADULT STARTER PAC -grass mixed pollen ext
tab sl 300 ir (index of reactivity)..................................... 17
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
ext tab sl 100 ir (index of reactivity)............................... 17
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
tab sl therpak 100 (3) ir & 300 (6) ir.............................. 17
ORALAIR -grass mixed pollen ext tab sl 300 ir (index of
reactivity)......................................................................... 17
ORAMAGICRX -oral wound care products - for susp
rinse............................................................................... 168
ORANGE CHICKEN/CARROTS/BR -nutritional
supplement liquid.......................................................... 142
ORAP -pimozide tab 1 mg................................................ 94
ORAP -pimozide tab 2 mg................................................ 94
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 168
ORENCIA -abatacept subcutaneous soln prefilled syringe
125 mg/ml..................................................................... 107
ORENCIA CLICKJECT -abatacept subcutaneous soln
auto-injector 125 mg/ml................................................ 107
ORENITRAM -treprostinil diolamine tab cr 0.125 mg
(base equiv).................................................................... 60
ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base
equiv)............................................................................... 60
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)............................................................................... 60
ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base
equiv)............................................................................... 60
ORFADIN -nitisinone cap 2 mg......................................... 41
ORFADIN -nitisinone cap 5 mg......................................... 41
ORFADIN -nitisinone cap 10 mg....................................... 41
ORFADIN -nitisinone cap 20 mg....................................... 41
ORFADIN -nitisinone susp 4 mg/ml.................................. 41
ORGANIC PEDIA SMART -nutritional supplement
powder........................................................................... 142
ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 68
ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 68
orphenadrine citrate tab sr 12hr 100 mg.................... 118
ORTHO D -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 154
ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr............................................................. 30
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg................................. 30
oseltamivir phosphate cap 30 mg (base equiv)
(Tamiflu)............................................................................ 9
oseltamivir phosphate cap 45 mg (base equiv)
(Tamiflu)............................................................................ 9
oseltamivir phosphate cap 75 mg (base equiv)
(Tamiflu)............................................................................ 9
OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 34
OSENI -alogliptin-pioglitazone tab 12.5-30 mg................. 34
OSENI -alogliptin-pioglitazone tab 12.5-45 mg................. 34
OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 34
OSENI -alogliptin-pioglitazone tab 25-30 mg.................... 34
OSENI -alogliptin-pioglitazone tab 25-45 mg.................... 34
OSMOLITE 1 CAL -nutritional supplement liquid............142
OSMOLITE 1.2 CAL -nutritional supplement liquid.........142
OSMOLITE 1.5 CAL -nutritional supplement liquid.........142
OSMOLITE HN -nutritional supplement liquid................ 142
OSMOLITE -nutritional supplement liquid....................... 142
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos).................................... 68
OS 2 -nutritional supplement powder.............................. 142
OSPHENA -ospemifene tab 60 mg................................... 41
OTEZLA -apremilast tab 30 mg...................................... 107
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.................................................................. 107
OTOVEL -ciprofloxacin-fluocinolone aceton (pf) otic soln
0.3-0.025%.................................................................... 167
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
OTREXUP -methotrexate soln pf auto-injector 7.5
mg/0.4ml........................................................................ 107
OTREXUP -methotrexate soln pf auto-injector 10
mg/0.4ml........................................................................ 107
OTREXUP -methotrexate soln pf auto-injector 12.5
mg/0.4ml........................................................................ 107
OTREXUP -methotrexate soln pf auto-injector 15
mg/0.4ml........................................................................ 107
OTREXUP -methotrexate soln pf auto-injector 17.5
mg/0.4ml........................................................................ 107
OTREXUP -methotrexate soln pf auto-injector 20
mg/0.4ml........................................................................ 107
OTREXUP -methotrexate soln pf auto-injector 22.5
mg/0.4ml........................................................................ 107
OTREXUP -methotrexate soln pf auto-injector 25
mg/0.4ml........................................................................ 107
OVACE PLUS -sulfacetamide sodium cream 10%......... 177
OVACE PLUS -sulfacetamide sodium foam 9.8%.......... 177
OVACE PLUS -sulfacetamide sodium lotion 9.8%......... 177
oxandrolone tab 2.5 mg (Oxandrin).............................. 25
oxandrolone tab 10 mg (Oxandrin)............................... 25
oxaprozin tab 600 mg (Daypro)................................... 107
OXAYDO -oxycodone hcl tab abuse deter 5 mg............ 102
OXAYDO -oxycodone hcl tab abuse deter 7.5 mg..........102
oxazepam cap 10 mg...................................................... 78
oxazepam cap 15 mg...................................................... 78
oxazepam cap 30 mg...................................................... 78
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)...................................................................... 113
oxcarbazepine tab 150 mg (Trileptal).......................... 113
oxcarbazepine tab 300 mg (Trileptal).......................... 113
oxcarbazepine tab 600 mg (Trileptal).......................... 113
OXEPA -nutritional supplement liquid............................. 142
OXEPA 1.5 -nutritional supplement liquid....................... 142
oxiconazole nitrate cream 1% (Oxistat)...................... 177
OXISTAT -oxiconazole nitrate cream 1%........................ 177
OXISTAT -oxiconazole nitrate lotion 1%......................... 177
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg...... 113
OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg...... 113
OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg...... 113
oxybutynin chloride syrup 5 mg/5ml............................ 75
oxybutynin chloride tab 5 mg........................................ 76
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 76
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 76
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 76
OXYCODONE/ACETAMINOPHEN -oxycodone w/
acetaminophen soln 5-325 mg/5ml.............................. 102
OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab
5-400 mg....................................................................... 102
oxycodone-aspirin tab 4.8355-325 mg
(Percodan).................................................................... 102
oxycodone hcl cap 5 mg.............................................. 102
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).......................................................... 102
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
10 mg............................................................................ 102
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
15 mg............................................................................ 102
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
20 mg............................................................................ 102
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
30 mg............................................................................ 102
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
40 mg............................................................................ 102
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
60 mg............................................................................ 102
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
80 mg............................................................................ 102
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl).........102
oxycodone hcl tab 10 mg............................................. 102
oxycodone hcl tab 20 mg............................................. 102
oxycodone hcl tab 5 mg (Roxicodone)....................... 102
oxycodone hcl tab 15 mg (Roxicodone)..................... 102
oxycodone hcl tab 30 mg (Roxicodone)..................... 102
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)..................................................................... 102
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)..................................................................... 102
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)..................................................................... 102
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)..................................................................... 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 10
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 15
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 20
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 30
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 40
mg.................................................................................. 102
OXYCONTIN -oxycodone hcl tab er 12hr deter 60
mg.................................................................................. 103
OXYCONTIN -oxycodone hcl tab er 12hr deter 80
mg.................................................................................. 103
oxymorphone hcl tab 5 mg (Opana)............................103
oxymorphone hcl tab 10 mg (Opana)..........................103
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 5 mg........................................................... 103
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 7.5 mg........................................................ 103
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 10 mg......................................................... 103
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 15 mg......................................................... 103
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 20 mg......................................................... 103
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 30 mg......................................................... 103
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 40 mg......................................................... 103
OXYTROL -oxybutynin td patch twice weekly 3.9
mg/24hr........................................................................... 76
P
paliperidone tab sr 24hr 1.5 mg (Invega)...................... 85
paliperidone tab sr 24hr 3 mg (Invega)......................... 85
paliperidone tab sr 24hr 6 mg (Invega)......................... 85
paliperidone tab sr 24hr 9 mg (Invega)......................... 85
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
2600-6200-10850 unit.....................................................72
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-14200-24600 unit...................................................72
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
10500-35500-61500 unit................................................ 72
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
16800-56800-98400 unit................................................ 72
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
21000-54700-83900 unit................................................ 72
PANDEL -hydrocortisone probutate cream 0.1%............ 177
PANRETIN -alitretinoin gel 0.1%..................................... 177
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................70
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................70
PARAGARD INTRAUTERINE COP -copper iud............... 30
PAREGORIC -paregoric tincture 2 mg/5ml (morphine
equivalent)....................................................................... 69
paricalcitol cap 4 mcg..................................................... 41
paricalcitol cap 1 mcg (Zemplar)................................... 41
paricalcitol cap 2 mcg (Zemplar)................................... 41
PARODONTAX -stannous fluoride paste 0.454%........... 168
paromomycin sulfate cap 250 mg................................... 5
paroxetine hcl tab 10 mg (Paxil).................................... 82
paroxetine hcl tab 20 mg (Paxil).................................... 82
paroxetine hcl tab 30 mg (Paxil).................................... 82
paroxetine hcl tab 40 mg (Paxil).................................... 82
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)............... 81
paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 81
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)............... 81
PASER -aminosalicylic acid cr granules packet 4 gm.........5
PATADAY -olopatadine hcl ophth soln 0.2% (base
equivalent)..................................................................... 165
PATANOL -olopatadine hcl ophth soln 0.1% (base
equivalent)..................................................................... 165
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)............................................................................... 82
PAZEO -olopatadine hcl ophth soln 0.7% (base
equivalent)..................................................................... 165
pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065
mg (Donnatal)................................................................ 70
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 4
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 4
PCP 100 -mag cit-bisacodyl-petrolat-pegmetoclopramide-electrol kit............................................. 68
PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv
vac inj.............................................................................. 16
PEDIASURE 1.0 CAL/FIBER -nutritional supplement
liquid.............................................................................. 143
PEDIASURE 1.5 CAL/FIBER -nutritional supplement
liquid.............................................................................. 143
PEDIASURE 1.5 CAL -nutritional supplement liquid...... 143
PEDIASURE 1.5 CAL WITH FI -nutritional supplement
liquid.............................................................................. 143
PEDIASURE ENTERAL FORMULA -nutritional
supplement liquid.......................................................... 142
PEDIASURE GROW & GAIN -nutritional supplement
liquid.............................................................................. 142
PEDIASURE NUTRIPALS -nutritional supplement
bar.................................................................................. 142
PEDIASURE NUTRIPALS -nutritional supplement
liquid.............................................................................. 142
PEDIASURE -nutritional supplement liquid.................... 142
PEDIASURE PEDIATRIC -nutritional supplement
liquid.............................................................................. 143
PEDIASURE PEPTIDE 1.0 CAL -nutritional supplement
liquid.............................................................................. 143
PEDIASURE PEPTIDE 1.5 CAL -nutritional supplement
liquid.............................................................................. 143
PEDIASURE SHAKE MIX -nutritional supplement
powder........................................................................... 143
PEDIASURE SHAKE WITH FIBE -nutritional supplement
liquid.............................................................................. 143
PEDIASURE SIDEKICKS CLEAR -nutritional supplement
liquid.............................................................................. 143
PEDIASURE SIDEKICKS -nutritional supplement
liquid.............................................................................. 143
PEDIASURE SIDEKICKS -nutritional supplement
powder........................................................................... 143
PEDIASURE SIDEKICKS SHAKE -nutritional supplement
liquid.............................................................................. 143
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
PEDIASURE WITH FIBER -nutritional supplement
liquid.............................................................................. 143
PEDIATRIC DRINK -nutritional supplement liquid.......... 143
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/
ml................................................................................... 123
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg................................................................................. 123
pediatric multiple vitamins w/ fluoride chew tab 0.5
mg................................................................................. 123
pediatric multiple vitamins w/ fluoride chew tab 1
mg................................................................................. 123
pediatric multiple vitamins w/ fluoride soln 0.25 mg/
ml................................................................................... 123
pediatric multiple vitamins w/ fluoride soln 0.5 mg/
ml................................................................................... 123
PEDIATRIC PEPTINEX DT/FIB -nutritional supplement
liquid.............................................................................. 143
PEDIATRIC PEPTINEX DT -nutritional supplement
liquid.............................................................................. 143
pediatric vitamins acd w/ fluoride soln 0.25 mg/
ml................................................................................... 123
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml..... 123
PEGANONE -ethotoin tab 250 mg.................................. 113
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 9
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml.......... 9
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 9
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 9
PEGINTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml.......................................................................... 9
PEGINTRON -peginterferon alfa-2b for inj kit 80
mcg/0.5ml.......................................................................... 9
PEGINTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml.......................................................................... 9
PEGINTRON -peginterferon alfa-2b for inj kit 150
mcg/0.5ml.......................................................................... 9
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml........................................................ 9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
50 mcg/0.5ml.....................................................................9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
80 mcg/0.5ml.....................................................................9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
120 mcg/0.5ml.................................................................. 9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
150 mcg/0.5ml.................................................................. 9
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm (Colyte-flavor packs)............................................. 68
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm (Golytely)................................................................. 68
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)................................................... 68
penicillin v potassium for soln 125 mg/5ml................... 1
penicillin v potassium for soln 250 mg/5ml................... 1
penicillin v potassium tab 250 mg...................................1
penicillin v potassium tab 500 mg...................................1
PENNSAID -diclofenac sodium soln 2%......................... 177
PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp............................................................... 16
PENTASA -mesalamine cap cr 250 mg............................ 74
PENTASA -mesalamine cap cr 500 mg............................ 74
pentazocine w/ naloxone tab 50-0.5 mg......................103
pentoxifylline tab cr 400 mg......................................... 161
PEPDITE JUNIOR -nutritional supplement pack............ 143
PEPTAMEN/PREBIO1 -nutritional supplement liquid..... 144
PEPTAMEN AF -nutritional supplement liquid................ 143
PEPTAMEN BARIATRIC -nutritional supplement
liquid.............................................................................. 143
PEPTAMEN 1 CAL/PREBIO1 -nutritional supplement
liquid.............................................................................. 144
PEPTAMEN 1.5 CAL/PREBIO1 -nutritional supplement
liquid.............................................................................. 144
PEPTAMEN 1 CAL -nutritional supplement liquid...........144
PEPTAMEN 1.5 CAL -nutritional supplement liquid........144
PEPTAMEN INTENSE VHP -nutritional supplement
liquid.............................................................................. 143
PEPTAMEN JUNIOR/PREBIO1 -nutritional supplement
liquid.............................................................................. 143
PEPTAMEN JUNIOR 1 CAL/PRE -nutritional supplement
liquid.............................................................................. 143
PEPTAMEN JUNIOR 1 CAL -nutritional supplement
liquid.............................................................................. 143
PEPTAMEN JUNIOR 1.5 CAL -nutritional supplement
liquid.............................................................................. 143
PEPTAMEN JUNIOR FIBER -nutritional supplement
liquid.............................................................................. 143
PEPTAMEN JUNIOR HP -nutritional supplement
liquid.............................................................................. 143
PEPTAMEN JUNIOR -nutritional supplement liquid....... 143
PEPTAMEN JUNIOR -nutritional supplement
powder........................................................................... 143
PEPTAMEN -nutritional supplement liquid...................... 143
PEPTAMEN 1.5 -nutritional supplement liquid................ 144
PEPTAMEN OS -nutritional supplement liquid............... 143
PEPTAMEN OS 1.5 -nutritional supplement liquid......... 143
PEPTAMEN VHP -nutritional supplement liquid............. 144
PEPTINEX DT -nutritional supplement liquid..................144
PEPTINEX DT WITH PREBIOTI -nutritional supplement
liquid.............................................................................. 144
PEPTINEX 1.0 -nutritional supplement liquid................. 144
PEPTINEX 1.5 -nutritional supplement liquid................. 144
PERATIVE -nutritional supplement liquid........................ 144
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml........................................................................... 66
PERIFLEX ADVANCE -nutritional supplement
powder........................................................................... 144
PERIFLEX JUNIOR -nutritional supplement powder...... 144
PERIFLEX LQ PKU -amino acids oral liquid.................. 131
perindopril erbumine tab 2 mg...................................... 52
perindopril erbumine tab 4 mg (Aceon)........................ 53
perindopril erbumine tab 8 mg (Aceon)........................ 53
permethrin cream 5% (Elimite).................................... 177
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................ 94
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................ 94
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................ 94
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................ 94
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................ 95
perphenazine tab 2 mg................................................... 85
perphenazine tab 4 mg................................................... 85
perphenazine tab 8 mg................................................... 85
perphenazine tab 16 mg................................................. 86
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
4000-14375-15125 unit...................................................72
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit...................................................72
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit................................................ 72
PEXEVA -paroxetine mesylate tab 10 mg (base
equiv)............................................................................... 82
PEXEVA -paroxetine mesylate tab 20 mg (base
equiv)............................................................................... 82
PEXEVA -paroxetine mesylate tab 30 mg (base
equiv)............................................................................... 82
PEXEVA -paroxetine mesylate tab 40 mg (base
equiv)............................................................................... 82
PFD 1 -nutritional supplement powder............................ 144
PFD 2 -nutritional supplement powder............................ 144
PHENACTIN AA PLUS -nutritional supplement
liquid.............................................................................. 144
phenazopyridine hcl tab 100 mg (Pyridium).................77
phenazopyridine hcl tab 200 mg (Pyridium).................77
phenelzine sulfate tab 15 mg (Nardil)........................... 82
PHENEX-1 -nutritional supplement powder.................... 144
PHENEX-2 -nutritional supplement powder.................... 144
phenobarbital elixir 20 mg/5ml...................................... 88
PHENOBARBITAL -phenobarbital tab 15 mg................... 88
PHENOBARBITAL -phenobarbital tab 30 mg................... 88
PHENOBARBITAL -phenobarbital tab 60 mg................... 88
PHENOBARBITAL -phenobarbital tab 100 mg................. 88
phenobarbital tab 16.2 mg.............................................. 88
phenobarbital tab 32.4 mg.............................................. 88
phenobarbital tab 64.8 mg.............................................. 88
phenobarbital tab 97.2 mg.............................................. 88
phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 53
PHENYLADE AMINO ACID -amino acids bar................ 131
PHENYLADE AMINO ACID BLEN -amino acids
pack............................................................................... 131
PHENYLADE -amino acids oral powder......................... 131
PHENYLADE40 DRINK MIX -amino acids pack.............132
PHENYLADE60 DRINK MIX -nutritional supplement
pack............................................................................... 144
PHENYLADE DRINK MIX -nutritional supplement
powder........................................................................... 144
PHENYLADE60 DRINK MIX -nutritional supplement
powder........................................................................... 144
PHENYLADE ESSENTIAL DRINK -nutritional supplement
pack............................................................................... 144
PHENYLADE ESSENTIAL DRINK -nutritional supplement
powder........................................................................... 144
PHENYLADE GMP MIX-IN -nutritional supplement
pack............................................................................... 144
PHENYLADE GMP -nutritional supplement pack........... 144
PHENYLADE GMP -nutritional supplement powder....... 144
PHENYLADE MTE AMINO ACID -amino acids pack..... 131
PHENYLADE MTE -amino acids oral powder................ 131
PHENYLADE PHEBLOC -amino acids oral powder....... 132
PHENYLADE PHEBLOC -amino acids tab..................... 132
PHENYLADE RTD PKU 10 -nutritional supplement
liquid.............................................................................. 144
PHENYLEPHRINE/GUAIFENESIN -phenylephrineguaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)........... 63
phenylephrine-brompheniramine-dm liquid 7.5-4-15
mg/5ml............................................................................ 63
phenylephrine hcl ophth soln 2.5%............................. 165
phenylephrine hcl ophth soln 10%.............................. 165
phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............ 63
PHENYL-FREE 2HP -nutritional supplement
powder........................................................................... 144
PHENYL-FREE 2 -nutritional supplement powder..........144
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................ 63
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 113
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 113
phenytoin chew tab 50 mg (Dilantin infatabs)............113
phenytoin sodium extended cap 100 mg
(Dilantin)....................................................................... 113
phenytoin sodium extended cap 200 mg
(Phenytek).................................................................... 113
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
phenytoin sodium extended cap 300 mg
(Phenytek).................................................................... 113
phenytoin susp 125 mg/5ml (Dilantin-125)................. 113
PHLEXY-10 -amino acids cap......................................... 132
PHLEXY-10 -nutritional supplement pack....................... 144
PHLEXY-VITS -multiple vitamins w/ minerals
powder........................................................................... 123
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse
0.044%.......................................................................... 168
PHOS FLUR -sodium fluoride rinse 0.044%................... 168
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml..................................................................... 74
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%.................................................................. 165
PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/
ml & lidocaine 1% & ammonia inh kit............................ 24
PHYTOFUSION -nutritional supplement pack................ 144
phytonadione inj 1 mg/0.5ml (2 mg/ml).......................119
PICATO -ingenol mebutate gel 0.015%.......................... 177
PICATO -ingenol mebutate gel 0.05%............................ 177
pilocarpine hcl ophth soln 1% (Isopto carpine)......... 165
pilocarpine hcl ophth soln 2% (Isopto carpine)......... 165
pilocarpine hcl ophth soln 4% (Isopto carpine)......... 165
pilocarpine hcl tab 5 mg (Salagen)..............................168
pilocarpine hcl tab 7.5 mg (Salagen)...........................168
pimozide tab 1 mg (Orap)............................................... 95
pimozide tab 2 mg (Orap)............................................... 95
pindolol tab 5 mg............................................................. 44
pindolol tab 10 mg........................................................... 44
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)..... 34
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)..... 34
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 34
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 34
pioglitazone hcl tab 15 mg (base equiv) (Actos)..........34
pioglitazone hcl tab 30 mg (base equiv) (Actos)..........34
pioglitazone hcl tab 45 mg (base equiv) (Actos)..........34
piroxicam cap 10 mg (Feldene)................................... 107
piroxicam cap 20 mg (Feldene)................................... 107
PIVOT 1.5 CAL -nutritional supplement liquid................ 144
PKU COOLER 10 -nutritional supplement liquid.............145
PKU COOLER 15 -nutritional supplement liquid.............145
PKU COOLER 20 -nutritional supplement liquid.............145
PKU EASY MICROTABS -nutritional supplement tabs
delayed release.............................................................145
PKU EXPRESS -nutritional supplement pack.................145
PKU EXPRESS20 -nutritional supplement pack.............145
PKU GEL -nutritional supplement pack.......................... 145
PKU LOPHLEX LQ 20 -nutritional supplement liquid..... 145
PKU 2 -nutritional supplement powder........................... 145
PKU 3 -nutritional supplement powder........................... 145
PKU PERIFLEX EARLY YEARS -nutritional supplement
powder........................................................................... 145
PKU PERIFLEX JUNIOR PLUS -nutritional supplement
powder........................................................................... 145
PKU SPHERE 20 -nutritional supplement pack.............. 145
PKU TRIO -nutritional supplement powder..................... 145
PLEGRIDY -peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 95
PLEGRIDY -peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................ 95
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack.................................... 95
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack................................... 95
PLEXION CLEANSING CLOTHS -sulfacetamide sodium
w/ sulfur cleansing cloth 9.8-4.8%............................... 177
PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 177
PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 16
PNEUMOVAX 23/5 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 16
PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj
25 mcg/0.5ml.................................................................. 16
PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg.......................................... 124
PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................ 123
PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dssfe fumarate-fa tab 29-1 mg.......................................... 123
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack...................................................123
PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 124
PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe
fumarate-fa tab 27-1 mg...............................................123
PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg................................................................ 124
PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 123
PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg................................................................... 124
PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 124
PODOCON 25 IN BENZOIN TIN -podophyllum resin soln
25%................................................................................177
podofilox soln 0.5% (Condylox)................................... 177
POLYCAL -nutritional supplement powder......................145
polyethylene glycol 3350 oral packet............................ 68
polyethylene glycol 3350 oral powder.......................... 68
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)...................................................... 165
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liquid 10-4-10 mg/5ml..................................................... 63
POLY-VI-FLOR/IRON -ped multiple vitamin w/ fl-fe
biphasic susp 0.25-7 mg/ml......................................... 124
POLY-VI-FLOR/IRON -ped multiple vit w/ fl-fe biphasic
chew tab 0.5-10 mg...................................................... 124
POLY-VI-FLOR FS -pediatric multiple vitamins w/ fluoride
oral strip 1 mg...............................................................124
POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral
strip 0.25 mg................................................................. 124
POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral
strip 0.5 mg................................................................... 124
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew
tab 0.25 mg................................................................... 124
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew
tab 0.5 mg..................................................................... 124
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew
tab 1 mg........................................................................ 124
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic susp
0.25 mg/ml.................................................................... 124
POMALYST -pomalidomide cap 1 mg.............................. 21
POMALYST -pomalidomide cap 2 mg.............................. 21
POMALYST -pomalidomide cap 3 mg.............................. 21
POMALYST -pomalidomide cap 4 mg.............................. 21
PORTAGEN -nutritional supplement powder.................. 145
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................ 77
POTABA -potassium aminobenzoate cap 500 mg..........119
potassium bicarbonate effer tab 25 meq.................... 130
potassium chloride cap cr 8 meq (Micro-k)................ 130
potassium chloride cap cr 10 meq (Micro-k).............. 130
POTASSIUM CHLORIDE ER -potassium chloride tab cr 8
meq (600 mg)............................................................... 130
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)........................................................ 130
potassium chloride microencapsulated crys cr tab 10
meq............................................................................... 130
potassium chloride microencapsulated crys cr tab 20
meq............................................................................... 130
potassium chloride oral soln 10% (20 meq/15ml)...... 130
POTASSIUM CHLORIDE -potassium chloride oral soln
20% (40 meq/15ml)...................................................... 130
potassium chloride powder packet 20 meq............... 130
potassium chloride tab cr 10 meq (K-tab).................. 130
potassium chloride tab cr 8 meq (600 mg)................. 130
potassium citrate & citric acid powder pack 3300-1002
mg................................................................................... 77
potassium citrate & citric acid soln 1100-334
mg/5ml............................................................................ 77
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)...................................................................................... 77
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10).................................................................................... 77
potassium citrate tab cr 15 meq (1620 mg) (Urocit-k
15).................................................................................... 77
pot bicarbonate & chloride effer tab 25 meq.............. 130
POTIGA -ezogabine tab 50 mg....................................... 113
POTIGA -ezogabine tab 200 mg..................................... 114
POTIGA -ezogabine tab 300 mg..................................... 114
POTIGA -ezogabine tab 400 mg..................................... 114
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)...............................130
PPA/MMA EXPRESS -nutritional supplement pack........ 145
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)........................................................ 155
PRADAXA -dabigatran etexilate mesylate cap 110 mg
(etexilate base eq)........................................................ 155
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)........................................................ 155
PRALUENT -alirocumab subcutaneous soln pen-injector
75 mg/ml......................................................................... 58
PRALUENT -alirocumab subcutaneous soln pen-injector
150 mg/ml....................................................................... 58
pramipexole dihydrochloride tab 0.125 mg
(Mirapex).......................................................................117
pramipexole dihydrochloride tab 0.25 mg
(Mirapex).......................................................................117
pramipexole dihydrochloride tab 0.5 mg
(Mirapex).......................................................................117
pramipexole dihydrochloride tab 0.75 mg
(Mirapex).......................................................................117
pramipexole dihydrochloride tab 1 mg (Mirapex)...... 117
pramipexole dihydrochloride tab 1.5 mg
(Mirapex).......................................................................117
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................. 116
pramipexole dihydrochloride tab sr 24hr 0.75 mg
(Mirapex er).................................................................. 116
pramipexole dihydrochloride tab sr 24hr 1.5 mg
(Mirapex er).................................................................. 116
pramipexole dihydrochloride tab sr 24hr 2.25 mg
(Mirapex er).................................................................. 116
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................. 116
pramipexole dihydrochloride tab sr 24hr 3.75 mg
(Mirapex er).................................................................. 117
pramipexole dihydrochloride tab sr 24hr 4.5 mg
(Mirapex er).................................................................. 117
PRAMOSONE E -pramoxine-hc emollient base cream
1-2.5%........................................................................... 178
PRAMOSONE -pramoxine-hc cream 1-1%.................... 177
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 177
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 177
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
PRAMOSONE -pramoxine-hc oint 1-1%.........................177
PRAMOSONE -pramoxine-hc oint 1-2.5%......................177
pramoxine-hc cream 1-2.5% (Pramosone)................. 178
pravastatin sodium tab 10 mg....................................... 58
pravastatin sodium tab 20 mg (Pravachol)...................58
pravastatin sodium tab 40 mg (Pravachol)...................58
pravastatin sodium tab 80 mg (Pravachol)...................58
prazosin hcl cap 1 mg (Minipress)................................ 53
prazosin hcl cap 2 mg (Minipress)................................ 53
prazosin hcl cap 5 mg (Minipress)................................ 53
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%........................................................................... 165
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%........................................................................ 165
PRED MILD -prednisolone acetate ophth susp
0.12%.............................................................................165
prednicarbate cream 0.1% (Dermatop)....................... 178
prednicarbate oint 0.1% (Dermatop)........................... 178
PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin-bromfenac opth sol 1-0.5-0.09%............. 165
PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin-ketorolac opth sol 1-0.5-0.5%................. 165
PREDNISOLONE/MOXIFLOXACIN -prednisolonemoxifloxacin opth soln 1-0.5%..................................... 165
prednisolone acetate ophth susp 1% (Pred forte)..... 165
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate ophth soln 1%................................ 165
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate oral soln 25 mg/5ml (base eq)......... 24
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt)............................................... 24
prednisolone sod phos orally disintegr tab 15 mg
(base eq) (Orapred odt)............................................... 24
prednisolone sod phos orally disintegr tab 30 mg
(base eq) (Orapred odt)............................................... 24
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)................................................................... 24
prednisolone sod phosphate oral soln 10 mg/5ml
(base equiv) (Millipred)................................................ 24
prednisolone sod phosphate oral soln 20 mg/5ml
(base equiv) (Veripred 20)........................................... 24
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................24
prednisolone syrup 15 mg/5ml (usp solution
equivalent)......................................................................24
PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 24
PREDNISONE -prednisone oral soln 5 mg/5ml................ 24
PREDNISONE -prednisone tab 50 mg............................. 24
PREDNISONE -prednisone tab therapy pack 5 mg
(21).................................................................................. 24
PREDNISONE -prednisone tab therapy pack 5 mg
(48).................................................................................. 24
PREDNISONE -prednisone tab therapy pack 10 mg
(21).................................................................................. 24
PREDNISONE -prednisone tab therapy pack 10 mg
(48).................................................................................. 24
prednisone tab 1 mg....................................................... 24
prednisone tab 2.5 mg.................................................... 24
prednisone tab 5 mg....................................................... 24
prednisone tab 10 mg..................................................... 24
prednisone tab 20 mg..................................................... 24
PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack.............................................124
PREFERAOB ONE -prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg............................................124
PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 34-1 mg...................................................................124
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................ 27
PRE-FOLIC -folic acid-vitamin c tab 1-100 mg............... 154
PREMARIN -estrogens, conjugated tab 0.3 mg............... 27
PREMARIN -estrogens, conjugated tab 0.45 mg............. 27
PREMARIN -estrogens, conjugated tab 0.625 mg........... 27
PREMARIN -estrogens, conjugated tab 0.9 mg............... 27
PREMARIN -estrogens, conjugated tab 1.25 mg............. 27
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 76
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14).......................................................... 27
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg................................................... 27
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.45-1.5 mg................................................. 27
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.625-2.5 mg............................................... 27
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.625-5 mg.................................................. 27
PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg..................................................................... 125
PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg........................................ 124
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg....................124
PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg....................................................... 124
PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 124
PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg................................................... 125
PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg..................................................... 124
PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg................................................... 125
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 125
PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa
tab 29-1 mg...................................................................125
PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 125
PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 125
PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 125
PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 125
PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 125
PRENATAL VITAMINS PLUS LO -prenatal vit w/ fe
fumarate-fa tab 27-1 mg...............................................125
PRENATE AM -prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg............................................................ 125
PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg................................................. 125
PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg........................................................ 125
PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg......................................................... 125
PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg................................................................ 125
PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg.......................................... 125
PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg..................................... 125
PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg....................................... 125
PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg................................................. 125
PRENATE MINI -prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg........................................................ 125
PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg................................................. 125
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg..................................................................... 125
PRENATE RESTORE -prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg.......................................... 125
PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg...................................................................125
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............39
PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 125
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm........................................................... 68
PREPROTEIN -amino acids oral liquid........................... 132
PREPROTEIN 20 -amino acids oral liquid...................... 132
PRESTALIA -perindopril arginine-amlodipine besylate tab
3.5-2.5 mg....................................................................... 53
PRESTALIA -perindopril arginine-amlodipine besylate tab
7-5 mg............................................................................. 53
PRESTALIA -perindopril arginine-amlodipine besylate tab
14-10 mg......................................................................... 53
PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg...... 126
PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
1.1%...............................................................................168
PREVIDENT 5000 BOOSTER -sodium fluoride paste
1.1%...............................................................................168
PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
1.1% (0.5% f)................................................................ 168
PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%................................... 168
PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
f)..................................................................................... 168
PREVIDENT 5000 PLUS -sodium fluoride cream
1.1%...............................................................................168
PREVIDENT 5000 SENSITIVE -sodium fluoridepotassium nitrate paste 1.1-5%................................... 168
PREVNAR 13 -Pneumococcal 13-valent conjugate
vaccine inj....................................................................... 16
PREZCOBIX -darunavir-cobicistat tab 800-150 mg............9
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 9
PREZISTA -darunavir ethanolate tab 75 mg (base
equiv)................................................................................. 9
PREZISTA -darunavir ethanolate tab 150 mg (base
equiv)................................................................................. 9
PREZISTA -darunavir ethanolate tab 600 mg (base
equiv)................................................................................. 9
PREZISTA -darunavir ethanolate tab 800 mg (base
equiv)................................................................................. 9
PRIFTIN -rifapentine tab 150 mg........................................ 5
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg (15 mg base).................................................... 12
primidone tab 50 mg (Mysoline).................................. 114
primidone tab 250 mg (Mysoline)................................ 114
PRIMLEV -oxycodone w/ acetaminophen tab 5-300
mg.................................................................................. 103
PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300
mg.................................................................................. 103
PRIMLEV -oxycodone w/ acetaminophen tab 10-300
mg.................................................................................. 103
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base
equiv)............................................................................... 12
PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg
(base equiv).................................................................... 82
PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg
(base equiv).................................................................... 82
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg
(base equiv).................................................................... 82
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk................................................... 124
PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk................................................... 124
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk.................................................... 124
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk.................................................... 124
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 66
PROAIR RESPICLICK -albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv)......................................... 66
PROBALANCE -nutritional supplement liquid................. 145
probenecid tab 500 mg................................................. 109
PROBUPHINE IMPLANT KIT -buprenorphine hcl
subdermal implant 74.2 mg (base equiv).....................103
PRO-CAL -nutritional supplement pack.......................... 145
PRO-CAL -nutritional supplement powder...................... 145
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)................................................................... 86
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)................................................................... 86
prochlorperazine suppos 25 mg.................................... 86
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33
mg/5ml............................................................................. 63
PROCORT -hydrocortisone acetate w/ pramoxine rectal
cream 1.85-1.15%........................................................ 170
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 154
PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 154
PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 154
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 154
PROCRIT -epoetin alfa inj 20000 unit/ml........................ 154
PROCRIT -epoetin alfa inj 40000 unit/ml........................ 154
PROCTOFOAM HC -hydrocortisone acetate w/
pramoxine rectal foam 1-1%........................................ 170
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv).............................................................. 77
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv).............................................................. 77
PROFERRIN-FORTE -iron heme polypeptide-folic acid
tab 12-1 mg (fe equiv).................................................. 154
PROFILNINE -factor ix complex for inj 500 unit............. 161
PROFILNINE -factor ix complex for inj 1000 unit........... 161
PROFILNINE -factor ix complex for inj 1500 unit........... 161
PROFILNINE SD -factor ix complex for inj 500 unit........161
PROFILNINE SD -factor ix complex for inj 1000 unit......161
PROFILNINE SD -factor ix complex for inj 1500 unit......161
progesterone im in oil 50 mg/ml.................................... 30
progesterone micronized cap 100 mg
(Prometrium).................................................................. 30
progesterone micronized cap 200 mg
(Prometrium).................................................................. 30
PROGLYCEM -diazoxide susp 50 mg/ml......................... 34
PROGRAF -tacrolimus cap 0.5 mg................................. 185
PROGRAF -tacrolimus cap 1 mg.................................... 185
PROGRAF -tacrolimus cap 5 mg.................................... 185
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)..................................................................... 165
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................. 154
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)............................................................................. 154
PROMACTA -eltrombopag olamine tab 50 mg (base
equiv)............................................................................. 154
PROMACTA -eltrombopag olamine tab 75 mg (base
equiv)............................................................................. 154
PROMACTIN AA PLUS -nutritional supplement
liquid.............................................................................. 145
promethazine & phenylephrine syrup 6.25-5
mg/5ml............................................................................ 63
promethazine-dm syrup 6.25-15 mg/5ml.......................63
promethazine hcl suppos 12.5 mg................................ 61
promethazine hcl suppos 25 mg................................... 61
promethazine hcl suppos 50 mg................................... 61
promethazine hcl syrup 6.25 mg/5ml............................ 61
promethazine hcl tab 12.5 mg........................................ 61
promethazine hcl tab 25 mg........................................... 61
promethazine hcl tab 50 mg........................................... 61
promethazine-phenylephrine-codeine syrup 6.25-5-10
mg/5ml............................................................................ 63
promethazine w/ codeine syrup 6.25-10 mg/5ml..........63
PROMISEB -antiseborrheic products misc - cream........ 178
PROMOD -nutritional supplement liquid......................... 145
PROMOD -nutritional supplement powder...................... 145
PROMOTE/FIBER -nutritional supplement liquid........... 145
PROMOTE -nutritional supplement liquid....................... 145
PROMOTE 1.0 -nutritional supplement liquid................. 145
PROMOTE WITH FIBER -nutritional supplement
liquid.............................................................................. 145
PROMOTE 1.0 WITH FIBER -nutritional supplement
liquid.............................................................................. 145
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 47
propafenone hcl cap sr 12hr 325 mg (Rythmol sr)...... 47
propafenone hcl cap sr 12hr 425 mg (Rythmol sr)...... 47
propafenone hcl tab 300 mg.......................................... 47
propafenone hcl tab 150 mg (Rythmol)........................ 47
propafenone hcl tab 225 mg (Rythmol)........................ 47
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg.............................................................................. 71
proparacaine hcl ophth soln 0.5% (Alcaine).............. 166
PRO-PHREE -nutritional supplement powder................ 145
PROPIMEX-1 -nutritional supplement powder................ 145
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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PROPIMEX-2 -nutritional supplement powder................ 145
PROPRANOLOL/HYDROCHLOROTH -propranolol &
hydrochlorothiazide tab 40-25 mg.................................. 53
PROPRANOLOL/HYDROCHLOROTH -propranolol &
hydrochlorothiazide tab 80-25 mg.................................. 53
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 44
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 44
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 45
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 45
PROPRANOLOL HCL -propranolol hcl oral soln 20
mg/5ml............................................................................. 44
PROPRANOLOL HCL -propranolol hcl oral soln 40
mg/5ml............................................................................. 44
propranolol hcl tab 10 mg.............................................. 45
propranolol hcl tab 20 mg.............................................. 45
propranolol hcl tab 40 mg.............................................. 45
propranolol hcl tab 60 mg.............................................. 45
propranolol hcl tab 80 mg.............................................. 45
propylthiouracil tab 50 mg............................................. 38
PRO-RED AC -phenylephrine-dexchlorphenir-codeine
syrup 5-1-9 mg/5ml.........................................................63
PROSOURCE NO CARB -nutritional supplement
liquid.............................................................................. 145
PROSOURCE -nutritional supplement liquid.................. 145
PROSOURCE -nutritional supplement powder............... 145
PROSOURCE PLUS -nutritional supplement liquid........145
PROSOURCE TF -nutritional supplement liquid.............145
PROSOURCE ZAC -nutritional supplement liquid.......... 146
PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 39
PROSURE -nutritional supplement liquid........................146
PROTAIN XL -nutritional supplement liquid.................... 146
PROTECTIRON -iron polysacch-fa-b complex-vit c-e &
minerals tab 60-1 mg................................................... 154
PROTEIN FORTIFIED COOKIE -nutritional supplement
misc............................................................................... 146
PROTHELIAL -sucralfate-malate paste 10%.................. 169
protriptyline hcl tab 5 mg............................................... 82
protriptyline hcl tab 10 mg............................................. 82
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/
act (90mcg base equiv).................................................. 66
PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg........................................................126
PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg...............................................................126
PROVIMIN -nutritional supplement powder.................... 146
PRUCLAIR -dermatological products misc - cream........ 178
PRUDOXIN -doxepin hcl cream 5%............................... 178
PRUMYX -dermatological products misc - cream...........178
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro).......................................................... 63
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml............................................................................ 63
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml............................................................................ 63
PSORCON -diflorasone diacetate cream 0.05%............ 178
PULMICORT -budesonide inhalation susp 1 mg/2ml....... 66
PULMICORT FLEXHALER -budesonide inhal aero powd
90 mcg/act (breath activated).........................................66
PULMICORT FLEXHALER -budesonide inhal aero powd
180 mcg/act (breath activated)...................................... 66
PULMOCARE -nutritional supplement liquid.................. 146
PULMOCARE 1.5 -nutritional supplement liquid............ 146
PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 68
PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg...................................................... 126
PUREFE PLUS -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg.................................................... 154
PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/
ml).................................................................................... 21
PX VANILLA PLUS -nutritional supplement liquid.......... 146
PYLERA -bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg..............................................................71
pyrazinamide tab 500 mg..................................................6
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)......................................................................119
pyridostigmine bromide tab 60 mg (Mestinon).......... 119
Q
QBRELIS -lisinopril oral soln 1 mg/ml............................... 53
QNASL -beclomethasone dipropionate nasal aerosol 80
mcg/act............................................................................ 62
QNASL CHILDRENS -beclomethasone dipropionate
nasal aerosol 40 mcg/act............................................... 62
QUADRACEL -diph-tetanus tox ad-acell pert & polio
virus, ipv vac inj.............................................................. 16
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg...................................................... 30
QUAZEPAM -quazepam tab 15 mg.................................. 88
QUDEXY XR -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 114
QUDEXY XR -topiramate cap er 24hr sprinkle 50
mg.................................................................................. 114
QUDEXY XR -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 114
QUDEXY XR -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 114
QUDEXY XR -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 114
QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr
24hr 50 mg......................................................................86
QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr
24hr 150 mg....................................................................86
QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr
24hr 200 mg....................................................................86
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr
24hr 300 mg....................................................................86
quetiapine fumarate tab 25 mg (Seroquel)................... 86
quetiapine fumarate tab 50 mg (Seroquel)................... 86
quetiapine fumarate tab 100 mg (Seroquel)................. 86
quetiapine fumarate tab 200 mg (Seroquel)................. 86
quetiapine fumarate tab 300 mg (Seroquel)................. 86
quetiapine fumarate tab 400 mg (Seroquel)................. 86
quetiapine fumarate tab sr 24hr 400 mg (Seroquel
xr).................................................................................... 86
QUFLORA FE -multi vit w/ min & fluoride-iron-fa chew tab
0.25 mg......................................................................... 126
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride chew tab 0.25 mg............................................ 126
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride chew tab 0.5 mg.............................................. 126
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride chew tab 1 mg................................................. 126
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml............................................... 126
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml................................................. 126
quinapril hcl tab 5 mg (Accupril)................................... 53
quinapril hcl tab 10 mg (Accupril)................................. 53
quinapril hcl tab 20 mg (Accupril)................................. 53
quinapril hcl tab 40 mg (Accupril)................................. 53
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 53
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 53
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 53
quinidine gluconate tab cr 324 mg................................ 47
QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 47
QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 48
quinine sulfate cap 324 mg (Qualaquin)....................... 12
QUINOA KALE & HEMP -nutritional supplement
liquid.............................................................................. 146
QVAR -beclomethasone diprop inhal aero soln 40 mcg/act
(50/valve)......................................................................... 66
QVAR -beclomethasone diprop inhal aero soln 80 mcg/act
(100/valve)....................................................................... 66
R
RA BALANCED NUTRITIONAL -nutritional supplement
liquid.............................................................................. 146
RA BALANCED NUTRITIONAL P -nutritional supplement
liquid.............................................................................. 146
RABAVERT -rabies vaccine, pcec for inj.......................... 16
rabeprazole sodium ec tab 20 mg (Aciphex)................ 71
RADIOGARDASE -prussian blue insoluble cap 0.5
gm.................................................................................. 183
RAGWITEK -short ragweed pollen allergen extract tab sl
12 amb a 1-u.................................................................. 17
raloxifene hcl tab 60 mg (Evista)................................... 41
ramipril cap 1.25 mg (Altace)......................................... 53
ramipril cap 2.5 mg (Altace)........................................... 53
ramipril cap 5 mg (Altace).............................................. 53
ramipril cap 10 mg (Altace)............................................ 53
RANEXA -ranolazine tab sr 12hr 500 mg......................... 43
RANEXA -ranolazine tab sr 12hr 1000 mg....................... 43
ranitidine hcl cap 150 mg............................................... 71
ranitidine hcl cap 300 mg............................................... 71
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 71
ranitidine hcl tab 300 mg (Zantac)................................. 71
RA NUTRITIONAL SUPPLEMENT -nutritional
supplement liquid.......................................................... 146
RA NUTRITIONAL SUPPORT -nutritional supplement
powder........................................................................... 146
RAPAFLO -silodosin cap 4 mg..........................................77
RAPAFLO -silodosin cap 8 mg..........................................77
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 185
RA PEDIATRIC NUTRITIONAL -nutritional supplement
liquid.............................................................................. 146
rasagiline mesylate tab 0.5 mg (base equiv)
(Azilect).........................................................................117
rasagiline mesylate tab 1 mg (base equiv)
(Azilect).........................................................................117
RASUVO -methotrexate soln pf auto-injector 7.5
mg/0.15ml...................................................................... 107
RASUVO -methotrexate soln pf auto-injector 10
mg/0.2ml........................................................................ 107
RASUVO -methotrexate soln pf auto-injector 12.5
mg/0.25ml...................................................................... 107
RASUVO -methotrexate soln pf auto-injector 15
mg/0.3ml........................................................................ 107
RASUVO -methotrexate soln pf auto-injector 17.5
mg/0.35ml...................................................................... 107
RASUVO -methotrexate soln pf auto-injector 20
mg/0.4ml........................................................................ 107
RASUVO -methotrexate soln pf auto-injector 22.5
mg/0.45ml...................................................................... 107
RASUVO -methotrexate soln pf auto-injector 25
mg/0.5ml........................................................................ 107
RASUVO -methotrexate soln pf auto-injector 27.5
mg/0.55ml...................................................................... 107
RASUVO -methotrexate soln pf auto-injector 30
mg/0.6ml........................................................................ 107
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........41
RAYOS -prednisone tab delayed release 1 mg................ 24
RAYOS -prednisone tab delayed release 2 mg................ 24
RAYOS -prednisone tab delayed release 5 mg................ 24
RE/GEN PROTEIN FORTIFIED -nutritional supplement
misc............................................................................... 146
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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RE/NEPH HP/HC -nutritional supplement liquid
(frozen).......................................................................... 146
RE/NEPH LP/HC -nutritional supplement liquid..............146
RE/NEPH -nutritional supplement liquid......................... 146
RE/NEPH REDUCED SUGAR -nutritional supplement
liquid.............................................................................. 146
REBETOL -ribavirin soln 40 mg/ml..................................... 9
REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)........................................................................ 95
REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml)........................................................................ 95
REBIF REBIDOSE -interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)...................................................... 95
REBIF REBIDOSE -interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)...................................................... 95
REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 95
REBIF TITRATION PACK -interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................... 95
RECEDO -scar treatment products - gel.........................178
RECOMBINATE -antihemophilic factor (recombinant) for
inj 220-400 unit............................................................. 161
RECOMBINATE -antihemophilic factor (recombinant) for
inj 401-800 unit............................................................. 161
RECOMBINATE -antihemophilic factor (recombinant) for
inj 801-1240 unit........................................................... 161
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1241-1800 unit......................................................... 161
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1801-2400 unit......................................................... 161
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 5 mcg/0.5ml........................................................... 16
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 10 mcg/ml.............................................................. 16
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 40 mcg/ml.............................................................. 16
RECTIV -nitroglycerin oint 0.4%..................................... 170
RECURA -antifungal combination products misc cream............................................................................. 178
REGENECARE -lidocaine hcl-collagen-aloe vera gel
2%.................................................................................. 178
REGRANEX -becaplermin gel 0.01%............................. 178
RELAGARD -acetic acid-oxyquinoline vaginal gel
0.9-0.025%...................................................................... 76
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister........................................................9
RELION R -insulin regular (human) inj 100 unit/ml........... 36
RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 74
RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)....................................................................... 74
RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 126
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)..................................................................... 108
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)..................................................................... 108
REMBRANDT DEEPLY WHITE+PE -sodium
monofluorophosphate paste 0.884%........................... 169
REMBRANDT INTENSE STAIN -sodium fluoride paste
0.243%.......................................................................... 169
REMBRANDT WHITENING -sodium fluoride rinse
0.02%.............................................................................169
RENAGEL -sevelamer hcl tab 400 mg............................. 74
RENAGEL -sevelamer hcl tab 800 mg............................. 74
RENALCAL -nutritional supplement liquid...................... 146
RENASTART -nutritional supplement powder................ 146
RENVELA -sevelamer carbonate packet 0.8 gm.............. 74
RENVELA -sevelamer carbonate packet 2.4 gm.............. 74
RENVELA -sevelamer carbonate tab 800 mg.................. 74
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 1-500 mg.............................................................34
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 2-500 mg.............................................................34
repaglinide tab 0.5 mg (Prandin)................................... 34
repaglinide tab 1 mg (Prandin)...................................... 34
repaglinide tab 2 mg (Prandin)...................................... 34
REPATHA -evolocumab subcutaneous soln prefilled
syringe 140 mg/ml.......................................................... 58
REPATHA PUSHTRONEX SYSTEM -evolocumab
subcutaneous soln cartridge/infusor 420 mg/3.5ml....... 59
REPATHA SURECLICK -evolocumab subcutaneous soln
auto-injector 140 mg/ml.................................................. 59
REPLETE/FIBER/ULTRAPAK -nutritional supplement
liquid.............................................................................. 146
REPLETE FIBER 1 CAL -nutritional supplement
liquid.............................................................................. 146
REPLETE FIBER -nutritional supplement liquid............. 146
REPLETE -nutritional supplement liquid......................... 146
RESCRIPTOR -delavirdine mesylate tab 100 mg.............. 9
RESCRIPTOR -delavirdine mesylate tab 200 mg............ 10
RESCULA -unoprostone isopropyl ophth soln
0.15%.............................................................................166
RESOURCE ARGINAID -nutritional supplement
pack............................................................................... 146
RESOURCE DAIRY THICK HONE -nutritional
supplement liquid.......................................................... 146
RESOURCE DIABETIC TF -nutritional supplement
liquid.............................................................................. 146
RESOURCE JUICE DRINK -nutritional supplement liquid
(frozen).......................................................................... 146
RESOURCE JUST FOR KIDS -nutritional supplement
liquid.............................................................................. 146
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
RESOURCE JUST FOR KIDS 1. -nutritional supplement
liquid.............................................................................. 146
RESOURCE JUST FOR KIDS WI -nutritional supplement
liquid.............................................................................. 146
RESOURCE 2.0 -nutritional supplement liquid............... 147
RESOURCE SUPPORT -nutritional supplement
liquid.............................................................................. 147
RESOURCE THICKENUP THICKE -nutritional
supplement liquid.......................................................... 147
RESPALOR -nutritional supplement liquid...................... 147
RESPIRATORY THERAPY SUPPLIES-VARIOUS......... 183
RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 166
RESTASIS MULTIDOSE -cyclosporine (ophth) emulsion
0.05%.............................................................................166
RESTORA RX -lactobacillus casei-folic acid cap 60-1.25
mg.................................................................................... 69
RESTORA SPRINKLES -lactobacillus casei-folic acid
packet 15-0.25 mg.......................................................... 69
RESURGEX -nutritional supplement pack...................... 147
RESURGEX PLUS -nutritional supplement pack........... 147
RESURGEX SELECT -nutritional supplement pack....... 147
REVATIO -sildenafil citrate for suspension 10 mg/ml....... 60
REVESTA -folic acid-cholecalciferol cap 1 mg-5750
unit................................................................................. 154
REVLIMID -lenalidomide cap 5 mg................................. 185
REVLIMID -lenalidomide cap 10 mg............................... 185
REVLIMID -lenalidomide cap 15 mg............................... 185
REVLIMID -lenalidomide cap 20 mg............................... 185
REVLIMID -lenalidomide cap 25 mg............................... 185
REVLIMID -lenalidomide caps 2.5 mg............................ 185
REXULTI -brexpiprazole tab 0.25 mg............................... 86
REXULTI -brexpiprazole tab 0.5 mg................................. 86
REXULTI -brexpiprazole tab 1 mg.................................... 86
REXULTI -brexpiprazole tab 2 mg.................................... 86
REXULTI -brexpiprazole tab 3 mg.................................... 86
REXULTI -brexpiprazole tab 4 mg.................................... 86
REYATAZ -atazanavir sulfate cap 150 mg (base
equiv)............................................................................... 10
REYATAZ -atazanavir sulfate cap 200 mg (base
equiv)............................................................................... 10
REYATAZ -atazanavir sulfate cap 300 mg (base
equiv)............................................................................... 10
REYATAZ -atazanavir sulfate oral powder packet 50 mg
(base equiv).................................................................... 10
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml............................................................................. 63
RIASTAP -fibrinogen conc (human) inj approximately 1
gm (900-1300 mg)........................................................ 161
RIAX -benzoyl peroxide foam 5.5%................................ 178
RIAX -benzoyl peroxide foam 9.5%................................ 178
RIBASPHERE RIBAPAK -ribavirin tab 400 mg................. 10
RIBASPHERE RIBAPAK -ribavirin tab 600 mg................. 10
RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack....................................................10
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack....................................................10
RIBASPHERE -ribavirin tab 400 mg................................. 10
RIBASPHERE -ribavirin tab 600 mg................................. 10
ribavirin cap 200 mg (Rebetol)....................................... 10
ribavirin for inhal soln 6 gm (Virazole)......................... 10
ribavirin tab 200 mg (Copegus)..................................... 10
RIDAURA -auranofin cap 3 mg....................................... 107
rifabutin cap 150 mg (Mycobutin).................................... 6
RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 6
rifampin cap 150 mg (Rifadin).......................................... 6
rifampin cap 300 mg (Rifadin).......................................... 6
RIFATER -isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg.................................................................. 6
riluzole tab 50 mg (Rilutek).......................................... 118
rimantadine hydrochloride tab 100 mg
(Flumadine).................................................................... 10
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 34
risedronate sodium tab delayed release 35 mg
(Atelvia).......................................................................... 41
risedronate sodium tab 5 mg (Actonel)........................ 41
risedronate sodium tab 30 mg (Actonel)...................... 41
risedronate sodium tab 35 mg (Actonel)...................... 41
risedronate sodium tab 150 mg (Actonel).................... 41
risperidone orally disintegrating tab 0.25 mg.............. 86
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 86
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 86
risperidone orally disintegrating tab 2 mg (Risperdal
m-tab).............................................................................. 86
risperidone orally disintegrating tab 3 mg (Risperdal
m-tab).............................................................................. 86
risperidone orally disintegrating tab 4 mg (Risperdal
m-tab).............................................................................. 86
risperidone soln 1 mg/ml (Risperdal)............................ 86
risperidone tab 0.25 mg (Risperdal).............................. 86
risperidone tab 0.5 mg (Risperdal)................................ 86
risperidone tab 1 mg (Risperdal)................................... 86
risperidone tab 2 mg (Risperdal)................................... 86
risperidone tab 3 mg (Risperdal)................................... 87
risperidone tab 4 mg (Risperdal)................................... 87
rivastigmine tartrate cap 1.5 mg (Exelon).....................95
rivastigmine tartrate cap 3 mg (Exelon)........................95
rivastigmine tartrate cap 4.5 mg (Exelon).....................95
rivastigmine tartrate cap 6 mg (Exelon)........................95
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 95
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 95
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 95
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
RIXUBIS -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 161
RIXUBIS -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 161
RIXUBIS -coagulation factor ix (recombinant) for inj 1000
unit................................................................................. 161
RIXUBIS -coagulation factor ix (recombinant) for inj 2000
unit................................................................................. 161
RIXUBIS -coagulation factor ix (recombinant) for inj 3000
unit................................................................................. 161
rizatriptan benzoate oral disintegrating tab 5 mg (base
eq) (Maxalt-mlt)........................................................... 108
rizatriptan benzoate oral disintegrating tab 10 mg
(base eq) (Maxalt-mlt)................................................ 108
rizatriptan benzoate tab 5 mg (base equivalent)
(Maxalt)......................................................................... 108
rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)......................................................................... 108
R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg.................................................................. 126
ropinirole hydrochloride tab 0.25 mg (Requip).......... 117
ropinirole hydrochloride tab 0.5 mg (Requip)............ 117
ropinirole hydrochloride tab 1 mg (Requip)............... 117
ropinirole hydrochloride tab 2 mg (Requip)............... 117
ropinirole hydrochloride tab 3 mg (Requip)............... 117
ropinirole hydrochloride tab 4 mg (Requip)............... 117
ropinirole hydrochloride tab 5 mg (Requip)............... 117
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)............................................... 117
ropinirole hydrochloride tab sr 24hr 4 mg (base
equivalent) (Requip xl)............................................... 117
ropinirole hydrochloride tab sr 24hr 6 mg (base
equivalent) (Requip xl)............................................... 117
ropinirole hydrochloride tab sr 24hr 8 mg (base
equivalent) (Requip xl)............................................... 117
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl)............................................... 117
ROSULA -sulfacetamide sodium w/ sulfur cleansing cloth
10-5%............................................................................ 178
rosuvastatin calcium tab 5 mg (Crestor)...................... 59
rosuvastatin calcium tab 10 mg (Crestor).................... 59
rosuvastatin calcium tab 20 mg (Crestor).................... 59
rosuvastatin calcium tab 40 mg (Crestor).................... 59
ROZEREM -ramelteon tab 8 mg....................................... 88
RUBRACA -rucaparib camsylate tab 200 mg (base
equivalent)....................................................................... 21
RUBRACA -rucaparib camsylate tab 300 mg (base
equivalent)....................................................................... 21
RUCONEST -c1 esterase inhibitor (recombinant) for iv inj
2100 unit....................................................................... 162
RULAVITE DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................. 126
RYNODERM -urea cream 37.5%.................................... 178
RYTARY -carbidopa & levodopa cap cr 23.75-95 mg..... 117
RYTARY -carbidopa & levodopa cap cr 36.25-145
mg.................................................................................. 117
RYTARY -carbidopa & levodopa cap cr 48.75-195
mg.................................................................................. 117
RYTARY -carbidopa & levodopa cap cr 61.25-245
mg.................................................................................. 117
S
SABRIL -vigabatrin powd pack 500 mg.......................... 114
SABRIL -vigabatrin tab 500 mg...................................... 114
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg..............................................................30
SALICEPT -oral wound care products - for susp
rinse............................................................................... 169
salicylic acid cream 6%................................................ 178
salicylic acid er film-forming soln 28.5% (Ultrasaler).................................................................................. 178
salicylic acid film forming liquid 27.5% (Virasal)....... 178
salicylic acid foam 6% (Salvax)................................... 178
salicylic acid gel 6% (Keralyt)...................................... 178
salicylic acid lotion 6%................................................. 178
salicylic acid shampoo 6% (Salex).............................. 178
salicylic acid soln 26%..................................................178
SALIVAMAX -artificial saliva - packet..............................169
SALIVATE RX -artificial saliva - packet........................... 169
SALMON/OATS/SQUASH -nutritional supplement
liquid.............................................................................. 147
salsalate tab 500 mg (Disalcid)...................................... 96
salsalate tab 750 mg (Disalcid)...................................... 96
SAMSCA -tolvaptan tab 15 mg......................................... 41
SAMSCA -tolvaptan tab 30 mg......................................... 41
SANARE SCAR THERAPY -cream base....................... 184
SANCUSO -granisetron td patch 3.1 mg/24hr (contains
34.3 mg).......................................................................... 71
SANDIMMUNE -cyclosporine cap 25 mg....................... 185
SANDIMMUNE -cyclosporine cap 100 mg..................... 185
SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 185
SANTYL -collagenase oint 250 unit/gm.......................... 178
SAPHRIS -asenapine maleate sl tab 2.5 mg (base
equiv)............................................................................... 87
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)............................................................................... 87
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)............................................................................... 87
SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.................... 95
SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.................... 95
SAVAYSA -edoxaban tosylate tab 15 mg (base
equivalent)..................................................................... 155
SAVAYSA -edoxaban tosylate tab 30 mg (base
equivalent)..................................................................... 155
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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SAVAYSA -edoxaban tosylate tab 60 mg (base
equivalent)..................................................................... 156
SAVELLA -milnacipran hcl tab 12.5 mg............................ 95
SAVELLA -milnacipran hcl tab 25 mg............................... 95
SAVELLA -milnacipran hcl tab 50 mg............................... 95
SAVELLA -milnacipran hcl tab 100 mg............................. 95
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak................................. 95
SB COMPLETE NUTRITION -nutritional supplement
liquid.............................................................................. 147
SB COMPLETE NUTRITION PLU -nutritional supplement
liquid.............................................................................. 147
SCANDICAL -nutritional supplement powder................. 147
SCANDISHAKE -nutritional supplement misc................ 147
SCANDISHAKE -nutritional supplement pack................ 147
SCANDISHAKE -nutritional supplement powder............ 147
scar treatment products - gel...................................... 178
SECONAL SODIUM -secobarbital sodium cap 100
mg.................................................................................... 88
SEEBRI NEOHALER -glycopyrrolate inhal cap 15.6
mcg.................................................................................. 66
SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak................................................. 126
SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg......................................................................... 126
SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg......................................................... 126
selegiline hcl cap 5 mg (Eldepryl)............................... 117
selegiline hcl tab 5 mg.................................................. 117
selenium sulfide lotion 2.5%........................................ 178
selenium sulfide-pyrithione zinc in urea shampoo
2.25%.............................................................................178
SELRX -selenium sulfide-pyrithione zinc in urea shampoo
2.3%...............................................................................178
SELZENTRY -maraviroc tab 25 mg.................................. 10
SELZENTRY -maraviroc tab 75 mg.................................. 10
SELZENTRY -maraviroc tab 150 mg................................ 10
SELZENTRY -maraviroc tab 300 mg................................ 10
SEMPREX-D -acrivastine & pseudoephedrine cap 8-60
mg.................................................................................... 63
SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 126
SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 126
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 41
SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 41
SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 41
SENSODYNE REPAIR & PROTEC -stannous fluoride
paste 0.454%................................................................ 169
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv)................................................... 66
SERNIVO -betamethasone dipropionate spray emulsion
0.05% (base equiv).......................................................178
SEROQUEL XR -quetiapine fumarate tab sr 24hr 50
mg.................................................................................... 87
SEROQUEL XR -quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 87
SEROQUEL XR -quetiapine fumarate tab sr 24hr 200
mg.................................................................................... 87
SEROQUEL XR -quetiapine fumarate tab sr 24hr 300
mg.................................................................................... 87
SEROQUEL XR -quetiapine fumarate tab sr 24hr 400
mg.................................................................................... 87
sertraline hcl oral conc 20 mg/ml (Zoloft).................... 82
sertraline hcl tab 25 mg (Zoloft).................................... 82
sertraline hcl tab 50 mg (Zoloft).................................... 82
sertraline hcl tab 100 mg (Zoloft).................................. 82
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml........................................................................... 74
SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base
equiv)............................................................................... 41
SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base
equiv)............................................................................... 41
SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base
equiv)............................................................................... 42
sildenafil citrate tab 20 mg (Revatio)............................ 60
SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)...... 88
SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)...... 88
SILVER NITRATE -silver nitrate oint 10%....................... 178
SILVER NITRATE -silver nitrate soln 0.5%..................... 178
SILVER NITRATE -silver nitrate soln 10%...................... 178
SILVER NITRATE -silver nitrate soln 25%...................... 178
SILVER NITRATE -silver nitrate soln 50%...................... 178
silver sulfadiazine cream 1% (Silvadene)................... 178
SILVRSTAT WOUND DRESSING -silver - gel................ 179
SIMBRINZA -brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.................................................................. 166
SIMPONI -golimumab subcutaneous soln auto-injector 50
mg/0.5ml........................................................................ 107
SIMPONI -golimumab subcutaneous soln auto-injector
100 mg/ml..................................................................... 107
SIMPONI -golimumab subcutaneous soln prefilled syringe
50 mg/0.5ml.................................................................. 107
SIMPONI -golimumab subcutaneous soln prefilled syringe
100 mg/ml..................................................................... 108
simvastatin tab 5 mg (Zocor)......................................... 59
simvastatin tab 10 mg (Zocor)....................................... 59
simvastatin tab 20 mg (Zocor)....................................... 59
simvastatin tab 40 mg (Zocor)....................................... 59
simvastatin tab 80 mg (Zocor)....................................... 59
sirolimus tab 0.5 mg (Rapamune)............................... 185
sirolimus tab 1 mg (Rapamune).................................. 185
sirolimus tab 2 mg (Rapamune).................................. 185
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
SIRTURO -bedaquiline fumarate tab 100 mg (base
equiv)................................................................................. 6
SITAVIG -acyclovir buccal tab 50 mg................................ 10
SIVEXTRO -tedizolid phosphate tab 200 mg....................12
skin protectants misc - cream..................................... 179
SKLICE -ivermectin lotion 0.5%...................................... 179
SM NUTRI-DRINK + -nutritional supplement liquid........ 147
SM NUTRI-DRINK -nutritional supplement liquid........... 147
sodium chloride soln nebu 0.9%................................... 63
sodium chloride soln nebu 3%...................................... 63
sodium chloride soln nebu 10%.................................... 64
sodium chloride soln nebu 7% (Hyper-sal).................. 63
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)................................................ 77
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)......................................................................... 130
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)......................................................................... 131
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)......................................................................... 131
sodium fluoride cream 1.1% (Prevident 5000
plus).............................................................................. 169
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)........................................................................ 169
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 169
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi)............................................... 169
sodium fluoride rinse 0.05%.........................................169
sodium fluoride rinse 0.0221% (0.01% f).................... 169
sodium fluoride rinse 0.2% (Prevident)...................... 169
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf)....................................................................130
SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from
2.2 mg naf)....................................................................130
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf)................................................................................ 131
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)......................................................................... 131
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)...................................................................... 42
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 185
sodium polystyrene sulfonate powder
(Kayexalate)................................................................. 185
sodium polystyrene sulfonate rectal susp 30
gm/120ml...................................................................... 185
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea emulsion 10-5%........................ 179
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea gel 10-5%.................................. 179
SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium
w/ sulfur lotion 10-5%................................................... 179
SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium
w/ sulfur susp 10-5%.................................................... 179
SODIUM SULFACETAMIDE WASH -sulfacetamide
sodium in bakuchiol vehicle wash 10%....................... 179
SOL CARB -nutritional supplement powder....................147
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)....................................................................... 21
SOLVIL -amino acids pack.............................................. 132
SOMA -carisoprodol tab 250 mg..................................... 118
SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 42
SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 42
SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 42
SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 42
SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 42
SOOLANTRA -ivermectin cream 1%.............................. 179
SORILUX -calcipotriene foam 0.005%............................ 179
S.O.S. 15 -nutritional supplement pack.......................... 147
S.O.S. 20 -nutritional supplement pack.......................... 147
S.O.S. 25 -nutritional supplement pack.......................... 147
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 45
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 45
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 45
sotalol hcl tab 240 mg.....................................................45
sotalol hcl tab 80 mg (Betapace)................................... 45
sotalol hcl tab 120 mg (Betapace)................................. 45
sotalol hcl tab 160 mg (Betapace)................................. 45
SOTYLIZE -sotalol hcl oral solution 5 mg/ml.................... 45
SOURCE COOKIE BAR -nutritional supplement bar......147
SOVALDI -sofosbuvir tab 400 mg..................................... 10
SOY PROTEIN SHAKE -nutritional supplement
powder........................................................................... 147
SPACERS-VARIOUS....................................................... 183
SPATONE PUR-ABSORB IRON -ferrous sulfate liquid 5
mg/20ml (elemental iron)..............................................154
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)......................................................................... 3
SPINOSAD -spinosad susp 0.9%................................... 179
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)....................................... 66
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act............................................. 66
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act............................................... 66
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide).................................................................. 55
spironolactone tab 25 mg (Aldactone).......................... 55
spironolactone tab 50 mg (Aldactone).......................... 56
spironolactone tab 100 mg (Aldactone)........................ 56
SPORANOX -itraconazole oral soln 10 mg/ml....................6
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
SPRITAM -levetiracetam tab disintegrating soluble 250
mg.................................................................................. 114
SPRITAM -levetiracetam tab disintegrating soluble 500
mg.................................................................................. 114
SPRITAM -levetiracetam tab disintegrating soluble 750
mg.................................................................................. 114
SPRITAM -levetiracetam tab disintegrating soluble 1000
mg.................................................................................. 114
SPRYCEL -dasatinib tab 20 mg........................................ 21
SPRYCEL -dasatinib tab 50 mg........................................ 21
SPRYCEL -dasatinib tab 70 mg........................................ 21
SPRYCEL -dasatinib tab 80 mg........................................ 21
SPRYCEL -dasatinib tab 100 mg...................................... 21
SPRYCEL -dasatinib tab 140 mg...................................... 21
SP SCAR MANAGEMENT -scar treatment products gel.................................................................................. 179
SSKI -potassium iodide soln 1 gm/ml............................. 131
SSS 10-5 -sulfacetamide sodium w/ sulfur foam
10-5%............................................................................ 179
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg..............................................................117
STALEVO 125 -carbidopa-levodopa-entacapone tabs
31.25-125-200 mg........................................................ 117
STALEVO 150 -carbidopa-levodopa-entacapone tabs
37.5-150-200 mg.......................................................... 117
STALEVO 200 -carbidopa-levodopa-entacapone tabs
50-200-200 mg..............................................................118
STALEVO 50 -carbidopa-levodopa-entacapone tabs
12.5-50-200 mg.............................................................118
STALEVO 75 -carbidopa-levodopa-entacapone tabs
18.75-75-200 mg.......................................................... 118
stannous fluoride conc 0.63% (Gel-kam oral care
ri)................................................................................... 169
stannous fluoride gel 0.4%........................................... 169
STANNOUS FLUORIDE RINSE -stannous fluoride liq
0.1%...............................................................................169
stavudine cap 15 mg (Zerit)............................................10
stavudine cap 20 mg (Zerit)............................................10
stavudine cap 30 mg (Zerit)............................................10
stavudine cap 40 mg (Zerit)............................................10
STELARA -ustekinumab inj 45 mg/0.5ml........................ 179
STELARA -ustekinumab soln prefilled syringe 45
mg/0.5ml........................................................................ 179
STELARA -ustekinumab soln prefilled syringe 90 mg/
ml................................................................................... 179
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 42
STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero
soln 2.5-2.5 mcg/act....................................................... 67
STIVARGA -regorafenib tab 40 mg................................... 21
STRATTERA -atomoxetine hcl cap 10 mg (base
equiv)............................................................................... 91
STRATTERA -atomoxetine hcl cap 18 mg (base
equiv)............................................................................... 91
STRATTERA -atomoxetine hcl cap 25 mg (base
equiv)............................................................................... 91
STRATTERA -atomoxetine hcl cap 40 mg (base
equiv)............................................................................... 91
STRATTERA -atomoxetine hcl cap 60 mg (base
equiv)............................................................................... 91
STRATTERA -atomoxetine hcl cap 80 mg (base
equiv)............................................................................... 91
STRATTERA -atomoxetine hcl cap 100 mg (base
equiv)............................................................................... 91
STRENSIQ -asfotase alfa subcutaneous inj 18
mg/0.45ml........................................................................ 42
STRENSIQ -asfotase alfa subcutaneous inj 28
mg/0.7ml.......................................................................... 42
STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 42
STRENSIQ -asfotase alfa subcutaneous inj 80
mg/0.8ml.......................................................................... 42
STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg...................................................... 10
STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)................................................ 67
SUBDUE -nutritional supplement liquid.......................... 147
SUBDUE PLUS -nutritional supplement liquid................ 147
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv)............................................................ 103
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)............................................................ 103
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv)............................................................ 103
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)............................................................ 103
SUBSYS -fentanyl sublingual spray 100 mcg................. 103
SUBSYS -fentanyl sublingual spray 200 mcg................. 103
SUBSYS -fentanyl sublingual spray 400 mcg................. 103
SUBSYS -fentanyl sublingual spray 600 mcg................. 103
SUBSYS -fentanyl sublingual spray 800 mcg................. 103
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2).................................................................................... 103
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2).................................................................................... 104
SUCRAID -sacrosidase soln 8500 unit/ml........................ 72
sucralfate tab 1 gm (Carafate)....................................... 71
sulfacetamide sodium cleansing gel 10% (Ovace plus
wash).............................................................................179
sulfacetamide sodium liquid 10% (Ovace wash)....... 179
sulfacetamide sodium lotion 10% (acne) (Klaron)..... 179
sulfacetamide sodium ophth soln 10%
(Bleph-10)..................................................................... 166
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%............................................................. 166
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
sulfacetamide sodium shampoo 10% (Ovace
plus).............................................................................. 179
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%........................................................................ 166
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar
ls cleanser).................................................................. 179
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%
(Plexion cleanser)....................................................... 179
sulfacetamide sodium w/ sulfur cleansing pad 10-4%
(Sumaxin)..................................................................... 179
sulfacetamide sodium w/ sulfur cream 10-5%........... 179
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls)................................................................................... 179
sulfacetamide sodium w/ sulfur cream 9.8-4.8%
(Plexion)....................................................................... 179
sulfacetamide sodium w/ sulfur emulsion 10-1%...... 179
sulfacetamide sodium w/ sulfur emulsion 10-5%...... 179
sulfacetamide sodium w/ sulfur lotion 9.8-4.8%
(Plexion)....................................................................... 179
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts).................................................................................. 179
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash)......................................................... 180
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash).............................................................................180
SULFADIAZINE -sulfadiazine tab 500 mg.......................... 5
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml............................................................................ 13
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)......................................................................... 13
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)................................................................... 13
SULFAMYLON -mafenide acetate cream 85 mg/gm...... 180
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 74
sulfasalazine tab 500 mg (Azulfidine)........................... 74
sulindac tab 150 mg...................................................... 108
sulindac tab 200 mg...................................................... 108
sumatriptan nasal spray 5 mg/act (Imitrex)................ 108
sumatriptan nasal spray 20 mg/act (Imitrex).............. 108
sumatriptan succinate inj 6 mg/0.5ml (Imitrex).......... 109
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)............................... 109
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)............................... 109
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref).................................................. 109
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref).................................................. 109
SUMATRIPTAN SUCCINATE -sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml........................... 109
sumatriptan succinate tab 25 mg (Imitrex)................. 109
sumatriptan succinate tab 50 mg (Imitrex)................. 109
sumatriptan succinate tab 100 mg (Imitrex)............... 109
SUPER-AMINO 1600 -amino acids tab.......................... 132
SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml
(per drop)...................................................................... 119
SUPER NU-THERA -multiple vitamins w/ minerals
powder........................................................................... 126
SUPLENA -nutritional supplement liquid.........................147
SUPLENA RTU -nutritional supplement liquid................ 147
SUPLENA WITH CARB STEADY -nutritional supplement
liquid.............................................................................. 147
SUPLENA 1.8 WITH CARBSTEA -nutritional supplement
liquid.............................................................................. 147
SUPRAX -cefixime cap 400 mg.......................................... 3
SUPRAX -cefixime chew tab 100 mg................................. 3
SUPRAX -cefixime chew tab 200 mg................................. 3
SUPRAX -cefixime for susp 100 mg/5ml............................ 3
SUPRAX -cefixime for susp 200 mg/5ml............................ 3
SUPRAX -cefixime for susp 500 mg/5ml............................ 3
SUPREP BOWEL PREP KIT -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln.............................. 68
SURMONTIL -trimipramine maleate cap 25 mg............... 82
SURMONTIL -trimipramine maleate cap 50 mg............... 82
SURMONTIL -trimipramine maleate cap 100 mg............. 82
SURVANTA INTRATRACHEAL -beractant in nacl 0.9%
intratracheal susp 25 mg/ml........................................... 68
SUSTIVA -efavirenz cap 50 mg........................................ 10
SUSTIVA -efavirenz cap 200 mg...................................... 10
SUSTIVA -efavirenz tab 600 mg....................................... 10
SUTENT -sunitinib malate cap 12.5 mg (base
equivalent)....................................................................... 21
SUTENT -sunitinib malate cap 25 mg (base
equivalent)....................................................................... 21
SUTENT -sunitinib malate cap 37.5 mg (base
equivalent)....................................................................... 21
SUTENT -sunitinib malate cap 50 mg (base
equivalent)....................................................................... 21
SYLATRON -peginterferon alfa-2b for inj kit 200 mcg...... 22
SYLATRON -peginterferon alfa-2b for inj kit 300 mcg...... 22
SYLATRON -peginterferon alfa-2b for inj kit 600 mcg...... 22
SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg
(0.125 mg ir/0.25 mg cr).................................................71
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act................................................... 67
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act................................................. 67
SYMLINPEN 120 -pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)............................................... 35
SYMLINPEN 60 -pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)............................................... 35
SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg.............................................................104
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200
mcg/act) (base eq)..........................................................42
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 180
SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000
mg.................................................................................... 35
SYNJARDY -empagliflozin-metformin hcl tab 12.5-500
mg.................................................................................... 35
SYNJARDY -empagliflozin-metformin hcl tab 5-500
mg.................................................................................... 35
SYNJARDY -empagliflozin-metformin hcl tab 5-1000
mg.................................................................................... 35
SYNTHROID -levothyroxine sodium tab 25 mcg.............. 38
SYNTHROID -levothyroxine sodium tab 50 mcg.............. 38
SYNTHROID -levothyroxine sodium tab 75 mcg.............. 38
SYNTHROID -levothyroxine sodium tab 88 mcg.............. 38
SYNTHROID -levothyroxine sodium tab 100 mcg............ 38
SYNTHROID -levothyroxine sodium tab 112 mcg............ 38
SYNTHROID -levothyroxine sodium tab 125 mcg............ 38
SYNTHROID -levothyroxine sodium tab 137 mcg............ 38
SYNTHROID -levothyroxine sodium tab 150 mcg............ 38
SYNTHROID -levothyroxine sodium tab 175 mcg............ 38
SYNTHROID -levothyroxine sodium tab 200 mcg............ 38
SYNTHROID -levothyroxine sodium tab 300 mcg............ 38
SYPRINE -trientine hcl cap 250 mg................................ 185
T
TABLOID -thioguanine tab 40 mg..................................... 22
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%....................................................... 180
tacrolimus cap 0.5 mg (Prograf).................................. 185
tacrolimus cap 1 mg (Prograf)..................................... 185
tacrolimus cap 5 mg (Prograf)..................................... 185
tacrolimus oint 0.03% (Protopic)................................. 180
tacrolimus oint 0.1% (Protopic)................................... 180
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)....................................................................... 22
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)....................................................................... 22
TAGRISSO -osimertinib mesylate tab 40 mg (base
equivalent)....................................................................... 22
TAGRISSO -osimertinib mesylate tab 80 mg (base
equivalent)....................................................................... 22
TALTZ -ixekizumab subcutaneous soln auto-injector 80
mg/ml............................................................................. 180
TALTZ -ixekizumab subcutaneous soln prefilled syringe
80 mg/ml....................................................................... 180
TAMIFLU -oseltamivir phosphate cap 30 mg (base
equiv)............................................................................... 10
TAMIFLU -oseltamivir phosphate cap 45 mg (base
equiv)............................................................................... 10
TAMIFLU -oseltamivir phosphate cap 75 mg (base
equiv)............................................................................... 10
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base
equiv)............................................................................... 10
tamoxifen citrate tab 10 mg (base equivalent)............. 22
tamoxifen citrate tab 20 mg (base equivalent)............. 22
tamsulosin hcl cap 0.4 mg (Flomax)............................. 77
TANDEM F -ferrous fum-iron polysacch-fa cap
162-115.2-1 mg (106 mg fe)........................................ 154
TANZEUM -albiglutide for soln pen-injector 30 mg........... 35
TANZEUM -albiglutide for soln pen-injector 50 mg........... 35
TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 22
TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 22
TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 22
TARGRETIN -bexarotene cap 75 mg................................22
TARGRETIN -bexarotene gel 1%....................................180
TARKA -trandolapril-verapamil hcl tab cr 1-240 mg..........53
TARKA -trandolapril-verapamil hcl tab cr 2-180 mg..........53
TARKA -trandolapril-verapamil hcl tab cr 2-240 mg..........53
TARKA -trandolapril-verapamil hcl tab cr 4-240 mg..........53
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak..................................................................... 126
TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 126
TARON FORTE -fe bisglycinate-fe polysacch-vit c-vit b12fa cap............................................................................ 154
TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg....................................................... 126
TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 22
TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 22
TASMAR -tolcapone tab 100 mg.....................................118
tazarotene cream 0.1% (Tazorac)................................. 180
TAZORAC -tazarotene cream 0.05%.............................. 180
TAZORAC -tazarotene cream 0.1%................................ 180
TAZORAC -tazarotene gel 0.05%................................... 180
TAZORAC -tazarotene gel 0.1%..................................... 180
TBC -trypsin w/ castor oil & peruvian balsam spray....... 180
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg............................................................................ 95
TECFIDERA -dimethyl fumarate capsule delayed release
240 mg............................................................................ 96
TECFIDERA STARTER PACK -dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg..................... 96
TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg................................................................. 10
TEGRETOL -carbamazepine susp 100 mg/5ml............. 114
TEGRETOL -carbamazepine tab 200 mg....................... 114
TEGRETOL-XR -carbamazepine tab sr 12hr 100
mg.................................................................................. 114
TEGRETOL-XR -carbamazepine tab sr 12hr 200
mg.................................................................................. 114
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
TEGRETOL-XR -carbamazepine tab sr 12hr 400
mg.................................................................................. 114
TEKTURNA -aliskiren fumarate tab 150 mg (base
equivalent)....................................................................... 53
TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)....................................................................... 53
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-12.5 mg.................................................................... 53
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-25 mg....................................................................... 53
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-12.5 mg.................................................................... 53
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-25 mg....................................................................... 54
telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 54
telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 54
telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 54
telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 54
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 54
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 54
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 54
telmisartan tab 20 mg (Micardis)................................... 54
telmisartan tab 40 mg (Micardis)................................... 54
telmisartan tab 80 mg (Micardis)................................... 54
temazepam cap 7.5 mg (Restoril).................................. 88
temazepam cap 15 mg (Restoril)................................... 88
temazepam cap 22.5 mg (Restoril)................................ 88
temazepam cap 30 mg (Restoril)................................... 88
temozolomide cap 5 mg (Temodar)............................... 22
temozolomide cap 20 mg (Temodar)............................. 22
temozolomide cap 100 mg (Temodar)........................... 22
temozolomide cap 140 mg (Temodar)........................... 22
temozolomide cap 180 mg (Temodar)........................... 22
temozolomide cap 250 mg (Temodar)........................... 22
TENCON -butalbital-acetaminophen tab 50-325 mg........ 96
TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 16
terazosin hcl cap 1 mg....................................................54
terazosin hcl cap 2 mg....................................................54
terazosin hcl cap 5 mg....................................................54
terazosin hcl cap 10 mg..................................................54
terbinafine hcl tab 250 mg (Lamisil)................................ 6
terbutaline sulfate tab 2.5 mg........................................ 67
terbutaline sulfate tab 5 mg........................................... 67
terconazole vaginal cream 0.4% (Terazol 7)................. 76
terconazole vaginal cream 0.8% (Terazol 3)................. 76
terconazole vaginal suppos 80 mg............................... 76
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 25
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 25
testosterone enanthate im inj in oil 200 mg/ml............ 25
testosterone td gel 12.5 mg/act (1%) (Androgel
pump).............................................................................. 25
testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 25
testosterone td gel 50 mg/5gm (1%) (Androgel).......... 25
TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml.............................................. 16
tetrabenazine tab 12.5 mg (Xenazine)........................... 96
tetrabenazine tab 25 mg (Xenazine).............................. 96
tetracaine hcl ophth soln 0.5%.................................... 166
tetracycline hcl cap 250 mg (Tetracycline hcl)............... 5
tetracycline hcl cap 500 mg (Tetracycline hcl)............... 5
TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........4
TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........4
TETRIX -dermatological products misc - cream............. 180
TEXACORT -hydrocortisone soln 2.5%.......................... 180
TEXAVITE LQ -pediatric multivitamins w/fl-fe-zn drops
0.25-7-3 mg/ml.............................................................. 126
THALOMID -thalidomide cap 50 mg............................... 185
THALOMID -thalidomide cap 100 mg............................. 185
THALOMID -thalidomide cap 150 mg............................. 185
THALOMID -thalidomide cap 200 mg............................. 185
theophylline soln 80 mg/15ml........................................ 67
theophylline tab sr 12hr 100 mg.................................... 67
theophylline tab sr 12hr 200 mg.................................... 67
theophylline tab sr 12hr 300 mg.................................... 67
theophylline tab sr 12hr 450 mg.................................... 67
theophylline tab sr 24hr 400 mg.................................... 67
theophylline tab sr 24hr 600 mg.................................... 67
THEO-24 -theophylline cap sr 24hr 100 mg..................... 67
THEO-24 -theophylline cap sr 24hr 200 mg..................... 67
THEO-24 -theophylline cap sr 24hr 300 mg..................... 67
THEO-24 -theophylline cap sr 24hr 400 mg..................... 67
THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)...... 169
THICK-IT BEEF LASAGNA PUR -nutritional supplement
misc............................................................................... 147
THICK-IT CHICKEN A LA KIN -nutritional supplement
misc............................................................................... 147
THICK-IT MAPLE CINNAMON F -nutritional supplement
misc............................................................................... 147
THICK-IT MIXED FRUIT AND -nutritional supplement
misc............................................................................... 147
THICK-IT SEASONED CHICKEN -nutritional supplement
misc............................................................................... 147
THICK-IT SWEET CORN PUREE -nutritional supplement
misc............................................................................... 147
THICK-IT THICKENED CRANBE -nutritional supplement
liquid.............................................................................. 148
THIOLA -tiopronin tab 100 mg.......................................... 77
thioridazine hcl tab 10 mg.............................................. 87
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
thioridazine hcl tab 25 mg.............................................. 87
thioridazine hcl tab 50 mg.............................................. 87
thioridazine hcl tab 100 mg............................................ 87
thiothixene cap 1 mg....................................................... 87
thiothixene cap 2 mg....................................................... 87
thiothixene cap 5 mg....................................................... 87
thiothixene cap 10 mg..................................................... 87
THRIVACIN DETOX -nutritional supplement liquid......... 148
THRIVACIN 30 -nutritional supplement liquid................. 148
THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 126
THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 126
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 38
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 38
thyroid tab 60 mg (1 grain) (Armour thyroid)............... 38
THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 38
THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 38
THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......38
THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100
mcg)................................................................................. 38
THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 38
tiagabine hcl tab 2 mg (Gabitril).................................. 114
tiagabine hcl tab 4 mg (Gabitril).................................. 114
TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 48
TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 48
TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 48
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe)................................................................ 166
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe)................................................................ 166
timolol maleate ophth soln 0.25% (Timoptic)............. 166
timolol maleate ophth soln 0.5% (Timoptic)............... 166
TIMOLOL MALEATE -timolol maleate tab 5 mg............... 45
TIMOLOL MALEATE -timolol maleate tab 10 mg............. 45
TIMOLOL MALEATE -timolol maleate tab 20 mg............. 45
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.25%.......................................................... 166
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................ 166
tinidazole tab 250 mg (Tindamax)..................................13
tinidazole tab 500 mg (Tindamax)..................................13
TIROSINT -levothyroxine sodium cap 13 mcg..................38
TIROSINT -levothyroxine sodium cap 25 mcg..................38
TIROSINT -levothyroxine sodium cap 50 mcg..................38
TIROSINT -levothyroxine sodium cap 75 mcg..................38
TIROSINT -levothyroxine sodium cap 88 mcg..................38
TIROSINT -levothyroxine sodium cap 100 mcg................38
TIROSINT -levothyroxine sodium cap 112 mcg................ 38
TIROSINT -levothyroxine sodium cap 125 mcg................39
TIROSINT -levothyroxine sodium cap 137 mcg................39
TIROSINT -levothyroxine sodium cap 150 mcg................39
TIVICAY -dolutegravir sodium tab 10 mg (base equiv)..... 11
TIVICAY -dolutegravir sodium tab 25 mg (base equiv)..... 11
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)..... 11
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)......................................................................118
tizanidine hcl cap 4 mg (base equivalent)
(Zanaflex)......................................................................118
tizanidine hcl cap 6 mg (base equivalent)
(Zanaflex)......................................................................119
tizanidine hcl tab 2 mg (base equivalent)................... 119
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)......................................................................119
TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg.................................................................. 127
TL-FLUORIVITE -pediatric multiple vitamins w/ fl-fe chew
tab 0.25-7.5 mg............................................................ 127
TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.5-0.5 mg................................................................ 126
TL G-FOL OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.................................................................... 127
TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg.............................................................127
TOBI PODHALER -tobramycin inhal cap 28 mg.................5
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%...................................................................... 166
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%........................................................................ 166
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).................................................................... 166
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 5
tobramycin ophth soln 0.3% (Tobrex)......................... 166
TOBRAMYCIN -tobramycin nebu soln 300 mg/5ml............ 5
TOBREX -tobramycin ophth oint 0.3%........................... 166
TOLAK -fluorouracil cream 4%........................................180
TOLAZAMIDE -tolazamide tab 250 mg.............................35
TOLAZAMIDE -tolazamide tab 500 mg.............................35
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 35
tolcapone tab 100 mg (Tasmar)................................... 118
TOLEREX -nutritional supplement pack......................... 148
TOLMETIN SODIUM -tolmetin sodium cap 400 mg....... 108
tolterodine tartrate cap sr 24hr 2 mg (Detrol la).......... 76
tolterodine tartrate cap sr 24hr 4 mg (Detrol la).......... 76
tolterodine tartrate tab 1 mg (Detrol)............................ 76
tolterodine tartrate tab 2 mg (Detrol)............................ 76
TOPICORT -desoximetasone cream 0.05%................... 180
TOPICORT -desoximetasone oint 0.05%....................... 180
TOPICORT -desoximetasone spray 0.25%.................... 180
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 114
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50
mg.................................................................................. 114
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 114
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 114
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 114
topiramate sprinkle cap 15 mg (Topamax
sprinkle)........................................................................114
topiramate sprinkle cap 25 mg (Topamax
sprinkle)........................................................................114
topiramate tab 25 mg (Topamax)................................. 114
topiramate tab 50 mg (Topamax)................................. 114
topiramate tab 100 mg (Topamax)............................... 114
topiramate tab 200 mg (Topamax)............................... 114
torsemide tab 5 mg (Demadex)...................................... 56
torsemide tab 10 mg (Demadex).................................... 56
torsemide tab 20 mg (Demadex).................................... 56
torsemide tab 100 mg (Demadex).................................. 56
TOUJEO SOLOSTAR -insulin glargine soln pen-injector
300 unit/ml.......................................................................37
TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg.............76
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg.............76
TRACLEER -bosentan tab 62.5 mg.................................. 60
TRACLEER -bosentan tab 125 mg................................... 60
TRADJENTA -linagliptin tab 5 mg..................................... 35
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)....................................................................... 104
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 100 mg............................................................. 104
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 150 mg............................................................. 104
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 200 mg............................................................. 104
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 300 mg............................................................. 104
tramadol hcl tab 50 mg (Ultram).................................. 104
tramadol hcl tab sr 24hr biphasic release 100 mg..... 104
tramadol hcl tab sr 24hr biphasic release 200 mg..... 104
tramadol hcl tab sr 24hr biphasic release 300 mg..... 104
tramadol hcl tab sr 24hr 100 mg (Ultram er).............. 104
tramadol hcl tab sr 24hr 200 mg (Ultram er).............. 104
tramadol hcl tab sr 24hr 300 mg (Ultram er).............. 104
trandolapril tab 1 mg (Mavik)......................................... 54
trandolapril tab 2 mg (Mavik)......................................... 54
trandolapril tab 4 mg (Mavik)......................................... 54
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 54
trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)...... 54
trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)...... 54
trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)...... 54
tranexamic acid tab 650 mg (Lysteda)........................ 156
TRANSDERM-SCOP -scopolamine td patch 72hr 1
mg/3days......................................................................... 71
tranylcypromine sulfate tab 10 mg (Parnate)............... 82
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free)..................................... 166
trazodone hcl tab 50 mg................................................. 82
trazodone hcl tab 100 mg............................................... 82
trazodone hcl tab 150 mg............................................... 82
trazodone hcl tab 300 mg............................................... 82
TRECATOR -ethionamide tab 250 mg................................ 6
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 100 unit/ml......................................................... 37
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 200 unit/ml......................................................... 37
tretinoin cap 10 mg......................................................... 22
tretinoin cream 0.025% (Retin-a)................................. 180
tretinoin cream 0.05% (Retin-a)................................... 180
tretinoin cream 0.1% (Retin-a)..................................... 180
tretinoin gel 0.05% (Atralin).......................................... 180
tretinoin gel 0.01% (Retin-a)......................................... 180
tretinoin gel 0.025% (Retin-a)....................................... 180
tretinoin microsphere gel 0.04% (Retin-a micro)....... 180
tretinoin microsphere gel 0.1% (Retin-a micro
pump)............................................................................ 180
TRETTEN -coagulation factor xiii a-subunit for inj
2000-3125 unit.............................................................. 162
TREXALL -methotrexate sodium tab 5 mg (base
equiv)............................................................................... 22
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)............................................................................... 22
TREXALL -methotrexate sodium tab 10 mg (base
equiv)............................................................................... 22
TREXALL -methotrexate sodium tab 15 mg (base
equiv)............................................................................... 22
TREZIX -acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg.............................................................104
TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 127
triamcinolone acetonide aerosol soln 0.147 mg/gm
(Kenalog)...................................................................... 180
triamcinolone acetonide cream 0.025%...................... 180
triamcinolone acetonide cream 0.1%.......................... 180
triamcinolone acetonide cream 0.5%.......................... 180
triamcinolone acetonide dental paste 0.1%............... 169
triamcinolone acetonide lotion 0.025%....................... 180
triamcinolone acetonide lotion 0.1%........................... 181
triamcinolone acetonide oint 0.025%.......................... 181
triamcinolone acetonide oint 0.1%.............................. 181
triamcinolone acetonide oint 0.5%.............................. 181
TRIAMINO -amino acids tab........................................... 132
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg................................. 56
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2016
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide).........................................................................56
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 56
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)........................................................................ 56
TRIANEX -triamcinolone acetonide oint 0.05%.............. 181
triazolam tab 0.25 mg (Halcion)..................................... 88
TRIAZOLAM -triazolam tab 0.125 mg............................... 88
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 20-5-12.5 mg............................................................ 54
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-5-12.5 mg............................................................ 54
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-5-25 mg............................................................... 54
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-10-12.5 mg.......................................................... 54
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 40-10-25 mg............................................................. 54
TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa
tab 27-1 mg & fish oil chew cap pak............................127
TRICARE PRENATAL DHA ONE -prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg................................... 127
TRICARE PRENATAL -prenat w/o a w/fepyro-mfol chw
4.5-1 mg & dha cap 150 thpk...................................... 127
TRICARE PRENATAL -prenat w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg........................................... 127
TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 127
TRI-CHLOR -trichloroacetic acid liqd 80%......................180
TRIDESILON -desonide cream 0.05%............................181
trifluoperazine hcl tab 1 mg........................................... 87
trifluoperazine hcl tab 2 mg........................................... 87
trifluoperazine hcl tab 5 mg........................................... 87
trifluoperazine hcl tab 10 mg......................................... 87
trifluridine ophth soln 1% (Viroptic)............................ 166
TRIGLIDE -fenofibrate tab 160 mg................................... 59
trihexyphenidyl hcl elixir 0.4 mg/ml............................ 118
trihexyphenidyl hcl tab 2 mg........................................118
trihexyphenidyl hcl tab 5 mg........................................118
trimethobenzamide hcl cap 300 mg (Tigan)................. 71
trimethoprim tab 100 mg................................................ 13
TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 127
TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................. 127
TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg..... 127
TRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)....... 82
TRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)..... 82
TRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)..... 82
TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg........................................................ 127
TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 127
TRIUMEQ -abacavir-dolutegravir-lamivudine tab
600-50-300 mg................................................................11
TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk................................................. 127
TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................ 127
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.25 mg/ml........................................................... 127
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.5 mg/ml............................................................. 127
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.25 mg/ml.................................................................... 127
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.5 mg/ml...................................................................... 127
TRI-VIT/FLUORIDE/IRON -pediatric vitamins acd fluoride
& fe drops 0.25-10 mg/ml.............................................127
TROKENDI XR -topiramate cap sr 24hr 25 mg.............. 115
TROKENDI XR -topiramate cap sr 24hr 50 mg.............. 115
TROKENDI XR -topiramate cap sr 24hr 100 mg............ 115
TROKENDI XR -topiramate cap sr 24hr 200 mg............ 115
tropicamide ophth soln 0.5%....................................... 166
tropicamide ophth soln 1% (Mydriacyl)...................... 166
trospium chloride cap sr 24hr 60 mg............................ 76
trospium chloride tab 20 mg.......................................... 76
TRULICITY -dulaglutide soln pen-injector 0.75
mg/0.5ml.......................................................................... 35
TRULICITY -dulaglutide soln pen-injector 1.5
mg/0.5ml.......................................................................... 35
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
100-150 mg..................................................................... 11
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
133-200 mg..................................................................... 11
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
167-250 mg..................................................................... 11
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg..................................................................... 11
TUDORZA PRESSAIR -aclidinium bromide aerosol powd
breath activated 400 mcg/act......................................... 67
TUSNEL -brompheniramine w/ dm-gg cap 2-15-200
mg.................................................................................... 64
TUSNEL C -pseudoephedrine w/ cod-gg syrup 30-10-100
mg/5ml............................................................................. 64
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
5-4 mg............................................................................. 64
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
10-8 mg........................................................................... 64
TUZISTRA XR -codeine polist-chlorphen polist er susp
14.7-2.8 mg/5ml.............................................................. 64
TWOCAL HN -nutritional supplement liquid....................148
TWOCAL HN 2.0 -nutritional supplement liquid..............148
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
TYBOST -cobicistat tab 150 mg....................................... 11
TYKERB -lapatinib ditosylate tab 250 mg (base
equiv)............................................................................... 22
TYLACTIN RESTORE 10 -nutritional supplement
liquid.............................................................................. 148
TYLACTIN RESTORE 5PE -nutritional supplement
pack............................................................................... 148
TYLACTIN RTD 15 -nutritional supplement liquid.......... 148
TYR ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 148
TYR ANAMIX NEXT -nutritional supplement powder..... 148
TYR COOLER -nutritional supplement liquid.................. 148
TYR COOLER20 -nutritional supplement liquid.............. 148
TYREX-1 -nutritional supplement powder....................... 148
TYREX-2 -nutritional supplement powder....................... 148
TYR EXPRESS -nutritional supplement pack................. 148
TYR EXPRESS20 -nutritional supplement pack............. 148
TYR GEL -nutritional supplement pack........................... 148
TYR LOPHLEX LQ -nutritional supplement liquid...........148
TYROS 1 -nutritional supplement powder...................... 148
TYROS 2 -nutritional supplement powder...................... 148
TYVASO REFILL -treprostinil inhalation solution 0.6 mg/
ml..................................................................................... 60
TYVASO STARTER -treprostinil inhalation solution 0.6
mg/ml............................................................................... 60
TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 60
U
UCD ANAMIX JUNIOR -nutritional supplement
powder........................................................................... 148
UCD 2 -nutritional supplement powder........................... 148
UCD TRIO -nutritional supplement powder.................... 148
UCERIS -budesonide rectal foam 2 mg/act.................... 170
UCERIS -budesonide tab sr 24hr 9 mg............................ 25
UDAMIN SP -multiple vitamins w/ minerals & fa tab 1
mg.................................................................................. 127
ULESFIA -benzyl alcohol lotion 5%................................ 181
ULORIC -febuxostat tab 40 mg....................................... 109
ULORIC -febuxostat tab 80 mg....................................... 109
ULTIMATECARE ONE NF -prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap 20-7-1 mg............................... 127
ULTIMATECARE ONE -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 127
ULTRACAL HN PLUS -nutritional supplement liquid...... 148
ULTRACAL -nutritional supplement liquid....................... 148
ULTRAMINO SOY PROTEIN -nutritional supplement
powder........................................................................... 148
ULTRASAL-ER -salicylic acid er film-forming soln
28.5%.............................................................................181
ULTRAVATE -halobetasol propionate lotion 0.05%........ 181
UMECTA -urea emulsion 40%........................................ 181
UPTRAVI -selexipag tab 200 mcg.....................................60
UPTRAVI -selexipag tab 400 mcg.....................................60
UPTRAVI -selexipag tab 600 mcg.....................................60
UPTRAVI -selexipag tab 800 mcg.....................................60
UPTRAVI -selexipag tab 1000 mcg...................................61
UPTRAVI -selexipag tab 1200 mcg...................................61
UPTRAVI -selexipag tab 1400 mcg...................................61
UPTRAVI -selexipag tab 1600 mcg...................................61
UPTRAVI -selexipag tab therapy pack 200 mcg (140) &
800 mcg (60)...................................................................60
URAMAXIN -urea in ammonium lactate vehicle foam
20%................................................................................181
urea cream 40%............................................................. 181
urea cream 50%............................................................. 181
urea cream 39% (Aluvea).............................................. 181
urea cream 47% (Keralac).............................................181
urea cream 45% (Uramaxin)......................................... 181
urea foam 40% (Hydro 40 foam).................................. 181
urea gel 40%................................................................... 181
urea gel 45% (Uramaxin)...............................................181
urea in lactic acid-salicylic acid vehicle susp
50%................................................................................181
urea in lactic acid vehicle foam 35% (Hydro 35)........ 181
urea in zinc undecylenate-lactic acid vehicle emulsion
50%................................................................................181
urea lotion 40%.............................................................. 181
UREA NAIL -urea in zinc undecylenate-lactic acid vehicle
stick 50%....................................................................... 181
urea suspension 40% (Umecta)................................... 181
UREVAZ -urea cream 44%............................................. 181
URIMAR-T -methenamine-hyosc-meth blue-sod phosphen sal tab 120 mg...................................................... 75
URINE TEST STRIPS-VARIOUS.................................... 183
ursodiol cap 300 mg (Actigall)....................................... 74
ursodiol tab 250 mg (Urso 250)..................................... 74
ursodiol tab 500 mg (Urso forte)................................... 74
UTIBRON NEOHALER -indacaterol-glycopyrrolate inhal
cap 27.5-15.6 mcg.......................................................... 67
UTOPIC -urea cream 41%.............................................. 181
UTYMAX -nutritional supplement pack........................... 148
V
VAGIFEM -estradiol vaginal tab 10 mcg........................... 77
valacyclovir hcl tab 1 gm (Valtrex)................................ 11
valacyclovir hcl tab 500 mg (Valtrex)............................ 11
VALCHLOR -mechlorethamine hcl gel 0.016% (base
equivalent)..................................................................... 181
VALCYTE -valganciclovir hcl for soln 50 mg/ml (base
equiv)............................................................................... 11
valganciclovir hcl for soln 50 mg/ml (base equiv)
(Valcyte).......................................................................... 11
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte).......................................................................... 11
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
valproate sodium oral soln 250 mg/5ml (base equiv)
(Depakene)................................................................... 115
valproic acid cap 250 mg (Depakene)......................... 115
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 54
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)................................................................... 54
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 54
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct)................................................................... 55
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 55
valsartan tab 40 mg (Diovan)......................................... 54
valsartan tab 80 mg (Diovan)......................................... 54
valsartan tab 160 mg (Diovan)....................................... 54
valsartan tab 320 mg (Diovan)....................................... 54
VANATOL LQ -butalbital-acetaminophen-caffeine soln
50-325-40 mg/15ml......................................................... 96
vancomycin hcl cap 125 mg (Vancocin hcl)................. 13
vancomycin hcl cap 250 mg (Vancocin hcl)................. 13
VARIZIG -varicella-zoster immune glob (human) im inj
125 unit/1.2ml................................................................. 17
VARUBI -rolapitant hcl tab 90 mg (base equiv)................ 71
VASCEPA -icosapent ethyl cap 0.5 gm............................ 59
VASCEPA -icosapent ethyl cap 1 gm............................... 59
VECAMYL -mecamylamine hcl tab 2.5 mg....................... 55
VECTICAL -calcitriol oint 3 mcg/gm................................ 181
VELPHORO -sucroferric oxyhydroxide chew tab 500
mg.................................................................................... 74
VELTASSA -patiromer sorbitex calcium for susp packet
8.4 gm (base eq).......................................................... 185
VELTASSA -patiromer sorbitex calcium for susp packet
16.8 gm (base eq)........................................................ 185
VELTASSA -patiromer sorbitex calcium for susp packet
25.2 gm (base eq)........................................................ 186
VEMAVITE-PRX 2 -prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg.............................................. 127
VENA-BAL DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg................................................... 128
VENCLEXTA STARTING PACK -venetoclax tab therapy
starter pack 10 & 50 & 100 mg...................................... 22
VENCLEXTA -venetoclax tab 10 mg.................................22
VENCLEXTA -venetoclax tab 50 mg.................................22
VENCLEXTA -venetoclax tab 100 mg...............................22
VENELEX -balsam peru-castor oil oint........................... 181
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 82
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 82
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 82
venlafaxine hcl tab 25 mg...............................................83
venlafaxine hcl tab 37.5 mg............................................83
venlafaxine hcl tab 50 mg...............................................83
venlafaxine hcl tab 75 mg...............................................83
venlafaxine hcl tab 100 mg.............................................83
venlafaxine hcl tab sr 24hr 225 mg (base
equivalent)......................................................................83
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 82
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 82
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 82
VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 61
VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 61
VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 67
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 47
verapamil hcl cap sr 24hr 180 mg (Verelan)................. 47
verapamil hcl cap sr 24hr 240 mg (Verelan)................. 47
verapamil hcl cap sr 24hr 360 mg (Verelan)................. 47
verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 46
verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 47
verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 47
verapamil hcl tab cr 120 mg (Calan sr)......................... 47
verapamil hcl tab cr 180 mg (Calan sr)......................... 47
verapamil hcl tab cr 240 mg (Calan sr)......................... 47
verapamil hcl tab 40 mg................................................. 47
verapamil hcl tab 80 mg (Calan).................................... 47
verapamil hcl tab 120 mg (Calan).................................. 47
VERDESO -desonide foam 0.05%.................................. 181
VEREGEN -sinecatechins oint 15%................................181
VERIPRED 20 -prednisolone sod phosphate oral soln 20
mg/5ml (base equiv)....................................................... 25
VERSACLOZ -clozapine susp 50 mg/ml.......................... 87
VESICARE -solifenacin succinate tab 5 mg..................... 76
VESICARE -solifenacin succinate tab 10 mg................... 76
VHC 2.25 -nutritional supplement liquid.......................... 148
VIBERZI -eluxadoline tab 75 mg....................................... 74
VIBERZI -eluxadoline tab 100 mg..................................... 74
VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 35
VIDEX -didanosine for soln 2 gm...................................... 11
VIDEX -didanosine for soln 4 gm...................................... 11
VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg..................................................... 11
VIEKIRA XR -dasab-ombit-paritap-riton tab sr 24hr
200-8.33-50-33.33 mg.................................................... 11
VIGAMOX -moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................. 166
VIIBRYD STARTER PACK -vilazodone hcl tab starter kit
10 (7) & 20 (23) mg....................................................... 83
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
VIIBRYD -vilazodone hcl tab 10 mg..................................83
VIIBRYD -vilazodone hcl tab 20 mg..................................83
VIIBRYD -vilazodone hcl tab 40 mg..................................83
VILACTIN AA PLUS -nutritional supplement liquid......... 148
VIMPAT -lacosamide oral solution 10 mg/ml.................. 115
VIMPAT -lacosamide tab 50 mg...................................... 115
VIMPAT -lacosamide tab 100 mg.................................... 115
VIMPAT -lacosamide tab 150 mg.................................... 115
VIMPAT -lacosamide tab 200 mg.................................... 115
VINATE DHA RF -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................. 128
VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab
29-1 mg......................................................................... 128
VINATE M -prenatal vit w/ sel-fe fumarate-fa tab 27-1
mg.................................................................................. 128
VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................. 128
VIOKACE -pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit................................................ 72
VIOKACE -pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit................................................ 72
VIRACEPT -nelfinavir mesylate tab 250 mg..................... 11
VIRACEPT -nelfinavir mesylate tab 625 mg..................... 11
VIRAMUNE -nevirapine susp 50 mg/5ml.......................... 11
VIRAMUNE XR -nevirapine tab sr 24hr 100 mg............... 11
VIRAZOLE -ribavirin for inhal soln 6 gm........................... 11
VIREAD -tenofovir disoproxil fumarate oral powder 40
mg/gm.............................................................................. 11
VIREAD -tenofovir disoproxil fumarate tab 150 mg.......... 11
VIREAD -tenofovir disoproxil fumarate tab 200 mg.......... 11
VIREAD -tenofovir disoproxil fumarate tab 250 mg.......... 11
VIREAD -tenofovir disoproxil fumarate tab 300 mg.......... 11
VIRT-ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 128
VIRT-CARE ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg................................................... 128
VIRT-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg................................................................. 128
VIRT-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 128
VIRT NATE -prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................. 128
VIRT-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................ 128
VIRT-PN PLUS -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 128
VIRT-PN -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg................................................................ 128
VIRTPREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg...............................................................128
VIRT-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg..................................................... 128
VIRT-VITE GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 128
VISTOGARD -uridine triacetate oral granules packet 10
gm.................................................................................. 183
VITAFOL FE+ -prenat-fepoly-methol-fa-dha cap 90-1-200
mg & dss 50mg cap..................................................... 128
VITAFOL GUMMIES -prenat vit w/ fe phos-fa-omega
chew tab 3.33-0.333-34.8 mg...................................... 128
VITAFOL-NANO -prenatal w/o a w/ fefum-l methylfol-fa
tab 18-0.6-0.4 mg......................................................... 128
VITAFOL-OB+DHA -prenatal mv w/fe fum-fa tab 65-1 mg
& dha cap 250 mg pack............................................... 128
VITAFOL-OB -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 128
VITAFOL-ONE -prenatal mv w/ fe polysac cmplx-fa-dha
cap 29-1-200 mg.......................................................... 128
VITAFOL ULTRA -prenat w/fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg........................................................ 128
VITAJOULE -nutritional supplement powder...................148
VITAL AF 1.2 CAL -nutritional supplement liquid............ 148
VITAL 1.0 CAL -nutritional supplement liquid................. 149
VITAL 1.5 CAL -nutritional supplement liquid................. 149
VITAL-D RX -b-complex w/ c-biotin-d-zinc & folic acid tab
1 mg.............................................................................. 128
VITAL HIGH PROTEIN -nutritional supplement
liquid.............................................................................. 148
VITAL HN -nutritional supplement pack.......................... 148
VITAL JR -nutritional supplement liquid.......................... 148
VITAL PEPTIDE 1.5 CAL -nutritional supplement
liquid.............................................................................. 149
VITAMEDMD ONE RX/QUATREFO -prenat w/o a w/
fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.............. 128
VITAMEDMD REDICHEW RX -prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg........................................... 128
VITAMELTS VITAMIN D -cholecalciferol orally
disintegrating tab 1000 unit.......................................... 119
VITAMIN D3 -cholecalciferol oral liquid 1200
unit/15ml........................................................................ 119
VITAMIN D3 -cholecalciferol spray 1000 unit/spray........119
VITAMIN D2 -ergocalciferol tab 400 unit.........................119
VITAPEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg...............................................................129
VITA-PREN -prenatal vit w/ docusate-iron-fa tab 65-1
mg.................................................................................. 128
VITAPRO -nutritional supplement powder...................... 149
VITAQUICK -nutritional supplement powder................... 149
VITATRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg & dha
cap 300mg pk............................................................... 129
VITUZ -hydrocodone-chlorpheniramine soln 5-4
mg/5ml............................................................................. 64
VIVA DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 129
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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VIVONEX PEDIATRIC -nutritional supplement pack...... 149
VIVONEX PLUS -nutritional supplement powder........... 149
VIVONEX RTF -nutritional supplement liquid................. 149
VIVONEX T.E.N. -nutritional supplement pack............... 149
VIVOTIF -typhoid vaccine cap delayed release................ 16
VOL-NATE -prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................. 129
VOL-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 129
VOL-TAB RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 129
VOLTAREN -diclofenac sodium gel 1%.......................... 181
voriconazole for susp 40 mg/ml (Vfend)......................... 6
voriconazole tab 50 mg (Vfend)....................................... 6
voriconazole tab 200 mg (Vfend)..................................... 6
VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 22
VP-CH PLUS -prenatal w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg.................................................................. 129
VP-CH-PNV -prenatal w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg.................................................................. 129
VP-GGR-B6 PRENATAL -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 129
VP-HEME OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................ 129
VP-HEME OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg............................................................... 129
VP-HEME ONE -prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg................................................ 129
VP-PNV-DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-215.8 mg...............................................................129
VRAYLAR -cariprazine hcl cap 1.5 mg (base
equivalent)....................................................................... 87
VRAYLAR -cariprazine hcl cap 3 mg (base
equivalent)....................................................................... 87
VRAYLAR -cariprazine hcl cap 4.5 mg (base
equivalent)....................................................................... 87
VRAYLAR -cariprazine hcl cap 6 mg (base
equivalent)....................................................................... 87
VRAYLAR -cariprazine hcl cap therapy pack 1.5 mg (1) &
3 mg (6).......................................................................... 87
VUSION -miconazole-zinc oxide-white petrolatum oint
0.25-15-81.35%............................................................. 181
VYTONE -iodoquinol-hydrocortisone in aloe vehicle
cream 1-1.9%................................................................ 181
VYTORIN -ezetimibe-simvastatin tab 10-10 mg............... 59
VYTORIN -ezetimibe-simvastatin tab 10-20 mg............... 59
VYTORIN -ezetimibe-simvastatin tab 10-40 mg............... 59
VYTORIN -ezetimibe-simvastatin tab 10-80 mg............... 59
VYVANSE -lisdexamfetamine dimesylate cap 10 mg....... 91
VYVANSE -lisdexamfetamine dimesylate cap 20 mg....... 91
VYVANSE -lisdexamfetamine dimesylate cap 30 mg....... 91
VYVANSE -lisdexamfetamine dimesylate cap 40 mg....... 91
VYVANSE -lisdexamfetamine dimesylate cap 50 mg....... 91
VYVANSE -lisdexamfetamine dimesylate cap 60 mg....... 91
VYVANSE -lisdexamfetamine dimesylate cap 70 mg....... 91
VYVANSE -lisdexamfetamine dimesylate chew tab 10
mg.................................................................................... 91
VYVANSE -lisdexamfetamine dimesylate chew tab 20
mg.................................................................................... 91
VYVANSE -lisdexamfetamine dimesylate chew tab 30
mg.................................................................................... 91
VYVANSE -lisdexamfetamine dimesylate chew tab 40
mg.................................................................................... 91
VYVANSE -lisdexamfetamine dimesylate chew tab 50
mg.................................................................................... 91
VYVANSE -lisdexamfetamine dimesylate chew tab 60
mg.................................................................................... 91
W
WALGREENS GLUCOSE -glucose chew tab 4 gm......... 35
WALGREENS GLUCOSE -glucose-vitamin c chew tab
4-0.006 gm...................................................................... 35
warfarin sodium tab 1 mg (Coumadin)....................... 156
warfarin sodium tab 2 mg (Coumadin)....................... 156
warfarin sodium tab 2.5 mg (Coumadin).................... 156
warfarin sodium tab 3 mg (Coumadin)....................... 156
warfarin sodium tab 4 mg (Coumadin)....................... 156
warfarin sodium tab 5 mg (Coumadin)....................... 156
warfarin sodium tab 6 mg (Coumadin)....................... 156
warfarin sodium tab 7.5 mg (Coumadin).................... 156
warfarin sodium tab 10 mg (Coumadin)..................... 156
WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 59
WELCHOL -colesevelam hcl tab 625 mg......................... 59
WELLESSE VITAMIN D3 -cholecalciferol oral liquid 1000
unit/10ml........................................................................ 119
WELLNESS ESSENTIALS AI -nutritional supplement
kit................................................................................... 149
WELLNESS ESSENTIALS BLOOD -nutritional
supplement kit............................................................... 149
WELLNESS ESSENTIALS FOR J -nutritional supplement
kit................................................................................... 149
WELLNESS ESSENTIALS FOR M -nutritional
supplement kit............................................................... 149
WELLNESS ESSENTIALS FOR P -nutritional supplement
kit................................................................................... 149
WELLNESS ESSENTIALS FOR W -nutritional
supplement kit............................................................... 149
WELLNESS ESSENTIALS -nutritional supplement
kit................................................................................... 149
WESTHROID -thyroid tab 32.5 mg................................... 39
WESTHROID -thyroid tab 65 mg...................................... 39
WESTHROID -thyroid tab 97.5 mg................................... 39
WESTHROID -thyroid tab 130 mg.................................... 39
WESTHROID -thyroid tab 195 mg.................................... 39
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60
mm................................................................................. 184
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65
mm................................................................................. 184
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 70
mm................................................................................. 184
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 75
mm................................................................................. 184
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 80
mm................................................................................. 184
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 85
mm................................................................................. 184
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 90
mm................................................................................. 184
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 95
mm................................................................................. 184
WILATE -antihemophilic factor/vwf (human) for inj
500-500 unit kit............................................................. 162
WILATE -antihemophilic factor/vwf (human) for inj
1000-1000 unit kit......................................................... 162
WND 1 -nutritional supplement powder.......................... 149
WND 2 -nutritional supplement powder.......................... 149
WP THYROID -thyroid tab 16.25 mg................................ 39
WP THYROID -thyroid tab 32.5 mg.................................. 39
WP THYROID -thyroid tab 65 mg..................................... 39
WP THYROID -thyroid tab 81.25 mg................................ 39
WP THYROID -thyroid tab 97.5 mg.................................. 39
WP THYROID -thyroid tab 113.75 mg.............................. 39
WP THYROID -thyroid tab 130 mg................................... 39
WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 39
X
XALKORI -crizotinib cap 200 mg...................................... 23
XALKORI -crizotinib cap 250 mg...................................... 23
XAQUIL XR -levomefolate glucosamine tab cr 30
mg.................................................................................. 149
XARELTO -rivaroxaban tab 10 mg..................................156
XARELTO -rivaroxaban tab 15 mg..................................156
XARELTO -rivaroxaban tab 20 mg..................................156
XARELTO STARTER PACK -rivaroxaban tab starter
therapy pack 15 mg & 20 mg.......................................156
XARTEMIS XR -oxycodone w/ acetaminophen tab cr
7.5-325 mg.................................................................... 104
XELJANZ -tofacitinib citrate tab 5 mg (base
equivalent)..................................................................... 108
XELJANZ XR -tofacitinib citrate tab sr 24hr 11 mg (base
equivalent)..................................................................... 108
XENAZINE -tetrabenazine tab 12.5 mg............................ 96
XENAZINE -tetrabenazine tab 25 mg............................... 96
XERESE -acyclovir-hydrocortisone cream 5-1%............ 181
XEROFORM NON-OCCLUSIVE OI -bismuth
tribromophenate-petrolatum dressing pads................. 181
XEROFORM OCCLUSIVE PETROL -bismuth
tribromophenate-petrolatum dressing - misc............... 182
XEROFORM OCCLUSIVE PETROL -bismuth
tribromophenate-petrolatum dressing pads................. 182
XEROFORM PETROLATUM DRESS -bismuth
tribromophenate-petrolatum dressing - misc............... 182
XEROFORM PETROLATUM DRESS -bismuth
tribromophenate-petrolatum dressing pads................. 182
XIFAXAN -rifaximin tab 200 mg........................................ 13
XIFAXAN -rifaximin tab 550 mg........................................ 13
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 35
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 35
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
10-500 mg....................................................................... 35
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
10-1000 mg..................................................................... 35
XIIDRA -lifitegrast ophth soln 5%.................................... 166
XLEU MAXAMAID -nutritional supplement powder........ 149
XLEU MAXAMUM -nutritional supplement powder.........149
XLYS-XTRP MAXAMAID -nutritional supplement
powder........................................................................... 149
XLYS-XTRP MAXAMUM -nutritional supplement
powder........................................................................... 149
XMET MAXAMAID -nutritional supplement powder........149
XMET MAXAMUM -nutritional supplement powder........ 149
XMTVI MAXAMAID -nutritional supplement powder.......149
XMTVI MAXAMUM -nutritional supplement powder....... 149
XOLEGEL -ketoconazole gel 2%.................................... 182
XOPENEX HFA -levalbuterol tartrate inhal aerosol 45
mcg/act (base equiv)...................................................... 67
XPHE MAXAMAID -nutritional supplement powder........ 149
XPHE MAXAMUM -amino acids oral powder................. 132
XPHE MAXAMUM -amino acids pack............................ 132
XPHE-XTYR MAXAMAID -nutritional supplement
powder........................................................................... 149
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9
mg.................................................................................. 104
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
13.5 mg......................................................................... 104
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
18 mg............................................................................ 104
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
27 mg............................................................................ 104
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
36 mg............................................................................ 104
XTANDI -enzalutamide cap 40 mg.................................... 23
XTRACAL PLUS -nutritional supplement liquid.............. 149
XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr.......................................................................... 30
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
XURIDEN -uridine triacetate oral granules packet 2
gm.................................................................................... 42
XYNTHA -antihemophilic factor recombinant paf for inj kit
250 unit......................................................................... 162
XYNTHA -antihemophilic factor recombinant paf for inj kit
500 unit......................................................................... 162
XYNTHA -antihemophilic factor recombinant paf for inj kit
1000 unit....................................................................... 162
XYNTHA -antihemophilic factor recombinant paf for inj kit
2000 unit....................................................................... 162
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 250 unit................................................... 162
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 500 unit................................................... 162
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 1000 unit................................................. 162
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 2000 unit................................................. 162
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 3000 unit................................................. 162
XYREM -sodium oxybate oral solution 500 mg/ml........... 96
XYZBAC -dietary management product - tabs................149
Y
Z
ZACLIR CLEANSING -benzoyl peroxide lotion 8%........ 182
zafirlukast tab 10 mg (Accolate).................................... 67
zafirlukast tab 20 mg (Accolate).................................... 67
zaleplon cap 5 mg (Sonata)............................................ 88
zaleplon cap 10 mg (Sonata).......................................... 88
ZAMICET -hydrocodone-acetaminophen soln 10-325
mg/15ml......................................................................... 104
ZARONTIN -ethosuximide cap 250 mg.......................... 115
ZARONTIN -ethosuximide soln 250 mg/5ml................... 115
ZARXIO -filgrastim-sndz soln prefilled syringe 300
mcg/0.5ml...................................................................... 154
ZARXIO -filgrastim-sndz soln prefilled syringe 480
mcg/0.8ml...................................................................... 154
ZATEAN-CH -prenatal w/o a w/fe cbn-dss-fa-dha cap
27-1-250 mg.................................................................. 129
ZATEAN-PN DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................. 129
ZATEAN-PN PLUS -prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................ 129
ZAVARA -folic acid-cholecalciferol cap 1 mg-5750
unit................................................................................. 154
ZAVESCA -miglustat cap 100 mg................................... 154
ZELAPAR -selegiline hcl orally disintegrating tab 1.25
mg.................................................................................. 118
ZELBORAF -vemurafenib tab 240 mg.............................. 23
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit...................................................72
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit...................................................72
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit................................................ 72
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
15000-51000-82000 unit................................................ 72
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
20000-68000-109000 unit.............................................. 72
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
25000-85000-136000 unit.............................................. 72
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
40000-136000-218000 unit............................................ 72
ZEPATIER -elbasvir-grazoprevir tab 50-100 mg............... 11
ZERIT -stavudine for oral soln 1 mg/ml............................ 11
ZETIA -ezetimibe tab 10 mg............................................. 59
ZETONNA -ciclesonide nasal aerosol soln 37 mcg/act (50
mcg/valve)....................................................................... 62
ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)..... 11
zidovudine cap 100 mg (Retrovir)................................. 11
zidovudine syrup 10 mg/ml (Retrovir)........................... 12
zidovudine tab 300 mg.................................................... 12
zileuton tab sr 12hr 600 mg (Zyflo cr)........................... 67
ZINBRYTA -daclizumab soln prefilled syringe 150 mg/
ml..................................................................................... 96
ZIOPTAN -tafluprost ophth soln 0.0015%....................... 166
ziprasidone hcl cap 20 mg (Geodon)............................ 87
ziprasidone hcl cap 40 mg (Geodon)............................ 87
ziprasidone hcl cap 60 mg (Geodon)............................ 87
ziprasidone hcl cap 80 mg (Geodon)............................ 87
ZIRGAN -ganciclovir ophth gel 0.15%............................ 166
ZITHRANOL -anthralin shampoo 1%.............................. 182
ZITHROMAX -azithromycin powd pack for susp 1 gm....... 4
ZMAX -azithromycin extended release for oral susp 2
gm...................................................................................... 4
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 10 mg................................................. 104
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 15 mg................................................. 104
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 20 mg................................................. 104
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 30 mg................................................. 104
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 40 mg................................................. 104
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 50 mg................................................. 104
ZOLATE -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 154
ZOLINZA -vorinostat cap 100 mg..................................... 23
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt)............................................................................... 109
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List June (2016 Plan Year)
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2016
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt)............................................................................... 109
zolmitriptan tab 2.5 mg (Zomig)................................... 109
zolmitriptan tab 5 mg (Zomig)...................................... 109
zolpidem tartrate sl tab 1.75 mg (Intermezzo).............. 88
zolpidem tartrate sl tab 3.5 mg (Intermezzo)................ 88
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 88
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 88
zolpidem tartrate tab 5 mg (Ambien).............................88
zolpidem tartrate tab 10 mg (Ambien)...........................88
ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit........109
ZOMIG -zolmitriptan nasal spray 5 mg/spray unit...........109
ZONALON -doxepin hcl cream 5%................................. 182
zonisamide cap 50 mg.................................................. 115
zonisamide cap 25 mg (Zonegran).............................. 115
zonisamide cap 100 mg (Zonegran)............................ 115
ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base
equivalent)..................................................................... 162
ZORTRESS -everolimus tab 0.25 mg............................. 186
ZORTRESS -everolimus tab 0.5 mg............................... 186
ZORTRESS -everolimus tab 0.75 mg............................. 186
ZOSTAVAX -zoster vaccine live for subcutaneous susp
19400 unit/0.65ml........................................................... 16
ZOVIRAX -acyclovir cream 5%....................................... 182
Z-TUSS AC -chlorpheniramine w/ codeine liquid 2-9
mg/5ml............................................................................. 64
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
0.7-0.18 mg (base eq).................................................. 105
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq).................................................. 105
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
2.9-0.71 mg (base eq).................................................. 105
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq)................................................................ 105
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
mg (base eq)................................................................ 105
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 11.4-2.9
mg (base eq)................................................................ 105
ZUPLENZ -ondansetron oral soluble film 4 mg................ 72
ZUPLENZ -ondansetron oral soluble film 8 mg................ 72
ZYBAN -bupropion hcl (smoking deterrent) tab sr 12hr
150 mg............................................................................ 96
ZYCLARA -imiquimod cream 3.75%............................... 182
ZYCLARA PUMP -imiquimod cream 2.5%..................... 182
ZYCLARA PUMP -imiquimod cream 3.75%................... 182
ZYDELIG -idelalisib tab 100 mg........................................ 23
ZYDELIG -idelalisib tab 150 mg........................................ 23
ZYFLO CR -zileuton tab sr 12hr 600 mg.......................... 67
ZYFLO -zileuton tab 600 mg............................................. 67
ZYKADIA -ceritinib cap 150 mg........................................ 23
ZYLET -loteprednol etabonate-tobramycin ophth susp
0.5-0.3%........................................................................ 166
ZYTAZE -zinc citrate-phytase cap 25-500 mg................ 149
ZYTIGA -abiraterone acetate tab 250 mg......................... 23
ZYVOX -linezolid for susp 100 mg/5ml............................. 13
ZYVOX -linezolid tab 600 mg............................................ 13
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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