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June 2017 Health Insurance Marketplace 3 Tier 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-medicine.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 ................................................... 16 How to use this list .......................................................... II Endocrine and Metabolic Drugs ................................... 22 Drugs used to treat multiple conditions .......................... II Cardiovascular Agents .................................................. 39 Generic drugs ................................................................. II Respiratory Agents ....................................................... 55 Consider talking to your doctor about generic Gastrointestinal Agents ................................................. 60 drugs ........................................................................... II Genitourinary Agents .................................................... 66 Coverage considerations ............................................... III Central Nervous System Drugs .................................... 68 Specialty drugs ............................................................... V Analgesics and Anesthetics .......................................... 85 Prime Therapeutics Specialty Pharmacy Neuromuscular Drugs ................................................... 96 Program ...................................................................... V Nutritional Products .................................................... 105 Abbreviation key ............................................................ VI Hematological Agents ................................................. 133 Topical Products ......................................................... 143 Miscellaneous Products .............................................. 155 Index ........................................................................... 160 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/TXMKT3TRG/en/find-medicine.html 41722-Q 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 list updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbstx.com. How drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. How member payment is determined This list shows prescription drug products in tiers. Generally, each drug is placed into one of three member payment tiers: Generic (Tier 1), Preferred Brand (Tier 2) or Non-preferred Brand (Tier 3). 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/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 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/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 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/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 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/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 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/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 V Abbreviation key cap ...................................................................... capsules chew .................................................................. chewable conc ............................................................. concentrate cr .......................................................... controlled release dr ............................................................. delayed release ec ................................................................enteric coated odt ............................................. orally disintegrating tabs oint ..................................................................... ointment ophth ................................................................. opthalmic osm .......................................................... osmotic release powd ..................................................................... powder effe................................................................. effervescent sa ............................................................ sustained action sl ...................................................................... sublingual equiv ................................................................ equivalent er ...........................................................extended release soln ....................................................................... solution sr .......................................................... sustained release inhal................................................................... inhalation inj ......................................................................... injection suppos ........................................................ suppositories susp ................................................................ suspension liq .............................................................................. liquid lotn ........................................................................... lotion 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/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 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 3 1 AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab 400-57 mg 3 1 AMPICILLIN - ampicillin for susp 125 mg/5ml 3 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 3 1 dicloxacillin sodium cap 250 mg 1 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin) 1 dicloxacillin sodium cap 500 mg amoxicillin & k clavulanate for susp 400-57 mg/5ml 1 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) 1 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr) 1 amoxicillin & k clavulanate tab 250-125 mg 1 3 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 1 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 3 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 3 amoxicillin (trihydrate) for susp 250 mg/5ml ACA 1 AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 200 mg/5ml Dispensing Limits amoxicillin & k clavulanate tab 875-125 mg (Augmentin) 3 amoxicillin (trihydrate) for susp 125 mg/5ml Step Therapy 1 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 2017 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 1 CEPHALOSPORINS CEDAX - ceftibuten cap 400 mg 3 cefpodoxime proxetil for susp 100 mg/5ml CEDAX - ceftibuten for susp 180 mg/5ml 3 cefpodoxime proxetil tab 100 mg CEFACLOR - cefaclor for susp 125 mg/5ml 3 cefpodoxime proxetil tab 200 mg CEFACLOR - cefaclor for susp 250 mg/5ml 3 cefprozil for susp 125 mg/5ml CEFACLOR - cefaclor for susp 375 mg/5ml 3 cefprozil for susp 250 mg/5ml cefaclor cap 250 mg 1 cefaclor cap 500 mg 1 cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml 3 1 CEFTIN - cefuroxime axetil for susp 250 mg/5ml 1 1 cefuroxime axetil tab 250 mg (Ceftin) cefuroxime axetil tab 500 mg (Ceftin) 1 CEPHALEXIN - cephalexin tab 250 mg 3 CEPHALEXIN - cephalexin tab 500 mg 3 cephalexin cap 250 mg (Keflex) 1 cephalexin cap 500 mg (Keflex) 1 cephalexin cap 750 mg (Keflex) 1 cephalexin for susp 125 mg/5ml 1 1 1 CEFDITOREN PIVOXIL cefditoren pivoxil tab 400 mg (base equivalent) 3 cefixime for susp 100 mg/5ml (Suprax) 1 1 1 Limited Distribution ACA Dispensing Limits 1 1 1 Step Therapy 1 2 3 cefpodoxime proxetil for susp 50 mg/5ml 1 CEFTIN - cefuroxime axetil for susp 125 mg/5ml CEFDITOREN PIVOXIL cefditoren pivoxil tab 200 mg (base equivalent) cefixime for susp 200 mg/5ml (Suprax) 1 3 1 cefdinir cap 300 mg 1 CEFTIBUTEN - ceftibuten for susp 180 mg/5ml cefadroxil cap 500 mg cefadroxil tab 1 gm 1 3 3 cefadroxil for susp 500 mg/5ml cefprozil tab 500 mg 1 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 2 1 clarithromycin tab 250 mg (Biaxin) 1 SPECTRACEF - cefditoren pivoxil tab 400 mg (base equivalent) 3 clarithromycin tab 500 mg (Biaxin) 1 DIFICID - fidaxomicin tab 200 mg 3 SUPRAX - cefixime cap 400 mg 3 3 E.E.S. GRANULES erythromycin ethylsuccinate for susp 200 mg/5ml 3 SUPRAX - cefixime chew tab 100 mg SUPRAX - cefixime chew tab 200 mg 3 E.E.S. 400 - erythromycin ethylsuccinate tab 400 mg 3 SUPRAX - cefixime for susp 100 mg/5ml 3 ERY-TAB - erythromycin tab delayed release 250 mg 3 SUPRAX - cefixime for susp 200 mg/5ml 3 ERY-TAB - erythromycin tab delayed release 333 mg 3 SUPRAX - cefixime for susp 500 mg/5ml 3 ERY-TAB - erythromycin tab delayed release 500 mg 3 3 cephalexin for susp 250 mg/5ml MACROLIDES AZITHROMYCIN azithromycin powd pack for susp 1 gm 3 ERYPED 200 - erythromycin ethylsuccinate for susp 200 mg/5ml 3 azithromycin for susp 100 mg/5ml (Zithromax) 1 ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml 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 azithromycin for susp 200 mg/5ml (Zithromax) 1 azithromycin tab 250 mg (Zithromax) 1 • azithromycin tab 500 mg (Zithromax) 1 • azithromycin tab 600 mg (Zithromax) 1 • clarithromycin for susp 125 mg/5ml 1 clarithromycin for susp 250 mg/5ml (Biaxin) clarithromycin tab sr 24hr 500 mg (Biaxin xl pac) 1 1 • 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 2017 erythromycin ethylsuccinate 1 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/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 3 erythromycin w/ delayed release particles cap 250 mg 1 doxycycline monohydrate tab 75 mg (Adoxa) doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) 1 1 PCE - erythromycin w/ enteric coated particles tab 333 mg PCE - erythromycin w/ enteric coated particles tab 500 mg 3 ZITHROMAX - azithromycin powd pack for susp 1 gm 3 doxycycline monohydrate tab 150 mg (Adoxa pak 1/150) 1 ZMAX - azithromycin extended release for oral susp 2 gm 3 minocycline hcl cap 50 mg (Minocin) minocycline hcl cap 75 mg (Minocin) 1 1 minocycline hcl cap 100 mg (Minocin) 1 1 minocycline hcl tab sr 24hr 45 mg 1 • 1 minocycline hcl tab sr 24hr 90 mg 1 • 1 minocycline hcl tab sr 24hr 135 mg 1 • 1 minocycline hcl tab 50 mg demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg (Vibramycin) doxycycline hyclate tab 20 mg doxycycline hyclate tab 100 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 75 mg (Monodox) doxycycline monohydrate cap 100 mg (Monodox) doxycycline monohydrate cap 150 mg (Adoxa) minocycline hcl tab 75 mg 1 minocycline hcl tab 100 mg 1 1 • 1 1 doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) 1 doxycycline monohydrate tab 50 mg (Adoxa) 1 • Limited Distribution 1 TETRACYCLINE HCL tetracycline hcl cap 500 mg 3 tetracycline hcl cap 250 mg (Tetracycline hcl) 1 tetracycline hcl cap 500 mg (Tetracycline hcl) 1 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro) ACA 1 3 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) • 1 TETRACYCLINE HCL tetracycline hcl cap 250 mg FLUOROQUINOLONES Dispensing Limits 1 3 TETRACYCLINES Step Therapy Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 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 2017 CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg (base equiv) 3 TOBI PODHALER - tobramycin inhal cap 28 mg 3 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) 1 • • • 1 TOBRAMYCIN - tobramycin nebu soln 300 mg/5ml 3 • • • 1 tobramycin nebu soln 300 mg/5ml (Tobi) 1 • • • 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) paromomycin sulfate cap 250 mg SULFONAMIDES 1 SULFADIAZINE - sulfadiazine tab 500 mg 3 ANTIMYCOBACTERIAL AGENTS 3 CYCLOSERINE - cycloserine cap 250 mg 1 ethambutol hcl tab 100 mg (Myambutol) 1 ethambutol hcl tab 400 mg (Myambutol) ISONIAZID - isoniazid syrup 50 3 mg/5ml 1 isoniazid tab 100 mg 1 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro xr) 3 FACTIVE - gemifloxacin mesylate tab 320 mg (base equiv) LEVOFLOXACIN - levofloxacin 1 oral soln 25 mg/ml 1 levofloxacin tab 250 mg (Levaquin) 1 levofloxacin tab 500 mg (Levaquin) 1 levofloxacin tab 750 mg (Levaquin) 1 moxifloxacin hcl tab 400 mg (base equiv) (Avelox) 3 OFLOXACIN - ofloxacin tab 300 mg 1 ofloxacin tab 400 mg AMINOGLYCOSIDES 1 isoniazid tab 300 mg BETHKIS - tobramycin nebu soln 300 mg/4ml 3 • • • KITABIS PAK - tobramycin nebu soln 300 mg/5ml 3 • • • neomycin sulfate tab 500 mg 1 1 PASER - aminosalicylic acid cr granules packet 4 gm 3 PRIFTIN - rifapentine tab 150 mg 2 pyrazinamide tab 500 mg 1 rifabutin cap 150 mg (Mycobutin) 1 RIFAMATE - isoniazid & rifampin cap 150-300 mg 3 rifampin cap 150 mg (Rifadin) 1 rifampin cap 300 mg (Rifadin) 1 RIFATER - isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 5 SIRTURO - bedaquiline fumarate tab 100 mg (base equiv) 3 TRECATOR - ethionamide tab 250 mg 3 ANTIFUNGALS CRESEMBA isavuconazonium sulfate cap 186 mg 3 fluconazole for susp 10 mg/ ml (Diflucan) 1 fluconazole for susp 40 mg/ ml (Diflucan) • 1 NOXAFIL - posaconazole tab delayed release 100 mg 2 nystatin tab 500000 unit 1 terbinafine hcl tab 250 mg (Lamisil) 1 voriconazole for susp 40 mg/ml (Vfend) 1 • voriconazole tab 50 mg (Vfend) 1 • voriconazole tab 200 mg (Vfend) 1 • fluconazole tab 100 mg (Diflucan) 1 abacavir sulfate tab 300 mg (base equiv) (Ziagen) fluconazole tab 150 mg (Diflucan) 1 abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) fluconazole tab 200 mg (Diflucan) 1 flucytosine cap 250 mg (Ancobon) 1 flucytosine cap 500 mg (Ancobon) 1 griseofulvin microsize susp 125 mg/5ml 1 griseofulvin ultramicrosize tab 125 mg (Gris-peg) griseofulvin ultramicrosize tab 250 mg (Gris-peg) ANTIVIRALS abacavir sulfatelamivudine-zidovudine tab 300-150-300 mg (Trizivir) 1 1 itraconazole cap 100 mg (Sporanox) 1 NOXAFIL - posaconazole susp 40 mg/ml 2 • • • 3 1 1 Limited Distribution ACA Dispensing Limits Step Therapy • SPORANOX - itraconazole oral soln 10 mg/ml fluconazole tab 50 mg (Diflucan) griseofulvin microsize tab 500 mg (Grifulvin v) Prior Authorization • Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • 1 • 1 • 1 • acyclovir cap 200 mg (Zovirax) 1 acyclovir susp 200 mg/5ml (Zovirax) 1 acyclovir tab 400 mg (Zovirax) 1 acyclovir tab 800 mg (Zovirax) 1 adefovir dipivoxil tab 10 mg (Hepsera) 1 APTIVUS - tipranavir cap 250 mg 3 • APTIVUS - tipranavir oral soln 100 mg/ml 3 • ATRIPLA - efavirenzemtricitabine-tenofovir df tab 600-200-300 mg 2 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 6 BARACLUDE - entecavir oral soln 0.05 mg/ml 2 COMPLERA - emtricitabinerilpivirine-tenofovir df tab 200-25-300 mg 3 CRIXIVAN - indinavir sulfate cap 200 mg 3 CRIXIVAN - indinavir sulfate cap 400 mg 3 DAKLINZA - daclatasvir dihydrochloride tab 30 mg (base equivalent) 2 • DAKLINZA - daclatasvir dihydrochloride tab 60 mg (base equivalent) 2 • DAKLINZA - daclatasvir dihydrochloride tab 90 mg (base equivalent) 2 DESCOVY - emtricitabinetenofovir alafenamide fumarate tab 200-25 mg 2 didanosine delayed release capsule 125 mg (Videx ec) entecavir tab 1 mg (Baraclude) 1 EPCLUSA - sofosbuvirvelpatasvir tab 400-100 mg 2 • EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3 • EPZICOM - abacavir sulfatelamivudine tab 600-300 mg 2 • • EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg (base equiv) 3 • • famciclovir tab 125 mg (Famvir) 1 famciclovir tab 250 mg (Famvir) 1 famciclovir tab 500 mg (Famvir) 1 • FUZEON - enfuvirtide for inj 90 mg 3 • 2 • 1 • GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab 150-150-200-10 mg 1 • HARVONI - ledipasvirsofosbuvir tab 90-400 mg 2 1 • INTELENCE - etravirine tab 25 mg 2 • 1 • INTELENCE - etravirine tab 100 mg 2 • EDURANT - rilpivirine hcl tab 25 mg (base equivalent) 3 • INTELENCE - etravirine tab 200 mg 2 • EMTRIVA - emtricitabine caps 200 mg 3 • INVIRASE - saquinavir mesylate cap 200 mg 3 • EMTRIVA - emtricitabine soln 10 mg/ml 3 • INVIRASE - saquinavir mesylate tab 500 mg 3 • entecavir tab 0.5 mg (Baraclude) 1 ISENTRESS - raltegravir potassium chew tab 25 mg (base equiv) 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 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 7 2 • KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 2 • KALETRA - lopinavir-ritonavir tab 100-25 mg 2 • KALETRA - lopinavir-ritonavir tab 200-50 mg 2 • lamivudine oral soln 10 mg/ ml (Epivir) 1 • MODERIBA - ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 3 • MODERIBA 1200 DOSE PACK - ribavirin tab 600 mg 3 • MODERIBA 800 DOSE PACK - 3 ribavirin tab 400 mg NEVIRAPINE - nevirapine susp 3 50 mg/5ml 1 nevirapine tab sr 24hr 100 mg 1 nevirapine tab sr 24hr 400 mg (Viramune xr) 1 nevirapine tab 200 mg (Viramune) NORVIR - ritonavir cap 100 mg 3 • NORVIR - ritonavir oral soln 80 mg/ml 2 NORVIR - ritonavir tab 100 mg 2 ODEFSEY - emtricitabinerilpivirine-tenofovir af tab 200-25-25 mg 2 OLYSIO - simeprevir sodium cap 150 mg (base equivalent) 3 • • • • • • lamivudine tab 100 mg (hbv) (Epivir hbv) 1 lamivudine tab 150 mg (Epivir) 1 • lamivudine tab 300 mg (Epivir) 1 • lamivudine-zidovudine tab 150-300 mg (Combivir) 1 • LEXIVA - fosamprenavir calcium susp 50 mg/ml (base equiv) 3 • oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) 1 • LEXIVA - fosamprenavir calcium tab 700 mg (base equiv) 3 • oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) 1 • lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ ml) (Kaletra) 1 • oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) 1 • PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 50 mcg/0.5ml 3 MODERIBA - ribavirin tab 200 mg & ribavirin tab 400 mg dose pack 3 • Limited Distribution ISENTRESS - raltegravir potassium tab 400 mg (base equiv) ACA • Dispensing Limits 2 Step Therapy ISENTRESS - raltegravir potassium packet for susp 100 mg (base equiv) Prior Authorization • Drug Name Drug Tier 2 Limited Distribution ISENTRESS - raltegravir potassium chew tab 100 mg (base equiv) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 8 3 • • PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 150 mcg/0.5ml 3 • • PEG-INTRON REDIPEN PAK 4 - peginterferon alfa-2b for inj kit 120 mcg/0.5ml 3 • • PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 2 • • PEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 2 • • PEGASYS PROCLICK peginterferon alfa-2a inj 135 mcg/0.5ml 2 • • PEGASYS PROCLICK peginterferon alfa-2a inj 180 mcg/0.5ml 2 • • PEGINTRON - peginterferon alfa-2b for inj kit 50 mcg/0.5ml 3 • • PEGINTRON - peginterferon alfa-2b for inj kit 80 mcg/0.5ml 3 • • PEGINTRON - peginterferon alfa-2b for inj kit 120 mcg/0.5ml 3 • PEGINTRON - peginterferon alfa-2b for inj kit 150 mcg/0.5ml 3 • PREZCOBIX - darunavircobicistat tab 800-150 mg 3 • PREZISTA - darunavir ethanolate susp 100 mg/ml (base equiv) 2 • Limited Distribution PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 120 mcg/0.5ml ACA • Dispensing Limits • Step Therapy 3 Prior Authorization PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 80 mcg/0.5ml Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 PREZISTA - darunavir ethanolate tab 75 mg (base equiv) 2 • PREZISTA - darunavir ethanolate tab 150 mg (base equiv) 2 • PREZISTA - darunavir ethanolate tab 600 mg (base equiv) 2 • PREZISTA - darunavir ethanolate tab 800 mg (base equiv) 2 • REBETOL - ribavirin soln 40 mg/ml 3 RELENZA DISKHALER zanamivir aero powder breath activated 5 mg/blister 3 • RESCRIPTOR - delavirdine mesylate tab 100 mg 3 • RESCRIPTOR - delavirdine mesylate tab 200 mg 3 • REYATAZ - atazanavir sulfate cap 150 mg (base equiv) 2 • REYATAZ - atazanavir sulfate cap 200 mg (base equiv) 2 • REYATAZ - atazanavir sulfate cap 300 mg (base equiv) 2 • • REYATAZ - atazanavir sulfate oral powder packet 50 mg (base equiv) 3 • • RIBASPHERE - ribavirin tab 400 mg 3 • RIBASPHERE - ribavirin tab 600 mg 3 • RIBASPHERE RIBAPAK ribavirin tab 400 mg 3 • RIBASPHERE RIBAPAK ribavirin tab 600 mg 3 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 9 3 RIBASPHERE RIBAPAK ribavirin tab 400 mg & ribavirin tab 600 mg dose pack 3 • ribavirin cap 200 mg (Rebetol) 1 • ribavirin for inhal soln 6 gm (Virazole) 1 ribavirin tab 200 mg (Copegus) 1 rimantadine hydrochloride tab 100 mg (Flumadine) 1 • SELZENTRY - maraviroc tab 25 mg 3 • SELZENTRY - maraviroc tab 75 mg 3 • SELZENTRY - maraviroc tab 150 mg 3 SELZENTRY - maraviroc tab 300 mg 3 SITAVIG - acyclovir buccal tab 50 mg 3 SOVALDI - sofosbuvir tab 400 mg 2 stavudine cap 15 mg (Zerit) 1 stavudine cap 20 mg (Zerit) stavudine cap 30 mg (Zerit) stavudine cap 40 mg (Zerit) 1 1 1 STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab 150-150-200-300 mg 2 SUSTIVA - efavirenz cap 50 mg 2 • • • • • • • • • • • • 2 • SUSTIVA - efavirenz tab 600 mg 2 • TAMIFLU - oseltamivir phosphate cap 30 mg (base equiv) 3 • TAMIFLU - oseltamivir phosphate cap 45 mg (base equiv) 3 • TAMIFLU - oseltamivir phosphate cap 75 mg (base equiv) 3 • TAMIFLU - oseltamivir phosphate for susp 6 mg/ml (base equiv) 3 • TECHNIVIE - ombitasvirparitaprevir-ritonavir tab 12.5-75-50 mg 3 TIVICAY - dolutegravir sodium tab 10 mg (base equiv) 2 • TIVICAY - dolutegravir sodium tab 25 mg (base equiv) 2 • TIVICAY - dolutegravir sodium tab 50 mg (base equiv) 2 • TRIUMEQ - abacavirdolutegravir-lamivudine tab 600-50-300 mg 3 • TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 100-150 mg 2 • TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 133-200 mg 2 • TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 167-250 mg 2 • • Limited Distribution SUSTIVA - efavirenz cap 200 mg ACA Dispensing Limits Step Therapy Prior Authorization • RIBASPHERE RIBAPAK ribavirin tab 200 mg & ribavirin tab 400 mg dose pack Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 10 • VIREAD - tenofovir disoproxil fumarate tab 200 mg 2 • VIREAD - tenofovir disoproxil fumarate tab 250 mg 2 valacyclovir hcl tab 500 mg (Valtrex) 1 • 1 VIREAD - tenofovir disoproxil fumarate tab 300 mg 2 valacyclovir hcl tab 1 gm (Valtrex) • ZEPATIER - elbasvirgrazoprevir tab 50-100 mg 3 VALCYTE - valganciclovir hcl for soln 50 mg/ml (base equiv) 2 3 • valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) 1 ZERIT - stavudine for oral soln 1 mg/ml ZIAGEN - abacavir sulfate soln 20 mg/ml (base equiv) 2 • valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) 1 zidovudine cap 100 mg (Retrovir) 1 • 1 • VIDEX - didanosine for soln 2 gm 2 • zidovudine syrup 10 mg/ml (Retrovir) zidovudine tab 300 mg 1 • VIDEX - didanosine for soln 4 gm 2 • VIEKIRA PAK - ombitasparitapre-riton & dasab tab pak 12.5-75-50 & 250 mg 3 VIEKIRA XR - dasab-ombitparitap-riton tab sr 24hr 200-8.33-50-33.33 mg 3 VIRACEPT - nelfinavir mesylate tab 250 mg 3 • VIRACEPT - nelfinavir mesylate tab 625 mg 3 • VIRAMUNE - nevirapine susp 50 mg/5ml 2 • VIRAZOLE - ribavirin for inhal soln 6 gm 3 VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/ gm 2 TYBOST - cobicistat tab 150 mg 3 • ANTIMALARIALS • • • • • atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) atovaquone-proguanil hcl tab 250-100 mg (Malarone) • 1 1 CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 250 mg 1 chloroquine phosphate tab 500 mg (Aralen) 1 COARTEM - artemetherlumefantrine tab 20-120 mg 3 DARAPRIM - pyrimethamine tab 25 mg 2 hydroxychloroquine sulfate tab 200 mg (Plaquenil) 1 mefloquine hcl tab 250 mg • Limited Distribution 2 2 ACA Dispensing Limits Step Therapy Prior Authorization Drug Tier Limited Distribution Drug Name VIREAD - tenofovir disoproxil fumarate tab 150 mg TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 200-300 mg • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • • • 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 11 PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg 2 quinine sulfate cap 324 mg (Qualaquin) 1 ANTHELMINTICS linezolid for susp 100 mg/5ml (Zyvox) linezolid tab 600 mg (Zyvox) 1 metronidazole tab 250 mg (Flagyl) 1 2 metronidazole tab 500 mg (Flagyl) 1 BILTRICIDE - praziquantel tab 600 mg NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 3 EMVERM - mebendazole chew tab 100 mg 3 ivermectin tab 3 mg (Stromectol) 1 PRIMSOL - trimethoprim hcl oral soln 50 mg/5ml (base equiv) 3 • SIVEXTRO - tedizolid phosphate tab 200 mg 3 • sulfamethoxazoletrimethoprim susp 200-40 mg/5ml 1 dapsone tab 100 mg IMPAVIDO - miltefosine cap 50 mg 1 2 • • sulfamethoxazoletrimethoprim tab 800-160 mg (Bactrim ds) Limited Distribution • ACA 1 2 • Dispensing Limits • metronidazole cap 375 mg (Flagyl) sulfamethoxazoletrimethoprim tab 400-80 mg (Bactrim) Step Therapy 1 ALBENZA - albendazole tab 200 mg ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 3 100 mg/5ml 3 ALINIA - nitazoxanide tab 500 mg 1 atovaquone susp 750 mg/5ml (Mepron) 3 CAYSTON - aztreonam lysine for inhal soln 75 mg (base equivalent) 1 clindamycin hcl cap 75 mg (Cleocin) 1 clindamycin hcl cap 150 mg (Cleocin) 1 clindamycin hcl cap 300 mg (Cleocin) 1 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) 1 dapsone tab 25 mg Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 tinidazole tab 250 mg (Tindamax) 1 tinidazole tab 500 mg (Tindamax) 1 trimethoprim tab 100 mg 1 vancomycin hcl cap 125 mg (Vancocin hcl) 1 vancomycin hcl cap 250 mg (Vancocin hcl) 1 XIFAXAN - rifaximin tab 200 mg 3 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 12 XIFAXAN - rifaximin tab 550 mg 2 BIOLOGICALS VACCINES FLUARIX QUADRIVALENT 2014 - influenza virus vac split quadrivalent susp pref syr 0.5ml A • FLUARIX QUADRIVALENT 2015 - influenza virus vac split quadrivalent susp pref syr 0.5ml A • A • AFLURIA PF 2014-2015 influenza virus vaccine split pf susp pref syringe 0.5 ml A • AFLURIA PF 2015-2016 influenza virus vaccine split pf susp pref syringe 0.5 ml A • AFLURIA PF 2016-2017 influenza virus vaccine split pf susp pref syringe 0.5 ml A • FLUARIX QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.5ml A • AFLURIA 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 • AFLURIA 2015-2016 influenza virus vaccine split im susp A • FLUBLOK 2014-2015 influenza virus vac recombinant hemagglutinin (ha) inj A • AFLURIA 2016-2017 influenza virus vaccine split im susp A FLUBLOK 2015-2016 influenza virus vac recombinant hemagglutinin (ha) inj • • ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml A • FLUBLOK 2016-2017 influenza virus vac recombinant hemagglutinin (ha) inj A ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml A A • ENGERIX-B - hepatitis b vaccine (recombinant) 10 mcg/0.5ml A • FLUCELVAX QUADRIVALENT 20 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml A • ENGERIX-B - hepatitis b vaccine (recombinant) 20 mcg/ml A FLUCELVAX 2014-2015 influenza virus vac tiss-cult subunit susp pref syr 0.5 ml A • FLUAD 2016-2017 - influenza vac type a&b surface ant adj susp pref syr 0.5 ml A FLUCELVAX 2015-2016 influenza virus vac tiss-cult subunit susp pref syr 0.5 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 13 FLUZONE HIGH-DOSE PF 2015 - influenza virus vac split high-dose pf susp pref syr 0.5ml A • FLUZONE HIGH-DOSE PF 2016 - influenza virus vac split high-dose pf susp pref syr 0.5ml A • FLULAVAL 2014-2015 influenza virus vaccine split im susp A • FLUZONE INTRADERMAL QUADR - influenza virus vac split quad intradermal pen 9 mcg/strain A • FLUMIST QUADRIVALENT influenza virus vaccine live quadrivalent intranasal susp A • FLUZONE PF 2014-2015 influenza virus vaccine split pf susp pref syringe 0.5 ml A • FLUVIRIN PF 2014-2015 influenza virus vac types a & b pf susp prefilled syr 0.5 ml A • FLUZONE QUADRIVALENT 2014 - influenza virus vac split quadrivalent susp pref syr 0.25 ml A FLUVIRIN 2014-2015 influenza virus vaccine types a & b surface antigen im susp A • • FLUZONE QUADRIVALENT 2014 - influenza virus vac split quadrivalent susp pref syr 0.5ml A • FLUVIRIN 2015-2016 influenza vac type a&b surface antigen susp pref syr 0.5 ml A • FLUZONE QUADRIVALENT 2014 - influenza virus vaccine split quadrivalent im inj A • FLUVIRIN 2015-2016 influenza virus vaccine types a & b surface antigen im susp A • FLUZONE QUADRIVALENT 2014 - influenza virus vaccine split quadrivalent inj 0.5 ml A • FLUVIRIN 2016-2017 influenza vac type a&b surface antigen susp pref syr 0.5 ml A • FLUZONE QUADRIVALENT 2015 - influenza virus vac split quadrivalent susp pref syr 0.25 ml A • FLUVIRIN 2016-2017 influenza virus vaccine types a & b surface antigen im susp A • FLUZONE QUADRIVALENT 2015 - 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 • Limited Distribution • ACA A Dispensing Limits FLULAVAL QUADRIVALENT 201 - influenza virus vaccine split quadrivalent im inj Step Therapy • Prior Authorization A Drug Name Drug Tier FLULAVAL QUADRIVALENT 201 - influenza virus vac split quadrivalent susp pref syr 0.5ml Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 14 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 • FLUZONE QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 0.25 ml A • PNEUMOVAX 23 pneumococcal vaccine polyvalent inj 25 mcg/0.5ml A • FLUZONE QUADRIVALENT 2016 - influenza virus vac split quadrivalent susp pref syr 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 A • FLUZONE QUADRIVALENT 2016 - influenza virus vaccine split quadrivalent im inj A PREVNAR 13 - pneumococcal 13-valent conjugate vaccine inj A • FLUZONE QUADRIVALENT 2016 - influenza virus vaccine split quadrivalent inj 0.5 ml A RABAVERT - rabies vaccine, pcec for inj A • A • • RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml FLUZONE SPLIT 2014-2015 influenza virus vaccine split im susp A A • • RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 10 mcg/ml FLUZONE SPLIT 2015-2016 influenza virus vaccine split im susp A A • A • RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 40 mcg/ml IMOVAX RABIES (H.D.C.V.) rabies virus vaccine, hdc inj MEDICAL PROVIDER EZ FLU S - influenza virus vac types a & b pf pref syringe kit 0.5 ml A • VIVOTIF - typhoid vaccine cap delayed release 3 3 MEDICAL PROVIDER SINGLE U - influenza virus vac split quad inj prefilled syr kit 0.25 ml A ZOSTAVAX - zoster vaccine live for subcutaneous susp 19400 unit/0.65ml • • • Limited Distribution • ACA A Dispensing Limits FLUZONE QUADRIVALENT 2015 - influenza virus vaccine split quadrivalent inj 0.5 ml Step Therapy • Prior Authorization A Drug Name Drug Tier FLUZONE QUADRIVALENT 2015 - influenza virus vaccine split quadrivalent im inj Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 TOXOIDS Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 15 DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml Limited Distribution • ACA A Dispensing Limits BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml Step Therapy • Prior Authorization A Drug Name Drug Tier ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 HYQVIA - immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit 3 • HYQVIA - immun glob inj 10 gm/100ml-hyaluron inj 800 unt/5 ml kit 3 • • 3 HYQVIA - immun glob inj 20 gm/200ml-hyaluron inj 1600 unt/10 ml kit 3 • • DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml 3 HYQVIA - immun glob inj 30 gm/300ml-hyaluron inj 2400 unt/15 ml kit 3 • • INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 3 3 • • KINRIX - diph-tetanus tox adacell pert & polio virus, ipv vac inj 3 GRASTEK - timothy grass pollen allergen ext tab sl 2800 bau 3 • • • PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio ipv vac inj 3 ORALAIR - grass mixed pollen ext tab sl 300 ir (index of reactivity) 3 • • • PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp 3 ORALAIR ADULT SAMPLE KIT - grass mixed pollen ext tab sl 300 ir (index of reactivity) 3 • • • QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 3 ORALAIR ADULT STARTER PAC - grass mixed pollen ext tab sl 300 ir (index of reactivity) 3 • • • TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3 ORALAIR CHILDREN/ ADOLESCE - grass mixed pollen ext tab sl 100 ir (index of reactivity) 3 TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu ORALAIR CHILDREN/ ADOLESCE - grass mixed pollen tab sl therpak 100 (3) ir & 300 (6) ir 3 RAGWITEK - short ragweed pollen allergen extract tab sl 12 amb a 1-u 3 PASSIVE IMMUNIZING AGENTS 3 HYQVIA - immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/1.25 ml kit BIOLOGICALS MISC • • • • • • ANTINEOPLASTIC AGENTS Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 16 ANTINEOPLASTICS ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml) 2 AFINITOR - everolimus tab 2.5 mg 3 AFINITOR - everolimus tab 5 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 2017 CABOMETYX - cabozantinib s-malate tab 20 mg (base equivalent) 3 • • CABOMETYX - cabozantinib s-malate tab 40 mg (base equivalent) 3 • • • 3 • • • • • • 3 • • • CABOMETYX - cabozantinib s-malate tab 60 mg (base equivalent) AFINITOR - everolimus tab 7.5 mg 3 • • • capecitabine tab 150 mg (Xeloda) 1 • • AFINITOR - everolimus tab 10 mg 3 • • • capecitabine tab 500 mg (Xeloda) 1 • • AFINITOR DISPERZ everolimus tab for oral susp 2 mg 3 • • • CAPRELSA - vandetanib tab 100 mg 3 • • • 3 • • • AFINITOR DISPERZ everolimus tab for oral susp 3 mg 3 CAPRELSA - vandetanib tab 300 mg 3 • • • AFINITOR DISPERZ everolimus tab for oral susp 5 mg 3 COMETRIQ - cabozantinib smal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit 3 • • • ALECENSA - alectinib hcl cap 150 mg (base equivalent) 3 COMETRIQ - cabozantinib smal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit 3 • • • ALKERAN - melphalan tab 2 mg 2 COMETRIQ - cabozantinib smalate cap 3 x 20 mg (60 mg dose) kit anastrozole tab 1 mg (Arimidex) 1 3 • • • bexarotene cap 75 mg (Targretin) 1 COTELLIC - cobimetinib fumarate tab 20 mg (base equivalent) 3 bicalutamide tab 50 mg (Casodex) 1 CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg BOSULIF - bosutinib tab 100 mg 3 • • • 3 BOSULIF - bosutinib tab 500 mg 3 • • • CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg 3 • • • • • • • • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 17 3 ERIVEDGE - vismodegib cap 150 mg 3 ETOPOSIDE - etoposide cap 50 mg 3 exemestane tab 25 mg (Aromasin) 1 FARESTON - toremifene citrate 3 tab 60 mg (base equivalent) 3 FARYDAK - panobinostat lactate cap 10 mg (base equivalent) 3 FARYDAK - panobinostat lactate cap 15 mg (base equivalent) 3 FARYDAK - panobinostat lactate cap 20 mg (base equivalent) 1 flutamide cap 125 mg • • • • • • • • • • • • • GILOTRIF - afatinib dimaleate tab 20 mg (base equivalent) 3 • • • GILOTRIF - afatinib dimaleate tab 30 mg (base equivalent) 3 • • • GILOTRIF - afatinib dimaleate tab 40 mg (base equivalent) 3 • • • GLEEVEC - imatinib mesylate tab 100 mg (base equivalent) 3 • • • Limited Distribution EMCYT - estramustine phosphate sodium cap 140 mg • • ACA 3 Dispensing Limits ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg • • Step Therapy • Prior Authorization 3 • Drug Name Drug Tier ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 mg Limited Distribution • ACA 3 Dispensing Limits ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit 30 mg Step Therapy Prior Authorization Drug Name Drug Tier 2017 • GLEEVEC - imatinib mesylate tab 400 mg (base equivalent) 3 GLEOSTINE - lomustine cap 5 mg 3 GLEOSTINE - lomustine cap 10 mg 3 GLEOSTINE - lomustine cap 40 mg 3 GLEOSTINE - lomustine cap 100 mg 3 HEXALEN - altretamine cap 50 mg 3 • • HYCAMTIN - topotecan hcl cap 3 0.25 mg (base equiv) HYCAMTIN - topotecan hcl cap 3 1 mg (base equiv) 1 hydroxyurea cap 500 mg (Hydrea) 3 IBRANCE - palbociclib cap 75 mg IBRANCE - palbociclib cap 100 3 mg IBRANCE - palbociclib cap 125 3 mg ICLUSIG - ponatinib hcl tab 15 3 mg (base equiv) ICLUSIG - ponatinib hcl tab 45 3 mg (base equiv) 1 imatinib mesylate tab 100 mg (base equivalent) (Gleevec) 1 imatinib mesylate tab 400 mg (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 140 3 mg 3 INLYTA - axitinib tab 1 mg • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 18 INTRON A - interferon alfa-2b inj 10000000 unit/ml 3 • • INTRON A - interferon alfa-2b for inj 10000000 unit 3 • • INTRON A - interferon alfa-2b for inj 18000000 unit 3 • • INTRON A - interferon alfa-2b for inj 50000000 unit 3 • • INTRON A W/DILUENT interferon alfa-2b for inj 10000000 unit 3 • • INTRON A W/DILUENT interferon alfa-2b for inj 18000000 unit 3 • • INTRON A W/DILUENT interferon alfa-2b for inj 50000000 unit 3 • • IRESSA - gefitinib tab 250 mg 3 JAKAFI - ruxolitinib phosphate tab 5 mg (base equivalent) 3 • • • • • • JAKAFI - ruxolitinib phosphate tab 10 mg (base equivalent) 3 • • JAKAFI - ruxolitinib phosphate tab 15 mg (base equivalent) 3 • JAKAFI - ruxolitinib phosphate tab 20 mg (base equivalent) 3 JAKAFI - ruxolitinib phosphate tab 25 mg (base equivalent) 3 LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack 10 mg (10 mg daily dose) 3 Limited Distribution 3 LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose) 3 • LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose) 3 • • • LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose) 3 • • • LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose) 3 • • • LENVIMA 8 MG DAILY DOSE - 3 lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose) letrozole tab 2.5 mg (Femara) 1 • • • LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg 2 • LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg 2 • • leucovorin calcium tab 5 mg 1 • • • • • • • • • leucovorin calcium tab 25 mg • ACA • • Dispensing Limits INTRON A - interferon alfa-2b inj 6000000 unit/ml • • Step Therapy 3 Prior Authorization INLYTA - axitinib tab 5 mg Drug Name Drug Tier Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • 1 LEUKERAN - chlorambucil tab 2 mg 2 LONSURF - trifluridine-tipiracil tab 15-6.14 mg 3 • • • LONSURF - trifluridine-tipiracil tab 20-8.19 mg 3 • • • LYNPARZA - olaparib cap 50 mg 3 • • • LYSODREN - mitotane tab 500 mg 3 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 19 MATULANE - procarbazine hcl cap 50 mg 3 megestrol acetate susp 40 mg/ml (Megace oral) megestrol acetate tab 20 mg megestrol acetate tab 40 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 2017 NILANDRON - nilutamide tab 150 mg 3 1 nilutamide tab 150 mg (Nilandron) 1 1 NINLARO - ixazomib citrate cap 2.3 mg (base equivalent) 3 • • • NINLARO - ixazomib citrate cap 3 mg (base equivalent) 3 • • • NINLARO - ixazomib citrate cap 4 mg (base equivalent) 3 • • • ODOMZO - sonidegib phosphate cap 200 mg (base equivalent) 3 • • • POMALYST - pomalidomide cap 1 mg 3 • • • POMALYST - pomalidomide cap 2 mg 3 • • • 1 MEKINIST - trametinib dimethyl 2 sulfoxide tab 0.5 mg (base equivalent) MEKINIST - trametinib dimethyl 2 sulfoxide tab 2 mg (base equivalent) 1 mercaptopurine tab 50 mg (Purinethol) 3 MESNEX - mesna tab 400 mg • • • • • • METHOTREXATE SODIUM methotrexate sodium inj 250 mg/10ml (25 mg/ml) 3 methotrexate sodium for inj 1 gm 1 POMALYST - pomalidomide cap 3 mg 3 • • • 1 POMALYST - pomalidomide cap 4 mg 3 • • • 1 PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml) 3 RUBRACA - rucaparib camsylate tab 200 mg (base equivalent) 3 • • • RUBRACA - rucaparib camsylate tab 300 mg (base equivalent) 3 • • • 3 1 SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml (base equivalent) 2 3 MYLERAN - busulfan tab 2 mg SPRYCEL - dasatinib tab 20 mg • • • NEXAVAR - sorafenib tosylate tab 200 mg (base equivalent) 2 SPRYCEL - dasatinib tab 50 mg 3 • • • 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) 1 1 1 1 • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 20 3 • • • SPRYCEL - dasatinib tab 100 mg 3 • • • SPRYCEL - dasatinib tab 140 mg 3 • • • STIVARGA - regorafenib tab 40 3 mg SUTENT - sunitinib malate cap 2 12.5 mg (base equivalent) SUTENT - sunitinib malate cap 2 25 mg (base equivalent) SUTENT - sunitinib malate cap 2 37.5 mg (base equivalent) SUTENT - sunitinib malate cap 2 50 mg (base equivalent) 2 SYLATRON - peginterferon alfa-2b for inj kit 296 mcg 2 SYLATRON - peginterferon alfa-2b for inj kit 444 mcg 2 SYLATRON - peginterferon alfa-2b for inj kit 888 mcg 3 TABLOID - thioguanine tab 40 mg 2 TAFINLAR - dabrafenib mesylate cap 50 mg (base equivalent) 2 TAFINLAR - dabrafenib mesylate cap 75 mg (base equivalent) 3 TAGRISSO - osimertinib mesylate tab 40 mg (base equivalent) 3 TAGRISSO - osimertinib mesylate tab 80 mg (base equivalent) • • • • • • • • • • • • • • • • • TARCEVA - erlotinib hcl tab 100 mg (base equivalent) 2 • • • TARCEVA - erlotinib hcl tab 150 mg (base equivalent) 2 • • • • • • • • • • TASIGNA - nilotinib hcl cap 150 2 mg (base equivalent) TASIGNA - nilotinib hcl cap 200 2 mg (base equivalent) 1 temozolomide cap 5 mg (Temodar) 1 temozolomide cap 20 mg (Temodar) 1 temozolomide cap 100 mg (Temodar) 1 temozolomide cap 140 mg (Temodar) 1 temozolomide cap 180 mg (Temodar) 1 temozolomide cap 250 mg (Temodar) 1 tretinoin cap 10 mg 3 • TREXALL - methotrexate sodium tab 5 mg (base equiv) 3 • TREXALL - methotrexate sodium tab 7.5 mg (base equiv) 3 • TREXALL - methotrexate sodium tab 10 mg (base equiv) • • • • • • • • • • • • • 1 2 • • • TARCEVA - erlotinib hcl tab 25 mg (base equivalent) • • tamoxifen citrate tab 20 mg (base equivalent) 1 Limited Distribution SPRYCEL - dasatinib tab 80 mg tamoxifen citrate tab 10 mg (base equivalent) ACA • Dispensing Limits • Step Therapy 3 Prior Authorization SPRYCEL - dasatinib tab 70 mg Drug Name Drug Tier Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • • • • • • • • • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 21 TREXALL - methotrexate sodium tab 15 mg (base equiv) 3 TYKERB - lapatinib ditosylate tab 250 mg (base equiv) 3 VOTRIENT - pazopanib hcl tab 200 mg (base equiv) 2 • XALKORI - crizotinib cap 200 mg 2 DEXAMETHASONE dexamethasone tab 2 mg 3 • dexamethasone elixir 0.5 mg/5ml 1 • • 3 • • • DEXAMETHASONE INTENSOL - dexamethasone conc 1 mg/ml dexamethasone tab 0.5 mg 1 XALKORI - crizotinib cap 250 mg 2 • • • XTANDI - enzalutamide cap 40 mg 3 • • • dexamethasone tab 4 mg ZELBORAF - vemurafenib tab 240 mg 2 • • • fludrocortisone acetate tab 0.1 mg ZOLINZA - vorinostat cap 100 mg 3 • • • hydrocortisone tab 5 mg (Cortef) 1 ZYDELIG - idelalisib tab 100 mg 3 • • • hydrocortisone tab 10 mg (Cortef) 1 ZYDELIG - idelalisib tab 150 mg 3 • • • hydrocortisone tab 20 mg (Cortef) 1 ZYKADIA - ceritinib cap 150 mg 3 • • • 3 ZYTIGA - abiraterone acetate tab 250 mg 2 • • • INTERARTICULAR JOINT KIT - triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit JTT PHYSICIANS KIT triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 3 MEDROL - methylprednisolone tab 2 mg 3 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) 1 methylprednisolone tab 4 mg (Medrol) 1 • ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap 3 mg (Entocort ec) 1 CORTISONE ACETATE cortisone acetate tab 25 mg 2 DEXAMETHASONE dexamethasone soln 0.5 mg/5ml 3 DEXAMETHASONE dexamethasone tab 1 mg 3 • dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 6 mg methylprednisolone tab 8 mg (Medrol) 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 2017 1 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 22 methylprednisolone tab 16 mg (Medrol) methylprednisolone tab 32 mg (Medrol) 1 1 PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) 3 1 MILLIPRED - prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) 3 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone) MILLIPRED - prednisolone tab 5 mg 3 PREDNISONE - prednisone oral soln 5 mg/5ml 3 MILLIPRED DP - prednisolone tab therapy pack 5 mg (21) 3 PREDNISONE - prednisone tab therapy pack 5 mg (21) 3 MILLIPRED DP - prednisolone tab therapy pack 5 mg (48) 3 PREDNISONE - prednisone tab therapy pack 5 mg (48) 3 PREDNISONE - prednisone tab therapy pack 10 mg (21) 3 PREDNISONE - prednisone tab therapy pack 10 mg (48) 3 PREDNISONE - prednisone tab 50 mg 3 PREDNISONE INTENSOL prednisone conc 5 mg/ml 3 prednisone tab 1 mg 1 3 PHYSICIANS EZ USE JOINT T - triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit 1 prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt) 1 prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt) 1 prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt) 1 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) prednisolone sod phosphate 1 oral soln 10 mg/5ml (base equiv) (Millipred) prednisolone sod phosphate 1 oral soln 20 mg/5ml (base equiv) (Veripred 20) prednisone tab 2.5 mg prednisone tab 5 mg prednisone tab 10 mg prednisone tab 20 mg Limited Distribution ACA Dispensing Limits Step Therapy 1 1 1 1 UCERIS - budesonide tab sr 24hr 9 mg 3 VERIPRED 20 - prednisolone sod phosphate oral soln 20 mg/5ml (base equiv) 3 ANDROGEN-ANABOLIC Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 ANADROL-50 - oxymetholone tab 50 mg 3 • ANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 23 ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 2 • • ANDROGEL PUMP testosterone td gel 20.25 mg/act (1.62%) 2 • • ANDROXY - fluoxymesterone tab 10 mg 3 • AXIRON - testosterone td soln 30 mg/act 2 • danazol cap 50 mg 1 • • • • • • • danazol cap 200 mg 1 1 • testosterone td gel 25 mg/2.5gm (1%) (Androgel) 1 • • testosterone td gel 50 mg/5gm (1%) (Androgel) 1 • • 1 • • testosterone td gel 12.5 mg/ act (1%) (Androgel pump) ESTROGENS • ALORA - estradiol td patch biweekly 0.025 mg/24hr 3 • ALORA - estradiol td patch biweekly 0.05 mg/24hr 3 • ALORA - estradiol td patch biweekly 0.075 mg/24hr 3 • ALORA - estradiol td patch biweekly 0.1 mg/24hr 3 • ANGELIQ - drospirenoneestradiol tab 0.25-0.5 mg 3 ANGELIQ - drospirenoneestradiol tab 0.5-1 mg 3 3 DEPO-TESTOSTERONE testosterone cypionate im inj in oil 100 mg/ml 3 DEPO-TESTOSTERONE testosterone cypionate im inj in oil 200 mg/ml 3 METHITEST methyltestosterone oral tab 10 mg 3 • CLIMARA PRO - estradiollevonorgestrel td patch weekly 0.045-0.015 mg/day 1 • oxandrolone tab 2.5 mg (Oxandrin) 1 • COMBIPATCH - estradiolnorethindrone ace td pttw 0.05-0.14 mg/day 2 methyltestosterone cap 10 mg (Testred) 2 oxandrolone tab 10 mg (Oxandrin) 1 • COMBIPATCH - estradiolnorethindrone ace td pttw 0.05-0.25 mg/day 2 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone) 1 DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%) DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%) 2 testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone) 1 DIVIGEL - estradiol td gel 1 mg/gm (0.1%) 2 • • • • • Limited Distribution • 1 testosterone enanthate im inj in oil 200 mg/ml ACA • Dispensing Limits 2 Step Therapy ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) danazol cap 100 mg • Prior Authorization • Drug Name Drug Tier 3 Limited Distribution ANDRODERM - testosterone td patch 24hr 4 mg/24hr ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 24 DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg 3 ELESTRIN - estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump) 3 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) 1 estradiol & norethindrone acetate tab 1-0.5 mg (Activella) 1 estradiol tab 2 mg (Estrace) 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) • 1 • 1 1 ESTROGEL - estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump) 3 ESTROPIPATE - estropipate tab 0.75 mg 3 ESTROPIPATE - estropipate tab 1.5 mg 3 ESTROPIPATE - estropipate tab 3 mg 3 estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) 1 • 1 • EVAMIST - estradiol transdermal spray 1.53 mg/ spray 3 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot) • MENEST - esterified estrogens tab 0.3 mg 3 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) 1 3 estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-dot) 1 • MENEST - esterified estrogens tab 0.625 mg MENEST - esterified estrogens tab 1.25 mg 3 estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) 1 • MENOSTAR - estradiol td patch weekly 14 mcg/24hr 3 • 3 • estradiol td patch weekly 0.025 mg/24hr (Climara) 1 • MINIVELLE - estradiol td patch biweekly 0.0375 mg/24hr 3 • 1 • MINIVELLE - estradiol td patch biweekly 0.05 mg/24hr MINIVELLE - estradiol td patch biweekly 0.075 mg/24hr 3 • 1 • MINIVELLE - estradiol td patch biweekly 0.1 mg/24hr 3 • 1 • MINIVELLE - estradiol td patch twice weekly 0.025 mg/24hr 3 • estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara) estradiol td patch weekly 0.05 mg/24hr (Climara) estradiol td patch weekly 0.06 mg/24hr (Climara) Limited Distribution 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Tier Limited Distribution Drug Name estradiol td patch weekly 0.075 mg/24hr (Climara) estradiol tab 0.5 mg (Estrace) 1 1 estradiol tab 1 mg (Estrace) 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 25 1 norethindrone acetateethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose) 1 norethindrone acetateethinyl estradiol tab 1 mg-5 mcg 3 PREFEST - estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15) 3 PREMARIN - estrogens, conjugated tab 0.3 mg 3 PREMARIN - estrogens, conjugated tab 0.45 mg 3 PREMARIN - estrogens, conjugated tab 0.625 mg 3 PREMARIN - estrogens, conjugated tab 0.9 mg 3 PREMARIN - estrogens, conjugated tab 1.25 mg 3 PREMPHASE - conj est 0.625(14)/conj estmedroxypro ac tab 0.625-5mg(14) 3 PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg 3 PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg 3 PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg 3 PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg CONTRACEPTIVES BEYAZ - drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 3 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp prefilled syr 150 mg/ml A • DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml A • DEPO-SUBQ PROVERA 104 - medroxyprogesterone acetate susp pref syr 104 mg/0.65ml A • desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette) A • 1 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) 1 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg (Beyaz) 1 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz) 1 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) ELLA - ulipristal acetate tab 30 A mg 1 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 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 2017 • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 26 • levonor-eth est tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg (Quartette) 1 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) 1 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 (Plan b one-step) • • • A 1 1 1 1 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mgmcg 1 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg • LO LOESTRIN FE - norethineth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2) 3 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depoprovera contrac) A • 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) 3 • NATAZIA - estradiol valeratedienogest tab 3 mg /2-2 mg/2-3 mg/1 mg 3 • NECON 1/50-28 norethindrone & mestranol tab 1 mg-50 mcg 3 • NECON 10/11-28 norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11) 3 • norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35) 1 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28) 1 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 Limited Distribution 3 • ACA GENERESS FE norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg Dispensing Limits • Step Therapy 3 Prior Authorization FALESSA - levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit Drug Name Drug Tier • Limited Distribution 1 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg (Zovia 1/50e) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 27 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe) 1 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Orthocyclen) norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe) 1 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21) 1 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21) 1 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) 1 1 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) 1 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg A NUVARING - etonogestrelethinyl estradiol va ring 0.120-0.015 mg/24hr 3 OGESTREL - norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg 3 ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg A PARAGARD INTRAUTERINE COP - copper iud QUARTETTE - levonor-eth est 3 tab 0.15-0.02/0.025/0.03 mg ð est 0.01 mg 3 SAFYRAL - drospirenoneethinyl estrad-levomefolate tab 3-0.03-0.451 mg A XULANE - norelgestrominethinyl estradiol td ptwk 150-35 mcg/24hr 1 norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) (Minastrin 24 fe) 1 norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg (24) (Lomedia 24 fe) A norethindrone tab 0.35 mg (Nor-qd) 1 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7) 1 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28) • • • PROGESTINS medroxyprogesterone acetate tab 2.5 mg (Provera) 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 2017 1 • • • • • • • • • • • 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 28 medroxyprogesterone acetate tab 5 mg (Provera) 1 1 medroxyprogesterone acetate tab 10 mg (Provera) 1 megestrol acetate susp 625 mg/5ml (Megace es) 1 norethindrone acetate tab 5 mg (Aygestin) 1 progesterone im in oil 50 mg/ml 1 progesterone micronized cap 100 mg (Prometrium) 1 progesterone micronized cap 200 mg (Prometrium) ANTIDIABETICS 3 • ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl tab 12.5-1000 mg 3 • ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-15 mg 3 • ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-30 mg 3 • ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 12.5-45 mg 3 • ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-15 mg 3 • ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-30 mg 3 • 3 • acarbose tab 25 mg (Precose) 1 acarbose tab 50 mg (Precose) 1 acarbose tab 100 mg (Precose) 1 ACTOPLUS MET XR pioglitazone hcl-metformin hcl tab sr 24hr 15-1000 mg 3 ALOGLIPTIN/ PIOGLITAZONE - alogliptinpioglitazone tab 25-45 mg 3 ACTOPLUS MET XR pioglitazone hcl-metformin hcl tab sr 24hr 30-1000 mg 3 AVANDIA - rosiglitazone maleate tab 2 mg (base equiv) 3 ALOGLIPTIN - alogliptin benzoate tab 6.25 mg (base equiv) 3 AVANDIA - rosiglitazone maleate tab 4 mg (base equiv) 3 • • ALOGLIPTIN - alogliptin benzoate tab 12.5 mg (base equiv) 3 BYDUREON - exenatide for inj extended release susp 2 mg 3 • • ALOGLIPTIN - alogliptin benzoate tab 25 mg (base equiv) 3 BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg BYETTA - exenatide soln peninjector 5 mcg/0.02ml 3 • • BYETTA - exenatide soln peninjector 10 mcg/0.04ml 3 • • • • • Limited Distribution ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl tab 12.5-500 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 29 CHLORPROPAMIDE chlorpropamide tab 100 mg 3 GLUCAGEN HYPOKIT glucagon hcl (rdna) for inj 1 mg (base equiv) 3 CHLORPROPAMIDE chlorpropamide tab 250 mg 3 GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 2 CYCLOSET - bromocriptine mesylate tab 0.8 mg (base equivalent) 3 DEX4 QUICK DISSOLVE GLUCO - glucose chew tab 4 gm 3 FARXIGA - dapagliflozin propanediol tab 5 mg (base equivalent) 3 • FARXIGA - dapagliflozin propanediol tab 10 mg (base equivalent) 3 • glimepiride tab 1 mg (Amaryl) 1 glimepiride tab 2 mg (Amaryl) 1 glimepiride tab 4 mg (Amaryl) 1 glipizide tab sr 24hr 2.5 mg (Glucotrol xl) 1 glyburide-metformin tab 1.25-250 mg (Glucovance) glipizide tab sr 24hr 5 mg (Glucotrol xl) 1 glyburide-metformin tab 2.5-500 mg (Glucovance) glipizide tab sr 24hr 10 mg (Glucotrol xl) 1 glyburide-metformin tab 5-500 mg (Glucovance) glipizide tab 5 mg (Glucotrol) 1 GLUMETZA - metformin hcl tab 3 sr 24hr modified release 500 mg 3 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 glyburide tab 5 mg • • • • 1 1 1 1 GLYSET - miglitol tab 25 mg 3 GLYSET - miglitol tab 50 mg 3 GLYSET - miglitol tab 100 mg 3 1 glipizide-metformin hcl tab 2.5-250 mg 1 GLYXAMBI - empagliflozinlinagliptin tab 10-5 mg 3 • 1 GLYXAMBI - empagliflozinlinagliptin tab 25-5 mg 3 • 1 INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg 2 • glipizide-metformin hcl tab 5-500 mg Limited Distribution 1 glipizide tab 10 mg (Glucotrol) glipizide-metformin hcl tab 2.5-500 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 30 2 • JANUVIA - sitagliptin phosphate tab 50 mg (base equiv) 2 • INVOKAMET - canagliflozinmetformin hcl tab 150-1000 mg 2 • JANUVIA - sitagliptin phosphate tab 100 mg (base equiv) 2 • INVOKAMET XR canagliflozin-metformin hcl tab sr 24hr 50-500 mg 2 • JARDIANCE - empagliflozin tab 10 mg 2 • INVOKAMET XR canagliflozin-metformin hcl tab sr 24hr 50-1000 mg 2 • JARDIANCE - empagliflozin tab 25 mg 2 • 3 • • JENTADUETO - linagliptinmetformin hcl tab 2.5-500 mg INVOKAMET XR canagliflozin-metformin hcl tab sr 24hr 150-500 mg 2 3 • • JENTADUETO - linagliptinmetformin hcl tab 2.5-850 mg INVOKAMET XR canagliflozin-metformin hcl tab sr 24hr 150-1000 mg 2 3 • • JENTADUETO - linagliptinmetformin hcl tab 2.5-1000 mg INVOKANA - canagliflozin tab 100 mg 2 INVOKANA - canagliflozin tab 300 mg 2 JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr 2.5-1000 mg 3 • • JANUMET - sitagliptinmetformin hcl tab 50-500 mg 2 • JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr 5-1000 mg 3 • JANUMET - sitagliptinmetformin hcl tab 50-1000 mg 2 • KAZANO - alogliptin-metformin hcl tab 12.5-500 mg 3 • • JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 50-500 mg 2 KAZANO - alogliptin-metformin hcl tab 12.5-1000 mg 3 • • JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 50-1000 mg 2 • KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr 2.5-1000 mg 2 • JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 100-1000 mg 2 • KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr 5-500 mg 2 • • Limited Distribution JANUVIA - sitagliptin phosphate tab 25 mg (base equiv) ACA • Dispensing Limits 2 Step Therapy INVOKAMET - canagliflozinmetformin hcl tab 150-500 mg Prior Authorization • Drug Name Drug Tier 2 Limited Distribution INVOKAMET - canagliflozinmetformin hcl tab 50-1000 mg ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 31 KOMBIGLYZE XR saxagliptin-metformin hcl tab sr 24hr 5-1000 mg 2 KORLYM - mifepristone tab 300 mg 3 metformin hcl tab sr 24hr 500 mg (Glucophage xr) metformin hcl tab sr 24hr 750 mg (Glucophage xr) 3 ONGLYZA - saxagliptin hcl tab 2.5 mg (base equiv) 2 • 1 ONGLYZA - saxagliptin hcl tab 5 mg (base equiv) 2 • 1 OSENI - alogliptin-pioglitazone tab 12.5-15 mg 3 • • • • • 1 • OSENI - alogliptin-pioglitazone tab 12.5-30 mg 3 • • • OSENI - alogliptin-pioglitazone tab 12.5-45 mg 3 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet) 1 • • 3 • • metformin hcl tab sr 24hr modified release 500 mg (Glumetza) 1 • • OSENI - alogliptin-pioglitazone tab 25-15 mg OSENI - alogliptin-pioglitazone tab 25-30 mg 3 • • metformin hcl tab sr 24hr modified release 1000 mg (Glumetza) 1 • • OSENI - alogliptin-pioglitazone tab 25-45 mg 3 • • 1 metformin hcl tab 500 mg (Glucophage) 1 pioglitazone hcl tab 15 mg (base equiv) (Actos) metformin hcl tab 850 mg (Glucophage) 1 metformin hcl tab 1000 mg (Glucophage) 1 miglitol tab 25 mg (Glyset) 1 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet) miglitol tab 50 mg (Glyset) miglitol tab 100 mg (Glyset) pioglitazone hcl tab 30 mg (base equiv) (Actos) pioglitazone hcl tab 45 mg (base equiv) (Actos) 1 1 nateglinide tab 60 mg (Starlix) 1 nateglinide tab 120 mg (Starlix) 1 NESINA - alogliptin benzoate tab 6.25 mg (base equiv) 3 • • NESINA - alogliptin benzoate tab 12.5 mg (base equiv) 3 • • Limited Distribution • NESINA - alogliptin benzoate tab 25 mg (base equiv) ACA Dispensing Limits • Step Therapy Prior Authorization Drug Name Drug Tier Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met) 1 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met) PROGLYCEM - diazoxide susp 3 50 mg/ml 1 repaglinide tab 0.5 mg (Prandin) 1 repaglinide tab 1 mg (Prandin) 1 repaglinide tab 2 mg (Prandin) Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 32 3 XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-500 mg 3 • REPAGLINIDE/METFORMIN HYD - repaglinide-metformin hcl tab 2-500 mg 3 XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-1000 mg 3 • RIOMET - metformin hcl oral soln 500 mg/5ml 3 3 • SYNJARDY - empagliflozinmetformin hcl tab 5-500 mg 3 XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 10-500 mg • 3 • 3 SYNJARDY - empagliflozinmetformin hcl tab 5-1000 mg XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 10-1000 mg SYNJARDY - empagliflozinmetformin hcl tab 12.5-500 mg 3 • Rapid-Acting Insulins SYNJARDY - empagliflozinmetformin hcl tab 12.5-1000 mg 3 • TANZEUM - albiglutide for soln pen-injector 30 mg 3 • • TANZEUM - albiglutide for soln pen-injector 50 mg 3 • • TOLAZAMIDE - tolazamide tab 250 mg 3 TOLAZAMIDE - tolazamide tab 500 mg 3 TOLBUTAMIDE - tolbutamide tab 500 mg 3 TRADJENTA - linagliptin tab 5 mg 3 • TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml 3 • • TRULICITY - dulaglutide soln pen-injector 1.5 mg/0.5ml 3 • • VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml) 2 • • WALGREENS GLUCOSE glucose chew tab 4 gm 3 • APIDRA - insulin glulisine inj 100 unit/ml 3 • • APIDRA SOLOSTAR - insulin glulisine soln pen-injector inj 100 unit/ml 3 • • HUMALOG - insulin lispro inj 100 unit/ml 3 • • HUMALOG - insulin lispro soln cartridge 100 unit/ml 3 • • HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml 3 • • HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 3 • • NOVOLOG - insulin aspart inj 100 unit/ml 1 • NOVOLOG FLEXPEN - insulin aspart soln pen-injector 100 unit/ml 1 • NOVOLOG PENFILL - insulin aspart soln cartridge 100 unit/ml 1 • Limited Distribution REPAGLINIDE/METFORMIN HYD - repaglinide-metformin hcl tab 1-500 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 2017 Short-Acting Insulins Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 33 • • • AFREZZA - insulin regular (human) inhal powd 4 (30) & 8 (60) unit/cart 3 • • AFREZZA - insulin regular (human) inhal powd 4 (60) & 8 (30) unit/cart 3 • • AFREZZA - insulin regular (human) inhal powd 4 (90) & 8 (90) unit/cart 3 AFREZZA - insulin regular (human) inhalation powder 4 unit/cartridge 3 HUMULIN R - insulin regular (human) inj 100 unit/ml 3 HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml (75-25) 3 • • HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro sus pen-inj 100 unit/ ml (75-25) 3 • • • HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 3 • • • • HUMULIN N KWIKPEN insulin nph (human) (isophane) susp pen-injector 100 unit/ml 3 • • • • HUMULIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30) 3 • • HUMULIN 70/30 KWIKPEN insulin nph & regular susp pen-inj 100 unit/ml (70-30) 3 • • NOVOLIN N - insulin nph (human) (isophane) inj 100 unit/ml 1 • NOVOLIN N RELION - insulin nph (human) (isophane) inj 100 unit/ml 1 • NOVOLIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml (70-30) 1 • NOVOLIN 70/30 RELION insulin nph isophane & regular human inj 100 unit/ ml (70-30) 1 • NOVOLOG MIX 70/30 - insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) 1 • • 3 HUMULIN R U-500 (CONCENTR - insulin regular (human) inj 500 unit/ml 3 HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml 1 NOVOLIN R - insulin regular (human) inj 100 unit/ml 1 NOVOLIN R RELION - insulin regular (human) inj 100 unit/ ml 2 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) 3 • • • • • • • Limited Distribution 3 ACA 3 Dispensing Limits AFREZZA - insulin regular (human) inh powd 4 & 8 & 12 unit/cart (60) Step Therapy HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro sus pen-inj 100 unit/ ml (50-50) • • Prior Authorization • Drug Name Drug Tier 3 Limited Distribution AFREZZA - insulin regular (human) inh powd 8 (60) & 12 (30) unit/cart ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 34 NOVOLOG MIX 70/30 PREFILL - insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30) Basal Insulins 1 levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) LANTUS - insulin glargine inj 100 unit/ml 2 • levothyroxine sodium tab 88 mcg (Synthroid) LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 2 • levothyroxine sodium tab 100 mcg (Synthroid) LEVEMIR - insulin detemir inj 100 unit/ml 2 • LEVEMIR FLEXTOUCH insulin detemir soln peninjector 100 unit/ml 2 • TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml 2 • TRESIBA FLEXTOUCH insulin degludec soln peninjector 100 unit/ml 2 • TRESIBA FLEXTOUCH insulin degludec soln peninjector 200 unit/ml 2 • 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 2017 1 1 1 1 1 1 1 1 1 1 1 1 1 ARMOUR THYROID - thyroid tab 15 mg (1/4 grain) 3 liothyronine sodium tab 25 mcg (Cytomel) ARMOUR THYROID - thyroid tab 120 mg (2 grain) 3 liothyronine sodium tab 50 mcg (Cytomel) ARMOUR THYROID - thyroid tab 180 mg (3 grain) 3 methimazole tab 5 mg (Tapazole) 1 ARMOUR THYROID - thyroid tab 240 mg (4 grain) 3 methimazole tab 10 mg (Tapazole) 1 ARMOUR THYROID - thyroid tab 300 mg (5 grain) 3 NATURE-THROID - thyroid tab 16.25 mg 3 levothyroxine sodium tab 25 mcg (Synthroid) 1 NATURE-THROID - thyroid tab 32.5 mg 3 NATURE-THROID - thyroid tab 48.75 mg (3/4 grain) 3 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 35 NATURE-THROID - thyroid tab 65 mg 3 SYNTHROID - levothyroxine sodium tab 175 mcg 3 NATURE-THROID - thyroid tab 81.25 mg 3 SYNTHROID - levothyroxine sodium tab 200 mcg 3 NATURE-THROID - thyroid tab 97.5 mg 3 SYNTHROID - levothyroxine sodium tab 300 mcg 3 NATURE-THROID - thyroid tab 113.75 mg 3 thyroid tab 30 mg (1/2 grain) (Armour thyroid) 1 NATURE-THROID - thyroid tab 130 mg 3 thyroid tab 60 mg (1 grain) (Armour thyroid) 1 NATURE-THROID - thyroid tab 195 mg 3 1 NATURE-THROID - thyroid tab 260 mg 3 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) NATURE-THROID - thyroid tab 325 mg (5 grain) THYROLAR-1 - liotrix (t3-t4) tab 60 mg (12.5-50 mcg) 3 3 THYROLAR-1/2 - liotrix (t3-t4) tab 30 mg (6.25-25 mcg) 3 NATURE-THROID - thyroid tab 146.25 mg 3 THYROLAR-1/4 - liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg) 3 propylthiouracil tab 50 mg 1 3 SYNTHROID - levothyroxine sodium tab 25 mcg 3 THYROLAR-2 - liotrix (t3-t4) tab 120 mg (25-100 mcg) 3 SYNTHROID - levothyroxine sodium tab 50 mcg 3 THYROLAR-3 - liotrix (t3-t4) tab 180 mg (37.5-150 mcg) 3 SYNTHROID - levothyroxine sodium tab 75 mcg 3 TIROSINT - levothyroxine sodium cap 13 mcg 3 SYNTHROID - levothyroxine sodium tab 88 mcg 3 TIROSINT - levothyroxine sodium cap 25 mcg 3 SYNTHROID - levothyroxine sodium tab 100 mcg 3 TIROSINT - levothyroxine sodium cap 50 mcg 3 SYNTHROID - levothyroxine sodium tab 112 mcg 3 TIROSINT - levothyroxine sodium cap 75 mcg 3 SYNTHROID - levothyroxine sodium tab 125 mcg 3 TIROSINT - levothyroxine sodium cap 88 mcg 3 SYNTHROID - levothyroxine sodium tab 137 mcg 3 TIROSINT - levothyroxine sodium cap 100 mcg 3 SYNTHROID - levothyroxine sodium tab 150 mcg 3 TIROSINT - levothyroxine sodium cap 112 mcg TIROSINT - levothyroxine sodium cap 125 mcg 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 36 TIROSINT - levothyroxine sodium cap 137 mcg 3 PROSTIN E2 - dinoprostone vaginal suppos 20 mg TIROSINT - levothyroxine sodium cap 150 mcg 3 WESTHROID - thyroid tab 32.5 mg 3 WESTHROID - thyroid tab 65 mg 3 WESTHROID - thyroid tab 97.5 mg 3 WESTHROID - thyroid tab 130 mg 3 WESTHROID - thyroid tab 195 mg 3 WP THYROID - thyroid tab 16.25 mg 3 WP THYROID - thyroid tab 32.5 mg 3 ENDOCRINE and METABOLIC AGENTS - MISC. 3 • 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) 3 • BUPHENYL - sodium phenylbutyrate tab 500 mg 1 cabergoline tab 0.5 mg WP THYROID - thyroid tab 48.75 mg (3/4 grain) 3 WP THYROID - thyroid tab 65 mg 3 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) 1 3 calcitriol cap 0.25 mcg (Rocaltrol) 1 WP THYROID - thyroid tab 81.25 mg 3 calcitriol cap 0.5 mcg (Rocaltrol) 1 WP THYROID - thyroid tab 97.5 mg 3 calcitriol oral soln 1 mcg/ml (Rocaltrol) 1 WP THYROID - thyroid tab 113.75 mg 3 CARBAGLU - carglumic acid tab 200 mg 3 WP THYROID - thyroid tab 130 mg 3 desmopressin acetate inj 4 mcg/ml (Ddavp) 1 OXYTOCICS CERVIDIL - dinoprostone vaginal inserts 10 mg 3 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) METHERGINE methylergonovine maleate tab 0.2 mg 1 desmopressin acetate nasal spray soln 0.01% (Ddavp) PREPIDIL - dinoprostone cervical gel 0.5 mg/3gm 3 desmopressin acetate nasal spray soln 0.01% (refrigerated) 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 2017 1 1 • • • 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 37 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 2017 KUVAN - sapropterin dihydrochloride powder packet 500 mg 3 • 3 • • doxercalciferol cap 0.5 mcg (Hectorol) 1 KUVAN - sapropterin dihydrochloride soluble tab 100 mg doxercalciferol cap 1 mcg (Hectorol) 1 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) 1 doxercalciferol cap 2.5 mcg (Hectorol) 1 levocarnitine tab 330 mg (Carnitor) 1 EGRIFTA - tesamorelin acetate for inj 1 mg (base equiv) 3 • • MYALEPT - metreleptin for subcutaneous inj 11.3 mg 3 • • EGRIFTA - tesamorelin acetate for inj 2 mg (base equiv) 3 • • 1 • • ETIDRONATE DISODIUM etidronate disodium tab 200 mg 3 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) 1 • • FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 3 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) 1 • • FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-2800 mg-unit 3 • octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) 1 • • FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-5600 mg-unit 3 • octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) 1 • • 2 • • H.P. ACTHAR - corticotropin inj gel 80 unit/ml 3 OMNITROPE - somatropin for inj 5.8 mg • • ibandronate sodium tab 150 mg (base equivalent) (Boniva) 1 OMNITROPE - somatropin inj 5 2 mg/1.5ml 2 OMNITROPE - somatropin inj 10 mg/1.5ml ORFADIN - nitisinone cap 2 mg 2 • • • • • • • • desmopressin acetate tab 0.1 mg (Ddavp) desmopressin acetate tab 0.2 mg (Ddavp) 1 1 INCRELEX - mecasermin inj 40 2 mg/4ml (10 mg/ml) 3 KUVAN - sapropterin dihydrochloride powder packet 100 mg • • • • • • • • • • ORFADIN - nitisinone cap 5 mg 2 2 ORFADIN - nitisinone cap 10 mg • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 38 • paricalcitol cap 1 mcg (Zemplar) 1 paricalcitol cap 2 mcg (Zemplar) 1 paricalcitol cap 4 mcg (Zemplar) 1 raloxifene hcl tab 60 mg (Evista) 1 RAVICTI - glycerol phenylbutyrate liquid 1.1 gm/ ml 3 risedronate sodium tab delayed release 35 mg (Atelvia) 1 risedronate sodium tab 5 mg (Actonel) 1 risedronate sodium tab 30 mg (Actonel) 1 risedronate sodium tab 35 mg (Actonel) risedronate sodium tab 150 mg (Actonel) • • • • • • 1 • 1 • SAMSCA - tolvaptan tab 15 mg 3 SAMSCA - tolvaptan tab 30 mg 3 SENSIPAR - cinacalcet hcl tab 30 mg (base equiv) 2 SENSIPAR - cinacalcet hcl tab 60 mg (base equiv) 2 SENSIPAR - cinacalcet hcl tab 90 mg (base equiv) 2 SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml (base equiv) 3 • • • • • • • • Limited Distribution 2 ACA ORFADIN - nitisinone susp 4 mg/ml Dispensing Limits • Step Therapy 2 Prior Authorization ORFADIN - nitisinone cap 20 mg Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 SIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml (base equiv) 3 • • SIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml (base equiv) 3 • sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl) 1 • • SOMAVERT - pegvisomant for inj 10 mg (as protein) 3 • • SOMAVERT - pegvisomant for inj 15 mg (as protein) 3 • • SOMAVERT - pegvisomant for inj 20 mg (as protein) 3 • • SOMAVERT - pegvisomant for inj 25 mg (as protein) 3 • • SOMAVERT - pegvisomant for inj 30 mg (as protein) 3 • • STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 2 STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml 2 • • STRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml 2 • • STRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml 2 • • STRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml 2 • • SYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) (base eq) 3 • CARDIOVASCULAR AGENTS CARDIOTONICS Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 39 DIGOXIN - digoxin oral soln 0.05 mg/ml 3 digoxin tab 125 mcg (0.125 mg) (Lanoxin) 1 digoxin tab 250 mcg (0.25 mg) (Lanoxin) 1 isosorbide mononitrate tab 10 mg isosorbide mononitrate tab 20 mg LANOXIN - digoxin tab 62.5 mcg (0.0625 mg) 3 NITRO-DUR - nitroglycerin td patch 24hr 0.3 mg/hr 3 LANOXIN - digoxin tab 125 mcg (0.125 mg) 3 NITRO-DUR - nitroglycerin td patch 24hr 0.8 mg/hr 3 LANOXIN - digoxin tab 187.5 mcg (0.1875 mg) 3 nitroglycerin cap cr 2.5 mg 1 LANOXIN - digoxin tab 250 mcg (0.25 mg) 3 3 3 3 nitroglycerin sl tab 0.3 mg (Nitrostat) 1 ISORDIL TITRADOSE isosorbide dinitrate tab 40 mg nitroglycerin sl tab 0.4 mg (Nitrostat) 1 nitroglycerin sl tab 0.6 mg (Nitrostat) 1 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 1 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 1 DILATRATE SR - isosorbide dinitrate cap cr 40 mg ISOSORBIDE DINITRATE ER - 3 isosorbide dinitrate tab cr 40 mg isosorbide dinitrate tab 5 mg 1 (Isordil titradose) 1 isosorbide dinitrate tab 10 mg 1 isosorbide dinitrate tab 20 mg 1 isosorbide dinitrate tab 30 mg 1 isosorbide mononitrate tab sr 24hr 30 mg (Imdur) 1 isosorbide mononitrate tab sr 24hr 60 mg (Imdur) 1 isosorbide mononitrate tab sr 24hr 120 mg (Imdur) ACA 1 NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/spray ANTIANGINAL AGENTS Dispensing Limits 1 3 nitroglycerin cap cr 9 mg Step Therapy 1 NITRO-BID - nitroglycerin oint 2% nitroglycerin cap cr 6.5 mg Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 nitroglycerin tl soln 0.4 mg/ spray (400 mcg/spray) (Nitrolingual pumpspr) 1 NITROMIST - nitroglycerin lingual aerosol 400 mcg/ spray 3 NITROSTAT - nitroglycerin sl tab 0.3 mg 2 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 40 NITROSTAT - nitroglycerin sl tab 0.4 mg 2 carvedilol tab 6.25 mg (Coreg) 1 NITROSTAT - nitroglycerin sl tab 0.6 mg 2 carvedilol tab 12.5 mg (Coreg) 1 RANEXA - ranolazine tab sr 12hr 500 mg 3 carvedilol tab 25 mg (Coreg) 1 3 COREG CR - carvedilol phosphate cap sr 24hr 10 mg 3 RANEXA - ranolazine tab sr 12hr 1000 mg 3 acebutolol hcl cap 200 mg (Sectral) 1 COREG CR - carvedilol phosphate cap sr 24hr 20 mg acebutolol hcl cap 400 mg (Sectral) 1 3 atenolol tab 25 mg (Tenormin) 1 COREG CR - carvedilol phosphate cap sr 24hr 40 mg 3 atenolol tab 50 mg (Tenormin) 1 COREG CR - carvedilol phosphate cap sr 24hr 80 mg atenolol tab 100 mg (Tenormin) 1 labetalol hcl tab 100 mg (Trandate) 1 betaxolol hcl tab 10 mg (Kerlone) 1 labetalol hcl tab 200 mg (Trandate) 1 betaxolol hcl tab 20 mg (Kerlone) 1 labetalol hcl tab 300 mg (Trandate) 1 bisoprolol fumarate tab 5 mg (Zebeta) 1 1 bisoprolol fumarate tab 10 mg (Zebeta) 1 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) (Toprol xl) metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) (Toprol xl) 1 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) (Toprol xl) 1 BETA BLOCKERS BYSTOLIC - nebivolol hcl tab 2.5 mg (base equivalent) 3 BYSTOLIC - nebivolol hcl tab 5 mg (base equivalent) 3 BYSTOLIC - nebivolol hcl tab 10 mg (base equivalent) 3 BYSTOLIC - nebivolol hcl tab 20 mg (base equivalent) 3 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) (Toprol xl) carvedilol tab 3.125 mg (Coreg) 1 metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg (Lopressor) 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 2017 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 41 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 propranolol hcl cap sr 24hr 60 mg (Inderal la) propranolol hcl cap sr 24hr 80 mg (Inderal la) 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 sotalol hcl (afib/afl) tab 80 mg (Betapace af) sotalol hcl (afib/afl) tab 120 mg (Betapace af) sotalol hcl (afib/afl) tab 160 mg (Betapace af) TIMOLOL MALEATE - timolol maleate tab 10 mg 3 1 TIMOLOL MALEATE - timolol maleate tab 20 mg 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 sotalol hcl tab 120 mg (Betapace) 1 sotalol hcl tab 160 mg (Betapace) 1 sotalol hcl tab 240 mg 1 3 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) 3 CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr 120 mg 1 diltiazem hcl cap sr 12hr 60 mg 1 diltiazem hcl cap sr 12hr 90 mg 1 diltiazem hcl cap sr 12hr 120 mg 1 diltiazem hcl cap sr 24hr 120 mg 1 diltiazem hcl cap sr 24hr 180 mg 1 diltiazem hcl cap sr 24hr 240 mg 1 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd) 1 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd) 1 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd) 1 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd) Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Drug Name 1 sotalol hcl tab 80 mg (Betapace) TIMOLOL MALEATE - timolol maleate tab 5 mg Prior Authorization Drug Name Drug Tier 2017 • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 42 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd) 1 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la) 1 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la) 1 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la) 1 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la) 1 nicardipine hcl cap 20 mg 1 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la) 1 nifedipine cap 10 mg (Procardia) nifedipine cap 20 mg 1 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac) 1 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) diltiazem hcl tab 30 mg (Cardizem) diltiazem hcl tab 60 mg (Cardizem) 1 diltiazem hcl tab 90 mg 1 diltiazem hcl tab 120 mg (Cardizem) 1 felodipine tab sr 24hr 2.5 mg 1 felodipine tab sr 24hr 5 mg felodipine tab sr 24hr 10 mg isradipine cap 2.5 mg isradipine cap 5 mg nicardipine hcl cap 30 mg Limited Distribution ACA Dispensing Limits Step Therapy 1 1 1 1 1 1 nifedipine tab sr 24hr 30 mg (Adalat cc) 1 nifedipine tab sr 24hr 60 mg (Adalat cc) 1 nifedipine tab sr 24hr 90 mg (Adalat cc) 1 1 nifedipine tab sr 24hr osmotic release 30 mg (Procardia xl) 1 1 nifedipine tab sr 24hr osmotic release 60 mg (Procardia xl) 1 1 nifedipine tab sr 24hr osmotic release 90 mg (Procardia xl) 1 1 nimodipine cap 30 mg 1 NISOLDIPINE ER - nisoldipine tab sr 24hr 20 mg 3 1 NISOLDIPINE ER - nisoldipine tab sr 24hr 25.5 mg 3 NISOLDIPINE ER - nisoldipine tab sr 24hr 30 mg 3 1 Prior Authorization Drug Name Drug Tier Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 43 NISOLDIPINE ER - nisoldipine tab sr 24hr 40 mg 3 amiodarone hcl tab 200 mg (Cordarone) 1 nisoldipine tab sr 24hr 8.5 mg (Sular) 1 amiodarone hcl tab 400 mg 1 1 disopyramide phosphate cap 100 mg (Norpace) 1 disopyramide phosphate cap 150 mg (Norpace) NYMALIZE - nimodipine oral soln 60 mg/20ml 3 dofetilide cap 125 mcg (0.125 mg) (Tikosyn) verapamil hcl cap sr 24hr 100 mg (Verelan pm) 1 dofetilide cap 250 mcg (0.25 mg) (Tikosyn) 1 dofetilide cap 500 mcg (0.5 mg) (Tikosyn) nisoldipine tab sr 24hr 17 mg (Sular) nisoldipine tab sr 24hr 34 mg (Sular) 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) 1 1 1 1 flecainide acetate tab 50 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg mexiletine hcl cap 150 mg mexiletine hcl cap 200 mg mexiletine hcl cap 250 mg 1 1 1 1 1 1 1 1 NORPACE - disopyramide phosphate cap 100 mg 3 verapamil hcl tab cr 180 mg (Calan sr) 1 NORPACE - disopyramide phosphate cap 150 mg 3 verapamil hcl tab cr 240 mg (Calan sr) 1 3 verapamil hcl tab 40 mg 1 NORPACE CR - disopyramide phosphate cap sr 12hr 100 mg NORPACE CR - disopyramide phosphate cap sr 12hr 150 mg 3 propafenone hcl cap sr 12hr 225 mg (Rythmol sr) 1 1 ANTIARRHYTHMICS amiodarone hcl tab 100 mg 1 propafenone hcl cap sr 12hr 325 mg (Rythmol sr) Limited Distribution 1 verapamil hcl tab cr 120 mg (Calan sr) verapamil hcl tab 120 mg (Calan) ACA 1 3 1 Dispensing Limits 1 MULTAQ - dronedarone hcl tab 400 mg (base equivalent) verapamil hcl tab 80 mg (Calan) Step Therapy 1 1 verapamil hcl cap sr 24hr 360 mg (Verelan) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 44 propafenone hcl cap sr 12hr 425 mg (Rythmol sr) 1 propafenone hcl tab 150 mg (Rythmol) 1 propafenone hcl tab 225 mg (Rythmol) 1 propafenone hcl tab 300 mg 1 quinidine gluconate tab cr 324 mg 1 QUINIDINE SULFATE quinidine sulfate tab 200 mg 3 QUINIDINE SULFATE quinidine sulfate tab 300 mg 3 TIKOSYN - dofetilide cap 125 mcg (0.125 mg) 3 TIKOSYN - dofetilide cap 250 mcg (0.25 mg) 3 TIKOSYN - dofetilide cap 500 mcg (0.5 mg) 3 ANTIHYPERTENSIVES amlodipine besylatebenazepril hcl cap 2.5-10 mg (Lotrel) 1 amlodipine besylatevalsartan tab 5-160 mg (Exforge) 1 amlodipine besylatevalsartan tab 5-320 mg (Exforge) 1 amlodipine besylatevalsartan tab 10-160 mg (Exforge) 1 amlodipine besylatevalsartan tab 10-320 mg (Exforge) 1 amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg (Exforge hct) 1 amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg (Exforge hct) 1 amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg (Exforge hct) 1 amlodipine besylatebenazepril hcl cap 5-10 mg (Lotrel) 1 amlodipine besylatebenazepril hcl cap 5-20 mg (Lotrel) 1 amlodipine besylatebenazepril hcl cap 5-40 mg (Lotrel) 1 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) 1 amlodipine besylatebenazepril hcl cap 10-20 mg (Lotrel) 1 benazepril & hydrochlorothiazide tab 5-6.25 mg 1 1 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) amlodipine besylatebenazepril hcl cap 10-40 mg (Lotrel) atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) Limited Distribution ACA Dispensing Limits Step Therapy 1 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 2017 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 45 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) benazepril hcl tab 5 mg 1 1 1 candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct) candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct) benazepril hcl tab 10 mg (Lotensin) 1 candesartan cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct) benazepril hcl tab 20 mg (Lotensin) 1 captopril tab 12.5 mg benazepril hcl tab 40 mg (Lotensin) 1 BENICAR - olmesartan medoxomil tab 5 mg 3 BENICAR - olmesartan medoxomil tab 20 mg 3 BENICAR - olmesartan medoxomil tab 40 mg 3 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) 1 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) candesartan cilexetil tab 4 mg (Atacand) candesartan cilexetil tab 8 mg (Atacand) candesartan cilexetil tab 16 mg (Atacand) candesartan cilexetil tab 32 mg (Atacand) 1 1 1 1 1 1 captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg Limited Distribution ACA 1 1 1 1 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) 1 clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2) 1 clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3) 1 DEMSER - metyrosine cap 250 mg 3 doxazosin mesylate tab 1 mg (Cardura) 1 doxazosin mesylate tab 8 mg (Cardura) Dispensing Limits 1 1 doxazosin mesylate tab 4 mg (Cardura) Step Therapy 1 clonidine hcl tab 0.1 mg (Catapres) doxazosin mesylate tab 2 mg (Cardura) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 46 EDARBI - azilsartan medoxomil 3 tab 40 mg EDARBI - azilsartan medoxomil 3 tab 80 mg 1 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) 1 enalapril maleate tab 2.5 mg (Vasotec) 1 enalapril maleate tab 5 mg (Vasotec) 1 enalapril maleate tab 10 mg (Vasotec) 1 enalapril maleate tab 20 mg (Vasotec) 1 eplerenone tab 25 mg (Inspra) 1 eplerenone tab 50 mg (Inspra) 3 EPROSARTAN MESYLATE eprosartan mesylate tab 600 mg 1 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 1 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 1 fosinopril sodium tab 10 mg hydralazine hcl tab 10 mg fosinopril sodium tab 20 mg losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar) fosinopril sodium tab 40 mg 1 1 guanfacine hcl tab 1 mg (Tenex) 1 guanfacine hcl tab 2 mg (Tenex) 1 hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydralazine hcl tab 100 mg irbesartan tab 300 mg (Avapro) 1 irbesartanhydrochlorothiazide tab 150-12.5 mg (Avalide) 1 lisinopril tab 2.5 mg (Zestril) lisinopril tab 5 mg (Prinivil) lisinopril tab 10 mg (Prinivil) lisinopril tab 20 mg (Prinivil) lisinopril tab 30 mg (Zestril) lisinopril tab 40 mg (Zestril) losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) Limited Distribution 1 1 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) ACA 1 irbesartan tab 150 mg (Avapro) lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) Dispensing Limits 1 1 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) Step Therapy 1 irbesartan tab 75 mg (Avapro) irbesartanhydrochlorothiazide tab 300-12.5 mg (Avalide) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 1 1 1 1 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 47 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar) losartan potassium tab 25 mg (Cozaar) losartan potassium tab 50 mg (Cozaar) losartan potassium tab 100 mg (Cozaar) methyldopa tab 250 mg methyldopa tab 500 mg metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) metoprolol & hydrochlorothiazide tab 100-50 mg minoxidil tab 2.5 mg minoxidil tab 10 mg 1 1 1 1 1 1 1 1 1 1 1 nadolol & bendroflumethiazide tab 80-5 mg (Corzide) olmesartan medoxomil tab 5 mg (Benicar) olmesartan medoxomil tab 20 mg (Benicar) olmesartan medoxomil tab 40 mg (Benicar) perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg (Aceon) perindopril erbumine tab 8 mg (Aceon) phenoxybenzamine hcl cap 10 mg (Dibenzyline) Limited Distribution 1 1 1 1 1 prazosin hcl cap 1 mg (Minipress) 1 prazosin hcl cap 2 mg (Minipress) 1 1 1 moexipril hcl tab 15 mg (Univasc) 1 quinapril hcl tab 5 mg (Accupril) 1 moexiprilhydrochlorothiazide tab 7.5-12.5 mg 1 quinapril hcl tab 10 mg (Accupril) quinapril hcl tab 20 mg (Accupril) 1 quinapril hcl tab 40 mg (Accupril) 1 1 quinaprilhydrochlorothiazide tab 10-12.5 mg (Accuretic) 1 1 quinaprilhydrochlorothiazide tab 20-12.5 mg (Accuretic) nadolol & bendroflumethiazide tab 40-5 mg (Corzide) ACA 1 1 moexiprilhydrochlorothiazide tab 15-25 mg Dispensing Limits 1 moexipril hcl tab 7.5 mg (Univasc) 1 Step Therapy 1 prazosin hcl cap 5 mg (Minipress) moexiprilhydrochlorothiazide tab 15-12.5 mg (Uniretic) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 48 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) 1 1 1 1 1 telmisartanhydrochlorothiazide tab 40-12.5 mg (Micardis hct) telmisartanhydrochlorothiazide tab 80-12.5 mg (Micardis hct) telmisartanhydrochlorothiazide tab 80-25 mg (Micardis hct) 3 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5 mg 3 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25 mg 3 TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg 3 telmisartan tab 20 mg (Micardis) 1 trandolapril-verapamil hcl tab cr 2-240 mg (Tarka) telmisartan tab 40 mg (Micardis) 1 trandolapril-verapamil hcl tab cr 4-240 mg (Tarka) telmisartan tab 80 mg (Micardis) 1 valsartan tab 160 mg (Diovan) 1 telmisartan-amlodipine tab 40-5 mg (Twynsta) 1 1 valsartan tab 320 mg (Diovan) 1 1 valsartanhydrochlorothiazide tab 80-12.5 mg (Diovan hct) 1 telmisartan-amlodipine tab 40-10 mg (Twynsta) telmisartan-amlodipine tab 80-5 mg (Twynsta) telmisartan-amlodipine tab 80-10 mg (Twynsta) terazosin hcl cap 10 mg trandolapril tab 1 mg (Mavik) trandolapril tab 2 mg (Mavik) 1 trandolapril tab 4 mg (Mavik) trandolapril-verapamil hcl tab cr 1-240 mg (Tarka) trandolapril-verapamil hcl tab cr 2-180 mg (Tarka) valsartan tab 40 mg (Diovan) valsartan tab 80 mg (Diovan) valsartanhydrochlorothiazide tab 160-12.5 mg (Diovan hct) Limited Distribution ACA 1 TEKTURNA - aliskiren fumarate tab 300 mg (base equivalent) terazosin hcl cap 5 mg Dispensing Limits 1 3 terazosin hcl cap 2 mg Step Therapy 1 TEKTURNA - aliskiren fumarate tab 150 mg (base equivalent) terazosin hcl cap 1 mg Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 49 valsartanhydrochlorothiazide tab 160-25 mg (Diovan hct) 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 EDECRIN - ethacrynic acid tab 25 mg 3 ethacrynic acid tab 25 mg 1 furosemide tab 40 mg (Lasix) furosemide tab 80 mg (Lasix) 1 1 hydrochlorothiazide tab 12.5 mg 1 1 1 1 1 hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg 1 1 1 1 1 1 methazolamide tab 25 mg (Neptazane) 1 methazolamide tab 50 mg (Neptazane) 1 METHYCLOTHIAZIDE methyclothiazide tab 5 mg 3 chlorothiazide tab 500 mg 1 metolazone tab 5 mg (Zaroxolyn) 1 metolazone tab 10 mg 1 DIURIL - chlorothiazide susp 250 mg/5ml 3 DYRENIUM - triamterene cap 50 mg 3 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) spironolactone tab 25 mg (Aldactone) Limited Distribution 1 1 1 ACA 1 metolazone tab 2.5 mg (Zaroxolyn) chlorthalidone tab 50 mg Dispensing Limits 1 3 1 Step Therapy 1 CHLOROTHIAZIDE chlorothiazide tab 250 mg chlorthalidone tab 25 mg Prior Authorization ACA Limited Distribution • Drug Tier 3 hydrochlorothiazide cap 12.5 mg (Microzide) 1 bumetanide tab 2 mg DYRENIUM - triamterene cap 100 mg furosemide tab 20 mg (Lasix) amiloride & hydrochlorothiazide tab 5-50 mg bumetanide tab 1 mg Drug Name furosemide oral soln 10 mg/ ml 1 3 bumetanide tab 0.5 mg Dispensing Limits 1 ALDACTAZIDE spironolactone & hydrochlorothiazide tab 50-50 mg amiloride hcl tab 5 mg Step Therapy 1 VECAMYL - mecamylamine hcl 3 tab 2.5 mg DIURETICS Prior Authorization Drug Name Drug Tier 2017 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 50 spironolactone tab 50 mg (Aldactone) 1 spironolactone tab 100 mg (Aldactone) 1 torsemide tab 5 mg (Demadex) 1 torsemide tab 10 mg (Demadex) 1 torsemide tab 20 mg (Demadex) 1 torsemide tab 100 mg (Demadex) 1 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 EPINEPHRINE AUTHORIZED GENERIC TO EPIPEN - epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 2 EPINEPHRINE AUTHORIZED GENERIC TO EPIPEN - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 2 EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 2 EPIPEN-JR 2-PAK epinephrine solution autoinjector 0.15 mg/0.3ml (1:2000) 2 midodrine hcl tab 2.5 mg 1 midodrine hcl tab 5 mg midodrine hcl tab 10 mg ANTIHYPERLIPIDEMICS 3 Limited Distribution ACA Dispensing Limits 1 1 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) 1 ADRENACLICK - epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) 3 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) 1 ADRENACLICK - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 3 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) 1 EPINEPHRINE - epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) 3 cholestyramine light powder packets 4 gm 1 EPINEPHRINE - epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 3 cholestyramine powder packets 4 gm (Questran) Step Therapy 1 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) cholestyramine light powder 4 gm/dose (Questran light) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 51 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) 1 • 1 • 1 1 colestipol hcl granules 5 gm (Colestid flavored) 1 colestipol hcl tab 1 gm (Colestid) 1 CRESTOR - rosuvastatin calcium tab 5 mg 3 • CRESTOR - rosuvastatin calcium tab 10 mg 3 • CRESTOR - rosuvastatin calcium tab 20 mg 3 • CRESTOR - rosuvastatin calcium tab 40 mg 3 • ezetimibe tab 10 mg (Zetia) 1 fenofibrate micronized cap 67 mg (Lofibra) fenofibrate micronized cap 130 mg fenofibrate micronized cap 134 mg (Lofibra) fenofibrate tab 48 mg (Tricor) 1 • • 1 • 1 • 1 • 1 • • fenofibrate tab 54 mg (Lofibra) 1 fenofibrate tab 145 mg (Tricor) 1 • fenofibrate tab 160 mg (Lofibra) 1 fluvastatin sodium cap 20 mg (Lescol) 1 fluvastatin sodium cap 40 mg (Lescol) Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Tier Limited Distribution ACA Drug Name fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl) colestipol hcl granule packets 5 gm (Colestid flavored) fenofibrate micronized cap 43 mg Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 • gemfibrozil tab 600 mg (Lopid) 1 JUXTAPID - lomitapide mesylate cap 5 mg (base equiv) 3 • • • JUXTAPID - lomitapide mesylate cap 10 mg (base equiv) 3 • • • JUXTAPID - lomitapide mesylate cap 20 mg (base equiv) 3 • • • JUXTAPID - lomitapide mesylate cap 30 mg (base equiv) 3 • • • JUXTAPID - lomitapide mesylate cap 40 mg (base equiv) 3 • • • JUXTAPID - lomitapide mesylate cap 60 mg (base equiv) 3 • • • KYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml 3 • • • LIVALO - pitavastatin calcium tab 1 mg (base equiv) 3 • LIVALO - pitavastatin calcium tab 2 mg (base equiv) 3 • LIVALO - pitavastatin calcium tab 4 mg (base equiv) 3 • lovastatin tab 10 mg 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 52 lovastatin tab 20 mg (Mevacor) 1 lovastatin tab 40 mg (Mevacor) 1 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan) 1 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan) 1 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan) 1 PRALUENT - alirocumab subcutaneous soln peninjector 75 mg/ml 2 • • • PRALUENT - alirocumab subcutaneous soln peninjector 150 mg/ml 2 • • • pravastatin sodium tab 10 mg 1 pravastatin sodium tab 20 mg (Pravachol) pravastatin sodium tab 40 mg (Pravachol) pravastatin sodium tab 80 mg (Pravachol) rosuvastatin calcium tab 10 mg (Crestor) rosuvastatin calcium tab 20 mg (Crestor) rosuvastatin calcium tab 40 mg (Crestor) simvastatin tab 5 mg (Zocor) 1 1 1 REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml 2 • • • REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneous soln cartridge/ infusor 420 mg/3.5ml 2 • • • REPATHA SURECLICK evolocumab subcutaneous soln auto-injector 140 mg/ml 2 rosuvastatin calcium tab 5 mg (Crestor) 1 • • • 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 2017 1 1 1 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 VASCEPA - icosapent ethyl cap 2 0.5 gm VASCEPA - icosapent ethyl cap 2 1 gm 3 WELCHOL - colesevelam hcl packet for susp 3.75 gm 3 WELCHOL - colesevelam hcl tab 625 mg 3 ZETIA - ezetimibe tab 10 mg • CARDIOVASCULAR AGENTS - MISC. ADCIRCA - tadalafil tab 20 mg 2 • (pah) 3 • ADEMPAS - riociguat tab 0.5 mg ADEMPAS - riociguat tab 1 mg 3 • • • • • • • • • ADEMPAS - riociguat tab 1.5 mg 3 • • • ADEMPAS - riociguat tab 2 mg 3 ADEMPAS - riociguat tab 2.5 mg 3 • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 53 BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5 mg 3 CIALIS - tadalafil tab 2.5 mg 2 CIALIS - tadalafil tab 5 mg 2 CORLANOR - ivabradine hcl tab 5 mg (base equiv) 3 • • • CORLANOR - ivabradine hcl tab 7.5 mg (base equiv) 3 • • ENTRESTO - sacubitrilvalsartan tab 24-26 mg 3 • • ENTRESTO - sacubitrilvalsartan tab 49-51 mg 3 • • ENTRESTO - sacubitrilvalsartan tab 97-103 mg 3 • • LETAIRIS - ambrisentan tab 5 mg 3 • • • LETAIRIS - ambrisentan tab 10 mg 3 • • • OPSUMIT - macitentan tab 10 mg 2 • • • ORENITRAM - treprostinil diolamine tab cr 0.125 mg (base equiv) 3 • • • ORENITRAM - treprostinil diolamine tab cr 0.25 mg (base equiv) 3 • • • ORENITRAM - treprostinil diolamine tab cr 1 mg (base equiv) 3 • • • ORENITRAM - treprostinil diolamine tab cr 2.5 mg (base equiv) 3 • • • REVATIO - sildenafil citrate for suspension 10 mg/ml 3 • • • sildenafil citrate tab 20 mg (Revatio) 1 • • Limited Distribution • TRACLEER - bosentan tab 125 2 mg 3 TYVASO - treprostinil inhalation solution 0.6 mg/ml 3 TYVASO REFILL - treprostinil inhalation solution 0.6 mg/ml 3 TYVASO STARTER treprostinil inhalation solution 0.6 mg/ml 2 UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg (60) 2 UPTRAVI - selexipag tab 200 mcg 2 UPTRAVI - selexipag tab 400 mcg 2 UPTRAVI - selexipag tab 600 mcg 2 UPTRAVI - selexipag tab 800 mcg UPTRAVI - selexipag tab 1000 2 mcg UPTRAVI - selexipag tab 1200 2 mcg UPTRAVI - selexipag tab 1400 2 mcg UPTRAVI - selexipag tab 1600 2 mcg VENTAVIS - iloprost inhalation 3 solution 10 mcg/ml VENTAVIS - iloprost inhalation 3 solution 20 mcg/ml • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • ERECTILE DYSFUNCTION CIALIS - tadalafil tab 2.5 mg 2 CIALIS - tadalafil tab 5 mg 2 • ACA Dispensing Limits Step Therapy 2 TRACLEER - bosentan tab 62.5 mg • • • Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 54 RESPIRATORY AGENTS ANTIHISTAMINES carbinoxamine maleate soln 4 mg/5ml carbinoxamine maleate tab 4 mg 1 1 1 cyproheptadine hcl syrup 2 mg/5ml 1 1 DESLORATADINE ODT desloratadine tab orally disintegrating 2.5 mg 3 DESLORATADINE ODT desloratadine tab orally disintegrating 5 mg 3 desloratadine tab 5 mg (Clarinex) 1 KARBINAL ER - carbinoxamine 3 maleate extended release susp 4 mg/5ml 1 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal) 1 levocetirizine dihydrochloride tab 5 mg (Xyzal) 1 promethazine hcl suppos 12.5 mg 1 promethazine hcl suppos 25 mg 1 promethazine hcl suppos 50 mg 1 promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 25 mg promethazine hcl tab 50 mg Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Drug Name promethazine hcl tab 12.5 mg CLEMASTINE FUMARATE clemastine fumarate tab 2.68 mg cyproheptadine hcl tab 4 mg Prior Authorization Drug Name Drug Tier 2017 1 1 1 NASAL AGENTS - SYSTEMIC and TOPICAL 1 • azelastine hcl nasal spray 137 mcg/spray (1 mg/ml) 1 • azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro) 3 • BACTROBAN NASAL mupirocin calcium nasal oint 2% 1 • budesonide nasal susp 32 mcg/act (Rhinocort aqua) 1 • flunisolide nasal soln 25 mcg/act (0.025%) (Flunisolide) • fluticasone propionate nasal 1 susp 50 mcg/act (Flonase) 1 • ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent) 1 • ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent) 1 • mometasone furoate nasal susp 50 mcg/act (Nasonex) 1 • olopatadine hcl nasal soln 0.6% (Patanase) 3 • OMNARIS - ciclesonide nasal susp 50 mcg/act 1 • triamcinolone acetonide nasal aerosol suspension 55 mcg/act COUGH/COLD/ALLERGY Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 55 acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% 1 1 MAR-COF BP pseudoephedrinebromphen-codeine liqd 30-2-7.5 mg/5ml 3 BENZONATATE - benzonatate cap 150 mg 1 NINJACOF-XG - guaifenesincodeine liquid 200-8 mg/5ml 1 benzonatate cap 100 mg (Tessalon perles) 1 3 benzonatate cap 200 mg 1 PHENYLHISTINE DH pseudoephedrine-chlorphen w/ codeine liq 30-2-10 mg/5ml POLY-TUSSIN AC phenylephrine-bromphen w/ codeine liquid 10-4-10 mg/5ml 3 PRO-CLEAR AC - codeinepyrilamine syrup 9-8.33 mg/5ml 3 3 1 CAPCOF - phenylephrinechlorphen w/ codeine syrup 5-2-10 mg/5ml 3 guaifenesin-codeine liquid 225-7.5 mg/5ml 1 guaifenesin-codeine soln 100-6.3 mg/5ml 1 1 HISTEX-AC - phenylephrinetriprolidine-codeine syrup 10-2.5-10 mg/5ml 3 PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup 5-1-9 mg/5ml hydrocod polst-chlorphen polst er susp 10-8 mg/5ml (Tussionex pennkineti) 1 promethazine & phenylephrine syrup 6.25-5 mg/5ml hydrocodone w/ homatropine syrup 5-1.5 mg/5ml 1 guaifenesin-codeine soln 100-10 mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg promethazine w/ codeine syrup 6.25-10 mg/5ml 1 M-END MAX D pseudoephedrinedexbromphen-codeine liqd 20-0.667-6 mg/5ml 3 M-END PE - phenylephrinebromphen w/ codeine liqd 3.33-1.33-6.33 mg/5ml 3 promethazine-dm syrup 6.25-15 mg/5ml promethazinephenylephrine-codeine syrup 6.25-5-10 mg/5ml pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro) pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml pseudoephedrine w/ cod-gg soln 30-10-100 mg/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 2017 1 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 56 pseudoephedrinebromphen-codeine liq 10-1.33-6.33 mg/5ml 1 TUSNEL C - pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml 1 VITUZ - hydrocodonechlorpheniramine soln 5-4 mg/5ml 3 Z-TUSS AC - chlorpheniramine w/ codeine liquid 2-9 mg/5ml 3 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 ANTIASTHMATIC and BRONCHODILATOR AGENTS • ADVAIR DISKUS - fluticasone- 2 salmeterol aer powder ba 100-50 mcg/dose • ADVAIR DISKUS - fluticasone- 2 salmeterol aer powder ba 250-50 mcg/dose • ADVAIR DISKUS - fluticasone- 2 salmeterol aer powder ba 500-50 mcg/dose 2 • ADVAIR HFA - fluticasonesalmeterol inhal aerosol 45-21 mcg/act 2 • ADVAIR HFA - fluticasonesalmeterol inhal aerosol 115-21 mcg/act 2 • ADVAIR HFA - fluticasonesalmeterol inhal aerosol 230-21 mcg/act 1 • albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 • albuterol sulfate soln nebu 0.5% (5 mg/ml) 1 • albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1 • albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) 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 2017 1 1 1 1 1 ANORO ELLIPTA umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh 2 • ARCAPTA NEOHALER indacaterol maleate inhal powder cap 75 mcg (base equiv) 3 • ARNUITY ELLIPTA fluticasone furoate aerosol powder breath activ 100 mcg/act 2 • ARNUITY ELLIPTA fluticasone furoate aerosol powder breath activ 200 mcg/act 2 • ASMANEX HFA - mometasone furoate inhal aerosol suspension 100 mcg/act 2 • ASMANEX HFA - mometasone furoate inhal aerosol suspension 200 mcg/act 2 • ASMANEX TWISTHALER 120 ME - mometasone furoate inhal powd 220 mcg/inh (breath activated) 2 • ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd 110 mcg/inh (breath activated) 2 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 57 2 ASMANEX TWISTHALER 60 MET - mometasone furoate inhal powd 220 mcg/inh (breath activated) 2 ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act 3 • BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh 2 • BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh 2 • BROVANA - arformoterol tartrate soln nebu 15 mcg/2ml (base equiv) 3 budesonide inhalation susp 0.25 mg/2ml (Pulmicort) 1 • 1 • budesonide inhalation susp 0.5 mg/2ml (Pulmicort) • 1 • COMBIVENT RESPIMAT ipratropium-albuterol inhal aerosol soln 20-100 mcg/act 3 • CROMOLYN SODIUM cromolyn sodium soln nebu 20 mg/2ml 3 budesonide inhalation susp 1 mg/2ml (Pulmicort) DALIRESP - roflumilast tab 500 3 mcg 2 DULERA - mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act • • 2 ELIXOPHYLLIN - theophylline elixir 80 mg/15ml 3 FLOVENT DISKUS fluticasone propionate aer pow ba 50 mcg/blister 2 • FLOVENT DISKUS fluticasone propionate aer pow ba 100 mcg/blister 2 • FLOVENT DISKUS fluticasone propionate aer pow ba 250 mcg/blister 2 • FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act (50/valve) 2 • FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act (125/valve) 2 • FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act (250/valve) 2 • INCRUSE ELLIPTA umeclidinium br aero powd breath act 62.5 mcg/inh (base eq) 2 • ipratropium bromide inhal soln 0.02% 1 • 1 • 1 • 1 • ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex) Limited Distribution • DULERA - mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Limited Distribution • ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd 220 mcg/inh (breath activated) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 58 2 • SPIRIVA HANDIHALER tiotropium bromide monohydrate inhal cap 18 mcg (base equiv) 2 • 3 SPIRIVA RESPIMAT tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act 2 • METAPROTERENOL SULFATE - metaproterenol sulfate tab 20 mg 3 montelukast sodium chew tab 4 mg (base equiv) (Singulair) 1 SPIRIVA RESPIMAT tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act 2 • montelukast sodium chew tab 5 mg (base equiv) (Singulair) 1 STIOLTO RESPIMAT tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act 2 • montelukast sodium tab 10 mg (base equiv) (Singulair) 1 STRIVERDI RESPIMAT olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv) 2 • NUCALA - mepolizumab for inj 100 mg 3 PERFOROMIST - formoterol fumarate soln nebu 20 mcg/2ml 3 SYMBICORT - budesonideformoterol fumarate dihyd aerosol 80-4.5 mcg/act 2 • • SYMBICORT - budesonideformoterol fumarate dihyd aerosol 160-4.5 mcg/act 2 • • terbutaline sulfate tab 2.5 mg 1 • • terbutaline sulfate tab 5 mg • • Limited Distribution METAPROTERENOL SULFATE - metaproterenol sulfate syrup 10 mg/5ml PROAIR HFA - albuterol sulfate 2 inhal aero 108 mcg/act (90mcg base equiv) 2 PROAIR RESPICLICK albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv) 2 QVAR - beclomethasone diprop inhal aero soln 40 mcg/act (50/valve) 2 QVAR - beclomethasone diprop inhal aero soln 80 mcg/act (100/valve) SEREVENT DISKUS salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv) ACA • Dispensing Limits 1 Step Therapy levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex) Prior Authorization • Drug Name Drug Tier 1 Limited Distribution levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 THEO-24 - theophylline cap sr 24hr 100 mg 3 THEO-24 - theophylline cap sr 24hr 200 mg 3 THEO-24 - theophylline cap sr 24hr 300 mg 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 59 THEO-24 - theophylline cap sr 24hr 400 mg 3 theophylline soln 80 mg/15ml 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 2017 3 1 INFASURF - calfactant in nacl 0.9% intratracheal susp 35 mg/ml 2 • • • 1 KALYDECO - ivacaftor packet 50 mg 2 • • • 1 KALYDECO - ivacaftor packet 75 mg 2 • • • 1 KALYDECO - ivacaftor tab 150 mg 3 • • • 1 OFEV - nintedanib esylate cap 100 mg (base equivalent) 3 • • • 1 OFEV - nintedanib esylate cap 150 mg (base equivalent) 3 • • • 1 ORKAMBI - lumacaftorivacaftor tab 100-125 mg 3 • • • VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/ act (90mcg base equiv) 2 ORKAMBI - lumacaftorivacaftor tab 200-125 mg PULMOZYME - dornase alfa inhal soln 1 mg/ml 2 • zafirlukast tab 10 mg (Accolate) 1 3 zafirlukast tab 20 mg (Accolate) 1 SURVANTA INTRATRACHEAL beractant in nacl 0.9% intratracheal susp 25 mg/ml zileuton tab sr 12hr 600 mg (Zyflo cr) 1 ZYFLO - zileuton tab 600 mg 3 ZYFLO CR - zileuton tab sr 12hr 600 mg 3 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 RESPIRATORY AGENTS - MISC. 3 CUROSURF - poractant alfa intratracheal susp 120 mg/1.5ml 3 CUROSURF - poractant alfa intratracheal susp 240 mg/3ml ESBRIET - pirfenidone cap 267 3 mg • • • • • • • • • • GASTROINTESTINAL AGENTS LAXATIVES bisacodyl tab & peg 3350kcl-sod bicarb-nacl for soln kit • 1 GIALAX - polyethylene glycol 3350 - kit 3 GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm 3 KRISTALOSE - lactulose oral crystal packet 10 gm 3 KRISTALOSE - lactulose oral crystal packet 20 gm 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 60 1 MYTESI - crofelemer tab delayed release 125 mg MOVIPREP - peg 3350-kclnacl-na sulfate-na acorbatec for soln 100 gm 3 ULCER DRUGS OSMOPREP - sod phos mono-sod phos di tabs 1.102-0.398 gm(1.5gm na phos) 3 PCP 100 - mag citbisacodyl-petrolat-pegmetoclopramide-electrol kit 3 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 1 lactulose solution 10 gm/15ml polyethylene glycol 3350 oral powder PREPOPIK - sod picosulfatemg oxide-citric acid pack 10 mg-3.5 gm-12 gm 3 SUPREP BOWEL PREP KIT sodium sulfate-potassium sulfate-magnesium sulfate oral soln 3 ANTIDIARRHEALS diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) DIPHENOXYLATE/ ATROPINE - diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml 3 cimetidine hcl soln 300 mg/5ml 1 cimetidine tab 400 mg cimetidine tab 800 mg 1 1 3 Limited Distribution ACA Dispensing Limits Step Therapy 3 CARAFATE - sucralfate susp 1 gm/10ml cimetidine tab 300 mg Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 CUVPOSA - glycopyrrolate oral 3 soln 1 mg/5ml 3 DEXILANT - dexlansoprazole cap delayed release 30 mg 3 DEXILANT - dexlansoprazole cap delayed release 60 mg 1 dicyclomine hcl cap 10 mg (Bentyl) 1 dicyclomine hcl oral soln 10 mg/5ml 1 dicyclomine hcl tab 20 mg (Bentyl) 1 esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium) 1 esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium) 1 famotidine for susp 40 mg/5ml (Pepcid) 1 famotidine tab 40 mg (Pepcid) 1 glycopyrrolate tab 1 mg (Robinul) 1 glycopyrrolate tab 2 mg (Robinul forte) • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 61 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) 1 1 1 • pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) 1 • PROPANTHELINE BROMIDE - 3 propantheline bromide tab 15 mg 1 rabeprazole sodium ec tab 20 mg (Aciphex) 1 ranitidine hcl cap 150 mg • misoprostol tab 100 mcg (Cytotec) 1 misoprostol tab 200 mcg (Cytotec) 1 NEXIUM - esomeprazole magnesium for delayed release susp packet 5 mg 3 NEXIUM - esomeprazole magnesium for delayed release susp packet 10 mg 3 • NEXIUM - esomeprazole magnesium for delayed release susp packet 20 mg 3 • NEXIUM - esomeprazole magnesium for delayed release susp packet 40 mg 3 • AKYNZEO - netupitantpalonosetron cap 300-0.5 mg 3 • NEXIUM - esomeprazole magnesium for delayed release susp pack 2.5 mg 3 • ANZEMET - dolasetron mesylate tab 50 mg 3 • 3 • NIZATIDINE - nizatidine oral soln 15 mg/ml 3 ANZEMET - dolasetron mesylate tab 100 mg 1 • nizatidine cap 150 mg 1 aprepitant capsule therapy pack 80 & 125 mg (Emend) aprepitant capsule 80 mg (Emend) 1 • CESAMET - nabilone cap 1 mg 3 DICLEGIS - doxylaminepyridoxine tab delayed release 10-10 mg 3 dronabinol cap 2.5 mg (Marinol) 1 nizatidine cap 300 mg (Axid) omeprazole cap delayed release 10 mg (Prilosec) omeprazole cap delayed release 20 mg (Prilosec) omeprazole cap delayed release 40 mg (Prilosec) • ranitidine hcl cap 300 mg ranitidine hcl syrup 15 mg/ ml (75 mg/5ml) 1 1 • 1 • 1 • 1 1 ranitidine hcl tab 300 mg (Zantac) 1 sucralfate tab 1 gm (Carafate) 1 ANTIEMETICS Limited Distribution pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) ACA Dispensing Limits Step Therapy • Prior Authorization 1 Drug Name Drug Tier • Limited Distribution 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 62 2 • EMEND - aprepitant capsule 40 mg 2 • EMEND - aprepitant capsule 80 mg 2 • EMEND - aprepitant capsule 125 mg 2 • EMEND - aprepitant for oral susp 125 mg (125 mg/5ml) 2 • granisetron hcl tab 1 mg 1 1 • • ondansetron hcl tab 4 mg (Zofran) 1 • ondansetron hcl tab 8 mg (Zofran) 1 • ondansetron hcl tab 24 mg 1 ondansetron hcl oral soln 4 mg/5ml (Zofran) ondansetron orally disintegrating tab 4 mg (Zofran odt) 1 • • ondansetron orally disintegrating tab 8 mg (Zofran odt) 1 • TRANSDERM-SCOP scopolamine td patch 72hr 1.5 mg 3 trimethobenzamide hcl cap 300 mg (Tigan) 1 VARUBI - rolapitant hcl tab 90 mg (base equiv) DIGESTIVE AIDS 3 • • 2 CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit 2 CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit 2 CREON - pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit 2 PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 2600-6200-10850 unit 3 PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 4200-14200-24600 unit 3 PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 10500-35500-61500 unit 3 PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 16800-56800-98400 unit 3 PANCREAZE - pancrelipase (lip-prot-amyl) dr cap 21000-54700-83900 unit 3 PERTZYE - pancrelipase (lip-prot-amyl) dr cap 4000-14375-15125 unit 3 PERTZYE - pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit 3 PERTZYE - pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit 3 Limited Distribution EMEND - aprepitant capsule therapy pack 80 & 125 mg CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit ACA • Dispensing Limits 1 2 Step Therapy dronabinol cap 10 mg (Marinol) CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit Prior Authorization • Drug Name Drug Tier 1 Limited Distribution dronabinol cap 5 mg (Marinol) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 63 1 Limited Distribution ACA VIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit 3 VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit 3 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo) 2 calcium acetate (phosphate binder) tab 667 mg (Eliphos) 1 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit CANASA - mesalamine suppos 1000 mg 2 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit 2 2 • • ZENPEP - pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit 2 CHENODAL - chenodiol tab 250 mg CHOLBAM - cholic acid cap 50 mg 3 • • ZENPEP - pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit 2 CHOLBAM - cholic acid cap 250 mg 3 • • • • • ZENPEP - pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit 2 • • • ZENPEP - pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit 2 ZENPEP - pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit 2 CIMZIA - certolizumab pegol inj 3 kit 2 x 200 mg/ml 3 CIMZIA STARTER KIT certolizumab pegol inj kit 6 x 200 mg/ml 1 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) 3 DELZICOL - mesalamine cap dr 400 mg 3 DIPENTUM - olsalazine sodium cap 250 mg ENTEREG - alvimopan cap 12 3 mg 3 FOSRENOL - lanthanum carbonate chew tab 500 mg (elemental) 3 FOSRENOL - lanthanum carbonate chew tab 750 mg (elemental) • balsalazide disodium cap 750 mg (Colazal) Dispensing Limits 3 • 3 Step Therapy SUCRAID - sacrosidase soln 8500 unit/ml GASTROINTESTINAL AGENTS- MISC. 1 alosetron hcl tab 0.5 mg (base equiv) (Lotronex) alosetron hcl tab 1 mg (base 1 equiv) (Lotronex) 3 APRISO - mesalamine cap sr 24hr 0.375 gm ASACOL HD - mesalamine tab 3 delayed release 800 mg AURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) Prior Authorization • Drug Name Drug Tier Limited Distribution ACA Dispensing Limits • Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 64 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 2017 FOSRENOL - lanthanum carbonate chew tab 1000 mg (elemental) 3 METOCLOPRAMIDE ODT metoclopramide hcl orally disintegrating tab 10 mg 3 FOSRENOL - lanthanum carbonate oral powder pack 750 mg (elemental) 3 MOVANTIK - naloxegol oxalate tab 12.5 mg (base equivalent) 2 • FOSRENOL - lanthanum carbonate oral powder pack 1000 mg (elemental) 3 MOVANTIK - naloxegol oxalate tab 25 mg (base equivalent) 2 • 3 OCALIVA - obeticholic acid tab 5 mg 3 GATTEX - teduglutide (rdna) for inj kit 5 mg • • • OCALIVA - obeticholic acid tab 10 mg 3 GIAZO - balsalazide disodium tab 1.1 gm 3 • • • PENTASA - mesalamine cap cr 250 mg 3 lactulose (encephalopathy) solution 10 gm/15ml 1 PENTASA - mesalamine cap cr 500 mg 3 LIALDA - mesalamine tab delayed release 1.2 gm 3 2 PHOSLYRA - calcium acetate (phosphate binder) oral soln 667 mg/5ml 3 LINZESS - linaclotide cap 72 mcg LINZESS - linaclotide cap 145 mcg 2 RENAGEL - sevelamer hcl tab 400 mg 3 LINZESS - linaclotide cap 290 mcg 2 RENAGEL - sevelamer hcl tab 800 mg 3 MESALAMINE DR mesalamine tab delayed release 800 mg 3 RENVELA - sevelamer carbonate packet 0.8 gm 2 1 RENVELA - sevelamer carbonate packet 2.4 gm 2 mesalamine enema 4 gm 1 RENVELA - sevelamer carbonate tab 800 mg 2 1 SFROWASA - mesalamine sulfite-free (sf) enema 4 gm/60ml 3 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) 1 sulfasalazine tab 500 mg (Azulfidine) 1 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg (Reglan) metoclopramide hcl tab 10 mg (Reglan) METOCLOPRAMIDE ODT metoclopramide hcl orally disintegrating tab 5 mg 1 1 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 65 ursodiol cap 300 mg (Actigall) 1 ursodiol tab 250 mg (Urso 250) 1 ursodiol tab 500 mg (Urso forte) 1 VELPHORO - sucroferric oxyhydroxide chew tab 500 mg 2 VIBERZI - eluxadoline tab 75 mg 3 • VIBERZI - eluxadoline tab 100 mg 3 • GENITOURINARY AGENTS URINARY ANTI-INFECTIVES methenamine hippurate tab 1 gm (Hiprex) 1 MONUROL - fosfomycin tromethamine powd pack 3 gm (base equivalent) 3 nitrofurantoin macrocrystalline cap 25 mg (Macrodantin) 1 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) nitrofurantoin macrocrystalline cap 100 mg (Macrodantin) nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid) nitrofurantoin susp 25 mg/5ml (Furadantin) URINARY ANTISPASMODICS bethanechol chloride tab 5 mg (Urecholine) 1 1 1 1 1 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) 1 flavoxate hcl tab 100 mg 1 MYRBETRIQ - mirabegron tab sr 24 hr 25 mg 2 MYRBETRIQ - mirabegron tab sr 24 hr 50 mg 2 oxybutynin chloride syrup 5 mg/5ml 1 tolterodine tartrate cap sr 24hr 2 mg (Detrol la) tolterodine tartrate cap sr 24hr 4 mg (Detrol la) Limited Distribution 1 3 oxybutynin chloride tab 5 mg ACA 1 ENABLEX - darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl) Dispensing Limits 1 3 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) Step Therapy 1 ENABLEX - darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 66 tolterodine tartrate tab 1 mg (Detrol) 1 tolterodine tartrate tab 2 mg (Detrol) 3 1 GYNAZOLE-1 - butoconazole nitrate (one dose) vaginal cream 2% 1 TOVIAZ - fesoterodine fumarate tab sr 24hr 4 mg 3 metronidazole vaginal gel 0.75% (Metrogel-vaginal) TOVIAZ - fesoterodine fumarate tab sr 24hr 8 mg trospium chloride cap sr 24hr 60 mg trospium chloride tab 20 mg 3 3 MICONAZOLE 3 - miconazole nitrate vaginal suppos 200 mg 1 NUVESSA - metronidazole vaginal gel 1.3% 3 1 PREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3 terconazole vaginal cream 0.4% (Terazol 7) 1 VESICARE - solifenacin succinate tab 5 mg 2 VESICARE - solifenacin succinate tab 10 mg 2 VAGINAL PRODUCTS AVC - sulfanilamide vaginal cream 15% 3 CLEOCIN - clindamycin phosphate vaginal suppos 100 mg 3 clindamycin phosphate vaginal cream 2% (Cleocin) 1 CLINDESSE - clindamycin phosphate (one dose) vaginal cream 2% 3 ESTRACE - estradiol vaginal cream 0.1 mg/gm 2 estradiol vaginal tab 10 mcg (Vagifem) 1 ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs) 3 FEMRING - estradiol acetate vaginal ring 0.05 mg/24hr 3 FEMRING - estradiol acetate vaginal ring 0.1 mg/24hr 3 terconazole vaginal cream 0.8% (Terazol 3) terconazole vaginal suppos 80 mg VAGIFEM - estradiol vaginal tab 10 mcg 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 2017 1 1 2 GENITOURINARY AGENTS - MISC. 1 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral) 2 CYSTAGON - cysteamine bitartrate cap 50 mg 2 CYSTAGON - cysteamine bitartrate cap 150 mg 1 dutasteride cap 0.5 mg (Avodart) 1 dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn) 3 ELMIRON - pentosan polysulfate sodium caps 100 mg 1 finasteride tab 5 mg (Proscar) • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 67 LITHOSTAT - acetohydroxamic acid tab 250 mg 3 alprazolam tab sr 24hr 2 mg (Xanax xr) 1 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5) 1 alprazolam tab sr 24hr 3 mg (Xanax xr) 1 alprazolam tab 0.25 mg (Xanax) 1 alprazolam tab 0.5 mg (Xanax) 1 alprazolam tab 1 mg (Xanax) 1 1 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10) 1 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15) 3 PROCYSBI - cysteamine bitartrate cap delayed release 25 mg (base equiv) 3 PROCYSBI - cysteamine bitartrate cap delayed release 75 mg (base equiv) RAPAFLO - silodosin cap 4 mg 3 RAPAFLO - silodosin cap 8 mg 3 tamsulosin hcl cap 0.4 mg (Flomax) 1 THIOLA - tiopronin tab 100 mg 3 • alprazolam tab 2 mg (Xanax) • CENTRAL NERVOUS SYSTEM DRUGS ANTIANXIETY AGENTS • • buspirone hcl tab 5 mg 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 1 1 1 1 1 alprazolam orally disintegrating tab 0.5 mg 1 clorazepate dipotassium tab 15 mg (Tranxene t) 1 DIAZEPAM - diazepam oral soln 1 mg/ml 3 1 diazepam conc 5 mg/ml 1 alprazolam tab sr 24hr 0.5 mg (Xanax xr) alprazolam tab sr 24hr 1 mg (Xanax xr) 1 1 diazepam tab 2 mg (Valium) diazepam tab 5 mg (Valium) diazepam tab 10 mg (Valium) hydroxyzine hcl syrup 10 mg/5ml hydroxyzine hcl tab 10 mg Limited Distribution 1 1 alprazolam orally disintegrating tab 2 mg ACA 1 alprazolam orally disintegrating tab 0.25 mg (Niravam) alprazolam orally disintegrating tab 1 mg Dispensing Limits 1 3 clorazepate dipotassium tab 7.5 mg (Tranxene t) Step Therapy 1 ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml clorazepate dipotassium tab 3.75 mg (Tranxene t) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 68 hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg 1 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr) 1 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr) hydroxyzine pamoate cap 25 mg (Vistaril) 1 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr) 1 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl) lorazepam conc 2 mg/ml (Lorazepam intensol) 1 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl) 1 lorazepam tab 0.5 mg (Ativan) 1 bupropion hcl tab 75 mg (Wellbutrin) 1 lorazepam tab 1 mg (Ativan) 1 bupropion hcl tab 100 mg (Wellbutrin) citalopram hydrobromide oral soln 10 mg/5ml 1 lorazepam tab 2 mg (Ativan) meprobamate tab 200 mg meprobamate tab 400 mg oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg ANTIDEPRESSANTS amitriptyline hcl tab 10 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg 1 1 1 1 1 1 1 1 1 1 1 1 • • Limited Distribution ACA Dispensing Limits 1 3 • Step Therapy 1 HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg hydroxyzine pamoate cap 50 mg (Vistaril) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 citalopram hydrobromide tab 10 mg (base equiv) (Celexa) 1 citalopram hydrobromide tab 20 mg (base equiv) (Celexa) 1 citalopram hydrobromide tab 40 mg (base equiv) (Celexa) 1 clomipramine hcl cap 25 mg (Anafranil) 1 clomipramine hcl cap 50 mg (Anafranil) 1 AMOXAPINE - amoxapine tab 25 mg 3 clomipramine hcl cap 75 mg (Anafranil) 1 AMOXAPINE - amoxapine tab 50 mg 3 desipramine hcl tab 10 mg (Norpramin) 1 AMOXAPINE - amoxapine tab 100 mg 3 desipramine hcl tab 25 mg (Norpramin) 1 AMOXAPINE - amoxapine tab 150 mg 3 desipramine hcl tab 50 mg (Norpramin) 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 69 desipramine hcl tab 75 mg (Norpramin) 1 EMSAM - selegiline td patch 24hr 9 mg/24hr 3 desipramine hcl tab 100 mg (Norpramin) 1 EMSAM - selegiline td patch 24hr 12 mg/24hr 3 desipramine hcl tab 150 mg (Norpramin) 1 1 desvenlafaxine succinate tab sr 24hr 25 mg (base equiv) (Pristiq) 1 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro) escitalopram oxalate tab 5 mg (base equiv) (Lexapro) 1 escitalopram oxalate tab 10 mg (base equiv) (Lexapro) 1 escitalopram oxalate tab 20 mg (base equiv) (Lexapro) 1 FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg 1 fluoxetine hcl cap 10 mg (Prozac) 1 fluoxetine hcl cap 20 mg (Prozac) 1 • • fluoxetine hcl cap 40 mg (Prozac) 1 1 • fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg desvenlafaxine succinate tab sr 24hr 50 mg (base equiv) (Pristiq) desvenlafaxine succinate tab sr 24hr 100 mg (base equiv) (Pristiq) 1 1 DOXEPIN HCL - doxepin hcl cap 75 mg 3 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 1 1 1 1 DULOXETINE HCL duloxetine hcl enteric coated pellets cap 40 mg 3 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta) 1 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta) 1 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta) 1 EMSAM - selegiline td patch 24hr 6 mg/24hr 3 fluoxetine hcl tab 20 mg • • fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg imipramine hcl tab 10 mg (Tofranil) 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 2017 • • 1 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 70 imipramine hcl tab 25 mg (Tofranil) 1 NEFAZODONE HCL nefazodone hcl tab 150 mg 3 imipramine hcl tab 50 mg (Tofranil) 1 NEFAZODONE HCL nefazodone hcl tab 200 mg 3 imipramine pamoate cap 75 mg (Tofranil-pm) 1 nefazodone hcl tab 50 mg 1 imipramine pamoate cap 100 mg (Tofranil-pm) nefazodone hcl tab 250 mg 1 3 1 1 nortriptyline hcl cap 10 mg (Pamelor) 1 • nortriptyline hcl cap 25 mg (Pamelor) 1 MAPROTILINE HCL maprotiline hcl tab 25 mg 3 • nortriptyline hcl cap 50 mg (Pamelor) 1 MAPROTILINE HCL maprotiline hcl tab 50 mg 3 3 • nortriptyline hcl cap 75 mg (Pamelor) 1 MAPROTILINE HCL maprotiline hcl tab 75 mg paroxetine hcl tab sr 24hr 25 mg (Paxil cr) 1 MARPLAN - isocarboxazid tab 10 mg 3 paroxetine hcl tab 10 mg (Paxil) 1 mirtazapine orally disintegrating tab 15 mg (Remeron soltab) 1 1 mirtazapine orally disintegrating tab 30 mg (Remeron soltab) 1 paroxetine hcl tab 20 mg (Paxil) paroxetine hcl tab 30 mg (Paxil) 1 mirtazapine orally disintegrating tab 45 mg (Remeron soltab) 1 paroxetine hcl tab 40 mg (Paxil) 1 1 mirtazapine tab 7.5 mg 1 phenelzine sulfate tab 15 mg (Nardil) PRISTIQ - desvenlafaxine succinate tab sr 24hr 25 mg (base equiv) 3 • • PRISTIQ - desvenlafaxine succinate tab sr 24hr 50 mg (base equiv) 3 • • PRISTIQ - desvenlafaxine succinate tab sr 24hr 100 mg (base equiv) 3 • • imipramine pamoate cap 150 mg (Tofranil-pm) mirtazapine tab 15 mg (Remeron) 1 mirtazapine tab 30 mg (Remeron) 1 mirtazapine tab 45 mg (Remeron) 1 NEFAZODONE HCL nefazodone hcl tab 100 mg 3 Limited Distribution 1 NORTRIPTYLINE HCL nortriptyline hcl soln 10 mg/5ml imipramine pamoate cap 125 mg (Tofranil-pm) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 71 protriptyline hcl tab 5 mg (Vivactil) 1 protriptyline hcl tab 10 mg (Vivactil) 1 sertraline hcl oral conc 20 mg/ml (Zoloft) venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er) 1 1 1 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er) sertraline hcl tab 25 mg (Zoloft) 1 venlafaxine hcl tab 25 mg 1 sertraline hcl tab 50 mg (Zoloft) 1 sertraline hcl tab 100 mg (Zoloft) 1 SURMONTIL - trimipramine maleate cap 25 mg 3 VIIBRYD - vilazodone hcl tab 10 mg 3 • SURMONTIL - trimipramine maleate cap 50 mg 3 VIIBRYD - vilazodone hcl tab 20 mg 3 • SURMONTIL - trimipramine maleate cap 100 mg 3 VIIBRYD - vilazodone hcl tab 40 mg 3 • tranylcypromine sulfate tab 10 mg (Parnate) 1 VIIBRYD STARTER PACK vilazodone hcl tab starter kit 10 (7) & 20 (23) mg 3 • trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg 1 1 1 1 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) 1 venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab 100 mg ANTIPSYCHOTICS 1 1 1 3 aripiprazole oral solution 1 mg/ml 1 • 1 • 1 • 1 aripiprazole orally disintegrating tab 15 mg aripiprazole tab 10 mg (Abilify) 1 • • • aripiprazole tab 15 mg (Abilify) 1 • aripiprazole tab 2 mg (Abilify) aripiprazole tab 5 mg (Abilify) Limited Distribution 1 ADASUVE - loxapine aerosol powder breath activated 10 mg aripiprazole orally disintegrating tab 10 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 2017 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 72 3 FANAPT - iloperidone tab 4 mg 3 FANAPT - iloperidone tab 6 mg 3 FANAPT - iloperidone tab 8 mg 3 FANAPT - iloperidone tab 10 mg 3 • • • • • • • • FANAPT - iloperidone tab 12 mg 3 • • 3 • • • • FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak FAZACLO - clozapine orally disintegrating tab 12.5 mg 3 • • FAZACLO - clozapine orally disintegrating tab 150 mg 3 • • FAZACLO - clozapine orally disintegrating tab 200 mg 3 • • • FLUPHENAZINE HCL fluphenazine hcl elixir 2.5 mg/5ml 2 FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/ml 2 fluphenazine hcl tab 1 mg 1 • chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg 1 1 1 CLOZAPINE ODT - clozapine orally disintegrating tab 12.5 mg 3 CLOZAPINE ODT - clozapine orally disintegrating tab 150 mg 3 CLOZAPINE ODT - clozapine orally disintegrating tab 200 mg 3 • • clozapine orally disintegrating tab 25 mg (Fazaclo) 1 • clozapine orally disintegrating tab 100 mg (Fazaclo) 1 clozapine tab 25 mg (Clozaril) 1 • clozapine tab 50 mg 1 • • clozapine tab 100 mg (Clozaril) 1 clozapine tab 200 mg 1 EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 100 mg 3 • 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 Limited Distribution Dispensing Limits FANAPT - iloperidone tab 2 mg • • • • • • 1 ACA Step Therapy 3 aripiprazole tab 30 mg (Abilify) chlorpromazine hcl tab 50 mg Prior Authorization FANAPT - iloperidone tab 1 mg • Drug Name Drug Tier 1 1 chlorpromazine hcl tab 25 mg Limited Distribution 3 1 EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 300 mg aripiprazole tab 20 mg (Abilify) ACA Dispensing Limits 3 Step Therapy EQUETRO - carbamazepine (antipsychotic) cap sr 12hr 200 mg Drug Tier Drug Name Prior Authorization 2017 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 73 haloperidol tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg haloperidol tab 20 mg 1 loxapine succinate cap 25 mg 1 1 1 1 loxapine succinate cap 50 mg • • MOLINDONE HYDROCHLORIDE molindone hcl tab 5 mg 3 MOLINDONE HYDROCHLORIDE molindone hcl tab 10 mg 3 MOLINDONE HYDROCHLORIDE molindone hcl tab 25 mg 3 NUPLAZID - pimavanserin tartrate tab 17 mg (base equivalent) 3 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) 1 • olanzapine orally disintegrating tab 10 mg (Zyprexa zydis) 1 • olanzapine orally disintegrating tab 15 mg (Zyprexa zydis) 1 • olanzapine orally disintegrating tab 20 mg (Zyprexa zydis) 1 • olanzapine tab 2.5 mg (Zyprexa) 1 • olanzapine tab 5 mg (Zyprexa) 1 • olanzapine tab 7.5 mg (Zyprexa) 1 • olanzapine tab 10 mg (Zyprexa) 1 • • • • • Limited Distribution 1 • • • • ACA Dispensing Limits Step Therapy Prior Authorization Drug Tier Limited Distribution loxapine succinate cap 10 mg 1 LATUDA - lurasidone hcl tab 20 3 mg LATUDA - lurasidone hcl tab 40 3 mg LATUDA - lurasidone hcl tab 60 3 mg LATUDA - lurasidone hcl tab 80 3 mg 3 LATUDA - lurasidone hcl tab 120 mg LITHIUM - lithium oral solution 3 8 meq/5ml 3 LITHIUM CARBONATE lithium carbonate cap 150 mg 3 LITHIUM CARBONATE lithium carbonate cap 600 mg 1 lithium carbonate cap 150 mg (Lithium carbonate) 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg (Lithium carbonate) 1 lithium carbonate tab cr 300 mg (Lithobid) 1 lithium carbonate tab cr 450 mg 1 lithium carbonate tab 300 mg 3 LITHOBID - lithium carbonate tab cr 300 mg Drug Name loxapine succinate cap 5 mg 1 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 74 1 • 1 • 1 • 1 • 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 perphenazine tab 16 mg prochlorperazine maleate tab 5 mg (Compazine) prochlorperazine maleate tab 10 mg (Compazine) prochlorperazine suppos 25 mg • 1 • 1 • 1 • 1 • REXULTI - brexpiprazole tab 0.25 mg 3 • • REXULTI - brexpiprazole tab 0.5 mg 3 • • REXULTI - brexpiprazole tab 1 mg 3 • • 1 REXULTI - brexpiprazole tab 2 mg 3 • • 1 REXULTI - brexpiprazole tab 3 mg 3 • • 1 REXULTI - brexpiprazole tab 4 mg 3 • • • • risperidone orally disintegrating tab 0.25 mg 1 • 1 • • • risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) 1 • • • risperidone orally disintegrating tab 1 mg (Risperdal m-tab) 1 • • • risperidone orally disintegrating tab 2 mg (Risperdal m-tab) 1 • • risperidone orally disintegrating tab 3 mg (Risperdal m-tab) 1 1 1 1 QUETIAPINE FUMARATE ER - 3 quetiapine fumarate tab sr 24hr 50 mg QUETIAPINE FUMARATE ER - 3 quetiapine fumarate tab sr 24hr 150 mg QUETIAPINE FUMARATE ER - 3 quetiapine fumarate tab sr 24hr 200 mg QUETIAPINE FUMARATE ER - 3 quetiapine fumarate tab sr 24hr 300 mg 1 quetiapine fumarate tab sr 24hr 400 mg (Seroquel xr) 1 quetiapine fumarate tab 25 mg (Seroquel) quetiapine fumarate tab 100 mg (Seroquel) quetiapine fumarate tab 200 mg (Seroquel) quetiapine fumarate tab 300 mg (Seroquel) quetiapine fumarate tab 400 mg (Seroquel) Limited Distribution paliperidone tab sr 24hr 1.5 mg (Invega) paliperidone tab sr 24hr 3 mg (Invega) 1 quetiapine fumarate tab 50 mg (Seroquel) ACA • Dispensing Limits 1 Step Therapy olanzapine tab 20 mg (Zyprexa) Prior Authorization • Drug Name Drug Tier 1 Limited Distribution olanzapine tab 15 mg (Zyprexa) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 75 risperidone orally disintegrating tab 4 mg (Risperdal m-tab) 1 risperidone soln 1 mg/ml (Risperdal) 1 • thiothixene cap 5 mg risperidone tab 0.25 mg (Risperdal) 1 • trifluoperazine hcl tab 1 mg risperidone tab 0.5 mg (Risperdal) 1 • trifluoperazine hcl tab 5 mg risperidone tab 1 mg (Risperdal) 1 • risperidone tab 2 mg (Risperdal) 1 • risperidone tab 3 mg (Risperdal) 1 • risperidone tab 4 mg (Risperdal) 1 • SAPHRIS - asenapine maleate sl tab 2.5 mg (base equiv) 3 • • SAPHRIS - asenapine maleate sl tab 5 mg (base equiv) 3 • • SAPHRIS - asenapine maleate sl tab 10 mg (base equiv) 3 • • DORAL - quazepam tab 15 mg 3 1 SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg 2 • • estazolam tab 1 mg estazolam tab 2 mg SEROQUEL XR - quetiapine fumarate tab sr 24hr 150 mg 2 SEROQUEL XR - quetiapine fumarate tab sr 24hr 200 mg 2 SEROQUEL XR - quetiapine fumarate tab sr 24hr 300 mg 2 SEROQUEL XR - quetiapine fumarate tab sr 24hr 400 mg 2 thioridazine hcl tab 10 mg 1 thioridazine hcl tab 25 mg thioridazine hcl tab 50 mg thioridazine hcl tab 100 mg thiothixene cap 1 mg thiothixene cap 2 mg 1 1 1 • • • • • • • • thiothixene cap 10 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 10 mg Limited Distribution 1 1 1 1 1 1 1 1 VERSACLOZ - clozapine susp 50 mg/ml 3 • • ziprasidone hcl cap 20 mg (Geodon) 1 • ziprasidone hcl cap 40 mg (Geodon) 1 • ziprasidone hcl cap 60 mg (Geodon) 1 • ziprasidone hcl cap 80 mg (Geodon) 1 • HYPNOTICS ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 eszopiclone tab 1 mg (Lunesta) 1 • eszopiclone tab 2 mg (Lunesta) 1 • eszopiclone tab 3 mg (Lunesta) 1 • FLURAZEPAM HCL flurazepam hcl cap 15 mg 3 FLURAZEPAM HCL flurazepam hcl cap 30 mg 3 HETLIOZ - tasimelteon capsule 3 20 mg 3 PHENOBARBITAL phenobarbital tab 15 mg • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 76 PHENOBARBITAL phenobarbital tab 30 mg 3 zolpidem tartrate tab 10 mg (Ambien) PHENOBARBITAL phenobarbital tab 60 mg 3 PHENOBARBITAL phenobarbital tab 100 mg 3 phenobarbital elixir 20 mg/5ml 1 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS 2 ADDERALL XR amphetaminedextroamphetamine cap sr 24hr 5 mg 2 ADDERALL XR amphetaminedextroamphetamine cap sr 24hr 10 mg 2 ADDERALL XR amphetaminedextroamphetamine cap sr 24hr 15 mg 2 ADDERALL XR amphetaminedextroamphetamine cap sr 24hr 20 mg 2 ADDERALL XR amphetaminedextroamphetamine cap sr 24hr 25 mg 2 ADDERALL XR amphetaminedextroamphetamine cap sr 24hr 30 mg 1 amphetaminedextroamphetamine cap sr 24hr 5 mg (Adderall xr) 1 amphetaminedextroamphetamine cap sr 24hr 10 mg (Adderall xr) 1 amphetaminedextroamphetamine cap sr 24hr 15 mg (Adderall xr) 1 amphetaminedextroamphetamine cap sr 24hr 20 mg (Adderall xr) phenobarbital tab 16.2 mg phenobarbital tab 32.4 mg phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg 1 1 1 1 QUAZEPAM - quazepam tab 15 mg 3 ROZEREM - ramelteon tab 8 mg 3 temazepam cap 7.5 mg (Restoril) 1 temazepam cap 15 mg (Restoril) 1 temazepam cap 22.5 mg (Restoril) 1 temazepam cap 30 mg (Restoril) 1 zaleplon cap 5 mg (Sonata) 1 zaleplon cap 10 mg (Sonata) zolpidem tartrate sl tab 1.75 mg (Intermezzo) 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) zolpidem tartrate tab 5 mg (Ambien) • 1 • • • 1 • 1 • 1 • 1 • 1 1 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 2017 • • • • • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 77 amphetaminedextroamphetamine cap sr 24hr 25 mg (Adderall xr) amphetaminedextroamphetamine cap sr 24hr 30 mg (Adderall xr) 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) • 1 • • APTENSIO XR methylphenidate hcl cap er 24hr 50 mg (xr) 3 • APTENSIO XR methylphenidate hcl cap er 24hr 60 mg (xr) 3 • armodafinil tab 50 mg (Nuvigil) 1 • • armodafinil tab 150 mg (Nuvigil) 1 • • armodafinil tab 200 mg (Nuvigil) 1 • • armodafinil tab 250 mg (Nuvigil) 1 • • 1 1 • 1 • caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit) 1 • clonidine hcl tab sr 12hr 0.1 mg (Kapvay) 1 • APTENSIO XR methylphenidate hcl cap er 24hr 10 mg (xr) 3 • APTENSIO XR methylphenidate hcl cap er 24hr 15 mg (xr) 3 APTENSIO XR methylphenidate hcl cap er 24hr 20 mg (xr) 3 APTENSIO XR methylphenidate hcl cap er 24hr 30 mg (xr) 3 amphetaminedextroamphetamine tab 30 mg (Adderall) 3 • • • 1 • CONCERTA - methylphenidate hcl tab sa osm 18 mg 2 • CONCERTA - methylphenidate hcl tab sa osm 27 mg 2 • CONCERTA - methylphenidate hcl tab sa osm 36 mg 2 • CONCERTA - methylphenidate hcl tab sa osm 54 mg 2 • dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin xr) 1 • 1 • 1 • 1 • dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr) dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin xr) Limited Distribution 1 APTENSIO XR methylphenidate hcl cap er 24hr 40 mg (xr) ACA • Dispensing Limits 1 Step Therapy • Prior Authorization 1 Drug Name Drug Tier • Limited Distribution 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 78 • 1 • 1 • 1 • dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine) 1 • dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine) 1 • dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine) 1 • dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra) 1 • dextroamphetamine sulfate tab 5 mg 1 • 1 • FOCALIN XR dexmethylphenidate hcl cap sr 24 hr 25 mg 3 • FOCALIN XR dexmethylphenidate hcl cap sr 24 hr 35 mg 3 • guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv) 1 • dexmethylphenidate hcl tab 2.5 mg (Focalin) dexmethylphenidate hcl tab 5 mg (Focalin) dexmethylphenidate hcl tab 10 mg (Focalin) dextroamphetamine sulfate tab 10 mg • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • METHYLPHENIDATE HCL ER - methylphenidate hcl tab sr 24hr 18 mg 1 • METHYLPHENIDATE HCL ER - methylphenidate hcl tab sr 24hr 27 mg 1 • 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) methylphenidate hcl chew tab 2.5 mg (Methylin) methylphenidate hcl chew tab 5 mg (Methylin) methylphenidate hcl chew tab 10 mg (Methylin) Limited Distribution 1 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr) 1 guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv) ACA • Dispensing Limits 1 dexmethylphenidate hcl cap sr 24 hr 35 mg (Focalin xr) Step Therapy • Prior Authorization 1 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr) Drug Name Drug Tier • Limited Distribution 1 dexmethylphenidate hcl cap sr 24 hr 25 mg (Focalin xr) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 79 1 METHYLPHENIDATE HCL ER - methylphenidate hcl tab sr 24hr 54 mg 1 methylphenidate hcl soln 5 mg/5ml (Methylin) 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • 1 • methylphenidate hcl soln 10 mg/5ml (Methylin) methylphenidate hcl tab cr 10 mg methylphenidate hcl tab cr 20 mg (Ritalin sr) 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) methylphenidate hcl tab 20 mg (Ritalin) • modafinil tab 100 mg (Provigil) 1 • • modafinil tab 200 mg (Provigil) 1 • • NUVIGIL - armodafinil tab 50 mg 3 • • NUVIGIL - armodafinil tab 150 mg 3 • • NUVIGIL - armodafinil tab 200 mg 3 • • 3 STRATTERA - atomoxetine hcl cap 10 mg (base equiv) 3 • STRATTERA - atomoxetine hcl cap 18 mg (base equiv) 3 • STRATTERA - atomoxetine hcl cap 25 mg (base equiv) 3 • STRATTERA - atomoxetine hcl cap 40 mg (base equiv) 3 • STRATTERA - atomoxetine hcl cap 60 mg (base equiv) 3 • STRATTERA - atomoxetine hcl cap 80 mg (base equiv) 3 • STRATTERA - atomoxetine hcl cap 100 mg (base equiv) 3 • VYVANSE - lisdexamfetamine dimesylate cap 10 mg 2 • VYVANSE - lisdexamfetamine dimesylate cap 20 mg 2 • VYVANSE - lisdexamfetamine dimesylate cap 30 mg 2 • VYVANSE - lisdexamfetamine dimesylate cap 40 mg 2 • VYVANSE - lisdexamfetamine dimesylate cap 50 mg 2 • VYVANSE - lisdexamfetamine dimesylate cap 60 mg 2 • VYVANSE - lisdexamfetamine dimesylate cap 70 mg 2 • VYVANSE - lisdexamfetamine dimesylate chew tab 10 mg 2 • VYVANSE - lisdexamfetamine dimesylate chew tab 20 mg 2 • VYVANSE - lisdexamfetamine dimesylate chew tab 30 mg 2 • VYVANSE - lisdexamfetamine dimesylate chew tab 40 mg 2 • Limited Distribution • NUVIGIL - armodafinil tab 250 mg ACA Dispensing Limits • Step Therapy Prior Authorization Drug Name Drug Tier Limited Distribution • METHYLPHENIDATE HCL ER - methylphenidate hcl tab sr 24hr 36 mg ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 80 PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC. 1 acamprosate calcium tab delayed release 333 mg (Campral) • AMPYRA - dalfampridine tab sr 3 • 12hr 10 mg • AUBAGIO - teriflunomide tab 7 2 mg 2 • AUBAGIO - teriflunomide tab 14 mg 2 • AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial) 2 • AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 2 • AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 2 • BETASERON - interferon beta-1b for inj kit 0.3 mg A bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban) CHANTIX - varenicline tartrate A tab 0.5 mg (base equiv) CHANTIX - varenicline tartrate A tab 1 mg (base equiv) A CHANTIX CONTINUING MONTH - varenicline tartrate tab 1 mg (base equiv) • Limited Distribution ACA • Dispensing Limits 2 Step Therapy VYVANSE - lisdexamfetamine dimesylate chew tab 60 mg Prior Authorization • Drug Name Drug Tier 2 Limited Distribution VYVANSE - lisdexamfetamine dimesylate chew tab 50 mg ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 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 3 CHLORDIAZEPOXIDE/ AMITRIPT chlordiazepoxideamitriptyline tab 10-25 mg 3 COMMIT - nicotine polacrilex lozenge 2 mg A • COMMIT - nicotine polacrilex lozenge 4 mg A • COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 2 • • COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 2 • • disulfiram tab 250 mg (Antabuse) 1 disulfiram tab 500 mg (Antabuse) 1 • donepezil hydrochloride orally disintegrating tab 5 mg 1 • donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt) • • • • • • • • • donepezil hydrochloride tab 5 mg (Aricept) donepezil hydrochloride tab 10 mg (Aricept) donepezil hydrochloride tab 23 mg (Aricept) 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 81 3 • 3 HORIZANT - gabapentin enacarbil tab cr 300 mg 3 • FLUOXETINE - fluoxetine hcl (pmdd) cap 20 mg 3 HORIZANT - gabapentin enacarbil tab cr 600 mg 3 • GALANTAMINE HYDROBROMIDE galantamine hydrobromide oral soln 4 mg/ml 3 memantine hcl oral solution 2 mg/ml (Namenda) 1 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er) 1 3 EXTAVIA - interferon beta-1b for inj kit 0.3 mg 3 FLUOXETINE - fluoxetine hcl (pmdd) cap 10 mg • • • memantine hcl tab 5 mg (Namenda) 1 memantine hcl tab 10 mg (Namenda) 1 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa) 1 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er) 1 1 NAMENDA XR - memantine hcl cap sr 24hr 7 mg 3 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er) 3 galantamine hydrobromide tab 4 mg (Razadyne) 1 NAMENDA XR - memantine hcl cap sr 24hr 14 mg NAMENDA XR - memantine hcl cap sr 24hr 21 mg 3 NAMENDA XR - memantine hcl cap sr 24hr 28 mg 3 galantamine hydrobromide tab 8 mg (Razadyne) galantamine hydrobromide tab 12 mg (Razadyne) 1 1 GILENYA - fingolimod hcl cap 0.5 mg (base equiv) 2 • • glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone) 1 • • GRALISE - gabapentin (oncedaily) tab 300 mg 3 • GRALISE - gabapentin (oncedaily) tab 600 mg 3 • Limited Distribution GRALISE STARTER gabapentin (once-daily) tab pack 300 mg (9) & 600 mg (69) ERGOLOID MESYLATES ergoloid mesylates tab 1 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 2017 3 NAMENDA XR TITRATION PACK - memantine hcl cap sr 24hr 7 mg & 14 mg & 21 mg & 28 mg pack 3 NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 7-10 mg 3 NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 14-10 mg 3 NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 21-10 mg Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 82 NICOTINE TRANSDERMAL SYST - nicotine td patch 24 hr kit 21-14-7 mg/24hr A • NICOTROL INHALER nicotine inhaler system 10 mg (4 mg delivered) A • NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/ spray) A • NUEDEXTA dextromethorphan hbrquinidine sulfate cap 20-10 mg 2 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax) 1 NAMZARIC - memantinedonepezil cap er 24hr 7 & 14 & 21 & 28-10 mg pack NICODERM CQ - nicotine td patch 24hr 7 mg/24hr A • NICODERM CQ - nicotine td patch 24hr 14 mg/24hr A • NICODERM CQ - nicotine td patch 24hr 21 mg/24hr A • NICORETTE - nicotine polacrilex gum 2 mg A • NICORETTE - nicotine polacrilex gum 4 mg A • NICORETTE - nicotine polacrilex lozenge 2 mg A • NICORETTE - nicotine polacrilex lozenge 4 mg A • NICORETTE MINI - nicotine polacrilex lozenge 2 mg A • NICORETTE MINI - nicotine polacrilex lozenge 4 mg A • NICORETTE STARTER KIT nicotine polacrilex gum 2 mg A • NICORETTE STARTER KIT nicotine polacrilex gum 4 mg A • nicotine polacrilex gum 2 mg A • nicotine polacrilex lozenge 4 mg nicotine td patch 24hr 7 mg/24hr A • A • A • olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax) olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax) olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax) olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax) Limited Distribution • nicotine td patch 24hr 21 mg/24hr nicotine polacrilex lozenge 2 mg ACA A 3 nicotine td patch 24hr 14 mg/24hr • Dispensing Limits • 3 A Step Therapy A NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 28-10 mg nicotine polacrilex gum 4 mg Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 1 ORAP - pimozide tab 1 mg 3 ORAP - pimozide tab 2 mg 3 PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 2-10 mg 3 PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 2-25 mg 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 83 • 2 • PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-50 mg 3 REBIF TITRATION PACK interferon beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml rivastigmine tartrate cap 1.5 mg (Exelon) 1 pimozide tab 1 mg (Orap) 1 3 PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-25 mg pimozide tab 2 mg (Orap) 1 rivastigmine tartrate cap 3 mg (Exelon) • • 2 • • PLEGRIDY STARTER PACK peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack 2 • • PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack 2 REBIF - interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml) 2 REBIF - interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml) 2 REBIF REBIDOSE - interferon beta-1a soln auto-inj 22 mcg/0.5ml (12mu/ml) 2 REBIF REBIDOSE - interferon beta-1a soln auto-inj 44 mcg/0.5ml (24mu/ml) 2 PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 2 PLEGRIDY - peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml 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 2 3 REBIF REBIDOSE TITRATION - interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml PERPHENAZINE/ AMITRIPTYLIN perphenazine-amitriptyline tab 4-10 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 2017 • • 1 1 1 1 1 1 SAVELLA - milnacipran hcl tab 12.5 mg 3 • SAVELLA - milnacipran hcl tab 25 mg 3 • SAVELLA - milnacipran hcl tab 50 mg 3 • SAVELLA - milnacipran hcl tab 100 mg 3 • SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak 3 • TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 2 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 84 ABSTRAL - fentanyl citrate sl tab 300 mcg (base equiv) 3 • • • ABSTRAL - fentanyl citrate sl tab 400 mcg (base equiv) 3 • • • • ABSTRAL - fentanyl citrate sl tab 600 mcg (base equiv) 3 • • • • ABSTRAL - fentanyl citrate sl tab 800 mcg (base equiv) 3 • • acetaminophen w/ codeine soln 120-12 mg/5ml 1 • • tetrabenazine tab 25 mg (Xenazine) 1 • XYREM - sodium oxybate oral solution 500 mg/ml 3 • ZYBAN - bupropion hcl (smoking deterrent) tab sr 12hr 150 mg A • • ANALGESICS AND ANESTHETICS • • acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine) 1 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3) 1 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4) 1 1 butalbital-acetaminophencaffeine cap 50-300-40 mg (Fioricet) 1 acetaminophen-caffeinedihydrocodeine cap 320.5-30-16 mg (Trezix) butalbital-acetaminophencaffeine cap 50-325-40 mg 1 BELBUCA - buprenorphine hcl buccal film 75 mcg (base equivalent) 3 • BELBUCA - buprenorphine hcl buccal film 150 mcg (base equivalent) 3 • BELBUCA - buprenorphine hcl buccal film 300 mcg (base equivalent) 3 • BELBUCA - buprenorphine hcl buccal film 450 mcg (base equivalent) 3 • butalbital-acetaminophencaffeine tab 50-325-40 mg (Esgic) 1 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) 1 diflunisal tab 500 mg TENCON - butalbitalacetaminophen tab 50-325 mg ANALGESICS - NARCOTIC 1 1 Limited Distribution • • • ACA • 1 1 Dispensing Limits 3 tetrabenazine tab 12.5 mg (Xenazine) butalbital-acetaminophen tab 50-325 mg Step Therapy ABSTRAL - fentanyl citrate sl tab 200 mcg (base equiv) TECFIDERA STARTER PACK - dimethyl fumarate capsule dr starter pack 120 mg & 240 mg A Prior Authorization • 2 aspirin tab delayed release 81 mg Drug Tier 3 2 • Drug Name ABSTRAL - fentanyl citrate sl tab 100 mcg (base equiv) TECFIDERA - dimethyl fumarate capsule delayed release 240 mg ANALGESICS - NON-NARCOTIC A aspirin chew tab 81 mg Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 85 BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr 3 • BUTRANS - buprenorphine td patch weekly 10 mcg/hr 3 • BUTRANS - buprenorphine td patch weekly 15 mcg/hr 3 • BUTRANS - buprenorphine td patch weekly 20 mcg/hr 3 • codeine sulfate tab 15 mg (Codeine sulfate) 1 • codeine sulfate tab 30 mg 1 1 • EMBEDA - morphinenaltrexone cap cr 20-0.8 mg 3 • 1 • EMBEDA - morphinenaltrexone cap cr 30-1.2 mg 3 • 1 • EMBEDA - morphinenaltrexone cap cr 50-2 mg 3 • EMBEDA - morphinenaltrexone cap cr 60-2.4 mg 3 • EMBEDA - morphinenaltrexone cap cr 80-3.2 mg 3 • EMBEDA - morphinenaltrexone cap cr 100-4 mg 3 • EXALGO - hydromorphone hcl tab er 24hr deter 32 mg 3 • FENTANYL - fentanyl td patch 72hr 37.5 mcg/hr 3 • FENTANYL - fentanyl td patch 72hr 62.5 mcg/hr 3 • FENTANYL - fentanyl td patch 72hr 87.5 mcg/hr 3 • BELBUCA - buprenorphine hcl buccal film 900 mcg (base equivalent) 3 • BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3 mg (base equiv) 3 • BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7 mg (base equiv) 3 • BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1 mg (base equiv) 3 buprenorphine hcl sl tab 2 mg (base equiv) 1 butalbital-acetaminophencaff w/ cod cap 50-300-40-30 mg (Fioricet/ codeine) 1 butalbital-acetaminophencaff w/ cod cap 50-325-40-30 mg 1 1 • • codeine sulfate tab 60 mg 1 Limited Distribution • butorphanol tartrate nasal soln 10 mg/ml ACA Dispensing Limits Step Therapy 3 BELBUCA - buprenorphine hcl buccal film 750 mcg (base equivalent) butalbital-aspirincaff w/ codeine cap 50-325-40-30 mg (Fiorinal/ codeine #3) Prior Authorization BUTRANS - buprenorphine td patch weekly 5 mcg/hr 3 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) Drug Tier • 3 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) Drug Name 1 BELBUCA - buprenorphine hcl buccal film 600 mcg (base equivalent) buprenorphine hcl sl tab 8 mg (base equiv) Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 86 fentanyl citrate lollipop 200 mcg (Actiq) fentanyl citrate lollipop 400 mcg (Actiq) fentanyl citrate lollipop 600 mcg (Actiq) fentanyl citrate lollipop 800 mcg (Actiq) fentanyl citrate lollipop 1200 mcg (Actiq) fentanyl citrate lollipop 1600 mcg (Actiq) fentanyl td patch 72hr 12 mcg/hr (Duragesic) fentanyl td patch 72hr 25 mcg/hr (Duragesic) fentanyl td patch 72hr 50 mcg/hr (Duragesic) fentanyl td patch 72hr 75 mcg/hr (Duragesic) fentanyl td patch 72hr 100 mcg/hr (Duragesic) • • 1 • • 1 • • 1 • • 1 • 1 • 1 • 1 • 1 • • • • • 3 • • FENTORA - fentanyl citrate buccal tab 600 mcg (base equiv) 3 • • FENTORA - fentanyl citrate buccal tab 800 mcg (base equiv) 3 FENTORA - fentanyl citrate buccal tab 100 mcg (base equiv) 3 FENTORA - fentanyl citrate buccal tab 200 mcg (base equiv) 3 FENTORA - fentanyl citrate buccal tab 400 mcg (base equiv) • • 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) hydrocodoneacetaminophen tab 10-300 mg (Xodol) hydrocodone-ibuprofen tab 5-200 mg (Reprexain) hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen) hydrocodone-ibuprofen tab 10-200 mg (Ibudone) hydromorphone hcl liqd 1 mg/ml (Dilaudid) hydromorphone hcl tab er 24hr deter 8 mg (Exalgo) hydromorphone hcl tab er 24hr deter 12 mg (Exalgo) Limited Distribution 1 hydrocodoneacetaminophen soln 10-325 mg/15ml (Zamicet) ACA • Dispensing Limits • Step Therapy 1 hydrocodoneacetaminophen soln 7.5-325 mg/15ml (Hycet) Prior Authorization • Drug Name Drug Tier • Limited Distribution 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 1 1 1 1 1 1 1 1 1 1 1 • 1 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 87 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) 3 • 1 LAZANDA - fentanyl citrate nasal spray 400 mcg/act (base equiv) 1 LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg 3 1 MEPERIDINE HCL meperidine hcl oral soln 50 mg/5ml 3 methadone hcl conc 10 mg/ ml (Methadose) 1 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 20 mg 3 • HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 30 mg 3 • HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 40 mg 3 HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 60 mg 3 • HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 80 mg 3 • HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 100 mg 3 • HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter 120 mg 3 • IONSYS - fentanyl hcl iontophoretic td system 40 mcg/act (base equiv) 3 LAZANDA - fentanyl citrate nasal spray 100 mcg/act (base equiv) 3 • methadone hcl soln 5 mg/5ml (Methadone hcl) methadone hcl soln 10 mg/5ml (Methadone hcl) methadone hcl tab for oral susp 40 mg 1 1 1 1 methadone hcl tab 10 mg (Dolophine) 1 MORPHINE SULFATE morphine sulfate tab 15 mg 2 MORPHINE SULFATE morphine sulfate tab 30 mg 2 morphine sulfate cap sr 24hr 10 mg (Kadian) 1 • 1 • 1 • 1 • 1 • morphine sulfate cap sr 24hr 30 mg (Kadian) • • methadone hcl tab 5 mg (Dolophine hcl) morphine sulfate cap sr 24hr 20 mg (Kadian) • • morphine sulfate cap sr 24hr 50 mg (Kadian) morphine sulfate cap sr 24hr 60 mg (Kadian) Limited Distribution • ACA 3 Dispensing Limits LAZANDA - fentanyl citrate nasal spray 300 mcg/act (base equiv) Step Therapy • Prior Authorization 1 Drug Name Drug Tier • Limited Distribution 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 88 morphine sulfate cap sr 24hr 80 mg (Kadian) morphine sulfate cap sr 24hr 100 mg (Kadian) • OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 7.5 mg 3 • • OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 10 mg 3 • • OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 15 mg 3 • • OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 20 mg 3 • • OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 30 mg 3 • • OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 40 mg 3 • 3 MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 45 mg 3 MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 60 mg 3 MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 75 mg 3 MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 90 mg 3 MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 120 mg 3 morphine sulfate oral soln 10 mg/5ml 1 OXAYDO - oxycodone hcl tab abuse deter 5 mg 3 1 OXAYDO - oxycodone hcl tab abuse deter 7.5 mg oxycodone hcl cap 5 mg 1 morphine sulfate tab cr 15 mg (Ms contin) morphine sulfate tab cr 30 mg (Ms contin) morphine sulfate tab cr 60 mg (Ms contin) morphine sulfate tab cr 100 mg (Ms contin) morphine sulfate tab cr 200 mg (Ms contin) 1 1 • 1 • 1 • 1 • 1 • oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl) 1 OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 10 mg 3 • OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 15 mg 3 • OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 20 mg 3 • Limited Distribution • ACA 3 MORPHINE SULFATE ER morphine sulfate beads cap sr 24hr 30 mg morphine sulfate oral soln 100 mg/5ml (20 mg/ml) Dispensing Limits OPANA ER (CRUSH RESISTANT - oxymorphone hcl tab er 12hr deter 5 mg 3 morphine sulfate oral soln 20 mg/5ml Step Therapy • Prior Authorization 1 Drug Name Drug Tier • Limited Distribution 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 89 3 OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 80 mg 3 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl) 1 OXYCODONE/IBUPROFEN oxycodone-ibuprofen tab 5-400 mg 3 OXYCONTIN - oxycodone hcl tab er 12hr deter 10 mg 2 • OXYCONTIN - oxycodone hcl tab er 12hr deter 15 mg 2 • 1 OXYCONTIN - oxycodone hcl tab er 12hr deter 20 mg 2 • oxycodone hcl tab 5 mg (Roxicodone) 1 OXYCONTIN - oxycodone hcl tab er 12hr deter 30 mg 2 • oxycodone hcl tab 10 mg 1 2 • • • oxycodone hcl tab 15 mg (Roxicodone) 1 OXYCONTIN - oxycodone hcl tab er 12hr deter 40 mg 2 • oxycodone hcl tab 20 mg 1 OXYCONTIN - oxycodone hcl tab er 12hr deter 60 mg • oxycodone hcl tab 30 mg (Roxicodone) 1 OXYCONTIN - oxycodone hcl tab er 12hr deter 80 mg 2 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet) 1 oxymorphone hcl tab 5 mg (Opana) 1 oxymorphone hcl tab 10 mg (Opana) 1 OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 5 mg 1 • OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 7.5 mg 1 • OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 10 mg 1 • oxycodone w/ acetaminophen tab 5-325 mg (Percocet) oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) oxycodone w/ acetaminophen tab 10-325 mg (Percocet) oxycodone-aspirin tab 4.8355-325 mg (Percodan) 1 1 1 1 Limited Distribution OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 60 mg OXYCODONE/ ACETAMINOPHEN oxycodone w/ acetaminophen soln 5-325 mg/5ml ACA • Dispensing Limits 3 Step Therapy OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 40 mg Prior Authorization • Drug Name Drug Tier 3 Limited Distribution OXYCODONE HCL ER oxycodone hcl tab er 12hr deter 30 mg ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 90 3 • SUBSYS - fentanyl sublingual spray 1600 mcg (800 mcg x 2) 3 • tramadol hcl tab sr 24hr 100 mg (Ultram er) 1 • 1 • 1 • 1 • 1 • 1 • tramadol hcl tab 50 mg (Ultram) 1 • • tramadol-acetaminophen tab 37.5-325 mg (Ultracet) 1 • XARTEMIS XR - oxycodone w/ acetaminophen tab cr 7.5-325 mg 1 OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 20 mg 1 OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 30 mg 1 OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 40 mg 1 SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv) 3 SUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv) 3 • SUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv) 3 SUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv) 3 SUBSYS - fentanyl sublingual spray 100 mcg 3 • • SUBSYS - fentanyl sublingual spray 200 mcg 3 • • SUBSYS - fentanyl sublingual spray 400 mcg 3 • • SUBSYS - fentanyl sublingual spray 600 mcg 3 • • SUBSYS - fentanyl sublingual spray 800 mcg 3 • • • • • • 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 • Limited Distribution SUBSYS - fentanyl sublingual spray 1200 mcg (600 mcg x 2) OXYMORPHONE HYDROCHLORIDE oxymorphone hcl tab sr 12hr 15 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 2017 • 3 • XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 9 mg XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 13.5 mg XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 18 mg XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 27 mg • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 91 XTAMPZA ER - oxycodone cap 3 er 12hr abuse-deterrent 36 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 10 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 15 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 20 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 30 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 40 mg 3 ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 50 mg ZUBSOLV - buprenorphine hcl- 3 naloxone hcl sl tab 0.7-0.18 mg (base eq) ZUBSOLV - buprenorphine hcl- 3 naloxone hcl sl tab 1.4-0.36 mg (base eq) ZUBSOLV - buprenorphine hcl- 3 naloxone hcl sl tab 2.9-0.71 mg (base eq) ZUBSOLV - buprenorphine hcl- 3 naloxone hcl sl tab 5.7-1.4 mg (base eq) ZUBSOLV - buprenorphine hcl- 3 naloxone hcl sl tab 8.6-2.1 mg (base eq) ZUBSOLV - buprenorphine hcl- 3 naloxone hcl sl tab 11.4-2.9 mg (base eq) • • • • • • • • • • • • ANALGESICS - ANTI-INFLAMMATORY 3 • ACTEMRA - tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml 3 • ARCALYST - rilonacept for inj 220 mg 1 celecoxib cap 50 mg (Celebrex) 1 celecoxib cap 100 mg (Celebrex) 1 celecoxib cap 200 mg (Celebrex) 1 celecoxib cap 400 mg (Celebrex) 1 diclofenac potassium tab 50 mg (Cataflam) 1 diclofenac sodium tab delayed release 25 mg 1 diclofenac sodium tab delayed release 50 mg 1 diclofenac sodium tab delayed release 75 mg 1 diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr) 1 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50) 1 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75) 2 • ENBREL - etanercept for subcutaneous inj 25 mg 2 • ENBREL - etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml 2 • ENBREL - etanercept subcutaneous soln prefilled syringe 50 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 2017 • • • • • • • • • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 92 ibuprofen tab 400 mg 1 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 indomethacin cap cr 75 mg 1 indomethacin cap 25 mg FENOPROFEN CALCIUM fenoprofen calcium cap 200 mg 3 indomethacin cap 50 mg FENOPROFEN CALCIUM fenoprofen calcium cap 400 mg 3 FENOPROFEN CALCIUM fenoprofen calcium tab 600 mg 3 flurbiprofen tab 50 mg 1 etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg etodolac tab 400 mg etodolac tab 500 mg flurbiprofen tab 100 mg ketoprofen cap 50 mg 1 HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 2 HUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 2 HUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 2 HUMIRA PEDIATRIC CROHNS D - adalimumab prefilled syringe kit 40 mg/0.8ml 2 HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 2 ketoprofen cap 75 mg ketorolac tromethamine tab 10 mg • • • • • • • • • • • 1 1 1 1 1 1 • 1 3 leflunomide tab 10 mg (Arava) 1 • leflunomide tab 20 mg (Arava) 1 3 • MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg 3 • MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg mefenamic acid cap 250 mg (Ponstel) 1 meloxicam tab 7.5 mg (Mobic) 1 • • 1 KINERET - anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml • • Limited Distribution 1 etodolac cap 300 mg • ACA • etodolac cap 200 mg Dispensing Limits 2 1 HUMIRA PEN-PSORIASIS STAR - adalimumab peninjector kit 40 mg/0.8ml Step Therapy Prior Authorization • 1 • Drug Tier Limited Distribution ACA Dispensing Limits 2 2 • Drug Name HUMIRA PEN-CROHNS DISEASE - adalimumab peninjector kit 40 mg/0.8ml ENBREL SURECLICK etanercept subcutaneous solution auto-injector 50 mg/ ml • Step Therapy Prior Authorization Drug Name Drug Tier 2017 • • • meloxicam tab 15 mg (Mobic) 1 1 nabumetone tab 500 mg nabumetone tab 750 mg 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 93 naproxen sodium tab sr 24hr 375 mg (base equiv) (Naprelan) 1 OTREXUP - methotrexate soln pf auto-injector 12.5 mg/0.4ml 3 naproxen sodium tab sr 24hr 500 mg (base equiv) (Naprelan) 1 OTREXUP - methotrexate soln pf auto-injector 15mg/0.4ml 3 1 3 naproxen sodium tab 275 mg (Anaprox) OTREXUP - methotrexate soln pf auto-injector 17.5 mg/0.4ml 1 OTREXUP - methotrexate soln pf auto-injector 20mg/0.4ml 3 naproxen susp 125 mg/5ml (Naprosyn) 1 3 naproxen tab ec 375 mg (Ecnaprosyn) 1 OTREXUP - methotrexate soln pf auto-injector 22.5 mg/0.4ml 3 naproxen tab ec 500 mg (Ecnaprosyn) 1 OTREXUP - methotrexate soln pf auto-injector 25mg/0.4ml 1 naproxen tab 250 mg (Naprosyn) 1 oxaprozin tab 600 mg (Daypro) 1 naproxen tab 375 mg (Naprosyn) 1 piroxicam cap 10 mg (Feldene) 1 naproxen tab 500 mg (Naprosyn) 1 piroxicam cap 20 mg (Feldene) 3 ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml 3 RASUVO - methotrexate soln pf auto-injector 7.5 mg/0.15ml 3 ORENCIA CLICKJECT abatacept subcutaneous soln auto-injector 125 mg/ml 3 RASUVO - methotrexate soln pf auto-injector 10 mg/0.2ml 3 OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg 2 RASUVO - methotrexate soln pf auto-injector 12.5 mg/0.25ml RASUVO - methotrexate soln pf auto-injector 15 mg/0.3ml 3 OTEZLA - apremilast tab 30 mg 2 3 OTREXUP - methotrexate soln pf auto-injector 7.5 mg/0.4ml 3 RASUVO - methotrexate soln pf auto-injector 17.5 mg/0.35ml 3 OTREXUP - methotrexate soln pf auto-injector 10mg/0.4ml 3 RASUVO - methotrexate soln pf auto-injector 20 mg/0.4ml RASUVO - methotrexate soln pf auto-injector 22.5 mg/0.45ml 3 naproxen sodium tab 550 mg (Anaprox ds) • • • • • • • • • • • • 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 94 RASUVO - methotrexate soln pf auto-injector 25 mg/0.5ml 3 RASUVO - methotrexate soln pf auto-injector 27.5 mg/0.55ml 3 RASUVO - methotrexate soln pf auto-injector 30 mg/0.6ml 3 RIDAURA - auranofin cap 3 mg 3 2 SIMPONI - golimumab subcutaneous soln autoinjector 50 mg/0.5ml 2 SIMPONI - golimumab subcutaneous soln autoinjector 100 mg/ml 2 SIMPONI - golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml 2 SIMPONI - golimumab subcutaneous soln prefilled syringe 100 mg/ml 1 sulindac tab 150 mg sulindac tab 200 mg ergotamine w/ caffeine tab 1-100 mg (Cafergot) • 1 • MIGRANAL dihydroergotamine mesylate nasal spray 4 mg/ml 3 • naratriptan hcl tab 1 mg (base equiv) (Amerge) 1 • 1 • RELPAX - eletriptan hydrobromide tab 20 mg (base equivalent) 3 • RELPAX - eletriptan hydrobromide tab 40 mg (base equivalent) 3 • rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt) 1 • 1 • rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) 1 • 1 • • rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) • sumatriptan nasal spray 5 mg/act (Imitrex) 1 • • sumatriptan nasal spray 20 mg/act (Imitrex) 1 • 1 • • • • • • • • • • • • 3 • • • XELJANZ XR - tofacitinib citrate tab sr 24hr 11 mg (base equivalent) 3 • • • almotriptan malate tab 12.5 mg (Axert) dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45) ERGOMAR - ergotamine tartrate sl tab 2 mg 1 3 naratriptan hcl tab 2.5 mg (base equiv) (Amerge) rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt) sumatriptan succinate inj 6 mg/0.5ml (Imitrex) Limited Distribution ACA Dispensing Limits frovatriptan succinate tab 2.5 mg (base equivalent) (Frova) XELJANZ - tofacitinib citrate tab 5 mg (base equivalent) 1 Step Therapy • 1 1 Prior Authorization 3 1 almotriptan malate tab 6.25 mg (Axert) 1 FROVA - frovatriptan succinate tab 2.5 mg (base equivalent) TOLMETIN SODIUM - tolmetin sodium cap 400 mg MIGRAINE PRODUCTS Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 95 1 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys) 1 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys) 1 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref) 1 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) 1 zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt) 1 zolmitriptan orally disintegrating tab 5 mg (Zomig zmt) 1 zolmitriptan tab 2.5 mg (Zomig) 1 zolmitriptan tab 5 mg (Zomig) 3 ZOMIG - zolmitriptan nasal spray 2.5 mg/spray unit GOUT AGENTS allopurinol tab 100 mg (Zyloprim) 1 allopurinol tab 300 mg (Zyloprim) 1 • • • • COLCHICINE - colchicine cap 0.6 mg 3 COLCHICINE - colchicine tab 0.6 mg 3 colchicine w/ probenecid tab 0.5-500 mg 1 COLCRYS - colchicine tab 0.6 mg 3 MITIGARE - colchicine cap 0.6 mg 3 probenecid tab 500 mg 1 ANTICONVULSANTS APTIOM - eslicarbazepine acetate tab 400 mg 3 APTIOM - eslicarbazepine acetate tab 600 mg 3 APTIOM - eslicarbazepine acetate tab 800 mg 3 BANZEL - rufinamide susp 40 mg/ml 3 • BANZEL - rufinamide tab 200 mg 3 • BANZEL - rufinamide tab 400 mg 3 • BRIVIACT - brivaracetam oral soln 10 mg/ml 3 BRIVIACT - brivaracetam tab 10 mg 3 BRIVIACT - brivaracetam tab 25 mg 3 BRIVIACT - brivaracetam tab 50 mg 3 • • Limited Distribution ACA Dispensing Limits NEUROMUSCULAR DRUGS 3 • Step Therapy ULORIC - febuxostat tab 40 mg 3 ULORIC - febuxostat tab 80 mg 3 APTIOM - eslicarbazepine acetate tab 200 mg • Prior Authorization Drug Name Drug Tier Limited Distribution • ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 96 BRIVIACT - brivaracetam tab 75 mg 3 BRIVIACT - brivaracetam tab 100 mg 3 carbamazepine cap sr 12hr 100 mg (Carbatrol) 1 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) clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab 2 mg 1 clonazepam tab 1 mg (Klonopin) 1 1 clonazepam tab 2 mg (Klonopin) 1 1 3 1 DEPAKENE - valproate sodium oral soln 250 mg/5ml (base equiv) 3 1 DEPAKENE - valproic acid cap 250 mg carbamazepine tab 200 mg (Tegretol) 1 CARBATROL - carbamazepine cap sr 12hr 100 mg 3 CARBATROL - carbamazepine cap sr 12hr 200 mg 3 CARBATROL - carbamazepine cap sr 12hr 300 mg 3 CELONTIN - methsuximide cap 3 300 mg 1 clonazepam orally disintegrating tab 0.125 mg 1 clonazepam orally disintegrating tab 0.25 mg 1 clonazepam orally disintegrating tab 0.5 mg Limited Distribution ACA Dispensing Limits 1 1 1 Step Therapy 1 clonazepam tab 0.5 mg (Klonopin) 1 Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 DIASTAT ACUDIAL - diazepam 2 rectal gel delivery system 10 mg DIASTAT ACUDIAL - diazepam 2 rectal gel delivery system 20 mg 2 DIASTAT PEDIATRIC diazepam rectal gel delivery system 2.5 mg 3 DIAZEPAM - diazepam rectal gel delivery system 2.5 mg 3 DIAZEPAM - diazepam rectal gel delivery system 10 mg 3 DIAZEPAM - diazepam rectal gel delivery system 20 mg 3 DILANTIN - phenytoin sodium extended cap 30 mg 3 DILANTIN - phenytoin sodium extended cap 100 mg 3 DILANTIN INFATABS phenytoin chew tab 50 mg 3 DILANTIN-125 - phenytoin susp 125 mg/5ml Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 97 divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles) 1 divalproex sodium tab delayed release 125 mg (Depakote) 1 divalproex sodium tab delayed release 250 mg (Depakote) 1 divalproex sodium tab delayed release 500 mg (Depakote) 1 divalproex sodium tab sr 24 hr 250 mg (Depakote er) 1 gabapentin tab 600 mg (Neurontin) 1 1 gabapentin tab 800 mg (Neurontin) 1 ethosuximide cap 250 mg (Zarontin) 1 GABITRIL - tiagabine hcl tab 12 mg 3 ethosuximide soln 250 mg/5ml (Zarontin) 1 GABITRIL - tiagabine hcl tab 16 mg 3 felbamate susp 600 mg/5ml (Felbatol) 1 3 felbamate tab 400 mg (Felbatol) 1 LAMICTAL STARTER/NOT TAKI - lamotrigine tab 25 mg (42) & 100 mg (7) starter kit 3 felbamate tab 600 mg (Felbatol) 1 LAMICTAL STARTER/TAKING C - lamotrigine tab 25 mg (84) & 100 mg (14) starter kit FYCOMPA - perampanel susp 0.5 mg/ml 3 3 FYCOMPA - perampanel tab 2 mg 3 LAMICTAL STARTER/TAKING V - lamotrigine tab 25 mg (35) starter kit FYCOMPA - perampanel tab 4 mg 3 FYCOMPA - perampanel tab 6 mg 3 FYCOMPA - perampanel tab 8 mg 3 divalproex sodium tab sr 24 hr 500 mg (Depakote er) FYCOMPA - perampanel tab 10 mg 3 FYCOMPA - perampanel tab 12 mg 3 gabapentin cap 100 mg (Neurontin) 1 gabapentin cap 300 mg (Neurontin) 1 gabapentin cap 400 mg (Neurontin) 1 gabapentin oral soln 250 mg/5ml (Neurontin) 1 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 2017 LAMICTAL XR - lamotrigine tab 3 sr 24hr 25 mg (21) & 50 mg (7) titration kit LAMICTAL XR - lamotrigine tab 3 sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit 3 LAMICTAL XR - lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 98 lamotrigine orally disintegrating tab 25 mg (Lamictal odt) 1 lamotrigine orally disintegrating tab 50 mg (Lamictal odt) 1 lamotrigine orally disintegrating tab 100 mg (Lamictal odt) 1 lamotrigine orally disintegrating tab 200 mg (Lamictal odt) 1 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) 1 1 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di) 1 lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit (LAMICTAL ODT) 1 lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit (LAMICTAL ODT) 1 lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit (LAMICTAL ODT) 1 lamotrigine tab sr 24hr 25 mg (Lamictal xr) 1 lamotrigine tab sr 24hr 50 mg (Lamictal xr) 1 lamotrigine tab sr 24hr 100 mg (Lamictal xr) 1 lamotrigine tab sr 24hr 200 mg (Lamictal xr) 1 lamotrigine tab sr 24hr 250 mg (Lamictal xr) 1 lamotrigine tab sr 24hr 300 mg (Lamictal xr) lamotrigine tab 25 mg (Lamictal) 1 lamotrigine tab 100 mg (Lamictal) 1 lamotrigine tab 150 mg (Lamictal) 1 lamotrigine tab 200 mg (Lamictal) 1 levetiracetam oral soln 100 mg/ml (Keppra) 1 levetiracetam tab sr 24hr 500 mg (Keppra xr) levetiracetam tab sr 24hr 750 mg (Keppra xr) 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 2017 1 1 levetiracetam tab 250 mg (Keppra) 1 levetiracetam tab 500 mg (Keppra) 1 levetiracetam tab 750 mg (Keppra) 1 levetiracetam tab 1000 mg (Keppra) 1 LYRICA - pregabalin cap 25 mg 3 • LYRICA - pregabalin cap 50 mg 3 • LYRICA - pregabalin cap 75 mg 3 • LYRICA - pregabalin cap 100 mg 3 • LYRICA - pregabalin cap 150 mg 3 • LYRICA - pregabalin cap 200 mg 3 • LYRICA - pregabalin cap 225 mg 3 • LYRICA - pregabalin cap 300 mg 3 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 99 LYRICA - pregabalin soln 20 mg/ml 3 ONFI - clobazam suspension 2.5 mg/ml 3 ONFI - clobazam tab 10 mg 3 ONFI - clobazam tab 20 mg 3 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) 1 oxcarbazepine tab 150 mg (Trileptal) 1 oxcarbazepine tab 300 mg (Trileptal) 1 oxcarbazepine tab 600 mg (Trileptal) 1 OXTELLAR XR oxcarbazepine tab sr 24hr 150 mg 3 OXTELLAR XR oxcarbazepine tab sr 24hr 300 mg 3 OXTELLAR XR oxcarbazepine tab sr 24hr 600 mg 3 PEGANONE - ethotoin tab 250 mg 3 PHENYTEK - phenytoin sodium extended cap 200 mg 3 PHENYTEK - phenytoin sodium extended cap 300 mg 3 phenytoin chew tab 50 mg (Dilantin infatabs) 1 phenytoin sodium extended cap 100 mg (Dilantin) 1 phenytoin sodium extended cap 200 mg (Phenytek) 1 phenytoin sodium extended cap 300 mg (Phenytek) phenytoin susp 125 mg/5ml (Dilantin) 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 2017 1 1 POTIGA - ezogabine tab 50 mg 3 3 POTIGA - ezogabine tab 200 mg 3 POTIGA - ezogabine tab 300 mg 3 POTIGA - ezogabine tab 400 mg 1 primidone tab 50 mg (Mysoline) 1 primidone tab 250 mg (Mysoline) 3 QUDEXY XR - topiramate cap er 24hr sprinkle 25 mg 3 QUDEXY XR - topiramate cap er 24hr sprinkle 50 mg 3 QUDEXY XR - topiramate cap er 24hr sprinkle 100 mg 3 QUDEXY XR - topiramate cap er 24hr sprinkle 150 mg 3 QUDEXY XR - topiramate cap er 24hr sprinkle 200 mg SABRIL - vigabatrin powd pack 2 500 mg 2 SABRIL - vigabatrin tab 500 mg 3 TEGRETOL - carbamazepine susp 100 mg/5ml 3 TEGRETOL - carbamazepine tab 200 mg 3 TEGRETOL-XR carbamazepine tab sr 12hr 100 mg • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 100 TEGRETOL-XR carbamazepine tab sr 12hr 200 mg 3 TROKENDI XR - topiramate cap sr 24hr 200 mg 3 valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene) 1 TEGRETOL-XR carbamazepine tab sr 12hr 400 mg 3 1 1 tiagabine hcl tab 2 mg (Gabitril) valproic acid cap 250 mg (Depakene) 1 VIMPAT - lacosamide oral solution 10 mg/ml 3 tiagabine hcl tab 4 mg (Gabitril) VIMPAT - lacosamide tab 50 mg 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 25 mg 3 VIMPAT - lacosamide tab 100 mg 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 50 mg 3 VIMPAT - lacosamide tab 150 mg 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 100 mg 3 3 VIMPAT - lacosamide tab 200 mg 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 150 mg 3 ZARONTIN - ethosuximide cap 250 mg 3 TOPIRAMATE ER - topiramate cap er 24hr sprinkle 200 mg topiramate sprinkle cap 15 mg (Topamax sprinkle) 1 topiramate sprinkle cap 25 mg (Topamax sprinkle) 1 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 2017 ZARONTIN - ethosuximide soln 3 250 mg/5ml 1 zonisamide cap 25 mg (Zonegran) 1 zonisamide cap 50 mg topiramate tab 25 mg (Topamax) 1 topiramate tab 50 mg (Topamax) 1 topiramate tab 100 mg (Topamax) 1 topiramate tab 200 mg (Topamax) 1 TROKENDI XR - topiramate cap sr 24hr 25 mg 3 APOKYN - apomorphine hcl soln cartridge 30 mg/3ml 3 TROKENDI XR - topiramate cap sr 24hr 50 mg 3 AZILECT - rasagiline mesylate tab 0.5 mg (base equiv) 3 TROKENDI XR - topiramate cap sr 24hr 100 mg 3 AZILECT - rasagiline mesylate tab 1 mg (base equiv) 3 zonisamide cap 100 mg (Zonegran) ANTIPARKINSON AGENTS amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml amantadine hcl tab 100 mg 1 1 1 1 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 101 benztropine mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg 1 1 1 bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel) 1 bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) 1 carbidopa & levodopa orally disintegrating tab 10-100 mg 1 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) 1 1 1 1 1 1 1 carbidopa tab 25 mg (Lodosyn) 1 CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 12.5-50-200 mg 3 CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 18.75-75-200 mg 3 CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 25-100-200 mg 3 CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 31.25-125-200 mg 3 CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 37.5-150-200 mg 3 CARBIDOPA/LEVODOPA/ ENTACA - carbidopalevodopa-entacapone tabs 50-200-200 mg 3 DUOPA - carbidopa-levodopa enteral susp 4.63-20 mg/ml 3 entacapone tab 200 mg (Comtan) 1 NEUPRO - rotigotine td patch 24hr 1 mg/24hr 3 NEUPRO - rotigotine td patch 24hr 2 mg/24hr 3 NEUPRO - rotigotine td patch 24hr 3 mg/24hr 3 NEUPRO - rotigotine td patch 24hr 4 mg/24hr 3 NEUPRO - rotigotine td patch 24hr 6 mg/24hr 3 NEUPRO - rotigotine td patch 24hr 8 mg/24hr 3 pramipexole dihydrochloride tab sr 24hr 0.375 mg (Mirapex er) 1 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 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 102 pramipexole dihydrochloride tab sr 24hr 0.75 mg (Mirapex er) 1 pramipexole dihydrochloride tab sr 24hr 1.5 mg (Mirapex er) 1 pramipexole dihydrochloride tab sr 24hr 2.25 mg (Mirapex er) 1 pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex er) 1 pramipexole dihydrochloride tab sr 24hr 3.75 mg (Mirapex er) 1 pramipexole dihydrochloride tab sr 24hr 4.5 mg (Mirapex er) 1 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) 1 1 1 1 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl) ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl) 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) Limited Distribution 1 1 1 1 1 1 1 1 3 rasagiline mesylate tab 0.5 mg (base equiv) (Azilect) RYTARY - carbidopa & levodopa cap cr 36.25-145 mg RYTARY - carbidopa & levodopa cap cr 48.75-195 mg 3 rasagiline mesylate tab 1 mg (base equiv) (Azilect) 1 RYTARY - carbidopa & levodopa cap cr 61.25-245 mg 3 1 ACA 1 1 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl) Dispensing Limits 1 3 1 Step Therapy 1 RYTARY - carbidopa & levodopa cap cr 23.75-95 mg pramipexole dihydrochloride tab 1.5 mg (Mirapex) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 103 selegiline hcl cap 5 mg (Eldepryl) 1 carisoprodol tab 250 mg (Soma) 1 selegiline hcl tab 5 mg 1 carisoprodol tab 350 mg (Soma) 1 chlorzoxazone tab 500 mg (Parafon forte dsc) 1 cyclobenzaprine hcl tab 5 mg 1 STALEVO 100 - carbidopalevodopa-entacapone tabs 25-100-200 mg 3 STALEVO 125 - carbidopalevodopa-entacapone tabs 31.25-125-200 mg 3 STALEVO 150 - carbidopalevodopa-entacapone tabs 37.5-150-200 mg 3 STALEVO 200 - carbidopalevodopa-entacapone tabs 50-200-200 mg 3 STALEVO 50 - carbidopalevodopa-entacapone tabs 12.5-50-200 mg 3 STALEVO 75 - carbidopalevodopa-entacapone tabs 18.75-75-200 mg 3 TASMAR - tolcapone tab 100 mg cyclobenzaprine hcl tab 7.5 mg (Fexmid) cyclobenzaprine hcl tab 10 mg dantrolene sodium cap 25 mg (Dantrium) dantrolene sodium cap 50 mg (Dantrium) dantrolene sodium cap 100 mg 1 1 tolcapone tab 100 mg (Tasmar) 1 methocarbamol tab 500 mg (Robaxin) 1 trihexyphenidyl hcl elixir 0.4 mg/ml 1 methocarbamol tab 750 mg (Robaxin-750) 1 1 orphenadrine citrate tab sr 12hr 100 mg 1 NEUROMUSCULAR AGENTS riluzole tab 50 mg (Rilutek) 3 1 MUSCULOSKELETAL THERAPY AGENTS 1 baclofen tab 10 mg baclofen tab 20 mg 1 Limited Distribution 1 metaxalone tab 800 mg (Skelaxin) ZELAPAR - selegiline hcl orally disintegrating tab 1.25 mg ACA 1 3 1 Dispensing Limits 1 3 trihexyphenidyl hcl tab 5 mg Step Therapy 1 METAXALONE - metaxalone tab 400 mg trihexyphenidyl hcl tab 2 mg Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 tizanidine hcl cap 2 mg (base equivalent) (Zanaflex) 1 • tizanidine hcl cap 4 mg (base equivalent) (Zanaflex) 1 • tizanidine hcl cap 6 mg (base equivalent) (Zanaflex) 1 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 104 tizanidine hcl tab 2 mg (base equivalent) tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) ANTIMYASTHENIC AGENTS D-VI-SOL - cholecalciferol oral liquid 400 unit/ml A • DDROPS - cholecalciferol drops 1000 unit/0.03ml (per drop) A • GUANIDINE HCL - guanidine hcl tab 125 mg 3 ergocalciferol cap 50000 unit (Drisdol) 1 MESTINON - pyridostigmine bromide syrup 60 mg/5ml 3 MEPHYTON - phytonadione tab 5 mg 2 pyridostigmine bromide tab cr 180 mg (Mestinon timespan) 1 phytonadione inj 1 mg/0.5ml (2 mg/ml) 1 A • pyridostigmine bromide tab 60 mg (Mestinon) 1 SUPER DAILY D3 cholecalciferol drops 1000 unit/0.03ml (per drop) VITAMELTS VITAMIN D cholecalciferol orally disintegrating tab 1000 unit A • VITAMIN D2 - ergocalciferol tab 400 unit A • VITAMIN D3 - cholecalciferol oral liquid 1200 unit/15ml A • 1 VITAMIN D3 - cholecalciferol spray 1000 unit/spray A • A • A • A • WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000 unit/10ml MULTIVITAMINS A • 3 A • ACTIVE OB - prenatal w/o a w/ fe cbn-fa-dha cap 20-1-320 mg 3 A • ATABEX EC - prenatal vit w/ dss-iron carbonyl-fa tab dr 29-1 mg BAL-CARE DHA - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg 3 NUTRITIONAL PRODUCTS VITAMINS BABY DDROPS cholecalciferol drops 400 unit/0.03ml (per drop) A • 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) cholecalciferol oral liquid 400 unit/ml cholecalciferol tab 400 unit cholecalciferol tab 1000 unit cholecalciferol tab 50000 unit A A A • • Limited Distribution ACA Dispensing Limits Step Therapy • Prior Authorization 1 Drug Name Drug Tier • Limited Distribution 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 105 BP FOLINATAL PLUS B - prenatal w/ calcium carbonate-b6-b12-fa tab 1 mg 3 COMPLETE NATAL DHA prenat-fe bis-fe prot succ-faca tab & omega 3 cap 250 pk 3 BP MULTINATAL PLUS prenatal w/o a vit w/ fe fumfa tab chew 40-1 mg 3 COMPLETENATE - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 3 BP MULTINATAL PLUS prenatal w/o a vit w/ fe fumarate-fa tab 30-1 mg 3 CONCEPT DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg 3 C-BUFF - multiple vitamins w/ minerals powder 3 3 C-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg 3 CONCEPT OB - prenatal w/ o a w/fe fum-fe poly-fa cap 130-92.4-1 mg 3 CALCIUM PNV - prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg 3 DOTHELLE DHA - prenatal w/ fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg 3 CITRANATAL ASSURE prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack 3 DUET DHA BALANCED prenat w/fe poly-na fered-fa tab 25-1 & omega cap 267 mg 3 CITRANATAL B-CALM - prenat w/o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak 3 DUET DHA 400 - prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg ELITE-OB - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg 3 CITRANATAL DHA - prenat w/ o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack 3 ENBRACE HR - prenatal vit w/ fe gly cys-fa-omega 3 fatty acids cap 3 CITRANATAL HARMONY prenat w/o a w/fe fum-fe cbn-dss-fa-dha cap 27-1-260 mg 3 END FATIGUE DAILY ENERGY - multiple vitamins w/ minerals powder 3 EXTRA-VIRT PLUS DHA prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg 3 CITRANATAL RX - prenatal w/ o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg 3 CITRANATAL 90 DHA - prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak 3 FOCALGIN CA - prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack 3 CO-NATAL FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 106 FOCALGIN 90 DHA - prenat w/ o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak 3 FOLCAL DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 3 FOLCAPS OMEGA 3 - prenatal 3 vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg 3 FOLET DHA - prenat w/fecbnbisg-methylf-dss tab dr & dha cap pak 3 FOLET ONE - prenat w/o a w/ fecbn-bisg-methylf-dss-dha cap 38-1-225 mg 3 FOLIVANE-OB - prenatal w/ o a w/fe fum-fe poly-fa cap 130-92.4-1 mg HEMENATAL OB - prenat vit-fe 3 poly cmplx-fe heme poly-fa tab 28-6-1 mg 3 HEMENATAL OB + DHA prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck 3 INATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 3 INATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg INATAL ULTRA - prenatal vit w/ 3 dss-iron carbonyl-fa tab 90-1 mg 3 INFANATE BALANCE prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg 3 M-VIT - prenatal vit w/ fe fumarate-fa tab 27-1 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 2017 MACNATAL CN DHA - prenatal 3 w/o a w/fe cbn-dss-fa-dha cap 28-1-250 mg MARNATAL-F - prenatal w/o vit 3 a w/ fe polysac cmplx-fa cap 60-1 mg 3 MEGA MULTIVITAMIN multiple vitamins w/ minerals powder 3 MYNATAL - prenatal multivitamins & minerals w/ iron & fa cap 1 mg 3 MYNATAL ADVANCE prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 3 MYNATAL PLUS - prenatal vit w/ fe fumarate-fa tab 65-1 mg 3 MYNATAL ULTRACAPLET prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg MYNATAL-Z - prenatal vit w/ fe 3 fumarate-fa tab 65-1 mg 3 MYNATE 90 PLUS - prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg NATACHEW - prenatal vit w/ fe 3 fum-fe bisglycin-fa chew tab 28-1 mg 3 NATALVIT - prenatal vit w/ fe fumarate-fa tab 75-1 mg 3 NATELLE ONE - prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg NEEVO DHA - prenat w/o a w/ 3 fefum-methylfol-omegas cap 27-1.13 mg Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 107 NESTABS - prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg 3 OB COMPLETE/DHA - prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg 3 NESTABS ABC - prenatal w/o vit a w/fe polysac-fa-ca tab & omega 3 cap 3 OBSTETRIX DHA - prenat w/ fecbn-fa-dss tab 29-1 mg & omega 3 cap 387 mg pak 3 NESTABS DHA - prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack 3 OBSTETRIX EC - prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg 3 NEWGEN - prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg 3 OBSTETRIX ONE - prenat w/o a w/fecbn-bisg-methylf-dssdha cap 38-1-225 mg 3 NEXA PLUS - prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg 3 PHLEXY-VITS - multiple vitamins w/ minerals powder 3 PNV FERROUS FUMARATE/ DOCU - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 3 NIVA-PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg 3 O-CAL FA - prenatal vit w/ fe fumarate-fa tab 27-1 mg 3 3 O-CAL PRENATAL - prenatal vit w/ fe fumarate-fa tab 15-1 mg 3 PNV OB+DHA - prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack 3 OB COMPLETE - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg 3 PNV PRENATAL PLUS MULTIVI - prenatal vit w/ fe fumarate-fa tab 27-1 mg 3 OB COMPLETE GOLD prenat w/o a w/fecbnmethfol-fa-dha cap 27.5-1-200 mg 3 PNV TABS 29-1 - prenatal vit w/ iron carbonyl-fa tab 29-1 mg PNV-DHA - prenat w/o a w/ fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg 3 OB COMPLETE ONE prenatal w/o a w/fecbnfe asp glyc-fa-fish cap 50-1-476 mg 3 PNV-DHA+DOCUSATE prenatal w/o vit a w/ fe fumdss-fa-dha cap 27-1.25-300 mg 3 OB COMPLETE PETITE prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg 3 PNV-OMEGA - prenat w/o a w/ fe fumerate-methylfolate-faomega 3 cap 3 PNV-SELECT - prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg 3 OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp glyc-fa tab 30-20-1 mg 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 108 PNV-TOTAL - prenat w/ fe cbn-fe bisglyc-fa-fish oil cap 35-5-1.2 mg 3 PRENAISSANCE NEXT-B prenatal w/ calcium-vit b6-faginger tab 1.22 mg 3 PNV-VP-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg 3 PRENAISSANCE PLUS prenatal w/o a w/fe cbn-dssfa-dha cap 28-1-250 mg 3 PR NATAL 400 - prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk 3 PRENATABS FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg 3 PR NATAL 400 EC - prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk 3 PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg 3 PR NATAL 430 - prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk 3 PRENATAL - prenatal vit w/ fe fumarate-fa tab 27-1 mg 3 PRENATAL PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 PR NATAL 430 EC - prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk 3 3 PRENATAL PLUS IRON prenatal vit w/ iron carbonylfa tab 29-1 mg 3 PREFERA OB - prenat vit-fe poly cmplx-fe heme poly-fa tab 34-1 mg PRENATAL VITAMINS PLUS LO - prenatal vit w/ fe fumarate-fa tab 27-1 mg 2 PREFERAOB +DHA - prenatfe poly cmplx 28mg-fe heme poly-fa tab&dha cap pack 3 PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 3 PREFERAOB ONE - prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg 3 3 3 PRENAISSANCE - prenatal w/ o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 3 PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg 3 PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg PRENATE - prenat mv & min w/ l-methylfolate-fa chew tab 0.6-0.4 mg 3 PRENAISSANCE HARMONY DHA - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg 3 3 PRENAISSANCE NEXT prenatal w/ calcium-vit b6-faginger tab 1.2 mg 3 PRENATE AM - prenatal w/ calcium-vit b6-vit b12-faginger tab 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 109 PRENATE DHA - prenat w/o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg 3 PRENA1 CHEW - prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg 3 PRENATE DHA - prenat w/o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-300 mg 3 PRENA1 PEARL - prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg 3 PRENATE ELITE - prenatal vit w/ fe fum-methylfolate-fa tab 26-0.6-0.4 mg 3 PREPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg 3 3 PRETAB - prenatal vit w/ fe fumarate-fa tab 29-1 mg 3 PRENATE ELITE - prenatal w/ fe asp gly-l methylfol-fa tab 20-0.6-0.4 mg 3 PRENATE ENHANCE - prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg 3 PROVIDA DHA - prenat w/o a w/fe fum-fe poly-fa-dha cap 16-16-1.25-110 mg 3 PRENATE ESSENTIAL prenat w/o a w/feaspmethylf-fa-omeg cap 29-0.6-0.4-340 mg 3 PROVIDA OB - prenatal w/o a w/fe fum-fe poly-fa cap 20-20-1.25 mg 3 PRENATE ESSENTIAL prenat w/o a w/feaspgmethfol-fa-dha cap 18-0.6-0.4-300 mg 3 PUREFE OB PLUS - prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg R-NATAL OB - prenatal w/ o a w/fe cbn-fa-dha cap 20-1-320 mg 3 PRENATE MINI - prenat w/o a w/fecbn-methylf-fa-dha cap 29-0.6-0.4-350 mg 3 RELNATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg 3 PRENATE MINI - prenat w/oa w/fecb-feasp-meth-fa-dha cap 18-0.6-0.4-350 mg 3 RULAVITE DHA - prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg 3 PRENATE PIXIE - prenat w/o a w/feaspg-methfol-fa-dha cap 10-0.6-0.4-200 mg 3 SE-NATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 3 PRENATE RESTORE - prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg 3 SE-NATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg 3 PRENATE STAR - prenatal vit w/ fe asparto glycinate-fa tab 20-1 mg 3 SELECT-OB - prenat w/ fepolycmplx-methylfol-fa chew tab 29-0.6-0.4 mg 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 110 SELECT-OB - prenatal vit w/ fe polysac cmplx-fa chew tab 29-1 mg 3 TRICARE PRENATAL - prenat w/o a w/fepyro-mfol chw 4.5-1 mg & dha cap 150 thpk 3 SELECT-OB+DHA - prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak 3 TRICARE PRENATAL - prenat w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg 3 SUPER NU-THERA - multiple vitamins w/ minerals powder 3 TRICARE PRENATAL COMPLEAT - prenat w/o a fefum-fa tab 27-1 mg & fish oil chew cap pak 3 TRICARE PRENATAL DHA ONE - prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg 3 TRINATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 3 TRINATAL RX 1 - prenatal vit w/ fe fumarate-fa tab 60-1 mg 3 TRINATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg 3 TRISTART DHA - prenat w/o a w/fecbn-methylf-fa-dha cap 31-0.6-0.4-200 mg 3 TRIVEEN-DUO DHA - prenatfe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk 3 TRIVEEN-PRX RNF - prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg 3 ULTIMATECARE ONE prenatal vit w/ fe cbn-fe asp glyc-fa-omega 3 cap 27-1mg 3 ULTIMATECARE ONE NF prenatal w/fe cbnyl-fe asp glyc-fa-dss-omega cap 20-7-1 mg 3 TARON-BC - prenat w/o a w/ fe 3 cbnyl-fa tab 20-1 mg & vit b6 tab pak TARON-C DHA - prenatal w/fe 3 fum-fe poly -fa-omega 3 cap 53.5-38-1 mg 3 TARON-PREX - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 30-1.2-265 mg 3 THRIVITE RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg 3 THRIVITE 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg 3 TL FOLATE - prenatal vit w/ fe fum-methylfolate-fa tab 27-0.5-0.5 mg 3 TL-CARE DHA - prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg 3 TL-SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg 3 TRI-TABS DHA - prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack TRIADVANCE - prenatal vit w/ 3 dss-iron carbonyl-fa tab 90-1 mg 3 TRICARE - prenatal vit w/ fe fumarate-fa tab 27-1 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 111 VEMAVITE-PRX 2 - prenatal w/ 3 o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg 3 VENA-BAL DHA - prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg 3 VINATE DHA RF - prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg 3 VINATE II - prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg VINATE M - prenatal vit w/ sel- 3 fe fumarate-fa tab 27-1 mg 3 VINATE ONE - prenatal vit w/ fe fumarate-fa tab 60-1 mg 3 VIRT NATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg 3 VIRT-ADVANCE - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 3 VIRT-C DHA - prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg 3 VIRT-CARE ONE - prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg 3 VIRT-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg 3 VIRT-PN - prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg 3 VIRT-PN DHA - prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg 3 VIRT-PN PLUS - prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap VIRT-SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg 3 VIRT-VITE GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg 3 VIRTPREX - prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg 3 VITA-PREN - prenatal vit w/ docusate-iron-fa tab 65-1 mg 3 VITAFOL FE+ - prenat-fepolymethol-fa-dha cap 90-1-200 mg & dss 50mg cap 3 VITAFOL ULTRA - prenat w/ fe poly-methylfol-fa-dha cap 29-0.6-0.4-200 mg 3 VITAFOL-NANO - prenatal w/o a w/ fefum-l methylfol-fa tab 18-0.6-0.4 mg 3 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 2017 VITAFOL-OB - prenatal vit w/ fe 3 fumarate-fa tab 65-1 mg 3 VITAFOL-OB+DHA - prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack VITAFOL-ONE - prenatal mv w/ 3 fe polysac cmplx-fa-dha cap 29-1-200 mg 3 VITAMEDMD ONE RX/ QUATREFO - prenat w/o a w/fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg VITAMEDMD REDICHEW RX - 3 prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg 3 VITAPEARL - prenat w/oa w/ fefum-na fered-fa-dha cap cr 30-1.4-200 mg Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 112 VITATRUE - prenat w/o a w/fe chel-fa tab 30-1.4 mg & dha cap 300mg pk 3 ZATEAN-PN PLUS - prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap VIVA DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg 3 VOL-NATE - prenatal vit w/ fe fumarate-fa tab 28-1 mg 3 VOL-PLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg 3 VOL-TAB RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg 3 VP-CH PLUS - prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg 3 VP-CH-PNV - prenatal w/o vit a w/ fe cbn-dss-fa-dha cap 30-1-260 mg 3 VP-GGR-B6 PRENATAL prenatal w/ calcium-vit b6-faginger tab 1.2 mg 3 VP-HEME OB - prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg 3 VP-HEME OB + DHA - prenatfe poly cmplx-fe heme polyfa tab & omega 3 cap pck 3 MINERALS and ELECTROLYTES FLORICAL - sodium fluoride w/ A calcium carb cap 8.3-364 mg FLORICAL - sodium fluoride w/ A calcium carb tab 8.3-364 mg 3 FLORIVA - sodium fluoridevitamin d liqd drops 0.25 mg/ ml-400 unit/ml 3 FLUOR-A-DAY - sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg 3 FLUOR-A-DAY - sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg FLUORABON - sodium fluoride 3 soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf) 3 FLURA-DROPS - sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) 3 GALZIN - zinc acetate cap 25 mg (elemental zinc) 3 GALZIN - zinc acetate cap 50 mg (elemental zinc) K-TAB - potassium chloride tab 3 cr 8 meq (600 mg) K-TAB - potassium chloride tab 3 cr 20 meq (1500 mg) 3 KLOR-CON M15 - potassium chloride microencapsulated crys cr tab 15 meq 3 LOZI-FLUR - sodium fluoride lozenge 1 mg f (from 2.2 mg naf) VP-HEME ONE - prenat-fe poly 3 cmplx-fe heme poly-fa-dha cap 22-6-1-200 mg 3 VP-PNV-DHA - prenatal vit w/ fe fum-fa-omega 3 cap 28-1-215.8 mg 3 ZATEAN-CH - prenatal w/o a w/fe cbn-dss-fa-dha cap 27-1-250 mg 3 ZATEAN-PN DHA - prenat w/ o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 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 2017 3 • • • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 113 POTASSIUM CHLORIDE potassium chloride oral soln 20% (40 meq/15ml) 1 potassium chloride cap cr 8 meq (Micro-k) 1 potassium chloride cap cr 10 meq (Micro-k) 1 SODIUM FLUORIDE - sodium fluoride tab 1 mg f (from 2.2 mg naf) 3 • sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride) 1 • sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride) 1 • sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride) 1 • 1 • 1 • POTASSIUM CHLORIDE ER potassium chloride tab cr 8 meq (600 mg) 3 sodium fluoride soln 0.125 mg/drop f (0.275 mg/ drop naf) POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq (1500 mg) 3 sodium fluoride soln 0.5 mg/ ml f (from 1.1 mg/ml naf) (Luride) potassium chloride microencapsulated crys cr tab 10 meq 1 potassium chloride microencapsulated crys cr tab 20 meq potassium chloride oral soln 10% (20 meq/15ml) potassium chloride powder packet 20 meq potassium chloride tab cr 8 meq (600 mg) potassium chloride tab cr 10 meq (K-tab) SODIUM FLUORIDE - sodium fluoride tab 0.5 mg f (from 1.1 mg naf) NUTRIENTS ADD-INS COMPLETE - amino acids pack 3 amino acids cap 1 1 1 amino acids tab ARGIMENT - amino acids pack 3 3 1 ARGIMENT AT - amino acids pack 3 1 COMPLETE AMINO ACID MIX - amino acids oral powder 1 COMPLEX ESSENTIAL MSD amino acids oral powder 3 1 COMPLEX JUNIOR MSD amino acids oral powder 3 COMPLEX MSUD - amino acids oral powder 3 COMPLEX MSUD AMINO ACID B - amino acids bar 3 DEQUASINE - amino acids tab 3 3 • Limited Distribution • ACA A Dispensing Limits MONOCAL - sodium monofluorophosphatecalcium carb tab 22.75-625 mg Step Therapy • Prior Authorization 3 Drug Name Drug Tier LURIDE - sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 114 ESSENTIAL AMINO ACID MIX - amino acids oral powder 3 PHENYLADE PHEBLOC amino acids oral powder 3 PHENYLADE PHEBLOC amino acids tab 3 G-PREPROTEIN - amino acids oral liquid 3 PHENYLADE40 DRINK MIX amino acids pack 3 GLUTARADE AMINO ACID BLEN - amino acids oral powder 3 PHLEXY-10 - amino acids cap 3 GLUTARADE ESSENTIAL GA-1 - amino acids oral powder 3 PREPROTEIN - amino acids oral liquid 3 3 GLUTARADE JUNIOR GA-1 amino acids oral powder 3 PREPROTEIN 20 - amino acids oral liquid SOLVIL - amino acids pack 3 HEPAMENT - amino acids pack 3 SUPER-AMINO 1600 - amino acids tab 3 L-CARNITINE - amino acids oral liquid 3 TRIAMINO - amino acids tab 3 3 LIQUACEL - amino acids oral liquid 3 XPHE MAXAMUM - amino acids oral powder 3 LIQUACEL PUMP + GO amino acids oral liquid 3 XPHE MAXAMUM - amino acids pack NUTRASENTIALS - amino acids oral powder 3 NUTRESTORE - glutamine powd pack 5 gm 3 PERIFLEX LQ PKU - amino acids oral liquid 3 PHENYLADE - amino acids oral powder 3 PHENYLADE AMINO ACID amino acids bar 3 PHENYLADE AMINO ACID BLEN - amino acids pack 3 PHENYLADE MTE - amino acids oral powder 3 PHENYLADE MTE AMINO ACID - amino acids pack 3 DIETARY PRODUCTS A-SOY - nutritional supplement liquid 3 ACERFLEX - nutritional supplement powder 3 ADVERA - nutritional supplement liquid 3 ALITRAQ - nutritional supplement pack 3 ARGINAID - nutritional supplement pack 3 ARGINAID EXTRA - nutritional supplement liquid 3 BALANCE TOTAL NUTRITIONAL - nutritional supplement liquid 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 115 3 BALANCED NUTRITIONAL DRIN - nutritional supplement liquid 3 BALANCED NUTRITIONAL SHAK - nutritional supplement liquid 3 BCAD 1 - nutritional supplement powder 3 BCAD 2 - nutritional supplement powder 3 BEEF/POTATOES/PEAS nutritional supplement liquid 3 BENECALORIE - nutritional supplement liquid 3 BOOST - nutritional supplement liquid 3 BOOST BREEZE - nutritional supplement liquid 3 BOOST CALORIE SMART nutritional supplement liquid BOOST COMPACT - nutritional 3 supplement liquid 3 BOOST GLUCOSE CONTROL - nutritional supplement liquid 3 BOOST HIGH PROTEIN nutritional supplement liquid 3 BOOST HIGH PROTEIN nutritional supplement powder 3 BOOST KID ESSENTIALS 1.0 - nutritional supplement liquid 3 BOOST KID ESSENTIALS 1.5 - nutritional supplement liquid 3 BOOST KIDS ESSENTIALS nutritional supplement liquid BOOST PLUS - nutritional supplement liquid 3 BOOST PUDDING - nutritional supplement pudding 3 BOOST SMOOTHIE nutritional supplement liquid 3 BOOST VHC - nutritional supplement liquid 3 BOOST 100 CALORIE SMART - nutritional supplement liquid 3 BOOST/BENEFIBER nutritional supplement liquid 3 CALCILO XD - infant foods powder 3 CAMINO PRO BETTERMILK/ GLY - nutritional supplement pack 3 CAMINO PRO COMPLETE/ GLYTA - nutritional supplement bar 3 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 2017 CAMINO PRO PKU - nutritional 3 supplement liquid 3 CAMINO PRO RESTORE/ GLYTAC - nutritional supplement liquid 3 CAMINO PRO SWIRL nutritional supplement pack 3 CAMINO PRO 15PE nutritional supplement liquid 3 CARNATION BREAKFAST ESSEN - nutritional supplement liquid 3 CARNATION BREAKFAST ESSEN - nutritional supplement pack 3 CARNATION INSTANT BREAKFA - nutritional supplement liquid Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 116 CHOICE DM - nutritional supplement liquid 3 CYCLINEX-1 - nutritional supplement powder 3 CHOICE DM TF - nutritional supplement liquid 3 CYCLINEX-2 - nutritional supplement powder 3 CHOLEXTRA - nutritional supplement powder 3 DIABETIC TF - nutritional supplement liquid 3 CLICK ESPRESSO PROTEIN DR - nutritional supplement powder 3 DIABETISHIELD - nutritional supplement liquid 3 DIABETISOURCE - nutritional supplement liquid 3 COMPLEAT - nutritional supplement liquid 3 DIABETISOURCE AC nutritional supplement liquid 3 COMPLEAT CLOSED SYSTEM - nutritional supplement liquid 3 3 COMPLEAT PEDIATRIC nutritional supplement liquid 3 DUOCAL - nutritional supplement powder 3 COMPLEAT PEDIATRIC REDUCE - nutritional supplement liquid 3 EAA SUPPLEMENT nutritional supplement pack EGG/PRO - nutritional supplement powder 3 COMPLETE NUTRITION nutritional supplement liquid 3 ELECARE - nutritional supplement powder 3 COMPLETE NUTRITION PLUS - nutritional supplement liquid 3 ELECARE JR - nutritional supplement powder 3 3 COMPLETE PROTEIN & VITAMI - nutritional supplement powder 3 ELECARE/DHA/ARA nutritional supplement powder 3 CRITICARE HN - nutritional supplement liquid 3 ENLIVE - nutritional supplement liquid 3 CRUCIAL - nutritional supplement liquid 3 ENSURE - nutritional supplement bar 3 CVS NUTRITION LIQUID nutritional supplement liquid 3 ENSURE - nutritional supplement liquid 3 CVS NUTRITION PLUS nutritional supplement liquid 3 ENSURE - nutritional supplement powder 3 CVS NUTRITIONAL SHAKE nutritional supplement liquid 3 ENSURE ACTIVE - nutritional supplement liquid ENSURE ACTIVE HEART HEALT - nutritional supplement liquid 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 117 ENSURE ACTIVE HIGH PROTEI - nutritional supplement liquid 3 ENSURE NUTRA SHAKE HICAL - nutritional supplement liquid 3 ENSURE ACTIVE LIGHT nutritional supplement liquid 3 3 ENSURE BONE HEALTH REVIGO - nutritional supplement liquid 3 ENSURE NUTRITION SHAKE - nutritional supplement liquid ENSURE PLUS - nutritional supplement liquid 3 ENSURE CLEAR - nutritional supplement liquid 3 ENSURE CLINICAL STRENGTH - nutritional supplement liquid 3 ENSURE COMPACT nutritional supplement liquid 3 ENSURE COMPLETE nutritional supplement liquid 3 ENSURE COMPLETE NUTRITION - nutritional supplement liquid 3 ENSURE ENLIVE - nutritional supplement liquid 3 ENSURE HEALTHY MOM nutritional supplement bar 3 ENSURE HEALTHY MOM nutritional supplement liquid 3 ENSURE HIGH CALCIUM nutritional supplement liquid 3 ENSURE HIGH PROTEIN nutritional supplement liquid 3 ENSURE HIGH PROTEIN nutritional supplement powder 3 ENSURE IMMUNE HEALTH nutritional supplement liquid 3 ENSURE MUSCLE HEALTH REVI - nutritional supplement liquid 3 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 2017 ENSURE PLUS HN - nutritional 3 supplement liquid 3 ENSURE PRE-SURGERY nutritional supplement liquid 3 ENSURE PUDDING nutritional supplement pudding 3 ENSURE SURGERY IMMUNONUTR - nutritional supplement liquid 3 ENSURE/FIBER - nutritional supplement liquid 3 ENU NUTRITIONAL SHAKE nutritional supplement liquid 3 EO28 SPLASH - nutritional supplement liquid 3 EQ NUTRITIONAL SHAKE nutritional supplement liquid 3 EQ NUTRITIONAL SHAKE PLUS - nutritional supplement liquid 3 EQ WEIGHT LOSS SHAKE ULTR - nutritional supplement liquid 3 EQUATE - nutritional supplement liquid 3 EQUATE PLUS - nutritional supplement liquid 3 F.A.A. - nutritional supplement liquid Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 118 FIBER FLOW - nutritional supplement liquid 3 GLUCERNA CARBSTEADY nutritional supplement liquid 3 FIBER-STAT - nutritional supplement liquid 3 3 FIBERSOURCE CLOSED SYSTEM - nutritional supplement liquid 3 GLUCERNA CEREAL CRUNCHY F - nutritional supplement misc 3 FIBERSOURCE HN nutritional supplement liquid 3 GLUCERNA CRISPY DELIGHTS - nutritional supplement bar 3 FIBERSOURCE HN CLOSED SYS - nutritional supplement liquid 3 GLUCERNA HUNGER SMART SHA - nutritional supplement liquid GLUCERNA MEAL - nutritional supplement bar 3 GLUCERNA MEAL REPLACEMENT - nutritional supplement bar 3 GLUCERNA MINI SNACK nutritional supplement bar 3 GLUCERNA MINI SNACKS nutritional supplement bar 3 GLUCERNA OS - nutritional supplement liquid 3 GLUCERNA SELECT nutritional supplement liquid 3 GLUCERNA SHAKE nutritional supplement liquid 3 GLUCERNA SNACK nutritional supplement bar 3 GLUCERNA SNACK SHAKE nutritional supplement liquid 3 GLUCERNA WEIGHT LOSS SHAK - nutritional supplement liquid 3 GLUCERNA 1.0 CAL nutritional supplement liquid 3 GLUCERNA 1.0 CAL/FIBER nutritional supplement liquid 3 FLAVOR PACKETS - nutritional 3 supplement flavor pack 3 FLAVOUR PAC - nutritional supplement flavor pack 3 FORTA DRINK - nutritional supplement powder 3 FORTA SHAKE - nutritional supplement powder 3 FRUITIVITS - nutritional supplement pack 3 GA - nutritional supplement powder 3 GA EXPRESS15 - nutritional supplement pack 3 GA GEL - nutritional supplement pack 3 GA-1 ANAMIX EARLY YEARS - nutritional supplement powder 3 GLUCERNA - nutritional supplement bar 3 GLUCERNA - nutritional supplement liquid 3 GLUCERNA ADVANCE SHAKE - 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 119 GLUCERNA 1.0 WITH CARBSTE - nutritional supplement liquid 3 GLYTACTIN RTD 15 nutritional supplement liquid 3 GLYTROL - nutritional supplement liquid 3 GLUCERNA 1.2 CAL nutritional supplement liquid 3 GLYTROL PREBIO1 nutritional supplement liquid 3 GLUCERNA 1.5 CAL nutritional supplement liquid 3 3 GNP NUTRITIONAL DRINK nutritional supplement liquid 3 GLUCO BURST - nutritional supplement liquid GNP NUTRITIONAL DRINK PLU - nutritional supplement liquid 3 GLUTAREX-1 - nutritional supplement powder 3 GLUTAREX-2 - nutritional supplement powder 3 GOAT MILK - nutritional supplement powder 3 GLYCOSADE - nutritional supplement pack 3 3 GLYTACTIN BETTERMILK DE-L - nutritional supplement pack 3 HAELAN HTPI FERMENTED ORG - nutritional supplement liquid HAELAN 951 FERMENTED ORGA - nutritional supplement liquid 3 GLYTACTIN BETTERMILK 15 - 3 nutritional supplement pack 3 GLYTACTIN BUILD 10PE nutritional supplement pack 3 GLYTACTIN COMPLETE 10PE - nutritional supplement bar 3 GLYTACTIN RESTORE LITE 10 - nutritional supplement liquid 3 GLYTACTIN RESTORE LITE 10 - nutritional supplement pack 3 GLYTACTIN RESTORE 10 nutritional supplement liquid 3 GLYTACTIN RESTORE 5 nutritional supplement pack 3 GLYTACTIN RTD 10 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 2017 HCU ANAMIX EARLY YEARS - 3 nutritional supplement powder 3 HCU ANAMIX NEXT nutritional supplement powder 3 HCU COOLER - nutritional supplement liquid 3 HCU EXPRESS - nutritional supplement pack HCU EXPRESS20 - nutritional 3 supplement pack 3 HCU GEL - nutritional supplement pack HCU LOPHLEX LQ - nutritional 3 supplement liquid HCY 1 - nutritional supplement 3 powder Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 120 HCY 2 - nutritional supplement powder 3 HEALTH SOURCE SOY PROTEIN - nutritional supplement powder 3 HEALTHY ACCENTS NUTRA FIT - nutritional supplement liquid 3 HEARTBAR - nutritional supplement bar 3 HI-CAL - nutritional supplement 3 liquid 3 HIGH-PROTEIN NUTRITIONAL - nutritional supplement liquid 3 HM NUTRISURE - nutritional supplement liquid 3 HM NUTRISURE PLUS nutritional supplement liquid HOM 2 - nutritional supplement 3 powder 3 HOMACTIN AA PLUS nutritional supplement liquid 3 HOMINEX-1 - nutritional supplement powder 3 HOMINEX-2 - nutritional supplement powder 3 I-VALEX-1 - nutritional supplement powder 3 I-VALEX-2 - nutritional supplement powder 3 IMMULIFE - nutritional supplement powder 3 IMMUNOPRO RX - nutritional supplement powder 3 IMPACT - nutritional supplement liquid IMPACT ADVANCED RECOVERY - nutritional supplement liquid 3 IMPACT GLUTAMINE nutritional supplement liquid 3 IMPACT PEPTIDE 1.5 nutritional supplement liquid 3 IMPACT 1.5 - nutritional supplement liquid 3 IMPACT/FIBER - nutritional supplement liquid 3 IMUPLUS - nutritional supplement pack 3 INNOVACIN - nutritional supplement liquid 3 INTROLITE - nutritional supplement liquid 3 ISOCAL - nutritional supplement liquid 3 ISOCAL HN - nutritional supplement liquid 3 ISOCAL HN PLUS - nutritional supplement liquid 3 ISOSOURCE - nutritional supplement liquid 3 ISOSOURCE CLOSED SYSTEM - nutritional supplement liquid 3 ISOSOURCE HN - nutritional supplement liquid 3 ISOSOURCE VHN - nutritional supplement liquid 3 ISOSOURCE 1.5 CAL nutritional supplement liquid 3 ISOVACTIN AA PLUS nutritional supplement liquid 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 121 IVA ANAMIX EARLY YEARS nutritional supplement powder 3 KETOCAL 4:1 LQ MULTI FIBE - nutritional supplement liquid 3 IVA ANAMIX NEXT - nutritional supplement powder 3 KETOGEN - nutritional supplement powder 3 JEVITY 1 CAL - nutritional supplement liquid 3 KETONEX-1 - nutritional supplement powder 3 JEVITY 1 CAL/FIBER nutritional supplement liquid 3 KETONEX-2 - nutritional supplement powder 3 JEVITY 1.2 CAL - nutritional supplement liquid 3 KETOVIE - nutritional supplement liquid 3 JEVITY 1.2 CAL/FIBER nutritional supplement liquid 3 KETOVIE PEPTIDE nutritional supplement liquid 3 JEVITY 1.5 CAL - nutritional supplement liquid 3 KETOVOLVE 4:1 - nutritional supplement powder 3 JEVITY 1.5 CAL/FIBER nutritional supplement liquid 3 KINRAY PREFERRED PLUS nutritional supplement liquid 3 JUICE PLUS FIBRE nutritional supplement liquid 3 LANAFLEX - nutritional supplement pack 3 LEU-FREE COOLER nutritional supplement liquid 3 LIPISTART - nutritional supplement powder 3 LIQUID HOPE - nutritional supplement liquid 3 LMD - nutritional supplement powder 3 LOPHLEX - nutritional supplement pack 3 LOPHLEX LQ 20 - nutritional supplement liquid 3 LPS CRITICAL CARE SUGAR F - nutritional supplement liquid 3 LPS SUGAR FREE - nutritional supplement liquid 3 MCT PRO-CAL - nutritional supplement pack 3 JUVEN - nutritional supplement 3 pack JUVEN - nutritional supplement 3 powder 3 JUVEN NUTRIVIGOR nutritional supplement pack 3 JUVEN REVIGOR - nutritional supplement pack 3 K-PAX IMMUNE BOOSTER PROT - nutritional supplement powder 3 KETOCAL 3:1 - nutritional supplement powder 3 KETOCAL 4:1 - nutritional supplement liquid 3 KETOCAL 4:1 - 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 122 MCT PROCAL - nutritional supplement powder 3 MSUD LOPHLEX LQ nutritional supplement liquid 3 MERITENE - nutritional supplement powder 3 MSUD MAXAMAID - nutritional supplement powder 3 METAFORM - nutritional supplement pack 3 MSUD MAXAMUM - nutritional supplement powder 3 METHIONAID - nutritional supplement powder 3 MSUD 2 - nutritional supplement powder 3 MMA/PA ANAMIX EARLY YEARS - nutritional supplement powder 3 NEOCATE INFANT DHA/ ARA - nutritional supplement powder 3 MMA/PA ANAMIX NEXT nutritional supplement powder 3 MMA/PA COOLER - nutritional supplement liquid 3 MMA/PA COOLER15 nutritional supplement liquid 3 MMA/PA GEL - nutritional supplement pack 3 MODULEN IBD - nutritional supplement powder 3 MONOGEN - nutritional supplement powder 3 MSUD AID - nutritional supplement powder 3 MSUD ANAMIX EARLY YEARS - nutritional supplement powder 3 MSUD COOLER - nutritional supplement liquid 3 MSUD EXPRESS - nutritional supplement pack 3 MSUD EXPRESS20 nutritional supplement pack 3 MSUD GEL - nutritional supplement pack 3 NEOCATE JUNIOR - nutritional 3 supplement powder 3 NEOCATE JUNIOR/ PREBIOTICS - nutritional supplement powder NEOCATE NUTRA - nutritional 3 supplement powder 3 NEOCATE SPLASH nutritional supplement liquid 3 NEPRO - nutritional supplement liquid 3 NEPRO WITH CARB STEADY - nutritional supplement liquid 3 NEPRO WITH CARBSTEADY - nutritional supplement liquid 3 NESTLE FLAVOR - nutritional supplement flavor pack 3 NESTLE FLAVOR EXTRA STREN - nutritional supplement flavor pack NESTLE FLAVOR FOR KIDS - 3 nutritional supplement flavor pack 3 NOURISH - 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 123 NOVASOURCE PULMONARY - nutritional supplement liquid 3 NUTRAMINE APPLE AMINO BIT - nutritional supplement pack 3 NOVASOURCE RENAL nutritional supplement liquid 3 3 NUTRA BALANCE DIABETIC NU - nutritional supplement bar 3 NUTRAMINE BANANA AMINO B - nutritional supplement pack 3 NUTRA BALANCE FIBER COOKI - nutritional supplement misc 3 NUTRAMINE CHOCOLATE AMINO - nutritional supplement pack 3 NUTRA BALANCE PROTEIN FOR - nutritional supplement misc 3 NUTRAMINE MANGO AMINO BI - nutritional supplement pack 3 NUTRA SHAKE - nutritional supplement liquid (frozen) 3 NUTRAMINE MIXED FLAVORS A - nutritional supplement pack 3 NUTRA SHAKE/SUPREME nutritional supplement liquid (frozen) 3 NUTRAMINE PEACHES & CREAM - nutritional supplement pack 3 NUTRA/BALANCE RE/GEN nutritional supplement liquid (frozen) 3 NUTRAMINE PINEAPPLE AMINO - nutritional supplement pack 3 NUTRA/BALANCE RE/ GEN FREE - nutritional supplement liquid (frozen) 3 NUTREN JR - nutritional supplement liquid NUTREN JR FIBER nutritional supplement liquid 3 NUTRA/SHAKE - nutritional supplement liquid (frozen) 3 NUTREN JUNIOR - nutritional supplement liquid 3 NUTRA/SHAKE FRUIT PLUS nutritional supplement liquid (frozen) 3 NUTREN JUNIOR 1.0 nutritional supplement liquid 3 NUTREN JUNIOR/FIBER nutritional supplement liquid 3 NUTRA/SHAKE SUPREME nutritional supplement liquid (frozen) 3 3 NUTRA/SHAKE SUPREME nutritional supplement liquid 3 NUTREN PULMONARY nutritional supplement liquid 3 NUTRAMENT - nutritional supplement liquid 3 NUTREN RENAL - nutritional supplement liquid 3 NUTRAMINE - nutritional supplement pack 3 NUTREN 1.0 - nutritional supplement liquid NUTREN 1.0 CAL - nutritional supplement liquid 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 124 NUTREN 1.0/FIBER nutritional supplement liquid 3 NUTREN 1.0/FIBER/ ULTRAPAK - nutritional supplement liquid 3 NUTREN 1.5 - nutritional supplement liquid 3 NUTREN 1.5 CAL - nutritional supplement liquid 3 NUTREN 1.5 FIBER nutritional supplement liquid NUTRITIONAL SHAKE COMPLET - nutritional supplement liquid 3 NUTRITIONAL SHAKE PLUS nutritional supplement liquid 3 NUTRITIONAL SHAKE PLUS PR - nutritional supplement liquid 3 3 3 NUTRITIONAL SUPPLEMENT - nutritional supplement liquid NUTREN 2.0 - nutritional supplement liquid 3 nutritional supplement liquid 1 3 NUTREN 2.0 CAL - nutritional supplement liquid 3 NUTRITIONAL SUPPLEMENT PL - nutritional supplement liquid NUTRICIA PREOP - nutritional supplement pack 3 NUTRIVENT - nutritional supplement liquid 3 NUTRIFOCUS - nutritional supplement liquid 3 NUTRIVENT 1.5 - nutritional supplement liquid 3 NUTRIHEAL - nutritional supplement liquid 3 NUTRIVIR - nutritional supplement powder 3 NUTRIHEP 1.5 CAL nutritional supplement liquid 3 NUTRIVIR NSA - nutritional supplement powder 3 NUTRIRENAL - nutritional supplement liquid 3 OA 1 - nutritional supplement powder 3 NUTRITIONAL DRINK nutritional supplement liquid 3 OA 2 - nutritional supplement powder 3 NUTRITIONAL DRINK MIX nutritional supplement powder 3 OPTIMENTAL - nutritional supplement liquid 3 3 NUTRITIONAL DRINK PLUS nutritional supplement liquid 3 OPTISOURCE VERY HIGH PROT - nutritional supplement liquid NUTRITIONAL DRINK SHAKE M - nutritional supplement powder 3 ORANGE CHICKEN/ CARROTS/BR - nutritional supplement liquid 3 NUTRITIONAL SHAKE nutritional supplement liquid 3 ORGANIC PEDIA SMART nutritional supplement powder 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 125 OS 2 - nutritional supplement powder 3 OSMOLITE - nutritional supplement liquid 3 3 PEDIASURE SHAKE WITH FIBE - nutritional supplement liquid 3 OSMOLITE HN - nutritional supplement liquid 3 PEDIASURE SIDEKICKS nutritional supplement liquid 3 OSMOLITE 1 CAL - nutritional supplement liquid 3 PEDIASURE SIDEKICKS nutritional supplement powder OSMOLITE 1.2 CAL nutritional supplement liquid 3 3 OSMOLITE 1.5 CAL nutritional supplement liquid 3 PEDIASURE SIDEKICKS CLEAR - nutritional supplement liquid 3 OXEPA - nutritional supplement liquid 3 PEDIASURE SIDEKICKS SHAKE - nutritional supplement liquid OXEPA 1.5 - nutritional supplement liquid 3 PEDIASURE WITH FIBER nutritional supplement liquid 3 PEDIASURE - nutritional supplement liquid 3 PEDIASURE 1.0 CAL/FIBER nutritional supplement liquid 3 PEDIASURE ENTERAL FORMULA - nutritional supplement liquid 3 PEDIASURE 1.5 CAL nutritional supplement liquid 3 3 PEDIASURE GROW & GAIN nutritional supplement liquid 3 PEDIASURE 1.5 CAL WITH FI - nutritional supplement liquid PEDIASURE NUTRIPALS nutritional supplement bar 3 PEDIASURE 1.5 CAL/FIBER nutritional supplement liquid 3 PEDIASURE NUTRIPALS nutritional supplement liquid 3 PEDIATRIC DRINK - nutritional supplement liquid 3 PEDIASURE PEDIATRIC nutritional supplement liquid 3 PEDIATRIC PEPTINEX DT nutritional supplement liquid 3 PEDIASURE PEPTIDE 1.0 CAL - nutritional supplement liquid 3 PEDIATRIC PEPTINEX DT/ FIB - nutritional supplement liquid 3 PEDIASURE PEPTIDE 1.5 CAL - nutritional supplement liquid 3 PEPDITE JUNIOR - nutritional supplement pack 3 3 PEDIASURE SHAKE MIX nutritional supplement powder 3 PEPTAMEN - nutritional supplement liquid PEPTAMEN AF - nutritional supplement liquid 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 126 PEPTAMEN BARIATRIC nutritional supplement liquid 3 PEPTAMEN INTENSE VHP nutritional supplement liquid 3 3 PEPTAMEN 1.5 CAL/ PREBIO1 - nutritional supplement liquid 3 PEPTAMEN JUNIOR nutritional supplement liquid 3 PEPTAMEN/PREBIO1 nutritional supplement liquid 3 PEPTAMEN JUNIOR nutritional supplement powder 3 PEPTINEX DT - nutritional supplement liquid 3 PEPTAMEN JUNIOR FIBER nutritional supplement liquid 3 PEPTINEX DT WITH PREBIOTI - nutritional supplement liquid 3 PEPTAMEN JUNIOR HP nutritional supplement liquid 3 PEPTINEX 1.0 - nutritional supplement liquid 3 PEPTAMEN JUNIOR 1 CAL nutritional supplement liquid 3 PEPTINEX 1.5 - nutritional supplement liquid 3 PEPTAMEN JUNIOR 1 CAL/ PRE - nutritional supplement liquid 3 PERATIVE - nutritional supplement liquid PERIFLEX ADVANCE nutritional supplement powder 3 PERIFLEX JUNIOR nutritional supplement powder 3 PFD 1 - nutritional supplement powder 3 PFD 2 - nutritional supplement powder 3 PHENACTIN AA PLUS nutritional supplement liquid 3 PHENEX-1 - nutritional supplement powder 3 PHENEX-2 - nutritional supplement powder 3 PHENYL-FREE 2 - nutritional supplement powder 3 PHENYL-FREE 2HP nutritional supplement powder 3 PEPTAMEN JUNIOR 1.5 CAL - 3 nutritional supplement liquid 3 PEPTAMEN JUNIOR/ PREBIO1 - nutritional supplement liquid 3 PEPTAMEN OS - nutritional supplement liquid PEPTAMEN OS 1.5 - nutritional 3 supplement liquid 3 PEPTAMEN VHP - nutritional supplement liquid PEPTAMEN 1 CAL - nutritional 3 supplement liquid PEPTAMEN 1 CAL/PREBIO1 - 3 nutritional supplement liquid 3 PEPTAMEN 1.5 - nutritional supplement liquid 3 PEPTAMEN 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 127 PHENYLADE DRINK MIX nutritional supplement powder 3 PKU GEL - nutritional supplement pack 3 PKU LOPHLEX LQ 20 nutritional supplement liquid 3 PHENYLADE ESSENTIAL DRINK - nutritional supplement pack 3 3 PHENYLADE ESSENTIAL DRINK - nutritional supplement powder 3 PKU PERIFLEX EARLY YEARS - nutritional supplement powder 3 PHENYLADE GMP - nutritional supplement pack 3 PKU PERIFLEX JUNIOR PLUS - nutritional supplement powder PKU SPHERE 20 - nutritional supplement pack 3 PHENYLADE GMP - nutritional supplement powder 3 PKU TRIO - nutritional supplement powder 3 PHENYLADE GMP MIX-IN nutritional supplement pack 3 PKU 2 - nutritional supplement powder 3 PHENYLADE RTD PKU 10 nutritional supplement liquid 3 3 PKU 3 - nutritional supplement powder 3 PHENYLADE60 DRINK MIX nutritional supplement pack POLYCAL - nutritional supplement powder 3 PHENYLADE60 DRINK MIX nutritional supplement powder 3 3 PHLEXY-10 - nutritional supplement pack 3 PORTAGEN - nutritional supplement powder 3 PHYTOFUSION - nutritional supplement pack 3 PPA/MMA EXPRESS nutritional supplement pack 3 PIVOT 1.5 CAL - nutritional supplement liquid 3 PRO-CAL - nutritional supplement pack 3 PKU COOLER 10 - nutritional supplement liquid 3 PRO-CAL - nutritional supplement powder 3 PKU COOLER 15 - nutritional supplement liquid 3 PRO-PHREE - nutritional supplement powder 3 PKU COOLER 20 - nutritional supplement liquid 3 PROBALANCE - nutritional supplement liquid 3 PKU EXPRESS - nutritional supplement pack 3 PROMACTIN AA PLUS nutritional supplement liquid 3 PKU EXPRESS20 - nutritional supplement pack 3 PROMOD - nutritional supplement liquid PROMOD - nutritional supplement powder 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 128 PROMOTE - nutritional supplement liquid 3 PULMOCARE 1.5 - nutritional supplement liquid 3 PROMOTE WITH FIBER nutritional supplement liquid 3 PX VANILLA PLUS - nutritional supplement liquid 3 PROMOTE 1.0 - nutritional supplement liquid 3 QUINOA KALE & HEMP nutritional supplement liquid 3 PROMOTE 1.0 WITH FIBER nutritional supplement liquid 3 3 PROMOTE/FIBER - nutritional supplement liquid 3 RA BALANCED NUTRITIONAL - nutritional supplement liquid 3 PROPIMEX-1 - nutritional supplement powder 3 RA BALANCED NUTRITIONAL P - nutritional supplement liquid PROPIMEX-2 - nutritional supplement powder 3 3 PROSOURCE - nutritional supplement liquid 3 RA NUTRITIONAL SUPPLEMENT - nutritional supplement liquid PROSOURCE - nutritional supplement powder 3 PROSOURCE NO CARB nutritional supplement liquid 3 PROSOURCE PLUS nutritional supplement liquid 3 PROSOURCE TF - nutritional supplement liquid 3 PROSOURCE ZAC - nutritional 3 supplement liquid 3 PROSURE - nutritional supplement liquid 3 PROTAIN XL - nutritional supplement liquid 3 PROTEIN FORTIFIED COOKIE - nutritional supplement misc 3 PROVIMIN - nutritional supplement powder 3 PULMOCARE - 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 2017 RA NUTRITIONAL SUPPORT - 3 nutritional supplement powder 3 RA PEDIATRIC NUTRITIONAL - nutritional supplement liquid 3 RE/GEN PROTEIN FORTIFIED - nutritional supplement misc 3 RE/NEPH - nutritional supplement liquid 3 RE/NEPH HP/HC - nutritional supplement liquid (frozen) 3 RE/NEPH LP/HC - nutritional supplement liquid 3 RE/NEPH REDUCED SUGAR - nutritional supplement liquid 3 RENALCAL - nutritional supplement liquid 3 RENASTART - nutritional supplement powder 3 REPLETE - nutritional supplement liquid Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 129 REPLETE FIBER - nutritional supplement liquid 3 RESURGEX SELECT nutritional supplement pack 3 REPLETE FIBER 1 CAL nutritional supplement liquid 3 S.O.S. 15 - nutritional supplement pack 3 REPLETE/FIBER/ULTRAPAK nutritional supplement liquid 3 S.O.S. 20 - nutritional supplement pack 3 RESOURCE ARGINAID nutritional supplement pack 3 S.O.S. 25 - nutritional supplement pack 3 RESOURCE DAIRY THICK HONE - nutritional supplement liquid 3 SALMON/OATS/SQUASH nutritional supplement liquid 3 SB COMPLETE NUTRITION nutritional supplement liquid 3 RESOURCE DIABETIC TF nutritional supplement liquid 3 SB COMPLETE NUTRITION PLU - nutritional supplement liquid 3 RESOURCE JUICE DRINK nutritional supplement liquid (frozen) 3 3 SCANDICAL - nutritional supplement powder 3 RESOURCE JUST FOR KIDS - nutritional supplement liquid 3 RESOURCE JUST FOR KIDS WI - nutritional supplement liquid 3 SCANDISHAKE - nutritional supplement misc SCANDISHAKE - nutritional supplement pack 3 RESOURCE JUST FOR KIDS 1. - nutritional supplement liquid 3 SCANDISHAKE - nutritional supplement powder 3 3 RESOURCE SUPPORT nutritional supplement liquid 3 SM NUTRI-DRINK - nutritional supplement liquid 3 RESOURCE THICKENUP THICKE - nutritional supplement liquid 3 SM NUTRI-DRINK + nutritional supplement liquid SOL CARB - nutritional supplement powder 3 RESOURCE 2.0 - nutritional supplement liquid 3 SOURCE COOKIE BAR nutritional supplement bar 3 RESPALOR - nutritional supplement liquid 3 3 RESURGEX - nutritional supplement pack 3 SOY PROTEIN SHAKE nutritional supplement powder 3 RESURGEX PLUS - nutritional supplement pack 3 SUBDUE - nutritional supplement liquid SUBDUE PLUS - nutritional supplement liquid 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 130 SUPLENA - nutritional supplement liquid 3 TYLACTIN RESTORE 10 nutritional supplement liquid 3 SUPLENA RTU - nutritional supplement liquid 3 TYLACTIN RESTORE 5PE nutritional supplement pack 3 SUPLENA WITH CARB STEADY - nutritional supplement liquid 3 TYLACTIN RTD 15 - nutritional supplement liquid 3 3 TYR ANAMIX EARLY YEARS nutritional supplement powder 3 SUPLENA 1.8 WITH CARBSTEA - nutritional supplement liquid TYR ANAMIX NEXT nutritional supplement powder 3 THICK-IT BEEF LASAGNA PUR - nutritional supplement misc 3 TYR COOLER - nutritional supplement liquid 3 TYR COOLER20 - nutritional supplement liquid 3 TYR EXPRESS - nutritional supplement pack 3 TYR EXPRESS20 - nutritional supplement pack 3 TYR GEL - nutritional supplement pack 3 TYR LOPHLEX LQ - nutritional supplement liquid 3 TYREX-1 - nutritional supplement powder 3 TYREX-2 - nutritional supplement powder 3 TYROS 1 - nutritional supplement powder 3 TYROS 2 - nutritional supplement powder 3 UCD ANAMIX JUNIOR nutritional supplement powder 3 UCD TRIO - nutritional supplement powder 3 THICK-IT CHICKEN A LA KIN - 3 nutritional supplement misc THICK-IT MAPLE CINNAMON 3 F - nutritional supplement misc THICK-IT MIXED FRUIT AND - 3 nutritional supplement misc 3 THICK-IT SEASONED CHICKEN - nutritional supplement misc 3 THICK-IT SWEET CORN PUREE - nutritional supplement misc 3 THICK-IT THICKENED CRANBE - nutritional supplement liquid 3 THRIVACIN DETOX nutritional supplement liquid 3 THRIVACIN 30 - nutritional supplement liquid 3 TOLEREX - nutritional supplement pack 3 TWOCAL HN - nutritional supplement liquid 3 TWOCAL HN 2.0 - 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 131 UCD 2 - nutritional supplement powder 3 VIVONEX PLUS - nutritional supplement powder 3 ULTRACAL - nutritional supplement liquid 3 VIVONEX RTF - nutritional supplement liquid 3 ULTRACAL HN PLUS nutritional supplement liquid 3 VIVONEX T.E.N. - nutritional supplement pack 3 ULTRAMINO SOY PROTEIN nutritional supplement powder 3 WELLNESS ESSENTIALS nutritional supplement kit 3 WELLNESS ESSENTIALS AI nutritional supplement kit 3 UTYMAX - nutritional supplement pack 3 WELLNESS ESSENTIALS BLOOD - nutritional supplement kit 3 VHC 2.25 - nutritional supplement liquid 3 VILACTIN AA PLUS nutritional supplement liquid 3 3 VITAJOULE - nutritional supplement powder 3 WELLNESS ESSENTIALS FOR J - nutritional supplement kit 3 VITAL AF 1.2 CAL - nutritional supplement liquid 3 WELLNESS ESSENTIALS FOR M - nutritional supplement kit VITAL HIGH PROTEIN nutritional supplement liquid 3 3 VITAL HN - nutritional supplement pack 3 WELLNESS ESSENTIALS FOR P - nutritional supplement kit 3 VITAL JR - nutritional supplement liquid 3 WELLNESS ESSENTIALS FOR W - nutritional supplement kit VITAL PEPTIDE 1.5 CAL nutritional supplement liquid 3 WND 1 - nutritional supplement powder 3 VITAL 1.0 CAL - nutritional supplement liquid 3 WND 2 - nutritional supplement powder 3 VITAL 1.5 CAL - nutritional supplement liquid 3 XLEU MAXAMAID - nutritional supplement powder 3 VITAPRO - nutritional supplement powder 3 XLEU MAXAMUM - nutritional supplement powder 3 VITAQUICK - nutritional supplement powder 3 3 VIVONEX PEDIATRIC nutritional supplement pack 3 XLYS-XTRP MAXAMAID nutritional supplement powder XLYS-XTRP MAXAMUM nutritional supplement powder 3 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 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 132 XMET MAXAMAID - nutritional supplement powder 3 XMET MAXAMUM - nutritional supplement powder 3 XMTVI MAXAMAID - nutritional supplement powder 3 XMTVI MAXAMUM - nutritional supplement powder 3 XPHE MAXAMAID - nutritional supplement powder 3 XPHE-XTYR MAXAMAID nutritional supplement powder 3 XTRACAL PLUS - nutritional supplement liquid 3 HEMATOLOGICAL AGENTS HEMATOPOIETIC AGENTS • • ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25 mcg/ml 3 ARANESP ALBUMIN FREE darbepoetin alfa soln inj 40 mcg/ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln inj 60 mcg/ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100 mcg/ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200 mcg/ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln inj 300 mcg/ml 3 • • ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml 3 • • 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 2017 ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml 3 • ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml 3 • • ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml 3 • • ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled syringe 500 mcg/ml 3 • • carbonyl iron susp 15 mg/1.25ml (elemental iron) A CERDELGA - eliglustat tartrate cap 84 mg (base equivalent) 3 cyanocobalamin inj 1000 mcg/ml 1 DROXIA - hydroxyurea cap 200 mg • • • • • 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 133 DROXIA - hydroxyurea cap 300 mg 3 DROXIA - hydroxyurea cap 400 mg 3 EPOGEN - epoetin alfa inj 2000 unit/ml 3 • • EPOGEN - epoetin alfa inj 3000 unit/ml 3 • • EPOGEN - epoetin alfa inj 4000 unit/ml 3 • • EPOGEN - epoetin alfa inj 10000 unit/ml 3 • • EPOGEN - epoetin alfa inj 20000 unit/ml 3 • • FER-IN-SOL - ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) A FERRETTS CHEWABLE IRON - carbonyl iron chew tab 18 mg (elemental iron) 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 2017 • GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 3 ICAR PEDIATRIC - carbonyl iron susp 15 mg/1.25ml (elemental iron) A • IRON CHEWS PEDIATRIC carbonyl iron chew tab 15 mg (elemental iron) A • LEUKINE - sargramostim lyophilized for inj 250 mcg 3 • MIRCERA - methoxy pegepoetin beta soln prefilled syr 30 mcg/0.3ml 3 • • MIRCERA - methoxy pegepoetin beta soln prefilled syr 50 mcg/0.3ml 3 • A • MIRCERA - methoxy pegepoetin beta soln prefilled syr 75 mcg/0.3ml 3 • FERROUS SULFATE - ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe) A • MIRCERA - methoxy pegepoetin beta soln prefilled syr 100 mcg/0.3ml 3 • FERROUS SULFATE - ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe) A • MIRCERA - methoxy pegepoetin beta soln prefilled syr 150 mcg/0.3ml 3 • ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) A • MIRCERA - methoxy pegepoetin beta soln prefilled syr 200 mcg/0.3ml 3 • A • MYKIDZ IRON 10 - iron susp 15 mg/1.5ml A A • • • NASCOBAL - cyanocobalamin nasal spray 500 mcg/0.1ml 3 NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml 3 • • NEULASTA ONPRO KIT pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml 3 • • ferrous sulfate soln 75 mg/ ml (15 mg/ml elemental fe) folic acid cap 0.8 mg folic acid tab 400 mcg folic acid tab 800 mcg folic acid tab 1 mg GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml A A 1 3 • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 134 2 • • NEUPOGEN - filgrastim soln prefilled syringe 300 mcg/0.5ml 2 • • NEUPOGEN - filgrastim soln prefilled syringe 480 mcg/0.8ml (600 mcg/ml) 2 • • PROCRIT - epoetin alfa inj 2000 unit/ml 2 • • PROCRIT - epoetin alfa inj 3000 unit/ml 2 • • PROCRIT - epoetin alfa inj 4000 unit/ml 2 • • PROCRIT - epoetin alfa inj 10000 unit/ml 2 • • PROCRIT - epoetin alfa inj 20000 unit/ml 2 • • PROCRIT - epoetin alfa inj 40000 unit/ml 2 • • PROMACTA - eltrombopag olamine tab 12.5 mg (base equiv) 3 • • • PROMACTA - eltrombopag olamine tab 25 mg (base equiv) 3 • • • PROMACTA - eltrombopag olamine tab 50 mg (base equiv) 3 PROMACTA - eltrombopag olamine tab 75 mg (base equiv) 3 ZARXIO - filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml 3 • • • • • • • • 3 • ZAVESCA - miglustat cap 100 mg 3 • ANTICOAGULANTS 3 COUMADIN - warfarin sodium tab 2 mg 3 COUMADIN - warfarin sodium tab 2.5 mg 3 COUMADIN - warfarin sodium tab 3 mg 3 COUMADIN - warfarin sodium tab 4 mg 3 COUMADIN - warfarin sodium tab 5 mg 3 COUMADIN - warfarin sodium tab 6 mg 3 COUMADIN - warfarin sodium tab 7.5 mg 3 COUMADIN - warfarin sodium tab 10 mg 3 ELIQUIS - apixaban tab 2.5 mg 2 ELIQUIS - apixaban tab 5 mg 2 enoxaparin sodium inj 30 mg/0.3ml (Lovenox) 1 • • • 1 • 1 • 1 • 1 • enoxaparin sodium inj 60 mg/0.6ml (Lovenox) enoxaparin sodium inj 80 mg/0.8ml (Lovenox) enoxaparin sodium inj 100 mg/ml (Lovenox) • • COUMADIN - warfarin sodium tab 1 mg enoxaparin sodium inj 40 mg/0.4ml (Lovenox) Limited Distribution NEUPOGEN - filgrastim inj 480 mcg/1.6ml (300 mcg/ml) ZARXIO - filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml ACA • Dispensing Limits • Step Therapy 2 Prior Authorization NEUPOGEN - filgrastim inj 300 mcg/ml Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 135 • 1 • 1 • 1 • FRAGMIN - dalteparin sodium inj 10000 unit/ml 3 1 1 1 PRADAXA - dabigatran etexilate mesylate cap 75 mg (etexilate base eq) 3 • PRADAXA - dabigatran etexilate mesylate cap 110 mg (etexilate base eq) 3 • PRADAXA - dabigatran etexilate mesylate cap 150 mg (etexilate base eq) 3 • SAVAYSA - edoxaban tosylate tab 15 mg (base equivalent) 3 • • SAVAYSA - edoxaban tosylate tab 30 mg (base equivalent) 3 • • SAVAYSA - edoxaban tosylate tab 60 mg (base equivalent) 3 FRAGMIN - dalteparin sodium inj 2500 unit/0.2ml 3 • • warfarin sodium tab 1 mg (Coumadin) 1 FRAGMIN - dalteparin sodium inj 5000 unit/0.2ml 3 • warfarin sodium tab 2 mg (Coumadin) 1 FRAGMIN - dalteparin sodium inj 7500 unit/0.3ml 3 3 • warfarin sodium tab 2.5 mg (Coumadin) 1 FRAGMIN - dalteparin sodium inj 12500 unit/0.5ml 3 • warfarin sodium tab 3 mg (Coumadin) 1 FRAGMIN - dalteparin sodium inj 15000 unit/0.6ml • warfarin sodium tab 4 mg (Coumadin) 1 FRAGMIN - dalteparin sodium inj 18000 unit/0.72ml 3 • warfarin sodium tab 5 mg (Coumadin) 1 FRAGMIN - dalteparin sodium inj 95000 unit/3.8ml 3 warfarin sodium tab 6 mg (Coumadin) 1 heparin sodium (porcine) inj 1000 unit/ml 1 1 warfarin sodium tab 7.5 mg (Coumadin) 1 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) heparin sodium (porcine) inj 5000 unit/ml Limited Distribution 1 heparin sodium (porcine) pf inj 5000 unit/0.5ml ACA • Dispensing Limits 1 enoxaparin sodium inj 300 mg/3ml (Lovenox) heparin sodium (porcine) inj 20000 unit/ml Step Therapy • heparin sodium (porcine) inj 10000 unit/ml Prior Authorization 1 enoxaparin sodium inj 150 mg/ml (Lovenox) Drug Name Drug Tier • Limited Distribution 1 enoxaparin sodium inj 120 mg/0.8ml (Lovenox) ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 136 warfarin sodium tab 10 mg (Coumadin) 1 XARELTO - rivaroxaban tab 10 mg 2 XARELTO - rivaroxaban tab 15 mg 2 • XARELTO - rivaroxaban tab 20 mg 2 • XARELTO STARTER PACK rivaroxaban tab starter therapy pack 15 mg & 20 mg 2 • HEMOSTATICS AMICAR - aminocaproic acid oral soln 0.25 gm/ml 3 AMICAR - aminocaproic acid tab 500 mg 3 AMICAR - aminocaproic acid tab 1000 mg 3 tranexamic acid tab 650 mg (Lysteda) 1 HEMATOLOGICAL AGENTS - MISC. ADVATE - antihemophilic factor 2 • rahf-pfm for inj 250 unit ADVATE - antihemophilic factor 2 • rahf-pfm for inj 500 unit ADVATE - antihemophilic factor 2 • rahf-pfm for inj 1000 unit ADVATE - antihemophilic factor 2 • rahf-pfm for inj 1500 unit ADVATE - antihemophilic factor 2 • rahf-pfm for inj 2000 unit ADVATE - antihemophilic factor 2 • rahf-pfm for inj 3000 unit ADVATE - antihemophilic factor 2 • rahf-pfm for inj 4000 unit 2 • ADYNOVATE - antihemophilic factor recomb pegylated for inj 250 unit • • • • • • • • • 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 2017 ADYNOVATE - antihemophilic factor recomb pegylated for inj 500 unit 2 • • ADYNOVATE - antihemophilic factor recomb pegylated for inj 750 unit 2 • • ADYNOVATE - antihemophilic factor recomb pegylated for inj 1000 unit 2 • • ADYNOVATE - antihemophilic factor recomb pegylated for inj 1500 unit 2 • • ADYNOVATE - antihemophilic factor recomb pegylated for inj 2000 unit 2 • • AGGRENOX - aspirindipyridamole cap sr 12hr 25-200 mg 3 ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 250 unit 2 • • ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 500 unit 2 • • ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 1000 unit 2 • • ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 1500 unit 2 • • ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for inj 2000 unit 2 • • ALPHANINE SD - coagulation factor ix for inj 500 unit 2 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 137 • • ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 250 unit 2 • ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 500 unit 2 ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 1000 unit 2 ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 2000 unit 2 ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 3000 unit 2 ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 4000 unit 2 anagrelide hcl cap 0.5 mg (Agrylin) 1 anagrelide hcl cap 1 mg 1 aspirin-dipyridamole cap sr 12hr 25-200 mg (Aggrenox) BENEFIX - coagulation factor ix (recombinant) for inj kit 2000 unit 2 • • BENEFIX - coagulation factor ix (recombinant) for inj kit 3000 unit 2 • • • BERINERT - c1 esterase inhibitor (human) for iv inj kit 500 unit 3 • • 2 • • BRILINTA - ticagrelor tab 60 mg 2 • • BRILINTA - ticagrelor tab 90 mg cilostazol tab 50 mg (Pletal) 1 cilostazol tab 100 mg (Pletal) • • • 1 1 • clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) 1 • clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) COAGADEX - coagulation factor x (human) for inj 250 unit 2 • • COAGADEX - coagulation factor x (human) for inj 500 unit 2 • • CORIFACT - factor xiii concentrate (human) for inj kit 1000-1600 unit 2 • • dipyridamole tab 25 mg (Persantine) 1 dipyridamole tab 50 mg (Persantine) 1 dipyridamole tab 75 mg (Persantine) 1 EFFIENT - prasugrel hcl tab 5 mg (base equiv) 3 1 BEBULIN - factor ix complex for inj 200-1200 unit 2 • • BENEFIX - coagulation factor ix (recombinant) for inj kit 250 unit 2 • • BENEFIX - coagulation factor ix (recombinant) for inj kit 500 unit 2 • • BENEFIX - coagulation factor ix (recombinant) for inj kit 1000 unit 2 • Limited Distribution 2 ACA ALPHANINE SD - coagulation factor ix for inj 1500 unit • • Dispensing Limits • Step Therapy 2 Prior Authorization ALPHANINE SD - coagulation factor ix for inj 1000 unit Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 138 EFFIENT - prasugrel hcl tab 10 mg (base equiv) 3 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 250 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 500 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 750 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 1000 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 1500 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 2000 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 3000 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 4000 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 5000 unit 2 ELOCTATE - antihemophilic factor (recomb) rfviiifc for inj 6000 unit 2 FEIBA - antiinhibitor coagulant complex for inj 2 FIRAZYR - icatibant acetate inj 30 mg/3ml (base equivalent) 2 • HELIXATE FS - antihemophilic factor (recombinant) for inj kit 250 unit 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 2017 HELIXATE FS - antihemophilic factor (recombinant) for inj kit 500 unit 2 • • HELIXATE FS - antihemophilic factor (recombinant) for inj kit 1000 unit 2 • • HELIXATE FS - antihemophilic factor (recombinant) for inj kit 2000 unit 2 • • HELIXATE FS - antihemophilic factor (recombinant) for inj kit 3000 unit 2 • • HEMOFIL M - antihemophilic factor (human) for inj 250 unit 2 • • HEMOFIL M - antihemophilic factor (human) for inj 500 unit 2 • • HEMOFIL M - antihemophilic factor (human) for inj 1000 unit 2 • • HEMOFIL M - antihemophilic factor (human) for inj 1700 unit 2 • • HUMATE-P - antihemophilic factor/vwf (human) for inj 250-600 unit 2 • • HUMATE-P - antihemophilic factor/vwf (human) for inj 500-1200 unit 2 • • HUMATE-P - antihemophilic factor/vwf (human) for inj 1000-2400 unit 2 • • IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 250 unit 2 • • IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 500 unit 2 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 139 • • IXINITY - coagulation factor ix (recombinant) for inj 250 unit 2 • • IXINITY - coagulation factor ix (recombinant) for inj 500 unit 2 • • IXINITY - coagulation factor ix (recombinant) for inj 1000 unit 2 • • IXINITY - coagulation factor ix (recombinant) for inj 1500 unit 2 • • IXINITY - coagulation factor ix (recombinant) for inj 2000 unit 2 • • IXINITY - coagulation factor ix (recombinant) for inj 3000 unit 2 KCENTRA - prothrombin complex conc human for inj kit 500 unit 3 KCENTRA - prothrombin complex conc human for inj kit 1000 unit 3 KOATE - antihemophilic factor (human) for inj 250 unit 2 • • KOATE - antihemophilic factor (human) for inj 500 unit 2 • • KOATE - antihemophilic factor (human) for inj 1000 unit 2 • • KOATE-DVI - antihemophilic factor (human) for inj 250 unit 2 • • • Limited Distribution 2 ACA IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 2000 unit • • Dispensing Limits • Step Therapy 2 Prior Authorization IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 1000 unit Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 KOATE-DVI - antihemophilic factor (human) for inj 500 unit 2 • • KOATE-DVI - antihemophilic factor (human) for inj 1000 unit 2 • • KOGENATE FS antihemophilic factor (recombinant) for inj kit 250 unit 2 • • KOGENATE FS antihemophilic factor (recombinant) for inj kit 500 unit 2 • • KOGENATE FS antihemophilic factor (recombinant) for inj kit 1000 unit 2 • • KOGENATE FS antihemophilic factor (recombinant) for inj kit 2000 unit 2 • • KOGENATE FS antihemophilic factor (recombinant) for inj kit 3000 unit 2 • • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 250 unit 2 • • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 500 unit 2 • • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 1000 unit 2 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 140 2 KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 3000 unit 2 KOVALTRY - antihemophilic factor (recombinant) for inj 250 unit 2 KOVALTRY - antihemophilic factor (recombinant) for inj 500 unit 2 • • KOVALTRY - antihemophilic factor (recombinant) for inj 1000 unit 2 • • KOVALTRY - antihemophilic factor (recombinant) for inj 2000 unit 2 • • KOVALTRY - antihemophilic factor (recombinant) for inj 3000 unit 2 • • MONOCLATE-P antihemophilic factor (human) for inj kit 1000 unit 2 • • MONOCLATE-P antihemophilic factor (human) for inj kit 1500 unit 2 • • MONONINE - coagulation factor ix for inj 1000 unit 2 • • NOVOEIGHT - antihemophilic factor (recombinant) for inj 250 unit 2 • • NOVOEIGHT - antihemophilic factor (recombinant) for inj 500 unit 2 • • NOVOEIGHT - antihemophilic factor (recombinant) for inj 1000 unit 2 • • • • • • Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization • KOGENATE FS BIO-SET antihemophilic factor (recombinant) for inj kit 2000 unit Drug Name Drug Tier Limited Distribution ACA Dispensing Limits • Step Therapy Prior Authorization Drug Name Drug Tier 2017 NOVOEIGHT - antihemophilic factor (recombinant) for inj 1500 unit 2 • • NOVOEIGHT - antihemophilic factor (recombinant) for inj 2000 unit 2 • • NOVOEIGHT - antihemophilic factor (recombinant) for inj 3000 unit 2 • • NOVOSEVEN RT - coagulation 2 factor viia (recomb) for inj 1 mg (1000 mcg) NOVOSEVEN RT - coagulation 2 factor viia (recomb) for inj 2 mg (2000 mcg) NOVOSEVEN RT - coagulation 2 factor viia (recomb) for inj 5 mg (5000 mcg) NOVOSEVEN RT - coagulation 2 factor viia (recomb) for inj 8 mg (8000 mcg) NUWIQ - antihemophilic factor 2 (bdd-rfviii) for inj kit 250 unit NUWIQ - antihemophilic factor 2 (bdd-rfviii) for inj kit 500 unit NUWIQ - antihemophilic factor 2 (bdd-rfviii) for inj kit 1000 unit NUWIQ - antihemophilic factor 2 (bdd-rfviii) for inj kit 2000 unit NUWIQ - antihemophilic factor 2 (bdd-rfviii) for inj 250 unit NUWIQ - antihemophilic factor 2 (bdd-rfviii) for inj 500 unit NUWIQ - antihemophilic factor 2 (bdd-rfviii) for inj 1000 unit NUWIQ - antihemophilic factor 2 (bdd-rfviii) for inj 2000 unit • • • • • • • • • • • • • • • • • • • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 141 OBIZUR - antihemophilic factor (recomb porc) rpfviii for inj 500 unit 2 pentoxifylline tab cr 400 mg 1 PROFILNINE - factor ix complex for inj 500 unit 2 • • PROFILNINE - factor ix complex for inj 1000 unit 2 • • PROFILNINE - factor ix complex for inj 1500 unit 2 • • PROFILNINE SD - factor ix complex for inj 500 unit 2 • • PROFILNINE SD - factor ix complex for inj 1000 unit 2 • • PROFILNINE SD - factor ix complex for inj 1500 unit 2 • • RECOMBINATE antihemophilic factor (recombinant) for inj 220-400 unit 2 • • RECOMBINATE antihemophilic factor (recombinant) for inj 401-800 unit 2 RECOMBINATE antihemophilic factor (recombinant) for inj 801-1240 unit 2 • • RECOMBINATE antihemophilic factor (recombinant) for inj 1241-1800 unit 2 • • RECOMBINATE antihemophilic factor (recombinant) for inj 1801-2400 unit 2 RIASTAP - fibrinogen conc (human) inj approximately 1 gm (900-1300 mg) 3 • • • • • 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 2017 RIXUBIS - coagulation factor ix (recombinant) for inj 250 unit 2 • • RIXUBIS - coagulation factor ix (recombinant) for inj 500 unit 2 • • RIXUBIS - coagulation factor ix (recombinant) for inj 1000 unit 2 • • RIXUBIS - coagulation factor ix (recombinant) for inj 2000 unit 2 • • RIXUBIS - coagulation factor ix (recombinant) for inj 3000 unit 2 • • RUCONEST - c1 esterase inhibitor (recombinant) for iv inj 2100 unit 3 TRETTEN - coagulation factor xiii a-subunit for inj 2000-3125 unit 2 • • WILATE - antihemophilic factor/ 2 vwf (human) for inj 500-500 unit kit 2 WILATE - antihemophilic factor/vwf (human) for inj 1000-1000 unit kit 2 XYNTHA - antihemophilic factor recombinant paf for inj kit 250 unit 2 XYNTHA - antihemophilic factor recombinant paf for inj kit 500 unit 2 XYNTHA - antihemophilic factor recombinant paf for inj kit 1000 unit 2 XYNTHA - antihemophilic factor recombinant paf for inj kit 2000 unit • • • • • • • • • • • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 142 2 XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 500 unit 2 XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 1000 unit 2 XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 2000 unit 2 • • XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 3000 unit 2 • • ZONTIVITY - vorapaxar sulfate tab 2.08 mg (base equivalent) 3 TOPICAL PRODUCTS OPHTHALMIC AGENTS ACUVAIL - ketorolac tromethamine ophth soln 0.45% 3 AKTEN - lidocaine hcl ophth gel 3.5% 3 ALOCRIL - nedocromil sodium ophth soln 2% 3 ALOMIDE - lodoxamide tromethamine ophth soln 0.1% 3 ALPHAGAN P - brimonidine tartrate ophth soln 0.1% 3 ALREX - loteprednol etabonate ophth susp 0.2% 3 • • • • apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) 1 ATROPINE SULFATE atropine sulfate ophth soln 1% 1 AZASITE - azithromycin ophth soln 1% 3 azelastine hcl ophth soln 0.05% (Optivar) 1 AZOPT - brinzolamide ophth susp 1% Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization • XYNTHA SOLOFUSE antihemophilic factor recombinant paf for inj kit 250 unit Drug Name Drug Tier Limited Distribution ACA Dispensing Limits • Step Therapy Prior Authorization Drug Name Drug Tier 2017 3 BACITRACIN - bacitracin ophth 2 oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 1 bacitracin-polymyxinneomycin-hc ophth oint 1% 3 BEPREVE - bepotastine besilate ophth soln 1.5% 3 BESIVANCE - besifloxacin hcl ophth susp 0.6% (base equiv) 3 BETADINE OPHTHALMIC PREP - povidone-iodine ophth soln 5% 1 betaxolol hcl ophth soln 0.5% 3 BETIMOL - timolol ophth soln 0.25% 3 BETIMOL - timolol ophth soln 0.5% 3 BETOPTIC-S - betaxolol hcl ophth susp 0.25% 3 BIMATOPROST - bimatoprost ophth soln 0.03% • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 143 BLEPHAMIDE - sulfacetamide sodium-prednisolone ophth susp 10-0.2% 3 BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint 10-0.2% 3 brimonidine tartrate ophth soln 0.15% (Alphagan p) 1 brimonidine tartrate ophth soln 0.2% 1 cyclopentolate hcl ophth soln 1% (Cyclogyl) cyclopentolate hcl ophth soln 2% (Cyclogyl) DEXAMETHASONE SODIUM PHOS - dexamethasone sodium phosphate ophth soln 0.1% 3 diclofenac sodium ophth soln 0.1% 1 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) 1 dorzolamide hcl ophth soln 2% (Trusopt) 1 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt) CILOXAN - ciprofloxacin hcl ophth oint 0.3% 3 ciprofloxacin hcl ophth soln 0.3% (Ciloxan) 1 COMBIGAN - brimonidine tartrate-timolol maleate ophth soln 0.2-0.5% 3 COSOPT PF - dorzolamide hcl- 3 timolol maleate ophth sol 22.3-6.8 mg/ml pf cromolyn sodium ophth soln 1 4% 3 CYCLOGYL - cyclopentolate hcl ophth soln 0.5% 3 CYCLOMYDRIL cyclopentolate w/ phenylephrine ophth soln 0.2-1% 1 cyclopentolate hcl ophth soln 0.5% (Cyclogyl) ACA Dispensing Limits Limited Distribution • 1 3 EMADINE - emedastine difumarate ophth soln 0.05% (base equiv) 3 epinastine hcl ophth soln 0.05% (Elestat) 1 1 FLAREX - fluorometholone acetate ophth susp 0.1% 3 fluorometholone ophth susp 0.1% (Fml liquifilm) 1 flurbiprofen sodium ophth soln 0.03% (Ocufen) • 1 DUREZOL - difluprednate ophth emulsion 0.05% erythromycin ophth oint 5 mg/gm Step Therapy 1 3 3 carteolol hcl ophth soln 1% 1 CYSTARAN - cysteamine hcl ophth soln 0.44% (base equivalent) BROMFENAC - bromfenac sodium ophth soln 0.09% (base equivalent) Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 FML - fluorometholone ophth oint 0.1% 3 FML FORTE - fluorometholone ophth susp 0.25% 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 144 gatifloxacin ophth soln 0.5% (Zymaxid) 1 gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% (Garamycin) 3 1 METIPRANOLOL metipranolol ophth soln 0.3% 3 1 MITOSOL - mitomycin for ophth soln kit 0.2 mg 3 ILEVRO - nepafenac ophth susp 0.3% 3 MOXEZA - moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily) IOPIDINE - apraclonidine hcl ophth soln 1% (base equivalent) 3 NATACYN - natamycin ophth susp 5% 2 1 ISTALOL - timolol maleate ophth soln 0.5% (once-daily) 3 ketorolac tromethamine ophth soln 0.4% (Acular ls) 1 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin ketorolac tromethamine ophth soln 0.5% (Acular) 1 LACRISERT - artificial tear ophth insert 3 LASTACAFT - alcaftadine ophth soln 0.25% 3 latanoprost ophth soln 0.005% (Xalatan) 1 levobunolol hcl ophth soln 0.5% (Betagan) levofloxacin ophth soln 0.5% neomycin-polymygramicid op sol 1.75-10000-0.025mg-untmg/ml (Neosporin) neomycin-polymyxindexamethasone ophth oint 0.1% (Maxitrol) • 1 1 neomycin-polymyxindexamethasone ophth susp 0.1% (Maxitrol) Limited Distribution ACA Dispensing Limits Step Therapy 1 1 1 NEOMYCIN/POLYMYXIN/ HYDROC - neomycinpolymyxin-hc ophth susp 3 LOTEMAX - loteprednol etabonate ophth gel 0.5% 3 NEVANAC - nepafenac ophth susp 0.1% 3 LOTEMAX - loteprednol etabonate ophth oint 0.5% 3 ofloxacin ophth soln 0.3% (Ocuflox) 1 LOTEMAX - loteprednol etabonate ophth susp 0.5% 3 1 LUMIGAN - bimatoprost ophth soln 0.01% 3 olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol) 3 MAXIDEX - dexamethasone ophth susp 0.1% 3 PATADAY - olopatadine hcl ophth soln 0.2% (base equivalent) phenylephrine hcl ophth soln 2.5% 1 • • Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 145 2 3 1 SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10% 1 sulfacetamide sodium ophth soln 10% (Bleph-10) 1 1 sulfacetamide sodiumprednisolone ophth soln 10-0.23(0.25)% PRED MILD - prednisolone acetate ophth susp 0.12% 3 tetracaine hcl ophth soln 0.5% PRED-G - gentamicinprednisolone ace ophth susp 0.3-1% 3 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe) 1 PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6% 3 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe) 1 prednisolone acetate ophth susp 1% (Pred forte) 1 timolol maleate ophth soln 0.25% (Timoptic) 1 PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate ophth soln 1% 3 timolol maleate ophth soln 0.5% (Timoptic) PROLENSA - bromfenac sodium ophth soln 0.07% (base equivalent) proparacaine hcl ophth soln 0.5% (Alcaine) 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) 1 3 1 TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.5% TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1% 3 TOBRADEX ST - tobramycindexamethasone ophth susp 0.3-0.05% 3 tobramycin ophth soln 0.3% (Tobrex) 1 RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 • • RESTASIS MULTIDOSE cyclosporine (ophth) emulsion 0.05% 3 • • Limited Distribution ACA 1 3 • • Dispensing Limits 1 3 3 Step Therapy 1 TIMOPTIC OCUDOSE - timolol maleate preservative free ophth soln 0.25% RESCULA - unoprostone isopropyl ophth soln 0.15% Prior Authorization Drug Tier Limited Distribution Drug Name SIMBRINZA - brinzolamidebrimonidine tartrate ophth susp 1-0.2% phenylephrine hcl ophth soln 10% 1 ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 146 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) 1 CIPROFLOXACIN ciprofloxacin hcl otic soln 0.2% (base equivalent) 3 TOBREX - tobramycin ophth oint 0.3% 3 3 TRAVATAN Z - travoprost ophth soln 0.004% (benzalkonium free) (bak free) 3 COLY-MYCIN S - neomycincolistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml fluocinolone acetonide (otic) oil 0.01% (Dermotic) 1 trifluridine ophth soln 1% (Viroptic) 1 VIGAMOX - moxifloxacin hcl ophth soln 0.5% (base equiv) 3 XIIDRA - lifitegrast ophth soln 5% 3 ZIOPTAN - tafluprost ophth soln 0.0015% 3 ZIRGAN - ganciclovir ophth gel 0.15% 3 • • • • • • hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc) 1 neomycin-polymyxin-hc otic soln 1% (Cortisporin) 1 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ ml-1% ofloxacin otic soln 0.3% 1 1 ACETIC ACID/ALUMINUM ACET - acetic acid 2% in aluminum acetate otic soln 3 MOUTH/THROAT/DENTAL AGENTS A ACT TOTAL CARE DRY MOUTH - sodium fluoride rinse 0.02% 1 cevimeline hcl cap 30 mg (Evoxac) 1 chlorhexidine gluconate soln 0.12% (Peridex) 1 clotrimazole troche 10 mg A • CETRAXAL - ciprofloxacin hcl otic soln 0.2% (base equivalent) 3 COLGATE DRY MOUTH RELIEF - sodium fluoride mouthwash 2.1 mg/10ml A • CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1% 3 CREST COMPLETE - sodium fluoride paste 0.243% 3 CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1% 3 DEBACTEROL - sulfuric acidsulfonated phenolics soln 30-50% EQL DENTAL TRAVEL PACK sodium fluoride paste 0.243% & mouthwash kit 3 ZYLET - loteprednol etabonate- 3 tobramycin ophth susp 0.5-0.3% OTIC AGENTS acetic acid otic soln 2% 1 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 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 147 NAFRINSE DAILY/ ACIDULATED - sodium fluoride-phosphoric acid for soln 1 mg/5ml (f equiv) 3 • NAFRINSE DAILY/NEUTRAL sodium fluoride for soln rinse 0.05% 3 • GEL-KAM ORAL CARE RINSE - stannous fluoride conc 0.63% 3 • NAFRINSE WEEKLY - sodium fluoride for soln rinse 0.2% 3 • LIDOCAINE HCL - lidocaine hcl laryngotracheal soln 4% 3 nystatin susp 100000 unit/ml 1 1 OMNI GEL - stannous fluoride gel 0.4% A lidocaine hcl viscous soln 2% ORAVIG - miconazole buccal tab 50 mg (mouth-throat) 3 LISTERINE ESSENTIAL CARE - sod monofluorophosph-eucalmen-methyl sal-thymol gel 0.76% A PARODONTAX - stannous fluoride paste 0.454% A • A • LISTERINE NATURALS WITH F - sodium fluoride rinse 0.02% 3 • PHOS FLUR - sodium fluoride rinse 0.044% A • LISTERINE RESTORING sodium fluoride rinse 0.0221% (0.01% f) A • PHOS-FLUR ORTHO DEFENSE - sodium fluoride rinse 0.044% pilocarpine hcl tab 5 mg (Salagen) 1 LISTERINE SMART RINSE sodium fluoride rinse 0.0221% (0.01% f) A • pilocarpine hcl tab 7.5 mg (Salagen) 1 3 A • LISTERINE TOTAL CARE sodium fluoride rinse 0.0221% (0.01% f) PREVIDENT FLUORIDE sodium fluoride gel 1.1% (0.5% f) A • • LISTERINE TOTAL CARE PLUS - sodium fluoride rinse 0.0221% (0.01% f) LISTERINE TOTAL CARE ZERO - sodium fluoride rinse 0.02% A • LISTERINE WHITENING/ RESTO - sodium fluoride rinse 0.0221% (0.01% f) A • PREVIDENT 5000 BOOSTER - 3 sodium fluoride paste 1.1% 3 PREVIDENT 5000 BOOSTER PL - sodium fluoride paste 1.1% 3 PREVIDENT 5000 DRY MOUTH - sodium fluoride gel 1.1% (0.5% f) • • Limited Distribution • ACA A Dispensing Limits GEL-KAM - stannous fluoride gel 0.4% Step Therapy • Prior Authorization A Drug Name Drug Tier EQL TRAVEL TOOTHBRUSH/ TOO - sodium monofluorophosphate paste 0.15% Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 148 PREVIDENT 5000 ENAMEL PRO - sodium fluoridepotassium nitrate paste 1.1-5% 3 PREVIDENT 5000 PLUS sodium fluoride cream 1.1% 3 • PREVIDENT 5000 SENSITIVE - sodium fluoride-potassium nitrate paste 1.1-5% 3 • REMBRANDT DEEPLY WHITE+PE - sodium monofluorophosphate paste 0.884% A • SENSODYNE REPAIR & PROTEC - stannous fluoride paste 0.454% A • sodium fluoride cream 1.1% (Prevident 5000 plus) 1 • hydrocortisone rectal cream 2.5% (Anusol-hc) sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) 1 • 3 sodium fluoride paste 1.1% (Prevident 5000 boost) 1 • PROCTOFOAM HC hydrocortisone acetate w/ pramoxine rectal foam 1-1% 3 sodium fluoride rinse 0.0221% (0.01% f) A • RECTIV - nitroglycerin oint 0.4% 3 A UCERIS - budesonide rectal foam 2 mg/act ANORECTAL AGENTS 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 sodium fluoride rinse 0.05% stannous fluoride gel 0.4% triamcinolone acetonide dental paste 0.1% STANNOUS FLUORIDE RINSE - stannous fluoride liq 0.1% A THERA-FLUR-N - sodium fluoride gel 1.1% (0.5% f) 3 3 CORTIFOAM - hydrocortisone acetate rectal foam 10% (90 mg/dose) 2 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc) 1 hydrocortisone rectal cream 1% (Proctocort) DERMATOLOGICALS Limited Distribution ACA 1 1 1 acitretin cap 17.5 mg (Soriatane) 1 • acitretin cap 25 mg (Soriatane) 1 • • acyclovir oint 5% (Zovirax) 1 adapalene cream 0.1% (Differin) 1 adapalene gel 0.1% (Differin) 1 adapalene gel 0.3% (Differin) Dispensing Limits 1 acitretin cap 10 mg (Soriatane) • Step Therapy 1 ANALPRAM-HC hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1% hydrocortisone enema 100 mg/60ml (Cortenema) Prior Authorization Drug Name Drug Tier • Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 149 alclometasone dipropionate cream 0.05% (Aclovate) alclometasone dipropionate oint 0.05% 1 3 AMCINONIDE - amcinonide cream 0.1% betamethasone valerate oint 0.1% 3 calcipotriene oint 0.005% 1 AMCINONIDE - amcinonide lotion 0.1% 3 calcipotriene soln 0.005% (50 mcg/ml) AMCINONIDE - amcinonide oint 0.1% 3 ASTERO - lidocaine hcl gel 4% 3 benzoyl peroxideerythromycin gel 5-3% (Benzamycin) 1 betamethasone dipropionate augmented cream 0.05% (Diprolene af) 1 betamethasone dipropionate augmented gel 0.05% 1 betamethasone dipropionate augmented lotion 0.05% (Diprolene) 1 betamethasone dipropionate augmented oint 0.05% (Diprolene) 1 betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% betamethasone dipropionate oint 0.05% betamethasone valerate aerosol foam 0.12% (Luxiq) betamethasone valerate cream 0.1% CENTANY - mupirocin oint 2% 3 ciclopirox gel 0.77% 1 ciclopirox solution 8% (Penlac Nail Lacquer) 1 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac) 1 1 clindamycin phosphate gel 1% (Cleocin-t) 1 clindamycin phosphate lotion 1% (Cleocin-t) 1 clindamycin phosphate soln 1% (Cleocin-t) clindamycin phosphate swab 1% (Cleocin-t) • • • 1 1 clindamycin phosphate foam 1% (Evoclin) • 1 ciclopirox shampoo 1% (Loprox shampoo) 1 Limited Distribution 1 3 ciclopirox olamine susp 0.77% (base equiv) ACA 1 CARAC - fluorouracil cream 0.5% ciclopirox olamine cream 0.77% (base equiv) Dispensing Limits 1 1 • Step Therapy 1 calcipotriene cream 0.005% (Dovonex) calcipotrienebetamethasone dipropionate oint 0.005-0.064% (Taclonex) Prior Authorization Drug Tier Limited Distribution Drug Name betamethasone valerate lotion 0.1% 1 ALTABAX - retapamulin oint 1% ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 1 1 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 150 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 2017 clindamycin phosphatebenzoyl peroxide gel 1-5% (Benzaclin) 1 CORTISPORIN - bacitracinpolymyxin-neomycin hc oint 1% 3 clindamycin phosphatetretinoin gel 1.2-0.025% (Ziana) 1 CORTISPORIN - neomycinpolymyxin-hc crm 3.5 mg/ gm-10000 unt/gm-0.5% 3 clobetasol propionate cream 0.05% (Temovate) 1 COSENTYX - secukinumab subcutaneous soln prefilled syringe 150 mg/ml 3 • • • COSENTYX SENSOREADY PEN - secukinumab subcutaneous soln autoinjector 150 mg/ml 3 • • • 1 DENAVIR - penciclovir cream 1% 3 1 desonide cream 0.05% (Desowen) 1 1 desonide lotion 0.05% (Desowen) 1 1 desonide oint 0.05% (Desowen) 1 CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1% 3 desoximetasone cream 0.25% (Topicort) 1 CLOCORTOLONE PIVALATE PUM - clocortolone pivalate cream 0.1% 3 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) • • clobetasol propionate emollient base cream 0.05% (Temovate e) clobetasol propionate gel 0.05% (Temovate) clobetasol propionate lotion 0.05% (Clobex) clobetasol propionate oint 0.05% (Temovate) clobetasol propionate shampoo 0.05% (Clobex) clobetasol propionate soln 0.05% (Temovate) 1 1 desoximetasone gel 0.05% (Topicort) 1 desoximetasone oint 0.25% (Topicort) 1 1 diclofenac sodium (actinic keratoses) gel 3% (Solaraze) 1 1 diclofenac sodium gel 1% (Voltaren) 1 • diclofenac sodium soln 1.5% (Pennsaid) 1 CONDYLOX - podofilox gel 0.5% 3 • DIFLORASONE DIACETATE diflorasone diacetate oint 0.05% 3 CORDRAN - flurandrenolide tape 4 mcg/sqcm 3 clotrimazole w/ betamethasone lotion 1-0.05% Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 151 DOXEPIN HYDROCHLORIDE doxepin hcl cream 5% 3 econazole nitrate cream 1% 1 fluocinolone acetonide oint 0.025% (Synalar) fluocinolone acetonide soln 0.01% (Synalar) ELIDEL - pimecrolimus cream 1% 3 ENSTILAR - calcipotrienebetamethasone dipropionate foam 0.005-0.064% 3 ERTACZO - sertaconazole nitrate cream 2% 3 FLUOROPLEX - fluorouracil cream 1% 3 erythromycin gel 2% (Erygel) 1 FLUOROURACIL - fluorouracil cream 0.5% 3 fluorouracil cream 5% (Efudex) 1 fluorouracil soln 2% 1 erythromycin pads 2% erythromycin soln 2% EURAX - crotamiton cream 10% fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% 1 1 3 EURAX - crotamiton lotion 10% 3 3 EXELDERM - sulconazole nitrate cream 1% 3 EXELDERM - sulconazole nitrate solution 1% 2 FINACEA - azelaic acid foam 15% 2 FINACEA - azelaic acid gel 15% 1 fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide cream 0.025% (Synalar) 1 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod) 1 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca) fluorouracil soln 5% flurandrenolide cream 0.05% 1 1 1 • • 1 1 fluticasone propionate cream 0.05% (Cutivate) 1 1 GENTAMICIN SULFATE gentamicin sulfate oint 0.1% 3 gentamicin sulfate cream 0.1% 1 halobetasol propionate oint 0.05% (Ultravate) Limited Distribution 1 1 halobetasol propionate cream 0.05% (Ultravate) ACA 1 flurandrenolide lotion 0.05% (Cordran) fluticasone propionate oint 0.005% (Cutivate) Dispensing Limits 1 3 • Step Therapy 1 ECOZA - econazole nitrate foam 1% fluocinonide cream 0.05% Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 1 HALOG - halcinonide oint 0.1% 3 hydrocortisone butyrate cream 0.1% (Locoid) 1 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 152 hydrocortisone butyrate oint 0.1% (Locoid) hydrocortisone butyrate soln 0.1% (Locoid) hydrocortisone cream 2.5% hydrocortisone lotion 2.5% hydrocortisone oint 2.5% hydrocortisone valerate cream 0.2% hydrocortisone valerate oint 0.2% (Westcort) 1 lidocaine-prilocaine cream 2.5-2.5% (Emla) 1 1 1 LUZU - luliconazole cream 1% 3 1 malathion lotion 0.5% (Ovide) 1 1 MENTAX - butenafine hcl cream 1% 3 1 methoxsalen rapid cap 10 mg (Oxsoralen ultra) 1 imiquimod cream 5% (Aldara) 1 • metronidazole cream 0.75% (Metrocream) 1 isotretinoin cap 10 mg 1 metronidazole gel 0.75% 1 JUBLIA - efinaconazole soln 10% 3 • • • • • • KERYDIN - tavaborole soln 5% 3 • • ketoconazole cream 2% 1 isotretinoin cap 20 mg isotretinoin cap 30 mg isotretinoin cap 40 mg 1 1 1 ketoconazole shampoo 2% (Nizoral) 1 lactic acid (ammonium lactate) lotion 12% (Lachydrin) 1 LEVULAN KERASTICK aminolevulinic acid hcl for soln 20% (stick applicator) 3 lidocaine hcl gel 2% 1 lidocaine hcl soln 4% (Xylocaine) 1 lidocaine patch 5% (Lidoderm) 1 lidocaine-prilocaine cream kit 2.5-2.5% 1 • • • • metronidazole gel 1% (Metrogel) 1 metronidazole lotion 0.75% (Metrolotion) 1 mometasone furoate cream 0.1% (Elocon) 1 mometasone furoate oint 0.1% (Elocon) Limited Distribution ACA Dispensing Limits Step Therapy 1 LINDANE - lindane shampoo 1% 1 Prior Authorization Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 1 mometasone furoate solution 0.1% (lotion) (Elocon) 1 mupirocin calcium cream 2% (Bactroban) 1 mupirocin oint 2% (Bactroban) 1 naftifine hcl cream 1% 1 naftifine hcl cream 2% (Naftin) 1 NAFTIN - naftifine hcl cream 2% 3 NAFTIN - naftifine hcl gel 1% 3 NAFTIN - naftifine hcl gel 2% 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 153 NATROBA - spinosad susp 0.9% 3 PRUDOXIN - doxepin hcl cream 5% 3 NEO-SYNALAR - neomycin sulfate-fluocinolone acetonide cream 0.5-0.025% 3 REGRANEX - becaplermin gel 0.01% 3 nystatin cream 100000 unit/ gm 1 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-% oxiconazole nitrate cream 1% (Oxistat) 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 2017 • SANTYL - collagenase oint 250 3 unit/gm 1 selenium sulfide lotion 2.5% 1 1 silver sulfadiazine cream 1% (Silvadene) 1 1 SKLICE - ivermectin lotion 0.5% 3 SOOLANTRA - ivermectin cream 1% 2 SPINOSAD - spinosad susp 0.9% 3 STELARA - ustekinumab inj 45 mg/0.5ml 2 • • • STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 2 • • • STELARA - ustekinumab soln prefilled syringe 90 mg/ml 2 • • • sulfacetamide sodium lotion 10% (acne) (Klaron) 1 1 1 OXISTAT - oxiconazole nitrate cream 1% 3 OXISTAT - oxiconazole nitrate lotion 1% 3 PANRETIN - alitretinoin gel 0.1% 3 permethrin cream 5% (Elimite) 1 PICATO - ingenol mebutate gel 0.015% 3 • PICATO - ingenol mebutate gel 0.05% 3 • PLIAGLIS - lidocaine-tetracaine 3 cream 7-7% 1 podofilox soln 0.5% (Condylox) 1 prednicarbate cream 0.1% (Dermatop) 1 prednicarbate oint 0.1% (Dermatop) SULFAMYLON - mafenide acetate cream 85 mg/gm 3 SYNERA - lidocaine-tetracaine topical patch 70-70 mg 3 TACLONEX - calcipotrienebetamethasone dipropionate susp 0.005-0.064% 3 tacrolimus oint 0.03% (Protopic) 1 • tacrolimus oint 0.1% (Protopic) 1 • TARGRETIN - bexarotene gel 1% 3 tazarotene cream 0.1% (Tazorac) 1 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 154 TAZORAC - tazarotene cream 0.05% 2 TAZORAC - tazarotene cream 0.1% 2 TAZORAC - tazarotene gel 0.05% 2 TAZORAC - tazarotene gel 0.1% 2 TOLAK - fluorouracil cream 4% 3 tretinoin cream 0.025% (Retin-a) 1 tretinoin cream 0.05% (Retina) 1 tretinoin cream 0.1% (Retina) 1 tretinoin gel 0.01% (Retin-a) 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) 1 1 1 1 triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog) 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide cream 0.1% triamcinolone acetonide cream 0.5% triamcinolone acetonide lotion 0.025% triamcinolone acetonide lotion 0.1% triamcinolone acetonide oint 0.025% 1 1 1 1 1 triamcinolone acetonide oint 0.1% 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 2017 1 TRIDESILON - desonide cream 1 0.05% 3 ULESFIA - benzyl alcohol lotion 5% VALCHLOR - mechlorethamine 2 hcl gel 0.016% (base equivalent) VEREGEN - sinecatechins oint 3 15% 2 VOLTAREN - diclofenac sodium gel 1% 3 VUSION - miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35% 3 XOLEGEL - ketoconazole gel 2% ZONALON - doxepin hcl cream 3 5% 3 ZYCLARA - imiquimod cream 3.75% 3 ZYCLARA PUMP - imiquimod cream 2.5% 3 ZYCLARA PUMP - imiquimod cream 3.75% • • • • • • • MISCELLANEOUS PRODUCTS ANTIDOTES CETYLEV - acetylcysteine effervescent tab 500 mg 3 CETYLEV - acetylcysteine effervescent tab 2.5 gm 3 CHEMET - succimer cap 100 mg 2 EVZIO - naloxone hcl solution auto-injector 0.4 mg/0.4ml 3 • • EVZIO - naloxone hcl solution auto-injector 2 mg/0.4ml 3 • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 155 3 • • EXJADE - deferasirox tab for oral susp 500 mg 3 • • FERRIPROX - deferiprone oral soln 100 mg/ml 3 • • FERRIPROX - deferiprone tab 500 mg 3 • • JADENU - deferasirox tab 90 mg 3 • • JADENU - deferasirox tab 180 mg 3 • • JADENU - deferasirox tab 360 mg 3 • • NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 3 naloxone hcl inj 0.4 mg/ml 1 2 BREATHERITE COLLAPSIBLE - spacer/ aerosol-holding chambers device 2 BREATHERITE RIGID SPACER - spacer/aerosolholding chambers - device 2 BREATHERITE W/LARGE MASK - spacer/aerosolholding chambers - device 2 BREATHERITE W/MEDIUM MASK - spacer/aerosolholding chambers - device 2 BREATHERITE W/SMALL MASK - spacer/aerosolholding chambers - device 2 CAYA - diaphragm arc-spring A HURRISEAL - dental desensitizing product solution 3 • naltrexone hcl tab 50 mg (Revia) 1 NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 2 INSULIN PEN NEEDLESVARIOUS 2 • RADIOGARDASE - prussian blue insoluble cap 0.5 gm 3 INSULIN SYRINGESVARIOUS 2 • LANCETS-VARIOUS 2 LANCING DEVICE-VARIOUS 3 OMNIFLEX DIAPHRAGM diaphragms A SPACERS – VARIOUS 3 WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 60 mm A • WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 65 mm A • DIAGNOSTIC PRODUCTS BAYER BREEZE 2 TEST DISC - glucose blood test disk 1 BAYER CONTOUR BLOOD GLUCO - glucose blood test strip 1 BAYER CONTOUR NEXT BLOOD - glucose blood test strip 1 MEDICAL DEVICES • • • Limited Distribution EXJADE - deferasirox tab for oral susp 250 mg BREATHERITE - spacer/ aerosol-holding chambers device ACA • Dispensing Limits • Step Therapy 3 Prior Authorization EXJADE - deferasirox tab for oral susp 125 mg Drug Name Drug Tier Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 156 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 • ASSORTED CLASSES cyclosporine cap 100 mg (Sandimmune) 1 • CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg 2 • cyclosporine modified cap 25 mg (Neoral) 1 1 • cyclosporine modified cap 50 mg (Cyclosporine modifie) cyclosporine modified cap 100 mg (Neoral) 1 cyclosporine modified oral soln 100 mg/ml (Neoral) DEPEN TITRATABS penicillamine tab 250 mg 2 ENVARSUS XR - tacrolimus tab sr 24hr 0.75 mg 3 3 • ENVARSUS XR - tacrolimus tab sr 24hr 1 mg 3 ASTAGRAF XL - tacrolimus cap sr 24hr 1 mg 3 • ENVARSUS XR - tacrolimus tab sr 24hr 4 mg 3 ASTAGRAF XL - tacrolimus cap sr 24hr 5 mg 3 • mycophenolate mofetil cap 250 mg (Cellcept) 1 ATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/ml(eq) 3 AZASAN - azathioprine tab 75 mg 3 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) 1 mycophenolate mofetil tab 500 mg (Cellcept) 1 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic) • • • mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic) NEORAL - cyclosporine modified cap 25 mg Limited Distribution ACA Dispensing Limits Step Therapy 1 ASTAGRAF XL - tacrolimus cap sr 24hr 0.5 mg AZASAN - azathioprine tab 100 3 mg 1 azathioprine tab 50 mg (Imuran) 3 CUPRIMINE - penicillamine cap 250 mg 1 cyclosporine cap 25 mg (Sandimmune) Prior Authorization Drug Name Drug Tier • WIDE-SEAL SILICONE DIAPHR - diaphragm wide seal 70 mm Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 • • 1 1 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 157 NEORAL - cyclosporine modified cap 100 mg 3 NEORAL - cyclosporine modified oral soln 100 mg/ml 3 PROGRAF - tacrolimus cap 0.5 3 mg 3 PROGRAF - tacrolimus cap 1 mg 3 PROGRAF - tacrolimus cap 5 mg 2 RAPAMUNE - sirolimus oral soln 1 mg/ml REVLIMID - lenalidomide caps 2 2.5 mg REVLIMID - lenalidomide cap 5 2 mg 2 REVLIMID - lenalidomide cap 10 mg 2 REVLIMID - lenalidomide cap 15 mg 2 REVLIMID - lenalidomide cap 20 mg 2 REVLIMID - lenalidomide cap 25 mg 3 SANDIMMUNE - cyclosporine cap 25 mg 3 SANDIMMUNE - cyclosporine cap 100 mg 3 SANDIMMUNE - cyclosporine oral soln 100 mg/ml 1 sirolimus tab 0.5 mg (Rapamune) 1 sirolimus tab 1 mg (Rapamune) 1 sirolimus tab 2 mg (Rapamune) sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps) • • • • • • • • • • • • • • • • • • 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 2017 1 sodium polystyrene sulfonate powder (Kayexalate) 1 sodium polystyrene sulfonate rectal susp 30 gm/120ml 1 • • SYPRINE - trientine hcl cap 250 mg 3 tacrolimus cap 0.5 mg (Prograf) 1 tacrolimus cap 1 mg (Prograf) 1 tacrolimus cap 5 mg (Prograf) 1 THALOMID - thalidomide cap 50 mg 2 • • • THALOMID - thalidomide cap 100 mg 2 • • • THALOMID - thalidomide cap 150 mg 2 • • • THALOMID - thalidomide cap 200 mg 2 • • • VELTASSA - patiromer sorbitex 3 calcium for susp packet 8.4 gm (base eq) VELTASSA - patiromer sorbitex 3 calcium for susp packet 16.8 gm (base eq) VELTASSA - patiromer sorbitex 3 calcium for susp packet 25.2 gm (base eq) 3 ZORTRESS - everolimus tab 0.25 mg 3 ZORTRESS - everolimus tab 0.5 mg • • • Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 158 ZORTRESS - everolimus tab 0.75 mg Limited Distribution ACA Dispensing Limits Step Therapy Prior Authorization Drug Name Drug Tier 2017 3 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 159 2017 INDEX A abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)......................................................................... 6 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg (Trizivir)................................................ 6 abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 6 ABSTRAL -fentanyl citrate sl tab 100 mcg (base equiv)............................................................................... 85 ABSTRAL -fentanyl citrate sl tab 200 mcg (base equiv)............................................................................... 85 ABSTRAL -fentanyl citrate sl tab 300 mcg (base equiv)............................................................................... 85 ABSTRAL -fentanyl citrate sl tab 400 mcg (base equiv)............................................................................... 85 ABSTRAL -fentanyl citrate sl tab 600 mcg (base equiv)............................................................................... 85 ABSTRAL -fentanyl citrate sl tab 800 mcg (base equiv)............................................................................... 85 acamprosate calcium tab delayed release 333 mg (Campral)........................................................................ 81 acarbose tab 25 mg (Precose)....................................... 29 acarbose tab 50 mg (Precose)....................................... 29 acarbose tab 100 mg (Precose)..................................... 29 acebutolol hcl cap 200 mg (Sectral).............................. 41 acebutolol hcl cap 400 mg (Sectral).............................. 41 ACERFLEX -nutritional supplement powder................... 115 acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg (Trezix)................................................ 85 acetaminophen w/ codeine soln 120-12 mg/5ml.......... 85 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ codeine).......................................................................... 85 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine #3).................................................................... 85 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine #4).................................................................... 85 acetazolamide cap sr 12hr 500 mg (Diamox)............... 50 acetazolamide tab 125 mg.............................................. 50 acetazolamide tab 250 mg.............................................. 50 ACETIC ACID/ALUMINUM ACET -acetic acid 2% in aluminum acetate otic soln...........................................147 acetic acid otic soln 2%................................................ 147 acetylcysteine inhal soln 10%........................................ 56 acetylcysteine inhal soln 20%........................................ 56 acitretin cap 10 mg (Soriatane).................................... 149 acitretin cap 17.5 mg (Soriatane)................................. 149 acitretin cap 25 mg (Soriatane).................................... 149 ACTEMRA -tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml..................................................... 92 ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)....................................................... 17 ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg.................................................................................. 105 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr 24hr 15-1000 mg........................................................ 29 ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr 24hr 30-1000 mg........................................................ 29 ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse 0.02%.............................................................................147 ACUVAIL -ketorolac tromethamine ophth soln 0.45%.............................................................................143 acyclovir cap 200 mg (Zovirax)........................................ 6 acyclovir oint 5% (Zovirax)........................................... 149 acyclovir susp 200 mg/5ml (Zovirax).............................. 6 acyclovir tab 400 mg (Zovirax)........................................ 6 acyclovir tab 800 mg (Zovirax)........................................ 6 ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 16 adapalene cream 0.1% (Differin).................................. 149 adapalene gel 0.1% (Differin)....................................... 149 adapalene gel 0.3% (Differin)....................................... 149 ADASUVE -loxapine aerosol powder breath activated 10 mg.................................................................................... 72 ADCIRCA -tadalafil tab 20 mg (pah)................................. 53 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 5 mg................................................................... 77 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 10 mg................................................................. 77 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 15 mg................................................................. 77 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 20 mg................................................................. 77 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 25 mg................................................................. 77 ADDERALL XR -amphetamine-dextroamphetamine cap sr 24hr 30 mg................................................................. 77 ADD-INS COMPLETE -amino acids pack...................... 114 adefovir dipivoxil tab 10 mg (Hepsera)........................... 6 ADEMPAS -riociguat tab 0.5 mg....................................... 53 ADEMPAS -riociguat tab 1 mg.......................................... 53 ADEMPAS -riociguat tab 1.5 mg....................................... 53 ADEMPAS -riociguat tab 2 mg.......................................... 53 ADEMPAS -riociguat tab 2.5 mg....................................... 53 ADRENACLICK -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)......................................................... 51 ADRENACLICK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................... 51 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 100-50 mcg/dose............................................................ 57 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 250-50 mcg/dose............................................................ 57 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 160 2017 ADVAIR DISKUS -fluticasone-salmeterol aer powder ba 500-50 mcg/dose............................................................ 57 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21 mcg/act............................................................................ 57 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21 mcg/act............................................................................ 57 ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21 mcg/act............................................................................ 57 ADVATE -antihemophilic factor rahf-pfm for inj 250 unit................................................................................. 137 ADVATE -antihemophilic factor rahf-pfm for inj 500 unit................................................................................. 137 ADVATE -antihemophilic factor rahf-pfm for inj 1000 unit................................................................................. 137 ADVATE -antihemophilic factor rahf-pfm for inj 1500 unit................................................................................. 137 ADVATE -antihemophilic factor rahf-pfm for inj 2000 unit................................................................................. 137 ADVATE -antihemophilic factor rahf-pfm for inj 3000 unit................................................................................. 137 ADVATE -antihemophilic factor rahf-pfm for inj 4000 unit................................................................................. 137 ADVERA -nutritional supplement liquid...........................115 ADYNOVATE -antihemophilic factor recomb pegylated for inj 250 unit.................................................................... 137 ADYNOVATE -antihemophilic factor recomb pegylated for inj 500 unit.................................................................... 137 ADYNOVATE -antihemophilic factor recomb pegylated for inj 750 unit.................................................................... 137 ADYNOVATE -antihemophilic factor recomb pegylated for inj 1000 unit.................................................................. 137 ADYNOVATE -antihemophilic factor recomb pegylated for inj 1500 unit.................................................................. 137 ADYNOVATE -antihemophilic factor recomb pegylated for inj 2000 unit.................................................................. 137 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.................................................................................... 17 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 2015-2016 -influenza virus vaccine split im susp................................................................................. 13 AFLURIA 2016-2017 -influenza virus vaccine split im susp................................................................................. 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.................................................................... 34 AFREZZA -insulin regular (human) inhal powd 4 (30) & 8 (60) unit/cart.................................................................... 34 AFREZZA -insulin regular (human) inhal powd 4 (60) & 8 (30) unit/cart.................................................................... 34 AFREZZA -insulin regular (human) inhal powd 4 (90) & 8 (90) unit/cart.................................................................... 34 AFREZZA -insulin regular (human) inh powd 4 & 8 & 12 unit/cart (60).................................................................... 34 AFREZZA -insulin regular (human) inh powd 8 (60) & 12 (30) unit/cart.................................................................... 34 AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200 mg.................................................................................. 137 AKTEN -lidocaine hcl ophth gel 3.5%............................. 143 AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 62 ALBENZA -albendazole tab 200 mg................................. 12 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 57 albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 57 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv).............................................................................. 57 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv).............................................................................. 57 albuterol sulfate syrup 2 mg/5ml................................... 57 albuterol sulfate tab 2 mg...............................................57 albuterol sulfate tab 4 mg...............................................57 albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 57 albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 57 alclometasone dipropionate cream 0.05% (Aclovate)..................................................................... 150 alclometasone dipropionate oint 0.05%......................150 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab 50-50 mg......................................................................... 50 ALECENSA -alectinib hcl cap 150 mg (base equivalent)....................................................................... 17 ALENDRONATE SODIUM -alendronate sodium tab 40 mg.................................................................................... 37 alendronate sodium tab 5 mg........................................ 37 alendronate sodium tab 10 mg...................................... 37 alendronate sodium tab 35 mg...................................... 37 alendronate sodium tab 70 mg (Fosamax)................... 37 alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 67 ALINIA -nitazoxanide for susp 100 mg/5ml.......................12 ALINIA -nitazoxanide tab 500 mg..................................... 12 ALITRAQ -nutritional supplement pack........................... 115 ALKERAN -melphalan tab 2 mg....................................... 17 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 161 2017 allopurinol tab 100 mg (Zyloprim)................................. 96 allopurinol tab 300 mg (Zyloprim)................................. 96 almotriptan malate tab 6.25 mg (Axert).........................95 almotriptan malate tab 12.5 mg (Axert).........................95 ALOCRIL -nedocromil sodium ophth soln 2%................ 143 ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl tab 12.5-500 mg............................................................. 29 ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl tab 12.5-1000 mg........................................................... 29 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-15 mg...................................................................... 29 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-30 mg...................................................................... 29 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 12.5-45 mg...................................................................... 29 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-15 mg......................................................................... 29 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-30 mg......................................................................... 29 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 25-45 mg......................................................................... 29 ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base equiv)............................................................................... 29 ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base equiv)............................................................................... 29 ALOGLIPTIN -alogliptin benzoate tab 25 mg (base equiv)............................................................................... 29 ALOMIDE -lodoxamide tromethamine ophth soln 0.1%...............................................................................143 ALORA -estradiol td patch biweekly 0.025 mg/24hr......... 24 ALORA -estradiol td patch biweekly 0.05 mg/24hr........... 24 ALORA -estradiol td patch biweekly 0.075 mg/24hr......... 24 ALORA -estradiol td patch biweekly 0.1 mg/24hr............. 24 alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 64 alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 64 ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 143 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 250 unit......................................... 137 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 500 unit......................................... 137 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 1000 unit....................................... 137 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 1500 unit....................................... 137 ALPHANATE/VON WILLEBRAND -antihemophilic factor/ vwf (human) for inj 2000 unit....................................... 137 ALPHANINE SD -coagulation factor ix for inj 500 unit................................................................................. 137 ALPHANINE SD -coagulation factor ix for inj 1000 unit................................................................................. 138 ALPHANINE SD -coagulation factor ix for inj 1500 unit................................................................................. 138 ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ ml..................................................................................... 68 alprazolam orally disintegrating tab 0.5 mg................. 68 alprazolam orally disintegrating tab 1 mg.................... 68 alprazolam orally disintegrating tab 2 mg.................... 68 alprazolam orally disintegrating tab 0.25 mg (Niravam)........................................................................ 68 alprazolam tab 0.25 mg (Xanax).................................... 68 alprazolam tab 0.5 mg (Xanax)...................................... 68 alprazolam tab 1 mg (Xanax)..........................................68 alprazolam tab 2 mg (Xanax)..........................................68 alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 68 alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 68 alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 68 alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 68 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 250 unit......................................................................... 138 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 500 unit......................................................................... 138 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 1000 unit....................................................................... 138 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 2000 unit....................................................................... 138 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 3000 unit....................................................................... 138 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj 4000 unit....................................................................... 138 ALREX -loteprednol etabonate ophth susp 0.2%........... 143 ALTABAX -retapamulin oint 1%.......................................150 amantadine hcl cap 100 mg......................................... 101 amantadine hcl syrup 50 mg/5ml................................ 101 amantadine hcl tab 100 mg.......................................... 101 AMCINONIDE -amcinonide cream 0.1%........................ 150 AMCINONIDE -amcinonide lotion 0.1%.......................... 150 AMCINONIDE -amcinonide oint 0.1%.............................150 AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 137 AMICAR -aminocaproic acid tab 500 mg........................ 137 AMICAR -aminocaproic acid tab 1000 mg...................... 137 amiloride & hydrochlorothiazide tab 5-50 mg.............. 50 amiloride hcl tab 5 mg.................................................... 50 amino acids cap............................................................. 114 amino acids tab.............................................................. 114 amiodarone hcl tab 100 mg............................................ 44 amiodarone hcl tab 400 mg............................................ 44 amiodarone hcl tab 200 mg (Cordarone)...................... 44 amitriptyline hcl tab 10 mg............................................. 69 amitriptyline hcl tab 25 mg............................................. 69 amitriptyline hcl tab 50 mg............................................. 69 amitriptyline hcl tab 75 mg............................................. 69 amitriptyline hcl tab 100 mg........................................... 69 amitriptyline hcl tab 150 mg........................................... 69 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 162 2017 amlodipine besylate-benazepril hcl cap 2.5-10 mg (Lotrel)............................................................................ 45 amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel)............................................................................ 45 amlodipine besylate-benazepril hcl cap 5-20 mg (Lotrel)............................................................................ 45 amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel)............................................................................ 45 amlodipine besylate-benazepril hcl cap 10-20 mg (Lotrel)............................................................................ 45 amlodipine besylate-benazepril hcl cap 10-40 mg (Lotrel)............................................................................ 45 amlodipine besylate tab 2.5 mg (Norvasc)................... 42 amlodipine besylate tab 5 mg (Norvasc)...................... 42 amlodipine besylate tab 10 mg (Norvasc).................... 42 amlodipine besylate-valsartan tab 5-160 mg (Exforge)......................................................................... 45 amlodipine besylate-valsartan tab 5-320 mg (Exforge)......................................................................... 45 amlodipine besylate-valsartan tab 10-160 mg (Exforge)......................................................................... 45 amlodipine besylate-valsartan tab 10-320 mg (Exforge)......................................................................... 45 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)........................................ 45 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg (Exforge hct)........................................... 45 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)...................................... 45 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg (Exforge hct)......................................... 45 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg (Exforge hct)......................................... 45 AMOXAPINE -amoxapine tab 25 mg................................ 69 AMOXAPINE -amoxapine tab 50 mg................................ 69 AMOXAPINE -amoxapine tab 100 mg.............................. 69 AMOXAPINE -amoxapine tab 150 mg.............................. 69 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 (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)................................................................... 77 amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr)................................................................... 77 amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr)................................................................... 77 amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr)................................................................... 77 amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall xr)................................................................... 78 amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall xr)................................................................... 78 amphetamine-dextroamphetamine tab 5 mg (Adderall)........................................................................ 78 amphetamine-dextroamphetamine tab 7.5 mg (Adderall)........................................................................ 78 amphetamine-dextroamphetamine tab 10 mg (Adderall)........................................................................ 78 amphetamine-dextroamphetamine tab 12.5 mg (Adderall)........................................................................ 78 amphetamine-dextroamphetamine tab 15 mg (Adderall)........................................................................ 78 amphetamine-dextroamphetamine tab 20 mg (Adderall)........................................................................ 78 amphetamine-dextroamphetamine tab 30 mg (Adderall)........................................................................ 78 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...................... 81 ANADROL-50 -oxymetholone tab 50 mg.......................... 23 anagrelide hcl cap 1 mg............................................... 138 anagrelide hcl cap 0.5 mg (Agrylin)............................ 138 ANALPRAM-HC -hydrocortisone acetate w/ pramoxine rectal lotn 2.5-1%..........................................................149 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 163 2017 anastrozole tab 1 mg (Arimidex)................................... 17 ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 23 ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 24 ANDROGEL PUMP -testosterone td gel 20.25 mg/act (1.62%)............................................................................ 24 ANDROGEL -testosterone td gel 20.25 mg/1.25gm (1.62%)............................................................................ 24 ANDROGEL -testosterone td gel 40.5 mg/2.5gm (1.62%)............................................................................ 24 ANDROXY -fluoxymesterone tab 10 mg........................... 24 ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 24 ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 24 ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba 62.5-25 mcg/inh.............................................................. 57 ANZEMET -dolasetron mesylate tab 50 mg..................... 62 ANZEMET -dolasetron mesylate tab 100 mg................... 62 APIDRA -insulin glulisine inj 100 unit/ml........................... 33 APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj 100 unit/ml.......................................................................33 APOKYN -apomorphine hcl soln cartridge 30 mg/3ml........................................................................... 101 apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine)...................................................................... 143 aprepitant capsule 80 mg (Emend)............................... 62 aprepitant capsule therapy pack 80 & 125 mg (Emend).......................................................................... 62 APRISO -mesalamine cap sr 24hr 0.375 gm.................... 64 APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg (xr)................................................................................... 78 APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg (xr)................................................................................... 78 APTENSIO XR -methylphenidate hcl cap er 24hr 20 mg (xr)................................................................................... 78 APTENSIO XR -methylphenidate hcl cap er 24hr 30 mg (xr)................................................................................... 78 APTENSIO XR -methylphenidate hcl cap er 24hr 40 mg (xr)................................................................................... 78 APTENSIO XR -methylphenidate hcl cap er 24hr 50 mg (xr)................................................................................... 78 APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg (xr)................................................................................... 78 APTIOM -eslicarbazepine acetate tab 200 mg................. 96 APTIOM -eslicarbazepine acetate tab 400 mg................. 96 APTIOM -eslicarbazepine acetate tab 600 mg................. 96 APTIOM -eslicarbazepine acetate tab 800 mg................. 96 APTIVUS -tipranavir cap 250 mg........................................ 6 APTIVUS -tipranavir oral soln 100 mg/ml........................... 6 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25 mcg/ml........................................................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40 mcg/ml........................................................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60 mcg/ml........................................................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100 mcg/ml........................................................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200 mcg/ml........................................................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 300 mcg/ml........................................................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml..................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml..................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml..................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml................................... 133 ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilled syringe 500 mcg/ml........................................ 133 ARCALYST -rilonacept for inj 220 mg...............................92 ARCAPTA NEOHALER -indacaterol maleate inhal powder cap 75 mcg (base equiv)................................................57 ARGIMENT -amino acids pack....................................... 114 ARGIMENT AT -amino acids pack.................................. 114 ARGINAID EXTRA -nutritional supplement liquid........... 115 ARGINAID -nutritional supplement pack......................... 115 aripiprazole orally disintegrating tab 10 mg.................72 aripiprazole orally disintegrating tab 15 mg.................72 aripiprazole oral solution 1 mg/ml................................. 72 aripiprazole tab 2 mg (Abilify)........................................ 72 aripiprazole tab 5 mg (Abilify)........................................ 72 aripiprazole tab 10 mg (Abilify)...................................... 72 aripiprazole tab 15 mg (Abilify)...................................... 72 aripiprazole tab 20 mg (Abilify)...................................... 73 aripiprazole tab 30 mg (Abilify)...................................... 73 armodafinil tab 50 mg (Nuvigil)......................................78 armodafinil tab 150 mg (Nuvigil)................................... 78 armodafinil tab 200 mg (Nuvigil)................................... 78 armodafinil tab 250 mg (Nuvigil)................................... 78 ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 35 ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 35 ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 35 ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 35 ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 35 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 164 2017 ARNUITY ELLIPTA -fluticasone furoate aerosol powder breath activ 100 mcg/act................................................ 57 ARNUITY ELLIPTA -fluticasone furoate aerosol powder breath activ 200 mcg/act................................................ 57 ASACOL HD -mesalamine tab delayed release 800 mg.................................................................................... 64 ASMANEX HFA -mometasone furoate inhal aerosol suspension 100 mcg/act................................................. 57 ASMANEX HFA -mometasone furoate inhal aerosol suspension 200 mcg/act................................................. 57 ASMANEX TWISTHALER 120 ME -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 57 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 110 mcg/inh (breath activated).................... 57 ASMANEX TWISTHALER 30 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 58 ASMANEX TWISTHALER 60 MET -mometasone furoate inhal powd 220 mcg/inh (breath activated).................... 58 A-SOY -nutritional supplement liquid.............................. 115 aspirin chew tab 81 mg...................................................85 aspirin-dipyridamole cap sr 12hr 25-200 mg (Aggrenox)................................................................... 138 aspirin tab delayed release 81 mg.................................85 ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 157 ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 157 ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 157 ASTERO -lidocaine hcl gel 4%....................................... 150 ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr 29-1 mg......................................................................... 105 atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50).................................................................................... 45 atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100).................................................................................. 45 atenolol tab 25 mg (Tenormin)....................................... 41 atenolol tab 50 mg (Tenormin)....................................... 41 atenolol tab 100 mg (Tenormin)..................................... 41 ATGAM -lymphocyte immune globulin anti-thymocyte g inj 50 mg/ml(eq)................................................................. 157 atorvastatin calcium tab 10 mg (base equivalent) (Lipitor)........................................................................... 51 atorvastatin calcium tab 20 mg (base equivalent) (Lipitor)........................................................................... 51 atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)........................................................................... 51 atorvastatin calcium tab 80 mg (base equivalent) (Lipitor)........................................................................... 51 atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)...................................................................... 11 atovaquone-proguanil hcl tab 250-100 mg (Malarone)...................................................................... 11 atovaquone susp 750 mg/5ml (Mepron)....................... 12 ATRIPLA -efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg................................................................6 ATROPINE SULFATE -atropine sulfate ophth soln 1%.................................................................................. 143 ATROVENT HFA -ipratropium bromide hfa inhal aerosol 17 mcg/act.......................................................................58 AUBAGIO -teriflunomide tab 7 mg.................................... 81 AUBAGIO -teriflunomide tab 14 mg.................................. 81 AUGMENTIN -amoxicillin & k clavulanate for susp 125-31.25 mg/5ml............................................................. 1 AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)....... 64 AVANDIA -rosiglitazone maleate tab 2 mg (base equiv)............................................................................... 29 AVANDIA -rosiglitazone maleate tab 4 mg (base equiv)............................................................................... 29 AVC -sulfanilamide vaginal cream 15%............................ 67 AVONEX -interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial)....................................................... 81 AVONEX -interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml........................................................................ 81 AVONEX PEN -interferon beta-1a im auto-injector kit 30 mcg/0.5ml........................................................................ 81 AXIRON -testosterone td soln 30 mg/act.......................... 24 AZASAN -azathioprine tab 75 mg................................... 157 AZASAN -azathioprine tab 100 mg................................. 157 AZASITE -azithromycin ophth soln 1%........................... 143 azathioprine tab 50 mg (Imuran).................................. 157 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro).........................................................................55 azelastine hcl nasal spray 137 mcg/spray (1 mg/ ml)................................................................................... 55 azelastine hcl ophth soln 0.05% (Optivar).................. 143 AZILECT -rasagiline mesylate tab 0.5 mg (base equiv)............................................................................. 101 AZILECT -rasagiline mesylate tab 1 mg (base equiv)............................................................................. 101 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%............................. 143 B BABY DDROPS -cholecalciferol drops 400 unit/0.03ml (per drop)...................................................................... 105 BACITRACIN -bacitracin ophth oint 500 unit/gm............ 143 bacitracin-polymyxin b ophth oint.............................. 143 bacitracin-polymyxin-neomycin-hc ophth oint 1%.................................................................................. 143 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 165 2017 baclofen tab 10 mg........................................................ 104 baclofen tab 20 mg........................................................ 104 BACTROBAN NASAL -mupirocin calcium nasal oint 2%.................................................................................... 55 BALANCED NUTRITIONAL DRIN -nutritional supplement liquid.............................................................................. 116 BALANCED NUTRITIONAL SHAK -nutritional supplement liquid.......................................................... 116 BALANCE TOTAL NUTRITIONAL -nutritional supplement liquid.............................................................................. 115 BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg................................................... 105 balsalazide disodium cap 750 mg (Colazal)................. 64 BANZEL -rufinamide susp 40 mg/ml................................. 96 BANZEL -rufinamide tab 200 mg...................................... 96 BANZEL -rufinamide tab 400 mg...................................... 96 BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7 BAYER BREEZE 2 TEST DISC -glucose blood test disk................................................................................ 156 BAYER CONTOUR BLOOD GLUCO -glucose blood test strip................................................................................ 156 BAYER CONTOUR NEXT BLOOD -glucose blood test strip................................................................................ 156 BCAD 1 -nutritional supplement powder......................... 116 BCAD 2 -nutritional supplement powder......................... 116 BEBULIN -factor ix complex for inj 200-1200 unit.......... 138 BEEF/POTATOES/PEAS -nutritional supplement liquid.............................................................................. 116 BELBUCA -buprenorphine hcl buccal film 75 mcg (base equivalent)....................................................................... 85 BELBUCA -buprenorphine hcl buccal film 150 mcg (base equivalent)....................................................................... 85 BELBUCA -buprenorphine hcl buccal film 300 mcg (base equivalent)....................................................................... 85 BELBUCA -buprenorphine hcl buccal film 450 mcg (base equivalent)....................................................................... 85 BELBUCA -buprenorphine hcl buccal film 600 mcg (base equivalent)....................................................................... 86 BELBUCA -buprenorphine hcl buccal film 750 mcg (base equivalent)....................................................................... 86 BELBUCA -buprenorphine hcl buccal film 900 mcg (base equivalent)....................................................................... 86 benazepril & hydrochlorothiazide tab 5-6.25 mg......... 45 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct)................................................................ 45 benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct)................................................................ 46 benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct)................................................................ 46 benazepril hcl tab 5 mg.................................................. 46 benazepril hcl tab 10 mg (Lotensin).............................. 46 benazepril hcl tab 20 mg (Lotensin).............................. 46 benazepril hcl tab 40 mg (Lotensin).............................. 46 BENECALORIE -nutritional supplement liquid................ 116 BENEFIX -coagulation factor ix (recombinant) for inj kit 250 unit......................................................................... 138 BENEFIX -coagulation factor ix (recombinant) for inj kit 500 unit......................................................................... 138 BENEFIX -coagulation factor ix (recombinant) for inj kit 1000 unit....................................................................... 138 BENEFIX -coagulation factor ix (recombinant) for inj kit 2000 unit....................................................................... 138 BENEFIX -coagulation factor ix (recombinant) for inj kit 3000 unit....................................................................... 138 BENICAR -olmesartan medoxomil tab 5 mg.....................46 BENICAR -olmesartan medoxomil tab 20 mg...................46 BENICAR -olmesartan medoxomil tab 40 mg...................46 BENZONATATE -benzonatate cap 150 mg...................... 56 benzonatate cap 200 mg................................................. 56 benzonatate cap 100 mg (Tessalon perles).................. 56 benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)............................................................... 150 benztropine mesylate tab 0.5 mg................................ 102 benztropine mesylate tab 1 mg................................... 102 benztropine mesylate tab 2 mg................................... 102 BEPREVE -bepotastine besilate ophth soln 1.5%.......... 143 BERINERT -c1 esterase inhibitor (human) for iv inj kit 500 unit................................................................................. 138 BESIVANCE -besifloxacin hcl ophth susp 0.6% (base equiv)............................................................................. 143 BETADINE OPHTHALMIC PREP -povidone-iodine ophth soln 5%......................................................................... 143 betamethasone dipropionate augmented cream 0.05% (Diprolene af)............................................................... 150 betamethasone dipropionate augmented gel 0.05%.............................................................................150 betamethasone dipropionate augmented lotion 0.05% (Diprolene)................................................................... 150 betamethasone dipropionate augmented oint 0.05% (Diprolene)................................................................... 150 betamethasone dipropionate cream 0.05%................ 150 betamethasone dipropionate lotion 0.05%................. 150 betamethasone dipropionate oint 0.05%.................... 150 betamethasone valerate aerosol foam 0.12% (Luxiq)........................................................................... 150 betamethasone valerate cream 0.1%.......................... 150 betamethasone valerate lotion 0.1%........................... 150 betamethasone valerate oint 0.1%.............................. 150 BETASERON -interferon beta-1b for inj kit 0.3 mg........... 81 betaxolol hcl ophth soln 0.5%......................................143 betaxolol hcl tab 10 mg (Kerlone)................................. 41 betaxolol hcl tab 20 mg (Kerlone)................................. 41 bethanechol chloride tab 5 mg (Urecholine)................ 66 bethanechol chloride tab 10 mg (Urecholine).............. 66 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 166 2017 bethanechol chloride tab 25 mg (Urecholine).............. 66 bethanechol chloride tab 50 mg (Urecholine).............. 66 BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 5 BETIMOL -timolol ophth soln 0.25%............................... 143 BETIMOL -timolol ophth soln 0.5%................................. 143 BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 143 bexarotene cap 75 mg (Targretin)..................................17 BEYAZ -drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg..............................................................26 bicalutamide tab 50 mg (Casodex)................................ 17 BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg.................................................................................... 54 BILTRICIDE -praziquantel tab 600 mg.............................. 12 BIMATOPROST -bimatoprost ophth soln 0.03%............ 143 bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln kit..................................................................................... 60 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac)............................................................................... 46 bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac)............................................................................... 46 bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac)............................................................................... 46 bisoprolol fumarate tab 5 mg (Zebeta)..........................41 bisoprolol fumarate tab 10 mg (Zebeta)........................41 BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 144 BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth susp 10-0.2%................................................................ 144 BOOST/BENEFIBER -nutritional supplement liquid....... 116 BOOST BREEZE -nutritional supplement liquid............. 116 BOOST CALORIE SMART -nutritional supplement liquid.............................................................................. 116 BOOST 100 CALORIE SMART -nutritional supplement liquid.............................................................................. 116 BOOST COMPACT -nutritional supplement liquid.......... 116 BOOST GLUCOSE CONTROL -nutritional supplement liquid.............................................................................. 116 BOOST HIGH PROTEIN -nutritional supplement liquid.............................................................................. 116 BOOST HIGH PROTEIN -nutritional supplement powder........................................................................... 116 BOOST KID ESSENTIALS 1.0 -nutritional supplement liquid.............................................................................. 116 BOOST KID ESSENTIALS 1.5 -nutritional supplement liquid.............................................................................. 116 BOOST KIDS ESSENTIALS -nutritional supplement liquid.............................................................................. 116 BOOST -nutritional supplement liquid............................. 116 BOOST PLUS -nutritional supplement liquid.................. 116 BOOST PUDDING -nutritional supplement pudding.......116 BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 16 BOOST SMOOTHIE -nutritional supplement liquid........ 116 BOOST VHC -nutritional supplement liquid.................... 116 BOSULIF -bosutinib tab 100 mg....................................... 17 BOSULIF -bosutinib tab 500 mg....................................... 17 BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg....................................................... 106 BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg.............................................................. 106 BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa tab chew 40-1 mg......................................................... 106 BREATHERITE COLLAPSIBLE -spacer/aerosol-holding chambers - device........................................................ 156 BREATHERITE RIGID SPACER -spacer/aerosol-holding chambers - device........................................................ 156 BREATHERITE -spacer/aerosol-holding chambers device............................................................................ 156 BREATHERITE W/LARGE MASK -spacer/aerosol-holding chambers - device........................................................ 156 BREATHERITE W/MEDIUM MASK -spacer/aerosolholding chambers - device........................................... 156 BREATHERITE W/SMALL MASK -spacer/aerosol-holding chambers - device........................................................ 156 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh.......................................................... 58 BREO ELLIPTA -fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh.......................................................... 58 BRILINTA -ticagrelor tab 60 mg...................................... 138 BRILINTA -ticagrelor tab 90 mg...................................... 138 brimonidine tartrate ophth soln 0.2%......................... 144 brimonidine tartrate ophth soln 0.15% (Alphagan p)................................................................................... 144 BRIVIACT -brivaracetam oral soln 10 mg/ml.................... 96 BRIVIACT -brivaracetam tab 10 mg................................. 96 BRIVIACT -brivaracetam tab 25 mg................................. 96 BRIVIACT -brivaracetam tab 50 mg................................. 96 BRIVIACT -brivaracetam tab 75 mg................................. 97 BRIVIACT -brivaracetam tab 100 mg............................... 97 BROMFENAC -bromfenac sodium ophth soln 0.09% (base equivalent).......................................................... 144 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily).................................................................. 144 bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel)...................................................................... 102 bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel)...................................................................... 102 BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml (base equiv).................................................................... 58 budesonide delayed release particles cap 3 mg (Entocort ec).................................................................. 22 budesonide inhalation susp 0.25 mg/2ml (Pulmicort)......................................................................58 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 167 2017 budesonide inhalation susp 0.5 mg/2ml (Pulmicort)......................................................................58 budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 58 budesonide nasal susp 32 mcg/act (Rhinocort aqua)............................................................................... 55 bumetanide tab 0.5 mg................................................... 50 bumetanide tab 1 mg...................................................... 50 bumetanide tab 2 mg...................................................... 50 BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3 mg (base equiv).............................................................. 86 BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7 mg (base equiv).............................................................. 86 BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg (base equiv).................................................................... 86 BUPHENYL -sodium phenylbutyrate tab 500 mg............. 37 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv).............................................................................. 86 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv).............................................................................. 86 buprenorphine hcl sl tab 2 mg (base equiv)................ 86 buprenorphine hcl sl tab 8 mg (base equiv)................ 86 bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban)............................................................................ 81 bupropion hcl tab 75 mg (Wellbutrin)........................... 69 bupropion hcl tab 100 mg (Wellbutrin)......................... 69 bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 69 bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 69 bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 69 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 69 bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 69 buspirone hcl tab 5 mg................................................... 68 buspirone hcl tab 7.5 mg................................................ 68 buspirone hcl tab 10 mg................................................. 68 buspirone hcl tab 15 mg................................................. 68 buspirone hcl tab 30 mg................................................. 68 butalbital-acetaminophen-caffeine cap 50-325-40 mg................................................................................... 85 butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet)......................................................................... 85 butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)............................................................................. 85 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg............................................................ 86 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg (Fioricet/codeine)............................ 86 butalbital-acetaminophen tab 50-325 mg......................85 butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)......................................................................... 85 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine #3)..................................................... 86 butorphanol tartrate nasal soln 10 mg/ml.................... 86 BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......86 BUTRANS -buprenorphine td patch weekly 7.5 mcg/ hr...................................................................................... 86 BUTRANS -buprenorphine td patch weekly 10 mcg/ hr...................................................................................... 86 BUTRANS -buprenorphine td patch weekly 15 mcg/ hr...................................................................................... 86 BUTRANS -buprenorphine td patch weekly 20 mcg/ hr...................................................................................... 86 BYDUREON -exenatide for inj extended release susp 2 mg.................................................................................... 29 BYDUREON PEN -exenatide extended release for susp pen-injector 2 mg............................................................ 29 BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 29 BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 29 BYSTOLIC -nebivolol hcl tab 2.5 mg (base equivalent)....................................................................... 41 BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......41 BYSTOLIC -nebivolol hcl tab 10 mg (base equivalent)....................................................................... 41 BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)....................................................................... 41 C cabergoline tab 0.5 mg................................................... 37 CABOMETYX -cabozantinib s-malate tab 20 mg (base equivalent)....................................................................... 17 CABOMETYX -cabozantinib s-malate tab 40 mg (base equivalent)....................................................................... 17 CABOMETYX -cabozantinib s-malate tab 60 mg (base equivalent)....................................................................... 17 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) (Cafcit)................................................................ 78 CALCILO XD -infant foods powder................................. 116 calcipotriene-betamethasone dipropionate oint 0.005-0.064% (Taclonex)............................................ 150 calcipotriene cream 0.005% (Dovonex).......................150 calcipotriene oint 0.005%..............................................150 calcipotriene soln 0.005% (50 mcg/ml)....................... 150 calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)...................................................................... 37 calcitriol cap 0.25 mcg (Rocaltrol)................................. 37 calcitriol cap 0.5 mcg (Rocaltrol)................................... 37 calcitriol oral soln 1 mcg/ml (Rocaltrol)........................37 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo)............................................................. 64 calcium acetate (phosphate binder) tab 667 mg (Eliphos)......................................................................... 64 CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg.......................................................... 106 CAMINO PRO BETTERMILK/GLY -nutritional supplement pack............................................................................... 116 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 168 2017 CAMINO PRO COMPLETE/GLYTA -nutritional supplement bar............................................................. 116 CAMINO PRO 15PE -nutritional supplement liquid........ 116 CAMINO PRO PKU -nutritional supplement liquid..........116 CAMINO PRO RESTORE/GLYTAC -nutritional supplement liquid.......................................................... 116 CAMINO PRO SWIRL -nutritional supplement pack...... 116 CANASA -mesalamine suppos 1000 mg.......................... 64 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand hct).......................................................... 46 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct).......................................................... 46 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand hct).......................................................... 46 candesartan cilexetil tab 4 mg (Atacand)..................... 46 candesartan cilexetil tab 8 mg (Atacand)..................... 46 candesartan cilexetil tab 16 mg (Atacand)................... 46 candesartan cilexetil tab 32 mg (Atacand)................... 46 CAPCOF -phenylephrine-chlorphen w/ codeine syrup 5-2-10 mg/5ml................................................................. 56 capecitabine tab 150 mg (Xeloda)................................. 17 capecitabine tab 500 mg (Xeloda)................................. 17 CAPRELSA -vandetanib tab 100 mg................................ 17 CAPRELSA -vandetanib tab 300 mg................................ 17 captopril tab 12.5 mg...................................................... 46 captopril tab 25 mg......................................................... 46 captopril tab 50 mg......................................................... 46 captopril tab 100 mg....................................................... 46 CARAC -fluorouracil cream 0.5%.................................... 150 CARAFATE -sucralfate susp 1 gm/10ml........................... 61 CARBAGLU -carglumic acid tab 200 mg.......................... 37 carbamazepine cap sr 12hr 100 mg (Carbatrol)........... 97 carbamazepine cap sr 12hr 200 mg (Carbatrol)........... 97 carbamazepine cap sr 12hr 300 mg (Carbatrol)........... 97 carbamazepine chew tab 100 mg.................................. 97 carbamazepine susp 100 mg/5ml (Tegretol)................. 97 carbamazepine tab 200 mg (Tegretol)........................... 97 carbamazepine tab sr 12hr 100 mg (Tegretol-xr)......... 97 carbamazepine tab sr 12hr 200 mg (Tegretol-xr)......... 97 carbamazepine tab sr 12hr 400 mg (Tegretol-xr)......... 97 CARBATROL -carbamazepine cap sr 12hr 100 mg......... 97 CARBATROL -carbamazepine cap sr 12hr 200 mg......... 97 CARBATROL -carbamazepine cap sr 12hr 300 mg......... 97 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 102 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 102 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................. 102 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg............................ 102 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg.............................. 102 CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................. 102 carbidopa & levodopa orally disintegrating tab 10-100 mg................................................................................. 102 carbidopa & levodopa orally disintegrating tab 25-100 mg................................................................................. 102 carbidopa & levodopa orally disintegrating tab 25-250 mg................................................................................. 102 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr).................................................................................. 102 carbidopa & levodopa tab cr 50-200 mg (Sinemet cr).................................................................................. 102 carbidopa & levodopa tab 10-100 mg (Sinemet)........ 102 carbidopa & levodopa tab 25-100 mg (Sinemet)........ 102 carbidopa & levodopa tab 25-250 mg (Sinemet)........ 102 carbidopa tab 25 mg (Lodosyn)................................... 102 carbinoxamine maleate soln 4 mg/5ml......................... 55 carbinoxamine maleate tab 4 mg.................................. 55 carbonyl iron susp 15 mg/1.25ml (elemental iron)............................................................................... 133 CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr 120 mg............................................................................ 42 carisoprodol tab 250 mg (Soma)................................. 104 carisoprodol tab 350 mg (Soma)................................. 104 CARNATION BREAKFAST ESSEN -nutritional supplement liquid.......................................................... 116 CARNATION BREAKFAST ESSEN -nutritional supplement pack........................................................... 116 CARNATION INSTANT BREAKFA -nutritional supplement liquid.............................................................................. 116 carteolol hcl ophth soln 1%......................................... 144 carvedilol tab 3.125 mg (Coreg)..................................... 41 carvedilol tab 6.25 mg (Coreg)....................................... 41 carvedilol tab 12.5 mg (Coreg)....................................... 41 carvedilol tab 25 mg (Coreg).......................................... 41 CAYA -diaphragm arc-spring........................................... 156 CAYSTON -aztreonam lysine for inhal soln 75 mg (base equivalent)....................................................................... 12 C-BUFF -multiple vitamins w/ minerals powder.............. 106 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 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 169 2017 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).................................... 92 celecoxib cap 100 mg (Celebrex).................................. 92 celecoxib cap 200 mg (Celebrex).................................. 92 celecoxib cap 400 mg (Celebrex).................................. 92 CELONTIN -methsuximide cap 300 mg............................ 97 CENTANY -mupirocin oint 2%.........................................150 cephalexin cap 250 mg (Keflex)....................................... 2 cephalexin cap 500 mg (Keflex)....................................... 2 cephalexin cap 750 mg (Keflex)....................................... 2 CEPHALEXIN -cephalexin tab 250 mg............................... 2 CEPHALEXIN -cephalexin tab 500 mg............................... 2 cephalexin for susp 125 mg/5ml...................................... 2 cephalexin for susp 250 mg/5ml...................................... 3 CERDELGA -eliglustat tartrate cap 84 mg (base equivalent)..................................................................... 133 CERVIDIL -dinoprostone vaginal inserts 10 mg............... 37 CESAMET -nabilone cap 1 mg......................................... 62 CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base equivalent)..................................................................... 147 CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 155 CETYLEV -acetylcysteine effervescent tab 500 mg....... 155 cevimeline hcl cap 30 mg (Evoxac)............................. 147 CHANTIX CONTINUING MONTH -varenicline tartrate tab 1 mg (base equiv).......................................................... 81 CHANTIX STARTING MONTH PA -varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42 pack.................................81 CHANTIX -varenicline tartrate tab 0.5 mg (base equiv)............................................................................... 81 CHANTIX -varenicline tartrate tab 1 mg (base equiv).......81 CHEMET -succimer cap 100 mg.................................... 155 CHENODAL -chenodiol tab 250 mg................................. 64 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................. 81 CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg.............................................. 81 chlordiazepoxide hcl cap 5 mg...................................... 68 chlordiazepoxide hcl cap 10 mg.................................... 68 chlordiazepoxide hcl cap 25 mg.................................... 68 chlorhexidine gluconate soln 0.12% (Peridex)...........147 CHLOROQUINE PHOSPHATE -chloroquine phosphate tab 250 mg...................................................................... 11 chloroquine phosphate tab 500 mg (Aralen)................ 11 CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 50 chlorothiazide tab 500 mg.............................................. 50 chlorpromazine hcl tab 10 mg....................................... 73 chlorpromazine hcl tab 25 mg....................................... 73 chlorpromazine hcl tab 50 mg....................................... 73 chlorpromazine hcl tab 100 mg..................................... 73 chlorpromazine hcl tab 200 mg..................................... 73 CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 30 CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 30 chlorthalidone tab 25 mg................................................ 50 chlorthalidone tab 50 mg................................................ 50 chlorzoxazone tab 500 mg (Parafon forte dsc).......... 104 CHOICE DM -nutritional supplement liquid.....................117 CHOICE DM TF -nutritional supplement liquid............... 117 CHOLBAM -cholic acid cap 50 mg................................... 64 CHOLBAM -cholic acid cap 250 mg................................. 64 cholecalciferol cap 400 unit......................................... 105 cholecalciferol cap 1000 unit....................................... 105 cholecalciferol cap 50000 unit..................................... 105 cholecalciferol chew tab 400 unit................................ 105 cholecalciferol chew tab 1000 unit.............................. 105 cholecalciferol drops 400 unit/0.03ml (per drop)....... 105 cholecalciferol drops 5000 unit/ml (1000 unit/0.2ml).....................................................................105 cholecalciferol oral liquid 400 unit/ml......................... 105 cholecalciferol tab 400 unit.......................................... 105 cholecalciferol tab 1000 unit........................................ 105 cholecalciferol tab 50000 unit...................................... 105 cholestyramine light powder 4 gm/dose (Questran light)................................................................................ 51 cholestyramine light powder packets 4 gm................. 51 cholestyramine powder 4 gm/dose (Questran)............ 52 cholestyramine powder packets 4 gm (Questran)....... 51 CHOLEXTRA -nutritional supplement powder................ 117 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix).............................................................. 52 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 170 2017 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix).............................................................. 52 CIALIS -tadalafil tab 2.5 mg......................................... 54,54 CIALIS -tadalafil tab 5 mg............................................ 54,54 ciclopirox gel 0.77%...................................................... 150 ciclopirox olamine cream 0.77% (base equiv)............150 ciclopirox olamine susp 0.77% (base equiv).............. 150 ciclopirox shampoo 1% (Loprox shampoo)............... 150 ciclopirox solution 8% (Penlac Nail Lacquer)............ 150 cilostazol tab 50 mg (Pletal)......................................... 138 cilostazol tab 100 mg (Pletal)....................................... 138 CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 144 cimetidine hcl soln 300 mg/5ml..................................... 61 cimetidine tab 300 mg..................................................... 61 cimetidine tab 400 mg..................................................... 61 cimetidine tab 800 mg..................................................... 61 CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 64 CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200 mg/ml............................................................................... 64 CIPRODEX -ciprofloxacin-dexamethasone otic susp 0.3-0.1%........................................................................ 147 CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base equivalent)..................................................................... 147 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)........................................................... 4 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro)........................................................... 4 CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg (base equiv)...................................................................... 5 ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 144 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%........................................................................... 147 citalopram hydrobromide oral soln 10 mg/5ml............ 69 citalopram hydrobromide tab 10 mg (base equiv) (Celexa)........................................................................... 69 citalopram hydrobromide tab 20 mg (base equiv) (Celexa)........................................................................... 69 citalopram hydrobromide tab 40 mg (base equiv) (Celexa)........................................................................... 69 CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack......................................... 106 CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab 20-1 mg & vit b6 tab pak............................................. 106 CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack............................................... 106 CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak........................................ 106 CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................ 106 CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg.........................................................106 clarithromycin for susp 125 mg/5ml............................... 3 clarithromycin for susp 250 mg/5ml (Biaxin)................. 3 clarithromycin tab 250 mg (Biaxin)................................. 3 clarithromycin tab 500 mg (Biaxin)................................. 3 clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)......... 3 CLEMASTINE FUMARATE -clemastine fumarate tab 2.68 mg.................................................................................... 55 CLEOCIN -clindamycin phosphate vaginal suppos 100 mg.................................................................................... 67 CLICK ESPRESSO PROTEIN DR -nutritional supplement powder........................................................................... 117 CLIMARA PRO -estradiol-levonorgestrel td patch weekly 0.045-0.015 mg/day........................................................ 24 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)................................................................... 151 clindamycin phosphate foam 1% (Evoclin)................ 150 clindamycin phosphate gel 1% (Cleocin-t)................. 150 clindamycin phosphate lotion 1% (Cleocin-t)............ 150 clindamycin phosphate soln 1% (Cleocin-t)............... 150 clindamycin phosphate swab 1% (Cleocin-t)............. 150 clindamycin phosphate-tretinoin gel 1.2-0.025% (Ziana)........................................................................... 151 clindamycin phosphate vaginal cream 2% (Cleocin)......................................................................... 67 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)............................................................... 150 CLINDESSE -clindamycin phosphate (one dose) vaginal cream 2%........................................................................ 67 clobetasol propionate cream 0.05% (Temovate)........ 151 clobetasol propionate emollient base cream 0.05% (Temovate e)................................................................ 151 clobetasol propionate gel 0.05% (Temovate)............. 151 clobetasol propionate lotion 0.05% (Clobex)............. 151 clobetasol propionate oint 0.05% (Temovate)............ 151 clobetasol propionate shampoo 0.05% (Clobex)....... 151 clobetasol propionate soln 0.05% (Temovate)........... 151 CLOCORTOLONE PIVALATE -clocortolone pivalate cream 0.1%................................................................... 151 CLOCORTOLONE PIVALATE PUM -clocortolone pivalate cream 0.1%................................................................... 151 clomipramine hcl cap 25 mg (Anafranil)....................... 69 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 171 2017 clomipramine hcl cap 50 mg (Anafranil)....................... 69 clomipramine hcl cap 75 mg (Anafranil)....................... 69 clonazepam orally disintegrating tab 0.125 mg........... 97 clonazepam orally disintegrating tab 0.25 mg............. 97 clonazepam orally disintegrating tab 0.5 mg............... 97 clonazepam orally disintegrating tab 1 mg.................. 97 clonazepam orally disintegrating tab 2 mg.................. 97 clonazepam tab 0.5 mg (Klonopin)................................ 97 clonazepam tab 1 mg (Klonopin)................................... 97 clonazepam tab 2 mg (Klonopin)................................... 97 clonidine hcl tab 0.1 mg (Catapres).............................. 46 clonidine hcl tab 0.2 mg (Catapres).............................. 46 clonidine hcl tab 0.3 mg (Catapres).............................. 46 clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 78 clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 46 clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 46 clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 46 clopidogrel bisulfate tab 75 mg (base equiv) (Plavix).......................................................................... 138 clopidogrel bisulfate tab 300 mg (base equiv) (Plavix).......................................................................... 138 clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 68 clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 68 clorazepate dipotassium tab 15 mg (Tranxene t)......... 68 clotrimazole troche 10 mg............................................ 147 clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone).................................................................... 151 clotrimazole w/ betamethasone lotion 1-0.05%..........151 CLOZAPINE ODT -clozapine orally disintegrating tab 12.5 mg.................................................................................... 73 CLOZAPINE ODT -clozapine orally disintegrating tab 150 mg.................................................................................... 73 CLOZAPINE ODT -clozapine orally disintegrating tab 200 mg.................................................................................... 73 clozapine orally disintegrating tab 25 mg (Fazaclo)......................................................................... 73 clozapine orally disintegrating tab 100 mg (Fazaclo)......................................................................... 73 clozapine tab 50 mg........................................................ 73 clozapine tab 200 mg...................................................... 73 clozapine tab 25 mg (Clozaril)........................................73 clozapine tab 100 mg (Clozaril)..................................... 73 C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................. 106 COAGADEX -coagulation factor x (human) for inj 250 unit................................................................................. 138 COAGADEX -coagulation factor x (human) for inj 500 unit................................................................................. 138 COARTEM -artemether-lumefantrine tab 20-120 mg....... 11 codeine sulfate tab 30 mg.............................................. 86 codeine sulfate tab 60 mg.............................................. 86 codeine sulfate tab 15 mg (Codeine sulfate)................ 86 COLCHICINE -colchicine cap 0.6 mg............................... 96 COLCHICINE -colchicine tab 0.6 mg................................ 96 colchicine w/ probenecid tab 0.5-500 mg..................... 96 COLCRYS -colchicine tab 0.6 mg..................................... 96 colestipol hcl granule packets 5 gm (Colestid flavored)......................................................................... 52 colestipol hcl granules 5 gm (Colestid flavored)......... 52 colestipol hcl tab 1 gm (Colestid)..................................52 COLGATE DRY MOUTH RELIEF -sodium fluoride mouthwash 2.1 mg/10ml.............................................. 147 COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic susp 3.3-3-10-0.5 mg/ml.............................................. 147 COMBIGAN -brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%................................................................ 144 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.14 mg/day............................................................ 24 COMBIPATCH -estradiol-norethindrone ace td pttw 0.05-0.25 mg/day............................................................ 24 COMBIVENT RESPIMAT -ipratropium-albuterol inhal aerosol soln 20-100 mcg/act.......................................... 58 COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit........................................................................... 17 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit............................................................17 COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit............................................................17 COMMIT -nicotine polacrilex lozenge 2 mg...................... 81 COMMIT -nicotine polacrilex lozenge 4 mg...................... 81 COMPLEAT CLOSED SYSTEM -nutritional supplement liquid.............................................................................. 117 COMPLEAT -nutritional supplement liquid...................... 117 COMPLEAT PEDIATRIC -nutritional supplement liquid.............................................................................. 117 COMPLEAT PEDIATRIC REDUCE -nutritional supplement liquid.......................................................... 117 COMPLERA -emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg.................................................................. 7 COMPLETE AMINO ACID MIX -amino acids oral powder........................................................................... 114 COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 250 pk.......................................... 106 COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab 29-1 mg......................................................................... 106 COMPLETE NUTRITION -nutritional supplement liquid.............................................................................. 117 COMPLETE NUTRITION PLUS -nutritional supplement liquid.............................................................................. 117 COMPLETE PROTEIN & VITAMI -nutritional supplement powder........................................................................... 117 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 172 2017 COMPLEX ESSENTIAL MSD -amino acids oral powder........................................................................... 114 COMPLEX JUNIOR MSD -amino acids oral powder...... 114 COMPLEX MSUD AMINO ACID B -amino acids bar..... 114 COMPLEX MSUD -amino acids oral powder..................114 CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................. 106 CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg......................................................... 106 CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg...............................................................106 CONCERTA -methylphenidate hcl tab sa osm 18 mg...... 78 CONCERTA -methylphenidate hcl tab sa osm 27 mg...... 78 CONCERTA -methylphenidate hcl tab sa osm 36 mg...... 78 CONCERTA -methylphenidate hcl tab sa osm 54 mg...... 78 CONDYLOX -podofilox gel 0.5%.................................... 151 COPAXONE -glatiramer acetate soln prefilled syringe 20 mg/ml............................................................................... 81 COPAXONE -glatiramer acetate soln prefilled syringe 40 mg/ml............................................................................... 81 CORDRAN -flurandrenolide tape 4 mcg/sqcm............... 151 COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 41 COREG CR -carvedilol phosphate cap sr 24hr 20 mg..... 41 COREG CR -carvedilol phosphate cap sr 24hr 40 mg..... 41 COREG CR -carvedilol phosphate cap sr 24hr 80 mg..... 41 CORIFACT -factor xiii concentrate (human) for inj kit 1000-1600 unit.............................................................. 138 CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 54 CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 54 CORTIFOAM -hydrocortisone acetate rectal foam 10% (90 mg/dose)................................................................. 149 CORTISONE ACETATE -cortisone acetate tab 25 mg..... 22 CORTISPORIN -bacitracin-polymyxin-neomycin hc oint 1%.................................................................................. 151 CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/ gm-10000 unt/gm-0.5%................................................ 151 COSENTYX -secukinumab subcutaneous soln prefilled syringe 150 mg/ml........................................................ 151 COSENTYX SENSOREADY PEN -secukinumab subcutaneous soln auto-injector 150 mg/ml................ 151 COSOPT PF -dorzolamide hcl-timolol maleate ophth sol 22.3-6.8 mg/ml pf..........................................................144 COTELLIC -cobimetinib fumarate tab 20 mg (base equivalent)....................................................................... 17 COUMADIN -warfarin sodium tab 1 mg.......................... 135 COUMADIN -warfarin sodium tab 2 mg.......................... 135 COUMADIN -warfarin sodium tab 2.5 mg....................... 135 COUMADIN -warfarin sodium tab 3 mg.......................... 135 COUMADIN -warfarin sodium tab 4 mg.......................... 135 COUMADIN -warfarin sodium tab 5 mg.......................... 135 COUMADIN -warfarin sodium tab 6 mg.......................... 135 COUMADIN -warfarin sodium tab 7.5 mg....................... 135 COUMADIN -warfarin sodium tab 10 mg........................ 135 CREON -pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit.....................................................63 CREON -pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 unit...................................................63 CREON -pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000 unit................................................ 63 CREON -pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit.............................................. 63 CREON -pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit............................................. 63 CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 6 CREST COMPLETE -sodium fluoride paste 0.243%..... 147 CRESTOR -rosuvastatin calcium tab 5 mg.......................52 CRESTOR -rosuvastatin calcium tab 10 mg.....................52 CRESTOR -rosuvastatin calcium tab 20 mg.....................52 CRESTOR -rosuvastatin calcium tab 40 mg.....................52 CRITICARE HN -nutritional supplement liquid................117 CRIXIVAN -indinavir sulfate cap 200 mg............................ 7 CRIXIVAN -indinavir sulfate cap 400 mg............................ 7 CROMOLYN SODIUM -cromolyn sodium soln nebu 20 mg/2ml............................................................................. 58 cromolyn sodium ophth soln 4%................................ 144 cromolyn sodium oral conc 100 mg/5ml (Gastrocrom).................................................................. 64 CRUCIAL -nutritional supplement liquid..........................117 CUPRIMINE -penicillamine cap 250 mg......................... 157 CUROSURF -poractant alfa intratracheal susp 120 mg/1.5ml.......................................................................... 60 CUROSURF -poractant alfa intratracheal susp 240 mg/3ml............................................................................. 60 CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 61 CVS NUTRITIONAL SHAKE -nutritional supplement liquid.............................................................................. 117 CVS NUTRITION LIQUID -nutritional supplement liquid.............................................................................. 117 CVS NUTRITION PLUS -nutritional supplement liquid.............................................................................. 117 cyanocobalamin inj 1000 mcg/ml................................ 133 CYCLINEX-1 -nutritional supplement powder................. 117 CYCLINEX-2 -nutritional supplement powder................. 117 cyclobenzaprine hcl tab 5 mg...................................... 104 cyclobenzaprine hcl tab 10 mg.................................... 104 cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 104 CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 144 CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth soln 0.2-1%................................................................... 144 cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........144 cyclopentolate hcl ophth soln 1% (Cyclogyl).............144 cyclopentolate hcl ophth soln 2% (Cyclogyl).............144 CYCLOPHOSPHAMIDE -cyclophosphamide cap 25 mg.................................................................................... 17 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 173 2017 CYCLOPHOSPHAMIDE -cyclophosphamide cap 50 mg.................................................................................... 17 CYCLOSERINE -cycloserine cap 250 mg.......................... 5 CYCLOSET -bromocriptine mesylate tab 0.8 mg (base equivalent)....................................................................... 30 cyclosporine cap 25 mg (Sandimmune)..................... 157 cyclosporine cap 100 mg (Sandimmune)................... 157 cyclosporine modified cap 50 mg (Cyclosporine modifie)......................................................................... 157 cyclosporine modified cap 25 mg (Neoral).................157 cyclosporine modified cap 100 mg (Neoral)...............157 CYCLOSPORINE MODIFIED -cyclosporine modified cap 50 mg............................................................................ 157 cyclosporine modified oral soln 100 mg/ml (Neoral)......................................................................... 157 cyproheptadine hcl syrup 2 mg/5ml.............................. 55 cyproheptadine hcl tab 4 mg......................................... 55 CYSTAGON -cysteamine bitartrate cap 50 mg.................67 CYSTAGON -cysteamine bitartrate cap 150 mg...............67 CYSTARAN -cysteamine hcl ophth soln 0.44% (base equivalent)..................................................................... 144 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................................. 58 danazol cap 50 mg.......................................................... 24 danazol cap 100 mg........................................................ 24 danazol cap 200 mg........................................................ 24 dantrolene sodium cap 100 mg................................... 104 dantrolene sodium cap 25 mg (Dantrium).................. 104 dantrolene sodium cap 50 mg (Dantrium).................. 104 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............................ 11 darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) (Enablex)............................................................ 66 darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) (Enablex)............................................................ 66 DDROPS -cholecalciferol drops 1000 unit/0.03ml (per drop).............................................................................. 105 DEBACTEROL -sulfuric acid-sulfonated phenolics soln 30-50%.......................................................................... 147 DELZICOL -mesalamine cap dr 400 mg........................... 64 demeclocycline hcl tab 150 mg....................................... 4 demeclocycline hcl tab 300 mg....................................... 4 DEMSER -metyrosine cap 250 mg................................... 46 DENAVIR -penciclovir cream 1%.................................... 151 DEPAKENE -valproate sodium oral soln 250 mg/5ml (base equiv).................................................................... 97 DEPAKENE -valproic acid cap 250 mg.............................97 DEPEN TITRATABS -penicillamine tab 250 mg............. 157 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml........ 26 DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp prefilled syr 150 mg/ml............................................................................... 26 DEPO-SUBQ PROVERA 104 -medroxyprogesterone acetate susp pref syr 104 mg/0.65ml.............................26 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 100 mg/ml.................................................................. 24 DEPO-TESTOSTERONE -testosterone cypionate im inj in oil 200 mg/ml.................................................................. 24 DEQUASINE -amino acids tab........................................ 114 DESCOVY -emtricitabine-tenofovir alafenamide fumarate tab 200-25 mg...................................................................7 desipramine hcl tab 10 mg (Norpramin)....................... 69 desipramine hcl tab 25 mg (Norpramin)....................... 69 desipramine hcl tab 50 mg (Norpramin)....................... 69 desipramine hcl tab 75 mg (Norpramin)....................... 70 desipramine hcl tab 100 mg (Norpramin)..................... 70 desipramine hcl tab 150 mg (Norpramin)..................... 70 DESLORATADINE ODT -desloratadine tab orally disintegrating 2.5 mg...................................................... 55 DESLORATADINE ODT -desloratadine tab orally disintegrating 5 mg......................................................... 55 desloratadine tab 5 mg (Clarinex)................................. 55 desmopressin acetate inj 4 mcg/ml (Ddavp)................ 37 desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)........................................................................... 37 desmopressin acetate nasal spray soln 0.01% (Ddavp)........................................................................... 37 desmopressin acetate nasal spray soln 0.01% (refrigerated).................................................................. 37 desmopressin acetate tab 0.1 mg (Ddavp)................... 38 desmopressin acetate tab 0.2 mg (Ddavp)................... 38 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette)........................................................ 26 desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).......................................................................26 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)....................................................................... 26 desonide cream 0.05% (Desowen).............................. 151 desonide lotion 0.05% (Desowen)............................... 151 desonide oint 0.05% (Desowen).................................. 151 desoximetasone cream 0.25% (Topicort)....................151 desoximetasone gel 0.05% (Topicort)......................... 151 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 174 2017 desoximetasone oint 0.25% (Topicort)........................ 151 desvenlafaxine succinate tab sr 24hr 25 mg (base equiv) (Pristiq)............................................................... 70 desvenlafaxine succinate tab sr 24hr 50 mg (base equiv) (Pristiq)............................................................... 70 desvenlafaxine succinate tab sr 24hr 100 mg (base equiv) (Pristiq)............................................................... 70 DEXAMETHASONE -dexamethasone soln 0.5 mg/5ml............................................................................. 22 DEXAMETHASONE -dexamethasone tab 1 mg...............22 DEXAMETHASONE -dexamethasone tab 2 mg...............22 dexamethasone elixir 0.5 mg/5ml.................................. 22 DEXAMETHASONE INTENSOL -dexamethasone conc 1 mg/ml............................................................................... 22 DEXAMETHASONE SODIUM PHOS -dexamethasone sodium phosphate ophth soln 0.1%............................. 144 dexamethasone tab 0.5 mg............................................ 22 dexamethasone tab 0.75 mg.......................................... 22 dexamethasone tab 1.5 mg............................................ 22 dexamethasone tab 4 mg............................................... 22 dexamethasone tab 6 mg............................................... 22 DEXILANT -dexlansoprazole cap delayed release 30 mg.................................................................................... 61 DEXILANT -dexlansoprazole cap delayed release 60 mg.................................................................................... 61 dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin xr).................................................................................... 78 dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin xr).................................................................................... 78 dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin xr).................................................................................... 78 dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin xr).................................................................................... 78 dexmethylphenidate hcl cap sr 24 hr 25 mg (Focalin xr).................................................................................... 79 dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr).................................................................................... 79 dexmethylphenidate hcl cap sr 24 hr 35 mg (Focalin xr).................................................................................... 79 dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr).................................................................................... 79 dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 79 dexmethylphenidate hcl tab 5 mg (Focalin)................. 79 dexmethylphenidate hcl tab 10 mg (Focalin)............... 79 DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4 gm.................................................................................... 30 dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine)..................................................................... 79 dextroamphetamine sulfate cap sr 24hr 10 mg (Dexedrine)..................................................................... 79 dextroamphetamine sulfate cap sr 24hr 15 mg (Dexedrine)..................................................................... 79 dextroamphetamine sulfate oral solution 5 mg/5ml (Procentra)..................................................................... 79 dextroamphetamine sulfate tab 5 mg........................... 79 dextroamphetamine sulfate tab 10 mg......................... 79 DIABETIC TF -nutritional supplement liquid................... 117 DIABETISHIELD -nutritional supplement liquid.............. 117 DIABETISOURCE AC -nutritional supplement liquid...... 117 DIABETISOURCE -nutritional supplement liquid............ 117 DIASTAT ACUDIAL -diazepam rectal gel delivery system 10 mg.............................................................................. 97 DIASTAT ACUDIAL -diazepam rectal gel delivery system 20 mg.............................................................................. 97 DIASTAT PEDIATRIC -diazepam rectal gel delivery system 2.5 mg................................................................ 97 diazepam conc 5 mg/ml.................................................. 68 DIAZEPAM -diazepam oral soln 1 mg/ml..........................68 DIAZEPAM -diazepam rectal gel delivery system 2.5 mg.................................................................................... 97 DIAZEPAM -diazepam rectal gel delivery system 10 mg.................................................................................... 97 DIAZEPAM -diazepam rectal gel delivery system 20 mg.................................................................................... 97 diazepam tab 2 mg (Valium)........................................... 68 diazepam tab 5 mg (Valium)........................................... 68 diazepam tab 10 mg (Valium)......................................... 68 DICLEGIS -doxylamine-pyridoxine tab delayed release 10-10 mg......................................................................... 62 diclofenac potassium tab 50 mg (Cataflam)................. 92 diclofenac sodium (actinic keratoses) gel 3% (Solaraze)..................................................................... 151 diclofenac sodium gel 1% (Voltaren)...........................151 diclofenac sodium ophth soln 0.1%............................ 144 diclofenac sodium soln 1.5% (Pennsaid)................... 151 diclofenac sodium tab delayed release 25 mg............. 92 diclofenac sodium tab delayed release 50 mg............. 92 diclofenac sodium tab delayed release 75 mg............. 92 diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 92 diclofenac w/ misoprostol tab delayed release 50-0.2 mg (Arthrotec 50)..........................................................92 diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Arthrotec 75)..........................................................92 dicloxacillin sodium cap 250 mg..................................... 1 dicloxacillin sodium cap 500 mg..................................... 1 dicyclomine hcl cap 10 mg (Bentyl).............................. 61 dicyclomine hcl oral soln 10 mg/5ml............................ 61 dicyclomine hcl tab 20 mg (Bentyl)............................... 61 didanosine delayed release capsule 125 mg (Videx ec)...................................................................................... 7 didanosine delayed release capsule 200 mg (Videx ec)...................................................................................... 7 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 175 2017 didanosine delayed release capsule 250 mg (Videx ec)...................................................................................... 7 didanosine delayed release capsule 400 mg (Videx ec)...................................................................................... 7 DIFICID -fidaxomicin tab 200 mg........................................ 3 DIFLORASONE DIACETATE -diflorasone diacetate oint 0.05%.............................................................................151 diflunisal tab 500 mg....................................................... 85 DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 40 digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 40 digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 40 dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45).................................................................................... 95 DILANTIN INFATABS -phenytoin chew tab 50 mg........... 97 DILANTIN -phenytoin sodium extended cap 30 mg......... 97 DILANTIN -phenytoin sodium extended cap 100 mg........97 DILANTIN-125 -phenytoin susp 125 mg/5ml.................... 97 DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 40 diltiazem hcl cap sr 12hr 60 mg.....................................42 diltiazem hcl cap sr 12hr 90 mg.....................................42 diltiazem hcl cap sr 12hr 120 mg...................................42 diltiazem hcl cap sr 24hr 120 mg...................................42 diltiazem hcl cap sr 24hr 180 mg...................................42 diltiazem hcl cap sr 24hr 240 mg...................................42 diltiazem hcl coated beads cap sr 24hr 120 mg (Cardizem cd)................................................................ 42 diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem cd)................................................................ 42 diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd)................................................................ 42 diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem cd)................................................................ 42 diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem cd)................................................................ 43 diltiazem hcl coated beads tab sr 24hr 180 mg (Cardizem la)................................................................. 43 diltiazem hcl coated beads tab sr 24hr 240 mg (Cardizem la)................................................................. 43 diltiazem hcl coated beads tab sr 24hr 300 mg (Cardizem la)................................................................. 43 diltiazem hcl coated beads tab sr 24hr 360 mg (Cardizem la)................................................................. 43 diltiazem hcl coated beads tab sr 24hr 420 mg (Cardizem la)................................................................. 43 diltiazem hcl extended release beads cap sr 24hr 120 mg (Tiazac).................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 180 mg (Tiazac).................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 240 mg (Tiazac).................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 300 mg (Tiazac).................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 360 mg (Tiazac).................................................................... 43 diltiazem hcl extended release beads cap sr 24hr 420 mg (Tiazac).................................................................... 43 diltiazem hcl tab 90 mg................................................... 43 diltiazem hcl tab 30 mg (Cardizem)............................... 43 diltiazem hcl tab 60 mg (Cardizem)............................... 43 diltiazem hcl tab 120 mg (Cardizem)............................. 43 DIPENTUM -olsalazine sodium cap 250 mg.....................64 DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml....................................................... 61 diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)......................................................................... 61 DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml............................... 16 dipyridamole tab 25 mg (Persantine).......................... 138 dipyridamole tab 50 mg (Persantine).......................... 138 dipyridamole tab 75 mg (Persantine).......................... 138 disopyramide phosphate cap 100 mg (Norpace)......... 44 disopyramide phosphate cap 150 mg (Norpace)......... 44 disulfiram tab 250 mg (Antabuse)................................. 81 disulfiram tab 500 mg (Antabuse)................................. 81 DIURIL -chlorothiazide susp 250 mg/5ml......................... 50 divalproex sodium cap delayed release sprinkle 125 mg (Depakote sprinkles).............................................. 98 divalproex sodium tab delayed release 125 mg (Depakote)...................................................................... 98 divalproex sodium tab delayed release 250 mg (Depakote)...................................................................... 98 divalproex sodium tab delayed release 500 mg (Depakote)...................................................................... 98 divalproex sodium tab sr 24 hr 250 mg (Depakote er).................................................................................... 98 divalproex sodium tab sr 24 hr 500 mg (Depakote er).................................................................................... 98 DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 24 DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 24 DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 24 dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................44 dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................44 dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................44 donepezil hydrochloride orally disintegrating tab 5 mg................................................................................... 81 donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt)............................................................ 81 donepezil hydrochloride tab 5 mg (Aricept)................. 81 donepezil hydrochloride tab 10 mg (Aricept)............... 81 donepezil hydrochloride tab 23 mg (Aricept)............... 81 DORAL -quazepam tab 15 mg.......................................... 76 dorzolamide hcl ophth soln 2% (Trusopt).................. 144 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml (Cosopt)............................................................144 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 176 2017 DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg......................................................... 106 doxazosin mesylate tab 1 mg (Cardura)....................... 46 doxazosin mesylate tab 2 mg (Cardura)....................... 46 doxazosin mesylate tab 4 mg (Cardura)....................... 46 doxazosin mesylate tab 8 mg (Cardura)....................... 46 doxepin hcl cap 10 mg....................................................70 doxepin hcl cap 25 mg....................................................70 doxepin hcl cap 50 mg....................................................70 doxepin hcl cap 100 mg..................................................70 doxepin hcl cap 150 mg..................................................70 doxepin hcl conc 10 mg/ml............................................ 70 DOXEPIN HCL -doxepin hcl cap 75 mg........................... 70 DOXEPIN HYDROCHLORIDE -doxepin hcl cream 5%.................................................................................. 152 doxercalciferol cap 0.5 mcg (Hectorol)......................... 38 doxercalciferol cap 1 mcg (Hectorol)............................ 38 doxercalciferol cap 2.5 mcg (Hectorol)......................... 38 doxycycline hyclate cap 50 mg....................................... 4 doxycycline hyclate cap 100 mg (Vibramycin)...............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 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 dronabinol cap 2.5 mg (Marinol).................................... 62 dronabinol cap 5 mg (Marinol)....................................... 63 dronabinol cap 10 mg (Marinol)..................................... 63 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28).................................................................................... 26 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 26 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg (Beyaz)............................................... 26 DROXIA -hydroxyurea cap 200 mg................................ 133 DROXIA -hydroxyurea cap 300 mg................................ 134 DROXIA -hydroxyurea cap 400 mg................................ 134 DUAVEE -conjugated estrogens-bazedoxifene tab 0.45-20 mg...................................................................... 25 DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab 25-1 & omega cap 267 mg.......................................... 106 DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 & omega cap 400 mg...................................................... 106 DULERA -mometasone furoate-formoterol fumarate aerosol 100-5 mcg/act.................................................... 58 DULERA -mometasone furoate-formoterol fumarate aerosol 200-5 mcg/act.................................................... 58 DULOXETINE HCL -duloxetine hcl enteric coated pellets cap 40 mg....................................................................... 70 duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta)...................................................................... 70 duloxetine hcl enteric coated pellets cap 30 mg (Cymbalta)...................................................................... 70 duloxetine hcl enteric coated pellets cap 60 mg (Cymbalta)...................................................................... 70 DUOCAL -nutritional supplement powder....................... 117 DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/ ml................................................................................... 102 DUREZOL -difluprednate ophth emulsion 0.05%........... 144 dutasteride cap 0.5 mg (Avodart).................................. 67 dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 67 D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............ 105 DYRENIUM -triamterene cap 50 mg................................. 50 DYRENIUM -triamterene cap 100 mg............................... 50 E EAA SUPPLEMENT -nutritional supplement pack......... 117 econazole nitrate cream 1%......................................... 152 ECOZA -econazole nitrate foam 1%............................... 152 EDARBI -azilsartan medoxomil tab 40 mg........................47 EDARBI -azilsartan medoxomil tab 80 mg........................47 EDECRIN -ethacrynic acid tab 25 mg.............................. 50 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 EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 138 EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 139 EGG/PRO -nutritional supplement powder..................... 117 EGRIFTA -tesamorelin acetate for inj 1 mg (base equiv)............................................................................... 38 EGRIFTA -tesamorelin acetate for inj 2 mg (base equiv)............................................................................... 38 ELECARE/DHA/ARA -nutritional supplement powder........................................................................... 117 ELECARE JR -nutritional supplement powder................117 ELECARE -nutritional supplement powder..................... 117 ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump)...................................................... 25 ELIDEL -pimecrolimus cream 1%................................... 152 ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5 mg.................................................................................... 18 ELIGARD -leuprolide acetate (3 month) for subcutaneous inj kit 22.5mg...................................................................17 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 177 2017 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....................................... 135 ELIQUIS -apixaban tab 5 mg.......................................... 135 ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg.................................................................................. 106 ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 58 ELLA -ulipristal acetate tab 30 mg.................................... 26 ELMIRON -pentosan polysulfate sodium caps 100 mg.................................................................................... 67 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 250 unit......................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 500 unit......................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 750 unit......................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 1000 unit....................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 1500 unit....................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 2000 unit....................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 3000 unit....................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 4000 unit....................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 5000 unit....................................................................... 139 ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 6000 unit....................................................................... 139 EMADINE -emedastine difumarate ophth soln 0.05% (base equiv).................................................................. 144 EMBEDA -morphine-naltrexone cap cr 20-0.8 mg............86 EMBEDA -morphine-naltrexone cap cr 30-1.2 mg............86 EMBEDA -morphine-naltrexone cap cr 50-2 mg...............86 EMBEDA -morphine-naltrexone cap cr 60-2.4 mg............86 EMBEDA -morphine-naltrexone cap cr 80-3.2 mg............86 EMBEDA -morphine-naltrexone cap cr 100-4 mg.............86 EMCYT -estramustine phosphate sodium cap 140 mg.................................................................................... 18 EMEND -aprepitant capsule 40 mg.................................. 63 EMEND -aprepitant capsule 80 mg.................................. 63 EMEND -aprepitant capsule 125 mg................................ 63 EMEND -aprepitant capsule therapy pack 80 & 125 mg.................................................................................... 63 EMEND -aprepitant for oral susp 125 mg (125 mg/5ml)............................................................................ 63 EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 70 EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 70 EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 70 EMTRIVA -emtricitabine caps 200 mg................................ 7 EMTRIVA -emtricitabine soln 10 mg/ml.............................. 7 EMVERM -mebendazole chew tab 100 mg...................... 12 ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv).................................................................... 66 ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg (base equiv).................................................................... 66 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg................................................................................... 47 enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)...................................................................... 47 enalapril maleate tab 2.5 mg (Vasotec)......................... 47 enalapril maleate tab 5 mg (Vasotec)............................ 47 enalapril maleate tab 10 mg (Vasotec).......................... 47 enalapril maleate tab 20 mg (Vasotec).......................... 47 ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty acids cap....................................................................... 106 ENBREL -etanercept for subcutaneous inj 25 mg............ 92 ENBREL -etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml.................................................................... 92 ENBREL -etanercept subcutaneous soln prefilled syringe 50 mg/ml......................................................................... 92 ENBREL SURECLICK -etanercept subcutaneous solution auto-injector 50 mg/ml.................................................... 93 END FATIGUE DAILY ENERGY -multiple vitamins w/ minerals powder............................................................106 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.............................117 enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 135 enoxaparin sodium inj 40 mg/0.4ml (Lovenox).......... 135 enoxaparin sodium inj 60 mg/0.6ml (Lovenox).......... 135 enoxaparin sodium inj 80 mg/0.8ml (Lovenox).......... 135 enoxaparin sodium inj 100 mg/ml (Lovenox)............. 135 enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 136 enoxaparin sodium inj 150 mg/ml (Lovenox)............. 136 enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 136 ENSTILAR -calcipotriene-betamethasone dipropionate foam 0.005-0.064%...................................................... 152 ENSURE/FIBER -nutritional supplement liquid............... 118 ENSURE ACTIVE HEART HEALT -nutritional supplement liquid.............................................................................. 117 ENSURE ACTIVE HIGH PROTEI -nutritional supplement liquid.............................................................................. 118 ENSURE ACTIVE LIGHT -nutritional supplement liquid.............................................................................. 118 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 178 2017 ENSURE ACTIVE -nutritional supplement liquid............ 117 ENSURE BONE HEALTH REVIGO -nutritional supplement liquid.......................................................... 118 ENSURE CLEAR -nutritional supplement liquid............. 118 ENSURE CLINICAL STRENGTH -nutritional supplement liquid.............................................................................. 118 ENSURE COMPACT -nutritional supplement liquid....... 118 ENSURE COMPLETE -nutritional supplement liquid..... 118 ENSURE COMPLETE NUTRITION -nutritional supplement liquid.......................................................... 118 ENSURE ENLIVE -nutritional supplement liquid............ 118 ENSURE HEALTHY MOM -nutritional supplement bar.................................................................................. 118 ENSURE HEALTHY MOM -nutritional supplement liquid.............................................................................. 118 ENSURE HIGH CALCIUM -nutritional supplement liquid.............................................................................. 118 ENSURE HIGH PROTEIN -nutritional supplement liquid.............................................................................. 118 ENSURE HIGH PROTEIN -nutritional supplement powder........................................................................... 118 ENSURE IMMUNE HEALTH -nutritional supplement liquid.............................................................................. 118 ENSURE MUSCLE HEALTH REVI -nutritional supplement liquid.......................................................... 118 ENSURE NUTRA SHAKE HI-CAL -nutritional supplement liquid.............................................................................. 118 ENSURE -nutritional supplement bar..............................117 ENSURE -nutritional supplement liquid.......................... 117 ENSURE -nutritional supplement powder....................... 117 ENSURE NUTRITION SHAKE -nutritional supplement liquid.............................................................................. 118 ENSURE PLUS HN -nutritional supplement liquid..........118 ENSURE PLUS -nutritional supplement liquid................ 118 ENSURE PRE-SURGERY -nutritional supplement liquid.............................................................................. 118 ENSURE PUDDING -nutritional supplement pudding.......................................................................... 118 ENSURE SURGERY IMMUNONUTR -nutritional supplement liquid.......................................................... 118 entacapone tab 200 mg (Comtan)............................... 102 entecavir tab 0.5 mg (Baraclude)..................................... 7 entecavir tab 1 mg (Baraclude)........................................ 7 ENTEREG -alvimopan cap 12 mg.................................... 64 ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 54 ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 54 ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 54 ENU NUTRITIONAL SHAKE -nutritional supplement liquid.............................................................................. 118 ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............157 ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 157 ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 157 EO28 SPLASH -nutritional supplement liquid................. 118 EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 7 epinastine hcl ophth soln 0.05% (Elestat).................. 144 EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN -epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)........................................................................... 51 EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................................... 51 EPINEPHRINE -epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)......................................................... 51 EPINEPHRINE -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................... 51 EPIPEN-JR 2-PAK -epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000).................................................. 51 EPIPEN 2-PAK -epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)........................................................... 51 EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 7 eplerenone tab 25 mg (Inspra)....................................... 47 eplerenone tab 50 mg (Inspra)....................................... 47 EPOGEN -epoetin alfa inj 2000 unit/ml...........................134 EPOGEN -epoetin alfa inj 3000 unit/ml...........................134 EPOGEN -epoetin alfa inj 4000 unit/ml...........................134 EPOGEN -epoetin alfa inj 10000 unit/ml.........................134 EPOGEN -epoetin alfa inj 20000 unit/ml.........................134 EPROSARTAN MESYLATE -eprosartan mesylate tab 600 mg.................................................................................... 47 EPZICOM -abacavir sulfate-lamivudine tab 600-300 mg...................................................................................... 7 EQL DENTAL TRAVEL PACK -sodium fluoride paste 0.243% & mouthwash kit..............................................147 EQL TRAVEL TOOTHBRUSH/TOO -sodium monofluorophosphate paste 0.15%............................. 148 EQ NUTRITIONAL SHAKE -nutritional supplement liquid.............................................................................. 118 EQ NUTRITIONAL SHAKE PLUS -nutritional supplement liquid.............................................................................. 118 EQUATE -nutritional supplement liquid........................... 118 EQUATE PLUS -nutritional supplement liquid................ 118 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 100 mg............................................................................ 73 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 200 mg............................................................................ 73 EQUETRO -carbamazepine (antipsychotic) cap sr 12hr 300 mg............................................................................ 73 EQ WEIGHT LOSS SHAKE ULTR -nutritional supplement liquid.............................................................................. 118 ergocalciferol cap 50000 unit (Drisdol)....................... 105 ERGOLOID MESYLATES -ergoloid mesylates tab 1 mg.................................................................................... 82 ERGOMAR -ergotamine tartrate sl tab 2 mg.................... 95 ergotamine w/ caffeine tab 1-100 mg (Cafergot).......... 95 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 179 2017 ERIVEDGE -vismodegib cap 150 mg............................... 18 ERTACZO -sertaconazole nitrate cream 2%.................. 152 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)....................................... 152 erythromycin ophth oint 5 mg/gm............................... 144 erythromycin pads 2%.................................................. 152 erythromycin soln 2%................................................... 152 erythromycin w/ delayed release particles cap 250 mg......................................................................................4 ESBRIET -pirfenidone cap 267 mg................................... 60 escitalopram oxalate soln 5 mg/5ml (base equiv) (Lexapro)........................................................................ 70 escitalopram oxalate tab 5 mg (base equiv) (Lexapro)........................................................................ 70 escitalopram oxalate tab 10 mg (base equiv) (Lexapro)........................................................................ 70 escitalopram oxalate tab 20 mg (base equiv) (Lexapro)........................................................................ 70 esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium)....................................................... 61 esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium)....................................................... 61 ESSENTIAL AMINO ACID MIX -amino acids oral powder........................................................................... 115 estazolam tab 1 mg......................................................... 76 estazolam tab 2 mg......................................................... 76 ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 67 estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella)....................................................................... 25 estradiol & norethindrone acetate tab 1-0.5 mg (Activella)....................................................................... 25 estradiol tab 0.5 mg (Estrace)........................................ 25 estradiol tab 1 mg (Estrace)........................................... 25 estradiol tab 2 mg (Estrace)........................................... 25 estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 25 estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-dot).................................................................... 25 estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 25 estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 25 estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 25 estradiol td patch weekly 0.025 mg/24hr (Climara)......25 estradiol td patch weekly 0.05 mg/24hr (Climara)........25 estradiol td patch weekly 0.06 mg/24hr (Climara)........25 estradiol td patch weekly 0.075 mg/24hr (Climara)......25 estradiol td patch weekly 0.1 mg/24hr (Climara)..........25 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) (Climara)...................................................... 25 estradiol vaginal tab 10 mcg (Vagifem).........................67 estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 25 estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 25 ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).......................................................................67 ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump)...................................................... 25 ESTROPIPATE -estropipate tab 0.75 mg......................... 25 ESTROPIPATE -estropipate tab 1.5 mg........................... 25 ESTROPIPATE -estropipate tab 3 mg.............................. 25 eszopiclone tab 1 mg (Lunesta).................................... 76 eszopiclone tab 2 mg (Lunesta).................................... 76 eszopiclone tab 3 mg (Lunesta).................................... 76 ethacrynic acid tab 25 mg.............................................. 50 ethambutol hcl tab 100 mg (Myambutol)........................ 5 ethambutol hcl tab 400 mg (Myambutol)........................ 5 ethosuximide cap 250 mg (Zarontin)............................ 98 ethosuximide soln 250 mg/5ml (Zarontin).................... 98 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg................................................................................. 26 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg (Zovia 1/50e)......................................................... 27 ETIDRONATE DISODIUM -etidronate disodium tab 200 mg.................................................................................... 38 etodolac cap 200 mg....................................................... 93 etodolac cap 300 mg....................................................... 93 etodolac tab 400 mg........................................................ 93 etodolac tab 500 mg........................................................ 93 etodolac tab sr 24hr 400 mg.......................................... 93 etodolac tab sr 24hr 500 mg.......................................... 93 etodolac tab sr 24hr 600 mg.......................................... 93 ETOPOSIDE -etoposide cap 50 mg..................................18 EURAX -crotamiton cream 10%...................................... 152 EURAX -crotamiton lotion 10%....................................... 152 EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 25 EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg (base equiv)...................................................................... 7 EVZIO -naloxone hcl solution auto-injector 0.4 mg/0.4ml........................................................................ 155 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 180 2017 EVZIO -naloxone hcl solution auto-injector 2 mg/0.4ml........................................................................ 155 EXALGO -hydromorphone hcl tab er 24hr deter 32 mg.................................................................................... 86 EXELDERM -sulconazole nitrate cream 1%................... 152 EXELDERM -sulconazole nitrate solution 1%................ 152 exemestane tab 25 mg (Aromasin)................................ 18 EXJADE -deferasirox tab for oral susp 125 mg.............. 156 EXJADE -deferasirox tab for oral susp 250 mg.............. 156 EXJADE -deferasirox tab for oral susp 500 mg.............. 156 EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 82 EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg................................... 106 ezetimibe tab 10 mg (Zetia)............................................ 52 F F.A.A. -nutritional supplement liquid................................ 118 FACTIVE -gemifloxacin mesylate tab 320 mg (base equiv)................................................................................. 5 FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa tab 1 mg kit..................................................................... 27 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)....................... 61 famotidine tab 40 mg (Pepcid)....................................... 61 FANAPT -iloperidone tab 1 mg......................................... 73 FANAPT -iloperidone tab 2 mg......................................... 73 FANAPT -iloperidone tab 4 mg......................................... 73 FANAPT -iloperidone tab 6 mg......................................... 73 FANAPT -iloperidone tab 8 mg......................................... 73 FANAPT -iloperidone tab 10 mg....................................... 73 FANAPT -iloperidone tab 12 mg....................................... 73 FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg & 4 mg & 6 mg titration pak........................................... 73 FARESTON -toremifene citrate tab 60 mg (base equivalent)....................................................................... 18 FARXIGA -dapagliflozin propanediol tab 5 mg (base equivalent)....................................................................... 30 FARXIGA -dapagliflozin propanediol tab 10 mg (base equivalent)....................................................................... 30 FARYDAK -panobinostat lactate cap 10 mg (base equivalent)....................................................................... 18 FARYDAK -panobinostat lactate cap 15 mg (base equivalent)....................................................................... 18 FARYDAK -panobinostat lactate cap 20 mg (base equivalent)....................................................................... 18 FAZACLO -clozapine orally disintegrating tab 12.5 mg.................................................................................... 73 FAZACLO -clozapine orally disintegrating tab 150 mg..... 73 FAZACLO -clozapine orally disintegrating tab 200 mg..... 73 FEIBA -antiinhibitor coagulant complex for inj................ 139 felbamate susp 600 mg/5ml (Felbatol).......................... 98 felbamate tab 400 mg (Felbatol).................................... 98 felbamate tab 600 mg (Felbatol).................................... 98 felodipine tab sr 24hr 2.5 mg......................................... 43 felodipine tab sr 24hr 5 mg............................................ 43 felodipine tab sr 24hr 10 mg.......................................... 43 FEMRING -estradiol acetate vaginal ring 0.05 mg/24hr........................................................................... 67 FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 67 fenofibrate micronized cap 43 mg................................. 52 fenofibrate micronized cap 130 mg............................... 52 fenofibrate micronized cap 67 mg (Lofibra)................. 52 fenofibrate micronized cap 134 mg (Lofibra)............... 52 fenofibrate tab 54 mg (Lofibra)...................................... 52 fenofibrate tab 160 mg (Lofibra).................................... 52 fenofibrate tab 48 mg (Tricor)........................................ 52 fenofibrate tab 145 mg (Tricor)...................................... 52 FENOPROFEN CALCIUM -fenoprofen calcium cap 200 mg.................................................................................... 93 FENOPROFEN CALCIUM -fenoprofen calcium cap 400 mg.................................................................................... 93 FENOPROFEN CALCIUM -fenoprofen calcium tab 600 mg.................................................................................... 93 fentanyl citrate lollipop 200 mcg (Actiq)....................... 87 fentanyl citrate lollipop 400 mcg (Actiq)....................... 87 fentanyl citrate lollipop 600 mcg (Actiq)....................... 87 fentanyl citrate lollipop 800 mcg (Actiq)....................... 87 fentanyl citrate lollipop 1200 mcg (Actiq)..................... 87 fentanyl citrate lollipop 1600 mcg (Actiq)..................... 87 FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr...............86 FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr...............86 FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr...............86 fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 87 fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. 87 fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. 87 fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. 87 fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 87 FENTORA -fentanyl citrate buccal tab 100 mcg (base equiv)............................................................................... 87 FENTORA -fentanyl citrate buccal tab 200 mcg (base equiv)............................................................................... 87 FENTORA -fentanyl citrate buccal tab 400 mcg (base equiv)............................................................................... 87 FENTORA -fentanyl citrate buccal tab 600 mcg (base equiv)............................................................................... 87 FENTORA -fentanyl citrate buccal tab 800 mcg (base equiv)............................................................................... 87 FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)................................................................. 134 FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18 mg (elemental iron)................................................. 134 FERRIPROX -deferiprone oral soln 100 mg/ml.............. 156 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 181 2017 FERRIPROX -deferiprone tab 500 mg............................ 156 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe).................................................................................. 134 FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml (44 mg/5ml elemental fe)............................................. 134 FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml (60 mg/5ml elemental fe)............................................. 134 ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe).................................................................................. 134 FIBER FLOW -nutritional supplement liquid................... 119 FIBERSOURCE CLOSED SYSTEM -nutritional supplement liquid.......................................................... 119 FIBERSOURCE HN CLOSED SYS -nutritional supplement liquid.......................................................... 119 FIBERSOURCE HN -nutritional supplement liquid......... 119 FIBER-STAT -nutritional supplement liquid..................... 119 FINACEA -azelaic acid foam 15%.................................. 152 FINACEA -azelaic acid gel 15%..................................... 152 finasteride tab 5 mg (Proscar)....................................... 67 FIRAZYR -icatibant acetate inj 30 mg/3ml (base equivalent)..................................................................... 139 FLAREX -fluorometholone acetate ophth susp 0.1%..... 144 FLAVOR PACKETS -nutritional supplement flavor pack............................................................................... 119 FLAVOUR PAC -nutritional supplement flavor pack....... 119 flavoxate hcl tab 100 mg.................................................66 flecainide acetate tab 50 mg.......................................... 44 flecainide acetate tab 100 mg........................................ 44 flecainide acetate tab 150 mg........................................ 44 FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364 mg.................................................................................. 113 FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364 mg.................................................................................. 113 FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/ ml-400 unit/ml............................................................... 113 FLOVENT DISKUS -fluticasone propionate aer pow ba 50 mcg/blister....................................................................... 58 FLOVENT DISKUS -fluticasone propionate aer pow ba 100 mcg/blister................................................................ 58 FLOVENT DISKUS -fluticasone propionate aer pow ba 250 mcg/blister................................................................ 58 FLOVENT HFA -fluticasone propionate hfa inhal aer 110 mcg/act (125/valve)........................................................ 58 FLOVENT HFA -fluticasone propionate hfa inhal aer 220 mcg/act (250/valve)........................................................ 58 FLOVENT HFA -fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)...........................................................58 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.......................................................... 13 FLUARIX QUADRIVALENT 2014 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 13 FLUARIX QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 13 FLUARIX QUADRIVALENT 2016 -influenza virus vac split quadrivalent susp pref syr 0.5ml.................................... 13 FLUBLOK 2014-2015 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 13 FLUBLOK 2015-2016 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 13 FLUBLOK 2016-2017 -influenza virus vac recombinant hemagglutinin (ha) inj..................................................... 13 FLUCELVAX 2014-2015 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml........................................... 13 FLUCELVAX 2015-2016 -influenza virus vac tiss-cult subunit susp pref syr 0.5 ml........................................... 13 FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult subunt quad susp pref syr 0.5 ml.................................. 13 fluconazole for susp 10 mg/ml (Diflucan)....................... 6 fluconazole for susp 40 mg/ml (Diflucan)....................... 6 fluconazole tab 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............................... 22 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)................................................................... 55 fluocinolone acetonide cream 0.01%.......................... 152 fluocinolone acetonide cream 0.025% (Synalar)........152 fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 152 fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................152 fluocinolone acetonide oint 0.025% (Synalar)............ 152 fluocinolone acetonide (otic) oil 0.01% (Dermotic).................................................................... 147 fluocinolone acetonide soln 0.01% (Synalar)............. 152 fluocinonide cream 0.05%............................................ 152 fluocinonide emulsified base cream 0.05%................ 152 fluocinonide gel 0.05%.................................................. 152 fluocinonide oint 0.05%................................................ 152 fluocinonide soln 0.05%................................................ 152 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 182 2017 FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from 0.55 mg/0.6ml naf)........................................................113 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25 mg f)-236.79 mg..................................................113 FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg f)-236.79 mg.................................................................. 113 fluorometholone ophth susp 0.1% (Fml liquifilm)..... 144 FLUOROPLEX -fluorouracil cream 1%........................... 152 fluorouracil cream 5% (Efudex)................................... 152 FLUOROURACIL -fluorouracil cream 0.5%.................... 152 fluorouracil soln 2%...................................................... 152 fluorouracil soln 5%...................................................... 152 FLUOXETINE DR -fluoxetine hcl cap delayed release 90 mg.................................................................................... 70 FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg.............. 82 FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg.............. 82 fluoxetine hcl cap 10 mg (Prozac)................................. 70 fluoxetine hcl cap 20 mg (Prozac)................................. 70 fluoxetine hcl cap 40 mg (Prozac)................................. 70 fluoxetine hcl solution 20 mg/5ml................................. 70 fluoxetine hcl tab 10 mg................................................. 70 fluoxetine hcl tab 20 mg................................................. 70 FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5 mg/5ml............................................................................. 73 FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/ ml..................................................................................... 73 fluphenazine hcl tab 1 mg.............................................. 73 fluphenazine hcl tab 2.5 mg........................................... 73 fluphenazine hcl tab 5 mg.............................................. 73 fluphenazine hcl tab 10 mg............................................ 73 FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf)............................................... 113 flurandrenolide cream 0.05%....................................... 152 flurandrenolide lotion 0.05% (Cordran).......................152 FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 76 FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 76 flurbiprofen sodium ophth soln 0.03% (Ocufen)........144 flurbiprofen tab 50 mg.................................................... 93 flurbiprofen tab 100 mg.................................................. 93 flutamide cap 125 mg...................................................... 18 fluticasone propionate cream 0.05% (Cutivate)......... 152 fluticasone propionate nasal susp 50 mcg/act (Flonase)......................................................................... 55 fluticasone propionate oint 0.005% (Cutivate)........... 152 fluvastatin sodium cap 20 mg (Lescol)......................... 52 fluvastatin sodium cap 40 mg (Lescol)......................... 52 fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........52 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 tab 25 mg..................................... 70 fluvoxamine maleate tab 50 mg..................................... 70 fluvoxamine maleate tab 100 mg................................... 70 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....................................14 FLUZONE INTRADERMAL QUADR -influenza virus vac split quad intradermal pen 9 mcg/strain......................... 14 FLUZONE PF 2014-2015 -influenza virus vaccine split pf susp pref syringe 0.5 ml................................................. 14 FLUZONE QUADRIVALENT 2014 -influenza virus vaccine split quadrivalent im inj..................................... 14 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............................... 14 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......................... 14 FLUZONE QUADRIVALENT 2014 -influenza virus vac split quadrivalent susp pref syr 0.5ml............................ 14 FLUZONE QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.25 ml......................... 14 FLUZONE QUADRIVALENT 2015 -influenza virus vac split quadrivalent susp pref syr 0.5ml............................ 14 FLUZONE 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 FLUZONE SPLIT 2015-2016 -influenza virus vaccine split im susp............................................................................ 15 FML -fluorometholone ophth oint 0.1%........................... 144 FML FORTE -fluorometholone ophth susp 0.25%.......... 144 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 183 2017 FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 300 mg pack...................................................106 FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dha cap 300mg pak.............................................. 107 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 25 mg.................................................................................... 79 FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 35 mg.................................................................................... 79 FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 27-1.25-300 mg..................................................... 107 FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 107 FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr & dha cap pak.................................................................. 107 FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha cap 38-1-225 mg.......................................................... 107 folic acid cap 0.8 mg..................................................... 134 folic acid tab 400 mcg................................................... 134 folic acid tab 800 mcg................................................... 134 folic acid tab 1 mg......................................................... 134 FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap 130-92.4-1 mg...............................................................107 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml (Arixtra).........................................................................136 fondaparinux sodium subcutaneous inj 5 mg/0.4ml (Arixtra).........................................................................136 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml (Arixtra).........................................................................136 fondaparinux sodium subcutaneous inj 10 mg/0.8ml (Arixtra).........................................................................136 FORTA DRINK -nutritional supplement powder.............. 119 FORTA SHAKE -nutritional supplement powder............. 119 FORTEO -teriparatide (recombinant) inj 600 mcg/2.4ml........................................................................ 38 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-2800 mg-unit....................................................... 38 FOSAMAX PLUS D -alendronate sodium-cholecalciferol tab 70-5600 mg-unit....................................................... 38 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg................................................................................... 47 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg................................................................................... 47 fosinopril sodium tab 10 mg.......................................... 47 fosinopril sodium tab 20 mg.......................................... 47 fosinopril sodium tab 40 mg.......................................... 47 FOSRENOL -lanthanum carbonate chew tab 500 mg (elemental).......................................................................64 FOSRENOL -lanthanum carbonate chew tab 750 mg (elemental).......................................................................64 FOSRENOL -lanthanum carbonate chew tab 1000 mg (elemental).......................................................................65 FOSRENOL -lanthanum carbonate oral powder pack 750 mg (elemental)................................................................ 65 FOSRENOL -lanthanum carbonate oral powder pack 1000 mg (elemental).......................................................65 FRAGMIN -dalteparin sodium inj 10000 unit/ml..............136 FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........136 FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml...........136 FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml...........136 FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........136 FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml.........136 FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......136 FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml.........136 FROVA -frovatriptan succinate tab 2.5 mg (base equivalent)....................................................................... 95 frovatriptan succinate tab 2.5 mg (base equivalent) (Frova).............................................................................95 FRUITIVITS -nutritional supplement pack.......................119 furosemide oral soln 10 mg/ml...................................... 50 furosemide tab 20 mg (Lasix)........................................ 50 furosemide tab 40 mg (Lasix)........................................ 50 furosemide tab 80 mg (Lasix)........................................ 50 FUZEON -enfuvirtide for inj 90 mg..................................... 7 FYCOMPA -perampanel susp 0.5 mg/ml.......................... 98 FYCOMPA -perampanel tab 2 mg.................................... 98 FYCOMPA -perampanel tab 4 mg.................................... 98 FYCOMPA -perampanel tab 6 mg.................................... 98 FYCOMPA -perampanel tab 8 mg.................................... 98 FYCOMPA -perampanel tab 10 mg.................................. 98 FYCOMPA -perampanel tab 12 mg.................................. 98 G GA-1 ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 119 gabapentin cap 100 mg (Neurontin).............................. 98 gabapentin cap 300 mg (Neurontin).............................. 98 gabapentin cap 400 mg (Neurontin).............................. 98 gabapentin oral soln 250 mg/5ml (Neurontin).............. 98 gabapentin tab 600 mg (Neurontin)............................... 98 gabapentin tab 800 mg (Neurontin)............................... 98 GABITRIL -tiagabine hcl tab 12 mg.................................. 98 GABITRIL -tiagabine hcl tab 16 mg.................................. 98 GA EXPRESS15 -nutritional supplement pack............... 119 GA GEL -nutritional supplement pack............................. 119 galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er)................................................................ 82 galantamine hydrobromide cap sr 24hr 16 mg (Razadyne er)................................................................ 82 galantamine hydrobromide cap sr 24hr 24 mg (Razadyne er)................................................................ 82 GALANTAMINE HYDROBROMIDE -galantamine hydrobromide oral soln 4 mg/ml.................................... 82 galantamine hydrobromide tab 4 mg (Razadyne)........ 82 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 184 2017 galantamine hydrobromide tab 8 mg (Razadyne)........ 82 galantamine hydrobromide tab 12 mg (Razadyne)...... 82 GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 113 GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 113 GA -nutritional supplement powder................................. 119 gatifloxacin ophth soln 0.5% (Zymaxid)..................... 145 GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 65 GEL-KAM ORAL CARE RINSE -stannous fluoride conc 0.63%.............................................................................148 GEL-KAM -stannous fluoride gel 0.4%........................... 148 gemfibrozil tab 600 mg (Lopid)...................................... 52 GENERESS FE -norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg................................................27 gentamicin sulfate cream 0.1%.................................... 152 GENTAMICIN SULFATE -gentamicin sulfate oint 0.1%...............................................................................152 gentamicin sulfate ophth oint 0.3%............................. 145 gentamicin sulfate ophth soln 0.3% (Garamycin)...... 145 GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg.......................................................... 7 GIALAX -polyethylene glycol 3350 - kit............................ 60 GIAZO -balsalazide disodium tab 1.1 gm......................... 65 GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 82 GILOTRIF -afatinib dimaleate tab 20 mg (base equivalent)....................................................................... 18 GILOTRIF -afatinib dimaleate tab 30 mg (base equivalent)....................................................................... 18 GILOTRIF -afatinib dimaleate tab 40 mg (base equivalent)....................................................................... 18 glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)..................................................................... 82 GLEEVEC -imatinib mesylate tab 100 mg (base equivalent)....................................................................... 18 GLEEVEC -imatinib mesylate tab 400 mg (base equivalent)....................................................................... 18 GLEOSTINE -lomustine cap 5 mg.................................... 18 GLEOSTINE -lomustine cap 10 mg.................................. 18 GLEOSTINE -lomustine cap 40 mg.................................. 18 GLEOSTINE -lomustine cap 100 mg................................ 18 glimepiride tab 1 mg (Amaryl)........................................30 glimepiride tab 2 mg (Amaryl)........................................30 glimepiride tab 4 mg (Amaryl)........................................30 glipizide-metformin hcl tab 2.5-250 mg......................... 30 glipizide-metformin hcl tab 2.5-500 mg......................... 30 glipizide-metformin hcl tab 5-500 mg............................ 30 glipizide tab 5 mg (Glucotrol).........................................30 glipizide tab 10 mg (Glucotrol).......................................30 glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 30 glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 30 glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 30 GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg (base equiv).................................................................... 30 GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj kit 1 mg........................................................................... 30 GLUCERNA ADVANCE SHAKE -nutritional supplement liquid.............................................................................. 119 GLUCERNA 1.0 CAL/FIBER -nutritional supplement liquid.............................................................................. 119 GLUCERNA 1.0 CAL -nutritional supplement liquid....... 119 GLUCERNA 1.2 CAL -nutritional supplement liquid....... 120 GLUCERNA 1.5 CAL -nutritional supplement liquid....... 120 GLUCERNA CARBSTEADY -nutritional supplement liquid.............................................................................. 119 GLUCERNA CEREAL CRUNCHY F -nutritional supplement misc........................................................... 119 GLUCERNA CRISPY DELIGHTS -nutritional supplement bar.................................................................................. 119 GLUCERNA HUNGER SMART SHA -nutritional supplement liquid.......................................................... 119 GLUCERNA MEAL -nutritional supplement bar..............119 GLUCERNA MEAL REPLACEMENT -nutritional supplement bar............................................................. 119 GLUCERNA MINI SNACK -nutritional supplement bar.................................................................................. 119 GLUCERNA MINI SNACKS -nutritional supplement bar.................................................................................. 119 GLUCERNA -nutritional supplement bar.........................119 GLUCERNA -nutritional supplement liquid..................... 119 GLUCERNA OS -nutritional supplement liquid............... 119 GLUCERNA SELECT -nutritional supplement liquid...... 119 GLUCERNA SHAKE -nutritional supplement liquid........ 119 GLUCERNA SNACK -nutritional supplement bar........... 119 GLUCERNA SNACK SHAKE -nutritional supplement liquid.............................................................................. 119 GLUCERNA WEIGHT LOSS SHAK -nutritional supplement liquid.......................................................... 119 GLUCERNA 1.0 WITH CARBSTE -nutritional supplement liquid.............................................................................. 120 GLUCO BURST -nutritional supplement liquid............... 120 GLUMETZA -metformin hcl tab sr 24hr modified release 500 mg............................................................................ 30 GLUMETZA -metformin hcl tab sr 24hr modified release 1000 mg.......................................................................... 30 GLUTARADE AMINO ACID BLEN -amino acids oral powder........................................................................... 115 GLUTARADE ESSENTIAL GA-1 -amino acids oral powder........................................................................... 115 GLUTARADE JUNIOR GA-1 -amino acids oral powder........................................................................... 115 GLUTAREX-1 -nutritional supplement powder................120 GLUTAREX-2 -nutritional supplement powder................120 glyburide-metformin tab 1.25-250 mg (Glucovance).................................................................. 30 glyburide-metformin tab 2.5-500 mg (Glucovance)..... 30 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 185 2017 glyburide-metformin tab 5-500 mg (Glucovance)........ 30 glyburide micronized tab 1.5 mg (Glynase)..................30 glyburide micronized tab 3 mg (Glynase).....................30 glyburide micronized tab 6 mg (Glynase).....................30 glyburide tab 1.25 mg..................................................... 30 glyburide tab 2.5 mg....................................................... 30 glyburide tab 5 mg.......................................................... 30 glycopyrrolate tab 1 mg (Robinul)................................. 61 glycopyrrolate tab 2 mg (Robinul forte)........................61 GLYCOSADE -nutritional supplement pack.................... 120 GLYSET -miglitol tab 25 mg.............................................. 30 GLYSET -miglitol tab 50 mg.............................................. 30 GLYSET -miglitol tab 100 mg............................................ 30 GLYTACTIN BETTERMILK DE-L -nutritional supplement pack............................................................................... 120 GLYTACTIN BETTERMILK 15 -nutritional supplement pack............................................................................... 120 GLYTACTIN BUILD 10PE -nutritional supplement pack............................................................................... 120 GLYTACTIN COMPLETE 10PE -nutritional supplement bar.................................................................................. 120 GLYTACTIN RESTORE LITE 10 -nutritional supplement liquid.............................................................................. 120 GLYTACTIN RESTORE LITE 10 -nutritional supplement pack............................................................................... 120 GLYTACTIN RESTORE 10 -nutritional supplement liquid.............................................................................. 120 GLYTACTIN RESTORE 5 -nutritional supplement pack............................................................................... 120 GLYTACTIN RTD 10 -nutritional supplement liquid........ 120 GLYTACTIN RTD 15 -nutritional supplement liquid........ 120 GLYTROL -nutritional supplement liquid......................... 120 GLYTROL PREBIO1 -nutritional supplement liquid........ 120 GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 30 GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 30 GNP NUTRITIONAL DRINK -nutritional supplement liquid.............................................................................. 120 GNP NUTRITIONAL DRINK PLU -nutritional supplement liquid.............................................................................. 120 GOAT MILK -nutritional supplement powder.................. 120 GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm............................................................. 60 G-PREPROTEIN -amino acids oral liquid....................... 115 GRALISE -gabapentin (once-daily) tab 300 mg................82 GRALISE -gabapentin (once-daily) tab 600 mg................82 GRALISE STARTER -gabapentin (once-daily) tab pack 300 mg (9) & 600 mg (69)............................................. 82 granisetron hcl tab 1 mg................................................ 63 GRANIX -tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml...................................................................... 134 GRANIX -tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml...................................................................... 134 GRASTEK -timothy grass pollen allergen ext tab sl 2800 bau................................................................................... 16 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.................. 56 guaifenesin-codeine soln 100-6.3 mg/5ml.................... 56 guaifenesin-codeine soln 100-10 mg/5ml..................... 56 guanfacine hcl tab 1 mg (Tenex)................................... 47 guanfacine hcl tab 2 mg (Tenex)................................... 47 guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv).......................................................................... 79 guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv).......................................................................... 79 guanfacine hcl tab sr 24hr 3 mg (base equiv) (Intuniv).......................................................................... 79 guanfacine hcl tab sr 24hr 4 mg (base equiv) (Intuniv).......................................................................... 79 GUANIDINE HCL -guanidine hcl tab 125 mg................. 105 GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal cream 2%........................................................................ 67 H HAELAN 951 FERMENTED ORGA -nutritional supplement liquid.......................................................... 120 HAELAN HTPI FERMENTED ORG -nutritional supplement liquid.......................................................... 120 halobetasol propionate cream 0.05% (Ultravate)....... 152 halobetasol propionate oint 0.05% (Ultravate)........... 152 HALOG -halcinonide oint 0.1%....................................... 152 haloperidol lactate oral conc 2 mg/ml...........................73 haloperidol tab 0.5 mg.................................................... 73 haloperidol tab 1 mg....................................................... 74 haloperidol tab 2 mg....................................................... 74 haloperidol tab 5 mg....................................................... 74 haloperidol tab 10 mg..................................................... 74 haloperidol tab 20 mg..................................................... 74 HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 7 HCU ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 120 HCU ANAMIX NEXT -nutritional supplement powder........................................................................... 120 HCU COOLER -nutritional supplement liquid................. 120 HCU EXPRESS -nutritional supplement pack................ 120 HCU EXPRESS20 -nutritional supplement pack............ 120 HCU GEL -nutritional supplement pack.......................... 120 HCU LOPHLEX LQ -nutritional supplement liquid.......... 120 HCY 1 -nutritional supplement powder........................... 120 HCY 2 -nutritional supplement powder........................... 121 HEALTH SOURCE SOY PROTEIN -nutritional supplement powder...................................................... 121 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 186 2017 HEALTHY ACCENTS NUTRA FIT -nutritional supplement liquid.............................................................................. 121 HEARTBAR -nutritional supplement bar......................... 121 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 250 unit.................................................................... 139 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 500 unit.................................................................... 139 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 1000 unit.................................................................. 139 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 2000 unit.................................................................. 139 HELIXATE FS -antihemophilic factor (recombinant) for inj kit 3000 unit.................................................................. 139 HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme poly-fa tab & omega 3 cap pck.................................... 107 HEMENATAL OB -prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg........................................................... 107 HEMOFIL M -antihemophilic factor (human) for inj 250 unit................................................................................. 139 HEMOFIL M -antihemophilic factor (human) for inj 500 unit................................................................................. 139 HEMOFIL M -antihemophilic factor (human) for inj 1000 unit................................................................................. 139 HEMOFIL M -antihemophilic factor (human) for inj 1700 unit................................................................................. 139 HEPAMENT -amino acids pack.......................................115 heparin sodium (porcine) inj 1000 unit/ml.................. 136 heparin sodium (porcine) inj 5000 unit/ml.................. 136 heparin sodium (porcine) inj 10000 unit/ml................ 136 heparin sodium (porcine) inj 20000 unit/ml................ 136 heparin sodium (porcine) pf inj 5000 unit/0.5ml........ 136 HETLIOZ -tasimelteon capsule 20 mg.............................. 76 HEXALEN -altretamine cap 50 mg................................... 18 HI-CAL -nutritional supplement liquid..............................121 HIGH-PROTEIN NUTRITIONAL -nutritional supplement liquid.............................................................................. 121 HISTEX-AC -phenylephrine-triprolidine-codeine syrup 10-2.5-10 mg/5ml............................................................ 56 HM NUTRISURE -nutritional supplement liquid..............121 HM NUTRISURE PLUS -nutritional supplement liquid.............................................................................. 121 HOMACTIN AA PLUS -nutritional supplement liquid...... 121 HOMINEX-1 -nutritional supplement powder.................. 121 HOMINEX-2 -nutritional supplement powder.................. 121 HOM 2 -nutritional supplement powder.......................... 121 HORIZANT -gabapentin enacarbil tab cr 300 mg............. 82 HORIZANT -gabapentin enacarbil tab cr 600 mg............. 82 H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 38 HUMALOG -insulin lispro inj 100 unit/ml...........................33 HUMALOG -insulin lispro soln cartridge 100 unit/ml.........33 HUMALOG KWIKPEN -insulin lispro soln pen-injector 100 unit/ml.............................................................................. 33 HUMALOG KWIKPEN -insulin lispro soln pen-injector 200 unit/ml.............................................................................. 33 HUMALOG MIX 75/25 -insulin lispro prot & lispro inj 100 unit/ml (75-25)................................................................. 34 HUMALOG MIX 50/50 -insulin lispro protamine & lispro inj 100 unit/ml (50-50)......................................................... 34 HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (50-50).............................34 HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25).............................34 HUMATE-P -antihemophilic factor/vwf (human) for inj 250-600 unit.................................................................. 139 HUMATE-P -antihemophilic factor/vwf (human) for inj 500-1200 unit................................................................ 139 HUMATE-P -antihemophilic factor/vwf (human) for inj 1000-2400 unit.............................................................. 139 HUMIRA -adalimumab prefilled syringe kit 10 mg/0.2ml.......................................................................... 93 HUMIRA -adalimumab prefilled syringe kit 20 mg/0.4ml.......................................................................... 93 HUMIRA -adalimumab prefilled syringe kit 40 mg/0.8ml.......................................................................... 93 HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled syringe kit 40 mg/0.8ml.................................................. 93 HUMIRA PEN -adalimumab pen-injector kit 40 mg/0.8ml.......................................................................... 93 HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml.................................................. 93 HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml.................................................. 93 HUMULIN 70/30 -insulin nph isophane & regular human inj 100 unit/ml (70-30).................................................... 34 HUMULIN 70/30 KWIKPEN -insulin nph & regular susp pen-inj 100 unit/ml (70-30)............................................. 34 HUMULIN N -insulin nph (human) (isophane) inj 100 unit/ ml..................................................................................... 34 HUMULIN N KWIKPEN -insulin nph (human) (isophane) susp pen-injector 100 unit/ml......................................... 34 HUMULIN R -insulin regular (human) inj 100 unit/ml........ 34 HUMULIN R U-500 (CONCENTR -insulin regular (human) inj 500 unit/ml..................................................................34 HUMULIN R U-500 KWIKPEN -insulin regular (human) soln pen-injector 500 unit/ml.......................................... 34 HURRISEAL -dental desensitizing product - solution..... 156 HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 18 HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 18 hydralazine hcl tab 10 mg.............................................. 47 hydralazine hcl tab 25 mg.............................................. 47 hydralazine hcl tab 50 mg.............................................. 47 hydralazine hcl tab 100 mg............................................ 47 hydrochlorothiazide cap 12.5 mg (Microzide).............. 50 hydrochlorothiazide tab 12.5 mg................................... 50 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 187 2017 hydrochlorothiazide tab 25 mg...................................... 50 hydrochlorothiazide tab 50 mg...................................... 50 hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet).............................................................................87 hydrocodone-acetaminophen soln 10-325 mg/15ml (Zamicet).........................................................................87 hydrocodone-acetaminophen tab 2.5-325 mg.............. 87 hydrocodone-acetaminophen tab 7.5-325 mg (Norco)............................................................................ 87 hydrocodone-acetaminophen tab 5-325 mg (Norco)............................................................................ 87 hydrocodone-acetaminophen tab 10-325 mg (Norco)............................................................................ 87 hydrocodone-acetaminophen tab 7.5-300 mg (Xodol)............................................................................ 87 hydrocodone-acetaminophen tab 5-300 mg (Xodol)............................................................................ 87 hydrocodone-acetaminophen tab 10-300 mg (Xodol)............................................................................ 87 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 87 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......87 hydrocodone-ibuprofen tab 7.5-200 mg (Vicoprofen)................................................................... 87 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 56 hydrocodone w/ homatropine tab 5-1.5 mg..................56 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml (Tussionex pennkineti)................................................. 56 hydrocortisone acetate w/ pramoxine rectal cream 1-1% (Analpram-hc).................................................... 149 hydrocortisone butyrate cream 0.1% (Locoid)...........152 hydrocortisone butyrate oint 0.1% (Locoid)............... 153 hydrocortisone butyrate soln 0.1% (Locoid).............. 153 hydrocortisone cream 2.5%..........................................153 hydrocortisone enema 100 mg/60ml (Cortenema)................................................................. 149 hydrocortisone lotion 2.5%.......................................... 153 hydrocortisone oint 2.5%..............................................153 hydrocortisone rectal cream 2.5% (Anusol-hc)......... 149 hydrocortisone rectal cream 1% (Proctocort)............ 149 hydrocortisone tab 5 mg (Cortef).................................. 22 hydrocortisone tab 10 mg (Cortef)................................ 22 hydrocortisone tab 20 mg (Cortef)................................ 22 hydrocortisone valerate cream 0.2%...........................153 hydrocortisone valerate oint 0.2% (Westcort)............ 153 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc)................................................................................. 147 hydromorphone hcl liqd 1 mg/ml (Dilaudid).................87 hydromorphone hcl tab er 24hr deter 8 mg (Exalgo).......................................................................... 87 hydromorphone hcl tab er 24hr deter 12 mg (Exalgo).......................................................................... 87 hydromorphone hcl tab er 24hr deter 16 mg (Exalgo).......................................................................... 88 hydromorphone hcl tab er 24hr deter 32 mg (Exalgo).......................................................................... 88 hydromorphone hcl tab 2 mg (Dilaudid)....................... 88 hydromorphone hcl tab 4 mg (Dilaudid)....................... 88 hydromorphone hcl tab 8 mg (Dilaudid)....................... 88 hydroxychloroquine sulfate tab 200 mg (Plaquenil)...................................................................... 11 hydroxyurea cap 500 mg (Hydrea)................................ 18 hydroxyzine hcl syrup 10 mg/5ml................................. 68 hydroxyzine hcl tab 10 mg............................................. 68 hydroxyzine hcl tab 25 mg............................................. 69 hydroxyzine hcl tab 50 mg............................................. 69 hydroxyzine pamoate cap 25 mg (Vistaril)................... 69 hydroxyzine pamoate cap 50 mg (Vistaril)................... 69 HYDROXYZINE PAMOATE -hydroxyzine pamoate cap 100 mg............................................................................ 69 HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/1.25 ml kit................................................................. 16 HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit................................................................... 16 HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800 unt/5 ml kit...................................................................... 16 HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600 unt/10 ml kit.................................................................... 16 HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400 unt/15 ml kit.................................................................... 16 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 20 mg.............................................................................. 88 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 30 mg.............................................................................. 88 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 40 mg.............................................................................. 88 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 60 mg.............................................................................. 88 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 80 mg.............................................................................. 88 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 100 mg............................................................................ 88 HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 120 mg............................................................................ 88 I ibandronate sodium tab 150 mg (base equivalent) (Boniva).......................................................................... 38 IBRANCE -palbociclib cap 75 mg..................................... 18 IBRANCE -palbociclib cap 100 mg................................... 18 IBRANCE -palbociclib cap 125 mg................................... 18 ibuprofen tab 400 mg...................................................... 93 ibuprofen tab 600 mg...................................................... 93 ibuprofen tab 800 mg...................................................... 93 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 188 2017 ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml (elemental iron)............................................................. 134 ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 18 ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 18 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj 250 unit......................................................................... 139 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj 500 unit......................................................................... 139 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj 1000 unit....................................................................... 140 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj 2000 unit....................................................................... 140 ILEVRO -nepafenac ophth susp 0.3%............................ 145 imatinib mesylate tab 100 mg (base equivalent) (Gleevec)........................................................................ 18 imatinib mesylate tab 400 mg (base equivalent) (Gleevec)........................................................................ 18 IMBRUVICA -ibrutinib cap 140 mg................................... 18 imipramine hcl tab 10 mg (Tofranil).............................. 70 imipramine hcl tab 25 mg (Tofranil).............................. 71 imipramine hcl tab 50 mg (Tofranil).............................. 71 imipramine pamoate cap 75 mg (Tofranil-pm)............. 71 imipramine pamoate cap 100 mg (Tofranil-pm)........... 71 imipramine pamoate cap 125 mg (Tofranil-pm)........... 71 imipramine pamoate cap 150 mg (Tofranil-pm)........... 71 imiquimod cream 5% (Aldara)...................................... 153 IMMULIFE -nutritional supplement powder..................... 121 IMMUNOPRO RX -nutritional supplement powder......... 121 IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc inj..................................................................................... 15 IMPACT/FIBER -nutritional supplement liquid................ 121 IMPACT ADVANCED RECOVERY -nutritional supplement liquid.......................................................... 121 IMPACT GLUTAMINE -nutritional supplement liquid...... 121 IMPACT -nutritional supplement liquid............................ 121 IMPACT 1.5 -nutritional supplement liquid...................... 121 IMPACT PEPTIDE 1.5 -nutritional supplement liquid..... 121 IMPAVIDO -miltefosine cap 50 mg.................................... 12 IMUPLUS -nutritional supplement pack.......................... 121 INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg...................................................................107 INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg.................................................................................. 107 INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg......................................................................... 107 INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........38 INCRUSE ELLIPTA -umeclidinium br aero powd breath act 62.5 mcg/inh (base eq)............................................ 58 indapamide tab 1.25 mg..................................................50 indapamide tab 2.5 mg.................................................... 50 indomethacin cap cr 75 mg............................................ 93 indomethacin cap 25 mg................................................ 93 indomethacin cap 50 mg................................................ 93 INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha cap 29-1-265 mg.......................................................... 107 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............................................................................... 60 INLYTA -axitinib tab 1 mg.................................................. 18 INLYTA -axitinib tab 5 mg.................................................. 19 INNOVACIN -nutritional supplement liquid......................121 INSULIN PEN NEEDLES-VARIOUS............................... 156 INSULIN SYRINGES-VARIOUS...................................... 156 INTELENCE -etravirine tab 25 mg...................................... 7 INTELENCE -etravirine tab 100 mg.................................... 7 INTELENCE -etravirine tab 200 mg.................................... 7 INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ ml & lidocaine 1% & ammonia inh kit............................ 22 INTROLITE -nutritional supplement liquid.......................121 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................................................................. 19 INVIRASE -saquinavir mesylate cap 200 mg..................... 7 INVIRASE -saquinavir mesylate tab 500 mg...................... 7 INVOKAMET -canagliflozin-metformin hcl tab 50-500 mg.................................................................................... 30 INVOKAMET -canagliflozin-metformin hcl tab 150-500 mg.................................................................................... 31 INVOKAMET -canagliflozin-metformin hcl tab 50-1000 mg.................................................................................... 31 INVOKAMET -canagliflozin-metformin hcl tab 150-1000 mg.................................................................................... 31 INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr 50-500 mg....................................................................... 31 INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr 50-1000 mg..................................................................... 31 INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr 150-500 mg..................................................................... 31 INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr 150-1000 mg................................................................... 31 INVOKANA -canagliflozin tab 100 mg.............................. 31 INVOKANA -canagliflozin tab 300 mg.............................. 31 IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act (base equiv).................................................................... 88 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 189 2017 IOPIDINE -apraclonidine hcl ophth soln 1% (base equivalent)..................................................................... 145 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 58 ipratropium bromide inhal soln 0.02%.......................... 58 ipratropium bromide nasal soln 0.03% (21 mcg/spray) (Atrovent)....................................................................... 55 ipratropium bromide nasal soln 0.06% (42 mcg/spray) (Atrovent)....................................................................... 55 irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide)..........................................................................47 irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide)..........................................................................47 irbesartan tab 75 mg (Avapro)....................................... 47 irbesartan tab 150 mg (Avapro)..................................... 47 irbesartan tab 300 mg (Avapro)..................................... 47 IRESSA -gefitinib tab 250 mg........................................... 19 IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg (elemental iron)............................................................. 134 ISENTRESS -raltegravir potassium chew tab 25 mg (base equiv)................................................................................. 7 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...................... 121 ISOCAL HN PLUS -nutritional supplement liquid........... 121 ISOCAL -nutritional supplement liquid............................ 121 ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 5 isoniazid tab 100 mg......................................................... 5 isoniazid tab 300 mg......................................................... 5 ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg.................................................................................... 40 ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr 40 mg.............................................................................. 40 isosorbide dinitrate tab 10 mg....................................... 40 isosorbide dinitrate tab 20 mg....................................... 40 isosorbide dinitrate tab 30 mg....................................... 40 isosorbide dinitrate tab 5 mg (Isordil titradose).......... 40 isosorbide mononitrate tab 10 mg................................ 40 isosorbide mononitrate tab 20 mg................................ 40 isosorbide mononitrate tab sr 24hr 30 mg (Imdur)...... 40 isosorbide mononitrate tab sr 24hr 60 mg (Imdur)...... 40 isosorbide mononitrate tab sr 24hr 120 mg (Imdur)............................................................................ 40 ISOSOURCE 1.5 CAL -nutritional supplement liquid......121 ISOSOURCE CLOSED SYSTEM -nutritional supplement liquid.............................................................................. 121 ISOSOURCE HN -nutritional supplement liquid............. 121 ISOSOURCE -nutritional supplement liquid.................... 121 ISOSOURCE VHN -nutritional supplement liquid........... 121 isotretinoin cap 10 mg.................................................. 153 isotretinoin cap 20 mg.................................................. 153 isotretinoin cap 30 mg.................................................. 153 isotretinoin cap 40 mg.................................................. 153 ISOVACTIN AA PLUS -nutritional supplement liquid...... 121 isradipine cap 2.5 mg...................................................... 43 isradipine cap 5 mg......................................................... 43 ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 145 itraconazole cap 100 mg (Sporanox).............................. 6 IVA ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 122 IVA ANAMIX NEXT -nutritional supplement powder....... 122 I-VALEX-1 -nutritional supplement powder..................... 121 I-VALEX-2 -nutritional supplement powder..................... 121 ivermectin tab 3 mg (Stromectol).................................. 12 IXINITY -coagulation factor ix (recombinant) for inj 250 unit................................................................................. 140 IXINITY -coagulation factor ix (recombinant) for inj 500 unit................................................................................. 140 IXINITY -coagulation factor ix (recombinant) for inj 1000 unit................................................................................. 140 IXINITY -coagulation factor ix (recombinant) for inj 1500 unit................................................................................. 140 IXINITY -coagulation factor ix (recombinant) for inj 2000 unit................................................................................. 140 IXINITY -coagulation factor ix (recombinant) for inj 3000 unit................................................................................. 140 J JADENU -deferasirox tab 90 mg..................................... 156 JADENU -deferasirox tab 180 mg................................... 156 JADENU -deferasirox tab 360 mg................................... 156 JAKAFI -ruxolitinib phosphate tab 5 mg (base equivalent)....................................................................... 19 JAKAFI -ruxolitinib phosphate tab 10 mg (base equivalent)....................................................................... 19 JAKAFI -ruxolitinib phosphate tab 15 mg (base equivalent)....................................................................... 19 JAKAFI -ruxolitinib phosphate tab 20 mg (base equivalent)....................................................................... 19 JAKAFI -ruxolitinib phosphate tab 25 mg (base equivalent)....................................................................... 19 JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 31 JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 31 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-500 mg....................................................................... 31 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-1000 mg..................................................................... 31 JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 100-1000 mg................................................................... 31 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 190 2017 JANUVIA -sitagliptin phosphate tab 25 mg (base equiv)............................................................................... 31 JANUVIA -sitagliptin phosphate tab 50 mg (base equiv)............................................................................... 31 JANUVIA -sitagliptin phosphate tab 100 mg (base equiv)............................................................................... 31 JARDIANCE -empagliflozin tab 10 mg............................. 31 JARDIANCE -empagliflozin tab 25 mg............................. 31 JENTADUETO -linagliptin-metformin hcl tab 2.5-1000 mg.................................................................................... 31 JENTADUETO -linagliptin-metformin hcl tab 2.5-500 mg.................................................................................... 31 JENTADUETO -linagliptin-metformin hcl tab 2.5-850 mg.................................................................................... 31 JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr 2.5-1000 mg.................................................................... 31 JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr 5-1000 mg....................................................................... 31 JEVITY 1 CAL/FIBER -nutritional supplement liquid...... 122 JEVITY 1.2 CAL/FIBER -nutritional supplement liquid.............................................................................. 122 JEVITY 1.5 CAL/FIBER -nutritional supplement liquid.............................................................................. 122 JEVITY 1 CAL -nutritional supplement liquid.................. 122 JEVITY 1.2 CAL -nutritional supplement liquid............... 122 JEVITY 1.5 CAL -nutritional supplement liquid............... 122 JTT PHYSICIANS KIT -triamcinolone inj 40 mg/ml & lidocaine 1% & ammonia inh kit..................................... 22 JUBLIA -efinaconazole soln 10%.................................... 153 JUICE PLUS FIBRE -nutritional supplement liquid......... 122 JUVEN -nutritional supplement pack.............................. 122 JUVEN -nutritional supplement powder.......................... 122 JUVEN NUTRIVIGOR -nutritional supplement pack.......122 JUVEN REVIGOR -nutritional supplement pack.............122 JUXTAPID -lomitapide mesylate cap 5 mg (base equiv)............................................................................... 52 JUXTAPID -lomitapide mesylate cap 10 mg (base equiv)............................................................................... 52 JUXTAPID -lomitapide mesylate cap 20 mg (base equiv)............................................................................... 52 JUXTAPID -lomitapide mesylate cap 30 mg (base equiv)............................................................................... 52 JUXTAPID -lomitapide mesylate cap 40 mg (base equiv)............................................................................... 52 JUXTAPID -lomitapide mesylate cap 60 mg (base equiv)............................................................................... 52 K 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................................ 60 KALYDECO -ivacaftor packet 75 mg................................ 60 KALYDECO -ivacaftor tab 150 mg.................................... 60 KARBINAL ER -carbinoxamine maleate extended release susp 4 mg/5ml................................................................ 55 KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 31 KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 31 KCENTRA -prothrombin complex conc human for inj kit 500 unit......................................................................... 140 KCENTRA -prothrombin complex conc human for inj kit 1000 unit....................................................................... 140 KERYDIN -tavaborole soln 5%........................................153 KETOCAL 4:1 LQ MULTI FIBE -nutritional supplement liquid.............................................................................. 122 KETOCAL 4:1 -nutritional supplement liquid.................. 122 KETOCAL 3:1 -nutritional supplement powder............... 122 KETOCAL 4:1 -nutritional supplement powder............... 122 ketoconazole cream 2%................................................ 153 ketoconazole shampoo 2% (Nizoral)........................... 153 KETOGEN -nutritional supplement powder.................... 122 KETONEX-1 -nutritional supplement powder..................122 KETONEX-2 -nutritional supplement powder..................122 ketoprofen cap 50 mg..................................................... 93 ketoprofen cap 75 mg..................................................... 93 ketorolac tromethamine ophth soln 0.5% (Acular)......................................................................... 145 ketorolac tromethamine ophth soln 0.4% (Acular ls)................................................................................... 145 ketorolac tromethamine tab 10 mg............................... 93 KETOVIE -nutritional supplement liquid.......................... 122 KETOVIE PEPTIDE -nutritional supplement liquid......... 122 KETOVOLVE 4:1 -nutritional supplement powder.......... 122 KINERET -anakinra subcutaneous soln prefilled syringe 100 mg/0.67ml................................................................ 93 KINRAY PREFERRED PLUS -nutritional supplement liquid.............................................................................. 122 KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv vac inj.............................................................................. 16 KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 5 KLOR-CON M15 -potassium chloride microencapsulated crys cr tab 15 meq....................................................... 113 KOATE -antihemophilic factor (human) for inj 250 unit................................................................................. 140 KOATE -antihemophilic factor (human) for inj 500 unit................................................................................. 140 KOATE -antihemophilic factor (human) for inj 1000 unit................................................................................. 140 KOATE-DVI -antihemophilic factor (human) for inj 250 unit................................................................................. 140 KOATE-DVI -antihemophilic factor (human) for inj 500 unit................................................................................. 140 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 191 2017 KOATE-DVI -antihemophilic factor (human) for inj 1000 unit................................................................................. 140 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 250 unit............................................................... 140 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 500 unit............................................................... 140 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 1000 unit............................................................. 140 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 2000 unit............................................................. 140 KOGENATE FS -antihemophilic factor (recombinant) for inj kit 3000 unit............................................................. 140 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 250 unit.................................. 140 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 500 unit.................................. 140 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 1000 unit................................ 140 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 2000 unit................................ 141 KOGENATE FS BIO-SET -antihemophilic factor (recombinant) for inj kit 3000 unit................................ 141 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 2.5-1000 mg.................................................................... 31 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 5-500 mg......................................................................... 31 KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr 5-1000 mg....................................................................... 32 KORLYM -mifepristone tab 300 mg.................................. 32 KOVALTRY -antihemophilic factor (recombinant) for inj 250 unit......................................................................... 141 KOVALTRY -antihemophilic factor (recombinant) for inj 500 unit......................................................................... 141 KOVALTRY -antihemophilic factor (recombinant) for inj 1000 unit....................................................................... 141 KOVALTRY -antihemophilic factor (recombinant) for inj 2000 unit....................................................................... 141 KOVALTRY -antihemophilic factor (recombinant) for inj 3000 unit....................................................................... 141 K-PAX IMMUNE BOOSTER PROT -nutritional supplement powder...................................................... 122 KRISTALOSE -lactulose oral crystal packet 10 gm.......... 60 KRISTALOSE -lactulose oral crystal packet 20 gm.......... 60 K-TAB -potassium chloride tab cr 8 meq (600 mg)......... 113 K-TAB -potassium chloride tab cr 20 meq (1500 mg)..... 113 KUVAN -sapropterin dihydrochloride powder packet 100 mg.................................................................................... 38 KUVAN -sapropterin dihydrochloride powder packet 500 mg.................................................................................... 38 KUVAN -sapropterin dihydrochloride soluble tab 100 mg.................................................................................... 38 KYNAMRO -mipomersen sodium soln prefilled syringe 200 mg/ml....................................................................... 52 L labetalol hcl tab 100 mg (Trandate)............................... 41 labetalol hcl tab 200 mg (Trandate)............................... 41 labetalol hcl tab 300 mg (Trandate)............................... 41 LACRISERT -artificial tear ophth insert...........................145 lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 153 lactulose (encephalopathy) solution 10 gm/15ml........ 65 lactulose solution 10 gm/15ml....................................... 61 LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg (42) & 100 mg (7) starter kit...........................................98 LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg (84) & 100 mg (14) starter kit.........................................98 LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg (35) starter kit..................................................................98 LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg (14) & 100 mg(7) kit....................................................... 98 LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100 mg(14) & 200 mg(7) kit.................................................. 98 LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50 mg (7) titration kit............................................................98 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).................................................................................. 99 lamotrigine orally disintegrating tab 50 mg (Lamictal odt).................................................................................. 99 lamotrigine orally disintegrating tab 100 mg (Lamictal odt).................................................................................. 99 lamotrigine orally disintegrating tab 200 mg (Lamictal odt).................................................................................. 99 lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di).................................................................. 99 lamotrigine tab chewable dispersible 25 mg (Lamictal chewable di).................................................................. 99 lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7) kit (LAMICTAL ODT)..................................................... 99 lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit (LAMICTAL ODT)..................................................... 99 lamotrigine tab disp 50 mg (42) & 100 mg (14) titration kit (LAMICTAL ODT)..................................................... 99 lamotrigine tab 25 mg (Lamictal)................................... 99 lamotrigine tab 100 mg (Lamictal)................................. 99 lamotrigine tab 150 mg (Lamictal)................................. 99 lamotrigine tab 200 mg (Lamictal)................................. 99 lamotrigine tab sr 24hr 25 mg (Lamictal xr)................. 99 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 192 2017 lamotrigine tab sr 24hr 50 mg (Lamictal xr)................. 99 lamotrigine tab sr 24hr 100 mg (Lamictal xr)............... 99 lamotrigine tab sr 24hr 200 mg (Lamictal xr)............... 99 lamotrigine tab sr 24hr 250 mg (Lamictal xr)............... 99 lamotrigine tab sr 24hr 300 mg (Lamictal xr)............... 99 LANAFLEX -nutritional supplement pack........................ 122 LANCETS-VARIOUS........................................................156 LANCING DEVICE-VARIOUS......................................... 156 LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 40 LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 40 LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 40 LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 40 lansoprazole cap delayed release 15 mg (Prevacid)....................................................................... 62 lansoprazole cap delayed release 30 mg (Prevacid)....................................................................... 62 LANTUS -insulin glargine inj 100 unit/ml.......................... 35 LANTUS SOLOSTAR -insulin glargine soln pen-injector 100 unit/ml.......................................................................35 LASTACAFT -alcaftadine ophth soln 0.25%................... 145 latanoprost ophth soln 0.005% (Xalatan).................... 145 LATUDA -lurasidone hcl tab 20 mg...................................74 LATUDA -lurasidone hcl tab 40 mg...................................74 LATUDA -lurasidone hcl tab 60 mg...................................74 LATUDA -lurasidone hcl tab 80 mg...................................74 LATUDA -lurasidone hcl tab 120 mg.................................74 LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base equiv)............................................................................... 88 LAZANDA -fentanyl citrate nasal spray 300 mcg/act (base equiv)............................................................................... 88 LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base equiv)............................................................................... 88 L-CARNITINE -amino acids oral liquid............................ 115 leflunomide tab 10 mg (Arava)....................................... 93 leflunomide tab 20 mg (Arava)....................................... 93 LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose)............................... 19 LENVIMA 18 MG DAILY DOSE -lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose)......................... 19 LENVIMA 24 MG DAILY DOSE -lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose)......................... 19 LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapy pack 10 mg (10 mg daily dose)..................................... 19 LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose)................................ 19 LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose).................................... 19 LETAIRIS -ambrisentan tab 5 mg..................................... 54 LETAIRIS -ambrisentan tab 10 mg................................... 54 letrozole tab 2.5 mg (Femara)........................................ 19 LEUCOVORIN CALCIUM -leucovorin calcium tab 10 mg.................................................................................... 19 LEUCOVORIN CALCIUM -leucovorin calcium tab 15 mg.................................................................................... 19 leucovorin calcium tab 5 mg.......................................... 19 leucovorin calcium tab 25 mg........................................ 19 LEU-FREE COOLER -nutritional supplement liquid....... 122 LEUKERAN -chlorambucil tab 2 mg................................. 19 LEUKINE -sargramostim lyophilized for inj 250 mcg...... 134 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv).............................................................................. 58 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex)....................................................................... 58 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex)....................................................................... 59 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)....................................................................... 59 LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector 100 unit/ml.......................................................................35 LEVEMIR -insulin detemir inj 100 unit/ml..........................35 levetiracetam oral soln 100 mg/ml (Keppra).................99 levetiracetam tab 250 mg (Keppra)............................... 99 levetiracetam tab 500 mg (Keppra)............................... 99 levetiracetam tab 750 mg (Keppra)............................... 99 levetiracetam tab 1000 mg (Keppra)............................. 99 levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 99 levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 99 levobunolol hcl ophth soln 0.5% (Betagan)............... 145 levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 38 levocarnitine tab 330 mg (Carnitor)............................... 38 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal)................................................................ 55 levocetirizine dihydrochloride tab 5 mg (Xyzal)...........55 LEVOFLOXACIN -levofloxacin oral soln 25 mg/ml............. 5 levofloxacin ophth soln 0.5%....................................... 145 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 ð est 0.01 mg (Quartette)....................................................... 27 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg.................................................................. 27 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg................................................................................. 27 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg................................................................................. 27 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg............................... 27 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg.......................................................................27 levonorgestrel tab 1.5 mg (Plan b one-step)................ 27 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) (Loseasonique)........................................... 27 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 193 2017 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) (Seasonique)............................................... 27 LEVORPHANOL TARTRATE -levorphanol tartrate tab 2 mg.................................................................................... 88 levothyroxine sodium tab 25 mcg (Synthroid)............. 35 levothyroxine sodium tab 50 mcg (Synthroid)............. 35 levothyroxine sodium tab 75 mcg (Synthroid)............. 35 levothyroxine sodium tab 88 mcg (Synthroid)............. 35 levothyroxine sodium tab 100 mcg (Synthroid)........... 35 levothyroxine sodium tab 112 mcg (Synthroid)........... 35 levothyroxine sodium tab 125 mcg (Synthroid)........... 35 levothyroxine sodium tab 137 mcg (Synthroid)........... 35 levothyroxine sodium tab 150 mcg (Synthroid)........... 35 levothyroxine sodium tab 175 mcg (Synthroid)........... 35 levothyroxine sodium tab 200 mcg (Synthroid)........... 35 levothyroxine sodium tab 300 mcg (Synthroid)........... 35 LEVULAN KERASTICK -aminolevulinic acid hcl for soln 20% (stick applicator)................................................... 153 LEXIVA -fosamprenavir calcium susp 50 mg/ml (base equiv)................................................................................. 8 LEXIVA -fosamprenavir calcium tab 700 mg (base equiv)................................................................................. 8 LIALDA -mesalamine tab delayed release 1.2 gm........... 65 lidocaine hcl gel 2%...................................................... 153 LIDOCAINE HCL -lidocaine hcl laryngotracheal soln 4%.................................................................................. 148 lidocaine hcl soln 4% (Xylocaine)............................... 153 lidocaine hcl viscous soln 2%..................................... 148 lidocaine patch 5% (Lidoderm).................................... 153 lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 153 lidocaine-prilocaine cream kit 2.5-2.5%...................... 153 LINDANE -lindane shampoo 1%..................................... 153 linezolid for susp 100 mg/5ml (Zyvox).......................... 12 linezolid tab 600 mg (Zyvox).......................................... 12 LINZESS -linaclotide cap 72 mcg..................................... 65 LINZESS -linaclotide cap 145 mcg................................... 65 LINZESS -linaclotide cap 290 mcg................................... 65 liothyronine sodium tab 5 mcg (Cytomel).................... 35 liothyronine sodium tab 25 mcg (Cytomel).................. 35 liothyronine sodium tab 50 mcg (Cytomel).................. 35 LIPISTART -nutritional supplement powder.................... 122 LIQUACEL -amino acids oral liquid................................ 115 LIQUACEL PUMP + GO -amino acids oral liquid........... 115 LIQUID HOPE -nutritional supplement liquid.................. 122 lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)..................................................................... 47 lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic)..................................................................... 47 lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic)..................................................................... 47 lisinopril tab 5 mg (Prinivil)............................................ 47 lisinopril tab 10 mg (Prinivil).......................................... 47 lisinopril tab 20 mg (Prinivil).......................................... 47 lisinopril tab 2.5 mg (Zestril).......................................... 47 lisinopril tab 30 mg (Zestril)........................................... 47 lisinopril tab 40 mg (Zestril)........................................... 47 LISTERINE ESSENTIAL CARE -sod monofluorophospheucal-men-methyl sal-thymol gel 0.76%...................... 148 LISTERINE NATURALS WITH F -sodium fluoride rinse 0.02%.............................................................................148 LISTERINE RESTORING -sodium fluoride rinse 0.0221% (0.01% f)........................................................................148 LISTERINE SMART RINSE -sodium fluoride rinse 0.0221% (0.01% f)........................................................ 148 LISTERINE TOTAL CARE PLUS -sodium fluoride rinse 0.0221% (0.01% f)........................................................ 148 LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221% (0.01% f)........................................................................148 LISTERINE TOTAL CARE ZERO -sodium fluoride rinse 0.02%.............................................................................148 LISTERINE WHITENING/RESTO -sodium fluoride rinse 0.0221% (0.01% f)........................................................ 148 lithium carbonate cap 300 mg....................................... 74 lithium carbonate cap 150 mg (Lithium carbonate)..... 74 lithium carbonate cap 600 mg (Lithium carbonate)..... 74 LITHIUM CARBONATE -lithium carbonate cap 150 mg.................................................................................... 74 LITHIUM CARBONATE -lithium carbonate cap 600 mg.................................................................................... 74 lithium carbonate tab cr 450 mg.................................... 74 lithium carbonate tab cr 300 mg (Lithobid).................. 74 lithium carbonate tab 300 mg........................................ 74 LITHIUM -lithium oral solution 8 meq/5ml......................... 74 LITHOBID -lithium carbonate tab cr 300 mg..................... 74 LITHOSTAT -acetohydroxamic acid tab 250 mg............... 68 LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 52 LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 52 LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 52 LMD -nutritional supplement powder.............................. 122 LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2)....................................................... 27 LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 19 LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 19 LOPHLEX LQ 20 -nutritional supplement liquid.............. 122 LOPHLEX -nutritional supplement pack..........................122 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra)............................................................................ 8 lorazepam conc 2 mg/ml (Lorazepam intensol)........... 69 lorazepam tab 0.5 mg (Ativan)....................................... 69 lorazepam tab 1 mg (Ativan).......................................... 69 lorazepam tab 2 mg (Ativan).......................................... 69 losartan potassium & hydrochlorothiazide tab 50-12.5 mg (Hyzaar)....................................................................47 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 194 2017 losartan potassium & hydrochlorothiazide tab 100-12.5 mg (Hyzaar).................................................... 47 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar)....................................................................48 losartan potassium tab 25 mg (Cozaar)........................ 48 losartan potassium tab 50 mg (Cozaar)........................ 48 losartan potassium tab 100 mg (Cozaar)...................... 48 LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 145 LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 145 LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 145 lovastatin tab 10 mg........................................................ 52 lovastatin tab 20 mg (Mevacor)..................................... 53 lovastatin tab 40 mg (Mevacor)..................................... 53 loxapine succinate cap 5 mg......................................... 74 loxapine succinate cap 10 mg....................................... 74 loxapine succinate cap 25 mg....................................... 74 loxapine succinate cap 50 mg....................................... 74 LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg naf)................................................................................. 113 LPS CRITICAL CARE SUGAR F -nutritional supplement liquid.............................................................................. 122 LPS SUGAR FREE -nutritional supplement liquid.......... 122 LUMIGAN -bimatoprost ophth soln 0.01%...................... 145 LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)................................................................................. 114 LUZU -luliconazole cream 1%......................................... 153 LYNPARZA -olaparib cap 50 mg....................................... 19 LYRICA -pregabalin cap 25 mg.........................................99 LYRICA -pregabalin cap 50 mg.........................................99 LYRICA -pregabalin cap 75 mg.........................................99 LYRICA -pregabalin cap 100 mg.......................................99 LYRICA -pregabalin cap 150 mg.......................................99 LYRICA -pregabalin cap 200 mg.......................................99 LYRICA -pregabalin cap 225 mg.......................................99 LYRICA -pregabalin cap 300 mg.......................................99 LYRICA -pregabalin soln 20 mg/ml................................. 100 LYSODREN -mitotane tab 500 mg....................................19 M MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha cap 28-1-250 mg.......................................................... 107 malathion lotion 0.5% (Ovide)...................................... 153 MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 71 MAPROTILINE HCL -maprotiline hcl tab 50 mg............... 71 MAPROTILINE HCL -maprotiline hcl tab 75 mg............... 71 MAR-COF BP -pseudoephedrine-bromphen-codeine liqd 30-2-7.5 mg/5ml.............................................................. 56 MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa cap 60-1 mg.................................................................. 107 MARPLAN -isocarboxazid tab 10 mg............................... 71 MATULANE -procarbazine hcl cap 50 mg........................ 20 MAXIDEX -dexamethasone ophth susp 0.1%................ 145 MCT PRO-CAL -nutritional supplement pack................. 122 MCT PROCAL -nutritional supplement powder.............. 123 MECLOFENAMATE SODIUM -meclofenamate sodium cap 50 mg....................................................................... 93 MECLOFENAMATE SODIUM -meclofenamate sodium cap 100 mg..................................................................... 93 MEDICAL PROVIDER EZ FLU S -influenza virus vac types a & b pf pref syringe kit 0.5 ml............................. 15 MEDICAL PROVIDER SINGLE U -influenza virus vaccine split pf susp pref syr kit 0.5 ml....................................... 15 MEDICAL PROVIDER SINGLE U -influenza virus vac split quad inj prefilled syr kit 0.25 ml.............................. 15 MEDICAL PROVIDER SINGLE U -influenza virus vac types a & b pf pref syringe kit 0.5 ml............................. 15 MEDROL -methylprednisolone tab 2 mg.......................... 22 medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera contrac)................................................ 27 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depo-provera contrac)............................. 27 medroxyprogesterone acetate tab 2.5 mg (Provera)......................................................................... 28 medroxyprogesterone acetate tab 5 mg (Provera)...... 29 medroxyprogesterone acetate tab 10 mg (Provera)......................................................................... 29 mefenamic acid cap 250 mg (Ponstel).......................... 93 mefloquine hcl tab 250 mg............................................. 11 MEGA MULTIVITAMIN -multiple vitamins w/ minerals powder........................................................................... 107 megestrol acetate susp 625 mg/5ml (Megace es)........ 29 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)....................................... 93 meloxicam tab 15 mg (Mobic)........................................ 93 memantine hcl oral solution 2 mg/ml (Namenda)........ 82 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak (Namenda titration pa)................................................. 82 memantine hcl tab 5 mg (Namenda)............................. 82 memantine hcl tab 10 mg (Namenda)........................... 82 M-END MAX D -pseudoephedrine-dexbromphen-codeine liqd 20-0.667-6 mg/5ml................................................... 56 M-END PE -phenylephrine-bromphen w/ codeine liqd 3.33-1.33-6.33 mg/5ml....................................................56 MENEST -esterified estrogens tab 0.3 mg....................... 25 MENEST -esterified estrogens tab 0.625 mg................... 25 MENEST -esterified estrogens tab 1.25 mg..................... 25 MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 25 MENTAX -butenafine hcl cream 1%................................153 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 195 2017 MEPERIDINE HCL -meperidine hcl oral soln 50 mg/5ml............................................................................. 88 MEPHYTON -phytonadione tab 5 mg............................. 105 meprobamate tab 200 mg............................................... 69 meprobamate tab 400 mg............................................... 69 mercaptopurine tab 50 mg (Purinethol)........................ 20 MERITENE -nutritional supplement powder................... 123 MESALAMINE DR -mesalamine tab delayed release 800 mg.................................................................................... 65 mesalamine enema 4 gm................................................ 65 MESNEX -mesna tab 400 mg........................................... 20 MESTINON -pyridostigmine bromide syrup 60 mg/5ml........................................................................... 105 METAFORM -nutritional supplement pack...................... 123 METAPROTERENOL SULFATE -metaproterenol sulfate syrup 10 mg/5ml............................................................. 59 METAPROTERENOL SULFATE -metaproterenol sulfate tab 20 mg........................................................................ 59 METAXALONE -metaxalone tab 400 mg........................ 104 metaxalone tab 800 mg (Skelaxin).............................. 104 metformin hcl tab 500 mg (Glucophage)...................... 32 metformin hcl tab 850 mg (Glucophage)...................... 32 metformin hcl tab 1000 mg (Glucophage).................... 32 metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 32 metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 32 metformin hcl tab sr 24hr modified release 500 mg (Glumetza)...................................................................... 32 metformin hcl tab sr 24hr modified release 1000 mg (Glumetza)...................................................................... 32 metformin hcl tab sr 24hr osmotic 500 mg (Fortamet)....................................................................... 32 metformin hcl tab sr 24hr osmotic 1000 mg (Fortamet)....................................................................... 32 methadone hcl conc 10 mg/ml (Methadose)................ 88 methadone hcl soln 5 mg/5ml (Methadone hcl)........... 88 methadone hcl soln 10 mg/5ml (Methadone hcl)......... 88 methadone hcl tab for oral susp 40 mg........................ 88 methadone hcl tab 10 mg (Dolophine).......................... 88 methadone hcl tab 5 mg (Dolophine hcl)..................... 88 methamphetamine hcl tab 5 mg (Desoxyn).................. 79 methazolamide tab 25 mg (Neptazane)......................... 50 methazolamide tab 50 mg (Neptazane)......................... 50 methenamine hippurate tab 1 gm (Hiprex)................... 66 METHERGINE -methylergonovine maleate tab 0.2 mg.................................................................................... 37 methimazole tab 5 mg (Tapazole).................................. 35 methimazole tab 10 mg (Tapazole)................................ 35 METHIONAID -nutritional supplement powder............... 123 METHITEST -methyltestosterone oral tab 10 mg............. 24 methocarbamol tab 750 mg (Robaxin-750).................104 methocarbamol tab 500 mg (Robaxin)........................ 104 methotrexate sodium for inj 1 gm................................. 20 methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 20 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 20 methotrexate sodium inj pf 100 mg/4ml (25 mg/ ml)................................................................................... 20 methotrexate sodium inj pf 200 mg/8ml (25 mg/ ml)................................................................................... 20 methotrexate sodium inj pf 250 mg/10ml (25 mg/ ml)................................................................................... 20 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ ml)................................................................................... 20 METHOTREXATE SODIUM -methotrexate sodium inj 250 mg/10ml (25 mg/ml)........................................................20 methotrexate sodium tab 2.5 mg (base equiv)............. 20 methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 153 methscopolamine bromide tab 2.5 mg (Pamine)......... 62 methscopolamine bromide tab 5 mg (Pamine forte)................................................................................62 METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........50 methyldopa tab 250 mg.................................................. 48 methyldopa tab 500 mg.................................................. 48 methylphenidate hcl cap cr 10 mg (cd) (Metadate cd)................................................................................... 79 methylphenidate hcl cap cr 20 mg (cd) (Metadate cd)................................................................................... 79 methylphenidate hcl cap cr 30 mg (cd) (Metadate cd)................................................................................... 79 methylphenidate hcl cap cr 40 mg (cd) (Metadate cd)................................................................................... 79 methylphenidate hcl cap cr 50 mg (cd) (Metadate cd)................................................................................... 79 methylphenidate hcl cap cr 60 mg (cd) (Metadate cd)................................................................................... 79 methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin la)..................................................................................... 79 methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin la)..................................................................................... 79 methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin la)..................................................................................... 79 methylphenidate hcl chew tab 2.5 mg (Methylin)........ 79 methylphenidate hcl chew tab 5 mg (Methylin)........... 79 methylphenidate hcl chew tab 10 mg (Methylin)......... 79 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sr 24hr 18 mg................................................................. 79 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sr 24hr 27 mg................................................................. 79 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sr 24hr 36 mg................................................................. 80 METHYLPHENIDATE HCL ER -methylphenidate hcl tab sr 24hr 54 mg................................................................. 80 methylphenidate hcl soln 5 mg/5ml (Methylin)............ 80 methylphenidate hcl soln 10 mg/5ml (Methylin).......... 80 methylphenidate hcl tab cr 10 mg................................. 80 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 196 2017 methylphenidate hcl tab cr 20 mg (Ritalin sr).............. 80 methylphenidate hcl tab 5 mg (Ritalin)......................... 80 methylphenidate hcl tab 10 mg (Ritalin)....................... 80 methylphenidate hcl tab 20 mg (Ritalin)....................... 80 methylphenidate hcl tab sa osm 18 mg (Concerta)..... 80 methylphenidate hcl tab sa osm 27 mg (Concerta)..... 80 methylphenidate hcl tab sa osm 36 mg (Concerta)..... 80 methylphenidate hcl tab sa osm 54 mg (Concerta)..... 80 methylprednisolone tab 4 mg (Medrol)......................... 22 methylprednisolone tab 8 mg (Medrol)......................... 22 methylprednisolone tab 16 mg (Medrol)....................... 23 methylprednisolone tab 32 mg (Medrol)....................... 23 methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak).......................................................... 22 methyltestosterone cap 10 mg (Testred)...................... 24 METIPRANOLOL -metipranolol ophth soln 0.3%........... 145 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 65 metoclopramide hcl tab 5 mg (Reglan)......................... 65 metoclopramide hcl tab 10 mg (Reglan)....................... 65 METOCLOPRAMIDE ODT -metoclopramide hcl orally disintegrating tab 5 mg................................................... 65 METOCLOPRAMIDE ODT -metoclopramide hcl orally disintegrating tab 10 mg................................................. 65 metolazone tab 10 mg..................................................... 50 metolazone tab 2.5 mg (Zaroxolyn)............................... 50 metolazone tab 5 mg (Zaroxolyn).................................. 50 metoprolol & hydrochlorothiazide tab 100-50 mg....... 48 metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)..............................................................48 metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct)..............................................................48 metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) (Toprol xl)........................................................... 41 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) (Toprol xl)........................................................... 41 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) (Toprol xl)........................................................... 41 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) (Toprol xl)........................................................... 41 metoprolol tartrate tab 25 mg........................................ 41 metoprolol tartrate tab 50 mg (Lopressor)................... 41 metoprolol tartrate tab 100 mg (Lopressor)................. 42 metronidazole cap 375 mg (Flagyl)............................... 12 metronidazole cream 0.75% (Metrocream)................. 153 metronidazole gel 0.75%............................................... 153 metronidazole gel 1% (Metrogel)................................. 153 metronidazole lotion 0.75% (Metrolotion)................... 153 metronidazole tab 250 mg (Flagyl)................................ 12 metronidazole tab 500 mg (Flagyl)................................ 12 metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 67 mexiletine hcl cap 150 mg.............................................. 44 mexiletine hcl cap 200 mg.............................................. 44 mexiletine hcl cap 250 mg.............................................. 44 MICONAZOLE 3 -miconazole nitrate vaginal suppos 200 mg.................................................................................... 67 midodrine hcl tab 2.5 mg................................................ 51 midodrine hcl tab 5 mg................................................... 51 midodrine hcl tab 10 mg................................................. 51 miglitol tab 25 mg (Glyset)............................................. 32 miglitol tab 50 mg (Glyset)............................................. 32 miglitol tab 100 mg (Glyset)........................................... 32 MIGRANAL -dihydroergotamine mesylate nasal spray 4 mg/ml............................................................................... 95 MILLIPRED DP -prednisolone tab therapy pack 5 mg (21).................................................................................. 23 MILLIPRED DP -prednisolone tab therapy pack 5 mg (48).................................................................................. 23 MILLIPRED -prednisolone sod phosphate oral soln 10 mg/5ml (base equiv)....................................................... 23 MILLIPRED -prednisolone tab 5 mg................................. 23 MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)........................................... 27 MINIVELLE -estradiol td patch biweekly 0.0375 mg/24hr........................................................................... 25 MINIVELLE -estradiol td patch biweekly 0.05 mg/24hr........................................................................... 25 MINIVELLE -estradiol td patch biweekly 0.075 mg/24hr........................................................................... 25 MINIVELLE -estradiol td patch biweekly 0.1 mg/24hr.......25 MINIVELLE -estradiol td patch twice weekly 0.025 mg/24hr........................................................................... 25 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........................................................ 48 minoxidil tab 10 mg......................................................... 48 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 30 mcg/0.3ml...................................................................... 134 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50 mcg/0.3ml...................................................................... 134 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75 mcg/0.3ml...................................................................... 134 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 100 mcg/0.3ml.............................................................. 134 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 150 mcg/0.3ml.............................................................. 134 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 197 2017 MIRCERA -methoxy peg-epoetin beta soln prefilled syr 200 mcg/0.3ml.............................................................. 134 mirtazapine orally disintegrating tab 15 mg (Remeron soltab)............................................................................. 71 mirtazapine orally disintegrating tab 30 mg (Remeron soltab)............................................................................. 71 mirtazapine orally disintegrating tab 45 mg (Remeron soltab)............................................................................. 71 mirtazapine tab 7.5 mg....................................................71 mirtazapine tab 15 mg (Remeron)................................. 71 mirtazapine tab 30 mg (Remeron)................................. 71 mirtazapine tab 45 mg (Remeron)................................. 71 misoprostol tab 100 mcg (Cytotec)............................... 62 misoprostol tab 200 mcg (Cytotec)............................... 62 MITIGARE -colchicine cap 0.6 mg.................................... 96 MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 145 MMA/PA ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 123 MMA/PA ANAMIX NEXT -nutritional supplement powder........................................................................... 123 MMA/PA COOLER -nutritional supplement liquid........... 123 MMA/PA COOLER15 -nutritional supplement liquid....... 123 MMA/PA GEL -nutritional supplement pack.................... 123 modafinil tab 100 mg (Provigil)...................................... 80 modafinil tab 200 mg (Provigil)...................................... 80 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............. 123 moexipril hcl tab 7.5 mg (Univasc)................................ 48 moexipril hcl tab 15 mg (Univasc)................................. 48 moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 48 moexipril-hydrochlorothiazide tab 15-25 mg............... 48 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic)......................................................................... 48 MOLINDONE HYDROCHLORIDE -molindone hcl tab 5 mg.................................................................................... 74 MOLINDONE HYDROCHLORIDE -molindone hcl tab 10 mg.................................................................................... 74 MOLINDONE HYDROCHLORIDE -molindone hcl tab 25 mg.................................................................................... 74 mometasone furoate cream 0.1% (Elocon)................ 153 mometasone furoate nasal susp 50 mcg/act (Nasonex)....................................................................... 55 mometasone furoate oint 0.1% (Elocon).................... 153 mometasone furoate solution 0.1% (lotion) (Elocon)........................................................................ 153 MONOCAL -sodium monofluorophosphate-calcium carb tab 22.75-625 mg......................................................... 114 MONOCLATE-P -antihemophilic factor (human) for inj kit 1000 unit....................................................................... 141 MONOCLATE-P -antihemophilic factor (human) for inj kit 1500 unit....................................................................... 141 MONOGEN -nutritional supplement powder................... 123 MONONINE -coagulation factor ix for inj 1000 unit........ 141 montelukast sodium chew tab 4 mg (base equiv) (Singulair)....................................................................... 59 montelukast sodium chew tab 5 mg (base equiv) (Singulair)....................................................................... 59 montelukast sodium tab 10 mg (base equiv) (Singulair)....................................................................... 59 MONUROL -fosfomycin tromethamine powd pack 3 gm (base equivalent)............................................................ 66 morphine sulfate cap sr 24hr 10 mg (Kadian).............. 88 morphine sulfate cap sr 24hr 20 mg (Kadian).............. 88 morphine sulfate cap sr 24hr 30 mg (Kadian).............. 88 morphine sulfate cap sr 24hr 50 mg (Kadian).............. 88 morphine sulfate cap sr 24hr 60 mg (Kadian).............. 88 morphine sulfate cap sr 24hr 80 mg (Kadian).............. 89 morphine sulfate cap sr 24hr 100 mg (Kadian)............ 89 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 30 mg......................................................................89 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 45 mg......................................................................89 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 60 mg......................................................................89 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 75 mg......................................................................89 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 90 mg......................................................................89 MORPHINE SULFATE ER -morphine sulfate beads cap sr 24hr 120 mg....................................................................89 MORPHINE SULFATE -morphine sulfate tab 15 mg........ 88 MORPHINE SULFATE -morphine sulfate tab 30 mg........ 88 morphine sulfate oral soln 10 mg/5ml.......................... 89 morphine sulfate oral soln 20 mg/5ml.......................... 89 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 89 morphine sulfate tab cr 15 mg (Ms contin).................. 89 morphine sulfate tab cr 30 mg (Ms contin).................. 89 morphine sulfate tab cr 60 mg (Ms contin).................. 89 morphine sulfate tab cr 100 mg (Ms contin)................ 89 morphine sulfate tab cr 200 mg (Ms contin)................ 89 MOVANTIK -naloxegol oxalate tab 12.5 mg (base equivalent)....................................................................... 65 MOVANTIK -naloxegol oxalate tab 25 mg (base equivalent)....................................................................... 65 MOVIPREP -peg 3350-kcl-nacl-na sulfate-na acorbate-c for soln 100 gm...............................................................61 MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 1 MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2 times daily).................................................................... 145 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 198 2017 moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 5 MSUD AID -nutritional supplement powder.................... 123 MSUD ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 123 MSUD COOLER -nutritional supplement liquid.............. 123 MSUD EXPRESS -nutritional supplement pack............. 123 MSUD EXPRESS20 -nutritional supplement pack......... 123 MSUD GEL -nutritional supplement pack....................... 123 MSUD LOPHLEX LQ -nutritional supplement liquid....... 123 MSUD MAXAMAID -nutritional supplement powder....... 123 MSUD MAXAMUM -nutritional supplement powder....... 123 MSUD 2 -nutritional supplement powder........................ 123 MULTAQ -dronedarone hcl tab 400 mg (base equivalent)....................................................................... 44 mupirocin calcium cream 2% (Bactroban)................. 153 mupirocin oint 2% (Bactroban).................................... 153 M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 107 MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 38 mycophenolate mofetil cap 250 mg (Cellcept)........... 157 mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)...................................................................... 157 mycophenolate mofetil tab 500 mg (Cellcept)............157 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)................................................. 157 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) (Myfortic)................................................. 157 MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 134 MYLERAN -busulfan tab 2 mg.......................................... 20 MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg...................................................................107 MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................. 107 MYNATAL -prenatal multivitamins & minerals w/ iron & fa cap 1 mg....................................................................... 107 MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg............................................... 107 MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................. 107 MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg.....................................................................107 MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 66 MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 66 MYTESI -crofelemer tab delayed release 125 mg............ 61 N nabumetone tab 500 mg................................................. 93 nabumetone tab 750 mg................................................. 93 nadolol & bendroflumethiazide tab 40-5 mg (Corzide)......................................................................... 48 nadolol & bendroflumethiazide tab 80-5 mg (Corzide)......................................................................... 48 nadolol tab 20 mg (Corgard).......................................... 42 nadolol tab 40 mg (Corgard).......................................... 42 nadolol tab 80 mg (Corgard).......................................... 42 NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................. 148 NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln rinse 0.05%................................................................... 148 NAFRINSE WEEKLY -sodium fluoride for soln rinse 0.2%...............................................................................148 naftifine hcl cream 1%.................................................. 153 naftifine hcl cream 2% (Naftin).................................... 153 NAFTIN -naftifine hcl cream 2%..................................... 153 NAFTIN -naftifine hcl gel 1%........................................... 153 NAFTIN -naftifine hcl gel 2%........................................... 153 naloxone hcl inj 0.4 mg/ml........................................... 156 NALOXONE HCL -naloxone hcl soln prefilled syringe 2 mg/2ml........................................................................... 156 naltrexone hcl tab 50 mg (Revia)................................. 156 NAMENDA XR -memantine hcl cap sr 24hr 7 mg............ 82 NAMENDA XR -memantine hcl cap sr 24hr 14 mg.......... 82 NAMENDA XR -memantine hcl cap sr 24hr 21 mg.......... 82 NAMENDA XR -memantine hcl cap sr 24hr 28 mg.......... 82 NAMENDA XR TITRATION PACK -memantine hcl cap sr 24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 82 NAMZARIC -memantine-donepezil cap er 24hr 7 & 14 & 21 & 28-10 mg pack....................................................... 83 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 7-10 mg........................................................................... 82 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 14-10 mg......................................................................... 82 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 21-10 mg......................................................................... 82 NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr 28-10 mg......................................................................... 83 naproxen sodium tab 275 mg (Anaprox)...................... 94 naproxen sodium tab 550 mg (Anaprox ds)................. 94 naproxen sodium tab sr 24hr 375 mg (base equiv) (Naprelan)....................................................................... 94 naproxen sodium tab sr 24hr 500 mg (base equiv) (Naprelan)....................................................................... 94 naproxen susp 125 mg/5ml (Naprosyn)........................ 94 naproxen tab ec 375 mg (Ec-naprosyn)........................ 94 naproxen tab ec 500 mg (Ec-naprosyn)........................ 94 naproxen tab 250 mg (Naprosyn).................................. 94 naproxen tab 375 mg (Naprosyn).................................. 94 naproxen tab 500 mg (Naprosyn).................................. 94 naratriptan hcl tab 1 mg (base equiv) (Amerge).......... 95 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)....... 95 NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 156 NASCOBAL -cyanocobalamin nasal spray 500 mcg/0.1ml...................................................................... 134 NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew tab 28-1 mg...................................................................107 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 199 2017 NATACYN -natamycin ophth susp 5%............................ 145 NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1 mg.................................................................................. 107 NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2 mg/2-3 mg/1 mg............................................................. 27 nateglinide tab 60 mg (Starlix)....................................... 32 nateglinide tab 120 mg (Starlix)..................................... 32 NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3 cap 28-1-250 mg.......................................................... 107 NATROBA -spinosad susp 0.9%..................................... 154 NATURE-THROID -thyroid tab 16.25 mg..........................35 NATURE-THROID -thyroid tab 32.5 mg............................35 NATURE-THROID -thyroid tab 65 mg...............................36 NATURE-THROID -thyroid tab 81.25 mg..........................36 NATURE-THROID -thyroid tab 97.5 mg............................36 NATURE-THROID -thyroid tab 113.75 mg........................ 36 NATURE-THROID -thyroid tab 130 mg.............................36 NATURE-THROID -thyroid tab 146.25 mg....................... 36 NATURE-THROID -thyroid tab 195 mg.............................36 NATURE-THROID -thyroid tab 260 mg.............................36 NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 35 NATURE-THROID -thyroid tab 325 mg (5 grain).............. 36 NEBUPENT -pentamidine isethionate for nebulization soln 300 mg.................................................................... 12 NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50 mcg.................................................................................. 27 NECON 10/11-28 -norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11)........................................... 27 NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg............................................................. 107 NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 71 NEFAZODONE HCL -nefazodone hcl tab 150 mg........... 71 NEFAZODONE HCL -nefazodone hcl tab 200 mg........... 71 nefazodone hcl tab 50 mg.............................................. 71 nefazodone hcl tab 250 mg............................................ 71 NEOCATE INFANT DHA/ARA -nutritional supplement powder........................................................................... 123 NEOCATE JUNIOR/PREBIOTICS -nutritional supplement powder........................................................................... 123 NEOCATE JUNIOR -nutritional supplement powder...... 123 NEOCATE NUTRA -nutritional supplement powder....... 123 NEOCATE SPLASH -nutritional supplement liquid......... 123 NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 145 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin............................. 145 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 145 neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)...................................................................... 145 neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol).............................................................145 neomycin-polymyxin-hc otic soln 1% (Cortisporin).................................................................147 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%.................................................................... 147 neomycin sulfate tab 500 mg........................................... 5 NEORAL -cyclosporine modified cap 25 mg...................157 NEORAL -cyclosporine modified cap 100 mg.................158 NEORAL -cyclosporine modified oral soln 100 mg/ ml................................................................................... 158 NEO-SYNALAR -neomycin sulfate-fluocinolone acetonide cream 0.5-0.025%........................................................ 154 NEPRO -nutritional supplement liquid.............................123 NEPRO WITH CARBSTEADY -nutritional supplement liquid.............................................................................. 123 NEPRO WITH CARB STEADY -nutritional supplement liquid.............................................................................. 123 NESINA -alogliptin benzoate tab 6.25 mg (base equiv)............................................................................... 32 NESINA -alogliptin benzoate tab 12.5 mg (base equiv)............................................................................... 32 NESINA -alogliptin benzoate tab 25 mg (base equiv).......32 NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab & omega 3 cap............................................................. 108 NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack....................................................... 108 NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab 32-1 mg......................................................................... 108 NESTLE FLAVOR EXTRA STREN -nutritional supplement flavor pack................................................ 123 NESTLE FLAVOR FOR KIDS -nutritional supplement flavor pack..................................................................... 123 NESTLE FLAVOR -nutritional supplement flavor pack............................................................................... 123 NEULASTA ONPRO KIT -pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml.................................................. 134 NEULASTA -pegfilgrastim soln prefilled syringe 6 mg/0.6ml........................................................................ 134 NEUPOGEN -filgrastim inj 300 mcg/ml........................... 135 NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/ ml).................................................................................. 135 NEUPOGEN -filgrastim soln prefilled syringe 300 mcg/0.5ml...................................................................... 135 NEUPOGEN -filgrastim soln prefilled syringe 480 mcg/0.8ml (600 mcg/ml)............................................... 135 NEUPRO -rotigotine td patch 24hr 1 mg/24hr................ 102 NEUPRO -rotigotine td patch 24hr 2 mg/24hr................ 102 NEUPRO -rotigotine td patch 24hr 3 mg/24hr................ 102 NEUPRO -rotigotine td patch 24hr 4 mg/24hr................ 102 NEUPRO -rotigotine td patch 24hr 6 mg/24hr................ 102 NEUPRO -rotigotine td patch 24hr 8 mg/24hr................ 102 NEVANAC -nepafenac ophth susp 0.1%........................ 145 NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 8 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 200 2017 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......................................................................... 108 NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap 29-1.25-350 mg.............................................................108 NEXAVAR -sorafenib tosylate tab 200 mg (base equivalent)....................................................................... 20 NEXIUM -esomeprazole magnesium for delayed release susp packet 5 mg........................................................... 62 NEXIUM -esomeprazole magnesium for delayed release susp packet 10 mg......................................................... 62 NEXIUM -esomeprazole magnesium for delayed release susp packet 20 mg......................................................... 62 NEXIUM -esomeprazole magnesium for delayed release susp packet 40 mg......................................................... 62 NEXIUM -esomeprazole magnesium for delayed release susp pack 2.5 mg........................................................... 62 niacin tab cr 500 mg (antihyperlipidemic) (Niaspan)........................................................................ 53 niacin tab cr 750 mg (antihyperlipidemic) (Niaspan)........................................................................ 53 niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan)........................................................................ 53 nicardipine hcl cap 20 mg.............................................. 43 nicardipine hcl cap 30 mg.............................................. 43 NICODERM CQ -nicotine td patch 24hr 7 mg/24hr.......... 83 NICODERM CQ -nicotine td patch 24hr 14 mg/24hr........ 83 NICODERM CQ -nicotine td patch 24hr 21 mg/24hr........ 83 NICORETTE MINI -nicotine polacrilex lozenge 2 mg....... 83 NICORETTE MINI -nicotine polacrilex lozenge 4 mg....... 83 NICORETTE -nicotine polacrilex gum 2 mg..................... 83 NICORETTE -nicotine polacrilex gum 4 mg..................... 83 NICORETTE -nicotine polacrilex lozenge 2 mg................ 83 NICORETTE -nicotine polacrilex lozenge 4 mg................ 83 NICORETTE STARTER KIT -nicotine polacrilex gum 2 mg.................................................................................... 83 NICORETTE STARTER KIT -nicotine polacrilex gum 4 mg.................................................................................... 83 nicotine polacrilex gum 2 mg.........................................83 nicotine polacrilex gum 4 mg.........................................83 nicotine polacrilex lozenge 2 mg................................... 83 nicotine polacrilex lozenge 4 mg................................... 83 nicotine td patch 24hr 7 mg/24hr...................................83 nicotine td patch 24hr 14 mg/24hr.................................83 nicotine td patch 24hr 21 mg/24hr.................................83 NICOTINE TRANSDERMAL SYST -nicotine td patch 24 hr kit 21-14-7 mg/24hr.................................................... 83 NICOTROL INHALER -nicotine inhaler system 10 mg (4 mg delivered).................................................................. 83 NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/ spray)............................................................................... 83 nifedipine cap 20 mg....................................................... 43 nifedipine cap 10 mg (Procardia).................................. 43 nifedipine tab sr 24hr 30 mg (Adalat cc).......................43 nifedipine tab sr 24hr 60 mg (Adalat cc).......................43 nifedipine tab sr 24hr 90 mg (Adalat cc).......................43 nifedipine tab sr 24hr osmotic release 30 mg (Procardia xl)................................................................. 43 nifedipine tab sr 24hr osmotic release 60 mg (Procardia xl)................................................................. 43 nifedipine tab sr 24hr osmotic release 90 mg (Procardia xl)................................................................. 43 NILANDRON -nilutamide tab 150 mg............................... 20 nilutamide tab 150 mg (Nilandron)................................ 20 nimodipine cap 30 mg..................................................... 43 NINJACOF-XG -guaifenesin-codeine liquid 200-8 mg/5ml............................................................................. 56 NINLARO -ixazomib citrate cap 2.3 mg (base equivalent)....................................................................... 20 NINLARO -ixazomib citrate cap 3 mg (base equivalent)....................................................................... 20 NINLARO -ixazomib citrate cap 4 mg (base equivalent)....................................................................... 20 NISOLDIPINE ER -nisoldipine tab sr 24hr 20 mg............. 43 NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 43 NISOLDIPINE ER -nisoldipine tab sr 24hr 30 mg............. 43 NISOLDIPINE ER -nisoldipine tab sr 24hr 40 mg............. 44 nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 44 nisoldipine tab sr 24hr 17 mg (Sular)............................44 nisoldipine tab sr 24hr 34 mg (Sular)............................44 NITRO-BID -nitroglycerin oint 2%..................................... 40 NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 40 NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 40 nitrofurantoin macrocrystalline cap 25 mg (Macrodantin).................................................................66 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin).................................................................66 nitrofurantoin macrocrystalline cap 100 mg (Macrodantin).................................................................66 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)............................................................... 66 nitrofurantoin susp 25 mg/5ml (Furadantin)................ 66 nitroglycerin cap cr 2.5 mg............................................ 40 nitroglycerin cap cr 6.5 mg............................................ 40 nitroglycerin cap cr 9 mg............................................... 40 NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol 400 mcg/spray................................................................ 40 nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 40 nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 40 nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 40 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 40 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 201 2017 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 40 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 40 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 40 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual pumpspr)................................................. 40 NITROMIST -nitroglycerin lingual aerosol 400 mcg/ spray................................................................................ 40 NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 40 NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 41 NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 41 NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 108 nizatidine cap 150 mg..................................................... 62 nizatidine cap 300 mg (Axid).......................................... 62 NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 62 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg (Femcon fe)............................................... 27 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg (Generess fe)............................................ 28 norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg (Brevicon-28)................................................................. 27 norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)................................................................ 27 norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg (Ovcon-35)...................................................................... 27 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe 1/20).................................................. 28 norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe 1.5/30)............................................... 28 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)................................................. 28 norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg (Loestrin 1.5/30-21).............................................. 28 norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) (Minastrin 24 fe)............................................28 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) (Lomedia 24 fe)............................................. 28 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg................................................................................. 26 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose)................................................ 26 norethindrone acetate tab 5 mg (Aygestin).................. 29 norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep fe)................................................. 28 norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)...................................... 28 norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 28 norethindrone tab 0.35 mg (Nor-qd).............................. 28 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen)................................................................ 28 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen)........................................... 28 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg (Ortho tri-cyclen lo)....................................... 28 norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 28 NORPACE CR -disopyramide phosphate cap sr 12hr 100 mg.................................................................................... 44 NORPACE CR -disopyramide phosphate cap sr 12hr 150 mg.................................................................................... 44 NORPACE -disopyramide phosphate cap 100 mg........... 44 NORPACE -disopyramide phosphate cap 150 mg........... 44 nortriptyline hcl cap 10 mg (Pamelor)...........................71 nortriptyline hcl cap 25 mg (Pamelor)...........................71 nortriptyline hcl cap 50 mg (Pamelor)...........................71 nortriptyline hcl cap 75 mg (Pamelor)...........................71 NORTRIPTYLINE HCL -nortriptyline hcl soln 10 mg/5ml............................................................................. 71 NORVIR -ritonavir cap 100 mg........................................... 8 NORVIR -ritonavir oral soln 80 mg/ml.................................8 NORVIR -ritonavir tab 100 mg............................................ 8 NOURISH -nutritional supplement liquid......................... 123 NOVASOURCE PULMONARY -nutritional supplement liquid.............................................................................. 124 NOVASOURCE RENAL -nutritional supplement liquid.............................................................................. 124 NOVOEIGHT -antihemophilic factor (recombinant) for inj 250 unit......................................................................... 141 NOVOEIGHT -antihemophilic factor (recombinant) for inj 500 unit......................................................................... 141 NOVOEIGHT -antihemophilic factor (recombinant) for inj 1000 unit....................................................................... 141 NOVOEIGHT -antihemophilic factor (recombinant) for inj 1500 unit....................................................................... 141 NOVOEIGHT -antihemophilic factor (recombinant) for inj 2000 unit....................................................................... 141 NOVOEIGHT -antihemophilic factor (recombinant) for inj 3000 unit....................................................................... 141 NOVOLIN 70/30 -insulin nph isophane & regular human inj 100 unit/ml (70-30).................................................... 34 NOVOLIN 70/30 RELION -insulin nph isophane & regular human inj 100 unit/ml (70-30)........................................ 34 NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/ ml..................................................................................... 34 NOVOLIN N RELION -insulin nph (human) (isophane) inj 100 unit/ml.......................................................................34 NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 34 NOVOLIN R RELION -insulin regular (human) inj 100 unit/ml.............................................................................. 34 NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100 unit/ml.......................................................................33 NOVOLOG -insulin aspart inj 100 unit/ml......................... 33 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 202 2017 NOVOLOG MIX 70/30 -insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)...................................... 34 NOVOLOG MIX 70/30 PREFILL -insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)........................... 35 NOVOLOG PENFILL -insulin aspart soln cartridge 100 unit/ml.............................................................................. 33 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 1 mg (1000 mcg).......................................................... 141 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 2 mg (2000 mcg).......................................................... 141 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 5 mg (5000 mcg).......................................................... 141 NOVOSEVEN RT -coagulation factor viia (recomb) for inj 8 mg (8000 mcg).......................................................... 141 NOXAFIL -posaconazole susp 40 mg/ml............................ 6 NOXAFIL -posaconazole tab delayed release 100 mg....... 6 NUCALA -mepolizumab for inj 100 mg............................. 59 NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap 20-10 mg......................................................................... 83 NUPLAZID -pimavanserin tartrate tab 17 mg (base equivalent)....................................................................... 74 NUTRA/BALANCE RE/GEN FREE -nutritional supplement liquid (frozen)............................................ 124 NUTRA/BALANCE RE/GEN -nutritional supplement liquid (frozen).......................................................................... 124 NUTRA/SHAKE FRUIT PLUS -nutritional supplement liquid (frozen)................................................................ 124 NUTRA/SHAKE -nutritional supplement liquid (frozen).......................................................................... 124 NUTRA/SHAKE SUPREME -nutritional supplement liquid.............................................................................. 124 NUTRA/SHAKE SUPREME -nutritional supplement liquid (frozen).......................................................................... 124 NUTRA BALANCE DIABETIC NU -nutritional supplement bar.................................................................................. 124 NUTRA BALANCE FIBER COOKI -nutritional supplement misc............................................................................... 124 NUTRA BALANCE PROTEIN FOR -nutritional supplement misc........................................................... 124 NUTRAMENT -nutritional supplement liquid................... 124 NUTRAMINE APPLE AMINO BIT -nutritional supplement pack............................................................................... 124 NUTRAMINE BANANA AMINO B -nutritional supplement pack............................................................................... 124 NUTRAMINE CHOCOLATE AMINO -nutritional supplement pack........................................................... 124 NUTRAMINE MANGO AMINO BI -nutritional supplement pack............................................................................... 124 NUTRAMINE MIXED FLAVORS A -nutritional supplement pack............................................................................... 124 NUTRAMINE -nutritional supplement pack..................... 124 NUTRAMINE PEACHES & CREAM -nutritional supplement pack........................................................... 124 NUTRAMINE PINEAPPLE AMINO -nutritional supplement pack........................................................... 124 NUTRASENTIALS -amino acids oral powder................. 115 NUTRA SHAKE/SUPREME -nutritional supplement liquid (frozen).......................................................................... 124 NUTRA SHAKE -nutritional supplement liquid (frozen).......................................................................... 124 NUTREN 1.0/FIBER/ULTRAPAK -nutritional supplement liquid.............................................................................. 125 NUTREN 1.0/FIBER -nutritional supplement liquid.........125 NUTREN 1.0 CAL -nutritional supplement liquid............ 124 NUTREN 1.5 CAL -nutritional supplement liquid............ 125 NUTREN 2.0 CAL -nutritional supplement liquid............ 125 NUTREN 1.5 FIBER -nutritional supplement liquid.........125 NUTREN JR FIBER -nutritional supplement liquid......... 124 NUTREN JR -nutritional supplement liquid..................... 124 NUTREN JUNIOR/FIBER -nutritional supplement liquid.............................................................................. 124 NUTREN JUNIOR -nutritional supplement liquid............ 124 NUTREN JUNIOR 1.0 -nutritional supplement liquid...... 124 NUTREN 1.0 -nutritional supplement liquid.................... 124 NUTREN 1.5 -nutritional supplement liquid.................... 125 NUTREN 2.0 -nutritional supplement liquid.................... 125 NUTREN PULMONARY -nutritional supplement liquid.............................................................................. 124 NUTREN RENAL -nutritional supplement liquid............. 124 NUTRESTORE -glutamine powd pack 5 gm.................. 115 NUTRICIA PREOP -nutritional supplement pack........... 125 NUTRIFOCUS -nutritional supplement liquid.................. 125 NUTRIHEAL -nutritional supplement liquid..................... 125 NUTRIHEP 1.5 CAL -nutritional supplement liquid......... 125 NUTRIRENAL -nutritional supplement liquid.................. 125 NUTRITIONAL DRINK MIX -nutritional supplement powder........................................................................... 125 NUTRITIONAL DRINK -nutritional supplement liquid..... 125 NUTRITIONAL DRINK PLUS -nutritional supplement liquid.............................................................................. 125 NUTRITIONAL DRINK SHAKE M -nutritional supplement powder........................................................................... 125 NUTRITIONAL SHAKE COMPLET -nutritional supplement liquid.......................................................... 125 NUTRITIONAL SHAKE -nutritional supplement liquid.............................................................................. 125 NUTRITIONAL SHAKE PLUS -nutritional supplement liquid.............................................................................. 125 NUTRITIONAL SHAKE PLUS PR -nutritional supplement liquid.............................................................................. 125 nutritional supplement liquid....................................... 125 NUTRITIONAL SUPPLEMENT -nutritional supplement liquid.............................................................................. 125 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 203 2017 NUTRITIONAL SUPPLEMENT PL -nutritional supplement liquid.............................................................................. 125 NUTRIVENT -nutritional supplement liquid..................... 125 NUTRIVENT 1.5 -nutritional supplement liquid...............125 NUTRIVIR NSA -nutritional supplement powder............ 125 NUTRIVIR -nutritional supplement powder..................... 125 NUVARING -etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr...................................................... 28 NUVESSA -metronidazole vaginal gel 1.3%.....................67 NUVIGIL -armodafinil tab 50 mg....................................... 80 NUVIGIL -armodafinil tab 150 mg..................................... 80 NUVIGIL -armodafinil tab 200 mg..................................... 80 NUVIGIL -armodafinil tab 250 mg..................................... 80 NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 250 unit................................................................................. 141 NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 500 unit................................................................................. 141 NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 1000 unit................................................................................. 141 NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 2000 unit................................................................................. 141 NUWIQ -antihemophilic factor (bdd-rfviii) for inj 250 unit................................................................................. 141 NUWIQ -antihemophilic factor (bdd-rfviii) for inj 500 unit................................................................................. 141 NUWIQ -antihemophilic factor (bdd-rfviii) for inj 1000 unit................................................................................. 141 NUWIQ -antihemophilic factor (bdd-rfviii) for inj 2000 unit................................................................................. 141 NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 44 nystatin cream 100000 unit/gm.................................... 154 nystatin oint 100000 unit/gm........................................ 154 nystatin susp 100000 unit/ml....................................... 148 nystatin tab 500000 unit....................................................6 nystatin topical powder 100000 unit/gm..................... 154 nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 154 nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 154 O OA 1 -nutritional supplement powder.............................. 125 OA 2 -nutritional supplement powder.............................. 125 OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg......................................... 108 OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fadha cap 27.5-1-200 mg................................................ 108 OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp glyc-fa-fish cap 50-1-476 mg........................................108 OB COMPLETE PETITE -prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg...................... 108 OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp glyc-fa tab 30-20-1 mg................................................. 108 OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg.................................................................... 108 OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj 500 unit......................................................................... 142 OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg & omega 3 cap 387 mg pak............................................ 108 OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg......................................................................... 108 OBSTETRIX ONE -prenat w/o a w/fecbn-bisg-methylfdss-dha cap 38-1-225 mg............................................ 108 O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 108 OCALIVA -obeticholic acid tab 5 mg................................. 65 OCALIVA -obeticholic acid tab 10 mg............................... 65 O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1 mg.................................................................................. 108 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin)................................................................. 38 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)................................................................. 38 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin)................................................................. 38 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)................................................................. 38 octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin)................................................................. 38 ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg.................................................................... 8 ODOMZO -sonidegib phosphate cap 200 mg (base equivalent)....................................................................... 20 OFEV -nintedanib esylate cap 100 mg (base equivalent)....................................................................... 60 OFEV -nintedanib esylate cap 150 mg (base equivalent)....................................................................... 60 OFLOXACIN -ofloxacin tab 300 mg.................................... 5 ofloxacin ophth soln 0.3% (Ocuflox)........................... 145 ofloxacin otic soln 0.3%................................................147 ofloxacin tab 400 mg......................................................... 5 OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg.................................................................................. 28 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 83 olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)...... 83 olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)...... 83 olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)...................................................................... 83 olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)...................................................................... 83 olanzapine orally disintegrating tab 5 mg (Zyprexa zydis)...............................................................................74 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 204 2017 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis)...............................................................................74 olanzapine orally disintegrating tab 15 mg (Zyprexa zydis)...............................................................................74 olanzapine orally disintegrating tab 20 mg (Zyprexa zydis)...............................................................................74 olanzapine tab 2.5 mg (Zyprexa)................................... 74 olanzapine tab 5 mg (Zyprexa)...................................... 74 olanzapine tab 7.5 mg (Zyprexa)................................... 74 olanzapine tab 10 mg (Zyprexa).................................... 74 olanzapine tab 15 mg (Zyprexa).................................... 75 olanzapine tab 20 mg (Zyprexa).................................... 75 olmesartan medoxomil tab 5 mg (Benicar).................. 48 olmesartan medoxomil tab 20 mg (Benicar)................ 48 olmesartan medoxomil tab 40 mg (Benicar)................ 48 olopatadine hcl nasal soln 0.6% (Patanase).................55 olopatadine hcl ophth soln 0.1% (base equivalent) (Patanol)....................................................................... 145 OLYSIO -simeprevir sodium cap 150 mg (base equivalent)......................................................................... 8 omeprazole cap delayed release 10 mg (Prilosec)...... 62 omeprazole cap delayed release 20 mg (Prilosec)...... 62 omeprazole cap delayed release 40 mg (Prilosec)...... 62 OMNARIS -ciclesonide nasal susp 50 mcg/act................ 55 OMNIFLEX DIAPHRAGM -diaphragms.......................... 156 OMNI GEL -stannous fluoride gel 0.4%.......................... 148 OMNITROPE -somatropin for inj 5.8 mg.......................... 38 OMNITROPE -somatropin inj 5 mg/1.5ml......................... 38 OMNITROPE -somatropin inj 10 mg/1.5ml....................... 38 ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 63 ondansetron hcl tab 24 mg............................................ 63 ondansetron hcl tab 4 mg (Zofran)................................63 ondansetron hcl tab 8 mg (Zofran)................................63 ondansetron orally disintegrating tab 4 mg (Zofran odt).................................................................................. 63 ondansetron orally disintegrating tab 8 mg (Zofran odt).................................................................................. 63 ONFI -clobazam suspension 2.5 mg/ml.......................... 100 ONFI -clobazam tab 10 mg............................................. 100 ONFI -clobazam tab 20 mg............................................. 100 ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 32 ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 32 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 5 mg......................................................... 89 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 7.5 mg...................................................... 89 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 10 mg....................................................... 89 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 15 mg....................................................... 89 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 20 mg....................................................... 89 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 30 mg....................................................... 89 OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab er 12hr deter 40 mg....................................................... 89 OPSUMIT -macitentan tab 10 mg..................................... 54 OPTIMENTAL -nutritional supplement liquid...................125 OPTISOURCE VERY HIGH PROT -nutritional supplement liquid.......................................................... 125 ORALAIR ADULT SAMPLE KIT -grass mixed pollen ext tab sl 300 ir (index of reactivity)..................................... 16 ORALAIR ADULT STARTER PAC -grass mixed pollen ext tab sl 300 ir (index of reactivity)..................................... 16 ORALAIR CHILDREN/ADOLESCE -grass mixed pollen ext tab sl 100 ir (index of reactivity)............................... 16 ORALAIR CHILDREN/ADOLESCE -grass mixed pollen tab sl therpak 100 (3) ir & 300 (6) ir.............................. 16 ORALAIR -grass mixed pollen ext tab sl 300 ir (index of reactivity)......................................................................... 16 ORANGE CHICKEN/CARROTS/BR -nutritional supplement liquid.......................................................... 125 ORAP -pimozide tab 1 mg................................................ 83 ORAP -pimozide tab 2 mg................................................ 83 ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 148 ORENCIA -abatacept subcutaneous soln prefilled syringe 125 mg/ml....................................................................... 94 ORENCIA CLICKJECT -abatacept subcutaneous soln auto-injector 125 mg/ml.................................................. 94 ORENITRAM -treprostinil diolamine tab cr 0.125 mg (base equiv).................................................................... 54 ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base equiv)............................................................................... 54 ORENITRAM -treprostinil diolamine tab cr 1 mg (base equiv)............................................................................... 54 ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base equiv)............................................................................... 54 ORFADIN -nitisinone cap 2 mg......................................... 38 ORFADIN -nitisinone cap 5 mg......................................... 38 ORFADIN -nitisinone cap 10 mg....................................... 38 ORFADIN -nitisinone cap 20 mg....................................... 39 ORFADIN -nitisinone susp 4 mg/ml.................................. 39 ORGANIC PEDIA SMART -nutritional supplement powder........................................................................... 125 ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 60 ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 60 orphenadrine citrate tab sr 12hr 100 mg.................... 104 ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg................................. 28 oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu)............................................................................ 8 oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu)............................................................................ 8 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 205 2017 oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu)............................................................................ 8 OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 32 OSENI -alogliptin-pioglitazone tab 12.5-30 mg................. 32 OSENI -alogliptin-pioglitazone tab 12.5-45 mg................. 32 OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 32 OSENI -alogliptin-pioglitazone tab 25-30 mg.................... 32 OSENI -alogliptin-pioglitazone tab 25-45 mg.................... 32 OSMOLITE 1 CAL -nutritional supplement liquid............126 OSMOLITE 1.2 CAL -nutritional supplement liquid.........126 OSMOLITE 1.5 CAL -nutritional supplement liquid.........126 OSMOLITE HN -nutritional supplement liquid................ 126 OSMOLITE -nutritional supplement liquid....................... 126 OSMOPREP -sod phos mono-sod phos di tabs 1.102-0.398 gm(1.5gm na phos).................................... 61 OS 2 -nutritional supplement powder.............................. 126 OTEZLA -apremilast tab 30 mg........................................ 94 OTEZLA -apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg.................................................................... 94 OTREXUP -methotrexate soln pf auto-injector 7.5 mg/0.4ml.......................................................................... 94 OTREXUP -methotrexate soln pf auto-injector 10mg/0.4ml...................................................................... 94 OTREXUP -methotrexate soln pf auto-injector 12.5 mg/0.4ml.......................................................................... 94 OTREXUP -methotrexate soln pf auto-injector 15mg/0.4ml...................................................................... 94 OTREXUP -methotrexate soln pf auto-injector 17.5 mg/0.4ml.......................................................................... 94 OTREXUP -methotrexate soln pf auto-injector 20mg/0.4ml...................................................................... 94 OTREXUP -methotrexate soln pf auto-injector 22.5 mg/0.4ml.......................................................................... 94 OTREXUP -methotrexate soln pf auto-injector 25mg/0.4ml...................................................................... 94 oxandrolone tab 2.5 mg (Oxandrin).............................. 24 oxandrolone tab 10 mg (Oxandrin)............................... 24 oxaprozin tab 600 mg (Daypro)..................................... 94 OXAYDO -oxycodone hcl tab abuse deter 5 mg.............. 89 OXAYDO -oxycodone hcl tab abuse deter 7.5 mg............89 oxazepam cap 10 mg...................................................... 69 oxazepam cap 15 mg...................................................... 69 oxazepam cap 30 mg...................................................... 69 oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)...................................................................... 100 oxcarbazepine tab 150 mg (Trileptal).......................... 100 oxcarbazepine tab 300 mg (Trileptal).......................... 100 oxcarbazepine tab 600 mg (Trileptal).......................... 100 OXEPA -nutritional supplement liquid............................. 126 OXEPA 1.5 -nutritional supplement liquid....................... 126 oxiconazole nitrate cream 1% (Oxistat)...................... 154 OXISTAT -oxiconazole nitrate cream 1%........................ 154 OXISTAT -oxiconazole nitrate lotion 1%......................... 154 OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg...... 100 OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg...... 100 OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg...... 100 oxybutynin chloride syrup 5 mg/5ml............................ 66 oxybutynin chloride tab 5 mg........................................ 66 oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 66 oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl)..................................................................................... 66 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl)..................................................................................... 66 OXYCODONE/ACETAMINOPHEN -oxycodone w/ acetaminophen soln 5-325 mg/5ml................................ 90 OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab 5-400 mg......................................................................... 90 oxycodone-aspirin tab 4.8355-325 mg (Percodan)...... 90 oxycodone hcl cap 5 mg................................................ 89 oxycodone hcl conc 100 mg/5ml (20 mg/ml) (Oxycodone hcl)............................................................ 89 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 10 mg.............................................................................. 89 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 15 mg.............................................................................. 89 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 20 mg.............................................................................. 89 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 30 mg.............................................................................. 90 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 40 mg.............................................................................. 90 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 60 mg.............................................................................. 90 OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter 80 mg.............................................................................. 90 oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)...........90 oxycodone hcl tab 10 mg............................................... 90 oxycodone hcl tab 20 mg............................................... 90 oxycodone hcl tab 5 mg (Roxicodone)......................... 90 oxycodone hcl tab 15 mg (Roxicodone)....................... 90 oxycodone hcl tab 30 mg (Roxicodone)....................... 90 oxycodone w/ acetaminophen tab 2.5-325 mg (Percocet)....................................................................... 90 oxycodone w/ acetaminophen tab 5-325 mg (Percocet)....................................................................... 90 oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)....................................................................... 90 oxycodone w/ acetaminophen tab 10-325 mg (Percocet)....................................................................... 90 OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg..... 90 OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg..... 90 OXYCONTIN -oxycodone hcl tab er 12hr deter 20 mg..... 90 OXYCONTIN -oxycodone hcl tab er 12hr deter 30 mg..... 90 OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg..... 90 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 206 2017 OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg..... 90 OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg..... 90 oxymorphone hcl tab 5 mg (Opana)..............................90 oxymorphone hcl tab 10 mg (Opana)............................90 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 5 mg............................................................. 90 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 7.5 mg.......................................................... 90 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 10 mg........................................................... 90 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 15 mg........................................................... 91 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 20 mg........................................................... 91 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 30 mg........................................................... 91 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl tab sr 12hr 40 mg........................................................... 91 P paliperidone tab sr 24hr 1.5 mg (Invega)...................... 75 paliperidone tab sr 24hr 3 mg (Invega)......................... 75 paliperidone tab sr 24hr 6 mg (Invega)......................... 75 paliperidone tab sr 24hr 9 mg (Invega)......................... 75 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 2600-6200-10850 unit.....................................................63 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 4200-14200-24600 unit...................................................63 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 10500-35500-61500 unit................................................ 63 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 16800-56800-98400 unit................................................ 63 PANCREAZE -pancrelipase (lip-prot-amyl) dr cap 21000-54700-83900 unit................................................ 63 PANRETIN -alitretinoin gel 0.1%..................................... 154 pantoprazole sodium ec tab 20 mg (base equiv) (Protonix)........................................................................62 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)........................................................................62 PARAGARD INTRAUTERINE COP -copper iud............... 28 paricalcitol cap 1 mcg (Zemplar)................................... 39 paricalcitol cap 2 mcg (Zemplar)................................... 39 paricalcitol cap 4 mcg (Zemplar)................................... 39 PARODONTAX -stannous fluoride paste 0.454%........... 148 paromomycin sulfate cap 250 mg................................... 5 paroxetine hcl tab 10 mg (Paxil).................................... 71 paroxetine hcl tab 20 mg (Paxil).................................... 71 paroxetine hcl tab 30 mg (Paxil).................................... 71 paroxetine hcl tab 40 mg (Paxil).................................... 71 paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 71 PASER -aminosalicylic acid cr granules packet 4 gm.........5 PATADAY -olopatadine hcl ophth soln 0.2% (base equivalent)..................................................................... 145 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............................................. 61 PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj.............................................................................. 16 PEDIASURE 1.0 CAL/FIBER -nutritional supplement liquid.............................................................................. 126 PEDIASURE 1.5 CAL/FIBER -nutritional supplement liquid.............................................................................. 126 PEDIASURE 1.5 CAL -nutritional supplement liquid...... 126 PEDIASURE 1.5 CAL WITH FI -nutritional supplement liquid.............................................................................. 126 PEDIASURE ENTERAL FORMULA -nutritional supplement liquid.......................................................... 126 PEDIASURE GROW & GAIN -nutritional supplement liquid.............................................................................. 126 PEDIASURE NUTRIPALS -nutritional supplement bar.................................................................................. 126 PEDIASURE NUTRIPALS -nutritional supplement liquid.............................................................................. 126 PEDIASURE -nutritional supplement liquid.................... 126 PEDIASURE PEDIATRIC -nutritional supplement liquid.............................................................................. 126 PEDIASURE PEPTIDE 1.0 CAL -nutritional supplement liquid.............................................................................. 126 PEDIASURE PEPTIDE 1.5 CAL -nutritional supplement liquid.............................................................................. 126 PEDIASURE SHAKE MIX -nutritional supplement powder........................................................................... 126 PEDIASURE SHAKE WITH FIBE -nutritional supplement liquid.............................................................................. 126 PEDIASURE SIDEKICKS CLEAR -nutritional supplement liquid.............................................................................. 126 PEDIASURE SIDEKICKS -nutritional supplement liquid.............................................................................. 126 PEDIASURE SIDEKICKS -nutritional supplement powder........................................................................... 126 PEDIASURE SIDEKICKS SHAKE -nutritional supplement liquid.............................................................................. 126 PEDIASURE WITH FIBER -nutritional supplement liquid.............................................................................. 126 PEDIATRIC DRINK -nutritional supplement liquid.......... 126 PEDIATRIC PEPTINEX DT/FIB -nutritional supplement liquid.............................................................................. 126 PEDIATRIC PEPTINEX DT -nutritional supplement liquid.............................................................................. 126 PEGANONE -ethotoin tab 250 mg.................................. 100 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 207 2017 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.....................................................................8 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)............................................. 61 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)................................................................. 61 peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)................................................... 61 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 PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp............................................................... 16 PENTASA -mesalamine cap cr 250 mg............................ 65 PENTASA -mesalamine cap cr 500 mg............................ 65 pentoxifylline tab cr 400 mg......................................... 142 PEPDITE JUNIOR -nutritional supplement pack............ 126 PEPTAMEN/PREBIO1 -nutritional supplement liquid..... 127 PEPTAMEN AF -nutritional supplement liquid................ 126 PEPTAMEN BARIATRIC -nutritional supplement liquid.............................................................................. 127 PEPTAMEN 1 CAL/PREBIO1 -nutritional supplement liquid.............................................................................. 127 PEPTAMEN 1.5 CAL/PREBIO1 -nutritional supplement liquid.............................................................................. 127 PEPTAMEN 1 CAL -nutritional supplement liquid...........127 PEPTAMEN 1.5 CAL -nutritional supplement liquid........127 PEPTAMEN INTENSE VHP -nutritional supplement liquid.............................................................................. 127 PEPTAMEN JUNIOR/PREBIO1 -nutritional supplement liquid.............................................................................. 127 PEPTAMEN JUNIOR 1 CAL/PRE -nutritional supplement liquid.............................................................................. 127 PEPTAMEN JUNIOR 1 CAL -nutritional supplement liquid.............................................................................. 127 PEPTAMEN JUNIOR 1.5 CAL -nutritional supplement liquid.............................................................................. 127 PEPTAMEN JUNIOR FIBER -nutritional supplement liquid.............................................................................. 127 PEPTAMEN JUNIOR HP -nutritional supplement liquid.............................................................................. 127 PEPTAMEN JUNIOR -nutritional supplement liquid....... 127 PEPTAMEN JUNIOR -nutritional supplement powder........................................................................... 127 PEPTAMEN -nutritional supplement liquid...................... 126 PEPTAMEN 1.5 -nutritional supplement liquid................ 127 PEPTAMEN OS -nutritional supplement liquid............... 127 PEPTAMEN OS 1.5 -nutritional supplement liquid......... 127 PEPTAMEN VHP -nutritional supplement liquid............. 127 PEPTINEX DT -nutritional supplement liquid..................127 PEPTINEX DT WITH PREBIOTI -nutritional supplement liquid.............................................................................. 127 PEPTINEX 1.0 -nutritional supplement liquid................. 127 PEPTINEX 1.5 -nutritional supplement liquid................. 127 PERATIVE -nutritional supplement liquid........................ 127 PERFOROMIST -formoterol fumarate soln nebu 20 mcg/2ml........................................................................... 59 PERIFLEX ADVANCE -nutritional supplement powder........................................................................... 127 PERIFLEX JUNIOR -nutritional supplement powder...... 127 PERIFLEX LQ PKU -amino acids oral liquid.................. 115 perindopril erbumine tab 2 mg...................................... 48 perindopril erbumine tab 4 mg (Aceon)........................ 48 perindopril erbumine tab 8 mg (Aceon)........................ 48 permethrin cream 5% (Elimite).................................... 154 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................ 83 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................ 83 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................ 84 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................ 84 PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................ 84 perphenazine tab 2 mg................................................... 75 perphenazine tab 4 mg................................................... 75 perphenazine tab 8 mg................................................... 75 perphenazine tab 16 mg................................................. 75 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 4000-14375-15125 unit...................................................63 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 208 2017 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit...................................................63 PERTZYE -pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500 unit................................................ 63 PFD 1 -nutritional supplement powder............................ 127 PFD 2 -nutritional supplement powder............................ 127 PHENACTIN AA PLUS -nutritional supplement liquid.............................................................................. 127 phenelzine sulfate tab 15 mg (Nardil)........................... 71 PHENEX-1 -nutritional supplement powder.................... 127 PHENEX-2 -nutritional supplement powder.................... 127 phenobarbital elixir 20 mg/5ml...................................... 77 PHENOBARBITAL -phenobarbital tab 15 mg................... 76 PHENOBARBITAL -phenobarbital tab 30 mg................... 77 PHENOBARBITAL -phenobarbital tab 60 mg................... 77 PHENOBARBITAL -phenobarbital tab 100 mg................. 77 phenobarbital tab 16.2 mg.............................................. 77 phenobarbital tab 32.4 mg.............................................. 77 phenobarbital tab 64.8 mg.............................................. 77 phenobarbital tab 97.2 mg.............................................. 77 phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 48 PHENYLADE AMINO ACID -amino acids bar................ 115 PHENYLADE AMINO ACID BLEN -amino acids pack............................................................................... 115 PHENYLADE -amino acids oral powder......................... 115 PHENYLADE40 DRINK MIX -amino acids pack.............115 PHENYLADE60 DRINK MIX -nutritional supplement pack............................................................................... 128 PHENYLADE DRINK MIX -nutritional supplement powder........................................................................... 128 PHENYLADE60 DRINK MIX -nutritional supplement powder........................................................................... 128 PHENYLADE ESSENTIAL DRINK -nutritional supplement pack............................................................................... 128 PHENYLADE ESSENTIAL DRINK -nutritional supplement powder........................................................................... 128 PHENYLADE GMP MIX-IN -nutritional supplement pack............................................................................... 128 PHENYLADE GMP -nutritional supplement pack........... 128 PHENYLADE GMP -nutritional supplement powder....... 128 PHENYLADE MTE AMINO ACID -amino acids pack..... 115 PHENYLADE MTE -amino acids oral powder................ 115 PHENYLADE PHEBLOC -amino acids oral powder....... 115 PHENYLADE PHEBLOC -amino acids tab..................... 115 PHENYLADE RTD PKU 10 -nutritional supplement liquid.............................................................................. 128 phenylephrine hcl ophth soln 2.5%............................. 145 phenylephrine hcl ophth soln 10%.............................. 146 PHENYL-FREE 2HP -nutritional supplement powder........................................................................... 127 PHENYL-FREE 2 -nutritional supplement powder..........127 PHENYLHISTINE DH -pseudoephedrine-chlorphen w/ codeine liq 30-2-10 mg/5ml............................................ 56 PHENYTEK -phenytoin sodium extended cap 200 mg.................................................................................. 100 PHENYTEK -phenytoin sodium extended cap 300 mg.................................................................................. 100 phenytoin chew tab 50 mg (Dilantin infatabs)............100 phenytoin sodium extended cap 100 mg (Dilantin)....................................................................... 100 phenytoin sodium extended cap 200 mg (Phenytek).................................................................... 100 phenytoin sodium extended cap 300 mg (Phenytek).................................................................... 100 phenytoin susp 125 mg/5ml (Dilantin)........................ 100 PHLEXY-10 -amino acids cap......................................... 115 PHLEXY-10 -nutritional supplement pack....................... 128 PHLEXY-VITS -multiple vitamins w/ minerals powder........................................................................... 108 PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse 0.044%.......................................................................... 148 PHOS FLUR -sodium fluoride rinse 0.044%................... 148 PHOSLYRA -calcium acetate (phosphate binder) oral soln 667 mg/5ml..................................................................... 65 PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/ ml & lidocaine 1% & ammonia inh kit............................ 23 PHYTOFUSION -nutritional supplement pack................ 128 phytonadione inj 1 mg/0.5ml (2 mg/ml).......................105 PICATO -ingenol mebutate gel 0.015%.......................... 154 PICATO -ingenol mebutate gel 0.05%............................ 154 pilocarpine hcl ophth soln 1% (Isopto carpine)......... 146 pilocarpine hcl ophth soln 2% (Isopto carpine)......... 146 pilocarpine hcl ophth soln 4% (Isopto carpine)......... 146 pilocarpine hcl tab 5 mg (Salagen)..............................148 pilocarpine hcl tab 7.5 mg (Salagen)...........................148 pimozide tab 1 mg (Orap)............................................... 84 pimozide tab 2 mg (Orap)............................................... 84 pindolol tab 5 mg............................................................. 42 pindolol tab 10 mg........................................................... 42 pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus met)............................................................... 32 pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus met)............................................................... 32 pioglitazone hcl tab 15 mg (base equiv) (Actos)..........32 pioglitazone hcl tab 30 mg (base equiv) (Actos)..........32 pioglitazone hcl tab 45 mg (base equiv) (Actos)..........32 piroxicam cap 10 mg (Feldene)..................................... 94 piroxicam cap 20 mg (Feldene)..................................... 94 PIVOT 1.5 CAL -nutritional supplement liquid................ 128 PKU COOLER 10 -nutritional supplement liquid.............128 PKU COOLER 15 -nutritional supplement liquid.............128 PKU COOLER 20 -nutritional supplement liquid.............128 PKU EXPRESS -nutritional supplement pack.................128 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 209 2017 PKU EXPRESS20 -nutritional supplement pack.............128 PKU GEL -nutritional supplement pack.......................... 128 PKU LOPHLEX LQ 20 -nutritional supplement liquid..... 128 PKU 2 -nutritional supplement powder........................... 128 PKU 3 -nutritional supplement powder........................... 128 PKU PERIFLEX EARLY YEARS -nutritional supplement powder........................................................................... 128 PKU PERIFLEX JUNIOR PLUS -nutritional supplement powder........................................................................... 128 PKU SPHERE 20 -nutritional supplement pack.............. 128 PKU TRIO -nutritional supplement powder..................... 128 PLEGRIDY -peginterferon beta-1a soln pen-injector 125 mcg/0.5ml........................................................................ 84 PLEGRIDY -peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml................................................................ 84 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack.................................... 84 PLEGRIDY STARTER PACK -peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack................................... 84 PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 154 PNEUMOVAX 23/1 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................ 15 PNEUMOVAX 23/5 DOSE -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml............................................ 15 PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj 25 mcg/0.5ml.................................................................. 15 PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg.......................................... 108 PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg........................................................ 108 PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dssfe fumarate-fa tab 29-1 mg.......................................... 108 PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mg pack...................................................108 PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 108 PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe fumarate-fa tab 27-1 mg...............................................108 PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg................................................................ 108 PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 108 PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap 35-5-1.2 mg................................................................... 109 PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg.................................................................... 109 podofilox soln 0.5% (Condylox)................................... 154 POLYCAL -nutritional supplement powder......................128 polyethylene glycol 3350 oral packet............................ 61 polyethylene glycol 3350 oral powder.......................... 61 polymyxin b-trimethoprim ophth soln 10000 unit/ ml-0.1% (Polytrim)...................................................... 146 POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine liquid 10-4-10 mg/5ml..................................................... 56 POMALYST -pomalidomide cap 1 mg.............................. 20 POMALYST -pomalidomide cap 2 mg.............................. 20 POMALYST -pomalidomide cap 3 mg.............................. 20 POMALYST -pomalidomide cap 4 mg.............................. 20 PORTAGEN -nutritional supplement powder.................. 128 potassium chloride cap cr 8 meq (Micro-k)................ 114 potassium chloride cap cr 10 meq (Micro-k).............. 114 POTASSIUM CHLORIDE ER -potassium chloride tab cr 8 meq (600 mg)............................................................... 114 POTASSIUM CHLORIDE ER -potassium chloride tab cr 20 meq (1500 mg)........................................................ 114 potassium chloride microencapsulated crys cr tab 10 meq............................................................................... 114 potassium chloride microencapsulated crys cr tab 20 meq............................................................................... 114 potassium chloride oral soln 10% (20 meq/15ml)...... 114 POTASSIUM CHLORIDE -potassium chloride oral soln 20% (40 meq/15ml)...................................................... 114 potassium chloride powder packet 20 meq............... 114 potassium chloride tab cr 10 meq (K-tab).................. 114 potassium chloride tab cr 8 meq (600 mg)................. 114 potassium citrate tab cr 5 meq (540 mg) (Urocit-k 5)...................................................................................... 68 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10).................................................................................... 68 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15).................................................................................... 68 POTIGA -ezogabine tab 50 mg....................................... 100 POTIGA -ezogabine tab 200 mg..................................... 100 POTIGA -ezogabine tab 300 mg..................................... 100 POTIGA -ezogabine tab 400 mg..................................... 100 PPA/MMA EXPRESS -nutritional supplement pack........ 128 PRADAXA -dabigatran etexilate mesylate cap 75 mg (etexilate base eq)........................................................ 136 PRADAXA -dabigatran etexilate mesylate cap 110 mg (etexilate base eq)........................................................ 136 PRADAXA -dabigatran etexilate mesylate cap 150 mg (etexilate base eq)........................................................ 136 PRALUENT -alirocumab subcutaneous soln pen-injector 75 mg/ml......................................................................... 53 PRALUENT -alirocumab subcutaneous soln pen-injector 150 mg/ml....................................................................... 53 pramipexole dihydrochloride tab 0.125 mg (Mirapex).......................................................................103 pramipexole dihydrochloride tab 0.25 mg (Mirapex).......................................................................103 pramipexole dihydrochloride tab 0.5 mg (Mirapex).......................................................................103 pramipexole dihydrochloride tab 0.75 mg (Mirapex).......................................................................103 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 210 2017 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 103 pramipexole dihydrochloride tab 1.5 mg (Mirapex).......................................................................103 pramipexole dihydrochloride tab sr 24hr 0.375 mg (Mirapex er).................................................................. 102 pramipexole dihydrochloride tab sr 24hr 0.75 mg (Mirapex er).................................................................. 103 pramipexole dihydrochloride tab sr 24hr 1.5 mg (Mirapex er).................................................................. 103 pramipexole dihydrochloride tab sr 24hr 2.25 mg (Mirapex er).................................................................. 103 pramipexole dihydrochloride tab sr 24hr 3 mg (Mirapex er).................................................................. 103 pramipexole dihydrochloride tab sr 24hr 3.75 mg (Mirapex er).................................................................. 103 pramipexole dihydrochloride tab sr 24hr 4.5 mg (Mirapex er).................................................................. 103 pravastatin sodium tab 10 mg....................................... 53 pravastatin sodium tab 20 mg (Pravachol)...................53 pravastatin sodium tab 40 mg (Pravachol)...................53 pravastatin sodium tab 80 mg (Pravachol)...................53 prazosin hcl cap 1 mg (Minipress)................................ 48 prazosin hcl cap 2 mg (Minipress)................................ 48 prazosin hcl cap 5 mg (Minipress)................................ 48 PRED-G -gentamicin-prednisolone ace ophth susp 0.3-1%........................................................................... 146 PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint 0.3-0.6%........................................................................ 146 PRED MILD -prednisolone acetate ophth susp 0.12%.............................................................................146 prednicarbate cream 0.1% (Dermatop)....................... 154 prednicarbate oint 0.1% (Dermatop)........................... 154 prednisolone acetate ophth susp 1% (Pred forte)..... 146 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate ophth soln 1%................................ 146 PREDNISOLONE SODIUM PHOSP -prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)......... 23 prednisolone sod phos orally disintegr tab 10 mg (base eq) (Orapred odt)............................................... 23 prednisolone sod phos orally disintegr tab 15 mg (base eq) (Orapred odt)............................................... 23 prednisolone sod phos orally disintegr tab 30 mg (base eq) (Orapred odt)............................................... 23 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)................................................................... 23 prednisolone sod phosphate oral soln 10 mg/5ml (base equiv) (Millipred)................................................ 23 prednisolone sod phosphate oral soln 20 mg/5ml (base equiv) (Veripred 20)........................................... 23 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred)............................................23 prednisolone syrup 15 mg/5ml (usp solution equivalent) (Prelone).................................................... 23 PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 23 PREDNISONE -prednisone oral soln 5 mg/5ml................ 23 PREDNISONE -prednisone tab 50 mg............................. 23 PREDNISONE -prednisone tab therapy pack 5 mg (21).................................................................................. 23 PREDNISONE -prednisone tab therapy pack 5 mg (48).................................................................................. 23 PREDNISONE -prednisone tab therapy pack 10 mg (21).................................................................................. 23 PREDNISONE -prednisone tab therapy pack 10 mg (48).................................................................................. 23 prednisone tab 1 mg....................................................... 23 prednisone tab 2.5 mg.................................................... 23 prednisone tab 5 mg....................................................... 23 prednisone tab 10 mg..................................................... 23 prednisone tab 20 mg..................................................... 23 PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme poly-fa tab&dha cap pack.............................................109 PREFERAOB ONE -prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg............................................109 PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa tab 34-1 mg...................................................................109 PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15)............................................................ 26 PREMARIN -estrogens, conjugated tab 0.3 mg............... 26 PREMARIN -estrogens, conjugated tab 0.45 mg............. 26 PREMARIN -estrogens, conjugated tab 0.625 mg........... 26 PREMARIN -estrogens, conjugated tab 0.9 mg............... 26 PREMARIN -estrogens, conjugated tab 1.25 mg............. 26 PREMARIN -estrogens, conjugated vaginal cream 0.625 mg/gm.............................................................................. 67 PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14).......................................................... 26 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg................................................... 26 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.45-1.5 mg................................................. 26 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-2.5 mg............................................... 26 PREMPRO -conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg.................................................. 26 PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg..................................................................... 110 PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg........................................ 109 PRENAISSANCE HARMONY DHA -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 380mg....................109 PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg....................................................... 109 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 211 2017 PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 109 PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg................................................... 109 PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg..................................................... 109 PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg................................................... 110 PRENATABS FA -prenatal vit w/ fe fumarate-fa tab 29-1 mg.................................................................................. 109 PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 109 PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa tab 29-1 mg...................................................................109 PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 109 PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................. 109 PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab 29-1 mg......................................................................... 109 PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 109 PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap 106.5-1 mg.................................................................... 109 PRENATAL VITAMINS PLUS LO -prenatal vit w/ fe fumarate-fa tab 27-1 mg...............................................109 PRENATE AM -prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg............................................................ 109 PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg................................................. 110 PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-300 mg........................................................ 110 PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa tab 26-0.6-0.4 mg......................................................... 110 PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab 20-0.6-0.4 mg................................................................ 110 PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg.......................................... 110 PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg..................................... 110 PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg....................................... 110 PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha cap 18-0.6-0.4-350 mg................................................. 110 PRENATE MINI -prenat w/o a w/fecbn-methylf-fa-dha cap 29-0.6-0.4-350 mg........................................................ 110 PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha cap 10-0.6-0.4-200 mg................................................. 110 PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab 0.6-0.4 mg..................................................................... 109 PRENATE RESTORE -prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg.......................................... 110 PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa tab 20-1 mg...................................................................110 PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............37 PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 110 PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10 mg-3.5 gm-12 gm........................................................... 61 PREPROTEIN -amino acids oral liquid........................... 115 PREPROTEIN 20 -amino acids oral liquid...................... 115 PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg...... 110 PREVIDENT 5000 BOOSTER PL -sodium fluoride paste 1.1%...............................................................................148 PREVIDENT 5000 BOOSTER -sodium fluoride paste 1.1%...............................................................................148 PREVIDENT 5000 DRY MOUTH -sodium fluoride gel 1.1% (0.5% f)................................................................ 148 PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%................................... 149 PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5% f)..................................................................................... 148 PREVIDENT 5000 PLUS -sodium fluoride cream 1.1%...............................................................................149 PREVIDENT 5000 SENSITIVE -sodium fluoridepotassium nitrate paste 1.1-5%................................... 149 PREVNAR 13 -pneumococcal 13-valent conjugate vaccine inj....................................................................... 15 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........................................................................... 12 primidone tab 50 mg (Mysoline).................................. 100 primidone tab 250 mg (Mysoline)................................ 100 PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base equiv)............................................................................... 12 PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg (base equiv).................................................................... 71 PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg (base equiv).................................................................... 71 PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg (base equiv).................................................................... 71 PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 400 pk................................................... 109 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 212 2017 PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab & omega cap dr 430 pk................................................... 109 PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk.................................................... 109 PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 430 pk.................................................... 109 PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)........................................................ 59 PROAIR RESPICLICK -albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv)......................................... 59 PROBALANCE -nutritional supplement liquid................. 128 probenecid tab 500 mg................................................... 96 PRO-CAL -nutritional supplement pack.......................... 128 PRO-CAL -nutritional supplement powder...................... 128 prochlorperazine maleate tab 5 mg (Compazine)........ 75 prochlorperazine maleate tab 10 mg (Compazine)...... 75 prochlorperazine suppos 25 mg.................................... 75 PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33 mg/5ml............................................................................. 56 PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 135 PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 135 PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 135 PROCRIT -epoetin alfa inj 10000 unit/ml........................ 135 PROCRIT -epoetin alfa inj 20000 unit/ml........................ 135 PROCRIT -epoetin alfa inj 40000 unit/ml........................ 135 PROCTOFOAM HC -hydrocortisone acetate w/ pramoxine rectal foam 1-1%........................................ 149 PROCYSBI -cysteamine bitartrate cap delayed release 25 mg (base equiv).............................................................. 68 PROCYSBI -cysteamine bitartrate cap delayed release 75 mg (base equiv).............................................................. 68 PROFILNINE -factor ix complex for inj 500 unit............. 142 PROFILNINE -factor ix complex for inj 1000 unit........... 142 PROFILNINE -factor ix complex for inj 1500 unit........... 142 PROFILNINE SD -factor ix complex for inj 500 unit........142 PROFILNINE SD -factor ix complex for inj 1000 unit......142 PROFILNINE SD -factor ix complex for inj 1500 unit......142 progesterone im in oil 50 mg/ml.................................... 29 progesterone micronized cap 100 mg (Prometrium).................................................................. 29 progesterone micronized cap 200 mg (Prometrium).................................................................. 29 PROGLYCEM -diazoxide susp 50 mg/ml......................... 32 PROGRAF -tacrolimus cap 0.5 mg................................. 158 PROGRAF -tacrolimus cap 1 mg.................................... 158 PROGRAF -tacrolimus cap 5 mg.................................... 158 PROLENSA -bromfenac sodium ophth soln 0.07% (base equivalent)..................................................................... 146 PROMACTA -eltrombopag olamine tab 12.5 mg (base equiv)............................................................................. 135 PROMACTA -eltrombopag olamine tab 25 mg (base equiv)............................................................................. 135 PROMACTA -eltrombopag olamine tab 50 mg (base equiv)............................................................................. 135 PROMACTA -eltrombopag olamine tab 75 mg (base equiv)............................................................................. 135 PROMACTIN AA PLUS -nutritional supplement liquid.............................................................................. 128 promethazine & phenylephrine syrup 6.25-5 mg/5ml............................................................................ 56 promethazine-dm syrup 6.25-15 mg/5ml.......................56 promethazine hcl suppos 12.5 mg................................ 55 promethazine hcl suppos 25 mg................................... 55 promethazine hcl suppos 50 mg................................... 55 promethazine hcl syrup 6.25 mg/5ml............................ 55 promethazine hcl tab 12.5 mg........................................ 55 promethazine hcl tab 25 mg........................................... 55 promethazine hcl tab 50 mg........................................... 55 promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5ml............................................................................ 56 promethazine w/ codeine syrup 6.25-10 mg/5ml..........56 PROMOD -nutritional supplement liquid......................... 128 PROMOD -nutritional supplement powder...................... 128 PROMOTE/FIBER -nutritional supplement liquid........... 129 PROMOTE -nutritional supplement liquid....................... 129 PROMOTE 1.0 -nutritional supplement liquid................. 129 PROMOTE WITH FIBER -nutritional supplement liquid.............................................................................. 129 PROMOTE 1.0 WITH FIBER -nutritional supplement liquid.............................................................................. 129 propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 44 propafenone hcl cap sr 12hr 325 mg (Rythmol sr)...... 44 propafenone hcl cap sr 12hr 425 mg (Rythmol sr)...... 45 propafenone hcl tab 300 mg.......................................... 45 propafenone hcl tab 150 mg (Rythmol)........................ 45 propafenone hcl tab 225 mg (Rythmol)........................ 45 PROPANTHELINE BROMIDE -propantheline bromide tab 15 mg.............................................................................. 62 proparacaine hcl ophth soln 0.5% (Alcaine).............. 146 PRO-PHREE -nutritional supplement powder................ 128 PROPIMEX-1 -nutritional supplement powder................ 129 PROPIMEX-2 -nutritional supplement powder................ 129 propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 42 propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 42 propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 42 propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 42 propranolol hcl tab 10 mg.............................................. 42 propranolol hcl tab 20 mg.............................................. 42 propranolol hcl tab 40 mg.............................................. 42 propranolol hcl tab 60 mg.............................................. 42 propranolol hcl tab 80 mg.............................................. 42 propylthiouracil tab 50 mg............................................. 36 PRO-RED AC -phenylephrine-dexchlorphenir-codeine syrup 5-1-9 mg/5ml.........................................................56 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 213 2017 PROSOURCE NO CARB -nutritional supplement liquid.............................................................................. 129 PROSOURCE -nutritional supplement liquid.................. 129 PROSOURCE -nutritional supplement powder............... 129 PROSOURCE PLUS -nutritional supplement liquid........129 PROSOURCE TF -nutritional supplement liquid.............129 PROSOURCE ZAC -nutritional supplement liquid.......... 129 PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 37 PROSURE -nutritional supplement liquid........................129 PROTAIN XL -nutritional supplement liquid.................... 129 PROTEIN FORTIFIED COOKIE -nutritional supplement misc............................................................................... 129 protriptyline hcl tab 5 mg (Vivactil)............................... 72 protriptyline hcl tab 10 mg (Vivactil)............................. 72 PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap 16-16-1.25-110 mg........................................................110 PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap 20-20-1.25 mg...............................................................110 PROVIMIN -nutritional supplement powder.................... 129 PRUDOXIN -doxepin hcl cream 5%............................... 154 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml (Zutripro).......................................................... 56 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml............................................................................ 56 pseudoephedrine-bromphen-codeine liq 10-1.33-6.33 mg/5ml............................................................................ 57 pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml............................................................................ 56 PULMOCARE -nutritional supplement liquid.................. 129 PULMOCARE 1.5 -nutritional supplement liquid............ 129 PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 60 PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa cap 162.115.2-1 mg...................................................... 110 PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/ ml).................................................................................... 20 PX VANILLA PLUS -nutritional supplement liquid.......... 129 pyrazinamide tab 500 mg..................................................5 pyridostigmine bromide tab cr 180 mg (Mestinon timespan)......................................................................105 pyridostigmine bromide tab 60 mg (Mestinon).......... 105 Q 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 ð est 0.01 mg...................................................... 28 QUAZEPAM -quazepam tab 15 mg.................................. 77 QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg.................................................................................. 100 QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg.................................................................................. 100 QUDEXY XR -topiramate cap er 24hr sprinkle 100 mg.................................................................................. 100 QUDEXY XR -topiramate cap er 24hr sprinkle 150 mg.................................................................................. 100 QUDEXY XR -topiramate cap er 24hr sprinkle 200 mg.................................................................................. 100 QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr 24hr 50 mg......................................................................75 QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr 24hr 150 mg....................................................................75 QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr 24hr 200 mg....................................................................75 QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr 24hr 300 mg....................................................................75 quetiapine fumarate tab 25 mg (Seroquel)................... 75 quetiapine fumarate tab 50 mg (Seroquel)................... 75 quetiapine fumarate tab 100 mg (Seroquel)................. 75 quetiapine fumarate tab 200 mg (Seroquel)................. 75 quetiapine fumarate tab 300 mg (Seroquel)................. 75 quetiapine fumarate tab 400 mg (Seroquel)................. 75 quetiapine fumarate tab sr 24hr 400 mg (Seroquel xr).................................................................................... 75 quinapril hcl tab 5 mg (Accupril)................................... 48 quinapril hcl tab 10 mg (Accupril)................................. 48 quinapril hcl tab 20 mg (Accupril)................................. 48 quinapril hcl tab 40 mg (Accupril)................................. 48 quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic)...................................................................... 48 quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic)...................................................................... 48 quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic)...................................................................... 49 quinidine gluconate tab cr 324 mg................................ 45 QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 45 QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 45 quinine sulfate cap 324 mg (Qualaquin)....................... 12 QUINOA KALE & HEMP -nutritional supplement liquid.............................................................................. 129 QVAR -beclomethasone diprop inhal aero soln 40 mcg/act (50/valve)......................................................................... 59 QVAR -beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)....................................................................... 59 R RA BALANCED NUTRITIONAL -nutritional supplement liquid.............................................................................. 129 RA BALANCED NUTRITIONAL P -nutritional supplement liquid.............................................................................. 129 RABAVERT -rabies vaccine, pcec for inj.......................... 15 rabeprazole sodium ec tab 20 mg (Aciphex)................ 62 RADIOGARDASE -prussian blue insoluble cap 0.5 gm.................................................................................. 156 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 214 2017 RAGWITEK -short ragweed pollen allergen extract tab sl 12 amb a 1-u.................................................................. 16 raloxifene hcl tab 60 mg (Evista)................................... 39 ramipril cap 1.25 mg (Altace)......................................... 49 ramipril cap 2.5 mg (Altace)........................................... 49 ramipril cap 5 mg (Altace).............................................. 49 ramipril cap 10 mg (Altace)............................................ 49 RANEXA -ranolazine tab sr 12hr 500 mg......................... 41 RANEXA -ranolazine tab sr 12hr 1000 mg....................... 41 ranitidine hcl cap 150 mg............................................... 62 ranitidine hcl cap 300 mg............................................... 62 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 62 ranitidine hcl tab 300 mg (Zantac)................................. 62 RA NUTRITIONAL SUPPLEMENT -nutritional supplement liquid.......................................................... 129 RA NUTRITIONAL SUPPORT -nutritional supplement powder........................................................................... 129 RAPAFLO -silodosin cap 4 mg..........................................68 RAPAFLO -silodosin cap 8 mg..........................................68 RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 158 RA PEDIATRIC NUTRITIONAL -nutritional supplement liquid.............................................................................. 129 rasagiline mesylate tab 0.5 mg (base equiv) (Azilect).........................................................................103 rasagiline mesylate tab 1 mg (base equiv) (Azilect).........................................................................103 RASUVO -methotrexate soln pf auto-injector 7.5 mg/0.15ml........................................................................ 94 RASUVO -methotrexate soln pf auto-injector 10 mg/0.2ml.......................................................................... 94 RASUVO -methotrexate soln pf auto-injector 12.5 mg/0.25ml........................................................................ 94 RASUVO -methotrexate soln pf auto-injector 15 mg/0.3ml.......................................................................... 94 RASUVO -methotrexate soln pf auto-injector 17.5 mg/0.35ml........................................................................ 94 RASUVO -methotrexate soln pf auto-injector 20 mg/0.4ml.......................................................................... 94 RASUVO -methotrexate soln pf auto-injector 22.5 mg/0.45ml........................................................................ 94 RASUVO -methotrexate soln pf auto-injector 25 mg/0.5ml.......................................................................... 95 RASUVO -methotrexate soln pf auto-injector 27.5 mg/0.55ml........................................................................ 95 RASUVO -methotrexate soln pf auto-injector 30 mg/0.6ml.......................................................................... 95 RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........39 RE/GEN PROTEIN FORTIFIED -nutritional supplement misc............................................................................... 129 RE/NEPH HP/HC -nutritional supplement liquid (frozen).......................................................................... 129 RE/NEPH LP/HC -nutritional supplement liquid..............129 RE/NEPH -nutritional supplement liquid......................... 129 RE/NEPH REDUCED SUGAR -nutritional supplement liquid.............................................................................. 129 REBETOL -ribavirin soln 40 mg/ml..................................... 9 REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml)........................................................................ 84 REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml)........................................................................ 84 REBIF REBIDOSE -interferon beta-1a soln auto-inj 22 mcg/0.5ml (12mu/ml)...................................................... 84 REBIF REBIDOSE -interferon beta-1a soln auto-inj 44 mcg/0.5ml (24mu/ml)...................................................... 84 REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 84 REBIF TITRATION PACK -interferon beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................... 84 RECOMBINATE -antihemophilic factor (recombinant) for inj 220-400 unit............................................................. 142 RECOMBINATE -antihemophilic factor (recombinant) for inj 401-800 unit............................................................. 142 RECOMBINATE -antihemophilic factor (recombinant) for inj 801-1240 unit........................................................... 142 RECOMBINATE -antihemophilic factor (recombinant) for inj 1241-1800 unit......................................................... 142 RECOMBINATE -antihemophilic factor (recombinant) for inj 1801-2400 unit......................................................... 142 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml........................................................... 15 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 10 mcg/ml.............................................................. 15 RECOMBIVAX HB -hepatitis b vaccine (recombinant) susp 40 mcg/ml.............................................................. 15 RECTIV -nitroglycerin oint 0.4%..................................... 149 REGRANEX -becaplermin gel 0.01%............................. 154 RELENZA DISKHALER -zanamivir aero powder breath activated 5 mg/blister........................................................9 RELION R -insulin regular (human) inj 100 unit/ml........... 34 RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................. 110 RELPAX -eletriptan hydrobromide tab 20 mg (base equivalent)....................................................................... 95 RELPAX -eletriptan hydrobromide tab 40 mg (base equivalent)....................................................................... 95 REMBRANDT DEEPLY WHITE+PE -sodium monofluorophosphate paste 0.884%........................... 149 RENAGEL -sevelamer hcl tab 400 mg............................. 65 RENAGEL -sevelamer hcl tab 800 mg............................. 65 RENALCAL -nutritional supplement liquid...................... 129 RENASTART -nutritional supplement powder................ 129 RENVELA -sevelamer carbonate packet 0.8 gm.............. 65 RENVELA -sevelamer carbonate packet 2.4 gm.............. 65 RENVELA -sevelamer carbonate tab 800 mg.................. 65 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 215 2017 REPAGLINIDE/METFORMIN HYD -repaglinide-metformin hcl tab 1-500 mg.............................................................33 REPAGLINIDE/METFORMIN HYD -repaglinide-metformin hcl tab 2-500 mg.............................................................33 repaglinide tab 0.5 mg (Prandin)................................... 32 repaglinide tab 1 mg (Prandin)...................................... 32 repaglinide tab 2 mg (Prandin)...................................... 32 REPATHA -evolocumab subcutaneous soln prefilled syringe 140 mg/ml.......................................................... 53 REPATHA PUSHTRONEX SYSTEM -evolocumab subcutaneous soln cartridge/infusor 420 mg/3.5ml....... 53 REPATHA SURECLICK -evolocumab subcutaneous soln auto-injector 140 mg/ml.................................................. 53 REPLETE/FIBER/ULTRAPAK -nutritional supplement liquid.............................................................................. 130 REPLETE FIBER 1 CAL -nutritional supplement liquid.............................................................................. 130 REPLETE FIBER -nutritional supplement liquid............. 130 REPLETE -nutritional supplement liquid......................... 129 RESCRIPTOR -delavirdine mesylate tab 100 mg.............. 9 RESCRIPTOR -delavirdine mesylate tab 200 mg.............. 9 RESCULA -unoprostone isopropyl ophth soln 0.15%.............................................................................146 RESOURCE ARGINAID -nutritional supplement pack............................................................................... 130 RESOURCE DAIRY THICK HONE -nutritional supplement liquid.......................................................... 130 RESOURCE DIABETIC TF -nutritional supplement liquid.............................................................................. 130 RESOURCE JUICE DRINK -nutritional supplement liquid (frozen).......................................................................... 130 RESOURCE JUST FOR KIDS -nutritional supplement liquid.............................................................................. 130 RESOURCE JUST FOR KIDS 1. -nutritional supplement liquid.............................................................................. 130 RESOURCE JUST FOR KIDS WI -nutritional supplement liquid.............................................................................. 130 RESOURCE 2.0 -nutritional supplement liquid............... 130 RESOURCE SUPPORT -nutritional supplement liquid.............................................................................. 130 RESOURCE THICKENUP THICKE -nutritional supplement liquid.......................................................... 130 RESPALOR -nutritional supplement liquid...................... 130 RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 146 RESTASIS MULTIDOSE -cyclosporine (ophth) emulsion 0.05%.............................................................................146 RESURGEX -nutritional supplement pack...................... 130 RESURGEX PLUS -nutritional supplement pack........... 130 RESURGEX SELECT -nutritional supplement pack....... 130 REVATIO -sildenafil citrate for suspension 10 mg/ml....... 54 REVLIMID -lenalidomide cap 5 mg................................. 158 REVLIMID -lenalidomide cap 10 mg............................... 158 REVLIMID -lenalidomide cap 15 mg............................... 158 REVLIMID -lenalidomide cap 20 mg............................... 158 REVLIMID -lenalidomide cap 25 mg............................... 158 REVLIMID -lenalidomide caps 2.5 mg............................ 158 REXULTI -brexpiprazole tab 0.25 mg............................... 75 REXULTI -brexpiprazole tab 0.5 mg................................. 75 REXULTI -brexpiprazole tab 1 mg.................................... 75 REXULTI -brexpiprazole tab 2 mg.................................... 75 REXULTI -brexpiprazole tab 3 mg.................................... 75 REXULTI -brexpiprazole tab 4 mg.................................... 75 REYATAZ -atazanavir sulfate cap 150 mg (base equiv)..... 9 REYATAZ -atazanavir sulfate cap 200 mg (base equiv)..... 9 REYATAZ -atazanavir sulfate cap 300 mg (base equiv)..... 9 REYATAZ -atazanavir sulfate oral powder packet 50 mg (base equiv)...................................................................... 9 RIASTAP -fibrinogen conc (human) inj approximately 1 gm (900-1300 mg)........................................................ 142 RIBASPHERE RIBAPAK -ribavirin tab 400 mg................... 9 RIBASPHERE RIBAPAK -ribavirin tab 600 mg................... 9 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................................... 9 RIBASPHERE -ribavirin tab 600 mg................................... 9 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......................................... 95 rifabutin cap 150 mg (Mycobutin).................................... 5 RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 5 rifampin cap 150 mg (Rifadin).......................................... 5 rifampin cap 300 mg (Rifadin).......................................... 5 RIFATER -isoniazid-rifampin w/ pyrazinamide tab 50-120-300 mg.................................................................. 5 riluzole tab 50 mg (Rilutek).......................................... 104 rimantadine hydrochloride tab 100 mg (Flumadine).................................................................... 10 RIOMET -metformin hcl oral soln 500 mg/5ml.................. 33 risedronate sodium tab delayed release 35 mg (Atelvia).......................................................................... 39 risedronate sodium tab 5 mg (Actonel)........................ 39 risedronate sodium tab 30 mg (Actonel)...................... 39 risedronate sodium tab 35 mg (Actonel)...................... 39 risedronate sodium tab 150 mg (Actonel).................... 39 risperidone orally disintegrating tab 0.25 mg.............. 75 risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab).............................................................................. 75 risperidone orally disintegrating tab 1 mg (Risperdal m-tab).............................................................................. 75 risperidone orally disintegrating tab 2 mg (Risperdal m-tab).............................................................................. 75 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 216 2017 risperidone orally disintegrating tab 3 mg (Risperdal m-tab).............................................................................. 75 risperidone orally disintegrating tab 4 mg (Risperdal m-tab).............................................................................. 76 risperidone soln 1 mg/ml (Risperdal)............................ 76 risperidone tab 0.25 mg (Risperdal).............................. 76 risperidone tab 0.5 mg (Risperdal)................................ 76 risperidone tab 1 mg (Risperdal)................................... 76 risperidone tab 2 mg (Risperdal)................................... 76 risperidone tab 3 mg (Risperdal)................................... 76 risperidone tab 4 mg (Risperdal)................................... 76 rivastigmine tartrate cap 1.5 mg (Exelon).....................84 rivastigmine tartrate cap 3 mg (Exelon)........................84 rivastigmine tartrate cap 4.5 mg (Exelon).....................84 rivastigmine tartrate cap 6 mg (Exelon)........................84 rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 84 rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 84 rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 84 RIXUBIS -coagulation factor ix (recombinant) for inj 250 unit................................................................................. 142 RIXUBIS -coagulation factor ix (recombinant) for inj 500 unit................................................................................. 142 RIXUBIS -coagulation factor ix (recombinant) for inj 1000 unit................................................................................. 142 RIXUBIS -coagulation factor ix (recombinant) for inj 2000 unit................................................................................. 142 RIXUBIS -coagulation factor ix (recombinant) for inj 3000 unit................................................................................. 142 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) (Maxalt-mlt)............................................................. 95 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt).................................................. 95 rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt)........................................................................... 95 rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)........................................................................... 95 R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg.................................................................. 110 ropinirole hydrochloride tab 0.25 mg (Requip).......... 103 ropinirole hydrochloride tab 0.5 mg (Requip)............ 103 ropinirole hydrochloride tab 1 mg (Requip)............... 103 ropinirole hydrochloride tab 2 mg (Requip)............... 103 ropinirole hydrochloride tab 3 mg (Requip)............... 103 ropinirole hydrochloride tab 4 mg (Requip)............... 103 ropinirole hydrochloride tab 5 mg (Requip)............... 103 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) (Requip xl)............................................... 103 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) (Requip xl)............................................... 103 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) (Requip xl)............................................... 103 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) (Requip xl)............................................... 103 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) (Requip xl)............................................... 103 rosuvastatin calcium tab 5 mg (Crestor)...................... 53 rosuvastatin calcium tab 10 mg (Crestor).................... 53 rosuvastatin calcium tab 20 mg (Crestor).................... 53 rosuvastatin calcium tab 40 mg (Crestor).................... 53 ROZEREM -ramelteon tab 8 mg....................................... 77 RUBRACA -rucaparib camsylate tab 200 mg (base equivalent)....................................................................... 20 RUBRACA -rucaparib camsylate tab 300 mg (base equivalent)....................................................................... 20 RUCONEST -c1 esterase inhibitor (recombinant) for iv inj 2100 unit....................................................................... 142 RULAVITE DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg................................................. 110 RYTARY -carbidopa & levodopa cap cr 23.75-95 mg..... 103 RYTARY -carbidopa & levodopa cap cr 36.25-145 mg.................................................................................. 103 RYTARY -carbidopa & levodopa cap cr 48.75-195 mg.................................................................................. 103 RYTARY -carbidopa & levodopa cap cr 61.25-245 mg.................................................................................. 103 S SABRIL -vigabatrin powd pack 500 mg.......................... 100 SABRIL -vigabatrin tab 500 mg...................................... 100 SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg..............................................................28 SALMON/OATS/SQUASH -nutritional supplement liquid.............................................................................. 130 SAMSCA -tolvaptan tab 15 mg......................................... 39 SAMSCA -tolvaptan tab 30 mg......................................... 39 SANDIMMUNE -cyclosporine cap 25 mg....................... 158 SANDIMMUNE -cyclosporine cap 100 mg..................... 158 SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 158 SANTYL -collagenase oint 250 unit/gm.......................... 154 SAPHRIS -asenapine maleate sl tab 2.5 mg (base equiv)............................................................................... 76 SAPHRIS -asenapine maleate sl tab 5 mg (base equiv)............................................................................... 76 SAPHRIS -asenapine maleate sl tab 10 mg (base equiv)............................................................................... 76 SAVAYSA -edoxaban tosylate tab 15 mg (base equivalent)..................................................................... 136 SAVAYSA -edoxaban tosylate tab 30 mg (base equivalent)..................................................................... 136 SAVAYSA -edoxaban tosylate tab 60 mg (base equivalent)..................................................................... 136 SAVELLA -milnacipran hcl tab 12.5 mg............................ 84 SAVELLA -milnacipran hcl tab 25 mg............................... 84 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 217 2017 SAVELLA -milnacipran hcl tab 50 mg............................... 84 SAVELLA -milnacipran hcl tab 100 mg............................. 84 SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg (5) & 25 mg (8) & 50 mg (42) pak................................. 84 SB COMPLETE NUTRITION -nutritional supplement liquid.............................................................................. 130 SB COMPLETE NUTRITION PLU -nutritional supplement liquid.............................................................................. 130 SCANDICAL -nutritional supplement powder................. 130 SCANDISHAKE -nutritional supplement misc................ 130 SCANDISHAKE -nutritional supplement pack................ 130 SCANDISHAKE -nutritional supplement powder............ 130 SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg & dha cap 250 mg pak................................................. 111 SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab 29-1 mg......................................................................... 111 SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew tab 29-0.6-0.4 mg......................................................... 110 selegiline hcl cap 5 mg (Eldepryl)............................... 104 selegiline hcl tab 5 mg.................................................. 104 selenium sulfide lotion 2.5%........................................ 154 SELZENTRY -maraviroc tab 25 mg.................................. 10 SELZENTRY -maraviroc tab 75 mg.................................. 10 SELZENTRY -maraviroc tab 150 mg................................ 10 SELZENTRY -maraviroc tab 300 mg................................ 10 SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................. 110 SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab 29-1 mg......................................................................... 110 SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 39 SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 39 SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 39 SENSODYNE REPAIR & PROTEC -stannous fluoride paste 0.454%................................................................ 149 SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv)................................................... 59 SEROQUEL XR -quetiapine fumarate tab sr 24hr 50 mg.................................................................................... 76 SEROQUEL XR -quetiapine fumarate tab sr 24hr 150 mg.................................................................................... 76 SEROQUEL XR -quetiapine fumarate tab sr 24hr 200 mg.................................................................................... 76 SEROQUEL XR -quetiapine fumarate tab sr 24hr 300 mg.................................................................................... 76 SEROQUEL XR -quetiapine fumarate tab sr 24hr 400 mg.................................................................................... 76 sertraline hcl oral conc 20 mg/ml (Zoloft).................... 72 sertraline hcl tab 25 mg (Zoloft).................................... 72 sertraline hcl tab 50 mg (Zoloft).................................... 72 sertraline hcl tab 100 mg (Zoloft).................................. 72 SFROWASA -mesalamine sulfite-free (sf) enema 4 gm/60ml........................................................................... 65 SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base equiv)............................................................................... 39 SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base equiv)............................................................................... 39 SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base equiv)............................................................................... 39 sildenafil citrate tab 20 mg (Revatio)............................ 54 silver sulfadiazine cream 1% (Silvadene)................... 154 SIMBRINZA -brinzolamide-brimonidine tartrate ophth susp 1-0.2%.................................................................. 146 SIMPONI -golimumab subcutaneous soln auto-injector 50 mg/0.5ml.......................................................................... 95 SIMPONI -golimumab subcutaneous soln auto-injector 100 mg/ml....................................................................... 95 SIMPONI -golimumab subcutaneous soln prefilled syringe 50 mg/0.5ml.................................................................... 95 SIMPONI -golimumab subcutaneous soln prefilled syringe 100 mg/ml....................................................................... 95 simvastatin tab 5 mg (Zocor)......................................... 53 simvastatin tab 10 mg (Zocor)....................................... 53 simvastatin tab 20 mg (Zocor)....................................... 53 simvastatin tab 40 mg (Zocor)....................................... 53 simvastatin tab 80 mg (Zocor)....................................... 53 sirolimus tab 0.5 mg (Rapamune)............................... 158 sirolimus tab 1 mg (Rapamune).................................. 158 sirolimus tab 2 mg (Rapamune).................................. 158 SIRTURO -bedaquiline fumarate tab 100 mg (base equiv)................................................................................. 6 SITAVIG -acyclovir buccal tab 50 mg................................ 10 SIVEXTRO -tedizolid phosphate tab 200 mg....................12 SKLICE -ivermectin lotion 0.5%...................................... 154 SM NUTRI-DRINK + -nutritional supplement liquid........ 130 SM NUTRI-DRINK -nutritional supplement liquid........... 130 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) (Luride)......................................................................... 114 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) (Luride)......................................................................... 114 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) (Luride)......................................................................... 114 sodium fluoride cream 1.1% (Prevident 5000 plus).............................................................................. 149 sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)........................................................................ 149 sodium fluoride paste 1.1% (Prevident 5000 boost)............................................................................ 149 sodium fluoride-potassium nitrate paste 1.1-5% (Prevident 5000 sensi)............................................... 149 sodium fluoride rinse 0.05%.........................................149 sodium fluoride rinse 0.0221% (0.01% f).................... 149 sodium fluoride rinse 0.2% (Prevident)...................... 149 SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from 1.1 mg naf)....................................................................114 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 218 2017 SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from 2.2 mg naf)....................................................................114 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf)................................................................................ 114 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride)......................................................................... 114 sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)...................................................................... 39 sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps).............................................................................. 158 sodium polystyrene sulfonate powder (Kayexalate)................................................................. 158 sodium polystyrene sulfonate rectal susp 30 gm/120ml...................................................................... 158 SOL CARB -nutritional supplement powder....................130 SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base equivalent)....................................................................... 20 SOLVIL -amino acids pack.............................................. 115 SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 39 SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 39 SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 39 SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 39 SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 39 SOOLANTRA -ivermectin cream 1%.............................. 154 S.O.S. 15 -nutritional supplement pack.......................... 130 S.O.S. 20 -nutritional supplement pack.......................... 130 S.O.S. 25 -nutritional supplement pack.......................... 130 sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 42 sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 42 sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 42 sotalol hcl tab 240 mg.....................................................42 sotalol hcl tab 80 mg (Betapace)................................... 42 sotalol hcl tab 120 mg (Betapace)................................. 42 sotalol hcl tab 160 mg (Betapace)................................. 42 SOURCE COOKIE BAR -nutritional supplement bar......130 SOVALDI -sofosbuvir tab 400 mg..................................... 10 SOY PROTEIN SHAKE -nutritional supplement powder........................................................................... 130 SPACERS – VARIOUS.................................................... 156 SPECTRACEF -cefditoren pivoxil tab 400 mg (base equivalent)......................................................................... 3 SPINOSAD -spinosad susp 0.9%................................... 154 SPIRIVA HANDIHALER -tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)....................................... 59 SPIRIVA RESPIMAT -tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act............................................. 59 SPIRIVA RESPIMAT -tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act............................................... 59 spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide).................................................................. 50 spironolactone tab 25 mg (Aldactone).......................... 50 spironolactone tab 50 mg (Aldactone).......................... 51 spironolactone tab 100 mg (Aldactone)........................ 51 SPORANOX -itraconazole oral soln 10 mg/ml....................6 SPRYCEL -dasatinib tab 20 mg........................................ 20 SPRYCEL -dasatinib tab 50 mg........................................ 20 SPRYCEL -dasatinib tab 70 mg........................................ 21 SPRYCEL -dasatinib tab 80 mg........................................ 21 SPRYCEL -dasatinib tab 100 mg...................................... 21 SPRYCEL -dasatinib tab 140 mg...................................... 21 STALEVO 100 -carbidopa-levodopa-entacapone tabs 25-100-200 mg..............................................................104 STALEVO 125 -carbidopa-levodopa-entacapone tabs 31.25-125-200 mg........................................................ 104 STALEVO 150 -carbidopa-levodopa-entacapone tabs 37.5-150-200 mg.......................................................... 104 STALEVO 200 -carbidopa-levodopa-entacapone tabs 50-200-200 mg..............................................................104 STALEVO 50 -carbidopa-levodopa-entacapone tabs 12.5-50-200 mg.............................................................104 STALEVO 75 -carbidopa-levodopa-entacapone tabs 18.75-75-200 mg.......................................................... 104 stannous fluoride conc 0.63% (Gel-kam oral care ri)................................................................................... 149 stannous fluoride gel 0.4%........................................... 149 STANNOUS FLUORIDE RINSE -stannous fluoride liq 0.1%...............................................................................149 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........................ 154 STELARA -ustekinumab soln prefilled syringe 45 mg/0.5ml........................................................................ 154 STELARA -ustekinumab soln prefilled syringe 90 mg/ ml................................................................................... 154 STIMATE -desmopressin acetate nasal soln 1.5 mg/ ml..................................................................................... 39 STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act....................................................... 59 STIVARGA -regorafenib tab 40 mg................................... 21 STRATTERA -atomoxetine hcl cap 10 mg (base equiv)............................................................................... 80 STRATTERA -atomoxetine hcl cap 18 mg (base equiv)............................................................................... 80 STRATTERA -atomoxetine hcl cap 25 mg (base equiv)............................................................................... 80 STRATTERA -atomoxetine hcl cap 40 mg (base equiv)............................................................................... 80 STRATTERA -atomoxetine hcl cap 60 mg (base equiv)............................................................................... 80 STRATTERA -atomoxetine hcl cap 80 mg (base equiv)............................................................................... 80 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 219 2017 STRATTERA -atomoxetine hcl cap 100 mg (base equiv)............................................................................... 80 STRENSIQ -asfotase alfa subcutaneous inj 18 mg/0.45ml........................................................................ 39 STRENSIQ -asfotase alfa subcutaneous inj 28 mg/0.7ml.......................................................................... 39 STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 39 STRENSIQ -asfotase alfa subcutaneous inj 80 mg/0.8ml.......................................................................... 39 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)................................................ 59 SUBDUE -nutritional supplement liquid.......................... 130 SUBDUE PLUS -nutritional supplement liquid................ 130 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv).............................................................. 91 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv).............................................................. 91 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv).............................................................. 91 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv).............................................................. 91 SUBSYS -fentanyl sublingual spray 100 mcg................... 91 SUBSYS -fentanyl sublingual spray 200 mcg................... 91 SUBSYS -fentanyl sublingual spray 400 mcg................... 91 SUBSYS -fentanyl sublingual spray 600 mcg................... 91 SUBSYS -fentanyl sublingual spray 800 mcg................... 91 SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x 2)...................................................................................... 91 SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x 2)...................................................................................... 91 SUCRAID -sacrosidase soln 8500 unit/ml........................ 64 sucralfate tab 1 gm (Carafate)....................................... 62 sulfacetamide sodium lotion 10% (acne) (Klaron)..... 154 sulfacetamide sodium ophth soln 10% (Bleph-10)..................................................................... 146 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%............................................................. 146 SULFACETAMIDE SODIUM -sulfacetamide sodium ophth oint 10%........................................................................ 146 SULFADIAZINE -sulfadiazine tab 500 mg.......................... 5 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml............................................................................ 12 sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)......................................................................... 12 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)................................................................... 12 SULFAMYLON -mafenide acetate cream 85 mg/gm...... 154 sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)........................................................................... 65 sulfasalazine tab 500 mg (Azulfidine)........................... 65 sulindac tab 150 mg........................................................ 95 sulindac tab 200 mg........................................................ 95 sumatriptan nasal spray 5 mg/act (Imitrex).................. 95 sumatriptan nasal spray 20 mg/act (Imitrex)................ 95 sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 95 sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys)................................. 96 sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)................................. 96 sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose ref).................................................... 96 sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref).................................................... 96 sumatriptan succinate tab 25 mg (Imitrex)................... 96 sumatriptan succinate tab 50 mg (Imitrex)................... 96 sumatriptan succinate tab 100 mg (Imitrex)................. 96 SUPER-AMINO 1600 -amino acids tab.......................... 115 SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml (per drop)...................................................................... 105 SUPER NU-THERA -multiple vitamins w/ minerals powder........................................................................... 111 SUPLENA -nutritional supplement liquid.........................131 SUPLENA RTU -nutritional supplement liquid................ 131 SUPLENA WITH CARB STEADY -nutritional supplement liquid.............................................................................. 131 SUPLENA 1.8 WITH CARBSTEA -nutritional supplement liquid.............................................................................. 131 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.............................. 61 SURMONTIL -trimipramine maleate cap 25 mg............... 72 SURMONTIL -trimipramine maleate cap 50 mg............... 72 SURMONTIL -trimipramine maleate cap 100 mg............. 72 SURVANTA INTRATRACHEAL -beractant in nacl 0.9% intratracheal susp 25 mg/ml........................................... 60 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 296 mcg...... 21 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 220 2017 SYLATRON -peginterferon alfa-2b for inj kit 444 mcg...... 21 SYLATRON -peginterferon alfa-2b for inj kit 888 mcg...... 21 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act................................................... 59 SYMBICORT -budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/act................................................. 59 SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) (base eq)..........................................................39 SYNERA -lidocaine-tetracaine topical patch 70-70 mg.................................................................................. 154 SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000 mg.................................................................................... 33 SYNJARDY -empagliflozin-metformin hcl tab 12.5-500 mg.................................................................................... 33 SYNJARDY -empagliflozin-metformin hcl tab 5-500 mg.................................................................................... 33 SYNJARDY -empagliflozin-metformin hcl tab 5-1000 mg.................................................................................... 33 SYNTHROID -levothyroxine sodium tab 25 mcg.............. 36 SYNTHROID -levothyroxine sodium tab 50 mcg.............. 36 SYNTHROID -levothyroxine sodium tab 75 mcg.............. 36 SYNTHROID -levothyroxine sodium tab 88 mcg.............. 36 SYNTHROID -levothyroxine sodium tab 100 mcg............ 36 SYNTHROID -levothyroxine sodium tab 112 mcg............ 36 SYNTHROID -levothyroxine sodium tab 125 mcg............ 36 SYNTHROID -levothyroxine sodium tab 137 mcg............ 36 SYNTHROID -levothyroxine sodium tab 150 mcg............ 36 SYNTHROID -levothyroxine sodium tab 175 mcg............ 36 SYNTHROID -levothyroxine sodium tab 200 mcg............ 36 SYNTHROID -levothyroxine sodium tab 300 mcg............ 36 SYPRINE -trientine hcl cap 250 mg................................ 158 T TABLOID -thioguanine tab 40 mg..................................... 21 TACLONEX -calcipotriene-betamethasone dipropionate susp 0.005-0.064%....................................................... 154 tacrolimus cap 0.5 mg (Prograf).................................. 158 tacrolimus cap 1 mg (Prograf)..................................... 158 tacrolimus cap 5 mg (Prograf)..................................... 158 tacrolimus oint 0.03% (Protopic)................................. 154 tacrolimus oint 0.1% (Protopic)................................... 154 TAFINLAR -dabrafenib mesylate cap 50 mg (base equivalent)....................................................................... 21 TAFINLAR -dabrafenib mesylate cap 75 mg (base equivalent)....................................................................... 21 TAGRISSO -osimertinib mesylate tab 40 mg (base equivalent)....................................................................... 21 TAGRISSO -osimertinib mesylate tab 80 mg (base equivalent)....................................................................... 21 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)............. 21 tamoxifen citrate tab 20 mg (base equivalent)............. 21 tamsulosin hcl cap 0.4 mg (Flomax)............................. 68 TANZEUM -albiglutide for soln pen-injector 30 mg........... 33 TANZEUM -albiglutide for soln pen-injector 50 mg........... 33 TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 21 TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 21 TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 21 TARGRETIN -bexarotene gel 1%....................................154 TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab pak..................................................................... 111 TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg......................................................... 111 TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 30-1.2-265 mg....................................................... 111 TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 21 TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 21 TASMAR -tolcapone tab 100 mg.....................................104 tazarotene cream 0.1% (Tazorac)................................. 154 TAZORAC -tazarotene cream 0.05%.............................. 155 TAZORAC -tazarotene cream 0.1%................................ 155 TAZORAC -tazarotene gel 0.05%................................... 155 TAZORAC -tazarotene gel 0.1%..................................... 155 TECFIDERA -dimethyl fumarate capsule delayed release 120 mg............................................................................ 84 TECFIDERA -dimethyl fumarate capsule delayed release 240 mg............................................................................ 85 TECFIDERA STARTER PACK -dimethyl fumarate capsule dr starter pack 120 mg & 240 mg..................... 85 TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg................................................................. 10 TEGRETOL -carbamazepine susp 100 mg/5ml............. 100 TEGRETOL -carbamazepine tab 200 mg....................... 100 TEGRETOL-XR -carbamazepine tab sr 12hr 100 mg.................................................................................. 100 TEGRETOL-XR -carbamazepine tab sr 12hr 200 mg.................................................................................. 101 TEGRETOL-XR -carbamazepine tab sr 12hr 400 mg.................................................................................. 101 TEKTURNA -aliskiren fumarate tab 150 mg (base equivalent)....................................................................... 49 TEKTURNA -aliskiren fumarate tab 300 mg (base equivalent)....................................................................... 49 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-12.5 mg.................................................................... 49 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 221 2017 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 150-25 mg....................................................................... 49 TEKTURNA HCT -aliskiren-hydrochlorothiazide tab 300-12.5 mg.................................................................... 49 telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 49 telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 49 telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 49 telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 49 telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)................................................................. 49 telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)................................................................. 49 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct)................................................................. 49 telmisartan tab 20 mg (Micardis)................................... 49 telmisartan tab 40 mg (Micardis)................................... 49 telmisartan tab 80 mg (Micardis)................................... 49 temazepam cap 7.5 mg (Restoril).................................. 77 temazepam cap 15 mg (Restoril)................................... 77 temazepam cap 22.5 mg (Restoril)................................ 77 temazepam cap 30 mg (Restoril)................................... 77 temozolomide cap 5 mg (Temodar)............................... 21 temozolomide cap 20 mg (Temodar)............................. 21 temozolomide cap 100 mg (Temodar)........................... 21 temozolomide cap 140 mg (Temodar)........................... 21 temozolomide cap 180 mg (Temodar)........................... 21 temozolomide cap 250 mg (Temodar)........................... 21 TENCON -butalbital-acetaminophen tab 50-325 mg........ 85 TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 16 terazosin hcl cap 1 mg....................................................49 terazosin hcl cap 2 mg....................................................49 terazosin hcl cap 5 mg....................................................49 terazosin hcl cap 10 mg..................................................49 terbinafine hcl tab 250 mg (Lamisil)................................ 6 terbutaline sulfate tab 2.5 mg........................................ 59 terbutaline sulfate tab 5 mg........................................... 59 terconazole vaginal cream 0.4% (Terazol 7)................. 67 terconazole vaginal cream 0.8% (Terazol 3)................. 67 terconazole vaginal suppos 80 mg............................... 67 testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 24 testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 24 testosterone enanthate im inj in oil 200 mg/ml............ 24 testosterone td gel 12.5 mg/act (1%) (Androgel pump).............................................................................. 24 testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 24 testosterone td gel 50 mg/5gm (1%) (Androgel).......... 24 TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml.............................................. 16 tetrabenazine tab 12.5 mg (Xenazine)........................... 85 tetrabenazine tab 25 mg (Xenazine).............................. 85 tetracaine hcl ophth soln 0.5%.................................... 146 tetracycline hcl cap 250 mg (Tetracycline hcl)............... 4 tetracycline hcl cap 500 mg (Tetracycline hcl)............... 4 TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........4 TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........4 THALOMID -thalidomide cap 50 mg............................... 158 THALOMID -thalidomide cap 100 mg............................. 158 THALOMID -thalidomide cap 150 mg............................. 158 THALOMID -thalidomide cap 200 mg............................. 158 theophylline soln 80 mg/15ml........................................ 60 theophylline tab sr 12hr 100 mg.................................... 60 theophylline tab sr 12hr 200 mg.................................... 60 theophylline tab sr 12hr 300 mg.................................... 60 theophylline tab sr 12hr 450 mg.................................... 60 theophylline tab sr 24hr 400 mg.................................... 60 theophylline tab sr 24hr 600 mg.................................... 60 THEO-24 -theophylline cap sr 24hr 100 mg..................... 59 THEO-24 -theophylline cap sr 24hr 200 mg..................... 59 THEO-24 -theophylline cap sr 24hr 300 mg..................... 59 THEO-24 -theophylline cap sr 24hr 400 mg..................... 60 THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)...... 149 THICK-IT BEEF LASAGNA PUR -nutritional supplement misc............................................................................... 131 THICK-IT CHICKEN A LA KIN -nutritional supplement misc............................................................................... 131 THICK-IT MAPLE CINNAMON F -nutritional supplement misc............................................................................... 131 THICK-IT MIXED FRUIT AND -nutritional supplement misc............................................................................... 131 THICK-IT SEASONED CHICKEN -nutritional supplement misc............................................................................... 131 THICK-IT SWEET CORN PUREE -nutritional supplement misc............................................................................... 131 THICK-IT THICKENED CRANBE -nutritional supplement liquid.............................................................................. 131 THIOLA -tiopronin tab 100 mg.......................................... 68 thioridazine hcl tab 10 mg.............................................. 76 thioridazine hcl tab 25 mg.............................................. 76 thioridazine hcl tab 50 mg.............................................. 76 thioridazine hcl tab 100 mg............................................ 76 thiothixene cap 1 mg....................................................... 76 thiothixene cap 2 mg....................................................... 76 thiothixene cap 5 mg....................................................... 76 thiothixene cap 10 mg..................................................... 76 THRIVACIN DETOX -nutritional supplement liquid......... 131 THRIVACIN 30 -nutritional supplement liquid................. 131 THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg.................................................................................. 111 THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 111 thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 36 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 36 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 222 2017 thyroid tab 60 mg (1 grain) (Armour thyroid)............... 36 THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25 mcg)................................................................................. 36 THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5 mcg)................................................................................. 36 THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......36 THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100 mcg)................................................................................. 36 THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150 mcg)................................................................................. 36 tiagabine hcl tab 2 mg (Gabitril).................................. 101 tiagabine hcl tab 4 mg (Gabitril).................................. 101 TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 45 TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 45 TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 45 timolol maleate ophth gel forming soln 0.25% (Timoptic-xe)................................................................ 146 timolol maleate ophth gel forming soln 0.5% (Timoptic-xe)................................................................ 146 timolol maleate ophth soln 0.25% (Timoptic)............. 146 timolol maleate ophth soln 0.5% (Timoptic)............... 146 TIMOLOL MALEATE -timolol maleate tab 5 mg............... 42 TIMOLOL MALEATE -timolol maleate tab 10 mg............. 42 TIMOLOL MALEATE -timolol maleate tab 20 mg............. 42 TIMOPTIC OCUDOSE -timolol maleate preservative free ophth soln 0.25%.......................................................... 146 TIMOPTIC OCUDOSE -timolol maleate preservative free ophth soln 0.5%............................................................ 146 tinidazole tab 250 mg (Tindamax)..................................12 tinidazole tab 500 mg (Tindamax)..................................12 TIROSINT -levothyroxine sodium cap 13 mcg..................36 TIROSINT -levothyroxine sodium cap 25 mcg..................36 TIROSINT -levothyroxine sodium cap 50 mcg..................36 TIROSINT -levothyroxine sodium cap 75 mcg..................36 TIROSINT -levothyroxine sodium cap 88 mcg..................36 TIROSINT -levothyroxine sodium cap 100 mcg................36 TIROSINT -levothyroxine sodium cap 112 mcg................ 36 TIROSINT -levothyroxine sodium cap 125 mcg................36 TIROSINT -levothyroxine sodium cap 137 mcg................37 TIROSINT -levothyroxine sodium cap 150 mcg................37 TIVICAY -dolutegravir sodium tab 10 mg (base equiv)..... 10 TIVICAY -dolutegravir sodium tab 25 mg (base equiv)..... 10 TIVICAY -dolutegravir sodium tab 50 mg (base equiv)..... 10 tizanidine hcl cap 2 mg (base equivalent) (Zanaflex)......................................................................104 tizanidine hcl cap 4 mg (base equivalent) (Zanaflex)......................................................................104 tizanidine hcl cap 6 mg (base equivalent) (Zanaflex)......................................................................104 tizanidine hcl tab 2 mg (base equivalent)................... 105 tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)......................................................................105 TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap 27-1-500 mg.................................................................. 111 TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab 27-0.5-0.5 mg................................................................ 111 TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg.............................................................111 TOBI PODHALER -tobramycin inhal cap 28 mg.................5 TOBRADEX ST -tobramycin-dexamethasone ophth susp 0.3-0.05%...................................................................... 146 TOBRADEX -tobramycin-dexamethasone ophth oint 0.3-0.1%........................................................................ 146 tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex).................................................................... 147 tobramycin nebu soln 300 mg/5ml (Tobi)....................... 5 tobramycin ophth soln 0.3% (Tobrex)......................... 146 TOBRAMYCIN -tobramycin nebu soln 300 mg/5ml............ 5 TOBREX -tobramycin ophth oint 0.3%........................... 147 TOLAK -fluorouracil cream 4%........................................155 TOLAZAMIDE -tolazamide tab 250 mg.............................33 TOLAZAMIDE -tolazamide tab 500 mg.............................33 TOLBUTAMIDE -tolbutamide tab 500 mg......................... 33 tolcapone tab 100 mg (Tasmar)................................... 104 TOLEREX -nutritional supplement pack......................... 131 TOLMETIN SODIUM -tolmetin sodium cap 400 mg......... 95 tolterodine tartrate cap sr 24hr 2 mg (Detrol la).......... 66 tolterodine tartrate cap sr 24hr 4 mg (Detrol la).......... 66 tolterodine tartrate tab 1 mg (Detrol)............................ 67 tolterodine tartrate tab 2 mg (Detrol)............................ 67 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25 mg.................................................................................. 101 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50 mg.................................................................................. 101 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100 mg.................................................................................. 101 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150 mg.................................................................................. 101 TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200 mg.................................................................................. 101 topiramate sprinkle cap 15 mg (Topamax sprinkle)........................................................................101 topiramate sprinkle cap 25 mg (Topamax sprinkle)........................................................................101 topiramate tab 25 mg (Topamax)................................. 101 topiramate tab 50 mg (Topamax)................................. 101 topiramate tab 100 mg (Topamax)............................... 101 topiramate tab 200 mg (Topamax)............................... 101 torsemide tab 5 mg (Demadex)...................................... 51 torsemide tab 10 mg (Demadex).................................... 51 torsemide tab 20 mg (Demadex).................................... 51 torsemide tab 100 mg (Demadex).................................. 51 TOUJEO SOLOSTAR -insulin glargine soln pen-injector 300 unit/ml.......................................................................35 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 223 2017 TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg.............67 TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg.............67 TRACLEER -bosentan tab 62.5 mg.................................. 54 TRACLEER -bosentan tab 125 mg................................... 54 TRADJENTA -linagliptin tab 5 mg..................................... 33 tramadol-acetaminophen tab 37.5-325 mg (Ultracet)......................................................................... 91 tramadol hcl tab 50 mg (Ultram).................................... 91 tramadol hcl tab sr 24hr biphasic release 100 mg....... 91 tramadol hcl tab sr 24hr biphasic release 200 mg....... 91 tramadol hcl tab sr 24hr biphasic release 300 mg....... 91 tramadol hcl tab sr 24hr 100 mg (Ultram er)................ 91 tramadol hcl tab sr 24hr 200 mg (Ultram er)................ 91 tramadol hcl tab sr 24hr 300 mg (Ultram er)................ 91 trandolapril tab 1 mg (Mavik)......................................... 49 trandolapril tab 2 mg (Mavik)......................................... 49 trandolapril tab 4 mg (Mavik)......................................... 49 trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 49 trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)...... 49 trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)...... 49 trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)...... 49 tranexamic acid tab 650 mg (Lysteda)........................ 137 TRANSDERM-SCOP -scopolamine td patch 72hr 1.5 mg.................................................................................... 63 tranylcypromine sulfate tab 10 mg (Parnate)............... 72 TRAVATAN Z -travoprost ophth soln 0.004% (benzalkonium free) (bak free)..................................... 147 trazodone hcl tab 50 mg................................................. 72 trazodone hcl tab 100 mg............................................... 72 trazodone hcl tab 150 mg............................................... 72 trazodone hcl tab 300 mg............................................... 72 TRECATOR -ethionamide tab 250 mg................................ 6 TRESIBA FLEXTOUCH -insulin degludec soln peninjector 100 unit/ml......................................................... 35 TRESIBA FLEXTOUCH -insulin degludec soln peninjector 200 unit/ml......................................................... 35 tretinoin cap 10 mg......................................................... 21 tretinoin cream 0.025% (Retin-a)................................. 155 tretinoin cream 0.05% (Retin-a)................................... 155 tretinoin cream 0.1% (Retin-a)..................................... 155 tretinoin gel 0.05% (Atralin).......................................... 155 tretinoin gel 0.01% (Retin-a)......................................... 155 tretinoin gel 0.025% (Retin-a)....................................... 155 tretinoin microsphere gel 0.04% (Retin-a micro)....... 155 tretinoin microsphere gel 0.1% (Retin-a micro)......... 155 TRETTEN -coagulation factor xiii a-subunit for inj 2000-3125 unit.............................................................. 142 TREXALL -methotrexate sodium tab 5 mg (base equiv)............................................................................... 21 TREXALL -methotrexate sodium tab 7.5 mg (base equiv)............................................................................... 21 TREXALL -methotrexate sodium tab 10 mg (base equiv)............................................................................... 21 TREXALL -methotrexate sodium tab 15 mg (base equiv)............................................................................... 22 TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg......................................................................... 111 triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog)...................................................................... 155 triamcinolone acetonide cream 0.025%...................... 155 triamcinolone acetonide cream 0.1%.......................... 155 triamcinolone acetonide cream 0.5%.......................... 155 triamcinolone acetonide dental paste 0.1%............... 149 triamcinolone acetonide lotion 0.025%....................... 155 triamcinolone acetonide lotion 0.1%........................... 155 triamcinolone acetonide nasal aerosol suspension 55 mcg/act........................................................................... 55 triamcinolone acetonide oint 0.025%.......................... 155 triamcinolone acetonide oint 0.1%.............................. 155 TRIAMINO -amino acids tab........................................... 115 TRIAMTERENE/HYDROCHLOROTH -triamterene & hydrochlorothiazide cap 50-25 mg................................. 51 triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide).........................................................................51 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)................................................................... 51 triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)........................................................................ 51 TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa tab 27-1 mg & fish oil chew cap pak............................111 TRICARE PRENATAL DHA ONE -prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg................................... 111 TRICARE PRENATAL -prenat w/o a w/fepyro-mfol chw 4.5-1 mg & dha cap 150 thpk...................................... 111 TRICARE PRENATAL -prenat w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg........................................... 111 TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 111 TRIDESILON -desonide cream 0.05%............................155 trifluoperazine hcl tab 1 mg........................................... 76 trifluoperazine hcl tab 2 mg........................................... 76 trifluoperazine hcl tab 5 mg........................................... 76 trifluoperazine hcl tab 10 mg......................................... 76 trifluridine ophth soln 1% (Viroptic)............................ 147 trihexyphenidyl hcl elixir 0.4 mg/ml............................ 104 trihexyphenidyl hcl tab 2 mg........................................104 trihexyphenidyl hcl tab 5 mg........................................104 trimethobenzamide hcl cap 300 mg (Tigan)................. 63 trimethoprim tab 100 mg................................................ 12 TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg......................................................................... 111 TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1 mg.................................................................................. 111 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 224 2017 TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg..... 111 TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap 31-0.6-0.4-200 mg........................................................ 111 TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg & omega cap pack....................................................... 111 TRIUMEQ -abacavir-dolutegravir-lamivudine tab 600-50-300 mg................................................................10 TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab & omega 3 cap 400 pk................................................. 111 TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................ 111 TROKENDI XR -topiramate cap sr 24hr 25 mg.............. 101 TROKENDI XR -topiramate cap sr 24hr 50 mg.............. 101 TROKENDI XR -topiramate cap sr 24hr 100 mg............ 101 TROKENDI XR -topiramate cap sr 24hr 200 mg............ 101 trospium chloride cap sr 24hr 60 mg............................ 67 trospium chloride tab 20 mg.......................................... 67 TRULICITY -dulaglutide soln pen-injector 0.75 mg/0.5ml.......................................................................... 33 TRULICITY -dulaglutide soln pen-injector 1.5 mg/0.5ml.......................................................................... 33 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg..................................................................... 10 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg..................................................................... 10 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 167-250 mg..................................................................... 10 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg..................................................................... 11 TUSNEL C -pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml............................................................................. 57 TWOCAL HN -nutritional supplement liquid....................131 TWOCAL HN 2.0 -nutritional supplement liquid..............131 TYBOST -cobicistat tab 150 mg....................................... 11 TYKERB -lapatinib ditosylate tab 250 mg (base equiv)............................................................................... 22 TYLACTIN RESTORE 10 -nutritional supplement liquid.............................................................................. 131 TYLACTIN RESTORE 5PE -nutritional supplement pack............................................................................... 131 TYLACTIN RTD 15 -nutritional supplement liquid.......... 131 TYR ANAMIX EARLY YEARS -nutritional supplement powder........................................................................... 131 TYR ANAMIX NEXT -nutritional supplement powder..... 131 TYR COOLER -nutritional supplement liquid.................. 131 TYR COOLER20 -nutritional supplement liquid.............. 131 TYREX-1 -nutritional supplement powder....................... 131 TYREX-2 -nutritional supplement powder....................... 131 TYR EXPRESS -nutritional supplement pack................. 131 TYR EXPRESS20 -nutritional supplement pack............. 131 TYR GEL -nutritional supplement pack........................... 131 TYR LOPHLEX LQ -nutritional supplement liquid...........131 TYROS 1 -nutritional supplement powder...................... 131 TYROS 2 -nutritional supplement powder...................... 131 TYVASO REFILL -treprostinil inhalation solution 0.6 mg/ ml..................................................................................... 54 TYVASO STARTER -treprostinil inhalation solution 0.6 mg/ml............................................................................... 54 TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 54 U UCD ANAMIX JUNIOR -nutritional supplement powder........................................................................... 131 UCD 2 -nutritional supplement powder........................... 132 UCD TRIO -nutritional supplement powder.................... 131 UCERIS -budesonide rectal foam 2 mg/act.................... 149 UCERIS -budesonide tab sr 24hr 9 mg............................ 23 ULESFIA -benzyl alcohol lotion 5%................................ 155 ULORIC -febuxostat tab 40 mg......................................... 96 ULORIC -febuxostat tab 80 mg......................................... 96 ULTIMATECARE ONE NF -prenatal w/fe cbnyl-fe asp glyc-fa-dss-omega cap 20-7-1 mg............................... 111 ULTIMATECARE ONE -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 111 ULTRACAL HN PLUS -nutritional supplement liquid...... 132 ULTRACAL -nutritional supplement liquid....................... 132 ULTRAMINO SOY PROTEIN -nutritional supplement powder........................................................................... 132 UPTRAVI -selexipag tab 200 mcg.....................................54 UPTRAVI -selexipag tab 400 mcg.....................................54 UPTRAVI -selexipag tab 600 mcg.....................................54 UPTRAVI -selexipag tab 800 mcg.....................................54 UPTRAVI -selexipag tab 1000 mcg...................................54 UPTRAVI -selexipag tab 1200 mcg...................................54 UPTRAVI -selexipag tab 1400 mcg...................................54 UPTRAVI -selexipag tab 1600 mcg...................................54 UPTRAVI -selexipag tab therapy pack 200 mcg (140) & 800 mcg (60)...................................................................54 ursodiol cap 300 mg (Actigall)....................................... 66 ursodiol tab 250 mg (Urso 250)..................................... 66 ursodiol tab 500 mg (Urso forte)................................... 66 UTYMAX -nutritional supplement pack........................... 132 V VAGIFEM -estradiol vaginal tab 10 mcg........................... 67 valacyclovir hcl tab 1 gm (Valtrex)................................ 11 valacyclovir hcl tab 500 mg (Valtrex)............................ 11 VALCHLOR -mechlorethamine hcl gel 0.016% (base equivalent)..................................................................... 155 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: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 225 2017 valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene)................................................................... 101 valproic acid cap 250 mg (Depakene)......................... 101 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct).................................................................................. 49 valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct)................................................................... 49 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct).................................................................................. 50 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct)................................................................... 50 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct).................................................................................. 50 valsartan tab 40 mg (Diovan)......................................... 49 valsartan tab 80 mg (Diovan)......................................... 49 valsartan tab 160 mg (Diovan)....................................... 49 valsartan tab 320 mg (Diovan)....................................... 49 vancomycin hcl cap 125 mg (Vancocin hcl)................. 12 vancomycin hcl cap 250 mg (Vancocin hcl)................. 12 VARUBI -rolapitant hcl tab 90 mg (base equiv)................ 63 VASCEPA -icosapent ethyl cap 0.5 gm............................ 53 VASCEPA -icosapent ethyl cap 1 gm............................... 53 VECAMYL -mecamylamine hcl tab 2.5 mg....................... 50 VELPHORO -sucroferric oxyhydroxide chew tab 500 mg.................................................................................... 66 VELTASSA -patiromer sorbitex calcium for susp packet 8.4 gm (base eq).......................................................... 158 VELTASSA -patiromer sorbitex calcium for susp packet 16.8 gm (base eq)........................................................ 158 VELTASSA -patiromer sorbitex calcium for susp packet 25.2 gm (base eq)........................................................ 158 VEMAVITE-PRX 2 -prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg.............................................. 112 VENA-BAL DHA -prenat w/fe poly-na fered-fa tab 27-1 & omega cap dr 430mg................................................... 112 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor xr)..................................................................... 72 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr)..................................................................... 72 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr)..................................................................... 72 venlafaxine hcl tab 25 mg...............................................72 venlafaxine hcl tab 37.5 mg............................................72 venlafaxine hcl tab 50 mg...............................................72 venlafaxine hcl tab 75 mg...............................................72 venlafaxine hcl tab 100 mg.............................................72 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er)....................................................... 72 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er)....................................................... 72 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er)....................................................... 72 VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 54 VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 54 VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)........................................................ 60 verapamil hcl cap sr 24hr 120 mg (Verelan)................. 44 verapamil hcl cap sr 24hr 180 mg (Verelan)................. 44 verapamil hcl cap sr 24hr 240 mg (Verelan)................. 44 verapamil hcl cap sr 24hr 360 mg (Verelan)................. 44 verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 44 verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 44 verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 44 verapamil hcl tab cr 120 mg (Calan sr)......................... 44 verapamil hcl tab cr 180 mg (Calan sr)......................... 44 verapamil hcl tab cr 240 mg (Calan sr)......................... 44 verapamil hcl tab 40 mg................................................. 44 verapamil hcl tab 80 mg (Calan).................................... 44 verapamil hcl tab 120 mg (Calan).................................. 44 VEREGEN -sinecatechins oint 15%................................155 VERIPRED 20 -prednisolone sod phosphate oral soln 20 mg/5ml (base equiv)....................................................... 23 VERSACLOZ -clozapine susp 50 mg/ml.......................... 76 VESICARE -solifenacin succinate tab 5 mg..................... 67 VESICARE -solifenacin succinate tab 10 mg................... 67 VHC 2.25 -nutritional supplement liquid.......................... 132 VIBERZI -eluxadoline tab 75 mg....................................... 66 VIBERZI -eluxadoline tab 100 mg..................................... 66 VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/ ml).................................................................................... 33 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)............................................................................. 147 VIIBRYD STARTER PACK -vilazodone hcl tab starter kit 10 (7) & 20 (23) mg....................................................... 72 VIIBRYD -vilazodone hcl tab 10 mg..................................72 VIIBRYD -vilazodone hcl tab 20 mg..................................72 VIIBRYD -vilazodone hcl tab 40 mg..................................72 VILACTIN AA PLUS -nutritional supplement liquid......... 132 VIMPAT -lacosamide oral solution 10 mg/ml.................. 101 VIMPAT -lacosamide tab 50 mg...................................... 101 VIMPAT -lacosamide tab 100 mg.................................... 101 VIMPAT -lacosamide tab 150 mg.................................... 101 VIMPAT -lacosamide tab 200 mg.................................... 101 VINATE DHA RF -prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg............................................................. 112 VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab 29-1 mg......................................................................... 112 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 226 2017 VINATE M -prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg.................................................................................. 112 VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1 mg.................................................................................. 112 VIOKACE -pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit................................................ 64 VIOKACE -pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit................................................ 64 VIRACEPT -nelfinavir mesylate tab 250 mg..................... 11 VIRACEPT -nelfinavir mesylate tab 625 mg..................... 11 VIRAMUNE -nevirapine susp 50 mg/5ml.......................... 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......................................................................... 112 VIRT-CARE ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg................................................... 112 VIRT-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap 53.5-38-1 mg................................................................. 112 VIRT-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................. 112 VIRT NATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg.................................................................................. 112 VIRT-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg........................................................ 112 VIRT-PN PLUS -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 112 VIRT-PN -prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg................................................................ 112 VIRTPREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 26-1.2-300 mg...............................................................112 VIRT-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap 29-1.25-325 mg..................................................... 112 VIRT-VITE GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg......................................................................... 112 VITAFOL FE+ -prenat-fepoly-methol-fa-dha cap 90-1-200 mg & dss 50mg cap..................................................... 112 VITAFOL-NANO -prenatal w/o a w/ fefum-l methylfol-fa tab 18-0.6-0.4 mg......................................................... 112 VITAFOL-OB+DHA -prenatal mv w/fe fum-fa tab 65-1 mg & dha cap 250 mg pack............................................... 112 VITAFOL-OB -prenatal vit w/ fe fumarate-fa tab 65-1 mg.................................................................................. 112 VITAFOL-ONE -prenatal mv w/ fe polysac cmplx-fa-dha cap 29-1-200 mg.......................................................... 112 VITAFOL ULTRA -prenat w/fe poly-methylfol-fa-dha cap 29-0.6-0.4-200 mg........................................................ 112 VITAJOULE -nutritional supplement powder...................132 VITAL AF 1.2 CAL -nutritional supplement liquid............ 132 VITAL 1.0 CAL -nutritional supplement liquid................. 132 VITAL 1.5 CAL -nutritional supplement liquid................. 132 VITAL HIGH PROTEIN -nutritional supplement liquid.............................................................................. 132 VITAL HN -nutritional supplement pack.......................... 132 VITAL JR -nutritional supplement liquid.......................... 132 VITAL PEPTIDE 1.5 CAL -nutritional supplement liquid.............................................................................. 132 VITAMEDMD ONE RX/QUATREFO -prenat w/o a w/ fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.............. 112 VITAMEDMD REDICHEW RX -prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg........................................... 112 VITAMELTS VITAMIN D -cholecalciferol orally disintegrating tab 1000 unit.......................................... 105 VITAMIN D3 -cholecalciferol oral liquid 1200 unit/15ml........................................................................ 105 VITAMIN D3 -cholecalciferol spray 1000 unit/spray........105 VITAMIN D2 -ergocalciferol tab 400 unit.........................105 VITAPEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr 30-1.4-200 mg...............................................................112 VITA-PREN -prenatal vit w/ docusate-iron-fa tab 65-1 mg.................................................................................. 112 VITAPRO -nutritional supplement powder...................... 132 VITAQUICK -nutritional supplement powder................... 132 VITATRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg & dha cap 300mg pk............................................................... 113 VITUZ -hydrocodone-chlorpheniramine soln 5-4 mg/5ml............................................................................. 57 VIVA DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg.................................................................. 113 VIVONEX PEDIATRIC -nutritional supplement pack...... 132 VIVONEX PLUS -nutritional supplement powder........... 132 VIVONEX RTF -nutritional supplement liquid................. 132 VIVONEX T.E.N. -nutritional supplement pack............... 132 VIVOTIF -typhoid vaccine cap delayed release................ 15 VOL-NATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg.................................................................................. 113 VOL-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg.................................................................................. 113 VOL-TAB RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg.................................................................................. 113 VOLTAREN -diclofenac sodium gel 1%.......................... 155 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.................................................................. 113 VP-CH-PNV -prenatal w/o vit a w/ fe cbn-dss-fa-dha cap 30-1-260 mg.................................................................. 113 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 227 2017 VP-GGR-B6 PRENATAL -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 113 VP-HEME OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................ 113 VP-HEME OB -prenat vit-fe poly cmplx-fe heme poly-fa tab 28-6-1 mg............................................................... 113 VP-HEME ONE -prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg................................................ 113 VP-PNV-DHA -prenatal vit w/ fe fum-fa-omega 3 cap 28-1-215.8 mg...............................................................113 VUSION -miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35%............................................................. 155 VYVANSE -lisdexamfetamine dimesylate cap 10 mg....... 80 VYVANSE -lisdexamfetamine dimesylate cap 20 mg....... 80 VYVANSE -lisdexamfetamine dimesylate cap 30 mg....... 80 VYVANSE -lisdexamfetamine dimesylate cap 40 mg....... 80 VYVANSE -lisdexamfetamine dimesylate cap 50 mg....... 80 VYVANSE -lisdexamfetamine dimesylate cap 60 mg....... 80 VYVANSE -lisdexamfetamine dimesylate cap 70 mg....... 80 VYVANSE -lisdexamfetamine dimesylate chew tab 10 mg.................................................................................... 80 VYVANSE -lisdexamfetamine dimesylate chew tab 20 mg.................................................................................... 80 VYVANSE -lisdexamfetamine dimesylate chew tab 30 mg.................................................................................... 80 VYVANSE -lisdexamfetamine dimesylate chew tab 40 mg.................................................................................... 80 VYVANSE -lisdexamfetamine dimesylate chew tab 50 mg.................................................................................... 81 VYVANSE -lisdexamfetamine dimesylate chew tab 60 mg.................................................................................... 81 W WALGREENS GLUCOSE -glucose chew tab 4 gm......... 33 warfarin sodium tab 1 mg (Coumadin)....................... 136 warfarin sodium tab 2 mg (Coumadin)....................... 136 warfarin sodium tab 2.5 mg (Coumadin).................... 136 warfarin sodium tab 3 mg (Coumadin)....................... 136 warfarin sodium tab 4 mg (Coumadin)....................... 136 warfarin sodium tab 5 mg (Coumadin)....................... 136 warfarin sodium tab 6 mg (Coumadin)....................... 136 warfarin sodium tab 7.5 mg (Coumadin).................... 136 warfarin sodium tab 10 mg (Coumadin)..................... 137 WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 53 WELCHOL -colesevelam hcl tab 625 mg......................... 53 WELLESSE VITAMIN D3 -cholecalciferol oral liquid 1000 unit/10ml........................................................................ 105 WELLNESS ESSENTIALS AI -nutritional supplement kit................................................................................... 132 WELLNESS ESSENTIALS BLOOD -nutritional supplement kit............................................................... 132 WELLNESS ESSENTIALS FOR J -nutritional supplement kit................................................................................... 132 WELLNESS ESSENTIALS FOR M -nutritional supplement kit............................................................... 132 WELLNESS ESSENTIALS FOR P -nutritional supplement kit................................................................................... 132 WELLNESS ESSENTIALS FOR W -nutritional supplement kit............................................................... 132 WELLNESS ESSENTIALS -nutritional supplement kit................................................................................... 132 WESTHROID -thyroid tab 32.5 mg................................... 37 WESTHROID -thyroid tab 65 mg...................................... 37 WESTHROID -thyroid tab 97.5 mg................................... 37 WESTHROID -thyroid tab 130 mg.................................... 37 WESTHROID -thyroid tab 195 mg.................................... 37 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60 mm................................................................................. 156 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65 mm................................................................................. 156 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 70 mm................................................................................. 157 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 75 mm................................................................................. 157 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 80 mm................................................................................. 157 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 85 mm................................................................................. 157 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 90 mm................................................................................. 157 WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 95 mm................................................................................. 157 WILATE -antihemophilic factor/vwf (human) for inj 500-500 unit kit............................................................. 142 WILATE -antihemophilic factor/vwf (human) for inj 1000-1000 unit kit......................................................... 142 WND 1 -nutritional supplement powder.......................... 132 WND 2 -nutritional supplement powder.......................... 132 WP THYROID -thyroid tab 16.25 mg................................ 37 WP THYROID -thyroid tab 32.5 mg.................................. 37 WP THYROID -thyroid tab 65 mg..................................... 37 WP THYROID -thyroid tab 81.25 mg................................ 37 WP THYROID -thyroid tab 97.5 mg.................................. 37 WP THYROID -thyroid tab 113.75 mg.............................. 37 WP THYROID -thyroid tab 130 mg................................... 37 WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 37 X XALKORI -crizotinib cap 200 mg...................................... 22 XALKORI -crizotinib cap 250 mg...................................... 22 XARELTO -rivaroxaban tab 10 mg..................................137 XARELTO -rivaroxaban tab 15 mg..................................137 XARELTO -rivaroxaban tab 20 mg..................................137 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 228 2017 XARELTO STARTER PACK -rivaroxaban tab starter therapy pack 15 mg & 20 mg.......................................137 XARTEMIS XR -oxycodone w/ acetaminophen tab cr 7.5-325 mg...................................................................... 91 XELJANZ -tofacitinib citrate tab 5 mg (base equivalent)....................................................................... 95 XELJANZ XR -tofacitinib citrate tab sr 24hr 11 mg (base equivalent)....................................................................... 95 XIFAXAN -rifaximin tab 200 mg........................................ 12 XIFAXAN -rifaximin tab 550 mg........................................ 13 XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr 5-500 mg......................................................................... 33 XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr 5-1000 mg....................................................................... 33 XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr 10-500 mg....................................................................... 33 XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr 10-1000 mg..................................................................... 33 XIIDRA -lifitegrast ophth soln 5%.................................... 147 XLEU MAXAMAID -nutritional supplement powder........ 132 XLEU MAXAMUM -nutritional supplement powder.........132 XLYS-XTRP MAXAMAID -nutritional supplement powder........................................................................... 132 XLYS-XTRP MAXAMUM -nutritional supplement powder........................................................................... 132 XMET MAXAMAID -nutritional supplement powder........133 XMET MAXAMUM -nutritional supplement powder........ 133 XMTVI MAXAMAID -nutritional supplement powder.......133 XMTVI MAXAMUM -nutritional supplement powder....... 133 XOLEGEL -ketoconazole gel 2%.................................... 155 XPHE MAXAMAID -nutritional supplement powder........ 133 XPHE MAXAMUM -amino acids oral powder................. 115 XPHE MAXAMUM -amino acids pack............................ 115 XPHE-XTYR MAXAMAID -nutritional supplement powder........................................................................... 133 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9 mg.................................................................................... 91 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 13.5 mg........................................................................... 91 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 18 mg.............................................................................. 91 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 27 mg.............................................................................. 91 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 36 mg.............................................................................. 92 XTANDI -enzalutamide cap 40 mg.................................... 22 XTRACAL PLUS -nutritional supplement liquid.............. 133 XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr.......................................................................... 28 XYNTHA -antihemophilic factor recombinant paf for inj kit 250 unit......................................................................... 142 XYNTHA -antihemophilic factor recombinant paf for inj kit 500 unit......................................................................... 142 XYNTHA -antihemophilic factor recombinant paf for inj kit 1000 unit....................................................................... 142 XYNTHA -antihemophilic factor recombinant paf for inj kit 2000 unit....................................................................... 142 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 250 unit................................................... 143 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 500 unit................................................... 143 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 1000 unit................................................. 143 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 2000 unit................................................. 143 XYNTHA SOLOFUSE -antihemophilic factor recombinant paf for inj kit 3000 unit................................................. 143 XYREM -sodium oxybate oral solution 500 mg/ml........... 85 Y Z zafirlukast tab 10 mg (Accolate).................................... 60 zafirlukast tab 20 mg (Accolate).................................... 60 zaleplon cap 5 mg (Sonata)............................................ 77 zaleplon cap 10 mg (Sonata).......................................... 77 ZARONTIN -ethosuximide cap 250 mg.......................... 101 ZARONTIN -ethosuximide soln 250 mg/5ml................... 101 ZARXIO -filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml...................................................................... 135 ZARXIO -filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml...................................................................... 135 ZATEAN-CH -prenatal w/o a w/fe cbn-dss-fa-dha cap 27-1-250 mg.................................................................. 113 ZATEAN-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-300 mg................................................. 113 ZATEAN-PN PLUS -prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................ 113 ZAVESCA -miglustat cap 100 mg................................... 135 ZELAPAR -selegiline hcl orally disintegrating tab 1.25 mg.................................................................................. 104 ZELBORAF -vemurafenib tab 240 mg.............................. 22 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000 unit...................................................64 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit...................................................64 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000 unit................................................ 64 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 15000-51000-82000 unit................................................ 64 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000 unit.............................................. 64 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 25000-85000-136000 unit.............................................. 64 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 229 2017 ZENPEP -pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000 unit............................................ 64 ZEPATIER -elbasvir-grazoprevir tab 50-100 mg............... 11 ZERIT -stavudine for oral soln 1 mg/ml............................ 11 ZETIA -ezetimibe tab 10 mg............................................. 53 ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)..... 11 zidovudine cap 100 mg (Retrovir)................................. 11 zidovudine syrup 10 mg/ml (Retrovir)........................... 11 zidovudine tab 300 mg.................................................... 11 zileuton tab sr 12hr 600 mg (Zyflo cr)........................... 60 ZIOPTAN -tafluprost ophth soln 0.0015%....................... 147 ziprasidone hcl cap 20 mg (Geodon)............................ 76 ziprasidone hcl cap 40 mg (Geodon)............................ 76 ziprasidone hcl cap 60 mg (Geodon)............................ 76 ziprasidone hcl cap 80 mg (Geodon)............................ 76 ZIRGAN -ganciclovir ophth gel 0.15%............................ 147 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................................................... 92 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 15 mg................................................... 92 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 20 mg................................................... 92 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 30 mg................................................... 92 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 40 mg................................................... 92 ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr abuse-deterrent 50 mg................................................... 92 ZOLINZA -vorinostat cap 100 mg..................................... 22 zolmitriptan orally disintegrating tab 2.5 mg (Zomig zmt)................................................................................. 96 zolmitriptan orally disintegrating tab 5 mg (Zomig zmt)................................................................................. 96 zolmitriptan tab 2.5 mg (Zomig)..................................... 96 zolmitriptan tab 5 mg (Zomig)........................................ 96 zolpidem tartrate sl tab 1.75 mg (Intermezzo).............. 77 zolpidem tartrate sl tab 3.5 mg (Intermezzo)................ 77 zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 77 zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 77 zolpidem tartrate tab 5 mg (Ambien).............................77 zolpidem tartrate tab 10 mg (Ambien)...........................77 ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit..........96 ZONALON -doxepin hcl cream 5%................................. 155 zonisamide cap 50 mg.................................................. 101 zonisamide cap 25 mg (Zonegran).............................. 101 zonisamide cap 100 mg (Zonegran)............................ 101 ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base equivalent)..................................................................... 143 ZORTRESS -everolimus tab 0.25 mg............................. 158 ZORTRESS -everolimus tab 0.5 mg............................... 158 ZORTRESS -everolimus tab 0.75 mg............................. 159 ZOSTAVAX -zoster vaccine live for subcutaneous susp 19400 unit/0.65ml........................................................... 15 Z-TUSS AC -chlorpheniramine w/ codeine liquid 2-9 mg/5ml............................................................................. 57 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 0.7-0.18 mg (base eq).................................................... 92 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 1.4-0.36 mg (base eq).................................................... 92 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 2.9-0.71 mg (base eq).................................................... 92 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4 mg (base eq)...................................................................92 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 8.6-2.1 mg (base eq)...................................................................92 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 11.4-2.9 mg (base eq)...................................................................92 ZYBAN -bupropion hcl (smoking deterrent) tab sr 12hr 150 mg............................................................................ 85 ZYCLARA -imiquimod cream 3.75%............................... 155 ZYCLARA PUMP -imiquimod cream 2.5%..................... 155 ZYCLARA PUMP -imiquimod cream 3.75%................... 155 ZYDELIG -idelalisib tab 100 mg........................................ 22 ZYDELIG -idelalisib tab 150 mg........................................ 22 ZYFLO CR -zileuton tab sr 12hr 600 mg.......................... 60 ZYFLO -zileuton tab 600 mg............................................. 60 ZYKADIA -ceritinib cap 150 mg........................................ 22 ZYLET -loteprednol etabonate-tobramycin ophth susp 0.5-0.3%........................................................................ 147 ZYTIGA -abiraterone acetate tab 250 mg......................... 22 Texas Residents -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017 230