Essential to your practice
The Medical Letter on
Drugs and Therapeutics
September 30, 2013
Radium-223 (Xofigo)
for Prostate Cancer
The full article is available to
subscribers
|
September 30, 2013
(Issue: 1426)
Radium Ra 223
dichloride (Xofigo – Bayer), a radiotherapeutic drug, has been
approved by the FDA for intravenous treatment of castration-resistant prostate
cancer with symptomatic bone metastases and no known visceral metastatic
disease.
MECHANISM OF ACTION — Radium-223 is a calcium mimetic that
targets and binds to areas of high bone turnover, such as sites of bone
metastases, and releases high-energy, short-range (<100 a="" alpha="" cytotoxic="" effect.="" localized="" micrometers="" o:p="" particles="" produce="" to="">
STANDARD TREATMENT — Docetaxel-based chemotherapy,
abiraterone acetate (Zytiga), cabazitaxel (Jevtana),
enzalutamide (Xtandi), and the autologous immunotherapy agent
sipuleucel-T (Provenge) have each been shown to prolong
survival in men with metastatic castration-resistant prostate cancer.Although
not ... more
41722-A TX © Prime Therapeutics LLC 07/17 July 2017 Basic
Drug List Please consider talking to your doctor about prescribing preferred
medications, which may help reduce your out-of-pocket costs. This list may help
guide you and your doctor in selecting an appropriate medication for you. The
drug list, also known as a formulary, is regularly updated. Please visit
bcbstx.com for the most up-to-date information. Contents Introduction
...................................................................... I how
drugs are selected ................................................... I How
member payment is determined .............................. I How to use this
list ........................................................... I Generic
drugs ................................................................. II
Coverage considerations ................................................III
Specialty drugs
..............................................................IV Abbreviation
key .............................................................V Therapeutic
Class Drug List Anti-Infective Agents
....................................................... 1 Cancer Drugs
.................................................................. 6 Hormones,
Diabetes and Related Drugs ........................ 8 Heart and Circulatory
Drugs ......................................... 14 Respiratory Agents
....................................................... 24 Gastrointestinal
Drugs .................................................. 27 Genitourinary Drugs
...................................................... 29 Central Nervous
System Drugs .................................... 30 Pain Relief Drugs
.......................................................... 37 Neuromuscular
Drugs ................................................... 42 Supplements
................................................................. 45 Blood
Modifying Drugs .................................................. 45 Topical
Products ........................................................... 51
Miscellaneous Categories (includes Supplies and Devices)
............................................................... 56 Index
.............................................................................
58 To search for a drug name within this PDF document, use the Control and F
keys on your keyboard, or go to Edit in the drop-down menu and select
Find/Search. Type in the word or phrase you are looking for and click on
Search. Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List I Introduction
Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to present the 2017
Drug List. This is a list of preferred drugs which includes Brand drugs and a
partial listing of generic drugs. Members are encouraged to show this list to
their physicians and pharmacists. Physicians are encouraged to prescribe drugs
on this list, when right for the member. However, decisions regarding therapy
and treatment are always between members and their physician. Drug List updates
– This list is regularly updated as generic drugs become available and changes
take place in the pharmaceuticals market. For the most up-to-date information,
visit bcbstx.com and log in to Blue Access for MembersSM or call the number on
the back of your ID card. Physicians can access the list from the provider
portal at bcbstx.com. How drugs are selected Drugs on this list are selected
based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least
one representative from BCBSTX, reviews drugs regulated by the U.S. Food and
Drug Administration (FDA). Both drugs that are newly approved by the FDA as
well as those that have been on the market for some time are considered. Drugs
are selected based on safety, efficacy, cost and how they compare to other
drugs currently on the list. How member payment is determined This list shows
prescription drug products in tiers. Generally, each drug is placed into one of
three or four member payment tiers: generic, Preferred Brand or Non-Preferred
Brand (not listed in this document). Specialty drugs can either be within the
previous three tiers or can be a separate fourth tier depending on your benefit
design. To verify your payment amount for a drug, visit bcbstx.com and log in
to Blue Access for Members or call the number on the back of your ID card. Your
pharmacy benefit includes coverage for many prescription drugs, although some
exclusions may apply. For example, drugs indicated for cosmetic purposes, e.g.,
Propecia, for hair growth, may not be covered. Prescription products that have
over-the-counter (OTC) equivalents may not be covered. Drugs that are not
FDAapproved for self-administration may be available through your medical
benefit. Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List II How to use
this list Generic drugs are shown in lower-case boldface type. Most generic
drugs are followed by a reference brand drug in (parentheses). The reference
brand drug is a non-preferred (NP) brand and is only included as a reference to
the brand. Some generic products have no reference brand. Example: atorvastatin
(Lipitor) Brand drugs are listed in all CAPITAL letters. Example: PROAIR HFA
Drugs used to treat multiple conditions Some drugs in the same dosage form may
be used to treat more than one medical condition. In these instances, each
medication is classified according to its first FDA-approved use. Please check
the index if you do not find your particular medication in the class/condition
section that corresponds to your use. Generic drugs Using generic drugs, when
right for you, can help you save on your out-of-pocket medication costs.
Generic drugs must be approved by the FDA just as brand drugs are, and must
meet the same standards. There are two types of generic drugs: · A generic equivalent is
made with the same active ingredient(s) at the same dosage as the reference
drug. · A generic alternative is
a drug typically used to treat the same condition, but the active ingredient(s)
differs from the brand drug. According to the FDA, compared to its brand
counterpart, an FDA-approved generic drug: ·
Is chemically the same ·
Works just as well in the body ·
Is as safe and effective ·
Meets the same standards set by the FDA The main difference between the
reference brand drug and the generic equivalent is that the generic often costs
much less. Preferred brand drugs typically move to a non-preferred brand tier
after a generic equivalent becomes available. You may be responsible for the
brand member payment amount plus the difference in cost between the brand and
generic equivalent if you or your doctor requests the reference brand rather
than the generic. Generic drugs have the lowest member payment amount. Consider
talking to your doctor about generic drugs If your doctor writes a prescription
for a brand drug that does not have a generic equivalent, consider asking if an
appropriate generic alternative is available. You can also let your pharmacist
know that you would like a generic equivalent for a brand drug, whenever one is
available. Your pharmacist can usually substitute a generic equivalent for its
brand counterpart without a new prescription from your doctor. Only your doctor
can determine whether a generic alternative is right for you and must prescribe
the medication. Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List III Coverage
considerations Most prescription drug benefit plans provide coverage for up to
a 30-day supply of medication, with some exceptions. Your plan may also provide
coverage for up to a 90-day supply of maintenance medications. Maintenance
medications are those drugs you may take on an ongoing basis for conditions
such as high blood pressure, diabetes or high cholesterol. Some plans may
exclude coverage for certain agents or drug categories, like those used for
erectile dysfunction or weight loss. Over-the-counter exclusions: Your benefit
plan may not provide coverage for prescription medications that have an
over-the-counter version. You should refer to your benefit plan material for
details about your particular benefits. Compounded medications: Your benefit
plan may not provide coverage for compounded medications. Please see your plan
materials or call the number on the back of your ID card to determine whether compounded
medications are covered and/or verify your payment amount. Repackaged
medications: Repackaged versions of medications already available on the market
are not covered. Prior Authorization (PA): Your benefit plan may require prior
authorization for certain drugs. This means that your doctor will need to
submit a prior authorization request for coverage of these medications, and the
request will need to be approved, before the medication will be covered under
your plan. For the preferred medications listed in this document, if a prior
authorization is commonly required, it will generally be noted next to the
medication with a dot under the prior authorization column. Some plans may have
prior authorization on additional medications beyond those noted in this
document. Refer to your benefit plan materials for details about your
particular benefits. Step Therapy (ST): Your benefit plan may include a step
therapy program. This means you may need to try another proven, cost-effective
medication before coverage may be available for the drug included in the
program. Many brand drugs have less-expensive generic or brand alternatives
that might be an option for you. For the preferred medications listed in this
document, if a step therapy is commonly required, it will generally be noted
next to the medication with a dot under the step therapy column. Some plans may
have step therapy programs on additional medications beyond those noted in this
document. Refer to your benefit plan materials for details about your
particular benefits. Dispensing Limits (DL): Drug Dispensing limits help
encourage medication use as intended by the FDA. Dispensing limits are placed
on medications in certain drug categories. For the preferred medications listed
in this document, if a dispensing limit applies, it will generally be noted
next to the medication with a dot under the dispensing limits column. Limits
may include: quantity of covered medication per prescription, quantity of
covered medication in a given time period, coverage only for members within a
certain age range, and coverage only for members of a specific gender. If your
doctor prescribes a greater quantity of medication than what the dispensing
limit allows, you can still get the medication. However, you will be responsible
for the full cost of the prescription beyond what your coverage allows.* For a
list of medications and their dispensing limits, visit bcbstx.com. *Please
note: For certain controlled substance medications, some state laws may not
allow coverage by a health benefit plan of such medication if dispensed in a
quantity beyond what the dispensing limit allows. You will be responsible for
the full cost of the prescription with no benefits applied if the dispensed
quantity exceeds the dispensing limit. Remember, medication decisions are
between you and your doctor. Only you and your doctor can determine which
medication is right for you. Discuss any questions or concerns you have about
medications you are taking or are prescribed with your doctor. BCBSTX does not
provide health care services and, therefore, cannot guarantee any results or
outcomes. Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 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 self-administered
or administered by a health care professional. For a current list of specialty
medications, visit myprime.com or bcbstx.com and log in to Blue Access for
Members. Note that some drug classes may be excluded by some plans and
therefore may not be covered under your pharmacy benefit. Your plan may have a
different coverage level for self-administered specialty drugs. If you have
questions about your coverage for specialty medications or your prescription
drug benefit, call the number on the back of your ID card. Prime Therapeutics
Specialty Pharmacy Program Through Prime Therapeutics Specialty Pharmacy,
members can have covered specialty medications delivered directly to them or
their doctor’s office. When you receive specialty medications through Prime,
you also receive at no additional charge the following services: · Coordination of coverage
between you, your doctor and your health plan ·
Educational materials about your particular condition and information about
managing potential medication side effects ·
Syringes, sharps containers and other supplies with every shipment for
self-injectables ·
24/7/365 phone access to a pharmacist for urgent medication issues To order
through Prime Therapeutics Specialty Pharmacy: ·
Have your doctor call or fax your prescription to Prime Therapeutics Specialty
Pharmacy. Your doctor can call 877-627-6337 or fax to 877-828-3939. · If you have an existing
prescription for a covered specialty medication, you can call 877-627-6337 to
transfer your prescription. ·
A Prime Therapeutics coordinator will contact you to arrange delivery of your
medication. · The
prescription can be shipped directly to you or your prescribing doctor’s
office. Each package is individually marked for each member. Refrigerated drugs
are shipped in temperature-controlled packaging. If you have questions, please
contact Prime Therapeutics Specialty Pharmacy at 877-627-6337, visit
www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID
card. * Blue Cross and Blue Shield of Texas (BCBSTX) is a Division of Health
Care Service Corporation, a Mutual Legal Reserve Company, an Independent
Licensee of the Blue Cross and Blue Shield Association. BCBSTX contracts with
Prime Therapeutics to provide pharmacy benefit management, home delivery
pharmacy and specialty pharmacy services. BCBSTX, as well as several
independent Blue Cross and Blue Shield Plans, has an ownership interest in
Prime Therapeutics LLC. Find and estimate prices for medicines on this
formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List V Abbreviation
key cap......................................................................
capsules chew..................................................................
chewable conc .............................................................
concentrate cr ..........................................................
controlled release dr .............................................................
delayed release
ec................................................................ enteric
coated effe.................................................................
effervescent equiv ................................................................
equivalent er ...........................................................
extended release
inhal...................................................................
inhalation inj.........................................................................
injection
liq..............................................................................
liquid lotn
...........................................................................
lotion nebu ...................................................................
nebulizer odt ............................................. orally
disintegrating tabs oint
..................................................................... ointment
ophth...............................................................ophthalmic
osm.......................................................... osmotic release
powd.....................................................................
powder sa ............................................................ sustained
action sl
......................................................................
sublingual
soln.......................................................................
solution sr ..........................................................
sustained release suppos
........................................................ suppositories
susp................................................................ suspension
tab...........................................................................
tablets td ...................................................................
transdermal Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 1 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy ANTI-INFECTIVE AGENTS
PENICILLINS amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap
500 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate)
for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin
(trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg
amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate for susp
200-28.5 mg/5ml amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin) amoxicillin & k clavulanate for susp 400-57 mg/5ml amoxicillin
& k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) amoxicillin
& k clavulanate tab sr 12hr 1000-62.5 mg (Augmentin xr) amoxicillin & k
clavulanate tab 250-125 mg amoxicillin & k clavulanate tab 500-125 mg
(Augmentin) amoxicillin & k clavulanate tab 875-125 mg (Augmentin)
ampicillin cap 250 mg ampicillin cap 500 mg dicloxacillin sodium cap 250 mg
dicloxacillin sodium cap 500 mg penicillin v potassium for soln 125 mg/5ml Drug
Name Specialty Prior Authorization Dispensing Limits Step Therapy penicillin v
potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v
potassium tab 500 mg CEPHALOSPORINS cefaclor cap 250 mg cefaclor cap 500 mg
cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500
mg/5ml cefadroxil tab 1 gm cefdinir cap 300 mg cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml cefixime for susp 100 mg/5ml (Suprax) cefixime for
susp 200 mg/5ml (Suprax) cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime
proxetil for susp 100 mg/5ml cefpodoxime proxetil tab 100 mg cefpodoxime
proxetil tab 200 mg cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg cefprozil tab 500 mg CEFTIN – cefuroxime axetil for susp
125 mg/5ml ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg
(Rocephin) ceftriaxone sodium for inj 1 gm (Rocephin) 2017 Find and estimate
prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 2 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy ceftriaxone sodium
for inj 2 gm cefuroxime axetil tab 250 mg (Ceftin) cefuroxime axetil tab 500 mg
(Ceftin) cephalexin cap 250 mg (Keflex) cephalexin cap 500 mg (Keflex)
cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml MACROLIDES
AZITHROMYCIN – azithromycin powd pack for susp 1 gm azithromycin for susp 100
mg/5ml (Zithromax) azithromycin for susp 200 mg/5ml (Zithromax) azithromycin
tab 250 mg (Zithromax) • azithromycin tab 500 mg (Zithromax) • azithromycin tab
600 mg (Zithromax) • clarithromycin for susp 125 mg/5ml clarithromycin for susp
250 mg/5ml (Biaxin) clarithromycin tab sr 24hr 500 mg (Biaxin xl pac) •
clarithromycin tab 250 mg (Biaxin) clarithromycin tab 500 mg (Biaxin)
erythromycin w/ delayed release particles cap 250 mg TETRACYCLINES
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 Drug Name Specialty Prior Authorization
Dispensing Limits Step Therapy doxycycline monohydrate cap 50 mg doxycycline
monohydrate cap 75 mg (Monodox) • doxycycline monohydrate cap 100 mg (Monodox)
doxycycline monohydrate cap 150 mg (Adoxa) • doxycycline monohydrate tab 50 mg
(Adoxa) doxycycline monohydrate tab 75 mg (Adoxa) doxycycline monohydrate tab
100 mg (Adoxa pak 1/100) doxycycline monohydrate tab 150 mg (Adoxa pak 1/150) •
minocycline hcl cap 50 mg (Minocin) minocycline hcl cap 75 mg (Minocin)
minocycline hcl cap 100 mg (Minocin) minocycline hcl tab 50 mg minocycline hcl
tab 75 mg minocycline hcl tab 100 mg tetracycline hcl cap 250 mg (Tetracycline
hcl) tetracycline hcl cap 500 mg (Tetracycline hcl) FLUOROQUINOLONES ciprofloxacin
for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml) (Cipro) ciprofloxacin hcl tab 250 mg (base
equiv) (Cipro) ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) 2017 Find and
estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 3 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy ciprofloxacin hcl
tab 750 mg (base equiv) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base
eq) (Cipro xr) levofloxacin tab 250 mg (Levaquin) levofloxacin tab 500 mg
(Levaquin) levofloxacin tab 750 mg (Levaquin) ofloxacin tab 400 mg
AMINOGLYCOSIDES neomycin sulfate tab 500 mg paromomycin sulfate cap 250 mg
tobramycin nebu soln 300 mg/5ml (Tobi) • • TUBERCULOSIS ethambutol hcl tab 100
mg (Myambutol) ethambutol hcl tab 400 mg (Myambutol) isoniazid tab 100 mg
isoniazid tab 300 mg PRIFTIN – rifapentine tab 150 mg pyrazinamide tab 500 mg
rifabutin cap 150 mg (Mycobutin) rifampin cap 150 mg (Rifadin) rifampin cap 300
mg (Rifadin) FUNGAL INFECTIONS fluconazole for susp 10 mg/ml (Diflucan) fluconazole
for susp 40 mg/ml (Diflucan) fluconazole tab 50 mg (Diflucan) fluconazole tab
100 mg (Diflucan) fluconazole tab 150 mg (Diflucan) Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy fluconazole tab 200 mg (Diflucan)
flucytosine cap 250 mg (Ancobon) flucytosine cap 500 mg (Ancobon) griseofulvin
microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg (Grifulvin v)
itraconazole cap 100 mg (Sporanox) • NOXAFIL – posaconazole tab delayed release
100 mg • NOXAFIL – posaconazole susp 40 mg/ ml • nystatin tab 500000 unit
terbinafine hcl tab 250 mg (Lamisil) voriconazole for susp 40 mg/ml (Vfend) •
voriconazole tab 50 mg (Vfend) • voriconazole tab 200 mg (Vfend) • VIRAL
INFECTIONS Cytomegalovirus VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv) valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte)
valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) Hepatitis adefovir
dipivoxil tab 10 mg (Hepsera) BARACLUDE – entecavir oral soln 0.05 mg/ml
DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base equivalent) • • 2017
Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 4 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy DAKLINZA –
daclatasvir dihydrochloride tab 60 mg (base equivalent) • • DAKLINZA –
daclatasvir dihydrochloride tab 90 mg (base equivalent) • • entecavir tab 0.5
mg (Baraclude) entecavir tab 1 mg (Baraclude) EPCLUSA – sofosbuvir-velpatasvir
tab 400-100 mg • • HARVONI – ledipasvir-sofosbuvir tab 90-400 mg • • lamivudine
tab 100 mg (hbv) (Epivir hbv) PEGASYS – peginterferon alfa-2a inj 180 mcg/ml •
• PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml • • PEGASYS PROCLICK –
peginterferon alfa-2a inj 135 mcg/0.5ml • • PEGASYS PROCLICK – peginterferon
alfa-2a inj 180 mcg/0.5ml • • ribavirin cap 200 mg (Rebetol) • ribavirin tab
200 mg (Copegus) • SOVALDI – sofosbuvir tab 400 mg • • Herpes acyclovir cap 200
mg (Zovirax) acyclovir susp 200 mg/5ml (Zovirax) acyclovir tab 400 mg (Zovirax)
acyclovir tab 800 mg (Zovirax) famciclovir tab 125 mg (Famvir) famciclovir tab
250 mg (Famvir) famciclovir tab 500 mg (Famvir) valacyclovir hcl tab 500 mg
(Valtrex) valacyclovir hcl tab 1 gm (Valtrex) Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy HIV/AIDS abacavir sulfate tab 300
mg (base equiv) (Ziagen) • abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)
• abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg (Trizivir) • ATRIPLA
– efavirenz-emtricitabinetenofovir df tab 600-200-300 mg • DESCOVY –
emtricitabine-tenofovir alafenamide fumarate tab 200-25 mg • didanosine delayed
release capsule 125 mg (Videx ec) • didanosine delayed release capsule 200 mg
(Videx ec) • didanosine delayed release capsule 250 mg (Videx ec) • didanosine
delayed release capsule 400 mg (Videx ec) • EPZICOM – abacavir
sulfatelamivudine tab 600-300 mg • GENVOYA – elvitegrav-cobicemtricitab-tenofov
af tab 150-150-200-10 mg • INTELENCE – etravirine tab 25 mg • INTELENCE –
etravirine tab 100 mg • INTELENCE – etravirine tab 200 mg • ISENTRESS –
raltegravir potassium tab 400 mg (base equiv) • ISENTRESS – raltegravir
potassium packet for susp 100 mg (base equiv) • ISENTRESS – raltegravir
potassium chew tab 25 mg (base equiv) • ISENTRESS – raltegravir potassium chew
tab 100 mg (base equiv) • 2017 Find and estimate prices for medicines on this
formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 5 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy KALETRA –
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) • KALETRA –
lopinavir-ritonavir tab 100-25 mg • KALETRA – lopinavir-ritonavir tab 200-50 mg
• lamivudine oral soln 10 mg/ml (Epivir) • lamivudine tab 150 mg (Epivir) •
lamivudine tab 300 mg (Epivir) • lamivudine-zidovudine tab 150-300 mg
(Combivir) • lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) •
nevirapine tab sr 24hr 100 mg (Viramune xr) • nevirapine tab sr 24hr 400 mg
(Viramune xr) • nevirapine tab 200 mg (Viramune) • NORVIR – ritonavir tab 100
mg • NORVIR – ritonavir oral soln 80 mg/ml • ODEFSEY –
emtricitabine-rilpivirinetenofovir af tab 200-25-25 mg • PREZISTA – darunavir
ethanolate susp 100 mg/ml (base equiv) • PREZISTA – darunavir ethanolate tab 75
mg (base equiv) • PREZISTA – darunavir ethanolate tab 150 mg (base equiv) •
PREZISTA – darunavir ethanolate tab 600 mg (base equiv) • PREZISTA – darunavir
ethanolate tab 800 mg (base equiv) • REYATAZ – atazanavir sulfate cap 150 mg
(base equiv) • Drug Name Specialty Prior Authorization Dispensing Limits Step
Therapy REYATAZ – atazanavir sulfate cap 200 mg (base equiv) • REYATAZ –
atazanavir sulfate cap 300 mg (base equiv) • stavudine cap 15 mg (Zerit) •
stavudine cap 20 mg (Zerit) • stavudine cap 30 mg (Zerit) • stavudine cap 40 mg
(Zerit) • STRIBILD – elvitegrav-cobic-emtricitabtenofovdf tab 150-150-200-300
mg • SUSTIVA – efavirenz tab 600 mg • SUSTIVA – efavirenz cap 50 mg • SUSTIVA –
efavirenz cap 200 mg • TIVICAY – dolutegravir sodium tab 10 mg (base equiv) •
TIVICAY – dolutegravir sodium tab 25 mg (base equiv) • TIVICAY – dolutegravir
sodium tab 50 mg (base equiv) • TRUVADA – emtricitabine-tenofovir disoproxil
fumarate tab 100-150 mg • TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 133-200 mg • TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab
167-250 mg • TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 200-300
mg • VIDEX – didanosine for soln 2 gm • VIDEX – didanosine for soln 4 gm •
VIRAMUNE – nevirapine susp 50 mg/5ml • VIREAD – tenofovir disoproxil fumarate
oral powder 40 mg/gm • VIREAD – tenofovir disoproxil fumarate tab 150 mg • 2017
Find and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 6 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy VIREAD – tenofovir
disoproxil fumarate tab 200 mg • VIREAD – tenofovir disoproxil fumarate tab 250
mg • VIREAD – tenofovir disoproxil fumarate tab 300 mg • ZIAGEN – abacavir
sulfate soln 20 mg/ ml (base equiv) • zidovudine cap 100 mg (Retrovir) •
zidovudine syrup 10 mg/ml (Retrovir) • zidovudine tab 300 mg • oseltamivir
phosphate cap 30 mg (base equiv) (Tamiflu) • oseltamivir phosphate cap 45 mg
(base equiv) (Tamiflu) • oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu)
• MALARIA atovaquone-proguanil hcl tab 62.5-25 mg (Malarone)
atovaquone-proguanil hcl tab 250-100 mg (Malarone) chloroquine phosphate tab
500 mg (Aralen) DARAPRIM – pyrimethamine tab 25 mg • • hydroxychloroquine
sulfate tab 200 mg (Plaquenil) mefloquine hcl tab 250 mg PRIMAQUINE PHOSPHATE –
primaquine phosphate tab 26.3 mg (15 mg base) WORM INFECTIONS ALBENZA –
albendazole tab 200 mg BILTRICIDE – praziquantel tab 600 mg ivermectin tab 3 mg
(Stromectol) OTHER ANTI-INFECTIVES Drug Name Specialty Prior Authorization
Dispensing Limits Step Therapy clindamycin hcl cap 75 mg (Cleocin) clindamycin
hcl cap 150 mg (Cleocin) clindamycin hcl cap 300 mg (Cleocin) clindamycin
palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) dapsone
tab 25 mg dapsone tab 100 mg IMPAVIDO – miltefosine cap 50 mg linezolid for
susp 100 mg/5ml (Zyvox) • linezolid tab 600 mg (Zyvox) • metronidazole tab 250
mg (Flagyl) metronidazole tab 500 mg (Flagyl) SIVEXTRO – tedizolid phosphate
tab 200 mg • sulfamethoxazole-trimethoprim susp 200-40 mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)
sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) trimethoprim tab 100
mg vancomycin hcl cap 125 mg (Vancocin hcl) vancomycin hcl cap 250 mg (Vancocin
hcl) XIFAXAN – rifaximin tab 550 mg • CANCER DRUGS ACTIMMUNE – interferon
gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml) • AFINITOR – everolimus tab 2.5
mg • • • AFINITOR – everolimus tab 5 mg • • • AFINITOR – everolimus tab 7.5 mg
• • • AFINITOR – everolimus tab 10 mg • • • 2017 Find and estimate prices for
medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 7 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy ALKERAN –
melphalan tab 2 mg anastrozole tab 1 mg (Arimidex) bexarotene cap 75 mg
(Targretin) • • • bicalutamide tab 50 mg (Casodex) capecitabine tab 150 mg
(Xeloda) • • capecitabine tab 500 mg (Xeloda) • • COTELLIC – cobimetinib
fumarate tab 20 mg (base equivalent) • • • EMCYT – estramustine phosphate
sodium cap 140 mg exemestane tab 25 mg (Aromasin) FARESTON – toremifene citrate
tab 60 mg (base equivalent) flutamide cap 125 mg hydroxyurea cap 500 mg
(Hydrea) IBRANCE – palbociclib cap 75 mg • • • IBRANCE – palbociclib cap 100 mg
• • • IBRANCE – palbociclib cap 125 mg • • • imatinib mesylate tab 100 mg (base
equivalent) (Gleevec) • • • imatinib mesylate tab 400 mg (base equivalent)
(Gleevec) • • • KISQALI – ribociclib succinate tab 200 mg (base equiv) • • •
letrozole tab 2.5 mg (Femara) LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg
LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg leucovorin calcium tab 5 mg
leucovorin calcium tab 25 mg LEUKERAN – chlorambucil tab 2 mg megestrol acetate
susp 40 mg/ml (Megace oral) megestrol acetate tab 20 mg Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy megestrol acetate tab 40 mg
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) • • •
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base equivalent) • • •
mercaptopurine tab 50 mg (Purinethol) MESNEX – mesna tab 400 mg methotrexate
sodium tab 2.5 mg (base equiv) MYLERAN – busulfan tab 2 mg NEXAVAR – sorafenib
tosylate tab 200 mg (base equivalent) • • • NILANDRON – nilutamide tab 150 mg
nilutamide tab 150 mg (Nilandron) PURIXAN – mercaptopurine susp 2000 mg/100ml
(20 mg/ml) • SPRYCEL – dasatinib tab 20 mg • • • SPRYCEL – dasatinib tab 50 mg
• • • SPRYCEL – dasatinib tab 70 mg • • • SPRYCEL – dasatinib tab 80 mg • • •
SPRYCEL – dasatinib tab 100 mg • • • SPRYCEL – dasatinib tab 140 mg • • •
SUTENT – sunitinib malate cap 12.5 mg (base equivalent) • • • SUTENT –
sunitinib malate cap 25 mg (base equivalent) • • • SUTENT – sunitinib malate
cap 37.5 mg (base equivalent) • • • SUTENT – sunitinib malate cap 50 mg (base
equivalent) • • • SYLATRON – peginterferon alfa-2b for inj kit 200 mcg • • •
SYLATRON – peginterferon alfa-2b for inj kit 300 mcg • • • 2017 Find and
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 8 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy SYLATRON –
peginterferon alfa-2b for inj kit 600 mcg • • • TABLOID – thioguanine tab 40 mg
TAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent) • • • TAFINLAR –
dabrafenib mesylate cap 75 mg (base equivalent) • • • tamoxifen citrate tab 10
mg (base equivalent) tamoxifen citrate tab 20 mg (base equivalent) TARCEVA –
erlotinib hcl tab 25 mg (base equivalent) • • • TARCEVA – erlotinib hcl tab 100
mg (base equivalent) • • • TARCEVA – erlotinib hcl tab 150 mg (base equivalent)
• • • TASIGNA – nilotinib hcl cap 150 mg (base equivalent) • • • TASIGNA –
nilotinib hcl cap 200 mg (base equivalent) • • • temozolomide cap 5 mg
(Temodar) • • temozolomide cap 20 mg (Temodar) • • temozolomide cap 100 mg
(Temodar) • • temozolomide cap 140 mg (Temodar) • • temozolomide cap 180 mg
(Temodar) • • temozolomide cap 250 mg (Temodar) • • tretinoin cap 10 mg • •
TREXALL – methotrexate sodium tab 5 mg (base equiv) TREXALL – methotrexate
sodium tab 7.5 mg (base equiv) TREXALL – methotrexate sodium tab 10 mg (base
equiv) TREXALL – methotrexate sodium tab 15 mg (base equiv) Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy VOTRIENT – pazopanib hcl tab
200 mg (base equiv) • • • XALKORI – crizotinib cap 200 mg • • • XALKORI –
crizotinib cap 250 mg • • • XTANDI – enzalutamide cap 40 mg • • • ZELBORAF –
vemurafenib tab 240 mg • • • ZYTIGA – abiraterone acetate tab 250 mg • • •
ZYTIGA – abiraterone acetate tab 500 mg • • • HORMONES, DIABETES AND RELATED
DRUGS CORTICOSTEROIDS budesonide delayed release particles cap 3 mg (Entocort
ec) CORTISONE ACETATE – cortisone acetate tab 25 mg DEXAMETHASONE – dexamethasone
soln 0.5 mg/5ml dexamethasone elixir 0.5 mg/5ml dexamethasone tab 0.5 mg
dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 4 mg
dexamethasone tab 6 mg fludrocortisone acetate tab 0.1 mg hydrocortisone tab 5
mg (Cortef) hydrocortisone tab 10 mg (Cortef) hydrocortisone tab 20 mg (Cortef)
methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)
methylprednisolone tab 4 mg (Medrol) methylprednisolone tab 8 mg (Medrol) 2017
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 9 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy methylprednisolone
tab 16 mg (Medrol) methylprednisolone tab 32 mg (Medrol) prednisolone sod
phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred) prednisolone sod
phosphate oral soln 15 mg/5ml (base equiv) prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone) PREDNISONE – prednisone tab 50 mg PREDNISONE –
prednisone oral soln 5 mg/5ml PREDNISONE INTENSOL – prednisone conc 5 mg/ml
prednisone tab 1 mg prednisone tab 2.5 mg prednisone tab 5 mg prednisone tab 10
mg prednisone tab 20 mg MALE HORMONES ANDROGEL – testosterone td gel 20.25
mg/1.25gm (1.62%) • • ANDROGEL – testosterone td gel 40.5 mg/2.5gm (1.62%) • •
ANDROGEL PUMP – testosterone td gel 20.25 mg/act (1.62%) • • ANDROXY –
fluoxymesterone tab 10 mg • AXIRON – testosterone td soln 30 mg/ act • •
danazol cap 50 mg • danazol cap 100 mg • danazol cap 200 mg • Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy testosterone
cypionate im inj in oil 100 mg/ml (Depo-testosterone) • • testosterone
cypionate im inj in oil 200 mg/ml (Depo-testosterone) • • testosterone enanthate
im inj in oil 200 mg/ml • • testosterone td gel 25 mg/2.5gm (1%) (Androgel) • •
testosterone td gel 50 mg/5gm (1%) (Androgel) • • testosterone td gel 12.5
mg/act (1%) (Androgel pump) • • ESTROGENS COMBIPATCH – estradiolnorethindrone
ace td pttw 0.05-0.14 mg/day COMBIPATCH – estradiolnorethindrone ace td pttw
0.05-0.25 mg/day DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%) DIVIGEL –
estradiol td gel 0.5 mg/0.5gm (0.1%) DIVIGEL – estradiol td gel 1 mg/gm (0.1%)
estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) estradiol
& norethindrone acetate tab 1-0.5 mg (Activella) estradiol tab 0.5 mg
(Estrace) estradiol tab 1 mg (Estrace) estradiol tab 2 mg (Estrace) estradiol
td patch twice weekly 0.025 mg/24hr (Vivelle-dot) • estradiol td patch twice
weekly 0.0375 mg/24hr (Vivelle-dot) • 2017 Find and estimate prices for
medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 10 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy estradiol td patch
twice weekly 0.05 mg/24hr (Vivelle-dot) • estradiol td patch twice weekly 0.075
mg/24hr (Vivelle-dot) • estradiol td patch twice weekly 0.1 mg/24hr
(Vivelle-dot) • estradiol td patch weekly 0.025 mg/24hr (Climara) • 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) • estradiol td patch weekly 0.075 mg/24hr (Climara) • estradiol td
patch weekly 0.1 mg/24hr (Climara) • norethindrone acetate-ethinyl estradiol
tab 0.5 mg-2.5 mcg (Femhrt low dose) norethindrone acetate-ethinyl estradiol
tab 1 mg-5 mcg PROGESTINS medroxyprogesterone acetate tab 2.5 mg (Provera) medroxyprogesterone
acetate tab 5 mg (Provera) medroxyprogesterone acetate tab 10 mg (Provera)
norethindrone acetate tab 5 mg (Aygestin) progesterone micronized cap 100 mg
(Prometrium) progesterone micronized cap 200 mg (Prometrium) Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy BIRTH CONTROL ELLA
– ulipristal acetate tab 30 mg • MIRENA – levonorgestrel releasing iud 20
mcg/day (52 mg total) NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr • oral contraceptives– all generics • SKYLA –
levonorgestrel releasing iud 14 mcg/day (13.5 mg total) INFERTILITY chorionic
gonadotropin for inj 10000 unit • • FOLLISTIM AQ – follitropin beta inj 75
unit/0.5ml • • FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml • •
FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml • • FOLLISTIM AQ –
follitropin beta inj 900 unit/1.08ml • • GANIRELIX ACETATE – ganirelix acetate
inj 250 mcg/0.5ml • • DIABETES acarbose tab 25 mg (Precose) acarbose tab 50 mg
(Precose) acarbose tab 100 mg (Precose) BYDUREON – exenatide for inj extended
release susp 2 mg • • BYDUREON PEN – exenatide extended release for susp
peninjector 2 mg • • glimepiride tab 1 mg (Amaryl) glimepiride tab 2 mg
(Amaryl) glimepiride tab 4 mg (Amaryl) glipizide tab sr 24hr 2.5 mg (Glucotrol
xl) 2017 Find and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 11 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy glipizide tab sr
24hr 5 mg (Glucotrol xl) glipizide tab sr 24hr 10 mg (Glucotrol xl) glipizide
tab 5 mg (Glucotrol) glipizide tab 10 mg (Glucotrol) glipizide-metformin hcl
tab 2.5-250 mg glipizide-metformin hcl tab 2.5-500 mg glipizide-metformin hcl
tab 5-500 mg GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg
glyburide micronized tab 1.5 mg (Glynase) glyburide micronized tab 3 mg
(Glynase) glyburide micronized tab 6 mg (Glynase) glyburide tab 1.25 mg
glyburide tab 2.5 mg glyburide tab 5 mg glyburide-metformin tab 1.25-250 mg
(Glucovance) glyburide-metformin tab 2.5-500 mg (Glucovance)
glyburide-metformin tab 5-500 mg (Glucovance) INVOKAMET –
canagliflozin-metformin hcl tab 50-500 mg • INVOKAMET – canagliflozin-metformin
hcl tab 50-1000 mg • INVOKAMET – canagliflozin-metformin hcl tab 150-500 mg •
INVOKAMET – canagliflozin-metformin hcl tab 150-1000 mg • Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy INVOKAMET XR –
canagliflozinmetformin hcl tab sr 24hr 50-500 mg • INVOKAMET XR –
canagliflozinmetformin hcl tab sr 24hr 50-1000 mg • INVOKAMET XR –
canagliflozinmetformin hcl tab sr 24hr 150-500 mg • INVOKAMET XR –
canagliflozinmetformin hcl tab sr 24hr 150-1000 mg • INVOKANA – canagliflozin
tab 100 mg • INVOKANA – canagliflozin tab 300 mg • JANUMET –
sitagliptin-metformin hcl tab 50-500 mg • JANUMET – sitagliptin-metformin hcl
tab 50-1000 mg • JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-500 mg •
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-1000 mg • JANUMET XR –
sitagliptin-metformin hcl tab sr 24hr 100-1000 mg • JANUVIA – sitagliptin
phosphate tab 25 mg (base equiv) • JANUVIA – sitagliptin phosphate tab 50 mg
(base equiv) • JANUVIA – sitagliptin phosphate tab 100 mg (base equiv) •
JARDIANCE – empagliflozin tab 10 mg • JARDIANCE – empagliflozin tab 25 mg •
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 2.5-1000 mg • KOMBIGLYZE
XR – saxagliptinmetformin hcl tab sr 24hr 5-500 mg • KOMBIGLYZE XR –
saxagliptinmetformin hcl tab sr 24hr 5-1000 mg • 2017 Find and estimate prices
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 12 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy metformin hcl tab
sr 24hr 500 mg (Glucophage xr) metformin hcl tab sr 24hr 750 mg (Glucophage xr)
metformin hcl tab 500 mg (Glucophage) metformin hcl tab 850 mg (Glucophage)
metformin hcl tab 1000 mg (Glucophage) nateglinide tab 60 mg (Starlix)
nateglinide tab 120 mg (Starlix) ONGLYZA – saxagliptin hcl tab 2.5 mg (base
equiv) • ONGLYZA – saxagliptin hcl tab 5 mg (base equiv) • pioglitazone hcl tab
15 mg (base equiv) (Actos) pioglitazone hcl tab 30 mg (base equiv) (Actos)
pioglitazone hcl tab 45 mg (base equiv) (Actos) pioglitazone hcl-metformin hcl
tab 15-500 mg (Actoplus met) pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met) repaglinide tab 0.5 mg (Prandin) repaglinide tab 1 mg (Prandin)
repaglinide tab 2 mg (Prandin) SYNJARDY – empagliflozin-metformin hcl tab 5-500
mg • SYNJARDY – empagliflozin-metformin hcl tab 5-1000 mg • SYNJARDY –
empagliflozin-metformin hcl tab 12.5-500 mg • SYNJARDY –
empagliflozin-metformin hcl tab 12.5-1000 mg • Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy VICTOZA – liraglutide soln
pen-injector 18 mg/3ml (6 mg/ml) • • DIABETES - INSULINS Rapid-Acting Insulins
NOVOLOG – insulin aspart inj 100 unit/ ml • NOVOLOG FLEXPEN – insulin aspart
soln pen-injector 100 unit/ml • NOVOLOG PENFILL – insulin aspart soln cartridge
100 unit/ml • Short-Acting Insulins HUMULIN R U-500 (CONCENTR – insulin regular
(human) inj 500 unit/ml • HUMULIN R U-500 KWIKPEN – insulin regular (human)
soln pen-injector 500 unit/ml • NOVOLIN R – insulin regular (human) inj 100
unit/ml • Intermediate-Acting Insulins NOVOLIN N – insulin nph (human)
(isophane) inj 100 unit/ml • NOVOLIN 70/30 – insulin nph isophane & regular
human inj 100 unit/ml (70-30) • NOVOLOG MIX 70/30 – insulin aspart prot &
aspart (human) inj 100 unit/ml (70-30) • NOVOLOG MIX 70/30 PREFILL – insulin
aspart prot & aspart sus peninj 100 unit/ml (70-30) • Basal Insulins LANTUS
– insulin glargine inj 100 unit/ ml • LANTUS SOLOSTAR – insulin glargine soln
pen-injector 100 unit/ml • LEVEMIR – insulin detemir inj 100 unit/ ml • 2017
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 13 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy LEVEMIR FLEXTOUCH
– insulin detemir soln pen-injector 100 unit/ml • TOUJEO SOLOSTAR – insulin
glargine soln pen-injector 300 unit/ml • TRESIBA FLEXTOUCH – insulin degludec
soln pen-injector 100 unit/ ml • TRESIBA FLEXTOUCH – insulin degludec soln
pen-injector 200 unit/ ml • THYROID REGULATION levothyroxine sodium tab 25 mcg
(Synthroid) levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium
tab 75 mcg (Synthroid) levothyroxine sodium tab 88 mcg (Synthroid)
levothyroxine sodium tab 100 mcg (Synthroid) 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) Drug Name Specialty Prior Authorization Dispensing Limits Step
Therapy liothyronine sodium tab 25 mcg (Cytomel) liothyronine sodium tab 50 mcg
(Cytomel) methimazole tab 5 mg (Tapazole) methimazole tab 10 mg (Tapazole)
propylthiouracil tab 50 mg GROWTH HORMONE INCRELEX – mecasermin inj 40 mg/4ml
(10 mg/ml) • OMNITROPE – somatropin for inj 5.8 mg • • OMNITROPE – somatropin
inj 5 mg/1.5ml • • OMNITROPE – somatropin inj 10 mg/1.5ml • • OTHER HORMONES
AND RELATED DRUGS alendronate sodium tab 5 mg • alendronate sodium tab 10 mg •
alendronate sodium tab 35 mg • alendronate sodium tab 70 mg (Fosamax) •
cabergoline tab 0.5 mg calcitonin (salmon) nasal soln 200 unit/act (Miacalcin)
calcitriol cap 0.25 mcg (Rocaltrol) calcitriol cap 0.5 mcg (Rocaltrol)
calcitriol oral soln 1 mcg/ml (Rocaltrol) desmopressin acetate inj 4 mcg/ml
(Ddavp) desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp)
desmopressin acetate nasal spray soln 0.01% (Ddavp) 2017 Find and estimate
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 14 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy desmopressin
acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg
(Ddavp) desmopressin acetate tab 0.2 mg (Ddavp) FORTEO – teriparatide
(recombinant) inj 600 mcg/2.4ml • • • ibandronate sodium tab 150 mg (base
equivalent) (Boniva) • levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)
levocarnitine tab 330 mg (Carnitor) octreotide acetate inj 50 mcg/ml (0.05
mg/ml) (Sandostatin) • octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin) • octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) •
octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) • octreotide
acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) • ORFADIN – nitisinone susp 4
mg/ml • ORFADIN – nitisinone cap 2 mg • ORFADIN – nitisinone cap 5 mg • ORFADIN
– nitisinone cap 10 mg • ORFADIN – nitisinone cap 20 mg • paricalcitol cap 1
mcg (Zemplar) paricalcitol cap 2 mcg (Zemplar) paricalcitol cap 4 mcg (Zemplar)
raloxifene hcl tab 60 mg (Evista) risedronate sodium tab 5 mg (Actonel) •
risedronate sodium tab 30 mg (Actonel) • Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy risedronate sodium tab 35 mg
(Actonel) • risedronate sodium tab 150 mg (Actonel) • SENSIPAR – cinacalcet hcl
tab 30 mg (base equiv) SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)
SENSIPAR – cinacalcet hcl tab 90 mg (base equiv) STIMATE – desmopressin acetate
nasal soln 1.5 mg/ml STRENSIQ – asfotase alfa subcutaneous inj 18 mg/0.45ml • •
STRENSIQ – asfotase alfa subcutaneous inj 28 mg/0.7ml • • STRENSIQ – asfotase
alfa subcutaneous inj 40 mg/ml • • STRENSIQ – asfotase alfa subcutaneous inj 80
mg/0.8ml • • HEART AND CIRCULATORY DRUGS ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATI benazepril & hydrochlorothiazide tab 5-6.25 mg
benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin a) benazepril
& hydrochlorothiazide tab 20-12.5 mg (Lotensin a) benazepril &
hydrochlorothiazide tab 20-25 mg (Lotensin hct) benazepril hcl tab 5 mg
benazepril hcl tab 10 mg (Lotensin) benazepril hcl tab 20 mg (Lotensin)
benazepril hcl tab 40 mg (Lotensin) captopril tab 12.5 mg 2017 Find and
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 15 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy captopril tab 25
mg captopril tab 50 mg captopril tab 100 mg enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg enalapril maleate & hydrochlorothiazide
tab 10-25 mg (Vaseretic) enalapril maleate tab 2.5 mg (Vasotec) enalapril
maleate tab 5 mg (Vasotec) enalapril maleate tab 10 mg (Vasotec) enalapril
maleate tab 20 mg (Vasotec) fosinopril sodium & hydrochlorothiazide tab
10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg
fosinopril sodium tab 10 mg fosinopril sodium tab 20 mg fosinopril sodium tab
40 mg lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic)
lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) lisinopril
& hydrochlorothiazide tab 20-25 mg (Zestoretic) lisinopril tab 2.5 mg
(Zestril) lisinopril tab 5 mg (Prinivil) lisinopril tab 10 mg (Prinivil)
lisinopril tab 20 mg (Prinivil) lisinopril tab 30 mg (Zestril) lisinopril tab
40 mg (Zestril) moexipril hcl tab 7.5 mg (Univasc) moexipril hcl tab 15 mg
(Univasc) Drug Name Specialty Prior Authorization Dispensing Limits Step
Therapy moexipril-hydrochlorothiazide tab 7.5-12.5 mg moexipril-hydrochlorothiazide
tab 15-12.5 mg (Uniretic) moexipril-hydrochlorothiazide tab 15-25 mg
perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg (Aceon) perindopril
erbumine tab 8 mg (Aceon) quinapril hcl tab 5 mg (Accupril) quinapril hcl tab
10 mg (Accupril) quinapril hcl tab 20 mg (Accupril) quinapril hcl tab 40 mg
(Accupril) quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic)
quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic)
quinapril-hydrochlorothiazide 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) trandolapril tab 1 mg (Mavik) trandolapril tab 2 mg (Mavik)
trandolapril tab 4 mg (Mavik) ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND
COMBINATIONS amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg (Exforge
hct) amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg (Exforge hct) 2017
Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 16 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy
amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg (Exforge hct)
amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg (Exforge hct)
amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg (Exforge hct) BENICAR
– olmesartan medoxomil tab 5 mg BENICAR – olmesartan medoxomil tab 20 mg
BENICAR – olmesartan medoxomil tab 40 mg BENICAR HCT – olmesartan
medoxomil-hydrochlorothiazide tab 20-12.5 mg BENICAR HCT – olmesartan
medoxomil-hydrochlorothiazide tab 40-12.5 mg BENICAR HCT – olmesartan
medoxomil-hydrochlorothiazide tab 40-25 mg candesartan cilexetil tab 4 mg
(Atacand) candesartan cilexetil tab 8 mg (Atacand) candesartan cilexetil tab 16
mg (Atacand) candesartan cilexetil tab 32 mg (Atacand) candesartan
cilexetilhydrochlorothiazide tab 16-12.5 mg (Atacand hct) candesartan
cilexetilhydrochlorothiazide tab 32-12.5 mg (Atacand hct) Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy candesartan
cilexetilhydrochlorothiazide tab 32-25 mg (Atacand hct) irbesartan tab 75 mg
(Avapro) irbesartan tab 150 mg (Avapro) irbesartan tab 300 mg (Avapro)
irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide)
irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) losartan potassium
& hydrochlorothiazide tab 50-12.5 mg (Hyzaar) losartan potassium &
hydrochlorothiazide tab 100-12.5 mg (Hyzaar) losartan potassium &
hydrochlorothiazide tab 100-25 mg (Hyzaar) losartan potassium tab 25 mg
(Cozaar) losartan potassium tab 50 mg (Cozaar) losartan potassium tab 100 mg
(Cozaar) olmesartan medoxomil tab 5 mg (Benicar) olmesartan medoxomil tab 20 mg
(Benicar) olmesartan medoxomil tab 40 mg (Benicar) olmesartan
medoxomilhydrochlorothiazide tab 20-12.5 mg (Benicar hct) olmesartan
medoxomilhydrochlorothiazide tab 40-12.5 mg (Benicar hct) 2017 Find and
estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 17 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy olmesartan
medoxomilhydrochlorothiazide tab 40-25 mg (Benicar hct) telmisartan tab 20 mg
(Micardis) telmisartan tab 40 mg (Micardis) telmisartan tab 80 mg (Micardis)
telmisartan-hydrochlorothiazide tab 40-12.5 mg (Micardis hct)
telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)
telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis hct) valsartan tab 40 mg
(Diovan) valsartan tab 80 mg (Diovan) valsartan tab 160 mg (Diovan) valsartan
tab 320 mg (Diovan) valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct)
valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan hct)
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct)
valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan hct)
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) BETA BLOCKERS AND
COMBINATIONS acebutolol hcl cap 200 mg (Sectral) acebutolol hcl cap 400 mg
(Sectral) atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) atenolol
& chlorthalidone tab 100-25 mg (Tenoretic 100) atenolol tab 25 mg
(Tenormin) atenolol tab 50 mg (Tenormin) atenolol tab 100 mg (Tenormin) Drug
Name Specialty Prior Authorization Dispensing Limits Step Therapy bisoprolol
& hydrochlorothiazide tab 2.5-6.25 mg (Ziac) bisoprolol &
hydrochlorothiazide tab 5-6.25 mg (Ziac) bisoprolol & hydrochlorothiazide
tab 10-6.25 mg (Ziac) bisoprolol fumarate tab 5 mg (Zebeta) bisoprolol fumarate
tab 10 mg (Zebeta) carvedilol tab 3.125 mg (Coreg) carvedilol tab 6.25 mg
(Coreg) carvedilol tab 12.5 mg (Coreg) carvedilol tab 25 mg (Coreg) INNOPRAN XL
– propranolol hcl sustained-release beads cap sr 24hr 80 mg INNOPRAN XL –
propranolol hcl sustained-release beads cap sr 24hr 120 mg labetalol hcl tab
100 mg (Trandate) labetalol hcl tab 200 mg (Trandate) labetalol hcl tab 300 mg
(Trandate) metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)
metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor hct) metoprolol
& hydrochlorothiazide tab 100-50 mg metoprolol succinate tab sr 24hr 25 mg
(tartrate equiv) (Toprol xl) metoprolol succinate tab sr 24hr 50 mg (tartrate
equiv) (Toprol xl) metoprolol succinate tab sr 24hr 100 mg (tartrate equiv)
(Toprol xl) metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) (Toprol
xl) 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 18 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy metoprolol
tartrate tab 25 mg metoprolol tartrate tab 50 mg (Lopressor) 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 – propranolol hcl oral soln 20 mg/5ml PROPRANOLOL HCL –
propranolol hcl oral soln 40 mg/5ml 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 TIMOLOL MALEATE – timolol maleate tab 5
mg TIMOLOL MALEATE – timolol maleate tab 10 mg TIMOLOL MALEATE – timolol
maleate tab 20 mg CALCIUM CHANNEL BLOCKERS AND COMBINATIONS Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy amlodipine besylate tab 2.5
mg (Norvasc) amlodipine besylate tab 5 mg (Norvasc) amlodipine besylate tab 10
mg (Norvasc) amlodipine besylate-atorvastatin calcium tab 2.5-10 mg (Caduet)
amlodipine besylate-atorvastatin calcium tab 2.5-20 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 2.5-40 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 5-10 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 5-20 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 5-40 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 5-80 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 10-10 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 10-20 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 10-40 mg (Caduet) amlodipine
besylate-atorvastatin calcium tab 10-80 mg (Caduet) amlodipine
besylate-benazepril hcl cap 2.5-10 mg (Lotrel) amlodipine besylate-benazepril
hcl cap 5-10 mg (Lotrel) amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel) amlodipine besylate-benazepril hcl cap 5-40 mg (Lotrel) 2017 Find and
estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 19 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy amlodipine
besylate-benazepril hcl cap 10-20 mg (Lotrel) amlodipine besylate-benazepril
hcl cap 10-40 mg (Lotrel) amlodipine besylate-valsartan tab 5-160 mg (Exforge)
amlodipine besylate-valsartan tab 5-320 mg (Exforge) amlodipine
besylate-valsartan tab 10-160 mg (Exforge) amlodipine besylate-valsartan tab
10-320 mg (Exforge) diltiazem hcl cap sr 24hr 120 mg diltiazem hcl cap sr 24hr
180 mg diltiazem hcl cap sr 24hr 240 mg diltiazem hcl coated beads cap sr 24hr
120 mg (Cardizem cd) • diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem
cd) • diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem cd) • diltiazem
hcl coated beads cap sr 24hr 300 mg (Cardizem cd) • diltiazem hcl coated beads
cap sr 24hr 360 mg (Cardizem cd) • diltiazem hcl extended release beads cap sr
24hr 120 mg (Tiazac) 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) Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy diltiazem hcl tab 30 mg (Cardizem)
diltiazem hcl tab 60 mg (Cardizem) diltiazem hcl tab 90 mg diltiazem hcl tab
120 mg (Cardizem) ENTRESTO – sacubitril-valsartan tab 24-26 mg • • ENTRESTO –
sacubitril-valsartan tab 49-51 mg • • ENTRESTO – sacubitril-valsartan tab
97-103 mg • • felodipine tab sr 24hr 2.5 mg felodipine tab sr 24hr 5 mg felodipine
tab sr 24hr 10 mg nifedipine tab sr 24hr 30 mg (Adalat cc) nifedipine tab sr
24hr 60 mg (Adalat cc) nifedipine tab sr 24hr 90 mg (Adalat cc) nifedipine tab
sr 24hr osmotic release 30 mg (Procardia xl) nifedipine tab sr 24hr osmotic
release 60 mg (Procardia xl) nifedipine tab sr 24hr osmotic release 90 mg
(Procardia xl) verapamil hcl cap sr 24hr 120 mg (Verelan) verapamil hcl cap sr
24hr 180 mg (Verelan) verapamil hcl cap sr 24hr 240 mg (Verelan) verapamil hcl
cap sr 24hr 360 mg (Verelan) verapamil hcl tab cr 120 mg (Calan sr) 2017 Find
and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 20 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy verapamil hcl tab
cr 180 mg (Calan sr) verapamil hcl tab cr 240 mg (Calan sr) verapamil hcl tab
40 mg verapamil hcl tab 80 mg (Calan) verapamil hcl tab 120 mg (Calan) CHEST
PAIN isosorbide dinitrate tab 5 mg (Isordil titradose) isosorbide dinitrate tab
10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg isosorbide
mononitrate tab sr 24hr 30 mg (Imdur) isosorbide mononitrate tab sr 24hr 60 mg
(Imdur) isosorbide mononitrate tab sr 24hr 120 mg (Imdur) isosorbide
mononitrate tab 10 mg isosorbide mononitrate tab 20 mg nitroglycerin sl tab 0.3
mg (Nitrostat) nitroglycerin sl tab 0.4 mg (Nitrostat) nitroglycerin sl tab 0.6
mg (Nitrostat) nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) 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) NITROSTAT –
nitroglycerin sl tab 0.3 mg NITROSTAT – nitroglycerin sl tab 0.4 mg Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy NITROSTAT –
nitroglycerin sl tab 0.6 mg CHOLESTEROL LOWERING atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor) atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor) atorvastatin calcium tab 40 mg (base equivalent) (Lipitor)
atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) cholestyramine light
powder packets 4 gm cholestyramine light powder 4 gm/ dose (Questran light)
cholestyramine powder packets 4 gm (Questran) cholestyramine powder 4 gm/dose
(Questran) choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)
• choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) •
colestipol hcl granule packets 5 gm (Colestid flavored) colestipol hcl granules
5 gm (Colestid flavored) colestipol hcl tab 1 gm (Colestid) ezetimibe tab 10 mg
(Zetia) • fenofibrate micronized cap 67 mg (Lofibra) • fenofibrate micronized
cap 134 mg (Lofibra) • fenofibrate micronized cap 200 mg (Lofibra) •
fenofibrate tab 48 mg (Tricor) • fenofibrate tab 54 mg (Lofibra) • 2017 Find
and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 21 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy fenofibrate tab
145 mg (Tricor) • fenofibrate tab 160 mg (Lofibra) • gemfibrozil tab 600 mg
(Lopid) • lovastatin tab 10 mg lovastatin tab 20 mg (Mevacor) lovastatin tab 40
mg (Mevacor) niacin tab cr 500 mg (antihyperlipidemic) (Niaspan) niacin tab cr
750 mg (antihyperlipidemic) (Niaspan) niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan) PRALUENT – alirocumab subcutaneous soln
pen-injector 75 mg/ml • • • PRALUENT – alirocumab subcutaneous soln
pen-injector 150 mg/ml • • • pravastatin sodium tab 10 mg pravastatin sodium
tab 20 mg (Pravachol) pravastatin sodium tab 40 mg (Pravachol) pravastatin
sodium tab 80 mg (Pravachol) REPATHA – evolocumab subcutaneous soln prefilled
syringe 140 mg/ml • • • REPATHA PUSHTRONEX SYSTEM – evolocumab subcutaneous
soln cartridge/infusor 420 mg/3.5ml • • • REPATHA SURECLICK – evolocumab
subcutaneous soln auto-injector 140 mg/ml • • • rosuvastatin calcium tab 5 mg
(Crestor) rosuvastatin calcium tab 10 mg (Crestor) Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy rosuvastatin calcium tab 20 mg
(Crestor) rosuvastatin calcium tab 40 mg (Crestor) simvastatin tab 5 mg (Zocor)
simvastatin tab 10 mg (Zocor) simvastatin tab 20 mg (Zocor) simvastatin tab 40
mg (Zocor) simvastatin tab 80 mg (Zocor) WELCHOL – colesevelam hcl tab 625 mg
WELCHOL – colesevelam hcl packet for susp 3.75 gm FLUID RETENTION acetazolamide
cap sr 12hr 500 mg (Diamox) acetazolamide tab 125 mg acetazolamide tab 250 mg
amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg
bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg chlorothiazide
tab 500 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg furosemide oral
soln 10 mg/ml furosemide tab 20 mg (Lasix) furosemide tab 40 mg (Lasix)
furosemide tab 80 mg (Lasix) hydrochlorothiazide cap 12.5 mg (Microzide)
hydrochlorothiazide tab 12.5 mg 2017 Find and estimate prices for medicines on
this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 22 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy
hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25
mg indapamide tab 2.5 mg methazolamide tab 25 mg (Neptazane) methazolamide tab
50 mg (Neptazane) metolazone tab 2.5 mg (Zaroxolyn) metolazone tab 5 mg
(Zaroxolyn) metolazone tab 10 mg spironolactone & hydrochlorothiazide tab
25-25 mg (Aldactazide) spironolactone tab 25 mg (Aldactone) spironolactone tab
50 mg (Aldactone) spironolactone tab 100 mg (Aldactone) torsemide tab 5 mg
(Demadex) torsemide tab 10 mg (Demadex) torsemide tab 20 mg (Demadex) torsemide
tab 100 mg (Demadex) triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide) triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)
triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) HEART RHYTHM
amiodarone hcl tab 100 mg amiodarone hcl tab 200 mg (Cordarone) amiodarone hcl
tab 400 mg disopyramide phosphate cap 100 mg (Norpace) Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy disopyramide phosphate cap 150 mg
(Norpace) 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 MULTAQ – dronedarone hcl tab 400 mg (base equivalent)
propafenone hcl cap sr 12hr 225 mg (Rythmol sr) propafenone hcl cap sr 12hr 325
mg (Rythmol sr) propafenone hcl cap sr 12hr 425 mg (Rythmol sr) propafenone hcl
tab 150 mg (Rythmol) propafenone hcl tab 225 mg (Rythmol) propafenone hcl tab
300 mg quinidine gluconate tab cr 324 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) sotalol hcl tab 80 mg (Betapace) sotalol
hcl tab 120 mg (Betapace) sotalol hcl tab 160 mg (Betapace) sotalol hcl tab 240
mg OTHER HEART RELATED DRUGS ADCIRCA – tadalafil tab 20 mg (pah) • • •
clonidine hcl tab 0.1 mg (Catapres) 2017 Find and estimate prices for medicines
on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 23 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy clonidine hcl tab
0.2 mg (Catapres) clonidine hcl tab 0.3 mg (Catapres) clonidine hcl td patch
weekly 0.1 mg/24hr (Catapres-tts-1) clonidine hcl td patch weekly 0.2 mg/24hr
(Catapres-tts-2) clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3)
digoxin tab 125 mcg (0.125 mg) (Lanoxin) digoxin tab 250 mcg (0.25 mg)
(Lanoxin) doxazosin mesylate tab 1 mg (Cardura) doxazosin mesylate tab 2 mg
(Cardura) doxazosin mesylate tab 4 mg (Cardura) doxazosin mesylate tab 8 mg
(Cardura) eplerenone tab 25 mg (Inspra) eplerenone tab 50 mg (Inspra)
guanfacine hcl tab 1 mg (Tenex) guanfacine hcl tab 2 mg (Tenex) hydralazine hcl
tab 10 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg hydralazine hcl
tab 100 mg LETAIRIS – ambrisentan tab 5 mg • • • LETAIRIS – ambrisentan tab 10
mg • • • methyldopa tab 250 mg methyldopa tab 500 mg midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg midodrine hcl tab 10 mg Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy minoxidil tab 2.5 mg minoxidil tab
10 mg OPSUMIT – macitentan tab 10 mg • • • phenoxybenzamine hcl cap 10 mg
(Dibenzyline) prazosin hcl cap 1 mg (Minipress) prazosin hcl cap 2 mg
(Minipress) prazosin hcl cap 5 mg (Minipress) sildenafil citrate tab 20 mg
(Revatio) • • terazosin hcl cap 1 mg terazosin hcl cap 2 mg terazosin hcl cap 5
mg terazosin hcl cap 10 mg TRACLEER – bosentan tab 62.5 mg • • • TRACLEER –
bosentan tab 125 mg • • • UPTRAVI – selexipag tab therapy pack 200 mcg (140)
& 800 mcg (60) • • • UPTRAVI – selexipag tab 200 mcg • • • UPTRAVI –
selexipag tab 400 mcg • • • UPTRAVI – selexipag tab 600 mcg • • • UPTRAVI –
selexipag tab 800 mcg • • • UPTRAVI – selexipag tab 1000 mcg • • • UPTRAVI –
selexipag tab 1200 mcg • • • UPTRAVI – selexipag tab 1400 mcg • • • UPTRAVI –
selexipag tab 1600 mcg • • • ERECTILE DYSFUNCTION CIALIS – tadalafil tab 2.5 mg
• • CIALIS – tadalafil tab 5 mg • • CIALIS – tadalafil tab 10 mg • • CIALIS –
tadalafil tab 20 mg • • BEE STING KITS EPINEPHRINE (Mylan Products) –
epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 2017 Find and
estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 24 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy EPINEPHRINE (Mylan
Products) – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) EPIPEN
2-PAK – epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) EPIPEN-JR
2-PAK – epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) RESPIRATORY
AGENTS ANTIHISTAMINES cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg desloratadine tab
5 mg (Clarinex) levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal) levocetirizine dihydrochloride tab 5 mg (Xyzal) promethazine hcl suppos
12.5 mg promethazine hcl suppos 25 mg promethazine hcl suppos 50 mg
promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg promethazine
hcl tab 25 mg promethazine hcl tab 50 mg NASAL PRODUCTS azelastine hcl nasal
spray 0.1% (137 mcg/spray) • azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro) • flunisolide nasal soln 25 mcg/act (0.025%) • fluticasone propionate
nasal susp 50 mcg/act (Flonase) • Drug Name Specialty Prior Authorization
Dispensing Limits Step Therapy ipratropium bromide nasal soln 0.03% (21
mcg/spray) (Atrovent) • ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent) • mometasone furoate nasal susp 50 mcg/act (Nasonex) • NASONEX –
mometasone furoate nasal susp 50 mcg/act • triamcinolone acetonide nasal
aerosol suspension 55 mcg/act (Nasacort aq) • COUGH/COLD/ALLERGY acetylcysteine
inhal soln 10% acetylcysteine inhal soln 20% ASTHMA/COPD ADVAIR DISKUS –
fluticasonesalmeterol aer powder ba 100-50 mcg/dose • ADVAIR DISKUS –
fluticasonesalmeterol aer powder ba 250-50 mcg/dose • ADVAIR DISKUS –
fluticasonesalmeterol aer powder ba 500-50 mcg/dose • ADVAIR HFA –
fluticasone-salmeterol inhal aerosol 45-21 mcg/act • ADVAIR HFA –
fluticasone-salmeterol inhal aerosol 115-21 mcg/act • ADVAIR HFA –
fluticasone-salmeterol inhal aerosol 230-21 mcg/act • albuterol sulfate soln
nebu 0.083% (2.5 mg/3ml) • albuterol sulfate soln nebu 0.5% (5 mg/ml) •
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) • 2017 Find and estimate
prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 25 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy albuterol sulfate
soln nebu 1.25 mg/3ml (base equiv) • albuterol sulfate syrup 2 mg/5ml albuterol
sulfate tab 2 mg albuterol sulfate tab 4 mg ANORO ELLIPTA –
umeclidiniumvilanterol aero powd ba 62.5-25 mcg/ inh • ARNUITY ELLIPTA –
fluticasone furoate aerosol powder breath activ 100 mcg/act • ARNUITY ELLIPTA –
fluticasone furoate aerosol powder breath activ 200 mcg/act • ASMANEX HFA –
mometasone furoate inhal aerosol suspension 100 mcg/act • ASMANEX HFA –
mometasone furoate inhal aerosol suspension 200 mcg/act • ASMANEX TWISTHALER
120 ME – mometasone furoate inhal powd 220 mcg/inh (breath activated) • ASMANEX
TWISTHALER 14 MET – mometasone furoate inhal powd 220 mcg/inh (breath
activated) • ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 110
mcg/inh (breath activated) • ASMANEX TWISTHALER 30 MET – mometasone furoate
inhal powd 220 mcg/inh (breath activated) • ASMANEX TWISTHALER 60 MET –
mometasone furoate inhal powd 220 mcg/inh (breath activated) • ASMANEX
TWISTHALER 7 METE – mometasone furoate inhal powd 110 mcg/inh (breath
activated) • ATROVENT HFA – ipratropium bromide hfa inhal aerosol 17 mcg/act •
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy BREO
ELLIPTA – fluticasone furoatevilanterol aero powd ba 100-25 mcg/ inh • BREO
ELLIPTA – fluticasone furoatevilanterol aero powd ba 200-25 mcg/ inh •
budesonide inhalation susp 0.25 mg/2ml (Pulmicort) • budesonide inhalation susp
0.5 mg/2ml (Pulmicort) • budesonide inhalation susp 1 mg/2ml (Pulmicort) •
COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100 mcg/act •
DULERA – mometasone furoateformoterol fumarate aerosol 100-5 mcg/act • DULERA –
mometasone furoateformoterol fumarate aerosol 200-5 mcg/act • FLOVENT DISKUS –
fluticasone propionate aer pow ba 50 mcg/blister • FLOVENT DISKUS – fluticasone
propionate aer pow ba 100 mcg/ blister • FLOVENT DISKUS – fluticasone
propionate aer pow ba 250 mcg/ blister • FLOVENT HFA – fluticasone propionate
hfa inhal aero 44 mcg/act (50/valve) • FLOVENT HFA – fluticasone propionate hfa
inhal aer 110 mcg/act (125/valve) • FLOVENT HFA – fluticasone propionate hfa
inhal aer 220 mcg/act (250/valve) • 2017 Find and estimate prices for medicines
on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 26 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy INCRUSE ELLIPTA –
umeclidinium br aero powd breath act 62.5 mcg/inh (base eq) • ipratropium
bromide inhal soln 0.02% • ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
(Duoneb) • levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) •
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) (Xopenex) • levalbuterol
hcl soln nebu 0.63 mg/3ml (base equiv) (Xopenex) • levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv) (Xopenex) • montelukast sodium chew tab 4 mg (base
equiv) (Singulair) montelukast sodium chew tab 5 mg (base equiv) (Singulair)
montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)
montelukast sodium tab 10 mg (base equiv) (Singulair) PROAIR HFA – albuterol
sulfate inhal aero 108 mcg/act (90mcg base equiv) • PROAIR RESPICLICK –
albuterol sulfate aer pow ba 108 mcg/act (90 mcg base equiv) • QVAR –
beclomethasone diprop inhal aero soln 40 mcg/act (50/valve) • QVAR –
beclomethasone diprop inhal aero soln 80 mcg/act (100/valve) • SEREVENT DISKUS
– salmeterol xinafoate aer pow ba 50 mcg/dose (base equiv) • SPIRIVA HANDIHALER
– tiotropium bromide monohydrate inhal cap 18 mcg (base equiv) • Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy SPIRIVA RESPIMAT –
tiotropium bromide monohydrate inhal aerosol 1.25 mcg/act • SPIRIVA RESPIMAT –
tiotropium bromide monohydrate inhal aerosol 2.5 mcg/act • STIOLTO RESPIMAT –
tiotropium brolodaterol inhal aero soln 2.5-2.5 mcg/act • STRIVERDI RESPIMAT –
olodaterol hcl inhal aerosol soln 2.5 mcg/act (base equiv) • SYMBICORT –
budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/ act • SYMBICORT –
budesonide-formoterol fumarate dihyd aerosol 160-4.5 mcg/ act • terbutaline
sulfate tab 2.5 mg terbutaline sulfate tab 5 mg theophylline tab sr 12hr 100 mg
theophylline tab sr 12hr 200 mg theophylline tab sr 12hr 300 mg theophylline
tab sr 12hr 450 mg theophylline tab sr 24hr 400 mg theophylline tab sr 24hr 600
mg VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) •
zafirlukast tab 10 mg (Accolate) zafirlukast tab 20 mg (Accolate) OTHER
RESPIRATORY DRUGS KALYDECO – ivacaftor tab 150 mg • • • KALYDECO – ivacaftor
packet 50 mg • • • KALYDECO – ivacaftor packet 75 mg • • • 2017 Find and
estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 27 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy PULMOZYME –
dornase alfa inhal soln 1 mg/ml • GASTROINTESTINAL DRUGS LAXATIVES lactulose
solution 10 gm/15ml peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack) peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyteflavor packs)
ANTIDIARRHEALS diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) loperamide
hcl cap 2 mg ULCER/GERD cimetidine hcl soln 300 mg/5ml cimetidine tab 300 mg
cimetidine tab 400 mg cimetidine tab 800 mg dicyclomine hcl cap 10 mg (Bentyl)
dicyclomine hcl oral soln 10 mg/5ml dicyclomine hcl tab 20 mg (Bentyl)
esomeprazole magnesium cap delayed release 20 mg (base eq) (Nexium) •
esomeprazole magnesium cap delayed release 40 mg (base eq) (Nexium) •
famotidine tab 20 mg (Pepcid) famotidine tab 40 mg (Pepcid) glycopyrrolate tab
1 mg (Robinul) glycopyrrolate tab 2 mg (Robinul forte) Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy 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) misoprostol tab 100 mcg (Cytotec) misoprostol tab 200 mcg
(Cytotec) NEXIUM – esomeprazole magnesium for delayed release susp pack 2.5 mg
• NEXIUM – esomeprazole magnesium for delayed release susp packet 5 mg • NEXIUM
– esomeprazole magnesium for delayed release susp packet 10 mg • NEXIUM –
esomeprazole magnesium for delayed release susp packet 20 mg • NEXIUM –
esomeprazole magnesium for delayed release susp packet 40 mg • omeprazole cap
delayed release 10 mg (Prilosec) • omeprazole cap delayed release 20 mg
(Prilosec) • omeprazole cap delayed release 40 mg (Prilosec) • pantoprazole
sodium ec tab 20 mg (base equiv) (Protonix) • pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix) • ranitidine hcl cap 150 mg ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2017 Find and estimate prices for
medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 28 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy ranitidine hcl tab
150 mg (Zantac) ranitidine hcl tab 300 mg (Zantac) sucralfate tab 1 gm
(Carafate) NAUSEA AND VOMITING aprepitant capsule therapy pack 80 & 125 mg
(Emend) • aprepitant capsule 80 mg (Emend) • EMEND – aprepitant for oral susp
125 mg (125 mg/5ml) • EMEND – aprepitant capsule therapy pack 80 & 125 mg •
EMEND – aprepitant capsule 40 mg • EMEND – aprepitant capsule 80 mg • EMEND –
aprepitant capsule 125 mg • granisetron hcl tab 1 mg • meclizine hcl tab 12.5
mg meclizine hcl tab 25 mg ondansetron hcl inj 4 mg/2ml (2 mg/ ml) ondansetron
hcl inj 40 mg/20ml (2 mg/ml) (Zofran) ondansetron hcl oral soln 4 mg/5ml
(Zofran) • ondansetron hcl tab 4 mg (Zofran) • ondansetron hcl tab 8 mg
(Zofran) • ondansetron hcl tab 24 mg • ondansetron orally disintegrating tab 4
mg (Zofran odt) • ondansetron orally disintegrating tab 8 mg (Zofran odt) •
trimethobenzamide hcl cap 300 mg (Tigan) DIGESTIVE ENZYMES CREON – pancrelipase
(lip-prot-amyl) dr cap 3000-9500-15000 unit Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy CREON – pancrelipase (lip-prot-amyl)
dr cap 6000-19000-30000 unit CREON – pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit CREON – pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit CREON – pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap
15000-51000-82000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap
20000-68000-109000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap
25000-85000-136000 unit ZENPEP – pancrelipase (lip-prot-amyl) dr cap
40000-136000-218000 unit OTHER GASTROINTESTINAL DRUGS ASACOL HD – mesalamine
tab delayed release 800 mg balsalazide disodium cap 750 mg (Colazal) calcium
acetate (phosphate binder) cap 667 mg (169 mg ca) (Phoslo) calcium acetate
(phosphate binder) tab 667 mg (Eliphos) CANASA – mesalamine suppos 1000 mg
CHENODAL – chenodiol tab 250 mg • DELZICOL – mesalamine cap dr 400 mg 2017 Find
and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 29 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy lactulose
(encephalopathy) solution 10 gm/15ml LIALDA – mesalamine tab delayed release
1.2 gm LINZESS – linaclotide cap 72 mcg LINZESS – linaclotide cap 145 mcg
LINZESS – linaclotide cap 290 mcg mesalamine enema 4 gm metoclopramide hcl soln
5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg (Reglan) metoclopramide hcl
tab 10 mg (Reglan) PENTASA – mesalamine cap cr 250 mg PENTASA – mesalamine cap
cr 500 mg sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)
sulfasalazine tab 500 mg (Azulfidine) ursodiol cap 300 mg (Actigall) ursodiol
tab 250 mg (Urso 250) ursodiol tab 500 mg (Urso forte) VELPHORO – sucroferric
oxyhydroxide chew tab 500 mg GENITOURINARY DRUGS URINARY TRACT INFECTIONS
nitrofurantoin macrocrystalline cap 25 mg (Macrodantin) nitrofurantoin
macrocrystalline cap 50 mg (Macrodantin) nitrofurantoin macrocrystalline cap
100 mg (Macrodantin) Drug Name Specialty Prior Authorization Dispensing Limits
Step Therapy nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)
nitrofurantoin susp 25 mg/5ml (Furadantin) URINARY TRACT SPASMS oxybutynin
chloride syrup 5 mg/5ml oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)
oxybutynin chloride tab sr 24hr 10 mg (Ditropan xl) oxybutynin chloride tab sr
24hr 15 mg (Ditropan xl) oxybutynin chloride tab 5 mg tolterodine tartrate cap
sr 24hr 2 mg (Detrol la) tolterodine tartrate cap sr 24hr 4 mg (Detrol la)
tolterodine tartrate tab 1 mg (Detrol) tolterodine tartrate tab 2 mg (Detrol)
VESICARE – solifenacin succinate tab 5 mg VESICARE – solifenacin succinate tab
10 mg VAGINAL PRODUCTS CLEOCIN – clindamycin phosphate vaginal suppos 100 mg
clindamycin phosphate vaginal cream 2% (Cleocin) CRINONE – progesterone vaginal
gel 4% • CRINONE – progesterone vaginal gel 8% • ESTRACE – estradiol vaginal
cream 0.1 mg/gm estradiol vaginal tab 10 mcg (Vagifem) 2017 Find and estimate
prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 30 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy metronidazole
vaginal gel 0.75% (Metrogel-vaginal) terconazole vaginal cream 0.4% (Terazol 7)
terconazole vaginal cream 0.8% (Terazol 3) terconazole vaginal suppos 80 mg
VAGIFEM – estradiol vaginal tab 10 mcg OTHER GENITOURINARY DRUGS alfuzosin hcl
tab sr 24hr 10 mg (Uroxatral) CYSTAGON – cysteamine bitartrate cap 50 mg •
CYSTAGON – cysteamine bitartrate cap 150 mg • dutasteride cap 0.5 mg (Avodart)
finasteride tab 5 mg (Proscar) potassium citrate tab cr 5 meq (540 mg)
(Urocit-k 5) potassium citrate tab cr 10 meq (1080 mg) (Urocit-k 10) potassium
citrate tab cr 15 meq (1620 mg) (Urocit-k 15) tamsulosin hcl cap 0.4 mg (Flomax)
CENTRAL NERVOUS SYSTEM DRUGS ANXIETY alprazolam tab sr 24hr 0.5 mg (Xanax xr)
alprazolam tab sr 24hr 1 mg (Xanax xr) alprazolam tab sr 24hr 2 mg (Xanax xr)
alprazolam tab sr 24hr 3 mg (Xanax xr) alprazolam tab 0.25 mg (Xanax) Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy alprazolam tab 0.5
mg (Xanax) alprazolam tab 1 mg (Xanax) alprazolam tab 2 mg (Xanax) buspirone
hcl tab 5 mg buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab
30 mg DIAZEPAM – diazepam oral soln 1 mg/ ml 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 hydroxyzine hcl tab 25 mg hydroxyzine hcl tab
50 mg hydroxyzine pamoate cap 25 mg (Vistaril) hydroxyzine pamoate cap 50 mg
(Vistaril) lorazepam conc 2 mg/ml (Lorazepam intensol) lorazepam tab 0.5 mg
(Ativan) • lorazepam tab 1 mg (Ativan) • lorazepam tab 2 mg (Ativan) •
DEPRESSION 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 bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr) 2017 Find and estimate prices for medicines on this formulary
at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 31 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy bupropion hcl tab
sr 12hr 150 mg (Wellbutrin sr) bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl) bupropion hcl tab sr 24hr 300
mg (Wellbutrin xl) bupropion hcl tab 75 mg (Wellbutrin) bupropion hcl tab 100
mg (Wellbutrin) citalopram hydrobromide oral soln 10 mg/5ml citalopram
hydrobromide tab 10 mg (base equiv) (Celexa) citalopram hydrobromide tab 20 mg
(base equiv) (Celexa) citalopram hydrobromide tab 40 mg (base equiv) (Celexa)
clomipramine hcl cap 25 mg (Anafranil) clomipramine hcl cap 50 mg (Anafranil)
clomipramine hcl cap 75 mg (Anafranil) desipramine hcl tab 10 mg (Norpramin)
desipramine hcl tab 25 mg (Norpramin) desipramine hcl tab 50 mg (Norpramin)
desipramine hcl tab 75 mg (Norpramin) desipramine hcl tab 100 mg (Norpramin)
desipramine hcl tab 150 mg (Norpramin) doxepin hcl cap 10 mg Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy doxepin hcl cap 25 mg
doxepin hcl cap 50 mg doxepin hcl cap 100 mg doxepin hcl conc 10 mg/ml
duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta) • duloxetine hcl
enteric coated pellets cap 30 mg (Cymbalta) • duloxetine hcl enteric coated
pellets cap 60 mg (Cymbalta) • escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro) escitalopram oxalate tab 5 mg (base equiv) (Lexapro) escitalopram
oxalate tab 10 mg (base equiv) (Lexapro) escitalopram oxalate tab 20 mg (base
equiv) (Lexapro) fluoxetine hcl cap 10 mg (Prozac) fluoxetine hcl cap 20 mg
(Prozac) fluoxetine hcl cap 40 mg (Prozac) fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg 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) imipramine hcl tab 25 mg (Tofranil) imipramine hcl tab 50 mg
(Tofranil) mirtazapine tab 7.5 mg mirtazapine tab 15 mg (Remeron) mirtazapine
tab 30 mg (Remeron) mirtazapine tab 45 mg (Remeron) 2017 Find and estimate
prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 32 Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy nortriptyline hcl cap 10 mg
(Pamelor) nortriptyline hcl cap 25 mg (Pamelor) nortriptyline hcl cap 50 mg
(Pamelor) nortriptyline hcl cap 75 mg (Pamelor) paroxetine hcl tab sr 24hr 12.5
mg (Paxil cr) paroxetine hcl tab sr 24hr 25 mg (Paxil cr) paroxetine hcl tab sr
24hr 37.5 mg (Paxil cr) paroxetine hcl tab 10 mg (Paxil) paroxetine hcl tab 20
mg (Paxil) paroxetine hcl tab 30 mg (Paxil) paroxetine hcl tab 40 mg (Paxil)
phenelzine sulfate tab 15 mg (Nardil) sertraline hcl oral conc 20 mg/ml
(Zoloft) sertraline hcl tab 25 mg (Zoloft) sertraline hcl tab 50 mg (Zoloft)
sertraline hcl tab 100 mg (Zoloft) tranylcypromine sulfate tab 10 mg (Parnate)
trazodone hcl tab 50 mg trazodone hcl tab 100 mg trazodone hcl tab 150 mg
trazodone hcl tab 300 mg venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr) venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor xr)
venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor xr) venlafaxine
hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl er) Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy venlafaxine hcl
tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl er) venlafaxine hcl tab sr
24hr 150 mg (base equivalent) (Venlafaxine hcl er) venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg PSYCHOTIC AND BIPOLAR DISORDERS aripiprazole tab 2
mg (Abilify) • aripiprazole tab 5 mg (Abilify) • aripiprazole tab 10 mg
(Abilify) • aripiprazole tab 15 mg (Abilify) • aripiprazole tab 20 mg (Abilify)
• aripiprazole tab 30 mg (Abilify) • chlorpromazine hcl tab 10 mg
chlorpromazine hcl tab 25 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl
tab 100 mg chlorpromazine hcl tab 200 mg clozapine tab 25 mg (Clozaril) •
clozapine tab 50 mg • clozapine tab 100 mg (Clozaril) • clozapine tab 200 mg •
fluphenazine decanoate inj 25 mg/ml FLUPHENAZINE HCL – fluphenazine hcl elixir
2.5 mg/5ml FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml fluphenazine
hcl tab 1 mg fluphenazine hcl tab 2.5 mg 2017 Find and estimate prices for
medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 33 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy fluphenazine hcl
tab 5 mg fluphenazine hcl tab 10 mg haloperidol decanoate im soln 50 mg/ml
(Haldol decanoate 50) haloperidol decanoate im soln 100 mg/ml (Haldol decanoate
100) haloperidol lactate oral conc 2 mg/ml haloperidol tab 0.5 mg haloperidol
tab 1 mg haloperidol tab 2 mg haloperidol tab 5 mg haloperidol tab 10 mg
haloperidol tab 20 mg lithium carbonate cap 150 mg (Lithium carbonate) lithium
carbonate cap 300 mg lithium carbonate cap 600 mg (Lithium carbonate) lithium
carbonate tab cr 300 mg (Lithobid) lithium carbonate tab cr 450 mg lithium
carbonate tab 300 mg loxapine succinate cap 5 mg (Loxitane) loxapine succinate
cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 50 mg olanzapine
orally disintegrating tab 5 mg (Zyprexa zydis) • olanzapine orally
disintegrating tab 10 mg (Zyprexa zydis) • olanzapine orally disintegrating tab
15 mg (Zyprexa zydis) • olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis) • Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy
olanzapine tab 2.5 mg (Zyprexa) • olanzapine tab 5 mg (Zyprexa) • olanzapine
tab 7.5 mg (Zyprexa) • olanzapine tab 10 mg (Zyprexa) • olanzapine tab 15 mg
(Zyprexa) • olanzapine tab 20 mg (Zyprexa) • perphenazine tab 2 mg perphenazine
tab 4 mg perphenazine tab 8 mg perphenazine tab 16 mg prochlorperazine maleate
tab 5 mg (base equivalent) (Compazine) prochlorperazine maleate tab 10 mg (base
equivalent) (Compazine) prochlorperazine suppos 25 mg quetiapine fumarate tab
sr 24hr 50 mg (Seroquel xr) • quetiapine fumarate tab sr 24hr 150 mg (Seroquel
xr) • quetiapine fumarate tab sr 24hr 200 mg (Seroquel xr) • quetiapine
fumarate tab sr 24hr 300 mg (Seroquel xr) • quetiapine fumarate tab sr 24hr 400
mg (Seroquel xr) • quetiapine fumarate tab 25 mg (Seroquel) • quetiapine
fumarate tab 50 mg (Seroquel) • quetiapine fumarate tab 100 mg (Seroquel) •
quetiapine fumarate tab 200 mg (Seroquel) • quetiapine fumarate tab 300 mg
(Seroquel) • 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 34 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy quetiapine
fumarate tab 400 mg (Seroquel) • risperidone orally disintegrating tab 0.25 mg
• risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) • risperidone
orally disintegrating tab 1 mg (Risperdal m-tab) • risperidone orally
disintegrating tab 2 mg (Risperdal m-tab) • risperidone orally disintegrating
tab 3 mg (Risperdal m-tab) • risperidone orally disintegrating tab 4 mg
(Risperdal m-tab) • risperidone soln 1 mg/ml (Risperdal) • risperidone tab 0.25
mg (Risperdal) • risperidone tab 0.5 mg (Risperdal) • risperidone tab 1 mg
(Risperdal) • risperidone tab 2 mg (Risperdal) • risperidone tab 3 mg
(Risperdal) • risperidone tab 4 mg (Risperdal) • SEROQUEL XR – quetiapine
fumarate tab sr 24hr 50 mg • • SEROQUEL XR – quetiapine fumarate tab sr 24hr
150 mg • • SEROQUEL XR – quetiapine fumarate tab sr 24hr 200 mg • • SEROQUEL XR
– quetiapine fumarate tab sr 24hr 300 mg • • SEROQUEL XR – quetiapine fumarate
tab sr 24hr 400 mg • • thiothixene cap 1 mg thiothixene cap 2 mg thiothixene
cap 5 mg thiothixene cap 10 mg trifluoperazine hcl tab 1 mg Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 5 mg trifluoperazine hcl tab 10 mg ziprasidone hcl cap
20 mg (Geodon) • ziprasidone hcl cap 40 mg (Geodon) • ziprasidone hcl cap 60 mg
(Geodon) • ziprasidone hcl cap 80 mg (Geodon) • SLEEP AIDS estazolam tab 1 mg
estazolam tab 2 mg eszopiclone tab 1 mg (Lunesta) • eszopiclone tab 2 mg
(Lunesta) • eszopiclone tab 3 mg (Lunesta) • phenobarbital elixir 20 mg/5ml
phenobarbital tab 16.2 mg phenobarbital tab 32.4 mg temazepam cap 7.5 mg
(Restoril) temazepam cap 15 mg (Restoril) temazepam cap 22.5 mg (Restoril)
temazepam cap 30 mg (Restoril) zaleplon cap 5 mg (Sonata) • zaleplon cap 10 mg
(Sonata) • zolpidem tartrate tab cr 6.25 mg (Ambien cr) • zolpidem tartrate tab
cr 12.5 mg (Ambien cr) • zolpidem tartrate tab 5 mg (Ambien) • zolpidem
tartrate tab 10 mg (Ambien) • HYPERACTIVITY/NARCOLEPSY
amphetamine-dextroamphetamine cap sr 24hr 5 mg (Adderall xr) •
amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall xr) • 2017 Find and
estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 35 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy
amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall xr) •
amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall xr) • amphetamine-dextroamphetamine
cap sr 24hr 25 mg (Adderall xr) • amphetamine-dextroamphetamine cap sr 24hr 30
mg (Adderall xr) • amphetamine-dextroamphetamine tab 5 mg (Adderall) •
amphetamine-dextroamphetamine tab 7.5 mg (Adderall) •
amphetamine-dextroamphetamine tab 10 mg (Adderall) •
amphetamine-dextroamphetamine tab 12.5 mg (Adderall) •
amphetamine-dextroamphetamine tab 15 mg (Adderall) •
amphetamine-dextroamphetamine tab 20 mg (Adderall) •
amphetamine-dextroamphetamine tab 30 mg (Adderall) • caffeine citrate oral soln
60 mg/3ml (10 mg/ml base equiv) (Cafcit) dexmethylphenidate hcl cap sr 24 hr 5
mg (Focalin xr) • 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) • dexmethylphenidate hcl cap sr 24 hr 30 mg
(Focalin xr) • dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin xr) • Drug
Name Specialty Prior Authorization Dispensing Limits Step Therapy
dextroamphetamine sulfate cap sr 24hr 5 mg (Dexedrine) • dextroamphetamine
sulfate cap sr 24hr 10 mg (Dexedrine) • dextroamphetamine sulfate cap sr 24hr
15 mg (Dexedrine) • dextroamphetamine sulfate tab 5 mg • dextroamphetamine
sulfate tab 10 mg • guanfacine hcl tab sr 24hr 1 mg (base equiv) (Intuniv) •
guanfacine hcl tab sr 24hr 2 mg (base equiv) (Intuniv) • guanfacine hcl tab sr
24hr 3 mg (base equiv) (Intuniv) • guanfacine hcl tab sr 24hr 4 mg (base equiv)
(Intuniv) • 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) • • modafinil tab 200 mg (Provigil) • • 2017 Find and estimate
prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 36 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy VYVANSE –
lisdexamfetamine dimesylate cap 10 mg • VYVANSE – lisdexamfetamine dimesylate
cap 20 mg • VYVANSE – lisdexamfetamine dimesylate cap 30 mg • VYVANSE –
lisdexamfetamine dimesylate cap 40 mg • VYVANSE – lisdexamfetamine dimesylate
cap 50 mg • VYVANSE – lisdexamfetamine dimesylate cap 60 mg • VYVANSE –
lisdexamfetamine dimesylate cap 70 mg • VYVANSE – lisdexamfetamine dimesylate
chew tab 10 mg • VYVANSE – lisdexamfetamine dimesylate chew tab 20 mg • VYVANSE
– lisdexamfetamine dimesylate chew tab 30 mg • VYVANSE – lisdexamfetamine
dimesylate chew tab 40 mg • VYVANSE – lisdexamfetamine dimesylate chew tab 50
mg • VYVANSE – lisdexamfetamine dimesylate chew tab 60 mg • MULTIPLE SCLEROSIS
AUBAGIO – teriflunomide tab 7 mg • • AUBAGIO – teriflunomide tab 14 mg • •
AVONEX – interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml • • AVONEX –
interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/vial) • • AVONEX PEN –
interferon beta-1a im auto-injector kit 30 mcg/0.5ml • • BETASERON – interferon
beta-1b for inj kit 0.3 mg • • Drug Name Specialty Prior Authorization
Dispensing Limits Step Therapy COPAXONE – glatiramer acetate soln prefilled
syringe 20 mg/ml • • COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml • • GILENYA – fingolimod hcl cap 0.5 mg (base equiv) • • glatiramer
acetate soln prefilled syringe 20 mg/ml (Copaxone) • • PLEGRIDY – peginterferon
beta-1a soln pen-injector 125 mcg/0.5ml • • PLEGRIDY – peginterferon beta-1a
soln prefilled syringe 125 mcg/0.5ml • • PLEGRIDY STARTER PACK – peginterferon
beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack • • PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml pack • • REBIF –
interferon beta-1a soln pref syr 22 mcg/0.5ml (12mu/ml) • • REBIF – interferon
beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml) • • REBIF REBIDOSE – interferon
beta-1a soln auto-inj 22 mcg/0.5ml (12mu/ml) • • REBIF REBIDOSE – interferon
beta-1a soln auto-inj 44 mcg/0.5ml (24mu/ml) • • REBIF REBIDOSE TITRATION –
interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml • • REBIF
TITRATION PACK – interferon beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
• • TECFIDERA – dimethyl fumarate capsule delayed release 120 mg • • TECFIDERA
– dimethyl fumarate capsule delayed release 240 mg • • 2017 Find and estimate
prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 37 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy TECFIDERA STARTER
PACK – dimethyl fumarate capsule dr starter pack 120 mg & 240 mg • • OTHER
CENTRAL NERVOUS SYSTEM DRUGS acamprosate calcium tab delayed release 333 mg
(Campral) bupropion hcl (smoking deterrent) tab sr 12hr 150 mg (Zyban) CHANTIX
– varenicline tartrate tab 0.5 mg (base equiv) CHANTIX – varenicline tartrate
tab 1 mg (base equiv) CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg
(base equiv) CHANTIX STARTING MONTH PA – varenicline tartrate tab 0.5 mg x 11
& tab 1 mg x 42 pack disulfiram tab 250 mg (Antabuse) disulfiram tab 500 mg
(Antabuse) donepezil hydrochloride orally disintegrating tab 5 mg (Aricept odt)
donepezil hydrochloride orally disintegrating tab 10 mg (Aricept odt) donepezil
hydrochloride tab 5 mg (Aricept) donepezil hydrochloride tab 10 mg (Aricept)
galantamine hydrobromide cap sr 24hr 8 mg (Razadyne er) galantamine hydrobromide
cap sr 24hr 16 mg (Razadyne er) galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er) galantamine hydrobromide tab 4 mg (Razadyne) Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy galantamine hydrobromide tab
8 mg (Razadyne) galantamine hydrobromide tab 12 mg (Razadyne) memantine hcl
oral solution 2 mg/ml (Namenda) memantine hcl tab 5 mg (Namenda) memantine hcl
tab 10 mg (Namenda) memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa) NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg
delivered) NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray) NUEDEXTA
– dextromethorphan hbrquinidine sulfate cap 20-10 mg pimozide tab 1 mg (Orap)
pimozide tab 2 mg (Orap) rivastigmine tartrate cap 1.5 mg (Exelon) rivastigmine
tartrate cap 3 mg (Exelon) rivastigmine tartrate cap 4.5 mg (Exelon)
rivastigmine tartrate cap 6 mg (Exelon) tetrabenazine tab 12.5 mg (Xenazine) •
• • tetrabenazine tab 25 mg (Xenazine) • • • PAIN RELIEF DRUGS NON-NARCOTIC
DRUGS butalbital-acetaminophen tab 50-325 mg butalbital-acetaminophen-caffeine
cap 50-325-40 mg 2017 Find and estimate prices for medicines on this formulary
at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 38 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy
butalbital-acetaminophen-caffeine tab 50-325-40 mg butalbital-aspirin-caffeine
cap 50-325-40 mg (Fiorinal) NARCOTIC DRUGS acetaminophen w/ codeine soln 120-12
mg/5ml acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) acetaminophen
w/ codeine tab 300-30 mg (Tylenol/codeine #3) acetaminophen w/ codeine tab
300-60 mg (Tylenol/codeine #4) buprenorphine hcl sl tab 2 mg (base equiv) •
buprenorphine hcl sl tab 8 mg (base equiv) • butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/codeine #3) codeine sulfate tab 15 mg (Codeine
sulfate) codeine sulfate tab 30 mg codeine sulfate tab 60 mg fentanyl citrate
lozenge on a handle 200 mcg (Actiq) • • fentanyl citrate lozenge on a handle
400 mcg (Actiq) • • fentanyl citrate lozenge on a handle 600 mcg (Actiq) • •
fentanyl citrate lozenge on a handle 800 mcg (Actiq) • • fentanyl citrate
lozenge on a handle 1200 mcg (Actiq) • • fentanyl citrate lozenge on a handle
1600 mcg (Actiq) • • Drug Name Specialty Prior Authorization Dispensing Limits
Step Therapy 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) • hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet)
hydrocodone-acetaminophen tab 10-325 mg (Norco) hydrocodone-acetaminophen tab
5-325 mg (Norco) hydrocodone-acetaminophen tab 7.5-325 mg (Norco)
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 2 mg (Dilaudid)
hydromorphone hcl tab 4 mg (Dilaudid) hydromorphone hcl tab 8 mg (Dilaudid)
KADIAN – morphine sulfate cap sr 24hr 40 mg • • KADIAN – morphine sulfate cap
sr 24hr 200 mg • • 2017 Find and estimate prices for medicines on this
formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 39 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy methadone hcl conc
10 mg/ml (Methadose) methadone hcl soln 5 mg/5ml (Methadone hcl) methadone hcl
soln 10 mg/5ml (Methadone hcl) methadone hcl tab for oral susp 40 mg methadone
hcl tab 5 mg (Dolophine hcl) methadone hcl tab 10 mg (Dolophine) MORPHINE
SULFATE – morphine sulfate tab 15 mg MORPHINE SULFATE – morphine sulfate tab 30
mg morphine sulfate oral soln 10 mg/5ml morphine sulfate oral soln 20 mg/5ml
morphine sulfate oral soln 100 mg/5ml (20 mg/ml) morphine sulfate tab cr 15 mg
(Ms contin) • morphine sulfate tab cr 30 mg (Ms contin) • morphine sulfate tab
cr 60 mg (Ms contin) • morphine sulfate tab cr 100 mg (Ms contin) • morphine
sulfate tab cr 200 mg (Ms contin) • NUCYNTA ER – tapentadol hcl tab sr 12hr 50
mg • NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg • NUCYNTA ER – tapentadol
hcl tab sr 12hr 150 mg • NUCYNTA ER – tapentadol hcl tab sr 12hr 200 mg • Drug
Name Specialty Prior Authorization Dispensing Limits Step Therapy NUCYNTA ER –
tapentadol hcl tab sr 12hr 250 mg • oxycodone hcl cap 5 mg oxycodone hcl conc
100 mg/5ml (20 mg/ml) (Oxycodone hcl) oxycodone hcl soln 5 mg/5ml (Oxycodone
hcl) oxycodone hcl tab 5 mg (Roxicodone) oxycodone hcl tab 10 mg oxycodone hcl
tab 15 mg (Roxicodone) oxycodone hcl tab 20 mg oxycodone hcl tab 30 mg
(Roxicodone) 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) OXYCONTIN –
oxycodone hcl tab er 12hr deter 10 mg • OXYCONTIN – oxycodone hcl tab er 12hr
deter 15 mg • OXYCONTIN – oxycodone hcl tab er 12hr deter 20 mg • OXYCONTIN –
oxycodone hcl tab er 12hr deter 30 mg • OXYCONTIN – oxycodone hcl tab er 12hr
deter 40 mg • OXYCONTIN – oxycodone hcl tab er 12hr deter 60 mg • OXYCONTIN –
oxycodone hcl tab er 12hr deter 80 mg • 2017 Find and estimate prices for
medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 40 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy tramadol hcl tab
sr 24hr 100 mg (Ultram er) • tramadol hcl tab sr 24hr 200 mg (Ultram er) •
tramadol hcl tab sr 24hr 300 mg (Ultram er) • tramadol hcl tab 50 mg (Ultram) •
tramadol-acetaminophen tab 37.5-325 mg (Ultracet) RHEUMATOID AND OSTEOARTHRITIS
celecoxib cap 50 mg (Celebrex) • celecoxib cap 100 mg (Celebrex) • celecoxib
cap 200 mg (Celebrex) • celecoxib cap 400 mg (Celebrex) • diclofenac potassium
tab 50 mg (Cataflam) diclofenac sodium tab delayed release 25 mg diclofenac
sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg
diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr) ENBREL – etanercept for
subcutaneous inj 25 mg • • • ENBREL – etanercept subcutaneous soln prefilled
syringe 25 mg/0.5ml • • • ENBREL – etanercept subcutaneous soln prefilled
syringe 50 mg/ml • • • ENBREL SURECLICK – etanercept subcutaneous solution
auto-injector 50 mg/ml • • • etodolac cap 200 mg etodolac cap 300 mg etodolac
tab sr 24hr 400 mg Drug Name Specialty Prior Authorization Dispensing Limits Step
Therapy etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg etodolac tab
400 mg etodolac tab 500 mg flurbiprofen tab 50 mg flurbiprofen tab 100 mg
HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml • • • HUMIRA – adalimumab
prefilled syringe kit 20 mg/0.4ml • • • HUMIRA – adalimumab prefilled syringe
kit 40 mg/0.8ml • • • HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe
kit 40 mg/0.8ml • • • HUMIRA PEN – adalimumab peninjector kit 40 mg/0.8ml • • •
HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit 40 mg/0.8ml • • •
HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit 40 mg/0.8ml • • •
ibuprofen susp 100 mg/5ml ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen
tab 800 mg indomethacin cap 25 mg indomethacin cap 50 mg ketoprofen cap 50 mg
ketoprofen cap 75 mg leflunomide tab 10 mg (Arava) leflunomide tab 20 mg
(Arava) meloxicam tab 7.5 mg (Mobic) meloxicam tab 15 mg (Mobic) 2017 Find and
estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 41 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy nabumetone tab 500
mg nabumetone tab 750 mg naproxen sodium tab 275 mg (Anaprox) naproxen sodium
tab 550 mg (Anaprox ds) naproxen susp 125 mg/5ml (Naprosyn) naproxen tab ec 375
mg (Ecnaprosyn) naproxen tab ec 500 mg (Ecnaprosyn) naproxen tab 250 mg
(Naprosyn) naproxen tab 375 mg (Naprosyn) naproxen tab 500 mg (Naprosyn) OTEZLA
– apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg • • •
OTEZLA – apremilast tab 30 mg • • • oxaprozin tab 600 mg (Daypro) piroxicam cap
10 mg (Feldene) piroxicam cap 20 mg (Feldene) SIMPONI – golimumab subcutaneous
soln auto-injector 50 mg/0.5ml • • • SIMPONI – golimumab subcutaneous soln
auto-injector 100 mg/ml • • • SIMPONI – golimumab subcutaneous soln prefilled
syringe 50 mg/0.5ml • • • SIMPONI – golimumab subcutaneous soln prefilled
syringe 100 mg/ml • • • sulindac tab 150 mg sulindac tab 200 mg MIGRAINE HEADACHES
IMITREX – sumatriptan nasal spray 5 mg/act • IMITREX – sumatriptan nasal spray
20 mg/act • Drug Name Specialty Prior Authorization Dispensing Limits Step
Therapy MIGRANAL – dihydroergotamine mesylate nasal spray 4 mg/ml • naratriptan
hcl tab 1 mg (base equiv) (Amerge) • naratriptan hcl tab 2.5 mg (base equiv)
(Amerge) • rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
(Maxalt-mlt) • rizatriptan benzoate oral disintegrating tab 10 mg (base eq)
(Maxalt-mlt) • rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) •
rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) • sumatriptan nasal
spray 5 mg/act (Imitrex) • sumatriptan nasal spray 20 mg/act (Imitrex) •
sumatriptan succinate inj 6 mg/0.5ml (Imitrex) • sumatriptan succinate solution
autoinjector 4 mg/0.5ml (Imitrex statdose sys) • sumatriptan succinate solution
autoinjector 6 mg/0.5ml (Imitrex statdose sys) • sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex statdose ref) • sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex statdose ref) • sumatriptan succinate tab 25 mg
(Imitrex) • sumatriptan succinate tab 50 mg (Imitrex) • 2017 Find and estimate
prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 42 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy sumatriptan
succinate tab 100 mg (Imitrex) • GOUT allopurinol tab 100 mg (Zyloprim)
allopurinol tab 300 mg (Zyloprim) colchicine w/ probenecid tab 0.5-500 mg
COLCRYS – colchicine tab 0.6 mg probenecid tab 500 mg LOCAL ANESTHETICS
INJECTABLE lidocaine hcl local inj 1% (Xylocaine) lidocaine hcl local
preservative free (pf) inj 1% (Xylocaine-mpf) NEUROMUSCULAR DRUGS SEIZURES
carbamazepine cap sr 12hr 100 mg (Carbatrol) 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) carbamazepine tab 200 mg (Tegretol) CELONTIN –
methsuximide cap 300 mg clonazepam tab 0.5 mg (Klonopin) clonazepam tab 1 mg
(Klonopin) Drug Name Specialty Prior Authorization Dispensing Limits Step
Therapy clonazepam tab 2 mg (Klonopin) DIASTAT ACUDIAL – diazepam rectal gel
delivery system 10 mg DIASTAT ACUDIAL – diazepam rectal gel delivery system 20
mg DIASTAT PEDIATRIC – diazepam rectal gel delivery system 2.5 mg DILANTIN –
phenytoin sodium extended cap 30 mg divalproex sodium cap delayed release
sprinkle 125 mg (Depakote sprinkles) divalproex sodium tab delayed release 125
mg (Depakote) divalproex sodium tab delayed release 250 mg (Depakote)
divalproex sodium tab delayed release 500 mg (Depakote) divalproex sodium tab
sr 24 hr 250 mg (Depakote er) divalproex sodium tab sr 24 hr 500 mg (Depakote
er) ethosuximide cap 250 mg (Zarontin) ethosuximide soln 250 mg/5ml (Zarontin)
gabapentin cap 100 mg (Neurontin) gabapentin cap 300 mg (Neurontin) gabapentin
cap 400 mg (Neurontin) gabapentin oral soln 250 mg/5ml (Neurontin) gabapentin
tab 600 mg (Neurontin) gabapentin tab 800 mg (Neurontin) GABITRIL – tiagabine
hcl tab 12 mg GABITRIL – tiagabine hcl tab 16 mg lamotrigine tab chewable
dispersible 5 mg (Lamictal chewable di) 2017 Find and estimate prices for
medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 43 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy lamotrigine tab
chewable dispersible 25 mg (Lamictal chewable di) lamotrigine tab 25 mg
(Lamictal) lamotrigine tab 100 mg (Lamictal) lamotrigine tab 150 mg (Lamictal)
lamotrigine tab 200 mg (Lamictal) levetiracetam oral soln 100 mg/ml (Keppra)
levetiracetam tab sr 24hr 500 mg (Keppra xr) levetiracetam tab sr 24hr 750 mg
(Keppra xr) levetiracetam tab 250 mg (Keppra) levetiracetam tab 500 mg (Keppra)
levetiracetam tab 750 mg (Keppra) levetiracetam tab 1000 mg (Keppra) LYRICA –
pregabalin cap 25 mg • LYRICA – pregabalin cap 50 mg • LYRICA – pregabalin cap
75 mg • LYRICA – pregabalin cap 100 mg • LYRICA – pregabalin cap 150 mg •
LYRICA – pregabalin cap 200 mg • LYRICA – pregabalin cap 225 mg • LYRICA –
pregabalin cap 300 mg • oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)
oxcarbazepine tab 150 mg (Trileptal) oxcarbazepine tab 300 mg (Trileptal)
oxcarbazepine tab 600 mg (Trileptal) phenytoin chew tab 50 mg (Dilantin
infatabs) phenytoin sodium extended cap 100 mg (Dilantin) phenytoin sodium
extended cap 200 mg (Phenytek) Drug Name Specialty Prior Authorization
Dispensing Limits Step Therapy phenytoin sodium extended cap 300 mg (Phenytek)
phenytoin susp 125 mg/5ml (Dilantin) primidone tab 50 mg (Mysoline) primidone
tab 250 mg (Mysoline) SABRIL – vigabatrin tab 500 mg SABRIL – vigabatrin powd
pack 500 mg topiramate sprinkle cap 15 mg (Topamax sprinkle) topiramate
sprinkle cap 25 mg (Topamax sprinkle) topiramate tab 25 mg (Topamax) topiramate
tab 50 mg (Topamax) topiramate tab 100 mg (Topamax) topiramate tab 200 mg
(Topamax) valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene)
valproic acid cap 250 mg (Depakene) zonisamide cap 25 mg (Zonegran) zonisamide
cap 50 mg zonisamide cap 100 mg (Zonegran) PARKINSON'S DISEASE amantadine hcl
cap 100 mg amantadine hcl syrup 50 mg/5ml AZILECT – rasagiline mesylate tab 0.5
mg (base equiv) AZILECT – rasagiline mesylate tab 1 mg (base equiv) benztropine
mesylate tab 0.5 mg benztropine mesylate tab 1 mg benztropine mesylate tab 2 mg
bromocriptine mesylate cap 5 mg (base equivalent) 2017 Find and estimate prices
for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 44 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy bromocriptine
mesylate tab 2.5 mg (base equivalent) (Parlodel) carbidopa & levodopa
orally disintegrating tab 10-100 mg carbidopa & levodopa orally disintegrating
tab 25-100 mg carbidopa & levodopa orally disintegrating tab 25-250 mg
carbidopa & levodopa tab cr 25-100 mg (Sinemet cr) carbidopa & levodopa
tab cr 50-200 mg (Sinemet cr) carbidopa & levodopa tab 10-100 mg (Sinemet)
carbidopa & levodopa tab 25-100 mg (Sinemet) carbidopa & levodopa tab
25-250 mg (Sinemet) entacapone tab 200 mg (Comtan) pramipexole dihydrochloride
tab 0.125 mg (Mirapex) pramipexole dihydrochloride tab 0.25 mg (Mirapex)
pramipexole dihydrochloride tab 0.5 mg (Mirapex) pramipexole dihydrochloride
tab 0.75 mg (Mirapex) pramipexole dihydrochloride tab 1 mg (Mirapex)
pramipexole dihydrochloride tab 1.5 mg (Mirapex) rasagiline mesylate tab 0.5 mg
(base equiv) (Azilect) rasagiline mesylate tab 1 mg (base equiv) (Azilect)
ropinirole hydrochloride tab 0.25 mg (Requip) Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy 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)
selegiline hcl cap 5 mg (Eldepryl) selegiline hcl tab 5 mg trihexyphenidyl hcl
elixir 0.4 mg/ml trihexyphenidyl hcl tab 2 mg trihexyphenidyl hcl tab 5 mg
MUSCLE RELAXANTS baclofen tab 10 mg baclofen tab 20 mg chlorzoxazone tab 500 mg
(Parafon forte dsc) cyclobenzaprine hcl tab 5 mg cyclobenzaprine hcl tab 10 mg
dantrolene sodium cap 25 mg (Dantrium) dantrolene sodium cap 50 mg (Dantrium)
dantrolene sodium cap 100 mg (Dantrolene sodium) metaxalone tab 800 mg
(Skelaxin) methocarbamol tab 500 mg (Robaxin) methocarbamol tab 750 mg
(Robaxin-750) orphenadrine citrate tab sr 12hr 100 mg 2017 Find and estimate
prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 45 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy tizanidine hcl tab
2 mg (base equivalent) • tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) •
OTHER NEUROMUSCULAR DRUGS pyridostigmine bromide tab 60 mg (Mestinon) riluzole
tab 50 mg (Rilutek) SUPPLEMENTS VITAMINS ergocalciferol cap 50000 unit
(Drisdol) MEPHYTON – phytonadione tab 5 mg MULTIVITAMINS KOSHER PRENATAL PLUS
IRON – prenatal vit w/ iron carbonyl-fa tab 30-1 mg PRENATAL LOW IRON –
prenatal vit w/ fe fumarate-fa tab 27-1 mg PRENATAL PLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg PRENATAL PLUS/IRON – prenatal vit w/ fe fumarate-fa tab
27-1 mg PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe fumarate-fa tab 27-1 mg
PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg PRENATAL 19 –
prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg SE-NATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa
tab 29-1 mg MINERALS AND ELECTROLYTES potassium chloride cap cr 8 meq (Micro-k)
Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy
potassium chloride cap cr 10 meq (Micro-k) potassium chloride microencapsulated
crys cr tab 10 meq 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 (Ktab) BLOOD MODIFYING DRUGS ADVATE – antihemophilic factor rahfpfm for inj
250 unit • ADVATE – antihemophilic factor rahfpfm for inj 500 unit • ADVATE –
antihemophilic factor rahfpfm for inj 1000 unit • ADVATE – antihemophilic
factor rahfpfm for inj 1500 unit • ADVATE – antihemophilic factor rahfpfm for
inj 2000 unit • ADVATE – antihemophilic factor rahfpfm for inj 3000 unit •
ADVATE – antihemophilic factor rahfpfm for inj 4000 unit • ADYNOVATE –
antihemophilic factor recomb pegylated for inj 250 unit • ADYNOVATE –
antihemophilic factor recomb pegylated for inj 500 unit • ADYNOVATE –
antihemophilic factor recomb pegylated for inj 750 unit • 2017 Find and
estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 46 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy ADYNOVATE –
antihemophilic factor recomb pegylated for inj 1000 unit • ADYNOVATE – antihemophilic
factor recomb pegylated for inj 1500 unit • ADYNOVATE – antihemophilic factor
recomb pegylated for inj 2000 unit • AFSTYLA – antihemophilic fact rcmb single
chain for inj kit 250 unit • AFSTYLA – antihemophilic fact rcmb single chain
for inj kit 500 unit • AFSTYLA – antihemophilic fact rcmb single chain for inj
kit 1000 unit • AFSTYLA – antihemophilic fact rcmb single chain for inj kit
2000 unit • AFSTYLA – antihemophilic fact rcmb single chain for inj kit 3000
unit • ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 250
unit • ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 500
unit • ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj
1000 unit • ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for
inj 1500 unit • ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human)
for inj 2000 unit • ALPHANINE SD – coagulation factor ix for inj 500 unit •
ALPHANINE SD – coagulation factor ix for inj 1000 unit • ALPHANINE SD –
coagulation factor ix for inj 1500 unit • Drug Name Specialty Prior
Authorization Dispensing Limits Step Therapy ALPROLIX – coagulation factor ix
(recomb) (rfixfc) for inj 250 unit • ALPROLIX – coagulation factor ix (recomb)
(rfixfc) for inj 500 unit • ALPROLIX – coagulation factor ix (recomb) (rfixfc)
for inj 1000 unit • ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
2000 unit • ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj 3000
unit • ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj 4000 unit •
anagrelide hcl cap 0.5 mg (Agrylin) anagrelide hcl cap 1 mg ARANESP ALBUMIN
FREE – darbepoetin alfa soln prefilled syringe 10 mcg/0.4ml • • ARANESP ALBUMIN
FREE – darbepoetin alfa soln prefilled syringe 25 mcg/0.42ml • • ARANESP
ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 40 mcg/0.4ml • • ARANESP
ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml • • ARANESP
ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 100 mcg/0.5ml • •
ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml •
• ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 200 mcg/0.4ml
• • ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 300
mcg/0.6ml • • 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 47 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy ARANESP ALBUMIN
FREE – darbepoetin alfa soln prefilled syringe 500 mcg/ml • • ARANESP ALBUMIN
FREE – darbepoetin alfa soln inj 25 mcg/ml • • ARANESP ALBUMIN FREE –
darbepoetin alfa soln inj 40 mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa
soln inj 60 mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 100
mcg/ml • • ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 200 mcg/ml • •
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 300 mcg/ml • • BEBULIN –
factor ix complex for inj 200-1200 unit • BENEFIX – coagulation factor ix
(recombinant) for inj kit 250 unit • BENEFIX – coagulation factor ix
(recombinant) for inj kit 500 unit • BENEFIX – coagulation factor ix
(recombinant) for inj kit 1000 unit • BENEFIX – coagulation factor ix
(recombinant) for inj kit 2000 unit • BENEFIX – coagulation factor ix
(recombinant) for inj kit 3000 unit • BRILINTA – ticagrelor tab 60 mg BRILINTA
– ticagrelor tab 90 mg cilostazol tab 50 mg (Pletal) cilostazol tab 100 mg
(Pletal) clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) COAGADEX – coagulation
factor x (human) for inj 250 unit • COAGADEX – coagulation factor x (human) for
inj 500 unit • Drug Name Specialty Prior Authorization Dispensing Limits Step
Therapy CORIFACT – factor xiii concentrate (human) for inj kit 1000-1600 unit •
cyanocobalamin inj 1000 mcg/ml dipyridamole tab 25 mg (Persantine) dipyridamole
tab 50 mg (Persantine) dipyridamole tab 75 mg (Persantine) DROXIA – hydroxyurea
cap 200 mg DROXIA – hydroxyurea cap 300 mg DROXIA – hydroxyurea cap 400 mg
ELIQUIS – apixaban tab 2.5 mg • ELIQUIS – apixaban tab 5 mg • ELOCTATE –
antihemophilic factor (recomb) rfviiifc for inj 250 unit • ELOCTATE –
antihemophilic factor (recomb) rfviiifc for inj 500 unit • ELOCTATE –
antihemophilic factor (recomb) rfviiifc for inj 750 unit • ELOCTATE – antihemophilic
factor (recomb) rfviiifc for inj 1000 unit • ELOCTATE – antihemophilic factor
(recomb) rfviiifc for inj 1500 unit • ELOCTATE – antihemophilic factor (recomb)
rfviiifc for inj 2000 unit • ELOCTATE – antihemophilic factor (recomb) rfviiifc
for inj 3000 unit • ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
4000 unit • ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 5000
unit • ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 6000 unit •
enoxaparin sodium inj 30 mg/0.3ml (Lovenox) • enoxaparin sodium inj 40 mg/0.4ml
(Lovenox) • 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 48 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy enoxaparin sodium
inj 60 mg/0.6ml (Lovenox) • enoxaparin sodium inj 80 mg/0.8ml (Lovenox) •
enoxaparin sodium inj 100 mg/ml (Lovenox) • enoxaparin sodium inj 120 mg/0.8ml
(Lovenox) • enoxaparin sodium inj 150 mg/ml (Lovenox) • enoxaparin sodium inj
300 mg/3ml (Lovenox) • EPOGEN – epoetin alfa inj 2000 unit/ml • • EPOGEN –
epoetin alfa inj 3000 unit/ml • • EPOGEN – epoetin alfa inj 4000 unit/ml • •
EPOGEN – epoetin alfa inj 10000 unit/ ml • • EPOGEN – epoetin alfa inj 20000
unit/ ml • • FEIBA – antiinhibitor coagulant complex for inj • FIRAZYR –
icatibant acetate inj 30 mg/3ml (base equivalent) • • folic acid tab 1 mg
HELIXATE FS – antihemophilic factor (recombinant) for inj kit 250 unit •
HELIXATE FS – antihemophilic factor (recombinant) for inj kit 500 unit •
HELIXATE FS – antihemophilic factor (recombinant) for inj kit 1000 unit •
HELIXATE FS – antihemophilic factor (recombinant) for inj kit 2000 unit •
HELIXATE FS – antihemophilic factor (recombinant) for inj kit 3000 unit •
HEMOFIL M – antihemophilic factor (human) for inj 250 unit • Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy HEMOFIL M –
antihemophilic factor (human) for inj 500 unit • HEMOFIL M – antihemophilic
factor (human) for inj 1000 unit • HEMOFIL M – antihemophilic factor (human)
for inj 1700 unit • HUMATE-P – antihemophilic factor/vwf (human) for inj
250-600 unit • HUMATE-P – antihemophilic factor/vwf (human) for inj 500-1200
unit • HUMATE-P – antihemophilic factor/vwf (human) for inj 1000-2400 unit •
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj 250 unit • IDELVION
– coagulation factor ix (recomb) (rix-fp) for inj 500 unit • IDELVION –
coagulation factor ix (recomb) (rix-fp) for inj 1000 unit • IDELVION –
coagulation factor ix (recomb) (rix-fp) for inj 2000 unit • KOATE –
antihemophilic factor (human) for inj 250 unit • KOATE – antihemophilic factor
(human) for inj 500 unit • KOATE – antihemophilic factor (human) for inj 1000
unit • KOATE-DVI – antihemophilic factor (human) for inj 250 unit • KOATE-DVI –
antihemophilic factor (human) for inj 500 unit • KOATE-DVI – antihemophilic
factor (human) for inj 1000 unit • KOGENATE FS – antihemophilic factor
(recombinant) for inj kit 250 unit • KOGENATE FS – antihemophilic factor
(recombinant) for inj kit 500 unit • 2017 Find and estimate prices for
medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 49 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy KOGENATE FS –
antihemophilic factor (recombinant) for inj kit 1000 unit • KOGENATE FS –
antihemophilic factor (recombinant) for inj kit 2000 unit • KOGENATE FS –
antihemophilic factor (recombinant) for inj kit 3000 unit • KOGENATE FS BIO-SET
– antihemophilic factor (recombinant) for inj kit 250 unit • KOGENATE FS
BIO-SET – antihemophilic factor (recombinant) for inj kit 500 unit • KOGENATE
FS BIO-SET – antihemophilic factor (recombinant) for inj kit 1000 unit •
KOGENATE FS BIO-SET – antihemophilic factor (recombinant) for inj kit 2000 unit
• KOGENATE FS BIO-SET – antihemophilic factor (recombinant) for inj kit 3000
unit • KOVALTRY – antihemophilic factor (recombinant) for inj 250 unit •
KOVALTRY – antihemophilic factor (recombinant) for inj 500 unit • KOVALTRY –
antihemophilic factor (recombinant) for inj 1000 unit • KOVALTRY –
antihemophilic factor (recombinant) for inj 2000 unit • KOVALTRY – antihemophilic
factor (recombinant) for inj 3000 unit • MONOCLATE-P – antihemophilic factor
(human) for inj kit 1000 unit • MONOCLATE-P – antihemophilic factor (human) for
inj kit 1500 unit • MONONINE – coagulation factor ix for inj 1000 unit • Drug
Name Specialty Prior Authorization Dispensing Limits Step Therapy NEULASTA –
pegfilgrastim soln prefilled syringe 6 mg/0.6ml • NEULASTA ONPRO KIT –
pegfilgrastim soln prefilled syringe kit 6 mg/0.6ml • NEUPOGEN – filgrastim
soln prefilled syringe 300 mcg/0.5ml • NEUPOGEN – filgrastim soln prefilled
syringe 480 mcg/0.8ml (600 mcg/ml) • NEUPOGEN – filgrastim inj 300 mcg/ml •
NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml) • NOVOEIGHT –
antihemophilic factor (recombinant) for inj 250 unit • NOVOEIGHT –
antihemophilic factor (recombinant) for inj 500 unit • NOVOEIGHT –
antihemophilic factor (recombinant) for inj 1000 unit • NOVOEIGHT –
antihemophilic factor (recombinant) for inj 1500 unit • NOVOEIGHT –
antihemophilic factor (recombinant) for inj 2000 unit • NOVOEIGHT – antihemophilic
factor (recombinant) for inj 3000 unit • NOVOSEVEN RT – coagulation factor viia
(recomb) for inj 1 mg (1000 mcg) • NOVOSEVEN RT – coagulation factor viia
(recomb) for inj 2 mg (2000 mcg) • NOVOSEVEN RT – coagulation factor viia
(recomb) for inj 5 mg (5000 mcg) • NOVOSEVEN RT – coagulation factor viia
(recomb) for inj 8 mg (8000 mcg) • NUWIQ – antihemophilic factor (bddrfviii)
for inj 250 unit • NUWIQ – antihemophilic factor (bddrfviii) for inj 500 unit •
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 50 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy NUWIQ – antihemophilic
factor (bddrfviii) for inj 1000 unit • NUWIQ – antihemophilic factor
(bddrfviii) for inj 2000 unit • NUWIQ – antihemophilic factor (bddrfviii) for
inj kit 250 unit • NUWIQ – antihemophilic factor (bddrfviii) for inj kit 500
unit • NUWIQ – antihemophilic factor (bddrfviii) for inj kit 1000 unit • NUWIQ
– antihemophilic factor (bddrfviii) for inj kit 2000 unit • OBIZUR –
antihemophilic factor (recomb porc) rpfviii for inj 500 unit • pentoxifylline
tab cr 400 mg PROCRIT – epoetin alfa inj 2000 unit/ ml • • PROCRIT – epoetin
alfa inj 3000 unit/ ml • • PROCRIT – epoetin alfa inj 4000 unit/ ml • • PROCRIT
– epoetin alfa inj 10000 unit/ ml • • PROCRIT – epoetin alfa inj 20000 unit/ ml
• • PROCRIT – epoetin alfa inj 40000 unit/ ml • • PROFILNINE – factor ix complex
for inj 500 unit • PROFILNINE – factor ix complex for inj 1000 unit •
PROFILNINE – factor ix complex for inj 1500 unit • PROFILNINE SD – factor ix
complex for inj 500 unit • PROFILNINE SD – factor ix complex for inj 1000 unit
• Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy
PROFILNINE SD – factor ix complex for inj 1500 unit • RECOMBINATE –
antihemophilic factor (recombinant) for inj 220-400 unit • RECOMBINATE –
antihemophilic factor (recombinant) for inj 401-800 unit • RECOMBINATE –
antihemophilic factor (recombinant) for inj 801-1240 unit • RECOMBINATE –
antihemophilic factor (recombinant) for inj 1241-1800 unit • RECOMBINATE –
antihemophilic factor (recombinant) for inj 1801-2400 unit • RIXUBIS –
coagulation factor ix (recombinant) for inj 250 unit • RIXUBIS – coagulation
factor ix (recombinant) for inj 500 unit • RIXUBIS – coagulation factor ix
(recombinant) for inj 1000 unit • RIXUBIS – coagulation factor ix (recombinant)
for inj 2000 unit • RIXUBIS – coagulation factor ix (recombinant) for inj 3000
unit • TRETTEN – coagulation factor xiii asubunit for inj 2000-3125 unit •
VONVENDI – von willebrand factor (recombinant) for inj 650 unit • VONVENDI –
von willebrand factor (recombinant) for inj 1300 unit • warfarin sodium tab 1 mg
(Coumadin) warfarin sodium tab 2 mg (Coumadin) warfarin sodium tab 2.5 mg
(Coumadin) warfarin sodium tab 3 mg (Coumadin) warfarin sodium tab 4 mg
(Coumadin) warfarin sodium tab 5 mg (Coumadin) warfarin sodium tab 6 mg
(Coumadin) 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 51 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy warfarin sodium
tab 7.5 mg (Coumadin) warfarin sodium tab 10 mg (Coumadin) WILATE –
antihemophilic factor/vwf (human) for inj 500-500 unit kit • WILATE –
antihemophilic factor/vwf (human) for inj 1000-1000 unit kit • XARELTO –
rivaroxaban tab 10 mg • XARELTO – rivaroxaban tab 15 mg • XARELTO – rivaroxaban
tab 20 mg • XARELTO STARTER PACK – rivaroxaban tab starter therapy pack 15 mg
& 20 mg • XYNTHA – antihemophilic factor recombinant paf for inj kit 250
unit • XYNTHA – antihemophilic factor recombinant paf for inj kit 500 unit •
XYNTHA – antihemophilic factor recombinant paf for inj kit 1000 unit • XYNTHA –
antihemophilic factor recombinant paf for inj kit 2000 unit • XYNTHA SOLOFUSE –
antihemophilic factor recombinant paf for inj kit 250 unit • XYNTHA SOLOFUSE –
antihemophilic factor recombinant paf for inj kit 500 unit • XYNTHA SOLOFUSE –
antihemophilic factor recombinant paf for inj kit 1000 unit • XYNTHA SOLOFUSE –
antihemophilic factor recombinant paf for inj kit 2000 unit • XYNTHA SOLOFUSE –
antihemophilic factor recombinant paf for inj kit 3000 unit • Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy ZARXIO –
filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml • ZARXIO – filgrastim-sndz
soln prefilled syringe 480 mcg/0.8ml • TOPICAL PRODUCTS EYE Anti-infectives
BACITRACIN – bacitracin ophth oint 500 unit/gm bacitracin-polymyxin b ophth
oint ciprofloxacin hcl ophth soln 0.3% (Ciloxan) erythromycin ophth oint 5
mg/gm gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3%
(Garamycin) NATACYN – natamycin ophth susp 5% neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin) ofloxacin ophth soln 0.3% (Ocuflox)
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim) sulfacetamide
sodium ophth soln 10% (Bleph-10) tobramycin ophth soln 0.3% (Tobrex)
trifluridine ophth soln 1% (Viroptic) VIGAMOX – moxifloxacin hcl ophth soln
0.5% (base equiv) Steroids and Combination Products bacitracin-polymyxin-neomycin-hc
ophth oint 1% fluorometholone ophth susp 0.1% (Fml liquifilm) 2017 Find and
estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 52 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy LOTEMAX –
loteprednol etabonate ophth susp 0.5% LOTEMAX – loteprednol etabonate ophth gel
0.5% LOTEMAX – loteprednol etabonate ophth oint 0.5% neomycin-polymyxindexamethasone
ophth oint 0.1% (Maxitrol) neomycin-polymyxindexamethasone ophth susp 0.1%
(Maxitrol) prednisolone acetate ophth susp 1% (Pred forte) PREDNISOLONE SODIUM
PHOSP – prednisolone sodium phosphate ophth soln 1% sulfacetamide
sodium-prednisolone ophth soln 10-0.23(0.25)% tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex) ZYLET – loteprednol etabonatetobramycin ophth susp
0.5-0.3% Glaucoma ALPHAGAN P – brimonidine tartrate ophth soln 0.1% AZOPT –
brinzolamide ophth susp 1% brimonidine tartrate ophth soln 0.15% (Alphagan p)
brimonidine tartrate ophth soln 0.2% carteolol hcl ophth soln 1% dorzolamide
hcl ophth soln 2% (Trusopt) dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt) latanoprost ophth soln 0.005% (Xalatan) • Drug Name Specialty
Prior Authorization Dispensing Limits Step Therapy levobunolol hcl ophth soln
0.5% (Betagan) LUMIGAN – bimatoprost ophth soln 0.01% • • pilocarpine hcl ophth
soln 1% (Isopto carpine) pilocarpine hcl ophth soln 2% (Isopto carpine)
pilocarpine hcl ophth soln 4% (Isopto carpine) SIMBRINZA –
brinzolamidebrimonidine tartrate ophth susp 1-0.2% timolol maleate ophth gel
forming soln 0.25% (Timoptic-xe) timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe) timolol maleate ophth soln 0.25% (Timoptic) timolol maleate ophth
soln 0.5% (Timoptic) TRAVATAN Z – travoprost ophth soln 0.004% (benzalkonium
free) (bak free) • • Other Eye Products azelastine hcl ophth soln 0.05%
(Optivar) cromolyn sodium ophth soln 4% cyclopentolate hcl ophth soln 1%
(Cyclogyl) diclofenac sodium ophth soln 0.1% flurbiprofen sodium ophth soln
0.03% (Ocufen) ketorolac tromethamine ophth soln 0.4% (Acular ls) ketorolac
tromethamine ophth soln 0.5% (Acular) 2017 Find and estimate prices for
medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 53 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy olopatadine hcl
ophth soln 0.1% (base equivalent) (Patanol) PATADAY – olopatadine hcl ophth
soln 0.2% (base equivalent) PAZEO – olopatadine hcl ophth soln 0.7% (base
equivalent) tropicamide ophth soln 0.5% tropicamide ophth soln 1% (Mydriacyl)
EAR acetic acid otic soln 2% CIPRODEX – ciprofloxacindexamethasone otic susp
0.3-0.1% hydrocortisone w/ acetic acid otic soln 1-2% (Vosol hc)
neomycin-polymyxin-hc otic soln 1% (Cortisporin) neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/ml-1% ofloxacin otic soln 0.3% MOUTH AND THROAT
(LOCAL) cevimeline hcl cap 30 mg (Evoxac) chlorhexidine gluconate soln 0.12%
(Peridex) clotrimazole troche 10 mg lidocaine hcl viscous soln 2% nystatin susp
100000 unit/ml pilocarpine hcl tab 5 mg (Salagen) pilocarpine hcl tab 7.5 mg
(Salagen) triamcinolone acetonide dental paste 0.1% ANORECTAL AGENTS CORTIFOAM
– hydrocortisone acetate rectal foam 10% (90 mg/dose) hydrocortisone enema 100
mg/60ml (Cortenema) Drug Name Specialty Prior Authorization Dispensing Limits
Step Therapy hydrocortisone rectal cream 2.5% (Anusol-hc) SKIN CONDITIONS/PRODUCTS
Acne adapalene cream 0.1% (Differin) adapalene gel 0.1% (Differin) adapalene
gel 0.3% (Differin) benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac) clindamycin
phosphate gel 1% (Cleocin-t) clindamycin phosphate lotion 1% (Cleocin-t)
clindamycin phosphate soln 1% (Cleocin-t) clindamycin phosphate swab 1%
(Cleocin-t) clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin)
erythromycin gel 2% (Erygel) erythromycin pads 2% erythromycin soln 2% FINACEA
– azelaic acid foam 15% FINACEA – azelaic acid gel 15% isotretinoin cap 10 mg •
isotretinoin cap 20 mg • isotretinoin cap 30 mg (Claravis) • isotretinoin cap
40 mg • metronidazole cream 0.75% (Metrocream) metronidazole gel 0.75% metronidazole
gel 1% (Metrogel) 2017 Find and estimate prices for medicines on this formulary
at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 54 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy metronidazole
lotion 0.75% (Metrolotion) SOOLANTRA – ivermectin cream 1% sulfacetamide sodium
lotion 10% (acne) (Klaron) tazarotene cream 0.1% (Tazorac) TAZORAC – tazarotene
cream 0.05% TAZORAC – tazarotene cream 0.1% TAZORAC – tazarotene gel 0.05%
TAZORAC – tazarotene gel 0.1% tretinoin cream 0.025% (Retin-a) tretinoin cream
0.05% (Retin-a) tretinoin cream 0.1% (Retin-a) tretinoin gel 0.01% (Retin-a)
tretinoin gel 0.025% (Retin-a) tretinoin microsphere gel 0.04% (Retin-a micro)
tretinoin microsphere gel 0.1% (Retin-a micro) Anti-infectives ciclopirox gel
0.77% (Loprox) ciclopirox olamine cream 0.77% (base equiv) ciclopirox olamine
susp 0.77% (base equiv) ciclopirox shampoo 1% (Loprox shampoo) ciclopirox solution
8% (Penlac nail lacquer) • • econazole nitrate cream 1% gentamicin sulfate
cream 0.1% ketoconazole cream 2% ketoconazole shampoo 2% (Nizoral) mupirocin
calcium cream 2% (Bactroban) Drug Name Specialty Prior Authorization Dispensing
Limits Step Therapy mupirocin oint 2% (Bactroban) nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm nystatin topical powder 100000 unit/ gm silver
sulfadiazine cream 1% (Silvadene) Corticosteroids alclometasone dipropionate
cream 0.05% (Aclovate) alclometasone dipropionate oint 0.05% betamethasone
dipropionate augmented cream 0.05% (Diprolene af) betamethasone dipropionate
augmented gel 0.05% betamethasone dipropionate augmented lotion 0.05%
(Diprolene) betamethasone dipropionate augmented oint 0.05% (Diprolene) betamethasone
dipropionate cream 0.05% betamethasone dipropionate lotion 0.05% betamethasone
dipropionate oint 0.05% betamethasone valerate cream 0.1% betamethasone
valerate lotion 0.1% betamethasone valerate oint 0.1% clobetasol propionate
cream 0.05% (Temovate) clobetasol propionate emollient base cream 0.05%
(Temovate e) clobetasol propionate foam 0.05% (Olux) 2017 Find and estimate
prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 55 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy clobetasol
propionate gel 0.05% (Temovate) clobetasol propionate oint 0.05% (Temovate)
clobetasol propionate soln 0.05% (Temovate) desonide cream 0.05% (Desowen)
desonide lotion 0.05% (Desowen) desonide oint 0.05% (Desowen) desoximetasone
cream 0.25% (Topicort) desoximetasone gel 0.05% (Topicort) desoximetasone oint
0.25% (Topicort) fluocinolone acetonide cream 0.01% fluocinolone acetonide
cream 0.025% (Synalar) fluocinolone acetonide oil 0.01% (body oil)
(Derma-smoothe/fs bod) fluocinolone acetonide oil 0.01% (scalp oil)
(Derma-smoothe/fs sca) fluocinolone acetonide oint 0.025% (Synalar)
fluocinolone acetonide soln 0.01% (Synalar) fluocinonide cream 0.05%
fluocinonide emulsified base cream 0.05% fluocinonide gel 0.05% fluocinonide
oint 0.05% fluocinonide soln 0.05% fluticasone propionate cream 0.05%
(Cutivate) fluticasone propionate oint 0.005% (Cutivate) halobetasol propionate
cream 0.05% (Ultravate) Drug Name Specialty Prior Authorization Dispensing
Limits Step Therapy halobetasol propionate oint 0.05% (Ultravate)
hydrocortisone cream 2.5% hydrocortisone lotion 2.5% hydrocortisone oint 2.5%
hydrocortisone valerate cream 0.2% hydrocortisone valerate oint 0.2% (Westcort)
mometasone furoate cream 0.1% (Elocon) mometasone furoate oint 0.1% (Elocon)
mometasone furoate solution 0.1% (lotion) (Elocon) nystatin-triamcinolone cream
100000-0.1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 unit/gm-%
triamcinolone acetonide cream 0.025% 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%
triamcinolone acetonide oint 0.1% triamcinolone acetonide oint 0.5% Other Skin
Products acitretin cap 10 mg (Soriatane) acitretin cap 17.5 mg (Soriatane)
acitretin cap 25 mg (Soriatane) calcipotriene cream 0.005% (Dovonex)
calcipotriene oint 0.005% 2017 Find and estimate prices for medicines on this
formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 56 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy calcipotriene soln
0.005% (50 mcg/ ml) CARAC – fluorouracil cream 0.5% • • diclofenac sodium
(actinic keratoses) gel 3% (Solaraze) • • diclofenac sodium gel 1% (Voltaren) •
• ELIDEL – pimecrolimus cream 1% • FLUOROPLEX – fluorouracil cream 1% • •
fluorouracil cream 5% (Efudex) • fluorouracil soln 2% fluorouracil soln 5%
imiquimod cream 5% (Aldara) • lidocaine hcl gel 2% • • lidocaine hcl soln 4%
(Xylocaine) • • lidocaine oint 5% • • lidocaine patch 5% (Lidoderm) • •
malathion lotion 0.5% (Ovide) permethrin cream 5% (Elimite) podofilox soln 0.5%
(Condylox) selenium sulfide lotion 2.5% STELARA – ustekinumab inj 45 mg/0.5ml •
• • STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml • • • STELARA –
ustekinumab soln prefilled syringe 90 mg/ml • • • tacrolimus oint 0.03%
(Protopic) • tacrolimus oint 0.1% (Protopic) • VALCHLOR – mechlorethamine hcl
gel 0.016% (base equivalent) • ZYCLARA – imiquimod cream 3.75% • • ZYCLARA PUMP
– imiquimod cream 2.5% • • ZYCLARA PUMP – imiquimod cream 3.75% • • Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy MISCELLANEOUS
CATEGORIES DIABETIC SUPPLIES TEST STRIPS – ASCENSIA BREEZE 2, CONTOUR, CONTOUR
NEXT • INSULIN PEN NEEDLES – BD ULTRAFINE, NOVOFINE, NOVOTWIST • INSULIN
SYRINGES – BD • LANCETS – BAYER FINGERSTIX, MICROLET, SINGLE-LET LANCETS – BD
MICROTAINER, ULTRAFINE RESPIRATORY INHALER-ASSIST DEVICES BREATHERITE –
spacer/aerosolholding chambers - device MISCELLANEOUS DRUGS azathioprine tab 50
mg (Imuran) buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) • buprenorphine
hcl-naloxone hcl sl tab 8-2 mg (base equiv) • CHEMET – succimer cap 100 mg
cyclosporine cap 25 mg (Sandimmune) cyclosporine cap 100 mg (Sandimmune)
CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg cyclosporine modified
cap 25 mg (Neoral) cyclosporine modified cap 50 mg (Cyclosporine modifie)
cyclosporine modified cap 100 mg (Neoral) cyclosporine modified oral soln 100
mg/ml (Neoral) 2017 Find and estimate prices for medicines on this formulary
at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 57 Drug Name
Specialty Prior Authorization Dispensing Limits Step Therapy DEPEN TITRATABS –
penicillamine tab 250 mg • mycophenolate mofetil cap 250 mg (Cellcept)
mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) mycophenolate mofetil
tab 500 mg (Cellcept) mycophenolate sodium tab dr 180 mg (mycophenolic acid
equiv) (Myfortic) mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)
(Myfortic) naloxone hcl inj 0.4 mg/ml naloxone hcl inj 4 mg/10ml naltrexone hcl
tab 50 mg (Revia) NARCAN – naloxone hcl nasal spray 4 mg/0.1ml RAPAMUNE –
sirolimus oral soln 1 mg/ ml REVLIMID – lenalidomide caps 2.5 mg • • • REVLIMID
– lenalidomide cap 5 mg • • • REVLIMID – lenalidomide cap 10 mg • • • REVLIMID
– lenalidomide cap 15 mg • • • REVLIMID – lenalidomide cap 20 mg • • • REVLIMID
– lenalidomide cap 25 mg • • • sirolimus tab 0.5 mg (Rapamune) sirolimus tab 1
mg (Rapamune) sirolimus tab 2 mg (Rapamune) sodium polystyrene sulfonate oral
susp 15 gm/60ml (Sps) sodium polystyrene sulfonate powder (Kayexalate) Drug
Name Specialty Prior Authorization Dispensing Limits Step Therapy SUBOXONE –
buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base equiv) • SUBOXONE – buprenorphine
hclnaloxone hcl sl film 4-1 mg (base equiv) • SUBOXONE – buprenorphine
hclnaloxone hcl sl film 8-2 mg (base equiv) • SUBOXONE – buprenorphine
hclnaloxone hcl sl film 12-3 mg (base equiv) • tacrolimus cap 0.5 mg (Prograf)
tacrolimus cap 1 mg (Prograf) tacrolimus cap 5 mg (Prograf) THALOMID –
thalidomide cap 50 mg • • • THALOMID – thalidomide cap 100 mg • • • THALOMID –
thalidomide cap 150 mg • • • THALOMID – thalidomide cap 200 mg • • • ZORTRESS –
everolimus tab 0.25 mg ZORTRESS – everolimus tab 0.5 mg ZORTRESS – everolimus
tab 0.75 mg 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 58 INDEX A abacavir
sulfate-lamivudine tab 600-300 mg
(Epzicom)............................................................................4
abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg
(Trizivir).................................................. 4 abacavir sulfate
tab 300 mg (base equiv) (Ziagen).........4 acamprosate calcium tab delayed
release 333 mg
(Campral)..........................................................................
37 acarbose tab 25 mg (Precose)........................................ 10
acarbose tab 50 mg (Precose)........................................ 10
acarbose tab 100 mg (Precose)...................................... 10
acebutolol hcl cap 200 mg (Sectral)...............................17 acebutolol
hcl cap 400 mg (Sectral)...............................17 acetaminophen w/
codeine soln 120-12 mg/5ml........... 38 acetaminophen w/ codeine tab 300-15 mg
(Tylenol/
codeine)............................................................................
38 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ codeine
#3).......................................................................38
acetaminophen w/ codeine tab 300-60 mg (Tylenol/ codeine
#4).......................................................................38
acetazolamide cap sr 12hr 500 mg (Diamox)................ 21 acetazolamide tab
125 mg............................................... 21 acetazolamide tab 250
mg............................................... 21 acetic acid otic soln
2%...................................................53 acetylcysteine inhal
soln 10%.........................................24 acetylcysteine inhal soln
20%.........................................24 acitretin cap 10 mg
(Soriatane).......................................55 acitretin cap 17.5 mg (Soriatane)....................................55
acitretin cap 25 mg (Soriatane).......................................55
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml (2000000
unit/0.5ml)........................................................... 6 acyclovir
cap 200 mg (Zovirax).........................................4 acyclovir susp
200 mg/5ml (Zovirax)............................... 4 acyclovir tab 400 mg
(Zovirax)..........................................4 acyclovir tab 800 mg
(Zovirax)..........................................4 adapalene cream 0.1%
(Differin).....................................53 adapalene gel 0.1%
(Differin).......................................... 53 adapalene gel 0.3%
(Differin).......................................... 53 ADCIRCA – tadalafil tab
20 mg (pah)................................22 adefovir dipivoxil tab 10 mg
(Hepsera)............................3 ADVAIR DISKUS – fluticasone-salmeterol
aer powder ba 100-50
mcg/dose...............................................................24
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 250-50
mcg/dose...............................................................24
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 500-50
mcg/dose...............................................................24
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21
mcg/act...............................................................................24
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21
mcg/act...............................................................................24
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 230-21
mcg/act..................................................................24
ADVATE – antihemophilic factor rahf-pfm for inj 250 unit......................................................................................45
ADVATE – antihemophilic factor rahf-pfm for inj 500
unit......................................................................................45
ADVATE – antihemophilic factor rahf-pfm for inj 1000
unit......................................................................................45
ADVATE – antihemophilic factor rahf-pfm for inj 1500
unit......................................................................................45
ADVATE – antihemophilic factor rahf-pfm for inj 2000
unit......................................................................................45
ADVATE – antihemophilic factor rahf-pfm for inj 3000
unit......................................................................................45
ADVATE – antihemophilic factor rahf-pfm for inj 4000
unit......................................................................................45
ADYNOVATE – antihemophilic factor recomb pegylated for inj 250 unit.........................................................................45
ADYNOVATE – antihemophilic factor recomb pegylated for inj 500
unit.........................................................................45
ADYNOVATE – antihemophilic factor recomb pegylated for inj 750
unit.........................................................................45
ADYNOVATE – antihemophilic factor recomb pegylated for inj 1000
unit.......................................................................46
ADYNOVATE – antihemophilic factor recomb pegylated for inj 1500
unit.......................................................................46
ADYNOVATE – antihemophilic factor recomb pegylated for inj 2000
unit.......................................................................46
AFINITOR – everolimus tab 2.5 mg.....................................6 AFINITOR
– everolimus tab 5 mg........................................6 AFINITOR –
everolimus tab 7.5 mg.....................................6 AFINITOR –
everolimus tab 10 mg......................................6 AFSTYLA –
antihemophilic fact rcmb single chain for inj kit 250
unit..............................................................................46
AFSTYLA – antihemophilic fact rcmb single chain for inj kit 500
unit..............................................................................46
AFSTYLA – antihemophilic fact rcmb single chain for inj kit 1000
unit............................................................................46
AFSTYLA – antihemophilic fact rcmb single chain for inj kit 2000
unit............................................................................46
AFSTYLA – antihemophilic fact rcmb single chain for inj kit 3000
unit............................................................................46
ALBENZA – albendazole tab 200 mg.................................. 6 albuterol
sulfate soln nebu 0.083% (2.5 mg/3ml)..........24 albuterol sulfate soln nebu
0.5% (5 mg/ml)...................24 albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).................................................................................24
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).................................................................................25
albuterol sulfate syrup 2 mg/5ml....................................25
albuterol sulfate tab 2 mg................................................25
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 59 albuterol
sulfate tab 4 mg................................................25
alclometasone dipropionate cream 0.05%
(Aclovate)..........................................................................54
alclometasone dipropionate oint 0.05%.........................54 alendronate
sodium tab 5 mg......................................... 13 alendronate sodium
tab 10 mg....................................... 13 alendronate sodium tab 35 mg.......................................
13 alendronate sodium tab 70 mg (Fosamax)....................13 alfuzosin hcl
tab sr 24hr 10 mg (Uroxatral)................... 30 ALKERAN – melphalan tab 2
mg.........................................7 allopurinol tab 100 mg
(Zyloprim).................................. 42 allopurinol tab 300 mg
(Zyloprim).................................. 42 ALPHAGAN P – brimonidine
tartrate ophth soln 0.1%...... 52 ALPHANATE/VON WILLEBRAND – antihemophilic
factor/ vwf (human) for inj 250
unit..............................................46 ALPHANATE/VON WILLEBRAND –
antihemophilic factor/ vwf (human) for inj 500
unit..............................................46 ALPHANATE/VON WILLEBRAND –
antihemophilic factor/ vwf (human) for inj 1000
unit............................................46 ALPHANATE/VON WILLEBRAND –
antihemophilic factor/ vwf (human) for inj 1500
unit............................................46 ALPHANATE/VON WILLEBRAND –
antihemophilic factor/ vwf (human) for inj 2000 unit............................................46
ALPHANINE SD – coagulation factor ix for inj 500 unit.....46 ALPHANINE SD –
coagulation factor ix for inj 1000
unit......................................................................................46
ALPHANINE SD – coagulation factor ix for inj 1500
unit......................................................................................46
alprazolam tab 0.25 mg (Xanax)......................................30
alprazolam tab 0.5 mg (Xanax)........................................30
alprazolam tab 1 mg (Xanax)...........................................30
alprazolam tab 2 mg (Xanax)...........................................30
alprazolam tab sr 24hr 0.5 mg (Xanax xr)......................30 alprazolam tab
sr 24hr 1 mg (Xanax xr).........................30 alprazolam tab sr 24hr 2 mg
(Xanax xr).........................30 alprazolam tab sr 24hr 3 mg (Xanax
xr).........................30 ALPROLIX – coagulation factor ix (recomb)
(rfixfc) for inj 250 unit..............................................................................46
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj 500
unit..............................................................................46
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj 1000
unit............................................................................46
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj 2000
unit............................................................................46
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj 3000
unit............................................................................46
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj 4000
unit............................................................................46
amantadine hcl cap 100 mg............................................ 43
amantadine hcl syrup 50 mg/5ml....................................43 amiloride
& hydrochlorothiazide tab 5-50 mg............... 21 amiloride hcl tab 5
mg..................................................... 21 amiodarone hcl tab
100 mg.............................................22 amiodarone hcl tab 400
mg.............................................22 amiodarone hcl tab 200 mg
(Cordarone).......................22 amitriptyline hcl tab 10
mg..............................................30 amitriptyline hcl tab 25
mg..............................................30 amitriptyline hcl tab 50
mg..............................................30 amitriptyline hcl tab 75
mg..............................................30 amitriptyline hcl tab 100
mg............................................30 amitriptyline hcl tab 150
mg............................................30 amlodipine
besylate-atorvastatin calcium tab 2.5-10 mg
(Caduet)......................................................................18
amlodipine besylate-atorvastatin calcium tab 2.5-20 mg
(Caduet)......................................................................18
amlodipine besylate-atorvastatin calcium tab 2.5-40 mg
(Caduet)......................................................................18
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).............................................................................18
amlodipine besylate-atorvastatin calcium tab 5-20 mg
(Caduet).............................................................................18
amlodipine besylate-atorvastatin calcium tab 5-40 mg
(Caduet).............................................................................18
amlodipine besylate-atorvastatin calcium tab 5-80 mg
(Caduet).............................................................................18
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet).............................................................................18
amlodipine besylate-atorvastatin calcium tab 10-20 mg
(Caduet).............................................................................18
amlodipine besylate-atorvastatin calcium tab 10-40 mg (Caduet).............................................................................18
amlodipine besylate-atorvastatin calcium tab 10-80 mg
(Caduet).............................................................................18
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)...............................................................................18
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)...............................................................................18
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel)...............................................................................18
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel)...............................................................................18
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)...............................................................................19
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel)...............................................................................19
amlodipine besylate tab 2.5 mg (Norvasc).................... 18 amlodipine
besylate tab 5 mg (Norvasc)....................... 18 amlodipine besylate tab
10 mg (Norvasc)..................... 18 amlodipine besylate-valsartan tab 5-160
mg
(Exforge)...........................................................................
19 amlodipine besylate-valsartan tab 5-320 mg
(Exforge)...........................................................................
19 amlodipine besylate-valsartan tab 10-160 mg
(Exforge)...........................................................................
19 amlodipine besylate-valsartan tab 10-320 mg
(Exforge)...........................................................................
19 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 60
amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct)...........................................15
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg (Exforge
hct)..............................................................15
amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg (Exforge hct).........................................16
amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg (Exforge
hct)............................................16
amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg (Exforge
hct)............................................16 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 (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)..................................................................... 34
amphetamine-dextroamphetamine cap sr 24hr 10 mg (Adderall
xr)..................................................................... 34
amphetamine-dextroamphetamine cap sr 24hr 15 mg (Adderall
xr)..................................................................... 35
amphetamine-dextroamphetamine cap sr 24hr 20 mg (Adderall
xr)..................................................................... 35
amphetamine-dextroamphetamine cap sr 24hr 25 mg (Adderall
xr)..................................................................... 35
amphetamine-dextroamphetamine cap sr 24hr 30 mg (Adderall
xr)..................................................................... 35
amphetamine-dextroamphetamine tab 5 mg
(Adderall)..........................................................................
35 amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)..........................................................................
35 amphetamine-dextroamphetamine tab 10 mg
(Adderall)..........................................................................
35 amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)..........................................................................
35 amphetamine-dextroamphetamine tab 15 mg
(Adderall)..........................................................................
35 amphetamine-dextroamphetamine tab 20 mg
(Adderall)..........................................................................
35 amphetamine-dextroamphetamine tab 30 mg
(Adderall)..........................................................................
35 ampicillin cap 250
mg........................................................ 1 ampicillin cap 500
mg........................................................ 1 anagrelide hcl cap
1 mg.................................................. 46 anagrelide hcl cap
0.5 mg (Agrylin)............................... 46 anastrozole tab 1 mg
(Arimidex).......................................7 ANDROGEL PUMP – testosterone
td gel 20.25 mg/act
(1.62%).................................................................................9
ANDROGEL – testosterone td gel 20.25 mg/1.25gm
(1.62%).................................................................................9
ANDROGEL – testosterone td gel 40.5 mg/2.5gm
(1.62%).................................................................................9
ANDROXY – fluoxymesterone tab 10 mg............................9 ANORO ELLIPTA
– umeclidinium-vilanterol aero powd ba 62.5-25
mcg/inh.................................................................25
aprepitant capsule 80 mg (Emend).................................28 aprepitant
capsule therapy pack 80 & 125 mg
(Emend).............................................................................28
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25
mcg/ml................................................................................47
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40
mcg/ml................................................................................47
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60
mcg/ml................................................................................47
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 100 mcg/ml........................................................................
47 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 200
mcg/ml........................................................................
47 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 300
mcg/ml........................................................................
47 ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 10
mcg/0.4ml..........................................46 ARANESP ALBUMIN FREE –
darbepoetin alfa soln prefilled syringe 25
mcg/0.42ml........................................46 ARANESP ALBUMIN FREE –
darbepoetin alfa soln prefilled syringe 40
mcg/0.4ml..........................................46 ARANESP ALBUMIN FREE –
darbepoetin alfa soln prefilled syringe 60 mcg/0.3ml..........................................46
ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 100
mcg/0.5ml........................................46 ARANESP ALBUMIN FREE –
darbepoetin alfa soln prefilled syringe 150 mcg/0.3ml........................................46
ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 200
mcg/0.4ml........................................46 ARANESP ALBUMIN FREE –
darbepoetin alfa soln prefilled syringe 300 mcg/0.6ml........................................46
ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled syringe 500
mcg/ml.............................................47 2017 Find and estimate
prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 61 aripiprazole
tab 2 mg (Abilify).........................................32 aripiprazole tab
5 mg (Abilify).........................................32 aripiprazole tab 10
mg (Abilify).......................................32 aripiprazole tab 15 mg
(Abilify).......................................32 aripiprazole tab 20 mg
(Abilify).......................................32 aripiprazole tab 30 mg
(Abilify).......................................32 ARNUITY ELLIPTA –
fluticasone furoate aerosol powder breath activ 100
mcg/act.................................................. 25 ARNUITY ELLIPTA –
fluticasone furoate aerosol powder breath activ 200
mcg/act.................................................. 25 ASACOL HD –
mesalamine tab delayed release 800
mg......................................................................................
28 ASMANEX HFA – mometasone furoate inhal aerosol suspension 100
mcg/act................................................... 25 ASMANEX HFA –
mometasone furoate inhal aerosol suspension 200
mcg/act................................................... 25 ASMANEX
TWISTHALER 120 ME – mometasone furoate inhal powd 220 mcg/inh (breath
activated)...................... 25 ASMANEX TWISTHALER 7 METE – mometasone
furoate inhal powd 110 mcg/inh (breath activated).......................25
ASMANEX TWISTHALER 14 MET – mometasone furoate inhal powd 220 mcg/inh (breath
activated)...................... 25 ASMANEX TWISTHALER 30 MET – mometasone
furoate inhal powd 110 mcg/inh (breath activated).......................25
ASMANEX TWISTHALER 30 MET – mometasone furoate inhal powd 220 mcg/inh (breath
activated)...................... 25 ASMANEX TWISTHALER 60 MET – mometasone
furoate inhal powd 220 mcg/inh (breath activated)...................... 25
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)......................................................................................
17 atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)....................................................................................
17 atenolol tab 25 mg (Tenormin)........................................ 17
atenolol tab 50 mg (Tenormin)........................................ 17 atenolol
tab 100 mg (Tenormin)...................................... 17 atorvastatin
calcium tab 10 mg (base equivalent)
(Lipitor)..............................................................................20
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor)..............................................................................20
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor)..............................................................................20
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor)..............................................................................20
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)...........................................................................6
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)...........................................................................6
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab 600-200-300
mg.................................................................. 4 ATROVENT
HFA – ipratropium bromide hfa inhal aerosol 17
mcg/act.........................................................................
25 AUBAGIO – teriflunomide tab 7 mg...................................36
AUBAGIO – teriflunomide tab 14 mg.................................36 AVONEX –
interferon beta-1a for im inj kit 30mcg (33mcg(6.6
mu)/vial)......................................................... 36 AVONEX –
interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml...........................................................................36
AVONEX PEN – interferon beta-1a im auto-injector kit 30
mcg/0.5ml...........................................................................36
AXIRON – testosterone td soln 30 mg/act...........................9
azathioprine tab 50 mg (Imuran).....................................56
azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 24 azelastine hcl
nasal spray 0.15% (205.5 mcg/spray)
(Astepro)...........................................................................
24 azelastine hcl ophth soln 0.05% (Optivar)..................... 52 AZILECT –
rasagiline mesylate tab 0.5 mg (base
equiv).................................................................................
43 AZILECT – rasagiline mesylate tab 1 mg (base equiv)......43 AZITHROMYCIN –
azithromycin powd pack for susp 1
gm........................................................................................
2 azithromycin for susp 100 mg/5ml (Zithromax).............. 2 azithromycin for
susp 200 mg/5ml (Zithromax).............. 2 azithromycin tab 250 mg
(Zithromax).............................. 2 azithromycin tab 500 mg
(Zithromax).............................. 2 azithromycin tab 600 mg
(Zithromax).............................. 2 AZOPT – brinzolamide ophth susp 1%..............................52
B BACITRACIN – bacitracin ophth oint 500 unit/gm............. 51
bacitracin-polymyxin b ophth oint..................................51
bacitracin-polymyxin-neomycin-hc ophth oint 1%.......51 baclofen tab 10
mg...........................................................44 baclofen tab 20
mg...........................................................44 balsalazide
disodium cap 750 mg (Colazal).................. 28 BARACLUDE – entecavir oral
soln 0.05 mg/ml...................3 BEBULIN – factor ix complex for inj
200-1200 unit............47 benazepril & hydrochlorothiazide tab 5-6.25
mg.......... 14 benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin
hct)...................................................................14 benazepril
& hydrochlorothiazide tab 20-12.5 mg (Lotensin
hct)...................................................................14
benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin
hct)...................................................................14
benazepril hcl tab 5 mg................................................... 14
benazepril hcl tab 10 mg (Lotensin)...............................14 benazepril
hcl tab 20 mg (Lotensin)...............................14 benazepril hcl tab 40
mg (Lotensin)...............................14 BENEFIX – coagulation factor ix
(recombinant) for inj kit 250
unit..............................................................................47
BENEFIX – coagulation factor ix (recombinant) for inj kit 500 unit..............................................................................47
BENEFIX – coagulation factor ix (recombinant) for inj kit 1000
unit............................................................................47
BENEFIX – coagulation factor ix (recombinant) for inj kit 2000
unit............................................................................47
2017 Find and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 62 BENEFIX –
coagulation factor ix (recombinant) for inj kit 3000
unit............................................................................47
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 20-12.5
mg................................. 16 BENICAR HCT – olmesartan
medoxomilhydrochlorothiazide tab 40-12.5 mg................................. 16
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-25
mg.................................... 16 BENICAR – olmesartan medoxomil tab 5
mg....................16 BENICAR – olmesartan medoxomil tab 20
mg..................16 BENICAR – olmesartan medoxomil tab 40
mg..................16 benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)....................................................................53
benztropine mesylate tab 0.5 mg....................................43
benztropine mesylate tab 1 mg.......................................43
benztropine mesylate tab 2 mg.......................................43
betamethasone dipropionate augmented cream 0.05% (Diprolene
af)................................................................... 54
betamethasone dipropionate augmented gel
0.05%.................................................................................
54 betamethasone dipropionate augmented lotion 0.05%
(Diprolene)........................................................................
54 betamethasone dipropionate augmented oint 0.05%
(Diprolene)........................................................................
54 betamethasone dipropionate cream 0.05%................... 54 betamethasone
dipropionate lotion 0.05%....................54 betamethasone dipropionate oint
0.05%....................... 54 betamethasone valerate cream 0.1%.............................
54 betamethasone valerate lotion 0.1%.............................. 54
betamethasone valerate oint 0.1%................................. 54 BETASERON
– interferon beta-1b for inj kit 0.3 mg.......... 36 bexarotene cap 75 mg (Targretin).....................................7
bicalutamide tab 50 mg (Casodex)...................................7 BILTRICIDE
– praziquantel tab 600 mg...............................6 bisoprolol &
hydrochlorothiazide tab 2.5-6.25 mg (Ziac)..................................................................................17
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)..................................................................................17
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)..................................................................................17
bisoprolol fumarate tab 5 mg (Zebeta)...........................17 bisoprolol
fumarate tab 10 mg (Zebeta).........................17 BREATHERITE –
spacer/aerosol-holding chambers -
device.................................................................................56
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 100-25
mcg/inh............................................................ 25 BREO
ELLIPTA – fluticasone furoate-vilanterol aero powd ba 200-25
mcg/inh............................................................ 25 BRILINTA
– ticagrelor tab 60 mg....................................... 47 BRILINTA –
ticagrelor tab 90 mg....................................... 47 brimonidine
tartrate ophth soln 0.2%.............................52 brimonidine tartrate
ophth soln 0.15% (Alphagan
p)........................................................................................
52 bromocriptine mesylate cap 5 mg (base
equivalent)........................................................................
43 bromocriptine mesylate tab 2.5 mg (base equivalent)
(Parlodel)...........................................................................44
budesonide delayed release particles cap 3 mg (Entocort
ec)...................................................................... 8
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)........................................................................
25 budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)........................................................................
25 budesonide inhalation susp 1 mg/2ml (Pulmicort).......25 bumetanide tab 0.5
mg.................................................... 21 bumetanide tab 1
mg........................................................21 bumetanide tab 2
mg........................................................21 buprenorphine
hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).................................................................................56
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).................................................................................56
buprenorphine hcl sl tab 2 mg (base equiv)................. 38 buprenorphine
hcl sl tab 8 mg (base equiv)................. 38 bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)..............................................................................
37 bupropion hcl tab 75 mg (Wellbutrin)............................ 31 bupropion
hcl tab 100 mg (Wellbutrin).......................... 31 bupropion hcl tab sr
12hr 100 mg (Wellbutrin sr).........30 bupropion hcl tab sr 12hr 150 mg
(Wellbutrin sr).........31 bupropion hcl tab sr 12hr 200 mg (Wellbutrin
sr).........31 bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 31
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 31 buspirone hcl tab
5 mg....................................................30 buspirone hcl tab 10
mg..................................................30 buspirone hcl tab 15
mg..................................................30 buspirone hcl tab 30
mg..................................................30
butalbital-acetaminophen-caffeine cap 50-325-40
mg......................................................................................
37 butalbital-acetaminophen-caffeine tab 50-325-40
mg......................................................................................
38 butalbital-acetaminophen tab 50-325 mg.......................37 butalbital-aspirin-caffeine
cap 50-325-40 mg
(Fiorinal)............................................................................38
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine
#3)....................................................... 38 BYDUREON –
exenatide for inj extended release susp 2
mg......................................................................................
10 BYDUREON PEN – exenatide extended release for susp pen-injector 2
mg.............................................................. 10 C
cabergoline tab 0.5 mg.................................................... 13
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
(Cafcit)...................................................................35
calcipotriene cream 0.005% (Dovonex)..........................55 calcipotriene
oint 0.005%.................................................55 2017 Find and
estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 63 calcipotriene
soln 0.005% (50 mcg/ml).......................... 56 calcitonin (salmon) nasal
soln 200 unit/act
(Miacalcin)........................................................................
13 calcitriol cap 0.25 mcg (Rocaltrol)..................................13
calcitriol cap 0.5 mcg (Rocaltrol)....................................13
calcitriol oral soln 1 mcg/ml (Rocaltrol).........................13 calcium
acetate (phosphate binder) cap 667 mg (169 mg ca)
(Phoslo)............................................................... 28
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)............................................................................28
CANASA – mesalamine suppos 1000 mg......................... 28 candesartan
cilexetil-hydrochlorothiazide tab 16-12.5 mg (Atacand
hct).............................................................16 candesartan
cilexetil-hydrochlorothiazide tab 32-12.5 mg (Atacand hct).............................................................16
candesartan cilexetil-hydrochlorothiazide tab 32-25 mg (Atacand
hct).............................................................16 candesartan
cilexetil tab 4 mg (Atacand)...................... 16 candesartan cilexetil tab
8 mg (Atacand)...................... 16 candesartan cilexetil tab 16 mg
(Atacand).................... 16 candesartan cilexetil tab 32 mg
(Atacand).................... 16 capecitabine tab 150 mg
(Xeloda).................................... 7 capecitabine tab 500 mg
(Xeloda).................................... 7 captopril tab 12.5
mg........................................................14 captopril tab 25
mg...........................................................15 captopril tab
50 mg...........................................................15 captopril
tab 100 mg.........................................................15 CARAC –
fluorouracil cream 0.5%.....................................56 carbamazepine
cap sr 12hr 100 mg (Carbatrol)............42 carbamazepine cap sr 12hr 200 mg
(Carbatrol)............42 carbamazepine cap sr 12hr 300 mg
(Carbatrol)............42 carbamazepine chew tab 100
mg................................... 42 carbamazepine susp 100 mg/5ml
(Tegretol)..................42 carbamazepine tab 200 mg
(Tegretol)............................42 carbamazepine tab sr 12hr 100 mg
(Tegretol-xr).......... 42 carbamazepine tab sr 12hr 200 mg
(Tegretol-xr).......... 42 carbamazepine tab sr 12hr 400 mg (Tegretol-xr)..........
42 carbidopa & levodopa orally disintegrating tab 10-100
mg......................................................................................
44 carbidopa & levodopa orally disintegrating tab 25-100
mg......................................................................................
44 carbidopa & levodopa orally disintegrating tab 25-250
mg......................................................................................
44 carbidopa & levodopa tab cr 25-100 mg (Sinemet cr).......................................................................................44
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).......................................................................................44
carbidopa & levodopa tab 10-100 mg (Sinemet)...........44 carbidopa &
levodopa tab 25-100 mg (Sinemet)...........44 carbidopa & levodopa tab
25-250 mg (Sinemet)...........44 carteolol hcl ophth soln
1%............................................ 52 carvedilol tab 3.125 mg
(Coreg)......................................17 carvedilol tab 6.25 mg
(Coreg)........................................17 carvedilol tab 12.5 mg
(Coreg)........................................17 carvedilol tab 25 mg
(Coreg)...........................................17 cefaclor cap 250
mg........................................................... 1 cefaclor cap
500 mg........................................................... 1 cefadroxil
cap 500 mg........................................................1 cefadroxil
for susp 250 mg/5ml........................................ 1 cefadroxil for
susp 500 mg/5ml........................................ 1 cefadroxil tab 1
gm.............................................................1 cefdinir cap
300 mg............................................................1 cefdinir
for susp 125 mg/5ml............................................ 1 cefdinir for
susp 250 mg/5ml............................................ 1 cefixime for susp
100 mg/5ml (Suprax)........................... 1 cefixime for susp 200 mg/5ml
(Suprax)........................... 1 cefpodoxime proxetil for susp 50
mg/5ml.......................1 cefpodoxime proxetil for susp 100
mg/5ml.....................1 cefpodoxime proxetil tab 100
mg..................................... 1 cefpodoxime proxetil tab 200
mg..................................... 1 cefprozil for susp 125
mg/5ml...........................................1 cefprozil for susp 250
mg/5ml...........................................1 cefprozil tab 250
mg...........................................................1 cefprozil tab
500 mg...........................................................1 CEFTIN –
cefuroxime axetil for susp 125 mg/5ml............... 1 ceftriaxone sodium for
inj 2 gm........................................2 ceftriaxone sodium for inj 1
gm (Rocephin)....................1 ceftriaxone sodium for inj 250
mg....................................1 ceftriaxone sodium for inj 500 mg
(Rocephin)................1 cefuroxime axetil tab 250 mg
(Ceftin).............................. 2 cefuroxime axetil tab 500 mg
(Ceftin).............................. 2 celecoxib cap 50 mg
(Celebrex)......................................40 celecoxib cap 100 mg
(Celebrex)....................................40 celecoxib cap 200 mg (Celebrex)....................................40
celecoxib cap 400 mg (Celebrex)....................................40 CELONTIN
– methsuximide cap 300 mg...........................42 cephalexin cap 250 mg
(Keflex)........................................2 cephalexin cap 500 mg
(Keflex)........................................2 cephalexin for susp 125
mg/5ml.......................................2 cephalexin for susp 250
mg/5ml.......................................2 cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)................... 24 cevimeline hcl cap 30 mg
(Evoxac)................................53 CHANTIX CONTINUING MONTH –
varenicline tartrate tab 1 mg (base
equiv).............................................................37 CHANTIX
STARTING MONTH PA – varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x 42
pack............................. 37 CHANTIX – varenicline tartrate tab 0.5 mg
(base
equiv).................................................................................
37 CHANTIX – varenicline tartrate tab 1 mg (base equiv)......37 CHEMET –
succimer cap 100 mg......................................56 CHENODAL –
chenodiol tab 250 mg.................................28 chlorhexidine gluconate
soln 0.12% (Peridex)..............53 chloroquine phosphate tab 500 mg (Aralen)...................6
chlorothiazide tab 500 mg............................................... 21
chlorpromazine hcl tab 10 mg........................................ 32
chlorpromazine hcl tab 25 mg........................................ 32 2017
Find and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 64 chlorpromazine
hcl tab 50 mg........................................ 32 chlorpromazine hcl tab
100 mg...................................... 32 chlorpromazine hcl tab 200
mg...................................... 32 chlorthalidone tab 25
mg.................................................21 chlorthalidone tab 50
mg.................................................21 chlorzoxazone tab 500 mg
(Parafon forte dsc)............. 44 cholestyramine light powder 4 gm/dose
(Questran
light)...................................................................................20
cholestyramine light powder packets 4 gm.................. 20 cholestyramine
powder 4 gm/dose (Questran).............20 cholestyramine powder packets 4 gm
(Questran)........20 choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
(Trilipix).................................................................20
choline fenofibrate cap dr 135 mg (fenofibric acid equiv)
(Trilipix).................................................................20
chorionic gonadotropin for inj 10000 unit..................... 10 CIALIS –
tadalafil tab 2.5 mg............................................. 23 CIALIS –
tadalafil tab 5 mg................................................ 23 CIALIS –
tadalafil tab 10 mg.............................................. 23 CIALIS –
tadalafil tab 20 mg.............................................. 23 ciclopirox
gel 0.77% (Loprox)......................................... 54 ciclopirox
olamine cream 0.77% (base equiv)...............54 ciclopirox olamine susp 0.77%
(base equiv).................54 ciclopirox shampoo 1% (Loprox
shampoo).................. 54 ciclopirox solution 8% (Penlac nail
lacquer).................54 cilostazol tab 50 mg
(Pletal)............................................47 cilostazol tab 100 mg
(Pletal)..........................................47 cimetidine hcl soln 300
mg/5ml...................................... 27 cimetidine tab 300
mg......................................................27 cimetidine tab 400
mg......................................................27 cimetidine tab 800
mg......................................................27 CIPRODEX –
ciprofloxacin-dexamethasone otic susp
0.3-0.1%.............................................................................53
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) (Cipro
xr)..................................................... 3
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) (Cipro
xr)...........................................................3 ciprofloxacin
for oral susp 250 mg/5ml (5%) (5 gm/100ml)
(Cipro)..............................................................2
ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)
(Cipro)..............................................................2
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)................. 51 ciprofloxacin
hcl tab 750 mg (base equiv).......................3 ciprofloxacin hcl tab 250
mg (base equiv) (Cipro)..........2 ciprofloxacin hcl tab 500 mg (base equiv)
(Cipro)..........2 citalopram hydrobromide oral soln 10 mg/5ml............. 31
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa).............................................................................
31 citalopram hydrobromide tab 20 mg (base equiv)
(Celexa).............................................................................
31 citalopram hydrobromide tab 40 mg (base equiv)
(Celexa).............................................................................
31 clarithromycin for susp 125 mg/5ml.................................2
clarithromycin for susp 250 mg/5ml (Biaxin).................. 2 clarithromycin
tab 250 mg (Biaxin).................................. 2 clarithromycin tab 500
mg (Biaxin).................................. 2 clarithromycin tab sr 24hr 500
mg (Biaxin xl pac)..........2 CLEOCIN – clindamycin phosphate vaginal suppos
100
mg......................................................................................
29 clindamycin hcl cap 75 mg (Cleocin)...............................6
clindamycin hcl cap 150 mg (Cleocin).............................6 clindamycin
hcl cap 300 mg (Cleocin).............................6 clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric
gr)............................................ 6 clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)........................................................................53
clindamycin phosphate gel 1% (Cleocin-t)....................53 clindamycin
phosphate lotion 1% (Cleocin-t)............... 53 clindamycin phosphate soln 1%
(Cleocin-t)..................53 clindamycin phosphate swab 1%
(Cleocin-t)................ 53 clindamycin phosphate vaginal cream 2%
(Cleocin)............................................................................29
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)....................................................................53
clobetasol propionate cream 0.05% (Temovate)...........54 clobetasol propionate
emollient base cream 0.05% (Temovate
e).....................................................................54
clobetasol propionate foam 0.05% (Olux)......................54 clobetasol
propionate gel 0.05% (Temovate)................ 55 clobetasol propionate oint
0.05% (Temovate)...............55 clobetasol propionate soln 0.05%
(Temovate).............. 55 clomipramine hcl cap 25 mg
(Anafranil)........................31 clomipramine hcl cap 50 mg
(Anafranil)........................31 clomipramine hcl cap 75 mg
(Anafranil)........................31 clonazepam tab 0.5 mg
(Klonopin).................................42 clonazepam tab 1 mg
(Klonopin)....................................42 clonazepam tab 2 mg
(Klonopin)....................................42 clonidine hcl tab 0.1 mg
(Catapres)............................... 22 clonidine hcl tab 0.2 mg
(Catapres)............................... 23 clonidine hcl tab 0.3 mg
(Catapres)............................... 23 clonidine hcl td patch weekly 0.1
mg/24hr
(Cataprestts-1)...................................................................................23
clonidine hcl td patch weekly 0.2 mg/24hr
(Cataprestts-2)...................................................................................23
clonidine hcl td patch weekly 0.3 mg/24hr
(Cataprestts-3)...................................................................................23
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)..............................................................................
47 clotrimazole troche 10 mg............................................... 53
clozapine tab 50 mg......................................................... 32
clozapine tab 200 mg....................................................... 32
clozapine tab 25 mg (Clozaril).........................................32
clozapine tab 100 mg (Clozaril).......................................32
COAGADEX – coagulation factor x (human) for inj 250
unit......................................................................................47
2017 Find and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 65 COAGADEX –
coagulation factor x (human) for inj 500
unit......................................................................................47
codeine sulfate tab 30 mg............................................... 38
codeine sulfate tab 60 mg............................................... 38
codeine sulfate tab 15 mg (Codeine sulfate).................38 colchicine w/
probenecid tab 0.5-500 mg...................... 42 COLCRYS – colchicine tab 0.6
mg....................................42 colestipol hcl granule packets 5 gm
(Colestid
flavored)............................................................................20
colestipol hcl granules 5 gm (Colestid flavored)..........20 colestipol hcl tab
1 gm (Colestid)...................................20 COMBIPATCH –
estradiol-norethindrone ace td pttw 0.05-0.14
mg/day.................................................................9
COMBIPATCH – estradiol-norethindrone ace td pttw 0.05-0.25
mg/day.................................................................9
COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100
mcg/act............................................ 25 COPAXONE – glatiramer
acetate soln prefilled syringe 20
mg/ml..................................................................................36
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml..................................................................................36
CORIFACT – factor xiii concentrate (human) for inj kit 1000-1600
unit...................................................................47
CORTIFOAM – hydrocortisone acetate rectal foam 10% (90
mg/dose).....................................................................
53 CORTISONE ACETATE – cortisone acetate tab 25 mg...... 8 COTELLIC –
cobimetinib fumarate tab 20 mg (base
equivalent)............................................................................7
CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000
unit....................................................... 28 CREON –
pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000
unit..................................................... 28 CREON –
pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000
unit...................................................28 CREON – pancrelipase
(lip-prot-amyl) dr cap 24000-76000-120000
unit.................................................28 CREON – pancrelipase
(lip-prot-amyl) dr cap 36000-114000-180000
unit............................................... 28 CRINONE – progesterone
vaginal gel 4%.........................29 CRINONE – progesterone vaginal gel
8%.........................29 cromolyn sodium ophth soln
4%....................................52 cyanocobalamin inj 1000
mcg/ml................................... 47 cyclobenzaprine hcl tab 5
mg.........................................44 cyclobenzaprine hcl tab 10
mg.......................................44 cyclopentolate hcl ophth soln 1%
(Cyclogyl)................52 cyclosporine cap 25 mg
(Sandimmune)........................ 56 cyclosporine cap 100 mg
(Sandimmune)...................... 56 cyclosporine modified cap 50 mg
(Cyclosporine modifie).............................................................................
56 cyclosporine modified cap 25 mg (Neoral)....................56 cyclosporine
modified cap 100 mg (Neoral)..................56 CYCLOSPORINE MODIFIED –
cyclosporine modified cap 50 mg.................................................................................56
cyclosporine modified oral soln 100 mg/ml
(Neoral)..............................................................................56
cyproheptadine hcl syrup 2 mg/5ml...............................24
cyproheptadine hcl tab 4 mg.......................................... 24
CYSTAGON – cysteamine bitartrate cap 50 mg................30 CYSTAGON –
cysteamine bitartrate cap 150 mg..............30 D DAKLINZA – daclatasvir
dihydrochloride tab 30 mg (base equivalent)............................................................................3
DAKLINZA – daclatasvir dihydrochloride tab 60 mg (base
equivalent)............................................................................4
DAKLINZA – daclatasvir dihydrochloride tab 90 mg (base
equivalent)............................................................................4
danazol cap 50
mg..............................................................9 danazol cap
100 mg............................................................9 danazol cap
200 mg............................................................9 dantrolene
sodium cap 25 mg (Dantrium)..................... 44 dantrolene sodium cap 50 mg
(Dantrium)..................... 44 dantrolene sodium cap 100 mg (Dantrolene sodium).............................................................................
44 dapsone tab 25
mg.............................................................6 dapsone tab
100 mg...........................................................6 DARAPRIM – pyrimethamine
tab 25 mg............................. 6 DELZICOL – mesalamine cap dr 400
mg..........................28 demeclocycline hcl tab 150
mg........................................ 2 demeclocycline hcl tab 300
mg........................................ 2 DEPEN TITRATABS – penicillamine
tab 250 mg.............. 57 DESCOVY – emtricitabine-tenofovir alafenamide
fumarate tab 200-25
mg..................................................................... 4
desipramine hcl tab 10 mg (Norpramin)........................ 31 desipramine
hcl tab 25 mg (Norpramin)........................ 31 desipramine hcl tab 50 mg
(Norpramin)........................ 31 desipramine hcl tab 75 mg
(Norpramin)........................ 31 desipramine hcl tab 100 mg
(Norpramin)...................... 31 desipramine hcl tab 150 mg
(Norpramin)...................... 31 desloratadine tab 5 mg
(Clarinex).................................. 24 desmopressin acetate inj 4
mcg/ml (Ddavp).................13 desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)..............................................................................13
desmopressin acetate nasal spray soln 0.01%
(Ddavp)..............................................................................13
desmopressin acetate nasal spray soln 0.01%
(refrigerated).....................................................................14
desmopressin acetate tab 0.1 mg (Ddavp)....................14 desmopressin
acetate tab 0.2 mg (Ddavp)....................14 desonide cream 0.05% (Desowen).................................
55 desonide lotion 0.05% (Desowen).................................. 55
desonide oint 0.05% (Desowen)......................................55
desoximetasone cream 0.25% (Topicort).......................55 desoximetasone
gel 0.05% (Topicort)............................ 55 desoximetasone oint 0.25%
(Topicort)...........................55 2017 Find and estimate prices for
medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 66 DEXAMETHASONE
– dexamethasone soln 0.5
mg/5ml..................................................................................8
dexamethasone elixir 0.5 mg/5ml..................................... 8
dexamethasone tab 0.5 mg............................................... 8
dexamethasone tab 0.75 mg............................................. 8
dexamethasone tab 1.5 mg............................................... 8
dexamethasone tab 4 mg.................................................. 8
dexamethasone tab 6 mg.................................................. 8
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).......................................................................................35
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr).......................................................................................35
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).......................................................................................35
dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin
xr).......................................................................................35
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin xr).......................................................................................35
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr).......................................................................................35
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine).......................................................................
35 dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine).......................................................................
35 dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine).......................................................................
35 dextroamphetamine sulfate tab 5 mg.............................35
dextroamphetamine sulfate tab 10 mg...........................35 DIASTAT
ACUDIAL – diazepam rectal gel delivery system 10
mg.................................................................................42
DIASTAT ACUDIAL – diazepam rectal gel delivery system 20
mg.................................................................................42
DIASTAT PEDIATRIC – diazepam rectal gel delivery system 2.5
mg...................................................................42
DIAZEPAM – diazepam oral soln 1 mg/ml.........................30 diazepam tab 2
mg (Valium)............................................30 diazepam tab 5 mg
(Valium)............................................30 diazepam tab 10 mg
(Valium)..........................................30 diclofenac potassium tab
50 mg (Cataflam)..................40 diclofenac sodium (actinic keratoses) gel
3%
(Solaraze)..........................................................................56
diclofenac sodium gel 1% (Voltaren)..............................56 diclofenac
sodium ophth soln 0.1%...............................52 diclofenac sodium tab
delayed release 25 mg..............40 diclofenac sodium tab delayed release 50
mg..............40 diclofenac sodium tab delayed release 75 mg..............40
diclofenac sodium tab sr 24hr 100 mg
(Voltarenxr).......................................................................................40
dicloxacillin sodium cap 250 mg...................................... 1
dicloxacillin sodium cap 500 mg...................................... 1
dicyclomine hcl cap 10 mg (Bentyl)...............................27 dicyclomine
hcl oral soln 10 mg/5ml............................. 27 dicyclomine hcl tab 20
mg (Bentyl)................................27 didanosine delayed release
capsule 125 mg (Videx
ec)........................................................................................
4 didanosine delayed release capsule 200 mg (Videx
ec)........................................................................................
4 didanosine delayed release capsule 250 mg (Videx
ec)........................................................................................
4 didanosine delayed release capsule 400 mg (Videx
ec)........................................................................................
4 digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 23 digoxin tab
250 mcg (0.25 mg) (Lanoxin)...................... 23 DILANTIN – phenytoin
sodium extended cap 30 mg.........42 diltiazem hcl cap sr 24hr 120
mg....................................19 diltiazem hcl cap sr 24hr 180
mg....................................19 diltiazem hcl cap sr 24hr 240
mg....................................19 diltiazem hcl coated beads cap sr 24hr
120 mg (Cardizem
cd)...................................................................19
diltiazem hcl coated beads cap sr 24hr 180 mg (Cardizem
cd)...................................................................19
diltiazem hcl coated beads cap sr 24hr 240 mg (Cardizem
cd)...................................................................19
diltiazem hcl coated beads cap sr 24hr 300 mg (Cardizem
cd)...................................................................19
diltiazem hcl coated beads cap sr 24hr 360 mg (Cardizem
cd)...................................................................19
diltiazem hcl extended release beads cap sr 24hr 120 mg
(Tiazac).......................................................................19
diltiazem hcl extended release beads cap sr 24hr 180 mg
(Tiazac).......................................................................19
diltiazem hcl extended release beads cap sr 24hr 240 mg
(Tiazac).......................................................................19
diltiazem hcl extended release beads cap sr 24hr 300 mg
(Tiazac).......................................................................19
diltiazem hcl extended release beads cap sr 24hr 360 mg
(Tiazac).......................................................................19
diltiazem hcl extended release beads cap sr 24hr 420 mg
(Tiazac).......................................................................19
diltiazem hcl tab 90 mg....................................................19
diltiazem hcl tab 30 mg (Cardizem)................................19 diltiazem
hcl tab 60 mg (Cardizem)................................19 diltiazem hcl tab
120 mg (Cardizem)..............................19 diphenoxylate w/ atropine tab
2.5-0.025 mg
(Lomotil)............................................................................27
dipyridamole tab 25 mg (Persantine)............................. 47 dipyridamole
tab 50 mg (Persantine)............................. 47 dipyridamole tab 75 mg
(Persantine)............................. 47 disopyramide phosphate cap 100 mg
(Norpace).......... 22 disopyramide phosphate cap 150 mg (Norpace).......... 22
disulfiram tab 250 mg (Antabuse).................................. 37
disulfiram tab 500 mg (Antabuse).................................. 37
divalproex sodium cap delayed release sprinkle 125 mg (Depakote
sprinkles)................................................ 42 divalproex sodium
tab delayed release 125 mg
(Depakote)........................................................................
42 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 67 divalproex
sodium tab delayed release 250 mg
(Depakote)........................................................................
42 divalproex sodium tab delayed release 500 mg
(Depakote)........................................................................
42 divalproex sodium tab sr 24 hr 250 mg (Depakote
er).......................................................................................42
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).......................................................................................42
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).............9 DIVIGEL –
estradiol td gel 0.5 mg/0.5gm (0.1%).................9 DIVIGEL – estradiol td
gel 1 mg/gm (0.1%).........................9 donepezil hydrochloride orally
disintegrating tab 5 mg (Aricept
odt)..................................................................... 37
donepezil hydrochloride orally disintegrating tab 10 mg (Aricept
odt).............................................................. 37 donepezil
hydrochloride tab 5 mg (Aricept)..................37 donepezil hydrochloride
tab 10 mg (Aricept)................37 dorzolamide hcl ophth soln 2%
(Trusopt)..................... 52 dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml
(Cosopt)................................................................ 52
doxazosin mesylate tab 1 mg (Cardura)........................23 doxazosin
mesylate tab 2 mg (Cardura)........................23 doxazosin mesylate tab 4
mg (Cardura)........................23 doxazosin mesylate tab 8 mg
(Cardura)........................23 doxepin hcl cap 10
mg.....................................................31 doxepin hcl cap 25
mg.....................................................31 doxepin hcl cap 50
mg.....................................................31 doxepin hcl cap 100
mg...................................................31 doxepin hcl conc 10
mg/ml............................................. 31 doxycycline hyclate cap
50 mg.........................................2 doxycycline hyclate cap 100 mg
(Vibramycin)................2 doxycycline hyclate tab 20
mg......................................... 2 doxycycline hyclate tab 100
mg....................................... 2 doxycycline monohydrate cap 50
mg.............................. 2 doxycycline monohydrate cap 150 mg
(Adoxa)..............2 doxycycline monohydrate cap 75 mg (Monodox)...........2
doxycycline monohydrate cap 100 mg (Monodox).........2 doxycycline monohydrate
tab 50 mg (Adoxa)................ 2 doxycycline monohydrate tab 75 mg
(Adoxa)................ 2 doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)...................................................................................
2 doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)...................................................................................
2 DROXIA – hydroxyurea cap 200 mg..................................47 DROXIA –
hydroxyurea cap 300 mg..................................47 DROXIA – hydroxyurea
cap 400 mg..................................47 DULERA – mometasone
furoate-formoterol fumarate aerosol 100-5
mcg/act...................................................... 25 DULERA –
mometasone furoate-formoterol fumarate aerosol 200-5
mcg/act...................................................... 25 duloxetine hcl
enteric coated pellets cap 20 mg
(Cymbalta)........................................................................
31 duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)........................................................................
31 duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)........................................................................
31 dutasteride cap 0.5 mg (Avodart)................................... 30 E
econazole nitrate cream 1%............................................ 54
ELIDEL – pimecrolimus cream 1%.................................... 56 ELIQUIS –
apixaban tab 2.5 mg........................................ 47 ELIQUIS –
apixaban tab 5 mg........................................... 47 ELLA –
ulipristal acetate tab 30 mg...................................10 ELOCTATE –
antihemophilic factor (recomb) rfviiifc for inj 250 unit..............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 500
unit..............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 750
unit..............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 1000
unit............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 1500
unit............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 2000
unit............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 3000
unit............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 4000 unit............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 5000
unit............................................................................47
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj 6000
unit............................................................................47
EMCYT – estramustine phosphate sodium cap 140 mg......7 EMEND – aprepitant
capsule 40 mg..................................28 EMEND – aprepitant capsule 80
mg..................................28 EMEND – aprepitant capsule 125
mg................................28 EMEND – aprepitant capsule therapy pack 80
& 125
mg......................................................................................
28 EMEND – aprepitant for oral susp 125 mg (125
mg/5ml)..............................................................................
28 enalapril maleate & hydrochlorothiazide tab 5-12.5
mg......................................................................................
15 enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic).........................................................................15
enalapril maleate tab 2.5 mg (Vasotec)..........................15 enalapril
maleate tab 5 mg (Vasotec).............................15 enalapril maleate tab
10 mg (Vasotec)...........................15 enalapril maleate tab 20 mg
(Vasotec)...........................15 ENBREL – etanercept for subcutaneous inj
25 mg........... 40 ENBREL – etanercept subcutaneous soln prefilled syringe 25
mg/0.5ml.......................................................................40
ENBREL – etanercept subcutaneous soln prefilled syringe 50
mg/ml............................................................................40
2017 Find and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 68 ENBREL
SURECLICK – etanercept subcutaneous solution auto-injector 50
mg/ml.........................................40 enoxaparin sodium inj 30
mg/0.3ml (Lovenox)............. 47 enoxaparin sodium inj 40 mg/0.4ml
(Lovenox)............. 47 enoxaparin sodium inj 60 mg/0.6ml
(Lovenox)............. 48 enoxaparin sodium inj 80 mg/0.8ml
(Lovenox)............. 48 enoxaparin sodium inj 100 mg/ml
(Lovenox)................ 48 enoxaparin sodium inj 120 mg/0.8ml
(Lovenox)........... 48 enoxaparin sodium inj 150 mg/ml
(Lovenox)................ 48 enoxaparin sodium inj 300 mg/3ml
(Lovenox).............. 48 entacapone tab 200 mg
(Comtan)...................................44 entecavir tab 0.5 mg
(Baraclude)......................................4 entecavir tab 1 mg
(Baraclude).........................................4 ENTRESTO –
sacubitril-valsartan tab 24-26 mg............... 19 ENTRESTO –
sacubitril-valsartan tab 49-51 mg............... 19 ENTRESTO –
sacubitril-valsartan tab 97-103 mg............. 19 EPCLUSA –
sofosbuvir-velpatasvir tab 400-100 mg........... 4 EPINEPHRINE (Mylan Products)
– epinephrine solution auto-injector 0.15 mg/0.3ml
(1:2000)................................23 EPINEPHRINE (Mylan Products) –
epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)..................................24 EPIPEN-JR 2-PAK – epinephrine
solution auto-injector 0.15 mg/0.3ml
(1:2000).....................................................24 EPIPEN 2-PAK –
epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................. 24 eplerenone
tab 25 mg (Inspra)........................................23 eplerenone tab 50
mg (Inspra)........................................23 EPOGEN – epoetin alfa inj
2000 unit/ml............................48 EPOGEN – epoetin alfa inj 3000
unit/ml............................48 EPOGEN – epoetin alfa inj 4000
unit/ml............................48 EPOGEN – epoetin alfa inj 10000
unit/ml..........................48 EPOGEN – epoetin alfa inj 20000
unit/ml..........................48 EPZICOM – abacavir sulfate-lamivudine tab
600-300
mg........................................................................................
4 ergocalciferol cap 50000 unit (Drisdol)..........................45
erythromycin gel 2% (Erygel)..........................................53 erythromycin
ophth oint 5 mg/gm..................................51 erythromycin pads
2%..................................................... 53 erythromycin soln
2%...................................................... 53 erythromycin w/
delayed release particles cap 250
mg........................................................................................
2 escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)...........................................................................31
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)...........................................................................31
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)...........................................................................31
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)...........................................................................31
esomeprazole magnesium cap delayed release 20 mg (base eq)
(Nexium)..........................................................27 esomeprazole
magnesium cap delayed release 40 mg (base eq)
(Nexium)..........................................................27 estazolam
tab 1 mg.......................................................... 34 estazolam
tab 2 mg.......................................................... 34 ESTRACE –
estradiol vaginal cream 0.1 mg/gm...............29 estradiol &
norethindrone acetate tab 0.5-0.1 mg
(Activella)............................................................................9
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)............................................................................9
estradiol tab 0.5 mg (Estrace)...........................................9
estradiol tab 1 mg (Estrace)..............................................9 estradiol
tab 2 mg (Estrace)..............................................9 estradiol td
patch twice weekly 0.025 mg/24hr
(Vivelledot).......................................................................................9
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).........................................................................9
estradiol td patch twice weekly 0.05 mg/24hr
(Vivelledot).....................................................................................10
estradiol td patch twice weekly 0.075 mg/24hr
(Vivelledot).....................................................................................10
estradiol td patch twice weekly 0.1 mg/24hr
(Vivelledot).....................................................................................10
estradiol td patch weekly 0.025 mg/24hr (Climara).......10 estradiol td patch
weekly 0.05 mg/24hr (Climara).........10 estradiol td patch weekly 0.06 mg/24hr
(Climara).........10 estradiol td patch weekly 0.075 mg/24hr (Climara).......10
estradiol td patch weekly 0.1 mg/24hr (Climara)...........10 estradiol td patch
weekly 0.0375 mg/24hr (37.5 mcg/24hr)
(Climara).........................................................10 estradiol
vaginal tab 10 mcg (Vagifem)..........................29 eszopiclone tab 1 mg
(Lunesta)......................................34 eszopiclone tab 2 mg
(Lunesta)......................................34 eszopiclone tab 3 mg
(Lunesta)......................................34 ethambutol hcl tab 100 mg
(Myambutol)......................... 3 ethambutol hcl tab 400 mg
(Myambutol)......................... 3 ethosuximide cap 250 mg
(Zarontin)..............................42 ethosuximide soln 250 mg/5ml
(Zarontin)..................... 42 etodolac cap 200 mg........................................................
40 etodolac cap 300 mg........................................................
40 etodolac tab 400
mg.........................................................40 etodolac tab 500
mg.........................................................40 etodolac tab sr
24hr 400 mg........................................... 40 etodolac tab sr 24hr
500 mg........................................... 40 etodolac tab sr 24hr 600
mg........................................... 40 exemestane tab 25 mg
(Aromasin)...................................7 ezetimibe tab 10 mg
(Zetia)............................................. 20 F famciclovir tab 125
mg (Famvir)....................................... 4 famciclovir tab 250 mg
(Famvir)....................................... 4 famciclovir tab 500 mg
(Famvir)....................................... 4 famotidine tab 20 mg
(Pepcid)........................................27 famotidine tab 40 mg
(Pepcid)........................................27 FARESTON – toremifene
citrate tab 60 mg (base
equivalent)............................................................................7
2017 Find and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 69 FEIBA –
antiinhibitor coagulant complex for inj................. 48 felodipine tab sr
24hr 2.5 mg.......................................... 19 felodipine tab sr 24hr
5 mg............................................. 19 felodipine tab sr 24hr 10
mg........................................... 19 fenofibrate micronized cap 67
mg (Lofibra).................. 20 fenofibrate micronized cap 134 mg
(Lofibra)................ 20 fenofibrate micronized cap 200 mg
(Lofibra)................ 20 fenofibrate tab 54 mg
(Lofibra)....................................... 20 fenofibrate tab 160 mg
(Lofibra)..................................... 21 fenofibrate tab 48 mg
(Tricor)......................................... 20 fenofibrate tab 145 mg
(Tricor)....................................... 21 fentanyl citrate lozenge on
a handle 200 mcg
(Actiq)................................................................................38
fentanyl citrate lozenge on a handle 400 mcg
(Actiq)................................................................................38
fentanyl citrate lozenge on a handle 600 mcg
(Actiq)................................................................................38
fentanyl citrate lozenge on a handle 800 mcg
(Actiq)................................................................................38
fentanyl citrate lozenge on a handle 1200 mcg
(Actiq)................................................................................38
fentanyl citrate lozenge on a handle 1600 mcg
(Actiq)................................................................................38
fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............38 fentanyl td patch
72hr 25 mcg/hr (Duragesic)...............38 fentanyl td patch 72hr 50 mcg/hr
(Duragesic)...............38 fentanyl td patch 72hr 75 mcg/hr
(Duragesic)...............38 fentanyl td patch 72hr 100 mcg/hr
(Duragesic).............38 FINACEA – azelaic acid foam
15%................................... 53 FINACEA – azelaic acid gel
15%.......................................53 finasteride tab 5 mg
(Proscar)........................................ 30 FIRAZYR – icatibant
acetate inj 30 mg/3ml (base
equivalent).........................................................................
48 flecainide acetate tab 50 mg........................................... 22
flecainide acetate tab 100 mg......................................... 22
flecainide acetate tab 150 mg......................................... 22 FLOVENT
DISKUS – fluticasone propionate aer pow ba 50
mcg/blister....................................................................
25 FLOVENT DISKUS – fluticasone propionate aer pow ba 100
mcg/blister..................................................................
25 FLOVENT DISKUS – fluticasone propionate aer pow ba 250
mcg/blister..................................................................
25 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/act
(125/valve)...........................................................25
FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/act
(250/valve)...........................................................25
FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/act
(50/valve)............................................................. 25
fluconazole for susp 10 mg/ml (Diflucan)........................3 fluconazole
for susp 40 mg/ml (Diflucan)........................3 fluconazole tab 50 mg
(Diflucan)......................................3 fluconazole tab 100 mg
(Diflucan)....................................3 fluconazole tab 150 mg
(Diflucan)....................................3 fluconazole tab 200 mg
(Diflucan)....................................3 flucytosine cap 250 mg
(Ancobon)...................................3 flucytosine cap 500 mg
(Ancobon)...................................3 fludrocortisone acetate tab 0.1
mg...................................8 flunisolide nasal soln 25 mcg/act
(0.025%)................... 24 fluocinolone acetonide cream 0.01%.............................
55 fluocinolone acetonide cream 0.025% (Synalar)...........55 fluocinolone
acetonide oil 0.01% (body oil) (Dermasmoothe/fs
bod).............................................................. 55
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs
sca)............................................................... 55
fluocinolone acetonide oint 0.025% (Synalar)...............55 fluocinolone
acetonide soln 0.01% (Synalar)................55 fluocinonide cream 0.05%...............................................
55 fluocinonide emulsified base cream 0.05%...................55 fluocinonide
gel 0.05%.....................................................55 fluocinonide
oint 0.05%....................................................55 fluocinonide
soln 0.05%...................................................55 fluorometholone
ophth susp 0.1% (Fml liquifilm)........ 51 FLUOROPLEX – fluorouracil cream
1%............................ 56 fluorouracil cream 5%
(Efudex)...................................... 56 fluorouracil soln
2%......................................................... 56 fluorouracil
soln 5%......................................................... 56 fluoxetine
hcl cap 10 mg (Prozac)..................................31 fluoxetine hcl cap
20 mg (Prozac)..................................31 fluoxetine hcl cap 40 mg
(Prozac)..................................31 fluoxetine hcl solution 20
mg/5ml.................................. 31 fluoxetine hcl tab 10
mg.................................................. 31 fluoxetine hcl tab 20
mg.................................................. 31 fluphenazine decanoate
inj 25 mg/ml.............................32 FLUPHENAZINE HCL – fluphenazine hcl
elixir 2.5 mg/5ml...............................................................................
32 FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
ml........................................................................................32
fluphenazine hcl tab 1 mg............................................... 32
fluphenazine hcl tab 2.5 mg............................................ 32
fluphenazine hcl tab 5 mg............................................... 33
fluphenazine hcl tab 10 mg............................................. 33
flurbiprofen sodium ophth soln 0.03% (Ocufen)...........52 flurbiprofen tab 50
mg......................................................40 flurbiprofen tab 100
mg................................................... 40 flutamide cap 125
mg.........................................................7 fluticasone
propionate cream 0.05% (Cutivate)............ 55 fluticasone propionate nasal
susp 50 mcg/act
(Flonase)...........................................................................
24 fluticasone propionate oint 0.005% (Cutivate).............. 55 fluvoxamine
maleate tab 25 mg......................................31 fluvoxamine maleate
tab 50 mg......................................31 fluvoxamine maleate tab 100
mg....................................31 folic acid tab 1
mg............................................................48 FOLLISTIM AQ –
follitropin beta inj 75 unit/0.5ml..............10 FOLLISTIM AQ – follitropin
beta inj 300 unit/0.36ml..........10 FOLLISTIM AQ – follitropin beta inj 600
unit/0.72ml..........10 2017 Find and estimate prices for medicines on this
formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 70 FOLLISTIM AQ –
follitropin beta inj 900 unit/1.08ml..........10 FORTEO – teriparatide
(recombinant) inj 600
mcg/2.4ml...........................................................................14
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg......................................................................................
15 fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg......................................................................................
15 fosinopril sodium tab 10 mg........................................... 15
fosinopril sodium tab 20 mg........................................... 15
fosinopril sodium tab 40 mg........................................... 15
furosemide oral soln 10 mg/ml....................................... 21
furosemide tab 20 mg (Lasix)......................................... 21
furosemide tab 40 mg (Lasix)......................................... 21
furosemide tab 80 mg (Lasix)......................................... 21 G
gabapentin cap 100 mg (Neurontin)...............................42 gabapentin
cap 300 mg (Neurontin)...............................42 gabapentin cap 400 mg
(Neurontin)...............................42 gabapentin oral soln 250 mg/5ml
(Neurontin)...............42 gabapentin tab 600 mg
(Neurontin)................................42 gabapentin tab 800 mg
(Neurontin)................................42 GABITRIL – tiagabine hcl tab 12
mg................................. 42 GABITRIL – tiagabine hcl tab 16
mg................................. 42 galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne
er)...................................................................37
galantamine hydrobromide cap sr 24hr 16 mg (Razadyne
er)...................................................................37
galantamine hydrobromide cap sr 24hr 24 mg (Razadyne
er)...................................................................37
galantamine hydrobromide tab 4 mg (Razadyne).........37 galantamine
hydrobromide tab 8 mg (Razadyne).........37 galantamine hydrobromide tab 12 mg
(Razadyne).......37 GANIRELIX ACETATE – ganirelix acetate inj 250
mcg/0.5ml...........................................................................10
gemfibrozil tab 600 mg (Lopid).......................................21
gentamicin sulfate cream 0.1%.......................................54
gentamicin sulfate ophth oint 0.3%................................51 gentamicin
sulfate ophth soln 0.3% (Garamycin).........51 GENVOYA –
elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10
mg.............................................................4 GILENYA –
fingolimod hcl cap 0.5 mg (base equiv)..........36 glatiramer acetate soln
prefilled syringe 20 mg/ml
(Copaxone).......................................................................
36 glimepiride tab 1 mg (Amaryl).........................................10
glimepiride tab 2 mg (Amaryl).........................................10
glimepiride tab 4 mg (Amaryl).........................................10
glipizide-metformin hcl tab 2.5-250 mg..........................11 glipizide-metformin
hcl tab 2.5-500 mg..........................11 glipizide-metformin hcl tab
5-500 mg.............................11 glipizide tab 5 mg
(Glucotrol)..........................................11 glipizide tab 10 mg
(Glucotrol)........................................11 glipizide tab sr 24hr 2.5
mg (Glucotrol xl)..................... 10 glipizide tab sr 24hr 5 mg (Glucotrol
xl)........................ 11 glipizide tab sr 24hr 10 mg (Glucotrol
xl)...................... 11 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1
mg..............................................................................11
glyburide-metformin tab 1.25-250 mg
(Glucovance)....................................................................
11 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 11 glyburide-metformin
tab 5-500 mg (Glucovance)......... 11 glyburide micronized tab 1.5 mg
(Glynase)...................11 glyburide micronized tab 3 mg
(Glynase)......................11 glyburide micronized tab 6 mg
(Glynase)......................11 glyburide tab 1.25
mg.......................................................11 glyburide tab 2.5
mg.........................................................11 glyburide tab 5
mg............................................................11 glycopyrrolate
tab 1 mg (Robinul)..................................27 glycopyrrolate tab 2 mg
(Robinul forte).........................27 granisetron hcl tab 1
mg................................................. 28 griseofulvin microsize
susp 125 mg/5ml......................... 3 griseofulvin microsize tab 500 mg
(Grifulvin v)..............3 guanfacine hcl tab 1 mg
(Tenex).................................... 23 guanfacine hcl tab 2 mg
(Tenex).................................... 23 guanfacine hcl tab sr 24hr 1 mg
(base equiv)
(Intuniv).............................................................................35
guanfacine hcl tab sr 24hr 2 mg (base equiv)
(Intuniv).............................................................................35
guanfacine hcl tab sr 24hr 3 mg (base equiv)
(Intuniv).............................................................................35
guanfacine hcl tab sr 24hr 4 mg (base equiv)
(Intuniv).............................................................................35
H halobetasol propionate cream 0.05% (Ultravate)..........55 halobetasol
propionate oint 0.05% (Ultravate)..............55 haloperidol decanoate im soln
50 mg/ml (Haldol decanoate
50)...................................................................33 haloperidol
decanoate im soln 100 mg/ml (Haldol decanoate
100).................................................................33
haloperidol lactate oral conc 2 mg/ml............................33 haloperidol
tab 0.5 mg..................................................... 33 haloperidol
tab 1 mg........................................................ 33 haloperidol
tab 2 mg........................................................ 33 haloperidol
tab 5 mg........................................................ 33 haloperidol
tab 10 mg...................................................... 33 haloperidol
tab 20 mg...................................................... 33 HARVONI –
ledipasvir-sofosbuvir tab 90-400 mg................4 HELIXATE FS –
antihemophilic factor (recombinant) for inj kit 250
unit.........................................................................48
HELIXATE FS – antihemophilic factor (recombinant) for inj kit 500
unit.........................................................................48
HELIXATE FS – antihemophilic factor (recombinant) for inj kit 1000
unit.......................................................................48
HELIXATE FS – antihemophilic factor (recombinant) for inj kit 2000
unit.......................................................................48
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 71 HELIXATE FS – antihemophilic
factor (recombinant) for inj kit 3000
unit.......................................................................48
HEMOFIL M – antihemophilic factor (human) for inj 250
unit......................................................................................48
HEMOFIL M – antihemophilic factor (human) for inj 500
unit......................................................................................48
HEMOFIL M – antihemophilic factor (human) for inj 1000
unit......................................................................................48
HEMOFIL M – antihemophilic factor (human) for inj 1700
unit......................................................................................48
HUMATE-P – antihemophilic factor/vwf (human) for inj 250-600
unit.......................................................................48
HUMATE-P – antihemophilic factor/vwf (human) for inj 500-1200
unit.....................................................................48
HUMATE-P – antihemophilic factor/vwf (human) for inj 1000-2400
unit...................................................................48
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml............................................................................
40 HUMIRA – adalimumab prefilled syringe kit 20
mg/0.4ml............................................................................
40 HUMIRA – adalimumab prefilled syringe kit 40
mg/0.8ml............................................................................
40 HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe kit 40
mg/0.8ml.....................................................40 HUMIRA PEN –
adalimumab pen-injector kit 40
mg/0.8ml............................................................................
40 HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40
mg/0.8ml.....................................................40 HUMIRA
PEN-PSORIASIS STAR – adalimumab peninjector kit 40
mg/0.8ml.....................................................40 HUMULIN R U-500
(CONCENTR – insulin regular (human) inj 500
unit/ml..................................................... 12 HUMULIN R U-500
KWIKPEN – insulin regular (human) soln pen-injector 500
unit/ml.............................................12 hydralazine hcl tab 10
mg............................................... 23 hydralazine hcl tab 25
mg............................................... 23 hydralazine hcl tab 50
mg............................................... 23 hydralazine hcl tab 100
mg............................................. 23 hydrochlorothiazide cap 12.5
mg (Microzide)............... 21 hydrochlorothiazide tab 12.5
mg.................................... 21 hydrochlorothiazide tab 25
mg....................................... 22 hydrochlorothiazide tab 50
mg....................................... 22 hydrocodone-acetaminophen soln
7.5-325 mg/15ml
(Hycet)...............................................................................
38 hydrocodone-acetaminophen tab 7.5-325 mg (Norco)..............................................................................
38 hydrocodone-acetaminophen tab 5-325 mg
(Norco)..............................................................................
38 hydrocodone-acetaminophen tab 10-325 mg (Norco)..............................................................................
38 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 38
hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......38 hydrocodone-ibuprofen
tab 7.5-200 mg (Vicoprofen)......................................................................38
hydrocortisone cream 2.5%.............................................55
hydrocortisone enema 100 mg/60ml (Cortenema)........53 hydrocortisone lotion
2.5%............................................. 55 hydrocortisone oint
2.5%.................................................55 hydrocortisone rectal
cream 2.5% (Anusol-hc)............ 53 hydrocortisone tab 5 mg
(Cortef)..................................... 8 hydrocortisone tab 10 mg
(Cortef)................................... 8 hydrocortisone tab 20 mg
(Cortef)................................... 8 hydrocortisone valerate cream
0.2%..............................55 hydrocortisone valerate oint 0.2%
(Westcort)...............55 hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)......................................................................................
53 hydromorphone hcl liqd 1 mg/ml (Dilaudid)..................38 hydromorphone
hcl tab 2 mg (Dilaudid)........................38 hydromorphone hcl tab 4 mg (Dilaudid)........................38
hydromorphone hcl tab 8 mg (Dilaudid)........................38
hydroxychloroquine sulfate tab 200 mg (Plaquenil).......6 hydroxyurea cap 500
mg (Hydrea)................................... 7 hydroxyzine hcl syrup 10 mg/5ml...................................30
hydroxyzine hcl tab 10 mg.............................................. 30
hydroxyzine hcl tab 25 mg.............................................. 30
hydroxyzine hcl tab 50 mg.............................................. 30
hydroxyzine pamoate cap 25 mg (Vistaril).................... 30 hydroxyzine
pamoate cap 50 mg (Vistaril).................... 30 I ibandronate sodium tab
150 mg (base equivalent)
(Boniva).............................................................................14
IBRANCE – palbociclib cap 75 mg...................................... 7 IBRANCE
– palbociclib cap 100 mg.................................... 7 IBRANCE –
palbociclib cap 125 mg.................................... 7 ibuprofen susp 100
mg/5ml.............................................40 ibuprofen tab 400
mg....................................................... 40 ibuprofen tab 600
mg....................................................... 40 ibuprofen tab 800
mg....................................................... 40 IDELVION –
coagulation factor ix (recomb) (rix-fp) for inj 250
unit..............................................................................48
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj 500 unit..............................................................................48
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj 1000
unit............................................................................48
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj 2000
unit............................................................................48
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec).............................................................................7
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec).............................................................................7
imipramine hcl tab 10 mg (Tofranil)............................... 31
imipramine hcl tab 25 mg (Tofranil)............................... 31
imipramine hcl tab 50 mg (Tofranil)............................... 31 imiquimod
cream 5% (Aldara).........................................56 2017 Find and
estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 72 IMITREX –
sumatriptan nasal spray 5 mg/act................... 41 IMITREX – sumatriptan
nasal spray 20 mg/act................. 41 IMPAVIDO – miltefosine cap 50
mg.....................................6 INCRELEX – mecasermin inj 40 mg/4ml
(10 mg/ml).........13 INCRUSE ELLIPTA – umeclidinium br aero powd breath act
62.5 mcg/inh (base eq)...............................................26
indapamide tab 1.25 mg...................................................22
indapamide tab 2.5 mg.....................................................22
indomethacin cap 25 mg................................................. 40
indomethacin cap 50 mg................................................. 40
INNOPRAN XL – propranolol hcl sustained-release beads cap sr 24hr 80
mg............................................................ 17 INNOPRAN XL –
propranolol hcl sustained-release beads cap sr 24hr 120
mg.......................................................... 17 INSULIN PEN
NEEDLES – BD ULTRAFINE, NOVOFINE,
NOVOTWIST.....................................................................
56 INSULIN SYRINGES – BD.................................................56
INTELENCE – etravirine tab 25 mg.....................................4
INTELENCE – etravirine tab 100 mg...................................4 INTELENCE
– etravirine tab 200 mg...................................4 INVOKAMET –
canagliflozin-metformin hcl tab 50-500 mg......................................................................................
11 INVOKAMET – canagliflozin-metformin hcl tab 50-1000
mg......................................................................................
11 INVOKAMET – canagliflozin-metformin hcl tab 150-500
mg......................................................................................
11 INVOKAMET – canagliflozin-metformin hcl tab 150-1000
mg......................................................................................
11 INVOKAMET XR – canagliflozin-metformin hcl tab sr 24hr 50-500
mg......................................................................... 11
INVOKAMET XR – canagliflozin-metformin hcl tab sr 24hr 50-1000
mg....................................................................... 11
INVOKAMET XR – canagliflozin-metformin hcl tab sr 24hr 150-500
mg....................................................................... 11
INVOKAMET XR – canagliflozin-metformin hcl tab sr 24hr 150-1000
mg..................................................................... 11
INVOKANA – canagliflozin tab 100 mg..............................11 INVOKANA –
canagliflozin tab 300 mg..............................11 ipratropium-albuterol
nebu soln 0.5-2.5(3) mg/3ml (Duoneb)...........................................................................
26 ipratropium bromide inhal soln 0.02%...........................26
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)..........................................................................24
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)..........................................................................24
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)............................................................................
16 irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)............................................................................
16 irbesartan tab 75 mg (Avapro)........................................ 16
irbesartan tab 150 mg (Avapro)...................................... 16
irbesartan tab 300 mg (Avapro)...................................... 16
ISENTRESS – raltegravir potassium chew tab 25 mg (base
equiv).........................................................................4
ISENTRESS – raltegravir potassium chew tab 100 mg (base
equiv).........................................................................4
ISENTRESS – raltegravir potassium packet for susp 100 mg (base
equiv).................................................................. 4
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)....................................................................................4
isoniazid tab 100 mg..........................................................
3 isoniazid tab 300
mg.......................................................... 3 isosorbide
dinitrate tab 10 mg........................................20 isosorbide
dinitrate tab 20 mg........................................20 isosorbide
dinitrate tab 30 mg........................................20 isosorbide
dinitrate tab 5 mg (Isordil titradose)........... 20 isosorbide mononitrate tab
10 mg................................. 20 isosorbide mononitrate tab 20
mg................................. 20 isosorbide mononitrate tab sr 24hr 30 mg
(Imdur).......20 isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......20
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....20 isotretinoin cap 10
mg..................................................... 53 isotretinoin cap 20
mg..................................................... 53 isotretinoin cap 40
mg..................................................... 53 isotretinoin cap 30
mg (Claravis)....................................53 itraconazole cap 100 mg
(Sporanox)................................3 ivermectin tab 3 mg
(Stromectol)..................................... 6 J JANUMET –
sitagliptin-metformin hcl tab 50-500 mg........11 JANUMET –
sitagliptin-metformin hcl tab 50-1000 mg......11 JANUMET XR –
sitagliptin-metformin hcl tab sr 24hr 50-500
mg......................................................................... 11
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 50-1000
mg....................................................................... 11
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr 100-1000
mg..................................................................... 11
JANUVIA – sitagliptin phosphate tab 25 mg (base
equiv).................................................................................
11 JANUVIA – sitagliptin phosphate tab 50 mg (base
equiv).................................................................................
11 JANUVIA – sitagliptin phosphate tab 100 mg (base
equiv).................................................................................
11 JARDIANCE – empagliflozin tab 10 mg.............................11 JARDIANCE
– empagliflozin tab 25 mg.............................11 K KADIAN – morphine
sulfate cap sr 24hr 40 mg.................38 KADIAN – morphine sulfate cap sr
24hr 200 mg...............38 KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20
mg/ml)...................................................................... 5
KALETRA – lopinavir-ritonavir tab 100-25 mg.....................5 KALETRA –
lopinavir-ritonavir tab 200-50 mg.....................5 KALYDECO – ivacaftor
packet 50 mg............................... 26 KALYDECO – ivacaftor packet 75
mg............................... 26 2017 Find and estimate prices for
medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 73 KALYDECO –
ivacaftor tab 150 mg................................... 26 ketoconazole cream
2%................................................... 54 ketoconazole shampoo
2% (Nizoral)..............................54 ketoprofen cap 50
mg...................................................... 40 ketoprofen cap 75
mg...................................................... 40 ketorolac tromethamine
ophth soln 0.5% (Acular)....... 52 ketorolac tromethamine ophth soln 0.4%
(Acular
ls).......................................................................................
52 KISQALI – ribociclib succinate tab 200 mg (base equiv).....7 KOATE – antihemophilic
factor (human) for inj 250
unit......................................................................................48
KOATE – antihemophilic factor (human) for inj 500
unit......................................................................................48
KOATE – antihemophilic factor (human) for inj 1000
unit......................................................................................48
KOATE-DVI – antihemophilic factor (human) for inj 250
unit......................................................................................48
KOATE-DVI – antihemophilic factor (human) for inj 500
unit......................................................................................48
KOATE-DVI – antihemophilic factor (human) for inj 1000 unit......................................................................................48
KOGENATE FS – antihemophilic factor (recombinant) for inj kit 250
unit....................................................................48
KOGENATE FS – antihemophilic factor (recombinant) for inj kit 500
unit....................................................................48
KOGENATE FS – antihemophilic factor (recombinant) for inj kit 1000
unit..................................................................49 KOGENATE
FS – antihemophilic factor (recombinant) for inj kit 2000
unit..................................................................49
KOGENATE FS – antihemophilic factor (recombinant) for inj kit 3000
unit..................................................................49
KOGENATE FS BIO-SET – antihemophilic factor (recombinant) for inj kit 250
unit.......................................49 KOGENATE FS BIO-SET –
antihemophilic factor (recombinant) for inj kit 500
unit.......................................49 KOGENATE FS BIO-SET –
antihemophilic factor (recombinant) for inj kit 1000
unit.....................................49 KOGENATE FS BIO-SET –
antihemophilic factor (recombinant) for inj kit 2000
unit.....................................49 KOGENATE FS BIO-SET –
antihemophilic factor (recombinant) for inj kit 3000
unit.....................................49 KOMBIGLYZE XR –
saxagliptin-metformin hcl tab sr 24hr 2.5-1000
mg...................................................................... 11
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr 5-500
mg............................................................................11
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr 5-1000
mg......................................................................... 11
KOSHER PRENATAL PLUS IRON – prenatal vit w/ iron carbonyl-fa tab 30-1
mg....................................................45 KOVALTRY –
antihemophilic factor (recombinant) for inj 250
unit..............................................................................49
KOVALTRY – antihemophilic factor (recombinant) for inj 500
unit..............................................................................49
KOVALTRY – antihemophilic factor (recombinant) for inj 1000
unit............................................................................49
KOVALTRY – antihemophilic factor (recombinant) for inj 2000
unit............................................................................49
KOVALTRY – antihemophilic factor (recombinant) for inj 3000
unit............................................................................49
L labetalol hcl tab 100 mg (Trandate)................................17
labetalol hcl tab 200 mg (Trandate)................................17 labetalol
hcl tab 300 mg (Trandate)................................17 lactulose
(encephalopathy) solution 10 gm/15ml......... 29 lactulose solution 10
gm/15ml........................................ 27 lamivudine oral soln 10
mg/ml (Epivir)............................ 5 lamivudine tab 150 mg
(Epivir)......................................... 5 lamivudine tab 300 mg
(Epivir)......................................... 5 lamivudine tab 100 mg (hbv)
(Epivir hbv)........................4 lamivudine-zidovudine tab 150-300 mg
(Combivir)........ 5 lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable
di)..................................................................... 42
lamotrigine tab chewable dispersible 25 mg (Lamictal chewable
di)..................................................................... 43
lamotrigine tab 25 mg (Lamictal)....................................43
lamotrigine tab 100 mg (Lamictal)..................................43
lamotrigine tab 150 mg (Lamictal)..................................43
lamotrigine tab 200 mg (Lamictal)..................................43 LANCETS –
BAYER FINGERSTIX, MICROLET,
SINGLELET.....................................................................................56
LANCETS – BD MICROTAINER, ULTRAFINE..................56 lansoprazole cap
delayed release 15 mg
(Prevacid)..........................................................................27
lansoprazole cap delayed release 30 mg
(Prevacid)..........................................................................27
LANTUS – insulin glargine inj 100 unit/ml......................... 12 LANTUS
SOLOSTAR – insulin glargine soln pen-injector 100
unit/ml.........................................................................
12 latanoprost ophth soln 0.005% (Xalatan).......................52 leflunomide
tab 10 mg (Arava)........................................40 leflunomide tab 20
mg (Arava)........................................40 LETAIRIS – ambrisentan tab
5 mg.................................... 23 LETAIRIS – ambrisentan tab 10
mg.................................. 23 letrozole tab 2.5 mg
(Femara)........................................... 7 LEUCOVORIN CALCIUM –
leucovorin calcium tab 10
mg........................................................................................
7 LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg........................................................................................
7 leucovorin calcium tab 5 mg.............................................7
leucovorin calcium tab 25 mg...........................................7
LEUKERAN – chlorambucil tab 2 mg.................................. 7
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv).................................................................................26
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)..........................................................................26
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 74 levalbuterol
hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)..........................................................................26
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) (Xopenex)..........................................................................26
LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector 100
unit/ml.........................................................................
13 LEVEMIR – insulin detemir inj 100 unit/ml.........................12
levetiracetam oral soln 100 mg/ml (Keppra)..................43 levetiracetam
tab 250 mg (Keppra).................................43 levetiracetam tab 500 mg
(Keppra).................................43 levetiracetam tab 750 mg
(Keppra).................................43 levetiracetam tab 1000 mg
(Keppra)...............................43 levetiracetam tab sr 24hr 500 mg
(Keppra xr)...............43 levetiracetam tab sr 24hr 750 mg (Keppra
xr)...............43 levobunolol hcl ophth soln 0.5%
(Betagan).................. 52 levocarnitine oral soln 1 gm/10ml (10%)
(Carnitor)...... 14 levocarnitine tab 330 mg
(Carnitor)................................14 levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ ml) (Xyzal).........................................................................24
levocetirizine dihydrochloride tab 5 mg (Xyzal)............24 levofloxacin tab
250 mg (Levaquin)................................. 3 levofloxacin tab 500 mg
(Levaquin)................................. 3 levofloxacin tab 750 mg
(Levaquin)................................. 3 levothyroxine sodium tab 25 mcg
(Synthroid)..............13 levothyroxine sodium tab 50 mcg
(Synthroid)..............13 levothyroxine sodium tab 75 mcg (Synthroid)..............13
levothyroxine sodium tab 88 mcg (Synthroid)..............13 levothyroxine
sodium tab 100 mcg (Synthroid)............13 levothyroxine sodium tab 112 mcg
(Synthroid)............ 13 levothyroxine sodium tab 125 mcg
(Synthroid)............13 levothyroxine sodium tab 137 mcg
(Synthroid)............13 levothyroxine sodium tab 150 mcg
(Synthroid)............13 levothyroxine sodium tab 175 mcg
(Synthroid)............13 levothyroxine sodium tab 200 mcg
(Synthroid)............13 levothyroxine sodium tab 300 mcg
(Synthroid)............13 LIALDA – mesalamine tab delayed release 1.2
gm...........29 lidocaine hcl gel
2%......................................................... 56 lidocaine hcl
local inj 1% (Xylocaine)............................ 42 lidocaine hcl local
preservative free (pf) inj 1%
(Xylocaine-mpf)................................................................42
lidocaine hcl soln 4% (Xylocaine)...................................56
lidocaine hcl viscous soln 2%........................................ 53
lidocaine oint
5%...............................................................56 lidocaine
patch 5% (Lidoderm)....................................... 56 linezolid for
susp 100 mg/5ml (Zyvox).............................6 linezolid tab 600 mg (Zyvox).............................................
6 LINZESS – linaclotide cap 72 mcg.................................... 29
LINZESS – linaclotide cap 145 mcg.................................. 29 LINZESS
– linaclotide cap 290 mcg.................................. 29 liothyronine
sodium tab 5 mcg (Cytomel)..................... 13 liothyronine sodium tab 25
mcg (Cytomel)................... 13 liothyronine sodium tab 50 mcg
(Cytomel)................... 13 lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic).......................................................................
15 lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic).......................................................................
15 lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic).......................................................................
15 lisinopril tab 5 mg (Prinivil).............................................
15 lisinopril tab 10 mg (Prinivil)...........................................
15 lisinopril tab 20 mg (Prinivil)...........................................
15 lisinopril tab 2.5 mg (Zestril)...........................................
15 lisinopril tab 30 mg (Zestril)............................................
15 lisinopril tab 40 mg (Zestril)............................................
15 lithium carbonate cap 300 mg.........................................33
lithium carbonate cap 150 mg (Lithium carbonate)......33 lithium carbonate cap
600 mg (Lithium carbonate)......33 lithium carbonate tab cr 450
mg.....................................33 lithium carbonate tab cr 300 mg
(Lithobid)................... 33 lithium carbonate tab 300
mg......................................... 33 loperamide hcl cap 2
mg................................................. 27 lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
(Kaletra)...............................................................................5
lorazepam conc 2 mg/ml (Lorazepam intensol)............ 30 lorazepam tab 0.5 mg
(Ativan)........................................ 30 lorazepam tab 1 mg
(Ativan)........................................... 30 lorazepam tab 2 mg
(Ativan)........................................... 30 losartan potassium &
hydrochlorothiazide tab 50-12.5 mg (Hyzaar)......................................................................
16 losartan potassium & hydrochlorothiazide tab 100-12.5 mg
(Hyzaar)......................................................................
16 losartan potassium & hydrochlorothiazide tab 100-25 mg (Hyzaar)......................................................................
16 losartan potassium tab 25 mg (Cozaar).........................16 losartan
potassium tab 50 mg (Cozaar).........................16 losartan potassium tab
100 mg (Cozaar).......................16 LOTEMAX – loteprednol etabonate ophth
gel 0.5%..........52 LOTEMAX – loteprednol etabonate ophth oint 0.5%.........52
LOTEMAX – loteprednol etabonate ophth susp 0.5%....... 52 lovastatin tab 10
mg.........................................................21 lovastatin tab 20
mg (Mevacor).......................................21 lovastatin tab 40 mg
(Mevacor).......................................21 loxapine succinate cap 10
mg........................................ 33 loxapine succinate cap 25 mg........................................
33 loxapine succinate cap 50 mg........................................ 33
loxapine succinate cap 5 mg (Loxitane)........................33 LUMIGAN –
bimatoprost ophth soln 0.01%.......................52 LYRICA – pregabalin cap
25 mg........................................43 LYRICA – pregabalin cap 50
mg........................................43 LYRICA – pregabalin cap 75
mg........................................43 LYRICA – pregabalin cap 100
mg......................................43 LYRICA – pregabalin cap 150
mg......................................43 LYRICA – pregabalin cap 200
mg......................................43 LYRICA – pregabalin cap 225
mg......................................43 LYRICA – pregabalin cap 300
mg......................................43 2017 Find and estimate prices for
medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 75 M malathion
lotion 0.5% (Ovide).........................................56 meclizine hcl
tab 12.5 mg................................................28 meclizine hcl tab
25 mg................................................... 28 medroxyprogesterone
acetate tab 2.5 mg
(Provera)...........................................................................
10 medroxyprogesterone acetate tab 5 mg (Provera).......10 medroxyprogesterone
acetate tab 10 mg (Provera).....10 mefloquine hcl tab 250 mg................................................
6 megestrol acetate susp 40 mg/ml (Megace oral)............ 7 megestrol acetate
tab 20 mg.............................................7 megestrol acetate tab
40 mg.............................................7 MEKINIST – trametinib
dimethyl sulfoxide tab 0.5 mg (base
equivalent).................................................................7
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)............................................................................7
meloxicam tab 7.5 mg (Mobic)........................................40
meloxicam tab 15 mg (Mobic).........................................40
memantine hcl oral solution 2 mg/ml (Namenda).........37 memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak (Namenda titration
pa)....................................................37 memantine hcl tab 5
mg (Namenda).............................. 37 memantine hcl tab 10 mg
(Namenda)............................ 37 MEPHYTON – phytonadione tab 5
mg.............................. 45 mercaptopurine tab 50 mg
(Purinethol)...........................7 mesalamine enema 4
gm................................................. 29 MESNEX – mesna tab 400
mg............................................7 metaxalone tab 800 mg
(Skelaxin)..................................44 metformin hcl tab 500 mg
(Glucophage)....................... 12 metformin hcl tab 850 mg
(Glucophage)....................... 12 metformin hcl tab 1000 mg
(Glucophage)..................... 12 metformin hcl tab sr 24hr 500 mg
(Glucophage xr)......12 metformin hcl tab sr 24hr 750 mg (Glucophage
xr)......12 methadone hcl conc 10 mg/ml (Methadose)................. 39
methadone hcl soln 5 mg/5ml (Methadone hcl)............39 methadone hcl soln 10
mg/5ml (Methadone hcl)..........39 methadone hcl tab for oral susp 40
mg.........................39 methadone hcl tab 10 mg
(Dolophine)...........................39 methadone hcl tab 5 mg (Dolophine
hcl).......................39 methazolamide tab 25 mg (Neptazane)..........................22
methazolamide tab 50 mg (Neptazane)..........................22 methimazole tab
5 mg (Tapazole)................................... 13 methimazole tab 10 mg
(Tapazole).................................13 methocarbamol tab 750 mg (Robaxin-750)....................44
methocarbamol tab 500 mg (Robaxin)...........................44 methotrexate
sodium tab 2.5 mg (base equiv)................7 methscopolamine bromide tab 2.5
mg (Pamine).......... 27 methscopolamine bromide tab 5 mg (Pamine forte)..................................................................................
27 methyldopa tab 250 mg................................................... 23
methyldopa tab 500 mg................................................... 23
methylphenidate hcl tab cr 10 mg..................................35
methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 35 methylphenidate
hcl tab 5 mg (Ritalin).......................... 35 methylphenidate hcl tab 10
mg (Ritalin)........................ 35 methylphenidate hcl tab 20 mg
(Ritalin)........................ 35 methylphenidate hcl tab sa osm 18 mg
(Concerta)......35 methylphenidate hcl tab sa osm 27 mg (Concerta)......35
methylphenidate hcl tab sa osm 36 mg (Concerta)......35 methylphenidate hcl tab
sa osm 54 mg (Concerta)......35 methylprednisolone tab 4 mg
(Medrol)............................8 methylprednisolone tab 8 mg
(Medrol)............................8 methylprednisolone tab 16 mg
(Medrol)..........................9 methylprednisolone tab 32 mg (Medrol)..........................9
methylprednisolone tab therapy pack 4 mg (21) (Medrol
dosepak)...............................................................8
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........29 metoclopramide hcl tab
5 mg (Reglan)..........................29 metoclopramide hcl tab 10 mg
(Reglan)........................29 metolazone tab 10
mg......................................................22 metolazone tab 2.5
mg (Zaroxolyn)................................22 metolazone tab 5 mg (Zaroxolyn)...................................22
metoprolol & hydrochlorothiazide tab 100-50 mg........ 17 metoprolol &
hydrochlorothiazide tab 50-25 mg (Lopressor
hct)................................................................ 17
metoprolol & hydrochlorothiazide tab 100-25 mg (Lopressor
hct)................................................................ 17
metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) (Toprol
xl)......................................................................... 17
metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) (Toprol
xl)......................................................................... 17
metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) (Toprol
xl)............................................................. 17 metoprolol
succinate tab sr 24hr 200 mg (tartrate equiv) (Toprol
xl)............................................................. 17 metoprolol
tartrate tab 25 mg......................................... 18 metoprolol
tartrate tab 50 mg (Lopressor).................... 18 metoprolol tartrate tab
100 mg (Lopressor).................. 18 metronidazole cream 0.75%
(Metrocream).................... 53 metronidazole gel
0.75%..................................................53 metronidazole gel 1%
(Metrogel).................................... 53 metronidazole lotion 0.75%
(Metrolotion)......................54 metronidazole tab 250 mg
(Flagyl)................................... 6 metronidazole tab 500 mg
(Flagyl)................................... 6 metronidazole vaginal gel 0.75%
(Metrogelvaginal)..............................................................................30
mexiletine hcl cap 150 mg...............................................22
mexiletine hcl cap 200 mg...............................................22
mexiletine hcl cap 250 mg...............................................22
midodrine hcl tab 2.5 mg.................................................23
midodrine hcl tab 5 mg....................................................23 midodrine
hcl tab 10 mg..................................................23 MIGRANAL –
dihydroergotamine mesylate nasal spray 4
mg/ml..................................................................................41
minocycline hcl cap 50 mg (Minocin).............................. 2 2017 Find
and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 76 minocycline
hcl cap 75 mg (Minocin).............................. 2 minocycline hcl cap 100
mg (Minocin)............................ 2 minocycline hcl tab 50
mg................................................ 2 minocycline hcl tab 75
mg................................................ 2 minocycline hcl tab 100
mg.............................................. 2 minoxidil tab 2.5
mg.........................................................23 minoxidil tab 10
mg..........................................................23 MIRENA – levonorgestrel
releasing iud 20 mcg/day (52 mg
total).............................................................................10
mirtazapine tab 7.5 mg.....................................................31
mirtazapine tab 15 mg (Remeron).................................. 31
mirtazapine tab 30 mg (Remeron).................................. 31
mirtazapine tab 45 mg (Remeron).................................. 31
misoprostol tab 100 mcg (Cytotec)................................ 27
misoprostol tab 200 mcg (Cytotec)................................ 27 modafinil
tab 100 mg (Provigil).......................................35 modafinil tab
200 mg (Provigil).......................................35 moexipril hcl tab
7.5 mg (Univasc).................................15 moexipril hcl tab 15 mg
(Univasc)..................................15 moexipril-hydrochlorothiazide tab
7.5-12.5 mg.............15 moexipril-hydrochlorothiazide tab 15-25
mg.................15 moexipril-hydrochlorothiazide tab 15-12.5 mg (Uniretic)...........................................................................
15 mometasone furoate cream 0.1% (Elocon)................... 55 mometasone
furoate nasal susp 50 mcg/act
(Nasonex)..........................................................................24
mometasone furoate oint 0.1% (Elocon)........................55 mometasone
furoate solution 0.1% (lotion)
(Elocon).............................................................................55
MONOCLATE-P – antihemophilic factor (human) for inj kit 1000
unit............................................................................49
MONOCLATE-P – antihemophilic factor (human) for inj kit 1500
unit............................................................................49
MONONINE – coagulation factor ix for inj 1000 unit..........49 montelukast
sodium chew tab 4 mg (base equiv)
(Singulair).........................................................................
26 montelukast sodium chew tab 5 mg (base equiv)
(Singulair).........................................................................
26 montelukast sodium oral granules packet 4 mg (base equiv)
(Singulair)............................................................. 26
montelukast sodium tab 10 mg (base equiv) (Singulair).........................................................................
26 MORPHINE SULFATE – morphine sulfate tab 15 mg....... 39 MORPHINE SULFATE –
morphine sulfate tab 30 mg....... 39 morphine sulfate oral soln 10
mg/5ml........................... 39 morphine sulfate oral soln 20
mg/5ml........................... 39 morphine sulfate oral soln 100 mg/5ml (20
mg/ml)...... 39 morphine sulfate tab cr 15 mg (Ms contin)................... 39
morphine sulfate tab cr 30 mg (Ms contin)................... 39 morphine
sulfate tab cr 60 mg (Ms contin)................... 39 morphine sulfate tab cr
100 mg (Ms contin)................. 39 morphine sulfate tab cr 200 mg (Ms
contin)................. 39 MULTAQ – dronedarone hcl tab 400 mg (base
equivalent).........................................................................
22 mupirocin calcium cream 2% (Bactroban).................... 54 mupirocin oint
2% (Bactroban).......................................54 mycophenolate mofetil
cap 250 mg (Cellcept)..............57 mycophenolate mofetil for oral susp 200
mg/ml
(Cellcept)...........................................................................57
mycophenolate mofetil tab 500 mg (Cellcept)...............57 mycophenolate
sodium tab dr 180 mg (mycophenolic acid equiv) (Myfortic)......................................................57
mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)
(Myfortic)......................................................57 MYLERAN –
busulfan tab 2 mg...........................................7 N nabumetone tab
500 mg.................................................. 41 nabumetone tab 750
mg.................................................. 41 nadolol tab 20 mg
(Corgard)........................................... 18 nadolol tab 40 mg
(Corgard)........................................... 18 nadolol tab 80 mg
(Corgard)........................................... 18 naloxone hcl inj 0.4
mg/ml.............................................. 57 naloxone hcl inj 4
mg/10ml............................................. 57 naltrexone hcl tab 50
mg (Revia)....................................57 naproxen sodium tab 275 mg
(Anaprox)....................... 41 naproxen sodium tab 550 mg (Anaprox
ds)..................41 naproxen susp 125 mg/5ml (Naprosyn).........................41
naproxen tab ec 375 mg (Ec-naprosyn).........................41 naproxen tab ec
500 mg (Ec-naprosyn).........................41 naproxen tab 250 mg
(Naprosyn)................................... 41 naproxen tab 375 mg
(Naprosyn)................................... 41 naproxen tab 500 mg
(Naprosyn)................................... 41 naratriptan hcl tab 1 mg (base
equiv) (Amerge)........... 41 naratriptan hcl tab 2.5 mg (base equiv)
(Amerge)........ 41 NARCAN – naloxone hcl nasal spray 4 mg/0.1ml.............
57 NASONEX – mometasone furoate nasal susp 50 mcg/
act.......................................................................................24
NATACYN – natamycin ophth susp 5%............................. 51 nateglinide
tab 60 mg (Starlix)........................................12 nateglinide tab
120 mg (Starlix)......................................12 neomycin-bacitrac
zn-polymyx 5(3.5)mg-400unt-10000unt op oin..................................51
neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml
(Neosporin)................51 neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)...........................................................................52
neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol).................................................................
52 neomycin-polymyxin-hc otic soln 1% (Cortisporin)..... 53
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.........................................................................53
neomycin sulfate tab 500 mg............................................3
NEULASTA ONPRO KIT – pegfilgrastim soln prefilled syringe kit 6
mg/0.6ml.......................................................49 2017 Find and
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 77 NEULASTA –
pegfilgrastim soln prefilled syringe 6
mg/0.6ml............................................................................
49 NEUPOGEN – filgrastim inj 300 mcg/ml............................49 NEUPOGEN
– filgrastim inj 480 mcg/1.6ml (300 mcg/
ml)......................................................................................
49 NEUPOGEN – filgrastim soln prefilled syringe 300
mcg/0.5ml...........................................................................49
NEUPOGEN – filgrastim soln prefilled syringe 480 mcg/0.8ml (600
mcg/ml)................................................... 49 nevirapine tab 200
mg (Viramune)....................................5 nevirapine tab sr 24hr 100
mg (Viramune xr)..................5 nevirapine tab sr 24hr 400 mg (Viramune
xr)..................5 NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)............................................................................7
NEXIUM – esomeprazole magnesium for delayed release susp packet 5
mg..............................................................27 NEXIUM –
esomeprazole magnesium for delayed release susp packet 10
mg............................................................27 NEXIUM –
esomeprazole magnesium for delayed release susp packet 20
mg............................................................27 NEXIUM –
esomeprazole magnesium for delayed release susp packet 40
mg............................................................27 NEXIUM –
esomeprazole magnesium for delayed release susp pack 2.5
mg..............................................................27 niacin tab
cr 500 mg (antihyperlipidemic) (Niaspan)...........................................................................21
niacin tab cr 750 mg (antihyperlipidemic)
(Niaspan)...........................................................................21
niacin tab cr 1000 mg (antihyperlipidemic) (Niaspan)...........................................................................21
NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg
delivered).....................................................................37
NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/
spray).................................................................................
37 nifedipine tab sr 24hr 30 mg (Adalat cc)........................19
nifedipine tab sr 24hr 60 mg (Adalat cc)........................19 nifedipine tab
sr 24hr 90 mg (Adalat cc)........................19 nifedipine tab sr 24hr
osmotic release 30 mg (Procardia
xl)....................................................................19
nifedipine tab sr 24hr osmotic release 60 mg (Procardia xl)....................................................................19
nifedipine tab sr 24hr osmotic release 90 mg (Procardia
xl)....................................................................19
NILANDRON – nilutamide tab 150 mg................................ 7 nilutamide
tab 150 mg (Nilandron)................................... 7 nitrofurantoin
macrocrystalline cap 25 mg
(Macrodantin)...................................................................
29 nitrofurantoin macrocrystalline cap 50 mg (Macrodantin)...................................................................
29 nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)...................................................................
29 nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)..................................................................29
nitrofurantoin susp 25 mg/5ml (Furadantin)..................29 nitroglycerin sl
tab 0.3 mg (Nitrostat)............................ 20 nitroglycerin sl tab 0.4
mg (Nitrostat)............................ 20 nitroglycerin sl tab 0.6 mg
(Nitrostat)............................ 20 nitroglycerin td patch 24hr 0.1
mg/hr (Nitro-dur)..........20 nitroglycerin td patch 24hr 0.2 mg/hr
(Nitro-dur)..........20 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........20
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........20 NITROSTAT –
nitroglycerin sl tab 0.3 mg..........................20 NITROSTAT –
nitroglycerin sl tab 0.4 mg..........................20 NITROSTAT –
nitroglycerin sl tab 0.6 mg..........................20 norethindrone
acetate-ethinyl estradiol tab 1 mg-5
mcg....................................................................................10
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low
dose).................................................. 10 norethindrone
acetate tab 5 mg (Aygestin)...................10 nortriptyline hcl cap 10 mg
(Pamelor)............................32 nortriptyline hcl cap 25 mg
(Pamelor)............................32 nortriptyline hcl cap 50 mg
(Pamelor)............................32 nortriptyline hcl cap 75 mg
(Pamelor)............................32 NORVIR – ritonavir oral soln 80
mg/ml................................5 NORVIR – ritonavir tab 100
mg........................................... 5 NOVOEIGHT – antihemophilic
factor (recombinant) for inj 250
unit..............................................................................49
NOVOEIGHT – antihemophilic factor (recombinant) for inj 500
unit..............................................................................49
NOVOEIGHT – antihemophilic factor (recombinant) for inj 1000
unit............................................................................49
NOVOEIGHT – antihemophilic factor (recombinant) for inj 1500 unit............................................................................49
NOVOEIGHT – antihemophilic factor (recombinant) for inj 2000
unit............................................................................49
NOVOEIGHT – antihemophilic factor (recombinant) for inj 3000
unit............................................................................49
NOVOLIN 70/30 – insulin nph isophane & regular human inj 100 unit/ml
(70-30).......................................................12 NOVOLIN N –
insulin nph (human) (isophane) inj 100 unit/
ml........................................................................................12
NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 12 NOVOLOG FLEXPEN –
insulin aspart soln pen-injector 100
unit/ml.........................................................................
12 NOVOLOG – insulin aspart inj 100 unit/ml........................ 12 NOVOLOG
MIX 70/30 – insulin aspart prot & aspart (human) inj 100 unit/ml
(70-30)........................................ 12 NOVOLOG MIX 70/30 PREFILL –
insulin aspart prot & aspart sus pen-inj 100 unit/ml
(70-30)..............................12 NOVOLOG PENFILL – insulin aspart soln
cartridge 100 unit/ml.................................................................................12
NOVOSEVEN RT – coagulation factor viia (recomb) for inj 1 mg (1000
mcg)...............................................................49 NOVOSEVEN
RT – coagulation factor viia (recomb) for inj 2 mg (2000 mcg)...............................................................49
2017 Find and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 78 NOVOSEVEN RT –
coagulation factor viia (recomb) for inj 5 mg (5000
mcg)...............................................................49 NOVOSEVEN
RT – coagulation factor viia (recomb) for inj 8 mg (8000
mcg)...............................................................49 NOXAFIL –
posaconazole susp 40 mg/ml...........................3 NOXAFIL – posaconazole
tab delayed release 100 mg......3 NUCYNTA ER – tapentadol hcl tab sr 12hr 50
mg............ 39 NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg.......... 39
NUCYNTA ER – tapentadol hcl tab sr 12hr 150 mg.......... 39 NUCYNTA ER –
tapentadol hcl tab sr 12hr 200 mg.......... 39 NUCYNTA ER – tapentadol hcl tab
sr 12hr 250 mg.......... 39 NUEDEXTA – dextromethorphan hbr-quinidine sulfate
cap 20-10 mg............................................................................37
NUVARING – etonogestrel-ethinyl estradiol va ring 0.120-0.015
mg/24hr.........................................................10 NUWIQ –
antihemophilic factor (bdd-rfviii) for inj kit 250
unit......................................................................................50
NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 500
unit......................................................................................50
NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 1000
unit......................................................................................50
NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 2000
unit......................................................................................50
NUWIQ – antihemophilic factor (bdd-rfviii) for inj 250
unit......................................................................................49
NUWIQ – antihemophilic factor (bdd-rfviii) for inj 500 unit......................................................................................49
NUWIQ – antihemophilic factor (bdd-rfviii) for inj 1000
unit......................................................................................50
NUWIQ – antihemophilic factor (bdd-rfviii) for inj 2000
unit......................................................................................50
nystatin cream 100000 unit/gm.......................................54 nystatin
oint 100000 unit/gm...........................................54 nystatin susp
100000 unit/ml.......................................... 53 nystatin tab 500000
unit.....................................................3 nystatin topical
powder 100000 unit/gm........................54 nystatin-triamcinolone cream
100000-0.1 unit/gm-
%........................................................................................
55 nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 55 O OBIZUR –
antihemophilic factor (recomb porc) rpfviii for inj 500 unit..............................................................................50
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)....................................................................14
octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)....................................................................14
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin)....................................................................14
octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)....................................................................14
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)....................................................................14
ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab 200-25-25
mg...................................................................... 5
ofloxacin ophth soln 0.3% (Ocuflox)..............................51 ofloxacin
otic soln 0.3%...................................................53 ofloxacin
tab 400 mg..........................................................3
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis).................................................................................
33 olanzapine orally disintegrating tab 10 mg (Zyprexa zydis).................................................................................
33 olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis).................................................................................
33 olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis).................................................................................
33 olanzapine tab 2.5 mg (Zyprexa).....................................33
olanzapine tab 5 mg (Zyprexa)........................................33
olanzapine tab 7.5 mg (Zyprexa).....................................33
olanzapine tab 10 mg (Zyprexa)......................................33
olanzapine tab 15 mg (Zyprexa)......................................33
olanzapine tab 20 mg (Zyprexa)......................................33
olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg (Benicar
hct)................................................ 16 olmesartan
medoxomil-hydrochlorothiazide tab 40-12.5 mg (Benicar
hct)................................................ 16 olmesartan
medoxomil-hydrochlorothiazide tab 40-25 mg (Benicar
hct)..............................................................17 olmesartan
medoxomil tab 5 mg (Benicar)................... 16 olmesartan medoxomil tab 20
mg (Benicar)................. 16 olmesartan medoxomil tab 40 mg
(Benicar)................. 16 olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)............................................................................53
omeprazole cap delayed release 10 mg (Prilosec)....... 27 omeprazole cap
delayed release 20 mg (Prilosec)....... 27 omeprazole cap delayed release 40 mg
(Prilosec)....... 27 OMNITROPE – somatropin for inj 5.8
mg......................... 13 OMNITROPE – somatropin inj 5
mg/1.5ml........................13 OMNITROPE – somatropin inj 10
mg/1.5ml......................13 ondansetron hcl inj 4 mg/2ml (2
mg/ml)........................ 28 ondansetron hcl inj 40 mg/20ml (2 mg/ml)
(Zofran)......28 ondansetron hcl oral soln 4 mg/5ml (Zofran)................28
ondansetron hcl tab 24 mg............................................. 28
ondansetron hcl tab 4 mg (Zofran).................................28
ondansetron hcl tab 8 mg (Zofran).................................28
ondansetron orally disintegrating tab 4 mg (Zofran
odt).....................................................................................28
ondansetron orally disintegrating tab 8 mg (Zofran
odt).....................................................................................28
ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv).........12 ONGLYZA –
saxagliptin hcl tab 5 mg (base equiv)............12 OPSUMIT – macitentan tab 10
mg....................................23 oral contraceptives– all
generics........................................10 ORFADIN – nitisinone cap 2
mg........................................14 ORFADIN – nitisinone cap 5
mg........................................14 ORFADIN – nitisinone cap 10
mg......................................14 2017 Find and estimate prices for
medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 79 ORFADIN –
nitisinone cap 20 mg......................................14 ORFADIN – nitisinone
susp 4 mg/ml................................. 14 orphenadrine citrate tab sr
12hr 100 mg....................... 44 oseltamivir phosphate cap 30 mg (base
equiv)
(Tamiflu)..............................................................................
6 oseltamivir phosphate cap 45 mg (base equiv)
(Tamiflu)..............................................................................
6 oseltamivir phosphate cap 75 mg (base equiv)
(Tamiflu)..............................................................................
6 OTEZLA – apremilast tab 30 mg....................................... 41
OTEZLA – apremilast tab starter therapy pack 10 mg & 20 mg & 30
mg.......................................................................41
oxaprozin tab 600 mg (Daypro).......................................41
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)...........................................................................43
oxcarbazepine tab 150 mg (Trileptal)............................. 43
oxcarbazepine tab 300 mg (Trileptal)............................. 43
oxcarbazepine tab 600 mg (Trileptal)............................. 43 oxybutynin
chloride syrup 5 mg/5ml..............................29 oxybutynin chloride tab
5 mg......................................... 29 oxybutynin chloride tab sr
24hr 5 mg (Ditropan xl)......29 oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl).......................................................................................
29 oxybutynin chloride tab sr 24hr 15 mg (Ditropan xl).......................................................................................
29 oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 39 oxycodone hcl cap 5
mg................................................. 39 oxycodone hcl conc 100
mg/5ml (20 mg/ml) (Oxycodone
hcl).............................................................. 39 oxycodone
hcl soln 5 mg/5ml (Oxycodone hcl)............39 oxycodone hcl tab 10
mg................................................ 39 oxycodone hcl tab 20
mg................................................ 39 oxycodone hcl tab 5 mg
(Roxicodone).......................... 39 oxycodone hcl tab 15 mg
(Roxicodone)........................ 39 oxycodone hcl tab 30 mg
(Roxicodone)........................ 39 oxycodone w/ acetaminophen tab 5-325 mg
(Percocet).........................................................................
39 oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet).........................................................................
39 oxycodone w/ acetaminophen tab 10-325 mg
(Percocet).........................................................................
39 OXYCONTIN – oxycodone hcl tab er 12hr deter 10
mg......................................................................................
39 OXYCONTIN – oxycodone hcl tab er 12hr deter 15
mg......................................................................................
39 OXYCONTIN – oxycodone hcl tab er 12hr deter 20
mg......................................................................................
39 OXYCONTIN – oxycodone hcl tab er 12hr deter 30
mg......................................................................................
39 OXYCONTIN – oxycodone hcl tab er 12hr deter 40
mg......................................................................................
39 OXYCONTIN – oxycodone hcl tab er 12hr deter 60
mg......................................................................................
39 OXYCONTIN – oxycodone hcl tab er 12hr deter 80
mg......................................................................................
39 P pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)..........................................................................
27 pantoprazole sodium ec tab 40 mg (base equiv) (Protonix)..........................................................................
27 paricalcitol cap 1 mcg (Zemplar).................................... 14
paricalcitol cap 2 mcg (Zemplar).................................... 14
paricalcitol cap 4 mcg (Zemplar).................................... 14
paromomycin sulfate cap 250 mg.................................... 3 paroxetine
hcl tab 10 mg (Paxil).....................................32 paroxetine hcl tab
20 mg (Paxil).....................................32 paroxetine hcl tab 30 mg
(Paxil).....................................32 paroxetine hcl tab 40 mg
(Paxil).....................................32 paroxetine hcl tab sr 24hr 12.5
mg (Paxil cr)................ 32 paroxetine hcl tab sr 24hr 25 mg (Paxil
cr)................... 32 paroxetine hcl tab sr 24hr 37.5 mg (Paxil
cr)................ 32 PATADAY – olopatadine hcl ophth soln 0.2% (base
equivalent).........................................................................
53 PAZEO – olopatadine hcl ophth soln 0.7% (base equivalent).........................................................................
53 PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 4 PEGASYS –
peginterferon alfa-2a inj 180 mcg/0.5ml......... 4 PEGASYS PROCLICK –
peginterferon alfa-2a inj 135
mcg/0.5ml.............................................................................4
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml.............................................................................4
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte-flavor
packs).......................................................27 peg 3350-kcl-na
bicarb-nacl-na sulfate for soln 236 gm
(Golytely)...........................................................................27
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor
pack)......................................................27 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 PENTASA – mesalamine cap cr 250
mg........................... 29 PENTASA – mesalamine cap cr 500
mg........................... 29 pentoxifylline tab cr 400
mg............................................50 perindopril erbumine tab 2
mg....................................... 15 perindopril erbumine tab 4 mg
(Aceon).........................15 perindopril erbumine tab 8 mg (Aceon).........................15
permethrin cream 5% (Elimite)........................................56
perphenazine tab 2 mg.................................................... 33
perphenazine tab 4 mg.................................................... 33 perphenazine
tab 8 mg.................................................... 33 perphenazine
tab 16 mg.................................................. 33 phenelzine
sulfate tab 15 mg (Nardil)............................ 32 phenobarbital elixir
20 mg/5ml........................................34 phenobarbital tab 16.2
mg...............................................34 2017 Find and estimate
prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html Blue
Cross and Blue Shield of Texas July 2017 Basic Drug List 80 phenobarbital tab
32.4 mg...............................................34 phenoxybenzamine hcl
cap 10 mg (Dibenzyline)......... 23 phenytoin chew tab 50 mg (Dilantin
infatabs)...............43 phenytoin sodium extended cap 100 mg
(Dilantin)...... 43 phenytoin sodium extended cap 200 mg
(Phenytek).........................................................................43
phenytoin sodium extended cap 300 mg (Phenytek).........................................................................43
phenytoin susp 125 mg/5ml (Dilantin)........................... 43 pilocarpine
hcl ophth soln 1% (Isopto carpine)............ 52 pilocarpine hcl ophth soln 2%
(Isopto carpine)............ 52 pilocarpine hcl ophth soln 4% (Isopto
carpine)............ 52 pilocarpine hcl tab 5 mg
(Salagen).................................53 pilocarpine hcl tab 7.5 mg
(Salagen)..............................53 pimozide tab 1 mg
(Orap)................................................ 37 pimozide tab 2 mg
(Orap)................................................ 37 pindolol tab 5
mg..............................................................18 pindolol tab
10 mg............................................................18
pioglitazone hcl-metformin hcl tab 15-500 mg (Actoplus
met)................................................................. 12
pioglitazone hcl-metformin hcl tab 15-850 mg (Actoplus
met)................................................................. 12
pioglitazone hcl tab 15 mg (base equiv) (Actos)...........12 pioglitazone hcl
tab 30 mg (base equiv) (Actos)...........12 pioglitazone hcl tab 45 mg (base
equiv) (Actos)...........12 piroxicam cap 10 mg
(Feldene).......................................41 piroxicam cap 20 mg
(Feldene).......................................41 PLEGRIDY – peginterferon
beta-1a soln pen-injector 125
mcg/0.5ml...........................................................................36
PLEGRIDY – peginterferon beta-1a soln prefilled syringe 125
mcg/0.5ml...................................................................36
PLEGRIDY STARTER PACK – peginterferon beta-1a soln pen-inj 63 & 94
mcg/0.5ml pack.......................................36 PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pref syr 63 & 94 mcg/0.5ml
pack..................................... 36 podofilox soln 0.5%
(Condylox)......................................56 polymyxin b-trimethoprim
ophth soln 10000 unit/ ml-0.1%
(Polytrim)...........................................................51
potassium chloride cap cr 8 meq (Micro-k)...................45 potassium
chloride cap cr 10 meq (Micro-k).................45 potassium chloride
microencapsulated crys cr tab 10
meq....................................................................................45
potassium chloride microencapsulated crys cr tab 20
meq....................................................................................45
potassium chloride oral soln 10% (20 meq/15ml).........45 potassium chloride
powder packet 20 meq.................. 45 potassium chloride tab cr 10 meq
(K-tab)..................... 45 potassium chloride tab cr 8 meq (600
mg)....................45 potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)........................................................................................
30 potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10)......................................................................................
30 potassium citrate tab cr 15 meq (1620 mg) (Urocit-k 15)......................................................................................
30 PRALUENT – alirocumab subcutaneous soln pen-injector 75
mg/ml............................................................................21
PRALUENT – alirocumab subcutaneous soln pen-injector 150
mg/ml..........................................................................21
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)...........................................................................
44 pramipexole dihydrochloride tab 0.25 mg
(Mirapex)...........................................................................
44 pramipexole dihydrochloride tab 0.5 mg (Mirapex)......44 pramipexole
dihydrochloride tab 0.75 mg
(Mirapex)...........................................................................
44 pramipexole dihydrochloride tab 1 mg (Mirapex).........44 pramipexole
dihydrochloride tab 1.5 mg (Mirapex)......44 pravastatin sodium tab 10
mg........................................ 21 pravastatin sodium tab 20 mg
(Pravachol)....................21 pravastatin sodium tab 40 mg
(Pravachol)....................21 pravastatin sodium tab 80 mg
(Pravachol)....................21 prazosin hcl cap 1 mg
(Minipress)................................. 23 prazosin hcl cap 2 mg
(Minipress)................................. 23 prazosin hcl cap 5 mg
(Minipress)................................. 23 prednisolone acetate ophth susp
1% (Pred forte)........ 52 PREDNISOLONE SODIUM PHOSP – prednisolone sodium
phosphate ophth soln 1%.................................... 52 prednisolone sod
phosphate oral soln 15 mg/5ml (base
equiv)........................................................................9
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)................................................ 9 prednisolone
syrup 15 mg/5ml (usp solution equivalent)
(Prelone).........................................................9 PREDNISONE
INTENSOL – prednisone conc 5 mg/ml......9 PREDNISONE – prednisone oral soln 5
mg/5ml.................9 PREDNISONE – prednisone tab 50
mg.............................. 9 prednisone tab 1
mg.......................................................... 9 prednisone tab
2.5 mg....................................................... 9 prednisone tab
5 mg.......................................................... 9 prednisone tab
10 mg........................................................ 9 prednisone tab
20 mg........................................................ 9 PRENATAL LOW
IRON – prenatal vit w/ fe fumarate-fa tab 27-1
mg..............................................................................45
PRENATAL PLUS/IRON – prenatal vit w/ fe fumarate-fa tab 27-1
mg....................................................................... 45
PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg......................................................................................
45 PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg..............................................................................45
PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1
mg..............................................................................45
PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe fumarate-fa tab 27-1
mg................................................... 45 PREZISTA – darunavir
ethanolate susp 100 mg/ml (base
equiv)....................................................................................5
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 81 PREZISTA –
darunavir ethanolate tab 75 mg (base
equiv)....................................................................................5
PREZISTA – darunavir ethanolate tab 150 mg (base
equiv)....................................................................................5
PREZISTA – darunavir ethanolate tab 600 mg (base
equiv)....................................................................................5
PREZISTA – darunavir ethanolate tab 800 mg (base
equiv)....................................................................................5
PRIFTIN – rifapentine tab 150 mg....................................... 3
PRIMAQUINE PHOSPHATE – primaquine phosphate tab 26.3 mg (15 mg
base)........................................................ 6 primidone tab
50 mg (Mysoline)..................................... 43 primidone tab 250 mg
(Mysoline)................................... 43 PROAIR HFA – albuterol sulfate
inhal aero 108 mcg/act (90mcg base
equiv).......................................................... 26 PROAIR
RESPICLICK – albuterol sulfate aer pow ba 108 mcg/act (90 mcg base
equiv)........................................... 26 probenecid tab 500
mg.................................................... 42 prochlorperazine
maleate tab 5 mg (base equivalent)
(Compazine).....................................................................
33 prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine).....................................................................
33 prochlorperazine suppos 25 mg.....................................33 PROCRIT
– epoetin alfa inj 2000 unit/ml...........................50 PROCRIT – epoetin alfa
inj 3000 unit/ml...........................50 PROCRIT – epoetin alfa inj 4000
unit/ml...........................50 PROCRIT – epoetin alfa inj 10000
unit/ml.........................50 PROCRIT – epoetin alfa inj 20000
unit/ml.........................50 PROCRIT – epoetin alfa inj 40000
unit/ml.........................50 PROFILNINE – factor ix complex for inj 500
unit...............50 PROFILNINE – factor ix complex for inj 1000
unit.............50 PROFILNINE – factor ix complex for inj 1500 unit.............50
PROFILNINE SD – factor ix complex for inj 500 unit.........50 PROFILNINE SD –
factor ix complex for inj 1000 unit.......50 PROFILNINE SD – factor ix complex
for inj 1500 unit.......50 progesterone micronized cap 100 mg
(Prometrium)....................................................................
10 progesterone micronized cap 200 mg
(Prometrium)....................................................................
10 promethazine hcl suppos 12.5 mg................................. 24
promethazine hcl suppos 25 mg.................................... 24
promethazine hcl suppos 50 mg.................................... 24
promethazine hcl syrup 6.25 mg/5ml............................. 24 promethazine
hcl tab 12.5 mg.........................................24 promethazine hcl tab
25 mg............................................24 promethazine hcl tab 50
mg............................................24 propafenone hcl cap sr 12hr
225 mg (Rythmol sr)....... 22 propafenone hcl cap sr 12hr 325 mg (Rythmol sr).......
22 propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 22 propafenone hcl
tab 300 mg........................................... 22 propafenone hcl tab
150 mg (Rythmol)......................... 22 propafenone hcl tab 225 mg
(Rythmol)......................... 22 propranolol hcl cap sr 24hr 60 mg
(Inderal la)..............18 propranolol hcl cap sr 24hr 80 mg (Inderal
la)..............18 propranolol hcl cap sr 24hr 120 mg (Inderal
la)............18 propranolol hcl cap sr 24hr 160 mg (Inderal la)............18
PROPRANOLOL HCL – propranolol hcl oral soln 20
mg/5ml...............................................................................
18 PROPRANOLOL HCL – propranolol hcl oral soln 40
mg/5ml...............................................................................
18 propranolol hcl tab 10 mg............................................... 18
propranolol hcl tab 20 mg............................................... 18
propranolol hcl tab 40 mg............................................... 18 propranolol
hcl tab 60 mg............................................... 18 propranolol hcl
tab 80 mg............................................... 18 propylthiouracil
tab 50 mg.............................................. 13 PULMOZYME – dornase
alfa inhal soln 1 mg/ml.............. 27 PURIXAN – mercaptopurine susp 2000
mg/100ml (20 mg/
ml)........................................................................................
7 pyrazinamide tab 500 mg...................................................3
pyridostigmine bromide tab 60 mg (Mestinon)............. 45 Q quetiapine
fumarate tab 25 mg (Seroquel).................... 33 quetiapine fumarate tab 50
mg (Seroquel).................... 33 quetiapine fumarate tab 100 mg
(Seroquel).................. 33 quetiapine fumarate tab 200 mg
(Seroquel).................. 33 quetiapine fumarate tab 300 mg
(Seroquel).................. 33 quetiapine fumarate tab 400 mg
(Seroquel).................. 34 quetiapine fumarate tab sr 24hr 50 mg (Seroquel
xr).......................................................................................33
quetiapine fumarate tab sr 24hr 150 mg (Seroquel
xr).......................................................................................33
quetiapine fumarate tab sr 24hr 200 mg (Seroquel xr).......................................................................................33
quetiapine fumarate tab sr 24hr 300 mg (Seroquel
xr).......................................................................................33
quetiapine fumarate tab sr 24hr 400 mg (Seroquel
xr).......................................................................................33
quinapril hcl tab 5 mg (Accupril)....................................15
quinapril hcl tab 10 mg (Accupril)..................................15
quinapril hcl tab 20 mg (Accupril)..................................15
quinapril hcl tab 40 mg (Accupril)..................................15
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)........................................................................
15 quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)........................................................................
15 quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)........................................................................
15 quinidine gluconate tab cr 324 mg.................................22 QVAR –
beclomethasone diprop inhal aero soln 40 mcg/ act
(50/valve).....................................................................26
QVAR – beclomethasone diprop inhal aero soln 80 mcg/ act
(100/valve)...................................................................26
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 82 R raloxifene
hcl tab 60 mg (Evista)....................................14 ramipril cap 1.25
mg (Altace).......................................... 15 ramipril cap 2.5 mg
(Altace)............................................ 15 ramipril cap 5 mg
(Altace)............................................... 15 ramipril cap 10 mg
(Altace)............................................. 15 ranitidine hcl cap 150
mg................................................ 27 ranitidine hcl cap 300
mg................................................ 27 ranitidine hcl syrup 15
mg/ml (75 mg/5ml).................... 27 ranitidine hcl tab 150 mg
(Zantac)..................................28 ranitidine hcl tab 300 mg (Zantac)..................................28
RAPAMUNE – sirolimus oral soln 1 mg/ml........................ 57 rasagiline
mesylate tab 0.5 mg (base equiv)
(Azilect).............................................................................
44 rasagiline mesylate tab 1 mg (base equiv) (Azilect)..... 44 REBIF –
interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)...........................................................................36
REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml (24mu/ml)...........................................................................36
REBIF REBIDOSE – interferon beta-1a soln auto-inj 22 mcg/0.5ml
(12mu/ml).........................................................36 REBIF
REBIDOSE – interferon beta-1a soln auto-inj 44 mcg/0.5ml
(24mu/ml).........................................................36 REBIF
REBIDOSE TITRATION – interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22
mcg/0.5ml............................ 36 REBIF TITRATION PACK – interferon
beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22
mcg/0.5ml................................. 36 RECOMBINATE – antihemophilic
factor (recombinant) for inj 220-400
unit..................................................................50
RECOMBINATE – antihemophilic factor (recombinant) for inj 401-800
unit..................................................................50
RECOMBINATE – antihemophilic factor (recombinant) for inj 801-1240
unit................................................................50
RECOMBINATE – antihemophilic factor (recombinant) for inj 1241-1800
unit..............................................................50
RECOMBINATE – antihemophilic factor (recombinant) for inj 1801-2400
unit..............................................................50
repaglinide tab 0.5 mg (Prandin).................................... 12
repaglinide tab 1 mg (Prandin)....................................... 12
repaglinide tab 2 mg (Prandin)....................................... 12
REPATHA – evolocumab subcutaneous soln prefilled syringe 140
mg/ml.............................................................21 REPATHA
PUSHTRONEX SYSTEM – evolocumab subcutaneous soln cartridge/infusor 420
mg/3.5ml..........21 REPATHA SURECLICK – evolocumab subcutaneous soln
auto-injector 140 mg/ml.................................................... 21
REVLIMID – lenalidomide cap 5 mg..................................57 REVLIMID –
lenalidomide cap 10 mg................................57 REVLIMID –
lenalidomide cap 15 mg................................57 REVLIMID –
lenalidomide cap 20 mg................................57 REVLIMID –
lenalidomide cap 25 mg................................57 REVLIMID –
lenalidomide caps 2.5 mg............................. 57 REYATAZ – atazanavir
sulfate cap 150 mg (base equiv)....................................................................................5
REYATAZ – atazanavir sulfate cap 200 mg (base
equiv)....................................................................................5
REYATAZ – atazanavir sulfate cap 300 mg (base
equiv)....................................................................................5
ribavirin cap 200 mg (Rebetol)..........................................4
ribavirin tab 200 mg (Copegus)........................................ 4 rifabutin
cap 150 mg (Mycobutin).....................................3 rifampin cap 150
mg (Rifadin)...........................................3 rifampin cap 300 mg
(Rifadin)...........................................3 riluzole tab 50 mg
(Rilutek)............................................. 45 risedronate sodium
tab 5 mg (Actonel)......................... 14 risedronate sodium tab 30 mg
(Actonel)....................... 14 risedronate sodium tab 35 mg
(Actonel)....................... 14 risedronate sodium tab 150 mg
(Actonel)..................... 14 risperidone orally disintegrating tab 0.25
mg............... 34 risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab)................................................................................
34 risperidone orally disintegrating tab 1 mg (Risperdal
m-tab)................................................................................
34 risperidone orally disintegrating tab 2 mg (Risperdal
m-tab)................................................................................
34 risperidone orally disintegrating tab 3 mg (Risperdal
m-tab)................................................................................
34 risperidone orally disintegrating tab 4 mg (Risperdal
m-tab)................................................................................
34 risperidone soln 1 mg/ml (Risperdal).............................34
risperidone tab 0.25 mg (Risperdal)...............................34
risperidone tab 0.5 mg (Risperdal).................................34
risperidone tab 1 mg (Risperdal)....................................34
risperidone tab 2 mg (Risperdal)....................................34
risperidone tab 3 mg (Risperdal)....................................34
risperidone tab 4 mg (Risperdal)....................................34
rivastigmine tartrate cap 1.5 mg (Exelon)......................37 rivastigmine
tartrate cap 3 mg (Exelon).........................37 rivastigmine tartrate cap
4.5 mg (Exelon)......................37 rivastigmine tartrate cap 6 mg
(Exelon).........................37 RIXUBIS – coagulation factor ix
(recombinant) for inj 250
unit......................................................................................50
RIXUBIS – coagulation factor ix (recombinant) for inj 500
unit......................................................................................50
RIXUBIS – coagulation factor ix (recombinant) for inj 1000
unit......................................................................................50
RIXUBIS – coagulation factor ix (recombinant) for inj 2000
unit......................................................................................50
RIXUBIS – coagulation factor ix (recombinant) for inj 3000
unit......................................................................................50
rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
(Maxalt-mlt)................................................................41
rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt).....................................................41
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 83 rizatriptan
benzoate tab 5 mg (base equivalent)
(Maxalt)..............................................................................41
rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)..............................................................................41
ropinirole hydrochloride tab 0.25 mg (Requip)............. 44 ropinirole
hydrochloride tab 0.5 mg (Requip)............... 44 ropinirole hydrochloride
tab 1 mg (Requip).................. 44 ropinirole hydrochloride tab 2 mg
(Requip).................. 44 ropinirole hydrochloride tab 3 mg
(Requip).................. 44 ropinirole hydrochloride tab 4 mg
(Requip).................. 44 ropinirole hydrochloride tab 5 mg
(Requip).................. 44 rosuvastatin calcium tab 5 mg (Crestor).......................
21 rosuvastatin calcium tab 10 mg (Crestor)..................... 21
rosuvastatin calcium tab 20 mg (Crestor)..................... 21 rosuvastatin
calcium tab 40 mg (Crestor)..................... 21 S SABRIL – vigabatrin powd
pack 500 mg........................... 43 SABRIL – vigabatrin tab 500
mg........................................43 selegiline hcl cap 5 mg
(Eldepryl).................................. 44 selegiline hcl tab 5
mg.....................................................44 selenium sulfide
lotion 2.5%........................................... 56 SE-NATAL 19 –
prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg......................................................................................
45 SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1
mg..............................................................................45
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)..........14 SENSIPAR –
cinacalcet hcl tab 60 mg (base equiv)..........14 SENSIPAR – cinacalcet hcl tab
90 mg (base equiv)..........14 SEREVENT DISKUS – salmeterol xinafoate aer pow
ba 50 mcg/dose (base equiv)................................................ 26
SEROQUEL XR – quetiapine fumarate tab sr 24hr 50
mg......................................................................................
34 SEROQUEL XR – quetiapine fumarate tab sr 24hr 150
mg......................................................................................
34 SEROQUEL XR – quetiapine fumarate tab sr 24hr 200 mg......................................................................................
34 SEROQUEL XR – quetiapine fumarate tab sr 24hr 300
mg......................................................................................
34 SEROQUEL XR – quetiapine fumarate tab sr 24hr 400
mg......................................................................................
34 sertraline hcl oral conc 20 mg/ml (Zoloft)......................32
sertraline hcl tab 25 mg (Zoloft)..................................... 32
sertraline hcl tab 50 mg (Zoloft)..................................... 32
sertraline hcl tab 100 mg (Zoloft)................................... 32
sildenafil citrate tab 20 mg (Revatio)............................. 23 silver
sulfadiazine cream 1% (Silvadene)...................... 54 SIMBRINZA –
brinzolamide-brimonidine tartrate ophth susp
1-0.2%.......................................................................52
SIMPONI – golimumab subcutaneous soln auto-injector 50
mg/0.5ml.......................................................................41
SIMPONI – golimumab subcutaneous soln auto-injector 100
mg/ml..........................................................................41
SIMPONI – golimumab subcutaneous soln prefilled syringe 50
mg/0.5ml..........................................................41 SIMPONI –
golimumab subcutaneous soln prefilled syringe 100
mg/ml.............................................................41
simvastatin tab 5 mg (Zocor).......................................... 21
simvastatin tab 10 mg (Zocor)........................................ 21
simvastatin tab 20 mg (Zocor)........................................ 21
simvastatin tab 40 mg (Zocor)........................................ 21
simvastatin tab 80 mg (Zocor)........................................ 21
sirolimus tab 0.5 mg (Rapamune)...................................57 sirolimus
tab 1 mg (Rapamune)......................................57 sirolimus tab 2 mg
(Rapamune)......................................57 SIVEXTRO – tedizolid phosphate
tab 200 mg.....................6 SKYLA – levonorgestrel releasing iud 14
mcg/day (13.5 mg
total).............................................................................10
sodium polystyrene sulfonate oral susp 15 gm/60ml (Sps)..................................................................................
57 sodium polystyrene sulfonate powder
(Kayexalate)......................................................................57
SOOLANTRA – ivermectin cream 1%............................... 54 sotalol hcl
(afib/afl) tab 80 mg (Betapace af).................22 sotalol hcl (afib/afl)
tab 120 mg (Betapace af)...............22 sotalol hcl (afib/afl) tab 160 mg
(Betapace af)...............22 sotalol hcl tab 240
mg......................................................22 sotalol hcl tab 80
mg (Betapace)....................................22 sotalol hcl tab 120 mg
(Betapace)..................................22 sotalol hcl tab 160 mg
(Betapace)..................................22 SOVALDI – sofosbuvir tab 400
mg...................................... 4 SPIRIVA HANDIHALER – tiotropium
bromide monohydrate inhal cap 18 mcg (base equiv)................... 26 SPIRIVA
RESPIMAT – tiotropium bromide monohydrate inhal aerosol 1.25
mcg/act................................................26 SPIRIVA RESPIMAT –
tiotropium bromide monohydrate inhal aerosol 2.5
mcg/act..................................................26 spironolactone
& hydrochlorothiazide tab 25-25 mg
(Aldactazide).....................................................................22
spironolactone tab 25 mg (Aldactone)...........................22
spironolactone tab 50 mg (Aldactone)...........................22
spironolactone tab 100 mg (Aldactone).........................22 SPRYCEL –
dasatinib tab 20 mg.........................................7 SPRYCEL –
dasatinib tab 50 mg.........................................7 SPRYCEL –
dasatinib tab 70 mg.........................................7 SPRYCEL –
dasatinib tab 80 mg.........................................7 SPRYCEL –
dasatinib tab 100 mg.......................................7 SPRYCEL –
dasatinib tab 140 mg.......................................7 stavudine cap 15
mg (Zerit)...............................................5 stavudine cap 20 mg
(Zerit)...............................................5 stavudine cap 30 mg
(Zerit)...............................................5 stavudine cap 40 mg
(Zerit)...............................................5 STELARA – ustekinumab
inj 45 mg/0.5ml.........................56 STELARA – ustekinumab soln prefilled
syringe 45
mg/0.5ml............................................................................
56 2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 84 STELARA –
ustekinumab soln prefilled syringe 90 mg/
ml........................................................................................56
STIMATE – desmopressin acetate nasal soln 1.5 mg/
ml........................................................................................14
STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero soln 2.5-2.5
mcg/act..........................................................26 STRENSIQ –
asfotase alfa subcutaneous inj 18
mg/0.45ml..........................................................................
14 STRENSIQ – asfotase alfa subcutaneous inj 28
mg/0.7ml............................................................................
14 STRENSIQ – asfotase alfa subcutaneous inj 40 mg/
ml........................................................................................14
STRENSIQ – asfotase alfa subcutaneous inj 80
mg/0.8ml............................................................................
14 STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300
mg...........................................................5 STRIVERDI
RESPIMAT – olodaterol hcl inhal aerosol soln 2.5 mcg/act (base
equiv).................................................. 26 SUBOXONE –
buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base
equiv).......................................................57 SUBOXONE –
buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)................................................................
57 SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 mg (base
equiv)................................................................ 57
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)................................................................
57 sucralfate tab 1 gm (Carafate).........................................28
sulfacetamide sodium lotion 10% (acne) (Klaron)........54 sulfacetamide sodium
ophth soln 10% (Bleph-10)....... 51 sulfacetamide sodium-prednisolone ophth
soln
10-0.23(0.25)%..................................................................
52 sulfamethoxazole-trimethoprim susp 200-40
mg/5ml.................................................................................6
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim).............................................................................
6 sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim
ds)........................................................................6
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs).............................................................................
29 sulfasalazine tab 500 mg (Azulfidine)............................ 29
sulindac tab 150 mg......................................................... 41
sulindac tab 200 mg......................................................... 41
sumatriptan nasal spray 5 mg/act (Imitrex)...................41 sumatriptan
nasal spray 20 mg/act (Imitrex).................41 sumatriptan succinate inj 6
mg/0.5ml (Imitrex).............41 sumatriptan succinate solution auto-injector
4 mg/0.5ml (Imitrex statdose sys)....................................41
sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)....................................41
sumatriptan succinate solution cartridge 4 mg/0.5ml (Imitrex statdose
ref)...................................................... 41 sumatriptan
succinate solution cartridge 6 mg/0.5ml (Imitrex statdose ref)......................................................
41 sumatriptan succinate tab 25 mg (Imitrex)....................41 sumatriptan
succinate tab 50 mg (Imitrex)....................41 sumatriptan succinate tab
100 mg (Imitrex)..................42 SUSTIVA – efavirenz cap 50
mg......................................... 5 SUSTIVA – efavirenz cap 200
mg....................................... 5 SUSTIVA – efavirenz tab 600
mg........................................ 5 SUTENT – sunitinib malate cap 12.5
mg (base equivalent)............................................................................7
SUTENT – sunitinib malate cap 25 mg (base
equivalent)............................................................................7
SUTENT – sunitinib malate cap 37.5 mg (base equivalent)............................................................................7
SUTENT – sunitinib malate cap 50 mg (base
equivalent)............................................................................7
SYLATRON – peginterferon alfa-2b for inj kit 200 mcg....... 7 SYLATRON –
peginterferon alfa-2b for inj kit 300 mcg....... 7 SYLATRON – peginterferon
alfa-2b for inj kit 600 mcg....... 8 SYMBICORT – budesonide-formoterol fumarate
dihyd aerosol 80-4.5 mcg/act.....................................................
26 SYMBICORT – budesonide-formoterol fumarate dihyd aerosol 160-4.5
mcg/act................................................... 26 SYNJARDY –
empagliflozin-metformin hcl tab 5-500
mg......................................................................................
12 SYNJARDY – empagliflozin-metformin hcl tab 5-1000
mg......................................................................................
12 SYNJARDY – empagliflozin-metformin hcl tab 12.5-500
mg......................................................................................
12 SYNJARDY – empagliflozin-metformin hcl tab 12.5-1000
mg......................................................................................
12 T TABLOID – thioguanine tab 40 mg...................................... 8
tacrolimus cap 0.5 mg (Prograf)..................................... 57
tacrolimus cap 1 mg (Prograf)........................................ 57
tacrolimus cap 5 mg (Prograf)........................................ 57
tacrolimus oint 0.03% (Protopic).................................... 56
tacrolimus oint 0.1% (Protopic)...................................... 56
TAFINLAR – dabrafenib mesylate cap 50 mg (base
equivalent)............................................................................8
TAFINLAR – dabrafenib mesylate cap 75 mg (base
equivalent)............................................................................8
tamoxifen citrate tab 10 mg (base equivalent)................8 tamoxifen
citrate tab 20 mg (base equivalent)................8 tamsulosin hcl cap 0.4 mg
(Flomax).............................. 30 TARCEVA – erlotinib hcl tab 25 mg
(base equivalent).........8 TARCEVA – erlotinib hcl tab 100 mg (base
equivalent).......8 TARCEVA – erlotinib hcl tab 150 mg (base equivalent).......8
TASIGNA – nilotinib hcl cap 150 mg (base equivalent)....... 8 TASIGNA –
nilotinib hcl cap 200 mg (base equivalent)....... 8 tazarotene cream 0.1%
(Tazorac)....................................54 TAZORAC – tazarotene cream
0.05%...............................54 TAZORAC – tazarotene cream
0.1%.................................54 TAZORAC – tazarotene gel
0.05%.................................... 54 2017 Find and estimate prices for
medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 85 TAZORAC –
tazarotene gel 0.1%...................................... 54 TECFIDERA –
dimethyl fumarate capsule delayed release 120 mg...............................................................................36
TECFIDERA – dimethyl fumarate capsule delayed release 240
mg...............................................................................36
TECFIDERA STARTER PACK – dimethyl fumarate capsule dr starter pack 120 mg &
240 mg....................... 37 telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis
hct)................................................................... 17
telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)...................................................................
17 telmisartan-hydrochlorothiazide tab 80-25 mg (Micardis
hct)................................................................... 17
telmisartan tab 20 mg (Micardis).................................... 17
telmisartan tab 40 mg (Micardis).................................... 17
telmisartan tab 80 mg (Micardis).................................... 17
temazepam cap 7.5 mg (Restoril)................................... 34 temazepam
cap 15 mg (Restoril).................................... 34 temazepam cap 22.5
mg (Restoril)................................. 34 temazepam cap 30 mg
(Restoril).................................... 34 temozolomide cap 5 mg
(Temodar).................................. 8 temozolomide cap 20 mg
(Temodar)................................8 temozolomide cap 100 mg
(Temodar)..............................8 temozolomide cap 140 mg
(Temodar)..............................8 temozolomide cap 180 mg
(Temodar)..............................8 temozolomide cap 250 mg
(Temodar)..............................8 terazosin hcl cap 1
mg.....................................................23 terazosin hcl cap 2
mg.....................................................23 terazosin hcl cap 5
mg.....................................................23 terazosin hcl cap 10
mg...................................................23 terbinafine hcl tab 250
mg (Lamisil).................................3 terbutaline sulfate tab 2.5
mg......................................... 26 terbutaline sulfate tab 5
mg............................................ 26 terconazole vaginal cream
0.4% (Terazol 7).................. 30 terconazole vaginal cream 0.8% (Terazol
3).................. 30 terconazole vaginal suppos 80 mg.................................30
testosterone cypionate im inj in oil 100 mg/ml
(Depotestosterone)......................................................................
9 testosterone cypionate im inj in oil 200 mg/ml
(Depotestosterone)......................................................................
9 testosterone enanthate im inj in oil 200 mg/ml...............9 testosterone
td gel 12.5 mg/act (1%) (Androgel
pump)..................................................................................
9 testosterone td gel 25 mg/2.5gm (1%) (Androgel).......... 9 testosterone td
gel 50 mg/5gm (1%) (Androgel)............. 9 TEST STRIPS – ASCENSIA BREEZE 2,
CONTOUR, CONTOUR
NEXT..............................................................56
tetrabenazine tab 12.5 mg (Xenazine)............................ 37
tetrabenazine tab 25 mg (Xenazine)............................... 37
tetracycline hcl cap 250 mg (Tetracycline hcl)................2 tetracycline
hcl cap 500 mg (Tetracycline hcl)................2 THALOMID – thalidomide cap
50 mg................................ 57 THALOMID – thalidomide cap 100
mg.............................. 57 THALOMID – thalidomide cap 150
mg.............................. 57 THALOMID – thalidomide cap 200
mg.............................. 57 theophylline tab sr 12hr 100
mg.....................................26 theophylline tab sr 12hr 200
mg.....................................26 theophylline tab sr 12hr 300
mg.....................................26 theophylline tab sr 12hr 450
mg.....................................26 theophylline tab sr 24hr 400
mg.....................................26 theophylline tab sr 24hr 600
mg.....................................26 thiothixene cap 1
mg........................................................34 thiothixene cap 2
mg........................................................34 thiothixene cap 5
mg........................................................34 thiothixene cap 10
mg......................................................34 timolol maleate
ophth gel forming soln 0.25%
(Timoptic-xe)....................................................................
52 timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe)....................................................................
52 timolol maleate ophth soln 0.25% (Timoptic)................52 timolol
maleate ophth soln 0.5% (Timoptic)..................52 TIMOLOL MALEATE –
timolol maleate tab 5 mg.............. 18 TIMOLOL MALEATE – timolol maleate tab
10 mg............ 18 TIMOLOL MALEATE – timolol maleate tab 20 mg............ 18
TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 5 TIVICAY –
dolutegravir sodium tab 25 mg (base equiv)...... 5 TIVICAY – dolutegravir
sodium tab 50 mg (base equiv)...... 5 tizanidine hcl tab 2 mg (base
equivalent)......................45 tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)..........................................................................
45 tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).........................................................................52
tobramycin nebu soln 300 mg/5ml (Tobi)........................ 3 tobramycin
ophth soln 0.3% (Tobrex)............................51 tolterodine tartrate cap
sr 24hr 2 mg (Detrol la)............29 tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)............29 tolterodine tartrate tab 1 mg
(Detrol)............................. 29 tolterodine tartrate tab 2 mg
(Detrol)............................. 29 topiramate sprinkle cap 15 mg (Topamax
sprinkle)..... 43 topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 43
topiramate tab 25 mg (Topamax).................................... 43
topiramate tab 50 mg (Topamax).................................... 43
topiramate tab 100 mg (Topamax)..................................43 topiramate
tab 200 mg (Topamax)..................................43 torsemide tab 5 mg
(Demadex).......................................22 torsemide tab 10 mg
(Demadex).....................................22 torsemide tab 20 mg
(Demadex).....................................22 torsemide tab 100 mg
(Demadex)...................................22 TOUJEO SOLOSTAR – insulin
glargine soln pen-injector 300
unit/ml.........................................................................
13 TRACLEER – bosentan tab 62.5 mg.................................23 TRACLEER
– bosentan tab 125 mg..................................23
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)...........................................................................
40 tramadol hcl tab 50 mg (Ultram).....................................40
tramadol hcl tab sr 24hr 100 mg (Ultram er)................. 40 2017 Find and
estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 86 tramadol hcl
tab sr 24hr 200 mg (Ultram er)................. 40 tramadol hcl tab sr 24hr 300
mg (Ultram er)................. 40 trandolapril tab 1 mg
(Mavik).......................................... 15 trandolapril tab 2 mg
(Mavik).......................................... 15 trandolapril tab 4 mg
(Mavik).......................................... 15 tranylcypromine sulfate
tab 10 mg (Parnate)................32 TRAVATAN Z – travoprost ophth soln 0.004%
(benzalkonium free) (bak free)......................................... 52
trazodone hcl tab 50 mg.................................................. 32
trazodone hcl tab 100 mg................................................32
trazodone hcl tab 150 mg................................................32
trazodone hcl tab 300 mg................................................32
TRESIBA FLEXTOUCH – insulin degludec soln peninjector 100
unit/ml............................................................13 TRESIBA
FLEXTOUCH – insulin degludec soln peninjector 200
unit/ml............................................................13 tretinoin
cap 10 mg.............................................................8
tretinoin cream 0.025% (Retin-a).....................................54 tretinoin
cream 0.05% (Retin-a).......................................54 tretinoin cream
0.1% (Retin-a).........................................54 tretinoin gel 0.01%
(Retin-a)............................................ 54 tretinoin gel 0.025%
(Retin-a)..........................................54 tretinoin microsphere gel
0.04% (Retin-a micro).......... 54 tretinoin microsphere gel 0.1% (Retin-a
micro)............ 54 TRETTEN – coagulation factor xiii a-subunit for inj
2000-3125 unit...................................................................50
TREXALL – methotrexate sodium tab 5 mg (base
equiv)....................................................................................8
TREXALL – methotrexate sodium tab 7.5 mg (base equiv)....................................................................................8
TREXALL – methotrexate sodium tab 10 mg (base
equiv)....................................................................................8
TREXALL – methotrexate sodium tab 15 mg (base equiv)....................................................................................8
triamcinolone acetonide cream 0.025%.........................55 triamcinolone
acetonide cream 0.1%............................. 55 triamcinolone acetonide
cream 0.5%............................. 55 triamcinolone acetonide dental paste
0.1%.................. 53 triamcinolone acetonide lotion
0.025%..........................55 triamcinolone acetonide lotion
0.1%..............................55 triamcinolone acetonide nasal aerosol
suspension 55 mcg/act (Nasacort
aq).................................................... 24 triamcinolone
acetonide oint 0.025%............................. 55 triamcinolone acetonide
oint 0.1%................................. 55 triamcinolone acetonide oint
0.5%................................. 55 triamterene & hydrochlorothiazide
cap 37.5-25 mg
(Dyazide)...........................................................................
22 triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25).....................................................................
22 triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)...........................................................................22
trifluoperazine hcl tab 1 mg............................................ 34
trifluoperazine hcl tab 2 mg............................................ 34
trifluoperazine hcl tab 5 mg............................................ 34
trifluoperazine hcl tab 10 mg.......................................... 34
trifluridine ophth soln 1% (Viroptic)............................... 51
trihexyphenidyl hcl elixir 0.4 mg/ml............................... 44
trihexyphenidyl hcl tab 2 mg...........................................44
trihexyphenidyl hcl tab 5 mg...........................................44
trimethobenzamide hcl cap 300 mg (Tigan).................. 28 trimethoprim tab
100 mg................................................... 6 tropicamide ophth
soln 0.5%.......................................... 53 tropicamide ophth soln 1%
(Mydriacyl)......................... 53 TRUVADA – emtricitabine-tenofovir
disoproxil fumarate tab 100-150
mg...................................................................5 TRUVADA
– emtricitabine-tenofovir disoproxil fumarate tab 133-200 mg...................................................................5
TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab 167-250
mg...................................................................5 TRUVADA
– emtricitabine-tenofovir disoproxil fumarate tab 200-300
mg...................................................................5 U
UPTRAVI – selexipag tab 200 mcg....................................23 UPTRAVI –
selexipag tab 400 mcg....................................23 UPTRAVI – selexipag
tab 600 mcg....................................23 UPTRAVI – selexipag tab 800
mcg....................................23 UPTRAVI – selexipag tab 1000
mcg..................................23 UPTRAVI – selexipag tab 1200
mcg..................................23 UPTRAVI – selexipag tab 1400
mcg..................................23 UPTRAVI – selexipag tab 1600
mcg..................................23 UPTRAVI – selexipag tab therapy pack
200 mcg (140) & 800 mcg
(60)..................................................................... 23
ursodiol cap 300 mg (Actigall)........................................29
ursodiol tab 250 mg (Urso 250)...................................... 29
ursodiol tab 500 mg (Urso forte).................................... 29 V
VAGIFEM – estradiol vaginal tab 10 mcg.......................... 30
valacyclovir hcl tab 1 gm (Valtrex)................................... 4
valacyclovir hcl tab 500 mg (Valtrex)............................... 4 VALCHLOR
– mechlorethamine hcl gel 0.016% (base equivalent).........................................................................
56 VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)....................................................................................3
valganciclovir hcl for soln 50 mg/ml (base equiv)
(Valcyte)..............................................................................
3 valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte)..............................................................................
3 valproate sodium oral soln 250 mg/5ml (base equiv)
(Depakene)........................................................................43
valproic acid cap 250 mg (Depakene)............................43
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct).....................................................................................17
valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan
hct).....................................................................................17
2017 Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXPREFDRUG/en/find-medicine.html
Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 87
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).....................................................................................17
valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan
hct).....................................................................................17
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct).....................................................................................17
valsartan tab 40 mg (Diovan).......................................... 17
valsartan tab 80 mg (Diovan).......................................... 17
valsartan tab 160 mg (Diovan)........................................ 17
valsartan tab 320 mg (Diovan)........................................ 17
vancomycin hcl cap 125 mg (Vancocin hcl)....................6 vancomycin hcl
cap 250 mg (Vancocin hcl)....................6 VELPHORO – sucroferric
oxyhydroxide chew tab 500
mg......................................................................................
29 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) (Effexor
xr)....................................................................... 32
venlafaxine hcl cap sr 24hr 75 mg (base equivalent) (Effexor
xr)....................................................................... 32
venlafaxine hcl cap sr 24hr 150 mg (base equivalent) (Effexor
xr)....................................................................... 32
venlafaxine hcl tab 25 mg................................................32
venlafaxine hcl tab 37.5 mg.............................................32
venlafaxine hcl tab 50 mg................................................32
venlafaxine hcl tab 75 mg................................................32
venlafaxine hcl tab 100 mg..............................................32
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) (Venlafaxine hcl
er)......................................................... 32 venlafaxine hcl
tab sr 24hr 75 mg (base equivalent) (Venlafaxine hcl
er)......................................................... 32 venlafaxine hcl
tab sr 24hr 150 mg (base equivalent) (Venlafaxine hcl er).........................................................
32 VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act (90mcg base
equiv).......................................................... 26 verapamil
hcl cap sr 24hr 120 mg (Verelan).................. 19 verapamil hcl cap sr 24hr
180 mg (Verelan).................. 19 verapamil hcl cap sr 24hr 240 mg
(Verelan).................. 19 verapamil hcl cap sr 24hr 360 mg
(Verelan).................. 19 verapamil hcl tab cr 120 mg (Calan
sr)..........................19 verapamil hcl tab cr 180 mg (Calan
sr)..........................20 verapamil hcl tab cr 240 mg (Calan
sr)..........................20 verapamil hcl tab 40
mg.................................................. 20 verapamil hcl tab 80 mg
(Calan).....................................20 verapamil hcl tab 120 mg
(Calan)...................................20 VESICARE – solifenacin succinate
tab 5 mg.................... 29 VESICARE – solifenacin succinate tab 10
mg...................29 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6
mg/
ml)......................................................................................
12 VIDEX – didanosine for soln 2 gm.......................................5
VIDEX – didanosine for soln 4 gm.......................................5
VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base
equiv).................................................................................
51 VIRAMUNE – nevirapine susp 50 mg/5ml...........................5 VIREAD –
tenofovir disoproxil fumarate oral powder 40
mg/gm..................................................................................
5 VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 5 VIREAD –
tenofovir disoproxil fumarate tab 200 mg........... 6 VIREAD – tenofovir
disoproxil fumarate tab 250 mg........... 6 VIREAD – tenofovir disoproxil
fumarate tab 300 mg........... 6 VONVENDI – von willebrand factor (recombinant)
for inj 650
unit..............................................................................50
VONVENDI – von willebrand factor (recombinant) for inj 1300
unit............................................................................50
voriconazole for susp 40 mg/ml (Vfend)..........................3 voriconazole
tab 50 mg (Vfend)........................................3 voriconazole tab 200
mg (Vfend)......................................3 VOTRIENT – pazopanib hcl tab
200 mg (base equiv).........8 VYVANSE – lisdexamfetamine dimesylate cap 10
mg...... 36 VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 36 VYVANSE –
lisdexamfetamine dimesylate cap 30 mg...... 36 VYVANSE – lisdexamfetamine
dimesylate cap 40 mg...... 36 VYVANSE – lisdexamfetamine dimesylate cap 50
mg...... 36 VYVANSE – lisdexamfetamine dimesylate cap 60 mg...... 36 VYVANSE –
lisdexamfetamine dimesylate cap 70 mg...... 36 VYVANSE – lisdexamfetamine
dimesylate chew tab 10
mg......................................................................................
36 VYVANSE – lisdexamfetamine dimesylate chew tab 20
mg......................................................................................
36 VYVANSE – lisdexamfetamine dimesylate chew tab 30
mg......................................................................................
36 VYVANSE – lisdexamfetamine dimesylate chew tab 40 mg......................................................................................
36 VYVANSE – lisdexamfetamine dimesylate chew tab 50
mg......................................................................................
36 VYVANSE – lisdexamfetamine dimesylate chew tab 60
mg......................................................................................
36 W warfarin sodium tab 1 mg (Coumadin).......................... 50 warfarin
sodium tab 2 mg (Coumadin).......................... 50 warfarin sodium tab 2.5
mg (Coumadin)....................... 50 warfarin sodium tab 3 mg
(Coumadin).......................... 50 warfarin sodium tab 4 mg
(Coumadin).......................... 50 warfarin sodium tab 5 mg
(Coumadin).......................... 50 warfarin sodium tab 6 mg
(Coumadin).......................... 50 warfarin sodium tab 7.5 mg
(Coumadin)....................... 51 warfarin sodium tab 10 mg
(Coumadin)........................ 51 WELCHOL – colesevelam hcl packet for susp
3.75 gm......................................................................................
21 WELCHOL – colesevelam hcl tab 625 mg........................ 21 WILATE –
antihemophilic factor/vwf (human) for inj 500-500 unit
kit..................................................................51 WILATE
– antihemophilic factor/vwf (human) for inj 1000-1000 unit
kit..............................................................51 2017 Find
and estimate prices for medicines on this formulary at:
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Blue Cross and Blue Shield of Texas July 2017 Basic Drug List 88 X XALKORI –
crizotinib cap 200 mg....................................... 8 XALKORI –
crizotinib cap 250 mg....................................... 8 XARELTO – rivaroxaban
tab 10 mg...................................51 XARELTO – rivaroxaban tab 15
mg...................................51 XARELTO – rivaroxaban tab 20
mg...................................51 XARELTO STARTER PACK – rivaroxaban tab
starter therapy pack 15 mg & 20
mg...........................................51 XIFAXAN – rifaximin tab 550
mg......................................... 6 XTANDI – enzalutamide cap 40
mg.....................................8 XYNTHA – antihemophilic factor
recombinant paf for inj kit 250
unit..............................................................................51
XYNTHA – antihemophilic factor recombinant paf for inj kit 500
unit..............................................................................51
XYNTHA – antihemophilic factor recombinant paf for inj kit 1000
unit............................................................................51
XYNTHA – antihemophilic factor recombinant paf for inj kit 2000
unit............................................................................51
XYNTHA SOLOFUSE – antihemophilic factor recombinant paf for inj kit 250
unit........................................................51 XYNTHA SOLOFUSE
– antihemophilic factor recombinant paf for inj kit 500
unit........................................................51 XYNTHA SOLOFUSE
– antihemophilic factor recombinant paf for inj kit 1000
unit......................................................51 XYNTHA SOLOFUSE –
antihemophilic factor recombinant paf for inj kit 2000 unit......................................................51
XYNTHA SOLOFUSE – antihemophilic factor recombinant paf for inj kit 3000
unit......................................................51 Y Z zafirlukast
tab 10 mg (Accolate)..................................... 26 zafirlukast tab 20
mg (Accolate)..................................... 26 zaleplon cap 5 mg
(Sonata).............................................34 zaleplon cap 10 mg
(Sonata)...........................................34 ZARXIO – filgrastim-sndz
soln prefilled syringe 300
mcg/0.5ml...........................................................................51
ZARXIO – filgrastim-sndz soln prefilled syringe 480
mcg/0.8ml...........................................................................51
ZELBORAF – vemurafenib tab 240 mg............................... 8 ZENPEP –
pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000
unit..................................................... 28 ZENPEP –
pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit.....................................................
28 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-34000-55000
unit...................................................28 ZENPEP – pancrelipase
(lip-prot-amyl) dr cap 15000-51000-82000 unit...................................................28
ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-68000-109000
unit.................................................28 ZENPEP – pancrelipase
(lip-prot-amyl) dr cap 25000-85000-136000 unit.................................................28
ZENPEP – pancrelipase (lip-prot-amyl) dr cap 40000-136000-218000
unit...............................................28 ZIAGEN – abacavir sulfate
soln 20 mg/ml (base equiv)...... 6 zidovudine cap 100 mg
(Retrovir).....................................6 zidovudine syrup 10 mg/ml
(Retrovir)..............................6 zidovudine tab 300
mg.......................................................6 ziprasidone hcl cap
20 mg (Geodon)............................. 34 ziprasidone hcl cap 40 mg (Geodon).............................
34 ziprasidone hcl cap 60 mg (Geodon)............................. 34
ziprasidone hcl cap 80 mg (Geodon)............................. 34 zolpidem
tartrate tab cr 6.25 mg (Ambien cr)................34 zolpidem tartrate tab cr
12.5 mg (Ambien cr)................34 zolpidem tartrate tab 5 mg
(Ambien)..............................34 zolpidem tartrate tab 10 mg
(Ambien)............................34 zonisamide cap 50
mg..................................................... 43 zonisamide cap 25 mg
(Zonegran)................................. 43 zonisamide cap 100 mg
(Zonegran)............................... 43 ZORTRESS – everolimus tab 0.25
mg.............................. 57 ZORTRESS – everolimus tab 0.5
mg................................ 57 ZORTRESS – everolimus tab 0.75
mg.............................. 57 ZYCLARA – imiquimod cream
3.75%................................56 ZYCLARA PUMP – imiquimod cream
2.5%...................... 56 ZYCLARA PUMP – imiquimod cream
3.75%.................... 56 ZYLET – loteprednol etabonate-tobramycin ophth
susp
0.5-0.3%.............................................................................52
ZYTIGA – abiraterone acetate tab 250 mg..........................8 ZYTIGA –
abiraterone acetate tab 500 mg..........................8
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