Health Insurance Marketplace 6 Tier Drug List

Transcription

1 February 08 Health Insurance Marketplace Tier Drug List Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug list is regularly updated. Please visit bcbstx.com for the most up-to-date information. To find a contracting pharmacy, please access the link below: Contents Therapeutic Class Drug List Summary of Formulary Benefits... I Introduction... VII How drugs are selected...vii How member payment is determined... VII How to use this list... VIII Drugs used to treat multiple conditions...viii Generic drugs... VIII Consider talking to your doctor about generic drugs... VIII Coverage considerations... IX Specialty drugs... XI lliancerx Walgreens Prime... XI bbreviation Key...XII nti-infective agents... Biologicals... ntineoplastic agents... Endocrine and metabolic drugs...0 Cardiovascular agents... Respiratory agents... Gastrointestinal agents... Genitourinary agents... Central nervous system drugs... nalgesics and anesthetics...78 Neuromuscular drugs Nutritional products...9 Hematological agents... Topical products... Miscellaneous products... Index...0 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. 7-W TX HIM Prime Therapeutics LLC 0/8

2 Summary of Formulary Benefits The information in this document is designed to help you understand the prescription drug benefits offered under this plan and compare these benefits to those offered by other plans. Information contained in this summary is designed to help you compare, both the value and scope of formulary benefits. How to Find Information on the Cost of Prescription Drugs: Your Summary of Benefits and Coverage (SBC) document lists information about your plan, including pharmacy deductibles, tiers, out of pocket maximums, and a link to this formulary document. This formulary document lists drugs covered by your plan, the coverage tiers and any special requirements for each drug. This formulary document includes a link on the bottom of each page to the Find a Medicine web-based tool on myprime.com, which you may use to search for drugs for information on formulary coverage and estimate prices. Price estimates include total cost, plan and member cost share amounts (excluding any deductible requirements), and are based on the most recent actual network pricing. You may also use Pharmacy finder to review differences in estimated pricing between pharmacies. Toll free number to obtain formulary information, including specific cost-sharing information for any formulary drug: Formulary by Health Benefit Plan: Some 08 Blue Cross and Blue Shield of Texas employer-offered small group plans use the 08 Health Insurance Marketplace Tier Drug List. These plans are offered on and off the Texas Health Insurance Marketplace. ll 08 Individual Plans use the 08 Health Insurance Marketplace Tier Drug List (except the 08 Blue dvantage Plus Silver 0 - Three $0 PCP Visits - Non-Marketplace plan which uses the 08 Health Insurance Marketplace Tier Drug List) Plan (Select plan name to view plan Summary of Benefits & Coverage) Blue dvantage Gold HMO 0 - Three $0 PCP Visits - Non-Marketplace ssociated Formulary Health Insurance Marketplace Tier Drug List Blue dvantage Gold HMO 0 - Three $0 PCP Visits - Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Gold HMO 0 - Marketplace Native merican Zero Health Insurance Marketplace Tier Drug List Blue dvantage Gold HMO 0 - Three $0 PCP Visits - Marketplace Native Health Insurance merican Limited Marketplace Tier Drug List Blue dvantage Gold HMO 07 - Non-Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Silver HMO 0 - Two $ PCP Visits - Non-Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Silver HMO 0 - Two $ PCP Visits - Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Silver HMO 0 - Marketplace Native merican Zero Health Insurance Marketplace Tier Drug List BCBSTX Health Insurance Marketplace Tier Drug List February 08 I

3 Plan (Select plan name to view plan Summary of Benefits & Coverage) Blue dvantage Silver HMO 0 - Two $ PCP Visits - Native merican Limited ssociated Formulary Health Insurance Marketplace Tier Drug List Blue dvantage Silver HMO 0 - Two $ PCP Visits - Marketplace 7% Health Insurance ctuarial Value Marketplace Tier Drug List Blue dvantage Silver HMO 0 - Two $ PCP Visits - Marketplace 87% Health Insurance ctuarial Value Marketplace Tier Drug List Blue dvantage Silver HMO 0 - Two $ PCP Visits - Marketplace 9% Health Insurance ctuarial Value Marketplace Tier Drug List Blue dvantage Bronze HMO 0 - Two $0 PCP Visits - Non-Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Bronze HMO 0 - Two $0 PCP Visits - Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Bronze HMO 0 - Marketplace Native merican Zero Health Insurance Marketplace Tier Drug List Blue dvantage Bronze HMO 0 - Two $0 PCP Visits - Marketplace Native Health Insurance merican Limited Marketplace Tier Drug List Blue dvantage Security HMO 00 - Non-Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Security HMO 00 - Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Plus Gold 0 - Non-Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Plus Gold 0 - Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Plus Gold 0 - Marketplace Native merican Zero Health Insurance Marketplace Tier Drug List Blue dvantage Plus Gold 0 - Marketplace Native merican Limited Health Insurance Marketplace Tier Drug List Blue dvantage Plus Silver 0 - Non-Marketplace Health Insurance Marketplace Tier Drug List BCBSTX Health Insurance Marketplace Tier Drug List February 08 II

4 Plan (Select plan name to view plan Summary of Benefits & Coverage) Blue dvantage Plus Silver 0 - Marketplace ssociated Formulary Health Insurance Marketplace Tier Drug List Blue dvantage Plus Silver 0 - Marketplace Native merican Zero Health Insurance Marketplace Tier Drug List Blue dvantage Plus Silver 0 - Marketplace Native merican Limited Health Insurance Marketplace Tier Drug List Blue dvantage Plus Silver 0 - Marketplace 7% ctuarial Value Health Insurance Marketplace Tier Drug List Blue dvantage Plus Silver 0 - Marketplace 87% ctuarial Value Health Insurance Marketplace Tier Drug List Blue dvantage Plus Silver 0 - Marketplace 9% ctuarial Value Health Insurance Marketplace Tier Drug List Blue dvantage Plus Bronze 0 - Non-Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Plus Bronze 0- Marketplace Health Insurance Marketplace Tier Drug List Blue dvantage Plus Bronze 0 - Marketplace Native merican Zero Health Insurance Marketplace Tier Drug List Blue dvantage Plus Bronze 0 - Marketplace Native merican Limited Health Insurance Marketplace Tier Drug List Blue dvantage Plus Silver 0 - Three $0 PCP Visits - Non-Marketplace Health Insurance Marketplace Tier Drug List BCBSTX Health Insurance Marketplace Tier Drug List February 08 III

5 Drugs by Cost-Sharing Tier: Tier Percentage of Drugs.% Tier.% Tier 9.7% Tier 7.% Tier.% Tier 9.% Tier.7% Formulary Composition: This drug list, (also known as a formulary) is a closed formulary; a closed formulary is a type of benefit design in which only medicines included on the drug list (or formulary) are covered. You may be able to get a medicine that is not on the drug list. But, you may have to pay 00% of the cost, unless a formulary coverage exception is submitted and your health plan approves it. The formulary or drug list is designed to provide you and your physician with the most safe, effective drugs at the most reasonable cost. The drug list is developed by a Pharmacy and Therapeutics (P&T) committee. The P&T committee is made up of a diverse group of doctors and pharmacists. When adding or removing drugs from the drug list, the P&T committee reviews each drug for its safety, effectiveness, and uniqueness. Health plans use the drug list to provide their members with effective drug therapies at reasonable costs. For this reason, using drugs from a drug list is important for both you and your health plan. Often, many drugs are available to treat the same condition. If two drugs are equivalent in effectiveness and safety, the drug list will include the lower cost drug. You are not limited to purchasing only those drugs that appear on your health plan's drug list. However, you may pay more out-of-pocket for a drug that is not on the drug list. You may need to pay the full cost of a drug if it is not covered by your benefit plan. Changes in a drug list result from decisions made at P&T committee meetings. The Prime P&T committee meets at least quarterly to consider changes to the drug list. For example, if a new drug is found to be more effective than one already on the drug list, the new drug may replace the less effective drug. drug may also be removed from a drug list for safety reasons. The Food and Drug dministration (FD) tracks drug safety information. The FD issues reports about side effects, warnings or contraindications. Prime monitors these reports because they may trigger a change in a drug list. Right to Request a Coverage Determination: If a drug is not covered under the drug list (also known as a formulary) or requires utilization review prior to coverage, but your physician has determined that the drug is medically necessary, you have the right to request a coverage determination. Your cost share for non-formulary medicines approved through coverage determination is based on your benefit plan s cost share for the appropriate non-preferred generic, non-preferred brand, or specialty tier. Right to ppeal: If your request for coverage is denied, but your physician has determined that the drug is medically necessary, you have the right to appeal and request coverage. Continuation of Coverage: You have the right to continued coverage for a prescription drug at the coverage level or tier at which the drug was covered at the beginning of the plan year, until your plan renewal date, provided that the drug continues to be medically necessary and safe. Off-Label Drug Use: Off-label use of FD approved drugs occurs when a drug is prescribed for a reason that has not been approved by the FD. Off-label use may be covered when all of the following apply: The medicine has been approved by the FD for at least one use; BCBSTX Health Insurance Marketplace Tier Drug List February 08 IV

6 The medicine is prescribed by a physician; The medicine is intended to treat chronic, disabling, or life-threatening illnesses; Sufficient clinical evidence is provided by your physician for the off-label use requested; The services and medicine are medically necessary. Off-Label use of FD approved drugs is not covered when these conditions are not met or when the determined its use to be contraindicated for treatment of the condition for which coverage is requested. pproved off-label medicine cost share is based on the tier in which the medicine is assigned within the drug list. Limitations and Exclusions: Pharmacy benefits are not available for: Drugs required by law to be labeled: Caution - Limited by Federal Law to Investigational Use, or Experimental drugs, even though a charge is made for the drugs, or Legend drugs not approved by the FD for a particular use or purpose or when used for a purpose other than the purpose for which the FD approval is given, except as required by law or regulation. Experimental / Investigational means the use of any treatment, procedure, facility, equipment, drug, device or supply not accepted as Standard Medical Treatment of the condition being treated or any of such items requiring federal or other governmental agency pproval not granted at the time services were provided. pproval by a federal agency means that the treatment, procedure, facility, equipment, drug, device or supply has been approved for the condition being treated and, in the case of a drug, in the dosage used on the patient. Medical treatment includes medical, surgical or dental treatment. Standard Medical Treatment means the services or supplies that are in general use in the medical community in the United States, and: have been demonstrated in peer-reviewed literature to have scientifically established medical value for curing or alleviating the condition being treated; are appropriate for the Hospital or Participating Provider; and the Health Care Professional has had the appropriate training and experience to provide the treatment or procedure. Cost-Sharing: Your deductible is listed on your Summary of Benefits and Coverage document. Your deductible is the amount of money that you and anyone covered by your plan must pay out-of-pocket each plan year for covered services before your plan starts to pay. certain set of drugs may be covered without cost-sharing, even before meeting the deductible. The out-of-pocket cost share for your covered prescriptions applies to your deductible until your deductible is met. Your cost share details are listed on your Summary of Benefits and Coverage for each of the tiers within this formulary. Your cost share may be a copayment (an amount you pay out-of-pocket for your prescription medicines after you ve met any deductible) or coinsurance (a percentage of the total cost that you pay for your medicines, after you've met any deductible). Your drug list (or formulary) has the following tiers: (Preventive Drugs Not Subject to Deductible) Tier (Preferred Generics) Tier (Non-Preferred Generics) Tier (Preferred Brand) Tier (Non-Preferred Brand) Tier (Specialty) Tier (Non-Preferred Specialty) Your cost share for a medicine is based on the tier in which the medicine is assigned within the drug list. Network discounts are applied to medicines dispensed at a network pharmacy, but are not available for medicines dispensed at a non-network pharmacy. You may be able to save time and money using the pharmacy mail home delivery option if you take maintenance medicine for a condition like high blood pressure, asthma or diabetes, and BCBSTX Health Insurance Marketplace Tier Drug List February 08 V

7 take your drugs for long periods of time. With home delivery pharmacy, you may get up to a three-month supply of medicines delivered to your home and, in some cases, you may pay a lower cost share. Medical Management Requirements: Medical or utilization management is a process that is part of your health plan. Utilization management helps to make sure that you are getting the right drugs -- all while helping to make medicine more affordable. Health plans call for utilization management on some medicines to keep you safe, by helping to make sure the medicines you take are prescribed by your doctor and used correctly. Health plan companies, hospitals, doctors and pharmacists work together and share information to help improve medicine for members. These programs help to catch mistakes, reduce waste, improve safety and keep medicine affordable by lowering costs. This formulary indicates when one of these programs applies to a drug. Medical or utilization management is made up of programs that include: : Prior authorization (sometimes called pre-approval) means that your medicine needs to be approved by your health plan before it will be covered. Prior authorization helps improve safety. Some drugs can be misused or overused, or may not be the best choice for your health condition. : This program uses a "step" approach with drugs for certain conditions. This means that you may have to first try a safe, lower-cost drug, or one that may be more clinically effective, before "stepping up" to a different drug. helps lower costs through safe, less expensive drugs. : This program controls how often or the amount you can get filled at once. These limits promote safe, cost-effective drug use. They also help reduce waste and overuse. helps to lower waste. : For some medications, you may need to use specified pharmacies to fill your prescription because the drug is only made available by the manufacturer to very limited pharmacies or because your plan requires use of specified pharmacies for these medicines. Some of these medicines may be specialty medicines that are filled at a Specialty Pharmacy which specializes in particular classes of medication and health conditions. Medicines requiring a health care provider to administer them and administered in a hospital, doctor s office, or other medical setting are covered by your medical benefits. Information on those medications may be found here: BCBSTX Health Insurance Marketplace Tier Drug List February 08 VI

8 Introduction Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician. Drug lists updates This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to SM Blue ccess for Members 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 dministration (FD). Both drugs that are newly approved by the FD 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 six member payment tiers: Preferred Generic (Tier ), Non-preferred Generic (Tier ), Preferred Brand (Tier ), Non-preferred Brand (Tier ), Specialty (Tier ) and Non-Preferred Specialty (Tier ). Some brands may be placed in generic tiers and some generics may be placed in brand tiers. Please refer to the Preventive () section for drugs marked with an "" in the drug tier column. To verify your payment amount for a drug, visit bcbstx.com and log in to Blue ccess for Members or call the number on the back of your ID card. Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FD-approved for selfadministration may be available through your medical benefit. BCBSTX Health Insurance Marketplace Tier Drug List February 08 VII

9 How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Example: atorvastatin (Lipitor brand is not covered) Brand prescription drugs are shown in capital letters followed by the generic name. Example: NOVOLOG - Insulin aspart inj 00 unit/ml 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 FD-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 FD just as brand drugs are, and must meet the same standards. There are two types of generic drugs: generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. generic equivalent is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. ccording to the FD, compared to its brand counterpart, an FD-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 FD 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 applicable 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. BCBSTX Health Insurance Marketplace Tier Drug List February 08 VIII

10 Coverage considerations Most prescription drug benefit plans provide coverage for up to a 0-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan materials for details about your particular benefits. Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount. Repackaged medications: Repackaged versions of medications already available on the market are not covered. (P): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the preferred medications listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. (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. (DL): Drug Dispensing limits are designed to help encourage medication use as intended by the FD. Coverage limits are placed on medications in certain drug categories. For the preferred medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription and quantity of covered medication in a given time period. 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. (LD): Medicines marked as "" have restrictions on where you may obtain a medication. This may include requiring the use of a designated pharmacy to fill a prescription. BCBSTX Health Insurance Marketplace Tier Drug List February 08 IX

11 Preventive (): Medicines marked in the column are under the ffordable Care ct coverage of preventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), when meeting the conditions as outlined under the regulation. These are also indicated with an "" in the drug tier column. To see what contraceptive products may be covered, visit 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. BCBSTX Health Insurance Marketplace Tier Drug List February 08 X

12 Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. Medications administered by a health care professional are not covered under the pharmacy benefit. For a current list of specialty medications, visit myprime.com or bcbstx.com and log in to Blue ccess for Members. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. 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. lliancerx Walgreens Prime Through lliancerx Walgreens Prime, members can have covered specialty medications delivered directly to them or their doctor s office. When you receive specialty medications through lliancerx Walgreens 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 /7/ phone access to a pharmacist for urgent medication issues To order through lliancerx Walgreens Prime: Have your doctor call or fax your prescription to lliancerx Walgreens Prime. Your doctor can call or fax to If you have an existing prescription for a covered specialty medication, you can call to transfer your prescription. 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 lliancerx Walgreens Prime at , visit or call the number on the back of your ID card. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ( HCSC ). HCSC is an independent licensee of the Blue Cross Blue Shield ssociation. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC. BCBSTX Health Insurance Marketplace Tier Drug List February 08 XI

13 bbreviation 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... opthalmic osm... osmotic release powd... powder sa... sustained action sl... sublinqual soln... solution sr... sustained release suppos... suppositories susp... suspension tab... tablets td... transdermal You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List (also known as a formulary). To request this exception, you, or your prescriber, can call the number on the back of your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be able to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage decision within hours after they receive your request for an expedited review. If the coverage request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). Call the number on the back of your ID card if you have any questions. BCBSTX Health Insurance Marketplace Tier Drug List February 08 XII

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15 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator 00 E. Randolph St. th Floor Chicago, Illinois 00 Phone: TTY/TDD: Fax: (voic ) CivilRightsCoordinator@hcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services 00 Independence venue SW Room 09F, HHH Building 09 Washington, DC 00 Phone: TTY/TDD: Complaint Portal: Complaint Forms: bcbstx.com XIV

16 MOXICILLIN/CLVULNTE P - amoxicillin & k clavulanate chew tab 00-7 MPICILLIN - ampicillin cap 00 UGMENTIN - amoxicillin & k clavulanate for susp -. /ml dicloxacillin sodium cap 0 dicloxacillin sodium cap 00 PENICILLIN V POTSSIUM penicillin v potassium for soln /ml PENICILLIN V POTSSIUM penicillin v potassium for soln 0 /ml penicillin v potassium tab 0 amoxicillin (trihydrate) tab 00 amoxicillin (trihydrate) tab 87 amoxicillin & k clavulanate for susp /ml amoxicillin & k clavulanate for susp 0-. /ml (ugmentin) amoxicillin & k clavulanate for susp 00-7 /ml amoxicillin & k clavulanate for susp /ml (ugmentin es-00) amoxicillin & k clavulanate tab er hr (ugmentin xr) amoxicillin & k clavulanate tab 0- penicillin v potassium tab 00 CEPHLOSPORINS CEDX - ceftibuten cap 00 cefaclor cap 0 cefaclor cap 00 amoxicillin (trihydrate) cap 0 amoxicillin (trihydrate) for susp 00 /ml MOXICILLIN/CLVULNTE P - amoxicillin & k clavulanate chew tab amoxicillin (trihydrate) for susp 0 /ml MOXICILLIN - amoxicillin (trihydrate) chew tab 0 amoxicillin (trihydrate) for susp 00 /ml amoxicillin & k clavulanate tab 87- (ugmentin) amoxicillin (trihydrate) for susp /ml MOXICILLIN - amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) cap 00 amoxicillin & k clavulanate tab 00- (ugmentin) NTI-INFECTIVE GENTS PENICILLINS 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08

17 cefadroxil cap 00 cefadroxil for susp 0 /ml cefadroxil for susp 00 /ml cefadroxil tab gm cefdinir cap 00 cefdinir for susp /ml cefdinir for susp 0 /ml cefprozil for susp 0 /ml cefprozil tab 0 cefprozil tab 00 cephalexin cap 70 (Keflex) cephalexin for susp /ml cephalexin for susp 0 /ml MCROLIDES azithromycin for susp 00 /ml (Zithromax) azithromycin tab 00 (Zithromax) azithromycin tab 00 (Zithromax) CLRITHROMYCIN clarithromycin for susp /ml CLRITHROMYCIN clarithromycin for susp 0 /ml clarithromycin tab er hr 00 CEFTIN - cefuroxime axetil for susp 0 /ml clarithromycin tab 0 (Biaxin) azithromycin tab 0 (Zithromax) CEFTIN - cefuroxime axetil for susp /ml ZITHROMYCIN azithromycin powd pack for susp gm azithromycin for susp 00 /ml (Zithromax) cephalexin cap 00 (Keflex) cefprozil for susp /ml cephalexin cap 0 (Keflex) cefixime for susp 00 /ml (Suprax) cefpodoxime proxetil tab 00 cefuroxime axetil tab 00 (Ceftin) cefpodoxime proxetil tab 00 CEFDITOREN PIVOXIL cefditoren pivoxil tab 00 (base equivalent) cefpodoxime proxetil for susp 00 /ml cefpodoxime proxetil for susp 0 /ml cefuroxime axetil tab 0 (Ceftin) CEFDITOREN PIVOXIL cefditoren pivoxil tab 00 (base equivalent) cefixime for susp 00 /ml (Suprax) 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08

18 clarithromycin tab 00 (Biaxin) PCE - erythromycin w/ enteric coated particles tab DIFICID - fidaxomicin tab 00 PCE - erythromycin w/ enteric coated particles tab 00 E.E.S. GRNULES erythromycin ethylsuccinate for susp 00 /ml ZITHROMX - azithromycin powd pack for susp gm ZMX - azithromycin extended release for oral susp gm E.E.S erythromycin ethylsuccinate tab 00 ERY-TB - erythromycin tab delayed release 0 ERY-TB - erythromycin tab delayed release ERY-TB - erythromycin tab delayed release 00 ERYPED 00 - erythromycin ethylsuccinate for susp 00 /ml ERYPED 00 - erythromycin ethylsuccinate for susp 00 /ml ERYTHROCIN STERTE erythromycin stearate tab 0 ERYTHROMYCIN BSE erythromycin tab 0 doxycycline monohydrate cap 7 (Monodox) ERYTHROMYCIN BSE erythromycin tab 00 doxycycline monohydrate cap 00 (Monodox) ERYTHROMYCIN ETHYLSUCCIN erythromycin ethylsuccinate tab 00 doxycycline monohydrate cap 0 (doxa) erythromycin ethylsuccinate for susp 00 /ml (E.e.s. granules) erythromycin w/ delayed release particles cap 0 TETRCYCLINES demeclocycline hcl tab 0 demeclocycline hcl tab 00 doxycycline hyclate cap 0 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab 0 doxycycline hyclate tab 00 doxycycline monohydrate cap 0 doxycycline monohydrate for susp /ml (Vibramycin) doxycycline monohydrate tab 0 (doxa) doxycycline monohydrate tab 7 (doxa) 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08

19 doxycycline monohydrate tab 00 (doxa pak /00) doxycycline monohydrate tab 0 (doxa pak /0) minocycline hcl cap 0 (Minocin) minocycline hcl cap 7 (Minocin) minocycline hcl cap 00 (Minocin) minocycline hcl tab 0 minocycline hcl tab 7 minocycline hcl tab 00 tetracycline hcl cap 0 (Tetracycline hcl) tetracycline hcl cap 00 (Tetracycline hcl) FLUOROQUINOLONES ciprofloxacin for oral susp 0 /ml (%) ( gm/00ml) (Cipro) ciprofloxacin for oral susp 00 /ml (0%) (0 gm/00ml) (Cipro) ciprofloxacin hcl tab 0 (base equiv) (Cipro) ciprofloxacin hcl tab 70 (base equiv) ciprofloxacin-ciprofloxacin hcl tab er hr 00 (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er hr 000 (base eq) (Cipro xr) FCTIVE - gemifloxacin mesylate tab 0 (base equiv) LEVOFLOXCIN - levofloxacin oral soln /ml levofloxacin tab 0 (Levaquin) levofloxacin tab 00 (Levaquin) levofloxacin tab 70 (Levaquin) moxifloxacin hcl tab 00 (base equiv) (velox) OFLOXCIN - ofloxacin tab 00 ofloxacin tab 00 MINOGLYCOSIDES CIPROFLOXCIN HCL ciprofloxacin hcl tab 00 (base equiv) ciprofloxacin hcl tab 00 (base equiv) (Cipro) 08 BETHKIS - tobramycin nebu soln 00 /ml KITBIS PK - tobramycin nebu soln 00 /ml neomycin sulfate tab 00 paromomycin sulfate cap 0 TOBI PODHLER - tobramycin inhal cap 8 TOBRMYCIN - tobramycin nebu soln 00 /ml tobramycin nebu soln 00 /ml (Tobi) SULFONMIDES SULFDIZINE - sulfadiazine tab 00 NTIMYCOBCTERIL GENTS BCBSTX Health Insurance Marketplace Tier Drug List February 08

20 CYCLOSERINE - cycloserine cap 0 fluconazole tab 0 (Diflucan) ethambutol hcl tab 00 (Myambutol) fluconazole tab 00 (Diflucan) ethambutol hcl tab 00 (Myambutol) fluconazole tab 0 (Diflucan) ISONIZID - isoniazid syrup 0 /ml fluconazole tab 00 (Diflucan) isoniazid tab 00 flucytosine cap 0 (ncobon) isoniazid tab 00 PSER - aminosalicylic acid er granules packet gm flucytosine cap 00 (ncobon) PRIFTIN - rifapentine tab 0 griseofulvin microsize susp /ml pyrazinamide tab 00 griseofulvin microsize tab 00 (Grifulvin v) rifabutin cap 0 (Mycobutin) RIFMTE - isoniazid & rifampin cap 0-00 griseofulvin ultramicrosize tab (Gris-peg) griseofulvin ultramicrosize tab 0 (Gris-peg) rifampin cap 0 (Rifadin) rifampin cap 00 (Rifadin) RIFTER - isoniazid-rifampin w/ pyrazinamide tab SIRTURO - bedaquiline fumarate tab 00 (base equiv) TRECTOR - ethionamide tab 0 NTIFUNGLS itraconazole cap 00 (Sporanox) NOXFIL - posaconazole susp 0 /ml NOXFIL - posaconazole tab delayed release 00 nystatin tab unit SPORNOX - itraconazole oral soln 0 /ml terbinafine hcl tab 0 (Lamisil) voriconazole for susp 0 /ml (Vfend) CRESEMB isavuconazonium sulfate cap 8 fluconazole for susp 0 / ml (Diflucan) voriconazole tab 0 (Vfend) voriconazole tab 00 (Vfend) fluconazole for susp 0 / ml (Diflucan) 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08

21 NTIVIRLS abacavir sulfate soln 0 / ml (base equiv) (Ziagen) abacavir sulfate tab 00 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab (Epzicom) abacavir sulfatelamivudine-zidovudine tab (Trizivir) DESCOVY - emtricitabinetenofovir alafenamide fumarate tab 00- didanosine delayed release capsule 00 (Videx ec) didanosine delayed release capsule 0 (Videx ec) didanosine delayed release capsule 00 (Videx ec) acyclovir cap 00 (Zovirax) EDURNT - rilpivirine hcl tab (base equivalent) acyclovir susp 00 /ml (Zovirax) EMTRIV - emtricitabine caps 00 acyclovir tab 00 (Zovirax) EMTRIV - emtricitabine soln 0 /ml acyclovir tab 800 (Zovirax) entecavir tab 0. (Baraclude) adefovir dipivoxil tab 0 (Hepsera) entecavir tab (Baraclude) PTIVUS - tipranavir cap 0 EPCLUS - sofosbuvirvelpatasvir tab PTIVUS - tipranavir oral soln 00 /ml EPIVIR HBV - lamivudine oral soln /ml (hbv) TRIPL - efavirenzemtricitabine-tenofovir df tab EPZICOM - abacavir sulfatelamivudine tab BRCLUDE - entecavir oral soln 0.0 /ml EVOTZ - atazanavir sulfatecobicistat tab 00-0 (base equiv) COMPLER - emtricitabinerilpivirine-tenofovir df tab famciclovir tab (Famvir) CRIXIVN - indinavir sulfate cap 00 famciclovir tab 0 (Famvir) CRIXIVN - indinavir sulfate cap 00 famciclovir tab 00 (Famvir) fosamprenavir calcium tab 700 (base equiv) (Lexiva) 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08

22 INTELENCE - etravirine tab lamivudine tab 00 (hbv) (Epivir hbv) lamivudine tab 0 (Epivir) lamivudine tab 00 (Epivir) lamivudine-zidovudine tab 0-00 (Combivir) INTELENCE - etravirine tab 00 INVIRSE - saquinavir mesylate cap 00 LEXIV - fosamprenavir calcium susp 0 /ml (base equiv) INTELENCE - etravirine tab 00 INVIRSE - saquinavir mesylate tab 00 LEXIV - fosamprenavir calcium tab 700 (base equiv) ISENTRESS - raltegravir potassium chew tab (base equiv) lopinavir-ritonavir soln /ml (80-0 / ml) (Kaletra) ISENTRESS - raltegravir potassium chew tab 00 (base equiv) ISENTRESS - raltegravir potassium packet for susp 00 (base equiv) ISENTRESS - raltegravir potassium tab 00 (base equiv) ISENTRESS HD - raltegravir potassium tab 00 (base equiv) KLETR - lopinavir-ritonavir soln /ml (80-0 /ml) KLETR - lopinavir-ritonavir tab 00- KLETR - lopinavir-ritonavir tab 00-0 HRVONI - ledipasvirsofosbuvir tab lamivudine oral soln 0 / ml (Epivir) GENVOY - elvitegrav-cobicemtricitab-tenofov af tab FUZEON - enfuvirtide for inj MVYRET - glecaprevirpibrentasvir tab 00-0 MODERIB - ribavirin tab 00 & ribavirin 00 tab therapy pack MODERIB - ribavirin tab 00 & ribavirin 00 tab therapy pack MODERIB 00 DOSE PCK - ribavirin tab 00 MODERIB 800 DOSE PCK - ribavirin tab 00 nevirapine tab er hr 00 (Viramune xr) nevirapine tab er hr 00 (Viramune xr) nevirapine tab 00 (Viramune) NORVIR - ritonavir cap 00 BCBSTX Health Insurance Marketplace Tier Drug List February 08 7

23 PEGINTRON - peginterferon alfa-b for inj kit 0 mcg/0.ml OLYSIO - simeprevir sodium cap 0 (base equivalent) PREZCOBIX - darunavircobicistat tab PREZIST - darunavir ethanolate susp 00 /ml (base equiv) oseltamivir phosphate cap 0 (base equiv) (Tamiflu) PREZIST - darunavir ethanolate tab 7 (base equiv) oseltamivir phosphate cap (base equiv) (Tamiflu) PREZIST - darunavir ethanolate tab 0 (base equiv) oseltamivir phosphate cap 7 (base equiv) (Tamiflu) PREZIST - darunavir ethanolate tab 00 (base equiv) oseltamivir phosphate for susp /ml (base equiv) (Tamiflu) PREZIST - darunavir ethanolate tab 800 (base equiv) PEGSYS - peginterferon alfa-a inj 80 mcg/ml PEGSYS - peginterferon alfa-a inj 80 mcg/0.ml REBETOL - ribavirin soln 0 /ml PEGSYS PROCLICK peginterferon alfa-a inj mcg/0.ml RELENZ DISKHLER zanamivir aero powder breath activated /blister PEGSYS PROCLICK peginterferon alfa-a inj 80 mcg/0.ml RESCRIPTOR - delavirdine mesylate tab 00 PEGINTRON - peginterferon alfa-b for inj kit 0 mcg/0.ml RESCRIPTOR - delavirdine mesylate tab 00 REYTZ - atazanavir sulfate cap 0 (base equiv) PEGINTRON - peginterferon alfa-b for inj kit 80 mcg/0.ml REYTZ - atazanavir sulfate cap 00 (base equiv) REYTZ - atazanavir sulfate cap 00 (base equiv) PEGINTRON - peginterferon alfa-b for inj kit 0 mcg/0.ml ODEFSEY - emtricitabinerilpivirine-tenofovir af tab 00-- NORVIR - ritonavir tab 00 NORVIR - ritonavir oral soln 80 /ml 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08 8

24 stavudine cap (Zerit) RIBSPHERE - ribavirin tab 00 RIBSPHERE - ribavirin tab 00 stavudine cap 0 (Zerit) RIBSPHERE RIBPK ribavirin tab 00 & ribavirin 00 tab therapy pack STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab RIBSPHERE RIBPK ribavirin tab 00 & ribavirin 00 tab therapy pack SUSTIV - efavirenz cap 0 SUSTIV - efavirenz cap 00 SUSTIV - efavirenz tab 00 RIBSPHERE RIBPK ribavirin tab 00 ribavirin cap 00 (Rebetol) TMIFLU - oseltamivir phosphate cap 0 (base equiv) RIBSPHERE RIBPK ribavirin tab 00 ribavirin for inhal soln gm (Virazole) TMIFLU - oseltamivir phosphate cap (base equiv) ribavirin tab 00 (Copegus) TMIFLU - oseltamivir phosphate cap 7 (base equiv) rimantadine hydrochloride tab 00 (Flumadine) TMIFLU - oseltamivir phosphate for susp /ml (base equiv) stavudine cap 0 (Zerit) stavudine cap 0 (Zerit) SELZENTRY - maraviroc oral soln 0 /ml SELZENTRY - maraviroc tab TECHNIVIE - ombitasvirparitaprevir-ritonavir tab.-7-0 SELZENTRY - maraviroc tab 7 TIVICY - dolutegravir sodium tab 0 (base equiv) SELZENTRY - maraviroc tab 0 TIVICY - dolutegravir sodium tab (base equiv) SELZENTRY - maraviroc tab 00 TIVICY - dolutegravir sodium tab 0 (base equiv) REYTZ - atazanavir sulfate oral powder packet 0 (base equiv) SOVLDI - sofosbuvir tab BCBSTX Health Insurance Marketplace Tier Drug List February 08 9

25 08 VIRCEPT - nelfinavir mesylate tab VIRMUNE - nevirapine susp 0 /ml VIRZOLE - ribavirin for inhal soln gm VIRED - tenofovir disoproxil fumarate oral powder 0 / gm VIRED - tenofovir disoproxil fumarate tab 0 VIRED - tenofovir disoproxil fumarate tab 00 VIRED - tenofovir disoproxil fumarate tab 0 VIRED - tenofovir disoproxil fumarate tab 00 VOSEVI - sofosbuvirvelpatasvir-voxilaprevir tab ZEPTIER - elbasvirgrazoprevir tab 0-00 ZERIT - stavudine for oral soln /ml ZIGEN - abacavir sulfate soln 0 /ml (base equiv) zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 00 TRIUMEQ - abacavirdolutegravir-lamivudine tab TRUVD - emtricitabinetenofovir disoproxil fumarate tab 00-0 TRUVD - emtricitabinetenofovir disoproxil fumarate tab -00 TRUVD - emtricitabinetenofovir disoproxil fumarate tab 7-0 TRUVD - emtricitabinetenofovir disoproxil fumarate tab TYBOST - cobicistat tab 0 valacyclovir hcl tab 00 (Valtrex) valacyclovir hcl tab gm (Valtrex) valganciclovir hcl for soln 0 /ml (base equiv) (Valcyte) valganciclovir hcl tab 0 (base equivalent) (Valcyte) VIDEX - didanosine for soln gm VIDEX - didanosine for soln gm VIEKIR PK - ombitasparitapre-riton & dasab tab pak.-7-0 & 0 VIEKIR XR - dasab-ombitparitap-riton tab er hr VIRCEPT - nelfinavir mesylate tab 0 NTIMLRILS atovaquone-proguanil hcl tab.- (Malarone) atovaquone-proguanil hcl tab 0-00 (Malarone) BCBSTX Health Insurance Marketplace Tier Drug List February 08 0

26 CHLOROQUINE PHOSPHTE - chloroquine phosphate tab 0 chloroquine phosphate tab 00 (ralen) clindamycin hcl cap 0 (Cleocin) clindamycin hcl cap 00 (Cleocin) DRPRIM - pyrimethamine tab clindamycin palmitate hcl for soln 7 /ml (base equiv) (Cleocin pediatric gr) CORTEM - artemetherlumefantrine tab 0-0 hydroxychloroquine sulfate tab 00 (Plaquenil) MEFLOQUINE HCL mefloquine hcl tab 0 PRIMQUINE PHOSPHTE primaquine phosphate tab. ( base) quinine sulfate cap (Qualaquin) NTHELMINTICS LBENZ - albendazole tab 00 BILTRICIDE - praziquantel tab 00 ivermectin tab (Stromectol) NTI-INFECTIVE GENTS - MISC. LINI - nitazoxanide for susp 00 /ml LINI - nitazoxanide tab 00 atovaquone susp 70 /ml (Mepron) CYSTON - aztreonam lysine for inhal soln 7 (base equivalent) clindamycin hcl cap 7 (Cleocin) dapsone tab dapsone tab 00 linezolid for susp 00 /ml (Zyvox) metronidazole cap 7 (Flagyl) metronidazole tab 0 (Flagyl) metronidazole tab 00 (Flagyl) NEBUPENT - pentamidine isethionate for nebulization soln 00 PRIMSOL - trimethoprim hcl oral soln 0 /ml (base equiv) SIVEXTRO - tedizolid phosphate tab 00 sulfamethoxazoletrimethoprim susp 00-0 /ml sulfamethoxazoletrimethoprim tab (Bactrim ds) sulfamethoxazoletrimethoprim tab (Bactrim) IMPVIDO - miltefosine cap 0 linezolid tab 00 (Zyvox) 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08

27 tinidazole tab 0 (Tindamax) tinidazole tab 00 (Tindamax) trimethoprim tab 00 vancomycin hcl cap (Vancocin hcl) vancomycin hcl cap 0 (Vancocin hcl) XIFXN - rifaximin tab 00 XIFXN - rifaximin tab 0 BIOLOGICLS VCCINES ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/0.ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/ml FLUD influenza vac type a&b surface ant adj susp pref syr 0. ml FLURIX QUDRIVLENT 07 - influenza virus vac split quadrivalent susp pref syr 0.ml FLUBLOK QUDRIVLENT 07 - influenza vac recomb ha quad pf soln pref syr 0. ml CTHIB - haemophilus b polysaccharide conjugate vaccine for inj FLURI PF influenza virus vaccine split pf susp pref syringe 0. ml FLURI QUDRIVLENT 07 - influenza virus vac split quadrivalent susp pref syr 0.ml FLUBLOK 0-0 influenza virus vac recombinant hemagglutinin (ha) pf inj FLURI QUDRIVLENT 07 - influenza virus vaccine split quadrivalent im inj FLUBLOK influenza virus vac recombinant hemagglutinin (ha) pf inj FLURI influenza virus vaccine split im susp FLUCELVX QUDRIVLENT 0 - influenza vac tiss-cult subunt quad susp pref syr 0. ml BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled syringe FLUCELVX QUDRIVLENT 0 - influenza vac tissuecultured subunit quadrivalent im susp ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/0.ml FLULVL QUDRIVLENT 0 - influenza virus vac split quadrivalent susp pref syr 0.ml 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08

28 FLUVIRIN 0-0 influenza virus vaccine types a & b surface antigen im susp FLUVIRIN influenza vac type a&b surface antigen susp pref syr 0. ml FLUVIRIN influenza virus vaccine types a & b surface antigen im susp FLUZONE HIGH-DOSE PF 07 - influenza virus vac split high-dose pf susp pref syr 0.ml FLUZONE INTRDERML QUDR - influenza virus vac split quad intradermal pen 9 mcg/strain FLUZONE QUDRIVLENT 07 - influenza virus vac split quadrivalent susp pref syr 0. ml FLUZONE QUDRIVLENT 07 - influenza virus vac split quadrivalent susp pref syr 0.ml FLUZONE QUDRIVLENT 07 - influenza virus vaccine split quadrivalent im inj FLUZONE QUDRIVLENT 07 - influenza virus vaccine split quadrivalent inj 0. ml GRDSIL 9 - human papillomavirus (hpv) 9-valent recomb vac im susp GRDSIL 9 - human papillomavirus (hpv) 9-valent recomb vac susp pref syr HVRIX - hepatitis a vaccine inj susp 70 el unit/0.ml HVRIX - hepatitis a vaccine inj susp 0 el unit/ml HIBERIX - haemophilus b polysaccharide conjugate vac for inj 0 mcg IPOL INCTIVTED IPV poliovirus vaccine, ipv injection M-M-R II - measles, mumps & rubella virus vaccines for inj MENCTR - meningococcal (a, c, y, and w-) conjugate vaccine inj MENVEO - meningococcal (a, c, y, and w-) oligo conj vac for inj PEDVX HIB - haemophilus b polysaccharide conj vac im susp 7. mcg/0. ml PNEUMOVX pneumococcal vaccine polyvalent inj mcg/0.ml PNEUMOVX / DOSE pneumococcal vaccine polyvalent inj mcg/0.ml FLUVIRIN 0-0 influenza vac type a&b surface antigen susp pref syr 0. ml FLULVL QUDRIVLENT 0 - influenza virus vaccine split quadrivalent im inj 08 BCBSTX Health Insurance Marketplace Tier Drug List February 08