Drug - Brand Name (Generic Name) bacitracin / polymyxin B topical ointment * Bactrim # (sulfamethoxazole / trimethoprim tablet)
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1 bacitracin / polymyxin B ophthalmic ointment bacitracin / polymyxin B topical ointment * bacitracin * bacitracin ophthalmic ointment baclofen injection baclofen intrathecal injection baclofen powder - PA baclofen tablet Bactrim # (sulfamethoxazole / trimethoprim tablet) Bactroban (mupirocin cream) - PA Bactroban (mupirocin nasal ointment) - PA Balcoltra (levonorgestrel / ethinyl estradiol / ferrous bisglycinate) BAL in Oil (dimercaprol) ^ balsalazide balsalazide 1.1 gram tablet - PA Banzel (rufinamide) - PA; See Table 20; See Table 71 Baraclude (entecavir solution) - PA > 600 ml/month Baraclude # (entecavir tablet) - PA > 30 units/month Basaglar (insulin glargine 100 units/ml prefilled syringe-basaglar) - PA basiliximab Bavencio (avelumab) - PA Baxdela (delafloxacin injection) - PA Baxdela (delafloxacin tablet) - PA BCG live, intravesical BCG live vaccine BCG Vaccine (BCG live vaccine) Bebulin VH Immuno (factor ix complex human-bebulin) becaplermin - PA beclomethasone MDI, breath-actuated - PA beclomethasone MDI, non-breath actuated beclomethasone nasal aerosol - PA beclomethasone nasal spray - PA Beconase AQ (beclomethasone nasal spray) - PA bedaquiline - PA belatacept - PA MUSCLE RELAXANT MUSCLE RELAXANT MUSCLE RELAXANT MUSCLE RELAXANT CONTRACEPTIVES ANTIDOTES GI ANTI-INFLAMMATORY GI ANTI-INFLAMMATORY ANTICONVULSANTS ANTIVIRALS ANTIVIRALS DIABETIC AGENTS ANTI-HEMOPHILIA AGENTS NASAL PREPARATIONS NASAL PREPARATIONS NASAL PREPARATIONS TB PREPARATIONS IMMUNOMODULATOR
2 Belbuca (buprenorphine buccal film) - PA Beleodaq (belinostat) - PA belimumab - PA belinostat - PA Belsomra (suvorexant) - PA; See Table 15; See Table 71 Benadryl # (diphenhydramine) * benazepril benazepril / hydrochlorothiazide bendamustine Bendeka (bendamustine) Benefix (factor IX human recombinant-benefix) Benicar (olmesartan) - PA Benicar HCT (olmesartan / hydrochlorothiazide) - PA Benlysta (belimumab) - PA benralizumab - PA Bentyl # (dicyclomine) Benzaclin (clindamycin / benzoyl peroxide-benzaclin) - PA Benzamycin (benzoyl peroxide / erythromycin) - PA Benzepro (benzoyl peroxide 7% microspheres) - PA Benzepro (benzoyl peroxide foaming cloth) - PA benznidazole benzoyl peroxide / erythromycin - PA benzoyl peroxide * - PA 22 years benzoyl peroxide 7% microspheres - PA benzoyl peroxide 9.8% foam - PA benzoyl peroxide foaming cloth - PA benztropine bepotastine - PA Bepreve (bepotastine) - PA Berinert (c1 esterase inhibitor, human-berinert) - PA besifloxacin ophthalmic suspension - PA Besivance (besifloxacin ophthalmic suspension) - PA Besponsa (inotuzumab ozogamicin) - PA SEDATIVE, NON-BARBITURATE ANTIHISTAMINES ANTI-HEMOPHILIA AGENTS ANTISPASMODICS,ANTICHOLINERGIC ANTIPARASITICS S, ALL OTHER ANTIPARKINSON ANTIHISTAMINES ANTIHISTAMINES ENZYMES 2
3 Betagan # (levobunolol) betaine betamethasone / calcipotriene foam - PA betamethasone / calcipotriene ointment, scalp suspension - PA betamethasone augmented gel betamethasone dipropionate, augmented cream betamethasone dipropionate, augmented lotion betamethasone dipropionate, augmented ointment betamethasone dipropionate cream betamethasone dipropionate lotion, ointment betamethasone dipropionate spray - PA betamethasone injection betamethasone valerate cream betamethasone valerate foam - PA betamethasone valerate lotion betamethasone valerate ointment Betapace # (sotalol tablet) Betaseron (interferon beta-1b-betaseron) betaxolol 0.25% betaxolol 0.5% betaxolol tablet bethanechol Bethkis (tobramycin inhalation solution-bethkis) - PA Betoptic S (betaxolol 0.25%) bevacizumab - PA Bevespi (glycopyrrolate / formoterol) - PA bexarotene Bexsero (meningococcal group B vaccine-bexsero) 1 Beyaz # (ethinyl estradiol / drospirenone / levomefolate-beyaz) bezlotoxumab - PA Biaxin # (clarithromycin) bicalutamide Bicillin CR (penicillin G benzathine / penicillin G procaine) ELECTROLYTES AND NUTRIENTS MULTIPLE SCLEROSIS AGENTS PARASYMPATHETIC AGENTS CONTRACEPTIVES 3
4 Bicillin LA (penicillin G 0.6 million, 1.2 million, 2.4 million units) Bicnu (carmustine) bictegravir / emtricitabine / tenofovir alafenamide PD Bidil (isosorbide dinitrate / hydralazine) - PA bifidobacterium infantis - PA 19 years Biktarvy (bictegravir / emtricitabine / tenofovir alafenamide) PD Biltricide (praziquantel) BP bimatoprost 0.01% ophthalmic solution - PA bimatoprost 0.03% ophthalmic solution - PA Binosto (alendronate effervescent tablet) - PA bisacodyl * bismuth subcitrate / metronidazole / tetracycline - PA bismuth subsalicylate * bisoprolol bisoprolol / hydrochlorothiazide Bivigam (immune globulin IV, human-bivigam) - PA bleomycin Bleph-10 # (sulfacetamide ophthalmic ointment, solution) Blephamide (sulfacetamide / prednisolone sodium acetate ophthalmic ointment, suspension) - PA blinatumomab - PA Blincyto (blinatumomab) - PA Boniva (ibandronate IV) - PA Boniva (ibandronate tablet) - PA Bonjesta (doxylamine / pyridoxine extended-release) - PA Boostrix (diphtheria / tetanus toxoids / acellular pertussis vaccine) 1 bortezomib bosentan - PA Bosulif (bosutinib) - PA bosutinib - PA Botox (onabotulinumtoxin A) - PA brentuximab - PA Breo (fluticasone / vilanterol) - PA Brevibloc # (esmolol) ANTIVIRALS GASTROINTESTINAL AGENT ANTIVIRALS ANTIPARASITICS ELECTROLYTES AND NUTRIENTS CONSTIPATION AGENTS H. PYLORI AGENTS ANTIDIARRHEALS ELECTROLYTES AND NUTRIENTS ELECTROLYTES AND NUTRIENTS ANTIEMETICS 4
5 Brevicon # (ethinyl estradiol / norethindrone-brevicon) brexpiprazole - PA; See Table 24; See Table 71 brigatinib - PA Brilinta (ticagrelor) - PA brimonidine / timolol, ophthalmic brimonidine 0.1%, 0.15% eye drops brimonidine 0.2% eye drops brimonidine topical gel, 0.33% - PA brinzolamide / brimonidine tartrate ophthalmic suspension - PA brinzolamide - PA Brisdelle (paroxetine 7.5 mg capsule) - PA brivaracetam solution, tablet - PA; See Table 20; See Table 71 Briviact (brivaracetam solution, tablet) - PA; See Table 20; See Table 71 brodalumab - PA bromfenac 0.07% - PA bromfenac 0.075% - PA bromfenac 0.09% - PA bromocriptine 0.8 mg tablet - PA bromocriptine 2.5 mg, 5 mg Bromsite (bromfenac 0.075%) - PA Brovana (arformoterol) - PA budesonide / formoterol - PA budesonide-entocort budesonide extended-release tablet BP - PA budesonide inhalation powder budesonide inhalation suspension BP budesonide OTC nasal spray - PA > 1 inhaler/month budesonide rectal foam - PA bumetanide Bunavail (buprenorphine / naloxone buccal film) - PA Buphenyl (sodium phenylbutyrate tablet) BP Buphenyl # (sodium phenylbutyrate powder) bupivacaine CONTRACEPTIVES ANTIPSYCHOTIC ANTIPLATELET AGENT UNCLASSIFIED DRUG PRODUCTS ANTICONVULSANTS ANTICONVULSANTS IMMUNOMODULATOR DIABETIC AGENTS ANTIPARKINSON NASAL PREPARATIONS ENZYMES ENZYMES ANESTHETICS 5
6 Buprenex (buprenorphine injection) - PA buprenorphine / naloxone buccal film - PA buprenorphine / naloxone film 16 mg/day BP PD buprenorphine / naloxone film BP PD - PA > 180 days (> 16 mg/day and 24 mg/day) buprenorphine / naloxone film BP PD - PA > 32 mg/day buprenorphine / naloxone film BP PD - PA > 90 days (> 24 mg/day and 32 mg/day) buprenorphine / naloxone tablet - PA buprenorphine / naloxone tablet-zubsolv - PA buprenorphine buccal film - PA buprenorphine extended-release injection - PA buprenorphine implant - PA buprenorphine injection - PA buprenorphine tablet - PA buprenorphine transdermal BP - PA > 20 mcg/hr and PA > 4 patches/28 days bupropion hydrobromide extended-release - PA; See Table 17; See Table 71 bupropion hydrochloride extended-release 150 mg, 300 mg tablets - PA < 6 years and PA > 30 units/month; See Table 17; See Table 71 bupropion hydrochloride extended-release 450 mg tablet - PA; See Table 17; See Table 71 bupropion hydrochloride - PA < 6 years; See Table 17; See Table 71 bupropion hydrochloride sustained-release-wellbutrin SR - PA < 6 years; See Table 17; See Table 71 bupropion hydrochloride sustained-release-zyban - PA < 6 years burosumab-twza - PA buspirone 30 mg - PA; See Table 69; See Table 71 buspirone 5 mg, 7.5 mg, 10 mg, 15 mg - PA < 6 years; See Table 69; See Table 71 busulfan injection busulfan tablet Busulfex # (busulfan injection) butabarbital butalbital / aspirin / caffeine / codeine - PA butalbital / aspirin / caffeine capsule - PA butalbital / aspirin / caffeine tablet - PA < 18 years and PA > 20 units/month butalbital 25 mg / acetaminophen 325 mg tablet - PA butalbital 50 mg / acetaminophen 300 mg / caffeine 40 mg / codeine 30 mg - PA SMOKING CESSATION ANTI-ANXIETY AGENT ANTI-ANXIETY AGENT BARBITURATES 6
7 butalbital 50 mg / acetaminophen 300 mg / caffeine 40 mg - PA butalbital 50 mg / acetaminophen 300 mg - PA butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg / codeine 30 mg - PA < 18 years and PA > 20 units/month butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg capsule, tablet - PA < 18 years and PA > 20 units/month butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg solution - PA butalbital 50 mg / acetaminophen 325 mg - PA butenafine - PA Butisol (butabarbital) butoconazole butorphanol injection butorphanol nasal spray - PA Butrans (buprenorphine transdermal) BP - PA > 20 mcg/hr and PA > 4 patches/28 days Bydureon (exenatide extended-release) - PA Byetta (exenatide) - PA Bystolic (nebivolol) - PA Byvalson (nebivolol / valsartan) - PA BARBITURATES DIABETIC AGENTS DIABETIC AGENTS 7
8
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