December 07 (06 Plan Year) Health Insurance Marketplace Generics Plus Drug List Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug list is regularly updated. Please visit bcbstx.com for the most up-to-date information. To find a contracting pharmacy, please access the link below: https://www.myprime.com/en/find-pharmacy.html Contents Introduction... I How drugs are selected... I How member payment is determined... I How to use this list... II Drugs used to treat multiple conditions... II Generic drugs... II Consider talking to your doctor about generic drugs... II Coverage considerations... III Specialty drugs... V Prime Specialty by AllianceRx Walgreens Prime... V Abbreviation key... VI Therapeutic Class Drug List Anti-Infective Agents... Biologicals... 3 Antineoplastic Agents... 5 Endocrine and Metabolic Drugs... Cardiovascular Agents... Respiratory Agents... 60 Gastrointestinal Agents... 67 Genitourinary Agents... 7 Central Nervous System Drugs... 77 Analgesics and Anesthetics... 96 Neuromuscular Drugs... 09 Nutritional Products... 9 Hematological Agents... 50 Topical Products... 6 Miscellaneous Products... 8 Index... 87 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-K TX HIM Prime Therapeutics LLC /7
Introduction Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician. Drug lists updates This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to Blue Access for Members SM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbstx.com. How drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. How member payment is determined This list shows prescription drug products in tiers. Generally, each drug is placed into one of five member payment tiers: Preferred Generic (Tier ), Non-preferred Generic (Tier ), Preferred Brand (Tier 3), Non-preferred Brand (Tier ) and Specialty (Tier 5). Please refer to the Preventive () section for drugs marked with an "A" in the drug tier column. To verify your payment amount for a drug, visit bcbstx.com and log in to Blue Access for Members or call the number on the back of your ID card. Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for selfadministration may be available through your medical benefit. BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December 07 (06 Plan Year) I
How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Example: atorvastatin (Lipitor brand is NF) Brand prescription drugs are shown in capital letters followed by the generic name. Drugs used to treat multiple conditions Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use. Generic drugs Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same standards. There are two types of generic drugs: A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. According to the FDA, compared to its brand counterpart, an FDA-approved generic drug: Is chemically the same Works just as well in the body Is as safe and effective Meets the same standards set by the FDA The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less. Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available. You may be responsible for the brand member payment amount plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount. Consider talking to your doctor about generic drugs If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication. BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December 07 (06 Plan Year) II
Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan materials for details about your particular benefits. Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount. Repackaged medications: Repackaged versions of medications already available on the market are not covered. (PA): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the preferred medications listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. (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 FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered medication in a given time period, coverage only for members within a certain age range, and coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit bcbstx.com. *Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit. (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 5 Tier Generics Plus Preferred Drug List December 07 (06 Plan Year) III
Preventive (): Medicines marked in the column are under the Affordable Care Act coverage of preventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), when meeting the conditions as outlined under the regulation. These are also indicated with an "A" in the drug tier column. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D supplements, and some FDA approved contraceptive methods. To see what contraceptive products may be covered, visit www.bcbstx.com/pdf/rx/contraceptive-list-tx.pdf Remember, medication decisions are between you and your doctor. Only you and your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor. BCBSTX does not provide health care services and, therefore, cannot guarantee any results or outcomes. BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December 07 (06 Plan Year) IV
Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications, visit myprime.com or bcbstx.com and log in to Blue Access for Members. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card. Prime Specialty by AllianceRx Walgreens Prime Through Prime Specialty by AllianceRx Walgreens Prime, members can have covered specialty medications delivered directly to them or their doctor s office. When you receive specialty medications through Prime Specialty by AllianceRx 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 /7/365 phone access to a pharmacist for urgent medication issues To order through Prime Specialty by AllianceRx Walgreens Prime: Have your doctor call or fax your prescription to Prime Specialty by AllianceRx Walgreens Prime. Your doctor can call 877-67-6337 or fax to 877-88-3939. If you have an existing prescription for a covered specialty medication, you can call 877-67-6337 to transfer your prescription. A 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 Specialty by AllianceRx Walgreens Prime at 877-67-6337, visit www.alliancerxwp.com, or call the number on the back of your ID card. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ( HCSC ). HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC. BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December 07 (06 Plan Year) 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... opthalmic osm... osmotic release powd... powder sa... sustained action sl... sublingual 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 5 Tier Generics Plus Preferred Drug List December 07 (06 Plan Year) VI
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Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at 855-70-698. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: 855-66-770 (voicemail) 300 E. Randolph St. TTY/TDD: 855-66-6965 35th Floor Fax: 855-66-6960 Chicago, Illinois 6060 Email: 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 Phone: 800-368-09 00 Independence Avenue SW TTY/TDD: 800-537-7697 Room 509F, HHH Building 09 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Washington, DC 00 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html bcbstx.com
06 ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN - amoxicillin (trihydrate) chew tab 5 AMOXICILLIN - amoxicillin (trihydrate) chew tab 50 amoxicillin (trihydrate) cap 50 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) for susp 5 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) for susp 50 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin & k clavulanate for susp 00-8.5 /5ml amoxicillin & k clavulanate for susp 50-6.5 /5ml (Augmentin) amoxicillin & k clavulanate for susp 00-57 /5ml amoxicillin & k clavulanate for susp 600-.9 /5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr 000-6.5 (Augmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab 500-5 (Augmentin) amoxicillin & k clavulanate tab 875-5 (Augmentin) AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab 00-8.5 AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab 00-57 AMPICILLIN - ampicillin cap 500 AUGMENTIN - amoxicillin & k clavulanate for susp 5-3.5 /5ml dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 MOXATAG - amoxicillin (trihydrate) tab er hr 775 PENICILLIN V POTASSIUM - penicillin v potassium for soln 5 /5ml PENICILLIN V POTASSIUM - penicillin v potassium for soln 50 /5ml penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHALOSPORINS CEDAX - ceftibuten cap 00 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year)
06 CEDAX - ceftibuten for susp 80 /5ml CEFACLOR - cefaclor for susp 5 /5ml CEFACLOR - cefaclor for susp 50 /5ml CEFACLOR - cefaclor for susp 375 /5ml cefaclor cap 50 cefaclor cap 500 CEFACLOR ER - cefaclor monohydrate tab er hr 500 cefadroxil cap 500 cefadroxil for susp 50 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 300 cefdinir for susp 5 /5ml cefdinir for susp 50 /5ml CEFDITOREN PIVOXIL - cefditoren pivoxil tab 00 (base equivalent) CEFDITOREN PIVOXIL - cefditoren pivoxil tab 00 (base equivalent) cefixime for susp 00 /5ml (Suprax) cefixime for susp 00 /5ml (Suprax) cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 00 /5ml cefpodoxime proxetil tab 00 cefpodoxime proxetil tab 00 cefprozil for susp 5 /5ml cefprozil for susp 50 /5ml cefprozil tab 50 cefprozil tab 500 CEFTIBUTEN - ceftibuten cap 00 CEFTIBUTEN - ceftibuten for susp 80 /5ml CEFTIN - cefuroxime axetil for susp 5 /5ml CEFTIN - cefuroxime axetil for susp 50 /5ml cefuroxime axetil tab 50 (Ceftin) cefuroxime axetil tab 500 (Ceftin) CEPHALEXIN - cephalexin tab 50 CEPHALEXIN - cephalexin tab 500 cephalexin cap 50 (Keflex) cephalexin cap 500 (Keflex) cephalexin cap 750 (Keflex) cephalexin for susp 5 /5ml cephalexin for susp 50 /5ml 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year)
06 SPECTRACEF - cefditoren pivoxil tab 00 (base equivalent) SUPRAX - cefixime cap 00 SUPRAX - cefixime chew tab 00 SUPRAX - cefixime chew tab 00 SUPRAX - cefixime for susp 00 /5ml SUPRAX - cefixime for susp 00 /5ml SUPRAX - cefixime for susp 500 /5ml MACROLIDES AZITHROMYCIN - azithromycin powd pack for susp gm azithromycin for susp 00 /5ml (Zithromax) azithromycin for susp 00 /5ml (Zithromax) azithromycin tab 50 (Zithromax) azithromycin tab 500 (Zithromax) azithromycin tab 600 (Zithromax) CLARITHROMYCIN - clarithromycin for susp 5 /5ml CLARITHROMYCIN - clarithromycin for susp 50 /5ml clarithromycin tab er hr 500 clarithromycin tab 50 (Biaxin) clarithromycin tab 500 (Biaxin) DIFICID - fidaxomicin tab 00 E.E.S. GRANULES - erythromycin ethylsuccinate for susp 00 /5ml E.E.S. 00 - erythromycin ethylsuccinate tab 00 ERY-TAB - erythromycin tab delayed release 50 ERY-TAB - erythromycin tab delayed release 333 ERY-TAB - erythromycin tab delayed release 500 ERYPED 00 - erythromycin ethylsuccinate for susp 00 /5ml ERYPED 00 - erythromycin ethylsuccinate for susp 00 /5ml ERYTHROCIN STEARATE - erythromycin stearate tab 50 ERYTHROMYCIN BASE - erythromycin tab 50 ERYTHROMYCIN BASE - erythromycin tab 500 ERYTHROMYCIN ETHYLSUCCINA - erythromycin ethylsuccinate tab 00 erythromycin ethylsuccinate for susp 00 /5ml (E.e.s. granules) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 3
06 erythromycin w/ delayed release particles cap 50 PCE - erythromycin w/ enteric coated particles tab 333 PCE - erythromycin w/ enteric coated particles tab 500 ZITHROMAX - azithromycin powd pack for susp gm ZMAX - azithromycin extended release for oral susp gm TETRACYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 300 doxycycline hyclate cap 50 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab delayed release 50 (Doryx) doxycycline hyclate tab delayed release 75 doxycycline hyclate tab delayed release 00 doxycycline hyclate tab delayed release 50 doxycycline hyclate tab delayed release 00 (Doryx) doxycycline hyclate tab 0 doxycycline hyclate tab 75 (Acticlate) doxycycline hyclate tab 00 doxycycline hyclate tab 50 (Acticlate) doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 (Monodox) doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 (Adoxa) doxycycline monohydrate for susp 5 /5ml (Vibramycin) doxycycline monohydrate tab 50 (Adoxa) doxycycline monohydrate tab 75 (Adoxa) doxycycline monohydrate tab 00 (Adoxa pak /00) doxycycline monohydrate tab 50 (Adoxa pak /50) minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) MINOCYCLINE HCL ER - minocycline hcl tab er hr 5 minocycline hcl tab er hr 90 minocycline hcl tab er hr 35 minocycline hcl tab 50 minocycline hcl tab 75 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year)
06 minocycline hcl tab 00 TETRACYCLINE HCL - tetracycline hcl cap 50 TETRACYCLINE HCL - tetracycline hcl cap 500 tetracycline hcl cap 50 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) moxifloxacin hcl tab 00 (base equiv) (Avelox) OFLOXACIN - ofloxacin tab 300 ofloxacin tab 00 FLUOROQUINOLONES ciprofloxacin for oral susp 50 /5ml (5%) (5 gm/00ml) (Cipro) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXACIN HCL - ciprofloxacin hcl tab 00 (base equiv) ciprofloxacin hcl tab 50 (base equiv) (Cipro) ciprofloxacin hcl tab 500 (base equiv) (Cipro) ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin-ciprofloxacin hcl tab er hr 500 (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er hr 000 (base eq) (Cipro xr) FACTIVE - gemifloxacin mesylate tab 30 (base equiv) LEVOFLOXACIN - levofloxacin oral soln 5 /ml levofloxacin tab 50 (Levaquin) AMINOGLYCOSIDES BETHKIS - tobramycin nebu soln 300 /ml KITABIS PAK - tobramycin nebu soln 300 /5ml neomycin sulfate tab 500 paromomycin sulfate cap 50 TOBI PODHALER - tobramycin inhal cap 8 TOBRAMYCIN - tobramycin nebu soln 300 /5ml tobramycin nebu soln 300 /5ml (Tobi) SULFONAMIDES SULFADIAZINE - sulfadiazine tab 500 ANTIMYCOBACTERIAL AGENTS CYCLOSERINE - cycloserine cap 50 ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 00 (Myambutol) ISONIAZID - isoniazid syrup 50 /5ml isoniazid tab 00 isoniazid tab 300 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 5
06 PASER - aminosalicylic acid er granules packet gm PRIFTIN - rifapentine tab 50 3 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) RIFAMATE - isoniazid & rifampin cap 50-300 rifampin cap 50 (Rifadin) rifampin cap 300 (Rifadin) RIFATER - isoniazid-rifampin w/ pyrazinamide tab 50-0-300 SIRTURO - bedaquiline fumarate tab 00 (base equiv) TRECATOR - ethionamide tab 50 ANTIFUNGALS BIO-STATIN - nystatin cap 500000 unit BIO-STATIN - nystatin cap 000000 unit CRESEMBA - isavuconazonium sulfate cap 86 fluconazole for susp 0 / ml (Diflucan) fluconazole for susp 0 / ml (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) flucytosine cap 50 (Ancobon) flucytosine cap 500 (Ancobon) griseofulvin microsize susp 5 /5ml griseofulvin microsize tab 500 (Grifulvin v) griseofulvin ultramicrosize tab 5 (Gris-peg) griseofulvin ultramicrosize tab 50 (Gris-peg) itraconazole cap 00 (Sporanox) ketoconazole tab 00 NOXAFIL - posaconazole susp 0 /ml NOXAFIL - posaconazole tab delayed release 00 nystatin oral powder nystatin tab 500000 unit ONMEL - itraconazole tab 00 SPORANOX - itraconazole oral soln 0 /ml terbinafine hcl tab 50 (Lamisil) voriconazole for susp 0 /ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 00 (Vfend) ANTIVIRALS 3 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 6
06 abacavir sulfate soln 0 / ml (base equiv) (Ziagen) abacavir sulfate tab 300 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab 600-300 (Epzicom) abacavir sulfatelamivudine-zidovudine tab 300-50-300 (Trizivir) acyclovir cap 00 (Zovirax) acyclovir susp 00 /5ml (Zovirax) acyclovir tab 00 (Zovirax) acyclovir tab 800 (Zovirax) adefovir dipivoxil tab 0 (Hepsera) APTIVUS - tipranavir cap 50 APTIVUS - tipranavir oral soln 00 /ml ATRIPLA - efavirenzemtricitabine-tenofovir df tab 600-00-300 BARACLUDE - entecavir oral soln 0.05 /ml COMPLERA - emtricitabinerilpivirine-tenofovir df tab 00-5-300 CRIXIVAN - indinavir sulfate cap 00 CRIXIVAN - indinavir sulfate cap 00 DAKLINZA - daclatasvir dihydrochloride tab 30 (base equivalent) 3 3 DAKLINZA - daclatasvir dihydrochloride tab 60 (base equivalent) DAKLINZA - daclatasvir dihydrochloride tab 90 (base equivalent) DESCOVY - emtricitabinetenofovir alafenamide fumarate tab 00-5 didanosine delayed release capsule 5 (Videx ec) didanosine delayed release capsule 00 (Videx ec) didanosine delayed release capsule 50 (Videx ec) didanosine delayed release capsule 00 (Videx ec) EDURANT - rilpivirine hcl tab 5 (base equivalent) EMTRIVA - emtricitabine caps 00 EMTRIVA - emtricitabine soln 0 /ml entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUSA - sofosbuvirvelpatasvir tab 00-00 EPIVIR - lamivudine oral soln 0 /ml EPIVIR HBV - lamivudine oral soln 5 /ml (hbv) EPZICOM - abacavir sulfatelamivudine tab 600-300 EVOTAZ - atazanavir sulfatecobicistat tab 300-50 (base equiv) 3 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 7
06 famciclovir tab 5 (Famvir) famciclovir tab 50 (Famvir) famciclovir tab 500 (Famvir) fosamprenavir calcium tab 700 (base equiv) (Lexiva) FUZEON - enfuvirtide for inj 90 GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab 50-50-00-0 HARVONI - ledipasvirsofosbuvir tab 90-00 INTELENCE - etravirine tab 5 INTELENCE - etravirine tab 00 INTELENCE - etravirine tab 00 INVIRASE - saquinavir mesylate cap 00 INVIRASE - saquinavir mesylate tab 500 ISENTRESS - raltegravir potassium chew tab 5 (base equiv) ISENTRESS - raltegravir potassium chew tab 00 (base equiv) ISENTRESS - raltegravir potassium packet for susp 00 (base equiv) ISENTRESS - raltegravir potassium tab 00 (base equiv) 3 3 3 3 3 3 3 3 ISENTRESS HD - raltegravir potassium tab 600 (base equiv) KALETRA - lopinavir-ritonavir soln 00-00 /5ml (80-0 /ml) KALETRA - lopinavir-ritonavir tab 00-5 KALETRA - lopinavir-ritonavir tab 00-50 lamivudine oral soln 0 / ml (Epivir) lamivudine tab 00 (hbv) (Epivir hbv) lamivudine tab 50 (Epivir) lamivudine tab 300 (Epivir) lamivudine-zidovudine tab 50-300 (Combivir) LEXIVA - fosamprenavir calcium susp 50 /ml (base equiv) LEXIVA - fosamprenavir calcium tab 700 (base equiv) lopinavir-ritonavir soln 00-00 /5ml (80-0 / ml) (Kaletra) MODERIBA - ribavirin tab 00 & ribavirin 00 tab therapy pack MODERIBA - ribavirin tab 00 & ribavirin 600 tab therapy pack MODERIBA 00 DOSE PACK - ribavirin tab 600 MODERIBA 800 DOSE PACK - ribavirin tab 00 3 3 3 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 8
06 nevirapine tab er hr 00 (Viramune xr) nevirapine tab er hr 00 (Viramune xr) nevirapine tab 00 (Viramune) NORVIR - ritonavir cap 00 NORVIR - ritonavir oral soln 80 3 /ml NORVIR - ritonavir tab 00 3 ODEFSEY - emtricitabinerilpivirine-tenofovir af tab 00-5-5 OLYSIO - simeprevir sodium cap 50 (base equivalent) oseltamivir phosphate cap 30 (base equiv) (Tamiflu) oseltamivir phosphate cap 5 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) PEGASYS - peginterferon alfa-a inj 80 mcg/ml PEGASYS - peginterferon alfa-a inj 80 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 35 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml 3 PEGINTRON - peginterferon alfa-b for inj kit 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 0 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREZCOBIX - darunavircobicistat tab 800-50 PREZISTA - darunavir ethanolate susp 00 /ml (base equiv) PREZISTA - darunavir ethanolate tab 75 (base equiv) PREZISTA - darunavir ethanolate tab 50 (base equiv) PREZISTA - darunavir ethanolate tab 600 (base equiv) PREZISTA - darunavir ethanolate tab 800 (base equiv) REBETOL - ribavirin soln 0 /ml RELENZA DISKHALER - zanamivir aero powder breath activated 5 /blister RESCRIPTOR - delavirdine mesylate tab 00 RESCRIPTOR - delavirdine mesylate tab 00 REYATAZ - atazanavir sulfate cap 50 (base equiv) REYATAZ - atazanavir sulfate cap 00 (base equiv) 3 3 3 3 3 3 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 9
06 REYATAZ - atazanavir sulfate cap 300 (base equiv) REYATAZ - atazanavir sulfate oral powder packet 50 (base equiv) RIBASPHERE - ribavirin tab 00 RIBASPHERE - ribavirin tab 600 RIBASPHERE RIBAPAK - ribavirin tab 00 & ribavirin 00 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 00 & ribavirin 600 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 00 RIBASPHERE RIBAPAK - ribavirin tab 600 ribavirin cap 00 (Rebetol) ribavirin for inhal soln 6 gm (Virazole) ribavirin tab 00 (Copegus) rimantadine hydrochloride tab 00 (Flumadine) SELZENTRY - maraviroc oral soln 0 /ml SELZENTRY - maraviroc tab 5 SELZENTRY - maraviroc tab 75 SELZENTRY - maraviroc tab 50 3 SELZENTRY - maraviroc tab 300 SITAVIG - acyclovir buccal tab 50 SOVALDI - sofosbuvir tab 00 stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 30 (Zerit) stavudine cap 0 (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab 50-50-00-300 3 SUSTIVA - efavirenz cap 50 SUSTIVA - efavirenz cap 00 SUSTIVA - efavirenz tab 600 TAMIFLU - oseltamivir phosphate cap 30 (base equiv) TAMIFLU - oseltamivir phosphate cap 5 (base equiv) TAMIFLU - oseltamivir phosphate cap 75 (base equiv) TAMIFLU - oseltamivir phosphate for susp 6 /ml (base equiv) TECHNIVIE - ombitasvirparitaprevir-ritonavir tab.5-75-50 TIVICAY - dolutegravir sodium tab 0 (base equiv) TIVICAY - dolutegravir sodium tab 5 (base equiv) 3 3 3 3 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 0
06 TIVICAY - dolutegravir sodium tab 50 (base equiv) TRIUMEQ - abacavirdolutegravir-lamivudine tab 600-50-300 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 00-50 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 33-00 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 67-50 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 00-300 TYBOST - cobicistat tab 50 valacyclovir hcl tab 500 (Valtrex) valacyclovir hcl tab gm (Valtrex) VALCYTE - valganciclovir hcl for soln 50 /ml (base equiv) valganciclovir hcl for soln 50 /ml (base equiv) (Valcyte) valganciclovir hcl tab 50 (base equivalent) (Valcyte) VIDEX - didanosine for soln gm VIDEX - didanosine for soln gm VIEKIRA PAK - ombitasparitapre-riton & dasab tab pak.5-75-50 & 50 3 3 3 3 3 3 3 3 VIEKIRA XR - dasab-ombitparitap-riton tab er hr 00-8.33-50-33.33 VIRACEPT - nelfinavir mesylate tab 50 VIRACEPT - nelfinavir mesylate tab 65 VIRAMUNE - nevirapine susp 50 /5ml VIRAMUNE XR - nevirapine tab er hr 00 VIRAZOLE - ribavirin for inhal soln 6 gm VIREAD - tenofovir disoproxil fumarate oral powder 0 / gm VIREAD - tenofovir disoproxil fumarate tab 50 VIREAD - tenofovir disoproxil fumarate tab 00 VIREAD - tenofovir disoproxil fumarate tab 50 VIREAD - tenofovir disoproxil fumarate tab 300 3 3 3 3 3 3 ZEPATIER - elbasvirgrazoprevir tab 50-00 ZERIT - stavudine for oral soln /ml ZIAGEN - abacavir sulfate soln 3 0 /ml (base equiv) zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 300 ANTIMALARIALS atovaquone-proguanil hcl tab 6.5-5 (Malarone) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year)
06 atovaquone-proguanil hcl tab 50-00 (Malarone) CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 50 chloroquine phosphate tab 500 (Aralen) COARTEM - artemetherlumefantrine tab 0-0 DARAPRIM - pyrimethamine tab 5 hydroxychloroquine sulfate tab 00 (Plaquenil) mefloquine hcl tab 50 PRIMAQUINE PHOSPHATE - primaquine phosphate tab 6.3 (5 base) quinine sulfate cap 3 (Qualaquin) ANTHELMINTICS ALBENZA - albendazole tab 00 BILTRICIDE - praziquantel tab 600 EMVERM - mebendazole chew tab 00 ivermectin tab 3 (Stromectol) 3 ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 00 /5ml ALINIA - nitazoxanide tab 500 atovaquone susp 750 /5ml (Mepron) CAYSTON - aztreonam lysine for inhal soln 75 (base equivalent) 3 3 3 clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 300 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 dapsone tab 00 IMPAVIDO - miltefosine cap 50 3 linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 375 (Flagyl) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) NEBUPENT - pentamidine isethionate for nebulization soln 300 PRIMSOL - trimethoprim hcl oral soln 50 /5ml (base equiv) SIVEXTRO - tedizolid phosphate tab 00 sulfamethoxazoletrimethoprim susp 00-0 /5ml sulfamethoxazoletrimethoprim tab 00-80 (Bactrim) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year)
06 sulfamethoxazoletrimethoprim tab 800-60 (Bactrim ds) tinidazole tab 50 (Tindamax) tinidazole tab 500 (Tindamax) trimethoprim tab 00 vancomycin hcl cap 5 (Vancocin hcl) vancomycin hcl cap 50 (Vancocin hcl) XIFAXAN - rifaximin tab 00 XIFAXAN - rifaximin tab 550 3 ZYVOX - linezolid for susp 00 /5ml ZYVOX - linezolid tab 600 BIOLOGICALS VACCINES AFLURIA PF 07-08 - influenza virus vaccine split pf susp pref syringe 0.5 ml AFLURIA QUADRIVALENT 07 - influenza virus vac split quadrivalent susp pref syr 0.5ml AFLURIA QUADRIVALENT 07 - influenza virus vaccine split quadrivalent im inj AFLURIA 07-08 - influenza virus vaccine split im susp ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/0.5ml A A A A A ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/ml FLUAD 07-08 - influenza vac type a&b surface ant adj susp pref syr 0.5 ml FLUARIX QUADRIVALENT 07 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUADRIVALENT 07 - influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUBLOK 05-06 - influenza virus vac recombinant hemagglutinin (ha) pf inj FLUBLOK 07-08 - influenza virus vac recombinant hemagglutinin (ha) pf inj FLUCELVAX QUADRIVALENT 0 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVAX QUADRIVALENT 0 - influenza vac tissuecultured subunit quadrivalent im susp FLULAVAL QUADRIVALENT 0 - influenza virus vac split quadrivalent susp pref syr 0.5ml A A A A A A A A A A A BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 3
06 FLULAVAL QUADRIVALENT 0 - influenza virus vaccine split quadrivalent im inj FLUMIST QUADRIVALENT - influenza virus vaccine live quadrivalent intranasal susp FLUVIRIN 05-06 - influenza vac type a&b surface antigen susp pref syr 0.5 ml FLUVIRIN 05-06 - influenza virus vaccine types a & b surface antigen im susp FLUVIRIN 07-08 - influenza vac type a&b surface antigen susp pref syr 0.5 ml FLUVIRIN 07-08 - 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 0.5ml FLUZONE INTRADERMAL QUADR - influenza virus vac split quad intradermal pen 9 mcg/strain FLUZONE QUADRIVALENT 07 - influenza virus vac split quadrivalent susp pref syr 0.5 ml FLUZONE QUADRIVALENT 07 - influenza virus vac split quadrivalent susp pref syr 0.5ml A A A A A A A A A A FLUZONE QUADRIVALENT 07 - influenza virus vaccine split quadrivalent im inj IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj PNEUMOVAX 3 - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PNEUMOVAX 3/ DOSE - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PREVNAR 3 - Pneumococcal 3-valent conjugate vaccine inj RABAVERT - rabies vaccine, pcec for inj RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml VIVOTIF - typhoid vaccine cap delayed release ZOSTAVAX - zoster vaccine live for subcutaneous susp 900 unit/0.65ml TOXOIDS ADACEL - tet tox-diph-acell pertuss ad inj 5--5.5 lf-lfmcg/0.5ml BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-.5-8.5 lf-lfmcg/0.5ml A A A A A A A A A A A A BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year)
06 DAPTACEL - diph, acellular pert & tet tox inj 5 lf-3 mcg-5 lf/0.5ml DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 5-5 unit/0.5ml INFANRIX - diph, acellular pert & tet tox inj 5 lf-58 mcg-0 lf/0.5ml KINRIX - diph-tetanus tox adacell pert & polio virus, ipv vac inj PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio ipv vac inj PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj TENIVAC - tetanus-diphtheria toxoids (td) inj 5- lfu TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td) inj - lf/0.5ml PASSIVE IMMUNIZING AGENTS HEPAGAM B - hepatitis b immune globulin (human) inj soln HYPERHEP B S/D - hepatitis b immune globulin (human) im inj soln HYPERRAB S/D - rabies immune globulin (human) inj 50 unit/ml HYPERTET S/D - tetanus immune globulin (human) inj 50 unit/ml HYQVIA - immun glob inj.5 gm/5ml-hyaluron inj 00 unt/.5 ml kit HYQVIA - immun glob inj 5 gm/50ml-hyaluron inj 00 unt/.5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 800 unt/5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 600 unt/0 ml kit HYQVIA - immun glob inj 30 gm/300ml-hyaluron inj 00 unt/5 ml kit IMOGAM RABIES-HT - rabies immune globulin (human) inj 50 unit/ml NABI-HB - hepatitis b immune globulin (human) im inj soln VARIZIG - varicella-zoster immune glob (human) im inj 5 unit/.ml BIOLOGICALS MISC GRASTEK - timothy grass pollen allergen ext tab sl 800 bau ORALAIR - grass mixed pollen ext tab sl 300 ir (index of reactivity) RAGWITEK - short ragweed pollen allergen extract tab sl amb a -u ANTINEOPLASTIC AGENTS ANTINEOPLASTICS BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 5
06 ACTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml (000000 unit/0.5ml) AFINITOR - everolimus tab.5 AFINITOR - everolimus tab 5 AFINITOR - everolimus tab 7.5 AFINITOR - everolimus tab 0 AFINITOR DISPERZ - everolimus tab for oral susp AFINITOR DISPERZ - everolimus tab for oral susp 3 AFINITOR DISPERZ - everolimus tab for oral susp 5 ALECENSA - alectinib hcl cap 50 (base equivalent) ALKERAN - melphalan tab ALUNBRIG - brigatinib tab 30 anastrozole tab (Arimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 500 3 CABOMETYX - cabozantinib s-malate tab 0 (base equivalent) CABOMETYX - cabozantinib s-malate tab 0 (base equivalent) CABOMETYX - cabozantinib s-malate tab 60 (base equivalent) capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA - vandetanib tab 00 CAPRELSA - vandetanib tab 300 COMETRIQ - cabozantinib s- mal cap x 80 & x 0 (00 dose) kit COMETRIQ - cabozantinib s- mal cap x 80 & 3 x 0 (0 dose) kit COMETRIQ - cabozantinib s- malate cap 3 x 0 (60 dose) kit COTELLIC - cobimetinib fumarate tab 0 (base equivalent) CYCLOPHOSPHAMIDE - cyclophosphamide cap 5 CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit.5 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 6
06 ELIGARD - leuprolide acetate ( month) for subcutaneous inj kit 30 ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 5 ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 EMCYT - estramustine phosphate sodium cap 0 ERIVEDGE - vismodegib cap 50 ETOPOSIDE - etoposide cap 50 exemestane tab 5 (Aromasin) FARESTON - toremifene citrate tab 60 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) FARYDAK - panobinostat lactate cap 5 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) flutamide cap 5 GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 30 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GLEEVEC - imatinib mesylate tab 00 (base equivalent) GLEEVEC - imatinib mesylate tab 00 (base equivalent) GLEOSTINE - lomustine cap 5 GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 00 HEXALEN - altretamine cap 50 HYCAMTIN - topotecan hcl cap 0.5 (base equiv) HYCAMTIN - topotecan hcl cap (base equiv) hydroxyurea cap 500 (Hydrea) IBRANCE - palbociclib cap 75 IBRANCE - palbociclib cap 00 IBRANCE - palbociclib cap 5 ICLUSIG - ponatinib hcl tab 5 (base equiv) ICLUSIG - ponatinib hcl tab 5 (base equiv) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 00 (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 0 INLYTA - axitinib tab BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 7
06 INLYTA - axitinib tab 5 INTRON A - interferon alfa-b inj 6000000 unit/ml INTRON A - interferon alfa-b inj 0000000 unit/ml INTRON A - interferon alfa-b for inj 0000000 unit INTRON A - interferon alfa-b for inj 8000000 unit INTRON A - interferon alfa-b for inj 50000000 unit INTRON A W/DILUENT - interferon alfa-b for inj 0000000 unit INTRON A W/DILUENT - interferon alfa-b for inj 8000000 unit INTRON A W/DILUENT - interferon alfa-b for inj 50000000 unit IRESSA - gefitinib tab 50 JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) KISQALI - ribociclib succinate tab 00 (base equiv) KISQALI FEMARA 00 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 00 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 600 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 (0 daily dose) LENVIMA MG DAILY DOSE - lenvatinib cap therapy pack 0 & ( daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 0 & () (8 daily dose) LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 () (0 daily dose) LENVIMA MG DAILY DOSE - lenvatinib cap therapy pack 0 () & ( daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack () (8 daily dose) letrozole tab.5 (Femara) LEUCOVORIN CALCIUM - 3 leucovorin calcium tab 0 LEUCOVORIN CALCIUM - 3 leucovorin calcium tab 5 leucovorin calcium tab 5 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 8
06 leucovorin calcium tab 5 LEUKERAN - chlorambucil tab leuprolide acetate inj kit 5 /ml LONSURF - trifluridine-tipiracil tab 5-6. LONSURF - trifluridine-tipiracil tab 0-8.9 LYNPARZA - olaparib cap 50 LYSODREN - mitotane tab 500 MATULANE - procarbazine hcl cap 50 megestrol acetate susp 0 /ml (Megace oral) megestrol acetate tab 0 megestrol acetate tab 0 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 (base equivalent) MEKINIST - trametinib dimethyl sulfoxide tab (base equivalent) melphalan tab (Alkeran) mercaptopurine tab 50 MESNEX - mesna tab 00 METHOTREXATE SODIUM - methotrexate sodium inj 50 /0ml (5 /ml) methotrexate sodium for inj gm methotrexate sodium inj pf 50 /ml (5 /ml) 3 methotrexate sodium inj pf 00 /ml (5 /ml) methotrexate sodium inj pf 00 /8ml (5 /ml) methotrexate sodium inj pf 50 /0ml (5 /ml) methotrexate sodium inj pf 000 /0ml (5 /ml) methotrexate sodium inj 50 /ml (5 /ml) methotrexate sodium tab.5 (base equiv) MYLERAN - busulfan tab 3 NEXAVAR - sorafenib tosylate tab 00 (base equivalent) NILANDRON - nilutamide tab 50 nilutamide tab 50 (Nilandron) NINLARO - ixazomib citrate cap.3 (base equivalent) NINLARO - ixazomib citrate cap 3 (base equivalent) NINLARO - ixazomib citrate cap (base equivalent) ODOMZO - sonidegib phosphate cap 00 (base equivalent) POMALYST - pomalidomide cap POMALYST - pomalidomide cap POMALYST - pomalidomide cap 3 POMALYST - pomalidomide cap BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 9
06 PURIXAN - mercaptopurine susp 000 /00ml (0 /ml) RUBR - rucaparib camsylate tab 00 (base equivalent) RUBR - rucaparib camsylate tab 50 (base equivalent) RUBR - rucaparib camsylate tab 300 (base equivalent) RYDAPT - midostaurin cap 5 SOLTAMOX - tamoxifen citrate oral soln 0 /5ml (base equivalent) SPRYCEL - dasatinib tab 0 SPRYCEL - dasatinib tab 50 SPRYCEL - dasatinib tab 70 SPRYCEL - dasatinib tab 80 SPRYCEL - dasatinib tab 00 SPRYCEL - dasatinib tab 0 STIVARGA - regorafenib tab 0 SUTENT - sunitinib malate cap.5 (base equivalent) SUTENT - sunitinib malate cap 5 (base equivalent) SUTENT - sunitinib malate cap 37.5 (base equivalent) 5 SUTENT - sunitinib malate cap 50 (base equivalent) SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 300 mcg SYLATRON - peginterferon alfa-b for inj kit 600 mcg TABLOID - thioguanine tab 0 TAFINLAR - dabrafenib mesylate cap 50 (base equivalent) TAFINLAR - dabrafenib mesylate cap 75 (base equivalent) TAGRISSO - osimertinib mesylate tab 0 (base equivalent) TAGRISSO - osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) tamoxifen citrate tab 0 (base equivalent) TARCEVA - erlotinib hcl tab 5 (base equivalent) TARCEVA - erlotinib hcl tab 00 (base equivalent) TARCEVA - erlotinib hcl tab 50 (base equivalent) TARGRETIN - bexarotene cap 75 TASIGNA - nilotinib hcl cap 50 (base equivalent) TASIGNA - nilotinib hcl cap 00 (base equivalent) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year) 0
06 temozolomide cap 5 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 00 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 50 (Temodar) tretinoin cap 0 TREXALL - methotrexate sodium tab 5 (base equiv) TREXALL - methotrexate sodium tab 7.5 (base equiv) TREXALL - methotrexate sodium tab 0 (base equiv) TREXALL - methotrexate sodium tab 5 (base equiv) TYKERB - lapatinib ditosylate tab 50 (base equiv) VENCLEXTA - venetoclax tab 0 VENCLEXTA - venetoclax tab 50 VENCLEXTA - venetoclax tab 00 VENCLEXTA STARTING PACK - venetoclax tab therapy starter pack 0 & 50 & 00 VOTRIENT - pazopanib hcl tab 00 (base equiv) XALKORI - crizotinib cap 00 XALKORI - crizotinib cap 50 XTANDI - enzalutamide cap 0 ZEJULA - niraparib tosylate cap 00 (base equivalent) ZELBORAF - vemurafenib tab 0 ZOLINZA - vorinostat cap 00 ZYDELIG - idelalisib tab 00 ZYDELIG - idelalisib tab 50 ZYKADIA - ceritinib cap 50 ZYTIGA - abiraterone acetate tab 50 ZYTIGA - abiraterone acetate tab 500 ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS ACTIVE INJECTION KIT KL-3 - triamcinolone inj 0 /ml & lidocaine % & ammonia inh kit budesonide delayed release particles cap 3 (Entocort ec) CORTISONE ACETATE - cortisone acetate tab 5 3 BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year)
06 DEXAMETHASONE - dexamethasone soln 0.5 /5ml DEXAMETHASONE - dexamethasone tab DEXAMETHASONE - dexamethasone tab dexamethasone elixir 0.5 /5ml DEXAMETHASONE INTENSOL - dexamethasone conc /ml dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab.5 dexamethasone tab dexamethasone tab 6 DEXPAK 0 DAY - dexamethasone tab therapy pack.5 (35) DEXPAK 3 DAY - dexamethasone tab therapy pack.5 (5) DEXPAK 6 DAY - dexamethasone tab therapy pack.5 () fludrocortisone acetate tab 0. hydrocortisone tab 5 (Cortef) hydrocortisone tab 0 (Cortef) hydrocortisone tab 0 (Cortef) JTT PHYSICIANS KIT - triamcinolone inj 0 /ml & lidocaine % & ammonia inh kit MEDROL - methylprednisolone tab methylprednisolone tab therapy pack () (Medrol dosepak) methylprednisolone tab (Medrol) methylprednisolone tab 8 (Medrol) methylprednisolone tab 6 (Medrol) methylprednisolone tab 3 (Medrol) MILLIPRED - prednisolone sod phosphate oral soln 0 /5ml (base equiv) MILLIPRED - prednisolone tab 5 MILLIPRED DP - prednisolone tab therapy pack 5 () MILLIPRED DP - prednisolone tab therapy pack 5 (8) PHYSICIANS EZ USE JOINT T - triamcinolone inj 0 /ml & lidocaine % & ammonia inh kit prednisolone sod phos orally disintegr tab 0 (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 5 (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 30 (base eq) (Orapred odt) prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base) (Pediapred) BCBSTX Health Insurance Marketplace 5 Tier Generics Plus Preferred Drug List December (06 Plan Year)