Blue Cross and Blue Shield of Illinois July 2024 Multi-Tier Basic

2656-1N IL © Prime Therapeutics LLC – 07/24

Multi-Tier Basic Annual Drug List – Updated as of 7/1/24

July 2024

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. You can view the most up-to-date list, or the specialty drug list, at

MyPrime.com

bcbsil.com

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 ................................................. III

Consider talking to your doctor about generic

drugs ........................................................... III

Coverage considerations ............................... IV

Specialty drugs .............................................. VI

Accredo .......................................................... VI

Abbreviation key ........................................... VII

Therapeutic Class Drug List

Anti-Infective Agents ........................................ 1

Antineoplastic Agents ...................................... 3

Endocrine and Metabolic Drugs ...................... 6

Cardiovascular Agents ................................... 10

Respiratory Agents ........................................ 14

Gastrointestinal Agents .................................. 16

Genitourinary Agents ..................................... 17

Central Nervous System Drugs ..................... 17

Analgesics and Anesthetics ........................... 21

Neuromuscular Drugs .................................... 23

Nutritional Products ....................................... 24

Hematological Agents .................................... 24

Topical Products ............................................ 27

Miscellaneous Products ................................. 29

Index .............................................................. 31

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Blue Cross and Blue Shield of Illinois July 2024 Multi-Tier Basic Annual Drug List – Updated as of 7/1/24

Introduction

Blue Cross and Blue Shield of Illinois is pleased to present the 2024 Drug List. This is a list of preferred drugs

which includes brand drugs and a partial listing of generic drugs

. Members are encouraged to show this list to

their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right

for the member. However, decisions regarding therapy and treatment are always between members and

their physician.

Drug List updates

– This list is regularly updated as generic drugs become available and changes take place in

the pharmaceuticals market. For the most up-to-date information, visit

MyPrime.com

bcbsil.com

and log in to

Blue Access for Members

(BAM

) or call the number on your ID card. Physicians can access the list from the

provider portal at

bcbsil.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

BCBSIL, 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

Generally, each drug is placed into one of up to six member payment tiers: Preferred Generic (Tier 1),

Non-Preferred Generic (Tier 2), Preferred Brand (Tier 3), Non-Preferred Brand (Tier 4), Preferred Specialty

(Tier 5) and Non-Preferred Specialty (Tier 6). Non-Preferred Generic, Non-Preferred Brand and Non-Preferred

Specialty drugs are not listed in this document. Based on your benefit design, drugs can either be in these tiers or

you may have fewer tiers, e.g., all generics in one tier. Some specialty medicines are marked with an “SP” in the

Special Requirements section. Some brands may be in a generic tier and some generics may be in a brand tier.

Note: Covered substance use disorder drugs (those FDA-approved for treatment of opioid drug abuse, alcohol

abuse and to quit tobacco use) may be in the lowest tiers. Substance use disorder brand drugs may be in the

lowest brand tier and generic drugs in the lowest generic tier, based on your benefit plan. These drugs are those

with such active ingredients as buprenorphine-naloxone, naltrexone, lofexidine, naloxone, disulfiram,

acamprosate, bupropion (smoking deterrent), varenicline and nicotine replacement therapy. To verify your

payment amount for a drug, visit

MyPrime.com

and log in or call the number on your ID card.

Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may

apply.

For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered.

Drugs that have not received FDA approval may not be covered. Prescription products that have over-the-counter

(OTC) equivalents may not be covered. Drugs that are not FDA-approved for self-administration may be available

through your medical benefit. Check your plan materials for details.

Blue Cross and Blue Shield of Illinois July 2024 Multi-Tier Basic Annual Drug List – Updated as of 7/1/24

How to use this list

Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference

brand drug in (parentheses). The reference brand drug is usually a non-preferred (NP) brand and is only included

as a reference to the brand. Some generic products have no reference brand.

Example:

atorvastatin

(Lipitor)

Brand prescription drugs are shown in all CAPITAL letters followed by the generic name.

Example: NOVOLOG – Insulin aspart inj 100 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 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.

Please note:

Drugs that need a health care provider to administer them and are often given to you in a hospital,

doctor’s office or other health care setting may be covered under your medical benefit. Some types of these drugs

are contraceptive implants and chemo infusions. If you are taking or are prescribed a drug that is not on this drug

list, call the number on your ID card to see if the drug may be covered.

Blue Cross and Blue Shield of Illinois July 2024 Multi-Tier Basic Annual Drug List – Updated as of 7/1/24

III

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 your member cost-share payment amount (copay or coinsurance) 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 generally 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.

Blue Cross and Blue Shield of Illinois July 2024 Multi-Tier Basic Annual Drug List – Updated as of 7/1/24

Coverage considerations

Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some

exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.

Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood

pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories,

like those used for erectile dysfunction or weight loss. Also, some drugs may only be covered for members within

a certain age range due to the drug being used for cosmetic purposes or for safety concerns. Drug coverage may

be limited to recommendations based on FDA-approved labeling and recognized evidence-based or clinical

practice guidelines.

Over-the-counter exclusions:

Your benefit plan may not provide coverage for prescription medications that

have an over-the-counter version. You should refer to your benefit plan material for details about your particular

benefits.

Compounded medications:

Your benefit plan may not provide coverage for compounded medications. Please

see your plan materials or call the number on 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.

Non FDA-approved drugs:

Drugs that have not received FDA approval are not covered.

Prior Authorization (PA):

Your benefit plan may require prior authorization for certain drugs. This means that

your doctor will need to submit a prior authorization request for coverage of these medications, and the request

will need to be approved, before the medication may be covered under your plan. For the medications listed in

this document, if a prior authorization is commonly required, it will generally be noted next to the medication with a

“PA” under the Special Requirements column. Some plans may have prior authorization on additional medications

beyond those noted in this document. Refer to your benefit plan materials for details about your particular

benefits.

Step Therapy (ST):

Your benefit plan may include a step therapy program. This means you may need to try

another proven, cost-effective medication before coverage may be available for the drug included in the program.

Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the

medications listed in this document, if a step therapy is commonly required, it will generally be noted next to the

medication with an “ST” under the Special Requirements column. Some plans may have step therapy programs

on additional medications beyond those noted in this document. Refer to your benefit plan materials for details

about your particular benefits.

Dispensing Limits (DL)/Quantity Limits (QL):

Drug dispensing limits help encourage medication use as

intended by the FDA. Dispensing limits are placed on medications in certain drug categories. For the medications

listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a “QL”

under the Special Requirements column. Limits may include: quantity of covered medication per prescription or

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 may be responsible for the

full cost of the prescription beyond what your coverage allows.* Some plans may have a dispensing limit on

additional medications beyond those noted in this document. For a list of medications and their dispensing limits, visit

MyPrime.com

bcbsil.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.

Blue Cross and Blue Shield of Illinois July 2024 Multi-Tier Basic Annual Drug List – Updated as of 7/1/24

ACA Preventive (ACA):

Medicines marked as “AC” in the Special Requirements column are under the Affordable

Care Act coverage of preventive services. These products may have limited or $0 member cost-sharing (copay or

co-insurance), when meeting the conditions as outlined under the regulation. Coverage may vary based on

benefit plan.

You, or your prescribing health care provider, can submit a copay waiver or coverage exception request for

ACA preventive medicines by calling the number on your ID card to ask for a review. If you meet the

conditions as outlined under the ACA regulations, you may have $0 member cost-sharing (copay or

coinsurance). BCBSIL will let you, and your prescriber, know the coverage decision after they receive your

request. If the request is denied, BCBSIL will let you and your prescriber know why it was denied and offer

you a covered alternative drug (if applicable).

Illinois mandated $0 cost share products: Based on your benefit plan, abortifacient medication, hormonal

therapy for gender dysphoria, HIV preexposure prophylaxis and/or post-exposure prophylaxis, and/or opioid

antagonist drug(s) may be covered at no charge to you, when obtained from a participating pharmacy. To verify

your payment amount for a drug, visit MyPrime.com and log in, or call the number on your ID card to request

payment amount or information on a copay waiver exception.

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. BCBSIL does not provide health care services and, therefore, cannot

guarantee any results or outcomes.

Blue Cross and Blue Shield of Illinois July 2024 Multi-Tier Basic Annual Drug List – Updated as of 7/1/24

Specialty drugs

Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis

and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be

self-administered or administered by a health care professional. Medications administered by a health care

professional are not covered under the pharmacy benefit. For a current list of specialty medications,

visit

MyPrime.com

bcbsil.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 your ID card.

Accredo

Members who use specialty medications deserve the care and support they need to manage their therapy. With

Accredo, members can have covered specialty medications delivered directly to them or their doctor’s office.

When using Accredo for specialty medications, you also receive at no additional charge the following services:

• One-on-one support

• Condition-specific staff to help answer questions about your medication(s) or condition

• 24/7 support

• Free shipping with safe, on-time delivery

• Refill reminders and other digital tools

To order through Accredo:

1. Have your doctor send a new prescription to Accredo electronically, by fax or by phone. Your doctor can

find contact information at accredo.com/prescribers.

2. Once the prescription has been received, you will receive a call from Accredo to get signed up and ready

for your first prescription fill.

3. You can also call Accredo at 833-721-1619 and an agent will work with you to get a new prescription sent

or transferred from another pharmacy.

If you have questions, please contact Accredo at 833-721-1619, visit accredo.com, or call the number on your ID

card.

Blue Cross and Blue Shield of Illinois is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent

Licensee of the Blue Cross and Blue Shield Association. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management

and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime

Therapeutics LLC.

Accredo is a specialty pharmacy that is contracted to provide services to members of BCBSIL. The relationship between Accredo and BCBSIL

is that of independent contractors. Accredo is a trademark of Express Scripts Strategic Development, Inc.

Blue Cross and Blue Shield of Illinois July 2024 Multi-Tier Basic Annual Drug List – Updated as of 7/1/24

VII

Abbreviation key

aer..................................................................... aerosol

cap ................................................................. capsules

chew ............................................................. chewable

conc .......................................................... concentrate

cr...................................................... controlled release

dr ........................................................ delayed release

ec ........................................................... enteric coated

equiv ........................................................... equivalent

er....................................................... extended release

gm........................................................................ gram

inhal .................................................................. inhaler

inj .................................................................... injection

liqd....................................................................... liquid

mg.................................................................. milligram

ml ..................................................................... milliliter

nebu .............................................................. nebulizer

odt. ....................................orally disintegrating tablets

oint .................................................................ointment

ophth .......................................................... ophthalmic

osm ..................................................... osmotic release

pack ................................................................. packets

powd .................................................................powder

pttw ................................................ twice-weekly patch

sl .................................................................. sublingual

soln .................................................................. solution

suppos ................................................... suppositories

susp ........................................................... suspension

tab ...................................................................... tablets

td ............................................................... transdermal

w/ ........................................................................... with

Health care coverage is important for everyone.

If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost. To talk

to an interpreter, call 855-710-6984. We provide free communication aids and services for anyone with a disability or who needs

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disability. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a

grievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)

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Floor TTY/TDD: 855-661-6965

Chicago, IL 60601 Fax: 855-661-6960

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services Phone: 800-368-1019

200 Independence Avenue SW TTY/TDD: 800-537-7697

Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

Washington, DC 20201 Complaint Forms: https://www.hhs.gov/civil-rights/filing-a-

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2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 1

Drug Name

Requirements/Limits

ANTI-INFECTIVE AGENTS

PENICILLINS

amoxicillin (trihydrate) cap 250 mg, 500 mg

amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml,

400 mg/5ml

amoxicillin (trihydrate) tab 500 mg, 875 mg

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 400-57 mg/5ml

amoxicillin & k clavulanate tab 500-125 mg, 875-125 mg (Augmentin)

penicillin v potassium tab 250 mg, 500 mg

CEPHALOSPORINS

cefadroxil cap 500 mg

cefdinir cap 300 mg

cefuroxime axetil tab 250 mg

cephalexin cap 250 mg, 500 mg (Keflex)

cephalexin for susp 125 mg/5ml

MACROLIDES

AZITHROMYCIN - azithromycin powd pack for susp 1 gm

azithromycin for susp 200 mg/5ml (Zithromax)

azithromycin tab 250 mg, 500 mg (Zithromax)

QL (60 tablets/180 days)

DIFICID - fidaxomicin tab 200 mg

DIFICID - fidaxomicin for susp 40 mg/ml

TETRACYCLINES

doxycycline hyclate cap 100 mg (Vibramycin)

doxycycline hyclate tab 20 mg, 100 mg

doxycycline monohydrate cap 50 mg

doxycycline monohydrate cap 100 mg (Monodox)

doxycycline monohydrate tab 50 mg, 100 mg

minocycline hcl cap 50 mg (Minocin)

FLUOROQUINOLONES

ciprofloxacin hcl tab 250 mg (base equiv), 500 mg (base equiv) (Cipro)

ciprofloxacin hcl tab 750 mg (base equiv)

levofloxacin tab 250 mg, 500 mg, 750 mg (Levaquin)

AMINOGLYCOSIDES

HUMATIN - paromomycin sulfate cap 250 mg

neomycin sulfate tab 500 mg

ANTIMYCOBACTERIAL AGENTS

isoniazid tab 300 mg

PRIFTIN - rifapentine tab 150 mg

ANTIFUNGALS

fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg (Diflucan)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 2

Drug Name

Requirements/Limits

NOXAFIL - posaconazole for delayed release susp packet 300 mg

terbinafine hcl tab 250 mg (Lamisil)

ANTIVIRALS

acyclovir cap 200 mg (Zovirax)

acyclovir tab 400 mg, 800 mg (Zovirax)

BARACLUDE - entecavir oral soln 0.05 mg/ml

BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 30-120-15 mg,

50-200-25 mg

QL (30 tablets/30 days)

CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg

QL (30 tablets/30 days)

DELSTRIGO - doravirine-lamivudine-tenofovir df tab 100-300-300 mg

QL (30 tablets/30 days)

DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab 120-15 mg,

200-25 mg

QL (30 tablets/30 days)

DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg (base eq)

QL (30 tablets/30 days)

EPCLUSA - sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mg

PA, QL (30 tablets/30 days), SP

EPCLUSA - sofosbuvir-velpatasvir pellet pack 150-37.5 mg, 200-50 mg

PA, QL (28 tablets/28 days), SP

GENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg

QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 45-200 mg, 90-400 mg

PA, QL (30 tablets/30 days), SP

HARVONI - ledipasvir-sofosbuvir pellet pack 33.75-150 mg, 45-200 mg

PA, QL (30 packets/30 days), SP

INTELENCE - etravirine tab 25 mg

QL (120 tablets/30 days)

ISENTRESS - raltegravir potassium chew tab 25 mg (base equiv), 100 mg

(base equiv)

QL (180 tablets/30 days)

ISENTRESS - raltegravir potassium packet for susp 100 mg (base equiv)

QL (60 packets/30 days)

ISENTRESS - raltegravir potassium tab 400 mg (base equiv)

QL (60 tablets/30 days)

ISENTRESS HD - raltegravir potassium tab 600 mg (base equiv)

QL (60 tablets/30 days)

JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg (base eq)

QL (30 tablets/30 days)

MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg

PA, QL (90 tablets/30 days), SP

MAVYRET - glecaprevir-pibrentasvir pellet pack 50-20 mg

PA, QL (140 tablets/28 days), SP

nevirapine tab 200 mg (Viramune)

QL (60 tablets/30 days)

NORVIR - ritonavir powder packet 100 mg

QL (360 packets/30 days)

ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg

QL (30 tablets/30 days)

PAXLOVID - nirmatrelvir tab 10 x 150 mg & ritonavir tab 10 x 100 mg pak

QL (20 tablets/90 days)

PAXLOVID - nirmatrelvir tab 20 x 150 mg & ritonavir tab 10 x 100 mg pak

QL (30 tablets/90 days)

PEGASYS - peginterferon alfa-2a soln prefilled syr 180 mcg/0.5ml

PA, SP

PEGASYS - peginterferon alfa-2a inj 180 mcg/ml

PA, SP

PREZISTA - darunavir oral susp 100 mg/ml

QL (2 bottles/30 days)

PREZISTA - darunavir tab 75 mg

QL (300 tablets/30 days)

PREZISTA - darunavir tab 150 mg

QL (180 tablets/30 days)

SOVALDI - sofosbuvir tab 200 mg, 400 mg

PA, QL (30 tablets/30 days), SP

SOVALDI - sofosbuvir pellet pack 150 mg, 200 mg

PA, QL (30 packets/30 days), SP

SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab 800-150-200-10 mg

QL (30 tablets/30 days)

TIVICAY - dolutegravir sodium tab 50 mg (base equiv)

QL (60 tablets/30 days)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 3

Drug Name

Requirements/Limits

TIVICAY PD - dolutegravir sodium tab for oral susp 5 mg (base equiv)

QL (360 tablets/30 days)

TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg

QL (30 tablets/30 days)

TRIUMEQ PD - abacavir-dolutegravir-lamivudine tab for oral sus 60-5-30 mg

QL (180 tablets/30 days)

valacyclovir hcl tab 500 mg (Valtrex)

VEMLIDY - tenofovir alafenamide fumarate tab 25 mg

VIREAD - tenofovir disoproxil fumarate tab 150 mg, 200 mg, 250 mg

QL (30 tablets/30 days)

VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm

QL (4 bottles/30 days)

VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg

PA, QL (30 tablets/30 days), SP

ANTHELMINTICS

BENZNIDAZOLE - benznidazole tab 12.5 mg, 100 mg

ANTI-INFECTIVE AGENTS - MISC.

ALINIA - nitazoxanide for susp 100 mg/5ml

QL (180 mls/30 days)

clindamycin hcl cap 75 mg, 150 mg, 300 mg (Cleocin)

IMPAVIDO - miltefosine cap 50 mg

metronidazole tab 250 mg, 500 mg (Flagyl)

nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)

sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)

sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)

trimethoprim tab 100 mg

XIFAXAN - rifaximin tab 550 mg

QL (60 tablets/30 days)

ANTINEOPLASTIC AGENTS

ANTINEOPLASTICS

ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)

ALECENSA - alectinib hcl cap 150 mg (base equivalent)

PA, QL (240 capsules/30 days), SP

ALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg

PA, QL (1 pack/180 days), SP

ALUNBRIG - brigatinib tab 30 mg

PA, QL (120 tablets/30 days), SP

ALUNBRIG - brigatinib tab 90 mg, 180 mg

PA, QL (30 tablets/30 days), SP

anastrozole tab 1 mg (Arimidex)

AYVAKIT - avapritinib tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mg

PA, QL (30 tablets/30 days), SP

bicalutamide tab 50 mg (Casodex)

BRUKINSA - zanubrutinib cap 80 mg

PA, QL (120 capsules/30 days), SP

CABOMETYX - cabozantinib s-malate tab 20 mg (base equivalent), 40 mg

(base equivalent), 60 mg (base equivalent)

PA, QL (30 tablets/30 days), SP

CALQUENCE - acalabrutinib maleate tab 100 mg

PA, QL (60 tablets/30 days), SP

COTELLIC - cobimetinib fumarate tab 20 mg (base equivalent)

PA, QL (63 tablets/28 days), SP

EMCYT - estramustine phosphate sodium cap 140 mg

ERIVEDGE - vismodegib cap 150 mg

PA, QL (30 capsules/30 days), SP

ERLEADA - apalutamide tab 60 mg

PA, QL (120 tablets/30 days), SP

ERLEADA - apalutamide tab 240 mg

PA, QL (30 tablets/30 days), SP

ETOPOSIDE - etoposide cap 50 mg

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 4

Drug Name

Requirements/Limits

GLEOSTINE - lomustine cap 10 mg, 40 mg, 100 mg

IBRANCE - palbociclib cap 75 mg, 100 mg, 125 mg

PA, QL (21 capsules/28 days), SP

IBRANCE - palbociclib tab 75 mg, 100 mg, 125 mg

PA, QL (21 tablets/28 days), SP

IMBRUVICA - ibrutinib tab 140 mg, 280 mg, 420 mg

PA, QL (30 tablets/30 days), SP

IMBRUVICA - ibrutinib oral susp 70 mg/ml

PA, QL (216 mls/30 days), SP

IMBRUVICA - ibrutinib cap 70 mg

PA, QL (30 capsules/30 days), SP

IMBRUVICA - ibrutinib cap 140 mg

PA, QL (90 capsules/30 days), SP

KISQALI - ribociclib succinate tab pack 200 mg daily dose

PA, QL (21 tablets/28 days), SP

KISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg tab)

PA, QL (42 tablets/28 days), SP

KISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mg tab)

PA, QL (63 tablets/28 days), SP

KISQALI FEMARA 200 DOSE - ribociclib 200 mg dose (200 mg tab) &

letrozole 2.5 mg tbpk

PA, QL (49 tablets/28 days), SP

KISQALI FEMARA 400 DOSE - ribociclib 400 mg dose (200 mg tab) &

letrozole 2.5 mg tbpk

PA, QL (70 tablets/28 days), SP

KISQALI FEMARA 600 DOSE - ribociclib 600 mg dose (200 mg tab) &

letrozole 2.5 mg tbpk

PA, QL (91 tablets/28 days), SP

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack 10 mg (10 mg

daily dose)

PA, QL (30 capsules/30 days), SP

LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 3 x 4 mg (12 mg

daily dose)

PA, QL (90 capsules/30 days), SP

LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 & 4 mg

(14 mg daily dose)

PA, QL (60 capsules/30 days), SP

LENVIMA 18 MG DAILY DOSE - lenvatinib cap ther pack 10 mg & 2 x 4 mg

(18 mg daily dose)

PA, QL (90 capsules/30 days), SP

LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 2 x 10 mg

(20 mg daily dose)

PA, QL (60 capsules/30 days), SP

LENVIMA 24 MG DAILY DOSE - lenvatinib cap ther pack 2 x 10 mg & 4 mg

(24 mg daily dose)

PA, QL (90 capsules/30 days), SP

LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg (4 mg daily

dose)

PA, QL (30 capsules/30 days), SP

LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 2 x 4 mg (8 mg

daily dose)

PA, QL (60 capsules/30 days), SP

letrozole tab 2.5 mg (Femara)

LEUKERAN - chlorambucil tab 2 mg

LYNPARZA - olaparib tab 100 mg, 150 mg

PA, QL (120 tablets/30 days), SP

MATULANE - procarbazine hcl cap 50 mg

PA, SP

megestrol acetate tab 20 mg, 40 mg

MEKINIST - trametinib dimethyl sulfoxide for soln 0.05 mg/ml (base eq)

PA, QL (13 bottles/28 days), SP

MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent)

PA, QL (90 tablets/30 days), SP

MEKINIST - trametinib dimethyl sulfoxide tab 2 mg (base equivalent)

PA, QL (30 tablets/30 days), SP

MESNEX - mesna tab 400 mg

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250 mg/10ml (25 mg/

ml)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 5

Drug Name

Requirements/Limits

methotrexate sodium inj 50 mg/2ml (25 mg/ml)

methotrexate sodium tab 2.5 mg (base equiv)

MYLERAN - busulfan tab 2 mg

NUBEQA - darolutamide tab 300 mg

PA, QL (120 tablets/30 days), SP

PIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack 200 mg daily dose

PA, QL (28 tablets/28 days), SP

PIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mg daily dose (200 mg

& 50 mg tabs)

PA, QL (56 tablets/28 days), SP

PIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mg daily dose

(2x150 mg tab)

PA, QL (56 tablets/28 days), SP

PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)

RETEVMO - selpercatinib cap 40 mg

PA, QL (180 capsules/30 days), SP

RETEVMO - selpercatinib cap 80 mg

PA, QL (120 capsules/30 days), SP

ROZLYTREK - entrectinib pellet pack 50 mg

PA, QL (336 pellets/28 days), SP

ROZLYTREK - entrectinib cap 100 mg

PA, QL (30 capsules/30 days), SP

ROZLYTREK - entrectinib cap 200 mg

PA, QL (90 capsules/30 days), SP

RUBRACA - rucaparib camsylate tab 200 mg (base equivalent), 250 mg (base

equivalent), 300 mg (base equivalent)

PA, QL (120 tablets/30 days), SP

RYDAPT - midostaurin cap 25 mg

PA, QL (240 capsules/30 days), SP

SPRYCEL - dasatinib tab 20 mg

PA, QL (90 tablets/30 days), SP

SPRYCEL - dasatinib tab 50 mg, 70 mg, 80 mg, 100 mg, 140 mg

PA, QL (30 tablets/30 days), SP

TABLOID - thioguanine tab 40 mg

TABRECTA - capmatinib hcl tab 150 mg, 200 mg

PA, QL (120 tablets/30 days), SP

TAFINLAR - dabrafenib mesylate cap 50 mg (base equivalent), 75 mg (base

equivalent)

PA, QL (120 capsules/30 days), SP

TAFINLAR - dabrafenib mesylate tab for oral susp 10 mg (base equiv)

PA, QL (4 bottles/28 days), SP

TAGRISSO - osimertinib mesylate tab 40 mg (base equivalent), 80 mg (base

equivalent)

PA, QL (30 tablets/30 days), SP

TALZENNA - talazoparib tosylate cap 0.1 mg (base equivalent), 0.35 mg

(base equivalent), 0.5 mg (base equivalent), 0.75 mg (base equivalent),

1 mg (base equivalent)

PA, QL (30 capsules/30 days), SP

TALZENNA - talazoparib tosylate cap 0.25 mg (base equivalent)

PA, QL (90 capsules/30 days), SP

tamoxifen citrate tab 10 mg (base equivalent), 20 mg (base equivalent)

TASIGNA - nilotinib hcl cap 50 mg (base equivalent), 150 mg (base

equivalent), 200 mg (base equivalent)

PA, QL (120 capsules/30 days), SP

TIBSOVO - ivosidenib tab 250 mg

PA, QL (60 tablets/30 days), SP

VENCLEXTA - venetoclax tab 10 mg

PA, QL (60 tablets/30 days), SP

VENCLEXTA - venetoclax tab 50 mg

PA, QL (30 tablets/30 days), SP

VENCLEXTA - venetoclax tab 100 mg

PA, QL (180 tablets/30 days), SP

VENCLEXTA STARTING PACK - venetoclax tab therapy starter pack 10 & 50

& 100 mg

PA, QL (1 pack/180 days), SP

VERZENIO - abemaciclib tab 50 mg, 100 mg, 150 mg, 200 mg

PA, QL (60 tablets/30 days), SP

VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml (base equivalent)

PA, QL (300 mls/30 days), SP

VITRAKVI - larotrectinib sulfate cap 25 mg (base equivalent)

PA, QL (180 capsules/30 days), SP

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 6

Drug Name

Requirements/Limits

VITRAKVI - larotrectinib sulfate cap 100 mg (base equivalent)

PA, QL (60 capsules/30 days), SP

VOTRIENT - pazopanib hcl tab 200 mg (base equiv)

PA, QL (120 tablets/30 days), SP

XALKORI - crizotinib cap 200 mg, 250 mg

PA, QL (60 capsules/30 days), SP

XALKORI - crizotinib cap sprinkle 20 mg, 50 mg

PA, QL (120 capsules/30 days), SP

XALKORI - crizotinib cap sprinkle 150 mg

PA, QL (180 capsules/30 days), SP

XTANDI - enzalutamide cap 40 mg

PA, QL (120 capsules/30 days), SP

XTANDI - enzalutamide tab 40 mg

PA, QL (120 tablets/30 days), SP

XTANDI - enzalutamide tab 80 mg

PA, QL (60 tablets/30 days), SP

YONSA - abiraterone acetate micronized tab 125 mg

PA, QL (120 tablets/30 days), SP

ZEJULA - niraparib tosylate tab 100 mg (base equivalent), 200 mg (base

equivalent), 300 mg (base equivalent)

PA, QL (30 tablets/30 days), SP

ZELBORAF - vemurafenib tab 240 mg

PA, QL (240 tablets/30 days), SP

ENDOCRINE AND METABOLIC DRUGS

CORTICOSTEROIDS

dexamethasone tab 1.5 mg, 4 mg, 6 mg

fludrocortisone acetate tab 0.1 mg

methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)

methylprednisolone tab 4 mg, 16 mg, 32 mg (Medrol)

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)

PREDNISONE - prednisone oral soln 5 mg/5ml

prednisone tab therapy pack 5 mg (21), 5 mg (48), 10 mg (21)

prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg

ANDROGEN-ANABOLIC

testosterone cypionate im inj in oil 100 mg/ml

PA, QL (10 ml/28 days)

ESTROGENS

COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/day,

0.05-0.25 mg/day

DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg

estradiol tab 0.5 mg, 1 mg, 2 mg (Estrace)

MYFEMBREE - relugolix-estradiol-norethindrone acetate tab 40-1-0.5 mg

PA, QL (30 tablets/30 days)

ORIAHNN - elagolix-estrad-noreth 300-1-0.5mg & elagolix 300mg cap pack

PA, QL (56 capsules/28 days)

PREMARIN - estrogens, conjugated tab 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg,

1.25 mg

PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14)

PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg,

0.45-1.5 mg, 0.625-2.5 mg, 0.625-5 mg

CONTRACEPTIVES

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) (Mircette)

AC, QL (28 tablets/21 days)

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)

QL (28 tablets/21 days)

drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28)

QL (28 tablets/21 days)

ELLA - ulipristal acetate tab 30 mg

AC, QL (2 tablets/365 days)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 7

Drug Name

Requirements/Limits

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg

QL (28 tablets/21 days)

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg, 0.15 mg-30 mcg

QL (28 tablets/21 days)

levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg

QL (28 tablets/21 days)

LO LOESTRIN FE - norethin-eth estradiol-fe tab 1 mg-10 mcg (24)/10 mcg (2)

QL (28 tablets/21 days)

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml (Depo-

provera contrac)

medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera

contrac)

norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)

QL (28 tablets/21 days)

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin 1/20-21)

QL (28 tablets/21 days)

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe

1/20)

AC, QL (28 tablets/21 days)

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe

1.5/30)

QL (28 tablets/21 days)

Norethindrone tab 0.35 mg (Nor-qd)

AC, QL (28 tablets/21 days)

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg

QL (28 tablets/21 days)

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho-cyclen)

QL (28 tablets/21 days)

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg (Ortho tri-

cyclen lo)

QL (28 tablets/21 days)

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-

cyclen)

AC, QL (28 tablets/21 days)

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg

QL (28 tablets/21 days)

NUVARING - etonogestrel-ethinyl estradiol va ring 0.12-0.015 mg/24hr

AC, QL (1 ring/21 days)

PROGESTINS

medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10 mg (Provera)

ANTIDIABETICS

BAQSIMI ONE PACK - glucagon nasal powder 3 mg/dose

BAQSIMI TWO PACK - glucagon nasal powder 3 mg/dose

FARXIGA - dapagliflozin propanediol tab 5 mg (base equivalent), 10 mg (base

equivalent)

QL (30 tablets/30 days)

glimepiride tab 1 mg, 2 mg, 4 mg (Amaryl)

glipizide tab er 24hr 2.5 mg, 5 mg, 10 mg (Glucotrol xl)

glipizide tab 5 mg, 10 mg (Glucotrol)

GLUCAGON EMERGENCY KIT FO - glucagon hcl for inj 1 mg

glyburide tab 1.25 mg, 2.5 mg, 5 mg

glyburide-metformin tab 1.25-250 mg, 2.5-500 mg, 5-500 mg (Glucovance)

GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg, 25-5 mg

QL (30 tablets/30 days)

GVOKE HYPOPEN 1-PACK - glucagon subcutaneous solution auto-injector

0.5 mg/0.1ml, 1 mg/0.2ml

GVOKE HYPOPEN 2-PACK - glucagon subcutaneous solution auto-injector

0.5 mg/0.1ml, 1 mg/0.2ml

GVOKE KIT - glucagon subcutaneous soln 1 mg/0.2ml

GVOKE PFS - glucagon subcutaneous soln pref syringe 1 mg/0.2ml

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 8

Drug Name

Requirements/Limits

JANUMET - sitagliptin-metformin hcl tab 50-500 mg, 50-1000 mg

QL (60 tablets/30 days)

JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg, 100-1000 mg

QL (30 tablets/30 days)

JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg

QL (60 tablets/30 days)

JANUVIA - sitagliptin phosphate tab 25 mg (base equiv), 50 mg (base equiv),

100 mg (base equiv)

QL (30 tablets/30 days)

JARDIANCE - empagliflozin tab 10 mg, 25 mg

QL (30 tablets/30 days)

metformin hcl tab er 24hr 500 mg, 750 mg (Glucophage xr)

metformin hcl tab 500 mg, 850 mg, 1000 mg (Glucophage)

MOUNJARO - tirzepatide soln pen-injector 2.5 mg/0.5ml, 5 mg/0.5ml,

7.5 mg/0.5ml, 10 mg/0.5ml, 12.5 mg/0.5ml, 15 mg/0.5ml

PA, QL (4 pens/28 days)

OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose (2 mg/3ml)

PA, QL (1 pen/28 days)

OZEMPIC - semaglutide soln pen-inj 1 mg/dose (4 mg/3ml)

PA, QL (3 ml/28 days)

OZEMPIC - semaglutide soln pen-inj 2 mg/dose (8 mg/3ml)

PA, QL (3 mls/28 days)

pioglitazone hcl tab 15 mg (base equiv), 30 mg (base equiv), 45 mg (base

equiv) (Actos)

RYBELSUS - semaglutide tab 3 mg

PA, QL (30 tablets/180 days)

RYBELSUS - semaglutide tab 7 mg, 14 mg

PA, QL (30 tablets/30 days)

SOLIQUA 100/33 - insulin glargine-lixisenatide sol pen-inj 100-33 unit-mcg/ml

QL (18 mls/30 days), ST

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg, 5-1000 mg,

12.5-500 mg, 12.5-1000 mg

QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr 5-1000 mg,

10-1000 mg, 12.5-1000 mg

QL (60 tablets/30 days)

SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr 25-1000 mg

QL (30 tablets/30 days)

TRIJARDY XR - empagliflozin-linagliptin-metformin tab er 24hr 5-2.5-1000mg

QL (60 tablets/30 days)

TRIJARDY XR - empagliflozin-linagliptin-metformin tab er 24hr 10-5-1000 mg,

25-5-1000 mg

QL (30 tablets/30 days)

TRIJARDY XR - empagliflozin-linaglip-metformin tab er 24hr 12.5-2.5-1000mg

QL (60 tablets/30 days)

TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml, 1.5 mg/0.5ml,

3 mg/0.5ml, 4.5 mg/0.5ml

PA, QL (4 pens/28 days)

XIGDUO XR - dapagliflozin prop-metformin hcl tab er 24hr 2.5-1000 mg,

5-1000 mg

QL (60 tablets/30 days)

XIGDUO XR - dapagliflozin prop-metformin hcl tab er 24hr 5-500 mg,

10-500 mg, 10-1000 mg

QL (30 tablets/30 days)

XULTOPHY 100/3.6 - insulin degludec-liraglutide sol pen-inj 100-3.6 unit-mg/

QL (15 mls/30 days), ST

ZEGALOGUE - dasiglucagon hcl subcutaneous soln auto-inj 0.6 mg/0.6ml

ZEGALOGUE - dasiglucagon hcl subcutaneous soln pref syringe

0.6 mg/0.6ml

Rapid-Acting Insulins

FIASP - insulin aspart (with niacinamide) inj 100 unit/ml

QL (100 mls/30 days)

FIASP FLEXTOUCH - insulin aspart (with niacinamide) sol pen-inj 100 unit/ml

QL (100 mls/30 days)

FIASP PENFILL - insulin aspart (with niacinamide) soln cartridge 100 unit/ml

QL (100 mls/30 days)

INSULIN ASPART - insulin aspart inj soln 100 unit/ml

PA, QL (100 mls/30 days)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 9

Drug Name

Requirements/Limits

INSULIN ASPART FLEXPEN - insulin aspart soln pen-injector 100 unit/ml

PA, QL (100 mls/30 days)

INSULIN ASPART PENFILL - insulin aspart soln cartridge 100 unit/ml

PA, QL (100 mls/30 days)

NOVOLOG - insulin aspart inj soln 100 unit/ml

QL (100 mls/30 days)

NOVOLOG FLEXPEN - insulin aspart soln pen-injector 100 unit/ml

QL (100 mls/30 days)

NOVOLOG PENFILL - insulin aspart soln cartridge 100 unit/ml

QL (100 mls/30 days)

Short-Acting Insulins

HUMULIN R U-500 (CONCENTR - insulin regular (human) inj 500 unit/ml

QL (100 mls/30 days)

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500

unit/ml

QL (100 mls/30 days)

NOVOLIN R - insulin regular (human) inj 100 unit/ml

QL (100 mls/30 days)

NOVOLIN R FLEXPEN - insulin regular (human) soln pen-injector 100 unit/ml

QL (100 mls/30 days)

Intermediate-Acting Insulins

INSULIN ASPART PROTAMINE/ - insulin aspart prot & aspart sus pen-inj 100

unit/ml (70-30)

PA, QL (100 mls/30 days)

INSULIN ASPART PROTAMINE/ - insulin aspart prot & aspart (human) inj 100

unit/ml (70-30)

PA, QL (100 mls/30 days)

NOVOLIN N - insulin nph (human) (isophane) inj 100 unit/ml

QL (100 mls/30 days)

NOVOLIN N FLEXPEN - insulin nph (human) (isophane) susp pen-injector

100 unit/ml

QL (100 mls/30 days)

NOVOLIN 70/30 - insulin nph isophane & regular human inj 100 unit/ml

(70-30)

QL (100 mls/30 days)

NOVOLIN 70/30 FLEXPEN - insulin nph & regular susp pen-inj 100 unit/ml

(70-30)

QL (100 mls/30 days)

NOVOLOG MIX 70/30 - insulin aspart prot & aspart (human) inj 100 unit/ml

(70-30)

QL (100 mls/30 days)

NOVOLOG MIX 70/30 PREFILL - insulin aspart prot & aspart sus pen-inj 100

unit/ml (70-30)

QL (100 mls/30 days)

Basal Insulins

INSULIN GLARGINE-YFGN - insulin glargine-yfgn soln pen-injector 100 unit/

QL (100 mls/30 days)

INSULIN GLARGINE-YFGN - insulin glargine-yfgn inj 100 unit/ml

QL (100 mls/30 days)

LEVEMIR - insulin detemir inj 100 unit/ml

QL (100 mls/30 days)

LEVEMIR FLEXPEN - insulin detemir soln pen-injector 100 unit/ml

QL (100 mls/30 days)

SEMGLEE - insulin glargine-yfgn soln pen-injector 100 unit/ml

QL (100 mls/30 days)

SEMGLEE - insulin glargine-yfgn inj 100 unit/ml

QL (100 mls/30 days)

TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (2

unit dial)

QL (100 mls/30 days)

TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (1 unit

dial)

QL (100 mls/30 days)

TRESIBA - insulin degludec inj 100 unit/ml

QL (100 mls/30 days)

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100 unit/ml, 200

unit/ml

QL (100 mls/30 days)

THYROID AGENTS

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 10

Drug Name

Requirements/Limits

levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg,

112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg

(Synthroid)

methimazole tab 5 mg, 10 mg (Tapazole)

ENDOCRINE and METABOLIC AGENTS - MISC.

alendronate sodium tab 10 mg

QL (30 tablets/30 days)

alendronate sodium tab 35 mg

QL (4 tablets/28 days)

alendronate sodium tab 70 mg (Fosamax)

QL (4 tablets/28 days)

calcitriol cap 0.25 mcg (Rocaltrol)

CLOMID - clomiphene citrate tab 50 mg

FOLLISTIM AQ - follitropin beta inj 300 unit/0.36ml

QL (15 cartridges/30 days), SP

FOLLISTIM AQ - follitropin beta inj 600 unit/0.72ml

QL (8 cartridges/30 days), SP

FOLLISTIM AQ - follitropin beta inj 900 unit/1.08ml

QL (5 cartridges/30 days), SP

FORTEO - teriparatide (recombinant) soln pen-inj 600 mcg/2.4ml

PA, QL (1 injection/28 days), SP

GENOTROPIN - somatropin for subcutaneous inj cartridge 5 mg, 12 mg (36

unit)

PA, SP

GENOTROPIN MINIQUICK - somatropin for subcutaneous inj prefilled syr

0.2 mg, 0.4 mg, 0.6 mg, 0.8 mg, 1 mg, 1.2 mg, 1.4 mg, 1.6 mg, 1.8 mg,

2 mg

PA, SP

ibandronate sodium tab 150 mg (base equivalent) (Boniva)

QL (1 tablet/30 days)

INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)

NITYR - nitisinone tab 2 mg, 5 mg, 10 mg

NORDITROPIN FLEXPRO - somatropin solution pen-injector 5 mg/1.5ml,

10 mg/1.5ml, 15 mg/1.5ml, 30 mg/3ml

PA, SP

OMNITROPE - somatropin solution cartridge 5 mg/1.5ml, 10 mg/1.5ml

PA, SP

OMNITROPE - somatropin for inj 5.8 mg

PA, SP

ORFADIN - nitisinone susp 4 mg/ml

ORILISSA - elagolix sodium tab 150 mg (base equiv)

PA, QL (30 tablets/30 days)

ORILISSA - elagolix sodium tab 200 mg (base equiv)

PA, QL (60 tablets/30 days)

OVIDREL - choriogonadotropin alfa inj 250 mcg/0.5ml

QL (2 syringes/30 days), SP

PREGNYL - chorionic gonadotropin for im inj 10000 unit

QL (20 vials/30 days), SP

PREGNYL W/DILUENT BENZYL - chorionic gonadotropin for im inj 10000 unit

QL (20 vials/30 days), SP

REVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 mg/ml)

STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml, 28 mg/0.7ml,

40 mg/ml, 80 mg/0.8ml

PA, SP

TYMLOS - abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56ml

PA, QL (1.56 mls/30 days), SP

CARDIOVASCULAR AGENTS

CARDIOTONICS

digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg) (Lanoxin)

ANTIANGINAL AGENTS

isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120 mg

nitroglycerin sl tab 0.4 mg (Nitrostat)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 11

Drug Name

Requirements/Limits

BETA BLOCKERS

atenolol tab 25 mg, 50 mg, 100 mg (Tenormin)

bisoprolol fumarate tab 5 mg

carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg (Coreg)

labetalol hcl tab 100 mg (Trandate)

metoprolol succinate tab er 24hr 25 mg (tartrate equiv), 50 mg (tartrate

equiv), 100 mg (tartrate equiv) (Toprol xl)

metoprolol tartrate tab 25 mg, 37.5 mg, 75 mg

metoprolol tartrate tab 50 mg, 100 mg (Lopressor)

PROPRANOLOL HCL - propranolol hcl oral soln 40 mg/5ml

propranolol hcl oral soln 20 mg/5ml

propranolol hcl tab 10 mg, 20 mg, 40 mg

sotalol hcl (afib/afl) tab 80 mg (Betapace af)

sotalol hcl tab 80 mg, 120 mg (Betapace)

CALCIUM CHANNEL BLOCKERS

amlodipine besylate tab 2.5 mg (base equivalent), 5 mg (base

equivalent), 10 mg (base equivalent) (Norvasc)

diltiazem hcl cap er 24hr 120 mg

diltiazem hcl coated beads cap er 24hr 120 mg, 180 mg, 240 mg

(Cardizem cd)

diltiazem hcl extended release beads cap er 24hr 120 mg, 180 mg

(Tiazac)

diltiazem hcl tab 30 mg, 60 mg (Cardizem)

felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg

nifedipine tab er 24hr 30 mg (Adalat cc)

nifedipine tab er 24hr osmotic release 30 mg (Procardia xl)

verapamil hcl tab er 120 mg, 180 mg, 240 mg (Calan sr)

verapamil hcl tab 40 mg

verapamil hcl tab 80 mg, 120 mg (Calan)

ANTIARRHYTHMICS

amiodarone hcl tab 200 mg (Cordarone)

MULTAQ - dronedarone hcl tab 400 mg (base equivalent)

propafenone hcl tab 150 mg

ANTIHYPERTENSIVES

amlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-10 mg, 5-20 mg,

5-40 mg, 10-20 mg, 10-40 mg (Lotrel)

atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)

benazepril hcl tab 5 mg

benazepril hcl tab 10 mg, 20 mg, 40 mg (Lotensin)

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg, 5-6.25 mg, 10-6.25 mg

(Ziac)

clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg (Catapres)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 12

Drug Name

Requirements/Limits

doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg (Cardura)

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)

enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg (Vasotec)

fosinopril sodium tab 10 mg, 20 mg, 40 mg

hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg

irbesartan tab 75 mg, 150 mg, 300 mg (Avapro)

irbesartan-hydrochlorothiazide tab 150-12.5 mg, 300-12.5 mg (Avalide)

lisinopril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg, 20-25 mg

(Zestoretic)

lisinopril tab 2.5 mg, 30 mg, 40 mg (Zestril)

lisinopril tab 5 mg, 10 mg, 20 mg (Prinivil)

losartan potassium & hydrochlorothiazide tab 50-12.5 mg, 100-12.5 mg,

100-25 mg (Hyzaar)

losartan potassium tab 25 mg, 50 mg, 100 mg (Cozaar)

minoxidil tab 2.5 mg, 10 mg

olmesartan medoxomil tab 5 mg, 20 mg, 40 mg (Benicar)

olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg, 40-12.5 mg,

40-25 mg (Benicar hct)

prazosin hcl cap 1 mg (Minipress)

quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg (Accupril)

ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg (Altace)

telmisartan tab 20 mg (Micardis)

terazosin hcl cap 1 mg (base equivalent), 2 mg (base equivalent), 5 mg

(base equivalent), 10 mg (base equivalent)

trandolapril tab 1 mg, 2 mg, 4 mg (Mavik)

valsartan tab 40 mg, 80 mg, 160 mg, 320 mg (Diovan)

DIURETICS

amiloride hcl tab 5 mg

bumetanide tab 0.5 mg (Bumex)

chlorthalidone tab 25 mg, 50 mg

furosemide oral soln 10 mg/ml

furosemide tab 20 mg, 40 mg, 80 mg (Lasix)

hydrochlorothiazide cap 12.5 mg (Microzide)

hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg

indapamide tab 1.25 mg, 2.5 mg

spironolactone tab 25 mg, 50 mg, 100 mg (Aldactone)

torsemide tab 5 mg, 10 mg, 20 mg, 100 mg (Demadex)

triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)

triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)

triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 13

Drug Name

Requirements/Limits

VASOPRESSORS

AUVI-Q - epinephrine solution auto-injector 0.1 mg/0.1ml, 0.15 mg/0.15ml

(1:1000), 0.3 mg/0.3ml (1:1000)

ANTIHYPERLIPIDEMICS

atorvastatin calcium tab 10 mg (base equivalent), 20 mg (base

equivalent), 40 mg (base equivalent), 80 mg (base equivalent) (Lipitor)

choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)

ezetimibe tab 10 mg (Zetia)

fenofibrate micronized cap 67 mg, 134 mg

fenofibrate tab 48 mg, 145 mg (Tricor)

fenofibrate tab 54 mg, 160 mg (Lofibra)

gemfibrozil tab 600 mg (Lopid)

lovastatin tab 10 mg

lovastatin tab 20 mg

lovastatin tab 40 mg (Mevacor)

NEXLETOL - bempedoic acid tab 180 mg

PA, QL (30 tablets/30 days)

NEXLIZET - bempedoic acid-ezetimibe tab 180-10 mg

PA, QL (30 tablets/30 days)

pravastatin sodium tab 10 mg

pravastatin sodium tab 20 mg, 40 mg, 80 mg (Pravachol)

REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml

PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneous soln

cartridge/infusor 420 mg/3.5ml

PA, QL (2 cartridges/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector

140 mg/ml

PA, QL (2 injectors/28 days)

rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40 mg (Crestor)

simvastatin tab 5 mg, 10 mg, 20 mg, 40 mg, 80 mg (Zocor)

CARDIOVASCULAR AGENTS - MISC.

CORLANOR - ivabradine hcl tab 5 mg (base equiv), 7.5 mg (base equiv)

PA, QL (60 tablets/30 days)

CORLANOR - ivabradine hcl oral soln 5 mg/5ml (base equiv)

PA, QL (600 mls/30 days)

ENTRESTO - sacubitril-valsartan tab 24-26 mg, 49-51 mg, 97-103 mg

OPSUMIT - macitentan tab 10 mg

PA, QL (30 tablets/30 days), SP

tadalafil tab 2.5 mg, 5 mg (Cialis)

QL (30 tablets/30 days)

tadalafil tab 10 mg, 20 mg (Cialis)

QL (8 tablets/30 days)

TRACLEER - bosentan tab for oral susp 32 mg

PA, QL (120 tablets/30 days), SP

UPTRAVI - selexipag tab 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1000 mcg,

1200 mcg, 1400 mcg, 1600 mcg

PA, QL (60 tablets/30 days), SP

UPTRAVI TITRATION PACK - selexipag tab therapy pack 200 mcg (140) &

800 mcg (60)

PA, QL (1 pack/180 days), SP

VERQUVO - vericiguat tab 2.5 mg, 5 mg, 10 mg

PA, QL (30 tablets/30 days)

VYNDAMAX - tafamidis cap 61 mg

PA, QL (30 capsules/30 days), SP

VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg

PA, QL (120 capsules/30 days), SP

ERECTILE DYSFUNCTION

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 14

Drug Name

Requirements/Limits

sildenafil citrate tab 25 mg, 50 mg, 100 mg (Viagra)

QL (8 tablets/30 days)

tadalafil tab 2.5 mg, 5 mg (Cialis)

QL (30 tablets/30 days)

tadalafil tab 10 mg, 20 mg (Cialis)

QL (8 tablets/30 days)

RESPIRATORY AGENTS

ANTIHISTAMINES

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)

cyproheptadine hcl syrup 2 mg/5ml

cyproheptadine hcl tab 4 mg

desloratadine tab 5 mg (Clarinex)

levocetirizine dihydrochloride tab 5 mg

promethazine hcl oral soln 6.25 mg/5ml

promethazine hcl tab 12.5 mg, 25 mg, 50 mg

NASAL AGENTS - SYSTEMIC and TOPICAL

azelastine hcl nasal spray 0.1% (137 mcg/spray)

QL (2 bottles/30 days)

fluticasone propionate nasal susp 50 mcg/act

QL (1 bottle/30 days)

COUGH/COLD/ALLERGY

benzonatate cap 100 mg (Tessalon perles)

benzonatate cap 200 mg

hydrocodone bitart-homatropine methylbrom soln 5-1.5 mg/5ml

(Hycodan)

promethazine w/ codeine syrup 6.25-10 mg/5ml

promethazine-dm syrup 6.25-15 mg/5ml

pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml

sodium chloride soln nebu 3%

sodium chloride soln nebu 7% (Hypersal)

ANTIASTHMATIC and BRONCHODILATOR AGENTS

ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act,

115-21 mcg/act, 230-21 mcg/act

QL (1 inhaler/30 days)

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)

QL (125 containers/30 days)

albuterol sulfate syrup 2 mg/5ml

ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba 62.5-25 mcg/act

QL (60 blisters/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breath activ 50 mcg/

act, 100 mcg/act, 200 mcg/act

QL (30 blisters/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension 50 mcg/act

QL (13 grams/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension 100 mcg/act,

200 mcg/act

QL (1 inhaler/30 days)

ASMANEX TWISTHALER 120 ME - mometasone furoate inhal powd

220 mcg/act (breath activated)

QL (1 inhaler/30 days)

ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd

110 mcg/act (breath activated), 220 mcg/act (breath activated)

QL (1 inhaler/30 days)

ASMANEX TWISTHALER 60 MET - mometasone furoate inhal powd

220 mcg/act (breath activated)

QL (1 inhaler/30 days)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 15

Drug Name

Requirements/Limits

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 50-25 mcg/act

QL (1 inhaler/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 100-25 mcg/act,

200-25 mcg/act

QL (60 blisters/30 days)

BREZTRI AEROSPHERE - budesonide-glycopyrrolate-formoterol aers

160-9-4.8 mcg/act

QL (1 inhaler/30 days)

COMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act

QL (2 inhalers/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol 50-5 mcg/act,

100-5 mcg/act, 200-5 mcg/act

QL (3 inhalers/30 days)

FASENRA PEN - benralizumab subcutaneous soln auto-injector 30 mg/ml

PA, QL (1 pen/56 days), SP

FLUTICASONE PROPIONATE/SA - fluticasone-salmeterol aer powder ba

55-14 mcg/act

FLUTICASONE PROPIONATE/SA - fluticasone-salmeterol aer powder ba

113-14 mcg/act, 232-14 mcg/act

QL (1 inhaler/30 days)

INCRUSE ELLIPTA - umeclidinium br aero powd breath act 62.5 mcg/act

(base eq)

QL (30 blisters/30 days)

ipratropium bromide inhal soln 0.02%

QL (150 containers/30 days)

montelukast sodium chew tab 4 mg (base equiv), 5 mg (base equiv)

(Singulair)

montelukast sodium tab 10 mg (base equiv) (Singulair)

NUCALA - mepolizumab subcutaneous solution auto-injector 100 mg/ml

PA, QL (3 ml/28 days), SP

NUCALA - mepolizumab subcutaneous solution pref syringe 40 mg/0.4ml

PA, QL (1 syringe/28 days), SP

NUCALA - mepolizumab subcutaneous solution pref syringe 100 mg/ml

PA, QL (3 ml/28 days), SP

QVAR REDIHALER - beclomethasone diprop hfa breath act inh aer 40 mcg/

act

QL (1 inhaler/30 days)

QVAR REDIHALER - beclomethasone diprop hfa breath act inh aer 80 mcg/

act

QL (2 inhalers/30 days)

SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/act (base

equiv)

QL (60 blisters/30 days)

SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal cap 18 mcg

(base equiv)

QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal aerosol

1.25 mcg/act

QL (4 grams/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal aerosol 2.5 mcg/

act

QL (1 cartridge/30 days)

STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/act

QL (1 inhaler/30 days)

STRIVERDI RESPIMAT - olodaterol hcl inhal aerosol soln 2.5 mcg/act (base

equiv)

QL (1 inhaler/30 days)

TEZSPIRE - tezepelumab-ekko subcutaneous soln auto-inj 210 mg/1.91ml

PA, QL (1 pen/28 days), SP

TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/act

QL (60 blisters/30 days)

TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

200-62.5-25 mcg/act

QL (1 inhaler/30 days)

VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)

QL (2 inhalers/30 days)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 16

Drug Name

Requirements/Limits

XOLAIR - omalizumab subcutaneous soln auto-injector 75 mg/0.5ml, 150 mg/

ml, 300 mg/2ml

PA, SP

XOLAIR - omalizumab subcutaneous soln prefilled syringe 75 mg/0.5ml,

150 mg/ml, 300 mg/2ml

PA, SP

RESPIRATORY AGENTS - MISC.

KALYDECO - ivacaftor tab 150 mg

PA, QL (60 tablets/30 days), SP

KALYDECO - ivacaftor packet 5.8 mg, 13.4 mg, 25 mg, 50 mg, 75 mg

PA, QL (60 packets/30 days), SP

PULMOZYME - dornase alfa inhal soln 2.5 mg/2.5ml

SYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab tbpk

PA, QL (60 tablets/30 days), SP

SYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mg tab tbpk

PA, QL (60 tablets/30 days), SP

TRIKAFTA - elexacaf-tezacaf-ivacaf 80-40-60 mg& ivacaf 59.5mg thpk gran

PA, QL (56 packets/28 days), SP

TRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg& ivacaf 75mg thpk gran

PA, QL (56 packets/28 days), SP

TRIKAFTA - elexacaf-tezacaf-ivacaf 50-25-37.5 mg & ivacaftor 75 mg tbpk

PA, QL (90 tablets/30 days), SP

TRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor 150 mg tbpk

PA, QL (90 tablets/30 days), SP

GASTROINTESTINAL AGENTS

LAXATIVES

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)

ULCER DRUGS

cimetidine tab 200 mg

dicyclomine hcl cap 10 mg (Bentyl)

dicyclomine hcl tab 20 mg (Bentyl)

esomeprazole magnesium cap delayed release 20 mg (base eq), 40 mg

(base eq) (Nexium)

QL (60 capsules/30 days)

famotidine tab 20 mg, 40 mg (Pepcid)

glycopyrrolate tab 1 mg (Robinul)

lansoprazole cap delayed release 30 mg (Prevacid)

QL (60 capsules/30 days)

misoprostol tab 100 mcg, 200 mcg (Cytotec)

NEXIUM - esomeprazole magnesium for delayed release susp pack 2.5 mg

PA, QL (60 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susp packet 5 mg

PA, QL (60 packets/30 days)

omeprazole cap delayed release 10 mg, 20 mg, 40 mg (Prilosec)

QL (60 capsules/30 days)

pantoprazole sodium ec tab 20 mg (base equiv), 40 mg (base equiv)

(Protonix)

QL (60 tablets/30 days)

rabeprazole sodium ec tab 20 mg (Aciphex)

QL (60 tablets/30 days)

ANTIEMETICS

EMEND - aprepitant for oral susp 125 mg (125 mg/5ml)

QL (9 kits/30 days)

meclizine hcl tab 12.5 mg, 25 mg

ondansetron hcl oral soln 4 mg/5ml

QL (300 ml/30 days)

ondansetron hcl tab 4 mg, 8 mg (Zofran)

QL (30 tablets/30 days)

ondansetron orally disintegrating tab 4 mg, 8 mg (Zofran odt)

QL (30 tablets/30 days)

DIGESTIVE AIDS

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 17

Drug Name

Requirements/Limits

CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit,

6000-19000-30000 unit, 12000-38000-60000 unit, 24000-76000-120000

unit, 36000-114000-180000 unit

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000 unit,

5000-17000-24000 unit, 10000-32000-42000 unit, 15000-47000-63000 unit,

20000-63000-84000 unit, 25000-79000-105000 unit, 40000-126000-168000

unit, 60000-189600-252600 unit

GASTROINTESTINAL AGENTS- MISC.

CHENODAL - chenodiol tab 250 mg

lactulose (encephalopathy) solution 10 gm/15ml

LINZESS - linaclotide cap 72 mcg, 145 mcg, 290 mcg

QL (30 capsules/30 days)

metoclopramide hcl tab 5 mg (base equivalent), 10 mg (base equivalent)

(Reglan)

MOVANTIK - naloxegol oxalate tab 12.5 mg (base equivalent), 25 mg (base

equivalent)

QL (30 tablets/30 days)

SKYRIZI - risankizumab-rzaa subcutaneous soln cartridge 180 mg/1.2ml

PA, QL (1 cartridge/56 days), SP

SKYRIZI - risankizumab-rzaa subcutaneous soln cartridge 360 mg/2.4ml

PA, QL (2.4 mls/56 days), SP

SYMPROIC - naldemedine tosylate tab 0.2 mg (base equivalent)

QL (30 tablets/30 days)

TRULANCE - plecanatide tab 3 mg

QL (30 tablets/30 days)

VELPHORO - sucroferric oxyhydroxide chew tab 500 mg

VIBERZI - eluxadoline tab 75 mg, 100 mg

QL (60 tablets/30 days)

GENITOURINARY AGENTS

URINARY ANTISPASMODICS

oxybutynin chloride solution 5 mg/5ml

oxybutynin chloride tab er 24hr 5 mg, 10 mg (Ditropan xl)

oxybutynin chloride tab er 24hr 15 mg

oxybutynin chloride tab 5 mg

solifenacin succinate tab 5 mg, 10 mg (Vesicare)

VAGINAL PRODUCTS

CRINONE - progesterone vaginal gel 4%, 8%

QL (60 applicators/30 days)

ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs)

GENITOURINARY AGENTS - MISC.

alfuzosin hcl tab er 24hr 10 mg (Uroxatral)

CYSTAGON - cysteamine bitartrate cap 50 mg, 150 mg

dutasteride cap 0.5 mg (Avodart)

finasteride tab 5 mg (Proscar)

tamsulosin hcl cap 0.4 mg (Flomax)

CENTRAL NERVOUS SYSTEM DRUGS

ANTIANXIETY AGENTS

alprazolam tab er 24hr 0.5 mg, 1 mg, 2 mg, 3 mg (Xanax xr)

alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg (Xanax)

buspirone hcl tab 5 mg, 10 mg, 15 mg

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 18

Drug Name

Requirements/Limits

chlordiazepoxide hcl cap 5 mg, 10 mg, 25 mg

diazepam oral soln 1 mg/ml

diazepam tab 2 mg, 5 mg, 10 mg (Valium)

hydroxyzine hcl tab 10 mg, 25 mg, 50 mg

hydroxyzine pamoate cap 25 mg, 50 mg (Vistaril)

lorazepam tab 0.5 mg, 1 mg, 2 mg (Ativan)

QL (150 tablets/30 days)

ANTIDEPRESSANTS

amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg

bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg (Wellbutrin sr)

bupropion hcl tab er 24hr 150 mg, 300 mg (Wellbutrin xl)

bupropion hcl tab 75 mg, 100 mg

citalopram hydrobromide tab 10 mg (base equiv), 20 mg (base equiv),

40 mg (base equiv) (Celexa)

doxepin hcl cap 10 mg, 25 mg

doxepin hcl conc 10 mg/ml

duloxetine hcl enteric coated pellets cap 20 mg (base eq), 60 mg (base

eq) (Cymbalta)

QL (60 capsules/30 days)

duloxetine hcl enteric coated pellets cap 30 mg (base eq) (Cymbalta)

QL (90 capsules/30 days)

escitalopram oxalate tab 5 mg (base equiv), 10 mg (base equiv), 20 mg

(base equiv) (Lexapro)

fluoxetine hcl cap 10 mg, 20 mg, 40 mg (Prozac)

fluoxetine hcl tab 10 mg

imipramine hcl tab 10 mg, 25 mg, 50 mg (Tofranil)

mirtazapine tab 15 mg, 30 mg, 45 mg (Remeron)

nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg (Pamelor)

paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg (Paxil)

sertraline hcl tab 25 mg, 50 mg, 100 mg (Zoloft)

trazodone hcl tab 50 mg, 100 mg, 150 mg

venlafaxine hcl cap er 24hr 37.5 mg (base equivalent), 75 mg (base

equivalent), 150 mg (base equivalent) (Effexor xr)

venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg (base equivalent),

50 mg (base equivalent), 75 mg (base equivalent), 100 mg (base

equivalent)

ZURZUVAE - zuranolone cap 20 mg, 25 mg

QL (28 capsules/365 days)

ZURZUVAE - zuranolone cap 30 mg

QL (14 capsule/365 days)

ANTIPSYCHOTICS

aripiprazole tab 2 mg, 5 mg (Abilify)

QL (60 tablets/30 days)

aripiprazole tab 10 mg, 15 mg (Abilify)

QL (30 tablets/30 days)

clozapine tab 25 mg (Clozaril)

QL (270 tablets/30 days)

FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml

FLUPHENAZINE HYDROCHLORID - fluphenazine hcl elixir 2.5 mg/5ml

haloperidol tab 0.5 mg, 1 mg

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 19

Drug Name

Requirements/Limits

lithium carbonate cap 150 mg, 600 mg (Lithium carbonate)

lithium carbonate cap 300 mg

lithium carbonate tab er 300 mg (Lithobid)

lithium carbonate tab er 450 mg

lithium carbonate tab 300 mg

olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg (Zyprexa)

QL (60 tablets/30 days)

olanzapine tab 15 mg, 20 mg (Zyprexa)

QL (30 tablets/30 days)

prochlorperazine maleate tab 5 mg (base equivalent) (Compazine)

quetiapine fumarate tab er 24hr 150 mg (Seroquel xr)

QL (30 tablets/30 days)

quetiapine fumarate tab 25 mg, 50 mg (Seroquel)

QL (180 tablets/30 days)

quetiapine fumarate tab 100 mg (Seroquel)

QL (120 tablets/30 days)

quetiapine fumarate tab 200 mg (Seroquel)

QL (90 tablets/30 days)

quetiapine fumarate tab 300 mg, 400 mg (Seroquel)

QL (60 tablets/30 days)

REXULTI - brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

QL (30 tablets/30 days), ST

risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg (Risperdal)

QL (120 tablets/30 days)

risperidone tab 3 mg (Risperdal)

QL (60 tablets/30 days)

HYPNOTICS

BELSOMRA - suvorexant tab 5 mg, 10 mg, 15 mg, 20 mg

QL (30 tablets/30 days), ST

eszopiclone tab 1 mg, 2 mg, 3 mg (Lunesta)

QL (30 tablets/30 days)

phenobarbital tab 15 mg, 30 mg, 60 mg, 100 mg

temazepam cap 15 mg, 30 mg (Restoril)

triazolam tab 0.125 mg

zaleplon cap 5 mg, 10 mg (Sonata)

QL (30 capsules/30 days)

zolpidem tartrate tab 5 mg, 10 mg (Ambien)

QL (30 tablets/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

amphetamine-dextroamphetamine tab 5 mg (Adderall)

QL (60 tablets/30 days)

armodafinil tab 50 mg (Nuvigil)

dexmethylphenidate hcl tab 2.5 mg, 5 mg (Focalin)

QL (60 tablets/30 days)

diethylpropion hcl tab 25 mg

PA, QL (90 tablets/30 days)

guanfacine hcl tab er 24hr 1 mg (base equiv), 2 mg (base equiv), 3 mg

(base equiv), 4 mg (base equiv) (Intuniv)

QL (30 tablets/30 days)

methylphenidate hcl tab 5 mg, 10 mg (Ritalin)

QL (90 tablets/30 days)

phendimetrazine tartrate tab 35 mg

PA, QL (180 tablets/30 days)

phentermine hcl cap 15 mg, 30 mg

QL (30 capsules/30 days)

phentermine hcl cap 37.5 mg (Adipex-p)

QL (30 capsules/30 days)

phentermine hcl tab 37.5 mg (Adipex-p)

QL (30 tablets/30 days)

SUNOSI - solriamfetol hcl tab 75 mg (base equiv), 150 mg (base equiv)

PA, QL (30 tablets/30 days)

VYVANSE - lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30 mg, 40 mg,

50 mg, 60 mg, 70 mg

QL (30 capsules/30 days)

VYVANSE - lisdexamfetamine dimesylate chew tab 10 mg, 20 mg, 30 mg,

40 mg, 50 mg, 60 mg

QL (30 tablets/30 days)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 20

Drug Name

Requirements/Limits

PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC.

AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml

PA, QL (1 kit/28 days), SP

AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml

PA, QL (1 kit/28 days), SP

BETASERON - interferon beta-1b for inj kit 0.3 mg

PA, QL (14 vials/28 days), SP

donepezil hydrochloride orally disintegrating tab 5 mg, 10 mg

donepezil hydrochloride tab 5 mg, 10 mg (Aricept)

KESIMPTA - ofatumumab soln auto-injector 20 mg/0.4ml

PA, QL (1 pen/28 days), SP

MAVENCLAD - cladribine tab therapy pack 10 mg (4 tabs), 10 mg (8 tabs)

PA, QL (8 tablets/301 days), SP

MAVENCLAD - cladribine tab therapy pack 10 mg (5 tabs)

PA, QL (10 tablets/301 days), SP

MAVENCLAD - cladribine tab therapy pack 10 mg (6 tabs)

PA, QL (12 tablets/301 days), SP

MAVENCLAD - cladribine tab therapy pack 10 mg (7 tabs)

PA, QL (14 tablets/301 days), SP

MAVENCLAD - cladribine tab therapy pack 10 mg (9 tabs)

PA, QL (9 tablets/301 days), SP

MAVENCLAD - cladribine tab therapy pack 10 mg (10 tabs)

PA, QL (20 tablets/301 days), SP

MAYZENT - siponimod fumarate tab 0.25 mg (base equiv)

PA, QL (120 tablets/30 days), SP

MAYZENT - siponimod fumarate tab 1 mg (base equiv), 2 mg (base equiv)

PA, QL (30 tablets/30 days), SP

MAYZENT STARTER PACK - siponimod fumarate tab 0.25 mg (7) starter pack

PA, QL (7 tablets/180 days), SP

MAYZENT STARTER PACK - siponimod fumarate tab 0.25 mg (12) starter

pack

PA, QL (12 tablets/180 days), SP

memantine hcl tab 5 mg, 10 mg (Namenda)

NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg delivered)

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray)

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml

PA, QL (2 pens/28 days), SP

PLEGRIDY - peginterferon beta-1a soln prefilled syringe 125 mcg/0.5ml

PA, QL (2 syringes/28 days), SP

PLEGRIDY - peginterferon beta-1a im soln prefilled syr 125 mcg/0.5ml

PA, QL (2 syringes/28 days), SP

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj 63 &

94 mcg/0.5ml pack

PA, QL (1 kit/180 days), SP

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr 63 &

94 mcg/0.5ml pack

PA, QL (1 kit/180 days), SP

REBIF - interferon beta-1a soln pref syr 22 mcg/0.5ml, 44 mcg/0.5ml

PA, QL (12 syringes/28 days), SP

REBIF REBIDOSE - interferon beta-1a soln auto-inj 22 mcg/0.5ml,

44 mcg/0.5ml

PA, QL (12 syringes/28 days), SP

REBIF REBIDOSE TITRATION - interferon beta-1a auto-inj 6x8.8 mcg/0.2ml

& 6x22 mcg/0.5ml

PA, QL (1 kit/180 days), SP

REBIF TITRATION PACK - interferon beta-1a pref syr 6x8.8 mcg/0.2ml &

6x22 mcg/0.5ml

PA, QL (1 kit/180 days), SP

SAVELLA - milnacipran hcl tab 12.5 mg, 25 mg, 50 mg, 100 mg

QL (60 tablets/30 days)

SAVELLA TITRATION PACK - milnacipran hcl tab 12.5 mg (5) & 25 mg (8) &

50 mg (42) pak

QL (55 tablets/180 days)

VUMERITY - diroximel fumarate capsule delayed release 231 mg

PA, QL (120 capsules/30 days), SP

ZEPOSIA - ozanimod hcl cap 0.92 mg

PA, QL (30 capsules/30 days), SP

ZEPOSIA STARTER KIT - ozanimod cap pack 4 x 0.23 mg & 3 x 0.46 mg &

21 x 0.92 mg

PA, QL (28 capsules/180 days), SP

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 21

Drug Name

Requirements/Limits

ZEPOSIA 7-DAY STARTER PAC - ozanimod cap pack 4 x 0.23 mg & 3 x

0.46 mg

PA, QL (7 capsules/180 days), SP

ANALGESICS AND ANESTHETICS

ANALGESICS - NON-NARCOTIC

aspirin chew tab 81 mg

aspirin tab delayed release 81 mg

ANALGESICS - NARCOTIC

acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)

BELBUCA - buprenorphine hcl buccal film 75 mcg (base equivalent), 150 mcg

(base equivalent), 300 mcg (base equivalent), 450 mcg (base equivalent),

600 mcg (base equivalent), 750 mcg (base equivalent), 900 mcg (base

equivalent)

QL (60 films/30 days)

hydrocodone-acetaminophen tab 10-325 mg, 5-300 mg

hydrocodone-acetaminophen tab 5-325 mg, 7.5-325 mg (Norco)

hydromorphone hcl tab 2 mg, 4 mg (Dilaudid)

methadone hcl tab 5 mg (Dolophine hcl)

methadone hcl tab 10 mg (Dolophine)

morphine sulfate tab er 15 mg (Ms contin)

QL (90 tablets/30 days)

oxycodone hcl tab 5 mg (Roxicodone)

oxycodone hcl tab 10 mg

oxycodone w/ acetaminophen tab 5-325 mg (Percocet)

tramadol hcl tab 50 mg (Ultram)

QL (240 tablets/30 days)

tramadol-acetaminophen tab 37.5-325 mg (Ultracet)

XTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 9 mg, 13.5 mg,

18 mg, 27 mg, 36 mg

QL (240 capsules/30 days)

ANALGESICS - ANTI-INFLAMMATORY

ACTEMRA - tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9ml

PA, QL (4 syringes/28 days), SP

ACTEMRA ACTPEN - tocilizumab subcutaneous soln auto-injector

162 mg/0.9ml

PA, QL (4 syringes/28 days), SP

AMJEVITA - adalimumab-atto soln auto-injector 40 mg/0.8ml

PA, QL (2 pens/28 days), SP

AMJEVITA - adalimumab-atto soln prefilled syringe 10 mg/0.2ml, 20 mg/0.4ml,

40 mg/0.8ml

PA, QL (2 syringes/28 days), SP

celecoxib cap 50 mg, 100 mg, 200 mg (Celebrex)

QL (60 capsules/30 days)

diclofenac sodium tab delayed release 50 mg, 75 mg

ENBREL - etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml,

50 mg/ml

PA, QL (4 syringes/28 days), SP

ENBREL - etanercept subcutaneous inj 25 mg/0.5ml

PA, QL (8 vials/28 days), SP

ENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/ml

PA, QL (4 cartridges/28 days), SP

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector

50 mg/ml

PA, QL (4 injections/28 days), SP

flurbiprofen tab 100 mg

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 22

Drug Name

Requirements/Limits

HADLIMA - adalimumab-bwwd soln prefilled syringe 40 mg/0.4ml,

40 mg/0.8ml

PA, QL (2 syringes/28 days), SP

HADLIMA PUSHTOUCH - adalimumab-bwwd soln auto-injector 40 mg/0.4ml,

40 mg/0.8ml

PA, QL (2 pens/28 days), SP

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml, 20 mg/0.2ml,

40 mg/0.4ml

PA, QL (2 syringes/28 days), SP

HUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml

PA, QL (2 syringes/180 days), SP

HUMIRA PEDIATRIC CROHNS D - adalimumab prefilled syringe kit

80 mg/0.8ml

PA, QL (3 syringes/180 days), SP

HUMIRA PEDIATRIC CROHNS D - adalimumab prefilled syringe kit

80 mg/0.8ml & 40 mg/0.4ml

PA, QL (2 syringes/180 days), SP

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml, 40 mg/0.4ml,

80 mg/0.8ml

PA, QL (2 pens/28 days), SP

HUMIRA PEN-CD/UC/HS START - adalimumab pen-injector kit 80 mg/0.8ml

PA, QL (1 kit/180 days), SP

HUMIRA PEN-PEDIATRIC UC S - adalimumab pen-injector kit 80 mg/0.8ml

PA, QL (4 pens/180 days), SP

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit 80 mg/0.8ml &

40 mg/0.4ml

PA, QL (3 pens/180 days), SP

ibuprofen susp 100 mg/5ml

ibuprofen tab 400 mg, 600 mg, 800 mg

indomethacin cap 25 mg, 50 mg

ketorolac tromethamine tab 10 mg

QL (20 tablets/30 days)

meloxicam tab 7.5 mg, 15 mg (Mobic)

nabumetone tab 500 mg

naproxen tab 250 mg, 375 mg, 500 mg (Naprosyn)

OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg & 30 mg

PA, QL (55 tablets/180 days), SP

OTEZLA - apremilast tab 30 mg

PA, QL (60 tablets/30 days), SP

RINVOQ - upadacitinib tab er 24hr 15 mg, 30 mg

PA, QL (30 tablets/30 days), SP

RINVOQ - upadacitinib tab er 24hr 45 mg

PA, QL (84 tablets/365 days), SP

SIMPONI - golimumab subcutaneous soln auto-injector 100 mg/ml

PA, QL (1 syringe/28 days), SP

SIMPONI - golimumab subcutaneous soln prefilled syringe 100 mg/ml

PA, QL (1 syringe/28 days), SP

sulindac tab 150 mg, 200 mg

XELJANZ - tofacitinib citrate oral soln 1 mg/ml (base equivalent)

PA, QL (240 mls/30 days), SP

XELJANZ - tofacitinib citrate tab 5 mg (base equivalent)

PA, QL (60 tablets/30 days), SP

XELJANZ - tofacitinib citrate tab 10 mg (base equivalent)

PA, QL (240 tablets/365 days), SP

XELJANZ XR - tofacitinib citrate tab er 24hr 11 mg (base equivalent)

PA, QL (30 tablets/30 days), SP

XELJANZ XR - tofacitinib citrate tab er 24hr 22 mg (base equivalent)

PA, QL (120 tablets/365 days), SP

MIGRAINE PRODUCTS

AIMOVIG - erenumab-aooe subcutaneous soln auto-injector 70 mg/ml,

140 mg/ml

PA, QL (1 injection/28 days)

AJOVY - fremanezumab-vfrm subcutaneous soln auto-inj 225 mg/1.5ml

PA, QL (3 pens/84 days)

AJOVY - fremanezumab-vfrm subcutaneous soln pref syr 225 mg/1.5ml

PA, QL (3 pens/90 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector 120 mg/ml

PA, QL (1 injection/28 days)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 23

Drug Name

Requirements/Limits

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr 100 mg/ml

PA, QL (9 syringes/180 days)

EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr 120 mg/ml

PA, QL (1 syringe/28 days)

NURTEC - rimegepant sulfate tab disint 75 mg

PA, QL (54 tablets/90 days)

QULIPTA - atogepant tab 10 mg, 30 mg, 60 mg

PA, QL (30 tablets/30 days)

REYVOW - lasmiditan succinate tab 50 mg, 100 mg

PA, QL (8 tablets/30 days)

rizatriptan benzoate oral disintegrating tab 5 mg (base eq)

QL (18 tablets/30 days)

rizatriptan benzoate oral disintegrating tab 10 mg (base eq) (Maxalt-mlt)

QL (18 tablets/30 days)

rizatriptan benzoate tab 5 mg (base equivalent), 10 mg (base equivalent)

(Maxalt)

QL (18 tablets/30 days)

sumatriptan succinate tab 25 mg, 50 mg, 100 mg (Imitrex)

QL (18 tablets/30 days)

UBRELVY - ubrogepant tab 50 mg, 100 mg

PA, QL (16 tablets/30 days)

GOUT AGENTS

allopurinol tab 100 mg, 300 mg (Zyloprim)

NEUROMUSCULAR DRUGS

ANTICONVULSANTS

APTIOM - eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg, 800 mg

clonazepam tab 0.5 mg, 1 mg, 2 mg (Klonopin)

DILANTIN - phenytoin sodium extended cap 30 mg

divalproex sodium tab delayed release 125 mg, 250 mg, 500 mg

(Depakote)

EPIDIOLEX - cannabidiol soln 100 mg/ml

gabapentin cap 100 mg, 300 mg, 400 mg (Neurontin)

gabapentin tab 600 mg, 800 mg (Neurontin)

lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg (Lamictal)

levetiracetam tab 250 mg, 500 mg (Keppra)

oxcarbazepine tab 150 mg (Trileptal)

pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg,

300 mg (Lyrica)

QL (90 capsules/30 days)

primidone tab 50 mg (Mysoline)

topiramate tab 25 mg, 50 mg, 100 mg, 200 mg (Topamax)

zonisamide cap 25 mg (Zonegran)

zonisamide cap 50 mg

ANTIPARKINSON AGENTS

benztropine mesylate tab 0.5 mg, 1 mg, 2 mg

carbidopa & levodopa tab 10-100 mg (Sinemet)

INBRIJA - levodopa inhal powder cap 42 mg

pramipexole dihydrochloride tab 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg,

1 mg, 1.5 mg (Mirapex)

ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg,

5 mg (Requip)

trihexyphenidyl hcl tab 2 mg, 5 mg

MUSCULOSKELETAL THERAPY AGENTS

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 24

Drug Name

Requirements/Limits

baclofen tab 10 mg, 20 mg

carisoprodol tab 350 mg (Soma)

cyclobenzaprine hcl tab 5 mg, 10 mg

methocarbamol tab 500 mg (Robaxin)

methocarbamol tab 750 mg (Robaxin-750)

tizanidine hcl cap 2 mg (base equivalent) (Zanaflex)

QL (180 capsules/30 days)

tizanidine hcl tab 2 mg (base equivalent)

QL (180 tablets/30 days)

tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)

QL (180 tablets/30 days)

NUTRITIONAL PRODUCTS

VITAMINS

cholecalciferol cap 1.25 mg (50000 unit)

ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)

MULTIVITAMINS

KOSHER PRENATAL PLUS IRON - prenatal vit w/ iron carbonyl-fa tab

30-1 mg

PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg

PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg

SE-NATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mg

SE-NATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg

MINERALS and ELECTROLYTES

potassium chloride cap er 8 meq, 10 meq

potassium chloride microencapsulated crys er tab 10 meq, 20 meq

potassium chloride tab er 8 meq (600 mg)

potassium chloride tab er 10 meq, 20 meq (1500 mg) (K-tab)

potassium phosphate monobasic tab 500 mg (K-phos)

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf), 0.5 mg f (from

1.1 mg naf), 1 mg f (from 2.2 mg naf) (Luride)

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride)

HEMATOLOGICAL AGENTS

HEMATOPOIETIC AGENTS

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml, 25 mcg/0.42ml, 40 mcg/0.4ml, 60 mcg/0.3ml, 100 mcg/0.5ml,

150 mcg/0.3ml, 200 mcg/0.4ml, 300 mcg/0.6ml, 500 mcg/ml

PA, SP

ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml, 40 mcg/ml,

60 mcg/ml, 100 mcg/ml, 200 mcg/ml

PA, SP

CERDELGA - eliglustat tartrate cap 84 mg (base equivalent)

PA, QL (60 capsules/30 days), SP

cyanocobalamin inj 1000 mcg/ml

DOPTELET - avatrombopag maleate tab 20 mg (base equiv)

PA, QL (60 tablets/30 days), SP

ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe), 220 mg/5ml

(44 mg/5ml elemental fe)

folic acid cap 0.8 mg

folic acid tab 400 mcg, 800 mcg

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 25

Drug Name

Requirements/Limits

folic acid tab 1 mg

FULPHILA - pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml

NIVESTYM - filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml,

480 mcg/0.8ml

NIVESTYM - filgrastim-aafi inj 300 mcg/ml, 480 mcg/1.6ml (300 mcg/ml)

PROCRIT - epoetin alfa inj 2000 unit/ml, 3000 unit/ml, 4000 unit/ml, 10000

unit/ml, 20000 unit/ml, 40000 unit/ml

PA, SP

RETACRIT - epoetin alfa-epbx inj 2000 unit/ml, 3000 unit/ml, 4000 unit/ml,

10000 unit/ml, 20000 unit/ml, 40000 unit/ml

PA, SP

ZARXIO - filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml, 480 mcg/0.8ml

ZIEXTENZO - pegfilgrastim-bmez soln prefilled syringe 6 mg/0.6ml

ANTICOAGULANTS

ELIQUIS - apixaban tab 2.5 mg

QL (74 tablets/19 days)

ELIQUIS - apixaban tab 5 mg

QL (74 tablets/30 days)

ELIQUIS STARTER PACK - apixaban tab starter pack 5 mg

QL (1 pack/180 days)

warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg,

10 mg (Coumadin)

XARELTO - rivaroxaban for susp 1 mg/ml

QL (600 mls/30 days)

XARELTO - rivaroxaban tab 2.5 mg, 15 mg

QL (60 tablets/30 days)

XARELTO - rivaroxaban tab 10 mg, 20 mg

QL (30 tablets/30 days)

XARELTO STARTER PACK - rivaroxaban tab starter therapy pack 15 mg &

20 mg

QL (51 tablets/30 days)

HEMATOLOGICAL AGENTS - MISC.

ADVATE - antihemophilic factor recomb (rahf-pfm) for inj 250 unit, 500 unit,

1000 unit, 1500 unit, 2000 unit, 3000 unit, 4000 unit

PA, QL (1 ml/30 days), SP

ADYNOVATE - antihemophilic factor recomb pegylated for inj 250 unit, 500

unit, 750 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit

PA, QL (1 vial/30 days), SP

AFSTYLA - antihemophilic fact rcmb single chain for inj kit 250 unit, 500 unit,

1000 unit, 1500 unit, 2000 unit, 2500 unit, 3000 unit

PA, QL (1 box/30 days), SP

ALPHANATE - antihemophilic factor/vwf (human) for inj 250 unit, 500 unit,

1000 unit, 1500 unit, 2000 unit

PA, QL (1 ml/30 days), SP

ALPHANINE SD - coagulation factor ix for inj 500 unit, 1000 unit, 1500 unit

PA, QL (1 ml/30 days), SP

ALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 250 unit, 500 unit,

1000 unit, 2000 unit, 3000 unit, 4000 unit

PA, QL (1 vial/30 days), SP

ALTUVIIIO - antihemophilic fact rcmb fc-vwf-xten-ehtl for inj 250 unit, 500 unit,

1000 unit, 2000 unit, 3000 unit, 4000 unit

PA, QL (1 mls/30 days), SP

BENEFIX - coagulation factor ix (recombinant) for inj kit 250 unit, 500 unit,

1000 unit, 2000 unit, 3000 unit

PA, QL (1 ml/30 days), SP

BRILINTA - ticagrelor tab 60 mg, 90 mg

cilostazol tab 50 mg, 100 mg (Pletal)

clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)

COAGADEX - coagulation factor x (human) for inj 250 unit, 500 unit

CORIFACT - factor xiii concentrate (human) for inj kit 1000-1600 unit

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 26

Drug Name

Requirements/Limits

ELOCTATE - antihemophilic factor rcmb (bdd-rfviiifc) for inj 250 unit, 500 unit,

750 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit, 4000 unit, 5000 unit,

6000 unit

PA, QL (1 vial/30 days), SP

EMPAVELI - pegcetacoplan subcutaneous soln 1080 mg/20ml (54 mg/ml)

PA, QL (8 vials/28 days), SP

ESPEROCT - antihemophilic factor recomb glycopeg-exei for inj 500 unit,

1000 unit, 1500 unit, 2000 unit, 3000 unit

PA, QL (1 syringe/30 days), SP

FEIBA - antiinhibitor coagulant complex for iv soln 500 unit, 1000 unit, 2500

unit

HEMLIBRA - emicizumab-kxwh subcutaneous soln 12 mg/0.4ml (30 mg/ml),

30 mg/ml, 60 mg/0.4ml (150 mg/ml), 105 mg/0.7ml (150 mg/ml), 150 mg/ml,

300 mg/2ml (150 mg/ml)

PA, QL (4 vials/28 days), SP

HEMOFIL M - antihemophilic factor (human) for inj 250 unit, 500 unit, 1000

unit, 1700 unit

PA, QL (1 ml/30 days), SP

HUMATE-P - antihemophilic factor/vwf (human) for inj 250-600 unit, 500-1200

unit, 1000-2400 unit

PA, QL (1 ml/30 days), SP

IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 250 unit, 500 unit,

1000 unit, 2000 unit, 3500 unit

PA, QL (1 box/30 days), SP

IXINITY - coagulation factor ix (recombinant) for inj 250 unit, 500 unit, 1000

unit, 1500 unit, 2000 unit, 3000 unit

PA, QL (1 ml/30 days), SP

JIVI - antihemophil fact rcmb(bdd-rfviii peg-aucl) for inj 500 unit

PA, QL (1 vial/30 days), SP

JIVI - antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj 1000 unit, 2000 unit,

3000 unit

PA, QL (1 vial/30 days), SP

KOATE - antihemophilic factor (human) for inj 250 unit, 500 unit, 1000 unit

PA, QL (1 ml/30 days), SP

KOATE-DVI - antihemophilic factor (human) for inj 500 unit, 1000 unit

PA, QL (1 ml/30 days), SP

KOGENATE FS - antihemophilic factor recomb (rfviii) for inj kit 250 unit, 500

unit, 1000 unit, 2000 unit, 3000 unit

PA, QL (1 ml/30 days), SP

KOVALTRY - antihemophilic factor recomb (rahf-pfm) for inj 250 unit, 500 unit,

1000 unit, 2000 unit, 3000 unit

PA, QL (1 ml/30 days), SP

NOVOEIGHT - antihemophilic fact rcmb (bd trunc-rfviii) for inj 250 unit, 500

unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit

PA, QL (1 ml/30 days), SP

NOVOSEVEN RT - coagulation factor viia (recomb) for inj 1 mg (1000 mcg),

2 mg (2000 mcg), 5 mg (5000 mcg), 8 mg (8000 mcg)

PA, QL (1 ml/30 days), SP

NUWIQ - antihemophilic factor rcmb (bdd-rfviii,sim) for inj 250 unit, 500 unit

PA, QL (1 ml/30 days), SP

NUWIQ - antihemophilic fact rcmb (bdd-rfviii,sim) for inj 1000 unit, 1500 unit,

2000 unit, 2500 unit, 3000 unit, 4000 unit

PA, QL (1 ml/30 days), SP

NUWIQ - antihemophil fact rcmb (bdd-rfviii,sim) for inj kit 250 unit, 500 unit

PA, QL (1 ml/30 days), SP

NUWIQ - antihemophil fact rcmb(bdd-rfviii,sim) for inj kit 1000 unit, 1500 unit,

2000 unit, 2500 unit, 3000 unit, 4000 unit

PA, QL (1 ml/30 days), SP

OBIZUR - antihemophilic factor (recomb porc) rpfviii for inj 500 unit

PROFILNINE - factor ix complex for inj 500 unit, 1000 unit, 1500 unit

PA, QL (1 ml/30 days), SP

REBINYN - coagulation factor ix recomb glycopegylated for inj 500 unt, 1000

unt, 2000 unt

PA, QL (1 vial/30 days), SP

REBINYN - coagulation factor ix recomb glycopegylated for inj 3000 unt

PA, QL (1 ml/30 days), SP

RECOMBINATE - antihemophilic factor recomb (rfviii) for inj 220-400 unit,

401-800 unit, 801-1240 unit, 1241-1800 unit, 1801-2400 unit

PA, QL (1 ml/30 days), SP

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 27

Drug Name

Requirements/Limits

RIXUBIS - coagulation factor ix (recombinant) for inj 250 unit, 500 unit, 1000

unit, 2000 unit, 3000 unit

PA, QL (1 ml/30 days), SP

TAKHZYRO - lanadelumab-flyo inj 300 mg/2ml (150 mg/ml)

PA, QL (2 vials/28 days), SP

TAKHZYRO - lanadelumab-flyo soln pref syringe 150 mg/ml

PA, QL (2 mls/28 days), SP

TAKHZYRO - lanadelumab-flyo soln pref syringe 300 mg/2ml (150 mg/ml)

PA, QL (2 vials/28 days), SP

TRETTEN - coagulation factor xiii a-subunit for inj 2500 unit

VONVENDI - von willebrand factor (recombinant) for inj 650 unit, 1300 unit

PA, QL (1 ml/30 days), SP

WILATE - antihemophilic factor/vwf (human) for inj 500-500 unit kit

PA, QL (1 ml/30 days), SP

WILATE - antihemophilic factor/vwf (human) for inj 1000-1000 unit kit

PA, QL (1 ml/30 days), SP

XYNTHA - antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250 unit, 500 unit

PA, QL (1 ml/30 days), SP

XYNTHA - antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000 unit, 2000 unit

PA, QL (1 ml/30 days), SP

XYNTHA SOLOFUSE - antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250

unit, 500 unit

PA, QL (1 ml/30 days), SP

XYNTHA SOLOFUSE - antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000

unit, 2000 unit, 3000 unit

PA, QL (1 ml/30 days), SP

TOPICAL PRODUCTS

OPHTHALMIC AGENTS

azelastine hcl ophth soln 0.05%

BACITRACIN - bacitracin ophth oint 500 unit/gm

bacitracin-polymyxin b ophth oint

brimonidine tartrate ophth soln 0.2%

ciprofloxacin hcl ophth soln 0.3% (base equivalent) (Ciloxan)

cyclopentolate hcl ophth soln 1% (Cyclogyl)

diclofenac sodium ophth soln 0.1%

dorzolamide hcl ophth soln 2% (Trusopt)

dorzolamide hcl-timolol maleate ophth soln 2-0.5% (Cosopt)

erythromycin ophth oint 5 mg/gm

gentamicin sulfate ophth soln 0.3% (Garamycin)

ketorolac tromethamine ophth soln 0.5% (Acular)

latanoprost ophth soln 0.005% (Xalatan)

QL (2.5 mls/20 days)

LOTEMAX - loteprednol etabonate ophth oint 0.5%

LOTEMAX SM - loteprednol etabonate ophth gel 0.38%

LUMIGAN - bimatoprost ophth soln 0.01%

QL (2.5 mls/20 days), ST

NATACYN - natamycin ophth susp 5%

neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)

neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)

ofloxacin ophth soln 0.3% (Ocuflox)

polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)

PREDNISOLONE ACETATE - prednisolone acetate ophth susp 1%

PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate ophth

soln 1%

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 28

Drug Name

Requirements/Limits

SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2%

timolol maleate ophth soln 0.25%, 0.5% (Timoptic)

tobramycin ophth soln 0.3% (Tobrex)

QL (15 ml/30 days)

TRIFLURIDINE - trifluridine ophth soln 1%

ZYLET - loteprednol etabonate-tobramycin ophth susp 0.5-0.3%

MOUTH/THROAT/DENTAL AGENTS

chlorhexidine gluconate soln 0.12% (Peridex)

lidocaine hcl viscous soln 2%

nystatin susp 100000 unit/ml

sodium fluoride cream 1.1% (Prevident 5000 plus)

sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)

sodium fluoride paste 1.1% (Prevident 5000 boost)

DERMATOLOGICALS

ADBRY - tralokinumab-ldrm subcutaneous soln prefilled syr 150 mg/ml

PA, QL (4 mls/28 days), SP

betamethasone dipropionate augmented cream 0.05% (Diprolene af)

QL (100 grams/30 days)

CIBINQO - abrocitinib tab 50 mg, 100 mg, 200 mg

PA, QL (30 tablets/30 days), SP

clotrimazole cream 1%

clotrimazole w/ betamethasone cream 1-0.05%

COSENTYX - secukinumab subcutaneous soln prefilled syringe 75 mg/0.5ml,

150 mg/ml

PA, QL (1 syringe/28 days), SP

COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml (300 mg dose)

PA, QL (2 syringes/28 days), SP

COSENTYX SENSOREADY PEN - secukinumab subcutaneous soln auto-

injector 150 mg/ml

PA, QL (1 pen/28 days), SP

COSENTYX SENSOREADY PEN - secukinumab subcutaneous auto-inj

150 mg/ml (300 mg dose)

PA, QL (2 pens/28 days), SP

COSENTYX UNOREADY - secukinumab subcutaneous soln auto-injector

300 mg/2ml

PA, QL (1 pen/28 day), SP

DUPIXENT - dupilumab subcutaneous soln pen-injector 200 mg/1.14ml

PA, QL (2 pens/28 days), SP

DUPIXENT - dupilumab subcutaneous soln pen-injector 300 mg/2ml

PA, QL (4 pens/28 days), SP

DUPIXENT - dupilumab subcutaneous soln prefilled syringe 200 mg/1.14ml

PA, QL (2 syringes/28 days), SP

DUPIXENT - dupilumab subcutaneous soln prefilled syringe 300 mg/2ml

PA, QL (4 syringes/28 days), SP

FINACEA - azelaic acid foam 15%

fluticasone propionate cream 0.05%

hydrocortisone cream 1%, 2.5%

hydrocortisone lotion 2.5%

hydrocortisone oint 1%, 2.5%

ketoconazole shampoo 2% (Nizoral)

lidocaine oint 5%

PA, QL (120 grams/30 days)

mafenide acetate packet for topical soln 5% (50 gm) (Sulfamylon)

mometasone furoate oint 0.1% (Elocon)

QL (100 grams/30 days)

mupirocin oint 2% (Bactroban)

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 29

Drug Name

Requirements/Limits

nystatin cream 100000 unit/gm

nystatin oint 100000 unit/gm

selenium sulfide lotion 2.5%

silver sulfadiazine cream 1% (Silvadene)

SKYRIZI - risankizumab-rzaa soln prefilled syringe 150 mg/ml

PA, QL (1 syringe/84 days), SP

SKYRIZI PEN - risankizumab-rzaa soln auto-injector 150 mg/ml

PA, QL (1 injection device/84 days), SP

SOOLANTRA - ivermectin cream 1%

QL (45 grams/30 days)

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml, 90 mg/ml

PA, QL (1 syringe/84 days), SP

STELARA - ustekinumab inj 45 mg/0.5ml

PA, QL (1 vial/84 days), SP

TAZORAC - tazarotene cream 0.05%

TREMFYA - guselkumab soln pen-injector 100 mg/ml

PA, QL (1 pen/56 days), SP

TREMFYA - guselkumab soln prefilled syringe 100 mg/ml

PA, QL (1 syringe/56 days), SP

triamcinolone acetonide cream 0.025%, 0.1%, 0.5%

triamcinolone acetonide oint 0.025%, 0.1%, 0.5%

VALCHLOR - mechlorethamine hcl gel 0.016% (base equivalent)

MISCELLANEOUS PRODUCTS

ANTIDOTES

CHEMET - succimer cap 100 mg

KLOXXADO - naloxone hcl nasal spray 8 mg/0.1ml

OPVEE - nalmefene hcl nasal spray 2.7 mg/0.1ml (base equiv)

DIAGNOSTIC PRODUCTS

INSULIN PEN NEEDLES – VARIOUS

QL (300 needles/30 days)

INSULIN SYRINGES – VARIOUS

QL (300 syringes/30 days)

LANCETS – VARIOUS

TEST STRIPS –CONTOUR, CONTOUR NEXT, ONETOUCH ULTRA,

ONETOUCH VERIO

QL (204 strips/30 days)

MEDICAL DEVICES

BREATHERITE– spacer/aerosol-holding chambers – device

DEXCOM G6 RECEIVER - continuous glucose system receiver

PA, QL (1 receiver/365 days)

DEXCOM G6 SENSOR - continuous glucose system sensor

PA, QL (3 sensors/30 days)

DEXCOM G6 TRANSMITTER - continuous glucose system transmitter

PA, QL (1 box/90 days)

DEXCOM G7 RECEIVER - continuous glucose system receiver

PA, QL (1 receiver/365 days)

DEXCOM G7 SENSOR - continuous glucose system sensor

PA, QL (3 sensors/30 days)

OMNIPOD DASH INTRO KIT (G - insulin infusion disposable pump kit

PA, QL (1 kit/720 days)

OMNIPOD DASH PODS (GEN 4) - insulin infusion disposable pump reservoir

PA, QL (30 pods/30 days)

OMNIPOD 5 G6 INTRO KIT (G - insulin infusion disposable pump kit

PA, QL (1 kit/720 days)

OMNIPOD 5 G6 PODS (GEN 5) - insulin infusion disposable pump reservoir

PA, QL (30 pods/30 days)

OMNIPOD 5 G7 INTRO KIT (G - insulin infusion disposable pump kit

PA, QL (1 kit/720 days)

OMNIPOD 5 G7 PODS (GEN 5) - insulin infusion disposable pump reservoir

PA, QL (30 pods/30 days)

ASSORTED CLASSES

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Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 30

Drug Name

Requirements/Limits

LOKELMA - sodium zirconium cyclosilicate for susp packet 5 gm, 10 gm

RAPAMUNE - sirolimus oral soln 1 mg/ml

REVLIMID - lenalidomide caps 2.5 mg

PA, QL (30 capsules/30 days), SP

REVLIMID - lenalidomide cap 5 mg, 10 mg

PA, QL (30 capsules/30 days), SP

REVLIMID - lenalidomide cap 15 mg, 20 mg, 25 mg

PA, QL (21 capsules/28 days), SP

THALOMID - thalidomide cap 50 mg

PA, QL (90 capsules/30 days), SP

THALOMID - thalidomide cap 100 mg

PA, QL (120 capsules/30 days), SP

VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm (base eq),

16.8 gm (base eq), 25.2 gm (base eq)

ZOKINVY - lonafarnib cap 50 mg, 75 mg

PA, QL (120 capsules/30 days), SP

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 31

INDEX

acetaminophen w/ codeine tab 300-15 mg.....................21

acetaminophen w/ codeine tab 300-30 mg.....................21

ACTEMRA............................................................................21

ACTEMRA ACTPEN........................................................... 21

ACTIMMUNE......................................................................... 3

acyclovir cap 200 mg..........................................................2

acyclovir tab 400 mg, 800 mg............................................2

ADBRY................................................................................. 28

ADVAIR HFA........................................................................14

ADVATE................................................................................25

ADYNOVATE....................................................................... 25

AFSTYLA............................................................................. 25

AIMOVIG.............................................................................. 22

AJOVY..................................................................................22

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 14

albuterol sulfate syrup 2 mg/5ml.................................... 14

ALECENSA............................................................................ 3

alendronate sodium tab 10 mg........................................10

alendronate sodium tab 35 mg........................................10

alendronate sodium tab 70 mg........................................10

alfuzosin hcl tab er 24hr 10 mg.......................................17

ALINIA.................................................................................... 3

allopurinol tab 100 mg, 300 mg.......................................23

ALPHANATE........................................................................ 25

ALPHANINE SD.................................................................. 25

alprazolam tab er 24hr 0.5 mg, 1 mg, 2 mg, 3 mg......... 17

alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg................. 17

ALPROLIX............................................................................25

ALTUVIIIO............................................................................ 25

ALUNBRIG.............................................................................3

amiloride hcl tab 5 mg......................................................12

amiodarone hcl tab 200 mg............................................. 11

amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg.........18

AMJEVITA............................................................................ 21

amlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-10

mg, 5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg..................11

amlodipine besylate tab 2.5 mg (base equivalent), 5 mg

(base equivalent), 10 mg (base equivalent)................. 11

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml,

400-57 mg/5ml.................................................................... 1

amoxicillin & k clavulanate tab 500-125 mg, 875-125

mg........................................................................................ 1

amoxicillin (trihydrate) cap 250 mg, 500 mg....................1

amoxicillin (trihydrate) for susp 125 mg/5ml, 200

mg/5ml, 250 mg/5ml, 400 mg/5ml.................................... 1

amoxicillin (trihydrate) tab 500 mg, 875 mg.................... 1

amphetamine-dextroamphetamine tab 5 mg................. 19

anastrozole tab 1 mg.......................................................... 3

ANORO ELLIPTA................................................................ 14

APTIOM................................................................................23

ARANESP ALBUMIN FREE............................................... 24

aripiprazole tab 2 mg, 5 mg............................................. 18

aripiprazole tab 10 mg, 15 mg......................................... 18

armodafinil tab 50 mg.......................................................19

ARNUITY ELLIPTA..............................................................14

ASMANEX HFA................................................................... 14

ASMANEX TWISTHALER 120 ME.....................................14

ASMANEX TWISTHALER 30 MET.................................... 14

ASMANEX TWISTHALER 60 MET.................................... 14

aspirin chew tab 81 mg.................................................... 21

aspirin tab delayed release 81 mg.................................. 21

atenolol & chlorthalidone tab 50-25 mg......................... 11

atenolol tab 25 mg, 50 mg, 100 mg.................................11

atorvastatin calcium tab 10 mg (base equivalent), 20

mg (base equivalent), 40 mg (base equivalent), 80 mg

(base equivalent)............................................................. 13

AUVI-Q................................................................................. 13

AVONEX...............................................................................20

AVONEX PEN......................................................................20

AYVAKIT.................................................................................3

azelastine hcl nasal spray 0.1% (137 mcg/spray)..........14

azelastine hcl ophth soln 0.05%......................................27

AZITHROMYCIN....................................................................1

azithromycin for susp 200 mg/5ml....................................1

azithromycin tab 250 mg, 500 mg..................................... 1

BACITRACIN....................................................................... 27

bacitracin-polymyxin b ophth oint.................................. 27

baclofen tab 10 mg, 20 mg.............................................. 24

BAQSIMI ONE PACK............................................................ 7

BAQSIMI TWO PACK........................................................... 7

BARACLUDE......................................................................... 2

BELBUCA............................................................................ 21

BELSOMRA......................................................................... 19

benazepril hcl tab 5 mg....................................................11

benazepril hcl tab 10 mg, 20 mg, 40 mg........................ 11

BENEFIX.............................................................................. 25

BENZNIDAZOLE................................................................... 3

benzonatate cap 100 mg.................................................. 14

benzonatate cap 200 mg.................................................. 14

benztropine mesylate tab 0.5 mg, 1 mg, 2 mg...............23

betamethasone dipropionate augmented cream

0.05%................................................................................. 28

BETASERON....................................................................... 20

bicalutamide tab 50 mg...................................................... 3

BIKTARVY..............................................................................2

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg,

5-6.25 mg, 10-6.25 mg..................................................... 11

bisoprolol fumarate tab 5 mg.......................................... 11

BREATHERITE– spacer/aerosol-holding chambers –

device................................................................................. 29

BREO ELLIPTA................................................................... 15

BREZTRI AEROSPHERE................................................... 15

BRILINTA............................................................................. 25

brimonidine tartrate ophth soln 0.2%.............................27

BRUKINSA.............................................................................3

bumetanide tab 0.5 mg.....................................................12

bupropion hcl tab er 24hr 150 mg, 300 mg.................... 18

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 32

bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg......18

bupropion hcl tab 75 mg, 100 mg................................... 18

buspirone hcl tab 5 mg, 10 mg, 15 mg...........................17

CABOMETYX.........................................................................3

calcitriol cap 0.25 mcg..................................................... 10

CALQUENCE.........................................................................3

carbidopa & levodopa tab 10-100 mg.............................23

carisoprodol tab 350 mg.................................................. 24

carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg........ 11

cefadroxil cap 500 mg........................................................ 1

cefdinir cap 300 mg............................................................ 1

cefuroxime axetil tab 250 mg............................................ 1

celecoxib cap 50 mg, 100 mg, 200 mg........................... 21

cephalexin cap 250 mg, 500 mg........................................1

cephalexin for susp 125 mg/5ml....................................... 1

CERDELGA......................................................................... 24

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)....................14

CHEMET.............................................................................. 29

CHENODAL......................................................................... 17

chlordiazepoxide hcl cap 5 mg, 10 mg, 25 mg.............. 18

chlorhexidine gluconate soln 0.12%...............................28

chlorthalidone tab 25 mg, 50 mg.................................... 12

cholecalciferol cap 1.25 mg (50000 unit)........................24

choline fenofibrate cap dr 45 mg (fenofibric acid

equiv)................................................................................. 13

CIBINQO.............................................................................. 28

cilostazol tab 50 mg, 100 mg...........................................25

CIMDUO.................................................................................2

cimetidine tab 200 mg...................................................... 16

ciprofloxacin hcl ophth soln 0.3% (base

equivalent)........................................................................ 27

ciprofloxacin hcl tab 750 mg (base equiv)....................... 1

ciprofloxacin hcl tab 250 mg (base equiv), 500 mg

(base equiv)........................................................................ 1

citalopram hydrobromide tab 10 mg (base equiv), 20

mg (base equiv), 40 mg (base equiv)............................18

clindamycin hcl cap 75 mg, 150 mg, 300 mg...................3

CLOMID............................................................................... 10

clonazepam tab 0.5 mg, 1 mg, 2 mg............................... 23

clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg....................... 11

clopidogrel bisulfate tab 75 mg (base equiv)................ 25

clotrimazole cream 1%..................................................... 28

clotrimazole w/ betamethasone cream 1-0.05%............ 28

clozapine tab 25 mg..........................................................18

COAGADEX.........................................................................25

COMBIPATCH........................................................................6

COMBIVENT RESPIMAT....................................................15

CORIFACT........................................................................... 25

CORLANOR.........................................................................13

COSENTYX......................................................................... 28

COSENTYX SENSOREADY PEN......................................28

COSENTYX UNOREADY................................................... 28

COTELLIC..............................................................................3

CREON................................................................................ 17

CRINONE.............................................................................17

cyanocobalamin inj 1000 mcg/ml....................................24

cyclobenzaprine hcl tab 5 mg, 10 mg.............................24

cyclopentolate hcl ophth soln 1%...................................27

cyproheptadine hcl syrup 2 mg/5ml............................... 14

cyproheptadine hcl tab 4 mg...........................................14

CYSTAGON......................................................................... 17

DELSTRIGO.......................................................................... 2

DESCOVY..............................................................................2

desloratadine tab 5 mg.....................................................14

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)...............................................................................6

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg.......6

dexamethasone tab 1.5 mg, 4 mg, 6 mg.......................... 6

DEXCOM G6 RECEIVER................................................... 29

DEXCOM G7 RECEIVER................................................... 29

DEXCOM G6 SENSOR...................................................... 29

DEXCOM G7 SENSOR...................................................... 29

DEXCOM G6 TRANSMITTER............................................29

dexmethylphenidate hcl tab 2.5 mg, 5 mg..................... 19

diazepam oral soln 1 mg/ml.............................................18

diazepam tab 2 mg, 5 mg, 10 mg.................................... 18

diclofenac sodium ophth soln 0.1%............................... 27

diclofenac sodium tab delayed release 50 mg, 75

mg...................................................................................... 21

dicyclomine hcl cap 10 mg.............................................. 16

dicyclomine hcl tab 20 mg...............................................16

diethylpropion hcl tab 25 mg...........................................19

DIFICID.................................................................................. 1

digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg).....10

DILANTIN.............................................................................23

diltiazem hcl cap er 24hr 120 mg.................................... 11

diltiazem hcl coated beads cap er 24hr 120 mg, 180

mg, 240 mg.......................................................................11

diltiazem hcl extended release beads cap er 24hr 120

mg, 180 mg.......................................................................11

diltiazem hcl tab 30 mg, 60 mg....................................... 11

divalproex sodium tab delayed release 125 mg, 250

mg, 500 mg.......................................................................23

donepezil hydrochloride orally disintegrating tab 5 mg,

10 mg.................................................................................20

donepezil hydrochloride tab 5 mg, 10 mg..................... 20

DOPTELET.......................................................................... 24

dorzolamide hcl ophth soln 2%.......................................27

dorzolamide hcl-timolol maleate ophth soln 2-0.5%.....27

DOVATO.................................................................................2

doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg.......... 12

doxepin hcl cap 10 mg, 25 mg........................................ 18

doxepin hcl conc 10 mg/ml..............................................18

doxycycline hyclate cap 100 mg....................................... 1

doxycycline hyclate tab 20 mg, 100 mg........................... 1

doxycycline monohydrate cap 50 mg.............................. 1

doxycycline monohydrate cap 100 mg............................ 1

doxycycline monohydrate tab 50 mg, 100 mg.................1

drospirenone-ethinyl estradiol tab 3-0.03 mg..................6

DUAVEE................................................................................. 6

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Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 33

DULERA...............................................................................15

duloxetine hcl enteric coated pellets cap 30 mg (base

eq)...................................................................................... 18

duloxetine hcl enteric coated pellets cap 20 mg (base

eq), 60 mg (base eq)....................................................... 18

DUPIXENT........................................................................... 28

dutasteride cap 0.5 mg.....................................................17

ELIQUIS............................................................................... 25

ELIQUIS STARTER PACK.................................................. 25

ELLA.......................................................................................6

ELOCTATE...........................................................................26

EMCYT...................................................................................3

EMEND................................................................................ 16

EMGALITY........................................................................... 22

EMPAVELI............................................................................26

enalapril maleate & hydrochlorothiazide tab 5-12.5

mg...................................................................................... 12

enalapril maleate & hydrochlorothiazide tab 10-25

mg...................................................................................... 12

enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg........ 12

ENBREL............................................................................... 21

ENBREL MINI......................................................................21

ENBREL SURECLICK........................................................ 21

ENTRESTO..........................................................................13

EPCLUSA...............................................................................2

EPIDIOLEX.......................................................................... 23

ergocalciferol cap 1.25 mg (50000 unit)......................... 24

ERIVEDGE.............................................................................3

ERLEADA...............................................................................3

erythromycin ophth oint 5 mg/gm.................................. 27

escitalopram oxalate tab 5 mg (base equiv), 10 mg

(base equiv), 20 mg (base equiv).................................. 18

esomeprazole magnesium cap delayed release 20 mg

(base eq), 40 mg (base eq).............................................16

ESPEROCT......................................................................... 26

estradiol tab 0.5 mg, 1 mg, 2 mg...................................... 6

ESTRING............................................................................. 17

eszopiclone tab 1 mg, 2 mg, 3 mg..................................19

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg...................................................................................... 7

ETOPOSIDE.......................................................................... 3

ezetimibe tab 10 mg..........................................................13

famotidine tab 20 mg, 40 mg........................................... 16

FARXIGA................................................................................7

FASENRA PEN....................................................................15

FEIBA................................................................................... 26

felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg................... 11

fenofibrate micronized cap 67 mg, 134 mg....................13

fenofibrate tab 48 mg, 145 mg.........................................13

fenofibrate tab 54 mg, 160 mg.........................................13

ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe),

220 mg/5ml (44 mg/5ml elemental fe)........................... 24

FIASP..................................................................................... 8

FIASP FLEXTOUCH............................................................. 8

FIASP PENFILL.....................................................................8

FINACEA..............................................................................28

finasteride tab 5 mg..........................................................17

fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg............ 1

fludrocortisone acetate tab 0.1 mg................................... 6

fluoxetine hcl cap 10 mg, 20 mg, 40 mg........................ 18

fluoxetine hcl tab 10 mg...................................................18

FLUPHENAZINE HCL......................................................... 18

FLUPHENAZINE HYDROCHLORID.................................. 18

flurbiprofen tab 100 mg....................................................21

FLUTICASONE PROPIONATE/SA.....................................15

fluticasone propionate cream 0.05%.............................. 28

fluticasone propionate nasal susp 50 mcg/act..............14

folic acid cap 0.8 mg........................................................ 24

folic acid tab 400 mcg, 800 mcg..................................... 24

folic acid tab 1 mg............................................................ 25

FOLLISTIM AQ.................................................................... 10

FORTEO.............................................................................. 10

fosinopril sodium tab 10 mg, 20 mg, 40 mg.................. 12

FULPHILA............................................................................ 25

furosemide oral soln 10 mg/ml........................................12

furosemide tab 20 mg, 40 mg, 80 mg............................. 12

gabapentin cap 100 mg, 300 mg, 400 mg.......................23

gabapentin tab 600 mg, 800 mg...................................... 23

gemfibrozil tab 600 mg.....................................................13

GENOTROPIN.....................................................................10

GENOTROPIN MINIQUICK................................................ 10

gentamicin sulfate ophth soln 0.3%............................... 27

GENVOYA..............................................................................2

GLEOSTINE...........................................................................4

glimepiride tab 1 mg, 2 mg, 4 mg..................................... 7

glipizide tab er 24hr 2.5 mg, 5 mg, 10 mg........................ 7

glipizide tab 5 mg, 10 mg...................................................7

GLUCAGON EMERGENCY KIT FO.................................... 7

glyburide-metformin tab 1.25-250 mg, 2.5-500 mg,

5-500 mg..............................................................................7

glyburide tab 1.25 mg, 2.5 mg, 5 mg................................ 7

glycopyrrolate tab 1 mg................................................... 16

GLYXAMBI............................................................................. 7

guanfacine hcl tab er 24hr 1 mg (base equiv), 2

mg (base equiv), 3 mg (base equiv), 4 mg (base

equiv)................................................................................. 19

GVOKE HYPOPEN 1-PACK................................................. 7

GVOKE HYPOPEN 2-PACK................................................. 7

GVOKE KIT........................................................................... 7

GVOKE PFS.......................................................................... 7

HADLIMA............................................................................. 22

HADLIMA PUSHTOUCH.....................................................22

haloperidol tab 0.5 mg, 1 mg...........................................18

HARVONI............................................................................... 2

HEMLIBRA...........................................................................26

HEMOFIL M.........................................................................26

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 34

HUMATE-P...........................................................................26

HUMATIN............................................................................... 1

HUMIRA............................................................................... 22

HUMIRA PEDIATRIC CROHNS D..................................... 22

HUMIRA PEN...................................................................... 22

HUMIRA PEN-CD/UC/HS START...................................... 22

HUMIRA PEN-PEDIATRIC UC S....................................... 22

HUMIRA PEN-PS/UV STARTER........................................22

HUMULIN R U-500 (CONCENTR........................................ 9

HUMULIN R U-500 KWIKPEN............................................. 9

hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg........ 12

hydrochlorothiazide cap 12.5 mg....................................12

hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg........... 12

hydrocodone-acetaminophen tab 10-325 mg, 5-300

mg...................................................................................... 21

hydrocodone-acetaminophen tab 5-325 mg, 7.5-325

mg...................................................................................... 21

hydrocodone bitart-homatropine methylbrom soln

5-1.5 mg/5ml..................................................................... 14

hydrocortisone cream 1%, 2.5%..................................... 28

hydrocortisone lotion 2.5%..............................................28

hydrocortisone oint 1%, 2.5%..........................................28

hydromorphone hcl tab 2 mg, 4 mg............................... 21

hydroxyzine hcl tab 10 mg, 25 mg, 50 mg..................... 18

hydroxyzine pamoate cap 25 mg, 50 mg....................... 18

ibandronate sodium tab 150 mg (base equivalent).......10

IBRANCE............................................................................... 4

ibuprofen susp 100 mg/5ml............................................. 22

ibuprofen tab 400 mg, 600 mg, 800 mg.......................... 22

IDELVION.............................................................................26

IMBRUVICA........................................................................... 4

imipramine hcl tab 10 mg, 25 mg, 50 mg....................... 18

IMPAVIDO.............................................................................. 3

INBRIJA................................................................................23

INCRELEX........................................................................... 10

INCRUSE ELLIPTA............................................................. 15

indapamide tab 1.25 mg, 2.5 mg..................................... 12

indomethacin cap 25 mg, 50 mg..................................... 22

INSULIN ASPART................................................................. 8

INSULIN ASPART FLEXPEN............................................... 9

INSULIN ASPART PENFILL................................................. 9

INSULIN ASPART PROTAMINE/..........................................9

INSULIN GLARGINE-YFGN................................................. 9

INSULIN PEN NEEDLES – VARIOUS............................... 29

INSULIN SYRINGES – VARIOUS...................................... 29

INTELENCE........................................................................... 2

ipratropium bromide inhal soln 0.02%........................... 15

irbesartan-hydrochlorothiazide tab 150-12.5 mg,

300-12.5 mg...................................................................... 12

irbesartan tab 75 mg, 150 mg, 300 mg........................... 12

ISENTRESS...........................................................................2

ISENTRESS HD.................................................................... 2

isoniazid tab 300 mg...........................................................1

isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120

mg...................................................................................... 10

IXINITY.................................................................................26

JANUMET.............................................................................. 8

JANUMET XR........................................................................8

JANUVIA................................................................................ 8

JARDIANCE...........................................................................8

JIVI....................................................................................... 26

JULUCA................................................................................. 2

KALYDECO.......................................................................... 16

KESIMPTA........................................................................... 20

ketoconazole shampoo 2%.............................................. 28

ketorolac tromethamine ophth soln 0.5%...................... 27

ketorolac tromethamine tab 10 mg.................................22

KISQALI................................................................................. 4

KISQALI FEMARA 200 DOSE..............................................4

KISQALI FEMARA 400 DOSE..............................................4

KISQALI FEMARA 600 DOSE..............................................4

KLOXXADO......................................................................... 29

KOATE................................................................................. 26

KOATE-DVI.......................................................................... 26

KOGENATE FS................................................................... 26

KOSHER PRENATAL PLUS IRON.....................................24

KOVALTRY...........................................................................26

labetalol hcl tab 100 mg................................................... 11

lactulose (encephalopathy) solution 10 gm/15ml......... 17

lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg...........23

LANCETS – VARIOUS........................................................29

lansoprazole cap delayed release 30 mg....................... 16

latanoprost ophth soln 0.005%........................................27

LENVIMA 4 MG DAILY DOSE..............................................4

LENVIMA 8 MG DAILY DOSE..............................................4

LENVIMA 10 MG DAILY DOSE............................................4

LENVIMA 12MG DAILY DOSE.............................................4

LENVIMA 14 MG DAILY DOSE............................................4

LENVIMA 18 MG DAILY DOSE............................................4

LENVIMA 20 MG DAILY DOSE............................................4

LENVIMA 24 MG DAILY DOSE............................................4

letrozole tab 2.5 mg............................................................ 4

LEUKERAN............................................................................4

LEVEMIR................................................................................9

LEVEMIR FLEXPEN............................................................. 9

levetiracetam tab 250 mg, 500 mg.................................. 23

levocetirizine dihydrochloride tab 5 mg.........................14

levofloxacin tab 250 mg, 500 mg, 750 mg........................1

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,

0.15 mg-30 mcg..................................................................7

levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg....................................7

levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88

mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg,

175 mcg, 200 mcg, 300 mcg.......................................... 10

lidocaine hcl viscous soln 2%.........................................28

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 35

lidocaine oint 5%...............................................................28

LINZESS.............................................................................. 17

lisinopril & hydrochlorothiazide tab 10-12.5 mg,

20-12.5 mg, 20-25 mg...................................................... 12

lisinopril tab 2.5 mg, 30 mg, 40 mg................................ 12

lisinopril tab 5 mg, 10 mg, 20 mg................................... 12

lithium carbonate cap 300 mg......................................... 19

lithium carbonate cap 150 mg, 600 mg.......................... 19

lithium carbonate tab er 300 mg..................................... 19

lithium carbonate tab er 450 mg..................................... 19

lithium carbonate tab 300 mg..........................................19

LOKELMA............................................................................ 30

LO LOESTRIN FE.................................................................7

lorazepam tab 0.5 mg, 1 mg, 2 mg..................................18

losartan potassium & hydrochlorothiazide tab 50-12.5

mg, 100-12.5 mg, 100-25 mg.......................................... 12

losartan potassium tab 25 mg, 50 mg, 100 mg..............12

LOTEMAX............................................................................ 27

LOTEMAX SM..................................................................... 27

lovastatin tab 10 mg......................................................... 13

lovastatin tab 20 mg......................................................... 13

lovastatin tab 40 mg......................................................... 13

LUMIGAN.............................................................................27

LYNPARZA.............................................................................4

mafenide acetate packet for topical soln 5% (50

gm)..................................................................................... 28

MATULANE............................................................................ 4

MAVENCLAD....................................................................... 20

MAVYRET.............................................................................. 2

MAYZENT............................................................................ 20

MAYZENT STARTER PACK............................................... 20

meclizine hcl tab 12.5 mg, 25 mg....................................16

medroxyprogesterone acetate im susp 150 mg/ml.........7

medroxyprogesterone acetate im susp prefilled syr

150 mg/ml............................................................................7

medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10

mg........................................................................................ 7

megestrol acetate tab 20 mg, 40 mg................................ 4

MEKINIST.............................................................................. 4

meloxicam tab 7.5 mg, 15 mg..........................................22

memantine hcl tab 5 mg, 10 mg......................................20

MESNEX................................................................................ 4

metformin hcl tab er 24hr 500 mg, 750 mg...................... 8

metformin hcl tab 500 mg, 850 mg, 1000 mg...................8

methadone hcl tab 5 mg.................................................. 21

methadone hcl tab 10 mg................................................ 21

methimazole tab 5 mg, 10 mg......................................... 10

methocarbamol tab 500 mg............................................. 24

methocarbamol tab 750 mg............................................. 24

methotrexate sodium inj 50 mg/2ml (25 mg/ml).............. 5

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250

mg/10ml (25 mg/ml)...........................................................4

methotrexate sodium tab 2.5 mg (base equiv)................ 5

methylphenidate hcl tab 5 mg, 10 mg............................ 19

methylprednisolone tab 4 mg, 16 mg, 32 mg.................. 6

methylprednisolone tab therapy pack 4 mg (21).............6

metoclopramide hcl tab 5 mg (base equivalent), 10 mg

(base equivalent)............................................................. 17

metoprolol succinate tab er 24hr 25 mg (tartrate

equiv), 50 mg (tartrate equiv), 100 mg (tartrate

equiv)................................................................................. 11

metoprolol tartrate tab 50 mg, 100 mg........................... 11

metoprolol tartrate tab 25 mg, 37.5 mg, 75 mg..............11

metronidazole tab 250 mg, 500 mg...................................3

minocycline hcl cap 50 mg................................................ 1

minoxidil tab 2.5 mg, 10 mg............................................ 12

mirtazapine tab 15 mg, 30 mg, 45 mg............................ 18

misoprostol tab 100 mcg, 200 mcg.................................16

mometasone furoate oint 0.1%........................................28

montelukast sodium chew tab 4 mg (base equiv), 5 mg

(base equiv)...................................................................... 15

montelukast sodium tab 10 mg (base equiv).................15

morphine sulfate tab er 15 mg........................................ 21

MOUNJARO...........................................................................8

MOVANTIK...........................................................................17

MULTAQ............................................................................... 11

mupirocin oint 2%............................................................. 28

MYFEMBREE........................................................................ 6

MYLERAN..............................................................................5

nabumetone tab 500 mg...................................................22

naproxen tab 250 mg, 375 mg, 500 mg.......................... 22

NATACYN.............................................................................27

neomycin-polymyxin-dexamethasone ophth oint

0.1%....................................................................................27

neomycin-polymyxin-dexamethasone ophth susp

0.1%....................................................................................27

neomycin sulfate tab 500 mg............................................ 1

nevirapine tab 200 mg........................................................ 2

NEXIUM............................................................................... 16

NEXLETOL.......................................................................... 13

NEXLIZET............................................................................ 13

NICOTROL INHALER......................................................... 20

NICOTROL NS.................................................................... 20

nifedipine tab er 24hr 30 mg............................................11

nifedipine tab er 24hr osmotic release 30 mg............... 11

nitrofurantoin monohydrate macrocrystalline cap 100

mg........................................................................................ 3

nitroglycerin sl tab 0.4 mg............................................... 10

NITYR...................................................................................10

NIVESTYM...........................................................................25

NORDITROPIN FLEXPRO................................................. 10

norethindrone & ethinyl estradiol tab 1 mg-35 mcg....... 7

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg...................................................................................... 7

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30

mcg...................................................................................... 7

norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg...................................................................................... 7

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-

mcg...................................................................................... 7

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 36

Norethindrone tab 0.35 mg................................................ 7

norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg...................................................................................... 7

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25

mg-mcg................................................................................7

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35

mg-mcg................................................................................7

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........... 7

nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg........ 18

NORVIR................................................................................. 2

NOVOEIGHT........................................................................26

NOVOLIN 70/30.....................................................................9

NOVOLIN 70/30 FLEXPEN.................................................. 9

NOVOLIN N........................................................................... 9

NOVOLIN N FLEXPEN......................................................... 9

NOVOLIN R........................................................................... 9

NOVOLIN R FLEXPEN......................................................... 9

NOVOLOG............................................................................. 9

NOVOLOG FLEXPEN...........................................................9

NOVOLOG MIX 70/30...........................................................9

NOVOLOG MIX 70/30 PREFILL...........................................9

NOVOLOG PENFILL.............................................................9

NOVOSEVEN RT................................................................ 26

NOXAFIL................................................................................ 2

NUBEQA................................................................................ 5

NUCALA...............................................................................15

NURTEC.............................................................................. 23

NUVARING.............................................................................7

NUWIQ................................................................................. 26

nystatin cream 100000 unit/gm....................................... 29

nystatin oint 100000 unit/gm........................................... 29

nystatin susp 100000 unit/ml...........................................28

OBIZUR................................................................................26

ODEFSEY.............................................................................. 2

ofloxacin ophth soln 0.3%............................................... 27

olanzapine tab 15 mg, 20 mg...........................................19

olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg................. 19

olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg, 40-12.5 mg, 40-25 mg.................................12

olmesartan medoxomil tab 5 mg, 20 mg, 40 mg........... 12

omeprazole cap delayed release 10 mg, 20 mg, 40

mg...................................................................................... 16

OMNIPOD DASH INTRO KIT (G........................................29

OMNIPOD DASH PODS (GEN 4)...................................... 29

OMNIPOD 5 G6 INTRO KIT (G..........................................29

OMNIPOD 5 G7 INTRO KIT (G..........................................29

OMNIPOD 5 G6 PODS (GEN 5)........................................ 29

OMNIPOD 5 G7 PODS (GEN 5)........................................ 29

OMNITROPE....................................................................... 10

ondansetron hcl oral soln 4 mg/5ml...............................16

ondansetron hcl tab 4 mg, 8 mg..................................... 16

ondansetron orally disintegrating tab 4 mg, 8 mg........ 16

OPSUMIT.............................................................................13

OPVEE................................................................................. 29

ORFADIN............................................................................. 10

ORIAHNN...............................................................................6

ORILISSA.............................................................................10

OTEZLA............................................................................... 22

OVIDREL..............................................................................10

oxcarbazepine tab 150 mg............................................... 23

oxybutynin chloride solution 5 mg/5ml..........................17

oxybutynin chloride tab er 24hr 15 mg.......................... 17

oxybutynin chloride tab er 24hr 5 mg, 10 mg................17

oxybutynin chloride tab 5 mg..........................................17

oxycodone hcl tab 5 mg...................................................21

oxycodone hcl tab 10 mg.................................................21

oxycodone w/ acetaminophen tab 5-325 mg................. 21

OZEMPIC............................................................................... 8

pantoprazole sodium ec tab 20 mg (base equiv), 40 mg

(base equiv)...................................................................... 16

paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg............18

PAXLOVID..............................................................................2

PEGASYS.............................................................................. 2

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm...................................................................................... 16

penicillin v potassium tab 250 mg, 500 mg..................... 1

phendimetrazine tartrate tab 35 mg................................19

phenobarbital tab 15 mg, 30 mg, 60 mg, 100 mg.......... 19

phentermine hcl cap 37.5 mg.......................................... 19

phentermine hcl cap 15 mg, 30 mg................................ 19

phentermine hcl tab 37.5 mg........................................... 19

pioglitazone hcl tab 15 mg (base equiv), 30 mg (base

equiv), 45 mg (base equiv)...............................................8

PIQRAY 200MG DAILY DOSE............................................. 5

PIQRAY 250MG DAILY DOSE............................................. 5

PIQRAY 300MG DAILY DOSE............................................. 5

PLEGRIDY........................................................................... 20

PLEGRIDY STARTER PACK..............................................20

polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%.............................................................................. 27

potassium chloride cap er 8 meq, 10 meq.....................24

potassium chloride microencapsulated crys er tab 10

meq, 20 meq.....................................................................24

potassium chloride tab er 10 meq, 20 meq (1500

mg)..................................................................................... 24

potassium chloride tab er 8 meq (600 mg).................... 24

potassium phosphate monobasic tab 500 mg.............. 24

pramipexole dihydrochloride tab 0.125 mg, 0.25 mg,

0.5 mg, 0.75 mg, 1 mg, 1.5 mg.......................................23

pravastatin sodium tab 10 mg.........................................13

pravastatin sodium tab 20 mg, 40 mg, 80 mg................13

prazosin hcl cap 1 mg...................................................... 12

PREDNISOLONE ACETATE...............................................27

PREDNISOLONE SODIUM PHOSP.................................. 27

prednisolone sod phosphate oral soln 15 mg/5ml

(base equiv)........................................................................ 6

PREDNISONE....................................................................... 6

prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50

mg........................................................................................ 6

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 37

prednisone tab therapy pack 5 mg (21), 5 mg (48), 10

mg (21)................................................................................ 6

pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg,

200 mg, 225 mg, 300 mg................................................ 23

PREGNYL............................................................................ 10

PREGNYL W/DILUENT BENZYL....................................... 10

PREMARIN............................................................................ 6

PREMPHASE.........................................................................6

PREMPRO............................................................................. 6

PRENATAL 19..................................................................... 24

PREZISTA.............................................................................. 2

PRIFTIN................................................................................. 1

primidone tab 50 mg.........................................................23

prochlorperazine maleate tab 5 mg (base

equivalent)........................................................................ 19

PROCRIT............................................................................. 25

PROFILNINE........................................................................26

promethazine-dm syrup 6.25-15 mg/5ml........................ 14

promethazine hcl oral soln 6.25 mg/5ml........................ 14

promethazine hcl tab 12.5 mg, 25 mg, 50 mg................ 14

promethazine w/ codeine syrup 6.25-10 mg/5ml........... 14

propafenone hcl tab 150 mg............................................11

PROPRANOLOL HCL......................................................... 11

propranolol hcl oral soln 20 mg/5ml...............................11

propranolol hcl tab 10 mg, 20 mg, 40 mg...................... 11

pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml.....14

PULMOZYME...................................................................... 16

PURIXAN............................................................................... 5

quetiapine fumarate tab er 24hr 150 mg........................ 19

quetiapine fumarate tab 100 mg......................................19

quetiapine fumarate tab 200 mg......................................19

quetiapine fumarate tab 25 mg, 50 mg...........................19

quetiapine fumarate tab 300 mg, 400 mg....................... 19

quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg.................12

QULIPTA.............................................................................. 23

QVAR REDIHALER............................................................. 15

rabeprazole sodium ec tab 20 mg...................................16

ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg.................... 12

RAPAMUNE......................................................................... 30

REBIF...................................................................................20

REBIF REBIDOSE.............................................................. 20

REBIF REBIDOSE TITRATION.......................................... 20

REBIF TITRATION PACK................................................... 20

REBINYN............................................................................. 26

RECOMBINATE................................................................... 26

REPATHA.............................................................................13

REPATHA PUSHTRONEX SYSTEM..................................13

REPATHA SURECLICK...................................................... 13

RETACRIT............................................................................25

RETEVMO..............................................................................5

REVCOVI............................................................................. 10

REVLIMID............................................................................ 30

REXULTI.............................................................................. 19

REYVOW............................................................................. 23

RINVOQ............................................................................... 22

risperidone tab 3 mg........................................................ 19

risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg...... 19

RIXUBIS............................................................................... 27

rizatriptan benzoate oral disintegrating tab 5 mg (base

eq)...................................................................................... 23

rizatriptan benzoate oral disintegrating tab 10 mg

(base eq)........................................................................... 23

rizatriptan benzoate tab 5 mg (base equivalent), 10 mg

(base equivalent)............................................................. 23

ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg, 5 mg.....................................................23

rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40

mg...................................................................................... 13

ROZLYTREK.......................................................................... 5

RUBRACA..............................................................................5

RYBELSUS............................................................................ 8

RYDAPT.................................................................................5

SAVELLA..............................................................................20

SAVELLA TITRATION PACK.............................................. 20

selenium sulfide lotion 2.5%............................................29

SEMGLEE..............................................................................9

SE-NATAL 19.......................................................................24

SEREVENT DISKUS...........................................................15

sertraline hcl tab 25 mg, 50 mg, 100 mg........................ 18

sildenafil citrate tab 25 mg, 50 mg, 100 mg................... 14

silver sulfadiazine cream 1%........................................... 29

SIMBRINZA..........................................................................28

SIMPONI.............................................................................. 22

simvastatin tab 5 mg, 10 mg, 20 mg, 40 mg, 80 mg...... 13

SKYRIZI............................................................................... 17

SKYRIZI PEN...................................................................... 29

sodium chloride soln nebu 3%........................................14

sodium chloride soln nebu 7%........................................14

sodium fluoride chew tab 0.25 mg f (from 0.55 mg

naf), 0.5 mg f (from 1.1 mg naf), 1 mg f (from 2.2 mg

naf)..................................................................................... 24

sodium fluoride cream 1.1%............................................ 28

sodium fluoride gel 1.1% (0.5% f)................................... 28

sodium fluoride paste 1.1%............................................. 28

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml

naf)..................................................................................... 24

solifenacin succinate tab 5 mg, 10 mg...........................17

SOLIQUA 100/33...................................................................8

SOOLANTRA....................................................................... 29

sotalol hcl (afib/afl) tab 80 mg.........................................11

sotalol hcl tab 80 mg, 120 mg......................................... 11

SOVALDI................................................................................ 2

SPIRIVA HANDIHALER...................................................... 15

SPIRIVA RESPIMAT........................................................... 15

spironolactone tab 25 mg, 50 mg, 100 mg.....................12

SPRYCEL...............................................................................5

STELARA.............................................................................29

STIOLTO RESPIMAT.......................................................... 15

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 38

STRENSIQ...........................................................................10

STRIVERDI RESPIMAT...................................................... 15

sulfamethoxazole-trimethoprim tab 400-80 mg............... 3

sulfamethoxazole-trimethoprim tab 800-160 mg.............3

sulindac tab 150 mg, 200 mg...........................................22

sumatriptan succinate tab 25 mg, 50 mg, 100 mg.........23

SUNOSI................................................................................19

SYMDEKO........................................................................... 16

SYMPROIC.......................................................................... 17

SYMTUZA.............................................................................. 2

SYNJARDY............................................................................ 8

SYNJARDY XR......................................................................8

TABLOID................................................................................ 5

TABRECTA.............................................................................5

tadalafil tab 2.5 mg, 5 mg............................................13,14

tadalafil tab 10 mg, 20 mg...........................................13,14

TAFINLAR.............................................................................. 5

TAGRISSO............................................................................. 5

TAKHZYRO.......................................................................... 27

TALZENNA.............................................................................5

tamoxifen citrate tab 10 mg (base equivalent), 20 mg

(base equivalent)............................................................... 5

tamsulosin hcl cap 0.4 mg...............................................17

TASIGNA................................................................................ 5

TAZORAC............................................................................ 29

telmisartan tab 20 mg....................................................... 12

temazepam cap 15 mg, 30 mg.........................................19

terazosin hcl cap 1 mg (base equivalent), 2 mg (base

equivalent), 5 mg (base equivalent), 10 mg (base

equivalent)........................................................................ 12

terbinafine hcl tab 250 mg................................................. 2

testosterone cypionate im inj in oil 100 mg/ml............... 6

TEST STRIPS – CONTOUR, CONTOUR NEXT,

ONETOUCH ULTRA, ONETOUCH VERIO...................... 29

TEZSPIRE............................................................................15

THALOMID...........................................................................30

TIBSOVO............................................................................... 5

timolol maleate ophth soln 0.25%, 0.5%........................ 28

TIVICAY..................................................................................2

TIVICAY PD........................................................................... 3

tizanidine hcl cap 2 mg (base equivalent)..................... 24

tizanidine hcl tab 2 mg (base equivalent)...................... 24

tizanidine hcl tab 4 mg (base equivalent)...................... 24

tobramycin ophth soln 0.3%............................................28

topiramate tab 25 mg, 50 mg, 100 mg, 200 mg..............23

torsemide tab 5 mg, 10 mg, 20 mg, 100 mg...................12

TOUJEO MAX SOLOSTAR.................................................. 9

TOUJEO SOLOSTAR............................................................9

TRACLEER.......................................................................... 13

tramadol-acetaminophen tab 37.5-325 mg.....................21

tramadol hcl tab 50 mg.................................................... 21

trandolapril tab 1 mg, 2 mg, 4 mg...................................12

trazodone hcl tab 50 mg, 100 mg, 150 mg..................... 18

TRELEGY ELLIPTA.............................................................15

TREMFYA............................................................................ 29

TRESIBA................................................................................ 9

TRESIBA FLEXTOUCH........................................................ 9

TRETTEN.............................................................................27

triamcinolone acetonide cream 0.025%, 0.1%, 0.5%.....29

triamcinolone acetonide oint 0.025%, 0.1%, 0.5%.........29

triamterene & hydrochlorothiazide cap 37.5-25 mg...... 12

triamterene & hydrochlorothiazide tab 37.5-25 mg.......12

triamterene & hydrochlorothiazide tab 75-50 mg..........12

triazolam tab 0.125 mg..................................................... 19

TRIFLURIDINE.................................................................... 28

trihexyphenidyl hcl tab 2 mg, 5 mg................................ 23

TRIJARDY XR....................................................................... 8

TRIKAFTA............................................................................ 16

trimethoprim tab 100 mg....................................................3

TRIUMEQ...............................................................................3

TRIUMEQ PD........................................................................ 3

TRULANCE..........................................................................17

TRULICITY.............................................................................8

TYMLOS...............................................................................10

UBRELVY.............................................................................23

UPTRAVI.............................................................................. 13

UPTRAVI TITRATION PACK.............................................. 13

valacyclovir hcl tab 500 mg............................................... 3

VALCHLOR.......................................................................... 29

valsartan tab 40 mg, 80 mg, 160 mg, 320 mg................ 12

VELPHORO......................................................................... 17

VELTASSA........................................................................... 30

VEMLIDY................................................................................3

VENCLEXTA.......................................................................... 5

VENCLEXTA STARTING PACK........................................... 5

venlafaxine hcl cap er 24hr 37.5 mg (base

equivalent), 75 mg (base equivalent), 150 mg (base

equivalent)........................................................................ 18

venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg

(base equivalent), 50 mg (base equivalent), 75 mg

(base equivalent), 100 mg (base equivalent)............... 18

VENTOLIN HFA...................................................................15

verapamil hcl tab er 120 mg, 180 mg, 240 mg............... 11

verapamil hcl tab 40 mg...................................................11

verapamil hcl tab 80 mg, 120 mg.................................... 11

VERQUVO........................................................................... 13

VERZENIO.............................................................................5

VIBERZI............................................................................... 17

VIREAD.................................................................................. 3

VITRAKVI............................................................................... 5

VONVENDI.......................................................................... 27

VOSEVI.................................................................................. 3

VOTRIENT............................................................................. 6

VUMERITY...........................................................................20

VYNDAMAX......................................................................... 13

VYNDAQEL..........................................................................13

VYVANSE.............................................................................19

2024

Blue Cross and Blue Shield July 2024 Multi Tier Basic Annual Drug List 39

warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5

mg, 6 mg, 7.5 mg, 10 mg................................................25

WILATE................................................................................ 27

XALKORI................................................................................6

XARELTO.............................................................................25

XARELTO STARTER PACK................................................25

XELJANZ..............................................................................22

XELJANZ XR....................................................................... 22

XIFAXAN................................................................................ 3

XIGDUO XR...........................................................................8

XOLAIR................................................................................ 16

XTAMPZA ER...................................................................... 21

XTANDI...................................................................................6

XULTOPHY 100/3.6...............................................................8

XYNTHA...............................................................................27

XYNTHA SOLOFUSE......................................................... 27

YONSA...................................................................................6

zaleplon cap 5 mg, 10 mg................................................ 19

ZARXIO................................................................................ 25

ZEGALOGUE.........................................................................8

ZEJULA.................................................................................. 6

ZELBORAF............................................................................ 6

ZENPEP............................................................................... 17

ZEPOSIA..............................................................................20

ZEPOSIA 7-DAY STARTER PAC....................................... 21

ZEPOSIA STARTER KIT.................................................... 20

ZIEXTENZO......................................................................... 25

ZOKINVY..............................................................................30

zolpidem tartrate tab 5 mg, 10 mg.................................. 19

zonisamide cap 25 mg......................................................23

zonisamide cap 50 mg......................................................23

ZURZUVAE.......................................................................... 18

ZYLET.................................................................................. 28