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4621-K © Prime Therapeutics LLC 07/23 [HCSC 5-state logo] Basic Drug List July 2023 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. 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 Abbreviation key ..........................................VII Therapeutic Class Drug List Anti-Infective Agents ...................................... 1 Antineoplastic Agents .................................... 5 Endocrine and Metabolic Drugs ..................... 9 Cardiovascular Agents ................................. 15 Respiratory Agents ...................................... 20 Gastrointestinal Drugs ................................. 23 Genitourinary Drugs ..................................... 25 Central Nervous System Drugs .................... 25 Analgesics and Anesthetics ......................... 30 Neuromuscular Drugs .................................. 33 Nutritional Products...................................... 35 Hematological Agents .................................. 36 Topical Products .......................................... 39 Miscellaneous Products ............................... 43 Index ........................................................... 46 To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

Blue Cross and Blue Shield July 2023 Basic Drug List I Introduction Blue Cross and Blue Shield is pleased to present the 2023 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 and log in or call the number on your ID card. 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 your health plan, 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 Brand or 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 brands may be in a generic tier and some generics may be in a brand tier. Some specialty medicines are marked with an "SP" in the Special Requirements column. Please refer to the Specialty Section for more information. 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. 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 July 2023 Basic Drug List II How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand drug is 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 July 2023 Basic Drug List 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 July 2023 Basic Drug List IV 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. *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 July 2023 Basic Drug List V Appropriate Use of Opioids (AUO) This program may require authorization for members new to opioid therapy exceeding the established days supply limit, or if cumulative quantity of all opioids filled is equal to or greater than the established morphine milligram equivalent threshold. If any medication listed in this document is a part of this program, it will generally be noted next to the medication with an “AUO” under the Special Requirements column. 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). We will let you, and your prescriber, know the coverage decision after they receive your request. If the request is denied, we will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). 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. Blue Cross and Blue Shield does not provide health care services and, therefore, cannot guarantee any results or outcomes.

Blue Cross and Blue Shield July 2023 Basic Drug List VI 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. 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. Blue Cross and Blue Shield of Illinois (BCBSIL), Blue Cross and Blue Shield of Montana (BCBSMT), Blue Cross and Blue Shield of New Mexico (BCBSNM), Blue Cross and Blue Shield of Oklahoma (BCBSOK) and Blue Cross and Blue Shield of Texas (BCBSTX) are Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. BCBSIL, BCBSMT, BCBSNM, BCBSOK and BCBSTX contract with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, BCBSMT, BCBSNM, BCBSOK and BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, have an ownership interest in Prime Therapeutics LLC.

Blue Cross and Blue Shield July 2023 Basic Drug List 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

Adalimumab Coverage This listing is reflective of FDA approved products and projected product launches. All Adalimumab products are subject to Prior Authorization, Quantity/Dispensing Limits, and Specialty designations as applicable. Preferred Adalimumab Products This list includes any existing preferred adalimumab products or biosimilar adalimumab additions to the drug list. TRADE NAME (generic name) Manufacturer Brand/Generic Product Effective Date Description of Coverage AMJEVITA (adalimumab-atto)* Amgen Brand 7/1/23 Preferred, biosimilar for HUMIRA HADLIMA (adalimumab-bwwd) Samsung/ Organon Brand Upon Launch Preferred, biosimilar for HUMIRA HUMIRA (adalimumab) AbbVie Brand Current Preferred * = NDCs starting with 55513 Non-Formulary/Non-Preferred Adalimumab ProductsThis list includes new-to-market biosimilar adalimumab products that have been evaluated and are non-formulary/non-preferred on the drug list.TRADE NAME (generic name) Manufacturer Brand/Generic Product Effective Date Description of CoverageABRILADA (adalimumab-afzb) Pfizer Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA ADALIMUMAB (adalimumab-adaz) Sandoz Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA ADALIMUMAB (adalimumab-fkjp) Viatris Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA AMJEVITA (adalimumab-atto)** Amgen Brand Current Non-Formulary/Non-Preferred, biosimilar for HUMIRA CYLTEZO (adalimumab-adbm) Boehringer Ingelheim Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA HULIO (adalimumab-fkjp) Viatris Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA HYRIMOZ (adalimumab-adaz) Sandoz Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA IDACIO (adalimumab-aacf) Fresenius Kabi Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA YUFLYMA (adalimumab-++++) Celltrion Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA YUSIMRY (adalimumab-aqvh) Coherus Brand Upon Launch Non-Formulary/Non-Preferred, biosimilar for HUMIRA + = Biosimilar suffix placeholder. Suffix is assigned upon FDA approval** = NDC starting with 72511

2023Blue Cross and Blue Shield July 2023 Basic Drug List 1Drug NameRequirements/LimitsANTI-INFECTIVE AGENTSPENICILLINSamoxicillin (trihydrate) cap 250 mg, 500 mgamoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml,400 mg/5mlamoxicillin (trihydrate) tab 500 mg, 875 mgamoxicillin & k clavulanate for susp 200-28.5 mg/5ml, 400-57 mg/5mlamoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)amoxicillin & k clavulanate tab 250-125 mgamoxicillin & k clavulanate tab 500-125 mg, 875-125 mg (Augmentin)dicloxacillin sodium cap 250 mg, 500 mgpenicillin v potassium tab 250 mg, 500 mgCEPHALOSPORINScefadroxil cap 500 mgcefadroxil for susp 250 mg/5ml, 500 mg/5mlcefdinir cap 300 mgcefdinir for susp 125 mg/5ml, 250 mg/5mlcefixime cap 400 mg (Suprax)cefixime for susp 100 mg/5ml, 200 mg/5ml (Suprax)cefpodoxime proxetil for susp 50 mg/5ml, 100 mg/5mlcefpodoxime proxetil tab 100 mg, 200 mgcefprozil for susp 125 mg/5ml, 250 mg/5mlcefprozil tab 250 mg, 500 mgcefuroxime axetil tab 250 mg, 500 mgcephalexin cap 250 mg, 500 mg (Keflex)cephalexin for susp 125 mg/5ml, 250 mg/5mlMACROLIDESAZITHROMYCIN - azithromycin powd pack for susp 1 gmazithromycin for susp 100 mg/5ml, 200 mg/5ml (Zithromax)azithromycin tab 250 mg, 500 mg, 600 mg (Zithromax)QL (60 tablets/180 days)clarithromycin tab er 24hr 500 mgQL (28 tablets/30 days)clarithromycin tab 250 mg, 500 mgDIFICID - fidaxomicin tab 200 mgDIFICID - fidaxomicin for susp 40 mg/mlTETRACYCLINESdemeclocycline hcl tab 150 mg, 300 mgdoxycycline hyclate cap 50 mgdoxycycline hyclate cap 100 mg (Vibramycin)doxycycline hyclate tab 20 mg, 100 mg

2023Blue Cross and Blue Shield July 2023 Basic Drug List 2Drug NameRequirements/Limitsdoxycycline monohydrate cap 50 mgdoxycycline monohydrate cap 100 mg (Monodox)doxycycline monohydrate tab 50 mg, 75 mg, 100 mgdoxycycline monohydrate tab 150 mgPAminocycline hcl cap 50 mg (Minocin)minocycline hcl cap 75 mg, 100 mgtetracycline hcl cap 250 mg, 500 mgFLUOROQUINOLONESciprofloxacin 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)ofloxacin tab 400 mgAMINOGLYCOSIDESneomycin sulfate tab 500 mgparomomycin sulfate cap 250 mgtobramycin nebu soln 300 mg/5ml (Tobi)QL (56 containers/56 days), SPANTIMYCOBACTERIAL AGENTSethambutol hcl tab 100 mg, 400 mg (Myambutol)isoniazid tab 300 mgPRIFTIN - rifapentine tab 150 mgpyrazinamide tab 500 mgrifabutin cap 150 mg (Mycobutin)rifampin cap 150 mg, 300 mg (Rifadin)ANTIFUNGALSfluconazole for susp 10 mg/ml, 40 mg/ml (Diflucan)fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg (Diflucan)flucytosine cap 250 mg, 500 mg (Ancobon)griseofulvin microsize susp 125 mg/5mlgriseofulvin microsize tab 500 mgitraconazole cap 100 mg (Sporanox)QL (120 capsules/30 days)itraconazole oral soln 10 mg/ml (Sporanox)QL (1200 mls/30 days)NOXAFIL - posaconazole susp 40 mg/mlPANOXAFIL - posaconazole for delayed release susp packet 300 mgPAnystatin tab 500000 unitposaconazole susp 40 mg/ml (Noxafil)PAposaconazole tab delayed release 100 mg (Noxafil)PAterbinafine hcl tab 250 mg (Lamisil)voriconazole for susp 40 mg/ml (Vfend)PAvoriconazole tab 50 mg, 200 mg (Vfend)PAANTIVIRALS

2023Blue Cross and Blue Shield July 2023 Basic Drug List 3Drug NameRequirements/Limitsabacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)QL (960 mls/30 days)abacavir sulfate tab 300 mg (base equiv) (Ziagen)QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)QL (30 tablets/30 days)acyclovir cap 200 mg (Zovirax)acyclovir susp 200 mg/5ml (Zovirax)acyclovir tab 400 mg, 800 mg (Zovirax)adefovir dipivoxil tab 10 mg (Hepsera)atazanavir sulfate cap 150 mg (base equiv), 300 mg (base equiv)(Reyataz)QL (30 capsules/30 days)atazanavir sulfate cap 200 mg (base equiv) (Reyataz)QL (60 capsules/30 days)BARACLUDE - entecavir oral soln 0.05 mg/mlBIKTARVY - bictegravir-emtricitabine-tenofovir af tab 30-120-15 mg,50-200-25 mgQL (30 tablets/30 days)CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mgQL (30 tablets/30 days)DELSTRIGO - doravirine-lamivudine-tenofovir df tab 100-300-300 mgQL (30 tablets/30 days)DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab 120-15 mg,200-25 mgQL (30 tablets/30 days)DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg (base eq)QL (30 tablets/30 days)efavirenz tab 600 mg (Sustiva)QL (30 tablets/30 days)efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg (Atripla)QL (30 tablets/30 days)efavirenz-lamivudine-tenofovir df tab 400-300-300 mg (Symfi lo)QL (30 tablets/30 days)efavirenz-lamivudine-tenofovir df tab 600-300-300 mg (Symfi)QL (30 tablets/30 days)emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg, 133-200 mg,167-250 mg (Truvada)QL (30 tablets/30 days)emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg (Truvada)AC, QL (30 tablets/30 days)entecavir tab 0.5 mg, 1 mg (Baraclude)EPCLUSA - sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mgPA, QL (30 tablets/30 days), SPEPCLUSA - sofosbuvir-velpatasvir pellet pack 150-37.5 mg, 200-50 mgPA, QL (28 tablets/28 days), SPetravirine tab 100 mg, 200 mg (Intelence)QL (60 tablets/30 days)famciclovir tab 125 mg (Famvir)famciclovir tab 250 mg, 500 mgGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mgQL (30 tablets/30 days)HARVONI - ledipasvir-sofosbuvir tab 45-200 mg, 90-400 mgPA, QL (30 tablets/30 days), SPHARVONI - ledipasvir-sofosbuvir pellet pack 33.75-150 mg, 45-200 mgPA, QL (30 packets/30 days), SPINTELENCE - etravirine tab 25 mgQL (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)lamivudine oral soln 10 mg/ml (Epivir)QL (4 bottles/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 4Drug NameRequirements/Limitslamivudine tab 100 mg (hbv) (Epivir hbv)lamivudine tab 150 mg, 300 mg (Epivir)QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg (Combivir)QL (60 tablets/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra)QL (3 bottles/30 days)lopinavir-ritonavir tab 100-25 mg (Kaletra)QL (180 tablets/90 days)lopinavir-ritonavir tab 200-50 mg (Kaletra)QL (120 tablets/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mgPA, QL (90 tablets/30 days), SPMAVYRET - glecaprevir-pibrentasvir pellet pack 50-20 mgPA, QL (140 tablets/28 days), SPnevirapine tab er 24hr 400 mgQL (30 tablets/30 days)nevirapine tab 200 mg (Viramune)QL (60 tablets/30 days)NORVIR - ritonavir powder packet 100 mgQL (360 packets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mgQL (30 tablets/30 days)oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu)QL (40 capsules/120 days)oseltamivir phosphate cap 45 mg (base equiv), 75 mg (base equiv)(Tamiflu)QL (20 capsules/120 days)oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu)QL (300 mls/120 days)PEGASYS - peginterferon alfa-2a soln prefilled syr 180 mcg/0.5mlPA, SPPEGASYS - peginterferon alfa-2a inj 180 mcg/mlPA, SPPREZISTA - darunavir oral susp 100 mg/mlQL (2 bottles/30 days)PREZISTA - darunavir tab 75 mgQL (300 tablets/30 days)PREZISTA - darunavir tab 150 mgQL (180 tablets/30 days)PREZISTA - darunavir tab 600 mgQL (60 tablets/30 days)PREZISTA - darunavir tab 800 mgQL (30 tablets/30 days)ritonavir tab 100 mg (Norvir)QL (360 tablets/30 days)SOVALDI - sofosbuvir tab 200 mg, 400 mgPA, QL (30 tablets/30 days), SPSOVALDI - sofosbuvir pellet pack 150 mg, 200 mgPA, QL (30 packets/30 days), SPSYMTUZA - darunavir-cobic-emtricitab-tenofov af tab 800-150-200-10 mgQL (30 tablets/30 days)tenofovir disoproxil fumarate tab 300 mg (Viread)QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg (base equiv)QL (240 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg (base equiv), 50 mg (base equiv)QL (60 tablets/30 days)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 mgQL (30 tablets/30 days)TRIUMEQ PD - abacavir-dolutegravir-lamivudine tab for oral sus 60-5-30 mgQL (180 tablets/30 days)valacyclovir hcl tab 500 mg, 1 gm (Valtrex)valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte)valganciclovir hcl tab 450 mg (base equivalent) (Valcyte)VEMLIDY - tenofovir alafenamide fumarate tab 25 mgVIREAD - tenofovir disoproxil fumarate tab 150 mg, 200 mg, 250 mgQL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gmQL (4 bottles/30 days)VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mgPA, QL (30 tablets/30 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 5Drug NameRequirements/Limitszidovudine cap 100 mg (Retrovir)QL (180 capsules/30 days)zidovudine syrup 10 mg/ml (Retrovir)QL (8 bottles/30 days)zidovudine tab 300 mgQL (60 tablets/30 days)ANTIMALARIALSatovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg (Malarone)QL (30 tablets/90 days)chloroquine phosphate tab 250 mg, 500 mghydroxychloroquine sulfate tab 200 mg (Plaquenil)mefloquine hcl tab 250 mgprimaquine phosphate tab 26.3 mg (15 mg base) (Primaquine phosphate)pyrimethamine tab 25 mg (Daraprim)PA, QL (116 tablets/180 days)ANTHELMINTICSalbendazole tab 200 mg (Albenza)BENZNIDAZOLE - benznidazole tab 12.5 mg, 100 mgivermectin tab 3 mg (Stromectol)praziquantel tab 600 mg (Biltricide)ANTI-INFECTIVE AGENTS - MISC.ALINIA - nitazoxanide for susp 100 mg/5mlQL (180 mls/30 days)atovaquone susp 750 mg/5ml (Mepron)clindamycin hcl cap 75 mg, 150 mg, 300 mg (Cleocin)clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocinpediatric gr)dapsone tab 25 mg, 100 mgIMPAVIDO - miltefosine cap 50 mglinezolid for susp 100 mg/5ml (Zyvox)QL (600 mls/180 days)linezolid tab 600 mg (Zyvox)QL (56 tablets/180 days)metronidazole tab 250 mg, 500 mg (Flagyl)nitazoxanide tab 500 mg (Alinia)nitrofurantoin macrocrystalline cap 25 mg, 50 mg, 100 mg (Macrodantin)nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)nitrofurantoin susp 25 mg/5mlpentamidine isethionate for nebulization soln 300 mg (Nebupent)sulfamethoxazole-trimethoprim susp 200-40 mg/5mlsulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)trimethoprim tab 100 mgvancomycin hcl cap 125 mg (base equivalent) (Vancocin hcl)QL (120 capsules/30 days)vancomycin hcl cap 250 mg (base equivalent) (Vancocin)QL (120 capsules/30 days)XIFAXAN - rifaximin tab 550 mgQL (60 tablets/30 days)ANTINEOPLASTIC AGENTSANTINEOPLASTICS

2023Blue Cross and Blue Shield July 2023 Basic Drug List 6Drug NameRequirements/Limitsabiraterone acetate tab 250 mg (Zytiga)PA, QL (120 tablets/30 days), SPabiraterone acetate tab 500 mg (Zytiga)PA, QL (60 tablets/30 days), SPACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)SPALECENSA - alectinib hcl cap 150 mg (base equivalent)PA, QL (240 capsules/30 days), SPALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mgPA, QL (1 pack/180 days), SPALUNBRIG - brigatinib tab 30 mgPA, QL (120 tablets/30 days), SPALUNBRIG - brigatinib tab 90 mg, 180 mgPA, QL (30 tablets/30 days), SPanastrozole tab 1 mg (Arimidex)ACAYVAKIT - avapritinib tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mgPA, QL (30 tablets/30 days), SPbexarotene cap 75 mg (Targretin)PA, SPbicalutamide tab 50 mg (Casodex)BRUKINSA - zanubrutinib cap 80 mgPA, QL (120 capsules/30 days), SPCABOMETYX - cabozantinib s-malate tab 20 mg (base equivalent), 40 mg(base equivalent), 60 mg (base equivalent)PA, QL (30 tablets/30 days), SPCALQUENCE - acalabrutinib maleate tab 100 mgPA, QL (60 tablets/30 days), SPcapecitabine tab 150 mg, 500 mg (Xeloda)SPCOTELLIC - cobimetinib fumarate tab 20 mg (base equivalent)PA, QL (63 tablets/28 days), SPcyclophosphamide cap 25 mg, 50 mg (Cyclophosphamide)EMCYT - estramustine phosphate sodium cap 140 mgSPERIVEDGE - vismodegib cap 150 mgPA, QL (30 capsules/30 days), SPERLEADA - apalutamide tab 60 mgPA, QL (120 tablets/30 days), SPERLEADA - apalutamide tab 240 mgPA, QL (30 tablets/30 days), SPerlotinib hcl tab 25 mg (base equivalent) (Tarceva)PA, QL (60 tablets/30 days), SPerlotinib hcl tab 100 mg (base equivalent), 150 mg (base equivalent)(Tarceva)PA, QL (30 tablets/30 days), SPETOPOSIDE - etoposide cap 50 mgSPeverolimus tab for oral susp 2 mg, 5 mg (Afinitor disperz)PA, QL (60 tablets/30 days), SPeverolimus tab for oral susp 3 mg (Afinitor disperz)PA, QL (90 tablets/30 days), SPeverolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg (Afinitor)PA, QL (30 tablets/30 days), SPexemestane tab 25 mg (Aromasin)GLEOSTINE - lomustine cap 10 mg, 40 mg, 100 mgSPhydroxyurea cap 500 mg (Hydrea)IBRANCE - palbociclib cap 75 mg, 100 mg, 125 mgPA, QL (21 capsules/28 days), SPIBRANCE - palbociclib tab 75 mg, 100 mg, 125 mgPA, QL (21 tablets/28 days), SPimatinib mesylate tab 100 mg (base equivalent) (Gleevec)PA, QL (90 tablets/30 days), SPimatinib mesylate tab 400 mg (base equivalent) (Gleevec)PA, QL (60 tablets/30 days), SPIMBRUVICA - ibrutinib tab 140 mg, 280 mg, 420 mg, 560 mgPA, QL (30 tablets/30 days), SPIMBRUVICA - ibrutinib oral susp 70 mg/mlPA, QL (216 mls/30 days), SPIMBRUVICA - ibrutinib cap 70 mgPA, QL (30 capsules/30 days), SPIMBRUVICA - ibrutinib cap 140 mgPA, QL (90 capsules/30 days), SPKISQALI - ribociclib succinate tab pack 200 mg daily dosePA, QL (21 tablets/28 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 7Drug NameRequirements/LimitsKISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg tab)PA, QL (42 tablets/28 days), SPKISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mg tab)PA, QL (63 tablets/28 days), SPKISQALI FEMARA 200 DOSE - ribociclib 200 mg dose (200 mg tab) &letrozole 2.5 mg tbpkPA, QL (49 tablets/28 days), SPKISQALI FEMARA 400 DOSE - ribociclib 400 mg dose (200 mg tab) &letrozole 2.5 mg tbpkPA, QL (70 tablets/28 days), SPKISQALI FEMARA 600 DOSE - ribociclib 600 mg dose (200 mg tab) &letrozole 2.5 mg tbpkPA, QL (91 tablets/28 days), SPlapatinib ditosylate tab 250 mg (base equiv) (Tykerb)PA, QL (180 tablets/30 days), SPLENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack 10 mg (10 mgdaily dose)PA, QL (30 capsules/30 days), SPLENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 3 x 4 mg (12 mgdaily dose)PA, QL (90 capsules/30 days), SPLENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 & 4 mg(14 mg daily dose)PA, QL (60 capsules/30 days), SPLENVIMA 18 MG DAILY DOSE - lenvatinib cap ther pack 10 mg & 2 x 4 mg(18 mg daily dose)PA, QL (90 capsules/30 days), SPLENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 2 x 10 mg(20 mg daily dose)PA, QL (60 capsules/30 days), SPLENVIMA 24 MG DAILY DOSE - lenvatinib cap ther pack 2 x 10 mg & 4 mg(24 mg daily dose)PA, QL (90 capsules/30 days), SPLENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg (4 mg dailydose)PA, QL (30 capsules/30 days), SPLENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 2 x 4 mg (8 mgdaily dose)PA, QL (60 capsules/30 days), SPletrozole tab 2.5 mg (Femara)leucovorin calcium tab 5 mg, 15 mg, 25 mgLEUKERAN - chlorambucil tab 2 mgSPleuprolide acetate inj kit 5 mg/mlSPLYNPARZA - olaparib tab 100 mg, 150 mgPA, QL (120 tablets/30 days), SPMATULANE - procarbazine hcl cap 50 mgPA, SPmegestrol acetate susp 40 mg/mlmegestrol acetate tab 20 mg, 40 mgMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent)PA, QL (90 tablets/30 days), SPMEKINIST - trametinib dimethyl sulfoxide tab 2 mg (base equivalent)PA, QL (30 tablets/30 days), SPmelphalan tab 2 mg (Alkeran)SPmercaptopurine tab 50 mgMESNEX - mesna tab 400 mgmethotrexate sodium for inj 1 gmmethotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250 mg/10ml (25 mg/ml), 1000 mg/40ml (25 mg/ml)methotrexate sodium inj 50 mg/2ml (25 mg/ml)methotrexate sodium tab 2.5 mg (base equiv)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 8Drug NameRequirements/LimitsMYLERAN - busulfan tab 2 mgSPnilutamide tab 150 mg (Nilandron)SPNUBEQA - darolutamide tab 300 mgPA, QL (120 tablets/30 days), SPPIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack 200 mg daily dosePA, QL (28 tablets/28 days), SPPIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mg daily dose (200 mg& 50 mg tabs)PA, QL (56 tablets/28 days), SPPIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mg daily dose(2x150 mg tab)PA, QL (56 tablets/28 days), SPPURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)SPRETEVMO - selpercatinib cap 40 mgPA, QL (180 capsules/30 days), SPRETEVMO - selpercatinib cap 80 mgPA, QL (120 capsules/30 days), SPROZLYTREK - entrectinib cap 100 mgPA, QL (30 capsules/30 days), SPROZLYTREK - entrectinib cap 200 mgPA, QL (90 capsules/30 days), SPRYDAPT - midostaurin cap 25 mgPA, QL (240 capsules/30 days), SPsorafenib tosylate tab 200 mg (base equivalent) (Nexavar)SPSPRYCEL - dasatinib tab 20 mgPA, QL (90 tablets/30 days), SPSPRYCEL - dasatinib tab 50 mg, 70 mg, 80 mg, 100 mg, 140 mgPA, QL (30 tablets/30 days), SPsunitinib malate cap 12.5 mg (base equivalent) (Sutent)PA, QL (90 capsules/30 days), SPsunitinib malate cap 25 mg (base equivalent), 37.5 mg (base equivalent),50 mg (base equivalent) (Sutent)PA, QL (30 capsules/30 days), SPTABLOID - thioguanine tab 40 mgSPTABRECTA - capmatinib hcl tab 150 mg, 200 mgPA, QL (120 tablets/30 days), SPTAFINLAR - dabrafenib mesylate cap 50 mg (base equivalent), 75 mg (baseequivalent)PA, QL (120 capsules/30 days), SPTAGRISSO - osimertinib mesylate tab 40 mg (base equivalent), 80 mg (baseequivalent)PA, QL (30 tablets/30 days), SPTALZENNA - talazoparib tosylate cap 0.25 mg (base equivalent)PA, QL (90 capsules/30 days), SPTALZENNA - talazoparib tosylate cap 0.5 mg (base equivalent), 0.75 mg(base equivalent), 1 mg (base equivalent)PA, QL (30 capsules/30 days), SPtamoxifen citrate tab 10 mg (base equivalent), 20 mg (base equivalent)ACTASIGNA - nilotinib hcl cap 50 mg (base equivalent), 150 mg (baseequivalent), 200 mg (base equivalent)PA, QL (120 capsules/30 days), SPtemozolomide cap 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg(Temodar)PA, SPtoremifene citrate tab 60 mg (base equivalent) (Fareston)SPtretinoin cap 10 mgPA, SPVENCLEXTA - venetoclax tab 10 mgPA, QL (60 tablets/30 days), SPVENCLEXTA - venetoclax tab 50 mgPA, QL (30 tablets/30 days), SPVENCLEXTA - venetoclax tab 100 mgPA, QL (180 tablets/30 days), SPVENCLEXTA STARTING PACK - venetoclax tab therapy starter pack 10 & 50& 100 mgPA, QL (1 pack/180 days), SPVERZENIO - abemaciclib tab 50 mg, 100 mg, 150 mg, 200 mgPA, QL (60 tablets/30 days), SPVITRAKVI - larotrectinib sulfate oral soln 20 mg/ml (base equivalent)PA, QL (300 mls/30 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 9Drug NameRequirements/LimitsVITRAKVI - larotrectinib sulfate cap 25 mg (base equivalent)PA, QL (180 capsules/30 days), SPVITRAKVI - larotrectinib sulfate cap 100 mg (base equivalent)PA, QL (60 capsules/30 days), SPVOTRIENT - pazopanib hcl tab 200 mg (base equiv)PA, QL (120 tablets/30 days), SPXALKORI - crizotinib cap 200 mg, 250 mgPA, QL (60 capsules/30 days), SPXTANDI - enzalutamide cap 40 mgPA, QL (120 capsules/30 days), SPXTANDI - enzalutamide tab 40 mgPA, QL (120 tablets/30 days), SPXTANDI - enzalutamide tab 80 mgPA, QL (60 tablets/30 days), SPYONSA - abiraterone acetate micronized tab 125 mgPA, QL (120 tablets/30 days), SPZEJULA - niraparib tosylate cap 100 mg (base equivalent)PA, QL (90 capsules/30 days), SPZELBORAF - vemurafenib tab 240 mgPA, QL (240 tablets/30 days), SPENDOCRINE AND METABOLIC DRUGSCORTICOSTEROIDSbudesonide delayed release particles cap 3 mg (Entocort ec)dexamethasone elixir 0.5 mg/5mldexamethasone tab 1.5 mg, 2 mg, 4 mg, 6 mgfludrocortisone acetate tab 0.1 mghydrocortisone tab 5 mg, 10 mg, 20 mg (Cortef)methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)methylprednisolone tab 4 mg, 8 mg, 16 mg, 32 mg (Medrol)prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)(Pediapred)prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)PREDNISONE - prednisone oral soln 5 mg/5mlprednisone tab therapy pack 5 mg (21), 5 mg (48), 10 mg (21), 10 mg (48)prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mgANDROGEN-ANABOLICdanazol cap 50 mg, 100 mg, 200 mgPAtestosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone)PA, QL (1 vial/28 days)testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)PA, QL (10 ml/28 days)testosterone td gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (Androgel)PA, QL (60 packets/30 days)testosterone td gel 12.5 mg/act (1%)PA, QL (4 pumps/30 days)testosterone td gel 20.25 mg/act (1.62%) (Androgel pump)PA, QL (2 pumps/30 days)testosterone td soln 30 mg/actPA, QL (2 pumps/30 days)ESTROGENSCOMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/day,0.05-0.25 mg/dayDIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm (0.1%),0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25 mg/1.25gm (0.1%)DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mgestradiol & norethindrone acetate tab 0.5-0.1 mg, 1-0.5 mg (Activella)estradiol tab 0.5 mg, 1 mg, 2 mg (Estrace)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 10Drug NameRequirements/Limitsestradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm (0.1%),0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25 mg/1.25gm (0.1%)(Divigel)estradiol td patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr,0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Vivelle-dot)QL (30 patches/30 days)estradiol td patch weekly 0.025 mg/24hr, 0.0375 mg/24hr (37.5 mcg/24hr),0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Climara)QL (30 patches/30 days)MYFEMBREE - relugolix-estradiol-norethindrone acetate tab 40-1-0.5 mgPA, QL (30 tablets/30 days)norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt lowdose)norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcgORIAHNN - elagolix-estrad-noreth 300-1-0.5mg & elagolix 300mg cap packPA, QL (56 capsules/28 days)PREMARIN - estrogens, conjugated tab 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg,1.25 mgPREMPHASE - 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 mgCONTRACEPTIVESdesogest-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 3-0.02 mg (Yaz)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 mgAC, QL (2 tablets/365 days)ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg, 1 mg-50 mcgQL (28 tablets/21 days)levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)(Loseasonique)AC, QL (28 tablets/21 days)levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)(Seasonique)QL (28 tablets/21 days)levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mgAC, QL (28 tablets/21 days)levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg, 0.15 mg-30 mcgQL (28 tablets/21 days)levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcgQL (28 tablets/21 days)norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hrAC, QL (3 patches/21 days)norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg, 0.5 mg-35 mcgQL (28 tablets/21 days)norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Norinyl 1+35)QL (28 tablets/21 days)norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcgAC, QL (28 tablets/21 days)norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostepfe)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 tab 1.5 mg-30 mcg (Loestrin1.5/30-21)QL (28 tablets/21 days)norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg (Loestrin fe1/20)AC, QL (28 tablets/21 days)norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg (Loestrin fe1.5/30)QL (28 tablets/21 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 11Drug NameRequirements/LimitsNorethindrone 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 (Ortho-novum 7/7/7)QL (28 tablets/21 days)norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcgQL (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 mcgQL (28 tablets/21 days)NUVARING - etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hrAC, QL (1 ring/21 days)PROGESTINSmedroxyprogesterone acetate tab 2.5 mg, 5 mg, 10 mg (Provera)norethindrone acetate tab 5 mg (Aygestin)progesterone cap 100 mg, 200 mg (Prometrium)ANTIDIABETICSacarbose tab 25 mg, 50 mg, 100 mg (Precose)BAQSIMI ONE PACK - glucagon nasal powder 3 mg/doseBAQSIMI TWO PACK - glucagon nasal powder 3 mg/dosediazoxide susp 50 mg/ml (Proglycem)FARXIGA - dapagliflozin propanediol tab 5 mg (base equivalent), 10 mg (baseequivalent)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)glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg, 5-500 mgglucagon (rdna) for inj kit 1 mg (Glucagon emergency k)GLUCAGON EMERGENCY KIT FO - glucagon hcl for inj 1 mgglyburide micronized tab 1.5 mg, 3 mg, 6 mg (Glynase)glyburide tab 1.25 mg, 2.5 mg, 5 mgglyburide-metformin tab 1.25-250 mg, 2.5-500 mg, 5-500 mg (Glucovance)GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg, 25-5 mgQL (30 tablets/30 days)GVOKE HYPOPEN 1-PACK - glucagon subcutaneous solution auto-injector0.5 mg/0.1ml, 1 mg/0.2mlGVOKE HYPOPEN 2-PACK - glucagon subcutaneous solution auto-injector0.5 mg/0.1ml, 1 mg/0.2mlGVOKE KIT - glucagon subcutaneous soln 1 mg/0.2mlGVOKE PFS - glucagon subcutaneous soln pref syringe 0.5 mg/0.1ml,1 mg/0.2mlJANUMET - sitagliptin-metformin hcl tab 50-500 mg, 50-1000 mgQL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg, 100-1000 mgQL (30 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mgQL (60 tablets/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 12Drug NameRequirements/LimitsJANUVIA - 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 mgQL (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/0.5mlPA, QL (4 pens/28 days)nateglinide tab 60 mg, 120 mg (Starlix)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 (baseequiv) (Actos)pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850 mg (Actoplus met)repaglinide tab 0.5 mgrepaglinide tab 1 mg, 2 mg (Prandin)RYBELSUS - semaglutide tab 3 mgPA, QL (30 tablets/180 days)RYBELSUS - semaglutide tab 7 mg, 14 mgPA, QL (30 tablets/30 days)SOLIQUA 100/33 - insulin glargine-lixisenatide sol pen-inj 100-33 unit-mcg/mlQL (18 mls/30 days), STSYNJARDY - empagliflozin-metformin hcl tab 5-500 mg, 5-1000 mg,12.5-500 mg, 12.5-1000 mgQL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr 5-1000 mg,10-1000 mg, 12.5-1000 mgQL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr 25-1000 mgQL (30 tablets/30 days)TRIJARDY XR - empagliflozin-linagliptin-metformin tab er 24hr 5-2.5-1000mgQL (60 tablets/30 days)TRIJARDY XR - empagliflozin-linagliptin-metformin tab er 24hr 10-5-1000 mg,25-5-1000 mgQL (30 tablets/30 days)TRIJARDY XR - empagliflozin-linaglip-metformin tab er 24hr 12.5-2.5-1000mgQL (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/0.5mlPA, QL (4 pens/28 days)VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)PA, QL (3 pens/30 days)XIGDUO XR - dapagliflozin-metformin hcl tab er 24hr 2.5-1000 mg,5-1000 mgQL (60 tablets/30 days)XIGDUO XR - dapagliflozin-metformin hcl tab er 24hr 5-500 mg, 10-500 mg,10-1000 mgQL (30 tablets/30 days)XULTOPHY 100/3.6 - insulin degludec-liraglutide sol pen-inj 100-3.6 unit-mg/mlQL (5 pens/30 days), STZEGALOGUE - dasiglucagon hcl subcutaneous soln auto-inj 0.6 mg/0.6mlZEGALOGUE - dasiglucagon hcl subcutaneous soln pref syringe0.6 mg/0.6mlRapid-Acting InsulinsFIASP - insulin aspart (with niacinamide) inj 100 unit/mlQL (100 mls/30 days)FIASP FLEXTOUCH - insulin aspart (with niacinamide) sol pen-inj 100 unit/mlQL (100 mls/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 13Drug NameRequirements/LimitsFIASP PENFILL - insulin aspart (with niacinamide) soln cartridge 100 unit/mlQL (100 mls/30 days)INSULIN ASPART - insulin aspart inj soln 100 unit/mlQL (100 mls/30 days)INSULIN ASPART FLEXPEN - insulin aspart soln pen-injector 100 unit/mlQL (100 mls/30 days)INSULIN ASPART PENFILL - insulin aspart soln cartridge 100 unit/mlQL (100 mls/30 days)NOVOLOG - insulin aspart inj soln 100 unit/mlQL (100 mls/30 days)NOVOLOG FLEXPEN - insulin aspart soln pen-injector 100 unit/mlQL (100 mls/30 days)NOVOLOG PENFILL - insulin aspart soln cartridge 100 unit/mlQL (100 mls/30 days)Short-Acting InsulinsHUMULIN R U-500 (CONCENTR - insulin regular (human) inj 500 unit/mlQL (100 mls/30 days)HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500unit/mlQL (100 mls/30 days)NOVOLIN R - insulin regular (human) inj 100 unit/mlQL (100 mls/30 days)NOVOLIN R FLEXPEN - insulin regular (human) soln pen-injector 100 unit/mlQL (100 mls/30 days)Intermediate-Acting InsulinsINSULIN ASPART PROTAMINE/ - insulin aspart prot & aspart sus pen-inj 100unit/ml (70-30)QL (100 mls/30 days)INSULIN ASPART PROTAMINE/ - insulin aspart prot & aspart (human) inj 100unit/ml (70-30)QL (100 mls/30 days)NOVOLIN N - insulin nph (human) (isophane) inj 100 unit/mlQL (100 mls/30 days)NOVOLIN N FLEXPEN - insulin nph (human) (isophane) susp pen-injector100 unit/mlQL (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 100unit/ml (70-30)QL (100 mls/30 days)Basal InsulinsINSULIN GLARGINE - insulin glargine-yfgn soln pen-injector 100 unit/mlQL (100 mls/30 days)INSULIN GLARGINE - insulin glargine-yfgn inj 100 unit/mlQL (100 mls/30 days)LEVEMIR - insulin detemir inj 100 unit/mlQL (100 mls/30 days)LEVEMIR FLEXPEN - insulin detemir soln pen-injector 100 unit/mlQL (100 mls/30 days)SEMGLEE - insulin glargine-yfgn soln pen-injector 100 unit/mlQL (100 mls/30 days)SEMGLEE - insulin glargine-yfgn inj 100 unit/mlQL (100 mls/30 days)TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (2unit dial)QL (100 mls/30 days)TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml (1 unitdial)QL (100 mls/30 days)TRESIBA - insulin degludec inj 100 unit/mlQL (100 mls/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100 unit/ml, 200unit/mlQL (100 mls/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 14Drug NameRequirements/LimitsTHYROID AGENTSlevothyroxine 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)liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg (Cytomel)methimazole tab 5 mg, 10 mg (Tapazole)propylthiouracil tab 50 mgOXYTOCICSmethylergonovine maleate tab 0.2 mgENDOCRINE and METABOLIC AGENTS - MISC.alendronate sodium tab 10 mgQL (30 tablets/30 days)alendronate sodium tab 35 mgQL (4 tablets/28 days)alendronate sodium tab 70 mg (Fosamax)QL (4 tablets/28 days)betaine powder for oral solution (Cystadane)SPcabergoline tab 0.5 mgcalcitonin (salmon) nasal soln 200 unit/actcalcitriol cap 0.25 mcg, 0.5 mcg (Rocaltrol)carglumic acid soluble tab 200 mg (Carbaglu)SPcinacalcet hcl tab 30 mg (base equiv), 60 mg (base equiv), 90 mg (baseequiv) (Sensipar)CLOMID - clomiphene citrate tab 50 mgdesmopressin acetate inj 4 mcg/ml (Ddavp)desmopressin acetate nasal spray soln 0.01% (Ddavp)desmopressin acetate nasal spray soln 0.01% (refrigerated)desmopressin acetate preservative free (pf) inj 4 mcg/ml (Ddavp)desmopressin acetate tab 0.1 mg, 0.2 mg (Ddavp)FOLLISTIM AQ - follitropin beta inj 300 unit/0.36mlQL (15 cartridges/30 days), SPFOLLISTIM AQ - follitropin beta inj 600 unit/0.72mlQL (8 cartridges/30 days), SPFOLLISTIM AQ - follitropin beta inj 900 unit/1.08mlQL (5 cartridges/30 days), SPFORTEO - teriparatide (recombinant) soln pen-inj 600 mcg/2.4mlPA, QL (1 injection/28 days), SPganirelix acetate soln prefilled syringe 250 mcg/0.5ml (Ganirelix acetate)QL (12 syringes/30 days), SPGENOTROPIN - somatropin for subcutaneous inj cartridge 5 mg, 12 mg (36unit)PA, SPGENOTROPIN MINIQUICK - somatropin for subcutaneous inj prefilled syr0.2 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 mgPA, SPibandronate sodium tab 150 mg (base equivalent) (Boniva)QL (1 tablet/30 days)INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)SPlevocarnitine oral soln 1 gm/10ml (10%) (Carnitor)levocarnitine tab 330 mg (Carnitor)nitisinone cap 2 mg, 5 mg, 10 mg (Orfadin)SPNITYR - nitisinone tab 2 mg, 5 mg, 10 mgSP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 15Drug NameRequirements/LimitsNORDITROPIN FLEXPRO - somatropin solution pen-injector 5 mg/1.5ml,10 mg/1.5ml, 15 mg/1.5ml, 30 mg/3mlPA, SPoctreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100 mcg/ml (0.1 mg/ml),500 mcg/ml (0.5 mg/ml) (Sandostatin)SPoctreotide acetate inj 200 mcg/ml (0.2 mg/ml), 1000 mcg/ml (1 mg/ml)SPORFADIN - nitisinone cap 20 mgSPORFADIN - nitisinone susp 4 mg/mlSPORILISSA - 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)raloxifene hcl tab 60 mg (Evista)ACREVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 mg/ml)risedronate sodium tab 5 mg, 30 mg (Actonel)QL (30 tablets/30 days)risedronate sodium tab 35 mg (Actonel)QL (4 tablets/28 days)risedronate sodium tab 150 mg (Actonel)QL (1 tablet/30 days)STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml, 28 mg/0.7ml,40 mg/ml, 80 mg/0.8mlPA, SPTYMLOS - abaloparatide subcutaneous soln pen-injector 3120 mcg/1.56mlPA, QL (1.56 mls/30 days), SPCARDIOVASCULAR AGENTSCARDIOTONICSdigoxin oral soln 0.05 mg/ml (Digoxin)PAdigoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg) (Lanoxin)ANTIANGINAL AGENTSisosorbide dinitrate tab 5 mg (Isordil titradose)isosorbide dinitrate tab 10 mg, 20 mg, 30 mgisosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120 mgnitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat)nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr(Nitro-dur)BETA BLOCKERSacebutolol hcl cap 200 mg, 400 mg (Sectral)atenolol tab 25 mg, 50 mg, 100 mg (Tenormin)bisoprolol fumarate tab 5 mg (Zebeta)bisoprolol fumarate tab 10 mgcarvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg (Coreg)labetalol hcl tab 100 mg (Trandate)labetalol hcl tab 200 mg, 300 mgmetoprolol succinate tab er 24hr 25 mg (tartrate equiv), 50 mg (tartrateequiv), 100 mg (tartrate equiv), 200 mg (tartrate equiv) (Toprol xl)metoprolol tartrate tab 25 mgmetoprolol tartrate tab 50 mg, 100 mg (Lopressor)nadolol tab 20 mg, 40 mg, 80 mg (Corgard)pindolol tab 5 mg, 10 mg

2023Blue Cross and Blue Shield July 2023 Basic Drug List 16Drug NameRequirements/LimitsPROPRANOLOL HCL - propranolol hcl oral soln 40 mg/5mlpropranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg, 160 mg (Inderal la)propranolol hcl oral soln 20 mg/5mlpropranolol hcl tab 10 mg, 20 mg, 40 mg, 60 mg, 80 mgsotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg (Betapace af)sotalol hcl tab 80 mg, 120 mg, 160 mg (Betapace)sotalol hcl tab 240 mgCALCIUM CHANNEL BLOCKERSamlodipine besylate tab 2.5 mg (base equivalent), 5 mg (baseequivalent), 10 mg (base equivalent) (Norvasc)diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mgdiltiazem hcl coated beads cap er 24hr 120 mg, 180 mg, 240 mg, 300 mg(Cardizem cd)diltiazem hcl extended release beads cap er 24hr 120 mg, 180 mg,240 mg, 300 mg, 360 mg, 420 mg (Tiazac)diltiazem hcl tab 30 mg, 60 mg, 120 mg (Cardizem)diltiazem hcl tab 90 mgfelodipine tab er 24hr 2.5 mg, 5 mg, 10 mgnifedipine tab er 24hr 30 mg, 60 mg, 90 mg (Adalat cc)nifedipine tab er 24hr osmotic release 30 mg, 60 mg, 90 mg (Procardia xl)nimodipine cap 30 mgverapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg (Verelan)verapamil hcl tab er 120 mg, 180 mg, 240 mg (Calan sr)verapamil hcl tab 40 mgverapamil hcl tab 80 mg, 120 mg (Calan)ANTIARRHYTHMICSamiodarone hcl tab 100 mgamiodarone hcl tab 200 mg (Cordarone)disopyramide phosphate cap 100 mg, 150 mg (Norpace)flecainide acetate tab 50 mg, 100 mg, 150 mgmexiletine hcl cap 150 mg, 200 mg, 250 mgMULTAQ - dronedarone hcl tab 400 mg (base equivalent)propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg (Rythmol sr)propafenone hcl tab 150 mg, 225 mg, 300 mgquinidine gluconate tab er 324 mgANTIHYPERTENSIVESamlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-10 mg, 5-20 mg,5-40 mg, 10-20 mg, 10-40 mg (Lotrel)amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg, 10-160 mg,10-320 mg (Exforge)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg,5-160-25 mg, 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg (Exforge hct)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 17Drug NameRequirements/Limitsatenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100)benazepril & hydrochlorothiazide tab 5-6.25 mgbenazepril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg, 20-25 mg(Lotensin hct)benazepril hcl tab 5 mgbenazepril 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)candesartan cilexetil tab 4 mg, 8 mg, 16 mg, 32 mg (Atacand)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg, 32-12.5 mg,32-25 mg (Atacand hct)captopril tab 12.5 mg, 25 mg, 50 mg, 100 mgclonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg (Catapres)clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1)clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2)clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3)doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg (Cardura)enalapril maleate & hydrochlorothiazide tab 5-12.5 mgenalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg (Vasotec)eplerenone tab 25 mg, 50 mg (Inspra)fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mgfosinopril sodium tab 10 mg, 20 mg, 40 mgguanfacine hcl tab 1 mg, 2 mg (Tenex)hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mgirbesartan 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)metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)metoprolol & hydrochlorothiazide tab 100-25 mg, 100-50 mgminoxidil tab 2.5 mg, 10 mgmoexipril hcl tab 7.5 mg, 15 mgolmesartan 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)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 18Drug NameRequirements/Limitsperindopril erbumine tab 2 mgperindopril erbumine tab 4 mg (Aceon)phenoxybenzamine hcl cap 10 mg (Dibenzyline)prazosin hcl cap 1 mg, 2 mg, 5 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, 40 mg, 80 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)valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5 mg, 160-25 mg,320-12.5 mg, 320-25 mg (Diovan hct)DIURETICSacetazolamide cap er 12hr 500 mgacetazolamide tab 125 mg, 250 mgamiloride hcl tab 5 mgbumetanide tab 0.5 mg, 1 mg, 2 mg (Bumex)chlorthalidone tab 25 mg, 50 mgfurosemide oral soln 10 mg/mlfurosemide tab 20 mg, 40 mg, 80 mg (Lasix)hydrochlorothiazide cap 12.5 mg (Microzide)hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mgindapamide tab 1.25 mg, 2.5 mgmethazolamide tab 25 mg, 50 mgmetolazone tab 2.5 mg, 5 mg, 10 mgspironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)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)VASOPRESSORSepinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) (Epipen-jr 2-pak)epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (Epipen 2-pak)midodrine hcl tab 2.5 mg, 5 mg, 10 mgSYMJEPI - epinephrine soln prefilled syringe 0.15 mg/0.3ml (1:2000)SYMJEPI - epinephrine solution prefilled syringe 0.3 mg/0.3ml (1:1000)ANTIHYPERLIPIDEMICS

2023Blue Cross and Blue Shield July 2023 Basic Drug List 19Drug NameRequirements/Limitsatorvastatin calcium tab 10 mg (base equivalent), 20 mg (baseequivalent), 40 mg (base equivalent), 80 mg (base equivalent) (Lipitor)ACcholestyramine light powder 4 gm/dose (Questran light)cholestyramine powder 4 gm/dose (Questran)colesevelam hcl tab 625 mg (Welchol)colestipol hcl granule packets 5 gm (Colestid flavored)colestipol hcl granules 5 gm (Colestid flavored)colestipol hcl tab 1 gm (Colestid)ezetimibe tab 10 mg (Zetia)ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg(Vytorin)fenofibrate micronized cap 67 mg, 134 mg, 200 mgQL (30 capsules/30 days)fenofibrate tab 48 mg (Tricor)QL (60 tablets/30 days)fenofibrate tab 54 mg (Lofibra)QL (60 tablets/30 days)fenofibrate tab 145 mg (Tricor)QL (30 tablets/30 days)fenofibrate tab 160 mg (Lofibra)QL (30 tablets/30 days)gemfibrozil tab 600 mg (Lopid)QL (60 tablets/30 days)lovastatin tab 10 mglovastatin tab 20 mgAClovastatin tab 40 mg (Mevacor)ACNEXLETOL - bempedoic acid tab 180 mgPA, QL (30 tablets/30 days)NEXLIZET - bempedoic acid-ezetimibe tab 180-10 mgPA, QL (30 tablets/30 days)niacin tab er 500 mg (antihyperlipidemic), 750 mg (antihyperlipidemic)niacin tab er 1000 mg (antihyperlipidemic) (Niaspan)pravastatin sodium tab 10 mgACpravastatin sodium tab 20 mg, 40 mg, 80 mg (Pravachol)ACREPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/mlPA, QL (2 syringes/28 days)REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneous solncartridge/infusor 420 mg/3.5mlPA, QL (2 cartridges/30 days)REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector140 mg/mlPA, 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.ambrisentan tab 5 mg, 10 mg (Letairis)PA, QL (30 tablets/30 days), SPbosentan tab 62.5 mg, 125 mg (Tracleer)PA, QL (60 tablets/30 days), SPCORLANOR - 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 mgOPSUMIT - macitentan tab 10 mgPA, QL (30 tablets/30 days), SPsildenafil citrate tab 20 mg (Revatio)QL (90 tablets/30 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 20Drug NameRequirements/Limitstadalafil tab 20 mg (pah) (Adcirca)PA, QL (60 tablets/30 days), SPtadalafil tab 2.5 mg, 5 mg (Cialis)PA, QL (30 tablets/30 days)tadalafil tab 10 mg, 20 mg (Cialis)PA, QL (8 tablets/30 days)TRACLEER - bosentan tab for oral susp 32 mgPA, QL (120 tablets/30 days), SPUPTRAVI - selexipag tab 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1000 mcg,1200 mcg, 1400 mcg, 1600 mcgPA, QL (60 tablets/30 days), SPUPTRAVI TITRATION PACK - selexipag tab therapy pack 200 mcg (140) &800 mcg (60)PA, QL (1 pack/180 days), SPVERQUVO - vericiguat tab 2.5 mg, 5 mg, 10 mgPA, QL (30 tablets/30 days)VYNDAMAX - tafamidis cap 61 mgPA, QL (30 capsules/30 days), SPVYNDAQEL - tafamidis meglumine (cardiac) cap 20 mgPA, QL (120 capsules/30 days), SPERECTILE DYSFUNCTIONtadalafil tab 2.5 mg, 5 mg (Cialis)PA, QL (30 tablets/30 days)tadalafil tab 10 mg, 20 mg (Cialis)PA, QL (8 tablets/30 days)RESPIRATORY AGENTSANTIHISTAMINEScetirizine hcl oral soln 1 mg/ml (5 mg/5ml)cyproheptadine hcl syrup 2 mg/5mlcyproheptadine hcl tab 4 mgdesloratadine tab 5 mg (Clarinex)levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)levocetirizine dihydrochloride tab 5 mgpromethazine hcl suppos 12.5 mg, 25 mgpromethazine hcl syrup 6.25 mg/5mlpromethazine hcl tab 12.5 mg, 25 mg, 50 mgNASAL AGENTS - SYSTEMIC and TOPICALazelastine hcl nasal spray 0.1% (137 mcg/spray)QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro)QL (2 bottles/30 days)flunisolide nasal soln 25 mcg/act (0.025%)QL (3 bottles/30 days)fluticasone propionate nasal susp 50 mcg/actQL (1 bottle/30 days)ipratropium bromide nasal soln 0.03% (21 mcg/spray)QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray)QL (3 bottles/30 days)mometasone furoate nasal susp 50 mcg/act (Nasonex)QL (1 bottle/30 days)COUGH/COLD/ALLERGYacetylcysteine inhal soln 10%, 20%sodium chloride soln nebu 3%sodium chloride soln nebu 7% (Hyper-sal)ANTIASTHMATIC and BRONCHODILATOR AGENTSADVAIR DISKUS - fluticasone-salmeterol aer powder ba 100-50 mcg/act,250-50 mcg/act, 500-50 mcg/actQL (60 blisters/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 21Drug NameRequirements/LimitsADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act,115-21 mcg/act, 230-21 mcg/actQL (1 inhaler/30 days)albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) (Proventilhfa)QL (2 inhalers/30 days)albuterol sulfate soln nebu 0.083% (2.5 mg/3ml), 0.63 mg/3ml (baseequiv), 1.25 mg/3ml (base equiv)QL (125 containers/30 days)albuterol sulfate syrup 2 mg/5mlalbuterol sulfate tab 2 mg, 4 mgANORO ELLIPTA - umeclidinium-vilanterol aero powd ba 62.5-25 mcg/actQL (60 blisters/30 days)ARNUITY ELLIPTA - fluticasone furoate aerosol powder breath activ 50 mcg/act, 100 mcg/act, 200 mcg/actQL (30 blisters/30 days)ASMANEX HFA - mometasone furoate inhal aerosol suspension 50 mcg/act,100 mcg/act, 200 mcg/actQL (1 inhaler/30 days)ASMANEX TWISTHALER 120 ME - mometasone furoate inhal powd220 mcg/act (breath activated)QL (1 inhaler/30 days)ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd110 mcg/act (breath activated), 220 mcg/act (breath activated)QL (1 inhaler/30 days)ASMANEX TWISTHALER 60 MET - mometasone furoate inhal powd220 mcg/act (breath activated)QL (1 inhaler/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba 100-25 mcg/act,200-25 mcg/actQL (60 blisters/30 days)BREZTRI AEROSPHERE - budesonide-glycopyrrolate-formoterol aers160-9-4.8 mcg/actQL (1 inhaler/30 days)budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml (Pulmicort)QL (120 mls/30 days)budesonide inhalation susp 1 mg/2ml (Pulmicort)QL (60 mls/30 days)COMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln20-100 mcg/actQL (2 inhalers/30 days)cromolyn sodium soln nebu 20 mg/2mlQL (240 mls/30 days)DULERA - mometasone furoate-formoterol fumarate aerosol 50-5 mcg/act,100-5 mcg/act, 200-5 mcg/actQL (3 inhalers/30 days)FASENRA PEN - benralizumab subcutaneous soln auto-injector 30 mg/mlPA, QL (1 pen/56 days), SPFLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/act, 100 mcg/actQL (60 blisters/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/actQL (240 blisters/30 days)FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act (50/valve)QL (60 blisters/30 days)FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act (125/valve),220 mcg/act (250/valve)QL (60 blisters/30 days)FLUTICASONE PROPIONATE/SA - fluticasone-salmeterol aer powder ba55-14 mcg/act, 113-14 mcg/actFLUTICASONE PROPIONATE/SA - fluticasone-salmeterol aer powder ba232-14 mcg/actQL (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)ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3mlQL (540 mls/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 22Drug NameRequirements/Limitslevalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenexconcentrate)QL (90 vials/30 days)levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv), 0.63 mg/3ml (baseequiv), 1.25 mg/3ml (base equiv) (Xopenex)QL (96 vials/30 days)montelukast sodium chew tab 4 mg (base equiv), 5 mg (base equiv)(Singulair)montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)montelukast sodium tab 10 mg (base equiv) (Singulair)NUCALA - mepolizumab subcutaneous solution auto-injector 100 mg/mlPA, QL (3 ml/28 days), SPNUCALA - mepolizumab subcutaneous solution pref syringe 40 mg/0.4mlPA, QL (1 syringe/28 days), SPNUCALA - mepolizumab subcutaneous solution pref syringe 100 mg/mlPA, QL (3 ml/28 days), SPQVAR REDIHALER - beclomethasone diprop hfa breath act inh aer 40 mcg/actQL (1 inhaler/30 days)QVAR REDIHALER - beclomethasone diprop hfa breath act inh aer 80 mcg/actQL (2 inhalers/30 days)SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/act (baseequiv)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 aerosol1.25 mcg/actQL (1 inhaler/30 days)SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal aerosol 2.5 mcg/actQL (1 cartridge/30 days)STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln 2.5-2.5 mcg/actQL (1 inhaler/30 days)STRIVERDI RESPIMAT - olodaterol hcl inhal aerosol soln 2.5 mcg/act (baseequiv)QL (1 inhaler/30 days)SYMBICORT - budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act,160-4.5 mcg/actQL (3 inhalers/30 days)terbutaline sulfate tab 2.5 mg, 5 mgtheophylline tab er 12hr 300 mg, 450 mgtheophylline tab er 24hr 400 mg, 600 mgTRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb100-62.5-25 mcg/actQL (60 blisters/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb200-62.5-25 mcg/actQL (1 inhaler/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)QL (2 inhalers/30 days)XOLAIR - omalizumab subcutaneous soln prefilled syringe 75 mg/0.5ml,150 mg/mlPA, SPzafirlukast tab 10 mg, 20 mg (Accolate)RESPIRATORY AGENTS - MISC.KALYDECO - ivacaftor tab 150 mgPA, QL (60 tablets/30 days), SPKALYDECO - ivacaftor packet 25 mg, 50 mg, 75 mgPA, QL (60 packets/30 days), SPPULMOZYME - dornase alfa inhal soln 2.5 mg/2.5mlSPSYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab tbpkPA, QL (60 tablets/30 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 23Drug NameRequirements/LimitsSYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mg tab tbpkPA, QL (60 tablets/30 days), SPTRIKAFTA - elexacaf-tezacaf-ivacaf 50-25-37.5 mg & ivacaftor 75 mg tbpkPA, QL (90 tablets/30 days), SPTRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor 150 mg tbpkPA, QL (90 tablets/30 days), SPGASTROINTESTINAL AGENTSLAXATIVESlactulose solution 10 gm/15mlpeg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)ACpeg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)ACSUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol17.5-3.13-1.6 gm/177mlANTIDIARRHEALSdiphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)loperamide hcl cap 2 mgULCER DRUGScimetidine tab 300 mg, 400 mg, 800 mgdicyclomine hcl cap 10 mg (Bentyl)dicyclomine hcl oral soln 10 mg/5mldicyclomine hcl tab 20 mg (Bentyl)esomeprazole magnesium cap delayed release 20 mg (base eq), 40 mg(base eq) (Nexium)QL (60 capsules/30 days)esomeprazole magnesium for delayed release susp packet 10 mg,20 mg, 40 mg (Nexium)QL (60 packets/30 days)famotidine for susp 40 mg/5mlfamotidine tab 20 mg, 40 mg (Pepcid)glycopyrrolate tab 1 mg, 2 mglansoprazole cap delayed release 15 mg, 30 mg (Prevacid)QL (60 capsules/30 days)methscopolamine bromide tab 2.5 mg, 5 mgmisoprostol tab 100 mcg, 200 mcg (Cytotec)NEXIUM - esomeprazole magnesium for delayed release susp pack 2.5 mgPA, QL (60 packets/30 days)NEXIUM - esomeprazole magnesium for delayed release susp packet 5 mgPA, 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)sucralfate tab 1 gm (Carafate)ANTIEMETICSaprepitant capsule therapy pack 80 & 125 mg (Emend tripack)QL (9 capsules/30 days)aprepitant capsule 40 mg (Emend)QL (2 capsules/30 days)aprepitant capsule 80 mg (Emend)QL (6 capsules/30 days)aprepitant capsule 125 mg (Emend)QL (3 capsules/30 days)EMEND - aprepitant for oral susp 125 mg (125 mg/5ml)QL (9 kits/30 days)granisetron hcl tab 1 mgQL (20 tablets/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 24Drug NameRequirements/Limitsmeclizine hcl tab 12.5 mg, 25 mgondansetron hcl oral soln 4 mg/5mlQL (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)scopolamine td patch 72hr 1 mg/3days (Transderm-scop)trimethobenzamide hcl cap 300 mg (Tigan)DIGESTIVE AIDSCREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit,6000-19000-30000 unit, 12000-38000-60000 unit, 24000-76000-120000unit, 36000-114000-180000 unitPA, QL (1 ml/30 days)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, 40000-126000-168000unitPA, QL (1 ml/30 days)GASTROINTESTINAL AGENTS- MISC.balsalazide disodium cap 750 mg (Colazal)calcium acetate (phosphate binder) cap 667 mg (169 mg ca)calcium acetate (phosphate binder) tab 667 mgCHENODAL - chenodiol tab 250 mgSPlactulose (encephalopathy) solution 10 gm/15mlLINZESS - linaclotide cap 72 mcg, 145 mcg, 290 mcgQL (30 capsules/30 days)mesalamine cap dr 400 mg (Delzicol)mesalamine cap er 24hr 0.375 gm (Apriso)mesalamine enema 4 gmmesalamine suppos 1000 mg (Canasa)mesalamine tab delayed release 800 mg (Asacol hd)mesalamine tab delayed release 1.2 gm (Lialda)metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv)metoclopramide hcl tab 5 mg (base equivalent), 10 mg (base equivalent)(Reglan)MOVANTIK - naloxegol oxalate tab 12.5 mg (base equivalent), 25 mg (baseequivalent)QL (30 tablets/30 days)sevelamer carbonate packet 0.8 gm, 2.4 gm (Renvela)sevelamer carbonate tab 800 mg (Renvela)SKYRIZI - risankizumab-rzaa subcutaneous soln cartridge 180 mg/1.2mlPA, QL (1 cartridge/56 days), SPSKYRIZI - risankizumab-rzaa subcutaneous soln cartridge 360 mg/2.4mlPA, QL (2.4 mls/56 days), SPsulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)sulfasalazine tab 500 mg (Azulfidine)SYMPROIC - naldemedine tosylate tab 0.2 mg (base equivalent)QL (30 tablets/30 days)TRULANCE - plecanatide tab 3 mgQL (30 tablets/30 days)ursodiol cap 300 mg (Actigall)ursodiol tab 250 mg (Urso 250)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 25Drug NameRequirements/Limitsursodiol tab 500 mg (Urso forte)VELPHORO - sucroferric oxyhydroxide chew tab 500 mgSTVIBERZI - eluxadoline tab 75 mg, 100 mgQL (60 tablets/30 days)GENITOURINARY AGENTSURINARY ANTISPASMODICSoxybutynin chloride syrup 5 mg/5mloxybutynin chloride tab er 24hr 5 mg, 10 mg (Ditropan xl)oxybutynin chloride tab er 24hr 15 mgoxybutynin chloride tab 5 mgsolifenacin succinate tab 5 mg, 10 mg (Vesicare)tolterodine tartrate cap er 24hr 2 mg, 4 mg (Detrol la)tolterodine tartrate tab 1 mg, 2 mg (Detrol)VAGINAL PRODUCTSclindamycin phosphate vaginal cream 2% (Cleocin)CRINONE - progesterone vaginal gel 4%, 8%QL (60 applicators/30 days)estradiol vaginal cream 0.1 mg/gm (Estrace)estradiol vaginal tab 10 mcg (Vagifem)ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs)metronidazole vaginal gel 0.75% (Metrogel-vaginal)terconazole vaginal cream 0.4%, 0.8%terconazole vaginal suppos 80 mgGENITOURINARY AGENTS - MISC.alfuzosin hcl tab er 24hr 10 mg (Uroxatral)CYSTAGON - cysteamine bitartrate cap 50 mg, 150 mgSPdutasteride cap 0.5 mg (Avodart)finasteride tab 5 mg (Proscar)potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10)potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15)sodium citrate & citric acid soln 500-334 mg/5mltamsulosin hcl cap 0.4 mg (Flomax)CENTRAL NERVOUS SYSTEM DRUGSANTIANXIETY AGENTSalprazolam 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, 30 mgdiazepam oral soln 1 mg/mldiazepam tab 2 mg, 5 mg, 10 mg (Valium)hydroxyzine hcl syrup 10 mg/5mlhydroxyzine hcl tab 10 mg, 25 mg, 50 mg

2023Blue Cross and Blue Shield July 2023 Basic Drug List 26Drug NameRequirements/Limitshydroxyzine pamoate cap 25 mg, 50 mg (Vistaril)lorazepam conc 2 mg/mllorazepam tab 0.5 mg, 1 mg, 2 mg (Ativan)QL (150 tablets/30 days)ANTIDEPRESSANTSamitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mgbupropion 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 mgcitalopram hydrobromide oral soln 10 mg/5mlcitalopram hydrobromide tab 10 mg (base equiv), 20 mg (base equiv),40 mg (base equiv) (Celexa)clomipramine hcl cap 25 mg, 50 mg, 75 mg (Anafranil)desipramine hcl tab 10 mg, 25 mg (Norpramin)desipramine hcl tab 50 mg, 75 mg, 100 mg, 150 mgdesvenlafaxine succinate tab er 24hr 25 mg (base equiv), 50 mg (baseequiv), 100 mg (base equiv) (Pristiq)QL (60 tablets/30 days)doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100 mgdoxepin hcl conc 10 mg/mlduloxetine hcl enteric coated pellets cap 20 mg (base eq), 60 mg (baseeq) (Cymbalta)QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg (base eq) (Cymbalta)QL (90 capsules/30 days)escitalopram oxalate soln 5 mg/5ml (base equiv)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 solution 20 mg/5mlfluvoxamine maleate tab 25 mg, 50 mg, 100 mgimipramine hcl tab 10 mg, 25 mg, 50 mg (Tofranil)mirtazapine tab 7.5 mgmirtazapine tab 15 mg, 30 mg, 45 mg (Remeron)nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg (Pamelor)paroxetine hcl tab er 24hr 12.5 mg, 25 mg, 37.5 mg (Paxil cr)paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg (Paxil)sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft)sertraline hcl tab 25 mg, 50 mg, 100 mg (Zoloft)tranylcypromine sulfate tab 10 mg (Parnate)trazodone hcl tab 50 mg, 100 mg, 150 mgvenlafaxine hcl cap er 24hr 37.5 mg (base equivalent), 75 mg (baseequivalent), 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 (baseequivalent)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 27Drug NameRequirements/LimitsANTIPSYCHOTICSaripiprazole tab 2 mg, 5 mg (Abilify)QL (60 tablets/30 days)aripiprazole tab 10 mg, 15 mg, 20 mg, 30 mg (Abilify)QL (30 tablets/30 days)chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg, 200 mgclozapine tab 25 mg (Clozaril)QL (270 tablets/30 days), STclozapine tab 50 mg (Clozapine)QL (90 tablets/30 days)clozapine tab 100 mg (Clozaril)QL (90 tablets/30 days), STclozapine tab 200 mg (Clozapine)QL (120 tablets/30 days)FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/mlfluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mgFLUPHENAZINE HYDROCHLORID - fluphenazine hcl elixir 2.5 mg/5mlhaloperidol lactate oral conc 2 mg/mlhaloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mgLATUDA - lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mgQL (30 tablets/30 days), STLATUDA - lurasidone hcl tab 80 mgQL (60 tablets/30 days), STlithium carbonate cap 150 mg, 600 mg (Lithium carbonate)lithium carbonate cap 300 mglithium carbonate tab er 300 mg (Lithobid)lithium carbonate tab er 450 mglithium carbonate tab 300 mgloxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mglurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg (Latuda)QL (30 tablets/30 days)lurasidone hcl tab 80 mg (Latuda)QL (60 tablets/30 days)olanzapine orally disintegrating tab 5 mg, 10 mg, 15 mg, 20 mg (Zyprexazydis)QL (30 tablets/30 days)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)perphenazine tab 2 mg, 4 mg, 8 mg, 16 mgprochlorperazine maleate tab 5 mg (base equivalent), 10 mg (baseequivalent)prochlorperazine suppos 25 mgquetiapine fumarate tab er 24hr 50 mg, 300 mg, 400 mg (Seroquel xr)QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg, 200 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)risperidone orally disintegrating tab 0.5 mg, 1 mg, 2 mg, 3 mgQL (60 tablets/30 days)risperidone orally disintegrating tab 4 mgQL (120 tablets/30 days)risperidone soln 1 mg/ml (Risperdal)QL (480 mls/30 days)risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg (Risperdal)QL (120 tablets/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 28Drug NameRequirements/Limitsrisperidone tab 3 mg (Risperdal)QL (60 tablets/30 days)thiothixene cap 1 mg, 2 mg, 5 mg, 10 mgtrifluoperazine hcl tab 1 mg (base equivalent), 2 mg (base equivalent),5 mg (base equivalent), 10 mg (base equivalent)ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg (Geodon)QL (60 capsules/30 days)HYPNOTICSBELSOMRA - suvorexant tab 5 mg, 10 mg, 15 mg, 20 mgQL (30 tablets/30 days), STestazolam tab 1 mg, 2 mgeszopiclone tab 1 mg, 2 mg, 3 mg (Lunesta)QL (30 tablets/30 days)phenobarbital elixir 20 mg/5mlphenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 100 mgtemazepam cap 15 mg, 30 mg (Restoril)zaleplon cap 5 mg, 10 mg (Sonata)QL (30 capsules/30 days)zolpidem tartrate tab er 6.25 mg, 12.5 mg (Ambien cr)QL (30 tablets/30 days)zolpidem tartrate tab 5 mg, 10 mg (Ambien)QL (30 tablets/30 days)ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSamphetamine-dextroamphetamine cap er 24hr 5 mg, 10 mg, 15 mg,20 mg, 25 mg, 30 mg (Adderall xr)QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg, 7.5 mg, 10 mg, 12.5 mg,15 mg, 30 mg (Adderall)QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg (Adderall)QL (90 tablets/30 days)armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg (Nuvigil)QL (30 tablets/30 days)atomoxetine hcl cap 10 mg (base equiv), 18 mg (base equiv), 25 mg(base equiv), 40 mg (base equiv) (Strattera)QL (60 capsules/30 days)atomoxetine hcl cap 60 mg (base equiv), 80 mg (base equiv), 100 mg(base equiv) (Strattera)QL (30 capsules/30 days)caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15 mg, 20 mg, 25 mg,30 mg, 35 mg, 40 mg (Focalin xr)QL (30 capsules/30 days)dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg (Focalin)QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mgQL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg, 15 mg (Dexedrine)QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mgQL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mgQL (180 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 er osmotic release (osm) 18 mg, 27 mg, 54 mg(Concerta)QL (30 tablets/30 days)methylphenidate hcl tab er osmotic release (osm) 36 mg (Concerta)QL (60 tablets/30 days)methylphenidate hcl tab er 10 mg, 20 mgQL (90 tablets/30 days)methylphenidate hcl tab 5 mg, 10 mg, 20 mg (Ritalin)QL (90 tablets/30 days)modafinil tab 100 mg (Provigil)QL (30 tablets/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 29Drug NameRequirements/Limitsmodafinil tab 200 mg (Provigil)QL (60 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 mgQL (30 capsules/30 days)VYVANSE - lisdexamfetamine dimesylate chew tab 10 mg, 20 mg, 30 mg,40 mg, 50 mg, 60 mgQL (30 tablets/30 days)PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC.acamprosate calcium tab delayed release 333 mgAUBAGIO - teriflunomide tab 7 mg, 14 mgPA, QL (30 tablets/30 days), SPAVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5mlPA, QL (1 kit/28 days), SPAVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5mlPA, QL (1 kit/28 days), SPBETASERON - interferon beta-1b for inj kit 0.3 mgPA, QL (14 vials/28 days), SPbupropion hcl (smoking deterrent) tab er 12hr 150 mgACdimethyl fumarate capsule delayed release 120 mg (Tecfidera)QL (14 capsules/180 days), SPdimethyl fumarate capsule delayed release 240 mg (Tecfidera)QL (60 capsules/30 days), SPdimethyl fumarate capsule dr starter pack 120 mg & 240 mg (Tecfiderastarter pa)QL (60 capsules/180 days), SPdisulfiram tab 250 mg, 500 mg (Antabuse)donepezil hydrochloride orally disintegrating tab 5 mg, 10 mgdonepezil hydrochloride tab 5 mg, 10 mg (Aricept)fingolimod hcl cap 0.5 mg (base equiv) (Gilenya)PA, QL (30 capsules/30 days), SPgalantamine hydrobromide cap er 24hr 8 mg, 16 mg, 24 mg (Razadyneer)galantamine hydrobromide tab 4 mg, 8 mg, 12 mg (Razadyne)glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)QL (30 syringes/30 days), SPglatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone)QL (12 syringes/28 days), SPKESIMPTA - ofatumumab soln auto-injector 20 mg/0.4mlPA, QL (1 pen/28 days), SPMAVENCLAD - cladribine tab therapy pack 10 mg (4 tabs), 10 mg (8 tabs)PA, QL (8 tablets/301 days), SPMAVENCLAD - cladribine tab therapy pack 10 mg (5 tabs)PA, QL (10 tablets/301 days), SPMAVENCLAD - cladribine tab therapy pack 10 mg (6 tabs)PA, QL (12 tablets/301 days), SPMAVENCLAD - cladribine tab therapy pack 10 mg (7 tabs)PA, QL (14 tablets/301 days), SPMAVENCLAD - cladribine tab therapy pack 10 mg (9 tabs)PA, QL (9 tablets/301 days), SPMAVENCLAD - cladribine tab therapy pack 10 mg (10 tabs)PA, QL (20 tablets/301 days), SPMAYZENT - siponimod fumarate tab 0.25 mg (base equiv)PA, QL (120 tablets/30 days), SPMAYZENT - siponimod fumarate tab 1 mg (base equiv), 2 mg (base equiv)PA, QL (30 tablets/30 days), SPMAYZENT STARTER PACK - siponimod fumarate tab 0.25 mg (7) starter packPA, QL (7 tablets/180 days), SPMAYZENT STARTER PACK - siponimod fumarate tab 0.25 mg (12) starterpackPA, QL (12 tablets/180 days), SPmemantine hcl oral solution 2 mg/mlmemantine hcl tab 5 mg, 10 mg (Namenda)memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack (Namendatitration pa)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 30Drug NameRequirements/LimitsNICOTROL INHALER - nicotine inhaler system 10 mg (4 mg delivered)ACNICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray)ACPLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5mlPA, QL (2 pens/28 days), SPPLEGRIDY - peginterferon beta-1a soln prefilled syringe 125 mcg/0.5mlPA, QL (2 syringes/28 days), SPPLEGRIDY - peginterferon beta-1a im soln prefilled syr 125 mcg/0.5mlPA, QL (2 syringes/28 days), SPPLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj 63 &94 mcg/0.5ml packPA, QL (1 kit/180 days), SPPLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr 63 &94 mcg/0.5ml packPA, QL (1 kit/180 days), SPREBIF - interferon beta-1a soln pref syr 22 mcg/0.5ml, 44 mcg/0.5mlPA, QL (12 syringes/28 days), SPREBIF REBIDOSE - interferon beta-1a soln auto-inj 22 mcg/0.5ml,44 mcg/0.5mlPA, QL (12 syringes/28 days), SPREBIF REBIDOSE TITRATION - interferon beta-1a auto-inj 6x8.8 mcg/0.2ml& 6x22 mcg/0.5mlPA, QL (1 kit/180 days), SPREBIF TITRATION PACK - interferon beta-1a pref syr 6x8.8 mcg/0.2ml &6x22 mcg/0.5mlPA, QL (1 kit/180 days), SPrivastigmine tartrate cap 1.5 mg (base equivalent), 3 mg (baseequivalent), 4.5 mg (base equivalent), 6 mg (base equivalent)SAVELLA - milnacipran hcl tab 12.5 mg, 25 mg, 50 mg, 100 mgQL (60 tablets/30 days)SAVELLA TITRATION PACK - milnacipran hcl tab 12.5 mg (5) & 25 mg (8) &50 mg (42) pakQL (55 tablets/180 days)teriflunomide tab 7 mg, 14 mg (Aubagio)PA, QL (30 tablets/30 days), SPtetrabenazine tab 12.5 mg (Xenazine)PA, QL (240 tablets/30 days), SPtetrabenazine tab 25 mg (Xenazine)PA, QL (120 tablets/30 days), SPVARENICLINE STARTING MONT - varenicline tartrate tab 11 x 0.5 mg & 42 x1 mg start packACvarenicline tartrate tab 0.5 mg (base equiv), 1 mg (base equiv)ACZEPOSIA - ozanimod hcl cap 0.92 mgPA, QL (30 capsules/30 days), SPZEPOSIA STARTER KIT - ozanimod cap pack 4 x 0.23 mg & 3 x 0.46 mg &30 x 0.92 mgPA, QL (37 capsules/180 days), SPZEPOSIA 7-DAY STARTER PAC - ozanimod cap pack 4 x 0.23 mg & 3 x0.46 mgPA, QL (7 capsules/180 days), SPANALGESICS AND ANESTHETICSANALGESICS - NON-NARCOTICbutalbital-acetaminophen tab 50-325 mgbutalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)ANALGESICS - NARCOTICacetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)AUOacetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)AUOacetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)AUO

2023Blue Cross and Blue Shield July 2023 Basic Drug List 31Drug NameRequirements/LimitsBELBUCA - 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 (baseequivalent)QL (60 films/30 days)buprenorphine hcl sl tab 2 mg (base equiv), 8 mg (base equiv)QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv), 4-1 mg(base equiv), 8-2 mg (base equiv), 12-3 mg (base equiv) (Suboxone)QL (90 films/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv), 8-2 mg(base equiv)QL (90 tablets/30 days)butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine#3)AUOcodeine sulfate tab 30 mg (Codeine sulfate)AUOfentanyl citrate lozenge on a handle 200 mcg, 400 mcg, 600 mcg,800 mcg, 1200 mcg, 1600 mcg (Actiq)PA, QL (120 units/30 days)fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr,100 mcg/hr (Duragesic)AUO, QL (15 patches/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15mlAUOhydrocodone-acetaminophen tab 10-325 mg, 5-325 mg, 7.5-325 mg(Norco)AUOhydrocodone-ibuprofen tab 7.5-200 mgAUOhydromorphone hcl liqd 1 mg/ml (Dilaudid)AUOhydromorphone hcl tab 2 mg, 4 mg, 8 mg (Dilaudid)AUOmethadone hcl conc 10 mg/ml (Methadose)AUOmethadone hcl soln 5 mg/5ml, 10 mg/5ml (Methadone hcl)AUOmethadone hcl tab for oral susp 40 mgAUOmethadone hcl tab 5 mg (Dolophine hcl)AUOmethadone hcl tab 10 mg (Dolophine)AUOmorphine sulfate oral soln 10 mg/5ml, 100 mg/5ml (20 mg/ml)AUOmorphine sulfate tab er 15 mg, 30 mg, 60 mg, 100 mg, 200 mg (Ms contin)AUO, QL (90 tablets/30 days)morphine sulfate tab 15 mg, 30 mg (Morphine sulfate)AUOoxycodone hcl conc 100 mg/5ml (20 mg/ml)AUOoxycodone hcl soln 5 mg/5mlAUOoxycodone hcl tab 5 mg, 15 mg, 30 mg (Roxicodone)AUOoxycodone hcl tab 10 mg, 20 mgAUOoxycodone w/ acetaminophen tab 5-325 mg, 7.5-325 mg, 10-325 mg(Percocet)AUOtramadol hcl tab er 24hr 100 mg, 200 mg, 300 mgAUO, QL (30 tablets/30 days)tramadol hcl tab 50 mg (Ultram)AUO, QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg (Ultracet)AUOXTAMPZA ER - oxycodone cap er 12hr abuse-deterrent 9 mg, 13.5 mg,18 mg, 27 mg, 36 mgAUO, QL (240 capsules/30 days)ANALGESICS - ANTI-INFLAMMATORYACTEMRA - tocilizumab subcutaneous soln prefilled syringe 162 mg/0.9mlPA, QL (4 syringes/28 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 32Drug NameRequirements/LimitsACTEMRA ACTPEN - tocilizumab subcutaneous soln auto-injector162 mg/0.9mlPA, QL (4 syringes/28 days), SPcelecoxib cap 50 mg, 100 mg, 200 mg (Celebrex)QL (60 capsules/30 days)celecoxib cap 400 mg (Celebrex)QL (30 capsules/30 days)diclofenac potassium tab 50 mgdiclofenac sodium tab delayed release 25 mg, 50 mg, 75 mgENBREL - etanercept subcutaneous soln prefilled syringe 25 mg/0.5ml,50 mg/mlPA, QL (4 syringes/28 days), SPENBREL - etanercept subcutaneous inj 25 mg/0.5mlPA, QL (8 vials/28 days), SPENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/mlPA, QL (4 cartridges/28 days), SPENBREL SURECLICK - etanercept subcutaneous solution auto-injector50 mg/mlPA, QL (4 injections/28 days), SPetodolac cap 200 mg, 300 mgetodolac tab er 24hr 400 mg, 500 mg, 600 mgetodolac tab 400 mg (Lodine)etodolac tab 500 mgflurbiprofen tab 100 mgibuprofen susp 100 mg/5mlibuprofen tab 400 mg, 600 mg, 800 mgindomethacin cap 25 mg, 50 mgleflunomide tab 10 mg, 20 mg (Arava)meloxicam tab 7.5 mg, 15 mg (Mobic)nabumetone tab 500 mg, 750 mgnaproxen sodium tab 275 mg, 550 mgnaproxen tab 250 mg, 375 mg, 500 mg (Naprosyn)OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg & 30 mgPA, QL (55 tablets/180 days), SPOTEZLA - apremilast tab 30 mgPA, QL (60 tablets/30 days), SPoxaprozin tab 600 mg (Daypro)piroxicam cap 10 mg, 20 mg (Feldene)REDITREX - methotrexate soln prefilled syringe 7.5 mg/0.3ml, 10 mg/0.4ml,12.5 mg/0.5ml, 15 mg/0.6ml, 17.5 mg/0.7ml, 20 mg/0.8ml, 22.5 mg/0.9ml,25 mg/mlSTRINVOQ - upadacitinib tab er 24hr 15 mg, 30 mgPA, QL (30 tablets/30 days), SPRINVOQ - upadacitinib tab er 24hr 45 mgPA, QL (56 tablets/365 days), SPSIMPONI - golimumab subcutaneous soln auto-injector 100 mg/mlPA, QL (1 syringe/28 days), SPSIMPONI - golimumab subcutaneous soln prefilled syringe 100 mg/mlPA, QL (1 syringe/28 days), SPsulindac tab 150 mg, 200 mgXELJANZ - tofacitinib citrate oral soln 1 mg/ml (base equivalent)PA, QL (240 mls/30 days), SPXELJANZ - tofacitinib citrate tab 5 mg (base equivalent)PA, QL (60 tablets/30 days), SPXELJANZ - tofacitinib citrate tab 10 mg (base equivalent)PA, QL (240 tablets/365 days), SPXELJANZ XR - tofacitinib citrate tab er 24hr 11 mg (base equivalent)PA, QL (30 tablets/30 days), SPXELJANZ XR - tofacitinib citrate tab er 24hr 22 mg (base equivalent)PA, QL (120 tablets/365 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 33Drug NameRequirements/LimitsMIGRAINE PRODUCTSAIMOVIG - erenumab-aooe subcutaneous soln auto-injector 70 mg/ml,140 mg/mlPA, QL (1 injection/28 days)AJOVY - fremanezumab-vfrm subcutaneous soln auto-inj 225 mg/1.5mlPA, QL (3 pens/84 days)AJOVY - fremanezumab-vfrm subcutaneous soln pref syr 225 mg/1.5mlPA, QL (3 pens/84 days)dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45)QL (24 ampules/28 days)dihydroergotamine mesylate nasal spray 4 mg/ml (Migranal)PA, QL (8 vials/30 days)eletriptan hydrobromide tab 20 mg (base equivalent), 40 mg (baseequivalent) (Relpax)QL (18 tablets/30 days)EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector 120 mg/mlPA, QL (1 injection/28 days)EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr 100 mg/mlPA, QL (9 syringes/180 days)EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr 120 mg/mlPA, QL (1 syringe/28 days)naratriptan hcl tab 1 mg (base equiv), 2.5 mg (base equiv) (Amerge)QL (18 tablets/30 days)NURTEC - rimegepant sulfate tab disint 75 mgPA, QL (54 tablets/90 days)QULIPTA - atogepant tab 10 mg, 30 mg, 60 mgPA, QL (30 tablets/30 days)REYVOW - lasmiditan succinate tab 50 mg, 100 mgPA, 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)QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act, 20 mg/act (Imitrex)QL (12 inhalers/30 days)sumatriptan succinate inj 6 mg/0.5ml (Imitrex)QL (12 vials/30 days)sumatriptan succinate solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml(Imitrex statdose sys)QL (12 doses/30 days)sumatriptan succinate tab 25 mg, 50 mg, 100 mg (Imitrex)QL (18 tablets/30 days)UBRELVY - ubrogepant tab 50 mg, 100 mgPA, QL (16 tablets/30 days)GOUT AGENTSallopurinol tab 100 mg, 300 mg (Zyloprim)colchicine tab 0.6 mg (Colcrys)colchicine w/ probenecid tab 0.5-500 mgprobenecid tab 500 mgNEUROMUSCULAR DRUGSANTICONVULSANTSAPTIOM - eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg, 800 mgcarbamazepine cap er 12hr 100 mg, 200 mg, 300 mg (Carbatrol)carbamazepine chew tab 100 mgcarbamazepine susp 100 mg/5ml (Tegretol)carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg (Tegretol-xr)carbamazepine tab 200 mg (Tegretol)clonazepam tab 0.5 mg, 1 mg, 2 mg (Klonopin)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg, 20 mg

2023Blue Cross and Blue Shield July 2023 Basic Drug List 34Drug NameRequirements/LimitsDIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mgDILANTIN - phenytoin sodium extended cap 30 mgdivalproex sodium cap delayed release sprinkle 125 mg (Depakotesprinkles)divalproex sodium tab delayed release 125 mg, 250 mg, 500 mg(Depakote)divalproex sodium tab er 24 hr 250 mg, 500 mg (Depakote er)EPIDIOLEX - cannabidiol soln 100 mg/mlPAethosuximide cap 250 mg (Zarontin)ethosuximide soln 250 mg/5ml (Zarontin)gabapentin cap 100 mg, 300 mg, 400 mg (Neurontin)gabapentin oral soln 250 mg/5ml (Neurontin)gabapentin tab 600 mg, 800 mg (Neurontin)lacosamide oral solution 10 mg/ml (Vimpat)lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg (Vimpat)lamotrigine tab chewable dispersible 5 mg, 25 mg (Lamictal chewable di)lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg (Lamictal)levetiracetam oral soln 100 mg/ml (Keppra)levetiracetam tab er 24hr 500 mg, 750 mg (Keppra xr)levetiracetam tab 250 mg, 500 mg, 750 mg, 1000 mg (Keppra)oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)oxcarbazepine tab 150 mg, 300 mg, 600 mg (Trileptal)phenytoin chew tab 50 mg (Dilantin infatabs)phenytoin sodium extended cap 100 mg (Dilantin)phenytoin sodium extended cap 200 mg, 300 mg (Phenytek)phenytoin susp 125 mg/5ml (Dilantin-125)pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg,300 mg (Lyrica)QL (90 capsules/30 days)pregabalin soln 20 mg/ml (Lyrica)QL (900 mls/30 days)primidone tab 50 mg, 250 mg (Mysoline)rufinamide tab 200 mg, 400 mg (Banzel)topiramate sprinkle cap 15 mg, 25 mg (Topamax sprinkle)topiramate tab 25 mg, 50 mg, 100 mg, 200 mg (Topamax)valproate sodium oral soln 250 mg/5ml (base equiv)valproic acid cap 250 mg (Depakene)vigabatrin powd pack 500 mg (Sabril)vigabatrin tab 500 mg (Sabril)zonisamide cap 25 mg, 100 mg (Zonegran)zonisamide cap 50 mgANTIPARKINSON AGENTSamantadine hcl cap 100 mg

2023Blue Cross and Blue Shield July 2023 Basic Drug List 35Drug NameRequirements/Limitsamantadine hcl soln 50 mg/5mlbenztropine mesylate tab 0.5 mg, 1 mg, 2 mgcarbidopa & levodopa tab er 25-100 mg, 50-200 mgcarbidopa & levodopa tab 10-100 mg, 25-100 mg, 25-250 mg (Sinemet)carbidopa-levodopa-entacapone tabs 12.5-50-200 mg (Stalevo 50)carbidopa-levodopa-entacapone tabs 18.75-75-200 mg (Stalevo 75)carbidopa-levodopa-entacapone tabs 25-100-200 mg (Stalevo 100)carbidopa-levodopa-entacapone tabs 31.25-125-200 mg (Stalevo 125)carbidopa-levodopa-entacapone tabs 37.5-150-200 mg (Stalevo 150)carbidopa-levodopa-entacapone tabs 50-200-200 mg (Stalevo 200)entacapone tab 200 mg (Comtan)INBRIJA - levodopa inhal powder cap 42 mgSPKYNMOBI - apomorphine hydrochloride film 10 mg, 15 mg, 20 mg, 25 mg,30 mgpramipexole dihydrochloride tab 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg,1 mg, 1.5 mg (Mirapex)rasagiline mesylate tab 0.5 mg (base equiv), 1 mg (base equiv) (Azilect)ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg,5 mg (Requip)selegiline hcl cap 5 mgselegiline hcl tab 5 mgtrihexyphenidyl hcl tab 2 mg, 5 mgNEUROMUSCULAR AGENTSriluzole tab 50 mg (Rilutek)MUSCULOSKELETAL THERAPY AGENTSbaclofen tab 10 mg, 20 mgchlorzoxazone tab 500 mgcyclobenzaprine hcl tab 5 mg, 10 mgmethocarbamol tab 500 mg (Robaxin)methocarbamol tab 750 mg (Robaxin-750)orphenadrine citrate tab er 12hr 100 mgtizanidine hcl tab 2 mg (base equivalent)QL (180 tablets/30 days)tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)QL (180 tablets/30 days)ANTIMYASTHENIC AGENTSpyridostigmine bromide tab 60 mg (Mestinon)NUTRITIONAL PRODUCTSVITAMINSergocalciferol cap 1.25 mg (50000 unit) (Drisdol)phytonadione tab 5 mg (Mephyton)MULTIVITAMINS

2023Blue Cross and Blue Shield July 2023 Basic Drug List 36Drug NameRequirements/LimitsKOSHER PRENATAL PLUS IRON - prenatal vit w/ iron carbonyl-fa tab30-1 mgPRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mgPRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mgSE-NATAL 19 - prenatal vit w/ fe fumarate-fa chew tab 29-1 mgSE-NATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1 mgMINERALS and ELECTROLYTESpot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-phos neutral)potassium chloride cap er 8 meq, 10 meqpotassium chloride microencapsulated crys er tab 10 meq, 20 meqpotassium chloride oral soln 10% (20 meq/15ml), 20% (40 meq/15ml)potassium chloride powder packet 20 meqpotassium chloride tab er 8 meq (600 mg)potassium chloride tab er 10 meq (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 (from1.1 mg naf), 1 mg f (from 2.2 mg naf) (Luride)ACsodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf)ACsodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) (Luride)ACHEMATOLOGICAL AGENTSHEMATOPOIETIC AGENTSARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe10 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/mlPA, SPARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml, 40 mcg/ml,60 mcg/ml, 100 mcg/ml, 200 mcg/mlPA, SPCERDELGA - eliglustat tartrate cap 84 mg (base equivalent)PA, QL (60 capsules/30 days), SPcyanocobalamin inj 1000 mcg/mlDOPTELET - avatrombopag maleate tab 20 mg (base equiv)PA, QL (60 tablets/30 days), SPfolic acid tab 1 mgFULPHILA - pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6mlSP, STNIVESTYM - filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml,480 mcg/0.8mlSP, STNIVESTYM - filgrastim-aafi inj 300 mcg/ml, 480 mcg/1.6ml (300 mcg/ml)SPPROCRIT - epoetin alfa inj 2000 unit/ml, 3000 unit/ml, 4000 unit/ml, 10000unit/ml, 20000 unit/ml, 40000 unit/mlPA, SPRETACRIT - epoetin alfa-epbx inj 2000 unit/ml, 3000 unit/ml, 4000 unit/ml,10000 unit/ml, 20000 unit/ml, 40000 unit/mlPA, SPZARXIO - filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml, 480 mcg/0.8mlSP, STZIEXTENZO - pegfilgrastim-bmez soln prefilled syringe 6 mg/0.6mlSPANTICOAGULANTSELIQUIS - apixaban tab 2.5 mgQL (60 tablets/30 days)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 37Drug NameRequirements/LimitsELIQUIS - apixaban tab 5 mgQL (74 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab starter pack 5 mgQL (1 pack/180 days)enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40 mg/0.4ml,60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120 mg/0.8ml, 150 mg/ml(Lovenox)enoxaparin sodium inj 300 mg/3ml (Lovenox)QL (360 vials/270 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/mlQL (600 mls/30 days)XARELTO - rivaroxaban tab 2.5 mg, 15 mgQL (60 tablets/30 days)XARELTO - rivaroxaban tab 10 mg, 20 mgQL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack 15 mg &20 mgQL (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 unitPA, QL (1 ml/30 days), SPADYNOVATE - antihemophilic factor recomb pegylated for inj 250 unit, 500unit, 750 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unitPA, QL (1 vial/30 days), SPAFSTYLA - antihemophilic fact rcmb single chain for inj kit 250 unit, 500 unit,1000 unit, 1500 unit, 2000 unit, 2500 unit, 3000 unitPA, QL (1 box/30 days), SPALPHANATE - antihemophilic factor/vwf (human) for inj 250 unit, 500 unit,1000 unit, 1500 unit, 2000 unitPA, QL (1 ml/30 days), SPALPHANINE SD - coagulation factor ix for inj 500 unit, 1000 unit, 1500 unitPA, QL (1 ml/30 days), SPALPROLIX - coagulation factor ix (recomb) (rfixfc) for inj 250 unit, 500 unit,1000 unit, 2000 unit, 3000 unit, 4000 unitPA, QL (1 vial/30 days), SPanagrelide hcl cap 0.5 mg (Agrylin)anagrelide hcl cap 1 mgBENEFIX - coagulation factor ix (recombinant) for inj kit 250 unit, 500 unit,1000 unit, 2000 unit, 3000 unitPA, QL (1 ml/30 days), SPBRILINTA - ticagrelor tab 60 mg, 90 mgcilostazol tab 50 mg, 100 mg (Pletal)clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)COAGADEX - coagulation factor x (human) for inj 250 unit, 500 unitSPCORIFACT - factor xiii concentrate (human) for inj kit 1000-1600 unitSPdipyridamole tab 25 mg, 50 mg, 75 mgELOCTATE - 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 unitPA, QL (1 vial/30 days), SPEMPAVELI - pegcetacoplan subcutaneous soln 1080 mg/20ml (54 mg/ml)PA, QL (8 vials/28 days), SPESPEROCT - antihemophilic factor recomb glycopeg-exei for inj 500 unit,1000 unit, 1500 unit, 2000 unit, 3000 unitPA, QL (1 syringe/30 days), SPFEIBA - antiinhibitor coagulant complex for iv soln 500 unit, 1000 unit, 2500unitSP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 38Drug NameRequirements/LimitsHEMLIBRA - emicizumab-kxwh subcutaneous soln 30 mg/ml, 60 mg/0.4ml(150 mg/ml), 105 mg/0.7ml (150 mg/ml), 150 mg/mlPA, QL (1 vial/30 days), SPHEMOFIL M - antihemophilic factor (human) for inj 250 unit, 500 unit, 1000unit, 1700 unitPA, QL (1 ml/30 days), SPHUMATE-P - antihemophilic factor/vwf (human) for inj 250-600 unit, 500-1200unit, 1000-2400 unitPA, QL (1 ml/30 days), SPicatibant acetate subcutaneous soln pref syr 30 mg/3ml (Firazyr)PA, QL (6 syringes/30 days), SPIDELVION - coagulation factor ix (recomb) (rix-fp) for inj 250 unit, 500 unit,1000 unit, 2000 unit, 3500 unitPA, QL (1 box/30 days), SPIXINITY - coagulation factor ix (recombinant) for inj 250 unit, 500 unit, 1000unit, 1500 unit, 2000 unit, 3000 unitPA, QL (1 ml/30 days), SPJIVI - antihemophil fact rcmb(bdd-rfviii peg-aucl) for inj 500 unitPA, QL (1 vial/30 days), SPJIVI - antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj 1000 unit, 2000 unit,3000 unitPA, QL (1 vial/30 days), SPKOATE - antihemophilic factor (human) for inj 250 unit, 500 unit, 1000 unitPA, QL (1 ml/30 days), SPKOATE-DVI - antihemophilic factor (human) for inj 500 unit, 1000 unitPA, QL (1 ml/30 days), SPKOGENATE FS - antihemophilic factor recomb (rfviii) for inj kit 250 unit, 500unit, 1000 unit, 2000 unit, 3000 unitPA, QL (1 ml/30 days), SPKOVALTRY - antihemophilic factor recomb (rahf-pfm) for inj 250 unit, 500 unit,1000 unit, 2000 unit, 3000 unitPA, QL (1 ml/30 days), SPNOVOEIGHT - antihemophilic fact rcmb (bd trunc-rfviii) for inj 250 unit, 500unit, 1000 unit, 1500 unit, 2000 unit, 3000 unitPA, QL (1 ml/30 days), SPNOVOSEVEN 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), SPNUWIQ - antihemophilic factor rcmb (bdd-rfviii,sim) for inj 250 unit, 500 unitPA, QL (1 ml/30 days), SPNUWIQ - antihemophilic fact rcmb (bdd-rfviii,sim) for inj 1000 unit, 1500 unit,2000 unit, 2500 unit, 3000 unit, 4000 unitPA, QL (1 ml/30 days), SPNUWIQ - antihemophil fact rcmb (bdd-rfviii,sim) for inj kit 250 unit, 500 unitPA, QL (1 ml/30 days), SPNUWIQ - antihemophil fact rcmb(bdd-rfviii,sim) for inj kit 1000 unit, 1500 unit,2000 unit, 2500 unit, 3000 unit, 4000 unitPA, QL (1 ml/30 days), SPpentoxifylline tab er 400 mgprasugrel hcl tab 5 mg (base equiv), 10 mg (base equiv) (Effient)PROFILNINE - factor ix complex for inj 500 unit, 1000 unit, 1500 unitPA, QL (1 ml/30 days), SPREBINYN - coagulation factor ix recomb glycopegylated for inj 500 unt, 1000unt, 2000 untPA, QL (1 vial/30 days), SPREBINYN - coagulation factor ix recomb glycopegylated for inj 3000 untPA, QL (1 ml/30 days), SPRECOMBINATE - antihemophilic factor recomb (rfviii) for inj 220-400 unit,401-800 unit, 801-1240 unit, 1241-1800 unit, 1801-2400 unitPA, QL (1 ml/30 days), SPRIXUBIS - coagulation factor ix (recombinant) for inj 250 unit, 500 unit, 1000unit, 2000 unit, 3000 unitPA, QL (1 ml/30 days), SPTAKHZYRO - lanadelumab-flyo inj 300 mg/2ml (150 mg/ml)PA, QL (2 vials/28 days), SPTAKHZYRO - lanadelumab-flyo soln pref syringe 150 mg/mlPA, QL (2 mls/28 days), SPTAKHZYRO - lanadelumab-flyo soln pref syringe 300 mg/2ml (150 mg/ml)PA, QL (2 vials/28 days), SPTRETTEN - coagulation factor xiii a-subunit for inj 2000-3125 unitSP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 39Drug NameRequirements/LimitsVONVENDI - von willebrand factor (recombinant) for inj 650 unit, 1300 unitPA, QL (1 ml/30 days), SPWILATE - antihemophilic factor/vwf (human) for inj 500-500 unit kitPA, QL (1 ml/30 days), SPWILATE - antihemophilic factor/vwf (human) for inj 1000-1000 unit kitPA, QL (1 ml/30 days), SPXYNTHA - antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250 unit, 500 unitPA, QL (1 ml/30 days), SPXYNTHA - antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000 unit, 2000 unitPA, QL (1 ml/30 days), SPXYNTHA SOLOFUSE - antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250unit, 500 unitPA, QL (1 ml/30 days), SPXYNTHA SOLOFUSE - antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000unit, 2000 unit, 3000 unitPA, QL (1 ml/30 days), SPTOPICAL PRODUCTSOPHTHALMIC AGENTSatropine sulfate ophth soln 1% (Atropine sulfate)azelastine hcl ophth soln 0.05%BACITRACIN - bacitracin ophth oint 500 unit/gmbacitracin-polymyxin b ophth ointbacitracin-polymyxin-neomycin-hc ophth oint 1%brimonidine tartrate ophth soln 0.15% (Alphagan p)PA, QL (5 ml/20 days)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 22.3-6.8 mg/ml (Cosopt)erythromycin ophth oint 5 mg/gmfluorometholone ophth susp 0.1% (Fml liquifilm)gentamicin sulfate ophth soln 0.3% (Garamycin)ketorolac tromethamine ophth soln 0.4% (Acular ls)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%loteprednol etabonate ophth susp 0.5% (Lotemax)LUMIGAN - bimatoprost ophth soln 0.01%QL (2.5 mls/20 days), STmoxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox)NATACYN - natamycin ophth susp 5%neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oinneomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)ofloxacin ophth soln 0.3% (Ocuflox)pilocarpine hcl ophth soln 1%, 2%, 4% (Isopto carpine)polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 40Drug NameRequirements/LimitsPREDNISOLONE ACETATE - prednisolone acetate ophth susp 1%PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate ophthsoln 1%SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2%sulfacetamide sodium ophth soln 10% (Bleph-10)timolol maleate ophth soln 0.25%, 0.5% (Timoptic)tobramycin ophth soln 0.3% (Tobrex)QL (15 ml/30 days)tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)TRIFLURIDINE - trifluridine ophth soln 1%tropicamide ophth soln 0.5%tropicamide ophth soln 1% (Mydriacyl)ZYLET - loteprednol etabonate-tobramycin ophth susp 0.5-0.3%OTIC AGENTSacetic acid otic soln 2%ciprofloxacin-dexamethasone otic susp 0.3-0.1% (Ciprodex)neomycin-polymyxin-hc otic soln 1%neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%ofloxacin otic soln 0.3% (Floxin otic)MOUTH/THROAT/DENTAL AGENTScevimeline hcl cap 30 mg (Evoxac)chlorhexidine gluconate soln 0.12% (Peridex)clotrimazole troche 10 mglidocaine hcl viscous soln 2%nystatin susp 100000 unit/mlpilocarpine hcl tab 5 mg, 7.5 mg (Salagen)sodium fluoride cream 1.1% (Prevident 5000 plus)ACsodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)ACtriamcinolone acetonide dental paste 0.1%ANORECTAL AGENTShydrocortisone acetate suppos 25 mghydrocortisone enema 100 mg/60ml (Cortenema)hydrocortisone perianal cream 2.5% (Anusol-hc)DERMATOLOGICALSacitretin cap 10 mg, 25 mg (Soriatane)acitretin cap 17.5 mgadapalene cream 0.1% (Differin)adapalene gel 0.1%, 0.3% (Differin)adapalene-benzoyl peroxide gel 0.1-2.5% (Epiduo)ADBRY - tralokinumab-ldrm subcutaneous soln prefilled syr 150 mg/mlPA, QL (4 mls/28 days), SPalclometasone dipropionate cream 0.05%

2023Blue Cross and Blue Shield July 2023 Basic Drug List 41Drug NameRequirements/Limitsalclometasone dipropionate oint 0.05%azelaic acid gel 15% (Finacea)betamethasone dipropionate augmented cream 0.05% (Diprolene af)QL (180 grams/90 days)betamethasone dipropionate augmented lotion 0.05%QL (180 grams/90 days)betamethasone dipropionate augmented oint 0.05% (Diprolene)QL (180 grams/90 days)betamethasone dipropionate cream 0.05%QL (180 grams/90 days)betamethasone dipropionate lotion 0.05%QL (180 grams/90 days)betamethasone dipropionate oint 0.05%QL (180 grams/90 days)betamethasone valerate cream 0.1% (base equivalent)betamethasone valerate lotion 0.1% (base equivalent)betamethasone valerate oint 0.1% (base equivalent)calcipotriene cream 0.005% (Dovonex)calcipotriene soln 0.005% (50 mcg/ml)ciclopirox gel 0.77%QL (180 grams/30 days)ciclopirox olamine cream 0.77% (base equiv) (Loprox)QL (180 grams/30 days)ciclopirox shampoo 1% (Loprox shampoo)ciclopirox solution 8% (Penlac Nail Lacquer)PA, QL (6.6 mls/30 days)clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)clindamycin phosphate gel 1% (Cleocin-t)clindamycin phosphate lotion 1% (Cleocin-t)clindamycin phosphate soln 1%QL (180 ml/30 days)clindamycin phosphate swab 1%clobetasol propionate cream 0.05% (Temovate)QL (180 grams/90 days)clobetasol propionate emollient base cream 0.05%clobetasol propionate foam 0.05% (Olux)QL (200 grams/28 days)clobetasol propionate gel 0.05%clobetasol propionate oint 0.05% (Temovate)QL (180 grams/90 days)clobetasol propionate soln 0.05%QL (180 grams/90 days)COSENTYX - secukinumab subcutaneous soln prefilled syringe 75 mg/0.5ml,150 mg/mlPA, QL (1 syringe/28 days), SPCOSENTYX - secukinumab subcutaneous pref syr 150 mg/ml (300 mg dose)PA, QL (2 syringes/28 days), SPCOSENTYX SENSOREADY PEN - secukinumab subcutaneous soln auto-injector 150 mg/mlPA, QL (1 pen/28 days), SPCOSENTYX SENSOREADY PEN - secukinumab subcutaneous auto-inj150 mg/ml (300 mg dose)PA, QL (2 pens/28 days), SPdesonide cream 0.05% (Desowen)desonide oint 0.05%desoximetasone cream 0.25% (Topicort)QL (180 grams/90 days)desoximetasone oint 0.25% (Topicort)QL (180 grams/90 days)diclofenac sodium (actinic keratoses) gel 3%PA, QL (1 tube/30 days)DUPIXENT - dupilumab subcutaneous soln pen-injector 200 mg/1.14mlPA, QL (2 pens/28 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 42Drug NameRequirements/LimitsDUPIXENT - dupilumab subcutaneous soln pen-injector 300 mg/2mlPA, QL (4 pens/28 days), SPDUPIXENT - dupilumab subcutaneous soln prefilled syringe 100 mg/0.67ml,200 mg/1.14mlPA, QL (2 syringes/28 days), SPDUPIXENT - dupilumab subcutaneous soln prefilled syringe 300 mg/2mlPA, QL (4 syringes/28 days), SPeconazole nitrate cream 1%QL (170 grams/30 days)erythromycin gel 2% (Erygel)QL (180 grams/30 days)erythromycin soln 2%QL (180 mls/30 days)FINACEA - azelaic acid foam 15%fluocinolone acetonide cream 0.01%fluocinolone acetonide cream 0.025% (Synalar)fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod)fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca)fluocinolone acetonide oint 0.025% (Synalar)fluocinolone acetonide soln 0.01% (Synalar)fluocinonide cream 0.05%QL (180 grams/90 days)fluocinonide cream 0.1% (Vanos)PA, QL (120 grams/180 days)fluocinonide gel 0.05%QL (180 grams/90 days)fluocinonide oint 0.05%QL (180 grams/90 days)fluocinonide soln 0.05%QL (180 grams/90 days)fluorouracil cream 5% (Efudex)PA, QL (240 grams/180 days)fluticasone propionate cream 0.05%fluticasone propionate oint 0.005%gentamicin sulfate cream 0.1%QL (120 grams/90 days)gentamicin sulfate oint 0.1%QL (120 grams/90 days)halobetasol propionate cream 0.05%QL (180 grams/90 days)hydrocortisone cream 2.5%hydrocortisone lotion 2.5%hydrocortisone oint 2.5%imiquimod cream 5% (Aldara)QL (48 packets/180 days)isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mgQL (60 capsules/30 days)ketoconazole cream 2%QL (180 grams/30 days)ketoconazole shampoo 2% (Nizoral)lidocaine hcl gel 2%QL (120 mls/30 days)lidocaine hcl soln 4%QL (120 mls/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2%lidocaine oint 5%PA, QL (120 grams/30 days)lidocaine patch 5% (Lidoderm)PA, QL (120 patches/30 days)lidocaine-prilocaine cream 2.5-2.5%malathion lotion 0.5% (Ovide)metronidazole cream 0.75% (Metrocream)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 43Drug NameRequirements/Limitsmetronidazole gel 0.75%metronidazole gel 1% (Metrogel)mometasone furoate cream 0.1% (Elocon)mometasone furoate oint 0.1% (Elocon)QL (180 grams/90 days)mometasone furoate solution 0.1% (lotion)mupirocin oint 2% (Bactroban)nystatin cream 100000 unit/gmnystatin oint 100000 unit/gmnystatin topical powder 100000 unit/gmnystatin-triamcinolone cream 100000-0.1 unit/gm-%nystatin-triamcinolone oint 100000-0.1 unit/gm-%permethrin cream 5% (Elimite)podofilox soln 0.5%selenium sulfide lotion 2.5%silver sulfadiazine cream 1% (Silvadene)SKYRIZI - risankizumab-rzaa soln prefilled syringe 150 mg/mlPA, QL (1 syringe/84 days), SPSKYRIZI PEN - risankizumab-rzaa soln auto-injector 150 mg/mlPA, QL (1 injection device/84 days), SPSOOLANTRA - ivermectin cream 1%QL (45 grams/30 days)STELARA - ustekinumab inj 45 mg/0.5mlPA, QL (1 vial/84 days), SPSTELARA - ustekinumab soln prefilled syringe 45 mg/0.5mlPA, QL (1 syringe/84 days), SPSTELARA - ustekinumab soln prefilled syringe 90 mg/mlPA, QL (1 syringe/56 days), SPsulfacetamide sodium lotion 10% (acne) (Klaron)tacrolimus oint 0.03%, 0.1% (Protopic)STtazarotene cream 0.1% (Tazorac)tazarotene gel 0.05%, 0.1% (Tazorac)TAZORAC - tazarotene cream 0.05%TREMFYA - guselkumab soln pen-injector 100 mg/mlPA, QL (1 pen/56 days), SPTREMFYA - guselkumab soln prefilled syringe 100 mg/mlPA, QL (1 syringe/56 days), SPtretinoin cream 0.025%, 0.05%, 0.1% (Retin-a)tretinoin gel 0.01% (Retin-a)triamcinolone acetonide cream 0.025%, 0.1%, 0.5%triamcinolone acetonide lotion 0.025%, 0.1%triamcinolone acetonide oint 0.025%, 0.1%, 0.5%VALCHLOR - mechlorethamine hcl gel 0.016% (base equivalent)SPMISCELLANEOUS PRODUCTSANTIDOTESCHEMET - succimer cap 100 mgKLOXXADO - naloxone hcl nasal spray 8 mg/0.1mlnaloxone hcl inj 0.4 mg/ml, 4 mg/10mlnaloxone hcl nasal spray 4 mg/0.1ml (Narcan)

2023Blue Cross and Blue Shield July 2023 Basic Drug List 44Drug NameRequirements/Limitsnaltrexone hcl tab 50 mgDIAGNOSTIC PRODUCTSINSULIN PEN NEEDLES – VARIOUSQL (300 needles/30 days)INSULIN SYRINGES – VARIOUSQL (300 syringes/30 days)LANCETS – VARIOUSTEST STRIPS – CONTOUR, CONTOUR NEXTQL (204 strips/30 days)MEDICAL DEVICESBREATHERITE– spacer/aerosol-holding chambers – deviceDEXCOM G6 RECEIVER - continuous blood glucose system receiverPA, QL (1 receiver/365 days)DEXCOM G6 SENSOR - continuous blood glucose system sensorPA, QL (3 sensors/30 days)DEXCOM G6 TRANSMITTER - continuous blood glucose system transmitterPA, QL (1 box/90 days)DEXCOM G7 RECEIVER - continuous blood glucose system receiverPA, QL (1 receiver/365 days)DEXCOM G7 SENSOR - continuous blood glucose system sensorPA, QL (3 sensors/30 days)ASSORTED CLASSESazathioprine tab 50 mg (Imuran)cyclosporine cap 25 mg, 100 mg (Sandimmune)cyclosporine modified cap 25 mg, 100 mg (Neoral)cyclosporine modified cap 50 mgcyclosporine modified oral soln 100 mg/ml (Neoral)everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg (Zortress)lenalidomide caps 2.5 mg (Revlimid)PA, QL (30 capsules/30 days), SPlenalidomide cap 5 mg, 10 mg (Revlimid)PA, QL (30 capsules/30 days), SPlenalidomide cap 15 mg, 20 mg, 25 mg (Revlimid)PA, QL (21 capsules/28 days), SPLOKELMA - sodium zirconium cyclosilicate for susp packet 5 gm, 10 gmmycophenolate mofetil cap 250 mg (Cellcept)mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)mycophenolate mofetil tab 500 mg (Cellcept)mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv),360 mg (mycophenolic acid equiv) (Myfortic)penicillamine tab 250 mg (Depen titratabs)SPRAPAMUNE - sirolimus oral soln 1 mg/mlREVLIMID - lenalidomide caps 2.5 mgPA, QL (30 capsules/30 days), SPREVLIMID - lenalidomide cap 5 mg, 10 mgPA, QL (30 capsules/30 days), SPREVLIMID - lenalidomide cap 15 mg, 20 mg, 25 mgPA, QL (21 capsules/28 days), SPsirolimus oral soln 1 mg/ml (Rapamune)sirolimus tab 0.5 mg, 1 mg, 2 mg (Rapamune)sodium polystyrene sulfonate powdertacrolimus cap 0.5 mg, 1 mg, 5 mg (Prograf)THALOMID - thalidomide cap 50 mg, 100 mgPA, QL (30 capsules/30 days), SPTHALOMID - thalidomide cap 150 mg, 200 mgPA, QL (60 capsules/30 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 45Drug NameRequirements/LimitsVELTASSA - 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 mgPA, QL (120 capsules/30 days), SP

2023Blue Cross and Blue Shield July 2023 Basic Drug List 46INDEXAabacavir sulfate-lamivudine tab 600-300 mg................... 3abacavir sulfate soln 20 mg/ml (base equiv)................... 3abacavir sulfate tab 300 mg (base equiv)........................ 3abiraterone acetate tab 250 mg.........................................6abiraterone acetate tab 500 mg.........................................6acamprosate calcium tab delayed release 333 mg....... 29acarbose tab 25 mg, 50 mg, 100 mg...............................11acebutolol hcl cap 200 mg, 400 mg................................ 15acetaminophen w/ codeine tab 300-15 mg.....................30acetaminophen w/ codeine tab 300-30 mg.....................30acetaminophen w/ codeine tab 300-60 mg.....................30acetazolamide cap er 12hr 500 mg................................. 18acetazolamide tab 125 mg, 250 mg.................................18acetic acid otic soln 2%................................................... 40acetylcysteine inhal soln 10%, 20%................................20acitretin cap 17.5 mg........................................................ 40acitretin cap 10 mg, 25 mg.............................................. 40ACTEMRA............................................................................31ACTEMRA ACTPEN........................................................... 32ACTIMMUNE......................................................................... 6acyclovir cap 200 mg..........................................................3acyclovir susp 200 mg/5ml................................................ 3acyclovir tab 400 mg, 800 mg............................................3adapalene-benzoyl peroxide gel 0.1-2.5%......................40adapalene cream 0.1%......................................................40adapalene gel 0.1%, 0.3%.................................................40ADBRY................................................................................. 40adefovir dipivoxil tab 10 mg.............................................. 3ADVAIR DISKUS................................................................. 20ADVAIR HFA........................................................................21ADVATE................................................................................37ADYNOVATE....................................................................... 37AFSTYLA............................................................................. 37AIMOVIG.............................................................................. 33AJOVY..................................................................................33albendazole tab 200 mg..................................................... 5albuterol sulfate inhal aero 108 mcg/act (90mcg baseequiv)................................................................................. 21albuterol sulfate soln nebu 0.083% (2.5 mg/3ml), 0.63mg/3ml (base equiv), 1.25 mg/3ml (base equiv).......... 21albuterol sulfate syrup 2 mg/5ml.................................... 21albuterol sulfate tab 2 mg, 4 mg..................................... 21alclometasone dipropionate cream 0.05%..................... 40alclometasone dipropionate oint 0.05%......................... 41ALECENSA............................................................................ 6alendronate sodium tab 10 mg........................................14alendronate sodium tab 35 mg........................................14alendronate sodium tab 70 mg........................................14alfuzosin hcl tab er 24hr 10 mg.......................................25ALINIA.................................................................................... 5allopurinol tab 100 mg, 300 mg.......................................33ALPHANATE........................................................................ 37ALPHANINE SD.................................................................. 37alprazolam tab er 24hr 0.5 mg, 1 mg, 2 mg, 3 mg......... 25alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg................. 25ALPROLIX............................................................................37ALUNBRIG.............................................................................6amantadine hcl cap 100 mg.............................................34amantadine hcl soln 50 mg/5ml...................................... 35ambrisentan tab 5 mg, 10 mg..........................................19amiloride hcl tab 5 mg......................................................18amiodarone hcl tab 100 mg............................................. 16amiodarone hcl tab 200 mg............................................. 16amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100mg, 150 mg.......................................................................26amlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-10mg, 5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg..................16amlodipine besylate tab 2.5 mg (base equivalent), 5 mg(base equivalent), 10 mg (base equivalent)................. 16amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg,10-160 mg, 10-320 mg.....................................................16amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg, 5-160-25 mg, 10-160-12.5 mg,10-160-25 mg, 10-320-25 mg.......................................... 16amoxicillin & k clavulanate for susp 250-62.5mg/5ml................................................................................. 1amoxicillin & k clavulanate for susp 600-42.9mg/5ml................................................................................. 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml,400-57 mg/5ml.................................................................... 1amoxicillin & k clavulanate tab 250-125 mg.................... 1amoxicillin & k clavulanate tab 500-125 mg, 875-125mg........................................................................................ 1amoxicillin (trihydrate) cap 250 mg, 500 mg....................1amoxicillin (trihydrate) for susp 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400 mg/5ml.................................... 1amoxicillin (trihydrate) tab 500 mg, 875 mg.................... 1amphetamine-dextroamphetamine cap er 24hr 5 mg,10 mg, 15 mg, 20 mg, 25 mg, 30 mg............................. 28amphetamine-dextroamphetamine tab 20 mg............... 28amphetamine-dextroamphetamine tab 5 mg, 7.5 mg, 10mg, 12.5 mg, 15 mg, 30 mg............................................28anagrelide hcl cap 0.5 mg................................................37anagrelide hcl cap 1 mg...................................................37anastrozole tab 1 mg.......................................................... 6ANORO ELLIPTA................................................................ 21aprepitant capsule 40 mg.................................................23aprepitant capsule 80 mg.................................................23aprepitant capsule 125 mg...............................................23aprepitant capsule therapy pack 80 & 125 mg.............. 23APTIOM................................................................................33ARANESP ALBUMIN FREE............................................... 36aripiprazole tab 2 mg, 5 mg............................................. 27aripiprazole tab 10 mg, 15 mg, 20 mg, 30 mg................ 27armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg...........28ARNUITY ELLIPTA..............................................................21ASMANEX HFA................................................................... 21ASMANEX TWISTHALER 120 ME.....................................21ASMANEX TWISTHALER 30 MET.................................... 21

2023Blue Cross and Blue Shield July 2023 Basic Drug List 47ASMANEX TWISTHALER 60 MET.................................... 21atazanavir sulfate cap 200 mg (base equiv).................... 3atazanavir sulfate cap 150 mg (base equiv), 300 mg(base equiv)........................................................................ 3atenolol & chlorthalidone tab 50-25 mg......................... 17atenolol & chlorthalidone tab 100-25 mg....................... 17atenolol tab 25 mg, 50 mg, 100 mg.................................15atomoxetine hcl cap 60 mg (base equiv), 80 mg (baseequiv), 100 mg (base equiv)...........................................28atomoxetine hcl cap 10 mg (base equiv), 18 mg (baseequiv), 25 mg (base equiv), 40 mg (base equiv).......... 28atorvastatin calcium tab 10 mg (base equivalent), 20mg (base equivalent), 40 mg (base equivalent), 80 mg(base equivalent)............................................................. 19atovaquone-proguanil hcl tab 62.5-25 mg, 250-100mg........................................................................................ 5atovaquone susp 750 mg/5ml............................................5atropine sulfate ophth soln 1%....................................... 39AUBAGIO.............................................................................29AVONEX...............................................................................29AVONEX PEN......................................................................29AYVAKIT.................................................................................6azathioprine tab 50 mg.....................................................44azelaic acid gel 15%......................................................... 41azelastine hcl nasal spray 0.1% (137 mcg/spray)..........20azelastine hcl nasal spray 0.15% (205.5 mcg/spray).................................................................................20azelastine hcl ophth soln 0.05%......................................39AZITHROMYCIN....................................................................1azithromycin for susp 100 mg/5ml, 200 mg/5ml..............1azithromycin tab 250 mg, 500 mg, 600 mg...................... 1BBACITRACIN....................................................................... 39bacitracin-polymyxin b ophth oint..................................39bacitracin-polymyxin-neomycin-hc ophth oint 1%....... 39baclofen tab 10 mg, 20 mg.............................................. 35balsalazide disodium cap 750 mg...................................24BAQSIMI ONE PACK..........................................................11BAQSIMI TWO PACK......................................................... 11BARACLUDE......................................................................... 3BELBUCA............................................................................ 31BELSOMRA......................................................................... 28benazepril & hydrochlorothiazide tab 5-6.25 mg...........17benazepril & hydrochlorothiazide tab 10-12.5 mg,20-12.5 mg, 20-25 mg......................................................17benazepril hcl tab 5 mg....................................................17benazepril hcl tab 10 mg, 20 mg, 40 mg........................ 17BENEFIX.............................................................................. 37BENZNIDAZOLE................................................................... 5benztropine mesylate tab 0.5 mg, 1 mg, 2 mg...............35betaine powder for oral solution.....................................14betamethasone dipropionate augmented cream0.05%................................................................................. 41betamethasone dipropionate augmented lotion0.05%................................................................................. 41betamethasone dipropionate augmented oint0.05%................................................................................. 41betamethasone dipropionate cream 0.05%....................41betamethasone dipropionate lotion 0.05%.................... 41betamethasone dipropionate oint 0.05%........................41betamethasone valerate cream 0.1% (baseequivalent)........................................................................ 41betamethasone valerate lotion 0.1% (baseequivalent)........................................................................ 41betamethasone valerate oint 0.1% (baseequivalent)........................................................................ 41BETASERON....................................................................... 29bexarotene cap 75 mg........................................................ 6bicalutamide tab 50 mg...................................................... 6BIKTARVY..............................................................................3bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg,5-6.25 mg, 10-6.25 mg.....................................................17bisoprolol fumarate tab 5 mg.......................................... 15bisoprolol fumarate tab 10 mg........................................ 15bosentan tab 62.5 mg, 125 mg........................................ 19BREATHERITE– spacer/aerosol-holding chambers –device................................................................................. 44BREO ELLIPTA................................................................... 21BREZTRI AEROSPHERE................................................... 21BRILINTA............................................................................. 37brimonidine tartrate ophth soln 0.15%...........................39brimonidine tartrate ophth soln 0.2%.............................39BRUKINSA.............................................................................6budesonide delayed release particles cap 3 mg............. 9budesonide inhalation susp 1 mg/2ml........................... 21budesonide inhalation susp 0.25 mg/2ml, 0.5mg/2ml............................................................................... 21bumetanide tab 0.5 mg, 1 mg, 2 mg............................... 18buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (baseequiv), 4-1 mg (base equiv), 8-2 mg (base equiv), 12-3mg (base equiv)............................................................... 31buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv), 8-2 mg (base equiv)............................................31buprenorphine hcl sl tab 2 mg (base equiv), 8 mg(base equiv)...................................................................... 31bupropion hcl (smoking deterrent) tab er 12hr 150mg...................................................................................... 29bupropion hcl tab er 24hr 150 mg, 300 mg.................... 26bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg......26bupropion hcl tab 75 mg, 100 mg................................... 26buspirone hcl tab 5 mg, 10 mg, 15 mg, 30 mg...............25butalbital-acetaminophen-caffeine tab 50-325-40mg...................................................................................... 30butalbital-acetaminophen tab 50-325 mg....................... 30butalbital-aspirin-caffeine cap 50-325-40 mg.................30butalbital-aspirin-caff w/ codeine cap 50-325-40-30mg...................................................................................... 31Ccabergoline tab 0.5 mg.....................................................14CABOMETYX.........................................................................6

2023Blue Cross and Blue Shield July 2023 Basic Drug List 48caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv)................................................................................. 28calcipotriene cream 0.005%............................................. 41calcipotriene soln 0.005% (50 mcg/ml)...........................41calcitonin (salmon) nasal soln 200 unit/act................... 14calcitriol cap 0.25 mcg, 0.5 mcg......................................14calcium acetate (phosphate binder) cap 667 mg (169mg ca)................................................................................24calcium acetate (phosphate binder) tab 667 mg........... 24CALQUENCE.........................................................................6candesartan cilexetil-hydrochlorothiazide tab 16-12.5mg, 32-12.5 mg, 32-25 mg.............................................. 17candesartan cilexetil tab 4 mg, 8 mg, 16 mg, 32 mg..... 17capecitabine tab 150 mg, 500 mg..................................... 6captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg................ 17carbamazepine cap er 12hr 100 mg, 200 mg, 300mg...................................................................................... 33carbamazepine chew tab 100 mg....................................33carbamazepine susp 100 mg/5ml....................................33carbamazepine tab er 12hr 100 mg, 200 mg, 400mg...................................................................................... 33carbamazepine tab 200 mg.............................................. 33carbidopa & levodopa tab er 25-100 mg, 50-200 mg.....35carbidopa & levodopa tab 10-100 mg, 25-100 mg,25-250 mg......................................................................... 35carbidopa-levodopa-entacapone tabs 12.5-50-200mg...................................................................................... 35carbidopa-levodopa-entacapone tabs 18.75-75-200mg...................................................................................... 35carbidopa-levodopa-entacapone tabs 31.25-125-200mg...................................................................................... 35carbidopa-levodopa-entacapone tabs 37.5-150-200mg...................................................................................... 35carbidopa-levodopa-entacapone tabs 25-100-200mg...................................................................................... 35carbidopa-levodopa-entacapone tabs 50-200-200mg...................................................................................... 35carglumic acid soluble tab 200 mg.................................14carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg........ 15cefadroxil cap 500 mg........................................................ 1cefadroxil for susp 250 mg/5ml, 500 mg/5ml................... 1cefdinir cap 300 mg............................................................ 1cefdinir for susp 125 mg/5ml, 250 mg/5ml....................... 1cefixime cap 400 mg...........................................................1cefixime for susp 100 mg/5ml, 200 mg/5ml..................... 1cefpodoxime proxetil for susp 50 mg/5ml, 100mg/5ml................................................................................. 1cefpodoxime proxetil tab 100 mg, 200 mg....................... 1cefprozil for susp 125 mg/5ml, 250 mg/5ml..................... 1cefprozil tab 250 mg, 500 mg............................................ 1cefuroxime axetil tab 250 mg, 500 mg..............................1celecoxib cap 400 mg.......................................................32celecoxib cap 50 mg, 100 mg, 200 mg........................... 32cephalexin cap 250 mg, 500 mg........................................1cephalexin for susp 125 mg/5ml, 250 mg/5ml................. 1CERDELGA......................................................................... 36cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)....................20cevimeline hcl cap 30 mg................................................ 40CHEMET.............................................................................. 43CHENODAL......................................................................... 24chlorhexidine gluconate soln 0.12%...............................40chloroquine phosphate tab 250 mg, 500 mg................... 5chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg,200 mg...............................................................................27chlorthalidone tab 25 mg, 50 mg.................................... 18chlorzoxazone tab 500 mg............................................... 35cholestyramine light powder 4 gm/dose........................19cholestyramine powder 4 gm/dose.................................19ciclopirox gel 0.77%..........................................................41ciclopirox olamine cream 0.77% (base equiv)............... 41ciclopirox shampoo 1%....................................................41ciclopirox solution 8%...................................................... 41cilostazol tab 50 mg, 100 mg...........................................37CIMDUO.................................................................................3cimetidine tab 300 mg, 400 mg, 800 mg.........................23cinacalcet hcl tab 30 mg (base equiv), 60 mg (baseequiv), 90 mg (base equiv).............................................14ciprofloxacin-dexamethasone otic susp 0.3-0.1%........ 40ciprofloxacin hcl ophth soln 0.3% (baseequivalent)........................................................................ 39ciprofloxacin hcl tab 750 mg (base equiv)....................... 2ciprofloxacin hcl tab 250 mg (base equiv), 500 mg(base equiv)........................................................................ 2citalopram hydrobromide oral soln 10 mg/5ml............. 26citalopram hydrobromide tab 10 mg (base equiv), 20mg (base equiv), 40 mg (base equiv)............................26clarithromycin tab er 24hr 500 mg....................................1clarithromycin tab 250 mg, 500 mg.................................. 1clindamycin hcl cap 75 mg, 150 mg, 300 mg...................5clindamycin palmitate hcl for soln 75 mg/5ml (baseequiv)................................................................................... 5clindamycin phosphate gel 1%....................................... 41clindamycin phosphate lotion 1%...................................41clindamycin phosphate soln 1%..................................... 41clindamycin phosphate swab 1%................................... 41clindamycin phosphate vaginal cream 2%.................... 25clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5%.................................................................................41clobetasol propionate cream 0.05%............................... 41clobetasol propionate emollient base cream 0.05%..... 41clobetasol propionate foam 0.05%................................. 41clobetasol propionate gel 0.05%.....................................41clobetasol propionate oint 0.05%................................... 41clobetasol propionate soln 0.05%...................................41CLOMID............................................................................... 14clomipramine hcl cap 25 mg, 50 mg, 75 mg.................. 26clonazepam tab 0.5 mg, 1 mg, 2 mg...............................33clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg....................... 17clonidine td patch weekly 0.1 mg/24hr...........................17clonidine td patch weekly 0.2 mg/24hr...........................17clonidine td patch weekly 0.3 mg/24hr...........................17clopidogrel bisulfate tab 75 mg (base equiv)................ 37clotrimazole troche 10 mg............................................... 40clozapine tab 25 mg..........................................................27

2023Blue Cross and Blue Shield July 2023 Basic Drug List 49clozapine tab 50 mg..........................................................27clozapine tab 100 mg........................................................27clozapine tab 200 mg........................................................27COAGADEX.........................................................................37codeine sulfate tab 30 mg................................................31colchicine tab 0.6 mg....................................................... 33colchicine w/ probenecid tab 0.5-500 mg.......................33colesevelam hcl tab 625 mg............................................ 19colestipol hcl granule packets 5 gm...............................19colestipol hcl granules 5 gm........................................... 19colestipol hcl tab 1 gm.....................................................19COMBIPATCH........................................................................9COMBIVENT RESPIMAT....................................................21CORIFACT........................................................................... 37CORLANOR.........................................................................19COSENTYX......................................................................... 41COSENTYX SENSOREADY PEN......................................41COTELLIC..............................................................................6CREON................................................................................ 24CRINONE.............................................................................25cromolyn sodium soln nebu 20 mg/2ml.........................21cyanocobalamin inj 1000 mcg/ml....................................36cyclobenzaprine hcl tab 5 mg, 10 mg.............................35cyclopentolate hcl ophth soln 1%...................................39cyclophosphamide cap 25 mg, 50 mg..............................6cyclosporine cap 25 mg, 100 mg.................................... 44cyclosporine modified cap 50 mg...................................44cyclosporine modified cap 25 mg, 100 mg.................... 44cyclosporine modified oral soln 100 mg/ml...................44cyproheptadine hcl syrup 2 mg/5ml............................... 20cyproheptadine hcl tab 4 mg...........................................20CYSTAGON......................................................................... 25Ddanazol cap 50 mg, 100 mg, 200 mg................................ 9dapsone tab 25 mg, 100 mg.............................................. 5DELSTRIGO.......................................................................... 3demeclocycline hcl tab 150 mg, 300 mg.......................... 1DESCOVY..............................................................................3desipramine hcl tab 10 mg, 25 mg..................................26desipramine hcl tab 50 mg, 75 mg, 100 mg, 150 mg..... 26desloratadine tab 5 mg.....................................................20desmopressin acetate inj 4 mcg/ml................................ 14desmopressin acetate nasal spray soln 0.01%............. 14desmopressin acetate nasal spray soln 0.01%(refrigerated).....................................................................14desmopressin acetate preservative free (pf) inj 4 mcg/ml........................................................................................14desmopressin acetate tab 0.1 mg, 0.2 mg..................... 14desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5).............................................................................10desogestrel & ethinyl estradiol tab 0.15 mg-30mcg.................................................................................... 10desonide cream 0.05%......................................................41desonide oint 0.05%..........................................................41desoximetasone cream 0.25%.........................................41desoximetasone oint 0.25%............................................. 41desvenlafaxine succinate tab er 24hr 25 mg (baseequiv), 50 mg (base equiv), 100 mg (base equiv)........ 26dexamethasone elixir 0.5 mg/5ml..................................... 9dexamethasone tab 1.5 mg, 2 mg, 4 mg, 6 mg................ 9DEXCOM G6 RECEIVER................................................... 44DEXCOM G7 RECEIVER................................................... 44DEXCOM G6 SENSOR...................................................... 44DEXCOM G7 SENSOR...................................................... 44DEXCOM G6 TRANSMITTER............................................44dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg......................28dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg.........28dextroamphetamine sulfate cap er 24hr 5 mg............... 28dextroamphetamine sulfate cap er 24hr 10 mg, 15mg...................................................................................... 28dextroamphetamine sulfate tab 5 mg.............................28dextroamphetamine sulfate tab 10 mg...........................28DIASTAT ACUDIAL............................................................. 33DIASTAT PEDIATRIC.......................................................... 34diazepam oral soln 1 mg/ml.............................................25diazepam tab 2 mg, 5 mg, 10 mg.................................... 25diazoxide susp 50 mg/ml................................................. 11diclofenac potassium tab 50 mg..................................... 32diclofenac sodium (actinic keratoses) gel 3%...............41diclofenac sodium ophth soln 0.1%............................... 39diclofenac sodium tab delayed release 25 mg, 50 mg,75 mg.................................................................................32dicloxacillin sodium cap 250 mg, 500 mg........................1dicyclomine hcl cap 10 mg.............................................. 23dicyclomine hcl oral soln 10 mg/5ml..............................23dicyclomine hcl tab 20 mg...............................................23DIFICID.................................................................................. 1digoxin oral soln 0.05 mg/ml........................................... 15digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg).....15dihydroergotamine mesylate inj 1 mg/ml.......................33dihydroergotamine mesylate nasal spray 4 mg/ml....... 33DILANTIN.............................................................................34diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mg....... 16diltiazem hcl coated beads cap er 24hr 120 mg, 180mg, 240 mg, 300 mg........................................................16diltiazem hcl extended release beads cap er 24hr 120mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg............ 16diltiazem hcl tab 90 mg.................................................... 16diltiazem hcl tab 30 mg, 60 mg, 120 mg.........................16dimethyl fumarate capsule delayed release 120 mg.....29dimethyl fumarate capsule delayed release 240 mg.....29dimethyl fumarate capsule dr starter pack 120 mg &240 mg...............................................................................29diphenoxylate w/ atropine tab 2.5-0.025 mg.................. 23dipyridamole tab 25 mg, 50 mg, 75 mg.......................... 37disopyramide phosphate cap 100 mg, 150 mg..............16disulfiram tab 250 mg, 500 mg........................................ 29divalproex sodium cap delayed release sprinkle 125mg...................................................................................... 34divalproex sodium tab delayed release 125 mg, 250mg, 500 mg.......................................................................34divalproex sodium tab er 24 hr 250 mg, 500 mg........... 34

2023Blue Cross and Blue Shield July 2023 Basic Drug List 50DIVIGEL................................................................................. 9donepezil hydrochloride orally disintegrating tab 5 mg,10 mg.................................................................................29donepezil hydrochloride tab 5 mg, 10 mg..................... 29DOPTELET.......................................................................... 36dorzolamide hcl ophth soln 2%.......................................39dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml................................................................................. 39DOVATO.................................................................................3doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg.......... 17doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100mg...................................................................................... 26doxepin hcl conc 10 mg/ml..............................................26doxycycline hyclate cap 50 mg......................................... 1doxycycline hyclate cap 100 mg.......................................1doxycycline hyclate tab 20 mg, 100 mg........................... 1doxycycline monohydrate cap 50 mg.............................. 2doxycycline monohydrate cap 100 mg............................ 2doxycycline monohydrate tab 150 mg............................. 2doxycycline monohydrate tab 50 mg, 75 mg, 100mg........................................................................................ 2drospirenone-ethinyl estradiol tab 3-0.02 mg................10drospirenone-ethinyl estradiol tab 3-0.03 mg................10DUAVEE................................................................................. 9DULERA...............................................................................21duloxetine hcl enteric coated pellets cap 30 mg (baseeq)...................................................................................... 26duloxetine hcl enteric coated pellets cap 20 mg (baseeq), 60 mg (base eq)....................................................... 26DUPIXENT........................................................................... 41dutasteride cap 0.5 mg.....................................................25Eeconazole nitrate cream 1%.............................................42efavirenz-emtricitabine-tenofovir df tab 600-200-300mg........................................................................................ 3efavirenz-lamivudine-tenofovir df tab 400-300-300mg........................................................................................ 3efavirenz-lamivudine-tenofovir df tab 600-300-300mg........................................................................................ 3efavirenz tab 600 mg.......................................................... 3eletriptan hydrobromide tab 20 mg (base equivalent),40 mg (base equivalent)................................................. 33ELIQUIS............................................................................... 36ELIQUIS STARTER PACK..................................................37ELLA.....................................................................................10ELOCTATE...........................................................................37EMCYT...................................................................................6EMEND................................................................................ 23EMGALITY........................................................................... 33EMPAVELI............................................................................37emtricitabine-tenofovir disoproxil fumarate tab200-300 mg......................................................................... 3emtricitabine-tenofovir disoproxil fumarate tab100-150 mg, 133-200 mg, 167-250 mg.............................3enalapril maleate & hydrochlorothiazide tab 5-12.5mg...................................................................................... 17enalapril maleate & hydrochlorothiazide tab 10-25mg...................................................................................... 17enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg........ 17ENBREL............................................................................... 32ENBREL MINI......................................................................32ENBREL SURECLICK........................................................ 32enoxaparin sodium inj 300 mg/3ml.................................37enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120mg/0.8ml, 150 mg/ml....................................................... 37entacapone tab 200 mg.................................................... 35entecavir tab 0.5 mg, 1 mg................................................ 3ENTRESTO..........................................................................19EPCLUSA...............................................................................3EPIDIOLEX.......................................................................... 34epinephrine solution auto-injector 0.15 mg/0.3ml(1:2000).............................................................................. 18epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000).............................................................................. 18eplerenone tab 25 mg, 50 mg..........................................17ergocalciferol cap 1.25 mg (50000 unit)......................... 35ERIVEDGE.............................................................................6ERLEADA...............................................................................6erlotinib hcl tab 25 mg (base equivalent).........................6erlotinib hcl tab 100 mg (base equivalent), 150 mg(base equivalent)............................................................... 6erythromycin gel 2%......................................................... 42erythromycin ophth oint 5 mg/gm.................................. 39erythromycin soln 2%.......................................................42escitalopram oxalate soln 5 mg/5ml (base equiv).........26escitalopram oxalate tab 5 mg (base equiv), 10 mg(base equiv), 20 mg (base equiv).................................. 26esomeprazole magnesium cap delayed release 20 mg(base eq), 40 mg (base eq).............................................23esomeprazole magnesium for delayed release susppacket 10 mg, 20 mg, 40 mg..........................................23ESPEROCT......................................................................... 37estazolam tab 1 mg, 2 mg................................................28estradiol & norethindrone acetate tab 0.5-0.1 mg, 1-0.5mg........................................................................................ 9estradiol tab 0.5 mg, 1 mg, 2 mg...................................... 9estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm(0.1%), 0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25mg/1.25gm (0.1%)............................................................ 10estradiol td patch twice weekly 0.025 mg/24hr,0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1mg/24hr..............................................................................10estradiol td patch weekly 0.025 mg/24hr, 0.0375mg/24hr (37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr,0.075 mg/24hr, 0.1 mg/24hr............................................ 10estradiol vaginal cream 0.1 mg/gm.................................25estradiol vaginal tab 10 mcg........................................... 25ESTRING............................................................................. 25eszopiclone tab 1 mg, 2 mg, 3 mg..................................28ethambutol hcl tab 100 mg, 400 mg................................. 2ethosuximide cap 250 mg................................................ 34ethosuximide soln 250 mg/5ml........................................34

2023Blue Cross and Blue Shield July 2023 Basic Drug List 51ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg, 1 mg-50 mcg...........................................................10etodolac cap 200 mg, 300 mg..........................................32etodolac tab er 24hr 400 mg, 500 mg, 600 mg...............32etodolac tab 400 mg......................................................... 32etodolac tab 500 mg......................................................... 32ETOPOSIDE.......................................................................... 6etravirine tab 100 mg, 200 mg...........................................3everolimus tab for oral susp 3 mg....................................6everolimus tab for oral susp 2 mg, 5 mg......................... 6everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg................... 6everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg............ 44exemestane tab 25 mg....................................................... 6ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40mg, 10-80 mg....................................................................19ezetimibe tab 10 mg..........................................................19Ffamciclovir tab 125 mg....................................................... 3famciclovir tab 250 mg, 500 mg........................................ 3famotidine for susp 40 mg/5ml........................................23famotidine tab 20 mg, 40 mg........................................... 23FARXIGA..............................................................................11FASENRA PEN....................................................................21FEIBA................................................................................... 37felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg................... 16fenofibrate micronized cap 67 mg, 134 mg, 200 mg..... 19fenofibrate tab 48 mg....................................................... 19fenofibrate tab 54 mg....................................................... 19fenofibrate tab 145 mg..................................................... 19fenofibrate tab 160 mg..................................................... 19fentanyl citrate lozenge on a handle 200 mcg, 400 mcg,600 mcg, 800 mcg, 1200 mcg, 1600 mcg......................31fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,75 mcg/hr, 100 mcg/hr.................................................... 31FIASP................................................................................... 12FIASP FLEXTOUCH........................................................... 12FIASP PENFILL...................................................................13FINACEA..............................................................................42finasteride tab 5 mg.......................................................... 25fingolimod hcl cap 0.5 mg (base equiv)......................... 29flecainide acetate tab 50 mg, 100 mg, 150 mg...............16FLOVENT DISKUS..............................................................21FLOVENT HFA.................................................................... 21fluconazole for susp 10 mg/ml, 40 mg/ml........................ 2fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg............ 2flucytosine cap 250 mg, 500 mg....................................... 2fludrocortisone acetate tab 0.1 mg................................... 9flunisolide nasal soln 25 mcg/act (0.025%)....................20fluocinolone acetonide cream 0.01%..............................42fluocinolone acetonide cream 0.025%............................42fluocinolone acetonide oil 0.01% (body oil)...................42fluocinolone acetonide oil 0.01% (scalp oil).................. 42fluocinolone acetonide oint 0.025%................................42fluocinolone acetonide soln 0.01%................................. 42fluocinonide cream 0.05%................................................ 42fluocinonide cream 0.1%..................................................42fluocinonide gel 0.05%..................................................... 42fluocinonide oint 0.05%....................................................42fluocinonide soln 0.05%................................................... 42fluorometholone ophth susp 0.1%..................................39fluorouracil cream 5%.......................................................42fluoxetine hcl cap 10 mg, 20 mg, 40 mg........................ 26fluoxetine hcl solution 20 mg/5ml...................................26FLUPHENAZINE HCL.........................................................27fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg........... 27FLUPHENAZINE HYDROCHLORID.................................. 27flurbiprofen tab 100 mg....................................................32FLUTICASONE PROPIONATE/SA.....................................21fluticasone propionate cream 0.05%.............................. 42fluticasone propionate nasal susp 50 mcg/act..............20fluticasone propionate oint 0.005%................................ 42fluvoxamine maleate tab 25 mg, 50 mg, 100 mg........... 26folic acid tab 1 mg............................................................ 36FOLLISTIM AQ.................................................................... 14FORTEO.............................................................................. 14fosinopril sodium & hydrochlorothiazide tab 10-12.5mg, 20-12.5 mg.................................................................17fosinopril sodium tab 10 mg, 20 mg, 40 mg.................. 17FULPHILA............................................................................ 36furosemide oral soln 10 mg/ml........................................18furosemide tab 20 mg, 40 mg, 80 mg............................. 18Ggabapentin cap 100 mg, 300 mg, 400 mg.......................34gabapentin oral soln 250 mg/5ml....................................34gabapentin tab 600 mg, 800 mg...................................... 34galantamine hydrobromide cap er 24hr 8 mg, 16 mg,24 mg.................................................................................29galantamine hydrobromide tab 4 mg, 8 mg, 12 mg.......29ganirelix acetate soln prefilled syringe 250mcg/0.5ml..........................................................................14gemfibrozil tab 600 mg.....................................................19GENOTROPIN.....................................................................14GENOTROPIN MINIQUICK................................................ 14gentamicin sulfate cream 0.1%....................................... 42gentamicin sulfate oint 0.1%........................................... 42gentamicin sulfate ophth soln 0.3%............................... 39GENVOYA..............................................................................3glatiramer acetate soln prefilled syringe 20 mg/ml.......29glatiramer acetate soln prefilled syringe 40 mg/ml.......29GLEOSTINE...........................................................................6glimepiride tab 1 mg, 2 mg, 4 mg................................... 11glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg,5-500 mg........................................................................... 11glipizide tab er 24hr 2.5 mg, 5 mg, 10 mg...................... 11glipizide tab 5 mg, 10 mg.................................................11GLUCAGON EMERGENCY KIT FO.................................. 11glucagon (rdna) for inj kit 1 mg...................................... 11glyburide-metformin tab 1.25-250 mg, 2.5-500 mg,5-500 mg........................................................................... 11glyburide micronized tab 1.5 mg, 3 mg, 6 mg............... 11glyburide tab 1.25 mg, 2.5 mg, 5 mg.............................. 11glycopyrrolate tab 1 mg, 2 mg........................................ 23

2023Blue Cross and Blue Shield July 2023 Basic Drug List 52GLYXAMBI........................................................................... 11granisetron hcl tab 1 mg..................................................23griseofulvin microsize susp 125 mg/5ml......................... 2griseofulvin microsize tab 500 mg....................................2guanfacine hcl tab er 24hr 1 mg (base equiv), 2mg (base equiv), 3 mg (base equiv), 4 mg (baseequiv)................................................................................. 28guanfacine hcl tab 1 mg, 2 mg........................................17GVOKE HYPOPEN 1-PACK............................................... 11GVOKE HYPOPEN 2-PACK............................................... 11GVOKE KIT......................................................................... 11GVOKE PFS........................................................................ 11Hhalobetasol propionate cream 0.05%............................. 42haloperidol lactate oral conc 2 mg/ml............................ 27haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20mg...................................................................................... 27HARVONI............................................................................... 3HEMLIBRA...........................................................................38HEMOFIL M.........................................................................38HUMATE-P...........................................................................38HUMULIN R U-500 (CONCENTR...................................... 13HUMULIN R U-500 KWIKPEN........................................... 13hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg........ 17hydrochlorothiazide cap 12.5 mg....................................18hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg........... 18hydrocodone-acetaminophen soln 7.5-325mg/15ml............................................................................. 31hydrocodone-acetaminophen tab 10-325 mg, 5-325mg, 7.5-325 mg.................................................................31hydrocodone-ibuprofen tab 7.5-200 mg......................... 31hydrocortisone acetate suppos 25 mg...........................40hydrocortisone cream 2.5%............................................. 42hydrocortisone enema 100 mg/60ml.............................. 40hydrocortisone lotion 2.5%..............................................42hydrocortisone oint 2.5%................................................. 42hydrocortisone perianal cream 2.5%..............................40hydrocortisone tab 5 mg, 10 mg, 20 mg.......................... 9hydromorphone hcl liqd 1 mg/ml....................................31hydromorphone hcl tab 2 mg, 4 mg, 8 mg.....................31hydroxychloroquine sulfate tab 200 mg.......................... 5hydroxyurea cap 500 mg....................................................6hydroxyzine hcl syrup 10 mg/5ml...................................25hydroxyzine hcl tab 10 mg, 25 mg, 50 mg..................... 25hydroxyzine pamoate cap 25 mg, 50 mg....................... 26Iibandronate sodium tab 150 mg (base equivalent).......14IBRANCE............................................................................... 6ibuprofen susp 100 mg/5ml............................................. 32ibuprofen tab 400 mg, 600 mg, 800 mg.......................... 32icatibant acetate subcutaneous soln pref syr 30mg/3ml............................................................................... 38IDELVION.............................................................................38imatinib mesylate tab 100 mg (base equivalent)............. 6imatinib mesylate tab 400 mg (base equivalent)............. 6IMBRUVICA........................................................................... 6imipramine hcl tab 10 mg, 25 mg, 50 mg....................... 26imiquimod cream 5%........................................................ 42IMPAVIDO.............................................................................. 5INBRIJA................................................................................35INCRELEX........................................................................... 14INCRUSE ELLIPTA............................................................. 21indapamide tab 1.25 mg, 2.5 mg..................................... 18indomethacin cap 25 mg, 50 mg.....................................32INSULIN ASPART............................................................... 13INSULIN ASPART FLEXPEN............................................. 13INSULIN ASPART PENFILL............................................... 13INSULIN ASPART PROTAMINE/........................................13INSULIN GLARGINE...........................................................13INSULIN PEN NEEDLES – VARIOUS............................... 44INSULIN SYRINGES – VARIOUS...................................... 44INTELENCE........................................................................... 3ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml.......21ipratropium bromide inhal soln 0.02%........................... 21ipratropium bromide nasal soln 0.03% (21 mcg/spray).................................................................................20ipratropium bromide nasal soln 0.06% (42 mcg/spray).................................................................................20irbesartan-hydrochlorothiazide tab 150-12.5 mg,300-12.5 mg...................................................................... 17irbesartan tab 75 mg, 150 mg, 300 mg........................... 17ISENTRESS...........................................................................3ISENTRESS HD.................................................................... 3isoniazid tab 300 mg...........................................................2isosorbide dinitrate tab 5 mg.......................................... 15isosorbide dinitrate tab 10 mg, 20 mg, 30 mg............... 15isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120mg...................................................................................... 15isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mg................42itraconazole cap 100 mg.................................................... 2itraconazole oral soln 10 mg/ml........................................ 2ivermectin tab 3 mg............................................................ 5IXINITY.................................................................................38JJANUMET............................................................................ 11JANUMET XR......................................................................11JANUVIA.............................................................................. 12JARDIANCE.........................................................................12JIVI....................................................................................... 38JULUCA................................................................................. 3KKALYDECO.......................................................................... 22KESIMPTA........................................................................... 29ketoconazole cream 2%................................................... 42ketoconazole shampoo 2%.............................................. 42ketorolac tromethamine ophth soln 0.4%...................... 39ketorolac tromethamine ophth soln 0.5%...................... 39KISQALI................................................................................. 6KISQALI FEMARA 200 DOSE..............................................7KISQALI FEMARA 400 DOSE..............................................7

2023Blue Cross and Blue Shield July 2023 Basic Drug List 53KISQALI FEMARA 600 DOSE..............................................7KLOXXADO......................................................................... 43KOATE................................................................................. 38KOATE-DVI.......................................................................... 38KOGENATE FS................................................................... 38KOSHER PRENATAL PLUS IRON.....................................36KOVALTRY...........................................................................38KYNMOBI.............................................................................35Llabetalol hcl tab 100 mg................................................... 15labetalol hcl tab 200 mg, 300 mg.................................... 15lacosamide oral solution 10 mg/ml.................................34lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg...........34lactulose (encephalopathy) solution 10 gm/15ml......... 24lactulose solution 10 gm/15ml.........................................23lamivudine oral soln 10 mg/ml.......................................... 3lamivudine tab 150 mg, 300 mg........................................ 4lamivudine tab 100 mg (hbv)............................................. 4lamivudine-zidovudine tab 150-300 mg............................4lamotrigine tab chewable dispersible 5 mg, 25 mg.......34lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg...........34LANCETS – VARIOUS........................................................44lansoprazole cap delayed release 15 mg, 30 mg.......... 23lapatinib ditosylate tab 250 mg (base equiv)................... 7latanoprost ophth soln 0.005%........................................39LATUDA............................................................................... 27leflunomide tab 10 mg, 20 mg......................................... 32lenalidomide cap 5 mg, 10 mg........................................ 44lenalidomide cap 15 mg, 20 mg, 25 mg..........................44lenalidomide caps 2.5 mg................................................ 44LENVIMA 4 MG DAILY DOSE..............................................7LENVIMA 8 MG DAILY DOSE..............................................7LENVIMA 10 MG DAILY DOSE............................................7LENVIMA 12MG DAILY DOSE.............................................7LENVIMA 14 MG DAILY DOSE............................................7LENVIMA 18 MG DAILY DOSE............................................7LENVIMA 20 MG DAILY DOSE............................................7LENVIMA 24 MG DAILY DOSE............................................7letrozole tab 2.5 mg............................................................ 7leucovorin calcium tab 5 mg, 15 mg, 25 mg.................... 7LEUKERAN............................................................................7leuprolide acetate inj kit 5 mg/ml......................................7levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (baseequiv)................................................................................. 22levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv),0.63 mg/3ml (base equiv), 1.25 mg/3ml (baseequiv)................................................................................. 22LEVEMIR..............................................................................13LEVEMIR FLEXPEN........................................................... 13levetiracetam oral soln 100 mg/ml..................................34levetiracetam tab er 24hr 500 mg, 750 mg..................... 34levetiracetam tab 250 mg, 500 mg, 750 mg, 1000mg...................................................................................... 34levocarnitine oral soln 1 gm/10ml (10%)........................ 14levocarnitine tab 330 mg..................................................14levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)...................................................................................... 20levocetirizine dihydrochloride tab 5 mg.........................20levofloxacin tab 250 mg, 500 mg, 750 mg........................2levonorgestrel & ethinyl estradiol (91-day) tab0.15-0.03 mg..................................................................... 10levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,0.15 mg-30 mcg................................................................10levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg..................................10levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7)...........................................................................10levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7)...........................................................................10levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg,175 mcg, 200 mcg, 300 mcg.......................................... 14lidocaine hcl gel 2%..........................................................42lidocaine hcl soln 4%....................................................... 42lidocaine hcl urethral/mucosal gel prefilled syringe2%.......................................................................................42lidocaine hcl viscous soln 2%.........................................40lidocaine oint 5%...............................................................42lidocaine patch 5%............................................................42lidocaine-prilocaine cream 2.5-2.5%............................... 42linezolid for susp 100 mg/5ml........................................... 5linezolid tab 600 mg............................................................5LINZESS.............................................................................. 24liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg.......... 14lisinopril & hydrochlorothiazide tab 10-12.5 mg,20-12.5 mg, 20-25 mg......................................................17lisinopril tab 2.5 mg, 30 mg, 40 mg................................ 17lisinopril tab 5 mg, 10 mg, 20 mg................................... 17lithium carbonate cap 300 mg......................................... 27lithium carbonate cap 150 mg, 600 mg.......................... 27lithium carbonate tab er 300 mg..................................... 27lithium carbonate tab er 450 mg..................................... 27lithium carbonate tab 300 mg..........................................27LOKELMA............................................................................ 44loperamide hcl cap 2 mg..................................................23lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)........................................................................................ 4lopinavir-ritonavir tab 100-25 mg...................................... 4lopinavir-ritonavir tab 200-50 mg...................................... 4lorazepam conc 2 mg/ml.................................................. 26lorazepam tab 0.5 mg, 1 mg, 2 mg..................................26losartan potassium & hydrochlorothiazide tab 50-12.5mg, 100-12.5 mg, 100-25 mg.......................................... 17losartan potassium tab 25 mg, 50 mg, 100 mg..............17LOTEMAX............................................................................ 39LOTEMAX SM..................................................................... 39loteprednol etabonate ophth susp 0.5%........................ 39lovastatin tab 10 mg......................................................... 19lovastatin tab 20 mg......................................................... 19lovastatin tab 40 mg......................................................... 19loxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mg..... 27LUMIGAN.............................................................................39

2023Blue Cross and Blue Shield July 2023 Basic Drug List 54lurasidone hcl tab 80 mg................................................. 27lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg..........27LYNPARZA.............................................................................7Mmalathion lotion 0.5%....................................................... 42MATULANE............................................................................ 7MAVENCLAD....................................................................... 29MAVYRET.............................................................................. 4MAYZENT............................................................................ 29MAYZENT STARTER PACK............................................... 29meclizine hcl tab 12.5 mg, 25 mg....................................24medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10mg...................................................................................... 11mefloquine hcl tab 250 mg................................................ 5megestrol acetate susp 40 mg/ml..................................... 7megestrol acetate tab 20 mg, 40 mg................................ 7MEKINIST.............................................................................. 7meloxicam tab 7.5 mg, 15 mg..........................................32melphalan tab 2 mg............................................................ 7memantine hcl oral solution 2 mg/ml............................. 29memantine hcl tab 5 mg, 10 mg......................................29memantine hcl tab 28 x 5 mg & 21 x 10 mg titrationpack....................................................................................29mercaptopurine tab 50 mg.................................................7mesalamine cap dr 400 mg..............................................24mesalamine cap er 24hr 0.375 gm.................................. 24mesalamine enema 4 gm................................................. 24mesalamine suppos 1000 mg..........................................24mesalamine tab delayed release 1.2 gm........................ 24mesalamine tab delayed release 800 mg....................... 24MESNEX................................................................................ 7metformin hcl tab er 24hr 500 mg, 750 mg.................... 12metformin hcl tab 500 mg, 850 mg, 1000 mg.................12methadone hcl conc 10 mg/ml........................................ 31methadone hcl soln 5 mg/5ml, 10 mg/5ml..................... 31methadone hcl tab for oral susp 40 mg......................... 31methadone hcl tab 5 mg.................................................. 31methadone hcl tab 10 mg................................................ 31methazolamide tab 25 mg, 50 mg................................... 18methimazole tab 5 mg, 10 mg......................................... 14methocarbamol tab 500 mg............................................. 35methocarbamol tab 750 mg............................................. 35methotrexate sodium for inj 1 gm.....................................7methotrexate sodium inj 50 mg/2ml (25 mg/ml).............. 7methotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250mg/10ml (25 mg/ml), 1000 mg/40ml (25 mg/ml)............. 7methotrexate sodium tab 2.5 mg (base equiv)................ 7methscopolamine bromide tab 2.5 mg, 5 mg................ 23methylergonovine maleate tab 0.2 mg........................... 14methylphenidate hcl tab er 10 mg, 20 mg......................28methylphenidate hcl tab er osmotic release (osm) 36mg...................................................................................... 28methylphenidate hcl tab er osmotic release (osm) 18mg, 27 mg, 54 mg............................................................28methylphenidate hcl tab 5 mg, 10 mg, 20 mg................28methylprednisolone tab 4 mg, 8 mg, 16 mg, 32 mg........ 9methylprednisolone tab therapy pack 4 mg (21).............9metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv)................................................................................. 24metoclopramide hcl tab 5 mg (base equivalent), 10 mg(base equivalent)............................................................. 24metolazone tab 2.5 mg, 5 mg, 10 mg..............................18metoprolol & hydrochlorothiazide tab 50-25 mg...........17metoprolol & hydrochlorothiazide tab 100-25 mg,100-50 mg......................................................................... 17metoprolol succinate tab er 24hr 25 mg (tartrateequiv), 50 mg (tartrate equiv), 100 mg (tartrate equiv),200 mg (tartrate equiv)................................................... 15metoprolol tartrate tab 25 mg..........................................15metoprolol tartrate tab 50 mg, 100 mg........................... 15metronidazole cream 0.75%.............................................42metronidazole gel 0.75%.................................................. 43metronidazole gel 1%....................................................... 43metronidazole tab 250 mg, 500 mg...................................5metronidazole vaginal gel 0.75%.................................... 25mexiletine hcl cap 150 mg, 200 mg, 250 mg.................. 16midodrine hcl tab 2.5 mg, 5 mg, 10 mg..........................18minocycline hcl cap 50 mg................................................ 2minocycline hcl cap 75 mg, 100 mg................................. 2minoxidil tab 2.5 mg, 10 mg............................................ 17mirtazapine tab 7.5 mg..................................................... 26mirtazapine tab 15 mg, 30 mg, 45 mg............................ 26misoprostol tab 100 mcg, 200 mcg.................................23modafinil tab 100 mg........................................................ 28modafinil tab 200 mg........................................................ 29moexipril hcl tab 7.5 mg, 15 mg......................................17mometasone furoate cream 0.1%................................... 43mometasone furoate nasal susp 50 mcg/act.................20mometasone furoate oint 0.1%........................................43mometasone furoate solution 0.1% (lotion)...................43montelukast sodium chew tab 4 mg (base equiv), 5 mg(base equiv)...................................................................... 22montelukast sodium oral granules packet 4 mg (baseequiv)................................................................................. 22montelukast sodium tab 10 mg (base equiv).................22morphine sulfate oral soln 10 mg/5ml, 100 mg/5ml (20mg/ml)................................................................................31morphine sulfate tab er 15 mg, 30 mg, 60 mg, 100 mg,200 mg...............................................................................31morphine sulfate tab 15 mg, 30 mg................................ 31MOUNJARO.........................................................................12MOVANTIK...........................................................................24moxifloxacin hcl ophth soln 0.5% (base equiv).............39MULTAQ...............................................................................16mupirocin oint 2%............................................................. 43mycophenolate mofetil cap 250 mg................................44mycophenolate mofetil for oral susp 200 mg/ml...........44mycophenolate mofetil tab 500 mg................................ 44mycophenolate sodium tab dr 180 mg (mycophenolicacid equiv), 360 mg (mycophenolic acid equiv).......... 44MYFEMBREE...................................................................... 10MYLERAN..............................................................................8

2023Blue Cross and Blue Shield July 2023 Basic Drug List 55Nnabumetone tab 500 mg, 750 mg....................................32nadolol tab 20 mg, 40 mg, 80 mg....................................15naloxone hcl inj 0.4 mg/ml, 4 mg/10ml........................... 43naloxone hcl nasal spray 4 mg/0.1ml............................. 43naltrexone hcl tab 50 mg................................................. 44naproxen sodium tab 275 mg, 550 mg........................... 32naproxen tab 250 mg, 375 mg, 500 mg.......................... 32naratriptan hcl tab 1 mg (base equiv), 2.5 mg (baseequiv)................................................................................. 33NATACYN.............................................................................39nateglinide tab 60 mg, 120 mg........................................ 12neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin.................................. 39neomycin-polymyxin-dexamethasone ophth oint0.1%....................................................................................39neomycin-polymyxin-dexamethasone ophth susp0.1%....................................................................................39neomycin-polymyxin-hc otic soln 1%............................ 40neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%......................................................................... 40neomycin sulfate tab 500 mg............................................ 2nevirapine tab er 24hr 400 mg...........................................4nevirapine tab 200 mg........................................................ 4NEXIUM............................................................................... 23NEXLETOL.......................................................................... 19NEXLIZET............................................................................ 19niacin tab er 1000 mg (antihyperlipidemic)....................19niacin tab er 500 mg (antihyperlipidemic), 750 mg(antihyperlipidemic).........................................................19NICOTROL INHALER......................................................... 30NICOTROL NS.................................................................... 30nifedipine tab er 24hr 30 mg, 60 mg, 90 mg.................. 16nifedipine tab er 24hr osmotic release 30 mg, 60 mg,90 mg.................................................................................16nilutamide tab 150 mg........................................................ 8nimodipine cap 30 mg...................................................... 16nitazoxanide tab 500 mg.................................................... 5nitisinone cap 2 mg, 5 mg, 10 mg...................................14nitrofurantoin macrocrystalline cap 25 mg, 50 mg, 100mg........................................................................................ 5nitrofurantoin monohydrate macrocrystalline cap 100mg........................................................................................ 5nitrofurantoin susp 25 mg/5ml.......................................... 5nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg....................15nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr...............................................................15NITYR...................................................................................14NIVESTYM...........................................................................36NORDITROPIN FLEXPRO................................................. 15norelgestromin-ethinyl estradiol td ptwk 150-35mcg/24hr........................................................................... 10norethindrone & ethinyl estradiol-fe chew tab 0.4mg-35 mcg........................................................................ 10norethindrone & ethinyl estradiol tab 1 mg-35 mcg..... 10norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,0.5 mg-35 mcg..................................................................10norethindrone ace & ethinyl estradiol-fe tab 1 mg-20mcg.................................................................................... 10norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30mcg.................................................................................... 10norethindrone ace & ethinyl estradiol tab 1 mg-20mcg.................................................................................... 10norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg.................................................................................... 10norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg.................................................................................... 10norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg.................................................................................... 10norethindrone acetate tab 5 mg...................................... 11norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35mg-mcg..............................................................................10norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg.................................................................................... 11norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg.................................................................................... 11Norethindrone tab 0.35 mg.............................................. 11norgestimate & ethinyl estradiol tab 0.25 mg-35mcg.................................................................................... 11norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg..............................................................................11norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg..............................................................................11norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg......... 11nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg........ 26NORVIR................................................................................. 4NOVOEIGHT........................................................................38NOVOLIN 70/30.................................................................. 13NOVOLIN 70/30 FLEXPEN................................................ 13NOVOLIN N......................................................................... 13NOVOLIN N FLEXPEN....................................................... 13NOVOLIN R......................................................................... 13NOVOLIN R FLEXPEN....................................................... 13NOVOLOG........................................................................... 13NOVOLOG FLEXPEN.........................................................13NOVOLOG MIX 70/30.........................................................13NOVOLOG MIX 70/30 PREFILL.........................................13NOVOLOG PENFILL...........................................................13NOVOSEVEN RT................................................................ 38NOXAFIL................................................................................ 2NUBEQA................................................................................ 8NUCALA...............................................................................22NURTEC.............................................................................. 33NUVARING.......................................................................... 11NUWIQ................................................................................. 38nystatin cream 100000 unit/gm....................................... 43nystatin oint 100000 unit/gm........................................... 43nystatin susp 100000 unit/ml...........................................40nystatin tab 500000 unit..................................................... 2nystatin topical powder 100000 unit/gm........................ 43nystatin-triamcinolone cream 100000-0.1 unit/gm-%.........................................................................................43

2023Blue Cross and Blue Shield July 2023 Basic Drug List 56nystatin-triamcinolone oint 100000-0.1 unit/gm-%........43Ooctreotide acetate inj 200 mcg/ml (0.2 mg/ml), 1000mcg/ml (1 mg/ml).............................................................15octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100mcg/ml (0.1 mg/ml), 500 mcg/ml (0.5 mg/ml)............... 15ODEFSEY.............................................................................. 4ofloxacin ophth soln 0.3%............................................... 39ofloxacin otic soln 0.3%................................................... 40ofloxacin tab 400 mg.......................................................... 2olanzapine orally disintegrating tab 5 mg, 10 mg, 15mg, 20 mg.........................................................................27olanzapine tab 15 mg, 20 mg...........................................27olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg................. 27olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg, 40-12.5 mg, 40-25 mg.................................17olmesartan medoxomil tab 5 mg, 20 mg, 40 mg........... 17omeprazole cap delayed release 10 mg, 20 mg, 40mg...................................................................................... 23ondansetron hcl oral soln 4 mg/5ml...............................24ondansetron hcl tab 4 mg, 8 mg..................................... 24ondansetron orally disintegrating tab 4 mg, 8 mg........ 24OPSUMIT.............................................................................19ORFADIN............................................................................. 15ORIAHNN.............................................................................10ORILISSA.............................................................................15orphenadrine citrate tab er 12hr 100 mg........................35oseltamivir phosphate cap 30 mg (base equiv)...............4oseltamivir phosphate cap 45 mg (base equiv), 75 mg(base equiv)........................................................................ 4oseltamivir phosphate for susp 6 mg/ml (baseequiv)................................................................................... 4OTEZLA............................................................................... 32oxaprozin tab 600 mg....................................................... 32oxcarbazepine susp 300 mg/5ml (60 mg/ml)................. 34oxcarbazepine tab 150 mg, 300 mg, 600 mg..................34oxybutynin chloride syrup 5 mg/5ml.............................. 25oxybutynin chloride tab er 24hr 15 mg.......................... 25oxybutynin chloride tab er 24hr 5 mg, 10 mg................25oxybutynin chloride tab 5 mg..........................................25oxycodone hcl conc 100 mg/5ml (20 mg/ml)................. 31oxycodone hcl soln 5 mg/5ml......................................... 31oxycodone hcl tab 10 mg, 20 mg....................................31oxycodone hcl tab 5 mg, 15 mg, 30 mg......................... 31oxycodone w/ acetaminophen tab 5-325 mg, 7.5-325mg, 10-325 mg..................................................................31OZEMPIC.............................................................................12Ppantoprazole sodium ec tab 20 mg (base equiv), 40 mg(base equiv)...................................................................... 23paromomycin sulfate cap 250 mg.....................................2paroxetine hcl tab er 24hr 12.5 mg, 25 mg, 37.5 mg..... 26paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg............26PEGASYS.............................................................................. 4peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236gm...................................................................................... 23peg 3350-kcl-sod bicarb-nacl for soln 420 gm.............. 23penicillamine tab 250 mg................................................. 44penicillin v potassium tab 250 mg, 500 mg..................... 1pentamidine isethionate for nebulization soln 300mg........................................................................................ 5pentoxifylline tab er 400 mg............................................ 38perindopril erbumine tab 2 mg........................................18perindopril erbumine tab 4 mg........................................18permethrin cream 5%........................................................43perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg...................27phenobarbital elixir 20 mg/5ml........................................ 28phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60mg, 100 mg.......................................................................28phenoxybenzamine hcl cap 10 mg................................. 18phenytoin chew tab 50 mg...............................................34phenytoin sodium extended cap 100 mg....................... 34phenytoin sodium extended cap 200 mg, 300 mg.........34phenytoin susp 125 mg/5ml.............................................34phytonadione tab 5 mg.................................................... 35pilocarpine hcl ophth soln 1%, 2%, 4%..........................39pilocarpine hcl tab 5 mg, 7.5 mg.....................................40pindolol tab 5 mg, 10 mg................................................. 15pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850mg...................................................................................... 12pioglitazone hcl tab 15 mg (base equiv), 30 mg (baseequiv), 45 mg (base equiv).............................................12PIQRAY 200MG DAILY DOSE............................................. 8PIQRAY 250MG DAILY DOSE............................................. 8PIQRAY 300MG DAILY DOSE............................................. 8piroxicam cap 10 mg, 20 mg........................................... 32PLEGRIDY........................................................................... 30PLEGRIDY STARTER PACK..............................................30podofilox soln 0.5%.......................................................... 43polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%.............................................................................. 39posaconazole susp 40 mg/ml............................................ 2posaconazole tab delayed release 100 mg......................2potassium chloride cap er 8 meq, 10 meq.....................36potassium chloride microencapsulated crys er tab 10meq, 20 meq.....................................................................36potassium chloride oral soln 10% (20 meq/15ml), 20%(40 meq/15ml)................................................................... 36potassium chloride powder packet 20 meq...................36potassium chloride tab er 10 meq.................................. 36potassium chloride tab er 8 meq (600 mg).................... 36potassium citrate tab er 5 meq (540 mg)....................... 25potassium citrate tab er 10 meq (1080 mg)................... 25potassium citrate tab er 15 meq (1620 mg)................... 25potassium phosphate monobasic tab 500 mg.............. 36pot phos monobasic w/sod phos di & monobas tab155-852-130mg................................................................. 36pramipexole dihydrochloride tab 0.125 mg, 0.25 mg,0.5 mg, 0.75 mg, 1 mg, 1.5 mg.......................................35prasugrel hcl tab 5 mg (base equiv), 10 mg (baseequiv)................................................................................. 38

2023Blue Cross and Blue Shield July 2023 Basic Drug List 57pravastatin sodium tab 10 mg.........................................19pravastatin sodium tab 20 mg, 40 mg, 80 mg................19praziquantel tab 600 mg.....................................................5prazosin hcl cap 1 mg, 2 mg, 5 mg................................ 18PREDNISOLONE ACETATE...............................................40PREDNISOLONE SODIUM PHOSP.................................. 40prednisolone sod phosphate oral soln 15 mg/5ml(base equiv)........................................................................ 9prednisolone sod phosph oral soln 6.7 mg/5ml (5mg/5ml base)...................................................................... 9PREDNISONE....................................................................... 9prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50mg........................................................................................ 9prednisone tab therapy pack 5 mg (21), 5 mg (48), 10mg (21), 10 mg (48)........................................................... 9pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg,200 mg, 225 mg, 300 mg................................................ 34pregabalin soln 20 mg/ml.................................................34PREMARIN.......................................................................... 10PREMPHASE.......................................................................10PREMPRO........................................................................... 10PRENATAL 19..................................................................... 36PREZISTA.............................................................................. 4PRIFTIN................................................................................. 2primaquine phosphate tab 26.3 mg (15 mg base)...........5primidone tab 50 mg, 250 mg..........................................34probenecid tab 500 mg.....................................................33prochlorperazine maleate tab 5 mg (base equivalent),10 mg (base equivalent)................................................. 27prochlorperazine suppos 25 mg..................................... 27PROCRIT............................................................................. 36PROFILNINE........................................................................38progesterone cap 100 mg, 200 mg................................. 11promethazine hcl suppos 12.5 mg, 25 mg..................... 20promethazine hcl syrup 6.25 mg/5ml............................. 20promethazine hcl tab 12.5 mg, 25 mg, 50 mg................ 20propafenone hcl cap er 12hr 225 mg, 325 mg, 425mg...................................................................................... 16propafenone hcl tab 150 mg, 225 mg, 300 mg...............16PROPRANOLOL HCL.........................................................16propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg, 160mg...................................................................................... 16propranolol hcl oral soln 20 mg/5ml...............................16propranolol hcl tab 10 mg, 20 mg, 40 mg, 60 mg, 80mg...................................................................................... 16propylthiouracil tab 50 mg...............................................14PULMOZYME...................................................................... 22PURIXAN............................................................................... 8pyrazinamide tab 500 mg................................................... 2pyridostigmine bromide tab 60 mg.................................35pyrimethamine tab 25 mg.................................................. 5Qquetiapine fumarate tab er 24hr 150 mg, 200 mg..........27quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400mg...................................................................................... 27quetiapine fumarate tab 100 mg......................................27quetiapine fumarate tab 200 mg......................................27quetiapine fumarate tab 25 mg, 50 mg...........................27quetiapine fumarate tab 300 mg, 400 mg....................... 27quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg.................18quinidine gluconate tab er 324 mg................................. 16QULIPTA.............................................................................. 33QVAR REDIHALER............................................................. 22Rraloxifene hcl tab 60 mg...................................................15ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg.................... 18RAPAMUNE......................................................................... 44rasagiline mesylate tab 0.5 mg (base equiv), 1 mg(base equiv)...................................................................... 35REBIF...................................................................................30REBIF REBIDOSE.............................................................. 30REBIF REBIDOSE TITRATION.......................................... 30REBIF TITRATION PACK................................................... 30REBINYN............................................................................. 38RECOMBINATE................................................................... 38REDITREX........................................................................... 32repaglinide tab 0.5 mg......................................................12repaglinide tab 1 mg, 2 mg.............................................. 12REPATHA.............................................................................19REPATHA PUSHTRONEX SYSTEM..................................19REPATHA SURECLICK...................................................... 19RETACRIT............................................................................36RETEVMO..............................................................................8REVCOVI............................................................................. 15REVLIMID............................................................................ 44REYVOW............................................................................. 33rifabutin cap 150 mg...........................................................2rifampin cap 150 mg, 300 mg............................................ 2riluzole tab 50 mg..............................................................35RINVOQ............................................................................... 32risedronate sodium tab 35 mg........................................ 15risedronate sodium tab 150 mg...................................... 15risedronate sodium tab 5 mg, 30 mg..............................15risperidone orally disintegrating tab 4 mg.....................27risperidone orally disintegrating tab 0.5 mg, 1 mg, 2mg, 3 mg...........................................................................27risperidone soln 1 mg/ml................................................. 27risperidone tab 3 mg........................................................ 28risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg...... 27ritonavir tab 100 mg............................................................4rivastigmine tartrate cap 1.5 mg (base equivalent), 3mg (base equivalent), 4.5 mg (base equivalent), 6 mg(base equivalent)............................................................. 30RIXUBIS............................................................................... 38rizatriptan benzoate oral disintegrating tab 5 mg (baseeq)...................................................................................... 33rizatriptan benzoate oral disintegrating tab 10 mg(base eq)........................................................................... 33rizatriptan benzoate tab 5 mg (base equivalent)........... 33rizatriptan benzoate tab 10 mg (base equivalent)......... 33ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2mg, 3 mg, 4 mg, 5 mg.....................................................35

2023Blue Cross and Blue Shield July 2023 Basic Drug List 58rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40mg...................................................................................... 19ROZLYTREK.......................................................................... 8rufinamide tab 200 mg, 400 mg.......................................34RYBELSUS.......................................................................... 12RYDAPT.................................................................................8SSAVELLA..............................................................................30SAVELLA TITRATION PACK.............................................. 30scopolamine td patch 72hr 1 mg/3days......................... 24selegiline hcl cap 5 mg.................................................... 35selegiline hcl tab 5 mg..................................................... 35selenium sulfide lotion 2.5%............................................43SEMGLEE............................................................................13SE-NATAL 19.......................................................................36SEREVENT DISKUS...........................................................22sertraline hcl oral concentrate for solution 20 mg/ml........................................................................................26sertraline hcl tab 25 mg, 50 mg, 100 mg........................ 26sevelamer carbonate packet 0.8 gm, 2.4 gm................. 24sevelamer carbonate tab 800 mg.................................... 24sildenafil citrate tab 20 mg.............................................. 19silver sulfadiazine cream 1%...........................................43SIMBRINZA..........................................................................40SIMPONI.............................................................................. 32simvastatin tab 5 mg, 10 mg, 20 mg, 40 mg, 80 mg...... 19sirolimus oral soln 1 mg/ml............................................. 44sirolimus tab 0.5 mg, 1 mg, 2 mg................................... 44SKYRIZI............................................................................... 24SKYRIZI PEN...................................................................... 43sodium chloride soln nebu 3%........................................20sodium chloride soln nebu 7%........................................20sodium citrate & citric acid soln 500-334 mg/5ml......... 25sodium fluoride chew tab 0.25 mg f (from 0.55 mgnaf), 0.5 mg f (from 1.1 mg naf), 1 mg f (from 2.2 mgnaf)..................................................................................... 36sodium fluoride cream 1.1%............................................ 40sodium fluoride gel 1.1% (0.5% f)................................... 40sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf)..................................................................................... 36sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/mlnaf)..................................................................................... 36sodium polystyrene sulfonate powder...........................44solifenacin succinate tab 5 mg, 10 mg...........................25SOLIQUA 100/33.................................................................12SOOLANTRA....................................................................... 43sorafenib tosylate tab 200 mg (base equivalent)............ 8sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg............16sotalol hcl tab 240 mg...................................................... 16sotalol hcl tab 80 mg, 120 mg, 160 mg...........................16SOVALDI................................................................................ 4SPIRIVA HANDIHALER...................................................... 22SPIRIVA RESPIMAT........................................................... 22spironolactone & hydrochlorothiazide tab 25-25mg...................................................................................... 18spironolactone tab 25 mg, 50 mg, 100 mg.....................18SPRYCEL...............................................................................8STELARA.............................................................................43STIOLTO RESPIMAT.......................................................... 22STRENSIQ...........................................................................15STRIVERDI RESPIMAT...................................................... 22sucralfate tab 1 gm........................................................... 23sulfacetamide sodium lotion 10% (acne)....................... 43sulfacetamide sodium ophth soln 10%.......................... 40sulfamethoxazole-trimethoprim susp 200-40mg/5ml................................................................................. 5sulfamethoxazole-trimethoprim tab 400-80 mg...............5sulfamethoxazole-trimethoprim tab 800-160 mg.............5sulfasalazine tab delayed release 500 mg..................... 24sulfasalazine tab 500 mg..................................................24sulindac tab 150 mg, 200 mg...........................................32sumatriptan nasal spray 5 mg/act, 20 mg/act................33sumatriptan succinate inj 6 mg/0.5ml............................ 33sumatriptan succinate solution auto-injector 4mg/0.5ml, 6 mg/0.5ml...................................................... 33sumatriptan succinate tab 25 mg, 50 mg, 100 mg.........33sunitinib malate cap 12.5 mg (base equivalent).............. 8sunitinib malate cap 25 mg (base equivalent), 37.5 mg(base equivalent), 50 mg (base equivalent)................... 8SUNOSI................................................................................29SUPREP BOWEL PREP KIT..............................................23SYMBICORT........................................................................22SYMDEKO........................................................................... 22SYMJEPI..............................................................................18SYMPROIC.......................................................................... 24SYMTUZA.............................................................................. 4SYNJARDY.......................................................................... 12SYNJARDY XR................................................................... 12TTABLOID................................................................................ 8TABRECTA.............................................................................8tacrolimus cap 0.5 mg, 1 mg, 5 mg................................ 44tacrolimus oint 0.03%, 0.1%.............................................43tadalafil tab 2.5 mg, 5 mg............................................20,20tadalafil tab 10 mg, 20 mg...........................................20,20tadalafil tab 20 mg (pah).................................................. 20TAFINLAR.............................................................................. 8TAGRISSO............................................................................. 8TAKHZYRO.......................................................................... 38TALZENNA.............................................................................8tamoxifen citrate tab 10 mg (base equivalent), 20 mg(base equivalent)............................................................... 8tamsulosin hcl cap 0.4 mg...............................................25TASIGNA................................................................................8tazarotene cream 0.1%..................................................... 43tazarotene gel 0.05%, 0.1%.............................................. 43TAZORAC............................................................................ 43telmisartan tab 20 mg, 40 mg, 80 mg............................. 18temazepam cap 15 mg, 30 mg.........................................28temozolomide cap 5 mg, 20 mg, 100 mg, 140 mg, 180mg, 250 mg.........................................................................8tenofovir disoproxil fumarate tab 300 mg........................4

2023Blue Cross and Blue Shield July 2023 Basic Drug List 59terazosin hcl cap 1 mg (base equivalent), 2 mg (baseequivalent), 5 mg (base equivalent), 10 mg (baseequivalent)........................................................................ 18terbinafine hcl tab 250 mg................................................. 2terbutaline sulfate tab 2.5 mg, 5 mg............................... 22terconazole vaginal cream 0.4%, 0.8%........................... 25terconazole vaginal suppos 80 mg.................................25teriflunomide tab 7 mg, 14 mg........................................ 30testosterone cypionate im inj in oil 100 mg/ml............... 9testosterone cypionate im inj in oil 200 mg/ml............... 9testosterone td gel 12.5 mg/act (1%)................................9testosterone td gel 20.25 mg/act (1.62%)......................... 9testosterone td gel 25 mg/2.5gm (1%), 50 mg/5gm(1%)...................................................................................... 9testosterone td soln 30 mg/act..........................................9TEST STRIPS – CONTOUR, CONTOUR NEXT............... 44tetrabenazine tab 12.5 mg................................................30tetrabenazine tab 25 mg...................................................30tetracycline hcl cap 250 mg, 500 mg................................ 2THALOMID...........................................................................44theophylline tab er 12hr 300 mg, 450 mg.......................22theophylline tab er 24hr 400 mg, 600 mg.......................22thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg...................... 28timolol maleate ophth soln 0.25%, 0.5%........................ 40TIVICAY..................................................................................4TIVICAY PD........................................................................... 4tizanidine hcl tab 2 mg (base equivalent)...................... 35tizanidine hcl tab 4 mg (base equivalent)...................... 35tobramycin-dexamethasone ophth susp 0.3-0.1%........40tobramycin nebu soln 300 mg/5ml....................................2tobramycin ophth soln 0.3%............................................40tolterodine tartrate cap er 24hr 2 mg, 4 mg................... 25tolterodine tartrate tab 1 mg, 2 mg................................. 25topiramate sprinkle cap 15 mg, 25 mg........................... 34topiramate tab 25 mg, 50 mg, 100 mg, 200 mg..............34toremifene citrate tab 60 mg (base equivalent)............... 8torsemide tab 5 mg, 10 mg, 20 mg, 100 mg...................18TOUJEO MAX SOLOSTAR................................................ 13TOUJEO SOLOSTAR..........................................................13TRACLEER.......................................................................... 20tramadol-acetaminophen tab 37.5-325 mg.....................31tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg........ 31tramadol hcl tab 50 mg.................................................... 31trandolapril tab 1 mg, 2 mg, 4 mg...................................18tranylcypromine sulfate tab 10 mg................................. 26trazodone hcl tab 50 mg, 100 mg, 150 mg..................... 26TRELEGY ELLIPTA.............................................................22TREMFYA............................................................................ 43TRESIBA.............................................................................. 13TRESIBA FLEXTOUCH...................................................... 13tretinoin cap 10 mg............................................................. 8tretinoin cream 0.025%, 0.05%, 0.1%..............................43tretinoin gel 0.01%............................................................ 43TRETTEN.............................................................................38triamcinolone acetonide cream 0.025%, 0.1%, 0.5%.....43triamcinolone acetonide dental paste 0.1%...................40triamcinolone acetonide lotion 0.025%, 0.1%................43triamcinolone acetonide oint 0.025%, 0.1%, 0.5%.........43triamterene & hydrochlorothiazide cap 37.5-25 mg...... 18triamterene & hydrochlorothiazide tab 37.5-25 mg.......18triamterene & hydrochlorothiazide tab 75-50 mg..........18trifluoperazine hcl tab 1 mg (base equivalent), 2 mg(base equivalent), 5 mg (base equivalent), 10 mg(base equivalent)............................................................. 28TRIFLURIDINE.................................................................... 40trihexyphenidyl hcl tab 2 mg, 5 mg................................ 35TRIJARDY XR..................................................................... 12TRIKAFTA............................................................................ 23trimethobenzamide hcl cap 300 mg................................24trimethoprim tab 100 mg....................................................5TRIUMEQ...............................................................................4TRIUMEQ PD........................................................................ 4tropicamide ophth soln 0.5%...........................................40tropicamide ophth soln 1%..............................................40TRULANCE..........................................................................24TRULICITY...........................................................................12TYMLOS...............................................................................15UUBRELVY.............................................................................33UPTRAVI.............................................................................. 20UPTRAVI TITRATION PACK.............................................. 20ursodiol cap 300 mg......................................................... 24ursodiol tab 250 mg.......................................................... 24ursodiol tab 500 mg.......................................................... 25Vvalacyclovir hcl tab 500 mg, 1 gm.................................... 4VALCHLOR.......................................................................... 43valganciclovir hcl for soln 50 mg/ml (base equiv).......... 4valganciclovir hcl tab 450 mg (base equivalent)............. 4valproate sodium oral soln 250 mg/5ml (baseequiv)................................................................................. 34valproic acid cap 250 mg................................................. 34valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5mg, 160-25 mg, 320-12.5 mg, 320-25 mg...................... 18valsartan tab 40 mg, 80 mg, 160 mg, 320 mg................ 18vancomycin hcl cap 125 mg (base equivalent)............... 5vancomycin hcl cap 250 mg (base equivalent)............... 5VARENICLINE STARTING MONT......................................30varenicline tartrate tab 0.5 mg (base equiv), 1 mg (baseequiv)................................................................................. 30VELPHORO......................................................................... 25VELTASSA........................................................................... 45VEMLIDY................................................................................4VENCLEXTA.......................................................................... 8VENCLEXTA STARTING PACK........................................... 8venlafaxine hcl cap er 24hr 37.5 mg (baseequivalent), 75 mg (base equivalent), 150 mg (baseequivalent)........................................................................ 26venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg(base equivalent), 50 mg (base equivalent), 75 mg(base equivalent), 100 mg (base equivalent)............... 26VENTOLIN HFA...................................................................22

2023Blue Cross and Blue Shield July 2023 Basic Drug List 60verapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg...... 16verapamil hcl tab er 120 mg, 180 mg, 240 mg............... 16verapamil hcl tab 40 mg...................................................16verapamil hcl tab 80 mg, 120 mg.................................... 16VERQUVO........................................................................... 20VERZENIO.............................................................................8VIBERZI............................................................................... 25VICTOZA..............................................................................12vigabatrin powd pack 500 mg......................................... 34vigabatrin tab 500 mg.......................................................34VIREAD.................................................................................. 4VITRAKVI............................................................................... 8VONVENDI.......................................................................... 39voriconazole for susp 40 mg/ml........................................2voriconazole tab 50 mg, 200 mg....................................... 2VOSEVI.................................................................................. 4VOTRIENT............................................................................. 9VYNDAMAX......................................................................... 20VYNDAQEL..........................................................................20VYVANSE.............................................................................29Wwarfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5mg, 6 mg, 7.5 mg, 10 mg................................................37WILATE................................................................................ 39XXALKORI................................................................................9XARELTO.............................................................................37XARELTO STARTER PACK................................................37XELJANZ..............................................................................32XELJANZ XR....................................................................... 32XIFAXAN................................................................................ 5XIGDUO XR.........................................................................12XOLAIR................................................................................ 22XTAMPZA ER...................................................................... 31XTANDI...................................................................................9XULTOPHY 100/3.6............................................................ 12XYNTHA...............................................................................39XYNTHA SOLOFUSE......................................................... 39YYONSA...................................................................................9Zzafirlukast tab 10 mg, 20 mg........................................... 22zaleplon cap 5 mg, 10 mg................................................ 28ZARXIO................................................................................ 36ZEGALOGUE.......................................................................12ZEJULA.................................................................................. 9ZELBORAF............................................................................ 9ZENPEP............................................................................... 24ZEPOSIA..............................................................................30ZEPOSIA 7-DAY STARTER PAC....................................... 30ZEPOSIA STARTER KIT.................................................... 30zidovudine cap 100 mg...................................................... 5zidovudine syrup 10 mg/ml................................................5zidovudine tab 300 mg....................................................... 5ZIEXTENZO......................................................................... 36ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg......... 28ZOKINVY..............................................................................45zolpidem tartrate tab er 6.25 mg, 12.5 mg......................28zolpidem tartrate tab 5 mg, 10 mg.................................. 28zonisamide cap 50 mg......................................................34zonisamide cap 25 mg, 100 mg.......................................34ZYLET.................................................................................. 40