BCBSTX Small Group Drug List : simplebooklet.com

Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicine 41722-W TX HIM © Prime Therapeutics LLC 03/23 Health Insurance Marketplace 6 Tier Drug List March 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. Please visit bcbstx.com or myprime.com for the most up-to-date information. To find a contracting pharmacy, please access the link below: https://www.myprime.com/en/find-pharmacy.html Contents Summary of Drug List Benefits ..................................... I Introduction ................................................................ IX How drugs are selected ............................................. IX How member payment is determined ........................ IX How to use this list ...................................................... X Drugs used to treat multiple conditions ....................... X Generic drugs ............................................................. X Consider talking to your doctor about generic drugs ....................................................................... X Coverage considerations ........................................... XI Specialty drugs ........................................................ XIII Accredo .................................................................... XIII Abbreviation key ...................................................... XIV Therapeutic Class Drug List Anti-Infective Agents .................................................... 1 Biologicals .................................................................... 8 Antineoplastic Agents................................................. 11 Endocrine and Metabolic Drugs ................................. 16 Cardiovascular Agents ..................................................... 26 Respiratory Agents..................................................... 33 Gastrointestinal Agents .............................................. 36 Genitourinary Agents ........................................................ 39 Central Nervous System Drugs ...................................... 40 Analgesics and Anesthetics ............................................ 47 Neuromuscular Drugs....................................................... 52 Nutritional Products ................................................... 56 Hematological Agents ................................................ 75 Topical Products......................................................... 80 Miscellaneous Products ............................................. 86 Index .......................................................................... 90 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.

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Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicine BCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 VI Drugs by Cost-Sharing Tier: Tier Percentage of Drugs ACA 2.7% Tier 1 15.8% Tier 2 27.4% Tier 3 8.3% Tier 4 27.6% Tier 5 Tier 6 13.3% 4.9% Drug List Composition: This drug list (also known as a formulary) is a closed drug list; a closed drug list is a type of benefit design in which only medicines included on the drug list are covered. You may be able to get a medicine that is not on the drug list. But, you may have to pay 100% of the cost, unless a coverage exception is submitted and your health plan approves it. The drug list is designed to provide you and your physician with the most safe, effective drugs at the most reasonable cost. The drug list is developed by a Pharmacy and Therapeutics (P&T) committee. The P&T committee is made up of a diverse group of doctors and pharmacists. When adding or removing drugs from the drug list, the P&T committee reviews each drug for its safety, effectiveness, and uniqueness. Health plans use the drug list to provide their members with effective drug therapies at reasonable costs. For this reason, using drugs from a drug list is important for both you and your health plan. Often, many drugs are available to treat the same condition. If two drugs are equivalent in effectiveness and safety, the drug list will include the lower cost drug. You are not limited to purchasing only those drugs that appear on your health plan's drug list. However, you may pay more out-of-pocket for a drug that is not on the drug list. You may need to pay the full cost of a drug if it is not covered by your benefit plan. Changes in a drug list result from decisions made at P&T committee meetings. The Prime P&T committee meets at least quarterly to consider changes to the drug list. For example, if a new drug is found to be more effective than one already on the drug list, the new drug may replace the less effective drug. A drug may also be removed from a drug list for safety reasons. The Food and Drug Administration (FDA) tracks drug safety information. The FDA issues reports about side effects, warnings or contraindications. Prime monitors these reports because they may trigger a change in a drug list. Right to Request a Coverage Determination: If a drug is not covered under the drug list or requires utilization review prior to coverage, but your physician has determined that the drug is medically necessary, you have the right to request a coverage determination. Your cost share for medicines approved through coverage determination is based on your benefit plan’s cost share for the appropriate non-preferred generic, non-preferred brand, or non-preferred specialty tier. Right to Appeal: If your request for coverage is denied, but your physician has determined that the drug is medically necessary, you have the right to appeal and request coverage. Continuation of Coverage: You have the right to continued coverage for a prescription drug at the coverage level or tier at which the drug was covered at the beginning of the plan year, until your plan renewal date, provided that the drug continues to be medically necessary and safe. Off-Label Drug Use: Off-label use of FDA approved drugs occurs when a drug is prescribed for a reason that has not been approved by the FDA. Off-label use may be covered when all of the following apply: • The medicine has been approved by the FDA for at least one use;

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Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicine BCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 VII • The medicine is prescribed by a physician; • The medicine is intended to treat chronic, disabling, or life -threatening illnesses; • Sufficient clinical evidence is provided by your physician for the off-label use requested; and • The services and medicine are medically necessary. Off-Label use of FDA approved drugs is not covered when these conditions are not met or when the FDA has determined its use to be contraindicated for treatment of the condition for which coverage is requested. Approved off-label medicine cost share is based on the tier in which the medicine is assigned within the drug list. Limitations and Exclusions: Pharmacy benefits are not available for: • Drugs required by law to be labeled: “Caution - Limited by Federal Law to Investigational Use,” or • Experimental drugs, even though a charge is made for the drugs, or • Legend drugs not approved by the FDA for a particular use or purpose or when used for a purpose other than the purpose for which the FDA approval is given, except as required by law or regulation. Experimental / Investigational means the use of any treatment, procedure, facility, equipment, drug, device or supply not accepted as Standard Medical Treatment of the condition being treated or any of such items requiring federal or other governmental agency Approval not granted at the time services were provided. “Approval” by a federal agency means that the treatment, procedure, facility, equipment, drug, device or supply has been approved for the condition being treated and, in the case of a drug, in th e dosage used on the patient. Medical treatment includes medical, surgical or dental treatment. “Standard Medical Treatment” means the services or supplies that are in general use in the medical community in the United States, and: • have been demonstrated in peer-reviewed literature to have scientifically established medical value for curing or alleviating the condition being treated; • are appropriate for the Hospital or Participating Provider; and • the Health Care Professional has had the appropriate training and experience to provide the treatment or procedure. Cost-Sharing: Your deductible is listed on your Summary of Benefits and Coverage document. Your deductible is the amount of money that you and anyone covered by your plan must pay out -of-pocket each plan year for covered services before your plan starts to pay. A certain set of drugs may be covered without cost-sharing, even before meeting the deductible. The out-of-pocket cost share for your covered prescriptions applies to your deductible until your deductible is met. Your cost share details are listed on your Summary of Benefits and Coverage for each of the tiers within this drug list. Your cost share may be a copayment (an amount you pay out-of-pocket for your prescription medicines after you’ve met any deductible) or coinsurance (a percentage of the total cost that you pay for your medicines, after you've met any deductible). Your drug list has the following tiers: • ACA (Preventive Drugs Not Subject to Deductible) • Tier 1 (Preferred Generics) • Tier 2 (Non-Preferred Generics) • Tier 3 (Preferred Brand) • Tier 4 (Non-Preferred Brand) • Tier 5 (Preferred Specialty) • Tier 6 (Non-Preferred Specialty) Your cost share for a medicine is based on the tier in which the medicine is assigned within the drug list. Network discounts are applied to medicines dispensed at a network pharmacy, but are not available for medicines dispensed at a non-network pharmacy. You may be able to save time and money using the pharmacy mail home delivery option if you take maintenance medicine for a condition like high blood pressure, asthma or diabetes, and take your drugs for long periods of time. With home delivery pharmacy, you may get up to a three-month supply of medicines delivered to your home and, in some cases, you may pay a lower cost share.

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Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicine BCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 X How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Note: most reference brand drugs (in parentheses) are not covered. Example: atorvastatin (Lipitor – brand is not covered) Brand prescription drugs are shown in capital letters followed by the generic name. Example: NOVOLOG - Insulin aspart inj 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. 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 may be excluded or moved to a non-preferred brand tier after a generic equivalent becomes available. You may be responsible for the applicable 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 usually 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.

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Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicine BCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 XI 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. 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 does not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan materials for details about your particular benefits. Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please see your plan materials or call the number on 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. 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. 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. 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 or bcbstx.com. *Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit. 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.

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Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicine BCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 XIV 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 tabs 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 Exception Process You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List. To request this exception, you, or your prescriber, can call the number on your ID card to ask for a review. BCBSTX will let you, and your prescriber, know the coverage decision within two business days (or no more than 72 hours) after they receive your request. If the coverage request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be able to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage decision within 24 hours after they receive your request for an expedited review. If the coverage request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). Call the number on your ID card if you have any questions. If you or your prescriber are asking for a copay waiver or coverage exception request for an ACA preventive product, please see the ACA preventive section.

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 90INDEXAabacavir 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..................................... 11acamprosate calcium tab delayed release 333 mg......45acarbose tab 25 mg, 50 mg, 100 mg............................. 20ACCU-CHEK FASTCLIX LANCET....................................87acebutolol hcl cap 200 mg, 400 mg...............................27ACERFLEX.........................................................................57acetaminophen w/ codeine soln 120-12 mg/5ml.......... 48acetaminophen w/ codeine tab 300-15 mg................... 48acetaminophen w/ codeine tab 300-30 mg................... 48acetaminophen w/ codeine tab 300-60 mg................... 48acetazolamide cap er 12hr 500 mg................................30acetazolamide tab 125 mg, 250 mg............................... 30acetic acid otic soln 2%..................................................82acetylcysteine inhal soln 10%, 20%.............................. 33acitretin cap 10 mg, 25 mg............................................. 83ACTEMRA.......................................................................... 49ACTEMRA ACTPEN..........................................................49ACTHAR............................................................................. 24ACTHIB.................................................................................8ACTIMMUNE......................................................................11ACTIVNUTRIENTS W/O COPPER...................................56acyclovir cap 200 mg........................................................ 3acyclovir oint 5%............................................................. 83acyclovir susp 200 mg/5ml...............................................3acyclovir tab 400 mg, 800 mg.......................................... 3ADACEL..............................................................................10ADBRY................................................................................83ADD-INS COMPLETE....................................................... 57adefovir dipivoxil tab 10 mg.............................................3ADEMPAS.......................................................................... 32ADJUSTABLE LANCING DEVICE.................................... 87ADVAIR DISKUS................................................................33ADVAIR HFA...................................................................... 33ADVANTAGE INFANT FORMULA/................................... 57ADVATE.............................................................................. 77ADVERA............................................................................. 58ADVOCATE INSULIN PEN NEED.................................... 87ADVOCATE INSULIN SYRINGE/......................................87ADYNOVATE...................................................................... 77AFLURIA QUADRIVALENT 2022........................................8AFSTYLA............................................................................77AIMOVIG............................................................................ 513232A INFANT FORMULA & ME..................................... 75AJOVY................................................................................ 51albendazole tab 200 mg.................................................... 7albuterol sulfate inhal aero 108 mcg/act (90mcg baseequiv).............................................................................. 33albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 33albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 33albuterol sulfate soln nebu 0.63 mg/3ml (base equiv),1.25 mg/3ml (base equiv).............................................33albuterol sulfate syrup 2 mg/5ml...................................33albuterol sulfate tab 2 mg, 4 mg....................................33alclometasone dipropionate cream 0.05%....................83alclometasone dipropionate oint 0.05%........................83ALECENSA.........................................................................11ALENDRONATE SODIUM.................................................24alendronate sodium tab 10 mg...................................... 24alendronate sodium tab 35 mg...................................... 24alendronate sodium tab 70 mg...................................... 24ALFAMINO INFANT........................................................... 58ALFAMINO JUNIOR.......................................................... 58alfuzosin hcl tab er 24hr 10 mg..................................... 40ALIMENTUM.......................................................................58ALINIA...................................................................................7ALITRAQ............................................................................ 58allopurinol tab 100 mg, 300 mg..................................... 52almotriptan malate tab 6.25 mg, 12.5 mg......................51ALOCRIL............................................................................ 80ALOMIDE............................................................................80alosetron hcl tab 0.5 mg (base equiv), 1 mg (baseequiv).............................................................................. 38ALPHANATE.......................................................................77ALPHANINE SD.................................................................77alprazolam tab er 24hr 0.5 mg, 1 mg, 2 mg, 3 mg........ 40alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg................ 40ALPROLIX.......................................................................... 77ALSOY SOY FORMULA................................................... 58ALTABAX............................................................................ 83ALUNBRIG......................................................................... 11amantadine hcl cap 100 mg........................................... 54amantadine hcl soln 50 mg/5ml..................................... 54ambrisentan tab 5 mg, 10 mg........................................ 32AMCINONIDE.....................................................................83amiloride & hydrochlorothiazide tab 5-50 mg.............. 30amiloride hcl tab 5 mg.................................................... 30amino acids cap...............................................................57amino acids tab................................................................57amiodarone hcl tab 100 mg............................................28amiodarone hcl tab 200 mg............................................28amitriptyline hcl tab 10 mg, 25 mg, 50 mg................... 41amitriptyline hcl tab 75 mg, 100 mg, 150 mg................41amlodipine besylate-benazepril hcl cap 2.5-10 mg,5-40 mg...........................................................................28amlodipine besylate-benazepril hcl cap 5-10 mg, 5-20mg, 10-20 mg, 10-40 mg.............................................. 28amlodipine besylate tab 2.5 mg (base equivalent), 5mg (base equivalent), 10 mg (base equivalent)........ 27amlodipine besylate-valsartan tab 5-160 mg, 5-320mg, 10-160 mg, 10-320 mg.......................................... 29AMOXICILLIN....................................................................... 1AMOXICILLIN/CLAVULANATE P........................................ 1

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 91amoxicillin & k clavulanate for susp 200-28.5mg/5ml.............................................................................. 1amoxicillin & k clavulanate for susp 250-62.5mg/5ml.............................................................................. 1amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1amoxicillin & k clavulanate for susp 600-42.9mg/5ml.............................................................................. 1amoxicillin & k clavulanate tab 250-125 mg................... 1amoxicillin & k clavulanate tab 500-125 mg................... 1amoxicillin & k clavulanate tab 875-125 mg................... 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.......................... 44amphetamine-dextroamphetamine tab 20 mg..............44amphetamine-dextroamphetamine tab 5 mg, 7.5 mg,10 mg, 12.5 mg, 15 mg, 30 mg....................................44AMPICILLIN..........................................................................1anagrelide hcl cap 0.5 mg.............................................. 77anagrelide hcl cap 1 mg................................................. 77ANALPRAM-HC................................................................. 82anastrozole tab 1 mg.......................................................11ANORO ELLIPTA...............................................................34APOKYN.............................................................................54apomorphine hcl soln cartridge 30 mg/3ml..................54apraclonidine hcl ophth soln 0.5% (baseequivalent)......................................................................80aprepitant capsule 40 mg............................................... 37aprepitant capsule 80 mg............................................... 37aprepitant capsule 125 mg............................................. 38aprepitant capsule therapy pack 80 & 125 mg.............37APTIVUS...............................................................................3ARANESP ALBUMIN FREE..............................................75ARCALYST......................................................................... 49ARGIMENT AT................................................................... 57ARGINAID.......................................................................... 58ARGINAID EXTRA.............................................................58ARIKAYCE............................................................................ 2aripiprazole oral solution 1 mg/ml.................................42aripiprazole tab 2 mg, 5 mg........................................... 42aripiprazole tab 10 mg, 15 mg....................................... 42aripiprazole tab 20 mg, 30 mg....................................... 42armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg......... 44ARMOUR THYROID..........................................................23ARNUITY ELLIPTA............................................................ 34asenapine maleate sl tab 2.5 mg (base equiv), 5 mg(base equiv), 10 mg (base equiv)............................... 42ASMANEX HFA..................................................................34ASMANEX TWISTHALER 120 ME................................... 34ASMANEX TWISTHALER 30 MET...................................34ASMANEX TWISTHALER 60 MET...................................34aspirin chew tab 81 mg...................................................47aspirin-dipyridamole cap er 12hr 25-200 mg................77aspirin tab delayed release 81 mg.................................47ASTAGRAF XL...................................................................88atazanavir sulfate cap 200 mg (base equiv)................... 4atazanavir sulfate cap 150 mg (base equiv), 300 mg(base equiv)..................................................................... 3atenolol & chlorthalidone tab 50-25 mg........................29atenolol & chlorthalidone tab 100-25 mg......................29atenolol tab 25 mg, 50 mg, 100 mg............................... 27atomoxetine hcl cap 60 mg (base equiv), 80 mg (baseequiv), 100 mg (base equiv)........................................ 44atomoxetine hcl cap 10 mg (base equiv), 18 mg (baseequiv), 25 mg (base equiv), 40 mg (base equiv)....... 44atorvastatin calcium tab 10 mg (base equivalent), 20mg (base equivalent)....................................................31atorvastatin calcium tab 40 mg (base equivalent), 80mg (base equivalent)....................................................31atovaquone-proguanil hcl tab 62.5-25 mg, 250-100mg......................................................................................7atovaquone susp 750 mg/5ml.......................................... 7ATROPINE SULFATE........................................................ 80atropine sulfate ophth soln 1%......................................80ATROVENT HFA................................................................34AUBAGIO........................................................................... 45AUSTEDO.......................................................................... 45AVONEX............................................................................. 45AVONEX PEN.................................................................... 45AYVAKIT............................................................................. 11azathioprine tab 50 mg................................................... 88azathioprine tab 75 mg, 100 mg.....................................88azelaic acid gel 15%........................................................ 83azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 33azelastine hcl ophth soln 0.05%.................................... 80AZITHROMYCIN.................................................................. 1azithromycin for susp 100 mg/5ml, 200 mg/5ml............ 1azithromycin tab 600 mg.................................................. 1azithromycin tab 250 mg, 500 mg....................................1BBABYS ONLY ORGANIC/DAIRY...................................... 58BABYS ONLY ORGANIC/DHA &...................................... 58BABYS ONLY ORGANIC/GENTLE...................................58BABYS ONLY ORGANIC/SENSIT.................................... 58BABYS ONLY ORGANIC/SOY..........................................58BACITRACIN......................................................................80bacitracin-polymyxin b ophth oint................................ 80bacitracin-polymyxin-neomycin-hc ophth oint 1%......80baclofen tab 10 mg..........................................................55baclofen tab 20 mg..........................................................55BALANCED NUTRITIONAL DRIN.................................... 58BALANCED NUTRITIONAL SHAK................................... 58balsalazide disodium cap 750 mg................................. 38BALVERSA......................................................................... 11BAQSIMI ONE PACK........................................................ 20BAQSIMI TWO PACK........................................................20BARACLUDE........................................................................4

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 92BCAD 1...............................................................................58BCAD 2...............................................................................58BD HYPODERMIC NEEDLES 22G.................................. 87BEEF/POTATOES/SPINACH.............................................58BELBUCA........................................................................... 48benazepril & hydrochlorothiazide tab 10-12.5 mg,20-12.5 mg, 20-25 mg................................................... 29benazepril hcl tab 5 mg.................................................. 29benazepril hcl tab 10 mg, 20 mg, 40 mg....................... 29BENECALORIE.................................................................. 58BENEFIX............................................................................ 78BENLYSTA..........................................................................88BENZNIDAZOLE.................................................................. 7benztropine mesylate tab 0.5 mg, 1 mg, 2 mg............. 54bepotastine besilate ophth soln 1.5%...........................80BESREMI............................................................................11betaine powder for oral solution................................... 24BETAMETHASONE DIPROPIONAT................................. 83betamethasone dipropionate augmented cream0.05%...............................................................................83betamethasone dipropionate augmented lotion0.05%...............................................................................83betamethasone dipropionate augmented oint0.05%...............................................................................83betamethasone dipropionate cream 0.05%.................. 83betamethasone dipropionate lotion 0.05%................... 83betamethasone valerate cream 0.1% (baseequivalent)......................................................................83betamethasone valerate lotion 0.1% (baseequivalent)......................................................................83betamethasone valerate oint 0.1% (baseequivalent)......................................................................83BETASERON......................................................................45betaxolol hcl ophth soln 0.5%........................................80betaxolol hcl tab 10 mg, 20 mg......................................27bethanechol chloride tab 5 mg, 10 mg, 25 mg, 50mg................................................................................... 39bexarotene cap 75 mg.....................................................11BEXSERO............................................................................ 8bicalutamide tab 50 mg...................................................11BIKTARVY............................................................................ 4BINAXNOW COVID-19 AG CARD....................................86bisoprolol & hydrochlorothiazide tab 5-6.25 mg..........29bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg,10-6.25 mg......................................................................29bisoprolol fumarate tab 5 mg.........................................27bisoprolol fumarate tab 10 mg.......................................27BOOST............................................................................... 58BOOST BREEZE............................................................... 58BOOST GLUCOSE CONTROL.........................................58BOOST GLUCOSE CONTROL MAX................................58BOOST HIGH PROTEIN................................................... 58BOOST KID ESSENTIALS 1.0..........................................58BOOST KID ESSENTIALS 1.5..........................................58BOOST MAX 30G PROTEIN............................................ 58BOOST MAX MEN............................................................ 58BOOST PLUS.................................................................... 58BOOST PUDDING............................................................. 58BOOSTRIX......................................................................... 10BOOST VERY HIGH CALORIE........................................ 58BOOST VHC...................................................................... 58BOOST WOMEN............................................................... 58bosentan tab 62.5 mg, 125 mg.......................................32BOSULIF............................................................................ 11BRAFTOVI..........................................................................11BRAINSUSTAIN FOR KIDS.............................................. 58BREO ELLIPTA.................................................................. 34BREZTRI AEROSPHERE..................................................34BRIGHT BEGINNINGS PEDIATR..................................... 58BRILINTA............................................................................ 78brimonidine tartrate gel 0.33% (base equivalent)........ 83brimonidine tartrate ophth soln 0.2%........................... 80brimonidine tartrate-timolol maleate ophth soln0.2-0.5%.......................................................................... 80brinzolamide ophth susp 1%..........................................80bromocriptine mesylate cap 5 mg (baseequivalent)......................................................................54bromocriptine mesylate tab 2.5 mg (baseequivalent)......................................................................54BRUKINSA......................................................................... 11budesonide delayed release particles cap 3 mg..........16budesonide inhalation susp 1 mg/2ml.......................... 34budesonide inhalation susp 0.25 mg/2ml, 0.5mg/2ml............................................................................ 34bumetanide tab 0.5 mg................................................... 30bumetanide tab 1 mg, 2 mg........................................... 30buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (baseequiv), 4-1 mg (base equiv), 8-2 mg (base equiv),12-3 mg (base equiv)....................................................48buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv), 8-2 mg (base equiv).........................................48buprenorphine hcl sl tab 2 mg (base equiv), 8 mg(base equiv)................................................................... 48bupropion hcl (smoking deterrent) tab er 12hr 150mg................................................................................... 45bupropion hcl tab er 24hr 150 mg, 300 mg...................41bupropion hcl tab er 12hr 100 mg, 150 mg, 200mg................................................................................... 41bupropion hcl tab 75 mg................................................ 41bupropion hcl tab 100 mg.............................................. 41buspirone hcl tab 30 mg.................................................40buspirone hcl tab 5 mg, 10 mg, 15 mg......................... 40butalbital-acetaminophen-caffeine tab 50-325-40mg................................................................................... 47butalbital-acetaminophen-caff w/ cod cap50-325-40-30 mg............................................................ 48butalbital-acetaminophen tab 50-325 mg......................47butalbital-aspirin-caffeine cap 50-325-40 mg............... 48butalbital-aspirin-caff w/ codeine cap 50-325-40-30mg................................................................................... 48

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 93BYDUREON BCISE...........................................................20BYLVAY...............................................................................38BYLVAY (PELLETS)...........................................................38Ccabergoline tab 0.5 mg................................................... 24CABOMETYX..................................................................... 11caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv).............................................................................. 44CALCILO XD...................................................................... 58calcipotriene cream 0.005%............................................83calcipotriene soln 0.005% (50 mcg/ml)......................... 83calcitonin (salmon) nasal soln 200 unit/act..................24calcitriol cap 0.25 mcg.................................................... 24calcitriol cap 0.5 mcg...................................................... 24calcitriol oral soln 1 mcg/ml...........................................25calcium acetate (phosphate binder) cap 667 mg (169mg ca).............................................................................38calcium acetate (phosphate binder) tab 667 mg..........38CALQUENCE..................................................................... 12CAMINO PRO COMPLETE/GLYTA.................................. 58CAMZYOS.......................................................................... 32candesartan cilexetil tab 4 mg, 8 mg, 16 mg, 32mg................................................................................... 29capecitabine tab 150 mg, 500 mg.................................. 12CAPRELSA.........................................................................12captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg...............29carbamazepine cap er 12hr 100 mg, 200 mg, 300mg................................................................................... 52carbamazepine chew tab 100 mg.................................. 52carbamazepine susp 100 mg/5ml.................................. 52carbamazepine tab er 12hr 100 mg, 200 mg, 400mg................................................................................... 52carbamazepine tab 200 mg.............................................52CARBIDOPA/LEVODOPA ODT.........................................55carbidopa & levodopa tab er 25-100 mg, 50-200mg................................................................................... 54carbidopa & levodopa tab 10-100 mg........................... 54carbidopa & levodopa tab 25-100 mg........................... 54carbidopa & levodopa tab 25-250 mg........................... 54carbidopa-levodopa-entacapone tabs 12.5-50-200mg................................................................................... 54carbidopa-levodopa-entacapone tabs 18.75-75-200mg................................................................................... 55carbidopa-levodopa-entacapone tabs 31.25-125-200mg................................................................................... 55carbidopa-levodopa-entacapone tabs 37.5-150-200mg................................................................................... 55carbidopa-levodopa-entacapone tabs 25-100-200mg................................................................................... 55carbidopa-levodopa-entacapone tabs 50-200-200mg................................................................................... 55carbidopa tab 25 mg....................................................... 54CARBINOXAMINE MALEATE........................................... 33carbinoxamine maleate tab 4 mg.................................. 33carbonyl iron susp 15 mg/1.25ml (elemental iron)...... 76CARDIZEM LA................................................................... 27CARESTART COVID-19 ANTIGE..................................... 87carglumic acid soluble tab 200 mg............................... 25CARNATION BREAKFAST ESSEN.................................. 58CARTEOLOL HCL............................................................. 80carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg....... 27CAYA...................................................................................87CAYSTON.............................................................................7C-BUFF...............................................................................56CEFACLOR.......................................................................... 1cefadroxil 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..................... 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..................................................... 49celecoxib cap 50 mg, 100 mg, 200 mg..........................49CELLTRION DIATRUST COVID-...................................... 87CELONTIN..........................................................................52cephalexin cap 250 mg, 500 mg...................................... 1cephalexin for susp 125 mg/5ml, 250 mg/5ml................ 1CERDELGA........................................................................ 76cevimeline hcl cap 30 mg............................................... 82CFPREOP.......................................................................... 58CHEMET.............................................................................86CHENODAL........................................................................38CHICKEN/PEAS/CARROTS..............................................58CHLORDIAZEPOXIDE/AMITRIPT.................................... 45chlordiazepoxide hcl cap 5 mg, 10 mg, 25 mg.............40chlorhexidine gluconate soln 0.12%............................. 82chloroquine phosphate tab 250 mg................................ 7chlorthalidone tab 25 mg, 50 mg................................... 30chlorzoxazone tab 500 mg..............................................55cholecalciferol cap 1.25 mg (50000 unit)...................... 56cholestyramine light powder 4 gm/dose...................... 31cholestyramine light powder packets 4 gm................. 31cholestyramine powder 4 gm/dose............................... 31cholestyramine powder packets 4 gm.......................... 31CHOLEXTRA......................................................................59ciclopirox gel 0.77%........................................................ 83ciclopirox olamine cream 0.77% (base equiv)..............83ciclopirox olamine susp 0.77% (base equiv)................83ciclopirox shampoo 1%.................................................. 83ciclopirox solution 8%.....................................................83cilostazol tab 50 mg, 100 mg......................................... 78CIMDUO............................................................................... 4cimetidine hcl soln 300 mg/5ml..................................... 37CIMZIA................................................................................38CIMZIA STARTER KIT...................................................... 38

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 94cinacalcet hcl tab 30 mg (base equiv), 60 mg (baseequiv), 90 mg (base equiv).......................................... 25CIPROFLOXACIN.............................................................. 82ciprofloxacin-dexamethasone otic susp 0.3-0.1%....... 82ciprofloxacin hcl ophth soln 0.3% (baseequivalent)......................................................................80ciprofloxacin hcl tab 750 mg (base equiv)..................... 2ciprofloxacin hcl tab 250 mg (base equiv), 500 mg(base equiv)..................................................................... 2citalopram hydrobromide oral soln 10 mg/5ml............ 41citalopram hydrobromide tab 10 mg (base equiv), 20mg (base equiv), 40 mg (base equiv).........................41CLARITHROMYCIN............................................................. 2clarithromycin tab er 24hr 500 mg.................................. 2clarithromycin tab 250 mg, 500 mg.................................2CLEARDETECT COVID-19 ANTI..................................... 87CLEMASTINE FUMARATE............................................... 33CLENPIQ............................................................................ 36CLICK ESPRESSO PROTEIN DR....................................59CLIMARA PRO.................................................................. 17clindamycin hcl cap 75 mg, 150 mg, 300 mg................. 7clindamycin palmitate hcl for soln 75 mg/5ml (baseequiv)................................................................................ 7clindamycin phosphate gel 1%...................................... 83clindamycin phosphate lotion 1%................................. 83clindamycin phosphate soln 1%....................................83clindamycin phosphate swab 1%.................................. 83clindamycin phosphate vaginal cream 2%...................39clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5%.............................................................................. 83CLINDESSE....................................................................... 40CLINITEST RAPID COVID-19...........................................87clobazam suspension 2.5 mg/ml................................... 52clobazam tab 10 mg, 20 mg........................................... 52clobetasol propionate cream 0.05%.............................. 83clobetasol propionate emollient base cream0.05%...............................................................................83clobetasol propionate oint 0.05%.................................. 83clobetasol propionate soln 0.05%................................. 83CLOMID..............................................................................25clomipramine hcl cap 25 mg, 50 mg, 75 mg.................41clonazepam tab 0.5 mg, 1 mg, 2 mg............................. 53clonidine hcl tab er 12hr 0.1 mg.................................... 44clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg...................... 29clonidine td patch weekly 0.1 mg/24hr......................... 29clonidine td patch weekly 0.2 mg/24hr......................... 29clonidine td patch weekly 0.3 mg/24hr......................... 29clopidogrel bisulfate tab 75 mg (base equiv)............... 78clorazepate dipotassium tab 7.5 mg............................. 40clorazepate dipotassium tab 3.75 mg, 15 mg...............40clotrimazole troche 10 mg.............................................. 82clotrimazole w/ betamethasone cream 1-0.05%...........83clozapine tab 25 mg........................................................ 42clozapine tab 50 mg........................................................ 42clozapine tab 100 mg...................................................... 42clozapine tab 200 mg...................................................... 42COAGADEX....................................................................... 78COARTEM............................................................................7codeine sulfate tab 30 mg.............................................. 48colchicine tab 0.6 mg...................................................... 52colchicine w/ probenecid tab 0.5-500 mg..................... 52colesevelam hcl tab 625 mg...........................................31colestipol hcl granule packets 5 gm............................. 31colestipol hcl granules 5 gm..........................................31colestipol hcl tab 1 gm................................................... 31COMBIGAN........................................................................ 80COMBIPATCH.................................................................... 17COMBIVENT RESPIMAT.................................................. 34COMETRIQ........................................................................ 12COMIRNATY........................................................................ 8COMPLEAT........................................................................ 59COMPLEAT ORGANIC BLENDS......................................59COMPLEAT PEDIATRIC................................................... 59COMPLEAT PEDIATRIC ORGANI....................................59COMPLEAT PEDIATRIC PEPTID..................................... 59COMPLEAT PEDIATRIC REDUCE...................................59COMPLEAT PEDIATRIC STANDA....................................59COMPLEAT PEPTIDE 1.5.................................................59COMPLEAT STANDARD 1.4.............................................59COMPLERA..........................................................................4COMPLETE AMINO ACID MIX.........................................57COMPLETE NUTRITION...................................................59COMPLETE NUTRITION PLUS........................................59COMPLEX ESSENTIAL MSD........................................... 57COMPLEX JUNIOR MSD..................................................57COMPLEX MSUD.............................................................. 57COMPLEX MSUD AMINO ACID B................................... 57CONDOMS......................................................................... 87CONTOUR BLOOD GLUCOSE TES................................87CONTOUR NEXT BLOOD GLUCOS................................87COPIKTRA......................................................................... 12CORIFACT..........................................................................78CORLANOR....................................................................... 32COSENTYX........................................................................ 84COSENTYX SENSOREADY PEN.................................... 84COTELLIC.......................................................................... 12COVID-19 AT-HOME TEST KIT........................................87CREON............................................................................... 38cromolyn sodium ophth soln 4%...................................80cromolyn sodium oral conc 100 mg/5ml...................... 38cromolyn sodium soln nebu 20 mg/2ml....................... 34CROTAN............................................................................. 84CVS ADVANTAGE/IRON...................................................59CVS COVID-19 AT HOME TEST......................................87CVS GENTLE INFANT FORMULA................................... 59CVS INFANT FORMULA/IRON.........................................59CVS NUTRITIONAL SHAKE............................................. 59CVS NUTRITION LIQUID..................................................59CVS NUTRITION PLUS.................................................... 59CVS SENSITIVITY/IRON...................................................59

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 95CVS TENDER/IRON..........................................................59CVS TODDLER & INFANT FORM....................................59CVS TODDLER BEGINNINGS/IR.....................................59cyanocobalamin inj 1000 mcg/ml.................................. 76CYCLINEX-1.......................................................................59CYCLINEX-2.......................................................................59cyclobenzaprine hcl tab 5 mg, 10 mg........................... 55CYCLOMYDRIL..................................................................80cyclopentolate hcl ophth soln 2%................................. 80cyclopentolate hcl ophth soln 0.5%, 1%.......................80CYCLOPHOSPHAMIDE.................................................... 12cyclosporine cap 25 mg, 100 mg...................................88cyclosporine modified cap 50 mg................................. 88cyclosporine modified cap 25 mg, 100 mg...................88cyclosporine modified oral soln 100 mg/ml................. 88cyproheptadine hcl syrup 2 mg/5ml..............................33cyproheptadine hcl tab 4 mg......................................... 33CYSTADROPS................................................................... 80CYSTAGON........................................................................40CYSTARAN........................................................................ 80Ddabigatran etexilate mesylate cap 75 mg (etexilatebase eq), 150 mg (etexilate base eq)......................... 77dalfampridine tab er 12hr 10 mg....................................45DALIRESP.......................................................................... 34danazol cap 50 mg, 100 mg, 200 mg.............................17dapsone tab 25 mg, 100 mg............................................. 7DAPTACEL......................................................................... 11darifenacin hydrobromide tab er 24hr 7.5 mg (baseequiv).............................................................................. 39darifenacin hydrobromide tab er 24hr 15 mg (baseequiv).............................................................................. 39DAURISMO........................................................................ 12DECUBAMINE....................................................................57deferasirox tab for oral susp 500 mg............................86deferasirox tab for oral susp 125 mg, 250 mg............. 86DELSTRIGO......................................................................... 4demeclocycline hcl tab 150 mg, 300 mg.........................2DEPO-ESTRADIOL............................................................17DEPO-SUBQ PROVERA 104........................................... 18DESCOVY............................................................................ 4desipramine hcl tab 10 mg, 25 mg................................ 41desipramine hcl tab 50 mg, 75 mg, 100 mg, 150mg................................................................................... 41desloratadine tab 5 mg................................................... 33desmopressin acetate nasal spray soln 0.01%............25desmopressin acetate tab 0.1 mg, 0.2 mg....................25desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5)..........................................................................18desogestrel & ethinyl estradiol tab 0.15 mg-30mcg................................................................................. 18desonide cream 0.05%.................................................... 84desonide oint 0.05%........................................................ 84desoximetasone cream 0.25%....................................... 84desoximetasone oint 0.25%............................................84desvenlafaxine succinate tab er 24hr 25 mg (baseequiv), 50 mg (base equiv), 100 mg (base equiv)..... 41DEXAMETHASONE...........................................................16dexamethasone elixir 0.5 mg/5ml.................................. 17DEXAMETHASONE INTENSOL....................................... 17DEXAMETHASONE SODIUM PHOS............................... 80dexamethasone tab 2 mg............................................... 17dexamethasone tab 1.5 mg, 4 mg, 6 mg....................... 17DEXCOM G6 RECEIVER..................................................87DEXCOM G6 SENSOR..................................................... 87DEXCOM G6 TRANSMITTER.......................................... 87DEXILANT.......................................................................... 37dexlansoprazole cap delayed release 30 mg, 60mg................................................................................... 37dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg................... 44dexmethylphenidate hcl tab 10 mg............................... 44dexmethylphenidate hcl tab 2.5 mg, 5 mg....................44DEX4 QUICK DISSOLVE GLUCO.................................... 20dextroamphetamine sulfate cap er 24hr 5 mg............. 44dextroamphetamine sulfate cap er 24hr 10 mg, 15mg................................................................................... 44dextroamphetamine sulfate oral solution 5mg/5ml............................................................................ 44dextroamphetamine sulfate tab 5 mg........................... 44dextroamphetamine sulfate tab 10 mg......................... 44DIABETISOURCE AC........................................................59DIACOMIT.......................................................................... 53DIARESQ CHILDRENS SOOTHIN................................... 59DIARESQ GENTLE RELIEF TOD.....................................59DIARESQ RAPID RECOVERY......................................... 59diazepam conc 5 mg/ml.................................................. 40diazepam oral soln 1 mg/ml........................................... 40DIAZEPAM RECTAL GEL................................................. 53diazepam tab 2 mg, 5 mg, 10 mg...................................40diazoxide susp 50 mg/ml................................................ 20diclofenac potassium tab 50 mg................................... 49diclofenac sodium ophth soln 0.1%.............................. 80diclofenac sodium soln 1.5%......................................... 84diclofenac sodium tab delayed release 25 mg.............49diclofenac sodium tab delayed release 50 mg, 75mg................................................................................... 49diclofenac w/ misoprostol tab delayed release 50-0.2mg................................................................................... 49diclofenac w/ misoprostol tab delayed release 75-0.2mg................................................................................... 49dicloxacillin sodium cap 250 mg, 500 mg...................... 1dicyclomine hcl cap 10 mg.............................................37dicyclomine hcl oral soln 10 mg/5ml............................ 37dicyclomine hcl tab 20 mg............................................. 37DIFICID................................................................................. 2diflorasone diacetate oint 0.05%................................... 84diflunisal tab 500 mg.......................................................48difluprednate ophth emulsion 0.05%............................ 80

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 96digoxin oral soln 0.05 mg/ml..........................................26digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25mg).................................................................................. 26dihydroergotamine mesylate inj 1 mg/ml..................... 51DILANTIN........................................................................... 53diltiazem hcl cap er 12hr 60 mg, 90 mg, 120 mg..........27diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mg...... 27diltiazem hcl coated beads cap er 24hr 120 mg, 180mg................................................................................... 27diltiazem hcl coated beads cap er 24hr 240 mg, 300mg................................................................................... 27diltiazem hcl coated beads tab er 24hr 180 mg, 240mg................................................................................... 27diltiazem hcl extended release beads cap er 24hr 120mg, 180 mg.................................................................... 27diltiazem hcl extended release beads cap er 24hr 240mg, 300 mg, 360 mg, 420 mg...................................... 28diltiazem hcl tab 90 mg...................................................28diltiazem hcl tab 120 mg.................................................28diltiazem hcl tab 30 mg, 60 mg...................................... 28dimethyl fumarate capsule delayed release 120mg................................................................................... 45dimethyl fumarate capsule delayed release 240mg................................................................................... 45dimethyl fumarate capsule dr starter pack 120 mg &240 mg............................................................................45DIPENTUM......................................................................... 38diphenoxylate w/ atropine tab 2.5-0.025 mg.................37DIPHTHERIA/TETANUS TOXOID.....................................11dipyridamole tab 25 mg, 50 mg, 75 mg.........................78disopyramide phosphate cap 100 mg, 150 mg............ 28disulfiram tab 250 mg, 500 mg...................................... 45divalproex sodium cap delayed release sprinkle 125mg................................................................................... 53divalproex sodium tab delayed release 125 mg, 250mg, 500 mg.................................................................... 53divalproex sodium tab er 24 hr 250 mg, 500 mg..........53DIVIGEL..............................................................................17dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg),500 mcg (0.5 mg).......................................................... 28donepezil hydrochloride orally disintegrating tab 5mg, 10 mg...................................................................... 45donepezil hydrochloride tab 23 mg...............................46donepezil hydrochloride tab 5 mg, 10 mg.................... 46DOPTELET.........................................................................76dorzolamide hcl ophth soln 2%..................................... 80dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml.............................................................................. 80DOVATO............................................................................... 4doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg.........29doxepin hcl cap 10 mg....................................................41doxepin hcl cap 25 mg, 50 mg, 75 mg, 100 mg............ 41doxepin hcl conc 10 mg/ml............................................ 41doxepin hcl (sleep) tab 3 mg (base equiv), 6 mg (baseequiv).............................................................................. 44doxercalciferol cap 0.5 mcg, 1 mcg, 2.5 mcg...............25doxycycline hyclate cap 50 mg....................................... 2doxycycline hyclate cap 100 mg..................................... 2doxycycline hyclate tab 20 mg........................................ 2doxycycline hyclate tab 100 mg...................................... 2doxycycline monohydrate cap 50 mg, 100 mg.............. 2doxycycline monohydrate for susp 25 mg/5ml..............2doxycycline monohydrate tab 100 mg............................2doxycycline monohydrate tab 50 mg, 75 mg................. 2dronabinol cap 2.5 mg, 5 mg, 10 mg.............................38drospirenone-ethinyl estradiol tab 3-0.02 mg.............. 18drospirenone-ethinyl estradiol tab 3-0.03 mg.............. 18drospirenone-ethinyl estrad-levomefolate tab3-0.02-0.451 mg............................................................. 18drospirenone-ethinyl estrad-levomefolate tab3-0.03-0.451 mg............................................................. 18DROXIA.............................................................................. 76DUAVEE............................................................................. 17DULERA............................................................................. 34duloxetine hcl enteric coated pellets cap 30 mg (baseeq)................................................................................... 41duloxetine hcl enteric coated pellets cap 20 mg (baseeq), 60 mg (base eq).................................................... 41DUOCAL.............................................................................59DUPIXENT..........................................................................84dutasteride cap 0.5 mg................................................... 40dutasteride-tamsulosin hcl cap 0.5-0.4 mg.................. 40EEAA SUPPLEMENT.......................................................... 59econazole nitrate cream 1%........................................... 84EDURANT............................................................................ 4efavirenz cap 50 mg.......................................................... 4efavirenz cap 200 mg........................................................ 4efavirenz-emtricitabine-tenofovir df tab 600-200-300mg......................................................................................4efavirenz-lamivudine-tenofovir df tab 400-300-300mg......................................................................................4efavirenz-lamivudine-tenofovir df tab 600-300-300mg......................................................................................4efavirenz tab 600 mg......................................................... 4EGG/PRO........................................................................... 59EGGS/APPLES/OATS....................................................... 59ELECARE........................................................................... 59ELECARE/DHA/ARA..........................................................59ELECARE DHA/ARA/IRON INFA......................................59ELECARE DHA/ARA INFANT........................................... 59ELECARE JR..................................................................... 59eletriptan hydrobromide tab 20 mg (base equivalent),40 mg (base equivalent).............................................. 51ELIQUIS..............................................................................77ELIQUIS STARTER PACK................................................ 77ELLA................................................................................... 18ELLUME COVID-19 HOME TEST.................................... 87ELMIRON........................................................................... 40

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 97ELOCTATE......................................................................... 78EMCYT............................................................................... 12EMGALITY..........................................................................51EMPAVELI.......................................................................... 78emtricitabine caps 200 mg............................................... 4emtricitabine-tenofovir disoproxil fumarate tab200-300 mg.......................................................................4emtricitabine-tenofovir disoproxil fumarate tab100-150 mg, 133-200 mg, 167-250 mg.......................... 4EMTRIVA.............................................................................. 4EMVERM.............................................................................. 7enalapril maleate & hydrochlorothiazide tab 5-12.5mg................................................................................... 29enalapril maleate & hydrochlorothiazide tab 10-25mg................................................................................... 29enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg.......29ENBREL..............................................................................49ENBREL MINI.................................................................... 50ENBREL SURECLICK....................................................... 50ENCALA..............................................................................59ENDARI.............................................................................. 76ENFAGROW PREMIUM LIPIL.......................................... 59ENFAGROW PREMIUM OLDER TO................................60ENFAGROW PREMIUM TODDLER................................. 60ENFAGROW TODDLER TRANSITI..................................60ENFAMIL AR/SPIT-UP...................................................... 60ENFAMIL ENFACARE LIPIL............................................. 60ENFAMIL ENSPIRE GENTLEASE....................................60ENFAMIL ENSPIRE INFANT FO...................................... 60ENFAMIL GENTLEASE..................................................... 60ENFAMIL GENTLEASE/FUSSINE.................................... 60ENFAMIL GENTLEASE FUSSINE....................................60ENFAMIL HUMAN MILK FORTIF..................................... 60ENFAMIL INFANT.............................................................. 60ENFAMIL NEUROPRO ENFACARE.................................60ENFAMIL NEUROPRO GENTLEAS................................. 60ENFAMIL NEUROPRO INFANT........................................60ENFAMIL NEUROPRO SENSITIV....................................60ENFAMIL NUTRAMIGEN TODDLE.................................. 60ENFAMIL NUTRAMIGEN W/PROB.................................. 60ENFAMIL PREMIUM INFANT........................................... 60ENFAMIL PREMIUM NEWBORN..................................... 60ENFAMIL PROSOBEE SOY............................................. 60ENFAMIL REGULINE/IRON.............................................. 60ENGERIX-B.......................................................................... 8ENLIVE............................................................................... 60enoxaparin sodium inj 300 mg/3ml............................... 77enoxaparin 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.................................................... 77ENSPRYNG........................................................................88ENSTILAR.......................................................................... 84ENSURE.............................................................................60ENSURE/FIBER................................................................. 61ENSURE ACTIVE.............................................................. 60ENSURE ACTIVE HEART HEALT....................................60ENSURE ACTIVE HIGH PROTEI..................................... 60ENSURE ACTIVE LIGHT.................................................. 60ENSURE BONE HEALTH REVIGO.................................. 60ENSURE CLEAR............................................................... 60ENSURE CLINICAL STRENGTH..................................... 60ENSURE COMPACT......................................................... 60ENSURE COMPLETE....................................................... 60ENSURE COMPLETE NUTRITION.................................. 60ENSURE ENLIVE.............................................................. 60ENSURE HARVEST 1.2 CAL........................................... 60ENSURE HEALTHY MOM.................................................60ENSURE HIGH CALCIUM................................................ 61ENSURE HIGH PROTEIN.................................................61ENSURE IMMUNE HEALTH............................................. 61ENSURE MAX PROTEIN..................................................61ENSURE MUSCLE HEALTH REVI................................... 61ENSURE NUTRA SHAKE HI-CAL....................................61ENSURE NUTRITION SHAKE..........................................61ENSURE ORIGINAL..........................................................61ENSURE ORIGINAL THERAPEUT.................................. 61ENSURE PLANT-BASED PROTEI................................... 61ENSURE PLUS..................................................................61ENSURE PLUS HIGH PROTEIN...................................... 61ENSURE PLUS HN........................................................... 61ENSURE PRE-SURGERY.................................................61ENSURE PUDDING.......................................................... 61ENSURE SURGERY IMMUNONUTR...............................61ENSURE SURGICAL NUTRITION................................... 61entacapone tab 200 mg...................................................55entecavir tab 0.5 mg, 1 mg...............................................4ENTERADE........................................................................ 61ENTERADE IBS-D............................................................. 61ENTRESTO........................................................................ 32ENU COMPLETE NUTRITION SH................................... 61ENU NUTRITIONAL SHAKE.............................................61ENVARSUS XR..................................................................88EO28 SPLASH...................................................................61EPCLUSA............................................................................. 4EPIDIOLEX.........................................................................53epinastine hcl ophth soln 0.05%....................................80epinephrine solution auto-injector 0.15 mg/0.3ml(1:2000)........................................................................... 31epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000)........................................................................... 31EPIVIR HBV......................................................................... 4eplerenone tab 25 mg, 50 mg........................................ 29EPOGEN............................................................................ 76EQ NUTRITIONAL SHAKE............................................... 61EQ NUTRITIONAL SHAKE PLUS.................................... 61EQUATE............................................................................. 61EQUATE PLUS.................................................................. 61EQ WEIGHT LOSS SHAKE ULTR....................................61ergocalciferol cap 1.25 mg (50000 unit)........................56ERGOLOID MESYLATES..................................................46

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 98ERIVEDGE......................................................................... 12ERLEADA........................................................................... 12erlotinib hcl tab 25 mg (base equivalent)..................... 12erlotinib hcl tab 100 mg (base equivalent), 150 mg(base equivalent)...........................................................12ERY.....................................................................................84ERYTHROMYCIN................................................................ 2erythromycin ethylsuccinate for susp 200 mg/5ml....... 2erythromycin gel 2%........................................................84erythromycin ophth oint 5 mg/gm................................. 81erythromycin soln 2%..................................................... 84erythromycin tab delayed release 250 mg, 333 mg,500 mg.............................................................................. 2erythromycin tab 250 mg, 500 mg................................... 2ESBRIET............................................................................ 36escitalopram oxalate soln 5 mg/5ml (base equiv)....... 41escitalopram oxalate tab 5 mg (base equiv), 10 mg(base equiv), 20 mg (base equiv)............................... 41esomeprazole magnesium for delayed release susppacket 10 mg, 20 mg, 40 mg....................................... 37ESPEROCT........................................................................ 78ESSENTIAL AMINO ACID MIX.........................................57estazolam tab 1 mg, 2 mg.............................................. 44estradiol & norethindrone acetate tab 0.5-0.1 mg........17estradiol & norethindrone acetate tab 1-0.5 mg...........17estradiol tab 0.5 mg, 1 mg, 2 mg................................... 18estradiol 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%)......................................................... 18estradiol td patch twice weekly 0.025 mg/24hr,0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1mg/24hr...........................................................................18estradiol td patch weekly 0.025 mg/24hr, 0.0375mg/24hr (37.5 mcg/24hr), 0.05 mg/24hr, 0.06mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr......................... 18estradiol vaginal cream 0.1 mg/gm............................... 40estradiol vaginal tab 10 mcg.......................................... 40estradiol valerate im in oil 20 mg/ml, 40 mg/ml........... 18ESTRING............................................................................40ESTROGEL........................................................................ 18eszopiclone tab 1 mg, 2 mg, 3 mg................................ 44ethambutol hcl tab 100 mg...............................................3ethambutol hcl tab 400 mg...............................................3ethosuximide cap 250 mg...............................................53ethosuximide soln 250 mg/5ml...................................... 53ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg................................................................................. 18ethynodiol diacetate & ethinyl estradiol tab 1 mg-50mcg................................................................................. 18etodolac cap 200 mg, 300 mg........................................ 50etodolac tab 400 mg........................................................50etodolac tab 500 mg........................................................50ETOPOSIDE.......................................................................12etravirine tab 100 mg, 200 mg......................................... 4euthyrox - euthyrox - levothyroxine sodium tab 25mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg................23euthyrox - levothyroxine sodium tab 25 mcg, 88 mcg,100 mcg, 112 mcg, 125 mcg........................................23euthyrox - levoxyl - levothyroxine sodium tab 75 mcg,150 mcg, 175 mcg, 200 mcg........................................23euthyrox - unithroid - levothyroxine sodium tab 50mcg, 137 mcg................................................................ 23everolimus tab for oral susp 3 mg................................ 12everolimus tab for oral susp 2 mg, 5 mg......................12everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg................12everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg...........88EVOTAZ................................................................................4EVRYSDI............................................................................ 55exemestane tab 25 mg.................................................... 12EXKIVITY............................................................................12EXPEDITE.......................................................................... 61ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40mg, 10-80 mg.................................................................31ezetimibe tab 10 mg........................................................ 31Ffamciclovir tab 125 mg, 250 mg, 500 mg........................ 4famotidine for susp 40 mg/5ml...................................... 37famotidine tab 20 mg, 40 mg......................................... 37FANAPT.............................................................................. 42FANAPT TITRATION PACK.............................................. 42FARXIGA............................................................................ 20FASENRA PEN.................................................................. 34FC2 FEMALE CONDOM................................................... 87febuxostat tab 40 mg, 80 mg......................................... 52FEIBA..................................................................................78felbamate susp 600 mg/5ml............................................53felbamate tab 400 mg, 600 mg....................................... 53felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg.................. 28fenofibrate micronized cap 200 mg...............................31fenofibrate micronized cap 67 mg, 134 mg.................. 31fenofibrate tab 48 mg...................................................... 31fenofibrate tab 54 mg...................................................... 31fenofibrate tab 145 mg.................................................... 31fenofibrate tab 160 mg.................................................... 31fentanyl citrate lozenge on a handle 200 mcg, 400mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg..........48fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr............................................48FERRIPROX.......................................................................86FERROUS SULFATE.........................................................76ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elementalfe).....................................................................................76ferrous sulfate soln 75 mg/ml (15 mg/ml elementalfe).....................................................................................76ferrous sulfate syrup 300 mg/5ml (60 mg/5mlelemental fe).................................................................. 76FETZIMA............................................................................ 41FETZIMA TITRATION PACK............................................. 41

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 99FIASP..................................................................................22FIASP FLEXTOUCH..........................................................22FIASP PENFILL................................................................. 22FIBER FLOW..................................................................... 61FIBERSOURCE HN...........................................................61FIBER-STAT....................................................................... 61FIBRYGA............................................................................ 78finasteride tab 5 mg........................................................ 40fingolimod hcl cap 0.5 mg (base equiv)........................46FIRVANQ.............................................................................. 7FITFOOD LEAN COMPLETE............................................61FLAREX..............................................................................81FLAVOR PACKETS........................................................... 61flavoxate hcl tab 100 mg.................................................39flecainide acetate tab 50 mg, 100 mg, 150 mg............. 28FLOVENT DISKUS............................................................ 34FLOVENT HFA...................................................................34FLOWFLEX COVID-19 ANTIGEN.................................... 87FLUAD QUADRIVALENT 2022-2........................................8FLUARIX QUADRIVALENT 2022........................................8FLUBLOK QUADRIVALENT 2022...................................... 8FLUCELVAX QUADRIVALENT 20...................................... 8fluconazole for susp 10 mg/ml, 40 mg/ml.......................3fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg........... 3flucytosine cap 250 mg, 500 mg...................................... 3fludrocortisone acetate tab 0.1 mg............................... 17FLULAVAL QUADRIVALENT 202....................................... 8flunisolide nasal soln 25 mcg/act (0.025%).................. 33fluocinolone acetonide cream 0.01%............................ 84fluocinolone acetonide cream 0.025%.......................... 84fluocinolone acetonide oil 0.01% (body oil)................. 84fluocinolone acetonide oil 0.01% (scalp oil).................84fluocinolone acetonide oint 0.025%.............................. 84fluocinolone acetonide (otic) oil 0.01%.........................82fluocinolone acetonide soln 0.01%............................... 84fluocinonide cream 0.05%.............................................. 84fluocinonide oint 0.05%.................................................. 84fluocinonide soln 0.05%..................................................84FLUORIDEX SENSITIVITY REL.......................................82fluorometholone ophth susp 0.1%................................ 81FLUOROURACIL............................................................... 84fluorouracil cream 5%..................................................... 84fluoxetine hcl cap 10 mg, 20 mg, 40 mg....................... 41fluoxetine hcl solution 20 mg/5ml................................. 41FLUPHENAZINE HCL....................................................... 42fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg..........42FLUPHENAZINE HYDROCHLORID................................. 42FLURBIPROFEN................................................................50FLURBIPROFEN SODIUM................................................81flurbiprofen tab 100 mg.................................................. 50FLUTICASONE PROPIONATE/SA................................... 34fluticasone propionate cream 0.05%.............................84fluticasone propionate nasal susp 50 mcg/act............ 33fluticasone propionate oint 0.005%...............................84fluvastatin sodium tab er 24 hr 80 mg (baseequivalent)......................................................................31fluvoxamine maleate tab 25 mg, 50 mg, 100 mg..........41FLUZONE HIGH-DOSE PF 2022........................................8FLUZONE QUADRIVALENT 2022...................................... 9FOLBIC............................................................................... 61folic acid cap 0.8 mg....................................................... 76folic acid tab 400 mcg, 800 mcg.................................... 76folic acid tab 1 mg...........................................................76fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml,5 mg/0.4ml, 7.5 mg/0.6ml, 10 mg/0.8ml...................... 77FORTA DRINK................................................................... 61FORTA SHAKE.................................................................. 61FORTEO.............................................................................25fosamprenavir calcium tab 700 mg (base equiv)...........4fosinopril sodium & hydrochlorothiazide tab 10-12.5mg, 20-12.5 mg..............................................................29fosinopril sodium tab 10 mg, 20 mg, 40 mg................. 29FOTIVDA............................................................................ 12frovatriptan succinate tab 2.5 mg (baseequivalent)......................................................................52FRUITIVITS........................................................................ 61FULPHILA...........................................................................76furosemide oral soln 10 mg/ml...................................... 30furosemide tab 20 mg, 40 mg, 80 mg............................30FUZEON............................................................................... 4FYCOMPA.......................................................................... 53GGA....................................................................................... 61GA-1 ANAMIX EARLY YEARS......................................... 62gabapentin cap 100 mg, 300 mg, 400 mg..................... 53gabapentin oral soln 250 mg/5ml.................................. 53gabapentin tab 600 mg, 800 mg.....................................53GA EXPRESS15................................................................ 62GA GEL.............................................................................. 62GALAFOLD.........................................................................25galantamine hydrobromide cap er 24hr 8 mg, 16 mg,24 mg.............................................................................. 46galantamine hydrobromide tab 4 mg, 8 mg, 12 mg..... 46GALZIN............................................................................... 56GARDASIL 9........................................................................ 9gatifloxacin ophth soln 0.5%..........................................81GATTEX..............................................................................38GAVILYTE-C.......................................................................36GAVRETO...........................................................................12GELATEIN MCT.................................................................62gemfibrozil tab 600 mg................................................... 31GENABIO COVID-19 RAPID SE.......................................87GENOTROPIN................................................................... 25GENOTROPIN MINIQUICK...............................................25GENTAK............................................................................. 81gentamicin sulfate cream 0.1%...................................... 85gentamicin sulfate oint 0.1%.......................................... 85gentamicin sulfate ophth soln 0.3%.............................. 81

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 100GENVOYA............................................................................ 4GERBER EXTENSIVE HA................................................ 62GERBER GOOD START A2/IRON................................... 62GERBER GOOD START A2/TODD.................................. 62GERBER GOOD START GENTLE................................... 62GERBER GOOD START GENTLE/.................................. 62GERBER GOOD START GENTLEP.................................62GERBER GOOD START GROW 3...................................62GERBER GOOD START NOURISH................................. 62GERBER GOOD START PREMATU................................ 62GERBER GOOD START PROTECT................................ 62GERBER GOOD START SOOTHE.................................. 62GERBER GOOD START SOOTHEP................................ 62GERBER GOOD START SOY.......................................... 62GERBER GOOD START SOY 2.......................................62GERBER GOOD START SOY/IRO...................................62GERBER GOOD START SUPREM.................................. 62GERBER GOOD START SUPREME................................62GERBER GRADUATES GENTLE/I...................................62GERBER GRADUATES PROTECT/................................. 62GERBER GRADUATES SOOTHE.................................... 62GERBER GRADUATES SOY/IRON................................. 62GERBER NATURA/STAGE 3/12.......................................62GERBER NATURA/STAGE 1/BIR.....................................62GERBER NATURA/STAGE 2/6 T..................................... 62GILENYA.............................................................................46GILOTRIF........................................................................... 12GLASSIA............................................................................ 36glatiramer acetate soln prefilled syringe 20 mg/ml..... 46glatiramer acetate soln prefilled syringe 40 mg/ml..... 46GLEOSTINE....................................................................... 12glimepiride tab 1 mg, 2 mg, 4 mg..................................20glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg,5-500 mg.........................................................................20glipizide tab er 24hr 2.5 mg, 5 mg, 10 mg.....................20glipizide tab 5 mg............................................................ 20glipizide tab 10 mg.......................................................... 20GLUCAGEN HYPOKIT...................................................... 20GLUCAGON EMERGENCY KIT FO................................. 20glucagon (rdna) for inj kit 1 mg..................................... 20GLUCERNA........................................................................62GLUCERNA ADVANCE SHAKE....................................... 62GLUCERNA 1.0 CAL.........................................................63GLUCERNA 1.2 CAL.........................................................63GLUCERNA 1.5 CAL.........................................................63GLUCERNA 1.0 CAL/FIBER............................................. 63GLUCERNA CARBSTEADY............................................. 62GLUCERNA CEREAL CRUNCHY F.................................62GLUCERNA CRISPY DELIGHTS..................................... 62GLUCERNA HUNGER SMART SHA................................62GLUCERNA MEAL............................................................ 62GLUCERNA MEAL REPLACEMENT................................62GLUCERNA MINI SNACK.................................................62GLUCERNA MINI SNACKS.............................................. 62GLUCERNA OS................................................................. 62GLUCERNA SELECT........................................................ 62GLUCERNA SHAKE..........................................................63GLUCERNA SNACK..........................................................63GLUCERNA SNACK BARS.............................................. 63GLUCERNA SNACK SHAKE............................................ 63GLUCERNA WEIGHT LOSS SHAK................................. 63GLUCERNA 1.0 WITH CARBSTE.................................... 63GLUCERNA WITH CARBSTEADY/..................................63GLUTARADE AMINO ACID BLEN....................................57GLUTARADE ESSENTIAL GA-1.......................................57GLUTARADE JUNIOR GA-1............................................. 57GLUTAREX-1..................................................................... 63GLUTAREX-2..................................................................... 63glyburide-metformin tab 1.25-250 mg, 2.5-500 mg,5-500 mg.........................................................................20glyburide micronized tab 1.5 mg, 3 mg, 6 mg.............. 20glyburide tab 1.25 mg, 2.5 mg, 5 mg.............................20glycopyrrolate oral soln 1 mg/5ml.................................37glycopyrrolate tab 1 mg..................................................37glycopyrrolate tab 2 mg..................................................37GLYCOSADE......................................................................63GLYTACTIN BETTERMILK 15.......................................... 63GLYTACTIN BETTERMILK DE-L...................................... 63GLYTACTIN BUILD 20/20 PKU.........................................63GLYTACTIN BUILD 10PE..................................................63GLYTACTIN COMPLETE 10PE........................................ 63GLYTACTIN RESTORE 5..................................................63GLYTACTIN RESTORE 10................................................63GLYTACTIN RESTORE LITE 10.......................................63GLYTACTIN RTD 10..........................................................63GLYTACTIN RTD 15..........................................................63GLYTACTIN RTD LITE 15.................................................63GLYTACTIN SWIRL 15PE.................................................63GLYTROL PREBIO1.......................................................... 63GLYXAMBI..........................................................................20GOODSENSE NUTRISURE ORIGI.................................. 63GOODSENSE NUTRISURE PLUS...................................63GOOD START....................................................................63GOOD START 2 ESSENTIALS S..................................... 63GOOD START ESSENTIALS SOY................................... 63GOOD START ESSENTIALS W/I..................................... 63GOOD START GENTLE PLUS......................................... 63GOOD START SOY PLUS 2.............................................63GOOD START SUPREME NATURA................................ 63GOOD START 2 SUPREME W/IR....................................63GOOD START SUPREME W/IRON..................................63GOOD START W/FE......................................................... 63G-PREPROTEIN................................................................ 57granisetron hcl tab 1 mg................................................ 38griseofulvin microsize susp 125 mg/5ml........................ 3griseofulvin microsize tab 500 mg.................................. 3griseofulvin ultramicrosize tab 125 mg, 250 mg............ 3guanfacine hcl tab er 24hr 1 mg (base equiv), 2mg (base equiv), 3 mg (base equiv), 4 mg (baseequiv).............................................................................. 45

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 101guanfacine hcl tab 1 mg, 2 mg...................................... 29GVOKE HYPOPEN 1-PACK............................................. 20GVOKE HYPOPEN 2-PACK............................................. 20GVOKE KIT........................................................................ 20GVOKE PFS.......................................................................20GYNAZOLE-1.....................................................................40HHAEGARDA........................................................................78HAELAN 951 FERMENTED ORGA..................................64HAELAN HTPI FERMENTED ORG.................................. 63halobetasol propionate cream 0.05%............................85haloperidol lactate oral conc 2 mg/ml...........................43haloperidol tab 0.5 mg, 1 mg......................................... 43haloperidol tab 2 mg, 5 mg, 10 mg, 20 mg................... 43HARVONI..............................................................................4HAVRIX................................................................................. 9HCU ANAMIX EARLY YEARS.......................................... 64HCU ANAMIX NEXT..........................................................64HCU COOLER................................................................... 64HCU GEL........................................................................... 64HCU LOPHLEX LQ............................................................64HCU MAXAMUM................................................................64HCY 1................................................................................. 64HCY 2................................................................................. 64HEALTH SOURCE SOY PROTEIN.................................. 64HEALTHY ACCENTS NUTRA FIT.................................... 64HEMLIBRA......................................................................... 78HEMOFIL M....................................................................... 78HEPAMENT........................................................................ 57HEPARIN SODIUM............................................................ 77heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/ml, 10000 unit/ml, 20000 unit/ml................................. 77heparin sodium (porcine) pf inj 5000 unit/0.5ml.......... 77HEPLISAV-B......................................................................... 9HETLIOZ.............................................................................44HETLIOZ LQ...................................................................... 44HIBERIX................................................................................9HI-CAL................................................................................ 64HIGH-PROTEIN NUTRITIONAL........................................64HM NUTRISURE................................................................64HM NUTRISURE PLUS.....................................................64HOM 2................................................................................ 64HOMACTIN AA PLUS....................................................... 64HOMINEX-1........................................................................64HOMINEX-2........................................................................64HUMATE-P......................................................................... 78HUMIRA..............................................................................50HUMIRA PEDIATRIC CROHNS D.................................... 50HUMIRA PEN.....................................................................50HUMIRA PEN-CD/UC/HS START.....................................50HUMIRA PEN-PEDIATRIC UC S...................................... 50HUMIRA PEN-PS/UV STARTER...................................... 50HUMULIN R U-500 (CONCENTR.....................................22HUMULIN R U-500 KWIKPEN.......................................... 22HYCAMTIN......................................................................... 12hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg....... 29hydrochlorothiazide cap 12.5 mg.................................. 30hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg..........30HYDROCODONE/IBUPROFEN........................................ 48hydrocodone-acetaminophen soln 7.5-325mg/15ml.......................................................................... 48hydrocodone-acetaminophen tab 10-325 mg...............48hydrocodone-acetaminophen tab 5-325 mg, 7.5-325mg................................................................................... 48HYDROCODONE BITARTRATE ER.................................48hydrocodone-ibuprofen tab 7.5-200 mg........................48hydrocod polst-chlorphen polst er susp 10-8mg/5ml............................................................................ 33hydrocortisone acetate suppos 25 mg......................... 82hydrocortisone cream 2.5%............................................85hydrocortisone enema 100 mg/60ml............................. 82hydrocortisone lotion 2.5%............................................ 85hydrocortisone oint 2.5%................................................85hydrocortisone perianal cream 1%............................... 82hydrocortisone perianal cream 2.5%............................ 82hydrocortisone tab 5 mg, 10 mg, 20 mg....................... 17hydrocortisone w/ acetic acid otic soln 1-2%.............. 82hydromorphone hcl liqd 1 mg/ml.................................. 48hydromorphone hcl tab er 24hr 8 mg, 12 mg, 16 mg,32 mg.............................................................................. 48hydromorphone hcl tab 8 mg.........................................48hydromorphone hcl tab 2 mg, 4 mg..............................48HYDROXOCOBALAMIN....................................................76hydroxychloroquine sulfate tab 200 mg......................... 7hydroxyurea cap 500 mg................................................ 12hydroxyzine hcl syrup 10 mg/5ml................................. 40hydroxyzine hcl tab 10 mg, 25 mg, 50 mg.................... 41hydroxyzine pamoate cap 25 mg, 50 mg...................... 41II5......................................................................................... 64ibandronate sodium tab 150 mg (base equivalent)..... 25IBRANCE............................................................................12ibuprofen tab 400 mg, 600 mg, 800 mg.........................50icatibant acetate inj 30 mg/3ml (base equivalent)........78ICLUSIG..............................................................................12icosapent ethyl cap 0.5 gm............................................ 31icosapent ethyl cap 1 gm............................................... 31IDELVION........................................................................... 78IDHIFA................................................................................ 12IHEALTH COVID-19 ANTIGEN......................................... 87imatinib mesylate tab 100 mg (base equivalent)..........12imatinib mesylate tab 400 mg (base equivalent)..........12IMBRUVICA........................................................................13IMCIVREE.......................................................................... 45imipramine hcl tab 10 mg, 25 mg, 50 mg......................41imiquimod cream 5%.......................................................85IMMULIFE...........................................................................64IMPACT...............................................................................64

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 102IMPACT ADVANCED RECOVERY................................... 64IMPACT PEPTIDE 1.5....................................................... 64IMPAVIDO.............................................................................7INBRIJA.............................................................................. 55INCRELEX..........................................................................25INCRUSE ELLIPTA............................................................35indapamide tab 1.25 mg, 2.5 mg....................................30INDICAID COVID-19 RAPID A..........................................87indomethacin cap er 75 mg............................................50indomethacin cap 25 mg, 50 mg....................................50INFANRIX........................................................................... 11INGREZZA..........................................................................46INLYTA................................................................................ 13INNOVACIN........................................................................ 64INQOVI............................................................................... 13INREBIC............................................................................. 13INSULIN ASPART..............................................................22INSULIN ASPART FLEXPEN............................................ 22INSULIN ASPART PENFILL..............................................22INSULIN ASPART PROTAMINE/...................................... 22INSULIN GLARGINE......................................................... 23INTELENCE..........................................................................4INTELISWAB COVID-19 RAPID....................................... 87INTROLITE......................................................................... 64IPOL INACTIVATED IPV..................................................... 9ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 35ipratropium bromide inhal soln 0.02%.......................... 35ipratropium bromide nasal soln 0.03% (21 mcg/spray).............................................................................. 33ipratropium bromide nasal soln 0.06% (42 mcg/spray).............................................................................. 33irbesartan-hydrochlorothiazide tab 150-12.5 mg,300-12.5 mg....................................................................29irbesartan tab 75 mg, 150 mg, 300 mg..........................29IRESSA...............................................................................13IRON UP............................................................................ 76ISENTRESS......................................................................... 5ISENTRESS HD...................................................................5ISOMIL 2............................................................................ 64ISOMIL/IRON..................................................................... 64ISOMIL SOY W/IRON........................................................64ISONIAZID............................................................................3isoniazid tab 300 mg......................................................... 3ISOPTO ATROPINE.......................................................... 81isosorbide dinitrate tab 5 mg......................................... 26isosorbide dinitrate tab 10 mg, 20 mg, 30 mg..............26ISOSORBIDE MONONITRATE......................................... 26isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120mg................................................................................... 26ISOSOURCE 1.5 CAL....................................................... 64ISOSOURCE HN............................................................... 64isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mg.............. 85isradipine cap 2.5 mg, 5 mg...........................................28itraconazole cap 100 mg...................................................3itraconazole oral soln 10 mg/ml.......................................3IVA ANAMIX EARLY YEARS............................................ 64IVA ANAMIX NEXT............................................................64I-VALEX-1........................................................................... 64I-VALEX-2........................................................................... 64IVA MAXAMUM.................................................................. 64ivermectin tab 3 mg...........................................................7JJAKAFI................................................................................13JANSSEN COVID-19 VACCINE..........................................9JANUMET...........................................................................20JANUMET XR.................................................................... 20JANUVIA.............................................................................21JARDIANCE....................................................................... 21JEVITY 1 CAL....................................................................64JEVITY 1.2 CAL.................................................................64JEVITY 1 CAL/FIBER........................................................ 64JEVITY 1.2 CAL/FIBER..................................................... 64JEVITY 1.5 CAL/FIBER..................................................... 64JIVI...................................................................................... 78JUICE PLUS FIBRE.......................................................... 65JULUCA................................................................................ 5JUVEN................................................................................ 65JUVEN NUTRIVIGOR........................................................65JUVEN REVIGOR..............................................................65JYNARQUE........................................................................ 25KKALE/QUINOA/BERRIES.................................................. 65KALYDECO........................................................................ 36KATE FARMS GLUCOSE SUPPOR.................................65KATE FARMS PEPTIDE 1.0............................................. 65KATE FARMS PEPTIDE 1.5............................................. 65KATE FARMS PEPTIDE 1.0 PE....................................... 65KATE FARMS PEPTIDE 1.5 PE....................................... 65KATE FARMS RENAL SUPPORT.................................... 65KATE FARMS STANDARD 1.0......................................... 65KATE FARMS STANDARD 1.4......................................... 65KATE FARMS STANDARD 1.0 P......................................65KATE FARMS STANDARD 1.2 P......................................65KESIMPTA.......................................................................... 46KETO.................................................................................. 65KETOCAL 3:1.....................................................................65KETOCAL 4:1.....................................................................65KETOCAL 2.5:1 LQ........................................................... 65KETOCAL 4:1 LQ MULTI FIBE......................................... 65ketoconazole cream 2%.................................................. 85ketoconazole shampoo 2%.............................................85ketoconazole tab 200 mg..................................................3KETOGEN.......................................................................... 65KETONEX-1....................................................................... 65KETONEX-2....................................................................... 65ketorolac tromethamine ophth soln 0.4%.....................81ketorolac tromethamine ophth soln 0.5%.....................81ketorolac tromethamine tab 10 mg............................... 50KETOVIE............................................................................ 65

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 103KETOVIE 4:1......................................................................65KETOVIE PEPTIDE........................................................... 65KEVZARA........................................................................... 50KFLO...................................................................................65KIDS PROTEIN ORGANIC NUTR.................................... 65KINDERSPROUT PLANT PROTEI...................................65KINRIX................................................................................ 11KISQALI..............................................................................13KISQALI FEMARA 200 DOSE.......................................... 13KISQALI FEMARA 400 DOSE.......................................... 13KISQALI FEMARA 600 DOSE.......................................... 13KLOXXADO........................................................................ 86KOATE................................................................................ 78KOATE-DVI.........................................................................78KOGENATE FS.................................................................. 78KOSELUGO........................................................................13KOVALTRY......................................................................... 78K-PAX IMMUNE BOOSTER PROT...................................65K-PHOS NO 2....................................................................40KRINTAFEL.......................................................................... 7KYNMOBI........................................................................... 55Llabetalol hcl tab 100 mg..................................................27labetalol hcl tab 200 mg, 300 mg...................................27lacosamide oral solution 10 mg/ml............................... 53lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg......... 53lactic acid (ammonium lactate) cream 12%..................85lactic acid (ammonium lactate) lotion 12%...................85lactulose (encephalopathy) solution 10 gm/15ml........ 38lactulose solution 10 gm/15ml....................................... 36LAGEVRIO........................................................................... 5lamivudine oral soln 10 mg/ml.........................................5lamivudine tab 150 mg, 300 mg....................................... 5lamivudine tab 100 mg (hbv)............................................5lamivudine-zidovudine tab 150-300 mg.......................... 5lamotrigine tab chewable dispersible 5 mg, 25 mg..... 53lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg,250 mg, 300 mg.............................................................53lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg......... 53LAMPIT................................................................................. 7LANAFLEX......................................................................... 65lansoprazole cap delayed release 15 mg......................37lansoprazole cap delayed release 30 mg......................37lanthanum carbonate chew tab 500 mg (elemental),750 mg (elemental), 1000 mg (elemental).................. 38lapatinib ditosylate tab 250 mg (base equiv)............... 13latanoprost ophth soln 0.005%...................................... 81LATUDA.............................................................................. 43LEDIPASVIR/SOFOSBUVIR................................................5leflunomide tab 10 mg, 20 mg........................................50lenalidomide cap 5 mg, 10 mg....................................... 88lenalidomide cap 15 mg, 20 mg, 25 mg........................ 88lenalidomide caps 2.5 mg...............................................88LENVIMA 4 MG DAILY DOSE.......................................... 13LENVIMA 8 MG DAILY DOSE.......................................... 13LENVIMA 10 MG DAILY DOSE........................................ 13LENVIMA 12MG DAILY DOSE......................................... 13LENVIMA 14 MG DAILY DOSE........................................ 13LENVIMA 18 MG DAILY DOSE........................................ 13LENVIMA 20 MG DAILY DOSE........................................ 13LENVIMA 24 MG DAILY DOSE........................................ 13letrozole tab 2.5 mg......................................................... 13leucovorin calcium tab 5 mg, 10 mg, 15 mg, 25mg................................................................................... 13LEUKERAN........................................................................ 14LEUKINE............................................................................ 76leuprolide acetate inj kit 5 mg/ml.................................. 14levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (baseequiv).............................................................................. 35levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv),0.63 mg/3ml (base equiv), 1.25 mg/3ml (baseequiv).............................................................................. 35LEVEMIR............................................................................ 23LEVEMIR FLEXPEN..........................................................23levetiracetam oral soln 100 mg/ml................................ 53levetiracetam tab er 24hr 500 mg, 750 mg....................53levetiracetam tab 250 mg, 500 mg.................................53levetiracetam tab 750 mg, 1000 mg...............................53LEVOBUNOLOL HCL........................................................ 81levocarnitine oral soln 1 gm/10ml (10%).......................25levocarnitine tab 330 mg................................................ 25levocetirizine dihydrochloride tab 5 mg....................... 33levofloxacin ophth soln 0.5%......................................... 81levofloxacin oral soln 25 mg/ml.......................................2levofloxacin tab 250 mg, 500 mg, 750 mg...................... 2levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est0.01 mg...........................................................................19levonorgestrel & ethinyl estradiol (91-day) tab0.15-0.03 mg.................................................................. 19levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,0.15 mg-30 mcg.............................................................19levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg...............................19levonorgestrel-ethinyl estradiol (continuous) tab90-20 mcg.......................................................................19levonorgestrel tab 1.5 mg...............................................19levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7)........................................................................19levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7)........................................................................19levo-t - euthyrox - levothyroxine sodium tab 25 mcg,88 mcg, 100 mcg, 112 mcg, 125 mcg......................... 23levo-t - levoxyl - levothyroxine sodium tab 75 mcg,150 mcg, 175 mcg, 200 mcg........................................23levo-t - unithroid - levothyroxine sodium tab 50 mcg,137 mcg, 300 mcg........................................................ 24levoxyl - euthyrox - levothyroxine sodium tab 25 mcg,88 mcg, 100 mcg, 112 mcg, 125 mcg......................... 24

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 104levoxyl - levothyroxine sodium tab 75 mcg, 150 mcg,175 mcg, 200 mcg........................................................ 24levoxyl - levoxyl - levothyroxine sodium tab 75 mcg,150 mcg, 175 mcg, 200 mcg........................................24levoxyl - unithroid - levothyroxine sodium tab 50 mcg,137 mcg.......................................................................... 24LEXIVA..................................................................................5lidocaine hcl soln 4%...................................................... 85lidocaine hcl viscous soln 2%....................................... 82lidocaine patch 5%.......................................................... 85lidocaine-prilocaine cream 2.5-2.5%..............................85LINDANE............................................................................ 85linezolid for susp 100 mg/5ml.......................................... 7linezolid tab 600 mg.......................................................... 7liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg.........24LIPISTART.......................................................................... 65LIQUACEL.......................................................................... 57LIQUACEL PUMP + GO....................................................57LIQUID HOPE.................................................................... 65LIQUID HOPE PEPTIDE................................................... 65LIQUID HOPE PEPTIDE HIGH.........................................65lisinopril & hydrochlorothiazide tab 10-12.5 mg,20-12.5 mg, 20-25 mg................................................... 29lisinopril tab 20 mg..........................................................29lisinopril tab 2.5 mg, 5 mg, 10 mg, 30 mg, 40 mg........ 29LITHIUM CARBONATE..................................................... 43lithium carbonate cap 300 mg....................................... 43lithium carbonate cap 150 mg, 600 mg.........................43lithium carbonate tab er 300 mg....................................43lithium carbonate tab er 450 mg....................................43lithium carbonate tab 300 mg........................................ 43LITHOSTAT.........................................................................40LIVMARLI........................................................................... 38LMD.................................................................................... 65LOKELMA...........................................................................88LONSURF...........................................................................14LOPHLEX........................................................................... 66LOPHLEX LQ 20............................................................... 66lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)......................................................................................5lopinavir-ritonavir tab 100-25 mg.....................................5lopinavir-ritonavir tab 200-50 mg.....................................5lorazepam conc 2 mg/ml.................................................41lorazepam tab 0.5 mg, 1 mg, 2 mg................................ 41LORBRENA........................................................................ 14losartan potassium & hydrochlorothiazide tab 50-12.5mg, 100-12.5 mg, 100-25 mg....................................... 29losartan potassium tab 25 mg, 50 mg, 100 mg............ 29lovastatin tab 10 mg........................................................31lovastatin tab 20 mg, 40 mg...........................................31loxapine succinate cap 5 mg, 10 mg, 25 mg, 50mg................................................................................... 43LPS CRITICAL CARE SUGAR F...................................... 66LPS SUGAR FREE............................................................66LUMAKRAS........................................................................ 14LUMIGAN........................................................................... 81lurasidone hcl tab 80 mg................................................43lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg........ 43LUTRISH CHOCOLATE SHAKE.......................................66LUTRISH VANILLA SHAKE.............................................. 66LYNPARZA......................................................................... 14LYSODREN........................................................................ 14Mmalathion lotion 0.5%......................................................85maraviroc tab 150 mg....................................................... 5maraviroc tab 300 mg....................................................... 5MARPLAN.......................................................................... 41MATULANE........................................................................ 14MAVENCLAD......................................................................46MAVYRET.............................................................................5MAXIDEX............................................................................81MAYZENT........................................................................... 46MAYZENT STARTER PACK..............................................46MCT PRO-CAL.................................................................. 66meclizine hcl tab 25 mg.................................................. 38MECLOFENAMATE SODIUM........................................... 50medroxyprogesterone acetate im susp 150 mg/ml..... 19medroxyprogesterone acetate im susp prefilled syr150 mg/ml.......................................................................19medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10mg................................................................................... 20mefenamic acid cap 250 mg.......................................... 50mefloquine hcl tab 250 mg............................................... 7megestrol acetate susp 40 mg/ml................................. 14megestrol acetate tab 20 mg, 40 mg............................. 14MEKINIST...........................................................................14MEKTOVI............................................................................14meloxicam tab 7.5 mg, 15 mg........................................ 50melphalan tab 2 mg......................................................... 14memantine hcl tab 5 mg, 10 mg.................................... 46memantine hcl tab 28 x 5 mg & 21 x 10 mg titrationpack.................................................................................46MENACTRA..........................................................................9MENEST.............................................................................18MENQUADFI........................................................................ 9MENTAX............................................................................. 85MENVEO.............................................................................. 9meprobamate tab 200 mg, 400 mg................................ 41mercaptopurine tab 50 mg............................................. 14mesalamine cap dr 400 mg............................................ 38mesalamine cap er 24hr 0.375 gm.................................38mesalamine enema 4 gm................................................ 38mesalamine suppos 1000 mg........................................ 39mesalamine tab delayed release 1.2 gm.......................39mesalamine tab delayed release 800 mg......................39MESNEX.............................................................................14metformin hcl tab er 24hr 500 mg, 750 mg...................21metformin hcl tab 500 mg, 850 mg, 1000 mg............... 21methadone hcl conc 10 mg/ml.......................................48

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 105methadone hcl soln 5 mg/5ml, 10 mg/5ml....................48methadone hcl tab for oral susp 40 mg........................48methadone hcl tab 5 mg, 10 mg.................................... 48methamphetamine hcl tab 5 mg.................................... 45methazolamide tab 25 mg, 50 mg..................................30methenamine hippurate tab 1 gm....................................7methimazole tab 5 mg, 10 mg........................................24METHIONAID..................................................................... 66METHITEST....................................................................... 17methocarbamol tab 500 mg, 750 mg............................. 55methotrexate sodium for inj 1 gm................................. 14methotrexate sodium inj 50 mg/2ml (25 mg/ml)...........14methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml)................................................................................... 14methotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250mg/10ml (25 mg/ml)...................................................... 14methotrexate sodium tab 2.5 mg (base equiv).............14METHOXSALEN................................................................ 85methscopolamine bromide tab 2.5 mg, 5 mg............... 37METHYLDOPA................................................................... 29methylergonovine maleate tab 0.2 mg..........................24methylphenidate hcl cap er 24hr 10 mg (la), 20 mg(la), 30 mg (la), 40 mg (la)............................................45methylphenidate hcl cap er 10 mg (cd), 20 mg (cd), 30mg (cd), 40 mg (cd), 50 mg (cd), 60 mg (cd)..............45methylphenidate hcl soln 5 mg/5ml.............................. 45methylphenidate hcl soln 10 mg/5ml............................ 45methylphenidate hcl tab er 10 mg, 20 mg.................... 45methylphenidate hcl tab er osmotic release (osm) 36mg................................................................................... 45methylphenidate hcl tab er osmotic release (osm) 18mg, 27 mg, 54 mg.........................................................45methylphenidate hcl tab 5 mg........................................45methylphenidate hcl tab 10 mg, 20 mg.........................45methylprednisolone tab 8 mg........................................ 17methylprednisolone tab 4 mg, 16 mg, 32 mg............... 17methylprednisolone tab therapy pack 4 mg (21)......... 17metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (baseequiv).............................................................................. 39metoclopramide hcl tab 5 mg (base equivalent), 10mg (base equivalent)....................................................39metolazone tab 2.5 mg, 5 mg, 10 mg............................ 30metoprolol & hydrochlorothiazide tab 50-25 mg,100-25 mg, 100-50 mg.................................................. 29metoprolol succinate tab er 24hr 200 mg (tartrateequiv).............................................................................. 27metoprolol succinate tab er 24hr 25 mg (tartrateequiv), 50 mg (tartrate equiv), 100 mg (tartrateequiv).............................................................................. 27metoprolol tartrate tab 25 mg........................................ 27metoprolol tartrate tab 50 mg, 100 mg..........................27metronidazole cream 0.75%........................................... 85metronidazole gel 0.75%.................................................85metronidazole gel 1%...................................................... 85metronidazole tab 250 mg................................................ 7metronidazole tab 500 mg................................................ 7metronidazole vaginal gel 0.75%................................... 40mexiletine hcl cap 150 mg, 200 mg, 250 mg.................28MICONAZOLE 3................................................................ 40midodrine hcl tab 2.5 mg, 5 mg, 10 mg........................ 31minocycline hcl cap 50 mg...............................................2minocycline hcl cap 75 mg, 100 mg................................2minoxidil tab 2.5 mg, 10 mg...........................................29MIRCERA........................................................................... 76mirtazapine orally disintegrating tab 15 mg, 30 mg, 45mg................................................................................... 42mirtazapine tab 45 mg.....................................................42mirtazapine tab 15 mg, 30 mg........................................42MIRVASO............................................................................85misoprostol tab 100 mcg, 200 mcg............................... 37MMA/PA ANAMIX EARLY YEARS....................................66MMA/PA ANAMIX NEXT................................................... 66MMA/PA COOLER15......................................................... 66MMA/PA GEL..................................................................... 66MMA/PA MAXAMUM......................................................... 66M-M-R II................................................................................9modafinil tab 100 mg.......................................................45modafinil tab 200 mg.......................................................45MODERNA COVID-19 VACCINE........................................9MODERNA COVID-19 VACCINE/.......................................9MODULEN..........................................................................66moexipril hcl tab 7.5 mg, 15 mg.................................... 29MOLINDONE HYDROCHLORIDE.................................... 43mometasone furoate cream 0.1%.................................. 85mometasone furoate oint 0.1%...................................... 85mometasone furoate solution 0.1% (lotion)................. 85MONOGEN.........................................................................66montelukast sodium chew tab 4 mg (base equiv), 5mg (base equiv)............................................................ 35montelukast sodium tab 10 mg (base equiv)............... 35MORPHINE SULFATE.......................................................48morphine sulfate oral soln 10 mg/5ml.......................... 48morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 49morphine sulfate tab er 15 mg.......................................49morphine sulfate tab er 30 mg, 60 mg, 100 mg, 200mg................................................................................... 49morphine sulfate tab 15 mg, 30 mg...............................49MOVANTIK......................................................................... 39moxifloxacin hcl ophth soln 0.5% (base equiv)........... 81moxifloxacin hcl tab 400 mg (base equiv)......................2MSUD 2..............................................................................66MSUD AID..........................................................................66MSUD ANALOG.................................................................66MSUD ANAMIX EARLY YEARS....................................... 66MSUD COOLER................................................................ 66MSUD EXPRESS 15 PLUS.............................................. 66MSUD EXPRESS 20 PLUS.............................................. 66MSUD GEL.........................................................................66MSUD LOPHLEX LQ.........................................................66MSUD MAXAMAID............................................................ 66

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 106MSUD MAXAMUM.............................................................66MULPLETA......................................................................... 76MULTAQ............................................................................. 28mupirocin oint 2%............................................................85MYALEPT........................................................................... 25mycophenolate mofetil cap 250 mg.............................. 88mycophenolate mofetil for oral susp 200 mg/ml......... 88mycophenolate mofetil tab 500 mg............................... 88mycophenolate sodium tab dr 180 mg (mycophenolicacid equiv), 360 mg (mycophenolic acid equiv)....... 88MYFEMBREE.....................................................................18MYLERAN.......................................................................... 14MYRBETRIQ...................................................................... 39Nnabumetone tab 500 mg................................................. 50nabumetone tab 750 mg................................................. 50nadolol tab 20 mg, 40 mg, 80 mg.................................. 27naloxone hcl inj 0.4 mg/ml, 4 mg/10ml......................... 86naloxone hcl nasal spray 4 mg/0.1ml............................86naloxone hcl soln prefilled syringe 2 mg/2ml.............. 86NALOXONE HYDROCHLORIDE...................................... 86naltrexone hcl tab 50 mg................................................86NANOVM ADULT...............................................................56NANOVM SENIOR 71+..................................................... 56naproxen sodium tab 550 mg........................................ 50naproxen tab 500 mg...................................................... 51naproxen tab 250 mg, 375 mg....................................... 50naratriptan hcl tab 1 mg (base equiv), 2.5 mg (baseequiv).............................................................................. 52NATACYN........................................................................... 81nateglinide tab 60 mg, 120 mg.......................................21NATPARA........................................................................... 25NATROBA...........................................................................85NAYZILAM.......................................................................... 53NEOCATE INFANT DHA/ARA...........................................66NEOCATE JUNIOR............................................................66NEOCATE JUNIOR/PREBIOTICS.................................... 66NEOCATE NUTRA.............................................................66NEOCATE SPLASH...........................................................66NEOCATE SYNEO INFANT.............................................. 66NEOMYCIN/POLYMYXIN/GRAMIC.................................. 81neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin............................... 81neomycin-polymyxin-dexamethasone ophth oint0.1%.................................................................................81neomycin-polymyxin-dexamethasone ophth susp0.1%.................................................................................81neomycin-polymyxin-hc otic soln 1%........................... 82neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%...................................................................... 82neomycin sulfate tab 500 mg........................................... 2NEPRO............................................................................... 66NEPRO WITH CARBSTEADY.......................................... 66NEPRO WITH CARB STEADY......................................... 66NESTLE NAN PRO 1/IRON.............................................. 66NESTLE NAN PRO/TODDLER......................................... 66NEVIRAPINE........................................................................ 5NEVIRAPINE ER................................................................. 5nevirapine tab er 24hr 400 mg......................................... 5nevirapine tab 200 mg.......................................................5NEXAVAR........................................................................... 14NEXIUM..............................................................................37NEXLETOL......................................................................... 31NEXLIZET...........................................................................31niacin tab er 500 mg (antihyperlipidemic),750 mg (antihyperlipidemic), 1000 mg(antihyperlipidemic)......................................................32nicardipine hcl cap 20 mg, 30 mg................................. 28nicotine polacrilex gum 2 mg, 4 mg..............................46nicotine polacrilex lozenge 2 mg, 4 mg........................ 46nicotine td patch 24hr 7 mg/24hr, 14 mg/24hr, 21mg/24hr...........................................................................46NICOTINE TRANSDERMAL SYST...................................46NICOTROL INHALER........................................................46NICOTROL NS...................................................................46nifedipine cap 10 mg.......................................................28nifedipine cap 20 mg.......................................................28nifedipine tab er 24hr 30 mg.......................................... 28nifedipine tab er 24hr 60 mg, 90 mg............................. 28nifedipine tab er 24hr osmotic release 30 mg..............28nifedipine tab er 24hr osmotic release 60 mg, 90mg................................................................................... 28nilutamide tab 150 mg.....................................................14nimodipine cap 30 mg.....................................................28NINLARO............................................................................14nisoldipine tab er 24hr 8.5 mg....................................... 28nitazoxanide tab 500 mg...................................................7nitisinone cap 2 mg, 5 mg, 10 mg................................. 25NITRO-BID......................................................................... 26nitrofurantoin macrocrystalline cap 50 mg, 100 mg......8nitrofurantoin monohydrate macrocrystalline cap 100mg......................................................................................8nitrofurantoin susp 25 mg/5ml.........................................8nitroglycerin sl tab 0.4 mg..............................................26nitroglycerin sl tab 0.3 mg, 0.6 mg................................26nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr............................................................26NITRO-TIME.......................................................................26NIVA-FOL............................................................................66NIVESTYM......................................................................... 76NIZATIDINE........................................................................ 37NORDITROPIN FLEXPRO................................................ 25norelgestromin-ethinyl estradiol td ptwk 150-35mcg/24hr.........................................................................19norethindrone & ethinyl estradiol-fe chew tab 0.4mg-35 mcg..................................................................... 19norethindrone & ethinyl estradiol-fe chew tab 0.8mg-25 mcg..................................................................... 19

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 107norethindrone & ethinyl estradiol tab 1 mg-35mcg................................................................................. 19norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,0.5 mg-35 mcg...............................................................19norethindrone ace & ethinyl estradiol-fe tab 1 mg-20mcg................................................................................. 19norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30mcg................................................................................. 19norethindrone ace & ethinyl estradiol tab 1 mg-20mcg................................................................................. 19norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg................................................................................. 19norethindrone ace-eth estradiol-fe chew tab 1 mg-20mcg (24)......................................................................... 19norethindrone ace-ethinyl estradiol-fe tab 1 mg-20mcg (24)......................................................................... 19norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg................................................................................. 18norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg................................................................................. 18norethindrone acetate tab 5 mg.................................... 20norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35mg-mcg...........................................................................19norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35mg-mcg...........................................................................19norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg................................................................................. 19norethindrone tab 0.35 mg............................................. 19norgestimate & ethinyl estradiol tab 0.25 mg-35mcg................................................................................. 19norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25mg-mcg...........................................................................19norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg...........................................................................19norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........19NORTRIPTYLINE HCL...................................................... 42nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg....... 42NORVIR................................................................................ 5NOURISH........................................................................... 66NOURISH PEPTIDE BERRY MED................................... 66NOURISH PEPTIDE FORMULA.......................................67NOVAFERRUM PEDIATRIC DROP..................................76NOVASOURCE RENAL.....................................................67NOVAVAX COVID-19 VACCINE..........................................9NOVOEIGHT...................................................................... 79NOVOLIN 70/30................................................................. 23NOVOLIN 70/30 FLEXPEN............................................... 23NOVOLIN 70/30 FLEXPEN REL.......................................23NOVOLIN 70/30 RELION.................................................. 23NOVOLIN N........................................................................22NOVOLIN N FLEXPEN......................................................22NOVOLIN N FLEXPEN RELION.......................................22NOVOLIN N RELION.........................................................22NOVOLIN R........................................................................22NOVOLIN R FLEXPEN......................................................22NOVOLIN R FLEXPEN RELION.......................................22NOVOLIN R RELION.........................................................22NOVOLOG..........................................................................22NOVOLOG FLEXPEN....................................................... 22NOVOLOG FLEXPEN RELION.........................................22NOVOLOG MIX 70/30....................................................... 23NOVOLOG MIX 70/30 PREFILL....................................... 23NOVOLOG MIX 70/30 RELION........................................ 23NOVOLOG PENFILL......................................................... 22NOVOLOG RELION.......................................................... 22NOVOSEVEN RT...............................................................79NP THYROID 15................................................................24NP THYROID 30................................................................24NP THYROID 60................................................................24NP THYROID 90................................................................24NP THYROID 120..............................................................24NUBEQA.............................................................................14NUCALA............................................................................. 35NUCYNTA ER.................................................................... 49NULIBRY............................................................................ 25NURTEC.............................................................................52NUTRA/BALANCE RE/GEN..............................................67NUTRA/BALANCE RE/GEN FREE...................................67NUTRA/SHAKE.................................................................. 67NUTRA/SHAKE FRUIT PLUS........................................... 67NUTRA/SHAKE SUPREME.............................................. 67NUTRA BALANCE DIABETIC NU.................................... 67NUTRA BALANCE FIBER COOKI....................................67NUTRA BALANCE PROTEIN FOR.................................. 67NUTRAMINE...................................................................... 67NUTRAMINE APPLE AMINO BIT..................................... 67NUTRAMINE BANANA AMINO B..................................... 67NUTRAMINE CHOCOLATE AMINO................................. 67NUTRAMINE MANGO AMINO BI..................................... 67NUTRAMINE MIXED FLAVORS A....................................67NUTRAMINE PEACHES & CREAM................................. 67NUTRAMINE PINEAPPLE AMINO................................... 67NUTRASENTIALS..............................................................57NUTRA SHAKE..................................................................67NUTRA SHAKE/SUPREME.............................................. 67NUTREN 1.5...................................................................... 67NUTREN 2.0...................................................................... 67NUTREN 1.0/FIBER.......................................................... 67NUTREN 1.0 CAL..............................................................67NUTREN 1.5 CAL..............................................................67NUTREN 2.0 CAL..............................................................67NUTREN JR....................................................................... 67NUTREN JR FIBER...........................................................67NUTREN JUNIOR 1.0....................................................... 67NUTREN JUNIOR/FIBER.................................................. 67NUTREN PULMONARY.................................................... 67NUTRICIA PREOP.............................................................67NUTRIFOCUS.................................................................... 67NUTRIHEP 1.5 CAL.......................................................... 67NUTRITIONAL DRINK.......................................................67

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 108NUTRITIONAL DRINK MIX............................................... 67NUTRITIONAL DRINK PLUS............................................ 67NUTRITIONAL DRINK SHAKE M..................................... 67NUTRITIONAL SHAKE......................................................67NUTRITIONAL SHAKE COMPLET...................................68NUTRITIONAL SHAKE HIGH PR..................................... 68NUTRITIONAL SHAKE PLUS........................................... 68NUTRITIONAL SHAKE PLUS PR.....................................68NUTRITIONAL SUPPLEMENT......................................... 68nutritional supplement liquid......................................... 68NUTRITIONAL SUPPLEMENT PL....................................68NUVARING......................................................................... 19NUWIQ................................................................................79NYMALIZE..........................................................................28nystatin cream 100000 unit/gm...................................... 85nystatin oint 100000 unit/gm.......................................... 85nystatin susp 100000 unit/ml......................................... 82nystatin tab 500000 unit....................................................3nystatin topical powder 100000 unit/gm.......................85nystatin-triamcinolone cream 100000-0.1 unit/gm-%......................................................................................85nystatin-triamcinolone oint 100000-0.1 unit/gm-%...... 85OOA 1................................................................................... 68OA 2................................................................................... 68OBIZUR.............................................................................. 79OCTREOTIDE ACETATE.................................................. 25octreotide acetate inj 200 mcg/ml (0.2 mg/ml), 1000mcg/ml (1 mg/ml).......................................................... 25octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100mcg/ml (0.1 mg/ml), 500 mcg/ml (0.5 mg/ml).............25ODEFSEY.............................................................................5ODOMZO............................................................................14OFEV.................................................................................. 36OFLOXACIN......................................................................... 2ofloxacin ophth soln 0.3%.............................................. 81ofloxacin otic soln 0.3%..................................................82ofloxacin tab 400 mg......................................................... 2olanzapine tab 15 mg, 20 mg......................................... 43olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg................ 43olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg......................................................................30olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg, 40-25 mg................................................... 30olmesartan medoxomil tab 5 mg, 20 mg, 40 mg.......... 30olopatadine hcl ophth soln 0.1% (baseequivalent)......................................................................81OLUMIANT......................................................................... 51omeprazole cap delayed release 10 mg, 20 mg, 40mg................................................................................... 37OMNIFLEX DIAPHRAGM..................................................87OMNIPOD DASH INTRO KIT (G...................................... 87OMNIPOD DASH PODS (GEN 4).................................... 87OMNIPOD 5 G6 INTRO KIT (G........................................ 87OMNIPOD 5 G6 PODS (GEN 5).......................................87ON/GO COVID-19 ANTIGEN SE...................................... 87ON/GO ONE COVID-19 ANTIGE..................................... 87ondansetron hcl oral soln 4 mg/5ml............................. 38ondansetron hcl tab 4 mg.............................................. 38ondansetron hcl tab 8 mg.............................................. 38ondansetron orally disintegrating tab 4 mg, 8 mg.......38ONUREG............................................................................ 14OPSUMIT........................................................................... 32OPTICLEANSE GHI...........................................................68OPTIMENTAL..................................................................... 68OPTIMETABOLIX...............................................................68OPTIMETABOLIX 2:1........................................................ 68OPTIONS GYNOL II VAGINAL......................................... 40ORANGE CHICKEN/CARROTS/BR................................. 68ORENCIA........................................................................... 51ORENCIA CLICKJECT...................................................... 51ORENITRAM...................................................................... 32ORFADIN............................................................................25ORGANIC NUTRITION ALL-IN-........................................68ORGANIC NUTRITION COMPLET...................................68ORGANIC NUTRITION PLANT B..................................... 68ORGANIC NUTRITION VEGAN-A....................................68ORGANIC PEDIA SMART.................................................68ORGOVYX..........................................................................14ORIAHNN........................................................................... 18ORILISSA........................................................................... 25ORKAMBI........................................................................... 36orphenadrine citrate tab er 12hr 100 mg...................... 55OS 2................................................................................... 68OSAPLEX MK-7.................................................................68oseltamivir phosphate cap 30 mg (base equiv)............. 5oseltamivir phosphate cap 45 mg (base equiv), 75 mg(base equiv)..................................................................... 5oseltamivir phosphate for susp 6 mg/ml (baseequiv)................................................................................ 5OSMOLITE......................................................................... 68OSMOLITE 1 CAL............................................................. 68OSMOLITE 1.0 CAL.......................................................... 68OSMOLITE 1.2 CAL.......................................................... 68OSMOLITE 1.5 CAL.......................................................... 68OSMOLITE HN.................................................................. 68OTEZLA..............................................................................51OTREXUP.......................................................................... 51oxandrolone tab 2.5 mg, 10 mg..................................... 17oxaprozin tab 600 mg......................................................51oxazepam cap 10 mg, 15 mg, 30 mg.............................41OXBRYTA........................................................................... 76oxcarbazepine susp 300 mg/5ml (60 mg/ml)................ 53oxcarbazepine tab 150 mg, 300 mg, 600 mg................ 53OXEPA................................................................................68OXEPA 1.5......................................................................... 68oxiconazole nitrate cream 1%........................................85oxybutynin chloride syrup 5 mg/5ml............................ 39oxybutynin chloride tab er 24hr 15 mg.........................39

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 109oxybutynin chloride tab er 24hr 5 mg, 10 mg.............. 39oxybutynin chloride tab 5 mg........................................ 39oxycodone hcl conc 100 mg/5ml (20 mg/ml)................49oxycodone hcl soln 5 mg/5ml........................................ 49oxycodone hcl tab 5 mg................................................. 49oxycodone hcl tab 10 mg............................................... 49oxycodone hcl tab 20 mg............................................... 49oxycodone hcl tab 15 mg, 30 mg.................................. 49oxycodone w/ acetaminophen tab 5-325 mg................49oxycodone w/ acetaminophen tab 2.5-325 mg, 7.5-325mg, 10-325 mg...............................................................49oxymorphone hcl tab 5 mg, 10 mg................................49OXYMORPHONE HYDROCHLORIDE............................. 49OZEMPIC........................................................................... 21Ppaliperidone tab er 24hr 6 mg........................................43paliperidone tab er 24hr 1.5 mg, 3 mg, 9 mg................43PALYNZIQ...........................................................................25pantoprazole sodium ec tab 20 mg (base equiv), 40mg (base equiv)............................................................ 37paricalcitol cap 2 mcg.....................................................25paricalcitol cap 4 mcg.....................................................25paromomycin sulfate cap 250 mg................................... 2paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg.......... 42PAXLOVID............................................................................ 5PEDIARIX........................................................................... 11PEDIASMART PEA PROTEIN.......................................... 68PEDIASURE....................................................................... 68PEDIASURE 1.5 CAL........................................................ 69PEDIASURE 1.0 CAL/FIBER............................................ 69PEDIASURE 1.5 CAL/FIBER............................................ 69PEDIASURE 1.5 CAL WITH FI......................................... 69PEDIASURE ENTERAL 1.0 CAL...................................... 68PEDIASURE GROW & GAIN............................................68PEDIASURE GROW & GAIN/FIB..................................... 68PEDIASURE GROW & GAIN ORG.................................. 68PEDIASURE GROW & GAIN SHA................................... 68PEDIASURE HARVEST 1.0 CAL......................................68PEDIASURE NUTRIPALS................................................. 68PEDIASURE PEDIATRIC.................................................. 69PEDIASURE PEPTIDE 1.0 CAL....................................... 69PEDIASURE PEPTIDE 1.5 CAL....................................... 69PEDIASURE REDUCED CALORIE.................................. 69PEDIASURE SHAKE MIX................................................. 69PEDIASURE SHAKE WITH FIBE..................................... 69PEDIASURE SIDEKICKS.................................................. 69PEDIASURE SIDEKICKS CLEAR.................................... 69PEDIASURE SIDEKICKS SHAKE.................................... 69PEDIASURE WITH FIBER................................................ 69PEDIATRIC DRINK............................................................ 69PEDVAX HIB........................................................................ 9PEGASYS.............................................................................5peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236gm................................................................................... 36peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln100 gm............................................................................36peg 3350-kcl-sod bicarb-nacl for soln 420 gm............. 37PEG-PREP......................................................................... 37PEMAZYRE........................................................................ 14penicillamine tab 250 mg................................................88PENICILLIN V POTASSIUM................................................1penicillin v potassium tab 250 mg, 500 mg.................... 1PENTACEL......................................................................... 11pentoxifylline tab er 400 mg...........................................79PEPTAMEN........................................................................ 69PEPTAMEN/PREBIO1....................................................... 69PEPTAMEN AF.................................................................. 69PEPTAMEN 1.5 CAL......................................................... 69PEPTAMEN 1 CAL/PREBIO1........................................... 69PEPTAMEN 1.5 CAL/PREBIO1........................................ 69PEPTAMEN INTENSE VHP.............................................. 69PEPTAMEN JUNIOR......................................................... 69PEPTAMEN JUNIOR 1.5...................................................69PEPTAMEN JUNIOR/PREBIO1........................................ 69PEPTAMEN JUNIOR 1 CAL............................................. 69PEPTAMEN JUNIOR 1.5 CAL.......................................... 69PEPTAMEN JUNIOR 1 CAL/PRE..................................... 69PEPTAMEN JUNIOR FIBER............................................. 69PEPTAMEN JUNIOR HP...................................................69PEPTAMEN JUNIOR PHGG 1.2.......................................69PEPTICATE........................................................................ 69PERATIVE.......................................................................... 69PERATIVE 1.3 CAL........................................................... 69PERIFLEX ADVANCE........................................................69PERIFLEX INFANT............................................................ 70PERIFLEX JUNIOR........................................................... 70PERIFLEX LQ PKU........................................................... 57perindopril erbumine tab 2 mg, 4 mg, 8 mg................. 30permethrin cream 5%...................................................... 85PERPHENAZINE/AMITRIPTYLIN..................................... 46perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg................. 43PFD 2................................................................................. 70PFD TODDLER..................................................................70PFIZER-BIONTECH COVID-19...........................................9PHENELZINE SULFATE....................................................42PHENEX-1..........................................................................70PHENEX-2..........................................................................70phenobarbital elixir 20 mg/5ml...................................... 44phenobarbital tab 15 mg, 30 mg, 60 mg, 100 mg......... 44phenobarbital tab 16.2 mg, 32.4 mg, 64.8 mg, 97.2mg................................................................................... 44phenoxybenzamine hcl cap 10 mg................................30PHENYLADE......................................................................57PHENYLADE AMINO ACID.............................................. 57PHENYLADE AMINO ACID BLEN....................................57PHENYLADE DRINK MIX................................................. 70PHENYLADE40 DRINK MIX............................................. 57PHENYLADE60 DRINK MIX............................................. 70PHENYLADE ESSENTIAL DRINK....................................70

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 110PHENYLADE GMP............................................................ 70PHENYLADE GMP MIX-IN............................................... 70PHENYLADE GMP READY.............................................. 70PHENYLADE GMP ULTRA............................................... 70PHENYLADE MTE.............................................................57PHENYLADE MTE AMINO ACID..................................... 57PHENYLADE PHEBLOC................................................... 57PHENYLADE RTD PKU 10...............................................70phenylephrine hcl ophth soln 2.5%, 10%..................... 81PHENYL-FREE 1............................................................... 70PHENYL-FREE 2............................................................... 70PHENYL-FREE 2HP..........................................................70phenytoin chew tab 50 mg............................................. 53phenytoin sodium extended cap 100 mg......................53phenytoin sodium extended cap 200 mg, 300 mg....... 53phenytoin susp 125 mg/5ml........................................... 53PHLEXY-10........................................................................ 70PHLEXY-VITS.................................................................... 56phytonadione tab 5 mg................................................... 56pilocarpine hcl ophth soln 1%, 2%, 4%........................ 81pilocarpine hcl tab 5 mg, 7.5 mg................................... 82PILOT COVID-19 AT-HOME TE....................................... 87pimecrolimus cream 1%................................................. 85PIMOZIDE.......................................................................... 46pindolol tab 5 mg, 10 mg................................................27pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850mg................................................................................... 21pioglitazone hcl tab 15 mg (base equiv), 30 mg (baseequiv), 45 mg (base equiv).......................................... 21PIQRAY 200MG DAILY DOSE.......................................... 14PIQRAY 250MG DAILY DOSE.......................................... 14PIQRAY 300MG DAILY DOSE.......................................... 14PIRFENIDONE................................................................... 36pirfenidone cap 267 mg.................................................. 36pirfenidone tab 267 mg................................................... 36pirfenidone tab 801 mg................................................... 36piroxicam cap 10 mg, 20 mg.......................................... 51PIVOT 1.5 CAL.................................................................. 70PKU 2................................................................................. 71PKU 3................................................................................. 71PKU AIR20 GOLD............................................................. 70PKU AIR20 GREEN...........................................................70PKU AIR20 YELLOW........................................................ 70PKU COOLER 10.............................................................. 70PKU COOLER 15.............................................................. 70PKU COOLER 20.............................................................. 70PKU EXPLORE5................................................................70PKU EXPLORE10 ORANGE.............................................70PKU EXPLORE10 RASPBERRY...................................... 70PKU GEL............................................................................70PKU GOLIKE 10G P.E...................................................... 57PKU GOLIKE 5G P.E.........................................................57PKU GOLIKE PLUS 4-16.................................................. 57PKU GOLIKE PLUS 16+................................................... 57PKU LOPHLEX LQ 20.......................................................70PKU MAXAMUM................................................................ 57PKU PERIFLEX EARLY YEARS.......................................70PKU PERIFLEX JUNIOR PLUS........................................70PKU SPHERE 15...............................................................70PKU SPHERE 20...............................................................70PKU START........................................................................70PKU TRIO.......................................................................... 70PLEGRIDY..........................................................................46PLEGRIDY STARTER PACK............................................ 47PNEUMOVAX 23............................................................... 10PNEUMOVAX 23/1 DOSE.................................................10podofilox soln 0.5%......................................................... 85POLYCAL............................................................................71polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%........................................................................... 81POMALYST........................................................................ 14PORTAGEN........................................................................71posaconazole tab delayed release 100 mg.....................3potassium chloride cap er 8 meq, 10 meq................... 56potassium chloride microencapsulated crys er tab 15meq................................................................................. 56potassium chloride microencapsulated crys er tab 10meq, 20 meq.................................................................. 56potassium chloride oral soln 10% (20 meq/15ml), 20%(40 meq/15ml)................................................................ 56potassium chloride powder packet 20 meq................. 56potassium chloride tab er 10 meq, 20 meq (1500mg).................................................................................. 56potassium chloride tab er 8 meq (600 mg)...................56potassium citrate tab er 5 meq (540 mg)...................... 40potassium citrate tab er 10 meq (1080 mg).................. 40potassium citrate tab er 15 meq (1620 mg).................. 40potassium phosphate monobasic tab 500 mg............. 56PPA/MMA EXPRESS.........................................................71PRADAXA...........................................................................77pramipexole dihydrochloride tab 0.25 mg, 1.5 mg...... 55pramipexole dihydrochloride tab 0.125 mg, 0.5 mg,0.75 mg, 1 mg................................................................55prasugrel hcl tab 5 mg (base equiv), 10 mg (baseequiv).............................................................................. 79pravastatin sodium tab 10 mg, 20 mg, 40 mg, 80mg................................................................................... 32praziquantel tab 600 mg................................................... 7prazosin hcl cap 1 mg.....................................................30prazosin hcl cap 2 mg, 5 mg..........................................30PREDNICARBATE............................................................. 85PREDNISOLONE ACETATE............................................. 81PREDNISOLONE SODIUM PHOSP.................................81prednisolone sod phosphate oral soln 15 mg/5ml(base equiv)................................................................... 17PREDNISONE....................................................................17prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50mg................................................................................... 17prednisone tab therapy pack 5 mg (21), 5 mg (48)...... 17

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 111prednisone tab therapy pack 10 mg (21), 10 mg(48).................................................................................. 17PREFEST........................................................................... 18pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg,200 mg, 225 mg, 300 mg..............................................53pregabalin soln 20 mg/ml............................................... 53PREGESTIMIL................................................................... 71PREHEVBRIO.................................................................... 10PREMARIN.........................................................................18PREMIUM INFANT FORMULA/IR.................................... 71PREMPHASE..................................................................... 18PREMPRO..........................................................................18PRENATABS RX................................................................ 56PRENATAL 19....................................................................56PRENATAL-U..................................................................... 56PREPROTEIN.................................................................... 57PREPROTEIN 20...............................................................57PRETOMANID......................................................................3PREVNAR 13..................................................................... 10PREVNAR 20..................................................................... 10PREZCOBIX......................................................................... 5PREZISTA.............................................................................5PRIFTIN................................................................................ 3primaquine phosphate tab 26.3 mg (15 mg base)..........7primidone tab 50 mg....................................................... 54primidone tab 250 mg..................................................... 54PRIORIX............................................................................. 10probenecid tab 500 mg................................................... 52prochlorperazine maleate tab 5 mg (baseequivalent)......................................................................43prochlorperazine maleate tab 10 mg (baseequivalent)......................................................................43prochlorperazine suppos 25 mg....................................43PROCRIT............................................................................76PROCTOFOAM HC........................................................... 83PROFILNINE...................................................................... 79progesterone cap 100 mg, 200 mg................................ 20progesterone im in oil 50 mg/ml....................................20PROGRAF.......................................................................... 88PROMACTA........................................................................76promethazine hcl suppos 12.5 mg, 25 mg....................33promethazine hcl syrup 6.25 mg/5ml............................ 33promethazine hcl tab 12.5 mg, 25 mg, 50 mg...............33PROMETHEGAN............................................................... 33PROMOD............................................................................71PROMOTE..........................................................................71PROMOTE 1.0................................................................... 71PROMOTE/FIBER..............................................................71PROMOTE WITH FIBER...................................................71PROMOTE 1.0 WITH FIBER............................................ 71propafenone hcl cap er 12hr 225 mg, 325 mg, 425mg................................................................................... 28propafenone hcl tab 150 mg.......................................... 28propafenone hcl tab 225 mg, 300 mg............................28proparacaine hcl ophth soln 0.5%.................................81PRO-PHREE...................................................................... 71PROPIMEX-1..................................................................... 71PROPIMEX-2..................................................................... 71PROPRANOLOL HCL....................................................... 27propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg,160 mg............................................................................27propranolol hcl oral soln 20 mg/5ml............................. 27propranolol hcl tab 60 mg, 80 mg................................. 27propranolol hcl tab 10 mg, 20 mg, 40 mg.....................27propylthiouracil tab 50 mg............................................. 24PROQUAD..........................................................................10PROSOURCE.................................................................... 71PROSOURCE NO CARB.................................................. 71PROSOURCE PLUS......................................................... 71PROSOURCE TF...............................................................71PROSOURCE ZAC............................................................71PROSURE.......................................................................... 71PROTEIN FORTIFIED COOKIE........................................71PROVIMIN.......................................................................... 71PULMOCARE.....................................................................71PULMOCARE 1.5.............................................................. 71PULMOZYME.....................................................................36PURAMINO DHA/ARA.......................................................71PURAMINO JR.................................................................. 71PURAMINO TODDLER..................................................... 71PURECARB........................................................................71PURIXAN............................................................................15PX VANILLA PLUS............................................................ 71pyrazinamide tab 500 mg..................................................3pyridostigmine bromide oral soln 60 mg/5ml.............. 55pyridostigmine bromide tab 60 mg............................... 56pyrimethamine tab 25 mg................................................. 7PYRUKYND........................................................................79PYRUKYND TAPER PACK............................................... 79QQINLOCK............................................................................15QUADRACEL..................................................................... 11quetiapine fumarate tab er 24hr 150 mg, 200 mg........ 43quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400mg................................................................................... 43quetiapine fumarate tab 100 mg.................................... 43quetiapine fumarate tab 200 mg.................................... 43quetiapine fumarate tab 25 mg, 50 mg......................... 43quetiapine fumarate tab 300 mg, 400 mg..................... 43QUICKVUE AT-HOME COVID-19.....................................87QUINAPRIL/HYDROCHLOROTHIA..................................30quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg............... 30quinidine gluconate tab er 324 mg................................28QUINIDINE SULFATE........................................................28quinine sulfate cap 324 mg.............................................. 7QUINOA/KALE/HEMP........................................................71QULIPTA.............................................................................52QVAR REDIHALER............................................................35

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 112Rrabeprazole sodium ec tab 20 mg................................. 37RADICAVA ORS.................................................................55RADICAVA ORS STARTER KIT........................................55raloxifene hcl tab 60 mg................................................. 25ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg...................30ranolazine tab er 12hr 500 mg, 1000 mg.......................27rasagiline mesylate tab 0.5 mg (base equiv), 1 mg(base equiv)................................................................... 55RE/GEN PROTEIN FORTIFIED........................................71RE/NEPH............................................................................71RE/NEPH LP/HC................................................................71RE/NEPH REDUCED SUGAR.......................................... 71REAL FOOD BLENDS.......................................................71REAL FOOD BLENDS MINI/PRU..................................... 71REASON.............................................................................72REBIF................................................................................. 47REBIF REBIDOSE............................................................. 47REBIF REBIDOSE TITRATION.........................................47REBIF TITRATION PACK..................................................47REBINYN............................................................................79RECOMBINATE................................................................. 79RECOMBIVAX HB............................................................. 10RECTIV...............................................................................83REDITREX..........................................................................51REGRANEX........................................................................85REGULAR NUTRITIONAL SHAKE...................................72RELENZA DISKHALER....................................................... 6RELION R.......................................................................... 22RENALCAL.........................................................................72RENASTART...................................................................... 72RENASTEP........................................................................ 72repaglinide tab 0.5 mg, 1 mg, 2 mg...............................21REPATHA........................................................................... 32REPATHA PUSHTRONEX SYSTEM................................ 32REPATHA SURECLICK..................................................... 32REPLETE........................................................................... 72REPLETE FIBER............................................................... 72REPLETE FIBER 1 CAL................................................... 72RESOURCE 2.0.................................................................72RESTORE FUSION RENAL SUPP...................................72RESTORE RENAL SUPPORT..........................................72RESURGEX........................................................................72RESURGEX PLUS.............................................................72RESURGEX SELECT........................................................72RETACRIT.......................................................................... 76RETEVMO.......................................................................... 15REVCOVI............................................................................26REVLIMID...........................................................................88REXULTI............................................................................. 43REYATAZ.............................................................................. 6REYVOW............................................................................52REZUROCK........................................................................88RHOPRESSA..................................................................... 81RIASTAP.............................................................................79ribavirin cap 200 mg..........................................................6ribavirin tab 200 mg.......................................................... 6rifabutin cap 150 mg......................................................... 3rifampin cap 150 mg, 300 mg...........................................3riluzole tab 50 mg............................................................ 55RINVOQ..............................................................................51risedronate sodium tab 35 mg.......................................26risedronate sodium tab 150 mg..................................... 26risedronate sodium tab 5 mg, 30 mg............................ 26risperidone soln 1 mg/ml................................................43risperidone tab 0.25 mg.................................................. 43risperidone tab 3 mg....................................................... 43risperidone tab 0.5 mg, 1 mg, 2 mg, 4 mg.................... 43ritonavir tab 100 mg.......................................................... 6rivastigmine tartrate cap 1.5 mg (base equivalent), 3mg (base equivalent), 4.5 mg (base equivalent), 6mg (base equivalent)....................................................47rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr,13.3 mg/24hr.................................................................. 47RIXUBIS..............................................................................79rizatriptan benzoate oral disintegrating tab 5 mg (baseeq)................................................................................... 52rizatriptan benzoate oral disintegrating tab 10 mg(base eq)........................................................................ 52rizatriptan benzoate tab 5 mg (base equivalent)..........52rizatriptan benzoate tab 10 mg (base equivalent)........52roflumilast tab 250 mcg, 500 mcg................................. 35ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2mg, 3 mg, 4 mg, 5 mg..................................................55rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40mg................................................................................... 32ROTARIX............................................................................ 10ROTATEQ........................................................................... 10ROZLYTREK...................................................................... 15RUBRACA.......................................................................... 15rufinamide susp 40 mg/ml.............................................. 54rufinamide tab 200 mg, 400 mg..................................... 54RUKOBIA..............................................................................6RYBELSUS.........................................................................21RYDAPT............................................................................. 15SSALMON/OATS/SQUASH................................................. 72SANDIMMUNE................................................................... 88SANTYL..............................................................................85sapropterin dihydrochloride powder packet 100 mg,500 mg............................................................................26sapropterin dihydrochloride tab 100 mg...................... 26SAVELLA............................................................................ 47SAVELLA TITRATION PACK.............................................47SB COMPLETE NUTRITION............................................ 72SB COMPLETE NUTRITION PLU.................................... 72SCANDICAL....................................................................... 72SCANDISHAKE..................................................................72

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 113SCEMBLIX..........................................................................15scopolamine td patch 72hr 1 mg/3days........................38selegiline hcl cap 5 mg................................................... 55selenium sulfide lotion 2.5%.......................................... 85SELZENTRY.........................................................................6SEMGLEE.......................................................................... 23SE-NATAL 19..................................................................... 56SEREVENT DISKUS......................................................... 35sertraline hcl oral concentrate for solution 20 mg/ml.....................................................................................42sertraline hcl tab 25 mg, 50 mg, 100 mg.......................42sevelamer carbonate tab 800 mg.................................. 39SEVENFACT...................................................................... 79SHINGRIX.......................................................................... 10SIGNIFOR.......................................................................... 26sildenafil citrate for suspension 10 mg/ml................... 32sildenafil citrate tab 20 mg............................................. 32silver sulfadiazine cream 1%......................................... 86SIMBRINZA........................................................................ 81SIMILAC..............................................................................72SIMILAC/IRON................................................................... 73SIMILAC 2/IRON................................................................73SIMILAC 2 ADVANCE....................................................... 73SIMILAC ADVANCE/IRON................................................ 72SIMILAC ADVANCE COMPLETE..................................... 72SIMILAC ADVANCE EARLY SHI...................................... 72SIMILAC ADVANCE LAMEHADRI.................................... 72SIMILAC ADVANCE NON-GMO....................................... 72SIMILAC ADVANCE OPTIGRO/I...................................... 72SIMILAC ADVANCE ORGANIC E.....................................72SIMILAC ALIMENTUM-IRON............................................ 72SIMILAC EXPERT CARE ALIME......................................72SIMILAC FOR SPIT-UP/OPTIG........................................ 72SIMILAC FOR SPIT-UP EARLY........................................72SIMILAC FOR SUPPLEMENTATI..................................... 72SIMILAC GO & GROW EARLY S..................................... 72SIMILAC GO & GROW FOR LAC.................................... 72SIMILAC GO & GROW HMO............................................72SIMILAC GO & GROW MIX-INS.......................................72SIMILAC GO & GROW NON-GMO.................................. 72SIMILAC GO & GROW TODDLER...................................73SIMILAC HUMAN MILK FORTIF...................................... 73SIMILAC LACTOSE FREE................................................ 73SIMILAC LACTOSE FREE ADVA..................................... 73SIMILAC LOW-IRON......................................................... 73SIMILAC NEOSURE..........................................................73SIMILAC NEOSURE OPTIGRO........................................73SIMILAC ORGANIC/A2 MILK/I..........................................73SIMILAC ORGANIC/IRON.................................................73SIMILAC PM 60/40............................................................ 73SIMILAC PRO-ADVANCE/IRON....................................... 73SIMILAC PRO-ADVANCE OPTIG.....................................73SIMILAC PRO-SENSITIVE/IRO........................................ 73SIMILAC PRO-SENSITIVE OPT.......................................73SIMILAC PRO-TOTAL COMFORT....................................73SIMILAC PURE BLISS INFANT........................................ 73SIMILAC PURE BLISS TODDLE...................................... 73SIMILAC SENSITIVE/FUSSINE........................................ 73SIMILAC SENSITIVE EARLY S........................................ 73SIMILAC SENSITIVE FOR FUS....................................... 73SIMILAC SENSITIVE NON-GMO..................................... 73SIMILAC SENSITIVE OPTIGRO.......................................73SIMILAC SENSITIVE SOY ISO........................................ 73SIMILAC SOY ISOMIL /FUSSI..........................................73SIMILAC SPIT-UP OPTIGRO/I......................................... 73SIMILAC 360 TOTAL CARE 5.......................................... 73SIMILAC 360 TOTAL CARE..............................................73SIMILAC 360 TOTAL CARE SE........................................73SIMILAC TOTAL COMFORT OPT.................................... 73SIMPONI.............................................................................51simvastatin tab 5 mg.......................................................32simvastatin tab 10 mg, 20 mg, 40 mg, 80 mg...............32sirolimus oral soln 1 mg/ml............................................88sirolimus tab 0.5 mg, 1 mg, 2 mg.................................. 88SIRTURO..............................................................................3SKYRIZI..............................................................................39SKYRIZI PEN..................................................................... 86SKYTROFA.........................................................................26SM NUTRI-DRINK............................................................. 73SM NUTRI-DRINK +..........................................................73SOD ANAMIX EARLY YEARS.......................................... 73sodium chloride soln nebu 3%...................................... 33sodium chloride soln nebu 7%...................................... 33SODIUM FLUORIDE......................................................... 56sodium 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).................................................................................. 56sodium fluoride cream 1.1%...........................................82sodium fluoride gel 1.1% (0.5% f)..................................82sodium fluoride paste 1.1%............................................82sodium fluoride-potassium nitrate gel 1.1-5%............. 82sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).................................................................................. 56sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/mlnaf).................................................................................. 56SODIUM OXYBATE........................................................... 47sodium phenylbutyrate oral powder 3 gm/teaspoonful.................................................................... 26sodium phenylbutyrate tab 500 mg...............................26sodium polystyrene sulfonate powder......................... 88sod sulfate-pot sulf-mg sulf oral sol 17.5-3.13-1.6gm/177ml........................................................................ 37SOFOSBUVIR/VELPATASVIR.............................................6SOL CARB......................................................................... 73solifenacin succinate tab 5 mg...................................... 39solifenacin succinate tab 10 mg....................................39SOLIQUA 100/33............................................................... 21SOMAVERT........................................................................26SOOLANTRA..................................................................... 86sorafenib tosylate tab 200 mg (base equivalent)......... 15

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 114S.O.S. 20............................................................................72S.O.S. 25............................................................................72sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg.......... 27sotalol hcl tab 160 mg.....................................................27sotalol hcl tab 240 mg.....................................................27sotalol hcl tab 80 mg, 120 mg........................................27SOVALDI...............................................................................6SPEEDY SWAB RAPID COVID-1.....................................87SPIKEVAX COVID-19 VACCINE.......................................10SPINOSAD......................................................................... 86SPIRIVA HANDIHALER.....................................................35SPIRIVA RESPIMAT.......................................................... 35spironolactone & hydrochlorothiazide tab 25-25mg................................................................................... 30spironolactone tab 25 mg, 50 mg, 100 mg................... 30SPRYCEL........................................................................... 15SPS.....................................................................................88stannous fluoride conc 0.63%........................................82stannous fluoride gel 0.4%.............................................82STAVUDINE..........................................................................6STELARA........................................................................... 86STIOLTO RESPIMAT......................................................... 35STIVARGA.......................................................................... 15STRENSIQ......................................................................... 26SUCRAID............................................................................38sucralfate tab 1 gm..........................................................37SULCONAZOLE NITRATE................................................ 86SULFACETAMIDE SODIUM..............................................81SULFACETAMIDE SODIUM/PRED.................................. 81sulfacetamide sodium lotion 10% (acne)......................86sulfacetamide sodium ophth soln 10%.........................81SULFADIAZINE.................................................................... 3sulfamethoxazole-trimethoprim susp 200-40mg/5ml.............................................................................. 8sulfamethoxazole-trimethoprim tab 400-80 mg............. 8sulfamethoxazole-trimethoprim tab 800-160 mg........... 8SULFAMYLON................................................................... 86sulfasalazine tab delayed release 500 mg.................... 39sulfasalazine tab 500 mg................................................ 39sulindac tab 150 mg, 200 mg......................................... 51sumatriptan nasal spray 5 mg/act, 20 mg/act.............. 52sumatriptan succinate inj 6 mg/0.5ml........................... 52SUMATRIPTAN SUCCINATE REF................................... 52sumatriptan succinate solution auto-injector 4mg/0.5ml, 6 mg/0.5ml................................................... 52sumatriptan succinate tab 25 mg, 50 mg, 100 mg....... 52sunitinib malate cap 12.5 mg (base equivalent)...........15sunitinib malate cap 25 mg (base equivalent), 37.5 mg(base equivalent), 50 mg (base equivalent)...............15SUNOSI.............................................................................. 45SUPLENA........................................................................... 73SUPLENA RTU.................................................................. 73SUPLENA 1.8 WITH CARBSTEA..................................... 74SUPLENA WITH CARB STEADY..................................... 73SUPREP BOWEL PREP KIT............................................ 37SUTAB................................................................................ 37SYMBICORT...................................................................... 35SYMDEKO..........................................................................36SYMJEPI............................................................................ 31SYMPROIC.........................................................................39SYMTUZA.............................................................................6SYNJARDY.........................................................................21SYNJARDY XR.................................................................. 21SYNRIBO............................................................................15SYNTHROID.......................................................................24TTABLOID.............................................................................15TABRECTA......................................................................... 15tacrolimus cap 0.5 mg, 1 mg, 5 mg............................... 88tacrolimus oint 0.03%, 0.1%........................................... 86tadalafil tab 2.5 mg, 5 mg.......................................... 32,33tadalafil tab 20 mg (pah)................................................. 32TAFINLAR...........................................................................15TAGRISSO......................................................................... 15TAKHZYRO........................................................................ 79TALZENNA......................................................................... 15tamoxifen citrate tab 10 mg (base equivalent)............. 15tamoxifen citrate tab 20 mg (base equivalent)............. 15tamsulosin hcl cap 0.4 mg............................................. 40TASIGNA............................................................................ 15tasimelteon capsule 20 mg.............................................44tazarotene cream 0.1%....................................................86TAZORAC........................................................................... 86TAZVERIK...........................................................................15TDVAX................................................................................ 11TEGSEDI............................................................................ 47telmisartan tab 20 mg, 40 mg, 80 mg............................30temazepam cap 7.5 mg................................................... 44temazepam cap 15 mg, 30 mg....................................... 44temozolomide cap 5 mg, 20 mg.....................................15temozolomide cap 100 mg, 140 mg, 180 mg, 250mg................................................................................... 15TENIVAC.............................................................................11tenofovir disoproxil fumarate tab 300 mg...................... 6TEPMETKO........................................................................ 15terazosin hcl cap 1 mg (base equivalent), 2 mg (baseequivalent), 5 mg (base equivalent), 10 mg (baseequivalent)......................................................................30terbinafine hcl tab 250 mg................................................3terbutaline sulfate tab 2.5 mg, 5 mg..............................35terconazole vaginal cream 0.4%, 0.8%..........................40terconazole vaginal suppos 80 mg............................... 40testosterone cypionate im inj in oil 100 mg/ml, 200mg/ml.............................................................................. 17TESTOSTERONE ENANTHATE.......................................17testosterone td gel 12.5 mg/act (1%).............................17testosterone td gel 20.25 mg/act (1.62%)......................17testosterone td gel 25 mg/2.5gm (1%).......................... 17testosterone td gel 50 mg/5gm (1%)............................. 17

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 115testosterone td soln 30 mg/act...................................... 17tetrabenazine tab 12.5 mg.............................................. 47tetrabenazine tab 25 mg................................................. 47tetracaine hcl ophth soln 0.5%...................................... 81tetracycline hcl cap 250 mg, 500 mg...............................2THALOMID......................................................................... 88THEO-24.............................................................................35theophylline elixir 80 mg/15ml....................................... 35theophylline soln 80 mg/15ml........................................ 35theophylline tab er 12hr 300 mg, 450 mg..................... 35theophylline tab er 24hr 400 mg, 600 mg..................... 35THICK-IT BEEF LASAGNA PUR...................................... 74THICK-IT CHICKEN A LA KIN.......................................... 74THICK-IT MAPLE CINNAMON F...................................... 74THICK-IT MIXED FRUIT AND...........................................74THICK-IT SEASONED CHICKEN..................................... 74THICK-IT SWEET CORN PUREE.................................... 74THICK-IT THICKENED CRANBE..................................... 74thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg.....................43THYQUIDITY......................................................................24tiagabine hcl tab 2 mg, 4 mg, 12 mg, 16 mg.................54TIBSOVO............................................................................15timolol maleate ophth soln 0.25%, 0.5%....................... 81tinidazole tab 250 mg, 500 mg......................................... 8tiopronin tab 100 mg....................................................... 40TIVICAY................................................................................ 6TIVICAY PD..........................................................................6tizanidine hcl tab 2 mg (base equivalent).....................55tizanidine hcl tab 4 mg (base equivalent).....................55TOBI PODHALER................................................................ 2tobramycin-dexamethasone ophth susp 0.3-0.1%...... 82tobramycin nebu soln 300 mg/5ml.................................. 2tobramycin ophth soln 0.3%.......................................... 82TODAY SPONGE...............................................................40tolcapone tab 100 mg......................................................55TOLEREX........................................................................... 74tolterodine tartrate cap er 24hr 2 mg, 4 mg..................39tolterodine tartrate tab 1 mg, 2 mg................................39tolvaptan tab 15 mg.........................................................26tolvaptan tab 30 mg.........................................................26topiramate sprinkle cap 15 mg, 25 mg..........................54topiramate tab 25 mg, 50 mg, 100 mg, 200 mg............ 54toremifene citrate tab 60 mg (base equivalent)............15torsemide tab 5 mg, 10 mg, 20 mg, 100 mg................. 30TOUJEO MAX SOLOSTAR............................................... 23TOUJEO SOLOSTAR........................................................ 23TRACLEER.........................................................................32tramadol-acetaminophen tab 37.5-325 mg................... 49tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg.......49tramadol hcl tab 50 mg................................................... 49trandolapril tab 1 mg, 2 mg, 4 mg................................. 30tranexamic acid tab 650 mg........................................... 77tranylcypromine sulfate tab 10 mg................................42travoprost ophth soln 0.004% (benzalkonium free)(bak free)........................................................................ 82trazodone hcl tab 50 mg, 100 mg, 150 mg....................42TRECATOR.......................................................................... 3TRELEGY ELLIPTA........................................................... 35TREMFYA........................................................................... 86TRESIBA............................................................................ 23TRESIBA FLEXTOUCH.....................................................23tretinoin cap 10 mg......................................................... 15tretinoin cream 0.025%, 0.05%, 0.1%............................ 86tretinoin gel 0.01%........................................................... 86TRETTEN........................................................................... 79triamcinolone acetonide cream 0.025%, 0.1%,0.5%.................................................................................86triamcinolone acetonide dental paste 0.1%................. 82triamcinolone acetonide lotion 0.025%, 0.1%.............. 86triamcinolone acetonide oint 0.025%, 0.1%, 0.5%....... 86TRIAMINO.......................................................................... 57triamterene & hydrochlorothiazide cap 37.5-25mg................................................................................... 30triamterene & hydrochlorothiazide tab 37.5-25 mg..... 31triamterene & hydrochlorothiazide tab 75-50 mg........ 31trientine hcl cap 250 mg................................................. 89trifluoperazine hcl tab 1 mg (base equivalent), 2 mg(base equivalent), 5 mg (base equivalent), 10 mg(base equivalent)...........................................................43TRIFLURIDINE...................................................................82TRIHEXYPHENIDYL HCL................................................. 55trihexyphenidyl hcl tab 2 mg, 5 mg...............................55TRIJARDY XR....................................................................21TRIKAFTA...........................................................................36trimethobenzamide hcl cap 300 mg.............................. 38TRIMETHOPRIM..................................................................8trimethoprim tab 100 mg.................................................. 8trimipramine maleate cap 25 mg, 50 mg, 100 mg........ 42TRINATE.............................................................................56TRINTELLIX....................................................................... 42TRIUMEQ............................................................................. 6TRIUMEQ PD.......................................................................6TRIZIVIR............................................................................... 6trospium chloride tab 20 mg.......................................... 39TRULANCE........................................................................ 39TRULICITY......................................................................... 21TRUMENBA........................................................................10TRUSELTIQ........................................................................15TUKYSA..............................................................................16TURALIO............................................................................ 16TURKEY/SWEET POTATOES/PEA.................................. 74TWINRIX.............................................................................10TWOCAL HN......................................................................74TWOCAL HN 2.0............................................................... 74TYBLUME...........................................................................19TYBOST................................................................................6TYLACTIN BUILD 20PE TYR........................................... 74TYLACTIN COMPLETE 15 PE......................................... 74TYLACTIN RESTORE 10.................................................. 74TYLACTIN RESTORE 5PE............................................... 74

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 116TYLACTIN RTD 15............................................................ 74TYMLOS............................................................................. 26TYR ANAMIX EARLY YEARS...........................................74TYR ANAMIX NEXT.......................................................... 74TYR COOLER.................................................................... 74TYREX-1.............................................................................74TYREX-2.............................................................................74TYR GEL............................................................................ 74TYR LOPHLEX GMP MIX-IN............................................ 74TYR LOPHLEX LQ............................................................ 74TYROS 1............................................................................ 74TYROS 2............................................................................ 74TYVASO..............................................................................32TYVASO REFILL................................................................32TYVASO STARTER........................................................... 32UUBRELVY........................................................................... 52UCD 2.................................................................................74UCD ANAMIX JUNIOR......................................................74UCD TRIO.......................................................................... 74ULTRAMINO SOY PROTEIN............................................ 74ULTRIENT 1.5 SAFE-T FEED...........................................74unithroid - euthyrox - levothyroxine sodium tab 25mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg................24unithroid - levothyroxine sodium tab 50 mcg, 137mcg, 300 mcg................................................................ 24unithroid - levoxyl - levothyroxine sodium tab 75 mcg,150 mcg, 175 mcg, 200 mcg........................................24unithroid - unithroid - levothyroxine sodium tab 50mcg, 137 mcg, 300 mcg...............................................24UPTRAVI.............................................................................32UPTRAVI TITRATION PACK............................................. 32ursodiol cap 300 mg........................................................39ursodiol tab 250 mg........................................................ 39ursodiol tab 500 mg........................................................ 39UTYMAX.............................................................................74Vvalacyclovir hcl tab 1 gm..................................................6valacyclovir hcl tab 500 mg..............................................6VALCHLOR.........................................................................86valganciclovir hcl for soln 50 mg/ml (base equiv)......... 6valganciclovir hcl tab 450 mg (base equivalent)............6valproate sodium oral soln 250 mg/5ml (baseequiv).............................................................................. 54valproic acid cap 250 mg................................................54valsartan-hydrochlorothiazide tab 80-12.5 mg,160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25mg................................................................................... 30valsartan tab 320 mg.......................................................30valsartan tab 40 mg, 80 mg, 160 mg............................. 30VALTOCO........................................................................... 54vancomycin hcl cap 125 mg (base equivalent)..............8vancomycin hcl cap 250 mg (base equivalent)..............8VANDAZOLE...................................................................... 40VAQTA................................................................................ 10VARENICLINE STARTING MONT.................................... 47varenicline tartrate tab 0.5 mg (base equiv), 1 mg(base equiv)................................................................... 47VARIVAX.............................................................................10VARUBI...............................................................................38VASCEPA........................................................................... 32VAXELIS............................................................................. 11VAXNEUVANCE................................................................. 10VECAMYL...........................................................................30VELIVET............................................................................. 20VELTASSA..........................................................................89VEMLIDY.............................................................................. 6VENCLEXTA.......................................................................16VENCLEXTA STARTING PACK........................................ 16venlafaxine hcl cap er 24hr 37.5 mg (baseequivalent), 75 mg (base equivalent), 150 mg (baseequivalent)......................................................................42venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg(base equivalent), 50 mg (base equivalent), 75 mg(base equivalent), 100 mg (base equivalent).............42VENTAVIS...........................................................................32VENTOLIN HFA................................................................. 36verapamil hcl cap er 24hr 120 mg, 180 mg, 240mg................................................................................... 28VERAPAMIL HCL SR........................................................ 28verapamil hcl tab er 120 mg, 180 mg, 240 mg..............28verapamil hcl tab 40 mg, 80 mg, 120 mg...................... 28VERQUVO..........................................................................32VERZENIO......................................................................... 16VIBERZI..............................................................................39VICTOZA............................................................................ 21vigabatrin powd pack 500 mg........................................54vigabatrin tab 500 mg..................................................... 54VIIBRYD..............................................................................42VIIBRYD STARTER PACK................................................ 42VIJOICE..............................................................................89VILACTIN AA PLUS.......................................................... 74vilazodone hcl tab 10 mg, 20 mg, 40 mg...................... 42VIMPAT............................................................................... 54VINATE II............................................................................56VINATE ONE......................................................................56VIRACEPT............................................................................6VIREAD.................................................................................6VITAL AF 1.2 CAL............................................................. 74VITAL AF 1.2 CAL ADVANCED........................................ 74VITAL 1.0 CAL................................................................... 75VITAL 1.5 CAL................................................................... 75VITAL HIGH PROTEIN...................................................... 74VITAL HN............................................................................74VITAL HP 1.0 CAL.............................................................74VITAL JR............................................................................ 74VITAL PEPTIDE 1.5 CAL.................................................. 74VITEYES CLASSIC+MULTI...............................................56VITRAKVI........................................................................... 16

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2023Shoppers: To find drug estimates go to https://www.myprime.com/en/plan-preview/medicines/find-medicine.html Members: Log in to your plan to find current drug pricing at https://www.myprime.com/en/medicines.html#find-medicineBCBSTX Health Insurance Marketplace 6 Tier Drug List March 2023 117VIVONEX PEDIATRIC....................................................... 75VIVONEX PLUS.................................................................75VIVONEX RTF................................................................... 75VIVONEX T.E.N................................................................. 75VIVOTIF.............................................................................. 10VIZIMPRO.......................................................................... 16VONJO................................................................................16VONVENDI......................................................................... 79voriconazole for susp 40 mg/ml...................................... 3voriconazole tab 50 mg, 200 mg......................................3VOSEVI.................................................................................6VOTRIENT..........................................................................16VOXZOGO..........................................................................26VRAYLAR........................................................................... 43VYNDAMAX........................................................................33VYNDAQEL........................................................................ 33VYVANSE........................................................................... 45VYZULTA............................................................................ 82WWALGREENS GLUCOSE................................................. 21warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5mg, 6 mg, 7.5 mg, 10 mg............................................. 77WELIREG........................................................................... 16WELLNESS ESSENTIALS................................................ 75WELLNESS ESSENTIALS AI........................................... 75WELLNESS ESSENTIALS BLOOD.................................. 75WELLNESS ESSENTIALS FOR J.................................... 75WELLNESS ESSENTIALS FOR M...................................75WELLNESS ESSENTIALS FOR P................................... 75WELLNESS ESSENTIALS FOR W.................................. 75WIDE-SEAL SILICONE DIAPHR...................................... 88WILATE...............................................................................79WND 1................................................................................ 75WND 2................................................................................ 75XXALKORI............................................................................ 16XARELTO........................................................................... 77XARELTO STARTER PACK.............................................. 77XCOPRI.............................................................................. 54XELJANZ............................................................................ 51XELJANZ XR......................................................................51XHANCE.............................................................................33XIFAXAN...............................................................................8XIGDUO XR....................................................................... 21XLEU ANALOG..................................................................75XLEU MAXAMAID..............................................................75XLEU MAXAMUM.............................................................. 75XLYS XTRP ANALOG....................................................... 75XLYS-XTRP MAXAMAID................................................... 75XLYS-XTRP MAXAMUM................................................... 75XMET ANALOG................................................................. 75XMET MAXAMAID............................................................. 75XMET MAXAMUM............................................................. 75XMET XCYS MAXAMAID..................................................75XMTVI ANALOG................................................................ 75XMTVI MAXAMAID............................................................ 75XMTVI MAXAMUM............................................................ 75XOFLUZA............................................................................. 7XOLAIR...............................................................................36XOSPATA............................................................................16XPHE MAXAMAID............................................................. 75XPHE MAXAMUM..............................................................57XPHE-XTYR ANALOG...................................................... 75XPHE-XTYR MAXAMAID.................................................. 75XPOVIO.............................................................................. 16XPOVIO 60 MG TWICE WEEKLY.................................... 16XPOVIO 80 MG TWICE WEEKLY.................................... 16XPTM ANALOG................................................................. 75XTAMPZA ER.....................................................................49XTANDI............................................................................... 16XTRACAL PLUS................................................................ 75XULTOPHY 100/3.6........................................................... 21XYMOBOIX.........................................................................57XYNTHA............................................................................. 79XYNTHA SOLOFUSE........................................................80XYREM............................................................................... 47XYWAV............................................................................... 47YYONSA............................................................................... 16Zzafirlukast tab 10 mg, 20 mg.......................................... 36zaleplon cap 5 mg, 10 mg.............................................. 44ZARXIO...............................................................................76ZEGALOGUE..................................................................... 21ZEJULA...............................................................................16ZELBORAF.........................................................................16ZENPEP..............................................................................38ZEPOSIA............................................................................ 47ZEPOSIA 7-DAY STARTER PAC......................................47ZEPOSIA STARTER KIT................................................... 47ZERVIATE...........................................................................82zidovudine cap 100 mg..................................................... 7zidovudine syrup 10 mg/ml.............................................. 7zidovudine tab 300 mg......................................................7ZIEXTENZO........................................................................76zileuton tab er 12hr 600 mg........................................... 36ZIMHI.................................................................................. 86ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg........ 44ZOKINVY............................................................................ 89ZOLINZA.............................................................................16zolmitriptan orally disintegrating tab 2.5 mg, 5 mg..... 52zolmitriptan tab 2.5 mg, 5 mg........................................ 52zolpidem tartrate tab er 6.25 mg, 12.5 mg.................... 44zolpidem tartrate tab 5 mg, 10 mg.................................44zonisamide cap 25 mg.................................................... 54zonisamide cap 50 mg.................................................... 54zonisamide cap 100 mg.................................................. 54ZONTIVITY......................................................................... 80