Blue Cross and Blue Shield July 2024 Basic Drug List

4621-K © Prime Therapeutics LLC 10/24

Basic Drug List – Updated 10/1/24

October 2024

Please consider talking to your doctor about prescribing preferred medications, which may help reduce

your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication

for you.

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

MyPrime.com

Contents

Introduction ....................................................... I

How drugs are selected .................................... I

How member payment is determined ............... I

How to use this list ........................................... II

Drugs used to treat multiple conditions ........... II

Generic drugs ................................................. III

Consider talking to your doctor about generic

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

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

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

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

Therapeutic Class Drug List

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

Antineoplastic Agents ...................................... 6

Endocrine and Metabolic Drugs ...................... 9

Cardiovascular Agents ................................... 16

Respiratory Agents ........................................ 21

Gastrointestinal Drugs ................................... 23

Genitourinary Drugs ....................................... 25

Central Nervous System Drugs ..................... 26

Analgesics and Anesthetics ........................... 31

Neuromuscular Drugs .................................... 34

Nutritional Products ....................................... 36

Hematological Agents .................................... 37

Topical Products ............................................ 40

Miscellaneous Products ................................. 44

Index .............................................................. 47

To search for a drug name within this PDF document, use the

Control

and

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

Blue Cross and Blue Shield October 2024 Basic Drug List – Updated 10/1/24

Introduction

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

includes brand drugs and a partial listing of generic drugs

. Members are encouraged to show this list to their

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

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

physician.

Drug List updates

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

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

MyPrime.com

and log in or call the

number on your ID card.

How drugs are selected

Drugs on this list are selected based on the recommendations of a committee made up of physicians and

pharmacists from throughout the country. The committee, which includes at least one representative from your

health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).

Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are

considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on

the list.

How member payment is determined

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

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

(Tier 5) and Non-Preferred Specialty (Tier 6). Non-Preferred Brand or Non-Preferred Specialty drugs are not listed

in this document. Based on your benefit design, drugs can either be in these tiers or you may have fewer tiers,

e.g., all generics in one tier. Some specialty medicines are marked with an “SP” in the Special Requirements

section. Some brands may be in a generic tier and some generics may be in a brand tier. Note: Covered

substance use disorder drugs (those FDA-approved for treatment of opioid drug abuse, alcohol abuse and to quit

tobacco use) may be in the lowest tiers. Substance use disorder brand drugs may be in the lowest brand tier and

generic drugs in the lowest generic tier, based on your benefit plan. To verify your payment amount for a drug,

visit

MyPrime.com

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

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

apply.

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

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

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

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

Blue Cross and Blue Shield October 2024 Basic Drug List – Updated 10/1/24

How to use this list

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

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

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

Example:

atorvastatin

(Lipitor)

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

Example: NOVOLOG – Insulin aspart inj 100 unit/ml

Drugs used to treat multiple conditions

Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,

each medication is classified according to its first FDA-approved use. Please check the index if you do not find

your particular medication in the class/condition section that corresponds to your use.

Please note:

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

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

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

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

Blue Cross and Blue Shield October 2024 Basic Drug List – Updated 10/1/24

III

Generic drugs

Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs

must be approved by the FDA just as brand drugs are and must meet the same standards.

There are two types of generic drugs:

• A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.

• A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s)

differs from the brand drug.

According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:

• Is chemically the same

• Works just as well in the body

• Is as safe and effective

• Meets the same standards set by the FDA

The main difference between the reference brand drug and the generic equivalent is that the generic often costs

much less.

Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.

You may be responsible for your member cost-share payment amount (copay or coinsurance) plus the difference

in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than

the generic. Generic drugs generally have the lowest member payment amount.

Consider talking to your doctor about generic drugs

If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an

appropriate generic alternative is available.

You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is

available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new

prescription from your doctor.

Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.

Blue Cross and Blue Shield October 2024 Basic Drug List – Updated 10/1/24

Coverage considerations

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

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

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

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

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

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

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

practice guidelines.

Over-the-counter exclusions:

Your benefit plan may not provide coverage for prescription medications that

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

benefits.

Compounded medications:

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

see your plan materials or call the number on your ID card to determine whether compounded medications are

covered and/or verify your payment amount.

Repackaged medications:

Repackaged versions of medications already available on the market are not

covered.

Non FDA-approved drugs:

Drugs that have not received FDA approval are not covered.

Prior Authorization (PA):

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

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

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

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

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

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

benefits.

Step Therapy (ST):

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

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

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

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

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

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

about your particular benefits.

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

Drug dispensing limits help encourage medication use as

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

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

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

quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication

than what the dispensing limit allows, you can still get the medication. However, you may be responsible for the

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

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

MyPrime.com

*Please note: For certain controlled substance medications, some state laws may not allow coverage by a health

benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be

responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the

dispensing limit.

Blue Cross and Blue Shield October 2024 Basic Drug List – Updated 10/1/24

ACA Preventive (ACA):

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

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

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

benefit plan.

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

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

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

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

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

covered alternative drug (if applicable).

Remember, medication decisions are between you and your doctor.

Only you and your doctor can determine

which medication is right for you. Discuss any questions or concerns you have about medications you are taking

or are prescribed with your doctor. Blue Cross and Blue Shield does not provide health care services and,

therefore, cannot guarantee any results or outcomes.

Blue Cross and Blue Shield October 2024 Basic Drug List – Updated 10/1/24

Specialty drugs

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

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

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

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

visit

MyPrime.com

Note that some drug classes may be excluded by some plans and therefore may not be covered under your

pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you

have questions about your coverage for specialty medications or your prescription drug benefit, call the

number on your ID card.

Blue Cross and Blue Shield of Illinois , Blue Cross and Blue Shield of Montana , Blue Cross and Blue Shield of New Mexico , Blue Cross and

Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas are Divisions of Health Care Service Corporation, a Mutual Legal

Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. BCBSIL, BCBSMT, BCBSNM, BCBSOK and

BCBSTX contract with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, BCBSMT,

BCBSNM, BCBSOK and BCBSTX, as well as several independent

Blue Cross and Blue Shield Plans, have an ownership interest in Prime Therapeutics LLC.

Blue Cross and Blue Shield October 2024 Basic Drug List – Updated 10/1/24

VII

Abbreviation key

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language

assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age,

sexual orientation, health status or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

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

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

300 E. Randolph St. TTY/TDD: 855-661-6965

35th Floor Fax: 855-661-6960

Chicago, Illinois 60601

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

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

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

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

Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

If you, or someone you are helping, have questions, you have the right to get help

and information in your language at no cost. To talk to an interpreter, call 855-710-6984.

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 1

Drug Name

Requirements/Limits

ANTI-INFECTIVE AGENTS

PENICILLINS

amoxicillin (trihydrate) cap 250 mg, 500 mg

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

400 mg/5ml

amoxicillin (trihydrate) tab 500 mg, 875 mg

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

amoxicillin & k clavulanate for susp 250-62.5 mg/5ml (Augmentin)

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600)

amoxicillin & k clavulanate tab 250-125 mg

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

ampicillin cap 500 mg

dicloxacillin sodium cap 250 mg, 500 mg

penicillin v potassium tab 250 mg, 500 mg

CEPHALOSPORINS

cefadroxil cap 500 mg

cefadroxil for susp 250 mg/5ml, 500 mg/5ml

cefdinir cap 300 mg

cefdinir for susp 125 mg/5ml, 250 mg/5ml

cefixime cap 400 mg (Suprax)

cefixime for susp 100 mg/5ml, 200 mg/5ml (Suprax)

cefpodoxime proxetil for susp 50 mg/5ml, 100 mg/5ml

cefpodoxime proxetil tab 100 mg, 200 mg

cefprozil for susp 125 mg/5ml, 250 mg/5ml

cefprozil tab 250 mg, 500 mg

cefuroxime axetil tab 250 mg, 500 mg

cephalexin cap 250 mg, 500 mg (Keflex)

cephalexin for susp 125 mg/5ml, 250 mg/5ml

MACROLIDES

AZITHROMYCIN - azithromycin powd pack for susp 1 gm

azithromycin for susp 100 mg/5ml, 200 mg/5ml (Zithromax)

azithromycin tab 250 mg, 500 mg, 600 mg (Zithromax)

QL (60 tablets/180 days)

clarithromycin tab er 24hr 500 mg

QL (28 tablets/30 days)

clarithromycin tab 250 mg, 500 mg

DIFICID - fidaxomicin tab 200 mg

DIFICID - fidaxomicin for susp 40 mg/ml

TETRACYCLINES

demeclocycline hcl tab 150 mg, 300 mg

doxycycline hyclate cap 50 mg

doxycycline hyclate cap 100 mg (Vibramycin)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 2

Drug Name

Requirements/Limits

doxycycline hyclate tab 20 mg, 100 mg

doxycycline monohydrate cap 50 mg

doxycycline monohydrate cap 100 mg (Monodox)

doxycycline monohydrate tab 50 mg, 75 mg, 100 mg, 150 mg

minocycline hcl cap 50 mg (Minocin)

minocycline hcl cap 75 mg, 100 mg

tetracycline hcl cap 250 mg, 500 mg

FLUOROQUINOLONES

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

ciprofloxacin hcl tab 750 mg (base equiv)

levofloxacin oral soln 25 mg/ml

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

ofloxacin tab 400 mg

AMINOGLYCOSIDES

HUMATIN - paromomycin sulfate cap 250 mg

neomycin sulfate tab 500 mg

tobramycin nebu soln 300 mg/5ml (Tobi)

QL (56 containers/56 days), SP

ANTIMYCOBACTERIAL AGENTS

ethambutol hcl tab 100 mg, 400 mg (Myambutol)

isoniazid syrup 50 mg/5ml

isoniazid tab 300 mg

PRIFTIN - rifapentine tab 150 mg

pyrazinamide tab 500 mg

rifabutin cap 150 mg (Mycobutin)

rifampin cap 150 mg, 300 mg (Rifadin)

ANTIFUNGALS

fluconazole for susp 10 mg/ml, 40 mg/ml (Diflucan)

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

flucytosine cap 250 mg, 500 mg (Ancobon)

griseofulvin microsize susp 125 mg/5ml

griseofulvin microsize tab 500 mg

itraconazole cap 100 mg (Sporanox)

QL (120 capsules/30 days)

itraconazole oral soln 10 mg/ml (Sporanox)

QL (1200 mls/30 days)

NOXAFIL - posaconazole for delayed release susp packet 300 mg

nystatin tab 500000 unit

posaconazole susp 40 mg/ml (Noxafil)

posaconazole tab delayed release 100 mg (Noxafil)

terbinafine hcl tab 250 mg (Lamisil)

voriconazole for susp 40 mg/ml (Vfend)

voriconazole tab 50 mg, 200 mg (Vfend)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 3

Drug Name

Requirements/Limits

ANTIVIRALS

abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)

QL (960 mls/30 days)

abacavir sulfate tab 300 mg (base equiv) (Ziagen)

QL (60 tablets/30 days)

abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)

QL (30 tablets/30 days)

acyclovir cap 200 mg (Zovirax)

acyclovir susp 200 mg/5ml (Zovirax)

acyclovir tab 400 mg, 800 mg (Zovirax)

adefovir dipivoxil tab 10 mg (Hepsera)

atazanavir sulfate cap 150 mg (base equiv), 300 mg (base equiv)

(Reyataz)

QL (30 capsules/30 days)

atazanavir sulfate cap 200 mg (base equiv) (Reyataz)

QL (60 capsules/30 days)

BARACLUDE - entecavir oral soln 0.05 mg/ml

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

50-200-25 mg

QL (30 tablets/30 days)

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

QL (30 tablets/30 days)

darunavir tab 600 mg (Prezista)

QL (60 tablets/30 days)

darunavir tab 800 mg (Prezista)

QL (30 tablets/30 days)

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

QL (30 tablets/30 days)

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

200-25 mg

QL (30 tablets/30 days)

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

QL (30 tablets/30 days)

efavirenz tab 600 mg (Sustiva)

QL (30 tablets/30 days)

efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg (Atripla)

QL (30 tablets/30 days)

efavirenz-lamivudine-tenofovir df tab 400-300-300 mg (Symfi lo)

QL (30 tablets/30 days)

efavirenz-lamivudine-tenofovir df tab 600-300-300 mg (Symfi)

QL (30 tablets/30 days)

emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg, 133-200 mg,

167-250 mg (Truvada)

QL (30 tablets/30 days)

emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg (Truvada)

AC, QL (30 tablets/30 days)

entecavir tab 0.5 mg, 1 mg (Baraclude)

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

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

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

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

etravirine tab 100 mg, 200 mg (Intelence)

QL (60 tablets/30 days)

famciclovir tab 125 mg (Famvir)

famciclovir tab 250 mg, 500 mg

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

QL (30 tablets/30 days)

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

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

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

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

INTELENCE - etravirine tab 25 mg

QL (120 tablets/30 days)

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

(base equiv)

QL (180 tablets/30 days)

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

QL (60 packets/30 days)

ISENTRESS - raltegravir potassium tab 400 mg (base equiv)

QL (60 tablets/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 4

Drug Name

Requirements/Limits

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

QL (60 tablets/30 days)

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

QL (30 tablets/30 days)

lamivudine oral soln 10 mg/ml (Epivir)

QL (4 bottles/30 days)

lamivudine tab 100 mg (hbv) (Epivir hbv)

lamivudine tab 150 mg, 300 mg (Epivir)

QL (30 tablets/30 days)

lamivudine-zidovudine tab 150-300 mg (Combivir)

QL (60 tablets/30 days)

lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra)

QL (3 bottles/30 days)

lopinavir-ritonavir tab 100-25 mg (Kaletra)

QL (180 tablets/90 days)

lopinavir-ritonavir tab 200-50 mg (Kaletra)

QL (120 tablets/30 days)

MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg

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

MAVYRET - glecaprevir-pibrentasvir pellet pack 50-20 mg

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

nevirapine tab er 24hr 400 mg

QL (30 tablets/30 days)

nevirapine tab 200 mg (Viramune)

QL (60 tablets/30 days)

NORVIR - ritonavir powder packet 100 mg

QL (360 packets/30 days)

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

QL (30 tablets/30 days)

oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu)

QL (40 capsules/120 days)

oseltamivir phosphate cap 45 mg (base equiv), 75 mg (base equiv)

(Tamiflu)

QL (20 capsules/120 days)

oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu)

QL (300 mls/120 days)

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

QL (20 tablets/90 days)

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

QL (30 tablets/90 days)

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

PA, SP

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

PA, SP

PREZISTA - darunavir oral susp 100 mg/ml

QL (2 bottles/30 days)

PREZISTA - darunavir tab 75 mg

QL (300 tablets/30 days)

PREZISTA - darunavir tab 150 mg

QL (180 tablets/30 days)

ritonavir tab 100 mg (Norvir)

QL (360 tablets/30 days)

SOVALDI - sofosbuvir tab 200 mg, 400 mg

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

SOVALDI - sofosbuvir pellet pack 150 mg, 200 mg

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

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

QL (30 tablets/30 days)

tenofovir disoproxil fumarate tab 300 mg (Viread)

QL (30 tablets/30 days)

TIVICAY - dolutegravir sodium tab 50 mg (base equiv)

QL (60 tablets/30 days)

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

QL (360 tablets/30 days)

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

QL (30 tablets/30 days)

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

QL (180 tablets/30 days)

valacyclovir hcl tab 500 mg, 1 gm (Valtrex)

valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte)

valganciclovir hcl tab 450 mg (base equivalent) (Valcyte)

VEMLIDY - tenofovir alafenamide fumarate tab 25 mg

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

QL (30 tablets/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 5

Drug Name

Requirements/Limits

VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm

QL (4 bottles/30 days)

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

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

zidovudine cap 100 mg (Retrovir)

QL (180 capsules/30 days)

zidovudine syrup 10 mg/ml (Retrovir)

QL (8 bottles/30 days)

zidovudine tab 300 mg

QL (60 tablets/30 days)

ANTIMALARIALS

atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg (Malarone)

QL (30 tablets/90 days)

chloroquine phosphate tab 250 mg, 500 mg

hydroxychloroquine sulfate tab 100 mg, 300 mg, 400 mg

hydroxychloroquine sulfate tab 200 mg (Plaquenil)

mefloquine hcl tab 250 mg

primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine phosphate)

pyrimethamine tab 25 mg (Daraprim)

PA, QL (116 tablets/180 days)

ANTHELMINTICS

albendazole tab 200 mg (Albenza)

BENZNIDAZOLE - benznidazole tab 12.5 mg, 100 mg

ivermectin tab 3 mg (Stromectol)

praziquantel tab 600 mg (Biltricide)

ANTI-INFECTIVE AGENTS - MISC.

ALINIA - nitazoxanide for susp 100 mg/5ml

QL (180 mls/30 days)

atovaquone susp 750 mg/5ml (Mepron)

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

clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin

pediatric gr)

dapsone tab 25 mg, 100 mg

IMPAVIDO - miltefosine cap 50 mg

linezolid for susp 100 mg/5ml (Zyvox)

QL (600 mls/180 days)

linezolid tab 600 mg (Zyvox)

QL (56 tablets/180 days)

metronidazole tab 250 mg, 500 mg (Flagyl)

nitazoxanide tab 500 mg (Alinia)

QL (6 tablets/30 days)

nitrofurantoin macrocrystalline cap 25 mg, 50 mg, 100 mg (Macrodantin)

nitrofurantoin monohydrate macrocrystalline cap 100 mg (Macrobid)

nitrofurantoin susp 25 mg/5ml

pentamidine isethionate for nebulization soln 300 mg (Nebupent)

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml

sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)

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

trimethoprim tab 100 mg

vancomycin hcl cap 125 mg (base equivalent) (Vancocin hcl)

QL (120 capsules/30 days)

vancomycin hcl cap 250 mg (base equivalent) (Vancocin)

QL (120 capsules/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 6

Drug Name

Requirements/Limits

XIFAXAN - rifaximin tab 550 mg

QL (60 tablets/30 days)

ANTINEOPLASTIC AGENTS

ANTINEOPLASTICS

abiraterone acetate tab 250 mg (Zytiga)

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

abiraterone acetate tab 500 mg (Zytiga)

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

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

ALECENSA - alectinib hcl cap 150 mg (base equivalent)

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

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

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

ALUNBRIG - brigatinib tab 30 mg

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

ALUNBRIG - brigatinib tab 90 mg, 180 mg

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

anastrozole tab 1 mg (Arimidex)

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

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

bexarotene cap 75 mg (Targretin)

PA, SP

bicalutamide tab 50 mg (Casodex)

BOSULIF - bosutinib cap 50 mg

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

BOSULIF - bosutinib cap 100 mg

PA, QL (150 capsules/30 days), SP

BOSULIF - bosutinib tab 100 mg

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

BOSULIF - bosutinib tab 400 mg, 500 mg

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

BRUKINSA - zanubrutinib cap 80 mg

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

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

(base equivalent), 60 mg (base equivalent)

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

CALQUENCE - acalabrutinib maleate tab 100 mg

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

capecitabine tab 150 mg, 500 mg (Xeloda)

COTELLIC - cobimetinib fumarate tab 20 mg (base equivalent)

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

cyclophosphamide cap 25 mg, 50 mg (Cyclophosphamide)

EMCYT - estramustine phosphate sodium cap 140 mg

ERIVEDGE - vismodegib cap 150 mg

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

ERLEADA - apalutamide tab 60 mg

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

ERLEADA - apalutamide tab 240 mg

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

erlotinib hcl tab 25 mg (base equivalent) (Tarceva)

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

erlotinib hcl tab 100 mg (base equivalent), 150 mg (base equivalent)

(Tarceva)

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

ETOPOSIDE - etoposide cap 50 mg

everolimus tab for oral susp 2 mg, 5 mg (Afinitor disperz)

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

everolimus tab for oral susp 3 mg (Afinitor disperz)

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

everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg (Afinitor)

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

exemestane tab 25 mg (Aromasin)

gefitinib tab 250 mg (Iressa)

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

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

hydroxyurea cap 500 mg (Hydrea)

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

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 7

Drug Name

Requirements/Limits

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

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

imatinib mesylate tab 100 mg (base equivalent) (Gleevec)

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

imatinib mesylate tab 400 mg (base equivalent) (Gleevec)

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

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

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

IMBRUVICA - ibrutinib oral susp 70 mg/ml

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

IMBRUVICA - ibrutinib cap 70 mg

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

IMBRUVICA - ibrutinib cap 140 mg

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

KISQALI - ribociclib succinate tab pack 200 mg daily dose

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

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

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

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

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

lapatinib ditosylate tab 250 mg (base equiv) (Tykerb)

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

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

daily dose)

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

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

daily dose)

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

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

(14 mg daily dose)

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

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

(18 mg daily dose)

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

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

(20 mg daily dose)

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

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

(24 mg daily dose)

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

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

dose)

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

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

daily dose)

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

letrozole tab 2.5 mg (Femara)

leucovorin calcium tab 5 mg, 15 mg, 25 mg

LEUKERAN - chlorambucil tab 2 mg

leuprolide acetate inj kit 1 mg/0.2ml (5 mg/ml)

LYNPARZA - olaparib tab 100 mg, 150 mg

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

MATULANE - procarbazine hcl cap 50 mg

PA, SP

megestrol acetate susp 40 mg/ml

megestrol acetate tab 20 mg, 40 mg

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

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

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

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

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

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

mercaptopurine tab 50 mg

MESNEX - mesna tab 400 mg

methotrexate sodium for inj 1 gm

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

ml), 1000 mg/40ml (25 mg/ml)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 8

Drug Name

Requirements/Limits

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

methotrexate sodium tab 2.5 mg (base equiv)

MYLERAN - busulfan tab 2 mg

nilutamide tab 150 mg (Nilandron)

NUBEQA - darolutamide tab 300 mg

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

pazopanib hcl tab 200 mg (base equiv) (Votrient)

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

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

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

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

& 50 mg tabs)

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

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

(2x150 mg tab)

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

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

RETEVMO - selpercatinib cap 40 mg

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

RETEVMO - selpercatinib cap 80 mg

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

ROZLYTREK - entrectinib pellet pack 50 mg

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

ROZLYTREK - entrectinib cap 100 mg

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

ROZLYTREK - entrectinib cap 200 mg

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

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

equivalent), 300 mg (base equivalent)

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

RYDAPT - midostaurin cap 25 mg

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

sorafenib tosylate tab 200 mg (base equivalent) (Nexavar)

SPRYCEL - dasatinib tab 20 mg

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

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

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

sunitinib malate cap 12.5 mg (base equivalent) (Sutent)

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

sunitinib malate cap 25 mg (base equivalent), 37.5 mg (base equivalent),

50 mg (base equivalent) (Sutent)

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

TABLOID - thioguanine tab 40 mg

TABRECTA - capmatinib hcl tab 150 mg, 200 mg

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

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

equivalent)

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

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

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

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

equivalent)

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

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

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

1 mg (base equivalent)

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

TALZENNA - talazoparib tosylate cap 0.25 mg (base equivalent)

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

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

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

equivalent), 200 mg (base equivalent)

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

temozolomide cap 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg

(Temodar)

PA, SP

TIBSOVO - ivosidenib tab 250 mg

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 9

Drug Name

Requirements/Limits

toremifene citrate tab 60 mg (base equivalent) (Fareston)

tretinoin cap 10 mg

PA, SP

VENCLEXTA - venetoclax tab 10 mg

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

VENCLEXTA - venetoclax tab 50 mg

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

VENCLEXTA - venetoclax tab 100 mg

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

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

& 100 mg

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

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

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

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

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

VITRAKVI - larotrectinib sulfate cap 25 mg (base equivalent)

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

VITRAKVI - larotrectinib sulfate cap 100 mg (base equivalent)

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

XALKORI - crizotinib cap 200 mg, 250 mg

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

XALKORI - crizotinib cap sprinkle 20 mg, 50 mg

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

XALKORI - crizotinib cap sprinkle 150 mg

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

XTANDI - enzalutamide cap 40 mg

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

XTANDI - enzalutamide tab 40 mg

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

XTANDI - enzalutamide tab 80 mg

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

YONSA - abiraterone acetate micronized tab 125 mg

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

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

equivalent), 300 mg (base equivalent)

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

ZELBORAF - vemurafenib tab 240 mg

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

ENDOCRINE AND METABOLIC DRUGS

CORTICOSTEROIDS

budesonide delayed release particles cap 3 mg (Entocort ec)

dexamethasone elixir 0.5 mg/5ml

dexamethasone tab 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

fludrocortisone acetate tab 0.1 mg

hydrocortisone tab 5 mg, 10 mg, 20 mg (Cortef)

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

methylprednisolone tab 4 mg, 8 mg, 16 mg, 32 mg (Medrol)

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)

(Pediapred)

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

prednisolone soln 15 mg/5ml

PREDNISONE - prednisone oral soln 5 mg/5ml

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

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

ANDROGEN-ANABOLIC

danazol cap 50 mg, 100 mg, 200 mg

testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone)

QL (1 vial/28 days)

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)

QL (10 ml/28 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 10

Drug Name

Requirements/Limits

testosterone td gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (Androgel)

PA, QL (60 packets/30 days)

testosterone td gel 12.5 mg/act (1%)

PA, QL (4 pumps/30 days)

testosterone td gel 20.25 mg/act (1.62%) (Androgel pump)

PA, QL (2 pumps/30 days)

testosterone td soln 30 mg/act

PA, QL (2 pumps/30 days)

ESTROGENS

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

0.05-0.25 mg/day

DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg

estradiol & norethindrone acetate tab 0.5-0.1 mg, 1-0.5 mg (Activella)

estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump) (Estrogel)

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

estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm (0.1%),

0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25 mg/1.25gm (0.1%)

(Divigel)

estradiol td patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr,

0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Vivelle-dot)

QL (30 patches/30 days)

estradiol td patch weekly 0.025 mg/24hr, 0.0375 mg/24hr (37.5 mcg/24hr),

0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Climara)

QL (30 patches/30 days)

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

PA, QL (30 tablets/30 days)

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low

dose)

norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg

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

PA, QL (56 capsules/28 days)

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

1.25 mg

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

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

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

CONTRACEPTIVES

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

AC, QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)

QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

ELLA - ulipristal acetate tab 30 mg

AC, QL (2 tablets/365 days)

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg, 1 mg-50 mcg

QL (28 tablets/21 days)

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)

(Loseasonique)

AC, QL (28 tablets/21 days)

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)

(Seasonique)

QL (28 tablets/21 days)

levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg

AC, QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 11

Drug Name

Requirements/Limits

norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr

AC, QL (3 patches/21 days)

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg, 0.5 mg-35 mcg

QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg

AC, QL (28 tablets/21 days)

norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg (Estrostep

fe)

QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

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

1.5/30-21)

QL (28 tablets/21 days)

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

1/20)

AC, QL (28 tablets/21 days)

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

1.5/30)

QL (28 tablets/21 days)

Norethindrone tab 0.35 mg (Nor-qd)

AC, QL (28 tablets/21 days)

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

novum 7/7/7)

QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

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

QL (28 tablets/21 days)

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

cyclen lo)

QL (28 tablets/21 days)

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

cyclen)

AC, QL (28 tablets/21 days)

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg

QL (28 tablets/21 days)

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

AC, QL (1 ring/21 days)

PROGESTINS

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

norethindrone acetate tab 5 mg (Aygestin)

progesterone cap 100 mg, 200 mg (Prometrium)

ANTIDIABETICS

acarbose tab 25 mg, 50 mg, 100 mg (Precose)

BAQSIMI ONE PACK - glucagon nasal powder 3 mg/dose

BAQSIMI TWO PACK - glucagon nasal powder 3 mg/dose

diazoxide susp 50 mg/ml (Proglycem)

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

equivalent)

QL (30 tablets/30 days)

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

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

glipizide tab 5 mg, 10 mg (Glucotrol)

glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg, 5-500 mg

GLUCAGON EMERGENCY KIT FO - glucagon hcl for inj 1 mg

glyburide tab 1.25 mg, 2.5 mg, 5 mg

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 12

Drug Name

Requirements/Limits

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

QL (30 tablets/30 days)

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

0.5 mg/0.1ml, 1 mg/0.2ml

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

0.5 mg/0.1ml, 1 mg/0.2ml

GVOKE KIT - glucagon subcutaneous soln 1 mg/0.2ml

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

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

QL (60 tablets/30 days)

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

QL (30 tablets/30 days)

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

QL (60 tablets/30 days)

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

100 mg (base equiv)

QL (30 tablets/30 days)

JARDIANCE - empagliflozin tab 10 mg, 25 mg

QL (30 tablets/30 days)

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

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

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

PA, QL (4 pens/180 days)

MOUNJARO - tirzepatide soln pen-injector 5 mg/0.5ml, 7.5 mg/0.5ml,

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

PA, QL (4 pens/28 days)

nateglinide tab 60 mg, 120 mg (Starlix)

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

PA, QL (1 pen/28 days)

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

PA, QL (3 ml/28 days)

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

PA, QL (3 mls/28 days)

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

equiv) (Actos)

pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850 mg (Actoplus met)

repaglinide tab 0.5 mg

repaglinide tab 1 mg, 2 mg (Prandin)

RYBELSUS - semaglutide tab 3 mg

PA, QL (30 tablets/180 days)

RYBELSUS - semaglutide tab 7 mg, 14 mg

PA, QL (30 tablets/30 days)

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

QL (18 mls/30 days), ST

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

12.5-500 mg, 12.5-1000 mg

QL (60 tablets/30 days)

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

10-1000 mg, 12.5-1000 mg

QL (60 tablets/30 days)

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

QL (30 tablets/30 days)

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

QL (60 tablets/30 days)

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

25-5-1000 mg

QL (30 tablets/30 days)

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

QL (60 tablets/30 days)

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

3 mg/0.5ml, 4.5 mg/0.5ml

PA, QL (4 pens/28 days)

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

5-1000 mg

QL (60 tablets/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 13

Drug Name

Requirements/Limits

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

10-500 mg, 10-1000 mg

QL (30 tablets/30 days)

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

QL (5 pens/30 days), ST

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

ZEGALOGUE - dasiglucagon hcl subcutaneous soln pref syringe

0.6 mg/0.6ml

Rapid-Acting Insulins

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

QL (100 mls/30 days)

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

QL (100 mls/30 days)

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

QL (100 mls/30 days)

HUMALOG - insulin lispro soln cartridge 100 unit/ml

PA, QL (100 mls/30 days)

HUMALOG - insulin lispro inj soln 100 unit/ml

PA, QL (100 mls/30 days)

HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100 unit/ml

(0.5 unit dial)

PA, QL (100 mls/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml (1 unit dial),

200 unit/ml

PA, QL (100 mls/30 days)

HUMALOG TEMPO PEN - insulin lispro soln pen-inj w/transmitter port 100

unit/ml

PA, QL (100 mls/30 days)

LYUMJEV - insulin lispro-aabc inj 100 unit/ml

PA, QL (100 mls/30 days)

LYUMJEV KWIKPEN - insulin lispro-aabc soln pen-inj 100 unit/ml (1 unit dial)

PA, QL (100 mls/30 days)

LYUMJEV KWIKPEN - insulin lispro-aabc soln pen-injector 200 unit/ml

PA, QL (100 mls/30 days)

LYUMJEV TEMPO PEN - insulin lispro-aabc soln pen-inj w/transmit port 100

unit/ml

PA, QL (100 mls/30 days)

NOVOLOG - insulin aspart inj soln 100 unit/ml

QL (100 mls/30 days)

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

QL (100 mls/30 days)

NOVOLOG PENFILL - insulin aspart soln cartridge 100 unit/ml

QL (100 mls/30 days)

Short-Acting Insulins

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

PA, QL (100 mls/30 days)

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

QL (100 mls/30 days)

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

unit/ml

QL (100 mls/30 days)

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

QL (100 mls/30 days)

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

QL (100 mls/30 days)

Intermediate-Acting Insulins

HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100 unit/ml (50-50)

PA, QL (100 mls/30 days)

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro sus pen-inj 100

unit/ml (50-50)

PA, QL (100 mls/30 days)

HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml (75-25)

PA, QL (100 mls/30 days)

HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro sus pen-inj 100

unit/ml (75-25)

PA, QL (100 mls/30 days)

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

PA, QL (100 mls/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 14

Drug Name

Requirements/Limits

HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-injector

100 unit/ml

PA, QL (100 mls/30 days)

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

(70-30)

PA, QL (100 mls/30 days)

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100 unit/ml

(70-30)

PA, QL (100 mls/30 days)

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

QL (100 mls/30 days)

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

100 unit/ml

QL (100 mls/30 days)

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

(70-30)

QL (100 mls/30 days)

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

(70-30)

QL (100 mls/30 days)

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

(70-30)

QL (100 mls/30 days)

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

unit/ml (70-30)

QL (100 mls/30 days)

Basal Insulins

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

QL (100 mls/30 days)

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

QL (100 mls/30 days)

LEVEMIR - insulin detemir inj 100 unit/ml

QL (100 mls/30 days)

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

QL (100 mls/30 days)

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

QL (100 mls/30 days)

SEMGLEE - insulin glargine-yfgn inj 100 unit/ml

QL (100 mls/30 days)

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

unit dial)

QL (100 mls/30 days)

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

dial)

QL (100 mls/30 days)

TRESIBA - insulin degludec inj 100 unit/ml

QL (100 mls/30 days)

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

unit/ml

QL (100 mls/30 days)

THYROID AGENTS

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

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

(Synthroid)

liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg (Cytomel)

methimazole tab 5 mg, 10 mg (Tapazole)

propylthiouracil tab 50 mg

OXYTOCICS

methylergonovine maleate tab 0.2 mg

ENDOCRINE and METABOLIC AGENTS - MISC.

alendronate sodium tab 10 mg

QL (30 tablets/30 days)

alendronate sodium tab 35 mg

QL (4 tablets/28 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 15

Drug Name

Requirements/Limits

alendronate sodium tab 70 mg (Fosamax)

QL (4 tablets/28 days)

betaine powder for oral solution (Cystadane)

cabergoline tab 0.5 mg

calcitonin (salmon) nasal soln 200 unit/act

calcitriol cap 0.25 mcg, 0.5 mcg (Rocaltrol)

carglumic acid soluble tab 200 mg (Carbaglu)

cinacalcet hcl tab 30 mg (base equiv), 60 mg (base equiv), 90 mg (base

equiv) (Sensipar)

CLOMID - clomiphene citrate tab 50 mg

desmopressin acetate inj 4 mcg/ml (Ddavp)

desmopressin acetate nasal spray soln 0.01% (Ddavp)

desmopressin acetate nasal spray soln 0.01% (refrigerated)

desmopressin acetate preservative free (pf) inj 4 mcg/ml (Ddavp)

desmopressin acetate tab 0.1 mg, 0.2 mg (Ddavp)

FOLLISTIM AQ - follitropin beta inj 300 unit/0.36ml

QL (15 cartridges/30 days), SP

FOLLISTIM AQ - follitropin beta inj 600 unit/0.72ml

QL (8 cartridges/30 days), SP

FOLLISTIM AQ - follitropin beta inj 900 unit/1.08ml

QL (5 cartridges/30 days), SP

ganirelix acetate soln prefilled syringe 250 mcg/0.5ml (Ganirelix acetate)

QL (12 syringes/30 days), SP

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

unit)

PA, SP

GENOTROPIN MINIQUICK - somatropin for subcutaneous inj prefilled syr

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

2 mg

PA, SP

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

QL (1 tablet/30 days)

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

levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)

levocarnitine tab 330 mg (Carnitor)

nitisinone cap 2 mg, 5 mg, 10 mg, 20 mg (Orfadin)

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

octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100 mcg/ml (0.1 mg/ml),

500 mcg/ml (0.5 mg/ml) (Sandostatin)

octreotide acetate inj 200 mcg/ml (0.2 mg/ml), 1000 mcg/ml (1 mg/ml)

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

PA, SP

OMNITROPE - somatropin for inj 5.8 mg

PA, SP

ORFADIN - nitisinone susp 4 mg/ml

ORILISSA - elagolix sodium tab 150 mg (base equiv)

PA, QL (30 tablets/30 days)

ORILISSA - elagolix sodium tab 200 mg (base equiv)

PA, QL (60 tablets/30 days)

OVIDREL - choriogonadotropin alfa inj 250 mcg/0.5ml

QL (2 syringes/30 days), SP

PREGNYL - chorionic gonadotropin for im inj 10000 unit

QL (20 vials/30 days), SP

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

QL (20 vials/30 days), SP

raloxifene hcl tab 60 mg (Evista)

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 16

Drug Name

Requirements/Limits

risedronate sodium tab 5 mg, 30 mg (Actonel)

QL (30 tablets/30 days)

risedronate sodium tab 35 mg (Actonel)

QL (4 tablets/28 days)

risedronate sodium tab 150 mg (Actonel)

QL (1 tablet/30 days)

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

40 mg/ml, 80 mg/0.8ml

PA, SP

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

PA, QL (2.4 mls/28 days), SP

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

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

CARDIOVASCULAR AGENTS

CARDIOTONICS

digoxin oral soln 0.05 mg/ml (Digoxin)

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

ANTIANGINAL AGENTS

isosorbide dinitrate tab 5 mg (Isordil titradose)

isosorbide dinitrate tab 10 mg, 20 mg, 30 mg

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

nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat)

nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

(Nitro-dur)

BETA BLOCKERS

acebutolol hcl cap 200 mg, 400 mg (Sectral)

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

bisoprolol fumarate tab 5 mg (Zebeta)

bisoprolol fumarate tab 10 mg

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

labetalol hcl tab 100 mg (Trandate)

labetalol hcl tab 200 mg, 300 mg

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

equiv), 100 mg (tartrate equiv), 200 mg (tartrate equiv) (Toprol xl)

metoprolol tartrate tab 25 mg

metoprolol tartrate tab 50 mg, 100 mg (Lopressor)

nadolol tab 20 mg, 40 mg, 80 mg (Corgard)

pindolol tab 5 mg, 10 mg

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

propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg, 160 mg (Inderal la)

propranolol hcl oral soln 20 mg/5ml

propranolol hcl tab 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg (Betapace af)

sotalol hcl tab 80 mg, 120 mg, 160 mg (Betapace)

sotalol hcl tab 240 mg

CALCIUM CHANNEL BLOCKERS

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 17

Drug Name

Requirements/Limits

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

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

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

diltiazem hcl coated beads cap er 24hr 120 mg, 180 mg, 240 mg, 300 mg

(Cardizem cd)

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

240 mg, 300 mg, 360 mg, 420 mg (Tiazac)

diltiazem hcl tab 30 mg, 60 mg, 120 mg (Cardizem)

diltiazem hcl tab 90 mg

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

nifedipine tab er 24hr 30 mg, 60 mg, 90 mg (Adalat cc)

nifedipine tab er 24hr osmotic release 30 mg, 60 mg, 90 mg (Procardia xl)

nimodipine cap 30 mg

verapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg (Verelan)

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

verapamil hcl tab 40 mg

verapamil hcl tab 80 mg, 120 mg (Calan)

ANTIARRHYTHMICS

amiodarone hcl tab 100 mg

amiodarone hcl tab 200 mg (Cordarone)

disopyramide phosphate cap 100 mg, 150 mg (Norpace)

flecainide acetate tab 50 mg, 100 mg, 150 mg

mexiletine hcl cap 150 mg, 200 mg, 250 mg

MULTAQ - dronedarone hcl tab 400 mg (base equivalent)

propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg (Rythmol sr)

propafenone hcl tab 150 mg, 225 mg, 300 mg

quinidine gluconate tab er 324 mg

ANTIHYPERTENSIVES

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

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

amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg, 10-160 mg,

10-320 mg (Exforge)

amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg,

5-160-25 mg, 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg (Exforge hct)

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

atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100)

benazepril & hydrochlorothiazide tab 5-6.25 mg

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

(Lotensin hct)

benazepril hcl tab 5 mg

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 18

Drug Name

Requirements/Limits

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

(Ziac)

candesartan cilexetil tab 4 mg, 8 mg, 16 mg, 32 mg (Atacand)

candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg, 32-12.5 mg,

32-25 mg (Atacand hct)

captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg

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

clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1)

clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2)

clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3)

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

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

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

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

eplerenone tab 25 mg, 50 mg (Inspra)

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg

fosinopril sodium tab 10 mg, 20 mg, 40 mg

guanfacine hcl tab 1 mg, 2 mg (Tenex)

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

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

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

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

(Zestoretic)

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

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

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

100-25 mg (Hyzaar)

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

metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)

metoprolol & hydrochlorothiazide tab 100-25 mg, 100-50 mg

minoxidil tab 2.5 mg, 10 mg

moexipril hcl tab 7.5 mg, 15 mg

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

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

40-25 mg (Benicar hct)

perindopril erbumine tab 4 mg (Aceon)

phenoxybenzamine hcl cap 10 mg (Dibenzyline)

prazosin hcl cap 1 mg, 2 mg, 5 mg (Minipress)

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

quinapril-hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg (Accuretic)

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

telmisartan tab 20 mg, 40 mg, 80 mg (Micardis)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 19

Drug Name

Requirements/Limits

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

(base equivalent), 10 mg (base equivalent)

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

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

valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5 mg, 160-25 mg,

320-12.5 mg, 320-25 mg (Diovan hct)

DIURETICS

acetazolamide cap er 12hr 500 mg

acetazolamide tab 125 mg, 250 mg

amiloride hcl tab 5 mg

bumetanide tab 0.5 mg, 1 mg, 2 mg (Bumex)

chlorthalidone tab 25 mg, 50 mg

furosemide oral soln 10 mg/ml

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

hydrochlorothiazide cap 12.5 mg (Microzide)

hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg

indapamide tab 1.25 mg, 2.5 mg

methazolamide tab 25 mg, 50 mg

metolazone tab 2.5 mg, 5 mg, 10 mg

spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)

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

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

triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)

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

triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)

VASOPRESSORS

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

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

epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) (Epipen-jr 2-

pak)

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (Epipen 2-pak)

midodrine hcl tab 2.5 mg, 5 mg, 10 mg

ANTIHYPERLIPIDEMICS

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

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

cholestyramine light powder 4 gm/dose (Questran light)

cholestyramine powder 4 gm/dose (Questran)

colesevelam hcl tab 625 mg (Welchol)

colestipol hcl granule packets 5 gm (Colestid flavored)

colestipol hcl granules 5 gm (Colestid flavored)

colestipol hcl tab 1 gm (Colestid)

ezetimibe tab 10 mg (Zetia)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 20

Drug Name

Requirements/Limits

ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

(Vytorin)

fenofibrate micronized cap 67 mg, 134 mg, 200 mg

fenofibrate tab 48 mg, 145 mg (Tricor)

fenofibrate tab 54 mg, 160 mg (Lofibra)

gemfibrozil tab 600 mg (Lopid)

lovastatin tab 10 mg

lovastatin tab 20 mg

lovastatin tab 40 mg (Mevacor)

NEXLETOL - bempedoic acid tab 180 mg

PA, QL (30 tablets/30 days)

NEXLIZET - bempedoic acid-ezetimibe tab 180-10 mg

PA, QL (30 tablets/30 days)

niacin tab er 500 mg (antihyperlipidemic), 750 mg (antihyperlipidemic)

niacin tab er 1000 mg (antihyperlipidemic) (Niaspan)

pravastatin sodium tab 10 mg

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

REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml

PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneous soln

cartridge/infusor 420 mg/3.5ml

PA, QL (2 cartridges/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector

140 mg/ml

PA, QL (2 injectors/28 days)

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

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

CARDIOVASCULAR AGENTS - MISC.

ambrisentan tab 5 mg, 10 mg (Letairis)

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

bosentan tab 62.5 mg, 125 mg (Tracleer)

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

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

PA, QL (60 tablets/30 days)

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

PA, QL (600 mls/30 days)

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

ENTRESTO - sacubitril-valsartan sprinkle cap 6-6 mg, 15-16 mg

OPSUMIT - macitentan tab 10 mg

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

sildenafil citrate tab 20 mg (Revatio)

QL (90 tablets/30 days), SP

tadalafil tab 20 mg (pah) (Adcirca)

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

tadalafil tab 2.5 mg, 5 mg (Cialis)

QL (30 tablets/30 days)

tadalafil tab 10 mg, 20 mg (Cialis)

QL (8 tablets/30 days)

TRACLEER - bosentan tab for oral susp 32 mg

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

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

1200 mcg, 1400 mcg, 1600 mcg

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

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

800 mcg (60)

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

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

PA, QL (30 tablets/30 days)

VYNDAMAX - tafamidis cap 61 mg

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

VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 21

Drug Name

Requirements/Limits

ERECTILE DYSFUNCTION

tadalafil tab 2.5 mg, 5 mg (Cialis)

QL (30 tablets/30 days)

tadalafil tab 10 mg, 20 mg (Cialis)

QL (8 tablets/30 days)

RESPIRATORY AGENTS

ANTIHISTAMINES

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

cyproheptadine hcl syrup 2 mg/5ml

cyproheptadine hcl tab 4 mg

desloratadine tab 5 mg (Clarinex)

levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)

levocetirizine dihydrochloride tab 5 mg

promethazine hcl oral soln 6.25 mg/5ml

promethazine hcl suppos 12.5 mg, 25 mg

promethazine hcl tab 12.5 mg, 25 mg, 50 mg

NASAL AGENTS - SYSTEMIC and TOPICAL

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

QL (2 bottles/30 days)

azelastine hcl nasal spray 0.15% (205.5 mcg/spray) (Astepro)

QL (2 bottles/30 days)

flunisolide nasal soln 25 mcg/act (0.025%)

QL (3 bottles/30 days)

fluticasone propionate nasal susp 50 mcg/act

QL (1 bottle/30 days)

ipratropium bromide nasal soln 0.03% (21 mcg/spray)

QL (2 bottles/30 days)

ipratropium bromide nasal soln 0.06% (42 mcg/spray)

QL (3 bottles/30 days)

mometasone furoate nasal susp 50 mcg/act (Nasonex)

QL (1 bottle/30 days)

COUGH/COLD/ALLERGY

acetylcysteine inhal soln 10%, 20%

sodium chloride soln nebu 3%

sodium chloride soln nebu 7% (Hyper-sal)

ANTIASTHMATIC and BRONCHODILATOR AGENTS

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

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

QL (1 inhaler/30 days)

albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) (Proventil

hfa)

QL (2 inhalers/30 days)

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml), 0.63 mg/3ml (base

equiv), 1.25 mg/3ml (base equiv)

QL (125 containers/30 days)

albuterol sulfate soln nebu 0.5% (5 mg/ml)

QL (60 mls/30 days)

albuterol sulfate syrup 2 mg/5ml

albuterol sulfate tab 2 mg, 4 mg

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

QL (60 blisters/30 days)

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

act, 100 mcg/act, 200 mcg/act

QL (30 blisters/30 days)

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

100 mcg/act, 200 mcg/act

QL (1 inhaler/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 22

Drug Name

Requirements/Limits

ASMANEX TWISTHALER 120 ME - mometasone furoate inhal powd

220 mcg/act (breath activated)

QL (1 inhaler/30 days)

ASMANEX TWISTHALER 30 MET - mometasone furoate inhal powd

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

QL (1 inhaler/30 days)

ASMANEX TWISTHALER 60 MET - mometasone furoate inhal powd

220 mcg/act (breath activated)

QL (1 inhaler/30 days)

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

QL (1 inhaler/30 days)

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

200-25 mcg/act

QL (60 blisters/30 days)

BREZTRI AEROSPHERE - budesonide-glycopyrrolate-formoterol aers

160-9-4.8 mcg/act

QL (1 inhaler/30 days)

budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml (Pulmicort)

QL (120 mls/30 days)

budesonide inhalation susp 1 mg/2ml (Pulmicort)

QL (60 mls/30 days)

COMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act

QL (2 inhalers/30 days)

cromolyn sodium soln nebu 20 mg/2ml

QL (240 mls/30 days)

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

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

QL (3 inhalers/30 days)

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

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

FLUTICASONE PROPIONATE/SA - fluticasone-salmeterol aer powder ba

55-14 mcg/act

FLUTICASONE PROPIONATE/SA - fluticasone-salmeterol aer powder ba

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

QL (1 inhaler/30 days)

fluticasone-salmeterol aer powder ba 100-50 mcg/act, 250-50 mcg/act,

500-50 mcg/act (Advair diskus)

QL (60 blisters/30 days)

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

(base eq)

QL (30 blisters/30 days)

ipratropium bromide inhal soln 0.02%

QL (150 containers/30 days)

ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml

QL (540 mls/30 days)

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) (Xopenex

concentrate)

QL (90 vials/30 days)

levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv), 0.63 mg/3ml (base

equiv), 1.25 mg/3ml (base equiv) (Xopenex)

QL (96 vials/30 days)

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

(Singulair)

montelukast sodium oral granules packet 4 mg (base equiv) (Singulair)

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

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

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

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

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

NUCALA - mepolizumab subcutaneous solution pref syringe 100 mg/ml

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

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

act

QL (1 inhaler/30 days)

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

act

QL (2 inhalers/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 23

Drug Name

Requirements/Limits

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

equiv)

QL (60 blisters/30 days)

SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal cap 18 mcg

(base equiv)

QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal aerosol

1.25 mcg/act

QL (1 inhaler/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal aerosol 2.5 mcg/

act

QL (1 cartridge/30 days)

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

QL (1 inhaler/30 days)

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

equiv)

QL (1 inhaler/30 days)

SYMBICORT - budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act,

160-4.5 mcg/act

QL (3 inhalers/30 days)

terbutaline sulfate tab 2.5 mg, 5 mg

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

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

theophylline tab er 12hr 300 mg, 450 mg

theophylline tab er 24hr 400 mg, 600 mg

TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

100-62.5-25 mcg/act

QL (60 blisters/30 days)

TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb

200-62.5-25 mcg/act

QL (1 inhaler/30 days)

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

QL (2 inhalers/30 days)

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

ml, 300 mg/2ml

PA, SP

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

150 mg/ml, 300 mg/2ml

PA, SP

zafirlukast tab 10 mg, 20 mg (Accolate)

RESPIRATORY AGENTS - MISC.

KALYDECO - ivacaftor tab 150 mg

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

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

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

PULMOZYME - dornase alfa inhal soln 2.5 mg/2.5ml

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

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

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

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

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

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

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

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

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

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

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

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

GASTROINTESTINAL AGENTS

LAXATIVES

lactulose solution 10 gm/15ml

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

peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack)

ANTIDIARRHEALS

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 24

Drug Name

Requirements/Limits

diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)

loperamide hcl cap 2 mg

ULCER DRUGS

cimetidine tab 300 mg, 400 mg, 800 mg

dicyclomine hcl cap 10 mg (Bentyl)

dicyclomine hcl oral soln 10 mg/5ml

dicyclomine hcl tab 20 mg (Bentyl)

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

(base eq) (Nexium)

QL (60 capsules/30 days)

esomeprazole magnesium for delayed release susp packet 10 mg,

20 mg, 40 mg (Nexium)

PA, QL (60 packets/30 days)

famotidine for susp 40 mg/5ml

famotidine tab 20 mg, 40 mg (Pepcid)

glycopyrrolate tab 1 mg, 2 mg

lansoprazole cap delayed release 15 mg, 30 mg (Prevacid)

QL (60 capsules/30 days)

methscopolamine bromide tab 2.5 mg, 5 mg

misoprostol tab 100 mcg, 200 mcg (Cytotec)

NEXIUM - esomeprazole magnesium for delayed release susp pack 2.5 mg

PA, QL (60 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susp packet 5 mg

PA, QL (60 packets/30 days)

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

QL (60 capsules/30 days)

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

(Protonix)

QL (60 tablets/30 days)

sucralfate tab 1 gm (Carafate)

ANTIEMETICS

aprepitant capsule therapy pack 80 & 125 mg (Emend tripack)

QL (9 capsules/30 days)

aprepitant capsule 40 mg (Emend)

QL (2 capsules/30 days)

aprepitant capsule 80 mg (Emend)

QL (6 capsules/30 days)

aprepitant capsule 125 mg (Emend)

QL (3 capsules/30 days)

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

QL (9 kits/30 days)

granisetron hcl tab 1 mg

QL (20 tablets/30 days)

meclizine hcl tab 12.5 mg, 25 mg

ondansetron hcl oral soln 4 mg/5ml

QL (300 ml/30 days)

ondansetron hcl tab 4 mg, 8 mg (Zofran)

QL (30 tablets/30 days)

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

QL (30 tablets/30 days)

scopolamine td patch 72hr 1 mg/3days (Transderm-scop)

trimethobenzamide hcl cap 300 mg (Tigan)

DIGESTIVE AIDS

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

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

unit, 36000-114000-180000 unit

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 25

Drug Name

Requirements/Limits

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

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

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

unit, 60000-189600-252600 unit

GASTROINTESTINAL AGENTS- MISC.

alosetron hcl tab 0.5 mg (base equiv), 1 mg (base equiv) (Lotronex)

QL (60 tablets/30 days)

balsalazide disodium cap 750 mg (Colazal)

calcium acetate (phosphate binder) cap 667 mg (169 mg ca)

calcium acetate (phosphate binder) tab 667 mg

CHENODAL - chenodiol tab 250 mg

lactulose (encephalopathy) solution 10 gm/15ml

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

QL (30 capsules/30 days)

mesalamine cap dr 400 mg (Delzicol)

mesalamine cap er 24hr 0.375 gm (Apriso)

mesalamine enema 4 gm

mesalamine suppos 1000 mg (Canasa)

mesalamine tab delayed release 1.2 gm (Lialda)

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv)

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

(Reglan)

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

equivalent)

QL (30 tablets/30 days)

sevelamer carbonate packet 0.8 gm, 2.4 gm (Renvela)

sevelamer carbonate tab 800 mg (Renvela)

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

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

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

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

sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)

sulfasalazine tab 500 mg (Azulfidine)

SYMPROIC - naldemedine tosylate tab 0.2 mg (base equivalent)

QL (30 tablets/30 days)

TRULANCE - plecanatide tab 3 mg

QL (30 tablets/30 days)

ursodiol cap 300 mg (Actigall)

ursodiol tab 250 mg (Urso 250)

ursodiol tab 500 mg (Urso forte)

VELPHORO - sucroferric oxyhydroxide chew tab 500 mg

VIBERZI - eluxadoline tab 75 mg, 100 mg

QL (60 tablets/30 days)

GENITOURINARY AGENTS

URINARY ANTISPASMODICS

oxybutynin chloride solution 5 mg/5ml

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

oxybutynin chloride tab er 24hr 15 mg

oxybutynin chloride tab 5 mg

solifenacin succinate tab 5 mg, 10 mg (Vesicare)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 26

Drug Name

Requirements/Limits

tolterodine tartrate cap er 24hr 2 mg, 4 mg (Detrol la)

tolterodine tartrate tab 1 mg, 2 mg (Detrol)

VAGINAL PRODUCTS

clindamycin phosphate vaginal cream 2% (Cleocin)

CRINONE - progesterone vaginal gel 4%, 8%

QL (60 applicators/30 days)

estradiol vaginal cream 0.1 mg/gm (Estrace)

estradiol vaginal tab 10 mcg (Vagifem)

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

metronidazole vaginal gel 0.75% (Metrogel-vaginal)

terconazole vaginal cream 0.4%, 0.8%

terconazole vaginal suppos 80 mg

GENITOURINARY AGENTS - MISC.

alfuzosin hcl tab er 24hr 10 mg (Uroxatral)

CYSTAGON - cysteamine bitartrate cap 50 mg, 150 mg

dutasteride cap 0.5 mg (Avodart)

finasteride tab 5 mg (Proscar)

potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)

potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10)

potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15)

silodosin cap 4 mg, 8 mg (Rapaflo)

sodium citrate & citric acid soln 500-334 mg/5ml

tamsulosin hcl cap 0.4 mg (Flomax)

CENTRAL NERVOUS SYSTEM DRUGS

ANTIANXIETY AGENTS

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

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

buspirone hcl tab 5 mg, 10 mg, 15 mg, 30 mg

diazepam oral soln 1 mg/ml

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

hydroxyzine hcl syrup 10 mg/5ml

hydroxyzine hcl tab 10 mg, 25 mg, 50 mg

hydroxyzine pamoate cap 25 mg, 50 mg (Vistaril)

lorazepam conc 2 mg/ml

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

QL (150 tablets/30 days)

ANTIDEPRESSANTS

amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg

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

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

bupropion hcl tab 75 mg, 100 mg

citalopram hydrobromide oral soln 10 mg/5ml

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 27

Drug Name

Requirements/Limits

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

40 mg (base equiv) (Celexa)

clomipramine hcl cap 25 mg, 50 mg, 75 mg (Anafranil)

desipramine hcl tab 10 mg, 25 mg (Norpramin)

desipramine hcl tab 50 mg, 75 mg, 100 mg, 150 mg

desvenlafaxine succinate tab er 24hr 25 mg (base equiv), 50 mg (base

equiv), 100 mg (base equiv) (Pristiq)

QL (60 tablets/30 days)

doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100 mg

doxepin hcl conc 10 mg/ml

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

eq) (Cymbalta)

QL (60 capsules/30 days)

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

QL (90 capsules/30 days)

escitalopram oxalate soln 5 mg/5ml (base equiv)

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

(base equiv) (Lexapro)

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

fluoxetine hcl solution 20 mg/5ml

fluvoxamine maleate tab 25 mg, 50 mg, 100 mg

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

mirtazapine tab 7.5 mg

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

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

nortriptyline hcl soln 10 mg/5ml

paroxetine hcl tab er 24hr 12.5 mg, 25 mg, 37.5 mg (Paxil cr)

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

sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft)

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

tranylcypromine sulfate tab 10 mg (Parnate)

trazodone hcl tab 50 mg, 100 mg, 150 mg

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

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

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

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

equivalent)

ZURZUVAE - zuranolone cap 20 mg, 25 mg

QL (28 capsules/365 days)

ZURZUVAE - zuranolone cap 30 mg

QL (14 capsule/365 days)

ANTIPSYCHOTICS

aripiprazole tab 2 mg, 5 mg (Abilify)

QL (60 tablets/30 days)

aripiprazole tab 10 mg, 15 mg, 20 mg, 30 mg (Abilify)

QL (30 tablets/30 days)

chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg, 200 mg

clozapine tab 25 mg (Clozaril)

QL (270 tablets/30 days)

clozapine tab 50 mg (Clozapine)

QL (90 tablets/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 28

Drug Name

Requirements/Limits

clozapine tab 100 mg (Clozaril)

QL (90 tablets/30 days)

clozapine tab 200 mg (Clozapine)

QL (120 tablets/30 days)

FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml

fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg

FLUPHENAZINE HYDROCHLORID - fluphenazine hcl elixir 2.5 mg/5ml

haloperidol lactate oral conc 2 mg/ml

haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg

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

lithium carbonate cap 300 mg

lithium carbonate tab er 300 mg (Lithobid)

lithium carbonate tab er 450 mg

lithium carbonate tab 300 mg

lithium oral solution 8 meq/5ml

loxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mg

lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg (Latuda)

QL (30 tablets/30 days)

lurasidone hcl tab 80 mg (Latuda)

QL (60 tablets/30 days)

olanzapine orally disintegrating tab 5 mg, 10 mg, 15 mg, 20 mg (Zyprexa

zydis)

QL (30 tablets/30 days)

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

QL (60 tablets/30 days)

olanzapine tab 15 mg, 20 mg (Zyprexa)

QL (30 tablets/30 days)

perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg

prochlorperazine maleate tab 5 mg (base equivalent), 10 mg (base

equivalent)

prochlorperazine suppos 25 mg

quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400 mg (Seroquel xr)

QL (60 tablets/30 days)

quetiapine fumarate tab er 24hr 150 mg, 200 mg (Seroquel xr)

QL (30 tablets/30 days)

quetiapine fumarate tab 25 mg, 50 mg (Seroquel)

QL (180 tablets/30 days)

quetiapine fumarate tab 100 mg (Seroquel)

QL (120 tablets/30 days)

quetiapine fumarate tab 200 mg (Seroquel)

QL (90 tablets/30 days)

quetiapine fumarate tab 300 mg, 400 mg (Seroquel)

QL (60 tablets/30 days)

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

QL (30 tablets/30 days), ST

risperidone orally disintegrating tab 0.5 mg, 1 mg, 2 mg, 3 mg

QL (60 tablets/30 days)

risperidone orally disintegrating tab 4 mg

QL (120 tablets/30 days)

risperidone soln 1 mg/ml (Risperdal)

QL (480 mls/30 days)

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

QL (120 tablets/30 days)

risperidone tab 3 mg (Risperdal)

QL (60 tablets/30 days)

thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg

trifluoperazine hcl tab 1 mg (base equivalent), 2 mg (base equivalent),

5 mg (base equivalent), 10 mg (base equivalent)

ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg (Geodon)

QL (60 capsules/30 days)

HYPNOTICS

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 29

Drug Name

Requirements/Limits

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

QL (30 tablets/30 days), ST

estazolam tab 1 mg, 2 mg

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

QL (30 tablets/30 days)

phenobarbital elixir 20 mg/5ml

phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 100 mg

temazepam cap 15 mg, 30 mg (Restoril)

zaleplon cap 5 mg, 10 mg (Sonata)

QL (30 capsules/30 days)

zolpidem tartrate tab er 6.25 mg, 12.5 mg (Ambien cr)

QL (30 tablets/30 days)

zolpidem tartrate tab 5 mg, 10 mg (Ambien)

QL (30 tablets/30 days)

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

amphetamine-dextroamphetamine cap er 24hr 5 mg, 10 mg, 15 mg,

20 mg, 25 mg, 30 mg (Adderall xr)

QL (30 capsules/30 days)

amphetamine-dextroamphetamine tab 5 mg, 7.5 mg, 10 mg, 12.5 mg,

15 mg, 30 mg (Adderall)

QL (60 tablets/30 days)

amphetamine-dextroamphetamine tab 20 mg (Adderall)

QL (90 tablets/30 days)

armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg (Nuvigil)

atomoxetine hcl cap 10 mg (base equiv), 18 mg (base equiv), 25 mg

(base equiv), 40 mg (base equiv) (Strattera)

QL (60 capsules/30 days)

atomoxetine hcl cap 60 mg (base equiv), 80 mg (base equiv), 100 mg

(base equiv) (Strattera)

QL (30 capsules/30 days)

caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)

dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15 mg, 20 mg, 25 mg,

30 mg, 35 mg, 40 mg (Focalin xr)

QL (30 capsules/30 days)

dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg (Focalin)

QL (60 tablets/30 days)

dextroamphetamine sulfate cap er 24hr 5 mg

QL (90 capsules/30 days)

dextroamphetamine sulfate cap er 24hr 10 mg, 15 mg (Dexedrine)

QL (120 capsules/30 days)

dextroamphetamine sulfate tab 5 mg

QL (90 tablets/30 days)

dextroamphetamine sulfate tab 10 mg

QL (180 tablets/30 days)

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

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

QL (30 tablets/30 days)

lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30 mg, 40 mg, 50 mg,

60 mg, 70 mg (Vyvanse)

QL (30 capsules/30 days)

lisdexamfetamine dimesylate chew tab 10 mg, 20 mg, 30 mg, 40 mg,

50 mg, 60 mg (Vyvanse)

QL (30 tablets/30 days)

methylphenidate hcl tab er osmotic release (osm) 18 mg, 27 mg, 54 mg

(Concerta)

QL (30 tablets/30 days)

methylphenidate hcl tab er osmotic release (osm) 36 mg (Concerta)

QL (60 tablets/30 days)

methylphenidate hcl tab er 10 mg, 20 mg

QL (90 tablets/30 days)

methylphenidate hcl tab 5 mg, 10 mg, 20 mg (Ritalin)

QL (90 tablets/30 days)

modafinil tab 100 mg, 200 mg (Provigil)

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

PA, QL (30 tablets/30 days)

PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS - MISC.

acamprosate calcium tab delayed release 333 mg

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 30

Drug Name

Requirements/Limits

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

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

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

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

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

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

bupropion hcl (smoking deterrent) tab er 12hr 150 mg

dimethyl fumarate capsule delayed release 120 mg (Tecfidera)

QL (14 capsules/180 days), SP

dimethyl fumarate capsule delayed release 240 mg (Tecfidera)

QL (60 capsules/30 days), SP

dimethyl fumarate capsule dr starter pack 120 mg & 240 mg (Tecfidera

starter pa)

QL (60 capsules/180 days), SP

disulfiram tab 250 mg, 500 mg (Antabuse)

donepezil hydrochloride orally disintegrating tab 5 mg, 10 mg

donepezil hydrochloride tab 5 mg, 10 mg (Aricept)

fingolimod hcl cap 0.5 mg (base equiv) (Gilenya)

QL (30 capsules/30 days), SP

galantamine hydrobromide cap er 24hr 8 mg, 16 mg, 24 mg (Razadyne

er)

galantamine hydrobromide tab 4 mg, 8 mg, 12 mg (Razadyne)

glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)

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

glatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MAYZENT - siponimod fumarate tab 0.25 mg (base equiv)

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

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

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

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

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

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

pack

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

memantine hcl oral solution 2 mg/ml

memantine hcl tab 5 mg, 10 mg (Namenda)

memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack (Namenda

titration pa)

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

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

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

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

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

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

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

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

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

94 mcg/0.5ml pack

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

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

94 mcg/0.5ml pack

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 31

Drug Name

Requirements/Limits

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

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

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

44 mcg/0.5ml

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

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

& 6x22 mcg/0.5ml

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

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

6x22 mcg/0.5ml

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

rivastigmine tartrate cap 1.5 mg (base equivalent), 3 mg (base

equivalent), 4.5 mg (base equivalent), 6 mg (base equivalent)

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

QL (60 tablets/30 days)

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

50 mg (42) pak

QL (55 tablets/180 days)

teriflunomide tab 7 mg, 14 mg (Aubagio)

QL (30 tablets/30 days), SP

tetrabenazine tab 12.5 mg (Xenazine)

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

tetrabenazine tab 25 mg (Xenazine)

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

varenicline tartrate tab 0.5 mg (base equiv), 1 mg (base equiv)

varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg start pack

VUMERITY - diroximel fumarate capsule delayed release 231 mg

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

ZEPOSIA - ozanimod hcl cap 0.92 mg

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

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

21 x 0.92 mg

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

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

0.46 mg

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

ANALGESICS AND ANESTHETICS

ANALGESICS - NON-NARCOTIC

butalbital-acetaminophen tab 50-325 mg

butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)

butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)

ANALGESICS - NARCOTIC

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

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

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4)

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

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

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

equivalent)

QL (60 films/30 days)

buprenorphine hcl sl tab 2 mg (base equiv), 8 mg (base equiv)

buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv), 4-1 mg

(base equiv), 8-2 mg (base equiv), 12-3 mg (base equiv) (Suboxone)

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv), 8-2 mg

(base equiv)

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/codeine

#3)

codeine sulfate tab 30 mg (Codeine sulfate)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 32

Drug Name

Requirements/Limits

fentanyl citrate lozenge on a handle 200 mcg, 400 mcg, 600 mcg,

800 mcg, 1200 mcg, 1600 mcg (Actiq)

PA, QL (120 units/30 days)

fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr,

100 mcg/hr (Duragesic)

QL (15 patches/30 days)

hydrocodone-acetaminophen soln 7.5-325 mg/15ml

hydrocodone-acetaminophen tab 10-325 mg, 5-325 mg, 7.5-325 mg

(Norco)

hydrocodone-ibuprofen tab 7.5-200 mg

hydromorphone hcl liqd 1 mg/ml (Dilaudid)

hydromorphone hcl tab 2 mg, 4 mg, 8 mg (Dilaudid)

methadone hcl conc 10 mg/ml (Methadose)

methadone hcl soln 5 mg/5ml, 10 mg/5ml (Methadone hcl)

methadone hcl tab for oral susp 40 mg

methadone hcl tab 5 mg (Dolophine hcl)

methadone hcl tab 10 mg (Dolophine)

morphine sulfate oral soln 10 mg/5ml, 100 mg/5ml (20 mg/ml)

morphine sulfate tab er 15 mg, 30 mg, 60 mg, 100 mg, 200 mg (Ms contin)

QL (90 tablets/30 days)

morphine sulfate tab 15 mg, 30 mg (Morphine sulfate)

oxycodone hcl conc 100 mg/5ml (20 mg/ml)

oxycodone hcl soln 5 mg/5ml

oxycodone hcl tab 5 mg, 15 mg, 30 mg (Roxicodone)

oxycodone hcl tab 10 mg, 20 mg

oxycodone w/ acetaminophen tab 5-325 mg, 7.5-325 mg, 10-325 mg

(Percocet)

tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg

QL (30 tablets/30 days)

tramadol hcl tab 50 mg (Ultram)

QL (240 tablets/30 days)

tramadol-acetaminophen tab 37.5-325 mg (Ultracet)

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

18 mg, 27 mg, 36 mg

QL (240 capsules/30 days)

ANALGESICS - ANTI-INFLAMMATORY

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

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

ACTEMRA ACTPEN - tocilizumab subcutaneous soln auto-injector

162 mg/0.9ml

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

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

QL (60 capsules/30 days)

celecoxib cap 400 mg (Celebrex)

QL (30 capsules/30 days)

diclofenac potassium tab 50 mg

diclofenac sodium tab delayed release 25 mg, 50 mg, 75 mg

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

50 mg/ml

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

ENBREL - etanercept subcutaneous inj 25 mg/0.5ml

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

ENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/ml

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 33

Drug Name

Requirements/Limits

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector

50 mg/ml

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

etodolac cap 200 mg, 300 mg

etodolac tab er 24hr 400 mg, 500 mg, 600 mg

etodolac tab 400 mg (Lodine)

etodolac tab 500 mg

flurbiprofen tab 100 mg

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

40 mg/0.8ml

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

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

40 mg/0.8ml

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

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

40 mg/0.4ml

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

HUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml

PA, SP

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

80 mg/0.8ml

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

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

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

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

40 mg/0.4ml

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

ibuprofen susp 100 mg/5ml

ibuprofen tab 400 mg, 600 mg, 800 mg

indomethacin cap 25 mg, 50 mg

leflunomide tab 10 mg, 20 mg (Arava)

meloxicam tab 7.5 mg, 15 mg (Mobic)

nabumetone tab 500 mg, 750 mg

naproxen sodium tab 275 mg, 550 mg

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

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

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

OTEZLA - apremilast tab 30 mg

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

oxaprozin tab 600 mg (Daypro)

piroxicam cap 10 mg, 20 mg (Feldene)

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

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

RINVOQ - upadacitinib tab er 24hr 45 mg

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

RINVOQ LQ - upadacitinib oral soln 1 mg/ml

PA, QL (360 mls/30 days), SP

SIMLANDI 1-PEN KIT - adalimumab-ryvk auto-injector kit 40 mg/0.4ml

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

SIMLANDI 2-PEN KIT - adalimumab-ryvk auto-injector kit 40 mg/0.4ml

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

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

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

SIMPONI - golimumab subcutaneous soln prefilled syringe 100 mg/ml

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

sulindac tab 150 mg, 200 mg

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

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

XELJANZ - tofacitinib citrate tab 5 mg (base equivalent)

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

XELJANZ - tofacitinib citrate tab 10 mg (base equivalent)

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 34

Drug Name

Requirements/Limits

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

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

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

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

MIGRAINE PRODUCTS

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

140 mg/ml

PA, QL (1 injection/28 days)

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

PA, QL (3 pens/84 days)

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

PA, QL (3 pens/84 days)

dihydroergotamine mesylate inj 1 mg/ml (D.h.e. 45)

QL (24 ampules/28 days)

dihydroergotamine mesylate nasal spray 4 mg/ml (Migranal)

PA, QL (8 vials/30 days)

eletriptan hydrobromide tab 20 mg (base equivalent), 40 mg (base

equivalent) (Relpax)

QL (18 tablets/30 days)

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

PA, QL (1 injection/28 days)

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

PA, QL (9 syringes/180 days)

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

PA, QL (1 syringe/28 days)

naratriptan hcl tab 1 mg (base equiv), 2.5 mg (base equiv) (Amerge)

QL (18 tablets/30 days)

NURTEC - rimegepant sulfate tab disint 75 mg

PA, QL (54 tablets/90 days)

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

PA, QL (30 tablets/30 days)

REYVOW - lasmiditan succinate tab 50 mg, 100 mg

PA, QL (8 tablets/30 days)

rizatriptan benzoate oral disintegrating tab 5 mg (base eq)

QL (18 tablets/30 days)

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

QL (18 tablets/30 days)

rizatriptan benzoate tab 5 mg (base equivalent)

QL (18 tablets/30 days)

rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)

QL (18 tablets/30 days)

sumatriptan nasal spray 5 mg/act, 20 mg/act (Imitrex)

QL (12 inhalers/30 days)

sumatriptan succinate inj 6 mg/0.5ml (Imitrex)

QL (12 vials/30 days)

sumatriptan succinate solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml

(Imitrex statdose sys)

QL (12 doses/30 days)

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

QL (18 tablets/30 days)

UBRELVY - ubrogepant tab 50 mg, 100 mg

PA, QL (16 tablets/30 days)

GOUT AGENTS

allopurinol tab 100 mg, 300 mg (Zyloprim)

colchicine tab 0.6 mg (Colcrys)

colchicine w/ probenecid tab 0.5-500 mg

probenecid tab 500 mg

NEUROMUSCULAR DRUGS

ANTICONVULSANTS

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

carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg (Carbatrol)

carbamazepine chew tab 100 mg

carbamazepine susp 100 mg/5ml (Tegretol)

carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg (Tegretol-xr)

carbamazepine tab 200 mg (Tegretol)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 35

Drug Name

Requirements/Limits

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

diazepam rectal gel delivery system 10 mg, 20 mg (Diastat acudial)

DILANTIN - phenytoin sodium extended cap 30 mg

divalproex sodium cap delayed release sprinkle 125 mg (Depakote

sprinkles)

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

(Depakote)

divalproex sodium tab er 24 hr 250 mg, 500 mg (Depakote er)

EPIDIOLEX - cannabidiol soln 100 mg/ml

ethosuximide cap 250 mg (Zarontin)

ethosuximide soln 250 mg/5ml (Zarontin)

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

gabapentin oral soln 250 mg/5ml (Neurontin)

gabapentin tab 600 mg, 800 mg (Neurontin)

lacosamide oral solution 10 mg/ml (Vimpat)

lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg (Vimpat)

lamotrigine tab chewable dispersible 5 mg, 25 mg (Lamictal chewable di)

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

levetiracetam oral soln 100 mg/ml (Keppra)

levetiracetam tab er 24hr 500 mg, 750 mg (Keppra xr)

levetiracetam tab 250 mg, 500 mg, 750 mg, 1000 mg (Keppra)

methsuximide cap 300 mg (Celontin)

oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)

oxcarbazepine tab 150 mg, 300 mg, 600 mg (Trileptal)

phenytoin chew tab 50 mg (Dilantin infatabs)

phenytoin sodium extended cap 100 mg (Dilantin)

phenytoin sodium extended cap 200 mg, 300 mg (Phenytek)

phenytoin susp 125 mg/5ml (Dilantin-125)

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

300 mg (Lyrica)

QL (90 capsules/30 days)

pregabalin soln 20 mg/ml (Lyrica)

QL (900 mls/30 days)

primidone tab 50 mg, 250 mg (Mysoline)

rufinamide tab 200 mg, 400 mg (Banzel)

topiramate sprinkle cap 15 mg, 25 mg (Topamax sprinkle)

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

valproate sodium oral soln 250 mg/5ml (base equiv)

valproic acid cap 250 mg (Depakene)

vigabatrin powd pack 500 mg (Sabril)

vigabatrin tab 500 mg (Sabril)

zonisamide cap 25 mg, 100 mg (Zonegran)

zonisamide cap 50 mg

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 36

Drug Name

Requirements/Limits

ANTIPARKINSON AGENTS

amantadine hcl cap 100 mg

amantadine hcl soln 50 mg/5ml

benztropine mesylate tab 0.5 mg, 1 mg, 2 mg

carbidopa & levodopa tab er 25-100 mg, 50-200 mg

carbidopa & levodopa tab 10-100 mg, 25-100 mg, 25-250 mg (Sinemet)

carbidopa-levodopa-entacapone tabs 12.5-50-200 mg (Stalevo 50)

carbidopa-levodopa-entacapone tabs 18.75-75-200 mg (Stalevo 75)

carbidopa-levodopa-entacapone tabs 25-100-200 mg (Stalevo 100)

carbidopa-levodopa-entacapone tabs 31.25-125-200 mg (Stalevo 125)

carbidopa-levodopa-entacapone tabs 37.5-150-200 mg (Stalevo 150)

carbidopa-levodopa-entacapone tabs 50-200-200 mg (Stalevo 200)

entacapone tab 200 mg (Comtan)

INBRIJA - levodopa inhal powder cap 42 mg

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

1 mg, 1.5 mg (Mirapex)

rasagiline mesylate tab 0.5 mg (base equiv), 1 mg (base equiv) (Azilect)

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

5 mg (Requip)

selegiline hcl cap 5 mg

selegiline hcl tab 5 mg

trihexyphenidyl hcl tab 2 mg, 5 mg

NEUROMUSCULAR AGENTS

riluzole tab 50 mg (Rilutek)

MUSCULOSKELETAL THERAPY AGENTS

baclofen tab 10 mg, 20 mg

chlorzoxazone tab 500 mg

cyclobenzaprine hcl tab 5 mg, 10 mg

methocarbamol tab 500 mg (Robaxin)

methocarbamol tab 750 mg (Robaxin-750)

orphenadrine citrate tab er 12hr 100 mg

tizanidine hcl tab 2 mg (base equivalent)

QL (180 tablets/30 days)

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

QL (180 tablets/30 days)

ANTIMYASTHENIC AGENTS

pyridostigmine bromide tab 60 mg (Mestinon)

NUTRITIONAL PRODUCTS

VITAMINS

ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)

phytonadione tab 5 mg (Mephyton)

MULTIVITAMINS

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 37

Drug Name

Requirements/Limits

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

30-1 mg

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

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

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

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

MINERALS and ELECTROLYTES

pot phos monobasic w/sod phos di & monobas tab 155-852-130mg (K-

phos neutral)

potassium chloride cap er 8 meq, 10 meq

potassium chloride microencapsulated crys er tab 10 meq, 20 meq

potassium chloride oral soln 10% (20 meq/15ml), 20% (40 meq/15ml)

potassium chloride powder packet 20 meq

potassium chloride tab er 8 meq (600 mg)

potassium chloride tab er 10 meq (K-tab)

potassium phosphate monobasic tab 500 mg (K-phos)

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

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

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

HEMATOLOGICAL AGENTS

HEMATOPOIETIC AGENTS

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

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

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

PA, SP

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

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

PA, SP

CERDELGA - eliglustat tartrate cap 84 mg (base equivalent)

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

cyanocobalamin inj 1000 mcg/ml

DOPTELET - avatrombopag maleate tab 20 mg (base equiv)

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

folic acid tab 1 mg

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

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

480 mcg/0.8ml

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

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

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

PA, SP

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

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

PA, SP

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

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

ANTICOAGULANTS

ELIQUIS - apixaban tab 2.5 mg

QL (74 tablets/19 days)

ELIQUIS - apixaban tab 5 mg

QL (74 tablets/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 38

Drug Name

Requirements/Limits

ELIQUIS STARTER PACK - apixaban tab starter pack 5 mg

QL (1 pack/180 days)

enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40 mg/0.4ml,

60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120 mg/0.8ml, 150 mg/ml

(Lovenox)

enoxaparin sodium inj 300 mg/3ml (Lovenox)

QL (360 vials/270 days)

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

10 mg (Coumadin)

XARELTO - rivaroxaban for susp 1 mg/ml

QL (600 mls/30 days)

XARELTO - rivaroxaban tab 2.5 mg, 15 mg

QL (60 tablets/30 days)

XARELTO - rivaroxaban tab 10 mg, 20 mg

QL (30 tablets/30 days)

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

20 mg

QL (51 tablets/30 days)

HEMATOLOGICAL AGENTS - MISC.

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

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

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

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

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

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

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

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

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

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

1000 unit, 1500 unit, 2000 unit

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

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

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

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

1000 unit, 2000 unit, 3000 unit, 4000 unit

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

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

1000 unit, 2000 unit, 3000 unit, 4000 unit

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

anagrelide hcl cap 0.5 mg (Agrylin)

anagrelide hcl cap 1 mg

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

1000 unit, 2000 unit, 3000 unit

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

BRILINTA - ticagrelor tab 60 mg, 90 mg

cilostazol tab 50 mg, 100 mg (Pletal)

clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)

COAGADEX - coagulation factor x (human) for inj 250 unit, 500 unit

CORIFACT - factor xiii concentrate (human) for inj kit 1000-1600 unit

dipyridamole tab 25 mg, 50 mg, 75 mg

ELOCTATE - antihemophilic factor rcmb (bdd-rfviiifc) for inj 250 unit, 500 unit,

750 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit, 4000 unit, 5000 unit,

6000 unit

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

EMPAVELI - pegcetacoplan subcutaneous soln 1080 mg/20ml (54 mg/ml)

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

ESPEROCT - antihemophilic factor recomb glycopeg-exei for inj 500 unit,

1000 unit, 1500 unit, 2000 unit, 3000 unit

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

FEIBA - antiinhibitor coagulant complex for iv soln 500 unit, 1000 unit, 2500

unit

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 39

Drug Name

Requirements/Limits

HEMLIBRA - emicizumab-kxwh subcutaneous soln 12 mg/0.4ml (30 mg/ml),

30 mg/ml, 60 mg/0.4ml (150 mg/ml), 105 mg/0.7ml (150 mg/ml), 150 mg/ml,

300 mg/2ml (150 mg/ml)

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

HEMOFIL M - antihemophilic factor (human) for inj 250 unit, 500 unit, 1000

unit, 1700 unit

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

HUMATE-P - antihemophilic factor/vwf (human) for inj 250-600 unit, 500-1200

unit, 1000-2400 unit

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

icatibant acetate subcutaneous soln pref syr 30 mg/3ml (Firazyr)

PA, QL (6 syringes/30 days), SP

IDELVION - coagulation factor ix (recomb) (rix-fp) for inj 250 unit, 500 unit,

1000 unit, 2000 unit, 3500 unit

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

IXINITY - coagulation factor ix (recombinant) for inj 250 unit, 500 unit, 1000

unit, 1500 unit, 2000 unit, 3000 unit

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

JIVI - antihemophil fact rcmb(bdd-rfviii peg-aucl) for inj 500 unit

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

JIVI - antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj 1000 unit, 2000 unit,

3000 unit

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

KOATE - antihemophilic factor (human) for inj 250 unit, 500 unit, 1000 unit

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

KOATE-DVI - antihemophilic factor (human) for inj 500 unit, 1000 unit

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

KOGENATE FS - antihemophilic factor recomb (rfviii) for inj kit 250 unit, 500

unit, 1000 unit, 2000 unit, 3000 unit

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

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

1000 unit, 2000 unit, 3000 unit

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

NOVOEIGHT - antihemophilic fact rcmb (bd trunc-rfviii) for inj 250 unit, 500

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

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

NOVOSEVEN RT - coagulation factor viia (recomb) for inj 1 mg (1000 mcg),

2 mg (2000 mcg), 5 mg (5000 mcg), 8 mg (8000 mcg)

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

NUWIQ - antihemophilic factor rcmb (bdd-rfviii,sim) for inj 250 unit, 500 unit

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

NUWIQ - antihemophilic fact rcmb (bdd-rfviii,sim) for inj 1000 unit, 1500 unit,

2000 unit, 2500 unit, 3000 unit, 4000 unit

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

NUWIQ - antihemophil fact rcmb (bdd-rfviii,sim) for inj kit 250 unit, 500 unit

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

NUWIQ - antihemophil fact rcmb(bdd-rfviii,sim) for inj kit 1000 unit, 1500 unit,

2000 unit, 2500 unit, 3000 unit, 4000 unit

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

OBIZUR - antihemophilic factor (recomb porc) rpfviii for inj 500 unit

pentoxifylline tab er 400 mg

prasugrel hcl tab 5 mg (base equiv), 10 mg (base equiv) (Effient)

PROFILNINE - factor ix complex for inj 500 unit, 1000 unit, 1500 unit

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

REBINYN - coagulation factor ix recomb glycopegylated for inj 500 unt, 1000

unt, 2000 unt

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

REBINYN - coagulation factor ix recomb glycopegylated for inj 3000 unt

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

RECOMBINATE - antihemophilic factor recomb (rfviii) for inj 220-400 unit,

401-800 unit, 801-1240 unit, 1241-1800 unit, 1801-2400 unit

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

RIXUBIS - coagulation factor ix (recombinant) for inj 250 unit, 500 unit, 1000

unit, 2000 unit, 3000 unit

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

TAKHZYRO - lanadelumab-flyo inj 300 mg/2ml (150 mg/ml)

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

TAKHZYRO - lanadelumab-flyo soln pref syringe 150 mg/ml

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 40

Drug Name

Requirements/Limits

TAKHZYRO - lanadelumab-flyo soln pref syringe 300 mg/2ml (150 mg/ml)

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

TRETTEN - coagulation factor xiii a-subunit for inj 2500 unit

VONVENDI - von willebrand factor (recombinant) for inj 650 unit, 1300 unit

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

WILATE - antihemophilic factor/vwf (human) for inj 500-500 unit kit

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

WILATE - antihemophilic factor/vwf (human) for inj 1000-1000 unit kit

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

XYNTHA - antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250 unit, 500 unit

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

XYNTHA - antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000 unit, 2000 unit

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

XYNTHA SOLOFUSE - antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250

unit, 500 unit

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

XYNTHA SOLOFUSE - antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000

unit, 2000 unit, 3000 unit

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

TOPICAL PRODUCTS

OPHTHALMIC AGENTS

atropine sulfate ophth soln 1% (Atropine sulfate)

azelastine hcl ophth soln 0.05%

BACITRACIN - bacitracin ophth oint 500 unit/gm

bacitracin-polymyxin b ophth oint

bacitracin-polymyxin-neomycin-hc ophth oint 1%

brimonidine tartrate ophth soln 0.1% (Alphagan p)

brimonidine tartrate ophth soln 0.15% (Alphagan p)

PA, QL (5 ml/20 days)

brimonidine tartrate ophth soln 0.2%

ciprofloxacin hcl ophth soln 0.3% (base equivalent) (Ciloxan)

cyclopentolate hcl ophth soln 1% (Cyclogyl)

diclofenac sodium ophth soln 0.1%

dorzolamide hcl ophth soln 2% (Trusopt)

dorzolamide hcl-timolol maleate ophth soln 2-0.5% (Cosopt)

erythromycin ophth oint 5 mg/gm

fluorometholone ophth susp 0.1% (Fml liquifilm)

gentamicin sulfate ophth soln 0.3% (Garamycin)

ketorolac tromethamine ophth soln 0.4% (Acular ls)

ketorolac tromethamine ophth soln 0.5% (Acular)

latanoprost ophth soln 0.005% (Xalatan)

QL (2.5 mls/20 days)

LOTEMAX - loteprednol etabonate ophth oint 0.5%

LOTEMAX SM - loteprednol etabonate ophth gel 0.38%

loteprednol etabonate ophth gel 0.5% (Lotemax)

loteprednol etabonate ophth susp 0.5% (Lotemax)

LUMIGAN - bimatoprost ophth soln 0.01%

QL (2.5 mls/20 days), ST

moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox)

NATACYN - natamycin ophth susp 5%

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin

neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 41

Drug Name

Requirements/Limits

neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)

ofloxacin ophth soln 0.3% (Ocuflox)

pilocarpine hcl ophth soln 1%, 2%, 4% (Isopto carpine)

polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)

PREDNISOLONE ACETATE - prednisolone acetate ophth susp 1%

PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate ophth

soln 1%

SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2%

sulfacetamide sodium ophth soln 10% (Bleph-10)

timolol maleate ophth soln 0.25%, 0.5% (Timoptic)

tobramycin ophth soln 0.3% (Tobrex)

QL (15 ml/30 days)

tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)

TRIFLURIDINE - trifluridine ophth soln 1%

tropicamide ophth soln 0.5%

tropicamide ophth soln 1% (Mydriacyl)

ZYLET - loteprednol etabonate-tobramycin ophth susp 0.5-0.3%

OTIC AGENTS

acetic acid otic soln 2%

ciprofloxacin-dexamethasone otic susp 0.3-0.1% (Ciprodex)

hydrocortisone w/ acetic acid otic soln 1-2%

neomycin-polymyxin-hc otic soln 1%

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%

ofloxacin otic soln 0.3% (Floxin otic)

MOUTH/THROAT/DENTAL AGENTS

cevimeline hcl cap 30 mg (Evoxac)

chlorhexidine gluconate soln 0.12% (Peridex)

clotrimazole troche 10 mg

lidocaine hcl viscous soln 2%

nystatin susp 100000 unit/ml

pilocarpine hcl tab 5 mg, 7.5 mg (Salagen)

sodium fluoride cream 1.1% (Prevident 5000 plus)

sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)

triamcinolone acetonide dental paste 0.1%

ANORECTAL AGENTS

hydrocortisone acetate suppos 25 mg

hydrocortisone enema 100 mg/60ml (Cortenema)

hydrocortisone perianal cream 2.5% (Anusol-hc)

DERMATOLOGICALS

acitretin cap 10 mg, 25 mg (Soriatane)

acitretin cap 17.5 mg

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 42

Drug Name

Requirements/Limits

adapalene cream 0.1% (Differin)

adapalene gel 0.1%, 0.3% (Differin)

adapalene-benzoyl peroxide gel 0.1-2.5% (Epiduo)

ADBRY - tralokinumab-ldrm subcutaneous soln auto-injector 300 mg/2ml

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

ADBRY - tralokinumab-ldrm subcutaneous soln prefilled syr 150 mg/ml

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

alclometasone dipropionate cream 0.05%

alclometasone dipropionate oint 0.05%

azelaic acid gel 15% (Finacea)

betamethasone dipropionate augmented cream 0.05% (Diprolene af)

QL (180 grams/90 days)

betamethasone dipropionate augmented lotion 0.05%

QL (180 grams/90 days)

betamethasone dipropionate augmented oint 0.05% (Diprolene)

QL (180 grams/90 days)

betamethasone dipropionate cream 0.05%

QL (180 grams/90 days)

betamethasone dipropionate lotion 0.05%

QL (180 grams/90 days)

betamethasone dipropionate oint 0.05%

QL (180 grams/90 days)

betamethasone valerate cream 0.1% (base equivalent)

betamethasone valerate lotion 0.1% (base equivalent)

betamethasone valerate oint 0.1% (base equivalent)

calcipotriene cream 0.005% (Dovonex)

CIBINQO - abrocitinib tab 50 mg, 100 mg, 200 mg

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

ciclopirox gel 0.77%

QL (180 grams/30 days)

ciclopirox olamine cream 0.77% (base equiv) (Loprox)

QL (180 grams/30 days)

ciclopirox shampoo 1% (Loprox shampoo)

ciclopirox solution 8% (Penlac Nail Lacquer)

PA, QL (6.6 mls/30 days)

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% (Duac)

clindamycin phosphate gel 1% (Cleocin-t)

clindamycin phosphate lotion 1% (Cleocin-t)

clindamycin phosphate soln 1%

QL (180 ml/30 days)

clindamycin phosphate swab 1%

clobetasol propionate cream 0.05% (Temovate)

QL (180 grams/90 days)

clobetasol propionate emollient base cream 0.05%

clobetasol propionate foam 0.05% (Olux)

QL (200 grams/28 days)

clobetasol propionate gel 0.05%

clobetasol propionate oint 0.05% (Temovate)

QL (180 grams/90 days)

clobetasol propionate soln 0.05%

QL (180 grams/90 days)

COSENTYX - secukinumab subcutaneous soln prefilled syringe 75 mg/0.5ml,

150 mg/ml

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

COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml (300 mg dose)

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

COSENTYX SENSOREADY PEN - secukinumab subcutaneous soln auto-

injector 150 mg/ml

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

COSENTYX SENSOREADY PEN - secukinumab subcutaneous auto-inj

150 mg/ml (300 mg dose)

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 43

Drug Name

Requirements/Limits

COSENTYX UNOREADY - secukinumab subcutaneous soln auto-injector

300 mg/2ml

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

desonide cream 0.05% (Desowen)

desonide oint 0.05%

desoximetasone cream 0.25% (Topicort)

QL (180 grams/90 days)

desoximetasone oint 0.25% (Topicort)

QL (180 grams/90 days)

diclofenac sodium (actinic keratoses) gel 3%

PA, QL (1 tube/30 days)

doxycycline (rosacea) cap delayed release 40 mg (Oracea)

DUPIXENT - dupilumab subcutaneous soln pen-injector 200 mg/1.14ml

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

DUPIXENT - dupilumab subcutaneous soln pen-injector 300 mg/2ml

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

DUPIXENT - dupilumab subcutaneous soln prefilled syringe 200 mg/1.14ml

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

DUPIXENT - dupilumab subcutaneous soln prefilled syringe 300 mg/2ml

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

econazole nitrate cream 1%

QL (170 grams/30 days)

erythromycin gel 2% (Erygel)

QL (180 grams/30 days)

erythromycin soln 2%

QL (180 mls/30 days)

FINACEA - azelaic acid foam 15%

fluocinolone acetonide cream 0.01%

fluocinolone acetonide cream 0.025% (Synalar)

fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod)

fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca)

fluocinolone acetonide oint 0.025% (Synalar)

fluocinolone acetonide soln 0.01% (Synalar)

fluocinonide cream 0.05%

QL (180 grams/90 days)

fluocinonide cream 0.1% (Vanos)

QL (120 grams/90 days)

fluocinonide oint 0.05%

QL (180 grams/90 days)

fluocinonide soln 0.05%

QL (180 grams/90 days)

fluorouracil cream 5% (Efudex)

PA, QL (240 grams/180 days)

fluorouracil soln 5%

fluticasone propionate cream 0.05%

fluticasone propionate oint 0.005%

gentamicin sulfate cream 0.1%

QL (120 grams/90 days)

gentamicin sulfate oint 0.1%

QL (120 grams/90 days)

halobetasol propionate cream 0.05%

QL (180 grams/90 days)

hydrocortisone cream 2.5%

hydrocortisone oint 2.5%

imiquimod cream 5% (Aldara)

QL (48 packets/180 days)

isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mg

QL (60 capsules/30 days)

ketoconazole cream 2%

QL (180 grams/30 days)

ketoconazole shampoo 2% (Nizoral)

lidocaine hcl gel 2%

QL (120 mls/30 days)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 44

Drug Name

Requirements/Limits

lidocaine hcl soln 4%

QL (120 mls/30 days)

lidocaine oint 5%

PA, QL (120 grams/30 days)

lidocaine patch 5% (Lidoderm)

PA, QL (120 patches/30 days)

lidocaine-prilocaine cream 2.5-2.5%

QL (60 grams/30 days)

malathion lotion 0.5% (Ovide)

metronidazole cream 0.75% (Metrocream)

metronidazole gel 0.75%

metronidazole gel 1% (Metrogel)

QL (60 grams/30 days)

mometasone furoate cream 0.1% (Elocon)

mometasone furoate oint 0.1% (Elocon)

QL (180 grams/90 days)

mometasone furoate solution 0.1% (lotion)

mupirocin oint 2% (Bactroban)

nystatin cream 100000 unit/gm

nystatin oint 100000 unit/gm

nystatin topical powder 100000 unit/gm

nystatin-triamcinolone cream 100000-0.1 unit/gm-%

nystatin-triamcinolone oint 100000-0.1 unit/gm-%

permethrin cream 5% (Elimite)

selenium sulfide lotion 2.5%

silver sulfadiazine cream 1% (Silvadene)

SKYRIZI - risankizumab-rzaa soln prefilled syringe 150 mg/ml

PA, QL (1 syringe/84 days), SP

SKYRIZI PEN - risankizumab-rzaa soln auto-injector 150 mg/ml

PA, QL (1 injection device/84 days), SP

SOOLANTRA - ivermectin cream 1%

QL (45 grams/30 days)

STELARA - ustekinumab inj 45 mg/0.5ml

PA, QL (1 vial/84 days), SP

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml

PA, QL (1 syringe/84 days), SP

STELARA - ustekinumab soln prefilled syringe 90 mg/ml

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

sulfacetamide sodium lotion 10% (acne) (Klaron)

tacrolimus oint 0.03%, 0.1% (Protopic)

tazarotene cream 0.1% (Tazorac)

tazarotene gel 0.05%, 0.1% (Tazorac)

TAZORAC - tazarotene cream 0.05%

TREMFYA - guselkumab soln pen-injector 100 mg/ml

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

TREMFYA - guselkumab soln prefilled syringe 100 mg/ml

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

tretinoin cream 0.025%, 0.05%, 0.1% (Retin-a)

tretinoin gel 0.01% (Retin-a)

triamcinolone acetonide cream 0.025%, 0.1%, 0.5%

triamcinolone acetonide lotion 0.025%, 0.1%

triamcinolone acetonide oint 0.025%, 0.1%, 0.5%

VALCHLOR - mechlorethamine hcl gel 0.016% (base equivalent)

MISCELLANEOUS PRODUCTS

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 45

Drug Name

Requirements/Limits

ANTIDOTES

CHEMET - succimer cap 100 mg

KLOXXADO - naloxone hcl nasal spray 8 mg/0.1ml

naloxone hcl inj 0.4 mg/ml, 4 mg/10ml

naloxone hcl nasal spray 4 mg/0.1ml (Narcan)

NALOXONE HYDROCHLORIDE - naloxone hcl soln prefilled syringe 0.4 mg/

naltrexone hcl tab 50 mg

OPVEE - nalmefene hcl nasal spray 2.7 mg/0.1ml (base equiv)

DIAGNOSTIC PRODUCTS

INSULIN PEN NEEDLES – VARIOUS

QL (300 needles/30 days)

INSULIN SYRINGES – VARIOUS

QL (300 syringes/30 days)

LANCETS – VARIOUS

TEST STRIPS –CONTOUR, CONTOUR NEXT, ONETOUCH ULTRA,

ONETOUCH VERIO

QL (204 strips/30 days)

MEDICAL DEVICES

BREATHERITE– spacer/aerosol-holding chambers – device

DEXCOM G6 RECEIVER - continuous glucose system receiver

PA, QL (1 receiver/365 days)

DEXCOM G6 SENSOR - continuous glucose system sensor

PA, QL (3 sensors/30 days)

DEXCOM G6 TRANSMITTER - continuous glucose system transmitter

PA, QL (1 box/90 days)

DEXCOM G7 RECEIVER - continuous glucose system receiver

PA, QL (1 receiver/365 days)

DEXCOM G7 SENSOR - continuous glucose system sensor

PA, QL (3 sensors/30 days)

OMNIPOD DASH INTRO KIT (G - insulin infusion disposable pump kit

PA, QL (1 kit/720 days)

OMNIPOD DASH PODS (GEN 4) - insulin infusion disposable pump reservoir

PA, QL (30 pods/30 days)

OMNIPOD 5 G6 INTRO KIT (G - insulin infusion disposable pump kit

PA, QL (1 kit/720 days)

OMNIPOD 5 G6 PODS (GEN 5) - insulin infusion disposable pump reservoir

PA, QL (30 pods/30 days)

ASSORTED CLASSES

azathioprine tab 50 mg (Imuran)

cyclosporine cap 25 mg, 100 mg (Sandimmune)

cyclosporine modified cap 25 mg, 100 mg (Neoral)

cyclosporine modified cap 50 mg

cyclosporine modified oral soln 100 mg/ml (Neoral)

everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg (Zortress)

lenalidomide caps 2.5 mg (Revlimid)

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

lenalidomide cap 5 mg, 10 mg (Revlimid)

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

lenalidomide cap 15 mg, 20 mg, 25 mg (Revlimid)

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

LOKELMA - sodium zirconium cyclosilicate for susp packet 5 gm, 10 gm

mycophenolate mofetil cap 250 mg (Cellcept)

mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)

mycophenolate mofetil tab 500 mg (Cellcept)

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 46

Drug Name

Requirements/Limits

mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv),

360 mg (mycophenolic acid equiv) (Myfortic)

penicillamine tab 250 mg (Depen titratabs)

RAPAMUNE - sirolimus oral soln 1 mg/ml

REVLIMID - lenalidomide caps 2.5 mg

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

REVLIMID - lenalidomide cap 5 mg, 10 mg

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

REVLIMID - lenalidomide cap 15 mg, 20 mg, 25 mg

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

sirolimus oral soln 1 mg/ml (Rapamune)

sirolimus tab 0.5 mg, 1 mg, 2 mg (Rapamune)

sodium polystyrene sulfonate oral susp 15 gm/60ml

sodium polystyrene sulfonate powder

tacrolimus cap 0.5 mg, 1 mg, 5 mg (Prograf)

THALOMID - thalidomide cap 50 mg

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

THALOMID - thalidomide cap 100 mg

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

VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm (base eq),

16.8 gm (base eq), 25.2 gm (base eq)

ZOKINVY - lonafarnib cap 50 mg, 75 mg

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

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 47

INDEX

abacavir sulfate-lamivudine tab 600-300 mg................... 3

abacavir sulfate soln 20 mg/ml (base equiv)................... 3

abacavir sulfate tab 300 mg (base equiv)........................ 3

abiraterone acetate tab 250 mg.........................................6

abiraterone acetate tab 500 mg.........................................6

acamprosate calcium tab delayed release 333 mg....... 29

acarbose tab 25 mg, 50 mg, 100 mg...............................11

acebutolol hcl cap 200 mg, 400 mg................................ 16

acetaminophen w/ codeine tab 300-15 mg.....................31

acetaminophen w/ codeine tab 300-30 mg.....................31

acetaminophen w/ codeine tab 300-60 mg.....................31

acetazolamide cap er 12hr 500 mg................................. 19

acetazolamide tab 125 mg, 250 mg.................................19

acetic acid otic soln 2%................................................... 41

acetylcysteine inhal soln 10%, 20%................................21

acitretin cap 17.5 mg........................................................ 41

acitretin cap 10 mg, 25 mg.............................................. 41

ACTEMRA............................................................................32

ACTEMRA ACTPEN........................................................... 32

ACTIMMUNE......................................................................... 6

acyclovir cap 200 mg..........................................................3

acyclovir susp 200 mg/5ml................................................ 3

acyclovir tab 400 mg, 800 mg............................................3

adapalene-benzoyl peroxide gel 0.1-2.5%......................42

adapalene cream 0.1%......................................................42

adapalene gel 0.1%, 0.3%.................................................42

ADBRY................................................................................. 42

adefovir dipivoxil tab 10 mg.............................................. 3

ADVAIR HFA........................................................................21

ADVATE................................................................................38

ADYNOVATE....................................................................... 38

AFSTYLA............................................................................. 38

AIMOVIG.............................................................................. 34

AJOVY..................................................................................34

albendazole tab 200 mg..................................................... 5

albuterol sulfate inhal aero 108 mcg/act (90mcg base

equiv)................................................................................. 21

albuterol sulfate soln nebu 0.5% (5 mg/ml)................... 21

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml), 0.63

mg/3ml (base equiv), 1.25 mg/3ml (base equiv).......... 21

albuterol sulfate syrup 2 mg/5ml.................................... 21

albuterol sulfate tab 2 mg, 4 mg..................................... 21

alclometasone dipropionate cream 0.05%..................... 42

alclometasone dipropionate oint 0.05%......................... 42

ALECENSA............................................................................ 6

alendronate sodium tab 10 mg........................................14

alendronate sodium tab 35 mg........................................14

alendronate sodium tab 70 mg........................................15

alfuzosin hcl tab er 24hr 10 mg.......................................26

ALINIA.................................................................................... 5

allopurinol tab 100 mg, 300 mg.......................................34

alosetron hcl tab 0.5 mg (base equiv), 1 mg (base

equiv)................................................................................. 25

ALPHANATE........................................................................ 38

ALPHANINE SD.................................................................. 38

alprazolam tab er 24hr 0.5 mg, 1 mg, 2 mg, 3 mg......... 26

alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg................. 26

ALPROLIX............................................................................38

ALTUVIIIO............................................................................ 38

ALUNBRIG.............................................................................6

amantadine hcl cap 100 mg.............................................36

amantadine hcl soln 50 mg/5ml...................................... 36

ambrisentan tab 5 mg, 10 mg..........................................20

amiloride hcl tab 5 mg......................................................19

amiodarone hcl tab 100 mg............................................. 17

amiodarone hcl tab 200 mg............................................. 17

amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100

mg, 150 mg.......................................................................26

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

mg, 5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg..................17

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

(base equivalent), 10 mg (base equivalent)................. 17

amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg,

10-160 mg, 10-320 mg.....................................................17

amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg, 5-160-25 mg, 10-160-12.5 mg,

10-160-25 mg, 10-320-25 mg.......................................... 17

amoxicillin & k clavulanate for susp 250-62.5

mg/5ml................................................................................. 1

amoxicillin & k clavulanate for susp 600-42.9

mg/5ml................................................................................. 1

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

400-57 mg/5ml.................................................................... 1

amoxicillin & k clavulanate tab 250-125 mg.................... 1

amoxicillin & k clavulanate tab 500-125 mg, 875-125

mg........................................................................................ 1

amoxicillin (trihydrate) cap 250 mg, 500 mg....................1

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

mg/5ml, 250 mg/5ml, 400 mg/5ml.................................... 1

amoxicillin (trihydrate) tab 500 mg, 875 mg.................... 1

amphetamine-dextroamphetamine cap er 24hr 5 mg,

10 mg, 15 mg, 20 mg, 25 mg, 30 mg............................. 29

amphetamine-dextroamphetamine tab 20 mg............... 29

amphetamine-dextroamphetamine tab 5 mg, 7.5 mg, 10

mg, 12.5 mg, 15 mg, 30 mg............................................29

ampicillin cap 500 mg.........................................................1

anagrelide hcl cap 0.5 mg................................................38

anagrelide hcl cap 1 mg...................................................38

anastrozole tab 1 mg.......................................................... 6

ANORO ELLIPTA................................................................ 21

aprepitant capsule 40 mg.................................................24

aprepitant capsule 80 mg.................................................24

aprepitant capsule 125 mg...............................................24

aprepitant capsule therapy pack 80 & 125 mg.............. 24

APTIOM................................................................................34

ARANESP ALBUMIN FREE............................................... 37

aripiprazole tab 2 mg, 5 mg............................................. 27

aripiprazole tab 10 mg, 15 mg, 20 mg, 30 mg................ 27

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 48

armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg...........29

ARNUITY ELLIPTA..............................................................21

ASMANEX HFA................................................................... 21

ASMANEX TWISTHALER 120 ME.....................................22

ASMANEX TWISTHALER 30 MET.................................... 22

ASMANEX TWISTHALER 60 MET.................................... 22

atazanavir sulfate cap 200 mg (base equiv).................... 3

atazanavir sulfate cap 150 mg (base equiv), 300 mg

(base equiv)........................................................................ 3

atenolol & chlorthalidone tab 50-25 mg......................... 17

atenolol & chlorthalidone tab 100-25 mg....................... 17

atenolol tab 25 mg, 50 mg, 100 mg.................................16

atomoxetine hcl cap 60 mg (base equiv), 80 mg (base

equiv), 100 mg (base equiv)...........................................29

atomoxetine hcl cap 10 mg (base equiv), 18 mg (base

equiv), 25 mg (base equiv), 40 mg (base equiv).......... 29

atorvastatin calcium tab 10 mg (base equivalent), 20

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

(base equivalent)............................................................. 19

atovaquone-proguanil hcl tab 62.5-25 mg, 250-100

mg........................................................................................ 5

atovaquone susp 750 mg/5ml............................................5

atropine sulfate ophth soln 1%....................................... 40

AUVI-Q................................................................................. 19

AVONEX...............................................................................30

AVONEX PEN......................................................................30

AYVAKIT.................................................................................6

azathioprine tab 50 mg.....................................................45

azelaic acid gel 15%......................................................... 42

azelastine hcl nasal spray 0.1% (137 mcg/spray)..........21

azelastine hcl nasal spray 0.15% (205.5 mcg/

spray).................................................................................21

azelastine hcl ophth soln 0.05%......................................40

AZITHROMYCIN....................................................................1

azithromycin for susp 100 mg/5ml, 200 mg/5ml..............1

azithromycin tab 250 mg, 500 mg, 600 mg...................... 1

BACITRACIN....................................................................... 40

bacitracin-polymyxin b ophth oint..................................40

bacitracin-polymyxin-neomycin-hc ophth oint 1%....... 40

baclofen tab 10 mg, 20 mg.............................................. 36

balsalazide disodium cap 750 mg...................................25

BAQSIMI ONE PACK..........................................................11

BAQSIMI TWO PACK......................................................... 11

BARACLUDE......................................................................... 3

BELBUCA............................................................................ 31

BELSOMRA......................................................................... 29

benazepril & hydrochlorothiazide tab 5-6.25 mg...........17

benazepril & hydrochlorothiazide tab 10-12.5 mg,

20-12.5 mg, 20-25 mg......................................................17

benazepril hcl tab 5 mg....................................................17

benazepril hcl tab 10 mg, 20 mg, 40 mg........................ 17

BENEFIX.............................................................................. 38

BENZNIDAZOLE................................................................... 5

benztropine mesylate tab 0.5 mg, 1 mg, 2 mg...............36

betaine powder for oral solution.....................................15

betamethasone dipropionate augmented cream

0.05%................................................................................. 42

betamethasone dipropionate augmented lotion

0.05%................................................................................. 42

betamethasone dipropionate augmented oint

0.05%................................................................................. 42

betamethasone dipropionate cream 0.05%....................42

betamethasone dipropionate lotion 0.05%.................... 42

betamethasone dipropionate oint 0.05%........................42

betamethasone valerate cream 0.1% (base

equivalent)........................................................................ 42

betamethasone valerate lotion 0.1% (base

equivalent)........................................................................ 42

betamethasone valerate oint 0.1% (base

equivalent)........................................................................ 42

BETASERON....................................................................... 30

bexarotene cap 75 mg........................................................ 6

bicalutamide tab 50 mg...................................................... 6

BIKTARVY..............................................................................3

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg,

5-6.25 mg, 10-6.25 mg.....................................................18

bisoprolol fumarate tab 5 mg.......................................... 16

bisoprolol fumarate tab 10 mg........................................ 16

bosentan tab 62.5 mg, 125 mg........................................ 20

BOSULIF................................................................................ 6

BREATHERITE– spacer/aerosol-holding chambers –

device................................................................................. 45

BREO ELLIPTA................................................................... 22

BREZTRI AEROSPHERE................................................... 22

BRILINTA............................................................................. 38

brimonidine tartrate ophth soln 0.1%............................. 40

brimonidine tartrate ophth soln 0.15%...........................40

brimonidine tartrate ophth soln 0.2%............................. 40

BRUKINSA.............................................................................6

budesonide delayed release particles cap 3 mg.............9

budesonide inhalation susp 1 mg/2ml........................... 22

budesonide inhalation susp 0.25 mg/2ml, 0.5

mg/2ml............................................................................... 22

bumetanide tab 0.5 mg, 1 mg, 2 mg............................... 19

buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base

equiv), 4-1 mg (base equiv), 8-2 mg (base equiv), 12-3

mg (base equiv)............................................................... 31

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base

equiv), 8-2 mg (base equiv)............................................31

buprenorphine hcl sl tab 2 mg (base equiv), 8 mg

(base equiv)...................................................................... 31

bupropion hcl (smoking deterrent) tab er 12hr 150

mg...................................................................................... 30

bupropion hcl tab er 24hr 150 mg, 300 mg.................... 26

bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg......26

bupropion hcl tab 75 mg, 100 mg................................... 26

buspirone hcl tab 5 mg, 10 mg, 15 mg, 30 mg...............26

butalbital-acetaminophen-caffeine tab 50-325-40

mg...................................................................................... 31

butalbital-acetaminophen tab 50-325 mg....................... 31

butalbital-aspirin-caffeine cap 50-325-40 mg.................31

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 49

butalbital-aspirin-caff w/ codeine cap 50-325-40-30

mg...................................................................................... 31

cabergoline tab 0.5 mg.....................................................15

CABOMETYX.........................................................................6

caffeine citrate oral soln 60 mg/3ml (10 mg/ml base

equiv)................................................................................. 29

calcipotriene cream 0.005%............................................. 42

calcitonin (salmon) nasal soln 200 unit/act................... 15

calcitriol cap 0.25 mcg, 0.5 mcg......................................15

calcium acetate (phosphate binder) cap 667 mg (169

mg ca)................................................................................25

calcium acetate (phosphate binder) tab 667 mg........... 25

CALQUENCE.........................................................................6

candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg, 32-12.5 mg, 32-25 mg.............................................. 18

candesartan cilexetil tab 4 mg, 8 mg, 16 mg, 32 mg..... 18

capecitabine tab 150 mg, 500 mg..................................... 6

captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg................ 18

carbamazepine cap er 12hr 100 mg, 200 mg, 300

mg...................................................................................... 34

carbamazepine chew tab 100 mg....................................34

carbamazepine susp 100 mg/5ml....................................34

carbamazepine tab er 12hr 100 mg, 200 mg, 400

mg...................................................................................... 34

carbamazepine tab 200 mg.............................................. 34

carbidopa & levodopa tab er 25-100 mg, 50-200 mg.....36

carbidopa & levodopa tab 10-100 mg, 25-100 mg,

25-250 mg......................................................................... 36

carbidopa-levodopa-entacapone tabs 12.5-50-200

mg...................................................................................... 36

carbidopa-levodopa-entacapone tabs 18.75-75-200

mg...................................................................................... 36

carbidopa-levodopa-entacapone tabs 31.25-125-200

mg...................................................................................... 36

carbidopa-levodopa-entacapone tabs 37.5-150-200

mg...................................................................................... 36

carbidopa-levodopa-entacapone tabs 25-100-200

mg...................................................................................... 36

carbidopa-levodopa-entacapone tabs 50-200-200

mg...................................................................................... 36

carglumic acid soluble tab 200 mg.................................15

carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg........ 16

cefadroxil cap 500 mg........................................................ 1

cefadroxil for susp 250 mg/5ml, 500 mg/5ml...................1

cefdinir cap 300 mg............................................................ 1

cefdinir for susp 125 mg/5ml, 250 mg/5ml.......................1

cefixime cap 400 mg........................................................... 1

cefixime for susp 100 mg/5ml, 200 mg/5ml..................... 1

cefpodoxime proxetil for susp 50 mg/5ml, 100

mg/5ml................................................................................. 1

cefpodoxime proxetil tab 100 mg, 200 mg.......................1

cefprozil for susp 125 mg/5ml, 250 mg/5ml..................... 1

cefprozil tab 250 mg, 500 mg............................................ 1

cefuroxime axetil tab 250 mg, 500 mg..............................1

celecoxib cap 400 mg.......................................................32

celecoxib cap 50 mg, 100 mg, 200 mg........................... 32

cephalexin cap 250 mg, 500 mg........................................1

cephalexin for susp 125 mg/5ml, 250 mg/5ml................. 1

CERDELGA......................................................................... 37

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)....................21

cevimeline hcl cap 30 mg................................................ 41

CHEMET.............................................................................. 45

CHENODAL......................................................................... 25

chlorhexidine gluconate soln 0.12%...............................41

chloroquine phosphate tab 250 mg, 500 mg................... 5

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

200 mg...............................................................................27

chlorthalidone tab 25 mg, 50 mg.................................... 19

chlorzoxazone tab 500 mg............................................... 36

cholestyramine light powder 4 gm/dose........................ 19

cholestyramine powder 4 gm/dose.................................19

CIBINQO.............................................................................. 42

ciclopirox gel 0.77%..........................................................42

ciclopirox olamine cream 0.77% (base equiv)............... 42

ciclopirox shampoo 1%....................................................42

ciclopirox solution 8%...................................................... 42

cilostazol tab 50 mg, 100 mg...........................................38

CIMDUO.................................................................................3

cimetidine tab 300 mg, 400 mg, 800 mg.........................24

cinacalcet hcl tab 30 mg (base equiv), 60 mg (base

equiv), 90 mg (base equiv).............................................15

ciprofloxacin-dexamethasone otic susp 0.3-0.1%........ 41

ciprofloxacin hcl ophth soln 0.3% (base

equivalent)........................................................................ 40

ciprofloxacin hcl tab 750 mg (base equiv).......................2

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

(base equiv)........................................................................ 2

citalopram hydrobromide oral soln 10 mg/5ml............. 26

citalopram hydrobromide tab 10 mg (base equiv), 20

mg (base equiv), 40 mg (base equiv)............................27

clarithromycin tab er 24hr 500 mg....................................1

clarithromycin tab 250 mg, 500 mg.................................. 1

clindamycin hcl cap 75 mg, 150 mg, 300 mg...................5

clindamycin palmitate hcl for soln 75 mg/5ml (base

equiv)................................................................................... 5

clindamycin phosphate gel 1%....................................... 42

clindamycin phosphate lotion 1%...................................42

clindamycin phosphate soln 1%..................................... 42

clindamycin phosphate swab 1%................................... 42

clindamycin phosphate vaginal cream 2%.................... 26

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2

(1)-5%.................................................................................42

clobetasol propionate cream 0.05%............................... 42

clobetasol propionate emollient base cream 0.05%..... 42

clobetasol propionate foam 0.05%................................. 42

clobetasol propionate gel 0.05%..................................... 42

clobetasol propionate oint 0.05%................................... 42

clobetasol propionate soln 0.05%...................................42

CLOMID............................................................................... 15

clomipramine hcl cap 25 mg, 50 mg, 75 mg.................. 27

clonazepam tab 0.5 mg, 1 mg, 2 mg............................... 35

clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg....................... 18

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 50

clonidine td patch weekly 0.1 mg/24hr...........................18

clonidine td patch weekly 0.2 mg/24hr...........................18

clonidine td patch weekly 0.3 mg/24hr...........................18

clopidogrel bisulfate tab 75 mg (base equiv)................ 38

clotrimazole troche 10 mg............................................... 41

clozapine tab 25 mg..........................................................27

clozapine tab 50 mg..........................................................27

clozapine tab 100 mg........................................................28

clozapine tab 200 mg........................................................28

COAGADEX.........................................................................38

codeine sulfate tab 30 mg................................................31

colchicine tab 0.6 mg....................................................... 34

colchicine w/ probenecid tab 0.5-500 mg.......................34

colesevelam hcl tab 625 mg............................................ 19

colestipol hcl granule packets 5 gm...............................19

colestipol hcl granules 5 gm........................................... 19

colestipol hcl tab 1 gm.....................................................19

COMBIPATCH......................................................................10

COMBIVENT RESPIMAT....................................................22

CORIFACT........................................................................... 38

CORLANOR.........................................................................20

COSENTYX......................................................................... 42

COSENTYX SENSOREADY PEN......................................42

COSENTYX UNOREADY................................................... 43

COTELLIC..............................................................................6

CREON................................................................................ 24

CRINONE.............................................................................26

cromolyn sodium soln nebu 20 mg/2ml.........................22

cyanocobalamin inj 1000 mcg/ml....................................37

cyclobenzaprine hcl tab 5 mg, 10 mg.............................36

cyclopentolate hcl ophth soln 1%...................................40

cyclophosphamide cap 25 mg, 50 mg..............................6

cyclosporine cap 25 mg, 100 mg.................................... 45

cyclosporine modified cap 50 mg...................................45

cyclosporine modified cap 25 mg, 100 mg.................... 45

cyclosporine modified oral soln 100 mg/ml...................45

cyproheptadine hcl syrup 2 mg/5ml............................... 21

cyproheptadine hcl tab 4 mg...........................................21

CYSTAGON......................................................................... 26

danazol cap 50 mg, 100 mg, 200 mg................................ 9

dapsone tab 25 mg, 100 mg.............................................. 5

darunavir tab 600 mg..........................................................3

darunavir tab 800 mg..........................................................3

DELSTRIGO.......................................................................... 3

demeclocycline hcl tab 150 mg, 300 mg.......................... 1

DESCOVY..............................................................................3

desipramine hcl tab 10 mg, 25 mg..................................27

desipramine hcl tab 50 mg, 75 mg, 100 mg, 150 mg..... 27

desloratadine tab 5 mg.....................................................21

desmopressin acetate inj 4 mcg/ml................................15

desmopressin acetate nasal spray soln 0.01%............. 15

desmopressin acetate nasal spray soln 0.01%

(refrigerated).....................................................................15

desmopressin acetate preservative free (pf) inj 4 mcg/

ml........................................................................................15

desmopressin acetate tab 0.1 mg, 0.2 mg..................... 15

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5).............................................................................10

desogestrel & ethinyl estradiol tab 0.15 mg-30

mcg.................................................................................... 10

desonide cream 0.05%......................................................43

desonide oint 0.05%..........................................................43

desoximetasone cream 0.25%.........................................43

desoximetasone oint 0.25%............................................. 43

desvenlafaxine succinate tab er 24hr 25 mg (base

equiv), 50 mg (base equiv), 100 mg (base equiv)........ 27

dexamethasone elixir 0.5 mg/5ml..................................... 9

dexamethasone tab 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2

mg, 4 mg, 6 mg..................................................................9

DEXCOM G6 RECEIVER................................................... 45

DEXCOM G7 RECEIVER................................................... 45

DEXCOM G6 SENSOR...................................................... 45

DEXCOM G7 SENSOR...................................................... 45

DEXCOM G6 TRANSMITTER............................................45

dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15

mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg......................29

dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg.........29

dextroamphetamine sulfate cap er 24hr 5 mg............... 29

dextroamphetamine sulfate cap er 24hr 10 mg, 15

mg...................................................................................... 29

dextroamphetamine sulfate tab 5 mg............................. 29

dextroamphetamine sulfate tab 10 mg...........................29

diazepam oral soln 1 mg/ml.............................................26

diazepam rectal gel delivery system 10 mg, 20 mg...... 35

diazepam tab 2 mg, 5 mg, 10 mg.................................... 26

diazoxide susp 50 mg/ml................................................. 11

diclofenac potassium tab 50 mg..................................... 32

diclofenac sodium (actinic keratoses) gel 3%...............43

diclofenac sodium ophth soln 0.1%............................... 40

diclofenac sodium tab delayed release 25 mg, 50 mg,

75 mg.................................................................................32

dicloxacillin sodium cap 250 mg, 500 mg........................1

dicyclomine hcl cap 10 mg.............................................. 24

dicyclomine hcl oral soln 10 mg/5ml..............................24

dicyclomine hcl tab 20 mg...............................................24

DIFICID.................................................................................. 1

digoxin oral soln 0.05 mg/ml........................................... 16

digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg).....16

dihydroergotamine mesylate inj 1 mg/ml.......................34

dihydroergotamine mesylate nasal spray 4 mg/ml....... 34

DILANTIN.............................................................................35

diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mg....... 17

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

mg, 240 mg, 300 mg........................................................17

diltiazem hcl extended release beads cap er 24hr 120

mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg............ 17

diltiazem hcl tab 90 mg.................................................... 17

diltiazem hcl tab 30 mg, 60 mg, 120 mg.........................17

dimethyl fumarate capsule delayed release 120 mg.....30

dimethyl fumarate capsule delayed release 240 mg.....30

dimethyl fumarate capsule dr starter pack 120 mg &

240 mg...............................................................................30

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 51

diphenoxylate w/ atropine tab 2.5-0.025 mg.................. 24

dipyridamole tab 25 mg, 50 mg, 75 mg.......................... 38

disopyramide phosphate cap 100 mg, 150 mg..............17

disulfiram tab 250 mg, 500 mg........................................ 30

divalproex sodium cap delayed release sprinkle 125

mg...................................................................................... 35

divalproex sodium tab delayed release 125 mg, 250

mg, 500 mg.......................................................................35

divalproex sodium tab er 24 hr 250 mg, 500 mg........... 35

donepezil hydrochloride orally disintegrating tab 5 mg,

10 mg.................................................................................30

donepezil hydrochloride tab 5 mg, 10 mg..................... 30

DOPTELET.......................................................................... 37

dorzolamide hcl ophth soln 2%.......................................40

dorzolamide hcl-timolol maleate ophth soln 2-0.5%.....40

DOVATO.................................................................................3

doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg.......... 18

doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100

mg...................................................................................... 27

doxepin hcl conc 10 mg/ml..............................................27

doxycycline hyclate cap 50 mg......................................... 1

doxycycline hyclate cap 100 mg....................................... 1

doxycycline hyclate tab 20 mg, 100 mg........................... 2

doxycycline monohydrate cap 50 mg.............................. 2

doxycycline monohydrate cap 100 mg............................ 2

doxycycline monohydrate tab 50 mg, 75 mg, 100 mg,

150 mg.................................................................................2

doxycycline (rosacea) cap delayed release 40 mg....... 43

drospirenone-ethinyl estradiol tab 3-0.02 mg................10

drospirenone-ethinyl estradiol tab 3-0.03 mg................10

DUAVEE...............................................................................10

DULERA...............................................................................22

duloxetine hcl enteric coated pellets cap 30 mg (base

eq)...................................................................................... 27

duloxetine hcl enteric coated pellets cap 20 mg (base

eq), 60 mg (base eq)....................................................... 27

DUPIXENT........................................................................... 43

dutasteride cap 0.5 mg.....................................................26

econazole nitrate cream 1%.............................................43

efavirenz-emtricitabine-tenofovir df tab 600-200-300

mg........................................................................................ 3

efavirenz-lamivudine-tenofovir df tab 400-300-300

mg........................................................................................ 3

efavirenz-lamivudine-tenofovir df tab 600-300-300

mg........................................................................................ 3

efavirenz tab 600 mg.......................................................... 3

eletriptan hydrobromide tab 20 mg (base equivalent),

40 mg (base equivalent)................................................. 34

ELIQUIS............................................................................... 37

ELIQUIS STARTER PACK.................................................. 38

ELLA.....................................................................................10

ELOCTATE...........................................................................38

EMCYT...................................................................................6

EMEND................................................................................ 24

EMGALITY........................................................................... 34

EMPAVELI............................................................................38

emtricitabine-tenofovir disoproxil fumarate tab

200-300 mg......................................................................... 3

emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg, 133-200 mg, 167-250 mg.............................3

enalapril maleate & hydrochlorothiazide tab 5-12.5

mg...................................................................................... 18

enalapril maleate & hydrochlorothiazide tab 10-25

mg...................................................................................... 18

enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg........ 18

ENBREL............................................................................... 32

ENBREL MINI......................................................................32

ENBREL SURECLICK........................................................ 33

enoxaparin sodium inj 300 mg/3ml.................................38

enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40

mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120

mg/0.8ml, 150 mg/ml....................................................... 38

entacapone tab 200 mg.................................................... 36

entecavir tab 0.5 mg, 1 mg................................................ 3

ENTRESTO..........................................................................20

EPCLUSA...............................................................................3

EPIDIOLEX.......................................................................... 35

epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000).............................................................................. 19

epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000).............................................................................. 19

eplerenone tab 25 mg, 50 mg.......................................... 18

ergocalciferol cap 1.25 mg (50000 unit)......................... 36

ERIVEDGE.............................................................................6

ERLEADA...............................................................................6

erlotinib hcl tab 25 mg (base equivalent).........................6

erlotinib hcl tab 100 mg (base equivalent), 150 mg

(base equivalent)............................................................... 6

erythromycin gel 2%......................................................... 43

erythromycin ophth oint 5 mg/gm.................................. 40

erythromycin soln 2%.......................................................43

escitalopram oxalate soln 5 mg/5ml (base equiv).........27

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

(base equiv), 20 mg (base equiv).................................. 27

esomeprazole magnesium cap delayed release 20 mg

(base eq), 40 mg (base eq).............................................24

esomeprazole magnesium for delayed release susp

packet 10 mg, 20 mg, 40 mg..........................................24

ESPEROCT......................................................................... 38

estazolam tab 1 mg, 2 mg................................................29

estradiol & norethindrone acetate tab 0.5-0.1 mg, 1-0.5

mg...................................................................................... 10

estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose

pump).................................................................................10

estradiol tab 0.5 mg, 1 mg, 2 mg.................................... 10

estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm

(0.1%), 0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25

mg/1.25gm (0.1%)............................................................ 10

estradiol td patch twice weekly 0.025 mg/24hr,

0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1

mg/24hr..............................................................................10

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 52

estradiol td patch weekly 0.025 mg/24hr, 0.0375

mg/24hr (37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr,

0.075 mg/24hr, 0.1 mg/24hr............................................ 10

estradiol vaginal cream 0.1 mg/gm.................................26

estradiol vaginal tab 10 mcg........................................... 26

ESTRING............................................................................. 26

eszopiclone tab 1 mg, 2 mg, 3 mg..................................29

ethambutol hcl tab 100 mg, 400 mg................................. 2

ethosuximide cap 250 mg................................................ 35

ethosuximide soln 250 mg/5ml........................................35

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg, 1 mg-50 mcg...........................................................10

etodolac cap 200 mg, 300 mg..........................................33

etodolac tab er 24hr 400 mg, 500 mg, 600 mg...............33

etodolac tab 400 mg......................................................... 33

etodolac tab 500 mg......................................................... 33

ETOPOSIDE.......................................................................... 6

etravirine tab 100 mg, 200 mg...........................................3

everolimus tab for oral susp 3 mg....................................6

everolimus tab for oral susp 2 mg, 5 mg......................... 6

everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg................... 6

everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg............ 45

exemestane tab 25 mg....................................................... 6

ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40

mg, 10-80 mg....................................................................20

ezetimibe tab 10 mg..........................................................19

famciclovir tab 125 mg....................................................... 3

famciclovir tab 250 mg, 500 mg........................................ 3

famotidine for susp 40 mg/5ml........................................24

famotidine tab 20 mg, 40 mg...........................................24

FARXIGA..............................................................................11

FASENRA PEN....................................................................22

FEIBA................................................................................... 38

felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg................... 17

fenofibrate micronized cap 67 mg, 134 mg, 200 mg..... 20

fenofibrate tab 48 mg, 145 mg.........................................20

fenofibrate tab 54 mg, 160 mg.........................................20

fentanyl citrate lozenge on a handle 200 mcg, 400 mcg,

600 mcg, 800 mcg, 1200 mcg, 1600 mcg......................32

fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,

75 mcg/hr, 100 mcg/hr.................................................... 32

FIASP................................................................................... 13

FIASP FLEXTOUCH........................................................... 13

FIASP PENFILL...................................................................13

FINACEA..............................................................................43

finasteride tab 5 mg.......................................................... 26

fingolimod hcl cap 0.5 mg (base equiv)......................... 30

flecainide acetate tab 50 mg, 100 mg, 150 mg...............17

fluconazole for susp 10 mg/ml, 40 mg/ml........................ 2

fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg............ 2

flucytosine cap 250 mg, 500 mg....................................... 2

fludrocortisone acetate tab 0.1 mg...................................9

flunisolide nasal soln 25 mcg/act (0.025%)....................21

fluocinolone acetonide cream 0.01%..............................43

fluocinolone acetonide cream 0.025%............................43

fluocinolone acetonide oil 0.01% (body oil)...................43

fluocinolone acetonide oil 0.01% (scalp oil).................. 43

fluocinolone acetonide oint 0.025%................................43

fluocinolone acetonide soln 0.01%.................................43

fluocinonide cream 0.05%................................................43

fluocinonide cream 0.1%..................................................43

fluocinonide oint 0.05%.................................................... 43

fluocinonide soln 0.05%................................................... 43

fluorometholone ophth susp 0.1%..................................40

fluorouracil cream 5%.......................................................43

fluorouracil soln 5%..........................................................43

fluoxetine hcl cap 10 mg, 20 mg, 40 mg........................ 27

fluoxetine hcl solution 20 mg/5ml...................................27

FLUPHENAZINE HCL.........................................................28

fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg........... 28

FLUPHENAZINE HYDROCHLORID.................................. 28

flurbiprofen tab 100 mg.................................................... 33

FLUTICASONE PROPIONATE/SA.....................................22

fluticasone propionate cream 0.05%.............................. 43

fluticasone propionate nasal susp 50 mcg/act..............21

fluticasone propionate oint 0.005%................................ 43

fluticasone-salmeterol aer powder ba 100-50 mcg/act,

250-50 mcg/act, 500-50 mcg/act.................................... 22

fluvoxamine maleate tab 25 mg, 50 mg, 100 mg........... 27

folic acid tab 1 mg............................................................ 37

FOLLISTIM AQ.................................................................... 15

fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg, 20-12.5 mg.................................................................18

fosinopril sodium tab 10 mg, 20 mg, 40 mg.................. 18

FULPHILA............................................................................ 37

furosemide oral soln 10 mg/ml........................................19

furosemide tab 20 mg, 40 mg, 80 mg............................. 19

gabapentin cap 100 mg, 300 mg, 400 mg.......................35

gabapentin oral soln 250 mg/5ml....................................35

gabapentin tab 600 mg, 800 mg...................................... 35

galantamine hydrobromide cap er 24hr 8 mg, 16 mg,

24 mg.................................................................................30

galantamine hydrobromide tab 4 mg, 8 mg, 12 mg.......30

ganirelix acetate soln prefilled syringe 250

mcg/0.5ml..........................................................................15

gefitinib tab 250 mg............................................................ 6

gemfibrozil tab 600 mg.....................................................20

GENOTROPIN.....................................................................15

GENOTROPIN MINIQUICK................................................ 15

gentamicin sulfate cream 0.1%....................................... 43

gentamicin sulfate oint 0.1%........................................... 43

gentamicin sulfate ophth soln 0.3%............................... 40

GENVOYA..............................................................................3

glatiramer acetate soln prefilled syringe 20 mg/ml.......30

glatiramer acetate soln prefilled syringe 40 mg/ml.......30

GLEOSTINE...........................................................................6

glimepiride tab 1 mg, 2 mg, 4 mg................................... 11

glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg,

5-500 mg........................................................................... 11

glipizide tab er 24hr 2.5 mg, 5 mg, 10 mg...................... 11

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 53

glipizide tab 5 mg, 10 mg.................................................11

GLUCAGON EMERGENCY KIT FO.................................. 11

glyburide-metformin tab 1.25-250 mg, 2.5-500 mg,

5-500 mg........................................................................... 11

glyburide tab 1.25 mg, 2.5 mg, 5 mg.............................. 11

glycopyrrolate tab 1 mg, 2 mg........................................ 24

GLYXAMBI........................................................................... 12

granisetron hcl tab 1 mg..................................................24

griseofulvin microsize susp 125 mg/5ml......................... 2

griseofulvin microsize tab 500 mg....................................2

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

mg (base equiv), 3 mg (base equiv), 4 mg (base

equiv)................................................................................. 29

guanfacine hcl tab 1 mg, 2 mg........................................18

GVOKE HYPOPEN 1-PACK............................................... 12

GVOKE HYPOPEN 2-PACK............................................... 12

GVOKE KIT......................................................................... 12

GVOKE PFS........................................................................ 12

HADLIMA............................................................................. 33

HADLIMA PUSHTOUCH.....................................................33

halobetasol propionate cream 0.05%............................. 43

haloperidol lactate oral conc 2 mg/ml............................ 28

haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20

mg...................................................................................... 28

HARVONI............................................................................... 3

HEMLIBRA...........................................................................39

HEMOFIL M.........................................................................39

HUMALOG........................................................................... 13

HUMALOG JUNIOR KWIKPEN..........................................13

HUMALOG KWIKPEN.........................................................13

HUMALOG MIX 50/50.........................................................13

HUMALOG MIX 75/25.........................................................13

HUMALOG MIX 50/50 KWIKPEN.......................................13

HUMALOG MIX 75/25 KWIKPEN.......................................13

HUMALOG TEMPO PEN....................................................13

HUMATE-P...........................................................................39

HUMATIN............................................................................... 2

HUMIRA............................................................................... 33

HUMIRA PEN...................................................................... 33

HUMIRA PEN-CD/UC/HS START...................................... 33

HUMIRA PEN-PS/UV STARTER........................................33

HUMULIN 70/30.................................................................. 14

HUMULIN 70/30 KWIKPEN................................................ 14

HUMULIN N.........................................................................13

HUMULIN N KWIKPEN.......................................................14

HUMULIN R.........................................................................13

HUMULIN R U-500 (CONCENTR...................................... 13

HUMULIN R U-500 KWIKPEN........................................... 13

hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg........ 18

hydrochlorothiazide cap 12.5 mg....................................19

hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg........... 19

hydrocodone-acetaminophen soln 7.5-325

mg/15ml............................................................................. 32

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

mg, 7.5-325 mg.................................................................32

hydrocodone-ibuprofen tab 7.5-200 mg......................... 32

hydrocortisone acetate suppos 25 mg...........................41

hydrocortisone cream 2.5%............................................. 43

hydrocortisone enema 100 mg/60ml.............................. 41

hydrocortisone oint 2.5%................................................. 43

hydrocortisone perianal cream 2.5%..............................41

hydrocortisone tab 5 mg, 10 mg, 20 mg.......................... 9

hydrocortisone w/ acetic acid otic soln 1-2%................41

hydromorphone hcl liqd 1 mg/ml....................................32

hydromorphone hcl tab 2 mg, 4 mg, 8 mg.....................32

hydroxychloroquine sulfate tab 200 mg.......................... 5

hydroxychloroquine sulfate tab 100 mg, 300 mg, 400

mg........................................................................................ 5

hydroxyurea cap 500 mg....................................................6

hydroxyzine hcl syrup 10 mg/5ml...................................26

hydroxyzine hcl tab 10 mg, 25 mg, 50 mg..................... 26

hydroxyzine pamoate cap 25 mg, 50 mg....................... 26

ibandronate sodium tab 150 mg (base equivalent).......15

IBRANCE............................................................................... 6

ibuprofen susp 100 mg/5ml............................................. 33

ibuprofen tab 400 mg, 600 mg, 800 mg.......................... 33

icatibant acetate subcutaneous soln pref syr 30

mg/3ml............................................................................... 39

IDELVION.............................................................................39

imatinib mesylate tab 100 mg (base equivalent).............7

imatinib mesylate tab 400 mg (base equivalent).............7

IMBRUVICA........................................................................... 7

imipramine hcl tab 10 mg, 25 mg, 50 mg....................... 27

imiquimod cream 5%........................................................ 43

IMPAVIDO.............................................................................. 5

INBRIJA................................................................................36

INCRELEX........................................................................... 15

INCRUSE ELLIPTA............................................................. 22

indapamide tab 1.25 mg, 2.5 mg..................................... 19

indomethacin cap 25 mg, 50 mg..................................... 33

INSULIN GLARGINE-YFGN............................................... 14

INSULIN PEN NEEDLES – VARIOUS............................... 45

INSULIN SYRINGES – VARIOUS...................................... 45

INTELENCE........................................................................... 3

ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml.......22

ipratropium bromide inhal soln 0.02%........................... 22

ipratropium bromide nasal soln 0.03% (21 mcg/

spray).................................................................................21

ipratropium bromide nasal soln 0.06% (42 mcg/

spray).................................................................................21

irbesartan-hydrochlorothiazide tab 150-12.5 mg,

300-12.5 mg...................................................................... 18

irbesartan tab 75 mg, 150 mg, 300 mg........................... 18

ISENTRESS...........................................................................3

ISENTRESS HD.................................................................... 4

isoniazid syrup 50 mg/5ml................................................. 2

isoniazid tab 300 mg...........................................................2

isosorbide dinitrate tab 5 mg.......................................... 16

isosorbide dinitrate tab 10 mg, 20 mg, 30 mg............... 16

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 54

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

mg...................................................................................... 16

isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mg................43

itraconazole cap 100 mg.................................................... 2

itraconazole oral soln 10 mg/ml........................................ 2

ivermectin tab 3 mg............................................................ 5

IXINITY.................................................................................39

JANUMET............................................................................ 12

JANUMET XR......................................................................12

JANUVIA.............................................................................. 12

JARDIANCE.........................................................................12

JIVI....................................................................................... 39

JULUCA................................................................................. 4

KALYDECO.......................................................................... 23

KESIMPTA........................................................................... 30

ketoconazole cream 2%................................................... 43

ketoconazole shampoo 2%.............................................. 43

ketorolac tromethamine ophth soln 0.4%...................... 40

ketorolac tromethamine ophth soln 0.5%...................... 40

KISQALI................................................................................. 7

KLOXXADO......................................................................... 45

KOATE................................................................................. 39

KOATE-DVI.......................................................................... 39

KOGENATE FS................................................................... 39

KOSHER PRENATAL PLUS IRON.....................................37

KOVALTRY...........................................................................39

labetalol hcl tab 100 mg................................................... 16

labetalol hcl tab 200 mg, 300 mg.................................... 16

lacosamide oral solution 10 mg/ml.................................35

lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg...........35

lactulose (encephalopathy) solution 10 gm/15ml......... 25

lactulose solution 10 gm/15ml.........................................23

lamivudine oral soln 10 mg/ml.......................................... 4

lamivudine tab 150 mg, 300 mg........................................ 4

lamivudine tab 100 mg (hbv)............................................. 4

lamivudine-zidovudine tab 150-300 mg............................4

lamotrigine tab chewable dispersible 5 mg, 25 mg.......35

lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg...........35

LANCETS – VARIOUS........................................................45

lansoprazole cap delayed release 15 mg, 30 mg.......... 24

lapatinib ditosylate tab 250 mg (base equiv)...................7

latanoprost ophth soln 0.005%........................................40

leflunomide tab 10 mg, 20 mg......................................... 33

lenalidomide cap 5 mg, 10 mg........................................ 45

lenalidomide cap 15 mg, 20 mg, 25 mg..........................45

lenalidomide caps 2.5 mg................................................ 45

LENVIMA 4 MG DAILY DOSE..............................................7

LENVIMA 8 MG DAILY DOSE..............................................7

LENVIMA 10 MG DAILY DOSE............................................7

LENVIMA 12MG DAILY DOSE.............................................7

LENVIMA 14 MG DAILY DOSE............................................7

LENVIMA 18 MG DAILY DOSE............................................7

LENVIMA 20 MG DAILY DOSE............................................7

LENVIMA 24 MG DAILY DOSE............................................7

letrozole tab 2.5 mg............................................................ 7

leucovorin calcium tab 5 mg, 15 mg, 25 mg.................... 7

LEUKERAN............................................................................7

leuprolide acetate inj kit 1 mg/0.2ml (5 mg/ml)................7

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base

equiv)................................................................................. 22

levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv),

0.63 mg/3ml (base equiv), 1.25 mg/3ml (base

equiv)................................................................................. 22

LEVEMIR..............................................................................14

LEVEMIR FLEXPEN........................................................... 14

levetiracetam oral soln 100 mg/ml.................................. 35

levetiracetam tab er 24hr 500 mg, 750 mg..................... 35

levetiracetam tab 250 mg, 500 mg, 750 mg, 1000

mg...................................................................................... 35

levocarnitine oral soln 1 gm/10ml (10%)........................ 15

levocarnitine tab 330 mg..................................................15

levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/

ml)...................................................................................... 21

levocetirizine dihydrochloride tab 5 mg.........................21

levofloxacin oral soln 25 mg/ml........................................ 2

levofloxacin tab 250 mg, 500 mg, 750 mg........................2

levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg..................................................................... 10

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,

0.15 mg-30 mcg................................................................10

levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg..................................10

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...........................................................................10

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...........................................................................10

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

mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg,

175 mcg, 200 mcg, 300 mcg.......................................... 14

lidocaine hcl gel 2%..........................................................43

lidocaine hcl soln 4%....................................................... 44

lidocaine hcl viscous soln 2%.........................................41

lidocaine oint 5%...............................................................44

lidocaine patch 5%............................................................44

lidocaine-prilocaine cream 2.5-2.5%............................... 44

linezolid for susp 100 mg/5ml........................................... 5

linezolid tab 600 mg............................................................5

LINZESS.............................................................................. 25

liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg.......... 14

lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30

mg, 40 mg, 50 mg, 60 mg, 70 mg.................................. 29

lisdexamfetamine dimesylate chew tab 10 mg, 20 mg,

30 mg, 40 mg, 50 mg, 60 mg..........................................29

lisinopril & hydrochlorothiazide tab 10-12.5 mg,

20-12.5 mg, 20-25 mg......................................................18

lisinopril tab 2.5 mg, 30 mg, 40 mg................................ 18

lisinopril tab 5 mg, 10 mg, 20 mg................................... 18

lithium carbonate cap 300 mg......................................... 28

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 55

lithium carbonate cap 150 mg, 600 mg.......................... 28

lithium carbonate tab er 300 mg..................................... 28

lithium carbonate tab er 450 mg..................................... 28

lithium carbonate tab 300 mg..........................................28

lithium oral solution 8 meq/5ml.......................................28

LOKELMA............................................................................ 45

LO LOESTRIN FE...............................................................10

loperamide hcl cap 2 mg..................................................24

lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)........................................................................................ 4

lopinavir-ritonavir tab 100-25 mg...................................... 4

lopinavir-ritonavir tab 200-50 mg...................................... 4

lorazepam conc 2 mg/ml.................................................. 26

lorazepam tab 0.5 mg, 1 mg, 2 mg..................................26

losartan potassium & hydrochlorothiazide tab 50-12.5

mg, 100-12.5 mg, 100-25 mg.......................................... 18

losartan potassium tab 25 mg, 50 mg, 100 mg..............18

LOTEMAX............................................................................ 40

LOTEMAX SM..................................................................... 40

loteprednol etabonate ophth gel 0.5%............................40

loteprednol etabonate ophth susp 0.5%........................ 40

lovastatin tab 10 mg......................................................... 20

lovastatin tab 20 mg......................................................... 20

lovastatin tab 40 mg......................................................... 20

loxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mg..... 28

LUMIGAN.............................................................................40

lurasidone hcl tab 80 mg................................................. 28

lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg..........28

LYNPARZA.............................................................................7

LYUMJEV............................................................................. 13

LYUMJEV KWIKPEN...........................................................13

LYUMJEV TEMPO PEN......................................................13

malathion lotion 0.5%....................................................... 44

MATULANE............................................................................ 7

MAVENCLAD....................................................................... 30

MAVYRET.............................................................................. 4

MAYZENT............................................................................ 30

MAYZENT STARTER PACK............................................... 30

meclizine hcl tab 12.5 mg, 25 mg....................................24

medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10

mg...................................................................................... 11

mefloquine hcl tab 250 mg................................................ 5

megestrol acetate susp 40 mg/ml..................................... 7

megestrol acetate tab 20 mg, 40 mg................................ 7

MEKINIST.............................................................................. 7

meloxicam tab 7.5 mg, 15 mg..........................................33

memantine hcl oral solution 2 mg/ml............................. 30

memantine hcl tab 5 mg, 10 mg......................................30

memantine hcl tab 28 x 5 mg & 21 x 10 mg titration

pack....................................................................................30

mercaptopurine tab 50 mg.................................................7

mesalamine cap dr 400 mg..............................................25

mesalamine cap er 24hr 0.375 gm.................................. 25

mesalamine enema 4 gm................................................. 25

mesalamine suppos 1000 mg.......................................... 25

mesalamine tab delayed release 1.2 gm........................ 25

MESNEX................................................................................ 7

metformin hcl tab er 24hr 500 mg, 750 mg.................... 12

metformin hcl tab 500 mg, 850 mg, 1000 mg.................12

methadone hcl conc 10 mg/ml........................................ 32

methadone hcl soln 5 mg/5ml, 10 mg/5ml..................... 32

methadone hcl tab for oral susp 40 mg......................... 32

methadone hcl tab 5 mg.................................................. 32

methadone hcl tab 10 mg................................................ 32

methazolamide tab 25 mg, 50 mg................................... 19

methimazole tab 5 mg, 10 mg......................................... 14

methocarbamol tab 500 mg............................................. 36

methocarbamol tab 750 mg............................................. 36

methotrexate sodium for inj 1 gm.....................................7

methotrexate sodium inj 50 mg/2ml (25 mg/ml).............. 8

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

mg/10ml (25 mg/ml), 1000 mg/40ml (25 mg/ml)............. 7

methotrexate sodium tab 2.5 mg (base equiv)................ 8

methscopolamine bromide tab 2.5 mg, 5 mg................ 24

methsuximide cap 300 mg............................................... 35

methylergonovine maleate tab 0.2 mg........................... 14

methylphenidate hcl tab er 10 mg, 20 mg......................29

methylphenidate hcl tab er osmotic release (osm) 36

mg...................................................................................... 29

methylphenidate hcl tab er osmotic release (osm) 18

mg, 27 mg, 54 mg............................................................29

methylphenidate hcl tab 5 mg, 10 mg, 20 mg................29

methylprednisolone tab 4 mg, 8 mg, 16 mg, 32 mg........ 9

methylprednisolone tab therapy pack 4 mg (21).............9

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base

equiv)................................................................................. 25

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

(base equivalent)............................................................. 25

metolazone tab 2.5 mg, 5 mg, 10 mg..............................19

metoprolol & hydrochlorothiazide tab 50-25 mg...........18

metoprolol & hydrochlorothiazide tab 100-25 mg,

100-50 mg......................................................................... 18

metoprolol succinate tab er 24hr 25 mg (tartrate

equiv), 50 mg (tartrate equiv), 100 mg (tartrate equiv),

200 mg (tartrate equiv)................................................... 16

metoprolol tartrate tab 25 mg..........................................16

metoprolol tartrate tab 50 mg, 100 mg........................... 16

metronidazole cream 0.75%.............................................44

metronidazole gel 0.75%.................................................. 44

metronidazole gel 1%....................................................... 44

metronidazole tab 250 mg, 500 mg...................................5

metronidazole vaginal gel 0.75%.................................... 26

mexiletine hcl cap 150 mg, 200 mg, 250 mg.................. 17

midodrine hcl tab 2.5 mg, 5 mg, 10 mg..........................19

minocycline hcl cap 50 mg................................................ 2

minocycline hcl cap 75 mg, 100 mg................................. 2

minoxidil tab 2.5 mg, 10 mg............................................ 18

mirtazapine tab 7.5 mg..................................................... 27

mirtazapine tab 15 mg, 30 mg, 45 mg............................ 27

misoprostol tab 100 mcg, 200 mcg.................................24

modafinil tab 100 mg, 200 mg......................................... 29

moexipril hcl tab 7.5 mg, 15 mg......................................18

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 56

mometasone furoate cream 0.1%................................... 44

mometasone furoate nasal susp 50 mcg/act.................21

mometasone furoate oint 0.1%........................................44

mometasone furoate solution 0.1% (lotion)...................44

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

(base equiv)...................................................................... 22

montelukast sodium oral granules packet 4 mg (base

equiv)................................................................................. 22

montelukast sodium tab 10 mg (base equiv).................22

morphine sulfate oral soln 10 mg/5ml, 100 mg/5ml (20

mg/ml)................................................................................32

morphine sulfate tab er 15 mg, 30 mg, 60 mg, 100 mg,

200 mg...............................................................................32

morphine sulfate tab 15 mg, 30 mg................................ 32

MOUNJARO.........................................................................12

MOVANTIK...........................................................................25

moxifloxacin hcl ophth soln 0.5% (base equiv).............40

MULTAQ...............................................................................17

mupirocin oint 2%............................................................. 44

mycophenolate mofetil cap 250 mg................................45

mycophenolate mofetil for oral susp 200 mg/ml...........45

mycophenolate mofetil tab 500 mg................................ 45

mycophenolate sodium tab dr 180 mg (mycophenolic

acid equiv), 360 mg (mycophenolic acid equiv).......... 46

MYFEMBREE...................................................................... 10

MYLERAN..............................................................................8

nabumetone tab 500 mg, 750 mg....................................33

nadolol tab 20 mg, 40 mg, 80 mg....................................16

naloxone hcl inj 0.4 mg/ml, 4 mg/10ml........................... 45

naloxone hcl nasal spray 4 mg/0.1ml............................. 45

NALOXONE HYDROCHLORIDE........................................45

naltrexone hcl tab 50 mg................................................. 45

naproxen sodium tab 275 mg, 550 mg........................... 33

naproxen tab 250 mg, 375 mg, 500 mg.......................... 33

naratriptan hcl tab 1 mg (base equiv), 2.5 mg (base

equiv)................................................................................. 34

NATACYN.............................................................................40

nateglinide tab 60 mg, 120 mg........................................ 12

neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin..................................40

neomycin-polymyxin-dexamethasone ophth oint

0.1%....................................................................................40

neomycin-polymyxin-dexamethasone ophth susp

0.1%....................................................................................41

neomycin-polymyxin-hc otic soln 1%............................ 41

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%......................................................................... 41

neomycin sulfate tab 500 mg............................................ 2

nevirapine tab er 24hr 400 mg...........................................4

nevirapine tab 200 mg........................................................ 4

NEXIUM............................................................................... 24

NEXLETOL.......................................................................... 20

NEXLIZET............................................................................ 20

niacin tab er 1000 mg (antihyperlipidemic)....................20

niacin tab er 500 mg (antihyperlipidemic), 750 mg

(antihyperlipidemic).........................................................20

NICOTROL INHALER......................................................... 30

NICOTROL NS.................................................................... 30

nifedipine tab er 24hr 30 mg, 60 mg, 90 mg.................. 17

nifedipine tab er 24hr osmotic release 30 mg, 60 mg,

90 mg.................................................................................17

nilutamide tab 150 mg........................................................ 8

nimodipine cap 30 mg...................................................... 17

nitazoxanide tab 500 mg.................................................... 5

nitisinone cap 2 mg, 5 mg, 10 mg, 20 mg...................... 15

nitrofurantoin macrocrystalline cap 25 mg, 50 mg, 100

mg........................................................................................ 5

nitrofurantoin monohydrate macrocrystalline cap 100

mg........................................................................................ 5

nitrofurantoin susp 25 mg/5ml.......................................... 5

nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg....................16

nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4

mg/hr, 0.6 mg/hr...............................................................16

NITYR...................................................................................15

NIVESTYM...........................................................................37

norelgestromin-ethinyl estradiol td ptwk 150-35

mcg/24hr........................................................................... 11

norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg........................................................................ 11

norethindrone & ethinyl estradiol tab 1 mg-35 mcg..... 11

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,

0.5 mg-35 mcg..................................................................11

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg.................................................................................... 11

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30

mcg.................................................................................... 11

norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg.................................................................................... 11

norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg.................................................................................... 11

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5

mcg.................................................................................... 10

norethindrone acetate-ethinyl estradiol tab 1 mg-5

mcg.................................................................................... 10

norethindrone acetate tab 5 mg...................................... 11

norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg..............................................................................11

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

mcg.................................................................................... 11

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

mcg.................................................................................... 11

Norethindrone tab 0.35 mg.............................................. 11

norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg.................................................................................... 11

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25

mg-mcg..............................................................................11

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35

mg-mcg..............................................................................11

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg......... 11

nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg........ 27

nortriptyline hcl soln 10 mg/5ml..................................... 27

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 57

NORVIR................................................................................. 4

NOVOEIGHT........................................................................39

NOVOLIN 70/30.................................................................. 14

NOVOLIN 70/30 FLEXPEN................................................ 14

NOVOLIN N......................................................................... 14

NOVOLIN N FLEXPEN....................................................... 14

NOVOLIN R......................................................................... 13

NOVOLIN R FLEXPEN....................................................... 13

NOVOLOG........................................................................... 13

NOVOLOG FLEXPEN.........................................................13

NOVOLOG MIX 70/30.........................................................14

NOVOLOG MIX 70/30 PREFILL.........................................14

NOVOLOG PENFILL...........................................................13

NOVOSEVEN RT................................................................ 39

NOXAFIL................................................................................ 2

NUBEQA................................................................................ 8

NUCALA...............................................................................22

NURTEC.............................................................................. 34

NUVARING.......................................................................... 11

NUWIQ................................................................................. 39

nystatin cream 100000 unit/gm....................................... 44

nystatin oint 100000 unit/gm........................................... 44

nystatin susp 100000 unit/ml...........................................41

nystatin tab 500000 unit..................................................... 2

nystatin topical powder 100000 unit/gm........................ 44

nystatin-triamcinolone cream 100000-0.1 unit/gm-

%.........................................................................................44

nystatin-triamcinolone oint 100000-0.1 unit/gm-%........44

OBIZUR................................................................................39

octreotide acetate inj 200 mcg/ml (0.2 mg/ml), 1000

mcg/ml (1 mg/ml).............................................................15

octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100

mcg/ml (0.1 mg/ml), 500 mcg/ml (0.5 mg/ml)............... 15

ODEFSEY.............................................................................. 4

ofloxacin ophth soln 0.3%............................................... 41

ofloxacin otic soln 0.3%................................................... 41

ofloxacin tab 400 mg.......................................................... 2

olanzapine orally disintegrating tab 5 mg, 10 mg, 15

mg, 20 mg.........................................................................28

olanzapine tab 15 mg, 20 mg...........................................28

olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg................. 28

olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg, 40-12.5 mg, 40-25 mg.................................18

olmesartan medoxomil tab 5 mg, 20 mg, 40 mg........... 18

omeprazole cap delayed release 10 mg, 20 mg, 40

mg...................................................................................... 24

OMNIPOD DASH INTRO KIT (G........................................45

OMNIPOD DASH PODS (GEN 4)...................................... 45

OMNIPOD 5 G6 INTRO KIT (G..........................................45

OMNIPOD 5 G6 PODS (GEN 5)........................................ 45

OMNITROPE....................................................................... 15

ondansetron hcl oral soln 4 mg/5ml...............................24

ondansetron hcl tab 4 mg, 8 mg..................................... 24

ondansetron orally disintegrating tab 4 mg, 8 mg........ 24

OPSUMIT.............................................................................20

OPVEE................................................................................. 45

ORFADIN............................................................................. 15

ORIAHNN.............................................................................10

ORILISSA.............................................................................15

orphenadrine citrate tab er 12hr 100 mg........................36

oseltamivir phosphate cap 30 mg (base equiv)...............4

oseltamivir phosphate cap 45 mg (base equiv), 75 mg

(base equiv)........................................................................ 4

oseltamivir phosphate for susp 6 mg/ml (base

equiv)................................................................................... 4

OTEZLA............................................................................... 33

OVIDREL..............................................................................15

oxaprozin tab 600 mg....................................................... 33

oxcarbazepine susp 300 mg/5ml (60 mg/ml)................. 35

oxcarbazepine tab 150 mg, 300 mg, 600 mg..................35

oxybutynin chloride solution 5 mg/5ml..........................25

oxybutynin chloride tab er 24hr 15 mg.......................... 25

oxybutynin chloride tab er 24hr 5 mg, 10 mg................25

oxybutynin chloride tab 5 mg..........................................25

oxycodone hcl conc 100 mg/5ml (20 mg/ml)................. 32

oxycodone hcl soln 5 mg/5ml......................................... 32

oxycodone hcl tab 10 mg, 20 mg....................................32

oxycodone hcl tab 5 mg, 15 mg, 30 mg......................... 32

oxycodone w/ acetaminophen tab 5-325 mg, 7.5-325

mg, 10-325 mg..................................................................32

OZEMPIC.............................................................................12

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

(base equiv)...................................................................... 24

paroxetine hcl tab er 24hr 12.5 mg, 25 mg, 37.5 mg..... 27

paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg............27

PAXLOVID..............................................................................4

pazopanib hcl tab 200 mg (base equiv)........................... 8

PEGASYS.............................................................................. 4

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm...................................................................................... 23

peg 3350-kcl-sod bicarb-nacl for soln 420 gm.............. 23

penicillamine tab 250 mg................................................. 46

penicillin v potassium tab 250 mg, 500 mg..................... 1

pentamidine isethionate for nebulization soln 300

mg........................................................................................ 5

pentoxifylline tab er 400 mg............................................ 39

perindopril erbumine tab 4 mg........................................18

permethrin cream 5%........................................................44

perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg................... 28

phenobarbital elixir 20 mg/5ml........................................ 29

phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60

mg, 100 mg.......................................................................29

phenoxybenzamine hcl cap 10 mg................................. 18

phenytoin chew tab 50 mg...............................................35

phenytoin sodium extended cap 100 mg....................... 35

phenytoin sodium extended cap 200 mg, 300 mg.........35

phenytoin susp 125 mg/5ml.............................................35

phytonadione tab 5 mg.................................................... 36

pilocarpine hcl ophth soln 1%, 2%, 4%..........................41

pilocarpine hcl tab 5 mg, 7.5 mg.....................................41

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 58

pindolol tab 5 mg, 10 mg................................................. 16

pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850

mg...................................................................................... 12

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

equiv), 45 mg (base equiv).............................................12

PIQRAY 200MG DAILY DOSE............................................. 8

PIQRAY 250MG DAILY DOSE............................................. 8

PIQRAY 300MG DAILY DOSE............................................. 8

piroxicam cap 10 mg, 20 mg........................................... 33

PLEGRIDY........................................................................... 30

PLEGRIDY STARTER PACK..............................................30

polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%.............................................................................. 41

posaconazole susp 40 mg/ml............................................ 2

posaconazole tab delayed release 100 mg...................... 2

potassium chloride cap er 8 meq, 10 meq.....................37

potassium chloride microencapsulated crys er tab 10

meq, 20 meq.....................................................................37

potassium chloride oral soln 10% (20 meq/15ml), 20%

(40 meq/15ml)................................................................... 37

potassium chloride powder packet 20 meq...................37

potassium chloride tab er 10 meq.................................. 37

potassium chloride tab er 8 meq (600 mg).................... 37

potassium citrate tab er 5 meq (540 mg)....................... 26

potassium citrate tab er 10 meq (1080 mg)................... 26

potassium citrate tab er 15 meq (1620 mg)................... 26

potassium phosphate monobasic tab 500 mg.............. 37

pot phos monobasic w/sod phos di & monobas tab

155-852-130mg................................................................. 37

pramipexole dihydrochloride tab 0.125 mg, 0.25 mg,

0.5 mg, 0.75 mg, 1 mg, 1.5 mg.......................................36

prasugrel hcl tab 5 mg (base equiv), 10 mg (base

equiv)................................................................................. 39

pravastatin sodium tab 10 mg.........................................20

pravastatin sodium tab 20 mg, 40 mg, 80 mg................20

praziquantel tab 600 mg.....................................................5

prazosin hcl cap 1 mg, 2 mg, 5 mg................................ 18

PREDNISOLONE ACETATE...............................................41

PREDNISOLONE SODIUM PHOSP.................................. 41

prednisolone sod phosphate oral soln 15 mg/5ml

(base equiv)........................................................................ 9

prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base)...................................................................... 9

prednisolone soln 15 mg/5ml............................................ 9

PREDNISONE....................................................................... 9

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

mg........................................................................................ 9

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

mg (21), 10 mg (48)........................................................... 9

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

200 mg, 225 mg, 300 mg................................................ 35

pregabalin soln 20 mg/ml.................................................35

PREGNYL............................................................................ 15

PREGNYL W/DILUENT BENZYL.......................................15

PREMARIN.......................................................................... 10

PREMPHASE.......................................................................10

PREMPRO........................................................................... 10

PRENATAL 19..................................................................... 37

PREZISTA.............................................................................. 4

PRIFTIN................................................................................. 2

primaquine phosphate tab 26.3 mg (15 mg base)........... 5

primidone tab 50 mg, 250 mg..........................................35

probenecid tab 500 mg.....................................................34

prochlorperazine maleate tab 5 mg (base equivalent),

10 mg (base equivalent)................................................. 28

prochlorperazine suppos 25 mg..................................... 28

PROCRIT............................................................................. 37

PROFILNINE........................................................................39

progesterone cap 100 mg, 200 mg................................. 11

promethazine hcl oral soln 6.25 mg/5ml........................ 21

promethazine hcl suppos 12.5 mg, 25 mg..................... 21

promethazine hcl tab 12.5 mg, 25 mg, 50 mg................ 21

propafenone hcl cap er 12hr 225 mg, 325 mg, 425

mg...................................................................................... 17

propafenone hcl tab 150 mg, 225 mg, 300 mg...............17

PROPRANOLOL HCL.........................................................16

propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg, 160

mg...................................................................................... 16

propranolol hcl oral soln 20 mg/5ml...............................16

propranolol hcl tab 10 mg, 20 mg, 40 mg, 60 mg, 80

mg...................................................................................... 16

propylthiouracil tab 50 mg...............................................14

PULMOZYME...................................................................... 23

PURIXAN............................................................................... 8

pyrazinamide tab 500 mg................................................... 2

pyridostigmine bromide tab 60 mg.................................36

pyrimethamine tab 25 mg.................................................. 5

quetiapine fumarate tab er 24hr 150 mg, 200 mg.......... 28

quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400

mg...................................................................................... 28

quetiapine fumarate tab 100 mg......................................28

quetiapine fumarate tab 200 mg......................................28

quetiapine fumarate tab 25 mg, 50 mg...........................28

quetiapine fumarate tab 300 mg, 400 mg.......................28

quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg.................18

quinapril-hydrochlorothiazide tab 10-12.5 mg, 20-12.5

mg...................................................................................... 18

quinidine gluconate tab er 324 mg................................. 17

QULIPTA.............................................................................. 34

QVAR REDIHALER............................................................. 22

raloxifene hcl tab 60 mg...................................................15

ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg.................... 18

RAPAMUNE......................................................................... 46

rasagiline mesylate tab 0.5 mg (base equiv), 1 mg

(base equiv)...................................................................... 36

REBIF...................................................................................31

REBIF REBIDOSE.............................................................. 31

REBIF REBIDOSE TITRATION.......................................... 31

REBIF TITRATION PACK................................................... 31

REBINYN............................................................................. 39

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 59

RECOMBINATE................................................................... 39

repaglinide tab 0.5 mg......................................................12

repaglinide tab 1 mg, 2 mg.............................................. 12

REPATHA.............................................................................20

REPATHA PUSHTRONEX SYSTEM..................................20

REPATHA SURECLICK...................................................... 20

RETACRIT............................................................................37

RETEVMO..............................................................................8

REVCOVI............................................................................. 15

REVLIMID............................................................................ 46

REXULTI.............................................................................. 28

REYVOW............................................................................. 34

rifabutin cap 150 mg........................................................... 2

rifampin cap 150 mg, 300 mg............................................ 2

riluzole tab 50 mg..............................................................36

RINVOQ............................................................................... 33

RINVOQ LQ.........................................................................33

risedronate sodium tab 35 mg........................................ 16

risedronate sodium tab 150 mg...................................... 16

risedronate sodium tab 5 mg, 30 mg..............................16

risperidone orally disintegrating tab 4 mg.....................28

risperidone orally disintegrating tab 0.5 mg, 1 mg, 2

mg, 3 mg...........................................................................28

risperidone soln 1 mg/ml................................................. 28

risperidone tab 3 mg........................................................ 28

risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg...... 28

ritonavir tab 100 mg............................................................4

rivastigmine tartrate cap 1.5 mg (base equivalent), 3

mg (base equivalent), 4.5 mg (base equivalent), 6 mg

(base equivalent)............................................................. 31

RIXUBIS............................................................................... 39

rizatriptan benzoate oral disintegrating tab 5 mg (base

eq)...................................................................................... 34

rizatriptan benzoate oral disintegrating tab 10 mg

(base eq)........................................................................... 34

rizatriptan benzoate tab 5 mg (base equivalent)........... 34

rizatriptan benzoate tab 10 mg (base equivalent)......... 34

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

mg, 3 mg, 4 mg, 5 mg.....................................................36

rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40

mg...................................................................................... 20

ROZLYTREK.......................................................................... 8

RUBRACA..............................................................................8

rufinamide tab 200 mg, 400 mg.......................................35

RYBELSUS.......................................................................... 12

RYDAPT.................................................................................8

SAVELLA..............................................................................31

SAVELLA TITRATION PACK.............................................. 31

scopolamine td patch 72hr 1 mg/3days......................... 24

selegiline hcl cap 5 mg.................................................... 36

selegiline hcl tab 5 mg..................................................... 36

selenium sulfide lotion 2.5%............................................44

SEMGLEE............................................................................14

SE-NATAL 19.......................................................................37

SEREVENT DISKUS...........................................................23

sertraline hcl oral concentrate for solution 20 mg/

ml........................................................................................27

sertraline hcl tab 25 mg, 50 mg, 100 mg........................ 27

sevelamer carbonate packet 0.8 gm, 2.4 gm................. 25

sevelamer carbonate tab 800 mg....................................25

sildenafil citrate tab 20 mg.............................................. 20

silodosin cap 4 mg, 8 mg.................................................26

silver sulfadiazine cream 1%........................................... 44

SIMBRINZA..........................................................................41

SIMLANDI 1-PEN KIT......................................................... 33

SIMLANDI 2-PEN KIT......................................................... 33

SIMPONI.............................................................................. 33

simvastatin tab 5 mg, 10 mg, 20 mg, 40 mg, 80 mg...... 20

sirolimus oral soln 1 mg/ml............................................. 46

sirolimus tab 0.5 mg, 1 mg, 2 mg................................... 46

SKYRIZI............................................................................... 25

SKYRIZI PEN...................................................................... 44

sodium chloride soln nebu 3%........................................21

sodium chloride soln nebu 7%........................................21

sodium citrate & citric acid soln 500-334 mg/5ml......... 26

sodium fluoride chew tab 0.25 mg f (from 0.55 mg

naf), 0.5 mg f (from 1.1 mg naf), 1 mg f (from 2.2 mg

naf)..................................................................................... 37

sodium fluoride cream 1.1%............................................ 41

sodium fluoride gel 1.1% (0.5% f)................................... 41

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml

naf)..................................................................................... 37

sodium polystyrene sulfonate oral susp 15

gm/60ml............................................................................. 46

sodium polystyrene sulfonate powder...........................46

solifenacin succinate tab 5 mg, 10 mg...........................25

SOLIQUA 100/33.................................................................12

SOOLANTRA....................................................................... 44

sorafenib tosylate tab 200 mg (base equivalent)............ 8

sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg............16

sotalol hcl tab 240 mg...................................................... 16

sotalol hcl tab 80 mg, 120 mg, 160 mg...........................16

SOVALDI................................................................................ 4

SPIRIVA HANDIHALER...................................................... 23

SPIRIVA RESPIMAT........................................................... 23

spironolactone & hydrochlorothiazide tab 25-25

mg...................................................................................... 19

spironolactone tab 25 mg, 50 mg, 100 mg.....................19

SPRYCEL...............................................................................8

STELARA.............................................................................44

STIOLTO RESPIMAT.......................................................... 23

STRENSIQ...........................................................................16

STRIVERDI RESPIMAT...................................................... 23

sucralfate tab 1 gm........................................................... 24

sulfacetamide sodium lotion 10% (acne)....................... 44

sulfacetamide sodium ophth soln 10%.......................... 41

sulfamethoxazole-trimethoprim susp 200-40

mg/5ml................................................................................. 5

sulfamethoxazole-trimethoprim tab 400-80 mg............... 5

sulfamethoxazole-trimethoprim tab 800-160 mg.............5

sulfasalazine tab delayed release 500 mg..................... 25

sulfasalazine tab 500 mg..................................................25

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 60

sulindac tab 150 mg, 200 mg...........................................33

sumatriptan nasal spray 5 mg/act, 20 mg/act................34

sumatriptan succinate inj 6 mg/0.5ml............................ 34

sumatriptan succinate solution auto-injector 4

mg/0.5ml, 6 mg/0.5ml...................................................... 34

sumatriptan succinate tab 25 mg, 50 mg, 100 mg.........34

sunitinib malate cap 12.5 mg (base equivalent).............. 8

sunitinib malate cap 25 mg (base equivalent), 37.5 mg

(base equivalent), 50 mg (base equivalent)................... 8

SUNOSI................................................................................29

SYMBICORT........................................................................23

SYMDEKO........................................................................... 23

SYMPROIC.......................................................................... 25

SYMTUZA.............................................................................. 4

SYNJARDY.......................................................................... 12

SYNJARDY XR................................................................... 12

TABLOID................................................................................ 8

TABRECTA.............................................................................8

tacrolimus cap 0.5 mg, 1 mg, 5 mg................................ 46

tacrolimus oint 0.03%, 0.1%.............................................44

tadalafil tab 2.5 mg, 5 mg............................................20,21

tadalafil tab 10 mg, 20 mg...........................................20,21

tadalafil tab 20 mg (pah).................................................. 20

TAFINLAR.............................................................................. 8

TAGRISSO............................................................................. 8

TAKHZYRO.......................................................................... 39

TALZENNA.............................................................................8

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

(base equivalent)............................................................... 8

tamsulosin hcl cap 0.4 mg...............................................26

TASIGNA................................................................................8

tazarotene cream 0.1%..................................................... 44

tazarotene gel 0.05%, 0.1%.............................................. 44

TAZORAC............................................................................ 44

telmisartan tab 20 mg, 40 mg, 80 mg............................. 18

temazepam cap 15 mg, 30 mg.........................................29

temozolomide cap 5 mg, 20 mg, 100 mg, 140 mg, 180

mg, 250 mg.........................................................................8

tenofovir disoproxil fumarate tab 300 mg........................4

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

equivalent), 5 mg (base equivalent), 10 mg (base

equivalent)........................................................................ 19

terbinafine hcl tab 250 mg................................................. 2

terbutaline sulfate tab 2.5 mg, 5 mg............................... 23

terconazole vaginal cream 0.4%, 0.8%........................... 26

terconazole vaginal suppos 80 mg................................. 26

teriflunomide tab 7 mg, 14 mg........................................ 31

teriparatide (recombinant) soln pen-inj 600

mcg/2.4ml..........................................................................16

testosterone cypionate im inj in oil 100 mg/ml............... 9

testosterone cypionate im inj in oil 200 mg/ml............... 9

testosterone td gel 12.5 mg/act (1%).............................. 10

testosterone td gel 20.25 mg/act (1.62%)....................... 10

testosterone td gel 25 mg/2.5gm (1%), 50 mg/5gm

(1%).................................................................................... 10

testosterone td soln 30 mg/act........................................10

TEST STRIPS – CONTOUR, CONTOUR NEXT,

ONETOUCH ULTRA, ONETOUCH VERIO...................... 45

tetrabenazine tab 12.5 mg................................................31

tetrabenazine tab 25 mg...................................................31

tetracycline hcl cap 250 mg, 500 mg................................ 2

TEZSPIRE............................................................................23

THALOMID...........................................................................46

theophylline tab er 12hr 300 mg, 450 mg.......................23

theophylline tab er 24hr 400 mg, 600 mg.......................23

thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg...................... 28

TIBSOVO............................................................................... 8

timolol maleate ophth soln 0.25%, 0.5%........................ 41

TIVICAY..................................................................................4

TIVICAY PD........................................................................... 4

tizanidine hcl tab 2 mg (base equivalent)...................... 36

tizanidine hcl tab 4 mg (base equivalent)...................... 36

tobramycin-dexamethasone ophth susp 0.3-0.1%........41

tobramycin nebu soln 300 mg/5ml....................................2

tobramycin ophth soln 0.3%............................................41

tolterodine tartrate cap er 24hr 2 mg, 4 mg................... 26

tolterodine tartrate tab 1 mg, 2 mg................................. 26

topiramate sprinkle cap 15 mg, 25 mg........................... 35

topiramate tab 25 mg, 50 mg, 100 mg, 200 mg..............35

toremifene citrate tab 60 mg (base equivalent)............... 9

torsemide tab 5 mg, 10 mg, 20 mg, 100 mg...................19

TOUJEO MAX SOLOSTAR................................................ 14

TOUJEO SOLOSTAR..........................................................14

TRACLEER.......................................................................... 20

tramadol-acetaminophen tab 37.5-325 mg.....................32

tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg........ 32

tramadol hcl tab 50 mg.................................................... 32

trandolapril tab 1 mg, 2 mg, 4 mg...................................19

tranylcypromine sulfate tab 10 mg................................. 27

trazodone hcl tab 50 mg, 100 mg, 150 mg..................... 27

TRELEGY ELLIPTA.............................................................23

TREMFYA............................................................................ 44

TRESIBA.............................................................................. 14

TRESIBA FLEXTOUCH...................................................... 14

tretinoin cap 10 mg.............................................................9

tretinoin cream 0.025%, 0.05%, 0.1%..............................44

tretinoin gel 0.01%............................................................ 44

TRETTEN.............................................................................40

triamcinolone acetonide cream 0.025%, 0.1%, 0.5%.....44

triamcinolone acetonide dental paste 0.1%...................41

triamcinolone acetonide lotion 0.025%, 0.1%................44

triamcinolone acetonide oint 0.025%, 0.1%, 0.5%.........44

triamterene & hydrochlorothiazide cap 37.5-25 mg...... 19

triamterene & hydrochlorothiazide tab 37.5-25 mg.......19

triamterene & hydrochlorothiazide tab 75-50 mg..........19

trifluoperazine hcl tab 1 mg (base equivalent), 2 mg

(base equivalent), 5 mg (base equivalent), 10 mg

(base equivalent)............................................................. 28

TRIFLURIDINE.................................................................... 41

trihexyphenidyl hcl tab 2 mg, 5 mg................................ 36

TRIJARDY XR..................................................................... 12

TRIKAFTA............................................................................ 23

2024

Blue Cross and Blue Shield October 2024 Basic Drug List 61

trimethobenzamide hcl cap 300 mg................................24

trimethoprim tab 100 mg....................................................5

TRIUMEQ...............................................................................4

TRIUMEQ PD........................................................................ 4

tropicamide ophth soln 0.5%...........................................41

tropicamide ophth soln 1%..............................................41

TRULANCE..........................................................................25

TRULICITY...........................................................................12

TYMLOS...............................................................................16

UBRELVY.............................................................................34

UPTRAVI.............................................................................. 20

UPTRAVI TITRATION PACK.............................................. 20

ursodiol cap 300 mg......................................................... 25

ursodiol tab 250 mg.......................................................... 25

ursodiol tab 500 mg.......................................................... 25

valacyclovir hcl tab 500 mg, 1 gm.................................... 4

VALCHLOR.......................................................................... 44

valganciclovir hcl for soln 50 mg/ml (base equiv).......... 4

valganciclovir hcl tab 450 mg (base equivalent)............. 4

valproate sodium oral soln 250 mg/5ml (base

equiv)................................................................................. 35

valproic acid cap 250 mg................................................. 35

valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5

mg, 160-25 mg, 320-12.5 mg, 320-25 mg...................... 19

valsartan tab 40 mg, 80 mg, 160 mg, 320 mg................ 19

vancomycin hcl cap 125 mg (base equivalent)............... 5

vancomycin hcl cap 250 mg (base equivalent)............... 5

varenicline tartrate tab 0.5 mg (base equiv), 1 mg (base

equiv)................................................................................. 31

varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg start

pack....................................................................................31

VELPHORO......................................................................... 25

VELTASSA........................................................................... 46

VEMLIDY................................................................................4

VENCLEXTA.......................................................................... 9

VENCLEXTA STARTING PACK........................................... 9

venlafaxine hcl cap er 24hr 37.5 mg (base

equivalent), 75 mg (base equivalent), 150 mg (base

equivalent)........................................................................ 27

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

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

(base equivalent), 100 mg (base equivalent)............... 27

VENTOLIN HFA...................................................................23

verapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg...... 17

verapamil hcl tab er 120 mg, 180 mg, 240 mg............... 17

verapamil hcl tab 40 mg...................................................17

verapamil hcl tab 80 mg, 120 mg.................................... 17

VERQUVO........................................................................... 20

VERZENIO.............................................................................9

VIBERZI............................................................................... 25

vigabatrin powd pack 500 mg......................................... 35

vigabatrin tab 500 mg.......................................................35

VIREAD.................................................................................. 4

VITRAKVI............................................................................... 9

VONVENDI.......................................................................... 40

voriconazole for susp 40 mg/ml........................................2

voriconazole tab 50 mg, 200 mg....................................... 2

VOSEVI.................................................................................. 5

VUMERITY...........................................................................31

VYNDAMAX......................................................................... 20

VYNDAQEL..........................................................................20

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

mg, 6 mg, 7.5 mg, 10 mg................................................38

WILATE................................................................................ 40

XALKORI................................................................................9

XARELTO.............................................................................38

XARELTO STARTER PACK................................................38

XELJANZ..............................................................................33

XELJANZ XR....................................................................... 34

XIFAXAN................................................................................ 6

XIGDUO XR.........................................................................12

XOLAIR................................................................................ 23

XTAMPZA ER...................................................................... 32

XTANDI...................................................................................9

XULTOPHY 100/3.6............................................................ 13

XYNTHA...............................................................................40

XYNTHA SOLOFUSE......................................................... 40

YONSA...................................................................................9

zafirlukast tab 10 mg, 20 mg........................................... 23

zaleplon cap 5 mg, 10 mg................................................29

ZARXIO................................................................................ 37

ZEGALOGUE.......................................................................13

ZEJULA.................................................................................. 9

ZELBORAF............................................................................ 9

ZENPEP............................................................................... 25

ZEPOSIA..............................................................................31

ZEPOSIA 7-DAY STARTER PAC....................................... 31

ZEPOSIA STARTER KIT.................................................... 31

zidovudine cap 100 mg...................................................... 5

zidovudine syrup 10 mg/ml................................................5

zidovudine tab 300 mg....................................................... 5

ZIEXTENZO......................................................................... 37

ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg......... 28

ZOKINVY..............................................................................46

zolpidem tartrate tab er 6.25 mg, 12.5 mg......................29

zolpidem tartrate tab 5 mg, 10 mg.................................. 29

zonisamide cap 50 mg......................................................35

zonisamide cap 25 mg, 100 mg.......................................35

ZURZUVAE.......................................................................... 27

ZYLET.................................................................................. 41