-
May 2018 (2017 Plan Year)
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
41722-K TX HIM Prime Therapeutics LLC 05/17
Health Insurance Marketplace 5 Tier Drug List
Please consider talking to your doctor about prescribing
preferred medications, which mayhelp reduce your out-of-pocket
costs. This list may help guide you and your doctor inselecting an
appropriate medication for you.
The drug list is regularly updated. Please visit bcbstx.com for
the most up-to-dateinformation.
To find a contracting pharmacy, please access the link
below:https://www.myprime.com/en/find-pharmacy.html
Contents Therapeutic Class Drug ListSummary of Formulary
Benefits .................................... IIntroduction
..................................................................
VIHow drugs are selected
...............................................VIHow member payment
is determined ..........................VIHow to use this list
..................................................... VIIDrugs used
to treat multiple conditions .......................VIIGeneric
drugs .............................................................
VIIConsider talking to your doctor about generic
drugs
.......................................................................
VIICoverage considerations
........................................... VIIISpecialty drugs
.............................................................
XPrime Specialty by AllianceRx Walgreens Prime ..........
XAbbreviation Key
..........................................................XI
Anti-infective
agents.......................................................
1Biologicals.....................................................................12Antineoplastic
agents...................................................
15Endocrine and metabolic
drugs....................................21Cardiovascular
agents..................................................39Respiratory
agents.......................................................
54Gastrointestinal
agents.................................................60Genitourinary
agents....................................................
65Central nervous system drugs.....................................
67Analgesics and
anesthetics..........................................85Neuromuscular
drugs...................................................
97Nutritional
products.....................................................105Hematological
agents................................................. 133Topical
products..........................................................143Miscellaneous
products.............................................. 156Index
..........................................................................160
To search for a drug name within this PDF document, use the
Control and F keys on your keyboard, orgo to Edit in the drop-down
menu and select Find/Search. Type in the word or phrase you are
looking forand click on Search.
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Texas Residents -- Find and estimate prices for medicines on
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BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) I
Summary of Formulary Benefits
The information in this document is designed to help you
understand the prescription drugbenefits offered under this plan
and compare these benefits to those offered by other
plans.Information contained in this summary is designed to help you
compare, both the value andscope of formulary benefits.
How to Find Information on the Cost of Prescription Drugs: Your
Summary of Benefits and Coverage (SBC)document lists information
about your plan, including pharmacy deductibles, tiers, out of
pocket maximums, and alink to this formulary document. This
formulary document lists drugs covered by your plan, the coverage
tiers andany special requirements for each drug. This formulary
document includes a link on the bottom of each page tothe Find a
Medicine web-based tool on myPrime.com, which you may use to search
for drugs for information onformulary coverage and estimate prices.
Price estimates include total cost, plan and member cost share
amounts(excluding any deductible requirements), and are based on
the most recent actual network pricing. You may alsouse Pharmacy
finder to review differences in estimated pricing between
pharmacies.
Toll free number to obtain formulary information, including
specific cost-sharing information for anyformulary drug:
1-800-423-1973
Formulary by Health Benefit Plan: Some 2017 Blue Cross and Blue
Shield of Texas employer-offered smallgroup plans use the 2017
Health Insurance Marketplace 5 Tier Drug List. These plans are
offered on and off theTexas Health Insurance Marketplace.
All Individual Plans use the 2017 Health Insurance Marketplace 5
Tier Drug List
Plan (Select plan name to view plan Summary of Benefits &
Coverage) Associated Formulary
Blue Advantage Bronze HMO 006 Non-Marketplace
Blue Advantage Bronze HMO 006 Marketplace
Blue Advantage Bronze HMO 006 Marketplace Native American
Zero
Blue Advantage Bronze HMO 006 Marketplace Native American
Limited
Blue Advantage Bronze HMO 105 Marketplace Native American
Zero
Blue Advantage Bronze HMO 105 - Two $40 PCP Visits
Non-Marketplace
Blue Advantage Bronze HMO 105 - Two $40 PCP Visits
Marketplace
Blue Advantage Bronze HMO 105 - Two $40 PCP Visits Marketplace
Native
American Limited Blue Advantage Gold HMO 101 Non-Marketplace
Blue Advantage Gold HMO 101 Marketplace
Blue Advantage Gold HMO 101 Marketplace Native American Zero
Health InsuranceBlue Advantage Gold HMO 101 Marketplace Native
American Limited Marketplace
Blue Advantage Gold HMO 111 Non-Marketplace 5 Tier Drug List
Blue Advantage Plus Bronze 103 Marketplace Native American
Zero
Blue Advantage Plus Bronze 103 - One $0 PCP Visit
Non-Marketplace
Blue Advantage Plus Bronze 103 - One $0 PCP Visit
Marketplace
Blue Advantage Plus Bronze 103 - One $0 PCP Visit Marketplace
Native American
Limited Blue Advantage Plus Bronze 104 Non-Marketplace
Blue Advantage Plus Bronze 104 Marketplace
Blue Advantage Plus Bronze 104 Marketplace Native American
Zero
Blue Advantage Plus Bronze 104 Marketplace Native American
Limited
http://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460006-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460006-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460006-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460006-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460241-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460241-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460241-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460241-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460237-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460237-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460237-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460237-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460236-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770003-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770003-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770003-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770003-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770079-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770079-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770079-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770079-03.pdf
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Texas Residents -- Find and estimate prices for medicines on
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at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) II
Plan (Select plan name to view plan Summary of Benefits &
Coverage) Associated Formulary
Blue Advantage Plus Gold 101 Non-Marketplace
Blue Advantage Plus Gold 101 Marketplace
Blue Advantage Plus Gold 101 Marketplace Native American
Zero
Blue Advantage Plus Gold 101 Marketplace Native American
Limited
Blue Advantage Plus Silver 102 Marketplace Native American
Zero
Blue Advantage Plus Silver 102 - Five $0 PCP Visits Marketplace
Native American
Zero Blue Advantage Plus Silver 102 - Three $0 PCP Visits
Non-Marketplace
Blue Advantage Plus Silver 102 - Three $0 PCP Visits
Marketplace
Blue Advantage Plus Silver 102 - Three $0 PCP Visits Marketplace
Native American
Limited Blue Advantage Plus Silver 102 - Three $0 PCP Visits
Marketplace 73% Actuarial
Value Blue Advantage Plus Silver 102 - Three $0 PCP Visits
Marketplace 87% Actuarial
Value Blue Advantage Security HMO 100 Non-Marketplace
Blue Advantage Security HMO 100 Marketplace
Blue Advantage Security HMO 102 Non-Marketplace
Blue Advantage Security HMO 102 Marketplace
Blue Advantage Security HMO 102 Marketplace Native American
Zero
Blue Advantage Security HMO 102 Marketplace Native American
Limited
Blue Advantage Security HMO 102 Marketplace 73% Actuarial Value
Health InsuranceBlue Advantage Security HMO 102 Marketplace 87%
Actuarial Value Marketplace
Blue Advantage Security HMO 102 Marketplace 94% Actuarial Value
5 Tier Drug List
Blue Advantage Security HMO 103 Non-Marketplace
Blue Advantage Security HMO 103 Marketplace
Blue Advantage Security HMO 103 Marketplace Native American
Zero
Blue Advantage Security HMO 103 Marketplace Native American
Limited
Blue Advantage Security HMO 103 Marketplace 73% Actuarial
Value
Blue Advantage Security HMO 103 Marketplace 87% Actuarial
Value
Blue Advantage Security HMO 103 Marketplace 94% Actuarial
Value
Blue Cross Blue Shield Basic 103, a Multi-State Plan
Marketplace
Blue Cross Blue Shield Basic 103, a Multi-State Plan Marketplace
Native American
Zero Blue Cross Blue Shield Basic 103, a Multi-State Plan
Marketplace Native American
Limited Blue Cross Blue Shield Premier 101, a Multi-State Plan
Marketplace
Blue Cross Blue Shield Premier 101, a Multi-State Plan
Marketplace Native American
Zero Blue Cross Blue Shield Premier 101, a Multi-State Plan
Marketplace Native American
Limited Blue Cross Blue Shield Solution 102, a Multi-State Plan
Marketplace
Blue Cross Blue Shield Solution 102, a Multi-State Plan
Marketplace Native American
Zero
http://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770001-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770001-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770001-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770001-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-06.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-04.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-05.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460242-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460242-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-04.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-05.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-06.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-04.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-05.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-06.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780003-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780003-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780003-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780001-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780001-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780001-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-02.pdf
-
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) III
Plan (Select plan name to view plan Summary of Benefits &
Coverage) Associated Formulary
Blue Cross Blue Shield Solution 102, a Multi-State Plan
Marketplace Native American
Limited Blue Cross Blue Shield Solution 102, a Multi-State Plan
Marketplace 73% Actuarial Health InsuranceValue MarketplaceBlue
Cross Blue Shield Solution 102, a Multi-State Plan Marketplace 87%
Actuarial 5 Tier Drug ListValue Blue Cross Blue Shield Solution
102, a Multi-State Plan Marketplace 94% Actuarial
Value
Drugs by Cost-Sharing Tier: Tier Percentage of DrugsACA 3.8%Tier
1 12.2%Tier 2 28.5%Tier 3 5.8%Tier 4 38.1%Tier 5 11.6%
Formulary Composition: This drug list, (also known as a
formulary) is a closed formulary; a closed formulary isa type of
benefit design in which only medicines included on the drug list
(or formulary) are covered. You may beable to get a medicine that
is not on the drug list. But, you may have to pay 100% of the cost,
unless a formularycoverage exception is submitted and your health
plan approves it.
The formulary or drug list is designed to provide you and your
physician with the most safe, effective drugs at themost reasonable
cost. The drug list is developed by a Pharmacy and Therapeutics
(P&T) committee. The P&Tcommittee is made up of a diverse
group of doctors and pharmacists. When adding or removing drugs
from thedrug list, the P&T committee reviews each drug for its
safety, effectiveness, and uniqueness. Health plans usethe drug
list to provide their members with effective drug therapies at
reasonable costs. For this reason, usingdrugs from a drug list is
important for both you and your health plan. Often, many drugs are
available to treat thesame condition. If two drugs are equivalent
in effectiveness and safety, the drug list will include the lower
cost drug.You are not limited to purchasing only those drugs that
appear on your health plan's drug list. However, you maypay more
out-of-pocket for a drug that is not on the drug list. You may need
to pay the full cost of a drug if it is notcovered by your benefit
plan. Changes in a drug list result from decisions made at P&T
committee meetings. ThePrime P&T committee meets at least
quarterly to consider changes to the drug list. For example, if a
new drug isfound to be more effective than one already on the drug
list, the new drug may replace the less effective drug. Adrug may
also be removed from a drug list for safety reasons. The Food and
Drug Administration (FDA) tracksdrug safety information. The FDA
issues reports about side effects, warnings or contraindications.
Prime monitorsthese reports because they may trigger a change in a
drug list.
Right to Request a Coverage Determination: If a drug is not
covered under the drug list (also known as aformulary) or requires
utilization review prior to coverage, but your physician has
determined that the drug ismedically necessary, you have the right
to request a coverage determination. Your cost share for
non-formularymedicines approved through coverage determination is
based on your benefit plans cost share for the
appropriatenon-preferred generic, non-preferred brand, or specialty
tier.
Right to Appeal: If your request for coverage is denied, but
your physician has determined that the drug ismedically necessary,
you have the right to appeal and request coverage.
Continuation of Coverage: You have the right to continued
coverage for a prescription drug at the coveragelevel or tier at
which the drug was covered at the beginning of the plan year, until
your plan renewal date, providedthat the drug continues to be
medically necessary and safe.
http://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-04.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-05.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-06.pdf
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Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) IV
Off-Label Drug Use: Off-label use of FDA approved drugs occurs
when a drug is prescribed for a reason thathas not been approved by
the FDA. Off-label use may be covered when all of the following
apply:
The medicine has been approved by the FDA for at least one use;
The medicine is prescribed by a physician; The medicine is intended
to treat chronic, disabling, or life-threatening illnesses;
Sufficient clinical evidence is provided by your physician for the
off-label use requested; The services and medicine are medically
necessary.
Off-Label use of FDA approved drugs is not covered when these
conditions are not met or when the determinedits use to be
contraindicated for treatment of the condition for which coverage
is requested. Approved off-labelmedicine cost share is based on the
tier in which the medicine is assigned within the drug list.
Limitations and Exclusions: Pharmacy benefits are not available
for: Drugs required by law to be labeled: Caution - Limited by
Federal Law to Investigational Use, or Experimental drugs, even
though a charge is made for the drugs, or Legend drugs not approved
by the FDA for a particular use or purpose or when used for a
purpose other
than the purpose for which the FDA approval is given, except as
required by law or regulation.
Experimental / Investigational means the use of any treatment,
procedure, facility, equipment, drug, device orsupply not accepted
as Standard Medical Treatment of the condition being treated or any
of such items requiringfederal or other governmental agency
Approval not granted at the time services were provided. Approval
by afederal agency means that the treatment, procedure, facility,
equipment, drug, device or supply has been approvedfor the
condition being treated and, in the case of a drug, in the dosage
used on the patient. Medical treatmentincludes medical, surgical or
dental treatment. Standard Medical Treatment means the services or
supplies thatare in general use in the medical community in the
United States, and:
have been demonstrated in peer-reviewed literature to have
scientifically established medical value forcuring or alleviating
the condition being treated;
are appropriate for the Hospital or Participating Provider; and
the Health Care Professional has had the appropriate training and
experience to provide the treatment or
procedure.
Cost-Sharing: Your deductible is listed on your Summary of
Benefits and Coverage document. Your deductible isthe amount of
money that you and anyone covered by your plan must pay
out-of-pocket each plan year for coveredservices before your plan
starts to pay. A certain set of drugs may be covered without
cost-sharing, even beforemeeting the deductible. The out-of-pocket
cost share for your covered prescriptions applies to your
deductible untilyour deductible is met. Your cost share details are
listed on your Summary of Benefits and Coverage for each ofthe
tiers within this formulary. Your cost share may be a copayment (an
amount you pay out-of-pocket for yourprescription medicines after
youve met any deductible) or coinsurance (a percentage of the total
cost that you payfor your medicines, after you've met any
deductible).
Your drug list (or formulary) has the following tiers:
ACA (Preventive Drugs Not Subject to Deductible) Tier 1
(Preferred Generics) Tier 2 (Non-Preferred Generics) Tier 3
(Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5
(Specialty)
Your cost share for a medicine is based on the tier in which the
medicine is assigned within the drug list. Networkdiscounts are
applied to medicines dispensed at a network pharmacy, but are not
available for medicines
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Texas Residents -- Find and estimate prices for medicines on
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BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) V
dispensed at a non-network pharmacy. You may be able to save
time and money using the pharmacy mail homedelivery option if you
take maintenance medicine for a condition like high blood pressure,
asthma or diabetes, andtake your drugs for long periods of time.
With home delivery pharmacy, you may get up to a three-month supply
ofmedicines delivered to your home and, in some cases, you may pay
a lower cost share.
Medical Management Requirements: Medical or utilization
management is a process that is part of your healthplan.
Utilization management helps to make sure that you are getting the
right drugs -- all while helping to makemedicine more affordable.
Health plans call for utilization management on some medicines to
keep you safe,by helping to make sure the medicines you take are
prescribed by your doctor and used correctly. Health plancompanies,
hospitals, doctors and pharmacists work together and share
information to help improve medicine formembers. These programs
help to catch mistakes, reduce waste, improve safety and keep
medicine affordableby lowering costs. This formulary indicates when
one of these programs applies to a drug. Medical or
utilizationmanagement is made up of programs that include:
Prior Authorization: Prior authorization (sometimes called
pre-approval) means that your medicineneeds to be approved by your
health plan before it will be covered. Prior authorization helps
improvesafety. Some drugs can be misused or overused, or may not be
the best choice for your health condition.
Step Therapy: This program uses a "step" approach with drugs for
certain conditions. This means thatyou may have to first try a
safe, lower-cost drug, or one that may be more clinically
effective, before"stepping up" to a different drug. Step Therapy
helps lower costs through safe, less expensive drugs.
Dispensing Limits: This program controls how often or the amount
you can get filled at once. Theselimits promote safe,
cost-effective drug use. They also help reduce waste and overuse.
Dispensing Limitshelps to lower waste.
Limited Distribution: For some medications, you may need to use
specified pharmacies to fill yourprescription because the drug is
only made available by the manufacturer to very limited pharmacies
orbecause your plan requires use of specified pharmacies for these
medicines. Some of these medicinesmay be specialty medicines that
are filled at a Specialty Pharmacy which specializes in particular
classesof medication and health conditions.
Medicines requiring a health care provider to administer them
and administered in a hospital, doctorsoffice, or other medical
setting are covered by your medical benefits. Information on those
medicationsmay be found here:
http://www.bcbstx.com/pdf/rx/tx-medical-drug-list-2017.pdf .
http://www.bcbstx.com/pdf/rx/tx-medical-drug-list-2017.pdf
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Texas Residents -- Find and estimate prices for medicines on
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BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) VI
Introduction
Members are encouraged to show this list to their physicians and
pharmacists. Physicians are encouragedto prescribe drugs on this
list, when right for the member. However decisions regarding
therapy andtreatment are always between members and their
physician.
Drug lists updates This list is regularly updated as generic
drugs become available and changes take place inthe pharmaceuticals
market. For the most up-to-date information, visit bcbstx.com and
log in toBlue Access for MembersSM or call the number on the back
of your ID card. Physicians can access the list fromthe provider
portal at bcbstx.com.
How drugs are selectedDrugs on this list are selected based on
the recommendations of a committee made up of physicians
andpharmacists from throughout the country. The committee, which
includes at least one representative fromBCBSTX, 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 areconsidered. Drugs are
selected based on safety, efficacy, cost and how they compare to
other drugs currently onthe list.
How member payment is determinedThis list shows prescription
drug products in tiers. Generally, each drug is placed into one of
five member paymenttiers: Preferred Generic (Tier 1), Non-preferred
Generic (Tier 2), Preferred Brand (Tier 3), Non-preferred
Brand(Tier 4) and Specialty (Tier 5). Please refer to the ACA
Preventive (ACA) section for drugs marked with an "A" inthe drug
tier column. To verify your payment amount for a drug, visit
bcbstx.com and log in to Blue Access forMembers or call the number
on the back of your ID card.
Your pharmacy benefit includes coverage for many prescription
drugs, although some exclusions may apply.Generally, if a drug is
not listed on the drug list it is not covered. For example, drugs
indicated for cosmeticpurposes, e.g., Propecia, for hair growth,
may not be covered. Drugs that are not FDA-approved for
self-administration may be available through your medical
benefit.
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Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) VII
How to use this list
Generic drugs are shown in lower-case boldface type. Most
generic drugs are followed by a reference branddrug in
(parentheses). Some generic products have no reference brand.
Example: atorvastatin (Lipitor brand is NF)
Brand prescription drugs are shown in capital letters followed
by the generic name.
Drugs used to treat multiple conditionsSome 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
yourparticular medication in the class/condition section that
corresponds to your use.
Generic drugs
Using generic drugs, when right for you, can help you save on
your out-of-pocket medication costs. Generic drugsmust 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 equivalent 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 costsmuch
less.Preferred brand drugs typically move to a non-preferred brand
tier after a generic equivalent becomes available.You may be
responsible for the brand member payment amount plus the difference
in cost between the brand andgeneric equivalent if you or your
doctor requests the reference brand rather than the generic.
Generic drugs havethe lowest member payment amount.
Consider talking to your doctor about generic drugsIf your
doctor writes a prescription for a brand drug that does not have a
generic equivalent, consider asking if anappropriate generic
alternative is available.You can also let your pharmacist know that
you would like a generic equivalent for a brand drug, wheneverone
is available. Your pharmacist can usually substitute a generic
equivalent for its brand counterpart without aprescription from
your doctor.Only your doctor can determine whether a generic
alternative is right for you and must prescribe the medication.
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Texas Residents -- Find and estimate prices for medicines on
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at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) VIII
Coverage considerations
Most prescription drug benefit plans provide coverage for up to
a 30-day supply of medication, with someexceptions. 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 bloodpressure,
diabetes or high cholesterol.
Over-the-counter exclusions: Your benefit plan does not provide
coverage for prescription medications thathave an over-the-counter
version. You should refer to your benefit plan materials for
details about your particularbenefits.
Compounded medications: Your benefit plan does not provide
coverage for compounded medications. Pleasesee your plan materials
or call the number on the back of your ID card to determine whether
compoundedmedications are covered and/or verify your payment
amount.
Repackaged medications: Repackaged versions of medications
already available on the market are not covered.
Prior Authorization (PA): Your benefit plan may require prior
authorization for certain drugs. This means thatyour doctor will
need to submit a prior authorization request for coverage of these
medications, and the request willneed to be approved, before the
medication will be covered under your plan. For the preferred
medications listed inthis document, if a prior authorization is
commonly required, it will be noted next to the medication with a
dot underthe prior authorization column. Some plans may have prior
authorization on additional medications beyond thosenoted in this
document.
Step Therapy (ST): Your benefit plan may include a step therapy
program. This means you may need to tryanother 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
thepreferred medications listed in this document, if a step therapy
is commonly required it will generally be notednext to the
medication with a dot under the step therapy column. Some plans may
have step therapy programs onadditional medications beyond those
noted in this document.
Dispensing Limits (DL): Drug Dispensing limits are designed to
help encourage medication use as intended bythe FDA. Coverage
limits are placed on medications in certain drug categories. For
the preferred medications listedin this document, if a dispensing
limit applies, it will generally be noted next to the medication
with a dot underthe dispensing limits column. Limits may include:
quantity of covered medication per prescription and quantity
ofcovered medication in a given time period. If your doctor
prescribes a greater quantity of medication than whatthe dispensing
limit allows, you can still get the medication. However, you will
be responsible for the full cost ofthe prescription beyond what
your coverage allows.* For a list of medications and their
dispensing limits, visit bcbstx.com.
*Please note: For certain controlled substance medications, some
state laws may not allow coverage by a healthbenefit plan of such
medication if dispensed in a quantity beyond what the dispensing
limit allows. You will beresponsible for the full cost of the
prescription with no benefits applied if the dispensed quantity
exceeds thedispensing limit.
Limited Distribution (LD): Medicines marked as "Limited
Distribution" have restrictions on where you may obtaina
medication. This may include requiring the use of a designated
pharmacy to fill a prescription.
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Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) IX
ACA Preventive (ACA): Medicines marked in the ACA column are
under the Affordable Care Act coverage ofpreventive services. These
products have limited or $0 member cost-sharing (copay or
co-insurance), whenmeeting the conditions as outlined under the
regulation. These are also indicated with an "A" in the drug
tiercolumn. Examples of these drug categories include aspirin,
breast cancer preventive, fluoride supplements, folicacid
supplements, gonorrhea prophylaxis (newborn), iron supplements,
tobacco cessation, vaccines, vitaminD supplements, and some FDA
approved contraceptive methods. To see what contraceptive products
may becovered, visit
www.bcbstx.com/pdf/rx/contraceptive-list-tx.pdf
Remember, medication decisions are between you and your doctor.
Only you and your doctor can determinewhich medication is right for
you. Discuss any questions or concerns you have about medications
you are taking orare prescribed with your doctor. BCBSTX does not
provide health care services and, therefore, cannot guaranteeany
results or outcomes.
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Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) X
Specialty drugs
Specialty drugs are used in the treatment of medical conditions
such as hepatitis, hemophilia, multiple sclerosisand rheumatoid
arthritis. Specialty drugs may be oral, topical, or injectable
medications that can either be self-administered or administered by
a health care professional. For a current list of specialty
medications, visit myprime.com or bcbstx.com and log in to Blue
Access for Members.
Note that some drug classes may be excluded by some plans and
therefore may not be covered under yourpharmacy benefit. Your plan
may have a different coverage level for self-administered specialty
drugs. If you havequestions about your coverage for specialty
medications or your prescription drug benefit, call the number on
theback of your ID card.
Prime Specialty by AllianceRx Walgreens Prime
Through Prime Specialty by AllianceRx Walgreens Prime, members
can have covered specialty medicationsdelivered directly to them or
their doctors office. When you receive specialty medications
through Prime Specialtyby AllianceRx Walgreens Prime, you also
receive at no additional charge the following services:
Coordination of coverage between you, your doctor and your
health plan Educational materials about your particular condition
and information about managing potential
medication side effects Syringes, sharps containers and other
supplies with every shipment for self-injectables 24/7/365 phone
access to a pharmacist for urgent medication issues
To order through Prime Specialty by AllianceRx Walgreens
Prime:
Have your doctor call or fax your prescription to Prime
Specialty by AllianceRx Walgreens Prime.Your doctor can call
877-627-6337 or fax to 877-828-3939.
If you have an existing prescription for a covered specialty
medication, you can call 877-627-6337 totransfer your
prescription.
A coordinator will contact you to arrange delivery of your
medication. The prescription can be shipped directly to you or your
prescribing doctors office. Each package is
individually marked for each member. Refrigerated drugs are
shipped in temperature-controlledpackaging.
If you have questions, please contact Prime Specialty by
AllianceRx Walgreens Prime at 877-627-6337,visit
www.alliancerxwp.com, or call the number on the back of your ID
card.
Blue Cross and Blue Shield of Texas, a Division of Health Care
Service Corporation, a Mutual Legal Reserve Company (HCSC).HCSC is
an independent licensee of the Blue Cross Blue Shield Association.
HCSC contracts with Prime Therapeutics to providepharmacy benefit
management and mail order pharmacy services and to administer this
specialty pharmacy program. HCSC, aswell as several other
independent Blue Cross and Blue Shield licensees, has an ownership
interest in Prime Therapeutics LLC.
-
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) XI
Abbreviation key cap
...................................................... capsules odt
.................................. orally disintegrating tabschew
................................................... chewable oint
...................................................... ointmentconc
................................................ concentrate ophth
.................................................. opthalmiccr
............................................ controlled release osm
........................................... osmotic releasedr
.............................................. delayed release powd
..................................................... powderec
................................................ enteric coated sa
.............................................. sustained actioneffe
................................................. effervescent sl
.......................................................
sublinqualequiv .................................................
equivalent soln
...................................................... solutioner
............................................. extended release sr
............................................ sustained releaseinhal
................................................... inhalation
suppos .......................................... suppositoriesinj
........................................................ injection
susp .................................................
suspensionliq
............................................................ liquid
tab .........................................................
tabletslotn
.......................................................... lotion
td ....................................................
transdermalnebu ...................................................
nebulizer
You, or your prescribing health care provider, can ask for a
Drug List exception if your drug is not on the Drug List(also known
as a formulary). To request this exception, you, or your
prescriber, can call the number on the backof your ID card to ask
for a review. If you have a health condition that may jeopardize
your life, health or keep youfrom regaining function, or your
current drug therapy uses a non-covered drug, you, or your
prescriber, may beable to ask for an expedited review process.
BCBSTX will let you, and your prescriber, know the coverage
decisionwithin 24 hours after they receive your request for an
expedited review. If the coverage request is denied, BCBSTXwill let
you and your prescriber know why it was denied and offer you a
covered alternative drug (if applicable). Callthe number on the
back of your ID card if you have any questions.
-
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) XII
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with
a disability or who needs language assistance.We do not
discriminate on the basis of race, color, national origin, sex,
gender identity, age or disability.
To receive language or communication assistance free of charge,
please call us at 855-710-6984. If you believe we have failed to
provide a service, or think we have discriminated in another way,
contact us to file agrievance.
Office of Civil Rights Coordinator Phone: 855-664-7270
(voicemail).300 E. Randolph St. TTY/TDD: 855-661-696535th Floor
Fax: 855-661-6960Chicago, Illinois 60601 Email:
[email protected]
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: 800-368-1019200
Independence Avenue SW TTY/TDD: 800-537-7697Room 509F, HHH Building
1019 Complaint Portal:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsfWashington, DC 20201
Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
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Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) XIII
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 1
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
ANTI-INFECTIVE AGENTSPENICILLINSAMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg4
AMOXICILLIN - amoxicillin(trihydrate) chew tab 250 mg
4
amoxicillin (trihydrate) cap250 mg
1
amoxicillin (trihydrate) cap500 mg
1
amoxicillin (trihydrate) forsusp 125 mg/5ml
1
amoxicillin (trihydrate) forsusp 200 mg/5ml
1
amoxicillin (trihydrate) forsusp 250 mg/5ml
1
amoxicillin (trihydrate) forsusp 400 mg/5ml
1
amoxicillin (trihydrate) tab500 mg
1
amoxicillin (trihydrate) tab875 mg
1
amoxicillin & k clavulanatefor susp 200-28.5 mg/5ml
2
amoxicillin & k clavulanatefor susp 250-62.5
mg/5ml(Augmentin)
2
amoxicillin & k clavulanatefor susp 400-57 mg/5ml
2
amoxicillin & k clavulanatefor susp 600-42.9
mg/5ml(Augmentin es-600)
2
amoxicillin & k clavulanatetab er 12hr 1000-62.5
mg(Augmentin xr)
2
amoxicillin & k clavulanatetab 250-125 mg
2
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
amoxicillin & k clavulanatetab 500-125 mg(Augmentin)
2
amoxicillin & k clavulanatetab 875-125 mg(Augmentin)
2
AMOXICILLIN/CLAVULANATEP - amoxicillin & kclavulanate chew
tab200-28.5 mg
4
AMOXICILLIN/CLAVULANATEP - amoxicillin & kclavulanate chew
tab 400-57mg
4
AMPICILLIN - ampicillin cap500 mg
1
AUGMENTIN - amoxicillin& k clavulanate for susp125-31.25
mg/5ml
4
dicloxacillin sodium cap250 mg
1
dicloxacillin sodium cap500 mg
2
MOXATAG - amoxicillin(trihydrate) tab er 24hr 775mg
4
PENICILLIN V POTASSIUM -penicillin v potassium forsoln 125
mg/5ml
1
PENICILLIN V POTASSIUM -penicillin v potassium forsoln 250
mg/5ml
1
penicillin v potassium tab250 mg
1
penicillin v potassium tab500 mg
1
CEPHALOSPORINScefaclor cap 250 mg 2
cefaclor cap 500 mg 2
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 2
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
CEFACLOR ER - cefaclormonohydrate tab er 12hr500 mg
4
cefadroxil cap 500 mg 1
cefadroxil for susp250 mg/5ml
2
cefadroxil for susp500 mg/5ml
2
cefadroxil tab 1 gm 2
cefdinir cap 300 mg 2
cefdinir for susp 125 mg/5ml 2
cefdinir for susp 250 mg/5ml 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg(base
equivalent)
4
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg(base
equivalent)
4
cefixime for susp100 mg/5ml (Suprax)
2
cefixime for susp200 mg/5ml (Suprax)
2
cefpodoxime proxetil forsusp 50 mg/5ml
2
cefpodoxime proxetil forsusp 100 mg/5ml
2
cefpodoxime proxetil tab100 mg
2
cefpodoxime proxetil tab200 mg
2
cefprozil for susp125 mg/5ml
2
cefprozil for susp250 mg/5ml
2
cefprozil tab 250 mg 2
cefprozil tab 500 mg 2
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
CEFTIN - cefuroxime axetil forsusp 125 mg/5ml
3
CEFTIN - cefuroxime axetil forsusp 250 mg/5ml
4
cefuroxime axetil tab 250 mg(Ceftin)
2
cefuroxime axetil tab 500 mg(Ceftin)
2
CEPHALEXIN - cephalexin tab250 mg
4
CEPHALEXIN - cephalexin tab500 mg
4
cephalexin cap 250 mg(Keflex)
1
cephalexin cap 500 mg(Keflex)
1
cephalexin cap 750 mg(Keflex)
2
cephalexin for susp125 mg/5ml
2
cephalexin for susp250 mg/5ml
2
SPECTRACEF - cefditorenpivoxil tab 400 mg (baseequivalent)
4
SUPRAX - cefixime cap 400mg
4
SUPRAX - cefixime chew tab100 mg
4
SUPRAX - cefixime chew tab200 mg
4
SUPRAX - cefixime for susp100 mg/5ml
4
SUPRAX - cefixime for susp200 mg/5ml
4
SUPRAX - cefixime for susp500 mg/5ml
4
MACROLIDES
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Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 3
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
AZITHROMYCIN -azithromycin powd pack forsusp 1 gm
4
azithromycin for susp100 mg/5ml (Zithromax)
2
azithromycin for susp200 mg/5ml (Zithromax)
2
azithromycin tab 250 mg(Zithromax)
1
azithromycin tab 500 mg(Zithromax)
1
azithromycin tab 600 mg(Zithromax)
2
CLARITHROMYCIN -clarithromycin for susp 125mg/5ml
2
CLARITHROMYCIN -clarithromycin for susp 250mg/5ml
2
clarithromycin tab er 24hr500 mg
2
clarithromycin tab 250 mg(Biaxin)
2
clarithromycin tab 500 mg(Biaxin)
2
DIFICID - fidaxomicin tab 200mg
4
E.E.S. GRANULES -erythromycin ethylsuccinatefor susp 200
mg/5ml
4
E.E.S. 400 - erythromycinethylsuccinate tab 400 mg
4
ERY-TAB - erythromycin tabdelayed release 250 mg
4
ERY-TAB - erythromycin tabdelayed release 333 mg
4
ERY-TAB - erythromycin tabdelayed release 500 mg
4
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
ERYPED 200 - erythromycinethylsuccinate for susp 200mg/5ml
4
ERYPED 400 - erythromycinethylsuccinate for susp 400mg/5ml
4
ERYTHROCIN STEARATE -erythromycin stearate tab250 mg
4
ERYTHROMYCINETHYLSUCCINA -erythromycin ethylsuccinatetab 400
mg
4
erythromycin ethylsuccinatefor susp 200 mg/5ml
(E.e.s.granules)
2
erythromycin tab 250 mg 2
erythromycin tab 500 mg 2
erythromycin w/ delayedrelease particles cap250 mg
2
PCE - erythromycin w/ entericcoated particles tab 333 mg
4
PCE - erythromycin w/ entericcoated particles tab 500 mg
4
ZITHROMAX - azithromycinpowd pack for susp 1 gm
4
ZMAX - azithromycin extendedrelease for oral susp 2 gm
4
TETRACYCLINESdemeclocycline hcl tab
150 mg2
demeclocycline hcl tab300 mg
2
doxycycline hyclate cap50 mg
2
doxycycline hyclate cap100 mg (Vibramycin)
2
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 4
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
doxycycline hyclate tab20 mg
2
doxycycline hyclate tab100 mg
2
doxycycline monohydratecap 50 mg
2
doxycycline monohydratecap 75 mg (Monodox)
2
doxycycline monohydratecap 100 mg (Monodox)
2
doxycycline monohydratecap 150 mg (Adoxa)
2
doxycycline monohydratefor susp 25 mg/5ml(Vibramycin)
2
doxycycline monohydratetab 50 mg (Adoxa)
2
doxycycline monohydratetab 75 mg (Adoxa)
2
doxycycline monohydratetab 100 mg (Adoxa pak1/100)
2
doxycycline monohydratetab 150 mg (Adoxa pak1/150)
2
minocycline hcl cap 50 mg(Minocin)
2
minocycline hcl cap 75 mg(Minocin)
2
minocycline hcl cap 100 mg(Minocin)
2
minocycline hcl tab er 24hr45 mg
2
minocycline hcl tab er 24hr90 mg
2
minocycline hcl tab er 24hr135 mg
2
minocycline hcl tab 50 mg 2
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
minocycline hcl tab 75 mg 2
minocycline hcl tab 100 mg 2
TETRACYCLINE HCL -tetracycline hcl cap 250 mg
4
TETRACYCLINE HCL -tetracycline hcl cap 500 mg
4
tetracycline hcl cap 250 mg(Tetracycline hcl)
2
tetracycline hcl cap 500 mg(Tetracycline hcl)
2
FLUOROQUINOLONESBAXDELA - delafloxacin
meglumine tab 450 mg(base equiv)
4
ciprofloxacin for oralsusp 500 mg/5ml (10%)(10 gm/100ml)
(Cipro)
2
CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg(base equiv)
4
ciprofloxacin hcl tab 250 mg(base equiv) (Cipro)
1
ciprofloxacin hcl tab 500 mg(base equiv) (Cipro)
1
ciprofloxacin hcl tab 750 mg(base equiv)
1
ciprofloxacin-ciprofloxacinhcl tab er 24hr 500 mg(base eq)
(Cipro xr)
2
ciprofloxacin-ciprofloxacinhcl tab er 24hr1000 mg(base eq)
(Cipro xr)
2
LEVOFLOXACIN - levofloxacinoral soln 25 mg/ml
2
levofloxacin tab 250 mg(Levaquin)
1
levofloxacin tab 500 mg(Levaquin)
1
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 5
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
levofloxacin tab 750 mg(Levaquin)
1
moxifloxacin hcl tab 400 mg(base equiv) (Avelox)
2
OFLOXACIN - ofloxacin tab300 mg
4
ofloxacin tab 400 mg 2
AMINOGLYCOSIDESBETHKIS - tobramycin nebu
soln 300 mg/4ml5
KITABIS PAK - tobramycinnebu soln 300 mg/5ml
5
neomycin sulfate tab 500 mg 1
paromomycin sulfate cap250 mg
2
TOBI PODHALER - tobramycininhal cap 28 mg
5
TOBRAMYCIN - tobramycinnebu soln 300 mg/5ml
5
tobramycin nebu soln300 mg/5ml (Tobi)
5
SULFONAMIDESSULFADIAZINE - sulfadiazine
tab 500 mg3
ANTIMYCOBACTERIAL AGENTSCYCLOSERINE - cycloserine
cap 250 mg4
ethambutol hcl tab 100 mg(Myambutol)
2
ethambutol hcl tab 400 mg(Myambutol)
2
ISONIAZID - isoniazid syrup 50mg/5ml
4
isoniazid tab 100 mg 1
isoniazid tab 300 mg 1
PASER - aminosalicylic acid ergranules packet 4 gm
4
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
PRIFTIN - rifapentine tab 150mg
3
pyrazinamide tab 500 mg 2
rifabutin cap 150 mg(Mycobutin)
2
RIFAMATE - isoniazid &rifampin cap 150-300 mg
4
rifampin cap 150 mg (Rifadin) 2
rifampin cap 300 mg (Rifadin) 2
RIFATER - isoniazid-rifampinw/ pyrazinamide tab50-120-300 mg
4
SIRTURO - bedaquilinefumarate tab 100 mg (baseequiv)
4
TRECATOR - ethionamide tab250 mg
4
ANTIFUNGALSCRESEMBA -
isavuconazonium sulfate cap186 mg
4
fluconazole for susp 10 mg/ml (Diflucan)
2
fluconazole for susp 40 mg/ml (Diflucan)
2
fluconazole tab 50 mg(Diflucan)
1
fluconazole tab 100 mg(Diflucan)
1
fluconazole tab 150 mg(Diflucan)
1
fluconazole tab 200 mg(Diflucan)
2
flucytosine cap 250 mg(Ancobon)
2
flucytosine cap 500 mg(Ancobon)
2
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 6
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
griseofulvin microsize susp125 mg/5ml
2
griseofulvin microsize tab500 mg (Grifulvin v)
2
griseofulvin ultramicrosizetab 125 mg (Gris-peg)
2
griseofulvin ultramicrosizetab 250 mg (Gris-peg)
2
itraconazole cap 100 mg(Sporanox)
2
NOXAFIL - posaconazole susp40 mg/ml
3
NOXAFIL - posaconazole tabdelayed release 100 mg
3
nystatin tab 500000 unit 2
SPORANOX - itraconazole oralsoln 10 mg/ml
4
terbinafine hcl tab 250 mg(Lamisil)
1
voriconazole for susp40 mg/ml (Vfend)
2
voriconazole tab 50 mg(Vfend)
2
voriconazole tab 200 mg(Vfend)
2
ANTIVIRALSabacavir sulfate soln 20 mg/
ml (base equiv) (Ziagen)2
abacavir sulfate tab 300 mg(base equiv) (Ziagen)
2
abacavir sulfate-lamivudinetab 600-300 mg (Epzicom)
2
abacavir sulfate-lamivudine-zidovudine tab300-150-300 mg
(Trizivir)
2
acyclovir cap 200 mg(Zovirax)
1
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
acyclovir susp 200 mg/5ml(Zovirax)
2
acyclovir tab 400 mg(Zovirax)
1
acyclovir tab 800 mg(Zovirax)
1
adefovir dipivoxil tab 10 mg(Hepsera)
2
APTIVUS - tipranavir cap 250mg
4
APTIVUS - tipranavir oral soln100 mg/ml
4
atazanavir sulfate cap150 mg (base equiv)(Reyataz)
2
atazanavir sulfate cap200 mg (base equiv)(Reyataz)
2
atazanavir sulfate cap300 mg (base equiv)(Reyataz)
2
ATRIPLA - efavirenz-emtricitabine-tenofovir df tab600-200-300
mg
3
BARACLUDE - entecavir oralsoln 0.05 mg/ml
3
COMPLERA - emtricitabine-rilpivirine-tenofovir df tab200-25-300
mg
4
CRIXIVAN - indinavir sulfatecap 200 mg
4
CRIXIVAN - indinavir sulfatecap 400 mg
4
DESCOVY - emtricitabine-tenofovir alafenamidefumarate tab 200-25
mg
3
didanosine delayed releasecapsule 200 mg (Videx ec)
2
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 7
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
didanosine delayed releasecapsule 250 mg (Videx ec)
2
didanosine delayed releasecapsule 400 mg (Videx ec)
2
EDURANT - rilpivirine hcl tab25 mg (base equivalent)
4
efavirenz cap 50 mg (Sustiva) 2 efavirenz cap 200 mg
(Sustiva)2
efavirenz tab 600 mg(Sustiva)
2
EMTRIVA - emtricitabine caps200 mg
4
EMTRIVA - emtricitabine soln10 mg/ml
4
entecavir tab 0.5 mg(Baraclude)
2
entecavir tab 1 mg(Baraclude)
2
EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg
5
EPIVIR HBV - lamivudine oralsoln 5 mg/ml (hbv)
4
EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg
3
EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg(base
equiv)
4
famciclovir tab 125 mg(Famvir)
2
famciclovir tab 250 mg(Famvir)
2
famciclovir tab 500 mg(Famvir)
2
fosamprenavir calciumtab 700 mg (base equiv)(Lexiva)
2
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
FUZEON - enfuvirtide for inj 90mg
5
GENVOYA - elvitegrav-cobic-emtricitab-tenofov af
tab150-150-200-10 mg
3
HARVONI - ledipasvir-sofosbuvir tab 90-400 mg
5
INTELENCE - etravirine tab 25mg
3
INTELENCE - etravirine tab100 mg
3
INTELENCE - etravirine tab200 mg
3
INVIRASE - saquinavirmesylate cap 200 mg
4
INVIRASE - saquinavirmesylate tab 500 mg
4
ISENTRESS - raltegravirpotassium chew tab 25 mg(base equiv)
3
ISENTRESS - raltegravirpotassium chew tab 100 mg(base equiv)
3
ISENTRESS - raltegravirpotassium packet for susp100 mg (base
equiv)
3
ISENTRESS - raltegravirpotassium tab 400 mg (baseequiv)
3
ISENTRESS HD - raltegravirpotassium tab 600 mg (baseequiv)
3
JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg(base
eq)
4
KALETRA - lopinavir-ritonavirsoln 400-100 mg/5ml
(80-20mg/ml)
3
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 8
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
KALETRA - lopinavir-ritonavirtab 100-25 mg
3
KALETRA - lopinavir-ritonavirtab 200-50 mg
3
lamivudine oral soln 10 mg/ml (Epivir)
2
lamivudine tab 100 mg (hbv)(Epivir hbv)
2
lamivudine tab 150 mg(Epivir)
2
lamivudine tab 300 mg(Epivir)
2
lamivudine-zidovudine tab150-300 mg (Combivir)
2
LEXIVA - fosamprenavircalcium susp 50 mg/ml(base equiv)
4
LEXIVA - fosamprenavircalcium tab 700 mg (baseequiv)
4
lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml)
(Kaletra)
2
MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg
5
MODERIBA - ribavirin tab 200mg & ribavirin 400 mg tabtherapy
pack
5
MODERIBA - ribavirin tab 400mg & ribavirin 600 mg tabtherapy
pack
5
MODERIBA 1200 DOSEPACK - ribavirin tab 600 mg
5
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg
5
nevirapine tab er 24hr100 mg (Viramune xr)
2
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
nevirapine tab er 24hr400 mg (Viramune xr)
2
nevirapine tab 200 mg(Viramune)
1
NORVIR - ritonavir cap 100 mg 4 NORVIR - ritonavir oral soln
80
mg/ml3
NORVIR - ritonavir tab 100 mg 3 ODEFSEY - emtricitabine-
rilpivirine-tenofovir af tab200-25-25 mg
3
OLYSIO - simeprevir sodiumcap 150 mg (baseequivalent)
5
oseltamivir phosphatecap 30 mg (base equiv)(Tamiflu)
2
oseltamivir phosphatecap 45 mg (base equiv)(Tamiflu)
2
oseltamivir phosphatecap 75 mg (base equiv)(Tamiflu)
2
oseltamivir phosphate forsusp 6 mg/ml (base equiv)(Tamiflu)
2
PEGASYS - peginterferonalfa-2a inj 180 mcg/ml
5
PEGASYS - peginterferonalfa-2a inj 180 mcg/0.5ml
5
PEGASYS PROCLICK -peginterferon alfa-2a inj 135mcg/0.5ml
5
PEGASYS PROCLICK -peginterferon alfa-2a inj 180mcg/0.5ml
5
PEGINTRON - peginterferonalfa-2b for inj kit 50mcg/0.5ml
5
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 9
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
PREVYMIS - letermovir tab240 mg
4
PREVYMIS - letermovir tab480 mg
4
PREZCOBIX - darunavir-cobicistat tab 800-150 mg
4
PREZISTA - darunavirethanolate susp 100 mg/ml(base equiv)
3
PREZISTA - darunavirethanolate tab 75 mg (baseequiv)
3
PREZISTA - darunavirethanolate tab 150 mg (baseequiv)
3
PREZISTA - darunavirethanolate tab 600 mg (baseequiv)
3
PREZISTA - darunavirethanolate tab 800 mg (baseequiv)
3
REBETOL - ribavirin soln 40mg/ml
5
RELENZA DISKHALER -zanamivir aero powderbreath activated 5
mg/blister
4
RESCRIPTOR - delavirdinemesylate tab 100 mg
4
RESCRIPTOR - delavirdinemesylate tab 200 mg
4
REYATAZ - atazanavir sulfatecap 150 mg (base equiv)
3
REYATAZ - atazanavir sulfatecap 200 mg (base equiv)
3
REYATAZ - atazanavir sulfatecap 300 mg (base equiv)
3
REYATAZ - atazanavir sulfateoral powder packet 50 mg(base
equiv)
4
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
RIBASPHERE - ribavirin tab400 mg
5
RIBASPHERE - ribavirin tab600 mg
5
RIBASPHERE RIBAPAK -ribavirin tab 200 mg &ribavirin 400 mg
tab therapypack
5
RIBASPHERE RIBAPAK -ribavirin tab 400 mg &ribavirin 600 mg
tab therapypack
5
RIBASPHERE RIBAPAK -ribavirin tab 400 mg
5
RIBASPHERE RIBAPAK -ribavirin tab 600 mg
5
ribavirin cap 200 mg(Rebetol)
5
ribavirin for inhal soln 6 gm(Virazole)
2
ribavirin tab 200 mg(Copegus)
5
rimantadine hydrochloridetab 100 mg (Flumadine)
2
ritonavir tab 100 mg (Norvir) 2 SELZENTRY - maraviroc oral
soln 20 mg/ml4
SELZENTRY - maraviroc tab25 mg
4
SELZENTRY - maraviroc tab75 mg
4
SELZENTRY - maraviroc tab150 mg
4
SELZENTRY - maraviroc tab300 mg
4
SOVALDI - sofosbuvir tab 400mg
5
stavudine cap 15 mg (Zerit) 2
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 10
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
stavudine cap 20 mg (Zerit) 2 stavudine cap 30 mg (Zerit) 2
stavudine cap 40 mg (Zerit) 2 STRIBILD - elvitegrav-cobic-
emtricitab-tenofovdf tab150-150-200-300 mg
3
SUSTIVA - efavirenz cap 50mg
3
SUSTIVA - efavirenz cap 200mg
3
SUSTIVA - efavirenz tab 600mg
3
TAMIFLU - oseltamivirphosphate cap 30 mg (baseequiv)
4
TAMIFLU - oseltamivirphosphate cap 45 mg (baseequiv)
4
TAMIFLU - oseltamivirphosphate cap 75 mg (baseequiv)
4
TAMIFLU - oseltamivirphosphate for susp 6 mg/ml(base equiv)
4
TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab12.5-75-50
mg
5
tenofovir disoproxilfumarate tab 300 mg(Viread)
2
TIVICAY - dolutegravir sodiumtab 10 mg (base equiv)
3
TIVICAY - dolutegravir sodiumtab 25 mg (base equiv)
3
TIVICAY - dolutegravir sodiumtab 50 mg (base equiv)
3
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
TRIUMEQ - abacavir-dolutegravir-lamivudine tab600-50-300 mg
4
TRUVADA - emtricitabine-tenofovir disoproxil fumaratetab 100-150
mg
3
TRUVADA - emtricitabine-tenofovir disoproxil fumaratetab 133-200
mg
3
TRUVADA - emtricitabine-tenofovir disoproxil fumaratetab 167-250
mg
3
TRUVADA - emtricitabine-tenofovir disoproxil fumaratetab 200-300
mg
3
TYBOST - cobicistat tab 150mg
4
valacyclovir hcl tab 500 mg(Valtrex)
2
valacyclovir hcl tab 1 gm(Valtrex)
2
VALCYTE - valganciclovir hclfor soln 50 mg/ml (baseequiv)
3
valganciclovir hcl for soln50 mg/ml (base equiv)(Valcyte)
2
valganciclovir hcl tab450 mg (base equivalent)(Valcyte)
2
VIDEX - didanosine for soln 2gm
3
VIDEX - didanosine for soln 4gm
3
VIEKIRA PAK - ombitas-paritapre-riton & dasab tabpak
12.5-75-50 & 250 mg
5
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 11
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
VIEKIRA XR - dasab-ombit-paritap-riton tab er
24hr200-8.33-50-33.33 mg
5
VIRACEPT - nelfinavirmesylate tab 250 mg
4
VIRACEPT - nelfinavirmesylate tab 625 mg
4
VIRAMUNE - nevirapine susp50 mg/5ml
3
VIRAZOLE - ribavirin for inhalsoln 6 gm
4
VIREAD - tenofovir disoproxilfumarate oral powder 40 mg/gm
3
VIREAD - tenofovir disoproxilfumarate tab 150 mg
3
VIREAD - tenofovir disoproxilfumarate tab 200 mg
3
VIREAD - tenofovir disoproxilfumarate tab 250 mg
3
VIREAD - tenofovir disoproxilfumarate tab 300 mg
3
VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab400-100-100
mg
5
ZEPATIER - elbasvir-grazoprevir tab 50-100 mg
5
ZERIT - stavudine for oral soln1 mg/ml
4
ZIAGEN - abacavir sulfate soln20 mg/ml (base equiv)
3
zidovudine cap 100 mg(Retrovir)
2
zidovudine syrup 10 mg/ml(Retrovir)
2
zidovudine tab 300 mg 2 ANTIMALARIALS
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
atovaquone-proguanil hcltab 62.5-25 mg (Malarone)
2
atovaquone-proguanil hcltab 250-100 mg (Malarone)
2
CHLOROQUINEPHOSPHATE - chloroquinephosphate tab 250 mg
1
chloroquine phosphate tab500 mg (Aralen)
1
COARTEM - artemether-lumefantrine tab 20-120 mg
4
DARAPRIM - pyrimethaminetab 25 mg
3
hydroxychloroquine sulfatetab 200 mg (Plaquenil)
2
MEFLOQUINE HCL -mefloquine hcl tab 250 mg
2
PRIMAQUINE PHOSPHATE -primaquine phosphate tab26.3 mg (15 mg
base)
3
quinine sulfate cap 324 mg(Qualaquin)
2
ANTHELMINTICSALBENZA - albendazole tab
200 mg3
BENZNIDAZOLE -benznidazole tab 12.5 mg
3
BENZNIDAZOLE -benznidazole tab 100 mg
3
BILTRICIDE - praziquantel tab600 mg
3
EMVERM - mebendazole chewtab 100 mg
4
ivermectin tab 3 mg(Stromectol)
2
ANTI-INFECTIVE AGENTS - MISC.ALINIA - nitazoxanide for susp
100 mg/5ml4
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 12
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
ALINIA - nitazoxanide tab 500mg
4
atovaquone susp750 mg/5ml (Mepron)
2
CAYSTON - aztreonam lysinefor inhal soln 75 mg
(baseequivalent)
5
clindamycin hcl cap 75 mg(Cleocin)
1
clindamycin hcl cap 150 mg(Cleocin)
1
clindamycin hcl cap 300 mg(Cleocin)
1
clindamycin palmitate hclfor soln 75 mg/5ml (baseequiv) (Cleocin
pediatric gr)
2
dapsone tab 25 mg 2
dapsone tab 100 mg 2
IMPAVIDO - miltefosine cap 50mg
3
linezolid for susp100 mg/5ml (Zyvox)
2
linezolid tab 600 mg (Zyvox) 2 metronidazole cap 375 mg
(Flagyl)2
metronidazole tab 250 mg(Flagyl)
1
metronidazole tab 500 mg(Flagyl)
1
NEBUPENT - pentamidineisethionate for nebulizationsoln 300
mg
4
PRIMSOL - trimethoprim hcloral soln 50 mg/5ml (baseequiv)
4
SIVEXTRO - tedizolidphosphate tab 200 mg
4
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
sulfamethoxazole-trimethoprim susp200-40 mg/5ml
2
sulfamethoxazole-trimethoprim tab400-80 mg (Bactrim)
1
sulfamethoxazole-trimethoprim tab800-160 mg (Bactrim ds)
1
tinidazole tab 250 mg(Tindamax)
2
tinidazole tab 500 mg(Tindamax)
2
trimethoprim tab 100 mg 1
vancomycin hcl cap 125 mg(Vancocin hcl)
2
vancomycin hcl cap 250 mg(Vancocin hcl)
2
XIFAXAN - rifaximin tab 200mg
4
XIFAXAN - rifaximin tab 550mg
3
BIOLOGICALSVACCINESAFLURIA PF 2017-2018 -
influenza virus vaccine splitpf susp pref syringe 0.5 ml
A
AFLURIA QUADRIVALENT2017 - influenza virus vacsplit quadrivalent
susp prefsyr 0.5ml
A
AFLURIA QUADRIVALENT2017 - influenza virusvaccine split
quadrivalent iminj
A
AFLURIA 2017-2018 -influenza virus vaccine splitim susp
A
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 13
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
ENGERIX-B - hepatitis bvaccine (recombinant) susp10
mcg/0.5ml
A
ENGERIX-B - hepatitis bvaccine (recombinant) susp20 mcg/ml
A
ENGERIX-B - hepatitis bvaccine (recombinant) 10mcg/0.5ml
A
ENGERIX-B - hepatitis bvaccine (recombinant) 20mcg/ml
A
FLUAD 2017-2018 - influenzavac type a&b surface ant adjsusp
pref syr 0.5 ml
A
FLUARIX QUADRIVALENT2017 - influenza virus vacsplit quadrivalent
susp prefsyr 0.5ml
A
FLUBLOK QUADRIVALENT2017 - influenza vac recombha quad pf soln
pref syr 0.5ml
A
FLUBLOK 2015-2016 -influenza virus vacrecombinant
hemagglutinin(ha) pf inj
A
FLUBLOK 2017-2018 -influenza virus vacrecombinant
hemagglutinin(ha) pf inj
A
FLUCELVAX QUADRIVALENT20 - influenza vac tiss-cultsubunt quad
susp pref syr0.5 ml
A
FLUCELVAX QUADRIVALENT20 - influenza vac tissue-cultured subunit
quadrivalentim susp
A
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
FLULAVAL QUADRIVALENT201 - influenza virus vac splitquadrivalent
susp pref syr0.5ml
A
FLULAVAL QUADRIVALENT201 - influenza virus vaccinesplit
quadrivalent im inj
A
FLUMIST QUADRIVALENT -influenza virus vaccine livequadrivalent
intranasal susp
A
FLUVIRIN 2015-2016 -influenza vac type a&bsurface antigen
susp pref syr0.5 ml
A
FLUVIRIN 2015-2016 -influenza virus vaccine typesa & b
surface antigen imsusp
A
FLUVIRIN 2017-2018 -influenza vac type a&bsurface antigen
susp pref syr0.5 ml
A
FLUVIRIN 2017-2018 -influenza virus vaccine typesa & b
surface antigen imsusp
A
FLUZONE HIGH-DOSE PF2017 - influenza virus vacsplit high-dose pf
susp prefsyr 0.5ml
A
FLUZONE INTRADERMALQUADR - influenza virus vacsplit quad
intradermal pen 9mcg/strain
A
FLUZONE QUADRIVALENT2017 - influenza virus vacsplit quadrivalent
susp prefsyr 0.25 ml
A
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 14
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
FLUZONE QUADRIVALENT2017 - influenza virus vacsplit quadrivalent
susp prefsyr 0.5ml
A
FLUZONE QUADRIVALENT2017 - influenza virusvaccine split
quadrivalent iminj
A
FLUZONE QUADRIVALENT2017 - influenza virusvaccine split
quadrivalent inj0.5 ml
A
IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc inj
A
PNEUMOVAX 23 -pneumococcal vaccinepolyvalent inj 25
mcg/0.5ml
A
PNEUMOVAX 23/1 DOSE -pneumococcal vaccinepolyvalent inj 25
mcg/0.5ml
A
PREVNAR 13 - Pneumococcal13-valent conjugate vaccineinj
A
RABAVERT - rabies vaccine,pcec for inj
A
RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp5
mcg/0.5ml
A
RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp10
mcg/ml
A
RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp40
mcg/ml
A
SHINGRIX - zoster vaccinerecombinant adjuvanted forim inj 50
mcg
A
VIVOTIF - typhoid vaccine capdelayed release
4
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
ZOSTAVAX - zoster vaccinelive for subcutaneous susp19400
unit/0.65ml
A
TOXOIDSADACEL - tet tox-diph-acell
pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml
A
BOOSTRIX - tet tox-diph-acellpertuss ad inj 5-2.5-18.5
lf-lf-mcg/0.5ml
A
DAPTACEL - diph, acellularpert & tet tox inj 15 lf-23mcg-5
lf/0.5ml
4
DIPHTHERIA/TETANUSTOXOID - diphtheria-tetanustox adsorbed (dt)
im inj 25-5unit/0.5ml
4
INFANRIX - diph, acellular pert& tet tox inj 25 lf-58
mcg-10lf/0.5ml
4
KINRIX - diph-tetanus tox ad-acell pert & polio virus,
ipvvac inj
4
PEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polioipv vac
inj
4
PENTACEL - diph-ac per-tettox ad-poliov-haemoph bpoly vac for im
susp
4
QUADRACEL - diph-tetanustox ad-acell pert & poliovirus, ipv
vac inj
4
TENIVAC - tetanus-diphtheriatoxoids (td) inj 5-2 lfu
4
TETANUS/DIPHTHERIATOXOID - tetanus-diphtheriatoxoids (td) inj
2-2 lf/0.5ml
4
PASSIVE IMMUNIZING AGENTS
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 15
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
HYQVIA - immun glob inj 2.5gm/25ml-hyaluron inj 200unt/1.25 ml
kit
4
HYQVIA - immun glob inj 5gm/50ml-hyaluron inj 400unt/2.5 ml
kit
4
HYQVIA - immun glob inj 10gm/100ml-hyaluron inj 800unt/5 ml
kit
4
HYQVIA - immun glob inj 20gm/200ml-hyaluron inj 1600unt/10 ml
kit
4
HYQVIA - immun glob inj 30gm/300ml-hyaluron inj 2400unt/15 ml
kit
4
BIOLOGICALS MISCGRASTEK - timothy grass
pollen allergen ext tab sl2800 bau
4
ORALAIR - grass mixed pollenext tab sl 300 ir (index
ofreactivity)
4
RAGWITEK - short ragweedpollen allergen extract tab sl12 amb a
1-u
4
ANTINEOPLASTIC AGENTSANTINEOPLASTICSACTIMMUNE - interferon
gamma-1b inj 100mcg/0.5ml (2000000unit/0.5ml)
5
AFINITOR - everolimus tab 2.5mg
5
AFINITOR - everolimus tab 5mg
5
AFINITOR - everolimus tab 7.5mg
5
AFINITOR - everolimus tab 10mg
5
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
AFINITOR DISPERZ -everolimus tab for oral susp2 mg
5
AFINITOR DISPERZ -everolimus tab for oral susp3 mg
5
AFINITOR DISPERZ -everolimus tab for oral susp5 mg
5
ALECENSA - alectinib hcl cap150 mg (base equivalent)
5
ALKERAN - melphalan tab 2mg
3
ALUNBRIG - brigatinib tabinitiation therapy pack 90 mg& 180
mg
5
ALUNBRIG - brigatinib tab 30mg
5
ALUNBRIG - brigatinib tab 90mg
5
ALUNBRIG - brigatinib tab 180mg
5
anastrozole tab 1 mg(Arimidex)
1
bexarotene cap 75 mg(Targretin)
5
bicalutamide tab 50 mg(Casodex)
1
BOSULIF - bosutinib tab 100mg
5
BOSULIF - bosutinib tab 400mg
5
BOSULIF - bosutinib tab 500mg
5
CABOMETYX - cabozantinibs-malate tab 20 mg (baseequivalent)
5
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 16
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
CABOMETYX - cabozantinibs-malate tab 40 mg (baseequivalent)
5
CABOMETYX - cabozantinibs-malate tab 60 mg (baseequivalent)
5
CALQUENCE - acalabrutinibcap 100 mg
5
capecitabine tab 150 mg(Xeloda)
5
capecitabine tab 500 mg(Xeloda)
5
CAPRELSA - vandetanib tab100 mg
5
CAPRELSA - vandetanib tab300 mg
5
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100
dose) kit
5
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140
dose) kit
5
COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60mg dose)
kit
5
COTELLIC - cobimetinibfumarate tab 20 mg (baseequivalent)
5
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25mg
4
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50mg
4
ELIGARD - leuprolide acetate(3 month) for subcutaneousinj kit
22.5mg
5
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
ELIGARD - leuprolide acetate(4 month) for subcutaneousinj kit 30
mg
5
ELIGARD - leuprolide acetate(6 month) for subcutaneousinj kit 45
mg
5
ELIGARD - leuprolide acetatefor subcutaneous inj kit 7.5mg
5
EMCYT - estramustinephosphate sodium cap 140mg
4
ERIVEDGE - vismodegib cap150 mg
5
ETOPOSIDE - etoposide cap50 mg
4
exemestane tab 25 mg(Aromasin)
2
FARESTON - toremifene citratetab 60 mg (base equivalent)
4
FARYDAK - panobinostatlactate cap 10 mg (baseequivalent)
5
FARYDAK - panobinostatlactate cap 15 mg (baseequivalent)
5
FARYDAK - panobinostatlactate cap 20 mg (baseequivalent)
5
flutamide cap 125 mg 2
GILOTRIF - afatinib dimaleatetab 20 mg (base equivalent)
5
GILOTRIF - afatinib dimaleatetab 30 mg (base equivalent)
5
GILOTRIF - afatinib dimaleatetab 40 mg (base equivalent)
5
GLEEVEC - imatinibmesylate tab 100 mg (baseequivalent)
5
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 17
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
GLEEVEC - imatinibmesylate tab 400 mg (baseequivalent)
5
GLEOSTINE - lomustine cap 5mg
4
GLEOSTINE - lomustine cap10 mg
4
GLEOSTINE - lomustine cap40 mg
4
GLEOSTINE - lomustine cap100 mg
4
HEXALEN - altretamine cap 50mg
5
HYCAMTIN - topotecan hcl cap0.25 mg (base equiv)
5
HYCAMTIN - topotecan hcl cap1 mg (base equiv)
5
hydroxyurea cap 500 mg(Hydrea)
2
IBRANCE - palbociclib cap 75mg
5
IBRANCE - palbociclib cap 100mg
5
IBRANCE - palbociclib cap 125mg
5
ICLUSIG - ponatinib hcl tab 15mg (base equiv)
5
ICLUSIG - ponatinib hcl tab 45mg (base equiv)
5
IDHIFA - enasidenib mesylatetab 50 mg (base equivalent)
5
IDHIFA - enasidenibmesylate tab 100 mg (baseequivalent)
5
imatinib mesylate tab100 mg (base equivalent)(Gleevec)
5
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio
n
Ste
p Th
erap
y
Dis
pens
ing
Lim
its
AC
A
Lim
ited
Dis
tribu
tion
imatinib mesylate tab400 mg (base equivalent)(Gleevec)
5
IMBRUVICA - ibrutinib cap 70mg
5
IMBRUVICA - ibrutinib cap 140mg
5
INLYTA - axitinib tab 1 mg 5 INLYTA - axitinib tab 5 mg 5 INTRON
A - interferon alfa-2b
inj 6000000 unit/ml5
INTRON A - interferon alfa-2binj 10000000 unit/ml
5
INTRON A - interferon alfa-2bfor inj 10000000 unit
5
INTRON A - interferon alfa-2bfor inj 18000000 unit
5
INTRON A - interferon alfa-2bfor inj 50000000 unit
5
IRESSA - gefitinib tab 250 mg 5 JAKAFI - ruxolitinib
phosphate
tab 5 mg (base equivalent)5
JAKAFI - ruxolitinib phosphatetab 10 mg (base equivalent)
5
JAKAFI - ruxolitinib phosphatetab 15 mg (base equivalent)
5
JAKAFI - ruxolitinib phosphatetab 20 mg (base equivalent)
5
JAKAFI - ruxolitinib phosphatetab 25 mg (base equivalent)
5
KISQALI - ribociclib succinatetab 200 mg (base equiv)
5
KISQALI FEMARA 200 DOSE -ribociclib tab 200 mg &letrozole
tab 2.5 mg therapypack
5
-
2017
Texas Residents -- Find and estimate prices for medicines on
this formulary
at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html
BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017
Plan Year) 18
Drug Name Dru
g Ti
er
Prio
r Aut
horiz
atio