your 2022 blue care network custom select drug list
TRANSCRIPT
Your 2022 Blue Care Network
Custom Select Drug List
HMO
Blue Cross® Metro Detroit HMO
Blue Cross® Preferred HMO
Blue Cross® Select HMO
Blue Elect PlusSM HSA POS
Blue Elect PlusSM POS
BCN Healthy Blue LivingSM HMO
BCN HMOSM
BCN HMO Fixed CostSM
BCN HRASM HMO
BCN HSASM HMO
BCN Routine CareSM HMO
If you have questions, call the number on the back of your member ID card to:
• Find a participating retail pharmacy by ZIP code
• Look up lower-cost medication alternatives
• Compare medication pricing and options
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the
Blue Cross and Blue Shield Association.
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Blue Care Network Custom Select Drug List
The Blue Care Network of Michigan Custom Select Drug List is a useful reference and educational tool for prescribers,
pharmacists and members.
We regularly update this list with medications approved by the U.S. Food and Drug Administration and reviewed by our
Pharmacy and Therapeutics Committee. The list represents the clinical judgment of Michigan doctors, pharmacists and
other experts in the diagnosis and treatment of disease and the promotion of health. The committee selects medications
based on safety, clinical effectiveness and opportunity for savings.
About this drug list
Use this list to find information about your drug coverage and medication options. It’s divided by chapter into major drug
classes or indications for use. Products approved for more than one use may be included in more than one chapter.
Within each chapter, drugs are identified according to their tier placement. Refer to the “Reading your drug list” section
for details.
We encourage doctors to prescribe preferred medications whenever possible. BCN respects the judgment of dispensing
pharmacists and expects them to contact the prescribing health care professional when a drug or dose may not be
appropriate for a member. We also encourage pharmacists to contact the prescriber to suggest an alternative when a
prescription is written for a nonpreferred or excluded drug.
Coverage and applicable out-of-pocket costs for drugs on this list are based on your drug plan. Not all drugs included in
the list are covered by each member’s plan. Drugs that aren’t listed may not be covered.
Some medications excluded by your pharmacy benefits may be covered under your medical benefits. These are
medications that are generally administered in a doctor’s office under the supervision of appropriate health care
personnel and aren’t normally dispensed for self-administration.
Drugs that aren’t covered
Our goals are to provide you with safe, high-quality prescription drug therapies and keep your medical costs low.
To accomplish this, we don’t cover some high-cost drugs that have comparable therapeutic alternatives with similar
effectiveness, quality and safety, but at a fraction of the cost. For the most recent list of drugs that aren’t covered with
suggested alternatives, refer to Custom Select Drug List Exclusions. If you have a question about a drug that isn’t
covered and doesn’t appear on this list, call the Customer Service number on the back of your BCN member ID card.
Several drugs and drug categories are excluded altogether from coverage under this drug list and are not shown. These
include:
• Brand-name drugs when there’s a generic equivalent available
• Prescription drugs for which there is an over-the-counter equivalent in both strength and dosage form (unless considered preventive by the United States Preventive Services Task Force)
• Over-the-counter medications (unless considered preventive by the U.S. Preventive Services Task Force)
• Lifestyle drugs (such as drugs to treat erectile dysfunction or weight loss)
• Prenatal vitamins
• Drugs used to treat heartburn and acid reflux (except select generic versions)
• Drugs that treat coughs and colds, including most antihistamines
• Drugs used for experimental purposes
• Drugs prescribed for cosmetic purposes
• Products covered as a medical benefit (for example, injectable drugs and vaccines that are usually administered in a doctor’s office)
- Note: All BCN members can get multiple common vaccines at network retail pharmacies. Restrictions may apply.
• Compounded products, with some exceptions
• Replacement prescriptions resulting from loss, theft or mishandling
• Drugs not approved by the FDA
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Specialty drugs
For more information on specialty drugs, see the Specialty Drug Program Pharmacy Benefit Member Guide.
Specialty drugs are limited to a 30-day supply. Select specialty drugs are managed by the 15-Day Specialty Drug
Limitation Program. Drugs included on this list are limited to a 15-day supply for all fills. Members pay half their usual
out-of-pocket cost for a 15-day supply. For more details, visit bcbsm.com/pharmacy.
Preventive drug coverage
Under the Affordable Care Act, also known as national health care reform, most health care plans must cover certain
preventive services and prescription drugs with no out-of-pocket costs. These drugs will have a “PV1,” “PV2” or “PV3”
listing in the “Notes” column of the drug list.
For a complete list of preventive drugs and coverage requirements, refer to our Preventive Drug Coverage list or visit
bcbsm.com/pharmacy. For information specific to your prescription drug benefits, check your plan documents.
New generics
When a generic version of a brand-name drug becomes available, the generic version is generally added to Tier 1. After
the generic drug is added, the original, brand-name version won’t be covered.
Brand-for-generic substitution
Select brand-name drugs may be covered at a generic copay, and the generic drug will not be covered. These brand-name drugs will be shown without the generic drug and will be listed with a generic copay.
Prescription coverage
For details about your prescription drug benefits, call the Customer Service phone number on the back of your BCN
member ID card. If you have online access, log in to your account at bcbsm.com or the Blue Cross mobile app. You can
also find general information about BCN prescription drug coverage at bcbsm.com/pharmacy.
Vaccines
Select vaccines are covered at pharmacies without out-of-pocket costs for most members whose pharmacies participate
with Blue Cross and are certified to administer vaccines.
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Reading your drug list
This drug list gives you options so you and your doctor can decide your best course of treatment. In this drug list, brand-
name medication names are shown in UPPERCASE (for example, CLOBEX). Generic medication names are shown in
lowercase (for example, clobetasol).
Tier information
Using lower tier or preferred medications can help you lower your out-of-pocket cost. Note: If you have a high-deductible
health plan, the tier cost levels will apply once you meet your deductible. For tiering information specific to your drug
benefit, check your plan documents.
Select drugs in Tier 1a, 1b, 2 or 3 may also be covered with no out-of-pocket costs when health care reform
requirements are met. These drugs will have a “PV1,” “PV2” or “PV3” listing in the “Notes” column of the drug list.
Drug Tier Includes Helpful Tips
Not
covered
Nonformulary This tier includes nonformulary high-cost, FDA-approved, prescription-
only drugs that have comparable therapeutic alternatives with
similar effectiveness, quality and safety, but at a fraction of the cost.
Nonformulary drugs are not covered.
Tier 0 No out-of-pocket costs This tier includes select products that will pay with no out-of-pocket costs.
Tier 0 Preventive
No out-of-pocket costs
This tier includes drugs that are covered with no out-of-pocket costs
when health care reform requirements are met. When health care reform
requirements are not met, the drug is not covered. These drugs are
shown on the drug list with “PV1” next to them.
Tier 1a Preferred generics
Lower generic drug
out-of-pocket costs
This tier includes common, nonspecialty generic and select brand-name
drugs that treat certain chronic diseases. Offering these drugs at the
lowest out-of-pocket costs makes them more accessible to members
and helps to ensure that they take them as prescribed.
Tier 1b Nonpreferred generics
Higher generic drug
out-of-pocket costs
This tier includes nonspecialty generic drugs that aren’t listed in Tier 1a.
The Tier 1b out-of-pocket costs are higher than those for Tier 1a but still
lower than the costs for brand-name drugs.
Tier 2 Preferred brand
Higher nonspecialty
out-of-pocket costs
This tier includes nonspecialty, preferred brand-name drugs. These
drugs are more expensive than generics, and members pay more for
them.
Tier 3 Nonpreferred brand
Highest nonspecialty
out-of-pocket costs
This tier includes nonspecialty, brand-name drugs for which there are
either generic alternatives or more cost-effective, preferred brand-name
drugs available. Members pay more for these nonpreferred brand-
name drugs.
Tier 4 Preferred specialty
Lower specialty-drug
out-of-pocket costs
This tier includes specialty drugs, both generic and brand name, that are
used to treat difficult health conditions. These drugs are generally more
cost-effective than nonpreferred specialty drugs.
Tier 5 Nonpreferred specialty
Higher specialty-drug
out-of-pocket costs
This tier includes nonpreferred brand-name, specialty drugs that are
used to treat difficult health conditions. Members pay a higher amount
for nonpreferred specialty drugs because there are more cost-effective
generic or preferred drugs available.
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Drug list information
In this drug list, some medications are noted with letters next to them to indicate which ones may have coverage
requirements or limits. Your drug plan determines how these medications may be covered.
AL Age limit – Age restrictions apply.
ABA
Authorized brand alternative – Approved brand medication marketed by either the brand company or
another company without the brand name on its label. Authorized brand alternatives are drugs that are
considered brand-name drugs and don’t have generic equivalents. These drugs are the same as the brand-
name drugs but are not true generic drugs. The respective brand out-of-pocket costs will apply for these
medications. Some authorized brand alternatives may not be covered.
PA Prior authorization – Your doctor is required to give more information to determine coverage.
PV1 Preventive 1 – Covered with no out-of-pocket costs when health care reform requirements are met. When
health care reform requirements are not met, the drug is not covered.
PV2
Preventive 2 – Covered with no out-of-pocket costs when health care reform requirements are met. When
health care reform requirements are not met, coverage and applicable out-of-pocket costs apply, based on
the members’ benefit design.
PV3
Preventive 3 – Covered with no out-of-pocket costs when health care reform requirements are met. When
health care reform requirements are not met, coverage and applicable out-of-pocket costs apply, based on
the members’ benefit design. Additional coverage requirements may apply.
QL Quantity limit – The quantity of medication dispensed at one time is limited.
SP Specialty medication – Specialty medications treat complex health conditions and may require special
handling or administration.
ST Step therapy – Requires you try one or more preferred drugs before a higher-cost medication can be
covered.
15DS 15 Days’ supply – Limits the amount of certain specialty drugs to a 15-day supply to help reduce out-of-pocket
costs and waste.
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How to fill a prescription
The type of drug you take determines which pharmacy you may use.
• Specialty drugs
- Local retail pharmacy
° Walgreens is our preferred specialty pharmacy. Find a location at walgreens.com/pharmacy/*.
° You can use any retail pharmacy in your applicable network.
- Limited-distribution specialty drugs
° Pharmacy options vary based on the drug. Refer to the Specialty Drug Program Pharmacy Benefit Member
Guide, and search for the drug you take.
- Mail order for home delivery
° AllianceRx Walgreens Prime** Specialty Pharmacy
° Website: alliancerxwp.com*
° Telephone: 1-866-515-1355
• All other drugs
- Local retail pharmacy — More than 2,300 retail pharmacies in Michigan and 65,000 retail pharmacies outside of
Michigan accept your member ID card.
- Mail order for home delivery
° OptumRx®*** home delivery pharmacy
° Telephone: 1-844-642-9087
If you have questions about which mail-order vendor to use, call the Customer Service phone number on the back of
your BCN member ID card or visit bcbsm.com/pharmacy.
* Blue Cross Blue Shield of Michigan doesn’t own or control this website.
** AllianceRx Walgreens Prime® is an independent company that provides specialty pharmacy benefit management services for Blue Cross Blue Shield of Michigan.
*** OptumRx® is an independent company that provides home delivery and other pharmacy benefit management services for Blue Cross Blue Shield of Michigan.
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How prior authorization, step therapy and quantity limits work
Prior authorization
Prior authorization may be necessary for coverage of certain medications. In these cases, the member must meet clinical
criteria or additional information must be provided before coverage is approved. Clinical criteria are based on current
medical information and approved by our Pharmacy and Therapeutics Committee.
Step therapy
Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage
is approved.
For a current list of drugs requiring prior authorization or step therapy, see the Prior Authorization and Step Therapy
Coverage Criteria and refer to the column labeled Blue Care Network Custom Select Drug List.
Quantity limits
For certain medications, BCN limits the quantity that can be dispensed per fill. BCN sets quantity limits based on clinical
appropriateness and manufacturer-recommended dosing for select drugs.
For a current list of drugs that have limits on the quantity that can be dispensed per fill, please see the Quantity Limit
Program, and refer to the Blue Care Network Custom Select Drug List.
How to request authorization
Consult your prescription drug benefit packet for information on how to get prior authorization or request reviews for
coverage of drugs that aren’t included in your plan. You can also call the Customer Service number on the back of your
BCN member ID card for more information.
• To request coverage of a drug: Fill out the Coverage Request Form online at bcbsm.com.
• Write to:
Pharmacy Services — Mail Code 512C
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd.
Detroit, MI 48226-2998
Doctors can request authorization for you. We’ll notify the doctor of approved requests and process the claim accordingly.
If a request isn’t approved, we’ll notify you and the doctor in writing. The notification includes the reason for the denial, an
explanation of your appeal rights and the appeals process.
Doctors can request authorization one of four ways:
• Electronic prior authorization: Doctors can use their electronic health record or CoverMyMeds® to submit electronic
prior authorization requests for commercial pharmacy members.
• Call: 1-800-437-3803
• Fax: 1-866-601-4425
• Write:
Pharmacy Services — Mail Code 512C
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd.
Detroit, MI 48226-2998
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This document is current at the time of publication and subject to change. Go to bcbsm.com/pharmacy and click
on Drug Lists for the most up-to-date information about this drug list.
This content was developed to comply with applicable federal and state regulations. To learn more about your plan, go
to bcbsm.com and type “How Health Insurance Works” in the search field.
Send us your feedback
Please send your comments and suggestions about this list to:
Drug Information Services – Mail Code 512C
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd.
Detroit, MI 48226-2998
BCN Custom Select Drug List - February 2022
Table of Contents
Analgesics ....................................................................................................................................................... 10Anesthetics ...................................................................................................................................................... 15Anti-Addiction/Substance Abuse Treatment Agents ...................................................................................16Antibacterials ...................................................................................................................................................17Anticonvulsants .............................................................................................................................................. 20Antidementia Agents ...................................................................................................................................... 22Antidepressants .............................................................................................................................................. 23Antiemetics ...................................................................................................................................................... 25Antifungals .......................................................................................................................................................25Antigout Agents .............................................................................................................................................. 27Antimigraine Agents ....................................................................................................................................... 27Antimyasthenic Agents .................................................................................................................................. 28Antimycobacterials ......................................................................................................................................... 28Antineoplastics ................................................................................................................................................29Antiparasitics ...................................................................................................................................................34Antiparkinson Agents ..................................................................................................................................... 34Antipsychotics .................................................................................................................................................36Antivirals .......................................................................................................................................................... 37Anxiolytics ....................................................................................................................................................... 41Bipolar Agents .................................................................................................................................................41Blood Glucose Monitoring ............................................................................................................................. 41Blood Glucose Regulators ............................................................................................................................. 44Blood Products and Modifiers ....................................................................................................................... 47Cardiovascular Agents ................................................................................................................................... 50Central Nervous System Agents ....................................................................................................................57Cholestatic Pruritus Agent ............................................................................................................................. 59Dental and Oral Agents ...................................................................................................................................59Dermatological Agents ................................................................................................................................... 60Electrolytes/Minerals/Metals/Vitamins .......................................................................................................... 64Gastrointestinal Agents ..................................................................................................................................66Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ............................................................ 70Genitourinary Agents ......................................................................................................................................71Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ................................................................73Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) ...............................................................76Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) ................................................... 77Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) ................................... 77Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) ................................................................ 85Hormonal Agents, Suppressant (Adrenal) ....................................................................................................85Hormonal Agents, Suppressant (Pituitary) ...................................................................................................85Hormonal Agents, Suppressant (Thyroid) .................................................................................................... 86Immunological Agents ....................................................................................................................................86Inflammatory Bowel Disease Agents ............................................................................................................ 90Metabolic Bone Disease Agents .................................................................................................................... 91Miscellaneous Therapeutic Agents ............................................................................................................... 91Ophthalmic Agents ......................................................................................................................................... 93Otic Agents ...................................................................................................................................................... 97Respiratory Tract/Pulmonary Agents ............................................................................................................97Skeletal Muscle Relaxants ............................................................................................................................102Sleep Disorder Agents ..................................................................................................................................103
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Drug Name Brand Reference Drug Tier Notes
Analgesics
Nonsteroidal Anti-inflammatory Drugs
adult aspirin regimen Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)
aspirin adult low dose Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)
aspirin adult low strength Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)
aspirin childrens Bayer Low Dose 0PV1; AL (Min 10 Years and Max 79 Years)
aspirin ec low dose Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)
aspirin ec low strength Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)
aspirin ec oral tablet delayed release 325 mg
Bayer Aspirin 0PV1; AL (Min 10 Years and Max 79 Years)
aspirin low dose Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)
aspirin oral tabletBayer Advanced Aspirin Reg St
0PV1; AL (Min 10 Years and Max 79 Years)
aspirin oral tablet delayed release Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)
celecoxib oral CeleBREX 1b
DICLOFENAC CAP 35MG Not covered QL
DICLOFENAC PATCH 1.3% Not covered ABA; QL
diclofenac potassium oral tablet 25 mg Lofena Not covered
diclofenac potassium oral tablet 50 mg Cataflam 1b
diclofenac sodium er 1b
diclofenac sodium external gel 1 %Aspercreme Arthritis Pain
1b QL
diclofenac sodium external solution Not covered
diclofenac sodium oral 1a
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
diclofenac-misoprostol Arthrotec 1b
diflunisal oral 1b
ec-naproxen EC-Naprosyn 1a
etodolac Lodine 1b
etodolac er 1b
fenoprofen calcium oral capsule Fenortho Not covered QL
fenoprofen calcium oral tablet Nalfon 1b PA; QL
fenortho Fenortho Not covered QL
FLECTOR Not covered QL
flurbiprofen oral 1b
goodsense aspirin adultsBayer Advanced Aspirin Reg St
0PV1; AL (Min 10 Years and Max 79 Years)
goodsense aspirin low dose Aspir-Low 0PV1; AL (Min 10 Years and Max 79 Years)
ibuprofen oral suspension 100 mg/5ml Childrens Advil 1a
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
IBUPROFEN 1a
ibuprofen-famotidine Duexis 1b PA; QL
INDOCIN ORAL Not covered
INDOCIN RECTAL 3 QL
indomethacin er 1b
INDOMETHACIN ORAL CAPSULE 20 MG
Not covered QL
indomethacin oral capsule 25 mg, 50 mg 1b
ketoprofen er 1b
ketoprofen oral capsule 25 mg 1b PA; QL
ketoprofen oral capsule 50 mg, 75 mg 1b
ketorolac tromethamine injection 1b
ketorolac tromethamine intramuscular 1b
KETOROLAC TROMETHAMINE NASAL Not covered ABA; QL
ketorolac tromethamine oral 1b QL
LICART Not covered QL
meclofenamate sodium oral 1b
mefenamic acid oral 1b
meloxicam oral capsule Vivlodex Not covered QL
meloxicam oral tablet Mobic 1a
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
nabumetone oral Relafen 1b
NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG
Not covered
naproxen oral suspension Naprosyn 1b
naproxen oral tablet Naprosyn 1a
naproxen oral tablet delayed release EC-Naprosyn 1a
naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg
Naprelan Not covered
NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG
Not covered ABA
naproxen sodium oral tablet 275 mg 1a
naproxen sodium oral tablet 550 mg Anaprox DS 1a
naproxen-esomeprazole Vimovo Not covered QL
oxaprozin Daypro 1b
PENNSAID Not covered QL
piroxicam oral Feldene 1b
RELAFEN DS Not covered
salsalate oral 1b
SPRIX Not covered QL
sulindac oral 1b
TIVORBEX Not covered QL
ZIPSOR Not covered QL
ZORVOLEX Not covered QL
Opioid Analgesics, Long-acting
BELBUCA Not covered QL
buprenorphine Butrans 1b QL
CONZIP Not covered
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
1b QL
fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr
Not covered QL
hydrocodone bitartrate er oral capsule extended release 12 hour
1b PA; QL
hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent
Hysingla ER Not covered QL
hydromorphone hcl er Not covered QL
levorphanol tartrate oral 1b PA; QL
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
methadone hcl intensol Methadone HCl Intensol 1b
methadone hcl oral Methadone HCl Intensol 1b
methadose oral concentrate 10 mg/ml Methadone HCl Intensol 1b
methadose oral tablet soluble Methadose 1b
methadose sugar-free Methadone HCl Intensol 1b
morphine sulfate er beads Not covered QL
morphine sulfate er oral capsule extended release 24 hour
Not covered QL
morphine sulfate er oral tablet extended release
MS Contin 1b QL
NUCYNTA ER 3 PA; QL
OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG, 30 MG, 60 MG, 80 MG
Not covered ABA; QL
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG ORAL
Not covered QL
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG ORAL
Not covered ABA; QL
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 20 MG ORAL
Not covered QL
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 20 MG ORAL
Not covered ABA; QL
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 40 MG ORAL
Not covered QL
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 40 MG ORAL
Not covered ABA; QL
OXYCONTIN Not covered QL
oxymorphone hcl er 1b PA; QL
QDOLO Not covered QL
tramadol hcl er (biphasic) 1b
TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR
Not covered ABA
tramadol hcl er oral tablet extended release 24 hour
1b
XTAMPZA ER 2 PA; QL
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
Opioid Analgesics, Short-acting
acetaminophen-codeine 1b
acetaminophen-codeine #2 1b
acetaminophen-codeine #3 1b
acetaminophen-codeine #4 1b
ALLZITAL Not covered
APADAZ Not covered QL
apap-caff-dihydrocodeine oral capsule Trezix 1b
apap-caff-dihydrocodeine oral tablet Not covered
ascomp-codeine Ascomp-Codeine 1b
bac Bac 1b
BENZHYDROCODONE-ACETAMINOPHEN
Not covered ABA; QL
butalbital-acetaminophen capsule 50-300 mg oral
Not covered
BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL
Not covered
butalbital-acetaminophen oral tablet 25-325 mg
Allzital Not covered
butalbital-acetaminophen oral tablet 50-300 mg
Bupap Not covered
butalbital-acetaminophen oral tablet 50-325 mg
Tencon 1b
butalbital-apap-caff-cod Fioricet/Codeine 1b
butalbital-apap-caffeine Bac 1b
butalbital-asa-caff-codeine Ascomp-Codeine 1b
butalbital-aspirin-caffeine 1b
butorphanol tartrate nasal 1b
carisoprodol-aspirin-codeine Not covered
codeine sulfate 1b
endocet Endocet 1b
fentanyl citrate buccal lozenge on a handle
Actiq 1b PA; QL
FENTANYL CITRATE BUCCAL TABLET Not covered ABA; QL
FENTORA Not covered QL
hydrocodone-acetaminophen Xodol 1b
hydrocodone-ibuprofen 1b
hydromorphone hcl oral Dilaudid 1b
hydromorphone hcl rectal 1b
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
LAZANDA Not covered QL
LORTAB Not covered
meperidine hcl oral 1b
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml
1b
morphine sulfate oral 1b
morphine sulfate rectal 1b
nalbuphine hcl injection 1b
NALOCET Not covered
NUCYNTA 3 PA; QL
OXAYDO Not covered QL
oxycodone hcl oral capsule 1b QL
oxycodone hcl oral concentrate 100 mg/5ml
1b QL
oxycodone hcl oral solution 1b QL
oxycodone hcl oral tablet Oxaydo 1b QL
OXYCODONE-ACETAMINOPHEN ORAL SOLUTION
Not covered
OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 2.5-300 MG, 5-300 MG, 7.5-300 MG
Not covered
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Endocet 1b
oxymorphone hcl 1b QL
pentazocine-naloxone hcl 1b
PROLATE Not covered
SUBSYS Not covered QL
TENCON Not covered
tramadol hcl ir Ultram 1b
tramadol-acetaminophen Ultracet 1b
VTOL LQ Not covered
Anesthetics
Local Anesthetics
glydo Glydo 1b
lidocaine external patch 5 % Lidoderm Not covered
lidocaine hcl external solution 1b
lidocaine hcl mouth/throat 1b
BCN Custom Select Drug List - February 2022
15
Drug Name Brand Reference Drug Tier Notes
lidocaine hcl urethral/mucosal external prefilled syringe
Glydo 1b
LIDOCAINE HCL-TETRACAINE HCL Not covered
lidocaine viscous hcl 1b
lidocaine-prilocaine external cream 1b
PLIAGLIS EXTERNAL CREAM Not covered
ZTLIDO Not covered QL
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium 1b
disulfiram oral 1b
naltrexone hcl oral 1b
Opioid Dependence Treatments
buprenorphine hcl sublingual 1b QL
buprenorphine hcl-naloxone hcl Suboxone 1b QL
LUCEMYRA 2 QL
ZUBSOLV 2 QL
Opioid Reversal Agents
KLOXXADO 2 QL
naloxone hcl injection 1b
naloxone hcl liquid 4 mg/0.1ml nasal Narcan 1a QL
NALOXONE HCL LIQUID 4 MG/0.1ML NASAL
2 QL
Smoking Cessation Agents
APO-VARENICLINE 2PV2; QL; AL (Min 18 Years)
bupropion hcl er (smoking det) 1bPV2; QL; AL (Min 18 Years)
goodsense nicotine mouth/throat lozenge 4 mg
KLS Quit4 0PV1; QL; AL (Min 18 Years)
habitrol Habitrol 0PV1; QL; AL (Min 18 Years)
nicotine polacrilex mini KLS Quit2 0PV1; QL; AL (Min 18 Years)
nicotine polacrilex mouth/throat KLS Quit2 0PV1; QL; AL (Min 18 Years)
nicotine step 1 Habitrol 0PV1; QL; AL (Min 18 Years)
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
nicotine step 2 Nicoderm CQ 0PV1; QL; AL (Min 18 Years)
nicotine step 3 Nicoderm CQ 0PV1; QL; AL (Min 18 Years)
nicotine transdermal kit 0PV1; QL; AL (Min 18 Years)
NICOTROL 3PV2; QL; AL (Min 18 Years)
NICOTROL NS 3PV2; QL; AL (Min 18 Years)
varenicline tartrate 1bPV2; QL; AL (Min 18 Years)
Antibacterials
Aminoglycosides
ARIKAYCE 4 PA; SP; QL
gentamicin sulfate external 1b
neomycin sulfate oral 1b
paromomycin sulfate oral Humatin 1b
Antibacterials, Other
AEMCOLO Not covered QL
ALTABAX Not covered
CLEOCIN VAGINAL SUPPOSITORY 3
clindamycin hcl oral Cleocin 1b
clindamycin palmitate hcl Cleocin 1b
clindamycin phosphate vaginal Cleocin 1b
CLINDESSE 3
FIRVANQ 3 QL
fosfomycin tromethamine Monurol 1b
linezolid oral Zyvox 1b
mafenide acetate external Sulfamylon Not covered
methenamine hippurate Hiprex 1b
metronidazole oral Flagyl 1b
metronidazole vaginal Vandazole 1b
mupirocin calcium Not covered
mupirocin external Centany 1b
NEO-SYNALAR EXTERNAL CREAM Not covered
nitrofurantoin 1b
nitrofurantoin macrocrystal Macrodantin 1b
BCN Custom Select Drug List - February 2022
17
Drug Name Brand Reference Drug Tier Notes
nitrofurantoin monohydrate macrocrystals
Macrobid 1b
NUVESSA Not covered
silver sulfadiazine external SSD 1b
SIVEXTRO ORAL 2 QL
SOLOSEC Not covered QL
ssd SSD 1b
SULFAMYLON EXTERNAL CREAM Not covered
tinidazole oral 1b QL
trimethoprim oral 1b
vancomycin hcl oral capsule Vancocin 1b
vancomycin hcl oral solution reconstituted
Firvanq 1b QL
vandazole Vandazole 1b
XENLETA ORAL 3 QL
XEPI Not covered QL
XIFAXAN ORAL TABLET 200 MG 3 QL
XIFAXAN ORAL TABLET 550 MG 3 PA; QL
Beta-lactam, Cephalosporins
cefaclor 1b
cefaclor er 1b
cefadroxil 1b
cefdinir 1b
cefixime Suprax 1b
cefpodoxime proxetil 1b
cefprozil 1b
cefuroxime axetil 1b
cephalexin 1b
SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 500 MG/5ML
3
SUPRAX ORAL TABLET CHEWABLE 3
Beta-lactam, Penicillins
amoxicillin 1b
amoxicillin-potassium clavulanate Augmentin 1b
amoxicillin-potassium clavulanate er 1b
ampicillin 1b
dicloxacillin sodium 1b
BCN Custom Select Drug List - February 2022
18
Drug Name Brand Reference Drug Tier Notes
penicillin v potassium 1b
Macrolides
azithromycin oral Zithromax 1b
clarithromycin er 1b
clarithromycin oral 1b
DIFICID 3 QL
E.E.S. 400 Not covered
ERYTHROCIN STEARATE Not covered
erythromycin base Ery-Tab 1b
erythromycin ethylsuccinate oral E.E.S. 400 1b
erythromycin oral Ery-Tab 1b
Quinolones
BAXDELA ORAL 3
CIPRO ORAL SUSPENSION RECONSTITUTED
3
ciprofloxacin hcl oral Cipro 1b
levofloxacin oral Levaquin 1b
moxifloxacin hcl oral 1b
ofloxacin oral 1b
Sulfonamides
sulfadiazine oral 1b
sulfamethoxazole-trimethoprim oral Bactrim 1b
sulfatrim pediatric Sulfatrim Pediatric 1b
Tetracyclines
avidoxy 1a
coremino CoreMino Not covered
demeclocycline hcl 1b
DORYX MPC Not covered
DORYX ORAL TABLET DELAYED RELEASE 80 MG
Not covered
doxycycline hyclate oral capsule Vibramycin 1a
doxycycline hyclate oral tablet 100 mg Lymepak 1a
doxycycline hyclate oral tablet 150 mg Acticlate Not covered QL
doxycycline hyclate oral tablet 20 mg 1a
doxycycline hyclate oral tablet 50 mg TargaDOX Not covered
doxycycline hyclate oral tablet 75 mg Acticlate Not covered
doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg
Not covered
BCN Custom Select Drug List - February 2022
19
Drug Name Brand Reference Drug Tier Notes
doxycycline hyclate oral tablet delayed release 200 mg, 50 mg
Doryx Not covered
DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG
Not covered ABA
doxycycline monohydrate oral capsule 100 mg
Mondoxyne NL 1a
doxycycline monohydrate oral capsule 150 mg
Not covered
doxycycline monohydrate oral capsule 50 mg, 75 mg
1a
doxycycline monohydrate oral suspension reconstituted
Vibramycin 1b
doxycycline monohydrate oral tablet 1a
LYMEPAK Not covered
MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR
Not covered
minocycline hcl er oral tablet extended release 24 hour
CoreMino Not covered
minocycline hcl oral Minocin 1a
MINOLIRA Not covered
mondoxyne nl Mondoxyne NL 1a
NUZYRA ORAL 3 QL
SEYSARA Not covered
tetracycline hcl oral 1b
VIBRAMYCIN ORAL SYRUP 3
XIMINO Not covered
Anticonvulsants
Anticonvulsants, Other
BRIVIACT ORAL 3 PA; QL
ELEPSIA XR Not covered QL
EPIDIOLEX 5 PA; SP; QL
FINTEPLA 5 PA; SP; QL
levetiracetam er Keppra XR 1a
levetiracetam oral Keppra 1a
roweepra Roweepra 1a
SPRITAM Not covered QL
Calcium Channel Modifying Agents
CELONTIN 3
BCN Custom Select Drug List - February 2022
20
Drug Name Brand Reference Drug Tier Notes
ethosuximide oral Zarontin 1b
zonisamide oral Zonegran 1a
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clobazam Onfi 1b QL
DIACOMIT 5 PA; SP; QL
diazepam rectal Diastat AcuDial 1b
gabapentin oral Neurontin 1a
NAYZILAM 2 QL
phenobarbital oral 1b
primidone oral Mysoline 1b
SYMPAZAN Not covered QL
tiagabine hcl Gabitril 1b
valproic acid oral 1a
VALTOCO 2 QL
vigabatrin Sabril 4 PA; SP; QL
vigadrone Vigadrone 4 PA; SP; QL
XCOPRI 3 PA; QL
Glutamate Reducing Agents
EPRONTIA 3 PA; QL
felbamate Felbatol 1b
FYCOMPA 3 QL
LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 42 X 50 MG & 14X100 MG
3
LAMICTAL XR ORAL KIT 3
lamotrigine er LaMICtal XR 1b
lamotrigine oral kit LaMICtal ODT 1b
lamotrigine oral tablet Subvenite 1a
lamotrigine oral tablet chewable LaMICtal 1a
lamotrigine oral tablet dispersible LaMICtal ODT 1b
lamotrigine starter kit-blueSubvenite Starter Kit-Blue
1b
lamotrigine starter kit-greenSubvenite Starter Kit-Green
1b
lamotrigine starter kit-orangeSubvenite Starter Kit-Orange
1b
subvenite Subvenite 1a
BCN Custom Select Drug List - February 2022
21
Drug Name Brand Reference Drug Tier Notes
subvenite starter kit-blueSubvenite Starter Kit-Blue
1b
subvenite starter kit-greenSubvenite Starter Kit-Green
1b
subvenite starter kit-orangeSubvenite Starter Kit-Orange
1b
topiramate er Qudexy XR Not covered QL
topiramate oral Topamax 1a
TROKENDI XR Not covered QL
Sodium Channel Agents
APTIOM Not covered QL
carbamazepine er Carbatrol 1b
carbamazepine oral Epitol 1a
DILANTIN ORAL CAPSULE 30 MG 2
epitol Epitol 1a
oxcarbazepine oral suspension Trileptal 1b
oxcarbazepine oral tablet Trileptal 1a
OXTELLAR XR Not covered QL
phenytoin infatabs Phenytoin Infatabs 1a
phenytoin oral suspension 125 mg/5ml Dilantin 1a
phenytoin oral tablet chewable Phenytoin Infatabs 1a
phenytoin sodium extended Dilantin 1a
rufinamide oral suspension Banzel 1b
rufinamide oral tablet Banzel 1b PA; QL
VIMPAT ORAL SOLUTION 2
VIMPAT ORAL TABLET 2 PA; QL
Antidementia Agents
Antidementia Agents, Other
NAMZARIC Not covered QL
Cholinesterase Inhibitors
donepezil hcl oral tablet 10 mg, 5 mg Aricept 1a
donepezil hcl oral tablet 23 mg Aricept Not covered QL
donepezil hcl oral tablet dispersible 1a
galantamine hydrobromide 1b
galantamine hydrobromide er Razadyne ER 1b
rivastigmine Exelon 1b
rivastigmine tartrate 1b
BCN Custom Select Drug List - February 2022
22
Drug Name Brand Reference Drug Tier Notes
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl er Namenda XR 1b QL
memantine hcl oral solution 2 mg/ml 1a
memantine hcl oral tablet 10 mg, 5 mg 1a
memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg
Namenda Titration Pak 1b QL
Antidepressants
Antidepressants, Other
APLENZIN Not covered
bupropion hcl er (sr) Wellbutrin SR 1a
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
Wellbutrin XL 1a
BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG
Not covered ABA; QL
bupropion hcl oral 1a
chlordiazepoxide-amitriptyline 1b
FORFIVO XL Not covered QL
LYBALVI 3 ST; QL
mirtazapine oral Remeron 1a
olanzapine-fluoxetine hcl Symbyax 1b
perphenazine-amitriptyline 1b
Monoamine Oxidase Inhibitors
EMSAM 3 PA; QL
MARPLAN 3
phenelzine sulfate oral Nardil 1b
tranylcypromine sulfate Parnate 1b
SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors)
citalopram hydrobromide CeleXA 1a
DESVENLAFAXINE ER Not covered QL
desvenlafaxine succinate er Pristiq 1a QL
DRIZALMA SPRINKLE Not covered QL
duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg
Cymbalta 1a
duloxetine hcl oral capsule delayed release particles 40 mg
Not covered
BCN Custom Select Drug List - February 2022
23
Drug Name Brand Reference Drug Tier Notes
escitalopram oxalate Lexapro 1a
FETZIMA Not covered QL
FETZIMA TITRATION Not covered QL
fluoxetine hcl (pmdd) 1a
fluoxetine hcl oral capsule PROzac 1a
fluoxetine hcl oral capsule delayed release
1a
fluoxetine hcl oral solution 1a
fluoxetine hcl oral tablet 10 mg, 20 mg 1a
fluoxetine hcl oral tablet 60 mg 1b
fluvoxamine maleate 1a
fluvoxamine maleate er 1b
nefazodone hcl 1b
paroxetine hcl er Paxil CR 1b
paroxetine hcl oral suspension Paxil 1b
paroxetine hcl oral tablet Paxil 1a
paroxetine mesylate Brisdelle Not covered QL
PEXEVA 3 ST; QL
SERTRALINE HCL ORAL CAPSULE Not covered QL
sertraline hcl oral concentrate Zoloft 1a
sertraline hcl oral tablet Zoloft 1a
trazodone hcl oral 1a
TRINTELLIX 3 ST; QL
venlafaxine hcl 1a
venlafaxine hcl er oral capsule extended release 24 hour
Effexor XR 1a
venlafaxine hcl er oral tablet extended release 24 hour
1b
VIIBRYD 3 ST; QL
VIIBRYD STARTER PACK 3 ST; QL
Tricyclics
amitriptyline hcl oral 1a
amoxapine 1a
clomipramine hcl oral Anafranil 1b
desipramine hcl oral Norpramin 1b
doxepin hcl oral capsule 1a
doxepin hcl oral concentrate 1a
imipramine hcl oral 1a
BCN Custom Select Drug List - February 2022
24
Drug Name Brand Reference Drug Tier Notes
imipramine pamoate 1b
nortriptyline hcl oral Pamelor 1a
protriptyline hcl 1b
trimipramine maleate oral 1b
Antiemetics
Antiemetics, Other
ANTIVERT ORAL TABLET Not covered
BONJESTA Not covered QL
compro Compro 1b
doxylamine-pyridoxine Diclegis Not covered QL
GIMOTI Not covered QL
meclizine hcl oral tablet Travel-Ease Not covered
metoclopramide hcl oral solution 1b
metoclopramide hcl oral tablet Reglan 1b
metoclopramide hcl oral tablet dispersible
Not covered
perphenazine oral 1a
prochlorperazine Compro 1b
prochlorperazine maleate oral 1b
scopolamine Transderm-Scop 1b
trimethobenzamide hcl oral 1b
Emetogenic Therapy Adjuncts
AKYNZEO ORAL 3 PA; QL
aprepitant Emend 1b QL
dronabinol Marinol 1b
EMEND ORAL SUSPENSION RECONSTITUTED
2 QL
granisetron hcl oral 1b QL
ondansetron hcl oral solution 1b
ondansetron hcl oral tablet 1b QL
ondansetron odt 1b QL
SANCUSO 3 PA; QL
SYNDROS Not covered
VARUBI (180 MG DOSE) 3 PA; QL
ZUPLENZ Not covered
Antifungals
BREXAFEMME Not covered QL
BCN Custom Select Drug List - February 2022
25
Drug Name Brand Reference Drug Tier Notes
ciclodan Ciclodan 1b
ciclopirox external Ciclodan 1b
ciclopirox olamine external Loprox 1b
clotrimazole external Desenex 1b
clotrimazole mouth/throat 1b
clotrimazole-betamethasone 1b
CRESEMBA ORAL 2 QL
econazole nitrate external 1b
ECOZA Not covered QL
ERTACZO Not covered
EXELDERM 3
fluconazole oral Diflucan 1b
flucytosine oral Ancobon 1b
griseofulvin microsize oral 1b
griseofulvin ultramicrosize 1b
GYNAZOLE-1 3
itraconazole oral Sporanox 1b
JUBLIA Not covered QL
ketoconazole external Ketodan 1b
ketoconazole oral 1b
ketodan external foam Ketodan 1b
LULICONAZOLE Not covered QL
LUZU Not covered QL
MENTAX Not covered
miconazole 3 1b
MICONAZOLE-ZINC OXIDE-PETROLAT Not covered ABA; QL
naftifine hcl Naftin Not covered QL
NAFTIN EXTERNAL GEL 2 % Not covered QL
NOXAFIL ORAL SUSPENSION 2
nyamyc Nyamyc 1b
nystatin external Nyamyc 1b
nystatin mouth/throat 1b
nystatin oral 1b
nystatin-triamcinolone 1b
nystop Nyamyc 1b
ORAVIG Not covered QL
oxiconazole nitrate Oxistat Not covered QL
BCN Custom Select Drug List - February 2022
26
Drug Name Brand Reference Drug Tier Notes
OXISTAT EXTERNAL LOTION Not covered QL
posaconazole Noxafil 1b QL
SULCONAZOLE NITRATE 3
tavaborole Kerydin Not covered QL
terbinafine hcl oral 1b
terconazole 1b
TOLSURA Not covered
voriconazole oral Vfend 1b
VUSION Not covered QL
XOLEGEL Not covered QL
Antigout Agents
allopurinol oral Zyloprim 1b
COLCHICINE ORAL CAPSULE Not covered
colchicine oral tablet Colcrys 1b
colchicine-probenecid 1b
febuxostat Uloric 1b ST; QL
GLOPERBA Not covered QL
MITIGARE Not covered
probenecid 1b
Antimigraine Agents
CAMBIA Not covered QL
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist
AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML
2 PA; QL
AJOVY 3 PA; QL
EMGALITY 2 PA; QL
EMGALITY (300 MG DOSE) 2 PA; QL
NURTEC 2 PA; QL
UBRELVY 2 PA; QL
Ergot Alkaloids
dihydroergotamine mesylate injection D.H.E. 45 1b QL
dihydroergotamine mesylate nasal Migranal Not covered QL
ERGOMAR Not covered QL
ergotamine-caffeine Cafergot 1b QL
MIGERGOT Not covered QL
BCN Custom Select Drug List - February 2022
27
Drug Name Brand Reference Drug Tier Notes
TRUDHESA Not covered QL
Serotonin (5-HT) Receptor Agonists
almotriptan malate 1b ST; QL
eletriptan hydrobromide Relpax 1b ST; QL
frovatriptan succinate Frova 1b ST; QL
naratriptan hcl Amerge 1b QL
ONZETRA XSAIL Not covered QL
REYVOW 3 PA; QL
rizatriptan benzoate Maxalt 1b QL
sumatriptan nasal Imitrex 1b QL
sumatriptan succinate oral Imitrex 1b QL
sumatriptan succinate refill Imitrex STATdose Refill 1b QL
sumatriptan succinate subcutaneous solution
1b
sumatriptan succinate subcutaneous solution auto-injector
Imitrex STATdose System
1b QL
sumatriptan-naproxen sodium Treximet Not covered QL
TOSYMRA Not covered QL
ZEMBRACE SYMTOUCH Not covered QL
ZOLMITRIPTAN NASAL SOLUTION 2.5 MG
3 ST; ABA; QL
zolmitriptan nasal solution 5 mg Zomig 1b ST; QL
zolmitriptan oral Zomig 1b QL
ZOMIG NASAL SOLUTION 2.5 MG 3 ST; QL
Antimyasthenic Agents
Parasympathomimetics
pyridostigmine bromide er Mestinon 1b
pyridostigmine bromide oral solution Mestinon 1b
pyridostigmine bromide oral tablet 30 mg Not covered
pyridostigmine bromide oral tablet 60 mg Mestinon 1b
Antimycobacterials
Antimycobacterials, Other
dapsone oral 1b
rifabutin Mycobutin 1b
Antituberculars
cycloserine oral 1b
ethambutol hcl oral Myambutol 1b
BCN Custom Select Drug List - February 2022
28
Drug Name Brand Reference Drug Tier Notes
isoniazid oral 1b
PASER 3
PRETOMANID 2 QL
PRIFTIN 3
pyrazinamide oral 1b
rifampin oral 1b
SIRTURO 2 PA; QL
TRECATOR 3
Antineoplastics
Alkylating Agents
cyclophosphamide oral capsule 1b
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG
3 ABA
CYCLOPHOSPHAMIDE ORAL TABLET 50 MG
3
GLEOSTINE 2
LEUKERAN 2
MATULANE 4 SP
melphalan Alkeran 1b
MYLERAN 2
temozolomide Temodar 4 SP
VALCHLOR 5 PA; SP; QL
Antiandrogens
abiraterone acetate oral tablet 250 mg Zytiga 4 SP; QL
abiraterone acetate oral tablet 500 mg Zytiga Not covered SP; QL
bicalutamide Casodex 1b
ERLEADA 4 PA; SP; QL
nilutamide Nilandron 1b PA; QL
NUBEQA 4 PA; 15DS; SP; QL
ORGOVYX 5 PA; SP; QL
XTANDI 4 PA; 15DS; SP; QL
YONSA Not covered SP; QL
Antiangiogenic Agents
POMALYST 5 PA; SP; QL
REVLIMID 5 SP; QL
THALOMID 4 SP
BCN Custom Select Drug List - February 2022
29
Drug Name Brand Reference Drug Tier Notes
Antiestrogens/Modifiers
EMCYT 2
fulvestrant Faslodex 1b
SOLTAMOX 3
tamoxifen citrate oral 1a PV3; QL
toremifene citrate Fareston 1b
Antimetabolites
capecitabine Xeloda 4 SP
DROXIA 2
hydroxyurea oral Hydrea 1a
mercaptopurine oral 1b
PURIXAN 5 SP
SIKLOS 3 PA
TABLOID 2
Antineoplastics, Other
BESREMI 4 PA; 15DS; SP; QL
CARAC Not covered QL
COPIKTRA 4 PA; SP; QL
diclofenac sodium external gel 3 % 1b PA; QL
FLUOROPLEX 3
FLUOROURACIL EXTERNAL CREAM 0.5 %
Not covered ABA; QL
fluorouracil external cream 5 % Efudex 1b
fluorouracil external solution 1b
INREBIC 5 PA; 15DS; SP; QL
KISQALI ORAL TABLET THERAPY PACK 200 MG
4 PA; SP; QL
KLISYRI 3 PA; QL
leucovorin calcium oral 1b
LONSURF 4 PA; SP; QL
LUMAKRAS 4 PA; 15DS; SP; QL
NINLARO 4 PA; SP; QL
ONUREG 4 PA; SP; QL
PIQRAY 4 PA; SP; QL
ROZLYTREK 4 PA; 15DS; SP; QL
RYLAZE Not covered
SYNRIBO 4 PA; SP; QL
BCN Custom Select Drug List - February 2022
30
Drug Name Brand Reference Drug Tier Notes
TAZVERIK 4 PA; 15DS; SP; QL
VERZENIO 4 PA; 15DS; SP; QL
WELIREG 4 PA; 15DS; SP; QL
XPOVIO (100 MG ONCE WEEKLY) 4 PA; 15DS; SP; QL
XPOVIO (40 MG ONCE WEEKLY) 4 PA; 15DS; SP; QL
XPOVIO (40 MG TWICE WEEKLY) 4 PA; 15DS; SP; QL
XPOVIO (60 MG ONCE WEEKLY) 4 PA; 15DS; SP; QL
XPOVIO (60 MG TWICE WEEKLY) 4 PA; 15DS; SP; QL
XPOVIO (80 MG ONCE WEEKLY) 4 PA; 15DS; SP; QL
XPOVIO (80 MG TWICE WEEKLY) 4 PA; 15DS; SP; QL
ZOLINZA 4 PA; 15DS; SP
Aromatase Inhibitors, 3rd Generation
anastrozole oral Arimidex 1a PV3; QL
exemestane Aromasin 1b PV3; QL
letrozole oral Femara 1a
Enzyme Inhibitors
BALVERSA 4 PA; 15DS; SP; QL
etoposide oral 1b
HYCAMTIN ORAL 4 SP
PEMAZYRE 4 PA; SP; QL
RUBRACA 4 PA; SP; QL
TALZENNA 4 PA; 15DS; SP; QL
TRUSELTIQ (100MG DAILY DOSE) 4 PA; SP; QL
TRUSELTIQ (125MG DAILY DOSE) 4 PA; SP; QL
TRUSELTIQ (50MG DAILY DOSE) 4 PA; SP; QL
TRUSELTIQ (75MG DAILY DOSE) 4 PA; SP; QL
ZEJULA 4 PA; 15DS; SP; QL
Molecular Target Inhibitors
ALECENSA 4 PA; SP; QL
ALUNBRIG 4 PA; SP; QL
AYVAKIT 4 PA; 15DS; SP; QL
BOSULIF 4 PA; 15DS; SP; QL
BRAFTOVI 4 PA; SP; QL
BRUKINSA 4 PA; 15DS; SP; QL
CABOMETYX 4 PA; 15DS; SP; QL
CALQUENCE 4 PA; 15DS; SP; QL
CAPRELSA 4 PA; 15DS; SP; QL
BCN Custom Select Drug List - February 2022
31
Drug Name Brand Reference Drug Tier Notes
COMETRIQ 4 PA; 15DS; SP; QL
COTELLIC 4 PA; SP; QL
DAURISMO 4 PA; 15DS; SP; QL
ERIVEDGE 4 PA; 15DS; SP; QL
erlotinib hcl Tarceva 4 PA; 15DS; SP
everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg
Afinitor 4 PA; 15DS; SP; QL
everolimus oral tablet soluble Afinitor Disperz 4 PA; 15DS; SP; QL
EXKIVITY 4 PA; 15DS; SP; QL
FARYDAK 4 PA; SP; QL
FOTIVDA 4 PA; SP; QL
GAVRETO 4 PA; 15DS; SP; QL
GILOTRIF 4 PA; SP; QL
IBRANCE 4 PA; SP; QL
ICLUSIG 4 PA; 15DS; SP; QL
IDHIFA 4 PA; SP; QL
imatinib mesylate Gleevec 4 SP
IMBRUVICA ORAL CAPSULE 4 PA; 15DS; SP; QL
IMBRUVICA ORAL TABLET 140 MG Not covered SP; QL
IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG
4 PA; SP; QL
INLYTA 4 PA; 15DS; SP; QL
INQOVI 4 PA; SP; QL
IRESSA 4 PA; SP; QL
JAKAFI 4 PA; 15DS; SP; QL
KISQALI FEMARA 4 PA; SP; QL
KOSELUGO 4 PA; SP; QL
lapatinib ditosylate Tykerb 4 PA; SP
LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 10 MG, 10 MG & 2 X 4 MG, 2 X 10 MG, 2 X 10 MG & 4 MG, 2 X 4 MG, 3 X 4 MG, 4 MG
4 PA; 15DS; SP; QL
LORBRENA 4 PA; 15DS; SP; QL
LYNPARZA 4 PA; 15DS; SP; QL
MEKINIST 4 PA; SP; QL
MEKTOVI 4 PA; SP; QL
NERLYNX 4 PA; 15DS; SP; QL
NEXAVAR 4 PA; 15DS; SP; QL
BCN Custom Select Drug List - February 2022
32
Drug Name Brand Reference Drug Tier Notes
ODOMZO 4 PA; 15DS; SP; QL
QINLOCK 4 PA; SP; QL
RETEVMO 4 PA; 15DS; SP; QL
RYDAPT 4 PA; SP; QL
SCEMBLIX 4 PA; SP; QL
SPRYCEL 4 PA; 15DS; SP
STIVARGA 4 PA; SP; QL
sunitinib malate Sutent 4 PA; 15DS; SP; QL
TABRECTA 4 PA; 15DS; SP; QL
TAFINLAR 4 PA; SP; QL
TAGRISSO 4 PA; 15DS; SP; QL
TASIGNA 4 PA; 15DS; SP; QL
TEPMETKO 4 PA; 15DS; SP; QL
TIBSOVO 4 PA; 15DS; SP; QL
TUKYSA 4 PA; SP; QL
TURALIO 4 PA; SP; QL
UKONIQ 4 PA; 15DS; SP; QL
VENCLEXTA 4 PA; SP; QL
VENCLEXTA STARTING PACK 4 PA; SP; QL
VITRAKVI ORAL CAPSULE 4 PA; 15DS; SP; QL
VITRAKVI ORAL SOLUTION 4 PA; SP; QL
VIZIMPRO 4 PA; 15DS; SP; QL
VOTRIENT 4 PA; 15DS; SP
XALKORI 4 PA; 15DS; SP; QL
XOSPATA 4 PA; SP; QL
ZELBORAF 4 PA; 15DS; SP; QL
ZYDELIG 4 PA; SP; QL
ZYKADIA 4 PA; 15DS; SP; QL
Retinoids
bexarotene Targretin 4 PA; 15DS; SP
PANRETIN 2
TARGRETIN EXTERNAL 5 PA; SP
tretinoin oral 1b
Treatment Adjuncts
MESNEX ORAL 2
BCN Custom Select Drug List - February 2022
33
Drug Name Brand Reference Drug Tier Notes
Antiparasitics
Anthelmintics
albendazole oral Albenza 1b QL
EMVERM Not covered QL
ivermectin external lotion 1b QL
ivermectin oral Stromectol 1b PA; QL
praziquantel oral Biltricide 1b
Antiprotozoals
ALINIA ORAL SUSPENSION RECONSTITUTED
2
ARAKODA 3 QL
atovaquone Mepron 1b
atovaquone-proguanil hcl Malarone 1b
BENZNIDAZOLE 2 QL
chloroquine phosphate oral 1b
COARTEM 2 QL
hydroxychloroquine sulfate oral Plaquenil 1b
IMPAVIDO 2 QL
KRINTAFEL 2 QL
LAMPIT 3 QL
mefloquine hcl 1b
nitazoxanide oral Alinia 1b
pentamidine isethionate inhalation Nebupent 1b
primaquine phosphate 1b
pyrimethamine oral Daraprim 4 PA; SP
quinine sulfate oral Qualaquin 1b
Pediculicides/Scabicides
crotan 1b
lindane 1b
malathion Ovide 1b
permethrin external 1b
spinosad Natroba 1b
Antiparkinson Agents
Anticholinergics
benztropine mesylate oral 1a
trihexyphenidyl hcl 1a
BCN Custom Select Drug List - February 2022
34
Drug Name Brand Reference Drug Tier Notes
Antiparkinson Agents, Other
amantadine hcl oral 1b
carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg
Stalevo 50 1b
carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg
Stalevo 75 1b
entacapone Comtan 1b
GOCOVRI Not covered QL
NOURIANZ 3 PA; QL
ONGENTYS 3 PA; QL
OSMOLEX ER Not covered
tolcapone Tasmar 1b
Dopamine Agonists
APOKYN Not covered SP; QL
bromocriptine mesylate oral Parlodel 1b
INBRIJA 3 PA; QL
KYNMOBI 2 PA; QL
NEUPRO Not covered QL
pramipexole dihydrochloride 1a
pramipexole dihydrochloride er Mirapex ER Not covered QL
ropinirole hcl 1a
ropinirole hcl er 1b
Dopamine Precursors and/or L-Amino Acid Decarboxylase Inhibitors
carbidopa-levodopa er oral tablet extended release 50-200 mg
1a
carbidopa-levodopa oral tablet 10-100 mg
Sinemet 1a
carbidopa-levodopa oral tablet 25-250 mg
1a
carbidopa-levodopa oral tablet dispersible 25-100 mg
1b
RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG
Not covered QL
Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors
carbidopa oral Lodosyn 1b
carbidopa-levodopa er oral tablet extended release 25-100 mg
1a
BCN Custom Select Drug List - February 2022
35
Drug Name Brand Reference Drug Tier Notes
carbidopa-levodopa oral tablet 25-100 mg
1a
carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-250 mg
1b
carbidopa-levodopa-entacapone oral tablet 25-100-200 mg
Stalevo 100 1b
carbidopa-levodopa-entacapone oral tablet 31.25-125-200 mg
Stalevo 125 1b
carbidopa-levodopa-entacapone oral tablet 37.5-150-200 mg
Stalevo 150 1b
carbidopa-levodopa-entacapone oral tablet 50-200-200 mg
Stalevo 200 1b
DHIVY Not covered QL
DUOPA 4 PA; SP; QL
RYTARY ORAL CAPSULE EXTENDED RELEASE 61.25-245 MG
Not covered QL
Monoamine Oxidase B (MAO-B) Inhibitors
rasagiline mesylate oral Azilect 1b
selegiline hcl oral 1b
XADAGO 3 QL
ZELAPAR Not covered QL
Antipsychotics
1st Generation/Typical
chlorpromazine hcl oral tablet 1b
fluphenazine decanoate injection 1b
fluphenazine hcl oral 1a
haloperidol decanoate intramuscular Haldol Decanoate 1b
haloperidol lactate oral 1a
haloperidol oral 1a
loxapine succinate 1a
molindone hcl Not covered QL
pimozide 1b
thioridazine hcl oral 1a
thiothixene 1b
trifluoperazine hcl 1a
2nd Generation/Atypical
ABILIFY MAINTENA 2
ABILIFY MYCITE Not covered
BCN Custom Select Drug List - February 2022
36
Drug Name Brand Reference Drug Tier Notes
ABILIFY MYCITE MAINTENANCE KIT Not covered
ABILIFY MYCITE STARTER KIT Not covered
aripiprazole Abilify 1b
ARISTADA 2 QL
ARISTADA INITIO 2
asenapine maleate Saphris 1b QL
CAPLYTA 3 ST; QL
FANAPT 3 ST
FANAPT TITRATION PACK 3 ST
INVEGA SUSTENNA 2
INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML
2 QL
LATUDA 3 ST
NUPLAZID 3 PA; QL
olanzapine oral ZyPREXA 1a
paliperidone er Invega 1b QL
PERSERIS 2 QL
quetiapine fumarate SEROquel 1a
quetiapine fumarate er SEROquel XR 1a QL
REXULTI Not covered QL
RISPERDAL CONSTA 2
risperidone RisperDAL 1a
SECUADO 3 ST; QL
VRAYLAR 3 ST; QL
ziprasidone hcl Geodon 1a
ZYPREXA RELPREVV 2
Treatment-Resistant
clozapine oral tablet Clozaril 1a
clozapine oral tablet dispersible 1b
VERSACLOZ Not covered
Antivirals
MOLNUPIRAVIR 0Anti-cytomegalovirus (CMV) Agents
PREVYMIS ORAL 3 QL
valganciclovir hcl Valcyte 1b
BCN Custom Select Drug List - February 2022
37
Drug Name Brand Reference Drug Tier Notes
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil Hepsera 4 SP
BARACLUDE ORAL SOLUTION 4 SP
entecavir Baraclude 4 SP
EPIVIR HBV ORAL SOLUTION 2
lamivudine oral tablet 100 mg Epivir HBV 1b
VEMLIDY 4 SP; QL
Anti-hepatitis C (HCV) Agents, Other
INTRON A 4 SP
Anti-hepatitis C (HCV) Agents
EPCLUSA 4 PA; SP; QL
HARVONI ORAL PACKET 5 PA; SP; QL
HARVONI ORAL TABLET Not covered SP; QL
LEDIPASVIR-SOFOSBUVIR Not covered ABA; SP; QL
MAVYRET 5 PA; SP; QL
PEGASYS 4 SP; QL
ribavirin oral 4 SP
SOFOSBUVIR-VELPATASVIR 4 PA; ABA; SP; QL
SOVALDI ORAL PACKET 5 PA; SP; QL
SOVALDI ORAL TABLET Not covered SP; QL
VIEKIRA PAK Not covered SP; QL
VOSEVI 5 PA; SP; QL
ZEPATIER 4 PA; SP; QL
Antiherpetic Agents
acyclovir external cream Zovirax Not covered
acyclovir external ointment Zovirax 1b
acyclovir oral Zovirax 1b
DENAVIR Not covered
famciclovir oral 1b
SITAVIG Not covered QL
valacyclovir hcl oral Valtrex 1b
XERESE Not covered QL
Anti-HIV Agents, Integrase Inhibitors (INSTI)
BIKTARVY 2 QL
DOVATO 2 QL
GENVOYA 2 QL
BCN Custom Select Drug List - February 2022
38
Drug Name Brand Reference Drug Tier Notes
ISENTRESS 2
ISENTRESS HD 2
JULUCA 2 QL
STRIBILD 2 QL
TIVICAY 2
TIVICAY PD 2 QL
TYBOST 2 QL
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
COMPLERA 2 QL
DELSTRIGO 2 QL
EDURANT 2 QL
efavirenz Sustiva 1b
efavirenz-emtricitab-tenofovir Atripla 1b
efavirenz-lamivudine-tenofovir Symfi 1b QL
etravirine Intelence 1b
INTELENCE ORAL TABLET 25 MG 2
nevirapine 1b
nevirapine er Viramune XR 1b
PIFELTRO 2 QL
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacavir sulfate Ziagen 1b
abacavir sulfate-lamivudine Epzicom 1b
abacavir-lamivudine-zidovudine Trizivir Not covered
CIMDUO 2 QL
DESCOVY 2 PA; QL
emtricitabine Emtriva 1b
emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg
Truvada 1b QL
emtricitabine-tenofovir df oral tablet 200-300 mg
Truvada 1b PV2; QL
EMTRIVA ORAL SOLUTION 2
lamivudine oral solution Epivir 1b
lamivudine oral tablet 150 mg, 300 mg Epivir 1b
lamivudine-zidovudine Combivir 1b
BCN Custom Select Drug List - February 2022
39
Drug Name Brand Reference Drug Tier Notes
ODEFSEY 2 QL
stavudine Not covered
TEMIXYS 2 QL
tenofovir disoproxil fumarate Viread 1b
TRIUMEQ 2 QL
VIREAD ORAL POWDER 2
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
2
zidovudine Retrovir 1b
Anti-HIV Agents, Other
FUZEON 2
RUKOBIA 2 PA; QL
SELZENTRY 2
Anti-HIV Agents, Protease Inhibitors
APTIVUS 2
atazanavir sulfate Reyataz 1b
EVOTAZ 2 QL
fosamprenavir calcium Lexiva 1b
INVIRASE 2
LEXIVA ORAL SUSPENSION 2
lopinavir-ritonavir Kaletra 1b
NORVIR ORAL PACKET 2
NORVIR ORAL SOLUTION 2
PREZCOBIX 2 QL
PREZISTA 2
REYATAZ ORAL PACKET 2
ritonavir Norvir 1b
SYMTUZA 2 QL
VIRACEPT Not covered
Anti-influenza Agents
oseltamivir phosphate oral Tamiflu 1b QL
RELENZA DISKHALER 2 QL
rimantadine hcl 1b
XOFLUZA (40 MG DOSE) 2 QL
XOFLUZA (80 MG DOSE) 2 QL
BCN Custom Select Drug List - February 2022
40
Drug Name Brand Reference Drug Tier Notes
Anxiolytics
Anxiolytics, Other
buspirone hcl oral 1b
hydroxyzine hcl oral 1b
hydroxyzine pamoate oral Vistaril 1b
meprobamate 1b
Benzodiazepines
alprazolam er Xanax XR 1b
alprazolam intensol 1b
alprazolam oral Xanax 1b
alprazolam xr Xanax XR 1b
chlordiazepoxide hcl 1b
clonazepam oral KlonoPIN 1b
clorazepate dipotassium Tranxene-T 1b
diazepam intensol Diazepam Intensol 1b
diazepam oral Diazepam Intensol 1b
estazolam 1b QL
lorazepam intensol LORazepam Intensol 1b
lorazepam oral concentrate 2 mg/ml LORazepam Intensol 1b
lorazepam oral tablet Ativan 1b
LOREEV XR Not covered QL
midazolam hcl oral 1b
oxazepam 1b
quazepam Doral Not covered QL
triazolam Halcion 1b QL
Bipolar Agents
Mood Stabilizers
divalproex sodium er Depakote ER 1a
divalproex sodium oral Depakote 1a
EQUETRO 3
lithium carbonate er Lithobid 1a
lithium carbonate oral 1a
Blood Glucose Monitoring
ACCU-CHEK AVIVA PLUS TEST STRIPS
2 QL
ACCU-CHEK COMPACT PLUS TEST STRIPS
2 QL
BCN Custom Select Drug List - February 2022
41
Drug Name Brand Reference Drug Tier Notes
ACCU-CHEK FASTCLIX LANCETS 2 QL
ACCU-CHEK GUIDE TEST STRIPS 2 QL
ACCU-CHEK MULTICLIX LANCETS 2 QL
ACCU-CHEK SAFE-T PRO LANCETS 2 QL
ACCU-CHEK SMARTVIEW TEST STRIPS
2 QL
ACCU-CHEK SOFTCLIX LANCETS 2 QL
AGAMATRIX PRESTO TEST 2 QL
ASSURE PLATINUM 2 QL
BLOOD GLUCOSE TEST 2 QL
BLULINK GLUCOSE TEST 2 QL
CARETOUCH TEST 2 QL
CONTOUR MONITOR DEVICE 0 QL
CONTOUR NEXT MONITOR KIT W/DEVICE
0 QL
CONTOUR NEXT ONE KIT 0 QL
CONTOUR NEXT TEST STRIPS 2 QL
CONTOUR TEST STRIPS 2 QL
DEXCOM G6 RECEIVER 0 PA; QL
DEXCOM G6 SENSOR 2 PA; QL
DEXCOM G6 TRANSMITTER 0 PA; QL
DIATHRIVE BLOOD GLUCOSE TEST 2 QL
DIATHRIVE GLUCOSE TEST 2 QL
DIATHRIVE+ GLUCOSE TEST 2 QL
EASY TALK PLUS II TEST STRIPS 2 QL
EASY TOUCH HEALTHPRO GLUCOSE 2 QL
EASY TRAK II GLUCOSE TEST 2 QL
EMBRACE PRESSURE ACTIVATED 21G
2 QL
EMBRACE PRESSURE ACTIVATED 28G
2 QL
EMBRACE TALK GLUCOSE TEST 2 QL
FORA 6 CONNECT 2 QL
FORA GTEL BLOOD GLUCOSE TEST 2 QL
FORA TN'G ADVANCE PRO IN VITRO 2 QL
FREESTYLE LIBRE 14 DAY READER 2 PA; QL
FREESTYLE LIBRE 14 DAY SENSOR 2 PA; QL
FREESTYLE LIBRE 2 READER 2 PA; QL
BCN Custom Select Drug List - February 2022
42
Drug Name Brand Reference Drug Tier Notes
FREESTYLE LIBRE 2 SENSOR 2 PA; QL
FREESTYLE LIBRE READER 2 PA; QL
FREESTYLE PRECISION NEO TEST 2 QL
GLUCOCARD 01 SENSOR PLUS 2 QL
GLUCOCARD EXPRESSION TEST 2 QL
GLUCOCARD SHINE TEST 2 QL
GLUCOCARD VITAL TEST 2 QL
GOJJI BLOOD GLUCOSE TEST 3 QL
HW EMBRACE PRO GLUCOSE TEST 2 QL
HW EMBRACE TALK GLUCOSE TEST 2 QL
INFINITY BLOOD GLUCOSE TEST 2 QL
KROGER HEALTHPRO GLUCOSE TEST
2 QL
LANCETS 2 QL
LANCETS IN VITRO STRIP 3 QL
MICRODOT TEST 2 QL
ONE DROP TEST 2 QL
ONETOUCH CLUB LANCETS FINE PT 2 QL
ONETOUCH DELICA LANCETS 30G 2 QL
ONETOUCH DELICA LANCETS 33G 2 QL
ONETOUCH DELICA PLUS LANCET30G
2 QL
ONETOUCH DELICA PLUS LANCET33G
2 QL
ONETOUCH FINEPOINT LANCETS 2 QL
ONETOUCH ULTRA TEST STRIPS 2 QL
ONETOUCH ULTRA 2 KIT W/DEVICE 0 QL
ONETOUCH ULTRASOFT LANCETS 2 QL
ONETOUCH VERIO FLEX SYSTEM 0 QL
ONETOUCH VERIO TEST STRIPS 2 QL
ONETOUCH VERIO REFLECT 0 QL
PRECISION XTRA BLOOD GLUCOSE 2 QL
RELION PREMIER TEST 2 QL
TRUE METRIX BLOOD GLUCOSE TEST
2 QL
TRUETRACK TEST 2 QL
VIVAGUARD INO TEST STRIPS 2 QL
BCN Custom Select Drug List - February 2022
43
Drug Name Brand Reference Drug Tier Notes
Blood Glucose Regulators
Antidiabetic Agents
acarbose oral Precose 1b
ADLYXIN Not covered QL
ADLYXIN STARTER PACK Not covered QL
ALOGLIPTIN BENZOATE Not covered ABA; QL
ALOGLIPTIN-METFORMIN HCL Not covered QL
ALOGLIPTIN-PIOGLITAZONE Not covered ABA; QL
BYDUREON BCISE AUTOINJECTOR Not covered QL
BYETTA 10 MCG PEN Not covered QL
BYETTA 5 MCG PEN Not covered QL
CYCLOSET 3 PA; QL
FARXIGA 2 QL
glimepiride Amaryl 1a
glipizide er Glucotrol XL 1a
glipizide ir 1a
glipizide xl Glucotrol XL 1a
glipizide-metformin hcl 1a
glyburide micronized Glynase 1a
glyburide oral 1a
glyburide-metformin 1a
GLYXAMBI 2 QL
INVOKAMET Not covered QL
INVOKAMET XR Not covered QL
INVOKANA Not covered QL
JANUMET 2 QL
JANUMET XR 2 QL
JANUVIA 2 QL
JARDIANCE 2 QL
JENTADUETO 2 QL
JENTADUETO XR 2 QL
KAZANO Not covered QL
KOMBIGLYZE XR Not covered
metformin hcl er 1a
metformin hcl er (mod) Glumetza Not covered
metformin hcl er (osm) Not covered
metformin hcl oral solution Riomet Not covered
BCN Custom Select Drug List - February 2022
44
Drug Name Brand Reference Drug Tier Notes
metformin hcl oral tablet 1a
miglitol 1b
nateglinide 1b
NESINA Not covered QL
ONGLYZA Not covered QL
OSENI Not covered QL
OZEMPIC 2 QL
pioglitazone hcl Actos 1a
pioglitazone hcl-glimepiride Duetact 1b
pioglitazone hcl-metformin hcl Actoplus Met 1b
QTERN Not covered QL
repaglinide 1b
RYBELSUS 2 QL
SEGLUROMET Not covered QL
SOLIQUA 2 QL
STEGLATRO Not covered QL
STEGLUJAN Not covered QL
SYMLINPEN 120 3
SYMLINPEN 60 3
SYNJARDY 2 QL
SYNJARDY XR 2 QL
TRADJENTA 2 QL
TRIJARDY XR 2 QL
TRULICITY 2 QL
VICTOZA 2 QL
XIGDUO XR 2 QL
XULTOPHY 2 QL
Glycemic Agents
BAQSIMI ONE PACK 2 QL
BAQSIMI TWO PACK 2 QL
diazoxide oral Proglycem 1b
GLUCAGEN HYPOKIT 2
glucagon emergency kit 1b
GLUCAGON EMERGENCY KIT 2
GVOKE HYPOPEN 1-PACK 2 QL
GVOKE HYPOPEN 2-PACK 2 QL
GVOKE PFS 2 QL
BCN Custom Select Drug List - February 2022
45
Drug Name Brand Reference Drug Tier Notes
ZEGALOGUE 3 QL
Insulins
ADMELOG Not covered
ADMELOG SOLOSTAR Not covered
AFREZZA Not covered
APIDRA SOLOSTAR Not covered
APIDRA VIAL Not covered
BASAGLAR KWIKPEN 3
FIASP 2
FIASP FLEXTOUCH 2
FIASP PENFILL 2
HUMALOG Not covered
HUMALOG KWIKPEN Not covered
HUMALOG MIX 50/50 KWIKPEN Not covered
HUMALOG MIX 50/50 VIAL Not covered
HUMALOG MIX 75/25 KWIKPEN Not covered
HUMALOG MIX 75/25 VIAL Not covered
HUMALOG U-100 JUNIOR KWIKPEN Not covered
HUMULIN 70/30 KWIKPEN Not covered
HUMULIN 70/30 VIAL Not covered
HUMULIN N KWIKPEN Not covered
HUMULIN N VIAL Not covered
HUMULIN R U-500 KWIKPEN 2
HUMULIN R U-500 VIAL 2
HUMULIN R VIAL Not covered
INSULIN ASP PROT & ASP FLEXPEN Not covered ABA
INSULIN ASPART Not covered ABA
INSULIN ASPART FLEXPEN Not covered ABA
INSULIN ASPART PENFILL Not covered ABA
INSULIN ASPART PROT & ASPART Not covered ABA
INSULIN GLARGINE-YFGN Not covered ABA
INSULIN LISPRO Not covered ABA
INSULIN LISPRO (1 UNIT DIAL) Not covered ABA
INSULIN LISPRO JUNIOR KWIKPEN 3 ABA
INSULIN LISPRO PROT & LISPRO Not covered ABA
LANTUS SOLOSTAR 1a
LANTUS U-100 VIAL 1a
BCN Custom Select Drug List - February 2022
46
Drug Name Brand Reference Drug Tier Notes
LEVEMIR U-100 FLEXTOUCH 1a
LEVEMIR U-100 VIAL 1a
LYUMJEV KWIKPEN Not covered
LYUMJEV VIAL Not covered
NOVOLIN 70/30 FLEXPEN 1a
NOVOLIN 70/30 RELION Not covered
NOVOLIN 70/30 VIAL 1a
NOVOLIN N FLEXPEN 1a
NOVOLIN N RELION Not covered
NOVOLIN N VIAL 1a
NOVOLIN R FLEXPEN 1a
NOVOLIN R RELION Not covered
NOVOLIN R VIAL 1a
NOVOLOG 70/30 FLEXPEN RELION Not covered
NOVOLOG FLEXPEN 1a
NOVOLOG FLEXPEN RELION Not covered
NOVOLOG MIX 70/30 FLEXPEN 1a
NOVOLOG MIX 70/30 RELION Not covered
NOVOLOG MIX 70/30 VIAL 1a
NOVOLOG PENFILL 1a
NOVOLOG RELION Not covered
NOVOLOG U-100 VIAL 1a
SEMGLEE Not covered
SEMGLEE (YFGN) Not covered
TOUJEO MAX SOLOSTAR 1a
TOUJEO SOLOSTAR 1a
TRESIBA 1a
TRESIBA FLEXTOUCH 1a
Blood Products and Modifiers
EMPAVELI 4 PA; SP; QL
Anticoagulants
ELIQUIS 2 QL
ELIQUIS DVT/PE STARTER PACK 2 QL
enoxaparin sodium Lovenox 1b
fondaparinux sodium Arixtra 1b
FRAGMIN 3
heparin sodium (porcine) 1b
BCN Custom Select Drug List - February 2022
47
Drug Name Brand Reference Drug Tier Notes
heparin sodium (porcine) pf 1b
jantoven Jantoven 1a
PRADAXA 2 QL
SAVAYSA 3 QL
warfarin sodium oral Jantoven 1a
XARELTO ORAL TABLET 2 QL
XARELTO STARTER PACK 2 QL
ZONTIVITY 3 QL
Blood Formation Modifiers
anagrelide hcl Agrylin 1b
ARANESP (ALBUMIN FREE) Not covered SP
DOPTELET 4 PA; SP; QL
EPOGEN Not covered SP
FULPHILA 5 ST; SP; QL
GRANIX Not covered SP
LEUKINE 5 SP
MIRCERA Not covered SP; QL
MULPLETA Not covered SP; QL
NEULASTA 4 SP; QL
NEUPOGEN Not covered SP
NIVESTYM 4 SP; QL
NYVEPRIA 4 SP; QL
OXBRYTA ORAL TABLET 5 PA; SP; QL
OXBRYTA ORAL TABLET SOLUBLE Not covered
PROCRIT 4 SP
PROMACTA 4 PA; SP
RETACRIT 4 SP
UDENYCA 5 ST; SP; QL
ZARXIO 4 SP
ZIEXTENZO 5 ST; SP; QL
Hemostasis Agents
ADVATE 2
ADYNOVATE 2
AFSTYLA 2
ALPHANATE 2
ALPHANINE SD 2
ALPROLIX 2
BCN Custom Select Drug List - February 2022
48
Drug Name Brand Reference Drug Tier Notes
aminocaproic acid oral Amicar 1b
BENEFIX 2
COAGADEX 2
CORIFACT 2
ELOCTATE 2
ESPEROCT 2
FEIBA 2
HEMLIBRA 2 PA
HEMOFIL M 2
HUMATE-P 2
IDELVION 2
IXINITY 2
JIVI 2
KOATE 2
KOATE-DVI 2
KOGENATE FS 2
KOVALTRY 2
MONONINE 2
NOVOEIGHT 2
NOVOSEVEN RT 2
NUWIQ 2
OBIZUR 2
PROFILNINE 2
REBINYN 2
RECOMBINATE 2
RIXUBIS 2
SEVENFACT 2
TAVALISSE 5 PA; SP; QL
tranexamic acid oral Lysteda 1b QL
TRETTEN 2
VONVENDI 2
WILATE 2
XYNTHA 2
XYNTHA SOLOFUSE 2
Platelet Modifying Agents
aspirin-dipyridamole er 1b
ASPIRIN-OMEPRAZOLE Not covered
BCN Custom Select Drug List - February 2022
49
Drug Name Brand Reference Drug Tier Notes
BRILINTA 2 QL
CABLIVI 4 PA; SP; QL
cilostazol 1b
clopidogrel bisulfate oral Plavix 1a
dipyridamole oral 1b
DURLAZA Not covered QL
prasugrel hcl Effient 1b QL
YOSPRALA Not covered
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine Catapres-TTS-1 1b
clonidine hcl oral 1a
guanfacine hcl 1b
methyldopa 1b
midodrine hcl 1b
Alpha-adrenergic Blocking Agents
doxazosin mesylate oral Cardura 1b
phenoxybenzamine hcl oral Dibenzyline 1b PA; QL
prazosin hcl oral Minipress 1b
Angiotensin II Receptor Antagonists
candesartan cilexetil Atacand 1b
EDARBI 3 ST; QL
irbesartan Avapro 1a
losartan potassium oral Cozaar 1a
olmesartan medoxomil oral Benicar 1a
telmisartan Micardis 1a
valsartan Diovan 1a
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl oral Lotensin 1a
captopril oral 1a
enalapril maleate oral solution Epaned Not covered
enalapril maleate oral tablet Vasotec 1a
fosinopril sodium 1a
lisinopril oral Zestril 1a
moexipril hcl 1a
perindopril erbumine 1a
BCN Custom Select Drug List - February 2022
50
Drug Name Brand Reference Drug Tier Notes
QBRELIS Not covered QL
quinapril hcl Accupril 1a
ramipril Altace 1a
trandolapril Mavik 1a
Antiarrhythmics
amiodarone hcl oral Pacerone 1b
disopyramide phosphate Norpace 1b
dofetilide Tikosyn 1b
flecainide acetate 1b
mexiletine hcl oral 1b
MULTAQ 2 QL
NORPACE CR 2
propafenone hcl 1b
propafenone hcl er Rythmol SR 1b
quinidine gluconate er 1b
quinidine sulfate 1b
sorine Sorine 1a
sotalol hcl (af) Betapace AF 1a
sotalol hcl oral Sorine 1a
SOTYLIZE Not covered
Beta-adrenergic Blocking Agents
acebutolol hcl oral 1a
atenolol oral Tenormin 1a
betaxolol hcl oral 1a
bisoprolol fumarate oral 1a
carvedilol Coreg 1a
carvedilol phosphate er Coreg CR Not covered QL
HEMANGEOL Not covered QL
INDERAL XL Not covered
INNOPRAN XL Not covered
KAPSPARGO SPRINKLE Not covered
labetalol hcl oral 1a
metoprolol succinate er Toprol XL 1a
metoprolol tartrate oral Lopressor 1a
nadolol oral Corgard 1a
nebivolol hcl Bystolic 1b QL
pindolol 1a
BCN Custom Select Drug List - February 2022
51
Drug Name Brand Reference Drug Tier Notes
propranolol hcl er Inderal LA 1a
propranolol hcl oral 1a
timolol maleate oral 1a
Calcium Channel Blocking Agents
amlodipine besylate oral Norvasc 1a
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG
3
cartia xt Cartia XT 1b
CONJUPRI Not covered
diltiazem hcl er 1b
diltiazem hcl er beads Taztia XT 1b
diltiazem hcl er coated beads Cardizem CD 1b
diltiazem hcl oral Cardizem 1b
dilt-xr 1b
felodipine er 1a
isradipine 1b
KATERZIA Not covered QL
matzim la Matzim LA 1b
nicardipine hcl oral 1b
nifedipine er Afeditab CR 1b
nifedipine er osmotic release Procardia XL 1b
nifedipine oral 1b
nimodipine oral 1b
nisoldipine er Sular 1b
NYMALIZE 3 QL
taztia xt Taztia XT 1b
tiadylt er Taztia XT 1b
verapamil hcl er Calan SR 1b
verapamil hcl oral 1b
Cardiovascular Agents, Other
ALDACTAZIDE ORAL TABLET 50-50 MG
3
aliskiren fumarate Tekturna 1b
amiloride-hydrochlorothiazide 1a
amlodipine besylate-benazepril hcl Lotrel 1a
amlodipine besylate-valsartan Exforge 1a
amlodipine-atorvastatin Caduet 1b QL
BCN Custom Select Drug List - February 2022
52
Drug Name Brand Reference Drug Tier Notes
amlodipine-olmesartan Azor 1b
atenolol-chlorthalidone Tenoretic 100 1a
benazepril-hydrochlorothiazide Lotensin HCT 1a
BIDIL 2
bisoprolol-hydrochlorothiazide Ziac 1a
candesartan cilexetil-hctz Atacand HCT 1b
CONSENSI Not covered QL
CORLANOR 2 QL
DEMSER 3
digitek Digitek 1b
digox Digitek 1b
digoxin oral Digitek 1b
droxidopa Northera Not covered SP; QL
DUTOPROL 3
EDARBYCLOR 3 ST; QL
enalapril-hydrochlorothiazide Vaseretic 1a
ENTRESTO 2 QL
EXFORGE HCT 3
fosinopril sodium-hctz 1a
irbesartan-hydrochlorothiazide Avalide 1a
LANOXIN ORAL TABLET 62.5 MCG Not covered
lisinopril-hydrochlorothiazide Zestoretic 1a
losartan potassium-hctz Hyzaar 1a
metoprolol-hydrochlorothiazide 1a
metyrosine Demser 1b
olmesartan medoxomil-hctz Benicar HCT 1a
olmesartan-amlodipine-hctz Tribenzor 1b QL
pentoxifylline er 1b
PRESTALIA Not covered QL
quinapril-hydrochlorothiazide Accuretic 1a
ranolazine er Ranexa 1b
spironolactone-hctz Aldactazide 1a
TEKTURNA HCT 3
telmisartan-amlodipine 1b
telmisartan-hctz Micardis HCT 1a
trandolapril-verapamil hcl er 1b
triamterene-hctz Maxzide 1a
BCN Custom Select Drug List - February 2022
53
Drug Name Brand Reference Drug Tier Notes
valsartan-hydrochlorothiazide Diovan HCT 1a
VECAMYL Not covered QL
VERQUVO 3 PA; QL
VYNDAMAX 4 PA; SP; QL
VYNDAQEL 4 PA; SP; QL
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide er 1b
acetazolamide oral 1b
KEVEYIS 5 PA; SP; QL
methazolamide oral 1b
Diuretics, Loop
bumetanide oral Bumex 1a
ethacrynic acid Edecrin 1b
furosemide oral Lasix 1a
torsemide 1a
Diuretics, Potassium-sparing
amiloride hcl oral 1a
CAROSPIR Not covered
eplerenone Inspra 1a
spironolactone oral Aldactone 1a
triamterene oral Dyrenium 1b
Diuretics, Thiazide
chlorthalidone 1a
DIURIL 3
hydrochlorothiazide oral 1a
indapamide 1a
metolazone 1a
THALITONE Not covered
Dyslipidemics, Fibric Acid Derivatives
ANTARA 3
fenofibrate micronized oral capsule 130 mg, 43 mg
1b
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
1a
FENOFIBRATE MICRONIZED ORAL CAPSULE 30 MG, 90 MG
3 ABA
BCN Custom Select Drug List - February 2022
54
Drug Name Brand Reference Drug Tier Notes
fenofibrate oral capsule 134 mg, 200 mg, 67 mg
1a
fenofibrate oral capsule 150 mg, 50 mg Lipofen Not covered
fenofibrate oral tablet 120 mg, 40 mg Fenoglide Not covered
fenofibrate oral tablet 145 mg, 48 mg Tricor 1a
fenofibrate oral tablet 160 mg, 54 mg 1a
fenofibric acid oral capsule delayed release
Trilipix 1b
fenofibric acid oral tablet Fibricor Not covered
FIBRICOR Not covered
gemfibrozil oral Lopid 1a
LIPOFEN Not covered
Dyslipidemics, HMG CoA Reductase Inhibitors
ALTOPREV Not covered QL
atorvastatin calcium oral tablet 10 mg, 20 mg
Lipitor 1aPV2; QL; AL (Min 40 Years and Max 75 Years)
atorvastatin calcium oral tablet 40 mg, 80 mg
Lipitor 1a QL
EZALLOR SPRINKLE Not covered
FLOLIPID Not covered
fluvastatin sodium 1bPV2; QL; AL (Min 40 Years and Max 75 Years)
fluvastatin sodium er Lescol XL 1bPV2; QL; AL (Min 40 Years and Max 75 Years)
LIVALO 3 ST; QL
lovastatin oral 1aPV2; QL; AL (Min 40 Years and Max 75 Years)
pravastatin sodium Pravachol 1aPV2; QL; AL (Min 40 Years and Max 75 Years)
rosuvastatin calcium oral tablet 10 mg, 5 mg
Crestor 1aPV2; QL; AL (Min 40 Years and Max 75 Years)
rosuvastatin calcium oral tablet 20 mg, 40 mg
Crestor 1a QL
BCN Custom Select Drug List - February 2022
55
Drug Name Brand Reference Drug Tier Notes
simvastatin oral tablet 10 mg, 20 mg, 40 mg
Zocor 1aPV2; QL; AL (Min 40 Years and Max 75 Years)
simvastatin oral tablet 5 mg 1aPV2; QL; AL (Min 40 Years and Max 75 Years)
simvastatin oral tablet 80 mg Zocor 1a QL
ZYPITAMAG Not covered
Dyslipidemics, Other
cholestyramine light Prevalite 1b
cholestyramine oral Questran 1b
colesevelam hcl Welchol 1b
colestipol hcl Colestid 1b
ezetimibe Zetia 1b QL
EZETIMIBE-ROSUVASTATIN Not covered ABA
ezetimibe-simvastatin Vytorin 1b QL
icosapent ethyl Vascepa 1b QL
JUXTAPID Not covered SP; QL
NEXLETOL 2 PA; QL
NEXLIZET 2 PA; QL
niacin (antihyperlipidemic) Niacor Not covered
niacin er (antihyperlipidemic) Niaspan 1b
niacor Niacor Not covered
omega-3-acid ethyl esters Lovaza 1b QL
PRALUENT 2 PA; QL
prevalite Prevalite 1b
REPATHA 2 PA; QL
REPATHA PUSHTRONEX SYSTEM 2 PA; QL
REPATHA SURECLICK 2 PA; QL
ROSZET Not covered
VASCEPA ORAL CAPSULE 0.5 GM 2 QL
Vasodilators, Direct-acting Arterial/Venous
GONITRO Not covered
isosorbide dinitrate Isordil Titradose 1b
isosorbide mononitrate 1a
isosorbide mononitrate er 1a
NITRO-BID 2
BCN Custom Select Drug List - February 2022
56
Drug Name Brand Reference Drug Tier Notes
NITRO-DUR Not covered
nitroglycerin sublingual Nitrostat 1b
nitroglycerin transdermal Nitro-Dur 1b
nitroglycerin translingual Nitrolingual 1b
NITROMIST Not covered
NITRO-TIME 2
RECTIV 3 QL
Vasodilators, Direct-acting Arterial
hydralazine hcl oral 1b
minoxidil oral 1b
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
ADZENYS XR-ODT Not covered QL
amphetamine sulfate Evekeo 1b PA; QL
amphetamine-dextroamphetamine Adderall 1b QL
amphetamine-dextroamphetamine er Adderall XR 1b QL
dextroamphetamine sulfate ProCentra 1b QL
dextroamphetamine sulfate er Dexedrine 1b QL
DYANAVEL XR Not covered QL
EVEKEO ODT Not covered QL
methamphetamine hcl Desoxyn 1b QL
MYDAYIS 2 QL
VYVANSE 2 QL
ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG
3 QL
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
ADHANSIA XR Not covered QL
atomoxetine hcl Strattera 1b QL
AZSTARYS Not covered QL
clonidine hcl er Kapvay 1b QL
COTEMPLA XR-ODT Not covered QL
DAYTRANA 3 QL
dexmethylphenidate hcl Focalin 1b QL
dexmethylphenidate hcl er Focalin XR 1b QL
guanfacine hcl er Intuniv 1b QL
JORNAY PM Not covered QL
BCN Custom Select Drug List - February 2022
57
Drug Name Brand Reference Drug Tier Notes
methylphenidate hcl er (cd) 1b QL
methylphenidate hcl er (la) Ritalin LA 1b QL
methylphenidate hcl er (xr) Aptensio XR Not covered QL
methylphenidate hcl er oral tablet extended release 10 mg, 20 mg
1b QL
methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg
Concerta 1b QL
methylphenidate hcl er oral tablet extended release 24 hour
1b QL
methylphenidate hcl er oral tablet extended release 72 mg
Relexxii Not covered QL
methylphenidate hcl oral Methylin 1b QL
QELBREE 3 PA; QL
QUILLICHEW ER Not covered QL
QUILLIVANT XR Not covered QL
relexxii Relexxii Not covered QL
Central Nervous System, Other
AUSTEDO 4 PA; SP; QL
caffeine citrate oral 1b
EXSERVAN 5 PA; SP; QL
GRALISE ORAL TABLET Not covered QL
HORIZANT Not covered QL
IMCIVREE 4 PA; SP; QL
INGREZZA 5 PA; SP; QL
NUEDEXTA 2 PA; QL
riluzole Rilutek 1b
tetrabenazine Xenazine 4 PA; SP; QL
TIGLUTIK 5 PA; SP; QL
Fibromyalgia Agents
pregabalin Lyrica 1b QL
pregabalin er Lyrica CR Not covered QL
SAVELLA 3 PA; QL
SAVELLA TITRATION PACK 3 PA; QL
Multiple Sclerosis Agents
AUBAGIO 5 SP; QL
AVONEX PEN 4 SP; QL
AVONEX PREFILLED 4 SP; QL
BCN Custom Select Drug List - February 2022
58
Drug Name Brand Reference Drug Tier Notes
BAFIERTAM 4 SP; QL
BETASERON 4 SP; QL
COPAXONE 4 SP; QL
dalfampridine er Ampyra 4 SP; QL
dimethyl fumarate oral Tecfidera 4 SP; QL
dimethyl fumarate starter pack Tecfidera 4 SP; QL
EXTAVIA 5 SP; QL
GILENYA ORAL CAPSULE 0.5 MG 4 SP; QL
glatiramer acetate Copaxone 4 SP; QL
glatopa Copaxone 4 SP; QL
KESIMPTA 4 SP; QL
MAVENCLAD 5 ST; SP; QL
MAYZENT 4 SP; QL
MAYZENT STARTER PACK 4 SP
PLEGRIDY INTRAMUSCULAR 5 SP; QL
PLEGRIDY STARTER PACK 5 SP; QL
PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR
5 SP; QL
PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
Not covered SP; QL
PONVORY Not covered SP; QL
PONVORY STARTER PACK Not covered SP; QL
REBIF 4 SP; QL
REBIF REBIDOSE 4 SP; QL
REBIF REBIDOSE TITRATION PACK 4 SP; QL
REBIF TITRATION PACK 4 SP; QL
VUMERITY 4 SP; QL
ZEPOSIA Not covered SP; QL
ZEPOSIA 7-DAY STARTER PACK Not covered SP; QL
ZEPOSIA STARTER KIT Not covered SP; QL
Cholestatic Pruritus Agent
Ileal Bile Acid Transporter Inhibitor
BYLVAY 4 PA; SP; QL
BYLVAY (PELLETS) 4 PA; SP; QL
LIVMARLI 4 PA; SP; QL
Dental and Oral Agents
cavarest Cavarest 1b
BCN Custom Select Drug List - February 2022
59
Drug Name Brand Reference Drug Tier Notes
cevimeline hcl Evoxac 1b
chlorhexidine gluconate mouth/throat Periogard Not covered
DENTA 5000 PLUS Not covered
DENTAGEL Not covered
oralone Oralone 1b
periogard Periogard Not covered
pilocarpine hcl oral Salagen 1b
PREVIDENT Not covered
PREVIDENT 5000 DRY MOUTH Not covered
PREVIDENT 5000 PLUS Not covered
sf Cavarest Not covered
sf 5000 plus Denta 5000 Plus Not covered
sodium fluoride 5000 plus Denta 5000 Plus Not covered
sodium fluoride 5000 ppm dental cream Denta 5000 Plus Not covered
sodium fluoride 5000 ppm dental gel Cavarest Not covered
sodium fluoride dental Cavarest Not covered
sodium fluoride mouth/throat PreviDent Not covered
triamcinolone acetonide mouth/throat Oralone 1b
Dermatological Agents
ABSORICA LD Not covered QL
accutane Accutane 1b QL
acitretin 1b
ACZONE EXTERNAL GEL 7.5 % Not covered
adapalene external cream Differin 1b
adapalene external gel 0.1 % Differin 1b
adapalene external gel 0.3 % Differin Not covered
ADAPALENE EXTERNAL PAD Not covered
adapalene-benzoyl peroxide external gel 0.1-2.5 %
Epiduo Not covered
adapalene-benzoyl peroxide external gel 0.3-2.5 %
Epiduo Forte Not covered QL
AKLIEF Not covered QL
ALTRENO 3 QL
ammonium lactate external AL12 1b
amnesteem Accutane 1b QL
AMZEEQ Not covered QL
ARAZLO Not covered QL
BCN Custom Select Drug List - February 2022
60
Drug Name Brand Reference Drug Tier Notes
AVAR CLEANSER 3
AVAR-E EMOLLIENT 3
AVAR-E GREEN 3
AVITA Not covered
azelaic acid external Finacea 1b
AZELEX Not covered
BENZAC AC WASH Not covered
BENZEPRO EXTERNAL Not covered
BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 %
Not covered
BENZEPRO EXTERNAL LIQUID Not covered
BENZOYL PEROXIDE EXTERNAL GEL 6.5 %
Not covered
benzoyl peroxide-erythromycin Benzamycin 1b
calcipotriene external cream Dovonex 1b
CALCIPOTRIENE EXTERNAL FOAM Not covered
calcipotriene external ointment Calcitrene 1b
calcipotriene external solution 1b
calcipotriene-betameth diprop Taclonex 1b PA
calcitriol external Vectical 1b
claravis Accutane 1b QL
clindacin etz external swab Clindacin ETZ 1b
clindacin-p Clindacin ETZ 1b
clindamycin phos-benzoyl perox external gel 1.2-2.5 %
Acanya Not covered
clindamycin phos-benzoyl perox external gel 1.2-5 %
Neuac Not covered
clindamycin phosphate-benzoyl peroxide external gel 1-5 %
BenzaClin 1b
clindamycin phosphate external foam Evoclin Not covered
clindamycin phosphate external lotion Cleocin-T Not covered
clindamycin phosphate external solution Not covered
clindamycin phosphate external swab Clindacin ETZ 1b
clindamycin phosphate gel 1 % external Cleocin-T 1b
clindamycin phosphate gel 1 % external Clindagel Not covered
clindamycin-tretinoin Veltin Not covered
CONDYLOX 2
COSENTYX (300 MG DOSE) Not covered SP; QL
BCN Custom Select Drug List - February 2022
61
Drug Name Brand Reference Drug Tier Notes
COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML
Not covered SP; QL
COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 75 MG/0.5ML
Not covered SP
COSENTYX SENSOREADY (300 MG) Not covered SP; QL
COSENTYX SENSOREADY PEN Not covered SP; QL
dapsone external gel 5 % Aczone Not covered QL
DAPSONE EXTERNAL GEL 7.5 % Not covered ABA
DIFFERIN EXTERNAL LOTION Not covered
doxepin hcl external Prudoxin 1b PA; QL
doxycycline Oracea Not covered
DRYSOL 2
DUOBRII 3 QL
DUPIXENT 4 PA; SP; QL
ENSTILAR Not covered QL
EPIFOAM 2
ery Not covered
erythromycin external Erygel Not covered
EUCRISA 2 PA; QL
FABIOR Not covered QL
FINACEA EXTERNAL FOAM Not covered QL
hydrocortisone ace-pramoxine external cream 2.5-1 %
Pramosone 1b
imiquimod cream 3.75 % external Zyclara Pump Not covered QL
imiquimod external cream 5 % Aldara 1b QL
IMIQUIMOD PUMP CREAM 3.75 % EXTERNAL
Not covered QL
IMIQUIMOD PUMP CREAM 3.75 % EXTERNAL
Not covered ABA; QL
isotretinoin oral capsule 10 mg Amnesteem 1b QL
isotretinoin oral capsule 20 mg, 30 mg, 40 mg
Accutane 1b QL
isotretinoin oral capsule 25 mg, 35 mg Absorica Not covered QL
ivermectin external cream Soolantra Not covered QL
LIDOCAINE-HYDROCORTISONE ACE EXTERNAL
Not covered
methoxsalen rapid 1b
BCN Custom Select Drug List - February 2022
62
Drug Name Brand Reference Drug Tier Notes
metronidazole external cream Rosadan 1b
metronidazole external gel 0.75 % Rosadan 1b
metronidazole external gel 1 % Metrogel Not covered
metronidazole external lotion MetroLotion 1b
myorisan Accutane 1b QL
neuac external gel Neuac Not covered
NORITATE Not covered
ONEXTON Not covered QL
OPZELURA 3 PA; QL
OVACE PLUS WASH EXTERNAL LIQUID
3
OVACE WASH Not covered
pimecrolimus Elidel 1b
podofilox external 1b
PR BENZOYL PEROXIDE Not covered
PRAMOSONE Not covered
QBREXZA Not covered QL
REGRANEX 3 QL
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %
Not covered
rosadan external cream Rosadan 1b
rosadan external gel Rosadan 1b
SANTYL 2
selenium sulfide external lotion 1b
SILIQ Not covered SP; QL
sodium sulfacetamide wash Ovace Plus Wash 1b
SORILUX Not covered
sss 10-5 external cream Avar-e Emollient 1b
STELARA SUBCUTANEOUS 4 PA; SP; QL
sulfacetamide sodium (acne) Klaron 1b
sulfacetamide sodium external Ovace Plus Wash 1b
sulfacetamide sodium-sulfur external cream 10-5 %
Avar-e Emollient 1b
sulfacetamide sodium-sulfur external liquid 10-5 %
Avar Cleanser 1b
tacrolimus external Protopic 1b
TALTZ 5 PA; SP; QL
tazarotene external cream Tazorac 1b
BCN Custom Select Drug List - February 2022
63
Drug Name Brand Reference Drug Tier Notes
TAZAROTENE EXTERNAL FOAM Not covered ABA; QL
TAZORAC EXTERNAL CREAM 0.05 % 2
TAZORAC EXTERNAL GEL 2
TREMFYA 4 PA; SP; QL
tretinoin external cream Avita 1b
tretinoin external gel 0.01 % Retin-A 1b
tretinoin external gel 0.025 % Avita 1b
tretinoin external gel 0.05 % Atralin Not covered
tretinoin microsphereRETIN-A MICRO GEL 0.04 %, 0.1 %
Not covered
tretinoin microsphere pumpRETIN-A MICRO GEL 0.04 %, 0.1 %
Not covered
VELTIN Not covered
VEREGEN 3
WINLEVI Not covered QL
WYNZORA Not covered QL
zenatane Accutane 1b QL
ZILXI Not covered QL
ZYCLARA PUMP Not covered QL
Electrolytes/Minerals/Metals/Vitamins
Electrolyte/Mineral Replacement
ACCRUFER 3 PA; QL
carglumic acid Carbaglu 4 PA; SP
EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ
Not covered
effer-k oral tablet effervescent 25 meq 1b
fluoritab NaFrinse Drops 1bPV2; AL (Min 6 Months and Max 16 Years)
GALZIN 3
iodine strong oral 1b
klor-con Klor-Con 1b
klor-con 10 Klor-Con 10 1b
klor-con m10 Klor-Con M10 1b
klor-con m15 Klor-Con M15 1b
klor-con m20 Klor-Con M20 1b
klor-con/ef 1b
BCN Custom Select Drug List - February 2022
64
Drug Name Brand Reference Drug Tier Notes
K-PHOS Not covered
K-PHOS NO 2 Not covered
k-prime 1b
levocarnitine oral solution Carnitor 1b
levocarnitine oral tablet Carnitor 1b
levocarnitine sf Carnitor 1b
nafrinse NaFrinse 1bPV2; AL (Min 6 Months and Max 16 Years)
nafrinse drops NaFrinse Drops 1bPV2; AL (Min 6 Months and Max 16 Years)
potassium chloride crys er Klor-Con M10 1b
potassium chloride er K-Tab 1b
potassium chloride oral packet Klor-Con 1b
potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)
1b
potassium citrate er Urocit-K 10 1b
sodium fluoride oral NaFrinse 1bPV2; AL (Min 6 Months and Max 16 Years)
Electrolyte/Mineral/Metal Modifiers
CHEMET 2
deferasirox granules Jadenu Sprinkle Not covered 15DS; SP
deferasirox oral packet Jadenu Sprinkle Not covered 15DS; SP
deferasirox oral tablet Jadenu Not covered 15DS; SP
deferasirox oral tablet soluble Exjade 4 PA; 15DS; SP
deferiprone Ferriprox 4 PA; SP; QL
FERRIPROX ORAL SOLUTION 5 PA; SP; QL
FERRIPROX ORAL TABLET 1000 MG 5 PA; SP; QL
FERRIPROX TWICE-A-DAY 5 PA; SP; QL
JYNARQUE 4 PA; SP; QL
LOKELMA 2 QL
SAMSCA ORAL TABLET 15 MG 4 PA; SP; QL
sodium polystyrene sulfonate 1b
sps 1b
TOLVAPTAN ORAL TABLET 15 MG 4 PA; SP; QL
tolvaptan oral tablet 30 mg Jynarque 4 PA; SP; QL
trientine hcl Syprine 4 PA; SP; QL
BCN Custom Select Drug List - February 2022
65
Drug Name Brand Reference Drug Tier Notes
VELTASSA 2 QL
Phosphate Binders
AURYXIA 3
calcium acetate (phos binder) Calphron 1b
calcium acetate oral tablet 667 mg Calphron 1b
FOSRENOL ORAL PACKET Not covered
lanthanum carbonate Fosrenol 1b
PHOSLYRA 3
sevelamer carbonate Renvela 1b
sevelamer hcl Renagel 1b
VELPHORO Not covered
Vitamins
cyanocobalamin injection solution 1000 mcg/ml
1b
CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML
Not covered
ergocalciferol oral capsule Drisdol 1b
folate 0 PV1
folic acid oral tablet 1 mg 1b
folic acid oral tablet 400 mcg, 800 mcg 0 PV1
hydroxocobalamin acetate 1b
NASCOBAL Not covered
phytonadione injection solution 10 mg/ml 1b
phytonadione oral Mephyton 1b
POTABA Not covered
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)
Drisdol 1b
vitamin k1 injection 1b
yl folic acid 0 PV1
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
belladonna alkaloids-opium 1b
CUVPOSA 3
dicyclomine hcl oral 1b
glycopyrrolate oral tablet 1b
hyoscyamine sulfate er Levbid 1b
hyoscyamine sulfate oral Levsin 1b
hyoscyamine sulfate sl Levsin/SL 1b
BCN Custom Select Drug List - February 2022
66
Drug Name Brand Reference Drug Tier Notes
hyoscyamine sulfate sublingual Levsin/SL 1b
hyosyne 1b
LEVBID Not covered
LEVSIN ORAL Not covered
LEVSIN/SL Not covered
methscopolamine bromide oral 1b
NULEV Not covered
OSCIMIN Not covered
oscimin sr oral tablet extended release 12 hour 0.375 mg
Levbid 1b
Gastrointestinal Agents, Other
amoxicill-clarithro-lansopraz 1b
CHENODAL 5 PA; SP
chlordiazepoxide-clidinium Librax 1b
cromolyn sodium oral Gastrocrom 1b
diphenoxylate-atropine Lomotil 1b
GATTEX 4 PA; SP; QL
HELIDAC THERAPY Not covered
loperamide hcl oral capsule Imodium A-D Not covered
MOTEGRITY 3 ST; QL
MOTOFEN Not covered
MOVANTIK Not covered QL
MYTESI 2 PA; QL
OMECLAMOX-PAK Not covered
PYLERA Not covered
RELISTOR ORAL Not covered QL
RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML
Not covered QL
RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML
Not covered ABA; QL
RELTONE Not covered
SEROSTIM 5 PA; SP
SYMPROIC 2 QL
TALICIA Not covered QL
TRULANCE Not covered QL
URSODIOL ORAL CAPSULE 200 MG, 400 MG
Not covered
ursodiol oral capsule 300 mg 1b
BCN Custom Select Drug List - February 2022
67
Drug Name Brand Reference Drug Tier Notes
ursodiol oral tablet Urso 250 1b
XERMELO 4 PA; SP; QL
ZORBTIVE 5 PA; SP
Histamine2 (H2) Receptor Antagonists
cimetidine hcl 1b
cimetidine oral Tagamet HB 1b
famotidine oral suspension reconstituted 1b
famotidine oral tablet 20 mgMM Acid-Pep Maximum Strength
1b
famotidine oral tablet 40 mg Pepcid 1b
nizatidine 1b
Irritable Bowel Syndrome Agents
alosetron hcl Lotronex 1b QL
AMITIZA 2 QL
LINZESS 2 QL
LUBIPROSTONE Not covered ABA; QL
VIBERZI Not covered QL
ZELNORM 3 PA; QL
Laxatives
bisacodyl ec Alophen 0PV1; QL; AL (Min 45 Years and Max 75 Years)
citroma Citroma 0PV1; QL; AL (Min 45 Years and Max 75 Years)
clearlax ClearLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)
CLENPIQ 3
constulose 1b
enulose 1b
gavilax oral powder ClearLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)
gavilyte-c 1bPV2; QL; AL (Min 45 Years and Max 75 Years)
gavilyte-g GaviLyte-G 1bPV2; QL; AL (Min 45 Years and Max 75 Years)
BCN Custom Select Drug List - February 2022
68
Drug Name Brand Reference Drug Tier Notes
gavilyte-n with flavor packGaviLyte-N with Flavor Pack
1bPV2; QL; AL (Min 45 Years and Max 75 Years)
generlac 1b
gentle laxative oral Alophen 0PV1; QL; AL (Min 45 Years and Max 75 Years)
healthylax HealthyLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)
KRISTALOSE Not covered
lactulose encephalopathy 1b
lactulose oral packet Kristalose Not covered
lactulose oral solution 1b
magnesium citrate oral solution Citroma 0PV1; QL; AL (Min 45 Years and Max 75 Years)
milk of magnesia concentrate 0PV1; QL; AL (Min 45 Years and Max 75 Years)
milk of magnesia oral suspension 1200 mg/15ml, 400 mg/5ml
Dulcolax 0PV1; QL; AL (Min 45 Years and Max 75 Years)
mm clearlax ClearLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)
OSMOPREP Not covered
peg 3350 oral packet HealthyLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)
peg 3350-kcl-na bicarb-naclGaviLyte-N with Flavor Pack
1bPV2; QL; AL (Min 45 Years and Max 75 Years)
peg-3350/electrolytes GaviLyte-G 1bPV2; QL; AL (Min 45 Years and Max 75 Years)
peg-3350/electrolytes/ascorbat MoviPrep 1bPV2; QL; AL (Min 45 Years and Max 75 Years)
peg-kcl-nacl-nasulf-na asc-c MoviPrep 1bPV2; QL; AL (Min 45 Years and Max 75 Years)
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
peg-prep 1bPV2; QL; AL (Min 45 Years and Max 75 Years)
PLENVU Not covered
polyethylene glycol 3350 oral packet 17 gm
HealthyLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)
polyethylene glycol 3350 oral powder ClearLax 0PV1; QL; AL (Min 45 Years and Max 75 Years)
qc magnesium citrate Citroma 0PV1; QL; AL (Min 45 Years and Max 75 Years)
SUPREP BOWEL PREP KIT 3
SUTAB Not covered QL
Protectants
CYTOTEC 3
misoprostol oral Cytotec 1b
sucralfate oral Carafate 1b
Proton Pump Inhibitors
ACIPHEX SPRINKLE Not covered QL
DEXILANT Not covered
DEXLANSOPRAZOLE Not covered
ESOMEPRAZOLE STRONTIUM Not covered ABA; QL
lansoprazole oral capsule delayed release
Prevacid 1b QL
NEXIUM ORAL PACKET 2.5 MG, 5 MG Not covered AL (Max 1 Years)
omeprazole oral capsule delayed release 1b QL
omeprazole-sodium bicarbonate Zegerid Not covered QL
pantoprazole sodium oral tablet delayed release
Protonix 1b QL
PRILOSEC Not covered
RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE
Not covered ABA; QL
rabeprazole sodium oral tablet delayed release
Aciphex 1b
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
CERDELGA 4 PA; SP; QL
CHOLBAM 4 PA; SP; QL
BCN Custom Select Drug List - February 2022
70
ABA
Drug Name Brand Reference Drug Tier Notes
CREON 2
CYSTADANE 5 SP
CYSTAGON 4 SP
EVRYSDI 4 PA; SP; QL
GALAFOLD 4 PA; SP; QL
GLASSIA 4 PA; SP; QL
miglustat Zavesca 4 PA; SP; QL
MYALEPT 5 PA; SP; QL
nitisinone Orfadin 4 PA; SP
NITYR 5 PA; SP
OCALIVA 4 PA; SP; QL
ORFADIN ORAL CAPSULE 20 MG 4 PA; SP
ORFADIN ORAL SUSPENSION 4 PA; SP
PALYNZIQ 4 PA; SP; QL
PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG
Not covered SP; QL
PROCYSBI ORAL CAPSULE DELAYED RELEASE 75 MG
Not covered SP
PROCYSBI ORAL PACKET Not covered SP; QL
RAVICTI 5 PA; SP; QL
REVCOVI 4 PA; SP; QL
sapropterin dihydrochloride Kuvan 4 PA; SP
sodium phenylbutyrate oral powder Buphenyl 1b
sodium phenylbutyrate oral tablet Buphenyl 1b QL
STRENSIQ 4 PA; SP; QL
SUCRAID 5 PA; SP; QL
TEGSEDI 4 PA; SP; QL
XURIDEN 4 PA; SP; QL
ZENPEP 2
Genitourinary Agents
Antispasmodics, Urinary
darifenacin hydrobromide er Enablex Not covered QL
flavoxate hcl 1b
GELNIQUE Not covered QL
GEMTESA Not covered QL
MYRBETRIQ 3 PA; QL
oxybutynin chloride er Ditropan XL 1a
BCN Custom Select Drug List - February 2022
71
Drug Name Brand Reference Drug Tier Notes
oxybutynin chloride oral 1a
OXYTROL Not covered QL
solifenacin succinate VESIcare 1b QL
tolterodine tartrate Detrol 1b
tolterodine tartrate er Detrol LA 1b
TOVIAZ Not covered QL
trospium chloride 1b QL
trospium chloride er 1b QL
VESICARE LS 3 PA; QL
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er Uroxatral 1b
CARDURA XL 3
dutasteride oral Avodart 1b
dutasteride-tamsulosin hcl Jalyn 1b QL
finasteride oral tablet 5 mg Proscar 1b
silodosin Rapaflo 1b QL
tamsulosin hcl Flomax 1b
terazosin hcl 1b
Genitourinary Agents, Other
acetic acid irrigation 1b
argyle sterile saline Argyle Sterile Saline 1b
bethanechol chloride oral 1b
curity sterile saline Argyle Sterile Saline 1b
ELMIRON 2
LITHOSTAT 3
OPTIONS GYNOL II CONTRACEPTIVE 0 PV1; QL
penicillamine oral capsule Cuprimine Not covered QL
penicillamine oral tablet Depen Titratabs 1b QL
RENACIDIN 2
sodium chloride irrigation Argyle Sterile Saline 1b
THIOLA EC 2 PA; QL
tiopronin Thiola 1b PA; QL
TODAY SPONGE 0 PV1; QL
VCF VAGINAL CONTRACEPTIVE VAGINAL FILM
0 PV1; QL
VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM
0 PV1; QL
BCN Custom Select Drug List - February 2022
72
Drug Name Brand Reference Drug Tier Notes
vcf vaginal contraceptive vaginal gel 0 PV1; QL
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
ALA SCALP Not covered
ala-cort external cream 1 % Aveeno Anti-Itch Max St Not covered
ala-cort external cream 2.5 % 1b
alclometasone dipropionate 1b
ALKINDI SPRINKLE 3 PA; QL
amcinonide Not covered
APEXICON E Not covered
betamethasone dipropionate aug Diprolene 1b
betamethasone dipropionate external 1b
betamethasone valerate external cream 1b
betamethasone valerate external foam Luxiq Not covered
betamethasone valerate external lotion 1b
betamethasone valerate external ointment
1b
BRYHALI 3 QL
CAPEX 2
clobetasol prop emollient base 1b
clobetasol propionate e 1b
clobetasol propionate emulsion Tovet Not covered
clobetasol propionate external cream Temovate 1b
clobetasol propionate external foam Olux Not covered
clobetasol propionate external gel 1b
clobetasol propionate external liquid Clobex Spray Not covered
clobetasol propionate external lotion Clobex Not covered
clobetasol propionate external ointment Temovate 1b
clobetasol propionate external shampoo Clodan 1b
clobetasol propionate external solution 1b
clocortolone pivalate Cloderm Not covered
clodan external shampoo Clodan 1b
CORDRAN EXTERNAL CREAM 0.025 %
Not covered
CORDRAN EXTERNAL TAPE Not covered
DECADRON Not covered
desonide external cream DesOwen 1b
BCN Custom Select Drug List - February 2022
73
Drug Name Brand Reference Drug Tier Notes
desonide external gel DesRx Not covered
desonide external lotion 1b
desonide external ointment 1b
desoximetasone external Topicort Not covered
desrx DesRx Not covered
DEXABLISS Not covered
dexamethasone intensol 1a
dexamethasone oral elixir 1a
dexamethasone oral solution 1a
dexamethasone oral tablet Decadron 1a
dexamethasone oral tablet therapy pack HiDex 6-Day 1b
diflorasone diacetate Not covered
DXEVO 11-DAY Not covered
EMFLAZA 5 PA; SP
fludrocortisone acetate oral 1b
fluocinolone acetonide bodyDerma-Smoothe/FS Body
1b
fluocinolone acetonide external Synalar 1b
fluocinolone acetonide scalpDerma-Smoothe/FS Scalp
1b
fluocinonide emulsified base 1b
fluocinonide external cream 0.05 % 1b
fluocinonide external cream 0.1 % Vanos 1b QL
fluocinonide external gel 1b
fluocinonide external ointment 1b
fluocinonide external solution 1b
flurandrenolide Cordran Not covered
fluticasone propionate external Cutivate 1b
halcinonide Halog Not covered
halobetasol propionate external cream 1b
HALOBETASOL PROPIONATE EXTERNAL FOAM
Not covered
halobetasol propionate external ointment 1b
HALOG EXTERNAL OINTMENT Not covered
HALOG EXTERNAL SOLUTION Not covered
HEMADY Not covered
HIDEX 6-DAY Not covered
hydrocortisone butyr lipo base Locoid Lipocream Not covered
BCN Custom Select Drug List - February 2022
74
Drug Name Brand Reference Drug Tier Notes
hydrocortisone butyrate Locoid 1b
hydrocortisone external cream 1 % Aveeno Anti-Itch Max St Not covered
hydrocortisone external cream 2.5 % 1b
hydrocortisone external lotion 2.5 % 1b
hydrocortisone external ointment 1 %Aquaphor Itch Relief Max Str
Not covered
hydrocortisone external ointment 2.5 % 1b
hydrocortisone oral Cortef 1a
hydrocortisone valerate 1b
IMPEKLO Not covered
IMPOYZ Not covered
LEXETTE Not covered
MEDROL ORAL TABLET 2 MG 3
methylprednisolone oral Medrol 1a
MILLIPRED 2
mometasone furoate external 1b
nolix Nolix Not covered
PANDEL Not covered
prednicarbate Not covered
prednisolone oral solution 1a
prednisolone sodium phosphate oral solution
Pediapred 1a
prednisolone sodium phosphate oral tablet dispersible
Orapred ODT Not covered
prednisone intensol 1a
prednisone oral 1a
PSORCON Not covered
RAYOS Not covered QL
SERNIVO Not covered QL
SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG
3
TAPERDEX 12-DAY Not covered
TAPERDEX 6-DAY Not covered
TAPERDEX 7-DAY Not covered
TEXACORT Not covered
tovet external foam Tovet Not covered
triamcinolone acetonide external aerosol solution
Kenalog 1b QL
BCN Custom Select Drug List - February 2022
75
Drug Name Brand Reference Drug Tier Notes
triamcinolone acetonide external cream Triderm 1b
triamcinolone acetonide external lotion 1b
triamcinolone acetonide external ointment
Tritocin 1b
triamcinolone in absorbase Tritocin 1b
TRIANEX Not covered
triderm Triderm 1b
tritocin Tritocin 1b
ULTRAVATE Not covered
VERDESO Not covered
ZCORT 7-DAY Not covered
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
ACTHAR Not covered SP; QL
cabergoline 1b
CHORIONIC GONADOTROPIN INTRAMUSCULAR
Not covered SP; QL
desmopressin ace spray refrig 1b
desmopressin acetate injection DDAVP 1b
desmopressin acetate oral DDAVP 1b
desmopressin acetate pf DDAVP PF 1b
desmopressin acetate spray 1b
EGRIFTA SV Not covered SP; QL
FOLLISTIM AQ 5 PA; SP; QL
GENOTROPIN 4 PA; SP
GENOTROPIN MINIQUICK 4 PA; SP
GONAL-F 4 PA; SP; QL
GONAL-F RFF 4 PA; SP; QL
GONAL-F RFF REDIJECT 4 PA; SP; QL
HUMATROPE 5 PA; SP
INCRELEX 4 PA; SP
ISTURISA 5 PA; SP; QL
NOCDURNA Not covered QL
NORDITROPIN FLEXPRO 4 PA; SP
NOVAREL Not covered SP; QL
NUTROPIN AQ NUSPIN 10 5 PA; SP
NUTROPIN AQ NUSPIN 20 5 PA; SP
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
NUTROPIN AQ NUSPIN 5 5 PA; SP
OMNITROPE 5 PA; SP
OVIDREL 4 PA; SP; QL
PREGNYL 4 PA; SP; QL
SAIZEN 5 PA; SP
SAIZENPREP 5 PA; SP
SKYTROFA 5 PA; SP
STIMATE 2
ZOMACTON 5 PA; SP
ZOMACTON (FOR ZOMA-JET 10) 5 PA; SP
Selective Estrogen Receptor Modifying Agents
clomiphene citrate oral 1b QL
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
KORLYM 4 PA; SP; QL
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Androgens
ANDRODERM 2 PA; QL
danazol oral 1b
INTRAROSA 3
JATENZO Not covered QL
METHITEST 3 QL
methyltestosterone oral Not covered QL
NATESTO Not covered QL
oxandrolone oral 1b PA
TESTOSTERONE CYPIONATE INJECTION
Not covered
testosterone cypionate intramuscular Depo-Testosterone 1b
testosterone enanthate intramuscular 1b
testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%)
AndroGel Pump 1b PA; QL
testosterone transdermal gel 10 mg/act (2%)
Fortesta Not covered QL
testosterone transdermal gel 12.5 mg/act (1%)
Vogelxo Pump 1b PA; QL
BCN Custom Select Drug List - February 2022
77
Drug Name Brand Reference Drug Tier Notes
testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)
AndroGel 1b PA; QL
testosterone transdermal solution Not covered QL
XYOSTED Not covered QL
Estrogens
afirmelle Afirmelle 1a PV2
ALORA 2
altavera Altavera 1a PV2
alyacen 1/35 Cyclafem 1/35 1a PV2
alyacen 7/7/7 Cyclafem 7/7/7 1a PV2
amabelz Amabelz 1b
amethia Amethia 1a PV2; QL
amethyst Amethyst 1a PV2
ANGELIQ 3
ANNOVERA Not covered QL
apri Apri 1a PV2
aranelle 1a PV2
ashlyna Amethia 1a PV2; QL
aubra Afirmelle 1a PV2
aubra eq Afirmelle 1a PV2
aurovela 1.5/30 Aurovela 1.5/30 1a PV2
aurovela 1/20 Aurovela 1/20 1a PV2
aurovela 24 fe 1a PV2
aurovela fe 1.5/30 Aurovela Fe 1.5/30 1a PV2
aurovela fe 1/20 Aurovela FE 1/20 1a PV2
aviane Afirmelle 1a PV2
ayuna Altavera 1a PV2
azurette Azurette 1a PV2
BALCOLTRA 3
balziva Balziva 1a PV2
BIJUVA Not covered QL
blisovi 24 fe 1a PV2
blisovi fe 1.5/30 Aurovela Fe 1.5/30 1a PV2
blisovi fe 1/20 Aurovela FE 1/20 1a PV2
briellyn Balziva 1a PV2
camrese Amethia 1a PV2; QL
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
camrese lo Camrese Lo 1a PV2; QL
caziant 1a PV2
charlotte 24 fe Charlotte 24 Fe 1a PV2
chateal Altavera 1a PV2
chateal eq Altavera 1a PV2
CLIMARA PRO 3
COMBIPATCH 3
COVARYX Not covered
COVARYX HS Not covered
cryselle-28 1a PV2
cyclafem 1/35 Cyclafem 1/35 1a PV2
cyclafem 7/7/7 Cyclafem 7/7/7 1a PV2
cyred Apri 1a PV2
cyred eq Apri 1a PV2
dasetta 1/35 Cyclafem 1/35 1a PV2
dasetta 7/7/7 Cyclafem 7/7/7 1a PV2
daysee Amethia 1a PV2; QL
DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML
3
delyla Afirmelle 1a PV2
desogestrel-ethinyl estradiol Apri 1a PV2
DIVIGEL 3
dolishale Amethyst 1a PV2
dotti Dotti 1b
drospiren-eth estrad-levomefol Beyaz 1a PV2
drospirenone-ethinyl estradiol Jasmiel 1a PV2
DUAVEE 3
EEMT Not covered
EEMT HS Not covered
ELESTRIN 3
elinest 1a PV2
eluryng EluRyng 1a PV2; QL
emoquette Apri 1a PV2
enpresse-28 Enpresse-28 1a PV2
enskyce Apri 1a PV2
est estrogens-methyltest Covaryx 1b
est estrogens-methyltest ds Covaryx 1b
BCN Custom Select Drug List - February 2022
79
Drug Name Brand Reference Drug Tier Notes
est estrogens-methyltest hs Covaryx HS 1b
estarylla Estarylla 1a PV2
estradiol oral Estrace 1b
estradiol transdermal Climara 1b
estradiol vaginal Estrace 1b
estradiol valerate intramuscular Delestrogen 1b
estradiol-norethindrone acet Amabelz 1b
ESTRING 2
ESTROGEL 2
ethynodiol diac-eth estradiol Kelnor 1/35 1a PV2
etonogestrel-ethinyl estradiol EluRyng 1a PV2; QL
EVAMIST 3
falmina Afirmelle 1a PV2
fayosim Fayosim 1a PV2; QL
FEMRING 3
femynor Estarylla 1a PV2
fyavolv Fyavolv 1b
gemmily Gemmily 1a PV2
hailey 1.5/30 Aurovela 1.5/30 1a PV2
hailey 24 fe 1a PV2
hailey fe 1.5/30 Aurovela Fe 1.5/30 1a PV2
hailey fe 1/20 Aurovela FE 1/20 1a PV2
iclevia Iclevia 1a PV2; QL
IMVEXXY MAINTENANCE PACK 3
IMVEXXY STARTER PACK 3
introvale Iclevia 1a PV2; QL
isibloom Apri 1a PV2
jaimiess Amethia 1a PV2; QL
jasmiel Jasmiel 1a PV2
jinteli Fyavolv 1b
jolessa Iclevia 1a PV2; QL
juleber Apri 1a PV2
junel 1.5/30 Aurovela 1.5/30 1a PV2
junel 1/20 Aurovela 1/20 1a PV2
junel fe 1.5/30 Aurovela Fe 1.5/30 1a PV2
junel fe 1/20 Aurovela FE 1/20 1a PV2
junel fe 24 1a PV2
BCN Custom Select Drug List - February 2022
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Drug Name Brand Reference Drug Tier Notes
kaitlib fe Kaitlib Fe 1a PV2
kalliga Apri 1a PV2
kariva Azurette 1a PV2
kelnor 1/35 Kelnor 1/35 1a PV2
kelnor 1/50 Kelnor 1/50 1a PV2
kurvelo Altavera 1a PV2
larin 1.5/30 Aurovela 1.5/30 1a PV2
larin 1/20 Aurovela 1/20 1a PV2
larin 24 fe 1a PV2
larin fe 1.5/30 Aurovela Fe 1.5/30 1a PV2
larin fe 1/20 Aurovela FE 1/20 1a PV2
larissia Afirmelle 1a PV2
layolis fe Kaitlib Fe 1a PV2
leena 1a PV2
lessina Afirmelle 1a PV2
levonest Enpresse-28 1a PV2
levonorgest-eth est & eth est Fayosim 1a PV2; QL
levonorgest-eth estrad 91-day Amethia 1a PV2; QL
levonorgestrel-ethinyl estrad Afirmelle 1a PV2
levonorg-eth estrad triphasic Enpresse-28 1a PV2
levora 0.15/30 (28) Altavera 1a PV2
lillow Altavera 1a PV2
LO LOESTRIN FE 3
lojaimiess Camrese Lo 1a PV2; QL
loryna Jasmiel 1a PV2
low-ogestrel 1a PV2
lo-zumandimine Jasmiel 1a PV2
lutera Afirmelle 1a PV2
lyllana Dotti 1b
marlissa Altavera 1a PV2
MENEST 3
MENOSTAR 3
merzee Gemmily 1a PV2
microgestin 1.5/30 Aurovela 1.5/30 1a PV2
microgestin 1/20 Aurovela 1/20 1a PV2
microgestin 24 fe 1a PV2
microgestin fe 1.5/30 Aurovela Fe 1.5/30 1a PV2
BCN Custom Select Drug List - February 2022
81
Drug Name Brand Reference Drug Tier Notes
microgestin fe 1/20 Aurovela FE 1/20 1a PV2
mili Estarylla 1a PV2
mimvey Amabelz 1b
mono-linyah Estarylla 1a PV2
MYFEMBREE 3 PA; QL
NATAZIA 3
necon 0.5/35 (28) 1a PV2
NEXTSTELLIS 3
nikki Jasmiel 1a PV2
norethin ace-eth estrad-fe Aurovela Fe 1.5/30 1a PV2
norethindrone acet-ethinyl est Aurovela 1.5/30 1a PV2
norethindrone-eth estradiol Fyavolv 1b
norethin-eth estradiol-fe Kaitlib Fe 1a PV2
norgestimate-eth estradiol Estarylla 1a PV2
norgestimate-ethinyl estradiol triphasic Tri Femynor 1a PV2
nortrel 0.5/35 (28) 1a PV2
nortrel 1/35 (21) Cyclafem 1/35 1a PV2
nortrel 1/35 (28) Cyclafem 1/35 1a PV2
nortrel 7/7/7 Cyclafem 7/7/7 1a PV2
nylia 1/35 Cyclafem 1/35 1a PV2
nylia 7/7/7 Cyclafem 7/7/7 1a PV2
nymyo Estarylla 1a PV2
ocella Ocella 1a PV2
ORIAHNN 3 PA; QL
orsythia Afirmelle 1a PV2
philith Balziva 1a PV2
pimtrea Azurette 1a PV2
pirmella 1/35 Cyclafem 1/35 1a PV2
pirmella 7/7/7 Cyclafem 7/7/7 1a PV2
portia-28 Altavera 1a PV2
PREFEST 3
PREMARIN ORAL 2
PREMARIN VAGINAL 2
PREMPHASE 2
PREMPRO 2
previfem Estarylla 1a PV2
reclipsen Apri 1a PV2
BCN Custom Select Drug List - February 2022
82
Drug Name Brand Reference Drug Tier Notes
rivelsa Fayosim 1a PV2; QL
setlakin Iclevia 1a PV2; QL
simliya Azurette 1a PV2
simpesse Amethia 1a PV2; QL
sprintec 28 Estarylla 1a PV2
sronyx Afirmelle 1a PV2
syeda Ocella 1a PV2
tarina 24 fe 1a PV2
tarina fe 1/20 Aurovela FE 1/20 1a PV2
tarina fe 1/20 eq Aurovela FE 1/20 1a PV2
taysofy Gemmily 1a PV2
tilia fe 1a PV2
tri femynor Tri Femynor 1a PV2
tri-estarylla Tri Femynor 1a PV2
tri-legest fe 1a PV2
tri-linyah Tri Femynor 1a PV2
tri-lo-estarylla Tri-Lo-Estarylla 1a PV2
tri-lo-marzia Tri-Lo-Estarylla 1a PV2
tri-lo-mili Tri-Lo-Estarylla 1a PV2
tri-lo-sprintec Tri-Lo-Estarylla 1a PV2
tri-mili Tri Femynor 1a PV2
tri-nymyo Tri Femynor 1a PV2
tri-previfem Tri Femynor 1a PV2
tri-sprintec Tri Femynor 1a PV2
trivora (28) Enpresse-28 1a PV2
tri-vylibra Tri Femynor 1a PV2
tri-vylibra lo Tri-Lo-Estarylla 1a PV2
TWIRLA Not covered QL
tyblume 1a PV2
tydemy Tydemy 1a PV2
velivet 1a PV2
vestura Jasmiel 1a PV2
vienva Afirmelle 1a PV2
viorele Azurette 1a PV2
volnea Azurette 1a PV2
vyfemla Balziva 1a PV2
vylibra Estarylla 1a PV2
BCN Custom Select Drug List - February 2022
83
Drug Name Brand Reference Drug Tier Notes
wera 1a PV2
wymzya fe Wymzya Fe 1a PV2
xulane 1a PV2; QL
yuvafem Yuvafem 1b
zafemy 1a PV2; QL
zarah Ocella 1a PV2
zovia 1/35 (28) Kelnor 1/35 1a PV2
zovia 1/35e (28) Kelnor 1/35 1a PV2
zumandimine Ocella 1a PV2
Progestins
camila Camila 1a PV2
deblitane Camila 1a PV2
DEPO-SUBQ PROVERA 104 2
ELLA 3 PV2; QL
ENDOMETRIN Not covered
errin Camila 1a PV2
heather Camila 1a PV2
incassia Camila 1a PV2
jencycla Camila 1a PV2
levonorgestrel Aftera 0 PV1; QL
lyleq Camila 1a PV2
lyza Camila 1a PV2
medroxyprogesterone acetate intramuscular
Depo-Provera 1a PV2
medroxyprogesterone acetate oral Provera 1b
megestrol acetate oral 1b
nora-be Camila 1a PV2
norethindrone acetate oral Aygestin 1b
norethindrone oral Camila 1a PV2
norlyda Camila 1a PV2
norlyroc Camila 1a PV2
progesterone intramuscular 1b
progesterone oral Prometrium 1b
sharobel Camila 1a PV2
SLYND 3 QL
tulana Camila 1a PV2
BCN Custom Select Drug List - February 2022
84
Drug Name Brand Reference Drug Tier Notes
Selective Estrogen Receptor Modifying Agents
OSPHENA 3
raloxifene hcl Evista 1b PV3; QL
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
ARMOUR THYROID 3
euthyrox Euthyrox 1a
levo-t Euthyrox 1a
LEVOTHYROXINE SODIUM ORAL CAPSULE
3 ABA
levothyroxine sodium oral tablet Euthyrox 1a
levoxyl Euthyrox 1a
liothyronine sodium oral Cytomel 1a
NATURE-THROID 2
np thyroid Armour Thyroid 1a
THYQUIDITY Not covered
TIROSINT 3
TIROSINT-SOL 3
unithroid Euthyrox 1a
WESTHROID 2
WP THYROID 3
Hormonal Agents, Suppressant (Adrenal)
LYSODREN 2
Hormonal Agents, Suppressant (Pituitary)
ganirelix acetate 4 SP
leuprolide acetate injection 4 SP
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG
4 SP
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG
4 SP
LUPRON DEPOT-PED (1-MONTH) 4 SP
LUPRON DEPOT-PED (3-MONTH) 4 SP
MYCAPSSA Not covered SP; QL
octreotide acetate SandoSTATIN 4 SP
BCN Custom Select Drug List - February 2022
85
Drug Name Brand Reference Drug Tier Notes
ORILISSA 2 PA; QL
SANDOSTATIN LAR DEPOT 4 PA; SP
SIGNIFOR 4 PA; SP; QL
SIGNIFOR LAR Not covered SP; QL
SOMATULINE DEPOT 4 PA; SP; QL
SOMAVERT 4 PA; SP
SYNAREL 3
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole oral 1b
propylthiouracil oral 1b
Immunological Agents
Angioedema Agents
HAEGARDA 4 PA; SP; QL
icatibant acetate Sajazir 4 PA; SP; QL
ORLADEYO 5 PA; SP; QL
RUCONEST 5 PA; SP; QL
sajazir Sajazir 4 PA; SP; QL
TAKHZYRO 4 PA; SP; QL
Immune Suppressants
ASTAGRAF XL 5 SP
azathioprine oral Azasan 1b
CIMZIA PREFILLED KIT 5 PA; SP; QL
CIMZIA STARTER KIT 5 PA; SP; QL
cyclosporine modified Gengraf 4 SP
cyclosporine oral SandIMMUNE 4 SP
ENBREL 4 PA; SP; QL
ENBREL MINI 4 PA; SP; QL
ENBREL SURECLICK 4 PA; SP; QL
ENVARSUS XR 5 SP
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg
Zortress 4 SP
gengraf Gengraf 4 SP
HUMIRA 4 PA; SP; QL
HUMIRA PEDIATRIC CROHNS START 4 PA; SP; QL
HUMIRA PEN 4 PA; SP; QL
BCN Custom Select Drug List - February 2022
86
Drug Name Brand Reference Drug Tier Notes
HUMIRA PEN-CD/UC/HS STARTER 4 PA; SP; QL
HUMIRA PEN-PEDIATRIC UC START 4 PA; SP; QL
HUMIRA PEN-PS/UV/ADOL HS START 4 PA; SP; QL
HUMIRA PEN-PSOR/UVEIT STARTER 4 PA; SP; QL
KINERET 5 PA; SP; QL
LUPKYNIS 5 PA; SP; QL
methotrexate oral 1b
methotrexate sodium (pf) 1b
methotrexate sodium injection solution 1b
methotrexate sodium oral 1b
mycophenolate mofetil oral CellCept 4 SP
mycophenolate sodium Myfortic 4 SP
OLUMIANT 5 PA; SP; QL
ORENCIA CLICKJECT 5 PA; SP; QL
ORENCIA SUBCUTANEOUS 5 PA; SP; QL
OTREXUP Not covered SP; QL
PROGRAF ORAL PACKET 5 SP
RASUVO Not covered SP; QL
REDITREX Not covered SP; QL
REZUROCK 4 PA; SP; QL
SANDIMMUNE ORAL SOLUTION 5 SP
SIMPONI 5 PA; SP; QL
sirolimus oral Rapamune 4 SP
SKYRIZI 4 PA; SP; QL
SKYRIZI (150 MG DOSE) 4 PA; SP; QL
SKYRIZI PEN 4 PA; SP; QL
tacrolimus oral Prograf 4 SP
TREXALL 2
XATMEP 5 SP
XELJANZ 4 PA; SP; QL
XELJANZ XR 4 PA; SP; QL
Immunoglobulins
CUTAQUIG 5 PA; SP
CUVITRU Not covered SP
GAMMAGARD 5 PA; SP
GAMMAKED 5 PA; SP
GAMUNEX-C 5 PA; SP
BCN Custom Select Drug List - February 2022
87
Drug Name Brand Reference Drug Tier Notes
HIZENTRA 5 PA; SP
HYQVIA 5 PA; SP
XEMBIFY 5 PA; SP
Immunomodulators
ACTEMRA ACTPEN 5 PA; SP; QL
ACTEMRA SUBCUTANEOUS 5 PA; SP; QL
ACTIMMUNE 4 SP
ALFERON N 2
ARCALYST 5 PA; SP; QL
BENLYSTA SUBCUTANEOUS 4 PA; SP; QL
ENSPRYNG 4 PA; SP; QL
KEVZARA 5 PA; SP; QL
leflunomide oral Arava 1b
OTEZLA 4 PA; SP; QL
RIDAURA 2
RINVOQ 4 PA; SP; QL
XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
4 PA; SP; QL
Vaccines
ACTHIB 0 PV1; QL
ADACEL 0 PV1; QL
AFLURIA QUADRIVALENT 0 PV1; QL
BEXSERO 0 PV1; QL
BOOSTRIX 0 PV1; QL
DAPTACEL 0 PV1; QL
DIPHTHERIA-TETANUS TOXOIDS DT 0 PV1; QL
ENGERIX-B 0 PV1; QL
FLUAD QUADRIVALENT 0 PV1; QL
FLUARIX QUADRIVALENT 0 PV1; QL
FLUBLOK QUADRIVALENT 0 PV1; QL
FLUCELVAX QUADRIVALENT 0 PV1; QL
FLULAVAL QUADRIVALENT 0 PV1; QL
FLUMIST QUADRIVALENT 0 PV1; QL
FLUZONE HIGH-DOSE QUADRIVALENT
0 PV1; QL
FLUZONE QUADRIVALENT 0 PV1; QL
BCN Custom Select Drug List - February 2022
88
Drug Name Brand Reference Drug Tier Notes
GARDASIL 9 0PV1; QL; AL (Min 9 Years and Max 45 Years)
HAVRIX 0 PV1; QL
HEPLISAV-B 0 PV1; QL
HIBERIX 0 PV1; QL
INFANRIX 0 PV1; QL
IPOL 0 PV1; QL
JANSSEN COVID-19 VACCINE 0 PV1; QL
KINRIX 0 PV1; QL
MENACTRA 0 PV1; QL
MENQUADFI 0 PV1; QL
MENVEO 0 PV1; QL
M-M-R II 0 PV1; QL
MODERNA COVID-19 VACCINE 0 PV1; QL
PEDIARIX 0 PV1; QL
PEDVAX HIB 0 PV1; QL
PENTACEL 0 PV1; QL
PFIZER COVID-19 VAC-TRIS 5-11Y 0 PV1
PFIZER-BIONT COVID-19 VAC-TRIS 0 PV1
PFIZER-BIONTECH COVID-19 VACC 0 PV1; QL
PNEUMOVAX 23 0 PV1; QL
PREVNAR 13 0PV1; QL; AL (Min 65 Years)
PROQUAD 0 PV1; QL
QUADRACEL 0 PV1; QL
RECOMBIVAX HB 0 PV1; QL
ROTARIX 0 PV1; QL
ROTATEQ 0 PV1; QL
SHINGRIX 0PV1; QL; AL (Min 50 Years)
TDVAX 0 PV1; QL
TENIVAC 0 PV1; QL
TRUMENBA 0 PV1; QL
TWINRIX 0 PV1; QL
VAQTA 0 PV1; QL
VARIVAX 0 PV1; QL
VAXELIS 0 PV1; QL
BCN Custom Select Drug List - February 2022
89
Drug Name Brand Reference Drug Tier Notes
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium Colazal 1b
DIPENTUM 3
mesalamine er oral capsule 0.375 gm Apriso 1b
mesalamine oral capsule delayed release 400 mg
Delzicol 1b
mesalamine oral tablet delayed release 1.2 gm
Lialda 1b QL
mesalamine oral tablet delayed release 800 mg
Asacol HD 1b
mesalamine rectal Canasa 1b
PENTASA 2
SFROWASA Not covered
Glucocorticoids
ANALPRAM HC Not covered
ANALPRAM HC SINGLES Not covered
ANALPRAM-HC EXTERNAL CREAM 2
ANALPRAM-HC EXTERNAL LOTION Not covered
anucort-hc Anusol-HC 1b
ANUSOL-HC RECTAL Not covered
budesonide er Uceris 1b QL
budesonide oral Entocort EC 1b
CORTIFOAM 3
HEMMOREX-HC Not covered
hydrocortisone (perianal) Procto-Med HC 1b
hydrocortisone ace-pramoxine external cream 1-1 %
Analpram-HC 1b
hydrocortisone acetate rectal Anusol-HC 1b
hydrocortisone rectal Cortenema 1b
hydrocort-pramoxine (perianal) Analpram HC 1b
lidocaine-hydrocort (perianal) Lidocort 1b
LIDOCORT Not covered
ORTIKOS Not covered
PROCTOCORT RECTAL Not covered
PROCTOFOAM HC 2
procto-med hc Procto-Med HC 1b
BCN Custom Select Drug List - February 2022
90
Drug Name Brand Reference Drug Tier Notes
procto-pak Procto-Pak 1b
proctosol hc Procto-Med HC 1b
proctozone-hc Procto-Med HC 1b
UCERIS RECTAL Not covered
Sulfonamides
sulfasalazine oral Azulfidine 1a
Metabolic Bone Disease Agents
alendronate sodium Fosamax 1a QL
BINOSTO Not covered QL
calcitonin (salmon) Miacalcin 1b
calcitriol oral Rocaltrol 1b
cinacalcet hcl Sensipar 4 SP
doxercalciferol oral 1b
FORTEO 4 PA; SP; QL
FOSAMAX PLUS D Not covered QL
ibandronate sodium oral Boniva 1a QL
NATPARA 4 PA; SP; QL
paricalcitol oral Zemplar 1b
RAYALDEE Not covered QL
risedronate sodium oral tablet Actonel 1b QL
risedronate sodium oral tablet delayed release
Atelvia 1b ST; QL
TERIPARATIDE (RECOMBINANT) Not covered SP; QL
TYMLOS 4 PA; SP; QL
Miscellaneous Therapeutic Agents
AEROCHAMBER MINI CHAMBER 3
AEROCHAMBER MV 3
AEROCHAMBER PLUS FLO-VU 3
AEROCHAMBER PLUS FLOW VU 3
AEROCHAMBER W/FLOWSIGNAL 3
BREATHE EASE LARGE 3
BREATHE EASE MEDIUM 3
BREATHE EASE SMALL 3
CAYA 3 PV2
CLEVER CHOICE HOLDING CHAMBER 3
COMPACT SPACE CHAMBER 3
BCN Custom Select Drug List - February 2022
91
Drug Name Brand Reference Drug Tier Notes
COMPACT SPACE CHAMBER/LG MASK
3
COMPACT SPACE CHAMBER/MED MASK
3
COMPACT SPACE CHAMBER/SM MASK
3
deferoxamine mesylate Desferal 1b
DOJOLVI 4 PA; SP
EASIVENT 3
ENDARI 3 PA; QL
ergoloid mesylates oral 1b
FC FEMALE CONDOM 0 PV1; QL
FC2 FEMALE CONDOM 0 PV1; QL
FEMCAP 3 PV2; QL
FIRDAPSE Not covered SP; QL
FLEXICHAMBER 3
KERENDIA 3 PA; QL
LEVOCARNITINE INJECTION 3
methergine Methergine 1b PA; QL
methylergonovine maleate oral Methergine 1b PA; QL
MICROCHAMBER 3
OMNIPOD 5 PACK 2 QL
OMNIPOD DASH 5 PACK PODS 2 QL
OPTICHAMBER DIAMOND 3
OPTICHAMBER DIAMOND-LG MASK 3
OPTICHAMBER DIAMOND-MD MASK 3
OPTICHAMBER DIAMOND-SM MASK 3
PALFORZIA ORAL PACKET 300 MG 4 PA; SP; QL
PHEXXI Not covered
POCKET SPACER 3
PRO COMFORT SPACER ADULT 3
PRO COMFORT SPACER CHILD 3
PRO COMFORT SPACER INFANT 3
PROCARE SPACER/ADULT MASK 3
PROCARE SPACER/CHILD MASK 3
RADIOGARDASE 2
RUZURGI 4 PA; SP; QL
SSKI 3
BCN Custom Select Drug List - February 2022
92
Drug Name Brand Reference Drug Tier Notes
sterile water for irrigation Argyle Sterile Water 1b
TAVNEOS 5 PA; SP; QL
V-GO 20 2 QL
V-GO 30 2 QL
V-GO 40 2 QL
VISTOGARD 4 SP; QL
VORTEX VALVED HOLDING CHAMBER
3
water for irrigation, sterile Argyle Sterile Water 1b
WIDE-SEAL DIAPHRAGM 60 3 PV2; QL
WIDE-SEAL DIAPHRAGM 65 3 PV2; QL
WIDE-SEAL DIAPHRAGM 70 3 PV2; QL
WIDE-SEAL DIAPHRAGM 75 3 PV2; QL
WIDE-SEAL DIAPHRAGM 80 3 PV2; QL
WIDE-SEAL DIAPHRAGM 85 3 PV2; QL
WIDE-SEAL DIAPHRAGM 90 3 PV2; QL
WIDE-SEAL DIAPHRAGM 95 3 PV2; QL
ZOKINVY 4 PA; SP; QL
Ophthalmic Agents
Aminoglycosides
gentak 1b
gentamicin sulfate ophthalmic 1b
neomycin-polymyxin-gramicidin 1b
TOBRADEX OPHTHALMIC OINTMENT 2
TOBRADEX ST 3
tobramycin ophthalmic Tobrex 1b
tobramycin-dexamethasone TobraDex 1b
TOBREX OPHTHALMIC OINTMENT 3
Antibacterials, Other
ak-poly-bac Polycin 1b
bacitracin ophthalmic 1b
bacitracin-polymyxin b ophthalmic Polycin 1b
bacitra-neomycin-polymyxin-hc Neo-Polycin HC 1b
neomycin-bacitracin zn-polymyx Neo-Polycin 1b
neomycin-polymyxin-dexameth ophthalmic ointment
Maxitrol 1b
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
Maxitrol 1b
BCN Custom Select Drug List - February 2022
93
Drug Name Brand Reference Drug Tier Notes
neomycin-polymyxin-hc ophthalmic 1b
neo-polycin Neo-Polycin 1b
neo-polycin hc Neo-Polycin HC 1b
polycin Polycin 1b
polymyxin b-trimethoprim Polytrim 1b
Anti-cytomegalovirus (CMV) Agents
ZIRGAN 2
Antifungals
NATACYN 2
Antiherpetic Agents
trifluridine 1b
Macrolides
AZASITE 3
erythromycin ophthalmic 1b
Ophthalmic Agents, Other
atropine sulfate ophthalmic ointment 1b
atropine sulfate ophthalmic solution 1 % Isopto Atropine 1b
BLEPHAMIDE 2
BLEPHAMIDE S.O.P. 2
CEQUA Not covered QL
cyclopentolate hcl ophthalmic Cyclogyl 1b
CYSTADROPS 5 PA; SP; QL
CYSTARAN 4 PA; SP; QL
homatropaire 1b
ISOPTO ATROPINE Not covered
LACRISERT 2
OXERVATE 4 PA; SP; QL
PAREMYD 3
PRED-G 3
PRED-G S.O.P. 3
RESTASIS 2
RESTASIS MULTIDOSE 2
sulfacetamide-prednisolone ophthalmic solution
1b
tropicamide ophthalmic Mydriacyl 1b
XIIDRA 2 QL
ZYLET 3
BCN Custom Select Drug List - February 2022
94
Drug Name Brand Reference Drug Tier Notes
Ophthalmic Anti-allergy Agents
ALOCRIL 3
ALOMIDE 3
altafrin Altafrin 1b
azelastine hcl ophthalmic 1b
bepotastine besilate Bepreve 1b
cromolyn sodium ophthalmic 1b
CYCLOMYDRIL 3
epinastine hcl 1b
LASTACAFT 3
olopatadine hcl ophthalmic Pataday 1b
phenylephrine hcl ophthalmic Altafrin 1b
UPNEEQ 2 PA; QL
ZERVIATE Not covered
Ophthalmic Antiglaucoma Agents
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
2
apraclonidine hcl 1b
betaxolol hcl ophthalmic 1b
BETIMOL Not covered
BETOPTIC-S 2
brimonidine tartrate ophthalmic Alphagan P 1b
brinzolamide Azopt 1b
carteolol hcl 1a
COMBIGAN 3
dorzolamide hcl ophthalmic Trusopt 1b
dorzolamide hcl-timolol mal Cosopt 1b
dorzolamide hcl-timolol mal pf Cosopt PF 1b
IOPIDINE 3
levobunolol hcl 1a
pilocarpine hcl ophthalmic Isopto Carpine 1b
RHOPRESSA 2 ST; QL
ROCKLATAN 2 ST; QL
SIMBRINZA Not covered
timolol maleate (once-daily) Istalol Not covered
timolol maleate ocudose Timoptic Ocudose Not covered
timolol maleate ophthalmic Timoptic 1a
BCN Custom Select Drug List - February 2022
95
Drug Name Brand Reference Drug Tier Notes
timolol maleate pf Timoptic Ocudose Not covered
TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 %
Not covered
Ophthalmic Anti-inflammatories
ACUVAIL Not covered
ALREX 2
bromfenac sodium (once-daily) 1b
BROMSITE Not covered
dexamethasone sodium phosphate ophthalmic
1b
diclofenac sodium ophthalmic 1b
difluprednate Durezol 1b
EYSUVIS Not covered QL
FLAREX Not covered
fluorometholone FML Liquifilm 1b
flurbiprofen sodium 1b
FML 2
FML FORTE 2
ILEVRO Not covered
INVELTYS Not covered QL
ketorolac tromethamine ophthalmic Acular 1b
LOTEMAX OPHTHALMIC OINTMENT 3
LOTEMAX SM Not covered QL
loteprednol etabonate Lotemax 1b
MAXIDEX 3
NEVANAC 3
PRED MILD 2
prednisolone acetate ophthalmic Pred Forte 1b
prednisolone acetate p-f Pred Forte 1b
prednisolone sodium phosphate ophthalmic
1b
PROLENSA Not covered
TYRVAYA Not covered QL
Ophthalmic Prostaglandin and Prostamide Analogs
bimatoprost ophthalmic 1b
latanoprost ophthalmic Xalatan 1a
LUMIGAN 2
BCN Custom Select Drug List - February 2022
96
Drug Name Brand Reference Drug Tier Notes
travoprost (bak free) Travatan Z 1b
VYZULTA Not covered
XELPROS Not covered QL
ZIOPTAN 3
Quinolones
BESIVANCE 3
CILOXAN OPHTHALMIC OINTMENT 2
ciprofloxacin hcl ophthalmic Ciloxan 1b
gatifloxacin ophthalmic Zymaxid 1b
levofloxacin ophthalmic 1b
moxifloxacin hcl (2x day) Moxeza 1b
moxifloxacin hcl ophthalmic solution Vigamox 1b
ofloxacin ophthalmic Ocuflox 1b
Sulfonamides
sulfacetamide sodium ophthalmic ointment
Not covered
sulfacetamide sodium ophthalmic solution
Bleph-10 1b
Otic Agents
acetic acid otic 1b
CIPRO HC 3
ciprofloxacin hcl otic Cetraxal 1b
ciprofloxacin-dexamethasone Ciprodex 1b
CIPROFLOXACIN-FLUOCINOLONE PF 2
CORTISPORIN-TC 3
flac Flac Not covered
fluocinolone acetonide otic Flac Not covered
hydrocortisone-acetic acid Acetasol HC Not covered
neomycin-polymyxin-hc otic 1b
ofloxacin otic 1b
OTOVEL 2
Respiratory Tract/Pulmonary Agents
Antihistamines
azelastine hcl nasal solution 0.1 %, 137 mcg/spray
1b QL
azelastine hcl nasal solution 0.15 % Not covered QL
carbinoxamine maleate RyVent Not covered
BCN Custom Select Drug List - February 2022
97
Drug Name Brand Reference Drug Tier Notes
clemastine fumarate oral syrup Not covered
clemastine fumarate oral tablet 2.68 mg 1b
cyproheptadine hcl oral 1b
diphenhydramine hcl oral elixir 1b
olopatadine hcl nasal Patanase Not covered QL
promethazine hcl oral 1b
promethazine hcl rectal Promethegan 1b
promethegan Promethegan 1b
ryvent RyVent Not covered
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR HFA 2 QL
AIRDUO DIGIHALER Not covered
AIRDUO RESPICLICK 113/14 Not covered QL
AIRDUO RESPICLICK 232/14 Not covered QL
AIRDUO RESPICLICK 55/14 Not covered QL
ALVESCO Not covered QL
ARMONAIR DIGIHALER Not covered QL
ARNUITY ELLIPTA 2 QL
ASMANEX (120 METERED DOSES) Not covered QL
ASMANEX (30 METERED DOSES) Not covered QL
ASMANEX (60 METERED DOSES) Not covered QL
ASMANEX (7 METERED DOSES) Not covered QL
ASMANEX HFA Not covered QL
BECONASE AQ Not covered QL
BEVESPI AEROSPHERE Not covered QL
BREO ELLIPTA 2 QL
budesonide inhalation Pulmicort 1a
BUDESONIDE-FORMOTEROL FUMARATE
Not covered ABA; QL
DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT
Not covered QL
DULERA INHALATION AEROSOL 50-5 MCG/ACT
Not covered
FLOVENT DISKUS 2 QL
FLOVENT HFA 2 QL
flunisolide nasal Not covered QL
fluticasone propionate nasal ClariSpray 1b QL
BCN Custom Select Drug List - February 2022
98
Drug Name Brand Reference Drug Tier Notes
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
Wixela Inhub 1b QL
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT
3 ABA; QL
mometasone furoate nasal Not covered QL
OMNARIS Not covered QL
PULMICORT FLEXHALER 2 QL
QNASL Not covered QL
QNASL CHILDRENS Not covered QL
QVAR REDIHALER 2 QL
SYMBICORT 2 QL
wixela inhub Wixela Inhub 1b QL
ZETONNA Not covered QL
Antileukotrienes
montelukast sodium oral Singulair 1a QL
zafirlukast Accolate 1b QL
zileuton er 1b QL
ZYFLO 3 QL
Bronchodilators, Anticholinergic
ATROVENT HFA 2 QL
BREZTRI AEROSPHERE 2 QL
INCRUSE ELLIPTA Not covered QL
ipratropium bromide inhalation 1b
ipratropium bromide nasal 1b QL
LONHALA MAGNAIR REFILL KIT Not covered QL
LONHALA MAGNAIR STARTER KIT Not covered QL
SPIRIVA HANDIHALER 2 QL
SPIRIVA RESPIMAT 2 QL
STIOLTO RESPIMAT 2 QL
TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH
2 QL
TUDORZA PRESSAIR Not covered QL
YUPELRI 3 QL
BCN Custom Select Drug List - February 2022
99
Drug Name Brand Reference Drug Tier Notes
Bronchodilators, Sympathomimetic
albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation
1b QL
ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION
Not covered ABA; QL
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml
1b
ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% INHALATION
2
albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation
1b
albuterol sulfate oral 1b
arformoterol tartrate Brovana 1b QL
AUVI-Q Not covered QL
epinephrine injection solution auto-injector
EpiPen Jr 2-Pak 1b QL
formoterol fumarate inhalation Perforomist 1b QL
levalbuterol hcl inhalation XOPENEX NEB 1b
LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT
3 ABA; QL
PROAIR DIGIHALER Not covered
PROAIR RESPICLICK Not covered QL
SEREVENT DISKUS 2 QL
STRIVERDI RESPIMAT Not covered QL
SYMJEPI 2 QL
terbutaline sulfate oral 1b
VENTOLIN HFA Not covered QL
XOPENEX HFA 3 QL
Cystic Fibrosis Agents
BRONCHITOL 5 PA; SP; QL
BRONCHITOL TOLERANCE TEST 5 PA; SP; QL
CAYSTON 5 PA; SP; QL
KALYDECO 4 PA; SP; QL
KITABIS PAK Not covered SP; QL
ORKAMBI 4 PA; SP; QL
PULMOZYME 4 PA; SP
BCN Custom Select Drug List - February 2022
100
Drug Name Brand Reference Drug Tier Notes
SYMDEKO 4 PA; SP; QL
TOBI PODHALER Not covered SP; QL
tobramycin inhalation nebulization solution 300 mg/4ml
Bethkis Not covered SP; QL
tobramycin nebulization solution 300 mg/5ml inhalation
Kitabis Pak 4 SP; QL
TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION
Not covered ABA; SP; QL
TRIKAFTA 4 PA; SP; QL
Mast Cell Stabilizers
cromolyn sodium inhalation 1b
Phosphodiesterase Inhibitors, Airways Disease
DALIRESP 2 QL
ELIXOPHYLLIN Not covered
THEO-24 2
theophylline 1b
theophylline er 1b
Pulmonary Antihypertensives
ADEMPAS 4 PA; SP; QL
alyq Alyq 4 PA; SP; QL
ambrisentan Letairis 4 PA; SP; QL
bosentan Tracleer 4 PA; SP; QL
OPSUMIT 4 PA; SP; QL
ORENITRAM 5 PA; SP; QL
sildenafil citrate oral suspension reconstituted
Revatio 1b PA; QL
sildenafil citrate oral tablet 20 mg Revatio 1b PA; QL
tadalafil (pah) Alyq 4 PA; SP; QL
TRACLEER 32 MG 5 PA; SP; QL
TYVASO 5 PA; SP; QL
TYVASO REFILL 5 PA; SP; QL
TYVASO STARTER 5 PA; SP; QL
UPTRAVI ORAL 5 PA; SP; QL
VENTAVIS 5 PA; SP; QL
Pulmonary Fibrosis Agents
ESBRIET 4 PA; SP; QL
OFEV 4 PA; SP; QL
BCN Custom Select Drug List - February 2022
101
Drug Name Brand Reference Drug Tier Notes
Respiratory Tract Agents, Other
acetylcysteine inhalation 1b
ANORO ELLIPTA 2 QL
azelastine-fluticasone Dymista Not covered QL
COMBIVENT RESPIMAT 2 QL
DUAKLIR PRESSAIR Not covered QL
FASENRA PEN 4 PA; SP; QL
GRASTEK Not covered QL
HYPERSAL 3
ipratropium-albuterol 1b
NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR
4 PA; SP; QL
NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
4 PA; SP; QL
ODACTRA Not covered QL
ORALAIR Not covered QL
RAGWITEK Not covered QL
sodium chloride inhalation HyperSal 1b
TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH
2 QL
Skeletal Muscle Relaxants
baclofen oral 1b
carisoprodol oral Soma Not covered
chlorzoxazone oral tablet 250 mg Not covered
chlorzoxazone oral tablet 375 mg, 750 mg
Lorzone Not covered
chlorzoxazone oral tablet 500 mg 1b
cyclobenzaprine hcl er Amrix Not covered QL
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
1b
cyclobenzaprine hcl oral tablet 7.5 mg Fexmid Not covered
dantrolene sodium oral Dantrium 1b
metaxalone Skelaxin 1b
methocarbamol oral 1b
NORGESIC FORTE Not covered
orphenadrine citrate er 1b
ORPHENGESIC FORTE Not covered
BCN Custom Select Drug List - February 2022
102
Drug Name Brand Reference Drug Tier Notes
OZOBAX Not covered QL
tizanidine hcl oral Zanaflex 1b
Sleep Disorder Agents
GABA Receptor Modulators
EDLUAR Not covered QL
eszopiclone Lunesta 1b QL
flurazepam hcl 1b QL
temazepam Restoril 1b QL
zaleplon 1b QL
zolpidem tartrate er Ambien CR 1b QL
zolpidem tartrate oral Ambien 1b QL
zolpidem tartrate sublingual Not covered QL
ZOLPIMIST Not covered
Sleep Disorders, Other
BELSOMRA Not covered QL
DAYVIGO Not covered QL
doxepin hcl oral tablet Silenor Not covered QL
HETLIOZ 5 PA; SP; QL
HETLIOZ LQ 5 PA; SP; QL
ramelteon Rozerem 1b QL
Wakefulness Promoting Agents
armodafinil Nuvigil 1b QL
modafinil Provigil 1b QL
SUNOSI 3 PA; QL
WAKIX 5 PA; SP; QL
XYREM 5 PA; SP; QL
XYWAV Not covered SP; QL
BCN Custom Select Drug List - February 2022
103
Index of Drugs
abacavir sulfate.........................39abacavir sulfate-lamivudine...... 39abacavir-lamivudine-zidovudine.................................39ABILIFY MAINTENA................. 36ABILIFY MYCITE...................... 36ABILIFY MYCITE MAINTENANCE KIT................. 37ABILIFY MYCITE STARTER KIT............................................ 37abiraterone acetate................... 29ABSORICA LD..........................60acamprosate calcium................ 16acarbose................................... 44ACCRUFER.............................. 64ACCU-CHEK AVIVA PLUS KIT W/DEVICE..........................41ACCU-CHEK COMPACT PLUS TEST STRIPS................ 41ACCU-CHEK FASTCLIX LANCETS................................. 42ACCU-CHEK GUIDE TEST STRIPS..................................... 42ACCU-CHEK MULTICLIX LANCETS................................. 42ACCU-CHEK SAFE-T PRO LANCETS................................. 42ACCU-CHEK SMARTVIEW TEST STRIPS...........................42ACCU-CHEK SOFTCLIX LANCETS................................. 42accutane................................... 60acebutolol hcl............................ 51acetaminophen-codeine............14acetaminophen-codeine #2.......14acetaminophen-codeine #3.......14acetaminophen-codeine #4.......14acetazolamide...........................54acetazolamide er.......................54acetic acid........................... 72, 97acetylcysteine......................... 102ACIPHEX SPRINKLE............... 70acitretin..................................... 60ACTEMRA................................ 88ACTEMRA ACTPEN.................88ACTHAR................................... 76ACTHIB.....................................88ACTIMMUNE............................ 88ACUVAIL...................................96acyclovir.................................... 38ACZONE................................... 60ADACEL....................................88adapalene................................. 60
ADAPALENE............................ 60adapalene-benzoyl peroxide.....60adefovir dipivoxil ....................... 38ADEMPAS.............................. 101ADHANSIA XR..........................57ADLYXIN...................................44ADLYXIN STARTER PACK...... 44ADMELOG................................ 46ADMELOG SOLOSTAR........... 46adult aspirin regimen.................10ADVAIR HFA............................ 98ADVATE....................................48ADYNOVATE............................48ADZENYS XR-ODT.................. 57AEMCOLO................................ 17AEROCHAMBER MINI CHAMBER................................ 91AEROCHAMBER MV............... 91AEROCHAMBER PLUS FLO-VU............................................. 91AEROCHAMBER PLUS FLOW VU..................................91AEROCHAMBER W/FLOWSIGNAL...................... 91afirmelle.................................... 78AFLURIA QUADRIVALENT......88AFREZZA..................................46AFSTYLA.................................. 48AGAMATRIX PRESTO TEST...42AIMOVIG...................................27AIRDUO DIGIHALER................98AIRDUO RESPICLICK 113/14..98AIRDUO RESPICLICK 232/14..98AIRDUO RESPICLICK 55/14....98AJOVY...................................... 27AKLIEF......................................60ak-poly-bac............................... 93AKYNZEO.................................25ALA SCALP.............................. 73ala-cort...................................... 73albendazole...............................34albuterol sulfate.......................100ALBUTEROL SULFATE......... 100albuterol sulfate hfa.................100ALBUTEROL SULFATE HFA. 100alclometasone dipropionate...... 73ALDACTAZIDE......................... 52ALECENSA...............................31alendronate sodium.................. 91ALFERON N............................. 88alfuzosin hcl er.......................... 72ALINIA.......................................34aliskiren fumarate......................52
ALKINDI SPRINKLE................. 73allopurinol..................................27ALLZITAL..................................14almotriptan malate.................... 28ALOCRIL...................................95ALOGLIPTIN BENZOATE........ 44ALOGLIPTIN-METFORMIN HCL...........................................44ALOGLIPTIN-PIOGLITAZONE. 44ALOMIDE..................................95ALORA......................................78alosetron hcl..............................68ALPHAGAN P........................... 95ALPHANATE.............................48ALPHANINE SD........................48alprazolam................................ 41alprazolam er............................ 41alprazolam intensol................... 41alprazolam xr............................ 41ALPROLIX................................ 48ALREX...................................... 96ALTABAX..................................17altafrin....................................... 95altavera..................................... 78ALTOPREV...............................55ALTRENO................................. 60ALUNBRIG................................31ALVESCO................................. 98alyacen 1/35..............................78alyacen 7/7/7.............................78alyq......................................... 101amabelz.................................... 78amantadine hcl..........................35ambrisentan............................ 101amcinonide................................73amethia..................................... 78amethyst................................... 78amiloride hcl..............................54amiloride-hydrochlorothiazide... 52aminocaproic acid..................... 49amiodarone hcl......................... 51AMITIZA....................................68amitriptyline hcl......................... 24amlodipine besylate.................. 52amlodipine besylate-benazepril hcl............................................. 52amlodipine besylate-valsartan.. 52amlodipine-atorvastatin.............52amlodipine-olmesartan..............53ammonium lactate.....................60amnesteem............................... 60amoxapine................................ 24amoxicill-clarithro-lansopraz..... 67
104
amoxicillin................................. 18amoxicillin-potassium clavulanate................................18amoxicillin-potassium clavulanate er............................18amphetamine sulfate.................57amphetamine-dextroamphetamine.................. 57amphetamine-dextroamphetamine er.............. 57ampicillin................................... 18AMZEEQ...................................60anagrelide hcl............................48ANALPRAM HC........................ 90ANALPRAM HC SINGLES....... 90ANALPRAM-HC........................90anastrozole............................... 31ANDRODERM.......................... 77ANGELIQ.................................. 78ANNOVERA..............................78ANORO ELLIPTA................... 102ANTARA................................... 54ANTIVERT................................ 25anucort-hc................................. 90ANUSOL-HC.............................90APADAZ....................................14apap-caff-dihydrocodeine......... 14APEXICON E............................ 73APIDRA SOLOSTAR................ 46APIDRA VIAL............................46APLENZIN................................ 23APOKYN................................... 35APO-VARENICLINE................. 16apraclonidine hcl....................... 95aprepitant.................................. 25apri............................................ 78APTIOM.................................... 22APTIVUS...................................40ARAKODA................................ 34aranelle..................................... 78ARANESP (ALBUMIN FREE)...48ARAZLO....................................60ARCALYST............................... 88arformoterol tartrate................ 100argyle sterile saline................... 72ARIKAYCE................................17aripiprazole............................... 37ARISTADA................................ 37ARISTADA INITIO.................... 37armodafinil .............................. 103ARMONAIR DIGIHALER.......... 98ARMOUR THYROID.................85ARNUITY ELLIPTA...................98
ascomp-codeine........................14asenapine maleate....................37ashlyna......................................78ASMANEX (120 METERED DOSES).................................... 98ASMANEX (30 METERED DOSES).................................... 98ASMANEX (60 METERED DOSES).................................... 98ASMANEX (7 METERED DOSES).................................... 98ASMANEX HFA........................ 98aspirin....................................... 10aspirin adult low dose............... 10aspirin adult low strength.......... 10aspirin childrens........................ 10aspirin ec...................................10aspirin ec low dose................... 10aspirin ec low strength.............. 10aspirin low dose........................ 10aspirin-dipyridamole er..............49ASPIRIN-OMEPRAZOLE......... 49ASSURE PLATINUM................ 42ASTAGRAF XL......................... 86atazanavir sulfate......................40atenolol..................................... 51atenolol-chlorthalidone..............53atomoxetine hcl.........................57atorvastatin calcium.................. 55atovaquone............................... 34atovaquone-proguanil hcl..........34atropine sulfate......................... 94ATROVENT HFA...................... 99AUBAGIO..................................58aubra.........................................78aubra eq....................................78aurovela 1.5/30......................... 78aurovela 1/20............................ 78aurovela 24 fe........................... 78aurovela fe 1.5/30..................... 78aurovela fe 1/20........................ 78AURYXIA.................................. 66AUSTEDO.................................58AUVI-Q....................................100AVAR CLEANSER....................61AVAR-E EMOLLIENT............... 61AVAR-E GREEN.......................61aviane....................................... 78avidoxy......................................19AVITA........................................61AVONEX PEN...........................58AVONEX PREFILLED.............. 58ayuna........................................ 78
AYVAKIT...................................31AZASITE................................... 94azathioprine.............................. 86azelaic acid............................... 61azelastine hcl...................... 95, 97azelastine-fluticasone............. 102AZELEX.................................... 61azithromycin..............................19AZSTARYS............................... 57azurette..................................... 78bac............................................ 14bacitracin...................................93bacitracin-polymyxin b.............. 93bacitra-neomycin-polymyxin-hc 93baclofen.................................. 102BAFIERTAM............................. 59BALCOLTRA.............................78balsalazide disodium.................90BALVERSA............................... 31balziva.......................................78BAQSIMI ONE PACK............... 45BAQSIMI TWO PACK...............45BARACLUDE............................ 38BASAGLAR KWIKPEN............. 46BAXDELA................................. 19BECONASE AQ........................98BELBUCA................................. 12belladonna alkaloids-opium...... 66BELSOMRA............................ 103benazepril hcl............................50benazepril-hydrochlorothiazide. 53BENEFIX...................................49BENLYSTA............................... 88BENZAC AC WASH..................61BENZEPRO.............................. 61BENZHYDROCODONE-ACETAMINOPHEN...................14BENZNIDAZOLE...................... 34BENZOYL PEROXIDE..............61benzoyl peroxide-erythromycin. 61benztropine mesylate................34bepotastine besilate.................. 95BESIVANCE............................. 97BESREMI..................................30betamethasone dipropionate.... 73betamethasone dipropionate aug............................................ 73betamethasone valerate........... 73BETASERON............................59betaxolol hcl........................ 51, 95bethanechol chloride.................72BETIMOL.................................. 95BETOPTIC-S............................ 95
105
BEVESPI AEROSPHERE.........98bexarotene................................ 33BEXSERO.................................88bicalutamide..............................29BIDIL......................................... 53BIJUVA..................................... 78BIKTARVY................................ 38bimatoprost............................... 96BINOSTO..................................91bisacodyl ec.............................. 68bisoprolol fumarate................... 51bisoprolol-hydrochlorothiazide.. 53BLEPHAMIDE...........................94BLEPHAMIDE S.O.P................ 94blisovi 24 fe............................... 78blisovi fe 1.5/30......................... 78blisovi fe 1/20............................ 78BLOOD GLUCOSE TEST.........42BLULINK GLUCOSE TEST...... 42BONJESTA............................... 25BOOSTRIX............................... 88bosentan................................. 101BOSULIF...................................31BRAFTOVI................................ 31BREATHE EASE LARGE......... 91BREATHE EASE MEDIUM.......91BREATHE EASE SMALL..........91BREO ELLIPTA........................ 98BREXAFEMME.........................25BREZTRI AEROSPHERE.........99briellyn.......................................78BRILINTA..................................50brimonidine tartrate................... 95brinzolamide..............................95BRIVIACT................................. 20bromfenac sodium (once-daily).96bromocriptine mesylate.............35BROMSITE............................... 96BRONCHITOL........................ 100BRONCHITOL TOLERANCE TEST.......................................100BRUKINSA................................31BRYHALI...................................73budesonide......................... 90, 98budesonide er........................... 90BUDESONIDE-FORMOTEROL FUMARATE....98bumetanide............................... 54buprenorphine...........................12buprenorphine hcl..................... 16buprenorphine hcl-naloxone hcl............................................. 16bupropion hcl............................ 23
bupropion hcl er (smoking det). 16bupropion hcl er (sr)..................23bupropion hcl er (xl).................. 23BUPROPION HCL ER (XL)...... 23buspirone hcl.............................41butalbital-acetaminophen..........14BUTALBITAL-ACETAMINOPHEN...................14butalbital-apap-caff-cod............ 14butalbital-apap-caffeine.............14butalbital-asa-caff-codeine........14butalbital-aspirin-caffeine.......... 14butorphanol tartrate...................14BYDUREON BCISE AUTOINJECTOR...................... 44BYETTA 10 MCG PEN............. 44BYETTA 5 MCG PEN............... 44BYLVAY.................................... 59BYLVAY (PELLETS).................59cabergoline............................... 76CABLIVI.................................... 50CABOMETYX........................... 31caffeine citrate...........................58calcipotriene..............................61CALCIPOTRIENE..................... 61calcipotriene-betameth diprop...61calcitonin (salmon).................... 91calcitriol ............................... 61, 91calcium acetate......................... 66calcium acetate (phos binder)...66CALQUENCE............................31CAMBIA.................................... 27camila........................................84camrese.................................... 78camrese lo................................ 79candesartan cilexetil ................. 50candesartan cilexetil-hctz..........53capecitabine..............................30CAPEX......................................73CAPLYTA..................................37CAPRELSA...............................31captopril .................................... 50CARAC..................................... 30carbamazepine......................... 22carbamazepine er..................... 22carbidopa.................................. 35carbidopa-levodopa............ 35, 36carbidopa-levodopa er.............. 35carbidopa-levodopa-entacapone......................... 35, 36carbinoxamine maleate.............97CARDIZEM LA..........................52CARDURA XL...........................72
CARETOUCH TEST................. 42carglumic acid........................... 64carisoprodol............................ 102carisoprodol-aspirin-codeine.....14CAROSPIR............................... 54carteolol hcl...............................95cartia xt..................................... 52carvedilol...................................51carvedilol phosphate er.............51cavarest.................................... 59CAYA........................................ 91CAYSTON...............................100caziant.......................................79cefaclor..................................... 18cefaclor er................................. 18cefadroxil ...................................18cefdinir...................................... 18cefixime.....................................18cefpodoxime proxetil ................. 18cefprozil .....................................18cefuroxime axetil ....................... 18celecoxib................................... 10CELONTIN................................20cephalexin.................................18CEQUA..................................... 94CERDELGA.............................. 70cevimeline hcl........................... 60charlotte 24 fe........................... 79chateal...................................... 79chateal eq................................. 79CHEMET...................................65CHENODAL.............................. 67chlordiazepoxide hcl................. 41chlordiazepoxide-amitriptyline...23chlordiazepoxide-clidinium........67chlorhexidine gluconate............ 60chloroquine phosphate..............34chlorpromazine hcl....................36chlorthalidone............................54chlorzoxazone.........................102CHOLBAM................................ 70cholestyramine..........................56cholestyramine light.................. 56CHORIONIC GONADOTROPIN.................... 76ciclodan.....................................26ciclopirox................................... 26ciclopirox olamine..................... 26cilostazol................................... 50CILOXAN.................................. 97CIMDUO................................... 39cimetidine..................................68cimetidine hcl............................ 68
106
CIMZIA PREFILLED KIT...........86CIMZIA STARTER KIT............. 86cinacalcet hcl............................ 91CIPRO.......................................19CIPRO HC................................ 97ciprofloxacin hcl.................. 19, 97ciprofloxacin-dexamethasone... 97CIPROFLOXACIN-FLUOCINOLONE PF................ 97citalopram hydrobromide.......... 23citroma...................................... 68claravis......................................61clarithromycin............................19clarithromycin er........................19clearlax......................................68clemastine fumarate..................98CLENPIQ.................................. 68CLEOCIN.................................. 17CLEVER CHOICE HOLDING CHAMBER................................ 91CLIMARA PRO......................... 79clindacin etz.............................. 61clindacin-p.................................61clindamycin hcl..........................17clindamycin palmitate hcl.......... 17clindamycin phosphate....... 17, 61clindamycin phosphate-benzoyl peroxide.......................61clindamycin-tretinoin................. 61CLINDESSE..............................17clobazam...................................21clobetasol prop emollient base. 73clobetasol propionate................73clobetasol propionate e.............73clobetasol propionate emulsion 73clocortolone pivalate................. 73clodan....................................... 73clomiphene citrate.....................77clomipramine hcl....................... 24clonazepam...............................41clonidine....................................50clonidine hcl.............................. 50clonidine hcl er.......................... 57clopidogrel bisulfate.................. 50clorazepate dipotassium........... 41clotrimazole...............................26clotrimazole-betamethasone.....26clozapine...................................37COAGADEX..............................49COARTEM................................ 34codeine sulfate..........................14COLCHICINE............................27colchicine.................................. 27
colchicine-probenecid............... 27colesevelam hcl........................ 56colestipol hcl............................. 56COMBIGAN.............................. 95COMBIPATCH.......................... 79COMBIVENT RESPIMAT....... 102COMETRIQ...............................32COMPACT SPACE CHAMBER................................ 91COMPACT SPACE CHAMBER/LG MASK............... 92COMPACT SPACE CHAMBER/MED MASK............92COMPACT SPACE CHAMBER/SM MASK.............. 92COMPLERA..............................39compro...................................... 25CONDYLOX..............................61CONJUPRI................................52CONSENSI............................... 53constulose.................................68CONTOUR MONITOR DEVICE.....................................42CONTOUR NEXT MONITOR KIT W/DEVICE..........................42CONTOUR NEXT ONE KIT......42CONTOUR NEXT TEST STRIPS..................................... 42CONTOUR TEST STRIPS........42CONZIP.................................... 12COPAXONE..............................59COPIKTRA................................30CORDRAN................................73coremino................................... 19CORIFACT................................49CORLANOR..............................53CORTIFOAM............................ 90CORTISPORIN-TC................... 97COSENTYX (300 MG DOSE)...61COSENTYX 150 MG/ML.......... 62COSENTYX SENSOREADY (300 MG)...................................62COSENTYX SENSOREADY PEN...........................................62COTELLIC................................ 32COTEMPLA XR-ODT............... 57COVARYX................................ 79COVARYX HS.......................... 79CREON..................................... 71CRESEMBA..............................26cromolyn sodium.........67, 95, 101crotan........................................ 34cryselle-28.................................79
curity sterile saline.................... 72CUTAQUIG............................... 87CUVITRU.................................. 87CUVPOSA................................ 66cyanocobalamin........................ 66CYANOCOBALAMIN................ 66cyclafem 1/35............................79cyclafem 7/7/7...........................79cyclobenzaprine hcl................ 102cyclobenzaprine hcl er............ 102CYCLOMYDRIL........................ 95cyclopentolate hcl..................... 94cyclophosphamide.................... 29CYCLOPHOSPHAMIDE........... 29cycloserine................................ 28CYCLOSET...............................44cyclosporine.............................. 86cyclosporine modified............... 86cyproheptadine hcl....................98cyred......................................... 79cyred eq.................................... 79CYSTADANE............................ 71CYSTADROPS......................... 94CYSTAGON..............................71CYSTARAN.............................. 94CYTOTEC.................................70dalfampridine er........................ 59DALIRESP.............................. 101danazol..................................... 77dantrolene sodium.................. 102dapsone.............................. 28, 62DAPSONE................................ 62DAPTACEL............................... 88darifenacin hydrobromide er..... 71dasetta 1/35.............................. 79dasetta 7/7/7............................. 79DAURISMO...............................32daysee...................................... 79DAYTRANA.............................. 57DAYVIGO................................103deblitane................................... 84DECADRON............................. 73deferasirox................................ 65deferasirox granules................. 65deferiprone................................65deferoxamine mesylate.............92DELESTROGEN.......................79DELSTRIGO............................. 39delyla.........................................79demeclocycline hcl....................19DEMSER...................................53DENAVIR.................................. 38DENTA 5000 PLUS.................. 60
107
DENTAGEL...............................60DEPO-SUBQ PROVERA 104...84DESCOVY................................ 39desipramine hcl.........................24desmopressin ace spray refrig..76desmopressin acetate...............76desmopressin acetate pf...........76desmopressin acetate spray..... 76desogestrel-ethinyl estradiol..... 79desonide............................. 73, 74desoximetasone........................74desrx......................................... 74DESVENLAFAXINE ER............23desvenlafaxine succinate er......23DEXABLISS.............................. 74dexamethasone........................ 74dexamethasone intensol........... 74dexamethasone sodium phosphate................................. 96DEXCOM G6 RECEIVER......... 42DEXCOM G6 SENSOR............ 42DEXCOM G6 TRANSMITTER..42DEXILANT................................ 70DEXLANSOPRAZOLE..............70dexmethylphenidate hcl............ 57dexmethylphenidate hcl er........ 57dextroamphetamine sulfate.......57dextroamphetamine sulfate er.. 57DHIVY....................................... 36DIACOMIT................................ 21DIATHRIVE BLOOD GLUCOSE TEST...................... 42DIATHRIVE GLUCOSE TEST.. 42DIATHRIVE+ GLUCOSE TEST.........................................42diazepam............................ 21, 41diazepam intensol..................... 41diazoxide...................................45DICLOFENAC CAP 35MG........10DICLOFENAC PATCH 1.3%.... 10diclofenac potassium................ 10diclofenac sodium......... 10, 30, 96diclofenac sodium er................. 10diclofenac-misoprostol.............. 11dicloxacillin sodium................... 18dicyclomine hcl..........................66DIFFERIN................................. 62DIFICID..................................... 19diflorasone diacetate.................74diflunisal.................................... 11difluprednate............................. 96digitek........................................53digox......................................... 53
digoxin.......................................53dihydroergotamine mesylate.....27DILANTIN..................................22diltiazem hcl.............................. 52diltiazem hcl er.......................... 52diltiazem hcl er beads............... 52diltiazem hcl er coated beads... 52dilt-xr......................................... 52dimethyl fumarate..................... 59dimethyl fumarate starter pack..59DIPENTUM............................... 90diphenhydramine hcl.................98diphenoxylate-atropine..............67DIPHTHERIA-TETANUS TOXOIDS DT............................ 88dipyridamole..............................50disopyramide phosphate...........51disulfiram...................................16DIURIL...................................... 54divalproex sodium..................... 41divalproex sodium er.................41DIVIGEL....................................79dofetilide....................................51DOJOLVI...................................92dolishale....................................79donepezil hcl............................. 22DOPTELET............................... 48DORYX..................................... 19DORYX MPC............................ 19dorzolamide hcl.........................95dorzolamide hcl-timolol mal...... 95dorzolamide hcl-timolol mal pf.. 95dotti ........................................... 79DOVATO...................................38doxazosin mesylate.................. 50doxepin hcl..................24, 62, 103doxercalciferol...........................91doxycycline............................... 62doxycycline hyclate............. 19, 20DOXYCYCLINE HYCLATE.......20doxycycline monohydrate......... 20doxylamine-pyridoxine.............. 25DRIZALMA SPRINKLE............. 23dronabinol................................. 25drospiren-eth estrad-levomefol. 79drospirenone-ethinyl estradiol...79DROXIA.................................... 30droxidopa.................................. 53DRYSOL................................... 62DUAKLIR PRESSAIR............. 102DUAVEE................................... 79DULERA................................... 98duloxetine hcl............................ 23
DUOBRII................................... 62DUOPA..................................... 36DUPIXENT................................62DURLAZA................................. 50dutasteride................................ 72dutasteride-tamsulosin hcl........ 72DUTOPROL.............................. 53DXEVO 11-DAY........................74DYANAVEL XR.........................57E.E.S. 400.................................19EASIVENT................................ 92EASY TALK PLUS II TEST STRIPS..................................... 42EASY TOUCH HEALTHPRO GLUCOSE................................ 42EASY TRAK II GLUCOSE TEST.........................................42ec-naproxen.............................. 11econazole nitrate.......................26ECOZA......................................26EDARBI.....................................50EDARBYCLOR......................... 53EDLUAR................................. 103EDURANT.................................39EEMT........................................ 79EEMT HS.................................. 79efavirenz................................... 39efavirenz-emtricitab-tenofovir....39efavirenz-lamivudine-tenofovir.. 39EFFER-K...................................64effer-k........................................64EGRIFTA SV.............................76ELEPSIA XR............................. 20ELESTRIN................................ 79eletriptan hydrobromide............ 28elinest........................................79ELIQUIS....................................47ELIQUIS DVT/PE STARTER PACK........................................ 47ELIXOPHYLLIN...................... 101ELLA......................................... 84ELMIRON..................................72ELOCTATE............................... 49eluryng...................................... 79EMBRACE PRESSURE ACTIVATED 21G...................... 42EMBRACE PRESSURE ACTIVATED 28G...................... 42EMBRACE TALK GLUCOSE TEST.........................................42EMCYT..................................... 30EMEND..................................... 25EMFLAZA................................. 74
108
EMGALITY................................27EMGALITY (300 MG DOSE).... 27emoquette................................. 79EMPAVELI................................ 47EMSAM.....................................23emtricitabine..............................39emtricitabine-tenofovir df...........39EMTRIVA.................................. 39EMVERM.................................. 34enalapril maleate.......................50enalapril-hydrochlorothiazide.... 53ENBREL....................................86ENBREL MINI........................... 86ENBREL SURECLICK.............. 86ENDARI.................................... 92endocet..................................... 14ENDOMETRIN..........................84ENGERIX-B.............................. 88enoxaparin sodium....................47enpresse-28.............................. 79enskyce.....................................79ENSPRYNG..............................88ENSTILAR................................ 62entacapone............................... 35entecavir................................... 38ENTRESTO.............................. 53enulose..................................... 68ENVARSUS XR........................ 86EPCLUSA................................. 38EPIDIOLEX............................... 20EPIFOAM..................................62epinastine hcl............................ 95epinephrine............................. 100epitol......................................... 22EPIVIR HBV..............................38eplerenone................................ 54EPOGEN...................................48EPRONTIA................................21EQUETRO................................ 41ergocalciferol.............................66ergoloid mesylates.................... 92ERGOMAR............................... 27ergotamine-caffeine.................. 27ERIVEDGE............................... 32ERLEADA................................. 29erlotinib hcl................................32errin...........................................84ERTACZO.................................26ery............................................. 62ERYTHROCIN STEARATE...... 19erythromycin................. 19, 62, 94erythromycin base.....................19erythromycin ethylsuccinate......19
ESBRIET.................................101escitalopram oxalate................. 24ESOMEPRAZOLE STRONTIUM.............................70ESPEROCT.............................. 49est estrogens-methyltest...........79est estrogens-methyltest ds...... 79est estrogens-methyltest hs...... 80estarylla.....................................80estazolam..................................41estradiol.................................... 80estradiol valerate.......................80estradiol-norethindrone acet..... 80ESTRING.................................. 80ESTROGEL.............................. 80eszopiclone............................. 103ethacrynic acid.......................... 54ethambutol hcl...........................28ethosuximide.............................21ethynodiol diac-eth estradiol..... 80etodolac.................................... 11etodolac er................................ 11etonogestrel-ethinyl estradiol.... 80etoposide.................................. 31etravirine................................... 39EUCRISA.................................. 62euthyrox.................................... 85EVAMIST.................................. 80EVEKEO ODT...........................57everolimus...........................32, 86EVOTAZ....................................40EVRYSDI.................................. 71EXELDERM.............................. 26exemestane.............................. 31EXFORGE HCT........................ 53EXKIVITY..................................32EXSERVAN.............................. 58EXTAVIA...................................59EYSUVIS.................................. 96EZALLOR SPRINKLE...............55ezetimibe...................................56EZETIMIBE-ROSUVASTATIN..56ezetimibe-simvastatin............... 56FABIOR.....................................62falmina...................................... 80famciclovir................................. 38famotidine................................. 68FANAPT....................................37FANAPT TITRATION PACK..... 37FARXIGA.................................. 44FARYDAK................................. 32FASENRA PEN.......................102fayosim......................................80
FC FEMALE CONDOM............ 92FC2 FEMALE CONDOM.......... 92febuxostat................................. 27FEIBA........................................49felbamate.................................. 21felodipine er.............................. 52FEMCAP................................... 92FEMRING................................. 80femynor..................................... 80fenofibrate................................. 55fenofibrate micronized...............54FENOFIBRATE MICRONIZED. 54fenofibric acid............................55fenoprofen calcium....................11fenortho.....................................11fentanyl..................................... 12fentanyl citrate...........................14FENTANYL CITRATE...............14FENTORA.................................14FERRIPROX............................. 65FERRIPROX TWICE-A-DAY.... 65FETZIMA...................................24FETZIMA TITRATION...............24FIASP........................................46FIASP FLEXTOUCH.................46FIASP PENFILL........................ 46FIBRICOR.................................55FINACEA.................................. 62finasteride................................. 72FINTEPLA.................................20FIRDAPSE................................ 92FIRVANQ.................................. 17flac............................................ 97FLAREX.................................... 96flavoxate hcl.............................. 71flecainide acetate...................... 51FLECTOR................................. 11FLEXICHAMBER...................... 92FLOLIPID.................................. 55FLOVENT DISKUS................... 98FLOVENT HFA......................... 98FLUAD QUADRIVALENT......... 88FLUARIX QUADRIVALENT......88FLUBLOK QUADRIVALENT.....88FLUCELVAX QUADRIVALENT...................... 88fluconazole................................26flucytosine................................. 26fludrocortisone acetate..............74FLULAVAL QUADRIVALENT... 88FLUMIST QUADRIVALENT......88flunisolide.................................. 98fluocinolone acetonide........ 74, 97
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fluocinolone acetonide body..... 74fluocinolone acetonide scalp.....74fluocinonide...............................74fluocinonide emulsified base.....74fluoritab..................................... 64fluorometholone........................ 96FLUOROPLEX..........................30FLUOROURACIL......................30fluorouracil ................................ 30fluoxetine hcl............................. 24fluoxetine hcl (pmdd).................24fluphenazine decanoate............36fluphenazine hcl........................ 36flurandrenolide.......................... 74flurazepam hcl.........................103flurbiprofen................................ 11flurbiprofen sodium................... 96fluticasone propionate.........74, 98fluticasone-salmeterol............... 99FLUTICASONE-SALMETEROL..........................99fluvastatin sodium..................... 55fluvastatin sodium er................. 55fluvoxamine maleate................. 24fluvoxamine maleate er.............24FLUZONE HIGH-DOSE QUADRIVALENT...................... 88FLUZONE QUADRIVALENT.... 88FML...........................................96FML FORTE..............................96folate......................................... 66folic acid.................................... 66FOLLISTIM AQ......................... 76fondaparinux sodium.................47FORA 6 CONNECT.................. 42FORA GTEL BLOOD GLUCOSE TEST...................... 42FORA TN'G ADVANCE PRO....42FORFIVO XL.............................23formoterol fumarate.................100FORTEO................................... 91FOSAMAX PLUS D.................. 91fosamprenavir calcium.............. 40fosfomycin tromethamine..........17fosinopril sodium....................... 50fosinopril sodium-hctz............... 53FOSRENOL.............................. 66FOTIVDA.................................. 32FRAGMIN................................. 47FREESTYLE LIBRE 14 DAY READER................................... 42FREESTYLE LIBRE 14 DAY SENSOR...................................42
FREESTYLE LIBRE 2 READER................................... 42FREESTYLE LIBRE 2 SENSOR...................................43FREESTYLE LIBRE READER..43FREESTYLE PRECISION NEO TEST................................ 43frovatriptan succinate................28FULPHILA.................................48fulvestrant................................. 30furosemide................................ 54FUZEON................................... 40fyavolv.......................................80FYCOMPA................................ 21gabapentin................................ 21GALAFOLD...............................71galantamine hydrobromide....... 22galantamine hydrobromide er... 22GALZIN..................................... 64GAMMAGARD.......................... 87GAMMAKED............................. 87GAMUNEX-C............................ 87ganirelix acetate........................85GARDASIL 9.............................89gatifloxacin................................ 97GATTEX....................................67gavilax.......................................68gavilyte-c...................................68gavilyte-g...................................68gavilyte-n with flavor pack.........69GAVRETO................................ 32GELNIQUE............................... 71gemfibrozil .................................55gemmily.....................................80GEMTESA................................ 71generlac.................................... 69gengraf......................................86GENOTROPIN..........................76GENOTROPIN MINIQUICK......76gentak....................................... 93gentamicin sulfate............... 17, 93gentle laxative........................... 69GENVOYA................................ 38GILENYA.................................. 59GILOTRIF................................. 32GIMOTI..................................... 25GLASSIA...................................71glatiramer acetate..................... 59glatopa...................................... 59GLEOSTINE............................. 29glimepiride.................................44glipizide er.................................44glipizide ir.................................. 44
glipizide xl................................. 44glipizide-metformin hcl.............. 44GLOPERBA.............................. 27GLUCAGEN HYPOKIT............. 45glucagon emergency kit ............ 45GLUCAGON EMERGENCY KIT............................................ 45GLUCOCARD 01 SENSOR PLUS.........................................43GLUCOCARD EXPRESSION TEST.........................................43GLUCOCARD SHINE TEST.....43GLUCOCARD VITAL TEST......43glyburide................................... 44glyburide micronized................. 44glyburide-metformin.................. 44glycopyrrolate............................66glydo......................................... 15GLYXAMBI................................44GOCOVRI................................. 35GOJJI BLOOD GLUCOSE TEST.........................................43GONAL-F.................................. 76GONAL-F RFF.......................... 76GONAL-F RFF REDIJECT....... 76GONITRO................................. 56goodsense aspirin adults.......... 11goodsense aspirin low dose......11goodsense nicotine................... 16GRALISE.................................. 58granisetron hcl.......................... 25GRANIX.................................... 48GRASTEK...............................102griseofulvin microsize................26griseofulvin ultramicrosize.........26guanfacine hcl...........................50guanfacine hcl er.......................57GVOKE HYPOPEN 1-PACK.....45GVOKE HYPOPEN 2-PACK.....45GVOKE PFS............................. 45GYNAZOLE-1........................... 26habitrol...................................... 16HAEGARDA..............................86hailey 1.5/30..............................80hailey 24 fe................................80hailey fe 1.5/30..........................80hailey fe 1/20.............................80halcinonide................................74halobetasol propionate..............74HALOBETASOL PROPIONATE.......................... 74HALOG..................................... 74haloperidol................................ 36
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haloperidol decanoate...............36haloperidol lactate.....................36HARVONI..................................38HAVRIX.....................................89healthylax..................................69heather......................................84HELIDAC THERAPY................ 67HEMADY...................................74HEMANGEOL........................... 51HEMLIBRA................................49HEMMOREX-HC...................... 90HEMOFIL M.............................. 49heparin sodium (porcine).......... 47heparin sodium (porcine) pf...... 48HEPLISAV-B.............................89HETLIOZ.................................103HETLIOZ LQ........................... 103HIBERIX....................................89HIDEX 6-DAY........................... 74HIZENTRA................................ 88homatropaire.............................94HORIZANT................................58HUMALOG................................46HUMALOG KWIKPEN.............. 46HUMALOG MIX 50/50 KWIKPEN................................. 46HUMALOG MIX 50/50 VIAL......46HUMALOG MIX 75/25 KWIKPEN................................. 46HUMALOG MIX 75/25 VIAL......46HUMALOG U-100 JUNIOR KWIKPEN................................. 46HUMATE-P............................... 49HUMATROPE........................... 76HUMIRA....................................86HUMIRA PEDIATRIC CROHNS START......................86HUMIRA PEN........................... 86HUMIRA PEN-CD/UC/HS STARTER................................. 87HUMIRA PEN-PEDIATRIC UC START...................................... 87HUMIRA PEN-PS/UV/ADOL HS START................................ 87HUMIRA PEN-PSOR/UVEIT STARTER................................. 87HUMULIN 70/30 KWIKPEN...... 46HUMULIN 70/30 VIAL...............46HUMULIN N KWIKPEN............ 46HUMULIN N VIAL..................... 46HUMULIN R U-500 KWIKPEN..46HUMULIN R U-500 VIAL.......... 46HUMULIN R VIAL..................... 46
HW EMBRACE PRO GLUCOSE TEST...................... 43HW EMBRACE TALK GLUCOSE TEST...................... 43HYCAMTIN............................... 31hydralazine hcl.......................... 57hydrochlorothiazide...................54hydrocodone bitartrate er..........12hydrocodone-acetaminophen... 14hydrocodone-ibuprofen............. 14hydrocortisone.................... 75, 90hydrocortisone (perianal).......... 90hydrocortisone ace-pramoxine............................................ 62, 90hydrocortisone acetate..............90hydrocortisone butyr lipo base.. 74hydrocortisone butyrate............ 75hydrocortisone valerate.............75hydrocortisone-acetic acid........ 97hydrocort-pramoxine (perianal).90hydromorphone hcl................... 14hydromorphone hcl er............... 12hydroxocobalamin acetate........ 66hydroxychloroquine sulfate....... 34hydroxyurea.............................. 30hydroxyzine hcl......................... 41hydroxyzine pamoate................41hyoscyamine sulfate........... 66, 67hyoscyamine sulfate er............. 66hyoscyamine sulfate sl..............66hyosyne.....................................67HYPERSAL.............................102HYQVIA.................................... 88ibandronate sodium.................. 91IBRANCE.................................. 32ibuprofen................................... 11ibuprofen-famotidine................. 11icatibant acetate........................86iclevia........................................ 80ICLUSIG....................................32icosapent ethyl.......................... 56IDELVION................................. 49IDHIFA...................................... 32ILEVRO.....................................96imatinib mesylate...................... 32IMBRUVICA.............................. 32IMCIVREE.................................58imipramine hcl...........................24imipramine pamoate................. 25imiquimod..................................62IMIQUIMOD PUMP...................62IMPAVIDO................................ 34IMPEKLO.................................. 75
IMPOYZ.................................... 75IMVEXXY MAINTENANCE PACK........................................ 80IMVEXXY STARTER PACK..... 80INBRIJA.................................... 35incassia..................................... 84INCRELEX................................ 76INCRUSE ELLIPTA.................. 99indapamide............................... 54INDERAL XL............................. 51INDOCIN...................................11INDOMETHACIN...................... 11indomethacin.............................11indomethacin er........................ 11INFANRIX................................. 89INFINITY BLOOD GLUCOSE TEST.........................................43INGREZZA................................58INLYTA..................................... 32INNOPRAN XL..........................51INQOVI..................................... 32INREBIC................................... 30INSULIN ASP PROT & ASP FLEXPEN..................................46INSULIN ASPART.................... 46INSULIN ASPART FLEXPEN... 46INSULIN ASPART PENFILL.....46INSULIN ASPART PROT & ASPART....................................46INSULIN GLARGINE-YFGN..... 46INSULIN LISPRO......................46INSULIN LISPRO (1 UNIT DIAL).........................................46INSULIN LISPRO JUNIOR KWIKPEN................................. 46INSULIN LISPRO PROT & LISPRO.....................................46INTELENCE..............................39INTRAROSA............................. 77INTRON A.................................38introvale.................................... 80INVEGA SUSTENNA................37INVEGA TRINZA...................... 37INVELTYS.................................96INVIRASE................................. 40INVOKAMET.............................44INVOKAMET XR.......................44INVOKANA............................... 44iodine strong............................. 64IOPIDINE.................................. 95IPOL..........................................89ipratropium bromide.................. 99ipratropium-albuterol............... 102
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irbesartan.................................. 50irbesartan-hydrochlorothiazide..53IRESSA.....................................32ISENTRESS..............................39ISENTRESS HD....................... 39isibloom.....................................80isoniazid.................................... 29ISOPTO ATROPINE................. 94isosorbide dinitrate....................56isosorbide mononitrate..............56isosorbide mononitrate er......... 56isotretinoin.................................62isradipine...................................52ISTURISA................................. 76itraconazole...............................26ivermectin............................34, 62IXINITY..................................... 49jaimiess..................................... 80JAKAFI......................................32JANSSEN COVID-19 VACCINE.................................. 89jantoven.................................... 48JANUMET................................. 44JANUMET XR........................... 44JANUVIA...................................44JARDIANCE..............................44jasmiel.......................................80JATENZO..................................77jencycla..................................... 84JENTADUETO.......................... 44JENTADUETO XR.................... 44jinteli ..........................................80JIVI............................................49jolessa.......................................80JORNAY PM............................. 57JUBLIA......................................26juleber....................................... 80JULUCA.................................... 39junel 1.5/30............................... 80junel 1/20.................................. 80junel fe 1.5/30........................... 80junel fe 1/20.............................. 80junel fe 24................................. 80JUXTAPID.................................56JYNARQUE.............................. 65kaitlib fe.....................................81kalliga........................................81KALYDECO............................ 100KAPSPARGO SPRINKLE.........51kariva........................................ 81KATERZIA................................ 52KAZANO................................... 44kelnor 1/35................................ 81
kelnor 1/50................................ 81KERENDIA................................92KESIMPTA................................59ketoconazole.............................26ketodan..................................... 26ketoprofen................................. 11ketoprofen er.............................11ketorolac tromethamine...... 11, 96KETOROLAC TROMETHAMINE.....................11KEVEYIS...................................54KEVZARA................................. 88KINERET.................................. 87KINRIX...................................... 89KISQALI.................................... 30KISQALI FEMARA.................... 32KITABIS PAK.......................... 100KLISYRI.................................... 30klor-con..................................... 64klor-con 10................................ 64klor-con m10............................. 64klor-con m15............................. 64klor-con m20............................. 64klor-con/ef................................. 64KLOXXADO.............................. 16KOATE......................................49KOATE-DVI...............................49KOGENATE FS........................ 49KOMBIGLYZE XR.....................44KORLYM...................................77KOSELUGO..............................32KOVALTRY...............................49K-PHOS.................................... 65K-PHOS NO 2...........................65k-prime...................................... 65KRINTAFEL.............................. 34KRISTALOSE........................... 69KROGER HEALTHPRO GLUCOSE TEST...................... 43kurvelo...................................... 81KYNMOBI................................. 35labetalol hcl............................... 51LACRISERT..............................94lactulose....................................69lactulose encephalopathy......... 69LAMICTAL ODT........................21LAMICTAL XR.......................... 21lamivudine...........................38, 39lamivudine-zidovudine.............. 39lamotrigine................................ 21lamotrigine er............................ 21lamotrigine starter kit-blue.........21lamotrigine starter kit-green...... 21
lamotrigine starter kit-orange.... 21LAMPIT..................................... 34LANCETS................................. 43LANOXIN.................................. 53lansoprazole..............................70lanthanum carbonate................ 66LANTUS SOLOSTAR............... 46LANTUS U-100 VIAL................ 46lapatinib ditosylate.................... 32larin 1.5/30................................ 81larin 1/20................................... 81larin 24 fe.................................. 81larin fe 1.5/30............................ 81larin fe 1/20............................... 81larissia.......................................81LASTACAFT............................. 95latanoprost................................ 96LATUDA....................................37layolis fe.................................... 81LAZANDA................................. 15LEDIPASVIR-SOFOSBUVIR.... 38leena......................................... 81leflunomide................................88LENVIMA.................................. 32lessina.......................................81letrozole.................................... 31leucovorin calcium.................... 30LEUKERAN...............................29LEUKINE...................................48leuprolide acetate......................85levalbuterol hcl........................ 100LEVALBUTEROL HFA............100LEVBID..................................... 67LEVEMIR U-100 FLEXTOUCH.47LEVEMIR U-100 VIAL...............47levetiracetam.............................20levetiracetam er........................ 20levobunolol hcl.......................... 95levocarnitine..............................65LEVOCARNITINE..................... 92levocarnitine sf.......................... 65levofloxacin......................... 19, 97levonest.....................................81levonorgest-eth est & eth est.... 81levonorgest-eth estrad 91-day.. 81levonorgestrel........................... 84levonorgestrel-ethinyl estrad.....81levonorg-eth estrad triphasic.....81levora 0.15/30 (28)....................81levorphanol tartrate................... 12levo-t......................................... 85LEVOTHYROXINE SODIUM.... 85levothyroxine sodium................ 85
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levoxyl....................................... 85LEVSIN..................................... 67LEVSIN/SL................................67LEXETTE.................................. 75LEXIVA..................................... 40LICART..................................... 11lidocaine....................................15lidocaine hcl.............................. 15lidocaine hcl urethral/mucosal...16LIDOCAINE HCL-TETRACAINE HCL................... 16lidocaine viscous hcl................. 16lidocaine-hydrocort (perianal)... 90LIDOCAINE-HYDROCORTISONE ACE....... 62lidocaine-prilocaine................... 16LIDOCORT............................... 90lillow.......................................... 81lindane...................................... 34linezolid..................................... 17LINZESS................................... 68liothyronine sodium................... 85LIPOFEN...................................55lisinopril ..................................... 50lisinopril-hydrochlorothiazide.....53lithium carbonate.......................41lithium carbonate er.................. 41LITHOSTAT.............................. 72LIVALO..................................... 55LIVMARLI..................................59LO LOESTRIN FE.....................81lojaimiess.................................. 81LOKELMA................................. 65LONHALA MAGNAIR REFILL KIT............................................ 99LONHALA MAGNAIR STARTER KIT...........................99LONSURF.................................30loperamide hcl...........................67lopinavir-ritonavir.......................40lorazepam................................. 41lorazepam intensol....................41LORBRENA.............................. 32LOREEV XR............................. 41LORTAB....................................15loryna........................................ 81losartan potassium....................50losartan potassium-hctz............ 53LOTEMAX.................................96LOTEMAX SM.......................... 96loteprednol etabonate............... 96lovastatin...................................55low-ogestrel...............................81
loxapine succinate.................... 36lo-zumandimine.........................81LUBIPROSTONE......................68LUCEMYRA.............................. 16LULICONAZOLE.......................26LUMAKRAS.............................. 30LUMIGAN..................................96LUPKYNIS................................ 87LUPRON DEPOT (1-MONTH)..85LUPRON DEPOT (3-MONTH)..85LUPRON DEPOT-PED (1-MONTH)....................................85LUPRON DEPOT-PED (3-MONTH)....................................85lutera......................................... 81LUZU.........................................26LYBALVI................................... 23lyleq...........................................84lyllana........................................81LYMEPAK................................. 20LYNPARZA............................... 32LYSODREN.............................. 85LYUMJEV KWIKPEN................47LYUMJEV VIAL.........................47lyza............................................84mafenide acetate...................... 17magnesium citrate.....................69malathion.................................. 34marlissa.....................................81MARPLAN.................................23MATULANE.............................. 29matzim la...................................52MAVENCLAD............................59MAVYRET.................................38MAXIDEX..................................96MAYZENT.................................59MAYZENT STARTER PACK.... 59meclizine hcl............................. 25meclofenamate sodium.............11MEDROL...................................75medroxyprogesterone acetate.. 84mefenamic acid.........................11mefloquine hcl...........................34megestrol acetate..................... 84MEKINIST................................. 32MEKTOVI..................................32meloxicam.................................11melphalan................................. 29memantine hcl...........................23memantine hcl er...................... 23MENACTRA..............................89MENEST................................... 81MENOSTAR..............................81
MENQUADFI............................ 89MENTAX................................... 26MENVEO.................................. 89meperidine hcl...........................15meprobamate............................41mercaptopurine......................... 30merzee...................................... 81mesalamine...............................90mesalamine er oral capsule 0.375 gm................................... 90MESNEX...................................33metaxalone............................. 102metformin hcl er........................ 44metformin hcl er (mod)..............44metformin hcl er (osm).............. 44metformin hcl ir ................... 44, 45methadone hcl.......................... 13methadone hcl intensol............. 13methadose................................ 13methadose sugar-free...............13methamphetamine hcl...............57methazolamide..........................54methenamine hippurate............ 17methergine................................ 92methimazole..............................86METHITEST..............................77methocarbamol....................... 102methotrexate............................. 87methotrexate sodium................ 87methotrexate sodium (pf).......... 87methoxsalen rapid.....................62methscopolamine bromide........67methyldopa............................... 50methylergonovine maleate........92methylphenidate hcl.................. 58methylphenidate hcl er..............58methylphenidate hcl er (cd).......58methylphenidate hcl er (la)........58methylphenidate hcl er (xr)....... 58methylprednisolone...................75methyltestosterone....................77metoclopramide hcl...................25metolazone............................... 54metoprolol succinate er.............51metoprolol tartrate.....................51metoprolol-hydrochlorothiazide.53metronidazole..................... 17, 63metyrosine................................ 53mexiletine hcl............................ 51miconazole 3.............................26MICONAZOLE-ZINC OXIDE-PETROLAT............................... 26MICROCHAMBER.................... 92
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MICRODOT TEST.................... 43microgestin 1.5/30.....................81microgestin 1/20........................81microgestin 24 fe.......................81microgestin fe 1.5/30.................81microgestin fe 1/20....................82midazolam hcl........................... 41midodrine hcl.............................50MIGERGOT.............................. 27miglitol.......................................45miglustat....................................71mili .............................................82milk of magnesia....................... 69milk of magnesia concentrate... 69MILLIPRED............................... 75mimvey......................................82minocycline hcl..........................20MINOCYCLINE HCL ER...........20minocycline hcl er..................... 20MINOLIRA.................................20minoxidil .................................... 57MIRCERA................................. 48mirtazapine............................... 23misoprostol................................70MITIGARE.................................27mm clearlax...............................69M-M-R II.................................... 89modafinil ..................................103MODERNA COVID-19 VACCINE.................................. 89moexipril hcl.............................. 50molindone hcl............................36MOLNUPIRAVIR.......................37mometasone furoate........... 75, 99mondoxyne nl............................20mono-linyah.............................. 82MONONINE.............................. 49montelukast sodium.................. 99morphine sulfate....................... 15morphine sulfate (concentrate). 15morphine sulfate er................... 13morphine sulfate er beads........ 13MOTEGRITY.............................67MOTOFEN................................ 67MOVANTIK............................... 67moxifloxacin hcl...................19, 97moxifloxacin hcl (2x day)...........97MULPLETA............................... 48MULTAQ................................... 51mupirocin.................................. 17mupirocin calcium..................... 17MYALEPT................................. 71MYCAPSSA.............................. 85
mycophenolate mofetil .............. 87mycophenolate sodium............. 87MYDAYIS..................................57MYFEMBREE........................... 82MYLERAN.................................29myorisan................................... 63MYRBETRIQ.............................71MYTESI.....................................67nabumetone.............................. 12nadolol...................................... 51nafrinse..................................... 65nafrinse drops........................... 65naftifine hcl................................26NAFTIN..................................... 26nalbuphine hcl...........................15NALOCET................................. 15naloxone hcl..............................16NALOXONE HCL......................16naltrexone hcl............................16NAMZARIC............................... 22NAPRELAN...............................12naproxen................................... 12naproxen sodium...................... 12naproxen sodium er.................. 12NAPROXEN SODIUM ER........ 12naproxen-esomeprazole........... 12naratriptan hcl........................... 28NASCOBAL.............................. 66NATACYN.................................94NATAZIA...................................82nateglinide.................................45NATESTO................................. 77NATPARA................................. 91NATURE-THROID.................... 85NAYZILAM................................ 21nebivolol hcl.............................. 51necon 0.5/35 (28)......................82nefazodone hcl..........................24neomycin sulfate....................... 17neomycin-bacitracin zn-polymyx.....................................93neomycin-polymyxin-dexameth 93neomycin-polymyxin-gramicidin..................................93neomycin-polymyxin-hc...... 94, 97neo-polycin................................94neo-polycin hc...........................94NEO-SYNALAR........................ 17NERLYNX................................. 32NESINA.....................................45neuac........................................ 63NEULASTA............................... 48NEUPOGEN............................. 48
NEUPRO...................................35NEVANAC.................................96nevirapine................................. 39nevirapine er............................. 39NEXAVAR.................................32NEXIUM.................................... 70NEXLETOL............................... 56NEXLIZET.................................56NEXTSTELLIS.......................... 82niacin (antihyperlipidemic)........ 56niacin er (antihyperlipidemic).... 56niacor........................................ 56nicardipine hcl........................... 52nicotine......................................17nicotine polacrilex..................... 16nicotine polacrilex mini..............16nicotine step 1...........................16nicotine step 2...........................17nicotine step 3...........................17NICOTROL............................... 17NICOTROL NS......................... 17nifedipine...................................52nifedipine er.............................. 52nifedipine er osmotic release.... 52nikki...........................................82nilutamide..................................29nimodipine.................................52NINLARO.................................. 30nisoldipine er.............................52nitazoxanide..............................34nitisinone...................................71NITRO-BID................................56NITRO-DUR..............................57nitrofurantoin............................. 17nitrofurantoin macrocrystal........17nitrofurantoin monohydrate macrocrystals............................18nitroglycerin...............................57NITROMIST.............................. 57NITRO-TIME............................. 57NITYR....................................... 71NIVESTYM................................48nizatidine...................................68NOCDURNA............................. 76nolix...........................................75nora-be......................................84NORDITROPIN FLEXPRO....... 76norethin ace-eth estrad-fe.........82norethindrone............................84norethindrone acetate............... 84norethindrone acet-ethinyl est...82norethindrone-eth estradiol....... 82norethin-eth estradiol-fe............ 82
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NORGESIC FORTE................102norgestimate-eth estradiol........ 82norgestimate-ethinyl estradiol triphasic.....................................82NORITATE................................63norlyda...................................... 84norlyroc..................................... 84NORPACE CR.......................... 51nortrel 0.5/35 (28)..................... 82nortrel 1/35 (21)........................ 82nortrel 1/35 (28)........................ 82nortrel 7/7/7...............................82nortriptyline hcl..........................25NORVIR.................................... 40NOURIANZ............................... 35NOVAREL.................................76NOVOEIGHT............................ 49NOVOLIN 70/30 FLEXPEN...... 47NOVOLIN 70/30 RELION......... 47NOVOLIN 70/30 VIAL............... 47NOVOLIN N FLEXPEN.............47NOVOLIN N RELION................47NOVOLIN N VIAL..................... 47NOVOLIN R FLEXPEN.............47NOVOLIN R RELION................47NOVOLIN R VIAL..................... 47NOVOLOG 70/30 FLEXPEN RELION.....................................47NOVOLOG FLEXPEN.............. 47NOVOLOG FLEXPEN RELION.....................................47NOVOLOG MIX 70/30 FLEXPEN..................................47NOVOLOG MIX 70/30 RELION.....................................47NOVOLOG MIX 70/30 VIAL......47NOVOLOG PENFILL................ 47NOVOLOG RELION................. 47NOVOLOG U-100 VIAL............ 47NOVOSEVEN RT..................... 49NOXAFIL...................................26np thyroid.................................. 85NUBEQA...................................29NUCALA................................. 102NUCYNTA.................................15NUCYNTA ER...........................13NUEDEXTA.............................. 58NULEV...................................... 67NUPLAZID................................ 37NURTEC................................... 27NUTROPIN AQ NUSPIN 10..... 76NUTROPIN AQ NUSPIN 20..... 76NUTROPIN AQ NUSPIN 5....... 77
NUVESSA.................................18NUWIQ......................................49NUZYRA................................... 20nyamyc......................................26nylia 1/35...................................82nylia 7/7/7..................................82NYMALIZE................................ 52nymyo....................................... 82nystatin......................................26nystatin-triamcinolone............... 26nystop....................................... 26NYVEPRIA................................48OBIZUR.................................... 49OCALIVA.................................. 71ocella.........................................82octreotide acetate..................... 85ODACTRA.............................. 102ODEFSEY.................................40ODOMZO..................................33OFEV...................................... 101ofloxacin..............................19, 97olanzapine.................................37olanzapine-fluoxetine hcl.......... 23olmesartan medoxomil..............50olmesartan medoxomil-hctz...... 53olmesartan-amlodipine-hctz......53olopatadine hcl....................95, 98OLUMIANT............................... 87OMECLAMOX-PAK.................. 67omega-3-acid ethyl esters.........56omeprazole............................... 70omeprazole-sodium bicarbonate............................... 70OMNARIS................................. 99OMNIPOD 5 PACK................... 92OMNIPOD DASH 5 PACK PODS........................................92OMNITROPE............................ 77ondansetron hcl........................ 25ondansetron odt........................ 25ONE DROP TEST.....................43ONETOUCH CLUB LANCETS FINE PT.................................... 43ONETOUCH DELICA LANCETS 30G..........................43ONETOUCH DELICA LANCETS 33G..........................43ONETOUCH DELICA PLUS LANCET30G............................. 43ONETOUCH DELICA PLUS LANCET33G............................. 43ONETOUCH FINEPOINT LANCETS................................. 43
ONETOUCH ULTRA 2 KIT W/DEVICE................................ 43ONETOUCH ULTRA TEST STRIPS..................................... 43ONETOUCH ULTRASOFT LANCETS................................. 43ONETOUCH VERIO FLEX SYSTEM................................... 43ONETOUCH VERIO KIT W/DEVICE................................ 43ONETOUCH VERIO REFLECT..................................43ONEXTON................................ 63ONGENTYS..............................35ONGLYZA.................................45ONUREG.................................. 30ONZETRA XSAIL......................28OPSUMIT................................101OPTICHAMBER DIAMOND......92OPTICHAMBER DIAMOND-LG MASK.................................. 92OPTICHAMBER DIAMOND-MD MASK................................. 92OPTICHAMBER DIAMOND-SM MASK................................. 92OPTIONS GYNOL II CONTRACEPTIVE................... 72OPZELURA...............................63ORALAIR................................ 102oralone...................................... 60ORAVIG.................................... 26ORENCIA..................................87ORENCIA CLICKJECT............. 87ORENITRAM.......................... 101ORFADIN..................................71ORGOVYX................................29ORIAHNN................................. 82ORILISSA................................. 86ORKAMBI............................... 100ORLADEYO.............................. 86orphenadrine citrate er............102ORPHENGESIC FORTE........ 102orsythia..................................... 82ORTIKOS..................................90OSCIMIN...................................67oscimin sr..................................67oseltamivir phosphate............... 40OSENI.......................................45OSMOLEX ER.......................... 35OSMOPREP............................. 69OSPHENA................................ 85OTEZLA.................................... 88OTOVEL................................... 97
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OTREXUP.................................87OVACE PLUS WASH............... 63OVACE WASH..........................63OVIDREL.................................. 77oxandrolone.............................. 77oxaprozin.................................. 12OXAYDO...................................15oxazepam................................. 41OXBRYTA.................................48oxcarbazepine...........................22OXERVATE.............................. 94oxiconazole nitrate.................... 26OXISTAT...................................27OXTELLAR XR......................... 22oxybutynin chloride................... 72oxybutynin chloride er............... 71oxycodone hcl........................... 15OXYCODONE HCL ER............ 13OXYCODONE-ACETAMINOPHEN...................15oxycodone-acetaminophen.......15OXYCONTIN.............................13oxymorphone hcl.......................15oxymorphone hcl er.................. 13OXYTROL.................................72OZEMPIC..................................45OZOBAX................................. 103PALFORZIA.............................. 92paliperidone er.......................... 37PALYNZIQ................................ 71PANDEL....................................75PANRETIN................................33pantoprazole sodium.................70PAREMYD................................ 94paricalcitol................................. 91paromomycin sulfate.................17paroxetine hcl............................24paroxetine hcl er....................... 24paroxetine mesylate..................24PASER......................................29PEDIARIX................................. 89PEDVAX HIB............................ 89peg 3350................................... 69peg 3350-kcl-na bicarb-nacl......69peg-3350/electrolytes................69peg-3350/electrolytes/ascorbat.69PEGASYS.................................38peg-kcl-nacl-nasulf-na asc-c..... 69peg-prep....................................70PEMAZYRE.............................. 31penicillamine............................. 72penicillin v potassium................ 19PENNSAID................................12
PENTACEL............................... 89pentamidine isethionate............ 34PENTASA................................. 90pentazocine-naloxone hcl......... 15pentoxifylline er......................... 53perindopril erbumine................. 50periogard...................................60permethrin.................................34perphenazine............................ 25perphenazine-amitriptyline........23PERSERIS................................37PEXEVA....................................24PFIZER COVID-19 VAC-TRIS 5-11Y........................................ 89PFIZER-BIONT COVID-19 VAC-TRIS................................. 89PFIZER-BIONTECH COVID-19 VACC................................... 89phenelzine sulfate..................... 23phenobarbital............................ 21phenoxybenzamine hcl............. 50phenylephrine hcl......................95phenytoin.................................. 22phenytoin infatabs.....................22phenytoin sodium extended...... 22PHEXXI.....................................92philith.........................................82PHOSLYRA.............................. 66phytonadione............................ 66PIFELTRO................................ 39pilocarpine hcl..................... 60, 95pimecrolimus.............................63pimozide....................................36pimtrea...................................... 82pindolol......................................51pioglitazone hcl......................... 45pioglitazone hcl-glimepiride.......45pioglitazone hcl-metformin hcl.. 45PIQRAY.................................... 30pirmella 1/35............................. 82pirmella 7/7/7............................ 82piroxicam...................................12PLEGRIDY................................59PLEGRIDY STARTER PACK... 59PLENVU....................................70PLIAGLIS.................................. 16PNEUMOVAX 23...................... 89POCKET SPACER................... 92podofilox....................................63polycin.......................................94polyethylene glycol 3350...........70polymyxin b-trimethoprim..........94POMALYST.............................. 29
PONVORY................................ 59PONVORY STARTER PACK... 59portia-28....................................82posaconazole............................27POTABA................................... 66potassium chloride.................... 65potassium chloride crys er........ 65potassium chloride er................65potassium citrate er...................65PR BENZOYL PEROXIDE........63PRADAXA.................................48PRALUENT...............................56pramipexole dihydrochloride..... 35pramipexole dihydrochloride er.35PRAMOSONE...........................63prasugrel hcl............................. 50pravastatin sodium....................55praziquantel.............................. 34prazosin hcl...............................50PRECISION XTRA BLOOD GLUCOSE................................ 43PRED MILD.............................. 96PRED-G.................................... 94PRED-G S.O.P......................... 94prednicarbate............................ 75prednisolone............................. 75prednisolone acetate.................96prednisolone acetate p-f........... 96prednisolone sodium phosphate........................... 75, 96prednisone................................ 75prednisone intensol...................75PREFEST................................. 82pregabalin................................. 58pregabalin er............................. 58PREGNYL.................................77PREMARIN............................... 82PREMPHASE........................... 82PREMPRO................................82PRESTALIA.............................. 53PRETOMANID.......................... 29prevalite.................................... 56PREVIDENT............................. 60PREVIDENT 5000 DRY MOUTH.....................................60PREVIDENT 5000 PLUS.......... 60previfem.................................... 82PREVNAR 13............................89PREVYMIS............................... 37PREZCOBIX............................. 40PREZISTA................................ 40PRIFTIN.................................... 29PRILOSEC................................70
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primaquine phosphate.............. 34primidone.................................. 21PRO COMFORT SPACER ADULT...................................... 92PRO COMFORT SPACER CHILD....................................... 92PRO COMFORT SPACER INFANT..................................... 92PROAIR DIGIHALER..............100PROAIR RESPICLICK............100probenecid................................ 27PROCARE SPACER/ADULT MASK........................................92PROCARE SPACER/CHILD MASK........................................92prochlorperazine....................... 25prochlorperazine maleate......... 25PROCRIT..................................48PROCTOCORT........................ 90PROCTOFOAM HC.................. 90procto-med hc........................... 90procto-pak................................. 91proctosol hc...............................91proctozone-hc........................... 91PROCYSBI............................... 71PROFILNINE............................ 49progesterone.............................84PROGRAF................................ 87PROLATE................................. 15PROLENSA.............................. 96PROMACTA..............................48promethazine hcl.......................98promethegan.............................98propafenone hcl........................ 51propafenone hcl er.................... 51propranolol hcl.......................... 52propranolol hcl er...................... 52propylthiouracil ..........................86PROQUAD................................89protriptyline hcl..........................25PSORCON................................75PULMICORT FLEXHALER.......99PULMOZYME......................... 100PURIXAN.................................. 30PYLERA....................................67pyrazinamide.............................29pyridostigmine bromide.............28pyridostigmine bromide er.........28pyrimethamine.......................... 34QBRELIS.................................. 51QBREXZA.................................63qc magnesium citrate................70QDOLO..................................... 13
QELBREE................................. 58QINLOCK..................................33QNASL......................................99QNASL CHILDRENS................ 99QTERN..................................... 45QUADRACEL............................89quazepam................................. 41quetiapine fumarate.................. 37quetiapine fumarate er.............. 37QUILLICHEW ER......................58QUILLIVANT XR....................... 58quinapril hcl...............................51quinapril-hydrochlorothiazide.... 53quinidine gluconate er...............51quinidine sulfate........................ 51quinine sulfate...........................34QVAR REDIHALER.................. 99RABEPRAZOLE SODIUM........ 70rabeprazole sodium.................. 70RADIOGARDASE..................... 92RAGWITEK.............................102raloxifene hcl.............................85ramelteon................................ 103ramipril ...................................... 51ranolazine er............................. 53rasagiline mesylate................... 36RASUVO...................................87RAVICTI....................................71RAYALDEE...............................91RAYOS..................................... 75REBIF....................................... 59REBIF REBIDOSE....................59REBIF REBIDOSE TITRATION PACK.................... 59REBIF TITRATION PACK.........59REBINYN.................................. 49reclipsen....................................82RECOMBINATE........................49RECOMBIVAX HB.................... 89RECTIV.....................................57REDITREX................................87REGRANEX..............................63RELAFEN DS........................... 12RELENZA DISKHALER............ 40relexxii .......................................58RELION PREMIER TEST......... 43RELISTOR................................ 67RELTONE................................. 67RENACIDIN.............................. 72repaglinide................................ 45REPATHA................................. 56REPATHA PUSHTRONEX SYSTEM................................... 56
REPATHA SURECLICK........... 56RESTASIS................................ 94RESTASIS MULTIDOSE.......... 94RETACRIT................................ 48RETEVMO................................ 33RETIN-A MICRO PUMP........... 63REVCOVI..................................71REVLIMID................................. 29REXULTI...................................37REYATAZ................................. 40REYVOW.................................. 28REZUROCK..............................87RHOPRESSA........................... 95ribavirin..................................... 38RIDAURA..................................88rifabutin..................................... 28rifampin..................................... 29riluzole.......................................58rimantadine hcl..........................40RINVOQ....................................88risedronate sodium................... 91RISPERDAL CONSTA..............37risperidone................................ 37ritonavir..................................... 40rivastigmine...............................22rivastigmine tartrate.................. 22rivelsa........................................83RIXUBIS....................................49rizatriptan benzoate.................. 28ROCKLATAN............................ 95ropinirole hcl..............................35ropinirole hcl er......................... 35rosadan..................................... 63rosuvastatin calcium................. 55ROSZET................................... 56ROTARIX.................................. 89ROTATEQ.................................89roweepra................................... 20ROZLYTREK............................ 30RUBRACA................................ 31RUCONEST..............................86rufinamide................................. 22RUKOBIA..................................40RUZURGI..................................92RYBELSUS...............................45RYDAPT................................... 33RYLAZE.................................... 30RYTARY............................. 35, 36ryvent........................................ 98SAIZEN..................................... 77SAIZENPREP........................... 77sajazir........................................86salsalate....................................12
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SAMSCA...................................65SANCUSO................................ 25SANDIMMUNE......................... 87SANDOSTATIN LAR DEPOT... 86SANTYL.................................... 63sapropterin dihydrochloride.......71SAVAYSA................................. 48SAVELLA.................................. 58SAVELLA TITRATION PACK... 58SCEMBLIX................................33scopolamine..............................25SECUADO................................ 37SEGLUROMET.........................45selegiline hcl............................. 36selenium sulfide........................ 63SELZENTRY.............................40SEMGLEE.................................47SEMGLEE (YFGN)................... 47SEREVENT DISKUS.............. 100SERNIVO..................................75SEROSTIM............................... 67SERTRALINE HCL................... 24sertraline hcl..............................24setlakin......................................83sevelamer carbonate................ 66sevelamer hcl............................66SEVENFACT............................ 49SEYSARA................................. 20sf............................................... 60sf 5000 plus...............................60SFROWASA............................. 90sharobel.................................... 84SHINGRIX.................................89SIGNIFOR.................................86SIGNIFOR LAR.........................86SIKLOS..................................... 30sildenafil citrate....................... 101SILIQ.........................................63silodosin.................................... 72silver sulfadiazine......................18SIMBRINZA.............................. 95simliya....................................... 83simpesse...................................83SIMPONI...................................87simvastatin................................ 56sirolimus....................................87SIRTURO..................................29SITAVIG....................................38SIVEXTRO................................18SKYRIZI.................................... 87SKYRIZI (150 MG DOSE).........87SKYRIZI PEN............................87SKYTROFA...............................77
SLYND...................................... 84sodium chloride.................72, 102sodium fluoride....................60, 65sodium fluoride 5000 plus......... 60sodium fluoride 5000 ppm.........60sodium phenylbutyrate..............71sodium polystyrene sulfonate... 65sodium sulfacetamide wash......63SOFOSBUVIR-VELPATASVIR.38solifenacin succinate.................72SOLIQUA.................................. 45SOLOSEC.................................18SOLTAMOX.............................. 30SOLU-CORTEF........................ 75SOMATULINE DEPOT............. 86SOMAVERT..............................86SORILUX.................................. 63sorine........................................ 51sotalol hcl.................................. 51sotalol hcl (af)............................51SOTYLIZE.................................51SOVALDI.................................. 38spinosad....................................34SPIRIVA HANDIHALER............99SPIRIVA RESPIMAT................ 99spironolactone...........................54spironolactone-hctz...................53sprintec 28................................ 83SPRITAM.................................. 20SPRIX....................................... 12SPRYCEL................................. 33sps............................................ 65sronyx....................................... 83ssd............................................ 18SSKI..........................................92sss 10-5.................................... 63stavudine...................................40STEGLATRO............................ 45STEGLUJAN.............................45STELARA..................................63sterile water for irrigation...........93STIMATE.................................. 77STIOLTO RESPIMAT............... 99STIVARGA................................33STRENSIQ................................71STRIBILD..................................39STRIVERDI RESPIMAT......... 100SUBSYS................................... 15subvenite...................................21subvenite starter kit-blue...........22subvenite starter kit-green........ 22subvenite starter kit-orange...... 22SUCRAID..................................71
sucralfate.................................. 70SULCONAZOLE NITRATE.......27sulfacetamide sodium......... 63, 97sulfacetamide sodium (acne).... 63sulfacetamide sodium-sulfur..... 63sulfacetamide-prednisolone...... 94sulfadiazine............................... 19sulfamethoxazole-trimethoprim.19SULFAMYLON..........................18sulfasalazine............................. 91sulfatrim pediatric......................19sulindac.....................................12sumatriptan............................... 28sumatriptan succinate............... 28sumatriptan succinate refill ....... 28sumatriptan-naproxen sodium.. 28sunitinib malate......................... 33SUNOSI.................................. 103SUPRAX................................... 18SUPREP BOWEL PREP KIT....70SUTAB...................................... 70syeda........................................ 83SYMBICORT.............................99SYMDEKO.............................. 101SYMJEPI.................................100SYMLINPEN 120...................... 45SYMLINPEN 60........................ 45SYMPAZAN.............................. 21SYMPROIC...............................67SYMTUZA.................................40SYNAREL................................. 86SYNDROS................................ 25SYNJARDY...............................45SYNJARDY XR.........................45SYNRIBO..................................30TABLOID...................................30TABRECTA...............................33tacrolimus............................63, 87tadalafil (pah).......................... 101TAFINLAR.................................33TAGRISSO............................... 33TAKHZYRO.............................. 86TALICIA.................................... 67TALTZ....................................... 63TALZENNA............................... 31tamoxifen citrate........................30tamsulosin hcl........................... 72TAPERDEX 12-DAY................. 75TAPERDEX 6-DAY................... 75TAPERDEX 7-DAY................... 75TARGRETIN............................. 33tarina 24 fe................................ 83tarina fe 1/20............................. 83
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tarina fe 1/20 eq........................ 83TASIGNA.................................. 33tavaborole................................. 27TAVALISSE.............................. 49TAVNEOS.................................93taysofy.......................................83tazarotene................................. 63TAZAROTENE..........................64TAZORAC.................................64taztia xt......................................52TAZVERIK................................ 31TDVAX...................................... 89TEGSEDI.................................. 71TEKTURNA HCT...................... 53telmisartan................................ 50telmisartan-amlodipine..............53telmisartan-hctz.........................53temazepam............................. 103TEMIXYS.................................. 40temozolomide............................29TENCON...................................15TENIVAC.................................. 89tenofovir disoproxil fumarate.....40TEPMETKO.............................. 33terazosin hcl..............................72terbinafine hcl............................27terbutaline sulfate....................100terconazole............................... 27TERIPARATIDE (RECOMBINANT)..................... 91testosterone........................ 77, 78TESTOSTERONE CYPIONATE............................. 77testosterone cypionate..............77testosterone enanthate............. 77tetrabenazine............................ 58tetracycline hcl.......................... 20TEXACORT.............................. 75THALITONE..............................54THALOMID............................... 29THEO-24.................................101theophylline.............................101theophylline er.........................101THIOLA EC............................... 72thioridazine hcl.......................... 36thiothixene.................................36THYQUIDITY............................ 85tiadylt er.................................... 52tiagabine hcl..............................21TIBSOVO.................................. 33TIGLUTIK..................................58tilia fe.........................................83timolol maleate....................52, 95
timolol maleate (once-daily)...... 95timolol maleate ocudose........... 95timolol maleate pf......................96TIMOPTIC OCUDOSE..............96tinidazole...................................18tiopronin.................................... 72TIROSINT................................. 85TIROSINT-SOL.........................85TIVICAY.................................... 39TIVICAY PD.............................. 39TIVORBEX................................12tizanidine hcl........................... 103TOBI PODHALER...................101TOBRADEX.............................. 93TOBRADEX ST.........................93tobramycin........................ 93, 101TOBRAMYCIN........................ 101tobramycin-dexamethasone......93TOBREX................................... 93TODAY SPONGE..................... 72tolcapone.................................. 35TOLSURA................................. 27tolterodine tartrate.....................72tolterodine tartrate er.................72TOLVAPTAN.............................65tolvaptan................................... 65topiramate................................. 22topiramate er.............................22toremifene citrate...................... 30torsemide.................................. 54TOSYMRA................................ 28TOUJEO MAX SOLOSTAR...... 47TOUJEO SOLOSTAR...............47tovet.......................................... 75TOVIAZ..................................... 72TRACLEER.............................101TRADJENTA.............................45TRAMADOL HCL ER................13tramadol hcl er.......................... 13tramadol hcl er (biphasic)..........13tramadol hcl ir ........................... 15tramadol-acetaminophen.......... 15trandolapril ................................ 51trandolapril-verapamil hcl er......53tranexamic acid.........................49tranylcypromine sulfate............. 23travoprost (bak free)..................97trazodone hcl............................ 24TRECATOR.............................. 29TRELEGY ELLIPTA..........99, 102TREMFYA.................................64TRESIBA...................................47TRESIBA FLEXTOUCH............47
tretinoin............................... 33, 64tretinoin microsphere................ 64tretinoin microsphere pump...... 64TRETTEN................................. 49TREXALL.................................. 87tri femynor................................. 83triamcinolone acetonide 60, 75, 76triamcinolone in absorbase....... 76triamterene................................54triamterene-hctz........................ 53TRIANEX.................................. 76triazolam................................... 41triderm.......................................76trientine hcl................................65tri-estarylla................................ 83trifluoperazine hcl......................36trifluridine.................................. 94trihexyphenidyl hcl.................... 34TRIJARDY XR.......................... 45TRIKAFTA...............................101tri-legest fe................................ 83tri-linyah.................................... 83tri-lo-estarylla............................ 83tri-lo-marzia............................... 83tri-lo-mili .................................... 83tri-lo-sprintec............................. 83trimethobenzamide hcl..............25trimethoprim.............................. 18tri-mili ........................................ 83trimipramine maleate................ 25TRINTELLIX..............................24tri-nymyo................................... 83tri-previfem................................ 83tri-sprintec................................. 83tritocin....................................... 76TRIUMEQ................................. 40trivora (28).................................83tri-vylibra................................... 83tri-vylibra lo................................83TROKENDI XR......................... 22tropicamide............................... 94trospium chloride.......................72trospium chloride er.................. 72TRUDHESA.............................. 28TRUE METRIX BLOOD GLUCOSE TEST...................... 43TRUETRACK TEST..................43TRULANCE...............................67TRULICITY............................... 45TRUMENBA..............................89TRUSELTIQ (100MG DAILY DOSE).......................................31
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TRUSELTIQ (125MG DAILY DOSE).......................................31TRUSELTIQ (50MG DAILY DOSE).......................................31TRUSELTIQ (75MG DAILY DOSE).......................................31TUDORZA PRESSAIR............. 99TUKYSA....................................33tulana........................................ 84TURALIO.................................. 33TWINRIX...................................89TWIRLA.................................... 83tyblume..................................... 83TYBOST....................................39tydemy...................................... 83TYMLOS................................... 91TYRVAYA................................. 96TYVASO................................. 101TYVASO REFILL.................... 101TYVASO STARTER................101UBRELVY................................. 27UCERIS.................................... 91UDENYCA................................ 48UKONIQ....................................33ULTRAVATE.............................76unithroid.................................... 85UPNEEQ...................................95UPTRAVI................................ 101URSODIOL............................... 67ursodiol............................... 67, 68valacyclovir hcl..........................38VALCHLOR...............................29valganciclovir hcl.......................37valproic acid.............................. 21valsartan................................... 50valsartan-hydrochlorothiazide... 54VALTOCO.................................21vancomycin hcl......................... 18vandazole..................................18VAQTA......................................89varenicline tartrate.................... 17VARIVAX.................................. 89VARUBI (180 MG DOSE)......... 25VASCEPA................................. 56VAXELIS................................... 89VCF VAGINAL CONTRACEPTIVE................... 72vcf vaginal contraceptive...........73VECAMYL.................................54velivet........................................83VELPHORO.............................. 66VELTASSA............................... 66VELTIN..................................... 64
VEMLIDY.................................. 38VENCLEXTA.............................33VENCLEXTA STARTING PACK........................................ 33venlafaxine hcl.......................... 24venlafaxine hcl er...................... 24VENTAVIS.............................. 101VENTOLIN HFA......................100verapamil hcl.............................52verapamil hcl er.........................52VERDESO................................ 76VEREGEN................................ 64VERQUVO................................ 54VERSACLOZ............................ 37VERZENIO................................31VESICARE LS.......................... 72vestura...................................... 83V-GO 20....................................93V-GO 30....................................93V-GO 40....................................93VIBERZI.................................... 68VIBRAMYCIN............................20VICTOZA.................................. 45VIEKIRA PAK............................38vienva........................................83vigabatrin.................................. 21vigadrone.................................. 21VIIBRYD....................................24VIIBRYD STARTER PACK....... 24VIMPAT.....................................22viorele....................................... 83VIRACEPT................................ 40VIREAD.....................................40VISTOGARD.............................93vitamin d (ergocalciferol)...........66vitamin k1..................................66VITRAKVI..................................33VIVAGUARD INO TEST STRIPS..................................... 43VIZIMPRO.................................33volnea....................................... 83VONVENDI............................... 49voriconazole..............................27VORTEX VALVED HOLDING CHAMBER................................ 93VOSEVI.....................................38VOTRIENT................................33VRAYLAR................................. 37VTOL LQ...................................15VUMERITY............................... 59VUSION.................................... 27vyfemla......................................83vylibra........................................83
VYNDAMAX..............................54VYNDAQEL.............................. 54VYVANSE................................. 57VYZULTA..................................97WAKIX.................................... 103warfarin sodium.........................48water for irrigation, sterile..........93WELIREG................................. 31wera.......................................... 84WESTHROID............................ 85WIDE-SEAL DIAPHRAGM 60.. 93WIDE-SEAL DIAPHRAGM 65.. 93WIDE-SEAL DIAPHRAGM 70.. 93WIDE-SEAL DIAPHRAGM 75.. 93WIDE-SEAL DIAPHRAGM 80.. 93WIDE-SEAL DIAPHRAGM 85.. 93WIDE-SEAL DIAPHRAGM 90.. 93WIDE-SEAL DIAPHRAGM 95.. 93WILATE.....................................49WINLEVI................................... 64wixela inhub.............................. 99WP THYROID........................... 85wymzya fe................................. 84WYNZORA................................64XADAGO...................................36XALKORI.................................. 33XARELTO................................. 48XARELTO STARTER PACK.....48XATMEP................................... 87XCOPRI.................................... 21XELJANZ.................................. 87XELJANZ XR............................ 87XELPROS................................. 97XEMBIFY.................................. 88XENLETA..................................18XEPI..........................................18XERESE................................... 38XERMELO................................ 68XIFAXAN...................................18XIGDUO XR..............................45XIIDRA...................................... 94XIMINO..................................... 20XOFLUZA (40 MG DOSE)........ 40XOFLUZA (80 MG DOSE)........ 40XOLAIR.....................................88XOLEGEL................................. 27XOPENEX HFA...................... 100XOSPATA................................. 33XPOVIO (100 MG ONCE WEEKLY)..................................31XPOVIO (40 MG ONCE WEEKLY)..................................31
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XPOVIO (40 MG TWICE WEEKLY)..................................31XPOVIO (60 MG ONCE WEEKLY)..................................31XPOVIO (60 MG TWICE WEEKLY)..................................31XPOVIO (80 MG ONCE WEEKLY)..................................31XPOVIO (80 MG TWICE WEEKLY)..................................31XTAMPZA ER........................... 13XTANDI.....................................29xulane....................................... 84XULTOPHY...............................45XURIDEN..................................71XYNTHA................................... 49XYNTHA SOLOFUSE...............49XYOSTED.................................78XYREM................................... 103XYWAV................................... 103yl folic acid................................ 66YONSA..................................... 29YOSPRALA...............................50YUPELRI...................................99yuvafem.................................... 84zafemy...................................... 84zafirlukast..................................99zaleplon...................................103zarah......................................... 84ZARXIO.....................................48ZCORT 7-DAY.......................... 76ZEGALOGUE............................46ZEJULA.....................................31ZELAPAR..................................36ZELBORAF............................... 33ZELNORM................................ 68ZEMBRACE SYMTOUCH........ 28zenatane................................... 64ZENPEP....................................71ZENZEDI...................................57ZEPATIER................................ 38ZEPOSIA.................................. 59ZEPOSIA 7-DAY STARTER PACK........................................ 59ZEPOSIA STARTER KIT.......... 59ZERVIATE................................ 95ZETONNA.................................99zidovudine.................................40ZIEXTENZO..............................48zileuton er................................. 99ZILXI......................................... 64ZIOPTAN.................................. 97ziprasidone hcl.......................... 37
ZIPSOR.....................................12ZIRGAN.................................... 94ZOKINVY.................................. 93ZOLINZA...................................31ZOLMITRIPTAN........................28zolmitriptan................................28zolpidem tartrate..................... 103zolpidem tartrate er................. 103ZOLPIMIST............................. 103ZOMACTON............................. 77ZOMACTON (FOR ZOMA-JET 10).............................................77ZOMIG...................................... 28zonisamide................................21ZONTIVITY............................... 48ZORBTIVE................................ 68ZORVOLEX.............................. 12zovia 1/35 (28).......................... 84zovia 1/35e (28)........................ 84ZTLIDO..................................... 16ZUBSOLV................................. 16zumandimine.............................84ZUPLENZ..................................25ZYCLARA PUMP...................... 64ZYDELIG...................................33ZYFLO...................................... 99ZYKADIA...................................33ZYLET.......................................94ZYPITAMAG............................. 56ZYPREXA RELPREVV............. 37
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