Balanced_Drug_List.pdf

41722-Z TX © Prime Therapeutics LLC 07/26

Balanced Drug List July 2026 Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.

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

Contents

Introduction ................................................................... I How drugs are selected ................................................ I How member payment is determined ........................... I How to use this list ....................................................... II Drugs used to treat multiple conditions ....................... II Generic drugs ............................................................. III Consider talking to your doctor about generic drugs ......................................................................... III Coverage considerations ............................................ IV Specialty drugs ........................................................... VI Abbreviation key ........................................................ VII

Therapeutic Class Drug List Anti-Infective Drugs Biologicals Antineoplastic Agents Endocrine and Metabolic Drugs Cardiovascular Agents Respiratory Agents Gastrointestinal Agents Genitourinary Agents Central Nervous System Drugs Analgesics and Anesthetics Neuromuscular Drugs Nutritional Products Hematological Agents Topical Products Miscellaneous Products Index

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

Blue Cross and Blue Shield of Texas July 2026 Balanced Drug List I

Introduction Blue Cross and Blue Shield of Texas is pleased to present the 2026 Drug List. All available covered drugs are shown on this list. Drugs that are not shown are not covered. Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However, decisions regarding therapy and treatment are always between members and their physician.

Drug List updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit MyPrime.com or bcbstx.com and log in or call the number on your ID card. Physicians can access the list from the provider portal at bcbstx.com.

How drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from your health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).

Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. Newly marketed drugs may not be covered until the committee has had an opportunity to evaluate based on these criteria.

How member payment is determined Generally, each prescription drug product is placed into one of up to six member payment tiers:

Preferred Generic (Tier 1), Non-Preferred Generic (Tier 2), Preferred Brand (Tier 3), Non-Preferred Brand (Tier 4), Preferred Specialty (Tier 5) and Non-Preferred Specialty (Tier 6). Depending on your benefit plan, drugs can either be in these tiers or you may have fewer tiers, e.g. all generics in one tier. Note: Some brands may be in a generic tier and some generics may be in a brand tier. To verify your payment amount for a drug, visit MyPrime.com and log in or call the number on your ID card.

Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered.

Drugs that have not received FDA approval may not be covered. Prescription products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA-approved for self-administration may be available through your medical benefit. Check your plan materials for details. Some medications covered under your pharmacy benefit(s) may need to be filled at a pharmacy that carries your medication.

Blue Cross and Blue Shield of Texas July 2026 Balanced Drug List II

How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Note: most reference brand drugs (in parentheses) are not covered.

Example: atorvastatin (Lipitor – brand is not covered)

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

Example: NOVOLOG – Insulin aspart inj 100 unit/ml

• Preferred Generics are marked with a “p” and shown in lower-case boldface type

• Non-Preferred Generics are marked with a “np” and shown in lower-case boldface type

• Preferred Brands are marked with a “P” and shown in all CAPITAL letters

• Non-Preferred Brands are marked with a “NP” and shown in all CAPITAL letters

• Preferred Specialty Drugs are marked with a “p, np, or P” and shown as lower-case boldface type or in all CAPITAL letters. These drugs are also marked as “SP” in the Special Requirements column.

• Non-Preferred Specialty Drugs are marked with a “NP” and shown in all CAPITAL letters. These drugs are also marked as “SP” in the Special Requirements column.

• Drugs that are also marked with a “+” indicate group-specific coverage. Please see your benefit plan materials for coverage details, or call the number on your ID card.

Drugs used to treat multiple conditions

Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use.

Please note: Drugs that need a health care provider to administer them and are often given to you in a hospital, doctor’s office or other health care setting may be covered under your medical benefit. Some types of these drugs are contraceptive implants and chemo infusions. If you are taking or are prescribed a drug that is not on this drug list, call the number on your ID card to see if the drug may be covered.

Blue Cross and Blue Shield of Texas July 2026 Balanced Drug List III

Generic drugs Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same standards.

There are two types of generic drugs:

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

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

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

• Is chemically the same

• Works just as well in the body

• Is as safe and effective

• Meets the same standards set by the FDA

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

Brand drugs may be removed from or moved to a higher tier on the drug list after a generic equivalent becomes available.

You may be responsible for your member cost-share payment amount (copay or coinsurance) plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic equivalent. Generic drugs generally have the lowest member payment amount.

Consider talking to your doctor about generic drugs

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

You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor.

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

Blue Cross and Blue Shield of Texas July 2026 Balanced Drug List IV

Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.

Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction or weight loss. Also, some drugs may only be covered for members within a certain age range due to the drug being used for cosmetic purposes or for safety concerns. Drug coverage may be limited to recommendations based on FDA-approved labeling and recognized evidence-based or clinical practice guidelines.

Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan material for details about your particular benefits.

Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please see your plan materials or call the number on your ID card to determine whether compounded medications are covered and/or verify your payment amount.

Repackaged medications: Repackaged versions of medications already available on the market are not covered.

Non FDA-approved drugs: Drugs that have not received FDA approval are not covered.

Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication may be covered under your plan. For the medications listed in this document, if a prior authorization is commonly required, it will generally be noted next to the medication with a “PA” under the Special Requirements column. Some plans may have prior authorization on additional medications beyond those noted in this document. Refer to your benefit plan materials for details about your particular benefits.

Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program.

Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the medications listed in this document, if a step therapy is commonly required, it will generally be noted next to the medication with an “ST” under the Special Requirements column. Some plans may have step therapy programs on additional medications beyond those noted in this document. Refer to your benefit plan materials for details about your particular benefits.

Dispensing Limits (DL)/Quantity Limits (QL): Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a “QL” under the Special Requirements column. Limits may include: quantity of covered medication per prescription or quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you may be responsible for the full cost of the prescription beyond what your coverage allows.* Some plans may have a dispensing limit on additional medications beyond those noted in this document. For a list of medications and their dispensing limits, visit MyPrime.com or bcbstx.com.

*Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit.

Blue Cross and Blue Shield of Texas July 2026 Balanced Drug List V

ACA Preventive (ACA): Medicines marked as “AC” in the Special Requirements column are under the Affordable Care Act coverage of preventive services. These products may have limited or $0 member cost-sharing (copay or co-insurance), when meeting the conditions as outlined under the regulation. Coverage may vary based on benefit plan.

You, or your prescribing health care provider, can submit a copay waiver or coverage exception request for ACA preventive medicines by calling the number on your ID card to ask for a review. Copay waiver and coverage exception forms for your provider to fill out are available at bcbstx.com/provider or myprime.com.

If you meet the conditions as outlined under the ACA regulations, these products may have $0 member cost-sharing (copay or coinsurance) when obtained from a participating pharmacy. BCBSTX will let you, and your prescriber, know the coverage decision after they receive your request. If the request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable).

Remember, medication decisions are between you and your doctor. Only you and your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor. Blue Cross and Blue Shield of Texas does not provide health care services and, therefore, cannot guarantee any results or outcomes.

Blue Cross and Blue Shield of Texas July 2026 Balanced Drug List VI

Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be self-administered or administered by a health care professional. Medications administered by a health care professional are not covered under the pharmacy benefit. For a current list of specialty medications, visit MyPrime.com or bcbstx.com.

Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on your ID card.

Blue Cross and Blue Shield of Texas is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Prime Therapeutics LLC is a separate company contracted by BCBSTX to provide pharmacy solutions. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

MyPrime.com is a pharmacy benefit website offered by Prime Therapeutics LLC.

Blue Cross and Blue Shield of Texas July 2026 Balanced Drug List VII

Abbreviation key aer..................................................................... aerosol cap ................................................................. capsules chew ............................................................. chewable conc .......................................................... concentrate cr...................................................... controlled release dr ........................................................ delayed release ec ........................................................... enteric coated equiv ........................................................... equivalent er....................................................... extended release gm........................................................................ gram inhal .................................................................. inhaler inj .................................................................... injection liqd....................................................................... liquid mg.................................................................. milligram ml ..................................................................... milliliter nebu .............................................................. nebulizer odt. ....................................orally disintegrating tablets oint .................................................................ointment ophth .......................................................... ophthalmic osm ..................................................... osmotic release pack ................................................................. packets powd .................................................................powder pttw ................................................ twice-weekly patch sl .................................................................. sublingual soln .................................................................. solution suppos ................................................... suppositories susp ........................................................... suspension tab ...................................................................... tablets td ............................................................... transdermal w/ ........................................................................... with

Exception Process You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List To request this exception, you, or your prescriber, can call the number on your ID card to ask for a review. BCBSTX will let you, your prescriber (or authorized representative) know the coverage decision within two business days after they receive your request. If the coverage request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable).

If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be able to ask for an expedited review process.

BCBSTX will let you, and your prescriber, know the coverage decision within two business days, not to exceed 72 calendar hours, after they receive your request for an expedited review. If the coverage request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable).

Call the number on your ID card if you have any questions.

If you or your prescriber are asking for a copay waiver or coverage exception request for an ACA preventive product, please see the ACA preventive section.

Blue Cross and Blue Shield July 2026 Balanced Drug List 1

Drug Name Drug Tier Requirements/Limits

ANTI-INFECTIVE AGENTS

PENICILLINS

AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg, 250 mg NP amoxicillin (trihydrate) cap 250 mg, 500 mg p amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml p amoxicillin (trihydrate) tab 500 mg, 875 mg p amoxicillin & k clavulanate for susp 200-28.5 mg/5ml p amoxicillin & k clavulanate for susp 250-62.5 mg/5ml, 400-57 mg/5ml np amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin es-600) np amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg np amoxicillin & k clavulanate tab 250-125 mg np amoxicillin & k clavulanate tab 500-125 mg (Augmentin) p amoxicillin & k clavulanate tab 875-125 mg p ampicillin cap 500 mg p AUGMENTIN - amoxicillin & k clavulanate for susp

125-31.25 mg/5ml

NP

dicloxacillin sodium cap 250 mg, 500 mg np PENICILLIN V POTASSIUM - penicillin v potassium for soln

125 mg/5ml, 250 mg/5ml

NP

penicillin v potassium tab 250 mg, 500 mg p

CEPHALOSPORINS

CEFACLOR - cefaclor cap 250 mg, 500 mg NP CEFACLOR - cefaclor for susp 250 mg/5ml NP CEFACLOR ER - cefaclor monohydrate tab er 12hr 500 mg NP CEFADROXIL - cefadroxil tab 1 gm NP cefadroxil cap 500 mg p cefadroxil for susp 250 mg/5ml, 500 mg/5ml np cefdinir cap 300 mg p cefdinir for susp 125 mg/5ml, 250 mg/5ml np CEFIXIME - cefixime tab 400 mg NP CEFIXIME - cefixime for susp 100 mg/5ml np cefixime cap 400 mg (Suprax) np cefixime for susp 200 mg/5ml (Suprax) np CEFPODOXIME PROXETIL - cefpodoxime proxetil for susp

50 mg/5ml, 100 mg/5ml

NP

cefpodoxime proxetil tab 100 mg, 200 mg np cefprozil for susp 125 mg/5ml, 250 mg/5ml np cefprozil tab 250 mg, 500 mg np cefuroxime axetil tab 250 mg p cefuroxime axetil tab 500 mg np

Blue Cross and Blue Shield July 2026 Balanced Drug List 2

Drug Name Drug Tier Requirements/Limits cephalexin cap 250 mg, 500 mg p cephalexin cap 750 mg np cephalexin for susp 125 mg/5ml, 250 mg/5ml np cephalexin tab 250 mg, 500 mg np

MACROLIDES

azithromycin for susp 100 mg/5ml (Zithromax) np azithromycin for susp 200 mg/5ml (Zithromax) p azithromycin tab 250 mg, 500 mg (Zithromax) p QL (60 tablets/180 days) azithromycin tab 600 mg np QL (60 tablets/180 days) CLARITHROMYCIN - clarithromycin for susp 125 mg/5ml, 250 mg/5ml

NP

clarithromycin tab er 24hr 500 mg np QL (28 tablets/180 days) clarithromycin tab 250 mg, 500 mg np DIFICID - fidaxomicin for susp 40 mg/ml P E.E.S. 400 - erythromycin ethylsuccinate tab 400 mg NP ERYTHROMYCIN DR - erythromycin w/ delayed release particles cap 250 mg

NP

erythromycin ethylsuccinate for susp 200 mg/5ml (E.e.s. granules) np erythromycin ethylsuccinate for susp 400 mg/5ml (Eryped 400) np erythromycin tab delayed release 250 mg, 333 mg, 500 mg np erythromycin tab 250 mg, 500 mg np fidaxomicin tab 200 mg (Dificid) np

TETRACYCLINES

demeclocycline hcl tab 150 mg, 300 mg np DORYX MPC - doxycycline hyclate tab delayed release 60 mg NP doxycycline hyclate cap 50 mg p doxycycline hyclate cap 100 mg (Vibramycin) p doxycycline hyclate tab delayed release 50 mg, 200 mg (Doryx) np doxycycline hyclate tab delayed release 75 mg, 100 mg, 150 mg np doxycycline hyclate tab 20 mg, 100 mg p doxycycline hyclate tab 50 mg np doxycycline hyclate tab 75 mg, 150 mg (Acticlate) np doxycycline monohydrate cap 50 mg, 100 mg p doxycycline monohydrate cap 75 mg, 150 mg np doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) np doxycycline monohydrate tab 50 mg, 100 mg p doxycycline monohydrate tab 75 mg, 150 mg np minocycline hcl cap 50 mg p minocycline hcl cap 75 mg, 100 mg np minocycline hcl tab er 24hr 55 mg, 65 mg, 80 mg, 105 mg, 115 mg (Solodyn) np minocycline hcl tab 50 mg, 75 mg, 100 mg np

Blue Cross and Blue Shield July 2026 Balanced Drug List 3

Drug Name Drug Tier Requirements/Limits MINOCYCLINE HYDROCHLORIDE - minocycline hcl tab er 24hr

45 mg, 90 mg, 135 mg

NP

NUZYRA - omadacycline tosylate tab 150 mg (base equivalent) NP QL (30 tablets/180 days) SEYSARA - sarecycline hcl tab 60 mg (base equivalent), 100 mg

(base equivalent), 150 mg (base equivalent)

NP

tetracycline hcl cap 250 mg, 500 mg np

FLUOROQUINOLONES

BAXDELA - delafloxacin meglumine tab 450 mg (base equiv) NP QL (28 tablets/180 days) CIPRO - ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml), 500 mg/5ml (10%) (10 gm/100ml)

NP

ciprofloxacin hcl tab 250 mg (base equiv), 500 mg (base equiv) (Cipro) p ciprofloxacin hcl tab 750 mg (base equiv) p levofloxacin oral soln 25 mg/ml np levofloxacin tab 250 mg, 500 mg, 750 mg p moxifloxacin hcl tab 400 mg (base equiv) np OFLOXACIN - ofloxacin tab 300 mg P OFLOXACIN - ofloxacin tab 400 mg NP

AMINOGLYCOSIDES

ARIKAYCE - amikacin sulfate liposome inhal susp 590 mg/8.4ml

(base eq) NP PA, QL (28 vials/28 days), SP

HUMATIN - paromomycin sulfate cap 250 mg P KITABIS PAK - tobramycin nebu soln 300 mg/5ml NP PA, QL (280 mls/56 days), SP neomycin sulfate tab 500 mg p TOBI PODHALER - tobramycin inhal cap 28 mg NP QL (224 capsules/56 days), SP TOBRAMYCIN - tobramycin nebu soln 300 mg/5ml NP PA, QL (280 mls/56 days), SP tobramycin nebu soln 300 mg/5ml (Tobi) np QL (280 mls/56 days), SP tobramycin nebu soln 300 mg/4ml (Bethkis) np QL (224 mls/56 days), SP

SULFONAMIDES

sulfadiazine tab 500 mg np

ANTIMYCOBACTERIAL AGENTS

CYCLOSERINE - cycloserine cap 250 mg NP ethambutol hcl tab 100 mg np ethambutol hcl tab 400 mg (Myambutol) np isoniazid syrup 50 mg/5ml np isoniazid tab 100 mg, 300 mg p PRETOMANID - pretomanid tab 200 mg P PRIFTIN - rifapentine tab 150 mg P pyrazinamide tab 500 mg np rifabutin cap 150 mg (Mycobutin) np rifampin cap 150 mg, 300 mg np SIRTURO - bedaquiline fumarate tab 20 mg (base equiv), 100 mg

(base equiv) P

Blue Cross and Blue Shield July 2026 Balanced Drug List 4

Drug Name Drug Tier Requirements/Limits

ANTIFUNGALS

CRESEMBA - isavuconazonium sulfate cap 74.5 mg, 186 mg NP PA fluconazole for susp 10 mg/ml, 40 mg/ml (Diflucan) np fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg (Diflucan) p flucytosine cap 250 mg, 500 mg (Ancobon) np griseofulvin microsize susp 125 mg/5ml np griseofulvin microsize tab 500 mg np GRISEOFULVIN ULTRAMICROSI - griseofulvin ultramicrosize tab

165 mg

NP

griseofulvin ultramicrosize tab 125 mg, 250 mg np itraconazole cap 100 mg (Sporanox) np QL (120 capsules/30 days) itraconazole oral soln 10 mg/ml (Sporanox) np QL (1200 mls/30 days) ketoconazole tab 200 mg np NOXAFIL - posaconazole for delayed release susp packet 300 mg P PA nystatin tab 500000 unit np posaconazole susp 40 mg/ml (Noxafil) np PA posaconazole tab delayed release 100 mg (Noxafil) np PA terbinafine hcl tab 250 mg p TOLSURA - itraconazole cap 65 mg NP PA VIVJOA - oteseconazole cap therapy pack 150 mg (12 weeks) NP PA, QL (18 capsules/180 days) voriconazole for susp 40 mg/ml (Vfend) np PA voriconazole tab 50 mg, 200 mg (Vfend) np PA

ANTIVIRALS

abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen) np QL (960 mls/30 days) abacavir sulfate tab 300 mg (base equiv) (Ziagen) np QL (60 tablets/30 days) abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) np QL (30 tablets/30 days) acyclovir cap 200 mg p acyclovir susp 200 mg/5ml (Zovirax) np acyclovir tab 400 mg, 800 mg p adefovir dipivoxil tab 10 mg (Hepsera) np APRETUDE - cabotegravir im extended release susp 600 mg/3ml P AC APTIVUS - tipranavir cap 250 mg NP QL (120 capsules/30 days) atazanavir sulfate cap 150 mg (base equiv) np QL (30 capsules/30 days) atazanavir sulfate cap 200 mg (base equiv) (Reyataz) np QL (60 capsules/30 days) atazanavir sulfate cap 300 mg (base equiv) (Reyataz) np QL (30 capsules/30 days) BARACLUDE - entecavir oral soln 0.05 mg/ml P BIKTARVY - bictegravir-emtricitabine-tenofovir af tab 30-120-15 mg, 50-200-25 mg P QL (30 tablets/30 days)

CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg P QL (30 tablets/30 days) darunavir tab 600 mg (Prezista) np QL (60 tablets/30 days) darunavir tab 800 mg (Prezista) np QL (30 tablets/30 days) DELSTRIGO - doravirine-lamivudine-tenofovir df tab

100-300-300 mg P QL (30 tablets/30 days)

Blue Cross and Blue Shield July 2026 Balanced Drug List 5

Drug Name Drug Tier Requirements/Limits DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

120-15 mg P QL (30 tablets/30 days)

DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab 200-25 mg

P AC, QL (30 tablets/30 days)

DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg (base eq) P QL (30 tablets/30 days) EDURANT - rilpivirine hcl tab 25 mg (base equivalent) NP QL (30 tablets/30 days) EDURANT PED - rilpivirine hcl tab for oral susp 2.5 mg (base equivalent) NP QL (180 tablets/30 days) efavirenz tab 600 mg (Sustiva) np QL (30 tablets/30 days) efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg np QL (30 tablets/30 days) efavirenz-lamivudine-tenofovir df tab 600-300-300 mg (Symfi) np QL (30 tablets/30 days) EFAVIRENZ/LAMIVUDINE/TENO - efavirenz-lamivudine-tenofovir df tab 400-300-300 mg NP QL (30 tablets/30 days) emtricitabine caps 200 mg (Emtriva) np QL (30 capsules/30 days) emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg

(Complera) np QL (30 tablets/30 days) emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg, 133-200 mg, 167-250 mg (Truvada) np QL (30 tablets/30 days) emtricitabine-tenofovir disoproxil fumarate tab 200-300 mg (Truvada) np AC, QL (30 tablets/30 days)

EMTRIVA - emtricitabine soln 10 mg/ml NP QL (720 mls/30 days) entecavir tab 0.5 mg, 1 mg (Baraclude) np EPCLUSA - sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mg P PA, QL (28 tablets/28 days), SP EPCLUSA - sofosbuvir-velpatasvir pellet pack 150-37.5 mg, 200-50 mg P PA, QL (28 packs/28 days), SP etravirine tab 100 mg, 200 mg (Intelence) np QL (60 tablets/30 days) EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg (base equiv) P QL (30 tablets/30 days) famciclovir tab 125 mg, 250 mg, 500 mg np fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) np QL (120 tablets/30 days) GENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg P QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 45-200 mg, 90-400 mg P PA, QL (28 tablets/28 days), SP HARVONI - ledipasvir-sofosbuvir pellet pack 33.75-150 mg, 45-200 mg P PA, QL (28 packs/28 days), SP

INTELENCE - etravirine tab 25 mg P QL (120 tablets/30 days) ISENTRESS - raltegravir potassium chew tab 25 mg (base equiv), 100 mg (base equiv) P QL (180 tablets/30 days)

ISENTRESS - raltegravir potassium tab 400 mg (base equiv) P QL (60 tablets/30 days) ISENTRESS - raltegravir potassium packet for susp 100 mg (base equiv) P QL (60 packets/30 days)

ISENTRESS HD - raltegravir potassium tab 600 mg (base equiv) P QL (60 tablets/30 days) JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg (base eq) P QL (30 tablets/30 days) KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) P QL (480 mls/30 days) LAGEVRIO - molnupiravir cap 200 mg P QL (40 capsules/90 days) lamivudine oral soln 10 mg/ml (Epivir) np QL (960 mls/30 days)

Blue Cross and Blue Shield July 2026 Balanced Drug List 6

Drug Name Drug Tier Requirements/Limits lamivudine tab 100 mg (hbv) (Epivir hbv) np lamivudine tab 150 mg (Epivir) np QL (60 tablets/30 days) lamivudine tab 300 mg (Epivir) np QL (30 tablets/30 days) lamivudine-zidovudine tab 150-300 mg (Combivir) np QL (60 tablets/30 days) LIVTENCITY - maribavir tab 200 mg NP SP lopinavir-ritonavir tab 100-25 mg (Kaletra) np QL (180 tablets/90 days) lopinavir-ritonavir tab 200-50 mg (Kaletra) np QL (120 tablets/30 days) maraviroc tab 150 mg (Selzentry) np QL (60 tablets/30 days) maraviroc tab 300 mg (Selzentry) np QL (120 tablets/30 days) MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg P PA, QL (90 tablets/30 days), SP MAVYRET - glecaprevir-pibrentasvir pellet pack 50-20 mg P PA, QL (140 packs/28 days), SP NEVIRAPINE - nevirapine susp 50 mg/5ml NP QL (1200 mls/30 days) nevirapine tab er 24hr 400 mg np QL (30 tablets/30 days) nevirapine tab 200 mg p QL (60 tablets/30 days) NORVIR - ritonavir powder packet 100 mg NP QL (360 packets/30 days) ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg P QL (30 tablets/30 days) oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) np QL (40 capsules/120 days) oseltamivir phosphate cap 45 mg (base equiv), 75 mg (base equiv) (Tamiflu) np QL (20 capsules/120 days) oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) np QL (300 mls/120 days) PAXLOVID - nirmatrelvir tab 6 x 150 mg & ritonavir tab 5 x 100 mg pak P QL (11 tablets/90 days)

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

P QL (20 tablets/90 days)

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

P QL (30 tablets/90 days)

PEGASYS - peginterferon alfa-2a soln prefilled syr 180 mcg/0.5ml P PA, SP PEGASYS - peginterferon alfa-2a inj 180 mcg/ml P PA, SP PIFELTRO - doravirine tab 100 mg NP QL (30 tablets/30 days) PREVYMIS - letermovir tab 240 mg, 480 mg NP QL (200 tablets/365 days) PREVYMIS - letermovir pellet pack 20 mg, 120 mg NP PREZCOBIX - darunavir-cobicistat tab 675-150 mg, 800-150 mg P QL (30 tablets/30 days) PREZISTA - darunavir oral susp 100 mg/ml P QL (400 mls/30 days) PREZISTA - darunavir tab 75 mg P QL (300 tablets/30 days) PREZISTA - darunavir tab 150 mg P QL (180 tablets/30 days) RELENZA DISKHALER - zanamivir aerosol powder breath activated

5 mg/act NP QL (40 blisters/120 days)

REYATAZ - atazanavir sulfate oral powder packet 50 mg (base equiv)

NP QL (240 packets/30 days)

RIBAVIRIN - ribavirin cap 200 mg P SP RIBAVIRIN - ribavirin tab 200 mg P SP rilpivirine hcl tab 25 mg (base equivalent) (Edurant) np QL (30 tablets/30 days) ritonavir tab 100 mg (Norvir) np QL (360 tablets/30 days) RUKOBIA - fostemsavir tromethamine tab er 12hr 600 mg NP QL (60 tablets/30 days)

Blue Cross and Blue Shield July 2026 Balanced Drug List 7

Drug Name Drug Tier Requirements/Limits SELZENTRY - maraviroc oral soln 20 mg/ml NP QL (1840 mls/30 days) SOVALDI - sofosbuvir tab 200 mg, 400 mg P PA, QL (30 tablets/30 days), SP SOVALDI - sofosbuvir pellet pack 150 mg, 200 mg P PA, QL (28 packs/28 days), SP STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg NP QL (30 tablets/30 days)

SUNLENCA - lenacapavir sodium tab therapy pack 4 x 300 mg NP QL (4 tablets/365 days) SUNLENCA - lenacapavir sodium tab therapy pack 5 x 300 mg NP QL (5 tablets/365 days) SUNLENCA - lenacapavir sodium tab 300 mg NP QL (4 tablets/365 days) SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab

800-150-200-10 mg P QL (30 tablets/30 days) tenofovir disoproxil fumarate tab 300 mg (Viread) np QL (30 tablets/30 days) TIVICAY - dolutegravir sodium tab 50 mg (base equiv) P QL (60 tablets/30 days) TIVICAY PD - dolutegravir sodium tab for oral susp 5 mg (base equiv) P QL (360 tablets/30 days)

TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg P QL (30 tablets/30 days) TRIUMEQ PD - abacavir-dolutegravir-lamivudine tab for oral sus

60-5-30 mg P QL (180 tablets/30 days) valacyclovir hcl tab 500 mg (Valtrex) p valacyclovir hcl tab 1 gm (Valtrex) np valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) np valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) np VEMLIDY - tenofovir alafenamide fumarate tab 25 mg P VIRACEPT - nelfinavir mesylate tab 250 mg NP QL (270 tablets/30 days) VIRACEPT - nelfinavir mesylate tab 625 mg NP QL (120 tablets/30 days) VIREAD - tenofovir disoproxil fumarate tab 150 mg, 200 mg, 250 mg P QL (30 tablets/30 days) VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm P QL (240 grams/30 days) VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg P PA, QL (30 tablets/30 days), SP XOFLUZA - baloxavir marboxil tab therapy pack 1 x 40 mg (40 mg dose), 1 x 80 mg (80 mg dose) NP QL (2 tablets/120 days)

YEZTUGO - lenacapavir sodium subcut soln 463.5 mg/1.5ml (prophylaxis)

P

YEZTUGO - lenacapavir sodium tab 300 mg (prophylaxis) P QL (4 tablets/365 days) zidovudine cap 100 mg (Retrovir) np QL (180 capsules/30 days) zidovudine syrup 10 mg/ml (Retrovir) np QL (1920 mls/30 days) zidovudine tab 300 mg np QL (60 tablets/30 days)

ANTIMALARIALS

ARAKODA - tafenoquine succinate tab 100 mg (base equivalent) NP atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg

(Malarone) np QL (30 tablets/90 days)

CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 250 mg NP chloroquine phosphate tab 500 mg np COARTEM - artemether-lumefantrine tab 20-120 mg NP hydroxychloroquine sulfate tab 100 mg, 300 mg p hydroxychloroquine sulfate tab 200 mg (Plaquenil) np

Blue Cross and Blue Shield July 2026 Balanced Drug List 8

Drug Name Drug Tier Requirements/Limits hydroxychloroquine sulfate tab 400 mg np KRINTAFEL - tafenoquine succinate tab 150 mg (base equivalent) NP mefloquine hcl tab 250 mg p primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine phosphate) np pyrimethamine tab 25 mg (Daraprim) np QL (116 tablets/180 days) quinine sulfate cap 324 mg (Qualaquin) np SOVUNA - hydroxychloroquine sulfate tab 200 mg NP PA, QL (90 tablets/30 days) SOVUNA - hydroxychloroquine sulfate tab 300 mg NP PA, QL (60 tablets/30 days)

AMEBICIDES

SOLOSEC - secnidazole granules packet 2 gm P

ANTHELMINTICS

albendazole tab 200 mg np BENZNIDAZOLE - benznidazole tab 12.5 mg, 100 mg P EMVERM - mebendazole chew tab 100 mg NP IVERMECTIN - ivermectin tab 6 mg NP ivermectin tab 3 mg (Stromectol) np praziquantel tab 600 mg (Biltricide) np

ANTI-INFECTIVE AGENTS - MISC.

atovaquone susp 750 mg/5ml (Mepron) np BLUJEPA - gepotidacin mesylate tab 750 mg NP CAYSTON - aztreonam lysine for inhal soln 75 mg (base equivalent) NP QL (1 kit/56 days), SP clindamycin hcl cap 75 mg, 150 mg, 300 mg (Cleocin) p clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)

(Cleocin pediatric gr) np dapsone tab 25 mg, 100 mg np fosfomycin tromethamine powd pack 3 gm (base equivalent)

(Monurol) np

IMPAVIDO - miltefosine cap 50 mg P LAMPIT - nifurtimox tab 30 mg, 120 mg NP linezolid for susp 100 mg/5ml (Zyvox) np QL (600 mls/180 days) linezolid tab 600 mg (Zyvox) np QL (56 tablets/180 days) methenamine hippurate tab 1 gm (Hiprex) np metronidazole cap 375 mg (Flagyl) np metronidazole tab 250 mg, 500 mg p nitazoxanide tab 500 mg (Alinia) np QL (6 tablets/30 days) NITROFURANTOIN - nitrofurantoin susp 50 mg/5ml NP nitrofurantoin macrocrystalline cap 25 mg, 100 mg

(Macrodantin) np nitrofurantoin macrocrystalline cap 50 mg (Macrodantin) p nitrofurantoin monohydrate macrocrystalline cap 100 mg

(Macrobid) p nitrofurantoin susp 25 mg/5ml np

Blue Cross and Blue Shield July 2026 Balanced Drug List 9

Drug Name Drug Tier Requirements/Limits ORLYNVAH - sulopenem etzadroxil-probenecid tab 500-500 mg NP pentamidine isethionate for nebulization soln 300 mg

(Nebupent) np

SIVEXTRO - tedizolid phosphate tab 200 mg NP QL (6 tablets/180 days) sulfamethoxazole-trimethoprim susp 200-40 mg/5ml np sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) p sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) p tinidazole tab 250 mg, 500 mg np trimethoprim tab 100 mg (Trimethoprim) np vancomycin hcl cap 125 mg (base equivalent), 250 mg (base equivalent) (Vancocin) np QL (120 capsules/30 days) vancomycin hcl for oral soln 25 mg/ml (base equivalent) (Firvanq) np vancomycin hcl for oral soln 50 mg/ml (base equivalent) (Vancomycin hydrochlo) np

XIFAXAN - rifaximin tab 200 mg NP QL (9 tablets/30 days) XIFAXAN - rifaximin tab 550 mg P QL (126 tablets/365 days)

BIOLOGICALS

VACCINES

ABRYSVO - rsv pre-fusion f a&b vac recomb for im soln

120 mcg/0.5ml

P AC

ACTHIB - haemophilus b polysaccharide conjugate vaccine for inj P AC AFLURIA 2025-2026 - influenza virus vaccine split im susp P AFLURIA 2025-2026 - influenza virus vaccine split pf susp pref syringe 0.5 ml

P AC

AREXVY - rsvpref3 vaccine recomb adjuvanted for im susp 120 mcg/0.5ml

P AC

BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled syringe

P AC

CAPVAXIVE - pneumococcal 21-valent conjugate vaccine soln pref syr 0.5ml

P AC

COMIRNATY 2025-26 - covid-19 mrna vac tris-pfizer im susp pref syr 30 mcg/0.3ml

P AC

COMIRNATY/5-11Y/2025-26 - covid-19 mrna vac tris-s 5-11y-pfizer im susp 10 mcg/0.3ml

P AC

ENGERIX-B - hepatitis b vaccine (recombinant) susp pref syr 10 mcg/0.5ml, 20 mcg/ml

P AC

ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml P AC FLUAD 2025-2026 - influenza vac type a&b surface ant adj susp pref syr 0.5 ml

P AC

FLUARIX 2025-2026 - influenza virus vaccine split pf susp pref syringe 0.5 ml

P AC

FLUBLOK 2025-2026 - influenza virus vacc recombinant ha pf soln pref syr 0.5 ml

P AC

Blue Cross and Blue Shield July 2026 Balanced Drug List 10

Drug Name Drug Tier Requirements/Limits FLUCELVAX 2025-2026 - influenza virus vac tiss-cult subunit susp pref syr 0.5 ml

P AC

FLUCELVAX 2025-2026 - influenza virus vac tiss-cult subunit im susp

P

FLULAVAL 2025-2026 - influenza virus vaccine split pf susp pref syringe 0.5 ml

P AC

FLUMIST NASAL VACCINE 202 - influenza virus vaccine live intranasal liquid

P AC

FLUZONE HIGH-DOSE 2025-20 - influenza virus vac split high-dose pf susp pref syr 0.5ml

P AC

FLUZONE 2025-2026 - influenza virus vaccine split im susp P FLUZONE 2025-2026 - influenza virus vaccine split pf susp pref syringe 0.5 ml

P AC

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac susp pref syr

P AC

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im susp

P AC

HAVRIX - hepatitis a vaccine susp prefilled syr 720 el unit/0.5ml, 1440 el unit/ml

P AC

HEPLISAV-B - hepatitis b vaccine recomb adjuvanted pref syr 20 mcg/0.5ml

P AC

HIBERIX - haemophilus b polysaccharide conjugate vac for inj 10 mcg

P AC

IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc for inj susp P IPOL INACTIVATED IPV - poliovirus vaccine, ipv inj susp P AC JYNNEOS - smallpox & monkeypox vac, live, non-replicating inj

0.5 ml

P AC

M-M-R II - measles-mumps-rubella virus vaccines for inj soln P AC MENQUADFI - meningococcal (a, c, y, and w-135) tetanus conjugate vaccine

P AC

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac im soln

P AC

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj P AC MNEXSPIKE COVID-19 VACCIN - covid-19 mrna vaccine-moderna im susp pref syr 10 mcg/0.2ml

P AC

MRESVIA - rsv mrna pre-f vaccine im susp pref syr 50 mcg/0.5ml P AC NUVAXOVID COVID-19 VACCIN - covid-19 subunit vacc-novavax im susp pref syr 5 mcg/0.5ml

P AC

PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml

P AC

PENBRAYA - meningococcal acyw (tet conj)-mening b (rcmb) vacc for inj

P AC

PENMENVY - meningococcal acwy (oligo conj)-mening b (rcmb) vacc for inj

P AC

PNEUMOVAX 23 - pneumococcal vaccine polyvalent soln pref syr 25 mcg/0.5ml

Blue Cross and Blue Shield July 2026 Balanced Drug List 11

Drug Name Drug Tier Requirements/Limits PREVNAR 20 - pneumococcal 20-valent conjugate vaccine sus pref syr 0.5 ml

P AC

PRIORIX - measles-mumps-rubella virus vaccines for subcutaneous susp

P AC

PROQUAD - measles-mumps-rubella-varicella virus vaccines for susp

P AC

RABAVERT - rabies vaccine, pcec for inj P RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp pref syr

5 mcg/0.5ml, 10 mcg/ml

P AC

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml, 10 mcg/ml, 40 mcg/ml

P AC

ROTARIX - rotavirus vaccine, live oral susp P AC ROTATEQ - rotavirus vaccine, live oral pentavalent soln P AC SHINGRIX - zoster vac recomb adjuvanted im susp pref syr

50 mcg/0.5ml

P AC

SHINGRIX - zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml

P AC

SPIKEVAX COVID-19 VACCINE - covid-19 mrna vac 6mo-11yr-moderna im susp pfs 25 mcg/0.25ml

P AC

SPIKEVAX COVID-19 VACCINE - covid-19 mrna vaccine-moderna im susp pref syr 50 mcg/0.5ml

P AC

TRUMENBA - meningococcal group b vac (recomb) im susp prefilled syr

P AC

TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml P AC VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml, 50 unit/ml P AC VAQTA - hepatitis a vaccine susp prefilled syr 25 unit/0.5ml, 50 unit/ ml

P AC

VARIVAX - varicella virus vac live for inj 1350 pfu/0.5ml P AC VAXNEUVANCE - pneumococcal 15-valent conjugate vaccine sus pref syr 0.5 ml

P AC

VIVOTIF - typhoid vaccine cap delayed release NP

TOXOIDS

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml P AC ADACEL - tet-diph-acell pertuss ad pref syr 5-2-15.5 lf-mcg/0.5ml P AC BOOSTRIX - tet-diph-acell pertuss ad pref syr 5-2.5-18.5 lf-mcg/0.5ml

P AC

DAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml P AC INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml P AC KINRIX - diph-tetanus-acell pert-polio, ipv vacc susp pref syr 0.5 ml P AC PEDIARIX - diph-tet tox-acell pert-hep b-polio ipv vac susp pref syr P AC PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp

P AC

QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj

Blue Cross and Blue Shield July 2026 Balanced Drug List 12

Drug Name Drug Tier Requirements/Limits QUADRACEL - diph-tetanus-acell pert-polio, ipv vacc susp pref syr

0.5 ml

P AC

TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lf/0.5ml P AC VAXELIS - diph-tet tox-ac pert ad-polio ipv-hib-hep b rec susp pre syr

P AC

VAXELIS - diph-tet tox-ac pert ad-polio ipv-hib-hepatitis b recmb susp

P AC

BIOLOGICALS MISC

GRASTEK - timothy grass pollen allergen ext sl tab 2800 bau NP ODACTRA - dust mite mixed ext sl tab 12 sq-hdm NP ORALAIR - grass mixed pollen ext sl tab 300 ir (index of reactivity) NP PALFORZIA INITIAL DOSE ES - peanut powder-dnfp starter pack

0.5 & 1 & 1.5 & 3 mg, 0.5 & 1 & 1.5 & 3 & 6 mg

NP SP

PALFORZIA LEVEL 0 - peanut powder-dnfp cap sprinkle pack 1 x 1 mg (1 mg dose)

NP SP

PALFORZIA LEVEL 1 - peanut powder-dnfp cap sprinkle pack 3 x 1 mg (3 mg dose)

NP SP

PALFORZIA LEVEL 10 - peanut powder-dnfp pack 2 x 20 mg & 2 x 100 mg (240 mg dose)

NP SP

PALFORZIA LEVEL 11 (MAINT - peanut allergen powder-dnfp maintenance packet 300 mg

NP SP

PALFORZIA LEVEL 11 (TITRA - peanut allergen powder-dnfp titration packet 300 mg

NP SP

PALFORZIA LEVEL 2 - peanut powder-dnfp cap sprinkle pack 6 x 1 mg (6 mg dose)

NP SP

PALFORZIA LEVEL 3 - peanut powder-dnfp pack 2 x 1 mg & 10 mg (12 mg dose)

NP SP

PALFORZIA LEVEL 4 - peanut powder-dnfp cap sprinkle pack 20 mg (20 mg dose)

NP SP

PALFORZIA LEVEL 5 - peanut powder-dnfp cap sprinkle pack 2 x 20 mg (40 mg dose)

NP SP

PALFORZIA LEVEL 6 - peanut powder-dnfp cap sprinkle pack 4 x 20 mg (80 mg dose)

NP SP

PALFORZIA LEVEL 7 - peanut powder-dnfp pack 20 mg & 100 mg (120 mg dose)

NP SP

PALFORZIA LEVEL 8 - peanut powder-dnfp pack 3 x 20 mg & 100 mg (160 mg dose)

NP SP

PALFORZIA LEVEL 9 - peanut powder-dnfp pack 2 x 100 mg (200 mg dose)

NP SP

RAGWITEK - short ragweed pollen allergen extract sl tab 12 amb a 1-u

NP

ANTINEOPLASTIC AGENTS

ANTINEOPLASTICS

abiraterone acetate tab 250 mg (Zytiga) np PA, QL (120 tablets/30 days), SP abiraterone acetate tab 500 mg (Zytiga) np PA, QL (60 tablets/30 days), SP

Blue Cross and Blue Shield July 2026 Balanced Drug List 13

Drug Name Drug Tier Requirements/Limits ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000 unit/0.5ml)

P SP

AKEEGA - niraparib tosylate-abiraterone acetate tab 50-500 mg, 100-500 mg

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

ALECENSA - alectinib hcl cap 150 mg (base equivalent) P PA, QL (240 capsules/30 days), SP ALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg P PA, QL (30 tablets/180 days), SP ALUNBRIG - brigatinib tab 30 mg P PA, QL (120 tablets/30 days), SP ALUNBRIG - brigatinib tab 90 mg, 180 mg P PA, QL (30 tablets/30 days), SP anastrozole tab 1 mg (Arimidex) p AC AUGTYRO - repotrectinib cap 40 mg NP PA, QL (240 capsules/30 days), SP AUGTYRO - repotrectinib cap 160 mg NP PA, QL (60 capsules/30 days), SP AVMAPKI FAKZYNJA CO-PACK - avutometinib cap 0.8 mg & defactinib tab 200 mg therapy pack NP PA, QL (66 tablets/28 days), SP

AYVAKIT - avapritinib tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mg P PA, QL (30 tablets/30 days), SP BALVERSA - erdafitinib tab 3 mg NP PA, QL (90 tablets/30 days), SP BALVERSA - erdafitinib tab 4 mg NP PA, QL (60 tablets/30 days), SP BALVERSA - erdafitinib tab 5 mg NP PA, QL (30 tablets/30 days), SP BESREMI - ropeginterferon alfa-2b-njft soln prefilled syr 500 mcg/ml P PA, QL (2 syringes/28 days), SP bexarotene cap 75 mg (Targretin) np PA, SP bicalutamide tab 50 mg (Casodex) p BOSULIF - bosutinib cap 50 mg P PA, QL (30 capsules/30 days), SP BOSULIF - bosutinib cap 100 mg P PA, QL (150 capsules/30 days), SP BOSULIF - bosutinib tab 100 mg P PA, QL (90 tablets/30 days), SP BOSULIF - bosutinib tab 400 mg, 500 mg P PA, QL (30 tablets/30 days), SP BRAFTOVI - encorafenib cap 75 mg NP PA, QL (180 capsules/30 days), SP BRUKINSA - zanubrutinib cap 80 mg P PA, QL (120 capsules/30 days), SP BRUKINSA - zanubrutinib tab 160 mg P PA, QL (60 tablets/30 days), SP CABOMETYX - cabozantinib s-malate tab 20 mg (base equivalent), 40 mg (base equivalent), 60 mg (base equivalent) P PA, QL (30 tablets/30 days), SP

CALQUENCE - acalabrutinib maleate tab 100 mg P PA, QL (60 tablets/30 days), SP capecitabine tab 150 mg, 500 mg (Xeloda) np SP CAPRELSA - vandetanib tab 100 mg P PA, QL (60 tablets/30 days), SP CAPRELSA - vandetanib tab 300 mg P PA, QL (30 tablets/30 days), SP COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit P PA, QL (1 kit/28 days), SP COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit P PA, QL (1 kit/28 days), SP

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit

P PA, QL (1 kit/28 days), SP

COPIKTRA - duvelisib cap 15 mg, 25 mg NP PA, QL (56 capsules/28 days), SP COTELLIC - cobimetinib fumarate tab 20 mg (base equivalent) P PA, QL (63 tablets/28 days), SP CYCLOPHOSPHAMIDE - cyclophosphamide tab 50 mg P cyclophosphamide cap 25 mg, 50 mg (Cyclophosphamide) np dasatinib tab 20 mg (Sprycel) np PA, QL (90 tablets/30 days), SP dasatinib tab 50 mg, 70 mg, 80 mg, 100 mg, 140 mg (Sprycel) np PA, QL (30 tablets/30 days), SP

Blue Cross and Blue Shield July 2026 Balanced Drug List 14

Drug Name Drug Tier Requirements/Limits DAURISMO - glasdegib maleate tab 25 mg (base equivalent) NP PA, QL (60 tablets/30 days), SP DAURISMO - glasdegib maleate tab 100 mg (base equivalent) NP PA, QL (30 tablets/30 days), SP ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg NP SP ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg

NP SP

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit 30 mg

NP SP

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 mg

NP SP

ENSACOVE - ensartinib hcl cap 25 mg (base equivalent) NP PA, QL (30 capsules/30 days), SP ENSACOVE - ensartinib hcl cap 100 mg (base equivalent) NP PA, QL (60 capsules/30 days), SP ERIVEDGE - vismodegib cap 150 mg P PA, QL (30 capsules/30 days), SP ERLEADA - apalutamide tab 60 mg P PA, QL (120 tablets/30 days), SP ERLEADA - apalutamide tab 240 mg P PA, QL (30 tablets/30 days), SP erlotinib hcl tab 25 mg (base equivalent) (Tarceva) np PA, QL (60 tablets/30 days), SP erlotinib hcl tab 100 mg (base equivalent), 150 mg (base equivalent) (Tarceva) np PA, QL (30 tablets/30 days), SP