Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023

THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE,

OMNIA SILVER, OMNIA SILVER VALUE, OMNIA SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE,

VALUE ACCESS SILVER. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP MARKET ARE: OMNIA BRONZE, OMNIA SILVER, OMNIA

SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BLUECARD, OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA

PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD

100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50, ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS

PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60 .

5517-E NJ HIM © Prime Therapeutics LLC 01/23

Horizon Blue Cross Blue Shield of New Jersey

Drug Guide for the Health Insurance Marketplace

January 2023

Please talk to your doctor about prescribing medicines from this drug list. It may help you and your doctor choose

an appropriate medicine and help reduce your out-of-pocket costs.

This Drug Guide is updated monthly. For the most up-to-date Drug Guide, visit HorizonBlue.com/formulary.

Contents

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

Drug Selection ...................................................... I

Member Prescription Benefit .................................. II

Generic Drugs ..................................................... II

Affordable Care Act .............................................IV

Utilization Management ........................................IV

Prior Authorization/Medical Necessity Review and

Determination ...............................................IV

Quantity Limits .................................................... V

Specialty ............................................................ V

How to Use This List ............................................VI

Abbreviation Key ................................................ VII

Anti-Infective Drugs .............................................. 1

Biologicals......................................................... 10

Antineoplastic Agents .................................... 11

Endocrine and Metabolic Drugs....................... 16

Cardiovascular Agents................................... 31

Respiratory Agents........................................ 42

Gastrointestinal Agents .................................. 47

Genitourinary Agents ..................................... 53

Central Nervous System Drugs ....................... 55

Analgesics and Anesthetics ............................ 66

Neuromuscular Drugs.................................... 75

Nutritional Products ....................................... 81

Hematological Agents.................................... 86

Topical Products ........................................... 89

Miscellaneous Products ............................... 104

Index ........................................................ 145

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.

An Independent Licensee of

the Blue Cross Blue Shield Association

THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE,

OMNIA SILVER, OMNIA SILVER VALUE, OMNIA SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE,

VALUE ACCESS SILVER. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP MARKET ARE: OMNIA BRONZE, OMNIA SILVER, OMNIA

SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BLUECARD, OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA

PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD

100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50, ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS

PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60.

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 I

EC004133 (0719)

Introduction

Horizon Blue Cross Blue Shield of New Jersey is pleased to present the Drug Guide for the Health Insurance

Marketplace. This Guide identifies the covered drug list (formulary) for your prescription drug plan. Horizon BCBSNJ

is committed to giving our members access to safe and effective medicine. Please refer to this guide for information,

and present the guide to your doctor if you require a prescription.

Please note: This drug list applies to Horizon BCBSNJ’s Health Insurance Marketplace individual on-exchange,

individual off-exchange, small group on-exchange and small group off-exchange products.

The applicable products for the individual market are:

ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE, OMNIA SILVER, OMNIA SILVER VALUE, OMNIA

SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE, VALUE ACCESS SILVER.

The

applicable products for the small group market are:

OMNIA BRONZE, OMNIA SILVER, OMNIA SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BL UECARD,

OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE

EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD 100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50,

ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND

ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60.

Drug selection

Each medicine chosen for the drug list was analyzed for its safety, efficacy and value by Horizon BCBSNJ’s

Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is made up of local, independent practicing

doctors and pharmacists, and meets at least quarterly. Coverage decisions are based on safety, efficacy,

uniqueness and cost. Newly marketed prescription drugs will not be covered until the P&T Committee has had an

opportunity to review the drug, to determine whether the drug will be covered and if so, which tier will apply based

on safety, efficacy, and the availability of other products within that class of drugs. If your physician feels that a new

drug is medically necessary prior to P&T Committee evaluation, a non-formulary exception request for coverage

may be submitted.

Horizon BCBSNJ encourages doctors to prescribe Generic (Tier 1) and Preferred Brand

(Tier 2) medicines. While coverage is provided for Non-Preferred Brand (Tier 3) medicines, you may pay higher

copayments and out-of-out pocket costs if you choose to fill these medicines.

To find recent changes or the most current version of this Guide, and to search for medicines covered by your

pharmacy plan as well as the applicable exclusions, sign in at HorizonBlue.com. You can also access the most

current version of the Guide at HorizonBlue.com/formulary.

THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE,

OMNIA SILVER, OMNIA SILVER VALUE, OMNIA SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE,

VALUE ACCESS SILVER. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP MARKET ARE: OMNIA BRONZE, OMNIA SILVER, OMNIA

SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BLUECARD, OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA

PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD

100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50, ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS

PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60.

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 II

EC004133 (0719)

Member prescription benefit

The drug list is grouped into tiers. Your copayment or cost share is determined by the tier that the medicine is on:

Generic (Tier 1), Preferred Brand (Tier 2) and Non-Preferred Brand (Tier 3).

Tier 1 – Lowest copayment/cost share – Generic drugs. Tier 1 includes most generic medicines,

although not all generics are listed in this Guide.

Tier 2 – Middle copayment/cost share – Preferred brand drugs.

Tier 3 – Highest copayment/cost share – Non-Preferred brand drugs.

All available covered drugs are shown on this list. Drugs that are not covered on the formulary will be noted in the

Prescription Drug List with the NF (non-formulary) indicator. If your physician feels that a non-formulary drug is

medically necessary, a non-formulary exception request for coverage may be submitted.

Certain drug classes are excluded from coverage (not covered) including investigational and cosmetic (such as

Propecia for hair growth), anti-obesity (such as Belviq or Contrave) and erectile dysfunction (such as Viagra) drugs.

Coverage, copayment, and additional restrictions and exclusions may vary depending on your pharmacy plan

design. Please refer to the policy and benefit information you received from Horizon BCBSNJ.

Exception Process

You, your prescribing health care provider, or your authorized representative, can ask for a Drug List exception if

your drug is not on (or is being removed from) the Drug List. To request this exception, you, your prescriber, or your

authorized representative, can call the number on your ID card to ask for a review. Horizon will let you, your

prescriber (or authorized representative) know the coverage decision within 72 hours after they receive your

request. If the coverage request is denied, Horizon will let you and your prescriber (or authorized representative)

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, your prescriber, or your authorized representative, may be able to ask for an expedited review

process. Horizon will let you, your prescriber (or authorized representative) know the coverage decision within 24

hours after they receive your request for an expedited review. If the coverage request is denied, BCBS will let you

and your prescriber (or authorized representative) 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.

Generic drugs

We encourage the use of generics as a way to provide high-quality medicines at a lower cost. Generics are

manufactured under the same strict requirements of the FDA’s current Good Manufacturing Practice regulations

required for brand name medicines in manufacturing, strength, purity and quality. Prescribing generic medications

can have many benefits, including:

• Safe and effective profiles equivalent to their brand name drug counterparts, as required by the FDA.

• Costing anywhere from 30 to 80 percent less than their equivalent brand name drugs, and generally lower

cost share when compared to a Preferred or a non-Preferred brand name medication.

THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE,

OMNIA SILVER, OMNIA SILVER VALUE, OMNIA SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE,

VALUE ACCESS SILVER. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP MARKET ARE: OMNIA BRONZE, OMNIA SILVER, OMNIA

SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BLUECARD, OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA

PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD

100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50, ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS

PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60.

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 III

EC004133 (0719)

• Showing in clinical studies similar clinical outcomes and may improve patient adherence for those unable to

afford the more costly brand name medicine.

An FDA-approved generic may be substituted for the brand equivalent when it:

• Contains the same active ingredient(s) as the brand medicine.

• Is identical in strength, dosage form and route of administration.

• Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.

To encourage use of generics, Tier 2 Preferred brands typically move to Tier 3 after an equivalent generic becomes

available.

If your doctor writes a prescription that permits generic substitution and you choose to receive the brand name

medicine instead, you will be responsible for the copayment plus the difference in cost between the brand and

generic.

The amount members save will be based on their benefit plans and the price of specific drugs. Source: Generic Pharmaceutical Association’s website:

gphaonline.org/about/generic-medicines.

THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE,

OMNIA SILVER, OMNIA SILVER VALUE, OMNIA SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE,

VALUE ACCESS SILVER. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP MARKET ARE: OMNIA BRONZE, OMNIA SILVER, OMNIA

SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BLUECARD, OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA

PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD

100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50, ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS

PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60.

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 IV

EC004133 (0719)

Affordable Care Act (ACA)

The Affordable Care Act (ACA), also known as health care reform, requires coverage of certain medicines. These

are indicated on the drug list in the column labelled “ACA”. Additionally, these medicines are covered for a $0 cost

share, when the conditions (such as age or gender) are met as outlined under the ACA regulation. These are

indicated with an “A” in the drug Tier column.

Examples of categories that may be subject to limited or $0 cost share include aspirin, some breast cancer

preventive medicines, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron

supplements, some tobacco cessation, vitamin D supplements, some bowel preparation medications, some statins,

and some contraceptive (birth control) drugs and devices. If you do not find the medicine you are searching for, call

Pharmacy Member Services, 24 hours a day, seven days a week, at 1-800-370-5088 to find out if the drug is

available over-the-counter, or is covered under your medical benefit.

Utilization Management (UM)

Some medicines have special requirements for which your doctor must provide clinical information to Horizon

BCBSNJ before the medicine will be approved and covered by the plan. This is called Utilization Management

(UM). Medicines that require Prior Authorization (PA), Medical Necessity Review and Determination (MND), or that

are subject to a Quantity Limit (QL) are noted on the drug list.

Prior Authorization/Medical Necessity Review and Determination

PA means that specific clinical criteria must be met to demonstrate the medical necessity of the medicine before

coverage can be approved. Only medicines that are medically necessary are approved. This ensures safe and

proper use of the medicine. If this drug list shows that you need a PA for a medicine, your doctor must send a PA

request to Horizon BCBSNJ for review. You and your doctor will be notified in writing of the decision. If the PA

request is approved, your medicine will be covered by your plan for a specific period of time.

If the PA request is not approved, there is an appeals process available, or you may choose to buy the medicine at

your own expense.

Also, some medicines may be reviewed for medical necessity from time to time, even though they are not subject to

our PA requirements. If so, your prescribing doctor may be asked for clinical information to support your use of the

medicine. In instances where the Medical Necessity Review and? Determination (MND) results in an unfavorable

decision, please remember such determinations may also be eligible for the appeals process or you may choose to

buy the medicine at your own expense.

THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE,

OMNIA SILVER, OMNIA SILVER VALUE, OMNIA SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE,

VALUE ACCESS SILVER. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP MARKET ARE: OMNIA BRONZE, OMNIA SILVER, OMNIA

SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BLUECARD, OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA

PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD

100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50, ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS

PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60.

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 V

EC004133 (0719)

Quantity Limits

A Quantity Limit (QL) controls the maximum amount of medicine covered per prescription. It can also identify

gender or age restrictions and the amount of medicine allowed. QLs are placed on certain categories and are based

upon FDA-approved drug labeling. These limits help encourage safe and proper use. If the drug list shows that

there is a QL, your doctor must submit a PA request to Horizon BCBSNJ for review if he/she wants to exceed the

QL for your medicine. Clinical information will be required to be submitted with the QL exception request to explain

why your condition requires the additional quantity. If the QL exception request is approved, your medicine will be

covered for a specific period of time. If the request is not approved, there is an appeals process available or you

may choose to buy the medicine at your own expense.

Specialty Medicines

Specialty medicines require education prior to use, patient monitoring for side effects and need to be handled or

stored correctly. These specialty medicines also require your doctor to submit a PA request to Horizon BCBSNJ for

review.

Horizon BCBSNJ has contracted with several specialty pharmacies that specialize in these therapies. Members

who want to minimize their cost sharing are required to obtain the specialty medicines from one of the participating

specialty pharmacies. You cannot get specialty medicines from a retail pharmacy or through home delivery. This

Guide indicates which medicines are classified as specialty. To find out more information about our Specialty

Prescription Program and to see the list and phone numbers of the participating specialty pharmacies, please refer

to the following webpage: HorizonBlue.com/specialtypharmacynetwork.

Specialty medicines that are administered or infused by a doctor or health care professional are not covered

through the pharmacy benefit. These are instead covered through a member’s medical benefit.

Limited Distribution:

Medicines marked as "limited distribution” mean the drug manufacturer chooses, or the FDA requires only one, or a

few pharmacies to be able to provide the medicine to members. This may include requiring use of a specialty

pharmacy or other designated pharmacy to fill the prescription. The specialty pharmacies contracted with Horizon

BCBSNJ’s specialty pharmacy network can help members with obtaining limited distribution drugs.

THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE,

OMNIA SILVER, OMNIA SILVER VALUE, OMNIA SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE,

VALUE ACCESS SILVER. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP MARKET ARE: OMNIA BRONZE, OMNIA SILVER, OMNIA

SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BLUECARD, OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA

PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD

100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50, ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS

PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60.

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 VI

EC004133 (0719)

How to use this list

The drug list is organized into broad categories (e.g. ANTINEOPLASTIC AGENTS AND RELATED DRUGS).

The graphic below shows the information that is provided in each column of the drug list and is only an example.

Please use the drug search function to find current information for drugs on the drug list.

The first column of the chart lists the medicine name. Generic medicines are shown in lower-case boldface

type. Most generics are followed by a reference brand medicine in (parentheses). Some generics have no

reference brand. Brand medicines are shown in capital letters followed by the generic name.

The second column indicates the tier: 1=Generic, 2=Preferred Brand, 3=Non-Preferred Brand, NF = Non-

formulary (exluded) and A=$0 if ACA requirements are met.

These columns indicate the UM program(s) that apply to the medicine, such as PA and QLs. If an indicator is

present in the column(s), then the UM program(s) applies.

The column indicates if the medicine is considered a specialty medicine.

The column indicates if the medicine is required to be covered under the ACA.

The column indicates if the medicine is considered limited distribution.

THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: ADVANTAGE EPO BRONZE, ADVANTAGE EPO SILVER, OMNIA BRONZE,

OMNIA SILVER, OMNIA SILVER VALUE, OMNIA SILVER H.S.A., OMNIA GOLD, AND ADVANTAGE EPO ESSENTIALS, VALUE ACCESS BRONZE,

VALUE ACCESS SILVER. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP MARKET ARE: OMNIA BRONZE, OMNIA SILVER, OMNIA

SILVER W/BLUECARD OMNIA SILVER H.S.A., OMNIA GOLD, OMNIA GOLD W/BLUECARD, OMNIA GOLD H.S.A. W/ BLUECARD, OMNIA

PLATINUM, OMNIA PLATINUM VALUE, ADVANTAGE EPO GOLD 100% C25/45, ADVANTAGE EPO GOLD 100% C40/60, ADVANTAGE EPO GOLD

100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO SILVER 100/50, ADVANTAGE EPO BRONZE 50, ADVANTAGE DIRECT ACCESS

PLATINUM 100/70, ADVANTAGE DIRECT ACCESS GOLD 100/80/60, AND ADVANTAGE DIRECT ACCESS SILVER HSA 100/70/60.

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 VII

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Abbreviation Key

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

odt. ................................. orally disintegrating tabs

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

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

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

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

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

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

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

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

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

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

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

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

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

This guide is subject to change.

This document contains prescription brand name drugs that are registered marks or trademarks of pharmaceutical manufacturers that are not

affiliated with either Horizon Blue Cross Blue Shield of New Jersey, the Blue Cross and Blue Shield Association or

Prime Therapeutics LLC.

Notice of Nondiscrimination

CMC0008179_A (0619)

An Independent Licensee of the Blue Cross and Blue Shield Association.

Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and does not discriminate against nor does

it exclude people or treat them differently on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex,

sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Horizon BCBSNJ

provides free aids and services to people with disabilities (e.g. qualified sign language interpreters and information in other formats) and to

those whose primary language is not English (e.g. information in other languages) to communicate effectively with us.

Contacting Member Services

Please call Member Services at 1-800-355-BLUE (2583) (TTY 711) or the phone number on the back of your member ID card, if you

need the free aids and services noted above and for all other Member Services issues.

Filing a Section 1557 Grievance

If you believe that Horizon BCBSNJ has failed to provide the free communication aids and services or discriminated against you for one of

the reasons described above, you can file a discrimination complaint also known as a Section 1557 Grievance. Horizon BCBSNJ’s Civil

Rights Coordinator can be reached by calling the Member Services number on the back of your member ID card or by writing to the

following address: Horizon BCBSNJ

Civil Rights Coordinator

PO Box 820, Newark, NJ 07101.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, through the Office

for Civil Rights Complaint Portal, online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail at U.S. Department of Health and

Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201or by phone at 1-800-368-1019

or 1-800-537-7697 (TDD). OCR Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

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Jeśli mówisz w języku innym niż angielski, pomoc udzielana jest bezpłatnie. Zadzwoń pod numer podany na odwrocie dowodu osobistego.

Se parli una lingua diversa dall'inglese, è disponibile un servizio di assistenza gratuito. Chiama il numero sul retro della tua carta d’identificaz

ione.

Kung nagsasalita ka ng isang wika maliban sa Ingles, magagamit ang tulong nang walang bayad. Tumawag sa numerong nasa likod ng iyong

ID card.

Если вы не говорите по-английски, вам помогут бесплатно. Позвоните по телефону, указанному на обратной стороне вашей ID-

карты.

Si ou pale on lòt lang ke Anglè, gen èd ki disponib gratis. Rele nan nimewo ki ekri nan do kat idantifyan w lan.

         



,  



             .

Nếu bạn nói ngôn ngữ khác ngoài tiếng Anh, thì chúng tôi có thể giúp bạn miễn phí. Hãy gọi số ở mặt sau thẻ ID của bạn.

Si vous parlez une langue autre que l'anglais, l'aide est gratuite. Appelez le numéro au dos de votre carte d'identité.

ةغل ثدحتت تنك اذإ ةيوهلا ةقاطب رهظ ىلع دوجوملا مقرلاب لاصتلاا كنكمُي .ا

ناجم ةدعاسملا كل رفون ،ةيزيلجنلإا ريغ ىرخأ

رگنا پآ رگايزی لاع ےکئوک ہوی رسودی لوب نابز ہ ےتکسيں تسد ددم تفم وتيبا نابرہم ہارب ۔ےہی تخانشی ک ڈراکی له چپی رک لاک رپ ربمن ہدش جرد فرطيں۔

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 1

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ANTI-INFECTIVE AGENTS

PENICILLINS

AMOXICILLIN - amoxicillin

(trihydrate) chew tab 125 mg, 250

amoxicillin (trihydrate) cap

250 mg, 500 mg

amoxicillin (trihydrate) for susp

125 mg/5ml, 200 mg/5ml,

250 mg/5ml, 400 mg/5ml

amoxicillin (trihydrate) tab

500 mg, 875 mg

amoxicillin & k clavulanate

for susp 200-28.5 mg/5ml,

250-62.5 mg/5ml, 400-57 mg/5ml

amoxicillin & k clavulanate

for susp 600-42.9 mg/5ml

(Augmentin es-600)

amoxicillin & k clavulanate tab

250-125 mg, 875-125 mg

amoxicillin & k clavulanate tab

500-125 mg (Augmentin)

AMOXICILLIN/CLAVULANATE P -

amoxicillin & k clavulanate chew

tab 200-28.5 mg, 400-57 mg

AMOXICILLIN/CLAVULANATE P -

amoxicillin & k clavulanate tab er

12hr 1000-62.5 mg

•

AMPICILLIN - ampicillin cap 500 mg

AUGMENTIN - amoxicillin & k

clavulanate tab 500-125 mg

AUGMENTIN ES-600 - amoxicillin

& k clavulanate for susp 600-42.9

mg/5ml

dicloxacillin sodium cap 250 mg,

500 mg

PENICILLIN V POTASSIUM -

penicillin v potassium for soln 250

mg/5ml

penicillin v potassium tab 250 mg,

500 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CEPHALOSPORINS

CEFACLOR - cefaclor cap 250 mg,

500 mg

CEFACLOR - cefaclor for susp 125

mg/5ml, 250 mg/5ml, 375 mg/5ml

CEFACLOR ER - cefaclor

monohydrate tab er 12hr 500 mg

CEFADROXIL - cefadroxil tab 1 gm

cefadroxil cap 500 mg

cefadroxil for susp 250 mg/5ml,

500 mg/5ml

cefdinir cap 300 mg

cefdinir for susp 125 mg/5ml,

250 mg/5ml

cefixime for susp 100 mg/5ml

cefixime for susp 200 mg/5ml

(Suprax)

cefpodoxime proxetil for susp

50 mg/5ml, 100 mg/5ml

cefpodoxime proxetil tab 100 mg,

200 mg

cefprozil for susp 125 mg/5ml,

250 mg/5ml

cefprozil tab 250 mg, 500 mg

cefuroxime axetil tab 250 mg,

500 mg

CEPHALEXIN - cephalexin cap 750

•

CEPHALEXIN - cephalexin tab 250

mg, 500 mg

cephalexin cap 250 mg, 500 mg

cephalexin for susp 125 mg/5ml,

250 mg/5ml

SUPRAX - cefixime cap 400 mg

SUPRAX - cefixime chew tab 100

mg, 200 mg

SUPRAX - cefixime for susp 200

mg/5ml, 500 mg/5ml

MACROLIDES

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 2

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

AZITHROMYCIN - azithromycin

powd pack for susp 1 gm

•

azithromycin for susp

100 mg/5ml, 200 mg/5ml

(Zithromax)

azithromycin tab 250 mg, 500 mg

(Zithromax)

•

azithromycin tab 600 mg

•

CLARITHROMYCIN - clarithromycin

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

clarithromycin tab er 24hr 500 mg

•

clarithromycin tab 250 mg,

500 mg

•

DIFICID - fidaxomicin for susp 40

mg/ml

• •

DIFICID - fidaxomicin tab 200 mg

•

E.E.S. GRANULES - erythromycin

ethylsuccinate for susp 200

mg/5ml

ERYPED 200 - erythromycin

ethylsuccinate for susp 200

mg/5ml

ERYPED 400 - erythromycin

ethylsuccinate for susp 400

mg/5ml

ERYTHROCIN STEARATE -

erythromycin stearate tab 250 mg

ERYTHROMYCIN - erythromycin w/

delayed release particles cap 250

ERYTHROMYCIN

ETHYLSUCCINA - erythromycin

ethylsuccinate tab 400 mg

erythromycin ethylsuccinate

for susp 200 mg/5ml (E.e.s.

granules)

erythromycin ethylsuccinate for

susp 400 mg/5ml (Eryped 400)

erythromycin tab delayed release

250 mg, 333 mg, 500 mg

erythromycin tab 250 mg, 500 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ZITHROMAX - azithromycin for susp

100 mg/5ml, 200 mg/5ml

ZITHROMAX - azithromycin powd

pack for susp 1 gm

•

ZITHROMAX - azithromycin tab 250

mg, 500 mg

ZITHROMAX TRI-PAK -

azithromycin tab 500 mg

ZITHROMAX Z-PAK - azithromycin

tab 250 mg

TETRACYCLINES

ACTICLATE - doxycycline hyclate

tab 75 mg, 150 mg

demeclocycline hcl tab 150 mg,

300 mg

•

DORYX - doxycycline hyclate tab

delayed release 50 mg, 80 mg,

200 mg

DORYX MPC - doxycycline hyclate

tab delayed release 60 mg, 120

doxycycline hyclate cap 50 mg

doxycycline hyclate cap 100 mg

(Vibramycin)

•

DOXYCYCLINE HYCLATE DR -

doxycycline hyclate tab delayed

release 80 mg

doxycycline hyclate tab delayed

release 50 mg, 200 mg (Doryx)

doxycycline hyclate tab delayed

release 75 mg, 100 mg, 150 mg

doxycycline hyclate tab 20 mg,

100 mg

doxycycline hyclate tab 50 mg

doxycycline hyclate tab 75 mg,

150 mg (Acticlate)

doxycycline monohydrate cap

50 mg, 100 mg

doxycycline monohydrate cap

75 mg, 150 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 3

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

doxycycline monohydrate cap

150 mg

•

doxycycline monohydrate for

susp 25 mg/5ml (Vibramycin)

doxycycline monohydrate tab

50 mg, 75 mg, 100 mg, 150 mg

•

minocycline hcl cap 50 mg,

75 mg, 100 mg

minocycline hcl tab er 24hr

45 mg, 90 mg, 135 mg

minocycline hcl tab er 24hr

55 mg, 65 mg, 80 mg, 105 mg,

115 mg (Solodyn)

minocycline hcl tab 50 mg, 75 mg,

100 mg

MINOCYCLINE

HYDROCHLORIDE - minocycline

hcl cap er 24hr 45 mg (base

equivalent), 90 mg (base

equivalent), 135 mg (base

equivalent)

MINOLIRA - minocycline hcl tab er

24hr biphasic release 105 mg, 135

NUZYRA - omadacycline tosylate

tab 150 mg (base equivalent)

• • •

SEYSARA - sarecycline hcl tab 60

mg (base equivalent), 100 mg

(base equivalent), 150 mg (base

equivalent)

SOLODYN - minocycline hcl tab er

24hr 55 mg, 65 mg, 80 mg, 105

mg, 115 mg

tetracycline hcl cap 250 mg,

500 mg

•

VIBRAMYCIN - doxycycline calcium

syrup 50 mg/5ml

VIBRAMYCIN - doxycycline hyclate

cap 100 mg

VIBRAMYCIN - doxycycline

monohydrate for susp 25 mg/5ml

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

XIMINO - minocycline hcl cap er

24hr 45 mg (base equivalent),

90 mg (base equivalent), 135 mg

(base equivalent)

FLUOROQUINOLONES

BAXDELA - delafloxacin meglumine

tab 450 mg (base equiv)

•

CIPRO - ciprofloxacin for oral susp

250 mg/5ml (5%) (5 gm/100ml),

500 mg/5ml (10%) (10 gm/100ml)

CIPRO - ciprofloxacin hcl tab 250 mg

(base equiv), 500 mg (base equiv)

CIPROFLOXACIN HCL -

ciprofloxacin hcl tab 100 mg (base

equiv)

ciprofloxacin hcl tab 250 mg

(base equiv), 500 mg (base

equiv) (Cipro)

ciprofloxacin hcl tab 750 mg

(base equiv)

levofloxacin oral soln 25 mg/ml

levofloxacin tab 250 mg, 500 mg,

750 mg

•

moxifloxacin hcl tab 400 mg (base

equiv)

•

OFLOXACIN - ofloxacin tab 300 mg

ofloxacin tab 400 mg

AMINOGLYCOSIDES

ARIKAYCE - amikacin sulfate

liposome inhal susp 590 mg/8.4ml

(base eq)

• • • •

BETHKIS - tobramycin nebu soln

300 mg/4ml

HUMATIN - paromomycin sulfate cap

250 mg

KITABIS PAK - tobramycin nebu soln

300 mg/5ml

• • • •

neomycin sulfate tab 500 mg

paromomycin sulfate cap 250 mg

(Humatin)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 4

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

TOBI - tobramycin nebu soln 300

mg/5ml

TOBI PODHALER - tobramycin inhal

cap 28 mg

• • • •

TOBRAMYCIN - tobramycin nebu

soln 300 mg/5ml

• • • •

tobramycin nebu soln 300 mg/5ml

(Tobi)

• • • •

tobramycin nebu soln 300 mg/4ml

(Bethkis)

• • • •

SULFONAMIDES

SULFADIAZINE - sulfadiazine tab

500 mg

ANTIMYCOBACTERIAL AGENTS

CYCLOSERINE - cycloserine cap

250 mg

ethambutol hcl tab 100 mg

ethambutol hcl tab 400 mg

(Myambutol)

ISONIAZID - isoniazid syrup 50

mg/5ml

ISONIAZID - isoniazid tab 100 mg

isoniazid tab 300 mg

MYAMBUTOL - ethambutol hcl tab

400 mg

MYCOBUTIN - rifabutin cap 150 mg

PASER - aminosalicylic acid er

granules packet 4 gm

PRETOMANID - pretomanid tab 200

•

PRIFTIN - rifapentine tab 150 mg

•

pyrazinamide tab 500 mg

rifabutin cap 150 mg (Mycobutin)

rifampin cap 150 mg, 300 mg

SIRTURO - bedaquiline fumarate tab

20 mg (base equiv), 100 mg (base

equiv)

• • •

TRECATOR - ethionamide tab 250

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ANTIFUNGALS

ANCOBON - flucytosine cap 250 mg,

500 mg

BREXAFEMME - ibrexafungerp

citrate tab 150 mg

CRESEMBA - isavuconazonium

sulfate cap 186 mg

(isavuconazole 100 mg)

•

DIFLUCAN - fluconazole for susp 10

mg/ml, 40 mg/ml

DIFLUCAN - fluconazole tab 50 mg,

100 mg, 150 mg, 200 mg

fluconazole for susp 10 mg/ml,

40 mg/ml (Diflucan)

fluconazole tab 50 mg, 100 mg,

150 mg, 200 mg (Diflucan)

flucytosine cap 250 mg, 500 mg

(Ancobon)

griseofulvin microsize susp

125 mg/5ml

griseofulvin microsize tab 500 mg

griseofulvin ultramicrosize tab

125 mg, 250 mg

itraconazole cap 100 mg

(Sporanox)

• •

itraconazole oral soln 10 mg/ml

(Sporanox)

• •

ketoconazole tab 200 mg

NOXAFIL - posaconazole susp 40

mg/ml

• •

NOXAFIL - posaconazole tab

delayed release 100 mg

nystatin tab 500000 unit

posaconazole tab delayed release

100 mg (Noxafil)

• •

SPORANOX - itraconazole cap 100

SPORANOX - itraconazole oral soln

10 mg/ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 5

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SPORANOX PULSEPAK -

itraconazole cap 100 mg

terbinafine hcl tab 250 mg

•

TOLSURA - itraconazole cap 65 mg

VFEND - voriconazole for susp 40

mg/ml

VFEND - voriconazole tab 50 mg,

200 mg

VIVJOA - oteseconazole cap therapy

pack 150 mg (12 weeks)

voriconazole for susp 40 mg/ml

(Vfend)

•

voriconazole tab 50 mg, 200 mg

(Vfend)

•

ANTIVIRALS

abacavir sulfate soln 20 mg/ml

(base equiv) (Ziagen)

•

abacavir sulfate tab 300 mg (base

equiv) (Ziagen)

•

abacavir sulfate-lamivudine tab

600-300 mg (Epzicom)

•

acyclovir cap 200 mg

acyclovir susp 200 mg/5ml

(Zovirax)

acyclovir tab 400 mg, 800 mg

adefovir dipivoxil tab 10 mg

(Hepsera)

APTIVUS - tipranavir cap 250 mg

•

atazanavir sulfate cap 150 mg

(base equiv)

•

atazanavir sulfate cap 200 mg

(base equiv), 300 mg (base

equiv) (Reyataz)

•

BARACLUDE - entecavir oral soln

0.05 mg/ml

BARACLUDE - entecavir tab 0.5 mg,

1 mg

BIKTARVY - bictegravir-

emtricitabine-tenofovir af tab

30-120-15 mg, 50-200-25 mg

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CIMDUO - lamivudine-tenofovir

disoproxil fumarate tab 300-300

•

COMBIVIR - lamivudine-zidovudine

tab 150-300 mg

COMPLERA - emtricitabine-

rilpivirine-tenofovir df tab

200-25-300 mg

•

DELSTRIGO - doravirine-

lamivudine-tenofovir df tab

100-300-300 mg

•

DOVATO - dolutegravir sodium-

lamivudine tab 50-300 mg (base

eq)

•

EDURANT - rilpivirine hcl tab 25 mg

(base equivalent)

•

efavirenz cap 50 mg, 200 mg

(Sustiva)

•

efavirenz tab 600 mg (Sustiva)

•

efavirenz-emtricitabine-tenofovir

df tab 600-200-300 mg

•

efavirenz-lamivudine-tenofovir df

tab 400-300-300 mg (Symfi lo)

•

efavirenz-lamivudine-tenofovir df

tab 600-300-300 mg (Symfi)

•

emtricitabine caps 200 mg

(Emtriva)

•

emtricitabine-tenofovir disoproxil

fumarate tab 100-150 mg,

133-200 mg, 167-250 mg

(Truvada)

•

emtricitabine-tenofovir disoproxil

fumarate tab 200-300 mg

(Truvada)

• •

EMTRIVA - emtricitabine caps 200

EMTRIVA - emtricitabine soln 10 mg/

•

entecavir tab 0.5 mg, 1 mg

(Baraclude)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 6

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

EPCLUSA - sofosbuvir-velpatasvir

pellet pack 150-37.5 mg, 200-50

• • • •

EPCLUSA - sofosbuvir-velpatasvir

tab 200-50 mg

• • • •

EPCLUSA - sofosbuvir-velpatasvir

tab 400-100 mg

EPIVIR - lamivudine oral soln 10 mg/

EPIVIR - lamivudine tab 150 mg, 300

EPIVIR HBV - lamivudine oral soln 5

mg/ml (hbv)

EPIVIR HBV - lamivudine tab 100

mg (hbv)

EPZICOM - abacavir sulfate-

lamivudine tab 600-300 mg

etravirine tab 100 mg, 200 mg

(Intelence)

•

EVOTAZ - atazanavir sulfate-

cobicistat tab 300-150 mg (base

equiv)

•

famciclovir tab 125 mg, 250 mg,

500 mg

fosamprenavir calcium tab

700 mg (base equiv) (Lexiva)

•

FUZEON - enfuvirtide for inj 90 mg

• • •

GENVOYA - elvitegrav-cobic-

emtricitab-tenofov af tab

150-150-200-10 mg

•

HARVONI - ledipasvir-sofosbuvir

pellet pack 33.75-150 mg, 45-200

• • • •

HARVONI - ledipasvir-sofosbuvir tab

45-200 mg

• • • •

HARVONI - ledipasvir-sofosbuvir tab

90-400 mg

HEPSERA - adefovir dipivoxil tab 10

INTELENCE - etravirine tab 25 mg

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

INTELENCE - etravirine tab 100 mg,

200 mg

ISENTRESS - raltegravir potassium

chew tab 25 mg (base equiv), 100

mg (base equiv)

•

ISENTRESS - raltegravir potassium

packet for susp 100 mg (base

equiv)

•

ISENTRESS - raltegravir potassium

tab 400 mg (base equiv)

•

ISENTRESS HD - raltegravir

potassium tab 600 mg (base

equiv)

•

JULUCA - dolutegravir sodium-

rilpivirine hcl tab 50-25 mg (base

eq)

•

KALETRA - lopinavir-ritonavir soln

400-100 mg/5ml (80-20 mg/ml)

KALETRA - lopinavir-ritonavir tab

100-25 mg, 200-50 mg

lamivudine oral soln 10 mg/ml

(Epivir)

•

lamivudine tab 100 mg (hbv)

(Epivir hbv)

lamivudine tab 150 mg, 300 mg

(Epivir)

•

lamivudine-zidovudine tab

150-300 mg (Combivir)

•

LEDIPASVIR/SOFOSBUVIR -

ledipasvir-sofosbuvir tab 90-400

• • • •

LEXIVA - fosamprenavir calcium

susp 50 mg/ml (base equiv)

•

LEXIVA - fosamprenavir calcium tab

700 mg (base equiv)

LIVTENCITY - maribavir tab 200 mg

• • • •

lopinavir-ritonavir soln

400-100 mg/5ml (80-20 mg/ml)

(Kaletra)

•

lopinavir-ritonavir tab 100-25 mg,

200-50 mg (Kaletra)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 7

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

maraviroc tab 150 mg, 300 mg

(Selzentry)

•

MAVYRET - glecaprevir-pibrentasvir

pellet pack 50-20 mg

• • • •

MAVYRET - glecaprevir-pibrentasvir

tab 100-40 mg

• • • •

NEVIRAPINE - nevirapine susp 50

mg/5ml

•

NEVIRAPINE ER - nevirapine tab er

24hr 100 mg

•

nevirapine tab er 24hr 400 mg

•

nevirapine tab 200 mg

•

NORVIR - ritonavir oral soln 80 mg/

•

NORVIR - ritonavir powder packet

100 mg

•

NORVIR - ritonavir tab 100 mg

ODEFSEY - emtricitabine-rilpivirine-

tenofovir af tab 200-25-25 mg

•

oseltamivir phosphate cap 30 mg

(base equiv), 45 mg (base

equiv), 75 mg (base equiv)

(Tamiflu)

•

oseltamivir phosphate for susp

6 mg/ml (base equiv) (Tamiflu)

•

PEGASYS - peginterferon alfa-2a inj

180 mcg/ml

• • • •

PEGASYS - peginterferon alfa-2a

soln prefilled syr 180 mcg/0.5ml

• • • •

PIFELTRO - doravirine tab 100 mg

PREVYMIS - letermovir tab 240 mg,

480 mg

•

PREZCOBIX - darunavir-cobicistat

tab 800-150 mg

•

PREZISTA - darunavir oral susp 100

mg/ml

•

PREZISTA - darunavir tab 75 mg,

150 mg, 600 mg, 800 mg

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

RELENZA DISKHALER - zanamivir

aero powder breath activated 5

mg/blister

•

RETROVIR - zidovudine cap 100 mg

RETROVIR - zidovudine syrup 10

mg/ml

REYATAZ - atazanavir sulfate cap

200 mg (base equiv), 300 mg

(base equiv)

REYATAZ - atazanavir sulfate oral

powder packet 50 mg (base equiv)

•

ribavirin cap 200 mg

• • •

ribavirin tab 200 mg

• • •

RIMANTADINE HYDROCHLORIDE -

rimantadine hydrochloride tab 100

ritonavir tab 100 mg (Norvir)

•

RUKOBIA - fostemsavir

tromethamine tab er 12hr 600 mg

•

SELZENTRY - maraviroc oral soln

20 mg/ml

•

SELZENTRY - maraviroc tab 25 mg,

75 mg

•

SELZENTRY - maraviroc tab 150

mg, 300 mg

SITAVIG - acyclovir buccal tab 50 mg

SOFOSBUVIR/VELPATASVIR -

sofosbuvir-velpatasvir tab 400-100

• • • •

SOVALDI - sofosbuvir pellet pack

150 mg, 200 mg

• • • •

SOVALDI - sofosbuvir tab 200 mg,

400 mg

• • • •

STAVUDINE - stavudine cap 15 mg,

20 mg, 30 mg, 40 mg

• •

STRIBILD - elvitegrav-cobic-

emtricitab-tenofovdf tab

150-150-200-300 mg

•

SUSTIVA - efavirenz cap 50 mg, 200

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 8

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SUSTIVA - efavirenz tab 600 mg

SYMFI - efavirenz-lamivudine-

tenofovir df tab 600-300-300 mg

SYMFI LO - efavirenz-lamivudine-

tenofovir df tab 400-300-300 mg

SYMTUZA - darunavir-cobic-

emtricitab-tenofov af tab

800-150-200-10 mg

•

TAMIFLU - oseltamivir phosphate

cap 30 mg (base equiv), 45 mg

(base equiv), 75 mg (base equiv)

TAMIFLU - oseltamivir phosphate for

susp 6 mg/ml (base equiv)

tenofovir disoproxil fumarate tab

300 mg (Viread)

•

TIVICAY - dolutegravir sodium tab

10 mg (base equiv), 25 mg (base

equiv), 50 mg (base equiv)

•

TIVICAY PD - dolutegravir sodium

tab for oral susp 5 mg (base

equiv)

•

TRIUMEQ - abacavir-dolutegravir-

lamivudine tab 600-50-300 mg

•

TRIUMEQ PD - abacavir-

dolutegravir-lamivudine tab for

oral sus 60-5-30 mg

•

TRUVADA - emtricitabine-tenofovir

disoproxil fumarate tab 100-150

mg, 133-200 mg, 167-250 mg,

200-300 mg

TYBOST - cobicistat tab 150 mg

•

valacyclovir hcl tab 500 mg, 1 gm

(Valtrex)

VALCYTE - valganciclovir hcl for soln

50 mg/ml (base equiv)

VALCYTE - valganciclovir hcl tab

450 mg (base equivalent)

valganciclovir hcl for soln 50 mg/

ml (base equiv) (Valcyte)

valganciclovir hcl tab 450 mg

(base equivalent) (Valcyte)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VALTREX - valacyclovir hcl tab 500

mg, 1 gm

VEMLIDY - tenofovir alafenamide

fumarate tab 25 mg

VIEKIRA PAK - ombitas-paritapre-

riton & dasab tab pak 12.5-75-50

& 250 mg

• • • •

VIRACEPT - nelfinavir mesylate tab

250 mg, 625 mg

•

VIRAZOLE - ribavirin for inhal soln 6

VIREAD - tenofovir disoproxil

fumarate oral powder 40 mg/gm

•

VIREAD - tenofovir disoproxil

fumarate tab 150 mg, 200 mg, 250

•

VIREAD - tenofovir disoproxil

fumarate tab 300 mg

VOSEVI - sofosbuvir-velpatasvir-

voxilaprevir tab 400-100-100 mg

• • • •

XOFLUZA - baloxavir marboxil tab

therapy pack 1 x 40 mg (40 mg

dose), 1 x 80 mg (80 mg dose)

•

ZEPATIER - elbasvir-grazoprevir tab

50-100 mg

ZIAGEN - abacavir sulfate soln 20

mg/ml (base equiv)

ZIAGEN - abacavir sulfate tab 300

mg (base equiv)

zidovudine cap 100 mg (Retrovir)

•

zidovudine syrup 10 mg/ml

(Retrovir)

•

zidovudine tab 300 mg

•

ZOVIRAX - acyclovir susp 200

mg/5ml

ANTIMALARIALS

ARAKODA - tafenoquine succinate

tab 100 mg (base equivalent)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 9

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

atovaquone-proguanil hcl

tab 62.5-25 mg, 250-100 mg

(Malarone)

CHLOROQUINE PHOSPHATE -

chloroquine phosphate tab 500

chloroquine phosphate tab

250 mg

COARTEM - artemether-

lumefantrine tab 20-120 mg

DARAPRIM - pyrimethamine tab 25

HYDROXYCHLOROQUINE

SULFAT - hydroxychloroquine

sulfate tab 100 mg, 300 mg, 400

hydroxychloroquine sulfate tab

200 mg (Plaquenil)

•

KRINTAFEL - tafenoquine succinate

tab 150 mg (base equivalent)

•

MALARONE - atovaquone-proguanil

hcl tab 62.5-25 mg, 250-100 mg

mefloquine hcl tab 250 mg

PLAQUENIL - hydroxychloroquine

sulfate tab 200 mg

PRIMAQUINE PHOSPHATE -

primaquine phosphate tab 26.3

mg (15 mg base)

primaquine phosphate tab

26.3 mg (15 mg base)

(Primaquine phosphate)

pyrimethamine tab 25 mg

(Daraprim)

• •

QUALAQUIN - quinine sulfate cap

324 mg

quinine sulfate cap 324 mg

(Qualaquin)

SOLOSEC - secnidazole granules

packet 2 gm

ANTHELMINTICS

albendazole tab 200 mg

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

BENZNIDAZOLE - benznidazole tab

12.5 mg, 100 mg

•

BILTRICIDE - praziquantel tab 600

EMVERM - mebendazole chew tab

100 mg

•

ivermectin tab 3 mg (Stromectol)

•

praziquantel tab 600 mg (Biltricide)

STROMECTOL - ivermectin tab 3

ANTI-INFECTIVE AGENTS - MISC.

AEMCOLO - rifamycin sodium tab

delayed release 194 mg (base

equiv)

ALINIA - nitazoxanide for susp 100

mg/5ml

•

ALINIA - nitazoxanide tab 500 mg

atovaquone susp 750 mg/5ml

(Mepron)

•

BACTRIM - sulfamethoxazole-

trimethoprim tab 400-80 mg

BACTRIM DS - sulfamethoxazole-

trimethoprim tab 800-160 mg

CAYSTON - aztreonam lysine for

inhal soln 75 mg (base equivalent)

• • • •

CLEOCIN - clindamycin hcl cap 75

mg, 150 mg, 300 mg

CLEOCIN PEDIATRIC GRANULE -

clindamycin palmitate hcl for soln

75 mg/5ml (base equiv)

clindamycin hcl cap 75 mg,

150 mg, 300 mg (Cleocin)

clindamycin palmitate hcl for soln

75 mg/5ml (base equiv) (Cleocin

pediatric gr)

dapsone tab 25 mg, 100 mg

FIRVANQ - vancomycin hcl for oral

soln 25 mg/ml (base equivalent),

50 mg/ml (base equivalent)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 10

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

FLAGYL - metronidazole cap 375

fosfomycin tromethamine powd

pack 3 gm (base equivalent)

(Monurol)

HIPREX - methenamine hippurate

tab 1 gm

IMPAVIDO - miltefosine cap 50 mg

LAMPIT - nifurtimox tab 30 mg, 120

•

linezolid tab 600 mg (Zyvox)

MACROBID - nitrofurantoin

monohydrate macrocrystalline cap

100 mg

MACRODANTIN - nitrofurantoin

macrocrystalline cap 25 mg, 50

mg, 100 mg

MEPRON - atovaquone susp 750

mg/5ml

methenamine hippurate tab 1 gm

(Hiprex)

metronidazole cap 375 mg (Flagyl)

metronidazole tab 250 mg,

500 mg

MONUROL - fosfomycin

tromethamine powd pack 3 gm

(base equivalent)

NEBUPENT - pentamidine

isethionate for nebulization soln

300 mg

nitazoxanide tab 500 mg (Alinia)

•

nitrofurantoin macrocrystalline

cap 25 mg, 50 mg, 100 mg

(Macrodantin)

nitrofurantoin monohydrate

macrocrystalline cap 100 mg

(Macrobid)

pentamidine isethionate for

nebulization soln 300 mg

(Nebupent)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SIVEXTRO - tedizolid phosphate tab

200 mg

•

sulfamethoxazole-trimethoprim

susp 200-40 mg/5ml

sulfamethoxazole-trimethoprim

tab 400-80 mg (Bactrim)

sulfamethoxazole-trimethoprim

tab 800-160 mg (Bactrim ds)

tinidazole tab 250 mg, 500 mg

• •

TRIMETHOPRIM - trimethoprim tab

100 mg

VANCOCIN - vancomycin hcl cap

125 mg (base equivalent), 250 mg

(base equivalent)

vancomycin hcl cap 125 mg

(base equivalent), 250 mg (base

equivalent) (Vancocin)

VANCOMYCIN HYDROCHLORIDE -

vancomycin hcl for oral soln 50

mg/ml (base equivalent)

XIFAXAN - rifaximin tab 200 mg

• •

XIFAXAN - rifaximin tab 550 mg

• •

ZYVOX - linezolid for susp 100

mg/5ml

ZYVOX - linezolid tab 600 mg

BIOLOGICALS

VACCINES

COMIRNATY - covid-19 mrna vac

tris-sucrose-pfizer im susp 30

mcg/0.3ml

JANSSEN COVID-19 VACCINE -

covid-19 (sars-cov-2) ad26 vector

vaccine-janssen im 0.5 ml

MODERNA COVID-19 VACCINE -

covid-19 mrna vaccine 6mo-5y-

moderna im susp 25 mcg/0.25ml

MODERNA COVID-19 VACCINE -

covid-19 (sars-cov-2)mrna vacc-

moderna im susp 50 mcg/0.5ml,

100 mcg/0.5ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 11

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MODERNA COVID-19 VACCINE/ -

covid-19 mrna bivalent vaccine-

moderna im susp 50 mcg/0.5ml

NOVAVAX COVID-19 VACCINE -

covid-19 subunit prot recom adjuv

vac-novavax im 5 mcg/0.5ml

PFIZER-BIONTECH COVID-19 -

covid-19 (sars-cov-2) mrna vacc-

pfizer im susp 30 mcg/0.3ml

PFIZER-BIONTECH COVID-19 -

covid-19 mrna vac tris-sucrose-

pfizer im susp 30 mcg/0.3ml

PFIZER-BIONTECH COVID-19 -

covid-19 mrna vac tris-s 5-11y-

pfizer im susp 10 mcg/0.2ml

PFIZER-BIONTECH COVID-19 -

covid-19 mrna vac tris-s 6mo-4y-

pfizer im susp 3 mcg/0.2ml

PFIZER-BIONTECH COVID-19 -

covid-19 mrna bivalent vaccine-

pfizer im susp 30 mcg/0.3ml

SPIKEVAX COVID-19 VACCINE -

covid-19 (sars-cov-2)mrna vacc-

moderna im susp 100 mcg/0.5ml

VIVOTIF - typhoid vaccine cap

delayed release

BIOLOGICALS MISC

GRASTEK - timothy grass pollen

allergen ext sl tab 2800 bau

• •

ODACTRA - dust mite mixed ext sl

tab 12 sq-hdm

• •

RAGWITEK - short ragweed pollen

allergen extract sl tab 12 amb a 1-

• •

ANTINEOPLASTIC AGENTS

ANTINEOPLASTICS

abiraterone acetate tab 250 mg,

500 mg (Zytiga)

• • • •

ACTIMMUNE - interferon gamma-1b

inj 100 mcg/0.5ml (2000000

unit/0.5ml)

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

AFINITOR - everolimus tab 2.5 mg, 5

mg, 7.5 mg, 10 mg

AFINITOR DISPERZ - everolimus

tab for oral susp 2 mg, 3 mg, 5 mg

ALECENSA - alectinib hcl cap 150

mg (base equivalent)

• • • •

ALKERAN - melphalan tab 2 mg

ALUNBRIG - brigatinib tab initiation

therapy pack 90 mg & 180 mg

• • • •

ALUNBRIG - brigatinib tab 30 mg, 90

mg, 180 mg

• • • •

anastrozole tab 1 mg (Arimidex)

• • •

ARIMIDEX - anastrozole tab 1 mg

AROMASIN - exemestane tab 25 mg

AYVAKIT - avapritinib tab 25 mg, 50

mg, 100 mg, 200 mg, 300 mg

• • • •

BALVERSA - erdafitinib tab 3 mg, 4

mg, 5 mg

• • • •

BESREMI - ropeginterferon alfa-2b-

njft soln prefilled syr 500 mcg/ml

• • • •

bexarotene cap 75 mg (Targretin)

• • •

bicalutamide tab 50 mg (Casodex)

BOSULIF - bosutinib tab 100 mg,

400 mg, 500 mg

• • • •

BRAFTOVI - encorafenib cap 75 mg

• • • •

BRUKINSA - zanubrutinib cap 80 mg

• • • •

CABOMETYX - cabozantinib

s-malate tab 20 mg (base

equivalent), 40 mg (base

equivalent), 60 mg (base

equivalent)

• • • •

CALQUENCE - acalabrutinib cap

100 mg

• • • •

CALQUENCE - acalabrutinib

maleate tab 100 mg

CAMCEVI - leuprolide mesylate (6

month) emulsion prefilled syr 42

capecitabine tab 150 mg, 500 mg

(Xeloda)

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 12

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CAPRELSA - vandetanib tab 100

mg, 300 mg

• • • •

CASODEX - bicalutamide tab 50 mg

COMETRIQ - cabozantinib s-mal

cap 1 x 80 mg & 1 x 20 mg (100

dose) kit

• • • •

COMETRIQ - cabozantinib s-mal

cap 1 x 80 mg & 3 x 20 mg (140

dose) kit

• • • •

COMETRIQ - cabozantinib s-malate

cap 3 x 20 mg (60 mg dose) kit

• • • •

COPIKTRA - duvelisib cap 15 mg, 25

• • • •

COTELLIC - cobimetinib fumarate

tab 20 mg (base equivalent)

• • • •

CYCLOPHOSPHAMIDE -

cyclophosphamide cap 25 mg, 50

CYCLOPHOSPHAMIDE -

cyclophosphamide tab 25 mg, 50

cyclophosphamide cap 25 mg,

50 mg (Cyclophosphamide)

DAURISMO - glasdegib maleate tab

25 mg (base equivalent), 100 mg

(base equivalent)

• • • •

ELIGARD - leuprolide acetate (3

month) for subcutaneous inj kit

22.5mg

• • •

ELIGARD - leuprolide acetate (4

month) for subcutaneous inj kit 30

• • •

ELIGARD - leuprolide acetate (6

month) for subcutaneous inj kit 45

• • •

ELIGARD - leuprolide acetate for

subcutaneous inj kit 7.5 mg

• • •

EMCYT - estramustine phosphate

sodium cap 140 mg

ERIVEDGE - vismodegib cap 150

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ERLEADA - apalutamide tab 60 mg

• • • •

erlotinib hcl tab 25 mg (base

equivalent), 100 mg (base

equivalent), 150 mg (base

equivalent) (Tarceva)

• • • •

ETOPOSIDE - etoposide cap 50 mg

• • •

EULEXIN - flutamide cap 125 mg

everolimus tab for oral susp

2 mg, 3 mg, 5 mg (Afinitor

disperz)

• • • •

everolimus tab 2.5 mg, 5 mg,

7.5 mg, 10 mg (Afinitor)

• • • •

exemestane tab 25 mg (Aromasin)

• •

EXKIVITY - mobocertinib succinate

cap 40 mg

• • • •

FARESTON - toremifene citrate tab

60 mg (base equivalent)

FEMARA - letrozole tab 2.5 mg

FLUTAMIDE - flutamide cap 125 mg

• •

FOTIVDA - tivozanib hcl cap 0.89 mg

(base equivalent), 1.34 mg (base

equivalent)

• • • •

GAVRETO - pralsetinib cap 100 mg

• • • •

GILOTRIF - afatinib dimaleate tab

20 mg (base equivalent), 30 mg

(base equivalent), 40 mg (base

equivalent)

• • • •

GLEEVEC - imatinib mesylate tab

100 mg (base equivalent), 400 mg

(base equivalent)

GLEOSTINE - lomustine cap 10 mg,

40 mg, 100 mg

HYCAMTIN - topotecan hcl cap

0.25 mg (base equiv), 1 mg (base

equiv)

• • •

HYDREA - hydroxyurea cap 500 mg

hydroxyurea cap 500 mg (Hydrea)

IBRANCE - palbociclib cap 75 mg,

100 mg, 125 mg

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 13

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

IBRANCE - palbociclib tab 75 mg,

100 mg, 125 mg

• • • •

ICLUSIG - ponatinib hcl tab 10 mg

(base equiv), 15 mg (base equiv),

30 mg (base equiv), 45 mg (base

equiv)

• • • •

IDHIFA - enasidenib mesylate tab

50 mg (base equivalent), 100 mg

(base equivalent)

• • • •

imatinib mesylate tab 100 mg

(base equivalent), 400 mg (base

equivalent) (Gleevec)

• • • •

IMBRUVICA - ibrutinib cap 70 mg,

140 mg

• • • •

IMBRUVICA - ibrutinib tab 140 mg,

280 mg, 420 mg, 560 mg

• • • •

INLYTA - axitinib tab 1 mg, 5 mg

• • • •

INQOVI - decitabine-cedazuridine

tab 35-100 mg

• • • •

INREBIC - fedratinib hcl cap 100 mg

• • • •

INTRON A - interferon alfa-2b for inj

10000000 unit, 50000000 unit

• • •

IRESSA - gefitinib tab 250 mg

• • • •

JAKAFI - ruxolitinib phosphate

tab 5 mg (base equivalent),

10 mg (base equivalent), 15

mg (base equivalent), 20 mg

(base equivalent), 25 mg (base

equivalent)

• • • •

KISQALI - ribociclib succinate tab

pack 200 mg daily dose, 400 mg

daily dose (200 mg tab), 600 mg

daily dose (200 mg tab)

• • • •

KISQALI FEMARA 200 DOSE -

ribociclib 200 mg dose (200 mg

tab) & letrozole 2.5 mg tbpk

• • • •

KISQALI FEMARA 400 DOSE -

ribociclib 400 mg dose (200 mg

tab) & letrozole 2.5 mg tbpk

• • • •

KISQALI FEMARA 600 DOSE -

ribociclib 600 mg dose (200 mg

tab) & letrozole 2.5 mg tbpk

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

KOSELUGO - selumetinib sulfate

cap 10 mg, 25 mg

• • • •

lapatinib ditosylate tab 250 mg

(base equiv) (Tykerb)

• • • •

LENVIMA 10 MG DAILY DOSE -

lenvatinib cap therapy pack 10 mg

(10 mg daily dose)

• • • •

LENVIMA 12MG DAILY DOSE -

lenvatinib cap therapy pack 3 x 4

mg (12 mg daily dose)

• • • •

LENVIMA 14 MG DAILY DOSE -

lenvatinib cap therapy pack 10 & 4

mg (14 mg daily dose)

• • • •

LENVIMA 18 MG DAILY DOSE -

lenvatinib cap ther pack 10 mg & 2

x 4 mg (18 mg daily dose)

• • • •

LENVIMA 20 MG DAILY DOSE -

lenvatinib cap therapy pack 2 x 10

mg (20 mg daily dose)

• • • •

LENVIMA 24 MG DAILY DOSE -

lenvatinib cap ther pack 2 x 10 mg

& 4 mg (24 mg daily dose)

• • • •

LENVIMA 4 MG DAILY DOSE -

lenvatinib cap therapy pack 4 mg

(4 mg daily dose)

• • • •

LENVIMA 8 MG DAILY DOSE -

lenvatinib cap therapy pack 2 x 4

mg (8 mg daily dose)

• • • •

letrozole tab 2.5 mg (Femara)

• •

leucovorin calcium tab 5 mg,

10 mg, 15 mg, 25 mg

LEUKERAN - chlorambucil tab 2 mg

leuprolide acetate inj kit 5 mg/ml

• • •

LONSURF - trifluridine-tipiracil tab

15-6.14 mg, 20-8.19 mg

• • • •

LORBRENA - lorlatinib tab 25 mg,

100 mg

• • • •

LUMAKRAS - sotorasib tab 120 mg

• • • •

LUPRON DEPOT (1-MONTH) -

leuprolide acetate for inj kit 3.75

mg, 7.5 mg

• • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 14

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

LUPRON DEPOT (3-MONTH) -

leuprolide acetate (3 month) for inj

kit 11.25 mg, 22.5 mg

• • •

LUPRON DEPOT (4-MONTH) -

leuprolide acetate (4 month) for inj

kit 30 mg

• • •

LUPRON DEPOT (6-MONTH) -

leuprolide acetate (6 month) for inj

kit 45 mg

• • •

LYNPARZA - olaparib tab 100 mg,

150 mg

• • • •

LYSODREN - mitotane tab 500 mg

• • •

MATULANE - procarbazine hcl cap

50 mg

• • •

megestrol acetate susp 40 mg/ml

megestrol acetate tab 20 mg,

40 mg

MEKINIST - trametinib dimethyl

sulfoxide tab 0.5 mg (base

equivalent), 2 mg (base

equivalent)

• • • •

MEKTOVI - binimetinib tab 15 mg

• • • •

melphalan tab 2 mg (Alkeran)

mercaptopurine tab 50 mg

MESNEX - mesna tab 400 mg

METHOTREXATE SODIUM -

methotrexate sodium inj 250

mg/10ml (25 mg/ml)

methotrexate sodium inj

pf 50 mg/2ml (25 mg/ml),

250 mg/10ml (25 mg/ml),

1000 mg/40ml (25 mg/ml)

methotrexate sodium inj

50 mg/2ml (25 mg/ml)

methotrexate sodium tab 2.5 mg

(base equiv)

MYLERAN - busulfan tab 2 mg

NERLYNX - neratinib maleate tab 40

mg (base equivalent)

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NEXAVAR - sorafenib tosylate tab

200 mg (base equivalent)

• • • •

NILANDRON - nilutamide tab 150

nilutamide tab 150 mg (Nilandron)

NINLARO - ixazomib citrate cap

2.3 mg (base equivalent), 3 mg

(base equivalent), 4 mg (base

equivalent)

• • • •

NUBEQA - darolutamide tab 300 mg

• • • •

ODOMZO - sonidegib phosphate

cap 200 mg (base equivalent)

• • • •

ONUREG - azacitidine tab 200 mg,

300 mg

• • • •

ORGOVYX - relugolix tab 120 mg

• • • •

PEMAZYRE - pemigatinib tab 4.5

mg, 9 mg, 13.5 mg

• • • •

PIQRAY 200MG DAILY DOSE -

alpelisib tab therapy pack 200 mg

daily dose

• • • •

PIQRAY 250MG DAILY DOSE -

alpelisib tab pack 250 mg daily

dose (200 mg & 50 mg tabs)

• • • •

PIQRAY 300MG DAILY DOSE -

alpelisib tab pack 300 mg daily

dose (2x150 mg tab)

• • • •

POMALYST - pomalidomide cap 1

mg, 2 mg, 3 mg, 4 mg

• • • •

PURIXAN - mercaptopurine susp

2000 mg/100ml (20 mg/ml)

•

QINLOCK - ripretinib tab 50 mg

• • • •

RETEVMO - selpercatinib cap 40

mg, 80 mg

• • • •

ROZLYTREK - entrectinib cap 100

mg, 200 mg

• • • •

RUBRACA - rucaparib camsylate tab

200 mg (base equivalent), 250 mg

(base equivalent), 300 mg (base

equivalent)

• • • •

RYDAPT - midostaurin cap 25 mg

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 15

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SCEMBLIX - asciminib hcl tab 20

mg, 40 mg

• • • •

SOLTAMOX - tamoxifen citrate oral

soln 10 mg/5ml (base equivalent)

•

sorafenib tosylate tab 200 mg

(base equivalent) (Nexavar)

• • • •

SPRYCEL - dasatinib tab 20 mg, 50

mg, 70 mg, 80 mg, 100 mg, 140

• • • •

STIVARGA - regorafenib tab 40 mg

• • • •

sunitinib malate cap 12.5 mg

(base equivalent), 25 mg

(base equivalent), 37.5 mg

(base equivalent), 50 mg (base

equivalent) (Sutent)

• • • •

SUTENT - sunitinib malate cap

12.5 mg (base equivalent), 25

mg (base equivalent), 37.5 mg

(base equivalent), 50 mg (base

equivalent)

TABLOID - thioguanine tab 40 mg

TABRECTA - capmatinib hcl tab 150

mg, 200 mg

• • • •

TAFINLAR - dabrafenib mesylate

cap 50 mg (base equivalent), 75

mg (base equivalent)

• • • •

TAGRISSO - osimertinib mesylate

tab 40 mg (base equivalent), 80

mg (base equivalent)

• • • •

TALZENNA - talazoparib tosylate

cap 0.25 mg (base equivalent),

0.5 mg (base equivalent), 0.75

mg (base equivalent), 1 mg (base

equivalent)

• • • •

tamoxifen citrate tab 10 mg

(base equivalent), 20 mg (base

equivalent)

•

TARCEVA - erlotinib hcl tab 25

mg (base equivalent), 100 mg

(base equivalent), 150 mg (base

equivalent)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

TARGRETIN - bexarotene cap 75

TASIGNA - nilotinib hcl cap 50

mg (base equivalent), 150 mg

(base equivalent), 200 mg (base

equivalent)

• • • •

TAZVERIK - tazemetostat hbr tab

200 mg

• • • •

TEMODAR - temozolomide cap 250

temozolomide cap 5 mg, 20 mg,

100 mg, 140 mg, 180 mg

• • • •

temozolomide cap 250 mg

(Temodar)

• • • •

TEPMETKO - tepotinib hcl tab 225

• • • •

TIBSOVO - ivosidenib tab 250 mg

• • • •

toremifene citrate tab 60 mg (base

equivalent) (Fareston)

tretinoin cap 10 mg

•

TREXALL - methotrexate sodium tab

5 mg (base equiv), 7.5 mg (base

equiv), 10 mg (base equiv), 15 mg

(base equiv)

TRUSELTIQ - infigratinib phos cap

pack 100 & 25 mg (125 mg daily

dose)

• • • •

TRUSELTIQ - infigratinib phos cap

ther pack 2 x 25 mg (50 mg daily

dose), 3 x 25 mg (75 mg daily

dose), 100 mg (100 mg daily

dose)

• • • •

TUKYSA - tucatinib tab 50 mg, 150

• • • •

TURALIO - pexidartinib hcl cap 200

mg (base equivalent)

• • • •

TYKERB - lapatinib ditosylate tab

250 mg (base equiv)

VENCLEXTA - venetoclax tab 10

mg, 50 mg, 100 mg

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 16

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VENCLEXTA STARTING PACK -

venetoclax tab therapy starter

pack 10 & 50 & 100 mg

• • • •

VERZENIO - abemaciclib tab 50 mg,

100 mg, 150 mg, 200 mg

• • • •

VITRAKVI - larotrectinib sulfate cap

25 mg (base equivalent), 100 mg

(base equivalent)

• • • •

VITRAKVI - larotrectinib sulfate oral

soln 20 mg/ml (base equivalent)

• • • •

VIZIMPRO - dacomitinib tab 15 mg,

30 mg, 45 mg

• • • •

VONJO - pacritinib citrate cap 100

• • • •

VOTRIENT - pazopanib hcl tab 200

mg (base equiv)

• • • •

WELIREG - belzutifan tab 40 mg

• • • •

XALKORI - crizotinib cap 200 mg,

250 mg

• • • •

XATMEP - methotrexate oral soln 2.5

mg/ml

XELODA - capecitabine tab 150 mg,

500 mg

XOSPATA - gilteritinib fumarate

tablet 40 mg (base equivalent)

• • • •

XPOVIO - selinexor tab therapy pack

40 mg (40 mg once weekly), 40

mg (40 mg twice weekly), 40 mg

(80 mg once weekly), 50 mg (100

mg once weekly), 60 mg (60 mg

once weekly)

• • • •

XPOVIO 60 MG TWICE WEEKLY -

selinexor tab therapy pack 20 mg

(60 mg twice weekly)

• • • •

XPOVIO 80 MG TWICE WEEKLY -

selinexor tab therapy pack 20 mg

(80 mg twice weekly)

• • • •

XTANDI - enzalutamide cap 40 mg

• • • •

XTANDI - enzalutamide tab 40 mg,

80 mg

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

YONSA - abiraterone acetate tab

125 mg

• • • •

ZEJULA - niraparib tosylate cap 100

mg (base equivalent)

• • • •

ZELBORAF - vemurafenib tab 240

• • • •

ZOLINZA - vorinostat cap 100 mg

• • • •

ZYDELIG - idelalisib tab 100 mg,

150 mg

• • • •

ZYKADIA - ceritinib tab 150 mg

• • • •

ZYTIGA - abiraterone acetate tab

250 mg, 500 mg

ENDOCRINE AND METABOLIC DRUGS

CORTICOSTEROIDS

ALKINDI SPRINKLE -

hydrocortisone cap sprinkle 0.5

mg, 1 mg, 2 mg, 5 mg

budesonide delayed release

particles cap 3 mg

budesonide tab er 24hr 9 mg

(Uceris)

CORTEF - hydrocortisone tab 5 mg,

10 mg, 20 mg

DEXABLISS - dexamethasone tab

therapy pack 1.5 mg (39)

DEXAMETHASONE -

dexamethasone soln 0.5 mg/5ml

DEXAMETHASONE -

dexamethasone tab 0.5 mg, 0.75

mg, 1 mg, 2 mg

dexamethasone elixir 0.5 mg/5ml

DEXAMETHASONE INTENSOL -

dexamethasone conc 1 mg/ml

dexamethasone tab therapy pack

1.5 mg (21)

dexamethasone tab 1.5 mg, 4 mg,

6 mg

DEXAMETHASONE 10-DAY DOSE -

dexamethasone tab therapy pack

1.5 mg (35)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 17

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DEXAMETHASONE 13-DAY DOSE -

dexamethasone tab therapy pack

1.5 mg (51)

DXEVO 11-DAY - dexamethasone

tab therapy pack 1.5 mg (39)

EMFLAZA - deflazacort susp 22.75

mg/ml

EMFLAZA - deflazacort tab 6 mg, 18

mg, 30 mg, 36 mg

fludrocortisone acetate tab

0.1 mg

HEMADY - dexamethasone tab 20

hydrocortisone tab 5 mg, 10 mg,

20 mg (Cortef)

MEDROL - methylprednisolone tab 2

MEDROL - methylprednisolone tab 4

mg, 8 mg, 16 mg, 32 mg

MEDROL DOSEPAK -

methylprednisolone tab therapy

pack 4 mg (21)

methylprednisolone tab therapy

pack 4 mg (21) (Medrol dosepak)

methylprednisolone tab 4 mg,

8 mg, 16 mg, 32 mg (Medrol)

MILLIPRED - prednisolone tab 5 mg

ORAPRED ODT - prednisolone sod

phos orally disintegr tab 10 mg

(base eq), 15 mg (base eq), 30

mg (base eq)

ORTIKOS - budesonide cap er 24hr

6 mg, 9 mg

PEDIAPRED - prednisolone sod

phosph oral soln 6.7 mg/5ml (5

mg/5ml base)

PREDNISOLONE - prednisolone

syrup 15 mg/5ml (usp solution

equivalent)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

prednisolone sod phosph oral

soln 6.7 mg/5ml (5 mg/5ml base)

(Pediapred)

prednisolone sod phosphate oral

soln 15 mg/5ml (base equiv)

prednisolone sod phosphate oral

soln 10 mg/5ml (base equiv),

20 mg/5ml (base equiv)

PREDNISOLONE SODIUM

PHOSP - prednisolone sod phos

orally disintegr tab 10 mg (base

eq), 15 mg (base eq), 30 mg

(base eq)

PREDNISOLONE SODIUM

PHOSP - prednisolone sodium

phosphate oral soln 25 mg/5ml

(base eq)

PREDNISONE - prednisone oral

soln 5 mg/5ml

PREDNISONE INTENSOL -

prednisone conc 5 mg/ml

prednisone tab therapy pack

5 mg (21), 5 mg (48), 10 mg (21),

10 mg (48)

prednisone tab 1 mg, 2.5 mg,

5 mg, 10 mg, 20 mg, 50 mg

RAYOS - prednisone tab delayed

release 1 mg, 2 mg, 5 mg

TAPERDEX 12-DAY -

dexamethasone tab therapy pack

1.5 mg (49)

TAPERDEX 7-DAY - dexamethasone

tab therapy pack 1.5 mg (27)

TARPEYO - budesonide delayed

release cap 4 mg

UCERIS - budesonide tab er 24hr 9

ZCORT 7-DAY - dexamethasone tab

therapy pack 1.5 mg (25)

ANDROGEN-ANABOLIC

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 18

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ANDRODERM - testosterone td

patch 24hr 2 mg/24hr, 4 mg/24hr

ANDROGEL - testosterone td gel 25

mg/2.5gm (1%)

ANDROGEL PUMP - testosterone td

gel 20.25 mg/act (1.62%)

danazol cap 50 mg, 100 mg,

200 mg

•

DEPO-TESTOSTERONE -

testosterone cypionate im inj in oil

100 mg/ml, 200 mg/ml

FORTESTA - testosterone td gel

10mg/act (2%)

JATENZO - testosterone

undecanoate cap 158 mg, 198

mg, 237 mg

METHITEST - methyltestosterone

oral tab 10 mg

• •

NATESTO - testosterone nasal gel

5.5 mg/act

oxandrolone tab 2.5 mg, 10 mg

•

TESTIM - testosterone td gel 50

mg/5gm (1%)

TESTOSTERONE - testosterone td

gel 50 mg/5gm (1%)

testosterone cypionate im inj in

oil 100 mg/ml, 200 mg/ml (Depo-

testosterone)

• •

TESTOSTERONE ENANTHATE -

testosterone enanthate im inj in oil

200 mg/ml

• •

TESTOSTERONE PUMP -

testosterone td gel 12.5 mg/act

(1%)

testosterone td gel 25 mg/2.5gm

(1%), 50 mg/5gm (1%),

20.25 mg/1.25gm (1.62%),

40.5 mg/2.5gm (1.62%)

(Androgel)

• •

testosterone td gel 12.5 mg/act

(1%)

• •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

testosterone td gel 20.25 mg/act

(1.62%) (Androgel pump)

• •

testosterone td gel 10mg/act (2%)

(Fortesta)

testosterone td soln 30 mg/act

• •

TLANDO - testosterone

undecanoate cap 112.5 mg

VOGELXO - testosterone td gel 50

mg/5gm (1%)

VOGELXO PUMP - testosterone td

gel 12.5 mg/act (1%)

XYOSTED - testosterone enanthate

solution auto-injector 50 mg/0.5ml,

75 mg/0.5ml, 100 mg/0.5ml

ESTROGENS

ACTIVELLA - estradiol &

norethindrone acetate tab 1-0.5

ALORA - estradiol td patch twice

weekly 0.025 mg/24hr, 0.075

mg/24hr

• •

ANGELIQ - drospirenone-estradiol

tab 0.25-0.5 mg, 0.5-1 mg

BIJUVA - estradiol-progesterone cap

1-100 mg

CLIMARA - estradiol td patch weekly

0.025 mg/24hr, 0.0375 mg/24hr

(37.5 mcg/24hr), 0.05 mg/24hr,

0.06 mg/24hr, 0.075 mg/24hr, 0.1

mg/24hr

CLIMARA PRO - estradiol-

levonorgestrel td patch weekly

0.045-0.015 mg/day

•

COMBIPATCH - estradiol-

norethindrone ace td pttw

0.05-0.14 mg/day, 0.05-0.25 mg/

day

•

DELESTROGEN - estradiol valerate

im in oil 10 mg/ml

DELESTROGEN - estradiol valerate

im in oil 20 mg/ml, 40 mg/ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 19

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DEPO-ESTRADIOL - estradiol

cypionate im in oil 5 mg/ml

DIVIGEL - estradiol td gel 0.25

mg/0.25gm (0.1%), 0.5 mg/0.5gm

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

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

(0.1%)

•

DUAVEE - conjugated estrogens-

bazedoxifene tab 0.45-20 mg

ELESTRIN - estradiol gel 0.06%

(0.52 mg/0.87 gm metered-dose

pump)

•

ESTRACE - estradiol tab 0.5 mg, 1

mg, 2 mg

estradiol & norethindrone acetate

tab 0.5-0.1 mg

estradiol & norethindrone acetate

tab 1-0.5 mg (Activella)

estradiol tab 0.5 mg, 1 mg, 2 mg

(Estrace)

estradiol td patch twice weekly

0.025 mg/24hr, 0.0375 mg/24hr,

0.05 mg/24hr, 0.075 mg/24hr,

0.1 mg/24hr (Vivelle-dot)

•

estradiol td patch weekly

0.025 mg/24hr, 0.0375 mg/24hr

(37.5 mcg/24hr), 0.05 mg/24hr,

0.06 mg/24hr, 0.075 mg/24hr,

0.1 mg/24hr (Climara)

•

estradiol valerate im in oil 20 mg/

ml, 40 mg/ml (Delestrogen)

ESTROGEL - estradiol gel 0.06%

(0.75 mg/1.25 gm metered-dose

pump)

•

EVAMIST - estradiol transdermal

spray 1.53 mg/spray

•

MENEST - esterified estrogens tab

0.3 mg, 0.625 mg, 1.25 mg

MENOSTAR - estradiol td patch

weekly 14 mcg/24hr

•

MINIVELLE - estradiol td patch twice

weekly 0.025 mg/24hr, 0.0375

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

mg/24hr, 0.05 mg/24hr, 0.075

mg/24hr, 0.1 mg/24hr

MYFEMBREE - relugolix-estradiol-

norethindrone acetate tab

40-1-0.5 mg

• •

norethindrone acetate-ethinyl

estradiol tab 0.5 mg-2.5 mcg,

1 mg-5 mcg

ORIAHNN - elagolix-estrad-noreth

300-1-0.5mg & elagolix 300mg

cap pack

• •

PREFEST - estradiol tab 1

mg(15)/estrad-norgestimate tab

1-0.09mg(15)

PREMARIN - estrogens, conjugated

tab 0.3 mg, 0.45 mg, 0.625 mg,

0.9 mg, 1.25 mg

PREMPHASE - conj est 0.625(14)/

conj est-medroxypro ac tab

0.625-5mg(14)

PREMPRO - conjugated estrogen-

medroxyprogest acetate tab

0.3-1.5 mg, 0.45-1.5 mg,

0.625-2.5 mg, 0.625-5 mg

VIVELLE-DOT - estradiol td patch

twice weekly 0.025 mg/24hr,

0.0375 mg/24hr, 0.05 mg/24hr,

0.075 mg/24hr, 0.1 mg/24hr

CONTRACEPTIVES

ANNOVERA - segesterone ace-

ethinyl estradiol va ring 0.15-0.013

mg/24hr

BALCOLTRA - levonorgestrel-ethinyl

estradiol-fe tab 0.1 mg-20 mcg

(21)

BEYAZ - drospirenone-ethinyl

estrad-levomefolate tab

3-0.02-0.451 mg

DEPO-PROVERA

CONTRACEPTIV -

medroxyprogesterone acetate im

susp prefilled syr 150 mg/ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 20

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DEPO-PROVERA

CONTRACEPTIV -

medroxyprogesterone acetate im

susp 150 mg/ml

DEPO-SUBQ PROVERA 104 -

medroxyprogesterone acetate

susp pref syr 104 mg/0.65ml

•

desogest-eth estrad & eth estrad

tab 0.15-0.02/0.01 mg(21/5)

(Mircette)

•

desogestrel & ethinyl estradiol

tab 0.15 mg-30 mcg

•

drospirenone-ethinyl

estrad-levomefolate tab

3-0.02-0.451 mg (Beyaz)

•

drospirenone-ethinyl

estrad-levomefolate tab

3-0.03-0.451 mg (Safyral)

•

drospirenone-ethinyl estradiol tab

3-0.02 mg (Yaz)

•

drospirenone-ethinyl estradiol tab

3-0.03 mg (Yasmin 28)

•

ELLA - ulipristal acetate tab 30 mg

ethynodiol diacetate & ethinyl

estradiol tab 1 mg-35 mcg,

1 mg-50 mcg

•

etonogestrel-ethinyl estradiol

va ring 0.120-0.015 mg/24hr

(Nuvaring)

GENERESS FE - norethindrone &

ethinyl estradiol-fe chew tab 0.8

mg-25 mcg

levonor-eth est tab

0.15-0.02/0.025/0.03 mg &eth est

0.01 mg (Quartette)

•

levonorg-eth est tab

0.1-0.02mg(84) & eth est tab

0.01mg(7) (Loseasonique)

•

levonorg-eth est tab

0.15-0.03mg(84) & eth est tab

0.01mg(7) (Seasonique)

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

levonorgestrel & ethinyl estradiol

(91-day) tab 0.15-0.03 mg

•

levonorgestrel & ethinyl

estradiol tab 0.1 mg-20 mcg,

0.15 mg-30 mcg

•

levonorgestrel tab 1.5 mg

•

levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-

mcg

•

levonorgestrel-ethinyl estradiol

(continuous) tab 90-20 mcg

•

LO LOESTRIN FE - norethin-eth

estradiol-fe tab 1 mg-10 mcg

(24)/10 mcg (2)

•

LOSEASONIQUE - levonorg-eth est

tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)

medroxyprogesterone acetate im

susp prefilled syr 150 mg/ml

(Depo-provera contrac)

•

medroxyprogesterone acetate im

susp 150 mg/ml (Depo-provera

contrac)

•

MINASTRIN 24 FE - norethindrone

ace-eth estradiol-fe chew tab 1

mg-20 mcg (24)

MIRCETTE - desogest-eth estrad

& eth estrad tab 0.15-0.02/0.01

mg(21/5)

NATAZIA - estradiol valerate-

dienogest tab 3 mg /2-2 mg/2-3

mg/1 mg

•

NEXTSTELLIS - drospirenone-

estetrol tab 3-14.2 mg

norelgestromin-ethinyl estradiol

td ptwk 150-35 mcg/24hr

•

norethindrone & ethinyl

estradiol tab 0.4 mg-35 mcg,

0.5 mg-35 mcg, 1 mg-35 mcg

•

norethindrone & ethinyl estradiol-

fe chew tab 0.4 mg-35 mcg

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 21

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

norethindrone & ethinyl estradiol-

fe chew tab 0.8 mg-25 mcg

(Generess fe)

•

norethindrone ac-ethinyl estrad-fe

tab 1-20/1-30/1-35 mg-mcg

•

norethindrone ace & ethinyl

estradiol tab 1 mg-20 mcg,

1.5 mg-30 mcg

•

norethindrone ace & ethinyl

estradiol-fe tab 1 mg-20 mcg,

1.5 mg-30 mcg

•

norethindrone ace-eth estradiol-

fe chew tab 1 mg-20 mcg (24)

(Minastrin 24 fe)

•

norethindrone ace-ethinyl

estradiol-fe cap 1 mg-20 mcg

(24) (Taytulla)

norethindrone ace-ethinyl

estradiol-fe tab 1 mg-20 mcg

(24)

•

norethindrone tab 0.35 mg

•

norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg,

0.5-35/1-35/0.5-35 mg-mcg

•

norgestimate & ethinyl estradiol

tab 0.25 mg-35 mcg

•

norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-

mcg,

0.18-35/0.215-35/0.25-35 mg-

mcg

•

norgestrel & ethinyl estradiol tab

0.3 mg-30 mcg

•

NUVARING - etonogestrel-ethinyl

estradiol va ring 0.120-0.015

mg/24hr

•

PLAN B ONE-STEP - levonorgestrel

tab 1.5 mg

QUARTETTE - levonor-eth est tab

0.15-0.02/0.025/0.03 mg &eth est

0.01 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SAFYRAL - drospirenone-

ethinyl estrad-levomefolate tab

3-0.03-0.451 mg

SEASONIQUE - levonorg-eth est

tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)

SLYND - drospirenone tab 4 mg

TAYTULLA - norethindrone ace-

ethinyl estradiol-fe cap 1 mg-20

mcg (24)

TWIRLA - levonorgestrel-ethinyl

estradiol td ptwk 120-30 mcg/24hr

TYBLUME - levonorgestrel & ethinyl

estradiol chew tab 0.1 mg-20 mcg

•

VELIVET - desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-

•

YASMIN 28 - drospirenone-ethinyl

estradiol tab 3-0.03 mg

YAZ - drospirenone-ethinyl estradiol

tab 3-0.02 mg

PROGESTINS

AYGESTIN - norethindrone acetate

tab 5 mg

hydroxyprogesterone caproate im

in oil 250 mg/ml (Makena)

MAKENA - hydroxyprogesterone

caproate im in oil 250 mg/ml

MAKENA - hydroxyprogesterone

caproate soln auto-injector 275

mg/1.1ml

medroxyprogesterone acetate tab

2.5 mg, 5 mg, 10 mg (Provera)

megestrol acetate susp

625 mg/5ml

norethindrone acetate tab 5 mg

(Aygestin)

progesterone cap 100 mg, 200 mg

(Prometrium)

progesterone im in oil 50 mg/ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 22

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PROMETRIUM - progesterone cap

100 mg, 200 mg

PROVERA - medroxyprogesterone

acetate tab 2.5 mg, 5 mg, 10 mg

ANTIDIABETICS

acarbose tab 25 mg, 50 mg,

100 mg (Precose)

•

ACTOPLUS MET - pioglitazone hcl-

metformin hcl tab 15-500 mg,

15-850 mg

ACTOS - pioglitazone hcl tab 15 mg

(base equiv), 30 mg (base equiv),

45 mg (base equiv)

ADLYXIN - lixisenatide soln pen-

injector 20 mcg/0.2ml (100 mcg/

ml)

ADLYXIN STARTER PACK -

lixisenatide pen-inj starter kit 10

mcg/0.2ml & 20 mcg/0.2ml

ALOGLIPTIN - alogliptin benzoate

tab 6.25 mg (base equiv), 12.5 mg

(base equiv), 25 mg (base equiv)

ALOGLIPTIN/METFORMIN HCL -

alogliptin-metformin hcl tab

12.5-500 mg, 12.5-1000 mg

ALOGLIPTIN/PIOGLITAZONE -

alogliptin-pioglitazone tab 12.5-30

mg, 12.5-45 mg, 25-15 mg, 25-30

mg, 25-45 mg

AMARYL - glimepiride tab 1 mg, 2

mg, 4 mg

BAQSIMI ONE PACK - glucagon

nasal powder 3 mg/dose

•

BAQSIMI TWO PACK - glucagon

nasal powder 3 mg/dose

•

BYDUREON BCISE - exenatide

extended release susp auto-

injector 2 mg/0.85ml

• •

BYETTA - exenatide soln pen-

injector 5 mcg/0.02ml, 10

mcg/0.04ml

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CYCLOSET - bromocriptine

mesylate tab 0.8 mg (base

equivalent)

diazoxide susp 50 mg/ml

(Proglycem)

DUETACT - pioglitazone hcl-

glimepiride tab 30-2 mg, 30-4 mg

FARXIGA - dapagliflozin propanediol

tab 5 mg (base equivalent), 10 mg

(base equivalent)

• •

glimepiride tab 1 mg, 2 mg, 4 mg

(Amaryl)

•

glipizide tab er 24hr 2.5 mg, 5 mg,

10 mg (Glucotrol xl)

•

glipizide tab 5 mg, 10 mg

•

glipizide-metformin hcl tab

2.5-250 mg, 2.5-500 mg,

5-500 mg

•

GLUCAGEN HYPOKIT - glucagon

hcl (rdna) for inj 1 mg (base equiv)

glucagon (rdna) for inj kit 1 mg

(Glucagon emergency k)

GLUCAGON EMERGENCY KIT -

glucagon (rdna) for inj kit 1 mg

GLUCAGON EMERGENCY KIT

FO - glucagon hcl for inj 1 mg

GLUCOTROL XL - glipizide tab er

24hr 2.5 mg, 5 mg, 10 mg

GLUMETZA - metformin hcl tab er

24hr modified release 500 mg,

1000 mg

glyburide micronized tab 1.5 mg,

3 mg, 6 mg (Glynase)

•

glyburide tab 1.25 mg, 2.5 mg,

5 mg

•

glyburide-metformin tab

1.25-250 mg, 2.5-500 mg,

5-500 mg

•

GLYNASE - glyburide micronized tab

1.5 mg, 3 mg, 6 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 23

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

GLYXAMBI - empagliflozin-linagliptin

tab 10-5 mg, 25-5 mg

• •

GVOKE HYPOPEN 1-PACK -

glucagon subcutaneous solution

auto-injector 0.5 mg/0.1ml, 1

mg/0.2ml

•

GVOKE HYPOPEN 2-PACK -

glucagon subcutaneous solution

auto-injector 0.5 mg/0.1ml, 1

mg/0.2ml

•

GVOKE KIT - glucagon

subcutaneous soln 1 mg/0.2ml

•

GVOKE PFS - glucagon

subcutaneous soln pref syringe

0.5 mg/0.1ml, 1 mg/0.2ml

•

INVOKAMET - canagliflozin-

metformin hcl tab 50-500 mg,

50-1000 mg, 150-500 mg,

150-1000 mg

INVOKAMET XR - canagliflozin-

metformin hcl tab er 24hr 50-500

mg, 50-1000 mg, 150-500 mg,

150-1000 mg

INVOKANA - canagliflozin tab 100

mg, 300 mg

JANUMET - sitagliptin-metformin hcl

tab 50-500 mg, 50-1000 mg

• •

JANUMET XR - sitagliptin-metformin

hcl tab er 24hr 50-500 mg,

50-1000 mg, 100-1000 mg

• •

JANUVIA - sitagliptin phosphate tab

25 mg (base equiv), 50 mg (base

equiv), 100 mg (base equiv)

• •

JARDIANCE - empagliflozin tab 10

mg, 25 mg

• •

JENTADUETO - linagliptin-metformin

hcl tab 2.5-500 mg, 2.5-850 mg,

2.5-1000 mg

JENTADUETO XR - linagliptin-

metformin hcl tab er 24hr 2.5-1000

mg, 5-1000 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

KAZANO - alogliptin-metformin hcl

tab 12.5-500 mg, 12.5-1000 mg

KOMBIGLYZE XR - saxagliptin-

metformin hcl tab er 24hr 2.5-1000

mg, 5-500 mg, 5-1000 mg

KORLYM - mifepristone tab 300 mg

• • • •

metformin hcl oral soln

500 mg/5ml (Riomet)

metformin hcl tab er 24hr 500 mg,

750 mg

•

metformin hcl tab er 24hr osmotic

500 mg, 1000 mg

metformin hcl tab er 24hr

modified release 500 mg,

1000 mg (Glumetza)

metformin hcl tab 500 mg,

850 mg, 1000 mg

•

METFORMIN HYDROCHLORIDE -

metformin hcl tab 625 mg

•

miglitol tab 25 mg, 50 mg, 100 mg

•

MOUNJARO - tirzepatide soln pen-

injector 2.5 mg/0.5ml, 5 mg/0.5ml,

7.5 mg/0.5ml, 10 mg/0.5ml, 12.5

mg/0.5ml, 15 mg/0.5ml

nateglinide tab 60 mg, 120 mg

•

NESINA - alogliptin benzoate tab

6.25 mg (base equiv), 12.5 mg

(base equiv), 25 mg (base equiv)

ONGLYZA - saxagliptin hcl tab 2.5

mg (base equiv), 5 mg (base

equiv)

OSENI - alogliptin-pioglitazone tab

12.5-15 mg, 12.5-30 mg, 12.5-45

mg, 25-15 mg, 25-30 mg, 25-45

OZEMPIC - semaglutide soln pen-inj

0.25 or 0.5 mg/dose (2 mg/1.5ml),

1 mg/dose (4 mg/3ml), 2 mg/dose

(8 mg/3ml)

• •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 24

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

pioglitazone hcl tab 15 mg (base

equiv), 30 mg (base equiv),

45 mg (base equiv) (Actos)

•

pioglitazone hcl-glimepiride tab

30-2 mg, 30-4 mg (Duetact)

pioglitazone hcl-metformin hcl

tab 15-500 mg, 15-850 mg

(Actoplus met)

•

PRECOSE - acarbose tab 25 mg, 50

mg, 100 mg

PROGLYCEM - diazoxide susp 50

mg/ml

QTERN - dapagliflozin-saxagliptin

tab 5-5 mg, 10-5 mg

repaglinide tab 0.5 mg, 1 mg,

2 mg

•

RIOMET - metformin hcl oral soln

500 mg/5ml

RYBELSUS - semaglutide tab 3 mg,

7 mg, 14 mg

• •

SEGLUROMET - ertugliflozin-

metformin hcl tab 2.5-500 mg,

2.5-1000 mg, 7.5-500 mg,

7.5-1000 mg

SOLIQUA 100/33 - insulin glargine-

lixisenatide sol pen-inj 100-33

unit-mcg/ml

• •

STEGLATRO - ertugliflozin l-

pyroglutamic acid tab 5 mg (base

equiv), 15 mg (base equiv)

STEGLUJAN - ertugliflozin-sitagliptin

tab 5-100 mg, 15-100 mg

SYMLINPEN 120 - pramlintide

acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)

SYMLINPEN 60 - pramlintide

acetate pen-inj 1500 mcg/1.5ml

(1000 mcg/ml)

SYNJARDY - empagliflozin-

metformin hcl tab 5-500 mg,

5-1000 mg, 12.5-500 mg,

12.5-1000 mg

• •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SYNJARDY XR - empagliflozin-

metformin hcl tab er 24hr 5-1000

mg, 10-1000 mg, 12.5-1000 mg,

25-1000 mg

• •

TRADJENTA - linagliptin tab 5 mg

TRIJARDY XR - empagliflozin-

linaglip-metformin tab er 24hr

12.5-2.5-1000mg

• •

TRIJARDY XR - empagliflozin-

linagliptin-metformin tab er 24hr

5-2.5-1000mg, 10-5-1000 mg,

25-5-1000 mg

• •

TRULICITY - dulaglutide soln

pen-injector 0.75 mg/0.5ml,

1.5 mg/0.5ml, 3 mg/0.5ml, 4.5

mg/0.5ml

• •

VICTOZA - liraglutide soln pen-

injector 18 mg/3ml (6 mg/ml)

• •

XIGDUO XR - dapagliflozin-

metformin hcl tab er 24hr 2.5-1000

mg, 5-500 mg, 5-1000 mg, 10-500

mg, 10-1000 mg

• •

XULTOPHY 100/3.6 - insulin

degludec-liraglutide sol pen-inj

100-3.6 unit-mg/ml

• •

ZEGALOGUE - dasiglucagon hcl

subcutaneous soln auto-inj 0.6

mg/0.6ml

•

ZEGALOGUE - dasiglucagon hcl

subcutaneous soln pref syringe

0.6 mg/0.6ml

•

Rapid-Acting Insulins

ADMELOG - insulin lispro inj soln

100 unit/ml

ADMELOG SOLOSTAR - insulin

lispro soln pen-injector 100 unit/ml

(1 unit dial)

APIDRA - insulin glulisine inj 100

unit/ml

APIDRA SOLOSTAR - insulin

glulisine soln pen-injector inj 100

unit/ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 25

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

FIASP - insulin aspart (with

niacinamide) inj 100 unit/ml

•

FIASP FLEXTOUCH - insulin aspart

(with niacinamide) sol pen-inj 100

unit/ml

•

FIASP PENFILL - insulin aspart (with

niacinamide) soln cartridge 100

unit/ml

•

HUMALOG - insulin lispro inj soln

100 unit/ml

• •

HUMALOG - insulin lispro soln

cartridge 100 unit/ml

• •

HUMALOG JUNIOR KWIKPEN -

insulin lispro soln pen-injector 100

unit/ml (0.5 unit dial)

• •

HUMALOG KWIKPEN - insulin lispro

soln pen-injector 100 unit/ml (1

unit dial), 200 unit/ml

• •

INSULIN ASPART - insulin aspart inj

soln 100 unit/ml

•

INSULIN ASPART FLEXPEN -

insulin aspart soln pen-injector

100 unit/ml

•

INSULIN ASPART PENFILL - insulin

aspart soln cartridge 100 unit/ml

•

INSULIN LISPRO - insulin lispro inj

soln 100 unit/ml

• •

INSULIN LISPRO JUNIOR KWI -

insulin lispro soln pen-injector 100

unit/ml (0.5 unit dial)

• •

INSULIN LISPRO KWIKPEN - insulin

lispro soln pen-injector 100 unit/ml

(1 unit dial)

• •

LYUMJEV - insulin lispro-aabc inj

100 unit/ml

LYUMJEV KWIKPEN - insulin lispro-

aabc soln pen-injector 200 unit/ml

LYUMJEV KWIKPEN - insulin lispro-

aabc soln pen-inj 100 unit/ml (1

unit dial)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NOVOLOG - insulin aspart inj soln

100 unit/ml

•

NOVOLOG FLEXPEN - insulin

aspart soln pen-injector 100 unit/

•

NOVOLOG FLEXPEN RELION -

insulin aspart soln pen-injector

100 unit/ml

•

NOVOLOG PENFILL - insulin aspart

soln cartridge 100 unit/ml

•

NOVOLOG RELION - insulin aspart

inj soln 100 unit/ml

•

Short-Acting Insulins

AFREZZA - insulin regular (human)

inh powd 90 x 8 unit & 90 x 12

unit, 60x4 & 60x8 & 60x12 ut/cart

AFREZZA - insulin regular (human)

inhal powd 90 x 4 unit & 90 x 8

unit

AFREZZA - insulin regular (human)

inhalation powder 4 unit/cartridge,

8 unit/cartridge, 12 unit/cartridge

HUMULIN R - insulin regular

(human) inj 100 unit/ml

• •

HUMULIN R U-500 (CONCENTR -

insulin regular (human) inj 500

unit/ml

•

HUMULIN R U-500 KWIKPEN -

insulin regular (human) soln pen-

injector 500 unit/ml

•

NOVOLIN R - insulin regular

(human) inj 100 unit/ml

•

NOVOLIN R FLEXPEN - insulin

regular (human) soln pen-injector

100 unit/ml

•

NOVOLIN R FLEXPEN RELION -

insulin regular (human) soln pen-

injector 100 unit/ml

•

NOVOLIN R RELION - insulin

regular (human) inj 100 unit/ml

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 26

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

RELION R - insulin regular (human)

inj 100 unit/ml

•

Intermediate-Acting Insulins

HUMALOG MIX 50/50 - insulin lispro

protamine & lispro inj 100 unit/ml

(50-50)

• •

HUMALOG MIX 50/50 KWIKPEN -

insulin lispro prot & lispro sus pen-

inj 100 unit/ml (50-50)

• •

HUMALOG MIX 75/25 - insulin lispro

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

• •

HUMALOG MIX 75/25 KWIKPEN -

insulin lispro prot & lispro sus pen-

inj 100 unit/ml (75-25)

• •

HUMULIN N - insulin nph (human)

(isophane) inj 100 unit/ml

• •

HUMULIN N KWIKPEN - insulin nph

(human) (isophane) susp pen-

injector 100 unit/ml

• •

HUMULIN 70/30 - insulin nph

isophane & regular human inj 100

unit/ml (70-30)

• •

HUMULIN 70/30 KWIKPEN - insulin

nph & regular susp pen-inj 100

unit/ml (70-30)

• •

INSULIN ASPART PROTAMINE/ -

insulin aspart prot & aspart

(human) inj 100 unit/ml (70-30)

•

INSULIN ASPART PROTAMINE/ -

insulin aspart prot & aspart sus

pen-inj 100 unit/ml (70-30)

•

INSULIN LISPRO PROTAMINE/ -

insulin lispro prot & lispro sus pen-

inj 100 unit/ml (75-25)

• •

NOVOLIN N - insulin nph (human)

(isophane) inj 100 unit/ml

•

NOVOLIN N FLEXPEN - insulin nph

(human) (isophane) susp pen-

injector 100 unit/ml

•

NOVOLIN N FLEXPEN RELION -

insulin nph (human) (isophane)

susp pen-injector 100 unit/ml

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NOVOLIN N RELION - insulin nph

(human) (isophane) inj 100 unit/ml

•

NOVOLIN 70/30 - insulin nph

isophane & regular human inj 100

unit/ml (70-30)

•

NOVOLIN 70/30 FLEXPEN - insulin

nph & regular susp pen-inj 100

unit/ml (70-30)

•

NOVOLIN 70/30 FLEXPEN REL -

insulin nph & regular susp pen-inj

100 unit/ml (70-30)

•

NOVOLIN 70/30 RELION - insulin

nph isophane & regular human inj

100 unit/ml (70-30)

•

NOVOLOG MIX 70/30 - insulin

aspart prot & aspart (human) inj

100 unit/ml (70-30)

•

NOVOLOG MIX 70/30 PREFILL -

insulin aspart prot & aspart sus

pen-inj 100 unit/ml (70-30)

•

NOVOLOG MIX 70/30 RELION -

insulin aspart prot & aspart

(human) inj 100 unit/ml (70-30)

•

Basal Insulins

BASAGLAR KWIKPEN - insulin

glargine soln pen-injector 100 unit/

INSULIN GLARGINE - insulin

glargine inj 100 unit/ml

INSULIN GLARGINE SOLOSTAR -

insulin glargine soln pen-injector

100 unit/ml

LANTUS - insulin glargine inj 100

unit/ml

LANTUS SOLOSTAR - insulin

glargine soln pen-injector 100 unit/

LEVEMIR - insulin detemir inj 100

unit/ml

•

LEVEMIR FLEXTOUCH - insulin

detemir soln pen-injector 100 unit/

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 27

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SEMGLEE - insulin glargine-yfgn inj

100 unit/ml

•

SEMGLEE - insulin glargine-yfgn

soln pen-injector 100 unit/ml

•

TOUJEO MAX SOLOSTAR - insulin

glargine soln pen-injector 300 unit/

ml (2 unit dial)

•

TOUJEO SOLOSTAR - insulin

glargine soln pen-injector 300 unit/

ml (1 unit dial)

•

TRESIBA - insulin degludec inj 100

unit/ml

•

TRESIBA FLEXTOUCH - insulin

degludec soln pen-injector 100

unit/ml, 200 unit/ml

•

THYROID AGENTS

ARMOUR THYROID - thyroid tab 15

mg (1/4 grain), 30 mg (1/2 grain),

60 mg (1 grain), 90 mg (1 1/2

grain), 120 mg (2 grain)

ARMOUR THYROID - thyroid tab

180 mg (3 grain), 240 mg (4

grain), 300 mg (5 grain)

CYTOMEL - liothyronine sodium tab

5 mcg, 25 mcg, 50 mcg

LEVOTHYROXINE SODIUM -

levothyroxine sodium cap 13 mcg,

25 mcg, 50 mcg, 75 mcg, 88 mcg,

100 mcg, 112 mcg, 125 mcg, 137

mcg, 150 mcg, 175 mcg, 200 mcg

•

levothyroxine sodium tab 25 mcg,

50 mcg, 75 mcg, 88 mcg,

100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg,

200 mcg, 300 mcg (Synthroid)

liothyronine sodium tab 5 mcg,

25 mcg, 50 mcg (Cytomel)

methimazole tab 5 mg, 10 mg

propylthiouracil tab 50 mg

SYNTHROID - levothyroxine sodium

tab 25 mcg, 50 mcg, 75 mcg, 88

mcg, 100 mcg, 112 mcg, 125 mcg,

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

137 mcg, 150 mcg, 175 mcg, 200

mcg, 300 mcg

THYQUIDITY - levothyroxine sodium

oral solution 100 mcg/5ml

•

TIROSINT - levothyroxine sodium

cap 13 mcg, 25 mcg, 50 mcg, 75

mcg, 88 mcg, 100 mcg, 112 mcg,

125 mcg, 137 mcg, 150 mcg, 175

mcg, 200 mcg

•

TIROSINT-SOL - levothyroxine

sodium oral solution 13 mcg/ml,

25 mcg/ml, 37.5 mcg/ml, 44 mcg/

ml, 50 mcg/ml, 62.5 mcg/ml, 75

mcg/ml, 88 mcg/ml, 100 mcg/

ml, 112 mcg/ml, 137 mcg/ml, 150

mcg/ml, 175 mcg/ml, 200 mcg/ml

•

TIROSINT-SOL - levothyroxine

sodium oral solution 125 mcg/ml

OXYTOCICS

methylergonovine maleate tab

0.2 mg

ENDOCRINE and METABOLIC AGENTS - MISC.

ACTONEL - risedronate sodium tab

35 mg, 150 mg

ALENDRONATE SODIUM -

alendronate sodium tab 5 mg

•

alendronate sodium tab 10 mg,

35 mg

•

alendronate sodium tab 70 mg

(Fosamax)

•

ATELVIA - risedronate sodium tab

delayed release 35 mg

betaine powder for oral solution

(Cystadane)

• •

BINOSTO - alendronate sodium

effervescent tab 70 mg

BUPHENYL - sodium phenylbutyrate

oral powder 3 gm/teaspoonful

BUPHENYL - sodium phenylbutyrate

tab 500 mg

cabergoline tab 0.5 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 28

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

calcitonin (salmon) inj 200 unit/ml

(Miacalcin)

•

calcitonin (salmon) nasal soln 200

unit/act

calcitriol cap 0.25 mcg, 0.5 mcg

(Rocaltrol)

calcitriol oral soln 1 mcg/ml

(Rocaltrol)

CARBAGLU - carglumic acid soluble

tab 200 mg

carglumic acid soluble tab

200 mg (Carbaglu)

• • •

CARNITOR - levocarnitine oral soln

1 gm/10ml (10%)

CARNITOR - levocarnitine tab 330

CARNITOR SF - levocarnitine oral

soln 1 gm/10ml (10%)

CETROTIDE - cetrorelix acetate for

inj kit 0.25 mg

CHORIONIC GONADOTROPIN -

chorionic gonadotropin for im inj

10000 unit

• • • •

cinacalcet hcl tab 30 mg (base

equiv), 60 mg (base equiv),

90 mg (base equiv) (Sensipar)

•

CLOMID - clomiphene citrate tab 50

• • •

CLOMIPHENE CITRATE -

clomiphene citrate tab 50 mg

• • •

CORTROPHIN - corticotropin inj gel

80 unit/ml

CYSTADANE - betaine powder for

oral solution

DDAVP - desmopressin acetate inj 4

mcg/ml

DDAVP - desmopressin acetate

preservative free (pf) inj 4 mcg/ml

DDAVP - desmopressin acetate tab

0.1 mg, 0.2 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

desmopressin acetate inj 4 mcg/

ml (Ddavp)

desmopressin acetate nasal

spray soln 0.01% (refrigerated),

0.01%

desmopressin acetate

preservative free (pf) inj 4 mcg/

ml (Ddavp)

desmopressin acetate tab 0.1 mg,

0.2 mg (Ddavp)

doxercalciferol cap 0.5 mcg,

1 mcg, 2.5 mcg

EGRIFTA SV - tesamorelin acetate

for inj 2 mg (base equiv)

EVISTA - raloxifene hcl tab 60 mg

FOLLISTIM AQ - follitropin beta inj

300 unit/0.36ml, 600 unit/0.72ml,

900 unit/1.08ml

• • • •

FORTEO - teriparatide (recombinant)

soln pen-inj 600 mcg/2.4ml

• • • •

FOSAMAX - alendronate sodium tab

70 mg

FOSAMAX PLUS D - alendronate

sodium-cholecalciferol tab

70-2800 mg-unit, 70-5600 mg-unit

•

GALAFOLD - migalastat hcl cap 123

mg (base equivalent)

• • • •

GANIRELIX ACETATE - ganirelix

acetate soln prefilled syringe 250

mcg/0.5ml

• • • •

ganirelix acetate soln prefilled

syringe 250 mcg/0.5ml (Ganirelix

acetate)

• • • •

GENOTROPIN - somatropin for

subcutaneous inj cartridge 5 mg,

12 mg (36 unit)

GENOTROPIN MINIQUICK -

somatropin for subcutaneous inj

prefilled syr 0.2 mg, 0.4 mg, 0.6

mg, 0.8 mg, 1 mg, 1.2 mg, 1.4 mg,

1.6 mg, 1.8 mg, 2 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 29

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

GONAL-F - follitropin alfa for inj 450

unit, 1050 unit

GONAL-F RFF - follitropin alfa for

subcutaneous inj 75 unit

GONAL-F RFF REDIJECT -

follitropin alfa subcutaneous

soln pen-inj 300 unit/0.5ml, 450

unit/0.75ml, 900 unit/1.5ml

HUMATROPE - somatropin for inj

cartridge 6 mg (18 unit), 12 mg

(36 unit), 24 mg

ibandronate sodium tab 150 mg

(base equivalent)

•

INCRELEX - mecasermin inj 40

mg/4ml (10 mg/ml)

• • •

ISTURISA - osilodrostat phosphate

tab 1 mg, 5 mg, 10 mg

• • • •

JYNARQUE - tolvaptan tab therapy

pack 15 mg, 30 & 15 mg, 45 & 15

mg, 60 & 30 mg, 90 & 30 mg

• • • •

JYNARQUE - tolvaptan tab 15 mg,

30 mg

• • • •

KERENDIA - finerenone tab 10 mg,

20 mg

KUVAN - sapropterin dihydrochloride

powder packet 100 mg, 500 mg

KUVAN - sapropterin dihydrochloride

tab 100 mg

levocarnitine oral soln 1 gm/10ml

(10%) (Carnitor)

levocarnitine tab 330 mg (Carnitor)

LUPRON DEPOT-PED (1-MONTH -

leuprolide acetate for inj pediatric

kit 7.5 mg, 11.25 mg, 15 mg

• • •

LUPRON DEPOT-PED (3-MONTH -

leuprolide acetate (3 month) for inj

pediatric kit 11.25 mg, 30 mg

• • •

MENOPUR - menotropins for

subcutaneous inj 75 unit

• • • •

MIACALCIN - calcitonin (salmon) inj

200 unit/ml

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MYALEPT - metreleptin for

subcutaneous inj 11.3 mg

• • • •

MYCAPSSA - octreotide acetate cap

delayed release 20 mg

• • • •

NATPARA - parathyroid hormone

(recombinant) for inj cartridge 25

mcg, 50 mcg, 75 mcg, 100 mcg

• • • •

nitisinone cap 2 mg, 5 mg, 10 mg

(Orfadin)

• • •

NITYR - nitisinone tab 2 mg, 5 mg,

10 mg

• • •

NOCDURNA - desmopressin acetate

sublingual tab 27.7 mcg, 55.3 mcg

NORDITROPIN FLEXPRO -

somatropin solution pen-injector

5 mg/1.5ml, 10 mg/1.5ml, 15

mg/1.5ml, 30 mg/3ml

• • •

NOVAREL - chorionic gonadotropin

for im inj 5000 unit

• • • •

NOVAREL - chorionic gonadotropin

for im inj 10000 unit

• • • •

NUTROPIN AQ NUSPIN 10 -

somatropin solution pen-injector

10 mg/2ml

NUTROPIN AQ NUSPIN 20 -

somatropin solution pen-injector

20 mg/2ml

NUTROPIN AQ NUSPIN 5 -

somatropin solution pen-injector 5

mg/2ml

OCTREOTIDE ACETATE -

octreotide acetate subcutaneous

soln pref syr 50 mcg/ml, 100 mcg/

ml, 500 mcg/ml

• • • •

octreotide acetate inj 50 mcg/

ml (0.05 mg/ml), 100 mcg/ml

(0.1 mg/ml), 500 mcg/ml (0.5 mg/

ml) (Sandostatin)

• • • •

octreotide acetate inj 200 mcg/ml

(0.2 mg/ml), 1000 mcg/ml (1 mg/

ml)

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 30

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

OMNITROPE - somatropin for inj 5.8

OMNITROPE - somatropin solution

cartridge 5 mg/1.5ml, 10 mg/1.5ml

ORFADIN - nitisinone cap 2 mg, 5

mg, 10 mg

ORFADIN - nitisinone cap 20 mg

• • •

ORFADIN - nitisinone susp 4 mg/ml

• • •

ORILISSA - elagolix sodium tab 150

mg (base equiv), 200 mg (base

equiv)

• •

OSPHENA - ospemifene tab 60 mg

OVIDREL - choriogonadotropin alfa

inj 250 mcg/0.5ml

PALYNZIQ - pegvaliase-pqpz

subcutaneous soln pref syringe

2.5 mg/0.5ml, 10 mg/0.5ml, 20

mg/ml

• • • •

paricalcitol cap 1 mcg, 2 mcg

(Zemplar)

paricalcitol cap 4 mcg

PHEBURANE - sodium

phenylbutyrate oral pellets 483

mg/gm

PREGNYL W/DILUENT BENZYL -

chorionic gonadotropin for im inj

10000 unit

• • • •

raloxifene hcl tab 60 mg (Evista)

RAVICTI - glycerol phenylbutyrate

liquid 1.1 gm/ml

• • • •

RAYALDEE - calcifediol cap er 30

mcg

RECORLEV - levoketoconazole tab

150 mg

REVCOVI - elapegademase-lvlr im

soln 2.4 mg/1.5ml (1.6 mg/ml)

• • •

risedronate sodium tab delayed

release 35 mg (Atelvia)

•

risedronate sodium tab 5 mg,

30 mg

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

risedronate sodium tab 35 mg,

150 mg (Actonel)

•

ROCALTROL - calcitriol cap 0.25

mcg, 0.5 mcg

ROCALTROL - calcitriol oral soln 1

mcg/ml

SAIZEN - somatropin (non-

refrigerated) for inj 5 mg, 8.8 mg

SAIZENPREP RECONSTITUTION -

somatropin (non-refrigerated) for

inj 8.8 mg

SAMSCA - tolvaptan tab 15 mg

• • • •

SAMSCA - tolvaptan tab 30 mg

SANDOSTATIN - octreotide acetate

inj 50 mcg/ml (0.05 mg/ml), 100

mcg/ml (0.1 mg/ml), 500 mcg/ml

(0.5 mg/ml)

sapropterin dihydrochloride

powder packet 100 mg, 500 mg

(Kuvan)

• • • •

sapropterin dihydrochloride tab

100 mg (Kuvan)

• • • •

SENSIPAR - cinacalcet hcl tab 30

mg (base equiv), 60 mg (base

equiv), 90 mg (base equiv)

SEROSTIM - somatropin (non-

refrigerated) for subcutaneous inj

4 mg, 5 mg, 6 mg

SIGNIFOR - pasireotide diaspartate

inj 0.3 mg/ml (base equiv), 0.6 mg/

ml (base equiv), 0.9 mg/ml (base

equiv)

• • • •

SKYTROFA - lonapegsomatropin-

tcgd for subcutaneous inj cartridge

3 mg, 3.6 mg, 4.3 mg, 5.2 mg, 6.3

mg, 7.6 mg, 9.1 mg, 11 mg

• • •

SKYTROFA - lonapegsomatropin-

tcgd for subcutaneous inj cart 13.3

• • •

sodium phenylbutyrate oral

powder 3 gm/teaspoonful

(Buphenyl)

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 31

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

sodium phenylbutyrate tab

500 mg (Buphenyl)

• • • •

SOMAVERT - pegvisomant for inj

10 mg (as protein), 15 mg (as

protein), 20 mg (as protein),

25 mg (as protein), 30 mg (as

protein)

• • • •

STIMATE - desmopressin acetate

nasal soln 1.5 mg/ml

STRENSIQ - asfotase alfa

subcutaneous inj 18 mg/0.45ml,

28 mg/0.7ml, 40 mg/ml, 80

mg/0.8ml

• • • •

SYNAREL - nafarelin acetate nasal

soln 2 mg/ml (200 mcg/act) (base

eq)

TERIPARATIDE - teriparatide

(recombinant) soln pen-inj 620

mcg/2.48ml

tolvaptan tab 15 mg, 30 mg

(Samsca)

• • • •

TYMLOS - abaloparatide

subcutaneous soln pen-injector

3120 mcg/1.56ml

• • • •

VOXZOGO - vosoritide for

subcutaneous inj 0.4 mg, 0.56 mg,

1.2 mg

• • • •

XURIDEN - uridine triacetate oral

granules packet 2 gm

ZEMPLAR - paricalcitol cap 1 mcg, 2

mcg

ZOMACTON - somatropin for inj 10

ZOMACTON - somatropin for

subcutaneous inj 5 mg

ZORBTIVE - somatropin (non-

refrigerated) for subcutaneous inj

8.8 mg

CARDIOVASCULAR AGENTS

CARDIOTONICS

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DIGOXIN - digoxin oral soln 0.05 mg/

•

digoxin oral soln 0.05 mg/ml

(Digoxin)

digoxin tab 62.5 mcg (0.0625 mg)

(Lanoxin)

•

digoxin tab 125 mcg (0.125 mg),

250 mcg (0.25 mg) (Lanoxin)

LANOXIN - digoxin tab 62.5 mcg

(0.0625 mg)

•

LANOXIN - digoxin tab 125 mcg

(0.125 mg), 250 mcg (0.25 mg)

ANTIANGINAL AGENTS

ASPRUZYO SPRINKLE - ranolazine

er granules packet 500 mg, 1000

• •

GONITRO - nitroglycerin sublingual

powder packet 400 mcg

ISORDIL TITRADOSE - isosorbide

dinitrate tab 5 mg, 40 mg

isosorbide dinitrate tab 5 mg

(Isordil titradose)

isosorbide dinitrate tab 10 mg,

20 mg, 30 mg

isosorbide dinitrate tab 40 mg

(Isordil titradose)

isosorbide mononitrate tab er

24hr 30 mg, 60 mg, 120 mg

isosorbide mononitrate tab

10 mg, 20 mg

NITRO-BID - nitroglycerin oint 2%

NITRO-DUR - nitroglycerin td patch

24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/

hr, 0.6 mg/hr

NITRO-DUR - nitroglycerin td patch

24hr 0.3 mg/hr, 0.8 mg/hr

NITRO-TIME - nitroglycerin cap er

2.5 mg, 6.5 mg, 9 mg

nitroglycerin sl tab 0.3 mg,

0.4 mg, 0.6 mg (Nitrostat)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 32

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

nitroglycerin td patch 24hr

0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr,

0.6 mg/hr (Nitro-dur)

nitroglycerin tl soln 0.4 mg/spray

(400 mcg/spray) (Nitrolingual

pumpspr)

NITROLINGUAL PUMPSPRAY -

nitroglycerin tl soln 0.4 mg/spray

(400 mcg/spray)

NITROMIST - nitroglycerin lingual

aerosol 400 mcg/spray

NITROSTAT - nitroglycerin sl tab 0.3

mg, 0.4 mg, 0.6 mg

RANEXA - ranolazine tab er 12hr

500 mg, 1000 mg

ranolazine tab er 12hr 500 mg,

1000 mg (Ranexa)

•

BETA BLOCKERS

acebutolol hcl cap 200 mg,

400 mg

atenolol tab 25 mg, 50 mg, 100 mg

(Tenormin)

BETAPACE - sotalol hcl tab 80 mg,

120 mg, 160 mg

BETAPACE AF - sotalol hcl (afib/afl)

tab 80 mg, 120 mg, 160 mg

betaxolol hcl tab 10 mg, 20 mg

bisoprolol fumarate tab 5 mg,

10 mg

BYSTOLIC - nebivolol hcl tab

2.5 mg (base equivalent), 5

mg (base equivalent), 10 mg

(base equivalent), 20 mg (base

equivalent)

carvedilol phosphate cap er 24hr

10 mg, 20 mg, 40 mg, 80 mg

(Coreg cr)

carvedilol tab 3.125 mg, 6.25 mg,

12.5 mg, 25 mg (Coreg)

COREG - carvedilol tab 3.125 mg,

6.25 mg, 12.5 mg, 25 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

COREG CR - carvedilol phosphate

cap er 24hr 10 mg, 20 mg, 40 mg,

80 mg

CORGARD - nadolol tab 20 mg, 40

mg, 80 mg

HEMANGEOL - propranolol hcl oral

soln 4.28 mg/ml (3.75 mg/ml base

equiv)

INDERAL LA - propranolol hcl cap er

24hr 60 mg, 80 mg, 120 mg, 160

INDERAL XL - propranolol hcl

sustained-release beads cap er

24hr 80 mg, 120 mg

INNOPRAN XL - propranolol hcl

sustained-release beads cap er

24hr 80 mg, 120 mg

KAPSPARGO SPRINKLE -

metoprolol succ cap er 24hr

sprinkle 25 mg (tartrate equiv),

50 mg (tartrate equiv), 100 mg

(tartrate equiv), 200 mg (tartrate

equiv)

labetalol hcl tab 100 mg, 200 mg,

300 mg

LOPRESSOR - metoprolol tartrate

tab 50 mg, 100 mg

metoprolol succinate tab er 24hr

25 mg (tartrate equiv), 50 mg

(tartrate equiv), 100 mg (tartrate

equiv), 200 mg (tartrate equiv)

(Toprol xl)

metoprolol tartrate tab 25 mg,

37.5 mg, 75 mg

metoprolol tartrate tab 50 mg,

100 mg (Lopressor)

nadolol tab 20 mg, 40 mg, 80 mg

(Corgard)

nebivolol hcl tab 2.5 mg (base

equivalent), 5 mg (base

equivalent), 10 mg (base

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 33

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

equivalent), 20 mg (base

equivalent) (Bystolic)

pindolol tab 5 mg, 10 mg

PROPRANOLOL HCL - propranolol

hcl oral soln 40 mg/5ml

•

propranolol hcl cap er 24hr

60 mg, 80 mg, 120 mg, 160 mg

(Inderal la)

propranolol hcl oral soln

20 mg/5ml

propranolol hcl tab 10 mg, 20 mg,

40 mg, 60 mg, 80 mg

sotalol hcl (afib/afl) tab 80 mg,

120 mg, 160 mg (Betapace af)

sotalol hcl tab 80 mg, 120 mg,

160 mg (Betapace)

sotalol hcl tab 240 mg

SOTYLIZE - sotalol hcl oral solution

5 mg/ml

TENORMIN - atenolol tab 25 mg, 50

mg, 100 mg

timolol maleate tab 5 mg, 10 mg,

20 mg

TOPROL XL - metoprolol succinate

tab er 24hr 25 mg (tartrate equiv),

50 mg (tartrate equiv), 100 mg

(tartrate equiv), 200 mg (tartrate

equiv)

CALCIUM CHANNEL BLOCKERS

amlodipine besylate tab 2.5 mg

(base equivalent), 5 mg (base

equivalent), 10 mg (base

equivalent) (Norvasc)

CALAN SR - verapamil hcl tab er

120 mg, 180 mg, 240 mg

CARDIZEM - diltiazem hcl tab 30

mg, 60 mg, 120 mg

CARDIZEM CD - diltiazem hcl

coated beads cap er 24hr 120 mg,

180 mg, 240 mg, 360 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CARDIZEM LA - diltiazem hcl coated

beads tab er 24hr 120 mg

CARDIZEM LA - diltiazem hcl coated

beads tab er 24hr 180 mg, 240

mg, 300 mg, 360 mg, 420 mg

CONJUPRI - levamlodipine maleate

tab 2.5 mg, 5 mg

diltiazem hcl cap er 12hr 60 mg,

90 mg, 120 mg

diltiazem hcl cap er 24hr 120 mg,

180 mg, 240 mg

diltiazem hcl coated beads cap er

24hr 120 mg, 180 mg, 240 mg,

300 mg, 360 mg (Cardizem cd)

diltiazem hcl coated beads tab er

24hr 180 mg, 240 mg, 300 mg,

360 mg, 420 mg (Cardizem la)

diltiazem hcl extended release

beads cap er 24hr 120 mg,

180 mg, 240 mg, 300 mg,

360 mg, 420 mg (Tiazac)

diltiazem hcl tab 30 mg, 60 mg,

120 mg (Cardizem)

diltiazem hcl tab 90 mg

felodipine tab er 24hr 2.5 mg,

5 mg, 10 mg

isradipine cap 2.5 mg, 5 mg

KATERZIA - amlodipine benzoate

oral susp 1 mg/ml (base

equivalent)

LEVAMLODIPINE - levamlodipine

maleate tab 2.5 mg, 5 mg

nicardipine hcl cap 20 mg, 30 mg

nifedipine cap 10 mg, 20 mg

nifedipine tab er 24hr 30 mg,

60 mg, 90 mg

nifedipine tab er 24hr osmotic

release 30 mg, 60 mg, 90 mg

(Procardia xl)

nimodipine cap 30 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 34

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NISOLDIPINE ER - nisoldipine tab er

24hr 20 mg, 25.5 mg, 30 mg, 40

nisoldipine tab er 24hr 8.5 mg,

17 mg, 34 mg (Sular)

NORLIQVA - amlodipine besylate

oral soln 1 mg/ml (base

equivalent)

• •

NORVASC - amlodipine besylate tab

2.5 mg (base equivalent), 5 mg

(base equivalent), 10 mg (base

equivalent)

NYMALIZE - nimodipine oral soln 6

mg/ml

•

PROCARDIA XL - nifedipine tab er

24hr osmotic release 30 mg, 60

mg, 90 mg

SULAR - nisoldipine tab er 24hr 8.5

mg, 17 mg, 34 mg

TIAZAC - diltiazem hcl extended

release beads cap er 24hr 120

mg, 180 mg, 240 mg, 300 mg, 360

mg, 420 mg

verapamil hcl cap er 24hr 120 mg,

180 mg, 240 mg (Verelan)

VERAPAMIL HCL ER - verapamil hcl

cap er 24hr 100 mg, 300 mg

VERAPAMIL HCL SR - verapamil hcl

cap er 24hr 360 mg

verapamil hcl tab er 120 mg,

180 mg, 240 mg (Calan sr)

verapamil hcl tab 40 mg, 80 mg,

120 mg

VERAPAMIL HYDROCHLORIDE E -

verapamil hcl cap er 24hr 200 mg

VERELAN - verapamil hcl cap er

24hr 120 mg, 180 mg, 240 mg,

360 mg

VERELAN PM - verapamil hcl cap er

24hr 100 mg, 200 mg, 300 mg

ANTIARRHYTHMICS

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

amiodarone hcl tab 100 mg,

200 mg, 400 mg

disopyramide phosphate cap

100 mg, 150 mg (Norpace)

dofetilide cap 125 mcg (0.125 mg),

250 mcg (0.25 mg), 500 mcg

(0.5 mg) (Tikosyn)

flecainide acetate tab 50 mg,

100 mg, 150 mg

mexiletine hcl cap 150 mg,

200 mg, 250 mg

MULTAQ - dronedarone hcl tab 400

mg (base equivalent)

NORPACE - disopyramide

phosphate cap 100 mg, 150 mg

NORPACE CR - disopyramide

phosphate cap er 12hr 100 mg,

150 mg

propafenone hcl cap er 12hr

225 mg, 325 mg, 425 mg

(Rythmol sr)

propafenone hcl tab 150 mg,

225 mg, 300 mg

quinidine gluconate tab er 324 mg

QUINIDINE SULFATE - quinidine

sulfate tab 200 mg, 300 mg

RYTHMOL SR - propafenone hcl cap

er 12hr 225 mg, 325 mg, 425 mg

TIKOSYN - dofetilide cap 125 mcg

(0.125 mg), 250 mcg (0.25 mg),

500 mcg (0.5 mg)

ANTIHYPERTENSIVES

ACCUPRIL - quinapril hcl tab 5 mg,

10 mg, 20 mg, 40 mg

ACCURETIC - quinapril-

hydrochlorothiazide tab 10-12.5

mg, 20-12.5 mg, 20-25 mg

aliskiren fumarate tab 150 mg

(base equivalent), 300 mg (base

equivalent) (Tekturna)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 35

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ALTACE - ramipril cap 1.25 mg, 2.5

mg, 5 mg, 10 mg

amlodipine besylate-benazepril

hcl cap 2.5-10 mg, 5-40 mg

amlodipine besylate-benazepril

hcl cap 5-10 mg, 5-20 mg,

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

amlodipine besylate-olmesartan

medoxomil tab 5-20 mg,

5-40 mg, 10-20 mg, 10-40 mg

(Azor)

•

amlodipine besylate-valsartan tab

5-160 mg, 5-320 mg, 10-160 mg,

10-320 mg (Exforge)

•

amlodipine-valsartan-

hydrochlorothiazide tab

5-160-12.5 mg, 5-160-25 mg,

10-160-12.5 mg, 10-160-25 mg,

10-320-25 mg (Exforge hct)

•

ATACAND - candesartan cilexetil tab

4 mg, 8 mg, 16 mg, 32 mg

ATACAND HCT - candesartan

cilexetil-hydrochlorothiazide tab

16-12.5 mg, 32-12.5 mg, 32-25

atenolol & chlorthalidone tab

50-25 mg (Tenoretic 50)

atenolol & chlorthalidone tab

100-25 mg (Tenoretic 100)

AVALIDE - irbesartan-

hydrochlorothiazide tab 150-12.5

mg, 300-12.5 mg

AVAPRO - irbesartan tab 75 mg, 150

mg, 300 mg

AZOR - amlodipine besylate-

olmesartan medoxomil tab 5-20

mg, 5-40 mg, 10-20 mg, 10-40 mg

benazepril & hydrochlorothiazide

tab 10-12.5 mg, 20-12.5 mg,

20-25 mg (Lotensin hct)

benazepril hcl tab 5 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

benazepril hcl tab 10 mg, 20 mg,

40 mg (Lotensin)

BENAZEPRIL HCL/HYDROCHLOR -

benazepril & hydrochlorothiazide

tab 5-6.25 mg

BENICAR - olmesartan medoxomil

tab 5 mg, 20 mg, 40 mg

BENICAR HCT - olmesartan

medoxomil-hydrochlorothiazide

tab 20-12.5 mg, 40-12.5 mg,

40-25 mg

bisoprolol & hydrochlorothiazide

tab 2.5-6.25 mg, 5-6.25 mg,

10-6.25 mg (Ziac)

candesartan cilexetil tab 4 mg,

8 mg, 16 mg, 32 mg (Atacand)

•

candesartan cilexetil-

hydrochlorothiazide tab

16-12.5 mg, 32-12.5 mg,

32-25 mg (Atacand hct)

•

captopril tab 12.5 mg, 25 mg,

50 mg, 100 mg

CARDURA - doxazosin mesylate tab

1 mg, 2 mg, 4 mg, 8 mg

CATAPRES-TTS-1 - clonidine td

patch weekly 0.1 mg/24hr

CATAPRES-TTS-2 - clonidine td

patch weekly 0.2 mg/24hr

CATAPRES-TTS-3 - clonidine td

patch weekly 0.3 mg/24hr

clonidine hcl tab 0.1 mg, 0.2 mg,

0.3 mg

clonidine td patch weekly

0.1 mg/24hr (Catapres-tts-1)

•

clonidine td patch weekly

0.2 mg/24hr (Catapres-tts-2)

•

clonidine td patch weekly

0.3 mg/24hr (Catapres-tts-3)

•

COZAAR - losartan potassium tab

25 mg, 50 mg, 100 mg

DEMSER - metyrosine cap 250 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 36

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DIBENZYLINE - phenoxybenzamine

hcl cap 10 mg

DIOVAN - valsartan tab 40 mg, 80

mg, 160 mg, 320 mg

DIOVAN HCT - valsartan-

hydrochlorothiazide tab 80-12.5

mg, 160-12.5 mg, 160-25 mg,

320-12.5 mg, 320-25 mg

doxazosin mesylate tab 1 mg,

2 mg, 4 mg, 8 mg (Cardura)

•

DUTOPROL - metoprolol &

hydrochlorothiazide tab er 24hr

50-12.5 mg

EDARBI - azilsartan medoxomil tab

40 mg, 80 mg

• •

EDARBYCLOR - azilsartan

medoxomil-chlorthalidone tab

40-12.5 mg, 40-25 mg

• •

enalapril maleate &

hydrochlorothiazide tab

5-12.5 mg

enalapril maleate &

hydrochlorothiazide tab

10-25 mg (Vaseretic)

enalapril maleate tab 2.5 mg,

5 mg, 10 mg, 20 mg (Vasotec)

EPANED - enalapril maleate oral

soln 1 mg/ml

eplerenone tab 25 mg, 50 mg

(Inspra)

EXFORGE - amlodipine besylate-

valsartan tab 5-160 mg, 5-320 mg,

10-160 mg, 10-320 mg

EXFORGE HCT - amlodipine-

valsartan-hydrochlorothiazide

tab 5-160-12.5 mg, 5-160-25 mg,

10-160-12.5 mg, 10-160-25 mg,

10-320-25 mg

fosinopril sodium &

hydrochlorothiazide tab

10-12.5 mg, 20-12.5 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

fosinopril sodium tab 10 mg,

20 mg, 40 mg

guanfacine hcl tab 1 mg, 2 mg

hydralazine hcl tab 10 mg, 25 mg,

50 mg, 100 mg

HYZAAR - losartan potassium &

hydrochlorothiazide tab 50-12.5

mg, 100-12.5 mg, 100-25 mg

INSPRA - eplerenone tab 25 mg, 50

irbesartan tab 75 mg, 150 mg,

300 mg (Avapro)

•

irbesartan-hydrochlorothiazide

tab 150-12.5 mg, 300-12.5 mg

(Avalide)

•

lisinopril & hydrochlorothiazide

tab 10-12.5 mg, 20-12.5 mg,

20-25 mg (Zestoretic)

lisinopril tab 2.5 mg, 5 mg, 10 mg,

20 mg, 30 mg, 40 mg (Zestril)

losartan potassium &

hydrochlorothiazide tab

50-12.5 mg, 100-12.5 mg,

100-25 mg (Hyzaar)

•

losartan potassium tab 25 mg,

50 mg, 100 mg (Cozaar)

•

LOTENSIN - benazepril hcl tab 10

mg, 20 mg, 40 mg

LOTENSIN HCT - benazepril &

hydrochlorothiazide tab 10-12.5

mg, 20-12.5 mg, 20-25 mg

LOTREL - amlodipine besylate-

benazepril hcl cap 5-10 mg, 5-20

mg, 10-20 mg, 10-40 mg

metoprolol & hydrochlorothiazide

tab 50-25 mg, 100-25 mg,

100-50 mg

metyrosine cap 250 mg (Demser)

MICARDIS - telmisartan tab 20 mg,

40 mg, 80 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 37

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MICARDIS HCT - telmisartan-

hydrochlorothiazide tab 40-12.5

mg, 80-12.5 mg, 80-25 mg

MINIPRESS - prazosin hcl cap 1 mg,

2 mg, 5 mg

minoxidil tab 2.5 mg, 10 mg

moexipril hcl tab 7.5 mg, 15 mg

NEXICLON XR - clonidine hcl tab er

24hr 0.17 mg (base equivalent)

olmesartan medoxomil tab 5 mg,

20 mg, 40 mg (Benicar)

•

olmesartan medoxomil-

hydrochlorothiazide tab

20-12.5 mg, 40-12.5 mg,

40-25 mg (Benicar hct)

•

olmesartan-amlodipine-

hydrochlorothiazide tab

20-5-12.5 mg, 40-5-12.5 mg,

40-5-25 mg, 40-10-12.5 mg,

40-10-25 mg (Tribenzor)

•

perindopril erbumine tab 2 mg,

4 mg, 8 mg

phenoxybenzamine hcl cap 10 mg

(Dibenzyline)

prazosin hcl cap 1 mg, 2 mg, 5 mg

(Minipress)

PRESTALIA - perindopril arginine-

amlodipine besylate tab 3.5-2.5

mg, 7-5 mg, 14-10 mg

quinapril hcl tab 5 mg, 10 mg,

20 mg, 40 mg (Accupril)

quinapril-hydrochlorothiazide

tab 10-12.5 mg, 20-12.5 mg,

20-25 mg (Accuretic)

ramipril cap 1.25 mg, 2.5 mg,

5 mg, 10 mg (Altace)

TEKTURNA - aliskiren fumarate tab

150 mg (base equivalent), 300 mg

(base equivalent)

TEKTURNA HCT - aliskiren-

hydrochlorothiazide tab 150-12.5

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

mg, 150-25 mg, 300-12.5 mg,

300-25 mg

telmisartan tab 20 mg, 40 mg,

80 mg (Micardis)

•

telmisartan-amlodipine tab

40-5 mg, 40-10 mg, 80-5 mg,

80-10 mg

•

telmisartan-hydrochlorothiazide

tab 40-12.5 mg, 80-12.5 mg,

80-25 mg (Micardis hct)

•

TENORETIC 100 - atenolol &

chlorthalidone tab 100-25 mg

TENORETIC 50 - atenolol &

chlorthalidone tab 50-25 mg

terazosin hcl cap 1 mg (base

equivalent), 2 mg (base

equivalent), 5 mg (base

equivalent), 10 mg (base

equivalent)

•

trandolapril tab 1 mg, 2 mg, 4 mg

TRANDOLAPRIL/VERAPAMIL HC -

trandolapril-verapamil hcl tab er

1-240 mg, 2-180 mg, 2-240 mg,

4-240 mg

TRIBENZOR - olmesartan-

amlodipine-hydrochlorothiazide

tab 20-5-12.5 mg, 40-5-12.5

mg, 40-5-25 mg, 40-10-12.5 mg,

40-10-25 mg

VALSARTAN - valsartan oral soln 4

mg/ml

• •

valsartan tab 40 mg, 80 mg,

160 mg, 320 mg (Diovan)

•

valsartan-hydrochlorothiazide

tab 80-12.5 mg, 160-12.5 mg,

160-25 mg, 320-12.5 mg,

320-25 mg (Diovan hct)

•

VASERETIC - enalapril maleate &

hydrochlorothiazide tab 10-25 mg

VASOTEC - enalapril maleate tab

2.5 mg, 5 mg, 10 mg, 20 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 38

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VECAMYL - mecamylamine hcl tab

2.5 mg

• • •

ZESTORETIC - lisinopril &

hydrochlorothiazide tab 10-12.5

mg, 20-12.5 mg, 20-25 mg

ZESTRIL - lisinopril tab 2.5 mg, 5

mg, 10 mg, 20 mg, 30 mg, 40 mg

ZIAC - bisoprolol &

hydrochlorothiazide tab 2.5-6.25

mg, 5-6.25 mg, 10-6.25 mg

DIURETICS

acetazolamide cap er 12hr 500 mg

acetazolamide tab 125 mg,

250 mg

ALDACTAZIDE - spironolactone &

hydrochlorothiazide tab 25-25 mg

ALDACTAZIDE - spironolactone &

hydrochlorothiazide tab 50-50 mg

ALDACTONE - spironolactone tab

25 mg, 50 mg, 100 mg

amiloride & hydrochlorothiazide

tab 5-50 mg

amiloride hcl tab 5 mg

bumetanide tab 0.5 mg (Bumex)

bumetanide tab 1 mg, 2 mg

BUMEX - bumetanide tab 0.5 mg

CAROSPIR - spironolactone susp 25

mg/5ml

chlorthalidone tab 25 mg, 50 mg

DIURIL - chlorothiazide susp 250

mg/5ml

•

DYRENIUM - triamterene cap 50 mg,

100 mg

EDECRIN - ethacrynic acid tab 25

•

ethacrynic acid tab 25 mg

(Edecrin)

FUROSEMIDE - furosemide oral

soln 8 mg/ml

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

furosemide oral soln 10 mg/ml

furosemide tab 20 mg, 40 mg,

80 mg (Lasix)

hydrochlorothiazide cap 12.5 mg

hydrochlorothiazide tab 12.5 mg,

25 mg, 50 mg

indapamide tab 1.25 mg, 2.5 mg

KEVEYIS - dichlorphenamide tab 50

LASIX - furosemide tab 20 mg, 40

mg, 80 mg

MAXZIDE - triamterene &

hydrochlorothiazide tab 75-50 mg

MAXZIDE-25 - triamterene &

hydrochlorothiazide tab 37.5-25

methazolamide tab 25 mg, 50 mg

metolazone tab 2.5 mg, 5 mg,

10 mg

SOAANZ - torsemide tab 20 mg, 40

mg, 60 mg

spironolactone &

hydrochlorothiazide tab

25-25 mg (Aldactazide)

spironolactone tab 25 mg, 50 mg,

100 mg (Aldactone)

THALITONE - chlorthalidone tab 15

torsemide tab 5 mg, 10 mg,

20 mg, 100 mg

triamterene &

hydrochlorothiazide cap

37.5-25 mg

triamterene &

hydrochlorothiazide tab

37.5-25 mg (Maxzide-25)

triamterene &

hydrochlorothiazide tab

75-50 mg (Maxzide)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 39

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

triamterene cap 50 mg, 100 mg

(Dyrenium)

VASOPRESSORS

AUVI-Q - epinephrine solution

auto-injector 0.1 mg/0.1ml, 0.15

mg/0.15ml (1:1000), 0.3 mg/0.3ml

(1:1000)

droxidopa cap 100 mg, 200 mg,

300 mg (Northera)

EPINEPHRINE - epinephrine

solution auto-injector 0.15

mg/0.15ml (1:1000), 0.3 mg/0.3ml

(1:1000)

epinephrine solution auto-injector

0.15 mg/0.3ml (1:2000) (Epipen-jr

2-pak)

•

epinephrine solution auto-injector

0.3 mg/0.3ml (1:1000) (Epipen 2-

pak)

•

EPIPEN 2-PAK - epinephrine

solution auto-injector 0.3 mg/0.3ml

(1:1000)

EPIPEN-JR 2-PAK - epinephrine

solution auto-injector 0.15

mg/0.3ml (1:2000)

midodrine hcl tab 2.5 mg, 5 mg,

10 mg

NORTHERA - droxidopa cap 100

mg, 200 mg, 300 mg

SYMJEPI - epinephrine soln prefilled

syringe 0.15 mg/0.3ml (1:2000)

•

SYMJEPI - epinephrine solution

prefilled syringe 0.3 mg/0.3ml

(1:1000)

•

ANTIHYPERLIPIDEMICS

ALTOPREV - lovastatin tab er 24hr

20 mg, 40 mg, 60 mg

ANTARA - fenofibrate micronized

cap 30 mg, 90 mg

atorvastatin calcium tab 10 mg

(base equivalent), 20 mg

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

(base equivalent), 40 mg

(base equivalent), 80 mg (base

equivalent) (Lipitor)

cholestyramine light powder

packets 4 gm

cholestyramine light powder

4 gm/dose (Questran light)

cholestyramine powder packets

4 gm (Questran)

cholestyramine powder 4 gm/

dose (Questran)

choline fenofibrate cap dr 45 mg

(fenofibric acid equiv), 135 mg

(fenofibric acid equiv) (Trilipix)

colesevelam hcl packet for susp

3.75 gm (Welchol)

colesevelam hcl tab 625 mg

(Welchol)

COLESTID - colestipol hcl granule

packets 5 gm

COLESTID - colestipol hcl granules

5 gm

COLESTID - colestipol hcl tab 1 gm

COLESTID FLAVORED - colestipol

hcl granule packets 5 gm

COLESTID FLAVORED - colestipol

hcl granules 5 gm

colestipol hcl granule packets

5 gm (Colestid flavored)

colestipol hcl granules 5 gm

(Colestid flavored)

colestipol hcl tab 1 gm (Colestid)

CRESTOR - rosuvastatin calcium tab

5 mg, 10 mg, 20 mg, 40 mg

EZALLOR SPRINKLE - rosuvastatin

calcium sprinkle cap 5 mg

(base equivalent), 10 mg

(base equivalent), 20 mg

(base equivalent), 40 mg (base

equivalent)

ezetimibe tab 10 mg (Zetia)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 40

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ezetimibe-simvastatin tab

10-10 mg, 10-20 mg, 10-40 mg,

10-80 mg (Vytorin)

EZETIMIBE/ROSUVASTATIN -

ezetimibe-rosuvastatin calcium

tab 10-5 mg, 10-10 mg, 10-20 mg,

10-40 mg

FENOFIBRATE - fenofibrate cap 50

mg, 150 mg

FENOFIBRATE MICRONIZED -

fenofibrate micronized cap 30 mg,

90 mg

fenofibrate micronized cap 43 mg,

130 mg

fenofibrate micronized cap 67 mg,

134 mg, 200 mg

•

fenofibrate tab 40 mg, 120 mg

(Fenoglide)

fenofibrate tab 48 mg, 145 mg

(Tricor)

•

fenofibrate tab 54 mg, 160 mg

•

FENOFIBRIC ACID - fenofibric acid

tab 35 mg, 105 mg

FENOGLIDE - fenofibrate tab 40 mg,

120 mg

FIBRICOR - fenofibric acid tab 35

mg, 105 mg

FLOLIPID - simvastatin susp 20

mg/5ml (4 mg/ml), 40 mg/5ml (8

mg/ml)

fluvastatin sodium cap 20 mg

(base equivalent), 40 mg (base

equivalent)

• •

fluvastatin sodium tab er 24 hr

80 mg (base equivalent) (Lescol

xl)

• •

gemfibrozil tab 600 mg (Lopid)

•

icosapent ethyl cap 1 gm

(Vascepa)

• •

JUXTAPID - lomitapide mesylate cap

5 mg (base equiv), 10 mg (base

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

equiv), 20 mg (base equiv), 30 mg

(base equiv)

LESCOL XL - fluvastatin sodium tab

er 24 hr 80 mg (base equivalent)

LIPITOR - atorvastatin calcium

tab 10 mg (base equivalent),

20 mg (base equivalent), 40 mg

(base equivalent), 80 mg (base

equivalent)

LIPOFEN - fenofibrate cap 50 mg,

150 mg

LIVALO - pitavastatin calcium tab 1

mg, 2 mg, 4 mg

LOPID - gemfibrozil tab 600 mg

lovastatin tab 10 mg

•

lovastatin tab 20 mg, 40 mg

• •

LOVAZA - omega-3-acid ethyl esters

cap 1 gm

NEXLETOL - bempedoic acid tab

180 mg

• •

NEXLIZET - bempedoic acid-

ezetimibe tab 180-10 mg

• •

NIACIN - niacin (antihyperlipidemic)

tab 500 mg

niacin tab er 750 mg

(antihyperlipidemic), 1000 mg

(antihyperlipidemic) (Niaspan)

NIACOR - niacin (antihyperlipidemic)

tab 500 mg

NIASPAN - niacin tab er 1000 mg

(antihyperlipidemic)

omega-3-acid ethyl esters cap

1 gm (Lovaza)

PRALUENT - alirocumab

subcutaneous solution auto-

injector 75 mg/ml, 150 mg/ml

pravastatin sodium tab 10 mg,

20 mg, 40 mg, 80 mg

• •

QUESTRAN - cholestyramine

powder packets 4 gm

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 41

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

QUESTRAN - cholestyramine

powder 4 gm/dose

QUESTRAN LIGHT - cholestyramine

light powder 4 gm/dose

REPATHA - evolocumab

subcutaneous soln prefilled

syringe 140 mg/ml

• •

REPATHA PUSHTRONEX

SYSTEM - evolocumab

subcutaneous soln cartridge/

infusor 420 mg/3.5ml

• •

REPATHA SURECLICK -

evolocumab subcutaneous soln

auto-injector 140 mg/ml

• •

rosuvastatin calcium tab 5 mg,

10 mg, 20 mg, 40 mg (Crestor)

•

ROSZET - ezetimibe-rosuvastatin

calcium tab 10-5 mg, 10-10 mg,

10-20 mg, 10-40 mg

simvastatin tab 5 mg

simvastatin tab 10 mg, 40 mg

(Zocor)

simvastatin tab 20 mg (Zocor)

•

simvastatin tab 80 mg

•

TRICOR - fenofibrate tab 48 mg, 145

TRILIPIX - choline fenofibrate cap dr

45 mg (fenofibric acid equiv), 135

mg (fenofibric acid equiv)

VYTORIN - ezetimibe-simvastatin

tab 10-10 mg, 10-20 mg, 10-40

mg, 10-80 mg

WELCHOL - colesevelam hcl packet

for susp 3.75 gm

WELCHOL - colesevelam hcl tab

625 mg

ZETIA - ezetimibe tab 10 mg

ZOCOR - simvastatin tab 10 mg, 20

mg, 40 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ZYPITAMAG - pitavastatin

magnesium tab 2 mg (base

equiv), 4 mg (base equiv)

CARDIOVASCULAR AGENTS - MISC.

ADCIRCA - tadalafil tab 20 mg (pah)

ADEMPAS - riociguat tab 0.5 mg, 1

mg, 1.5 mg, 2 mg, 2.5 mg

• • • •

ambrisentan tab 5 mg, 10 mg

(Letairis)

• • • •

amlodipine besylate-atorvastatin

calcium tab 2.5-10 mg,

2.5-20 mg, 2.5-40 mg

amlodipine besylate-atorvastatin

calcium tab 5-10 mg, 5-20 mg,

5-40 mg, 5-80 mg, 10-10 mg,

10-20 mg, 10-40 mg, 10-80 mg

(Caduet)

BIDIL - isosorbide dinitrate-

hydralazine hcl tab 20-37.5 mg

•

bosentan tab 62.5 mg, 125 mg

(Tracleer)

• • • •

CADUET - amlodipine besylate-

atorvastatin calcium tab 5-10 mg,

5-20 mg, 5-40 mg, 5-80 mg, 10-10

mg, 10-20 mg, 10-40 mg, 10-80

CIALIS - tadalafil tab 2.5 mg, 5 mg,

10 mg, 20 mg

CORLANOR - ivabradine hcl oral

soln 5 mg/5ml (base equiv)

•

CORLANOR - ivabradine hcl tab 5

mg (base equiv), 7.5 mg (base

equiv)

•

ENTRESTO - sacubitril-valsartan tab

24-26 mg, 49-51 mg, 97-103 mg

•

isosorbide dinitrate-hydralazine

hcl tab 20-37.5 mg (Bidil)

LETAIRIS - ambrisentan tab 5 mg,

10 mg

OPSUMIT - macitentan tab 10 mg

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 42

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ORENITRAM - treprostinil diolamine

tab er 0.125 mg (base equiv),

0.25 mg (base equiv), 1 mg (base

equiv), 2.5 mg (base equiv), 5 mg

(base equiv)

• • • •

REVATIO - sildenafil citrate for

suspension 10 mg/ml

REVATIO - sildenafil citrate tab 20

sildenafil citrate tab 20 mg

(Revatio)

• • • •

tadalafil tab 20 mg (pah) (Adcirca)

• • • •

tadalafil tab 5 mg (Cialis)

• •

TRACLEER - bosentan tab for oral

susp 32 mg

• • • •

TRACLEER - bosentan tab 62.5 mg,

125 mg

TYVASO DPI MAINTENANCE KI -

treprostinil inh powder 16 mcg/

cartridge, 32 mcg/cartridge, 48

mcg/cartridge, 64 mcg/cartridge,

112 x 32mcg & 112 x 48mcg

• • • •

TYVASO DPI TITRATION KIT -

treprostinil inh powder 112 x

16mcg & 84 x 32mcg

• • • •

TYVASO DPI TITRATION KIT -

treprostinil inh powd 112 x 16mcg

& 112 x 32mcg & 28 x 48mcg

• • • •

UPTRAVI - selexipag tab therapy

pack 200 mcg (140) & 800 mcg

(60)

• • • •

UPTRAVI - selexipag tab 200 mcg,

400 mcg, 600 mcg, 800 mcg,

1000 mcg, 1200 mcg, 1400 mcg,

1600 mcg

• • • •

VERQUVO - vericiguat tab 2.5 mg, 5

mg, 10 mg

• •

VIAGRA - sildenafil citrate tab 25

mg, 50 mg, 100 mg

VYNDAMAX - tafamidis cap 61 mg

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VYNDAQEL - tafamidis meglumine

(cardiac) cap 20 mg

• • • •

CIALIS - tadalafil tab 2.5 mg, 5 mg,

10 mg, 20 mg

tadalafil tab 5 mg (Cialis)

• •

VIAGRA - sildenafil citrate tab 25

mg, 50 mg, 100 mg

RESPIRATORY AGENTS

ANTIHISTAMINES

CARBINOXAMINE MALEATE -

carbinoxamine maleate soln 4

mg/5ml

CARBINOXAMINE MALEATE -

carbinoxamine maleate tab 6 mg

carbinoxamine maleate tab 4 mg

cetirizine hcl oral soln 1 mg/ml

(5 mg/5ml)

CLARINEX - desloratadine tab 5 mg

CLEMASTINE FUMARATE -

clemastine fumarate syrup 0.67

mg/5ml (0.5 mg/5ml base eq)

CLEMASTINE FUMARATE -

clemastine fumarate tab 2.68 mg

cyproheptadine hcl syrup

2 mg/5ml

cyproheptadine hcl tab 4 mg

DESLORATADINE ODT -

desloratadine tab orally

disintegrating 2.5 mg, 5 mg

desloratadine tab 5 mg (Clarinex)

diphenhydramine hcl elixir

12.5 mg/5ml

KARBINAL ER - carbinoxamine

maleate extended release susp 4

mg/5ml

levocetirizine dihydrochloride

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

levocetirizine dihydrochloride tab

5 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 43

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

promethazine hcl suppos

12.5 mg, 25 mg

promethazine hcl syrup

6.25 mg/5ml

promethazine hcl tab 12.5 mg,

25 mg, 50 mg

PROMETHEGAN - promethazine hcl

suppos 50 mg

RYCLORA - dexchlorpheniramine

maleate oral soln 2 mg/5ml

•

RYVENT - carbinoxamine maleate

tab 6 mg

NASAL AGENTS - SYSTEMIC and TOPICAL

azelastine hcl nasal spray 0.1%

(137 mcg/spray)

•

azelastine hcl nasal spray 0.15%

(205.5 mcg/spray)

azelastine hcl-fluticasone prop

nasal spray 137-50 mcg/act

(Dymista)

BECONASE AQ - beclomethasone

dipropionate monohyd nasal susp

42 mcg/spray

DYMISTA - azelastine hcl-fluticasone

prop nasal spray 137-50 mcg/act

flunisolide nasal soln 25 mcg/act

(0.025%)

ipratropium bromide nasal soln

0.03% (21 mcg/spray), 0.06%

(42 mcg/spray)

•

mometasone furoate nasal susp

50 mcg/act

olopatadine hcl nasal soln 0.6%

(Patanase)

•

OMNARIS - ciclesonide nasal susp

50 mcg/act

PATANASE - olopatadine hcl nasal

soln 0.6%

QNASL - beclomethasone

dipropionate nasal aerosol 80

mcg/act

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

QNASL CHILDRENS -

beclomethasone dipropionate

nasal aerosol 40 mcg/act

RYALTRIS - olopatadine hcl-

mometasone furoate nasal susp

665-25 mcg/act

XHANCE - fluticasone propionate

nasal exhaler susp 93 mcg/act

ZETONNA - ciclesonide nasal

aerosol soln 37 mcg/act (50 mcg/

valve)

COUGH/COLD/ALLERGY

acetylcysteine inhal soln 10%,

20%

benzonatate cap 150 mg

CLARINEX-D 12 HOUR -

desloratadine & pseudoephedrine

tab er 12hr 2.5-120 mg

HYCODAN - hydrocodone bitart-

homatropine methylbrom soln

5-1.5 mg/5ml

HYCODAN - hydrocodone bitart-

homatropine methylbromide tab

5-1.5 mg

hydrocod polst-chlorphen polst

er susp 10-8 mg/5ml

HYPERSAL - sodium chloride soln

nebu 7%

pseudoephed-bromphen-dm

syrup 30-2-10 mg/5ml

sodium chloride soln nebu 3%

sodium chloride soln nebu 7%

(Hypersal)

TUXARIN ER - codeine phos-

chlorpheniramine maleate tab er

12hr 54.3-8 mg

TUZISTRA XR - codeine polist-

chlorphen polist er susp 14.7-2.8

mg/5ml

ANTIASTHMATIC and BRONCHODILATOR AGENTS

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 44

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ACCOLATE - zafirlukast tab 10 mg,

20 mg

ADVAIR DISKUS - fluticasone-

salmeterol aer powder ba 100-50

mcg/act, 250-50 mcg/act, 500-50

mcg/act

•

ADVAIR HFA - fluticasone-salmeterol

inhal aerosol 45-21 mcg/act,

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

•

AIRDUO DIGIHALER 113/14 -

fluticasone-salmeterol aer powder

ba 113-14 mcg/act w/sensor

AIRDUO DIGIHALER 232/14 -

fluticasone-salmeterol aer powder

ba 232-14 mcg/act w/sensor

AIRDUO DIGIHALER 55/14 -

fluticasone-salmeterol aer powder

ba 55-14 mcg/act w/ sensor

AIRDUO RESPICLICK 113/14 -

fluticasone-salmeterol aer powder

ba 113-14 mcg/act

AIRDUO RESPICLICK 232/14 -

fluticasone-salmeterol aer powder

ba 232-14 mcg/act

AIRDUO RESPICLICK 55/14 -

fluticasone-salmeterol aer powder

ba 55-14 mcg/act

ALBUTEROL SULFATE HFA -

albuterol sulfate inhal aero 108

mcg/act (90mcg base equiv)

albuterol sulfate inhal aero

108 mcg/act (90mcg base equiv)

(Proventil hfa)

•

albuterol sulfate soln nebu

0.083% (2.5 mg/3ml), 0.5%

(5 mg/ml), 0.63 mg/3ml (base

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

albuterol sulfate syrup 2 mg/5ml

albuterol sulfate tab 2 mg, 4 mg

ALVESCO - ciclesonide inhal aerosol

80 mcg/act, 160 mcg/act

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ANORO ELLIPTA - umeclidinium-

vilanterol aero powd ba 62.5-25

mcg/inh

•

arformoterol tartrate soln nebu

15 mcg/2ml (base equiv)

(Brovana)

•

ARMONAIR DIGIHALER -

fluticasone propionate aer pow ba

55 mcg/act with sensor, 113 mcg/

act with sensor, 232 mcg/act with

sensor

ARNUITY ELLIPTA - fluticasone

furoate aerosol powder breath

activ 50 mcg/act, 100 mcg/act,

200 mcg/act

•

ASMANEX HFA - mometasone

furoate inhal aerosol suspension

50 mcg/act, 100 mcg/act, 200

mcg/act

•

ASMANEX TWISTHALER 120 ME -

mometasone furoate inhal powd

220 mcg/inh (breath activated)

•

ASMANEX TWISTHALER 30 MET -

mometasone furoate inhal powd

110 mcg/inh (breath activated),

220 mcg/inh (breath activated)

•

ASMANEX TWISTHALER 60 MET -

mometasone furoate inhal powd

220 mcg/inh (breath activated)

•

ATROVENT HFA - ipratropium

bromide hfa inhal aerosol 17 mcg/

act

•

BEVESPI AEROSPHERE -

glycopyrrolate-formoterol fumarate

aerosol 9-4.8 mcg/act

BREO ELLIPTA - fluticasone furoate-

vilanterol aero powd ba 100-25

mcg/inh, 200-25 mcg/inh

•

BREZTRI AEROSPHERE -

budesonide-glycopyrrolate-

formoterol aers 160-9-4.8 mcg/act

• •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 45

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

BROVANA - arformoterol tartrate

soln nebu 15 mcg/2ml (base

equiv)

budesonide inhalation susp

0.25 mg/2ml, 0.5 mg/2ml,

1 mg/2ml (Pulmicort)

•

BUDESONIDE/FORMOTEROL

FUM - budesonide-formoterol

fumarate dihyd aerosol 80-4.5

mcg/act, 160-4.5 mcg/act

COMBIVENT RESPIMAT -

ipratropium-albuterol inhal aerosol

soln 20-100 mcg/act

•

cromolyn sodium soln nebu

20 mg/2ml

•

DALIRESP - roflumilast tab 250 mcg,

500 mcg

•

DULERA - mometasone furoate-

formoterol fumarate aerosol 50-5

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

mcg/act

•

ELIXOPHYLLIN - theophylline elixir

80 mg/15ml

FASENRA PEN - benralizumab

subcutaneous soln auto-injector

30 mg/ml

• • • •

FLOVENT DISKUS - fluticasone

propionate aer pow ba 50 mcg/

blister, 100 mcg/blister, 250 mcg/

blister

•

FLOVENT HFA - fluticasone

propionate hfa inhal aero 44 mcg/

act (50/valve)

•

FLOVENT HFA - fluticasone

propionate hfa inhal aer 110 mcg/

act (125/valve), 220 mcg/act (250/

valve)

•

FLUTICASONE FUROATE/VILAN -

fluticasone furoate-vilanterol aero

powd ba 100-25 mcg/inh, 200-25

mcg/inh

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

FLUTICASONE PROPIONATE HF -

fluticasone propionate hfa inhal

aero 44 mcg/act (50/valve)

FLUTICASONE PROPIONATE HF -

fluticasone propionate hfa inhal

aer 110 mcg/act (125/valve), 220

mcg/act (250/valve)

FLUTICASONE PROPIONATE/SA -

fluticasone-salmeterol aer powder

ba 55-14 mcg/act, 113-14 mcg/

act, 232-14 mcg/act

•

fluticasone-salmeterol aer powder

ba 100-50 mcg/act, 250-50 mcg/

act, 500-50 mcg/act (Advair

diskus)

formoterol fumarate soln nebu

20 mcg/2ml (Perforomist)

INCRUSE ELLIPTA - umeclidinium

br aero powd breath act 62.5 mcg/

inh (base eq)

•

ipratropium bromide inhal soln

0.02%

•

ipratropium-albuterol nebu soln

0.5-2.5(3) mg/3ml

levalbuterol hcl soln nebu conc

1.25 mg/0.5ml (base equiv)

(Xopenex concentrate)

levalbuterol hcl soln nebu

0.31 mg/3ml (base equiv),

0.63 mg/3ml (base equiv),

1.25 mg/3ml (base equiv)

(Xopenex)

LEVALBUTEROL TARTRATE HFA -

levalbuterol tartrate inhal aerosol

45 mcg/act (base equiv)

LONHALA MAGNAIR REFILL KI -

glycopyrrolate inhal solution 25

mcg/ml

LONHALA MAGNAIR STARTER K -

glycopyrrolate inhal solution 25

mcg/ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 46

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

montelukast sodium chew tab

4 mg (base equiv), 5 mg (base

equiv) (Singulair)

•

montelukast sodium

oral granules packet 4 mg (base

equiv) (Singulair)

montelukast sodium tab 10 mg

(base equiv) (Singulair)

•

NUCALA - mepolizumab

subcutaneous solution auto-

injector 100 mg/ml

• • • •

NUCALA - mepolizumab

subcutaneous solution pref

syringe 40 mg/0.4ml, 100 mg/ml

• • • •

PERFOROMIST - formoterol

fumarate soln nebu 20 mcg/2ml

PROAIR DIGIHALER - albuterol

sulfate aer pow ba 108 mcg/act

with sensor

PROAIR HFA - albuterol sulfate inhal

aero 108 mcg/act (90mcg base

equiv)

PROAIR RESPICLICK - albuterol

sulfate aer pow ba 108 mcg/act

(90 mcg base equiv)

PROVENTIL HFA - albuterol sulfate

inhal aero 108 mcg/act (90mcg

base equiv)

PULMICORT - budesonide inhalation

susp 0.25 mg/2ml, 0.5 mg/2ml, 1

mg/2ml

PULMICORT FLEXHALER -

budesonide inhal aero powd 90

mcg/act (breath activated), 180

mcg/act (breath activated)

QVAR REDIHALER -

beclomethasone diprop hfa breath

act inh aer 40 mcg/act, 80 mcg/act

•

SEREVENT DISKUS - salmeterol

xinafoate aer pow ba 50 mcg/dose

(base equiv)

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SINGULAIR - montelukast sodium

chew tab 4 mg (base equiv), 5 mg

(base equiv)

SINGULAIR - montelukast sodium

oral granules packet 4 mg (base

equiv)

SINGULAIR - montelukast sodium

tab 10 mg (base equiv)

SPIRIVA HANDIHALER - tiotropium

bromide monohydrate inhal cap

18 mcg (base equiv)

•

SPIRIVA RESPIMAT - tiotropium

bromide monohydrate inhal

aerosol 1.25 mcg/act, 2.5 mcg/act

•

STIOLTO RESPIMAT - tiotropium br-

olodaterol inhal aero soln 2.5-2.5

mcg/act

•

STRIVERDI RESPIMAT - olodaterol

hcl inhal aerosol soln 2.5 mcg/act

(base equiv)

•

SYMBICORT - budesonide-

formoterol fumarate dihyd aerosol

80-4.5 mcg/act, 160-4.5 mcg/act

•

terbutaline sulfate tab 2.5 mg,

5 mg

THEO-24 - theophylline cap er 24hr

100 mg, 200 mg, 300 mg, 400 mg

theophylline soln 80 mg/15ml

theophylline tab er 12hr 300 mg,

450 mg

theophylline tab er 24hr 400 mg,

600 mg

TRELEGY ELLIPTA - fluticasone-

umeclidinium-vilanterol aepb

100-62.5-25 mcg/inh, 200-62.5-25

mcg/inh

•

TUDORZA PRESSAIR - aclidinium

bromide aerosol powd breath

activated 400 mcg/act

VENTOLIN HFA - albuterol sulfate

inhal aero 108 mcg/act (90mcg

base equiv)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 47

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

XOLAIR - omalizumab subcutaneous

soln prefilled syringe 75 mg/0.5ml,

150 mg/ml

• • •

XOPENEX - levalbuterol hcl soln

nebu 0.31 mg/3ml (base equiv),

0.63 mg/3ml (base equiv), 1.25

mg/3ml (base equiv)

XOPENEX CONCENTRATE -

levalbuterol hcl soln nebu conc

1.25 mg/0.5ml (base equiv)

XOPENEX HFA - levalbuterol tartrate

inhal aerosol 45 mcg/act (base

equiv)

YUPELRI - revefenacin inhalation

solution 175 mcg/3ml

zafirlukast tab 10 mg, 20 mg

(Accolate)

•

zileuton tab er 12hr 600 mg

•

ZYFLO - zileuton tab 600 mg

RESPIRATORY AGENTS - MISC.

BRONCHITOL - mannitol inhal cap

40 mg

BRONCHITOL TOLERANCE TEST -

mannitol inhal cap 40 mg

ESBRIET - pirfenidone cap 267 mg

• • • •

ESBRIET - pirfenidone tab 267 mg,

801 mg

• • • •

KALYDECO - ivacaftor packet 25

mg, 50 mg, 75 mg

• • • •

KALYDECO - ivacaftor tab 150 mg

• • • •

OFEV - nintedanib esylate cap 100

mg (base equivalent), 150 mg

(base equivalent)

• • • •

ORKAMBI - lumacaftor-ivacaftor

granules packet 100-125 mg,

150-188 mg

• • • •

ORKAMBI - lumacaftor-ivacaftor tab

100-125 mg, 200-125 mg

• • • •

PIRFENIDONE - pirfenidone tab 534

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

pirfenidone tab 267 mg, 801 mg

(Esbriet)

• • • •

PULMOZYME - dornase alfa inhal

soln 2.5 mg/2.5ml

• • •

SYMDEKO - tezacaftor-ivacaftor

50-75 mg & ivacaftor 75 mg tab

tbpk

• • • •

SYMDEKO - tezacaftor-ivacaftor

100-150 mg & ivacaftor 150 mg

tab tbpk

• • • •

TRIKAFTA - elexacaf-tezacaf-ivacaf

50-25-37.5 mg & ivacaftor 75 mg

tbpk

• • • •

TRIKAFTA - elexacaf-tezacaf-ivacaf

100-50-75 mg &ivacaftor 150 mg

tbpk

• • • •

GASTROINTESTINAL AGENTS

LAXATIVES

CLENPIQ - sod picosulfate-mg ox-

citric ac sol 10 mg-3.5 gm-12

gm/160ml

GAVILYTE-C - peg 3350-kcl-na

bicarb-nacl-na sulfate for soln 240

GOLYTELY - peg 3350-kcl-na

bicarb-nacl-na sulfate for soln 236

KRISTALOSE - lactulose oral crystal

packet 10 gm, 20 gm

LACTULOSE - lactulose oral crystal

packet 10 gm

lactulose solution 10 gm/15ml

MOVIPREP - peg 3350-kcl-nacl-na

sulfate-na ascorbate-c for soln

100 gm

OSMOPREP - sod phos mono-

sod phos di tabs 1.102-0.398

gm(1.5gm na phos)

peg 3350-kcl-na bicarb-nacl-

na sulfate for soln 236 gm

(Golytely)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 48

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

peg 3350-kcl-nacl-na sulfate-na

ascorbate-c for soln 100 gm

(Moviprep)

peg 3350-kcl-sod bicarb-nacl for

soln 420 gm

•

PEG-PREP - bisacodyl tab & peg

3350-kcl-sod bicarb-nacl for soln

kit

PLENVU - peg 3350-kcl-nacl-na

sulfate-na ascorbate-c for soln

140 gm

sod sulfate-pot sulf-mg sulf oral

sol 17.5-3.13-1.6 gm/177ml

(Suprep bowel prep ki)

SUPREP BOWEL PREP KIT - sod

sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/177ml

SUTAB - sod sulfate-mg sulfate-pot

chloride tab 1479-225-188 mg

•

ANTIDIARRHEALS

diphenoxylate w/ atropine tab

2.5-0.025 mg (Lomotil)

DIPHENOXYLATE/ATROPINE -

diphenoxylate w/ atropine liq

2.5-0.025 mg/5ml

LOMOTIL - diphenoxylate w/

atropine tab 2.5-0.025 mg

loperamide hcl cap 2 mg

MYTESI - crofelemer tab delayed

release 125 mg

ULCER DRUGS

ACIPHEX - rabeprazole sodium ec

tab 20 mg

CARAFATE - sucralfate susp 1

gm/10ml

CARAFATE - sucralfate tab 1 gm

chlordiazepoxide hcl-clidinium

bromide cap 5-2.5 mg (Librax)

cimetidine hcl soln 300 mg/5ml

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

cimetidine tab 200 mg, 300 mg,

400 mg, 800 mg

CUVPOSA - glycopyrrolate oral soln

1 mg/5ml

CYTOTEC - misoprostol tab 100

mcg, 200 mcg

DARTISLA ODT - glycopyrrolate tab

disintegrating 1.7 mg

DEXILANT - dexlansoprazole cap

delayed release 30 mg, 60 mg

• •

DEXLANSOPRAZOLE -

dexlansoprazole cap delayed

release 30 mg, 60 mg

dicyclomine hcl cap 10 mg

dicyclomine hcl oral soln

10 mg/5ml

dicyclomine hcl tab 20 mg

DONNATAL - pb-hyoscy-

atrop-scopol elix

16.2-0.1037-0.0194-0.0065

mg/5ml

DONNATAL - pb-hyoscy-

atrop-scopol tab

16.2-0.1037-0.0194-0.0065 mg

esomeprazole magnesium cap

delayed release 20 mg (base

eq), 40 mg (base eq) (Nexium)

esomeprazole magnesium for

delayed release susp packet

10 mg, 20 mg, 40 mg (Nexium)

•

ESOMEPRAZOLE STRONTIUM -

esomeprazole strontium cap

delayed release 49.3 mg

famotidine tab 20 mg (Pepcid)

famotidine tab 40 mg (Pepcid)

GLYCATE - glycopyrrolate tab 1.5

GLYCOPYRROLATE -

glycopyrrolate tab 1.5 mg

glycopyrrolate oral soln 1 mg/5ml

(Cuvposa)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 49

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

glycopyrrolate tab 1 mg (Robinul)

glycopyrrolate tab 2 mg (Robinul

forte)

HELIDAC THERAPY - metronidaz

tab-tetracyc cap-bis subsal chew

tab therapy pack

lansoprazole cap delayed release

15 mg

lansoprazole cap delayed release

30 mg (Prevacid)

•

lansoprazole tab delayed release

orally disintegrating 15 mg,

30 mg (Prevacid solutab)

LANSOPRAZOLE/AMOXICILLIN/ -

amoxicillin cap-clarithro tab-

lansopraz cap dr therapy pack

• •

LIBRAX - chlordiazepoxide hcl-

clidinium bromide cap 5-2.5 mg

methscopolamine bromide tab

2.5 mg, 5 mg

misoprostol tab 100 mcg,

200 mcg (Cytotec)

NEXIUM - esomeprazole

magnesium cap delayed release

20 mg (base eq), 40 mg (base eq)

NEXIUM - esomeprazole

magnesium for delayed release

susp packet 5 mg

• •

NEXIUM - esomeprazole

magnesium for delayed release

susp packet 10 mg, 20 mg, 40 mg

NEXIUM - esomeprazole

magnesium for delayed release

susp pack 2.5 mg

• •

NIZATIDINE - nizatidine cap 150 mg,

300 mg

OMECLAMOX-PAK - amoxicillin cap-

clarithro tab w/ omepraz cap dr

therapy pack

omeprazole cap delayed release

10 mg, 40 mg

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

omeprazole-sodium bicarbonate

cap 20-1100 mg, 40-1100 mg

(Zegerid)

omeprazole-sodium bicarbonate

powd pack for susp

20-1680 mg, 40-1680 mg

(Zegerid)

pantoprazole sodium ec tab

20 mg (base equiv), 40 mg (base

equiv) (Protonix)

•

pantoprazole sodium for delayed

release susp packet 40 mg

(Protonix)

PEPCID - famotidine tab 20 mg, 40

PREVACID - lansoprazole cap

delayed release 30 mg

PREVACID SOLUTAB - lansoprazole

tab delayed release orally

disintegrating 15 mg, 30 mg

PRILOSEC - omeprazole

magnesium for delayed release

susp packet 2.5 mg, 10 mg

PROTONIX - pantoprazole sodium

ec tab 20 mg (base equiv), 40 mg

(base equiv)

PROTONIX - pantoprazole sodium

for delayed release susp packet

40 mg

PYLERA - bismuth subcit-

metronidazole-tetracycline cap

140-125-125 mg

RABEPRAZOLE SODIUM DR SPR -

rabeprazole sodium capsule

sprinkle dr 10 mg

rabeprazole sodium ec tab 20 mg

(Aciphex)

•

ROBINUL - glycopyrrolate tab 1 mg

ROBINUL FORTE - glycopyrrolate

tab 2 mg

sucralfate susp 1 gm/10ml

(Carafate)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 50

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

sucralfate tab 1 gm (Carafate)

TALICIA - amoxicillin-rifabutin-

omeprazole cap dr 250-12.5-10

VOQUEZNA DUAL PAK - amoxicillin

cap 500 mg & vonoprazan tab 20

mg therapy pack

• •

VOQUEZNA TRIPLE PAK -

amoxicillin cap & clarithromycin

tab & vonoprazan tab pack

• •

ZEGERID - omeprazole-sodium

bicarbonate cap 20-1100 mg,

40-1100 mg

ZEGERID - omeprazole-sodium

bicarbonate powd pack for susp

20-1680 mg, 40-1680 mg

ANTIEMETICS

AKYNZEO - netupitant-palonosetron

cap 300-0.5 mg

ANTIVERT - meclizine hcl chew tab

25 mg

ANTIVERT - meclizine hcl tab 50 mg

ANZEMET - dolasetron mesylate tab

50 mg

•

aprepitant capsule therapy pack

80 & 125 mg (Emend tripack)

•

aprepitant capsule 40 mg, 125 mg

•

aprepitant capsule 80 mg (Emend)

•

BONJESTA - doxylamine-pyridoxine

tab er 20-20 mg

DICLEGIS - doxylamine-pyridoxine

tab delayed release 10-10 mg

doxylamine-pyridoxine tab

delayed release 10-10 mg

(Diclegis)

dronabinol cap 2.5 mg (Marinol)

dronabinol cap 5 mg, 10 mg

EMEND - aprepitant capsule 80 mg

EMEND - aprepitant for oral susp

125 mg (125 mg/5ml)

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

EMEND TRIPACK - aprepitant

capsule therapy pack 80 & 125

granisetron hcl tab 1 mg

•

MARINOL - dronabinol cap 2.5 mg

meclizine hcl chew tab 25 mg

(Antivert)

meclizine hcl tab 12.5 mg

meclizine hcl tab 25 mg

ONDANSETRON HCL -

ondansetron hcl tab 24 mg

•

ondansetron hcl oral soln

4 mg/5ml

•

ondansetron hcl tab 4 mg, 8 mg

•

ondansetron orally disintegrating

tab 4 mg, 8 mg

•

SANCUSO - granisetron td patch 3.1

mg/24hr (contains 34.3 mg)

scopolamine td patch 72hr

1 mg/3days (Transderm-scop)

•

SYNDROS - dronabinol soln 5 mg/ml

TRANSDERM-SCOP - scopolamine

td patch 72hr 1 mg/3days

trimethobenzamide hcl cap

300 mg

VARUBI - rolapitant hcl tab therapy

pack 2 x 90 mg (base equiv)

• •

DIGESTIVE AIDS

CREON - pancrelipase (lip-prot-

amyl) dr cap 3000-9500-15000

unit, 6000-19000-30000 unit,

12000-38000-60000 unit,

24000-76000-120000 unit,

36000-114000-180000 unit

PANCREAZE - pancrelipase

(lip-prot-amyl) dr cap

2600-8800-15200 unit,

4200-14200-24600 unit,

10500-35500-61500 unit,

16800-56800-98400 unit,

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 51

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

21000-54700-83900 unit,

37000-97300-149900 unit

PERTZYE - pancrelipase (lip-prot-

amyl) dr cap 4000-14375-15125

unit, 8000-28750-30250 unit,

16000-57500-60500 unit,

24000-86250-90750 unit

SUCRAID - sacrosidase soln 8500

unit/ml

• • • •

VIOKACE - pancrelipase (lip-prot-

amyl) tab 10440-39150-39150

unit, 20880-78300-78300 unit

ZENPEP - pancrelipase (lip-prot-

amyl) dr cap 3000-10000-14000

unit, 5000-17000-24000 unit,

10000-32000-42000 unit,

15000-47000-63000 unit,

20000-63000-84000 unit,

25000-79000-105000 unit,

40000-126000-168000 unit

GASTROINTESTINAL AGENTS- MISC.

alosetron hcl tab 0.5 mg (base

equiv), 1 mg (base equiv)

(Lotronex)

AMITIZA - lubiprostone cap 8 mcg,

24 mcg

APRISO - mesalamine cap er 24hr

0.375 gm

ASACOL HD - mesalamine tab

delayed release 800 mg

AURYXIA - ferric citrate tab 1 gm

(210 mg ferric iron)

• •

AZULFIDINE - sulfasalazine tab 500

AZULFIDINE EN-TABS -

sulfasalazine tab delayed release

500 mg

balsalazide disodium cap 750 mg

(Colazal)

•

BYLVAY - odevixibat cap 400 mcg,

1200 mcg

• • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

BYLVAY (PELLETS) - odevixibat

pellets cap sprinkle 200 mcg, 600

mcg

• • •

calcium acetate (phosphate

binder) cap 667 mg (169 mg ca)

calcium acetate (phosphate

binder) tab 667 mg

CANASA - mesalamine suppos 1000

CHENODAL - chenodiol tab 250 mg

• • •

CIMZIA - certolizumab pegol prefilled

syringe kit 2 x 200 mg/ml

• • • •

CIMZIA STARTER KIT -

certolizumab pegol prefilled

syringe kit 6 x 200 mg/ml

• • • •

COLAZAL - balsalazide disodium

cap 750 mg

cromolyn sodium oral conc

100 mg/5ml (Gastrocrom)

DELZICOL - mesalamine cap dr 400

DIPENTUM - olsalazine sodium cap

250 mg

•

FOSRENOL - lanthanum carbonate

chew tab 500 mg (elemental),

750 mg (elemental), 1000 mg

(elemental)

FOSRENOL - lanthanum carbonate

oral powder pack 750 mg

(elemental), 1000 mg (elemental)

• •

GASTROCROM - cromolyn sodium

oral conc 100 mg/5ml

GATTEX - teduglutide (rdna) for inj

kit 5 mg

• • •

GIMOTI - metoclopramide hcl nasal

spray 15 mg/act

IBSRELA - tenapanor hcl tab 50 mg

lactulose (encephalopathy)

solution 10 gm/15ml

lanthanum carbonate chew

tab 500 mg (elemental),

• •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 52

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

750 mg (elemental), 1000 mg

(elemental) (Fosrenol)

LIALDA - mesalamine tab delayed

release 1.2 gm

LINZESS - linaclotide cap 72 mcg,

145 mcg, 290 mcg

LIVMARLI - maralixibat chloride oral

soln 9.5 mg/ml

• • •

LOTRONEX - alosetron hcl tab 0.5

mg (base equiv), 1 mg (base

equiv)

LUBIPROSTONE - lubiprostone cap

8 mcg, 24 mcg

• •

mesalamine cap dr 400 mg

(Delzicol)

•

mesalamine cap er 24hr 0.375 gm

(Apriso)

•

mesalamine cap er 500 mg

(Pentasa)

mesalamine enema 4 gm

•

mesalamine suppos 1000 mg

(Canasa)

•

mesalamine tab delayed release

800 mg (Asacol hd)

•

mesalamine tab delayed release

1.2 gm (Lialda)

•

metoclopramide hcl soln

5 mg/5ml (10 mg/10ml) (base

equiv)

metoclopramide hcl tab 5 mg

(base equivalent), 10 mg (base

equivalent) (Reglan)

METOCLOPRAMIDE ODT -

metoclopramide hcl orally

disintegrating tab 5 mg (base eq)

MOTEGRITY - prucalopride

succinate tab 1 mg (base

equivalent), 2 mg (base

equivalent)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MOVANTIK - naloxegol oxalate tab

12.5 mg (base equivalent), 25 mg

(base equivalent)

• •

OCALIVA - obeticholic acid tab 5 mg,

10 mg

• • • •

PENTASA - mesalamine cap er 250

mg, 500 mg

PHOSLYRA - calcium acetate

(phosphate binder) oral soln 667

mg/5ml

REGLAN - metoclopramide hcl tab

5 mg (base equivalent), 10 mg

(base equivalent)

RELISTOR - methylnaltrexone

bromide inj 8 mg/0.4ml (20 mg/

ml), 12 mg/0.6ml (20 mg/ml)

RELISTOR - methylnaltrexone

bromide tab 150 mg

RELTONE - ursodiol cap 200 mg,

400 mg

RENAGEL - sevelamer hcl tab 800

RENVELA - sevelamer carbonate

packet 0.8 gm, 2.4 gm

RENVELA - sevelamer carbonate

tab 800 mg

sevelamer carbonate packet

0.8 gm, 2.4 gm (Renvela)

•

sevelamer carbonate tab 800 mg

(Renvela)

•

sevelamer hcl tab 800 mg

(Renagel)

•

SEVELAMER HYDROCHLORIDE -

sevelamer hcl tab 400 mg

• •

SKYRIZI - risankizumab-rzaa

subcutaneous soln cartridge 360

mg/2.4ml

• •

sulfasalazine tab delayed release

500 mg (Azulfidine en-tabs)

•

sulfasalazine tab 500 mg

(Azulfidine)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 53

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SYMPROIC - naldemedine tosylate

tab 0.2 mg (base equivalent)

• •

TRULANCE - plecanatide tab 3 mg

• •

URSO FORTE - ursodiol tab 500 mg

URSO 250 - ursodiol tab 250 mg

URSODIOL - ursodiol cap 200 mg,

400 mg

ursodiol cap 300 mg

ursodiol tab 250 mg (Urso 250)

ursodiol tab 500 mg (Urso forte)

VELPHORO - sucroferric

oxyhydroxide chew tab 500 mg

• •

VIBERZI - eluxadoline tab 75 mg,

100 mg

• •

XERMELO - telotristat ethyl tab 250

mg (as telotristat etiprate)

• • • •

GENITOURINARY AGENTS

URINARY ANTISPASMODICS

bethanechol chloride tab 5 mg,

10 mg, 25 mg, 50 mg

darifenacin hydrobromide tab er

24hr 7.5 mg (base equiv), 15 mg

(base equiv)

•

DETROL - tolterodine tartrate tab 1

mg, 2 mg

DETROL LA - tolterodine tartrate cap

er 24hr 2 mg, 4 mg

DITROPAN XL - oxybutynin chloride

tab er 24hr 5 mg, 10 mg

fesoterodine fumarate tab er 24hr

4 mg, 8 mg (Toviaz)

flavoxate hcl tab 100 mg

•

GELNIQUE - oxybutynin chloride td

gel 10%

GEMTESA - vibegron tab 75 mg

MYRBETRIQ - mirabegron granules

for oral extended release susp 8

mg/ml

• •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MYRBETRIQ - mirabegron tab er 24

hr 25 mg, 50 mg

• •

oxybutynin chloride syrup

5 mg/5ml

•

oxybutynin chloride tab er 24hr

5 mg, 10 mg (Ditropan xl)

•

oxybutynin chloride tab er 24hr

15 mg

•

oxybutynin chloride tab 5 mg

•

OXYTROL - oxybutynin td patch

twice weekly 3.9 mg/24hr

solifenacin succinate tab 5 mg,

10 mg (Vesicare)

•

tolterodine tartrate cap er 24hr

2 mg, 4 mg (Detrol la)

•

tolterodine tartrate tab 1 mg, 2 mg

(Detrol)

•

TOVIAZ - fesoterodine fumarate tab

er 24hr 4 mg, 8 mg

trospium chloride cap er 24hr

60 mg

•

trospium chloride tab 20 mg

•

VESICARE - solifenacin succinate

tab 5 mg, 10 mg

VESICARE LS - solifenacin

succinate susp 5 mg/5ml (1 mg/

ml)

VAGINAL PRODUCTS

CLEOCIN - clindamycin phosphate

vaginal cream 2%

CLEOCIN - clindamycin phosphate

vaginal suppos 100 mg

clindamycin phosphate vaginal

cream 2% (Cleocin)

CRINONE - progesterone vaginal gel

4%, 8%

ENCARE - nonoxynol-9 vaginal

suppos 100 mg

•

ENDOMETRIN - progesterone

vaginal insert 100 mg

• •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 54

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ESTRACE - estradiol vaginal cream

0.1 mg/gm

estradiol vaginal cream 0.1 mg/

gm (Estrace)

•

ESTRING - estradiol vaginal ring 2

mg (7.5 mcg/24hrs)

•

FEMRING - estradiol acetate vaginal

ring 0.05 mg/24hr, 0.1 mg/24hr

GYNAZOLE-1 - butoconazole nitrate

(one dose) vaginal cream 2%

IMVEXXY MAINTENANCE PACK -

estradiol vaginal insert 4 mcg, 10

mcg

IMVEXXY STARTER PACK -

estradiol vaginal insert starter

pack 4 mcg, 10 mcg

INTRAROSA - prasterone vaginal

insert 6.5 mg

• •

metronidazole vaginal gel 0.75%

NUVESSA - metronidazole vaginal

gel 1.3%

OPTIONS GYNOL II VAGINAL -

nonoxynol-9 gel 3%

•

PHEXXI - lactic acid-citric acid-

potassium bitartrate gel

1.8-1-0.4%

•

PREMARIN - estrogens, conjugated

vaginal cream 0.625 mg/gm

SHUR-SEAL - nonoxynol-9 gel 2%

•

terconazole vaginal cream 0.4%,

0.8%

terconazole vaginal suppos

80 mg

TODAY SPONGE - nonoxynol-9

vaginal sponge 1000 mg

•

VAGIFEM - estradiol vaginal tab 10

mcg

•

VANDAZOLE - metronidazole

vaginal gel 0.75%

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VCF VAGINAL CONTRACEPTIVE -

nonoxynol-9 gel 4%

•

VCF VAGINAL CONTRACEPTIVE -

nonoxynol-9 film 28%

•

VCF VAGINAL CONTRACEPTIVE -

nonoxynol-9 foam 12.5%

•

GENITOURINARY AGENTS - MISC.

alfuzosin hcl tab er 24hr 10 mg

(Uroxatral)

•

AVODART - dutasteride cap 0.5 mg

CARDURA XL - doxazosin mesylate

tab er 24 hr 4 mg (base equiv), 8

mg (base equiv)

CYSTAGON - cysteamine bitartrate

cap 50 mg, 150 mg

• •

dutasteride cap 0.5 mg (Avodart)

•

dutasteride-tamsulosin hcl cap

0.5-0.4 mg (Jalyn)

•

ELMIRON - pentosan polysulfate

sodium caps 100 mg

• •

ENTADFI - finasteride-tadalafil cap

5-5 mg

• •

finasteride tab 5 mg (Proscar)

•

FLOMAX - tamsulosin hcl cap 0.4

JALYN - dutasteride-tamsulosin hcl

cap 0.5-0.4 mg

K-PHOS NO 2 - potassium & sodium

acid phosphates tab 305-700 mg

LITHOSTAT - acetohydroxamic acid

tab 250 mg

potassium citrate tab er 5 meq

(540 mg) (Urocit-k 5)

potassium citrate tab er 10 meq

(1080 mg) (Urocit-k 10)

potassium citrate tab er 15 meq

(1620 mg) (Urocit-k 15)

PROSCAR - finasteride tab 5 mg

RAPAFLO - silodosin cap 4 mg, 8

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 55

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

silodosin cap 4 mg, 8 mg

(Rapaflo)

•

sodium citrate & citric acid soln

500-334 mg/5ml

tamsulosin hcl cap 0.4 mg

(Flomax)

•

THIOLA - tiopronin tab 100 mg

THIOLA EC - tiopronin tab delayed

release 100 mg, 300 mg

•

tiopronin tab 100 mg (Thiola)

UROCIT-K 10 - potassium citrate tab

er 10 meq (1080 mg)

UROCIT-K 15 - potassium citrate tab

er 15 meq (1620 mg)

UROCIT-K 5 - potassium citrate tab

er 5 meq (540 mg)

UROXATRAL - alfuzosin hcl tab er

24hr 10 mg

CENTRAL NERVOUS SYSTEM DRUGS

ANTIANXIETY AGENTS

ALPRAZOLAM INTENSOL -

alprazolam conc 1 mg/ml

alprazolam orally disintegrating

tab 0.25 mg, 0.5 mg, 1 mg, 2 mg

alprazolam tab er 24hr 0.5 mg,

1 mg, 2 mg, 3 mg (Xanax xr)

alprazolam tab 0.25 mg, 0.5 mg,

1 mg, 2 mg (Xanax)

ATIVAN - lorazepam tab 0.5 mg, 1

mg, 2 mg

buspirone hcl tab 5 mg, 10 mg,

15 mg, 30 mg

buspirone hcl tab 7.5 mg

chlordiazepoxide hcl cap 5 mg,

10 mg, 25 mg

clorazepate dipotassium tab

3.75 mg, 15 mg

clorazepate dipotassium tab

7.5 mg (Tranxene t)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

diazepam conc 5 mg/ml

diazepam oral soln 1 mg/ml

diazepam tab 2 mg, 5 mg, 10 mg

(Valium)

hydroxyzine hcl syrup 10 mg/5ml

hydroxyzine hcl tab 10 mg, 25 mg,

50 mg

HYDROXYZINE PAMOATE -

hydroxyzine pamoate cap 100 mg

hydroxyzine pamoate cap 25 mg,

50 mg (Vistaril)

lorazepam conc 2 mg/ml

lorazepam tab 0.5 mg, 1 mg, 2 mg

(Ativan)

LOREEV XR - lorazepam cap er

24hr sprinkle 1 mg, 1.5 mg, 2 mg,

3 mg

meprobamate tab 200 mg, 400 mg

oxazepam cap 10 mg, 15 mg,

30 mg

TRANXENE T - clorazepate

dipotassium tab 7.5 mg

VALIUM - diazepam tab 2 mg, 5 mg,

10 mg

VISTARIL - hydroxyzine pamoate

cap 25 mg, 50 mg

XANAX - alprazolam tab 0.25 mg,

0.5 mg, 1 mg, 2 mg

XANAX XR - alprazolam tab er 24hr

0.5 mg, 1 mg, 2 mg, 3 mg

ANTIDEPRESSANTS

amitriptyline hcl tab 10 mg,

25 mg, 50 mg, 75 mg, 100 mg,

150 mg

AMOXAPINE - amoxapine tab 25

mg, 50 mg, 100 mg, 150 mg

ANAFRANIL - clomipramine hcl cap

25 mg, 50 mg, 75 mg

APLENZIN - bupropion hbr tab er

24hr 174 mg, 348 mg, 522 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 56

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

bupropion hcl tab er 12hr 100 mg,

150 mg, 200 mg (Wellbutrin sr)

bupropion hcl tab er 24hr 150 mg,

300 mg (Wellbutrin xl)

bupropion hcl tab 75 mg, 100 mg

BUPROPION HYDROCHLORIDE

E - bupropion hcl tab er 24hr 450

CELEXA - citalopram hydrobromide

tab 10 mg (base equiv), 20 mg

(base equiv), 40 mg (base equiv)

CITALOPRAM HYDROBROMIDE -

citalopram hydrobromide cap 30

citalopram hydrobromide oral

soln 10 mg/5ml

citalopram hydrobromide tab

10 mg (base equiv), 20 mg (base

equiv), 40 mg (base equiv)

(Celexa)

clomipramine hcl cap 25 mg,

50 mg, 75 mg (Anafranil)

CYMBALTA - duloxetine hcl enteric

coated pellets cap 20 mg (base

eq), 30 mg (base eq), 60 mg

(base eq)

desipramine hcl tab 10 mg, 25 mg

(Norpramin)

desipramine hcl tab 50 mg,

75 mg, 100 mg, 150 mg

DESVENLAFAXINE ER -

desvenlafaxine tab er 24hr 50 mg,

100 mg

desvenlafaxine succinate tab er

24hr 25 mg (base equiv), 50 mg

(base equiv), 100 mg (base

equiv) (Pristiq)

•

doxepin hcl cap 10 mg, 25 mg,

50 mg, 75 mg, 100 mg, 150 mg

doxepin hcl conc 10 mg/ml

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DRIZALMA SPRINKLE - duloxetine

hcl cap delayed release sprinkle

20 mg (base eq), 30 mg (base

eq), 40 mg (base eq), 60 mg

(base eq)

duloxetine hcl enteric coated

pellets cap 20 mg (base eq),

30 mg (base eq), 60 mg (base

eq) (Cymbalta)

•

duloxetine hcl enteric coated

pellets cap 40 mg (base eq)

EFFEXOR XR - venlafaxine hcl cap

er 24hr 37.5 mg (base equivalent),

75 mg (base equivalent), 150 mg

(base equivalent)

EMSAM - selegiline td patch 24hr 6

mg/24hr, 9 mg/24hr, 12 mg/24hr

escitalopram oxalate soln

5 mg/5ml (base equiv)

escitalopram oxalate tab 5 mg

(base equiv), 10 mg (base

equiv), 20 mg (base equiv)

(Lexapro)

FETZIMA - levomilnacipran hcl cap

er 24hr 20 mg (base equivalent),

40 mg (base equivalent), 80 mg

(base equivalent), 120 mg (base

equivalent)

• •

FETZIMA TITRATION PACK -

levomilnacipran hcl cap er 24hr 20

& 40 mg therapy pack

• •

FLUOXETINE DR - fluoxetine hcl

cap delayed release 90 mg

• •

fluoxetine hcl cap 10 mg, 20 mg,

40 mg (Prozac)

fluoxetine hcl solution 20 mg/5ml

fluoxetine hcl tab 10 mg, 20 mg

fluoxetine hcl tab 60 mg

(Fluoxetine hydrochlo)

FLUOXETINE HYDROCHLORIDE -

fluoxetine hcl tab 60 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 57

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

fluvoxamine maleate cap er 24hr

100 mg, 150 mg

fluvoxamine maleate tab 25 mg,

50 mg, 100 mg

FORFIVO XL - bupropion hcl tab er

24hr 450 mg

imipramine hcl tab 10 mg, 25 mg,

50 mg

imipramine pamoate cap 75 mg,

100 mg, 125 mg, 150 mg

LEXAPRO - escitalopram oxalate tab

5 mg (base equiv), 10 mg (base

equiv), 20 mg (base equiv)

MARPLAN - isocarboxazid tab 10

mirtazapine orally disintegrating

tab 15 mg, 30 mg, 45 mg

(Remeron soltab)

mirtazapine tab 7.5 mg, 45 mg

mirtazapine tab 15 mg, 30 mg

(Remeron)

NARDIL - phenelzine sulfate tab 15

NEFAZODONE

HYDROCHLORIDE - nefazodone

hcl tab 50 mg, 100 mg, 150 mg,

200 mg, 250 mg

NORPRAMIN - desipramine hcl tab

10 mg, 25 mg

NORTRIPTYLINE HCL - nortriptyline

hcl soln 10 mg/5ml

nortriptyline hcl cap 10 mg,

25 mg, 50 mg, 75 mg (Pamelor)

PAMELOR - nortriptyline hcl cap 10

mg, 25 mg, 50 mg, 75 mg

PARNATE - tranylcypromine sulfate

tab 10 mg

paroxetine hcl oral susp

10 mg/5ml (base equiv) (Paxil)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

paroxetine hcl tab er 24hr

12.5 mg, 25 mg, 37.5 mg (Paxil

cr)

paroxetine hcl tab 10 mg, 20 mg,

30 mg, 40 mg (Paxil)

PAXIL - paroxetine hcl oral susp 10

mg/5ml (base equiv)

PAXIL - paroxetine hcl tab 10 mg, 20

mg, 30 mg, 40 mg

PAXIL CR - paroxetine hcl tab er

24hr 12.5 mg, 25 mg, 37.5 mg

PEXEVA - paroxetine mesylate tab

10 mg (base equiv), 20 mg (base

equiv), 30 mg (base equiv)

PHENELZINE SULFATE -

phenelzine sulfate tab 15 mg

•

PRISTIQ - desvenlafaxine succinate

tab er 24hr 25 mg (base equiv),

50 mg (base equiv), 100 mg (base

equiv)

protriptyline hcl tab 5 mg, 10 mg

PROZAC - fluoxetine hcl cap 10 mg,

20 mg, 40 mg

REMERON - mirtazapine tab 15 mg,

30 mg

REMERON SOLTAB - mirtazapine

orally disintegrating tab 15 mg, 30

mg, 45 mg

sertraline hcl oral concentrate for

solution 20 mg/ml (Zoloft)

sertraline hcl tab 25 mg, 50 mg,

100 mg (Zoloft)

SERTRALINE HYDROCHLORIDE -

sertraline hcl cap 150 mg, 200 mg

tranylcypromine sulfate tab 10 mg

(Parnate)

trazodone hcl tab 50 mg, 100 mg,

150 mg

trazodone hcl tab 300 mg

trimipramine maleate cap 25 mg,

50 mg, 100 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 58

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

TRINTELLIX - vortioxetine hbr tab

5 mg (base equiv), 10 mg (base

equiv), 20 mg (base equiv)

• •

VENLAFAXINE BESYLATE ER -

venlafaxine besylate tab er 24hr

112.5 mg

• •

venlafaxine hcl cap er 24hr

37.5 mg (base equivalent),

75 mg (base equivalent), 150 mg

(base equivalent) (Effexor xr)

•

venlafaxine hcl tab er 24hr

37.5 mg (base equivalent),

75 mg (base equivalent), 150 mg

(base equivalent), 225 mg (base

equivalent)

venlafaxine hcl tab 25 mg (base

equivalent), 37.5 mg (base

equivalent), 50 mg (base

equivalent), 75 mg (base

equivalent), 100 mg (base

equivalent)

•

VIIBRYD - vilazodone hcl tab 10 mg,

20 mg, 40 mg

•

VIIBRYD STARTER PACK -

vilazodone hcl tab starter kit 10 (7)

& 20 (23) mg

•

vilazodone hcl tab 10 mg, 20 mg,

40 mg (Viibryd)

WELLBUTRIN SR - bupropion hcl

tab er 12hr 100 mg, 150 mg, 200

WELLBUTRIN XL - bupropion hcl

tab er 24hr 150 mg, 300 mg

ZOLOFT - sertraline hcl oral

concentrate for solution 20 mg/ml

ZOLOFT - sertraline hcl tab 25 mg,

50 mg, 100 mg

ANTIPSYCHOTICS

ABILIFY - aripiprazole tab 2 mg, 5

mg, 10 mg, 15 mg, 20 mg, 30 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ABILIFY MYCITE MAINTENANC -

aripiprazole tab 2 mg with

sensor&strips (for pod) maint pak

ABILIFY MYCITE MAINTENANC -

aripiprazole tab 5 mg with

sensor&strips (for pod) maint pak

ABILIFY MYCITE MAINTENANC -

aripiprazole tab 10 mg with

sensor&strips(for pod) maint pak

ABILIFY MYCITE MAINTENANC -

aripiprazole tab 15 mg with

sensor&strips(for pod) maint pak

ABILIFY MYCITE MAINTENANC -

aripiprazole tab 20 mg with

sensor&strips(for pod) maint pak

ABILIFY MYCITE MAINTENANC -

aripiprazole tab 30 mg with

sensor&strips(for pod) maint pak

ABILIFY MYCITE STARTER KI -

aripiprazole tab 2 mg with sensor,

strips & pod starter pak

ABILIFY MYCITE STARTER KI -

aripiprazole tab 5 mg with sensor,

strips & pod starter pak

ABILIFY MYCITE STARTER KI -

aripiprazole tab 10 mg with

sensor, strips & pod starter pak

ABILIFY MYCITE STARTER KI -

aripiprazole tab 15 mg with

sensor, strips & pod starter pak

ABILIFY MYCITE STARTER KI -

aripiprazole tab 20 mg with

sensor, strips & pod starter pak

ABILIFY MYCITE STARTER KI -

aripiprazole tab 30 mg with

sensor, strips & pod starter pak

aripiprazole oral solution 1 mg/ml

•

aripiprazole orally disintegrating

tab 10 mg, 15 mg

•

aripiprazole tab 2 mg, 5 mg,

10 mg, 15 mg, 20 mg, 30 mg

(Abilify)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 59

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

asenapine maleate sl tab 2.5 mg

(base equiv), 5 mg (base equiv),

10 mg (base equiv) (Saphris)

•

CAPLYTA - lumateperone tosylate

cap 10.5 mg, 21 mg, 42 mg

chlorpromazine hcl tab 10 mg,

25 mg, 50 mg, 100 mg, 200 mg

CLOZAPINE ODT - clozapine orally

disintegrating tab 12.5 mg, 150

mg, 200 mg

• •

clozapine orally disintegrating tab

25 mg, 100 mg

•

clozapine tab 25 mg, 50 mg,

100 mg, 200 mg (Clozaril)

•

CLOZARIL - clozapine tab 25 mg, 50

mg, 100 mg, 200 mg

EQUETRO - carbamazepine (mood)

cap er 12hr 100 mg, 200 mg, 300

FANAPT - iloperidone tab 1 mg, 2

mg, 4 mg, 6 mg, 8 mg, 10 mg, 12

• •

FANAPT TITRATION PACK -

iloperidone tab 1 mg & 2 mg & 4

mg & 6 mg titration pak

• •

FLUPHENAZINE HCL - fluphenazine

hcl oral conc 5 mg/ml

fluphenazine hcl tab 1 mg, 2.5 mg,

5 mg, 10 mg

FLUPHENAZINE

HYDROCHLORID - fluphenazine

hcl elixir 2.5 mg/5ml

GEODON - ziprasidone hcl cap 20

mg, 40 mg, 60 mg, 80 mg

haloperidol lactate oral conc

2 mg/ml

haloperidol tab 0.5 mg, 1 mg,

2 mg, 5 mg, 10 mg, 20 mg

INVEGA - paliperidone tab er 24hr

1.5 mg, 3 mg, 6 mg, 9 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

LATUDA - lurasidone hcl tab 20 mg,

40 mg, 60 mg, 80 mg, 120 mg

• •

LITHIUM CARBONATE - lithium

carbonate cap 150 mg, 300 mg,

600 mg

lithium carbonate cap 150 mg,

300 mg, 600 mg (Lithium

carbonate)

lithium carbonate tab er 300 mg

(Lithobid)

lithium carbonate tab er 450 mg

lithium carbonate tab 300 mg

loxapine succinate cap 5 mg,

10 mg, 25 mg, 50 mg

MOLINDONE HYDROCHLORIDE -

molindone hcl tab 5 mg, 10 mg, 25

NUPLAZID - pimavanserin tartrate

cap 34 mg (base equivalent)

NUPLAZID - pimavanserin tartrate

tab 10 mg (base equivalent)

olanzapine orally disintegrating

tab 5 mg, 10 mg, 15 mg, 20 mg

(Zyprexa zydis)

•

olanzapine tab 2.5 mg, 5 mg,

7.5 mg, 10 mg, 15 mg, 20 mg

(Zyprexa)

•

paliperidone tab er 24hr 1.5 mg,

3 mg, 6 mg, 9 mg (Invega)

•

perphenazine tab 2 mg, 4 mg,

8 mg, 16 mg

prochlorperazine maleate tab

5 mg (base equivalent), 10 mg

(base equivalent)

prochlorperazine suppos 25 mg

QUETIAPINE FUMARATE -

quetiapine fumarate tab 150 mg

• •

quetiapine fumarate tab er 24hr

50 mg, 150 mg, 200 mg, 300 mg,

400 mg (Seroquel xr)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 60

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

quetiapine fumarate tab 25 mg,

50 mg, 100 mg, 200 mg, 300 mg,

400 mg (Seroquel)

•

REXULTI - brexpiprazole tab 0.25

mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4

• •

RISPERDAL - risperidone soln 1 mg/

RISPERDAL - risperidone tab 0.5

mg, 1 mg, 2 mg, 3 mg, 4 mg

RISPERIDONE ODT - risperidone

orally disintegrating tab 0.25 mg

• •

risperidone orally disintegrating

tab 0.5 mg, 1 mg, 2 mg, 3 mg,

4 mg

•

risperidone soln 1 mg/ml

(Risperdal)

•

risperidone tab 0.25 mg

•

risperidone tab 0.5 mg, 1 mg,

2 mg, 3 mg, 4 mg (Risperdal)

•

SAPHRIS - asenapine maleate sl tab

2.5 mg (base equiv), 5 mg (base

equiv), 10 mg (base equiv)

SECUADO - asenapine td patch 24

hr 3.8 mg/24hr, 5.7 mg/24hr, 7.6

mg/24hr

• •

SEROQUEL - quetiapine fumarate

tab 25 mg, 50 mg, 100 mg, 200

mg, 300 mg, 400 mg

SEROQUEL XR - quetiapine

fumarate tab er 24hr 50 mg, 150

mg, 200 mg, 300 mg, 400 mg

thioridazine hcl tab 10 mg, 25 mg,

50 mg, 100 mg

thiothixene cap 1 mg, 2 mg, 5 mg,

10 mg

trifluoperazine hcl tab 1 mg

(base equivalent), 2 mg

(base equivalent), 5 mg (base

equivalent), 10 mg (base

equivalent)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VERSACLOZ - clozapine susp 50

mg/ml

• •

VRAYLAR - cariprazine hcl cap

therapy pack 1.5 mg (1) & 3 mg

(6)

• •

VRAYLAR - cariprazine hcl cap

1.5 mg (base equivalent), 3

mg (base equivalent), 4.5 mg

(base equivalent), 6 mg (base

equivalent)

• •

ziprasidone hcl cap 20 mg, 40 mg,

60 mg, 80 mg (Geodon)

•

ZYPREXA - olanzapine tab 2.5 mg, 5

mg, 7.5 mg, 10 mg, 15 mg, 20 mg

ZYPREXA ZYDIS - olanzapine orally

disintegrating tab 5 mg, 10 mg, 15

mg, 20 mg

HYPNOTICS

AMBIEN - zolpidem tartrate tab 5

mg, 10 mg

AMBIEN CR - zolpidem tartrate tab

er 6.25 mg, 12.5 mg

BELSOMRA - suvorexant tab 5 mg,

10 mg, 15 mg, 20 mg

• •

DAYVIGO - lemborexant tab 5 mg,

10 mg

• •

DORAL - quazepam tab 15 mg

doxepin hcl (sleep) tab 3 mg

(base equiv), 6 mg (base equiv)

(Silenor)

EDLUAR - zolpidem tartrate sl tab 5

mg, 10 mg

estazolam tab 1 mg, 2 mg

eszopiclone tab 1 mg, 2 mg, 3 mg

(Lunesta)

•

FLURAZEPAM HCL - flurazepam hcl

cap 15 mg, 30 mg

HALCION - triazolam tab 0.25 mg

HETLIOZ - tasimelteon capsule 20

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 61

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

HETLIOZ LQ - tasimelteon oral susp

4 mg/ml

• • • •

LUNESTA - eszopiclone tab 1 mg, 2

mg, 3 mg

phenobarbital elixir 20 mg/5ml

phenobarbital tab 15 mg, 16.2 mg,

30 mg, 32.4 mg, 60 mg, 64.8 mg,

97.2 mg, 100 mg

QUAZEPAM - quazepam tab 15 mg

QUVIVIQ - daridorexant hcl tab 25

mg, 50 mg

ramelteon tab 8 mg (Rozerem)

• •

RESTORIL - temazepam cap 7.5

mg, 15 mg, 22.5 mg, 30 mg

ROZEREM - ramelteon tab 8 mg

SILENOR - doxepin hcl (sleep) tab

3 mg (base equiv), 6 mg (base

equiv)

temazepam cap 7.5 mg, 22.5 mg

(Restoril)

temazepam cap 15 mg, 30 mg

(Restoril)

triazolam tab 0.125 mg

triazolam tab 0.25 mg (Halcion)

zaleplon cap 5 mg, 10 mg

•

ZOLPIDEM TARTRATE - zolpidem

tartrate sl tab 1.75 mg, 3.5 mg

zolpidem tartrate tab er 6.25 mg,

12.5 mg (Ambien cr)

•

zolpidem tartrate tab 5 mg, 10 mg

(Ambien)

•

ZOLPIMIST - zolpidem tartrate oral

spray 5 mg/act

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/

ANOREXIANTS

ADDERALL - amphetamine-

dextroamphetamine tab 5 mg, 7.5

mg, 10 mg, 12.5 mg, 15 mg, 20

mg, 30 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ADDERALL XR - amphetamine-

dextroamphetamine cap er 24hr 5

mg, 10 mg, 15 mg, 20 mg, 25 mg,

30 mg

ADHANSIA XR - methylphenidate

hcl cap er 24hr 25 mg, 35 mg, 45

mg, 55 mg, 70 mg, 85 mg

ADIPEX-P - phentermine hcl cap

37.5 mg

ADIPEX-P - phentermine hcl tab

37.5 mg

ADZENYS XR-ODT - amphetamine

tab extended release

disintegrating 3.1 mg, 6.3 mg, 9.4

mg, 12.5 mg, 15.7 mg, 18.8 mg

amphetamine sulfate tab 5 mg,

10 mg (Evekeo)

amphetamine-

dextroamphetamine cap er 24hr

5 mg, 10 mg, 15 mg, 20 mg,

25 mg, 30 mg (Adderall xr)

•

amphetamine-

dextroamphetamine tab 5 mg,

7.5 mg, 10 mg, 12.5 mg, 15 mg,

20 mg, 30 mg (Adderall)

•

APTENSIO XR - methylphenidate hcl

cap er 24hr 10 mg (xr), 15 mg (xr),

20 mg (xr), 30 mg (xr), 40 mg (xr),

50 mg (xr), 60 mg (xr)

armodafinil tab 50 mg, 150 mg,

200 mg, 250 mg (Nuvigil)

•

atomoxetine hcl cap 10 mg (base

equiv), 18 mg (base equiv),

25 mg (base equiv), 40 mg (base

equiv), 60 mg (base equiv),

80 mg (base equiv), 100 mg

(base equiv) (Strattera)

•

AZSTARYS -

serdexmethylphenidate-

dexmethylphenidate cap 26.1-5.2

mg, 39.2-7.8 mg, 52.3-10.4 mg

BENZPHETAMINE HCL -

benzphetamine hcl tab 25 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 62

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

benzphetamine hcl tab 50 mg

caffeine citrate oral soln

60 mg/3ml (10 mg/ml base

equiv)

clonidine hcl tab er 12hr 0.1 mg

(Kapvay)

•

CONCERTA - methylphenidate hcl

tab er osmotic release (osm) 18

mg, 27 mg, 36 mg, 54 mg

CONTRAVE - naltrexone hcl-

bupropion hcl tab er 12hr 8-90 mg

COTEMPLA XR-ODT -

methylphenidate tab extended

release disintegrating 8.6 mg, 17.3

mg, 25.9 mg

DAYTRANA - methylphenidate td

patch 10 mg/9hr, 15 mg/9hr, 20

mg/9hr, 30 mg/9hr

DESOXYN - methamphetamine hcl

tab 5 mg

DEXEDRINE - dextroamphetamine

sulfate cap er 24hr 10 mg, 15 mg

dexmethylphenidate hcl cap er 24

hr 5 mg, 10 mg, 15 mg, 20 mg,

25 mg, 30 mg, 35 mg, 40 mg

(Focalin xr)

•

dexmethylphenidate hcl tab

2.5 mg, 5 mg, 10 mg (Focalin)

•

dextroamphetamine sulfate cap er

24hr 5 mg

•

dextroamphetamine sulfate cap er

24hr 10 mg, 15 mg (Dexedrine)

•

dextroamphetamine sulfate oral

solution 5 mg/5ml

•

dextroamphetamine sulfate tab

5 mg, 10 mg

•

dextroamphetamine sulfate tab

15 mg, 20 mg, 30 mg

DIETHYLPROPION HCL ER -

diethylpropion hcl tab er 24hr 75

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

diethylpropion hcl tab 25 mg

DYANAVEL XR - amphetamine chew

tab extended release 5 mg, 10

mg, 15 mg, 20 mg

DYANAVEL XR - amphetamine

extended release susp 2.5 mg/ml

EVEKEO - amphetamine sulfate tab

5 mg, 10 mg

EVEKEO ODT - amphetamine

sulfate orally disintegrating tab 5

mg, 10 mg, 15 mg, 20 mg

FOCALIN - dexmethylphenidate hcl

tab 2.5 mg, 5 mg, 10 mg

FOCALIN XR - dexmethylphenidate

hcl cap er 24 hr 5 mg, 10 mg, 15

mg, 20 mg, 25 mg, 30 mg, 35 mg,

40 mg

guanfacine hcl tab er 24hr 1 mg

(base equiv), 2 mg (base equiv),

3 mg (base equiv), 4 mg (base

equiv) (Intuniv)

•

INTUNIV - guanfacine hcl tab er 24hr

1 mg (base equiv), 2 mg (base

equiv), 3 mg (base equiv), 4 mg

(base equiv)

JORNAY PM - methylphenidate hcl

cap delayed er 24hr 20 mg (pm),

40 mg (pm), 60 mg (pm), 80 mg

(pm), 100 mg (pm)

KAPVAY - clonidine hcl tab er 12hr

0.1 mg

methamphetamine hcl tab 5 mg

(Desoxyn)

•

METHYLIN - methylphenidate hcl

soln 5 mg/5ml, 10 mg/5ml

methylphenidate hcl cap er 10 mg

(cd), 20 mg (cd), 30 mg (cd),

40 mg (cd), 50 mg (cd), 60 mg

(cd)

•

methylphenidate hcl cap er 24hr

10 mg (la) (Ritalin la)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 63

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

methylphenidate hcl cap er 24hr

20 mg (la), 30 mg (la), 40 mg (la)

(Ritalin la)

•

methylphenidate hcl cap er 24hr

60 mg (la)

methylphenidate hcl cap er 24hr

10 mg (xr), 15 mg (xr), 20 mg

(xr), 30 mg (xr), 40 mg (xr),

50 mg (xr), 60 mg (xr) (Aptensio

xr)

methylphenidate hcl chew tab

2.5 mg, 5 mg, 10 mg

•

methylphenidate hcl soln

5 mg/5ml, 10 mg/5ml (Methylin)

•

methylphenidate hcl tab er

osmotic release (osm) 18 mg,

27 mg, 36 mg, 54 mg (Concerta)

•

methylphenidate hcl tab er 24hr

27 mg, 36 mg, 54 mg

methylphenidate hcl tab er 10 mg,

20 mg

•

methylphenidate hcl tab 5 mg,

10 mg, 20 mg (Ritalin)

•

METHYLPHENIDATE

HYDROCHLO - methylphenidate

hcl tab er osmotic release (osm)

72 mg

METHYLPHENIDATE

HYDROCHLO - methylphenidate

hcl tab er 24hr 18 mg

methylphenidate td patch

10 mg/9hr, 15 mg/9hr,

20 mg/9hr, 30 mg/9hr (Daytrana)

modafinil tab 100 mg, 200 mg

(Provigil)

•

MYDAYIS - amphetamine-

dextroamphetamine 3-bead cap er

24hr 12.5 mg, 25 mg, 37.5 mg, 50

NUVIGIL - armodafinil tab 50 mg,

150 mg, 200 mg, 250 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PHENDIMETRAZINE TARTRATE -

phendimetrazine tartrate cap er

24hr 105 mg

phendimetrazine tartrate tab

35 mg

PROVIGIL - modafinil tab 100 mg,

200 mg

QELBREE - viloxazine hcl cap er

24hr 100 mg, 150 mg, 200 mg

QUILLICHEW ER - methylphenidate

hcl chew tab extended release 20

mg, 30 mg, 40 mg

QUILLIVANT XR - methylphenidate

hcl for er susp 25 mg/5ml (5 mg/

ml)

RELEXXII - methylphenidate hcl tab

er osmotic release (osm) 72 mg

RITALIN - methylphenidate hcl tab 5

mg, 10 mg, 20 mg

RITALIN LA - methylphenidate hcl

cap er 24hr 10 mg (la), 20 mg (la),

30 mg (la), 40 mg (la)

STRATTERA - atomoxetine hcl cap

10 mg (base equiv), 18 mg (base

equiv), 25 mg (base equiv), 40 mg

(base equiv), 60 mg (base equiv),

80 mg (base equiv), 100 mg (base

equiv)

SUNOSI - solriamfetol hcl tab 75 mg

(base equiv), 150 mg (base equiv)

• •

VYVANSE - lisdexamfetamine

dimesylate cap 10 mg, 20 mg, 30

mg, 40 mg, 50 mg, 60 mg, 70 mg

• •

VYVANSE - lisdexamfetamine

dimesylate chew tab 10 mg, 20

mg, 30 mg, 40 mg, 50 mg, 60 mg

• •

WAKIX - pitolisant hcl tab 4.45 mg

(base equivalent), 17.8 mg (base

equivalent)

ZENZEDI - dextroamphetamine

sulfate tab 2.5 mg, 7.5 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 64

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS

- MISC.

acamprosate calcium tab delayed

release 333 mg

ADLARITY - donepezil hydrochloride

td patch weekly 5 mg/day, 10 mg/

day

• •

ADUHELM - aducanumab-avwa iv

soln 170 mg/1.7ml (100 mg/ml),

300 mg/3ml (100 mg/ml)

AMPYRA - dalfampridine tab er 12hr

10 mg

AMVUTTRA - vutrisiran sodium soln

prefilled syringe 25 mg/0.5ml

ARICEPT - donepezil hydrochloride

tab 5 mg, 10 mg, 23 mg

AUBAGIO - teriflunomide tab 7 mg,

14 mg

• • • •

AUSTEDO - deutetrabenazine tab 6

mg, 9 mg, 12 mg

• • • •

AVONEX - interferon beta-1a im

prefilled syringe kit 30 mcg/0.5ml

• • • •

AVONEX PEN - interferon beta-1a

im auto-injector kit 30 mcg/0.5ml

• • • •

BAFIERTAM - monomethyl fumarate

capsule delayed release 95 mg

BETASERON - interferon beta-1b for

inj kit 0.3 mg

• • • •

bupropion hcl (smoking

deterrent) tab er 12hr 150 mg

•

CHLORDIAZEPOXIDE/AMITRIPT -

chlordiazepoxide-amitriptyline tab

5-12.5 mg, 10-25 mg

COPAXONE - glatiramer acetate

soln prefilled syringe 20 mg/ml, 40

mg/ml

dalfampridine tab er 12hr 10 mg

(Ampyra)

• • • •

dimethyl fumarate capsule

delayed release 120 mg, 240 mg

(Tecfidera)

• • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg

(Tecfidera starter pa)

• • •

disulfiram tab 250 mg, 500 mg

donepezil hydrochloride orally

disintegrating tab 5 mg, 10 mg

•

donepezil hydrochloride tab 5 mg,

10 mg, 23 mg (Aricept)

•

ERGOLOID MESYLATES - ergoloid

mesylates tab 1 mg

EXELON - rivastigmine td patch 24hr

4.6 mg/24hr, 9.5 mg/24hr, 13.3

mg/24hr

EXTAVIA - interferon beta-1b for inj

kit 0.3 mg

FLUOXETINE HYDROCHLORIDE -

fluoxetine hcl (pmdd) tab 10 mg,

20 mg

GALANTAMINE HYDROBROMIDE -

galantamine hydrobromide oral

soln 4 mg/ml

•

galantamine hydrobromide cap

er 24hr 8 mg, 16 mg, 24 mg

(Razadyne er)

•

galantamine hydrobromide tab

4 mg, 8 mg, 12 mg

•

GILENYA - fingolimod hcl cap 0.5 mg

(base equiv)

• • • •

glatiramer acetate soln prefilled

syringe 20 mg/ml - glatopa

(Copaxone)

glatiramer acetate soln prefilled

syringe 20 mg/ml, 40 mg/ml

(Copaxone)

• • • •

glatiramer acetate soln prefilled

syringe 40 mg/ml - glatopa

(Copaxone)

GRALISE - gabapentin (once-daily)

tab 300 mg, 600 mg

HORIZANT - gabapentin enacarbil

tab er 300 mg, 600 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 65

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

INGREZZA - valbenazine tosylate

cap therapy pack 40 mg (7) & 80

mg (21)

• • • •

INGREZZA - valbenazine tosylate

cap 40 mg (base equiv), 60 mg

(base equiv), 80 mg (base equiv)

• • • •

KESIMPTA - ofatumumab soln auto-

injector 20 mg/0.4ml

• • • •

LUCEMYRA - lofexidine hcl tab 0.18

mg (base equivalent)

•

LYBALVI - olanzapine-samidorphan

l-malate tab 5-10 mg, 10-10 mg,

15-10 mg, 20-10 mg

LYRICA CR - pregabalin tab er 24hr

82.5 mg, 165 mg, 330 mg

MAVENCLAD - cladribine tab

therapy pack 10 mg (4 tabs), 10

mg (5 tabs), 10 mg (6 tabs), 10

mg (7 tabs), 10 mg (8 tabs), 10

mg (9 tabs), 10 mg (10 tabs)

• • • •

MAYZENT - siponimod fumarate tab

0.25 mg (base equiv), 1 mg (base

equiv), 2 mg (base equiv)

• • • •

MAYZENT STARTER PACK -

siponimod fumarate tab 0.25 mg

(7) starter pack

• • • •

MAYZENT STARTER PACK -

siponimod fumarate tab 0.25 mg

(12) starter pack

• • • •

memantine hcl cap er 24hr 7 mg,

14 mg, 21 mg, 28 mg (Namenda

xr)

memantine hcl tab 5 mg, 10 mg

(Namenda)

•

memantine hcl tab 28 x 5 mg & 21

x 10 mg titration pack (Namenda

titration pa)

•

NAMENDA - memantine hcl tab 5

mg, 10 mg

NAMENDA TITRATION PAK -

memantine hcl tab 28 x 5 mg & 21

x 10 mg titration pack

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NAMENDA XR - memantine hcl cap

er 24hr 7 mg, 14 mg, 21 mg, 28

NAMZARIC - memantine hcl-

donepezil hcl cap er 24hr 7-10

mg, 14-10 mg, 21-10 mg, 28-10

NAMZARIC - memantine-donepezil

cap er 24hr 7 & 14 & 21 & 28-10

mg pack

nicotine polacrilex gum 2 mg,

4 mg

•

nicotine polacrilex lozenge 2 mg,

4 mg

•

nicotine td patch 24hr 7 mg/24hr,

14 mg/24hr, 21 mg/24hr

•

NICOTINE TRANSDERMAL SYST -

nicotine td patch 24 hr kit 21-14-7

mg/24hr

•

NICOTROL INHALER - nicotine

inhaler system 10 mg (4 mg

delivered)

•

NICOTROL NS - nicotine nasal

spray 10 mg/ml (0.5 mg/spray)

•

olanzapine-fluoxetine hcl cap

3-25 mg, 6-25 mg (Symbyax)

olanzapine-fluoxetine hcl cap

6-50 mg, 12-25 mg, 12-50 mg

paroxetine mesylate cap 7.5 mg

(base equiv)

PERPHENAZINE/AMITRIPTYLIN -

perphenazine-amitriptyline tab

2-10 mg, 2-25 mg, 4-10 mg, 4-25

mg, 4-50 mg

PIMOZIDE - pimozide tab 1 mg, 2

PLEGRIDY - peginterferon beta-1a

soln pen-injector 125 mcg/0.5ml

• • • •

PLEGRIDY - peginterferon beta-1a

soln prefilled syringe 125

mcg/0.5ml

• • • •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 66

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PLEGRIDY - peginterferon

beta-1a im soln prefilled syr 125

mcg/0.5ml

• • • •

PLEGRIDY STARTER PACK -

peginterferon beta-1a soln pen-inj

63 & 94 mcg/0.5ml pack

• • • •

PLEGRIDY STARTER PACK -

peginterferon beta-1a soln pref syr

63 & 94 mcg/0.5ml pack

• • • •

PONVORY - ponesimod tab 20 mg

PONVORY 14-DAY STARTER

PA - ponesimod tab starter pack

2,3,4,5,6,7,8,9 &10 mg

pregabalin tab er 24hr 82.5 mg,

165 mg, 330 mg (Lyrica cr)

RAZADYNE ER - galantamine

hydrobromide cap er 24hr 8 mg,

16 mg, 24 mg

REBIF - interferon beta-1a soln pref

syr 22 mcg/0.5ml, 44 mcg/0.5ml

• • • •

REBIF REBIDOSE - interferon

beta-1a soln auto-inj 22

mcg/0.5ml, 44 mcg/0.5ml

• • • •

REBIF REBIDOSE TITRATION -

interferon beta-1a auto-inj 6x8.8

mcg/0.2ml & 6x22 mcg/0.5ml

• • • •

REBIF TITRATION PACK - interferon

beta-1a pref syr 6x8.8 mcg/0.2ml

& 6x22 mcg/0.5ml

• • • •

rivastigmine tartrate cap 1.5 mg

(base equivalent), 3 mg

(base equivalent), 4.5 mg

(base equivalent), 6 mg (base

equivalent)

•

rivastigmine td patch 24hr

4.6 mg/24hr, 9.5 mg/24hr,

13.3 mg/24hr (Exelon)

•

SAVELLA - milnacipran hcl tab 12.5

mg, 25 mg, 50 mg, 100 mg

•

SAVELLA TITRATION PACK -

milnacipran hcl tab 12.5 mg (5) &

25 mg (8) & 50 mg (42) pak

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SYMBYAX - olanzapine-fluoxetine

hcl cap 3-25 mg, 6-25 mg

TASCENSO ODT - fingolimod lauryl

sulfate tablet disintegrating 0.25

• •

TECFIDERA - dimethyl fumarate

capsule delayed release 120 mg,

240 mg

TECFIDERA STARTER PACK -

dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg

TEGSEDI - inotersen sod

subcutaneous pref syr 284

mg/1.5ml (base eq)

• • • •

tetrabenazine tab 12.5 mg, 25 mg

(Xenazine)

• • • •

VARENICLINE STARTING MONT -

varenicline tartrate tab 0.5 mg x 11

& tab 1 mg x 42 pack

•

VARENICLINE TARTRATE -

varenicline tartrate tab 0.5 mg

(base equiv), 1 mg (base equiv)

•

XENAZINE - tetrabenazine tab 12.5

mg, 25 mg

XYREM - sodium oxybate oral

solution 500 mg/ml

• • • •

XYWAV - calcium, mag, potassium,

& sod oxybates oral soln 500 mg/

• • • •

ZEPOSIA - ozanimod hcl cap 0.92

• • • •

ZEPOSIA STARTER KIT - ozanimod

cap pack 4 x 0.23 mg & 3 x 0.46

mg & 30 x 0.92 mg

• • • •

ZEPOSIA 7-DAY STARTER PAC -

ozanimod cap pack 4 x 0.23 mg &

3 x 0.46 mg

• • • •

ANALGESICS AND ANESTHETICS

ANALGESICS - NON-NARCOTIC

ALLZITAL - butalbital-acetaminophen

tab 25-325 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 67

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

aspirin chew tab 81 mg

•

aspirin tab delayed release 81 mg

•

butalbital-acetaminophen cap

50-300 mg (Butalbital/acetamino)

butalbital-acetaminophen tab

50-300 mg

butalbital-acetaminophen tab

50-325 mg

•

butalbital-acetaminophen-caffeine

cap 50-300-40 mg (Fioricet)

butalbital-acetaminophen-caffeine

cap 50-325-40 mg

butalbital-acetaminophen-caffeine

tab 50-325-40 mg (Esgic)

•

butalbital-aspirin-caffeine cap

50-325-40 mg

•

BUTALBITAL/ACETAMINOPHEN -

butalbital-acetaminophen cap

50-300 mg

diflunisal tab 500 mg

ESGIC - butalbital-acetaminophen-

caffeine tab 50-325-40 mg

FIORICET - butalbital-

acetaminophen-caffeine cap

50-300-40 mg

TENCON - butalbital-acetaminophen

tab 50-325 mg

•

VTOL LQ - butalbital-

acetaminophen-caffeine soln

50-325-40 mg/15ml

ANALGESICS - NARCOTIC

acetaminophen w/ codeine soln

120-12 mg/5ml

•

acetaminophen w/ codeine tab

300-15 mg (Tylenol/codeine)

•

acetaminophen w/ codeine tab

300-30 mg, 300-60 mg

•

ACETAMINOPHEN/CAFFEINE/

DI - acetaminophen-caffeine-

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

dihydrocodeine cap 320.5-30-16

ACTIQ - fentanyl citrate lozenge on

a handle 200 mcg, 400 mcg, 600

mcg, 800 mcg, 1200 mcg, 1600

mcg

APADAZ - benzhydrocodone hcl-

acetaminophen tab 4.08-325 mg,

6.12-325 mg, 8.16-325 mg

•

BELBUCA - buprenorphine hcl

buccal film 75 mcg (base

equivalent), 150 mcg (base

equivalent), 300 mcg (base

equivalent), 450 mcg (base

equivalent), 600 mcg (base

equivalent), 750 mcg (base

equivalent), 900 mcg (base

equivalent)

• •

BENZHYDROCODONE/

ACETAMINO - benzhydrocodone

hcl-acetaminophen tab 4.08-325

mg, 6.12-325 mg, 8.16-325 mg

•

buprenorphine hcl sl tab 2 mg

(base equiv), 8 mg (base equiv)

•

buprenorphine hcl-naloxone hcl

sl film 2-0.5 mg (base equiv),

4-1 mg (base equiv), 8-2 mg

(base equiv), 12-3 mg (base

equiv) (Suboxone)

•

buprenorphine hcl-naloxone hcl

sl tab 2-0.5 mg (base equiv),

8-2 mg (base equiv)

•

buprenorphine td patch weekly

5 mcg/hr, 7.5 mcg/hr, 10 mcg/hr,

15 mcg/hr, 20 mcg/hr (Butrans)

butalbital-acetaminophen-caff

w/ cod cap 50-300-40-30 mg

(Fioricet/codeine)

butalbital-acetaminophen-caff w/

cod cap 50-325-40-30 mg

•

butalbital-aspirin-caff w/ codeine

cap 50-325-40-30 mg

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 68

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

butorphanol tartrate nasal soln

10 mg/ml

•

BUTRANS - buprenorphine td patch

weekly 5 mcg/hr, 7.5 mcg/hr, 10

mcg/hr, 15 mcg/hr, 20 mcg/hr

CODEINE SULFATE - codeine

sulfate tab 15 mg, 60 mg

•

CODEINE SULFATE - codeine

sulfate tab 30 mg

codeine sulfate tab 30 mg

(Codeine sulfate)

•

CONZIP - tramadol hcl cap er 24hr

biphasic release 100 mg, 200 mg,

300 mg

DILAUDID - hydromorphone hcl liqd

1 mg/ml

DILAUDID - hydromorphone hcl tab

2 mg, 4 mg, 8 mg

FENTANYL CITRATE - fentanyl

citrate buccal tab 100 mcg (base

equiv), 200 mcg (base equiv), 400

mcg (base equiv), 600 mcg (base

equiv), 800 mcg (base equiv)

fentanyl citrate lozenge on a

handle 200 mcg, 400 mcg,

600 mcg, 800 mcg, 1200 mcg,

1600 mcg (Actiq)

• •

fentanyl td patch 72hr 12 mcg/hr,

25 mcg/hr, 50 mcg/hr, 75 mcg/

hr, 100 mcg/hr

• •

fentanyl td patch 72hr 37.5 mcg/

hr, 62.5 mcg/hr, 87.5 mcg/hr

FENTORA - fentanyl citrate buccal

tab 100 mcg (base equiv), 200

mcg (base equiv), 400 mcg (base

equiv), 600 mcg (base equiv), 800

mcg (base equiv)

FIORICET/CODEINE - butalbital-

acetaminophen-caff w/ cod cap

50-300-40-30 mg

HYDROCODONE BITARTRATE

ER - hydrocodone bitartrate cap er

• •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

12hr 10 mg, 15 mg, 20 mg, 30 mg,

40 mg, 50 mg

hydrocodone bitartrate tab er

24hr deter 20 mg, 30 mg, 40 mg,

60 mg, 80 mg, 100 mg, 120 mg

(Hysingla er)

hydrocodone-acetaminophen

soln 7.5-325 mg/15ml

•

hydrocodone-acetaminophen

tab 10-325 mg, 5-325 mg,

7.5-325 mg

•

hydrocodone-acetaminophen

tab 5-300 mg, 7.5-300 mg,

10-300 mg

hydrocodone-ibuprofen tab

7.5-200 mg

•

HYDROCODONE/IBUPROFEN -

hydrocodone-ibuprofen tab 5-200

mg, 10-200 mg

•

hydromorphone hcl liqd 1 mg/ml

(Dilaudid)

•

hydromorphone hcl tab er 24hr

8 mg, 12 mg, 16 mg, 32 mg

• •

hydromorphone hcl tab 2 mg,

4 mg, 8 mg (Dilaudid)

•

HYSINGLA ER - hydrocodone

bitartrate tab er 24hr deter 20 mg,

30 mg, 40 mg, 60 mg, 80 mg, 100

mg, 120 mg

LAZANDA - fentanyl citrate nasal

spray 100 mcg/act (base equiv),

400 mcg/act (base equiv)

levorphanol tartrate tab 2 mg,

3 mg

LORTAB - hydrocodone-

acetaminophen soln 10-300

mg/15ml

MEPERIDINE HCL - meperidine hcl

oral soln 50 mg/5ml

MEPERIDINE HCL - meperidine hcl

tab 50 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 69

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

METHADONE HCL - methadone hcl

soln 5 mg/5ml, 10 mg/5ml

methadone hcl conc 10 mg/ml

(Methadose)

•

methadone hcl soln 5 mg/5ml,

10 mg/5ml (Methadone hcl)

•

methadone hcl tab for oral susp

40 mg

•

methadone hcl tab 5 mg, 10 mg

•

METHADOSE - methadone hcl conc

10 mg/ml

METHADOSE SUGAR-FREE -

methadone hcl conc 10 mg/ml

MORPHINE SULFATE - morphine

sulfate oral soln 20 mg/5ml

•

MORPHINE SULFATE - morphine

sulfate tab 15 mg, 30 mg

•

MORPHINE SULFATE ER -

morphine sulfate beads cap er

24hr 30 mg, 45 mg, 60 mg, 75 mg,

90 mg, 120 mg

MORPHINE SULFATE ER -

morphine sulfate cap er 24hr 10

mg, 20 mg, 30 mg, 50 mg, 60 mg,

80 mg, 100 mg

• •

morphine sulfate oral soln

10 mg/5ml, 100 mg/5ml (20 mg/

ml)

•

morphine sulfate tab er 15 mg,

30 mg, 60 mg, 100 mg, 200 mg

(Ms contin)

• •

morphine sulfate tab 15 mg,

30 mg (Morphine sulfate)

•

MS CONTIN - morphine sulfate tab

er 15 mg, 30 mg, 60 mg, 100 mg,

200 mg

NALOCET - oxycodone w/

acetaminophen tab 2.5-300 mg

NUCYNTA - tapentadol hcl tab 50

mg, 75 mg, 100 mg

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NUCYNTA ER - tapentadol hcl tab er

12hr 50 mg, 100 mg, 150 mg, 200

mg, 250 mg

• •

OXAYDO - oxycodone hcl tab 5 mg,

7.5 mg

OXYCODONE AND

ACETAMINOPH - oxycodone w/

acetaminophen tab 7.5-300 mg

oxycodone hcl cap 5 mg

•

oxycodone hcl conc 100 mg/5ml

(20 mg/ml)

•

oxycodone hcl soln 5 mg/5ml

•

oxycodone hcl tab 5 mg, 15 mg,

30 mg (Roxicodone)

•

oxycodone hcl tab 10 mg, 20 mg

•

OXYCODONE HYDROCHLORIDE/

A - oxycodone w/ acetaminophen

soln 5-325 mg/5ml, 10-300

mg/5ml

oxycodone w/ acetaminophen

tab 2.5-325 mg, 5-325 mg,

7.5-325 mg, 10-325 mg

(Percocet)

•

OXYCODONE/ACETAMINOPHEN -

oxycodone w/ acetaminophen tab

2.5-300 mg, 5-300 mg, 10-300 mg

oxymorphone hcl tab 5 mg, 10 mg

•

OXYMORPHONE

HYDROCHLORIDE -

oxymorphone hcl tab er 12hr 5

mg, 7.5 mg, 10 mg, 15 mg, 20 mg,

30 mg, 40 mg

• •

pentazocine w/ naloxone hcl tab

50-0.5 mg

PERCOCET - oxycodone w/

acetaminophen tab 2.5-325 mg,

5-325 mg, 7.5-325 mg, 10-325 mg

PROLATE - oxycodone w/

acetaminophen soln 10-300

mg/5ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 70

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PROLATE - oxycodone w/

acetaminophen tab 5-300 mg,

7.5-300 mg, 10-300 mg

QDOLO - tramadol hcl oral soln 5

mg/ml

ROXICODONE - oxycodone hcl tab

15 mg, 30 mg

ROXYBOND - oxycodone hcl tab

abuse deter 5 mg, 15 mg, 30 mg

•

SEGLENTIS - celecoxib-tramadol hcl

tab 56-44 mg

SUBOXONE - buprenorphine hcl-

naloxone hcl sl film 2-0.5 mg

(base equiv), 4-1 mg (base equiv),

8-2 mg (base equiv), 12-3 mg

(base equiv)

SUBSYS - fentanyl sublingual spray

100 mcg, 200 mcg, 400 mcg, 600

mcg, 800 mcg, 1200 mcg (600

mcg x 2), 1600 mcg (800 mcg x 2)

TRAMADOL HCL ER - tramadol hcl

cap er 24hr biphasic release 100

mg, 200 mg, 300 mg

TRAMADOL HCL ER - tramadol hcl

tab er 24hr biphasic release 100

mg, 200 mg, 300 mg

• •

tramadol hcl tab er 24hr 100 mg,

200 mg, 300 mg

• •

tramadol hcl tab 50 mg (Ultram)

•

tramadol hcl tab 100 mg

TRAMADOL HYDROCHLORIDE -

tramadol hcl oral soln 5 mg/ml

tramadol-acetaminophen tab

37.5-325 mg (Ultracet)

•

TREZIX - acetaminophen-caffeine-

dihydrocodeine cap 320.5-30-16

ULTRACET - tramadol-

acetaminophen tab 37.5-325 mg

ULTRAM - tramadol hcl tab 50 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

XTAMPZA ER - oxycodone cap er

12hr abuse-deterrent 9 mg, 13.5

mg, 18 mg, 27 mg, 36 mg

• •

ZUBSOLV - buprenorphine hcl-

naloxone hcl sl tab 0.7-0.18 mg

(base eq), 1.4-0.36 mg (base eq),

2.9-0.71 mg (base eq), 5.7-1.4 mg

(base eq), 8.6-2.1 mg (base eq),

11.4-2.9 mg (base eq)

ANALGESICS - ANTI-INFLAMMATORY

ACTEMRA - tocilizumab

subcutaneous soln prefilled

syringe 162 mg/0.9ml

• • • •

ACTEMRA ACTPEN - tocilizumab

subcutaneous soln auto-injector

162 mg/0.9ml

• • • •

ARAVA - leflunomide tab 10 mg, 20

ARCALYST - rilonacept for inj 220

• • • •

ARTHROTEC 50 - diclofenac w/

misoprostol tab delayed release

50-0.2 mg

ARTHROTEC 75 - diclofenac w/

misoprostol tab delayed release

75-0.2 mg

CELEBREX - celecoxib cap 50 mg,

100 mg, 200 mg, 400 mg

celecoxib cap 50 mg, 100 mg,

200 mg, 400 mg (Celebrex)

•

DAYPRO - oxaprozin tab 600 mg

DICLOFENAC - diclofenac cap 35

diclofenac potassium cap 25 mg

(Zipsor)

diclofenac potassium tab 25 mg

diclofenac potassium tab 50 mg

diclofenac sodium tab delayed

release 25 mg, 50 mg, 75 mg

diclofenac sodium tab er 24hr

100 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 71

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

diclofenac w/ misoprostol tab

delayed release 50-0.2 mg

(Arthrotec 50)

diclofenac w/ misoprostol tab

delayed release 75-0.2 mg

(Arthrotec 75)

DUEXIS - ibuprofen-famotidine tab

800-26.6 mg

EC-NAPROSYN - naproxen tab ec

375 mg, 500 mg

ENBREL - etanercept subcutaneous

inj 25 mg/0.5ml

• • • •

ENBREL - etanercept subcutaneous

soln prefilled syringe 25 mg/0.5ml,

50 mg/ml

• • • •

ENBREL MINI - etanercept

subcutaneous solution cartridge

50 mg/ml

• • • •

ENBREL SURECLICK - etanercept

subcutaneous solution auto-

injector 50 mg/ml

• • • •

etodolac cap 200 mg, 300 mg

etodolac tab er 24hr 400 mg,

500 mg

etodolac tab er 24hr 600 mg

•

etodolac tab 400 mg (Lodine)

etodolac tab 500 mg

FELDENE - piroxicam cap 10 mg, 20

FENOPROFEN CALCIUM -

fenoprofen calcium cap 200 mg

fenoprofen calcium cap 400 mg

(Nalfon)

fenoprofen calcium tab 600 mg

(Nalfon)

•

FENORTHO - fenoprofen calcium

cap 200 mg

FLURBIPROFEN - flurbiprofen tab

50 mg

•

flurbiprofen tab 100 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

HUMIRA - adalimumab prefilled

syringe kit 10 mg/0.1ml, 20

mg/0.2ml, 40 mg/0.8ml, 40

mg/0.4ml

• • • •

HUMIRA PEDIATRIC CROHNS D -

adalimumab prefilled syringe kit

80 mg/0.8ml, 80 mg/0.8ml & 40

mg/0.4ml

• • • •

HUMIRA PEN - adalimumab pen-

injector kit 40 mg/0.8ml, 40

mg/0.4ml, 80 mg/0.8ml

• • • •

HUMIRA PEN-CD/UC/HS START -

adalimumab pen-injector kit 40

mg/0.8ml, 80 mg/0.8ml

• • • •

HUMIRA PEN-PEDIATRIC UC S -

adalimumab pen-injector kit 80

mg/0.8ml

• • • •

HUMIRA PEN-PS/UV STARTER -

adalimumab pen-injector kit 40

mg/0.8ml, 80 mg/0.8ml & 40

mg/0.4ml

• • • •

ibuprofen susp 100 mg/5ml

ibuprofen tab 400 mg, 600 mg,

800 mg

ibuprofen-famotidine tab

800-26.6 mg (Duexis)

• •

INDOCIN - indomethacin suppos 50

INDOCIN - indomethacin susp 25

mg/5ml

INDOMETHACIN - indomethacin cap

20 mg

indomethacin cap er 75 mg

indomethacin cap 25 mg, 50 mg

KETOPROFEN - ketoprofen cap 25

KETOPROFEN ER - ketoprofen cap

er 24hr 200 mg

•

KETOROLAC TROMETHAMINE -

ketorolac tromethamine nasal

spray 15.75 mg/spray

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 72

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ketorolac tromethamine tab

10 mg

•

KEVZARA - sarilumab subcutaneous

soln prefilled syringe 150

mg/1.14ml, 200 mg/1.14ml

• • • •

KEVZARA - sarilumab subcutaneous

solution auto-injector 150

mg/1.14ml, 200 mg/1.14ml

• • • •

KINERET - anakinra subcutaneous

soln prefilled syringe 100

mg/0.67ml

leflunomide tab 10 mg, 20 mg

(Arava)

LODINE - etodolac tab 400 mg

MECLOFENAMATE SODIUM -

meclofenamate sodium cap 50

mg, 100 mg

•

mefenamic acid cap 250 mg

MELOXICAM - meloxicam susp 7.5

mg/5ml

• •

meloxicam cap 5 mg, 10 mg

meloxicam tab 7.5 mg, 15 mg

•

nabumetone tab 500 mg, 750 mg

NALFON - fenoprofen calcium cap

400 mg

NALFON - fenoprofen calcium tab

600 mg

NAPRELAN - naproxen sodium tab

er 24hr 375 mg (base equiv), 500

mg (base equiv), 750 mg (base

equiv)

NAPROSYN - naproxen susp 125

mg/5ml

NAPROXEN SODIUM - naproxen

sodium tab er 24hr 750 mg (base

equiv)

naproxen sodium tab er 24hr

375 mg (base equiv), 500 mg

(base equiv) (Naprelan)

naproxen sodium tab 275 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

naproxen sodium tab 550 mg

(Anaprox ds)

naproxen susp 125 mg/5ml

(Naprosyn)

naproxen tab ec 375 mg, 500 mg

(Ec-naprosyn)

naproxen tab 250 mg, 375 mg

naproxen tab 500 mg (Naprosyn)

naproxen-esomeprazole

magnesium tab dr 375-20 mg,

500-20 mg (Vimovo)

• •

ORENCIA - abatacept subcutaneous

soln prefilled syringe 50 mg/0.4ml,

87.5 mg/0.7ml, 125 mg/ml

• • • •

ORENCIA CLICKJECT - abatacept

subcutaneous soln auto-injector

125 mg/ml

• • • •

OTEZLA - apremilast tab starter

therapy pack 10 mg & 20 mg & 30

• • • •

OTEZLA - apremilast tab 30 mg

• • • •

OTREXUP - methotrexate soln pf

auto-injector 10 mg/0.4ml, 12.5

mg/0.4ml, 15 mg/0.4ml, 17.5

mg/0.4ml, 20 mg/0.4ml, 22.5

mg/0.4ml, 25 mg/0.4ml

• •

oxaprozin tab 600 mg (Daypro)

piroxicam cap 10 mg, 20 mg

(Feldene)

RASUVO - methotrexate soln pf

auto-injector 7.5 mg/0.15ml, 10

mg/0.2ml, 12.5 mg/0.25ml, 15

mg/0.3ml, 17.5 mg/0.35ml, 20

mg/0.4ml, 22.5 mg/0.45ml, 25

mg/0.5ml, 30 mg/0.6ml

REDITREX - methotrexate soln

prefilled syringe 7.5 mg/0.3ml,

10 mg/0.4ml, 12.5 mg/0.5ml,

15 mg/0.6ml, 17.5 mg/0.7ml, 20

mg/0.8ml, 22.5 mg/0.9ml, 25 mg/

• •

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 73

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

RELAFEN DS - nabumetone tab

1000 mg

RIDAURA - auranofin cap 3 mg

RINVOQ - upadacitinib tab er 24hr

15 mg, 30 mg, 45 mg

• • • •

SIMPONI - golimumab

subcutaneous soln auto-injector

50 mg/0.5ml

SIMPONI - golimumab

subcutaneous soln auto-injector

100 mg/ml

• • • •

SIMPONI - golimumab

subcutaneous soln prefilled

syringe 50 mg/0.5ml

SIMPONI - golimumab

subcutaneous soln prefilled

syringe 100 mg/ml

• • • •

SPRIX - ketorolac tromethamine

nasal spray 15.75 mg/spray

sulindac tab 150 mg, 200 mg

TIVORBEX - indomethacin cap 20

VIMOVO - naproxen-esomeprazole

magnesium tab dr 375-20 mg,

500-20 mg

XELJANZ - tofacitinib citrate oral

soln 1 mg/ml (base equivalent)

• • • •

XELJANZ - tofacitinib citrate tab

5 mg (base equivalent), 10 mg

(base equivalent)

• • • •

XELJANZ XR - tofacitinib citrate tab

er 24hr 11 mg (base equivalent),

22 mg (base equivalent)

• • • •

ZIPSOR - diclofenac potassium cap

25 mg

ZORVOLEX - diclofenac cap 18 mg,

35 mg

MIGRAINE PRODUCTS

AIMOVIG - erenumab-aooe

subcutaneous soln auto-injector

70 mg/ml, 140 mg/ml

• •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

AJOVY - fremanezumab-vfrm

subcutaneous soln auto-inj 225

mg/1.5ml

• •

AJOVY - fremanezumab-vfrm

subcutaneous soln pref syr 225

mg/1.5ml

• •

almotriptan malate tab 6.25 mg,

12.5 mg

• •

CAFERGOT - ergotamine w/ caffeine

tab 1-100 mg

CAMBIA - diclofenac potassium

(migraine) packet 50 mg

dihydroergotamine mesylate inj

1 mg/ml

• •

dihydroergotamine mesylate

nasal spray 4 mg/ml (Migranal)

eletriptan hydrobromide tab

20 mg (base equivalent), 40 mg

(base equivalent) (Relpax)

• •

ELYXYB - celecoxib oral soln 120

mg/4.8ml (25 mg/ml)

EMGALITY - galcanezumab-gnlm

subcutaneous soln auto-injector

120 mg/ml

• •

EMGALITY - galcanezumab-gnlm

subcutaneous soln prefilled syr

100 mg/ml, 120 mg/ml

• •

ERGOMAR - ergotamine tartrate sl

tab 2 mg

• •

ergotamine w/ caffeine tab

1-100 mg (Cafergot)

• •

FROVA - frovatriptan succinate tab

2.5 mg (base equivalent)

frovatriptan succinate tab 2.5 mg

(base equivalent) (Frova)

• •

IMITREX - sumatriptan nasal spray 5

mg/act, 20 mg/act

IMITREX - sumatriptan succinate tab

25 mg, 50 mg, 100 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 74

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

IMITREX STATDOSE REFILL -

sumatriptan succinate solution

cartridge 4 mg/0.5ml, 6 mg/0.5ml

IMITREX STATDOSE SYSTEM -

sumatriptan succinate solution

auto-injector 4 mg/0.5ml, 6

mg/0.5ml

MAXALT - rizatriptan benzoate tab

10 mg (base equivalent)

MAXALT-MLT - rizatriptan benzoate

oral disintegrating tab 10 mg

(base eq)

MIGRANAL - dihydroergotamine

mesylate nasal spray 4 mg/ml

naratriptan hcl tab 1 mg (base

equiv), 2.5 mg (base equiv)

•

NURTEC - rimegepant sulfate tab

disint 75 mg

• •

ONZETRA XSAIL - sumatriptan

succinate exhaler powder 11 mg/

nosepiece

RELPAX - eletriptan hydrobromide

tab 20 mg (base equivalent), 40

mg (base equivalent)

REYVOW - lasmiditan succinate tab

50 mg, 100 mg

• •

rizatriptan benzoate oral

disintegrating tab 5 mg (base

eq)

•

rizatriptan benzoate oral

disintegrating tab 10 mg (base

eq) (Maxalt-mlt)

•

rizatriptan benzoate tab 5 mg

(base equivalent)

•

rizatriptan benzoate tab 10 mg

(base equivalent) (Maxalt)

•

sumatriptan nasal spray 5 mg/act,

20 mg/act (Imitrex)

•

sumatriptan succinate inj

6 mg/0.5ml

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SUMATRIPTAN SUCCINATE REF -

sumatriptan succinate solution

cartridge 4 mg/0.5ml, 6 mg/0.5ml

• •

sumatriptan succinate solution

auto-injector 4 mg/0.5ml,

6 mg/0.5ml (Imitrex statdose sys)

•

sumatriptan succinate tab 25 mg,

50 mg, 100 mg (Imitrex)

•

sumatriptan-naproxen sodium tab

85-500 mg (Treximet)

• •

TOSYMRA - sumatriptan nasal spray

10 mg/act

TREXIMET - sumatriptan-naproxen

sodium tab 85-500 mg

TRUDHESA - dihydroergotamine

mesylate hfa nasal aerosol 0.725

mg/act

UBRELVY - ubrogepant tab 50 mg,

100 mg

• •

ZEMBRACE SYMTOUCH -

sumatriptan succinate solution

auto-injector 3 mg/0.5ml

ZOLMITRIPTAN - zolmitriptan nasal

spray 2.5 mg/spray unit

zolmitriptan nasal spray 5 mg/

spray unit (Zomig)

zolmitriptan orally disintegrating

tab 2.5 mg, 5 mg

• •

zolmitriptan tab 2.5 mg, 5 mg

(Zomig)

• •

ZOMIG - zolmitriptan nasal spray 2.5

mg/spray unit, 5 mg/spray unit

ZOMIG - zolmitriptan tab 2.5 mg, 5

GOUT AGENTS

allopurinol tab 100 mg, 300 mg

(Zyloprim)

COLCHICINE - colchicine cap 0.6

colchicine tab 0.6 mg (Colcrys)

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 75

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

colchicine w/ probenecid tab

0.5-500 mg

COLCRYS - colchicine tab 0.6 mg

febuxostat tab 40 mg, 80 mg

(Uloric)

•

MITIGARE - colchicine cap 0.6 mg

probenecid tab 500 mg

ULORIC - febuxostat tab 40 mg, 80

ZYLOPRIM - allopurinol tab 100 mg,

300 mg

NEUROMUSCULAR DRUGS

ANTICONVULSANTS

APTIOM - eslicarbazepine acetate

tab 200 mg, 400 mg, 600 mg, 800

•

BANZEL - rufinamide susp 40 mg/ml

BANZEL - rufinamide tab 200 mg,

400 mg

BRIVIACT - brivaracetam oral soln

10 mg/ml

• •

BRIVIACT - brivaracetam tab 10 mg

BRIVIACT - brivaracetam tab 25 mg,

50 mg, 75 mg, 100 mg

•

carbamazepine cap er 12hr

100 mg, 200 mg, 300 mg

(Carbatrol)

carbamazepine chew tab 100 mg

carbamazepine susp 100 mg/5ml

(Tegretol)

carbamazepine tab er 12hr

100 mg, 200 mg, 400 mg

(Tegretol-xr)

carbamazepine tab 200 mg

(Tegretol)

CARBATROL - carbamazepine cap

er 12hr 100 mg, 200 mg, 300 mg

•

CELONTIN - methsuximide cap 300

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

clobazam suspension 2.5 mg/ml

(Onfi)

clobazam tab 10 mg, 20 mg (Onfi)

clonazepam orally disintegrating

tab 0.125 mg, 0.25 mg, 0.5 mg,

1 mg, 2 mg

clonazepam tab 0.5 mg, 1 mg,

2 mg (Klonopin)

DEPAKOTE - divalproex sodium tab

delayed release 125 mg, 250 mg,

500 mg

DEPAKOTE ER - divalproex sodium

tab er 24 hr 250 mg, 500 mg

DEPAKOTE SPRINKLES -

divalproex sodium cap delayed

release sprinkle 125 mg

DIACOMIT - stiripentol cap 250 mg,

500 mg

• •

DIACOMIT - stiripentol packet 250

• •

DIACOMIT - stiripentol packet 500

• • •

DIASTAT ACUDIAL - diazepam

rectal gel delivery system 10 mg,

20 mg

DIASTAT PEDIATRIC - diazepam

rectal gel delivery system 2.5 mg

DIAZEPAM RECTAL GEL -

diazepam rectal gel delivery

system 2.5 mg, 10 mg, 20 mg

DILANTIN - phenytoin sodium

extended cap 30 mg, 100 mg

DILANTIN INFATABS - phenytoin

chew tab 50 mg

DILANTIN-125 - phenytoin susp 125

mg/5ml

divalproex sodium cap delayed

release sprinkle 125 mg

(Depakote sprinkles)

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 76

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

divalproex sodium tab delayed

release 125 mg, 250 mg, 500 mg

(Depakote)

divalproex sodium tab er 24 hr

250 mg, 500 mg (Depakote er)

ELEPSIA XR - levetiracetam tab er

24hr 1000 mg, 1500 mg

EPIDIOLEX - cannabidiol soln 100

mg/ml

• • • •

EPRONTIA - topiramate oral soln 25

mg/ml

ethosuximide cap 250 mg

(Zarontin)

ethosuximide soln 250 mg/5ml

(Zarontin)

felbamate susp 600 mg/5ml

(Felbatol)

felbamate tab 400 mg, 600 mg

(Felbatol)

FELBATOL - felbamate susp 600

mg/5ml

FELBATOL - felbamate tab 400 mg,

600 mg

FINTEPLA - fenfluramine hcl oral

soln 2.2 mg/ml

• • • •

FYCOMPA - perampanel susp 0.5

mg/ml

• •

FYCOMPA - perampanel tab 2 mg, 4

mg, 6 mg, 8 mg, 10 mg, 12 mg

•

gabapentin cap 100 mg, 300 mg,

400 mg (Neurontin)

•

gabapentin oral soln 250 mg/5ml

(Neurontin)

•

gabapentin tab 600 mg, 800 mg

(Neurontin)

•

GABITRIL - tiagabine hcl tab 2 mg, 4

mg, 12 mg, 16 mg

KEPPRA - levetiracetam oral soln

100 mg/ml

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

KEPPRA - levetiracetam tab 250 mg,

500 mg, 750 mg, 1000 mg

KEPPRA XR - levetiracetam tab er

24hr 500 mg, 750 mg

KLONOPIN - clonazepam tab 0.5

mg, 1 mg, 2 mg

lacosamide oral solution 10 mg/

ml (Vimpat)

• •

lacosamide tab 50 mg, 100 mg,

150 mg, 200 mg (Vimpat)

•

LAMICTAL - lamotrigine tab 25 mg,

100 mg, 150 mg, 200 mg

LAMICTAL CHEWABLE DISPERS -

lamotrigine tab chewable

dispersible 5 mg, 25 mg

LAMICTAL ODT - lamotrigine orally

disintegrating tab 25 mg, 50 mg,

100 mg, 200 mg

LAMICTAL ODT - lamotrigine tab

disint 25 (14) & 50 mg (14) & 100

mg (7) kit

LAMICTAL STARTER/NOT TAKI -

lamotrigine tab 25 mg (42) & 100

mg (7) starter kit

LAMICTAL STARTER/TAKING C -

lamotrigine tab 84 x 25 mg & 14 x

100 mg starter kit

LAMICTAL STARTER/TAKING V -

lamotrigine tab 35 x 25 mg starter

kit

LAMICTAL XR - lamotrigine tab er

24hr 25 mg, 50 mg, 100 mg, 200

mg, 250 mg, 300 mg

LAMICTAL XR - lamotrigine tab er

24hr 21 x 25 mg & 7 x 50 mg

titration kit

LAMICTAL XR - lamotrigine tab er

24hr 25 (14) & 50 mg (14) & 100

mg(7) kit

LAMICTAL XR - lamotrigine tab er

24hr 50 (14) & 100 mg(14) & 200

mg(7) kit

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 77

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

lamotrigine orally disintegrating

tab 25 mg, 50 mg, 100 mg,

200 mg (Lamictal odt)

lamotrigine tab chewable

dispersible 5 mg, 25 mg

(Lamictal chewable di)

lamotrigine tab disint 25 (14)

& 50 mg (14) & 100 mg (7) kit

(Lamictal odt)

lamotrigine tab er 24hr 25 mg,

50 mg, 100 mg, 200 mg, 250 mg,

300 mg (Lamictal xr)

lamotrigine tab 25 mg, 100 mg,

150 mg, 200 mg (Lamictal)

lamotrigine tab 35 x 25 mg starter

kit (Lamictal starter/tak)

lamotrigine tab 25 mg (42) &

100 mg (7) starter kit (Lamictal

starter/not)

lamotrigine tab 84 x 25 mg & 14

x 100 mg starter kit (Lamictal

starter/tak)

levetiracetam oral soln 100 mg/ml

(Keppra)

levetiracetam tab er 24hr 500 mg,

750 mg (Keppra xr)

levetiracetam tab 250 mg, 500 mg,

750 mg, 1000 mg (Keppra)

LYRICA - pregabalin cap 25 mg, 50

mg, 75 mg, 100 mg, 150 mg, 200

mg, 225 mg, 300 mg

LYRICA - pregabalin soln 20 mg/ml

MYSOLINE - primidone tab 50 mg,

250 mg

•

NAYZILAM - midazolam nasal spray

soln 5 mg/0.1 ml

• •

NEURONTIN - gabapentin cap 100

mg, 300 mg, 400 mg

NEURONTIN - gabapentin oral soln

250 mg/5ml

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NEURONTIN - gabapentin tab 600

mg, 800 mg

ONFI - clobazam suspension 2.5

mg/ml

ONFI - clobazam tab 10 mg, 20 mg

oxcarbazepine susp 300 mg/5ml

(60 mg/ml) (Trileptal)

oxcarbazepine tab 150 mg,

300 mg, 600 mg (Trileptal)

OXTELLAR XR - oxcarbazepine tab

er 24hr 150 mg, 300 mg, 600 mg

PHENYTEK - phenytoin sodium

extended cap 200 mg, 300 mg

phenytoin chew tab 50 mg

(Dilantin infatabs)

phenytoin sodium extended cap

100 mg (Dilantin)

phenytoin sodium extended cap

200 mg, 300 mg (Phenytek)

phenytoin susp 125 mg/5ml

(Dilantin-125)

pregabalin cap 25 mg, 50 mg,

75 mg, 100 mg, 150 mg, 200 mg,

225 mg, 300 mg (Lyrica)

•

primidone tab 50 mg, 250 mg

(Mysoline)

QUDEXY XR - topiramate cap er

24hr sprinkle 25 mg, 50 mg, 100

mg, 150 mg, 200 mg

• •

rufinamide susp 40 mg/ml

(Banzel)

• •

rufinamide tab 200 mg, 400 mg

(Banzel)

•

SABRIL - vigabatrin powd pack 500

SABRIL - vigabatrin tab 500 mg

SPRITAM - levetiracetam tab

disintegrating soluble 250 mg, 500

mg, 750 mg, 1000 mg

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 78

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SYMPAZAN - clobazam oral film 5

mg, 10 mg, 20 mg

TEGRETOL - carbamazepine susp

100 mg/5ml

TEGRETOL - carbamazepine tab

200 mg

TEGRETOL-XR - carbamazepine tab

er 12hr 100 mg, 200 mg, 400 mg

tiagabine hcl tab 2 mg, 4 mg,

12 mg, 16 mg (Gabitril)

TOPAMAX - topiramate tab 25 mg,

50 mg, 100 mg, 200 mg

TOPAMAX SPRINKLE - topiramate

sprinkle cap 15 mg, 25 mg

topiramate cap er 24hr sprinkle

25 mg, 50 mg, 100 mg, 150 mg,

200 mg (Qudexy xr)

topiramate sprinkle cap 15 mg,

25 mg (Topamax sprinkle)

topiramate tab 25 mg, 50 mg,

100 mg, 200 mg (Topamax)

TRILEPTAL - oxcarbazepine susp

300 mg/5ml (60 mg/ml)

TRILEPTAL - oxcarbazepine tab 150

mg, 300 mg, 600 mg

TROKENDI XR - topiramate cap er

24hr 25 mg, 50 mg, 100 mg, 200

valproate sodium oral soln

250 mg/5ml (base equiv)

valproic acid cap 250 mg

VALTOCO - diazepam nasal spray

ther pack 2 x 7.5 mg/0.1ml (15 mg

dose), 2 x 10 mg/0.1ml (20 mg

dose)

• •

VALTOCO - diazepam nasal spray 5

mg/0.1 ml, 10 mg/0.1 ml

• •

vigabatrin powd pack 500 mg

(Sabril)

• • •

vigabatrin tab 500 mg (Sabril)

• • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VIMPAT - lacosamide oral solution

10 mg/ml

• •

VIMPAT - lacosamide tab 50 mg, 100

mg, 150 mg, 200 mg

• •

XCOPRI - cenobamate tab pack 100

mg & 150 mg tabs (250 mg daily

dose)

• •

XCOPRI - cenobamate tab pack 150

mg & 200 mg tabs (350 mg daily

dose)

•

XCOPRI - cenobamate tab titration

pack 14 x 12.5 mg & 14 x 25 mg,

14 x 50 mg & 14 x 100 mg, 14 x

150 mg & 14 x 200 mg

•

XCOPRI - cenobamate tab 50 mg,

100 mg, 150 mg, 200 mg

•

ZARONTIN - ethosuximide cap 250

ZARONTIN - ethosuximide soln 250

mg/5ml

ZONEGRAN - zonisamide cap 25

mg, 100 mg

ZONISADE - zonisamide oral susp

100 mg/5ml (20 mg/ml)

zonisamide cap 25 mg, 100 mg

(Zonegran)

zonisamide cap 50 mg

ZTALMY - ganaxolone susp 50 mg/

• •

ANTIPARKINSON AGENTS

amantadine hcl cap 100 mg

amantadine hcl soln 50 mg/5ml

amantadine hcl tab 100 mg

APOKYN - apomorphine hcl soln

cartridge 30 mg/3ml

• • • •

apomorphine hcl soln cartridge

30 mg/3ml (Apokyn)

• • • •

AZILECT - rasagiline mesylate tab

0.5 mg (base equiv), 1 mg (base

equiv)

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 79

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

benztropine mesylate tab 0.5 mg,

1 mg, 2 mg

bromocriptine mesylate cap 5 mg

(base equivalent) (Parlodel)

bromocriptine mesylate tab

2.5 mg (base equivalent)

(Parlodel)

carbidopa & levodopa tab er

25-100 mg, 50-200 mg

carbidopa & levodopa tab

10-100 mg (Sinemet)

carbidopa & levodopa tab

25-100 mg (Sinemet)

•

carbidopa & levodopa tab

25-250 mg

carbidopa tab 25 mg (Lodosyn)

carbidopa-levodopa-entacapone

tabs 12.5-50-200 mg (Stalevo 50)

carbidopa-levodopa-entacapone

tabs 18.75-75-200 mg (Stalevo

75)

carbidopa-levodopa-entacapone

tabs 25-100-200 mg (Stalevo

100)

carbidopa-levodopa-entacapone

tabs 31.25-125-200 mg (Stalevo

125)

carbidopa-levodopa-entacapone

tabs 37.5-150-200 mg (Stalevo

150)

carbidopa-levodopa-entacapone

tabs 50-200-200 mg (Stalevo

200)

CARBIDOPA/LEVODOPA ODT -

carbidopa & levodopa orally

disintegrating tab 10-100 mg,

25-100 mg, 25-250 mg

COMTAN - entacapone tab 200 mg

DHIVY - carbidopa & levodopa tab

25-100 mg

entacapone tab 200 mg (Comtan)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

GOCOVRI - amantadine hcl cap er

24hr 68.5 mg (base equivalent),

137 mg (base equivalent)

INBRIJA - levodopa inhal powder

cap 42 mg

• • • •

KYNMOBI - apomorphine

hydrochloride film 10 mg, 15 mg,

20 mg, 25 mg, 30 mg

• •

LODOSYN - carbidopa tab 25 mg

MIRAPEX ER - pramipexole

dihydrochloride tab er 24hr 0.375

mg, 0.75 mg, 1.5 mg, 2.25 mg, 3

mg, 3.75 mg, 4.5 mg

NEUPRO - rotigotine td patch 24hr 1

mg/24hr, 2 mg/24hr, 3 mg/24hr, 4

mg/24hr, 6 mg/24hr, 8 mg/24hr

NOURIANZ - istradefylline tab 20

mg, 40 mg

ONGENTYS - opicapone cap 25 mg,

50 mg

OSMOLEX ER - amantadine hcl tab

er 24hr pak 129 mg & 193 mg

(322 mg dose)

OSMOLEX ER - amantadine hcl tab

er 24hr 129 mg (base equivalent),

193 mg (base equivalent)

PARLODEL - bromocriptine mesylate

cap 5 mg (base equivalent)

PARLODEL - bromocriptine mesylate

tab 2.5 mg (base equivalent)

pramipexole dihydrochloride

tab er 24hr 0.375 mg, 0.75 mg,

1.5 mg, 2.25 mg, 3 mg, 3.75 mg,

4.5 mg (Mirapex er)

pramipexole dihydrochloride

tab 0.125 mg, 0.25 mg, 0.5 mg,

0.75 mg, 1 mg, 1.5 mg

rasagiline mesylate tab 0.5 mg

(base equiv), 1 mg (base equiv)

(Azilect)

ropinirole hydrochloride tab er

24hr 2 mg (base equivalent),

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 80

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

4 mg (base equivalent), 6 mg

(base equivalent), 8 mg (base

equivalent), 12 mg (base

equivalent)

ropinirole hydrochloride tab

0.25 mg, 0.5 mg, 1 mg, 2 mg,

3 mg, 4 mg, 5 mg

RYTARY - carbidopa & levodopa cap

er 23.75-95 mg, 36.25-145 mg,

48.75-195 mg, 61.25-245 mg

•

selegiline hcl cap 5 mg

selegiline hcl tab 5 mg

SINEMET - carbidopa & levodopa

tab 10-100 mg, 25-100 mg

STALEVO 100 - carbidopa-levodopa-

entacapone tabs 25-100-200 mg

STALEVO 125 - carbidopa-levodopa-

entacapone tabs 31.25-125-200

STALEVO 150 - carbidopa-levodopa-

entacapone tabs 37.5-150-200 mg

STALEVO 200 - carbidopa-levodopa-

entacapone tabs 50-200-200 mg

STALEVO 50 - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg

STALEVO 75 - carbidopa-levodopa-

entacapone tabs 18.75-75-200 mg

TASMAR - tolcapone tab 100 mg

tolcapone tab 100 mg (Tasmar)

TRIHEXYPHENIDYL HCL -

trihexyphenidyl hcl oral soln 0.4

mg/ml

trihexyphenidyl hcl tab 2 mg,

5 mg

XADAGO - safinamide mesylate tab

50 mg (base equiv), 100 mg (base

equiv)

ZELAPAR - selegiline hcl orally

disintegrating tab 1.25 mg

NEUROMUSCULAR AGENTS

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

AMONDYS 45 - casimersen iv soln

100 mg/2ml (50 mg/ml)

EVRYSDI - risdiplam for soln 0.75

mg/ml

• • • •

EXONDYS 51 - eteplirsen iv soln

100 mg/2ml (50 mg/ml), 500

mg/10ml (50 mg/ml)

EXSERVAN - riluzole oral film 50 mg

RILUTEK - riluzole tab 50 mg

riluzole tab 50 mg (Rilutek)

• •

TIGLUTIK - riluzole susp 50 mg/10ml

VILTEPSO - viltolarsen iv soln 250

mg/5ml (50 mg/ml)

VYONDYS 53 - golodirsen iv soln

100 mg/2ml (50 mg/ml)

MUSCULOSKELETAL THERAPY AGENTS

AMRIX - cyclobenzaprine hcl cap er

24hr 15 mg, 30 mg

BACLOFEN - baclofen oral soln 5

mg/5ml

baclofen tab 5 mg

baclofen tab 10 mg, 20 mg

carisoprodol tab 250 mg (Soma)

• •

carisoprodol tab 350 mg (Soma)

•

chlorzoxazone tab 250 mg,

375 mg, 750 mg

chlorzoxazone tab 500 mg

•

cyclobenzaprine hcl cap er 24hr

15 mg, 30 mg (Amrix)

cyclobenzaprine hcl tab 5 mg,

10 mg

•

cyclobenzaprine hcl tab 7.5 mg

DANTRIUM - dantrolene sodium cap

25 mg

dantrolene sodium cap 25 mg

(Dantrium)

dantrolene sodium cap 50 mg,

100 mg

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 81

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

FLEQSUVY - baclofen susp 25

mg/5ml

LYVISPAH - baclofen granules

packet 5 mg, 10 mg, 20 mg

• •

metaxalone tab 400 mg, 800 mg

• •

methocarbamol tab 500 mg,

750 mg

NORGESIC FORTE - orphenadrine

w/ aspirin & caffeine tab

50-770-60 mg

orphenadrine citrate tab er 12hr

100 mg

orphenadrine w/ aspirin &

caffeine tab 25-385-30 mg

orphenadrine w/ aspirin &

caffeine tab 50-770-60 mg

(Norgesic forte)

• •

OZOBAX - baclofen oral soln 5

mg/5ml

SOMA - carisoprodol tab 250 mg,

350 mg

tizanidine hcl cap 2 mg (base

equivalent), 4 mg (base

equivalent), 6 mg (base

equivalent) (Zanaflex)

tizanidine hcl tab 2 mg (base

equivalent)

tizanidine hcl tab 4 mg (base

equivalent) (Zanaflex)

ZANAFLEX - tizanidine hcl cap

2 mg (base equivalent), 4 mg

(base equivalent), 6 mg (base

equivalent)

ZANAFLEX - tizanidine hcl tab 4 mg

(base equivalent)

ANTIMYASTHENIC AGENTS

FIRDAPSE - amifampridine

phosphate tab 10 mg (base

equivalent)

• • • •

MESTINON - pyridostigmine

bromide oral soln 60 mg/5ml

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MESTINON - pyridostigmine

bromide tab 60 mg

MESTINON TIMESPAN -

pyridostigmine bromide tab er 180

PYRIDOSTIGMINE BROMIDE -

pyridostigmine bromide tab 30 mg

pyridostigmine bromide oral soln

60 mg/5ml (Mestinon)

pyridostigmine bromide tab er

180 mg (Mestinon timespan)

pyridostigmine bromide tab

60 mg (Mestinon)

NUTRITIONAL PRODUCTS

VITAMINS

DRISDOL - ergocalciferol cap 1.25

mg (50000 unit)

ergocalciferol cap 1.25 mg (50000

unit) (Drisdol)

MEPHYTON - phytonadione tab 5

phytonadione tab 5 mg

(Mephyton)

MULTIVITAMINS

ATABEX EC - prenatal vit w/ dss-iron

carbonyl-fa tab dr 29-1 mg

ATABEX OB - prenatal vit w/ fe

bisglycinate chelate-fa tab 29-1

AZESCO - prenatal vit w/ fe

gluconate-fa tab 13-1 mg

C-NATE DHA - prenatal vit w/ fe fum-

fa-omega 3 cap 28-1-200 mg

CITRANATAL ASSURE - prenat w/

o a w/fecbn-fegl-dss-fa tab & dha

cap 300 mg pack

CITRANATAL B-CALM - prenat w/o

a w/fecbn-feglu-fa tab 20-1 mg &

vit b6 tab pak

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 82

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CITRANATAL BLOOM - prenatal vit

w/ dss-fe cbn-fe gluc-fa tab 90-1

CITRANATAL DHA - prenat w/o a w/

fecbn-fegl-dss-fa tab & dha cap

250 mg pack

CITRANATAL HARMONY - prenat

w/o a w/fe fum-fe cbn-dss-fa-dha

cap 27-1-260 mg

CITRANATAL 90 DHA - prenat w/o

a w/fecbn-fegl-dss-fa tab 90 &dha

cap 300mg pak

CO-NATAL FA - prenatal vit w/ fe

fumarate-fa tab 29-1 mg

COMPLETE NATAL DHA - prenat-fe

bis-fe prot succ-fa-ca tab & omega

3 cap 200 pk

COMPLETENATE - prenatal vit w/ fe

fumarate-fa chew tab 29-1 mg

CONCEPT DHA - prenatal w/fe fum-

fe poly -fa-omega 3 cap 53.5-38-1

CONCEPT OB - prenatal w/o a w/fe

fum-fe poly-fa cap 130-92.4-1 mg

DERMACINRX PRETRATE -

prenatal multivitamins & minerals

w/ iron & fa tab 1 mg

DUET DHA BALANCED - prenat

w/fe poly-na fered-fa tab 25-1 &

omega cap 267 mg

DUET DHA 400 - prenat w/fe poly-

na fered-fa tab 25-1 & omega cap

400 mg

ELITE-OB - prenatal vit w/ iron

carbonyl-fa tab 50-1.25 mg

ENBRACE HR - prenatal vit w/ fe gly

cys-fa-omega 3 fatty acids cap

FOLIVANE-OB - prenatal w/o a w/fe

fum-fe poly-fa cap 85-1 mg

INATAL GT - prenatal vit w/ dss-iron

carbonyl-fa tab 90-1 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

JENLIVA PRENATAL/POSTNATA -

prenatal multivitamins & minerals

w/ iron & fa cap 1 mg

KOSHER PRENATAL PLUS IRON -

prenatal vit w/ iron carbonyl-fa tab

30-1 mg

M-NATAL PLUS - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

MULTI-MAC - prenatal vit w/ fe fum-

methylfolate-fa tab 15-0.75-1 mg

NATACHEW - prenatal vit w/ fe fum-

fe bisglycin-fa chew tab 28-1 mg

NATALVIT - prenatal vit w/ fe

fumarate-fa tab 75-1 mg

NEEVO DHA - prenat w/o a w/fefum-

methylfol-omegas cap 27-1.13 mg

NEONATAL COMPLETE - prenatal

vit w/ fe fumarate-fa tab 27-1 mg,

29-1 mg

NEONATAL FE - prenatal vitamin w/

iron-folic acid tab 90-1 mg

NEONATAL PLUS - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

NEONATAL VITAMIN - prenatal vit

w/ fe fumarate-fa tab 27-0.8 mg

NEONATAL 19 - prenatal vitamin-

folic acid tab 1 mg

NEONATAL/DHA - prenatal mv w/fe

fum-fa tab 29-1 mg & dha cap 200

mg pack

NESTABS - prenatal vit w/o vit a w/

fe bisglycinate-fa tab 32-1 mg

NESTABS DHA - prenat w/o a w/ fe

bisglyc-fa tab 32-1 mg & omega

cap pack

NESTABS ONE - prenat w/o a

w/fecbn-bisg-methylf-dha cap

38-1-225 mg

NIVA-PLUS - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 83

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

OB COMPLETE - prenatal vit w/ iron

carbonyl-fa tab 50-1.25 mg

OB COMPLETE ONE - prenatal w/o

a w/fecbn-fe asp glyc-fa-fish cap

50-1-476 mg

OB COMPLETE PETITE - prenat w/

o a w/fecbn-feaspglyc-fa-omega

cap 35-5-1-200 mg

OB COMPLETE PREMIER -

prenatal vit w/ fe cbn-fe asp glyc-

fa tab 30-20-1 mg

OB COMPLETE/DHA - prenat w/

iron cbn-fe asp glyc-fa-omega cap

30-10-1-200 mg

OBSTETRIX DHA - prenat w/fecbn-

fa-dss tab 29-1 mg & omega 3 cap

387 mg pak

OBSTETRIX EC - prenatal vit w/

dss-iron carbonyl-fa tab 29-1 mg

OBSTETRIX ONE - prenat w/o a w/

fecbn-bisg-methylf-dss-dha cap

38-1-225 mg

ONE VITE WOMENS PRENATAL -

prenatal vit w/ fe fumarate-fa tab

27-1 mg

PNV TABS 20-1 - prenat vit w/fe

bisglyc chelate-fa tab 20-1mg

(1.7mg dfe)

PNV-DHA - prenat w/o a w/fefum-

methfol-fa-dha cap 27-0.6-0.4-300

PNV-DHA+DOCUSATE - prenatal w/

o vit a w/ fe fum-dss-fa-dha cap

27-1.25-300 mg

PNV-OMEGA - prenat w/o a w/ fe

fumarate-methylfolate-fa-omega 3

cap

PNV-SELECT - prenatal vit w/ fe

fum-methylfolate-fa tab 27-0.6-0.4

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PREGEN DHA - prenatal mv & min

w/fe carbonyl-fa-dha cap 28-1-35

PREGENNA - prenat vit w/fe bisglyc

chelate-fa tab 20-1mg (1.7mg dfe)

PREMESISRX - prenatal w/ calcium-

vit b6-vit b12-fa-ginger tab 1 mg

PRENA 1 TRUE - prenat w/o a w/fe

chel-fa tab 30-1.4 mg & dha cap

300mg pk

PRENAISSANCE - prenatal w/o

vit a w/ fe fum-dss-fa-dha cap

29-1.25-325 mg

PRENAISSANCE PLUS - prenatal

w/o a w/fe cbn-dss-fa-dha cap

28-1-250 mg

PRENARA - prenatal vit w/ fe

fumarate-fa cap 15-1 mg

PRENATABS RX - prenatal vit w/

iron carbonyl-fa tab 29-1 mg

PRENATAL - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

PRENATAL PLUS - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

PRENATAL PLUS VITAMIN AND -

prenatal vit w/ fe fumarate-fa tab

27-1 mg

PRENATAL 19 - prenatal vit w/ dss-

fe fumarate-fa tab 29-1 mg

PRENATAL 19 - prenatal vit w/ fe

fumarate-fa chew tab 29-1 mg

PRENATAL-U - prenatal w/o a vit w/

fe fumarate-fa cap 106.5-1 mg

PRENATE - prenat mv & min w/ l-

methylfolate-fa chew tab 0.6-0.4

PRENATE AM - prenatal w/ calcium-

vit b6-vit b12-fa-ginger tab 1 mg

PRENATE DHA - prenat w/o a

w/feaspg-methfol-fa-dha cap

18-0.6-0.4-300 mg

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 84

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PRENATE ELITE - prenatal w/ fe asp

gly-l methylfol-fa tab 20-0.6-0.4

PRENATE ENHANCE - prenat w/

o a w/fefum-methfol-fa-dha cap

28-0.6-0.4-400 mg

PRENATE ESSENTIAL - prenat w/

o a w/feaspg-methfol-fa-dha cap

18-0.6-0.4-300 mg

PRENATE MINI - prenat w/oa w/

fecb-feasp-meth-fa-dha cap

18-0.6-0.4-350 mg

PRENATE PIXIE - prenat w/o a

w/feaspg-methfol-fa-dha cap

10-0.6-0.4-200 mg

PRENATE RESTORE - prenat w/

o a w/fefum-methfol-fa-dha cap

27-0.6-0.4-400 mg

PRENATRIX - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

PRENATRYL - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

PRENATVITE COMPLETE - prenatal

multivitamins & minerals w/ iron &

fa tab 1 mg

PRENATVITE PLUS - prenatal

multivitamins & minerals w/ iron &

fa tab 1 mg

PRENATVITE RX - prenatal

multivitamins & minerals w/iron &

fa tab 0.8 mg

PRENA1 CHEW - prenat w/ b2-b6-

b12-d3-folic acid chew tab 1.4 mg

PRENA1 PEARL - prenat w/oa w/

fefum-na fered-fa-dha cap er

30-1.4-200 mg

PRIMACARE - prenat w/o a w/

feasp-methlf-fa-omeg cap

30-0.75-0.25-470mg

PROVIDA OB - prenatal w/o a w/fe

fum-fe poly-fa cap 20-20-1.25 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

RELNATE DHA - prenatal vit w/ fe

fum-fa-omega 3 cap 28-1-200 mg

SE-NATAL 19 - prenatal vit w/ dss-fe

fumarate-fa tab 29-1 mg

SE-NATAL 19 - prenatal vit w/ fe

fumarate-fa chew tab 29-1 mg

SELECT-OB - prenat w/

fepolycmplx-methylfol-fa chew tab

29-0.6-0.4 mg

SELECT-OB - prenatal vit w/ fe

polysac cmplx-fa chew tab 29-1

SELECT-OB+DHA - prenatal mv w/

fe poly-fa chw 29-1 mg & dha cap

250 mg pak

TARON-C DHA - prenatal w/fe fum-

fe poly -fa-omega 3 cap 35-1 mg

TARON-PREX - prenatal w/o vit a w/

fe fum-dss-fa-dha cap 30-1.2-265

THRIVITE RX - prenatal vit w/ iron

carbonyl-fa tab 29-1 mg

TRICARE - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

TRINATAL RX 1 - prenatal vit w/ fe

fumarate-fa tab 60-1 mg

TRINATE - prenatal vit w/ fe

fumarate-fa tab 28-1 mg

TRISTART DHA - prenat w/o a

w/fecbn-methylf-fa-dha cap

31-0.6-0.4-200 mg

TRISTART FREE - prenat w/o a w/

dha & fecbn-methylf-fa cap 33-1

TRISTART ONE - prenat w/o a w/

fecbn-methylf-fa-dha cap 35-1-215

VINATE DHA RF - prenat w/o a

w/fefum-methylfol-omegas cap

27-1.13 mg

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 85

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VINATE II - prenatal vit w/ fe

bisglycinate chelate-fa tab 29-1

VINATE ONE - prenatal vit w/ fe

fumarate-fa tab 60-1 mg

VIRT-NATE DHA - prenatal vit w/ fe

fum-fa-omega 3 cap 28-1-200 mg

VIRT-PN DHA - prenat w/o a

w/fefum-methfol-fa-dha cap

27-0.6-0.4-300 mg

VITAFOL FE+ - prenat w/fe

poly-methylfol-fa-dha cap

90-0.6-0.4-200 mg

VITAFOL GUMMIES - prenat vit

w/ fe phos-fa-omega chew tab

3.33-0.333-34.8 mg

VITAFOL STRIPS - prenatal w/ b6-

b12-cholecalciferol-folic acid film 1

VITAFOL ULTRA - prenat w/

fe poly-methylfol-fa-dha cap

29-0.6-0.4-200 mg

VITAFOL-NANO - prenatal w/o a w/

fefum-l methylfol-fa tab 18-0.6-0.4

VITAFOL-OB - prenatal vit w/ fe

fumarate-fa tab 65-1 mg

VITAFOL-OB+DHA - prenatal mv w/

fe fum-fa tab 65-1 mg & dha cap

250 mg pack

VITAFOL-ONE - prenatal mv w/

fe polysac cmplx-fa-dha cap

29-1-200 mg

VITAMEDMD REDICHEW RX -

prenat w/ b2-b6-b12-d3-folic acid

chew tab 1.4 mg

VITAPEARL - prenat w/oa w/fefum-

na fered-fa-dha cap er 30-1.4-200

VITATHELY/GINGER - prenatal vit w/

fe fumarate-fa tab 27-1 mg

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VITATRUE - prenat w/o a w/fe

chel-fa tab 30-1.4 mg & dha cap

300mg pk

VIVA DHA - prenatal vit w/ fe fum-fa-

omega 3 cap 28-1-200 mg

WESCAP-C DHA - prenatal w/fe

fum-fe poly -fa-omega 3 cap

53.5-38-1 mg

WESCAP-PN DHA - prenat w/o

a w/fefum-methfol-fa-dha cap

27-0.6-0.4-300 mg

WESNATE DHA - prenatal vit w/ fe

fum-fa-omega 3 cap 28-1-200 mg

WESTAB PLUS - prenatal vit w/ fe

fumarate-fa tab 27-1 mg

WESTGEL DHA - prenat w/o a

w/fecbn-methylf-fa-dha cap

31-0.6-0.4-200 mg

ZALVIT - prenatal vit w/ fe gluconate-

fa tab 13-1 mg

ZATEAN-PN DHA - prenat w/o

a w/fefum-methfol-fa-dha cap

27-0.6-0.4-300 mg

ZIPHEX - prenatal vit w/ fe

gluconate-fa tab 13-1 mg

MINERALS and ELECTROLYTES

FLORIVA - sodium fluoride-vitamin d

liqd drops 0.25 mg/ml-400 unit/ml

•

GALZIN - zinc acetate cap 25 mg

(elemental zinc), 50 mg (elemental

zinc)

K-PHOS - potassium phosphate

monobasic tab 500 mg

•

K-PHOS NEUTRAL - pot phos

monobasic w/sod phos di &

monobas tab 155-852-130mg

K-TAB - potassium chloride tab er 10

meq, 20 meq (1500 mg)

pot phos monobasic w/sod

phos di & monobas tab

155-852-130mg (K-phos neutral)

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 86

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

potassium chloride cap er 8 meq,

10 meq

POTASSIUM CHLORIDE ER -

potassium chloride tab er 8 meq

(600 mg)

potassium chloride

microencapsulated crys er tab

10 meq, 15 meq, 20 meq

potassium chloride oral soln

10% (20 meq/15ml), 20% (40

meq/15ml)

potassium chloride powder

packet 20 meq

potassium chloride tab er 8 meq

(600 mg)

potassium chloride tab er 10 meq,

20 meq (1500 mg) (K-tab)

potassium phosphate monobasic

tab 500 mg (K-phos)

SODIUM FLUORIDE - sodium

fluoride tab 0.5 mg f (from 1.1 mg

naf), 1 mg f (from 2.2 mg naf)

•

sodium fluoride chew tab 0.25 mg

f (from 0.55 mg naf), 0.5 mg f

(from 1.1 mg naf), 1 mg f (from

2.2 mg naf)

•

sodium fluoride soln 0.125 mg/

drop f (0.275 mg/drop naf)

•

sodium fluoride soln 0.5 mg/ml f

(from 1.1 mg/ml naf)

•

NUTRIENTS

DOJOLVI - triheptanoin oral liquid

100%

HEMATOLOGICAL AGENTS

HEMATOPOIETIC AGENTS

ACCRUFER - ferric maltol cap 30

mg (fe equiv)

ARANESP ALBUMIN FREE -

darbepoetin alfa soln inj 25 mcg/

ml, 40 mcg/ml, 60 mcg/ml, 100

mcg/ml, 200 mcg/ml

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ARANESP ALBUMIN FREE -

darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml, 25

mcg/0.42ml, 40 mcg/0.4ml, 60

mcg/0.3ml, 100 mcg/0.5ml, 150

mcg/0.3ml, 200 mcg/0.4ml, 300

mcg/0.6ml, 500 mcg/ml

• • • •

carbonyl iron susp 15 mg/1.25ml

(elemental iron)

•

CERDELGA - eliglustat tartrate cap

84 mg (base equivalent)

• • • •

cyanocobalamin inj 1000 mcg/ml

DOPTELET - avatrombopag maleate

tab 20 mg (base equiv)

• • • •

DROXIA - hydroxyurea cap 200 mg,

300 mg, 400 mg

• • •

ENDARI - glutamine (sickle cell)

powd pack 5 gm

• • • •

EPOGEN - epoetin alfa inj 2000 unit/

ml, 3000 unit/ml, 4000 unit/ml,

10000 unit/ml, 20000 unit/ml

FERROUS SULFATE - ferrous

sulfate liquid 220 mg/5ml (44

mg/5ml elemental fe)

•

ferrous sulfate elixir 220 mg/5ml

(44 mg/5ml elemental fe)

•

ferrous sulfate soln 75 mg/ml

(15 mg/ml elemental fe)

•

ferrous sulfate syrup 300 mg/5ml

(60 mg/5ml elemental fe)

•

folic acid cap 0.8 mg

•

folic acid tab 400 mcg, 800 mcg

•

folic acid tab 1 mg

FULPHILA - pegfilgrastim-jmdb soln

prefilled syringe 6 mg/0.6ml

• • • •

GRANIX - tbo-filgrastim soln prefilled

syringe 300 mcg/0.5ml, 480

mcg/0.8ml

• • • •

GRANIX - tbo-filgrastim

subcutaneous inj 300 mcg/ml, 480

mcg/1.6ml (300 mcg/ml)

• • • •

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 87

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

LEUKINE - sargramostim lyophilized

for inj 250 mcg

• • • •

MIRCERA - methoxy peg-epoetin

beta soln prefilled syr 30

mcg/0.3ml, 50 mcg/0.3ml, 75

mcg/0.3ml, 100 mcg/0.3ml, 150

mcg/0.3ml, 200 mcg/0.3ml

• • • •

MULPLETA - lusutrombopag tab 3

• • • •

NASCOBAL - cyanocobalamin nasal

spray 500 mcg/0.1ml

NEULASTA - pegfilgrastim soln

prefilled syringe 6 mg/0.6ml

• • • •

NEULASTA ONPRO KIT -

pegfilgrastim soln prefilled syringe

kit 6 mg/0.6ml

• • • •

NEUPOGEN - filgrastim inj 300 mcg/

ml, 480 mcg/1.6ml (300 mcg/ml)

NEUPOGEN - filgrastim soln prefilled

syringe 300 mcg/0.5ml, 480

mcg/0.8ml (600 mcg/ml)

NYVEPRIA - pegfilgrastim-apgf soln

prefilled syringe 6 mg/0.6ml

OXBRYTA - voxelotor tab for oral

susp 300 mg

• • • •

OXBRYTA - voxelotor tab 500 mg

• • • •

PROCRIT - epoetin alfa inj 2000

unit/ml, 3000 unit/ml, 4000 unit/

ml, 10000 unit/ml, 20000 unit/ml,

40000 unit/ml

PROMACTA - eltrombopag olamine

powder pack for susp 25 mg (base

equiv), 12.5 mg (base eq)

• • • •

PROMACTA - eltrombopag olamine

tab 12.5 mg (base equiv), 25 mg

(base equiv), 50 mg (base equiv),

75 mg (base equiv)

• • • •

RELEUKO - filgrastim-ayow inj soln

300 mcg/ml, 480 mcg/1.6ml (300

mcg/ml)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

RELEUKO - filgrastim-ayow soln

prefilled syringe 300 mcg/0.5ml,

480 mcg/0.8ml

RETACRIT - epoetin alfa-epbx inj

2000 unit/ml, 3000 unit/ml, 4000

unit/ml, 10000 unit/ml, 20000 unit/

ml, 40000 unit/ml

• • • •

SIKLOS - hydroxyurea tab 100 mg,

1000 mg

• • •

UDENYCA - pegfilgrastim-cbqv soln

prefilled syringe 6 mg/0.6ml

• • • •

ZARXIO - filgrastim-sndz soln

prefilled syringe 300 mcg/0.5ml,

480 mcg/0.8ml

• • • •

ZAVESCA - miglustat cap 100 mg

ANTICOAGULANTS

ARIXTRA - fondaparinux sodium

subcutaneous inj 2.5 mg/0.5ml,

5 mg/0.4ml, 7.5 mg/0.6ml, 10

mg/0.8ml

dabigatran etexilate mesylate

cap 75 mg (etexilate base eq),

150 mg (etexilate base eq)

(Pradaxa)

•

ELIQUIS - apixaban tab 2.5 mg, 5

•

ELIQUIS STARTER PACK -

apixaban tab starter pack 5 mg

•

enoxaparin sodium inj soln pref

syr 30 mg/0.3ml, 40 mg/0.4ml,

60 mg/0.6ml, 80 mg/0.8ml,

100 mg/ml, 120 mg/0.8ml,

150 mg/ml (Lovenox)

•

enoxaparin sodium inj

300 mg/3ml (Lovenox)

•

fondaparinux sodium

subcutaneous inj 2.5 mg/0.5ml,

5 mg/0.4ml, 7.5 mg/0.6ml,

10 mg/0.8ml (Arixtra)

•

FRAGMIN - dalteparin sodium inj

95000 unit/3.8ml

•

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 88

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

FRAGMIN - dalteparin sodium soln

prefilled syr 2500 unit/0.2ml, 5000

unit/0.2ml, 7500 unit/0.3ml, 10000

unit/ml, 12500 unit/0.5ml, 15000

unit/0.6ml, 18000 unit/0.72ml

•

HEPARIN SODIUM - heparin sodium

(porcine) pf inj 5000 unit/ml

heparin sodium (porcine) inj 1000

unit/ml, 5000 unit/ml, 10000 unit/

ml, 20000 unit/ml

heparin sodium (porcine) pf inj

5000 unit/0.5ml

LOVENOX - enoxaparin sodium

inj soln pref syr 30 mg/0.3ml,

40 mg/0.4ml, 60 mg/0.6ml,

80 mg/0.8ml, 100 mg/ml, 120

mg/0.8ml, 150 mg/ml

LOVENOX - enoxaparin sodium inj

300 mg/3ml

PRADAXA - dabigatran etexilate

mesylate cap 75 mg (etexilate

base eq)

• •

PRADAXA - dabigatran etexilate

mesylate cap 110 mg (etexilate

base eq), 150 mg (etexilate base

eq)

•

SAVAYSA - edoxaban tosylate tab

15 mg (base equivalent), 30 mg

(base equivalent), 60 mg (base

equivalent)

warfarin sodium tab 1 mg, 2 mg,

2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,

7.5 mg, 10 mg

XARELTO - rivaroxaban for susp 1

mg/ml

•

XARELTO - rivaroxaban tab 2.5 mg,

10 mg, 15 mg, 20 mg

•

XARELTO STARTER PACK -

rivaroxaban tab starter therapy

pack 15 mg & 20 mg

•

HEMOSTATICS

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

AMICAR - aminocaproic acid oral

soln 0.25 gm/ml

AMICAR - aminocaproic acid tab 500

mg, 1000 mg

LYSTEDA - tranexamic acid tab 650

tranexamic acid tab 650 mg

(Lysteda)

HEMATOLOGICAL AGENTS - MISC.

AGRYLIN - anagrelide hcl cap 0.5

anagrelide hcl cap 0.5 mg (Agrylin)

•

anagrelide hcl cap 1 mg

•

aspirin-dipyridamole cap er 12hr

25-200 mg

•

ASPIRIN/OMEPRAZOLE - aspirin-

omeprazole tab delayed release

81-40 mg

• •

BRILINTA - ticagrelor tab 60 mg, 90

•

CABLIVI - caplacizumab-yhdp for inj

kit 11 mg

• • • •

cilostazol tab 50 mg, 100 mg

•

clopidogrel bisulfate tab 75 mg

(base equiv) (Plavix)

•

clopidogrel bisulfate tab 300 mg

(base equiv)

•

dipyridamole tab 25 mg, 50 mg,

75 mg

•

DURLAZA - aspirin capsule er 24hr

162.5 mg

EFFIENT - prasugrel hcl tab 5 mg

(base equiv), 10 mg (base equiv)

EMPAVELI - pegcetacoplan

subcutaneous soln 1080 mg/20ml

(54 mg/ml)

• • • •

FIRAZYR - icatibant acetate inj 30

mg/3ml (base equivalent)

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 89

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

HAEGARDA - c1 esterase inhibitor

(human) for subcutaneous inj

2000 unit, 3000 unit

• • • •

icatibant acetate inj 30 mg/3ml

(base equivalent) (Firazyr)

• • • •

ORLADEYO - berotralstat hcl cap

110 mg, 150 mg

pentoxifylline tab er 400 mg

PLAVIX - clopidogrel bisulfate tab 75

mg (base equiv)

prasugrel hcl tab 5 mg (base

equiv), 10 mg (base equiv)

(Effient)

•

PYRUKYND - mitapivat sulfate tab 5

mg, 20 mg, 50 mg

• • • •

PYRUKYND TAPER PACK -

mitapivat sulfate tab therapy pack

5 mg, 7 x 20 mg & 7 x 5 mg, 7 x

50 mg & 7 x 20 mg

• • • •

TAKHZYRO - lanadelumab-flyo inj

300 mg/2ml (150 mg/ml)

• • • •

TAKHZYRO - lanadelumab-flyo soln

pref syringe 300 mg/2ml (150 mg/

ml)

• • • •

TAVALISSE - fostamatinib disodium

tab 100 mg (base equivalent), 150

mg (base equivalent)

• • • •

TAVNEOS - avacopan cap 10 mg

YOSPRALA - aspirin-omeprazole tab

delayed release 81-40 mg, 325-40

ZONTIVITY - vorapaxar sulfate tab

2.08 mg (base equivalent)

•

TOPICAL PRODUCTS

OPHTHALMIC AGENTS

ACULAR - ketorolac tromethamine

ophth soln 0.5%

ACULAR LS - ketorolac

tromethamine ophth soln 0.4%

ACUVAIL - ketorolac tromethamine

(pf) ophth soln 0.45%

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ALOCRIL - nedocromil sodium ophth

soln 2%

•

ALOMIDE - lodoxamide

tromethamine ophth soln 0.1%

ALPHAGAN P - brimonidine tartrate

ophth soln 0.1%, 0.15%

ALREX - loteprednol etabonate

ophth susp 0.2%

apraclonidine hcl ophth soln 0.5%

(base equivalent)

ATROPINE SULFATE - atropine

sulfate ophth soln 1%

atropine sulfate ophth soln 1%

(Atropine sulfate)

AZASITE - azithromycin ophth soln

azelastine hcl ophth soln 0.05%

•

AZOPT - brinzolamide ophth susp

BACITRACIN - bacitracin ophth oint

500 unit/gm

bacitracin-polymyxin b ophth oint

bacitracin-polymyxin-neomycin-

hc ophth oint 1%

bepotastine besilate ophth soln

1.5% (Bepreve)

•

BEPREVE - bepotastine besilate

ophth soln 1.5%

BESIVANCE - besifloxacin hcl ophth

susp 0.6% (base equiv)

betaxolol hcl ophth soln 0.5%

BETIMOL - timolol ophth soln 0.25%,

0.5%

BETOPTIC-S - betaxolol hcl ophth

susp 0.25%

bimatoprost ophth soln 0.03%

• •

BLEPHAMIDE S.O.P. -

sulfacetamide sodium-

prednisolone ophth oint 10-0.2%

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 90

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

brimonidine tartrate ophth soln

0.15% (Alphagan p)

brimonidine tartrate ophth soln

0.2%

brimonidine tartrate-timolol

maleate ophth soln 0.2-0.5%

(Combigan)

•

brinzolamide ophth susp 1%

(Azopt)

bromfenac sodium ophth soln

0.09% (base equiv) (once-daily)

BROMSITE - bromfenac sodium

ophth soln 0.075% (base

equivalent)

CARTEOLOL HCL - carteolol hcl

ophth soln 1%

CEQUA - cyclosporine (ophth) soln

0.09% (pf)

CILOXAN - ciprofloxacin hcl ophth

oint 0.3%

ciprofloxacin hcl ophth soln 0.3%

(base equivalent)

COMBIGAN - brimonidine tartrate-

timolol maleate ophth soln

0.2-0.5%

• •

COSOPT - dorzolamide hcl-timolol

maleate ophth soln 22.3-6.8 mg/

COSOPT PF - dorzolamide hcl-

timolol maleate ophth sol 22.3-6.8

mg/ml pf

cromolyn sodium ophth soln 4%

CYCLOGYL - cyclopentolate hcl

ophth soln 0.5%, 1%, 2%

cyclosporine (ophth) emulsion

0.05% (Restasis multidose)

•

CYSTADROPS - cysteamine

hcl ophth soln 0.37% (base

equivalent)

• • • •

CYSTARAN - cysteamine hcl ophth

soln 0.44% (base equivalent)

• • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DEXAMETHASONE SODIUM

PHOS - dexamethasone sodium

phosphate ophth soln 0.1%

diclofenac sodium ophth soln

0.1%

difluprednate ophth emulsion

0.05% (Durezol)

dorzolamide hcl ophth soln 2%

(Trusopt)

dorzolamide hcl-timolol maleate

ophth soln 22.3-6.8 mg/ml

(Cosopt)

•

dorzolamide hcl-timolol maleate

ophth sol 22.3-6.8 mg/ml pf

(Cosopt pf)

DUREZOL - difluprednate ophth

emulsion 0.05%

epinastine hcl ophth soln 0.05%

•

erythromycin ophth oint 5 mg/gm

EYSUVIS - loteprednol etabonate

ophth susp 0.25%

FLAREX - fluorometholone acetate

ophth susp 0.1%

fluorometholone ophth susp 0.1%

(Fml liquifilm)

FLURBIPROFEN SODIUM -

flurbiprofen sodium ophth soln

0.03%

FML - fluorometholone ophth oint

0.1%

FML FORTE - fluorometholone ophth

susp 0.25%

FML LIQUIFILM - fluorometholone

ophth susp 0.1%

gatifloxacin ophth soln 0.5%

(Zymaxid)

GENTAK - gentamicin sulfate ophth

oint 0.3%

gentamicin sulfate ophth soln

0.3%

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 91

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ILEVRO - nepafenac ophth susp

0.3%

ILEVRO - nepafenac ophth susp

0.3%

INVELTYS - loteprednol etabonate

ophth susp 1%

IOPIDINE - apraclonidine hcl ophth

soln 1% (base equivalent)

ISOPTO ATROPINE - atropine

sulfate ophth soln 1%

ISTALOL - timolol maleate ophth

soln 0.5% (once-daily)

ketorolac tromethamine ophth

soln 0.4% (Acular ls)

ketorolac tromethamine ophth

soln 0.5% (Acular)

latanoprost ophth soln 0.005%

(Xalatan)

•

LEVOBUNOLOL HCL - levobunolol

hcl ophth soln 0.5%

•

levofloxacin ophth soln 0.5%

LOTEMAX - loteprednol etabonate

ophth gel 0.5%

LOTEMAX - loteprednol etabonate

ophth oint 0.5%

LOTEMAX - loteprednol etabonate

ophth susp 0.5%

LOTEMAX SM - loteprednol

etabonate ophth gel 0.38%

loteprednol etabonate ophth gel

0.5% (Lotemax)

loteprednol etabonate ophth susp

0.5% (Lotemax)

LUMIGAN - bimatoprost ophth soln

0.01%

MAXIDEX - dexamethasone ophth

susp 0.1%

MAXITROL - neomycin-polymyxin-

dexamethasone ophth oint 0.1%

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MAXITROL - neomycin-polymyxin-

dexamethasone ophth susp 0.1%

MITOSOL - mitomycin for ophth soln

kit 0.2 mg

moxifloxacin hcl ophth soln 0.5%

(base equiv) (Vigamox)

MOXIFLOXACIN

HYDROCHLORID - moxifloxacin

hcl ophth soln 0.5% (base eq) (2

times daily)

NATACYN - natamycin ophth susp

neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op

oin

neomycin-polymyxin-

dexamethasone ophth oint 0.1%

(Maxitrol)

neomycin-polymyxin-

dexamethasone ophth susp

0.1% (Maxitrol)

NEOMYCIN/POLYMYXIN/GRAMIC -

neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml

•

NEOMYCIN/POLYMYXIN/

HYDROC - neomycin-polymyxin-

hc ophth susp

NEVANAC - nepafenac ophth susp

0.1%

OCUFLOX - ofloxacin ophth soln

0.3%

ofloxacin ophth soln 0.3%

(Ocuflox)

olopatadine hcl ophth soln 0.1%

(base equivalent), 0.2% (base

equivalent)

OXERVATE - cenegermin-bkbj ophth

soln 0.002% (20 mcg/ml)

• • • •

phenylephrine hcl ophth soln

2.5%, 10%

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 92

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PHOSPHOLINE IODIDE -

echothiophate iodide ophth for

soln 0.125%

pilocarpine hcl ophth soln 1%,

2%, 4%

polymyxin b-trimethoprim

ophth soln 10000 unit/ml-0.1%

(Polytrim)

POLYTRIM - polymyxin b-

trimethoprim ophth soln 10000

unit/ml-0.1%

PRED FORTE - prednisolone

acetate ophth susp 1%

PRED MILD - prednisolone acetate

ophth susp 0.12%

PRED-G - gentamicin-prednisolone

ace ophth susp 0.3-1%

PRED-G S.O.P. - gentamicin-

prednisolone ace ophth oint

0.3-0.6%

PREDNISOLONE ACETATE -

prednisolone acetate ophth susp

•

PREDNISOLONE SODIUM

PHOSP - prednisolone sodium

phosphate ophth soln 1%

PROLENSA - bromfenac sodium

ophth soln 0.07% (base

equivalent)

RESTASIS - cyclosporine (ophth)

emulsion 0.05%

RESTASIS MULTIDOSE -

cyclosporine (ophth) emulsion

0.05%

RHOPRESSA - netarsudil

dimesylate ophth soln 0.02%

• •

ROCKLATAN - netarsudil

dimesylate-latanoprost ophth soln

0.02-0.005%

SIMBRINZA - brinzolamide-

brimonidine tartrate ophth susp

1-0.2%

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SULFACETAMIDE SODIUM -

sulfacetamide sodium ophth oint

10%

sulfacetamide sodium ophth soln

10%

SULFACETAMIDE SODIUM/

PRED - sulfacetamide sodium-

prednisolone ophth soln

10-0.23(0.25)%

timolol maleate ophth gel forming

soln 0.25%, 0.5% (Timoptic-xe)

timolol maleate ophth soln 0.25%,

0.5% (Timoptic)

timolol maleate ophth soln 0.5%

(once-daily) (Istalol)

timolol maleate preservative

free ophth soln 0.5% (Timoptic

ocudose)

TIMOPTIC - timolol maleate ophth

soln 0.25%, 0.5%

TIMOPTIC OCUDOSE - timolol

maleate preservative free ophth

soln 0.25%, 0.5%

TIMOPTIC-XE - timolol maleate

ophth gel forming soln 0.25%,

0.5%

TOBRADEX - tobramycin-

dexamethasone ophth oint

0.3-0.1%

TOBRADEX - tobramycin-

dexamethasone ophth susp

0.3-0.1%

TOBRADEX ST - tobramycin-

dexamethasone ophth susp

0.3-0.05%

tobramycin ophth soln 0.3%

tobramycin-dexamethasone

ophth susp 0.3-0.1% (Tobradex)

TOBREX - tobramycin ophth oint

0.3%

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 93

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

TRAVATAN Z - travoprost ophth soln

0.004% (benzalkonium free) (bak

free)

travoprost ophth soln 0.004%

(benzalkonium free) (bak free)

(Travatan z)

• •

TRIFLURIDINE - trifluridine ophth

soln 1%

•

TRUSOPT - dorzolamide hcl ophth

soln 2%

TYRVAYA - varenicline tartrate nasal

soln 0.03 mg/act

UPNEEQ - oxymetazoline hcl ophth

soln 0.1%

VERKAZIA - cyclosporine (ophth)

emulsion 0.1%

• •

VIGAMOX - moxifloxacin hcl ophth

soln 0.5% (base equiv)

VUITY - pilocarpine hcl ophth soln

1.25%

VYZULTA - latanoprostene bunod

ophth soln 0.024%

XALATAN - latanoprost ophth soln

0.005%

XELPROS - latanoprost ophth

emulsion 0.005%

XIIDRA - lifitegrast ophth soln 5%

• •

ZERVIATE - cetirizine hcl ophth soln

0.24% (base equiv)

• •

ZIOPTAN - tafluprost preservative

free (pf) ophth soln 0.0015%

• •

ZIRGAN - ganciclovir ophth gel

0.15%

ZYLET - loteprednol etabonate-

tobramycin ophth susp 0.5-0.3%

ZYMAXID - gatifloxacin ophth soln

0.5%

OTIC AGENTS

acetic acid otic soln 2%

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CETRAXAL - ciprofloxacin hcl otic

soln 0.2% (base equivalent)

CIPRO HC - ciprofloxacin-

hydrocortisone otic susp 0.2-1%

CIPRODEX - ciprofloxacin-

dexamethasone otic susp

0.3-0.1%

CIPROFLOXACIN - ciprofloxacin hcl

otic soln 0.2% (base equivalent)

ciprofloxacin-dexamethasone otic

susp 0.3-0.1% (Ciprodex)

CIPROFLOXACIN/FLUOCINOLON -

ciprofloxacin-fluocinolone aceton

(pf) otic soln 0.3-0.025%

CORTISPORIN-TC - neomycin-

colistin-hc-thonzonium otic susp

3.3-3-10-0.5 mg/ml

DERMOTIC - fluocinolone acetonide

(otic) oil 0.01%

fluocinolone acetonide (otic) oil

0.01% (Dermotic)

hydrocortisone w/ acetic acid otic

soln 1-2%

neomycin-polymyxin-hc otic soln

neomycin-polymyxin-hc otic susp

3.5 mg/ml-10000 unit/ml-1%

ofloxacin otic soln 0.3%

OTOVEL - ciprofloxacin-fluocinolone

aceton (pf) otic soln 0.3-0.025%

MOUTH/THROAT/DENTAL AGENTS

ASTRING-O-SOL - mouthwashes -

liquid

BIOTENE DRY MOUTH GENTLE -

mouthwashes - liquid

BIOTENE DRY MOUTH

MOUTHWA - mouthwashes - liquid

BIOTENE DRY MOUTH ORAL RI -

mouthwashes - liquid

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 94

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

BIOTENE PBF DRY MOUTH MOU -

mouthwashes - liquid

cevimeline hcl cap 30 mg (Evoxac)

chlorhexidine gluconate soln

0.12% (Peridex)

clotrimazole troche 10 mg

EVOXAC - cevimeline hcl cap 30 mg

FLUORIDEX SENSITIVITY REL -

sodium fluoride-potassium nitrate

paste 1.1-5%

• •

FLUORIMAX 5000 SENSITIVE -

sodium fluoride-potassium nitrate

paste 1.1-5%

lidocaine hcl viscous soln 2%

LISTERINE - mouthwashes - liquid

LISTERINE ANTISEPTIC -

mouthwashes - liquid

LISTERINE POCKETMIST -

mouthwashes - liquid

LISTERINE POCKETPAKS -

mouthwashes - strips

LISTERINE POCKETPAKS COOL -

mouthwashes - strips

LISTERINE ULTRACLEAN -

mouthwashes - liquid

LISTERINE ULTRACLEAN/EVER -

mouthwashes - liquid

LISTERINE ZERO - mouthwashes -

liquid

LUMINEUX CLEAN/FRESH MOUT -

mouthwashes - liquid

LUMINEUX HYDRATING

MOUTHW - mouthwashes - liquid

LUMINEUX SENSITIVITY MOUT -

mouthwashes - liquid

LUMINEUX WHITENING

MOUTHW - mouthwashes - liquid

mouthwashes - liquid

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NAFRINSE DAILY/ACIDULATED -

sodium fluoride-phosphoric acid

for soln 1 mg/5ml (f equiv)

•

NAFRINSE DAILY/NEUTRAL -

sodium fluoride for soln rinse

0.05%

•

NAFRINSE WEEKLY - sodium

fluoride for soln rinse 0.2%

•

nystatin susp 100000 unit/ml

ORAVIG - miconazole buccal tab 50

mg (mouth-throat)

PARODONTAX - stannous fluoride

paste 0.454%

•

PERIDEX - chlorhexidine gluconate

soln 0.12%

pilocarpine hcl tab 5 mg, 7.5 mg

(Salagen)

PREVIDENT FLUORIDE - sodium

fluoride gel 1.1% (0.5% f)

PREVIDENT RINSE - sodium

fluoride rinse 0.2%

PREVIDENT 5000 BOOSTER PL -

sodium fluoride paste 1.1%

PREVIDENT 5000 DRY MOUTH -

sodium fluoride gel 1.1% (0.5% f)

PREVIDENT 5000 ENAMEL PRO -

sodium fluoride-potassium nitrate

gel 1.1-5%

PREVIDENT 5000 ORTHO DEFE -

sodium fluoride paste 1.1%

PREVIDENT 5000 PLUS - sodium

fluoride cream 1.1%

PREVIDENT 5000 SENSITIVE -

sodium fluoride-potassium nitrate

gel 1.1-5%

QC ANTISEPTIC MOUTH RINSE -

mouthwashes - liquid

QC MOUTHWASH/MINT FRESH -

mouthwashes - liquid

RA DRY MOUTH MOUTHWASH -

mouthwashes - liquid

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 95

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SALAGEN - pilocarpine hcl tab 5 mg,

7.5 mg

SCOPE - mouthwashes - liquid

SENSODYNE COMPLETE

PROTEC - stannous fluoride paste

0.454%

•

SENSODYNE RAPID RELIEF -

stannous fluoride paste 0.454%

•

SENSODYNE REPAIR & PROTEC -

stannous fluoride paste 0.454%

•

sodium fluoride cream 1.1%

(Prevident 5000 plus)

•

sodium fluoride gel 1.1% (0.5% f)

(Prevident fluoride)

•

sodium fluoride paste 1.1%

(Prevident 5000 boost)

•

sodium fluoride rinse 0.2%

(Prevident rinse)

•

sodium fluoride-potassium

nitrate gel 1.1-5% (Prevident

5000 sensi)

•

stannous fluoride conc 0.63%

•

stannous fluoride gel 0.4%

•

THERABREATH ORAL RINSE/DR -

mouthwashes - liquid

THERABREATH ORAL RINSE/FR -

mouthwashes - liquid

TONSILINE - mouthwashes - liquid

triamcinolone acetonide dental

paste 0.1%

ANORECTAL AGENTS

ANALPRAM HC - hydrocortisone

acetate w/ pramoxine perianal

cream 2.5-1%

ANALPRAM HC SINGLES -

hydrocortisone acetate w/

pramoxine perianal cream 2.5-1%

ANALPRAM-HC - hydrocortisone

acetate w/ pramoxine perianal

cream 1-1%

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ANALPRAM-HC - hydrocortisone

acetate w/ pramoxine perianal lotn

2.5-1%

ANUSOL-HC - hydrocortisone

perianal cream 2.5%

CORTENEMA - hydrocortisone

enema 100 mg/60ml

CORTIFOAM - hydrocortisone

acetate perianal foam 10% (90

mg/dose)

hydrocortisone enema

100 mg/60ml (Cortenema)

hydrocortisone perianal cream

1% (Proctocort)

hydrocortisone perianal cream

2.5% (Anusol-hc)

PROCTOCORT - hydrocortisone

perianal cream 1%

PROCTOFOAM HC - hydrocortisone

acetate w/ pramoxine perianal

foam 1-1%

RECTIV - nitroglycerin oint 0.4%

•

DERMATOLOGICALS

ABSORICA - isotretinoin cap 10 mg,

20 mg, 25 mg, 30 mg, 35 mg, 40

ABSORICA LD - isotretinoin

micronized cap 8 mg, 16 mg, 24

mg, 32 mg

ACANYA - clindamycin phosphate-

benzoyl peroxide gel 1.2-2.5%

acitretin cap 10 mg, 17.5 mg,

25 mg

acyclovir cream 5% (Zovirax)

acyclovir oint 5% (Zovirax)

ACZONE - dapsone gel 5%, 7.5%

ADAPALENE - adapalene pads 0.1%

ADAPALENE - adapalene soln 0.1%

adapalene cream 0.1% (Differin)

adapalene gel 0.1%

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 96

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

adapalene gel 0.3% (Differin)

adapalene-benzoyl peroxide gel

0.1-2.5% (Epiduo)

•

adapalene-benzoyl peroxide gel

0.3-2.5% (Epiduo forte)

ADBRY - tralokinumab-ldrm

subcutaneous soln prefilled syr

150 mg/ml

• • • •

AKLIEF - trifarotene cream 0.005%

ALA-SCALP - hydrocortisone lotion

alclometasone dipropionate

cream 0.05%

alclometasone dipropionate oint

0.05%

ALTABAX - retapamulin oint 1%

ALTRENO - tretinoin lotion 0.05%

AMCINONIDE - amcinonide cream

0.1%

AMCINONIDE - amcinonide lotion

0.1%

•

AMCINONIDE - amcinonide oint

0.1%

AMZEEQ - minocycline hcl

micronized foam 4%

APEXICON E - diflorasone diacetate

emollient base cream 0.05%

ARAZLO - tazarotene (acne) lotion

0.045%

ATRALIN - tretinoin gel 0.05%

azelaic acid gel 15% (Finacea)

AZELEX - azelaic acid cream 20%

BENZAMYCIN - benzoyl peroxide-

erythromycin gel 5-3%

benzoyl peroxide-

erythromycin gel 5-3%

(Benzamycin)

BETAMETHASONE

DIPROPIONAT - betamethasone

•

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

dipropionate augmented gel

0.05%

betamethasone dipropionate

augmented cream 0.05%

betamethasone dipropionate

augmented lotion 0.05%

betamethasone dipropionate

augmented oint 0.05%

(Diprolene)

betamethasone dipropionate

cream 0.05%

betamethasone dipropionate

lotion 0.05%

betamethasone dipropionate oint

0.05%

betamethasone valerate aerosol

foam 0.12% (Luxiq)

betamethasone valerate cream

0.1% (base equivalent)

betamethasone valerate lotion

0.1% (base equivalent)

betamethasone valerate oint 0.1%

(base equivalent)

bexarotene gel 1% (Targretin)

•

BRYHALI - halobetasol propionate

lotion 0.01%

CALCIPOTRIENE - calcipotriene

foam 0.005%

calcipotriene cream 0.005%

(Dovonex)

calcipotriene oint 0.005%

calcipotriene soln 0.005%

(50 mcg/ml)

calcipotriene-betamethasone

dipropionate oint 0.005-0.064%

(Taclonex)

calcipotriene-betamethasone

dipropionate susp 0.005-0.064%

(Taclonex)

CALCITRIOL - calcitriol oint 3 mcg/

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 97

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CAPEX - fluocinolone acetonide

shampoo 0.01%

CARAC - fluorouracil cream 0.5%

CENTANY - mupirocin oint 2%

CIBINQO - abrocitinib tab 50 mg,

100 mg, 200 mg

ciclopirox gel 0.77%

ciclopirox olamine cream 0.77%

(base equiv) (Loprox)

ciclopirox olamine susp 0.77%

(base equiv) (Loprox)

ciclopirox shampoo 1% (Loprox

shampoo)

ciclopirox solution 8% (Penlac

Nail Lacquer)

•

CLEOCIN-T - clindamycin phosphate

lotion 1%

CLINDAGEL - clindamycin

phosphate gel 1%

clindamycin phosph-benzoyl

peroxide (refrig) gel 1.2 (1)-5%

clindamycin phosphate foam 1%

(Evoclin)

clindamycin phosphate gel 1%

(Clindagel)

clindamycin phosphate gel 1%

(Clindagel)

clindamycin phosphate lotion 1%

(Cleocin-t)

clindamycin phosphate soln 1%

clindamycin phosphate swab 1%

clindamycin phosphate-benzoyl

peroxide gel 1-5%

clindamycin phosphate-benzoyl

peroxide gel 1.2-2.5% (Acanya)

clindamycin phosphate-

tretinoin gel 1.2-0.025% (Ziana)

clobetasol propionate cream

0.05%

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

clobetasol propionate emollient

base cream 0.05%

clobetasol propionate emulsion

foam 0.05% (Olux-e)

clobetasol propionate foam 0.05%

(Olux)

clobetasol propionate gel 0.05%

clobetasol propionate lotion

0.05% (Clobex)

clobetasol propionate oint 0.05%

clobetasol propionate shampoo

0.05% (Clobex)

clobetasol propionate soln 0.05%

clobetasol propionate spray

0.05% (Clobex)

CLOBEX - clobetasol propionate

lotion 0.05%

CLOBEX - clobetasol propionate

shampoo 0.05%

CLOBEX - clobetasol propionate

spray 0.05%

clocortolone pivalate cream 0.1%

(Cloderm)

•

CLODERM - clocortolone pivalate

cream 0.1%

clotrimazole cream 1%

clotrimazole soln 1%

clotrimazole w/ betamethasone

cream 1-0.05%

clotrimazole w/ betamethasone

lotion 1-0.05%

CONDYLOX - podofilox gel 0.5%

CORDRAN - flurandrenolide cream

0.025%, 0.05%

CORDRAN - flurandrenolide lotion

0.05%

CORDRAN - flurandrenolide oint

0.05%

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 98

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CORDRAN - flurandrenolide tape 4

mcg/sqcm

•

COSENTYX - secukinumab

subcutaneous pref syr 150 mg/ml

(300 mg dose)

• • • •

COSENTYX - secukinumab

subcutaneous soln prefilled

syringe 75 mg/0.5ml, 150 mg/ml

• • • •

COSENTYX SENSOREADY PEN -

secukinumab subcutaneous auto-

inj 150 mg/ml (300 mg dose)

• • • •

COSENTYX SENSOREADY PEN -

secukinumab subcutaneous soln

auto-injector 150 mg/ml

• • • •

CROTAN - crotamiton lotion 10%

dapsone gel 5%, 7.5% (Aczone)

DENAVIR - penciclovir cream 1%

DERMA-SMOOTHE/FS BODY -

fluocinolone acetonide oil 0.01%

(body oil)

DERMA-SMOOTHE/FS SCALP -

fluocinolone acetonide oil 0.01%

(scalp oil)

desonide cream 0.05% (Desowen)

desonide gel 0.05%

desonide lotion 0.05%

desonide oint 0.05%

DESOWEN - desonide cream 0.05%

desoximetasone cream 0.05%

(Topicort)

desoximetasone cream 0.25%

(Topicort)

desoximetasone gel 0.05%

(Topicort)

desoximetasone oint 0.05%

(Topicort)

desoximetasone oint 0.25%

(Topicort)

desoximetasone spray 0.25%

(Topicort)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DICLOFENAC EPOLAMINE -

diclofenac epolamine patch 1.3%

diclofenac sodium gel 1%

diclofenac sodium soln 1.5%

•

diclofenac sodium soln 2%

(Pennsaid)

DIFFERIN - adapalene cream 0.1%

DIFFERIN - adapalene gel 0.3%

DIFFERIN - adapalene lotion 0.1%

DIFLORASONE DIACETATE -

diflorasone diacetate cream

0.05%

diflorasone diacetate oint 0.05%

DIPROLENE - betamethasone

dipropionate augmented oint

0.05%

DOVONEX - calcipotriene cream

0.005%

DOXEPIN HYDROCHLORIDE -

doxepin hcl cream 5%

DOXYCYCLINE - doxycycline

(rosacea) cap delayed release 40

DUOBRII - halobetasol propionate-

tazarotene lotion 0.01-0.045%

DUPIXENT - dupilumab

subcutaneous soln pen-injector

200 mg/1.14ml, 300 mg/2ml

• • • •

DUPIXENT - dupilumab

subcutaneous soln prefilled

syringe 100 mg/0.67ml, 200

mg/1.14ml, 300 mg/2ml

• • • •

econazole nitrate cream 1%

ECOZA - econazole nitrate foam 1%

EFUDEX - fluorouracil cream 5%

ELIDEL - pimecrolimus cream 1%

ENSTILAR - calcipotriene-

betamethasone dipropionate foam

0.005-0.064%

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 99

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

EPIDUO - adapalene-benzoyl

peroxide gel 0.1-2.5%

EPIDUO FORTE - adapalene-

benzoyl peroxide gel 0.3-2.5%

EPIFOAM - pramoxine-hc aerosol

foam 1-1%

EPSOLAY - benzoyl peroxide cream

ERTACZO - sertaconazole nitrate

cream 2%

•

ERY - erythromycin pads 2%

•

ERYGEL - erythromycin gel 2%

erythromycin gel 2% (Erygel)

erythromycin soln 2%

EUCRISA - crisaborole oint 2%

EVOCLIN - clindamycin phosphate

foam 1%

EXELDERM - sulconazole nitrate

cream 1%

•

EXELDERM - sulconazole nitrate

solution 1%

•

EXTINA - ketoconazole foam 2%

FABIOR - tazarotene (acne) foam

0.1%

FINACEA - azelaic acid foam 15%

FINACEA - azelaic acid gel 15%

FLECTOR - diclofenac epolamine

patch 1.3%

fluocinolone acetonide cream

0.01%

fluocinolone acetonide cream

0.025% (Synalar)

fluocinolone acetonide oil 0.01%

(body oil) (Derma-smoothe/fs

bod)

fluocinolone acetonide oil 0.01%

(scalp oil) (Derma-smoothe/fs

sca)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

fluocinolone acetonide oint

0.025% (Synalar)

fluocinolone acetonide soln

0.01% (Synalar)

fluocinonide cream 0.05%

fluocinonide cream 0.1% (Vanos)

fluocinonide emulsified base

cream 0.05%

fluocinonide gel 0.05%

fluocinonide oint 0.05%

fluocinonide soln 0.05%

FLUOROURACIL - fluorouracil

cream 0.5%

FLUOROURACIL - fluorouracil soln

2%, 5%

fluorouracil cream 5% (Efudex)

• •

flurandrenolide cream 0.05%

(Cordran)

flurandrenolide lotion 0.05%

(Cordran)

fluticasone propionate cream

0.05%

fluticasone propionate lotion

0.05%

fluticasone propionate oint

0.005%

gentamicin sulfate cream 0.1%

halcinonide cream 0.1% (Halog)

HALOBETASOL PROPIONATE -

halobetasol propionate foam

0.05%

halobetasol propionate cream

0.05%

halobetasol propionate oint 0.05%

HALOG - halcinonide cream 0.1%

HALOG - halcinonide oint 0.1%

HALOG - halcinonide soln 0.1%

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 100

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

HYDROCORTISONE BUTYRATE -

hydrocortisone butyrate cream

0.1%

HYDROCORTISONE BUTYRATE -

hydrocortisone butyrate soln 0.1%

hydrocortisone butyrate

hydrophilic lipo base cream

0.1% (Locoid lipocream)

hydrocortisone butyrate lotion

0.1% (Locoid)

hydrocortisone butyrate oint 0.1%

hydrocortisone cream 1%

hydrocortisone cream 2.5%

hydrocortisone lotion 2.5%

hydrocortisone oint 1%

hydrocortisone oint 2.5%

hydrocortisone valerate cream

0.2%

hydrocortisone valerate oint 0.2%

HYFTOR - sirolimus gel 0.2%

imiquimod cream 3.75% (Zyclara)

imiquimod cream 5%

•

IMPEKLO - clobetasol propionate

lotion 0.15 mg/act (0.05%)

IMPOYZ - clobetasol propionate

cream 0.025%

isotretinoin cap 10 mg, 20 mg,

25 mg, 30 mg, 35 mg, 40 mg

(Absorica)

•

IVERMECTIN - ivermectin lotion

0.5%

•

ivermectin cream 1% (Soolantra)

JUBLIA - efinaconazole soln 10%

KENALOG - triamcinolone acetonide

aerosol soln 0.147 mg/gm

KERYDIN - tavaborole soln 5%

ketoconazole cream 2%

ketoconazole foam 2% (Extina)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ketoconazole shampoo 2%

KLARON - sulfacetamide sodium

lotion 10% (acne)

KLISYRI - tirbanibulin ointment 1%

lactic acid (ammonium lactate)

cream 12%

lactic acid (ammonium lactate)

lotion 12%

LEXETTE - halobetasol propionate

foam 0.05%

LICART - diclofenac epolamine

patch 24hr 1.3%

LIDOCAINE HCL JELLY - lidocaine

hcl urethral/mucosal gel 2%

• •

lidocaine hcl soln 4%

• •

lidocaine hcl urethral/mucosal gel

prefilled syringe 2%

• •

lidocaine oint 5%

lidocaine patch 5% (Lidoderm)

• •

lidocaine-prilocaine cream

2.5-2.5%

• •

LIDOCAINE/TETRACAINE -

lidocaine-tetracaine cream 7-7%

LIDODERM - lidocaine patch 5%

LINDANE - lindane shampoo 1%

LOCOID - hydrocortisone butyrate

lotion 0.1%

LOCOID LIPOCREAM -

hydrocortisone butyrate

hydrophilic lipo base cream 0.1%

LOPROX - ciclopirox olamine cream

0.77% (base equiv)

LOPROX - ciclopirox olamine susp

0.77% (base equiv)

LOPROX SHAMPOO - ciclopirox

shampoo 1%

LULICONAZOLE - luliconazole

cream 1%

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 101

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

LUXIQ - betamethasone valerate

aerosol foam 0.12%

LUZU - luliconazole cream 1%

mafenide acetate packet for

topical soln 5% (50 gm)

(Sulfamylon)

malathion lotion 0.5% (Ovide)

MENTAX - butenafine hcl cream 1%

METHOXSALEN - methoxsalen

rapid cap 10 mg

•

METROCREAM - metronidazole

cream 0.75%

METROGEL - metronidazole gel 1%

METROLOTION - metronidazole

lotion 0.75%

metronidazole cream 0.75%

(Metrocream)

metronidazole gel 0.75%

metronidazole gel 1% (Metrogel)

metronidazole lotion 0.75%

(Metrolotion)

MICONAZOLE NITRATE/ZINC

O - miconazole-zinc oxide-white

petrolatum oint 0.25-15-81.35%

mometasone furoate cream 0.1%

mometasone furoate oint 0.1%

mometasone furoate solution

0.1% (lotion)

mupirocin calcium cream 2%

mupirocin oint 2%

NAFTIFINE HCL - naftifine hcl cream

•

naftifine hcl cream 2%

•

NAFTIN - naftifine hcl gel 1%, 2%

NATROBA - spinosad susp 0.9%

NEO-SYNALAR - neomycin sulfate-

fluocinolone acetonide cream

0.5-0.025%

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

NORITATE - metronidazole cream

nystatin cream 100000 unit/gm

nystatin oint 100000 unit/gm

nystatin topical powder 100000

unit/gm

nystatin-triamcinolone cream

100000-0.1 unit/gm-%

nystatin-triamcinolone oint

100000-0.1 unit/gm-%

OLUX - clobetasol propionate foam

0.05%

OLUX-E - clobetasol propionate

emulsion foam 0.05%

ONEXTON - clindamycin phosphate-

benzoyl peroxide gel 1.2-3.75%

OPZELURA - ruxolitinib phosphate

cream 1.5%

ORACEA - doxycycline (rosacea)

cap delayed release 40 mg

OVIDE - malathion lotion 0.5%

oxiconazole nitrate cream 1%

(Oxistat)

•

OXISTAT - oxiconazole nitrate cream

OXISTAT - oxiconazole nitrate lotion

PANDEL - hydrocortisone probutate

cream 0.1%

PANRETIN - alitretinoin gel 0.1%

PENNSAID - diclofenac sodium soln

permethrin cream 5%

pimecrolimus cream 1% (Elidel)

PLIAGLIS - lidocaine-tetracaine

cream 7-7%

podofilox soln 0.5%

PRAMOSONE - pramoxine-hc

cream 1-1%

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 102

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PRAMOSONE - pramoxine-hc lotion

1-1%, 1-2.5%

PREDNICARBATE - prednicarbate

oint 0.1%

•

PROTOPIC - tacrolimus oint 0.03%,

0.1%

PRUDOXIN - doxepin hcl cream 5%

QBREXZA - glycopyrronium tosylate

pad 2.4% (base equivalent)

REGRANEX - becaplermin gel

0.01%

• •

RETIN-A - tretinoin cream 0.025%,

0.05%, 0.1%

RETIN-A - tretinoin gel 0.01%,

0.025%

RETIN-A MICRO - tretinoin

microsphere gel 0.04%, 0.06%,

0.1%

RETIN-A MICRO PUMP - tretinoin

microsphere gel 0.04%, 0.08%,

0.1%

RHOFADE - oxymetazoline hcl

cream 1%

SANTYL - collagenase oint 250 unit/

selenium sulfide lotion 2.5%

SERNIVO - betamethasone

dipropionate spray emulsion

0.05% (base equiv)

SILIQ - brodalumab subcutaneous

soln prefilled syringe 210

mg/1.5ml

SILVADENE - silver sulfadiazine

cream 1%

silver sulfadiazine cream 1%

(Silvadene)

SKYRIZI - risankizumab-rzaa sol

prefilled syringe 2 x 75 mg/0.83ml

kit

• • • •

SKYRIZI - risankizumab-rzaa soln

prefilled syringe 150 mg/ml

• • • •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SKYRIZI PEN - risankizumab-rzaa

soln auto-injector 150 mg/ml

• • • •

SOOLANTRA - ivermectin cream 1%

•

SORILUX - calcipotriene foam

0.005%

SPINOSAD - spinosad susp 0.9%

STELARA - ustekinumab inj 45

mg/0.5ml

• • • •

STELARA - ustekinumab soln

prefilled syringe 45 mg/0.5ml, 90

mg/ml

• • • •

SULCONAZOLE NITRATE -

sulconazole nitrate cream 1%

•

SULCONAZOLE NITRATE -

sulconazole nitrate solution 1%

•

sulfacetamide sodium lotion 10%

(acne) (Klaron)

SULFAMYLON - mafenide acetate

cream 85 mg/gm

SULFAMYLON - mafenide acetate

packet for topical soln 5% (50 gm)

SYNALAR - fluocinolone acetonide

cream 0.025%

SYNALAR - fluocinolone acetonide

oint 0.025%

SYNALAR - fluocinolone acetonide

soln 0.01%

SYNERA - lidocaine-tetracaine

topical patch 70-70 mg

• •

TACLONEX - calcipotriene-

betamethasone dipropionate oint

0.005-0.064%

TACLONEX - calcipotriene-

betamethasone dipropionate susp

0.005-0.064%

tacrolimus oint 0.03%, 0.1%

(Protopic)

•

TALTZ - ixekizumab subcutaneous

soln auto-injector 80 mg/ml

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 103

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

TALTZ - ixekizumab subcutaneous

soln prefilled syringe 80 mg/ml

TARGRETIN - bexarotene gel 1%

•

tavaborole soln 5% (Kerydin)

TAZAROTENE - tazarotene (acne)

foam 0.1%

tazarotene cream 0.1% (Tazorac)

•

TAZORAC - tazarotene cream 0.05%

•

TAZORAC - tazarotene cream 0.1%

TAZORAC - tazarotene gel 0.05%,

0.1%

•

TEXACORT - hydrocortisone soln

2.5%

TOPICORT - desoximetasone cream

0.05%, 0.25%

TOPICORT - desoximetasone gel

0.05%

TOPICORT - desoximetasone oint

0.05%, 0.25%

TOPICORT - desoximetasone spray

0.25%

TREMFYA - guselkumab soln pen-

injector 100 mg/ml

• • • •

TREMFYA - guselkumab soln

prefilled syringe 100 mg/ml

• • • •

tretinoin cream 0.025%, 0.05%,

0.1% (Retin-a)

•

tretinoin gel 0.01%, 0.025% (Retin-

•

tretinoin gel 0.05% (Atralin)

tretinoin microsphere gel 0.04%,

0.1% (Retin-a micro)

triamcinolone acetonide aerosol

soln 0.147 mg/gm (Kenalog)

triamcinolone acetonide cream

0.025%, 0.1%, 0.5%

triamcinolone acetonide lotion

0.025%, 0.1%

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

triamcinolone acetonide oint

0.025%, 0.1%, 0.5%

triamcinolone acetonide oint

0.05%

TRIDESILON - desonide cream

0.05%

TWYNEO - tretinoin-benzoyl

peroxide cream 0.1-3%

ULTRAVATE - halobetasol

propionate lotion 0.05%

VALCHLOR - mechlorethamine hcl

gel 0.016% (base equivalent)

• •

VANOS - fluocinonide cream 0.1%

VECTICAL - calcitriol oint 3 mcg/gm

VELTIN - clindamycin phosphate-

tretinoin gel 1.2-0.025%

VERDESO - desonide foam 0.05%

VEREGEN - sinecatechins oint 15%

VOLTAREN - diclofenac sodium gel

VTAMA - tapinarof cream 1%

VUSION - miconazole-zinc

oxide-white petrolatum oint

0.25-15-81.35%

WINLEVI - clascoterone cream 1%

WYNZORA - calcipotriene-

betamethasone dipropionate

cream 0.005-0.064%

XEPI - ozenoxacin cream 1%

XERESE - acyclovir-hydrocortisone

cream 5-1%

XOLEGEL - ketoconazole gel 2%

ZIANA - clindamycin phosphate-

tretinoin gel 1.2-0.025%

ZILXI - minocycline hcl micronized

foam 1.5%

ZONALON - doxepin hcl cream 5%

ZORYVE - roflumilast cream 0.3%

ZOVIRAX - acyclovir cream 5%

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 104

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ZOVIRAX - acyclovir oint 5%

ZTLIDO - lidocaine patch 1.8% (36

mg)

ZYCLARA - imiquimod cream 3.75%

ZYCLARA PUMP - imiquimod cream

2.5%, 3.75%

MISCELLANEOUS PRODUCTS

ANTIDOTES

CHEMET - succimer cap 100 mg

deferiprone tab 500 mg, 1000 mg

(Ferriprox)

• • • •

EXJADE - deferasirox tab for oral

susp 125 mg, 250 mg, 500 mg

FERRIPROX - deferiprone oral soln

100 mg/ml

• • • •

FERRIPROX - deferiprone tab 500

mg, 1000 mg

FERRIPROX TWICE-A-DAY -

deferiprone (twice daily) tab 1000

JADENU - deferasirox tab 90 mg,

180 mg, 360 mg

JADENU SPRINKLE - deferasirox

granules packet 90 mg, 180 mg,

360 mg

KLOXXADO - naloxone hcl nasal

spray 8 mg/0.1ml

•

naloxone hcl inj 4 mg/10ml

naloxone hcl nasal spray

4 mg/0.1ml (Narcan)

•

NALOXONE HYDROCHLORIDE -

naloxone hcl soln cartridge 0.4

mg/ml

naltrexone hcl tab 50 mg

NARCAN - naloxone hcl nasal spray

4 mg/0.1ml

VISTOGARD - uridine triacetate oral

granules packet 10 gm

DIAGNOSTIC PRODUCTS

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ACCU-CHEK AVIVA PLUS - glucose

blood test strip

ACCU-CHEK COMPACT STRIPS -

glucose blood test strip

ACCU-CHEK COMPACT TEST DR -

glucose blood test strip

ACCU-CHEK GUIDE - glucose blood

test strip

ACCU-CHEK SMARTVIEW STRIP -

glucose blood test strip

ACCUTREND GLUCOSE - glucose

blood test strip

ADVANCE INTUITION TEST ST -

glucose blood test strip

ADVANCE MICRO-DRAW TEST S -

glucose blood test strip

ADVOCATE REDI-CODE - glucose

blood test strip

ADVOCATE REDI-CODE+ TEST -

glucose blood test strip

ADVOCATE TEST STRIPS - glucose

blood test strip

AGAMATRIX AMP NO CODE TES -

glucose blood test strip

AGAMATRIX JAZZ TEST STRIP -

glucose blood test strip

AGAMATRIX KEYNOTE TEST ST -

glucose blood test strip

AGAMATRIX PRESTO TEST STR -

glucose blood test strip

ASSURE II - glucose blood test strip

ASSURE II CHECK STRIP - glucose

blood test strip

ASSURE II TEST STRIPS - glucose

blood test strip

ASSURE PLATINUM TEST STRI -

glucose blood test strip

ASSURE PRISM MULTI TEST S -

glucose blood test strip

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 105

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ASSURE PRO TEST STRIPS -

glucose blood test strip

ASSURE 3 TEST STRIPS - glucose

blood test strip

ASSURE 4 TEST STRIPS - glucose

blood test strip

AT LAST TEST STRIPS - glucose

blood test strip

BINAXNOW COVID-19 AG CARD -

covid-19 at home antigen test kit

BLOOD GLUCOSE TEST STRIPS -

glucose blood test strip

BLULINK GLUCOSE TEST STRI -

glucose blood test strip

CAREONE BLOOD GLUCOSE

TES - glucose blood test strip

CARESENS N BLOOD GLUCOSE -

glucose blood test strip

CARESTART COVID-19 ANTIGE -

covid-19 at home antigen test kit

CARETOUCH BLOOD GLUCOSE

T - glucose blood test strip

CELLTRION DIATRUST COVID- -

covid-19 at home antigen test kit

CLEARDETECT COVID-19 ANTI -

covid-19 at home antigen test kit

CLEVER CHEK AUTO-CODE TES -

glucose blood test strip

CLEVER CHEK AUTO-CODE VOI -

glucose blood test strip

CLEVER CHEK TEST STRIPS -

glucose blood test strip

CLEVER CHOICE AUTO-CODE P -

glucose blood test strip

CLEVER CHOICE MICRO TEST -

glucose blood test strip

CLEVER CHOICE NO CODING T -

glucose blood test strip

CLEVER CHOICE TALK NO COD -

glucose blood test strip

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CLINITEST RAPID COVID-19 -

covid-19 at home antigen test kit

CONTOUR BLOOD GLUCOSE

TES - glucose blood test strip

•

CONTOUR NEXT BLOOD

GLUCOS - glucose blood test strip

•

COOL BLOOD GLUCOSE TEST S -

glucose blood test strip

COVID-19 AT-HOME TEST KIT -

covid-19 at home antigen test kit

COVID-19 RAPID SELF TEST -

covid-19 at home antigen test kit

CVS ADVANCED GLUCOSE

METE - glucose blood test strip

CVS GLUCOSE METER TEST ST -

glucose blood test strip

DIATHRIVE BLOOD GLUCOSE T -

glucose blood test strip

DIATHRIVE+ BLOOD GLUCOSE -

glucose blood test strip

DIATRUE PLUS BLOOD GLUCOS -

glucose blood test strip

DUO-CARE TEST STRIPS - glucose

blood test strip

EASY PLUS II BLOOD GLUCOS -

glucose blood test strip

EASY STEP TEST STRIPS -

glucose blood test strip

EASY TALK BLOOD GLUCOSE T -

glucose blood test strip

EASY TALK PLUS II BLOOD G -

glucose blood test strip

EASY TOUCH GLUCOSE TEST S -

glucose blood test strip

EASY TOUCH HEALTHPRO GLUC -

glucose blood test strip

EASY TRAK BLOOD GLUCOSE T -

glucose blood test strip

EASY TRAK II BLOOD GLUCOS -

glucose blood test strip

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 106

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

EASYGLUCO - glucose blood test

strip

EASYMAX TEST STRIPS - glucose

blood test strip

EASYMAX 15 TEST STRIPS -

glucose blood test strip

EASYPRO BLOOD GLUCOSE

TES - glucose blood test strip

EASYPRO PLUS - glucose blood

test strip

ELEMENT COMPACT TEST STRI -

glucose blood test strip

ELEMENT TEST STRIPS - glucose

blood test strip

ELLUME COVID-19 HOME TEST -

covid-19 at home antigen test kit

EMBRACE BLOOD GLUCOSE

TES - glucose blood test strip

EMBRACE EVO BLOOD

GLUCOSE - glucose blood test

strip

EMBRACE PRO BLOOD

GLUCOSE - glucose blood test

strip

EMBRACE TALK BLOOD

GLUCOS - glucose blood test strip

EQ BLOOD GLUCOSE TEST STR -

glucose blood test strip

EVENCARE BLOOD GLUCOSE

TE - glucose blood test strip

EVOLUTION AUTOCODE - glucose

blood test strip

FIFTY50 GLUCOSE TEST STRI -

glucose blood test strip

FLOWFLEX COVID-19 ANTIGEN -

covid-19 at home antigen test kit

FORA BLOOD GLUCOSE TEST S -

glucose blood test strip

FORA D15G BLOOD GLUCOSE T -

glucose blood test strip

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

FORA D20 BLOOD GLUCOSE TE -

glucose blood test strip

FORA D40/G31 BLOOD GLUCOS -

glucose blood test strip

FORA GD20 TEST STRIPS -

glucose blood test strip

FORA GD50 BLOOD GLUCOSE T -

glucose blood test strip

FORA GTEL BLOOD GLUCOSE T -

glucose blood test strip

FORA G20 BLOOD GLUCOSE TE -

glucose blood test strip

FORA G30/PREMIUM V10 BLOO -

glucose blood test strip

FORA TN'G ADVANCE PRO BLO -

glucose blood test strip

FORA TN'G/TN'G VOICE BLOO -

glucose blood test strip

FORA V10 BLOOD GLUCOSE TE -

glucose blood test strip

FORA V12 BLOOD GLUCOSE TE -

glucose blood test strip

FORA V20 BLOOD GLUCOSE TE -

glucose blood test strip

FORA V30A BLOOD GLUCOSE T -

glucose blood test strip

FORA 6 CONNECT - glucose blood

test strip

FORACARE GD40 - glucose blood

test strip

FORACARE PREMIUM V10 TEST -

glucose blood test strip

FORACARE TEST N GO TEST S -

glucose blood test strip

FORTISCARE BLOOD GLUCOSE -

glucose blood test strip

FORTISCARE G1 BLOOD GLUCO -

glucose blood test strip

FREESTYLE INSULINX BLOOD -

glucose blood test strip

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 107

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

FREESTYLE LITE TEST STRIP -

glucose blood test strip

FREESTYLE PRECISION NEO B -

glucose blood test strip

FREESTYLE TEST STRIPS -

glucose blood test strip

GENULTIMATE TEST STRIPS -

glucose blood test strip

GE100 BLOOD GLUCOSE TEST -

glucose blood test strip

GHT TEST STRIPS - glucose blood

test strip

GLUCO PERFECT 3 TEST STRI -

glucose blood test strip

GLUCOCARD EXPRESSION

BLOO - glucose blood test strip

GLUCOCARD SHINE TEST STRI -

glucose blood test strip

GLUCOCARD VITAL TEST STRI -

glucose blood test strip

GLUCOCARD X-SENSOR - glucose

blood test strip

GLUCOCARD 01 SENSOR PLUS -

glucose blood test strip

GLUCOCOM TEST STRIPS -

glucose blood test strip

GLUCONAVII BLOOD GLUCOSE -

glucose blood test strip

GLUCOSE METER TEST STRIPS -

glucose blood test strip

GNP EASY TOUCH GLUCOSE TE -

glucose blood test strip

GNP TRUE METRIX SELF MONI -

glucose blood test strip

GNP TRUETRACK BLOOD

GLUCO - glucose blood test strip

GNP TRUETRACK SMART SYSTE -

glucose blood test strip

GOJJI BLOOD GLUCOSE TEST -

glucose blood test strip

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

GOODSENSE PREMIUM BLOOD

G - glucose blood test strip

HW EMBRACE PRO BLOOD

GLUC - glucose blood test strip

HW EMBRACE TALK BLOOD GLU -

glucose blood test strip

IGLUCOSE BLOOD GLUCOSE TE -

glucose blood test strip

IHEALTH COVID-19 ANTIGEN -

covid-19 at home antigen test kit

IN TOUCH BLOOD GLUCOSE TE -

glucose blood test strip

INDICAID COVID-19 RAPID A -

covid-19 at home antigen test kit

INFINITY BLOOD GLUCOSE TE -

glucose blood test strip

INFINITY VOICE - glucose blood test

strip

INTELISWAB COVID-19 RAPID -

covid-19 at home antigen test kit

KROGER BLOOD GLUCOSE

TEST - glucose blood test strip

KROGER HEALTHPRO GLUCOSE -

glucose blood test strip

KROGER PREMIUM BLOOD

GLUC - glucose blood test strip

LIBERTY NEXT GENERATION B -

glucose blood test strip

LIBERTY TEST STRIPS - glucose

blood test strip

MEIJER BLOOD GLUCOSE TEST -

glucose blood test strip

MEIJER ESSENTIAL BLOOD GL -

glucose blood test strip

MEIJER PREMIUM BLOOD GLUC -

glucose blood test strip

MEIJER TRUETEST BLOOD GLU -

glucose blood test strip

MEIJER TRUETRACK BLOOD GL -

glucose blood test strip

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 108

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MICRODOT TEST STRIPS - glucose

blood test strip

MICRODOT XTRA TEST STRIPS -

glucose blood test strip

MM EASY TOUCH GLUCOSE TES -

glucose blood test strip

MYGLUCOHEALTH BLOOD

GLUCO - glucose blood test strip

NEUTEK 2TEK TEST STRIPS -

glucose blood test strip

NOVA MAX GLUCOSE TEST STR -

glucose blood test strip

ON/GO COVID-19 ANTIGEN SE -

covid-19 at home antigen test kit

ON/GO ONE COVID-19 ANTIGE -

covid-19 at home antigen test kit

ONE DROP BLOOD GLUCOSE TE -

glucose blood test strip

ONETOUCH ULTRA - glucose blood

test strip

•

ONETOUCH ULTRA BLUE - glucose

blood test strip

•

ONETOUCH ULTRA TEST STRIP -

glucose blood test strip

•

ONETOUCH VERIO TEST STRIP -

glucose blood test strip

•

OPTIUMEZ TEST STRIPS - glucose

blood test strip

PHARMACIST CHOICE

AUTOCOD - glucose blood test

strip

PHARMACIST CHOICE NO CODI -

glucose blood test strip

PILOT COVID-19 AT-HOME TE -

covid-19 at home antigen test kit

POCKETCHEM EZ BLOOD

GLUCO - glucose blood test strip

POGO AUTOMATIC TEST CARTR -

glucose blood test automatic

cartridge

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PRECISION SOF-TACT TEST S -

glucose blood test strip

PRECISION XTRA BLOOD GLUC -

glucose blood test strip

PREMIUM BLOOD GLUCOSE TES -

glucose blood test strip

PRESTIGE TEST STRIPS - glucose

blood test strip

PRO VOICE V8/V9 BLOOD GLU -

glucose blood test strip

PRODIGY NO CODING BLOOD G -

glucose blood test strip

PTS PANELS EGLU - glucose blood

test strip

QUICKTEK TEST STRIPS - glucose

blood test strip

QUICKVUE AT-HOME COVID-19 -

covid-19 at home antigen test kit

QUINTET AC BLOOD GLUCOSE -

glucose blood test strip

QUINTET BLOOD GLUCOSE TES -

glucose blood test strip

REFUAH PLUS BLOOD

GLUCOSE - glucose blood test

strip

RELION CONFIRM/MICRO TEST -

glucose blood test strip

RELION PREMIER BLOOD GLUC -

glucose blood test strip

RELION PRIME BLOOD GLUCOS -

glucose blood test strip

RELION TRUE METRIX BLOOD -

glucose blood test strip

RELION ULTIMA BLOOD GLUCO -

glucose blood test strip

REXALL BLOOD GLUCOSE TEST -

glucose blood test strip

RIGHTEST GS100 BLOOD GLUC -

glucose blood test strip

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 109

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

RIGHTEST GS300 BLOOD GLUC -

glucose blood test strip

RIGHTEST GS333 BLOOD GLUC -

glucose blood test strip

RIGHTEST GS550 BLOOD GLUC -

glucose blood test strip

SMART SENSE PREMIUM

BLOOD - glucose blood test strip

SMART SENSE VALUE BLOOD G -

glucose blood test strip

SMARTEST BLOOD GLUCOSE

TE - glucose blood test strip

SOLUS V2 AUDIBLE TEST -

glucose blood test strip

SUPREME TEST STRIPS - glucose

blood test strip

TGT BLOOD GLUCOSE TEST ST -

glucose blood test strip

TRUE FOCUS SELF MONITORIN -

glucose blood test strip

TRUE METRIX BLOOD GLUCOSE -

glucose blood test strip

TRUE METRIX SELF MONITORI -

glucose blood test strip

TRUETEST STRIPS - glucose blood

test strip

TRUETRACK BLOOD GLUCOSE

T - glucose blood test strip

TRUETRACK TEST - glucose blood

test strip

UNISTRIP1 GENERIC - glucose

blood test strip

VERASENS BLOOD GLUCOSE

TE - glucose blood test strip

VIVAGUARD INO BLOOD GLUCO -

glucose blood test strip

MEDICAL DEVICES

ABOUTTIME PEN NEEDLE 32G -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ABOUTTIME PEN NEEDLES 30G -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

ABOUTTIME PEN NEEDLES 31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

ACCU-CHEK FASTCLIX LANCET -

lancets

ACCU-CHEK SAFE-T-PRO LANC -

lancets

ACCU-CHEK SOFTCLIX LANCET -

lancets

ACTI-LANCE LANCETS 28G -

lancets

ACTI-LANCE LITE SAFETY LA -

lancets

ACTI-LANCE SPECIAL SAFETY -

lancets

ACTI-LANCE UNIVERSAL SAFE -

lancets

ADJUSTABLE LANCING DEVICE -

lancet devices

ADVANCED MOBILE LANCET 30 -

lancets

ADVOCATE INSULIN PEN NEED -

insulin pen needle 29 g x 12.7 mm

(1/2")

ADVOCATE INSULIN PEN NEED -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

ADVOCATE INSULIN PEN NEED -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

ADVOCATE INSULIN SYRINGE/ -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 29 x 1/2", u-100 1/2

ml 30 x 5/16", u-100 1 ml 29 x

1/2", u-100 1 ml 30 x 5/16", u-100

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 110

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

1 ml 31 x 5/16", u-100 0.3 ml 31 x

5/16"

ADVOCATE LANCETS - lancets

ADVOCATE LANCETS 30G -

lancets

ADVOCATE LANCING DEVICE -

lancet devices

ADVOCATE RAPID-SAFE LANCI -

lancet devices

ADVOCATE SAFETY LANCETS -

lancets

ADVOCATE SAFETY LANCETS 2 -

lancets

AF LANCETS SUPER THIN -

lancets

AGAMATRIX ULTRA-THIN LANC -

lancets

AIMSCO TWIST LANCETS 32G -

lancets

AIMSCO TWIST LANCETS 33G -

lancets

AQUALANCE LANCETS UL -

lancets

ASSURE COMFORT LANCETS UL -

lancets

ASSURE HAEMOLANCE PLUS HI -

lancets

ASSURE HAEMOLANCE PLUS LO -

lancets

ASSURE HAEMOLANCE PLUS MI -

lancets

ASSURE HAEMOLANCE PLUS

NO - lancets

ASSURE HAEMOLANCE PLUS PE -

lancets

ASSURE ID INSULIN SAFETY -

insulin syringe/needle u-100 1/2

ml 31 x 15/64", u-100 1 ml 31 x

15/64"

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ASSURE ID SAFETY PEN NEED -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

ASSURE LANCE LANCETS -

lancets

ASSURE LANCE LANCETS 21G -

lancets

ASSURE LANCE PLUS SAFETY -

lancets

ASSURE LANCE SAFETY LANCE -

lancets

AT LAST LANCETS - lancets

AUM MINI INSULIN PEN NEED -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64"), x 8

mm (1/3" or 5/16")

AUM MINI INSULIN PEN NEED -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64")

AUM READYGARD DUO SAFETY -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

AUM SAFETY PEN NEEDLE/31 -

insulin pen needle 31 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16")

AURORA LANCET SUPER THIN -

lancets

AURORA LANCET THIN 23G -

lancets

AURORA PEN NEEDLES 29GX12 -

insulin pen needle 29 g x 12 mm

(1/2")

AURORA PEN NEEDLES 31G X -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

AURORA UNIFINE PENTIPS/MI -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

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Drug Name

Drug Tier

Prior Authorization

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Specialty

ACA

Limited Distribution

AURORA UNIFINE PENTIPS/32 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

AUTO-LANCET - lancet devices

AUTO-LANCET MINI - lancet

devices

AUTOLET IMPRESSION LANCIN -

lancet devices

AUTOLET LANCING DEVICE -

lancet devices

AUTOLET MINI - lancet devices

AUTOLET PLUS - lancet devices

AUTOPEN - injection device for

insulin

AUTOPEN - injection device for

insulin

B-D INSULIN SYRINGE MICRO -

insulin syringe/needle u-100 1 ml

28 x 1/2"

B-D INSULIN SYRINGE ULTRA -

insulin syringe/needle u-100 0.3

ml 30 x 1/2", u-100 1/2 ml 31 x

5/16", u-100 1/2 ml 30 x 1/2",

u-100 0.3 ml 31 x 5/16"

BD LO-DOSE INSULIN SYRIN -

insulin syringe/needle u-100 1/2

ml 28 x 1/2"

BD AUTOSHIELD DUO 30G X 5 -

insulin pen needle 30 g x 5 mm

(1/5" or 3/16")

BD AUTOSHIELD 29G X 3/16" -

insulin pen needle 29 g x 5 mm

(1/5" or 3/16")

BD AUTOSHIELD 29G X 5/16" -

insulin pen needle 29 g x 8 mm

(1/3" or 5/16")

BD INSULIN SYRINGE LUER-L -

insulin syringe (disp) u-100 1 ml

BD INSULIN SYRINGE MICROF -

insulin syringe/needle u-100 0.3

ml 28 x 1/2", u-100 1/2 ml 28 x

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

1/2", u-100 1 ml 27 x 5/8", u-100 1

ml 28 x 1/2"

BD INSULIN SYRINGE SAFETY -

insulin syringe/needle u-100 1 ml

29 x 1/2"

BD INSULIN SYRINGE SLIP T -

insulin syringe (disp) u-100 1 ml

BD INSULIN SYRINGE ULTRA -

insulin syringe/needle u-100 1 ml

30 x 1/2"

BD INSULIN SYRINGE ULTRA- -

insulin syringe/needle u-100 0.3

ml 30 x 1/2", u-100 1/2 ml 31 x

5/16", u-100 1/2 ml 30 x 1/2",

u-100 1 ml 30 x 1/2", u-100 1 ml

31 x 5/16", u-100 0.3 ml 31 x 5/16"

BD INSULIN SYRINGE ULTRAF -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

1/2", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 29 x 1/2", u-100 1/2

ml 30 x 1/2", u-100 1 ml 29 x 1/2",

u-100 1 ml 30 x 1/2", u-100 1 ml

31 x 5/16", u-100 0.3 ml 31 x 5/16"

BD INSULIN SYRINGE/DETACH -

insulin syringe/needle u-100 1

ml 25 x 5/8", u-100 1 ml 25 x 1",

u-100 1 ml 26 x 1/2"

BD INSULIN SYRINGE/U-100/ -

insulin syringe/needle u-100 1 ml

27 x 1/2", u-100 2 ml 27.5 x 5/8"

BD INSULIN SYRINGE/U-500/ -

insulin syringe/needle u-500 0.5

ml 31g x 6mm (15/64")

BD INSULIN SYRINGE/0.3ML/ -

insulin syringe/needle u-100 0.3

ml 29 x 1/2"

BD INSULIN SYRINGE/0.5ML/ -

insulin syringe/needle u-100 1/2

ml 29 x 1/2"

BD INSULIN SYRINGE/1ML/27 -

insulin syringe/needle u-100 1 ml

27 x 1/2"

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Drug Tier

Prior Authorization

Quantity Limits

Specialty

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Limited Distribution

BD INSULIN SYRINGE/1ML/29 -

insulin syringe/needle u-100 1 ml

29 x 1/2"

BD LANCET ULTRAFINE 30G -

lancets

BD LANCET ULTRAFINE 33G -

lancets

BD MICROTAINER LANCETS -

lancets

BD PEN - injection device for insulin

BD PEN MINI - injection device for

insulin

BD PEN NEEDLE/MICRO/ULTRA -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64")

BD PEN NEEDLE/MINI/ULTRA- -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

BD PEN NEEDLE/NANO 2ND GE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

BD PEN NEEDLE/NANO/ULTRA -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

BD PEN NEEDLE/ORIGINAL/UL -

insulin pen needle 29 g x 12.7 mm

(1/2")

BD PEN NEEDLE/SHORT/ULTRA -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

BD SAFETY-GLIDE INSULIN S -

insulin syringe/needle u-100 1/2

ml 29 x 1/2"

BD SAFETY-LOK INSULIN SYR -

insulin syringe/needle u-100 1 ml

29 x 1/2"

BD SAFETYGLIDE INSULIN SY -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 1/2 ml 30 x

5/16", u-100 0.3 ml 31 x 15/64",

u-100 0.3 ml 31 x 5/16", u-100 1/2

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 31 x 15/64", u-100 1 ml 31 x

15/64"

BD VEO INSULIN SYRINGE UL -

insulin syringe/needle u-100 0.3

ml 31 x 15/64", u-100 1/2 ml 31 x

15/64", u-100 1 ml 31 x 15/64"

CARDIOCOM LANCING DEVICE -

lancet devices

CAREFINE PEN NEEDLE 32GX4 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

CAREFINE PEN NEEDLES 29GX -

insulin pen needle 29 g x 12 mm

(1/2")

CAREFINE PEN NEEDLES 30GX -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

CAREFINE PEN NEEDLES 31GX -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

CAREFINE PEN NEEDLES 32GX -

insulin pen needle 32 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64")

CAREONE ADVANCED LANCING -

lancet devices

CAREONE INSULIN SYRINGES/ -

insulin syringe/needle u-100 0.3

ml 30 x 1/2", u-100 1/2 ml 31 x

5/16", u-100 1/2 ml 30 x 1/2",

u-100 1 ml 30 x 1/2", u-100 1 ml

31 x 5/16", u-100 0.3 ml 31 x 5/16"

CAREONE LANCET SUPER THIN -

lancets

CAREONE LANCET THIN - lancets

CAREONE LANCET ULTRA THIN -

lancets

CAREONE UNIFINE PENTIPS P -

insulin pen needle 29 g x 12 mm

(1/2")

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Drug Name

Drug Tier

Prior Authorization

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Specialty

ACA

Limited Distribution

CAREONE UNIFINE PENTIPS P -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

CAREONE UNIFINE PENTIPS P -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

CAREONE UNIFINE PENTIPS P -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

CAREONE UNIFINE PENTIPS 2 -

insulin pen needle 29 g x 12 mm

(1/2")

CAREONE UNIFINE PENTIPS 3 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

CARESENS LANCETS - lancets

CARETOUCH INSULIN SYRINGE -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1/2 ml 30

x 5/16", u-100 1 ml 28 x 5/16",

u-100 1 ml 29 x 5/16", u-100 1 ml

30 x 5/16", u-100 1 ml 31 x 5/16",

u-100 0.3 ml 31 x 5/16"

CARETOUCH LANCING DEVICE -

lancet devices

CARETOUCH PEN NEEDLE 29GX -

insulin pen needle 29 g x 12 mm

(1/2")

CARETOUCH PEN NEEDLES 31 -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

CARETOUCH PEN NEEDLES 31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

CARETOUCH PEN NEEDLES 32G -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16")

CARETOUCH SAFETY LANCETS/ -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CARETOUCH TWIST LANCETS 2 -

lancets

CARETOUCH TWIST LANCETS 3 -

lancets

CAYA - diaphragm arc-spring

•

CEQUR SIMPLICITY INSERTER -

injection device for insulin -

accessories

CEQUR SIMPLICITY 2U - injection

device for insulin

CLEANLET LANCETS 28G - lancets

CLEVER CHEK LANCETS ULTRA -

lancets

CLEVER CHOICE COMFORT EZ -

insulin pen needle 29 g x 12 mm

(1/2")

CLEVER CHOICE COMFORT EZ -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

CLEVER CHOICE COMFORT EZ -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64"), x 8

mm (1/3" or 5/16")

CLEVER CHOICE COMFORT EZ -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64"), x 8

mm (1/3" or 5/16")

CLEVER CHOICE COMFORT EZ -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 0.3 ml 30 x 1/2",

u-100 1/2 ml 31 x 5/16", u-100

1/2 ml 28 x 1/2", u-100 1/2 ml 29

x 1/2", u-100 1/2 ml 30 x 5/16",

u-100 1/2 ml 30 x 1/2", u-100 1

ml 28 x 1/2", u-100 1 ml 29 x 1/2",

u-100 1 ml 30 x 5/16", u-100 1 ml

30 x 1/2", u-100 1 ml 31 x 5/16",

u-100 0.3 ml 31 x 5/16"

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Drug Tier

Prior Authorization

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Specialty

ACA

Limited Distribution

CLEVER CHOICE COMFORT EZ -

lancets

CLICKFINE PEN NEEDLE UNIV -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

CLICKFINE PEN NEEDLE 32GX -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

CLICKFINE PEN NEEDLES 31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

CLICKFINE PEN NEEDLES 32G -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

CLICKFINE PEN NEEDLES/31G -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

CLICKFINE UNIVERSAL PEN N -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

COAGUCHEK LANCETS - lancets

COMFORT ASSIST INSULIN SY -

insulin syringe/needle u-100 0.3

ml 31 x 5/16"

COMFORT ASSURED LANCETS

M - lancets

COMFORT ASSURED LANCETS

S - lancets

COMFORT EZ INSULIN SYRING -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1 ml 31 x

5/16"

COMFORT EZ MICRO/32G X 4M -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

COMFORT EZ SHORT/31G X 8M -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

COMFORT EZ/31G X 5MM - insulin

pen needle 31 g x 5 mm (1/5" or

3/16")

COMFORT EZ/31G X 6MM - insulin

pen needle 31 g x 6 mm (1/4" or

15/64")

COMFORT LANCETS - lancets

COMFORT TOUCH LANCETS ULT -

lancets

COMFORT TOUCH PEN

NEEDLES - insulin pen needle 31

g x 4 mm (1/6" or 5/32"), x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

COMFORT TOUCH PEN

NEEDLES - insulin pen needle 32

g x 4 mm (1/6" or 5/32"), x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

COMFORT TOUCH PEN

NEEDLES - insulin pen needle 33

g x 4 mm (1/6" or 5/32"), x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64")

COMFORT TOUCH PLUS

SAFETY - lancets

CONDOMS-MALE-VARIOUS

• •

CONTOUR BLOOD GLUCOSE

MON - blood glucose monitoring

devices

•

CONTOUR BLOOD GLUCOSE

MON - blood glucose monitoring kit

w/ device

•

CONTOUR HIGH CONTROL - blood

glucose calibration - liquid - high

CONTOUR LOW CONTROL - blood

glucose calibration - liquid - low

CONTOUR NEXT BLOOD

GLUCOS - blood glucose

monitoring kit w/ device

•

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 115

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

CONTOUR NEXT CONTROL

LEVE - blood glucose calibration -

liquid - normal, - low

CONTOUR NEXT EZ BLOOD GLU -

blood glucose monitoring kit w/

device

•

CONTOUR NEXT GEN BLOOD GL -

blood glucose monitoring kit w/

device

•

CONTOUR NEXT LINK BLOOD G -

blood glucose monitoring kit w/

device

•

CONTOUR NEXT LINK WIRELES -

blood glucose monitoring kit w/

device

•

CONTOUR NEXT ONE BLOOD GL -

blood glucose monitoring devices

•

CONTOUR NEXT ONE BLOOD GL -

blood glucose monitoring kit

•

CONTOUR NORMAL CONTROL -

blood glucose calibration - liquid -

normal

CVS LANCETS MICRO THIN 33 -

lancets

CVS LANCETS MICRO-THIN 33 -

lancets

CVS LANCETS ORIGINAL - lancets

CVS LANCETS THIN 26G - lancets

CVS LANCETS ULTRA THIN 30 -

lancets

CVS LANCETS ULTRA-THIN 30 -

lancets

CVS LANCETS 21G - lancets

CVS LANCING DEVICE - lancet

devices

CVS ULTRA THIN LANCETS -

lancets

DEXCOM G6 RECEIVER -

continuous blood glucose system

receiver

• •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DEXCOM G6 SENSOR - continuous

blood glucose system sensor

• •

DEXCOM G6 TRANSMITTER -

continuous blood glucose system

transmitter

• •

DIATHRIVE LANCETS - lancets

DIATHRIVE LANCETS ULTRA T -

lancets

DIATHRIVE LANCING DEVICE -

lancet devices

DIATHRIVE PEN NEEDLE/31 G -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

DIATHRIVE PEN NEEDLE/31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

DIATHRIVE PEN NEEDLE/32G -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

DROPLET GENTEEL LANCING D -

lancet devices

DROPLET INSULIN SYRINGE U -

insulin syringe/needle u-100 0.3

ml 30 x 5/16", u-100 0.3 ml 30

x 1/2", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 30 x 5/16", u-100 1/2

ml 30 x 1/2", u-100 0.3 ml 31 x

15/64", u-100 0.3 ml 30 x 15/64",

u-100 0.5 ml 30 x 15/64", u-100

1 ml 30 x 15/64", u-100 1 ml 30 x

5/16", u-100 1 ml 30 x 1/2", u-100

1 ml 31 x 5/16", u-100 0.3 ml 31 x

5/16", u-100 1 ml 31 x 15/64"

DROPLET INSULIN SYRINGE 0 -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 1/2 ml 29 x

1/2"

DROPLET INSULIN SYRINGE 1 -

insulin syringe/needle u-100 1 ml

29 x 1/2"

DROPLET INSULIN SYRINGE/U -

insulin syringe/needle u-100 1/2

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 116

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 31 x 5/16", u-100 1/2 ml 30 x

1/2", u-100 0.3 ml 31 x 15/64",

u-100 1 ml 30 x 1/2", u-100 1

ml 31 x 5/16", u-100 0.3 ml 31 x

5/16", u-100 1/2 ml 31 x 15/64",

u-100 1 ml 31 x 15/64"

DROPLET LANCETS ULTRA THI -

lancets

DROPLET LANCING DEVICE -

lancet devices

DROPLET MICRON 34G X 9/64 -

insulin pen needle 34 g x 3.5 mm

(9/64")

DROPLET PEN NEEDLES 29G X -

insulin pen needle 29 g x 12 mm

(1/2")

DROPLET PEN NEEDLES 29GX1 -

insulin pen needle 29 g x 10 mm,

x 12 mm (1/2")

DROPLET PEN NEEDLES 30G X -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

DROPLET PEN NEEDLES 31G X -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

DROPLET PEN NEEDLES 31GX5 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

DROPLET PEN NEEDLES 31GX6 -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

DROPLET PEN NEEDLES 31GX8 -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

DROPLET PEN NEEDLES 32G X -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64"), x 8

mm (1/3" or 5/16")

DROPLET PEN NEEDLES 32GX4 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DROPLET PEN NEEDLES 32GX5 -

insulin pen needle 32 g x 5 mm

(1/5" or 3/16")

DROPLET PEN NEEDLES 32GX6 -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64")

DROPLET PEN NEEDLES 32GX8 -

insulin pen needle 32 g x 8 mm

(1/3" or 5/16")

DROPLET PERSONAL LANCETS -

lancets

DROPSAFE SAFETY PEN NEEDL -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

DROPSAFE SAFTEY PEN NEEDL -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

DRUG MART ADJUSTABLE LANC -

lancet devices

DRUG MART LANCETS THIN -

lancets

DRUG MART LANCETS ULTRA T -

lancets

DRUG MART ON-THE-GO LANCE -

lancets

DRUG MART UNIFINE PENTIPS -

insulin pen needle 29 g x 12 mm

(1/2")

DRUG MART UNIFINE PENTIPS -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

DRUG MART UNIFINE PENTIPS -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

DRUG MART UNILET LANCETS -

lancets

DRUG MART UNILET MICRO TH -

lancets

DUANE READE LANCET ALTERN -

lancets

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Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

DUANE READE LANCET SUPER -

lancets

DUANE READE LANCET ULTRA -

lancets

DUANE READE UNIFINE PENTI -

insulin pen needle 29 g x 12 mm

(1/2")

DUANE READE UNIFINE PENTI -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

E-Z JECT LANCETS - lancets

E-Z JECT LANCETS COLOR -

lancets

E-Z JECT LANCETS SUPER TH -

lancets

E-Z JECT LANCETS THIN 26G -

lancets

E-Z JECT LANCETS 21G - lancets

E-ZJECT LANCETS MICRO-THI -

lancets

EASY COMFORT INSULIN SYRI -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1/2 ml 30

x 5/16", u-100 1/2 ml 30 x 1/2",

u-100 0.5 ml 32 x 5/16", u-100

1 ml 32 x 5/16", u-100 1 ml 30 x

5/16", u-100 1 ml 30 x 1/2", u-100

1 ml 31 x 5/16"

EASY COMFORT LANCETS -

lancets

EASY COMFORT LANCETS TWIS -

lancets

EASY COMFORT LANCETS 30G/ -

lancets

EASY COMFORT PEN NEEDLES -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

EASY COMFORT PEN NEEDLES -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

EASY COMFORT PEN NEEDLES -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64")

EASY GLIDE PEN NEEDLES 33 -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

EASY MINI EJECT LANCING D -

lancet devices

EASY MINI LANCING DEVICE -

lancet devices

EASY TOUCH FLIPLOCK SAFET -

insulin syringe/needle u-100 1 ml

29 x 1/2", u-100 1 ml 30 x 5/16",

u-100 1 ml 30 x 1/2", u-100 1 ml

31 x 5/16"

EASY TOUCH INSULIN SYRING -

insulin syringe/needle u-100 0.3

ml 30 x 5/16", u-100 0.3 ml 30 x

1/2", u-100 1/2 ml 27 x 1/2", u-100

1/2 ml 31 x 5/16", u-100 1/2 ml

28 x 1/2", u-100 1/2 ml 29 x 1/2",

u-100 1/2 ml 30 x 5/16", u-100 1/2

ml 30 x 1/2", u-100 1 ml 27 x 1/2",

u-100 1 ml 27 x 5/8", u-100 1 ml

28 x 1/2", u-100 1 ml 29 x 1/2",

u-100 1 ml 30 x 5/16", u-100 1 ml

30 x 1/2", u-100 1 ml 31 x 5/16",

u-100 0.3 ml 31 x 5/16"

EASY TOUCH LANCETS 21G/PR -

lancets

EASY TOUCH LANCETS 23G/PR -

lancets

EASY TOUCH LANCETS 26G/PR -

lancets

EASY TOUCH LANCETS 26G/PU -

lancets

EASY TOUCH LANCETS 28G/PR -

lancets

EASY TOUCH LANCETS 28G/PU -

lancets

EASY TOUCH LANCETS 28G/TW -

lancets

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 118

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

EASY TOUCH LANCETS 30G/BU -

lancets

EASY TOUCH LANCETS 30G/PR -

lancets

EASY TOUCH LANCETS 30G/PU -

lancets

EASY TOUCH LANCETS 30G/TW -

lancets

EASY TOUCH LANCETS 32G/PR -

lancets

EASY TOUCH LANCETS 32G/PU -

lancets

EASY TOUCH LANCETS 32G/TW -

lancets

EASY TOUCH LANCETS 33G/TW -

lancets

EASY TOUCH LANCING DEVICE -

lancet devices

EASY TOUCH PEN NEEDLE 30 -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

EASY TOUCH PEN NEEDLE/30 -

insulin pen needle 30 g x 5 mm

(1/5" or 3/16")

EASY TOUCH PEN NEEDLES 29 -

insulin pen needle 29 g x 12 mm

(1/2")

EASY TOUCH PEN NEEDLES 31 -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

EASY TOUCH PEN NEEDLES 32 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64")

EASY TOUCH PEN NEEDLES/31 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

EASY TOUCH SAFETY LANCETS -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

EASY TOUCH SAFETY PEN NEE -

insulin pen needle 29 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

EASY TOUCH SAFETY PEN NEE -

insulin pen needle 30 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

EASY TOUCH SHEATHLOCK SAF -

insulin syringe/needle u-100 1 ml

29 x 1/2", u-100 1 ml 30 x 5/16",

u-100 1 ml 30 x 1/2", u-100 1 ml

31 x 5/16"

EASY TOUCH 32GX5MM - insulin

pen needle 32 g x 5 mm (1/5" or

3/16")

EASY TOUCH 32GX6MM - insulin

pen needle 32 g x 6 mm (1/4" or

15/64")

EMBRACE LANCETS ULTRA THI -

lancets

EMBRACE LANCING DEVICE WI -

lancet devices

EMBRACE PRESSURE ACTIVATE -

lancets

EQL COLOR LANCETS MICRO T -

lancets

EQL COLOR LANCETS 21G -

lancets

EQL INSULIN SYRINGE/0.3ML -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 0.3 ml 31 x 5/16"

EQL INSULIN SYRINGE/0.5ML -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1/2 ml 29 x

1/2", u-100 1/2 ml 30 x 5/16"

EQL INSULIN SYRINGE/1ML/2 -

insulin syringe/needle u-100 1 ml

29 x 1/2"

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 119

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Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

EQL INSULIN SYRINGE/1ML/3 -

insulin syringe/needle u-100 1 ml

30 x 5/16", u-100 1 ml 31 x 5/16"

EQL SHORT PEN NEEDLES 31G -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

EQL SUPER THIN LANCETS 30 -

lancets

EQL THIN LANCETS 26G - lancets

EQL ULTRA SHORT PEN NEEDL -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

EXCEL COMFORT POINT INSUL -

insulin pen needle 31 g x 4 mm

(1/6" or 5/32")

EXEL COMFORT POINT INSULI -

insulin pen needle 29 g x 12 mm

(1/2")

EXEL COMFORT POINT INSULI -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

EXEL COMFORT POINT INSULI -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 28 x 1/2",

u-100 1/2 ml 29 x 1/2", u-100 1/2

ml 30 x 5/16", u-100 1 ml 28 x

1/2", u-100 1 ml 29 x 1/2", u-100 1

ml 30 x 5/16"

EZ-LETS LANCETS 21G - lancets

EZ-LETS LANCETS 26G SUPER -

lancets

EZ-LETS LANCETS 28G ULTRA -

lancets

EZ-LETS LANCETS 30G - lancets

FC2 FEMALE CONDOM

•

FEMCAP - cervical cap 22 mm, 26

mm, 30 mm

•

FIFTY50 PEN NEEDLES 31G X -

insulin pen needle 31 g x 5 mm

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

FIFTY50 PEN NEEDLES 31GX5 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

FIFTY50 PEN NEEDLES/31GX8 -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

FIFTY50 PEN NEEDLES/32GX4 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

FIFTY50 PEN NEEDLES/32GX6 -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64")

FIFTY50 SAFETY SEAL LANCE -

lancets

FIFTY50 SUPERIOR COMFORT -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1 ml 31 x

5/16", u-100 0.3 ml 31 x 5/16"

FIFTY50 UNILET LANCETS 33 -

lancets

FINE 30 - lancets

FINGERSTIX LANCETS - lancets

FORA LANCETS - lancets

FORA LANCING DEVICE - lancet

devices

FORA LANCING DEVICE/CLEAR -

lancet devices

FREDS PHARMACY AUTOLET LA -

lancet devices

FREDS PHARMACY UNIFINE PE -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

FREDS PHARMACY UNIFINE PE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

FREDS PHARMACY UNILET LAN -

lancets

FREESTYLE LANCETS - lancets

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 120

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

FREESTYLE LIBRE 14 DAY/RE -

continuous blood glucose system

receiver

FREESTYLE LIBRE 14 DAY/SE -

continuous blood glucose system

sensor

FREESTYLE LIBRE 2/READER/ -

continuous blood glucose system

receiver

FREESTYLE LIBRE 2/SENSOR/ -

continuous blood glucose system

sensor

FREESTYLE LIBRE 3/SENSOR/ -

continuous blood glucose system

sensor

FREESTYLE LIBRE/READER/FL -

continuous blood glucose system

receiver

FREESTYLE UNISTICK II LAN -

lancets

GENTEEL BUTTERFLY TOUCH L -

lancets

GENTEEL PLUS LANCING DEVI -

lancet devices

GENTLE-LET GP LANCETS -

lancets

GENTLE-LET LANCETS GENERA -

lancets

GENTLE-LET LANCETS SAFETY -

lancets

GLOBAL EASE INJECT PEN NE -

insulin pen needle 29 g x 12 mm

(1/2")

GLOBAL EASE INJECT PEN NE -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

GLOBAL EASE INJECT PEN NE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

GLOBAL EASY GLIDE INSULIN -

insulin syringe/needle u-100 0.3

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 31 x 15/64", u-100 0.3 ml 31 x

5/16", u-100 1/2 ml 31 x 15/64",

u-100 1 ml 31 x 15/64"

GLOBAL EASY GLIDE PEN NEE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

GLOBAL INJECT EASE INSULI -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 0.3 ml 30 x 1/2",

u-100 1/2 ml 31 x 5/16", u-100

1/2 ml 28 x 1/2", u-100 1/2 ml 29

x 1/2", u-100 1/2 ml 30 x 5/16",

u-100 1/2 ml 30 x 1/2", u-100 1

ml 28 x 1/2", u-100 1 ml 29 x 1/2",

u-100 1 ml 30 x 5/16", u-100 1 ml

30 x 1/2", u-100 1 ml 31 x 5/16",

u-100 0.3 ml 31 x 5/16"

GLOBAL INJECT EASE LANCET -

lancets

GLOBAL INSULIN SYRINGE/U- -

insulin syringe/needle u-100 0.3

ml 30 x 1/2"

GLOBAL INSULIN SYRINGES/U -

insulin syringe/needle u-100 0.3

ml 30 x 5/16"

GLOBAL LANCING DEVICE - lancet

devices

GLUCOCOM LANCETS 28G -

lancets

GLUCOCOM LANCETS 30G -

lancets

GLUCOCOM LANCETS 33G -

lancets

GLUCOPRO INSULIN SYRINGE/ -

insulin syringe/needle u-100 0.3

ml 30 x 5/16", u-100 0.3 ml 30

x 1/2", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 30 x 5/16", u-100

1/2 ml 30 x 1/2", u-100 1 ml 30 x

5/16", u-100 1 ml 30 x 1/2", u-100

1 ml 31 x 5/16", u-100 0.3 ml 31 x

5/16"

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 121

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

GNP CLICKFINE UNIVERSAL P -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

GNP INSULIN SYRINGE/0.3ML -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 0.3 ml 31 x 5/16"

GNP INSULIN SYRINGE/0.5ML -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1/2 ml 28 x

1/2", u-100 1/2 ml 29 x 1/2", u-100

1/2 ml 30 x 5/16"

GNP INSULIN SYRINGE/1ML/2 -

insulin syringe/needle u-100 1 ml

29 x 1/2"

GNP INSULIN SYRINGE/1ML/3 -

insulin syringe/needle u-100 1 ml

30 x 5/16", u-100 1 ml 31 x 5/16"

GNP INSULIN SYRINGES/0.3M -

insulin syringe/needle u-100 0.3

ml 30 x 5/16"

GNP INSULIN SYRINGES/1/2M -

insulin syringe/needle u-100 1/2

ml 29 x 1/2"

GNP INSULIN SYRINGES/1ML/ -

insulin syringe/needle u-100 1 ml

28 x 1/2", u-100 1 ml 29 x 1/2",

u-100 1 ml 30 x 5/16"

GNP INSULIN SYRINGES/3ML/ -

insulin syringe/needle u-100 0.3

ml 31 x 5/16"

GNP LANCETS THIN 26G - lancets

GNP LANCETS 21G - lancets

GNP LANCING SYSTEM DEVICE -

lancet devices

GNP STERILE LANCETS 28G -

lancets

GNP STERILE LANCETS 30G -

lancets

GNP STERILE LANCETS 33G -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

GNP ULTICARE PEN NEEDLES -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

GNP ULTICARE PEN NEEDLES/ -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 6 mm (1/4" or

15/64")

GNP ULTIGUARD SAFEPACK/MI -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

GNP ULTIGUARD SAFEPACK/MI -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 6 mm (1/4" or

15/64")

GNP ULTIGUARD SAFEPACK/SH -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

GNP ULTRA COMFORT INSULIN -

insulin syringe/needle u-100 1 ml

28 x 1/2"

GOJJI LANCING DEVICE/CLEA -

lancet devices

GOJJI STERILE LANCETS 30G -

lancets

GOODSENSE CLICKFINE SAFET -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

GOODSENSE COLOR LANCETS

M - lancets

GOODSENSE LANCETS MICRO-T -

lancets

GOODSENSE LANCETS ULTRA-T -

lancets

GOODSENSE LANCING DEVICE -

lancet devices

GOODSENSE PEN NEEDLE/

PENF - insulin pen needle 31 g x

5 mm (1/5" or 3/16"), x 8 mm (1/3"

or 5/16")

GOODSENSE PEN NEEDLE/

PENF - insulin pen needle 32 g x

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 122

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

4 mm (1/6" or 5/32"), x 6 mm (1/4"

or 15/64")

H-E-B IN CONTROL PEN NEED -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

H-E-B IN CONTROL PEN NEED -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

H-E-B IN CONTROL UNIFINE -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

H-E-B IN CONTROL UNIFINE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

H-E-B IN CONTROL UNIFINE -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

H-E-B INCONTROL ADVANCED -

lancet devices

H-E-B INCONTROL LANCETS M -

lancets

H-E-B INCONTROL LANCETS S -

lancets

H-E-B INCONTROL LANCETS U -

lancets

H-E-B INCONTROL PEN NEEDL -

insulin pen needle 29 g x 12 mm

(1/2")

HAEMOLANCE - lancets

HAEMOLANCE LOW FLOW

LANCE - lancets

HAEMOLANCE PLUS - lancets

HAEMOLANCE PLUS HIGH FLOW -

lancets

HAEMOLANCE PLUS LOW FLOW -

lancets

HAEMOLANCE PLUS MAX FLOW -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

HAEMOLANCE PLUS PEDIATRIC -

lancets

HEALTH CARE LANCING DEVIC -

lancet devices

HEALTHWISE INSULIN SYRING -

insulin syringe/needle u-100 0.3

ml 30 x 5/16", u-100 1/2 ml 31 x

5/16", u-100 1/2 ml 30 x 5/16",

u-100 1 ml 30 x 5/16", u-100 1 ml

31 x 5/16", u-100 0.3 ml 31 x 5/16"

HEALTHWISE MICRON PEN NEE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

HEALTHWISE MINI PEN NEEDL -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

HEALTHWISE PEN NEEDLES 29 -

insulin pen needle 29 g x 12 mm

(1/2")

HEALTHWISE SHORT PEN NEED -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

HEALTHWISE UNIFINE PENTIP -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

HEALTHY ACCENTS AUTOLET I -

lancet devices

HEALTHY ACCENTS UNIFINE P -

insulin pen needle 29 g x 12 mm

(1/2")

HEALTHY ACCENTS UNIFINE P -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

HEALTHY ACCENTS UNIFINE P -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

HEALTHY ACCENTS UNILET LA -

lancets

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 123

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

HM ULTICARE INSULIN SYRIN -

insulin syringe/needle u-100 1 ml

30 x 1/2", u-100 0.3 ml 31 x 5/16"

HM ULTICARE MINI PEN NEED -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

HM ULTICARE SHORT PEN NEE -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

HY-VEE LANCETS - lancets

HY-VEE THIN LANCETS - lancets

IN TOUCH LANCING DEVICE -

lancet devices

IN TOUCH STERILE LANCETS -

lancets

INCONTROL ULTICARE MINI P -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

INCONTROL ULTICARE MINI P -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

INPEN 100/BLUE/LILLY/HUMA -

injection device for insulin

INPEN 100/BLUE/NOVOLOG/FI -

injection device for insulin

INPEN 100/GREY/LILLY/HUMA -

injection device for insulin

INPEN 100/GREY/NOVOLOG/FI -

injection device for insulin

INPEN 100/PINK/LILLY/HUMA -

injection device for insulin

INPEN 100/PINK/NOVOLOG/FI -

injection device for insulin

INSULIN SYRINGE 1ML/31G X -

insulin syringe/needle u-100 1 ml

31 x 1/4" (6 mm)

INSULIN SYRINGE/NEEDLE 0. -

insulin syringe/needle u-100 0.3

ml 30 x 5/16", u-100 1/2 ml 31

x 5/16", u-100 1/2 ml 29 x 1/2",

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

u-100 1/2 ml 30 x 5/16", u-100 0.3

ml 31 x 5/16"

INSULIN SYRINGE/NEEDLE 1M -

insulin syringe/needle u-100 1 ml

29 x 1/2", u-100 1 ml 30 x 5/16",

u-100 1 ml 31 x 5/16"

INSULIN SYRINGE/U-100/0.3 -

insulin syringe/needle u-100 0.3

ml 29 x 1/2"

INSULIN SYRINGE/U-100/0.5 -

insulin syringe/needle u-100 1/2

ml 29 x 1/2"

INSULIN SYRINGE/U-100/1ML -

insulin syringe/needle u-100 1 ml

29 x 1/2", u-100 1 ml 30 x 5/16",

u-100 1 ml 31 x 5/16", u-100 0.3

ml 31 x 5/16"

INSULIN SYRINGE/0.3ML/30G -

insulin syringe/needle u-100 0.3

ml 30 x 5/16"

INSULIN SYRINGE/0.3ML/31G -

insulin syringe/needle u-100 0.3

ml 31 x 5/16"

INSULIN SYRINGE/0.5ML/27G -

insulin syringe/needle u-100 1/2

ml 27 x 1/2"

INSULIN SYRINGE/0.5ML/28G -

insulin syringe/needle u-100 1/2

ml 28 x 1/2"

INSULIN SYRINGE/0.5ML/30G -

insulin syringe/needle u-100 1/2

ml 30 x 5/16"

INSULIN SYRINGE/0.5ML/31G -

insulin syringe/needle u-100 1/2

ml 31 x 5/16"

INSULIN SYRINGE/1ML/28G X -

insulin syringe/needle u-100 1 ml

28 x 1/2"

INSULIN SYRINGE/1ML/29G X -

insulin syringe/needle u-100 1 ml

29 x 1/2"

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 124

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

INSULIN SYRINGE/1ML/30G X -

insulin syringe/needle u-100 1 ml

30 x 5/16"

INSULIN SYRINGES 0.3ML/31 -

insulin syringe/needle u-100 0.3

ml 31 x 1/4" (6 mm)

INSULIN SYRINGES 0.5ML/31 -

insulin syringe/needle u-100 0.5

ml 31 x 1/4" (6 mm)

INSULIN SYRINGES/0.5ML/27 -

insulin syringe/needle u-100 1/2

ml 27 x 1/2"

INSULIN SYRINGES/0.5ML/28 -

insulin syringe/needle u-100 1/2

ml 28 x 1/2"

INSULIN SYRINGES/0.5ML/29 -

insulin syringe/needle u-100 1/2

ml 29 x 1/2"

INSULIN SYRINGES/0.5ML/30 -

insulin syringe/needle u-100 1/2

ml 30 x 5/16"

INSULIN SYRINGES/0.5ML/31 -

insulin syringe/needle u-100 1/2

ml 31 x 5/16"

INSULIN SYRINGES/1ML/27GX -

insulin syringe/needle u-100 1 ml

27 x 1/2"

INSULIN SYRINGES/1ML/28GX -

insulin syringe/needle u-100 1 ml

28 x 1/2"

INSULIN SYRINGES/1ML/29GX -

insulin syringe/needle u-100 1 ml

29 x 1/2"

INSULIN SYRINGES/1ML/30GX -

insulin syringe/needle u-100 1 ml

30 x 1/2"

INSULIN SYRINGES/1ML/31GX -

insulin syringe/needle u-100 1 ml

31 x 5/16"

INSUPEN PEN NEEDLES 32G X -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

INSUPEN SENSITIVE 32GX6MM -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64")

INSUPEN SENSITIVE 32GX8MM -

insulin pen needle 32 g x 8 mm

(1/3" or 5/16")

INSUPEN ULTRAFIN 30GX8MM -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

INSUPEN ULTRAFIN 31GX6MM -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

INSUPEN ULTRAFIN 31GX8MM -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

INSUPEN 29G X 12MM - insulin pen

needle 29 g x 12 mm (1/2")

INSUPEN 31G X 5MM - insulin pen

needle 31 g x 5 mm (1/5" or 3/16")

INSUPEN 31G X 8MM - insulin pen

needle 31 g x 8 mm (1/3" or 5/16")

INSUPEN 32G X 4MM - insulin pen

needle 32 g x 4 mm (1/6" or 5/32")

INSUPEN 33GX4MM - insulin pen

needle 33 g x 4 mm (1/6" or 5/32")

KINNEY LANCETS - lancets

KINNEY THIN LANCETS - lancets

KINRAY INSULIN SYRINGE PR -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1 ml 31 x

5/16", u-100 0.3 ml 31 x 5/16"

KINRAY INSULIN SYRINGE/0. -

insulin syringe/needle u-100 1/2

ml 29 x 1/2"

KMART VALU PLUS INSULIN S -

insulin syringe (disp) u-100 0.3 ml,

u-100 1/2 ml, u-100 1 ml

KROGER AUTOLET LANCING DE -

lancet devices

KROGER HEALTHPRO TWIST LA -

lancets

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 125

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

KROGER INSULIN SYRINGE/U- -

insulin syringe/needle u-100 0.3

ml 30 x 1/2"

KROGER INSULIN SYRINGE/0. -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 29 x 1/2", u-100 1/2

ml 30 x 5/16", u-100 0.3 ml 31 x

5/16"

KROGER INSULIN SYRINGE/1M -

insulin syringe/needle u-100 1 ml

29 x 1/2", u-100 1 ml 30 x 5/16",

u-100 1 ml 31 x 5/16"

KROGER LANCETS - lancets

KROGER LANCETS MICRO THIN -

lancets

KROGER LANCETS SUPER THIN -

lancets

KROGER LANCETS THIN - lancets

KROGER LANCETS THIN 26G -

lancets

KROGER LANCETS ULTRATHIN -

lancets

KROGER LANCETS 21G - lancets

KROGER LANCING DEVICE -

lancet devices

KROGER PEN NEEDLES 29G X -

insulin pen needle 29 g x 12 mm

(1/2")

KROGER PEN NEEDLES 31G X -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

KROGER PEN NEEDLES 31GX1/ -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

KROGER PEN NEEDLES/31G X -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

KROGER PEN NEEDLES/32G X -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

KROGER PEN NEEDLES/33G X -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

LANCET DEVICE ADJUSTABLE -

lancet devices

LANCET DEVICE WITH EJECTO -

lancet devices

LANCETS - lancets

LANCETS - BAYER ASCENCIA -

lancets

LANCETS MICRO THIN 33G -

lancets

LANCETS SUPER THIN 28G -

lancets

LANCETS THIN - lancets

LANCETS ULTRA THIN - lancets

LANCETS ULTRA THIN 30G -

lancets

LANCETS 30G - lancets

LANCETS 30G TWIST TOP -

lancets

LANCETS 30G/TWIST TOP -

lancets

LANCETS 33G EXTRA FINE -

lancets

LANCETS 33G UNIVERSAL DES -

lancets

LANCING DEVICE - lancet devices

LANZO - lancet devices

LEADER ADVANCED LANCING D -

lancet devices

LEADER INSULIN SYRINGE/0. -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 31 x 5/16",

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 126

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

u-100 1/2 ml 28 x 1/2", u-100 1/2

ml 29 x 1/2", u-100 1/2 ml 30 x

5/16", u-100 0.3 ml 31 x 5/16"

LEADER INSULIN SYRINGE/1M -

insulin syringe/needle u-100 1 ml

28 x 1/2", u-100 1 ml 29 x 1/2",

u-100 1 ml 30 x 5/16", u-100 1 ml

31 x 5/16"

LEADER LANCETS COLORED -

lancets

LEADER SUPER THIN LANCET -

lancets

LEADER THIN LANCETS - lancets

LEADER UNIFINE PENTIPS PL -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

LEADER UNIFINE PENTIPS/MI -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

LEADER UNIFINE PENTIPS/NA -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

LEADER UNIFINE PENTIPS/PL -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

LIBERTY MEDICAL LANCETS 3 -

lancets

LIBERTY MINI LANCING DEVI -

lancet devices

LIFESCAN UNISTIK II LANCE -

lancets

LIFESCAN UNISTIK 2 DEEP P -

lancets

LITE TOUCH LANCETS - lancets

LITE TOUCH LANCING PEN -

lancet devices

LITETOUCH INSULIN PEN NEE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

LITETOUCH INSULIN SYRINGE -

insulin syringe/needle u-100 0.3

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 28 x 1/2", u-100

1/2 ml 29 x 1/2", u-100 1/2 ml

30 x 5/16", u-100 1 ml 28 x 1/2",

u-100 1 ml 29 x 1/2", u-100 1 ml

30 x 5/16", u-100 1 ml 31 x 5/16",

u-100 0.3 ml 31 x 5/16"

LITETOUCH LANCETS MICRO T -

lancets

LITETOUCH PEN NEEDLES 29G -

insulin pen needle 29 g x 12.7 mm

(1/2")

LITETOUCH PEN NEEDLES 31G -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

LITETOUCH PEN NEEDLES/31 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

LITETOUCH PEN NEEDLES/31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

LIVE BETTER ADVANCED LANC -

lancet devices

LIVE BETTER LANCET SUPER -

lancets

LIVE BETTER LANCET ULTRA -

lancets

LIVE BETTER PEN NEEDLES 2 -

insulin pen needle 29 g x 12 mm

(1/2")

LIVE BETTER PEN NEEDLES 3 -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

LONGS INSULIN SYRINGE/0.5 -

insulin syringe/needle u-100 1/2

ml 31 x 5/16"

LONGS LANCETS STANDARD -

lancets

LONGS LANCETS THIN - lancets

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 127

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

LONGS LANCETS ULTRA THIN -

lancets

MAGELLAN INSULIN SAFETY

S - insulin syringe/needle u-100

0.3 ml 29 x 1/2", u-100 0.3 ml 30

x 5/16", u-100 1/2 ml 29 x 1/2",

u-100 1/2 ml 30 x 5/16", u-100 1

ml 29 x 1/2", u-100 1 ml 30 x 5/16"

MARATHON MEDICAL PENTIPS -

insulin pen needle 29 g x 12 mm

(1/2")

MARATHON MEDICAL PENTIPS -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

MARATHON MEDICAL PENTIPS -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

MAXI-COMFORT INSULIN SYRI -

insulin syringe/needle u-100 1/2

ml 28 x 1/2", u-100 1 ml 28 x 1/2"

MAXI-COMFORT SAFETY PEN N -

insulin pen needle 29 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

MAXICOMFORT II PEN NEEDLE -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

MAXICOMFORT INSULIN SYRIN -

insulin syringe/needle u-100 1/2

ml 27 x 1/2", u-100 1 ml 27 x 1/2"

MEDIC INSULIN SYRINGE/0.3 -

insulin syringe/needle u-100 0.3

ml 30 x 5/16"

MEDIC INSULIN SYRINGE/0.5 -

insulin syringe/needle u-100 1/2

ml 30 x 5/16"

MEDICHOICE PRE-SET SAFETY -

lancets

MEDICHOICE SAFETY LANCET -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MEDICINE SHOPPE LANCETS -

lancets

MEDICINE SHOPPE LANCETS T -

lancets

MEDICINE SHOPPE PEN NEEDL -

insulin pen needle 29 g x 12 mm

(1/2")

MEDICINE SHOPPE PEN NEEDL -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

MEDLANCE PLUS EXTRA LANCE -

lancets

MEDLANCE PLUS LANCETS -

lancets

MEDLANCE PLUS LANCETS LIT -

lancets

MEDLANCE PLUS LITE LANCET -

lancets

MEDLANCE PLUS SPECIAL LAN -

lancets

MEDLANCE PLUS SUPERLITE 3 -

lancets

MEDLANCE PLUS UNIVERSAL L -

lancets

MEDLANCE PLUS/LITE 25G -

lancets

MEDLANCE/EXTRA - lancets

MEDLANCE/LITE - lancets

MEDLANCE/UNIVERSAL - lancets

MEIJER COLOR LANCETS UNIV -

lancets

MEIJER LANCETS - lancets

MEIJER LANCETS THIN - lancets

MEIJER LANCETS UNIVERSAL -

lancets

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 128

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MEIJER PEN NEEDLES 29G X -

insulin pen needle 29 g x 12 mm

(1/2")

MEIJER PEN NEEDLES 31G X -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

MEIJER SUPER THIN LANCETS -

lancets

MICRODOT PEN NEEDLE/31G X -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

MICRODOT PEN NEEDLE/32G X -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

MICRODOT PEN NEEDLE/33G X -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

MICROLET LANCETS - lancets

MICROLET NEXT - lancet devices

MINI LANCING DEVICE - lancet

devices

MM INSULIN SYRINGE/U-100/ -

insulin syringe/needle u-100 0.3

ml 30 x 5/16", u-100 1/2 ml 31 x

5/16", u-100 1/2 ml 30 x 5/16",

u-100 1 ml 30 x 5/16", u-100 1 ml

31 x 5/16", u-100 0.3 ml 31 x 5/16"

MM LANCING DEVICE - lancet

devices

MM PEN NEEDLES 31G X 1/4" -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

MM PEN NEEDLES 31G X 3/16 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

MM PEN NEEDLES 31G X 5/16 -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

MM PEN NEEDLES 32G X 5/32 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

MM TWIST LANCETS - lancets

MONOJECT INSULIN SYRINGE -

insulin syringe (disp) u-100 1 ml

MONOJECT INSULIN SYRINGE/ -

insulin syringe (disp) u-100 1 ml

MONOJECT INSULIN SYRINGE/ -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 28 x 1/2",

u-100 1/2 ml 29 x 1/2", u-100 1/2

ml 30 x 5/16", u-100 1 ml 25 x

5/8", u-100 1 ml 27 x 1/2", u-100 1

ml 28 x 1/2", u-100 1 ml 29 x 1/2",

u-100 1 ml 30 x 5/16", u-100 1 ml

31 x 5/16"

MONOJECT ULTRA COMFORT

IN - insulin syringe/needle u-100

0.3 ml 29 x 1/2", u-100 0.3 ml 30

x 5/16", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 28 x 1/2", u-100 1/2

ml 29 x 1/2", u-100 1/2 ml 30 x

5/16", u-100 1 ml 28 x 1/2", u-100

1 ml 29 x 1/2", u-100 0.3 ml 31 x

5/16"

MONOLET LANCETS - lancets

MONOLET OPD LANCETS - lancets

MONOLETTOR SAFETY

LANCETS - lancets

MPD SAFETY LANCET 21G/1.8 -

lancets

MPD SAFETY LANCET 28G/1.8 -

lancets

MPD SAFETY LANCET 30G/1.8 -

lancets

MPD SAFETY LANCETS 23G/1. -

lancets

MS INSULIN SYRINGE/0.3ML/ -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 0.3 ml 31 x 5/16"

MS INSULIN SYRINGE/0.5ML/ -

insulin syringe/needle u-100 1/2

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 129

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 31 x 5/16", u-100 1/2 ml 29 x

1/2", u-100 1/2 ml 30 x 5/16"

MS INSULIN SYRINGE/1ML/29 -

insulin syringe/needle u-100 1 ml

29 x 1/2"

MS INSULIN SYRINGE/1ML/30 -

insulin syringe/needle u-100 1 ml

30 x 5/16"

MS INSULIN SYRINGE/1ML/31 -

insulin syringe/needle u-100 1 ml

31 x 5/16"

MULTI-LANCET DEVICE - lancet

devices

MYGLUCOHEALTH MGH

SOFTLAN - lancets

NORDIPEN 5 INJECTION DEVI -

injection device - misc

NOVA SAFETY LANCETS 23G -

lancets

NOVA SAFETY LANCETS 28G -

lancets

NOVA SUREFLEX LANCETS -

lancets

NOVA SUREFLEX LANCING DEV -

lancet devices

NOVOFINE AUTOCOVER PEN NE -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

NOVOFINE PEN NEEDLE 32G X -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64")

NOVOFINE PLUS PEN NEEDLE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

NOVOPEN ECHO - injection device

for insulin

OMNIFLEX DIAPHRAGM -

diaphragms

•

OMNIPOD 5 G6 INTRO KIT (G -

insulin infusion disposable pump

kit

• •

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

OMNIPOD 5 G6 PODS (GEN 5) -

insulin infusion disposable pump

supplies

• •

OMNITROPE PEN 5 INJECTION -

injection device - misc

ONETOUCH CLUB LANCETS FIN -

lancets

ONETOUCH DELICA LANCETS E -

lancets

ONETOUCH DELICA LANCETS F -

lancets

ONETOUCH DELICA LANCING D -

lancet devices

ONETOUCH DELICA PLUS LANC -

lancet devices

ONETOUCH DELICA PLUS LANC -

lancets

ONETOUCH DELICA SAFETY LA -

lancet devices

ONETOUCH FINEPOINT LANCET -

lancets

ONETOUCH LANCETS - lancets

ONETOUCH SURESOFT

LANCING - lancets misc.

ONETOUCH ULTRA CONTROL -

blood glucose calibration - liquid

ONETOUCH ULTRA MINI - blood

glucose monitoring kit w/ device

•

ONETOUCH ULTRA 2 - blood

glucose monitoring kit w/ device

•

ONETOUCH ULTRASOFT

LANCET - lancets

ONETOUCH VERIO - blood glucose

monitoring kit w/ device

•

ONETOUCH VERIO CONTROL

SO - blood glucose calibration -

liquid - high

ONETOUCH VERIO FLEX BLOOD -

blood glucose monitoring kit w/

device

•

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 130

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ONETOUCH VERIO IQ BLOOD G -

blood glucose monitoring kit w/

device

•

ONETOUCH VERIO MID CONTRO -

blood glucose calibration - liquid

ONETOUCH VERIO REFLECT -

blood glucose monitoring kit w/

device

•

PC LANCETS SUPER THIN 30G -

lancets

PC UNIFINE PENTIPS 29G X -

insulin pen needle 29 g x 12 mm

(1/2")

PC UNIFINE PENTIPS 31G X -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

PEN NEEDLES 29GX12MM - insulin

pen needle 29 g x 12 mm (1/2")

PEN NEEDLES 30GX5MM - insulin

pen needle 30 g x 5 mm (1/5" or

3/16")

PEN NEEDLES 30GX8MM - insulin

pen needle 30 g x 8 mm (1/3" or

5/16")

PEN NEEDLES 31G X 3/16" - insulin

pen needle 31 g x 5 mm (1/5" or

3/16")

PEN NEEDLES 31G X 5MM - insulin

pen needle 31 g x 5 mm (1/5" or

3/16")

PEN NEEDLES 31G X 6MM - insulin

pen needle 31 g x 6 mm (1/4" or

15/64")

PEN NEEDLES 31G X 8MM - insulin

pen needle 31 g x 8 mm (1/3" or

5/16")

PEN NEEDLES 31GX5/16" - insulin

pen needle 31 g x 8 mm (1/3" or

5/16")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PEN NEEDLES 31GX6MM (1/4" -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

PEN NEEDLES 31GX8MM - insulin

pen needle 31 g x 8 mm (1/3" or

5/16")

PEN NEEDLES 31GX8MM (5/16 -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

PEN NEEDLES 32G X 4MM - insulin

pen needle 32 g x 4 mm (1/6" or

5/32")

PEN NEEDLES 32G X 5MM - insulin

pen needle 32 g x 5 mm (1/5" or

3/16")

PEN NEEDLES 32G X 6MM - insulin

pen needle 32 g x 6 mm (1/4" or

15/64")

PEN NEEDLES 32GX4MM - insulin

pen needle 32 g x 4 mm (1/6" or

5/32")

PEN NEEDLES 33G X 5/32" - insulin

pen needle 33 g x 4 mm (1/6" or

5/32")

PEN NEEDLES/29G X 1/2" - insulin

pen needle 29 g x 12 mm (1/2")

PEN NEEDLES/31G X 1/4" - insulin

pen needle 31 g x 6 mm (1/4" or

15/64")

PEN NEEDLES/31G X 3/16" - insulin

pen needle 31 g x 5 mm (1/5" or

3/16")

PEN NEEDLES/31G X 5/16" - insulin

pen needle 31 g x 8 mm (1/3" or

5/16")

PEN NEEDLES/31G X 6MM - insulin

pen needle 31 g x 6 mm (1/4" or

15/64")

PEN NEEDLES/32G X 5/32" - insulin

pen needle 32 g x 4 mm (1/6" or

5/32")

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 131

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PENTIPS 29G X 12MM - insulin pen

needle 29 g x 12 mm (1/2")

PENTIPS 29GX12MM - insulin pen

needle 29 g x 12 mm (1/2")

PENTIPS 31G X 5MM - insulin pen

needle 31 g x 5 mm (1/5" or 3/16")

PENTIPS 31G X 8MM - insulin pen

needle 31 g x 8 mm (1/3" or 5/16")

PENTIPS 31GX5MM - insulin pen

needle 31 g x 5 mm (1/5" or 3/16")

PENTIPS 31GX6MM - insulin pen

needle 31 g x 6 mm (1/4" or

15/64")

PENTIPS 31GX8MM - insulin pen

needle 31 g x 8 mm (1/3" or 5/16")

PENTIPS 32G X 4MM - insulin pen

needle 32 g x 4 mm (1/6" or 5/32")

PENTIPS 32GX4MM - insulin pen

needle 32 g x 4 mm (1/6" or 5/32")

PENTIPS 32GX6MM - insulin pen

needle 32 g x 6 mm (1/4" or

15/64")

PERFECT LANCETS 30G - lancets

PERFECT PRESSURE ACTIVATE -

lancets

PHARMACIST CHOICE ULTRA T -

lancets

PHARMACY COUNTER LANCETS -

lancets

PIP LANCETS/28G - lancets

PIP LANCETS/30G - lancets

PRECISION SURE-DOSE INSUL -

insulin syringe/needle u-100 0.3

ml 30 x 5/16"

PRECISION THINS GP LANCET -

lancets

PREFERRED PLUS INSULIN SY -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 28 x 1/2",

u-100 1/2 ml 29 x 1/2", u-100 1/2

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 30 x 5/16", u-100 1 ml 28 x

1/2", u-100 1 ml 29 x 1/2", u-100 1

ml 30 x 5/16"

PREFERRED PLUS LANCETS CO -

lancets

PREFERRED PLUS LANCETS SU -

lancets

PREFERRED PLUS LANCETS TH -

lancets

PREFERRED PLUS UNIFINE PE -

insulin pen needle 29 g x 12 mm

(1/2")

PREFERRED PLUS UNIFINE PE -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

PREFERRED PLUS UNIFINE PE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

PREVENT DROPSAFE SAFETY P -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

PREVENT SAFETY PEN NEEDLE -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

PRO COMFORT INSULIN SYRIN -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1/2 ml 30

x 5/16", u-100 1/2 ml 30 x 1/2",

u-100 1 ml 30 x 5/16", u-100 1 ml

30 x 1/2", u-100 1 ml 31 x 5/16"

PRO COMFORT LANCETS 30G -

lancets

PRO COMFORT LANCETS 31G -

lancets

PRO COMFORT PEN NEEDLES/ -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

PRO COMFORT PEN NEEDLES/ -

insulin pen needle 32 g x 4 mm

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 132

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64")

PRODIGY INSULIN SYRING/U- -

insulin syringe/needle u-100 0.3

ml 31 x 5/16"

PRODIGY INSULIN SYRINGE/1 -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1 ml 28 x 1/2"

PRODIGY LANCING DEVICE -

lancet devices

PRODIGY PRESSURE ACTIVATE -

lancets

PRODIGY SAFETY LANCETS -

lancets

PRODIGY TWIST TOP LANCETS -

lancets

PSS SELECT GP LANCETS -

lancets

PSS SELECT SAFETY LANCETS -

lancets

PURE COMFORT LANCETS 30G -

lancets

PURE COMFORT PEN NEEDLE 3 -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

PURE COMFORT PEN NEEDLE/3 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16")

PX ADVANCED LANCING DEVIC -

lancet devices

PX EXTRA SHORT PEN NEEDLE -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

PX INSULIN SYRINGE/U-100/ -

insulin syringe/needle u-100 1/2

ml 30 x 1/2"

PX LANCET AUTO INJECTOR -

lancet devices

PX LANCETS MICROTHIN 33G -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

PX LANCETS ULTRA THIN - lancets

PX LANCETS ULTRA THIN 28G -

lancets

PX MINI PEN NEEDLES 31GX5 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

PX PEN NEEDLE 29GX12MM -

insulin pen needle 29 g x 12 mm

(1/2")

PX PEN NEEDLE 31GX8MM -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

PX SHORTLENGTH PEN NEEDLE -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

QC ADVANCED LANCING DEVIC -

lancet devices

QC INSULIN SYRINGE/0.3ML/ -

insulin syringe/needle u-100 0.3

ml 29 x 1/2"

QC INSULIN SYRINGE/0.5ML/ -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1/2 ml 29 x

1/2"

QC INSULIN SYRINGE/1ML/29 -

insulin syringe/needle u-100 1 ml

29 x 1/2"

QC INSULIN SYRINGE/1ML/31 -

insulin syringe/needle u-100 1 ml

31 x 5/16"

QC LANCETS SUPER THIN -

lancets

QC LANCETS ULTRA THIN -

lancets

QC PEN NEEDLES 29G X 12MM -

insulin pen needle 29 g x 12 mm

(1/2")

QC PEN NEEDLES 31G X 6MM -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 133

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

QC PEN NEEDLES 31G X 8MM -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

QC UNIFINE PENTIPS 32GX4M -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

QC UNILET LANCETS 28G/ULT -

lancets

QC UNILET LANCETS 33G/MIC -

lancets

RA E-ZJECT LANCETS THIN 2 -

lancets

RA E-ZJECT LANCETS ULTRA -

lancets

RA E-ZJECT LANCETS 28G -

lancets

RA INSULIN SYRINGE/U-100/ -

insulin syringe/needle u-100 1/2

ml 30 x 5/16", u-100 1 ml 30 x

5/16"

RA INSULIN SYRINGE/0.5ML/ -

insulin syringe/needle u-100 1/2

ml 29 x 1/2"

RA INSULIN SYRINGE/1ML/29 -

insulin syringe/needle u-100 1 ml

29 x 1/2"

RA PEN NEEDLES 31G X 5MM -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

RA PEN NEEDLES 31G X 8MM -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

READYLANCE SAFETY LANCETS -

lancets

REALITY INSULIN SYRINGE/U -

insulin syringe/needle u-100 1/2

ml 28 x 1/2", u-100 1/2 ml 29 x

1/2", u-100 1 ml 28 x 1/2", u-100 1

ml 29 x 1/2"

REALITY LANCETS - lancets

REALITY TRIGGER LANCETS -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

RELION INSULIN SYRINGE 0. -

insulin syringe/needle u-100 1/2

ml 31 x 15/64"

RELION INSULIN SYRINGE 1M -

insulin syringe/needle u-100 1 ml

31 x 15/64"

RELION INSULIN SYRINGE/U- -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 1/2 ml 31 x

5/16", u-100 1/2 ml 29 x 1/2",

u-100 0.3 ml 31 x 15/64", u-100

1 ml 29 x 1/2", u-100 1 ml 31 x

5/16", u-100 0.3 ml 31 x 5/16",

u-100 1 ml 31 x 15/64"

RELION LANCETS - lancets

RELION LANCETS MICRO-THIN -

lancets

RELION LANCETS THIN 26G -

lancets

RELION LANCETS ULTRA-THIN -

lancets

RELION LANCING DEVICE - lancet

devices

RELION MINI PEN NEEDLES 3 -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

RELION PEN NEEDLES 29GX12 -

insulin pen needle 29 g x 12 mm

(1/2")

RELION PEN NEEDLES 31G X -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

RELION PEN NEEDLES 31GX5/ -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

RELION PEN NEEDLES 31GX6M -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

RELION PEN NEEDLES 31GX8M -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 134

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

RELION PEN NEEDLES 32G X -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

RELION PEN NEEDLES 32GX4M -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

RELION PEN NEEDLES/31G X -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

RELION SHORT PEN NEEDLES -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

RELION THIN LANCETS - lancets

RELION ULTRA THIN LANCETS -

lancets

RELION ULTRA THIN PLUS LA -

lancets

RELION 2-IN-1 LANCET DEV -

lancet devices

RELION 2-IN-1 LANCING DEV -

lancet devices

REXALL LANCETS ULTRA THIN -

lancets

RIGHTEST GD500 LANCING DE -

lancet devices

RIGHTEST GL300 LANCETS -

lancets

SAFE-T-LANCE LOW FLOW 25G -

lancets

SAFE-T-LANCE NORMAL FLOW -

lancets

SAFE-T-LANCE PLUS SAFETY -

lancets

SAFETY LANCET 30G/PRESSUR -

lancets

SAFETY LANCETS - lancets

SAFETY LANCETS 21G - lancets

SAFETY LANCETS 28G - lancets

SAFETY PEN NEEDLES/30G X -

insulin pen needle 30 g x 5 mm

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

SAPS HEALTH CARE TWIST TO -

lancets

SAPS HEALTH TWIST TOP LAN -

lancets

SAPSCARE TWIST TOP LANCET -

lancets

SB INSULIN SYRINGE/U-100/ -

insulin syringe/needle u-100 1/2

ml 29 x 1/2", u-100 1/2 ml 30 x

5/16", u-100 1 ml 29 x 1/2", u-100

1 ml 30 x 5/16", u-100 1 ml 31 x

5/16"

SB LANCETS THIN - lancets

SB LANCETS ULTRA THIN - lancets

SCHNUCKS INSULIN SYRINGE -

insulin syringe/needle u-100 1/2

ml 29 x 1/2", u-100 1/2 ml 30 x

5/16"

SECURESAFE SAFETY INSULIN -

insulin syringe/needle u-100 1/2

ml 29 x 1/2", u-100 1 ml 29 x 1/2"

SECURESAFE SAFETY PEN NEE -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

SELECT-LITE LANCING DEVIC -

lancet devices

SHOPKO AUTOLET LANCING DE -

lancet devices

SHOPKO ON-THE-GO COMFORT -

lancets

SHOPKO UNIFINE PENTIPS PE -

insulin pen needle 29 g x 12 mm

(1/2")

SHOPKO UNIFINE PENTIPS PE -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

SHOPKO UNIFINE PENTIPS PE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 135

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SHOPKO UNIFINE PENTIPS PL -

insulin pen needle 29 g x 12 mm

(1/2")

SHOPKO UNIFINE PENTIPS PL -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

SHOPKO UNIFINE PENTIPS PL -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

SHOPKO UNILET LANCETS SUP -

lancets

SHOPKO UNILET LANCETS ULT -

lancets

SIMPLE DIAGNOSTICS LANCIN -

lancet devices

SINGLE-LET - lancets

SM MICRO THIN LANCETS 33G -

lancets

SM TRUEDRAW LANCING DEVIC -

lancet devices

SMART DIABETES VANTAGE LA -

lancet devices

SMART SENSE COLOR LANCETS -

lancets

SMART SENSE STANDARD LANC -

lancets

SMART SENSE SUPER THIN LA -

lancets

SMART SENSE THIN LANCETS -

lancets

SMARTEST LANCETS 28G -

lancets

SOLUS V2 LANCING DEVICE -

lancet devices

SOLUS V2 PRESSURE ACTIVAT -

lancets

SOLUS V2 TWIST LANCETS 30 -

lancets

STERILANCE TL - lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SUPER THIN LANCETS - lancets

SURE COMFORT AUTOKEEPER

S - insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

SURE COMFORT AUTOKEEPER

S - insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

SURE COMFORT INSULIN SYRI -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 0.3 ml 30 x 1/2",

u-100 1/2 ml 31 x 5/16", u-100

1/2 ml 28 x 1/2", u-100 1/2 ml 29

x 1/2", u-100 1/2 ml 30 x 5/16",

u-100 1/2 ml 30 x 1/2", u-100 0.3

ml 31 x 1/4" (6 mm), u-100 0.5 ml

31 x 1/4" (6 mm), u-100 1 ml 31 x

1/4" (6 mm), u-100 1 ml 28 x 1/2",

u-100 1 ml 29 x 1/2", u-100 1 ml

30 x 5/16", u-100 1 ml 30 x 1/2",

u-100 1 ml 31 x 5/16", u-100 0.3

ml 31 x 5/16"

SURE COMFORT LANCETS 18G -

lancets

SURE COMFORT LANCETS 21G -

lancets

SURE COMFORT LANCETS 23G -

lancets

SURE COMFORT LANCETS 28G -

lancets

SURE COMFORT LANCETS 30G -

lancets

SURE COMFORT LANCING PEN -

lancet devices

SURE COMFORT PEN NEEDLES -

insulin pen needle 29 g x 12.7 mm

(1/2")

SURE COMFORT PEN NEEDLES -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

SURE COMFORT PEN NEEDLES -

insulin pen needle 31 g x 5 mm

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 136

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

SURE COMFORT PEN NEEDLES -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 6 mm (1/4" or

15/64")

SURELITE LANCETS - lancets

TECHLITE AST LANCETS - lancets

TECHLITE INSULIN SYRINGE -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 29 x 1/2", u-100 1/2

ml 30 x 5/16", u-100 1/2 ml 30 x

1/2", u-100 0.3 ml 31 x 15/64",

u-100 1 ml 29 x 1/2", u-100 1 ml

30 x 1/2", u-100 1 ml 31 x 5/16",

u-100 0.3 ml 31 x 5/16", u-100 1/2

ml 31 x 15/64", u-100 1 ml 31 x

15/64"

TECHLITE LANCETS - lancets

TECHLITE LANCETS 30G - lancets

TECHLITE PEN NEEDLES 29G -

insulin pen needle 29 g x 10 mm,

x 12 mm (1/2")

TECHLITE PEN NEEDLES 31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

TECHLITE PEN NEEDLES/31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

TECHLITE PEN NEEDLES/32G -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

TGT ADVANCED LANCING DEVI -

lancet devices

TGT LANCET ALTERNATE SITE -

lancets

TGT LANCET MICRO THIN 33G -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

TGT LANCET SUPER THIN 30G -

lancets

TGT LANCET THIN 23G - lancets

TGT LANCET THIN 26G - lancets

TGT LANCET ULTRA THIN 28G -

lancets

TGT LANCET ULTRA THIN 30G -

lancets

TGT LANCING DEVICE - lancet

devices

THINLETS GP LANCETS - lancets

TODAYS HEALTH ADVANCED LA -

lancet devices

TODAYS HEALTH MINI PEN NE -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

TODAYS HEALTH ORIGINAL PE -

insulin pen needle 29 g x 12 mm

(1/2")

TODAYS HEALTH SHORT PEN N -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

TODAYS HEALTH SUPER THIN -

lancets

TODAYS HEALTH ULTRA THIN -

lancets

TOPCARE CLICKFINE UNIVERS -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

TOPCARE LANCETS MICRO-THI -

lancets

TOPCARE ULTRA COMFORT INS -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 29 x 1/2", u-100 1/2

ml 30 x 5/16", u-100 1 ml 29 x

1/2", u-100 1 ml 30 x 5/16", u-100

1 ml 31 x 5/16", u-100 0.3 ml 31 x

5/16"

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 137

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

TRAVEL LANCETS ADVANCED 2 -

lancets

TRAVEL LANCETS 30G - lancets

TRUE COMFORT INSULIN SYRI -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1 ml 31 x

5/16"

TRUE COMFORT PEN NEEDLES -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64")

TRUE COMFORT PEN NEEDLES -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

TRUE COMFORT PRO INSULIN -

insulin syringe/needle u-100 1/2

ml 31 x 5/16", u-100 1/2 ml 30

x 5/16", u-100 1/2 ml 30 x 1/2",

u-100 0.5 ml 32 x 5/16", u-100

1 ml 32 x 5/16", u-100 1 ml 30 x

5/16", u-100 1 ml 30 x 1/2", u-100

1 ml 31 x 5/16"

TRUE COMFORT PRO PEN NEED -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

TRUE COMFORT PRO PEN NEED -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64")

TRUE COMFORT PRO PEN NEED -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64")

TRUE COMFORT TWIST TOP LA -

lancets

TRUEDRAW LANCING DEVICE -

lancet devices

TRUEPLUS INSULIN SYRINGE -

insulin syringe/needle u-100 1 ml

29 x 1/2"

TRUEPLUS INSULIN SYRINGE/ -

insulin syringe/needle u-100 0.3

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 31 x 5/16",

u-100 1/2 ml 28 x 1/2", u-100 1/2

ml 29 x 1/2", u-100 1/2 ml 30 x

5/16", u-100 1 ml 28 x 1/2", u-100

1 ml 30 x 5/16", u-100 1 ml 31 x

5/16", u-100 0.3 ml 31 x 5/16"

TRUEPLUS LANCETS 26G - lancets

TRUEPLUS LANCETS 28G - lancets

TRUEPLUS LANCETS 28G SUPE -

lancets

TRUEPLUS LANCETS 30G - lancets

TRUEPLUS LANCETS 30G ULTR -

lancets

TRUEPLUS LANCETS 33G - lancets

TRUEPLUS LANCETS 33G MICR -

lancets

TRUEPLUS PEN NEEDLES 31GX -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

TRUEPLUS PEN NEEDLES 32GX -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

TRUEPLUS SAFETY LANCETS 2 -

lancets

TRUEPLUS 5-BEVEL PEN NEED -

insulin pen needle 29 g x 12.7 mm

(1/2")

TRUEPLUS 5-BEVEL PEN NEED -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

TRUEPLUS 5-BEVEL PEN NEED -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

ULTI-LANCE AUTOMATIC/ CLE -

lancet devices

ULTICARE INSULIN SAFETY S -

insulin syringe/needle u-100 1/2

ml 29 x 1/2", u-100 1 ml 29 x 1/2"

ULTICARE INSULIN SYRINGE -

insulin syringe/needle u-100 1/2

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 138

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 31 x 5/16", u-100 1 ml 31 x

5/16", u-100 0.3 ml 31 x 5/16"

ULTICARE INSULIN SYRINGE/ -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 0.3 ml 30 x 1/2",

u-100 1/2 ml 31 x 5/16", u-100

1/2 ml 28 x 1/2", u-100 1/2 ml 29

x 1/2", u-100 1/2 ml 30 x 5/16",

u-100 1/2 ml 30 x 1/2", u-100 1

ml 28 x 1/2", u-100 1 ml 29 x 1/2",

u-100 1 ml 30 x 5/16", u-100 1 ml

30 x 1/2", u-100 1 ml 31 x 5/16",

u-100 0.3 ml 31 x 5/16"

ULTICARE MICRO PEN NEEDLE -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

ULTICARE MICRO PEN NEEDLE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

ULTICARE MINI PEN NEEDLES -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

ULTICARE MINI PEN NEEDLES -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64")

ULTICARE MINI SAFETY PEN -

insulin pen needle 30 g x 5 mm

(1/5" or 3/16")

ULTICARE ORIGINAL PEN NEE -

insulin pen needle 29 g x 12.7 mm

(1/2")

ULTICARE PEN NEEDLES 31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

ULTICARE PEN NEEDLES/29G -

insulin pen needle 29 g x 12.7 mm

(1/2")

ULTICARE SHORT PEN NEEDLE -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ULTICARE SHORT SAFETY PEN -

insulin pen needle 30 g x 8 mm

(1/3" or 5/16")

ULTICARE U-100 INSULIN SY -

insulin syringe/needle u-100 0.3

ml 31 x 1/4" (6 mm), u-100 0.5 ml

31 x 1/4" (6 mm), u-100 1 ml 31 x

1/4" (6 mm)

ULTIGUARD INSULIN SYRINGE -

insulin syringe/needle u-100 0.3

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 1/2 ml 29 x 1/2",

u-100 1/2 ml 30 x 5/16", u-100 1

ml 29 x 1/2", u-100 1 ml 30 x 5/16"

ULTIGUARD SAFEPACK INSULI -

insulin syringe/needle u-100 0.3

ml 30 x 1/2", u-100 1/2 ml 30 x

1/2", u-100 1 ml 30 x 1/2", u-100

1 ml 31 x 5/16", u-100 0.3 ml 31 x

5/16"

ULTIGUARD SAFEPACK MINI P -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

ULTIGUARD SAFEPACK PEN NE -

insulin pen needle 29 g x 12.7 mm

(1/2")

ULTIGUARD SAFEPACK/MICRO -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

ULTIGUARD SAFEPACK/MINI P -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64")

ULTIGUARD SAFEPACK/MINI P -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64")

ULTIGUARD SAFEPACK/SHORT -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

ULTIGUARD SAFEPACK/SYRING -

insulin syringe/needle u-100 1/2

ml 31 x 5/16"

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Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ULTILET CLASSIC LANCETS -

lancets

ULTILET LANCETS - lancets

ULTILET LANCETS 33G - lancets

ULTILET PEN NEEDLE 29GX12 -

insulin pen needle 29 g x 12.7 mm

(1/2")

ULTILET PEN NEEDLE 31GX5M -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

ULTILET PEN NEEDLE 31GX8M -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

ULTILET PEN NEEDLE 32GX4M -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

ULTILET SAFETY LANCETS 21 -

lancets

ULTILET SAFETY LANCETS 23 -

lancets

ULTILET SHORT PEN NEEDLES -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

ULTRA COMFORT INSULIN SYR -

insulin syringe/needle u-100 0.3

ml 30 x 5/16"

ULTRA FLO INSULIN PEN NEE -

insulin pen needle 29 g x 12 mm

(1/2")

ULTRA FLO INSULIN PEN NEE -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

ULTRA FLO INSULIN PEN NEE -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

ULTRA FLO INSULIN PEN NEE -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

ULTRA FLO INSULIN SYRINGE -

insulin syringe/needle u-100 0.3

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 29 x 1/2", u-100 0.3 ml 30 x

5/16", u-100 0.3 ml 30 x 1/2",

u-100 1/2 ml 31 x 5/16", u-100

1/2 ml 29 x 1/2", u-100 1/2 ml 30

x 5/16", u-100 1/2 ml 30 x 1/2",

u-100 1 ml 29 x 1/2", u-100 1 ml

30 x 5/16", u-100 1 ml 30 x 1/2",

u-100 1 ml 31 x 5/16", u-100 0.3

ml 31 x 5/16"

ULTRA INSULIN SYRINGE/U-1 -

insulin syringe/needle u-100 1/2

ml 29 x 1/2"

ULTRA THIN LANCETS 28G -

lancets

ULTRA THIN LANCETS 31G -

lancets

ULTRA THIN PEN NEEDLES 32 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

ULTRA-CARE LANCETS 30G -

lancets

ULTRA-THIN II AUTO LANCET -

lancets

ULTRA-THIN II INSULIN SYR -

insulin syringe/needle u-100 0.3

ml 30 x 5/16", u-100 1/2 ml 31

x 5/16", u-100 1/2 ml 29 x 1/2",

u-100 1/2 ml 30 x 5/16", u-100

1 ml 29 x 1/2", u-100 1 ml 30

x 5/16", u-100 1 ml 31 x 5/16",

u-100 0.3 ml 31 x 5/16"

ULTRA-THIN II LANCETS 28G -

lancets

ULTRA-THIN II LANCETS 30G -

lancets

ULTRA-THIN II MINI PEN NE -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

ULTRA-THIN II PEN NEEDLES -

insulin pen needle 29 g x 12.7 mm

(1/2")

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 140

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ULTRA-THIN II PEN NEEDLES -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

ULTRACARE INSULIN SYRINGE -

insulin syringe/needle u-100 0.3

ml 30 x 5/16", u-100 1/2 ml 31 x

5/16", u-100 1/2 ml 30 x 5/16",

u-100 1/2 ml 30 x 1/2", u-100 1 ml

30 x 5/16", u-100 1 ml 30 x 1/2",

u-100 1 ml 31 x 5/16", u-100 0.3

ml 31 x 5/16"

ULTRACARE PEN NEEDLES/31G -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

ULTRACARE PEN NEEDLES/32G -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 5 mm (1/5" or

3/16"), x 6 mm (1/4" or 15/64")

ULTRACARE PEN NEEDLES/33G -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

UNIFINE PEN NEEDLE/32G X -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

UNIFINE PENTIPS PLUS 29GX -

insulin pen needle 29 g x 12 mm

(1/2")

UNIFINE PENTIPS PLUS 31GX -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

UNIFINE PENTIPS PLUS 32GX -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

UNIFINE PENTIPS PLUS 33G -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

UNIFINE PENTIPS PLUS 33GX -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

UNIFINE PENTIPS PLUS/30G -

insulin pen needle 30 g x 5 mm

(1/5" or 3/16")

UNIFINE PENTIPS 29GX12MM -

insulin pen needle 29 g x 12 mm

(1/2")

UNIFINE PENTIPS 31G X 3/1 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

UNIFINE PENTIPS 31G X 6MM -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

UNIFINE PENTIPS 31G X 8MM -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

UNIFINE PENTIPS 31GX5MM -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

UNIFINE PENTIPS 31GX6MM -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

UNIFINE PENTIPS 31GX8MM -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

UNIFINE PENTIPS 32GX4MM -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

UNIFINE PENTIPS 32GX6MM -

insulin pen needle 32 g x 6 mm

(1/4" or 15/64")

UNIFINE PENTIPS 33GX4MM -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

UNIFINE PENTIPS/30G X 3/1 -

insulin pen needle 30 g x 5 mm

(1/5" or 3/16")

UNIFINE SAFECONTROL PEN N -

insulin pen needle 30 g x 5 mm

(1/5" or 3/16"), x 8 mm (1/3" or

5/16")

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 141

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

UNIFINE SAFECONTROL PEN N -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

UNIFINE ULTRA PEN NEEDLE/ -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

UNIFINE ULTRA PEN NEEDLE/ -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

UNILET COMFORTOUCH

LANCET - lancets

UNILET EXCELITE - lancets

UNILET EXCELITE II - lancets

UNILET G.P. LANCET - lancets

UNILET G.P. SUPERLITE LAN -

lancets

UNILET GP 28 ULTRA THIN -

lancets

UNILET LANCET - lancets

UNILET LANCETS MICRO-THIN -

lancets

UNILET LANCETS SUPER-THIN -

lancets

UNILET LANCETS ULTRA-THIN -

lancets

UNILET SUPERLITE LANCET -

lancets

UNISTIK PRO SAFETY LANCET -

lancets

UNISTIK SAFETY LANCETS 28 -

lancets

UNISTIK SAFETY LANCETS 30 -

lancets

UNISTIK TOUCH SAFETY LANC -

lancets

UNISTIK 3 GENTLE - lancets

UNIVERSAL 1 LANCETS THIN -

lancets

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

UNIVERSAL 1 LANCETS ULTRA -

lancets

UNIVERSAL 1 LANCETS/33G/M -

lancets

VALUE HEALTH INSULIN SYRI -

insulin syringe/needle u-100 1/2

ml 29 x 1/2", u-100 1 ml 29 x 1/2"

VALUE PLUS LANCETS STANDA -

lancets

VALUE PLUS LANCETS SUPER -

lancets

VALUE PLUS LANCETS THIN 2 -

lancets

VALUE PLUS LANCING DEVICE -

lancet devices

VALUMARK LANCET SUPER THI -

lancets

VALUMARK LANCET ULTRA THI -

lancets

VALUMARK PEN NEEDLES 29GX -

insulin pen needle 29 g x 12 mm

(1/2")

VALUMARK PEN NEEDLES 31G -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64"), x 8 mm (1/3" or

5/16")

VANISHPOINT INSULIN SYRIN -

insulin syringe/needle u-100 1/2

ml 30 x 5/16", u-100 1/2 ml 30

x 1/2", u-100 1 ml 30 x 3/16" (5

mm), u-100 0.5 ml 30 x 3/16" (5

mm), u-100 1 ml 29 x 1/2", u-100

1 ml 29 x 5/16", u-100 1 ml 30 x

5/16"

VIDA MIA AUTOLET LANCING -

lancet devices

VIDA MIA UNIFINE PENTIPS -

insulin pen needle 29 g x 12 mm

(1/2")

VIDA MIA UNIFINE PENTIPS -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 142

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

VIDA MIA UNIFINE PENTIPS -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

VIDA MIA UNILET LANCETS S -

lancets

VIDA MIA UNILET LANCETS U -

lancets

VIDA MIA UNIPFINE PENTIPS -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

VIVAGUARD LANCETS - lancets

VIVAGUARD LANCING DEVICE -

lancet devices

VIVAGUARD SAFETY LANCETS/ -

lancets

VP INSULIN SYRINGE/U-100/ -

insulin syringe/needle u-100 0.3

ml 29 x 1/2"

WALGREENS ADVANCED

TRAVEL - lancets

WALGREENS COMFORT

ASSURED - lancets

WALGREENS LANCETS - lancets

WALGREENS THIN LANCETS -

lancets

WALGREENS ULTRA THIN LANC -

lancets

WEGMANS UNIFINE PENTIPS P -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

WEGMANS UNIFINE PENTIPS P -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

WIDE-SEAL SILICONE DIAPHR -

diaphragm wide seal 60 mm, 65

mm, 70 mm, 75 mm, 80 mm, 85

mm, 90 mm, 95 mm

•

ZEVRX INSULIN SYRINGE/0.5 -

insulin syringe/needle u-100 1/2

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ml 30 x 5/16", u-100 1/2 ml 30 x

1/2"

ZEVRX INSULIN SYRINGE/1ML -

insulin syringe/needle u-100 1 ml

30 x 5/16", u-100 1 ml 30 x 1/2"

ZEVRX PEN NEEDLES 31G X 5 -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16")

ZEVRX PEN NEEDLES 31G X 6 -

insulin pen needle 31 g x 6 mm

(1/4" or 15/64")

ZEVRX PEN NEEDLES 31G X 8 -

insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

ZEVRX PEN NEEDLES 32G X 4 -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32")

ZEVRX TWIST TOP LANCETS 3 -

lancets

1ST CHOICE LANCETS SUPER -

lancets

1ST CHOICE LANCETS THIN -

lancets

1ST CHOICE LANCETS ULTRA -

lancets

1ST TIER UNIFINE PENTIPS -

insulin pen needle 29 g x 12 mm

(1/2")

1ST TIER UNIFINE PENTIPS -

insulin pen needle 31 g x 5 mm

(1/5" or 3/16"), x 6 mm (1/4" or

15/64"), x 8 mm (1/3" or 5/16")

1ST TIER UNIFINE PENTIPS -

insulin pen needle 32 g x 4 mm

(1/6" or 5/32"), x 6 mm (1/4" or

15/64")

1ST TIER UNIFINE PENTIPS -

insulin pen needle 33 g x 4 mm

(1/6" or 5/32")

1ST TIER UNILET COMFORTOU -

lancets

ASSORTED CLASSES

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 143

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

ASTAGRAF XL - tacrolimus cap er

24hr 0.5 mg, 1 mg, 5 mg

azathioprine tab 50 mg (Imuran)

BENLYSTA - belimumab

subcutaneous solution auto-

injector 200 mg/ml

• • • •

BENLYSTA - belimumab

subcutaneous solution prefilled

syringe 200 mg/ml

• • • •

CUPRIMINE - penicillamine cap 250

cyclosporine cap 25 mg, 100 mg

(Sandimmune)

cyclosporine modified cap 25 mg,

100 mg (Neoral)

cyclosporine modified cap 50 mg

cyclosporine modified oral soln

100 mg/ml (Neoral)

DEPEN TITRATABS - penicillamine

tab 250 mg

ENSPRYNG - satralizumab-mwge

subcutaneous soln pref syringe

120 mg/ml

• • • •

ENVARSUS XR - tacrolimus tab er

24hr 0.75 mg, 1 mg, 4 mg

EUA PATIENT ASSESSMENT -

patient assessment by pharmacist

- no drug dispensed

everolimus tab 0.25 mg, 0.5 mg,

0.75 mg, 1 mg (Zortress)

lenalidomide cap 5 mg, 10 mg,

15 mg, 25 mg (Revlimid)

• • • •

LOKELMA - sodium zirconium

cyclosilicate for susp packet 5 gm,

10 gm

• •

LUPKYNIS - voclosporin cap 7.9 mg

• • • •

mycophenolate mofetil cap

250 mg (Cellcept)

mycophenolate mofetil for oral

susp 200 mg/ml (Cellcept)

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

mycophenolate mofetil tab

500 mg (Cellcept)

mycophenolate sodium tab dr

180 mg (mycophenolic acid

equiv), 360 mg (mycophenolic

acid equiv) (Myfortic)

NEORAL - cyclosporine modified

cap 25 mg, 100 mg

NEORAL - cyclosporine modified

oral soln 100 mg/ml

penicillamine cap 250 mg

(Cuprimine)

penicillamine tab 250 mg (Depen

titratabs)

PROGRAF - tacrolimus cap 0.5 mg,

1 mg, 5 mg

PROGRAF - tacrolimus packet for

susp 0.2 mg, 1 mg

RAPAMUNE - sirolimus oral soln 1

mg/ml

RAPAMUNE - sirolimus tab 0.5 mg,

1 mg, 2 mg

•

REVLIMID - lenalidomide caps 2.5

• • • •

REVLIMID - lenalidomide cap 5 mg,

10 mg, 15 mg, 20 mg, 25 mg

• • • •

REZUROCK - belumosudil mesylate

tab 200 mg

• • • •

SANDIMMUNE - cyclosporine cap

25 mg, 100 mg

SANDIMMUNE - cyclosporine oral

soln 100 mg/ml

sirolimus oral soln 1 mg/ml

(Rapamune)

sirolimus tab 0.5 mg, 1 mg, 2 mg

(Rapamune)

sodium polystyrene sulfonate

powder

SPS - sodium polystyrene sulfonate

oral susp 15 gm/60ml

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 144

Drug Name

Drug Tier

Prior Authorization

Quantity Limits

Specialty

ACA

Limited Distribution

SYPRINE - trientine hcl cap 250 mg

tacrolimus cap 0.5 mg, 1 mg,

5 mg (Prograf)

THALOMID - thalidomide cap 50 mg,

100 mg, 150 mg, 200 mg

• • • •

trientine hcl cap 250 mg (Syprine)

• • • •

VELTASSA - patiromer sorbitex

calcium for susp packet 8.4 gm

(base eq), 16.8 gm (base eq),

25.2 gm (base eq)

• •

VIJOICE - alpelisib (pros) pak 250

mg daily dose (200 mg & 50 mg

tabs)

• • • •

VIJOICE - alpelisib (pros) tab

therapy pack 50 mg daily dose,

125 mg daily dose

• • • •

ZOKINVY - lonafarnib cap 50 mg, 75

• • • •

ZORTRESS - everolimus tab 0.25

mg, 0.5 mg, 0.75 mg, 1 mg

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 145

INDEX

abacavir sulfate-lamivudine tab 600-300 mg

(Epzicom)......................................................................... 5

abacavir sulfate soln 20 mg/ml (base equiv)

(Ziagen).............................................................................5

abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 5

ABILIFY...............................................................................58

ABILIFY MYCITE MAINTENANC......................................58

ABILIFY MYCITE STARTER KI........................................ 58

abiraterone acetate tab 250 mg, 500 mg (Zytiga).........11

ABOUTTIME PEN NEEDLE 32G....................................109

ABOUTTIME PEN NEEDLES 30G................................. 109

ABOUTTIME PEN NEEDLES 31G................................. 109

ABSORICA......................................................................... 95

ABSORICA LD................................................................... 95

acamprosate calcium tab delayed release 333 mg......64

ACANYA............................................................................. 95

acarbose tab 25 mg, 50 mg, 100 mg (Precose)............ 22

ACCOLATE.........................................................................44

ACCRUFER........................................................................86

ACCU-CHEK AVIVA PLUS..............................................104

ACCU-CHEK COMPACT STRIPS.................................. 104

ACCU-CHEK COMPACT TEST DR................................104

ACCU-CHEK FASTCLIX LANCET..................................109

ACCU-CHEK GUIDE....................................................... 104

ACCU-CHEK SAFE-T-PRO LANC..................................109

ACCU-CHEK SMARTVIEW STRIP.................................104

ACCU-CHEK SOFTCLIX LANCET................................. 109

ACCUPRIL..........................................................................34

ACCURETIC.......................................................................34

ACCUTREND GLUCOSE................................................104

acebutolol hcl cap 200 mg, 400 mg...............................32

ACETAMINOPHEN/CAFFEINE/DI.................................... 67

acetaminophen w/ codeine soln 120-12 mg/5ml.......... 67

acetaminophen w/ codeine tab 300-30 mg, 300-60

mg................................................................................... 67

acetaminophen w/ codeine tab 300-15 mg (Tylenol/

codeine)..........................................................................67

acetazolamide cap er 12hr 500 mg................................38

acetazolamide tab 125 mg, 250 mg............................... 38

acetic acid otic soln 2%..................................................93

acetylcysteine inhal soln 10%, 20%.............................. 43

ACIPHEX............................................................................ 48

acitretin cap 10 mg, 17.5 mg, 25 mg............................. 95

ACTEMRA.......................................................................... 70

ACTEMRA ACTPEN..........................................................70

ACTICLATE.......................................................................... 2

ACTI-LANCE LANCETS 28G..........................................109

ACTI-LANCE LITE SAFETY LA...................................... 109

ACTI-LANCE SPECIAL SAFETY....................................109

ACTI-LANCE UNIVERSAL SAFE................................... 109

ACTIMMUNE......................................................................11

ACTIQ................................................................................. 67

ACTIVELLA........................................................................ 18

ACTONEL...........................................................................27

ACTOPLUS MET............................................................... 22

ACTOS................................................................................22

ACULAR............................................................................. 89

ACULAR LS....................................................................... 89

ACUVAIL.............................................................................89

acyclovir cap 200 mg........................................................ 5

acyclovir cream 5% (Zovirax).........................................95

acyclovir oint 5% (Zovirax).............................................95

acyclovir susp 200 mg/5ml (Zovirax).............................. 5

acyclovir tab 400 mg, 800 mg.......................................... 5

ACZONE.............................................................................95

ADAPALENE...................................................................... 95

adapalene-benzoyl peroxide gel 0.1-2.5%

(Epiduo).......................................................................... 96

adapalene-benzoyl peroxide gel 0.3-2.5% (Epiduo

forte)................................................................................96

adapalene cream 0.1% (Differin)....................................95

adapalene gel 0.1%..........................................................95

adapalene gel 0.3% (Differin)......................................... 96

ADBRY................................................................................96

ADCIRCA............................................................................41

ADDERALL.........................................................................61

ADDERALL XR.................................................................. 61

adefovir dipivoxil tab 10 mg (Hepsera)........................... 5

ADEMPAS.......................................................................... 41

ADHANSIA XR................................................................... 61

ADIPEX-P........................................................................... 61

ADJUSTABLE LANCING DEVICE.................................. 109

ADLARITY.......................................................................... 64

ADLYXIN.............................................................................22

ADLYXIN STARTER PACK............................................... 22

ADMELOG..........................................................................24

ADMELOG SOLOSTAR.....................................................24

ADUHELM.......................................................................... 64

ADVAIR DISKUS................................................................44

ADVAIR HFA...................................................................... 44

ADVANCED MOBILE LANCET 30..................................109

ADVANCE INTUITION TEST ST.................................... 104

ADVANCE MICRO-DRAW TEST S................................ 104

ADVOCATE INSULIN PEN NEED.................................. 109

ADVOCATE INSULIN SYRINGE/....................................109

ADVOCATE LANCETS....................................................110

ADVOCATE LANCETS 30G............................................110

ADVOCATE LANCING DEVICE......................................110

ADVOCATE RAPID-SAFE LANCI...................................110

ADVOCATE REDI-CODE................................................ 104

ADVOCATE REDI-CODE+ TEST................................... 104

ADVOCATE SAFETY LANCETS.................................... 110

ADVOCATE SAFETY LANCETS 2................................. 110

ADVOCATE TEST STRIPS.............................................104

ADZENYS XR-ODT........................................................... 61

AEMCOLO............................................................................9

AFINITOR........................................................................... 11

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 146

AFINITOR DISPERZ..........................................................11

AF LANCETS SUPER THIN........................................... 110

AFREZZA........................................................................... 25

AGAMATRIX AMP NO CODE TES.................................104

AGAMATRIX JAZZ TEST STRIP.................................... 104

AGAMATRIX KEYNOTE TEST ST................................. 104

AGAMATRIX PRESTO TEST STR................................. 104

AGAMATRIX ULTRA-THIN LANC...................................110

AGRYLIN............................................................................ 88

AIMOVIG............................................................................ 73

AIMSCO TWIST LANCETS 32G.................................... 110

AIMSCO TWIST LANCETS 33G.................................... 110

AIRDUO DIGIHALER 113/14............................................ 44

AIRDUO DIGIHALER 232/14............................................ 44

AIRDUO DIGIHALER 55/14.............................................. 44

AIRDUO RESPICLICK 113/14.......................................... 44

AIRDUO RESPICLICK 232/14.......................................... 44

AIRDUO RESPICLICK 55/14............................................ 44

AJOVY................................................................................ 73

AKLIEF................................................................................96

AKYNZEO...........................................................................50

ALA-SCALP........................................................................ 96

albendazole tab 200 mg.................................................... 9

ALBUTEROL SULFATE HFA............................................ 44

albuterol sulfate inhal aero 108 mcg/act (90mcg base

equiv) (Proventil hfa)....................................................44

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml), 0.5%

(5 mg/ml), 0.63 mg/3ml (base equiv), 1.25 mg/3ml

(base equiv)................................................................... 44

albuterol sulfate syrup 2 mg/5ml................................... 44

albuterol sulfate tab 2 mg, 4 mg....................................44

alclometasone dipropionate cream 0.05%....................96

alclometasone dipropionate oint 0.05%........................96

ALDACTAZIDE................................................................... 38

ALDACTONE......................................................................38

ALECENSA.........................................................................11

ALENDRONATE SODIUM.................................................27

alendronate sodium tab 10 mg, 35 mg......................... 27

alendronate sodium tab 70 mg (Fosamax)................... 27

alfuzosin hcl tab er 24hr 10 mg (Uroxatral).................. 54

ALINIA...................................................................................9

aliskiren fumarate tab 150 mg (base equivalent), 300

mg (base equivalent) (Tekturna)................................. 34

ALKERAN........................................................................... 11

ALKINDI SPRINKLE.......................................................... 16

allopurinol tab 100 mg, 300 mg (Zyloprim)...................74

ALLZITAL............................................................................ 66

almotriptan malate tab 6.25 mg, 12.5 mg......................73

ALOCRIL............................................................................ 89

ALOGLIPTIN.......................................................................22

ALOGLIPTIN/METFORMIN HCL...................................... 22

ALOGLIPTIN/PIOGLITAZONE.......................................... 22

ALOMIDE............................................................................89

ALORA................................................................................18

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

equiv) (Lotronex)...........................................................51

ALPHAGAN P.................................................................... 89

ALPRAZOLAM INTENSOL................................................55

alprazolam orally disintegrating tab 0.25 mg, 0.5 mg, 1

mg, 2 mg........................................................................ 55

alprazolam tab er 24hr 0.5 mg, 1 mg, 2 mg, 3 mg

(Xanax xr).......................................................................55

alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg

(Xanax)............................................................................55

ALREX................................................................................ 89

ALTABAX............................................................................ 96

ALTACE.............................................................................. 35

ALTOPREV.........................................................................39

ALTRENO........................................................................... 96

ALUNBRIG......................................................................... 11

ALVESCO........................................................................... 44

amantadine hcl cap 100 mg........................................... 78

amantadine hcl soln 50 mg/5ml.....................................78

amantadine hcl tab 100 mg............................................ 78

AMARYL............................................................................. 22

AMBIEN.............................................................................. 60

AMBIEN CR....................................................................... 60

ambrisentan tab 5 mg, 10 mg (Letairis)........................ 41

AMCINONIDE.....................................................................96

AMICAR..............................................................................88

amiloride & hydrochlorothiazide tab 5-50 mg.............. 38

amiloride hcl tab 5 mg.................................................... 38

amiodarone hcl tab 100 mg, 200 mg, 400 mg...............34

AMITIZA..............................................................................51

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

mg, 150 mg.................................................................... 55

amlodipine besylate-atorvastatin calcium tab 2.5-10

mg, 2.5-20 mg, 2.5-40 mg............................................ 41

amlodipine besylate-atorvastatin calcium tab 5-10 mg,

5-20 mg, 5-40 mg, 5-80 mg, 10-10 mg, 10-20 mg,

10-40 mg, 10-80 mg (Caduet)...................................... 41

amlodipine besylate-benazepril hcl cap 2.5-10 mg,

5-40 mg...........................................................................35

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

mg, 10-20 mg, 10-40 mg (Lotrel).................................35

amlodipine besylate-olmesartan medoxomil tab 5-20

mg, 5-40 mg, 10-20 mg, 10-40 mg (Azor)................... 35

amlodipine besylate tab 2.5 mg (base equivalent),

5 mg (base equivalent), 10 mg (base equivalent)

(Norvasc)........................................................................ 33

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

mg, 10-160 mg, 10-320 mg (Exforge)......................... 35

amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg, 5-160-25 mg, 10-160-12.5 mg,

10-160-25 mg, 10-320-25 mg (Exforge hct)................ 35

AMONDYS 45.................................................................... 80

AMOXAPINE...................................................................... 55

AMOXICILLIN....................................................................... 1

AMOXICILLIN/CLAVULANATE P........................................ 1

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

250-62.5 mg/5ml, 400-57 mg/5ml.................................. 1

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 147

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml

(Augmentin es-600)........................................................ 1

amoxicillin & k clavulanate tab 250-125 mg, 875-125

mg......................................................................................1

amoxicillin & k clavulanate tab 500-125 mg

(Augmentin)..................................................................... 1

amoxicillin (trihydrate) cap 250 mg, 500 mg.................. 1

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

mg/5ml, 250 mg/5ml, 400 mg/5ml................................. 1

amoxicillin (trihydrate) tab 500 mg, 875 mg................... 1

amphetamine-dextroamphetamine cap er 24hr 5 mg,

10 mg, 15 mg, 20 mg, 25 mg, 30 mg (Adderall

xr).................................................................................... 61

amphetamine-dextroamphetamine tab 5 mg, 7.5 mg,

10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg (Adderall)...... 61

amphetamine sulfate tab 5 mg, 10 mg (Evekeo).......... 61

AMPICILLIN..........................................................................1

AMPYRA.............................................................................64

AMRIX.................................................................................80

AMVUTTRA........................................................................ 64

AMZEEQ.............................................................................96

ANAFRANIL........................................................................55

anagrelide hcl cap 1 mg................................................. 88

anagrelide hcl cap 0.5 mg (Agrylin).............................. 88

ANALPRAM-HC................................................................. 95

ANALPRAM HC................................................................. 95

ANALPRAM HC SINGLES................................................ 95

anastrozole tab 1 mg (Arimidex)................................... 11

ANCOBON............................................................................4

ANDRODERM.................................................................... 18

ANDROGEL........................................................................18

ANDROGEL PUMP............................................................18

ANGELIQ............................................................................18

ANNOVERA........................................................................19

ANORO ELLIPTA............................................................... 44

ANTARA..............................................................................39

ANTIVERT.......................................................................... 50

ANUSOL-HC.......................................................................95

ANZEMET...........................................................................50

APADAZ..............................................................................67

APEXICON E..................................................................... 96

APIDRA...............................................................................24

APIDRA SOLOSTAR......................................................... 24

APLENZIN.......................................................................... 55

APOKYN.............................................................................78

apomorphine hcl soln cartridge 30 mg/3ml

(Apokyn)......................................................................... 78

apraclonidine hcl ophth soln 0.5% (base

equivalent)......................................................................89

aprepitant capsule 40 mg, 125 mg................................ 50

aprepitant capsule 80 mg (Emend)............................... 50

aprepitant capsule therapy pack 80 & 125 mg (Emend

tripack)............................................................................50

APRISO.............................................................................. 51

APTENSIO XR................................................................... 61

APTIOM.............................................................................. 75

APTIVUS...............................................................................5

AQUALANCE LANCETS UL........................................... 110

ARAKODA............................................................................ 8

ARANESP ALBUMIN FREE..............................................86

ARAVA................................................................................ 70

ARAZLO..............................................................................96

ARCALYST......................................................................... 70

arformoterol tartrate soln nebu 15 mcg/2ml (base

equiv) (Brovana)............................................................44

ARICEPT............................................................................ 64

ARIKAYCE............................................................................ 3

ARIMIDEX.......................................................................... 11

aripiprazole orally disintegrating tab 10 mg, 15

mg................................................................................... 58

aripiprazole oral solution 1 mg/ml.................................58

aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30

mg (Abilify).................................................................... 58

ARIXTRA............................................................................ 87

armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg

(Nuvigil).......................................................................... 61

ARMONAIR DIGIHALER................................................... 44

ARMOUR THYROID..........................................................27

ARNUITY ELLIPTA............................................................ 44

AROMASIN.........................................................................11

ARTHROTEC 50................................................................70

ARTHROTEC 75................................................................70

ASACOL HD.......................................................................51

asenapine maleate sl tab 2.5 mg (base equiv), 5 mg

(base equiv), 10 mg (base equiv) (Saphris)...............59

ASMANEX HFA..................................................................44

ASMANEX TWISTHALER 120 ME................................... 44

ASMANEX TWISTHALER 30 MET................................... 44

ASMANEX TWISTHALER 60 MET................................... 44

ASPIRIN/OMEPRAZOLE...................................................88

aspirin chew tab 81 mg...................................................67

aspirin-dipyridamole cap er 12hr 25-200 mg................88

aspirin tab delayed release 81 mg.................................67

ASPRUZYO SPRINKLE.................................................... 31

ASSURE COMFORT LANCETS UL............................... 110

ASSURE HAEMOLANCE PLUS HI................................ 110

ASSURE HAEMOLANCE PLUS LO............................... 110

ASSURE HAEMOLANCE PLUS MI................................110

ASSURE HAEMOLANCE PLUS NO.............................. 110

ASSURE HAEMOLANCE PLUS PE............................... 110

ASSURE ID INSULIN SAFETY.......................................110

ASSURE ID SAFETY PEN NEED.................................. 110

ASSURE II........................................................................104

ASSURE II CHECK STRIP............................................. 104

ASSURE II TEST STRIPS.............................................. 104

ASSURE LANCE LANCETS........................................... 110

ASSURE LANCE LANCETS 21G................................... 110

ASSURE LANCE PLUS SAFETY................................... 110

ASSURE LANCE SAFETY LANCE................................ 110

ASSURE PLATINUM TEST STRI................................... 104

ASSURE PRISM MULTI TEST S....................................104

ASSURE PRO TEST STRIPS.........................................105

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 148

ASSURE 3 TEST STRIPS.............................................. 105

ASSURE 4 TEST STRIPS.............................................. 105

ASTAGRAF XL.................................................................143

ASTRING-O-SOL............................................................... 93

ATABEX EC........................................................................81

ATABEX OB........................................................................81

ATACAND........................................................................... 35

ATACAND HCT.................................................................. 35

atazanavir sulfate cap 150 mg (base equiv)................... 5

atazanavir sulfate cap 200 mg (base equiv), 300 mg

(base equiv) (Reyataz)....................................................5

ATELVIA..............................................................................27

atenolol & chlorthalidone tab 50-25 mg (Tenoretic

50)....................................................................................35

atenolol & chlorthalidone tab 100-25 mg (Tenoretic

100)..................................................................................35

atenolol tab 25 mg, 50 mg, 100 mg (Tenormin)............ 32

ATIVAN............................................................................... 55

AT LAST LANCETS.........................................................110

AT LAST TEST STRIPS.................................................. 105

atomoxetine hcl cap 10 mg (base equiv), 18 mg (base

equiv), 25 mg (base equiv), 40 mg (base equiv), 60

mg (base equiv), 80 mg (base equiv), 100 mg (base

equiv) (Strattera)........................................................... 61

atorvastatin calcium tab 10 mg (base equivalent), 20

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

mg (base equivalent) (Lipitor).....................................39

atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg

(Malarone)........................................................................ 9

atovaquone susp 750 mg/5ml (Mepron)......................... 9

ATRALIN............................................................................. 96

ATROPINE SULFATE........................................................ 89

atropine sulfate ophth soln 1% (Atropine sulfate).......89

ATROVENT HFA................................................................44

AUBAGIO........................................................................... 64

AUGMENTIN........................................................................ 1

AUGMENTIN ES-600.......................................................... 1

AUM MINI INSULIN PEN NEED.....................................110

AUM READYGARD DUO SAFETY................................ 110

AUM SAFETY PEN NEEDLE/31.................................... 110

AURORA LANCET SUPER THIN................................... 110

AURORA LANCET THIN 23G.........................................110

AURORA PEN NEEDLES 29GX12................................ 110

AURORA PEN NEEDLES 31G X................................... 110

AURORA UNIFINE PENTIPS/32.................................... 111

AURORA UNIFINE PENTIPS/MI.................................... 110

AURYXIA............................................................................ 51

AUSTEDO.......................................................................... 64

AUTO-LANCET................................................................ 111

AUTO-LANCET MINI....................................................... 111

AUTOLET IMPRESSION LANCIN.................................. 111

AUTOLET LANCING DEVICE.........................................111

AUTOLET MINI................................................................ 111

AUTOLET PLUS.............................................................. 111

AUTOPEN........................................................................ 111

AUVI-Q................................................................................39

AVALIDE............................................................................. 35

AVAPRO............................................................................. 35

AVODART...........................................................................54

AVONEX............................................................................. 64

AVONEX PEN.................................................................... 64

AYGESTIN.......................................................................... 21

AYVAKIT............................................................................. 11

AZASITE.............................................................................89

azathioprine tab 50 mg (Imuran)..................................143

azelaic acid gel 15% (Finacea)....................................... 96

azelastine hcl-fluticasone prop nasal spray 137-50

mcg/act (Dymista).........................................................43

azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 43

azelastine hcl nasal spray 0.15% (205.5 mcg/

spray).............................................................................. 43

azelastine hcl ophth soln 0.05%.................................... 89

AZELEX.............................................................................. 96

AZESCO............................................................................. 81

AZILECT............................................................................. 78

AZITHROMYCIN.................................................................. 2

azithromycin for susp 100 mg/5ml, 200 mg/5ml

(Zithromax).......................................................................2

azithromycin tab 600 mg.................................................. 2

azithromycin tab 250 mg, 500 mg (Zithromax)...............2

AZOPT................................................................................ 89

AZOR.................................................................................. 35

AZSTARYS......................................................................... 61

AZULFIDINE.......................................................................51

AZULFIDINE EN-TABS......................................................51

BACITRACIN......................................................................89

bacitracin-polymyxin b ophth oint................................ 89

bacitracin-polymyxin-neomycin-hc ophth oint 1%......89

BACLOFEN........................................................................ 80

baclofen tab 5 mg............................................................ 80

baclofen tab 10 mg, 20 mg.............................................80

BACTRIM..............................................................................9

BACTRIM DS....................................................................... 9

BAFIERTAM....................................................................... 64

BALCOLTRA.......................................................................19

balsalazide disodium cap 750 mg (Colazal)................. 51

BALVERSA......................................................................... 11

BANZEL..............................................................................75

BAQSIMI ONE PACK........................................................ 22

BAQSIMI TWO PACK........................................................22

BARACLUDE........................................................................5

BASAGLAR KWIKPEN...................................................... 26

BAXDELA............................................................................. 3

BD AUTOSHIELD DUO 30G X 5....................................111

BD AUTOSHIELD 29G X 3/16".......................................111

BD AUTOSHIELD 29G X 5/16".......................................111

BD INSULIN SYRINGE/DETACH....................................111

BD INSULIN SYRINGE/0.3ML/....................................... 111

BD INSULIN SYRINGE/0.5ML/....................................... 111

BD INSULIN SYRINGE/1ML/27...................................... 111

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 149

BD INSULIN SYRINGE/1ML/29...................................... 112

BD INSULIN SYRINGE/U-100/....................................... 111

BD INSULIN SYRINGE/U-500/....................................... 111

BD INSULIN SYRINGE LUER-L..................................... 111

B-D INSULIN SYRINGE MICRO.....................................111

BD INSULIN SYRINGE MICROF....................................111

BD INSULIN SYRINGE SAFETY....................................111

BD INSULIN SYRINGE SLIP T.......................................111

B-D INSULIN SYRINGE ULTRA..................................... 111

BD INSULIN SYRINGE ULTRA...................................... 111

BD INSULIN SYRINGE ULTRA-..................................... 111

BD INSULIN SYRINGE ULTRAF.................................... 111

BD LANCET ULTRAFINE 30G........................................112

BD LANCET ULTRAFINE 33G........................................112

BD LO-DOSE INSULIN SYRIN....................................... 111

BD MICROTAINER LANCETS........................................ 112

BD PEN............................................................................ 112

BD PEN MINI................................................................... 112

BD PEN NEEDLE/MICRO/ULTRA.................................. 112

BD PEN NEEDLE/MINI/ULTRA-..................................... 112

BD PEN NEEDLE/NANO/ULTRA....................................112

BD PEN NEEDLE/NANO 2ND GE................................. 112

BD PEN NEEDLE/ORIGINAL/UL....................................112

BD PEN NEEDLE/SHORT/ULTRA..................................112

BD SAFETY-GLIDE INSULIN S......................................112

BD SAFETYGLIDE INSULIN SY.................................... 112

BD SAFETY-LOK INSULIN SYR.................................... 112

BD VEO INSULIN SYRINGE UL.................................... 112

BECONASE AQ................................................................. 43

BELBUCA........................................................................... 67

BELSOMRA........................................................................60

benazepril & hydrochlorothiazide tab 10-12.5 mg,

20-12.5 mg, 20-25 mg (Lotensin hct)..........................35

BENAZEPRIL HCL/HYDROCHLOR................................. 35

benazepril hcl tab 5 mg.................................................. 35

benazepril hcl tab 10 mg, 20 mg, 40 mg (Lotensin)..... 35

BENICAR............................................................................35

BENICAR HCT................................................................... 35

BENLYSTA....................................................................... 143

BENZAMYCIN.................................................................... 96

BENZHYDROCODONE/ACETAMINO.............................. 67

BENZNIDAZOLE.................................................................. 9

benzonatate cap 150 mg.................................................43

benzoyl peroxide-erythromycin gel 5-3%

(Benzamycin)................................................................. 96

BENZPHETAMINE HCL.................................................... 61

benzphetamine hcl tab 50 mg........................................62

benztropine mesylate tab 0.5 mg, 1 mg, 2 mg............. 79

bepotastine besilate ophth soln 1.5% (Bepreve)......... 89

BEPREVE...........................................................................89

BESIVANCE....................................................................... 89

BESREMI............................................................................11

betaine powder for oral solution (Cystadane)..............27

BETAMETHASONE DIPROPIONAT................................. 96

betamethasone dipropionate augmented cream

0.05%...............................................................................96

betamethasone dipropionate augmented lotion

0.05%...............................................................................96

betamethasone dipropionate augmented oint 0.05%

(Diprolene)......................................................................96

betamethasone dipropionate cream 0.05%.................. 96

betamethasone dipropionate lotion 0.05%................... 96

betamethasone dipropionate oint 0.05%...................... 96

betamethasone valerate aerosol foam 0.12%

(Luxiq).............................................................................96

betamethasone valerate cream 0.1% (base

equivalent)......................................................................96

betamethasone valerate lotion 0.1% (base

equivalent)......................................................................96

betamethasone valerate oint 0.1% (base

equivalent)......................................................................96

BETAPACE......................................................................... 32

BETAPACE AF................................................................... 32

BETASERON......................................................................64

betaxolol hcl ophth soln 0.5%........................................89

betaxolol hcl tab 10 mg, 20 mg......................................32

bethanechol chloride tab 5 mg, 10 mg, 25 mg, 50

mg................................................................................... 53

BETHKIS...............................................................................3

BETIMOL............................................................................ 89

BETOPTIC-S...................................................................... 89

BEVESPI AEROSPHERE..................................................44

bexarotene cap 75 mg (Targretin)..................................11

bexarotene gel 1% (Targretin)........................................ 96

BEYAZ................................................................................ 19

bicalutamide tab 50 mg (Casodex)................................ 11

BIDIL................................................................................... 41

BIJUVA................................................................................18

BIKTARVY............................................................................ 5

BILTRICIDE.......................................................................... 9

bimatoprost ophth soln 0.03%....................................... 89

BINAXNOW COVID-19 AG CARD..................................105

BINOSTO............................................................................27

BIOTENE DRY MOUTH GENTLE.................................... 93

BIOTENE DRY MOUTH MOUTHWA................................93

BIOTENE DRY MOUTH ORAL RI.................................... 93

BIOTENE PBF DRY MOUTH MOU.................................. 94

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg,

5-6.25 mg, 10-6.25 mg (Ziac)....................................... 35

bisoprolol fumarate tab 5 mg, 10 mg............................ 32

BLEPHAMIDE S.O.P..........................................................89

BLOOD GLUCOSE TEST STRIPS.................................105

BLULINK GLUCOSE TEST STRI................................... 105

BONJESTA......................................................................... 50

bosentan tab 62.5 mg, 125 mg (Tracleer)..................... 41

BOSULIF............................................................................ 11

BRAFTOVI..........................................................................11

BREO ELLIPTA..................................................................44

BREXAFEMME.................................................................... 4

BREZTRI AEROSPHERE..................................................44

BRILINTA............................................................................ 88

brimonidine tartrate ophth soln 0.2%........................... 90

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 150

brimonidine tartrate ophth soln 0.15% (Alphagan

p)......................................................................................90

brimonidine tartrate-timolol maleate ophth soln

0.2-0.5% (Combigan).................................................... 90

brinzolamide ophth susp 1% (Azopt)............................ 90

BRIVIACT........................................................................... 75

bromfenac sodium ophth soln 0.09% (base equiv)

(once-daily).................................................................... 90

bromocriptine mesylate cap 5 mg (base equivalent)

(Parlodel)........................................................................ 79

bromocriptine mesylate tab 2.5 mg (base equivalent)

(Parlodel)........................................................................ 79

BROMSITE......................................................................... 90

BRONCHITOL.................................................................... 47

BRONCHITOL TOLERANCE TEST..................................47

BROVANA.......................................................................... 45

BRUKINSA......................................................................... 11

BRYHALI.............................................................................96

BUDESONIDE/FORMOTEROL FUM................................45

budesonide delayed release particles cap 3 mg..........16

budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml,

1 mg/2ml (Pulmicort).................................................... 45

budesonide tab er 24hr 9 mg (Uceris).......................... 16

bumetanide tab 1 mg, 2 mg........................................... 38

bumetanide tab 0.5 mg (Bumex)....................................38

BUMEX............................................................................... 38

BUPHENYL........................................................................ 27

buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base

equiv), 4-1 mg (base equiv), 8-2 mg (base equiv),

12-3 mg (base equiv) (Suboxone)...............................67

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base

equiv), 8-2 mg (base equiv).........................................67

buprenorphine hcl sl tab 2 mg (base equiv), 8 mg

(base equiv)................................................................... 67

buprenorphine td patch weekly 5 mcg/hr, 7.5 mcg/hr,

10 mcg/hr, 15 mcg/hr, 20 mcg/hr (Butrans)............... 67

bupropion hcl (smoking deterrent) tab er 12hr 150

mg................................................................................... 64

bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg

(Wellbutrin sr)................................................................56

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

xl).....................................................................................56

bupropion hcl tab 75 mg, 100 mg..................................56

BUPROPION HYDROCHLORIDE E.................................56

buspirone hcl tab 7.5 mg................................................55

buspirone hcl tab 5 mg, 10 mg, 15 mg, 30 mg............. 55

BUTALBITAL/ACETAMINOPHEN......................................67

butalbital-acetaminophen-caffeine cap 50-325-40

mg................................................................................... 67

butalbital-acetaminophen-caffeine cap 50-300-40 mg

(Fioricet)......................................................................... 67

butalbital-acetaminophen-caffeine tab 50-325-40 mg

(Esgic).............................................................................67

butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg............................................................ 67

butalbital-acetaminophen-caff w/ cod cap

50-300-40-30 mg (Fioricet/codeine)............................ 67

butalbital-acetaminophen cap 50-300 mg (Butalbital/

acetamino)......................................................................67

butalbital-acetaminophen tab 50-300 mg......................67

butalbital-acetaminophen tab 50-325 mg......................67

butalbital-aspirin-caffeine cap 50-325-40 mg............... 67

butalbital-aspirin-caff w/ codeine cap 50-325-40-30

mg................................................................................... 67

butorphanol tartrate nasal soln 10 mg/ml.................... 68

BUTRANS...........................................................................68

BYDUREON BCISE...........................................................22

BYETTA.............................................................................. 22

BYLVAY...............................................................................51

BYLVAY (PELLETS)...........................................................51

BYSTOLIC.......................................................................... 32

cabergoline tab 0.5 mg................................................... 27

CABLIVI.............................................................................. 88

CABOMETYX..................................................................... 11

CADUET............................................................................. 41

CAFERGOT........................................................................73

caffeine citrate oral soln 60 mg/3ml (10 mg/ml base

equiv).............................................................................. 62

CALAN SR......................................................................... 33

CALCIPOTRIENE...............................................................96

calcipotriene-betamethasone dipropionate oint

0.005-0.064% (Taclonex)...............................................96

calcipotriene-betamethasone dipropionate susp

0.005-0.064% (Taclonex)...............................................96

calcipotriene cream 0.005% (Dovonex).........................96

calcipotriene oint 0.005%................................................96

calcipotriene soln 0.005% (50 mcg/ml)......................... 96

calcitonin (salmon) inj 200 unit/ml (Miacalcin).............28

calcitonin (salmon) nasal soln 200 unit/act..................28

CALCITRIOL.......................................................................96

calcitriol cap 0.25 mcg, 0.5 mcg (Rocaltrol)................. 28

calcitriol oral soln 1 mcg/ml (Rocaltrol)........................28

calcium acetate (phosphate binder) cap 667 mg (169

mg ca).............................................................................51

calcium acetate (phosphate binder) tab 667 mg..........51

CALQUENCE..................................................................... 11

CAMBIA.............................................................................. 73

CAMCEVI........................................................................... 11

CANASA............................................................................. 51

candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg, 32-12.5 mg, 32-25 mg (Atacand hct)................... 35

candesartan cilexetil tab 4 mg, 8 mg, 16 mg, 32 mg

(Atacand)........................................................................ 35

capecitabine tab 150 mg, 500 mg (Xeloda)...................11

CAPEX................................................................................97

CAPLYTA............................................................................ 59

CAPRELSA.........................................................................12

captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg...............35

CARAC............................................................................... 97

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 151

CARAFATE......................................................................... 48

CARBAGLU........................................................................ 28

carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg

(Carbatrol)...................................................................... 75

carbamazepine chew tab 100 mg.................................. 75

carbamazepine susp 100 mg/5ml (Tegretol).................75

carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg

(Tegretol-xr)....................................................................75

carbamazepine tab 200 mg (Tegretol)........................... 75

CARBATROL...................................................................... 75

CARBIDOPA/LEVODOPA ODT.........................................79

carbidopa & levodopa tab er 25-100 mg, 50-200

mg................................................................................... 79

carbidopa & levodopa tab 25-250 mg........................... 79

carbidopa & levodopa tab 10-100 mg (Sinemet).......... 79

carbidopa & levodopa tab 25-100 mg (Sinemet).......... 79

carbidopa-levodopa-entacapone tabs 12.5-50-200 mg

(Stalevo 50).................................................................... 79

carbidopa-levodopa-entacapone tabs 18.75-75-200

mg (Stalevo 75)............................................................. 79

carbidopa-levodopa-entacapone tabs 25-100-200 mg

(Stalevo 100).................................................................. 79

carbidopa-levodopa-entacapone tabs 31.25-125-200

mg (Stalevo 125)........................................................... 79

carbidopa-levodopa-entacapone tabs 37.5-150-200

mg (Stalevo 150)........................................................... 79

carbidopa-levodopa-entacapone tabs 50-200-200 mg

(Stalevo 200).................................................................. 79

carbidopa tab 25 mg (Lodosyn).....................................79

CARBINOXAMINE MALEATE........................................... 42

carbinoxamine maleate tab 4 mg.................................. 42

carbonyl iron susp 15 mg/1.25ml (elemental iron)...... 86

CARDIOCOM LANCING DEVICE...................................112

CARDIZEM......................................................................... 33

CARDIZEM CD.................................................................. 33

CARDIZEM LA................................................................... 33

CARDURA.......................................................................... 35

CARDURA XL.................................................................... 54

CAREFINE PEN NEEDLE 32GX4.................................. 112

CAREFINE PEN NEEDLES 29GX..................................112

CAREFINE PEN NEEDLES 30GX..................................112

CAREFINE PEN NEEDLES 31GX..................................112

CAREFINE PEN NEEDLES 32GX..................................112

CAREONE ADVANCED LANCING.................................112

CAREONE BLOOD GLUCOSE TES.............................. 105

CAREONE INSULIN SYRINGES/...................................112

CAREONE LANCET SUPER THIN................................ 112

CAREONE LANCET THIN.............................................. 112

CAREONE LANCET ULTRA THIN................................. 112

CAREONE UNIFINE PENTIPS 2....................................113

CAREONE UNIFINE PENTIPS 3....................................113

CAREONE UNIFINE PENTIPS P................................... 112

CARESENS LANCETS....................................................113

CARESENS N BLOOD GLUCOSE.................................105

CARESTART COVID-19 ANTIGE................................... 105

CARETOUCH BLOOD GLUCOSE T.............................. 105

CARETOUCH INSULIN SYRINGE................................. 113

CARETOUCH LANCING DEVICE.................................. 113

CARETOUCH PEN NEEDLE 29GX............................... 113

CARETOUCH PEN NEEDLES 31.................................. 113

CARETOUCH PEN NEEDLES 31G............................... 113

CARETOUCH PEN NEEDLES 32G............................... 113

CARETOUCH SAFETY LANCETS/................................ 113

CARETOUCH TWIST LANCETS 2.................................113

CARETOUCH TWIST LANCETS 3.................................113

carglumic acid soluble tab 200 mg (Carbaglu)............ 28

carisoprodol tab 250 mg (Soma)................................... 80

carisoprodol tab 350 mg (Soma)................................... 80

CARNITOR......................................................................... 28

CARNITOR SF................................................................... 28

CAROSPIR......................................................................... 38

CARTEOLOL HCL............................................................. 90

carvedilol phosphate cap er 24hr 10 mg, 20 mg, 40

mg, 80 mg (Coreg cr)................................................... 32

carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg

(Coreg)............................................................................32

CASODEX.......................................................................... 12

CATAPRES-TTS-1............................................................. 35

CATAPRES-TTS-2............................................................. 35

CATAPRES-TTS-3............................................................. 35

CAYA.................................................................................113

CAYSTON.............................................................................9

CEFACLOR.......................................................................... 1

CEFACLOR ER.................................................................... 1

CEFADROXIL....................................................................... 1

cefadroxil cap 500 mg.......................................................1

cefadroxil for susp 250 mg/5ml, 500 mg/5ml................. 1

cefdinir cap 300 mg...........................................................1

cefdinir for susp 125 mg/5ml, 250 mg/5ml..................... 1

cefixime for susp 100 mg/5ml..........................................1

cefixime for susp 200 mg/5ml (Suprax).......................... 1

cefpodoxime proxetil for susp 50 mg/5ml, 100

mg/5ml.............................................................................. 1

cefpodoxime proxetil tab 100 mg, 200 mg..................... 1

cefprozil for susp 125 mg/5ml, 250 mg/5ml....................1

cefprozil tab 250 mg, 500 mg........................................... 1

cefuroxime axetil tab 250 mg, 500 mg............................ 1

CELEBREX.........................................................................70

celecoxib cap 50 mg, 100 mg, 200 mg, 400 mg

(Celebrex)....................................................................... 70

CELEXA..............................................................................56

CELLTRION DIATRUST COVID-.................................... 105

CELONTIN..........................................................................75

CENTANY........................................................................... 97

CEPHALEXIN....................................................................... 1

cephalexin cap 250 mg, 500 mg...................................... 1

cephalexin for susp 125 mg/5ml, 250 mg/5ml................1

CEQUA............................................................................... 90

CEQUR SIMPLICITY INSERTER................................... 113

CEQUR SIMPLICITY 2U................................................. 113

CERDELGA........................................................................ 86

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).................. 42

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 152

CETRAXAL.........................................................................93

CETROTIDE....................................................................... 28

cevimeline hcl cap 30 mg (Evoxac)...............................94

CHEMET...........................................................................104

CHENODAL........................................................................51

CHLORDIAZEPOXIDE/AMITRIPT.................................... 64

chlordiazepoxide hcl cap 5 mg, 10 mg, 25 mg.............55

chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg

(Librax)........................................................................... 48

chlorhexidine gluconate soln 0.12% (Peridex).............94

CHLOROQUINE PHOSPHATE........................................... 9

chloroquine phosphate tab 250 mg................................ 9

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

200 mg............................................................................59

chlorthalidone tab 25 mg, 50 mg................................... 38

chlorzoxazone tab 500 mg..............................................80

chlorzoxazone tab 250 mg, 375 mg, 750 mg................ 80

cholestyramine light powder 4 gm/dose (Questran

light)................................................................................ 39

cholestyramine light powder packets 4 gm................. 39

cholestyramine powder 4 gm/dose (Questran)............39

cholestyramine powder packets 4 gm (Questran).......39

choline fenofibrate cap dr 45 mg (fenofibric acid

equiv), 135 mg (fenofibric acid equiv) (Trilipix)........ 39

CHORIONIC GONADOTROPIN........................................28

CIALIS.................................................................................41

CIBINQO.............................................................................97

ciclopirox gel 0.77%........................................................ 97

ciclopirox olamine cream 0.77% (base equiv)

(Loprox).......................................................................... 97

ciclopirox olamine susp 0.77% (base equiv)

(Loprox).......................................................................... 97

ciclopirox shampoo 1% (Loprox shampoo)................. 97

ciclopirox solution 8% (Penlac Nail Lacquer).............. 97

cilostazol tab 50 mg, 100 mg......................................... 88

CILOXAN............................................................................ 90

CIMDUO............................................................................... 5

cimetidine hcl soln 300 mg/5ml..................................... 48

cimetidine tab 200 mg, 300 mg, 400 mg, 800 mg......... 48

CIMZIA................................................................................51

CIMZIA STARTER KIT...................................................... 51

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

equiv), 90 mg (base equiv) (Sensipar)....................... 28

CIPRO...................................................................................3

CIPRODEX......................................................................... 93

CIPROFLOXACIN.............................................................. 93

CIPROFLOXACIN/FLUOCINOLON.................................. 93

ciprofloxacin-dexamethasone otic susp 0.3-0.1%

(Ciprodex).......................................................................93

CIPROFLOXACIN HCL....................................................... 3

ciprofloxacin hcl ophth soln 0.3% (base

equivalent)......................................................................90

ciprofloxacin hcl tab 750 mg (base equiv)..................... 3

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

(base equiv) (Cipro)........................................................3

CIPRO HC..........................................................................93

CITALOPRAM HYDROBROMIDE.....................................56

citalopram hydrobromide oral soln 10 mg/5ml............ 56

citalopram hydrobromide tab 10 mg (base equiv), 20

mg (base equiv), 40 mg (base equiv) (Celexa).......... 56

CITRANATAL ASSURE..................................................... 81

CITRANATAL B-CALM.......................................................81

CITRANATAL BLOOM....................................................... 82

CITRANATAL DHA.............................................................82

CITRANATAL 90 DHA....................................................... 82

CITRANATAL HARMONY..................................................82

CLARINEX..........................................................................42

CLARINEX-D 12 HOUR.................................................... 43

CLARITHROMYCIN............................................................. 2

clarithromycin tab er 24hr 500 mg.................................. 2

clarithromycin tab 250 mg, 500 mg.................................2

CLEANLET LANCETS 28G.............................................113

CLEARDETECT COVID-19 ANTI................................... 105

CLEMASTINE FUMARATE............................................... 42

CLENPIQ............................................................................ 47

CLEOCIN..............................................................................9

CLEOCIN PEDIATRIC GRANULE...................................... 9

CLEOCIN-T........................................................................ 97

CLEVER CHEK AUTO-CODE TES................................ 105

CLEVER CHEK AUTO-CODE VOI................................. 105

CLEVER CHEK LANCETS ULTRA.................................113

CLEVER CHEK TEST STRIPS.......................................105

CLEVER CHOICE AUTO-CODE P................................. 105

CLEVER CHOICE COMFORT EZ.................................. 113

CLEVER CHOICE MICRO TEST....................................105

CLEVER CHOICE NO CODING T..................................105

CLEVER CHOICE TALK NO COD..................................105

CLICKFINE PEN NEEDLE 32GX................................... 114

CLICKFINE PEN NEEDLES/31G....................................114

CLICKFINE PEN NEEDLES 31G................................... 114

CLICKFINE PEN NEEDLES 32G................................... 114

CLICKFINE PEN NEEDLE UNIV.................................... 114

CLICKFINE UNIVERSAL PEN N.................................... 114

CLIMARA............................................................................18

CLIMARA PRO.................................................................. 18

CLINDAGEL....................................................................... 97

clindamycin hcl cap 75 mg, 150 mg, 300 mg

(Cleocin)........................................................................... 9

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

equiv) (Cleocin pediatric gr)..........................................9

clindamycin phosphate-benzoyl peroxide gel

1-5%................................................................................ 97

clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%

(Acanya)......................................................................... 97

clindamycin phosphate foam 1% (Evoclin).................. 97

clindamycin phosphate gel 1% (Clindagel).................. 97

clindamycin phosphate lotion 1% (Cleocin-t).............. 97

clindamycin phosphate soln 1%....................................97

clindamycin phosphate swab 1%.................................. 97

clindamycin phosphate-tretinoin gel 1.2-0.025%

(Ziana)............................................................................. 97

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 153

clindamycin phosphate vaginal cream 2%

(Cleocin)......................................................................... 53

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2

(1)-5%.............................................................................. 97

CLINITEST RAPID COVID-19.........................................105

clobazam suspension 2.5 mg/ml (Onfi)........................ 75

clobazam tab 10 mg, 20 mg (Onfi).................................75

clobetasol propionate cream 0.05%.............................. 97

clobetasol propionate emollient base cream

0.05%...............................................................................97

clobetasol propionate emulsion foam 0.05% (Olux-

e)......................................................................................97

clobetasol propionate foam 0.05% (Olux).................... 97

clobetasol propionate gel 0.05%................................... 97

clobetasol propionate lotion 0.05% (Clobex)............... 97

clobetasol propionate oint 0.05%.................................. 97

clobetasol propionate shampoo 0.05% (Clobex)......... 97

clobetasol propionate soln 0.05%................................. 97

clobetasol propionate spray 0.05% (Clobex)............... 97

CLOBEX............................................................................. 97

clocortolone pivalate cream 0.1% (Cloderm)............... 97

CLODERM..........................................................................97

CLOMID..............................................................................28

CLOMIPHENE CITRATE................................................... 28

clomipramine hcl cap 25 mg, 50 mg, 75 mg

(Anafranil).......................................................................56

clonazepam orally disintegrating tab 0.125 mg, 0.25

mg, 0.5 mg, 1 mg, 2 mg...............................................75

clonazepam tab 0.5 mg, 1 mg, 2 mg (Klonopin)...........75

clonidine hcl tab er 12hr 0.1 mg (Kapvay)....................62

clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg...................... 35

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

tts-1)................................................................................ 35

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

tts-2)................................................................................ 35

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

tts-3)................................................................................ 35

clopidogrel bisulfate tab 300 mg (base equiv)............. 88

clopidogrel bisulfate tab 75 mg (base equiv)

(Plavix)............................................................................88

clorazepate dipotassium tab 3.75 mg, 15 mg...............55

clorazepate dipotassium tab 7.5 mg (Tranxene t)........55

clotrimazole cream 1%.................................................... 97

clotrimazole soln 1%....................................................... 97

clotrimazole troche 10 mg.............................................. 94

clotrimazole w/ betamethasone cream 1-0.05%...........97

clotrimazole w/ betamethasone lotion 1-0.05%............97

CLOZAPINE ODT.............................................................. 59

clozapine orally disintegrating tab 25 mg, 100 mg...... 59

clozapine tab 25 mg, 50 mg, 100 mg, 200 mg

(Clozaril)......................................................................... 59

CLOZARIL.......................................................................... 59

C-NATE DHA......................................................................81

COAGUCHEK LANCETS................................................ 114

COARTEM............................................................................9

CODEINE SULFATE.......................................................... 68

codeine sulfate tab 30 mg (Codeine sulfate)................68

COLAZAL........................................................................... 51

COLCHICINE..................................................................... 74

colchicine tab 0.6 mg (Colcrys)..................................... 74

colchicine w/ probenecid tab 0.5-500 mg..................... 75

COLCRYS.......................................................................... 75

colesevelam hcl packet for susp 3.75 gm

(Welchol)........................................................................ 39

colesevelam hcl tab 625 mg (Welchol)......................... 39

COLESTID..........................................................................39

COLESTID FLAVORED.....................................................39

colestipol hcl granule packets 5 gm (Colestid

flavored)......................................................................... 39

colestipol hcl granules 5 gm (Colestid flavored)......... 39

colestipol hcl tab 1 gm (Colestid)..................................39

COMBIGAN........................................................................ 90

COMBIPATCH.................................................................... 18

COMBIVENT RESPIMAT.................................................. 45

COMBIVIR............................................................................ 5

COMETRIQ........................................................................ 12

COMFORT ASSIST INSULIN SY................................... 114

COMFORT ASSURED LANCETS M.............................. 114

COMFORT ASSURED LANCETS S...............................114

COMFORT EZ/31G X 5MM............................................ 114

COMFORT EZ/31G X 6MM............................................ 114

COMFORT EZ INSULIN SYRING...................................114

COMFORT EZ MICRO/32G X 4M.................................. 114

COMFORT EZ SHORT/31G X 8M..................................114

COMFORT LANCETS..................................................... 114

COMFORT TOUCH LANCETS ULT............................... 114

COMFORT TOUCH PEN NEEDLES.............................. 114

COMFORT TOUCH PLUS SAFETY............................... 114

COMIRNATY...................................................................... 10

COMPLERA..........................................................................5

COMPLETE NATAL DHA.................................................. 82

COMPLETENATE.............................................................. 82

COMTAN.............................................................................79

CO-NATAL FA.................................................................... 82

CONCEPT DHA................................................................. 82

CONCEPT OB................................................................... 82

CONCERTA........................................................................ 62

CONDOMS....................................................................... 114

CONDYLOX........................................................................97

CONJUPRI......................................................................... 33

CONTOUR BLOOD GLUCOSE MON............................ 114

CONTOUR BLOOD GLUCOSE TES..............................105

CONTOUR HIGH CONTROL..........................................114

CONTOUR LOW CONTROL...........................................114

CONTOUR NEXT BLOOD GLUCOS..............................105

CONTOUR NEXT CONTROL LEVE...............................115

CONTOUR NEXT EZ BLOOD GLU................................115

CONTOUR NEXT GEN BLOOD GL............................... 115

CONTOUR NEXT LINK BLOOD G................................. 115

CONTOUR NEXT LINK WIRELES................................. 115

CONTOUR NEXT ONE BLOOD GL............................... 115

CONTOUR NORMAL CONTROL................................... 115

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 154

CONTRAVE........................................................................ 62

CONZIP.............................................................................. 68

COOL BLOOD GLUCOSE TEST S................................ 105

COPAXONE........................................................................64

COPIKTRA......................................................................... 12

CORDRAN..........................................................................97

COREG...............................................................................32

COREG CR........................................................................ 32

CORGARD......................................................................... 32

CORLANOR....................................................................... 41

CORTEF............................................................................. 16

CORTENEMA.....................................................................95

CORTIFOAM...................................................................... 95

CORTISPORIN-TC.............................................................93

CORTROPHIN....................................................................28

COSENTYX........................................................................ 98

COSENTYX SENSOREADY PEN.................................... 98

COSOPT.............................................................................90

COSOPT PF.......................................................................90

COTELLIC.......................................................................... 12

COTEMPLA XR-ODT........................................................ 62

COVID-19 AT-HOME TEST KIT......................................105

COVID-19 RAPID SELF TEST........................................105

COZAAR.............................................................................35

CREON............................................................................... 50

CRESEMBA..........................................................................4

CRESTOR.......................................................................... 39

CRINONE........................................................................... 53

cromolyn sodium ophth soln 4%...................................90

cromolyn sodium oral conc 100 mg/5ml

(Gastrocrom)..................................................................51

cromolyn sodium soln nebu 20 mg/2ml....................... 45

CROTAN............................................................................. 98

CUPRIMINE..................................................................... 143

CUVPOSA.......................................................................... 48

CVS ADVANCED GLUCOSE METE.............................. 105

CVS GLUCOSE METER TEST ST.................................105

CVS LANCETS 21G........................................................ 115

CVS LANCETS MICRO-THIN 33....................................115

CVS LANCETS MICRO THIN 33....................................115

CVS LANCETS ORIGINAL............................................. 115

CVS LANCETS THIN 26G.............................................. 115

CVS LANCETS ULTRA-THIN 30.................................... 115

CVS LANCETS ULTRA THIN 30.................................... 115

CVS LANCING DEVICE..................................................115

CVS ULTRA THIN LANCETS......................................... 115

cyanocobalamin inj 1000 mcg/ml.................................. 86

cyclobenzaprine hcl cap er 24hr 15 mg, 30 mg

(Amrix)............................................................................ 80

cyclobenzaprine hcl tab 7.5 mg.....................................80

cyclobenzaprine hcl tab 5 mg, 10 mg........................... 80

CYCLOGYL........................................................................ 90

CYCLOPHOSPHAMIDE.................................................... 12

cyclophosphamide cap 25 mg, 50 mg

(Cyclophosphamide).................................................... 12

CYCLOSERINE....................................................................4

CYCLOSET........................................................................ 22

cyclosporine cap 25 mg, 100 mg (Sandimmune).......143

cyclosporine modified cap 50 mg............................... 143

cyclosporine modified cap 25 mg, 100 mg

(Neoral)......................................................................... 143

cyclosporine modified oral soln 100 mg/ml

(Neoral)......................................................................... 143

cyclosporine (ophth) emulsion 0.05% (Restasis

multidose)...................................................................... 90

CYMBALTA.........................................................................56

cyproheptadine hcl syrup 2 mg/5ml..............................42

cyproheptadine hcl tab 4 mg......................................... 42

CYSTADANE...................................................................... 28

CYSTADROPS................................................................... 90

CYSTAGON........................................................................54

CYSTARAN........................................................................ 90

CYTOMEL.......................................................................... 27

CYTOTEC...........................................................................48

dabigatran etexilate mesylate cap 75 mg (etexilate

base eq), 150 mg (etexilate base eq) (Pradaxa)........ 87

dalfampridine tab er 12hr 10 mg (Ampyra)...................64

DALIRESP.......................................................................... 45

danazol cap 50 mg, 100 mg, 200 mg.............................18

DANTRIUM.........................................................................80

dantrolene sodium cap 50 mg, 100 mg.........................80

dantrolene sodium cap 25 mg (Dantrium).................... 80

dapsone gel 5%, 7.5% (Aczone).................................... 98

dapsone tab 25 mg, 100 mg.............................................9

DARAPRIM...........................................................................9

darifenacin hydrobromide tab er 24hr 7.5 mg (base

equiv), 15 mg (base equiv).......................................... 53

DARTISLA ODT................................................................. 48

DAURISMO........................................................................ 12

DAYPRO............................................................................. 70

DAYTRANA........................................................................ 62

DAYVIGO............................................................................60

DDAVP................................................................................28

deferiprone tab 500 mg, 1000 mg (Ferriprox).............104

DELESTROGEN................................................................ 18

DELSTRIGO......................................................................... 5

DELZICOL.......................................................................... 51

demeclocycline hcl tab 150 mg, 300 mg.........................2

DEMSER............................................................................ 35

DENAVIR............................................................................ 98

DEPAKOTE........................................................................ 75

DEPAKOTE ER.................................................................. 75

DEPAKOTE SPRINKLES.................................................. 75

DEPEN TITRATABS........................................................ 143

DEPO-ESTRADIOL............................................................19

DEPO-PROVERA CONTRACEPTIV................................ 19

DEPO-SUBQ PROVERA 104........................................... 20

DEPO-TESTOSTERONE.................................................. 18

DERMACINRX PRETRATE...............................................82

DERMA-SMOOTHE/FS BODY..........................................98

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 155

DERMA-SMOOTHE/FS SCALP........................................ 98

DERMOTIC.........................................................................93

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

mg................................................................................... 56

desipramine hcl tab 10 mg, 25 mg (Norpramin)...........56

DESLORATADINE ODT.....................................................42

desloratadine tab 5 mg (Clarinex)................................. 42

desmopressin acetate inj 4 mcg/ml (Ddavp)................ 28

desmopressin acetate nasal spray soln 0.01%

(refrigerated), 0.01%..................................................... 28

desmopressin acetate preservative free (pf) inj 4 mcg/

ml (Ddavp)......................................................................28

desmopressin acetate tab 0.1 mg, 0.2 mg (Ddavp)......28

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5) (Mircette)........................................................20

desogestrel & ethinyl estradiol tab 0.15 mg-30

mcg................................................................................. 20

desonide cream 0.05% (Desowen)................................ 98

desonide gel 0.05%..........................................................98

desonide lotion 0.05%..................................................... 98

desonide oint 0.05%........................................................ 98

DESOWEN......................................................................... 98

desoximetasone cream 0.05% (Topicort)......................98

desoximetasone cream 0.25% (Topicort)......................98

desoximetasone gel 0.05% (Topicort)........................... 98

desoximetasone oint 0.05% (Topicort)..........................98

desoximetasone oint 0.25% (Topicort)..........................98

desoximetasone spray 0.25% (Topicort).......................98

DESOXYN.......................................................................... 62

DESVENLAFAXINE ER..................................................... 56

desvenlafaxine succinate tab er 24hr 25 mg (base

equiv), 50 mg (base equiv), 100 mg (base equiv)

(Pristiq)........................................................................... 56

DETROL............................................................................. 53

DETROL LA....................................................................... 53

DEXABLISS........................................................................16

DEXAMETHASONE...........................................................16

DEXAMETHASONE 10-DAY DOSE................................. 16

DEXAMETHASONE 13-DAY DOSE................................. 17

dexamethasone elixir 0.5 mg/5ml.................................. 16

DEXAMETHASONE INTENSOL....................................... 16

DEXAMETHASONE SODIUM PHOS............................... 90

dexamethasone tab 1.5 mg, 4 mg, 6 mg....................... 16

dexamethasone tab therapy pack 1.5 mg (21)............. 16

DEXCOM G6 RECEIVER................................................115

DEXCOM G6 SENSOR...................................................115

DEXCOM G6 TRANSMITTER........................................ 115

DEXEDRINE.......................................................................62

DEXILANT.......................................................................... 48

DEXLANSOPRAZOLE.......................................................48

dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15

mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg (Focalin

xr).................................................................................... 62

dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg

(Focalin)..........................................................................62

dextroamphetamine sulfate cap er 24hr 5 mg............. 62

dextroamphetamine sulfate cap er 24hr 10 mg, 15 mg

(Dexedrine).....................................................................62

dextroamphetamine sulfate oral solution 5

mg/5ml............................................................................ 62

dextroamphetamine sulfate tab 5 mg, 10 mg............... 62

dextroamphetamine sulfate tab 15 mg, 20 mg, 30

mg................................................................................... 62

DHIVY................................................................................. 79

DIACOMIT.......................................................................... 75

DIASTAT ACUDIAL............................................................75

DIASTAT PEDIATRIC........................................................ 75

DIATHRIVE+ BLOOD GLUCOSE................................... 105

DIATHRIVE BLOOD GLUCOSE T.................................. 105

DIATHRIVE LANCETS.................................................... 115

DIATHRIVE LANCETS ULTRA T.................................... 115

DIATHRIVE LANCING DEVICE...................................... 115

DIATHRIVE PEN NEEDLE/31G...................................... 115

DIATHRIVE PEN NEEDLE/32G...................................... 115

DIATHRIVE PEN NEEDLE/31 G.....................................115

DIATRUE PLUS BLOOD GLUCOS.................................105

diazepam conc 5 mg/ml.................................................. 55

diazepam oral soln 1 mg/ml........................................... 55

DIAZEPAM RECTAL GEL................................................. 75

diazepam tab 2 mg, 5 mg, 10 mg (Valium)....................55

diazoxide susp 50 mg/ml (Proglycem)..........................22

DIBENZYLINE.................................................................... 36

DICLEGIS........................................................................... 50

DICLOFENAC.................................................................... 70

DICLOFENAC EPOLAMINE..............................................98

diclofenac potassium cap 25 mg (Zipsor).................... 70

diclofenac potassium tab 25 mg................................... 70

diclofenac potassium tab 50 mg................................... 70

diclofenac sodium gel 1%.............................................. 98

diclofenac sodium ophth soln 0.1%.............................. 90

diclofenac sodium soln 1.5%......................................... 98

diclofenac sodium soln 2% (Pennsaid)........................ 98

diclofenac sodium tab delayed release 25 mg, 50 mg,

75 mg.............................................................................. 70

diclofenac sodium tab er 24hr 100 mg......................... 70

diclofenac w/ misoprostol tab delayed release 50-0.2

mg (Arthrotec 50)..........................................................71

diclofenac w/ misoprostol tab delayed release 75-0.2

mg (Arthrotec 75)..........................................................71

dicloxacillin sodium cap 250 mg, 500 mg...................... 1

dicyclomine hcl cap 10 mg.............................................48

dicyclomine hcl oral soln 10 mg/5ml............................ 48

dicyclomine hcl tab 20 mg............................................. 48

DIETHYLPROPION HCL ER.............................................62

diethylpropion hcl tab 25 mg......................................... 62

DIFFERIN........................................................................... 98

DIFICID................................................................................. 2

DIFLORASONE DIACETATE............................................ 98

diflorasone diacetate oint 0.05%................................... 98

DIFLUCAN............................................................................4

diflunisal tab 500 mg....................................................... 67

difluprednate ophth emulsion 0.05% (Durezol)............90

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 156

DIGOXIN.............................................................................31

digoxin oral soln 0.05 mg/ml (Digoxin)......................... 31

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

(Lanoxin)........................................................................ 31

digoxin tab 62.5 mcg (0.0625 mg) (Lanoxin)................ 31

dihydroergotamine mesylate inj 1 mg/ml..................... 73

dihydroergotamine mesylate nasal spray 4 mg/ml

(Migranal)....................................................................... 73

DILANTIN........................................................................... 75

DILANTIN-125.................................................................... 75

DILANTIN INFATABS.........................................................75

DILAUDID........................................................................... 68

diltiazem hcl cap er 12hr 60 mg, 90 mg, 120 mg..........33

diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mg...... 33

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

mg, 240 mg, 300 mg, 360 mg (Cardizem cd)............. 33

diltiazem hcl coated beads tab er 24hr 180 mg, 240

mg, 300 mg, 360 mg, 420 mg (Cardizem la).............. 33

diltiazem hcl extended release beads cap er 24hr 120

mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

(Tiazac)........................................................................... 33

diltiazem hcl tab 90 mg...................................................33

diltiazem hcl tab 30 mg, 60 mg, 120 mg

(Cardizem)...................................................................... 33

dimethyl fumarate capsule delayed release 120 mg,

240 mg (Tecfidera)........................................................ 64

dimethyl fumarate capsule dr starter pack 120 mg &

240 mg (Tecfidera starter pa)...................................... 64

DIOVAN.............................................................................. 36

DIOVAN HCT..................................................................... 36

DIPENTUM......................................................................... 51

diphenhydramine hcl elixir 12.5 mg/5ml.......................42

DIPHENOXYLATE/ATROPINE..........................................48

diphenoxylate w/ atropine tab 2.5-0.025 mg

(Lomotil)......................................................................... 48

DIPROLENE....................................................................... 98

dipyridamole tab 25 mg, 50 mg, 75 mg.........................88

disopyramide phosphate cap 100 mg, 150 mg

(Norpace)........................................................................34

disulfiram tab 250 mg, 500 mg...................................... 64

DITROPAN XL....................................................................53

DIURIL................................................................................ 38

divalproex sodium cap delayed release sprinkle 125

mg (Depakote sprinkles)..............................................75

divalproex sodium tab delayed release 125 mg, 250

mg, 500 mg (Depakote)................................................76

divalproex sodium tab er 24 hr 250 mg, 500 mg

(Depakote er)................................................................. 76

DIVIGEL..............................................................................19

dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg),

500 mcg (0.5 mg) (Tikosyn).........................................34

DOJOLVI.............................................................................86

donepezil hydrochloride orally disintegrating tab 5

mg, 10 mg...................................................................... 64

donepezil hydrochloride tab 5 mg, 10 mg, 23 mg

(Aricept)..........................................................................64

DONNATAL.........................................................................48

DOPTELET.........................................................................86

DORAL................................................................................60

DORYX................................................................................. 2

DORYX MPC........................................................................2

dorzolamide hcl ophth soln 2% (Trusopt).................... 90

dorzolamide hcl-timolol maleate ophth sol 22.3-6.8

mg/ml pf (Cosopt pf).................................................... 90

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml (Cosopt)..............................................................90

DOVATO............................................................................... 5

DOVONEX..........................................................................98

doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg

(Cardura)........................................................................ 36

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

150 mg............................................................................56

doxepin hcl conc 10 mg/ml............................................ 56

doxepin hcl (sleep) tab 3 mg (base equiv), 6 mg (base

equiv) (Silenor)..............................................................60

DOXEPIN HYDROCHLORIDE.......................................... 98

doxercalciferol cap 0.5 mcg, 1 mcg, 2.5 mcg...............28

DOXYCYCLINE..................................................................98

doxycycline hyclate cap 50 mg....................................... 2

doxycycline hyclate cap 100 mg (Vibramycin)...............2

DOXYCYCLINE HYCLATE DR........................................... 2

doxycycline hyclate tab delayed release 75 mg, 100

mg, 150 mg...................................................................... 2

doxycycline hyclate tab delayed release 50 mg, 200

mg (Doryx)....................................................................... 2

doxycycline hyclate tab 50 mg........................................ 2

doxycycline hyclate tab 20 mg, 100 mg..........................2

doxycycline hyclate tab 75 mg, 150 mg (Acticlate)....... 2

doxycycline monohydrate cap 150 mg........................... 3

doxycycline monohydrate cap 50 mg, 100 mg.............. 2

doxycycline monohydrate cap 75 mg, 150 mg.............. 2

doxycycline monohydrate for susp 25 mg/5ml

(Vibramycin).....................................................................3

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

150 mg.............................................................................. 3

doxylamine-pyridoxine tab delayed release 10-10 mg

(Diclegis)........................................................................ 50

DRISDOL............................................................................81

DRIZALMA SPRINKLE...................................................... 56

dronabinol cap 5 mg, 10 mg.......................................... 50

dronabinol cap 2.5 mg (Marinol)....................................50

DROPLET GENTEEL LANCING D.................................115

DROPLET INSULIN SYRINGE 0....................................115

DROPLET INSULIN SYRINGE 1....................................115

DROPLET INSULIN SYRINGE/U................................... 115

DROPLET INSULIN SYRINGE U................................... 115

DROPLET LANCETS ULTRA THI.................................. 116

DROPLET LANCING DEVICE........................................ 116

DROPLET MICRON 34G X 9/64.................................... 116

DROPLET PEN NEEDLES 29GX1.................................116

DROPLET PEN NEEDLES 31GX5.................................116

DROPLET PEN NEEDLES 31GX6.................................116

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 157

DROPLET PEN NEEDLES 31GX8.................................116

DROPLET PEN NEEDLES 32GX4.................................116

DROPLET PEN NEEDLES 32GX5.................................116

DROPLET PEN NEEDLES 32GX6.................................116

DROPLET PEN NEEDLES 32GX8.................................116

DROPLET PEN NEEDLES 29G X..................................116

DROPLET PEN NEEDLES 30G X..................................116

DROPLET PEN NEEDLES 31G X..................................116

DROPLET PEN NEEDLES 32G X..................................116

DROPLET PERSONAL LANCETS................................. 116

DROPSAFE SAFETY PEN NEEDL................................ 116

DROPSAFE SAFTEY PEN NEEDL................................ 116

drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin

28)....................................................................................20

drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz).....20

drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg (Beyaz)...............................................20

drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg (Safyral)............................................. 20

DROXIA.............................................................................. 86

droxidopa cap 100 mg, 200 mg, 300 mg (Northera).....39

DRUG MART ADJUSTABLE LANC................................ 116

DRUG MART LANCETS THIN........................................116

DRUG MART LANCETS ULTRA T................................. 116

DRUG MART ON-THE-GO LANCE................................ 116

DRUG MART UNIFINE PENTIPS...................................116

DRUG MART UNILET LANCETS................................... 116

DRUG MART UNILET MICRO TH..................................116

DUANE READE LANCET ALTERN................................ 116

DUANE READE LANCET SUPER..................................117

DUANE READE LANCET ULTRA...................................117

DUANE READE UNIFINE PENTI................................... 117

DUAVEE............................................................................. 19

DUETACT........................................................................... 22

DUET DHA 400................................................................. 82

DUET DHA BALANCED.................................................... 82

DUEXIS...............................................................................71

DULERA............................................................................. 45

duloxetine hcl enteric coated pellets cap 40 mg (base

eq)................................................................................... 56

duloxetine hcl enteric coated pellets cap 20 mg

(base eq), 30 mg (base eq), 60 mg (base eq)

(Cymbalta)...................................................................... 56

DUOBRII.............................................................................98

DUO-CARE TEST STRIPS............................................. 105

DUPIXENT..........................................................................98

DUREZOL...........................................................................90

DURLAZA........................................................................... 88

dutasteride cap 0.5 mg (Avodart).................................. 54

dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)......54

DUTOPROL........................................................................36

DXEVO 11-DAY..................................................................17

DYANAVEL XR...................................................................62

DYMISTA............................................................................ 43

DYRENIUM.........................................................................38

EASY COMFORT INSULIN SYRI................................... 117

EASY COMFORT LANCETS.......................................... 117

EASY COMFORT LANCETS 30G/................................. 117

EASY COMFORT LANCETS TWIS................................ 117

EASY COMFORT PEN NEEDLES................................. 117

EASY GLIDE PEN NEEDLES 33................................... 117

EASYGLUCO................................................................... 106

EASYMAX TEST STRIPS............................................... 106

EASYMAX 15 TEST STRIPS..........................................106

EASY MINI EJECT LANCING D.....................................117

EASY MINI LANCING DEVICE.......................................117

EASY PLUS II BLOOD GLUCOS................................... 105

EASYPRO BLOOD GLUCOSE TES...............................106

EASYPRO PLUS............................................................. 106

EASY STEP TEST STRIPS............................................ 105

EASY TALK BLOOD GLUCOSE T................................. 105

EASY TALK PLUS II BLOOD G......................................105

EASY TOUCH FLIPLOCK SAFET.................................. 117

EASY TOUCH GLUCOSE TEST S.................................105

EASY TOUCH 32GX5MM............................................... 118

EASY TOUCH 32GX6MM............................................... 118

EASY TOUCH HEALTHPRO GLUC............................... 105

EASY TOUCH INSULIN SYRING................................... 117

EASY TOUCH LANCETS 30G/BU..................................118

EASY TOUCH LANCETS 21G/PR..................................117

EASY TOUCH LANCETS 23G/PR..................................117

EASY TOUCH LANCETS 26G/PR..................................117

EASY TOUCH LANCETS 28G/PR..................................117

EASY TOUCH LANCETS 30G/PR..................................118

EASY TOUCH LANCETS 32G/PR..................................118

EASY TOUCH LANCETS 26G/PU..................................117

EASY TOUCH LANCETS 28G/PU..................................117

EASY TOUCH LANCETS 30G/PU..................................118

EASY TOUCH LANCETS 32G/PU..................................118

EASY TOUCH LANCETS 28G/TW................................. 117

EASY TOUCH LANCETS 30G/TW................................. 118

EASY TOUCH LANCETS 32G/TW................................. 118

EASY TOUCH LANCETS 33G/TW................................. 118

EASY TOUCH LANCING DEVICE..................................118

EASY TOUCH PEN NEEDLE 30.................................... 118

EASY TOUCH PEN NEEDLE/30.................................... 118

EASY TOUCH PEN NEEDLES 29..................................118

EASY TOUCH PEN NEEDLES 31..................................118

EASY TOUCH PEN NEEDLES 32..................................118

EASY TOUCH PEN NEEDLES/31..................................118

EASY TOUCH SAFETY LANCETS................................ 118

EASY TOUCH SAFETY PEN NEE................................. 118

EASY TOUCH SHEATHLOCK SAF................................118

EASY TRAK BLOOD GLUCOSE T................................ 105

EASY TRAK II BLOOD GLUCOS................................... 105

EC-NAPROSYN................................................................. 71

econazole nitrate cream 1%........................................... 98

ECOZA................................................................................98

EDARBI...............................................................................36

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 158

EDARBYCLOR...................................................................36

EDECRIN............................................................................38

EDLUAR............................................................................. 60

EDURANT............................................................................ 5

E.E.S. GRANULES.............................................................. 2

efavirenz cap 50 mg, 200 mg (Sustiva)........................... 5

efavirenz-emtricitabine-tenofovir df tab 600-200-300

mg......................................................................................5

efavirenz-lamivudine-tenofovir df tab 600-300-300 mg

(Symfi)...............................................................................5

efavirenz-lamivudine-tenofovir df tab 400-300-300 mg

(Symfi lo)..........................................................................5

efavirenz tab 600 mg (Sustiva)........................................ 5

EFFEXOR XR.................................................................... 56

EFFIENT.............................................................................88

EFUDEX............................................................................. 98

EGRIFTA SV...................................................................... 28

ELEMENT COMPACT TEST STRI................................. 106

ELEMENT TEST STRIPS............................................... 106

ELEPSIA XR...................................................................... 76

ELESTRIN.......................................................................... 19

eletriptan hydrobromide tab 20 mg (base equivalent),

40 mg (base equivalent) (Relpax)............................... 73

ELIDEL................................................................................98

ELIGARD............................................................................ 12

ELIQUIS..............................................................................87

ELIQUIS STARTER PACK................................................ 87

ELITE-OB........................................................................... 82

ELIXOPHYLLIN.................................................................. 45

ELLA................................................................................... 20

ELLUME COVID-19 HOME TEST.................................. 106

ELMIRON........................................................................... 54

ELYXYB.............................................................................. 73

EMBRACE BLOOD GLUCOSE TES.............................. 106

EMBRACE EVO BLOOD GLUCOSE..............................106

EMBRACE LANCETS ULTRA THI..................................118

EMBRACE LANCING DEVICE WI..................................118

EMBRACE PRESSURE ACTIVATE................................118

EMBRACE PRO BLOOD GLUCOSE............................. 106

EMBRACE TALK BLOOD GLUCOS............................... 106

EMCYT............................................................................... 12

EMEND............................................................................... 50

EMEND TRIPACK..............................................................50

EMFLAZA........................................................................... 17

EMGALITY..........................................................................73

EMPAVELI.......................................................................... 88

EMSAM...............................................................................56

emtricitabine caps 200 mg (Emtriva).............................. 5

emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg, 133-200 mg, 167-250 mg (Truvada).........5

emtricitabine-tenofovir disoproxil fumarate tab

200-300 mg (Truvada).....................................................5

EMTRIVA.............................................................................. 5

EMVERM.............................................................................. 9

enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................... 36

enalapril maleate & hydrochlorothiazide tab 10-25 mg

(Vaseretic)...................................................................... 36

enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg

(Vasotec).........................................................................36

ENBRACE HR....................................................................82

ENBREL..............................................................................71

ENBREL MINI.................................................................... 71

ENBREL SURECLICK....................................................... 71

ENCARE.............................................................................53

ENDARI.............................................................................. 86

ENDOMETRIN................................................................... 53

enoxaparin sodium inj 300 mg/3ml (Lovenox)............. 87

enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40

mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120

mg/0.8ml, 150 mg/ml (Lovenox)..................................87

ENSPRYNG......................................................................143

ENSTILAR.......................................................................... 98

entacapone tab 200 mg (Comtan)................................. 79

ENTADFI.............................................................................54

entecavir tab 0.5 mg, 1 mg (Baraclude).......................... 5

ENTRESTO........................................................................ 41

ENVARSUS XR................................................................143

EPANED............................................................................. 36

EPCLUSA............................................................................. 6

EPIDIOLEX.........................................................................76

EPIDUO.............................................................................. 99

EPIDUO FORTE................................................................ 99

EPIFOAM............................................................................99

epinastine hcl ophth soln 0.05%....................................90

EPINEPHRINE................................................................... 39

epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000) (Epipen-jr 2-pak)............................................ 39

epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (Epipen 2-pak)................................................ 39

EPIPEN-JR 2-PAK............................................................. 39

EPIPEN 2-PAK................................................................... 39

EPIVIR.................................................................................. 6

EPIVIR HBV......................................................................... 6

eplerenone tab 25 mg, 50 mg (Inspra).......................... 36

EPOGEN............................................................................ 86

EPRONTIA......................................................................... 76

EPSOLAY........................................................................... 99

EPZICOM..............................................................................6

EQ BLOOD GLUCOSE TEST STR................................ 106

EQL COLOR LANCETS 21G..........................................118

EQL COLOR LANCETS MICRO T................................. 118

EQL INSULIN SYRINGE/0.3ML......................................118

EQL INSULIN SYRINGE/0.5ML......................................118

EQL INSULIN SYRINGE/1ML/2......................................118

EQL INSULIN SYRINGE/1ML/3......................................119

EQL SHORT PEN NEEDLES 31G................................. 119

EQL SUPER THIN LANCETS 30................................... 119

EQL THIN LANCETS 26G.............................................. 119

EQL ULTRA SHORT PEN NEEDL................................. 119

EQUETRO.......................................................................... 59

ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)........ 81

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 159

ERGOLOID MESYLATES..................................................64

ERGOMAR......................................................................... 73

ergotamine w/ caffeine tab 1-100 mg (Cafergot).......... 73

ERIVEDGE......................................................................... 12

ERLEADA........................................................................... 12

erlotinib hcl tab 25 mg (base equivalent), 100

mg (base equivalent), 150 mg (base equivalent)

(Tarceva).........................................................................12

ERTACZO........................................................................... 99

ERY.....................................................................................99

ERYGEL............................................................................. 99

ERYPED 200........................................................................2

ERYPED 400........................................................................2

ERYTHROCIN STEARATE................................................. 2

ERYTHROMYCIN................................................................ 2

ERYTHROMYCIN ETHYLSUCCINA...................................2

erythromycin ethylsuccinate for susp 200 mg/5ml

(E.e.s. granules).............................................................. 2

erythromycin ethylsuccinate for susp 400 mg/5ml

(Eryped 400).....................................................................2

erythromycin gel 2% (Erygel).........................................99

erythromycin ophth oint 5 mg/gm.................................90

erythromycin soln 2%..................................................... 99

erythromycin tab delayed release 250 mg, 333 mg,

500 mg.............................................................................. 2

erythromycin tab 250 mg, 500 mg................................... 2

ESBRIET............................................................................ 47

escitalopram oxalate soln 5 mg/5ml (base equiv)....... 56

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

(base equiv), 20 mg (base equiv) (Lexapro).............. 56

ESGIC.................................................................................67

esomeprazole magnesium cap delayed release 20 mg

(base eq), 40 mg (base eq) (Nexium)......................... 48

esomeprazole magnesium for delayed release susp

packet 10 mg, 20 mg, 40 mg (Nexium).......................48

ESOMEPRAZOLE STRONTIUM...................................... 48

estazolam tab 1 mg, 2 mg.............................................. 60

ESTRACE...........................................................................19

estradiol & norethindrone acetate tab 0.5-0.1 mg........19

estradiol & norethindrone acetate tab 1-0.5 mg

(Activella)....................................................................... 19

estradiol tab 0.5 mg, 1 mg, 2 mg (Estrace)...................19

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

mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

(Vivelle-dot)....................................................................19

estradiol td patch weekly 0.025 mg/24hr, 0.0375

mg/24hr (37.5 mcg/24hr), 0.05 mg/24hr, 0.06

mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Climara).........19

estradiol vaginal cream 0.1 mg/gm (Estrace)...............54

estradiol valerate im in oil 20 mg/ml, 40 mg/ml

(Delestrogen)................................................................. 19

ESTRING............................................................................54

ESTROGEL........................................................................ 19

eszopiclone tab 1 mg, 2 mg, 3 mg (Lunesta)............... 60

ethacrynic acid tab 25 mg (Edecrin)............................. 38

ethambutol hcl tab 100 mg...............................................4

ethambutol hcl tab 400 mg (Myambutol)........................ 4

ethosuximide cap 250 mg (Zarontin)............................ 76

ethosuximide soln 250 mg/5ml (Zarontin).................... 76

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg, 1 mg-50 mcg........................................................20

etodolac cap 200 mg, 300 mg........................................ 71

etodolac tab er 24hr 600 mg.......................................... 71

etodolac tab er 24hr 400 mg, 500 mg............................71

etodolac tab 500 mg........................................................71

etodolac tab 400 mg (Lodine)........................................ 71

etonogestrel-ethinyl estradiol va ring 0.120-0.015

mg/24hr (Nuvaring).......................................................20

ETOPOSIDE.......................................................................12

etravirine tab 100 mg, 200 mg (Intelence)...................... 6

EUA PATIENT ASSESSMENT........................................143

EUCRISA............................................................................99

EULEXIN............................................................................ 12

EVAMIST............................................................................ 19

EVEKEO............................................................................. 62

EVEKEO ODT.................................................................... 62

EVENCARE BLOOD GLUCOSE TE...............................106

everolimus tab for oral susp 2 mg, 3 mg, 5 mg

(Afinitor disperz)........................................................... 12

everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg

(Afinitor)......................................................................... 12

everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg

(Zortress)......................................................................143

EVISTA............................................................................... 28

EVOCLIN............................................................................ 99

EVOLUTION AUTOCODE...............................................106

EVOTAZ................................................................................6

EVOXAC.............................................................................94

EVRYSDI............................................................................ 80

EXCEL COMFORT POINT INSUL..................................119

EXEL COMFORT POINT INSULI................................... 119

EXELDERM........................................................................ 99

EXELON............................................................................. 64

exemestane tab 25 mg (Aromasin)................................12

EXFORGE.......................................................................... 36

EXFORGE HCT................................................................. 36

EXJADE............................................................................104

EXKIVITY............................................................................12

EXONDYS 51.....................................................................80

EXSERVAN.........................................................................80

EXTAVIA............................................................................. 64

EXTINA............................................................................... 99

EYSUVIS............................................................................ 90

EZALLOR SPRINKLE........................................................39

EZETIMIBE/ROSUVASTATIN............................................40

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

mg, 10-80 mg (Vytorin).................................................40

ezetimibe tab 10 mg (Zetia)............................................ 39

E-Z JECT LANCETS....................................................... 117

E-Z JECT LANCETS COLOR......................................... 117

E-Z JECT LANCETS 21G............................................... 117

E-ZJECT LANCETS MICRO-THI.................................... 117

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 160

E-Z JECT LANCETS SUPER TH................................... 117

E-Z JECT LANCETS THIN 26G..................................... 117

EZ-LETS LANCETS 21G................................................ 119

EZ-LETS LANCETS 30G................................................ 119

EZ-LETS LANCETS 26G SUPER...................................119

EZ-LETS LANCETS 28G ULTRA....................................119

FABIOR...............................................................................99

famciclovir tab 125 mg, 250 mg, 500 mg........................ 6

famotidine tab 20 mg (Pepcid)....................................... 48

famotidine tab 40 mg (Pepcid)....................................... 48

FANAPT.............................................................................. 59

FANAPT TITRATION PACK.............................................. 59

FARESTON........................................................................ 12

FARXIGA............................................................................ 22

FASENRA PEN.................................................................. 45

FC2 FEMALE CONDOM................................................. 119

febuxostat tab 40 mg, 80 mg (Uloric)............................75

felbamate susp 600 mg/5ml (Felbatol).......................... 76

felbamate tab 400 mg, 600 mg (Felbatol)......................76

FELBATOL..........................................................................76

FELDENE........................................................................... 71

felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg.................. 33

FEMARA.............................................................................12

FEMCAP...........................................................................119

FEMRING........................................................................... 54

FENOFIBRATE...................................................................40

FENOFIBRATE MICRONIZED.......................................... 40

fenofibrate micronized cap 43 mg, 130 mg.................. 40

fenofibrate micronized cap 67 mg, 134 mg, 200

mg................................................................................... 40

fenofibrate tab 54 mg, 160 mg....................................... 40

fenofibrate tab 40 mg, 120 mg (Fenoglide)...................40

fenofibrate tab 48 mg, 145 mg (Tricor)..........................40

FENOFIBRIC ACID............................................................40

FENOGLIDE....................................................................... 40

FENOPROFEN CALCIUM.................................................71

fenoprofen calcium cap 400 mg (Nalfon)......................71

fenoprofen calcium tab 600 mg (Nalfon)...................... 71

FENORTHO........................................................................71

FENTANYL CITRATE........................................................ 68

fentanyl citrate lozenge on a handle 200 mcg, 400

mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg

(Actiq)............................................................................. 68

fentanyl td patch 72hr 37.5 mcg/hr, 62.5 mcg/hr, 87.5

mcg/hr.............................................................................68

fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/

hr, 75 mcg/hr, 100 mcg/hr............................................68

FENTORA...........................................................................68

FERRIPROX.....................................................................104

FERRIPROX TWICE-A-DAY........................................... 104

FERROUS SULFATE.........................................................86

ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental

fe).....................................................................................86

ferrous sulfate soln 75 mg/ml (15 mg/ml elemental

fe).....................................................................................86

ferrous sulfate syrup 300 mg/5ml (60 mg/5ml

elemental fe).................................................................. 86

fesoterodine fumarate tab er 24hr 4 mg, 8 mg

(Toviaz)........................................................................... 53

FETZIMA............................................................................ 56

FETZIMA TITRATION PACK............................................. 56

FIASP..................................................................................25

FIASP FLEXTOUCH..........................................................25

FIASP PENFILL................................................................. 25

FIBRICOR...........................................................................40

FIFTY50 GLUCOSE TEST STRI.................................... 106

FIFTY50 PEN NEEDLES/31GX8.................................... 119

FIFTY50 PEN NEEDLES/32GX4.................................... 119

FIFTY50 PEN NEEDLES/32GX6.................................... 119

FIFTY50 PEN NEEDLES 31GX5....................................119

FIFTY50 PEN NEEDLES 31G X.....................................119

FIFTY50 SAFETY SEAL LANCE.................................... 119

FIFTY50 SUPERIOR COMFORT....................................119

FIFTY50 UNILET LANCETS 33......................................119

FINACEA............................................................................ 99

finasteride tab 5 mg (Proscar)....................................... 54

FINE 30............................................................................ 119

FINGERSTIX LANCETS..................................................119

FINTEPLA...........................................................................76

FIORICET........................................................................... 67

FIORICET/CODEINE......................................................... 68

FIRAZYR............................................................................ 88

FIRDAPSE..........................................................................81

FIRVANQ.............................................................................. 9

FLAGYL.............................................................................. 10

FLAREX..............................................................................90

flavoxate hcl tab 100 mg.................................................53

flecainide acetate tab 50 mg, 100 mg, 150 mg............. 34

FLECTOR........................................................................... 99

FLEQSUVY.........................................................................81

FLOLIPID............................................................................40

FLOMAX............................................................................. 54

FLORIVA.............................................................................85

FLOVENT DISKUS............................................................ 45

FLOVENT HFA...................................................................45

FLOWFLEX COVID-19 ANTIGEN.................................. 106

fluconazole for susp 10 mg/ml, 40 mg/ml (Diflucan)..... 4

fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg

(Diflucan).......................................................................... 4

flucytosine cap 250 mg, 500 mg (Ancobon)...................4

fludrocortisone acetate tab 0.1 mg............................... 17

flunisolide nasal soln 25 mcg/act (0.025%).................. 43

fluocinolone acetonide cream 0.01%............................ 99

fluocinolone acetonide cream 0.025% (Synalar)..........99

fluocinolone acetonide oil 0.01% (body oil) (Derma-

smoothe/fs bod)............................................................ 99

fluocinolone acetonide oil 0.01% (scalp oil) (Derma-

smoothe/fs sca).............................................................99

fluocinolone acetonide oint 0.025% (Synalar)..............99

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 161

fluocinolone acetonide (otic) oil 0.01% (Dermotic)......93

fluocinolone acetonide soln 0.01% (Synalar)...............99

fluocinonide cream 0.05%.............................................. 99

fluocinonide cream 0.1% (Vanos).................................. 99

fluocinonide emulsified base cream 0.05%..................99

fluocinonide gel 0.05%.................................................... 99

fluocinonide oint 0.05%.................................................. 99

fluocinonide soln 0.05%..................................................99

FLUORIDEX SENSITIVITY REL....................................... 94

FLUORIMAX 5000 SENSITIVE.........................................94

fluorometholone ophth susp 0.1% (Fml liquifilm)....... 90

FLUOROURACIL............................................................... 99

fluorouracil cream 5% (Efudex)..................................... 99

FLUOXETINE DR.............................................................. 56

fluoxetine hcl cap 10 mg, 20 mg, 40 mg (Prozac)........ 56

fluoxetine hcl solution 20 mg/5ml................................. 56

fluoxetine hcl tab 10 mg, 20 mg.................................... 56

fluoxetine hcl tab 60 mg (Fluoxetine hydrochlo)......... 56

FLUOXETINE HYDROCHLORIDE................................... 56

FLUPHENAZINE HCL....................................................... 59

fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg..........59

FLUPHENAZINE HYDROCHLORID................................. 59

flurandrenolide cream 0.05% (Cordran)........................99

flurandrenolide lotion 0.05% (Cordran).........................99

FLURAZEPAM HCL........................................................... 60

FLURBIPROFEN................................................................71

FLURBIPROFEN SODIUM................................................90

flurbiprofen tab 100 mg.................................................. 71

FLUTAMIDE........................................................................12

FLUTICASONE FUROATE/VILAN.................................... 45

FLUTICASONE PROPIONATE/SA................................... 45

fluticasone propionate cream 0.05%.............................99

FLUTICASONE PROPIONATE HF................................... 45

fluticasone propionate lotion 0.05%..............................99

fluticasone propionate oint 0.005%...............................99

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

250-50 mcg/act, 500-50 mcg/act (Advair diskus)...... 45

fluvastatin sodium cap 20 mg (base equivalent), 40

mg (base equivalent)....................................................40

fluvastatin sodium tab er 24 hr 80 mg (base

equivalent) (Lescol xl)..................................................40

fluvoxamine maleate cap er 24hr 100 mg, 150 mg.......57

fluvoxamine maleate tab 25 mg, 50 mg, 100 mg..........57

FML.....................................................................................90

FML FORTE....................................................................... 90

FML LIQUIFILM................................................................. 90

FOCALIN............................................................................ 62

FOCALIN XR......................................................................62

folic acid cap 0.8 mg....................................................... 86

folic acid tab 400 mcg, 800 mcg....................................86

folic acid tab 1 mg...........................................................86

FOLIVANE-OB....................................................................82

FOLLISTIM AQ.................................................................. 28

fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml,

5 mg/0.4ml, 7.5 mg/0.6ml, 10 mg/0.8ml (Arixtra)....... 87

FORA BLOOD GLUCOSE TEST S................................ 106

FORACARE GD40...........................................................106

FORACARE PREMIUM V10 TEST.................................106

FORACARE TEST N GO TEST S.................................. 106

FORA 6 CONNECT......................................................... 106

FORA D40/G31 BLOOD GLUCOS................................. 106

FORA D20 BLOOD GLUCOSE TE.................................106

FORA D15G BLOOD GLUCOSE T................................ 106

FORA G30/PREMIUM V10 BLOO.................................. 106

FORA G20 BLOOD GLUCOSE TE................................ 106

FORA GD50 BLOOD GLUCOSE T................................ 106

FORA GD20 TEST STRIPS............................................106

FORA GTEL BLOOD GLUCOSE T................................ 106

FORA LANCETS..............................................................119

FORA LANCING DEVICE............................................... 119

FORA LANCING DEVICE/CLEAR.................................. 119

FORA TN'G/TN'G VOICE BLOO.....................................106

FORA TN'G ADVANCE PRO BLO..................................106

FORA V30A BLOOD GLUCOSE T.................................106

FORA V10 BLOOD GLUCOSE TE.................................106

FORA V12 BLOOD GLUCOSE TE.................................106

FORA V20 BLOOD GLUCOSE TE.................................106

FORFIVO XL...................................................................... 57

formoterol fumarate soln nebu 20 mcg/2ml

(Perforomist)..................................................................45

FORTEO.............................................................................28

FORTESTA......................................................................... 18

FORTISCARE BLOOD GLUCOSE................................. 106

FORTISCARE G1 BLOOD GLUCO................................ 106

FOSAMAX.......................................................................... 28

FOSAMAX PLUS D........................................................... 28

fosamprenavir calcium tab 700 mg (base equiv)

(Lexiva)............................................................................. 6

fosfomycin tromethamine powd pack 3 gm (base

equivalent) (Monurol)................................................... 10

fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg, 20-12.5 mg..............................................................36

fosinopril sodium tab 10 mg, 20 mg, 40 mg................. 36

FOSRENOL........................................................................ 51

FOTIVDA............................................................................ 12

FRAGMIN........................................................................... 87

FREDS PHARMACY AUTOLET LA................................119

FREDS PHARMACY UNIFINE PE................................. 119

FREDS PHARMACY UNILET LAN.................................119

FREESTYLE INSULINX BLOOD.................................... 106

FREESTYLE LANCETS.................................................. 119

FREESTYLE LIBRE 2/READER/.................................... 120

FREESTYLE LIBRE/READER/FL................................... 120

FREESTYLE LIBRE 2/SENSOR/....................................120

FREESTYLE LIBRE 3/SENSOR/....................................120

FREESTYLE LIBRE 14 DAY/RE.....................................120

FREESTYLE LIBRE 14 DAY/SE..................................... 120

FREESTYLE LITE TEST STRIP.....................................107

FREESTYLE PRECISION NEO B.................................. 107

FREESTYLE TEST STRIPS........................................... 107

FREESTYLE UNISTICK II LAN.......................................120

FROVA................................................................................73

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 162

frovatriptan succinate tab 2.5 mg (base equivalent)

(Frova).............................................................................73

FULPHILA...........................................................................86

FUROSEMIDE....................................................................38

furosemide oral soln 10 mg/ml...................................... 38

furosemide tab 20 mg, 40 mg, 80 mg (Lasix)............... 38

FUZEON............................................................................... 6

FYCOMPA.......................................................................... 76

gabapentin cap 100 mg, 300 mg, 400 mg

(Neurontin)..................................................................... 76

gabapentin oral soln 250 mg/5ml (Neurontin)..............76

gabapentin tab 600 mg, 800 mg (Neurontin)................ 76

GABITRIL........................................................................... 76

GALAFOLD.........................................................................28

GALANTAMINE HYDROBROMIDE.................................. 64

galantamine hydrobromide cap er 24hr 8 mg, 16 mg,

24 mg (Razadyne er).................................................... 64

galantamine hydrobromide tab 4 mg, 8 mg, 12 mg..... 64

GALZIN............................................................................... 85

GANIRELIX ACETATE.......................................................28

ganirelix acetate soln prefilled syringe 250 mcg/0.5ml

(Ganirelix acetate).........................................................28

GASTROCROM................................................................. 51

gatifloxacin ophth soln 0.5% (Zymaxid)....................... 90

GATTEX..............................................................................51

GAVILYTE-C.......................................................................47

GAVRETO...........................................................................12

GE100 BLOOD GLUCOSE TEST...................................107

GELNIQUE......................................................................... 53

gemfibrozil tab 600 mg (Lopid)...................................... 40

GEMTESA.......................................................................... 53

GENERESS FE..................................................................20

GENOTROPIN................................................................... 28

GENOTROPIN MINIQUICK...............................................28

GENTAK............................................................................. 90

gentamicin sulfate cream 0.1%......................................99

gentamicin sulfate ophth soln 0.3%..............................90

GENTEEL BUTTERFLY TOUCH L................................. 120

GENTEEL PLUS LANCING DEVI...................................120

GENTLE-LET GP LANCETS...........................................120

GENTLE-LET LANCETS GENERA................................ 120

GENTLE-LET LANCETS SAFETY..................................120

GENULTIMATE TEST STRIPS....................................... 107

GENVOYA............................................................................ 6

GEODON............................................................................59

GHT TEST STRIPS......................................................... 107

GILENYA.............................................................................64

GILOTRIF........................................................................... 12

GIMOTI............................................................................... 51

glatiramer acetate soln prefilled syringe 20 mg/ml, 40

mg/ml (Copaxone)........................................................ 64

glatiramer acetate soln prefilled syringe 20 mg/ml -

glatopa (Copaxone)...................................................... 64

glatiramer acetate soln prefilled syringe 40 mg/ml -

glatopa (Copaxone)...................................................... 64

GLEEVEC...........................................................................12

GLEOSTINE....................................................................... 12

glimepiride tab 1 mg, 2 mg, 4 mg (Amaryl).................. 22

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

5-500 mg.........................................................................22

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

xl).....................................................................................22

glipizide tab 5 mg, 10 mg............................................... 22

GLOBAL EASE INJECT PEN NE................................... 120

GLOBAL EASY GLIDE INSULIN.................................... 120

GLOBAL EASY GLIDE PEN NEE.................................. 120

GLOBAL INJECT EASE INSULI..................................... 120

GLOBAL INJECT EASE LANCET.................................. 120

GLOBAL INSULIN SYRINGE/U-.....................................120

GLOBAL INSULIN SYRINGES/U....................................120

GLOBAL LANCING DEVICE...........................................120

GLUCAGEN HYPOKIT...................................................... 22

GLUCAGON EMERGENCY KIT....................................... 22

GLUCAGON EMERGENCY KIT FO.................................22

glucagon (rdna) for inj kit 1 mg (Glucagon emergency

k)......................................................................................22

GLUCOCARD EXPRESSION BLOO.............................. 107

GLUCOCARD 01 SENSOR PLUS..................................107

GLUCOCARD SHINE TEST STRI..................................107

GLUCOCARD VITAL TEST STRI................................... 107

GLUCOCARD X-SENSOR.............................................. 107

GLUCOCOM LANCETS 28G.......................................... 120

GLUCOCOM LANCETS 30G.......................................... 120

GLUCOCOM LANCETS 33G.......................................... 120

GLUCOCOM TEST STRIPS........................................... 107

GLUCONAVII BLOOD GLUCOSE.................................. 107

GLUCO PERFECT 3 TEST STRI................................... 107

GLUCOPRO INSULIN SYRINGE/.................................. 120

GLUCOSE METER TEST STRIPS.................................107

GLUCOTROL XL............................................................... 22

GLUMETZA........................................................................ 22

glyburide-metformin tab 1.25-250 mg, 2.5-500 mg,

5-500 mg.........................................................................22

glyburide micronized tab 1.5 mg, 3 mg, 6 mg

(Glynase)........................................................................ 22

glyburide tab 1.25 mg, 2.5 mg, 5 mg............................. 22

GLYCATE............................................................................48

GLYCOPYRROLATE..........................................................48

glycopyrrolate oral soln 1 mg/5ml (Cuvposa).............. 48

glycopyrrolate tab 1 mg (Robinul).................................49

glycopyrrolate tab 2 mg (Robinul forte)........................49

GLYNASE........................................................................... 22

GLYXAMBI..........................................................................23

GNP CLICKFINE UNIVERSAL P....................................121

GNP EASY TOUCH GLUCOSE TE................................107

GNP INSULIN SYRINGE/0.3ML..................................... 121

GNP INSULIN SYRINGE/0.5ML..................................... 121

GNP INSULIN SYRINGE/1ML/2..................................... 121

GNP INSULIN SYRINGE/1ML/3..................................... 121

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 163

GNP INSULIN SYRINGES/1/2M.....................................121

GNP INSULIN SYRINGES/0.3M.....................................121

GNP INSULIN SYRINGES/1ML/.....................................121

GNP INSULIN SYRINGES/3ML/.....................................121

GNP LANCETS 21G........................................................121

GNP LANCETS THIN 26G..............................................121

GNP LANCING SYSTEM DEVICE................................. 121

GNP STERILE LANCETS 28G....................................... 121

GNP STERILE LANCETS 30G....................................... 121

GNP STERILE LANCETS 33G....................................... 121

GNP TRUE METRIX SELF MONI.................................. 107

GNP TRUETRACK BLOOD GLUCO.............................. 107

GNP TRUETRACK SMART SYSTE............................... 107

GNP ULTICARE PEN NEEDLES....................................121

GNP ULTICARE PEN NEEDLES/...................................121

GNP ULTIGUARD SAFEPACK/MI.................................. 121

GNP ULTIGUARD SAFEPACK/SH................................. 121

GNP ULTRA COMFORT INSULIN..................................121

GOCOVRI...........................................................................79

GOJJI BLOOD GLUCOSE TEST....................................107

GOJJI LANCING DEVICE/CLEA.................................... 121

GOJJI STERILE LANCETS 30G.....................................121

GOLYTELY......................................................................... 47

GONAL-F............................................................................29

GONAL-F RFF................................................................... 29

GONAL-F RFF REDIJECT................................................ 29

GONITRO........................................................................... 31

GOODSENSE CLICKFINE SAFET.................................121

GOODSENSE COLOR LANCETS M..............................121

GOODSENSE LANCETS MICRO-T............................... 121

GOODSENSE LANCETS ULTRA-T................................121

GOODSENSE LANCING DEVICE..................................121

GOODSENSE PEN NEEDLE/PENF...............................121

GOODSENSE PREMIUM BLOOD G..............................107

GRALISE............................................................................ 64

granisetron hcl tab 1 mg................................................ 50

GRANIX.............................................................................. 86

GRASTEK...........................................................................11

griseofulvin microsize susp 125 mg/5ml........................ 4

griseofulvin microsize tab 500 mg.................................. 4

griseofulvin ultramicrosize tab 125 mg, 250 mg............ 4

guanfacine hcl tab er 24hr 1 mg (base equiv), 2 mg

(base equiv), 3 mg (base equiv), 4 mg (base equiv)

(Intuniv).......................................................................... 62

guanfacine hcl tab 1 mg, 2 mg...................................... 36

GVOKE HYPOPEN 1-PACK............................................. 23

GVOKE HYPOPEN 2-PACK............................................. 23

GVOKE KIT........................................................................ 23

GVOKE PFS.......................................................................23

GYNAZOLE-1.....................................................................54

HAEGARDA........................................................................89

HAEMOLANCE................................................................ 122

HAEMOLANCE LOW FLOW LANCE............................. 122

HAEMOLANCE PLUS..................................................... 122

HAEMOLANCE PLUS HIGH FLOW............................... 122

HAEMOLANCE PLUS LOW FLOW................................ 122

HAEMOLANCE PLUS MAX FLOW................................ 122

HAEMOLANCE PLUS PEDIATRIC.................................122

halcinonide cream 0.1% (Halog).................................... 99

HALCION............................................................................60

HALOBETASOL PROPIONATE........................................ 99

halobetasol propionate cream 0.05%............................99

halobetasol propionate oint 0.05%................................99

HALOG............................................................................... 99

haloperidol lactate oral conc 2 mg/ml...........................59

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

mg................................................................................... 59

HARVONI..............................................................................6

HEALTH CARE LANCING DEVIC.................................. 122

HEALTHWISE INSULIN SYRING................................... 122

HEALTHWISE MICRON PEN NEE.................................122

HEALTHWISE MINI PEN NEEDL................................... 122

HEALTHWISE PEN NEEDLES 29.................................. 122

HEALTHWISE SHORT PEN NEED................................ 122

HEALTHWISE UNIFINE PENTIP.................................... 122

HEALTHY ACCENTS AUTOLET I.................................. 122

HEALTHY ACCENTS UNIFINE P................................... 122

HEALTHY ACCENTS UNILET LA...................................122

H-E-B INCONTROL ADVANCED....................................122

H-E-B INCONTROL LANCETS M...................................122

H-E-B INCONTROL LANCETS S................................... 122

H-E-B INCONTROL LANCETS U................................... 122

H-E-B IN CONTROL PEN NEED....................................122

H-E-B INCONTROL PEN NEEDL................................... 122

H-E-B IN CONTROL UNIFINE........................................ 122

HELIDAC THERAPY......................................................... 49

HEMADY............................................................................ 17

HEMANGEOL.....................................................................32

HEPARIN SODIUM............................................................ 88

heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/

ml, 10000 unit/ml, 20000 unit/ml................................. 88

heparin sodium (porcine) pf inj 5000 unit/0.5ml.......... 88

HEPSERA.............................................................................6

HETLIOZ.............................................................................60

HETLIOZ LQ...................................................................... 61

HIPREX...............................................................................10

HM ULTICARE INSULIN SYRIN..................................... 123

HM ULTICARE MINI PEN NEED.................................... 123

HM ULTICARE SHORT PEN NEE..................................123

HORIZANT......................................................................... 64

HUMALOG..........................................................................25

HUMALOG JUNIOR KWIKPEN........................................ 25

HUMALOG KWIKPEN....................................................... 25

HUMALOG MIX 50/50....................................................... 26

HUMALOG MIX 75/25....................................................... 26

HUMALOG MIX 50/50 KWIKPEN..................................... 26

HUMALOG MIX 75/25 KWIKPEN..................................... 26

HUMATIN..............................................................................3

HUMATROPE..................................................................... 29

HUMIRA..............................................................................71

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 164

HUMIRA PEDIATRIC CROHNS D.................................... 71

HUMIRA PEN.....................................................................71

HUMIRA PEN-CD/UC/HS START.....................................71

HUMIRA PEN-PEDIATRIC UC S...................................... 71

HUMIRA PEN-PS/UV STARTER...................................... 71

HUMULIN 70/30.................................................................26

HUMULIN 70/30 KWIKPEN...............................................26

HUMULIN N....................................................................... 26

HUMULIN N KWIKPEN..................................................... 26

HUMULIN R....................................................................... 25

HUMULIN R U-500 (CONCENTR.....................................25

HUMULIN R U-500 KWIKPEN..........................................25

HW EMBRACE PRO BLOOD GLUC..............................107

HW EMBRACE TALK BLOOD GLU................................107

HYCAMTIN......................................................................... 12

HYCODAN..........................................................................43

hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg....... 36

HYDREA.............................................................................12

hydrochlorothiazide cap 12.5 mg.................................. 38

hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg.......... 38

HYDROCODONE/IBUPROFEN........................................ 68

hydrocodone-acetaminophen soln 7.5-325

mg/15ml.......................................................................... 68

hydrocodone-acetaminophen tab 10-325 mg, 5-325

mg, 7.5-325 mg..............................................................68

hydrocodone-acetaminophen tab 5-300 mg, 7.5-300

mg, 10-300 mg...............................................................68

HYDROCODONE BITARTRATE ER.................................68

hydrocodone bitartrate tab er 24hr deter 20 mg, 30

mg, 40 mg, 60 mg, 80 mg, 100 mg, 120 mg (Hysingla

er).................................................................................... 68

hydrocodone-ibuprofen tab 7.5-200 mg........................68

hydrocod polst-chlorphen polst er susp 10-8

mg/5ml............................................................................ 43

HYDROCORTISONE BUTYRATE.................................. 100

hydrocortisone butyrate hydrophilic lipo base cream

0.1% (Locoid lipocream)............................................ 100

hydrocortisone butyrate lotion 0.1% (Locoid)........... 100

hydrocortisone butyrate oint 0.1%.............................. 100

hydrocortisone cream 1%.............................................100

hydrocortisone cream 2.5%..........................................100

hydrocortisone enema 100 mg/60ml (Cortenema).......95

hydrocortisone lotion 2.5%.......................................... 100

hydrocortisone oint 1%.................................................100

hydrocortisone oint 2.5%..............................................100

hydrocortisone perianal cream 2.5% (Anusol-hc)....... 95

hydrocortisone perianal cream 1% (Proctocort)..........95

hydrocortisone tab 5 mg, 10 mg, 20 mg (Cortef)......... 17

hydrocortisone valerate cream 0.2%...........................100

hydrocortisone valerate oint 0.2%...............................100

hydrocortisone w/ acetic acid otic soln 1-2%.............. 93

hydromorphone hcl liqd 1 mg/ml (Dilaudid).................68

hydromorphone hcl tab er 24hr 8 mg, 12 mg, 16 mg,

32 mg.............................................................................. 68

hydromorphone hcl tab 2 mg, 4 mg, 8 mg

(Dilaudid)........................................................................ 68

HYDROXYCHLOROQUINE SULFAT..................................9

hydroxychloroquine sulfate tab 200 mg (Plaquenil)......9

hydroxyprogesterone caproate im in oil 250 mg/ml

(Makena)......................................................................... 21

hydroxyurea cap 500 mg (Hydrea)................................ 12

hydroxyzine hcl syrup 10 mg/5ml................................. 55

hydroxyzine hcl tab 10 mg, 25 mg, 50 mg.................... 55

HYDROXYZINE PAMOATE...............................................55

hydroxyzine pamoate cap 25 mg, 50 mg (Vistaril).......55

HYFTOR........................................................................... 100

HYPERSAL.........................................................................43

HYSINGLA ER................................................................... 68

HY-VEE LANCETS.......................................................... 123

HY-VEE THIN LANCETS................................................ 123

HYZAAR............................................................................. 36

ibandronate sodium tab 150 mg (base equivalent)..... 29

IBRANCE............................................................................12

IBSRELA.............................................................................51

ibuprofen-famotidine tab 800-26.6 mg (Duexis)...........71

ibuprofen susp 100 mg/5ml............................................71

ibuprofen tab 400 mg, 600 mg, 800 mg.........................71

icatibant acetate inj 30 mg/3ml (base equivalent)

(Firazyr).......................................................................... 89

ICLUSIG..............................................................................13

icosapent ethyl cap 1 gm (Vascepa)............................. 40

IDHIFA................................................................................ 13

IGLUCOSE BLOOD GLUCOSE TE................................107

IHEALTH COVID-19 ANTIGEN....................................... 107

ILEVRO...............................................................................91

imatinib mesylate tab 100 mg (base equivalent), 400

mg (base equivalent) (Gleevec).................................. 13

IMBRUVICA........................................................................13

imipramine hcl tab 10 mg, 25 mg, 50 mg......................57

imipramine pamoate cap 75 mg, 100 mg, 125 mg, 150

mg................................................................................... 57

imiquimod cream 5%.....................................................100

imiquimod cream 3.75% (Zyclara)............................... 100

IMITREX............................................................................. 73

IMITREX STATDOSE REFILL........................................... 74

IMITREX STATDOSE SYSTEM........................................ 74

IMPAVIDO...........................................................................10

IMPEKLO..........................................................................100

IMPOYZ............................................................................ 100

IMVEXXY MAINTENANCE PACK.....................................54

IMVEXXY STARTER PACK...............................................54

INATAL GT......................................................................... 82

INBRIJA.............................................................................. 79

INCONTROL ULTICARE MINI P.....................................123

INCRELEX..........................................................................29

INCRUSE ELLIPTA............................................................45

indapamide tab 1.25 mg, 2.5 mg....................................38

INDERAL LA...................................................................... 32

INDERAL XL...................................................................... 32

INDICAID COVID-19 RAPID A........................................107

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 165

INDOCIN.............................................................................71

INDOMETHACIN................................................................71

indomethacin cap er 75 mg............................................71

indomethacin cap 25 mg, 50 mg....................................71

INFINITY BLOOD GLUCOSE TE................................... 107

INFINITY VOICE.............................................................. 107

INGREZZA..........................................................................65

INLYTA................................................................................13

INNOPRAN XL................................................................... 32

INPEN 100/BLUE/LILLY/HUMA.......................................123

INPEN 100/BLUE/NOVOLOG/FI.....................................123

INPEN 100/GREY/LILLY/HUMA......................................123

INPEN 100/GREY/NOVOLOG/FI.................................... 123

INPEN 100/PINK/LILLY/HUMA........................................123

INPEN 100/PINK/NOVOLOG/FI......................................123

INQOVI............................................................................... 13

INREBIC............................................................................. 13

INSPRA...............................................................................36

INSULIN ASPART..............................................................25

INSULIN ASPART FLEXPEN............................................ 25

INSULIN ASPART PENFILL..............................................25

INSULIN ASPART PROTAMINE/...................................... 26

INSULIN GLARGINE......................................................... 26

INSULIN GLARGINE SOLOSTAR.................................... 26

INSULIN LISPRO...............................................................25

INSULIN LISPRO JUNIOR KWI........................................25

INSULIN LISPRO KWIKPEN.............................................25

INSULIN LISPRO PROTAMINE/....................................... 26

INSULIN SYRINGE/0.3ML/30G...................................... 123

INSULIN SYRINGE/0.3ML/31G...................................... 123

INSULIN SYRINGE/0.5ML/27G...................................... 123

INSULIN SYRINGE/0.5ML/28G...................................... 123

INSULIN SYRINGE/0.5ML/30G...................................... 123

INSULIN SYRINGE/0.5ML/31G...................................... 123

INSULIN SYRINGE/1ML/28G X......................................123

INSULIN SYRINGE/1ML/29G X......................................123

INSULIN SYRINGE/1ML/30G X......................................124

INSULIN SYRINGE/NEEDLE 0.......................................123

INSULIN SYRINGE/NEEDLE 1M....................................123

INSULIN SYRINGE/U-100/0.3.........................................123

INSULIN SYRINGE/U-100/0.5.........................................123

INSULIN SYRINGE/U-100/1ML...................................... 123

INSULIN SYRINGE 1ML/31G X......................................123

INSULIN SYRINGES/0.5ML/27.......................................124

INSULIN SYRINGES/0.5ML/28.......................................124

INSULIN SYRINGES/0.5ML/29.......................................124

INSULIN SYRINGES/0.5ML/30.......................................124

INSULIN SYRINGES/0.5ML/31.......................................124

INSULIN SYRINGES/1ML/27GX.....................................124

INSULIN SYRINGES/1ML/28GX.....................................124

INSULIN SYRINGES/1ML/29GX.....................................124

INSULIN SYRINGES/1ML/30GX.....................................124

INSULIN SYRINGES/1ML/31GX.....................................124

INSULIN SYRINGES 0.3ML/31.......................................124

INSULIN SYRINGES 0.5ML/31.......................................124

INSUPEN 33GX4MM.......................................................124

INSUPEN 29G X 12MM.................................................. 124

INSUPEN 31G X 5MM.................................................... 124

INSUPEN 31G X 8MM.................................................... 124

INSUPEN 32G X 4MM.................................................... 124

INSUPEN PEN NEEDLES 32G X...................................124

INSUPEN SENSITIVE 32GX6MM.................................. 124

INSUPEN SENSITIVE 32GX8MM.................................. 124

INSUPEN ULTRAFIN 30GX8MM.................................... 124

INSUPEN ULTRAFIN 31GX6MM.................................... 124

INSUPEN ULTRAFIN 31GX8MM.................................... 124

INTELENCE..........................................................................6

INTELISWAB COVID-19 RAPID..................................... 107

IN TOUCH BLOOD GLUCOSE TE................................. 107

IN TOUCH LANCING DEVICE........................................123

IN TOUCH STERILE LANCETS..................................... 123

INTRAROSA.......................................................................54

INTRON A.......................................................................... 13

INTUNIV..............................................................................62

INVEGA.............................................................................. 59

INVELTYS...........................................................................91

INVOKAMET.......................................................................23

INVOKAMET XR................................................................ 23

INVOKANA......................................................................... 23

IOPIDINE............................................................................ 91

ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 45

ipratropium bromide inhal soln 0.02%..........................45

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

0.06% (42 mcg/spray)................................................... 43

irbesartan-hydrochlorothiazide tab 150-12.5 mg,

300-12.5 mg (Avalide)...................................................36

irbesartan tab 75 mg, 150 mg, 300 mg (Avapro).......... 36

IRESSA...............................................................................13

ISENTRESS......................................................................... 6

ISENTRESS HD...................................................................6

ISONIAZID............................................................................4

isoniazid tab 300 mg......................................................... 4

ISOPTO ATROPINE.......................................................... 91

ISORDIL TITRADOSE....................................................... 31

isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg

(Bidil)...............................................................................41

isosorbide dinitrate tab 10 mg, 20 mg, 30 mg..............31

isosorbide dinitrate tab 5 mg (Isordil titradose).......... 31

isosorbide dinitrate tab 40 mg (Isordil titradose)........ 31

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

mg................................................................................... 31

isosorbide mononitrate tab 10 mg, 20 mg....................31

isotretinoin cap 10 mg, 20 mg, 25 mg, 30 mg, 35 mg,

40 mg (Absorica)........................................................ 100

isradipine cap 2.5 mg, 5 mg........................................... 33

ISTALOL............................................................................. 91

ISTURISA........................................................................... 29

itraconazole cap 100 mg (Sporanox).............................. 4

itraconazole oral soln 10 mg/ml (Sporanox).................. 4

IVERMECTIN................................................................... 100

ivermectin cream 1% (Soolantra)................................ 100

ivermectin tab 3 mg (Stromectol).................................... 9

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 166

JADENU........................................................................... 104

JADENU SPRINKLE........................................................104

JAKAFI................................................................................13

JALYN................................................................................. 54

JANSSEN COVID-19 VACCINE........................................10

JANUMET...........................................................................23

JANUMET XR.................................................................... 23

JANUVIA.............................................................................23

JARDIANCE....................................................................... 23

JATENZO............................................................................18

JENLIVA PRENATAL/POSTNATA..................................... 82

JENTADUETO.................................................................... 23

JENTADUETO XR............................................................. 23

JORNAY PM.......................................................................62

JUBLIA..............................................................................100

JULUCA................................................................................ 6

JUXTAPID...........................................................................40

JYNARQUE........................................................................ 29

KALETRA..............................................................................6

KALYDECO........................................................................ 47

KAPSPARGO SPRINKLE..................................................32

KAPVAY.............................................................................. 62

KARBINAL ER................................................................... 42

KATERZIA...........................................................................33

KAZANO............................................................................. 23

KENALOG........................................................................ 100

KEPPRA............................................................................. 76

KEPPRA XR.......................................................................76

KERENDIA......................................................................... 29

KERYDIN..........................................................................100

KESIMPTA.......................................................................... 65

ketoconazole cream 2%................................................ 100

ketoconazole foam 2% (Extina)................................... 100

ketoconazole shampoo 2%...........................................100

ketoconazole tab 200 mg..................................................4

KETOPROFEN...................................................................71

KETOPROFEN ER............................................................ 71

KETOROLAC TROMETHAMINE...................................... 71

ketorolac tromethamine ophth soln 0.5% (Acular)...... 91

ketorolac tromethamine ophth soln 0.4% (Acular

ls).....................................................................................91

ketorolac tromethamine tab 10 mg............................... 72

KEVEYIS............................................................................ 38

KEVZARA........................................................................... 72

KINERET............................................................................ 72

KINNEY LANCETS.......................................................... 124

KINNEY THIN LANCETS................................................ 124

KINRAY INSULIN SYRINGE/0........................................ 124

KINRAY INSULIN SYRINGE PR.....................................124

KISQALI..............................................................................13

KISQALI FEMARA 200 DOSE.......................................... 13

KISQALI FEMARA 400 DOSE.......................................... 13

KISQALI FEMARA 600 DOSE.......................................... 13

KITABIS PAK........................................................................3

KLARON........................................................................... 100

KLISYRI............................................................................ 100

KLONOPIN......................................................................... 76

KLOXXADO......................................................................104

KMART VALU PLUS INSULIN S.................................... 124

KOMBIGLYZE XR.............................................................. 23

KORLYM............................................................................. 23

KOSELUGO........................................................................13

KOSHER PRENATAL PLUS IRON................................... 82

K-PHOS.............................................................................. 85

K-PHOS NEUTRAL............................................................85

K-PHOS NO 2....................................................................54

KRINTAFEL.......................................................................... 9

KRISTALOSE..................................................................... 47

KROGER AUTOLET LANCING DE................................ 124

KROGER BLOOD GLUCOSE TEST.............................. 107

KROGER HEALTHPRO GLUCOSE............................... 107

KROGER HEALTHPRO TWIST LA................................ 124

KROGER INSULIN SYRINGE/0..................................... 125

KROGER INSULIN SYRINGE/1M.................................. 125

KROGER INSULIN SYRINGE/U-....................................125

KROGER LANCETS........................................................125

KROGER LANCETS 21G................................................125

KROGER LANCETS MICRO THIN.................................125

KROGER LANCETS SUPER THIN................................ 125

KROGER LANCETS THIN.............................................. 125

KROGER LANCETS THIN 26G......................................125

KROGER LANCETS ULTRATHIN...................................125

KROGER LANCING DEVICE..........................................125

KROGER PEN NEEDLES/31G X................................... 125

KROGER PEN NEEDLES/32G X................................... 125

KROGER PEN NEEDLES/33G X................................... 125

KROGER PEN NEEDLES 29G X................................... 125

KROGER PEN NEEDLES 31G X................................... 125

KROGER PEN NEEDLES 31GX1/................................. 125

KROGER PREMIUM BLOOD GLUC.............................. 107

K-TAB..................................................................................85

KUVAN................................................................................29

KYNMOBI........................................................................... 79

labetalol hcl tab 100 mg, 200 mg, 300 mg.................... 32

lacosamide oral solution 10 mg/ml (Vimpat)................76

lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg

(Vimpat).......................................................................... 76

lactic acid (ammonium lactate) cream 12%................100

lactic acid (ammonium lactate) lotion 12%.................100

LACTULOSE...................................................................... 47

lactulose (encephalopathy) solution 10 gm/15ml........ 51

lactulose solution 10 gm/15ml....................................... 47

LAMICTAL.......................................................................... 76

LAMICTAL CHEWABLE DISPERS................................... 76

LAMICTAL ODT................................................................. 76

LAMICTAL STARTER/NOT TAKI...................................... 76

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 167

LAMICTAL STARTER/TAKING C...................................... 76

LAMICTAL STARTER/TAKING V...................................... 76

LAMICTAL XR.................................................................... 76

lamivudine oral soln 10 mg/ml (Epivir)........................... 6

lamivudine tab 150 mg, 300 mg (Epivir)......................... 6

lamivudine tab 100 mg (hbv) (Epivir hbv).......................6

lamivudine-zidovudine tab 150-300 mg (Combivir)....... 6

lamotrigine orally disintegrating tab 25 mg, 50 mg,

100 mg, 200 mg (Lamictal odt)................................... 77

lamotrigine tab chewable dispersible 5 mg, 25 mg

(Lamictal chewable di)................................................. 77

lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg

(7) kit (Lamictal odt)..................................................... 77

lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg,

250 mg, 300 mg (Lamictal xr)......................................77

lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg

(Lamictal)........................................................................77

lamotrigine tab 25 mg (42) & 100 mg (7) starter kit

(Lamictal starter/not).................................................... 77

lamotrigine tab 84 x 25 mg & 14 x 100 mg starter kit

(Lamictal starter/tak).................................................... 77

lamotrigine tab 35 x 25 mg starter kit (Lamictal

starter/tak)...................................................................... 77

LAMPIT............................................................................... 10

LANCET DEVICE ADJUSTABLE.................................... 125

LANCET DEVICE WITH EJECTO.................................. 125

LANCETS......................................................................... 125

LANCETS - BAYER ASCENCIA..................................... 125

LANCETS 30G.................................................................125

LANCETS 30G/TWIST TOP............................................125

LANCETS 33G EXTRA FINE..........................................125

LANCETS 30G TWIST TOP........................................... 125

LANCETS 33G UNIVERSAL DES.................................. 125

LANCETS MICRO THIN 33G..........................................125

LANCETS SUPER THIN 28G......................................... 125

LANCETS THIN............................................................... 125

LANCETS ULTRA THIN.................................................. 125

LANCETS ULTRA THIN 30G.......................................... 125

LANCING DEVICE...........................................................125

LANOXIN............................................................................ 31

LANSOPRAZOLE/AMOXICILLIN/..................................... 49

lansoprazole cap delayed release 15 mg......................49

lansoprazole cap delayed release 30 mg

(Prevacid)....................................................................... 49

lansoprazole tab delayed release orally disintegrating

15 mg, 30 mg (Prevacid solutab)................................49

lanthanum carbonate chew tab 500 mg (elemental),

750 mg (elemental), 1000 mg (elemental)

(Fosrenol)....................................................................... 51

LANTUS..............................................................................26

LANTUS SOLOSTAR.........................................................26

LANZO..............................................................................125

lapatinib ditosylate tab 250 mg (base equiv)

(Tykerb)...........................................................................13

LASIX..................................................................................38

latanoprost ophth soln 0.005% (Xalatan)......................91

LATUDA.............................................................................. 59

LAZANDA........................................................................... 68

LEADER ADVANCED LANCING D................................ 125

LEADER INSULIN SYRINGE/0.......................................125

LEADER INSULIN SYRINGE/1M....................................126

LEADER LANCETS COLORED......................................126

LEADER SUPER THIN LANCET....................................126

LEADER THIN LANCETS............................................... 126

LEADER UNIFINE PENTIPS/MI..................................... 126

LEADER UNIFINE PENTIPS/NA.................................... 126

LEADER UNIFINE PENTIPS/PL.....................................126

LEADER UNIFINE PENTIPS PL.....................................126

LEDIPASVIR/SOFOSBUVIR................................................6

leflunomide tab 10 mg, 20 mg (Arava).......................... 72

lenalidomide cap 5 mg, 10 mg, 15 mg, 25 mg

(Revlimid)..................................................................... 143

LENVIMA 4 MG DAILY DOSE.......................................... 13

LENVIMA 8 MG DAILY DOSE.......................................... 13

LENVIMA 10 MG DAILY DOSE........................................ 13

LENVIMA 12MG DAILY DOSE......................................... 13

LENVIMA 14 MG DAILY DOSE........................................ 13

LENVIMA 18 MG DAILY DOSE........................................ 13

LENVIMA 20 MG DAILY DOSE........................................ 13

LENVIMA 24 MG DAILY DOSE........................................ 13

LESCOL XL........................................................................40

LETAIRIS............................................................................ 41

letrozole tab 2.5 mg (Femara)........................................ 13

leucovorin calcium tab 5 mg, 10 mg, 15 mg, 25

mg................................................................................... 13

LEUKERAN........................................................................ 13

LEUKINE............................................................................ 87

leuprolide acetate inj kit 5 mg/ml.................................. 13

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

equiv) (Xopenex concentrate).....................................45

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

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

(Xopenex)....................................................................... 45

LEVALBUTEROL TARTRATE HFA................................... 45

LEVAMLODIPINE...............................................................33

LEVEMIR............................................................................ 26

LEVEMIR FLEXTOUCH.................................................... 26

levetiracetam oral soln 100 mg/ml (Keppra).................77

levetiracetam tab er 24hr 500 mg, 750 mg (Keppra

xr).................................................................................... 77

levetiracetam tab 250 mg, 500 mg, 750 mg, 1000 mg

(Keppra)..........................................................................77

LEVOBUNOLOL HCL........................................................ 91

levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 29

levocarnitine tab 330 mg (Carnitor)...............................29

levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5

mg/ml)............................................................................. 42

levocetirizine dihydrochloride tab 5 mg....................... 42

levofloxacin ophth soln 0.5%......................................... 91

levofloxacin oral soln 25 mg/ml.......................................3

levofloxacin tab 250 mg, 500 mg, 750 mg...................... 3

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 168

levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est

0.01 mg (Quartette).......................................................20

levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg.................................................................. 20

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,

0.15 mg-30 mcg.............................................................20

levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg...............................20

levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg.......................................................................20

levonorgestrel tab 1.5 mg...............................................20

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

0.01mg(7) (Loseasonique)........................................... 20

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

0.01mg(7) (Seasonique)............................................... 20

levorphanol tartrate tab 2 mg, 3 mg..............................68

LEVOTHYROXINE SODIUM.............................................27

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

88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150

mcg, 175 mcg, 200 mcg, 300 mcg (Synthroid).......... 27

LEXAPRO...........................................................................57

LEXETTE..........................................................................100

LEXIVA..................................................................................6

LIALDA................................................................................52

LIBERTY MEDICAL LANCETS 3....................................126

LIBERTY MINI LANCING DEVI...................................... 126

LIBERTY NEXT GENERATION B...................................107

LIBERTY TEST STRIPS..................................................107

LIBRAX............................................................................... 49

LICART............................................................................. 100

LIDOCAINE/TETRACAINE..............................................100

LIDOCAINE HCL JELLY..................................................100

lidocaine hcl soln 4%.................................................... 100

lidocaine hcl urethral/mucosal gel prefilled syringe

2%..................................................................................100

lidocaine hcl viscous soln 2%....................................... 94

lidocaine oint 5%........................................................... 100

lidocaine patch 5% (Lidoderm).................................... 100

lidocaine-prilocaine cream 2.5-2.5%............................100

LIDODERM.......................................................................100

LIFESCAN UNISTIK 2 DEEP P...................................... 126

LIFESCAN UNISTIK II LANCE........................................126

LINDANE.......................................................................... 100

linezolid tab 600 mg (Zyvox).......................................... 10

LINZESS.............................................................................52

liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg

(Cytomel)........................................................................ 27

LIPITOR..............................................................................40

LIPOFEN............................................................................ 40

lisinopril & hydrochlorothiazide tab 10-12.5 mg,

20-12.5 mg, 20-25 mg (Zestoretic).............................. 36

lisinopril tab 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40

mg (Zestril).....................................................................36

LISTERINE......................................................................... 94

LISTERINE ANTISEPTIC.................................................. 94

LISTERINE POCKETMIST................................................ 94

LISTERINE POCKETPAKS............................................... 94

LISTERINE POCKETPAKS COOL....................................94

LISTERINE ULTRACLEAN................................................94

LISTERINE ULTRACLEAN/EVER.....................................94

LISTERINE ZERO..............................................................94

LITETOUCH INSULIN PEN NEE.................................... 126

LITETOUCH INSULIN SYRINGE....................................126

LITE TOUCH LANCETS..................................................126

LITETOUCH LANCETS MICRO T.................................. 126

LITE TOUCH LANCING PEN..........................................126

LITETOUCH PEN NEEDLES/31..................................... 126

LITETOUCH PEN NEEDLES/31G.................................. 126

LITETOUCH PEN NEEDLES 29G.................................. 126

LITETOUCH PEN NEEDLES 31G.................................. 126

LITHIUM CARBONATE..................................................... 59

lithium carbonate cap 150 mg, 300 mg, 600 mg

(Lithium carbonate)...................................................... 59

lithium carbonate tab er 450 mg....................................59

lithium carbonate tab er 300 mg (Lithobid).................. 59

lithium carbonate tab 300 mg........................................ 59

LITHOSTAT.........................................................................54

LIVALO................................................................................40

LIVE BETTER ADVANCED LANC.................................. 126

LIVE BETTER LANCET SUPER.....................................126

LIVE BETTER LANCET ULTRA......................................126

LIVE BETTER PEN NEEDLES 2....................................126

LIVE BETTER PEN NEEDLES 3....................................126

LIVMARLI........................................................................... 52

LIVTENCITY......................................................................... 6

LOCOID............................................................................ 100

LOCOID LIPOCREAM..................................................... 100

LODINE...............................................................................72

LODOSYN.......................................................................... 79

LOKELMA.........................................................................143

LO LOESTRIN FE............................................................. 20

LOMOTIL............................................................................ 48

LONGS INSULIN SYRINGE/0.5..................................... 126

LONGS LANCETS STANDARD......................................126

LONGS LANCETS THIN................................................. 126

LONGS LANCETS ULTRA THIN.................................... 127

LONHALA MAGNAIR REFILL KI...................................... 45

LONHALA MAGNAIR STARTER K...................................45

LONSURF...........................................................................13

loperamide hcl cap 2 mg................................................ 48

LOPID................................................................................. 40

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

(Kaletra)............................................................................ 6

lopinavir-ritonavir tab 100-25 mg, 200-50 mg

(Kaletra)............................................................................ 6

LOPRESSOR..................................................................... 32

LOPROX...........................................................................100

LOPROX SHAMPOO.......................................................100

lorazepam conc 2 mg/ml.................................................55

lorazepam tab 0.5 mg, 1 mg, 2 mg (Ativan).................. 55

LORBRENA........................................................................ 13

LOREEV XR.......................................................................55

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 169

LORTAB.............................................................................. 68

losartan potassium & hydrochlorothiazide tab 50-12.5

mg, 100-12.5 mg, 100-25 mg (Hyzaar)........................ 36

losartan potassium tab 25 mg, 50 mg, 100 mg

(Cozaar).......................................................................... 36

LOSEASONIQUE...............................................................20

LOTEMAX...........................................................................91

LOTEMAX SM....................................................................91

LOTENSIN..........................................................................36

LOTENSIN HCT.................................................................36

loteprednol etabonate ophth gel 0.5% (Lotemax)........91

loteprednol etabonate ophth susp 0.5%

(Lotemax)....................................................................... 91

LOTREL..............................................................................36

LOTRONEX........................................................................ 52

lovastatin tab 10 mg........................................................40

lovastatin tab 20 mg, 40 mg........................................... 40

LOVAZA.............................................................................. 40

LOVENOX.......................................................................... 88

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

mg................................................................................... 59

LUBIPROSTONE............................................................... 52

LUCEMYRA........................................................................65

LULICONAZOLE.............................................................. 100

LUMAKRAS........................................................................ 13

LUMIGAN........................................................................... 91

LUMINEUX CLEAN/FRESH MOUT.................................. 94

LUMINEUX HYDRATING MOUTHW................................ 94

LUMINEUX SENSITIVITY MOUT..................................... 94

LUMINEUX WHITENING MOUTHW.................................94

LUNESTA............................................................................61

LUPKYNIS........................................................................ 143

LUPRON DEPOT (1-MONTH).......................................... 13

LUPRON DEPOT (3-MONTH).......................................... 14

LUPRON DEPOT (4-MONTH).......................................... 14

LUPRON DEPOT (6-MONTH).......................................... 14

LUPRON DEPOT-PED (1-MONTH...................................29

LUPRON DEPOT-PED (3-MONTH...................................29

LUXIQ............................................................................... 101

LUZU.................................................................................101

LYBALVI..............................................................................65

LYNPARZA......................................................................... 14

LYRICA............................................................................... 77

LYRICA CR........................................................................ 65

LYSODREN........................................................................ 14

LYSTEDA............................................................................88

LYUMJEV............................................................................25

LYUMJEV KWIKPEN......................................................... 25

LYVISPAH...........................................................................81

MACROBID........................................................................ 10

MACRODANTIN.................................................................10

mafenide acetate packet for topical soln 5% (50 gm)

(Sulfamylon).................................................................101

MAGELLAN INSULIN SAFETY S................................... 127

MAKENA.............................................................................21

MALARONE..........................................................................9

malathion lotion 0.5% (Ovide)...................................... 101

MARATHON MEDICAL PENTIPS...................................127

maraviroc tab 150 mg, 300 mg (Selzentry)..................... 7

MARINOL........................................................................... 50

MARPLAN.......................................................................... 57

MATULANE........................................................................ 14

MAVENCLAD......................................................................65

MAVYRET.............................................................................7

MAXALT..............................................................................74

MAXALT-MLT..................................................................... 74

MAXICOMFORT II PEN NEEDLE...................................127

MAXI-COMFORT INSULIN SYRI....................................127

MAXICOMFORT INSULIN SYRIN.................................. 127

MAXI-COMFORT SAFETY PEN N................................. 127

MAXIDEX............................................................................91

MAXITROL......................................................................... 91

MAXZIDE............................................................................38

MAXZIDE-25.......................................................................38

MAYZENT........................................................................... 65

MAYZENT STARTER PACK..............................................65

meclizine hcl chew tab 25 mg (Antivert).......................50

meclizine hcl tab 12.5 mg............................................... 50

meclizine hcl tab 25 mg.................................................. 50

MECLOFENAMATE SODIUM........................................... 72

MEDICHOICE PRE-SET SAFETY..................................127

MEDICHOICE SAFETY LANCET................................... 127

MEDICINE SHOPPE LANCETS..................................... 127

MEDICINE SHOPPE LANCETS T..................................127

MEDICINE SHOPPE PEN NEEDL................................. 127

MEDIC INSULIN SYRINGE/0.3...................................... 127

MEDIC INSULIN SYRINGE/0.5...................................... 127

MEDLANCE/EXTRA........................................................ 127

MEDLANCE/LITE.............................................................127

MEDLANCE/UNIVERSAL................................................127

MEDLANCE PLUS/LITE 25G..........................................127

MEDLANCE PLUS EXTRA LANCE................................127

MEDLANCE PLUS LANCETS.........................................127

MEDLANCE PLUS LANCETS LIT.................................. 127

MEDLANCE PLUS LITE LANCET.................................. 127

MEDLANCE PLUS SPECIAL LAN..................................127

MEDLANCE PLUS SUPERLITE 3..................................127

MEDLANCE PLUS UNIVERSAL L................................. 127

MEDROL............................................................................ 17

MEDROL DOSEPAK..........................................................17

medroxyprogesterone acetate im susp 150 mg/ml

(Depo-provera contrac)................................................ 20

medroxyprogesterone acetate im susp prefilled syr

150 mg/ml (Depo-provera contrac).............................20

medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10

mg (Provera).................................................................. 21

mefenamic acid cap 250 mg.......................................... 72

mefloquine hcl tab 250 mg............................................... 9

megestrol acetate susp 40 mg/ml................................. 14

megestrol acetate susp 625 mg/5ml............................. 21

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 170

megestrol acetate tab 20 mg, 40 mg............................. 14

MEIJER BLOOD GLUCOSE TEST.................................107

MEIJER COLOR LANCETS UNIV.................................. 127

MEIJER ESSENTIAL BLOOD GL................................... 107

MEIJER LANCETS.......................................................... 127

MEIJER LANCETS THIN................................................ 127

MEIJER LANCETS UNIVERSAL.................................... 127

MEIJER PEN NEEDLES 29G X..................................... 128

MEIJER PEN NEEDLES 31G X..................................... 128

MEIJER PREMIUM BLOOD GLUC................................ 107

MEIJER SUPER THIN LANCETS...................................128

MEIJER TRUETEST BLOOD GLU................................. 107

MEIJER TRUETRACK BLOOD GL.................................107

MEKINIST...........................................................................14

MEKTOVI............................................................................14

MELOXICAM...................................................................... 72

meloxicam cap 5 mg, 10 mg.......................................... 72

meloxicam tab 7.5 mg, 15 mg........................................ 72

melphalan tab 2 mg (Alkeran)........................................14

memantine hcl cap er 24hr 7 mg, 14 mg, 21 mg, 28 mg

(Namenda xr)................................................................. 65

memantine hcl tab 5 mg, 10 mg (Namenda).................65

memantine hcl tab 28 x 5 mg & 21 x 10 mg titration

pack (Namenda titration pa)........................................65

MENEST.............................................................................19

MENOPUR......................................................................... 29

MENOSTAR........................................................................19

MENTAX........................................................................... 101

MEPERIDINE HCL.............................................................68

MEPHYTON....................................................................... 81

meprobamate tab 200 mg, 400 mg................................ 55

MEPRON............................................................................ 10

mercaptopurine tab 50 mg............................................. 14

mesalamine cap dr 400 mg (Delzicol)........................... 52

mesalamine cap er 24hr 0.375 gm (Apriso)..................52

mesalamine cap er 500 mg (Pentasa)........................... 52

mesalamine enema 4 gm................................................52

mesalamine suppos 1000 mg (Canasa)........................ 52

mesalamine tab delayed release 1.2 gm (Lialda)......... 52

mesalamine tab delayed release 800 mg (Asacol

hd)................................................................................... 52

MESNEX.............................................................................14

MESTINON.........................................................................81

MESTINON TIMESPAN.....................................................81

metaxalone tab 400 mg, 800 mg....................................81

metformin hcl oral soln 500 mg/5ml (Riomet).............. 23

metformin hcl tab er 24hr 500 mg, 750 mg...................23

metformin hcl tab er 24hr modified release 500 mg,

1000 mg (Glumetza)......................................................23

metformin hcl tab er 24hr osmotic 500 mg, 1000

mg................................................................................... 23

metformin hcl tab 500 mg, 850 mg, 1000 mg............... 23

METFORMIN HYDROCHLORIDE.................................... 23

METHADONE HCL............................................................ 69

methadone hcl conc 10 mg/ml (Methadose)................ 69

methadone hcl soln 5 mg/5ml, 10 mg/5ml (Methadone

hcl).................................................................................. 69

methadone hcl tab for oral susp 40 mg........................69

methadone hcl tab 5 mg, 10 mg.................................... 69

METHADOSE.....................................................................69

METHADOSE SUGAR-FREE........................................... 69

methamphetamine hcl tab 5 mg (Desoxyn)..................62

methazolamide tab 25 mg, 50 mg..................................38

methenamine hippurate tab 1 gm (Hiprex)................... 10

methimazole tab 5 mg, 10 mg........................................ 27

METHITEST....................................................................... 18

methocarbamol tab 500 mg, 750 mg............................. 81

METHOTREXATE SODIUM.............................................. 14

methotrexate sodium inj 50 mg/2ml (25 mg/ml)...........14

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

mg/10ml (25 mg/ml), 1000 mg/40ml (25 mg/ml).........14

methotrexate sodium tab 2.5 mg (base equiv).............14

METHOXSALEN.............................................................. 101

methscopolamine bromide tab 2.5 mg, 5 mg............... 49

methylergonovine maleate tab 0.2 mg..........................27

METHYLIN..........................................................................62

methylphenidate hcl cap er 24hr 60 mg (la)................. 63

methylphenidate hcl cap er 24hr 20 mg (la), 30 mg

(la), 40 mg (la) (Ritalin la)............................................ 63

methylphenidate hcl cap er 24hr 10 mg (la) (Ritalin

la).....................................................................................62

methylphenidate hcl cap er 24hr 10 mg (xr), 15 mg

(xr), 20 mg (xr), 30 mg (xr), 40 mg (xr), 50 mg (xr), 60

mg (xr) (Aptensio xr)....................................................63

methylphenidate hcl cap er 10 mg (cd), 20 mg (cd), 30

mg (cd), 40 mg (cd), 50 mg (cd), 60 mg (cd)..............62

methylphenidate hcl chew tab 2.5 mg, 5 mg, 10

mg................................................................................... 63

methylphenidate hcl soln 5 mg/5ml, 10 mg/5ml

(Methylin)........................................................................63

methylphenidate hcl tab er 24hr 27 mg, 36 mg, 54

mg................................................................................... 63

methylphenidate hcl tab er 10 mg, 20 mg.................... 63

methylphenidate hcl tab er osmotic release (osm) 18

mg, 27 mg, 36 mg, 54 mg (Concerta)......................... 63

methylphenidate hcl tab 5 mg, 10 mg, 20 mg

(Ritalin)........................................................................... 63

METHYLPHENIDATE HYDROCHLO................................63

methylphenidate td patch 10 mg/9hr, 15 mg/9hr, 20

mg/9hr, 30 mg/9hr (Daytrana)......................................63

methylprednisolone tab 4 mg, 8 mg, 16 mg, 32 mg

(Medrol).......................................................................... 17

methylprednisolone tab therapy pack 4 mg (21)

(Medrol dosepak).......................................................... 17

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

equiv).............................................................................. 52

metoclopramide hcl tab 5 mg (base equivalent), 10

mg (base equivalent) (Reglan)....................................52

METOCLOPRAMIDE ODT................................................ 52

metolazone tab 2.5 mg, 5 mg, 10 mg............................ 38

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 171

metoprolol & hydrochlorothiazide tab 50-25 mg,

100-25 mg, 100-50 mg.................................................. 36

metoprolol succinate tab er 24hr 25 mg (tartrate

equiv), 50 mg (tartrate equiv), 100 mg (tartrate

equiv), 200 mg (tartrate equiv) (Toprol xl)................. 32

metoprolol tartrate tab 25 mg, 37.5 mg, 75 mg............ 32

metoprolol tartrate tab 50 mg, 100 mg (Lopressor).....32

METROCREAM................................................................101

METROGEL..................................................................... 101

METROLOTION............................................................... 101

metronidazole cap 375 mg (Flagyl)............................... 10

metronidazole cream 0.75% (Metrocream)................. 101

metronidazole gel 0.75%...............................................101

metronidazole gel 1% (Metrogel)................................. 101

metronidazole lotion 0.75% (Metrolotion)...................101

metronidazole tab 250 mg, 500 mg............................... 10

metronidazole vaginal gel 0.75%................................... 54

metyrosine cap 250 mg (Demser)..................................36

mexiletine hcl cap 150 mg, 200 mg, 250 mg.................34

MIACALCIN........................................................................ 29

MICARDIS.......................................................................... 36

MICARDIS HCT................................................................. 37

MICONAZOLE NITRATE/ZINC O................................... 101

MICRODOT PEN NEEDLE/31G X..................................128

MICRODOT PEN NEEDLE/32G X..................................128

MICRODOT PEN NEEDLE/33G X..................................128

MICRODOT TEST STRIPS.............................................108

MICRODOT XTRA TEST STRIPS..................................108

MICROLET LANCETS.....................................................128

MICROLET NEXT............................................................ 128

midodrine hcl tab 2.5 mg, 5 mg, 10 mg........................ 39

miglitol tab 25 mg, 50 mg, 100 mg................................ 23

MIGRANAL......................................................................... 74

MILLIPRED.........................................................................17

MINASTRIN 24 FE............................................................ 20

MINI LANCING DEVICE..................................................128

MINIPRESS........................................................................ 37

MINIVELLE......................................................................... 19

minocycline hcl cap 50 mg, 75 mg, 100 mg................... 3

minocycline hcl tab er 24hr 45 mg, 90 mg, 135 mg....... 3

minocycline hcl tab er 24hr 55 mg, 65 mg, 80 mg, 105

mg, 115 mg (Solodyn).................................................... 3

minocycline hcl tab 50 mg, 75 mg, 100 mg.................... 3

MINOCYCLINE HYDROCHLORIDE................................... 3

MINOLIRA............................................................................ 3

minoxidil tab 2.5 mg, 10 mg........................................... 37

MIRAPEX ER..................................................................... 79

MIRCERA........................................................................... 87

MIRCETTE......................................................................... 20

mirtazapine orally disintegrating tab 15 mg, 30 mg, 45

mg (Remeron soltab)....................................................57

mirtazapine tab 7.5 mg, 45 mg.......................................57

mirtazapine tab 15 mg, 30 mg (Remeron).....................57

misoprostol tab 100 mcg, 200 mcg (Cytotec).............. 49

MITIGARE.......................................................................... 75

MITOSOL............................................................................91

MM EASY TOUCH GLUCOSE TES............................... 108

MM INSULIN SYRINGE/U-100/...................................... 128

MM LANCING DEVICE................................................... 128

MM PEN NEEDLES 31G X 3/16.................................... 128

MM PEN NEEDLES 31G X 5/16.................................... 128

MM PEN NEEDLES 32G X 5/32.................................... 128

MM PEN NEEDLES 31G X 1/4"..................................... 128

MM TWIST LANCETS..................................................... 128

M-NATAL PLUS..................................................................82

modafinil tab 100 mg, 200 mg (Provigil)....................... 63

MODERNA COVID-19 VACCINE......................................10

MODERNA COVID-19 VACCINE/.....................................11

moexipril hcl tab 7.5 mg, 15 mg.................................... 37

MOLINDONE HYDROCHLORIDE.................................... 59

mometasone furoate cream 0.1%................................ 101

mometasone furoate nasal susp 50 mcg/act............... 43

mometasone furoate oint 0.1%.................................... 101

mometasone furoate solution 0.1% (lotion)............... 101

MONOJECT INSULIN SYRINGE....................................128

MONOJECT INSULIN SYRINGE/...................................128

MONOJECT ULTRA COMFORT IN................................128

MONOLET LANCETS......................................................128

MONOLET OPD LANCETS............................................ 128

MONOLETTOR SAFETY LANCETS.............................. 128

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

mg (base equiv) (Singulair)......................................... 46

montelukast sodium oral granules packet 4 mg (base

equiv) (Singulair)...........................................................46

montelukast sodium tab 10 mg (base equiv)

(Singulair).......................................................................46

MONUROL......................................................................... 10

MORPHINE SULFATE....................................................... 69

MORPHINE SULFATE ER.................................................69

morphine sulfate oral soln 10 mg/5ml, 100 mg/5ml (20

mg/ml)............................................................................. 69

morphine sulfate tab er 15 mg, 30 mg, 60 mg, 100 mg,

200 mg (Ms contin).......................................................69

morphine sulfate tab 15 mg, 30 mg (Morphine

sulfate)............................................................................69

MOTEGRITY...................................................................... 52

MOUNJARO....................................................................... 23

mouthwashes - liquid...................................................... 94

MOVANTIK......................................................................... 52

MOVIPREP.........................................................................47

moxifloxacin hcl ophth soln 0.5% (base equiv)

(Vigamox)....................................................................... 91

moxifloxacin hcl tab 400 mg (base equiv)......................3

MOXIFLOXACIN HYDROCHLORID................................. 91

MPD SAFETY LANCET 21G/1.8.................................... 128

MPD SAFETY LANCET 28G/1.8.................................... 128

MPD SAFETY LANCET 30G/1.8.................................... 128

MPD SAFETY LANCETS 23G/1.....................................128

MS CONTIN....................................................................... 69

MS INSULIN SYRINGE/0.3ML/.......................................128

MS INSULIN SYRINGE/0.5ML/.......................................128

MS INSULIN SYRINGE/1ML/29......................................129

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 172

MS INSULIN SYRINGE/1ML/30......................................129

MS INSULIN SYRINGE/1ML/31......................................129

MULPLETA......................................................................... 87

MULTAQ............................................................................. 34

MULTI-LANCET DEVICE.................................................129

MULTI-MAC........................................................................ 82

mupirocin calcium cream 2%.......................................101

mupirocin oint 2%..........................................................101

MYALEPT........................................................................... 29

MYAMBUTOL....................................................................... 4

MYCAPSSA........................................................................29

MYCOBUTIN........................................................................ 4

mycophenolate mofetil cap 250 mg (Cellcept)...........143

mycophenolate mofetil for oral susp 200 mg/ml

(Cellcept)...................................................................... 143

mycophenolate mofetil tab 500 mg (Cellcept)............143

mycophenolate sodium tab dr 180 mg (mycophenolic

acid equiv), 360 mg (mycophenolic acid equiv)

(Myfortic)...................................................................... 143

MYDAYIS............................................................................ 63

MYFEMBREE.....................................................................19

MYGLUCOHEALTH BLOOD GLUCO.............................108

MYGLUCOHEALTH MGH SOFTLAN............................. 129

MYLERAN.......................................................................... 14

MYRBETRIQ...................................................................... 53

MYSOLINE......................................................................... 77

MYTESI...............................................................................48

nabumetone tab 500 mg, 750 mg.................................. 72

nadolol tab 20 mg, 40 mg, 80 mg (Corgard)................. 32

NAFRINSE DAILY/ACIDULATED......................................94

NAFRINSE DAILY/NEUTRAL............................................94

NAFRINSE WEEKLY......................................................... 94

NAFTIFINE HCL.............................................................. 101

naftifine hcl cream 2%.................................................. 101

NAFTIN.............................................................................101

NALFON............................................................................. 72

NALOCET...........................................................................69

naloxone hcl inj 4 mg/10ml.......................................... 104

naloxone hcl nasal spray 4 mg/0.1ml (Narcan).......... 104

NALOXONE HYDROCHLORIDE.................................... 104

naltrexone hcl tab 50 mg..............................................104

NAMENDA..........................................................................65

NAMENDA TITRATION PAK............................................. 65

NAMENDA XR................................................................... 65

NAMZARIC......................................................................... 65

NAPRELAN........................................................................ 72

NAPROSYN........................................................................72

naproxen-esomeprazole magnesium tab dr 375-20

mg, 500-20 mg (Vimovo)..............................................72

NAPROXEN SODIUM....................................................... 72

naproxen sodium tab er 24hr 375 mg (base equiv),

500 mg (base equiv) (Naprelan)..................................72

naproxen sodium tab 275 mg........................................ 72

naproxen sodium tab 550 mg (Anaprox ds)................. 72

naproxen susp 125 mg/5ml (Naprosyn)........................72

naproxen tab ec 375 mg, 500 mg (Ec-naprosyn)......... 72

naproxen tab 250 mg, 375 mg....................................... 72

naproxen tab 500 mg (Naprosyn).................................. 72

naratriptan hcl tab 1 mg (base equiv), 2.5 mg (base

equiv).............................................................................. 74

NARCAN...........................................................................104

NARDIL...............................................................................57

NASCOBAL........................................................................ 87

NATACHEW........................................................................82

NATACYN........................................................................... 91

NATALVIT........................................................................... 82

NATAZIA............................................................................. 20

nateglinide tab 60 mg, 120 mg.......................................23

NATESTO........................................................................... 18

NATPARA........................................................................... 29

NATROBA.........................................................................101

NAYZILAM.......................................................................... 77

nebivolol hcl tab 2.5 mg (base equivalent), 5 mg (base

equivalent), 10 mg (base equivalent), 20 mg (base

equivalent) (Bystolic)................................................... 32

NEBUPENT........................................................................ 10

NEEVO DHA...................................................................... 82

NEFAZODONE HYDROCHLORIDE................................. 57

NEOMYCIN/POLYMYXIN/GRAMIC.................................. 91

NEOMYCIN/POLYMYXIN/HYDROC................................. 91

neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin............................... 91

neomycin-polymyxin-dexamethasone ophth oint 0.1%

(Maxitrol)........................................................................ 91

neomycin-polymyxin-dexamethasone ophth susp

0.1% (Maxitrol)...............................................................91

neomycin-polymyxin-hc otic soln 1%........................... 93

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%...................................................................... 93

neomycin sulfate tab 500 mg........................................... 3

NEONATAL 19................................................................... 82

NEONATAL/DHA................................................................ 82

NEONATAL COMPLETE................................................... 82

NEONATAL FE...................................................................82

NEONATAL PLUS.............................................................. 82

NEONATAL VITAMIN.........................................................82

NEORAL........................................................................... 143

NEO-SYNALAR................................................................101

NERLYNX........................................................................... 14

NESINA...............................................................................23

NESTABS........................................................................... 82

NESTABS DHA.................................................................. 82

NESTABS ONE.................................................................. 82

NEULASTA......................................................................... 87

NEULASTA ONPRO KIT................................................... 87

NEUPOGEN....................................................................... 87

NEUPRO............................................................................ 79

NEURONTIN...................................................................... 77

NEUTEK 2TEK TEST STRIPS........................................108

NEVANAC...........................................................................91

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 173

NEVIRAPINE........................................................................ 7

NEVIRAPINE ER................................................................. 7

nevirapine tab er 24hr 400 mg......................................... 7

nevirapine tab 200 mg.......................................................7

NEXAVAR........................................................................... 14

NEXICLON XR................................................................... 37

NEXIUM..............................................................................49

NEXLETOL......................................................................... 40

NEXLIZET...........................................................................40

NEXTSTELLIS....................................................................20

NIACIN................................................................................40

niacin tab er 750 mg (antihyperlipidemic), 1000 mg

(antihyperlipidemic) (Niaspan)....................................40

NIACOR..............................................................................40

NIASPAN............................................................................ 40

nicardipine hcl cap 20 mg, 30 mg................................. 33

nicotine polacrilex gum 2 mg, 4 mg..............................65

nicotine polacrilex lozenge 2 mg, 4 mg........................ 65

nicotine td patch 24hr 7 mg/24hr, 14 mg/24hr, 21

mg/24hr...........................................................................65

NICOTINE TRANSDERMAL SYST...................................65

NICOTROL INHALER........................................................65

NICOTROL NS...................................................................65

nifedipine cap 10 mg, 20 mg.......................................... 33

nifedipine tab er 24hr 30 mg, 60 mg, 90 mg................. 33

nifedipine tab er 24hr osmotic release 30 mg, 60 mg,

90 mg (Procardia xl).....................................................33

NILANDRON.......................................................................14

nilutamide tab 150 mg (Nilandron)................................ 14

nimodipine cap 30 mg.....................................................33

NINLARO............................................................................14

NISOLDIPINE ER.............................................................. 34

nisoldipine tab er 24hr 8.5 mg, 17 mg, 34 mg

(Sular)............................................................................. 34

nitazoxanide tab 500 mg (Alinia)................................... 10

nitisinone cap 2 mg, 5 mg, 10 mg (Orfadin)................. 29

NITRO-BID......................................................................... 31

NITRO-DUR........................................................................31

nitrofurantoin macrocrystalline cap 25 mg, 50 mg, 100

mg (Macrodantin)..........................................................10

nitrofurantoin monohydrate macrocrystalline cap 100

mg (Macrobid)............................................................... 10

nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg

(Nitrostat)....................................................................... 31

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

mg/hr, 0.6 mg/hr (Nitro-dur).........................................32

nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)

(Nitrolingual pumpspr)................................................. 32

NITROLINGUAL PUMPSPRAY.........................................32

NITROMIST........................................................................ 32

NITROSTAT........................................................................32

NITRO-TIME.......................................................................31

NITYR................................................................................. 29

NIVA-PLUS......................................................................... 82

NIZATIDINE........................................................................ 49

NOCDURNA....................................................................... 29

NORDIPEN 5 INJECTION DEVI.....................................129

NORDITROPIN FLEXPRO................................................ 29

norelgestromin-ethinyl estradiol td ptwk 150-35

mcg/24hr.........................................................................20

norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg..................................................................... 20

norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg (Generess fe)............................................ 21

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,

0.5 mg-35 mcg, 1 mg-35 mcg......................................20

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg, 1.5 mg-30 mcg.....................................................21

norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg, 1.5 mg-30 mcg.....................................................21

norethindrone ace-eth estradiol-fe chew tab 1 mg-20

mcg (24) (Minastrin 24 fe)............................................21

norethindrone ace-ethinyl estradiol-fe cap 1 mg-20

mcg (24) (Taytulla)........................................................ 21

norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24)......................................................................... 21

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5

mcg, 1 mg-5 mcg..........................................................19

norethindrone acetate tab 5 mg (Aygestin)..................21

norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg...........................................................................21

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg, 0.5-35/1-35/0.5-35 mg-mcg...........................21

norethindrone tab 0.35 mg............................................. 21

NORGESIC FORTE...........................................................81

norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg................................................................................. 21

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25

mg-mcg, 0.18-35/0.215-35/0.25-35 mg-mcg............... 21

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........21

NORITATE........................................................................ 101

NORLIQVA......................................................................... 34

NORPACE.......................................................................... 34

NORPACE CR....................................................................34

NORPRAMIN......................................................................57

NORTHERA........................................................................39

NORTRIPTYLINE HCL...................................................... 57

nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg

(Pamelor)........................................................................ 57

NORVASC.......................................................................... 34

NORVIR................................................................................ 7

NOURIANZ......................................................................... 79

NOVA MAX GLUCOSE TEST STR................................ 108

NOVAREL........................................................................... 29

NOVA SAFETY LANCETS 23G...................................... 129

NOVA SAFETY LANCETS 28G...................................... 129

NOVA SUREFLEX LANCETS......................................... 129

NOVA SUREFLEX LANCING DEV................................. 129

NOVAVAX COVID-19 VACCINE........................................11

NOVOFINE AUTOCOVER PEN NE............................... 129

NOVOFINE PEN NEEDLE 32G X.................................. 129

NOVOFINE PLUS PEN NEEDLE................................... 129

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 174

NOVOLIN 70/30................................................................. 26

NOVOLIN 70/30 FLEXPEN............................................... 26

NOVOLIN 70/30 FLEXPEN REL.......................................26

NOVOLIN 70/30 RELION.................................................. 26

NOVOLIN N........................................................................26

NOVOLIN N FLEXPEN......................................................26

NOVOLIN N FLEXPEN RELION.......................................26

NOVOLIN N RELION.........................................................26

NOVOLIN R........................................................................25

NOVOLIN R FLEXPEN......................................................25

NOVOLIN R FLEXPEN RELION.......................................25

NOVOLIN R RELION.........................................................25

NOVOLOG..........................................................................25

NOVOLOG FLEXPEN....................................................... 25

NOVOLOG FLEXPEN RELION.........................................25

NOVOLOG MIX 70/30....................................................... 26

NOVOLOG MIX 70/30 PREFILL....................................... 26

NOVOLOG MIX 70/30 RELION........................................ 26

NOVOLOG PENFILL......................................................... 25

NOVOLOG RELION.......................................................... 25

NOVOPEN ECHO............................................................129

NOXAFIL...............................................................................4

NUBEQA.............................................................................14

NUCALA............................................................................. 46

NUCYNTA...........................................................................69

NUCYNTA ER.................................................................... 69

NUPLAZID.......................................................................... 59

NURTEC.............................................................................74

NUTROPIN AQ NUSPIN 5................................................29

NUTROPIN AQ NUSPIN 10..............................................29

NUTROPIN AQ NUSPIN 20..............................................29

NUVARING......................................................................... 21

NUVESSA...........................................................................54

NUVIGIL..............................................................................63

NUZYRA............................................................................... 3

NYMALIZE..........................................................................34

nystatin cream 100000 unit/gm....................................101

nystatin oint 100000 unit/gm........................................ 101

nystatin susp 100000 unit/ml......................................... 94

nystatin tab 500000 unit....................................................4

nystatin topical powder 100000 unit/gm.....................101

nystatin-triamcinolone cream 100000-0.1 unit/gm-

%....................................................................................101

nystatin-triamcinolone oint 100000-0.1 unit/gm-

%....................................................................................101

NYVEPRIA..........................................................................87

OB COMPLETE................................................................. 83

OB COMPLETE/DHA........................................................ 83

OB COMPLETE ONE........................................................ 83

OB COMPLETE PETITE................................................... 83

OB COMPLETE PREMIER............................................... 83

OBSTETRIX DHA.............................................................. 83

OBSTETRIX EC.................................................................83

OBSTETRIX ONE.............................................................. 83

OCALIVA.............................................................................52

OCTREOTIDE ACETATE.................................................. 29

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

mcg/ml (1 mg/ml).......................................................... 29

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

100 mcg/ml (0.1 mg/ml), 500 mcg/ml (0.5 mg/ml)

(Sandostatin)................................................................. 29

OCUFLOX.......................................................................... 91

ODACTRA.......................................................................... 11

ODEFSEY.............................................................................7

ODOMZO............................................................................14

OFEV.................................................................................. 47

OFLOXACIN......................................................................... 3

ofloxacin ophth soln 0.3% (Ocuflox).............................91

ofloxacin otic soln 0.3%..................................................93

ofloxacin tab 400 mg.........................................................3

olanzapine-fluoxetine hcl cap 6-50 mg, 12-25 mg,

12-50 mg.........................................................................65

olanzapine-fluoxetine hcl cap 3-25 mg, 6-25 mg

(Symbyax)...................................................................... 65

olanzapine orally disintegrating tab 5 mg, 10 mg, 15

mg, 20 mg (Zyprexa zydis).......................................... 59

olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20

mg (Zyprexa)................................................................. 59

olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg, 40-5-12.5 mg, 40-5-25 mg, 40-10-12.5

mg, 40-10-25 mg (Tribenzor)....................................... 37

olmesartan medoxomil-hydrochlorothiazide tab

20-12.5 mg, 40-12.5 mg, 40-25 mg (Benicar hct)....... 37

olmesartan medoxomil tab 5 mg, 20 mg, 40 mg

(Benicar)......................................................................... 37

olopatadine hcl nasal soln 0.6% (Patanase).................43

olopatadine hcl ophth soln 0.1% (base equivalent),

0.2% (base equivalent).................................................91

OLUX................................................................................ 101

OLUX-E............................................................................ 101

OMECLAMOX-PAK............................................................ 49

omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 40

omeprazole cap delayed release 10 mg, 40 mg........... 49

omeprazole-sodium bicarbonate cap 20-1100 mg,

40-1100 mg (Zegerid)....................................................49

omeprazole-sodium bicarbonate powd pack for susp

20-1680 mg, 40-1680 mg (Zegerid)............................. 49

OMNARIS........................................................................... 43

OMNIFLEX DIAPHRAGM................................................129

OMNIPOD 5 G6 INTRO KIT (G...................................... 129

OMNIPOD 5 G6 PODS (GEN 5).....................................129

OMNITROPE......................................................................30

OMNITROPE PEN 5 INJECTION................................... 129

ON/GO COVID-19 ANTIGEN SE....................................108

ON/GO ONE COVID-19 ANTIGE................................... 108

ONDANSETRON HCL.......................................................50

ondansetron hcl oral soln 4 mg/5ml............................. 50

ondansetron hcl tab 4 mg, 8 mg....................................50

ondansetron orally disintegrating tab 4 mg, 8 mg.......50

ONE DROP BLOOD GLUCOSE TE............................... 108

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 175

ONETOUCH CLUB LANCETS FIN.................................129

ONETOUCH DELICA LANCETS E.................................129

ONETOUCH DELICA LANCETS F................................. 129

ONETOUCH DELICA LANCING D................................. 129

ONETOUCH DELICA PLUS LANC.................................129

ONETOUCH DELICA SAFETY LA................................. 129

ONETOUCH FINEPOINT LANCET................................ 129

ONETOUCH LANCETS...................................................129

ONETOUCH SURESOFT LANCING.............................. 129

ONETOUCH ULTRA........................................................ 108

ONETOUCH ULTRA 2.....................................................129

ONETOUCH ULTRA BLUE............................................. 108

ONETOUCH ULTRA CONTROL.....................................129

ONETOUCH ULTRA MINI............................................... 129

ONETOUCH ULTRASOFT LANCET...............................129

ONETOUCH ULTRA TEST STRIP................................. 108

ONETOUCH VERIO........................................................ 129

ONETOUCH VERIO CONTROL SO...............................129

ONETOUCH VERIO FLEX BLOOD................................ 129

ONETOUCH VERIO IQ BLOOD G................................. 130

ONETOUCH VERIO MID CONTRO............................... 130

ONETOUCH VERIO REFLECT...................................... 130

ONETOUCH VERIO TEST STRIP..................................108

ONE VITE WOMENS PRENATAL.................................... 83

ONEXTON........................................................................ 101

ONFI................................................................................... 77

ONGENTYS........................................................................79

ONGLYZA........................................................................... 23

ONUREG............................................................................ 14

ONZETRA XSAIL...............................................................74

OPSUMIT........................................................................... 41

OPTIONS GYNOL II VAGINAL......................................... 54

OPTIUMEZ TEST STRIPS..............................................108

OPZELURA...................................................................... 101

ORACEA...........................................................................101

ORAPRED ODT.................................................................17

ORAVIG.............................................................................. 94

ORENCIA........................................................................... 72

ORENCIA CLICKJECT...................................................... 72

ORENITRAM...................................................................... 42

ORFADIN............................................................................30

ORGOVYX..........................................................................14

ORIAHNN........................................................................... 19

ORILISSA........................................................................... 30

ORKAMBI........................................................................... 47

ORLADEYO........................................................................89

orphenadrine citrate tab er 12hr 100 mg...................... 81

orphenadrine w/ aspirin & caffeine tab 25-385-30

mg................................................................................... 81

orphenadrine w/ aspirin & caffeine tab 50-770-60 mg

(Norgesic forte)............................................................. 81

ORTIKOS............................................................................17

oseltamivir phosphate cap 30 mg (base equiv), 45 mg

(base equiv), 75 mg (base equiv) (Tamiflu)................. 7

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

(Tamiflu)............................................................................7

OSENI.................................................................................23

OSMOLEX ER................................................................... 79

OSMOPREP....................................................................... 47

OSPHENA.......................................................................... 30

OTEZLA..............................................................................72

OTOVEL............................................................................. 93

OTREXUP.......................................................................... 72

OVIDE...............................................................................101

OVIDREL............................................................................ 30

oxandrolone tab 2.5 mg, 10 mg..................................... 18

oxaprozin tab 600 mg (Daypro)..................................... 72

OXAYDO.............................................................................69

oxazepam cap 10 mg, 15 mg, 30 mg.............................55

OXBRYTA........................................................................... 87

oxcarbazepine susp 300 mg/5ml (60 mg/ml)

(Trileptal)........................................................................ 77

oxcarbazepine tab 150 mg, 300 mg, 600 mg

(Trileptal)........................................................................ 77

OXERVATE.........................................................................91

oxiconazole nitrate cream 1% (Oxistat)...................... 101

OXISTAT........................................................................... 101

OXTELLAR XR.................................................................. 77

oxybutynin chloride syrup 5 mg/5ml............................ 53

oxybutynin chloride tab er 24hr 15 mg.........................53

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

xl).....................................................................................53

oxybutynin chloride tab 5 mg........................................ 53

OXYCODONE/ACETAMINOPHEN................................... 69

OXYCODONE AND ACETAMINOPH............................... 69

oxycodone hcl cap 5 mg................................................ 69

oxycodone hcl conc 100 mg/5ml (20 mg/ml)................69

oxycodone hcl soln 5 mg/5ml........................................69

oxycodone hcl tab 10 mg, 20 mg.................................. 69

oxycodone hcl tab 5 mg, 15 mg, 30 mg

(Roxicodone)................................................................. 69

OXYCODONE HYDROCHLORIDE/A............................... 69

oxycodone w/ acetaminophen tab 2.5-325 mg, 5-325

mg, 7.5-325 mg, 10-325 mg (Percocet).......................69

oxymorphone hcl tab 5 mg, 10 mg................................69

OXYMORPHONE HYDROCHLORIDE............................. 69

OXYTROL...........................................................................53

OZEMPIC........................................................................... 23

OZOBAX.............................................................................81

paliperidone tab er 24hr 1.5 mg, 3 mg, 6 mg, 9 mg

(Invega)...........................................................................59

PALYNZIQ...........................................................................30

PAMELOR.......................................................................... 57

PANCREAZE...................................................................... 50

PANDEL............................................................................101

PANRETIN........................................................................101

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

mg (base equiv) (Protonix)..........................................49

pantoprazole sodium for delayed release susp packet

40 mg (Protonix)........................................................... 49

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 176

paricalcitol cap 4 mcg.....................................................30

paricalcitol cap 1 mcg, 2 mcg (Zemplar)...................... 30

PARLODEL.........................................................................79

PARNATE........................................................................... 57

PARODONTAX................................................................... 94

paromomycin sulfate cap 250 mg (Humatin)................. 3

paroxetine hcl oral susp 10 mg/5ml (base equiv)

(Paxil).............................................................................. 57

paroxetine hcl tab er 24hr 12.5 mg, 25 mg, 37.5 mg

(Paxil cr)......................................................................... 57

paroxetine hcl tab 10 mg, 20 mg, 30 mg, 40 mg

(Paxil).............................................................................. 57

paroxetine mesylate cap 7.5 mg (base equiv)..............65

PASER.................................................................................. 4

PATANASE......................................................................... 43

PAXIL.................................................................................. 57

PAXIL CR........................................................................... 57

PC LANCETS SUPER THIN 30G................................... 130

PC UNIFINE PENTIPS 29G X........................................ 130

PC UNIFINE PENTIPS 31G X........................................ 130

PEDIAPRED....................................................................... 17

PEGASYS.............................................................................7

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm (Golytely)................................................................. 47

peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm (Moviprep)........................................................48

peg 3350-kcl-sod bicarb-nacl for soln 420 gm.............48

PEG-PREP......................................................................... 48

PEMAZYRE........................................................................ 14

penicillamine cap 250 mg (Cuprimine)....................... 143

penicillamine tab 250 mg (Depen titratabs)................143

PENICILLIN V POTASSIUM................................................1

penicillin v potassium tab 250 mg, 500 mg.................... 1

PEN NEEDLES/29G X 1/2".............................................130

PEN NEEDLES/31G X 1/4".............................................130

PEN NEEDLES/31G X 3/16"...........................................130

PEN NEEDLES/31G X 5/16"...........................................130

PEN NEEDLES/32G X 5/32"...........................................130

PEN NEEDLES/31G X 6MM........................................... 130

PEN NEEDLES 31GX5/16".............................................130

PEN NEEDLES 31G X 3/16".......................................... 130

PEN NEEDLES 33G X 5/32".......................................... 130

PEN NEEDLES 30GX5MM............................................. 130

PEN NEEDLES 30GX8MM............................................. 130

PEN NEEDLES 31GX8MM............................................. 130

PEN NEEDLES 32GX4MM............................................. 130

PEN NEEDLES 29GX12MM........................................... 130

PEN NEEDLES 31G X 5MM...........................................130

PEN NEEDLES 31G X 6MM...........................................130

PEN NEEDLES 31G X 8MM...........................................130

PEN NEEDLES 32G X 4MM...........................................130

PEN NEEDLES 32G X 5MM...........................................130

PEN NEEDLES 32G X 6MM...........................................130

PEN NEEDLES 31GX8MM (5/16....................................130

PEN NEEDLES 31GX6MM (1/4".................................... 130

PENNSAID....................................................................... 101

pentamidine isethionate for nebulization soln 300 mg

(Nebupent)......................................................................10

PENTASA........................................................................... 52

pentazocine w/ naloxone hcl tab 50-0.5 mg................. 69

PENTIPS 31GX5MM....................................................... 131

PENTIPS 31GX6MM....................................................... 131

PENTIPS 31GX8MM....................................................... 131

PENTIPS 32GX4MM....................................................... 131

PENTIPS 32GX6MM....................................................... 131

PENTIPS 29GX12MM..................................................... 131

PENTIPS 29G X 12MM...................................................131

PENTIPS 31G X 5MM.....................................................131

PENTIPS 31G X 8MM.....................................................131

PENTIPS 32G X 4MM.....................................................131

pentoxifylline tab er 400 mg...........................................89

PEPCID...............................................................................49

PERCOCET........................................................................69

PERFECT LANCETS 30G.............................................. 131

PERFECT PRESSURE ACTIVATE.................................131

PERFOROMIST................................................................. 46

PERIDEX............................................................................ 94

perindopril erbumine tab 2 mg, 4 mg, 8 mg................. 37

permethrin cream 5%.................................................... 101

PERPHENAZINE/AMITRIPTYLIN..................................... 65

perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg................. 59

PERTZYE........................................................................... 51

PEXEVA..............................................................................57

PFIZER-BIONTECH COVID-19.........................................11

PHARMACIST CHOICE AUTOCOD...............................108

PHARMACIST CHOICE NO CODI................................. 108

PHARMACIST CHOICE ULTRA T.................................. 131

PHARMACY COUNTER LANCETS................................131

PHEBURANE..................................................................... 30

PHENDIMETRAZINE TARTRATE.....................................63

phendimetrazine tartrate tab 35 mg.............................. 63

PHENELZINE SULFATE....................................................57

phenobarbital elixir 20 mg/5ml...................................... 61

phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60

mg, 64.8 mg, 97.2 mg, 100 mg.................................... 61

phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 37

phenylephrine hcl ophth soln 2.5%, 10%..................... 91

PHENYTEK........................................................................ 77

phenytoin chew tab 50 mg (Dilantin infatabs)..............77

phenytoin sodium extended cap 200 mg, 300 mg

(Phenytek)...................................................................... 77

phenytoin sodium extended cap 100 mg (Dilantin)..... 77

phenytoin susp 125 mg/5ml (Dilantin-125)................... 77

PHEXXI...............................................................................54

PHOSLYRA........................................................................ 52

PHOSPHOLINE IODIDE....................................................92

phytonadione tab 5 mg (Mephyton).............................. 81

PIFELTRO.............................................................................7

pilocarpine hcl ophth soln 1%, 2%, 4%........................ 92

pilocarpine hcl tab 5 mg, 7.5 mg (Salagen).................. 94

PILOT COVID-19 AT-HOME TE..................................... 108

pimecrolimus cream 1% (Elidel).................................. 101

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 177

PIMOZIDE.......................................................................... 65

pindolol tab 5 mg, 10 mg................................................33

pioglitazone hcl-glimepiride tab 30-2 mg, 30-4 mg

(Duetact)......................................................................... 24

pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850

mg (Actoplus met)........................................................ 24

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

equiv), 45 mg (base equiv) (Actos)............................ 24

PIP LANCETS/28G..........................................................131

PIP LANCETS/30G..........................................................131

PIQRAY 200MG DAILY DOSE.......................................... 14

PIQRAY 250MG DAILY DOSE.......................................... 14

PIQRAY 300MG DAILY DOSE.......................................... 14

PIRFENIDONE................................................................... 47

pirfenidone tab 267 mg, 801 mg (Esbriet).................... 47

piroxicam cap 10 mg, 20 mg (Feldene).........................72

PLAN B ONE-STEP...........................................................21

PLAQUENIL..........................................................................9

PLAVIX................................................................................89

PLEGRIDY..........................................................................65

PLEGRIDY STARTER PACK............................................ 66

PLENVU..............................................................................48

PLIAGLIS..........................................................................101

PNV-DHA............................................................................83

PNV-DHA+DOCUSATE..................................................... 83

PNV-OMEGA......................................................................83

PNV-SELECT..................................................................... 83

PNV TABS 20-1................................................................. 83

POCKETCHEM EZ BLOOD GLUCO..............................108

podofilox soln 0.5%.......................................................101

POGO AUTOMATIC TEST CARTR................................ 108

polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1% (Polytrim)........................................................ 92

POLYTRIM..........................................................................92

POMALYST........................................................................ 14

PONVORY..........................................................................66

PONVORY 14-DAY STARTER PA.................................... 66

posaconazole tab delayed release 100 mg (Noxafil)..... 4

potassium chloride cap er 8 meq, 10 meq................... 86

POTASSIUM CHLORIDE ER............................................ 86

potassium chloride microencapsulated crys er tab 10

meq, 15 meq, 20 meq...................................................86

potassium chloride oral soln 10% (20 meq/15ml), 20%

(40 meq/15ml)................................................................ 86

potassium chloride powder packet 20 meq................. 86

potassium chloride tab er 10 meq, 20 meq (1500 mg)

(K-tab)............................................................................. 86

potassium chloride tab er 8 meq (600 mg)...................86

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

5)......................................................................................54

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

10)....................................................................................54

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

15)....................................................................................54

potassium phosphate monobasic tab 500 mg (K-

phos)............................................................................... 86

pot phos monobasic w/sod phos di & monobas tab

155-852-130mg (K-phos neutral).................................85

PRADAXA...........................................................................88

PRALUENT.........................................................................40

pramipexole dihydrochloride tab er 24hr 0.375 mg,

0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg

(Mirapex er)....................................................................79

pramipexole dihydrochloride tab 0.125 mg, 0.25 mg,

0.5 mg, 0.75 mg, 1 mg, 1.5 mg....................................79

PRAMOSONE.................................................................. 101

prasugrel hcl tab 5 mg (base equiv), 10 mg (base

equiv) (Effient)...............................................................89

pravastatin sodium tab 10 mg, 20 mg, 40 mg, 80

mg................................................................................... 40

praziquantel tab 600 mg (Biltricide)................................ 9

prazosin hcl cap 1 mg, 2 mg, 5 mg (Minipress)........... 37

PRECISION SOF-TACT TEST S.................................... 108

PRECISION SURE-DOSE INSUL...................................131

PRECISION THINS GP LANCET................................... 131

PRECISION XTRA BLOOD GLUC................................. 108

PRECOSE.......................................................................... 24

PRED FORTE.................................................................... 92

PRED-G..............................................................................92

PRED-G S.O.P................................................................... 92

PRED MILD........................................................................92

PREDNICARBATE........................................................... 102

PREDNISOLONE...............................................................17

PREDNISOLONE ACETATE............................................. 92

PREDNISOLONE SODIUM PHOSP.................................17

prednisolone sod phosphate oral soln 15 mg/5ml

(base equiv)................................................................... 17

prednisolone sod phosphate oral soln 10 mg/5ml

(base equiv), 20 mg/5ml (base equiv)........................ 17

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

mg/5ml base) (Pediapred)............................................17

PREDNISONE....................................................................17

PREDNISONE INTENSOL................................................ 17

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

mg................................................................................... 17

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

mg (21), 10 mg (48)...................................................... 17

PREFERRED PLUS INSULIN SY...................................131

PREFERRED PLUS LANCETS CO................................131

PREFERRED PLUS LANCETS SU................................ 131

PREFERRED PLUS LANCETS TH................................ 131

PREFERRED PLUS UNIFINE PE.................................. 131

PREFEST........................................................................... 19

pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg,

200 mg, 225 mg, 300 mg (Lyrica)................................77

pregabalin tab er 24hr 82.5 mg, 165 mg, 330 mg

(Lyrica cr)....................................................................... 66

PREGEN DHA................................................................... 83

PREGENNA........................................................................83

PREGNYL W/DILUENT BENZYL..................................... 30

PREMARIN.........................................................................19

PREMESISRX.................................................................... 83

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 178

PREMIUM BLOOD GLUCOSE TES............................... 108

PREMPHASE..................................................................... 19

PREMPRO..........................................................................19

PRENA1 CHEW.................................................................84

PRENAISSANCE............................................................... 83

PRENAISSANCE PLUS.................................................... 83

PRENA1 PEARL................................................................ 84

PRENARA.......................................................................... 83

PRENATABS RX................................................................ 83

PRENATAL......................................................................... 83

PRENATAL 19....................................................................83

PRENATAL PLUS.............................................................. 83

PRENATAL PLUS VITAMIN AND..................................... 83

PRENATAL-U..................................................................... 83

PRENATE........................................................................... 83

PRENATE AM.................................................................... 83

PRENATE DHA.................................................................. 83

PRENATE ELITE............................................................... 84

PRENATE ENHANCE........................................................84

PRENATE ESSENTIAL..................................................... 84

PRENATE MINI.................................................................. 84

PRENATE PIXIE................................................................ 84

PRENATE RESTORE........................................................ 84

PRENATRIX....................................................................... 84

PRENA 1 TRUE.................................................................83

PRENATRYL...................................................................... 84

PRENATVITE COMPLETE................................................84

PRENATVITE PLUS.......................................................... 84

PRENATVITE RX............................................................... 84

PRESTALIA........................................................................ 37

PRESTIGE TEST STRIPS.............................................. 108

PRETOMANID......................................................................4

PREVACID..........................................................................49

PREVACID SOLUTAB....................................................... 49

PREVENT DROPSAFE SAFETY P................................ 131

PREVENT SAFETY PEN NEEDLE................................ 131

PREVIDENT 5000 BOOSTER PL.....................................94

PREVIDENT 5000 DRY MOUTH...................................... 94

PREVIDENT 5000 ENAMEL PRO.................................... 94

PREVIDENT FLUORIDE................................................... 94

PREVIDENT 5000 ORTHO DEFE.................................... 94

PREVIDENT 5000 PLUS...................................................94

PREVIDENT RINSE...........................................................94

PREVIDENT 5000 SENSITIVE......................................... 94

PREVYMIS........................................................................... 7

PREZCOBIX......................................................................... 7

PREZISTA.............................................................................7

PRIFTIN................................................................................ 4

PRILOSEC..........................................................................49

PRIMACARE...................................................................... 84

PRIMAQUINE PHOSPHATE............................................... 9

primaquine phosphate tab 26.3 mg (15 mg base)

(Primaquine phosphate).................................................9

primidone tab 50 mg, 250 mg (Mysoline)..................... 77

PRISTIQ..............................................................................57

PROAIR DIGIHALER.........................................................46

PROAIR HFA......................................................................46

PROAIR RESPICLICK.......................................................46

probenecid tab 500 mg................................................... 75

PROCARDIA XL................................................................ 34

prochlorperazine maleate tab 5 mg (base equivalent),

10 mg (base equivalent).............................................. 59

prochlorperazine suppos 25 mg....................................59

PRO COMFORT INSULIN SYRIN.................................. 131

PRO COMFORT LANCETS 30G.................................... 131

PRO COMFORT LANCETS 31G.................................... 131

PRO COMFORT PEN NEEDLES/.................................. 131

PROCRIT............................................................................87

PROCTOCORT.................................................................. 95

PROCTOFOAM HC........................................................... 95

PRODIGY INSULIN SYRING/U-..................................... 132

PRODIGY INSULIN SYRINGE/1.................................... 132

PRODIGY LANCING DEVICE.........................................132

PRODIGY NO CODING BLOOD G................................ 108

PRODIGY PRESSURE ACTIVATE................................. 132

PRODIGY SAFETY LANCETS....................................... 132

PRODIGY TWIST TOP LANCETS..................................132

progesterone cap 100 mg, 200 mg (Prometrium)........ 21

progesterone im in oil 50 mg/ml....................................21

PROGLYCEM..................................................................... 24

PROGRAF........................................................................ 143

PROLATE........................................................................... 69

PROLENSA........................................................................ 92

PROMACTA........................................................................87

promethazine hcl suppos 12.5 mg, 25 mg....................43

promethazine hcl syrup 6.25 mg/5ml............................ 43

promethazine hcl tab 12.5 mg, 25 mg, 50 mg...............43

PROMETHEGAN............................................................... 43

PROMETRIUM................................................................... 22

propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg

(Rythmol sr)................................................................... 34

propafenone hcl tab 150 mg, 225 mg, 300 mg............. 34

PROPRANOLOL HCL....................................................... 33

propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg,

160 mg (Inderal la)........................................................33

propranolol hcl oral soln 20 mg/5ml............................. 33

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

mg................................................................................... 33

propylthiouracil tab 50 mg............................................. 27

PROSCAR.......................................................................... 54

PROTONIX......................................................................... 49

PROTOPIC....................................................................... 102

protriptyline hcl tab 5 mg, 10 mg.................................. 57

PROVENTIL HFA...............................................................46

PROVERA.......................................................................... 22

PROVIDA OB..................................................................... 84

PROVIGIL...........................................................................63

PRO VOICE V8/V9 BLOOD GLU................................... 108

PROZAC.............................................................................57

PRUDOXIN.......................................................................102

pseudoephed-bromphen-dm syrup 30-2-10

mg/5ml............................................................................ 43

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 179

PSS SELECT GP LANCETS.......................................... 132

PSS SELECT SAFETY LANCETS................................. 132

PTS PANELS EGLU........................................................ 108

PULMICORT.......................................................................46

PULMICORT FLEXHALER................................................46

PULMOZYME.....................................................................47

PURE COMFORT LANCETS 30G..................................132

PURE COMFORT PEN NEEDLE 3................................ 132

PURE COMFORT PEN NEEDLE/3................................ 132

PURIXAN............................................................................14

PX ADVANCED LANCING DEVIC..................................132

PX EXTRA SHORT PEN NEEDLE................................. 132

PX INSULIN SYRINGE/U-100/....................................... 132

PX LANCET AUTO INJECTOR...................................... 132

PX LANCETS MICROTHIN 33G.....................................132

PX LANCETS ULTRA THIN............................................ 132

PX LANCETS ULTRA THIN 28G.................................... 132

PX MINI PEN NEEDLES 31GX5.................................... 132

PX PEN NEEDLE 31GX8MM..........................................132

PX PEN NEEDLE 29GX12MM....................................... 132

PX SHORTLENGTH PEN NEEDLE............................... 132

PYLERA..............................................................................49

pyrazinamide tab 500 mg..................................................4

PYRIDOSTIGMINE BROMIDE..........................................81

pyridostigmine bromide oral soln 60 mg/5ml

(Mestinon)...................................................................... 81

pyridostigmine bromide tab er 180 mg (Mestinon

timespan)........................................................................81

pyridostigmine bromide tab 60 mg (Mestinon)............ 81

pyrimethamine tab 25 mg (Daraprim)............................. 9

PYRUKYND........................................................................89

PYRUKYND TAPER PACK............................................... 89

QBREXZA.........................................................................102

QC ADVANCED LANCING DEVIC................................. 132

QC ANTISEPTIC MOUTH RINSE.................................... 94

QC INSULIN SYRINGE/0.3ML/.......................................132

QC INSULIN SYRINGE/0.5ML/.......................................132

QC INSULIN SYRINGE/1ML/29......................................132

QC INSULIN SYRINGE/1ML/31......................................132

QC LANCETS SUPER THIN...........................................132

QC LANCETS ULTRA THIN........................................... 132

QC MOUTHWASH/MINT FRESH..................................... 94

QC PEN NEEDLES 29G X 12MM.................................. 132

QC PEN NEEDLES 31G X 6MM.................................... 132

QC PEN NEEDLES 31G X 8MM.................................... 133

QC UNIFINE PENTIPS 32GX4M....................................133

QC UNILET LANCETS 33G/MIC.................................... 133

QC UNILET LANCETS 28G/ULT.................................... 133

QDOLO............................................................................... 70

QELBREE...........................................................................63

QINLOCK............................................................................14

QNASL................................................................................43

QNASL CHILDRENS......................................................... 43

QTERN............................................................................... 24

QUALAQUIN.........................................................................9

QUARTETTE......................................................................21

QUAZEPAM........................................................................61

QUDEXY XR...................................................................... 77

QUESTRAN........................................................................40

QUESTRAN LIGHT............................................................41

QUETIAPINE FUMARATE.................................................59

quetiapine fumarate tab er 24hr 50 mg, 150 mg, 200

mg, 300 mg, 400 mg (Seroquel xr)............................. 59

quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200

mg, 300 mg, 400 mg (Seroquel)..................................60

QUICKTEK TEST STRIPS.............................................. 108

QUICKVUE AT-HOME COVID-19...................................108

QUILLICHEW ER...............................................................63

QUILLIVANT XR................................................................ 63

quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg

(Accupril)........................................................................37

quinapril-hydrochlorothiazide tab 10-12.5 mg, 20-12.5

mg, 20-25 mg (Accuretic)............................................ 37

quinidine gluconate tab er 324 mg................................34

QUINIDINE SULFATE........................................................34

quinine sulfate cap 324 mg (Qualaquin)......................... 9

QUINTET AC BLOOD GLUCOSE.................................. 108

QUINTET BLOOD GLUCOSE TES................................ 108

QUVIVIQ.............................................................................61

QVAR REDIHALER............................................................46

RABEPRAZOLE SODIUM DR SPR..................................49

rabeprazole sodium ec tab 20 mg (Aciphex)................49

RA DRY MOUTH MOUTHWASH......................................94

RA E-ZJECT LANCETS 28G.......................................... 133

RA E-ZJECT LANCETS THIN 2..................................... 133

RA E-ZJECT LANCETS ULTRA..................................... 133

RAGWITEK.........................................................................11

RA INSULIN SYRINGE/0.5ML/....................................... 133

RA INSULIN SYRINGE/1ML/29...................................... 133

RA INSULIN SYRINGE/U-100/....................................... 133

raloxifene hcl tab 60 mg (Evista)................................... 30

ramelteon tab 8 mg (Rozerem)...................................... 61

ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg (Altace).....37

RANEXA............................................................................. 32

ranolazine tab er 12hr 500 mg, 1000 mg (Ranexa).......32

RAPAFLO........................................................................... 54

RAPAMUNE......................................................................143

RA PEN NEEDLES 31G X 5MM.....................................133

RA PEN NEEDLES 31G X 8MM.....................................133

rasagiline mesylate tab 0.5 mg (base equiv), 1 mg

(base equiv) (Azilect)....................................................79

RASUVO.............................................................................72

RAVICTI.............................................................................. 30

RAYALDEE......................................................................... 30

RAYOS................................................................................17

RAZADYNE ER..................................................................66

READYLANCE SAFETY LANCETS............................... 133

REALITY INSULIN SYRINGE/U..................................... 133

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 180

REALITY LANCETS........................................................ 133

REALITY TRIGGER LANCETS...................................... 133

REBIF................................................................................. 66

REBIF REBIDOSE............................................................. 66

REBIF REBIDOSE TITRATION.........................................66

REBIF TITRATION PACK..................................................66

RECORLEV........................................................................ 30

RECTIV...............................................................................95

REDITREX..........................................................................72

REFUAH PLUS BLOOD GLUCOSE...............................108

REGLAN............................................................................. 52

REGRANEX..................................................................... 102

RELAFEN DS.....................................................................73

RELENZA DISKHALER....................................................... 7

RELEUKO...........................................................................87

RELEXXII............................................................................63

RELION CONFIRM/MICRO TEST.................................. 108

RELION 2-IN-1 LANCET DEV........................................ 134

RELION 2-IN-1 LANCING DEV...................................... 134

RELION INSULIN SYRINGE 0....................................... 133

RELION INSULIN SYRINGE/U-......................................133

RELION INSULIN SYRINGE 1M.................................... 133

RELION LANCETS.......................................................... 133

RELION LANCETS MICRO-THIN...................................133

RELION LANCETS THIN 26G........................................ 133

RELION LANCETS ULTRA-THIN................................... 133

RELION LANCING DEVICE............................................133

RELION MINI PEN NEEDLES 3.....................................133

RELION PEN NEEDLES/31G X..................................... 134

RELION PEN NEEDLES 29GX12.................................. 133

RELION PEN NEEDLES 31G X..................................... 133

RELION PEN NEEDLES 32G X..................................... 134

RELION PEN NEEDLES 31GX5/................................... 133

RELION PEN NEEDLES 31GX6M................................. 133

RELION PEN NEEDLES 31GX8M................................. 133

RELION PEN NEEDLES 32GX4M................................. 134

RELION PREMIER BLOOD GLUC.................................108

RELION PRIME BLOOD GLUCOS.................................108

RELION R.......................................................................... 26

RELION SHORT PEN NEEDLES................................... 134

RELION THIN LANCETS................................................ 134

RELION TRUE METRIX BLOOD....................................108

RELION ULTIMA BLOOD GLUCO..................................108

RELION ULTRA THIN LANCETS................................... 134

RELION ULTRA THIN PLUS LA..................................... 134

RELISTOR..........................................................................52

RELNATE DHA.................................................................. 84

RELPAX.............................................................................. 74

RELTONE........................................................................... 52

REMERON......................................................................... 57

REMERON SOLTAB.......................................................... 57

RENAGEL...........................................................................52

RENVELA........................................................................... 52

repaglinide tab 0.5 mg, 1 mg, 2 mg...............................24

REPATHA........................................................................... 41

REPATHA PUSHTRONEX SYSTEM................................ 41

REPATHA SURECLICK.....................................................41

RESTASIS.......................................................................... 92

RESTASIS MULTIDOSE....................................................92

RESTORIL..........................................................................61

RETACRIT.......................................................................... 87

RETEVMO.......................................................................... 14

RETIN-A........................................................................... 102

RETIN-A MICRO..............................................................102

RETIN-A MICRO PUMP..................................................102

RETROVIR........................................................................... 7

REVATIO.............................................................................42

REVCOVI............................................................................30

REVLIMID.........................................................................143

REXALL BLOOD GLUCOSE TEST................................ 108

REXALL LANCETS ULTRA THIN................................... 134

REXULTI............................................................................. 60

REYATAZ.............................................................................. 7

REYVOW............................................................................74

REZUROCK..................................................................... 143

RHOFADE........................................................................ 102

RHOPRESSA..................................................................... 92

ribavirin cap 200 mg..........................................................7

ribavirin tab 200 mg.......................................................... 7

RIDAURA............................................................................73

rifabutin cap 150 mg (Mycobutin)....................................4

rifampin cap 150 mg, 300 mg...........................................4

RIGHTEST GD500 LANCING DE...................................134

RIGHTEST GL300 LANCETS......................................... 134

RIGHTEST GS100 BLOOD GLUC................................. 108

RIGHTEST GS300 BLOOD GLUC................................. 109

RIGHTEST GS333 BLOOD GLUC................................. 109

RIGHTEST GS550 BLOOD GLUC................................. 109

RILUTEK.............................................................................80

riluzole tab 50 mg (Rilutek)............................................ 80

RIMANTADINE HYDROCHLORIDE................................... 7

RINVOQ..............................................................................73

RIOMET..............................................................................24

risedronate sodium tab delayed release 35 mg

(Atelvia).......................................................................... 30

risedronate sodium tab 5 mg, 30 mg............................ 30

risedronate sodium tab 35 mg, 150 mg (Actonel)........30

RISPERDAL....................................................................... 60

RISPERIDONE ODT..........................................................60

risperidone orally disintegrating tab 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg.............................................................60

risperidone soln 1 mg/ml (Risperdal)............................60

risperidone tab 0.25 mg.................................................. 60

risperidone tab 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

(Risperdal)......................................................................60

RITALIN.............................................................................. 63

RITALIN LA........................................................................ 63

ritonavir tab 100 mg (Norvir)............................................ 7

rivastigmine tartrate cap 1.5 mg (base equivalent), 3

mg (base equivalent), 4.5 mg (base equivalent), 6

mg (base equivalent)....................................................66

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 181

rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr,

13.3 mg/24hr (Exelon).................................................. 66

rizatriptan benzoate oral disintegrating tab 5 mg (base

eq)................................................................................... 74

rizatriptan benzoate oral disintegrating tab 10 mg

(base eq) (Maxalt-mlt).................................................. 74

rizatriptan benzoate tab 5 mg (base equivalent)..........74

rizatriptan benzoate tab 10 mg (base equivalent)

(Maxalt)........................................................................... 74

ROBINUL............................................................................49

ROBINUL FORTE.............................................................. 49

ROCALTROL...................................................................... 30

ROCKLATAN...................................................................... 92

ropinirole hydrochloride tab er 24hr 2 mg (base

equivalent), 4 mg (base equivalent), 6 mg (base

equivalent), 8 mg (base equivalent), 12 mg (base

equivalent)......................................................................79

ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg, 5 mg..................................................80

rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40 mg

(Crestor)......................................................................... 41

ROSZET............................................................................. 41

ROXICODONE................................................................... 70

ROXYBOND....................................................................... 70

ROZEREM..........................................................................61

ROZLYTREK...................................................................... 14

RUBRACA.......................................................................... 14

rufinamide susp 40 mg/ml (Banzel)...............................77

rufinamide tab 200 mg, 400 mg (Banzel)...................... 77

RUKOBIA..............................................................................7

RYALTRIS...........................................................................43

RYBELSUS.........................................................................24

RYCLORA.......................................................................... 43

RYDAPT............................................................................. 14

RYTARY..............................................................................80

RYTHMOL SR....................................................................34

RYVENT............................................................................. 43

SABRIL............................................................................... 77

SAFE-T-LANCE LOW FLOW 25G..................................134

SAFE-T-LANCE NORMAL FLOW...................................134

SAFE-T-LANCE PLUS SAFETY..................................... 134

SAFETY LANCET 30G/PRESSUR................................. 134

SAFETY LANCETS......................................................... 134

SAFETY LANCETS 21G................................................. 134

SAFETY LANCETS 28G................................................. 134

SAFETY PEN NEEDLES/30G X.....................................134

SAFYRAL........................................................................... 21

SAIZEN............................................................................... 30

SAIZENPREP RECONSTITUTION...................................30

SALAGEN...........................................................................95

SAMSCA.............................................................................30

SANCUSO.......................................................................... 50

SANDIMMUNE................................................................. 143

SANDOSTATIN...................................................................30

SANTYL............................................................................102

SAPHRIS............................................................................ 60

sapropterin dihydrochloride powder packet 100 mg,

500 mg (Kuvan).............................................................30

sapropterin dihydrochloride tab 100 mg (Kuvan)........30

SAPSCARE TWIST TOP LANCET................................. 134

SAPS HEALTH CARE TWIST TO.................................. 134

SAPS HEALTH TWIST TOP LAN................................... 134

SAVAYSA............................................................................88

SAVELLA............................................................................ 66

SAVELLA TITRATION PACK.............................................66

SB INSULIN SYRINGE/U-100/....................................... 134

SB LANCETS THIN......................................................... 134

SB LANCETS ULTRA THIN............................................ 134

SCEMBLIX..........................................................................15

SCHNUCKS INSULIN SYRINGE....................................134

SCOPE............................................................................... 95

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

scop)............................................................................... 50

SEASONIQUE....................................................................21

SECUADO.......................................................................... 60

SECURESAFE SAFETY INSULIN..................................134

SECURESAFE SAFETY PEN NEE................................ 134

SEGLENTIS........................................................................70

SEGLUROMET.................................................................. 24

SELECT-LITE LANCING DEVIC.....................................134

SELECT-OB....................................................................... 84

SELECT-OB+DHA............................................................. 84

selegiline hcl cap 5 mg................................................... 80

selegiline hcl tab 5 mg....................................................80

selenium sulfide lotion 2.5%........................................ 102

SELZENTRY.........................................................................7

SEMGLEE.......................................................................... 27

SE-NATAL 19..................................................................... 84

SENSIPAR.......................................................................... 30

SENSODYNE COMPLETE PROTEC............................... 95

SENSODYNE RAPID RELIEF.......................................... 95

SENSODYNE REPAIR & PROTEC.................................. 95

SEREVENT DISKUS......................................................... 46

SERNIVO..........................................................................102

SEROQUEL........................................................................60

SEROQUEL XR................................................................. 60

SEROSTIM......................................................................... 30

sertraline hcl oral concentrate for solution 20 mg/ml

(Zoloft)............................................................................ 57

sertraline hcl tab 25 mg, 50 mg, 100 mg (Zoloft)......... 57

SERTRALINE HYDROCHLORIDE................................... 57

sevelamer carbonate packet 0.8 gm, 2.4 gm

(Renvela)........................................................................ 52

sevelamer carbonate tab 800 mg (Renvela)................. 52

sevelamer hcl tab 800 mg (Renagel)............................. 52

SEVELAMER HYDROCHLORIDE.................................... 52

SEYSARA.............................................................................3

SHOPKO AUTOLET LANCING DE................................ 134

SHOPKO ON-THE-GO COMFORT................................ 134

SHOPKO UNIFINE PENTIPS PE................................... 134

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 182

SHOPKO UNIFINE PENTIPS PL....................................135

SHOPKO UNILET LANCETS SUP................................. 135

SHOPKO UNILET LANCETS ULT.................................. 135

SHUR-SEAL....................................................................... 54

SIGNIFOR.......................................................................... 30

SIKLOS............................................................................... 87

sildenafil citrate tab 20 mg (Revatio)............................ 42

SILENOR............................................................................ 61

SILIQ.................................................................................102

silodosin cap 4 mg, 8 mg (Rapaflo).............................. 55

SILVADENE...................................................................... 102

silver sulfadiazine cream 1% (Silvadene)................... 102

SIMBRINZA........................................................................ 92

SIMPLE DIAGNOSTICS LANCIN................................... 135

SIMPONI.............................................................................73

simvastatin tab 5 mg.......................................................41

simvastatin tab 80 mg.....................................................41

simvastatin tab 10 mg, 40 mg (Zocor).......................... 41

simvastatin tab 20 mg (Zocor)....................................... 41

SINEMET............................................................................80

SINGLE-LET.....................................................................135

SINGULAIR........................................................................ 46

sirolimus oral soln 1 mg/ml (Rapamune)....................143

sirolimus tab 0.5 mg, 1 mg, 2 mg (Rapamune).......... 143

SIRTURO..............................................................................4

SITAVIG................................................................................ 7

SIVEXTRO..........................................................................10

SKYRIZI..............................................................................52

SKYRIZI PEN................................................................... 102

SKYTROFA.........................................................................30

SLYND................................................................................ 21

SMART DIABETES VANTAGE LA.................................. 135

SMARTEST BLOOD GLUCOSE TE...............................109

SMARTEST LANCETS 28G............................................135

SMART SENSE COLOR LANCETS............................... 135

SMART SENSE PREMIUM BLOOD...............................109

SMART SENSE STANDARD LANC............................... 135

SMART SENSE SUPER THIN LA.................................. 135

SMART SENSE THIN LANCETS....................................135

SMART SENSE VALUE BLOOD G................................ 109

SM MICRO THIN LANCETS 33G................................... 135

SM TRUEDRAW LANCING DEVIC................................ 135

SOAANZ............................................................................. 38

sodium chloride soln nebu 3%...................................... 43

sodium chloride soln nebu 7% (Hypersal)................... 43

sodium citrate & citric acid soln 500-334 mg/5ml........55

SODIUM FLUORIDE......................................................... 86

sodium fluoride chew tab 0.25 mg f (from 0.55 mg

naf), 0.5 mg f (from 1.1 mg naf), 1 mg f (from 2.2 mg

naf).................................................................................. 86

sodium fluoride cream 1.1% (Prevident 5000 plus)..... 95

sodium fluoride gel 1.1% (0.5% f) (Prevident

fluoride).......................................................................... 95

sodium fluoride paste 1.1% (Prevident 5000

boost)..............................................................................95

sodium fluoride-potassium nitrate gel 1.1-5%

(Prevident 5000 sensi)................................................. 95

sodium fluoride rinse 0.2% (Prevident rinse)...............95

sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop

naf).................................................................................. 86

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml

naf).................................................................................. 86

sodium phenylbutyrate oral powder 3 gm/teaspoonful

(Buphenyl)......................................................................30

sodium phenylbutyrate tab 500 mg (Buphenyl)...........31

sodium polystyrene sulfonate powder....................... 143

sod sulfate-pot sulf-mg sulf oral sol 17.5-3.13-1.6

gm/177ml (Suprep bowel prep ki)...............................48

SOFOSBUVIR/VELPATASVIR.............................................7

solifenacin succinate tab 5 mg, 10 mg (Vesicare)....... 53

SOLIQUA 100/33............................................................... 24

SOLODYN............................................................................ 3

SOLOSEC............................................................................ 9

SOLTAMOX........................................................................ 15

SOLUS V2 AUDIBLE TEST............................................ 109

SOLUS V2 LANCING DEVICE....................................... 135

SOLUS V2 PRESSURE ACTIVAT.................................. 135

SOLUS V2 TWIST LANCETS 30....................................135

SOMA................................................................................. 81

SOMAVERT........................................................................31

SOOLANTRA................................................................... 102

sorafenib tosylate tab 200 mg (base equivalent)

(Nexavar)........................................................................ 15

SORILUX.......................................................................... 102

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

(Betapace af)................................................................. 33

sotalol hcl tab 240 mg.....................................................33

sotalol hcl tab 80 mg, 120 mg, 160 mg (Betapace)...... 33

SOTYLIZE.......................................................................... 33

SOVALDI...............................................................................7

SPIKEVAX COVID-19 VACCINE.......................................11

SPINOSAD....................................................................... 102

SPIRIVA HANDIHALER.....................................................46

SPIRIVA RESPIMAT.......................................................... 46

spironolactone & hydrochlorothiazide tab 25-25 mg

(Aldactazide).................................................................. 38

spironolactone tab 25 mg, 50 mg, 100 mg

(Aldactone).....................................................................38

SPORANOX......................................................................... 4

SPORANOX PULSEPAK.....................................................5

SPRITAM............................................................................ 77

SPRIX................................................................................. 73

SPRYCEL........................................................................... 15

SPS...................................................................................143

STALEVO 50...................................................................... 80

STALEVO 75...................................................................... 80

STALEVO 100.................................................................... 80

STALEVO 125.................................................................... 80

STALEVO 150.................................................................... 80

STALEVO 200.................................................................... 80

stannous fluoride conc 0.63%........................................95

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 183

stannous fluoride gel 0.4%.............................................95

STAVUDINE..........................................................................7

1ST CHOICE LANCETS SUPER....................................142

1ST CHOICE LANCETS THIN........................................142

1ST CHOICE LANCETS ULTRA.....................................142

STEGLATRO...................................................................... 24

STEGLUJAN.......................................................................24

STELARA......................................................................... 102

STERILANCE TL............................................................. 135

STIMATE.............................................................................31

STIOLTO RESPIMAT.........................................................46

STIVARGA.......................................................................... 15

STRATTERA.......................................................................63

STRENSIQ......................................................................... 31

STRIBILD..............................................................................7

STRIVERDI RESPIMAT.....................................................46

STROMECTOL.....................................................................9

1ST TIER UNIFINE PENTIPS.........................................142

1ST TIER UNILET COMFORTOU.................................. 142

SUBOXONE....................................................................... 70

SUBSYS............................................................................. 70

SUCRAID............................................................................51

sucralfate susp 1 gm/10ml (Carafate)........................... 49

sucralfate tab 1 gm (Carafate)....................................... 50

SULAR................................................................................ 34

SULCONAZOLE NITRATE..............................................102

SULFACETAMIDE SODIUM..............................................92

SULFACETAMIDE SODIUM/PRED.................................. 92

sulfacetamide sodium lotion 10% (acne) (Klaron).....102

sulfacetamide sodium ophth soln 10%.........................92

SULFADIAZINE.................................................................... 4

sulfamethoxazole-trimethoprim susp 200-40

mg/5ml............................................................................ 10

sulfamethoxazole-trimethoprim tab 400-80 mg

(Bactrim).........................................................................10

sulfamethoxazole-trimethoprim tab 800-160 mg

(Bactrim ds)................................................................... 10

SULFAMYLON................................................................. 102

sulfasalazine tab delayed release 500 mg (Azulfidine

en-tabs)...........................................................................52

sulfasalazine tab 500 mg (Azulfidine)........................... 52

sulindac tab 150 mg, 200 mg......................................... 73

sumatriptan-naproxen sodium tab 85-500 mg

(Treximet)....................................................................... 74

sumatriptan nasal spray 5 mg/act, 20 mg/act

(Imitrex).......................................................................... 74

sumatriptan succinate inj 6 mg/0.5ml........................... 74

SUMATRIPTAN SUCCINATE REF................................... 74

sumatriptan succinate solution auto-injector 4

mg/0.5ml, 6 mg/0.5ml (Imitrex statdose sys).............74

sumatriptan succinate tab 25 mg, 50 mg, 100 mg

(Imitrex).......................................................................... 74

sunitinib malate cap 12.5 mg (base equivalent), 25 mg

(base equivalent), 37.5 mg (base equivalent), 50 mg

(base equivalent) (Sutent)........................................... 15

SUNOSI.............................................................................. 63

SUPER THIN LANCETS................................................. 135

SUPRAX............................................................................... 1

SUPREME TEST STRIPS...............................................109

SUPREP BOWEL PREP KIT............................................ 48

SURE COMFORT AUTOKEEPER S.............................. 135

SURE COMFORT INSULIN SYRI...................................135

SURE COMFORT LANCETS 18G..................................135

SURE COMFORT LANCETS 21G..................................135

SURE COMFORT LANCETS 23G..................................135

SURE COMFORT LANCETS 28G..................................135

SURE COMFORT LANCETS 30G..................................135

SURE COMFORT LANCING PEN..................................135

SURE COMFORT PEN NEEDLES................................. 135

SURELITE LANCETS......................................................136

SUSTIVA...............................................................................7

SUTAB................................................................................ 48

SUTENT..............................................................................15

SYMBICORT...................................................................... 46

SYMBYAX...........................................................................66

SYMDEKO..........................................................................47

SYMFI................................................................................... 8

SYMFI LO.............................................................................8

SYMJEPI............................................................................ 39

SYMLINPEN 60................................................................. 24

SYMLINPEN 120............................................................... 24

SYMPAZAN........................................................................ 78

SYMPROIC.........................................................................53

SYMTUZA.............................................................................8

SYNALAR......................................................................... 102

SYNAREL........................................................................... 31

SYNDROS.......................................................................... 50

SYNERA........................................................................... 102

SYNJARDY.........................................................................24

SYNJARDY XR.................................................................. 24

SYNTHROID.......................................................................27

SYPRINE.......................................................................... 144

TABLOID.............................................................................15

TABRECTA......................................................................... 15

TACLONEX.......................................................................102

tacrolimus cap 0.5 mg, 1 mg, 5 mg (Prograf)............. 144

tacrolimus oint 0.03%, 0.1% (Protopic).......................102

tadalafil tab 5 mg (Cialis)...........................................42,42

tadalafil tab 20 mg (pah) (Adcirca)................................ 42

TAFINLAR...........................................................................15

TAGRISSO......................................................................... 15

TAKHZYRO........................................................................ 89

TALICIA...............................................................................50

TALTZ............................................................................... 102

TALZENNA......................................................................... 15

TAMIFLU...............................................................................8

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

(base equivalent)...........................................................15

tamsulosin hcl cap 0.4 mg (Flomax)............................. 55

TAPERDEX 7-DAY.............................................................17

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 184

TAPERDEX 12-DAY...........................................................17

TARCEVA........................................................................... 15

TARGRETIN....................................................................... 15

TARON-C DHA...................................................................84

TARON-PREX.................................................................... 84

TARPEYO........................................................................... 17

TASCENSO ODT............................................................... 66

TASIGNA............................................................................ 15

TASMAR............................................................................. 80

tavaborole soln 5% (Kerydin).......................................103

TAVALISSE......................................................................... 89

TAVNEOS........................................................................... 89

TAYTULLA.......................................................................... 21

TAZAROTENE..................................................................103

tazarotene cream 0.1% (Tazorac).................................103

TAZORAC.........................................................................103

TAZVERIK...........................................................................15

TECFIDERA....................................................................... 66

TECFIDERA STARTER PACK.......................................... 66

TECHLITE AST LANCETS..............................................136

TECHLITE INSULIN SYRINGE.......................................136

TECHLITE LANCETS...................................................... 136

TECHLITE LANCETS 30G..............................................136

TECHLITE PEN NEEDLES/31G..................................... 136

TECHLITE PEN NEEDLES/32G..................................... 136

TECHLITE PEN NEEDLES 29G.....................................136

TECHLITE PEN NEEDLES 31G.....................................136

TEGRETOL........................................................................ 78

TEGRETOL-XR.................................................................. 78

TEGSEDI............................................................................ 66

TEKTURNA........................................................................ 37

TEKTURNA HCT............................................................... 37

telmisartan-amlodipine tab 40-5 mg, 40-10 mg, 80-5

mg, 80-10 mg.................................................................37

telmisartan-hydrochlorothiazide tab 40-12.5 mg,

80-12.5 mg, 80-25 mg (Micardis hct).......................... 37

telmisartan tab 20 mg, 40 mg, 80 mg (Micardis).......... 37

temazepam cap 7.5 mg, 22.5 mg (Restoril).................. 61

temazepam cap 15 mg, 30 mg (Restoril)...................... 61

TEMODAR..........................................................................15

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

mg................................................................................... 15

temozolomide cap 250 mg (Temodar)........................... 15

TENCON.............................................................................67

tenofovir disoproxil fumarate tab 300 mg (Viread)........ 8

TENORETIC 50................................................................. 37

TENORETIC 100............................................................... 37

TENORMIN.........................................................................33

TEPMETKO........................................................................ 15

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

equivalent), 5 mg (base equivalent), 10 mg (base

equivalent)......................................................................37

terbinafine hcl tab 250 mg................................................5

terbutaline sulfate tab 2.5 mg, 5 mg..............................46

terconazole vaginal cream 0.4%, 0.8%..........................54

terconazole vaginal suppos 80 mg............................... 54

TERIPARATIDE.................................................................. 31

TESTIM...............................................................................18

TESTOSTERONE.............................................................. 18

testosterone cypionate im inj in oil 100 mg/ml, 200

mg/ml (Depo-testosterone)..........................................18

TESTOSTERONE ENANTHATE.......................................18

TESTOSTERONE PUMP.................................................. 18

testosterone td gel 12.5 mg/act (1%).............................18

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

pump)..............................................................................18

testosterone td gel 10mg/act (2%) (Fortesta)............... 18

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

(1%), 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm

(1.62%) (Androgel)........................................................ 18

testosterone td soln 30 mg/act...................................... 18

tetrabenazine tab 12.5 mg, 25 mg (Xenazine).............. 66

tetracycline hcl cap 250 mg, 500 mg...............................3

TEXACORT...................................................................... 103

TGT ADVANCED LANCING DEVI.................................. 136

TGT BLOOD GLUCOSE TEST ST.................................109

TGT LANCET ALTERNATE SITE................................... 136

TGT LANCET MICRO THIN 33G................................... 136

TGT LANCET SUPER THIN 30G................................... 136

TGT LANCET THIN 23G.................................................136

TGT LANCET THIN 26G.................................................136

TGT LANCET ULTRA THIN 28G.................................... 136

TGT LANCET ULTRA THIN 30G.................................... 136

TGT LANCING DEVICE.................................................. 136

THALITONE........................................................................38

THALOMID....................................................................... 144

THEO-24.............................................................................46

theophylline soln 80 mg/15ml........................................ 46

theophylline tab er 12hr 300 mg, 450 mg..................... 46

theophylline tab er 24hr 400 mg, 600 mg..................... 46

THERABREATH ORAL RINSE/DR................................... 95

THERABREATH ORAL RINSE/FR................................... 95

THINLETS GP LANCETS............................................... 136

THIOLA............................................................................... 55

THIOLA EC........................................................................ 55

thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg.......60

thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg.....................60

THRIVITE RX..................................................................... 84

THYQUIDITY......................................................................27

tiagabine hcl tab 2 mg, 4 mg, 12 mg, 16 mg

(Gabitril)..........................................................................78

TIAZAC............................................................................... 34

TIBSOVO............................................................................15

TIGLUTIK............................................................................80

TIKOSYN............................................................................ 34

timolol maleate ophth gel forming soln 0.25%, 0.5%

(Timoptic-xe)..................................................................92

timolol maleate ophth soln 0.25%, 0.5% (Timoptic).....92

timolol maleate ophth soln 0.5% (once-daily)

(Istalol)............................................................................92

timolol maleate preservative free ophth soln 0.5%

(Timoptic ocudose).......................................................92

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 185

timolol maleate tab 5 mg, 10 mg, 20 mg.......................33

TIMOPTIC...........................................................................92

TIMOPTIC OCUDOSE.......................................................92

TIMOPTIC-XE.................................................................... 92

tinidazole tab 250 mg, 500 mg....................................... 10

tiopronin tab 100 mg (Thiola).........................................55

TIROSINT........................................................................... 27

TIROSINT-SOL.................................................................. 27

TIVICAY................................................................................ 8

TIVICAY PD..........................................................................8

TIVORBEX..........................................................................73

tizanidine hcl cap 2 mg (base equivalent), 4 mg (base

equivalent), 6 mg (base equivalent) (Zanaflex)......... 81

tizanidine hcl tab 2 mg (base equivalent).....................81

tizanidine hcl tab 4 mg (base equivalent)

(Zanaflex)........................................................................81

TLANDO............................................................................. 18

TOBI......................................................................................4

TOBI PODHALER................................................................ 4

TOBRADEX........................................................................ 92

TOBRADEX ST..................................................................92

TOBRAMYCIN......................................................................4

tobramycin-dexamethasone ophth susp 0.3-0.1%

(Tobradex)...................................................................... 92

tobramycin nebu soln 300 mg/4ml (Bethkis)..................4

tobramycin nebu soln 300 mg/5ml (Tobi)....................... 4

tobramycin ophth soln 0.3%.......................................... 92

TOBREX............................................................................. 92

TODAYS HEALTH ADVANCED LA.................................136

TODAYS HEALTH MINI PEN NE....................................136

TODAYS HEALTH ORIGINAL PE...................................136

TODAYS HEALTH SHORT PEN N................................. 136

TODAYS HEALTH SUPER THIN.................................... 136

TODAYS HEALTH ULTRA THIN..................................... 136

TODAY SPONGE...............................................................54

tolcapone tab 100 mg (Tasmar)..................................... 80

TOLSURA.............................................................................5

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

la).....................................................................................53

tolterodine tartrate tab 1 mg, 2 mg (Detrol)..................53

tolvaptan tab 15 mg, 30 mg (Samsca)...........................31

TONSILINE.........................................................................95

TOPAMAX...........................................................................78

TOPAMAX SPRINKLE....................................................... 78

TOPCARE CLICKFINE UNIVERS.................................. 136

TOPCARE LANCETS MICRO-THI................................. 136

TOPCARE ULTRA COMFORT INS................................ 136

TOPICORT....................................................................... 103

topiramate cap er 24hr sprinkle 25 mg, 50 mg, 100

mg, 150 mg, 200 mg (Qudexy xr)............................... 78

topiramate sprinkle cap 15 mg, 25 mg (Topamax

sprinkle)..........................................................................78

topiramate tab 25 mg, 50 mg, 100 mg, 200 mg

(Topamax).......................................................................78

TOPROL XL....................................................................... 33

toremifene citrate tab 60 mg (base equivalent)

(Fareston)....................................................................... 15

torsemide tab 5 mg, 10 mg, 20 mg, 100 mg................. 38

TOSYMRA.......................................................................... 74

TOUJEO MAX SOLOSTAR............................................... 27

TOUJEO SOLOSTAR........................................................ 27

TOVIAZ............................................................................... 53

TRACLEER.........................................................................42

TRADJENTA.......................................................................24

tramadol-acetaminophen tab 37.5-325 mg

(Ultracet).........................................................................70

TRAMADOL HCL ER.........................................................70

tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg....... 70

tramadol hcl tab 100 mg................................................. 70

tramadol hcl tab 50 mg (Ultram)....................................70

TRAMADOL HYDROCHLORIDE...................................... 70

TRANDOLAPRIL/VERAPAMIL HC................................... 37

trandolapril tab 1 mg, 2 mg, 4 mg................................. 37

tranexamic acid tab 650 mg (Lysteda).......................... 88

TRANSDERM-SCOP......................................................... 50

TRANXENE T.....................................................................55

tranylcypromine sulfate tab 10 mg (Parnate)............... 57

TRAVATAN Z...................................................................... 93

TRAVEL LANCETS ADVANCED 2................................. 137

TRAVEL LANCETS 30G..................................................137

travoprost ophth soln 0.004% (benzalkonium free)

(bak free) (Travatan z).................................................. 93

trazodone hcl tab 300 mg............................................... 57

trazodone hcl tab 50 mg, 100 mg, 150 mg....................57

TRECATOR.......................................................................... 4

TRELEGY ELLIPTA........................................................... 46

TREMFYA.........................................................................103

TRESIBA............................................................................ 27

TRESIBA FLEXTOUCH.....................................................27

tretinoin cap 10 mg......................................................... 15

tretinoin cream 0.025%, 0.05%, 0.1% (Retin-a)...........103

tretinoin gel 0.01%, 0.025% (Retin-a).......................... 103

tretinoin gel 0.05% (Atralin)..........................................103

tretinoin microsphere gel 0.04%, 0.1% (Retin-a

micro)............................................................................103

TREXALL............................................................................15

TREXIMET..........................................................................74

TREZIX............................................................................... 70

triamcinolone acetonide aerosol soln 0.147 mg/gm

(Kenalog)...................................................................... 103

triamcinolone acetonide cream 0.025%, 0.1%,

0.5%...............................................................................103

triamcinolone acetonide dental paste 0.1%................. 95

triamcinolone acetonide lotion 0.025%, 0.1%............ 103

triamcinolone acetonide oint 0.05%............................ 103

triamcinolone acetonide oint 0.025%, 0.1%, 0.5%..... 103

triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................... 38

triamterene & hydrochlorothiazide tab 37.5-25 mg

(Maxzide-25)...................................................................38

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 186

triamterene & hydrochlorothiazide tab 75-50 mg

(Maxzide)........................................................................ 38

triamterene cap 50 mg, 100 mg (Dyrenium)................. 39

triazolam tab 0.125 mg....................................................61

triazolam tab 0.25 mg (Halcion)..................................... 61

TRIBENZOR....................................................................... 37

TRICARE............................................................................ 84

TRICOR.............................................................................. 41

TRIDESILON.................................................................... 103

trientine hcl cap 250 mg (Syprine).............................. 144

trifluoperazine hcl tab 1 mg (base equivalent), 2 mg

(base equivalent), 5 mg (base equivalent), 10 mg

(base equivalent)...........................................................60

TRIFLURIDINE...................................................................93

TRIHEXYPHENIDYL HCL................................................. 80

trihexyphenidyl hcl tab 2 mg, 5 mg...............................80

TRIJARDY XR....................................................................24

TRIKAFTA...........................................................................47

TRILEPTAL.........................................................................78

TRILIPIX............................................................................. 41

trimethobenzamide hcl cap 300 mg.............................. 50

TRIMETHOPRIM................................................................10

trimipramine maleate cap 25 mg, 50 mg, 100 mg........ 57

TRINATAL RX 1................................................................. 84

TRINATE.............................................................................84

TRINTELLIX....................................................................... 58

TRISTART DHA................................................................. 84

TRISTART FREE............................................................... 84

TRISTART ONE................................................................. 84

TRIUMEQ............................................................................. 8

TRIUMEQ PD.......................................................................8

TROKENDI XR...................................................................78

trospium chloride cap er 24hr 60 mg............................53

trospium chloride tab 20 mg.......................................... 53

TRUDHESA........................................................................ 74

TRUE COMFORT INSULIN SYRI...................................137

TRUE COMFORT PEN NEEDLES................................. 137

TRUE COMFORT PRO INSULIN................................... 137

TRUE COMFORT PRO PEN NEED............................... 137

TRUE COMFORT TWIST TOP LA................................. 137

TRUEDRAW LANCING DEVICE.................................... 137

TRUE FOCUS SELF MONITORIN................................. 109

TRUE METRIX BLOOD GLUCOSE................................109

TRUE METRIX SELF MONITORI................................... 109

TRUEPLUS 5-BEVEL PEN NEED..................................137

TRUEPLUS INSULIN SYRINGE.....................................137

TRUEPLUS INSULIN SYRINGE/....................................137

TRUEPLUS LANCETS 26G............................................ 137

TRUEPLUS LANCETS 28G............................................ 137

TRUEPLUS LANCETS 30G............................................ 137

TRUEPLUS LANCETS 33G............................................ 137

TRUEPLUS LANCETS 33G MICR................................. 137

TRUEPLUS LANCETS 28G SUPE.................................137

TRUEPLUS LANCETS 30G ULTR..................................137

TRUEPLUS PEN NEEDLES 31GX.................................137

TRUEPLUS PEN NEEDLES 32GX.................................137

TRUEPLUS SAFETY LANCETS 2................................. 137

TRUETEST STRIPS........................................................ 109

TRUETRACK BLOOD GLUCOSE T...............................109

TRUETRACK TEST.........................................................109

TRULANCE........................................................................ 53

TRULICITY......................................................................... 24

TRUSELTIQ........................................................................15

TRUSOPT...........................................................................93

TRUVADA............................................................................. 8

TUDORZA PRESSAIR...................................................... 46

TUKYSA..............................................................................15

TURALIO............................................................................ 15

TUXARIN ER......................................................................43

TUZISTRA XR....................................................................43

TWIRLA.............................................................................. 21

TWYNEO.......................................................................... 103

TYBLUME...........................................................................21

TYBOST................................................................................8

TYKERB..............................................................................15

TYMLOS............................................................................. 31

TYRVAYA............................................................................ 93

TYVASO DPI MAINTENANCE KI..................................... 42

TYVASO DPI TITRATION KIT...........................................42

UBRELVY........................................................................... 74

UCERIS.............................................................................. 17

UDENYCA.......................................................................... 87

ULORIC.............................................................................. 75

ULTICARE INSULIN SAFETY S..................................... 137

ULTICARE INSULIN SYRINGE.......................................137

ULTICARE INSULIN SYRINGE/......................................138

ULTICARE MICRO PEN NEEDLE.................................. 138

ULTICARE MINI PEN NEEDLES.................................... 138

ULTICARE MINI SAFETY PEN.......................................138

ULTICARE ORIGINAL PEN NEE....................................138

ULTICARE PEN NEEDLES/29G..................................... 138

ULTICARE PEN NEEDLES 31G.....................................138

ULTICARE SHORT PEN NEEDLE................................. 138

ULTICARE SHORT SAFETY PEN..................................138

ULTICARE U-100 INSULIN SY....................................... 138

ULTIGUARD INSULIN SYRINGE....................................138

ULTIGUARD SAFEPACK/MICRO................................... 138

ULTIGUARD SAFEPACK/MINI P.................................... 138

ULTIGUARD SAFEPACK/SHORT...................................138

ULTIGUARD SAFEPACK/SYRING................................. 138

ULTIGUARD SAFEPACK INSULI................................... 138

ULTIGUARD SAFEPACK MINI P....................................138

ULTIGUARD SAFEPACK PEN NE................................. 138

ULTI-LANCE AUTOMATIC/ CLE.....................................137

ULTILET CLASSIC LANCETS........................................ 139

ULTILET LANCETS......................................................... 139

ULTILET LANCETS 33G................................................. 139

ULTILET PEN NEEDLE 29GX12.................................... 139

ULTILET PEN NEEDLE 31GX5M................................... 139

ULTILET PEN NEEDLE 31GX8M................................... 139

2023

Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 187

ULTILET PEN NEEDLE 32GX4M................................... 139

ULTILET SAFETY LANCETS 21.....................................139

ULTILET SAFETY LANCETS 23.....................................139

ULTILET SHORT PEN NEEDLES.................................. 139

ULTRACARE INSULIN SYRINGE.................................. 140

ULTRA-CARE LANCETS 30G........................................ 139

ULTRACARE PEN NEEDLES/31G.................................140

ULTRACARE PEN NEEDLES/32G.................................140

ULTRACARE PEN NEEDLES/33G.................................140

ULTRACET......................................................................... 70

ULTRA COMFORT INSULIN SYR.................................. 139

ULTRA FLO INSULIN PEN NEE.....................................139

ULTRA FLO INSULIN SYRINGE.................................... 139

ULTRA INSULIN SYRINGE/U-1......................................139

ULTRAM............................................................................. 70

ULTRA-THIN II AUTO LANCET...................................... 139

ULTRA-THIN II INSULIN SYR.........................................139

ULTRA-THIN II LANCETS 28G.......................................139

ULTRA-THIN II LANCETS 30G.......................................139

ULTRA-THIN II MINI PEN NE......................................... 139

ULTRA-THIN II PEN NEEDLES...................................... 139

ULTRA THIN LANCETS 28G.......................................... 139

ULTRA THIN LANCETS 31G.......................................... 139

ULTRA THIN PEN NEEDLES 32.................................... 139

ULTRAVATE......................................................................103

UNIFINE PEN NEEDLE/32G X....................................... 140

UNIFINE PENTIPS/30G X 3/1........................................ 140

UNIFINE PENTIPS 31G X 3/1........................................ 140

UNIFINE PENTIPS 31GX5MM........................................140

UNIFINE PENTIPS 31GX6MM........................................140

UNIFINE PENTIPS 31GX8MM........................................140

UNIFINE PENTIPS 32GX4MM........................................140

UNIFINE PENTIPS 32GX6MM........................................140

UNIFINE PENTIPS 33GX4MM........................................140

UNIFINE PENTIPS 29GX12MM..................................... 140

UNIFINE PENTIPS 31G X 6MM..................................... 140

UNIFINE PENTIPS 31G X 8MM..................................... 140

UNIFINE PENTIPS PLUS/30G........................................140

UNIFINE PENTIPS PLUS 33G....................................... 140

UNIFINE PENTIPS PLUS 29GX.....................................140

UNIFINE PENTIPS PLUS 31GX.....................................140

UNIFINE PENTIPS PLUS 32GX.....................................140

UNIFINE PENTIPS PLUS 33GX.....................................140

UNIFINE SAFECONTROL PEN N..................................140

UNIFINE ULTRA PEN NEEDLE/.....................................141

UNILET COMFORTOUCH LANCET...............................141

UNILET EXCELITE..........................................................141

UNILET EXCELITE II.......................................................141

UNILET G.P. LANCET..................................................... 141

UNILET G.P. SUPERLITE LAN.......................................141

UNILET GP 28 ULTRA THIN.......................................... 141

UNILET LANCET............................................................. 141

UNILET LANCETS MICRO-THIN................................... 141

UNILET LANCETS SUPER-THIN................................... 141

UNILET LANCETS ULTRA-THIN.................................... 141

UNILET SUPERLITE LANCET........................................141

UNISTIK 3 GENTLE........................................................ 141

UNISTIK PRO SAFETY LANCET................................... 141

UNISTIK SAFETY LANCETS 28.................................... 141

UNISTIK SAFETY LANCETS 30.................................... 141

UNISTIK TOUCH SAFETY LANC...................................141

UNISTRIP1 GENERIC.....................................................109

UNIVERSAL 1 LANCETS/33G/M....................................141

UNIVERSAL 1 LANCETS THIN......................................141

UNIVERSAL 1 LANCETS ULTRA...................................141

UPNEEQ.............................................................................93

UPTRAVI.............................................................................42

UROCIT-K 5....................................................................... 55

UROCIT-K 10..................................................................... 55

UROCIT-K 15..................................................................... 55

UROXATRAL...................................................................... 55

URSO 250.......................................................................... 53

URSODIOL......................................................................... 53

ursodiol cap 300 mg........................................................53

ursodiol tab 250 mg (Urso 250)..................................... 53

ursodiol tab 500 mg (Urso forte)................................... 53

URSO FORTE....................................................................53

VAGIFEM............................................................................ 54

valacyclovir hcl tab 500 mg, 1 gm (Valtrex)....................8

VALCHLOR.......................................................................103

VALCYTE..............................................................................8

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

(Valcyte)............................................................................8

valganciclovir hcl tab 450 mg (base equivalent)

(Valcyte)............................................................................8

VALIUM...............................................................................55

valproate sodium oral soln 250 mg/5ml (base

equiv).............................................................................. 78

valproic acid cap 250 mg................................................78

VALSARTAN....................................................................... 37

valsartan-hydrochlorothiazide tab 80-12.5 mg,

160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg

(Diovan hct)................................................................... 37

valsartan tab 40 mg, 80 mg, 160 mg, 320 mg

(Diovan).......................................................................... 37

VALTOCO........................................................................... 78

VALTREX.............................................................................. 8

VALUE HEALTH INSULIN SYRI..................................... 141

VALUE PLUS LANCETS STANDA................................. 141

VALUE PLUS LANCETS SUPER................................... 141

VALUE PLUS LANCETS THIN 2.................................... 141

VALUE PLUS LANCING DEVICE................................... 141

VALUMARK LANCET SUPER THI................................. 141

VALUMARK LANCET ULTRA THI.................................. 141

VALUMARK PEN NEEDLES 31G...................................141

VALUMARK PEN NEEDLES 29GX................................ 141

VANCOCIN......................................................................... 10

vancomycin hcl cap 125 mg (base equivalent), 250 mg

(base equivalent) (Vancocin).......................................10

VANCOMYCIN HYDROCHLORIDE..................................10

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 188

VANDAZOLE...................................................................... 54

VANISHPOINT INSULIN SYRIN..................................... 141

VANOS..............................................................................103

VARENICLINE STARTING MONT.................................... 66

VARENICLINE TARTRATE................................................66

VARUBI...............................................................................50

VASERETIC........................................................................37

VASOTEC........................................................................... 37

VCF VAGINAL CONTRACEPTIVE................................... 54

VECAMYL...........................................................................38

VECTICAL........................................................................ 103

VELIVET............................................................................. 21

VELPHORO........................................................................53

VELTASSA........................................................................144

VELTIN..............................................................................103

VEMLIDY.............................................................................. 8

VENCLEXTA.......................................................................15

VENCLEXTA STARTING PACK........................................ 16

VENLAFAXINE BESYLATE ER.........................................58

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

75 mg (base equivalent), 150 mg (base equivalent)

(Effexor xr)..................................................................... 58

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

75 mg (base equivalent), 150 mg (base equivalent),

225 mg (base equivalent)............................................ 58

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

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

(base equivalent), 100 mg (base equivalent).............58

VENTOLIN HFA................................................................. 46

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

(Verelan)......................................................................... 34

VERAPAMIL HCL ER........................................................ 34

VERAPAMIL HCL SR........................................................ 34

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

sr).................................................................................... 34

verapamil hcl tab 40 mg, 80 mg, 120 mg...................... 34

VERAPAMIL HYDROCHLORIDE E.................................. 34

VERASENS BLOOD GLUCOSE TE...............................109

VERDESO........................................................................ 103

VEREGEN........................................................................ 103

VERELAN........................................................................... 34

VERELAN PM.................................................................... 34

VERKAZIA.......................................................................... 93

VERQUVO..........................................................................42

VERSACLOZ......................................................................60

VERZENIO......................................................................... 16

VESICARE..........................................................................53

VESICARE LS....................................................................53

VFEND..................................................................................5

VIAGRA.............................................................................. 42

VIBERZI..............................................................................53

VIBRAMYCIN....................................................................... 3

VICTOZA............................................................................ 24

VIDA MIA AUTOLET LANCING...................................... 141

VIDA MIA UNIFINE PENTIPS.........................................141

VIDA MIA UNILET LANCETS S......................................142

VIDA MIA UNILET LANCETS U..................................... 142

VIDA MIA UNIPFINE PENTIPS...................................... 142

VIEKIRA PAK....................................................................... 8

vigabatrin powd pack 500 mg (Sabril).......................... 78

vigabatrin tab 500 mg (Sabril)........................................78

VIGAMOX........................................................................... 93

VIIBRYD..............................................................................58

VIIBRYD STARTER PACK................................................ 58

VIJOICE............................................................................144

vilazodone hcl tab 10 mg, 20 mg, 40 mg (Viibryd)....... 58

VILTEPSO.......................................................................... 80

VIMOVO..............................................................................73

VIMPAT............................................................................... 78

VINATE DHA RF................................................................84

VINATE II............................................................................85

VINATE ONE......................................................................85

VIOKACE............................................................................51

VIRACEPT............................................................................8

VIRAZOLE............................................................................ 8

VIREAD.................................................................................8

VIRT-NATE DHA................................................................ 85

VIRT-PN DHA.................................................................... 85

VISTARIL............................................................................ 55

VISTOGARD.....................................................................104

VITAFOL FE+.....................................................................85

VITAFOL GUMMIES.......................................................... 85

VITAFOL-NANO................................................................. 85

VITAFOL-OB.......................................................................85

VITAFOL-OB+DHA.............................................................85

VITAFOL-ONE.................................................................... 85

VITAFOL STRIPS.............................................................. 85

VITAFOL ULTRA................................................................ 85

VITAMEDMD REDICHEW RX...........................................85

VITAPEARL........................................................................ 85

VITATHELY/GINGER......................................................... 85

VITATRUE...........................................................................85

VITRAKVI........................................................................... 16

VIVA DHA........................................................................... 85

VIVAGUARD INO BLOOD GLUCO.................................109

VIVAGUARD LANCETS.................................................. 142

VIVAGUARD LANCING DEVICE.................................... 142

VIVAGUARD SAFETY LANCETS/..................................142

VIVELLE-DOT.................................................................... 19

VIVJOA................................................................................. 5

VIVOTIF.............................................................................. 11

VIZIMPRO.......................................................................... 16

VOGELXO.......................................................................... 18

VOGELXO PUMP.............................................................. 18

VOLTAREN.......................................................................103

VONJO................................................................................16

VOQUEZNA DUAL PAK.................................................... 50

VOQUEZNA TRIPLE PAK................................................. 50

voriconazole for susp 40 mg/ml (Vfend).........................5

voriconazole tab 50 mg, 200 mg (Vfend)........................ 5

VOSEVI.................................................................................8

VOTRIENT..........................................................................16

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 189

VOXZOGO..........................................................................31

VP INSULIN SYRINGE/U-100/....................................... 142

VRAYLAR........................................................................... 60

VTAMA..............................................................................103

VTOL LQ............................................................................ 67

VUITY................................................................................. 93

VUSION............................................................................ 103

VYNDAMAX........................................................................42

VYNDAQEL........................................................................ 42

VYONDYS 53.....................................................................80

VYTORIN............................................................................41

VYVANSE........................................................................... 63

VYZULTA............................................................................ 93

WAKIX.................................................................................63

WALGREENS ADVANCED TRAVEL.............................. 142

WALGREENS COMFORT ASSURED............................ 142

WALGREENS LANCETS................................................ 142

WALGREENS THIN LANCETS.......................................142

WALGREENS ULTRA THIN LANC.................................142

warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5

mg, 6 mg, 7.5 mg, 10 mg............................................. 88

WEGMANS UNIFINE PENTIPS P.................................. 142

WELCHOL.......................................................................... 41

WELIREG........................................................................... 16

WELLBUTRIN SR.............................................................. 58

WELLBUTRIN XL...............................................................58

WESCAP-C DHA............................................................... 85

WESCAP-PN DHA.............................................................85

WESNATE DHA................................................................. 85

WESTAB PLUS.................................................................. 85

WESTGEL DHA................................................................. 85

WIDE-SEAL SILICONE DIAPHR.................................... 142

WINLEVI........................................................................... 103

WYNZORA....................................................................... 103

XADAGO............................................................................ 80

XALATAN............................................................................ 93

XALKORI............................................................................ 16

XANAX................................................................................55

XANAX XR......................................................................... 55

XARELTO........................................................................... 88

XARELTO STARTER PACK.............................................. 88

XATMEP............................................................................. 16

XCOPRI.............................................................................. 78

XELJANZ............................................................................ 73

XELJANZ XR......................................................................73

XELODA............................................................................. 16

XELPROS...........................................................................93

XENAZINE..........................................................................66

XEPI..................................................................................103

XERESE........................................................................... 103

XERMELO.......................................................................... 53

XHANCE.............................................................................43

XIFAXAN.............................................................................10

XIGDUO XR....................................................................... 24

XIIDRA................................................................................ 93

XIMINO................................................................................. 3

XOFLUZA............................................................................. 8

XOLAIR...............................................................................47

XOLEGEL......................................................................... 103

XOPENEX.......................................................................... 47

XOPENEX CONCENTRATE............................................. 47

XOPENEX HFA.................................................................. 47

XOSPATA............................................................................16

XPOVIO.............................................................................. 16

XPOVIO 60 MG TWICE WEEKLY.................................... 16

XPOVIO 80 MG TWICE WEEKLY.................................... 16

XTAMPZA ER.....................................................................70

XTANDI............................................................................... 16

XULTOPHY 100/3.6........................................................... 24

XURIDEN............................................................................31

XYOSTED...........................................................................18

XYREM............................................................................... 66

XYWAV............................................................................... 66

YASMIN 28.........................................................................21

YAZ..................................................................................... 21

YONSA............................................................................... 16

YOSPRALA........................................................................ 89

YUPELRI............................................................................ 47

zafirlukast tab 10 mg, 20 mg (Accolate)....................... 47

zaleplon cap 5 mg, 10 mg.............................................. 61

ZALVIT................................................................................ 85

ZANAFLEX......................................................................... 81

ZARONTIN......................................................................... 78

ZARXIO...............................................................................87

ZATEAN-PN DHA.............................................................. 85

ZAVESCA........................................................................... 87

ZCORT 7-DAY....................................................................17

ZEGALOGUE..................................................................... 24

ZEGERID............................................................................50

ZEJULA...............................................................................16

ZELAPAR............................................................................80

ZELBORAF.........................................................................16

ZEMBRACE SYMTOUCH................................................. 74

ZEMPLAR...........................................................................31

ZENPEP..............................................................................51

ZENZEDI............................................................................ 63

ZEPATIER.............................................................................8

ZEPOSIA............................................................................ 66

ZEPOSIA 7-DAY STARTER PAC......................................66

ZEPOSIA STARTER KIT................................................... 66

ZERVIATE...........................................................................93

ZESTORETIC.....................................................................38

ZESTRIL............................................................................. 38

ZETIA..................................................................................41

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Horizon BCBSNJ Health Insurance Marketplace Formulary Drug Guide January 2023 190

ZETONNA...........................................................................43

ZEVRX INSULIN SYRINGE/0.5...................................... 142

ZEVRX INSULIN SYRINGE/1ML.................................... 142

ZEVRX PEN NEEDLES 31G X 5....................................142

ZEVRX PEN NEEDLES 31G X 6....................................142

ZEVRX PEN NEEDLES 31G X 8....................................142

ZEVRX PEN NEEDLES 32G X 4....................................142

ZEVRX TWIST TOP LANCETS 3................................... 142

ZIAC....................................................................................38

ZIAGEN.................................................................................8

ZIANA............................................................................... 103

zidovudine cap 100 mg (Retrovir)................................... 8

zidovudine syrup 10 mg/ml (Retrovir).............................8

zidovudine tab 300 mg......................................................8

zileuton tab er 12hr 600 mg........................................... 47

ZILXI................................................................................. 103

ZIOPTAN.............................................................................93

ZIPHEX............................................................................... 85

ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg

(Geodon).........................................................................60

ZIPSOR...............................................................................73

ZIRGAN.............................................................................. 93

ZITHROMAX.........................................................................2

ZITHROMAX TRI-PAK......................................................... 2

ZITHROMAX Z-PAK.............................................................2

ZOCOR............................................................................... 41

ZOKINVY.......................................................................... 144

ZOLINZA.............................................................................16

ZOLMITRIPTAN................................................................. 74

zolmitriptan nasal spray 5 mg/spray unit (Zomig)....... 74

zolmitriptan orally disintegrating tab 2.5 mg, 5 mg..... 74

zolmitriptan tab 2.5 mg, 5 mg (Zomig).......................... 74

ZOLOFT..............................................................................58

ZOLPIDEM TARTRATE..................................................... 61

zolpidem tartrate tab er 6.25 mg, 12.5 mg (Ambien

cr).................................................................................... 61

zolpidem tartrate tab 5 mg, 10 mg (Ambien)................ 61

ZOLPIMIST.........................................................................61

ZOMACTON....................................................................... 31

ZOMIG................................................................................ 74

ZONALON........................................................................ 103

ZONEGRAN....................................................................... 78

ZONISADE......................................................................... 78

zonisamide cap 50 mg.................................................... 78

zonisamide cap 25 mg, 100 mg (Zonegran)................. 78

ZONTIVITY......................................................................... 89

ZORBTIVE..........................................................................31

ZORTRESS...................................................................... 144

ZORVOLEX........................................................................ 73

ZORYVE........................................................................... 103

ZOVIRAX.............................................................................. 8

ZTALMY.............................................................................. 78

ZTLIDO............................................................................. 104

ZUBSOLV........................................................................... 70

ZYCLARA......................................................................... 104

ZYCLARA PUMP............................................................. 104

ZYDELIG............................................................................ 16

ZYFLO................................................................................ 47

ZYKADIA............................................................................ 16

ZYLET.................................................................................93

ZYLOPRIM......................................................................... 75

ZYMAXID............................................................................93

ZYPITAMAG....................................................................... 41

ZYPREXA........................................................................... 60

ZYPREXA ZYDIS...............................................................60

ZYTIGA............................................................................... 16

ZYVOX................................................................................10