Drug List - B

B
Drug Name Tier Restrictions
B-D 3CC LUER-LOK SYRINGE/25 MIS 25GX1" 1
B-D GLUCOSE NC
B-D INSLUIN SYRINGE ULTRAFI MIS 1CC/31G 1
B-D NEEDLE/27G X 1/2" MIS 27GX1/2" 1
B-D ULTRAFINE ORIGINAL PEN MIS PEN NEEDLE 1
BACIT/POLYMY OIN OP 1
BACITRACIN OPTHAL 1
BACLOFEN 1
BACTROBAN 3 Prior authorization, Quantity limit
BACTROBAN NASAL 3 Quantity limit
BALSALAZIDE DIS 1
BALZIVA 1*
BANZEL 3
BARACLUDE 3 Prior authorization
BAYER CONTOR TES NEXT 3
BECONASE-AQ NC
BELBUCA MIS 3 Prior authorization
BELLADONNA ALK/PHENOB 1
BELSOMRA TAB 3 Prior authorization
BELVIQ 3 Prior authorization
BENAZEPRIL HCL 1
BENAZEPRIL HCL/HYDROCHLOROT TAB 1
BENICAR 3 Prior authorization
BENICAR HCT 3 Prior authorization
BENPROX 3 Quantity limit
BENZACLIN 3 Prior authorization, Quantity limit, Step therapy
BENZAMYCIN GEL 3 Quantity limit, Step therapy
BENZASHAVE NC
BENZEFOAM 3 Prior authorization
BENZONATATE 1
BENZOYL PEROXIDE CREAMY WAS KIT WASH 1 Quantity limit, Step therapy
BENZOYL PEROXIDE GEL 1 Quantity limit, Step therapy
BENZOYL PEROXIDE PAD 3 Quantity limit, Step therapy
BENZOYLE PEROXIDE WASH NC
BENZTROPINE MESYLATE 1
BETAMETHASONE DIPROPIONATE 1 Quantity limit
BETAMETHASONE VALERATE 1 Quantity limit
BETASERON 3 Prior authorization, Step therapy
BETASERON INJ 0.3MG 1 Prior authorization
BETAXOLOL HCL 1
BETAXOLOL L 1
BETHANECHOL 1
BETIMOL 3
BETOPTIC 3 Prior authorization
BEYAZ TAB 3
BIAFINE EMU 2 Quantity limit
BICALUTAMIDE TAB 50MG 1
BILTRICIDE 2
BISOPROLOL /HYDROCHLOROTHIAZIDE 1
BISOPROLOL FUMARATE 1
BLEPHAMIDE LIQUIFILM 3
BLEPHAMIDE-S.O.P. 3
BLISOVI FE TAB 1/20 1*
BONIVA 3 Prior authorization
BONIVA KIT $0 Prior authorization
BOTOX INJ 3
BREO ELLIPTA 2
BREVOXYL 3 Quantity limit, Step therapy
BRILINTA 2
BRIMONIDINE 1
BROMOCRIPTINE MESYLATE 1
BROVANA NEB 15MCG 3
BUDEPRION SR 1
BUDESONIDE INHALATION AMPULE 1
BUDESONIDE NASAL SPRAY NC
BUMETANIDE 1
BUNAVAIL MIS 4.2-0.7 1
BUPIVACAINE INJ 0.25% 1
BUPREN/NALOX SUB 1
BUPRENORPHIN SUB 1
BUPRENORPHINE TRANSDERMAL PATCH 1 Prior authorization
BUPROPION HCL 1
BUPROPION HCL ER 1
BUPROPION HCL SR 1
BUPROPION HCL XL 1
BUSPIRONE TAB 1
BUT/APAP/CAF CAP CODEINE 1
BUTALBITAL/APAP/CAFFEINE 1
BUTALBITAL/ASA/CAFF 1
BUTRANS PATCH 3 Prior authorization
BYDUREON 2 Step therapy
BYETTA INJ 2 Step therapy
BYSTOLIC 3 Prior authorization