Drug - Brand Name (Generic Name) PA Status Class Drug Notes "Bystolic (nebivolol) BP, M90" CARDIOVASCULAR "BP, M90" Byooviz (ranibizumab-nuna) MB OPHTHALMIC PREPARATIONS MB Bynfezia (octreotide prefilled syringe) ENDOCRINE/METABOLIC AGENTS Bylvay (odevixibat) - PA PA BILE THERAPY Byfavo (remimazolam) MB - PA PA BENZODIAZEPINES MB Byetta (exenatide 5 mcg injection) BP - PA > 1.2 mL/30 days PA > 1.2 mL/30 days DIABETIC AGENTS BP Byetta (exenatide 10 mcg injection) BP - PA > 2.4 mL/30 days PA > 2.4 mL/30 days DIABETIC AGENTS BP Bydureon Bcise (exenatide extended-release auto-injection) - PA PA DIABETIC AGENTS Bydureon (exenatide extended-release pen) DIABETIC AGENTS Butrans (buprenorphine transdermal) BP - PA > 20 mcg/hr and PA > 4 patches/28 days PA > 20 mcg/hr and PA > 4 patches/28 days OPIOID ANALGESICS BP butorphanol nasal spray - PA PA OPIOID ANALGESICS butorphanol injection OPIOID ANALGESICS butoconazole A90 ANTIBIOTICS A90 butenafine FUNGICIDES butalbital 50 mg / acetaminophen 325 mg - PA PA ANALGESICS butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg tablet - PA 20 units/month PA 20 units/month ANALGESICS butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg solution - PA PA ANALGESICS butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg capsule - PA PA ANALGESICS butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg / codeine 30 mg - PA 20 units/month PA 20 units/month OPIOID ANALGESICS butalbital 50 mg / acetaminophen 300 mg - PA PA ANALGESICS butalbital 50 mg / acetaminophen 300 mg / caffeine 40 mg - PA PA ANALGESICS butalbital 50 mg / acetaminophen 300 mg / caffeine 40 mg / codeine 30 mg - PA PA ANALGESICS butalbital 25 mg / acetaminophen 325 mg tablet - PA PA ANALGESICS butalbital / aspirin / caffeine tablet - PA 20 units/month PA 20 units/month ANALGESICS butalbital / aspirin / caffeine capsule - PA PA ANALGESICS butalbital / aspirin / caffeine / codeine - PA PA OPIOID ANALGESICS Busulfex (busulfan injection) MB CHEMOTHERAPY MB busulfan tablet CHEMOTHERAPY busulfan injection MB CHEMOTHERAPY MB buspirone A90 - PA < 6 years; See Table 69; See Table 71 PA ANTI-ANXIETY AGENT A90 burosumab-twza - PA PA BIOLOGICAL bupropion hydrochloride sustained-release-Zyban A90 - PA < 6 years PA SMOKING CESSATION "A90, #" bupropion hydrochloride sustained-release-Wellbutrin SR A90 - PA < 6 years; See Table 17; See Table 71 PA ANTIDEPRESSANTS "A90, #" bupropion hydrochloride extended-release 450 mg tablet A90 - PA; See Table 17; See Table 71 PA ANTIDEPRESSANTS A90 "bupropion hydrochloride extended-release 150 mg, 300 mg tablet A90 - PA 1 unit/day; See Table 17; See Table 71" PA 1 unit/day ANTIDEPRESSANTS "A90, #" bupropion hydrochloride A90 - PA < 6 years; See Table 17; See Table 71 PA ANTIDEPRESSANTS A90 bupropion hydrobromide extended-release - PA 1 unit/day; See Table 17; See Table 71 PA 1 unit/day ANTIDEPRESSANTS buprenorphine transdermal BP - PA > 20 mcg/hr and PA > 4 patches/28 days PA > 20 mcg/hr and PA > 4 patches/28 days OPIOID ANALGESICS BP buprenorphine sublingual tablet - PA PA ALCOHOL AND DRUG CESSATION AGENT buprenorphine injection - PA PA OPIOID ANALGESICS buprenorphine extended-release injection-Sublocade PD ALCOHOL AND DRUG CESSATION AGENT PD buprenorphine extended-release injection-Brixadi - PA PA ALCOHOL AND DRUG CESSATION AGENT buprenorphine buccal film - PA PA OPIOID ANALGESICS buprenorphine / naloxone sublingual tablet-Zubsolv - PA PA ALCOHOL AND DRUG CESSATION AGENT buprenorphine / naloxone sublingual tablet - PA PA ALCOHOL AND DRUG CESSATION AGENT "buprenorphine / naloxone film BP, PD - PA > 90 days (> 24 mg/day and ≤ 32 mg/day)" PA > 90 days (> 24 mg/day and ≤ 32 mg/day) ALCOHOL AND DRUG CESSATION AGENT "BP, PD" "buprenorphine / naloxone film BP, PD - PA > 32 mg/day" PA > 32 mg/day ALCOHOL AND DRUG CESSATION AGENT "BP, PD" "buprenorphine / naloxone film ≤ 24 mg/day BP, PD" ALCOHOL AND DRUG CESSATION AGENT "BP, PD" Buprenex (buprenorphine injection) - PA PA OPIOID ANALGESICS bupivacaine MB ANESTHETICS MB bupivacaine / meloxicam MB ANESTHETIC LOCAL TOPICAL MB "Buphenyl (sodium phenylbutyrate powder, tablet) BP, A90" ENZYMES "BP, A90" bumetanide M90 CARDIOVASCULAR M90 budesonide rectal foam A90 - PA PA GLUCOCORTICOIDS A90 budesonide OTC nasal spray M90 - PA > 1 inhaler/30 days PA > 1 inhaler/30 days NASAL PREPARATIONS M90 budesonide inhalation suspension A90 - PA ≥ 13 years PA ≥ 13 years BRONCHODILATORS "A90, #" budesonide inhalation powder BRONCHODILATORS "budesonide extended-release tablet BP, A90" GLUCOCORTICOIDS "BP, A90" budesonide extended-release capsule - PA PA GLUCOCORTICOIDS budesonide 4 mg delayed-release capsule - PA PA GLUCOCORTICOIDS budesonide 3 mg delayed-release capsule A90 GLUCOCORTICOIDS A90 budesonide / glycopyrrolate / formoterol - PA PA BRONCHODILATORS "budesonide / formoterol BP, A90" BRONCHODILATORS "BP, A90" Bryhali (halobetasol lotion) - PA PA GLUCOCORTICOIDS Brukinsa (zanubrutinib) - PA PA CHEMOTHERAPY Brovana (arformoterol) A90 - PA PA BRONCHODILATORS A90 Bronchitol (mannitol inhalation powder) - PA PA MUCOLYTICS Bromsite (bromfenac 0.075%) - PA PA OPHTHALMIC PREPARATIONS "bromocriptine 2.5 mg, 5 mg A90" ANTIPARKINSON "A90, #" bromocriptine 0.8 mg tablet DIABETIC AGENTS bromfenac 0.09% A90 - PA PA OPHTHALMIC PREPARATIONS A90 bromfenac 0.075% - PA PA OPHTHALMIC PREPARATIONS "bromfenac 0.07% BP, A90" OPHTHALMIC PREPARATIONS "BP, A90" brolucizumab-dbll MB OPHTHALMIC PREPARATIONS MB brodalumab - PA PA IMMUNOMODULATOR Brixadi (buprenorphine extended-release injection-Brixadi) - PA PA ALCOHOL AND DRUG CESSATION AGENT "Briviact (brivaracetam solution, tablet) - PA" PA ANTICONVULSANTS "brivaracetam solution, tablet - PA" PA ANTICONVULSANTS Briumvi (ublituximab-xiiy) - PA PA MULTIPLE SCLEROSIS AGENTS "brinzolamide BP, M90" OPHTHALMIC PREPARATIONS "BP, M90" brinzolamide / brimonidine OPHTHALMIC PREPARATIONS "brimonidine topical gel, 0.33% A90 - PA" PA DERMATOLOGICAL A90 brimonidine 0.2% eye drops M90 OPHTHALMIC PREPARATIONS M90 "brimonidine 0.1%, 0.15% eye drops BP, M90" OPHTHALMIC PREPARATIONS "BP, M90" "brimonidine / timolol, ophthalmic M90 - PA" PA OPHTHALMIC PREPARATIONS M90 Brilinta (ticagrelor) ANTIPLATELET AGENT brigatinib - PA PA CHEMOTHERAPY Breztri (budesonide / glycopyrrolate / formoterol) - PA PA BRONCHODILATORS "Breyanzi (lisocabtagene maraleucel) CO, MB - PA" PA CHEMOTHERAPY "CO, MB" "brexucabtagene autoleucel CO, MB - PA" PA CHEMOTHERAPY "CO, MB" brexpiprazole - PA; See Table 24; See Table 71 PA ANTIPSYCHOTIC brexanolone MB - PA PA ANTIDEPRESSANTS MB Brexafemme (ibrexafungerp) - PA PA FUNGICIDES Brevibloc # (esmolol) CARDIOVASCULAR # "Breo (fluticasone / vilanterol) BP, A90" BRONCHODILATORS "BP, A90" brentuximab MB - PA PA CHEMOTHERAPY MB Braftovi (encorafenib) - PA PA CHEMOTHERAPY Botox (onabotulinumtoxinA) - PA PA BIOLOGICAL bosutinib - PA PA CHEMOTHERAPY Bosulif (bosutinib) - PA PA CHEMOTHERAPY "bosentan BP, A90 - PA" PA CARDIOVASCULAR "BP, A90" bortezomib MB CHEMOTHERAPY MB Boostrix (tetanus toxoids / diphtheria / acellular pertussis vaccine) 1 BIOLOGICAL 1 Bonjesta (doxylamine / pyridoxine extended-release) - PA PA ANTIEMETICS Boniva # (ibandronate tablet) M90 ELECTROLYTES AND NUTRIENTS "M90, #" Blincyto (blinatumomab) MB - PA PA CHEMOTHERAPY MB blinatumomab MB - PA PA CHEMOTHERAPY MB bleomycin MB CHEMOTHERAPY MB Blenrep (belantamab mafodotin-blmf) - PA PA CHEMOTHERAPY "Bivigam (immune globulin IV, human-Bivigam) - PA" PA BIOLOGICAL bisoprolol M90 CARDIOVASCULAR M90 bisoprolol / hydrochlorothiazide M90 CARDIOVASCULAR "M90, #" "bismuth subsalicylate *, A90" ANTIDIARRHEALS "*, A90" "bismuth subcitrate / metronidazole / tetracycline BP, A90" H. PYLORI AGENTS "BP, A90" "bisacodyl tablet *, M90" CONSTIPATION AGENTS "*, M90" "bisacodyl enema, suppository *, A90" CONSTIPATION AGENTS "*, A90" binimetinib - PA PA CHEMOTHERAPY Binaxnow (COVID-19 antigen self-test) - PA > 2 tests/28 days; Non-Drug Product PA > 2 tests/28 days DIAGNOSTICS bimatoprost implant MB - PA PA OPHTHALMIC PREPARATIONS MB bimatoprost 0.03% ophthalmic solution M90 - PA PA OPHTHALMIC PREPARATIONS M90 bimatoprost 0.01% ophthalmic solution - PA PA OPHTHALMIC PREPARATIONS "Biltricide (praziquantel) BP, A90" ANTIPARASITICS "BP, A90" Biktarvy (bictegravir / emtricitabine / tenofovir alafenamide) PD ANTIVIRALS PD Bijuva (estradiol / progesterone) - PA PA HORMONE REPLACEMENT THERAPY bifidobacterium infantis - PA ≥ 22 years PA ≥ 22 years GASTROINTESTINAL AGENT Bidil # (isosorbide dinitrate / hydralazine) M90 CARDIOVASCULAR "M90, #" bictegravir / emtricitabine / tenofovir alafenamide PD ANTIVIRALS PD Bicnu (carmustine) MB CHEMOTHERAPY MB "Bicillin LA (penicillin G 0.6 million, 1.2 million, 2.4 million units)" ANTIBIOTICS Bicillin CR (penicillin G benzathine / penicillin G procaine) ANTIBIOTICS bicalutamide A90 CHEMOTHERAPY "A90, #" bezlotoxumab - PA PA BIOLOGICAL Beyfortus (nirsevimab-alip) - PA ≥ 8 months of age PA ≥ 8 months of age ANTIVIRALS Beyaz # (ethinyl estradiol / drospirenone / levomefolate-Beyaz) M90 CONTRACEPTIVES "M90, #" Bexsero (meningococcal group B vaccine-Bexsero) 1 BIOLOGICAL 1 "bexarotene BP, A90" CHEMOTHERAPY "BP, A90" Bevespi (glycopyrrolate / formoterol) - PA PA BRONCHODILATORS bevacizumab MB - PA PA CHEMOTHERAPY MB bevacizumab-maly MB - PA PA CHEMOTHERAPY MB bevacizumab-bvzr MB - PA PA CHEMOTHERAPY MB bevacizumab-awwb MB - PA PA CHEMOTHERAPY MB bevacizumab-adcd MB - PA PA ANTINEOPLASTICS MB Betoptic S (betaxolol 0.25%) OPHTHALMIC PREPARATIONS Betimol (timolol-Betimol) - PA PA OPHTHALMIC PREPARATIONS "betibeglogene autotemcel CO, PD, MB - PA" PA HEMATINICS & BLOOD CELL STIMULATORS "CO, PD, MB" "Bethkis (tobramycin inhalation solution-Bethkis) BP, A90 - PA" PA ANTIBIOTICS "BP, A90" bethanechol A90 PARASYMPATHETIC AGENTS A90 betaxolol tablet M90 CARDIOVASCULAR M90 betaxolol 0.5% M90 OPHTHALMIC PREPARATIONS M90 betaxolol 0.25% OPHTHALMIC PREPARATIONS Betaseron (interferon beta-1b-Betaseron) MULTIPLE SCLEROSIS AGENTS Betapace # (sotalol tablet) M90 CARDIOVASCULAR "M90, #" betamethasone valerate ointment A90 GLUCOCORTICOIDS A90 betamethasone valerate lotion A90 GLUCOCORTICOIDS A90 betamethasone valerate foam A90 GLUCOCORTICOIDS "A90, #" betamethasone valerate cream A90 GLUCOCORTICOIDS A90 betamethasone injection GLUCOCORTICOIDS # betamethasone dipropionate spray - PA PA GLUCOCORTICOIDS "betamethasone dipropionate lotion, ointment A90" GLUCOCORTICOIDS A90 betamethasone dipropionate cream A90 GLUCOCORTICOIDS A90 "betamethasone dipropionate, augmented ointment A90" GLUCOCORTICOIDS "A90, #" "betamethasone dipropionate, augmented cream, lotion A90" GLUCOCORTICOIDS A90 betamethasone augmented gel A90 GLUCOCORTICOIDS A90 "betamethasone / calcipotriene scalp suspension BP, A90 - PA" PA GLUCOCORTICOIDS "BP, A90" betamethasone / calcipotriene ointment A90 - PA PA GLUCOCORTICOIDS A90 betamethasone / calcipotriene foam GLUCOCORTICOIDS betaine BP ELECTROLYTES AND NUTRIENTS BP Besremi (ropeginterferon alfa-2b-njft) - PA PA CHEMOTHERAPY Besponsa (inotuzumab ozogamicin) MB - PA PA CHEMOTHERAPY MB Besivance (besifloxacin ophthalmic suspension) OPHTHALMIC PREPARATIONS besifloxacin ophthalmic suspension OPHTHALMIC PREPARATIONS berotralstat - PA PA ENZYMES "Berinert (c1 esterase inhibitor, human-Berinert) - PA" PA ENZYMES beremagene geperpavec-svdt MB - PA PA DERMATOLOGICAL MB "Bepreve (bepotastine) BP, A90" ANTIHISTAMINES "BP, A90" "bepotastine BP, A90" ANTIHISTAMINES "BP, A90" Beovu (brolucizumab-dbll) MB OPHTHALMIC PREPARATIONS MB benztropine A90 ANTIPARKINSON A90 benzphetamine - PA PA ANTI-OBESITY AGENTS benzoyl peroxide 9.8% foam A90 - PA PA DERMATOLOGICAL A90 "benzoyl peroxide *, A90" DERMATOLOGICAL "*, A90" benzoyl peroxide / erythromycin A90 - PA PA ANTIBIOTICS A90 benznidazole ANTIPARASITICS benzhydrocodone / acetaminophen - PA PA OPIOID ANALGESICS Benzamycin (benzoyl peroxide / erythromycin) A90 - PA PA ANTIBIOTICS A90 Benzaclin (clindamycin / benzoyl peroxide-Benzaclin) A90 - PA PA DERMATOLOGICAL A90 Bentyl # (dicyclomine) A90 "ANTISPASMODICS,ANTICHOLINERGIC" "A90, #" benralizumab - PA PA BIOLOGICAL Benlysta (belimumab vial) MB - PA PA BIOLOGICAL MB "Benlysta (belimumab auto-injection, prefilled syringe) - PA" PA BIOLOGICAL Benicar HCT # (olmesartan / hydrochlorothiazide) M90 CARDIOVASCULAR "M90, #" Benicar # (olmesartan) M90 CARDIOVASCULAR "M90, #" Benefix (factor IX human recombinant-Benefix) PD ANTI-HEMOPHILIA AGENTS PD Bendeka (bendamustine) MB CHEMOTHERAPY MB bendamustine MB CHEMOTHERAPY MB benazepril M90 CARDIOVASCULAR "M90, #" benazepril / hydrochlorothiazide M90 CARDIOVASCULAR "M90, #" "Benadryl   # (diphenhydramine) *, A90" ANTIHISTAMINES "*, A90, #" bempedoic acid - PA PA LIPID LOWERING AGENTS bempedoic acid / ezetimibe - PA PA LIPID LOWERING AGENTS belzutifan - PA PA CHEMOTHERAPY belumosudil - PA PA MISCELLANEOUS Belsomra (suvorexant) - PA; See Table 15; See Table 71 PA "SEDATIVE, NON-BARBITURATE" Belrapzo (bendamustine) MB CHEMOTHERAPY MB belinostat MB - PA PA CHEMOTHERAPY MB belimumab vial MB - PA PA BIOLOGICAL MB "belimumab auto-injection, prefilled syringe - PA" PA BIOLOGICAL Beleodaq (belinostat) MB - PA PA CHEMOTHERAPY MB Belbuca (buprenorphine buccal film) - PA PA OPIOID ANALGESICS belatacept - PA PA IMMUNOMODULATOR belantamab mafodotin-blmf - PA PA CHEMOTHERAPY bedaquiline - PA PA TB PREPARATIONS Beconase AQ (beclomethasone nasal spray) - PA > 1 inhaler/30 days PA > 1 inhaler/30 days NASAL PREPARATIONS beclomethasone nasal spray - PA > 1 inhaler/30 days PA > 1 inhaler/30 days NASAL PREPARATIONS beclomethasone nasal aerosol - PA PA NASAL PREPARATIONS beclomethasone inhaler - PA PA BRONCHODILATORS becaplermin - PA PA DERMATOLOGICAL BCG Vaccine (BCG live vaccine) BIOLOGICAL BCG live vaccine BIOLOGICAL "BCG live, intravesical MB" CHEMOTHERAPY MB Baxdela (delafloxacin tablet) - PA PA ANTIBIOTICS Baxdela (delafloxacin injection) - PA PA ANTIBIOTICS Bavencio (avelumab) MB - PA PA CHEMOTHERAPY MB basiliximab MB BIOLOGICAL MB Basaglar Tempo (insulin glargine-Basaglar) - PA PA DIABETIC THERAPY Basaglar (insulin glargine-Basaglar) - PA PA DIABETIC AGENTS baricitinib - PA PA IMMUNOMODULATOR baricitinib for members ≥ 18 years of age COVID MB COVID - 19 related Treatments and Vaccines MB "baricitinib COVID EUA - November 19, 2020 for members 2 to 17 years of age MB" COVID - 19 related Treatments and Vaccines MB Baraclude # (entecavir tablet) A90 - PA > 1 unit/day PA > 1 unit/day ANTIVIRALS "A90, #" Baraclude (entecavir solution) - PA > 20 mL/day PA > 20 mL/day ANTIVIRALS Baqsimi (glucagon nasal powder) PD DIABETIC AGENTS PD "Banzel (rufinamide) BP, A90 - PA" PA ANTICONVULSANTS "BP, A90" Balversa (erdafitinib) - PA PA CHEMOTHERAPY balsalazide A90 GI ANTI-INFLAMMATORY "A90, #" baloxavir - PA PA ANTIVIRALS BAL in Oil (dimercaprol) MB ANTIDOTES MB "Balfaxar (prothrombin complex concentrate, human)" HEMOSTATICS Balcoltra (levonorgestrel / ethinyl estradiol / ferrous bisglycinate) M90 CONTRACEPTIVES M90 Bafiertam (monomethyl fumarate) - PA PA MULTIPLE SCLEROSIS AGENTS Bactrim # (sulfamethoxazole / trimethoprim tablet) ANTIBIOTICS # baclofen tablet A90 MUSCLE RELAXANT A90 baclofen suspension A90 - PA PA MUSCLE RELAXANT A90 baclofen oral solution A90 - PA PA MUSCLE RELAXANT A90 baclofen intrathecal injection MUSCLE RELAXANT baclofen injection MUSCLE RELAXANT # baclofen granules - PA PA MUSCLE RELAXANT bacitracin ophthalmic ointment A90 - PA PA OPHTHALMIC PREPARATIONS A90 "bacitracin *, A90" ANTIBIOTICS "*, A90" "bacitracin / polymyxin B topical ointment *, A90" ANTIBIOTICS "*, A90" bacitracin / polymyxin B ophthalmic ointment A90 OPHTHALMIC PREPARATIONS A90