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