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Empire BlueCross BlueShield HealthPlus – New York Essential Plan - Drug ListTable of ContentsNOTE: Not all medications and not all plans are subject to prior authorization and quantity limits. For moreinformation regarding prior authorization or quantity limits, contact Member Services at the telephonenumber listed on your identification card.List of AbbreviationsTier 1: Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others thattreat the same conditions.Tier 2: Tier 2 have a medium cost share. They may be preferred drugs, based on their effectiveness andvalue. Some are newer, more expensive generic drugs.Tier 3: Tier 3 drugs have a higher cost share. They may cost more than others used to treat the samecondition. Tier 3 may also include drugs that were recently approved by the FDA.Tier 4: Tier 4 specialty drugs have the highest cost share. They may cost more than others used to treat thesame condition. Specialty drugs are used to treat complex, chronic conditions and may need special handling.DO: DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to aonce-daily dosing schedule.PA: PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval ofbenefits before certain prescriptions may be filled.QL: QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or permonth.ST: STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use ofanother medication can be authorized. Please note: Foradil and Serevent are safety edits that preventduplication of therapy.www.empireblue.com/nyessentialplanEmpire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licenseeof the Blue Cross and Blue Shield Association.1
New York Essential Plan Drug ListDrug NameTierNotesTierNotesdihydroergotamine nasalspray,non-aerosolTier 2Tier 1QLdiskets oral tablet,solubleTier 1acetaminophen-codeineoral solution 120 mg-12mg /5 ml (5 ml), 120-12mg/5 mlELMIRON ORALCAPSULETier 3acetaminophen-codeineoral solution 240 mg-24mg /10 ml (10 ml), 300mg-30 mg /12.5 mlTier 1EMBEDA ORALCAPSULE,ORALONLY,EXT.RELPELLTier 3acetaminophen-codeineoral tablet 300-15 mg,300-30 mg, 300-60 mgTier 1endocet oral tabletTier 1endodan oral tabletTier 1ST; QLTier 1fentanyl transdermalpatch 72 hourTier 2almotriptan malate oraltabletST; QLTier 1FROVA ORALTABLETTier 3ascomp with codeineoral capsuleQLTier 2buprenorphine hclinjection syringeTier 2hydrocodoneacetaminophen oralsolution 10-325 mg/15ml(15 ml), 2.5-167 mg/5ml, 5-163mg/7.5ml(7.5ml)Tier 1buprenorphine hclinjection solutionbutalbital compoundw/codeine oral capsuleTier 1Tier 1QLbutalbital-acetaminopcaf-cod oral capsuleTier 1butalbitalacetaminophen-caff oralcapsuleTier 1hydrocodoneacetaminophen oraltablet 10-300 mg, 10-325mg, 2.5-325 mg, 5-300mg, 5-325 mg, 7.5-300mg, 7.5-325 mgTier 1QLbutalbitalacetaminophen-caff oraltabletTier 1hydromorphone oralliquidhydromorphone oraltablet 2 mg, 4 mg, 8 mgTier 1QLbutalbital-aspirincaffeine oral capsuleTier 1Tier 2ST; QLbutorphanol tartratenasal spray,non-aerosolTier 1PA; QLhydromorphone oraltablet extended release24 hr 12 mg, 16 mg, 32mg, 8 mgTier 3QLhydromorphone rectalsuppositoryTier 1CAMBIA ORALPOWDER INPACKETTier 1capacet oral capsuleTier 1ibuprofen-oxycodoneoral tabletcodeine sulfate oraltablet 15 mg, 30 mg, 60mgTier 1isometh-dichloralacetaminophn oralcapsuleTier 1diclofenac potassiumoral tabletTier 1ketorolac injectioncartridge 15 mg/ml, 30mg/mlTier 2diflunisal oral tabletTier 1Drug NameANALGESICSQLQLQLQLWEBMENY-0030-15Revised 1/1/20162QLQLQL
Drug NameTierNotesDrug NameTierketorolac injectionsolution 15 mg/ml, 30mg/ml, 30 mg/ml (1 ml)Tier 2QLmorphine rectalsuppositoryTier 1Tier 2QLnalbuphine injectionsolutionTier 2ketorolac intramuscularsolutionnaratriptan oral tabletTier 1ketorolac oral tabletTier 1QLnodolor oral capsuleTier 1levorphanol tartrate oraltabletTier 2Tier 3ST; QLmargesic oral capsuleTier 1NUCYNTA ER ORALTABLET EXTENDEDRELEASE 12 HRmarten-tab oral tabletTier 1Tier 3QLmefenamic acid oralcapsuleTier 1NUCYNTA ORALTABLET 100 MG, 50MG, 75 MGmeperidine oral solutionTier 1QLoxycodone oral capsuleTier 1QLmeperidine oral tablet100 mg, 50 mgTier 1QLoxycodone oralconcentrateTier 1QLmeperitab oral tabletTier 1QLoxycodone oral solutionTier 1QLmethadone intensol oralconcentrateTier 1QLoxycodone oral tablet 10mg, 15 mg, 20 mg, 30mg, 5 mgTier 1QLmethadone oralconcentrateTier 1QLTier 1QLmethadone oral solution10 mg/5 ml, 5 mg/5 mlTier 1QLoxycodoneacetaminophen oraltabletQLTier 1QLoxycodone-aspirin oraltabletTier 1methadone oral tablet 10mg, 5 mgST; QLTier 1methadose oralconcentrateTier 1OXYCONTIN ORALTABLET,ORALONLY,EXT.REL.12HR 10 MG, 15 MG, 20MG, 30 MG, 40 MG, 60MG, 80 MGTier 3methadone oraltablet,solublemethadose oraltablet,solubleTier 1oxymorphone oral tablet10 mg, 5 mgTier 1QLmorphine concentrateoral solutionTier 1QLTier 1QLmorphine oralcapsule,extend.releasepelletsTier 2QLoxymorphone oral tabletextended release 12 hr10 mg, 15 mg, 20 mg, 30mg, 40 mg, 5 mg, 7.5 mgTier 3ST; QLmorphine oral solution10 mg/5 ml, 20 mg/5 mlTier 1QLRELPAX ORALTABLETrizatriptan oral tabletTier 1QLmorphine oral tablet 15mg, 30 mgTier 1QLrizatriptan oraltablet,disintegratingTier 1QLmorphine oral tabletextended release 100 mg,15 mg, 200 mg, 30 mg,60 mgTier 2QLsumatriptan succinateoral tabletTier 1QLsumatriptan succinatesubcutaneous cartridgeTier 2QLQLWEBMENY-0030-15Revised 1/1/20163NotesQL
Drug NameTierNotesDrug NameTiersumatriptan succinatesubcutaneous peninjectorTier 2QLCALDOLORINTRAVENOUSRECON SOLNTier 3sumatriptan succinatesubcutaneous solutionTier 2QLTier 2sumatriptan succinatesubcutaneous syringeTier 2QLcelecoxib oral capsule100 mg, 200 mg, 400mg, 50 mgTier 1tramadol oral tabletTier 1QLcolchicine-probenecidoral tablettramadol oral tabletextended release 24 hrTier 1QLCOLCRYS ORALTABLETTier 3tramadol oral tablet, ermultiphase 24 hrTier 1QLCUPRIMINE ORALCAPSULETier 3vicodin es oral tabletTier 1QLDAYPRO ORALTABLETTier 3vicodin hp oral tabletTier 1QLTier 1vicodin oral tabletTier 1QLzamicet oral solutionTier 1QLdiclofenac sodium oraltablet extended release24 hrzebutal oral capsuleTier 2Tier 1ZIPSOR ORALCAPSULETier 3diclofenac sodium oraltablet,delayed release(dr/ec)Tier 3PA; QLzolmitriptan oral tabletTier 1QLENBRELSUBCUTANEOUSRECON SOLNzolmitriptan oraltablet,disintegratingTier 1QLENBRELSUBCUTANEOUSSYRINGE 25MG/0.5ML (0.51), 50MG/ML (0.98 ML)Tier 3PA; QLENBRELSURECLICKSUBCUTANEOUSPEN INJECTORTier 3PA; QLetodolac oral capsuleTier 1ANESTHETICSNotesST; QLPA; QLlidocaine hcl mucousmembrane solutionTier 1lidocaine viscousmucous membranesolutionTier 1lidocaine-prilocainetopical creamTier 1lidocaine-prilocainetopical kitTier 1etodolac oral tabletTier 1Tier 1lta pre-attachedlaryngotracheal solutionTier 1etodolac oral tabletextended release 24 hrfenoprofen oral tabletTier 1phenazopyridine oraltabletTier 1flurbiprofen oral tabletTier 1PA; QLTier 3HUMIRA PEDIATRICCROHN'S STARTSUBCUTANEOUSSYRINGE KITTier 3SYNERA TOPICALPATCH,MEDICATED SELFHEATINGHUMIRA PENCROHN'S-UC-HSSTARTSUBCUTANEOUSPEN INJECTOR KITTier 3PA; QLANTIARTHRITICSallopurinol oral tabletTier 1WEBMENY-0030-15Revised 1/1/20164
Drug NameTierNotesDrug NameTierNotesHUMIRA PENPSORIASISSTARTERSUBCUTANEOUSPEN INJECTOR KITTier 3PA; QLORENCIASUBCUTANEOUSSYRINGETier 3PA; QLoxaprozin oral tabletTier 1HUMIRA PENSUBCUTANEOUSPEN INJECTOR KITTier 3piroxicam oral capsuleTier 1probenecid oral tabletTier 1PATier 3SIMPONI ARIAINTRAVENOUSSOLUTIONTier 3HUMIRASUBCUTANEOUSSYRINGE KITPA; QLTier 1SIMPONISUBCUTANEOUSPEN INJECTORTier 3ibuprofen oralsuspensionibuprofen oral tabletTier 1Tier 3PA; QLindomethacin oralcapsuleTier 1SIMPONISUBCUTANEOUSSYRINGEindomethacin oralcapsule, extended releaseTier 1sulindac oral tabletTier 1tolmetin oral capsuleTier 1ketoprofen oral capsuleTier 1tolmetin oral tabletTier 1ketoprofen oralcapsule,ext rel. pellets 24hrTier 1ULORIC ORALTABLETTier 3KINERETSUBCUTANEOUSSYRINGETier 3leflunomide oral tabletTier 2meclofenamate oralcapsuleTier 1meloxicam oralsuspensionTier 1meloxicam oral tabletTier 1nabumetone oral tabletTier 1naproxen oral suspensionTier 1naproxen oral tabletTier 1naproxen oraltablet,delayed release(dr/ec)Tier 1naproxen sodium oraltabletTier 1ORENCIA (WITHMALTOSE)INTRAVENOUSRECON SOLNTier 3PA; QLPA; QLSTANTIASTHMATICSPAQLPA; QLacetylcysteine solutionTier 2ADVAIR DISKUSINHALATIONBLISTER WITHDEVICETier 2QLADVAIR HFAINHALATION HFAAEROSOL INHALERTier 2QLalbuterol sulfateinhalation solution fornebulizationTier 1albuterol sulfate oralsyrupTier 1ASMANEXTWISTHALERINHALATIONAEROSOL POWDRBREATHACTIVATEDTier 2QLBROVANAINHALATIONSOLUTION FORNEBULIZATIONTier 3QLWEBMENY-0030-15Revised 1/1/20165
Drug NameTierNotesDrug NameTierNotesbudesonide inhalationsuspension fornebulization 0.25 mg/2ml, 0.5 mg/2 mlTier 1QLPROAIR HFAINHALATION HFAAEROSOL INHALERTier 2QLQLTier 1PROVENTIL HFAINHALATION HFAAEROSOL INHALERTier 3budesonide inhalationsuspension fornebulization 1 mg/2 mlQLTier 1DALIRESP ORALTABLETTier 3QLPULMICORTFLEXHALERINHALATIONAEROSOL POWDRBREATHACTIVATEDTier 2cromolyn inhalationsolution for nebulizationDULERAINHALATION HFAAEROSOL INHALERTier 2QLTier 2QLFLOVENT DISKUSINHALATIONBLISTER WITHDEVICE 100MCG/ACTUATION,250MCG/ACTUATION,50 MCG/ACTUATIONTier 2QLQVAR INHALATIONAEROSOL 40MCG/ACTUATION,80 MCG/ACTUATIONSEREVENT DISKUSINHALATIONBLISTER WITHDEVICETier 2QLTier 3FLOVENT HFAINHALATION HFAAEROSOL INHALER110MCG/ACTUATION,220MCG/ACTUATION,44 MCG/ACTUATIONTier 2SPIRIVA RESPIMATINHALATION MIST1.25MCG/ACTUATIONSPIRIVA RESPIMATINHALATION MIST2.5MCG/ACTUATIONTier 3QLTier 3QLipratropium bromideinhalation solutionTier 1levalbuterol hclinhalation solution fornebulizationTier 2SPIRIVA Tier 2QLmetaproterenol oralsyrupTier 1SYMBICORTINHALATION HFAAEROSOL INHALERmetaproterenol oraltabletTier 1terbutaline oral tabletTier 1Tier 1montelukast oralgranules in packetTier 1theochron oral tabletextended release 12 hrTier 1montelukast oral tabletTier 1QLtheophylline oral tabletextended releasemontelukast oraltablet,chewableTier 1QLtheophylline oral tabletextended release 12 hrTier 1PERFOROMISTINHALATIONSOLUTION FORNEBULIZATIONTier 3QLVENTOLIN HFAINHALATION HFAAEROSOL INHALERTier 3QLQLQLWEBMENY-0030-15Revised 1/1/20166QL
Drug NameTierNotesDrug NameTierXOPENEX HFAINHALATION HFAAEROSOL INHALERTier 3QLbacitracin ophthalmicointmentTier 1Tier 1bacitracin-polymyxin bophthalmic ointmentTier 1zafirlukast oral tabletZYFLO CR ORALTABLET, ERMULTIPHASE 12 HRTier 3PABESIVANCEOPHTHALMICDROPS,SUSPENSIONTier 3ZYFLO ORALTABLETTier 3PAbp 10-1 topical cleanserTier 1cefaclor oral capsuleTier 1ANTIBIOTICSTier 1cefaclor oral suspensionfor reconstitutionTier 1ak-poly-bac ophthalmicointmentTier 1cefaclor oral tabletextended release 12 hrTier 1amoxicillin oral capsuleamoxicillin oralsuspension forreconstitutionTier 1cefadroxil oral capsuleTier 1Tier 1amoxicillin oral tabletTier 1cefadroxil oralsuspension forreconstitutionamoxicillin oraltablet,chewableTier 1cefadroxil oral tabletTier 1Tier 1cefazolin in dextrose(iso-os) intravenouspiggybackTier 2amoxicillin-potclavulanate oralsuspension forreconstitutioncefazolin injection reconsolnTier 2amoxicillin-potclavulanate oral tabletTier 1cefazolin intravenousrecon solnTier 2amoxicillin-potclavulanate oral tabletextended release 12 hrTier 1cefdinir oral capsuleTier 1Tier 1amoxicillin-potclavulanate oraltablet,chewableTier 1cefdinir oral suspensionfor reconstitutioncefditoren pivoxil oraltabletTier 1ampicillin oral capsuleTier 1Tier 2ampicillin oralsuspension forreconstitutionTier 1cefotaxime injectionrecon solnTier 2avar topical cleanserTier 1cefpodoxime oralsuspension forreconstitutionavidoxy oral tabletTier 1cefpodoxime oral tabletTier 2azithromycin oral packetTier 1QLcefprozil oral suspensionfor reconstitutionTier 1azithromycin oralsuspension forreconstitution 100 mg/5ml, 200 mg/5 mlTier 1QLcefprozil oral tabletTier 1ceftibuten oral capsuleTier 2Tier 1ceftibuten oralsuspension forreconstitutionTier 2azithromycin oral tablet250 mg, 500 mg, 600 mgQLWEBMENY-0030-15Revised 1/1/20167Notes
Drug NameTierclindacin etz topicalswabTier 1clindacin p topical swabTier 1CLINDACIN PACTOPICAL KITTier 3clindamycin hcl oralcapsuleTier 1clindamycin palmitatehcl oral recon solnTier 1clindamycin pediatricoral recon solnTier 1clindamycin phosphatetopical foamTier 1clindamycin phosphatetopical gelTier 1clindamycin phosphatetopical lotionTier 1clindamycin phosphatetopical solutionTier 1clindamycin phosphatetopical swabTier 1clindamycin phosphatevaginal creamTier 1COLY-MYCIN SOTICDROPS,SUSPENSIONTier 3CORTISPORINTOPICAL CREAMTier 3CORTISPORINTOPICALOINTMENTTier 3DAPSONE ORALTABLETTier 3demeclocycline oraltabletTier 2dicloxacillin oral capsuleTier 1DIFICID ORALTABLETTier 3Tier 1doxycycline hyclate oralcapsuleTier 1cleansing wash topicalcleanserTier 1doxycycline hyclate oraltabletTier 1CLINDACIN ETZTOPICAL KITTier 3doxycycline hyclate oraltablet,delayed release(dr/ec)Tier 1Drug NameTierNotesceftriaxone indextrose,iso-osintravenous piggybackTier 2ceftriaxone injectionrecon solnTier 2ceftriaxone intravenousrecon solnTier 2cefuroxime axetil oraltabletTier 1cephalexin oral capsuleTier 1cephalexin oralsuspension forreconstitutionTier 1cephalexin oral tabletTier 1chloramphenicol sodsuccinate intravenousrecon solnTier 2CIPRO HC OTICDROPS,SUSPENSIONTier 3CIPRODEX OTICDROPS,SUSPENSIONTier 3PAciprofloxacin (mixture)oral tablet, er multiphase24 hr 1,000 mg, 500 mgTier 1QLciprofloxacin hclophthalmic dropsTier 1ciprofloxacin hcl oraltabletTier 1ciprofloxacin hcl oticdropperetteTier 1ciprofloxacin in 5 %dextrose intravenouspiggybackTier 2ciprofloxacin lactateintravenous solutionTier 2clarithromycin oralsuspension forreconstitutionTier 1clarithromycin oral tabletTier 1clarithromycin oral tabletextended release 24 hrQLWEBMENY-0030-15Revised 1/1/20168NotesPAPA
Drug NameTiergentamicin ophthalmicointmentTier 1isoniazid oral solutionTier 1isoniazid oral tabletTier 1KETEK ORALTABLETTier 3Tier 1levofloxacin oral tabletTier 1Tier 1ery pads topical swabTier 1LINCOCININJECTIONSOLUTIONTier 3e.e.s. 400 oral tableterygel topical gelTier 1linezolid oral tabletTier 2ery-tab oraltablet,delayed release(dr/ec)Tier 1meropenem intravenousrecon solnTier 2Tier 2erythrocin (as stearate)oral tabletTier 1methenamine hippurateoral tabletTier 1erythromycinethylsuccinate oral tabletTier 1methenamine mandelateoral tabletTier 1erythromycin ophthalmicointmentTier 1metronidazole oralcapsulemetronidazole oral tabletTier 1erythromycin oralcapsule,delayedrelease(dr/ec)Tier 1metronidazole vaginalgelTier 1minocycline oral capsuleTier 1erythromycin oral tabletTier 1minocycline oral tabletTier 1erythromycin withethanol topical gelTier 1minocycline oral tabletextended release 24 hrTier 1erythromycin withethanol topical solutionTier 1MORGIDOX 1X100KITTier 3erythromycin withethanol topical swabTier 1MORGIDOX 2X100KITTier 3erythromycin-benzoylperoxide topical gelTier 1morgidox oral capsuleTier 1ethambutol oral tabletTier 1mupirocin topicalointmentTier 1FACTIVE ORALTABLETTier 3neomycin oral tabletTier 1garamycin ophthalmicdropsTier 1neomycin-bacitracinpoly-hc ophthalmicointmentTier 1gatifloxacin ophthalmicdropsTier 1Tier 1gentak ophthalmicointmentTier 1neomycin-bacitracinpolymyxin ophthalmicointmentTier 1neomycin-polymyxin bdexameth ophthalmicdrops,suspensionTier 1gentamicin ophthalmicdropsDrug NameTierdoxycyclinemonohydrate oralcapsuleTier 1doxycyclinemonohydrate oralsuspension forreconstitutionTier 1doxycyclinemonohydrate oral tabletNotesQLWEBMENY-0030-15Revised 1/1/20169NotesQLPA; QLPA
Drug NameTierTier 1PRED-GOPHTHALMICDROPS,SUSPENSIONTier 3neomycin-polymyxingramicidin ophthalmicdropsTier 1PRED-G S.O.P.OPHTHALMICOINTMENTTier er 1PRIMSOL ORALSOLUTIONTier 3pyrazinamide oral tabletTier 1neomycin-polymyxin-hcotic drops,suspensionTier 1rifabutin oral capsuleTier 2neomycin-polymyxin-hcotic solutionTier 1rifampin oral capsuleTier 1Tier 3neo-polycin hcophthalmic ointmentTier 1RIFATER ORALTABLETTier 1neo-polycin ophthalmicointmentTier 1silver sulfadiazinetopical creamssd topical creamTier 1nitrofurantoinmacrocrystal oralcapsuleTier 1sss 10-5 topical creamTier 1sss 10-5 topical foamTier 1nitrofurantoinmonohyd/m-cryst oralcapsuleTier 1sulfacetamide sodiumophthalmic dropsTier 1Tier 1nitrofurantoin oralsuspensionTier 1sulfacetamide sodiumophthalmic ointmentTier 1ofloxacin ophthalmicdropsTier 1sulfacetamide sodiumsulfur topical cleanserTier 1ofloxacin oral tabletTier 1sulfacetamide sodiumsulfur topical creamofloxacin otic dropsTier 1sulfacetamide sodiumsulfur topical foamTier 1ORACEA ORALCAPSULE,IR &DELAYREL,BIPHASETier 3sulfacetamide sodiumsulfur topical lotionTier 1Tier 1penicillin v potassiumoral recon solnTier 1sulfacetamide sodiumsulfur topical pads,medicatedpenicillin v potassiumoral tabletTier 1sulfacetamide sodiumsulfur topical suspensionTier 1piperacillin-tazobactamintravenous recon solnTier 1sulfacetamide sod-sulfururea topical cleanserTier 1polycin ophthalmicointmentTier 1sulfacetamideprednisolone ophthalmicdropsTier 1polymyxin b sulftrimethoprim ophthalmicdropsTier 1sulfacetamide-sulfurcleansr23 topical kitTier 1sulfacleanse 8-4 topicalsuspensionTier 1Drug NameTierneomycin-polymyxin bdexameth ophthalmicointmentNotesQLWEBMENY-0030-15Revised 1/1/201610Notes
Drug NameTierNotesenoxaparin subcutaneoussyringeTier 3PAfondaparinuxsubcutaneous syringeTier 3PAFRAGMINSUBCUTANEOUSSOLUTIONTier 3PAFRAGMINSUBCUTANEOUSSYRINGETier 3PAhep flush-10 (pf)intravenous solutionTier 2heparin (porcine) in 5 %dex intravenousparenteral solutionTier 2heparin (porcine) in nacl(pf) intravenousparenteral solutionTier 2Tier 1heparin (porcine)injection cartridgeTier 2tobramycin in 0.225 %nacl inhalation solutionfor nebulizationTier 3heparin (porcine)injection solutionTier 2Tier 2tobramycin ophthalmicdropsTier 1heparin flush intravenouskitTier 1heparin flush(porcine)0.9nacl intravenous kitTier heparin lock flush(porcine) intravenoussolutionTier 2trimethoprim oral tabletTier 1Tier 2vancomycin oral capsuleTier 2vandazole vaginal gelTier 1heparin lock flush(porcine) intravenoussyringeVIBATIVINTRAVENOUSRECON SOLNTier 3heparin lock flushintravenous solutionTier 2Tier 2VIGAMOXOPHTHALMICDROPSTier 3heparin lock flushintravenous syringeheparin lock intravenoussolutionTier 2zencia topical cleanserTier 1Tier 2ZYVOX ORALSUSPENSION FORRECONSTITUTIONTier 3heparinlockflush(porcine)(pf)intravenous syringeheparin(porcine) in0.45% nacl intravenousparenteral solutionTier 2heparin, porcine (pf)injection solutionTier 2Drug NameTiersulfadiazine oral tabletTier 2sulfamethoxazoletrimethoprim oralsuspensionTier 1sulfamethoxazoletrimethoprim oral tabletTier 1SULFAMYLONTOPICAL CREAMTier 3sulfatrim oral suspensionTier 1SUPRAX ORALCAPSULETier 3SUPRAX ORALSUSPENSION FORRECONSTITUTIONTier 3tetracycline oral capsuleTier 1THALOMID ORALCAPSULETier 3thermazene topicalcreamNotesPAPAPA; QLANTICOAGULANTSenoxaparin subcutaneoussolutionTier 3PAWEBMENY-0030-15Revised 1/1/201611
Drug NameTierTier 2ciclopirox topicalshampooTier 1heparin, porcine (pf)intravenous solutionTier 2ciclopirox topicalsolutionTier 1heparin, porcine (pf)intravenous syringeTier 2ciclopirox topicalsuspensionTier 1jantoven oral tabletTier 1Tier 1monoject prefill (pf)intravenous syringeTier 2clotrimazole mucousmembrane trocheTier 1monoject prefilladvanced (pf)intravenous syringeTier 2clotrimazole topicalcreamclotrimazole topicalsolutionTier 1PRADAXA ORALCAPSULETier 3Tier 1warfarin oral tabletTier 1clotrimazolebetamethasone topicalcreamXARELTO ORALTABLET 10 MG, 15MG, 20 MGTier 3PA; QLclotrimazolebetamethasone topicallotionTier 1XARELTO ORALTABLETS,DOSEPACKTier 3PAeconazole topical creamTier 1ERAXIS(WATERDILUENT)INTRAVENOUSRECON SOLNTier 3ERTACZO TOPICALCREAMTier 3EXELDERMTOPICAL CREAMTier 3EXELDERMTOPICAL SOLUTIONTier 3fluconazole oralsuspension forreconstitutionTier 1fluconazole oral tabletTier 1flucytosine oral capsuleTier 1griseofulvin microsizeoral suspensionTier 1griseofulvin microsizeoral tabletTier 1griseofulvinultramicrosize oral tabletTier 1itraconazole oral capsuleTier 2ketoconazole oral tabletTier 1ketoconazole topicalcreamTier 1Drug NameTierheparin, porcine (pf)injection syringeNotesQLANTIDOTESdepade oral tabletTier 1naltrexone oral tabletTier 1RELISTORSUBCUTANEOUSSOLUTIONTier 3PARELISTORSUBCUTANEOUSSYRINGETier 3PAANTIFUNGALSCANCIDASINTRAVENOUSRECON SOLNTier 3CICLODAN KITTOPICAL COMBOPACKTier 3CICLODAN KITTOPICAL SOLUTIONTier 3ciclodan topical creamTier 1ciclodan topical solutionTier 1ciclopirox topical creamTier 1ciclopirox topical gelTier 1WEBMENY-0030-15Revised 1/1/201612NotesPA
Drug NameTierTier 1arbinoxa oral tabletTier 1QLTier 1azelastine ophthalmicdropsTier 1ketoconazole topicalshampooPA; QLTier 3BEPREVEOPHTHALMICDROPSTier 3MENTAX TOPICALCREAMmiconazole-3 vaginalsuppositoryTier 1carbinoxamine maleateoral liquidTier 1NAFTIN TOPICALCREAMTier 3carbinoxamine maleateoral tabletTier 1NAFTIN TOPICALGELTier 3cetirizine oral solutionTier 1clemastine oral tabletTier 1NATACYNOPHTHALMICDROPS,SUSPENSIONTier 3cyproheptadine oraltabletTier 1nyamyc topical powderTier 1desloratadine oral tabletTier 1QLnystatin oral powderTier 1desloratadine oraltablet,disintegratingTier 1QLnystatin oral suspensionTier 1Tier 1diphenhydramine hclinjection solutionTier 2nystatin oral tabletnystatin topical creamTier 1Tier 2nystatin topical ointmentTier 1diphenhydramine hclinjection syringenystatin topical powderTier 1diphenhydramine hcloral capsuleTier 1nystatin-triamcinolonetopical creamTier 1Tier 3PA; QLnystatin-triamcinolonetopical ointmentTier 1EMADINEOPHTHALMICDROPSQLTier 1epinastine ophthalmicdropsTier 1nystop topical powderOXISTAT TOPICALCREAMTier 3fexofenadine oral tabletTier 1QLTier 3hydroxyzine hcl oraltabletTier 1OXISTAT TOPICALLOTIONTier 1hydroxyzine pamoateoral capsuleTier 1terbinafine hcl oral tabletterconazole vaginalcreamTier 1Tier 3QLterconazole vaginalsuppositoryTier r 3PA; QLPATANOLOPHTHALMICDROPSTier 3PA; QLpromethazine oral syrupTier 1promethazine oral tabletTier 1Drug NameTierketoconazole topicalfoamNotesPAANTIHISTAMINE AND DECONGESTANTCOMBINATIONpromethazine vc oralsyrupTier 1ANTIHISTAMINESarbinoxa oral liquidTier 1WEBMENY-0030-15Revised 1/1/201613NotesQL
Drug NameTierNotesANTIHYPERGLYCEMICSDrug NameTierHUMALOGSUBCUTANEOUSCARTRIDGETier 2HUMALOGSUBCUTANEOUSSOLUTIONTier 2Tier 2Notesacarbose oral tabletTier 1APIDRA SOLOSTARSUBCUTANEOUSINSULIN PENTier 3STAPIDRASUBCUTANEOUSSOLUTIONTier 3STBYDUREONSUBCUTANEOUSPEN INJECTORTier 3ST; QLHUMULIN 70/30KWIKPENSUBCUTANEOUSINSULIN PENTier 2BYDUREONSUBCUTANEOUSSUSPENSION,EXTENDED REL RECONTier 3ST; QLHUMULIN 70/30SUBCUTANEOUSSUSPENSIONTier 2chlorpropamide oraltabletTier 1HUMULIN NKWIKPENSUBCUTANEOUSINSULIN PENTier 2glimepiride oral tabletTier 1glipizide oral tabletTier 1HUMULIN NSUBCUTANEOUSSUSPENSIONglipizide oral tabletextended release 24hrTier 1HUMULIN RINJECTIONSOLUTIONTier 2glipizide-metformin oraltabletTier 1Tier 2glyburide oral tabletTier 1HUMULIN R etformin oraltabletTier 1JANUMET ORALTABLETTier 3ST; QLGLYSET ORALTABLETTier 3Tier 3ST; QLHUMALOGKWIKPENSUBCUTANEOUSINSULIN PENTier 2JANUMET XR ORALTABLET, ERMULTIPHASE 24 HR100-1,000 MG, 50-1,000MG, 50-500 MGST; QLTier 2JANUVIA ORALTABLETTier 3HUMALOG MIX 5050 KWIKPENSUBCUTANEOUSINSULIN PENJARDIANCE ORALTABLETTier 3STHUMALOG MIX 5050 SUBCUTANEOUSSUSPENSIONTier 2LANTUS SOLOSTARSUBCUTANEOUSINSULIN PENTier 2HUMALOG MIX 7525 KWIKPENSUBCUTANEOUSINSULIN PENTier 2LANTUSSUBCUTANEOUSSOLUTIONTier 2Tier 2LEVEMIRFLEXTOUCHSUBCUTANEOUSINSULIN PENTier 2HUMALOG MIX 7525 SUBCUTANEOUSSUSPENSIONWEBMENY-0030-15Revised 1/1/201614
Drug NameTierNotesLEVEMIRSUBCUTANEOUSSOLUTIONTier 2metformin oral tabletTier 1metformin oral tabletextended release 24 hrTier 1metformin oral tabletextended release 24hrTier 1nateglinide oral tabletTier 2NOVOLIN 70/30SUBCUTANEOUSSUSPENSIONTier 2Tier 2ALBENZA ORALTABLETTier 3NOVOLIN NSUBCUTANEOUSSUSPENSIONTier 3NOVOLIN RINJECTIONSOLUTIONTier 2ALINIA ORALSUSPENSION FORRECONSTITUTIONALINIA ORALTABLETTier 3NOVOLOG FLEXPENSUBCUTANEOUSINSULIN PENTier 2atovaquone oralsuspensionTier 2NOVOLOG MIX 70-30FLEXPENSUBCUTANEOUSINSULIN PENTier 2atovaquone-proguaniloral tabletTier 1BILTRICIDE ORALTABLETTier 3NOVOLOG MIX 70-30SUBCUTANEOUSSOLUTIONTier 2chloroquine phosphateoral tabletTier 1Tier 2COARTEM ORALTABLETTier 3NOVOLOG PENFILLSUBCUTANEOUSCARTRIDGEDARAPRIM ORALTABLETTier 3NOVOLOGSUBCUTANEOUSSOLUTIONTier 2hydroxychloroquine oraltabletTier 1ONGLYZA ORALTABLET 2.5 MGTier 3ivermectin oral tabletTier 1mefloquine oral tabletTier 1ONGLYZA ORALTABLET 5 MGTier 3ST; QLparomomycin oralcapsuleTier 1pioglitazone oral tabletTier 1QLTier 3repaglinide oral tabletTier 2PRIMAQUINE ORALTABLETSYMLINPEN 120SUBCUTANEOUSPEN INJECTORTier 3PAquinine sulfate oralcapsuleTier 1SYMLINPEN 60SUBCUTANEOUSPEN INJECTORTier 3PAPADrug NameTierNotestolazamide oral tabletTier 1tolbutamide oral tabletTier 1TRADJENTA ORALTABLETTier 3ST; DOVICTOZA 2-PAKSUBCUTANEOUSPEN INJECTORTier 3ST; QLVICTOZA 3-PAKSUBCUTANEOUSPEN INJECTORTier 3ST; QLANTIINFECTIVES/MISCELLANEOUSST; DOANTIINFECTIVESARESTIN DENTALCARTRIDGEWEBMENY-0030-15Revised 1/1/201615Tier 3PA; QL
Drug NameTierNotesANTINEOPLASTICSPADrug NameTierFLUOROPLEXTOPICAL CREAMTier 3fluorouracil topicalcreamTier 1fluorouracil topicalsolutionTier 1flutamide oral capsuleTier 3GILOTRIF ORALTABLETTier 3QLGLEEVEC ORALTABLETTier 3PAHEXALEN ORALCAPSULETier 3HYCAMTIN ORALCAPSULETier 3hydroxyurea oral capsuleTier 3ICLUSIG ORALTABLET 15 MG, 45MGTier 3PA; QLINLYTA ORALTABLETTier 3PAINTRON AINJECTION RECONSOLNTier 3PAINTRON AINJECTIONSOLUTIONTier 3PAAFINITOR DISPERZORAL TABLET FORSUSPENSIONTier 3AFINITOR ORALTABLETTier 3ALFERON NINJECTIONSOLUTIONTier 3ALKERAN ORALTABLETTier 3anastrozole oral tabletTier 3PAbexarotene oral capsuleTier 3PA; QLbicalutamide oral tabletTier 3BOSULIF ORALTABLETTier 3capecitabine oral tabletTier 3PACAPRELSA ORALTABLETTier 3PACOMETRIQ ORALCAPSULE 100MG/DAY(80 MG[1]-20MG[1]), 140MG/DAY(80 MG[1]-20MG[3]), 60 MG/DAY(20 MG [3]/DAY)Tier 3PA; QLCYCLOPHOSPHAMIDE ORAL CAPSULETier 3Tier 2PAIRESSA ORALTABLETTier 3diclofenac sodiumtopical gelTier 3PAJAKAFI ORALTABLETTier 3EMCYT ORALCAPSULEletrozole oral tabletTier 3ERIVEDGE ORALCAPSULETier 3PALEUKERAN ORALTABLETTier 3etoposide oral capsuleTier 3Tier 3leuprolide subcutaneouskitTier 3exemestane oral tabletFARESTON ORALTABLETTier 3LOMUSTINE ORALCAPSULETier 3FIRMAGON KIT WDILUENT SYRINGESUBCUTANEOUSRECON SOLNTier 3LYSODREN ORALTABLETTier 3MATULANE ORALCAPSULETier 3FIRMAGONSUBCUTANEOUSRECON SOLNTier 3MEKINIST ORALTABLET 0.5 MG, 2MGTier 3PAPAPAPAPAWEBMENY-0030-15Revised 1/1/201616NotesPAPAPA; QL
Drug NameTiermercaptopurine oraltabletTier 3methotrexate sodiumoral tabletTier 3mitoxantroneintravenous concentrateTier 3MYLERAN ORALTABLETTier 3NEXAVAR ORALTABLETTier 3NILANDRON ORALTABLETTier 3PANRETIN TOPICALGELTier 3POMALYST ORALCAPSULE 1 MG, 2MG, 3 MG, 4 MGTier 3REVLIMID ORALCAPSULETier 3RITUXANINTRAVENOUSCONCENTRATETier 3SPRYCEL ORALTABLETTier 3STIVARGA ORALTABLETNotesDrug NameTierNotesTRELSTAR DEPOTINTRAMUSCULARSUSPENSION FORRECONSTITUTIONTier 3PATRELSTARINTRAMUSCULARSUSPENSION FORRECONSTITUTIONTier 3PATRELSTARINTRAMUSCULARSYRINGETier 3PATRELSTAR LAINTRAMUSCULARSUSPENSION FORRECONSTITUTIONTier 3PAtretinoin (chemotherapy)oral capsuleTier 3TYKERB ORALTABLETTier 3PAVOTRIENT ORALTABLETTier 3PAXALKORI ORALCAPSULETier 3PAPAXTANDI ORALCAPSULETier 3PATier 3PATier 3SUTENT ORALCAPSULETier 3PAZANOSARINTRAVENOUSRECON SOLNTier 3PATABLOID ORALTABLETTier 3ZELBORAF ORALTABLETTier 3PATAFINLAR ORALCAPSULETier 3ZOLINZA ORALCAPSULETier 3PAtamoxifen oral tabletTier 3ZYTIGA ORALTABLETTARCEVA ORALTABLETTier 3TARGRETINTOPICAL GELTier 3TASIGNA ORALCAPSULETier 3temozolomide oralcapsuleTier 3TORISELINTRAVENOUSRECON SOLNTier 3PAQLPA; QLPAPAPAPAPAANTIPARKINSON DRUGSamantadine hcl oralcapsuleTier 1amantadine hcl oralsolutionTier 1amantadine hcl oraltabletTier 1AZILECT ORALTABLETTier 3benztropine oral tabletTier 1bromocriptine oralcapsuleTier 1WEBMENY-0030-15Revised 1/1/201617
Drug NameTierbromocriptine oral tabletTier 1carbidopa oral tabletTier 2carbidopa-levodopa oraltabletTier 1carbidopa-levodopa oraltablet extended releaseTier 1carbidopa-levodopa oraltablet,disintegratingTier 1entacapone oral tabletTier 2pramipexole oral tabletTier 1ropinirole oral tabletTier 1ropinirole oral tabletextended release 24 hrTier 1selegiline hcl oralcapsuleTier 1selegiline hcl oral tabletTier 1tolcapone oral tabletTier 2trihexyphenidyl oralelixirTier 1trihexyphenidyl oraltabletTier 1NotesANTIPLATELET DRUGSTierabacavir-lamivudinezidovudine oral tabletTier 3acyclovir oral capsuleTier 1acyclovir oral suspensionTier 1acyclovir oral tabletTier 1adefovir oral tabletTier 3APTIVUS ORALCAPSULETier 3APTIVUS ORALSOLUTIONTier 3ATRIPLA ORALTABLETTier 3BARACLUDE ORALSOLUTIONTier 3CRIXIVAN ORALCAPSULETier 3DAKLINZA ORALTABLETTier 1didanosine oralcapsule,delayedrelease(dr/ec)Tier 3EDURANT ORALTABLETTier 3EMTRIVA ORALCAPSULETier 3EMTRIVA ORALSOLUTIONTier 3entecavir oral tabletTier 3PAEPIVIR HBV ORALSOLUTIONTier 3PAEPZICOM ORALTABLETTier 3famciclovir oral tabletTier 1foscarnet intravenoussolutionTier 2anagrelide oral capsuleTier 3aspirin-dipyridamole oralcapsule, er multiphase 12hrTier 2BRILINTA ORALTABLET 60 MG, 90MGTier 3cilostazol oral tabletTier 2clopidogrel oral tablet300 mgTier 1clopidogrel oral tablet 75mgTier 1dipyridamole oral tabletTier 1Tier 3QLFUZEONSUBCUTANEOUSRECON SOLNTier 3EFFIENT ORALTABLET 10 MGEFFIENT ORALTABLET 5 MGTier 3DOganciclovir sodiumintravenous recon solnTier 3ticlopidine oral tabletTier 1HARVONI ORALTABLETTier 3ANTIVIRALSabacavir oral tabletQLQLNotesDrug NameTier 3WEBMENY-0030-15Revised 1/1/201618PAQLPA; QL
Drug NameTierNotesPEGINTRONREDIPENSUBCUTANEOUSPEN INJECTOR KITTier 3PAPEGINTRONSUBCUTANEOUSKITTier 3PAPREZISTA ORALSUSPENSIONTier 3PR
Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross and Blue Shield Association. 1 . WEBMENY-0030-15 Revised 1/1/2016 2 . New York Essential Plan Drug List . Drug Name Tier. Notes ANALGESICS; acetaminophen-codeine
