The tables below outline changes determined for our Braven Health Plan Formulary as of January 1, 2023 and prescriptions for a listing of drugs currently approved for treatment of common conditions.
Most medications have quantity limits in place based on FDA labeling. This does not represent an exhaustive list, please reference the full formulary for more detail. Cost represents initial coverage copay, based on member’s Part D benefit and coverage period, final cost of medicine may be different.
New Formulary Additions for 2023
| Prescription |
Tier |
Cost |
| Telmisartan |
Tier 6 |
$0 |
| Candesartan |
Tier 6 |
$0 |
| Tresiba |
Tier 3 |
$47 |
| Farxiga |
Tier 3 |
$47 |
| Trulicity |
Tier 3 |
$47 |
| Nebivolol |
Tier 4 |
$100 |
| Symbicort |
Tier 3 |
$47 |
| Torsemide |
Tier 2 |
$8 |
| Fenofibric Acid |
Tier 3 |
$47 |
| Finsateride |
Tier 2 |
$8 |
| Pantoprozole |
Tier 2 |
$8 |
| Cartia XT |
Tier 3 |
$47 |
| Fenofiberate |
Tier 3 |
$47 |
| Oxybutynin |
Tier 3 |
$47 |
| Ezetimbe |
Tier 3 |
$47 |
| Diltiazem ER |
Tier 3 |
$47 |
Current Covered Drugs to Treat Common Conditions
Asthma/COPD Medications
| Prescription |
Tier |
Cost |
| Albuterol Sulfate 108 mcg/act (generics for ProAir HFA, Proventil HFA) (SABA) |
3 |
$47 |
| Ventolin HFA 108 mcg/act (SABA) |
3 |
$47 |
| Combivent (SABA + SAMA) |
4 |
$100 |
| Flovent Diskus and Flovent HFA (Corticosteroid) |
3 |
$47 |
| Asmanex HFA and Twisthalers (Corticosteroid) |
3 |
$47 |
| Advair Diskus and Advair HFA (Corticosteroid plus LABA) |
3 |
$47 |
| Fluticasone propionate/Salmeterol (Corticosteroid plus LABA) |
3 |
$47 |
| Arnuity Ellipta (Corticosteroid) |
3 |
$47 |
| Breo Ellipta (LABA) |
3 |
$47 |
| Serevent Diskus (LABA) |
3 |
$47 |
| Symbicort (LABA + ICS) |
3 |
$47 |
| Incruse Ellipta (LAMA) |
3 |
$47 |
| Anoro Ellipta (LABA + LAMA) |
3 |
$47 |
| Atrovent HFA (Anticholinergic) |
4 |
$100 |
| Combivent Respimat (Anticholinergic plus SABA) |
4 |
$100 |
| Trelegy Ellipta (Combo product) |
3 |
$47 |
Blood Products
| Prescription |
Tier |
Cost |
| Brilinta |
3 |
$47 |
| Eliquis |
3 |
$47 |
| Xarelto |
3 |
$47 |
Cholesterol Medications
| Prescription |
Tier |
Cost |
| Repatha prefilled syringe 140 mg/ml |
3 |
$47 |
| Colestipol hcl tab 1 gm |
3 |
$47 |
| Ezetimibe tab 10 mg |
3 |
$47 |
| Fenofibrate micronized cap and tab |
3 |
$47 |
| Icosapent ethyl cap 1 gm |
4 |
$100 |
| Omega-3-acid ethyl esters cap 1 gm |
3 |
$47 |
| Vascepa cap |
3 |
$47 |
Diabetic Medications
| Prescription |
Tier |
Cost |
| Bydureon inj (GLP1) |
3 |
$47 |
| Ozempic inj (GLP1) |
3 |
$47 |
| Rybelsus tab 3 mg (GLP1) |
3 |
$47 |
| Trulicity inj (GLP1) |
3 |
$47 |
| Victoza inj 18 mg/3 ml (6 mg/ml) (GLP1) |
3 |
$47 |
| Januvia tab 25 mg (DPP-4) |
3 |
$47 |
| Janumet tab and Janumet XR tab (DPP-4) |
3 |
$47 |
| Jentadueto tab and Jentadueto XR tab (DPP4 + metformin) |
3 |
$47 |
| Tradjenta tab 5 mg (DDP4) |
3 |
$47 |
| Jardiance tab 10 mg (SGLT2) |
3 |
$47 |
| Farxiga tab 5 mg and 10 mg (SGLT2) |
3 |
$47 |
| Synjardy tab 12.5-1000 mg and Synjardy XR (SGLT2) |
3 |
$47 |
| Glyxambi tab 10-5 mg and 25-5 mg (SGLT2 + DPP4) |
4 |
$100 |
| Xigduo XR tab 2.5-100 mg, 5-1000 mg, 5-500 mg, 10-500 mg, 10-1000 mg (SGLT2 + metformin) |
3 |
$47 |
| Humalog, Humulin N, Humulin R insulins (fast acting) |
3 |
$47 |
| Lantus inj 100 unit/ml and Lantus Solostar (long acting) |
3 |
$47 |
| Soliqua inj 100/33 |
3 |
$47 |
| Toujeo Max Solostar inj and Toujeo Solostar inj (long acting) |
3 |
$47 |
| Tresiba Flextouch (long acting) |
3 |
$47 |
This document contains references to brand name prescription medicines that are trademarks or registered marks of pharmaceutical manufacturers that are not affiliated with Braven Health, Horizon Blue Cross Blue Shield of New Jersey, the Blue Cross Blue Shield Association or Prime Therapeutics.
