Health Insurance Marketplace 3 Tier Drug List

Transcription

1 March 208 (207 Plan Year) Health Insurance Marketplace Tier Drug List Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug list is regularly updated. Please visit bcbstx.com for the most up-to-date information. To find a contracting pharmacy, please access the link below: Contents Introduction... I How drugs are selected... I How member payment is determined... I How to use this list... II Drugs used to treat multiple conditions... II Generic drugs... II Consider talking to your doctor about generic drugs... II Coverage considerations... III Specialty drugs... V Prime Specialty by AllianceRx Walgreens Prime... V Abbreviation key... VI Therapeutic Class Drug List Anti-Infective Agents... Biologicals... 2 Antineoplastic Agents... 5 Endocrine and Metabolic Drugs... 2 Cardiovascular Agents... 9 Respiratory Agents Gastrointestinal Agents Genitourinary Agents Central Nervous System Drugs Analgesics and Anesthetics Neuromuscular Drugs Nutritional Products Hematological Agents... 2 Topical Products... 4 Miscellaneous Products Index To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. Texas Residents -- Find and estimate prices for medicines on this drug list at: Q TX HIM Prime Therapeutics LLC 0/8

2 Introduction Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician. Drug list updates This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to Blue Access for Members SM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbstx.com. How drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. How member payment is determined This list shows prescription drug products in tiers. Generally, each drug is placed into one of three member payment tiers: Generic (Tier ), Preferred Brand (Tier 2) or Non-preferred Brand (Tier ). Please refer to the Preventive () section for drugs marked with an "A" in the drug tier column. To verify your payment amount for a drug, visit bcbstx.com and log in to Blue Access for Members or call the number on the back of your ID card. Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for selfadministration may be available through your medical benefit. Texas Residents -- Find and estimate prices for medicines on this drug list at: BCBSTX Health Insurance Marketplace Tier Drug List March 208 (207 Plan Year) I

3 How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Example: atorvastatin (Lipitor brand is NF) Brand prescription drugs are shown in capital letters followed by the generic name. Drugs used to treat multiple conditions Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use. Generic drugs Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same standards. There are two types of generic drugs: A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. According to the FDA, compared to its brand counterpart, an FDA-approved generic drug: Is chemically the same Works just as well in the body Is as safe and effective Meets the same standards set by the FDA The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less. Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available. You may be responsible for the brand member payment amount plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount. Consider talking to your doctor about generic drugs If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication. Texas Residents -- Find and estimate prices for medicines on this drug list at: BCBSTX Health Insurance Marketplace Tier Drug List March 208 (207 Plan Year) II

4 Coverage considerations Most prescription drug benefit plans provide coverage for up to a 0-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan materials for details about your particular benefits. Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount. Repackaged medications: Repackaged versions of medications already available on the market are not covered. (PA): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the preferred medications listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the preferred medications listed in this document, if a step therapy is commonly required it will generally be noted next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on additional medications beyond those noted in this document. (DL): Drug Dispensing limits are designed to help encourage medication use as intended by the FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit bcbstx.com. *Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit. (LD): Medicines marked as "" have restrictions on where you may obtain a medication. This may include requiring the use of a designated pharmacy to fill a prescription. Texas Residents -- Find and estimate prices for medicines on this drug list at: BCBSTX Health Insurance Marketplace Tier Drug List March 208 (207 Plan Year) III

5 Preventive (): Medicines marked in the column are under the Affordable Care Act coverage of preventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), when meeting the conditions as outlined under the regulation. These are also indicated with an "A" in the drug tier column. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D supplements, and some FDA approved contraceptive methods. To see what contraceptive products may be covered, visit Remember, medication decisions are between you and your doctor. Only you and your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor. BCBSTX does not provide health care services and, therefore, cannot guarantee any results or outcomes. Texas Residents -- Find and estimate prices for medicines on this drug list at: BCBSTX Health Insurance Marketplace Tier Drug List March 208 (207 Plan Year) IV

6 Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications, visit myprime.com or bcbstx.com and log in to Blue Access for Members. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card. Prime Specialty by AllianceRx Walgreens Prime Through Prime Specialty by AllianceRx Walgreens Prime, members can have covered specialty medications delivered directly to them or their doctor s office. When you receive specialty medications through Prime Specialty by AllianceRx Walgreens Prime, you also receive at no additional charge the following services: Coordination of coverage between you, your doctor and your health plan Educational materials about your particular condition and information about managing potential medication side effects Syringes, sharps containers and other supplies with every shipment for self-injectables 24/7/65 phone access to a pharmacist for urgent medication issues To order through Prime Specialty by AllianceRx Walgreens Prime: Have your doctor call or fax your prescription to Prime Specialty by AllianceRx Walgreens Prime. Your doctor can call or fax to If you have an existing prescription for a covered specialty medication, you can call to transfer your prescription. A coordinator will contact you to arrange delivery of your medication. The prescription can be shipped directly to you or your prescribing doctor s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging. If you have questions, please contact Prime Specialty by AllianceRx Walgreens Prime at , visit or call the number on the back of your ID card. * Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ( HCSC ). HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC. Texas Residents -- Find and estimate prices for medicines on this drug list at: BCBSTX Health Insurance Marketplace Tier Drug List March 208 (207 Plan Year) V

7 Abbreviation key cap... capsules chew... chewable conc... concentrate cr... controlled release dr... delayed release ec... enteric coated effe... effervescent equiv... equivalent er... extended release inhal... inhalation inj... injection liq... liquid lotn... lotion nebu... nebulizer odt... orally disintegrating tabs oint... ointment ophth... opthalmic osm... osmotic release powd... powder sa... sustained action sl... sublingual soln... solution sr... sustained release suppos... suppositories susp... suspension tab...tablets td... transdermal You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List. To request this exception, you, or your prescriber, can call the number on the back of your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be able to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage decision within 24 hours after they receive your request for an expedited review. If the coverage request is denied, BCBSTX will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). Call the number on the back of your ID card if you have any questions. Texas Residents -- Find and estimate prices for medicines on this drug list at: BCBSTX Health Insurance Marketplace Tier Drug List March 208 (207 Plan Year) VI

8 bcbstx.com

9 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: (voic ) 00 E. Randolph St. TTY/TDD: th Floor Fax: Chicago, Illinois CivilRightsCoordinator@hcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: Independence Avenue SW TTY/TDD: Room 509F, HHH Building 09 Complaint Portal: Washington, DC 2020 Complaint Forms: bcbstx.com

10 207 ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN - amoxicillin (trihydrate) chew tab 25 AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 amoxicillin (trihydrate) cap 250 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) for susp 25 /5ml amoxicillin (trihydrate) for susp 200 /5ml amoxicillin (trihydrate) for susp 250 /5ml amoxicillin (trihydrate) for susp 400 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin es-600) amoxicillin & k clavulanate tab er 2hr (Augmentin xr) amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab (Augmentin) amoxicillin & k clavulanate tab (Augmentin) AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab AMPICILLIN - ampicillin cap 500 AUGMENTIN - amoxicillin & k clavulanate for susp /5ml dicloxacillin sodium cap 250 dicloxacillin sodium cap 500 MOXATAG - amoxicillin (trihydrate) tab er 24hr 775 PENICILLIN V POTASSIUM - penicillin v potassium for soln 25 /5ml PENICILLIN V POTASSIUM - penicillin v potassium for soln 250 /5ml penicillin v potassium tab 250 penicillin v potassium tab 500 CEPHALOSPORINS CEDAX - ceftibuten cap BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year)

11 207 CEDAX - ceftibuten for susp 80 /5ml CEFACLOR - cefaclor for susp 25 /5ml CEFACLOR - cefaclor for susp 250 /5ml CEFACLOR - cefaclor for susp 75 /5ml cefaclor cap 250 cefaclor cap 500 CEFACLOR ER - cefaclor monohydrate tab er 2hr 500 cefadroxil cap 500 cefadroxil for susp 250 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 00 cefdinir for susp 25 /5ml cefdinir for susp 250 /5ml CEFDITOREN PIVOXIL - cefditoren pivoxil tab 200 (base equivalent) CEFDITOREN PIVOXIL - cefditoren pivoxil tab 400 (base equivalent) cefixime for susp 00 /5ml (Suprax) cefixime for susp 200 /5ml (Suprax) cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 00 /5ml cefpodoxime proxetil tab 00 cefpodoxime proxetil tab 200 cefprozil for susp 25 /5ml cefprozil for susp 250 /5ml cefprozil tab 250 cefprozil tab 500 CEFTIN - cefuroxime axetil for susp 25 /5ml CEFTIN - cefuroxime axetil for susp 250 /5ml cefuroxime axetil tab 250 (Ceftin) cefuroxime axetil tab 500 (Ceftin) CEPHALEXIN - cephalexin tab 250 CEPHALEXIN - cephalexin tab 500 cephalexin cap 250 (Keflex) cephalexin cap 500 (Keflex) cephalexin cap 750 (Keflex) cephalexin for susp 25 /5ml cephalexin for susp 250 /5ml SPECTRACEF - cefditoren pivoxil tab 400 (base equivalent) SUPRAX - cefixime cap BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 2

12 207 SUPRAX - cefixime chew tab 00 SUPRAX - cefixime chew tab 200 SUPRAX - cefixime for susp 00 /5ml SUPRAX - cefixime for susp 200 /5ml SUPRAX - cefixime for susp 500 /5ml MACROLIDES AZITHROMYCIN - azithromycin powd pack for susp gm azithromycin for susp 00 /5ml (Zithromax) azithromycin for susp 200 /5ml (Zithromax) azithromycin tab 250 (Zithromax) azithromycin tab 500 (Zithromax) azithromycin tab 600 (Zithromax) CLARITHROMYCIN - clarithromycin for susp 25 /5ml CLARITHROMYCIN - clarithromycin for susp 250 /5ml clarithromycin tab er 24hr 500 clarithromycin tab 250 (Biaxin) clarithromycin tab 500 (Biaxin) DIFICID - fidaxomicin tab 200 E.E.S. GRANULES - erythromycin ethylsuccinate for susp 200 /5ml E.E.S erythromycin ethylsuccinate tab 400 ERY-TAB - erythromycin tab delayed release 250 ERY-TAB - erythromycin tab delayed release ERY-TAB - erythromycin tab delayed release 500 ERYPED erythromycin ethylsuccinate for susp 200 /5ml ERYPED erythromycin ethylsuccinate for susp 400 /5ml ERYTHROCIN STEARATE - erythromycin stearate tab 250 ERYTHROMYCIN BASE - erythromycin tab 250 ERYTHROMYCIN BASE - erythromycin tab 500 ERYTHROMYCIN ETHYLSUCCINA - erythromycin ethylsuccinate tab 400 erythromycin ethylsuccinate for susp 200 /5ml (E.e.s. granules) erythromycin w/ delayed release particles cap 250 PCE - erythromycin w/ enteric coated particles tab PCE - erythromycin w/ enteric coated particles tab BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year)

13 207 ZITHROMAX - azithromycin powd pack for susp gm ZMAX - azithromycin extended release for oral susp 2 gm TETRACYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 00 doxycycline hyclate cap 50 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab 20 doxycycline hyclate tab 00 doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 (Monodox) doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 (Adoxa) doxycycline monohydrate for susp 25 /5ml (Vibramycin) doxycycline monohydrate tab 50 (Adoxa) doxycycline monohydrate tab 75 (Adoxa) doxycycline monohydrate tab 00 (Adoxa pak /00) doxycycline monohydrate tab 50 (Adoxa pak /50) minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) minocycline hcl tab er 24hr 45 minocycline hcl tab er 24hr 90 minocycline hcl tab er 24hr 5 minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 00 TETRACYCLINE HCL - tetracycline hcl cap 250 TETRACYCLINE HCL - tetracycline hcl cap 500 tetracycline hcl cap 250 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) FLUOROQUINOLONES ciprofloxacin for oral susp 250 /5ml (5%) (5 gm/00ml) (Cipro) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXACIN HCL - ciprofloxacin hcl tab 00 (base equiv) ciprofloxacin hcl tab 250 (base equiv) (Cipro) ciprofloxacin hcl tab 500 (base equiv) (Cipro) BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 4

14 207 ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er 24hr 000 (base eq) (Cipro xr) LEVOFLOXACIN - levofloxacin oral soln 25 /ml levofloxacin tab 250 (Levaquin) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) moxifloxacin hcl tab 400 (base equiv) (Avelox) OFLOXACIN - ofloxacin tab 00 ofloxacin tab 400 AMINOGLYCOSIDES BETHKIS - tobramycin nebu soln 00 /4ml KITABIS PAK - tobramycin nebu soln 00 /5ml neomycin sulfate tab 500 paromomycin sulfate cap 250 TOBI PODHALER - tobramycin inhal cap 28 TOBRAMYCIN - tobramycin nebu soln 00 /5ml tobramycin nebu soln 00 /5ml (Tobi) SULFONAMIDES SULFADIAZINE - sulfadiazine tab 500 ANTIMYCOBACTERIAL AGENTS CYCLOSERINE - cycloserine cap 250 ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 400 (Myambutol) ISONIAZID - isoniazid syrup 50 /5ml isoniazid tab 00 isoniazid tab 00 PASER - aminosalicylic acid er granules packet 4 gm PRIFTIN - rifapentine tab 50 2 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) RIFAMATE - isoniazid & rifampin cap rifampin cap 50 (Rifadin) rifampin cap 00 (Rifadin) RIFATER - isoniazid-rifampin w/ pyrazinamide tab SIRTURO - bedaquiline fumarate tab 00 (base equiv) TRECATOR - ethionamide tab 250 ANTIFUNGALS CRESEMBA - isavuconazonium sulfate cap BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 5

15 207 fluconazole for susp 0 / ml (Diflucan) fluconazole for susp 40 / ml (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 200 (Diflucan) flucytosine cap 250 (Ancobon) flucytosine cap 500 (Ancobon) griseofulvin microsize susp 25 /5ml griseofulvin microsize tab 500 (Grifulvin v) griseofulvin ultramicrosize tab 25 (Gris-peg) griseofulvin ultramicrosize tab 250 (Gris-peg) itraconazole cap 00 (Sporanox) NOXAFIL - posaconazole susp 40 /ml NOXAFIL - posaconazole tab delayed release 00 nystatin tab unit SPORANOX - itraconazole oral soln 0 /ml terbinafine hcl tab 250 (Lamisil) voriconazole for susp 40 /ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 200 (Vfend) ANTIVIRALS abacavir sulfate soln 20 / ml (base equiv) (Ziagen) abacavir sulfate tab 00 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab (Epzicom) abacavir sulfatelamivudine-zidovudine tab (Trizivir) acyclovir cap 200 (Zovirax) acyclovir susp 200 /5ml (Zovirax) acyclovir tab 400 (Zovirax) acyclovir tab 800 (Zovirax) adefovir dipivoxil tab 0 (Hepsera) APTIVUS - tipranavir cap 250 APTIVUS - tipranavir oral soln 00 /ml atazanavir sulfate cap 50 (base equiv) (Reyataz) atazanavir sulfate cap 200 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 6

16 207 ATRIPLA - efavirenzemtricitabine-tenofovir df tab BARACLUDE - entecavir oral 2 soln 0.05 /ml COMPLERA - emtricitabinerilpivirine-tenofovir df tab CRIXIVAN - indinavir sulfate cap 200 CRIXIVAN - indinavir sulfate cap 400 DESCOVY - emtricitabinetenofovir alafenamide fumarate tab didanosine delayed release capsule 200 (Videx ec) didanosine delayed release capsule 250 (Videx ec) didanosine delayed release capsule 400 (Videx ec) EDURANT - rilpivirine hcl tab 25 (base equivalent) efavirenz cap 50 (Sustiva) efavirenz cap 200 (Sustiva) EMTRIVA - emtricitabine caps 200 EMTRIVA - emtricitabine soln 0 /ml entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUSA - sofosbuvirvelpatasvir tab EPIVIR HBV - lamivudine oral soln 5 /ml (hbv) EPZICOM - abacavir sulfatelamivudine tab EVOTAZ - atazanavir sulfatecobicistat tab (base equiv) famciclovir tab 25 (Famvir) famciclovir tab 250 (Famvir) famciclovir tab 500 (Famvir) fosamprenavir calcium tab 700 (base equiv) (Lexiva) FUZEON - enfuvirtide for inj 90 GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab HARVONI - ledipasvirsofosbuvir tab INTELENCE - etravirine tab 25 INTELENCE - etravirine tab 00 INTELENCE - etravirine tab 200 INVIRASE - saquinavir mesylate cap 200 INVIRASE - saquinavir mesylate tab 500 ISENTRESS - raltegravir potassium chew tab 25 (base equiv) ISENTRESS - raltegravir potassium chew tab 00 (base equiv) BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 7

17 207 ISENTRESS - raltegravir potassium packet for susp 00 (base equiv) ISENTRESS - raltegravir potassium tab 400 (base equiv) ISENTRESS HD - raltegravir potassium tab 600 (base equiv) KALETRA - lopinavir-ritonavir soln /5ml (80-20 /ml) KALETRA - lopinavir-ritonavir tab KALETRA - lopinavir-ritonavir tab lamivudine oral soln 0 / ml (Epivir) lamivudine tab 00 (hbv) (Epivir hbv) lamivudine tab 50 (Epivir) lamivudine tab 00 (Epivir) lamivudine-zidovudine tab (Combivir) LEXIVA - fosamprenavir calcium susp 50 /ml (base equiv) LEXIVA - fosamprenavir calcium tab 700 (base equiv) lopinavir-ritonavir soln /5ml (80-20 / ml) (Kaletra) MAVYRET - glecaprevirpibrentasvir tab MODERIBA - ribavirin tab 200 & ribavirin 400 tab therapy pack MODERIBA - ribavirin tab 400 & ribavirin 600 tab therapy pack MODERIBA 200 DOSE PACK - ribavirin tab 600 MODERIBA 800 DOSE PACK - ribavirin tab 400 nevirapine tab er 24hr 00 (Viramune xr) nevirapine tab er 24hr 400 (Viramune xr) nevirapine tab 200 (Viramune) NORVIR - ritonavir cap 00 NORVIR - ritonavir oral soln 80 /ml NORVIR - ritonavir tab 00 ODEFSEY - emtricitabinerilpivirine-tenofovir af tab OLYSIO - simeprevir sodium cap 50 (base equivalent) oseltamivir phosphate cap 0 (base equiv) (Tamiflu) oseltamivir phosphate cap 45 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) oseltamivir phosphate for susp 6 /ml (base equiv) (Tamiflu) BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 8

18 207 PEGASYS - peginterferon alfa-2a inj 80 mcg/ml PEGASYS - peginterferon alfa-2a inj 80 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-2a inj 5 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-2a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-2b for inj kit 50 mcg/0.5ml PEGINTRON - peginterferon alfa-2b for inj kit 80 mcg/0.5ml PEGINTRON - peginterferon alfa-2b for inj kit 20 mcg/0.5ml PEGINTRON - peginterferon alfa-2b for inj kit 50 mcg/0.5ml PREZCOBIX - darunavircobicistat tab PREZISTA - darunavir ethanolate susp 00 /ml (base equiv) PREZISTA - darunavir ethanolate tab 75 (base equiv) PREZISTA - darunavir ethanolate tab 50 (base equiv) PREZISTA - darunavir ethanolate tab 600 (base equiv) PREZISTA - darunavir ethanolate tab 800 (base equiv) REBETOL - ribavirin soln 40 /ml RELENZA DISKHALER - zanamivir aero powder breath activated 5 /blister RESCRIPTOR - delavirdine mesylate tab 00 RESCRIPTOR - delavirdine mesylate tab 200 REYATAZ - atazanavir sulfate cap 50 (base equiv) REYATAZ - atazanavir sulfate cap 200 (base equiv) REYATAZ - atazanavir sulfate cap 00 (base equiv) REYATAZ - atazanavir sulfate oral powder packet 50 (base equiv) RIBASPHERE - ribavirin tab 400 RIBASPHERE - ribavirin tab 600 RIBASPHERE RIBAPAK - ribavirin tab 200 & ribavirin 400 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 400 & ribavirin 600 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 400 RIBASPHERE RIBAPAK - ribavirin tab 600 ribavirin cap 200 (Rebetol) ribavirin for inhal soln 6 gm (Virazole) BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 9

19 207 ribavirin tab 200 (Copegus) rimantadine hydrochloride tab 00 (Flumadine) SELZENTRY - maraviroc oral soln 20 /ml SELZENTRY - maraviroc tab 25 SELZENTRY - maraviroc tab 75 SELZENTRY - maraviroc tab 50 SELZENTRY - maraviroc tab 00 SOVALDI - sofosbuvir tab 400 stavudine cap 5 (Zerit) stavudine cap 20 (Zerit) stavudine cap 0 (Zerit) stavudine cap 40 (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab SUSTIVA - efavirenz cap 50 SUSTIVA - efavirenz cap 200 SUSTIVA - efavirenz tab 600 TAMIFLU - oseltamivir phosphate cap 0 (base equiv) TAMIFLU - oseltamivir phosphate cap 45 (base equiv) TAMIFLU - oseltamivir phosphate cap 75 (base equiv) TAMIFLU - oseltamivir phosphate for susp 6 /ml (base equiv) TECHNIVIE - ombitasvirparitaprevir-ritonavir tab tenofovir disoproxil fumarate tab 00 (Viread) TIVICAY - dolutegravir sodium tab 0 (base equiv) TIVICAY - dolutegravir sodium tab 25 (base equiv) TIVICAY - dolutegravir sodium tab 50 (base equiv) TRIUMEQ - abacavirdolutegravir-lamivudine tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab -200 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TYBOST - cobicistat tab 50 valacyclovir hcl tab 500 (Valtrex) valacyclovir hcl tab gm (Valtrex) VALCYTE - valganciclovir hcl for soln 50 /ml (base equiv) 2 BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 0

20 207 valganciclovir hcl for soln 50 /ml (base equiv) (Valcyte) valganciclovir hcl tab 450 (base equivalent) (Valcyte) VIDEX - didanosine for soln 2 gm VIDEX - didanosine for soln 4 gm VIEKIRA PAK - ombitasparitapre-riton & dasab tab pak & 250 VIEKIRA XR - dasab-ombitparitap-riton tab er 24hr VIRACEPT - nelfinavir mesylate tab 250 VIRACEPT - nelfinavir mesylate tab 625 VIRAMUNE - nevirapine susp 50 /5ml VIRAZOLE - ribavirin for inhal soln 6 gm VIREAD - tenofovir disoproxil fumarate oral powder 40 / gm VIREAD - tenofovir disoproxil fumarate tab 50 VIREAD - tenofovir disoproxil fumarate tab 200 VIREAD - tenofovir disoproxil fumarate tab 250 VIREAD - tenofovir disoproxil fumarate tab 00 VOSEVI - sofosbuvirvelpatasvir-voxilaprevir tab ZEPATIER - elbasvirgrazoprevir tab ZERIT - stavudine for oral soln /ml ZIAGEN - abacavir sulfate soln 20 /ml (base equiv) zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 00 ANTIMALARIALS atovaquone-proguanil hcl tab (Malarone) atovaquone-proguanil hcl tab (Malarone) CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 250 chloroquine phosphate tab 500 (Aralen) COARTEM - artemetherlumefantrine tab DARAPRIM - pyrimethamine tab 25 hydroxychloroquine sulfate tab 200 (Plaquenil) MEFLOQUINE HCL - mefloquine hcl tab 250 PRIMAQUINE PHOSPHATE - primaquine phosphate tab 26. quinine sulfate cap 24 (Qualaquin) ANTHELMINTICS ALBENZA - albendazole tab BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year)

21 207 BILTRICIDE - praziquantel tab 600 EMVERM - mebendazole chew tab 00 ivermectin tab (Stromectol) 2 ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 00 /5ml ALINIA - nitazoxanide tab 500 atovaquone susp 750 /5ml (Mepron) CAYSTON - aztreonam lysine for inhal soln 75 (base equivalent) clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 00 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 25 dapsone tab 00 IMPAVIDO - miltefosine cap 50 2 linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 75 (Flagyl) metronidazole tab 250 (Flagyl) metronidazole tab 500 (Flagyl) NEBUPENT - pentamidine isethionate for nebulization soln 00 PRIMSOL - trimethoprim hcl oral soln 50 /5ml (base equiv) SIVEXTRO - tedizolid phosphate tab 200 sulfamethoxazoletrimethoprim susp /5ml sulfamethoxazoletrimethoprim tab (Bactrim) sulfamethoxazoletrimethoprim tab (Bactrim ds) tinidazole tab 250 (Tindamax) tinidazole tab 500 (Tindamax) trimethoprim tab 00 vancomycin hcl cap 25 (Vancocin hcl) vancomycin hcl cap 250 (Vancocin hcl) XIFAXAN - rifaximin tab 200 XIFAXAN - rifaximin tab 550 BIOLOGICALS VACCINES AFLURIA PF influenza virus vaccine split pf susp pref syringe 0.5 ml A BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 2

22 207 AFLURIA QUADRIVALENT influenza virus vac split quadrivalent susp pref syr 0.5ml AFLURIA QUADRIVALENT influenza virus vaccine split quadrivalent im inj AFLURIA influenza virus vaccine split im susp ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) 20 mcg/ml FLUAD influenza vac type a&b surface ant adj susp pref syr 0.5 ml FLUARIX QUADRIVALENT influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUADRIVALENT influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUBLOK influenza virus vac recombinant hemagglutinin (ha) pf inj A A A A A A A A A A A FLUBLOK influenza virus vac recombinant hemagglutinin (ha) pf inj FLUCELVAX QUADRIVALENT 20 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVAX QUADRIVALENT 20 - influenza vac tissuecultured subunit quadrivalent im susp FLULAVAL QUADRIVALENT 20 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLULAVAL QUADRIVALENT 20 - influenza virus vaccine split quadrivalent im inj FLUMIST QUADRIVALENT - influenza virus vaccine live quadrivalent intranasal susp FLUVIRIN influenza vac type a&b surface antigen susp pref syr 0.5 ml FLUVIRIN influenza virus vaccine types a & b surface antigen im susp FLUVIRIN influenza vac type a&b surface antigen susp pref syr 0.5 ml FLUVIRIN influenza virus vaccine types a & b surface antigen im susp A A A A A A A A A A BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year)

23 207 FLUZONE HIGH-DOSE PF influenza virus vac split high-dose pf susp pref syr 0.5ml FLUZONE INTRADERMAL QUADR - influenza virus vac split quad intradermal pen 9 mcg/strain FLUZONE QUADRIVALENT influenza virus vac split quadrivalent susp pref syr 0.25 ml FLUZONE QUADRIVALENT influenza virus vac split quadrivalent susp pref syr 0.5ml FLUZONE QUADRIVALENT influenza virus vaccine split quadrivalent im inj FLUZONE QUADRIVALENT influenza virus vaccine split quadrivalent inj 0.5 ml IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj PNEUMOVAX 2 - pneumococcal vaccine polyvalent inj 25 mcg/0.5ml PNEUMOVAX 2/ DOSE - pneumococcal vaccine polyvalent inj 25 mcg/0.5ml PREVNAR - pneumococcal -valent conjugate vaccine inj RABAVERT - rabies vaccine, pcec for inj RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml A A A A A A A A A A A A RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 40 mcg/ml VIVOTIF - typhoid vaccine cap delayed release ZOSTAVAX - zoster vaccine live for subcutaneous susp 9400 unit/0.65ml TOXOIDS ADACEL - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml BOOSTRIX - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml DAPTACEL - diph, acellular pert & tet tox inj 5 lf-2 mcg-5 lf/0.5ml DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-0 lf/0.5ml KINRIX - diph-tetanus tox adacell pert & polio virus, ipv vac inj PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio ipv vac inj PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp A A A A A BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 4

24 207 QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml PASSIVE IMMUNIZING AGENTS HYQVIA - immun glob inj 2.5 gm/25ml-hyaluron inj 200 unt/.25 ml kit HYQVIA - immun glob inj 5 gm/50ml-hyaluron inj 400 unt/2.5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 800 unt/5 ml kit HYQVIA - immun glob inj 20 gm/200ml-hyaluron inj 600 unt/0 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 2400 unt/5 ml kit BIOLOGICALS MISC GRASTEK - timothy grass pollen allergen ext tab sl 2800 bau ORALAIR - grass mixed pollen ext tab sl 00 ir (index of reactivity) RAGWITEK - short ragweed pollen allergen extract tab sl 2 amb a -u ANTINEOPLASTIC AGENTS ANTINEOPLASTICS ACTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) AFINITOR - everolimus tab 2.5 AFINITOR - everolimus tab 5 AFINITOR - everolimus tab 7.5 AFINITOR - everolimus tab 0 AFINITOR DISPERZ - everolimus tab for oral susp 2 AFINITOR DISPERZ - everolimus tab for oral susp AFINITOR DISPERZ - everolimus tab for oral susp 5 ALECENSA - alectinib hcl cap 50 (base equivalent) ALKERAN - melphalan tab 2 ALUNBRIG - brigatinib tab initiation therapy pack 90 & 80 ALUNBRIG - brigatinib tab 0 ALUNBRIG - brigatinib tab 90 ALUNBRIG - brigatinib tab 80 anastrozole tab (Arimidex) bexarotene cap 75 (Targretin) 2 BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 5

25 207 bicalutamide tab 50 (Casodex) BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 400 BOSULIF - bosutinib tab 500 CABOMETYX - cabozantinib s-malate tab 20 (base equivalent) CABOMETYX - cabozantinib s-malate tab 40 (base equivalent) CABOMETYX - cabozantinib s-malate tab 60 (base equivalent) capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA - vandetanib tab 00 CAPRELSA - vandetanib tab 00 COMETRIQ - cabozantinib s- mal cap x 80 & x 20 (00 dose) kit COMETRIQ - cabozantinib s- mal cap x 80 & x 20 (40 dose) kit COMETRIQ - cabozantinib s- malate cap x 20 (60 dose) kit COTELLIC - cobimetinib fumarate tab 20 (base equivalent) CYCLOPHOSPHAMIDE - cyclophosphamide cap 25 CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 ELIGARD - leuprolide acetate ( month) for subcutaneous inj kit 22.5 ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit 0 ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 EMCYT - estramustine phosphate sodium cap 40 ERIVEDGE - vismodegib cap 50 ETOPOSIDE - etoposide cap 50 exemestane tab 25 (Aromasin) FARESTON - toremifene citrate tab 60 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) FARYDAK - panobinostat lactate cap 5 (base equivalent) FARYDAK - panobinostat lactate cap 20 (base equivalent) flutamide cap 25 BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 6

26 207 GILOTRIF - afatinib dimaleate tab 20 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 40 (base equivalent) GLEEVEC - imatinib mesylate tab 00 (base equivalent) GLEEVEC - imatinib mesylate tab 400 (base equivalent) GLEOSTINE - lomustine cap 5 GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 40 GLEOSTINE - lomustine cap 00 HEXALEN - altretamine cap 50 HYCAMTIN - topotecan hcl cap 0.25 (base equiv) HYCAMTIN - topotecan hcl cap (base equiv) hydroxyurea cap 500 (Hydrea) IBRANCE - palbociclib cap 75 IBRANCE - palbociclib cap 00 IBRANCE - palbociclib cap 25 ICLUSIG - ponatinib hcl tab 5 (base equiv) ICLUSIG - ponatinib hcl tab 45 (base equiv) IDHIFA - enasidenib mesylate tab 50 (base equivalent) IDHIFA - enasidenib mesylate tab 00 (base equivalent) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 400 (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 40 INLYTA - axitinib tab INLYTA - axitinib tab 5 INTRON A - interferon alfa-2b inj unit/ml INTRON A - interferon alfa-2b inj unit/ml INTRON A - interferon alfa-2b for inj unit INTRON A - interferon alfa-2b for inj unit INTRON A - interferon alfa-2b for inj unit IRESSA - gefitinib tab 250 JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 20 (base equivalent) JAKAFI - ruxolitinib phosphate tab 25 (base equivalent) KISQALI - ribociclib succinate tab 200 (base equiv) BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 7

27 207 KISQALI FEMARA 200 DOSE - ribociclib tab 200 & letrozole tab 2.5 therapy pack KISQALI FEMARA 400 DOSE - ribociclib tab 200 & letrozole tab 2.5 therapy pack KISQALI FEMARA 600 DOSE - ribociclib tab 200 & letrozole tab 2.5 therapy pack LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 (0 daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 (2) (8 daily dose) LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 0 (2) (20 daily dose) LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 0 (2) & 4 (24 daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4 (2) (8 daily dose) letrozole tab 2.5 (Femara) LEUCOVORIN CALCIUM - leucovorin calcium tab 0 2 LEUCOVORIN CALCIUM - 2 leucovorin calcium tab 5 leucovorin calcium tab 5 leucovorin calcium tab 25 LEUKERAN - chlorambucil tab 2 LONSURF - trifluridine-tipiracil tab LONSURF - trifluridine-tipiracil tab LYNPARZA - olaparib cap 50 LYNPARZA - olaparib tab 00 LYNPARZA - olaparib tab 50 LYSODREN - mitotane tab 500 MATULANE - procarbazine hcl cap 50 megestrol acetate susp 40 /ml (Megace oral) megestrol acetate tab 20 megestrol acetate tab 40 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 (base equivalent) MEKINIST - trametinib dimethyl sulfoxide tab 2 (base equivalent) melphalan tab 2 (Alkeran) mercaptopurine tab 50 (Purinethol) MESNEX - mesna tab BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 8

28 207 METHOTREXATE SODIUM - methotrexate sodium inj 250 /0ml (25 /ml) methotrexate sodium for inj gm methotrexate sodium inj pf 50 /2ml (25 /ml) methotrexate sodium inj pf 00 /4ml (25 /ml) methotrexate sodium inj pf 200 /8ml (25 /ml) methotrexate sodium inj pf 250 /0ml (25 /ml) methotrexate sodium inj pf 000 /40ml (25 /ml) methotrexate sodium inj 50 /2ml (25 /ml) methotrexate sodium tab 2.5 (base equiv) MYLERAN - busulfan tab 2 2 NEXAVAR - sorafenib tosylate tab 200 (base equivalent) NILANDRON - nilutamide tab 50 nilutamide tab 50 (Nilandron) NINLARO - ixazomib citrate cap 2. (base equivalent) NINLARO - ixazomib citrate cap (base equivalent) NINLARO - ixazomib citrate cap 4 (base equivalent) ODOMZO - sonidegib phosphate cap 200 (base equivalent) POMALYST - pomalidomide cap POMALYST - pomalidomide cap 2 POMALYST - pomalidomide cap POMALYST - pomalidomide cap 4 PURIXAN - mercaptopurine susp 2000 /00ml (20 /ml) RUBR - rucaparib camsylate tab 200 (base equivalent) RUBR - rucaparib camsylate tab 250 (base equivalent) RUBR - rucaparib camsylate tab 00 (base equivalent) RYDAPT - midostaurin cap 25 SOLTAMOX - tamoxifen citrate oral soln 0 /5ml (base equivalent) SPRYCEL - dasatinib tab 20 SPRYCEL - dasatinib tab 50 SPRYCEL - dasatinib tab 70 SPRYCEL - dasatinib tab 80 SPRYCEL - dasatinib tab 00 SPRYCEL - dasatinib tab 40 BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 9

29 207 STIVARGA - regorafenib tab 40 SUTENT - sunitinib malate cap 2.5 (base equivalent) SUTENT - sunitinib malate cap 25 (base equivalent) SUTENT - sunitinib malate cap 7.5 (base equivalent) SUTENT - sunitinib malate cap 50 (base equivalent) SYLATRON - peginterferon alfa-2b for inj kit 296 mcg SYLATRON - peginterferon alfa-2b for inj kit 444 mcg SYLATRON - peginterferon alfa-2b for inj kit 888 mcg TABLOID - thioguanine tab 40 TAFINLAR - dabrafenib mesylate cap 50 (base equivalent) TAFINLAR - dabrafenib mesylate cap 75 (base equivalent) TAGRISSO - osimertinib mesylate tab 40 (base equivalent) TAGRISSO - osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) tamoxifen citrate tab 20 (base equivalent) TARCEVA - erlotinib hcl tab 25 (base equivalent) TARCEVA - erlotinib hcl tab 00 (base equivalent) TARCEVA - erlotinib hcl tab 50 (base equivalent) TASIGNA - nilotinib hcl cap 50 (base equivalent) TASIGNA - nilotinib hcl cap 200 (base equivalent) temozolomide cap 5 (Temodar) temozolomide cap 20 (Temodar) temozolomide cap 00 (Temodar) temozolomide cap 40 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 250 (Temodar) tretinoin cap 0 TREXALL - methotrexate sodium tab 5 (base equiv) TREXALL - methotrexate sodium tab 7.5 (base equiv) TREXALL - methotrexate sodium tab 0 (base equiv) TREXALL - methotrexate sodium tab 5 (base equiv) TYKERB - lapatinib ditosylate tab 250 (base equiv) VOTRIENT - pazopanib hcl tab 200 (base equiv) XALKORI - crizotinib cap BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 20

30 207 XALKORI - crizotinib cap 250 XTANDI - enzalutamide cap 40 ZEJULA - niraparib tosylate cap 00 (base equivalent) ZELBORAF - vemurafenib tab 240 ZOLINZA - vorinostat cap 00 ZYDELIG - idelalisib tab 00 ZYDELIG - idelalisib tab 50 ZYKADIA - ceritinib cap 50 ZYTIGA - abiraterone acetate tab 250 ZYTIGA - abiraterone acetate tab 500 ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap (Entocort ec) CORTISONE ACETATE - cortisone acetate tab 25 DEXAMETHASONE - dexamethasone soln 0.5 /5ml DEXAMETHASONE - dexamethasone tab DEXAMETHASONE - dexamethasone tab 2 dexamethasone elixir 0.5 /5ml 2 DEXAMETHASONE INTENSOL - dexamethasone conc /ml dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab.5 dexamethasone tab 4 dexamethasone tab 6 fludrocortisone acetate tab 0. hydrocortisone tab 5 (Cortef) hydrocortisone tab 0 (Cortef) hydrocortisone tab 20 (Cortef) JTT PHYSICIANS KIT - triamcinolone inj 40 /ml & lidocaine % & ammonia inh kit MEDROL - methylprednisolone tab 2 methylprednisolone tab therapy pack 4 (2) (Medrol dosepak) methylprednisolone tab 4 (Medrol) methylprednisolone tab 8 (Medrol) methylprednisolone tab 6 (Medrol) methylprednisolone tab 2 (Medrol) MILLIPRED - prednisolone sod phosphate oral soln 0 /5ml (base equiv) MILLIPRED - prednisolone tab 5 BCBSTX Health Insurance Marketplace Tier Drug List March (207 Plan Year) 2