Blue Cross and Blue Shield of Minnesota BasicRx Individual, Small Group

Transcription

1 January 09 Blue Cross and Blue Shield of Minnesota BasicRx Individual, Small Group Please consider talking to your doctor about prescribing formulary 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 formulary is regularly updated. Please visit for the most up-to-date formulary. Contents Introduction... I Pharmacy and Therapeutics (P&T) Committee and Coverage Committee....I Formulary guidelines... II Formulary addition request... II Generic drugs... II Frequently asked questions about generics... II How to use the drug list... III Benefit programs... IV Managing drug usage... VI Key... VIII Therapeutic Class Drug List nti-infective gents... Biologicals... 8 ntineoplastic gents... 0 Endocrine and Metabolic Drugs... 5 Cardiovascular gents... 5 Respiratory gents... 5 Gastrointestinal gents... 8 Genitourinary gents Central Nervous System Drugs... 4 nalgesics and nesthetics... 5 Neuromuscular Drugs Nutritional Products... 6 Hematological gents... 6 Topical Products Miscellaneous Products Index... 9 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. 746-Q MN HIM Prime Therapeutics 0/9

2 Introduction Blue Cross and Blue Shield of Minnesota and Blue Plus are pleased to present the BCBSMN BasicRx Individual and Small Group drug formulary (drug list). Our goal is to give members access to safe and cost-effective prescription drugs by maximizing the use of generic drugs. Brand name drugs are typically included on the BCBSMN BasicRx Individual and Small Group formulary only when a generic drug is not available to treat a specific medical condition or when the brand name drug offers an advantage over generic drugs. This BCBSMN BasicRx Individual and Small Group list shows prescription drug products in tiers. Each drug is placed into one of four member payment tiers: Tier, Tier, Tier, and Tier 4. Blue Cross may choose to not add a drug to formulary for reasons including safety or effectiveness, or because a similar, more cost-effective drug is already on the formulary. New drugs are not covered until reviewed and approved for inclusion by the Pharmacy and Therapeutics (P&T) Committee and Coverage Committee. Blue Cross encourages providers to prescribe preferred drugs. Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. Generally, if a drug is not listed on the formulary it is not covered. For example, certain topical androgens, e.g. Testim, are not covered. Drugs that are not FD-approved for self-administration may be available through your medical benefit. There are various types of pharmacy benefit programs. To understand which program you have, please refer to your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement or call the number on your member ID card for more information. Pharmacy and Therapeutics (P&T) Committee and Coverage Committee The Blue Cross Coverage Committee selects drugs for this formulary based on recommendations of an independent Pharmacy and Therapeutics (P&T) Committee that includes practicing physicians and pharmacists. Decisions to add or remove drugs from the BCBSMN BasicRx Individual and Small Group formulary are based on the drug s safety, effectiveness, uniqueness, and cost. The P&T Committee and Coverage Committee meet at least quarterly. ll drugs are reviewed each year as required by the National Committee on Quality ssurance (NCQ) standards. You can find recent changes and the current version of the formulary at bluecrossmnonline.com. BCBSMN BasicRx Individual, Small Group January 09. I

3 Formulary guidelines The requirement of P&T and Coverage Committee review is a precondition of Blue Cross coverage and: pplies in addition to all other conditions and terms stated in Blue Cross contracts and stated herein; and pplies to medications and medical devices when administered in any manner that is approved by the U. S. Food and Drug dministration (FD); and pplies to approved medications legally prescribed and select medical devices legally used when administered in any manner that is not mentioned in the labeling approved by the FD (referred to as an offlabel use). Use of a medication or medical device for an indication, dosage form, dose regimen, population, or other use parameter not mentioned in the approved labeling is considered to be an off-label use. These guidelines in no way imply that members should not receive specific services based on the recommendation of the provider. These guidelines govern coverage and not clinical practices. Providers are responsible for giving medical advice and treating members. Members with specific health care needs should consult an appropriate health care provider. Members and providers have the right to appeal coverage decisions. These rights are explained in member and provider plan documents. Members with questions about appeal rights should call customer service at the number on the back of their member ID card. Providers can call provider services at or toll free at This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. ll products and coverage guidelines are subject to applicable laws and regulations. Member or provider coverage is contingent on all the applicable terms, conditions, limitations and exclusions of member or provider plan documents Formulary addition request ny health care provider may request in writing that the Blue Cross Coverage Committee consider adding or deleting a drug from the formulary. ll formulary requests are brought before the Coverage Committee. Generic drugs Blue Cross encourages use of generic drugs as a way to provide high-quality, cost-effective care. Generic drugs are safe, effective and they may cost less than brand name drugs. Members will likely pay a lower copayment or coinsurance for a generic drug. Frequently asked questions about generics re generics as good as brand name drugs? Both brand name and generic drugs must be approved by the FD. Generic drugs meet the same high standards as brand name drugs. Why should I take generics rather than brand name drugs? We must all do our part to make health care affordable. One way is to be wise consumers of drugs. Generics provide the same effectiveness and safety as their brand name counterparts, but are often lower in cost. This typically occurs when competition among several manufacturers who produce the generic drug, results in lower prices for it. Lower costs generally mean lower copayments for members. Generics also save money for your health plan, so it can help keep insurance premiums as low as possible. How can I take advantage of lower-cost generics? sk your pharmacist for a generic whenever available. lso, talk with your doctor or other provider about prescribing generic drugs. Most drug classes include some generic drugs. BCBSMN BasicRx Individual, Small Group January 09. II

4 How to use this list The drug list is organized into broad categories (e.g., HORMONES, DIBETES ND RELTED DRUGS). Please use the drug search function to find current information for drugs on the medication list. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic drugs have no reference brand. Example: imatinib (Gleevec) Brand drugs are shown in capital letters followed by the generic name. Example: JNUVI- sitagliptin The indicators in the columns to the right of the drug names displays information about whether that drug is a specialty drug, requires prior authorization, quantity limits, step therapy, or is available at $0 cost share for eligible members.. - Each drug is placed into one of four member payment tiers: Tier, Tier, Tier, and Tier a dot present in this column indicates this is a specialty drug. Note: dditional information about specialty drugs can be found in this document under the topic Benefit Programs.. (P)- Some drugs require prior authorization because of their high potential for misuse or overuse. Coverage may be approved after certain criteria are met. pproval is required for claims to process at network pharmacies. If an indicator is present in this column, then the P program noted is applied to your benefit. 4. (QL)- Certain drugs have quantity limits to encourage appropriate drug usage, enhance drug therapy and reduce costs. The quantity limit is the maximum quantity that can be dispensed over a given period of time. If an indicator is present in this column, then the QL program noted is applied to your benefit. 5. (ST)- Step therapy programs help manage the cost of expensive drugs by redirecting members to safe, effective and less expensive alternatives. If an indicator is present in this column, then the ST program noted is applied to your benefit. 6. Preventive: Medicines marked in the column are applicable to the ffordable Care ct coverage of preventive services. These products are covered at zero dollar cost share, when meeting the conditions outlined under the regulation. Examples of categories that may be subject to $0 cost share include aspirin, bowel preparation for colonoscopy, breast cancer preventive, FD approved contraceptive methods, fluoride supplements, folic acid supplements, iron supplements, lipid lowering medications (statins), tobacco cessation products, and select vaccines. Call the customer service number on the back of your ID card to find out if the drug is available over-the-counter or is covered under your medical benefit. Compounded prescriptions Compounded prescriptions contain two or more drugs mixed together. The end product cannot be available in an equivalent commercial form. The ingredients must be FD-approved prescription drugs. Compounded prescriptions are processed according to member benefits. Injectable drugs Self-administered injectable drugs are generally part of the pharmacy benefit and may be included on the formulary. Injectable drugs are processed according to the member s benefits. Injectable drugs that are not considered self-injectable, or that need to be administered by a health care professional may be covered only under the member s medical benefit. BCBSMN BasicRx Individual, Small Group January 09. III

5 Benefit programs 9dayRx Blue Cross has an optional 9dayRx program. Members with this benefit may be able to receive up to a 90-day supply of drugs. In addition to being able to obtain up to a 9-day supply of drugs through our mail order pharmacy you may be able to receive up to a 9-day supply of drugs through a participating retail pharmacy. Please refer to your plan documents for complete coverage details. Retail pharmacy vaccine program Blue Cross has an optional vaccine pharmacy program for flu, pneumonia, shingles, diphtheria tetanus combinations, human papillomavirus (HPV), and meningitis vaccines. Members with this benefit can simply present their health plan member ID card when visiting a participating pharmacy. The cost share will be based on their pharmacy coverage for this benefit. Members can go to MyPrime.com to locate network pharmacies that administer approved vaccines for Blue Cross and Blue Shield of Minnesota members. Please note that age limitations, advance registration or other requirements may apply. The availability of each vaccine may vary by individual pharmacy or location. For your convenience, you may contact the pharmacy in advance if you have questions or to make sure these services are available at a particular location. drugs Blue Cross has an optional specialty pharmacy network. Members with this benefit must obtain their specialty drugs from an in-network specialty provider or they will pay 00 percent of the drug cost. The specialty drug vendors and drugs covered by this specialty drug benefit are listed at bluecrossmn.com under Shop Plan Click on Prescription Drugs. There you ll find general information about Prescription Drug Programs. On the Prescription Drugs page, click on See all drug Programs then click on Learn more about specialty BCBSMN BasicRx Individual, Small Group January 09. IV

6 ffordable Care ct Bowel Prep for Colonoscopy Select bowel preparation drugs will be covered without cost share, in accordance with each member s specific benefit plan. ffordable Care ct Breast Cancer Preventive Drugs Select Breast Cancer drugs when prescribed for prevention of breast cancer for men and women at elevated risk will be covered without cost share in accordance with each member s specific benefit plan. The following select Breast Cancer drugs will be available at $0 cost to eligible members with a prescription. tamoxifen, for ages 5 and older raloxifene, for ages 5 and older ffordable Care ct Contraceptives Select contraceptives will be covered without cost share for women in accordance with each member s specific benefit plan. The following select contraceptive medications will be available at $0 cost to eligible members: Barrier Method Types > Cervical Caps > Diaphragms > Female Condom > Spermicide > Sponge Selected Emergency Contraceptives Selected Injectables Hormonal Methods > NUVRING > Selected oral combination triphasic contraceptives > Selected oral extended cycle/continuous use contraceptives > Selected oral progestin contraceptives > Patch For a specific list of contraceptives covered without cost share for eligible members, go to the Forms section under myprime.com. ffordable Care ct Lipid Lowering (Statin) Preventive Drugs Starting//8, select low-moderate dose statin drugs will be covered without cost share for eligible members, in accordance with each member s specific benefit plan. Low to moderate intensity statins are recommended for primary prevention of cardiovascular disease in adults who meet the following criteria: a) Between the ages of b) No previous history of cardiovascular disease c) One or more risk factors for cardiovascular disease, such as dyslipidemia, diabetes, hypertension, or smoking d) Calculated 0-year cardiovascular event risk of 0% or greater. The following select statin drugs will be available at $0 cost to eligible members with a prescription. lovastatin 0 mg, 40 mg pravastatin 0 mg, 0 mg, 40 mg, 80 mg simvastatin 0 mg, 0 mg, 40 mg The following select OTC supplements will be available at $0 cost to eligible members with a prescription. spirin 8 mg (OTC) Folic acid- containing mg (OTC) Iron- children ages 6- months and women ages -64 BCBSMN BasicRx Individual, Small Group January 09. V

7 The following products will be available at $0 cost to eligible members with a prescription Select generic fluoride products- for children ages 6 months-6 years sodium fluoride cream, gel, oral rinse, paste sodium fluoride/potassium nitrate stannous fluoride ffordable Care ct Tobacco Cessation Select tobacco cessation will be covered without cost share in accordance with each member s specific benefit plan. The following select tobacco cessation products will be available at $0 cost to eligible members with a prescription. bupropion ext-release (Zyban) CHNTIX nicotine gum, lozenge, kit, patch NICOTROL NS NICOTROL Inhaler Managing drug usage You, your prescribing health care provider, or your authorized representative, can ask for a Drug List coverage exception if your drug is not on (or is being removed from) the Drug List (also known as a formulary), or the drug required as part of a prior authorization, step therapy or quantity limits has been found to be (or likely to be) not right for you or does not work as well in treating your condition. Steps on how a prescriber may request a Coverage Exception: prescriber may obtain a Minnesota Uniform Form for Prescription Drug Request & Formulary Exceptions online at providers.bluecrossmnonline.com in the Forms section. The prescriber can also obtain the form by calling provider services at or Submit the completed request form to the following address or fax: Prime Therapeutics Clinical Review Department 05 Corporate Center Drive Eagan, MN 55 Fax number: Some drugs require prior authorization because of their high potential for misuse or overuse. Coverage may be approved after certain criteria are met. pproval is required for claims to process at network pharmacies. Policies regarding the covered uses of drugs and drug classes requiring prior authorization can be found at bluecrossmnonline.com. For more information, call the number on the back of your member ID card. Providers can call provider services at or toll free at For the medications listed in this document, if a prior authorization is commonly required, it will generally be noted next to the medication with a dot under the prior authorization column. There may be prior authorization requirements on additional medications beyond those noted in this document. Steps on how a prescriber may request a : For an easy way to submit P requests for your patients at no additional cost, consider using an electronic prior authorization tool, through CoverMyMeds. CoverMyMeds is an online submission method for doctors and pharmacists to submit P requests to our pharmacy benefit manager. It eliminates traditional paper forms and faxes and greatly reduces follow-up calls. To get started, go to CoverMyMeds.com and click on the link to Create an ccount. BCBSMN BasicRx Individual, Small Group January 09. VI

8 lternatively, a prescriber may obtain a Minnesota Uniform Form for Prescription Drug Request & Formulary Exceptions online at providers.bluecrossmnonline.com in the Forms section. The prescriber can also obtain the form by calling provider services at or Submit the completed request form along with relevant medical records to the following address or fax: Prime Therapeutics Clinical Review Department 05 Corporate Center Drive Eagan, MN 55 Fax number: Step therapy programs help manage the cost of expensive drugs by redirecting members to safe, effective and less expensive alternatives. Selected drugs may be subject to step therapy. If a member does not meet the criteria in the automated review of the member s claims, their doctor can submit a request for review. For the 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. There may be step therapy programs on additional medications beyond those noted in this document. Steps on how a prescriber may request a Step prescriber may obtain a Request for Prescription Drug Coverage Exception request form online at myprime.com in the Forms section. The prescriber can also obtain the form by calling provider services at or Submit the completed request form to the following address or fax: Prime Therapeutics Clinical Review Department 05 Corporate Center Drive Eagan, MN 55 Fax number: Certain drugs have quantity limits to encourage appropriate drug usage, enhance drug therapy and reduce costs. The quantity limit is the maximum quantity that can be dispensed over a given period of time. For the medications listed in this document, it will generally be noted next to the medication with a dot under the quantity limit column. There may be quantity limit programs on additional medications beyond those noted in this document. Steps on how a prescriber may request a Quantity Limit exception: prescriber may obtain a Request for Prescription Drug Coverage Exception request form online at myprime.com in the Forms section. The prescriber can also obtain the form by calling provider services at or Submit the completed request form to the following address or fax: Prime Therapeutics Clinical Review Department 05 Corporate Center Drive Eagan, MN 55 Fax number: BCBSMN BasicRx Individual, Small Group January 09. VII

9 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... ophthalmic osm... osmotic release powd... powder sa...sustained action sl... sublingual soln... solution sr... sustained release suppos... suppositories susp... suspension tab... tablets td... transdermal BCBSMN BasicRx Individual, Small Group January 09. VIII

10 NOTICE OF NONDISCRIMINTION PRCTICES Effective July 8, 06 Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or gender. Blue Cross does not exclude people or treat them differently because of race, color, national origin, age, disability, or gender. Blue Cross provides resources to access information in alternative formats and languages: uxiliary aids and services, such as qualified interpreters and written information available in other formats, are available free of charge to people with disabilities to assist in communicating with us. Language services, such as qualified interpreters and information written in other languages, are available free of charge to people whose primary language is not English. If you need these services, contact us at or by using the telephone number on the back of your member identification card. TTY users call 7. If you believe that Blue Cross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or gender, you can file a grievance with the Nondiscrimination Civil Rights Coordinator by at: Civil.Rights.Coord@bluecrossmn.com by mail at: Nondiscrimination Civil Rights Coordinator Blue Cross and Blue Shield of Minnesota and Blue Plus M495 PO Box Eagan, MN or by phone at: Grievance forms are available by contacting us at the contacts listed above, by calling or by using the telephone number on the back of your member identification card. TTY users call 7. If you need help filing a grievance, assistance is available by contacting us at the numbers listed above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at: by phone at: or (TDD) or by mail at: U.S. Department of Health and Human Services 00 Independence venue SW Room 509F HHH Building Washington, DC 00 Complaint forms are available at image_0006_ndl_portrait (09/6) Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield ssociation. F077R0 (/7)

11 This information is available in other languages. Free language assistance services are available by calling the toll free number below. For TTY, call 7. Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al Para TTY, llame al 7. Yog tias koj hais lus Hmoob, muaj kev pab txhais lus pub dawb rau koj. Hu rau Rau TTY, hu rau 7. Haddii aad ku hadasho Soomaali, adigu waxaad heli kartaa caawimo luqad lacag la'aan ah. Wac Markay tahay dad maqalku ku adag yahay (TTY), wac 7. erh>uwdrundusdm'd;< w>u[h.erusdmw>rrpxruvdwz.m.vdriud; vx TTY t*d><ud; 7 wuh>i إذا كنت تتحدث العربية تتوفر لك خدمات المساعدة اللغوية المجانية. اتصل بالرقم للھاتف النصي اتصل بالرقم. 7 Nếu quý vị nói Tiếng Việt, có sẵn các dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Gọi số Người dùng TTY xin gọi 7. faan Oromoo dubbattu yoo ta e, tajaajila gargaarsa afaan hiikuu kaffaltii malee. rgachuuf bilbilaa. TTY dhaaf, 7 bilbilaa. 如果您說中文, 我們可以為您提供免費的語言協助服務 請撥打 聽語障專 (TTY), 請撥打 7 Если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Звоните Для использования телефонного аппарата с текстовым выходом звоните 7. Si vous parlez français, des services d assistance linguistique sont disponibles gratuitement. ppelez le Pour les personnes malentendantes, appelez le 7. አማርኛ የሚናገሩ ከሆነ ነጻ የቋንቋ አገልግሎት እርዳ አለሎት በ ይደውሉ ለ TTY በ 7 한국어를사용하시는경우, 무료언어지원서비스가제공됩니다 으로전화하십시오. TTY 사용자는 7 로전화하십시오. ຖ າເຈ າເວ າພາສາລາວໄດ, ມການບລການຊວຍເຫ ອພາສາໃຫເຈ າຟຣ. ໃຫໂທຫາ ສາລ ບ. TTY, ໃຫ ໂທຫາ 7. Kung nagsasalita kayo ng Tagalog, mayroon kayong magagamit na libreng tulong na mga serbisyo sa wika. Tumawag sa Para sa TTY, tumawag sa 7. Wenn Sie Deutsch sprechen, steht Ihnen fremdsprachliche Unterstützung zur Verfügung. Wählen Sie Für TTY wählen Sie 7. របស ន បអកនយ យភ ស ខរមន ន ម អកអ ចរកប ន សវ ជនយភ ស ឥតគត ថ ន ល ទរសពមក លខ ទ សរម ប TTY សមទរសពមក លខ ទ 7 Din4 k'ehj7 yn7[t'i'go saad bee yt'i' 47 t'j77k'e bee n7k'a'doowo[go 47 n'ahoot'i'. Koj8 47 b44sh bee hod77lnih TTY biniiy4go 47 7 j8 b44sh bee hod77lnih. image_000r0_general_portrait (0/7)

12 09 NTI-INFECTIVE GENTS PENICILLINS MOXICILLIN - amoxicillin (trihydrate) chew tab 50 mg amoxicillin (trihydrate) cap 50 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) for susp 5 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) for susp 50 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml (ugmentin) amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml (ugmentin es-600) amoxicillin & k clavulanate tab er hr mg (ugmentin xr) amoxicillin & k clavulanate tab 50-5 mg amoxicillin & k clavulanate tab mg (ugmentin) amoxicillin & k clavulanate tab mg (ugmentin) MOXICILLIN/CLVULNTE P - amoxicillin & k clavulanate chew tab mg MOXICILLIN/CLVULNTE P - amoxicillin & k clavulanate chew tab mg MPICILLIN - ampicillin cap 500 mg dicloxacillin sodium cap 50 mg dicloxacillin sodium cap 500 mg PENICILLIN V POTSSIUM - penicillin v potassium for soln 5 mg/5ml PENICILLIN V POTSSIUM - penicillin v potassium for soln 50 mg/5ml penicillin v potassium tab 50 mg penicillin v potassium tab 500 mg CEPHLOSPORINS cefaclor cap 50 mg cefaclor cap 500 mg cefadroxil cap 500 mg cefadroxil for susp 50 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab gm cefdinir cap 00 mg cefdinir for susp 5 mg/5ml cefdinir for susp 50 mg/5ml cefixime for susp 00 mg/5ml (Suprax) cefixime for susp 00 mg/5ml (Suprax) cefprozil for susp 5 mg/5ml cefprozil for susp 50 mg/5ml cefprozil tab 50 mg cefprozil tab 500 mg cefuroxime axetil tab 50 mg cefuroxime axetil tab 500 mg (Ceftin) cephalexin cap 50 mg (Keflex) BCBSM 4T BasicRx Individual, Small Group

13 09 cephalexin cap 500 mg (Keflex) cephalexin cap 750 mg (Keflex) cephalexin for susp 5 mg/5ml cephalexin for susp 50 mg/5ml MCROLIDES ZITHROMYCIN - azithromycin powd pack for susp gm azithromycin for susp 00 mg/5ml (Zithromax) azithromycin for susp 00 mg/5ml (Zithromax) azithromycin tab 50 mg (Zithromax) azithromycin tab 500 mg (Zithromax) azithromycin tab 600 mg (Zithromax) CLRITHROMYCIN - clarithromycin for susp 5 mg/5ml CLRITHROMYCIN - clarithromycin for susp 50 mg/5ml clarithromycin tab er 4hr 500 mg clarithromycin tab 50 mg (Biaxin) clarithromycin tab 500 mg (Biaxin) DIFICID - fidaxomicin tab 00 mg TETRCYCLINES demeclocycline hcl tab 50 mg demeclocycline hcl tab 00 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 00 mg (Vibramycin) doxycycline hyclate tab 0 mg doxycycline hyclate tab 00 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 75 mg (Monodox) doxycycline monohydrate cap 00 mg (Monodox) doxycycline monohydrate cap 50 mg (doxa) doxycycline monohydrate for susp 5 mg/5ml (Vibramycin) doxycycline monohydrate tab 50 mg (doxa) doxycycline monohydrate tab 75 mg (doxa) doxycycline monohydrate tab 00 mg (doxa pak /00) doxycycline monohydrate tab 50 mg (doxa pak /50) minocycline hcl cap 50 mg (Minocin) minocycline hcl cap 75 mg (Minocin) minocycline hcl cap 00 mg (Minocin) minocycline hcl tab 50 mg minocycline hcl tab 75 mg minocycline hcl tab 00 mg tetracycline hcl cap 50 mg (Tetracycline hcl) tetracycline hcl cap 500 mg (Tetracycline hcl) FLUOROQUINOLONES BXDEL - delafloxacin meglumine tab 450 mg (base equiv) CIPRO - ciprofloxacin for oral susp 50 mg/5ml (5%) (5 gm/00ml) CIPROFLOXCIN ER - ciprofloxacin-ciprofloxacin hcl tab er 4hr 500 mg (base eq) CIPROFLOXCIN ER - ciprofloxacin-ciprofloxacin hcl tab er 4hr 000 mg(base eq) ciprofloxacin for oral susp 500 mg/5ml (0%) (0 gm/00ml) (Cipro) ciprofloxacin hcl tab 50 mg (base equiv) (Cipro) BCBSM 4T BasicRx Individual, Small Group

14 09 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) ciprofloxacin hcl tab 750 mg (base equiv) levofloxacin oral soln 5 mg/ml levofloxacin tab 50 mg (Levaquin) levofloxacin tab 500 mg (Levaquin) levofloxacin tab 750 mg (Levaquin) moxifloxacin hcl tab 400 mg (base equiv) (velox) OFLOXCIN - ofloxacin tab 00 mg ofloxacin tab 400 mg MINOGLYCOSIDES BETHKIS - tobramycin nebu soln 00 mg/4ml neomycin sulfate tab 500 mg paromomycin sulfate cap 50 mg TOBI PODHLER - tobramycin inhal cap 8 mg tobramycin nebu soln 00 mg/5ml (Tobi) SULFONMIDES SULFDIZINE - sulfadiazine tab 500 mg NTIMYCOBCTERIL GENTS ethambutol hcl tab 00 mg (Myambutol) ethambutol hcl tab 400 mg (Myambutol) isoniazid tab 00 mg isoniazid tab 00 mg PRIFTIN - rifapentine tab 50 mg pyrazinamide tab 500 mg rifabutin cap 50 mg (Mycobutin) RIFMTE - isoniazid & rifampin cap mg rifampin cap 50 mg (Rifadin) rifampin cap 00 mg (Rifadin) NTIFUNGLS fluconazole for susp 0 mg/ml (Diflucan) fluconazole for susp 40 mg/ml (Diflucan) fluconazole tab 50 mg (Diflucan) fluconazole tab 00 mg (Diflucan) fluconazole tab 50 mg (Diflucan) fluconazole tab 00 mg (Diflucan) flucytosine cap 50 mg (ncobon) flucytosine cap 500 mg (ncobon) griseofulvin microsize susp 5 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 5 mg (Gris-peg) griseofulvin ultramicrosize tab 50 mg (Gris-peg) itraconazole cap 00 mg (Sporanox) NOXFIL - posaconazole susp 40 mg/ml NOXFIL - posaconazole tab delayed release 00 mg nystatin tab unit terbinafine hcl tab 50 mg (Lamisil) voriconazole for susp 40 mg/ml (Vfend) voriconazole tab 50 mg (Vfend) voriconazole tab 00 mg (Vfend) NTIVIRLS abacavir sulfate soln 0 mg/ml (base equiv) (Ziagen) abacavir sulfate tab 00 mg (base equiv) (Ziagen) BCBSM 4T BasicRx Individual, Small Group

15 09 abacavir sulfate-lamivudine tab mg (Epzicom) abacavir sulfate-lamivudinezidovudine tab mg (Trizivir) acyclovir cap 00 mg (Zovirax) acyclovir susp 00 mg/5ml (Zovirax) acyclovir tab 400 mg (Zovirax) acyclovir tab 800 mg (Zovirax) adefovir dipivoxil tab 0 mg (Hepsera) PTIVUS - tipranavir cap 50 mg PTIVUS - tipranavir oral soln 00 mg/ml atazanavir sulfate cap 50 mg (base equiv) (Reyataz) atazanavir sulfate cap 00 mg (base equiv) (Reyataz) atazanavir sulfate cap 00 mg (base equiv) (Reyataz) TRIPL - efavirenz-emtricitabinetenofovir df tab mg BRCLUDE - entecavir oral soln 0.05 mg/ml BIKTRVY - bictegraviremtricitabine-tenofovir af tab mg CIMDUO - lamivudine-tenofovir disoproxil fumarate tab mg COMPLER - emtricitabinerilpivirine-tenofovir df tab mg CRIXIVN - indinavir sulfate cap 00 mg CRIXIVN - indinavir sulfate cap 400 mg DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab 00-5 mg didanosine delayed release capsule 00 mg (Videx ec) didanosine delayed release capsule 50 mg (Videx ec) didanosine delayed release capsule 400 mg (Videx ec) EDURNT - rilpivirine hcl tab 5 mg (base equivalent) efavirenz cap 50 mg (Sustiva) efavirenz cap 00 mg (Sustiva) efavirenz tab 600 mg (Sustiva) EMTRIV - emtricitabine caps 00 mg EMTRIV - emtricitabine soln 0 mg/ ml entecavir tab 0.5 mg (Baraclude) entecavir tab mg (Baraclude) EPCLUS - sofosbuvir-velpatasvir tab mg EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) EVOTZ - atazanavir sulfatecobicistat tab mg (base equiv) famciclovir tab 5 mg (Famvir) famciclovir tab 50 mg (Famvir) famciclovir tab 500 mg (Famvir) fosamprenavir calcium tab 700 mg (base equiv) (Lexiva) FUZEON - enfuvirtide for inj 90 mg GENVOY - elvitegrav-cobicemtricitab-tenofov af tab mg HRVONI - ledipasvir-sofosbuvir tab mg INTELENCE - etravirine tab 5 mg INTELENCE - etravirine tab 00 mg INTELENCE - etravirine tab 00 mg INVIRSE - saquinavir mesylate cap 00 mg BCBSM 4T BasicRx Individual, Small Group 4

16 09 INVIRSE - saquinavir mesylate tab 500 mg ISENTRESS - raltegravir potassium chew tab 5 mg (base equiv) ISENTRESS - raltegravir potassium chew tab 00 mg (base equiv) ISENTRESS - raltegravir potassium packet for susp 00 mg (base equiv) ISENTRESS - raltegravir potassium tab 400 mg (base equiv) ISENTRESS HD - raltegravir potassium tab 600 mg (base equiv) JULUC - dolutegravir sodiumrilpivirine hcl tab 50-5 mg (base eq) KLETR - lopinavir-ritonavir tab 00-5 mg KLETR - lopinavir-ritonavir tab mg lamivudine oral soln 0 mg/ml (Epivir) lamivudine tab 00 mg (hbv) (Epivir hbv) lamivudine tab 50 mg (Epivir) lamivudine tab 00 mg (Epivir) lamivudine-zidovudine tab mg (Combivir) LEXIV - fosamprenavir calcium susp 50 mg/ml (base equiv) lopinavir-ritonavir soln mg/5ml (80-0 mg/ml) (Kaletra) MVYRET - glecaprevir-pibrentasvir tab mg MODERIB 00 DOSE PCK - ribavirin tab 600 mg nevirapine susp 50 mg/5ml (Viramune) nevirapine tab er 4hr 00 mg (Viramune xr) nevirapine tab er 4hr 400 mg (Viramune xr) nevirapine tab 00 mg (Viramune) NORVIR - ritonavir oral soln 80 mg/ ml NORVIR - ritonavir powder packet 00 mg ODEFSEY - emtricitabine-rilpivirinetenofovir af tab mg oseltamivir phosphate cap 0 mg (base equiv) (Tamiflu) oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu) PEGSYS - peginterferon alfa-a inj 80 mcg/ml PEGSYS - peginterferon alfa-a inj 80 mcg/0.5ml PEGSYS PROCLICK - peginterferon alfa-a inj 5 mcg/0.5ml PEGSYS PROCLICK - peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREZCOBIX - darunavir-cobicistat tab mg PREZIST - darunavir ethanolate susp 00 mg/ml (base equiv) PREZIST - darunavir ethanolate tab 75 mg (base equiv) PREZIST - darunavir ethanolate tab 50 mg (base equiv) PREZIST - darunavir ethanolate tab 600 mg (base equiv) BCBSM 4T BasicRx Individual, Small Group 5

17 09 PREZIST - darunavir ethanolate tab 800 mg (base equiv) REBETOL - ribavirin soln 40 mg/ml RELENZ DISKHLER - zanamivir aero powder breath activated 5 mg/blister RESCRIPTOR - delavirdine mesylate tab 00 mg REYTZ - atazanavir sulfate oral powder packet 50 mg (base equiv) RIBSPHERE - ribavirin tab 400 mg RIBSPHERE - ribavirin tab 600 mg RIBSPHERE RIBPK - ribavirin tab 00 mg & ribavirin 400 mg tab therapy pack RIBSPHERE RIBPK - ribavirin tab 400 mg & ribavirin 600 mg tab therapy pack RIBSPHERE RIBPK - ribavirin tab 400 mg RIBSPHERE RIBPK - ribavirin tab 600 mg ribavirin cap 00 mg (Rebetol) ribavirin for inhal soln 6 gm (Virazole) ribavirin tab 00 mg (Copegus) rimantadine hydrochloride tab 00 mg (Flumadine) ritonavir tab 00 mg (Norvir) SELZENTRY - maraviroc oral soln 0 mg/ml SELZENTRY - maraviroc tab 5 mg SELZENTRY - maraviroc tab 75 mg SELZENTRY - maraviroc tab 50 mg SELZENTRY - maraviroc tab 00 mg SOVLDI - sofosbuvir tab 400 mg stavudine cap 5 mg (Zerit) stavudine cap 0 mg (Zerit) stavudine cap 0 mg (Zerit) stavudine cap 40 mg (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab mg SYMFI - efavirenz-lamivudinetenofovir df tab mg SYMFI LO - efavirenz-lamivudinetenofovir df tab mg SYMTUZ - darunavir-cobicemtricitab-tenofov af tab mg tenofovir disoproxil fumarate tab 00 mg (Viread) TIVICY - dolutegravir sodium tab 0 mg (base equiv) TIVICY - dolutegravir sodium tab 5 mg (base equiv) TIVICY - dolutegravir sodium tab 50 mg (base equiv) TRIUMEQ - abacavir-dolutegravirlamivudine tab mg TRUVD - emtricitabine-tenofovir disoproxil fumarate tab mg TRUVD - emtricitabine-tenofovir disoproxil fumarate tab -00 mg TRUVD - emtricitabine-tenofovir disoproxil fumarate tab mg TRUVD - emtricitabine-tenofovir disoproxil fumarate tab mg TYBOST - cobicistat tab 50 mg valacyclovir hcl tab 500 mg (Valtrex) valacyclovir hcl tab gm (Valtrex) valganciclovir hcl for soln 50 mg/ ml (base equiv) (Valcyte) BCBSM 4T BasicRx Individual, Small Group 6

18 09 valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) VEMLIDY - tenofovir alafenamide fumarate tab 5 mg VIDEX - didanosine for soln gm VIDEX - didanosine for soln 4 gm VIDEX EC - didanosine delayed release capsule 5 mg VIEKIR PK - ombitas-paritapreriton & dasab tab pak & 50 mg VIEKIR XR - dasab-ombitparitap-riton tab er 4hr mg VIRCEPT - nelfinavir mesylate tab 50 mg VIRCEPT - nelfinavir mesylate tab 65 mg VIRED - tenofovir disoproxil fumarate oral powder 40 mg/gm VIRED - tenofovir disoproxil fumarate tab 50 mg VIRED - tenofovir disoproxil fumarate tab 00 mg VIRED - tenofovir disoproxil fumarate tab 50 mg VOSEVI - sofosbuvir-velpatasvirvoxilaprevir tab mg zidovudine cap 00 mg (Retrovir) zidovudine syrup 0 mg/ml (Retrovir) zidovudine tab 00 mg NTIMLRILS atovaquone-proguanil hcl tab mg (Malarone) atovaquone-proguanil hcl tab mg (Malarone) CHLOROQUINE PHOSPHTE - chloroquine phosphate tab 50 mg chloroquine phosphate tab 500 mg (ralen) DRPRIM - pyrimethamine tab 5 mg hydroxychloroquine sulfate tab 00 mg (Plaquenil) MEFLOQUINE HCL - mefloquine hcl tab 50 mg PRIMQUINE PHOSPHTE - primaquine phosphate tab 6. mg (5 mg base) quinine sulfate cap 4 mg (Qualaquin) NTHELMINTICS albendazole tab 00 mg (lbenza) LBENZ - albendazole tab 00 mg BENZNIDZOLE - benznidazole tab.5 mg BENZNIDZOLE - benznidazole tab 00 mg BILTRICIDE - praziquantel tab 600 mg ivermectin tab mg (Stromectol) praziquantel tab 600 mg (Biltricide) NTI-INFECTIVE GENTS - MISC. LINI - nitazoxanide for susp 00 mg/5ml LINI - nitazoxanide tab 500 mg CYSTON - aztreonam lysine for inhal soln 75 mg (base equivalent) clindamycin hcl cap 75 mg (Cleocin) clindamycin hcl cap 50 mg (Cleocin) clindamycin hcl cap 00 mg (Cleocin) clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 mg BCBSM 4T BasicRx Individual, Small Group 7

19 09 dapsone tab 00 mg IMPVIDO - miltefosine cap 50 mg linezolid for susp 00 mg/5ml (Zyvox) linezolid tab 600 mg (Zyvox) metronidazole cap 75 mg (Flagyl) metronidazole tab 50 mg (Flagyl) metronidazole tab 500 mg (Flagyl) sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg (Bactrim) sulfamethoxazole-trimethoprim tab mg (Bactrim ds) tinidazole tab 50 mg (Tindamax) tinidazole tab 500 mg (Tindamax) trimethoprim tab 00 mg vancomycin hcl cap 5 mg (base equivalent) (Vancocin hcl) vancomycin hcl cap 50 mg (base equivalent) (Vancocin hcl) XIFXN - rifaximin tab 550 mg BIOLOGICLS VCCINES CTHIB - haemophilus b polysaccharide conjugate vaccine for inj FLURI PF influenza virus vaccine split pf susp pref syringe 0.5 ml FLURI QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLURI QUDRIVLENT 08 - influenza virus vaccine split quadrivalent im inj FLURI influenza virus vaccine split im susp BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled syringe ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/ml FLURIX QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUDRIVLENT 08 - influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUCELVX QUDRIVLENT 0 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVX QUDRIVLENT 0 - influenza vac tissue-cultured subunit quadrivalent im susp FLULVL QUDRIVLENT 0 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLULVL QUDRIVLENT 0 - influenza virus vaccine split quadrivalent im inj FLUMIST QUDRIVLENT - influenza virus vaccine live quadrivalent intranasal susp FLUZONE HIGH-DOSE PF 08 - influenza virus vac split high-dose pf susp pref syr 0.5ml FLUZONE QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5 ml FLUZONE QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml BCBSM 4T BasicRx Individual, Small Group 8

20 09 FLUZONE QUDRIVLENT 08 - influenza virus vaccine split quadrivalent im inj FLUZONE QUDRIVLENT 08 - influenza virus vaccine split quadrivalent inj 0.5 ml GRDSIL 9 - human papillomavirus (hpv) 9-valent recomb vac im susp GRDSIL 9 - human papillomavirus (hpv) 9-valent recomb vac susp pref syr HVRIX - hepatitis a vaccine inj susp 70 el unit/0.5ml HVRIX - hepatitis a vaccine inj susp 440 el unit/ml HEPLISV-B - hepatitis b vaccine recomb adjuvanted pref syr 0 mcg/0.5ml HEPLISV-B - hepatitis b vaccine recombinant adjuvanted 0 mcg/0.5ml HIBERIX - haemophilus b polysaccharide conjugate vac for inj 0 mcg IMOVX RBIES (H.D.C.V.) - rabies virus vaccine, hdc inj IPOL INCTIVTED IPV - poliovirus vaccine, ipv injection M-M-R II - measles, mumps & rubella virus vaccines for inj MENCTR - meningococcal (a, c, y, and w-5) conjugate vaccine inj MENVEO - meningococcal (a, c, y, and w-5) oligo conj vac for inj PEDVX HIB - haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml PNEUMOVX - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PROQUD - measles-mumpsrubella-varicella virus vaccines for susp RBVERT - rabies vaccine, pcec for inj RECOMBIVX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml PNEUMOVX / DOSE - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PREVNR - pneumococcal - valent conjugate vaccine inj RECOMBIVX HB - hepatitis b vaccine (recombinant) susp 40 mcg/ml ROTRIX - rotavirus vaccine, live for oral susp ROTTEQ - rotavirus vaccine, live oral pentavalent soln SHINGRIX - zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml TRUMENB - meningococcal group b vac (recomb) im susp prefilled syr TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 70-0 elu-mcg/ ml VQT - hepatitis a vaccine inj susp 5 unit/0.5ml VQT - hepatitis a vaccine inj susp 50 unit/ml VRIVX - varicella virus vac live for subcutaneous inj 50 pfu/0.5ml ZOSTVX - zoster vaccine live for subcutaneous susp 9400 unit/0.65ml TOXOIDS BCBSM 4T BasicRx Individual, Small Group 9

21 09 DCEL - tet tox-diph-acell pertuss ad inj lf-lf-mcg/0.5ml BOOSTRIX - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml DPTCEL - diph, acellular pert & tet tox inj 5 lf- mcg-5 lf/0.5ml DIPHTHERI/TETNUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 5-5 unit/0.5ml INFNRIX - diph, acellular pert & tet tox inj 5 lf-58 mcg-0 lf/0.5ml KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj PEDIRIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj PENTCEL - diph-ac per-tet tox adpoliov-haemoph b poly vac for im susp QUDRCEL - diph-tetanus tox adacell pert & polio virus, ipv vac inj TENIVC - tetanus-diphtheria toxoids (td) inj 5- lfu TETNUS/DIPHTHERI TOXOID - tetanus-diphtheria toxoids (td) inj - lf/0.5ml PSSIVE IMMUNIZING GENTS CUVITRU - immune globulin (human) subcutaneous inj gm/5ml CUVITRU - immune globulin (human) subcutaneous inj gm/0ml CUVITRU - immune globulin (human) subcutaneous inj 4 gm/0ml CUVITRU - immune globulin (human) subcutaneous inj 8 gm/40ml HIZENTR - immune globulin (human) subcutaneous inj gm/5ml HIZENTR - immune globulin (human) subcutaneous inj gm/0ml HIZENTR - immune globulin (human) subcutaneous inj 4 gm/0ml HIZENTR - immune globulin (human) subcutaneous inj 0 gm/50ml HYQVI - immun glob inj.5 gm/5ml-hyaluron inj 00 unt/.5 ml kit HYQVI - immun glob inj 5 gm/50mlhyaluron inj 400 unt/.5 ml kit HYQVI - immun glob inj 0 gm/00ml-hyaluron inj 800 unt/5 ml kit HYQVI - immun glob inj 0 gm/00ml-hyaluron inj 600 unt/0 ml kit HYQVI - immun glob inj 0 gm/00ml-hyaluron inj 400 unt/5 ml kit NTINEOPLSTIC GENTS NTINEOPLSTICS CTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) FINITOR - everolimus tab.5 mg FINITOR - everolimus tab 5 mg FINITOR - everolimus tab 7.5 mg FINITOR - everolimus tab 0 mg FINITOR DISPERZ - everolimus tab for oral susp mg FINITOR DISPERZ - everolimus tab for oral susp mg FINITOR DISPERZ - everolimus tab for oral susp 5 mg LECENS - alectinib hcl cap 50 mg (base equivalent) BCBSM 4T BasicRx Individual, Small Group 0

22 09 LUNBRIG - brigatinib tab initiation therapy pack 90 mg & 80 mg LUNBRIG - brigatinib tab 0 mg LUNBRIG - brigatinib tab 90 mg LUNBRIG - brigatinib tab 80 mg anastrozole tab mg (rimidex) bexarotene cap 75 mg (Targretin) bicalutamide tab 50 mg (Casodex) BOSULIF - bosutinib tab 00 mg BOSULIF - bosutinib tab 400 mg BOSULIF - bosutinib tab 500 mg BRFTOVI - encorafenib cap 50 mg BRFTOVI - encorafenib cap 75 mg CBOMETYX - cabozantinib s-malate tab 0 mg (base equivalent) CBOMETYX - cabozantinib s-malate tab 40 mg (base equivalent) CBOMETYX - cabozantinib s-malate tab 60 mg (base equivalent) CLQUENCE - acalabrutinib cap 00 mg capecitabine tab 50 mg (Xeloda) capecitabine tab 500 mg (Xeloda) CPRELS - vandetanib tab 00 mg CPRELS - vandetanib tab 00 mg COMETRIQ - cabozantinib s-mal cap x 80 mg & x 0 mg (00 dose) kit COMETRIQ - cabozantinib s-mal cap x 80 mg & x 0 mg (40 dose) kit COMETRIQ - cabozantinib s-malate cap x 0 mg (60 mg dose) kit COTELLIC - cobimetinib fumarate tab 0 mg (base equivalent) cyclophosphamide cap 5 mg (Cyclophosphamide) cyclophosphamide cap 50 mg (Cyclophosphamide) ELIGRD - leuprolide acetate ( month) for subcutaneous inj kit.5mg ELIGRD - leuprolide acetate (4 month) for subcutaneous inj kit 0 mg ELIGRD - leuprolide acetate (6 month) for subcutaneous inj kit 45 mg ELIGRD - leuprolide acetate for subcutaneous inj kit 7.5 mg EMCYT - estramustine phosphate sodium cap 40 mg ERIVEDGE - vismodegib cap 50 mg ERLED - apalutamide tab 60 mg ETOPOSIDE - etoposide cap 50 mg exemestane tab 5 mg (romasin) FRESTON - toremifene citrate tab 60 mg (base equivalent) FRYDK - panobinostat lactate cap 0 mg (base equivalent) FRYDK - panobinostat lactate cap 5 mg (base equivalent) FRYDK - panobinostat lactate cap 0 mg (base equivalent) flutamide cap 5 mg GILOTRIF - afatinib dimaleate tab 0 mg (base equivalent) GILOTRIF - afatinib dimaleate tab 0 mg (base equivalent) GILOTRIF - afatinib dimaleate tab 40 mg (base equivalent) GLEOSTINE - lomustine cap 0 mg GLEOSTINE - lomustine cap 40 mg GLEOSTINE - lomustine cap 00 mg HYCMTIN - topotecan hcl cap 0.5 mg (base equiv) BCBSM 4T BasicRx Individual, Small Group

23 09 HYCMTIN - topotecan hcl cap mg (base equiv) HYDROXYPROGESTERONE CPRO - hydroxyprogesterone caproate im in oil.5 gm/5ml hydroxyurea cap 500 mg (Hydrea) IBRNCE - palbociclib cap 75 mg IBRNCE - palbociclib cap 00 mg IBRNCE - palbociclib cap 5 mg ICLUSIG - ponatinib hcl tab 5 mg (base equiv) ICLUSIG - ponatinib hcl tab 45 mg (base equiv) IDHIF - enasidenib mesylate tab 50 mg (base equivalent) IDHIF - enasidenib mesylate tab 00 mg (base equivalent) imatinib mesylate tab 00 mg (base equivalent) (Gleevec) imatinib mesylate tab 400 mg (base equivalent) (Gleevec) IMBRUVIC - ibrutinib cap 70 mg IMBRUVIC - ibrutinib cap 40 mg IMBRUVIC - ibrutinib tab 40 mg IMBRUVIC - ibrutinib tab 80 mg IMBRUVIC - ibrutinib tab 40 mg IMBRUVIC - ibrutinib tab 560 mg INLYT - axitinib tab mg INLYT - axitinib tab 5 mg INTRON - interferon alfa-b inj unit/ml INTRON - interferon alfa-b inj unit/ml INTRON - interferon alfa-b for inj unit INTRON - interferon alfa-b for inj unit INTRON - interferon alfa-b for inj unit IRESS - gefitinib tab 50 mg JKFI - ruxolitinib phosphate tab 5 mg (base equivalent) JKFI - ruxolitinib phosphate tab 0 mg (base equivalent) JKFI - ruxolitinib phosphate tab 5 mg (base equivalent) JKFI - ruxolitinib phosphate tab 0 mg (base equivalent) JKFI - ruxolitinib phosphate tab 5 mg (base equivalent) KISQLI - ribociclib succinate tab 00 mg (base equiv) KISQLI FEMR 00 DOSE - ribociclib tab 00 mg & letrozole tab.5 mg therapy pack KISQLI FEMR 400 DOSE - ribociclib tab 00 mg & letrozole tab.5 mg therapy pack KISQLI FEMR 600 DOSE - ribociclib tab 00 mg & letrozole tab.5 mg therapy pack LENVIM 0 MG DILY DOSE - lenvatinib cap therapy pack 0 mg (0 mg daily dose) LENVIM MG DILY DOSE - lenvatinib cap therapy pack 4 () mg ( mg daily dose) LENVIM 4 MG DILY DOSE - lenvatinib cap therapy pack 0 & 4 mg (4 mg daily dose) LENVIM 8 MG DILY DOSE - lenvatinib cap therapy pack 0 & 4 () mg (8 mg daily dose) LENVIM 0 MG DILY DOSE - lenvatinib cap therapy pack 0 () mg (0 mg daily dose) LENVIM 4 MG DILY DOSE - lenvatinib cap therapy pack 0 () & 4 mg (4 mg daily dose) BCBSM 4T BasicRx Individual, Small Group

24 09 LENVIM 4 MG DILY DOSE - lenvatinib cap therapy pack 4 mg (4 mg daily dose) LENVIM 8 MG DILY DOSE - lenvatinib cap therapy pack 4 () mg (8 mg daily dose) letrozole tab.5 mg (Femara) LEUCOVORIN CLCIUM - leucovorin calcium tab 0 mg LEUCOVORIN CLCIUM - leucovorin calcium tab 5 mg leucovorin calcium tab 5 mg leucovorin calcium tab 5 mg LEUKERN - chlorambucil tab mg LONSURF - trifluridine-tipiracil tab mg LONSURF - trifluridine-tipiracil tab mg LYNPRZ - olaparib tab 00 mg LYNPRZ - olaparib tab 50 mg LYSODREN - mitotane tab 500 mg MTULNE - procarbazine hcl cap 50 mg megestrol acetate susp 40 mg/ml (Megace oral) megestrol acetate tab 0 mg megestrol acetate tab 40 mg MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg (base equivalent) MEKINIST - trametinib dimethyl sulfoxide tab mg (base equivalent) MEKTOVI - binimetinib tab 5 mg melphalan tab mg (lkeran) mercaptopurine tab 50 mg MESNEX - mesna tab 400 mg METHOTREXTE SODIUM - methotrexate sodium inj 50 mg/0ml (5 mg/ml) methotrexate sodium inj pf 50 mg/ml (5 mg/ml) methotrexate sodium inj pf 50 mg/0ml (5 mg/ml) methotrexate sodium inj pf 000 mg/40ml (5 mg/ml) methotrexate sodium inj 50 mg/ml (5 mg/ml) methotrexate sodium tab.5 mg (base equiv) MYLERN - busulfan tab mg NERLYNX - neratinib maleate tab 40 mg (base equivalent) NEXVR - sorafenib tosylate tab 00 mg (base equivalent) nilutamide tab 50 mg (Nilandron) NINLRO - ixazomib citrate cap. mg (base equivalent) NINLRO - ixazomib citrate cap mg (base equivalent) NINLRO - ixazomib citrate cap 4 mg (base equivalent) ODOMZO - sonidegib phosphate cap 00 mg (base equivalent) POMLYST - pomalidomide cap mg POMLYST - pomalidomide cap mg POMLYST - pomalidomide cap mg POMLYST - pomalidomide cap 4 mg PURIXN - mercaptopurine susp 000 mg/00ml (0 mg/ml) RUBR - rucaparib camsylate tab 00 mg (base equivalent) RUBR - rucaparib camsylate tab 50 mg (base equivalent) RUBR - rucaparib camsylate tab 00 mg (base equivalent) RYDPT - midostaurin cap 5 mg BCBSM 4T BasicRx Individual, Small Group