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

Transcription

1 March 08 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 Anti-infective Agents... Biologicals... 8 Antineoplastic Agents... 0 Endocrine and Metabolic Drugs... 4 Cardiovascular Agents... 3 Respiratory Agents Gastrointestinal Agents Genitourinary Agents Central Nervous System Drugs Analgesics and Anesthetics Neuromuscular Drugs Nutritional Products Hematological Agents Topical Products Miscellaneous Products... 7 Index... 4 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 03/8

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 three member payment tiers: Generic (Tier ), Brand (Tier ), and (Tier 3). Blue Cross may choose to not add a drug to formulary for reasons including safety or effectiveness, or because a similar, more costeffective 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 FDA-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. All drugs are reviewed each year as required by the National Committee on Quality Assurance (NCQA) standards. You can find recent changes and the current version of the formulary at bluecrossmn.com. BCBSMN BasicRx Individual, Small Group March 08 I

3 Formulary guidelines The requirement of P&T and Coverage Committee review is a precondition of Blue Cross coverage and: Applies in addition to all other conditions and terms stated in Blue Cross contracts and stated herein; and Applies to medications and medical devices when administered in any manner that is approved by the U. S. Food and Drug Administration (FDA); and Applies 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 FDA (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. All 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 Any health care provider may request in writing that the Blue Cross Coverage Committee consider adding or deleting a drug from the formulary. All 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 Are generics as good as brand name drugs? Both brand name and generic drugs must be approved by the FDA. 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? Ask your pharmacist for a generic whenever available. Also, talk with your doctor or other provider about prescribing generic drugs. Most drug classes include some generic drugs. BCBSMN BasicRx Individual, Small Group March 08 II

4 How to use this list The drug list is organized into broad categories (e.g., HORMONES, DIABETES AND RELATED 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: JANUVIA- 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 three member payment tiers: Generic (Tier ), Brand (Tier ), and (Tier 3).. - a dot present in this column indicates this is a specialty drug. Note: Additional information about specialty drugs can be found in this document under the topic Benefit Programs. 3. (PA)- Some drugs require prior authorization because of their high potential for misuse or overuse. Coverage may be approved after certain criteria are met. Approval is required for claims to process at network pharmacies. If an indicator is present in this column, then the PA 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 Affordable Care Act 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, FDA approved contraceptive methods, fluoride supplements, folic acid supplements, lipid lowering medications (statins), tobacco cessation products, and vitamin D supplements. 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 FDA-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 March 08 III

5 Benefit programs 90dayRx Blue Cross has an optional 90dayRx 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 90-day supply of drugs through our mail order pharmacy you may be able to receive up to a 90-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 a 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. BCBSMN BasicRx Individual, Small Group March 08 IV

6 Affordable Care Act Bowel Prep for Colonoscopy Select bowel preparation drugs will be covered without cost share, in accordance with each member s specific benefit plan. Affordable Care Act 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 35 and older raloxifene, for ages 35 and older Affordable Care Act 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 > NUVARING > 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. Affordable Care Act 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 Affordable Care Act OTC Supplements Select OTC supplements will be covered without cost share in accordance with each member s specific benefit plan. The following OTC supplements will be available at $0 cost to eligible members with a prescription. Aspirin 8 mg Folic acid- containing mg BCBSMN BasicRx Individual, Small Group March 08 V

7 Select generic fluoride products- for children ages 6 months-6 years o sodium fluoride cream, gel, oral rinse, paste o sodium fluoride/potassium nitrate o stannous fluoride Iron- children ages 6- months and women ages -64 Vitamin D- adults ages 65 and older Affordable Care Act 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) CHANTIX 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: A prescriber may obtain a Minnesota Uniform Form for Prescription Drug Request & Formulary Exceptions online at providers.bluecrossmn.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 305 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. Approval 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 bluecrossmn.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 PA 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 PA 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 Account. BCBSMN BasicRx Individual, Small Group March 08 VI

8 Alternatively, a prescriber may obtain a Minnesota Uniform Form for Prescription Drug Request & Formulary Exceptions online at providers.bluecrossmn.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 305 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 A 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 305 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: A 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 305 Corporate Center Drive Eagan, MN 55 Fax number: BCBSMN BasicRx Individual, Small Group March 08 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 March 08 VIII

10 NOTICE OF NONDISCRIMINATION PRACTICES 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: Auxiliary 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 Avenue 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 Association. F0773R0 (/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;< Aw>u[h.eRusdmw>rRpXRuvDwz.M.vDRIAud; vx ATTY t*d><aud; 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. Afaan Oromoo dubbattu yoo ta e, tajaajila gargaarsa afaan hiikuu kaffaltii malee. Argachuuf 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. Appelez 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 08 ANTI-INFECTIVE AGENTS PENICILLINS 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 (Augmentin) amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr mg (Augmentin xr) amoxicillin & k clavulanate tab 50-5 mg amoxicillin & k clavulanate tab mg (Augmentin) amoxicillin & k clavulanate tab mg (Augmentin) AMPICILLIN - ampicillin cap 500 mg dicloxacillin sodium cap 50 mg dicloxacillin sodium cap 500 mg PENICILLIN V POTASSIUM - penicillin v potassium for soln 5 mg/5ml PENICILLIN V POTASSIUM - penicillin v potassium for soln 50 mg/5ml penicillin v potassium tab 50 mg penicillin v potassium tab 500 mg CEPHALOSPORINS 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 300 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) cephalexin cap 500 mg (Keflex) cephalexin cap 750 mg (Keflex) cephalexin for susp 5 mg/5ml cephalexin for susp 50 mg/5ml MACROLIDES azithromycin for susp 00 mg/5ml (Zithromax) BCBSMN BasicRx Individual, Small Group

13 08 azithromycin for susp 00 mg/5ml (Zithromax) azithromycin tab 50 mg (Zithromax) azithromycin tab 500 mg (Zithromax) azithromycin tab 600 mg (Zithromax) CLARITHROMYCIN - clarithromycin for susp 5 mg/5ml CLARITHROMYCIN - 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 TETRACYCLINES demeclocycline hcl tab 50 mg demeclocycline hcl tab 300 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 (Adoxa) doxycycline monohydrate for susp 5 mg/5ml (Vibramycin) doxycycline monohydrate tab 50 mg (Adoxa) doxycycline monohydrate tab 75 mg (Adoxa) doxycycline monohydrate tab 00 mg (Adoxa pak /00) doxycycline monohydrate tab 50 mg (Adoxa 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 ciprofloxacin for oral susp 50 mg/5ml (5%) (5 gm/00ml) (Cipro) ciprofloxacin for oral susp 500 mg/5ml (0%) (0 gm/00ml) (Cipro) ciprofloxacin hcl tab 50 mg (base equiv) (Cipro) ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) ciprofloxacin hcl tab 750 mg (base equiv) ciprofloxacin-ciprofloxacin hcl tab er 4hr 500 mg (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er 4hr 000 mg(base eq) (Cipro xr) LEVOFLOXACIN - levofloxacin oral soln 5 mg/ml levofloxacin tab 50 mg (Levaquin) levofloxacin tab 500 mg (Levaquin) BCBSMN BasicRx Individual, Small Group

14 08 levofloxacin tab 750 mg (Levaquin) moxifloxacin hcl tab 400 mg (base equiv) (Avelox) AMINOGLYCOSIDES BETHKIS - tobramycin nebu soln 300 mg/4ml neomycin sulfate tab 500 mg paromomycin sulfate cap 50 mg TOBI PODHALER - tobramycin inhal cap 8 mg tobramycin nebu soln 300 mg/5ml (Tobi) SULFONAMIDES SULFADIAZINE - sulfadiazine tab 500 mg ANTIMYCOBACTERIAL AGENTS ethambutol hcl tab 00 mg (Myambutol) ethambutol hcl tab 400 mg (Myambutol) isoniazid tab 00 mg isoniazid tab 300 mg PRIFTIN - rifapentine tab 50 mg pyrazinamide tab 500 mg rifabutin cap 50 mg (Mycobutin) RIFAMATE - isoniazid & rifampin cap mg rifampin cap 50 mg (Rifadin) rifampin cap 300 mg (Rifadin) ANTIFUNGALS 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 (Ancobon) flucytosine cap 500 mg (Ancobon) 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) NOXAFIL - posaconazole susp 40 mg/ml NOXAFIL - 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) ANTIVIRALS abacavir sulfate soln 0 mg/ml (base equiv) (Ziagen) abacavir sulfate tab 300 mg (base equiv) (Ziagen) 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) APTIVUS - tipranavir cap 50 mg BCBSMN BasicRx Individual, Small Group 3

15 08 APTIVUS - 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 300 mg (base equiv) (Reyataz) ATRIPLA - efavirenz-emtricitabinetenofovir df tab mg BARACLUDE - entecavir oral soln 0.05 mg/ml COMPLERA - emtricitabinerilpivirine-tenofovir df tab mg CRIXIVAN - indinavir sulfate cap 00 mg CRIXIVAN - 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) EDURANT - rilpivirine hcl tab 5 mg (base equivalent) efavirenz cap 50 mg (Sustiva) efavirenz cap 00 mg (Sustiva) EMTRIVA - emtricitabine caps 00 mg EMTRIVA - emtricitabine soln 0 mg/ ml entecavir tab 0.5 mg (Baraclude) entecavir tab mg (Baraclude) EPCLUSA - sofosbuvir-velpatasvir tab mg EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) EVOTAZ - 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 GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab mg HARVONI - ledipasvir-sofosbuvir tab mg INTELENCE - etravirine tab 5 mg INTELENCE - etravirine tab 00 mg INTELENCE - etravirine tab 00 mg INVIRASE - saquinavir mesylate cap 00 mg INVIRASE - 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) KALETRA - lopinavir-ritonavir tab 00-5 mg KALETRA - lopinavir-ritonavir tab mg lamivudine oral soln 0 mg/ml (Epivir) BCBSMN BasicRx Individual, Small Group 4

16 08 lamivudine tab 00 mg (hbv) (Epivir hbv) lamivudine tab 50 mg (Epivir) lamivudine tab 300 mg (Epivir) lamivudine-zidovudine tab mg (Combivir) LEXIVA - fosamprenavir calcium susp 50 mg/ml (base equiv) lopinavir-ritonavir soln mg/5ml (80-0 mg/ml) (Kaletra) MAVYRET - glecaprevir-pibrentasvir tab mg MODERIBA - ribavirin tab 00 mg & ribavirin 400 mg tab therapy pack MODERIBA - ribavirin tab 400 mg & ribavirin 600 mg tab therapy pack MODERIBA 00 DOSE PACK - ribavirin tab 600 mg MODERIBA 800 DOSE PACK - ribavirin tab 400 mg nevirapine tab er 4hr 00 mg (Viramune xr) nevirapine tab er 4hr 400 mg (Viramune xr) nevirapine tab 00 mg (Viramune) NORVIR - ritonavir cap 00 mg NORVIR - ritonavir oral soln 80 mg/ ml NORVIR - ritonavir tab 00 mg ODEFSEY - emtricitabine-rilpivirinetenofovir af tab mg OLYSIO - simeprevir sodium cap 50 mg (base equivalent) oseltamivir phosphate cap 30 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) PEGASYS - peginterferon alfa-a inj 80 mcg/ml PEGASYS - peginterferon alfa-a inj 80 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 35 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 0 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREZCOBIX - darunavir-cobicistat tab mg PREZISTA - darunavir ethanolate susp 00 mg/ml (base equiv) PREZISTA - darunavir ethanolate tab 75 mg (base equiv) PREZISTA - darunavir ethanolate tab 50 mg (base equiv) PREZISTA - darunavir ethanolate tab 600 mg (base equiv) PREZISTA - darunavir ethanolate tab 800 mg (base equiv) REBETOL - ribavirin soln 40 mg/ml RELENZA DISKHALER - zanamivir aero powder breath activated 5 mg/blister RESCRIPTOR - delavirdine mesylate tab 00 mg RESCRIPTOR - delavirdine mesylate tab 00 mg BCBSMN BasicRx Individual, Small Group 5

17 08 REYATAZ - atazanavir sulfate cap 50 mg (base equiv) REYATAZ - atazanavir sulfate cap 00 mg (base equiv) REYATAZ - atazanavir sulfate cap 300 mg (base equiv) REYATAZ - atazanavir sulfate oral powder packet 50 mg (base equiv) RIBASPHERE - ribavirin tab 400 mg RIBASPHERE - ribavirin tab 600 mg RIBASPHERE RIBAPAK - ribavirin tab 00 mg & ribavirin 400 mg tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 400 mg & ribavirin 600 mg tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 400 mg RIBASPHERE RIBAPAK - 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) 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 300 mg SOVALDI - sofosbuvir tab 400 mg stavudine cap 5 mg (Zerit) stavudine cap 0 mg (Zerit) stavudine cap 30 mg (Zerit) stavudine cap 40 mg (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab mg SUSTIVA - efavirenz cap 50 mg SUSTIVA - efavirenz cap 00 mg SUSTIVA - efavirenz tab 600 mg TAMIFLU - oseltamivir phosphate for susp 6 mg/ml (base equiv) tenofovir disoproxil fumarate tab 300 mg (Viread) TIVICAY - dolutegravir sodium tab 0 mg (base equiv) TIVICAY - dolutegravir sodium tab 5 mg (base equiv) TIVICAY - dolutegravir sodium tab 50 mg (base equiv) TRIUMEQ - abacavir-dolutegravirlamivudine tab mg TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab mg TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab mg TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab mg TRUVADA - 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) valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) VIDEX - didanosine for soln gm VIDEX - didanosine for soln 4 gm BCBSMN BasicRx Individual, Small Group 6

18 08 VIEKIRA PAK - ombitas-paritapreriton & dasab tab pak & 50 mg VIEKIRA XR - dasab-ombitparitap-riton tab er 4hr mg VIRACEPT - nelfinavir mesylate tab 50 mg VIRACEPT - nelfinavir mesylate tab 65 mg VIRAMUNE - nevirapine susp 50 mg/5ml VIRAZOLE - ribavirin for inhal soln 6 gm VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm VIREAD - tenofovir disoproxil fumarate tab 50 mg VIREAD - tenofovir disoproxil fumarate tab 00 mg VIREAD - tenofovir disoproxil fumarate tab 50 mg VIREAD - tenofovir disoproxil fumarate tab 300 mg VOSEVI - sofosbuvir-velpatasvirvoxilaprevir tab mg ZERIT - stavudine for oral soln mg/ ml zidovudine cap 00 mg (Retrovir) zidovudine syrup 0 mg/ml (Retrovir) zidovudine tab 300 mg ANTIMALARIALS atovaquone-proguanil hcl tab mg (Malarone) atovaquone-proguanil hcl tab mg (Malarone) CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 50 mg chloroquine phosphate tab 500 mg (Aralen) DARAPRIM - pyrimethamine tab 5 mg hydroxychloroquine sulfate tab 00 mg (Plaquenil) MEFLOQUINE HCL - mefloquine hcl tab 50 mg PRIMAQUINE PHOSPHATE - primaquine phosphate tab 6.3 mg (5 mg base) quinine sulfate cap 34 mg (Qualaquin) ANTHELMINTICS ALBENZA - albendazole tab 00 mg BILTRICIDE - praziquantel tab 600 mg ivermectin tab 3 mg (Stromectol) ANTI-INFECTIVE AGENTS - MISC. CAYSTON - aztreonam lysine for inhal soln 75 mg (base equivalent) clindamycin hcl cap 75 mg (Cleocin) clindamycin hcl cap 50 mg (Cleocin) clindamycin hcl cap 300 mg (Cleocin) clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 mg dapsone tab 00 mg IMPAVIDO - miltefosine cap 50 mg linezolid for susp 00 mg/5ml (Zyvox) linezolid tab 600 mg (Zyvox) metronidazole cap 375 mg (Flagyl) metronidazole tab 50 mg (Flagyl) metronidazole tab 500 mg (Flagyl) BCBSMN BasicRx Individual, Small Group 7

19 08 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 (Vancocin hcl) vancomycin hcl cap 50 mg (Vancocin hcl) XIFAXAN - rifaximin tab 550 mg BIOLOGICALS VACCINES ACTHIB - haemophilus b polysaccharide conjugate vaccine for inj AFLURIA PF influenza virus vaccine split pf susp pref syringe 0.5 ml AFLURIA QUADRIVALENT 07 - influenza virus vac split quadrivalent susp pref syr 0.5ml AFLURIA QUADRIVALENT 07 - influenza virus vaccine split quadrivalent im inj AFLURIA 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 FLUARIX QUADRIVALENT 07 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUADRIVALENT 07 - influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUBLOK influenza virus vac recombinant hemagglutinin (ha) pf inj FLUBLOK influenza virus vac recombinant hemagglutinin (ha) pf inj FLUCELVAX QUADRIVALENT 0 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVAX QUADRIVALENT 0 - influenza vac tissue-cultured subunit quadrivalent im susp FLULAVAL QUADRIVALENT 0 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLULAVAL QUADRIVALENT 0 - influenza virus vaccine split quadrivalent im inj 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 FLUZONE HIGH-DOSE PF 07 - 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 BCBSMN BasicRx Individual, Small Group 8

20 08 FLUZONE QUADRIVALENT 07 - influenza virus vac split quadrivalent susp pref syr 0.5 ml FLUZONE QUADRIVALENT 07 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUZONE QUADRIVALENT 07 - influenza virus vaccine split quadrivalent im inj FLUZONE QUADRIVALENT 07 - influenza virus vaccine split quadrivalent inj 0.5 ml GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im susp GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac susp pref syr HAVRIX - hepatitis a vaccine inj susp 70 el unit/0.5ml HAVRIX - hepatitis a vaccine inj susp 440 el unit/ml HIBERIX - haemophilus b polysaccharide conjugate vac for inj 0 mcg IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection M-M-R II - measles, mumps & rubella virus vaccines for inj MENACTRA - meningococcal (a, c, y, and w-35) conjugate vaccine inj MENVEO - meningococcal (a, c, y, and w-35) oligo conj vac for inj PEDVAX HIB - haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml PNEUMOVAX 3 - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PNEUMOVAX 3/ DOSE - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PREVNAR 3 - pneumococcal 3- valent conjugate vaccine inj PROQUAD - measles-mumpsrubella-varicella virus vaccines for inj RABAVERT - rabies vaccine, pcec for inj RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 40 mcg/ml ROTARIX - rotavirus vaccine, live for oral susp ROTATEQ - rotavirus vaccine, live oral pentavalent soln TRUMENBA - meningococcal group b vac (recomb) im susp prefilled syr TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 70-0 elu-mcg/ ml VAQTA - hepatitis a vaccine inj susp 5 unit/0.5ml VAQTA - hepatitis a vaccine inj susp 50 unit/ml VARIVAX - varicella virus vac live for subcutaneous inj 350 pfu/0.5ml ZOSTAVAX - zoster vaccine live for subcutaneous susp 9400 unit/0.65ml TOXOIDS ADACEL - tet tox-diph-acell pertuss ad inj lf-lf-mcg/0.5ml BCBSMN BasicRx Individual, Small Group 9

21 08 BOOSTRIX - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml DAPTACEL - diph, acellular pert & tet tox inj 5 lf-3 mcg-5 lf/0.5ml DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 5-5 unit/0.5ml INFANRIX - 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 PEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj PENTACEL - diph-ac per-tet tox adpoliov-haemoph b poly vac for im susp QUADRACEL - diph-tetanus tox adacell pert & polio virus, ipv vac inj TENIVAC - tetanus-diphtheria toxoids (td) inj 5- lfu TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td) inj - lf/0.5ml PASSIVE IMMUNIZING AGENTS 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 HIZENTRA - immune globulin (human) subcutaneous inj gm/5ml HIZENTRA - immune globulin (human) subcutaneous inj gm/0ml HIZENTRA - immune globulin (human) subcutaneous inj 4 gm/0ml HIZENTRA - immune globulin (human) subcutaneous inj 0 gm/50ml HYQVIA - immun glob inj.5 gm/5ml-hyaluron inj 00 unt/.5 ml kit HYQVIA - immun glob inj 5 gm/50mlhyaluron inj 400 unt/.5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 800 unt/5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 600 unt/0 ml kit HYQVIA - immun glob inj 30 gm/300ml-hyaluron inj 400 unt/5 ml kit ANTINEOPLASTIC AGENTS ANTINEOPLASTICS ACTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) AFINITOR - everolimus tab.5 mg AFINITOR - everolimus tab 5 mg AFINITOR - everolimus tab 7.5 mg AFINITOR - everolimus tab 0 mg AFINITOR DISPERZ - everolimus tab for oral susp mg AFINITOR DISPERZ - everolimus tab for oral susp 3 mg AFINITOR DISPERZ - everolimus tab for oral susp 5 mg ALECENSA - alectinib hcl cap 50 mg (base equivalent) BCBSMN BasicRx Individual, Small Group 0

22 08 ALFERON N - interferon alfa-n3 inj unit/ml ALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 80 mg ALUNBRIG - brigatinib tab 30 mg ALUNBRIG - brigatinib tab 90 mg ALUNBRIG - brigatinib tab 80 mg anastrozole tab mg (Arimidex) 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 CABOMETYX - cabozantinib s-malate tab 0 mg (base equivalent) CABOMETYX - cabozantinib s-malate tab 40 mg (base equivalent) CABOMETYX - cabozantinib s-malate tab 60 mg (base equivalent) capecitabine tab 50 mg (Xeloda) capecitabine tab 500 mg (Xeloda) CAPRELSA - vandetanib tab 00 mg CAPRELSA - vandetanib tab 300 mg COMETRIQ - cabozantinib s-mal cap x 80 mg & x 0 mg (00 dose) kit COMETRIQ - cabozantinib s-mal cap x 80 mg & 3 x 0 mg (40 dose) kit COMETRIQ - cabozantinib s-malate cap 3 x 0 mg (60 mg dose) kit COTELLIC - cobimetinib fumarate tab 0 mg (base equivalent) CYCLOPHOSPHAMIDE - cyclophosphamide cap 5 mg CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 mg ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit.5mg ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit 30 mg ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 mg ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg EMCYT - estramustine phosphate sodium cap 40 mg ERIVEDGE - vismodegib cap 50 mg ETOPOSIDE - etoposide cap 50 mg exemestane tab 5 mg (Aromasin) FARESTON - toremifene citrate tab 60 mg (base equivalent) FARYDAK - panobinostat lactate cap 0 mg (base equivalent) FARYDAK - panobinostat lactate cap 5 mg (base equivalent) FARYDAK - panobinostat lactate cap 0 mg (base equivalent) flutamide cap 5 mg GILOTRIF - afatinib dimaleate tab 0 mg (base equivalent) GILOTRIF - afatinib dimaleate tab 30 mg (base equivalent) GILOTRIF - afatinib dimaleate tab 40 mg (base equivalent) GLEOSTINE - lomustine cap 5 mg GLEOSTINE - lomustine cap 0 mg GLEOSTINE - lomustine cap 40 mg GLEOSTINE - lomustine cap 00 mg HEXALEN - altretamine cap 50 mg HYCAMTIN - topotecan hcl cap 0.5 mg (base equiv) BCBSMN BasicRx Individual, Small Group

23 08 HYCAMTIN - topotecan hcl cap mg (base equiv) HYDROXYPROGESTERONE CAPRO - hydroxyprogesterone caproate im in oil.5 gm/5ml hydroxyurea cap 500 mg (Hydrea) IBRANCE - palbociclib cap 75 mg IBRANCE - palbociclib cap 00 mg IBRANCE - palbociclib cap 5 mg ICLUSIG - ponatinib hcl tab 5 mg (base equiv) ICLUSIG - ponatinib hcl tab 45 mg (base equiv) IDHIFA - enasidenib mesylate tab 50 mg (base equivalent) IDHIFA - enasidenib mesylate tab 00 mg (base equivalent) imatinib mesylate tab 00 mg (base equivalent) (Gleevec) imatinib mesylate tab 400 mg (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 40 mg INLYTA - axitinib tab mg INLYTA - axitinib tab 5 mg INTRON A - interferon alfa-b inj unit/ml INTRON A - interferon alfa-b inj unit/ml INTRON A - interferon alfa-b for inj unit INTRON A - interferon alfa-b for inj unit INTRON A - interferon alfa-b for inj unit IRESSA - gefitinib tab 50 mg JAKAFI - ruxolitinib phosphate tab 5 mg (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 mg (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 mg (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 mg (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 mg (base equivalent) KISQALI - ribociclib succinate tab 00 mg (base equiv) KISQALI FEMARA 00 DOSE - ribociclib tab 00 mg & letrozole tab.5 mg therapy pack KISQALI FEMARA 400 DOSE - ribociclib tab 00 mg & letrozole tab.5 mg therapy pack KISQALI FEMARA 600 DOSE - ribociclib tab 00 mg & letrozole tab.5 mg therapy pack LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 mg (0 mg daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 mg (4 mg daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 () mg (8 mg daily dose) LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 () mg (0 mg daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 0 () & 4 mg (4 mg daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4 () mg (8 mg daily dose) letrozole tab.5 mg (Femara) LEUCOVORIN CALCIUM - leucovorin calcium tab 0 mg LEUCOVORIN CALCIUM - leucovorin calcium tab 5 mg leucovorin calcium tab 5 mg leucovorin calcium tab 5 mg BCBSMN BasicRx Individual, Small Group

24 08 LEUKERAN - chlorambucil tab mg LONSURF - trifluridine-tipiracil tab mg LONSURF - trifluridine-tipiracil tab mg LYNPARZA - olaparib cap 50 mg LYNPARZA - olaparib tab 00 mg LYNPARZA - olaparib tab 50 mg LYSODREN - mitotane tab 500 mg MATULANE - 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) melphalan tab mg (Alkeran) mercaptopurine tab 50 mg MESNEX - mesna tab 400 mg METHOTREXATE SODIUM - methotrexate sodium inj 50 mg/0ml (5 mg/ml) methotrexate sodium inj pf 50 mg/ml (5 mg/ml) methotrexate sodium inj pf 00 mg/4ml (5 mg/ml) methotrexate sodium inj pf 00 mg/8ml (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) MYLERAN - busulfan tab mg NERLYNX - neratinib maleate tab 40 mg (base equivalent) NEXAVAR - sorafenib tosylate tab 00 mg (base equivalent) nilutamide tab 50 mg (Nilandron) NINLARO - ixazomib citrate cap.3 mg (base equivalent) NINLARO - ixazomib citrate cap 3 mg (base equivalent) NINLARO - ixazomib citrate cap 4 mg (base equivalent) ODOMZO - sonidegib phosphate cap 00 mg (base equivalent) POMALYST - pomalidomide cap mg POMALYST - pomalidomide cap mg POMALYST - pomalidomide cap 3 mg POMALYST - pomalidomide cap 4 mg PURIXAN - 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 300 mg (base equivalent) RYDAPT - midostaurin cap 5 mg SPRYCEL - dasatinib tab 0 mg SPRYCEL - dasatinib tab 50 mg SPRYCEL - dasatinib tab 70 mg SPRYCEL - dasatinib tab 80 mg SPRYCEL - dasatinib tab 00 mg SPRYCEL - dasatinib tab 40 mg STIVARGA - regorafenib tab 40 mg BCBSMN BasicRx Individual, Small Group 3