Health Insurance Marketplace 6 Tier Drug List

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1 May 08 Health Insurance Marketplace 6 Tier Drug List Please consider talking to your doctor about prescribing preferred medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug list is regularly updated. Please visit bcbsok.com for the most up-to-date information. To find a contracting pharmacy, please access the link below: Contents Introduction... I How drugs are selected... I How member payment is determined... I How to use this list... II Drugs used to treat multiple conditions... II Generic drugs... II Consider talking to your doctor about generic drugs... II Coverage considerations... III Specialty drugs... V AllianceRx Walgreens Prime... V Abbreviation key... VI Therapeutic Class Drug List Anti-Infective Agents... Biologicals... Antineoplastic Agents... Endocrine and Metabolic Drugs... 9 Cardiovascular Agents... Respiratory Agents... 8 Gastrointestinal Agents... 5 Genitourinary Agents Central Nervous System Drugs Analgesics and Anesthetics... 7 Neuromuscular Drugs... 8 Nutritional Products Hematological Agents Topical Products... 9 Miscellaneous Products... 8 Index... To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. 90-O OK HIM Prime Therapeutics LLC 05/8

2 Introduction Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician. Drug list updates This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbsok.com and log in to Blue Access for Members SM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbsok.com. How drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from BCBSOK, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. How member payment is determined This list shows prescription drug products in tiers. Generally, each drug is placed into one of five member payment tiers: Preferred Generic (Tier ), Non-Preferred Generic (Tier ), Preferred Brand (Tier ), Non-Preferred Brand (Tier ), Preferred Specialty (Tier 5) and Non-Preferred Specialty (Tier 6). Some brands may be placed in generic tiers and some generics may be placed in brand tiers. Please refer to the Preventive () section for drugs marked with an "A" in the drug tier column. To verify your payment amount for a drug, visit bcbsok.com and log in to Blue Access for Members or call the number on the back of your ID card. Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for selfadministration may be available through your medical benefit. BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 I

3 How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Note: most reference brand drugs (in parentheses) are not covered. Example: atorvastatin (Lipitor brand is not covered) Brand prescription drugs are shown in capital letters followed by the generic name. Example: NOVOLOG - Insulin aspart inj 00 unit/ml Drugs used to treat multiple conditions Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use. Generic drugs Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same standards. There are two types of generic drugs: A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. According to the FDA, compared to its brand counterpart, an FDA-approved generic drug: Is chemically the same Works just as well in the body Is as safe and effective Meets the same standards set by the FDA The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less. Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available. You may be responsible for the applicable member payment amount plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount. Consider talking to your doctor about generic drugs If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication. BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 II

4 Coverage considerations Most prescription drug benefit plans provide coverage for up to a 0-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan materials for details about your particular benefits. Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount. Repackaged medications: Repackaged versions of medications already available on the market are not covered. (PA): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the medications listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the medications listed in this document, if a step therapy is commonly required it will generally be noted next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on additional medications beyond those noted in this document. (DL): Drug Dispensing limits are designed to help encourage medication use as intended by the FDA. Coverage limits are placed on medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit bcbsok.com. *Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit. (LD): Medicines marked as "" have restrictions on where you may obtain a medication. This may include requiring the use of a designated pharmacy to fill a prescription. BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 III

5 Preventive (): Medicines marked in the column are under the Affordable Care Act coverage of preventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), when meeting the conditions as outlined under the regulation. These are also indicated with an "A" in the drug tier column. To see what contraceptive products may be covered, visit Remember, medication decisions are between you and your doctor. Only you and your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor. BCBSOK does not provide health care services and, therefore, cannot guarantee any results or outcomes. BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 IV

6 Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. Medications administered by a health care professional are not covered under the pharmacy benefit. For a current list of specialty medications, visit myprime.com or bcbsok.com and log in to Blue Access for Members. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card. AllianceRx Walgreens Prime Through AllianceRx Walgreens Prime, members can have covered specialty medications delivered directly to them or their doctor s office. When you receive specialty medications through AllianceRx Walgreens Prime, you also receive at no additional charge the following services: Coordination of coverage between you, your doctor and your health plan Educational materials about your particular condition and information about managing potential medication side effects Syringes, sharps containers and other supplies with every shipment for self-injectables /7/65 phone access to a pharmacist for urgent medication issues To order through AllianceRx Walgreens Prime: Have your doctor call or fax your prescription to AllianceRx Walgreens Prime. Your doctor can call or fax to If you have an existing prescription for a covered specialty medication, you can call to transfer your prescription. A coordinator will contact you to arrange delivery of your medication. The prescription can be shipped directly to you or your prescribing doctor s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging. If you have questions, please contact AllianceRx Walgreens Prime at , visit or call the number on the back of your ID card. Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ( HCSC ). HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC. BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 V

7 Abbreviation key cap... capsules odt... orally disintegrating tabs chew... chewable oint... ointment conc... concentrate ophth...opthalmic cr...controlled release osm... osmotic release dr... delayed release powd... powder ec...enteric coated sa... sustained action effe...effervescent sl... sublingual equiv... equivalent soln...solution er...extended release sr... sustained release inhal... inhalation suppos... suppositories inj... injection susp... suspension liq... liquid tab...tablets lotn...lotion td... transdermal nebu...nebulizer You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List. To request this exception, you, or your prescriber, can call the number on the back of your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be able to ask for an expedited review process. BCBSOK will let you, and your prescriber, know the coverage decision within hours after they receive your request for an expedited review. If the coverage request is denied, BCBSOK will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). Call the number on the back of your ID card if you have any questions. BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 VI

8 bcbsok.com

9 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: (voic ) 00 E. Randolph St. TTY/TDD: th Floor Fax: Chicago, Illinois CivilRightsCoordinator@hcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: Independence Avenue SW TTY/TDD: Room 509F, HHH Building 09 Complaint Portal: Washington, DC 00 Complaint Forms: BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

10 08 ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN - amoxicillin (trihydrate) chew tab 5 AMOXICILLIN - amoxicillin (trihydrate) chew tab 50 amoxicillin (trihydrate) cap 50 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) for susp 5 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) for susp 50 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr (Augmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab (Augmentin) amoxicillin & k clavulanate tab (Augmentin) AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab AMPICILLIN - ampicillin cap 500 AUGMENTIN - amoxicillin & k clavulanate for susp 5-.5 /5ml dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 PENICILLIN V POTASSIUM - penicillin v potassium for soln 5 /5ml PENICILLIN V POTASSIUM - penicillin v potassium for soln 50 /5ml penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHALOSPORINS cefaclor cap 50 cefaclor cap 500 cefadroxil cap 500 cefadroxil for susp 50 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 00 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

11 08 cefdinir for susp 5 /5ml cefdinir for susp 50 /5ml CEFDITOREN PIVOXIL - cefditoren pivoxil tab 00 (base equivalent) CEFDITOREN PIVOXIL - cefditoren pivoxil tab 00 (base equivalent) cefixime for susp 00 /5ml (Suprax) cefixime for susp 00 /5ml (Suprax) cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 00 /5ml cefpodoxime proxetil tab 00 cefpodoxime proxetil tab 00 cefprozil for susp 5 /5ml cefprozil for susp 50 /5ml cefprozil tab 50 cefprozil tab 500 CEFTIN - cefuroxime axetil for susp 5 /5ml CEFTIN - cefuroxime axetil for susp 50 /5ml cefuroxime axetil tab 50 (Ceftin) cefuroxime axetil tab 500 (Ceftin) cephalexin cap 50 (Keflex) cephalexin cap 500 (Keflex) cephalexin cap 750 (Keflex) cephalexin for susp 5 /5ml cephalexin for susp 50 /5ml MACROLIDES AZITHROMYCIN - azithromycin powd pack for susp gm azithromycin for susp 00 /5ml (Zithromax) azithromycin for susp 00 /5ml (Zithromax) azithromycin tab 50 (Zithromax) azithromycin tab 500 (Zithromax) azithromycin tab 600 (Zithromax) CLARITHROMYCIN - clarithromycin for susp 5 /5ml CLARITHROMYCIN - clarithromycin for susp 50 /5ml clarithromycin tab er hr 500 clarithromycin tab 50 (Biaxin) clarithromycin tab 500 (Biaxin) DIFICID - fidaxomicin tab 00 E.E.S. GRANULES - erythromycin ethylsuccinate for susp 00 /5ml E.E.S erythromycin ethylsuccinate tab 00 ERY-TAB - erythromycin tab delayed release 50 ERY-TAB - erythromycin tab delayed release BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

12 08 ERY-TAB - erythromycin tab delayed release 500 ERYPED 00 - erythromycin ethylsuccinate for susp 00 /5ml ERYPED 00 - erythromycin ethylsuccinate for susp 00 /5ml ERYTHROCIN STEARATE - erythromycin stearate tab 50 ERYTHROMYCIN ETHYLSUCCINA - erythromycin ethylsuccinate tab 00 erythromycin ethylsuccinate for susp 00 /5ml (E.e.s. granules) erythromycin tab 50 erythromycin tab 500 erythromycin w/ delayed release particles cap 50 PCE - erythromycin w/ enteric coated particles tab PCE - erythromycin w/ enteric coated particles tab 500 ZITHROMAX - azithromycin powd pack for susp gm ZMAX - azithromycin extended release for oral susp gm TETRACYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 00 doxycycline hyclate cap 50 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab 0 doxycycline hyclate tab 00 doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 (Monodox) doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 (Adoxa) doxycycline monohydrate for susp 5 /5ml (Vibramycin) doxycycline monohydrate tab 50 (Adoxa) doxycycline monohydrate tab 75 (Adoxa) doxycycline monohydrate tab 00 (Adoxa pak /00) doxycycline monohydrate tab 50 (Adoxa pak /50) minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 00 tetracycline hcl cap 50 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) FLUOROQUINOLONES BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

13 08 BAXDELA - delafloxacin meglumine tab 50 (base equiv) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXACIN HCL - ciprofloxacin hcl tab 00 (base equiv) ciprofloxacin hcl tab 50 (base equiv) (Cipro) ciprofloxacin hcl tab 500 (base equiv) (Cipro) ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin-ciprofloxacin hcl tab er hr 500 (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er hr 000 (base eq) (Cipro xr) LEVOFLOXACIN - levofloxacin oral soln 5 /ml levofloxacin tab 50 (Levaquin) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) moxifloxacin hcl tab 00 (base equiv) (Avelox) OFLOXACIN - ofloxacin tab 00 ofloxacin tab 00 AMINOGLYCOSIDES BETHKIS - tobramycin nebu soln 00 /ml KITABIS PAK - tobramycin nebu soln 00 /5ml neomycin sulfate tab paromomycin sulfate cap 50 TOBI PODHALER - tobramycin inhal cap 8 TOBRAMYCIN - tobramycin nebu soln 00 /5ml tobramycin nebu soln 00 /5ml (Tobi) SULFONAMIDES SULFADIAZINE - sulfadiazine tab 500 ANTIMYCOBACTERIAL AGENTS CYCLOSERINE - cycloserine cap 50 ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 00 (Myambutol) ISONIAZID - isoniazid syrup 50 /5ml isoniazid tab 00 isoniazid tab 00 PASER - aminosalicylic acid er granules packet gm PRIFTIN - rifapentine tab 50 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) RIFAMATE - isoniazid & rifampin cap rifampin cap 50 (Rifadin) rifampin cap 00 (Rifadin) RIFATER - isoniazid-rifampin w/ pyrazinamide tab SIRTURO - bedaquiline fumarate tab 00 (base equiv) 6 6 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

14 08 TRECATOR - ethionamide tab 50 ANTIFUNGALS CRESEMBA - isavuconazonium sulfate cap 86 fluconazole for susp 0 / ml (Diflucan) fluconazole for susp 0 / ml (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) flucytosine cap 50 (Ancobon) flucytosine cap 500 (Ancobon) griseofulvin microsize susp 5 /5ml griseofulvin microsize tab 500 (Grifulvin v) griseofulvin ultramicrosize tab 5 (Gris-peg) griseofulvin ultramicrosize tab 50 (Gris-peg) itraconazole cap 00 (Sporanox) NOXAFIL - posaconazole susp 0 /ml NOXAFIL - posaconazole tab delayed release 00 nystatin tab unit SPORANOX - itraconazole oral soln 0 /ml terbinafine hcl tab 50 (Lamisil) voriconazole for susp 0 /ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 00 (Vfend) ANTIVIRALS abacavir sulfate soln 0 / ml (base equiv) (Ziagen) abacavir sulfate tab 00 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab (Epzicom) abacavir sulfatelamivudine-zidovudine tab (Trizivir) acyclovir cap 00 (Zovirax) acyclovir susp 00 /5ml (Zovirax) acyclovir tab 00 (Zovirax) acyclovir tab 800 (Zovirax) adefovir dipivoxil tab 0 (Hepsera) APTIVUS - tipranavir cap 50 APTIVUS - tipranavir oral soln 00 /ml atazanavir sulfate cap 50 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 5

15 08 ATRIPLA - efavirenzemtricitabine-tenofovir df tab BARACLUDE - entecavir oral soln 0.05 /ml COMPLERA - emtricitabinerilpivirine-tenofovir df tab CRIXIVAN - indinavir sulfate cap 00 CRIXIVAN - indinavir sulfate cap 00 DESCOVY - emtricitabinetenofovir alafenamide fumarate tab 00-5 didanosine delayed release capsule 00 (Videx ec) didanosine delayed release capsule 50 (Videx ec) didanosine delayed release capsule 00 (Videx ec) EDURANT - rilpivirine hcl tab 5 (base equivalent) efavirenz cap 50 (Sustiva) efavirenz cap 00 (Sustiva) efavirenz tab 600 (Sustiva) EMTRIVA - emtricitabine caps 00 EMTRIVA - emtricitabine soln 0 /ml entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUSA - sofosbuvirvelpatasvir tab EPIVIR HBV - lamivudine oral soln 5 /ml (hbv) EPZICOM - abacavir sulfatelamivudine tab EVOTAZ - atazanavir sulfatecobicistat tab (base equiv) famciclovir tab 5 (Famvir) famciclovir tab 50 (Famvir) famciclovir tab 500 (Famvir) fosamprenavir calcium tab 700 (base equiv) (Lexiva) FUZEON - enfuvirtide for inj 90 GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab HARVONI - ledipasvirsofosbuvir tab INTELENCE - etravirine tab 5 INTELENCE - etravirine tab 00 INTELENCE - etravirine tab 00 INVIRASE - saquinavir mesylate cap 00 INVIRASE - saquinavir mesylate tab 500 ISENTRESS - raltegravir potassium chew tab 5 (base equiv) ISENTRESS - raltegravir potassium chew tab 00 (base equiv) ISENTRESS - raltegravir potassium packet for susp 00 (base equiv) 6 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 6

16 08 ISENTRESS - raltegravir potassium tab 00 (base equiv) ISENTRESS HD - raltegravir potassium tab 600 (base equiv) JULUCA - dolutegravir sodiumrilpivirine hcl tab 50-5 (base eq) KALETRA - lopinavir-ritonavir soln /5ml (80-0 /ml) KALETRA - lopinavir-ritonavir tab 00-5 KALETRA - lopinavir-ritonavir tab lamivudine oral soln 0 / ml (Epivir) lamivudine tab 00 (hbv) (Epivir hbv) lamivudine tab 50 (Epivir) lamivudine tab 00 (Epivir) lamivudine-zidovudine tab (Combivir) LEXIVA - fosamprenavir calcium susp 50 /ml (base equiv) LEXIVA - fosamprenavir calcium tab 700 (base equiv) lopinavir-ritonavir soln /5ml (80-0 / ml) (Kaletra) MAVYRET - glecaprevirpibrentasvir tab 00-0 MODERIBA - ribavirin tab 00 & ribavirin 00 tab therapy pack 6 MODERIBA - ribavirin tab 00 & ribavirin 600 tab therapy pack MODERIBA 00 DOSE PACK - ribavirin tab MODERIBA 800 DOSE PACK - ribavirin tab 00 nevirapine tab er hr 00 (Viramune xr) nevirapine tab er hr 00 (Viramune xr) nevirapine tab 00 (Viramune) NORVIR - ritonavir cap 00 NORVIR - ritonavir oral soln 80 /ml NORVIR - ritonavir tab 00 ODEFSEY - emtricitabinerilpivirine-tenofovir af tab OLYSIO - simeprevir sodium cap 50 (base equivalent) oseltamivir phosphate cap 0 (base equiv) (Tamiflu) oseltamivir phosphate cap 5 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) oseltamivir phosphate for susp 6 /ml (base equiv) (Tamiflu) PEGASYS - peginterferon alfa-a inj 80 mcg/ml PEGASYS - peginterferon alfa-a inj 80 mcg/0.5ml 6 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 7

17 08 PEGASYS PROCLICK - peginterferon alfa-a inj 5 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREVYMIS - letermovir tab 0 PREVYMIS - letermovir tab 80 PREZCOBIX - darunavircobicistat tab PREZISTA - darunavir ethanolate susp 00 /ml (base equiv) PREZISTA - darunavir ethanolate tab 75 (base equiv) PREZISTA - darunavir ethanolate tab 50 (base equiv) PREZISTA - darunavir ethanolate tab 600 (base equiv) PREZISTA - darunavir ethanolate tab 800 (base equiv) REBETOL - ribavirin soln 0 /ml RELENZA DISKHALER - zanamivir aero powder breath activated 5 /blister RESCRIPTOR - delavirdine mesylate tab 00 RESCRIPTOR - delavirdine mesylate tab 00 REYATAZ - atazanavir sulfate cap 50 (base equiv) 6 6 REYATAZ - atazanavir sulfate cap 00 (base equiv) REYATAZ - atazanavir sulfate cap 00 (base equiv) REYATAZ - atazanavir sulfate oral powder packet 50 (base equiv) RIBASPHERE - ribavirin tab 00 RIBASPHERE - ribavirin tab 600 RIBASPHERE RIBAPAK - ribavirin tab 00 & ribavirin 00 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 00 & ribavirin 600 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 00 RIBASPHERE RIBAPAK - ribavirin tab 600 ribavirin cap 00 (Rebetol) ribavirin for inhal soln 6 gm (Virazole) ribavirin tab 00 (Copegus) rimantadine hydrochloride tab 00 (Flumadine) ritonavir tab 00 (Norvir) SELZENTRY - maraviroc oral soln 0 /ml SELZENTRY - maraviroc tab 5 SELZENTRY - maraviroc tab 75 SELZENTRY - maraviroc tab 50 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 8

18 08 SELZENTRY - maraviroc tab 00 SOVALDI - sofosbuvir tab 00 stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 0 (Zerit) stavudine cap 0 (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab SUSTIVA - efavirenz cap 50 SUSTIVA - efavirenz cap 00 SUSTIVA - efavirenz tab 600 TAMIFLU - oseltamivir phosphate cap 0 (base equiv) TAMIFLU - oseltamivir phosphate cap 5 (base equiv) TAMIFLU - oseltamivir phosphate cap 75 (base equiv) TAMIFLU - oseltamivir phosphate for susp 6 /ml (base equiv) TECHNIVIE - ombitasvirparitaprevir-ritonavir tab tenofovir disoproxil fumarate tab 00 (Viread) TIVICAY - dolutegravir sodium tab 0 (base equiv) TIVICAY - dolutegravir sodium tab 5 (base equiv) TIVICAY - dolutegravir sodium tab 50 (base equiv) 6 TRIUMEQ - abacavirdolutegravir-lamivudine tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab -00 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TYBOST - cobicistat tab 50 valacyclovir hcl tab 500 (Valtrex) valacyclovir hcl tab gm (Valtrex) valganciclovir hcl for soln 50 /ml (base equiv) (Valcyte) valganciclovir hcl tab 50 (base equivalent) (Valcyte) VIDEX - didanosine for soln gm VIDEX - didanosine for soln gm VIEKIRA PAK - ombitasparitapre-riton & dasab tab pak & 50 VIEKIRA XR - dasab-ombitparitap-riton tab er hr VIRACEPT - nelfinavir mesylate tab 50 VIRACEPT - nelfinavir mesylate tab BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 9

19 08 VIRAMUNE - nevirapine susp 50 /5ml VIRAZOLE - ribavirin for inhal soln 6 gm VIREAD - tenofovir disoproxil fumarate oral powder 0 / gm VIREAD - tenofovir disoproxil fumarate tab 50 VIREAD - tenofovir disoproxil fumarate tab 00 VIREAD - tenofovir disoproxil fumarate tab 50 VIREAD - tenofovir disoproxil fumarate tab 00 VOSEVI - sofosbuvirvelpatasvir-voxilaprevir tab ZEPATIER - elbasvirgrazoprevir tab ZERIT - stavudine for oral soln /ml ZIAGEN - abacavir sulfate soln 0 /ml (base equiv) zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 00 ANTIMALARIALS atovaquone-proguanil hcl tab (Malarone) atovaquone-proguanil hcl tab (Malarone) CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 50 chloroquine phosphate tab 500 (Aralen) COARTEM - artemetherlumefantrine tab 0-0 DARAPRIM - pyrimethamine tab 5 hydroxychloroquine sulfate tab 00 (Plaquenil) MEFLOQUINE HCL - mefloquine hcl tab 50 PRIMAQUINE PHOSPHATE - primaquine phosphate tab 6. (5 base) quinine sulfate cap (Qualaquin) ANTHELMINTICS ALBENZA - albendazole tab 00 BENZNIDAZOLE - benznidazole tab.5 BENZNIDAZOLE - benznidazole tab 00 BILTRICIDE - praziquantel tab 600 ivermectin tab (Stromectol) ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 00 /5ml ALINIA - nitazoxanide tab 500 atovaquone susp 750 /5ml (Mepron) CAYSTON - aztreonam lysine for inhal soln 75 (base equivalent) clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 00 (Cleocin) 6 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 0

20 08 clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 dapsone tab 00 IMPAVIDO - miltefosine cap 50 linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 75 (Flagyl) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) NEBUPENT - pentamidine isethionate for nebulization soln 00 PRIMSOL - trimethoprim hcl oral soln 50 /5ml (base equiv) SIVEXTRO - tedizolid phosphate tab 00 sulfamethoxazoletrimethoprim susp 00-0 /5ml sulfamethoxazoletrimethoprim tab (Bactrim) sulfamethoxazoletrimethoprim tab (Bactrim ds) tinidazole tab 50 (Tindamax) tinidazole tab 500 (Tindamax) trimethoprim tab 00 vancomycin hcl cap 5 (Vancocin hcl) vancomycin hcl cap 50 (Vancocin hcl) XIFAXAN - rifaximin tab 00 XIFAXAN - rifaximin tab 550 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 A A A A A A A A A A BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

21 08 FLUAD influenza vac type a&b surface ant adj susp pref syr 0.5 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 tissuecultured 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 A A A A A A A A A A A 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 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 0 el unit/ml A A A A A A A A A A A A BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

22 08 HIBERIX - haemophilus b polysaccharide conjugate vac for inj 0 mcg 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-5) conjugate vaccine inj MENVEO - meningococcal (a, c, y, and w-5) oligo conj vac for inj PEDVAX HIB - haemophilus b polysaccharide conj vac im susp 7.5 mcg/0.5 ml PNEUMOVAX - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PNEUMOVAX / DOSE - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PREVNAR - Pneumococcal -valent conjugate vaccine inj PROQUAD - measles-mumpsrubella-varicella virus vaccines 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 0 mcg/ml ROTARIX - rotavirus vaccine, live for oral susp ROTATEQ - rotavirus vaccine, live oral pentavalent soln A A A A A A A A A A A A A A A SHINGRIX - zoster vaccine recombinant adjuvanted for im inj 50 mcg 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 50 pfu/0.5ml VIVOTIF - typhoid vaccine cap delayed release ZOSTAVAX - zoster vaccine live for subcutaneous susp 900 unit/0.65ml TOXOIDS ADACEL - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml BOOSTRIX - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml DAPTACEL - diph, acellular pert & tet tox inj 5 lf- 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 adacell pert & polio virus, ipv vac inj A A A A A A A A A A A A BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

23 08 PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio ipv vac inj PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp QUADRACEL - diph-tetanus tox ad-acell 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 ANTINEOPLASTIC AGENTS ANTINEOPLASTICS ACTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) AFINITOR - everolimus tab.5 AFINITOR - everolimus tab 5 AFINITOR - everolimus tab 7.5 AFINITOR - everolimus tab 0 AFINITOR DISPERZ - everolimus tab for oral susp AFINITOR DISPERZ - everolimus tab for oral susp AFINITOR DISPERZ - everolimus tab for oral susp 5 ALECENSA - alectinib hcl cap 50 (base equivalent) ALKERAN - melphalan tab A A A A A ALUNBRIG - brigatinib tab initiation therapy pack 90 & 80 ALUNBRIG - brigatinib tab 0 ALUNBRIG - brigatinib tab 90 ALUNBRIG - brigatinib tab 80 anastrozole tab (Arimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 500 CABOMETYX - cabozantinib s-malate tab 0 (base equivalent) CABOMETYX - cabozantinib s-malate tab 0 (base equivalent) CABOMETYX - cabozantinib s-malate tab 60 (base equivalent) CALQUENCE - acalabrutinib cap 00 capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA - vandetanib tab 00 CAPRELSA - vandetanib tab BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

24 08 COMETRIQ - cabozantinib s- mal cap x 80 & x 0 (00 dose) kit COMETRIQ - cabozantinib s- mal cap x 80 & x 0 (0 dose) kit COMETRIQ - cabozantinib s- malate cap x 0 (60 dose) kit COTELLIC - cobimetinib fumarate tab 0 (base equivalent) CYCLOPHOSPHAMIDE - cyclophosphamide cap 5 CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 ELIGARD - leuprolide acetate ( month) for subcutaneous inj kit.5 ELIGARD - leuprolide acetate ( month) for subcutaneous inj kit 0 ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 5 ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 EMCYT - estramustine phosphate sodium cap 0 ERIVEDGE - vismodegib cap 50 ETOPOSIDE - etoposide cap 50 exemestane tab 5 (Aromasin) FARESTON - toremifene citrate tab 60 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) FARYDAK - panobinostat lactate cap 5 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) flutamide cap 5 GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GLEOSTINE - lomustine cap 5 GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 00 HEXALEN - altretamine cap 50 HYCAMTIN - topotecan hcl cap 0.5 (base equiv) HYCAMTIN - topotecan hcl cap (base equiv) hydroxyurea cap 500 (Hydrea) IBRANCE - palbociclib cap 75 IBRANCE - palbociclib cap 00 IBRANCE - palbociclib cap 5 ICLUSIG - ponatinib hcl tab 5 (base equiv) BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 5

25 08 ICLUSIG - ponatinib hcl tab 5 (base equiv) IDHIFA - enasidenib mesylate tab 50 (base equivalent) IDHIFA - enasidenib mesylate tab 00 (base equivalent) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 00 (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 70 IMBRUVICA - ibrutinib cap INLYTA - axitinib tab INLYTA - axitinib tab 5 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 JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) KISQALI - ribociclib succinate tab 00 (base equiv) KISQALI FEMARA 00 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 00 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 600 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 (0 daily dose) LENVIMA MG DAILY DOSE - lenvatinib cap therapy pack 0 & ( daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 0 & () (8 daily dose) LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 () (0 daily dose) LENVIMA MG DAILY DOSE - lenvatinib cap therapy pack 0 () & ( daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack () (8 daily dose) letrozole tab.5 (Femara) LEUCOVORIN CALCIUM - leucovorin calcium tab 0 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 6

26 08 LEUCOVORIN CALCIUM - leucovorin calcium tab 5 leucovorin calcium tab 5 leucovorin calcium tab 5 LEUKERAN - chlorambucil tab leuprolide acetate inj kit 5 /ml LONSURF - trifluridine-tipiracil tab 5-6. LONSURF - trifluridine-tipiracil tab LYNPARZA - olaparib cap 50 LYNPARZA - olaparib tab 00 LYNPARZA - olaparib tab 50 LYSODREN - mitotane tab 500 MATULANE - procarbazine hcl cap 50 megestrol acetate susp 0 /ml (Megace oral) megestrol acetate tab 0 megestrol acetate tab 0 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 (base equivalent) MEKINIST - trametinib dimethyl sulfoxide tab (base equivalent) melphalan tab (Alkeran) mercaptopurine tab 50 MESNEX - mesna tab 00 METHOTREXATE SODIUM - methotrexate sodium inj 50 /0ml (5 /ml) methotrexate sodium for inj gm methotrexate sodium inj pf 50 /ml (5 /ml) methotrexate sodium inj pf 00 /ml (5 /ml) methotrexate sodium inj pf 00 /8ml (5 /ml) methotrexate sodium inj pf 50 /0ml (5 /ml) methotrexate sodium inj pf 000 /0ml (5 /ml) methotrexate sodium inj 50 /ml (5 /ml) methotrexate sodium tab.5 (base equiv) MYLERAN - busulfan tab NEXAVAR - sorafenib tosylate tab 00 (base equivalent) nilutamide tab 50 (Nilandron) NINLARO - ixazomib citrate cap. (base equivalent) NINLARO - ixazomib citrate cap (base equivalent) NINLARO - ixazomib citrate cap (base equivalent) ODOMZO - sonidegib phosphate cap 00 (base equivalent) POMALYST - pomalidomide cap POMALYST - pomalidomide cap POMALYST - pomalidomide cap POMALYST - pomalidomide cap BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 7

27 08 PURIXAN - mercaptopurine susp 000 /00ml (0 /ml) RUBR - rucaparib camsylate tab 00 (base equivalent) RUBR - rucaparib camsylate tab 50 (base equivalent) RUBR - rucaparib camsylate tab 00 (base equivalent) RYDAPT - midostaurin cap 5 SOLTAMOX - tamoxifen citrate oral soln 0 /5ml (base equivalent) SPRYCEL - dasatinib tab 0 SPRYCEL - dasatinib tab 50 SPRYCEL - dasatinib tab 70 SPRYCEL - dasatinib tab 80 SPRYCEL - dasatinib tab 00 SPRYCEL - dasatinib tab 0 STIVARGA - regorafenib tab 0 SUTENT - sunitinib malate cap.5 (base equivalent) SUTENT - sunitinib malate cap 5 (base equivalent) SUTENT - sunitinib malate cap 7.5 (base equivalent) SUTENT - sunitinib malate cap 50 (base equivalent) SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 600 mcg SYNRIBO - omacetaxine mepesuccinate for inj.5 TABLOID - thioguanine tab 0 TAFINLAR - dabrafenib mesylate cap 50 (base equivalent) TAFINLAR - dabrafenib mesylate cap 75 (base equivalent) TAGRISSO - osimertinib mesylate tab 0 (base equivalent) TAGRISSO - osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) tamoxifen citrate tab 0 (base equivalent) TARCEVA - erlotinib hcl tab 5 (base equivalent) TARCEVA - erlotinib hcl tab 00 (base equivalent) TARCEVA - erlotinib hcl tab 50 (base equivalent) TASIGNA - nilotinib hcl cap 50 (base equivalent) TASIGNA - nilotinib hcl cap 00 (base equivalent) temozolomide cap 5 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 00 (Temodar) BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 8

28 08 temozolomide cap 0 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 50 (Temodar) tretinoin cap 0 TREXALL - methotrexate sodium tab 5 (base equiv) TREXALL - methotrexate sodium tab 7.5 (base equiv) TREXALL - methotrexate sodium tab 0 (base equiv) TREXALL - methotrexate sodium tab 5 (base equiv) TYKERB - lapatinib ditosylate tab 50 (base equiv) VENCLEXTA - venetoclax tab 0 VENCLEXTA - venetoclax tab 50 VENCLEXTA - venetoclax tab 00 VENCLEXTA STARTING PACK - venetoclax tab therapy starter pack 0 & 50 & 00 VERZENIO - abemaciclib tab 50 VERZENIO - abemaciclib tab 00 VERZENIO - abemaciclib tab 50 VERZENIO - abemaciclib tab 00 VOTRIENT - pazopanib hcl tab 00 (base equiv) XALKORI - crizotinib cap 00 XALKORI - crizotinib cap 50 XTANDI - enzalutamide cap 0 ZEJULA - niraparib tosylate cap 00 (base equivalent) ZELBORAF - vemurafenib tab 0 ZOLINZA - vorinostat cap 00 ZYDELIG - idelalisib tab 00 ZYDELIG - idelalisib tab 50 ZYKADIA - ceritinib cap 50 ZYTIGA - abiraterone acetate tab 50 ZYTIGA - abiraterone acetate tab 500 ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap (Entocort ec) CORTISONE ACETATE - cortisone acetate tab 5 DEXAMETHASONE - dexamethasone soln 0.5 /5ml DEXAMETHASONE - dexamethasone tab DEXAMETHASONE - dexamethasone tab dexamethasone elixir 0.5 /5ml 6 6 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 9

29 08 DEXAMETHASONE INTENSOL - dexamethasone conc /ml dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab.5 dexamethasone tab dexamethasone tab 6 fludrocortisone acetate tab 0. hydrocortisone tab 5 (Cortef) hydrocortisone tab 0 (Cortef) hydrocortisone tab 0 (Cortef) MEDROL - methylprednisolone tab methylprednisolone tab therapy pack () (Medrol dosepak) methylprednisolone tab (Medrol) methylprednisolone tab 8 (Medrol) methylprednisolone tab 6 (Medrol) methylprednisolone tab (Medrol) prednisolone sod phos orally disintegr tab 0 (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 5 (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 0 (base eq) (Orapred odt) prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base) (Pediapred) prednisolone sod phosphate oral soln 5 /5ml (base equiv) PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate oral soln 5 /5ml (base eq) prednisolone syrup 5 /5ml (usp solution equivalent) PREDNISONE - prednisone oral soln 5 /5ml PREDNISONE - prednisone tab therapy pack 5 () PREDNISONE - prednisone tab therapy pack 5 (8) PREDNISONE - prednisone tab therapy pack 0 () PREDNISONE - prednisone tab therapy pack 0 (8) PREDNISONE - prednisone tab 50 PREDNISONE INTENSOL - prednisone conc 5 /ml prednisone tab prednisone tab.5 prednisone tab 5 prednisone tab 0 prednisone tab 0 ANDROGEN-ANABOLIC ANADROL-50 - oxymetholone tab 50 ANDROGEL - testosterone td gel 0.5 /.5gm (.6%) BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08 0

30 08 ANDROGEL - testosterone td gel 0.5 /.5gm (.6%) ANDROGEL PUMP - testosterone td gel 0.5 /act (.6%) danazol cap 50 danazol cap 00 danazol cap 00 METHITEST - methyltestosterone oral tab 0 oxandrolone tab.5 (Oxandrin) oxandrolone tab 0 (Oxandrin) testosterone cypionate im inj in oil 00 /ml (Depotestosterone) testosterone cypionate im inj in oil 00 /ml (Depotestosterone) testosterone enanthate im inj in oil 00 /ml testosterone td gel 5 /.5gm (%) (Androgel) testosterone td gel 50 /5gm (%) (Androgel) testosterone td gel.5 / act (%) (Androgel pump) testosterone td soln 0 / act (Axiron) ESTROGENS ALORA - estradiol td patch twice weekly 0.05 /hr ALORA - estradiol td patch twice weekly 0.05 /hr ALORA - estradiol td patch twice weekly /hr ALORA - estradiol td patch twice weekly 0. /hr ANGELIQ - drospirenoneestradiol tab ANGELIQ - drospirenoneestradiol tab 0.5- CLIMARA PRO - estradiollevonorgestrel td patch weekly /day COMBIPATCH - estradiolnorethindrone ace td pttw /day COMBIPATCH - estradiolnorethindrone ace td pttw /day DELESTROGEN - estradiol valerate im in oil 0 /ml DEPO-ESTRADIOL - estradiol cypionate im in oil 5 /ml DIVIGEL - estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL - estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL - estradiol td gel /gm (0.%) DUAVEE - conjugated estrogens-bazedoxifene tab ELESTRIN - estradiol gel 0.06% (0.5 /0.87 gm metered-dose pump) estradiol & norethindrone acetate tab (Activella) estradiol & norethindrone acetate tab -0.5 (Activella) estradiol tab 0.5 (Estrace) estradiol tab (Estrace) estradiol tab (Estrace) BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

31 08 estradiol td patch twice weekly 0.05 /hr (Vivelle-dot) estradiol td patch twice weekly /hr (Vivelle-dot) estradiol td patch twice weekly 0.05 /hr (Vivelle-dot) estradiol td patch twice weekly /hr (Vivelle-dot) estradiol td patch twice weekly 0. /hr (Vivelle-dot) estradiol td patch weekly 0.05 /hr (Climara) estradiol td patch weekly /hr (7.5 mcg/hr) (Climara) estradiol td patch weekly 0.05 /hr (Climara) estradiol td patch weekly 0.06 /hr (Climara) estradiol td patch weekly /hr (Climara) estradiol td patch weekly 0. /hr (Climara) estradiol valerate im in oil 0 /ml (Delestrogen) estradiol valerate im in oil 0 /ml (Delestrogen) ESTROGEL - estradiol gel 0.06% (0.75 /.5 gm metered-dose pump) ESTROPIPATE - estropipate tab 0.75 ESTROPIPATE - estropipate tab.5 EVAMIST - estradiol transdermal spray.5 / spray MENEST - esterified estrogens tab 0. MENEST - esterified estrogens tab 0.65 MENEST - esterified estrogens tab.5 MENOSTAR - estradiol td patch weekly mcg/hr MINIVELLE - estradiol td patch twice weekly 0.05 /hr MINIVELLE - estradiol td patch twice weekly /hr MINIVELLE - estradiol td patch twice weekly 0.05 /hr MINIVELLE - estradiol td patch twice weekly /hr MINIVELLE - estradiol td patch twice weekly 0. /hr norethindrone acetateethinyl estradiol tab mcg (Femhrt low dose) norethindrone acetateethinyl estradiol tab -5 mcg PREFEST - estradiol tab (5)/estrad-norgestimate tab -0.09(5) PREMARIN - estrogens, conjugated tab 0. PREMARIN - estrogens, conjugated tab 0.5 PREMARIN - estrogens, conjugated tab 0.65 PREMARIN - estrogens, conjugated tab 0.9 BCBSOK Health Insurance Marketplace 6 Tier Drug List May 08

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