Health Insurance Marketplace 5 Tier Drug List

Transcription

1 September 08 (07 Plan Year) Health Insurance Marketplace 5 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 bcbsmt.com for the most up-to-date information. To find a contracting pharmacy, please access the link below: Contents Introduction... I How drug list drugs are selected... I How member payment is determined... I How to use this list... II Drugs used to treat multiple conditions... II Generic drugs... II Consider talking to your doctor about generic drugs... II Coverage considerations... III Specialty drugs... V Prime Specialty by lliancerx Walgreens Prime...V bbreviation key... VI Therapeutic Class Drug List nti-infective gents... Biologicals... ntineoplastic gents... Endocrine and Metabolic Drugs... 0 Cardiovascular gents Respiratory gents... 5 Gastrointestinal gents Genitourinary gents... 6 Central Nervous System Drugs nalgesics and nesthetics Neuromuscular Drugs... 9 Nutritional Products Hematological gents... Topical Products... 3 Miscellaneous Products... 6 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 L MT HIM Prime Therapeutics LLC 09/8

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 bcbsmt.com and log in to Blue ccess for Members SM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbsmt.com. How drug list 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 BCBSMT, reviews drugs regulated by the U.S. Food and Drug dministration (FD). Both drugs that are newly approved by the FD 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 3), Non-Preferred Brand (Tier ) and Specialty (Tier 5). Please refer to the Preventive () section for drugs marked with an "" in the drug tier column. To verify your payment amount for a drug, visit bcbsmt.com and log in to Blue ccess 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 FD-approved for selfadministration may be available through your medical benefit. BCBSMT Health Insurance Marketplace 5 Tier Drug List September 08 (07 Plan Year) I

3 How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Example: atorvastatin (Lipitor brand is NF) Brand prescription drugs are shown in capital letters followed by the generic name. Drugs used to treat multiple conditions Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FD-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 FD just as brand drugs are, and must meet the same standards. There are two types of generic drugs: generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. ccording to the FD, compared to its brand counterpart, an FD-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 FD The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less. Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available. You may be responsible for the brand member payment amount plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount. Consider talking to your doctor about generic drugs If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication. BCBSMT Health Insurance Marketplace 5 Tier Drug List September 08 (07 Plan Year) II

4 Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-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. (P): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the preferred medications listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the drug list 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 FD. Coverage limits are placed on medications in certain drug categories. For the preferred medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit bcbsmt.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. BCBSMT Health Insurance Marketplace 5 Tier Drug List September 08 (07 Plan Year) III

5 Preventive (): Medicines marked in the column are under the ffordable Care ct 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 "" in the drug tier column. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D supplements, and some FD approved contraceptive methods. To see what contraceptive products may be covered, visit Remember, medication decisions are between you and your doctor. Only you and your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor. BCBSMT does not provide health care services and, therefore, cannot guarantee any results or outcomes. BCBSMT Health Insurance Marketplace 5 Tier Drug List September 08 (07 Plan Year) IV

6 Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications, visit myprime.com or bcbsmt.com and log in to Blue ccess for Members. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card. Prime Specialty by lliancerx Walgreens Prime Through Prime Specialty by lliancerx Walgreens Prime, members can have covered specialty medications delivered directly to them or their doctor s office. When you receive specialty medications through Prime Specialty by lliancerx 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 /7/365 phone access to a pharmacist for urgent medication issues To order through Prime Specialty by lliancerx Walgreens Prime: Have your doctor call or fax your prescription to Prime Specialty by lliancerx 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. Prime Therapeutics coordinator will contact you to arrange delivery of your medication. The prescription can be shipped directly to you or your prescribing doctor s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging. If you have questions, please contact Prime Specialty by lliancerx Walgreens Prime at , visit or call the number on the back of your ID card. Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ( HCSC ). HCSC is an independent licensee of the Blue Cross Blue Shield ssociation. 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. BCBSMT Health Insurance Marketplace 5 Tier Drug List September 08 (07 Plan Year) V

7 bbreviation key cap... capsules chew... chewable conc... concentrate cr... controlled release dr... delayed release ec... enteric coated effe... effervescent equiv... equivalent er... extended release inhal... inhalation inj... injection liq... liquid lotn... lotion nebu... nebulizer odt... orally disintegrating tabs oint... ointment ophth... opthalmic osm... osmotic release powd... powder sa... sustained action sl... sublingual soln... solution sr... sustained release suppos... suppositories susp... suspension tab...tablets td... transdermal You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List. To request this exception, you, or your prescriber, can call the number on the back of your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be able to ask for an expedited review process. BCBSMT 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, BCBSMT 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. BCBSMT Health Insurance Marketplace 5 Tier Drug List September 08 (07 Plan Year) VI

8 bcbsmt.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 ) 300 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 venue SW TTY/TDD: Room 509F, HHH Building 09 Complaint Portal: Washington, DC 00 Complaint Forms: bcbsmt.com

10 07 NTI-INFECTIVE GENTS PENICILLINS MOXICILLIN - amoxicillin (trihydrate) chew tab 5 MOXICILLIN - 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 (ugmentin) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (ugmentin es-600) amoxicillin & k clavulanate tab er hr (ugmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab (ugmentin) amoxicillin & k clavulanate tab (ugmentin) MOXICILLIN/CLVULNTE P - amoxicillin & k clavulanate chew tab MOXICILLIN/CLVULNTE P - amoxicillin & k clavulanate chew tab MPICILLIN - ampicillin cap 500 UGMENTIN - amoxicillin & k clavulanate for susp /5ml dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 MOXTG - amoxicillin (trihydrate) tab er hr 775 PENICILLIN V POTSSIUM - penicillin v potassium for soln 5 /5ml PENICILLIN V POTSSIUM - penicillin v potassium for soln 50 /5ml penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHLOSPORINS CEFCLOR - cefaclor for susp 5 /5ml CEFCLOR - cefaclor for susp 50 /5ml CEFCLOR - cefaclor for susp 375 /5ml cefaclor cap 50 BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year)

11 07 cefaclor cap 500 CEFCLOR ER - cefaclor monohydrate tab er hr 500 cefadroxil cap 500 cefadroxil for susp 50 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 300 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 cefuroxime axetil tab 50 (Ceftin) cefuroxime axetil tab 500 (Ceftin) CEPHLEXIN - cephalexin tab 50 CEPHLEXIN - cephalexin tab 500 cephalexin cap 50 (Keflex) cephalexin cap 500 (Keflex) cephalexin cap 750 (Keflex) cephalexin for susp 5 /5ml cephalexin for susp 50 /5ml SPECTRCEF - cefditoren pivoxil tab 00 (base equivalent) SUPRX - cefixime cap 00 SUPRX - cefixime chew tab 00 SUPRX - cefixime chew tab 00 SUPRX - cefixime for susp 00 /5ml SUPRX - cefixime for susp 00 /5ml SUPRX - cefixime for susp 500 /5ml MCROLIDES ZITHROMYCIN - azithromycin powd pack for susp gm azithromycin for susp 00 /5ml (Zithromax) azithromycin for susp 00 /5ml (Zithromax) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year)

12 07 azithromycin tab 50 (Zithromax) azithromycin tab 500 (Zithromax) azithromycin tab 600 (Zithromax) CLRITHROMYCIN - clarithromycin for susp 5 /5ml CLRITHROMYCIN - 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. GRNULES - erythromycin ethylsuccinate for susp 00 /5ml E.E.S erythromycin ethylsuccinate tab 00 ERY-TB - erythromycin tab delayed release 50 ERY-TB - erythromycin tab delayed release 333 ERY-TB - erythromycin tab delayed release 500 ERYPED 00 - erythromycin ethylsuccinate for susp 00 /5ml ERYPED 00 - erythromycin ethylsuccinate for susp 00 /5ml ERYTHROCIN STERTE - erythromycin stearate tab 50 ERYTHROMYCIN ETHYLSUCCIN - 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 ZITHROMX - azithromycin powd pack for susp gm TETRCYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 300 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 (doxa) doxycycline monohydrate for susp 5 /5ml (Vibramycin) doxycycline monohydrate tab 50 (doxa) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 3

13 07 doxycycline monohydrate tab 75 (doxa) doxycycline monohydrate tab 00 (doxa pak /00) doxycycline monohydrate tab 50 (doxa pak /50) minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) minocycline hcl tab er hr 5 minocycline hcl tab er hr 90 minocycline hcl tab er hr 35 minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 00 TETRCYCLINE HCL - tetracycline hcl cap 50 TETRCYCLINE HCL - tetracycline hcl cap 500 tetracycline hcl cap 50 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) FLUOROQUINOLONES BXDEL - delafloxacin meglumine tab 50 (base equiv) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXCIN 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) LEVOFLOXCIN - levofloxacin oral soln 5 /ml levofloxacin tab 50 (Levaquin) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) moxifloxacin hcl tab 00 (base equiv) (velox) OFLOXCIN - ofloxacin tab 300 ofloxacin tab 00 MINOGLYCOSIDES BETHKIS - tobramycin nebu soln 300 /ml KITBIS PK - tobramycin nebu soln 300 /5ml neomycin sulfate tab 500 paromomycin sulfate cap 50 TOBI PODHLER - tobramycin inhal cap 8 TOBRMYCIN - tobramycin nebu soln 300 /5ml BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year)

14 07 tobramycin nebu soln 300 /5ml (Tobi) SULFONMIDES SULFDIZINE - sulfadiazine tab 500 NTIMYCOBCTERIL GENTS CYCLOSERINE - cycloserine cap 50 ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 00 (Myambutol) ISONIZID - isoniazid syrup 50 /5ml isoniazid tab 00 isoniazid tab 300 PSER - aminosalicylic acid er granules packet gm PRIFTIN - rifapentine tab 50 3 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) RIFMTE - isoniazid & rifampin cap rifampin cap 50 (Rifadin) rifampin cap 300 (Rifadin) RIFTER - isoniazid-rifampin w/ pyrazinamide tab SIRTURO - bedaquiline fumarate tab 00 (base equiv) TRECTOR - ethionamide tab 50 NTIFUNGLS CRESEMB - isavuconazonium sulfate cap 86 3 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 (ncobon) flucytosine cap 500 (ncobon) 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) NOXFIL - posaconazole susp 0 /ml NOXFIL - posaconazole tab delayed release 00 nystatin tab unit SPORNOX - itraconazole oral soln 0 /ml terbinafine hcl tab 50 (Lamisil) voriconazole for susp 0 /ml (Vfend) voriconazole tab 50 (Vfend) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 5

15 07 voriconazole tab 00 (Vfend) NTIVIRLS abacavir sulfate soln 0 / ml (base equiv) (Ziagen) abacavir sulfate tab 300 (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) PTIVUS - tipranavir cap 50 PTIVUS - tipranavir oral soln 00 /ml atazanavir sulfate cap 50 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) atazanavir sulfate cap 300 (base equiv) (Reyataz) TRIPL - efavirenzemtricitabine-tenofovir df tab BRCLUDE - entecavir oral soln 0.05 /ml 3 BIKTRVY - bictegraviremtricitabine-tenofovir af tab COMPLER - emtricitabinerilpivirine-tenofovir df tab CRIXIVN - indinavir sulfate cap 00 CRIXIVN - 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) EDURNT - rilpivirine hcl tab 5 (base equivalent) efavirenz cap 50 (Sustiva) efavirenz cap 00 (Sustiva) efavirenz tab 600 (Sustiva) EMTRIV - emtricitabine caps 00 EMTRIV - emtricitabine soln 0 /ml entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUS - sofosbuvirvelpatasvir tab EPIVIR HBV - lamivudine oral soln 5 /ml (hbv) EPZICOM - abacavir sulfatelamivudine tab BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 6

16 07 EVOTZ - 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 GENVOY - elvitegrav-cobicemtricitab-tenofov af tab HRVONI - ledipasvirsofosbuvir tab INTELENCE - etravirine tab 5 INTELENCE - etravirine tab 00 INTELENCE - etravirine tab 00 INVIRSE - saquinavir mesylate cap 00 INVIRSE - 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) ISENTRESS - raltegravir potassium tab 00 (base equiv) ISENTRESS HD - raltegravir potassium tab 600 (base equiv) JULUC - dolutegravir sodiumrilpivirine hcl tab 50-5 (base eq) KLETR - lopinavir-ritonavir soln /5ml (80-0 /ml) KLETR - lopinavir-ritonavir tab 00-5 KLETR - lopinavir-ritonavir tab lamivudine oral soln 0 / ml (Epivir) lamivudine tab 00 (hbv) (Epivir hbv) lamivudine tab 50 (Epivir) lamivudine tab 300 (Epivir) lamivudine-zidovudine tab (Combivir) LEXIV - fosamprenavir calcium susp 50 /ml (base equiv) LEXIV - fosamprenavir calcium tab 700 (base equiv) lopinavir-ritonavir soln /5ml (80-0 / ml) (Kaletra) MVYRET - glecaprevirpibrentasvir tab 00-0 MODERIB - ribavirin tab 00 & ribavirin 00 tab therapy pack MODERIB - ribavirin tab 00 & ribavirin 600 tab therapy pack 5 5 BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 7

17 07 MODERIB 00 DOSE PCK - ribavirin tab MODERIB 800 DOSE PCK - 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 powder packet 00 NORVIR - ritonavir tab 00 ODEFSEY - emtricitabinerilpivirine-tenofovir af tab oseltamivir phosphate cap 30 (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) PEGSYS - peginterferon alfa-a inj 80 mcg/ml PEGSYS - peginterferon alfa-a inj 80 mcg/0.5ml PEGSYS PROCLICK - peginterferon alfa-a inj 35 mcg/0.5ml PEGSYS 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 PREZIST - darunavir ethanolate susp 00 /ml (base equiv) PREZIST - darunavir ethanolate tab 75 (base equiv) PREZIST - darunavir ethanolate tab 50 (base equiv) PREZIST - darunavir ethanolate tab 600 (base equiv) PREZIST - darunavir ethanolate tab 800 (base equiv) REBETOL - ribavirin soln 0 /ml RELENZ DISKHLER - zanamivir aero powder breath activated 5 /blister RESCRIPTOR - delavirdine mesylate tab 00 RESCRIPTOR - delavirdine mesylate tab 00 REYTZ - atazanavir sulfate cap 50 (base equiv) REYTZ - atazanavir sulfate cap 00 (base equiv) REYTZ - atazanavir sulfate cap 300 (base equiv) 5 BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 8

18 07 REYTZ - atazanavir sulfate oral powder packet 50 (base equiv) RIBSPHERE - ribavirin tab 00 RIBSPHERE - ribavirin tab 600 RIBSPHERE RIBPK - ribavirin tab 00 & ribavirin 00 tab therapy pack RIBSPHERE RIBPK - ribavirin tab 00 & ribavirin 600 tab therapy pack RIBSPHERE RIBPK - ribavirin tab 00 RIBSPHERE RIBPK - 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 SELZENTRY - maraviroc tab 300 SOVLDI - sofosbuvir tab 00 stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 30 (Zerit) stavudine cap 0 (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab SUSTIV - efavirenz cap 50 SUSTIV - efavirenz cap 00 SUSTIV - efavirenz tab 600 TMIFLU - oseltamivir phosphate cap 30 (base equiv) TMIFLU - oseltamivir phosphate cap 5 (base equiv) TMIFLU - oseltamivir phosphate cap 75 (base equiv) TMIFLU - oseltamivir phosphate for susp 6 /ml (base equiv) TECHNIVIE - ombitasvirparitaprevir-ritonavir tab tenofovir disoproxil fumarate tab 300 (Viread) TIVICY - dolutegravir sodium tab 0 (base equiv) TIVICY - dolutegravir sodium tab 5 (base equiv) TIVICY - dolutegravir sodium tab 50 (base equiv) TRIUMEQ - abacavirdolutegravir-lamivudine tab BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 9

19 07 TRUVD - emtricitabinetenofovir disoproxil fumarate tab TRUVD - emtricitabinetenofovir disoproxil fumarate tab TRUVD - emtricitabinetenofovir disoproxil fumarate tab TRUVD - emtricitabinetenofovir disoproxil fumarate tab TYBOST - cobicistat tab 50 valacyclovir hcl tab 500 (Valtrex) valacyclovir hcl tab gm (Valtrex) VLCYTE - valganciclovir hcl for soln 50 /ml (base equiv) 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 VIEKIR PK - ombitasparitapre-riton & dasab tab pak & 50 VIEKIR XR - dasab-ombitparitap-riton tab er hr VIRCEPT - nelfinavir mesylate tab 50 VIRCEPT - nelfinavir mesylate tab 65 3 VIRMUNE - nevirapine susp 50 /5ml VIRZOLE - ribavirin for inhal soln 6 gm VIRED - tenofovir disoproxil fumarate oral powder 0 / gm VIRED - tenofovir disoproxil fumarate tab 50 VIRED - tenofovir disoproxil fumarate tab 00 VIRED - tenofovir disoproxil fumarate tab 50 VIRED - tenofovir disoproxil fumarate tab 300 VOSEVI - sofosbuvirvelpatasvir-voxilaprevir tab ZEPTIER - elbasvirgrazoprevir tab ZERIT - stavudine for oral soln /ml ZIGEN - abacavir sulfate soln 0 /ml (base equiv) zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 300 NTIMLRILS atovaquone-proguanil hcl tab (Malarone) atovaquone-proguanil hcl tab (Malarone) CHLOROQUINE PHOSPHTE - chloroquine phosphate tab 50 chloroquine phosphate tab 500 (ralen) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 0

20 07 CORTEM - artemetherlumefantrine tab 0-0 DRPRIM - pyrimethamine tab 5 hydroxychloroquine sulfate tab 00 (Plaquenil) MEFLOQUINE HCL - mefloquine hcl tab 50 PRIMQUINE PHOSPHTE - primaquine phosphate tab 6.3 (5 base) quinine sulfate cap 3 (Qualaquin) NTHELMINTICS LBENZ - albendazole tab 00 BENZNIDZOLE - benznidazole tab.5 BENZNIDZOLE - benznidazole tab 00 BILTRICIDE - praziquantel tab 600 EMVERM - mebendazole chew tab 00 ivermectin tab 3 (Stromectol) praziquantel tab 600 (Biltricide) NTI-INFECTIVE GENTS - MISC. LINI - nitazoxanide for susp 00 /5ml LINI - nitazoxanide tab 500 atovaquone susp 750 /5ml (Mepron) CYSTON - aztreonam lysine for inhal soln 75 (base equivalent) clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 300 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 dapsone tab 00 IMPVIDO - miltefosine cap 50 3 linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 375 (Flagyl) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) NEBUPENT - pentamidine isethionate for nebulization soln 300 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) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year)

21 07 trimethoprim tab 00 vancomycin hcl cap 5 (Vancocin hcl) vancomycin hcl cap 50 (Vancocin hcl) XIFXN - rifaximin tab 00 XIFXN - rifaximin tab 550 BIOLOGICLS VCCINES ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/ml FLURIX QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUDRIVLENT 08 - influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUBLOK influenza virus vac recombinant hemagglutinin (ha) pf inj FLUBLOK influenza virus vac recombinant hemagglutinin (ha) pf inj FLUCELVX QUDRIVLENT 0 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVX QUDRIVLENT 0 - influenza vac tissuecultured subunit quadrivalent im susp FLULVL QUDRIVLENT 0 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLULVL QUDRIVLENT 0 - influenza virus vaccine split quadrivalent im inj FLUMIST QUDRIVLENT - influenza virus vaccine live quadrivalent intranasal susp 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 08 - influenza virus vac split high-dose pf susp pref syr 0.5ml FLUZONE INTRDERML QUDR - influenza virus vac split quad intradermal pen 9 mcg/strain FLUZONE QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5 ml FLUZONE QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year)

22 07 FLUZONE QUDRIVLENT 08 - influenza virus vaccine split quadrivalent im inj FLUZONE QUDRIVLENT 08 - influenza virus vaccine split quadrivalent inj 0.5 ml HEPLISV-B - hepatitis b vaccine recombinant adjuvanted 0 mcg/0.5ml IMOVX RBIES (H.D.C.V.) - rabies virus vaccine, hdc inj PNEUMOVX 3 - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PNEUMOVX 3/ DOSE - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PREVNR 3 - pneumococcal 3-valent conjugate vaccine inj RBVERT - rabies vaccine, pcec for inj RECOMBIVX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml RECOMBIVX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml SHINGRIX - zoster vaccine recombinant adjuvanted for im inj 50 mcg VIVOTIF - typhoid vaccine cap delayed release ZOSTVX - zoster vaccine live for subcutaneous susp 900 unit/0.65ml 3 DCEL - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml BOOSTRIX - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml DPTCEL - diph, acellular pert & tet tox inj 5 lf-3 mcg-5 lf/0.5ml DIPHTHERI/TETNUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 5-5 unit/0.5ml INFNRIX - diph, acellular pert & tet tox inj 5 lf-58 mcg-0 lf/0.5ml KINRIX - diph-tetanus tox adacell pert & polio virus, ipv vac inj PEDIRIX - diph-tetanus toxacell pert-hepatitis b-polio ipv vac inj PENTCEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for im susp QUDRCEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj TENIVC - tetanus-diphtheria toxoids (td) inj 5- lfu TETNUS/DIPHTHERI TOXOID - tetanus-diphtheria toxoids (td) inj - lf/0.5ml PSSIVE IMMUNIZING GENTS HYQVI - immun glob inj.5 gm/5ml-hyaluron inj 00 unt/.5 ml kit HYQVI - immun glob inj 5 gm/50ml-hyaluron inj 00 unt/.5 ml kit TOXOIDS BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 3

23 07 HYQVI - immun glob inj 0 gm/00ml-hyaluron inj 800 unt/5 ml kit HYQVI - immun glob inj 0 gm/00ml-hyaluron inj 600 unt/0 ml kit HYQVI - immun glob inj 30 gm/300ml-hyaluron inj 00 unt/5 ml kit BIOLOGICLS MISC GRSTEK - timothy grass pollen allergen ext tab sl 800 bau ODCTR - dust mite mixed ext tab sl sq-hdm ORLIR - grass mixed pollen ext tab sl 300 ir (index of reactivity) RGWITEK - short ragweed pollen allergen extract tab sl amb a -u NTINEOPLSTIC GENTS NTINEOPLSTICS CTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) FINITOR - everolimus tab.5 FINITOR - everolimus tab 5 FINITOR - everolimus tab 7.5 FINITOR - everolimus tab 0 FINITOR DISPERZ - everolimus tab for oral susp FINITOR DISPERZ - everolimus tab for oral susp 3 FINITOR DISPERZ - everolimus tab for oral susp 5 LECENS - alectinib hcl cap 50 (base equivalent) LKERN - melphalan tab LUNBRIG - brigatinib tab initiation therapy pack 90 & 80 LUNBRIG - brigatinib tab 30 LUNBRIG - brigatinib tab 90 LUNBRIG - brigatinib tab 80 anastrozole tab (rimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 500 CBOMETYX - cabozantinib s-malate tab 0 (base equivalent) CBOMETYX - cabozantinib s-malate tab 0 (base equivalent) CBOMETYX - cabozantinib s-malate tab 60 (base equivalent) CLQUENCE - acalabrutinib cap 00 capecitabine tab 50 (Xeloda) 3 BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year)

24 07 capecitabine tab 500 (Xeloda) CPRELS - vandetanib tab 00 CPRELS - vandetanib tab 300 COMETRIQ - cabozantinib s- mal cap x 80 & x 0 (00 dose) kit COMETRIQ - cabozantinib s- mal cap x 80 & 3 x 0 (0 dose) kit COMETRIQ - cabozantinib s- malate cap 3 x 0 (60 dose) kit COTELLIC - cobimetinib fumarate tab 0 (base equivalent) CYCLOPHOSPHMIDE - cyclophosphamide cap 5 CYCLOPHOSPHMIDE - cyclophosphamide cap 50 cyclophosphamide cap 5 (Cyclophosphamide) cyclophosphamide cap 50 (Cyclophosphamide) ELIGRD - leuprolide acetate (3 month) for subcutaneous inj kit.5 ELIGRD - leuprolide acetate ( month) for subcutaneous inj kit 30 ELIGRD - leuprolide acetate (6 month) for subcutaneous inj kit 5 ELIGRD - 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 (romasin) FRESTON - toremifene citrate tab 60 (base equivalent) FRYDK - panobinostat lactate cap 0 (base equivalent) FRYDK - panobinostat lactate cap 5 (base equivalent) FRYDK - panobinostat lactate cap 0 (base equivalent) flutamide cap 5 GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 30 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GLEEVEC - imatinib mesylate tab 00 (base equivalent) GLEEVEC - imatinib mesylate tab 00 (base equivalent) GLEOSTINE - lomustine cap 5 GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 00 BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 5

25 07 HEXLEN - altretamine cap 50 HYCMTIN - topotecan hcl cap 0.5 (base equiv) HYCMTIN - topotecan hcl cap (base equiv) hydroxyurea cap 500 (Hydrea) IBRNCE - palbociclib cap 75 IBRNCE - palbociclib cap 00 IBRNCE - palbociclib cap 5 ICLUSIG - ponatinib hcl tab 5 (base equiv) ICLUSIG - ponatinib hcl tab 5 (base equiv) IDHIF - enasidenib mesylate tab 50 (base equivalent) IDHIF - enasidenib mesylate tab 00 (base equivalent) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 00 (base equivalent) (Gleevec) IMBRUVIC - ibrutinib cap 70 IMBRUVIC - ibrutinib cap 0 IMBRUVIC - ibrutinib tab 0 IMBRUVIC - ibrutinib tab 80 IMBRUVIC - ibrutinib tab 0 IMBRUVIC - ibrutinib tab 560 INLYT - axitinib tab INLYT - axitinib tab 5 INTRON - interferon alfa-b inj unit/ml INTRON - interferon alfa-b inj unit/ml INTRON - interferon alfa-b for inj unit INTRON - interferon alfa-b for inj unit INTRON - interferon alfa-b for inj unit IRESS - gefitinib tab 50 JKFI - ruxolitinib phosphate tab 5 (base equivalent) JKFI - ruxolitinib phosphate tab 0 (base equivalent) JKFI - ruxolitinib phosphate tab 5 (base equivalent) JKFI - ruxolitinib phosphate tab 0 (base equivalent) JKFI - ruxolitinib phosphate tab 5 (base equivalent) KISQLI - ribociclib succinate tab 00 (base equiv) KISQLI FEMR 00 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQLI FEMR 00 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQLI FEMR 600 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack LENVIM 0 MG DILY DOSE - lenvatinib cap therapy pack 0 (0 daily dose) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 6

26 07 LENVIM MG DILY DOSE - lenvatinib cap therapy pack 0 & ( daily dose) LENVIM 8 MG DILY DOSE - lenvatinib cap therapy pack 0 & () (8 daily dose) LENVIM 0 MG DILY DOSE - lenvatinib cap therapy pack 0 () (0 daily dose) LENVIM MG DILY DOSE - lenvatinib cap therapy pack 0 () & ( daily dose) LENVIM 8 MG DILY DOSE - lenvatinib cap therapy pack () (8 daily dose) letrozole tab.5 (Femara) LEUCOVORIN CLCIUM - 3 leucovorin calcium tab 0 LEUCOVORIN CLCIUM - 3 leucovorin calcium tab 5 leucovorin calcium tab 5 leucovorin calcium tab 5 LEUKERN - chlorambucil tab LONSURF - trifluridine-tipiracil tab 5-6. LONSURF - trifluridine-tipiracil tab LYNPRZ - olaparib cap 50 LYNPRZ - olaparib tab 00 LYNPRZ - olaparib tab 50 3 LYSODREN - mitotane tab 500 MTULNE - 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 (lkeran) mercaptopurine tab 50 MESNEX - mesna tab 00 METHOTREXTE 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 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) MYLERN - busulfan tab 3 NEXVR - sorafenib tosylate tab 00 (base equivalent) NILNDRON - nilutamide tab 50 nilutamide tab 50 (Nilandron) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 7

27 07 NINLRO - ixazomib citrate cap.3 (base equivalent) NINLRO - ixazomib citrate cap 3 (base equivalent) NINLRO - ixazomib citrate cap (base equivalent) ODOMZO - sonidegib phosphate cap 00 (base equivalent) POMLYST - pomalidomide cap POMLYST - pomalidomide cap POMLYST - pomalidomide cap 3 POMLYST - pomalidomide cap PURIXN - mercaptopurine susp 000 /00ml (0 /ml) RUBR - rucaparib camsylate tab 00 (base equivalent) RUBR - rucaparib camsylate tab 50 (base equivalent) RUBR - rucaparib camsylate tab 300 (base equivalent) RYDPT - midostaurin cap 5 SOLTMOX - tamoxifen citrate oral soln 0 /5ml (base equivalent) SPRYCEL - dasatinib tab 0 SPRYCEL - dasatinib tab 50 SPRYCEL - dasatinib tab 70 5 SPRYCEL - dasatinib tab 80 SPRYCEL - dasatinib tab 00 SPRYCEL - dasatinib tab 0 STIVRG - regorafenib tab 0 SUTENT - sunitinib malate cap.5 (base equivalent) SUTENT - sunitinib malate cap 5 (base equivalent) SUTENT - sunitinib malate cap 37.5 (base equivalent) SUTENT - sunitinib malate cap 50 (base equivalent) SYLTRON - peginterferon alfa-b for inj kit 00 mcg SYLTRON - peginterferon alfa-b for inj kit 300 mcg SYLTRON - peginterferon alfa-b for inj kit 600 mcg TBLOID - thioguanine tab 0 TFINLR - dabrafenib mesylate cap 50 (base equivalent) TFINLR - dabrafenib mesylate cap 75 (base equivalent) TGRISSO - osimertinib mesylate tab 0 (base equivalent) TGRISSO - osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) tamoxifen citrate tab 0 (base equivalent) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 8

28 07 TRCEV - erlotinib hcl tab 5 (base equivalent) TRCEV - erlotinib hcl tab 00 (base equivalent) TRCEV - erlotinib hcl tab 50 (base equivalent) TSIGN - nilotinib hcl cap 50 (base equivalent) TSIGN - nilotinib hcl cap 50 (base equivalent) TSIGN - nilotinib hcl cap 00 (base equivalent) temozolomide cap 5 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 00 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 50 (Temodar) tretinoin cap 0 TREXLL - methotrexate sodium tab 5 (base equiv) TREXLL - methotrexate sodium tab 7.5 (base equiv) TREXLL - methotrexate sodium tab 0 (base equiv) TREXLL - methotrexate sodium tab 5 (base equiv) TYKERB - lapatinib ditosylate tab 50 (base equiv) VENCLEXT - venetoclax tab 0 VENCLEXT - venetoclax tab 50 VENCLEXT - venetoclax tab 00 VENCLEXT STRTING PCK - 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) XLKORI - crizotinib cap 00 XLKORI - crizotinib cap 50 XTNDI - enzalutamide cap 0 ZEJUL - niraparib tosylate cap 00 (base equivalent) ZELBORF - vemurafenib tab 0 ZOLINZ - vorinostat cap 00 ZYDELIG - idelalisib tab 00 ZYDELIG - idelalisib tab 50 ZYKDI - ceritinib cap 50 ZYTIG - abiraterone acetate tab 50 ZYTIG - abiraterone acetate tab 500 BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 9

29 07 ENDOCRINE ND METBOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap 3 (Entocort ec) budesonide tab er hr 9 (Uceris) CORTISONE CETTE - 3 cortisone acetate tab 5 DEXMETHSONE - dexamethasone soln 0.5 /5ml DEXMETHSONE - dexamethasone tab DEXMETHSONE - dexamethasone tab dexamethasone elixir 0.5 /5ml DEXMETHSONE 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) JTT PHYSICINS KIT - triamcinolone inj 0 /ml & lidocaine % & ammonia inh kit MEDROL - methylprednisolone tab methylprednisolone tab therapy pack () (Medrol dosepak) methylprednisolone tab (Medrol) methylprednisolone tab 8 (Medrol) methylprednisolone tab 6 (Medrol) methylprednisolone tab 3 (Medrol) MILLIPRED - prednisolone sod phosphate oral soln 0 /5ml (base equiv) MILLIPRED - prednisolone tab 5 MILLIPRED DP - prednisolone tab therapy pack 5 () MILLIPRED DP - prednisolone tab therapy pack 5 (8) PHYSICINS EZ USE JOINT T - triamcinolone inj 0 /ml & lidocaine % & ammonia inh kit PREDNISOLONE - prednisolone syrup 5 /5ml (usp solution equivalent) 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 30 (base eq) (Orapred odt) prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base) (Pediapred) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year) 0

30 07 prednisolone sod phosphate oral soln 5 /5ml (base equiv) prednisolone sod phosphate oral soln 0 /5ml (base equiv) (Millipred) prednisolone sod phosphate oral soln 0 /5ml (base equiv) (Veripred 0) PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate oral soln 5 /5ml (base eq) 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 UCERIS - budesonide tab er hr 9 VERIPRED 0 - prednisolone sod phosphate oral soln 0 /5ml (base equiv) NDROGEN-NBOLIC NDROL-50 - oxymetholone tab 50 NDRODERM - testosterone td patch hr /hr NDRODERM - testosterone td patch hr /hr NDROGEL - testosterone td gel 0.5 /.5gm (.6%) NDROGEL - testosterone td gel 0.5 /.5gm (.6%) NDROGEL PUMP - testosterone td gel 0.5 /act (.6%) danazol cap 50 danazol cap 00 danazol cap 00 DEPO-TESTOSTERONE - testosterone cypionate im inj in oil 00 /ml DEPO-TESTOSTERONE - testosterone cypionate im inj in oil 00 /ml METHITEST - methyltestosterone oral tab 0 METHYLTESTOSTERONE - methyltestosterone cap 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 BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year)

31 07 testosterone td gel 5 /.5gm (%) (ndrogel) testosterone td gel 50 /5gm (%) (ndrogel) testosterone td gel.5 / act (%) (ndrogel pump) testosterone td soln 30 / act (xiron) ESTROGENS LOR - estradiol td patch twice weekly 0.05 /hr LOR - estradiol td patch twice weekly 0.05 /hr LOR - estradiol td patch twice weekly /hr LOR - estradiol td patch twice weekly 0. /hr NGELIQ - drospirenoneestradiol tab NGELIQ - drospirenoneestradiol tab 0.5- CLIMR PRO - estradiollevonorgestrel td patch weekly /day COMBIPTCH - estradiolnorethindrone ace td pttw /day COMBIPTCH - estradiolnorethindrone ace td pttw /day DIVIGEL - estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL - estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL - estradiol td gel /gm (0.%) DUVEE - conjugated estrogens-bazedoxifene tab ELESTRIN - estradiol gel 0.06% (0.5 /0.87 gm metered-dose pump) estradiol & norethindrone acetate tab (ctivella) estradiol & norethindrone acetate tab -0.5 (ctivella) estradiol tab 0.5 (Estrace) estradiol tab (Estrace) estradiol tab (Estrace) 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 (37.5 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) BCBSMT Health Insurance Marketplace 5 Tier Drug List September (07 Plan Year)