Blue Cross and Blue Shield of Alabama Source+Rx 1.0 Prescription Drug List

Transcription

1 < December 07 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List The Prescription Drug List is regularly updated. Please visit AlabamaBlue.com/pharmacy and click on Prescription Drug Guides for the most up-to-date information. Contents Introduction... I How Drugs are Selected... I Coverage Considerations... I Member Prescription Benefit... II Brand Drugs and Generic Drugs... II Generic Substitution... III Affordable Care Act... III Compound Drugs... IV Contraceptives... IV Specialty... IV Utilization Management... IV... IV... V... V Drugs... V Notice... V Key... VI Therapeutic Class Drug List Anti-Infective Drugs... Biologicals... Antineoplastic Agents... Endocrine and Metabolic Drugs... 0 Cardiovascular Agents... 7 Respiratory Agents Gastrointestinal Agents Genitourinary Agents Central Nervous System Drugs... 6 Analgesics and Anesthetics Neuromuscular Drugs Nutritional Products Hematological Agents Topical Products Miscellaneous Products... 8 Index... 7 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. Prime Therapeutics LLC, an independent company, provides pharmacy benefit management services for Blue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association. 57-L AL HIM Prime Therapeutics LLC /7

2 Introduction The attached Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List shows covered drugs for a broad range of diseases. 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. Brand prescription drugs are shown in capital letters followed by the generic name. The Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List is organized into broad categories (e.g. anti-infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. penicillins) or by use for a specific medical condition (e.g. diabetes). 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. The current version of this Prescription Drug List is available by visiting AlabamaBlue.com/pharmacy and clicking on Prescription Drug Guides or by calling the customer service number listed on the back of your identification card. Online pharmacy tools are available at AlabamaBlue.com/pharmacy. Blue Cross members can find drug cost estimates or check if a particular drug is on the Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List. How Drugs are Selected for Coverage and Tier Placement Covered drugs on this list are selected and placed into tiers (refer to Member Prescription Benefit section) based on the recommendations of a Pharmacy and Therapeutics (P&T) Committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from the health insurer or claims administrator of your health plan, reviews prescription drugs regulated by the U.S. Food and Drug Administration (FDA) based on safety, efficacy, and uniqueness. Once drugs are deemed appropriate for coverage, and safety and efficacy have been evaluated, cost may be considered to determine final tier placement and coverage requirements. Drugs are reviewed by the P&T Committee when newly approved by the FDA and at least annually after initial review. Drug coverage is subject to change at any time but the drug list will be updated monthly. There are many reasons why drug coverage or tier placement may change. Some examples are listed below. The tier level of a drug may increase or the drug may no longer be covered when an equivalent generic drug becomes available. The tier level of a drug may decrease if the cost of the drug decreases. Additional Coverage Considerations Coverage is limited to prescription drugs approved by the Food and Drug Administration (FDA) as evidenced by a New Drug Application (NDA), Abbreviated New Drug Application (ANDA), or Biologics License Application (BLA) on file. Any legal requirements or group specific benefits for coverage will supersede this (e.g. preventive drugs per the Affordable Care Act). Newly marketed prescription drugs will not be covered until the P&T Committee has had an opportunity to review the drug, to determine whether the drug will be covered and if so, which tier will apply based on safety, efficiacy, and the availability of other products within that class of drugs. If your physician feels that a new drug is medically necessary prior to P&T Committee evaluation, a non-formulary exception request for coverage may be submitted. Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List, December 07 I

3 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 drugs. Maintenance drugs are those drugs you may take on an ongoing basis for chronic conditions such as high blood pressure, diabetes or high cholesterol. You should refer to your benefit plan booklet for details about your particular benefits. Member Prescription Benefit The Blue Cross prescription benefit is multi-tiered, placing prescription drugs into one of six tier levels. Tier primarily contains preferred (lowest cost) generic drugs (but may include low cost brands), Tier primarily contains non-preferred generic drugs (higher in cost but covered for efficacy or uniqueness purposes). Similar to Tier, based on cost consideration, there may be brands placed into this tier on occasion as well. Tier primarily contains preferred (based on efficiacy, uniqueness, safety advantages, and/or cost considerations) brands. Tier primarily contains non-preferred (less preferred compared to alternatives available based on efficiacy, uniqueness, safety, and cost) brands. Tier 5 primarily contains preferred specialty drugs, and Tier 6 contains primarily non-preferred specialty drugs. All tiers may contain drugs otherwise categorized as generic, brand, or specialty. Preferred drugs may offer a clinical or cost advantage over non-preferred drugs within the same therapeutic category. Coverage and copayment/co-insurance levels vary depending on the plan. Drugs that require, Step Therapy, or that have or are considered are noted in the Prescription Drug List. Tier - primarily preferred generics Tier - primarily non-preferred generics Tier - primarily preferred brands Tier - primarily non-preferred brands Tier 5 - primarily preferred specialty Tier 6 - primarily non-preferred specialty Note: An displayed in the drug tier field indicates the drug may only be covered if a member meets criteria for $0 preventative coverage under the Affordable Care Act (ACA). If a member does not meet ACA coverage criteria, these drugs are not covered under the plan but may be available over the counter without a prescription. Brand Drugs and Generic Drugs Classification Prescription drugs are classified as either a Brand drug or a Generic drug. Blue Cross uses the Brand or Generic status provided by a nationally recognized company providing drug product information. The Brand/Generic status for a specific drug/specific marketer can sometimes change over the life of a product in the marketplace and change from Brand to Generic or from Generic to Brand. Such changes might change your copayment/co-insurance share. Brand drug or Generic drug status is never based upon a product having a trade name. Generic drugs often have trade names. Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List, December 07 II

4 Generic Substitution Blue Cross encourages generic utilization as a way to provide high quality drugs at a reduced cost. Generic drugs are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are manufactured under the same strict requirements of FDA s current Good Manufacturing Practice regulations required for Brand drugs and cover the manufacturing, and identity, strength, purity and quality. An FDA-approved Generic drug may be substituted for the Brand counterpart when it: Contains the same active ingredient(s) as the brand drug; Is identical in strength, dosage form and route of administration; and Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile. Affordable Care Act Drugs marked with a dot in the ACA column may have limited or $0 member cost-sharing under the Affordable Care Act if certain criteria are met. Examples of categories of drugs that may be subject to limited or $0 member cost share include aspirin, breast cancer prevention drugs, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation drugs, vaccines, vitamin D supplements, and some contraceptive drugs and devices. If you do not find the drug you are searching for, consult or contact Blue Cross to find out if the drug is available over the counter or is covered under your medical benefit. Please visit AlabamaBlue.com/pharmacy and click on Prescription Drug Guides to obtain a list of drugs available under the ACA. Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List, December 07 III

5 Compound Drugs Compound drugs are defined as a drug product made or modified to have characteristics that are specifically prescribed for an individual patient when commercial drug products are not available or appropriate. To be eligible for coverage, compounded drugs must contain at least one FDA-approved prescription ingredient and must not be a copy of a commercially available product. Compounds containing any ingredient not approved by the FDA will not be covered. All compounded drugs are subject to review and may require prior authorization. Drugs used in compounded drugs may be subject to additional coverage criteria and utilization management edits. Compounds are covered only when medically necessary. Compound drugs are always classified as the highest cost-sharing non-specialty drug Tier. Contraceptives Under the Affordable Care Act, members are provided coverage for select FDA-approved contraceptive methods and drugs at a $0 member cost-share. If a contraceptive drug is available at $0 member cost-share, it will be noted next to the drug with a dot under the ACA column. If you have health coverage through your employer, some or all of the contraceptive methods or prescription drugs listed in this Prescription Drug Guide may not be covered under your plan because of your employer s religious beliefs. To find out if contraceptive methods and prescription drugs are excluded, you may find this information in the exclusions section of your benefit booklet or you may contact your group administrator. Specialty Drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid arthritis. Specialty drugs covered under this prescription benefit may be oral or injectable medications may be self-administered. Blue Cross members must obtain their specialty drugs from Prime Therapeutics Specialty Pharmacy Network as the preferred provider. If the preferred provider is not utilized you may be responsible for up to 00 percent of the drug cost. If you have questions about your coverage for specialty drugs or your prescription drug benefit, call the number on the back of your ID card. You may also visit AlabamaBlue.com/pharmacy and click on Prescription Drug Guides to obtain a complete listing of specialty drugs. Utilization Management Blue Cross is committed to supporting proper selection and use of drugs for its members. To help assure these goals are met, several programs have been developed to promote drug selection that encourages both cost-effectiveness and safety. Detailed coverage criteria can be found by visiting AlabamaBlue.com/pharmacy and clicking on Prescription Drug Guides. Drugs requiring or, or drugs with will be noted in the Therapeutic Class Drug List portion of the Prescription Drug List. Your benefit plan includes a step therapy program. This means you may need to try another proven, costeffective drug before coverage may be available for the drug included in the step therapy program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. If step therapy is required for a drug listed in this document, it will be noted next to the drug with a dot under the step therapy column. Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List, December 07 IV

6 Your benefit plan may require prior authorization for certain drugs that have the potential for misuse. 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 drug will be covered under your plan. If prior authorization is required for a drug listed in this document, it will be noted next to the drug with a dot under the prior authorization column. Drug dispensing limits help encourage drug use as intended by the FDA. Dispensing limits are placed on drugs in certain categories for safety reasons. For the drugs listed in this document, if a dispensing limit applies, it will be noted next to the drug with a dot under the dispensing limits column. Limits may include: quantity of covered drug per prescription and/or quantity of covered drug in a given time period. If your doctor prescribes a greater quantity of drug than what the dispensing limit allows, you can still get the drug. However, you will be responsible for the full cost of the prescription beyond what your coverage allows or your doctor will need to submit a request for an exception to the dispensing limit. If a dispensing limit applies for a drug listed in this document, it will be noted next to the drug with a dot under the dispensing limit column. For a list of drugs and their dispensing limits, visit AlabamaBlue.com/pharmacy and click on Prescription Drug Guides. Drugs Limited distribution drugs have a restriction on which pharmacies have access to and can dispense certain drugs, thereby limiting where the member may obtain the prescription. Blue Cross members may be required to use Prime Therapeutics Specialty Pharmacy Network or other pharmacy for limited distribution prescription drugs. If a drug has limits on where it can be filled, it will be noted next to the drug with a dot under the limited distribution column. Notice The purpose of the Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List is to provide a guide to coverage. This Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List is not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients. Drug List, nor the successful adjudication of a pharmacy claim, is guarantee of payment Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List, December 07 V

7 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List, December 07 VI

8 Notice of Nondiscrimination Blue Cross and Blue Shield of Alabama complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Alabama: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages If you need these services, contact our 557 Compliance Coordinator. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person or by mail, fax, or at: Blue Cross and Blue Shield of Alabama, Compliance Office, 50 Riverchase Parkway East, Birmingham, Alabama 5, Attn: 557 Compliance Coordinator, , 7 (TTY), (fax), 557Grievance@bcbsal.org ( ). If you need help filing a grievance, our 557 Compliance Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Service, 00 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 00, , (TDD). Complaint forms are available at Foreign Language Assistance Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 7) Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 7) 번으로전화해주십시오. Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 7) Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 7). انتباه: إذا كنت تتحدث العربية توجد خدمات مساعدة فيما يتعلق باللغة بدون تكلفة متاحة لك. اتصل ب Arabic: )الهاتف النصي: 7(.

9 German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 7). French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 7). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 7). Gujarati: ધ ય ન આપ : જ તમ ગ જર ત બ લત હ ય, ત ભ ષ સહ યત સ વ, તમ ર મ ટ નન શ લ ક ઉપલબ ધ છ પર ક લ કર (TTY: 7). Tagalog: PAUWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 7). Hindi: ध य न द : अगर आपक भ ष ह द ह, त आपक ल ए भ ष सह यत स व ए नन श ल क उप ब ध ह (TTY: 7) पर क कर Laotian: ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 7). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7). Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 7). Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 7). Turkish: DİKKAT: Eğer Türkçe konuşuyor iseniz, dil yardımı hizmetlerinden ücretsiz olarak yararlanabilirsiniz (TTY: 7) irtibat numaralarını arayın. Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 7). Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 7) まで お電話にてご連絡ください

10 07 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/CLAVULATE P - amoxicillin & k clavulanate chew tab AMOXICILLIN/CLAVULATE 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 MOXATAG - amoxicillin (trihydrate) tab er hr 775 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 CEDAX - ceftibuten cap 00 cefaclor cap 50 cefaclor cap 500 cefadroxil cap 500 cefadroxil for susp 50 /5ml Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07

11 07 cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 00 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 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 SUPRAX - cefixime for susp 00 /5ml SUPRAX - cefixime for susp 00 /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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07

12 07 E.E.S erythromycin ethylsuccinate tab 00 ERY-TAB - erythromycin tab delayed release 50 ERY-TAB - erythromycin tab delayed release 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 BASE - erythromycin tab 50 ERYTHROMYCIN BASE - erythromycin tab 500 ERYTHROMYCIN ETHYLSUCCI - erythromycin ethylsuccinate tab 00 erythromycin ethylsuccinate for susp 00 /5ml (E.e.s. granules) 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) Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07

13 07 MINOCYCLINE HCL ER - minocycline hcl tab er hr 5 minocycline hcl tab er hr 90 minocycline hcl tab er hr 5 minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 00 TETRACYCLINE HCL - tetracycline hcl cap 50 TETRACYCLINE HCL - tetracycline hcl cap 500 tetracycline hcl cap 50 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) FLUOROQUINOLONES ciprofloxacin for oral susp 50 /5ml (5%) (5 gm/00ml) (Cipro) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXACIN HCL - ciprofloxacin hcl tab 00 (base equiv) ciprofloxacin hcl tab 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) FACTIVE - gemifloxacin mesylate tab 0 (base equiv) 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 amikacin sulfate inj 500 /ml (50 /ml) amikacin sulfate inj gm/ml (50 /ml) BETHKIS - tobramycin nebu soln 00 /ml KITABIS PAK - tobramycin nebu soln 00 /5ml neomycin sulfate tab 500 paromomycin sulfate cap 50 TOBI PODHALER - tobramycin inhal cap 8 TOBRAMYCIN - tobramycin nebu soln 00 /5ml tobramycin nebu soln 00 /5ml (Tobi) TOBRAMYCIN SULFATE - tobramycin sulfate inj 0 / ml (base equivalent) Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07

14 07 TOBRAMYCIN SULFATE - tobramycin sulfate inj gm/50ml (0 /ml) (base equiv) tobramycin sulfate inj 80 /ml (0 /ml) (base equiv) tobramycin sulfate inj. gm/0ml (0 /ml) (base equiv) SULFOMIDES 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) 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 5

15 07 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 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 5 (Videx ec) 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) 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) Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 6

16 07 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) ISENTRESS - raltegravir potassium tab 00 (base equiv) ISENTRESS HD - raltegravir potassium tab 600 (base equiv) 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) MODERIBA - ribavirin tab 00 & ribavirin 00 tab therapy pack 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 7

17 07 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) PEGASYS - peginterferon alfa-a inj 80 mcg/ml PEGASYS - peginterferon alfa-a inj 80 mcg/0.5ml 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 PEGINTRON - peginterferon alfa-b for inj kit 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 0 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREZCOBIX - 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) 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 8

18 07 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) SELZENTRY - maraviroc oral soln 0 /ml SELZENTRY - maraviroc tab 5 SELZENTRY - maraviroc tab 75 SELZENTRY - maraviroc tab 50 SELZENTRY - maraviroc tab 00 SOVALDI - sofosbuvir tab 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 TIVICAY - dolutegravir sodium tab 0 (base equiv) TIVICAY - dolutegravir sodium tab 5 (base equiv) TIVICAY - dolutegravir sodium tab 50 (base equiv) 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) VALCYTE - valganciclovir hcl for soln 50 /ml (base equiv) 6 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 9

19 07 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 65 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 ZEPATIER - elbasvirgrazoprevir tab 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 tab 50 PRIMAQUINE PHOSPHATE - primaquine phosphate tab 6. (5 base) quinine sulfate cap (Qualaquin) ANTHELMINTICS ALBENZA - albendazole tab 00 BILTRICIDE - praziquantel tab 600 ivermectin tab (Stromectol) STROMECTOL - ivermectin tab ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 00 /5ml ALINIA - nitazoxanide tab 500 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 0

20 07 atovaquone susp 750 /5ml (Mepron) CAYSTON - aztreonam lysine for inhal soln 75 (base equivalent) clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 00 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 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) 6 sulfamethoxazoletrimethoprim tab (Bactrim ds) tinidazole tab 50 (Tindamax) tinidazole tab 500 (Tindamax) trimethoprim tab 00 TRIMPEX - trimethoprim hcl oral soln 50 /5ml (base equiv) 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07

21 07 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 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 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 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 GARDASIL - human papillomavirus (hpv) quadrivalent recombinant vac inj GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im susp Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07

22 07 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 HIBERIX - haemophilus b polysaccharide conjugate vac for inj 0 mcg IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj IPOL ICTIVATED IPV - poliovirus vaccine, ipv injection M-M-R II - measles, mumps & rubella virus vaccines for inj MECTRA - 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 PREVR - pneumococcal -valent conjugate vaccine inj PROQUAD - measles-mumpsrubella-varicella virus vaccines for inj RABAVERT - rabies vaccine, pcec for inj RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 5 mcg/0.5ml RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp 0 mcg/ml ROTARIX - rotavirus vaccine, live for oral susp ROTATEQ - rotavirus vaccine, live oral pentavalent soln TRUMENBA - meningococcal group b vac (recomb) im susp prefilled syr TWINRIX - hepatitis a (inact)- hep b (recomb) vac inj 70-0 elu-mcg/ml VAQTA - hepatitis a vaccine inj susp 5 unit/0.5ml VAQTA - hepatitis a vaccine inj susp 50 unit/ml VARIVAX - varicella virus vac live for subcutaneous inj 50 pfu/0.5ml ZOSTAVAX - zoster vaccine live for subcutaneous susp 900 unit/0.65ml 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07

23 07 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 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 PASSIVE IMMUNIZING AGENTS GAMUNEX-C - immune globulin (human) iv or subcutaneous soln gm/0ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln.5 gm/5ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 5 gm/50ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 0 gm/00ml HIZENTRA - immune globulin (human) subcutaneous inj gm/5ml HIZENTRA - immune globulin (human) subcutaneous inj gm/0ml HIZENTRA - immune globulin (human) subcutaneous inj gm/0ml HIZENTRA - immune globulin (human) subcutaneous inj 0 gm/50ml HYQVIA - immun glob inj.5 gm/5ml-hyaluron inj 00 unt/.5 ml kit HYQVIA - immun glob inj 5 gm/50ml-hyaluron inj 00 unt/.5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 800 unt/5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 600 unt/0 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 00 unt/5 ml kit ANTINEOPLASTIC AGENTS ANTINEOPLASTICS ACTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) AFINITOR - everolimus tab.5 AFINITOR - everolimus tab Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07

24 07 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) ALFERON N - interferon alfan inj unit/ml ALUNBRIG - brigatinib tab 0 anastrozole tab (Arimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) 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) capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA - vandetanib tab 00 CAPRELSA - vandetanib tab 00 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 5

25 07 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) FIRMAGON - degarelix acetate for inj 80 (base equiv) FIRMAGON - degarelix acetate for inj 0 (base equiv) flutamide cap 5 GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (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 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) ICLUSIG - ponatinib hcl tab 5 (base equiv) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 00 (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 0 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 6

26 07 INTRON A W/DILUENT - interferon alfa-b for inj unit INTRON A W/DILUENT - interferon alfa-b for inj unit INTRON A W/DILUENT - 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 LEUCOVORIN CALCIUM - leucovorin calcium tab 5 leucovorin calcium tab 5 leucovorin calcium tab 5 LEUKERAN - chlorambucil tab LONSURF - trifluridine-tipiracil tab 5-6. LONSURF - trifluridine-tipiracil tab LYNPARZA - olaparib cap 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 Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 7

27 07 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 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) NILANDRON - nilutamide tab 50 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 PURIXAN - mercaptopurine susp 000 /00ml (0 /ml) 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) Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 8

28 07 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 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) TASIG - nilotinib hcl cap 50 (base equivalent) TASIG - 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 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 VOTRIENT - pazopanib hcl tab 00 (base equiv) XALKORI - crizotinib cap 00 XALKORI - crizotinib cap 50 XTANDI - enzalutamide cap Blue Cross and Blue Shield of Alabama Source+Rx.0 Prescription Drug List December 07 9