Your Drug Lists. See Inside: 2018 Extra Covered Drugs 2018 Part D Formulary (List of Covered Drugs) Bonus: $0 Copay Select Generics

Transcription

1 Your Lists See Inside: 08 Extra Covered s 08 Part D Formulary (List of Covered s) Bonus: $0 Copay Select Generics

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3 Your Extra Covered s for 08 The prescription drugs in this list are covered above and beyond the drugs in your plan's Part D formulary. Y0_8_066_I_07 05//07 696MUSENMUB_07_ABC_MLP ECDMLP_v_80_

4 This booklet shows you which Extra Covered s are included in your plan. This list may change at any time. You will receive notice when necessary. For the full list of your covered Part D drugs, please refer to your formulary booklet. Your plan includes cough/cold medications, vitamins/minerals and life style drugs that are not normally covered under a Part D plan. How do "Extra Covered s" fit into your plan s prescription drug benefits? "Extra Covered s" are separate from your Part D coverage. If you fill a prescription for one of these drugs, the cost does not count toward your true out-of-pocket (TrOOP) expenses. These drugs do not qualify for lower Part D catastrophic copays. Like your covered Part D drugs, your cost for "Extra Covered s" is based on the tier each drug is in. You can find the tier number next to the drug name in the chart below. You can find the cost for each drug tier by checking the benefit chart in your Evidence of Coverage. If you are receiving Medicare s "Extra Help" to pay for your prescriptions, this program will not lower your cost for these drugs. We're here to answer your questions. Please call Member Services at the number listed on your membership card if you have any questions about this benefit. ECDMLP_v_80_

5 List of Extra Covered s Legend Generic drugs are shown in lower-case italics. Brand name drugs are shown in capital letters. QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled. This is most often set on a monthly basis. - Mail Order: Prescription drugs available through mail order. Name / Limits Name STENDRA VIAGRA Obstetrics / Gynecology OSPHENA Antineoplastic / Immunosuppressant s IODOPEN Cardiovascular, Hypertension / Lipids MEPHYTON PHYTONADIONE (VITAMIN K) INJECTION vitamin k vitamin k injection Dermatologicals/Topical Therapy NSEL'S TOPICAL SOLUTION Diagnostics / Miscellaneous Agents FERRLECIT sodium ferric gluconatsucrose Endocrine/Diabetes SSKI Erectile Dysfunction CAVERJECT ; QLL (6 EA per 0 CAVERJECT IMPULSE ; QLL (6 EA per 0 CIALIS ; QLL (6 EA per 0 EDEX ; QLL (6 EA per 0 LEVITRA ; QLL (6 EA per 0 MUSE ; QLL (6 EA per 0 STAXYN ; QLL (6 EA per 0 Respiratory And Allergy benzonatate BROMFED DM brompheniraminepseudoeph-dm oral syrup CAPCOF cheratussin ac codeine-guaifenesin CODITUSSIN AC CODITUSSIN DAC FLOWTUSS g tussin ac guaiatussin ac guaifenesin ac guaifenesin dac HISTEX-AC HYCOFENIX hydrocodonechlorpheniramine hydrocodone-cpmpseudoephed hydrocodone-homatropine oral syrup 5-.5 mg/5 ml / Limits ; QLL (6 EA per 0 ; QLL (6 EA per 0 ; QLL (0 EA ECDMLP_v_80_

6 Name HYDROCODONE- HOMATROPINE ORAL SYRUP 5-.5 /5 ML (5 ML) hydrocodone-homatropine oral tablet hydromet lortuss ex oral syrup m-clear wc M-END PE MAR-COF BP MAR-COF CG NINJACOF-XG OBREDON phenylhistine dh POLY-TUSSIN AC ORAL LIQUID -0-0 /5 ML PRO-RED AC (W/ DEXCHLORPHENIR) promethazine vc-codeine promethazine-codeine promethazine-dm promethazine-phenylephcodeine relcof c RESPA-AR REZIRA rydex TESSALON PERLES tusnel c TUSNEL PEDIATRIC ORAL LIQUID TUSSICAPS tussigon TUSSIONEX PENNKINETIC ER TUZISTRA XR virtussin ac virtussin dac Z-TUSS AC ZODRYL AC 5 ZODRYL AC 0 ZODRYL AC 5 ZODRYL AC 0 ZODRYL AC 50 ZODRYL AC 60 ZODRYL AC 80 ZODRYL DAC 5 / Limits Name ZODRYL DAC 0 ZODRYL DAC 5 ZODRYL DAC 0 ZODRYL DAC 50 ZODRYL DAC 60 ZODRYL DAC 80 ZODRYL DEC 5 ZODRYL DEC 0 ZODRYL DEC 5 ZODRYL DEC 0 ZODRYL DEC 50 ZODRYL DEC 60 ZODRYL DEC 80 ZUTRIPRO Vitamins, Hematinics / Electrolytes AQUASOL A ascorbic acid (vitamin c) injection b complex 00 injection BIFERA RX CARDIOTEK-RX (BIOPERINE) centratex chromium chloride corvita corvita 50 CORVITE CORVITE FE ORAL TABLET 50 IRON- dialyvite DIALYVITE 000 DIALYVITE 5000 DIALYVITE 800 WITH IRON DIALYVITE SUPREME D ergocalciferol (vitamin d) oral capsule fabb FERAHEME ferocon FERRALET 90 DUAL-IRON DELIVERY ferrex 50 forte ferrex 50 forte plus ferrocite plus focalgin dss folbee folbee ar / Limits ECDMLP_v_80_

7 Name folbee plus oral tablet mg folbic FOLGARD OS FOLGARD RX folic acid injection folic acid oral tablet mg folic acid-vit b6-vit b oral tablet mg folivane-f folivane-plus folplex. FOLTRATE GALZIN hematinic plus vit/minerals hematinic/folic acid hematogen hematogen fa hematogen forte HEMATRON-AF hemetab hydroxocobalamin iferex 50 forte infed INFUVITE ADULT INFUVITE PEDIATRIC INTEGRA F INTEGRA PLUS IROSPAN /6 lugols oral m.v.i. adult M.V.I. PEDIATRIC manganese chloride manganese sulfate intravenous multigen folic MULTITRACE- MULTITRACE- CONCENTRATE MULTITRACE- NEONATAL multitrace- pediatric MULTITRACE-5 MULTITRACE-5 CONCENTRATE myferon 50 forte mynephrocaps / Limits Name mynephron NASCOBAL nephplex rx nephro-vite rx NEPHRON FA NEURIN-SL poly-iron 50 forte POTABA ORAL CAPSULE PROFERRIN-FORTE PROTECT IRON purevit dualfe plus pyridoxine (vitamin b6) injection rena-vite rx renal caps reno caps se-tan plus selenium intravenous strong iodine oral SUPERVITE TANDEM PLUS taron forte thiamine hcl (vitamin b) injection tl g-fol os tl gard rx tl icon tl-hem 50 TRACE ELEMENTS / PEDIATRIC tricon trigels-f forte triphrocaps UDAMIN SP VENOFER INTRAVENOUS SOLUTION 00 IRON/5 ML, 00 IRON/0 ML VENOFER INTRAVENOUS SOLUTION 50 IRON/.5 ML virt-gard virt-vite virt-vite forte vit VITAFOL VITAL-D RX / Limits 5 ECDMLP_v_80_

8 Name vitamin d vol-care rx vp-vite rx vp-zel zinc chloride zinc sulfate intravenous solution 5 mg/ml zinc sulfate oral capsule / Limits 6 ECDMLP_v_80_

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10 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

11 Part D Formulary <65505MUSENMUB_XXXXXX> 8MEDDIV

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13 Your Blue Cross MedicareRx (PDP) with Senior Rx Plus 08 Part D Formulary (List of Covered s) with $0 copay Select Generics Your Medicare Prescription benefits and Senior Rx Plus benefits cover the same Part D Formulary (drug list). Please read: This document contains information about the drugs we cover in this plan. Y0_8_806_I_UC7 09//07 Last updated August 6, 07 ETC_7_89_v6_80_

14 Note to members: Please review this Part D Formulary Please review this document to make sure that it contains the drugs you take. When this Part D Formulary ( List) refers to we, us or our, it means Anthem Blue Cross. When it refers to plan or your plan, it means your 08 group retiree drug plan. This document includes a list of the covered Part D drugs for our plan which is current as of January, 08. For updated formulary information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the back cover. You must generally use network pharmacies to use your prescription drug benefi t. Your formulary and pharmacy network may change on January, 09, and from time to time during the year. You will receive notice when necessary. Depending on your group sponsor s renewal date, your benefi ts, premium or copayments/coinsurance may also change on January, 09. The benefit information provided is not a complete description of benefi ts. Limitations, copayments and restrictions may apply. Please refer to your Evidence of Coverage for information specific to your plan. Our plan has free language interpreter services available to answer questions from non-english speaking members. Please call the Member Services number listed on the back cover to request interpreter services. This document may be available in an alternate format, such as large print. Please call the Member Services phone number on the back cover for additional information. This formulary was updated on August 6, 07. For more recent information or other questions, please contact us, Anthem Blue Cross, at or, for TTY users, 7, Monday through Friday, 5:00 a.m. to 8:00 p.m. PT, except holidays, or visit

15 Table of Contents What is the Blue Cross MedicareRx (PDP) with Senior Rx Plus Part D Formulary?... Can the Part D Formulary ( List) change?... How do I use the Part D Formulary?... What are generic drugs?... Are there any restrictions on my coverage?... What if my drug is not on the Part D Formulary?... How do I request an exception to the Blue Cross MedicareRx (PDP) with Senior Rx Plus Part D Formulary?... What do I do before I can talk to my doctor about changing my drugs or requesting an exception?...5 For more information...5 Your plan s Part D Formulary...6 Select Generics...7 Covered Medications by Therapeutic Category Part D-Eligible s...0 Index of s...7

16 What is the Blue Cross MedicareRx (PDP) with Senior Rx Plus Part D Formulary? A formulary is a list of covered Part D drugs selected by us in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Your plan will generally cover the drugs listed in the formulary as long as you follow these basic rules: y The drug is medically necessary. y The prescription is filled at a network pharmacy and other plan rules are followed. y The drug is a Medicare Part D-eligible drug. Medicare Part D-eligible drugs are all approved by the Food and Administration (FDA) and if brand, the drug manufacturer has agreed to provide the Coverage Gap Discount. The drugs covered under your retiree drug coverage are listed in this document. If your plan uses a Closed List (Closed Formulary), you have coverage for most, but not all, Medicare Part D-eligible drugs. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. Not all drugs are on the Closed Formulary. If your plan uses an Open List (Open Formulary), you have coverage for almost all Medicare Part D-eligible drugs. For both types of formularies, some drugs may sometimes be covered under the medical benefits of your plan rather than under the drug benefit of your plan. Some of the drugs that are covered under your medical benefits are marked with a B/D in this drug list. You may also have coverage for certain additional drugs not covered by Medicare Part D plans. These drugs are referred to as Extra Covered s and are covered by your Senior Rx Plus supplemental benefits. You can find out which specific drugs are covered by checking your Extra Covered list. To find out whether you have a Closed or Open Formulary benefit or if your plan includes coverage for additional drugs, please check the benefit chart located at the front of your Evidence of Coverage. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Part D Formulary change? Generally, if you are taking a drug on our 08 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 08 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. There are three instances when a drug listed as covered on your Part D Formulary may immediately be removed from our formulary, and you may not receive notification:

17 . The FDA deems a drug on our formulary to be unsafe,. The drug s manufacturer removes the drug from the market, or. The Centers for Medicare & Medicaid Services (CMS) notifies us that they no longer consider a drug to be Part D eligible. We evaluate new drugs as they come onto the market. Once we have completed a full evaluation based upon clinical effectiveness and cost relative to other drug therapies, the drug will be assigned to a drug plan tier or non-formulary designation. If a new Part D-eligible drug is designated as non-formulary following our review, this drug will not be covered on a Closed Formulary. You will have coverage for it only if your plan uses an Open Formulary. Please note that during the period between the time the drug is first available and our review, the drug will not be automatically covered on an Open Formulary. If your physician feels you should use the new drug, you or your physician may request a coverage exception. This formulary is current as of January, 08. To get updated information about the drugs covered by your plan, please contact us. Our contact information appears on the back cover. How do I use the Part D Formulary? There are two ways to find your drug within the formulary: Medical condition The formulary begins on page 0. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Medication. If you know what your drug is used for, look for the category name in the list that begins on page 0. Then look under the category name for your drug. Alphabetical listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 7. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and fi nd your drug. Next to your drug, you will see the page number where you can fi nd coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Your plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

18 y Prior authorization: Your plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, your plan may not cover the drug. y Quantity limits: For certain drugs, we limit the amount of the drug that we will cover. For example, we cover 0 tablets per 0 days of irbesartan 75 mg tablets. This may be in addition to a standard one-month or three-month supply. y Step therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can fi nd out if your drug has any additional requirements or limits by looking in the formulary that begins on page 0. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the plan s formulary? for information about how to request an exception. What if my drug is not on the Part D Formulary? If you learn that access to your drug is limited, for any reason, you have two options: y You can ask Member Services for a list of similar drugs that are covered by your plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by your plan. y You can ask your plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Blue Cross MedicareRx (PDP) with Senior Rx Plus Part D Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. y You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. y You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. y You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

19 Generally, your plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescribing provider supporting your request. Generally, we must make our decision within 7 hours of getting your provider s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your prescribing provider. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will cover a temporary 98-day transition supply consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please contact us. Our contact information, along with the date we last updated this formulary, appears on the back cover. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ), hours a day/7 days a week. TTY users should call Or visit 5

20 Your plan s Part D Formulary The formulary that begins on page 0 provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 7. The fi rst column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., enalapril). The second column of the chart identifi es the tier placement of each medication covered in your formulary. Our drug plans group drugs based upon cost with the lowest cost drugs in. These are typically generic drugs. Some more expensive generic drugs may be on a higher tier. To fi nd out what your copayment is for each drug tier, please check the benefit chart located at the front of your Evidence of Coverage. Your drug plan benefit chart uses the following tier labels: Number Label Generics Preferred Brands Non-preferred Brands Specialty s (Generic and Brand) The benefit chart in your Evidence of Coverage will also tell you if the amount that you pay for covered drugs changes after the total drug cost paid by you and the plan reaches the initial coverage amount of $,750. Please check your benefit chart and Evidence of Coverage for complete details on the cost you must pay for drugs covered by your drug plan. The third column tells you if your plan has any special requirements for coverage of your drug. The formulary chart legend, located on page 0, contains the list of special requirements which can be applied to drugs in your plan. The legend also gives you a description of the restriction and the code used in the drug chart to tell you that the restriction applies to a specific drug. 6

21 Select Generics for 08 The following drugs are covered under your retiree drug plan at $0 copay. Legend QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled. This is most often set on a monthly basis. - Mail Order: Prescription drugs available through mail order. Name Antihypertensive Therapy atenolol oral tablet 00 mg atenolol oral tablet 5 mg atenolol oral tablet 50 mg atenolol-chlorthalidone oral tablet 00-5 mg atenolol-chlorthalidone oral tablet 50-5 mg benazepril oral tablet 0 mg benazepril oral tablet 0 mg benazepril oral tablet 0 mg benazepril oral tablet 5 mg benazepril-hydrochlorothiazide oral tablet 0-.5 mg benazepril-hydrochlorothiazide oral tablet 0-.5 mg benazepril-hydrochlorothiazide oral tablet 0-5 mg benazepril-hydrochlorothiazide oral tablet mg bisoprolol-hydrochlorothiazide oral tablet mg bisoprolol-hydrochlorothiazide oral tablet mg bisoprolol-hydrochlorothiazide oral tablet mg captopril oral tablet 00 mg captopril oral tablet.5 mg captopril oral tablet 5 mg captopril oral tablet 50 mg captopril-hydrochlorothiazide oral tablet 5-5 mg / Limits Name captopril-hydrochlorothiazide oral tablet 5-5 mg captopril-hydrochlorothiazide oral tablet 50-5 mg captopril-hydrochlorothiazide oral tablet 50-5 mg chlorthalidone oral tablet 5 mg chlorthalidone oral tablet 50 mg enalapril maleate oral tablet 0 mg enalapril maleate oral tablet.5 mg enalapril maleate oral tablet 0 mg enalapril maleate oral tablet 5 mg enalapril-hydrochlorothiazide oral tablet 0-5 mg enalapril-hydrochlorothiazide oral tablet 5-.5 mg hydrochlorothiazide oral capsule.5 mg hydrochlorothiazide oral tablet.5 mg hydrochlorothiazide oral tablet 5 mg hydrochlorothiazide oral tablet 50 mg irbesartan oral tablet 50 mg irbesartan oral tablet 00 mg irbesartan oral tablet 75 mg irbesartan-hydrochlorothiazide oral tablet mg irbesartan-hydrochlorothiazide oral tablet mg lisinopril oral tablet 0 mg lisinopril oral tablet.5 mg lisinopril oral tablet 0 mg lisinopril oral tablet 0 mg lisinopril oral tablet 0 mg / Limits ; QLL (0 per 0 7

22 Name lisinopril oral tablet 5 mg lisinopril-hydrochlorothiazide oral tablet 0-.5 mg lisinopril-hydrochlorothiazide oral tablet 0-.5 mg lisinopril-hydrochlorothiazide oral tablet 0-5 mg losartan oral tablet 00 mg losartan oral tablet 5 mg losartan oral tablet 50 mg losartan-hydrochlorothiazide oral tablet mg losartan-hydrochlorothiazide oral tablet 00-5 mg losartan-hydrochlorothiazide oral tablet mg metoprolol tartrate oral tablet 00 mg metoprolol tartrate oral tablet 5 mg metoprolol tartrate oral tablet 50 mg ramipril oral capsule.5 mg ramipril oral capsule 0 mg ramipril oral capsule.5 mg ramipril oral capsule 5 mg valsartan oral tablet 60 mg valsartan oral tablet 0 mg valsartan oral tablet 0 mg valsartan oral tablet 80 mg valsartan-hydrochlorothiazide oral tablet mg valsartan-hydrochlorothiazide oral tablet 60-5 mg valsartan-hydrochlorothiazide oral tablet 0-.5 mg valsartan-hydrochlorothiazide oral tablet 0-5 mg valsartan-hydrochlorothiazide oral tablet mg Diabetes Therapy glimepiride oral tablet mg / Limits ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 / Name Limits glimepiride oral tablet mg ; QLL (0 per 0 glimepiride oral tablet mg ; QLL (60 per 0 glipizide oral tablet 0 mg ; QLL (0 per 0 glipizide oral tablet 5 mg ; QLL (0 per 0 glipizide oral tablet extended release ; QLL (60 per hr 0 mg 0 glipizide oral tablet extended release ; QLL (0 per hr.5 mg 0 glipizide oral tablet extended release ; QLL (0 per hr 5 mg 0 glipizide-metformin oral tablet.5-50 ; QLL (0 per mg 0 glipizide-metformin oral tablet ; QLL (0 per mg 0 glipizide-metformin oral tablet ; QLL (0 per mg 0 metformin oral tablet,000 mg ; QLL (76 per 0 metformin oral tablet 500 mg ; QLL (5 per 0 metformin oral tablet 850 mg ; QLL (90 per 0 metformin oral tablet extended release ; QLL (0 per hr 500 mg 0 metformin oral tablet extended release ; QLL (80 per hr 750 mg 0 Lipid/Cholesterol Lowering Agents lovastatin oral tablet 0 mg ; QLL (0 per 0 lovastatin oral tablet 0 mg ; QLL (0 per 0 lovastatin oral tablet 0 mg ; QLL (60 per 0 pravastatin oral tablet 0 mg ; QLL (0 per 0 pravastatin oral tablet 0 mg ; QLL (0 per 0 pravastatin oral tablet 0 mg ; QLL (0 per 0 8

23 Name pravastatin oral tablet 80 mg simvastatin oral tablet 0 mg simvastatin oral tablet 0 mg simvastatin oral tablet 0 mg simvastatin oral tablet 5 mg Osteoporosis Therapy alendronate oral tablet 0 mg alendronate oral tablet 5 mg alendronate oral tablet 0 mg alendronate oral tablet 5 mg alendronate oral tablet 70 mg / Limits ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL ( per 8 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL ( per 8 9

24 Covered Medications by Therapeutic Category Legend Generic drugs are shown in lowercase italics (e.g., enalapril) Brand name drugs are shown in capital letters (e.g., HUMALOG) QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled. This is most often set on a monthly basis. PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services. The phone numbers are listed on the back cover of this booklet. INJ - Injectable: The drug is available in injectable form. - Mail Order: Prescription drugs available through mail order. S - Specialty: Specialty drugs cost $670 or more for a 0 day supply. Most plans limit Specialty drug fills to a 0 day supply. You can find out if Specialty drug fills are limited to a 0 day supply by checking the benefit chart in the front of your Evidence of Coverage. Part D-Eligible s Name Anti - Infectives abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 mg/ 5 ml acyclovir oral tablet ; QLL (60 ; S; QLL (0 ; S; QLL (60 B/D PAR; ; S Name acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amantadine hcl AMBISOME amikacin injection solution,000 mg/ ml, 500 mg/ ml amoxicillin oral capsule B/D PAR; PAR; ; S ; S ; QLL (80 ; S; QLL (6 B/D PAR; ; S You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 0 ETC_7_89_v6_80_

25 Name amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 5 mg amoxicillin oral tablet,chewable 50 mg amoxicillin-pot clavulanate amphotericin b ampicillin oral capsule ampicillin oral suspension for reconstitution ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln.5 gram, gram ampicillin-sulbactam injection recon soln 5 gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil ATRIPLA AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 5-.5 /5 ML AVELOX AZACTAM IN DEXTROSE (ISO-OSM) azithromycin intravenous AZITHROMYCIN ORAL PACKET azithromycin oral suspension for reconstitution azithromycin oral tablet 50 mg azithromycin oral tablet 50 mg (6 pack), 500 mg, 600 mg aztreonam baciim bacitracin intramuscular B/D PAR; ; S; QLL (0 S; QLL (80 per 0 PAR; ; S ; S; QLL (0 Name BARACLUDE BICILLIN C-R BICILLIN L-A BILTRICIDE CANCIDAS CAPASTAT CAYSTON CEDAX ORAL SUSPENSION 80 /5ML cefaclor oral capsule cefaclor oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefaclor oral suspension for reconstitution 75 mg/5 ml cefaclor oral tablet extended release hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 ml cefazolin injection recon soln gram, 500 mg cefazolin injection recon soln 0 gram, 00 gram, 0 gram, 00 g cefazolin intravenous cefdinir cefepime cefepime in dextrose,iso-osm intravenous piggyback gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback gram/00 ml cefixime cefotaxime injection recon soln gram, gram, 500 mg cefotaxime injection recon soln 0 gram cefotetan PAR; ; S B/D PAR; ; S PAR; ; LA; S You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 ETC_7_89_v6_80_

26 Name cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln gram, gram cefoxitin intravenous recon soln 0 gram cefpodoxime cefprozil CEFTAZIDIME IN D5W ceftazidime injection recon soln gram, gram ceftazidime injection recon soln 6 gram ceftibuten CEFTIN ORAL SUSPENSION FOR RECONSTITUTION ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln gram, gram, 50 mg, 500 mg ceftriaxone injection recon soln 0 gram, 00 gram ceftriaxone intravenous solution cefuroxime axetil oral tablet 50 mg cefuroxime axetil oral tablet 500 mg cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 50 mg, 500 mg cephalexin oral capsule 750 mg cephalexin oral suspension for reconstitution 5 mg/5 ml cephalexin oral suspension for reconstitution 50 mg/5 ml cephalexin oral tablet chloramphenicol sod succinate chloroquine phosphate cidofovir B/D PAR; ; S Name CIPRO IN D5W INTRAVENOUS PIGGYBACK 00 /00 ML CIPRO ORAL SUSPENSION, MICROCAPSULE RECON ciprofloxacin ciprofloxacin hcl oral tablet 00 mg, 750 mg ciprofloxacin hcl oral tablet 50 mg, 500 mg ciprofloxacin in 5 % dextrose ciprofloxacin lactate intravenous solution 00 mg/0 ml ciprofloxacin lactate intravenous solution 00 mg/0 ml ciprofloxacin oral tablet extended release hr mphase clarithromycin CLEOCIN PEDIATRIC clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate intravenous solution 00 mg/ ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/ ml clotrimazole mucous membrane COARTEM colistin (colistimethate na) COLY-MYCIN M PARENTERAL COMBIVIR COMPLERA CRIXIVAN ORAL CAPSULE 00 CRIXIVAN ORAL CAPSULE 00 CUBICIN dapsone B/D PAR; ; S; QLL (60 ; S; QLL (0 ; QLL (60 ; QLL (80 ; S You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 ETC_7_89_v6_80_

27 Name daptomycin DARAPRIM demeclocycline DESCOVY dicloxacillin didanosine oral capsule,delayed release(dr/ec) 5 mg didanosine oral capsule,delayed release(dr/ec) 00 mg didanosine oral capsule,delayed release(dr/ec) 50 mg, 00 mg DIFICID DORIBAX INTRAVENOUS RECON SOLN 50 DORIBAX INTRAVENOUS RECON SOLN 500 DORIPENEM INTRAVENOUS RECON SOLN 50 DORIPENEM INTRAVENOUS RECON SOLN 500 doxy-00 doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline monohydrate oral capsule 00 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet e.e.s. 00 oral tablet E.E.S. GRANULES EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA ; S ; S; QLL (0 QLL (90 per 0 ; QLL (60 ; QLL (0 PAR; ; S S ; S ; S; QLL (0 ; QLL (0 ; QLL (850 PAR; ; S PAR; ; S; QLL (0 per 0 Name EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPIVIR ORAL SOLUTION EPIVIR ORAL TABLET 50 EPIVIR ORAL TABLET 00 EPZICOM ery-tab oral tablet,delayed release (dr/ec) 50 mg, mg ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 500 ERYPED 00 ERYPED 00 erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet ethambutol EVOTAZ famciclovir oral tablet 5 mg, 50 mg famciclovir oral tablet 500 mg FLAGYL ORAL CAPSULE fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/50 ml ; QLL (960 ; QLL (60 ; QLL (0 ; S; QLL (0 ; S ; S ; S; QLL (0 ; QLL (60 ; QLL ( per 7 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 ETC_7_89_v6_80_

28 Name fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/00 ml flucytosine oral capsule 50 mg flucytosine oral capsule 500 mg foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 80 mg/50 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 /50 ML, 0 /00 ML gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 90 mg/00 ml gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 00 mg/0 ml gentamicin sulfate (pf) intravenous solution 60 mg/6 ml GENVOYA GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 50 griseofulvin microsize griseofulvin ultramicrosize HARVONI HEPSERA HIPREX hydroxychloroquine imipenem-cilastatin ; S B/D PAR ; S; QLL (60 B/D PAR; ; S; QLL (0 PAR; ; S; QLL (8 per 8 PAR; ; S Name INTELENCE ORAL TABLET 00 INTELENCE ORAL TABLET 00 INTELENCE ORAL TABLET 5 INVANZ INTRAVENOUS INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET, CHEWABLE 00 ISENTRESS ORAL TABLET, CHEWABLE 5 isoniazid injection isoniazid oral solution isoniazid oral tablet 00 mg isoniazid oral tablet 00 mg itraconazole ivermectin KALETRA ORAL SOLUTION KALETRA ORAL TABLET 00-5 KALETRA ORAL TABLET ketoconazole oral LAMISIL ORAL TABLET lamivudine oral solution lamivudine oral tablet 00 mg lamivudine oral tablet 50 mg lamivudine oral tablet 00 mg lamivudine-zidovudine ; S; QLL (0 ; S; QLL (60 ; QLL (80 ; S; QLL (00 ; S; QLL (0 ; S; QLL (60 ; S; QLL (0 ; S; QLL (80 ; QLL (70 PAR; ; QLL (80 ; QLL (00 ; S; QLL (0 ; S ; QLL (960 ; QLL (60 ; QLL (0 ; QLL (60 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 ETC_7_89_v6_80_

29 Name LEVAQUIN ORAL TABLET levofloxacin in d5w intravenous piggyback 50 mg/50 ml levofloxacin in d5w intravenous piggyback 500 mg/00 ml, 750 mg/50 ml levofloxacin oral solution levofloxacin oral tablet 50 mg, 500 mg levofloxacin oral tablet 750 mg LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET LINCOCIN lincomycin linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet linezolid-0.9% sodium chloride lopinavir-ritonavir MALARONE MALARONE PEDIATRIC mefloquine MEPRON meropenem intravenous methenamine hippurate methenamine mandelate metro i.v. metronidazole in nacl (iso-os) metronidazole oral minocycline oral capsule minocycline oral tablet NUROL morgidox oral capsule 00 mg morgidox oral capsule 50 mg moxifloxacin oral MYAMBUTOL ORAL TABLET 00 ; QLL (800 ; S; QLL (0 PAR; ; QLL (800 per 0 PAR; ; S; QLL (56 per 0 S ; QLL (80 PAR; ; S Name MYCAMINE INTRAVENOUS RECON SOLN 00 MYCAMINE INTRAVENOUS RECON SOLN 50 MYCOBUTIN nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml nafcillin in dextrose iso-osm intravenous piggyback gram/00 ml nafcillin injection recon soln gram, gram nafcillin injection recon soln 0 gram nafcillin intravenous recon soln gram nafcillin intravenous recon soln gram NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release hr 00 mg nevirapine oral tablet extended release hr 00 mg nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOXAFIL ORAL nystatin oral suspension nystatin oral tablet ODEFSEY ofloxacin oral tablet 00 mg ; S ; S S ; S ; S B/D PAR; ; QLL (00 ; QLL (60 ; QLL (0 PAR; PAR; PAR; ; QLL (60 ; QLL (80 ; QLL (60 PAR; ; S ; S; QLL (0 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 5 ETC_7_89_v6_80_

30 Name ofloxacin oral tablet 00 mg ORACEA oseltamivir oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin injection recon soln gram, 0 gram oxacillin injection recon soln gram paromomycin PASER PCE PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/50 ML, MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/50 ML penicillin g potassium injection recon soln 0 million unit penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium PENTAM pfizerpen-g piperacillin-tazobactam intravenous recon soln.5 gram,.75 gram,.5 gram, 0.5 gram polymyxin b sulfate PREZCOBIX ; S S ; S ; S; QLL (0 Name PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50 PREZISTA ORAL TABLET 600, 800 PREZISTA ORAL TABLET 75 PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 50, 00 REYATAZ ORAL CAPSULE 00 REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg, 00 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 00 mg (8)- 00 mg (8) ribasphere ribapak oral tablets,dose pack 00 mg (7)- 00 mg (7), 00 mg (7)- 00 mg (7), 600 mg (7)- 00 mg (7), 600 mg (7)- 600 mg (7) ribavirin inhalation ribavirin oral capsule ribavirin oral tablet 00 mg rifabutin RIFADIN RIFAMATE rifampin RIFATER ; S; QLL (00 ; QLL (80 ; S; QLL (60 ; QLL (00 PAR; ; QLL (60 per 80 ; QLL (80 ; QLL (60 ; S; QLL (60 ; S; QLL (0 ; QLL (0 ; S ; S S PAR; S ; S You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 6 ETC_7_89_v6_80_

31 Name rimantadine SELZENTRY ORAL TABLET 50, 00 SELZENTRY ORAL TABLET 5 SELZENTRY ORAL TABLET 75 SIRTURO stavudine oral capsule 5 mg, 0 mg stavudine oral capsule 0 mg, 0 mg STREPTOMYCIN STRIBILD STROMECTOL sulfadiazine sulfamethoxazole-trimethoprim intravenous sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML, 00 /5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 /5 ML SUPRAX ORAL TABLET, CHEWABLE SUSTIVA ORAL CAPSULE 00 SUSTIVA ORAL CAPSULE 50 SUSTIVA ORAL TABLET SYNAGIS SYNERCID TAMIFLU ORAL CAPSULE 0, 5 ; S; QLL (0 ; QLL (0 ; QLL (60 PAR; ; LA; S ; QLL (0 ; QLL (60 ; S; QLL (0 ; QLL (0 ; QLL (60 ; S; QLL (0 PAR; ; LA; S S Name TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TECHNIVIE TEFLARO terbinafine hcl oral tetracycline TIGECYCLINE tinidazole TIVICAY ORAL TABLET 0 TIVICAY ORAL TABLET 5, 50 TOBI SOLUTION FOR NEBULIZATION tobramycin in 0.5 % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRIZIVIR TRUVADA TYBOST valacyclovir oral tablet gram valacyclovir oral tablet 500 mg VALCYTE ORAL RECON SOLN valganciclovir PAR; ; S; QLL (56 per 8 ; S S ; QLL (60 ; S; QLL (60 B/D PAR; ; S; QLL (80 per 8 B/D PAR; ; S; QLL (80 per 8 ; S; QLL (0 ; S; QLL (60 ; S; QLL (0 ; QLL (0 ; QLL (0 ; QLL (60 ; S ; S You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 7 ETC_7_89_v6_80_

32 Name VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK GRAM/00 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 /00 ML, 750 /50 ML vancomycin intravenous recon soln,000 mg, 0 gram, 5 gram, 500 mg VANCOMYCIN INTRAVENOUS RECON SOLN 750 vancomycin oral capsule 5 mg vancomycin oral capsule 50 mg VFEND ORAL SUSPENSION FOR RECONSTITUTION VIBATIV INTRAVENOUS RECON SOLN 750 VIBRAMYCIN ORAL CAPSULE 00 VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP VIDEX GRAM PEDIATRIC VIDEX GRAM PEDIATRIC VIDEX EC ORAL CAPSULE, DELAYED RELEASE(DR/EC) 5 VIDEX EC ORAL CAPSULE, DELAYED RELEASE(DR/EC) 00 B/D PAR B/D PAR; B/D PAR B/D PAR; PAR; ; QLL (0 per 0 PAR; ; S; QLL (80 per 0 PAR; ; S PAR; S ; S ; QLL (00 ; QLL (00 ; QLL (90 ; QLL (60 Name VIDEX EC ORAL CAPSULE, DELAYED RELEASE(DR/EC) 50, 00 VIRACEPT ORAL TABLET 50 VIRACEPT ORAL TABLET 65 VIRAMUNE ORAL SUSPENSION VIRAMUNE ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE HR 00 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE HR 00 VIREAD ORAL POWDER VIREAD ORAL TABLET voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 00 mg voriconazole oral tablet 50 mg XIFAXAN ORAL TABLET 550 ZERIT ORAL CAPSULE 5, 0 ZERIT ORAL CAPSULE 0, 0 ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZMAX ; QLL (0 ; S; QLL (00 ; S; QLL (0 ; QLL (00 ; S; QLL (60 ; QLL (0 ; S; QLL (0 ; S; QLL (0 PAR; ; S PAR; ; S PAR; PAR; ; S; QLL (8 per 8 ; QLL (0 ; QLL (60 ; QLL (00 ; QLL (960 ; QLL (80 ; QLL (90 ; QLL (60 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 8 ETC_7_89_v6_80_

33 Name ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION ZYVOX INTRAVENOUS PARENTERAL SOLUTION 00 /00 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 /00 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION S ; S PAR; ; S; QLL (800 per 0 Antineoplastic / Immunosuppressant s ABRAXANE PAR; ; S adriamycin intravenous solution B/D PAR adrucil intravenous solution.5 gram/50 ml B/D PAR adrucil intravenous solution 5 gram/00 ml, 500 mg/0 ml B/D PAR; AFINITOR PAR; ; S AFINITOR DISPERZ PAR; ; S ALECENSA PAR; ; S; QLL (0 per 0 ALIMTA ALKERAN INTRAVENOUS ALKERAN ORAL ALUNBRIG anastrozole ARRANON ARZERRA AVASTIN azacitidine azathioprine azathioprine sodium BAVENCIO BELEODAQ BENDEKA bexarotene bicalutamide PAR; ; S B/D PAR B/D PAR; PAR; ; S; QLL (80 per 0 ; QLL (0 B/D PAR PAR; ; S PAR; ; S PAR; ; S B/D PAR; B/D PAR PAR; ; LA; S PAR; ; S B/D PAR; ; S PAR; ; S ; QLL (0 Name BICNU bleo 5k bleomycin BLINCYTO INTRAVENOUS KIT BOSULIF ORAL TABLET 00 BOSULIF ORAL TABLET 500 busulfan BUSULFEX CABOMETYX ORAL TABLET 0 CABOMETYX ORAL TABLET 0, 60 CAPRELSA ORAL TABLET 00 CAPRELSA ORAL TABLET 00 carboplatin intravenous solution CELLCEPT CELLCEPT INTRAVENOUS cisplatin cladribine clofarabine CLOLAR COMETRIQ ORAL CAPSULE 00 /DAY(80 X-0 X) COMETRIQ ORAL CAPSULE 0 /DAY(80 X-0 X) COMETRIQ ORAL CAPSULE 60 /DAY (0 X /DAY) COSMEGEN B/D PAR; ; S B/D PAR B/D PAR; PAR; ; S PAR; ; S; QLL (0 per 0 PAR; ; S; QLL (0 per 0 B/D PAR B/D PAR PAR; ; LA; S; QLL (90 per 0 PAR; ; LA; S; QLL (0 per 0 PAR; ; LA; S; QLL (90 per 0 PAR; ; LA; S; QLL (0 per 0 B/D PAR; B/D PAR; ; S B/D PAR; B/D PAR; B/D PAR; ; S S B/D PAR; S PAR; ; S; QLL (56 per 8 PAR; ; S; QLL ( per 8 PAR; ; S; QLL (8 per 8 B/D PAR; ; S You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 9 ETC_7_89_v6_80_

34 Name COTELLIC CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule CYRAMZA cytarabine (pf) injection solution 00 mg/5 ml (0 mg/ml), gram/ 0 ml (00 mg/ml) cytarabine (pf) injection solution 0 mg/ml cytarabine injection solution 0 mg/ml dacarbazine DACOGEN DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 50 mg dexrazoxane hcl intravenous recon soln 500 mg docetaxel intravenous solution 60 mg/6 ml (0 mg/ml), 0 mg/ ml (0 mg/ml) docetaxel intravenous solution 60 mg/8 ml (0 mg/ml), 0 mg/ml ( ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (0 mg/ml) DOCETAXEL INTRAVENOUS SOLUTION 0 /ML DOXIL doxorubicin intravenous recon soln doxorubicin intravenous solution 0 mg/5 ml, 0 mg/0 ml, 50 mg/ 5 ml doxorubicin intravenous solution mg/ml doxorubicin, peg-liposomal PAR; ; LA; S; QLL (90 per 0 B/D PAR; B/D PAR B/D PAR; B/D PAR; ; S B/D PAR; PAR; ; S B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; ; S PAR; ; LA; S B/D PAR B/D PAR; ; S S ; S B/D PAR; S B/D PAR; ; S B/D PAR; S PAR; ; S B/D PAR B/D PAR; B/D PAR; ; S PAR; ; S Name DROXIA ELIGARD ( NTH) ELIGARD ( NTH) ELIGARD ( NTH) ELIGARD (6 NTH) ELITEK ELLENCE EMCYT EMPLICITI ENVARSUS XR epirubicin intravenous solution ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 0 FARYDAK ORAL CAPSULE 5, 0 FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 0 FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 fludarabine intravenous recon soln fludarabine intravenous solution PAR; ; QLL ( per 8 PAR; ; QLL ( per 8 PAR; ; QLL ( per PAR; ; QLL ( per 68 PAR; ; S B/D PAR; ; S PAR; ; S B/D PAR; B/D PAR; PAR; ; S PAR; ; S; QLL (0 per 0 PAR; ; S B/D PAR; ; S B/D PAR; B/D PAR; ; S ; QLL (60 ; S; QLL (0 PAR; ; S; QLL (60 per 0 PAR; ; S; QLL (0 per 0 PAR; ; S PAR; ; S; QLL ( per 65 PAR; ; QLL ( per 8 B/D PAR; B/D PAR You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 0 ETC_7_89_v6_80_

35 Name fluorouracil intravenous flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln gram, 00 mg gemcitabine intravenous recon soln gram gemcitabine intravenous solution gram/6. ml (8 mg/ml), 00 mg/5.6 ml (8 mg/ml) gemcitabine intravenous solution gram/5.6 ml (8 mg/ml) gengraf GILOTRIF GLEEVEC ORAL TABLET 00 GLEEVEC ORAL TABLET 00 GLEOSTINE HALAVEN HERCEPTIN INTRAVENOUS RECON SOLN 0 HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET 5 ICLUSIG ORAL TABLET 5 IDAMYCIN PFS idarubicin IFEX ifosfamide intravenous recon soln ifosfamide intravenous solution B/D PAR; B/D PAR; ; S PAR; ; S PAR; ; S B/D PAR; ; S B/D PAR; S B/D PAR; ; S B/D PAR; S B/D PAR; PAR; ; S; QLL (0 per 0 PAR; ; S; QLL (0 per 0 PAR; ; S; QLL (60 per 0 PAR; PAR; ; S B/D PAR; ; S ; S PAR; ; S; QLL (0 per 0 PAR; S; QLL (60 PAR; ; S; QLL (0 per 0 B/D PAR; ; S B/D PAR; S B/D PAR; B/D PAR; B/D PAR Name imatinib oral tablet 00 mg imatinib oral tablet 00 mg IMBRUVICA IMFINZI INTRAVENOUS SOLUTION 50 /ML INLYTA ORAL TABLET INLYTA ORAL TABLET 5 IRESSA irinotecan intravenous solution 00 mg/5 ml irinotecan intravenous solution 0 mg/ ml irinotecan intravenous solution 500 mg/5 ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 0 JAKAFI ORAL TABLET 5 JAKAFI ORAL TABLET 0 JAKAFI ORAL TABLET 5 JAKAFI ORAL TABLET 5 JEVTANA KADCYLA KEYTRUDA PAR; ; S; QLL (0 per 0 PAR; ; S; QLL (60 per 0 PAR; ; S; QLL (0 per 0 PAR; ; LA; S PAR; ; S; QLL (0 per 0 PAR; ; S; QLL (0 per 0 ; S B/D PAR; B/D PAR; ; S B/D PAR PAR; ; S PAR; ; S PAR; ; S; QLL (50 per 0 PAR; ; S; QLL (00 per 0 PAR; ; S; QLL (75 per 0 PAR; ; S; QLL (60 per 0 PAR; ; S; QLL (00 per 0 PAR; ; S PAR; ; S PAR; ; S You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 ETC_7_89_v6_80_

36 Name KISQALI FEMARA CO-PACK ORAL TABLET 00 / DAY(00 X )-.5 KISQALI FEMARA CO-PACK ORAL TABLET 00 / DAY(00 X )-.5 KISQALI FEMARA CO-PACK ORAL TABLET 600 / DAY(00 X )-.5 KISQALI ORAL TABLET 00 /DAY (00 X ) KISQALI ORAL TABLET 00 /DAY (00 X ) KISQALI ORAL TABLET 600 /DAY (00 X ) KYPROLIS LARTRUVO LENVIMA ORAL CAPSULE 0 /DAY (0 X /DAY) LENVIMA ORAL CAPSULE /DAY(0 X - X ), 0 /DAY (0 X ), 8 /DAY ( X ) LENVIMA ORAL CAPSULE 8 /DAY (0 X - X), /DAY(0 X - X ) letrozole leucovorin calcium injection recon soln 00 mg, 00 mg, 50 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral LEUKERAN leuprolide subcutaneous kit levoleucovorin intravenous recon soln 50 mg LONSURF PAR; ; S; QLL (9 per 8 PAR; ; S; QLL (70 per 8 PAR; ; S; QLL (9 per 8 PAR; ; S; QLL ( per PAR; ; S; QLL ( per PAR; ; S; QLL (6 per PAR; ; S PAR; ; LA; S PAR; ; S; QLL (0 per 0 PAR; ; S; QLL (60 per 0 PAR; ; S; QLL (90 per 0 ; QLL (0 PAR; PAR; S PAR; ; S Name LUPRON DEPOT LUPRON DEPOT ( NTH) LUPRON DEPOT ( NTH) LUPRON DEPOT (6 NTH) LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 (PED) LYNPARZA LYSODREN MARQIBO MATULANE MEGACE megestrol oral suspension 00 mg/ 0 ml (0 ml), 800 mg/0 ml (0 ml) megestrol oral suspension 00 mg/ 0 ml (0 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MEKINIST ORAL TABLET melphalan melphalan hcl mercaptopurine mesna MESNEX INTRAVENOUS MESNEX ORAL methotrexate sodium methotrexate sodium (pf) injection recon soln PAR; ; S; QLL ( per 8 PAR; ; S; QLL ( per 8 PAR; ; S; QLL ( per PAR; ; S; QLL ( per 68 PAR; ; S; QLL ( per 8 PAR; ; S; QLL (80 per 0 ; S ; S PAR; PAR PAR; PAR; PAR; ; S; QLL (90 per 0 PAR; ; S; QLL (0 per 0 B/D PAR ; S You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. Effective January, 08 ETC_7_89_v6_80_