drug tier list - myprime insurance marketplace 5 tier drug list. please consider talking to your...

May 2018 (2017 Plan Year)

Texas Residents -- Find and estimate prices for medicines on this formulary at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKTGNPLS/en/find-medicine.html

41722-K TX HIM Prime Therapeutics LLC 05/17

Health Insurance Marketplace 5 Tier Drug List

Please consider talking to your doctor about prescribing preferred medications, which mayhelp reduce your out-of-pocket costs. This list may help guide you and your doctor inselecting an appropriate medication for you.

The drug list is regularly updated. Please visit bcbstx.com for the most up-to-dateinformation.

To find a contracting pharmacy, please access the link below:https://www.myprime.com/en/find-pharmacy.html

Contents Therapeutic Class Drug ListSummary of Formulary Benefits .................................... IIntroduction .................................................................. VIHow drugs are selected ...............................................VIHow member payment is determined ..........................VIHow to use this list ..................................................... VIIDrugs used to treat multiple conditions .......................VIIGeneric drugs ............................................................. VIIConsider talking to your doctor about generic

drugs ....................................................................... VIICoverage considerations ........................................... VIIISpecialty drugs ............................................................. XPrime Specialty by AllianceRx Walgreens Prime .......... XAbbreviation Key ..........................................................XI

Anti-infective agents....................................................... 1Biologicals.....................................................................12Antineoplastic agents................................................... 15Endocrine and metabolic drugs....................................21Cardiovascular agents..................................................39Respiratory agents....................................................... 54Gastrointestinal agents.................................................60Genitourinary agents.................................................... 65Central nervous system drugs..................................... 67Analgesics and anesthetics..........................................85Neuromuscular drugs................................................... 97Nutritional products.....................................................105Hematological agents................................................. 133Topical products..........................................................143Miscellaneous products.............................................. 156Index ..........................................................................160

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, orgo to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking forand click on Search.


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) I

Summary of Formulary Benefits

The information in this document is designed to help you understand the prescription drugbenefits offered under this plan and compare these benefits to those offered by other plans.Information contained in this summary is designed to help you compare, both the value andscope of formulary benefits.

How to Find Information on the Cost of Prescription Drugs: Your Summary of Benefits and Coverage (SBC)document lists information about your plan, including pharmacy deductibles, tiers, out of pocket maximums, and alink to this formulary document. This formulary document lists drugs covered by your plan, the coverage tiers andany special requirements for each drug. This formulary document includes a link on the bottom of each page tothe Find a Medicine web-based tool on myPrime.com, which you may use to search for drugs for information onformulary coverage and estimate prices. Price estimates include total cost, plan and member cost share amounts(excluding any deductible requirements), and are based on the most recent actual network pricing. You may alsouse Pharmacy finder to review differences in estimated pricing between pharmacies.

Toll free number to obtain formulary information, including specific cost-sharing information for anyformulary drug: 1-800-423-1973

Formulary by Health Benefit Plan: Some 2017 Blue Cross and Blue Shield of Texas employer-offered smallgroup plans use the 2017 Health Insurance Marketplace 5 Tier Drug List. These plans are offered on and off theTexas Health Insurance Marketplace.

All Individual Plans use the 2017 Health Insurance Marketplace 5 Tier Drug List

Plan (Select plan name to view plan Summary of Benefits & Coverage) Associated Formulary

Blue Advantage Bronze HMO 006 Non-Marketplace

Blue Advantage Bronze HMO 006 Marketplace

Blue Advantage Bronze HMO 006 Marketplace Native American Zero

Blue Advantage Bronze HMO 006 Marketplace Native American Limited

Blue Advantage Bronze HMO 105 Marketplace Native American Zero

Blue Advantage Bronze HMO 105 - Two $40 PCP Visits Non-Marketplace

Blue Advantage Bronze HMO 105 - Two $40 PCP Visits Marketplace

Blue Advantage Bronze HMO 105 - Two $40 PCP Visits Marketplace Native

American Limited Blue Advantage Gold HMO 101 Non-Marketplace

Blue Advantage Gold HMO 101 Marketplace

Blue Advantage Gold HMO 101 Marketplace Native American Zero Health InsuranceBlue Advantage Gold HMO 101 Marketplace Native American Limited Marketplace

Blue Advantage Gold HMO 111 Non-Marketplace 5 Tier Drug List

Blue Advantage Plus Bronze 103 Marketplace Native American Zero

Blue Advantage Plus Bronze 103 - One $0 PCP Visit Non-Marketplace

Blue Advantage Plus Bronze 103 - One $0 PCP Visit Marketplace

Blue Advantage Plus Bronze 103 - One $0 PCP Visit Marketplace Native American

Limited Blue Advantage Plus Bronze 104 Non-Marketplace

Blue Advantage Plus Bronze 104 Marketplace

Blue Advantage Plus Bronze 104 Marketplace Native American Zero

Blue Advantage Plus Bronze 104 Marketplace Native American Limited

http://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460006-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460006-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460006-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460006-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460241-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460241-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460241-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460241-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460237-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460237-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460237-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460237-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460236-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770003-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770003-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770003-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770003-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770079-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770079-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770079-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770079-03.pdf


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) II


Blue Advantage Plus Gold 101 Non-Marketplace

Blue Advantage Plus Gold 101 Marketplace

Blue Advantage Plus Gold 101 Marketplace Native American Zero

Blue Advantage Plus Gold 101 Marketplace Native American Limited

Blue Advantage Plus Silver 102 Marketplace Native American Zero

Blue Advantage Plus Silver 102 - Five $0 PCP Visits Marketplace Native American

Zero Blue Advantage Plus Silver 102 - Three $0 PCP Visits Non-Marketplace

Blue Advantage Plus Silver 102 - Three $0 PCP Visits Marketplace

Blue Advantage Plus Silver 102 - Three $0 PCP Visits Marketplace Native American

Limited Blue Advantage Plus Silver 102 - Three $0 PCP Visits Marketplace 73% Actuarial

Value Blue Advantage Plus Silver 102 - Three $0 PCP Visits Marketplace 87% Actuarial

Value Blue Advantage Security HMO 100 Non-Marketplace

Blue Advantage Security HMO 100 Marketplace

Blue Advantage Security HMO 102 Non-Marketplace


Blue Advantage Security HMO 102 Marketplace Native American Zero

Blue Advantage Security HMO 102 Marketplace Native American Limited

Blue Advantage Security HMO 102 Marketplace 73% Actuarial Value Health InsuranceBlue Advantage Security HMO 102 Marketplace 87% Actuarial Value Marketplace

Blue Advantage Security HMO 102 Marketplace 94% Actuarial Value 5 Tier Drug List

Blue Advantage Security HMO 103 Non-Marketplace


Blue Advantage Security HMO 103 Marketplace Native American Zero

Blue Advantage Security HMO 103 Marketplace Native American Limited

Blue Advantage Security HMO 103 Marketplace 73% Actuarial Value



Blue Cross Blue Shield Basic 103, a Multi-State Plan Marketplace

Blue Cross Blue Shield Basic 103, a Multi-State Plan Marketplace Native American

Zero Blue Cross Blue Shield Basic 103, a Multi-State Plan Marketplace Native American

Limited Blue Cross Blue Shield Premier 101, a Multi-State Plan Marketplace

Blue Cross Blue Shield Premier 101, a Multi-State Plan Marketplace Native American

Zero Blue Cross Blue Shield Premier 101, a Multi-State Plan Marketplace Native American

Limited Blue Cross Blue Shield Solution 102, a Multi-State Plan Marketplace

Blue Cross Blue Shield Solution 102, a Multi-State Plan Marketplace Native American

Zero

http://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770001-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770001-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770001-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770001-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-06.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-04.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0770002-05.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460242-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460242-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-04.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-05.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460238-06.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-00.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-04.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-05.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0460239-06.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780003-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780003-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780003-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780001-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780001-02.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780001-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-01.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-02.pdf


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) III


Blue Cross Blue Shield Solution 102, a Multi-State Plan Marketplace Native American

Limited Blue Cross Blue Shield Solution 102, a Multi-State Plan Marketplace 73% Actuarial Health InsuranceValue MarketplaceBlue Cross Blue Shield Solution 102, a Multi-State Plan Marketplace 87% Actuarial 5 Tier Drug ListValue Blue Cross Blue Shield Solution 102, a Multi-State Plan Marketplace 94% Actuarial

Value

Drugs by Cost-Sharing Tier: Tier Percentage of DrugsACA 3.8%Tier 1 12.2%Tier 2 28.5%Tier 3 5.8%Tier 4 38.1%Tier 5 11.6%

Formulary Composition: This drug list, (also known as a formulary) is a closed formulary; a closed formulary isa type of benefit design in which only medicines included on the drug list (or formulary) are covered. You may beable to get a medicine that is not on the drug list. But, you may have to pay 100% of the cost, unless a formularycoverage exception is submitted and your health plan approves it.

The formulary or drug list is designed to provide you and your physician with the most safe, effective drugs at themost reasonable cost. The drug list is developed by a Pharmacy and Therapeutics (P&T) committee. The P&Tcommittee is made up of a diverse group of doctors and pharmacists. When adding or removing drugs from thedrug list, the P&T committee reviews each drug for its safety, effectiveness, and uniqueness. Health plans usethe drug list to provide their members with effective drug therapies at reasonable costs. For this reason, usingdrugs from a drug list is important for both you and your health plan. Often, many drugs are available to treat thesame condition. If two drugs are equivalent in effectiveness and safety, the drug list will include the lower cost drug.You are not limited to purchasing only those drugs that appear on your health plan's drug list. However, you maypay more out-of-pocket for a drug that is not on the drug list. You may need to pay the full cost of a drug if it is notcovered by your benefit plan. Changes in a drug list result from decisions made at P&T committee meetings. ThePrime P&T committee meets at least quarterly to consider changes to the drug list. For example, if a new drug isfound to be more effective than one already on the drug list, the new drug may replace the less effective drug. Adrug may also be removed from a drug list for safety reasons. The Food and Drug Administration (FDA) tracksdrug safety information. The FDA issues reports about side effects, warnings or contraindications. Prime monitorsthese reports because they may trigger a change in a drug list.

Right to Request a Coverage Determination: If a drug is not covered under the drug list (also known as aformulary) or requires utilization review prior to coverage, but your physician has determined that the drug ismedically necessary, you have the right to request a coverage determination. Your cost share for non-formularymedicines approved through coverage determination is based on your benefit plans cost share for the appropriatenon-preferred generic, non-preferred brand, or specialty tier.

Right to Appeal: If your request for coverage is denied, but your physician has determined that the drug ismedically necessary, you have the right to appeal and request coverage.

Continuation of Coverage: You have the right to continued coverage for a prescription drug at the coveragelevel or tier at which the drug was covered at the beginning of the plan year, until your plan renewal date, providedthat the drug continues to be medically necessary and safe.

http://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-03.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-04.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-05.pdfhttp://www.bcbstx.com/static/tx/pdf/sbc/2017/33602TX0780002-06.pdf


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) IV

Off-Label Drug Use: Off-label use of FDA approved drugs occurs when a drug is prescribed for a reason thathas not been approved by the FDA. Off-label use may be covered when all of the following apply:

The medicine has been approved by the FDA for at least one use; The medicine is prescribed by a physician; The medicine is intended to treat chronic, disabling, or life-threatening illnesses; Sufficient clinical evidence is provided by your physician for the off-label use requested; The services and medicine are medically necessary.

Off-Label use of FDA approved drugs is not covered when these conditions are not met or when the determinedits use to be contraindicated for treatment of the condition for which coverage is requested. Approved off-labelmedicine cost share is based on the tier in which the medicine is assigned within the drug list.

Limitations and Exclusions: Pharmacy benefits are not available for: Drugs required by law to be labeled: Caution - Limited by Federal Law to Investigational Use, or Experimental drugs, even though a charge is made for the drugs, or Legend drugs not approved by the FDA for a particular use or purpose or when used for a purpose other

than the purpose for which the FDA approval is given, except as required by law or regulation.

Experimental / Investigational means the use of any treatment, procedure, facility, equipment, drug, device orsupply not accepted as Standard Medical Treatment of the condition being treated or any of such items requiringfederal or other governmental agency Approval not granted at the time services were provided. Approval by afederal agency means that the treatment, procedure, facility, equipment, drug, device or supply has been approvedfor the condition being treated and, in the case of a drug, in the dosage used on the patient. Medical treatmentincludes medical, surgical or dental treatment. Standard Medical Treatment means the services or supplies thatare in general use in the medical community in the United States, and:

have been demonstrated in peer-reviewed literature to have scientifically established medical value forcuring or alleviating the condition being treated;

are appropriate for the Hospital or Participating Provider; and the Health Care Professional has had the appropriate training and experience to provide the treatment or

procedure.

Cost-Sharing: Your deductible is listed on your Summary of Benefits and Coverage document. Your deductible isthe amount of money that you and anyone covered by your plan must pay out-of-pocket each plan year for coveredservices before your plan starts to pay. A certain set of drugs may be covered without cost-sharing, even beforemeeting the deductible. The out-of-pocket cost share for your covered prescriptions applies to your deductible untilyour deductible is met. Your cost share details are listed on your Summary of Benefits and Coverage for each ofthe tiers within this formulary. Your cost share may be a copayment (an amount you pay out-of-pocket for yourprescription medicines after youve met any deductible) or coinsurance (a percentage of the total cost that you payfor your medicines, after you've met any deductible).

Your drug list (or formulary) has the following tiers:

ACA (Preventive Drugs Not Subject to Deductible) Tier 1 (Preferred Generics) Tier 2 (Non-Preferred Generics) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty)

Your cost share for a medicine is based on the tier in which the medicine is assigned within the drug list. Networkdiscounts are applied to medicines dispensed at a network pharmacy, but are not available for medicines


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) V

dispensed at a non-network pharmacy. You may be able to save time and money using the pharmacy mail homedelivery option if you take maintenance medicine for a condition like high blood pressure, asthma or diabetes, andtake your drugs for long periods of time. With home delivery pharmacy, you may get up to a three-month supply ofmedicines delivered to your home and, in some cases, you may pay a lower cost share.

Medical Management Requirements: Medical or utilization management is a process that is part of your healthplan. Utilization management helps to make sure that you are getting the right drugs -- all while helping to makemedicine more affordable. Health plans call for utilization management on some medicines to keep you safe,by helping to make sure the medicines you take are prescribed by your doctor and used correctly. Health plancompanies, hospitals, doctors and pharmacists work together and share information to help improve medicine formembers. These programs help to catch mistakes, reduce waste, improve safety and keep medicine affordableby lowering costs. This formulary indicates when one of these programs applies to a drug. Medical or utilizationmanagement is made up of programs that include:

Prior Authorization: Prior authorization (sometimes called pre-approval) means that your medicineneeds to be approved by your health plan before it will be covered. Prior authorization helps improvesafety. Some drugs can be misused or overused, or may not be the best choice for your health condition.

Step Therapy: This program uses a "step" approach with drugs for certain conditions. This means thatyou may have to first try a safe, lower-cost drug, or one that may be more clinically effective, before"stepping up" to a different drug. Step Therapy helps lower costs through safe, less expensive drugs.

Dispensing Limits: This program controls how often or the amount you can get filled at once. Theselimits promote safe, cost-effective drug use. They also help reduce waste and overuse. Dispensing Limitshelps to lower waste.

Limited Distribution: For some medications, you may need to use specified pharmacies to fill yourprescription because the drug is only made available by the manufacturer to very limited pharmacies orbecause your plan requires use of specified pharmacies for these medicines. Some of these medicinesmay be specialty medicines that are filled at a Specialty Pharmacy which specializes in particular classesof medication and health conditions.

Medicines requiring a health care provider to administer them and administered in a hospital, doctorsoffice, or other medical setting are covered by your medical benefits. Information on those medicationsmay be found here: http://www.bcbstx.com/pdf/rx/tx-medical-drug-list-2017.pdf .

http://www.bcbstx.com/pdf/rx/tx-medical-drug-list-2017.pdf


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) VI

Introduction

Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouragedto prescribe drugs on this list, when right for the member. However decisions regarding therapy andtreatment are always between members and their physician.

Drug lists updates This list is regularly updated as generic drugs become available and changes take place inthe pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in toBlue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list fromthe provider portal at bcbstx.com.

How drugs are selectedDrugs on this list are selected based on the recommendations of a committee made up of physicians andpharmacists from throughout the country. The committee, which includes at least one representative fromBCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).

Both drugs that are newly approved by the FDA as well as those that have been on the market for some time areconsidered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently onthe list.

How member payment is determinedThis list shows prescription drug products in tiers. Generally, each drug is placed into one of five member paymenttiers: Preferred Generic (Tier 1), Non-preferred Generic (Tier 2), Preferred Brand (Tier 3), Non-preferred Brand(Tier 4) and Specialty (Tier 5). Please refer to the ACA Preventive (ACA) section for drugs marked with an "A" inthe drug tier column. To verify your payment amount for a drug, visit bcbstx.com and log in to Blue Access forMembers or call the number on the back of your ID card.

Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply.Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmeticpurposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for self-administration may be available through your medical benefit.


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) VII

How to use this list

Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference branddrug in (parentheses). Some generic products have no reference brand.

Example: atorvastatin (Lipitor brand is NF)

Brand prescription drugs are shown in capital letters followed by the generic name.

Drugs used to treat multiple conditionsSome drugs in the same dosage form may be used to treat more than one medical condition. In these instances,each medication is classified according to its first FDA-approved use. Please check the index if you do not find yourparticular medication in the class/condition section that corresponds to your use.

Generic drugs

Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugsmust be approved by the FDA just as brand drugs are, and must meet the same standards.

There are two types of generic drugs:

A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. A generic equivalent is a drug typically used to treat the same condition, but the active ingredient(s)

differs from the brand drug.

According to the FDA, compared to its brand counterpart, an FDA-approved generic drug: Is chemically the same Works just as well in the body Is as safe and effective Meets the same standards set by the FDA

The main difference between the reference brand drug and the generic equivalent is that the generic often costsmuch less.Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.You may be responsible for the brand member payment amount plus the difference in cost between the brand andgeneric equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs havethe lowest member payment amount.

Consider talking to your doctor about generic drugsIf your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if anappropriate generic alternative is available.You can also let your pharmacist know that you would like a generic equivalent for a brand drug, wheneverone is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without aprescription from your doctor.Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) VIII

Coverage considerations

Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with someexceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high bloodpressure, diabetes or high cholesterol.

Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications thathave an over-the-counter version. You should refer to your benefit plan materials for details about your particularbenefits.

Compounded medications: Your benefit plan does not provide coverage for compounded medications. Pleasesee your plan materials or call the number on the back of your ID card to determine whether compoundedmedications are covered and/or verify your payment amount.

Repackaged medications: Repackaged versions of medications already available on the market are not covered.

Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means thatyour doctor will need to submit a prior authorization request for coverage of these medications, and the request willneed to be approved, before the medication will be covered under your plan. For the preferred medications listed inthis document, if a prior authorization is commonly required, it will be noted next to the medication with a dot underthe prior authorization column. Some plans may have prior authorization on additional medications beyond thosenoted in this document.

Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to tryanother proven, cost-effective medication before coverage may be available for the drug included in the program.Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For thepreferred medications listed in this document, if a step therapy is commonly required it will generally be notednext to the medication with a dot under the step therapy column. Some plans may have step therapy programs onadditional medications beyond those noted in this document.

Dispensing Limits (DL): Drug Dispensing limits are designed to help encourage medication use as intended bythe FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications listedin this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot underthe dispensing limits column. Limits may include: quantity of covered medication per prescription and quantity ofcovered medication in a given time period. If your doctor prescribes a greater quantity of medication than whatthe dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost ofthe prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit bcbstx.com.

*Please note: For certain controlled substance medications, some state laws may not allow coverage by a healthbenefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will beresponsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds thedispensing limit.

Limited Distribution (LD): Medicines marked as "Limited Distribution" have restrictions on where you may obtaina medication. This may include requiring the use of a designated pharmacy to fill a prescription.


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) IX

ACA Preventive (ACA): Medicines marked in the ACA column are under the Affordable Care Act coverage ofpreventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), whenmeeting the conditions as outlined under the regulation. These are also indicated with an "A" in the drug tiercolumn. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folicacid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitaminD supplements, and some FDA approved contraceptive methods. To see what contraceptive products may becovered, visit www.bcbstx.com/pdf/rx/contraceptive-list-tx.pdf

Remember, medication decisions are between you and your doctor. Only you and your doctor can determinewhich medication is right for you. Discuss any questions or concerns you have about medications you are taking orare prescribed with your doctor. BCBSTX does not provide health care services and, therefore, cannot guaranteeany results or outcomes.


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) X

Specialty drugs

Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosisand rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be self-administered or administered by a health care professional. For a current list of specialty medications, visit myprime.com or bcbstx.com and log in to Blue Access for Members.

Note that some drug classes may be excluded by some plans and therefore may not be covered under yourpharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you havequestions about your coverage for specialty medications or your prescription drug benefit, call the number on theback of your ID card.

Prime Specialty by AllianceRx Walgreens Prime

Through Prime Specialty by AllianceRx Walgreens Prime, members can have covered specialty medicationsdelivered directly to them or their doctors office. When you receive specialty medications through Prime Specialtyby AllianceRx Walgreens Prime, you also receive at no additional charge the following services:

Coordination of coverage between you, your doctor and your health plan Educational materials about your particular condition and information about managing potential

medication side effects Syringes, sharps containers and other supplies with every shipment for self-injectables 24/7/365 phone access to a pharmacist for urgent medication issues

To order through Prime Specialty by AllianceRx Walgreens Prime:

Have your doctor call or fax your prescription to Prime Specialty by AllianceRx Walgreens Prime.Your doctor can call 877-627-6337 or fax to 877-828-3939.

If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 totransfer your prescription.

A coordinator will contact you to arrange delivery of your medication. The prescription can be shipped directly to you or your prescribing doctors office. Each package is

individually marked for each member. Refrigerated drugs are shipped in temperature-controlledpackaging.

If you have questions, please contact Prime Specialty by AllianceRx Walgreens Prime at 877-627-6337,visit www.alliancerxwp.com, or call the number on the back of your ID card.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC).HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to providepharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, aswell as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) XI

Abbreviation key cap ...................................................... capsules odt .................................. orally disintegrating tabschew ................................................... chewable oint ...................................................... ointmentconc ................................................ concentrate ophth .................................................. opthalmiccr ............................................ controlled release osm ........................................... osmotic releasedr .............................................. delayed release powd ..................................................... powderec ................................................ enteric coated sa .............................................. sustained actioneffe ................................................. effervescent sl ....................................................... sublinqualequiv ................................................. equivalent soln ...................................................... solutioner ............................................. extended release sr ............................................ sustained releaseinhal ................................................... inhalation suppos .......................................... suppositoriesinj ........................................................ injection susp ................................................. suspensionliq ............................................................ liquid tab ......................................................... tabletslotn .......................................................... lotion td .................................................... transdermalnebu ................................................... nebulizer

You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List(also known as a formulary). To request this exception, you, or your prescriber, can call the number on the backof your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep youfrom regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may beable to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage decisionwithin 24 hours after they receive your request for an expedited review. If the coverage request is denied, BCBSTXwill let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). Callthe number on the back of your ID card if you have any questions.


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) XII

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984. If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file agrievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail).300 E. Randolph St. TTY/TDD: 855-661-696535th Floor Fax: 855-661-6960Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services Phone: 800-368-1019200 Independence Avenue SW TTY/TDD: 800-537-7697Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsfWashington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) XIII

2017


BCBSTX Health Insurance Marketplace 5 Tier Drug List May (2017 Plan Year) 1

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

ANTI-INFECTIVE AGENTSPENICILLINSAMOXICILLIN - amoxicillin

(trihydrate) chew tab 125 mg4

AMOXICILLIN - amoxicillin(trihydrate) chew tab 250 mg

4

amoxicillin (trihydrate) cap250 mg

1

amoxicillin (trihydrate) cap500 mg

1

amoxicillin (trihydrate) forsusp 125 mg/5ml

1


1


1


1

amoxicillin (trihydrate) tab500 mg

1

amoxicillin (trihydrate) tab875 mg

1

amoxicillin & k clavulanatefor susp 200-28.5 mg/5ml

2

amoxicillin & k clavulanatefor susp 250-62.5 mg/5ml(Augmentin)

2

amoxicillin & k clavulanatefor susp 400-57 mg/5ml

2

amoxicillin & k clavulanatefor susp 600-42.9 mg/5ml(Augmentin es-600)

2

amoxicillin & k clavulanatetab er 12hr 1000-62.5 mg(Augmentin xr)

2

amoxicillin & k clavulanatetab 250-125 mg

2

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

amoxicillin & k clavulanatetab 500-125 mg(Augmentin)

2

amoxicillin & k clavulanatetab 875-125 mg(Augmentin)

2

AMOXICILLIN/CLAVULANATEP - amoxicillin & kclavulanate chew tab200-28.5 mg

4

AMOXICILLIN/CLAVULANATEP - amoxicillin & kclavulanate chew tab 400-57mg

4

AMPICILLIN - ampicillin cap500 mg

1

AUGMENTIN - amoxicillin& k clavulanate for susp125-31.25 mg/5ml

4

dicloxacillin sodium cap250 mg

1

dicloxacillin sodium cap500 mg

2

MOXATAG - amoxicillin(trihydrate) tab er 24hr 775mg

4

PENICILLIN V POTASSIUM -penicillin v potassium forsoln 125 mg/5ml

1

PENICILLIN V POTASSIUM -penicillin v potassium forsoln 250 mg/5ml

1

penicillin v potassium tab250 mg

1

penicillin v potassium tab500 mg

1

CEPHALOSPORINScefaclor cap 250 mg 2

cefaclor cap 500 mg 2

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

CEFACLOR ER - cefaclormonohydrate tab er 12hr500 mg

4

cefadroxil cap 500 mg 1

cefadroxil for susp250 mg/5ml

2

cefadroxil for susp500 mg/5ml

2

cefadroxil tab 1 gm 2

cefdinir cap 300 mg 2

cefdinir for susp 125 mg/5ml 2

cefdinir for susp 250 mg/5ml 2

CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg(base equivalent)

4

CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg(base equivalent)

4

cefixime for susp100 mg/5ml (Suprax)

2

cefixime for susp200 mg/5ml (Suprax)

2

cefpodoxime proxetil forsusp 50 mg/5ml

2

cefpodoxime proxetil forsusp 100 mg/5ml

2

cefpodoxime proxetil tab100 mg

2

cefpodoxime proxetil tab200 mg

2

cefprozil for susp125 mg/5ml

2

cefprozil for susp250 mg/5ml

2

cefprozil tab 250 mg 2

cefprozil tab 500 mg 2

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

CEFTIN - cefuroxime axetil forsusp 125 mg/5ml

3

CEFTIN - cefuroxime axetil forsusp 250 mg/5ml

4

cefuroxime axetil tab 250 mg(Ceftin)

2

cefuroxime axetil tab 500 mg(Ceftin)

2

CEPHALEXIN - cephalexin tab250 mg

4

CEPHALEXIN - cephalexin tab500 mg

4

cephalexin cap 250 mg(Keflex)

1


1


2

cephalexin for susp125 mg/5ml

2

cephalexin for susp250 mg/5ml

2

SPECTRACEF - cefditorenpivoxil tab 400 mg (baseequivalent)

4

SUPRAX - cefixime cap 400mg

4

SUPRAX - cefixime chew tab100 mg

4

SUPRAX - cefixime chew tab200 mg

4

SUPRAX - cefixime for susp100 mg/5ml

4


4


4

MACROLIDES

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

AZITHROMYCIN -azithromycin powd pack forsusp 1 gm

4

azithromycin for susp100 mg/5ml (Zithromax)

2

azithromycin for susp200 mg/5ml (Zithromax)

2

azithromycin tab 250 mg(Zithromax)

1


1


2

CLARITHROMYCIN -clarithromycin for susp 125mg/5ml

2

CLARITHROMYCIN -clarithromycin for susp 250mg/5ml

2

clarithromycin tab er 24hr500 mg

2

clarithromycin tab 250 mg(Biaxin)

2

clarithromycin tab 500 mg(Biaxin)

2

DIFICID - fidaxomicin tab 200mg

4

E.E.S. GRANULES -erythromycin ethylsuccinatefor susp 200 mg/5ml

4

E.E.S. 400 - erythromycinethylsuccinate tab 400 mg

4

ERY-TAB - erythromycin tabdelayed release 250 mg

4


4


4

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

ERYPED 200 - erythromycinethylsuccinate for susp 200mg/5ml

4

ERYPED 400 - erythromycinethylsuccinate for susp 400mg/5ml

4

ERYTHROCIN STEARATE -erythromycin stearate tab250 mg

4

ERYTHROMYCINETHYLSUCCINA -erythromycin ethylsuccinatetab 400 mg

4

erythromycin ethylsuccinatefor susp 200 mg/5ml (E.e.s.granules)

2

erythromycin tab 250 mg 2

erythromycin tab 500 mg 2

erythromycin w/ delayedrelease particles cap250 mg

2

PCE - erythromycin w/ entericcoated particles tab 333 mg

4

PCE - erythromycin w/ entericcoated particles tab 500 mg

4

ZITHROMAX - azithromycinpowd pack for susp 1 gm

4

ZMAX - azithromycin extendedrelease for oral susp 2 gm

4

TETRACYCLINESdemeclocycline hcl tab

150 mg2

demeclocycline hcl tab300 mg

2

doxycycline hyclate cap50 mg

2

doxycycline hyclate cap100 mg (Vibramycin)

2

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

doxycycline hyclate tab20 mg

2

doxycycline hyclate tab100 mg

2

doxycycline monohydratecap 50 mg

2

doxycycline monohydratecap 75 mg (Monodox)

2

doxycycline monohydratecap 100 mg (Monodox)

2

doxycycline monohydratecap 150 mg (Adoxa)

2

doxycycline monohydratefor susp 25 mg/5ml(Vibramycin)

2

doxycycline monohydratetab 50 mg (Adoxa)

2

doxycycline monohydratetab 75 mg (Adoxa)

2

doxycycline monohydratetab 100 mg (Adoxa pak1/100)

2

doxycycline monohydratetab 150 mg (Adoxa pak1/150)

2

minocycline hcl cap 50 mg(Minocin)

2


2


2

minocycline hcl tab er 24hr45 mg

2


2


2

minocycline hcl tab 50 mg 2

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion



TETRACYCLINE HCL -tetracycline hcl cap 250 mg

4

TETRACYCLINE HCL -tetracycline hcl cap 500 mg

4

tetracycline hcl cap 250 mg(Tetracycline hcl)

2

tetracycline hcl cap 500 mg(Tetracycline hcl)

2

FLUOROQUINOLONESBAXDELA - delafloxacin

meglumine tab 450 mg(base equiv)

4

ciprofloxacin for oralsusp 500 mg/5ml (10%)(10 gm/100ml) (Cipro)

2

CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg(base equiv)

4

ciprofloxacin hcl tab 250 mg(base equiv) (Cipro)

1

ciprofloxacin hcl tab 500 mg(base equiv) (Cipro)

1

ciprofloxacin hcl tab 750 mg(base equiv)

1

ciprofloxacin-ciprofloxacinhcl tab er 24hr 500 mg(base eq) (Cipro xr)

2

ciprofloxacin-ciprofloxacinhcl tab er 24hr1000 mg(base eq) (Cipro xr)

2

LEVOFLOXACIN - levofloxacinoral soln 25 mg/ml

2

levofloxacin tab 250 mg(Levaquin)

1


1

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion


1

moxifloxacin hcl tab 400 mg(base equiv) (Avelox)

2

OFLOXACIN - ofloxacin tab300 mg

4

ofloxacin tab 400 mg 2

AMINOGLYCOSIDESBETHKIS - tobramycin nebu

soln 300 mg/4ml5

KITABIS PAK - tobramycinnebu soln 300 mg/5ml

5

neomycin sulfate tab 500 mg 1

paromomycin sulfate cap250 mg

2

TOBI PODHALER - tobramycininhal cap 28 mg

5

TOBRAMYCIN - tobramycinnebu soln 300 mg/5ml

5

tobramycin nebu soln300 mg/5ml (Tobi)

5

SULFONAMIDESSULFADIAZINE - sulfadiazine

tab 500 mg3

ANTIMYCOBACTERIAL AGENTSCYCLOSERINE - cycloserine

cap 250 mg4

ethambutol hcl tab 100 mg(Myambutol)

2

ethambutol hcl tab 400 mg(Myambutol)

2

ISONIAZID - isoniazid syrup 50mg/5ml

4

isoniazid tab 100 mg 1

isoniazid tab 300 mg 1

PASER - aminosalicylic acid ergranules packet 4 gm

4

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

PRIFTIN - rifapentine tab 150mg

3

pyrazinamide tab 500 mg 2

rifabutin cap 150 mg(Mycobutin)

2

RIFAMATE - isoniazid &rifampin cap 150-300 mg

4

rifampin cap 150 mg (Rifadin) 2

rifampin cap 300 mg (Rifadin) 2

RIFATER - isoniazid-rifampinw/ pyrazinamide tab50-120-300 mg

4

SIRTURO - bedaquilinefumarate tab 100 mg (baseequiv)

4

TRECATOR - ethionamide tab250 mg

4

ANTIFUNGALSCRESEMBA -

isavuconazonium sulfate cap186 mg

4

fluconazole for susp 10 mg/ml (Diflucan)

2

fluconazole for susp 40 mg/ml (Diflucan)

2

fluconazole tab 50 mg(Diflucan)

1


1


1


2

flucytosine cap 250 mg(Ancobon)

2

flucytosine cap 500 mg(Ancobon)

2

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

griseofulvin microsize susp125 mg/5ml

2

griseofulvin microsize tab500 mg (Grifulvin v)

2

griseofulvin ultramicrosizetab 125 mg (Gris-peg)

2

griseofulvin ultramicrosizetab 250 mg (Gris-peg)

2

itraconazole cap 100 mg(Sporanox)

2

NOXAFIL - posaconazole susp40 mg/ml

3

NOXAFIL - posaconazole tabdelayed release 100 mg

3

nystatin tab 500000 unit 2

SPORANOX - itraconazole oralsoln 10 mg/ml

4

terbinafine hcl tab 250 mg(Lamisil)

1

voriconazole for susp40 mg/ml (Vfend)

2

voriconazole tab 50 mg(Vfend)

2

voriconazole tab 200 mg(Vfend)

2

ANTIVIRALSabacavir sulfate soln 20 mg/

ml (base equiv) (Ziagen)2

abacavir sulfate tab 300 mg(base equiv) (Ziagen)

2

abacavir sulfate-lamivudinetab 600-300 mg (Epzicom)

2

abacavir sulfate-lamivudine-zidovudine tab300-150-300 mg (Trizivir)

2

acyclovir cap 200 mg(Zovirax)

1

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

acyclovir susp 200 mg/5ml(Zovirax)

2

acyclovir tab 400 mg(Zovirax)

1

acyclovir tab 800 mg(Zovirax)

1

adefovir dipivoxil tab 10 mg(Hepsera)

2

APTIVUS - tipranavir cap 250mg

4

APTIVUS - tipranavir oral soln100 mg/ml

4

atazanavir sulfate cap150 mg (base equiv)(Reyataz)

2


2


2

ATRIPLA - efavirenz-emtricitabine-tenofovir df tab600-200-300 mg

3

BARACLUDE - entecavir oralsoln 0.05 mg/ml

3

COMPLERA - emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg

4

CRIXIVAN - indinavir sulfatecap 200 mg

4

CRIXIVAN - indinavir sulfatecap 400 mg

4

DESCOVY - emtricitabine-tenofovir alafenamidefumarate tab 200-25 mg

3

didanosine delayed releasecapsule 200 mg (Videx ec)

2

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion


2


2

EDURANT - rilpivirine hcl tab25 mg (base equivalent)

4

efavirenz cap 50 mg (Sustiva) 2 efavirenz cap 200 mg

(Sustiva)2

efavirenz tab 600 mg(Sustiva)

2

EMTRIVA - emtricitabine caps200 mg

4

EMTRIVA - emtricitabine soln10 mg/ml

4

entecavir tab 0.5 mg(Baraclude)

2

entecavir tab 1 mg(Baraclude)

2

EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg

5

EPIVIR HBV - lamivudine oralsoln 5 mg/ml (hbv)

4

EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg

3

EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg(base equiv)

4

famciclovir tab 125 mg(Famvir)

2


2


2

fosamprenavir calciumtab 700 mg (base equiv)(Lexiva)

2

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

FUZEON - enfuvirtide for inj 90mg

5

GENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab150-150-200-10 mg

3

HARVONI - ledipasvir-sofosbuvir tab 90-400 mg

5

INTELENCE - etravirine tab 25mg

3

INTELENCE - etravirine tab100 mg

3

INTELENCE - etravirine tab200 mg

3

INVIRASE - saquinavirmesylate cap 200 mg

4

INVIRASE - saquinavirmesylate tab 500 mg

4

ISENTRESS - raltegravirpotassium chew tab 25 mg(base equiv)

3

ISENTRESS - raltegravirpotassium chew tab 100 mg(base equiv)

3

ISENTRESS - raltegravirpotassium packet for susp100 mg (base equiv)

3

ISENTRESS - raltegravirpotassium tab 400 mg (baseequiv)

3

ISENTRESS HD - raltegravirpotassium tab 600 mg (baseequiv)

3

JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg(base eq)

4

KALETRA - lopinavir-ritonavirsoln 400-100 mg/5ml (80-20mg/ml)

3

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

KALETRA - lopinavir-ritonavirtab 100-25 mg

3

KALETRA - lopinavir-ritonavirtab 200-50 mg

3

lamivudine oral soln 10 mg/ml (Epivir)

2

lamivudine tab 100 mg (hbv)(Epivir hbv)

2

lamivudine tab 150 mg(Epivir)

2

lamivudine tab 300 mg(Epivir)

2

lamivudine-zidovudine tab150-300 mg (Combivir)

2

LEXIVA - fosamprenavircalcium susp 50 mg/ml(base equiv)

4

LEXIVA - fosamprenavircalcium tab 700 mg (baseequiv)

4

lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml) (Kaletra)

2

MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg

5

MODERIBA - ribavirin tab 200mg & ribavirin 400 mg tabtherapy pack

5

MODERIBA - ribavirin tab 400mg & ribavirin 600 mg tabtherapy pack

5

MODERIBA 1200 DOSEPACK - ribavirin tab 600 mg

5

MODERIBA 800 DOSE PACK -ribavirin tab 400 mg

5

nevirapine tab er 24hr100 mg (Viramune xr)

2

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

nevirapine tab er 24hr400 mg (Viramune xr)

2

nevirapine tab 200 mg(Viramune)

1

NORVIR - ritonavir cap 100 mg 4 NORVIR - ritonavir oral soln 80

mg/ml3

NORVIR - ritonavir tab 100 mg 3 ODEFSEY - emtricitabine-

rilpivirine-tenofovir af tab200-25-25 mg

3

OLYSIO - simeprevir sodiumcap 150 mg (baseequivalent)

5

oseltamivir phosphatecap 30 mg (base equiv)(Tamiflu)

2


2


2

oseltamivir phosphate forsusp 6 mg/ml (base equiv)(Tamiflu)

2

PEGASYS - peginterferonalfa-2a inj 180 mcg/ml

5

PEGASYS - peginterferonalfa-2a inj 180 mcg/0.5ml

5

PEGASYS PROCLICK -peginterferon alfa-2a inj 135mcg/0.5ml

5

PEGASYS PROCLICK -peginterferon alfa-2a inj 180mcg/0.5ml

5

PEGINTRON - peginterferonalfa-2b for inj kit 50mcg/0.5ml

5

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

PREVYMIS - letermovir tab240 mg

4

PREVYMIS - letermovir tab480 mg

4

PREZCOBIX - darunavir-cobicistat tab 800-150 mg

4

PREZISTA - darunavirethanolate susp 100 mg/ml(base equiv)

3

PREZISTA - darunavirethanolate tab 75 mg (baseequiv)

3


3


3


3

REBETOL - ribavirin soln 40mg/ml

5

RELENZA DISKHALER -zanamivir aero powderbreath activated 5 mg/blister

4

RESCRIPTOR - delavirdinemesylate tab 100 mg

4

RESCRIPTOR - delavirdinemesylate tab 200 mg

4

REYATAZ - atazanavir sulfatecap 150 mg (base equiv)

3


3


3

REYATAZ - atazanavir sulfateoral powder packet 50 mg(base equiv)

4

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

RIBASPHERE - ribavirin tab400 mg

5

RIBASPHERE - ribavirin tab600 mg

5

RIBASPHERE RIBAPAK -ribavirin tab 200 mg &ribavirin 400 mg tab therapypack

5

RIBASPHERE RIBAPAK -ribavirin tab 400 mg &ribavirin 600 mg tab therapypack

5

RIBASPHERE RIBAPAK -ribavirin tab 400 mg

5

RIBASPHERE RIBAPAK -ribavirin tab 600 mg

5

ribavirin cap 200 mg(Rebetol)

5

ribavirin for inhal soln 6 gm(Virazole)

2

ribavirin tab 200 mg(Copegus)

5

rimantadine hydrochloridetab 100 mg (Flumadine)

2

ritonavir tab 100 mg (Norvir) 2 SELZENTRY - maraviroc oral

soln 20 mg/ml4

SELZENTRY - maraviroc tab25 mg

4


4


4


4

SOVALDI - sofosbuvir tab 400mg

5

stavudine cap 15 mg (Zerit) 2

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

stavudine cap 20 mg (Zerit) 2 stavudine cap 30 mg (Zerit) 2 stavudine cap 40 mg (Zerit) 2 STRIBILD - elvitegrav-cobic-

emtricitab-tenofovdf tab150-150-200-300 mg

3

SUSTIVA - efavirenz cap 50mg

3

SUSTIVA - efavirenz cap 200mg

3

SUSTIVA - efavirenz tab 600mg

3

TAMIFLU - oseltamivirphosphate cap 30 mg (baseequiv)

4


4


4

TAMIFLU - oseltamivirphosphate for susp 6 mg/ml(base equiv)

4

TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab12.5-75-50 mg

5

tenofovir disoproxilfumarate tab 300 mg(Viread)

2

TIVICAY - dolutegravir sodiumtab 10 mg (base equiv)

3


3


3

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

TRIUMEQ - abacavir-dolutegravir-lamivudine tab600-50-300 mg

4

TRUVADA - emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg

3


3


3


3

TYBOST - cobicistat tab 150mg

4

valacyclovir hcl tab 500 mg(Valtrex)

2

valacyclovir hcl tab 1 gm(Valtrex)

2

VALCYTE - valganciclovir hclfor soln 50 mg/ml (baseequiv)

3

valganciclovir hcl for soln50 mg/ml (base equiv)(Valcyte)

2

valganciclovir hcl tab450 mg (base equivalent)(Valcyte)

2

VIDEX - didanosine for soln 2gm

3

VIDEX - didanosine for soln 4gm

3

VIEKIRA PAK - ombitas-paritapre-riton & dasab tabpak 12.5-75-50 & 250 mg

5

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

VIEKIRA XR - dasab-ombit-paritap-riton tab er 24hr200-8.33-50-33.33 mg

5

VIRACEPT - nelfinavirmesylate tab 250 mg

4

VIRACEPT - nelfinavirmesylate tab 625 mg

4

VIRAMUNE - nevirapine susp50 mg/5ml

3

VIRAZOLE - ribavirin for inhalsoln 6 gm

4

VIREAD - tenofovir disoproxilfumarate oral powder 40 mg/gm

3

VIREAD - tenofovir disoproxilfumarate tab 150 mg

3


3


3


3

VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab400-100-100 mg

5

ZEPATIER - elbasvir-grazoprevir tab 50-100 mg

5

ZERIT - stavudine for oral soln1 mg/ml

4

ZIAGEN - abacavir sulfate soln20 mg/ml (base equiv)

3

zidovudine cap 100 mg(Retrovir)

2

zidovudine syrup 10 mg/ml(Retrovir)

2

zidovudine tab 300 mg 2 ANTIMALARIALS

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

atovaquone-proguanil hcltab 62.5-25 mg (Malarone)

2

atovaquone-proguanil hcltab 250-100 mg (Malarone)

2

CHLOROQUINEPHOSPHATE - chloroquinephosphate tab 250 mg

1

chloroquine phosphate tab500 mg (Aralen)

1

COARTEM - artemether-lumefantrine tab 20-120 mg

4

DARAPRIM - pyrimethaminetab 25 mg

3

hydroxychloroquine sulfatetab 200 mg (Plaquenil)

2

MEFLOQUINE HCL -mefloquine hcl tab 250 mg

2

PRIMAQUINE PHOSPHATE -primaquine phosphate tab26.3 mg (15 mg base)

3

quinine sulfate cap 324 mg(Qualaquin)

2

ANTHELMINTICSALBENZA - albendazole tab

200 mg3

BENZNIDAZOLE -benznidazole tab 12.5 mg

3

BENZNIDAZOLE -benznidazole tab 100 mg

3

BILTRICIDE - praziquantel tab600 mg

3

EMVERM - mebendazole chewtab 100 mg

4

ivermectin tab 3 mg(Stromectol)

2

ANTI-INFECTIVE AGENTS - MISC.ALINIA - nitazoxanide for susp

100 mg/5ml4

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

ALINIA - nitazoxanide tab 500mg

4

atovaquone susp750 mg/5ml (Mepron)

2

CAYSTON - aztreonam lysinefor inhal soln 75 mg (baseequivalent)

5

clindamycin hcl cap 75 mg(Cleocin)

1


1


1

clindamycin palmitate hclfor soln 75 mg/5ml (baseequiv) (Cleocin pediatric gr)

2

dapsone tab 25 mg 2

dapsone tab 100 mg 2

IMPAVIDO - miltefosine cap 50mg

3

linezolid for susp100 mg/5ml (Zyvox)

2

linezolid tab 600 mg (Zyvox) 2 metronidazole cap 375 mg

(Flagyl)2

metronidazole tab 250 mg(Flagyl)

1

metronidazole tab 500 mg(Flagyl)

1

NEBUPENT - pentamidineisethionate for nebulizationsoln 300 mg

4

PRIMSOL - trimethoprim hcloral soln 50 mg/5ml (baseequiv)

4

SIVEXTRO - tedizolidphosphate tab 200 mg

4

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

sulfamethoxazole-trimethoprim susp200-40 mg/5ml

2

sulfamethoxazole-trimethoprim tab400-80 mg (Bactrim)

1

sulfamethoxazole-trimethoprim tab800-160 mg (Bactrim ds)

1

tinidazole tab 250 mg(Tindamax)

2

tinidazole tab 500 mg(Tindamax)

2

trimethoprim tab 100 mg 1

vancomycin hcl cap 125 mg(Vancocin hcl)

2

vancomycin hcl cap 250 mg(Vancocin hcl)

2

XIFAXAN - rifaximin tab 200mg

4

XIFAXAN - rifaximin tab 550mg

3

BIOLOGICALSVACCINESAFLURIA PF 2017-2018 -

influenza virus vaccine splitpf susp pref syringe 0.5 ml

A

AFLURIA QUADRIVALENT2017 - influenza virus vacsplit quadrivalent susp prefsyr 0.5ml

A

AFLURIA QUADRIVALENT2017 - influenza virusvaccine split quadrivalent iminj

A

AFLURIA 2017-2018 -influenza virus vaccine splitim susp

A

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

ENGERIX-B - hepatitis bvaccine (recombinant) susp10 mcg/0.5ml

A

ENGERIX-B - hepatitis bvaccine (recombinant) susp20 mcg/ml

A

ENGERIX-B - hepatitis bvaccine (recombinant) 10mcg/0.5ml

A

ENGERIX-B - hepatitis bvaccine (recombinant) 20mcg/ml

A

FLUAD 2017-2018 - influenzavac type a&b surface ant adjsusp pref syr 0.5 ml

A

FLUARIX QUADRIVALENT2017 - influenza virus vacsplit quadrivalent susp prefsyr 0.5ml

A

FLUBLOK QUADRIVALENT2017 - influenza vac recombha quad pf soln pref syr 0.5ml

A

FLUBLOK 2015-2016 -influenza virus vacrecombinant hemagglutinin(ha) pf inj

A

FLUBLOK 2017-2018 -influenza virus vacrecombinant hemagglutinin(ha) pf inj

A

FLUCELVAX QUADRIVALENT20 - influenza vac tiss-cultsubunt quad susp pref syr0.5 ml

A

FLUCELVAX QUADRIVALENT20 - influenza vac tissue-cultured subunit quadrivalentim susp

A

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

FLULAVAL QUADRIVALENT201 - influenza virus vac splitquadrivalent susp pref syr0.5ml

A

FLULAVAL QUADRIVALENT201 - influenza virus vaccinesplit quadrivalent im inj

A

FLUMIST QUADRIVALENT -influenza virus vaccine livequadrivalent intranasal susp

A

FLUVIRIN 2015-2016 -influenza vac type a&bsurface antigen susp pref syr0.5 ml

A

FLUVIRIN 2015-2016 -influenza virus vaccine typesa & b surface antigen imsusp

A

FLUVIRIN 2017-2018 -influenza vac type a&bsurface antigen susp pref syr0.5 ml

A

FLUVIRIN 2017-2018 -influenza virus vaccine typesa & b surface antigen imsusp

A

FLUZONE HIGH-DOSE PF2017 - influenza virus vacsplit high-dose pf susp prefsyr 0.5ml

A

FLUZONE INTRADERMALQUADR - influenza virus vacsplit quad intradermal pen 9mcg/strain

A

FLUZONE QUADRIVALENT2017 - influenza virus vacsplit quadrivalent susp prefsyr 0.25 ml

A

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

FLUZONE QUADRIVALENT2017 - influenza virus vacsplit quadrivalent susp prefsyr 0.5ml

A

FLUZONE QUADRIVALENT2017 - influenza virusvaccine split quadrivalent iminj

A

FLUZONE QUADRIVALENT2017 - influenza virusvaccine split quadrivalent inj0.5 ml

A

IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc inj

A

PNEUMOVAX 23 -pneumococcal vaccinepolyvalent inj 25 mcg/0.5ml

A

PNEUMOVAX 23/1 DOSE -pneumococcal vaccinepolyvalent inj 25 mcg/0.5ml

A

PREVNAR 13 - Pneumococcal13-valent conjugate vaccineinj

A

RABAVERT - rabies vaccine,pcec for inj

A

RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp5 mcg/0.5ml

A

RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp10 mcg/ml

A

RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp40 mcg/ml

A

SHINGRIX - zoster vaccinerecombinant adjuvanted forim inj 50 mcg

A

VIVOTIF - typhoid vaccine capdelayed release

4

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

ZOSTAVAX - zoster vaccinelive for subcutaneous susp19400 unit/0.65ml

A

TOXOIDSADACEL - tet tox-diph-acell

pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml

A

BOOSTRIX - tet tox-diph-acellpertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

A

DAPTACEL - diph, acellularpert & tet tox inj 15 lf-23mcg-5 lf/0.5ml

4

DIPHTHERIA/TETANUSTOXOID - diphtheria-tetanustox adsorbed (dt) im inj 25-5unit/0.5ml

4

INFANRIX - diph, acellular pert& tet tox inj 25 lf-58 mcg-10lf/0.5ml

4

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipvvac inj

4

PEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polioipv vac inj

4

PENTACEL - diph-ac per-tettox ad-poliov-haemoph bpoly vac for im susp

4

QUADRACEL - diph-tetanustox ad-acell pert & poliovirus, ipv vac inj

4

TENIVAC - tetanus-diphtheriatoxoids (td) inj 5-2 lfu

4

TETANUS/DIPHTHERIATOXOID - tetanus-diphtheriatoxoids (td) inj 2-2 lf/0.5ml

4

PASSIVE IMMUNIZING AGENTS

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

HYQVIA - immun glob inj 2.5gm/25ml-hyaluron inj 200unt/1.25 ml kit

4

HYQVIA - immun glob inj 5gm/50ml-hyaluron inj 400unt/2.5 ml kit

4

HYQVIA - immun glob inj 10gm/100ml-hyaluron inj 800unt/5 ml kit

4


4


4

BIOLOGICALS MISCGRASTEK - timothy grass

pollen allergen ext tab sl2800 bau

4

ORALAIR - grass mixed pollenext tab sl 300 ir (index ofreactivity)

4

RAGWITEK - short ragweedpollen allergen extract tab sl12 amb a 1-u

4

ANTINEOPLASTIC AGENTSANTINEOPLASTICSACTIMMUNE - interferon

gamma-1b inj 100mcg/0.5ml (2000000unit/0.5ml)

5

AFINITOR - everolimus tab 2.5mg

5

AFINITOR - everolimus tab 5mg

5

AFINITOR - everolimus tab 7.5mg

5

AFINITOR - everolimus tab 10mg

5

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

AFINITOR DISPERZ -everolimus tab for oral susp2 mg

5


5


5

ALECENSA - alectinib hcl cap150 mg (base equivalent)

5

ALKERAN - melphalan tab 2mg

3

ALUNBRIG - brigatinib tabinitiation therapy pack 90 mg& 180 mg

5

ALUNBRIG - brigatinib tab 30mg

5


5


5

anastrozole tab 1 mg(Arimidex)

1

bexarotene cap 75 mg(Targretin)

5

bicalutamide tab 50 mg(Casodex)

1

BOSULIF - bosutinib tab 100mg

5


5


5

CABOMETYX - cabozantinibs-malate tab 20 mg (baseequivalent)

5

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion


5


5

CALQUENCE - acalabrutinibcap 100 mg

5

capecitabine tab 150 mg(Xeloda)

5

capecitabine tab 500 mg(Xeloda)

5

CAPRELSA - vandetanib tab100 mg

5

CAPRELSA - vandetanib tab300 mg

5

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit

5

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit

5

COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60mg dose) kit

5

COTELLIC - cobimetinibfumarate tab 20 mg (baseequivalent)

5

CYCLOPHOSPHAMIDE -cyclophosphamide cap 25mg

4

CYCLOPHOSPHAMIDE -cyclophosphamide cap 50mg

4

ELIGARD - leuprolide acetate(3 month) for subcutaneousinj kit 22.5mg

5

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

ELIGARD - leuprolide acetate(4 month) for subcutaneousinj kit 30 mg

5

ELIGARD - leuprolide acetate(6 month) for subcutaneousinj kit 45 mg

5

ELIGARD - leuprolide acetatefor subcutaneous inj kit 7.5mg

5

EMCYT - estramustinephosphate sodium cap 140mg

4

ERIVEDGE - vismodegib cap150 mg

5

ETOPOSIDE - etoposide cap50 mg

4

exemestane tab 25 mg(Aromasin)

2

FARESTON - toremifene citratetab 60 mg (base equivalent)

4

FARYDAK - panobinostatlactate cap 10 mg (baseequivalent)

5


5


5

flutamide cap 125 mg 2

GILOTRIF - afatinib dimaleatetab 20 mg (base equivalent)

5


5


5

GLEEVEC - imatinibmesylate tab 100 mg (baseequivalent)

5

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

GLEEVEC - imatinibmesylate tab 400 mg (baseequivalent)

5

GLEOSTINE - lomustine cap 5mg

4

GLEOSTINE - lomustine cap10 mg

4


4


4

HEXALEN - altretamine cap 50mg

5

HYCAMTIN - topotecan hcl cap0.25 mg (base equiv)

5

HYCAMTIN - topotecan hcl cap1 mg (base equiv)

5

hydroxyurea cap 500 mg(Hydrea)

2

IBRANCE - palbociclib cap 75mg

5


5


5

ICLUSIG - ponatinib hcl tab 15mg (base equiv)

5

ICLUSIG - ponatinib hcl tab 45mg (base equiv)

5

IDHIFA - enasidenib mesylatetab 50 mg (base equivalent)

5

IDHIFA - enasidenibmesylate tab 100 mg (baseequivalent)

5

imatinib mesylate tab100 mg (base equivalent)(Gleevec)

5

Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

AC

A

Lim

ited

Dis

tribu

tion

imatinib mesylate tab400 mg (base equivalent)(Gleevec)

5

IMBRUVICA - ibrutinib cap 70mg

5

IMBRUVICA - ibrutinib cap 140mg

5

INLYTA - axitinib tab 1 mg 5 INLYTA - axitinib tab 5 mg 5 INTRON A - interferon alfa-2b

inj 6000000 unit/ml5

INTRON A - interferon alfa-2binj 10000000 unit/ml

5

INTRON A - interferon alfa-2bfor inj 10000000 unit

5


5


5

IRESSA - gefitinib tab 250 mg 5 JAKAFI - ruxolitinib phosphate

tab 5 mg (base equivalent)5

JAKAFI - ruxolitinib phosphatetab 10 mg (base equivalent)

5


5


5


5

KISQALI - ribociclib succinatetab 200 mg (base equiv)

5

KISQALI FEMARA 200 DOSE -ribociclib tab 200 mg &letrozole tab 2.5 mg therapypack

5

2017



Drug Name Dru

g Ti

er

Prio

r Aut

horiz

atio

drug tier list - myprime insurance marketplace 5 tier drug list. please consider talking to your...

Documents