Summary of Drug Coverage Location - Georgia SHBP



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Summary of Drug Coverage Location - Georgia SHBP Last Update: 12/07/2015 Therapeutic Category Description Trade Name Description SHBP Coverage Location Route Description Date of Revision to Document ADJUNCTIVE AGENTS LEVOLEUCOVORIN CALCIUM medical INTRAVENOUS 6/1/2015 ADRENAL HORMONES BETA 1 medical INJECTION 10/8/2015 ADRENAL HORMONES PRO-C-DURE 5 medical INJECTION 10/8/2015 ADRENAL HORMONES TRIAMCINOLONE ACETONIDE medical INJECTION 6/5/2014 ADRENOCORTICOTROPHIC HORMONES ACTHAR H.P. both INJECTION AGENTS TO TREAT MULTIPLE SCLEROSIS AUBAGIO pharmacy ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS AVONEX ADMINISTRATION PACK pharmacy INTRAMUSCULAR AGENTS TO TREAT MULTIPLE SCLEROSIS AVONEX PEN pharmacy INTRAMUSCULAR AGENTS TO TREAT MULTIPLE SCLEROSIS BETASERON pharmacy SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS COPAXONE pharmacy SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS EXTAVIA pharmacy SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS GILENYA pharmacy ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS REBIF pharmacy SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS REBIF REBIDOSE pharmacy SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS TECFIDERA pharmacy ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR AMPYRA pharmacy ORAL ALKYLATING AGENTS ALKERAN medical INTRAVENOUS ALKYLATING AGENTS BICNU medical INTRAVENOUS ALKYLATING AGENTS BUSULFEX medical INTRAVENOUS ALKYLATING AGENTS CARBOPLATIN medical INTRAVENOUS ALKYLATING AGENTS CISPLATIN medical INTRAVENOUS ALKYLATING AGENTS CYCLOPHOSPHAMIDE medical INTRAVENOUS ALKYLATING AGENTS ELOXATIN medical INTRAVENOUS ALKYLATING AGENTS IFEX medical INTRAVENOUS ALKYLATING AGENTS IFOSFAMIDE medical INTRAVENOUS ALKYLATING AGENTS IFOSFAMIDE-MESNA medical INTRAVENOUS ALKYLATING AGENTS MELPHALAN HCL medical INTRAVENOUS ALKYLATING AGENTS MUSTARGEN medical INJECTION ALKYLATING AGENTS OXALIPLATIN medical INTRAVENOUS ALKYLATING AGENTS TEMODAR medical INTRAVENOUS ALKYLATING AGENTS THIOTEPA medical INJECTION ALKYLATING AGENTS TREANDA medical INTRAVENOUS ALKYLATING AGENTS pharmacy ORAL AMINOGLYCOSIDES TOBI pharmacy INHALATION AMINOGLYCOSIDES TOBI PODHALER pharmacy INHALATION AMMONIA INHIBITORS CARBAGLU pharmacy ORAL 1

AMYOTROPHIC LATERAL SCLEROSIS AGENTS RILUTEK pharmacy ORAL ANALGESICS, NARCOTICS MORPHINE SULFATE medical INTRAVENOUS 5/8/2014 ANALGESICS, NARCOTICS ONSOLIS pharmacy BUCCAL ANALGESICS, NEURONAL-TYPE CALCIUM CHANNEL BLOCKERS PRIALT medical INTRATHECAL ANDROGENIC AGENTS AVEED medical INTRAMUSCULAR 3/24/2014 ANDROGENIC AGENTS TESTOPEL medical IMPLANTATION ANTI-ALCOHOLIC PREPARATIONS VIVITROL medical INTRAMUSCULAR ANTIANDROGENIC AGENTS XTANDI pharmacy ORAL ANTIANDROGENIC AGENTS ZYTIGA pharmacy ORAL ANTIARRHYTHMICS, OTHER ADENOSINE medical INTRAVENOUS 3/24/2014 ANTIBIOTIC ANTINEOPLASTICS ADRIAMYCIN medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS BLEOMYCIN SULFATE medical INJECTION ANTIBIOTIC ANTINEOPLASTICS CERUBIDINE medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS COSMEGEN medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS DACTINOMYCIN medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS DAUNORUBICIN HCL medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS DAUNOXOME medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS DOXIL medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS DOXORUBICIN HCL medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS ELLENCE medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS EPIRUBICIN HCL medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS IDAMYCIN PFS medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS IDARUBICIN HCL medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS LIPODOX medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS MITOMYCIN medical INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VALSTAR medical INTRAVESICAL ANTIBIOTIC ANTINEOPLASTICS ZANOSAR medical INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY ARZERRA medical INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY RITUXAN medical INTRAVENOUS ANTICOAGULANTS ARGATROBAN medical INTRAVENOUS 6/1/2015 ANTICONVULSANTS SABRIL pharmacy ORAL ANTIDIURETIC AND VASOPRESSOR HORMONES DDAVP medical INJECTION ANTIDIURETIC AND VASOPRESSOR HORMONES DESMOPRESSIN ACETATE medical INJECTION ANTIDIURETIC AND VASOPRESSOR HORMONES Stimate Nasal Spray pharmacy intranasal 3/6/2015 ANTIFIBRINOLYTIC AGENTS RIASTAP medical INTRAVENOUS ANTIFUNGAL AGENTS CRESEMBA medical INTRAVENOUS 5/6/2015 ANTIFUNGAL AGENTS NOXAFIL medical INTRAVENOUS 5/8/2014 ANTIHEMOPHILIC FACTORS ADVATE both INTRAVENOUS 4/21/2014 2

ANTIHEMOPHILIC FACTORS ADVATE H both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS ADVATE L both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS ADVATE M both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS ADVATE SH both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS ADVATE UH both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS ALPHANATE both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS FEIBA NF both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS FEIBA VH IMMUNO both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS HELIXATE FS both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS HEMOFIL-M both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS HUMATE-P both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS KOATE-DVI both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS KOGENATE FS both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS MONARC-M both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS MONOCLATE-P both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS NOVOSEVEN both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS NOVOSEVEN RT both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS RECOMBINATE both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS TRETTEN both INTRAVENOUS 5/8/2014 ANTIHEMOPHILIC FACTORS XYNTHA both INTRAVENOUS 4/21/2014 ANTIHEMOPHILIC FACTORS XYNTHA SOLOFUSE both INTRAVENOUS 4/21/2014 ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE & BIGUANIDE AVANDAMET pharmacy ORAL ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE & SULFONYLUREA AVANDARYL pharmacy ORAL ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE(PPARG AGONIST) AVANDIA pharmacy ORAL ANTI-INFLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST ARCALYST pharmacy (w/qll) SUBCUTANEOUS ANTI-INFLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST KINERET pharmacy SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR ENBREL pharmacy SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR HUMIRA pharmacy SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SIMPONI pharmacy SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SIMPONI ARIA medical INTRAVENOUS 3/24/2014 ANTI-INFLAMMATORY, INTERLEUKIN-1 BETA BLOCKERS ILARIS pharmacy SUBCUTANEOUS ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC. EUFLEXXA medical INTRAARTICULAR ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC. GEL-ONE medical INTRAARTICULAR 4/21/2014 ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC. HYALGAN medical INTRAARTICULAR ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC. ORTHOVISC medical INTRAARTICULAR ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC. SUPARTZ medical INTRAARTICULAR ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC. SYNVISC medical INTRAARTICULAR ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC. SYNVISC-ONE medical INTRAARTICULAR 3

ANTILEPROTICS THALOMID pharmacy ORAL ANTIMETABOLITES ADRUCIL medical INTRAVENOUS ANTIMETABOLITES ALIMTA medical INTRAVENOUS ANTIMETABOLITES ARRANON medical INTRAVENOUS ANTIMETABOLITES CLADRIBINE medical INTRAVENOUS ANTIMETABOLITES CLOLAR medical INTRAVENOUS ANTIMETABOLITES CYTARABINE medical INJECTION ANTIMETABOLITES DACOGEN both INTRAVENOUS ANTIMETABOLITES DEPOCYT medical INTRATHECAL ANTIMETABOLITES FLOXURIDINE medical INJECTION ANTIMETABOLITES FLUDARA medical INTRAVENOUS ANTIMETABOLITES FLUDARABINE PHOSPHATE medical INTRAVENOUS ANTIMETABOLITES FLUOROURACIL medical INTRAVENOUS ANTIMETABOLITES FOLOTYN medical INTRAVENOUS ANTIMETABOLITES GEMCITABINE HCL medical INTRAVENOUS ANTIMETABOLITES GEMZAR medical INTRAVENOUS ANTIMETABOLITES LEUSTATIN medical INTRAVENOUS ANTIMETABOLITES METHOTREXATE medical INJECTION ANTIMETABOLITES METHOTREXATE SODIUM medical INJECTION ANTIMETABOLITES NIPENT medical INTRAVENOUS ANTIMETABOLITES OFORTA pharmacy ORAL ANTIMETABOLITES PENTOSTATIN medical INTRAVENOUS 4/21/2014 ANTIMETABOLITES PURIXAN pharmacy ORAL 7/7/2014 ANTIMETABOLITES VIDAZA medical INJECTION ANTIMETABOLITES XELODA pharmacy ORAL ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGT XYREM pharmacy ORAL ANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODY AVASTIN medical INTRAVENOUS ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS ISTODAX medical INTRAVENOUS ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS ZOLINZA pharmacy ORAL ANTINEOPLASTIC - EPOTHILONES AND ANALOGS IXEMPRA medical INTRAVENOUS ANTINEOPLASTIC - HALICHONDRIN B ANALOGS HALAVEN medical INTRAVENOUS ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR ERIVEDGE pharmacy ORAL ANTINEOPLASTIC - IMMUNOTHERAPY, THERAPEUTIC VAC SIPULEUCEL-T PROVENGE medical INTRAVENOUS ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS JAKAFI pharmacy ORAL ANTINEOPLASTIC - MTOR KINASE INHIBITORS AFINITOR pharmacy ORAL ANTINEOPLASTIC - MTOR KINASE INHIBITORS TORISEL medical INTRAVENOUS ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS CAMPTOSAR medical INTRAVENOUS ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS HYCAMTIN medical INTRAVENOUS 4

ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS IRINOTECAN HCL medical INTRAVENOUS ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS TOPOTECAN HCL medical INTRAVENOUS ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS pharmacy ORAL ANTINEOPLASTIC - VEGF-A,B & PLGF INHIBITOR ZALTRAP medical INTRAVENOUS ANTINEOPLASTIC DRUGS CYRAMZA medical INTRAVENOUS 5/8/2014 ANTINEOPLASTIC DRUGS CYRAMZA medical INTRAVENOUS 6/5/2014 ANTINEOPLASTIC DRUGS Kadcyla medical INTRAVENOUS 5/12/2014 ANTINEOPLASTIC DRUGS SYLVANT medical INTRAVENOUS 6/5/2014 ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY ERBITUX medical INTRAVENOUS ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY HERCEPTIN medical INTRAVENOUS ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY PERJETA medical INTRAVENOUS ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY VECTIBIX medical INTRAVENOUS ANTINEOPLASTIC IMMUNOMODULATOR AGENTS POMALYST pharmacy ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS REVLIMID pharmacy ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS SYLATRON both SUBCUTANEOUS ANTINEOPLASTIC IMMUNOMODULATOR AGENTS SYLATRON 4-PACK both SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. ELIGARD medical SUBCUTANEOUS - MD inj only 4/21/2014 ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. LEUPROLIDE ACETATE pharmacy SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. LUPANETA PACK medical INTRAMUSCULAR 3/24/2014 ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. LUPRON DEPOT medical INTRAMUSCULAR ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. TRELSTAR medical INTRAMUSCULAR ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. TRELSTAR DEPOT medical INTRAMUSCULAR ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. TRELSTAR LA medical INTRAMUSCULAR ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. ZOLADEX medical SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) ANTAGONIST,PITUIT.SUPPRS FIRMAGON both SUBCUTANEOUS ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS BOSULIF pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS GLEEVEC pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS INLYTA pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS KYPROLIS medical INTRAVENOUS ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS MEKINIST pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS NEXAVAR pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS SPRYCEL pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS STIVARGA pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS SUTENT pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TAFINLAR pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TARCEVA pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TASIGNA pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TYKERB pharmacy ORAL 5

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS VANDETANIB pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS VELCADE medical INJECTION ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS VOTRIENT pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS XALKORI pharmacy ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS ZELBORAF pharmacy ORAL ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES ADCETRIS medical INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES BEXXAR medical INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES MYLOTARG medical INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES ZEVALIN medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS ABRAXANE medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS DACARBAZINE medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS DOCEFREZ medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS DOCETAXEL medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS ELSPAR medical INJECTION ANTINEOPLASTICS,MISCELLANEOUS ERWINAZE medical INTRAMUSCULAR ANTINEOPLASTICS,MISCELLANEOUS ETOPOPHOS medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS ETOPOSIDE medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS JEVTANA medical INTRAVENOUS 3/28/2014 ANTINEOPLASTICS,MISCELLANEOUS MITOXANTRONE medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS NOVANTRONE medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS ONCASPAR medical INJECTION ANTINEOPLASTICS,MISCELLANEOUS ONTAK medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS ONXOL medical INTRAVENOUS 4/21/2014 ANTINEOPLASTICS,MISCELLANEOUS PACLITAXEL medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS TAXOTERE medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS TENIPOSIDE medical INTRAVENOUS 4/21/2014 ANTINEOPLASTICS,MISCELLANEOUS THERACYS medical INTRAVESICAL ANTINEOPLASTICS,MISCELLANEOUS TICE BCG medical INTRAVESICAL ANTINEOPLASTICS,MISCELLANEOUS TOPOSAR medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS TRISENOX medical INTRAVENOUS ANTINEOPLASTICS,MISCELLANEOUS VUMON medical INTRAVENOUS ANTINEOPLASTICS/IMMUNOSUPPRESANT DRUGS GAZYVA medical INTRAVENOUS 3/24/2014 ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR ORENCIA both INTRAVENOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR pharmacy SUBCUTANEOUS ANTI-OBESITY - ANOREXIC AGENTS QSYMIA Not covered ORAL ANTIPARKINSONISM AGENTS DUOPA medical MISCELLANEOUS 3/6/2015 ANTIPARKINSONISM DRUGS,OTHER APOKYN pharmacy SUBCUTANEOUS ANTIPLATELET DRUGS KENGREAL medical INTRAVENOUS 7/8/2015 6

ANTIPSORIATIC / ANTISEBORRHEIC COSENTYX pharmacy SUBCUTANEOUS 3/6/2015 ANTIPSORIATIC AGENTS,SYSTEMIC 8-MOP pharmacy ORAL ANTIPSORIATIC AGENTS,SYSTEMIC AMEVIVE medical INTRAMUSCULAR ANTISERA ATGAM medical INTRAVENOUS ANTISERA BIVIGAM medical INTRAVENOUS 4/21/2014 ANTISERA CARIMUNE NF NANOFILTERED medical INTRAVENOUS ANTISERA CYTOGAM medical INTRAVENOUS ANTISERA FLEBOGAMMA medical INTRAVENOUS ANTISERA FLEBOGAMMA DIF medical INTRAVENOUS ANTISERA GAMASTAN S-D medical INTRAMUSCULAR ANTISERA GAMMAGARD LIQUID medical INTRAVENOUS ANTISERA GAMMAGARD S-D medical INTRAVENOUS ANTISERA GAMMAKED medical INJECTION ANTISERA GAMMAPLEX medical INTRAVENOUS ANTISERA GAMUNEX medical INTRAVENOUS ANTISERA GAMUNEX-C medical INJECTION ANTISERA HEPAGAM B medical INJECTION ANTISERA HIZENTRA both SUBCUTANEOUS 3/28/2014 ANTISERA HYPERHEP B S-D medical INTRAMUSCULAR ANTISERA HYPERRAB S-D medical INTRAMUSCULAR ANTISERA HYPERRHO S-D medical INTRAMUSCULAR ANTISERA IMOGAM RABIES-HT medical INTRAMUSCULAR ANTISERA MICRHOGAM PLUS medical INTRAMUSCULAR ANTISERA NABI-HB medical INTRAMUSCULAR ANTISERA OCTAGAM medical INTRAVENOUS ANTISERA PRIVIGEN medical INTRAVENOUS ANTISERA RHOGAM PLUS medical INTRAMUSCULAR ANTISERA RHOPHYLAC medical INJECTION ANTISERA THYMOGLOBULIN medical INTRAVENOUS ANTISERA VIVAGLOBIN medical SUBCUTANEOUS ANTISERA WINRHO SDF medical INJECTION ANTIVIRAL MONOCLONAL ANTIBODIES SYNAGIS both INTRAMUSCULAR 4/21/2014 ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS FUZEON pharmacy SUBCUTANEOUS ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI RETROVIR medical INTRAVENOUS ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS SAMSCA pharmacy ORAL BETALACTAMS CAYSTON pharmacy INHALATION BILE SALTS CHENODAL pharmacy ORAL BLOOD DERIVATIVES FLEXBUMIN medical INTRAVENOUS 10/9/2014 7

BLOOD FACTORS,MISCELLANEOUS CORIFACT medical INTRAVENOUS BONE FORMATION STIM. AGENTS - PARATHYROID HORMONE FORTEO pharmacy SUBCUTANEOUS BONE RESORPTION INHIBITORS AREDIA medical INTRAVENOUS BONE RESORPTION INHIBITORS BONIVA medical INTRAVENOUS BONE RESORPTION INHIBITORS IBANDRONATE medical INTRAVENOUS 4/21/2014 BONE RESORPTION INHIBITORS PAMIDRONATE DISODIUM medical INTRAVENOUS BONE RESORPTION INHIBITORS PROLIA medical SUBCUTANEOUS BONE RESORPTION INHIBITORS RECLAST medical INTRAVENOUS BONE RESORPTION INHIBITORS XGEVA medical SUBCUTANEOUS BONE RESORPTION INHIBITORS ZOLEDRONIC ACID medical INTRAVENOUS BONE RESORPTION INHIBITORS ZOMETA medical INTRAVENOUS BRADYKININ B2 RECEPTOR ANTAGONISTS FIRAZYR pharmacy SUBCUTANEOUS C1 ESTERASE INHIBITORS BERINERT both INTRAVENOUS C1 ESTERASE INHIBITORS CINRYZE medical INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS AMIFOSTINE medical INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS CALCIUM FOLINATE medical INJECTION CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS DEXRAZOXANE medical INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS ETHYOL medical INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS FUSILEV medical INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN CALCIUM medical INJECTION CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS MESNA medical INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS MESNEX medical INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS ZINECARD medical INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS pharmacy ORAL COMBINATION NARCOTIC /ANALGESICS APAP-CAFFEINE-DIHYDROCODEINE medical ORAL 9/10/2015 CONTRACEPTIVES,IMPLANTABLE IMPLANON medical SUBCUTANEOUS CONTRACEPTIVES,IMPLANTABLE NEXPLANON medical SUBCUTANEOUS contrast agent GADAVIST medical INTRAVENOUS contrast agent ISOVUE medical INTRAVENOUS 6/5/2014 CXCR4 CHEMOKINE RECEPTOR ANTAGONIST MOZOBIL both SUBCUTANEOUS CYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR KALYDECO pharmacy ORAL CYTOTOXIC T-LYMPHOCYTE ANTIGEN(CTLA-4)RMC ANTIBODY YERVOY medical INTRAVENOUS DIAGNOSTIC PRODUCT MD-GASTROVIEW 66%-10% SOLN medical 3/24/2014 DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES LILETTA medical INTRAUTERINE 4/10/2015 DRUGS TO TREAT HEREDITARY TYROSINEMIA ORFADIN pharmacy ORAL DRUGS TO TX CHRONIC INFLAMMATORY DISEASE OF COLON CIMZIA pharmacy SUBCUTANEOUS DRUGS TO TX CHRONIC INFLAMMATORY DISEASE OF COLON REMICADE medical INTRAVENOUS DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCING ZAVESCA pharmacy ORAL 8

ERYTHROPOIESIS-STIMULATING AGENTS ARANESP both INJECTION ERYTHROPOIESIS-STIMULATING AGENTS EPOGEN both INJECTION ERYTHROPOIESIS-STIMULATING AGENTS OMONTYS medical INJECTION ERYTHROPOIESIS-STIMULATING AGENTS PROCRIT both INJECTION FACTOR IX PREPARATIONS ALPHANINE SD both INTRAVENOUS 4/21/2014 FACTOR IX PREPARATIONS BEBULIN both INTRAVENOUS 4/21/2014 FACTOR IX PREPARATIONS BEBULIN VH IMMUNO both INTRAVENOUS 4/21/2014 FACTOR IX PREPARATIONS BENEFIX both INTRAVENOUS 4/21/2014 FACTOR IX PREPARATIONS MONONINE both INTRAVENOUS 4/21/2014 FACTOR IX PREPARATIONS PROFILNINE SD both INTRAVENOUS 4/21/2014 FLUOROQUINOLONES MOXIFLOXACIN HCL medical INTRAVENOUS 9/10/2015 FOLLICLE-STIMULATING & LUTEINIZING HORMONES MENOPUR pharmacy - under appeal SUBCUTANEOUS FOLLICLE-STIMULATING & LUTEINIZING HORMONES REPRONEX pharmacy - under appeal INJECTION FOLLICLE-STIMULATING HORMONE (FSH) BRAVELLE pharmacy - under appeal INJECTION FOLLICLE-STIMULATING HORMONE (FSH) FOLLISTIM AQ pharmacy - under appeal INJECTION FOLLICLE-STIMULATING HORMONE (FSH) GONAL-F pharmacy - under appeal SUBCUTANEOUS FOLLICLE-STIMULATING HORMONE (FSH) GONAL-F RFF pharmacy - under appeal SUBCUTANEOUS FOLLICLE-STIMULATING HORMONE (FSH) GASTRIC ENZYMES SUCRAID pharmacy ORAL SUBCUTANEOUS GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT pharmacy SUBCUTANEOUS GROWTH HORMONE RELEASING HORMONE (GHRH) & ANALOGS EGRIFTA pharmacy SUBCUTANEOUS GROWTH HORMONES GENOTROPIN pharmacy SUBCUTANEOUS GROWTH HORMONES HUMATROPE pharmacy INJECTION GROWTH HORMONES NORDITROPIN pharmacy SUBCUTANEOUS GROWTH HORMONES NORDITROPIN FLEXPRO pharmacy SUBCUTANEOUS GROWTH HORMONES NORDITROPIN NORDIFLEX pharmacy SUBCUTANEOUS GROWTH HORMONES NUTROPIN pharmacy SUBCUTANEOUS GROWTH HORMONES NUTROPIN AQ pharmacy SUBCUTANEOUS GROWTH HORMONES NUTROPIN AQ NUSPIN pharmacy SUBCUTANEOUS GROWTH HORMONES OMNITROPE pharmacy SUBCUTANEOUS GROWTH HORMONES SAIZEN pharmacy SUBCUTANEOUS GROWTH HORMONES SEROSTIM pharmacy SUBCUTANEOUS GROWTH HORMONES TEV-TROPIN pharmacy SUBCUTANEOUS GROWTH HORMONES ZOMACTON pharmacy SUBCUTANEOUS 6/1/2015 GROWTH HORMONES ZOMACTON pharmacy SUBCUTANEOUS 7/8/2015 GROWTH HORMONES ZORBTIVE pharmacy SUBCUTANEOUS HEMOSTATICS CYKLOKAPRON medical INTRAVENOUS 3/6/2015 HEPARIN AND RELATED PREPARATIONS ARIXTRA Both SUBCUTANEOUS 9/10/2015 9

HEPARIN AND RELATED PREPARATIONS ENOXAPARIN SODIUM Both SUBCUTANEOUS 9/10/2015 HEPARIN AND RELATED PREPARATIONS FONDAPARINUX SODIUM Both SUBCUTANEOUS 9/10/2015 HEPARIN AND RELATED PREPARATIONS FRAGMIN Both SUBCUTANEOUS 9/10/2015 HEPARIN AND RELATED PREPARATIONS INNOHEP Both SUBCUTANEOUS 9/10/2015 HEPARIN AND RELATED PREPARATIONS LOVENOX both SUBCUTANEOUS 9/10/2015 HEPATITIS C TREATMENT AGENTS COPEGUS pharmacy ORAL HEPATITIS C TREATMENT AGENTS INFERGEN pharmacy SUBCUTANEOUS HEPATITIS C TREATMENT AGENTS PEGASYS pharmacy SUBCUTANEOUS HEPATITIS C TREATMENT AGENTS PEGASYS PROCLICK pharmacy SUBCUTANEOUS HEPATITIS C TREATMENT AGENTS PEG-INTRON pharmacy SUBCUTANEOUS HEPATITIS C TREATMENT AGENTS PEG-INTRON REDIPEN pharmacy SUBCUTANEOUS HEPATITIS C TREATMENT AGENTS REBETOL pharmacy ORAL HEPATITIS C TREATMENT AGENTS RIBAPAK pharmacy ORAL HEPATITIS C TREATMENT AGENTS RIBASPHERE pharmacy ORAL HEPATITIS C TREATMENT AGENTS RIBATAB pharmacy ORAL HEPATITIS C TREATMENT AGENTS RIBAVIRIN pharmacy ORAL HEPATITIS C VIRUS NS3/4A SERINE PROTEASE INHIB. INCIVEK pharmacy ORAL HEPATITIS C VIRUS NS3/4A SERINE PROTEASE INHIB. VICTRELIS pharmacy ORAL HUMAN CHORIONIC GONADOTROPIN (HCG) CHORIONIC GONADOTROPIN medical INTRAMUSCULAR HUMAN CHORIONIC GONADOTROPIN (HCG) NOVAREL medical INTRAMUSCULAR HUMAN CHORIONIC GONADOTROPIN (HCG) OVIDREL medical SUBCUTANEOUS HUMAN CHORIONIC GONADOTROPIN (HCG) PREGNYL medical INTRAMUSCULAR HUMAN MONOCLONAL ANTIBODY COMPLEMENT(C5) INHIBITOR SOLIRIS medical INTRAVENOUS HYPERURICEMIA TX - URATE-OXIDASE ENZYME-TYPE ELITEK medical INTRAVENOUS HYPERURICEMIA TX - URATE-OXIDASE ENZYME-TYPE KRYSTEXXA medical INTRAVENOUS HYPNOTIC AGENTS DEXMEDETOMIDINE HCL medical INTRAVENOUS 9/8/2014 HYPNOTIC AGENTS PRECEDEX medical INTRAVENOUS 3/6/2015 Both - Medical should only cover IMMUNOLOGICALS AND VACCINES GRASTEK SUBLINGUAL 2/3/2015 1st dose Both - Medical should only cover IMMUNOLOGICALS AND VACCINES ORALAIR SUBLINGUAL 2/3/2015 1st dose Both - Medical should only cover IMMUNOLOGICALS AND VACCINES RAGWITEK SUBLINGUAL 2/3/2015 1st dose IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIB BENLYSTA medical INTRAVENOUS IMMUNOMODULATORS ACTIMMUNE pharmacy SUBCUTANEOUS IMMUNOMODULATORS ALFERON N pharmacy INJECTION IMMUNOMODULATORS INTRON A pharmacy INJECTION IMMUNOMODULATORS PROLEUKIN medical INTRAVENOUS IMMUNOSUPP - MONOCLONAL AB INHIBITING T LYMPH FXN ORTHOCLONE OKT-3 medical INTRAVENOUS IMMUNOSUPP - MONOCLONAL AB INHIBITING T LYMPH FXN SIMULECT medical INTRAVENOUS IMMUNOSUPPRESSIVES CELLCEPT medical INTRAVENOUS 3/24/2014 10

IMMUNOSUPPRESSIVES CELLCEPT pharmacy ORAL 3/24/2014 IMMUNOSUPPRESSIVES CYCLOSPORINE pharmacy ORAL 3/24/2014 IMMUNOSUPPRESSIVES CYCLOSPORINE medical INTRAVENOUS 3/24/2014 IMMUNOSUPPRESSIVES NULOJIX medical INTRAVENOUS IMMUNOSUPPRESSIVES PROGRAF pharmacy ORAL 3/24/2014 IMMUNOSUPPRESSIVES PROGRAF medical INTRAVENOUS 3/24/2014 IMMUNOSUPPRESSIVES SANDIMMUNE pharmacy ORAL 3/24/2014 IMMUNOSUPPRESSIVES SANDIMMUNE medical INTRAVENOUS 3/24/2014 INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONES INCRELEX pharmacy SUBCUTANEOUS INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS ACTEMRA medical INTRAVENOUS INTRA-UTERINE DEVICES (IUDS) MIRENA medical INTRAUTERINE INTRA-UTERINE DEVICES (IUDS) SKYLA medical INTRAUTERINE IRRITANTS/COUNTER-IRRITANTS QUTENZA pharmacy TOPICAL JANUS KINASE (JAK) INHIBITORS XELJANZ pharmacy ORAL JOINT CONTRACTURE THERAPY, COLLAGENASE ENZYME XIAFLEX medical INJECTION KERATINOCYTE GROWTH FACTOR (KGF) KEPIVANCE medical INTRAVENOUS KIDNEY STONE AGENTS CYSTAGON pharmacy ORAL KIDNEY STONE AGENTS PROCYSBI pharmacy ORAL LEUKOCYTE (WBC) STIMULANTS LEUKINE both INJECTION LEUKOCYTE (WBC) STIMULANTS NEULASTA both SUBCUTANEOUS LEUKOCYTE (WBC) STIMULANTS NEUPOGEN both INJECTION LEUKOCYTE ADHESION INHIB,ALPHA4-MEDIAT IGG4K MC AB TYSABRI medical INTRAVENOUS LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS LUPRON DEPOT medical INTRAMUSCULAR LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS SUPPRELIN LA medical IMPLANTATION LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS VANTAS medical IMPLANTATION LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS CETROTIDE pharmacy - under appeal SUBCUTANEOUS LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS GANIRELIX ACETATE pharmacy - under appeal SUBCUTANEOUS LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY LUPRON DEPOT-PED medical INTRAMUSCULAR LIPID/CHOLESTEROL LOWERING AGENTS PRALUENT pharmacy SUBCUTANEOUS 8/5/2015 LIPID/CHOLESTEROL LOWERING AGENTS REPATHA SURECLICK pharmacy SUBCUTANEOUS 9/10/2015 LIPID/CHOLESTEROL LOWERING AGENTS REPATHA SYRINGE pharmacy SUBCUTANEOUS 9/10/2015 LUTEINIZING HORMONES LUVERIS pharmacy - under appeal SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DX FABRAZYME medical INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX CEREDASE medical INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX CEREZYME medical INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX ELELYSO medical INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX VPRIV medical INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT,POMPE DISEASE LUMIZYME medical INTRAVENOUS 11

METABOLIC DISEASE ENZYME REPLACEMENT,POMPE DISEASE MYOZYME medical INTRAVENOUS METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSIS ALDURAZYME medical INTRAVENOUS METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSIS ELAPRASE medical INTRAVENOUS METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSIS NAGLAZYME medical INTRAVENOUS METABOLIC DX ENZYME REPLACEMT,SEV.COMB.IMMUNE DEF. ADAGEN medical INTRAMUSCULAR METALLIC POISON,AGENTS TO TREAT CALCIUM DISODIUM VERSENATE medical INTRAVENOUS 3/24/2014 METALLIC POISON,AGENTS TO TREAT DEFEROXAMINE MESYLATE medical INJECTION METALLIC POISON,AGENTS TO TREAT DESFERAL medical INJECTION METALLIC POISON,AGENTS TO TREAT EXJADE pharmacy ORAL METALLIC POISON,AGENTS TO TREAT FERRIPROX pharmacy ORAL MISCELLANEOUS AGENT BELZER UW-CSS-VIASPAN medical PERFUSION 3/24/2014 MISCELLANEOUS AGENT DOXERCALCIFEROL medical INTRAVENOUS 3/24/2014 MISCELLANEOUS AGENT DOXERCALCIFEROL pharmacy ORAL 3/24/2014 MISCELLANEOUS AGENT ISOVUE medical INTRAVENOUS 5/8/2014 MISCELLANEOUS AGENT VARITHENA medical INTRAVENOUS 5/8/2014 MISCELLANEOUS AGENT VIMIZIM medical INTRAVENOUS 3/24/2014 MISCELLANEOUS AGENTS CERDELGA pharmacy oral 9/8/2014 MISCELLANEOUS AGENTS MYOVIEW medical INTRAVENOUS 3/6/2015 MISCELLANEOUS AGENTS PARICALCITOL medical INJECTION 12/1/2014 MISCELLANEOUS AGENTS SCULPTRA Not covered INJECTION 9/8/2014 MISCELLANEOUS AGENTS STRENSIQ pharmacy SUBCUTANEOUS 11/10/2015 MISCELLANEOUS ANALGESICS MONOVISC medical INTRAARTICULAR 5/8/2014 MISCELLANEOUS ANALGESICS SUPARTZ FX medical INTRAARTICULAR 10/8/2015 MISCELLANEOUS ANTIINFECTIVES DALVANCE medical INTRAVENOUS 7/7/2014 MISCELLANEOUS ANTIINFECTIVES MEROPENEM-0.9% NACL medical INTRAVENOUS 11/10/2015 MISCELLANEOUS ANTIINFECTIVES ORBACTIV medical INTRAVENOUS 10/9/2014 MISCELLANEOUS ANTIINFECTIVES SIVEXTRO medical INTRAVENOUS 7/7/2014 MISCELLANEOUS ANTINEOPLASTIC DRUGS BELEODAQ medical INTRAVENOUS 8/5/2014 MISCELLANEOUS ANTINEOPLASTIC DRUGS BLINCYTO medical INTRAVENOUS 1/5/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS DOCETAXEL medical INTRAVENOUS 3/6/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS KEYTRUDA medical INTRAVENOUS 10/9/2014 MISCELLANEOUS ANTINEOPLASTIC DRUGS LENVIMA pharmacy ORAL 3/6/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS LONSURF pharmacy ORAL 10/8/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS ODOMZO pharmacy ORAL 10/8/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS ONIVYDE both INTRAVENOUS 11/10/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS OPDIVO medical INTRAVENOUS 1/5/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS SANDOSTATIN LAR DEPOT pharmacy INTRAMUSCULAR 5/6/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS SIGNIFOR LAR both INTRAMUSCULAR 3/6/2015 12

MISCELLANEOUS ANTINEOPLASTIC DRUGS UNITUXIN medical INTRAVENOUS 8/5/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS YONDELIS medical INTRAVENOUS 11/10/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS ZYDELIG pharmacy ORAL 8/5/2014 MISCELLANEOUS ANTIPSYCHOTICS ABILIFY medical INTRAMUSCULAR 11/10/2015 MISCELLANEOUS ANTIPSYCHOTICS ABILIFY MAINTENA medical INTRAMUSCULAR 11/10/2015 MISCELLANEOUS ANTIPSYCHOTICS ARISTADA medical INTRAMUSCULAR 11/10/2015 MISCELLANEOUS ANTIPSYCHOTICS GEODON IM INJ medical INTRAMUSCULAR 11/10/2015 MISCELLANEOUS ANTIPSYCHOTICS HALDOL DECANOATE medical INTRAMUSCULAR 11/10/2015 MISCELLANEOUS ANTIPSYCHOTICS HALOPERIDOL DECANOATE medical INTRAMUSCULAR 11/10/2015 MISCELLANEOUS ANTIPSYCHOTICS INVEGA SUSTENNA medical INTRAMUSCULAR 11/11/2015 MISCELLANEOUS ANTIPSYCHOTICS INVEGA TRINZA medical INTRAMUSCULAR 7/8/2015 MISCELLANEOUS ANTIPSYCHOTICS OLANZAPINE IM INJ medical INTRAMUSCULAR 11/13/2015 MISCELLANEOUS ANTIPSYCHOTICS RISPERDAL CONSTA medical INTRAMUSCULAR 11/14/2015 MISCELLANEOUS ANTIPSYCHOTICS ZYPREXA IM INJ medical INTRAMUSCULAR 11/15/2015 MISCELLANEOUS ANTIPSYCHOTICS ZYPREXA RELPREVV medical INTRAMUSCULAR 11/16/2015 MISCELLANEOUS ANTIVIRALS DAKLINZA pharmacy ORAL 8/5/2015 MISCELLANEOUS ANTIVIRALS RAPIVAB medical INTRAVENOUS 1/5/2015 MISCELLANEOUS ANTIVIRALS TECHNIVIE pharmacy ORAL 8/5/2015 MISCELLANEOUS COAGULATION AGENTS ALPROLIX both INTRAVENOUS 5/8/2014 MISCELLANEOUS COAGULATION AGENTS BIVALIRUDIN medical INTRAVENOUS 9/10/2015 MISCELLANEOUS COAGULATION AGENTS BIVALIRUDIN medical INTRAVENOUS 9/10/2015 MISCELLANEOUS COAGULATION AGENTS ELOCTATE both INTRAVENOUS 8/5/2014 MISCELLANEOUS COAGULATION AGENTS IXINITY Both INTRAVENOUS 7/8/2015 MISCELLANEOUS COAGULATION AGENTS KCENTRA medical INTRAVENOUS 5/8/2014 MISCELLANEOUS COAGULATION AGENTS NOVOEIGHT Both INTRAVENOUS 4/10/2015 MISCELLANEOUS COAGULATION AGENTS NUWIQ both INTRAVENOUS 11/10/2015 MISCELLANEOUS COAGULATION AGENTS OBIZUR both INTRAVENOUS 12/1/2014 MISCELLANEOUS COAGULATION AGENTS PRAXBIND medical INTRAVENOUS 11/10/2015 MISCELLANEOUS GASTROINTESTINAL AGENTS ENTYVIO medical INTRAVENOUS 6/5/2014 MISCELLANEOUS NEUROLOGICAL THERAPY GLATOPA pharmacy SUBCUTANEOUS 7/8/2015 MISCELLANEOUS NEUROLOGICAL THERAPY LEMTRADA medical INTRAVENOUS 1/5/2015 MISCELLANEOUS NUTRITION PRODUCTS KABIVEN medical INTRAVENOUS 10/9/2014 MISCELLANEOUS NUTRITION PRODUCTS PERIKABIVEN medical INTRAVENOUS 11/4/2014 MISCELLANEOUS NUTRITION PRODUCTS TYR ANAMIX NEXT pharmacy ORAL 10/9/2014 MISCELLANEOUS OPHTHALMOLOGICS OMIDRIA medical INTRAOCULAR 5/6/2015 MISCELLANEOUS PULMONARY AGENTS ORKAMBI pharmacy ORAL 8/5/2015 MISCELLANEOUS PULMONARY AGENTS RUCONEST both INTRAVENOUS 9/8/2014 MISCELLANEOUS RHEUMATOLOGICAL AGENTS RASUVO pharmacy SUBCUTANEOUS 9/8/2014 13

MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E (IGE) XOLAIR pharmacy SUBCUTANEOUS MONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIB STELARA both SUBCUTANEOUS MOVEMENT DISORDERS (DRUG THERAPY) XENAZINE pharmacy ORAL MUCOLYTICS PULMOZYME pharmacy INHALATION MUSCLE RELAXANTS & ANTISPASMODIC AGENTS METHOCARBAMOL medical INJECTION 1/5/2015 MUSCLE RELAXANTS & ANTISPASMODIC AGENTS RYANODEX medical INTRAVENOUS 9/8/2014 MYASTHENIA GRAVIS NEOSTIGMINE METHYLSULFATE medical INTRAVENOUS 4/10/2015 MYELOID STIMULANTS NEULASTA Delivery Kit medical SUBCUTANEOUS 2/3/2015 MYELOID STIMULANTS ZARXIO both INJECTION 10/8/2015 NARCOTIC ANTAGONISTS EVZIO medical INJECTION 7/7/2014 NARCOTICS MORPHINE SULFATE medical INTRAVENOUS 10/8/2015 NEUROMUSCULAR BLOCKING AGENTS BOTOX medical INJECTION NEUROMUSCULAR BLOCKING AGENTS BOTOX COSMETIC Not covered INJECTION NEUROMUSCULAR BLOCKING AGENTS DYSPORT medical INTRAMUSCULAR NEUROMUSCULAR BLOCKING AGENTS MYOBLOC medical INTRAMUSCULAR NEUROMUSCULAR BLOCKING AGENTS XEOMIN medical INTRAMUSCULAR NSAIDS DYLOJECT medical INTRAVENOUS 9/10/2015 NSAIDS KETOROLAC TROMETHAMINE medical INJECTION 7/7/2014 OCULAR PHOTOACTIVATED VESSEL-OCCLUDING AGENTS VISUDYNE medical INTRAVENOUS OPHTH VASC. ENDOTHELIAL GROWTH FACTOR ANTAGONISTS EYLEA medical INTRAOCULAR OPHTH VASC. ENDOTHELIAL GROWTH FACTOR ANTAGONISTS MACUGEN medical INTRAOCULAR OPHTH. VEGF-A RECEPTOR ANTAG. RCMB MC ANTIBODY LUCENTIS medical INTRAOCULAR ORAL DRUGS FOR GLAUCOMA KEVEYIS pharmacy ORAL 10/8/2015 ORAL MUCOSITIS/STOMATITIS AGENTS MUGARD medical MUCOUS MEMBRANE OTHER ELECTROLYTES ZINC GLUCONATE medical INTRAVENOUS 10/9/2014 PERIODONTAL TETRACYCLINE ANTIINFECTIVE, LOCAL ARESTIN medical DENTAL PHOTOACTIVATED, ANTINEOPLASTIC AGENTS (SYSTEMIC) PHOTOFRIN medical INTRAVENOUS PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE KUVAN pharmacy ORAL PLASMA KALLIKREIN INHIBITORS KALBITOR medical SUBCUTANEOUS PLATELET PROLIFERATION STIMULANTS NEUMEGA pharmacy SUBCUTANEOUS PROGESTATIONAL AGENTS MAKENA medical INTRAMUSCULAR PROGESTATIONAL AGENTS PROGESTERONE medical INTRAMUSCULAR PROTEIN C PREPARATIONS CEPROTIN medical INTRAVENOUS PROTON PUMP INHIBITORS ESOMEPRAZOLE SODIUM medical INTRAVENOUS 3/24/2014 PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB ADCIRCA pharmacy ORAL PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB REVATIO medical INTRAVENOUS PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB SILDENAFIL CITRATE pharmacy ORAL PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB pharmacy ORAL 14

PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST LETAIRIS pharmacy ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TRACLEER pharmacy ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE EPOPROSTENOL SODIUM medical INTRAVENOUS PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE FLOLAN medical INTRAVENOUS PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE REMODULIN medical INJECTION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TYVASO pharmacy INHALATION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE VELETRI medical INTRAVENOUS PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE VENTAVIS pharmacy INHALATION RAPID ACTING NITRATES NITRONAL medical INTRAVENOUS 6/5/2014 SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) FASLODEX medical INTRAMUSCULAR SOMATOSTATIC AGENTS OCTREOTIDE ACETATE pharmacy INJECTION SOMATOSTATIC AGENTS SANDOSTATIN pharmacy INJECTION 3/24/2014 SOMATOSTATIC AGENTS SANDOSTATIN LAR medical INTRAMUSCULAR 3/24/2014 SOMATOSTATIC AGENTS SOMATULINE DEPOT both SUBCUTANEOUS STEROIDS ILUVIEN medical INTRAOCULAR 1/5/2015 SYSTEMIC ENZYME INHIBITORS ARALAST medical INTRAVENOUS SYSTEMIC ENZYME INHIBITORS ARALAST NP medical INTRAVENOUS SYSTEMIC ENZYME INHIBITORS GLASSIA medical INTRAVENOUS SYSTEMIC ENZYME INHIBITORS PROLASTIN medical INTRAVENOUS SYSTEMIC ENZYME INHIBITORS PROLASTIN C medical INTRAVENOUS SYSTEMIC ENZYME INHIBITORS ZEMAIRA medical INTRAVENOUS THIAZIDE & RELATED DIURETICS ETHACRYNATE SODIUM medical INTRAVENOUS 9/10/2015 THIRD GENERATION CEPHALOSPORINS AVYCAZ medical INTRAVENOUS 5/6/2015 THIRD GENERATION CEPHALOSPORINS ZERBAXA medical INTRAVENOUS 1/5/2015 THROMBIN INHIBITORS,SEL.,DIRECT,&REV.-HIRUDIN TYPE IPRIVASK medical SUBCUTANEOUS THROMBIN INHIBITORS,SEL.,DIRECT,&REV.-HIRUDIN TYPE REFLUDAN medical INTRAVENOUS THROMBOPOIETIN RECEPTOR AGONISTS NPLATE medical SUBCUTANEOUS THROMBOPOIETIN RECEPTOR AGONISTS PROMACTA pharmacy ORAL THYROID FUNCTION DIAGNOSTIC AGENTS THYROGEN medical INTRAMUSCULAR TISSUE BULKING IMPLANTS SOLESTA medical IMPLANTATION TISSUE PROTECTIVE TX OF CHEMOTHERAPY EXTRAVASATION TOTECT medical INTRAVENOUS TOPICAL ANESTHETICS LIVIXIL PAK medical TOPICAL 9/10/2015 TOPICAL ANESTHETICS NAROPIN medical INJECTION 1/5/2015 TOPICAL ANESTHETICS ROPIVACAINE HCL-NS medical INJECTION 8/5/2014 TOPICAL ANESTHETICS ZINGO medical INTRADERMAL 10/8/2015 TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS PANRETIN pharmacy TOPICAL TOXIN-PRODUCING BACILLI VACCINES/TOXOIDS TICE BCG medical INJECTION VACCINES & MISCELLANEOUS IMMUNOLOGICALS AFLURIA both INTRAMUSCULAR 15 9/8/2014

VACCINES & MISCELLANEOUS IMMUNOLOGICALS ALTERNARIA medical INJECTION 9/10/2015 VACCINES & MISCELLANEOUS IMMUNOLOGICALS AMERICAN COCKROACH EXTRACT medical INJECTION 9/10/2015 VACCINES & MISCELLANEOUS IMMUNOLOGICALS AMERICAN ELM medical INJECTION 9/10/2015 VACCINES & MISCELLANEOUS IMMUNOLOGICALS ASPERGILLUS FUMIGATUS medical SUBCUTANEOUS 9/10/2015 VACCINES & MISCELLANEOUS IMMUNOLOGICALS BEXSERO medical INTRAMUSCULAR 3/6/2015 VACCINES & MISCELLANEOUS IMMUNOLOGICALS FLUARIX both INTRAMUSCULAR 8/5/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS FLUBLOK both INTRAMUSCULAR 9/8/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS FLUCELVAX both INTRAMUSCULAR 8/5/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS FLULAVAL both INTRAMUSCULAR 8/5/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS FLUMIST both NASAL 8/5/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS FLUVIRIN both INTRAMUSCULAR 8/5/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS FLUZONE both INTRAMUSCULAR 8/5/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS GARDASIL 9 both INTRAMUSCULAR 1/5/2015 VACCINES & MISCELLANEOUS IMMUNOLOGICALS HYQVIA both SUBCUTANEOUS 10/9/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS MIXED RAGWEED EXTRACT medical INJECTION 9/10/2015 VACCINES & MISCELLANEOUS IMMUNOLOGICALS PNEUMOVAX 23 medical INJECTION 8/5/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS QUADRACEL DTAP-IPV medical INTRAMUSCULAR 5/6/2015 VACCINES & MISCELLANEOUS IMMUNOLOGICALS SINGLE USE EZ FLU 2014-2015 both INTRAMUSCULAR 9/8/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS SPHERUSOL medical INTRADERMAL 11/4/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS TRUMENBA medical INTRAMUSCULAR 12/1/2014 VACCINES & MISCELLANEOUS IMMUNOLOGICALS VARIZIG medical INTRAMUSCULAR 7/8/2015 VINCA ALKALOIDS NAVELBINE medical INTRAVENOUS VINCA ALKALOIDS VINBLASTINE SULFATE medical INTRAVENOUS VINCA ALKALOIDS VINCASAR PFS medical INTRAVENOUS VINCA ALKALOIDS VINCRISTINE SULFATE medical INTRAVENOUS VINCA ALKALOIDS VINORELBINE TARTRATE medical INTRAVENOUS VITAMINS & HEMATINICS M.V.I.-12 medical INTRAVENOUS 9/10/2015 VITAMINS & HEMATINICS TRIFERIC medical HEMODIALYSIS 10/8/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS IMLYGIC medical INJECTION 12/7/2015 MISCELLANEOUS PULMONARY AGENTS NUCALA medical SUBCUTANEOUS 12/7/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS COTELLIC pharmacy ORAL 12/7/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS TAGRISSO pharmacy ORAL 12/7/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS DARZALEX medical INTRAVENOUS 12/7/2015 MISCELLANEOUS COAGULATION AGENTS ADYNOVATE medical INTRAVENOUS 12/7/2015 MISCELLANEOUS COAGULATION AGENTS COAGADEX medical INTRAVENOUS 12/7/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS EMPLICITI medical INTRAVENOUS 12/7/2015 MISCELLANEOUS ANTINEOPLASTIC DRUGS NINLARO pharmacy ORAL 12/7/2015 MISCELLANEOUS AGENTS VELTASSA pharmacy ORAL 12/7/2015 16

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