http://planinfo.bluecrossma.com/ekit/2021- MASSACHUSETTS umasspostdoctoralresearchers-en_US.pdf

Effective: 7/1/2021

WELCOME Umass Post- Doctoral Researchers

Get the most out of your plan

Plan Options Medical Blue Care Elect Ded $250 Summary View SBC

helpFul resources

Quick Start - PPO Emergency Room Alternatives Telehealth Brochure 24/7 Nurse Line ahealthyme rewards Fitness $150 Reimbursement Weight-Loss $150 Reimbursement Your Best Shot at Avoiding the Flu Blue Card Program Brochure Commitment To Confidentiality MyBlue App MyBlue Fact Sheet Mail Service Pharmacy Brochure & Form $9 Generic Medications List Medication Look-up Tool Fact Sheet 2021 Pharmacy Formulary

Follow us:

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. ®’ Registered Marks and TM Trademarks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Back to Start Plan Options Wellness Resources

Left Blank Intentionally SUMMARY OF BENEFITS

® Umass Post-Doctoral Blue Care Elect Researchers $250 Deductible

Plan-Year Deductible: $250/$500

UNLOCK THE POWER OF YOUR PLAN MyBlue gives you an instant snapshot of your plan:

COVERAGE AND CLAIMS AND DIGITAL BENEFITS BALANCES ID CARD

Sign in Download the app, or create an account at bluecrossma.com.

This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law.

An Association of Independent Blue Cross and Blue Shield Plans Your Choice

Your Deductible Emergency Room Services Your deductible is the amount of money you pay out-of-pocket each plan In an emergency, such as a suspected heart attack, stroke, or poisoning, year before you can receive coverage for most benefits under this plan. If you you should go directly to the nearest medical facility or call 911 (or the local are not sure when your plan year begins, contact Blue Cross Blue Shield emergency phone number). You pay a copayment per visit for in-network or of Massachusetts. Your deductibles are $250 per member (or $500 per family) out-of-network emergency room services. The copayment is waived if you are for in-network services and $250 per member (or $500 per family) for admitted to the hospital or for an observation stay. See the chart for your out-of-network services. cost share.

When You Choose Preferred Providers Telehealth Services You receive the highest level of benefits under your health care plan when You are covered for certain medical and mental health services for conditions you obtain covered services from preferred providers. These are called your that can be treated through video visits from an approved telehealth provider. “in-network” benefits. See the charts for your cost share. Most telehealth services are available by using the Well Connection website at wellconnection.com on your computer, or the Well Connection app on your Note: If a preferred provider refers you to another provider for covered services (such as a lab or specialist), make sure the provider is a preferred provider in order to receive benefits at the mobile device, when you prefer not to make an in-person visit for any reason to in-network level. If the provider you use is not a preferred provider, you’re still covered, but your a doctor or therapist. Some providers offer telehealth services through their own benefits, in most situations, will be covered at the out-of-network level, even if the preferred provider refers you. video platforms. For a list of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.com, consult the Provider Directory, How to Find a Preferred Provider or call the Member Service number on your ID card. To find a preferred provider: Utilization Review Requirements • Look up a provider in the Provider Directory. If you need a copy of your directory Certain services require pre-approval/prior authorization through Blue Cross or help choosing a provider, call the Member Service number on your ID card. Blue Shield of Massachusetts for you to have benefit coverage; this includes • Visit the Blue Cross Blue Shield of Massachusetts website at non-emergency and non-maternity hospitalization and may include certain bluecrossma.com/findadoctor outpatient services, therapies, procedures, and drugs. You should work with your health care provider to determine if pre-approval is required for any service When You Choose Non-Preferred Providers your provider is suggesting. If your provider, or you, don’t get pre-approval when You can also obtain covered services from non-preferred providers, but your it’s required, your benefits will be denied, and you may be fully responsible for out-of-pocket costs are higher. These are called your “out-of-network” benefits. payment to the provider of the service. Refer to your subscriber certificate for See the charts for your cost share. requirements and the process you should follow for Utilization Review, including Pre-Admission Review, Pre-Service Approval, Concurrent Review and Discharge Payments for out-of-network benefits are based on the Blue Cross Blue Shield Planning, and Individual Case Management. allowed charge as defined in your subscriber certificate. You may be responsible for any difference between the allowed charge and the provider’s actual billed Dependent Benefits charge (this is in addition to your deductible and/or your coinsurance). This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their dependent’s financial dependency, student status, Your Out-of-Pocket Maximum or employment status. See your subscriber certificate (and riders, if any) for Your out-of-pocket maximum is the most that you could pay during a plan year exact coverage details. for deductible, copayments (including prescription drug copayments), and coinsurance for covered services. Your out-of-pocket maximums are $1,000 per Domestic Partner Coverage member (or $2,500 per family) for in-network services and $3,500 per member Domestic partner coverage may be available for eligible dependents. Contact (or $7,000 per family) for out-of-network services. your plan sponsor for more information. Covered Services Your Cost In-Network Your Cost Out-of-Network

Preventive Care

Well-child care exams, including related tests, according to age-based schedule as follows: Nothing, no deductible 20% coinsurance after deductible • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year for age 3 and older

Routine adult physical exams, including related tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible

Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible

Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible

Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) All charges beyond the 20% coinsurance after deductible maximum, no deductible and all charges beyond the maximum

Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible

Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care

Emergency room visits $50 per visit, no deductible $50 per visit, no deductible (waived if admitted or for an (waived if admitted or for an observation stay) observation stay)

Office or health center visits $10 per visit, no deductible 20% coinsurance after deductible

Mental health or substance use treatment $10 per visit, no deductible 20% coinsurance after deductible

Telehealth services for simple medical conditions or mental health $10 per visit, no deductible 20% coinsurance after deductible

Chiropractors’ office visits $10 per visit, no deductible 20% coinsurance after deductible

Acupuncture visits (up to 12 visits per calendar year) $10 per visit, no deductible 20% coinsurance after deductible

Short-term rehabilitation therapy–physical and occupational (up to 100 visits per calendar year*) $10 per visit, no deductible 20% coinsurance after deductible

Speech, hearing, and language disorder treatment–speech therapy $10 per visit, no deductible 20% coinsurance after deductible

Diagnostic X-rays and lab tests, including CT scans, MRIs, PET scans, Nothing after deductible 20% coinsurance after deductible and nuclear cardiac imaging tests

Home health care and hospice services Nothing after deductible 20% coinsurance after deductible

Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible

Durable medical equipment such as wheelchairs, crutches, hospital beds 20% coinsurance after 40% coinsurance after deductible** deductible**

Prosthetic devices 20% coinsurance after deductible 40% coinsurance after deductible Surgery and related anesthesia: • Office or health center services $10 per visit***, no deductible 20% coinsurance after deductible • Ambulatory surgical facility, hospital outpatient department, or surgical day care unit Nothing after deductible 20% coinsurance after deductible Inpatient Care (including maternity care)

General or chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible

Mental hospital or substance use facility care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible

Rehabilitation hospital care (up to 60 days per calendar year) Nothing after deductible 20% coinsurance after deductible

Skilled nursing facility care (up to 100 days per calendar year) Nothing after deductible 20% coinsurance after deductible

* No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth (20% coinsurance after deductible out-of-network). *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Covered Services Your Cost In-Network Your Cost Out-of-Network

Prescription Drug Benefits*

At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill)** No deductible Not covered $5 for Tier 1 $15 for Tier 2 $25 for Tier 3

Through the designated mail order pharmacy (up to a 90-day formulary supply for each prescription or refill)** No deductible Not covered $10 for Tier 1*** $30 for Tier 2 $50 for Tier 3

* Generally, Tier 1 refers to generic drugs; Tier 2 refers to preferred brand-name drugs; Tier 3 refers to non-preferred brand-name drugs. ** Cost share may be waived for certain covered drugs and supplies. *** Certain generic medications are available through the mail order pharmacy at $9. For more information, go to bluecrossma.com/mail-order-pharmacy.

Get the Most from Your Plan: Visit us at bluecrossma.com or call 1-800-588-5508 to learn about discounts, savings, resources, and special programs available to you, like those listed below.

Wellness Participation Program Fitness Reimbursement: a program that rewards participation in qualified fitness programs $150 per calendar year per policy This fitness program applies for fees paid to: a health club with cardiovascular and strength- training equipment; a fitness studio offering instructor-led group classes for cardiovascular and strength-training; or virtual fitness memberships or classes.(See your subscriber certificate for details.)

Weight Loss Reimbursement: a program that rewards participation in a qualified weight loss program $150 per calendar year per policy This weight loss program applies for fees paid to: hospital-based or non-hospital-based weight loss programs that focus on eating and physical activity habits and behavioral/lifestyle counseling with certified health professionals.(See your subscriber certificate for details.)

phone-plus 24/7 Nurse Line: A 24-hour nurse line to answer your health care questions—call 1-888-247-BLUE (2583). No additional charge. Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-588-5508, or visit us online at bluecrossma.com.

Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your subscriber certificate and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the subscriber certificate and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers’ compensation. For a complete list of limitations and exclusions, refer to your subscriber certificate and riders. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2021 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 000843490 (03/21) LC Back to Start Plan Options Wellness Resources

Left Blank Intentionally

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: on or after 07/01/2021 Blue Care® Elect $250 Deductible: Umass Post-Doctoral Researchers Coverage for: Individual and Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see bluecrossma.com/coverage-info. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at bluecrossma.com/sbcglossary or call 1-800-588-5508 to request a copy.

Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan $250 member / $500 family in- What is the overall begins to pay. If you have other family members on the plan, each family member must meet their own network; $250 member / $500 deductible? individual deductible until the total amount of deductible expenses paid by all family members meets family out-of-network. the overall family deductible. Yes. In-network preventive and This plan covers some items and services even if you haven’t yet met the deductible amount. But a Are there services prenatal care, emergency room, copayment or coinsurance may apply. For example, this plan covers certain preventive services without covered before you meet most office visits, therapy visits, cost sharing and before you meet your deductible. See a list of covered preventive services at your deductible? mental health visits, prescription https://www.healthcare.gov/coverage/preventive-care-benefits/. drugs. Are there other deductibles for specific No. You don’t have to meet deductibles for specific services. services? $1,000 member / $2,500 family in- The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family What is the out-of-pocket network; $3,500 member / $7,000 members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of- limit for this plan? family out-of-network. pocket limit has been met. Premiums, balance-billing charges, What is not included in and health care this plan doesn't Even though you pay these expenses, they don't count toward the out-of-pocket limit. the out-of-pocket limit? cover. Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will bluecrossma.com/findadoctor or pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the Will you pay less if you call the Member Service number difference between the provider’s charge and what your plan pays (balance billing). Be aware, your use a network provider? on your ID card for a list of network network provider might use an out-of-network provider for some services (such as lab work). Check providers. with your provider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist?

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Limitations, Exceptions, & Other Common Medical Event Services You May Need In-Network Out-of-Network (You will pay the (You will pay the Important Information least) most) Deductible applies first for out-of- Primary care visit to treat an injury or illness $10 / visit 20% coinsurance network 20% coinsurance; $10 / visit; $10 / 20% coinsurance / Deductible applies first for out-of- Specialist visit chiropractor visit; $10 chiropractor visit; network; limited to 12 acupuncture / acupuncture visit 20% coinsurance / visits per calendar year If you visit a health care acupuncture visit provider’s office or clinic Deductible applies first for out-of- network; limited to age-based schedule and / or frequency. You may Preventive care/screening/immunization No charge 20% coinsurance have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Deductible applies first; pre- Diagnostic test (x-ray, blood work) No charge 20% coinsurance authorization may be required If you have a test Deductible applies first; pre- Imaging (CT/PET scans, MRIs) No charge 20% coinsurance authorization may be required $5 / retail supply or Generic drugs $10 / mail order Not covered supply Up to 30-day retail (90-day mail order) If you need drugs to treat $15 / retail supply or supply; cost share may be waived for your illness or condition Preferred brand drugs $30 / mail order Not covered certain covered drugs and supplies; More information about supply pre-authorization required for certain prescription drug coverage drugs is available at $25 / retail supply or bluecrossma.com/medicati Non-preferred brand drugs $50 / mail order Not covered supply ons Applicable cost share When obtained from a designated Specialty drugs (generic, preferred, Not covered specialty pharmacy; pre-authorization non-preferred) required for certain drugs

Page 2 of 7

What You Will Pay Limitations, Exceptions, & Other Common Medical Event Services You May Need In-Network Out-of-Network (You will pay the (You will pay the Important Information least) most) Deductible applies first; pre- Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance authorization required for certain If you have outpatient services surgery Deductible applies first; pre- Physician/surgeon fees No charge 20% coinsurance authorization required for certain services $50 / visit; $50 / visit; Copayment waived if admitted or for Emergency room care deductible does not deductible does not observation stay apply apply If you need immediate In-network deductible applies first for medical attention Emergency medical transportation No charge No charge in-network and out-of-network services Deductible applies first for out-of- Urgent care $10 / visit 20% coinsurance network Deductible applies first; pre- Facility fee (e.g., hospital room) No charge 20% coinsurance authorization required If you have a hospital stay Deductible applies first; pre- Physician/surgeon fees No charge 20% coinsurance authorization required Deductible applies first for out-of- Outpatient services $10 / visit 20% coinsurance network; pre-authorization required for If you need mental health, certain services behavioral health, or substance abuse services Deductible applies first; pre- Inpatient services No charge 20% coinsurance authorization required for certain services Office visits No charge 20% coinsurance Deductible applies first except for in- Childbirth/delivery professional services No charge 20% coinsurance network prenatal care; cost sharing does not apply for in-network If you are pregnant preventive services; maternity care Childbirth/delivery facility services No charge 20% coinsurance may include tests and services described elsewhere in the SBC (i.e. ultrasound)

Page 3 of 7

What You Will Pay Limitations, Exceptions, & Other Common Medical Event Services You May Need In-Network Out-of-Network (You will pay the (You will pay the Important Information least) most) Deductible applies first; pre- Home health care No charge 20% coinsurance authorization required Deductible applies first for out-of- network; limited to 100 visits per Rehabilitation services $10 / visit 20% coinsurance calendar year (other than for autism, home health care, and speech therapy) Deductible applies first for out-of- network; rehabilitation therapy coverage limits apply; cost share and Habilitation services $10 / visit 20% coinsurance If you need help recovering coverage limits waived for early or have other special health intervention services for eligible needs children Deductible applies first; limited to 100 Skilled nursing care No charge 20% coinsurance days per calendar year; pre- authorization required Deductible applies first; in-network cost share waived for one breast Durable medical equipment 20% coinsurance 40% coinsurance pump per birth (20% coinsurance for out-of-network) Deductible applies first; pre- Hospice services No charge 20% coinsurance authorization required for certain services Deductible applies first for out-of- Children’s eye exam No charge 20% coinsurance network; limited to one exam every 24 months If your child needs dental Children’s glasses Not covered Not covered None or eye care No charge for 20% coinsurance for Deductible applies first for out-of- members with a cleft members with a cleft Children’s dental check-up network; limited to members under palate / cleft lip palate / cleft lip age 18 condition condition

Page 4 of 7

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Children's glasses • Dental care (Adult) • Private-duty nursing • Cosmetic surgery • Long-term care

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (12 visits per calendar year) • Infertility treatment • Routine foot care (only for patients with systemic • Bariatric surgery • Non-emergency care when traveling outside the circulatory disease) • Chiropractic care U.S. • Weight loss programs ($150 per calendar year per • Hearing aids ($2,000 per ear every 36 months for • Routine eye care - adult (one exam every 24 policy) members age 21 or younger) months)

Page 5 of 7

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform and the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your state insurance department might also be able to help. If you are a Massachusetts resident, you can contact the Massachusetts Division of Insurance at 1-877-563-4467 or www.mass.gov/doi. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. For more information about possibly buying individual coverage through a state exchange, you can contact your state’s marketplace, if applicable. If you are a Massachusetts resident, contact the Massachusetts Health Connector by visiting www.mahealthconnector.org. For more information on your rights to continue your employer coverage, contact your plan sponsor. (A plan sponsor is usually the member’s employer or organization that provides group health coverage to the member.) Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, call 1-800-472-2689 or contact your plan sponsor. (A plan sponsor is usually the member’s employer or organization that provides group health coverage to the member.) You may also contact The Office of Patient Protection at 1-800-436-7757 or www.mass.gov/hpc/opp. Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Disclaimer: This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and the policy, the terms and conditions of the policy will govern.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 6 of 7

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe's Type 2 Diabetes Mia’s Simple Fracture

(9 months of in-network prenatal care and a hospital (a year of routine in-network care of a well- (in-network emergency room visit and follow-up

delivery) controlled condition) care)

■The plan’s overall deductible $250 ■The plan’s overall deductible $250 ■The plan’s overall deductible $250 ■Delivery fee copay $0 ■Specialist visit copay $10 ■Specialist visit copay $10 ■Facility fee copay $0 ■Primary care visit copay $10 ■Emergency room copay $50 ■Diagnostic tests copay $0 ■Diagnostic tests copay $0 ■Ambulance services copay $0

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $250 Deductibles $100 Deductibles $250 Copayments $10 Copayments $700 Copayments $100 Coinsurance $0 Coinsurance $0 Coinsurance $0 What isn't covered What isn't covered What isn't covered Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0 The total Peg would pay is $320 The total Joe would pay is $820 The total Mia would pay is $350

The plan would be responsible for the other costs of these EXAMPLE covered services. 000843473 (03/21) LC ® Registered Marks of the Blue Cross and Blue Shield Association. © 2021 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Page 7 of 7

MCC COMPLIANCE

This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2021 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000488899 55-0647 (6/20) Back to Start Plan Options Wellness Resources

Left Blank Intentionally Preferred Provider Organization (PPO) Important Information About Your Plan

Your health plan lets you get care from providers who participate in a Blue Cross Blue Shield PPO Network (preferred), as well as from providers who are out of our network. You’ll pay a lower cost for care when you see an in-network provider, and a higher cost when you see an out-of-network provider. For help finding a provider, visit myfindadoctor.bluecrossma.comand sign in to select the following network: PPO or EPO.  handshake chart-network PCP REFERRAL IN NETWORK

How to Access Important Resources

We’re committed to your health—that’s why we offer assessment, sign up for wellness workshops, access additional programs, benefits, and discounts beyond health tools and resources, and more. Sign in to traditional health care coverage. Use these tools and myblue.bluecrossma.com and select AHealthyMe resources to monitor your health and overall wellness. from the drop-down menu in the top right corner for more information about ahealthyme. Get Connected with Message Wire: We can send you important information about your health and wellness, Take Advantage of Discounts: Use Blue365®, a relevant discounts, and plan information directly to your members-only website that offers local health and phone. Text bluecrossma to 73529, or call 1-844-779-8813 wellness deals, for discounts on health and fitness to join with your Blue Cross member ID number. products, family events, spa services, and more. Sign in to myblue.bluecrossma.com, and select My Plan and Visit ahealthyme®’: Learn about your health and set then Discounts & Savings from the drop-down menu in personal goals for a healthy life. You can take a health the top right corner for more information about Blue365.

Sign In Visit myblue.bluecrossma.com to create an account, or download the app from the App Store®’’ or Google PlayTM.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. How to Get Care

Routine annual checkups are one of the best ways you and any requests for prior authorization to us. If you or your your doctor can stay on top of your health. When selecting doctor don’t get prior authorization when it’s needed, a doctor, consider the hospital where that doctor has the care may not be covered and you may be financially admitting privileges. responsible. Talk to your doctor to see if prior authorization is needed before you receive any services, procedures, or drugs. Finding a Provider: You don’t have to choose a primary care provider (PCP) to help manage your care, but you Taking Action in an Emergency: In case of a medical or should see in-network doctors to pay the lowest cost. You behavioral health emergency, call 911 or your local emergency can also see out-of-network doctors, but you’ll pay higher number, or go directly to the nearest medical facility. Be sure out-of-pocket costs. to notify your PCP, if applicable, within 48 hours to coordinate any follow-up care. Seeing a Specialist: You don’t need a referral from your PCP to see a specialist. However, you should talk with your Getting Care Worldwide with BlueCard®: Your doctor about the specialty care you may need. Blue Cross member ID card is widely recognized and lets you get urgent and emergency care worldwide. If you’re Understanding Prior Authorization: We require prior traveling within the U.S. or abroad and need emergency authorization (pre-approval) before we cover certain medical care, go to the nearest hospital. Once you get services, procedures, or drugs. Prior authorization ensures care, call 1-800-810-BLUE (2583) or 1-804-673-1177 that you get the care that is medically necessary for you for 24/7 assistance. and covered by your health plan. Your doctor should submit

How to Read Your ID Card How to Contact Us

Your Blue Cross member ID card contains our Member Service General questions about your health plan coverage? telephone number and your member ID number, and sometimes Member Service: Call the number on the front of your lists the costs you’ll pay for certain health services. You should member ID card (TTY: 711) Monday–Friday. 8:00 a.m.–6:00 p.m. always carry your ID card with you when you visit the doctor or ET. Or sign in to bluecrossma.com and select Review My download the MyBlue App to keep a digital copy of your ID card. Benefits to check what your plan covers and your costs.

Plan Name Health questions if you’re hurt or sick? PPO Your ID 24/7 Nurse Line: 1-888-247-BLUE (2583) Registered Number JOHN SAMPLE Member Service Call Us nurses are available at no cost. XXP123456789 1-800-000-0000 MEMBER SUFFIX: 00 Number to call Copays with questions Questions about your prescription drug coverage? OV 15 BH 15 about your plan Mail Order Pharmacy: 1-800-892-5119 Available 24/7 ER 50SAMPLE Copays Order a new Blue Cross member ID card? OV: Office visit for primary care provider or specialist Lost member ID card? Call 1-800-253-5210 BH: Behavioral health office visit Monday–Friday, 8:00 a.m.–6:00 p.m. ET. ER: Emergency room (waived if admitted)

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.

ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®’ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. ®’’ Registered Marks and TM Trademarks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000536083 39-0110 (8/20) Back to Start Plan Options Wellness Resources

Left Blank Intentionally Mail Order Pharmacy

The Mail Order Pharmacy Saves You Time and Money You can get 90-day prescriptions for certain maintenance medications delivered right to your door, and for a fraction of the cost, when you order them through the mail order pharmacy. Maintenance medications, also known as long-term medications, are prescribed to treat chronic or ongoing conditions, such as high blood pressure or diabetes.

Advantages of Using the How to Order Refills Mail Order Pharmacy • Log in to Express Scripts at express-scripts.com, select the medications to be filled, then clickAdd to Cart • You'll pay less for a 90-day supply than you would for three • Call Express Scripts at 1-800-892-5119 (TTY: 1-800-305-5376), 30-day supplies of your maintenance medications 24 hours a day • Medications are shipped to you at no additional cost for standard shipping Have Your Prescriptions • With fewer refills and no trips to the pharmacy, you’ll be less likely to miss a dose Refilled Automatically • Get your prescriptions on time, every time with automatic refills Worry Free Fills®´ are available for qualifying maintenance medications. When enrolled, Express Scripts will calculate when you’ll need your How to Order Prescriptions prescriptions and deliver them on time. They’ll contact you before processing each fill to confirm delivery, and the delivery date. Enroll in ®´ Express Scripts , an independent company that administers Worry Free Fills by choosing one of the following methods: your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts, will deliver your prescriptions straight to your door. • Visit Express Scripts at express-scripts.com, and select To order prescriptions, choose one of the following options. In most Automatic Refills cases, Express Scripts will contact your doctor directly to arrange • When refilling a prescription, answer yes when asked to enroll 90-day prescriptions, plus refills. in Worry Free Fills • Visit Express Scripts at express-scripts.com /starthd, • Call Express Scripts at 1-800-892-5119 (TTY: 1-800-305-5376) and select Register • Download the Express Scripts mobile app and select Register • Call Express Scripts at 1-800-892-5119 (TTY: 1-800-305-5376) • Ask your doctor to e-prescribe a new, 90-day prescription to Save up to Express Scripts, or fax it to 1-800-837-0959 • Fill out the order form* and mail it to: When you use the Home Delivery Service mail order pharmacy.** PO Box 66566 % St Louis, MO 63166-9967 33

*You can download and print a copy of the mail order form at express-scripts.com. **Compared to three 30-day prescriptions purchased at a retail pharmacy.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Back to Start Plan Options Wellness Resources

Left Blank Intentionally Blue Cross Blue Shield of Massachusetts Formulary: $9 Generic Medication List Last Updated: January 1, 2021 Valid Until: July 1, 2021 The following list includes generic medications covered by plans with the Blue Cross Blue Shield of Massachusetts Formulary. Members can get these medications in 90-day supplies for $91 when they order them through the mail order pharmacy available through Express Scripts®’, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts. Normal prescription guidelines apply, which in some cases result in prescription supplies for less than 90 days. If your copayment for a 90-day supply through the mail order pharmacy is less than $9, you’ll pay the lesser amount. The $9-or-less price is based only on a 90-day supply of each generic medication.2 The price of the medication may differ if the quantity purchased is different. This isn’t a complete list of covered medications, and inclusion on the list doesn’t guarantee coverage.3 You must have a valid prescription from a licensed health provider to receive coverage for these medications. Some medications may also be subject to pharmacy management programs, such as Step Therapy, Prior Authorization, or Quality Care Dosing, or have other coverage requirements. $9 Generic Medications Included in the National Preferred Formulary (NPF) The generic medications listed in this document are also included in the National Preferred Formulary (NPF), which is available through Express Scripts. Pharmacy management program requirements apply to generic medications included in the NPF.

Learn More About Your Coverage For more information about your pharmacy benefits, including the NPF and the medications listed in this document, sign in to your MyBlue account at bluecrossma.org.

1. Medications and pricing are subject to change without notice, so you should always confirm your cost prior to filling a prescription. A processing fee may apply. In applicable states, sales tax may be added to the cost of your prescriptions. Cost of standard shipping is included as part of your prescription plan. The coverage and prices of certain medications are also subject to the specific terms of your plan. Changes are made available to your Plan Sponsor. 2. Pre-packaged medications are only available for $9 in the package sizes specified. 3. Not all medications listed are covered by all prescription plans. Check your benefit materials for details.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Drug Class Medication Name Strength Form $9 Quantity Antibiotics/Antifungals/ ACYCLOVIR 200 MG CAPSULE 180 Antivirals AMOXICILLIN 500 MG TABLET 180 CIPROFLOXACIN HCL 250 MG TABLET 90 CIPROFLOXACIN HCL 500 MG TABLET 180 FLUCONAZOLE 150 MG TABLET 3 METRONIDAZOLE 250 MG TABLET 270 METRONIDAZOLE 500 MG TABLET 42 PENICILLIN V POTASSIUM 250 MG TABLET 180 PENICILLIN V POTASSIUM 500 MG TABLET 180 SOLUTION, PENICILLIN V POTASSIUM 250 MG/5ML RECONSTITUTED, 900 ORAL Antiseizure Medications ZONISAMIDE 25 MG CAPSULE 180 ZONISAMIDE 50 MG CAPSULE 180 TABLET, ENTERIC Arthritis/Pain DICLOFENAC SODIUM 50 MG 180 COATED TABLET, ENTERIC DICLOFENAC SODIUM 75 MG 180 COATED IBUPROFEN 400 MG TABLET 270 IBUPROFEN 600 MG TABLET 270 IBUPROFEN 800 MG TABLET 270 INDOMETHACIN 25 MG CAPSULE 270 MELOXICAM 7.5 MG TABLET 90 MELOXICAM 15 MG TABLET 90 NAPROXEN 250 MG TABLET 180 NAPROXEN 375 MG TABLET 180 NAPROXEN 500 MG TABLET 180 NAPROXEN SODIUM 220 MG TABLET 72 NAPROXEN SODIUM 275 MG TABLET 180 VIAL, NEBULIZER Asthma/Respiratory ALBUTEROL SULFATE 2.5 MG/3ML 225 (ML) Behavioral Health BUSPIRONE HCL 5 MG TABLET 180 BUSPIRONE HCL 10 MG TABLET 180 BUSPIRONE HCL 15 MG TABLET 180 CHLORDIAZEPOXIDE HCL 5 MG CAPSULE 180 CHLORDIAZEPOXIDE HCL 10 MG CAPSULE 180 CHLORDIAZEPOXIDE HCL 25 MG CAPSULE 180 DONEPEZIL HCL 0.3 MG TABLET 90

2 Drug Class Medication Name Strength Form $9 Quantity Behavioral Health (Cont.) DONEPEZIL HCL 5 MG TABLET 90 DONEPEZIL HCL 10 MG TABLET 90 DOXEPIN HCL 10 MG CAPSULE 90 FLUOXETINE HCL 10 MG CAPSULE 90 FLUOXETINE HCL 20 MG CAPSULE 90 FLUOXETINE HCL 40 MG CAPSULE 90 HYDROXYZINE PAMOATE 25 MG CAPSULE 180 IMIPRAMINE HCL 10 MG TABLET 90 IMIPRAMINE HCL 25 MG TABLET 90 IMIPRAMINE HCL 50 MG TABLET 90 LITHIUM CARBONATE 150 MG CAPSULE 90 LITHIUM CARBONATE 300 MG CAPSULE 180 LITHIUM CARBONATE 600 MG CAPSULE 180 MIRTAZAPINE 15 MG TABLET 90 MIRTAZAPINE 30 MG TABLET 90 MIRTAZAPINE 45 MG TABLET 90 NORTRIPTYLINE HCL 10 MG CAPSULE 90 NORTRIPTYLINE HCL 25 MG CAPSULE 90 PAROXETINE HCL 10 MG TABLET 90 PAROXETINE HCL 20 MG TABLET 90 PAROXETINE HCL 30 MG TABLET 90 PAROXETINE HCL 40 MG TABLET 90 SERTRALINE HCL 25 MG TABLET 90 TRAZODONE HCL 50 MG TABLET 90 TRAZODONE HCL 100 MG TABLET 90 TRAZODONE HCL 150 MG TABLET 90 Blood Pressure/Heart Health AMIODARONE HCL 200 MG TABLET 90 ATENOLOL 25 MG TABLET 90 ATENOLOL 50 MG TABLET 90 ATENOLOL 100 MG TABLET 90 BENAZEPRIL HCL 5 MG TABLET 90 BENAZEPRIL HCL 10 MG TABLET 90 BENAZEPRIL HCL 20 MG TABLET 90 BENAZEPRIL HCL 40 MG TABLET 90 BISOPROLOL FUMARATE 5 MG TABLET 90 BISOPROLOL FUMARATE 10 MG TABLET 90

3 Drug Class Medication Name Strength Form $9 Quantity Blood Pressure/Heart Health CARVEDILOL 3.125 MG TABLET 180 (Cont.) CARVEDILOL 6.25 MG TABLET 180 CARVEDILOL 12.5 MG TABLET 180 CARVEDILOL 25 MG TABLET 180 CLONIDINE HCL 0.1 MG TABLET 90 CLONIDINE HCL 0.2 MG TABLET 90 DILTIAZEM HCL 30 MG TABLET 180 DILTIAZEM HCL 60 MG TABLET 180 DOXAZOSIN MESYLATE 1 MG TABLET 90 DOXAZOSIN MESYLATE 2 MG TABLET 90 DOXAZOSIN MESYLATE 4 MG TABLET 90 DOXAZOSIN MESYLATE 8 MG TABLET 90 ENALAPRIL MALEATE 2.5 MG TABLET 90 ENALAPRIL MALEATE 5 MG TABLET 90 ENALAPRIL MALEATE 10 MG TABLET 90 ENALAPRIL MALEATE 20 MG TABLET 90 FUROSEMIDE 20 MG TABLET 90 FUROSEMIDE 40 MG TABLET 90 FUROSEMIDE 80 MG TABLET 90 HYDRALAZINE HCL 10 MG TABLET 270 HYDRALAZINE HCL 25 MG TABLET 270 HYDRALAZINE HCL 50 MG TABLET 270 HYDRALAZINE HCL 100 MG TABLET 270 HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE 90 HYDROCHLOROTHIAZIDE 25 MG TABLET 90 HYDROCHLOROTHIAZIDE 50 MG TABLET 90 INDAPAMIDE 1.25 MG TABLET 90 INDAPAMIDE 2.5 MG TABLET 90 ISOSORBIDE MONONITRATE 10 MG TABLET 180 LABETALOL HCL 100 MG TABLET 180 LABETALOL HCL 200 MG TABLET 180 LABETALOL HCL 300 MG TABLET 180 LISINOPRIL 2.5 MG TABLET 90 LISINOPRIL 5 MG TABLET 90 LISINOPRIL 10 MG TABLET 90 LISINOPRIL 20 MG TABLET 90

4 Drug Class Medication Name Strength Form $9 Quantity Blood Pressure/Heart Health LISINOPRIL 30 MG TABLET 90 (Cont.) LISINOPRIL 40 MG TABLET 90 METHYLDOPA 250 MG TABLET 180 METOPROLOL TARTRATE 25 MG TABLET 180 METOPROLOL TARTRATE 50 MG TABLET 180 METOPROLOL TARTRATE 100 MG TABLET 180 MINOXIDIL 2.5 MG TABLET 90 MINOXIDIL 10 MG TABLET 180 PRAVASTATIN SODIUM 10 MG TABLET 90 PRAVASTATIN SODIUM 40 MG TABLET 90 PRAZOSIN HCL 1 MG CAPSULE 90 PROPRANOLOL HCL 10 MG TABLET 180 PROPRANOLOL HCL 20 MG TABLET 180 PROPRANOLOL HCL 40 MG TABLET 180 PROPRANOLOL HCL 60 MG TABLET 180 PROPRANOLOL HCL 80 MG TABLET 180 QUINAPRIL HCL 5 MG TABLET 90 QUINAPRIL HCL 10 MG TABLET 90 QUINAPRIL HCL 20 MG TABLET 90 QUINAPRIL HCL 40 MG TABLET 90 RAMIPRIL 1.25 MG CAPSULE 90 RAMIPRIL 2.5 MG CAPSULE 90 RAMIPRIL 5 MG CAPSULE 90 RAMIPRIL 10 MG CAPSULE 90 SPIRONOLACTONE 25 MG TABLET 90 TERAZOSIN HCL 1 MG CAPSULE 90 TERAZOSIN HCL 2 MG CAPSULE 90 TERAZOSIN HCL 5 MG CAPSULE 90 TERAZOSIN HCL 10 MG CAPSULE 90 TORSEMIDE 5 MG TABLET 90 TORSEMIDE 10 MG TABLET 90 TORSEMIDE 20 MG TABLET 90 TORSEMIDE 100 MG TABLET 90 TRANDOLAPRIL 1 MG TABLET 90 TRANDOLAPRIL 2 MG TABLET 90 TRANDOLAPRIL 4 MG TABLET 90

5 Drug Class Medication Name Strength Form $9 Quantity Blood Pressure/Heart Health VERAPAMIL HCL 80 MG TABLET 90 (Cont.) VERAPAMIL HCL 120 MG TABLET 270 WARFARIN SODIUM 1 MG TABLET 90 WARFARIN SODIUM 2 MG TABLET 90 WARFARIN SODIUM 2.5 MG TABLET 90 WARFARIN SODIUM 3 MG TABLET 90 WARFARIN SODIUM 4 MG TABLET 90 WARFARIN SODIUM 5 MG TABLET 90 WARFARIN SODIUM 6 MG TABLET 90 WARFARIN SODIUM 7.5 MG TABLET 90 WARFARIN SODIUM 10 MG TABLET 90 Cold and Allergy Therapy BENZONATATE 100 MG CAPSULE 270 CYPROHEPTADINE HCL 4 MG TABLET 90 PROMETHAZINE HCL 6.25 MG/5ML SYRUP 360 PROMETHAZINE HCL 12.5 MG TABLET 90 PROMETHAZINE HCL 25 MG TABLET 270 PROMETHAZINE HCL 50 MG TABLET 90 Diabetes GLIMEPIRIDE 1 MG TABLET 180 GLIMEPIRIDE 2 MG TABLET 90 GLIMEPIRIDE 4 MG TABLET 90 GLIPIZIDE 5 MG TABLET 180 GLIPIZIDE 10 MG TABLET 180 GLYBURIDE 1.25 MG TABLET 90 GLYBURIDE 2.5 MG TABLET 90 GLYBURIDE 5 MG TABLET 180 METFORMIN HCL 500 MG TABLET 180 METFORMIN HCL 850 MG TABLET 180 METFORMIN HCL 1000 MG TABLET 180 Eye Health GENTAMICIN SULFATE 0.30% DROPS 15 SULFACETAMIDE SODIUM 10% DROPS 45 GI Drugs HYOSCYAMINE SULFATE 0.125 MG TABLET 270 METOCLOPRAMIDE HCL 5 MG TABLET 360 METOCLOPRAMIDE HCL 10 MG TABLET 360 Heartburn/Ulcer FAMOTIDINE 40 MG TABLET 90 RANITIDINE HCL 300 MG TABLET 90

6 Drug Class Medication Name Strength Form $9 Quantity High Cholesterol LOVASTATIN 10 MG TABLET 90 LOVASTATIN 20 MG TABLET 90 LOVASTATIN 40 MG TABLET 90 PRAVASTATIN SODIUM 20 MG TABLET 90 Muscle Relaxants BACLOFEN 10 MG TABLET 270 CYCLOBENZAPRINE HCL 5 MG TABLET 90 CYCLOBENZAPRINE HCL 10 MG TABLET 90 DOXEPIN HCL 25 MG CAPSULE 90 TIZANIDINE HCL 2 MG TABLET 270 TIZANIDINE HCL 4 MG TABLET 270 Parkinson’s Disease BENZTROPINE MESYLATE 0.5 MG TABLET 180 BENZTROPINE MESYLATE 1 MG TABLET 180 BENZTROPINE MESYLATE 2 MG TABLET 180 TRIHEXYPHENIDYL HCL 2 MG TABLET 180 TRIHEXYPHENIDYL HCL 5 MG TABLET 180 Skin Conditions HYDROCORTISONE 2.50% CREAM 90 TRIAMCINOLONE ACETONIDE 0.50% CREAM 180 Thyroid Therapy LEVOTHYROXINE SODIUM 25 MCG TABLET 90 LEVOTHYROXINE SODIUM 50 MCG TABLET 90 LEVOTHYROXINE SODIUM 75 MCG TABLET 90 LEVOTHYROXINE SODIUM 88 MCG TABLET 90 LEVOTHYROXINE SODIUM 100 MCG TABLET 90 LEVOTHYROXINE SODIUM 112 MCG TABLET 90 LEVOTHYROXINE SODIUM 125 MCG TABLET 90 LEVOTHYROXINE SODIUM 137 MCG TABLET 90 LEVOTHYROXINE SODIUM 150 MCG TABLET 90 LEVOTHYROXINE SODIUM 175 MCG TABLET 90

LEVOTHYROXINE SODIUM 200 MCG TABLET 90

METHIMAZOLE 5 MG TABLET 90 METHIMAZOLE 10 MG TABLET 90 Vitamins and Electrolytes FOLIC ACID 1 MG TABLET 90 PARTICLES/ POTASSIUM CHLORIDE 10 MEQ 90 CRYSTALS

7 Drug Class Medication Name Strength Form $9 Quantity Women’s Health ESTRADIOL 0.5 MG TABLET 90 ESTRADIOL 1 MG TABLET 90 ESTRADIOL 2 MG TABLET 90 NORGESTIMATE-ETHINYL ESTRADIOL 7 DAYS X 3 28 TABLET 84 Other Medications ALENDRONATE SODIUM 5 MG TABLET 90 ALENDRONATE SODIUM 10 MG TABLET 12 ALENDRONATE SODIUM 35 MG TABLET 90 ALENDRONATE SODIUM 70 MG TABLET 12 ALLOPURINOL 100 MG TABLET 90 ALLOPURINOL 300 MG TABLET 90 CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH 1,419 DEXAMETHASONE 0.5 MG TABLET 90 DEXAMETHASONE 0.75 MG TABLET 90 FLUDROCORTISONE ACETATE 0.1 MG TABLET 90 ISONIAZID 300 MG TABLET 90 MEGESTROL ACETATE 20 MG TABLET 90 METHYLPREDNISOLONE 4 MG TABLET DS PK 63 OXYBUTYNIN CHLORIDE 5 MG TABLET 180 PREDNISONE 1 MG TABLET 360 PREDNISONE 2.5 MG TABLET 90 PREDNISONE 5 MG TABLET 90 PREDNISONE 10 MG TABLET 90 PREDNISONE 20 MG TABLET 90

8 Blue Cross Blue Shield of Massachusetts complies with applicable ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos federal civil rights laws and does not discriminate on the basis of de asistencia con el idioma. Llame al número de Servicio al Cliente que race, color, national origin, age, disability, sex, sexual orientation, or figura en su tarjeta de identificación (TTY:711 ). gender identity. ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente ATTENTION: If you don’t speak English, language assistance services, serviços de assistência de idiomas. Telefone para os Serviços aos free of charge, are available to you. Call Member Service at the number Membros, através do número no seu cartão ID (TTY: 711). on your ID card (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM Trademarks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000578810 50-0233 (1/21) Back to Start Plan Options Wellness Resources

Left Blank Intentionally Get to Know the New Medication Lookup Tool

With a simple search, you can see which medications our plans cover.

See Which Medications Are Covered by Your Plan KeY FEATURES Medication coverage is determined by a plan's tier structure. The tool defaults to a 3-tier medication plan, Using the tool, you can: which is our most common pharmacy plan. If you have a different plan, you can filter your search, using the tier plan drop-down next to the search bar. If you're not sure Search for any medication  which plan you have, you can follow the easy instructions included within the tool to find this information. View medications by: Anyone Can Use It • Strength This is a public search tool, so anyone can use it. It’s a great SORT-SHAPES-DOWN-ALT • Tier plan option if you, a friend, or a family member is considering • How they're dispensed, such as one of our plans. You can easily find out if your medication pills, liquids, and injections is covered, or see covered alternatives if it’s not. Learn More in the Important Information Section Learn which medications have Within the tool, you can find additional information and additional coverage requirements, resources about medications and coverage, such as FILE-PRESCRIPTION such as Prior Authorization, Step Specialty Pharmacy Contact Information, and medication Therapy, and Quality Care Dosing lists such as $9 Generics, Maintenance Medications, Specialty Medications, and Over-the-Counter Exclusions. See covered alternatives for Now Mobile Friendly PRESCRIPTION-BOTTLE-ALT non-covered medications Search medications anywhere, anytime through the web browser on your mobile device.

Get Started

To search for a medication, visit bluecrossma.com/medications.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000390316 55-1868 (4/20) Back to Start Plan Options Wellness Resources

Left Blank Intentionally Covered Medications (Formulary)

Learn About Your Pharmacy Program

Effective January 1, 2021

This guide provides an overview of your pharmacy program, lists some of the medications covered under your plan, lists medications not covered under your plan, and provides other important information about your pharmacy coverage.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Table of Contents

Pharmacy Program Overview 1 About This Guide 1 Mail Order Pharmacy 1 How Tiers Determine What You Pay for Medications 2 How Covered Medications Are Placed into Tiers 2 Compounded Medications 4 Covered Medications List Changes 4 Your ID Card 4 Over-the-Counter Medications 5 Benefit Exclusions 6 Quality Care Dosing 7 Prior Authorization 12 Step Therapy 15 Specialty Pharmacy Medications 17 Non-Covered Medications 22 Medication Resource List Index 30 New Medication Approval Process 43 Pharmacy Program Overview

Your pharmacy program is designed to provide you and your doctor with access to a wide variety of safe, clinically effective medications. We’ve carefully developed a substantial covered medication list, also known as a formulary, that includes many medications that are available at affordable out-of-pocket costs. About This Guide This guide is up to date as of January 1, 2021, and is subject to change. Use it as a reference whenever you need coverage information about your pharmacy program. For the most current and complete information about covered medications, use our Medication Lookup tool at bluecrossma.com/medications. Mail Order Pharmacy You can have certain prescriptions delivered right to your door when you order them through Express Scripts®´, an independent company that administers your pharmacy benefits on behalf of Blue Cross Blue Shield of Massachusetts. With mail order pharmacy, most maintenance medications (also known as long-term medications) can be automatically refilled and shipped every 90 days at a lower cost. No more running out of medicine or last-minute trips to the pharmacy.

To get started with the Mail Order Pharmacy, sign in to MyBlue, then select 90-Day Mail Order Pharmacy in the drop-down menu or under My Pharmacy. You can also call Express Scripts at 1-800-892-5119.

Unlock the Power of Your Plan MyBlue is your key to more features and savings. Sign in to your account at bluecrossma.org to review claims, track medications, look up plan information, and get easy access to these online resources:

Medication Lookup Express Scripts Use the tool to search for covered Get information about your specific pharmacy medications and learn about your coverage coverage by selecting Express Scripts under for prescribed medications, quickly and My Pharmacy on your MyBlue homepage.There, easily, at bluecrossma.com/medications. you can look up the cost of medications, find a Your individual coverage may vary. pharmacy, and sign up for the Mail Order Pharmacy.

1 How Tiers Determine What You Pay for Medications Our list of covered medications is based on a tiered cost structure. When you fill a prescription, the amount you pay the pharmacy is determined by the tier your medication is on and your benefits. The amount you pay may also include your copayment, co-insurance, and deductibles. The pharmacist will tell you how much you owe. To find your out-of-pocket costs for specific prescriptions, sign in toMyBlue, then select Express Scripts under My Pharmacy on your MyBlue homepage. How Covered Medications Are Placed into Tiers Medications are placed on tiers according to a variety of factors, including what they’re used for, their cost, and whether equivalent or alternative medications are available. Lower-tier medications typically cost less than higher-tier medications. For example, in a 3-tier structure, you’ll likely pay the least for Tier 1 medications and the most for Tier 3 medications. Pharmacy plans can use one of the five different tier structures outlined below. Check your plan materials to see which tier structure your plan uses, and learn more about how medications are covered.*

2-Tier Generic medications are effective, low-cost alternatives to brand- Tier 1: Generics name medications. They’re expected to work the same as brand- name medications, and meet the same FDA requirements. Brand-name medications cost more than generic medications, so Tier 2: Brands you’ll pay more if you use them.

3-Tier Generic medications are effective, low-cost alternatives to brand- Tier 1: Generics name medications. They’re expected to work the same as brand- name medications, and meet the same FDA requirements. These are preferred brand-name medications because they’re safe, Tier 2: Preferred Brands effective alternatives to more expensive brands. Non-preferred brand-name medications cost more than preferred Tier 3: Non-Preferred brands, so you’ll pay more if you use them instead of any generics Brands or preferred brands.

4-Tier These medications are preferred because they cost less than Tier 1: Preferred Generics other generic medications. Tier 2: Non-Preferred Non-preferred generic medications cost more than preferred generics, Generics so you’ll pay more if you use them instead of preferred generics. These are preferred brand-name medications because they’re safe, Tier 3: Preferred Brands effective alternatives to more expensive brands. Non-preferred brand-name medications cost more than preferred Tier 4: Non-Preferred brands, so you’ll pay more if you use them instead of any generics Brands or preferred brands.

*Exceptions may apply. For example, the brands and preferred brands tiers could include some generic medications in addition to brand-name medications. 2 5-Tier Generic medications are effective, low-cost alternatives to brand- Tier 1: Generics name medications. They’re expected to work the same as brand- name medications, and meet the same FDA requirements. These are preferred brand-name medications because they’re safe, Tier 2: Preferred Brands effective alternatives to more expensive brands. Non-preferred brand-name medications cost more than preferred Tier 3: Non-Preferred brands, so you’ll pay more if you use them instead of any generics Brands or preferred brands. These specialty medications are preferred because they’re safe, Tier 4: Preferred Brand effective alternatives to more expensive brand-name specialty Specialty medications. Non-preferred brand-name medications cost more than preferred Tier 5: Non-Preferred brands, so you’ll pay more if you use them instead of any generics Brand Specialty or preferred brand specialty medications.

6-Tier These medications are preferred because they cost less than Tier 1: Preferred Generics other generic medications. Non-preferred generic medications cost more than preferred Tier 2: Non-Preferred generics, so you’ll pay more if you use them instead of Generics preferred generics. These are preferred brand-name medications because they’re safe, Tier 3: Preferred Brands effective alternatives to more expensive brands. Non-preferred brand-name medications cost more than preferred Tier 4: Non-Preferred brands, so you’ll pay more if you use them instead of any generics Brands or preferred brands. These specialty medications are preferred because they’re safe, Tier 5: Preferred Brand effective alternatives to more expensive brand-name specialty Specialty medications. Non-preferred brand-name medications cost more than preferred Tier 6: Non-Preferred brands, so you’ll pay more if you use them instead of any generics Brand Specialty or preferred brand specialty medications.

*Exceptions may apply. For example, the brands and preferred brands tiers could include some generic medications in addition to brand-name medications.

For more information about your pharmacy benefit, sign in to your MyBlue account at bluecrossma.org.

3 Compounded Medications Covered compounded medications that require a prescription will be processed at your highest pharmacy benefit tier, regardless of the ingredients in the medication. Compounded medications are made to order by a pharmacist when existing, commercially available medications don’t meet your specific needs as determined by your doctor. Some compounded medications may need Prior Authorization, have Quality Care Dosing guidelines, or require an exception. Covered Medications List Changes Our covered medications list may change from time to time. This may include changing medications to a non-covered status, changing medication tier status, applying Quality Care Dosing limitations, and/or moving medications to a specialty pharmacy. We notify any impacted members of these changes via direct mail at least 30 days in advance of the change.

HMO Blue Your ID Card JOHN SAMPLE Member Service XXH123456789 1-800-358-2227 Your ID card contains important information about your RxBin: 003858 PCN: A4 RxGrp: MASA pharmacy benefits. Be sure to bring the card with you Copays OV 10/25 and give it to your pharmacist when you fill a BH 10 ER 100 prescription. Preventive 0

Sample ID card for illustrative purposes only.

4 Over-the-Counter Medications

For non-grandfathered health plans under the Affordable Care Act (ACA), the following list includes over-the-counter medications that are covered at no cost to you when they’re prescribed by your doctor. This list is up to date as of January 1, 2021, and may change from time to time.

• Generic Aspirin (81mg) • Generic Folic Acid is covered for people up to age 50 • Generic Iron is covered for infants up to 12 months old • Generic Smoking Cessation (such as nicotine gum, lozenges, and patches) is covered for up to two 90-day supplies per calendar year • Generic Vitamin D is covered for people aged 65 and older • Generic contraceptives (such as female condoms, sponges, and spermicide) are covered

5 Benefit Exclusions

The following are considered benefit exclusions under your policy. This means these medications and other health products aren’t covered, and exceptions aren’t available. Some medications within these categories have over-the-counter alternatives available.

• Anorexiants • Cough and cold products that contain one or more of the following ingredients in equivalent over-the-counter doses: guaifenesin, chlorpheniramine, pseudoephedrine, phenylephrine, clemastine, dextromethorphan, and pyrilamine • Non-sedating antihistamines • Ophthalmic drug solutions to treat allergies • Inhaled nasal steroids • Proton pump inhibitors (PPI), except for prescription proton pump inhibitors that are prescribed for members under age 18 or prescribed as part of a combination drug used to treat helicobacter pylori • Topical acne medications (benzoyl peroxide products 10% in strength or less, and some combinations) • Pharmaceuticals that you can buy without a prescription, except as described in this Pharmacy Program booklet • Medical supplies such as dressings and antiseptics • Combination vitamins that require a prescription, except for: prescription prenatal vitamins and pediatric vitamins with fluoride

This list is up to date as of January 1, 2021. See your subscriber certificate for additional exclusions.

6 Quality Care Dosing

Our Quality Care Dosing program helps to ensure that the quantity and dosage of the medications you receive meet the Food and Drug Administration’s (FDA) regulations, clinical standards, and manufacturer’s guidelines. When you fill a prescription for one of the following medications, it’s checked electronically in two ways:

Dose Consolidation Recommended Monthly Dosing Level Checks to see whether you’re taking two or Checks to see that your monthly dosage is more pills a day that can be replaced with consistent with the FDA’s and manufacturer’s one pill providing the same daily dosage monthly dosing recommendations and clinical information

You may fill a quantity up to the allowed limit, but quantities greater than the allowed limit will be denied.

Note: Your doctor may request an exception for medications that are subject to Quality Care Dosing when medically necessary. Some medications on this list may also be subject to Step Therapy and/or Prior Authorization requirements, be considered non-covered, or be considered a specialty medication. Please check the corresponding pages to determine coverage requirements.

This list of medications in our Quality Care Dosing program is up to date as of January 1, 2021, and may change from time to time. For the most current list of medications subject to Quality Care Dosing, along with associated dosing limits, use our Medication Lookup tool at bluecrossma.com/medications.

7 Quality Care Dosing

Abilify Mycite Amethia Bijuva Clindamycin 1% solution Abstral Amethia Lo Binosto Clindamycin 1% lotion AcipHex (excluded for 18 Amerge Boniva tablets Clindamycin 1% foam years and older) Amitiza Breo Ellipta Clindamycin 2% vaginal AcipHex Sprinkle (excluded Amlodipine Breztri Aerosphere Clonidine patch for 18 years and older) Amlodipine-Atorvastatin Brisdelle Combivent Actemra Ampyra Brovana Combivent Respimat Actiq Anzemet Brukinsa Concerta Actonel Apidra Budeprion SR Conjupri ACTOplus Met Apidra Solostar Budeprion XL Cotempla XR ODT ACTOplus Met XR Aplenzin ER Budesonide (nebules) Contrave ER Actos Aprepitant Budesonide/Formoterol Copaxone Acular Aptenzio XR Bunavail Cosentyx Acular LS Aranesp Buprenorphine Crestor Acular PF Arava Buprenorphine-Naloxone Cromolyn ophthalmic Acyclovir cream Arcapta Neohaler Buprenorphine patch Cymbalta Adderall XR ArmonAir DigiHaler Bupropion SR Daklinza Adhansia XR ArmonAir RespiClick Bupropion XL Dalfampridine Adlyxin Arnuity Ellipta Butorphanol NS Daurismo Admelog Arixtra Butrans Daysee Admelog Solostar Arymo ER Bydureon Desvenlafaxine ER Advair Diskus Ashlyna Bydureon Bcise Dexilant (excluded for 18 Advair HFA Asmanex HFA Byetta years and older) Adyphren Asmanex Twisthaler Cabergoline Dexmethylphenidate ER Adyphren II Aspirin/Omeprazole (excluded Caduet Dexmethylphenidate XR Adyphren Amp for 18 years and older) Calcipotriene Dextroamphetamine/ Adyphren Amp II Amphetamine ER Astepro Calcipotriene/Betamethasone Adzenys XR Diabetic Testing Strips (all) Atelvia DR Calypta Aemcolo Diclofenac 3% gel Atomoxetine Camrese Aerospan Diclofenac solution Atorvastatin Camrese Lo Aimovig Diflorasone cream Atrovent (nasal spray) Cardura AirDuo DigiHaler Diflucan (150 mg only) Atrovent HFA Cardura XL AirDuo RespiClick Dihydroergotamine Auvi-Q Catapres TTS Ajovy (nasal spray) Avandia Celebrex Akynzeo DM 2 Kit Avinza Celecoxib Albuterol Sulfate HFA Doptelet Avonex Celexa Alendronate Sodium Dotti Axert Cesamet Almotriptan Dovonex Azelastine (nasal spray) Cholbam Alora Doxazosin Baqsimi Ciclodin solution/kit Alosetron Doxepin cream Basaglar Ciclopirox nail lacquer Alrex Doxepin tablets Belbuca Cimzia Alsuma Drizalma Sprinkle Belsomra Citalopram Altoprev Duaklir Pressair Betaseron Climara Alvesco Dulera Bevespi AeroSphere Climara Pro Ambien Duloxetine DR Bevyxxa Clindamycin 1% gel Ambien CR Duragesic

8 Quality Care Dosing

Edluar Flovent Diskus Insulins (all) Lidocaine Patch Effexor XR Flovent HFA Insulins Lispro Lidoderm Eletriptan Fluconazole (150 mg only) Intermezzo Linzess Embeda Fluoxetine Introvale Lipitor Emend Fluoxetine DR Invokamet Livalo Emgality Fluticasone/Salmeterol Invokamet XR Lonhala Magnair Emverm Fluvastatin Invokana LoSeasonique Enbrel Fluvastatin XR Ipratropium NS Lotronex Enoxaparin Fluvoxamine Irenka DR Lovastatin Epclusa Fluvoxamine CR Itraconazole Lovenox Epinephrine injection Focalin XR Jardiance Lucemyra Epinephrine Professional kit Fondaparinux Jolessa Lunesta Epinephrine Professional Forfivo XL Jornay PM Lyrica CR EMS kit Forteo Jynarque Lysteda Epi-Pen Auto-Injector Fosamax Kadian Lyumjev Epogen Fosamax Plus D Kalydeco Mavyret Escitalopram Fragmin Kenalog aerosol Maxalt Esomep-EZS (excluded for 18 Frova Kerydin Maxalt-MLT years and older) Frovatriptan Ketoconazole 2% Meloxicam Esomeprazole (excluded for 18 years and older) Fulphila Ketorolac ophthalmic Menostar Esomeprazole Strontium Gatifloxacin Keveyis Methylphenidate CD (excluded for 18 years Gavreto Kevzara Methylphenidate ER and older) Glatiramer Khedezla Methylphenidate LA Estradiol patch Glatopa Krintafel Migranal Estrogel Glucose testing strips (all) Kynmobi Migranow Kit Eszopiclone Glyxambi Lamisil Minivelle Evamist Granisetron Lansoprazole (excluded for 18 Mirtazapine Evenity Granix years and older) Mirtazapine Rapid Dissolve Evzio Grastek Lansoprazole ODT (excluded Mobic for 18 years and older) Exalgo Harvoni Morphabond ER Extavia Lansoprazole/Amoxicillin/ Hetlioz Clarithromycin Morphine Sulfate ER Ezallor Sprinkle Humalog Lantus Movantik Ezetimibe Humalog Jr. Lazanda Moxifloxacin Ezetimibe/Simvastatin Humulin Leflunomide Moxeza Famciclovir Humira Ledipasvir/Sofosbuvir MS Contin Farydak Hydromorphone ER Lescol Mupirocin Farxiga Hysingla ER Lescol XL Mulpleta Fasenra Ibandronate Levalbuterol HFA Mydayis Fayosim Ibrance Levemir Naloxone Fentanyl Citrate Ilumya Levonorgestrel/ Naratriptan Fentanyl oral/mucosal Imitrex Ethinyl Estradiol Narcan Fentanyl patch Impavido Levonorgestrel/Ethinyl NebuPent Fentora Incruse Ellipta Estradiol/Ethinyl Estradiol Neulasta Fetzima Indomethacin 20mg Lexapro Neupogen Fiasp Infergen Lidociane 5% cream

9 Quality Care Dosing

Nexium (excluded for 18 years Patanase Rabeprazole (excluded for 18 Sovaldi and older) Paxil years and older) Spiriva Nexletol Paxil CR Ramelteon Sporanox Nexlizet Perforomist Ragwitek Stelara Nivestym Pegasys Rebif Steglatro Nocdurna PEG-Intron Relexxii ER Steglujan Norvasc Penlac Relpax Stiolto Respimat Novolin Pennsaid Remeron Strattera Novolog Pexeva Remeron Soltab Striverdi Respimat Nucynta ER Pioglitazone Repatha Suboxone Nuplazid Pioglitazone-Glimepiride Restasis Subsys Ocaliva Pioglitazone-Metformin Retacrit Sumatriptan Odomzo Plegridy Rexulti Sumavel Dosepro Olanzepine-Fluoxetine Praluent Reyvow Symbicort Olopatadine Nasal Pravachol Rhopressa Symbyax Olumiant Pravastatin Rinvoq ER Symdeko Olysio Prevacid (excluded for 18 Risedronate Symjepi Omeprazole (excluded for 18 years and older) Ritalin LA Symproic years and older) PrevPac Rivelsa Synjardy Omeprazole-Sod. Prilosec (excluded for 18 Rizatriptan Synjardy XR Bicarbonate (excluded for 18 years and older) years and older) Rizatriptan ODT Talicia DR Pristiq OmePPI (excluded for 18 Rocklatan Taltz years and older) Pristiq ER Rozerem Tanzeum ProAir HFA Omontys Rosuvastatin Technivie ProAir Respiclick Ondansetron Rybelsus Tegsedi Procrit Ondansetron ODT Sancuso Teriparatide Onmel Protonix (excluded for 18 Sarafem years and older) Terazosin Onsolis Saxenda Proventil HFA Terbinafine Onzetra Xsail Seasonique Prozac Tivorbex Opana ER Secuado Prozac Weekly Tolsura Oralair Seebri Neohaler Prudoxin Tosymra Oramorph SR Segluromet Pulmicort Flexhaler Toujeo Solostar Orencia Semglee Pulmicort Respules Toujeo Max Solostar Orkambi Serevent Diskus Qbrexxa Tranexamic Acid Otezla Sertraline Qinlock Trelegy Ellipta Oxbryta Setlakin Qmiiz ODT Tremfya Oxiconazole Nitrate Silenor Qtern Tresiba Oxistat Siliq Qualaquin Treximet Oxycodone ER Simponi Quartette Triamcinolone spray OxyContin Simvastatin Quasense Trijardy XR Oxymorphone ER Skyrizi Quillichew Trikafta Ozempic Sofosbuvir/Velpatasvir Quinine Sulfate Trintellix Pantoprazole (excluded for 18 Soliqua Triptodur years and older) Qutenza Solosec Trulance Paroxetine QVAR Sonata Trulicity Paroxetine CR

10 Quality Care Dosing

Tudorza Xtampza ER Tukysa Xultophy Tymlos Xuriden Ubrelvy Yosprala Undenyca Yupelri Utibron Neohaler Zaleplon Valacylovir Zarxio Valtrex Zegerid (excluded for 18 years Varubi and older) Venlafaxine ER capsule Zembrace Symtouch Venlafaxine ER tablet Zepatier Ventolin HFA Zeposia Viberzi Zetia Victoza Ziextenzo Viekira PAK Zinbryta Viekira XR Zocor Vigamox Zofran Viibryd Zofran ODT Vitrakvi Zohydro ER Vivelle Zoladex Vivelle-Dot Zolmitriptan Vivitrol Zolmitriptan ODT Vivlodex Zoloft Vosevi Zolpidem Vumerity DR Zolpidem CR Vyleesi Zolpidem SL Vyndaqel Zolpimist Vyndamax Zomig Vytorin Zomig ZMT Vyvanse Zonalon Wakix Zovirax cream Wellbutrin SR Zubsolv Wellbutrin XL Zuplenz Wixela Inhub Zydelig Xartemis XR Zymaxid Xeljanz Zypitamag Xeljanz XR Xenleta Xermelo Xiidra Xifaxan Xigduo Xigduo XR Xopenex HFA Xospata

11 Prior Authorization

Your doctor is required to obtain Prior Authorization before prescribing specific medications. This ensures that your doctor has determined that this medication is necessary to treat you, based on specific medical standards.

Our Prior Authorization program includes Step Therapy. Please refer to the Step Therapy section in this booklet for more information.

Note: Some medications on this list may also be subject to Step Therapy and/or Quality Care Dosing requirements, be considered non-covered, or be considered a specialty medication. Please check the corresponding pages to determine coverage requirements.

This list of medications that require Prior Authorization is up to date as of January 1, 2021, and may change from time to time. For the most current list of medications that require Prior Authorization, use our Medication Lookup tool at bluecrossma.com/medications.

12 Prior Authorization

Abstral Capital and Codeine Esomep-EZS (excluded for 18 Ilumya AcipHex (excluded for 18 Cequa years and older) Increlex years and older) Cerezyme Euflexxa Incruse Ellipta Actemra Cimzia Evekeo Inflectra Acthar Cinqair Evenity Infumorph Actimmune Cinryze Exalgo Inribec Actiq Cocet/Plus Exondys 51 Interferons (alpha, gamma) Adakveo Co-gesic Factor VIII, VIIIa, IX, XIII Iressa (medical benefit only) Adcirca Copkitra Isturisa Farydak Addyi Contrave IV Immunoglobulin Fasenra Advair Diskus Cotellic Juxtapid Fentanyl Citrate Advair HFA Cosentyx Kadian Fentanyl patch Air Duo Daklinza Kalbitor Fentanyl oral/mucosal Aimovig Dalfampridine Kalydeco Fentora Ajovy Demerol Kanuma Firazyr Alecensa Desoxyn Kevzara Firdapse Alfenta Dexilant (excluded for 18 Kineret Fluticasone/Salmeterol Alyq years and older) Kisqali Forteo Amphetamines (e.g Dexedrine Kisqali Femara Amphetamine, Galafold Dextroamphetamines Kynamro Methamphetamine, Liquadd, Gamifant Procentra) Dificid Lazanda Gel-One Ampyra Dilaudid Ledipasvir/sofosbuvir Gelsyn-3 Apadaz Diskets Lemtrada Genotropin Aralast Dulera Lenvima Genvisc Armodafinil Dolophine Liquadd Gilotrif Aranesp Dupixent Lorbrena Givlaari Arikayce Duragesic Lorcet Grastek Arymo ER Doramorph Lynparza Harvoni Aspirin/Omeprazole (excluded Durolane Lyrica for 18 years and older) Haegarda Dvorah Lyrica CR Hetlioz Astramorph/PF Dysport Magnacet Humatrope Avinza Egrifta Mavyret Humira Avsola Elidel Maxidone Hyalgan Ayvakit Embeda Makena Hycet Balversa Emgality Margesic-H Hydrocodone ER Belbuca Enbrel Mekinist Hydrogesic Benzhydrocodone/APAP Enteral formula Mektovi Hydromorphone ER Berinert Entyvio Meperitab Hydroxyprogesterone Boniva syringe Epclusa Methadone Hymovis Botox/Botulinum Toxin Epogen Methadose Hysingla ER Braftovi Erlotinib Methamphetamine Ibandronate injection/syringe Breo Ellipta Esomeprazole (excluded for Modafinil 18 years and older) Ibrance Budesonide/Formoterol Monovisc Esomeprazole Strontium Ibudone Buprenorphine patch Morphabond ER (excluded for 18 years Idhifa Butrans and older) Morphine Sulfate CR Ilaris

13 Prior Authorization

Morphine Sulfate ER Percodan Skyrizi Vicoprofen MS Contin Pimecrolimus Sodium Hyaluronate 1% Viekira XR Myalept Piqray Syringe Viekira PAK Myobloc Polygesic Sofosbuvir/Velpatasvir Visco-3 Nalocet Praluent Sovaldi Vitrakvi Natrecor Pregablin Spinraza Vizimpro Nexium (excluded for 18 years Prevacid (excluded for 18 Stagesic Vosevi and older) years and older) Stelara Vyepti Neulasta Prilosec (excluded for 18 Subsys Vyleesi years and older) Neupogen Sunosi Vyndamax Primlev Nexlitol Supartz Vyndaqel Procentra Nexlizet Symbicort Vyondis 53 Procrit Norco Symdeko Wakix Prolate Norditropin Synalgos-DC Wixela Inhub Proleukin Nucala Synvisc Xalkori Prolia Nucynta ER Synvisc One Xartemis XR Nutritional Supplements Protonix (excluded for 18 Tabrecta years and older) Xeljanz Nutropin Tacrolimus (topical) Protopic Xeljanz XR Nuvigil Tadalafil (antihypertensive) Provigil Xeomin Olumiant Tafinlar Ragwitek Xgeva Olysio Takhzyro Reblozyl Xiaflex Omeprazole-Sod. Tarceva Regranex Xiidra Bicarbonate (excluded for 18 Tagrisso years and older) Remicade Xodol Taltz OmePPI (excluded for 18 Renflexis Xolair Talzenna years and older) Repatha Xospata Technivie Omnitrope Respiratory Xtampza ER Onpattro SyncytialVirus IG/Synagis Tegsedi Yosprala Onsolis Retacrit Tepezza Zamicet Opana ER Restasis Teriparatide Zegerid (excluded for 18 years Opdivo Retevmo Tev-Tropin and older) Oralair Revatio Tibsovo Zelboraf Oramorph SR Rinvoq ER Topical Retinoic Acid Zenzedi Derivatives (e.g. Retin-A) Orencia Rituxan Zepatier TPN (total parenteral nutrition) Zerlor Orkambi Roxybond (medical benefit only) Zohydro ER Orthovisc Rozlytrek Tremfya Zolvit Otezla Ruconest Trezix Zomactin Oxbryta Rydapt Trikafta Zorbtive Oxecta Saizen Triluron Zydelig Oxervate SaizenPrep Trivisc Zydone Oxycodone ER Saxenda Tylenol with Codeine Zykadia Oxycontin Serostim Tylox Oxymorphone ER Sildenafil (antihypertensive) Tymlos Panlor SS Siliq Verdrocet Pemazyre Simponi Verzenio Percocet Simponi Aria Vicodin

14 Step Therapy

Step Therapy is a key part of our Prior Authorization program that allows us to help your doctor provide you with an appropriate and affordable medication treatment. Before coverage is allowed for certain costly “second-step” medications, we require that you first try an effective, but less expensive, “first-step” medication. Some medications may have multiple steps.

Note: Some medications on this list may also be subject to Quality Care Dosing requirements, be considered non-covered, or be considered a specialty medication. Please check the corresponding pages to determine coverage requirements.

This list of medications in our Step Therapy program is up to date as of January 1, 2021, and may change from time to time. For the most current list of medications that require Step Therapy, use our Medication Lookup tool at bluecrossma.com/medications.

15 Step Therapy

Fortamet Jalyn Anti-Migraine Glucophage Glaucoma Proscar Almotriptan Glucophage XR Lumigan Amerge Glumetza Rescula Topical Antibiotics Axert Glyxambi Rocklatan Mupirocin cream Eletriptan Travatan Invokana Topical Testosterone Frova Invokamet Travatan Z Androgel Frovatriptan Invokamet XR Xalatan Axiron Imitrex Janumet Xelpros Fortesta Maxalt Janumet XR Vyzulta Natesto Nasal Maxalt-MLT Januvia Zioptan Testim Nurtec Jardiance Onzetra Xsail Osteoporosis Testosterone gel (Fortesta Jentadueto Treatment (Oral) Authorized product) Replax Jentadueto XR Actonel Testosterone gel (Testim Sumatriptan/Naproxen Kazano Authorized product) Atelvia DR Tosymra Kombiglyze XR Testosterone gel (Vogelxo Binosto Authorized product) Treximet Metformin Film Coated ER Boniva tablets Ubrelvy (generic for Glumetza) Testone CIK Kit Fosamax Zembrace Symtouch Metformin ER (generic Testosterone CIK Kit Zomig for Fortamet) Fosamax Plus D Vogelxo Zomig Nasal Nesina Overactive Bladder Onglyza Treatment Bone Marrow Oseni Detrol Stimulants Ozempic Detrol LA Nivestym Pioglitazone Ditropan XL Ziextenzo Pioglitazone-Glimepiride Enablex Pioglitazone-Metformin Cardiovascular Gelnique Prandin Entresto Myrbetriq Qtern Oxytrol Riomet Diabetes Toviaz Riomet ER Management Vesicare Adlyxin Rybelsus Alogliptin Segluromet Pain Relievers Alogliptin/Metformin Soliqua (Cox II Inhibitors) Alogliptin/Pioglitazone Steglatro Capxib ACTOplus Met Steglujan Celebrex ACTOplus Met XR Synjardy Celecoxib Actos Synjardy XR Lidoxib Afrezza Tanzeum Tradjenta Parkinson's Disease Avandaryl Management Avandia Trijardy XR Inbrija Bydureon Trulicity Nourianz Byetta Victoza Duetact Xigduo Prostate Treatment Xigduo XR Farxiga Avodart Xultophy

16 Specialty Pharmacy Medications

In our formulary, some medications are classified as specialty medications. These medications are usually used to treat complex health conditions. We’ve developed a network of specialty pharmacies that are experienced in dispensing these medications. Members are required to fill most specialty medications through one of the pharmacies listed below. However, if a highly specialized medication isn’t available at one of our specialty pharmacies, we’ll cover the cost of the medication when it’s filled at an in-network pharmacy. For a list of specialty medications, see the following pages.

Specialty Network Pharmacy Specialty Network Pharmacy Contact Information Contact Information for AcariaHealthTM Fertility Medications 1-866-892-1202 Freedom Fertility Pharmacy Fax: 1-877-541-1503 1-866-297-9452 acariahealth.envolvehealth.com Fax: 1-888-660-4283 Accredo®´ freedomfertility.com 1-877-988-0058 Metro Drugs Fax: 1-800-391-9707 1-888-258-0106 accredo.com Fax: 1-201-253-1101 CVS SpecialtyTM metrodrugs.com 1-866-846-3096 Village Fertility Pharmacy Fax: 1-800-323-2445 1-877-334-1610 cvsspecialty.com Fax: 1-866-935-0719 villagepharmacy.com

Note: Some medications on this list may also be subject to Step Therapy, Prior Authorization, and/or Quality Care Dosing requirements, or be considered non-covered. Please check the corresponding pages to determine coverage requirements.

This list of Specialty Medications is up to date as of January 1, 2021, and may change from time to time. For the most current specialty medication and specialty pharmacy network information, use our Medication Lookup tool at bluecrossma.com/medications.

17 Specialty Pharmacy Medications

Cladribine Fludarabine phosphate Irinotecan Injectable Copaxone Fluorouracil Istodax Medications Required to Be Filled Cosentyx Forteo Kalbitor at an In-Network Cosmegen Fulphila Kanjinti Specialty Pharmacy Crysvita Fulvestrant Kenalog Cuvitru Fusilev Kesimpta Abraxane Cyclophosphamide Fuzeon Kevzara Actemra Cyramza GamaSTAN Keytruda Acthar Cytarabine Gammagard Kynamro Actimmune Cytogam Gammagard Liquid Lartruvo Adakveo Dacarbazine Gammaked Lemtrada Adriamycin Dactinomycin Gammaplex Leucovorin Calcium Adrucil Daunorubicin HCL Gamunex Leukine Alferon-N DDAVP Gattex Leuprolide Acetate Alkeran Depocyt Gazyva Levoleucovorin Apokyn Desmopressin Acetate Gemcitabine Lipodox Aranesp Dexrazoxane Gemzar Lipodox-50 Arcalyst Docefrez Genotropin Lumoxiti Arzerra Docetaxel Givlaari Lupaneta Pack Asceniv Doxil Glatiramer Lupron Depot Aveed Doxorubicin HCL Glatopa Lupron Depot-Ped Avonex Dupixent Granix Makena Avsola Dysport Haegarda Marqibo Beleodaq Egrifta Herceptin Mepsevii Berinert Eligard Herceptin Hylecta Mesna Besponsa Ellence Herzuma Mesnex Betaseron Empliciti Hizentra Methotrexate BiCNu Enbrel Humatrope Mitomycin Bivigam Enspryng Humira Mitoxantrone Bleomycin Sulfate Entyvio Hycamtin Mozobil Blincyto Epirubicin Hydroxyprogesterone Mustargen Boniva Epogen HyQvia Mylotarg Bortezomib Ethyol Ibandronate injection/syringe Myobloc Botox Etopophos Icatibant Naptara Busulfex Etoposide Idamycin PFS Navelbine Bynfezia Evenity Idarubicin Neulasta Calcium Folinate Extavia Ifex Neupogen Camptosar Fasenra Ifosfamide Nipent Carboplatin Faslodex Ifosfamide/Mesna Nivestym Carimune Fintepla Ilaris Norditropin Carmustine Firazyr Ilumya Norditropin Flexpro Cerezyme Firmagon Imfinzi Norditropin Nordiflex Cimzia Flebogamma Increlex Nplate Cinqair Floxuridine Inflectra Nucala Cinryze Fludara Intron A Nutropin AQ Nuspin Cisplatin

18 Specialty Pharmacy Medications

Ocrevus Simponi Aria Xolair Rocephin Octagam Skyrizi Zaltrap Romidepsin Octreotide injection Somatuline Zanosar Sandimmune Ogivri Somavert Zarxio Sildenafil antihypertensive Omnitrope Spinraza Ziextenzo Strensiq Oncaspar Stelara Zilretta Synribo Onivyde Sublocade Zinecard Tazicef Ontruzant Sylatron Zoladex Testosterone Enanthate Opdivo Sylvant Zomacton Triptodur Orencia Synagis Zorbtive Unituxin Otrexup Takhzyro Viltepso Oxaliplatin Taltz Injectable Vyepti Medications That Paclitaxel Taxotere Can Be Filled at Vyleesi Palynziq Tecentriq Other In-Network Vyondys-53 Pamidronate Tegsedi Pharmacies Vyxeos Pamidronate disodium Temodar Xiaflex Acetadote Panzyga Teniposide Yondelis Arikayce Pegasys Tepadina Bavencio Pegasys Proclick Tepezza Oral Medications Benlysta Autoinject/syringe Required to Be Filled Peg-Intron Teriparatide Bicillin at an In-Network Photofrin Tev-Tropin Bleo 15 Specialty Pharmacy Plegridy TheraCys Cablivi Abiraterone Poteligeo Thiotepa Ceftazadime Adcirca Privigen Thyrogen Cutaquig Adempas Procrit Toposar Cuvposa Afinitor Proleukin Totect Delestrogen Alcensa Prolia Trazimera Depo-Estradiol Alkeran Rebif Trelstar Desferal Alunbrig Remicade Trelstar Depot Desferoxamine Alyq Renflexis Trelstar LA Evomela Ambrisentan Retacrit Tremfya Exondys Ampyra Revatio Truxima Fensolvi Aubagio Rituxan Tymlos Fortaz Bafiertam Roferon-A Udenyca Gamifant Bethkis Ruconest Valrubicin Kanuma Bosentan Ruxience Valstar Khapzory Bosulif Saizen Velcade Kineret Cabometyx SaizenPrep Vimizim Libtayo Capecitabine Sandostatin Vinblastine Nabi-HB Carbaglu Sandostatin-LAR Vincristine Neulasta Onpro Cayston Serostim Vinorelbine Onpattro Cerdelga Signafor Vivitrol Portrazza Copegus Signafor LAR Xembify Radicava Cotellic Siliq Xeomin Revcovi Cyclophosphamide Simponi Xgeva Rimso-50 Cystagon

19 Specialty Pharmacy Medications

Daklinza Lonsurf Rinvoq ER Votrient Dalfampridine Mavenclad Rozlytrek Vumerity DR Daurismo Mavyret Rubraca Vyndamax Deferasirox Mayzent Rydapt Vyndaqel Dimethyl Fumarate Mekinist Sabril Wakix Dojolvi Mesnex Samsca Xalkori Doptelet Miglustat Sapropterin Xeljanz Duopa Moderiba Sildenafil antihypertensive Xeljanz XR Epclusa Mulpleta Sofosbuvir/Velpatasvir Xeloda Erivedge Mycapssa DR Sovaldi Xenazine Erleada Nerlynx Sprycel Xtandi Erlotinib Nexavar Stivarga Xyrem Esbriet Ninlaro Sucraid Zavesca Etoposide Northera Sutent Zelboraf Everolimus Nubeqa Symdeko Zepatier Evrysdi Nuplazid Tabrecta Zeposia Exjade Ocaliva Tadalafil antihypertensive Zolinza Farydak Odomzo Tafinlar Zykadia Galafold Ofev Tagrisso Zytiga Gilenya Olumiant Talzenna Gilotrif Olysio Tarceva Oral Medications That Can Be Filled at Gleevec Onureg Tasigna Other In-Network Harvoni Opsumit Tecfidera Pharmacies Hetlioz Orenitram Technivie 8-Mop Hycamtin Orkambi Temodar Afinitor Disperz Ibrance Otezla Temozoloamide Austedo Idhifa Oxbryta Tetrabenazine Ayvakit Imatinib Palforzia Thalomid Balversa Inbrija Piqray TOBI ampules Boniva 150mg Inlyta Pomalyst TOBI-Podhaler Calquence Inqovi Procysbi Tobramycin ampules Chenodal Inrebic Promacta Tolvaptan Cholbam Iressa Pulmozyme Tracleer Cometriq Jadenu Pyrimethamine Trikafta Copiktra Jakafi Ravicti Tykerb Daraprim Juxtapid Rebetol Tyvaso DDAVP Kalydeco Retevmo Uptravi Diacomit Kisqali Revatio Veltassa Emflaza Kisqali Femara Revlimid Verzenio Firdapse Kitabis PAK Ribasphere Viekira PAK Gavreto Kuvan Ribasphere Ribapak Viekira XR Gocovri ER Ledipasvir/Sofosbuvir Ribatab Vigabatrin Iclusig Lenvima Ribavirin Vitrakvi Imbruvica Letairis Rilutek Vizimpro Ingrezza Lobrena Riluzole Vosevi Isturisa

20 Specialty Pharmacy Medications

Jynarque Keveyis Fertility Medications Required to be Filled Korlym at an In-Network Koselugo Specialty Fertility Nityr Pharmacy Orfadin Bravelle Otezla Starter Pack Cetrotide Pemazyre Clomid Qinlock Clomiphene Ruzurgi Crinone Tavalisse Endometrin Thiola Follistim AQ Tiglutik Ganirelix Tukysa Gonal F/Gonal F RFF Turalio Gonal F Rff Redi-Ject Venclexta Human Chorionic Vigadrone Gonadotropin (HCG) Vistogard Leuprolide Xermelo Lupron Depot Xospata Lupron Depot-Ped Xpovio Luveris Xuriden Makena Yonsa Menopur Zejula Novarel Zydelig Ovidrel Topical Medications Pregnyl Required to Be Filled Serophene at an In-Network Specialty Pharmacy Mugard Oxervate Panretin Qutenza Valchlor Zecuity Topical Medications That Can Be Filled at Other In-Network Pharmacies Cystadrops Cystaran Synarel

21 Non-Covered Medications

Your pharmacy program provides coverage for over 4,000 prescription medications. This section lists medications that aren’t covered under your benefits. Most medications on our non-covered list have covered alternatives that have been proven to be equally safe and effective for treating the same medical conditions. If a non-covered medication is approved, it will be covered at the highest tier.

Check with your doctor about appropriate alternatives if you currently take any of these medications. Your doctor may request coverage for a non-covered medication if no covered alternative is appropriate for treating your condition.

Note: Some medications on this list may also be subject to Prior Authorization, Quality Care Dosing and/or Step Therapy requirements, or be considered a specialty medication. Please check the corresponding pages to determine coverage requirements.

This list of non-covered medications is up to date as of January 1, 2021, and may change from time to time. For the most current list of non-covered medications, and to see covered alternatives, use our Medication Lookup tool at bluecrossma.com/medications.

22 Non-Covered Medications

Abilify Albuterol Hfa (Ventolin Armonair Respiclick Benzaclin Abilify Discmelt Authorized Product) Aromasin Benzaclin Kit Abilify Mycite Alcortin-A Arthrotec Benzhydrocodone/ Absorica Alveicyn Antipruritic SG gel Arymo ER Acetaminophen Absorica LD Alevicyn Plus Kit Arze-Ject-A Kit Benzonatate 150mg Abstral Alodox Asacol HD Beser Acanya Alogliptin Ascensia Test Strips Besivance Accolate Alogliptin/Metformin Asmanex HFA Betaloan Suik Accucaine Alogliptin/Pioglitazone Asmanex Twisthaler Betimol Accu-Chek Diabetic Aloquin Aspirin/Omeprazole (excluded Betoptic S Testing Supplies Alora for 18 years and older) Bevespi Aerosphere Accupril Alphagan P Assure Diabetic Bg-Star Diabetic Accuretic Alrex Testing Supplies Testing Supplies Aciphex (excluded for 18 Alsuma Astepro Bijuva years and older) Altabax Atacand Binosto Acticlate Altace Atacand HCT Bionect Actigall Altoprev Atelvia Boniva Actiq Alvesco Ativan Bravelle Active Injection D Ambien Atopaderm Breo Ellipta Activella Ambien CR Atopavo Brevicon Active-Pac Amrix Atopiclair Brilinta ActoPlus Met Amzeeq Atralin Brisdelle ActoPlus Met XR Anafranil Atrapo Dermal Spray Bromsite Acular Ana-Lex Atrapro CP Brovana Acular LS Angeliq Atrapro Hydrogel Brylhali Acuvail Anodyne LPT Atropen Budesonide/Formoterol Aczone Augmentin XR (Symbicort Antara Authorized Product) Adalat CC Auryxia Anusol HC suppository Bunavail Adazin Auvi-Q Anzemet Bystolic Adderall Avalide Apadaz Byvalson Addyi Avapro Apidra Caduet Adhansia XR Avelox Aplenzin Calcipotriene Foam (Sorilux Adlyxin Apriso Avidoxy Authorized Product) Admelog Aprizio Pak Avidoxy DK Calcitriol Topical Advanced Allergy Aprizio Pak II Avita Cambia Powder Collection Kit Aptensio XR Axert Caphosol Advocate Diabetic Azasite Testing Supplies Aqua Glycolic HC Caplyta Azesco Adyphren Arakoda Capsfenac Azopt Adzenys XR Aranesp Capxib Azor Aemcolo DR Arava Carac Balcoltra Aerospan Arazlo Cardene Basadrox Agoneaze Arcapta Neohaler Cardizem CD B-D Testing Strips Airduo Digihaler Arimidex Cardizem LA Belsomra Airduo Respiclick Arixtra Cardura XL Benicar Akynzeo Armonair Digihaler Careone Diabetic Benicar HCT Testing Supplies

23 Non-Covered Medications

Caresens Diabetic Contempla XR ODT Desowen Kit Durezol Testing Supplies Cozaar Desvenlafaxine ER Durlaza Caretouch Diabetic Crestor Detrol Durolane Testing Supplies CVS Advanced Diabetic Detrol LA Duzallo Cedax testing supplies Dexedrine Dyloject Celexa Cyclobenzaprine 7.5mg Dexilant (Kapidex) (excluded Easy Step Diabetic Cem-Urea Cymbalta for 18 years and older) Testing Supplies Centany Daklinza Diclo Gel Easy Talk Diabetic Centany AT Daliresp Diclofenac Epolamine Testing Supplies Cequa Dapsone 7.5% Diclofenac Submicronized Easy Touch Diabetic Testing Supplies Ceracade Skin Barrier Daxbia Diclofono Ceramax Easy Trak Diabetic Daypro Diclopak Testing Supplies Cesamet Daytrana Diclopr Combo Pack Easymax Diabetic Cetraxal D-Care 100X Diclotral Testing Supplies Chenodal DDAVP Diclotrex EC-Naprosyn Chorionic Gonadotropin Deluo Diclovix Econasil Cialis Delzicol Diclovix M Edarbi Cimzia Delzicol XR Diclo-Xrylix Sheet Kit Edarbyclor Cipro XR Depakote Diclozor Edluar Clenpiq Depakote ER Differin Effexor Cleocin T Depakote Sprinkle Dificid Effexor XR Clever Choice Diabetic Depo-Sub Q Provera 104 Dilaudid Elestrin Testing Supplies Dermacin Dimentho Eletone Clindcin ETZ Kit Silazone Pharmapak Diovan Ellzia Clindacin PAC Dermacin Cinolone-1 CPI Diovan HCT Embeda Clindagel Dermacinrx Clorhexacin Dipentum Embrace Diabetic Clobex Dermacinrx Empricaine Dithol Combo Pack Testing Supplies Clodan Kit Dermacinrx PHN Ditropan XL Empraciane II Colazal Dermacinrx Prizopak Divigel Emsam Colchicine Capsules Dermacinrx Silapak DM2 kit Enablex Colcrys Dermacinrx DMT Suik Entresto Colyte Surgical Pharmpak Dolotranz Entyvio Combigan Dermacinrx Therazole Pak Doryx DR 80mg Epaned Conjupri Dermacinrx ZRM Doubledex Epiceram Consensi Derma-Smoothe/FS Body Oil Doxycycline DR 80mg Epiduo Contour Diabetic Derma-Smoothe/FS Scalp Oil Epiduo Forte Testing Supplies Doxycycline DR 200mg Dermasorb-AF Epinephrine Autoinject Conzip Doxycycline Hyclate Dermasorb-HC 50mg tablets (Amneal Authorized Product Cool Diabetic For Adrenaclick) Dermasorb-TA Drizalma Sprinkle Testing Supplies Epinephrine Snap-V Dermasorb-XM Duac Copaxone Episil Dermawerx SDS Duac CS Coreg Episnap Convenience Kit Dermawerx Surgical Duaklir Pressair Coreg CR Plus Pack Epogen Duavee Corlanor Dermazone EQ Diabetic Testing Supplies Duexis Cosentyx Dermazyl Equetro Duobrii Cosopt PF Dermotic Ertaczo Duragesic

24 Non-Covered Medications

Esomeprazole Stronum Flarex Glucometer Diabetic Inflatherm (excluded for 18 years Flector Testing Supplies Innopran XL and older) Flexipak Glucophage Insulin Aspart Esomeprazole-EZS Kit Glucophage XR (excluded for 18 years Flolipid Insulin Lispro and older) Fluopar Glumetza Insulin Lispro Jr. Estrace Fluoroplex Gmate Diabetic Insulin Lispro Mix 75-25 Testing Supplies Estrogel Fluovix Intermezzo Gnp Diabetic Testing Supplies Eucrisa Fluovix Plus Intuniv Gocovri ER Euflexxa Fluoxetine Tablets Invega Golytely Evamist FML Forte Inveltys Halobetasol Foam Evekeo FML Liquifilm Invokana Harmony Diabetic Evencare Diabetic FML S.O.P. Testing Supplies Invokamet Tetsing Supplies Focalin Healthpro Diabetic Invokamet XR Evoclin Focalin XR Testing Supplies Irenka DR Exactech Diabetic Follistim Helidac Therapy Pak Istalol Testing Supplies Fora Diabetic Testing Supplies Hemady Jentadueto Exalgo Forfivo XL Horizant Jentadueto XR Exforge Fortamet HPR Jornay PM Exforge HCT Fortesta HPR Plus Jublia Extavia Fosamax HPR Plus Hydrogel Kadian Extina Fragmin Humana True Metrix Diabetic Kapvay EZ Use joint Tunnel-Trigger Testing Supplies Freestyle Diabetic Kaspargo Sprinkle Ezallor Sprinkle Testing Supplies Hyalgan Katerzia Fabior Frova Hydrocodone ER Kazano Factive (persion Pharmaceuticals) Fusilev I.V. Keppra Fanapt Hydrocortisone-Lidocaine Gabacaine Keppra XR Fazaclo Hylaguard Gabapal Keralyt Scalp 6% Kit Femring Hylatopic Ganirelix Kerydin Fenofibrate 50mg Hylatopic Plus Ge 100 Diabetic Ketoprofen 25mg Fenofibrate 150mg Testing Supplies Hylatopic Plus-Aurstat Ketorolac Nasal Spray Fenoglide Gelclair Hymovis (Branded Product) Fentanyl Citrate Gelnique Hysingla ER Khedezla Fentora Gel-One Hyzaar Kitabis Pak Fetzima Gelsyn-3 Iglucose Diabetic Klonopin Testing Supplies Fexmid Gelx Krintafel Ilevro Fiasp Genotropin Kiristalose Imitrex Kit Refill Fibricor Genstrip Diabetic KRO premium Imitrex Pen Injector Fifty50 Diabetic Testing Supplies Diabetic supplies Testing Supplies Geodon Imitrex Vial Lamictal Finacea Plus Gialax Imvexxy Lamictal ODT Fiorinal Giazo Inavix Lamictal XR Fiorinal /Codeine #3 Gimoti Inderal LA Lamisil Flagyl Gleevec Inderal XL Lamisil Granules Flagyl ER Gloperba Indomethacin 20Mg Lancet Diabetic Flagyl I.V. Glucocard Diabetic (Branded Product) Testing Supplies Flagyl I.V. RTU Vialflex Testing Supplies Inflamma-K Latuda

25 Non-Covered Medications

Lazanda Lotemax Minolira ER Northera Ledipasvir/Sofosbuvir Lotemax SM Mirapex Norvasc Lemtrada Lotensin Mirapex ER Nova Max Diabetic Lescol Lotensin HCT Mobic Testing Supplies Lescol XL Lotrel Monodox Novacort Leva Set Loutrex Monovisc Novolin Levalbuterol HFA Lovaza (Omacor) Morgidox Kit Novolog Levaquin Lovenox Morphabond ER Noxipak Levemir Luliconazole Motegrity Nucaraclinpak Levicyn Antipruritic SG Lunesta Moviprep Nucararxpak Levitra Luzu Moxatag Nucort Lexapro Lyumjev Moxeza Nucynta Lexette Lyrica Cr Mulpleta Nucynta ER Lexixryl Lysteda Mydayis Nudermrxpack Liberty Diabetic Mac Patch Nalfon Nudiclo Solupak Testing Supplies Marvona Suik Namzaric Nudiclo Tabpak Licart Mas Care-Pak Naprelan Nulytely Lidocidex I Mavyret Naprelan CR Dose Card Nusurgepak Surgical Prep Lidoderm Maxalt Naprosyn Nutraseb Lidomark Maxalt-Mlt Naproxen/Esomeprazole Nutria Rx Lidopac Maxaquin Naproxen DR NuvaRing Lidopril Maxidex Nascobal Nuvakaan Lido-Prilo Caine Pack Maxipime Natazia Nuvakaan II Lidotin Mb Hydrogel Natesto Nasal Nuvessa Lidotrans 5 Pak Medolor Kit Neocera Advanced Nuvigil Lidotrex Medroloan II Suik Neosalus Ocudox Kit Lidovix Medroloan Suik Neosalus CP Olux Lidoxib Megace ES Neo-Synalar Kit Olysio Lipitor Menostar Nesina Omnitrope Lipofen Mentho-Caine Kit Neuac Kit Onexton Lipritin Mesalamine DR Neumaxin Onmel Lipritin II Metformin ER (Fortamet Neupogen Onsolis Liprozonepak Authroized product) Neupro Onzetra Xsail Livalo Metformin ER (Glumetza Neurcaine Opana Authroized product) Livixil Pak Neurontin Opana ER Micardis Livostin Nevanac Optium Diabetic Micardis HCT Testing Supplies LMR Plus Kit Nexiclon XR Lodine Microdot Diabetic Oracea Testing Supplies Nexium (excluded for 18 years Lodine XL and older) Oramorph SR Microvix LP Lokelma Niravam Orapred ODT Migranow Lonhala Magnair Nitro-Dur Oravig Minastrin Fe Lopressor Nocdurna Orencia Minocin Loprox Kit Noctiva Oriahnn Minocin Combo Pack Lorzone Nopioid-TC Orilissa Minocycline ER Orthovisc Loseasonique (Branded product) Norditropin Oseni

26 Non-Covered Medications

Osmolex ER Pram-HCA Prozac Weekly Rexulti Osmoprep Pramosone E Pylera Rhopressa Osphena Pravachol Qbrelis Risperdal M-Tab Otrexup PR-Cream Qbrexza Ritalin Oxaydo Precision Diabetic Qmiiz ODT Ritalin LA Oxytrol Testing Supplies Qtern Ritalin SR Ozempic Pred Mild Quartette Rocklatan Paingo KFT Prefest Quillichew ER Rosadan Pamelor Pregnyl Quillivant XR Roxybond Pancreaze Premium Diabetic Quinixil Rytary ER Testing Supplies Panixine Quinja Rythmol Prepopik Patanase Quinosone Combo Pack Ryvent Presera Paxil Radiaplex Rx Saizen Prestalia Paxil CR Radigel Salicylic Acid 6% Kit Prestige Diabetic P-Care Testing Supplies Rapaflo Salicylic Acid/Ceramide Kit P-Care K Prevacid (excluded for 18 Rasuvo Auto-Injector Salkera P-Care M years and older) Raxar Salvax Duo P-Care MG Prevpac Rayaldee Salvax Duo Plus P-Care X Prikaan Rayos SanadermRx Skin Repair PCE Prilo Patch Kit Readysharp Betamethasone Sancuso PCE Dispertab Prilolid Readysharp Bupivicaine Saphris Pedizol Prilosec (excluded for 18 Readysharp Dexamethasone Sarafem years and older) Penetrex Readysharp Ketorolac Savaysa Penlac Prilovix Readysharp Lidocaine Savella Pennsaid Prilovixil Readysharp Methylprednisolone Scalacort Pentican Prinivil Readysharp Triamcinolone Seasonique Pepcid Pristiq Recothrom Sebuderm Percocet Prozopak II Regenecare Secuado Pergonal Prizotral Relador Pak Seebri Neohaler Perseris Prizotral II Relador Pak Plus Segluromet Pertzye Proair Digihaler Relafen DS Sernivo Pexeva Procentra Relexxii ER Seroquel Pharmacist Choice Diabetic Procort Relion Diabetic Seroquel XR Testing Supplies Procrit Testing Supplies Seysara Physicians EX USE B12 Kit Prodigy Diabetic Relpax Sila III Testing Supplies Physicians USE EZ M- Remeron Silalite Pak Pred Kit Prolensa Remeron Soltab Silazone-II Picato Promiseb Repatha Silenor Plaquenil Protonix (excluded for 18 Requip years and older) Siliq Plenvu Requip XL Proventil HFA Silvrstat Plixda Rescula Proventil Inhaler Simbrinza Pod-Care 100C Restoril Provigil Simvastatin Suspension Pod-Care 100CG Retin-A Cream (Flolipid Authorized Product) Pod-Care 100K Pro-Voice Diabetic Testing Supplies Retin-A Micro Sinemet 25/100 Pod-Care 100KG Prozac Revatio Singulair Pradaxa

27 Non-Covered Medications

Sitavig Sustol Topamax Ultravate X Sklice Suvicort Toronova II Suik Unistrip Diabetic Smart Sense Diabetic Sympazan Toronova Suik Testing Supplies Testing Supplies Symproic Tovet Kit Up & Up Diabetic Testing Supplies SmartRx Gabakit Synalar Combo-Pack Toviaz Uramaxin SmartRx Gaba-V Synalar TS Tradjenta Urea Kit Sodium Hyaluronate Synvexia TC Tramadol 100Mg Tablets Utibron Neohaler Sofosbuvir/Velpatasvir Synvisc (Branded Product) Vacustim Silver Kit Sof-Tact Diabetic Synvisc-One Tramadol ER Capsules Testing Supplies Valium Talcia DR Tranxene -T Solaice Vanos Tanzeum Trinaz Solaravix Varophen Kit Targadox Trelegy Ellipta Solaraze Vascepa Tarka Tresiba Soliqua Vaseretic Tasoprol Tretin-X Solodyn Vasotec Taytulla Treximet Solosec Vectical Tazorac Trezix Soltamox Velphoro Technivie Tribenzor Solupak Veltassa Teczem Tricor Solus Diabetic Triglide Veltin Testing Supplies Tekturna Trijardy XR Venlafaxine ER Tablets Soma Tekturna HCT Trileptal Ventolin Sonata Tenormin Trilipix Ventolin HFA Soolantra Tequin Trilipx DR Verasens Diabetic Sovaldi Teriparatide Testing Supplies Triloan II Suik Spectracef Tersi Veregen Triloan Suik Sporanox Test N'Go Diabetic Vesicare Testing Supplies Triluron Spritam Vexa Testim Tri-Norinyl Sprix Vexasyn Wound Gel Testone CIK Trinaz Stalevo Viagra Testosterone (Testim Trintellix (Formerly Brintellix) Staxyn Viberzi Authorized Product) Tri-Sila Topical Steglatro Victoza Testosterone (Vogelxo Trivisc Steglujan Authorized Product) Viekira Trivix Stendra Testosterone CIK Kit Viekira PAK Trixylitral Striant Testosterone Gel (Fortesta Vigamox Authorized Product) True Metrix Diabetic Suboxone Testing Supplies Viibryd Tev-Tropin Subsys Truetest Diabetic Vimovo Suclear Tiazac Testing Supplies Virasal Sular Timoptic Truetrack Diabetic Visco-3 Sumadan Tindamax Testing Supplies Vivaguard Ino Diabetic Sumavel Dosepro Tirosint Trulance Testing Supplies Sumaxin Tivorbex Twynsta Vivlodex Sumaxin CP Tobradex Ultracet Vogelxo Sumaxin TS Tobradex ST Ultram Voltaren Supartz Tofranil Ultram ER Voltaren-XR Suprep Tolak Ultrasal ER Vopac MDS Sure Result Tac Pak Tolsura Ultravate PAC Vraylar

28 Non-Covered Medications

Vumerity DR Zestril Vusion Zetia Vytorin Zeyocaine Vyvanse Ziana Vyzulta Zilacaine Wavesense Diabetic Zilxi Testing Supplies Zinbryta Welchol Zioptan Wellbutrin Zipsor Wellbutrin SR Zithromax Wellbutrin XL Zmax Whytederm Surgipak Zocor Whytederm Trilasil Pak Zofran Wound Debride 4% Lidocaine Zofran ODT WPR Plus Zohydro ER Xadago Zoloft Xalix Zolpak Xanax Zolpimist Xanax XR Zomacton Xartemis XR Zomig X-Clair Zomig ZMT Xelpros Zonegran Xepi Zontivity Xerese Zorvolex Xifaxan Zovirax Xilapak Ztlido Ximino ER Zubsolv Xolegel Zuplenz Xopenex HFA Zurampic Xopenex Nebules Zyban Xryliderm Zyclara Xrylix Zyflo Xtampza ER Zyflo CR Xultophy Zylet Xyosted Zymaxid Yosprala DR Zypitamag Yupelri Zypram Zagam Zyprexa Zanaflex Zyprexa Intramuscular Zantac Zyprexa Relprevv Zegerid (excluded for 18 years Zyprexa Zydis and older) Zelapar Zelnorm Zembrace Symtouch Zepatier

29 Medication Resource List Index

This index is a list of the medications referenced in this guide.

30 Medication Resource List Index

Adderall 23 Alogliptin 16, 23 Aptenzio XR 8 8 Adderall XR 8 Alogliptin/Metformin 16, 23 Aqua Glycolic HC 23 8-Mop 20 Addyi 13, 23 Alogliptin/Pioglitazone 16, 23 Arakoda 23 A Adempas 19 Aloquin 23 Aralast 13 Adhansia XR 8, 23 Alora 8, 23 Aranesp 8, 13, 18, 23 ACTOplus Met 8, 16 Adlyxin 8, 16, 23 Alosetron 8 Arava 8, 23 ACTOplus Met XR 8, 16 Admelog 8, 23 Alphagan P 23 Arazlo 23 Abilify 23 Admelog Solostar 8 Alrex 8, 23 Arcalyst 18 Abilify Discmelt 23 Adriamycin 18 Alsuma 8, 23 Arcapta Neohaler 8, 23 Abilify Mycite 8, 23 Adrucil 18 Altabax 23 Arikayce 13, 19 Abiraterone 19 Advair Diskus 8, 13 Altace 23 Arimidex 23 Abraxane 18 Advair HFA 8, 13 Altoprev 8, 23 Arixtra 8, 23 Absorica 23 Advanced Allergy Collection Alunbrig 19 Armodafinil 13 Absorica LD 23 Kit 23 Alveicyn Antipruritic SG gel 23 ArmonAir DigiHaler 8 Abstral 8, 13, 23 Advocate Diabetic Testing Alvesco 8, 23 ArmonAir RespiClick 8 Supplies 23 Acanya 23 Alyq 13, 19 Armonair Digihaler 23 Adyphren 8, 23 Accolate 23 Ambien 8, 23 Armonair Respiclick 23 Adyphren Amp 8 Accu-Chek Diabetic Testing Ambien CR 8, 23 Arnuity Ellipta 8 Supplies 23 Adyphren Amp II 8 Ambrisentan 19 Aromasin 23 Accucaine 23 Adyphren II 8 Amerge 8, 16 Arthrotec 23 Accupril 23 Adzenys XR 8, 23 Amethia 8 Arymo ER 8, 13, 23 Accuretic 23 Aemcolo 8 Amethia Lo 8 Arze-Ject-A Kit 23 Acetadote 19 Aemcolo DR 23 Amitiza 8 Arzerra 18 AcipHex 8, 13 Aerospan 8, 23 Amlodipine 8 Asacol HD 23 AcipHex Sprinkle 8 Afinitor 19 Amlodipine-Atorvastatin 8 Asceniv 18 Aciphex 23 Afinitor Disperz 20 Amphetamines 13 Ascensia Test Strips 23 Actemra 8, 13, 18 Afrezza 16 Ampyra 8, 13, 19 Ashlyna 8 Acthar 13, 18 Agoneaze 23 Amrix 23 Asmanex HFA 8, 23 Acticlate 23 Aimovig 8, 13 Amzeeq 23 Asmanex Twisthaler 8, 23 Actigall 23 Air Duo 13 Ana-Lex 23 Aspirin/Omeprazole 8, 13, 23 Actimmune 13, 18 AirDuo DigiHaler 8 Anafranil 23 Assure Diabetic Testing Actiq 8, 13, 23 AirDuo RespiClick 8 Androgel 16 Supplies 23 Active Injection D 23 Airduo Digihaler 23 Angeliq 23 Astepro 8, 23 Active-Pac 23 Airduo Respiclick 23 Anodyne LPT 23 Astramorph/PF 13 Activella 23 Ajovy 8, 13 Antara 23 Atacand 23 ActoPlus Met 23 Akynzeo 8, 23 Anusol HC suppository 23 Atacand HCT 23 ActoPlus Met XR 23 Albuterol Hfa (Ventolin Atelvia 23 Authorized Product) 23 Anzemet 8, 23 Actonel 8, 16 Atelvia DR 8, 16 Albuterol Sulfate HFA 8 Apadaz 13, 23 Actos 8, 16 Ativan 23 Alcensa 19 Apidra 8, 23 Acular 8, 23 Atomoxetine 8 Alcortin-A 23 Apidra Solostar 8 Acular LS 8, 23 Atopaderm 23 Alecensa 13 Aplenzin 23 Acular PF 8 Atopavo 23 Alendronate Sodium 8 Aplenzin ER 8 Acuvail 23 Atopiclair 23 Alevicyn Plus Kit 23 Apokyn 18 Acyclovir cream 8 Atorvastatin 8 Alfenta 13 Aprepitant 8 Aczone 23 Atralin 23 Alferon-N 18 Apriso 23 Adakveo 13, 18 Atrapo Dermal Spray 23 Alkeran 18, 19 Aprizio Pak 23 Adalat CC 23 Atrapro CP 23 Almotriptan 8, 16 Aprizio Pak II 23 Adazin 23 Atrapro Hydrogel 23 Alodox 23 Aptensio XR 23 Adcirca 13, 19 Atropen 23

31 Medication Resource List Index

Atrovent 8 Benzonatate 150mg 23 Budesonide/Formoterol Cardizem LA 23 Atrovent HFA 8 Berinert 13, 18 (Symbicort Authorized Cardura 8 Product) 23 Aubagio 19 Beser 23 Cardura XL 8, 23 Bunavail 8, 23 Augmentin XR 23 Besivance 23 Careone Diabetic Testing Buprenorphine 8 Auryxia 23 Besponsa 18 Supplies 23 Buprenorphine patch 8, 13 Austedo 20 Betaloan Suik 23 Caresens Diabetic Testing Buprenorphine-Naloxone 8 Supplies 24 Auvi-Q 8, 23 Betaseron 8, 18 Bupropion SR 8 Caretouch Diabetic Testing Avalide 23 Bethkis 19 Bupropion XL 8 Supplies 24 Avandaryl 16 Betimol 23 Busulfex 18 Carimune 18 Avandia 8, 16 Betoptic S 23 Butorphanol NS 8 Carmustine 18 Avapro 23 Bevespi AeroSphere 8 Butrans 8, 13 Catapres TTS 8 Aveed 18 Bevespi Aerosphere 23 Bydureon 8, 16 Cayston 19 Avelox 23 Bevyxxa 8 Bydureon Bcise 8 Cedax 24 Avidoxy 23 Bg-Star Diabetic Testing Ceftazadime 19 Supplies 23 Byetta 8, 16 Avidoxy DK 23 Celebrex 8, 16 BiCNu 18 Bynfezia 18 Avinza 8, 13 Celecoxib 8, 16 Bicillin 19 Bystolic 23 Avita 23 Celexa 8, 24 Bijuva 8, 23 Byvalson 23 Avodart 16 Cem-Urea 24 Binosto 8, 16, 23 Avonex 8, 18 C Centany 24 Bionect 23 Avsola 13, 18 CVS Advanced Diabetic Centany AT 24 Bivigam 18 Axert 8, 16, 23 testing supplies 24 Cequa 13, 24 Bleo 15 19 Axiron 16 Cabergoline 8 Ceracade Skin Barrier 24 Bleomycin Sulfate 18 Ayvakit 13, 20 Cablivi 19 Ceramax 24 Blincyto 18 Azasite 23 Cabometyx 19 Cerdelga 19 Boniva 18, 23 Azelastine 8 Caduet 8, 23 Cerezyme 13, 18 Boniva 150mg 20 Azesco 23 Calcipotriene 8 Cesamet 8, 24 Boniva syringe 13 Azopt 23 Calcipotriene Foam (Sorilux Cetraxal 24 Boniva tablets 8, 16 Authorized Product) 23 Azor 23 Cetrotide 21 Bortezomib 18 Calcipotriene/Betamethasone Chenodal 20, 24 B Bosentan 19 8 Calcitriol Topical 23 Cholbam 8, 20 B-D Testing Strips 23 Bosulif 19 Calcium Folinate 18 Chorionic Gonadotropin 24 Bafiertam 19 Botox 18 Calquence 20 Cialis 24 Balcoltra 23 Botox/Botulinum Toxin 13 Calypta 8 Ciclodin solution/kit 8 Balversa 13, 20 Braftovi 13 Cambia Powder 23 Ciclopirox nail lacquer 8 Baqsimi 8 Bravelle 21, 23 Camptosar 18 Cimzia 8, 13, 18, 24 Basadrox 23 Breo Ellipta 8, 13, 23 Camrese 8 Cinqair 13, 18 Basaglar 8 Brevicon 23 Camrese Lo 8 Cinryze 13, 18 Bavencio 19 Breztri Aerosphere 8 Capecitabine 19 Cipro XR 24 Belbuca 8, 13 Brilinta 23 Caphosol 23 Cisplatin 18 Beleodaq 18 Brisdelle 8, 23 Capital and Codeine 13 Citalopram 8 Belsomra 8, 23 Bromsite 23 Caplyta 23 Cladribine 18 Benicar 23 Brovana 8, 23 Capsfenac 23 Clenpiq 24 Benicar HCT 23 Brukinsa 8 Capxib 16, 23 Cleocin T 24 Benlysta Autoinject/syringe 19 Brylhali 23 Carac 23 Clever Choice Diabetic Benzaclin 23 Budeprion SR 8 Testing Supplies 24 Carbaglu 19 Benzaclin Kit 23 Budeprion XL 8 Climara 8 Carboplatin 18 Benzhydrocodone/APAP 13 Budesonide 8 Climara Pro 8 Cardene 23 Benzhydrocodone/Acetamin­ Budesonide/Formoterol 8, 13 Clindacin PAC 24 ophen 23 Cardizem CD 23

32 Medication Resource List Index

Clindagel 24 Crysvita 18 Dermacin Cinolone-1 CPI 24 Diclopr Combo Pack 24 Clindamycin 1% foam 8 Cutaquig 19 Dermacin Silazone Diclotral 24 Clindamycin 1% gel 8 Cuvitru 18 Pharmapak 24 Diclotrex 24 Clindamycin 1% lotion 8 Cuvposa 19 Dermacinrx Clorhexacin 24 Diclovix 24 Clindamycin 1% solution 8 Cyclobenzaprine 7.5mg 24 Dermacinrx Empricaine 24 Diclovix M 24 Clindamycin 2% vaginal 8 Cyclophosphamide 18, 19 Dermacinrx PHN 24 Diclozor 24 Clindcin ETZ Kit 24 Cymbalta 8, 24 Dermacinrx Prizopak 24 Differin 24 Clobex 24 Cyramza 18 Dermacinrx Silapak 24 Dificid 13, 24 Clodan Kit 24 Cystadrops 21 Dermacinrx Surgical Diflorasone cream 8 Pharmpak 24 Clomid 21 Cystagon 19 Diflucan 8 Dermacinrx Therazole Pak 24 Clomiphene 21 Cystaran 21 Dihydroergotamine 8 Dermacinrx ZRM 24 Clonidine patch 8 Cytarabine 18 Dilaudid 13, 24 Dermasorb-AF 24 Co-gesic 13 Cytogam 18 Dimentho 24 Dermasorb-HC 24 Cocet/Plus 13 Dimethyl Fumarate 20 Dermasorb-TA 24 Colazal 24 D Diovan 24 Dermasorb-XM 24 Colchicine Capsules 24 D-Care 100X 24 Diovan HCT 24 Dermawerx SDS 24 Colcrys 24 DDAVP 18, 20, 24 Dipentum 24 Dermawerx Surgical Plus Colyte 24 DM 2 Kit 8 Pack 24 Diskets 13 Combigan 24 DM2 kit 24 Dermazone 24 Dithol Combo Pack 24 Combivent 8 DMT Suik 24 Dermazyl 24 Ditropan XL 16, 24 Combivent Respimat 8 Dacarbazine 18 Dermotic 24 Divigel 24 Cometriq 20 Dactinomycin 18 Desferal 19 Docefrez 18 Concerta 8 Daklinza 8, 13, 20, 24 Desferoxamine 19 Docetaxel 18 Conjupri 8, 24 Dalfampridine 8, 13, 20 Desmopressin Acetate 18 Dojolvi 20 Consensi 24 Daliresp 24 Desowen Kit 24 Dolophine 13 Contempla XR ODT 24 Dapsone 7.5% 24 Desoxyn 13 Dolotranz 24 Contour Diabetic Testing Daraprim 20 Desvenlafaxine ER 8, 24 Doptelet 8, 20 Supplies 24 Daunorubicin HCL 18 Detrol 16, 24 Doramorph 13 Contrave 13 Daurismo 8, 20 Detrol LA 16, 24 Doryx DR 80mg 24 Contrave ER 8 Daxbia 24 Dexedrine 13, 24 Dotti 8 Conzip 24 Daypro 24 Dexilant 8, 13 Doubledex 24 Cool Diabetic Testing Daysee 8 Dovonex 8 Supplies 24 Dexilant (Kapidex) 24 Daytrana 24 Doxazosin 8 Copaxone 8, 18, 24 Dexmethylphenidate ER 8 Deferasirox 20 Doxepin cream 8 Copegus 19 Dexmethylphenidate XR 8 Delestrogen 19 Doxepin tablets 8 Copiktra 20 Dexrazoxane 18 Deluo 24 Doxil 18 Copkitra 13 Dextroamphetamine/ Delzicol 24 Amphetamine ER 8 Doxorubicin HCL 18 Coreg 24 Delzicol XR 24 Dextroamphetamines 13 Doxycycline DR 200mg 24 Coreg CR 24 Demerol 13 Diabetic Testing Strips (all) 8 Doxycycline DR 80mg 24 Corlanor 24 Depakote 24 Diacomit 20 Doxycycline Hyclate 50mg Cosentyx 8, 13, 18, 24 Depakote ER 24 Diclo Gel 24 tablets 24 Cosmegen 18 Depakote Sprinkle 24 Diclo-Xrylix Sheet Kit 24 Drizalma Sprinkle 8, 24 Cosopt PF 24 Depo-Estradiol 19 Diclofenac 3% gel 8 Duac 24 Cotellic 13, 19 Depo-Sub Q Provera 104 24 Diclofenac Epolamine 24 Duac CS 24 Cotempla XR ODT 8 Depocyt 18 Diclofenac Submicronized 24 Duaklir Pressair 8, 24 Cozaar 24 Derma-Smoothe/FS Body Diclofenac solution 8 Duavee 24 Crestor 8, 24 Oil 24 Diclofono 24 Duetact 16 Crinone 21 Derma-Smoothe/FS Scalp Diclopak 24 Duexis 24 Oil 24 Cromolyn ophthalmic 8 Dulera 8, 13

33 Medication Resource List Index

Duloxetine DR 8 Emverm 9 Evekeo 13, 25 Fiasp 9, 25 Duobrii 24 Enablex 16, 24 Evencare Diabetic Tetsing Fibricor 25 Duopa 20 Enbrel 9, 13, 18 Supplies 25 Fifty50 Diabetic Testing Dupixent 13, 18 Endometrin 21 Evenity 9, 13, 18 Supplies 25 Duragesic 8, 13, 24 Enoxaparin 9 Everolimus 20 Finacea Plus 25 Durezol 24 Enspryng 18 Evoclin 25 Fintepla 18 Durlaza 24 Enteral formula 13 Evomela 19 Fiorinal 25 Durolane 13, 24 Entresto 16, 24 Evrysdi 20 Fiorinal /Codeine #3 25 Duzallo 24 Entyvio 13, 18, 24 Evzio 9 Firazyr 13, 18 Dvorah 13 Epaned 24 Exactech Diabetic Testing Firdapse 13, 20 Supplies 25 Dyloject 24 Epclusa 9, 13, 20 Firmagon 18 Exalgo 9, 13, 25 Dysport 13, 18 Epi-Pen Auto-Injector 9 Flagyl 25 Exforge 25 Epiceram 24 Flagyl ER 25 Exforge HCT 25 E Epiduo 24 Flagyl I.V. 25 Exjade 20 EC-Naprosyn 24 Epiduo Forte 24 Flagyl I.V. RTU Vialflex 25 Exondys 19 EQ Diabetic Testing Epinephrine Autoinject Flarex 25 Supplies 24 (Amneal Authorized Product Exondys 51 13 Flebogamma 18 EZ Use joint Tunnel-Trigger 25 For Adrenaclick) 24 Extavia 9, 18, 25 Flector 25 Easy Step Diabetic Testing Epinephrine Professional EMS Extina 25 Flexipak 25 Supplies 24 kit 9 Ezallor Sprinkle 9, 25 Flolipid 25 Easy Talk Diabetic Testing Epinephrine Professional kit 9 Ezetimibe 9 Flovent Diskus 9 Supplies 24 Epinephrine Snap-V 24 Ezetimibe/Simvastatin 9 Flovent HFA 9 Easy Touch Diabetic Testing Epinephrine injection 9 Supplies 24 Floxuridine 18 Epirubicin 18 F Easy Trak Diabetic Testing Fluconazole 9 Episil 24 FML Forte 25 Supplies 24 Fludara 18 Episnap Convenience Kit 24 FML Liquifilm 25 Easymax Diabetic Testing Fludarabine phosphate 18 Supplies 24 Epogen 9, 13, 18, 24 FML S.O.P. 25 Fluopar 25 Econasil 24 Equetro 24 Fabior 25 Fluoroplex 25 Edarbi 24 Erivedge 20 Factive 25 Fluorouracil 18 Edarbyclor 24 Erleada 20 Factor VIII, VIIIa, IX, XIII 13 Fluovix 25 Edluar 9, 24 Erlotinib 13, 20 Famciclovir 9 Fluovix Plus 25 Effexor 24 Ertaczo 24 Fanapt 25 Fluoxetine 9 Effexor XR 9, 24 Esbriet 20 Farxiga 9, 16 Fluoxetine DR 9 Egrifta 13, 18 Escitalopram 9 Farydak 9, 13, 20 Fluoxetine Tablets 25 Elestrin 24 Esomep-EZS 9, 13 Fasenra 9, 13, 18 Fluticasone/Salmeterol 9, 13 Eletone 24 Esomeprazole 9, 13 Faslodex 18 Fluvastatin 9 Eletriptan 9, 16 Esomeprazole Strontium 9, 13 Fayosim 9 Fluvastatin XR 9 Elidel 13 Esomeprazole Stronum 25 Fazaclo 25 Fluvoxamine 9 Eligard 18 Esomeprazole-EZS Kit 25 Femring 25 Fluvoxamine CR 9 Ellence 18 Estrace 25 Fenofibrate 150mg 25 Focalin 25 Ellzia 24 Estradiol patch 9 Fenofibrate 50mg 25 Focalin XR 9, 25 Embeda 9, 13, 24 Estrogel 9, 25 Fenoglide 25 Follistim 25 Embrace Diabetic Testing Eszopiclone 9 Fensolvi 19 Supplies 24 Follistim AQ 21 Ethyol 18 Fentanyl Citrate 9, 13, 25 Emend 9 Fondaparinux 9 Etopophos 18 Fentanyl oral/mucosal 9, 13 Emflaza 20 Fora Diabetic Testing Etoposide 18, 20 Fentanyl patch 9, 13 Supplies 25 Emgality 9, 13 Eucrisa 25 Fentora 9, 13, 25 Forfivo XL 9, 25 Empliciti 18 Euflexxa 13, 25 Fetzima 9, 25 Fortamet 16, 25 Empraciane II 24 Evamist 9, 25 Fexmid 25 Fortaz 19 Emsam 24

34 Medication Resource List Index

Forteo 9, 13, 18 Gimoti 25 Humana True Metrix Diabetic Imitrex Vial 25 Fortesta 16, 25 Givlaari 13, 18 Testing Supplies 25 Impavido 9 Fosamax 9, 16, 25 Glatiramer 9, 18 Humatrope 13, 18 Imvexxy 25 Fosamax Plus D 9, 16 Glatopa 9, 18 Humira 9, 13, 18 Inavix 25 Fragmin 9, 25 Gleevec 20, 25 Humulin 9 Inbrija 16, 20 Freestyle Diabetic Testing Gloperba 25 HyQvia 18 Increlex 13, 18 Supplies 25 Glucocard Diabetic Testing Hyalgan 13, 25 Incruse Ellipta 9, 13 Frova 9, 16, 25 Supplies 25 Hycamtin 18, 20 Inderal LA 25 Frovatriptan 9, 16 Glucometer Diabetic Testing Hycet 13 Inderal XL 25 Supplies 25 Fulphila 9, 18 Hydrocodone ER 13 Indomethacin 20Mg (Branded Fulvestrant 18 Glucophage 16, 25 Hydrocodone ER (persion Product) 25 Fusilev 18 Glucophage XR 16, 25 Pharmaceuticals) 25 Indomethacin 20mg 9 Fusilev I.V. 25 Glucose testing strips (all) 9 Hydrocortisone-Lidocaine 25 Infergen 9 Fuzeon 18 Glumetza 16, 25 Hydrogesic 13 Inflamma-K 25 Glyxambi 9, 16 Hydromorphone ER 9, 13 Inflatherm 25 G Gmate Diabetic Testing Hydroxyprogesterone 13, 18 Inflectra 13, 18 Supplies 25 Gabacaine 25 Hylaguard 25 Infumorph 13 Gnp Diabetic Testing Hylatopic 25 Gabapal 25 Supplies 25 Ingrezza 20 Hylatopic Plus 25 Galafold 13, 20 Gocovri ER 20, 25 Inlyta 20 Hylatopic Plus-Aurstat 25 GamaSTAN 18 Golytely 25 Innopran XL 25 Hymovis 13, 25 Gamifant 13, 19 Gonal F Rff Redi-Ject 21 Inqovi 20 Hysingla ER 9, 13, 25 Gammagard 18 Gonal F/Gonal F RFF 21 Inrebic 20 Hyzaar 25 Gammagard Liquid 18 Granisetron 9 Inribec 13 Gammaked 18 Granix 9, 18 I Insulin Aspart 25 Gammaplex 18 Grastek 9, 13 Insulin Lispro 25 IV Immunoglobulin 13 Gamunex 18 Insulin Lispro Jr. 25 Ibandronate 9 Ganirelix 21, 25 H Insulin Lispro Mix 75-25 25 Gatifloxacin 9 Ibandronate HPR 25 injection/syringe 13, 18 Insulins (all) 9 Gattex 18 HPR Plus 25 Ibrance 9, 13, 20 Insulins Lispro 9 Gavreto 9, 20 HPR Plus Hydrogel 25 Ibudone 13 Interferons (alpha, gamma) 13 Gazyva 18 Haegarda 13, 18 Icatibant 18 Intermezzo 9, 25 Ge 100 Diabetic Testing Halobetasol Foam 25 Intron A 18 Supplies 25 Iclusig 20 Harmony Diabetic Testing Introvale 9 Gel-One 13, 25 Idamycin PFS 18 Supplies 25 Intuniv 25 Gelclair 25 Idarubicin 18 Harvoni 9, 13, 20 Invega 25 Gelnique 16, 25 Idhifa 13, 20 Healthpro Diabetic Testing Inveltys 25 Gelsyn-3 13, 25 Supplies 25 Ifex 18 Invokamet 9, 16, 25 Gelx 25 Helidac Therapy Pak 25 Ifosfamide 18 Invokamet XR 9, 16, 25 Gemcitabine 18 Hemady 25 Ifosfamide/Mesna 18 Invokana 9, 16, 25 Gemzar 18 Herceptin 18 Iglucose Diabetic Testing Supplies 25 Ipratropium NS 9 Genotropin 13, 18, 25 Herceptin Hylecta 18 Ilaris 13, 18 Irenka DR 9, 25 Genstrip Diabetic Testing Herzuma 18 Ilevro 25 Iressa 13, 20 Supplies 25 Hetlioz 9, 13, 20 Ilumya 9, 13, 18 Irinotecan 18 Genvisc 13 Hizentra 18 Imatinib 20 Istalol 25 Geodon 25 Horizant 25 Imbruvica 20 Istodax 18 Gialax 25 Humalog 9 Imfinzi 18 Isturisa 13, 20 Giazo 25 Humalog Jr. 9 Imitrex 9, 16 Itraconazole 9 Gilenya 20 Human Chorionic Gilotrif 13, 20 Gonadotropin (HCG) 21 Imitrex Kit Refill 25 Imitrex Pen Injector 25

35 Medication Resource List Index

Kisqali Femara 13, 20 Levonorgestrel/Ethinyl Lotemax 26 J Kitabis PAK 20 Estradiol 9 Lotemax SM 26 Jadenu 20 Kitabis Pak 25 Levonorgestrel/Ethinyl Lotensin 26 Estradiol/Ethinyl Estradiol 9 Jakafi 20 Klonopin 25 Lotensin HCT 26 Lexapro 9, 26 Jalyn 16 Kombiglyze XR 16 Lotrel 26 Lexette 26 Janumet 16 Korlym 21 Lotronex 9 Lexixryl 26 Janumet XR 16 Koselugo 21 Loutrex 26 Liberty Diabetic Testing Januvia 16 Krintafel 9, 25 Supplies 26 Lovastatin 9 Jardiance 9, 16 Kuvan 20 Libtayo 19 Lovaza (Omacor) 26 Jentadueto 16, 25 Kynamro 13, 18 Licart 26 Lovenox 9, 26 Jentadueto XR 16, 25 Kynmobi 9 Lido-Prilo Caine Pack 26 Lucemyra 9 Jolessa 9 Lidocaine Patch 9 Luliconazole 26 Jornay PM 9, 25 L Lidociane 5% cream 9 Lumigan 16 Jublia 25 LMR Plus Kit 26 Lidocidex I 26 Lumoxiti 18 Juxtapid 13, 20 Lamictal 25 Lidoderm 9, 26 Lunesta 9, 26 Jynarque 9, 21 Lamictal ODT 25 Lidomark 26 Lupaneta Pack 18 Lamictal XR 25 K Lidopac 26 Lupron Depot 18, 21 Lamisil 9, 25 Lidopril 26 Lupron Depot-Ped 18, 21 KRO premium Diabetic Lamisil Granules 25 Luveris 21 supplies 25 Lidotin 26 Lancet Diabetic Testing Lidotrans 5 Pak 26 Luzu 26 Kadian 9, 13, 25 Supplies 25 Lidotrex 26 Lynparza 13 Kalbitor 13, 18 Lansoprazole 9 Lidovix 26 Lyrica 13 Kalydeco 9, 13, 20 Lansoprazole ODT 9 Lidoxib 16, 26 Lyrica CR 9, 13 Kanjinti 18 Lansoprazole/Amoxicillin/Cla­ Lyrica Cr 26 Kanuma 13, 19 rithromycin 9 Linzess 9 Lysteda 9, 26 Kapvay 25 Lantus 9 Lipitor 9, 26 Lyumjev 9, 26 Kaspargo Sprinkle 25 Lartruvo 18 Lipodox 18 Katerzia 25 Latuda 25 Lipodox-50 18 M Kazano 16, 25 Lazanda 9, 13, 26 Lipofen 26 MS Contin 9, 14 Kenalog 18 Ledipasvir/Sofosbuvir 9, 20, 26 Lipritin 26 Mac Patch 26 Kenalog aerosol 9 Ledipasvir/sofosbuvir 13 Lipritin II 26 Magnacet 13 Keppra 25 Leflunomide 9 Liprozonepak 26 Makena 13, 18, 21 Keppra XR 25 Lemtrada 13, 18, 26 Liquadd 13 Margesic-H 13 Keralyt Scalp 6% Kit 25 Lenvima 13, 20 Livalo 9, 26 Marqibo 18 Kerydin 9, 25 Lescol 9, 26 Livixil Pak 26 Marvona Suik 26 Kesimpta 18 Lescol XL 9, 26 Livostin 26 Mas Care-Pak 26 Ketoconazole 2% 9 Letairis 20 LoSeasonique 9 Mavenclad 20 Ketoprofen 25mg 25 Leucovorin Calcium 18 Lobrena 20 Mavyret 9, 13, 20, 26 Ketorolac Nasal Spray Leukine 18 Lodine 26 Maxalt 9, 16, 26 (Branded Product) 25 Leuprolide 21 Lodine XL 26 Maxalt-MLT 9, 16 Ketorolac ophthalmic 9 Leuprolide Acetate 18 Lokelma 26 Maxalt-Mlt 26 Keveyis 9, 21 Leva Set 26 Lonhala Magnair 9, 26 Maxaquin 26 Kevzara 9, 13, 18 Levalbuterol HFA 9, 26 Lonsurf 20 Maxidex 26 Keytruda 18 Levaquin 26 Lopressor 26 Maxidone 13 Khapzory 19 Levemir 9, 26 Loprox Kit 26 Maxipime 26 Khedezla 9, 25 Levicyn Antipruritic SG 26 Lorbrena 13 Mayzent 20 Kineret 13, 19 Levitra 26 Lorcet 13 Mb Hydrogel 26 Kiristalose 25 Levoleucovorin 18 Lorzone 26 Kisqali 13, 20 Loseasonique 26 Medolor Kit 26 Medroloan II Suik 26

36 Medication Resource List Index

Medroloan Suik 26 Mobic 9, 26 Neocera Advanced 26 Nucynta 26 Megace ES 26 Modafinil 13 Neosalus 26 Nucynta ER 10, 14, 26 Mekinist 13, 20 Moderiba 20 Neosalus CP 26 Nudermrxpack 26 Mektovi 13 Monodox 26 Nerlynx 20 Nudiclo Solupak 26 Meloxicam 9 Monovisc 13, 26 Nesina 16, 26 Nudiclo Tabpak 26 Menopur 21 Morgidox Kit 26 Neuac Kit 26 Nulytely 26 Menostar 9, 26 Morphabond ER 9, 13, 26 Neulasta 9, 14, 18 Nuplazid 10, 20 Mentho-Caine Kit 26 Morphine Sulfate CR 13 Neulasta Onpro 19 Nurtec 16 Meperitab 13 Morphine Sulfate ER 9, 14 Neumaxin 26 Nusurgepak Surgical Prep 26 Mepsevii 18 Motegrity 26 Neupogen 9, 14, 18, 26 Nutraseb 26 Mesalamine DR 26 Movantik 9 Neupro 26 Nutria Rx 26 Mesna 18 Moviprep 26 Neurcaine 26 Nutritional Supplements 14 Mesnex 18, 20 Moxatag 26 Neurontin 26 Nutropin 14 Metformin ER (Fortamet Moxeza 9, 26 Nevanac 26 Nutropin AQ Nuspin 18 Authroized product) 26 Moxifloxacin 9 Nexavar 20 NuvaRing 26 Metformin ER (Glumetza Mozobil 18 Nexiclon XR 26 Nuvakaan 26 Authroized product) 26 Mugard 21 Nexium 10, 14, 26 Nuvakaan II 26 Metformin ER (generic for Fortamet) 16 Mulpleta 9, 20, 26 Nexletol 10 Nuvessa 26 Metformin Film Coated ER Mupirocin 9 Nexlitol 14 Nuvigil 14, 26 (generic for Glumetza) 16 Mupirocin cream 16 Nexlizet 10, 14 Methadone 13 Mustargen 18 Ninlaro 20 O Methadose 13 Myalept 14 Nipent 18 Ocaliva 10, 20 Methamphetamine 13 Mycapssa DR 20 Niravam 26 Ocrevus 19 Methotrexate 18 Mydayis 9, 26 Nitro-Dur 26 Octagam 19 Methylphenidate CD 9 Mylotarg 18 Nityr 21 Octreotide injection 19 Methylphenidate ER 9 Myobloc 14, 18 Nivestym 10, 16, 18 Ocudox Kit 26 Methylphenidate LA 9 Myrbetriq 16 Nocdurna 10, 26 Odomzo 10, 20 Micardis 26 Noctiva 26 Ofev 20 Micardis HCT 26 N Nopioid-TC 26 Ogivri 19 Microdot Diabetic Testing Nabi-HB 19 Norco 14 Olanzepine-Fluoxetine 10 Supplies 26 Nalfon 26 Norditropin 14, 18, 26 Olopatadine Nasal 10 Microvix LP 26 Nalocet 14 Norditropin Flexpro 18 Olumiant 10, 14, 20 Miglustat 20 Naloxone 9 Norditropin Nordiflex 18 Olux 26 Migranal 9 Namzaric 26 Northera 20, 26 Olysio 10, 14, 20, 26 Migranow 26 Naprelan 26 Norvasc 10, 26 OmePPI 10, 14 Migranow Kit 9 Naprelan CR Dose Card 26 Nourianz 16 Omeprazole 10 Minastrin Fe 26 Naprosyn 26 Nova Max Diabetic Testing Omeprazole-Sod. Minivelle 9 Naproxen DR 26 Supplies 26 Bicarbonate 10, 14 Minocin 26 Naproxen/Esomeprazole 26 Novacort 26 Omnitrope 14, 19, 26 Minocin Combo Pack 26 Naptara 18 Novarel 21 Omontys 10 Minocycline ER (Branded Naratriptan 9 Novolin 10, 26 Oncaspar 19 product) 26 Narcan 9 Novolog 10, 26 Ondansetron 10 Minolira ER 26 Nascobal 26 Noxipak 26 Ondansetron ODT 10 Mirapex 26 Natazia 26 Nplate 18 Onexton 26 Mirapex ER 26 Natesto Nasal 16, 26 Nubeqa 20 Onglyza 16 Mirtazapine 9 Natrecor 14 Nucala 14, 18 Onivyde 19 Mirtazapine Rapid Dissolve 9 Navelbine 18 Nucaraclinpak 26 Onmel 10, 26 Mitomycin 18 NebuPent 9 Nucararxpak 26 Onpattro 14, 19 Mitoxantrone 18 Neo-Synalar Kit 26 Nucort 26 Onsolis 10, 14, 26

37 Medication Resource List Index

Ontruzant 19 PCE 27 Pioglitazone- Privigen 19 Onureg 20 PCE Dispertab 27 Glimepiride 10, 16 Prizotral 27 Onzetra Xsail 10, 16, 26 PEG-Intron 10 Pioglitazone-Metformin 10, 16 Prizotral II 27 Opana 26 PR-Cream 27 Piqray 14, 20 Pro-Voice Diabetic Testing Opana ER 10, 14, 26 Paclitaxel 19 Plaquenil 27 Supplies 27 Opdivo 14, 19 Paingo KFT 27 Plegridy 10, 19 ProAir HFA 10 Opsumit 20 Palforzia 20 Plenvu 27 ProAir Respiclick 10 Optium Diabetic Testing Palynziq 19 Plixda 27 Proair Digihaler 27 Supplies 26 Pamelor 27 Pod-Care 100C 27 Procentra 14, 27 Oracea 26 Pamidronate 19 Pod-Care 100CG 27 Procort 27 Oralair 10, 14 Pamidronate disodium 19 Pod-Care 100K 27 Procrit 10, 14, 19, 27 Oramorph SR 10, 14, 26 Pancreaze 27 Pod-Care 100KG 27 Procysbi 20 Orapred ODT 26 Panixine 27 Polygesic 14 Prodigy Diabetic Testing Supplies 27 Oravig 26 Panlor SS 14 Pomalyst 20 Prolate 14 Orencia 10, 14, 19, 26 Panretin 21 Portrazza 19 Prolensa 27 Orenitram 20 Pantoprazole 10 Poteligeo 19 Proleukin 14, 19 Orfadin 21 Panzyga 19 Pradaxa 27 Prolia 14, 19 Oriahnn 26 Paroxetine 10 Praluent 10, 14 Promacta 20 Orilissa 26 Paroxetine CR 10 Pram-HCA 27 Promiseb 27 Orkambi 10, 14, 20 Patanase 10, 27 Pramosone E 27 Proscar 16 Orthovisc 14, 26 Paxil 10, 27 Prandin 16 Protonix 10, 14, 27 Oseni 16, 26 Paxil CR 10, 27 Pravachol 10, 27 Protopic 14 Osmolex ER 27 Pedizol 27 Pravastatin 10 Proventil HFA 10, 27 Osmoprep 27 Peg-Intron 19 Precision Diabetic Testing Supplies 27 Proventil Inhaler 27 Osphena 27 Pegasys 10, 19 Pred Mild 27 Provigil 14, 27 Otezla 10, 14, 20 Pegasys Proclick 19 Prefest 27 Prozac 10, 27 Otezla Starter Pack 21 Pemazyre 14, 21 Pregablin 14 Prozac Weekly 10, 27 Otrexup 19, 27 Penetrex 27 Pregnyl 21, 27 Prozopak II 27 Ovidrel 21 Penlac 10, 27 Premium Diabetic Testing Prudoxin 10 Oxaliplatin 19 Pennsaid 10, 27 Supplies 27 Pulmicort Flexhaler 10 Oxaydo 27 Pentican 27 Prepopik 27 Pulmicort Respules 10 Oxbryta 10, 14, 20 Pepcid 27 Presera 27 Pulmozyme 20 Oxecta 14 Percocet 14, 27 Prestalia 27 Pylera 27 Oxervate 14, 21 Percodan 14 Prestige Diabetic Testing Pyrimethamine 20 Oxiconazole Nitrate 10 Perforomist 10 Supplies 27 Oxistat 10 Pergonal 27 PrevPac 10 Q OxyContin 10 Prevacid 10, 14, 27 Perseris 27 QVAR 10 Oxycodone ER 10, 14 Prevpac 27 Pertzye 27 Qbrelis 27 Oxycontin 14 Prikaan 27 Pexeva 10, 27 Qbrexxa 10 Oxymorphone ER 10, 14 Prilo Patch Kit 27 Pharmacist Choice Diabetic Qbrexza 27 Oxytrol 16, 27 Testing Supplies 27 Prilolid 27 Qinlock 10, 21 Ozempic 10, 16, 27 Photofrin 19 Prilosec 10, 14, 27 Qmiiz ODT 10, 27 Physicians EX USE B12 Kit 27 Prilovix 27 Qtern 10, 16, 27 P Physicians USE EZ M-Pred Prilovixil 27 Kit 27 Qualaquin 10 P-Care 27 Primlev 14 Picato 27 Quartette 10, 27 P-Care K 27 Prinivil 27 Pimecrolimus 14 Quasense 10 P-Care M 27 Pristiq 10, 27 Pioglitazone 10, 16 Quillichew 10 P-Care MG 27 Pristiq ER 10 P-Care X 27 Quillichew ER 27

38 Medication Resource List Index

Quillivant XR 27 Requip XL 27 Rydapt 14, 20 Sildenafil Quinine Sulfate 10 Rescula 16, 27 Rytary ER 27 antihypertensive 19, 20 Quinixil 27 Respiratory SyncytialVirus Rythmol 27 Silenor 10, 27 Quinja 27 IG/Synagis 14 Ryvent 27 Siliq 10, 14, 19, 27 Quinosone Combo Pack 27 Restasis 10, 14 Silvrstat 27 Qutenza 10, 21 Restoril 27 S Simbrinza 27 Retacrit 10, 14, 19 Sabril 20 Simponi 10, 14, 19 R Retevmo 14, 20 Saizen 14, 19, 27 Simponi Aria 14, 19 Rabeprazole 10 Retin-A Cream 27 SaizenPrep 14, 19 Simvastatin 10 Radiaplex Rx 27 Retin-A Micro 27 Salicylic Acid 6% Kit 27 Simvastatin Suspension Revatio 14, 19, 20, 27 (Flolipid Authorized Radicava 19 Salicylic Acid/Ceramide Kit 27 Product) 27 Revcovi 19 Radigel 27 Salkera 27 Sinemet 25/100 27 Revlimid 20 Ragwitek 10, 14 Salvax Duo 27 Singulair 27 Rexulti 10, 27 Ramelteon 10 Salvax Duo Plus 27 Sitavig 28 Reyvow 10 Rapaflo 27 Samsca 20 Sklice 28 Rhopressa 10, 27 Rasuvo Auto-Injector 27 SanadermRx Skin Repair 27 Skyrizi 10, 14, 19 Ribasphere 20 Ravicti 20 Sancuso 10, 27 Smart Sense Diabetic Testing Raxar 27 Ribasphere Ribapak 20 Sandimmune 19 Supplies 28 Rayaldee 27 Ribatab 20 Sandostatin 19 SmartRx Gaba-V 28 Rayos 27 Ribavirin 20 Sandostatin-LAR 19 SmartRx Gabakit 28 Readysharp Rilutek 20 Saphris 27 Sodium Hyaluronate 28 Betamethasone 27 Riluzole 20 Sapropterin 20 Sodium Hyaluronate 1% Readysharp Bupivicaine 27 Rimso-50 19 Sarafem 10, 27 Syringe 14 Readysharp Rinvoq ER 10, 14, 20 Savaysa 27 Sof-Tact Diabetic Testing Dexamethasone 27 Supplies 28 Riomet 16 Savella 27 Readysharp Ketorolac 27 Sofosbuvir/Velpatasvir Riomet ER 16 Saxenda 10, 14 Readysharp Lidocaine 27 10, 14, 20, 28 Risedronate 10 Scalacort 27 Readysharp Solaice 28 Methylprednisolone 27 Risperdal M-Tab 27 Seasonique 10, 27 Solaravix 28 Readysharp Triamcinolone 27 Ritalin 27 Sebuderm 27 Solaraze 28 Rebetol 20 Ritalin LA 10, 27 Secuado 10, 27 Soliqua 10, 16, 28 Rebif 10, 19 Ritalin SR 27 Seebri Neohaler 10, 27 Solodyn 28 Reblozyl 14 Rituxan 14, 19 Segluromet 10, 16, 27 Solosec 10, 28 Recothrom 27 Rivelsa 10 Semglee 10 Soltamox 28 Regenecare 27 Rizatriptan 10 Serevent Diskus 10 Solupak 28 Regranex 14 Rizatriptan ODT 10 Sernivo 27 Solus Diabetic Testing Relador Pak 27 Rocephin 19 Serophene 21 Supplies 28 Relador Pak Plus 27 Rocklatan 10, 16, 27 Seroquel 27 Soma 28 Relafen DS 27 Roferon-A 19 Seroquel XR 27 Somatuline 19 Relexxii ER 10, 27 Romidepsin 19 Serostim 14, 19 Somavert 19 Relion Diabetic Testing Rosadan 27 Sertraline 10 Sonata 10, 28 Supplies 27 Rosuvastatin 10 Setlakin 10 Soolantra 28 Relpax 10, 27 Roxybond 14, 27 Seysara 27 Sovaldi 10, 14, 20, 28 Remeron 10, 27 Rozerem 10 Signafor 19 Spectracef 28 Remeron Soltab 10, 27 Rozlytrek 14, 20 Signafor LAR 19 Spinraza 14, 19 Remicade 14, 19 Rubraca 20 Sila III 27 Spiriva 10 Renflexis 14, 19 Ruconest 14, 19 Silalite Pak 27 Sporanox 10, 28 Repatha 10, 14, 27 Ruxience 19 Silazone-II 27 Spritam 28 Replax 16 Ruzurgi 21 Sildenafil (antihypertensive) 14 Sprix 28 Requip 27 Rybelsus 10, 16 Sprycel 20

39 Medication Resource List Index

Stagesic 14 Synribo 19 Tersi 28 Tovet Kit 28 Stalevo 28 Synvexia TC 28 Test N'Go Diabetic Testing Toviaz 16, 28 Staxyn 28 Synvisc 14, 28 Supplies 28 Tracleer 20 Steglatro 10, 16, 28 Synvisc One 14 Testim 16, 28 Tradjenta 16, 28 Steglujan 10, 16, 28 Synvisc-One 28 Testone CIK 28 Tramadol 100Mg Tablets Stelara 10, 14, 19 Testone CIK Kit 16 (Branded Product) 28 Stendra 28 T Testosterone (Testim Tramadol ER Capsules 28 Authorized Product) 28 Stiolto Respimat 10 TOBI ampules 20 Tranexamic Acid 10 Testosterone (Vogelxo Tranxene -T 28 Stivarga 20 TOBI-Podhaler 20 Authorized Product) 28 Travatan 16 Strattera 10 TPN 14 Testosterone CIK Kit 16, 28 Travatan Z 16 Strensiq 19 Tabrecta 14, 20 Testosterone Enanthate 19 Trazimera 19 Striant 28 Tacrolimus (topical) 14 Testosterone Gel (Fortesta Striverdi Respimat 10 Tadalafil (antihypertensive) 14 Authorized Product) 28 Trelegy Ellipta 10, 28 Sublocade 19 Tadalafil antihypertensive 20 Testosterone gel (Fortesta Trelstar 19 Authorized product) 16 Suboxone 10, 28 Tafinlar 14, 20 Trelstar Depot 19 Tagrisso 14, 20 Testosterone gel (Testim Trelstar LA 19 Subsys 10, 14, 28 Authorized product) 16 Takhzyro 14, 19 Tremfya 10, 14, 19 Suclear 28 Testosterone gel (Vogelxo Sucraid 20 Talcia DR 28 Authorized product) 16 Tresiba 10, 28 Sular 28 Talicia DR 10 Tetrabenazine 20 Tretin-X 28 Sumadan 28 Taltz 10, 14, 19 Tev-Tropin 14, 19, 28 Treximet 10, 16, 28 Sumatriptan 10 Talzenna 14, 20 Thalomid 20 Trezix 14, 28 Sumatriptan/Naproxen 16 Tanzeum 10, 16, 28 TheraCys 19 Tri-Norinyl 28 Sumavel Dosepro 10, 28 Tarceva 14, 20 Thiola 21 Tri-Sila Topical 28 Sumaxin 28 Targadox 28 Thiotepa 19 Triamcinolone spray 10 Sumaxin CP 28 Tarka 28 Thyrogen 19 Tribenzor 28 Sumaxin TS 28 Tasigna 20 Tiazac 28 Tricor 28 Sunosi 14 Tasoprol 28 Tibsovo 14 Triglide 28 Supartz 14, 28 Tavalisse 21 Tiglutik 21 Trijardy XR 10, 16, 28 Suprep 28 Taxotere 19 Timoptic 28 Trikafta 10, 14, 20 Sure Result Tac Pak 28 Taytulla 28 Tindamax 28 Trileptal 28 Sustol 28 Tazicef 19 Tirosint 28 Trilipix 28 Sutent 20 Tazorac 28 Tivorbex 10, 28 Trilipx DR 28 Suvicort 28 Tecentriq 19 Tobradex 28 Triloan II Suik 28 Sylatron 19 Tecfidera 20 Tobradex ST 28 Triloan Suik 28 Sylvant 19 Technivie 10, 14, 20, 28 Tobramycin ampules 20 Triluron 14, 28 Symbicort 10, 14 Teczem 28 Tofranil 28 Trinaz 28 Symbyax 10 Tegsedi 10, 14, 19 Tolak 28 Trintellix 10 Symdeko 10, 14, 20 Tekturna 28 Tolsura 10, 28 Trintellix (Formerly Brintellix) 28 Symjepi 10 Tekturna HCT 28 Tolvaptan 20 Triptodur 10, 19 Sympazan 28 Temodar 19, 20 Topamax 28 Trivisc 14, 28 Symproic 10, 28 Temozoloamide 20 Topical Retinoic Acid Trivix 28 Synagis 19 Teniposide 19 Derivatives 14 Trixylitral 28 Synalar Combo-Pack 28 Tenormin 28 Toposar 19 Toronova II Suik 28 True Metrix Diabetic Testing Synalar TS 28 Tepadina 19 Supplies 28 Toronova Suik 28 Synalgos-DC 14 Tepezza 14, 19 Truetest Diabetic Testing Synarel 21 Tequin 28 Tosymra 10, 16 Supplies 28 Synjardy 10, 16 Terazosin 10 Totect 19 Truetrack Diabetic Testing Supplies 28 Synjardy XR 10, 16 Terbinafine 10 Toujeo Max Solostar 10 Teriparatide 10, 14, 19, 28 Toujeo Solostar 10 Trulance 10, 28

40 Medication Resource List Index

Trulicity 10, 16 Veltassa 20, 28 Vosevi 11, 14, 20 Xerese 29 Truxima 19 Veltin 28 Votrient 20 Xermelo 11, 21 Tudorza 11 Venclexta 21 Vraylar 28 Xgeva 14, 19 Tukysa 11, 21 Venlafaxine ER Tablets 28 Vumerity DR 11, 20, 29 Xiaflex 14, 19 Turalio 21 Venlafaxine ER capsule 11 Vusion 29 Xifaxan 11, 29 Twynsta 28 Venlafaxine ER tablet 11 Vyepti 14, 19 Xigduo 11, 16 Tykerb 20 Ventolin 28 Vyleesi 11, 14, 19 Xigduo XR 11, 16 Tylenol with Codeine 14 Ventolin HFA 11, 28 Vyndamax 11, 14, 20 Xiidra 11, 14 Tylox 14 Verasens Diabetic Testing Vyndaqel 11, 14, 20 Xilapak 29 Tymlos 11, 14, 19 Supplies 28 Vyondis 53 14 Ximino ER 29 Tyvaso 20 Verdrocet 14 Vyondys-53 19 Xodol 14 Veregen 28 Vytorin 11, 29 Xolair 14, 19 U Verzenio 14, 20 Vyvanse 11, 29 Xolegel 29 Ubrelvy 11, 16 Vesicare 16, 28 Vyxeos 19 Xopenex HFA 11, 29 Udenyca 19 Vexa 28 Vyzulta 16, 29 Xopenex Nebules 29 Ultracet 28 Vexasyn Wound Gel 28 Xospata 11, 14, 21 Ultram 28 Viagra 28 W Xpovio 21 Ultram ER 28 Viberzi 11, 28 WPR Plus 29 Xryliderm 29 Ultrasal ER 28 Vicodin 14 Wakix 11, 14, 20 Xrylix 29 Ultravate PAC 28 Vicoprofen 14 Wavesense Diabetic Testing Xtampza ER 11, 14, 29 Supplies 29 Ultravate X 28 Victoza 11, 16, 28 Xtandi 20 Welchol 29 Undenyca 11 Viekira 28 Xultophy 11, 16, 29 Wellbutrin 29 Unistrip Diabetic Testing Viekira PAK 11, 14, 20, 28 Xuriden 11, 21 Supplies 28 Wellbutrin SR 11, 29 Viekira XR 11, 14, 20 Xyosted 29 Unituxin 19 Wellbutrin XL 11, 29 Vigabatrin 20 Xyrem 20 Up & Up Diabetic Testing Vigadrone 21 Whytederm Surgipak 29 Supplies 28 Vigamox 11, 28 Whytederm Trilasil Pak 29 Y Uptravi 20 Viibryd 11, 28 Wixela Inhub 11, 14 Yondelis 19 Uramaxin 28 Viltepso 19 Wound Debride 4% Yonsa 21 Urea Kit 28 Lidocaine 29 Vimizim 19 Yosprala 11, 14 Utibron Neohaler 11, 28 Vimovo 28 X Yosprala DR 29 Vinblastine 19 V X-Clair 29 Yupelri 11, 29 Vincristine 19 Vacustim Silver Kit 28 Xadago 29 Vinorelbine 19 Z Valacylovir 11 Xalatan 16 Virasal 28 Zagam 29 Valchlor 21 Xalix 29 Visco-3 14, 28 Zaleplon 11 Valium 28 Xalkori 14, 20 Vistogard 21 Zaltrap 19 Valrubicin 19 Xanax 29 Vitrakvi 11, 14, 20 Zamicet 14 Valstar 19 Xanax XR 29 Vivaguard Ino Diabetic Testing Zanaflex 29 Valtrex 11 Xartemis XR 11, 14, 29 Supplies 28 Zanosar 19 Vanos 28 Xeljanz 11, 14, 20 Vivelle 11 Zantac 29 Varophen Kit 28 Xeljanz XR 11, 14, 20 Vivelle-Dot 11 Zarxio 11, 19 Varubi 11 Xeloda 20 Vivitrol 11, 19 Zavesca 20 Vascepa 28 Xelpros 16, 29 Vivlodex 11, 28 Zecuity 21 Vaseretic 28 Xembify 19 Vizimpro 14, 20 Zegerid 11, 14, 29 Vasotec 28 Xenazine 20 Vogelxo 16, 28 Zejula 21 Vectical 28 Xenleta 11 Voltaren 28 Zelapar 29 Velcade 19 Xeomin 14, 19 Voltaren-XR 28 Zelboraf 14, 20 Velphoro 28 Xepi 29 Vopac MDS 28 Zelnorm 29

41 Medication Resource List Index

Zembrace Zuplenz 11, 29 Symtouch 11, 16, 29 Zurampic 29 Zenzedi 14 Zyban 29 Zepatier 11, 14, 20, 29 Zyclara 29 Zeposia 11, 20 Zydelig 11, 14, 21 Zerlor 14 Zydone 14 Zestril 29 Zyflo 29 Zetia 11, 29 Zyflo CR 29 Zeyocaine 29 Zykadia 14, 20 Ziana 29 Zylet 29 Ziextenzo 11, 16, 19 Zymaxid 11, 29 Zilacaine 29 Zypitamag 11, 29 Zilretta 19 Zypram 29 Zilxi 29 Zyprexa 29 Zinbryta 11, 29 Zyprexa Intramuscular 29 Zinecard 19 Zyprexa Relprevv 29 Zioptan 16, 29 Zyprexa Zydis 29 Zipsor 29 Zytiga 20 Zithromax 29 Zmax 29 Zocor 11, 29 Zofran 11, 29 Zofran ODT 11, 29 Zohydro ER 11, 14, 29 Zoladex 11, 19 Zolinza 20 Zolmitriptan 11 Zolmitriptan ODT 11 Zoloft 11, 29 Zolpak 29 Zolpidem 11 Zolpidem CR 11 Zolpidem SL 11 Zolpimist 11, 29 Zolvit 14 Zomactin 14 Zomacton 19, 29 Zomig 11, 16, 29 Zomig Nasal 16 Zomig ZMT 11, 29 Zonalon 11 Zonegran 29 Zontivity 29 Zorbtive 14, 19 Zorvolex 29 Zovirax 29 Zovirax cream 11 Ztlido 29 Zubsolv 11, 29

42 New Medication Approval Process

Our Pharmacy and Therapeutics Committee (the Committee), which is made up of pharmacists and doctors of various specialties, reviews the effectiveness and overall value of new medications approved by the FDA on an ongoing basis. The Committee provides expertise and advice to help us give our members prescription drug options that meet their medical needs and achieve desired treatment goals. Approved medications are added to our list as they’re approved by the Committee throughout the year.

While under review, new medications won’t be covered by your plan. As with other medications that aren’t covered, your doctor may request coverage when medically necessary. If a non-covered drug is approved, it will be covered at the highest tier.

43 ® Registered Marks of the Blue Cross and Blue Shield Association. ®´, TM, Registered Marks and Trademarks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000560726 55-0071 (10/20) Back to Start Plan Options Wellness Resources

Left Blank Intentionally THE CARE YOU NEED. WHENEVER AND WHEREVER.

Because guidance and advice should happen round the clock. Learn more about your medical care options to save you time and money at bluecrossma.org.

You have more ways than ever to get expert medical opinions and advice. Right when you need them.

   

24/7 NURSE VIDEO DOCTOR DOCTOR’S URGENT LINE VISIT OFFICE CARE

Learn More

Visit bluecrossma.org to review your medical care options.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. When you’re uncertain if your symptoms are serious or if an injury needs immediate care, get a nurse’s advice 24/7, even Cost: on holidays. And get answers at no additional cost to you.  Speak to a registered nurse. Call 1-888-247-BLUE (2583). Time: 24/7 NURSE LINE Best for: advice on when to seek care or questions about Severity: your symptoms, or whether they might be serious.

See a licensed doctor online in real time, without leaving home. Doctors on call on your device visit Cost:  wellconnection.com. Time: VIDEO DOCTOR Best for: colds, minor cuts, cough, wheezing, sore throat, VISIT headache or migraine, mild allergies, fever, skin rash, Severity: anxiety, depression.

Go to your doctor’s office for scheduled checkups and for urgent health concerns that occur during office hours. Use Cost:  Find a Doctor at bluecrossma.org. Time: DOCTOR’S Best for: asthma, minor burns, nausea, urination problems, back OFFICE pain, minor injuries, suspected flu, sinus infection, Severity: behavioral health, conjunctivitis or other eye irritation.

Go to a nearby urgent care center when you need immediate, in-person help for a non-life-threatening Cost:  problem and you can’t see your doctor. Time: URGENT Best for: joint/muscle pain or injuries, nausea or diarrhea, CARE respiratory issues, bites, cuts, concussion screening, stitches, Severity: asthma attack, X-rays, and suspected strep throat or bronchitis.

Go to the nearest emergency room when you’re facing a life-threatening situation or think you could put your health in danger by delaying care.

The information in this document doesn’t replace the advice of a health care provider. You should speak to your provider about any specific health concerns.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY:711 ). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM Trademarks are the property of their respective owners. 000350150 55-0432 (5/20) © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Back to Start Plan Options Wellness Resources

Left Blank Intentionally DOCTORS ON CALL. ON YOUR DEVICE.

Get convenient access to telehealth care by using the Well Connection platform.

REAL DOCTORS. REAL EXPERIENCE. REALLY FAST.

CLOCK comments AWARD

GET CONFIDENTIAL CARE, THERAPY THAT HIGHLY EXPERIENCED, REMOTELY COMES TO YOU HIGHLY RATED

Speak face to face with Talk to a licensed therapist – on Qualified practitioners. a doctor, in the privacy your terms. It’s convenient and Rated 4.8/5 stars and averaging of your home.1 completely confidential. 15 years of experience.2

Sign In

Download the Well Connection App from the App Store®´ or Google PlayTM, or go to wellconnection.com.

1. Medical services are available 24/7. Behavioral health visits must be made by appointment. If your local doctor in the Blue Cross Blue Shield of Massachusetts network offers covered services using live video visits through a service other than Well Connection, you’re still covered. This service is only available in the United States. 2. Source: American Well. AmWell TeleHealth Report, February 2018. Patient Satisfaction Survey Data compiled December 2017-February 2018. Data, compiled December 2017-February 2018.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. IS A VIDEO DOCTOR VISIT RIGHT FOR ME?

Our doctors can do a lot over your tablet, laptop, or smartphone. Here’s how members are using this service.

“I’m not feeling well.”  Get care for: • Cold and flu symptoms • Sore throat • Fever • Headaches and migraines • Runny nose, sinus pain • Diarrhea • Cough, wheezing • Skin rash

“I need emotional support.”  Talk to a therapist about: • Depression and anxiety • Couples therapy • Substance use disorder • Emotional trauma • Loss of a loved one • Stress

“My loved one is under the weather.”  If they’re on your plan: • Set up an appointment • Save time in your busy • Get quick, expert family care family schedule

AWARD Well Connection is highly rated: 4.8 out of 5 Doctor and Provider rating from our members3

Licensed doctors and providers in the Well Connection network have an average of 15 years of experience. They can look up your medical history, diagnose and treat your symptoms, and prescribe medication,4 if necessary.

3. Source: American Well. AmWell TeleHealth Report, February 2018. Patient Satisfaction Survey Data, compiled December 2017-February 2018. 4. Prescription availability is defined by physician judgment.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM Trademarks are the property of their respective owners. 000351590 55-1287 (5/20) © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Back to Start Plan Options Wellness Resources

Left Blank Intentionally NURSES RIGHT NOW. NO IFS, ANDS, OR BUTS.

Call our 24/7 Nurse Line 1-888-247-BLUE (2583).

Speak to a registered nurse, when you need to, day or night. Because guidance and advice should happen round the clock.

YES, YOUR PLAN COVERS IT!

Nurses are ready around the clock to answer your questions. Call our Nurse Line 24/7 to determine if you need immediate care. comments calendar-alt HAND-HOLDING-USD ENVELOPE

GET CONNECTED DIRECTLY 365 DAYS A YEAR THERE’S NO EMAIL* A NURSE TO A NURSE ADDITIONAL COST 24/7, TOO Immediate advice, no waiting Including holidays. Because your health Create an account to email a for a callback. For access that’s ready comes first. nurse for general questions when you are. or advice, day or night.

*We partner with Carenet Health®´, an independent health care engagement company, to administer this service. You’ll need to create a Carenet Health account or sign in to their secure website. When creating your account, you’ll need to enter your nine-digit Blue Cross member ID number. Please don't include the letter prefix. Questions? Visit myblue.bluecrossma.com and select Find a Doctor & Estimate Costs to find a provider near you. Download the MyBlue App from the App Store®´ or Google PlayTM.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks, SM Service Marks, and TM Trademarks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000351214 32-6765 (5/20) Back to Start Plan Options Wellness Resources

Left Blank Intentionally The every day challenge.

Introducing

The wellness program that rewards you for making smart, healthy choices, every day.

When you sign up, you’ll receive: FREE! • A free Max Buzz™ health tracker • Up to $400 annually in rewards • Personalized guidance on how and up to to set and meet your health goals • Motivation through team and individual challenges $400

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID Card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ahealthymerewards.com ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. ®’ Registered Marks and ™ Trademarks are the property of their respective owners © 2017 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 101 Huntington Avenue, Suite 1300, Boston, MA 02199-7611 | 1-800-262-BLUE (2583) 176315 (10/17) *Program is available to Blue Cross subscribers only. Back to Start Plan Options Wellness Resources

Left Blank Intentionally Fitness Reimbursement

Your reward for healthy behavior: Save up to $150 annually for participating in a qualified fitness program.1

 Qualified for Fitness Reimbursement:  Not Qualified for Fitness Reimbursement: Membership or fitness class fees at: • One-time initiation or termination fees • A full service health club with cardiovascular and • Fees paid for gymnastics, tennis, pool-only facilities, strength-training equipment like treadmills, bikes, weight martial arts schools, instructional dance studios, country machines, and free weights clubs or social clubs, sports teams or leagues • A fitness studio with instructor-led group classes • Personal trainer sessions ®´ such as yoga, Pilates, Zumba , kickboxing, indoor • Fitness equipment or clothing cycling/spinning, and other exercise programs

Get Reimbursed in Three Easy Steps 1 2 3 Choose Complete Mail Start by picking a qualified Once you pay for the program, Send the completed form fitness program. fill out the attached form. to the address listed.

Be sure to check with your doctor before starting any exercise program.

1. To verify this reimbursement is offered for your plan, or for more information, sign in to MyBlue at bluecrossma.com/myblue or call the Member Service number on your ID card. Most plans offer the reimbursement shown, but refer to your plan information for specific details.

Questions? Call Member Service at 1-855-279-4176, Monday, Tuesday, Wednesday, and Friday from 8:00 a.m. to 8:00 p.m. ET, and Thursday from 9:00 a.m. to 5:00 p.m. ET.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Fitness Reimbursement Request

Please Print All Information Clearly: To verify this reimbursement is offered within your plan, or for more information, please sign in to MyBlue at bluecrossma.com/myblue or call the Member Service number on your ID card. All fitness reimbursement requests must be submitted by March 31 of the following year.

Complete this form and mail it to: Blue Cross Blue Shield of Massachusetts, Local Claims Department, PO Box 986030, Boston, MA 02298

Subscriber Information (Policyholder)

Identification Number on Subscriber ID Card Subscriber's Last Name First Name Middle Initial (including first 3 characters)

Address - Number and Street City State Zip Code

Employer’s Name

Claim Information

Member Last Name First Name Middle Initial Gender Date of Birth (color in the entire box) ___ /___ /____ q Male q Female

Claim is for (choose one and Name, Address, and Phone Number of Qualified Fitness Program color in the entire box): q Subscriber (policyholder) q Spouse (of policyholder) Total dollars requested: $ ______for (choose one and color in the entire box): q Ex-Spouse q Membership fees. Monthly membership fee: $ ______q Dependent (up to age 26) q Fitness class fees. Fee per class: $ ______q Other (specify): Year Fees Paid: ______

Blue Cross Blue Shield of Massachusetts will make a reimbursement decision within 30 calendar days of receiving a completed request form. Reimbursement is sent to the member's address on file with Blue Cross. Reimbursement may be considered taxable income, so consult your tax advisor.

Certification and Authorization (This form must be signed and dated below.) I certify that the information provided in support of this submission is complete and correct and that I have not previously submitted for these services. I enrolled in the qualified program with the full intention of using such program. I understand that Blue Cross Blue Shield of Massachusetts may require proof of payment for a reimbursement decision. I authorize the release of any information about my qualified fitness program to Blue Cross Blue Shield of Massachusetts.

Subscriber’s or Member’s Signature: Date: ___ /___ /____

Important Information: • Fitness reimbursement can be granted for any single member or combination of members enrolled under the same Blue Cross health plan. Blue Cross will make a reimbursement decision within 30 days of receiving a complete request. • Reimbursement requests must be submitted by March 31 of the following year. • Keep copies of proof of payment in case we request it from you. Proof of payment includes: • Receipts (cash/check/credit/electronic) for membership or class fees clearly documenting your name, the fitness program name, and individual amounts charged with date paid. • Your fitness program membership or participation agreement clearly documenting your name and date signed. • Reimbursement may be considered taxable income, so consult a tax advisor.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY:711 ). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM Trademarks are the property of their respective owners. 000427503 55-0773 (5/20) © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Back to Start Plan Options Wellness Resources

Left Blank Intentionally Weight-Loss Reimbursement

Your reward for healthy behavior: Receive up to $150 annually when you participate in a qualified weight-loss program.1

 Qualified for Weight-Loss Reimbursement  Not Qualified for Weight-Loss Reimbursement Participation fees for: • One-time initiation or termination fees • Hospital-based programs and Weight Watchers®´ • Food, supplements, books, scales, or exercise in-person equipment • Weight Watchers online and other non-hospital • Individual nutrition counseling sessions, doctor/nurse programs (in-person or online) that combine healthy visits, lab tests, or other services that are covered eating, exercise, and coaching sessions with certified benefits under your medical plan health professionals such as nutritionists, registered dietitians, or exercise physiologists.

Get Reimbursed in Three Easy Steps 1 2 3 Choose Complete Mail Start by picking a qualified Once you pay for the program, fill out the Send the completed form weight-loss program. attached form, or sign in to MyBlue to submit to the address listed. online at member.bluecrossma.com/login.

Be sure to check with your doctor before starting any weight-loss program.

1. To verify this reimbursement is offered for your plan, or for more information, sign in to MyBlue at bluecrossma.com/myblue or call the Member Service number on your ID card. Most plans offer the reimbursement shown, but refer to your plan information for specific details.

Questions?

Contact Member Service by calling the phone number on your member ID card.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Weight-Loss Reimbursement Request

Please Print All Information Clearly: To verify this reimbursement is offered within your plan, or for more information, please sign in to MyBlue at bluecrossma.com/myblue or call the Member Service number on your ID card. All weight-loss reimbursement requests must be submitted by March 31 of the following year.

Complete this form and mail it to: Blue Cross Blue Shield of Massachusetts, Local Claims Department , PO Box 986030, Boston, MA 02298

Subscriber Information (Policyholder)

Identification Number on Subscriber ID Card Subscriber’s Last Name First Name Middle Initial (including first 3 characters)

Address - Number and Street City State Zip Code

Employer’s Name

Claim Information

Member Last Name First Name Middle Initial Gender Date of Birth (color in the entire box) ___ /___ /____ q Male q Female

Claim is for (choose one and Name, Address, and Phone Number of Qualified Weight-Loss Program color in the entire box): q Subscriber (policyholder) q Spouse (of policyholder) Total dollars requested: $ ______q Ex-Spouse Monthly program participation fee: $ ______q Dependent (up to age 26) Calendar Year: ___ /___ /____ q Other (specify):

Blue Cross Blue Shield of Massachusetts will make a reimbursement decision within 30 calendar days of receiving a completed request form. Reimbursement is sent to the member’s address on file with Blue Cross. Reimbursement may be considered taxable income, so consult your tax advisor.

Certification and Authorization (This form must be signed and dated below.) I certify that the information provided in support of this submission is complete and correct and that I have not previously submitted for these services. I understand that Blue Cross Blue Shield of Massachusetts may require proof of payment for a reimbursement decision. I authorize the release of any information about my qualified weight-loss program to Blue Cross Blue Shield of Massachusetts.

Subscriber’s or Member’s Signature: Date: ___ /___ /____

Important Information: • Weight-loss reimbursement can be granted for any single member or combination of members enrolled under the same Blue Cross Blue Shield of Massachusetts health plan. Blue Cross will make a reimbursement decision within 30 days of receiving a completed request. • Reimbursement requests must be submitted by March 31 of the following year. • Keep copies of proof of payment in case we request it from you. Proof of payment includes: • Receipts (cash/check/credit/electronic) for participation fees clearly documenting your name, the weight-loss program name, and individual amounts charged with date paid. • Your weight-loss program membership or participation agreement clearly documenting your name and date of enrollment/participation. • Your reimbursement may be considered taxable income, so consult a tax advisor.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY:711 ). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM Trademarks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of 000414912 55-0774 (5/20) Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Back to Start Plan Options Wellness Resources

Left Blank Intentionally THIS YEAR’S FLU SHOT IS CRUCIAL COVID-19 means getting your flu shot is more important this year than ever.

It will help keep you, your family, and community from getting sick. And it could keep you all out of the doctor’s office at a time when so many others may need critical care. Plus, getting your shot is no cost* and safe.1

LET’S DO THIS! HERE’S WHERE AND HOW TO GET YOUR SHOT  

WHERE TO GET YOUR FLU SHOT HOW TO FIND A VACCINE PROVIDER • Your In-network Primary Care Provider • To find a provider, visit vaccinefinder.org • Limited Service Clinics (such as a MinuteClinic®´ at CVS) • Verify that the provider is part of our network by signing • Urgent Care Centers in to MyBlue at bluecrossma.org, and using the • Community Health Centers Find a Doctor tool • Public Access Clinics (available in some cities and •  To see if a pharmacy is in our network, sign in to your towns and may be available at no charge) MyBlue account and click Express Scripts®´ under My Pharmacy on the MyBlue home page • Hospital Outpatient Departments • If you need additional help, call Team Blue at • Skilled Nursing Facilities, for members in outpatient care, 1-800-262-2583 like physical or occupational therapy • Home Health Care Providers (in your home, or at a flu clinic hosted by a home health care provider) • Certified Nurse/Midwife’s Office • Physician Assistant’s Office or Specialist Physician’s Office

*CDC-recommended flu vaccines are covered in full when administered by an in-network provider. • Nurse Practitioner’s Office Exceptions may apply. Check your plan materials for details. • Pharmacies 1. cdc.gov/flu/prevent/vaccinesafety.htm.

Myth: “The Flu Shot Will Make Me Sick”

Learn fact from fiction atbluecrossma.org/flu .

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. YOUR BEST SHOT AT AVOIDING THE FLU

To prevent getting sick, make the following steps part of your routine. SYRINGE PEOPLE-ARROWS HANDS-WASH  

GET YOUR AVOID CLOSE WASH YOUR HANDS AVOID TOUCHING GET PLENTY OF FLU SHOT CONTACT IN PUBLIC FREQUENTLY YOUR EYES, NOSE, REST, EXERCISE, AND WITH PEOPLE AND MOUTH FLUIDS, AND GOOD WHO ARE SICK NUTRITION

How do I stay safe when I go for my shot?

Here are some tips when heading out:

• Make an appointment ahead of time, if possible, • Wear a mask and maintain your social distancing to avoid a wait practices throughout your visit • If the location doesn’t take appointments, call • Pharmacies inside big box retail chains and grocery and ask when slower times of day/week are—try stores, or local independent pharmacies, may be to go then less busy than standalone pharmacies for flu shots

 Learn More

Just about everyone 6 months and older should get the flu shot. Talk to your doctor to see if it’s right for you, especially if you’re 65 or older, or have a chronic health condition. Learn more about the flu and the flu shot at bluecrossma.org/flu.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000626727 55-000626727 (11/20) Back to Start Plan Options Wellness Resources

Left Blank Intentionally Worldwide Coverage For Foreign and Domestic Travelers

Get quality health care no matter Take this reference card with you where you are in the world. when you travel. When you need care, you’ll be prepared. Whether you’re traveling within the United States or abroad, BlueCard®’ and Blue Cross Blue Shield Global® Core make sure you have access TEAR HERE to top doctors and hospitals and Urgent Care concierge-level service. 1. Call 1-800-810-BLUE (2583), or visit bcbs.com to find nearby doctors and hospitals anywhere in the world that participate in the Blue Cross Blue Shield network. 2. Show your member ID card when you get care. 3. If you’re admitted, or if you have questions about your coverage, call Member Service at the number on the front of your ID card. Your Passport to Good Health Always carry your Blue Cross Blue Shield of Massachusetts ID card.

FOLD HERE Call 1-800-810-BLUE (2583) for a list of participating doctors and hospitals, or to obtain an international Emergency Care For emergency services, call the local emergency number claim form. or go to the nearest hospital immediately.

An Association of Independent Blue Cross and Blue Shield Plans Getting Care in the United States For Inpatient Services: More than 85 percent of all doctors and hospitals in the United • Call the Service Center at 1-800-810-BLUE (2583), or States participate in the BlueCard program. If you need care outside Member Service at the number on your ID card, for your plan’s service area, call 1-800-810-BLUE (2583), or visit precertification or preauthorization to find a doctor near you. Be sure to show your ID card bcbs.com • In most cases, all you pay is the copayment, co-insurance, before you receive service. or deductible

When you get service: • The hospital should submit the claim on your behalf • There’s no paperwork For Outpatient Services: • Participating doctors and hospitals submit claims for you • Show your ID card

• All you pay is the copayment, co-insurance, or deductible • Pay the doctor or hospital

• If you receive care from a non-participating doctor or hospital, • Fill out a Blue Cross Blue Shield Global® Core International Claim you may need to pay for the services up front and submit a claim form for reimbursement (Call 1-800-810-BLUE (2583) or visit for reimbursement bcbsglobalcore.com for the form)

BlueCard PPO Members Only: If you see this symbol, , • You’re only responsible for copayments, co-insurance, or on your ID card, you’re a BlueCard PPO member. To save the deductible when seeing in-network doctors and hospitals most money when getting service, use a participating BlueCard • You’ll pay more when seeing out-of-network doctors and hospitals PPO doctor or hospital. Doctors and Hospitals In Case of Emergency In most cases, participating doctors and hospitals will file the claim For emergency services, call the local emergency number for you. If they need information about eligibility or your coverage, or go to the nearest hospital immediately. have them call 1-800-676-BLUE (2583).

Getting Care Outside the United States Your Member Responsibilities ® The Blue Cross Blue Shield Global Core network gives you access As a Blue Cross Blue Shield of Massachusetts member, you’re to doctors and hospitals around the world. If you need care, call the still responsible for any copayments, co-insurance, deductible, Service Center at 1-800-810-BLUE (2583), or call collect at or non-covered services. For out-of-country services, Blue Cross 1-804-673-1177, 24 hours a day, 7 days a week. An assistance Blue Shield of Massachusetts payments will be based on the coordinator, along with a medical professional, will arrange a provider’s charge. doctor’s appointment or hospitalization if necessary. You can also visit bcbsglobalcore.com.

TEAR HERE

An Association of Independent Blue Cross and Blue Shield Plans

FOLD HERE

Primary Care Provider’s Name: Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Doctor’s Phone: ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID Card (TTY: 711). Doctor’s Hospital Affiliation: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY:711 ). Your Blue Cross Blue Shield Member ID: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711). Member Service Phone Number (from your ID card):

® Registered Marks of Blue Cross and Blue Shield Association. ®´ Registered Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 182617M 32-5585 (02/18) Back to Start Plan Options Wellness Resources

Left Blank Intentionally Important Notices

OUR COMMITMENT TO CONFIDENTIALITY (NOTICE OF PRIVACY PRACTICES) AND WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA) NOTICE THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Commitment your information. We may use and disclose information about you without your written We respect your right to privacy. We will not authorization for the following purposes, to the disclose personally identifiable information extent otherwise permitted or required by law: about you without your permission, unless the disclosure is necessary to provide our services to you or is otherwise in accordance • You or Your Representatives—to you with the law. or your “personal representative” upon request or to help you (or your personal representative) understand treatment Collection of Information options, benefits, or the rights available to We collect only the information about you you. Your “personal representative” is a that we need to operate our business. We person who has legal authority to make collect information from other parties, such health-related decisions on your behalf, as your health care providers and employers. such as a person with a health-care power Examples of the information we collect are (i) of attorney. Your request must be in writing. medical and dental information from providers Please complete the Documentation of when they submit claims for services and (ii) Legal Representative Status for Members personal information such as name, address, form available on our website. You also and date of birth, which is most often may designate a family member or friend supplied by you or your employer when you to receive information and interact with us enroll in a plan. on your behalf. Your designation and any subsequent revocation must be in writing. Use and Disclosure of Information Please complete the Member’s Designation We are required by law to protect the of an Authorized Representative form on confidentiality of information about you and our website. You may also call Member to notify you in case of a breach affecting Service for a copy of these forms.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. • Treatment —to help health care providers • Research—for health-related research manage or coordinate your health care studies that meet legal standards for and related services. For example, we may protection of the individuals involved in use and disclose information about you to the studies and their personal information. inform providers of medications you take We may also create a database of our or to remind you of appointments. members’ information that does not • Payment—to obtain payment for your include individual identifiers and use the coverage, pay claims for your health database for research or other purposes, benefits, or help another health plan provided that the information cannot be or health care provider in its payment traced back to specific members. activities. For example, we may use or • To Your Employer (or other plan sponsor), disclose information about you to make if applicable, for administration of its coverage determinations, administer health plan. This applies only if you receive claims, or coordinate benefits with other coverage through an employer-sponsored coverage you may have. plan (or plan sponsored by your union or • Health Care Operations—to perform other other entity). For example, we may disclose activities necessary for the operation of information about you to your employer (or our business, including customer service, other plan sponsor) to confirm enrollment disease management, and determining how in the plan or (if the employer or other to improve the quality of care. For example, plan sponsor is self-insured) for claim we may use or disclose information about review and audits. We will disclose your you to respond to your call to customer information only to designated individuals. service, arrange for medical review of your That, along with legal prohibitions on claims, or conduct quality assessment and use of your personal information for improvement activities. discriminatory purposes, helps protect your information from unauthorized use. • Legal Compliance—to comply with applicable law. For example, we may be To carry out these purposes, we share required to use or disclose information information with entities that perform functions about you to respond to regulatory for us subject to contracts that limit use and authorities responsible for oversight of disclosure for intended purposes. We use government benefit programs or our physical, electronic, and procedural safeguards business operations; to parties or courts to protect your privacy. Even when allowed, we in the course of judicial or administrative limit uses and disclosures of your information to proceedings; or pursuant to workers’ the minimum amount reasonably necessary for compensation laws. the intended task. • Government Agencies—under limited circumstances established by law, to The Health Insurance Portability and public health authorities, coroners or Accountability Act (HIPAA) generally does medical examiners, law enforcement, not override other laws that give people or other government officials greater privacy protections. As a result, we

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. must comply with any state or federal privacy • You have the right to receive information laws that require us to provide you with more about privacy protections. Your member- privacy protections. For example, federal law education materials include a notice of provides special protections for substance use your rights, and you may request a paper disorder information; Massachusetts state law copy of this notice at any time. restricts the disclosure of HIV and AIDS related • You have the right to inspect and get copies information. In addition, we will not use (and are of information that we use to make decisions prohibited from using) your genetic information about you. This is your designated record for underwriting purposes. set. Your request must be in writing. We may charge a reasonable fee for copying and Other Disclosures Require Your mailing you this information. Please complete Written Authorization the Request for Access to Copies of Protected Health Information in Designated Record Set Except as provided in this notice, we will not form to request copies of your information. use or disclose information about you without your written authorization. For example, we • You have the right to receive an accounting must have your written authorization to use of certain disclosures that we make of or disclose your information for marketing information about you. Your request must purposes or (in most cases) to use or disclose be in writing. Please complete the Members psychotherapy notes. Although we would need Request for an Accounting of Disclosures written authorization to sell information about form. Our response will exclude any you, we do not sell members’ information. disclosures made in support of treatment, payment, and health care operations or that You may revoke your authorization at any you authorized (among others). An example time. Your authorization must be in writing. of a disclosure that would be reported to Your revocation will not affect any action that you is our disclosure of your information in we have already taken in reliance on your response to a court order. authorization. If you would like us to disclose information about you to a third party, please • You have the right to ask us to correct complete the Permission for One-Time or amend information you believe to be Disclosure of Information form available on incorrect. Your request to correct or amend our website or call Member Service for a copy information must be in writing. Please of the form. complete the Members Request to Amend Protected Health Information form. If we Your Privacy Rights deny your request, you may ask us to make your request part of your records. You have the following rights with respect to information about you. You may exercise any • You have the right to ask that we restrict or of these rights by calling the Member Service refuse the disclosure of information about number listed on your member ID card or you and that we direct communications to contacting us at the address listed at the end you by alternative means or to alternative While we may not always be able to of this notice. The forms listed below are also locations. agree to your request, we will make reasonable available on our website.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. efforts to accommodate requests. Unless to obtain the revised notice in our next regular you’ve notified us to request a different mailing mailing to you. If you have any questions, please address, Summary of Health Plan Payments call the Member Service number listed on your statements for the subscriber, and all members member ID card, or write us at: listed on the subscriber’s plan, are generally Blue Cross Blue Shield of Massachusetts delivered to the subscriber’s address. Under certain circumstances, you can request to not Privacy Officer receive statements for a particular service, 101 Huntington Ave. or to have statements delivered through an Suite 1300 alternate method or to an alternate address, when required by state law. If you have Boston, MA 02199-7611 concerns about protecting the privacy of your medical information in your statements, WHCRA NOTICE you can have these statements delivered to Did you know that your medical plan provides an address other than the plan subscriber’s benefits for many mastectomy-related services? address, or have them delivered only via This is the case even if you were not covered electronic means. For help understanding your by Blue Cross Blue Shield of Massachusetts delivery options, please call Member Service at the time of the mastectomy. It’s required by at the number listed on your member ID card. the Women’s Health and Cancer Rights Act of Your request and any subsequent revocation 1998. If you are covered for a mastectomy and must be in writing. elect breast reconstruction in connection with a If you believe your privacy rights have been mastectomy, then benefits are also provided for: violated, you have the right to complain to • All stages of reconstruction of the breast us using the grievance process outlined in on which the mastectomy has been your benefit materials, or to the Secretary of performed; the U.S. Department of Health and Human Services, without fear of retaliation. • Surgery and reconstruction of the other breast to produce a symmetrical About This Notice appearance; and The original effective date of this notice was April 14, 2003. The effective date of the most recent • Prostheses and treatment of physical revision is indicated in the footer of this notice. complications at all stages of the We are required by law to provide you with this mastectomy, including lymphedemas. notice of our legal duties and privacy practices and to abide by the notice for as long as it is in Coverage will be provided as determined in effect. We reserve the right to change this notice. consultation with you and your attending doctor. Any changes will apply to all information that we The costs that you pay for these services are maintain, regardless of when it was created or the same as those you pay for other services received. If we make a material change to this in the same category. To learn more, please notice, we will post the revised notice on our call the Member Service number on your website and notify you of the change and how member ID card.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY:711 ). Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO, Inc. © 2017 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 175470M 32-7900 (10/17) Back to Start Plan Options Wellness Resources

Left Blank Intentionally Getting more. Now there’s a plan. Your plan has more benefits than you probably realize. Tap into all of them, all in one place. MyBlue is your key to more features and savings. Plus, up-to-date status for claims, your deductible, account balances, and more. It’s like a free upgrade for the plan you already have.

UNLOCK THE POWER OF YOUR PLAN MyBlue gives you an instant snapshot of your plan, including:

COVERAGE CLAIMS AND FITNESS AND WEIGHT-LOSS MEDICATION AND BENEFITS BALANCES REIMBURSEMENT LOOKUP

Sign In

Download the app, or create an account at bluecrossma.com.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. STAY ON TOP OF YOUR COVERAGE It’s never been easier, faster, or more convenient. YOUR PLAN IN YOUR HAND

Track claims Fitness and Your medications and benefits weight-loss at a glance Keep up to date on reimbursement Their names, costs, benefits and coverage. The online forms are and prescriptions at here, along with other your fingertips. savings and offers.

Once you sign in or create a MyBlue App account, Check deductible Find a Doctor Need your cards you can see all of your benefits, all in one place. balances Or a specialist, Access your ID cards Track your claims, medications, account balances, End the guesswork dentist, or facility. On without opening your and more from your device. And, you can easily and know for sure your phone and on wallet. keep track of reimbursements and savings. every time. the fly.

 Get the myblue app You can download the MyBlue App from the App Store®´ or Google PlayTM.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM Trademarks are the property 000308005 55-1353 (5/20) of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Back to Start Plan Options Wellness Resources

Left Blank Intentionally Getting more. Now there’s a plan. Your plan has more benefits than you probably realize. Tap into all of them, all in one place. MyBlue is your key to more features and savings. Plus, up-to-date status for claims, your deductible, account balances, and more. It’s like a free upgrade for the plan you already have.

UNLOCK THE POWER OF YOUR PLAN MyBlue gives you an instant snapshot of your plan, including:

COVERAGE CLAIMS AND FITNESS AND WEIGHT-LOSS MEDICATION AND BENEFITS BALANCES REIMBURSEMENT LOOKUP

Sign In

Download the app, or create an account at bluecrossma.com.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. STAY ON TOP OF YOUR COVERAGE It’s never been easier, faster, or more convenient. YOUR PLAN IN YOUR HAND

Track claims Fitness and Your medications and benefits weight-loss at a glance Keep up to date on reimbursement Their names, costs, benefits and coverage. The online forms are and prescriptions at here, along with other your fingertips. savings and offers.

Once you sign in or create a MyBlue App account, Check deductible Find a Doctor Need your cards you can see all of your benefits, all in one place. balances Or a specialist, Access your ID cards Track your claims, medications, account balances, End the guesswork dentist, or facility. On without opening your and more from your device. And, you can easily and know for sure your phone and on wallet. keep track of reimbursements and savings. every time. the fly.

 Get the myblue app You can download the MyBlue App from the App Store®´ or Google PlayTM.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM Trademarks are the property 000308005 55-1353 (5/20) of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Back to Start Plan Options Wellness Resources

Left Blank Intentionally Nondiscrimination Notice

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call Member Service at the number on your ID card. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email at [email protected].

If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, online atocrportal.hhs.gov ; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at hhs.gov.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 164264M 55-1487 (8/16) Back to Start Plan Options Wellness Resources

Left Blank Intentionally Translation Resources Proficiency of Language Assistance Services

Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY:711 ). Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711). Chinese/简体中文: 注意：如果您讲中文，我们可向您免费提供语言协助服务。请拨打您 ID 卡上的 号码联系会员服务部（TTY 号码：711）。 Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan TTY: 711). Vietnamese/Tiếng Việt: LƯU Ý: Nếu quý vị nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711). Russian/Русский: ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте (телетайп: 711). :ةيرب/Arabic انتباه: إذا كنت تتحدث اللغة العربية، فتتوفر خدمات املساعدة اللغوية ا مجانًبالنسبة لك. اتصل بخدمات األعضاء عىل الرقم املوجود عىل بطاقة ُهويتك )جهاز الهاتف النيص للصم والبكم “TTY”: 711(. Mon-Khmer, Cambodian/ : ខ្揂រ ζរជូនដំណឹង៖ ប䮚សិនប�ើអ䮓កនិ架យ徶羶 ខ្揂រ សេ玶ជំនួយ徶羶ឥតគិតថ្濃 គឺ讶ចរក厶នសម殶ប់អ䮓ក។ សូមទូរស័ព䮑ទៅផ្នកសេ玶សមជិក㾶មលេខ (TTY: 711) នៅល�ើប័ណ䮎​សមஶ ល់ខ្លនរបស់អ䮓ក ។ French/Français: ATTENTION : si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré (TTY : 711). Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa (TTY: 711). Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오. Greek/λληνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze (TTY: 711). Hindi/हिंदी: ध्봾न दᴂ: यदि आप हिन्饀 बोलते हℂ, तो भाषा सहायता सेवाएँ, आप के लिए नि:शुल् उपलब㔧 हℂ। सदस् सेवाओं को आपके आई.डी. कार 㔡 पर दिए गए नंबर पर कॉल करᴂ (टी.टी.वाई.: 711). Gujarati/ગુજરાતી: ધ્뺾ન આપો: જો તમે ગુજરાતી બોલતા હો, તો તમને ભાષાકીય સહાયતા સેવાઓ વિના મૂલ્ય ઉપલબ㚧 છે. તમારા આઈડી કાર㚡 પર આપેલા નંબર પર Member Service ને કૉલ કરો (TTY: 711). Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card (TTY: 711). Japanese/日本語 : お知らせ：日本語をお話しになる方は無料の言語アシスタンスサービスをご 利用いただけます。IDカードに記載の電話番号を使用してメンバーサービスまでお電話ください （TTY: 711）。 German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an (TTY: 711). :پارسیان/Persian توج: اگر زبان شما فارسی است، خدمات کمک زبانی ب صورت رایگان در اختیار شما قرار می گیرد. با شمار تلفن مندرج بر روی کارت شناسایی خود با بخش »خدمات اعضا« تماس بگیر ید )TTY: 711(. Lao/ພາສາລາວ: ໍຂ້ ຄວນໃສ່ ໃຈ: ຖ້ າເຈົ້ າເວົ້ າພາສາລາວໄດ້ , ີມການບໍ ິລການຊ່ ວຍເຫືຼ ອດ້ ານພາສາໃຫ້ ທ່ ານໂດຍ ່ໍບເສຍຄ່ າ. ໂທ​ຫາ​ຝ່ າຍບໍ ິລການສະ​ມາິ​ຊກທ່ີ ໝາຍເລກໂທລະສັ ບຢູ່ ໃນບັ ດຂອງທ່ ານ (TTY: 711). Navajo/Diné Bizaad: BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47 t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’ b44sh bee hod77lnih (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 164711MB 55-1493 (8/16)