Trial Flipbook2

►About Your Medications

Retail Medications

Medications dispensed at MaxorPlus participating retail pharmacies are limited to a 30-day supply.

Mail Order Medications

MXP Pharmacy offers a convenient, cost effective way to order prescribed long-term medications for
delivery to your home. Medications obtained through mail order are limited to a 90-day supply. To
maximize your savings, please ask your doctor to write, submit electronically, or fax your prescription
for a 90-day supply with refills up to one year. Once MXP Pharmacy has your prescription, refills can
easily be obtained. To get started, please use one of the following options:

1) Go Online - Create a MaxorPlus member web portal account at www.maxorplus.com. After
you have successfully created an account, select the “Sign-Up for Mail Order” feature.

2) By Mail - Print and fill out a mail order form from the MaxorPlus website. Mail in your
completed form to the pharmacy with your prescription(s) and form of payment.

3) By Phone - Call (800) 687-8629 and follow menu instructions to speak to a representative.

Specialty Medications

Specialty medications are limited to a 30-day supply. For more information on obtaining specialty
medications, please see the Maxor Specialty Pharmacy insert.

Refills

If your physician has authorized refills, you may refill your prescription once 75% of the prescription has
been used. For example, on a 30-day supply prescription, you may refill when 7 days are left.

Formulary

The MaxorPlus Formulary will be utilized with your drug program. The formulary is a list of medications
to be used as a guide for physicians when prescribing. For the comprehensive formulary, please create
a member portal account by visiting our website at www.maxorplus.com*

How Your Formulary Works
Generic - Generic medications contain the same active ingredients as their corresponding

brand-name medications. The generics on this formulary are listed in lower case letters.

Preferred - Brand-name medications listed on the formulary in all capital letters.

Non-Preferred - Brand-name medications not listed on the formulary or listed as non-preferred for

example purposes.

* Not all drugs listed on the formulary are covered by all prescription drug benefit programs: check your

benefit materials for the specific drugs that are covered and those which are excluded.

►Prescription Copay Amounts

DRUG RETAIL COPAY MAIL ORDER
Generic
Preferred Brand* 30 Day Supply 90 Day Supply
Non-Preferred Brand*
Specialty $0.00 $0.00
$0.00 $0.00
$0.00 $0.00
$0.00 N/A

►About Your Benefits Coverage

Covered Drugs, Limitations and Exclusions

Most prescription drugs that require a “written” prescription by a licensed physician are covered.
Anti-wrinkle agents (e.g. Renova), cosmetic hair removal products (e.g. Vaniqa), growth hormones, hair
growth stimulants, non-legend drugs other than insulin, therapeutic devices or appliances, and other
non-medicinal substances, regardless of intended use, except those listed above, and charges for the
administration or injection of any drug are generally not covered under your drug benefit. In addition,
certain restrictions, quantity limits or prior authorization requirements may apply.* To obtain additional
information about these restrictions, or for more coverage information, contact your HR Department or
a MaxorPlus customer service representative.

*This is not intended to be a full explanation of benefits, limitations, or exclusions.
For more information, please review your benefit documents.

Using A Non-Participating Pharmacy

This program requires eligible members to use a MaxorPlus participating pharmacy (refer to the
pharmacy network list). When an out-of-network pharmacy is used, you may be responsible for paying
more than just the required co-pay. Prescriptions purchased at “non-participating pharmacies” are
covered only in emergency situations, for example, you’re out-of-town and unable to locate a MaxorPlus
participating pharmacy or you need an emergency prescription filled late at night. You will need to pay
100% of the prescription drug cost and obtain a receipt. Then you must submit a paper claim along with
the receipt for reimbursement to MaxorPlus. You can request this form from your employee benefits
office or MaxorPlus. You will be reimbursed the network-discounted rate minus your co-pay.

Pharmacy Network

Chains Available Nationwide

ALBERTSONS PHARMACY
CVS PHARMACY

GIANT EAGLE PHARMACY
KMART PHARMACY

YOUR HOME TOWN PHARMACY
WALGREENS

WALMART PHARMACY

MaxorPlus’ participating pharmacy network includes more than 64,000 retail pharmacies, including
regional and national chains, as well as independently owned pharmacies. To locate a pharmacy near
you, log on to www.maxorplus.com and access our online pharmacy locator. You may also contact
MaxorPlus customer service at 1-800-687-0707 and speak with a customer service representative to

assist in finding a pharmacy near you.

Contact Us

For questions concerning your prescription
drug program call MaxorPlus at:

806-324-5430 OR 1-800-687-0707

Customer Service Representatives are available Monday through Friday from 7AM to 9PM,
Saturday from 8AM to 6PM and Sunday from 9AM to 5PM CT (Central Time).

Your network pharmacist can also call MaxorPlus for
specific questions about your prescriptions.

For questions regarding your
mail order program call MXP Pharmacy at:

806-324-5500* OR 1-800-687-8629*

Customer Service Representatives are available Monday through Friday from 7AM to 9PM,
Saturday from 8AM to 6PM and Sunday from 9AM to 5PM CT (Central Time).

*Note: To order refills at anytime, call 806-324-5500 or 1-800-687-8629 to access
our 24-hour automated mail order system or log-on to www.maxorplus.com

320 S. Polk Street, Suite 200 01/2018
Amarillo, Texas 79101

320 S. POLK STREET, SUITE 200, AMARILLO, TEXAS 79101

Welcome to MaxorPlus and MXP Pharmacy!

Below are frequently asked questions and answers about our Mail Order Program.

How do I register with MXP Pharmacy?

There are multiple ways to order prescriptions from MXP Pharmacy. Once you receive your ID card, you have several
options:

• You may go online and activate your mail order account at www.maxorplus.com.
• You may fill out the MAIL ORDER FORM that is available on the website, and mail it to the pharmacy, along with

your prescription and payment. You may also contact customer service to have a MAIL ORDER FORM mailed to
your address of choice.
• You may call our toll-free (800) 687-8629 and speak to a Member Advocate who will help you activate your mail
order account.

How do I pay for my prescriptions?

• If an online mail order account has been activated, the credit/debit card saved securely will be used to process
payments on new and existing refill prescriptions.

• If you are mailing in your prescriptions, you can send a check, money order, or credit/debit card information along
with your MAIL ORDER FORM. Orders cannot be processed without payment.

How will my prescription order be mailed to me?

• Your medications are generally delivered via first-class mail by the US Postal Service.
• We also offer expedited shipping through UPS or FedEx for an additional fee. Please note that UPS or FedEx

requires a physical address and will not deliver to PO Boxes.
• Refrigerated medications, such as insulin, are shipped Second Day UPS or FedEx at no additional cost to you.

How long does it take to receive my prescriptions?

• Please allow 7-14 days from when you send your request to receive your medications.

What happens if my prescription requires a prior authorization?

• If your prescription claim rejects at MXP Pharmacy due to a prior authorization, we will obtain the necessary
information to process the request and reach out to you if needed.

• It is sometimes necessary for us to contact your physician for additional information. Typically this process
takes 24-48 hours, depending on how quickly the required information is obtained from your physician.

• You may call MaxorPlus Member Services at (800) 687-0707 if you have any questions regarding the status
of a prior authorization request.

What happens when my prescription is out of refills?

• When your prescription has no refills remaining, we will contact the prescribing doctor for a new prescription.
• If you have changed physicians since you last filled your prescription, you will need to contact your physician

to request a new prescription.

May I transfer my prescription from my local pharmacy?

• Yes, in most cases. Members should contact MaxorPlus Member Services at (800) 687-8629 and speak with
a Member Advocate to transfer prescriptions to MXP Pharmacy.

May I fax or email new prescriptions?

• Only your doctor can fax, electronically submit, or call in new prescriptions.

How do I refill my prescriptions?

There are several options available for ordering refills:

• You may refill your prescriptions on our website at www.maxorplus.com once you have registered. Please
choose REFILL PRESCRIPTIONS under the Member Services Section.

• Members can call (800) 687-8629 and follow the menu instructions to refill their medications or to speak with
a Member Advocate about your refills.

• You may print a MAIL ORDER FORM from the MaxorPlus website and mail it to the pharmacy, along with
your prescription and payment. Please include a check, money order, or fill out the credit/debit card section
on the form. Our mailing address is: MXP Pharmacy, P.O. Box 32050, Amarillo, Texas 79120-2050.

• MXP Pharmacy offers the ability to automatically refill your prescriptions. To sign up for this program, please
visit our website and select AUTOMATIC MAIL ORDER REFILLS or call (800) 687-8629 to speak with a
member advocate.

Note: You may be asked for your prescription number when discussing refills. It is a number, beginning with
an 11, found at the top left corner of your prescription bottle. It remains the same until your refills run out.
When you get a new prescription from your doctor for the same drug, it is assigned a new prescription (Rx)
number.

What happens if I need my refill and it is too soon to fill?

• We will mail your prescription on the earliest available refill date upon request if the medication is available
for refill within 30 days.

• Your plan requires members use 75% of the most recent refill before you can refill again. The earliest refill
date is printed at the lower left of your prescription bottle.

Helpful Tips:

There are times when a new prescription is needed by the pharmacy. The most common reasons which require
MXP Pharmacy to obtain a new prescription include having no refills remaining, dosage increases, or new medications
that your doctor prescribes. We will reach out to you or your physician when necessary.

Make sure your address is correct when filling a prescription at MXP Pharmacy. If you want your medications mailed to a
different address than what is on your profile, make sure it is noted by logging in to the website and changing the mailing
address, calling a Member Advocate, or noting the new address on the mail order form.

MAXORPLUS ADVANTAGE SPECIALTY PRODUCTS

Maxor Specialty is the exclusive provider of specialty products for your plan. The most common
specialty products are listed on this sheet. If you or a family member are currently taking any of
these medications, you will need to contact Maxor Specialty for future refills, unless designated as
limited distribution.
Maxor Specialty can be contacted at 1-866-Maxor-Rx (866-629-6779). To simplify the process,
please have your prescription label close by when you call. Maxor Specialty will contact your
provider to have your prescription transferred. If you have questions concerning a medication,
please contact Maxor Specialty. Some drugs listed may not be covered under your prescription
benefit. Please refer to your prescription drug benefit coverage. All brand and generic formulations
of the drugs listed are considered specialty, unless otherwise noted.

YOUR PLAN REQUIRES YOU OBTAIN THESE DRUGS THROUGH MAXOR
SPECIALTY, UNLESS OTHERWISE SPECIFIED.

ABILIFY MAIN ATGAM INJ CERDELGA CAPSULE-LD
ABRAXANE VIAL AUBAGIO TABLET-LD CEREDASE VIAL
ACTEMRA VIAL AUSTEDO TAB CEREZYME VIAL
ACTHAR H.P. GEL VIAL-LD AVASTIN VIAL CERUBIDINE VIAL (Brand only)
ACTHREL VIAL AVEED INJ-LD CHENODAL TAB-LD
ACTIMMUNE VIAL-LD AVONEX INJ CHOLBAM CAP
ADAGEN VIAL-LD AZACITIDINE CIDOFOVIR
ADCETRIS INJ BARACLUDE TABLET CIMZIA KIT
ADEFOVIR DIPIVOXIL BAVENCIO INJ-LD CINQAIR INJ
ADEMPAS-LD BEBULIN VH IMMUNO INJ CINRYZE VIAL-LD
ADRUCIL BELEODAQ INJ CINVANTI INJ
ADVATE VIAL BENDEKA INJ CISPLATIN-AQ VIAL
ADYNOVATE INJ BENEFIX VIAL CLADRIBINE INJ
AFINITOR TABLET BENLYSTA INJ CLOFARABINE INJ
AFSTYLA INJ BERINERT INJ-LD CLOLAR VIAL
ALBUMIN BESPONSA INJ COAGADEX INJ
ALDURAZYME VIAL BETASERON VIAL COLISTIMETHATE VIAL
ALECENSA CAP-LD BETHKIS COLY-MYCIN M VIAL
ALFERON N VIAL-LD BEXAROTENE CAP COMETRIQ CAPSULE-LD
ALIMTA VIAL BEXXAR INJ-LD COPAXONE INJECTION KIT
ALIQOPA INJ BICNU VIAL COPEGUS TABLET
ALKERAN TABLET BIVIGAM CORIFACT KIT
ALKERAN VIAL BLENOXANE VIAL CORTROSYN VIAL
ALOXI VIAL BLEOMYCIN SULFATE VIAL COSENTYX INJ
ALPHANATE VIAL BLINCYTO INJ-LD COSMEGEN VIAL
ALPHANINE SD VIAL BONIVA SYRINGE COTELLIC TAB-LD
ALPROLIX BORTEZOMIB INJ CRYSVITA-LD
ALUNBRIG TAB-LD BOSULIF TABLET CUVITRU INJ-LD
AMEVIVE VIAL BOTOX 1 VIAL CYCLOPHOSPHAMIDE VIAL
AMIFOSTINE INJ BRINEURA INJ CYCLOSPORINE MODIFIED
AMPYRA ER TABLET-LD BUPHENYL ORAL CYCLOSPORINE ORAL
ANASCORP INJ BUSULFEX 6 AMPUL CYRAMZA INJ-LD
ANDEXXA CABOMETYX TAB-LD CYSTADANE POW-LD
ANZEMET INJ CALQUENCE CAP CYSTAGON CAPSULE-LD
APOKYN CARTRIDGE-LD CAMPATH VIAL CYSTARAN OPHTH-LD
ARALAST VIAL-LD CAMPTOSAR VIAL CYTARABINE VIAL
ARANESP VIAL* CAPECITABINE CYTOGAM VIAL
ARCALYST INJECTION-LD CAPRELSA TABLET-LD CYTOVENE VIAL
AREDIA VIAL CARBAGLU-LD CYTOXAN VIAL
ARESTIN-LD CARBOPLATIN VIAL DACARBAZINE VIAL
ARISTADA INJ CARIMUNE NF VIAL DACOGEN VIAL
ARIXTRA SYRINGE* CAYSTON 75 MG INHAL DACTINOMYCIN INJ
ARRANON VIAL-LD CEENU CAPSULE DAKLINZA TAB
ARZERRA VIAL-LD CELLCEPT ORAL DALVANCE
ASTAGRAF XL CAP CEPROTIN INJ DARAPRIM TAB

3Q18

DARZALEX INJ FLUDARABINE VIAL IMATINIB TAB
DAUNOXOME VIAL FLUOROURACIL VIAL IMBRUVICA CAP-LD
DECITABINE FOLOTYN VIAL IMFINZI INJ-LD
DEFEROXAMINE VIAL FONDAPARINUX INJ* IMLYGIC INJ
DEFITELIO INJ FORTEO INJ INCIVEK TABLET
DEPOCYT INJ FUDR VIAL INCRELEX VIAL-LD
DEPO-MEDROL VIAL FUSILEV I.V. INFERGEN VIAL
DESFERAL VIAL FUZEON CONVENIENCE KIT INFLECTRA INJ
DEXRAZOXANE VIAL GAMASTAN S-D VIAL INGREZZA CAP-LD
DIPRIVAN GAMMAGARD S-D VL INJECTAFER INJ
DOCEFREZ INJ GAMMAKED INLYTA TABLET-LD
DOCETAXEL VIAL GAMMAPLEX VIAL INTRON A VIAL
DOXIL VIAL GAMUNEX VIAL INVEGA SUSTENNA INJ
DOXORUBICIN VIAL GANCICLOVIR INJ INVEGA TRINZ INJ
DUPIXENT INJ GATTEX INJ-LD IPRIVASK VIAL
DUROLANE INJ GAZYVA INJ IRESSA TABLET-LD
DYSPORT INJ GEL-ONE INJ IRINOTECAN HCL INJ
EGRIFTA INJ-LD GELSYN-3 ISTODAX VIAL
ELAPRASE INJ GEMCITABINE INJ IXEMPRA INJ
ELELYSO INJ-LD GEMZAR VIAL IXINITY INJ
ELIGARD SYRINGE GENGRAF CAPSULE JADENU TABLET
ELITEK VIAL GENOTROPIN INJ JAKAFI TABLET-LD
ELLENCE VIAL GENOTROPIN MINIQUICK INJ JETREA INJ-LD
ELOCATE GENVISC 850 INJ JEVTANA KIT
ELOXATIN VIAL GILENYA CAPSULE JUXTAPID CAPSULE-LD
ELSPAR VIAL GILOTRIF TAB-LD JYNARQUE-LD
EMCYT CAPSULE GLASSIA INJ-LD KADCYLA INJ
EMEND VIAL GLATOPA INJ KALBITOR INJ
EMFLAZA ORAL GLEEVEC TABLET KALYDECO TABLET
EMPLICITI INJ GLEOSTINE CAP KANUMA INJ-LD
ENBREL INJ GOLD SOD THIOMALATE INJ KCENTRA KIT
ENTECAVIR GRANISETRON HCL VIAL KENGREAL INJ
ENTEREG CAPSULE GRANIX INJ KEPIVANCE VIAL-LD
ENTYVIO INJ HAEGARDA INJ-LD KEVEYIS TAB-LD
ENVARSUS XR TAB HALAVEN INJ-LD KEVZARA INJ
EPCLUSA TAB HARVONI KEYTRUDA INJ
EPIRUBICIN VIAL HELIXATE FS VIAL KINERET SYR-LD
EPIVIR HBV SOLN HEMLIBRA INJ KISQALI TAB
EPIVIR HBV TABLET HEMOFIL M VL KITABIS PAK
EPOGEN VIAL* HEPAGAM B INJ KOATE-DVI KIT
EPOPROSTENOL SODIUM VIAL-LD HEPSERA TABLET KOGENATE FS VIAL
ERBITUX VIAL HERCEPTIN VIAL KORLYM TABLET-LD
ERIVEDGE CAPSULE-LD HETLIOZ CAPSULE-LD KOVALTRY INJ
ERLEADA-LD HEXALEN CAPSULE KRYSTEXXA INJ
ERWINAZE INJ-LD HIZENTRA INJ 10/50ML KUVAN TABLET-LD
ESBRIET CAP-LD HIZENTRA INJ 1GM/5ML KYLEENA IUD-LD
ETHYOL VIAL HIZENTRA INJ 2GM/10ML KYMRIAH INJ-LD
ETOPOPHOS VIAL HIZENTRA INJ 4GM/20ML KYNAMRO INJ-LD
ETOPOSIDE VIAL HUMATE-P KIT KYPROLIS INJ
ETOPOSIDE CAPSULE HUMATROPE INJ KYTRIL VIAL
EUFLEXXA SYRINGE HUMIRA 10 MG INJ-LD LAMIVUDINE HBV TABLET
EVOMELA INJ HUMIRA 20 MG INJ-LD LARTRUVO INJ-LD
EXJADE TABLET-LD HUMIRA 40 MG INJ LEMTRADA INJ-LD
EXONDYS 51 INJ HYALGAN 1SYRINGE LENVIMA CAPSULE-LD
EXTAVIA KIT HYCAMTIN CAPSULE LETAIRIS TABLET-LD
EYLEA INJ-LD HYCAMTIN VIAL LEUKINE VIAL
FABRAZYME VIAL HYLENEX INJ LEUPROLIDE KIT
FARYDAK CAPSULE HYMOVIS INJ LEVOLEUCOVORIN
FASENRA INJ-LD HYQVIA INJ-LD LILETTA IUD-LD
FASLODEX SYRNGE IBRANCE CAP-LD LOMUSTINE CAPSULE
FEIBA VH IMMU INJ ICLUSIG TABLET-LD LONSURF TAB-LD
FERAHEME VIAL IDAMYCIN PFS VIAL LUCENTIS INJ-LD
FERRIPROX TABLET-LD IDARUBICIN HCL VIAL LUMIZYME INJ
FERRLECIT AMPUL IDELVION VIAL LUPANETA
FIBRYGA IDHIFA TAB LUPRON DEPOT
FIRAZYR INJ IFEX INJ LUPRON INJ
FIRMAGON VIAL IFEX-MESNEX KIT LUXTURNA SUS-LD
FLEBOGAMMA 5% VIAL IFOSFAMIDE INJ LYNPARZA CAP-LD
FLOLAN VIAL-LD IFOSFAMIDE-MESNA KIT LYSODREN TABLET
FLOXURIDINE VIAL ILARIS VIAL-LD MACUGEN INJ
FLUDARA VIAL ILUVIEN-LD MAKENA INJ

3Q18

MARQIBO ONXOL VIAL RILUTEK TABLET
MATULANE CAPSULE-LD OPDIVO INJ RILUZOLE TABLET
MAVYRET TAB OPSUMIT TAB-LD RISPERDAL INJ
MEKINIST TAB ORBACTIV INJ RITUXAN VIAL
MELPHALAN ORENCIA VIAL RITUXAN/HYCELA INJ
MEPSEVII INJ ORENITRAM TAB-LD RIXUBIS INJ
MESNA INJ ORFADIN CAPSULE-LD ROMIDEPSIN INJ (branded generic)
MESNEX INJ ORKAMBI TAB RUBRACA TAB-LD
METHYLPREDNISOLONE INJ ORTHOVISC SYRINGE RUCONEST INJ
MIGLUSTAT-LD OTEZLA TAB RYDAPT CAP
MIRCERA INJ* OXALIPLATIN VIAL SABRIL ORAL-LD
MIRENA IUD-LD OZURDEX SAIZEN VIAL
MITOMYCIN VIAL PACLITAXEL VIAL SAMSCA TAB-LD
MITOXANTRONE VIAL PALONOSETRON INJ SANDIMMUNE ORAL CAPS/INJ
MODERIBA PAMIDRONATE VIAL SANDIMMUNE ORAL SOLUTION
MONOCLATE-P KIT PARSABIV INJ SANDOSTATIN AMPUL
MONONINE VIAL PEGASYS INJ SANDOSTATIN LAR KIT
MONOVISC PEGINTRON KIT SENSIPAR TABLET
MOZOBIL VIAL PENTAM VIAL SEROSTIM 4 MG VIAL
MUSTARGEN VIAL PENTAMIDINE VIAL SEROSTIM 5 MG VIAL
MYALEPT INJ-LD PENTOSTATIN VIAL SEROSTIM 6 MG VIAL
MYCOPHENOLATE ORAL PERJETA INJ SIGNIFOR INJ-LD
MYFORTIC TABLET PHOTOFRIN VIAL SIGNIFOR LAR-LD
MYLERAN TABLET PITRESSIN VIAL SILIQ INJ
MYOBLOC VIAL PLASMANATE INJ SIMPONI INJ
MYOCHRYSINE VIAL PLEGRDIY INJ-LD SIMULECT INJ
MYOZYME VIAL POMALYST CAPSULE-LD SIROLIMUS
NAGLAZYME VIAL PORTRAZZA INJ-LD SIRTURO TAB-LD
NATPARA INJ-LD PRALUENT INJ SKYLA-LD
NEBUPENT INHAL POWDER PREVTNUS SODIUM PHENYLBUTYRATE
NEORAL CAPSULE PREVYMIS INJ SOLESTA INJ-LD
NERLYNX TAB-LD PRIALT INJ-LD SOLIRIS INJ
NEULASTA SYRINGE* PRIVIGEN VIAL SOMATULINE INJ
NEUMEGA VIAL* PROCRIT VIAL* SOMAVERT VIAL-LD
NEUPOGEN SYR* PROCYSBI CAP-LD SOVALDI TAB
NEUTREXIN INJ PROFILNINE SD VIAL SPINRAZA INJ-LD
NEXAVAR TABLET-LD PROGRAF INJ SPRIX SPRAY-LD
NEXPLANON-LD PROGRAF ORAL SPRYCEL TABLET
NILANDRON TAB PROLASTIN VIAL-LD STELARA INJ
NILUTAMIDE TAB PROLEUKIN VIAL STELARA SYRINGE
NINLARO CAP PROLIA SYRINGE STIMATE NASAL SPRAY
NIPENT VIAL PROMACTA TABLET STIVARGA TABLET-LD
NITYR TAB-LD PROVENGE INFUSION BAG-LD STRENSIQ INJ-LD
NORDITROPIN INJ PULMOZYME AMPUL SUBLOCADE INJ
NORDITROPIN NORDIFLEX PURIXAN SUSP SUCRAID ORAL-LD
NORTHERA-LD RADICAVA INJ SUPARTZ SYRINGE
NOVANTRONE VIAL RAPAMUNE TABLET SUPPRELIN LA INJ
NOVOEIGHT RAPTIVA KIT SUTENT CAPSULE
NOVOSEVEN VIAL RAVICTI ORAL LIQ-LD SYLATRON KIT
NPLATE VIAL REBETOL SYLVANT INJ
NUCALA INJ REBIF INJ SYMDEKO
NULECIT INJ REBIF TITRATION PACK SYNAGIS VIAL
NULOJIX INJ REBINYN INJ SYNRIBO INJ-LD
NUTROPIN VIAL RECLAST INJ SYNVISC ONE
NUTROPIN AQ INJ RECOMBINATE VIAL SYNVISC SYRINGE
NUWIQ REFACTO VIAL SYPRINE CAPSULE
OBIZUR INJ REFLUDAN VIAL TACROLIMUS ANHYDROUS CAP
OCALIVA TAB-LD RELISTOR TABLET TAFINLAR CAP
OCREVUS INJ RELISTOR VIAL TAGRISSO TAB-LD
OCTAGAM REMICADE VIAL TALTZ INJ-LD
OCTAPLAS INJ REMODULIN VIAL-LD TARCEVA TABLET
OCTREOTIDE VIAL RENFLEXIS INJ TARGRETIN SOFTGEL
ODOMZO REOPRO VIAL TASIGNA CAPSULE
OFEV CAP-LD REPATHA INJ TAVALISSE
OLYSIO CAP RETISERT IMP-LD TAXOTERE VIAL
OMNITROPE INJ REVLIMID CAPSULE-LD TECENTRIQ INJ
OMONTYS INJ RIASTAP INJ TECFIDERA CAPSULE-LD
ONCASPAR VIAL RIBAPAK TECHNIVIE TAB
ONDANSETRON INJ RIBASPHERE CAPSULE TEMODAR CAPSULE
ONNIVYDE INJ RIBATAB TEMODAR INJECTION
ONTAK VIAL RIBAVIRIN CAPSULE TEMOZOLOMIDE CAPSULE

3Q18

TENIPOSIDE INJ VANTAS KIT XELJANZ TAB/ XR TAB
TEPADINA INJ VARITHENA INJ/TOP.-LD XELODA TABLET
TESTOPEL IMPANT-LD VASOPRESSIN VIAL XENAZINE TABLET-LD
TETRABENAZINE VECTIBIX VIAL XEOMIN VIAL
TEV-TROPIN VIAL VELCADE VIAL XERMELO-LD
THALOMID CAPSULE VELETRI INJ-LD XGEVA INJ
THIOLA TAB-LD VELTASSA POW-LD XIAFLEX INJ-LD
THIOTEPA VIAL VEMLIDY TAB XOLAIR 150 MG VIAL
THROMBAT III INJ VENCLEXTA TAB XTANDI CAPSULE-LD
THYMOGLOBULIN INJ VENOFER VIAL XURIDEN GRANULES
THYROGEN INJ VENTAVIS SOLUTION-LD XYNTHA KIT
TICE BCG INJ VERZENIO TAB-LD XYREM ORAL SOLUTION-LD
TOBI INH. SOL./PODHAL. VESANOID CAPSULE YERVOY INJ-LD
TOBRAMCYIN NEB VIBATIV INJ YESCARTA INJ-LD
TOPOSAR VIAL VICTRELIS CAPSULE YONDELIS INJ
TOPOTECAN INJ VIDAZA VIAL ZALTRAP INJ
TORISEL INJ VIEKIRA PAK/XR ZANOSAR INJ
TOTECT VIAL VIGABATRIN ORAL PWD-LD ZARXIO INJ*
TRACLEER TABLET-LD VIMIZIM INJ ZAVESCA CAPSULE-LD
TREANDA VIAL VINBLASTINE VIAL ZELBORAF TABLET-LD
TRELSTAR DEPOT SYRINGE VINCRISTINE VIAL ZEJULA CAP-LD
TREMFYA INJ VINORELBINE VIAL ZEMAIRA VIAL-LD
TRETINOIN CAPSULE VIRAZOLE VIAL ZENAPAX INJ
TRETTEN VISCO-3 INJ ZEPATIER TAB
TRIENTINE VISTIDE VIAL ZEVALIN KIT-LD
TRIPTODUR INJ VISUDYNE VIAL-LD ZINECARD VIAL
TRISENOX AMPULE VITEKTA ZINPLAVA INJ
TYKERB TABLET VITRASE INJ ZOFRAN INJ
TYMLOS INJ VIVAGLOBIN VIAL ZOLADEX IMPLANT SYRN
TYSABRI VIAL-LD VIVITROL INJ ZOLEDRONIC INJ
TYVASO INH.-LD VONVENDI INJ ZOLINZA CAPSULE
TYZEKA TAB VORAXAZE INJ ZOMACTON INJ
UNITUXIN INJ VOSEVI TAB ZOMETA VIAL
UPTRAVI TAB-LD VOTRIENT TABLET ZORBTIVE VIAL
VALCHLOR TOP. GEL-LD VPRIV VIAL-LD ZORTRESS TABLET
VALCYTE TABLET VUMON AMPUL ZYDELIG TAB-LD
VALGANCICLOVIR TAB VYXEOS INJ ZYKADIA
VALSTAR VIAL WILATE KIT ZYPREXA RELPREVV VIAL
VANDETANIB TABLET-LD XALKORI CAPSULE ZYTIGA TABLET

* Boldfaced items with an asterisk (*) may be obtained in a 21 day supply or less at your local network retail pharmacy.
LD These drugs have limited distribution and must be obtained from the designated provider(s).
# Harvoni and Epclusa are the exclusive agents for Hep C
† List is subject to change. Some drugs may not be covered. Please refer to your prescription benefit.

3Q18





Pharmacy Benefit Management Services

NDC / ENVOY BIN 005377 RxPCN 10000019 Effective Date: 00/00/0000

Member Rx ID: 123456789 RXGROUP: SAMPLE

Members Person Code
Name 1 01
Name 2 02
Name 3 03
Name 4 04
Name 5 05
Name 6 06

COPAYS:
RETAIL: Generic $xx / Preferred $xx / Non-Preferred $xx
MAIL: Generic $xx / Preferred $xx / Non-Preferred $xx

Pharmacy Benefit Management Services

NDC / ENVOY BIN 005377 RxPCN 10000019 Effective Date: 00/00/0000

Member Rx ID: 123456789 RXGROUP: SAMPLE

Members Person Code
Name 1 01
Name 2 02
Name 3 03
Name 4 04
Name 5 05
Name 6 06

COPAYS:
RETAIL: Generic $xx / Preferred $xx / Non-Preferred $xx
MAIL: Generic $xx / Preferred $xx / Non-Preferred $xx

1