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The presence of a drug on this list does not guarantee coverage. Your benefit plan determines coverage of medications. Where differences are noted between this reference guide and your benefit plan documents, the benefit plan documents will govern.

All medications listed are still subject to Formulary management such as prior authorization, step-edits, quantity limits, and tier placement.

This list is subject to change and may include additional drugs based on your plan benefits.

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A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association. 13201_WNY_10_20 Ace Inhibitors TELMISARTAN ...... GENERIC TELMISARTAN‐HYDROCHLOROTHIAZID...... GENERIC BENAZEPRIL ...... GENERIC VALSARTAN ...... GENERIC CAPTOPRIL ...... GENERIC VALSARTAN‐HYDROCHLOROTHIAZIDE ...... GENERIC ENALAPRIL ...... GENERIC ENALAPRILAT ...... GENERIC Anticoagulants/Antithrombotics FOSINOPRIL ...... GENERIC LISINOPRIL ...... GENERIC ADULT ASPIRIN REGIMEN ...... GENERIC MOEXIPRIL ...... GENERIC ADULT LOW DOSE ASPIRIN ...... GENERIC PERINDOPRIL ...... GENERIC ANAGRELIDE ...... GENERIC QUINAPRIL ...... GENERIC ASPIR 81 ...... GENERIC RAMIPRIL ...... GENERIC ASPIRIN ...... GENERIC TRANDOLAPRIL ...... GENERIC ASPIRIN E.C...... GENERIC ASPIRIN‐DIPYRIDAMOLE ER ...... GENERIC Adrenergic Agonist ASPIR‐LOW ...... GENERIC ASPIR‐TRIN ...... GENERIC MIDODRINE ...... GENERIC CHILDREN'S ASPIRIN ...... GENERIC CLOPIDOGREL ...... GENERIC DIPYRIDAMOLE ...... GENERIC Adrenergic Antagonists and ECOTRIN ...... GENERIC Related Drugs ECPIRIN ...... GENERIC ENOXAPARIN ...... GENERIC CLONIDINE ...... GENERIC ENTERIC COATED ASPIRIN...... GENERIC DOXAZOSIN MESYLATE ...... GENERIC FONDAPARINUX ...... GENERIC GUANFACINE ...... GENERIC JANTOVEN ...... GENERIC METHYLDOPA ...... GENERIC LITE COAT ASPIRIN ...... GENERIC METHYLDOPA‐HYDROCHLOROTHIAZIDE .... GENERIC LOW DOSE ASPIRIN ...... GENERIC METHYLDOPATE ...... GENERIC PRASUGREL ...... GENERIC PHENOXYBENZAMINE ...... GENERIC ST. JOSEPH ASPIRIN ...... GENERIC PRAZOSIN ...... GENERIC TICLOPIDINE ...... GENERIC TERAZOSIN ...... GENERIC WARFARIN ...... GENERIC BAYER CHEWABLE ...... BRAND Angiotensin II Receptor Blockers and Renin Inhibitors Antiemetics

ALISKIREN ...... GENERIC APREPITANT ...... GENERIC CANDESARTAN CILEXETIL ...... GENERIC COMPRO ...... GENERIC CANDESARTAN‐HYDROCHLOROTHIAZIDE .. GENERIC DOXYLAMINE SUCC‐PYRIDOXINE ...... GENERIC EPROSARTAN MESYLATE ...... GENERIC DRONABINOL ...... GENERIC IRBESARTAN POTASSIUM ...... GENERIC FOSAPREPITANT DIMEGLUMINE ...... GENERIC IRBESARTAN‐HYDROCHLOROTHIAZIDE ...... GENERIC GRANISETRON ...... GENERIC LOSARTAN POTASSIUM ...... GENERIC ONDANSETRON ...... GENERIC LOSARTAN‐HYDROCHLOROTHIAZIDE ...... GENERIC ONDANSETRON ODT ...... GENERIC OLMESARTAN MEDOXOMIL ...... GENERIC PALONOSETRON ...... GENERIC OLMESARTAN‐HYDROCHLOROTHIAZIDE .... GENERIC PHENADOZ ...... GENERIC PHENERGAN ...... GENERIC 2 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. PROCHLORPERAZINE ...... GENERIC MEFLOQUINE ...... GENERIC PROMETHAZINE ...... GENERIC OSELTAMIVIR ...... GENERIC PROMETHEGAN ...... GENERIC PENTAMIDINE ...... GENERIC SCOPOLAMINE ...... GENERIC PRIMAQUINE …………………………………………..GENERIC TRIMETHOBENZAMIDE ...... GENERIC QUININE SULFATE ...... GENERIC RIMANTADINE ...... GENERIC Antiestrogens VALACYCLOVIR ...... GENERIC VALGANCICLOVIR ...... GENERIC ANASTROZOLE ...... GENERIC EXEMESTANE...... GENERIC Beta Blockers LETROZOLE ...... GENERIC RALOXIFENE ...... GENERIC ACEBUTOLOL ...... GENERIC TAMOXIFEN ...... GENERIC ATENOLOL ...... GENERIC BETAXOLOL ...... GENERIC Antihypertensive, Other BISOPROLOL FUMARATE...... GENERIC CARVEDILOL ...... GENERIC AMLODIPINE BESYLATE‐BENAZEPRIL ...... GENERIC CARVEDILOL ER ...... GENERIC AMLODIPINE‐OLMESARTAN ...... GENERIC LABETALOL HCL ...... GENERIC AMLODIPINE‐VALSARTAN ...... GENERIC METOPROLOL SUCCINATE ...... GENERIC AMLODIPINE‐VALSARTAN‐HCTZ ...... GENERIC METOPROLOL TARTRATE ...... GENERIC ATENOLOL‐CHLORTHALIDONE ...... GENERIC NADOLOL ...... GENERIC BENAZEPRIL‐HYDROCHLOROTHIAZIDE ...... GENERIC PINDOLOL ...... GENERIC BISOPROLOL‐HYDROCHLOROTHIAZIDE ...... GENERIC PROPRANOLOL ...... GENERIC CAPTOPRIL‐HYDROCHLOROTHIAZIDE ...... GENERIC PROPRANOLOL ER ...... GENERIC ENALAPRIL‐HYDROCHLOROTHIAZIDE ...... GENERIC TIMOLOL MALEATE ...... GENERIC FOSINOPRIL‐HYDROCHLOROTHIAZIDE ...... GENERIC HYDRALAZINE ...... GENERIC Bowel Prep* LISINOPRIL‐HYDROCHLOROTHIAZIDE ...... GENERIC METOPROLOL‐HYDROCHLOROTHIAZIDE .... GENERIC ALOPHEN PILLS ...... GENERIC MOEXIPRIL‐HYDROCHLOROTHIAZIDE ...... GENERIC BISACODYL ...... GENERIC NADOLOL‐BENDROFLUMETHIAZIDE ...... GENERIC BISA‐LAX ...... GENERIC OLMESARTAN‐AMLODIPINE‐HCTZ ...... GENERIC CITRATE OF MAGNESIA ...... GENERIC PROPRANOLOL‐HYDROCHLOROTHIAZID .... GENERIC CITROMA ...... GENERIC QUINAPRIL‐HYDROCHLOROTHIAZIDE ...... GENERIC CLEARLAX ...... GENERIC TELMISARTAN‐AMLODIPINE ...... GENERIC DUCODYL ...... GENERIC TRANDOLAPRIL‐VERAPAMIL ER ...... GENERIC DULCOLAX ...... GENERIC FEMININE LAXATIVE ...... GENERIC Antivirals GAVILAX ...... GENERIC GAVILYTE‐C...... GENERIC ACYCLOVIR ...... GENERIC GAVILYTE‐G ...... GENERIC ATOVAQUONE ...... GENERIC GAVILYTE‐N ...... GENERIC ATOVAQUONE‐PROGUANIL ...... GENERIC GENTLE LAXATIVE ...... GENERIC CHLOROQUINE ...... GENERIC GENTLELAX ...... GENERIC FAMCICLOVIR ...... GENERIC GLYCOLAX...... GENERIC HYDROXYCHLOROQUINE ...... GENERIC HEALTHYLAX ...... GENERIC LAXA CLEAR ...... GENERIC 3 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. LAXACLEAR ...... GENERIC NICARDIPINE ...... GENERIC LAXATIVE ...... GENERIC NIFEDIPINE ...... GENERIC LAXATIVE PEG 3350 ...... GENERIC NIFEDIPINE ER ...... GENERIC MAGNESIUM CITRATE...... GENERIC NISOLDIPINE ...... GENERIC MILK OF MAGNESIA ...... GENERIC TAZTIA XT ...... GENERIC MIRALAX ...... GENERIC VERAPAMIL ...... GENERIC NATURA‐LAX ...... GENERIC VERAPAMIL ER ...... GENERIC ORAL SALINE LAXATIVE ...... GENERIC VERAPAMIL ER PM ...... GENERIC PEG 3350‐ELECTROLYTE ...... GENERIC VERAPAMIL SR ...... GENERIC PEG3350‐SOD SUL‐NACL‐KCL‐ASB‐C ...... GENERIC PEG‐PREP ...... GENERIC Contraceptives* PHOSPHATE LAXATIVE ...... GENERIC POLYETHYLENE GLYCOL ...... GENERIC AFIRMELLE ...... GENERIC POWDERLAX ...... GENERIC ALTAVERA ...... GENERIC PURELAX ...... GENERIC ALYACEN ...... GENERIC SMOOTHLAX ...... GENERIC AMETHIA ...... GENERIC TRILYTE WITH FLAVOR PACKETS ...... GENERIC AMETHIA LO ...... GENERIC WOMAN'S LAXATIVE ...... GENERIC AMETHYST ...... GENERIC WOMEN'S GENTLE LAXATIVE ...... GENERIC APRI ...... GENERIC WOMEN'S LAXATIVE ...... GENERIC ARANELLE ...... GENERIC CLENPIQ ...... BRAND ASHLYNA ...... GENERIC GIALAX ...... BRAND AUBRA ...... GENERIC GOLYTELY ...... BRAND AUBRA EQ ...... GENERIC MILK OF MAGNESIA ...... BRAND AUROVELA ...... GENERIC MOVIPREP ...... BRAND AUROVELA 24 FE ...... GENERIC NULYTELY ...... BRAND AUROVELA FE ...... GENERIC OSMOPREP ...... BRAND AVIANE ...... GENERIC PLENVU ...... BRAND AYUNA ...... GENERIC PREPOPIK ...... BRAND AZURETTE ...... GENERIC SUPREP ...... BRAND BALZIVA ...... GENERIC BEKYREE ...... GENERIC Calcium Channel Blockers BLISOVI 24 FE ...... GENERIC BLISOVI FE ...... GENERIC AFEDITAB CR ...... GENERIC BRIELLYN ...... GENERIC AMLODIPINE BESYLATE ...... GENERIC CAMILA ...... GENERIC CARTIA XT ...... GENERIC CAMRESE ...... GENERIC DILTIAZEM ...... GENERIC CAMRESE LO...... GENERIC DILTIAZEM 12HR ER ...... GENERIC CAZIANT ...... GENERIC DILTIAZEM 24HR ER ...... GENERIC CHARLOTTE 24 FE ...... GENERIC DILTIAZEM 24HR ER (CD) ...... GENERIC CHATEAL ...... GENERIC DILTIAZEM 24HR ER (LA) ...... GENERIC CHATEAL EQ ...... GENERIC DILTIAZEM 24HR ER (XR) ...... GENERIC CRYSELLE ...... GENERIC DILT‐XR ...... GENERIC CYCLAFEM ...... GENERIC FELODIPINE ER ...... GENERIC CYRED ...... GENERIC ISRADIPINE ...... GENERIC CYRED EQ ...... GENERIC MATZIM LA ...... GENERIC DASETTA ...... GENERIC 4 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. DAYSEE ...... GENERIC KELNOR 1‐50 ...... GENERIC DEBLITANE ...... GENERIC KIMIDESS ...... GENERIC DELYLA ...... GENERIC KURVELO ...... GENERIC DESOGESTREL‐ETHINYL ESTRADIOL ...... GENERIC LARIN ...... GENERIC DESOGESTR‐ETH ESTRAD ETH ESTRA ...... GENERIC LARIN 24 FE ...... GENERIC DROSPIRENONE‐ETH ESTRA‐LEVOMEF ...... GENERIC LARIN FE ...... GENERIC DROSPIRENONE‐ETHINYL ESTRADIOL ...... GENERIC LARISSIA ...... GENERIC ECONTRA EZ ...... GENERIC LAYOLIS FE ...... GENERIC ECONTRA ONE‐STEP ...... GENERIC LEENA ...... GENERIC ELINEST ...... GENERIC LESSINA ...... GENERIC ELURYNG ...... GENERIC LEVONEST ...... GENERIC EMOQUETTE ...... GENERIC ...... GENERIC ENPRESSE ...... GENERIC LEVONORGESTREL‐ETH ESTRADIOL ...... GENERIC ENSKYCE ...... GENERIC LEVONORG‐ETH ESTRAD ETH ESTRAD ...... GENERIC ERRIN ...... GENERIC LEVORA ...... GENERIC ESTARYLLA ...... GENERIC LEVORA‐28 ...... GENERIC ETHYNODIOL‐ETHINYL ESTRADIOL ...... GENERIC LILLOW ...... GENERIC ‐ETHINYL ESTRADIOL ...... GENERIC LOJAIMIESS ...... GENERIC FALLBACK SOLO ...... GENERIC LOMEDIA 24 FE ...... GENERIC FALMINA ...... GENERIC LORYNA ...... GENERIC FAYOSIM ...... GENERIC LOW‐OGESTREL ...... GENERIC FEMYNOR ...... GENERIC LO‐ZUMANDIMINE ...... GENERIC GIANVI ...... GENERIC LUTERA ...... GENERIC GILDAGIA ...... GENERIC LYZA ...... GENERIC GYNOL II ...... GENERIC MARLISSA ...... GENERIC HAILEY ...... GENERIC MEDROXYPROGESTERONE ACETATE ...... GENERIC HAILEY 24 FE ...... GENERIC MELODETTA 24 FE ...... GENERIC HAILEY FE ...... GENERIC MIBELAS 24 FE ...... GENERIC HEATHER ...... GENERIC MICROGESTIN ...... GENERIC HYDROXYPROGESTERONE CAPROATE ...... GENERIC MICROGESTIN FE ...... GENERIC INCASSIA ...... GENERIC MILI ...... GENERIC INTROVALE ...... GENERIC MONO‐LINYAH ...... GENERIC ISIBLOOM ...... GENERIC MONONESSA ...... GENERIC JAIMIESS ...... GENERIC MY CHOICE ...... GENERIC JASMIEL ...... GENERIC MY WAY ...... GENERIC JENCYCLA ...... GENERIC MYZILRA ...... GENERIC JOLESSA ...... GENERIC NECON ...... GENERIC JOLIVETTE ...... GENERIC NEW DAY ...... GENERIC JULEBER ...... GENERIC NEXT CHOICE ONE DOSE ...... GENERIC JUNEL ...... GENERIC NIKKI ...... GENERIC JUNEL FE ...... GENERIC NORA‐BE ...... GENERIC JUNEL FE 24 ...... GENERIC NORETHINDRONE ...... GENERIC KAITLIB FE ...... GENERIC NORETHINDRONE ACETATE ...... GENERIC KALLIGA ...... GENERIC NORETHINDRONE‐ETH ESTRADIOL‐FE ...... GENERIC KARIVA ...... GENERIC NORETHINDRONE‐ETHIN ESTRADIOL ...... GENERIC KELNOR 1‐35 ...... GENERIC NORETHINDRONE‐ETHINYL ESTRADIOL ...... GENERIC

5 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. NORETHIN‐ETH ESTRA‐FERROUS FUM ...... GENERIC TRIVORA ...... GENERIC NORGESTIMATE‐ETHINYL ESTRADIOL ...... GENERIC TRIVORA‐28 ...... GENERIC NORGESTIMATE‐ETHINYL ESTRADIOL ...... GENERIC TRI‐VYLIBRA ...... GENERIC NORGESTREL‐ETHINY ESTRA ...... GENERIC TRI‐VYLIBRA LO ...... GENERIC NORLYDA ...... GENERIC TULANA ...... GENERIC NORLYROC ...... GENERIC TYDEMY ...... GENERIC NORTREL ...... GENERIC VCF ...... GENERIC OCELLA ...... GENERIC VELIVET ...... GENERIC OGESTREL ...... GENERIC VESTURA ...... GENERIC OPCICON ONE‐STEP ...... GENERIC VIENVA ...... GENERIC OPTION 2 ...... GENERIC VIORELE ...... GENERIC ORSYTHIA ...... GENERIC VOLNEA ...... GENERIC PHILITH ...... GENERIC VYFEMLA ...... GENERIC PIMTREA ...... GENERIC VYLIBRA ...... GENERIC PIRMELLA ...... GENERIC WERA...... GENERIC PORTIA ...... GENERIC WYMZYA FE ...... GENERIC PREVIFEM ...... GENERIC XULANE ...... GENERIC PROGESTERONE ...... GENERIC ZARAH ...... GENERIC QUASENSE ...... GENERIC ZENCHENT ...... GENERIC RAJANI ...... GENERIC ZENCHENT FE ...... GENERIC RECLIPSEN ...... GENERIC ZOVIA ...... GENERIC RIVELSA ...... GENERIC ZOVIA 1‐35E ...... GENERIC SETLAKIN ...... GENERIC ZOVIA 1‐50E ...... GENERIC SHAROBEL ...... GENERIC ZUMANDIMINE ...... GENERIC SIMLIYA ...... GENERIC AFTERA ...... BRAND SIMPESSE ...... GENERIC ANNOVERA ...... BRAND SPRINTEC ...... GENERIC BALCOLTRA ...... BRAND SRONYX ...... GENERIC BEYAZ ...... BRAND SYEDA ...... GENERIC BREVICON ...... BRAND TARINA 24 FE ...... GENERIC CAYA CONTOURED ...... BRAND TARINA FE ...... GENERIC CONCEPTROL ...... BRAND TARINA FE 1‐20 EQ ...... GENERIC CYCLESSA ...... BRAND TILIA FE ...... GENERIC DEPO‐PROVERA ...... BRAND TRI FEMYNOR ...... GENERIC DEPO‐SUBQ PROVERA ...... BRAND TRI‐ESTARYLLA ...... GENERIC ELLA ...... BRAND TRI‐LEGEST FE ...... GENERIC ESTROSTEP FE ...... BRAND TRI‐LINYAH ...... GENERIC FC2 FEMALE ...... BRAND TRI‐LO‐ESTARYLLA ...... GENERIC FEMCAP ...... BRAND TRI‐LO‐MARZIA ...... GENERIC GENERESS FE ...... BRAND TRI‐LO‐MILI ...... GENERIC KYLEENA ...... BRAND TRI‐LO‐SPRINTEC ...... GENERIC LILETTA ...... BRAND TRI‐MILI ...... GENERIC LO LOESTRIN FE ...... BRAND TRINESSA ...... GENERIC LOESTRIN ...... BRAND TRINESSA LO ...... GENERIC LOESTRIN FE ...... BRAND TRI‐PREVIFEM ...... GENERIC LOSEASONIQUE ...... BRAND TRI‐SPRINTEC ...... GENERIC MICROGESTIN 24 FE ...... BRAND

6 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. MINASTRIN 24 FE ...... BRAND METOLAZONE ...... GENERIC MIRCETTE ...... BRAND SPIRONOLACTONE ...... GENERIC MIRENA ...... BRAND SPIRONOLACTONE‐HCTZ ...... GENERIC NATAZIA ...... BRAND TORSEMIDE ...... GENERIC NEXPLANON ...... BRAND TRIAMTERENE ...... GENERIC NUVARING ...... BRAND TRIAMTERENE‐HCTZ ...... GENERIC ORTHO MICRONOR ...... BRAND TRIAMTERENE‐HYDROCHLOROTHIAZID ..... GENERIC ORTHO TRI‐CYCLEN ...... BRAND ORTHO TRI‐CYCLEN LO ...... BRAND Estrogens/Estrogen Combinations ORTHO‐CEPT ...... BRAND ORTHO‐CYCLEN ...... BRAND AMABELZ ...... GENERIC ORTHO‐NOVUM ...... BRAND COVARYX ...... GENERIC PARAGARD T 380‐A ...... BRAND COVARYX H.S...... GENERIC PHEXXI ...... BRAND DOTTI ...... GENERIC PLAN B ONE‐STEP ...... BRAND EEMT ...... GENERIC QUARTETTE ...... BRAND EEMT H.S...... GENERIC SAFYRAL ...... BRAND ESTRADIOL ...... GENERIC SEASONIQUE ...... BRAND ESTRADIOL (ONCE WEEKLY) ...... GENERIC SKYLA ...... BRAND ESTRADIOL (TWICE WEEKLY) ...... GENERIC SLYND ...... BRAND ESTRADIOL VALERATE ...... GENERIC TAKE ACTION ...... BRAND ESTRADIOL‐NORETHINDRONE ACETAT ...... GENERIC TAYTULLA ...... BRAND ESTROGEN‐METHYLTESTOSTERONE ...... GENERIC TODAY CONTRACEPTIVE SPONGE ...... BRAND ESTROPIPATE ...... GENERIC TRI‐NORINYL ...... BRAND FYAVOLV ...... GENERIC TWIRLA ...... BRAND JEVANTIQUE LO ...... GENERIC WIDE SEAL DIAPHRAGM ...... BRAND JINTELI ...... GENERIC YASMIN ...... BRAND LOPREEZA ...... GENERIC YAZ ...... BRAND MIMVEY ...... GENERIC MIMVEY LO ...... GENERIC Diuretics Gout Therapy ACETAZOLAMIDE ...... GENERIC ACETAZOLAMIDE ER ...... GENERIC ALLOPURINOL ...... GENERIC AMILORIDE ...... GENERIC ALOPRIM ...... GENERIC AMILORIDE‐HYDROCHLOROTHIAZIDE ...... GENERIC COLCHICINE ...... GENERIC BUMETANIDE ...... GENERIC FEBUXOSTAT ...... GENERIC CHLOROTHIAZIDE ...... GENERIC CHLORTHALIDONE ...... GENERIC EPLERENONE ...... GENERIC HIV/AIDS Therapy ETHACRYNATE ...... GENERIC ETHACRYNIC ACID ...... GENERIC ABACAVIR ...... GENERIC FUROSEMIDE ...... GENERIC ABACAVIR‐LAMIVUDINE ...... GENERIC HYDROCHLOROTHIAZIDE ...... GENERIC ABACAVIR‐LAMIVUDINE‐ZIDOVUDINE ...... GENERIC INDAPAMIDE ...... GENERIC ATAZANAVIR SULFATE ...... GENERIC METHAZOLAMIDE ...... GENERIC DIDANOSINE ...... GENERIC METHYCLOTHIAZIDE ...... GENERIC EFAVIRENZ ...... GENERIC 7 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. EFAVIRENZ‐LAMIVU‐TENOFOV DISOP ...... GENERIC BUDESONIDE‐FORMOTEROL FUMARATE ..... BRAND FOSAMPRENAVIR ...... GENERIC DULERA ...... BRAND LAMIVUDINE ...... GENERIC FLOVENT DISKUS ...... BRAND LAMIVUDINE‐ZIDOVUDINE ...... GENERIC FLOVENT HFA ...... BRAND LOPINAVIR‐RITONAVIR ...... GENERIC PULMICORT ...... BRAND NEVIRAPINE ...... GENERIC PULMICORT FLEXHALER ...... BRAND NEVIRAPINE ER ...... GENERIC QVAR ...... BRAND RITONAVIR ...... GENERIC QVAR REDIHALER ...... BRAND STAVUDINE ...... GENERIC SYMBICORT ...... BRAND TENOFOVIR DISOPROXIL FUMARATE ...... GENERIC TRELEGY ELLIPTA ...... BRAND ZIDOVUDINE ...... GENERIC DESCOVY ...... BRAND Insulin Therapy TRUVADA ...... BRAND VIREAD ...... BRAND ADMELOG...... BRAND ADMELOG SOLOSTAR...... BRAND Immunosuppressant Drugs AFREZZA ...... BRAND APIDRA ...... BRAND AZATHIOPRINE ...... GENERIC APIDRA SOLOSTAR ...... BRAND CYCLOSPORINE ...... GENERIC BASAGLAR KWIKPEN U‐100 ...... BRAND EVEROLIMUS ...... GENERIC FIASP ...... BRAND GENGRAF ...... GENERIC FIASP FLEXTOUCH ...... BRAND MYCOPHENOLATE MOFETIL ...... GENERIC HUMALOG ...... BRAND MYCOPHENOLIC ACID ...... GENERIC HUMALOG JUNIOR KWIKPEN ...... BRAND SIROLIMUS ...... GENERIC HUMALOG KWIKPEN U‐100 ...... BRAND TACROLIMUS ...... GENERIC HUMALOG KWIKPEN U‐200 ...... BRAND HUMALOG MIX 50‐50 ...... BRAND Inhaled Corticosteroids HUMALOG MIX 50‐50 KWIKPEN ...... BRAND HUMALOG MIX 75‐25 ...... BRAND BUDESONIDE ...... GENERIC HUMALOG MIX 75‐25 KWIKPEN ...... BRAND FLUTICASONE‐SALMETEROL ...... GENERIC HUMULIN 70/30 KWIKPEN ...... BRAND WIXELA INHUB ...... GENERIC HUMULIN 70‐30 ...... BRAND ADVAIR DISKUS ...... BRAND HUMULIN N ...... BRAND ADVAIR HFA ...... BRAND HUMULIN N KWIKPEN ...... BRAND AEROSPAN ...... BRAND HUMULIN R ...... BRAND AIRDUO RESPICLICK ...... BRAND HUMULIN R U‐500 ...... BRAND ALVESCO ...... BRAND HUMULIN R U‐500 KWIKPEN ...... BRAND AIRDUO DIGIHALER ...... BRAND INSULIN ASPART ...... BRAND AIRDUO RESPICLICK ...... BRAND INSULIN ASPART FLEXPEN ...... BRAND ALVESCO ...... BRAND INSULIN ASPART PENFILL ...... BRAND ARMONAIR DIGIHALER ...... BRAND INSULIN ASPART PROT‐INSULN ASP ...... BRAND ARMONAIR RESPICLICK ...... BRAND INSULIN LISPRO ...... BRAND ARNUITY ELLIPTA ...... BRAND INSULIN LISPRO JUNIOR KWIKPEN ...... BRAND ASMANEX ...... BRAND INSULIN LISPRO KWIKPEN U‐100 ...... BRAND ASMANEX HFA ...... BRAND INSULIN LISPRO PROTAMINE MIX ...... BRAND BREO ELLIPTA ...... BRAND LANTUS ...... BRAND BREZTRI AEROSPHERE ...... BRAND LANTUS SOLOSTAR ...... BRAND 8 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. LEVEMIR ...... BRAND ROSUVASTATIN ...... GENERIC LEVEMIR FLEXTOUCH ...... BRAND ROSUVASTATIN CALCIUM ...... GENERIC LYUMJEV ...... BRAND SIMVASTATIN ...... GENERIC LYUMJEV KWIKPEN U‐100 ...... BRAND ALTOPREV ...... BRAND LYUMJEV KWIKPEN U‐200 ...... BRAND CRESTOR ...... BRAND MYXREDLIN ...... BRAND EZALLOR SPRINKLE ...... BRAND NOVOLIN 70‐30 ...... BRAND FLOLIPID ...... BRAND NOVOLIN 70‐30 FLEXPEN ...... BRAND LESCOL ...... BRAND NOVOLIN N ...... BRAND LESCOL XL ...... BRAND NOVOLIN N FLEXPEN ...... BRAND LIPITOR ...... BRAND NOVOLIN R ...... BRAND LIVALO ...... BRAND NOVOLIN R FLEXPEN ...... BRAND PRAVACHOL ...... BRAND NOVOLOG...... BRAND ZOCOR ...... BRAND NOVOLOG FLEXPEN ...... BRAND ZYPITAMAG ...... BRAND NOVOLOG MIX 70‐30 ...... BRAND NOVOLOG MIX 70‐30 FLEXPEN ...... BRAND Non‐Insulin Hypoglycemic Agents SEMGLEE ...... BRAND SEMGLEE PEN ...... BRAND ACARBOSE ...... GENERIC TOUJEO MAX SOLOSTAR ...... BRAND CHLORPROPAMIDE ...... GENERIC TOUJEO SOLOSTAR ...... BRAND GLIMEPIRIDE ...... GENERIC TRESIBA ...... BRAND GLIPIZIDE ...... GENERIC TRESIBA FLEXTOUCH U‐100 ...... BRAND GLIPIZIDE ER ...... GENERIC TRESIBA FLEXTOUCH U‐200 ...... BRAND GLIPIZIDE XL ...... GENERIC GLIPIZIDE‐METFORMIN ...... GENERIC Leukotriene Antagonists/Modifiers GLYBURIDE ...... GENERIC GLYBURIDE MICRONIZED ...... GENERIC MONTELUKAST ...... GENERIC GLYBURIDE‐METFORMIN ...... GENERIC ZAFIRLUKAST ...... GENERIC METFORMIN ...... GENERIC ZILEUTON ER ...... GENERIC METFORMIN ER ...... GENERIC METFORMIN ER GASTRIC ...... GENERIC Lipid/Cholesterol Lowering Agents* METFORMIN ER OSMOTIC ...... GENERIC MIGLITOL ...... GENERIC AMLODIPINE‐ATORVASTATIN ...... GENERIC NATEGLINIDE ...... GENERIC ATORVASTATIN ...... GENERIC PIOGLITAZONE ...... GENERIC CHOLESTYRAMINE ...... GENERIC PIOGLITAZONE‐GLIMEPIRIDE ...... GENERIC CHOLESTYRAMINE LIGHT ...... GENERIC PIOGLITAZONE‐METFORMIN ...... GENERIC COLESEVELAM ...... GENERIC REPAGLINIDE ...... GENERIC COLESTIPOL ...... GENERIC REPAGLINIDE‐METFORMIN ...... GENERIC EZETIMIBE‐SIMVASTATIN...... GENERIC TOLAZAMIDE ...... GENERIC FLUVASTATIN ...... GENERIC TOLBUTAMIDE ...... GENERIC FLUVASTATIN ER ...... GENERIC ACTOPLUS MET ...... BRAND FLUVASTATIN SODIUM ...... GENERIC ACTOPLUS MET XR ...... BRAND LOVASTATIN ...... GENERIC ACTOS ...... BRAND PRAVASTATIN ...... GENERIC ADLYXIN ...... BRAND PRAVASTATIN SODIUM ...... GENERIC ALOGLIPTIN ...... BRAND PREVALITE ...... GENERIC ALOGLIPTIN‐METFORMIN ...... BRAND 9 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. ALOGLIPTIN‐PIOGLITAZONE ...... BRAND STARLIX ...... BRAND AMARYL ...... BRAND STEGLATRO ...... BRAND AVANDAMET ...... BRAND STEGLUJAN ...... BRAND AVANDIA ...... BRAND SYMLINPEN 120 ...... BRAND BYDUREON ...... BRAND SYMLINPEN 60 ...... BRAND BYDUREON BCISE ...... BRAND SYNJARDY ...... BRAND BYDUREON PEN ...... BRAND SYNJARDY XR ...... BRAND BYETTA ...... BRAND TANZEUM ...... BRAND CYCLOSET ...... BRAND TRADJENTA ...... BRAND DM2 ...... BRAND TRULICITY ...... BRAND DUETACT ...... BRAND VICTOZA 2‐PAK ...... BRAND FARXIGA ...... BRAND VICTOZA 3‐PAK ...... BRAND FORTAMET ...... BRAND XIGDUO XR ...... BRAND GLUCOPHAGE ...... BRAND XULTOPHY 100‐3.6 ...... BRAND GLUCOPHAGE XR ...... BRAND GLUCOTROL...... BRAND Osteoporosis Therapy GLUCOTROL XL ...... BRAND GLUCOVANCE ...... BRAND ALENDRONATE ...... GENERIC GLUMETZA ...... BRAND CALCITONIN‐SALMON ...... GENERIC GLYNASE ...... BRAND ETIDRONATE...... GENERIC GLYSET ...... BRAND IBANDRONATE ...... GENERIC GLYXAMBI ...... BRAND PAMIDRONATE ...... GENERIC INVOKAMET ...... BRAND RALOXIFENE ...... GENERIC INVOKAMET XR ...... BRAND RISEDRONATE ...... GENERIC INVOKANA ...... BRAND RISEDRONATE DR ...... GENERIC JANUMET ...... BRAND ZOLEDRONIC ACID ...... GENERIC JANUMET XR ...... BRAND JANUVIA ...... BRAND JARDIANCE ...... BRAND Phosphate Binding Agents JENTADUETO ...... BRAND JENTADUETO XR ...... BRAND CALCIUM ...... GENERIC KAZANO ...... BRAND ELIPHOS ...... GENERIC KOMBIGLYZE XR ...... BRAND LANTHANUM CARBONATE ...... GENERIC METFORMIN ...... BRAND SEVELAMER ...... GENERIC NESINA ...... BRAND SEVELAMER CARBONATE ...... GENERIC ONGLYZA ...... BRAND OSENI ...... BRAND Smoking Cessation OZEMPIC ...... BRAND PRANDIN ...... BRAND BUPROPION SR ...... GENERIC PRECOSE ...... BRAND NICORELIEF ...... GENERIC QTERN ...... BRAND NICORETTE ...... GENERIC RIOMET ...... BRAND NICOTINE ...... GENERIC RIOMET ER ...... BRAND NICOTINE GUM ...... GENERIC RYBELSUS ...... BRAND NICOTINE LOZENGE ...... GENERIC SEGLUROMET ...... BRAND NICOTINE PATCH ...... GENERIC SOLIQUA 100‐33...... BRAND NTS ...... GENERIC

10 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit. QUIT 2 ...... GENERIC FLUVIRIN ...... BRAND QUIT 4 ...... GENERIC FLUZONE ...... BRAND STOP SMOKING AID ...... GENERIC FLUZONE HIGH‐DOSE ...... BRAND CHANTIX ...... BRAND FLUZONE HIGH‐DOSE QUAD 2020‐21 ...... BRAND NICODERM CQ ...... BRAND FLUZONE QUAD 2019‐2020 ...... BRAND NICORETTE ...... BRAND FLUZONE QUAD 2020‐2021 ...... BRAND NICOTINE ...... BRAND FLUZONE QUAD PEDI 2019‐2020 ...... BRAND NICOTROL ...... BRAND INFANRIX ...... BRAND NICOTROL NS ...... BRAND MENACTRA ...... BRAND ZYBAN ...... BRAND MENVEO A‐C‐Y‐W‐135‐DIP ...... BRAND PNEUMOVAX 23 ...... BRAND Vaccine PREVNAR 13 ...... BRAND SHINGRIX ...... BRAND ADACEL ...... BRAND TENIVAC ...... BRAND AFLURIA ...... BRAND TETANUS DIPHTHERIA TOXOIDS ...... BRAND AFLURIA QUAD 2019‐20 (3YR UP) ...... BRAND TRUMENBA ...... BRAND AFLURIA QUAD 2019‐20 (6‐35MO) ...... BRAND ZOSTAVAX ...... BRAND AFLURIA QUAD 2019‐2020 ...... BRAND AFLURIA QUAD 2020‐2021 ...... BRAND Vitamins/Minerals AFLURIA QUAD 2020‐21 (3YR UP) ...... BRAND AFLURIA QUAD 2020‐21 (6‐35MO) ...... BRAND CALCITRIOL ...... GENERIC BEXSERO ...... BRAND FLUORIDE ...... GENERIC BOOSTRIX ...... BRAND FLUORITAB ...... GENERIC DAPTACEL ...... BRAND FOLIC ACID ...... GENERIC DIPHTHERIA‐TETANUS TOXOIDS‐PED ...... BRAND IRON ...... GENERIC FLUAD 2019‐2020 ...... BRAND LUDENT FLUORIDE ...... GENERIC FLUAD 2020‐2021 ...... BRAND POTASSIUM CHLORIDE ...... GENERIC FLUARIX ...... BRAND PRESCRIPTION PRENATAL VITAMINS ...... GENERIC FLUBLOK QUAD 2019‐2020 ...... BRAND SODIUM FLUORIDE ...... GENERIC FLUBLOK QUAD 2020‐2021 ...... BRAND FA‐8 ...... BRAND FLUCELVAX QUAD 2019‐2020 ...... BRAND FLUORABON ...... BRAND FLUCELVAX QUAD 2020‐2021 ...... BRAND FLURA‐DROPS ...... BRAND FLULAVAL ...... BRAND FLUMIST ...... BRAND

Revised October 12, 2020 11485 Working File

11 *Restrictions apply. Please consult your doctor or pharmacist for more information. The presence of a drug on this list does not guarantee specific coverage benefits. In some cases, additional information — such as the dose of the medication or the age of the member — must be taken into consideration when determining benefit.