Multi-Tier Enhanced Drug List

October 2019

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

The drug list is regularly updated. You can view the most up-to-date list, or the specialty drug list, at MyPrime.com.

Contents Therapeutic Class Drug List Introduction ...... I Anti-Infective Agents ...... 1 How drugs are selected ...... I Cancer Drugs ...... 3 How member payment is determined ...... I Hormones, Diabetes and Related Drugs ...... 4 How to use this list ...... II Heart and Circulatory Drugs ...... 9 Generic drugs ...... III Respiratory Agents ...... 13 Coverage considerations ...... IV Gastrointestinal Drugs ...... 15 Specialty drugs ...... V Genitourinary Drugs ...... 16 Abbreviation/acronym key ...... VI Central Nervous System Drugs ...... 16 Pain Relief Drugs ...... 19 Neuromuscular Drugs ...... 21 Supplements...... 22 Blood Modifying Drugs ...... 23 Topical Products ...... 28 Miscellaneous Categories (includes Supplies and Devices) ...... 30 Index ...... 31

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4621-D HCSC © Prime Therapeutics LLC 10/19 Introduction Blue Cross and Blue Shield is pleased to present the 2019 Drug List. This is a list of preferred drugs which includes brand drugs and a partial listing of generic drugs. Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However, decisions regarding therapy and treatment are always between members and their physician.

Drug List updates – This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit MyPrime.com and log in or call the number on your ID card.

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

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

How member payment is determined This list shows prescription drug products in tiers. Generally, each drug is placed into one of up to six member payment tiers: Preferred Generic (Tier 1), Non-Preferred Generic (Tier 2), Preferred Brand (Tier 3), Non-Preferred Brand (Tier 4), Preferred Specialty (Tier 5) and Non-Preferred Specialty (Tier 6). Non-Preferred Brand and Non- Preferred Specialty drugs are not listed in this document. Based on your benefit design, drugs can either be in these tiers or you may have fewer tiers, e.g., all generics in one tier. Note: Covered substance use disorder drugs (those FDA-approved for treatment of opioid drug abuse, alcohol abuse and to quit tobacco use) may be in the lowest tiers. Substance use disorder brand drugs may be in the lowest brand tier and generic drugs in the lowest generic tier, based on your benefit plan. To verify your payment amount for a drug, visit myprime.com and log in or call the number on your ID card.

Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Prescription products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA- approved for self-administration may be available through your medical benefit.

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List I How to use this list Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand drug is usually a non-preferred (NP) brand and is only included as a reference to the brand. Some generic products have no reference brand.

Example: atorvastatin (Lipitor) Brand drugs are listed in all CAPITAL letters. Example: PROAIR HFA Drugs used to treat multiple conditions

Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use. Please note: Drugs that need a health care provider to administer them and are often given to you in a hospital, doctor’s office or other health care setting may be covered under your medical benefit. Some types of these drugs are contraceptive implants and chemo infusions. If you are taking or are prescribed a drug that is not on this drug list, call the number on your ID card to see if the drug may be covered.

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List II

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

There are two types of generic drugs: • A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. • A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. According to the FDA, compared to its brand counterpart, an FDA-approved generic drug: • Is chemically the same • Works just as well in the body • Is as safe and effective • Meets the same standards set by the FDA The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less. Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.

You may be responsible for your member share payment amount (copay/coinsurance) plus the difference in cost between the brand and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs generally have the lowest member payment amount. Consider talking to your doctor about generic drugs

If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor.

Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List III Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction or weight loss. Also, some drugs may only be covered for members within a certain age range due to the drug being used for cosmetic purposes or for safety concerns. Drug coverage may be limited to recommendations based on FDA-approved labeling and recognized evidence-based or clinical practice guidelines. Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan material for details about your particular benefits. Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please see your plan materials or call the number on your ID card to determine whether compounded medications are covered and/or verify your payment amount.

Repackaged medications: Repackaged versions of medications already available on the market are not covered. Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication may be covered under your plan. For the medications listed in this document, if a prior authorization is commonly required, it will generally be noted next to the medication with a dot under the prior authorization column. Some plans may have prior authorization on additional medications beyond those noted in this document. Refer to your benefit plan materials for details about your particular benefits. Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the medications listed in this document, if a step therapy is commonly required, it will generally be noted next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on additional medications beyond those noted in this document. Refer to your benefit plan materials for details about your particular benefits. Dispensing Limits (DL): Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the dispensing limits column. Limits may include: quantity of covered medication per prescription or quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you may be responsible for the full cost of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit myprime.com. *Please note: For certain controlled substance medications, some state laws may not allow coverage by a health benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the dispensing limit. Remember, medication decisions are between you and your doctor. Only you and your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor. Blue Cross and Blue Shield does not provide health care services and, therefore, cannot guarantee any results or outcomes.

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List IV Specialty drugs Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be self-administered or administered by a health care professional. For a current list of specialty medications, visit MyPrime.com.

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

Through AllianceRx Walgreens Prime, members can have covered specialty medications delivered directly to them or their doctor’s office. When you receive specialty medications through AllianceRx Walgreens Prime, you also receive at no additional charge the following services: • Coordination of coverage between you, your doctor and your health plan • Educational materials about your particular condition and information about managing potential medication side effects • Syringes, sharps containers and other supplies with every shipment for self-injectables • 24/7/365 phone access to a pharmacist for urgent medication issues To order throughAllianceRx Walgreens Prime: • Have your doctor call 877-627-6337 or e-prescribe your prescription to AllianceRx Walgreens Prime. Your doctor can find e-prescribing information at www.alliancerxwp.com. • If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to transfer your prescription. • A coordinator will contact you to arrange delivery of your medication. • The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging. If you have questions, please contact AllianceRx Walgreens Prime at 877-627-6337, visit www.alliancerxwp.com, or call the number on your ID card. * Blue Cross and Blue Shield of Illinois (BCBSIL), Blue Cross and Blue Shield of Montana (BCBSMT), Blue Cross and Blue Shield of New Mexico (BCBSNM), Blue Cross and Blue Shield of Oklahoma (BCBSOK), and Blue Cross and Blue Shield of Texas (BCBSTX) are Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross Blue Shield Association. BCBSIL, BCBSMT, BCBSNM, BCBSOK, and BCBSTX contract with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, BCBSMT, BCBSNM, BCBSOK, and BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, have an ownership interest in Prime Therapeutics LLC.

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List V Abbreviation/acronym key caps ...... capsules odt ...... orally disintegrating tablets chew ...... chewable oint ...... ointment conc ...... concentrate ophth ...... ophthalmic cr ...... controlled release osm ...... osmotic release dr ...... delayed release powd ...... powder ec ...... enteric coated sa ...... sustained action effe ...... effervescent sl ...... sublingual equiv ...... equivalent soln ...... solution er ...... extended release sr ...... sustained release inhal ...... inhalation suppos ...... suppositories inj ...... injection susp ...... suspension liq ...... liquid tab...... tablets lotn ...... lotion td ...... transdermal nebu...... nebulizer

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List VI 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ANTI-INFECTIVE AGENTS levofloxacin tab 250 mg (Levaquin) PENICILLINS levofloxacin tab 500 mg (Levaquin) amoxicillin (trihydrate) cap 250 mg levofloxacin tab 750 mg (Levaquin) amoxicillin (trihydrate) cap 500 mg AMINOGLYCOSIDES amoxicillin (trihydrate) for susp neomycin sulfate tab 500 mg 125 mg/5ml TUBERCULOSIS amoxicillin (trihydrate) for susp isoniazid tab 100 mg 200 mg/5ml isoniazid tab 300 mg amoxicillin (trihydrate) for susp 250 mg/5ml PRIFTIN – rifapentine tab 150 mg amoxicillin (trihydrate) for susp FUNGAL INFECTIONS 400 mg/5ml fluconazole for susp 10 mg/ml amoxicillin (trihydrate) tab 500 mg (Diflucan) amoxicillin (trihydrate) tab 875 mg fluconazole tab 50 mg (Diflucan) penicillin v potassium tab 250 mg fluconazole tab 100 mg (Diflucan) penicillin v potassium tab 500 mg fluconazole tab 150 mg (Diflucan) CEPHALOSPORINS ketoconazole tab 200 mg cefadroxil cap 500 mg NOXAFIL – posaconazole tab delayed • release 100 mg cephalexin cap 250 mg (Keflex) NOXAFIL – posaconazole susp 40 mg/ • cephalexin cap 500 mg (Keflex) ml MACROLIDES terbinafine hcl tab 250 mg (Lamisil) azithromycin tab 250 mg (Zithromax) • VIRAL INFECTIONS azithromycin tab 500 mg (Zithromax) • Hepatitis TETRACYCLINES BARACLUDE – entecavir oral soln 0.05 minocycline hcl cap 50 mg (Minocin) mg/ml minocycline hcl cap 75 mg (Minocin) EPCLUSA – sofosbuvir-velpatasvir tab • • minocycline hcl cap 100 mg (Minocin) 400-100 mg FLUOROQUINOLONES HARVONI – ledipasvir-sofosbuvir tab • • 90-400 mg ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) MAVYRET – glecaprevir-pibrentasvir • • tab 100-40 mg ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) PEGASYS – peginterferon alfa-2a inj • • 180 mcg/ml ciprofloxacin hcl tab 750 mg (base equiv) PEGASYS – peginterferon alfa-2a inj • • 180 mcg/0.5ml

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 1 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy PEGASYS PROCLICK – peginterferon • • KALETRA – lopinavir-ritonavir tab • alfa-2a inj 180 mcg/0.5ml 100-25 mg SOVALDI – sofosbuvir tab 400 mg • • KALETRA – lopinavir-ritonavir tab • VOSEVI – sofosbuvir-velpatasvir- • • 200-50 mg voxilaprevir tab 400-100-100 mg nevirapine tab 200 mg (Viramune) • Herpes NORVIR – ritonavir oral soln 80 mg/ml • acyclovir cap 200 mg (Zovirax) NORVIR – ritonavir powder packet 100 • acyclovir tab 400 mg (Zovirax) mg acyclovir tab 800 mg (Zovirax) ODEFSEY – emtricitabine-rilpivirine- • tenofovir af tab 200-25-25 mg HIV/AIDS PREZISTA – darunavir ethanolate susp • ATRIPLA – efavirenz-emtricitabine- • 100 mg/ml (base equiv) tenofovir df tab 600-200-300 mg PREZISTA – darunavir ethanolate tab • BIKTARVY – bictegravir-emtricitabine- • 75 mg (base equiv) tenofovir af tab 50-200-25 mg PREZISTA – darunavir ethanolate tab • CIMDUO – lamivudine-tenofovir • 150 mg (base equiv) disoproxil fumarate tab 300-300 mg PREZISTA – darunavir ethanolate tab • DELSTRIGO – doravirine-lamivudine- • 600 mg (base equiv) tenofovir df tab 100-300-300 mg PREZISTA – darunavir ethanolate tab • DESCOVY – emtricitabine-tenofovir • 800 mg (base equiv) alafenamide fumarate tab 200-25 mg SYMFI – efavirenz-lamivudine-tenofovir • GENVOYA – elvitegrav-cobic- • df tab 600-300-300 mg emtricitab-tenofov af tab 150-150-200-10 mg SYMFI LO – efavirenz-lamivudine- • tenofovir df tab 400-300-300 mg INTELENCE – etravirine tab 25 mg • TIVICAY – dolutegravir sodium tab 10 • INTELENCE – etravirine tab 100 mg • mg (base equiv) INTELENCE – etravirine tab 200 mg • TIVICAY – dolutegravir sodium tab 25 • ISENTRESS – raltegravir potassium • mg (base equiv) packet for susp 100 mg (base equiv) TIVICAY – dolutegravir sodium tab 50 • ISENTRESS – raltegravir potassium • mg (base equiv) tab 400 mg (base equiv) TRUVADA – emtricitabine-tenofovir • ISENTRESS – raltegravir potassium • disoproxil fumarate tab 100-150 mg chew tab 25 mg (base equiv) TRUVADA – emtricitabine-tenofovir • ISENTRESS – raltegravir potassium • disoproxil fumarate tab 133-200 mg chew tab 100 mg (base equiv) TRUVADA – emtricitabine-tenofovir • ISENTRESS HD – raltegravir • disoproxil fumarate tab 167-250 mg potassium tab 600 mg (base equiv)

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 2 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy TRUVADA – emtricitabine-tenofovir • SULFADIAZINE – sulfadiazine tab 500 disoproxil fumarate tab 200-300 mg mg VIDEX – didanosine for soln 2 gm • sulfamethoxazole-trimethoprim susp VIREAD – tenofovir disoproxil fumarate • 200-40 mg/5ml oral powder 40 mg/gm sulfamethoxazole-trimethoprim tab VIREAD – tenofovir disoproxil fumarate • 400-80 mg (Bactrim) tab 150 mg sulfamethoxazole-trimethoprim tab VIREAD – tenofovir disoproxil fumarate • 800-160 mg (Bactrim ds) tab 200 mg trimethoprim tab 100 mg VIREAD – tenofovir disoproxil fumarate • XIFAXAN – rifaximin tab 550 mg • tab 250 mg CANCER DRUGS MALARIA ACTIMMUNE – interferon gamma-1b • CHLOROQUINE PHOSPHATE – inj 100 mcg/0.5ml (2000000 chloroquine phosphate tab 250 mg unit/0.5ml) chloroquine phosphate tab 500 mg anastrozole tab 1 mg (Arimidex) (Aralen) bicalutamide tab 50 mg (Casodex) • DARAPRIM – pyrimethamine tab 25 mg • • ERLEADA – apalutamide tab 60 mg • • • hydroxychloroquine sulfate tab KISQALI – ribociclib succinate tab pack • • • 200 mg (Plaquenil) 200 mg daily dose MEFLOQUINE HCL – mefloquine hcl KISQALI – ribociclib succinate tab pack • • • tab 250 mg 400 mg daily dose (200 mg tab) WORM INFECTIONS KISQALI – ribociclib succinate tab pack • • • BENZNIDAZOLE – benznidazole tab 600 mg daily dose (200 mg tab) 12.5 mg KISQALI FEMARA 200 DOSE – • • • BENZNIDAZOLE – benznidazole tab ribociclib 200 mg dose (200 mg tab) 100 mg & letrozole 2.5 mg tbpk OTHER ANTI-INFECTIVES KISQALI FEMARA 400 DOSE – • • • ALINIA – nitazoxanide tab 500 mg • ribociclib 400 mg dose (200 mg tab) & letrozole 2.5 mg tbpk ALINIA – nitazoxanide for susp 100 • mg/5ml KISQALI FEMARA 600 DOSE – • • • ribociclib 600 mg dose (200 mg tab) clindamycin hcl cap 75 mg (Cleocin) & letrozole 2.5 mg tbpk clindamycin hcl cap 150 mg (Cleocin) letrozole tab 2.5 mg (Femara) clindamycin hcl cap 300 mg (Cleocin) LEUCOVORIN CALCIUM – leucovorin IMPAVIDO – miltefosine cap 50 mg calcium tab 10 mg metronidazole tab 250 mg (Flagyl) LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg metronidazole tab 500 mg (Flagyl)

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 3 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy LEUKERAN – chlorambucil tab 2 mg • TARCEVA – erlotinib hcl tab 100 mg • • • megestrol acetate tab 20 mg (base equivalent) megestrol acetate tab 40 mg TARCEVA – erlotinib hcl tab 150 mg • • • (base equivalent) MEKINIST – trametinib dimethyl • • • sulfoxide tab 0.5 mg (base TASIGNA – nilotinib hcl cap 50 mg • • • equivalent) (base equivalent) MEKINIST – trametinib dimethyl • • • TASIGNA – nilotinib hcl cap 150 mg • • • sulfoxide tab 2 mg (base equivalent) (base equivalent) MYLERAN – busulfan tab 2 mg • TASIGNA – nilotinib hcl cap 200 mg • • • (base equivalent) NEXAVAR – sorafenib tosylate tab 200 • • • mg (base equivalent) VENCLEXTA – venetoclax tab 10 mg • • • RYDAPT – midostaurin cap 25 mg • • • VENCLEXTA – venetoclax tab 50 mg • • • SUTENT – sunitinib malate cap 12.5 • • • VENCLEXTA – venetoclax tab 100 mg • • • mg (base equivalent) VENCLEXTA STARTING PACK – • • • SUTENT – sunitinib malate cap 25 mg • • • venetoclax tab therapy starter pack (base equivalent) 10 & 50 & 100 mg SUTENT – sunitinib malate cap 37.5 • • • VOTRIENT – pazopanib hcl tab 200 mg • • • mg (base equivalent) (base equiv) SUTENT – sunitinib malate cap 50 mg • • • XALKORI – crizotinib cap 200 mg • • • (base equivalent) XALKORI – crizotinib cap 250 mg • • • SYLATRON – peginterferon alfa-2b for • • XTANDI – enzalutamide cap 40 mg • • • inj kit 200 mcg YONSA – abiraterone acetate tab 125 • • • SYLATRON – peginterferon alfa-2b for • • mg inj kit 300 mcg ZELBORAF – vemurafenib tab 240 mg • • • SYLATRON – peginterferon alfa-2b for • • ZYTIGA – abiraterone acetate tab 500 • • • inj kit 600 mcg mg TAFINLAR – dabrafenib mesylate cap • • • HORMONES, DIABETES AND RELATED DRUGS 50 mg (base equivalent) CORTICOSTEROIDS TAFINLAR – dabrafenib mesylate cap • • • 75 mg (base equivalent) CORTISONE ACETATE – cortisone acetate tab 25 mg tamoxifen citrate tab 10 mg (base equivalent) dexamethasone tab 0.5 mg tamoxifen citrate tab 20 mg (base dexamethasone tab 0.75 mg equivalent) dexamethasone tab 1.5 mg TARCEVA – erlotinib hcl tab 25 mg • • • dexamethasone tab 4 mg (base equivalent) dexamethasone tab 6 mg

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 4 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy prednisolone sod phosphate oral PREMPHASE – conj est 0.625(14)/conj soln 15 mg/5ml (base equiv) est-medroxypro ac tab 0.625-5mg(14) prednisone tab 1 mg PREMPRO – conjugated estrogen- prednisone tab 2.5 mg medroxyprogest acetate tab 0.3-1.5 mg prednisone tab 5 mg PREMPRO – conjugated estrogen- prednisone tab 10 mg medroxyprogest acetate tab 0.45-1.5 prednisone tab 20 mg mg ESTROGENS PREMPRO – conjugated estrogen- COMBIPATCH – estradiol- medroxyprogest acetate tab norethindrone ace td pttw 0.05-0.14 0.625-2.5 mg mg/day PREMPRO – conjugated estrogen- COMBIPATCH – estradiol- medroxyprogest acetate tab 0.625-5 norethindrone ace td pttw 0.05-0.25 mg mg/day PROGESTINS DIVIGEL – estradiol td gel 0.25 medroxyprogesterone acetate tab mg/0.25gm (0.1%) 2.5 mg (Provera) DIVIGEL – estradiol td gel 0.5 medroxyprogesterone acetate tab mg/0.5gm (0.1%) 5 mg (Provera) DIVIGEL – estradiol td gel 0.75 medroxyprogesterone acetate tab mg/0.75gm (0.1%) 10 mg (Provera) DIVIGEL – estradiol td gel 1 mg/gm BIRTH CONTROL (0.1%) desogestrel & ethinyl estradiol tab • estradiol tab 0.5 mg (Estrace) 0.15 mg-30 mcg (Desogen) estradiol tab 1 mg (Estrace) ELLA – ulipristal acetate tab 30 mg • estradiol tab 2 mg (Estrace) levonorgestrel & ethinyl estradiol tab • PREMARIN – estrogens, conjugated 0.1 mg-20 mcg tab 0.3 mg norethindrone & ethinyl estradiol tab • PREMARIN – estrogens, conjugated 1 mg-35 mcg (Norinyl 1+35) tab 0.45 mg norgestimate & ethinyl estradiol tab • PREMARIN – estrogens, conjugated 0.25 mg-35 mcg (Ortho-cyclen) tab 0.625 mg norgestimate-eth estrad tab • PREMARIN – estrogens, conjugated 0.18-35/0.215-35/0.25-35 mg-mcg tab 0.9 mg (Ortho tri-cyclen) PREMARIN – estrogens, conjugated NUVARING – etonogestrel-ethinyl • tab 1.25 mg estradiol va ring 0.120-0.015 mg/24hr INFERTILITY

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 5 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy CLOMIPHENE CITRATE – clomiphene GLYXAMBI – empagliflozin-linagliptin • citrate tab 50 mg tab 10-5 mg FOLLISTIM AQ – follitropin beta inj 300 • • GLYXAMBI – empagliflozin-linagliptin • unit/0.36ml tab 25-5 mg FOLLISTIM AQ – follitropin beta inj 600 • • INVOKAMET – canagliflozin-metformin • unit/0.72ml hcl tab 50-500 mg FOLLISTIM AQ – follitropin beta inj 900 • • INVOKAMET – canagliflozin-metformin • unit/1.08ml hcl tab 50-1000 mg DIABETES INVOKAMET – canagliflozin-metformin • glimepiride tab 1 mg (Amaryl) hcl tab 150-500 mg glimepiride tab 2 mg (Amaryl) INVOKAMET – canagliflozin-metformin • hcl tab 150-1000 mg glimepiride tab 4 mg (Amaryl) INVOKAMET XR – canagliflozin- • glipizide tab er 24hr 2.5 mg (Glucotrol metformin hcl tab er 24hr 50-500 mg xl) INVOKAMET XR – canagliflozin- • glipizide tab er 24hr 5 mg (Glucotrol metformin hcl tab er 24hr 50-1000 mg xl) INVOKAMET XR – canagliflozin- • glipizide tab 5 mg (Glucotrol) metformin hcl tab er 24hr 150-500 mg glipizide tab 10 mg (Glucotrol) INVOKAMET XR – canagliflozin- • GLUCAGON EMERGENCY KIT – metformin hcl tab er 24hr 150-1000 glucagon (rdna) for inj kit 1 mg mg glyburide micronized tab 1.5 mg INVOKANA – canagliflozin tab 100 mg • (Glynase) INVOKANA – canagliflozin tab 300 mg • glyburide micronized tab 3 mg JANUVIA – sitagliptin phosphate tab 25 • (Glynase) mg (base equiv) glyburide micronized tab 6 mg JANUVIA – sitagliptin phosphate tab 50 • (Glynase) mg (base equiv) glyburide tab 1.25 mg JANUVIA – sitagliptin phosphate tab • glyburide tab 2.5 mg 100 mg (base equiv) glyburide tab 5 mg JARDIANCE – empagliflozin tab 10 mg • glyburide-metformin tab 1.25-250 mg JARDIANCE – empagliflozin tab 25 mg • (Glucovance) KOMBIGLYZE XR – saxagliptin- • glyburide-metformin tab 2.5-500 mg metformin hcl tab er 24hr 2.5-1000 (Glucovance) mg glyburide-metformin tab 5-500 mg KOMBIGLYZE XR – saxagliptin- • (Glucovance) metformin hcl tab er 24hr 5-500 mg

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 6 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy KOMBIGLYZE XR – saxagliptin- • FIASP FLEXTOUCH – insulin aspart • metformin hcl tab er 24hr 5-1000 mg (with niacinamide) sol pen-inj 100 metformin hcl tab er 24hr 500 mg unit/ml (Glucophage xr) NOVOLOG – insulin aspart inj 100 unit/ • metformin hcl tab er 24hr 750 mg ml (Glucophage xr) NOVOLOG FLEXPEN – insulin aspart • metformin hcl tab 500 mg soln pen-injector 100 unit/ml (Glucophage) NOVOLOG PENFILL – insulin aspart • metformin hcl tab 850 mg soln cartridge 100 unit/ml (Glucophage) Short-Acting Insulins metformin hcl tab 1000 mg HUMULIN R U-500 (CONCENTR – • (Glucophage) insulin regular (human) inj 500 unit/ml ONGLYZA – saxagliptin hcl tab 2.5 mg • HUMULIN R U-500 KWIKPEN – insulin • (base equiv) regular (human) soln pen-injector 500 ONGLYZA – saxagliptin hcl tab 5 mg • unit/ml (base equiv) NOVOLIN R – insulin regular (human) • OZEMPIC – semaglutide soln pen-inj • • inj 100 unit/ml 0.25 or 0.5 mg/dose (2 mg/1.5ml) Intermediate-Acting Insulins OZEMPIC – semaglutide soln pen-inj 1 • • NOVOLIN N – insulin nph (human) • mg/dose (2 mg/1.5ml) (isophane) inj 100 unit/ml pioglitazone hcl tab 15 mg (base NOVOLIN 70/30 – insulin nph isophane • equiv) (Actos) & regular human inj 100 unit/ml pioglitazone hcl tab 30 mg (base (70-30) equiv) (Actos) NOVOLIN 70/30 FLEXPEN – insulin • pioglitazone hcl tab 45 mg (base nph & regular susp pen-inj 100 unit/ equiv) (Actos) ml (70-30) TRULICITY – dulaglutide soln pen- • • NOVOLOG MIX 70/30 – insulin aspart • injector 0.75 mg/0.5ml prot & aspart (human) inj 100 unit/ml (70-30) TRULICITY – dulaglutide soln pen- • • injector 1.5 mg/0.5ml NOVOLOG MIX 70/30 PREFILL – • insulin aspart prot & aspart sus pen- VICTOZA – liraglutide soln pen-injector • • inj 100 unit/ml (70-30) 18 mg/3ml (6 mg/ml) Basal Insulins DIABETES - INSULINS LANTUS – insulin glargine inj 100 unit/ • Rapid-Acting Insulins ml FIASP – insulin aspart (with • LANTUS SOLOSTAR – insulin glargine • niacinamide) inj 100 unit/ml soln pen-injector 100 unit/ml

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 7 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy LEVEMIR – insulin detemir inj 100 unit/ • levothyroxine sodium tab 200 mcg ml (Synthroid) LEVEMIR FLEXTOUCH – insulin • levothyroxine sodium tab 300 mcg detemir soln pen-injector 100 unit/ml (Synthroid) TOUJEO MAX SOLOSTAR – insulin • methimazole tab 5 mg (Tapazole) glargine soln pen-injector 300 unit/ml methimazole tab 10 mg (Tapazole) TOUJEO SOLOSTAR – insulin glargine • thyroid tab 30 mg (1/2 grain) (Armour soln pen-injector 300 unit/ml thyroid) TRESIBA – insulin degludec inj 100 • thyroid tab 60 mg (1 grain) (Armour unit/ml thyroid) TRESIBA FLEXTOUCH – insulin • thyroid tab 90 mg (1 1/2 grain) degludec soln pen-injector 100 unit/ (Armour thyroid) ml GROWTH HORMONE TRESIBA FLEXTOUCH – insulin • degludec soln pen-injector 200 unit/ INCRELEX – mecasermin inj 40 • ml mg/4ml (10 mg/ml) THYROID REGULATION OMNITROPE – somatropin for inj 5.8 • • mg levothyroxine sodium tab 25 mcg (Synthroid) OMNITROPE – somatropin inj 5 • • mg/1.5ml levothyroxine sodium tab 50 mcg (Synthroid) OMNITROPE – somatropin inj 10 • • mg/1.5ml levothyroxine sodium tab 75 mcg (Synthroid) OTHER HORMONES AND RELATED DRUGS levothyroxine sodium tab 88 mcg alendronate sodium tab 5 mg • (Synthroid) alendronate sodium tab 10 mg • levothyroxine sodium tab 100 mcg alendronate sodium tab 35 mg • (Synthroid) alendronate sodium tab 70 mg • levothyroxine sodium tab 112 mcg (Fosamax) (Synthroid) CYSTADANE – betaine powder for oral levothyroxine sodium tab 125 mcg solution (Synthroid) NITYR – nitisinone tab 2 mg • levothyroxine sodium tab 137 mcg NITYR – nitisinone tab 5 mg • (Synthroid) NITYR – nitisinone tab 10 mg • levothyroxine sodium tab 150 mcg (Synthroid) ORFADIN – nitisinone susp 4 mg/ml • levothyroxine sodium tab 175 mcg ORFADIN – nitisinone cap 2 mg • (Synthroid) ORFADIN – nitisinone cap 5 mg •

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 8 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ORFADIN – nitisinone cap 10 mg • enalapril maleate & ORFADIN – nitisinone cap 20 mg • hydrochlorothiazide tab 10-25 mg (Vaseretic) ORILISSA – elagolix sodium tab 150 • • mg (base equiv) enalapril maleate tab 2.5 mg (Vasotec) ORILISSA – elagolix sodium tab 200 • • mg (base equiv) enalapril maleate tab 5 mg (Vasotec) REVCOVI – elapegademase-lvlr im enalapril maleate tab 10 mg (Vasotec) soln 2.4 mg/1.5ml (1.6 mg/ml) enalapril maleate tab 20 mg (Vasotec) SENSIPAR – cinacalcet hcl tab 30 mg fosinopril sodium tab 10 mg (base equiv) fosinopril sodium tab 20 mg SENSIPAR – cinacalcet hcl tab 60 mg fosinopril sodium tab 40 mg (base equiv) lisinopril & hydrochlorothiazide tab SENSIPAR – cinacalcet hcl tab 90 mg 10-12.5 mg (Zestoretic) (base equiv) lisinopril & hydrochlorothiazide tab STIMATE – desmopressin acetate 20-12.5 mg (Zestoretic) nasal soln 1.5 mg/ml lisinopril & hydrochlorothiazide tab STRENSIQ – asfotase alfa • • 20-25 mg (Zestoretic) subcutaneous inj 18 mg/0.45ml lisinopril tab 2.5 mg (Zestril) STRENSIQ – asfotase alfa • • subcutaneous inj 28 mg/0.7ml lisinopril tab 5 mg (Prinivil) STRENSIQ – asfotase alfa • • lisinopril tab 10 mg (Prinivil) subcutaneous inj 40 mg/ml lisinopril tab 20 mg (Prinivil) STRENSIQ – asfotase alfa • • lisinopril tab 30 mg (Zestril) subcutaneous inj 80 mg/0.8ml lisinopril tab 40 mg (Zestril) TYMLOS – abaloparatide • • • perindopril erbumine tab 2 mg subcutaneous soln pen-injector 3120 mcg/1.56ml quinapril hcl tab 5 mg (Accupril) HEART AND CIRCULATORY DRUGS quinapril hcl tab 10 mg (Accupril) ANGIOTENSIN CONVERTING ENZYME (ACE) quinapril hcl tab 20 mg (Accupril) INHIBITORS AND COMBINATI quinapril hcl tab 40 mg (Accupril) benazepril hcl tab 5 mg ramipril cap 1.25 mg (Altace) benazepril hcl tab 10 mg (Lotensin) ramipril cap 2.5 mg (Altace) benazepril hcl tab 20 mg (Lotensin) ramipril cap 5 mg (Altace) benazepril hcl tab 40 mg (Lotensin) ramipril cap 10 mg (Altace) enalapril maleate & trandolapril tab 1 mg (Mavik) hydrochlorothiazide tab 5-12.5 mg trandolapril tab 2 mg (Mavik)

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 9 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy trandolapril tab 4 mg (Mavik) atenolol & chlorthalidone tab ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) 100-25 mg (Tenoretic 100) AND COMBINATIONS atenolol tab 25 mg (Tenormin) irbesartan tab 75 mg (Avapro) atenolol tab 50 mg (Tenormin) irbesartan tab 150 mg (Avapro) atenolol tab 100 mg (Tenormin) irbesartan tab 300 mg (Avapro) bisoprolol & hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab 2.5-6.25 mg (Ziac) 150-12.5 mg (Avalide) bisoprolol & hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab 5-6.25 mg (Ziac) 300-12.5 mg (Avalide) bisoprolol & hydrochlorothiazide tab losartan potassium & 10-6.25 mg (Ziac) hydrochlorothiazide tab 50-12.5 mg bisoprolol fumarate tab 5 mg (Hyzaar) (Zebeta) losartan potassium & carvedilol tab 3.125 mg (Coreg) hydrochlorothiazide tab carvedilol tab 6.25 mg (Coreg) 100-12.5 mg (Hyzaar) carvedilol tab 12.5 mg (Coreg) losartan potassium & hydrochlorothiazide tab 100-25 mg carvedilol tab 25 mg (Coreg) (Hyzaar) metoprolol succinate tab er 24hr losartan potassium tab 25 mg 25 mg (tartrate equiv) (Toprol xl) (Cozaar) metoprolol succinate tab er 24hr losartan potassium tab 50 mg 50 mg (tartrate equiv) (Toprol xl) (Cozaar) metoprolol tartrate tab 25 mg losartan potassium tab 100 mg metoprolol tartrate tab 50 mg (Cozaar) (Lopressor) valsartan-hydrochlorothiazide tab metoprolol tartrate tab 100 mg 80-12.5 mg (Diovan hct) (Lopressor) valsartan-hydrochlorothiazide tab propranolol hcl tab 10 mg (Diovan hct) 320-12.5 mg propranolol hcl tab 20 mg valsartan-hydrochlorothiazide tab propranolol hcl tab 40 mg 320-25 mg (Diovan hct) propranolol hcl tab 80 mg BETA BLOCKERS AND COMBINATIONS CALCIUM CHANNEL BLOCKERS AND (Sectral) acebutolol hcl cap 200 mg COMBINATIONS (Sectral) acebutolol hcl cap 400 mg amlodipine besylate tab 2.5 mg (base atenolol & chlorthalidone tab equivalent) (Norvasc) (Tenoretic 50) 50-25 mg amlodipine besylate tab 5 mg (base equivalent) (Norvasc)

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 10 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy amlodipine besylate tab 10 mg (base CHOLESTEROL LOWERING equivalent) (Norvasc) atorvastatin calcium tab 10 mg (base diltiazem hcl coated beads cap er equivalent) (Lipitor) 24hr 120 mg (Cardizem cd) atorvastatin calcium tab 20 mg (base diltiazem hcl coated beads cap er equivalent) (Lipitor) 24hr 180 mg (Cardizem cd) atorvastatin calcium tab 40 mg (base diltiazem hcl tab 30 mg (Cardizem) equivalent) (Lipitor) diltiazem hcl tab 60 mg (Cardizem) atorvastatin calcium tab 80 mg (base diltiazem hcl tab 90 mg equivalent) (Lipitor) diltiazem hcl tab 120 mg (Cardizem) fenofibrate tab 54 mg (Lofibra) • ENTRESTO – sacubitril-valsartan tab gemfibrozil tab 600 mg (Lopid) • 24-26 mg lovastatin tab 10 mg ENTRESTO – sacubitril-valsartan tab lovastatin tab 20 mg (Mevacor) 49-51 mg lovastatin tab 40 mg (Mevacor) ENTRESTO – sacubitril-valsartan tab pravastatin sodium tab 10 mg 97-103 mg pravastatin sodium tab 20 mg nifedipine tab er 24hr 30 mg (Adalat (Pravachol) cc) pravastatin sodium tab 40 mg nifedipine tab er 24hr osmotic (Pravachol) release 30 mg (Procardia xl) REPATHA – evolocumab subcutaneous • • • verapamil hcl tab er 120 mg (Calan soln prefilled syringe 140 mg/ml sr) REPATHA PUSHTRONEX SYSTEM • • • verapamil hcl tab er 180 mg (Calan – evolocumab subcutaneous soln sr) cartridge/infusor 420 mg/3.5ml verapamil hcl tab er 240 mg (Calan REPATHA SURECLICK – evolocumab • • • sr) subcutaneous soln auto-injector 140 verapamil hcl tab 80 mg (Calan) mg/ml verapamil hcl tab 120 mg (Calan) simvastatin tab 5 mg (Zocor) CHEST PAIN simvastatin tab 10 mg (Zocor) isosorbide mononitrate tab er 24hr simvastatin tab 20 mg (Zocor) 30 mg simvastatin tab 40 mg (Zocor) isosorbide mononitrate tab er 24hr simvastatin tab 80 mg (Zocor) 60 mg FLUID RETENTION isosorbide mononitrate tab 10 mg amiloride & hydrochlorothiazide tab isosorbide mononitrate tab 20 mg 5-50 mg nitroglycerin cap er 2.5 mg bumetanide tab 0.5 mg

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 11 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy bumetanide tab 1 mg doxazosin mesylate tab 1 mg chlorothiazide tab 500 mg (Cardura) furosemide oral soln 10 mg/ml doxazosin mesylate tab 2 mg (Cardura) furosemide tab 20 mg (Lasix) doxazosin mesylate tab 4 mg furosemide tab 40 mg (Lasix) (Cardura) furosemide tab 80 mg (Lasix) doxazosin mesylate tab 8 mg hydrochlorothiazide cap 12.5 mg (Cardura) (Microzide) guanfacine hcl tab 1 mg (Tenex) hydrochlorothiazide tab 12.5 mg guanfacine hcl tab 2 mg (Tenex) hydrochlorothiazide tab 25 mg hydralazine hcl tab 10 mg hydrochlorothiazide tab 50 mg hydralazine hcl tab 25 mg indapamide tab 1.25 mg hydralazine hcl tab 50 mg indapamide tab 2.5 mg methyldopa tab 250 mg spironolactone tab 25 mg (Aldactone) methyldopa tab 500 mg spironolactone tab 50 mg (Aldactone) minoxidil tab 2.5 mg torsemide tab 5 mg (Demadex) minoxidil tab 10 mg torsemide tab 10 mg (Demadex) OPSUMIT – macitentan tab 10 mg • • • torsemide tab 20 mg (Demadex) prazosin hcl cap 1 mg (Minipress) triamterene & hydrochlorothiazide prazosin hcl cap 2 mg (Minipress) cap 37.5-25 mg (Dyazide) terazosin hcl cap 1 mg (base triamterene & hydrochlorothiazide equivalent) tab 37.5-25 mg (Maxzide-25) terazosin hcl cap 2 mg (base triamterene & hydrochlorothiazide equivalent) tab 75-50 mg (Maxzide) terazosin hcl cap 5 mg (base HEART RHYTHM equivalent) amiodarone hcl tab 200 mg terazosin hcl cap 10 mg (base (Cordarone) equivalent) sotalol hcl tab 80 mg (Betapace) TRACLEER – bosentan tab for oral • • • sotalol hcl tab 120 mg (Betapace) susp 32 mg sotalol hcl tab 160 mg (Betapace) TRACLEER – bosentan tab 62.5 mg • • • OTHER HEART RELATED DRUGS TRACLEER – bosentan tab 125 mg • • • clonidine hcl tab 0.1 mg (Catapres) UPTRAVI – selexipag tab therapy pack • • • 200 mcg (140) & 800 mcg (60) clonidine hcl tab 0.2 mg (Catapres) UPTRAVI – selexipag tab 200 mcg clonidine hcl tab 0.3 mg (Catapres) • • •

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 12 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy UPTRAVI – selexipag tab 400 mcg • • • ADVAIR DISKUS – fluticasone- • UPTRAVI – selexipag tab 600 mcg • • • salmeterol aer powder ba 100-50 mcg/dose UPTRAVI – selexipag tab 800 mcg • • • ADVAIR DISKUS – fluticasone- • UPTRAVI – selexipag tab 1000 mcg • • • salmeterol aer powder ba 250-50 UPTRAVI – selexipag tab 1200 mcg • • • mcg/dose UPTRAVI – selexipag tab 1400 mcg • • • ADVAIR DISKUS – fluticasone- • UPTRAVI – selexipag tab 1600 mcg • • • salmeterol aer powder ba 500-50 mcg/dose BEE STING KITS ADVAIR HFA – fluticasone-salmeterol • EPINEPHRINE (Mylan Products) – inhal aerosol 45-21 mcg/act epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) ADVAIR HFA – fluticasone-salmeterol • inhal aerosol 115-21 mcg/act EPIPEN-JR 2-PAK – epinephrine solution auto-injector 0.15 mg/0.3ml ADVAIR HFA – fluticasone-salmeterol • (1:2000) inhal aerosol 230-21 mcg/act SYMJEPI – epinephrine soln prefilled albuterol sulfate syrup 2 mg/5ml syringe 0.15 mg/0.3ml (1:2000) ANORO ELLIPTA – umeclidinium- • SYMJEPI – epinephrine solution vilanterol aero powd ba 62.5-25 mcg/ prefilled syringe 0.3 mg/0.3ml inh (1:1000) ARNUITY ELLIPTA – fluticasone • furoate aerosol powder breath activ RESPIRATORY AGENTS 50 mcg/act ANTIHISTAMINES ARNUITY ELLIPTA – fluticasone • promethazine hcl syrup 6.25 mg/5ml furoate aerosol powder breath activ promethazine hcl tab 12.5 mg 100 mcg/act promethazine hcl tab 25 mg ARNUITY ELLIPTA – fluticasone • furoate aerosol powder breath activ promethazine hcl tab 50 mg 200 mcg/act NASAL PRODUCTS ASMANEX HFA – mometasone furoate • fluticasone propionate nasal susp • inhal aerosol suspension 100 mcg/act 50 mcg/act (Flonase) ASMANEX HFA – mometasone furoate • COUGH/COLD/ALLERGY inhal aerosol suspension 200 mcg/act benzonatate cap 100 mg (Tessalon ASMANEX TWISTHALER 120 ME – • perles) mometasone furoate inhal powd 220 benzonatate cap 200 mg mcg/inh (breath activated) promethazine w/ codeine syrup • ASMANEX TWISTHALER 30 MET – • 6.25-10 mg/5ml mometasone furoate inhal powd 110 mcg/inh (breath activated) ASTHMA/COPD

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 13 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ASMANEX TWISTHALER 30 MET – • FLUTICASONE PROPIONATE/SA – • mometasone furoate inhal powd 220 fluticasone-salmeterol aer powder ba mcg/inh (breath activated) 113-14 mcg/act ASMANEX TWISTHALER 60 MET – • FLUTICASONE PROPIONATE/SA – • mometasone furoate inhal powd 220 fluticasone-salmeterol aer powder ba mcg/inh (breath activated) 232-14 mcg/act BREO ELLIPTA – fluticasone furoate- • INCRUSE ELLIPTA – umeclidinium br • vilanterol aero powd ba 100-25 mcg/ aero powd breath act 62.5 mcg/inh inh (base eq) BREO ELLIPTA – fluticasone furoate- • ipratropium bromide inhal soln • vilanterol aero powd ba 200-25 mcg/ 0.02% inh montelukast sodium chew tab 4 mg DULERA – mometasone furoate- • (base equiv) (Singulair) formoterol fumarate aerosol 100-5 montelukast sodium chew tab 5 mg mcg/act (base equiv) (Singulair) DULERA – mometasone furoate- • montelukast sodium tab 10 mg (base formoterol fumarate aerosol 200-5 equiv) (Singulair) mcg/act PROAIR HFA – albuterol sulfate inhal • FLOVENT DISKUS – fluticasone • aero 108 mcg/act (90mcg base equiv) propionate aer pow ba 50 mcg/blister PROAIR RESPICLICK – albuterol • FLOVENT DISKUS – fluticasone • sulfate aer pow ba 108 mcg/act (90 propionate aer pow ba 100 mcg/ mcg base equiv) blister QVAR REDIHALER – beclomethasone • FLOVENT DISKUS – fluticasone • diprop hfa breath act inh aer 40 mcg/ propionate aer pow ba 250 mcg/ act blister QVAR REDIHALER – beclomethasone • FLOVENT HFA – fluticasone • diprop hfa breath act inh aer 80 mcg/ propionate hfa inhal aero 44 mcg/act act (50/valve) SEREVENT DISKUS – salmeterol • FLOVENT HFA – fluticasone • xinafoate aer pow ba 50 mcg/dose propionate hfa inhal aer 110 mcg/act (base equiv) (125/valve) SPIRIVA HANDIHALER – tiotropium • FLOVENT HFA – fluticasone • bromide monohydrate inhal cap 18 propionate hfa inhal aer 220 mcg/act mcg (base equiv) (250/valve) SPIRIVA RESPIMAT – tiotropium • FLUTICASONE PROPIONATE/SA – • bromide monohydrate inhal aerosol fluticasone-salmeterol aer powder ba 1.25 mcg/act 55-14 mcg/act

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 14 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy SPIRIVA RESPIMAT – tiotropium • peg 3350-kcl-sod bicarb-nacl for soln bromide monohydrate inhal aerosol 420 gm (Nulytely/flavor pack) 2.5 mcg/act peg 3350-kcl-na bicarb-nacl-na STIOLTO RESPIMAT – tiotropium br- • sulfate for soln 236 gm (Golytely) olodaterol inhal aero soln 2.5-2.5 peg 3350-kcl-na bicarb-nacl-na mcg/act sulfate for soln 240 gm (Colyte- STRIVERDI RESPIMAT – olodaterol • flavor packs) hcl inhal aerosol soln 2.5 mcg/act ULCER/GERD (base equiv) cimetidine tab 300 mg SYMBICORT – budesonide-formoterol • fumarate dihyd aerosol 80-4.5 mcg/ cimetidine tab 400 mg act dicyclomine hcl cap 10 mg (Bentyl) SYMBICORT – budesonide-formoterol • dicyclomine hcl tab 20 mg (Bentyl) fumarate dihyd aerosol 160-4.5 mcg/ famotidine tab 40 mg (Pepcid) act misoprostol tab 100 mcg (Cytotec) theophylline tab er 12hr 100 mg misoprostol tab 200 mcg (Cytotec) TRELEGY ELLIPTA – fluticasone- • umeclidinium-vilanterol aepb nizatidine cap 150 mg 100-62.5-25 mcg/inh omeprazole cap delayed release • VENTOLIN HFA – albuterol sulfate • 10 mg (Prilosec) inhal aero 108 mcg/act (90mcg base omeprazole cap delayed release • equiv) 20 mg (Prilosec) OTHER RESPIRATORY DRUGS omeprazole cap delayed release • KALYDECO – ivacaftor tab 150 mg • • • 40 mg (Prilosec) KALYDECO – ivacaftor packet 25 mg • • • pantoprazole sodium ec tab 20 mg • (base equiv) (Protonix) KALYDECO – ivacaftor packet 50 mg • • • pantoprazole sodium ec tab 40 mg • KALYDECO – ivacaftor packet 75 mg • • • (base equiv) (Protonix) PULMOZYME – dornase alfa inhal soln • ranitidine hcl syrup 15 mg/ml 1 mg/ml (75 mg/5ml) SYMDEKO – tezacaftor-ivacaftor 50-75 • • ranitidine hcl tab 300 mg (Zantac) mg & ivacaftor 75 mg tab tbpk NAUSEA AND VOMITING SYMDEKO – tezacaftor-ivacaftor • • • 100-150 mg & ivacaftor 150 mg tab EMEND – aprepitant for oral susp 125 • tbpk mg (125 mg/5ml) GASTROINTESTINAL DRUGS ondansetron hcl tab 4 mg (Zofran) • LAXATIVES ondansetron orally disintegrating tab • 4 mg (Zofran odt) lactulose solution 10 gm/15ml DIGESTIVE ENZYMES

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 15 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy CREON – pancrelipase (lip-prot-amyl) VIBERZI – eluxadoline tab 100 mg • dr cap 3000-9500-15000 unit GENITOURINARY DRUGS CREON – pancrelipase (lip-prot-amyl) URINARY TRACT SPASMS dr cap 6000-19000-30000 unit bethanechol chloride tab 5 mg CREON – pancrelipase (lip-prot-amyl) (Urecholine) dr cap 12000-38000-60000 unit oxybutynin chloride syrup 5 mg/5ml CREON – pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000 unit OTHER GENITOURINARY DRUGS CREON – pancrelipase (lip-prot-amyl) alfuzosin hcl tab er 24hr 10 mg dr cap 36000-114000-180000 unit (Uroxatral) ZENPEP – pancrelipase (lip-prot-amyl) CYSTAGON – cysteamine bitartrate • dr cap 3000-10000-14000 unit cap 50 mg ZENPEP – pancrelipase (lip-prot-amyl) CYSTAGON – cysteamine bitartrate • dr cap 5000-17000-24000 unit cap 150 mg ZENPEP – pancrelipase (lip-prot-amyl) finasteride tab 5 mg (Proscar) dr cap 10000-32000-42000 unit tamsulosin hcl cap 0.4 mg (Flomax) ZENPEP – pancrelipase (lip-prot-amyl) CENTRAL NERVOUS SYSTEM DRUGS dr cap 15000-47000-63000 unit ANXIETY ZENPEP – pancrelipase (lip-prot-amyl) alprazolam tab 0.25 mg (Xanax) dr cap 20000-63000-84000 unit alprazolam tab 0.5 mg (Xanax) ZENPEP – pancrelipase (lip-prot-amyl) dr cap 25000-79000-105000 unit alprazolam tab 1 mg (Xanax) ZENPEP – pancrelipase (lip-prot-amyl) alprazolam tab 2 mg (Xanax) dr cap 40000-126000-168000 unit buspirone hcl tab 5 mg OTHER GASTROINTESTINAL DRUGS buspirone hcl tab 10 mg APRISO – mesalamine cap er 24hr buspirone hcl tab 15 mg 0.375 gm chlordiazepoxide hcl cap 5 mg CHENODAL – chenodiol tab 250 mg • chlordiazepoxide hcl cap 10 mg lactulose (encephalopathy) solution chlordiazepoxide hcl cap 25 mg 10 gm/15ml clorazepate dipotassium tab 3.75 mg metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv) clorazepate dipotassium tab 7.5 mg (Tranxene t) metoclopramide hcl tab 5 mg (base equivalent) (Reglan) diazepam tab 2 mg (Valium) metoclopramide hcl tab 10 mg (base diazepam tab 5 mg (Valium) equivalent) (Reglan) diazepam tab 10 mg (Valium) VIBERZI – eluxadoline tab 75 mg • hydroxyzine hcl syrup 10 mg/5ml

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 16 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy hydroxyzine hcl tab 10 mg fluoxetine hcl cap 10 mg (Prozac) hydroxyzine hcl tab 25 mg fluoxetine hcl cap 20 mg (Prozac) hydroxyzine hcl tab 50 mg fluoxetine hcl cap 40 mg (Prozac) hydroxyzine pamoate cap 25 mg fluoxetine hcl solution 20 mg/5ml (Vistaril) fluoxetine hcl tab 10 mg hydroxyzine pamoate cap 50 mg imipramine hcl tab 10 mg (Tofranil) (Vistaril) imipramine hcl tab 25 mg (Tofranil) lorazepam tab 0.5 mg (Ativan) • imipramine hcl tab 50 mg (Tofranil) lorazepam tab 1 mg (Ativan) • mirtazapine tab 15 mg (Remeron) lorazepam tab 2 mg (Ativan) • mirtazapine tab 30 mg (Remeron) DEPRESSION mirtazapine tab 45 mg (Remeron) amitriptyline hcl tab 10 mg nortriptyline hcl cap 10 mg (Pamelor) amitriptyline hcl tab 25 mg nortriptyline hcl cap 25 mg (Pamelor) amitriptyline hcl tab 50 mg nortriptyline hcl cap 50 mg (Pamelor) amitriptyline hcl tab 75 mg nortriptyline hcl cap 75 mg (Pamelor) amitriptyline hcl tab 100 mg paroxetine hcl tab 10 mg (Paxil) bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) paroxetine hcl tab 20 mg (Paxil) bupropion hcl tab er 12hr 150 mg paroxetine hcl tab 30 mg (Paxil) (Wellbutrin sr) paroxetine hcl tab 40 mg (Paxil) citalopram hydrobromide tab 10 mg sertraline hcl tab 25 mg (Zoloft) (Celexa) (base equiv) sertraline hcl tab 50 mg (Zoloft) citalopram hydrobromide tab 20 mg sertraline hcl tab 100 mg (Zoloft) (base equiv) (Celexa) trazodone hcl tab 50 mg citalopram hydrobromide tab 40 mg (base equiv) (Celexa) trazodone hcl tab 100 mg doxepin hcl cap 10 mg trazodone hcl tab 150 mg doxepin hcl cap 25 mg venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor xr) doxepin hcl conc 10 mg/ml venlafaxine hcl cap er 24hr 75 mg escitalopram oxalate tab 5 mg (base (base equivalent) (Effexor xr) equiv) (Lexapro) venlafaxine hcl cap er 24hr 150 mg escitalopram oxalate tab 10 mg (base equivalent) (Effexor xr) (base equiv) (Lexapro) PSYCHOTIC AND BIPOLAR DISORDERS escitalopram oxalate tab 20 mg (base equiv) (Lexapro) FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 17 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy FLUPHENAZINE HCL – fluphenazine BELSOMRA – suvorexant tab 15 mg • • hcl oral conc 5 mg/ml BELSOMRA – suvorexant tab 20 mg • • haloperidol lactate oral conc 2 mg/ml estazolam tab 1 mg haloperidol tab 0.5 mg estazolam tab 2 mg haloperidol tab 1 mg phenobarbital tab 16.2 mg haloperidol tab 2 mg phenobarbital tab 32.4 mg lithium carbonate cap 150 mg temazepam cap 15 mg (Restoril) (Lithium carbonate) temazepam cap 30 mg (Restoril) lithium carbonate cap 300 mg zaleplon cap 5 mg (Sonata) • lithium carbonate cap 600 mg (Lithium carbonate) zaleplon cap 10 mg (Sonata) • lithium carbonate tab 300 mg zolpidem tartrate tab 5 mg (Ambien) • olanzapine tab 2.5 mg (Zyprexa) • zolpidem tartrate tab 10 mg (Ambien) • olanzapine tab 5 mg (Zyprexa) • MULTIPLE SCLEROSIS olanzapine tab 7.5 mg (Zyprexa) • AUBAGIO – teriflunomide tab 7 mg • • olanzapine tab 10 mg (Zyprexa) • AUBAGIO – teriflunomide tab 14 mg • • prochlorperazine maleate tab 5 mg AVONEX – interferon beta-1a im • • (base equivalent) prefilled syringe kit 30 mcg/0.5ml prochlorperazine maleate tab 10 mg AVONEX PEN – interferon beta-1a im • • (base equivalent) auto-injector kit 30 mcg/0.5ml quetiapine fumarate tab 25 mg • BETASERON – interferon beta-1b for • • (Seroquel) inj kit 0.3 mg quetiapine fumarate tab 50 mg • COPAXONE – glatiramer acetate soln • • (Seroquel) prefilled syringe 20 mg/ml quetiapine fumarate tab 100 mg • COPAXONE – glatiramer acetate soln • • (Seroquel) prefilled syringe 40 mg/ml risperidone tab 0.25 mg (Risperdal) • GILENYA – fingolimod hcl cap 0.5 mg • • (base equiv) risperidone tab 0.5 mg (Risperdal) • MAYZENT – siponimod fumarate tab • • risperidone tab 1 mg (Risperdal) • 0.25 mg (base equiv) risperidone tab 2 mg (Risperdal) • MAYZENT – siponimod fumarate tab 2 • • risperidone tab 3 mg (Risperdal) • mg (base equiv) risperidone tab 4 mg (Risperdal) • PLEGRIDY – peginterferon beta-1a • • SLEEP AIDS soln pen-injector 125 mcg/0.5ml BELSOMRA – suvorexant tab 5 mg • • PLEGRIDY – peginterferon beta-1a • • soln prefilled syringe 125 mcg/0.5ml BELSOMRA – suvorexant tab 10 mg • •

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 18 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy PLEGRIDY STARTER PACK – • • donepezil hydrochloride tab 10 mg peginterferon beta-1a soln pen-inj 63 (Aricept) & 94 mcg/0.5ml pack NICOTROL INHALER – nicotine inhaler PLEGRIDY STARTER PACK – • • system 10 mg (4 mg delivered) peginterferon beta-1a soln pref syr 63 NICOTROL NS – nicotine nasal spray & 94 mcg/0.5ml pack 10 mg/ml (0.5 mg/spray) REBIF – interferon beta-1a soln pref syr • • PAIN RELIEF DRUGS 22 mcg/0.5ml (12mu/ml) NARCOTIC DRUGS REBIF – interferon beta-1a soln pref syr • • 44 mcg/0.5ml (24mu/ml) acetaminophen w/ codeine soln • 120-12 mg/5ml REBIF REBIDOSE – interferon beta-1a • • soln auto-inj 22 mcg/0.5ml (12mu/ml) acetaminophen w/ codeine tab • 300-15 mg (Tylenol/codeine) REBIF REBIDOSE – interferon beta-1a • • soln auto-inj 44 mcg/0.5ml (24mu/ml) acetaminophen w/ codeine tab • 300-30 mg (Tylenol/codeine #3) REBIF REBIDOSE TITRATION – • • interferon beta-1a auto-inj 6x8.8 acetaminophen w/ codeine tab • mcg/0.2ml & 6x22 mcg/0.5ml 300-60 mg (Tylenol/codeine #4) REBIF TITRATION PACK – interferon • • hydrocodone-acetaminophen tab • beta-1a pref syr 6x8.8 mcg/0.2ml & 10-325 mg (Norco) 6x22 mcg/0.5ml hydrocodone-acetaminophen tab • TECFIDERA – dimethyl fumarate • • 5-325 mg (Norco) capsule delayed release 120 mg hydrocodone-acetaminophen tab • TECFIDERA – dimethyl fumarate • • 7.5-325 mg (Norco) capsule delayed release 240 mg hydrocodone-ibuprofen tab • TECFIDERA STARTER PACK – • • 7.5-200 mg (Vicoprofen) dimethyl fumarate capsule dr starter hydromorphone hcl tab 2 mg • pack 120 mg & 240 mg (Dilaudid) OTHER CENTRAL NERVOUS SYSTEM DRUGS hydromorphone hcl tab 4 mg • CHANTIX – varenicline tartrate tab 0.5 (Dilaudid) mg (base equiv) methadone hcl tab for oral susp • CHANTIX – varenicline tartrate tab 1 40 mg mg (base equiv) methadone hcl tab 5 mg (Dolophine • CHANTIX CONTINUING MONTH – hcl) varenicline tartrate tab 1 mg (base methadone hcl tab 10 mg (Dolophine) • equiv) MORPHINE SULFATE – morphine • donepezil hydrochloride tab 5 mg sulfate tab 15 mg (Aricept) MORPHINE SULFATE – morphine • sulfate tab 30 mg

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 19 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy oxycodone hcl tab 5 mg (Roxicodone) • HUMIRA – adalimumab prefilled • • • oxycodone w/ acetaminophen tab • syringe kit 10 mg/0.2ml 5-325 mg (Percocet) HUMIRA – adalimumab prefilled • • • tramadol hcl tab 50 mg (Ultram) • • syringe kit 20 mg/0.2ml tramadol-acetaminophen tab • HUMIRA – adalimumab prefilled • • • 37.5-325 mg (Ultracet) syringe kit 20 mg/0.4ml XTAMPZA ER – oxycodone cap er 12hr • • HUMIRA – adalimumab prefilled • • • abuse-deterrent 9 mg syringe kit 40 mg/0.8ml XTAMPZA ER – oxycodone cap er 12hr • • HUMIRA – adalimumab prefilled • • • abuse-deterrent 13.5 mg syringe kit 40 mg/0.4ml XTAMPZA ER – oxycodone cap er 12hr • • HUMIRA PEDIATRIC CROHNS D – • • • abuse-deterrent 18 mg adalimumab prefilled syringe kit 40 mg/0.8ml XTAMPZA ER – oxycodone cap er 12hr • • abuse-deterrent 27 mg HUMIRA PEDIATRIC CROHNS D – • • • adalimumab prefilled syringe kit 80 XTAMPZA ER – oxycodone cap er 12hr • • mg/0.8ml abuse-deterrent 36 mg HUMIRA PEDIATRIC CROHNS D – • • • RHEUMATOID AND OSTEOARTHRITIS adalimumab prefilled syringe kit 80 diclofenac sodium tab delayed mg/0.8ml & 40 mg/0.4ml release 50 mg HUMIRA PEN – adalimumab pen- • • • diclofenac sodium tab delayed injector kit 40 mg/0.8ml release 75 mg HUMIRA PEN – adalimumab pen- • • • ENBREL – etanercept for • • • injector kit 40 mg/0.4ml subcutaneous inj 25 mg HUMIRA PEN-CD/UC/HS START • • • ENBREL – etanercept subcutaneous • • • – adalimumab pen-injector kit 40 soln prefilled syringe 25 mg/0.5ml mg/0.8ml ENBREL – etanercept subcutaneous • • • HUMIRA PEN-CD/UC/HS START • • • soln prefilled syringe 50 mg/ml – adalimumab pen-injector kit 80 ENBREL MINI – etanercept • • • mg/0.8ml subcutaneous solution cartridge 50 HUMIRA PEN-PS/UV STARTER – • • • mg/ml adalimumab pen-injector kit 40 ENBREL SURECLICK – etanercept • • • mg/0.8ml subcutaneous solution auto-injector HUMIRA PEN-PS/UV STARTER – • • • 50 mg/ml adalimumab pen-injector kit 80 mg/0.8ml & 40 mg/0.4ml flurbiprofen tab 50 mg flurbiprofen tab 100 mg ibuprofen tab 400 mg HUMIRA – adalimumab prefilled • • • ibuprofen tab 600 mg syringe kit 10 mg/0.1ml ibuprofen tab 800 mg

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 20 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy indomethacin cap 25 mg AIMOVIG – erenumab-aooe • • indomethacin cap 50 mg subcutaneous soln auto-injector 140 mg/ml ketorolac tromethamine tab 10 mg • EMGALITY – galcanezumab-gnlm • • meloxicam tab 7.5 mg (Mobic) subcutaneous soln auto-injector 120 meloxicam tab 15 mg (Mobic) mg/ml nabumetone tab 500 mg EMGALITY – galcanezumab-gnlm • • subcutaneous soln prefilled syr 120 nabumetone tab 750 mg mg/ml naproxen sodium tab 275 mg (Anaprox) sumatriptan succinate tab 25 mg • (Imitrex) naproxen sodium tab 550 mg (Anaprox ds) sumatriptan succinate tab 50 mg • (Imitrex) naproxen tab ec 375 mg (Ec- naprosyn) sumatriptan succinate tab 100 mg • (Imitrex) naproxen tab ec 500 mg (Ec- naprosyn) GOUT (Zyloprim) naproxen tab 250 mg (Naprosyn) allopurinol tab 100 mg (Zyloprim) naproxen tab 375 mg (Naprosyn) allopurinol tab 300 mg MITIGARE – colchicine cap 0.6 mg naproxen tab 500 mg (Naprosyn) OTEZLA – apremilast tab starter • • • NEUROMUSCULAR DRUGS therapy pack 10 mg & 20 mg & 30 mg SEIZURES OTEZLA – apremilast tab 30 mg • • • clonazepam tab 0.5 mg (Klonopin) SIMPONI – golimumab subcutaneous • • • clonazepam tab 1 mg (Klonopin) soln auto-injector 50 mg/0.5ml clonazepam tab 2 mg (Klonopin) SIMPONI – golimumab subcutaneous • • • DIASTAT ACUDIAL – diazepam rectal soln auto-injector 100 mg/ml gel delivery system 10 mg SIMPONI – golimumab subcutaneous • • • DIASTAT ACUDIAL – diazepam rectal soln prefilled syringe 50 mg/0.5ml gel delivery system 20 mg SIMPONI – golimumab subcutaneous • • • DIASTAT PEDIATRIC – diazepam soln prefilled syringe 100 mg/ml rectal gel delivery system 2.5 mg sulindac tab 150 mg divalproex sodium tab delayed sulindac tab 200 mg release 125 mg (Depakote) MIGRAINE HEADACHES divalproex sodium tab delayed AIMOVIG – erenumab-aooe • • release 250 mg (Depakote) subcutaneous soln auto-injector 70 EPIDIOLEX – cannabidiol soln 100 mg/ • mg/ml ml

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 21 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy gabapentin cap 100 mg (Neurontin) pramipexole dihydrochloride tab gabapentin cap 300 mg (Neurontin) 1.5 mg (Mirapex) gabapentin cap 400 mg (Neurontin) ropinirole hydrochloride tab 0.25 mg (Requip) lamotrigine tab 25 mg (Lamictal) ropinirole hydrochloride tab 0.5 mg lamotrigine tab 100 mg (Lamictal) (Requip) lamotrigine tab 150 mg (Lamictal) ropinirole hydrochloride tab 1 mg lamotrigine tab 200 mg (Lamictal) (Requip) levetiracetam tab 250 mg (Keppra) ropinirole hydrochloride tab 2 mg (Requip) oxcarbazepine tab 150 mg (Trileptal) primidone tab 50 mg (Mysoline) ropinirole hydrochloride tab 3 mg (Requip) topiramate tab 25 mg (Topamax) ropinirole hydrochloride tab 4 mg topiramate tab 50 mg (Topamax) (Requip) topiramate tab 100 mg (Topamax) ropinirole hydrochloride tab 5 mg topiramate tab 200 mg (Topamax) (Requip) zonisamide cap 25 mg (Zonegran) trihexyphenidyl hcl tab 2 mg PARKINSON'S DISEASE trihexyphenidyl hcl tab 5 mg amantadine hcl syrup 50 mg/5ml MUSCLE RELAXANTS benztropine mesylate tab 0.5 mg baclofen tab 10 mg benztropine mesylate tab 1 mg carisoprodol tab 350 mg (Soma) benztropine mesylate tab 2 mg cyclobenzaprine hcl tab 5 mg carbidopa & levodopa tab 10-100 mg cyclobenzaprine hcl tab 10 mg (Sinemet) methocarbamol tab 500 mg (Robaxin) INBRIJA – levodopa inhal powder cap • methocarbamol tab 750 mg 42 mg (Robaxin-750) pramipexole dihydrochloride tab tizanidine hcl tab 2 mg (base • 0.125 mg (Mirapex) equivalent) pramipexole dihydrochloride tab tizanidine hcl tab 4 mg (base • 0.25 mg (Mirapex) equivalent) (Zanaflex) pramipexole dihydrochloride tab SUPPLEMENTS 0.5 mg (Mirapex) VITAMINS pramipexole dihydrochloride tab 0.75 mg (Mirapex) ergocalciferol cap 50000 unit (Drisdol) pramipexole dihydrochloride tab 1 mg (Mirapex) MULTIVITAMINS

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 22 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy KOSHER PRENATAL PLUS IRON – ADYNOVATE – antihemophilic factor • • • prenatal vit w/ iron carbonyl-fa tab recomb pegylated for inj 1000 unit 30-1 mg ADYNOVATE – antihemophilic factor • • • PRENATAL VITAMINS PLUS LO – recomb pegylated for inj 1500 unit prenatal vit w/ fe fumarate-fa tab 27-1 ADYNOVATE – antihemophilic factor • • • mg recomb pegylated for inj 2000 unit MINERALS AND ELECTROLYTES ADYNOVATE – antihemophilic factor • • • potassium chloride recomb pegylated for inj 3000 unit microencapsulated crys er tab 10 AFSTYLA – antihemophilic fact rcmb • • • meq single chain for inj kit 250 unit potassium chloride AFSTYLA – antihemophilic fact rcmb • • • microencapsulated crys er tab 20 single chain for inj kit 500 unit meq AFSTYLA – antihemophilic fact rcmb • • • potassium chloride tab er 8 meq single chain for inj kit 1000 unit (600 mg) AFSTYLA – antihemophilic fact rcmb • • • potassium chloride tab er 10 meq (K- single chain for inj kit 1500 unit tab) AFSTYLA – antihemophilic fact rcmb • • • BLOOD MODIFYING DRUGS single chain for inj kit 2000 unit ADVATE – antihemophilic factor rahf- • AFSTYLA – antihemophilic fact rcmb • • • pfm for inj 250 unit single chain for inj kit 2500 unit ADVATE – antihemophilic factor rahf- • AFSTYLA – antihemophilic fact rcmb • • • pfm for inj 500 unit single chain for inj kit 3000 unit ADVATE – antihemophilic factor rahf- • ALPHANATE/VON WILLEBRAND – • pfm for inj 1000 unit antihemophilic factor/vwf (human) for ADVATE – antihemophilic factor rahf- • inj 250 unit pfm for inj 1500 unit ALPHANATE/VON WILLEBRAND – • ADVATE – antihemophilic factor rahf- • antihemophilic factor/vwf (human) for pfm for inj 2000 unit inj 500 unit ADVATE – antihemophilic factor rahf- • ALPHANATE/VON WILLEBRAND – • pfm for inj 3000 unit antihemophilic factor/vwf (human) for ADVATE – antihemophilic factor rahf- • inj 1000 unit pfm for inj 4000 unit ALPHANATE/VON WILLEBRAND – • ADYNOVATE – antihemophilic factor • • • antihemophilic factor/vwf (human) for recomb pegylated for inj 250 unit inj 1500 unit ADYNOVATE – antihemophilic factor • • • ALPHANATE/VON WILLEBRAND – • recomb pegylated for inj 500 unit antihemophilic factor/vwf (human) for inj 2000 unit ADYNOVATE – antihemophilic factor • • • recomb pegylated for inj 750 unit

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 23 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ALPHANINE SD – coagulation factor ix • COAGADEX – coagulation factor x • for inj 500 unit (human) for inj 250 unit ALPHANINE SD – coagulation factor ix • COAGADEX – coagulation factor x • for inj 1000 unit (human) for inj 500 unit ALPHANINE SD – coagulation factor ix • CORIFACT – factor xiii concentrate • for inj 1500 unit (human) for inj kit 1000-1600 unit ALPROLIX – coagulation factor ix • • • cyanocobalamin inj 1000 mcg/ml (recomb) (rfixfc) for inj 250 unit dipyridamole tab 25 mg (Persantine) ALPROLIX – coagulation factor ix • • • ELIQUIS – apixaban tab 2.5 mg • (recomb) (rfixfc) for inj 500 unit ELIQUIS – apixaban tab 5 mg • ALPROLIX – coagulation factor ix • • • (recomb) (rfixfc) for inj 1000 unit ELIQUIS STARTER PACK – apixaban • tab 5 mg ALPROLIX – coagulation factor ix • • • (recomb) (rfixfc) for inj 2000 unit ELOCTATE – antihemophilic factor • • • (recomb) rfviiifc for inj 250 unit ALPROLIX – coagulation factor ix • • • (recomb) (rfixfc) for inj 3000 unit ELOCTATE – antihemophilic factor • • • (recomb) rfviiifc for inj 500 unit ALPROLIX – coagulation factor ix • • • (recomb) (rfixfc) for inj 4000 unit ELOCTATE – antihemophilic factor • • • (recomb) rfviiifc for inj 750 unit BENEFIX – coagulation factor ix • (recombinant) for inj kit 250 unit ELOCTATE – antihemophilic factor • • • (recomb) rfviiifc for inj 1000 unit BENEFIX – coagulation factor ix • (recombinant) for inj kit 500 unit ELOCTATE – antihemophilic factor • • • (recomb) rfviiifc for inj 1500 unit BENEFIX – coagulation factor ix • (recombinant) for inj kit 1000 unit ELOCTATE – antihemophilic factor • • • (recomb) rfviiifc for inj 2000 unit BENEFIX – coagulation factor ix • (recombinant) for inj kit 2000 unit ELOCTATE – antihemophilic factor • • • (recomb) rfviiifc for inj 3000 unit BENEFIX – coagulation factor ix • (recombinant) for inj kit 3000 unit ELOCTATE – antihemophilic factor • • • (recomb) rfviiifc for inj 4000 unit BRILINTA – ticagrelor tab 60 mg ELOCTATE – antihemophilic factor • • • BRILINTA – ticagrelor tab 90 mg (recomb) rfviiifc for inj 5000 unit CEREZYME – imiglucerase for inj 400 • ELOCTATE – antihemophilic factor • • • unit (recomb) rfviiifc for inj 6000 unit cilostazol tab 50 mg (Pletal) FEIBA – antiinhibitor coagulant • cilostazol tab 100 mg (Pletal) complex for iv soln 500 unit clopidogrel bisulfate tab 75 mg (base FEIBA – antiinhibitor coagulant • equiv) (Plavix) complex for iv soln 1000 unit

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 24 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy FEIBA – antiinhibitor coagulant • HEMOFIL M – antihemophilic factor • complex for iv soln 2500 unit (human) for inj 500 unit FIRAZYR – icatibant acetate inj 30 • • • HEMOFIL M – antihemophilic factor • mg/3ml (base equivalent) (human) for inj 1000 unit folic acid tab 1 mg HEMOFIL M – antihemophilic factor • FULPHILA – pegfilgrastim-jmdb soln • (human) for inj 1700 unit prefilled syringe 6 mg/0.6ml HUMATE-P – antihemophilic factor/vwf • GRANIX – tbo-filgrastim soln prefilled • (human) for inj 250-600 unit syringe 300 mcg/0.5ml HUMATE-P – antihemophilic factor/vwf • GRANIX – tbo-filgrastim soln prefilled • (human) for inj 500-1200 unit syringe 480 mcg/0.8ml HUMATE-P – antihemophilic factor/vwf • GRANIX – tbo-filgrastim subcutaneous • (human) for inj 1000-2400 unit inj 300 mcg/ml IDELVION – coagulation factor ix • • • GRANIX – tbo-filgrastim subcutaneous • (recomb) (rix-fp) for inj 250 unit inj 480 mcg/1.6ml (300 mcg/ml) IDELVION – coagulation factor ix • • • HELIXATE FS – antihemophilic factor • (recomb) (rix-fp) for inj 500 unit (recombinant) for inj kit 250 unit IDELVION – coagulation factor ix • • • HELIXATE FS – antihemophilic factor • (recomb) (rix-fp) for inj 1000 unit (recombinant) for inj kit 500 unit IDELVION – coagulation factor ix • • • HELIXATE FS – antihemophilic factor • (recomb) (rix-fp) for inj 2000 unit (recombinant) for inj kit 1000 unit IDELVION – coagulation factor ix • • • HELIXATE FS – antihemophilic factor • (recomb) (rix-fp) for inj 3500 unit (recombinant) for inj kit 2000 unit IXINITY – coagulation factor ix • HELIXATE FS – antihemophilic factor • (recombinant) for inj 250 unit (recombinant) for inj kit 3000 unit IXINITY – coagulation factor ix • HEMLIBRA – emicizumab-kxwh • • • (recombinant) for inj 500 unit subcutaneous soln 30 mg/ml IXINITY – coagulation factor ix • HEMLIBRA – emicizumab-kxwh • • • (recombinant) for inj 1000 unit subcutaneous soln 60 mg/0.4ml (150 IXINITY – coagulation factor ix • mg/ml) (recombinant) for inj 1500 unit HEMLIBRA – emicizumab-kxwh • • • IXINITY – coagulation factor ix • subcutaneous soln 105 mg/0.7ml (recombinant) for inj 2000 unit (150 mg/ml) IXINITY – coagulation factor ix • HEMLIBRA – emicizumab-kxwh • • • (recombinant) for inj 3000 unit subcutaneous soln 150 mg/ml KOATE – antihemophilic factor (human) • HEMOFIL M – antihemophilic factor • for inj 250 unit (human) for inj 250 unit

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 25 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy KOATE – antihemophilic factor (human) • NEUPOGEN – filgrastim inj 480 • for inj 500 unit mcg/1.6ml (300 mcg/ml) KOATE – antihemophilic factor (human) • NIVESTYM – filgrastim-aafi soln • for inj 1000 unit prefilled syringe 300 mcg/0.5ml KOATE-DVI – antihemophilic factor • NIVESTYM – filgrastim-aafi soln • (human) for inj 250 unit prefilled syringe 480 mcg/0.8ml KOATE-DVI – antihemophilic factor • NIVESTYM – filgrastim-aafi inj 300 • (human) for inj 500 unit mcg/ml KOATE-DVI – antihemophilic factor • NIVESTYM – filgrastim-aafi inj 480 • (human) for inj 1000 unit mcg/1.6ml (300 mcg/ml) KOGENATE FS – antihemophilic factor • NOVOEIGHT – antihemophilic factor • (recombinant) for inj kit 250 unit (recombinant) for inj 250 unit KOGENATE FS – antihemophilic factor • NOVOEIGHT – antihemophilic factor • (recombinant) for inj kit 500 unit (recombinant) for inj 500 unit KOGENATE FS – antihemophilic factor • NOVOEIGHT – antihemophilic factor • (recombinant) for inj kit 1000 unit (recombinant) for inj 1000 unit KOGENATE FS – antihemophilic factor • NOVOEIGHT – antihemophilic factor • (recombinant) for inj kit 2000 unit (recombinant) for inj 1500 unit KOGENATE FS – antihemophilic factor • NOVOEIGHT – antihemophilic factor • (recombinant) for inj kit 3000 unit (recombinant) for inj 2000 unit KOVALTRY – antihemophilic factor • NOVOEIGHT – antihemophilic factor • (recombinant) for inj 250 unit (recombinant) for inj 3000 unit KOVALTRY – antihemophilic factor • NOVOSEVEN RT – coagulation factor • (recombinant) for inj 500 unit viia (recomb) for inj 1 mg (1000 mcg) KOVALTRY – antihemophilic factor • NOVOSEVEN RT – coagulation factor • (recombinant) for inj 1000 unit viia (recomb) for inj 2 mg (2000 mcg) KOVALTRY – antihemophilic factor • NOVOSEVEN RT – coagulation factor • (recombinant) for inj 2000 unit viia (recomb) for inj 5 mg (5000 mcg) KOVALTRY – antihemophilic factor • NOVOSEVEN RT – coagulation factor • (recombinant) for inj 3000 unit viia (recomb) for inj 8 mg (8000 mcg) MONONINE – coagulation factor ix for • NUWIQ – antihemophilic factor (bdd- • inj 1000 unit rfviii) for inj 250 unit NEUPOGEN – filgrastim soln prefilled • NUWIQ – antihemophilic factor (bdd- • syringe 300 mcg/0.5ml rfviii) for inj 500 unit NEUPOGEN – filgrastim soln prefilled • NUWIQ – antihemophilic factor (bdd- • syringe 480 mcg/0.8ml (600 mcg/ml) rfviii) for inj 1000 unit NEUPOGEN – filgrastim inj 300 mcg/ml •

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 26 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy NUWIQ – antihemophilic factor (bdd- • PROFILNINE – factor ix complex for inj • rfviii) for inj 2000 unit 500 unit NUWIQ – antihemophilic factor (bdd- • PROFILNINE – factor ix complex for inj • rfviii) for inj 2500 unit 1000 unit NUWIQ – antihemophilic factor (bdd- • PROFILNINE – factor ix complex for inj • rfviii) for inj 3000 unit 1500 unit NUWIQ – antihemophilic factor (bdd- • PROFILNINE SD – factor ix complex • rfviii) for inj 4000 unit for inj 500 unit NUWIQ – antihemophilic factor (bdd- • PROFILNINE SD – factor ix complex • rfviii) for inj kit 250 unit for inj 1000 unit NUWIQ – antihemophilic factor (bdd- • PROFILNINE SD – factor ix complex • rfviii) for inj kit 500 unit for inj 1500 unit NUWIQ – antihemophilic factor (bdd- • REBINYN – coagulation factor ix • • • rfviii) for inj kit 1000 unit recomb glycopegylated for inj 500 unt NUWIQ – antihemophilic factor (bdd- • REBINYN – coagulation factor ix • • • rfviii) for inj kit 2000 unit recomb glycopegylated for inj 1000 NUWIQ – antihemophilic factor (bdd- • unt rfviii) for inj kit 2500 unit REBINYN – coagulation factor ix • • • NUWIQ – antihemophilic factor (bdd- • recomb glycopegylated for inj 2000 rfviii) for inj kit 3000 unit unt NUWIQ – antihemophilic factor (bdd- • RECOMBINATE – antihemophilic factor • rfviii) for inj kit 4000 unit (recombinant) for inj 220-400 unit OBIZUR – antihemophilic factor • RECOMBINATE – antihemophilic factor • (recomb porc) rpfviii for inj 500 unit (recombinant) for inj 401-800 unit pentoxifylline tab er 400 mg RECOMBINATE – antihemophilic factor • (recombinant) for inj 801-1240 unit PROCRIT – epoetin alfa inj 2000 unit/ • • ml RECOMBINATE – antihemophilic factor • (recombinant) for inj 1241-1800 unit PROCRIT – epoetin alfa inj 3000 unit/ • • ml RECOMBINATE – antihemophilic factor • (recombinant) for inj 1801-2400 unit PROCRIT – epoetin alfa inj 4000 unit/ • • ml RETACRIT – epoetin alfa-epbx inj 2000 • • unit/ml PROCRIT – epoetin alfa inj 10000 unit/ • • ml RETACRIT – epoetin alfa-epbx inj 3000 • • unit/ml PROCRIT – epoetin alfa inj 20000 unit/ • • ml RETACRIT – epoetin alfa-epbx inj 4000 • • unit/ml PROCRIT – epoetin alfa inj 40000 unit/ • • ml RETACRIT – epoetin alfa-epbx inj • • 10000 unit/ml

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 27 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy RETACRIT – epoetin alfa-epbx inj • • XARELTO – rivaroxaban tab 2.5 mg • 40000 unit/ml XARELTO – rivaroxaban tab 10 mg • RIXUBIS – coagulation factor ix • XARELTO – rivaroxaban tab 15 mg • (recombinant) for inj 250 unit XARELTO – rivaroxaban tab 20 mg • RIXUBIS – coagulation factor ix • (recombinant) for inj 500 unit XARELTO STARTER PACK – • rivaroxaban tab starter therapy pack RIXUBIS – coagulation factor ix • 15 mg & 20 mg (recombinant) for inj 1000 unit XYNTHA – antihemophilic factor • RIXUBIS – coagulation factor ix • recombinant paf for inj kit 250 unit (recombinant) for inj 2000 unit XYNTHA – antihemophilic factor • RIXUBIS – coagulation factor ix • recombinant paf for inj kit 500 unit (recombinant) for inj 3000 unit XYNTHA – antihemophilic factor • TRETTEN – coagulation factor xiii a- • recombinant paf for inj kit 1000 unit subunit for inj 2000-3125 unit XYNTHA – antihemophilic factor • UDENYCA – pegfilgrastim-cbqv soln • recombinant paf for inj kit 2000 unit prefilled syringe 6 mg/0.6ml XYNTHA SOLOFUSE – antihemophilic • VONVENDI – von willebrand factor • factor recombinant paf for inj kit 250 (recombinant) for inj 650 unit unit VONVENDI – von willebrand factor • XYNTHA SOLOFUSE – antihemophilic • (recombinant) for inj 1300 unit factor recombinant paf for inj kit 500 warfarin sodium tab 1 mg (Coumadin) unit warfarin sodium tab 2 mg (Coumadin) XYNTHA SOLOFUSE – antihemophilic • warfarin sodium tab 2.5 mg factor recombinant paf for inj kit 1000 (Coumadin) unit warfarin sodium tab 3 mg (Coumadin) XYNTHA SOLOFUSE – antihemophilic • factor recombinant paf for inj kit 2000 warfarin sodium tab 4 mg (Coumadin) unit warfarin sodium tab 5 mg (Coumadin) XYNTHA SOLOFUSE – antihemophilic • warfarin sodium tab 6 mg (Coumadin) factor recombinant paf for inj kit 3000 unit warfarin sodium tab 7.5 mg (Coumadin) ZARXIO – filgrastim-sndz soln prefilled • syringe 300 mcg/0.5ml warfarin sodium tab 10 mg (Coumadin) ZARXIO – filgrastim-sndz soln prefilled • WILATE – antihemophilic factor/vwf • syringe 480 mcg/0.8ml (human) for inj 500-500 unit kit TOPICAL PRODUCTS WILATE – antihemophilic factor/vwf • EYE (human) for inj 1000-1000 unit kit Anti-infectives

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 28 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy BACITRACIN – bacitracin ophth oint diclofenac sodium ophth soln 0.1% 500 unit/gm ketorolac tromethamine ophth soln bacitracin-polymyxin b ophth oint 0.5% (Acular) ciprofloxacin hcl ophth soln 0.3% proparacaine hcl ophth soln 0.5% (base equivalent) (Ciloxan) tetracaine hcl ophth soln 0.5% erythromycin ophth oint 5 mg/gm tropicamide ophth soln 0.5% gentamicin sulfate ophth soln 0.3% tropicamide ophth soln 1% (Garamycin) (Mydriacyl) NATACYN – natamycin ophth susp 5% MOUTH AND THROAT (LOCAL) ofloxacin ophth soln 0.3% (Ocuflox) chlorhexidine gluconate soln 0.12% polymyxin b-trimethoprim ophth (Peridex) soln 10000 unit/ml-0.1% (Polytrim) lidocaine hcl viscous soln 2% tobramycin ophth soln 0.3% (Tobrex) ANORECTAL AGENTS Steroids and Combination Products hydrocortisone rectal cream 2.5% neomycin-polymyxin- (Anusol-hc) dexamethasone ophth oint 0.1% SKIN CONDITIONS/PRODUCTS (Maxitrol) Acne neomycin-polymyxin- dexamethasone ophth susp 0.1% FINACEA – azelaic acid foam 15% (Maxitrol) SOOLANTRA – ivermectin cream 1% Glaucoma TAZORAC – tazarotene cream 0.05% brimonidine tartrate ophth soln 0.2% TAZORAC – tazarotene gel 0.05% dorzolamide hcl-timolol maleate TAZORAC – tazarotene gel 0.1% (Cosopt) ophth soln 22.3-6.8 mg/ml Anti-infectives latanoprost ophth soln 0.005% • mupirocin oint 2% (Bactroban) (Xalatan) silver sulfadiazine cream 1% levobunolol hcl ophth soln 0.5% (Silvadene) (Betagan) Corticosteroids timolol maleate ophth soln 0.25% (Timoptic) hydrocortisone cream 2.5% timolol maleate ophth soln 0.5% hydrocortisone oint 2.5% (Timoptic) triamcinolone acetonide cream Other Eye Products 0.025% cromolyn sodium ophth soln 4% triamcinolone acetonide cream 0.1% cyclopentolate hcl ophth soln 1% triamcinolone acetonide cream 0.5% (Cyclogyl) triamcinolone acetonide oint 0.025%

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 29 2019

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy triamcinolone acetonide oint 0.1% BREATHERITE – spacer/aerosol- Other Skin Products holding chambers - device COSENTYX – secukinumab • • • MISCELLANEOUS DRUGS subcutaneous soln prefilled syringe CHEMET – succimer cap 100 mg 150 mg/ml DEPEN TITRATABS – penicillamine tab • COSENTYX SENSOREADY PEN – • • • 250 mg secukinumab subcutaneous soln EXJADE – deferasirox tab for oral susp • auto-injector 150 mg/ml 125 mg lidocaine hcl gel 2% • EXJADE – deferasirox tab for oral susp • lidocaine hcl soln 4% (Xylocaine) • 250 mg lidocaine hcl urethral/mucosal gel • EXJADE – deferasirox tab for oral susp • 2% 500 mg selenium sulfide lotion 2.5% JADENU – deferasirox tab 90 mg • SKYRIZI – risankizumab-rzaa sol • • • JADENU – deferasirox tab 180 mg • prefilled syringe 2 x 75 mg/0.83ml kit JADENU – deferasirox tab 360 mg • STELARA – ustekinumab inj 45 • • • NARCAN – naloxone hcl nasal spray 4 mg/0.5ml mg/0.1ml STELARA – ustekinumab soln prefilled • • • RAPAMUNE – sirolimus oral soln 1 mg/ syringe 45 mg/0.5ml ml STELARA – ustekinumab soln prefilled • • • REVLIMID – lenalidomide caps 2.5 mg • • • syringe 90 mg/ml REVLIMID – lenalidomide cap 5 mg • • • TREMFYA – guselkumab soln pen- • • • injector 100 mg/ml REVLIMID – lenalidomide cap 10 mg • • • TREMFYA – guselkumab soln prefilled • • • REVLIMID – lenalidomide cap 15 mg • • • syringe 100 mg/ml REVLIMID – lenalidomide cap 20 mg • • • VALCHLOR – mechlorethamine hcl gel • REVLIMID – lenalidomide cap 25 mg • • • 0.016% (base equivalent) THALOMID – thalidomide cap 50 mg • • • MISCELLANEOUS CATEGORIES THALOMID – thalidomide cap 100 mg • • • DIABETIC SUPPLIES THALOMID – thalidomide cap 150 mg • • • TEST STRIPS – ASCENSIA BREEZE • THALOMID – thalidomide cap 200 mg • • • 2, CONTOUR, CONTOUR NEXT INSULIN PEN NEEDLES – VARIOUS • INSULIN SYRINGES – VARIOUS • LANCETS – VARIOUS RESPIRATORY INHALER-ASSIST DEVICES

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 30 2019

ADYNOVATE – antihemophilic factor recomb pegylated for INDEX inj 1500 unit...... 23 ADYNOVATE – antihemophilic factor recomb pegylated for A inj 2000 unit...... 23 ADYNOVATE – antihemophilic factor recomb pegylated for acebutolol hcl cap 200 mg (Sectral)...... 10 inj 3000 unit...... 23 acebutolol hcl cap 400 mg (Sectral)...... 10 AFSTYLA – antihemophilic fact rcmb single chain for inj kit acetaminophen w/ codeine soln 120-12 mg/5ml...... 19 250 unit...... 23 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ AFSTYLA – antihemophilic fact rcmb single chain for inj kit codeine)...... 19 500 unit...... 23 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ AFSTYLA – antihemophilic fact rcmb single chain for inj kit codeine #3)...... 19 1000 unit...... 23 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ AFSTYLA – antihemophilic fact rcmb single chain for inj kit codeine #4)...... 19 1500 unit...... 23 ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml AFSTYLA – antihemophilic fact rcmb single chain for inj kit (2000000 unit/0.5ml)...... 3 2000 unit...... 23 acyclovir cap 200 mg (Zovirax)...... 2 AFSTYLA – antihemophilic fact rcmb single chain for inj kit acyclovir tab 400 mg (Zovirax)...... 2 2500 unit...... 23 acyclovir tab 800 mg (Zovirax)...... 2 AFSTYLA – antihemophilic fact rcmb single chain for inj kit ADVAIR DISKUS – fluticasone-salmeterol aer powder ba 3000 unit...... 23 100-50 mcg/dose...... 13 AIMOVIG – erenumab-aooe subcutaneous soln auto- ADVAIR DISKUS – fluticasone-salmeterol aer powder ba injector 70 mg/ml...... 21 250-50 mcg/dose...... 13 AIMOVIG – erenumab-aooe subcutaneous soln auto- ADVAIR DISKUS – fluticasone-salmeterol aer powder ba injector 140 mg/ml...... 21 500-50 mcg/dose...... 13 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 albuterol sulfate syrup 2 mg/5ml...... 13 mcg/act...... 13 alendronate sodium tab 5 mg...... 8 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 alendronate sodium tab 10 mg...... 8 mcg/act...... 13 alendronate sodium tab 35 mg...... 8 ADVAIR HFA – fluticasone-salmeterol inhal aerosol alendronate sodium tab 70 mg (Fosamax)...... 8 230-21 mcg/act...... 13 alfuzosin hcl tab er 24hr 10 mg (Uroxatral)...... 16 ALINIA – nitazoxanide for susp 100 mg/5ml...... 3 ADVATE – antihemophilic factor rahf-pfm for inj 250 ALINIA – nitazoxanide tab 500 mg...... 3 unit...... 23 ADVATE – antihemophilic factor rahf-pfm for inj 500 allopurinol tab 100 mg (Zyloprim)...... 21 unit...... 23 allopurinol tab 300 mg (Zyloprim)...... 21 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 1000 vwf (human) for inj 250 unit...... 23 unit...... 23 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 1500 vwf (human) for inj 500 unit...... 23 unit...... 23 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 2000 vwf (human) for inj 1000 unit...... 23 unit...... 23 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 3000 vwf (human) for inj 1500 unit...... 23 unit...... 23 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 4000 vwf (human) for inj 2000 unit...... 23 unit...... 23 ALPHANINE SD – coagulation factor ix for inj 500 unit..... 24 ADYNOVATE – antihemophilic factor recomb pegylated for ALPHANINE SD – coagulation factor ix for inj 1000 inj 250 unit...... 23 unit...... 24 ADYNOVATE – antihemophilic factor recomb pegylated for ALPHANINE SD – coagulation factor ix for inj 1500 inj 500 unit...... 23 unit...... 24 ADYNOVATE – antihemophilic factor recomb pegylated for inj 750 unit...... 23 alprazolam tab 0.25 mg (Xanax)...... 16 ADYNOVATE – antihemophilic factor recomb pegylated for alprazolam tab 0.5 mg (Xanax)...... 16 inj 1000 unit...... 23 alprazolam tab 1 mg (Xanax)...... 16 alprazolam tab 2 mg (Xanax)...... 16

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 31 2019

ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj ASMANEX TWISTHALER 30 MET – mometasone furoate 250 unit...... 24 inhal powd 220 mcg/inh (breath activated)...... 14 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj ASMANEX TWISTHALER 60 MET – mometasone furoate 500 unit...... 24 inhal powd 220 mcg/inh (breath activated)...... 14 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj atenolol & chlorthalidone tab 50-25 mg (Tenoretic 1000 unit...... 24 50)...... 10 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj atenolol & chlorthalidone tab 100-25 mg (Tenoretic 2000 unit...... 24 100)...... 10 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj atenolol tab 25 mg (Tenormin)...... 10 3000 unit...... 24 atenolol tab 50 mg (Tenormin)...... 10 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj atenolol tab 100 mg (Tenormin)...... 10 4000 unit...... 24 atorvastatin calcium tab 10 mg (base equivalent) amantadine hcl syrup 50 mg/5ml...... 22 (Lipitor)...... 11 amiloride & hydrochlorothiazide tab 5-50 mg...... 11 atorvastatin calcium tab 20 mg (base equivalent) amiodarone hcl tab 200 mg (Cordarone)...... 12 (Lipitor)...... 11 amitriptyline hcl tab 10 mg...... 17 atorvastatin calcium tab 40 mg (base equivalent) amitriptyline hcl tab 25 mg...... 17 (Lipitor)...... 11 amitriptyline hcl tab 50 mg...... 17 atorvastatin calcium tab 80 mg (base equivalent) amitriptyline hcl tab 75 mg...... 17 (Lipitor)...... 11 amitriptyline hcl tab 100 mg...... 17 ATRIPLA – efavirenz-emtricitabine-tenofovir df tab amlodipine besylate tab 2.5 mg (base equivalent) 600-200-300 mg...... 2 (Norvasc)...... 10 AUBAGIO – teriflunomide tab 7 mg...... 18 amlodipine besylate tab 5 mg (base equivalent) AUBAGIO – teriflunomide tab 14 mg...... 18 (Norvasc)...... 10 AVONEX – interferon beta-1a im prefilled syringe kit 30 amlodipine besylate tab 10 mg (base equivalent) mcg/0.5ml...... 18 (Norvasc)...... 11 AVONEX PEN – interferon beta-1a im auto-injector kit 30 amoxicillin (trihydrate) cap 250 mg...... 1 mcg/0.5ml...... 18 amoxicillin (trihydrate) cap 500 mg...... 1 azithromycin tab 250 mg (Zithromax)...... 1 amoxicillin (trihydrate) for susp 125 mg/5ml...... 1 azithromycin tab 500 mg (Zithromax)...... 1 amoxicillin (trihydrate) for susp 200 mg/5ml...... 1 B amoxicillin (trihydrate) for susp 250 mg/5ml...... 1 amoxicillin (trihydrate) for susp 400 mg/5ml...... 1 BACITRACIN – bacitracin ophth oint 500 unit/gm...... 29 amoxicillin (trihydrate) tab 500 mg...... 1 bacitracin-polymyxin b ophth oint...... 29 amoxicillin (trihydrate) tab 875 mg...... 1 baclofen tab 10 mg...... 22 anastrozole tab 1 mg (Arimidex)...... 3 BARACLUDE – entecavir oral soln 0.05 mg/ml...... 1 ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba BELSOMRA – suvorexant tab 5 mg...... 18 62.5-25 mcg/inh...... 13 BELSOMRA – suvorexant tab 10 mg...... 18 APRISO – mesalamine cap er 24hr 0.375 gm...... 16 BELSOMRA – suvorexant tab 15 mg...... 18 ARNUITY ELLIPTA – fluticasone furoate aerosol powder BELSOMRA – suvorexant tab 20 mg...... 18 breath activ 50 mcg/act...... 13 benazepril hcl tab 5 mg...... 9 ARNUITY ELLIPTA – fluticasone furoate aerosol powder benazepril hcl tab 10 mg (Lotensin)...... 9 breath activ 100 mcg/act...... 13 benazepril hcl tab 20 mg (Lotensin)...... 9 ARNUITY ELLIPTA – fluticasone furoate aerosol powder benazepril hcl tab 40 mg (Lotensin)...... 9 breath activ 200 mcg/act...... 13 BENEFIX – coagulation factor ix (recombinant) for inj kit ASMANEX HFA – mometasone furoate inhal aerosol 250 unit...... 24 suspension 100 mcg/act...... 13 BENEFIX – coagulation factor ix (recombinant) for inj kit ASMANEX HFA – mometasone furoate inhal aerosol 500 unit...... 24 suspension 200 mcg/act...... 13 BENEFIX – coagulation factor ix (recombinant) for inj kit ASMANEX TWISTHALER 120 ME – mometasone furoate 1000 unit...... 24 inhal powd 220 mcg/inh (breath activated)...... 13 BENEFIX – coagulation factor ix (recombinant) for inj kit ASMANEX TWISTHALER 30 MET – mometasone furoate 2000 unit...... 24 inhal powd 110 mcg/inh (breath activated)...... 13 BENEFIX – coagulation factor ix (recombinant) for inj kit 3000 unit...... 24

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 32 2019

BENZNIDAZOLE – benznidazole tab 12.5 mg...... 3 CHENODAL – chenodiol tab 250 mg...... 16 BENZNIDAZOLE – benznidazole tab 100 mg...... 3 chlordiazepoxide hcl cap 5 mg...... 16 benzonatate cap 200 mg...... 13 chlordiazepoxide hcl cap 10 mg...... 16 benzonatate cap 100 mg (Tessalon perles)...... 13 chlordiazepoxide hcl cap 25 mg...... 16 benztropine mesylate tab 0.5 mg...... 22 chlorhexidine gluconate soln 0.12% (Peridex)...... 29 benztropine mesylate tab 1 mg...... 22 CHLOROQUINE PHOSPHATE – chloroquine phosphate benztropine mesylate tab 2 mg...... 22 tab 250 mg...... 3 BETASERON – interferon beta-1b for inj kit 0.3 mg...... 18 chloroquine phosphate tab 500 mg (Aralen)...... 3 bethanechol chloride tab 5 mg (Urecholine)...... 16 chlorothiazide tab 500 mg...... 12 bicalutamide tab 50 mg (Casodex)...... 3 cilostazol tab 50 mg (Pletal)...... 24 BIKTARVY – bictegravir-emtricitabine-tenofovir af tab cilostazol tab 100 mg (Pletal)...... 24 50-200-25 mg...... 2 CIMDUO – lamivudine-tenofovir disoproxil fumarate tab bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 300-300 mg...... 2 (Ziac)...... 10 cimetidine tab 300 mg...... 15 bisoprolol & hydrochlorothiazide tab 5-6.25 mg cimetidine tab 400 mg...... 15 (Ziac)...... 10 ciprofloxacin hcl ophth soln 0.3% (base equivalent) bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ciloxan)...... 29 (Ziac)...... 10 ciprofloxacin hcl tab 750 mg (base equiv)...... 1 bisoprolol fumarate tab 5 mg (Zebeta)...... 10 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...... 1 BREATHERITE – spacer/aerosol-holding chambers - ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...... 1 device...... 30 citalopram hydrobromide tab 10 mg (base equiv) BREO ELLIPTA – fluticasone furoate-vilanterol aero powd (Celexa)...... 17 ba 100-25 mcg/inh...... 14 citalopram hydrobromide tab 20 mg (base equiv) BREO ELLIPTA – fluticasone furoate-vilanterol aero powd (Celexa)...... 17 ba 200-25 mcg/inh...... 14 citalopram hydrobromide tab 40 mg (base equiv) BRILINTA – ticagrelor tab 60 mg...... 24 (Celexa)...... 17 BRILINTA – ticagrelor tab 90 mg...... 24 clindamycin hcl cap 75 mg (Cleocin)...... 3 brimonidine tartrate ophth soln 0.2%...... 29 clindamycin hcl cap 150 mg (Cleocin)...... 3 bumetanide tab 0.5 mg...... 11 clindamycin hcl cap 300 mg (Cleocin)...... 3 bumetanide tab 1 mg...... 12 CLOMIPHENE CITRATE – clomiphene citrate tab 50 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)...... 17 mg...... 6 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)...... 17 clonazepam tab 0.5 mg (Klonopin)...... 21 buspirone hcl tab 5 mg...... 16 clonazepam tab 1 mg (Klonopin)...... 21 buspirone hcl tab 10 mg...... 16 clonazepam tab 2 mg (Klonopin)...... 21 buspirone hcl tab 15 mg...... 16 clonidine hcl tab 0.1 mg (Catapres)...... 12 C clonidine hcl tab 0.2 mg (Catapres)...... 12 clonidine hcl tab 0.3 mg (Catapres)...... 12 carbidopa & levodopa tab 10-100 mg (Sinemet)...... 22 clopidogrel bisulfate tab 75 mg (base equiv) carisoprodol tab 350 mg (Soma)...... 22 (Plavix)...... 24 carvedilol tab 3.125 mg (Coreg)...... 10 clorazepate dipotassium tab 3.75 mg...... 16 carvedilol tab 6.25 mg (Coreg)...... 10 clorazepate dipotassium tab 7.5 mg (Tranxene t)...... 16 carvedilol tab 12.5 mg (Coreg)...... 10 COAGADEX – coagulation factor x (human) for inj 250 carvedilol tab 25 mg (Coreg)...... 10 unit...... 24 cefadroxil cap 500 mg...... 1 COAGADEX – coagulation factor x (human) for inj 500 cephalexin cap 250 mg (Keflex)...... 1 unit...... 24 cephalexin cap 500 mg (Keflex)...... 1 COMBIPATCH – estradiol-norethindrone ace td pttw CEREZYME – imiglucerase for inj 400 unit...... 24 0.05-0.14 mg/day...... 5 CHANTIX CONTINUING MONTH – varenicline tartrate tab COMBIPATCH – estradiol-norethindrone ace td pttw 1 mg (base equiv)...... 19 0.05-0.25 mg/day...... 5 CHANTIX – varenicline tartrate tab 0.5 mg (base COPAXONE – glatiramer acetate soln prefilled syringe 20 equiv)...... 19 mg/ml...... 18 CHANTIX – varenicline tartrate tab 1 mg (base equiv)...... 19 COPAXONE – glatiramer acetate soln prefilled syringe 40 CHEMET – succimer cap 100 mg...... 30 mg/ml...... 18

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 33 2019

CORIFACT – factor xiii concentrate (human) for inj kit dicyclomine hcl tab 20 mg (Bentyl)...... 15 1000-1600 unit...... 24 diltiazem hcl coated beads cap er 24hr 120 mg CORTISONE ACETATE – cortisone acetate tab 25 mg...... 4 (Cardizem cd)...... 11 COSENTYX – secukinumab subcutaneous soln prefilled diltiazem hcl coated beads cap er 24hr 180 mg syringe 150 mg/ml...... 30 (Cardizem cd)...... 11 COSENTYX SENSOREADY PEN – secukinumab diltiazem hcl tab 90 mg...... 11 subcutaneous soln auto-injector 150 mg/ml...... 30 diltiazem hcl tab 30 mg (Cardizem)...... 11 CREON – pancrelipase (lip-prot-amyl) dr cap diltiazem hcl tab 60 mg (Cardizem)...... 11 3000-9500-15000 unit...... 16 diltiazem hcl tab 120 mg (Cardizem)...... 11 CREON – pancrelipase (lip-prot-amyl) dr cap dipyridamole tab 25 mg (Persantine)...... 24 6000-19000-30000 unit...... 16 divalproex sodium tab delayed release 125 mg CREON – pancrelipase (lip-prot-amyl) dr cap (Depakote)...... 21 12000-38000-60000 unit...... 16 divalproex sodium tab delayed release 250 mg CREON – pancrelipase (lip-prot-amyl) dr cap (Depakote)...... 21 24000-76000-120000 unit...... 16 DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)...... 5 CREON – pancrelipase (lip-prot-amyl) dr cap DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)...... 5 36000-114000-180000 unit...... 16 DIVIGEL – estradiol td gel 0.75 mg/0.75gm (0.1%)...... 5 cromolyn sodium ophth soln 4%...... 29 DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...... 5 cyanocobalamin inj 1000 mcg/ml...... 24 donepezil hydrochloride tab 5 mg (Aricept)...... 19 cyclobenzaprine hcl tab 5 mg...... 22 donepezil hydrochloride tab 10 mg (Aricept)...... 19 cyclobenzaprine hcl tab 10 mg...... 22 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 cyclopentolate hcl ophth soln 1% (Cyclogyl)...... 29 mg/ml (Cosopt)...... 29 CYSTADANE – betaine powder for oral solution...... 8 doxazosin mesylate tab 1 mg (Cardura)...... 12 CYSTAGON – cysteamine bitartrate cap 50 mg...... 16 doxazosin mesylate tab 2 mg (Cardura)...... 12 CYSTAGON – cysteamine bitartrate cap 150 mg...... 16 doxazosin mesylate tab 4 mg (Cardura)...... 12 D doxazosin mesylate tab 8 mg (Cardura)...... 12 doxepin hcl cap 10 mg...... 17 DARAPRIM – pyrimethamine tab 25 mg...... 3 doxepin hcl cap 25 mg...... 17 DELSTRIGO – doravirine-lamivudine-tenofovir df tab doxepin hcl conc 10 mg/ml...... 17 100-300-300 mg...... 2 DULERA – mometasone furoate-formoterol fumarate DEPEN TITRATABS – penicillamine tab 250 mg...... 30 aerosol 100-5 mcg/act...... 14 DESCOVY – emtricitabine-tenofovir alafenamide fumarate DULERA – mometasone furoate-formoterol fumarate tab 200-25 mg...... 2 aerosol 200-5 mcg/act...... 14 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen)...... 5 E dexamethasone tab 0.5 mg...... 4 ELIQUIS – apixaban tab 2.5 mg...... 24 dexamethasone tab 0.75 mg...... 4 ELIQUIS – apixaban tab 5 mg...... 24 dexamethasone tab 1.5 mg...... 4 ELIQUIS STARTER PACK – apixaban tab 5 mg...... 24 dexamethasone tab 4 mg...... 4 ELLA – ulipristal acetate tab 30 mg...... 5 dexamethasone tab 6 mg...... 4 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj DIASTAT ACUDIAL – diazepam rectal gel delivery system 250 unit...... 24 10 mg...... 21 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj DIASTAT ACUDIAL – diazepam rectal gel delivery system 500 unit...... 24 20 mg...... 21 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj DIASTAT PEDIATRIC – diazepam rectal gel delivery 750 unit...... 24 system 2.5 mg...... 21 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj diazepam tab 2 mg (Valium)...... 16 1000 unit...... 24 diazepam tab 5 mg (Valium)...... 16 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj diazepam tab 10 mg (Valium)...... 16 1500 unit...... 24 diclofenac sodium ophth soln 0.1%...... 29 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj diclofenac sodium tab delayed release 50 mg...... 20 2000 unit...... 24 diclofenac sodium tab delayed release 75 mg...... 20 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj dicyclomine hcl cap 10 mg (Bentyl)...... 15 3000 unit...... 24

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 34 2019

ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj EXJADE – deferasirox tab for oral susp 250 mg...... 30 4000 unit...... 24 EXJADE – deferasirox tab for oral susp 500 mg...... 30 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj F 5000 unit...... 24 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj famotidine tab 40 mg (Pepcid)...... 15 6000 unit...... 24 FEIBA – antiinhibitor coagulant complex for iv soln 500 EMEND – aprepitant for oral susp 125 mg (125 unit...... 24 mg/5ml)...... 15 FEIBA – antiinhibitor coagulant complex for iv soln 1000 EMGALITY – galcanezumab-gnlm subcutaneous soln unit...... 24 auto-injector 120 mg/ml...... 21 FEIBA – antiinhibitor coagulant complex for iv soln 2500 EMGALITY – galcanezumab-gnlm subcutaneous soln unit...... 25 prefilled syr 120 mg/ml...... 21 fenofibrate tab 54 mg (Lofibra)...... 11 enalapril maleate & hydrochlorothiazide tab 5-12.5 FIASP FLEXTOUCH – insulin aspart (with niacinamide) mg...... 9 sol pen-inj 100 unit/ml...... 7 enalapril maleate & hydrochlorothiazide tab 10-25 mg FIASP – insulin aspart (with niacinamide) inj 100 unit/ (Vaseretic)...... 9 ml...... 7 enalapril maleate tab 2.5 mg (Vasotec)...... 9 FINACEA – azelaic acid foam 15%...... 29 enalapril maleate tab 5 mg (Vasotec)...... 9 finasteride tab 5 mg (Proscar)...... 16 enalapril maleate tab 10 mg (Vasotec)...... 9 FIRAZYR – icatibant acetate inj 30 mg/3ml (base enalapril maleate tab 20 mg (Vasotec)...... 9 equivalent)...... 25 ENBREL – etanercept for subcutaneous inj 25 mg...... 20 FLOVENT DISKUS – fluticasone propionate aer pow ba ENBREL – etanercept subcutaneous soln prefilled syringe 50 mcg/blister...... 14 25 mg/0.5ml...... 20 FLOVENT DISKUS – fluticasone propionate aer pow ba ENBREL – etanercept subcutaneous soln prefilled syringe 100 mcg/blister...... 14 50 mg/ml...... 20 FLOVENT DISKUS – fluticasone propionate aer pow ba ENBREL MINI – etanercept subcutaneous solution 250 mcg/blister...... 14 cartridge 50 mg/ml...... 20 FLOVENT HFA – fluticasone propionate hfa inhal aer 110 ENBREL SURECLICK – etanercept subcutaneous mcg/act (125/valve)...... 14 solution auto-injector 50 mg/ml...... 20 FLOVENT HFA – fluticasone propionate hfa inhal aer 220 ENTRESTO – sacubitril-valsartan tab 24-26 mg...... 11 mcg/act (250/valve)...... 14 ENTRESTO – sacubitril-valsartan tab 49-51 mg...... 11 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 ENTRESTO – sacubitril-valsartan tab 97-103 mg...... 11 mcg/act (50/valve)...... 14 EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg...... 1 fluconazole for susp 10 mg/ml (Diflucan)...... 1 EPIDIOLEX – cannabidiol soln 100 mg/ml...... 21 fluconazole tab 50 mg (Diflucan)...... 1 EPINEPHRINE (Mylan Products) – epinephrine solution fluconazole tab 100 mg (Diflucan)...... 1 auto-injector 0.15 mg/0.3ml (1:2000)...... 13 fluconazole tab 150 mg (Diflucan)...... 1 EPIPEN-JR 2-PAK – epinephrine solution auto-injector fluoxetine hcl cap 10 mg (Prozac)...... 17 0.15 mg/0.3ml (1:2000)...... 13 fluoxetine hcl cap 20 mg (Prozac)...... 17 ergocalciferol cap 50000 unit (Drisdol)...... 22 fluoxetine hcl cap 40 mg (Prozac)...... 17 ERLEADA – apalutamide tab 60 mg...... 3 fluoxetine hcl solution 20 mg/5ml...... 17 erythromycin ophth oint 5 mg/gm...... 29 fluoxetine hcl tab 10 mg...... 17 escitalopram oxalate tab 5 mg (base equiv) FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 (Lexapro)...... 17 mg/5ml...... 17 escitalopram oxalate tab 10 mg (base equiv) FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ (Lexapro)...... 17 ml...... 18 escitalopram oxalate tab 20 mg (base equiv) flurbiprofen tab 50 mg...... 20 (Lexapro)...... 17 flurbiprofen tab 100 mg...... 20 estazolam tab 1 mg...... 18 FLUTICASONE PROPIONATE/SA – fluticasone- estazolam tab 2 mg...... 18 salmeterol aer powder ba 55-14 mcg/act...... 14 estradiol tab 0.5 mg (Estrace)...... 5 FLUTICASONE PROPIONATE/SA – fluticasone- estradiol tab 1 mg (Estrace)...... 5 salmeterol aer powder ba 113-14 mcg/act...... 14 estradiol tab 2 mg (Estrace)...... 5 FLUTICASONE PROPIONATE/SA – fluticasone- EXJADE – deferasirox tab for oral susp 125 mg...... 30 salmeterol aer powder ba 232-14 mcg/act...... 14

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 35 2019 fluticasone propionate nasal susp 50 mcg/act guanfacine hcl tab 2 mg (Tenex)...... 12 (Flonase)...... 13 H folic acid tab 1 mg...... 25 FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml...... 6 haloperidol lactate oral conc 2 mg/ml...... 18 FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml...... 6 haloperidol tab 0.5 mg...... 18 FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml...... 6 haloperidol tab 1 mg...... 18 fosinopril sodium tab 10 mg...... 9 haloperidol tab 2 mg...... 18 fosinopril sodium tab 20 mg...... 9 HARVONI – ledipasvir-sofosbuvir tab 90-400 mg...... 1 fosinopril sodium tab 40 mg...... 9 HELIXATE FS – antihemophilic factor (recombinant) for inj FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 kit 250 unit...... 25 mg/0.6ml...... 25 HELIXATE FS – antihemophilic factor (recombinant) for inj furosemide oral soln 10 mg/ml...... 12 kit 500 unit...... 25 furosemide tab 20 mg (Lasix)...... 12 HELIXATE FS – antihemophilic factor (recombinant) for inj furosemide tab 40 mg (Lasix)...... 12 kit 1000 unit...... 25 furosemide tab 80 mg (Lasix)...... 12 HELIXATE FS – antihemophilic factor (recombinant) for inj kit 2000 unit...... 25 G HELIXATE FS – antihemophilic factor (recombinant) for inj gabapentin cap 100 mg (Neurontin)...... 22 kit 3000 unit...... 25 gabapentin cap 300 mg (Neurontin)...... 22 HEMLIBRA – emicizumab-kxwh subcutaneous soln 30 gabapentin cap 400 mg (Neurontin)...... 22 mg/ml...... 25 gemfibrozil tab 600 mg (Lopid)...... 11 HEMLIBRA – emicizumab-kxwh subcutaneous soln 150 gentamicin sulfate ophth soln 0.3% (Garamycin)...... 29 mg/ml...... 25 GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab HEMLIBRA – emicizumab-kxwh subcutaneous soln 60 150-150-200-10 mg...... 2 mg/0.4ml (150 mg/ml)...... 25 GILENYA – fingolimod hcl cap 0.5 mg (base equiv)...... 18 HEMLIBRA – emicizumab-kxwh subcutaneous soln 105 glimepiride tab 1 mg (Amaryl)...... 6 mg/0.7ml (150 mg/ml)...... 25 glimepiride tab 2 mg (Amaryl)...... 6 HEMOFIL M – antihemophilic factor (human) for inj 250 glimepiride tab 4 mg (Amaryl)...... 6 unit...... 25 glipizide tab er 24hr 2.5 mg (Glucotrol xl)...... 6 HEMOFIL M – antihemophilic factor (human) for inj 500 glipizide tab er 24hr 5 mg (Glucotrol xl)...... 6 unit...... 25 glipizide tab 5 mg (Glucotrol)...... 6 HEMOFIL M – antihemophilic factor (human) for inj 1000 glipizide tab 10 mg (Glucotrol)...... 6 unit...... 25 GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj HEMOFIL M – antihemophilic factor (human) for inj 1700 kit 1 mg...... 6 unit...... 25 glyburide-metformin tab 1.25-250 mg (Glucovance)...... 6 HUMATE-P – antihemophilic factor/vwf (human) for inj glyburide-metformin tab 2.5-500 mg (Glucovance)...... 6 250-600 unit...... 25 glyburide-metformin tab 5-500 mg (Glucovance)...... 6 HUMATE-P – antihemophilic factor/vwf (human) for inj glyburide micronized tab 1.5 mg (Glynase)...... 6 500-1200 unit...... 25 glyburide micronized tab 3 mg (Glynase)...... 6 HUMATE-P – antihemophilic factor/vwf (human) for inj glyburide micronized tab 6 mg (Glynase)...... 6 1000-2400 unit...... 25 glyburide tab 1.25 mg...... 6 HUMIRA – adalimumab prefilled syringe kit 10 glyburide tab 2.5 mg...... 6 mg/0.1ml...... 20 glyburide tab 5 mg...... 6 HUMIRA – adalimumab prefilled syringe kit 10 GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg...... 6 mg/0.2ml...... 20 GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg...... 6 HUMIRA – adalimumab prefilled syringe kit 20 GRANIX – tbo-filgrastim soln prefilled syringe 300 mg/0.2ml...... 20 mcg/0.5ml...... 25 HUMIRA – adalimumab prefilled syringe kit 20 GRANIX – tbo-filgrastim soln prefilled syringe 480 mg/0.4ml...... 20 mcg/0.8ml...... 25 HUMIRA – adalimumab prefilled syringe kit 40 GRANIX – tbo-filgrastim subcutaneous inj 300 mcg/ml..... 25 mg/0.8ml...... 20 GRANIX – tbo-filgrastim subcutaneous inj 480 mcg/1.6ml HUMIRA – adalimumab prefilled syringe kit 40 (300 mcg/ml)...... 25 mg/0.4ml...... 20 guanfacine hcl tab 1 mg (Tenex)...... 12

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 36 2019

HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled ibuprofen tab 800 mg...... 20 syringe kit 40 mg/0.8ml...... 20 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled 250 unit...... 25 syringe kit 80 mg/0.8ml...... 20 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled 500 unit...... 25 syringe kit 80 mg/0.8ml & 40 mg/0.4ml...... 20 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEN – adalimumab pen-injector kit 40 1000 unit...... 25 mg/0.8ml...... 20 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEN – adalimumab pen-injector kit 40 2000 unit...... 25 mg/0.4ml...... 20 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEN-CD/UC/HS START – adalimumab pen- 3500 unit...... 25 injector kit 40 mg/0.8ml...... 20 imipramine hcl tab 10 mg (Tofranil)...... 17 HUMIRA PEN-CD/UC/HS START – adalimumab pen- imipramine hcl tab 25 mg (Tofranil)...... 17 injector kit 80 mg/0.8ml...... 20 imipramine hcl tab 50 mg (Tofranil)...... 17 HUMIRA PEN-PS/UV STARTER – adalimumab pen- IMPAVIDO – miltefosine cap 50 mg...... 3 injector kit 40 mg/0.8ml...... 20 INBRIJA – levodopa inhal powder cap 42 mg...... 22 HUMIRA PEN-PS/UV STARTER – adalimumab pen- INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)...... 8 injector kit 80 mg/0.8ml & 40 mg/0.4ml...... 20 INCRUSE ELLIPTA – umeclidinium br aero powd breath HUMULIN R U-500 (CONCENTR – insulin regular act 62.5 mcg/inh (base eq)...... 14 (human) inj 500 unit/ml...... 7 indapamide tab 1.25 mg...... 12 HUMULIN R U-500 KWIKPEN – insulin regular (human) indapamide tab 2.5 mg...... 12 soln pen-injector 500 unit/ml...... 7 indomethacin cap 25 mg...... 21 hydralazine hcl tab 10 mg...... 12 indomethacin cap 50 mg...... 21 hydralazine hcl tab 25 mg...... 12 INSULIN PEN NEEDLES – VARIOUS...... 30 hydralazine hcl tab 50 mg...... 12 INSULIN SYRINGES – VARIOUS...... 30 hydrochlorothiazide cap 12.5 mg (Microzide)...... 12 INTELENCE – etravirine tab 25 mg...... 2 hydrochlorothiazide tab 12.5 mg...... 12 INTELENCE – etravirine tab 100 mg...... 2 hydrochlorothiazide tab 25 mg...... 12 INTELENCE – etravirine tab 200 mg...... 2 hydrochlorothiazide tab 50 mg...... 12 INVOKAMET – canagliflozin-metformin hcl tab 50-500 hydrocodone-acetaminophen tab 7.5-325 mg mg...... 6 (Norco)...... 19 INVOKAMET – canagliflozin-metformin hcl tab 50-1000 hydrocodone-acetaminophen tab 5-325 mg mg...... 6 (Norco)...... 19 INVOKAMET – canagliflozin-metformin hcl tab 150-500 hydrocodone-acetaminophen tab 10-325 mg mg...... 6 (Norco)...... 19 INVOKAMET – canagliflozin-metformin hcl tab 150-1000 hydrocodone-ibuprofen tab 7.5-200 mg mg...... 6 (Vicoprofen)...... 19 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydrocortisone cream 2.5%...... 29 50-500 mg...... 6 hydrocortisone oint 2.5%...... 29 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydrocortisone rectal cream 2.5% (Anusol-hc)...... 29 50-1000 mg...... 6 hydromorphone hcl tab 2 mg (Dilaudid)...... 19 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydromorphone hcl tab 4 mg (Dilaudid)...... 19 150-500 mg...... 6 hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 3 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydroxyzine hcl syrup 10 mg/5ml...... 16 150-1000 mg...... 6 hydroxyzine hcl tab 10 mg...... 17 INVOKANA – canagliflozin tab 100 mg...... 6 hydroxyzine hcl tab 25 mg...... 17 INVOKANA – canagliflozin tab 300 mg...... 6 hydroxyzine hcl tab 50 mg...... 17 ipratropium bromide inhal soln 0.02%...... 14 hydroxyzine pamoate cap 25 mg (Vistaril)...... 17 irbesartan-hydrochlorothiazide tab 150-12.5 mg hydroxyzine pamoate cap 50 mg (Vistaril)...... 17 (Avalide)...... 10 I irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide)...... 10 ibuprofen tab 400 mg...... 20 irbesartan tab 75 mg (Avapro)...... 10 ibuprofen tab 600 mg...... 20 irbesartan tab 150 mg (Avapro)...... 10

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 37 2019 irbesartan tab 300 mg (Avapro)...... 10 KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose ISENTRESS HD – raltegravir potassium tab 600 mg (base (200 mg tab) & letrozole 2.5 mg tbpk...... 3 equiv)...... 2 KISQALI FEMARA 400 DOSE – ribociclib 400 mg dose ISENTRESS – raltegravir potassium chew tab 25 mg (200 mg tab) & letrozole 2.5 mg tbpk...... 3 (base equiv)...... 2 KISQALI FEMARA 600 DOSE – ribociclib 600 mg dose ISENTRESS – raltegravir potassium chew tab 100 mg (200 mg tab) & letrozole 2.5 mg tbpk...... 3 (base equiv)...... 2 KISQALI – ribociclib succinate tab pack 200 mg daily ISENTRESS – raltegravir potassium packet for susp 100 dose...... 3 mg (base equiv)...... 2 KISQALI – ribociclib succinate tab pack 400 mg daily dose ISENTRESS – raltegravir potassium tab 400 mg (base (200 mg tab)...... 3 equiv)...... 2 KISQALI – ribociclib succinate tab pack 600 mg daily dose isoniazid tab 100 mg...... 1 (200 mg tab)...... 3 isoniazid tab 300 mg...... 1 KOATE – antihemophilic factor (human) for inj 250 isosorbide mononitrate tab er 24hr 30 mg...... 11 unit...... 25 isosorbide mononitrate tab er 24hr 60 mg...... 11 KOATE – antihemophilic factor (human) for inj 500 isosorbide mononitrate tab 10 mg...... 11 unit...... 26 isosorbide mononitrate tab 20 mg...... 11 KOATE – antihemophilic factor (human) for inj 1000 IXINITY – coagulation factor ix (recombinant) for inj 250 unit...... 26 unit...... 25 KOATE-DVI – antihemophilic factor (human) for inj 250 IXINITY – coagulation factor ix (recombinant) for inj 500 unit...... 26 unit...... 25 KOATE-DVI – antihemophilic factor (human) for inj 500 IXINITY – coagulation factor ix (recombinant) for inj 1000 unit...... 26 unit...... 25 KOATE-DVI – antihemophilic factor (human) for inj 1000 IXINITY – coagulation factor ix (recombinant) for inj 1500 unit...... 26 unit...... 25 KOGENATE FS – antihemophilic factor (recombinant) for IXINITY – coagulation factor ix (recombinant) for inj 2000 inj kit 250 unit...... 26 unit...... 25 KOGENATE FS – antihemophilic factor (recombinant) for IXINITY – coagulation factor ix (recombinant) for inj 3000 inj kit 500 unit...... 26 unit...... 25 KOGENATE FS – antihemophilic factor (recombinant) for inj kit 1000 unit...... 26 J KOGENATE FS – antihemophilic factor (recombinant) for JADENU – deferasirox tab 90 mg...... 30 inj kit 2000 unit...... 26 JADENU – deferasirox tab 180 mg...... 30 KOGENATE FS – antihemophilic factor (recombinant) for JADENU – deferasirox tab 360 mg...... 30 inj kit 3000 unit...... 26 JANUVIA – sitagliptin phosphate tab 25 mg (base KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr equiv)...... 6 2.5-1000 mg...... 6 JANUVIA – sitagliptin phosphate tab 50 mg (base KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr equiv)...... 6 5-500 mg...... 6 JANUVIA – sitagliptin phosphate tab 100 mg (base KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr equiv)...... 6 5-1000 mg...... 7 JARDIANCE – empagliflozin tab 10 mg...... 6 KOSHER PRENATAL PLUS IRON – prenatal vit w/ iron JARDIANCE – empagliflozin tab 25 mg...... 6 carbonyl-fa tab 30-1 mg...... 23 K KOVALTRY – antihemophilic factor (recombinant) for inj 250 unit...... 26 KALETRA – lopinavir-ritonavir tab 100-25 mg...... 2 KOVALTRY – antihemophilic factor (recombinant) for inj KALETRA – lopinavir-ritonavir tab 200-50 mg...... 2 500 unit...... 26 KALYDECO – ivacaftor packet 25 mg...... 15 KOVALTRY – antihemophilic factor (recombinant) for inj KALYDECO – ivacaftor packet 50 mg...... 15 1000 unit...... 26 KALYDECO – ivacaftor packet 75 mg...... 15 KOVALTRY – antihemophilic factor (recombinant) for inj KALYDECO – ivacaftor tab 150 mg...... 15 2000 unit...... 26 ketoconazole tab 200 mg...... 1 KOVALTRY – antihemophilic factor (recombinant) for inj ketorolac tromethamine ophth soln 0.5% (Acular)...... 29 3000 unit...... 26 ketorolac tromethamine tab 10 mg...... 21

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 38 2019

L lisinopril tab 20 mg (Prinivil)...... 9 lisinopril tab 2.5 mg (Zestril)...... 9 lactulose (encephalopathy) solution 10 gm/15ml...... 16 lisinopril tab 30 mg (Zestril)...... 9 lactulose solution 10 gm/15ml...... 15 lisinopril tab 40 mg (Zestril)...... 9 lamotrigine tab 25 mg (Lamictal)...... 22 lithium carbonate cap 300 mg...... 18 lamotrigine tab 100 mg (Lamictal)...... 22 lithium carbonate cap 150 mg (Lithium carbonate)...... 18 lamotrigine tab 150 mg (Lamictal)...... 22 lithium carbonate cap 600 mg (Lithium carbonate)...... 18 lamotrigine tab 200 mg (Lamictal)...... 22 lithium carbonate tab 300 mg...... 18 LANCETS – VARIOUS...... 30 lorazepam tab 0.5 mg (Ativan)...... 17 LANTUS – insulin glargine inj 100 unit/ml...... 7 lorazepam tab 1 mg (Ativan)...... 17 LANTUS SOLOSTAR – insulin glargine soln pen-injector lorazepam tab 2 mg (Ativan)...... 17 100 unit/ml...... 7 losartan potassium & hydrochlorothiazide tab 50-12.5 latanoprost ophth soln 0.005% (Xalatan)...... 29 mg (Hyzaar)...... 10 letrozole tab 2.5 mg (Femara)...... 3 losartan potassium & hydrochlorothiazide tab 100-12.5 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg (Hyzaar)...... 10 mg...... 3 losartan potassium & hydrochlorothiazide tab 100-25 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg (Hyzaar)...... 10 mg...... 3 losartan potassium tab 25 mg (Cozaar)...... 10 LEUKERAN – chlorambucil tab 2 mg...... 4 losartan potassium tab 50 mg (Cozaar)...... 10 LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector losartan potassium tab 100 mg (Cozaar)...... 10 100 unit/ml...... 8 lovastatin tab 10 mg...... 11 LEVEMIR – insulin detemir inj 100 unit/ml...... 8 lovastatin tab 20 mg (Mevacor)...... 11 levetiracetam tab 250 mg (Keppra)...... 22 lovastatin tab 40 mg (Mevacor)...... 11 levobunolol hcl ophth soln 0.5% (Betagan)...... 29 levofloxacin tab 250 mg (Levaquin)...... 1 M levofloxacin tab 500 mg (Levaquin)...... 1 MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg...... 1 levofloxacin tab 750 mg (Levaquin)...... 1 MAYZENT – siponimod fumarate tab 0.25 mg (base levonorgestrel & ethinyl estradiol tab 0.1 mg-20 equiv)...... 18 mcg...... 5 MAYZENT – siponimod fumarate tab 2 mg (base levothyroxine sodium tab 25 mcg (Synthroid)...... 8 equiv)...... 18 levothyroxine sodium tab 50 mcg (Synthroid)...... 8 medroxyprogesterone acetate tab 2.5 mg (Provera)...... 5 levothyroxine sodium tab 75 mcg (Synthroid)...... 8 medroxyprogesterone acetate tab 5 mg (Provera)...... 5 levothyroxine sodium tab 88 mcg (Synthroid)...... 8 medroxyprogesterone acetate tab 10 mg (Provera)...... 5 levothyroxine sodium tab 100 mcg (Synthroid)...... 8 MEFLOQUINE HCL – mefloquine hcl tab 250 mg...... 3 levothyroxine sodium tab 112 mcg (Synthroid)...... 8 megestrol acetate tab 20 mg...... 4 levothyroxine sodium tab 125 mcg (Synthroid)...... 8 megestrol acetate tab 40 mg...... 4 levothyroxine sodium tab 137 mcg (Synthroid)...... 8 MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg levothyroxine sodium tab 150 mcg (Synthroid)...... 8 (base equivalent)...... 4 levothyroxine sodium tab 175 mcg (Synthroid)...... 8 MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base levothyroxine sodium tab 200 mcg (Synthroid)...... 8 equivalent)...... 4 levothyroxine sodium tab 300 mcg (Synthroid)...... 8 meloxicam tab 7.5 mg (Mobic)...... 21 lidocaine hcl gel 2%...... 30 meloxicam tab 15 mg (Mobic)...... 21 lidocaine hcl soln 4% (Xylocaine)...... 30 metformin hcl tab er 24hr 500 mg (Glucophage xr)...... 7 lidocaine hcl urethral/mucosal gel 2%...... 30 metformin hcl tab er 24hr 750 mg (Glucophage xr)...... 7 lidocaine hcl viscous soln 2%...... 29 metformin hcl tab 500 mg (Glucophage)...... 7 lisinopril & hydrochlorothiazide tab 10-12.5 mg metformin hcl tab 850 mg (Glucophage)...... 7 (Zestoretic)...... 9 metformin hcl tab 1000 mg (Glucophage)...... 7 lisinopril & hydrochlorothiazide tab 20-12.5 mg methadone hcl tab for oral susp 40 mg...... 19 (Zestoretic)...... 9 methadone hcl tab 10 mg (Dolophine)...... 19 lisinopril & hydrochlorothiazide tab 20-25 mg methadone hcl tab 5 mg (Dolophine hcl)...... 19 (Zestoretic)...... 9 methimazole tab 5 mg (Tapazole)...... 8 lisinopril tab 5 mg (Prinivil)...... 9 methimazole tab 10 mg (Tapazole)...... 8 lisinopril tab 10 mg (Prinivil)...... 9 methocarbamol tab 750 mg (Robaxin-750)...... 22

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 39 2019 methocarbamol tab 500 mg (Robaxin)...... 22 neomycin-polymyxin-dexamethasone ophth oint 0.1% methyldopa tab 250 mg...... 12 (Maxitrol)...... 29 methyldopa tab 500 mg...... 12 neomycin-polymyxin-dexamethasone ophth susp metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base 0.1% (Maxitrol)...... 29 equiv)...... 16 neomycin sulfate tab 500 mg...... 1 metoclopramide hcl tab 5 mg (base equivalent) NEUPOGEN – filgrastim inj 300 mcg/ml...... 26 (Reglan)...... 16 NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ metoclopramide hcl tab 10 mg (base equivalent) ml)...... 26 (Reglan)...... 16 NEUPOGEN – filgrastim soln prefilled syringe 300 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) mcg/0.5ml...... 26 (Toprol xl)...... 10 NEUPOGEN – filgrastim soln prefilled syringe 480 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) mcg/0.8ml (600 mcg/ml)...... 26 (Toprol xl)...... 10 nevirapine tab 200 mg (Viramune)...... 2 metoprolol tartrate tab 25 mg...... 10 NEXAVAR – sorafenib tosylate tab 200 mg (base metoprolol tartrate tab 50 mg (Lopressor)...... 10 equivalent)...... 4 metoprolol tartrate tab 100 mg (Lopressor)...... 10 NICOTROL INHALER – nicotine inhaler system 10 mg (4 metronidazole tab 250 mg (Flagyl)...... 3 mg delivered)...... 19 metronidazole tab 500 mg (Flagyl)...... 3 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ minocycline hcl cap 50 mg (Minocin)...... 1 spray)...... 19 minocycline hcl cap 75 mg (Minocin)...... 1 nifedipine tab er 24hr 30 mg (Adalat cc)...... 11 minocycline hcl cap 100 mg (Minocin)...... 1 nifedipine tab er 24hr osmotic release 30 mg minoxidil tab 2.5 mg...... 12 (Procardia xl)...... 11 minoxidil tab 10 mg...... 12 nitroglycerin cap er 2.5 mg...... 11 mirtazapine tab 15 mg (Remeron)...... 17 NITYR – nitisinone tab 2 mg...... 8 mirtazapine tab 30 mg (Remeron)...... 17 NITYR – nitisinone tab 5 mg...... 8 mirtazapine tab 45 mg (Remeron)...... 17 NITYR – nitisinone tab 10 mg...... 8 misoprostol tab 100 mcg (Cytotec)...... 15 NIVESTYM – filgrastim-aafi inj 300 mcg/ml...... 26 misoprostol tab 200 mcg (Cytotec)...... 15 NIVESTYM – filgrastim-aafi inj 480 mcg/1.6ml (300 mcg/ MITIGARE – colchicine cap 0.6 mg...... 21 ml)...... 26 MONONINE – coagulation factor ix for inj 1000 unit...... 26 NIVESTYM – filgrastim-aafi soln prefilled syringe 300 montelukast sodium chew tab 4 mg (base equiv) mcg/0.5ml...... 26 (Singulair)...... 14 NIVESTYM – filgrastim-aafi soln prefilled syringe 480 montelukast sodium chew tab 5 mg (base equiv) mcg/0.8ml...... 26 (Singulair)...... 14 nizatidine cap 150 mg...... 15 montelukast sodium tab 10 mg (base equiv) norethindrone & ethinyl estradiol tab 1 mg-35 mcg (Singulair)...... 14 (Norinyl 1+35)...... 5 MORPHINE SULFATE – morphine sulfate tab 15 mg...... 19 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg MORPHINE SULFATE – morphine sulfate tab 30 mg...... 19 (Ortho-cyclen)...... 5 mupirocin oint 2% (Bactroban)...... 29 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 MYLERAN – busulfan tab 2 mg...... 4 mg-mcg (Ortho tri-cyclen)...... 5 N nortriptyline hcl cap 10 mg (Pamelor)...... 17 nortriptyline hcl cap 25 mg (Pamelor)...... 17 nabumetone tab 500 mg...... 21 nortriptyline hcl cap 50 mg (Pamelor)...... 17 nabumetone tab 750 mg...... 21 nortriptyline hcl cap 75 mg (Pamelor)...... 17 naproxen sodium tab 275 mg (Anaprox)...... 21 NORVIR – ritonavir oral soln 80 mg/ml...... 2 naproxen sodium tab 550 mg (Anaprox ds)...... 21 NORVIR – ritonavir powder packet 100 mg...... 2 naproxen tab ec 375 mg (Ec-naprosyn)...... 21 NOVOEIGHT – antihemophilic factor (recombinant) for inj naproxen tab ec 500 mg (Ec-naprosyn)...... 21 250 unit...... 26 naproxen tab 250 mg (Naprosyn)...... 21 NOVOEIGHT – antihemophilic factor (recombinant) for inj naproxen tab 375 mg (Naprosyn)...... 21 500 unit...... 26 naproxen tab 500 mg (Naprosyn)...... 21 NOVOEIGHT – antihemophilic factor (recombinant) for inj NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...... 30 1000 unit...... 26 NATACYN – natamycin ophth susp 5%...... 29

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 40 2019

NOVOEIGHT – antihemophilic factor (recombinant) for inj NUWIQ – antihemophilic factor (bdd-rfviii) for inj 1000 1500 unit...... 26 unit...... 26 NOVOEIGHT – antihemophilic factor (recombinant) for inj NUWIQ – antihemophilic factor (bdd-rfviii) for inj 2000 2000 unit...... 26 unit...... 27 NOVOEIGHT – antihemophilic factor (recombinant) for inj NUWIQ – antihemophilic factor (bdd-rfviii) for inj 2500 3000 unit...... 26 unit...... 27 NOVOLIN 70/30 FLEXPEN – insulin nph & regular susp NUWIQ – antihemophilic factor (bdd-rfviii) for inj 3000 pen-inj 100 unit/ml (70-30)...... 7 unit...... 27 NOVOLIN 70/30 – insulin nph isophane & regular human NUWIQ – antihemophilic factor (bdd-rfviii) for inj 4000 inj 100 unit/ml (70-30)...... 7 unit...... 27 NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ O ml...... 7 NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 7 OBIZUR – antihemophilic factor (recomb porc) rpfviii for inj NOVOLOG FLEXPEN – insulin aspart soln pen-injector 500 unit...... 27 100 unit/ml...... 7 ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab NOVOLOG – insulin aspart inj 100 unit/ml...... 7 200-25-25 mg...... 2 NOVOLOG MIX 70/30 – insulin aspart prot & aspart ofloxacin ophth soln 0.3% (Ocuflox)...... 29 (human) inj 100 unit/ml (70-30)...... 7 olanzapine tab 2.5 mg (Zyprexa)...... 18 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & olanzapine tab 5 mg (Zyprexa)...... 18 aspart sus pen-inj 100 unit/ml (70-30)...... 7 olanzapine tab 7.5 mg (Zyprexa)...... 18 NOVOLOG PENFILL – insulin aspart soln cartridge 100 olanzapine tab 10 mg (Zyprexa)...... 18 unit/ml...... 7 omeprazole cap delayed release 10 mg (Prilosec)...... 15 NOVOSEVEN RT – coagulation factor viia (recomb) for inj omeprazole cap delayed release 20 mg (Prilosec)...... 15 1 mg (1000 mcg)...... 26 omeprazole cap delayed release 40 mg (Prilosec)...... 15 NOVOSEVEN RT – coagulation factor viia (recomb) for inj OMNITROPE – somatropin for inj 5.8 mg...... 8 2 mg (2000 mcg)...... 26 OMNITROPE – somatropin inj 5 mg/1.5ml...... 8 NOVOSEVEN RT – coagulation factor viia (recomb) for inj OMNITROPE – somatropin inj 10 mg/1.5ml...... 8 5 mg (5000 mcg)...... 26 ondansetron hcl tab 4 mg (Zofran)...... 15 NOVOSEVEN RT – coagulation factor viia (recomb) for inj ondansetron orally disintegrating tab 4 mg (Zofran 8 mg (8000 mcg)...... 26 odt)...... 15 NOXAFIL – posaconazole susp 40 mg/ml...... 1 ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)...... 7 NOXAFIL – posaconazole tab delayed release 100 mg...... 1 ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)...... 7 NUVARING – etonogestrel-ethinyl estradiol va ring OPSUMIT – macitentan tab 10 mg...... 12 0.120-0.015 mg/24hr...... 5 ORFADIN – nitisinone cap 2 mg...... 8 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 250 ORFADIN – nitisinone cap 5 mg...... 8 unit...... 27 ORFADIN – nitisinone cap 10 mg...... 9 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 500 ORFADIN – nitisinone cap 20 mg...... 9 unit...... 27 ORFADIN – nitisinone susp 4 mg/ml...... 8 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 1000 ORILISSA – elagolix sodium tab 150 mg (base equiv)...... 9 unit...... 27 ORILISSA – elagolix sodium tab 200 mg (base equiv)...... 9 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 2000 OTEZLA – apremilast tab 30 mg...... 21 unit...... 27 OTEZLA – apremilast tab starter therapy pack 10 mg & 20 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 2500 mg & 30 mg...... 21 unit...... 27 oxcarbazepine tab 150 mg (Trileptal)...... 22 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 3000 oxybutynin chloride syrup 5 mg/5ml...... 16 unit...... 27 oxycodone hcl tab 5 mg (Roxicodone)...... 20 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 4000 oxycodone w/ acetaminophen tab 5-325 mg unit...... 27 (Percocet)...... 20 NUWIQ – antihemophilic factor (bdd-rfviii) for inj 250 OZEMPIC – semaglutide soln pen-inj 1 mg/dose (2 unit...... 26 mg/1.5ml)...... 7 NUWIQ – antihemophilic factor (bdd-rfviii) for inj 500 OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/dose unit...... 26 (2 mg/1.5ml)...... 7

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 41 2019

P pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 22 pravastatin sodium tab 10 mg...... 11 pantoprazole sodium ec tab 20 mg (base equiv) pravastatin sodium tab 20 mg (Pravachol)...... 11 (Protonix)...... 15 pravastatin sodium tab 40 mg (Pravachol)...... 11 pantoprazole sodium ec tab 40 mg (base equiv) prazosin hcl cap 1 mg (Minipress)...... 12 (Protonix)...... 15 prazosin hcl cap 2 mg (Minipress)...... 12 paroxetine hcl tab 10 mg (Paxil)...... 17 prednisolone sod phosphate oral soln 15 mg/5ml paroxetine hcl tab 20 mg (Paxil)...... 17 (base equiv)...... 5 paroxetine hcl tab 30 mg (Paxil)...... 17 prednisone tab 1 mg...... 5 paroxetine hcl tab 40 mg (Paxil)...... 17 prednisone tab 2.5 mg...... 5 PEGASYS – peginterferon alfa-2a inj 180 mcg/ml...... 1 prednisone tab 5 mg...... 5 PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml...... 1 prednisone tab 10 mg...... 5 PEGASYS PROCLICK – peginterferon alfa-2a inj 180 prednisone tab 20 mg...... 5 mcg/0.5ml...... 2 PREMARIN – estrogens, conjugated tab 0.3 mg...... 5 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm PREMARIN – estrogens, conjugated tab 0.45 mg...... 5 (Colyte-flavor packs)...... 15 PREMARIN – estrogens, conjugated tab 0.625 mg...... 5 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm PREMARIN – estrogens, conjugated tab 0.9 mg...... 5 (Golytely)...... 15 PREMARIN – estrogens, conjugated tab 1.25 mg...... 5 peg 3350-kcl-sod bicarb-nacl for soln 420 gm PREMPHASE – conj est 0.625(14)/conj est-medroxypro (Nulytely/flavor pack)...... 15 ac tab 0.625-5mg(14)...... 5 penicillin v potassium tab 250 mg...... 1 PREMPRO – conjugated estrogen-medroxyprogest penicillin v potassium tab 500 mg...... 1 acetate tab 0.3-1.5 mg...... 5 pentoxifylline tab er 400 mg...... 27 PREMPRO – conjugated estrogen-medroxyprogest perindopril erbumine tab 2 mg...... 9 acetate tab 0.45-1.5 mg...... 5 phenobarbital tab 16.2 mg...... 18 PREMPRO – conjugated estrogen-medroxyprogest phenobarbital tab 32.4 mg...... 18 acetate tab 0.625-2.5 mg...... 5 pioglitazone hcl tab 15 mg (base equiv) (Actos)...... 7 PREMPRO – conjugated estrogen-medroxyprogest pioglitazone hcl tab 30 mg (base equiv) (Actos)...... 7 acetate tab 0.625-5 mg...... 5 pioglitazone hcl tab 45 mg (base equiv) (Actos)...... 7 PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe PLEGRIDY – peginterferon beta-1a soln pen-injector 125 fumarate-fa tab 27-1 mg...... 23 mcg/0.5ml...... 18 PREZISTA – darunavir ethanolate susp 100 mg/ml (base PLEGRIDY – peginterferon beta-1a soln prefilled syringe equiv)...... 2 125 mcg/0.5ml...... 18 PREZISTA – darunavir ethanolate tab 75 mg (base PLEGRIDY STARTER PACK – peginterferon beta-1a soln equiv)...... 2 pen-inj 63 & 94 mcg/0.5ml pack...... 19 PREZISTA – darunavir ethanolate tab 150 mg (base PLEGRIDY STARTER PACK – peginterferon beta-1a soln equiv)...... 2 pref syr 63 & 94 mcg/0.5ml pack...... 19 PREZISTA – darunavir ethanolate tab 600 mg (base polymyxin b-trimethoprim ophth soln 10000 unit/ equiv)...... 2 ml-0.1% (Polytrim)...... 29 PREZISTA – darunavir ethanolate tab 800 mg (base potassium chloride microencapsulated crys er tab 10 equiv)...... 2 meq...... 23 PRIFTIN – rifapentine tab 150 mg...... 1 potassium chloride microencapsulated crys er tab 20 primidone tab 50 mg (Mysoline)...... 22 meq...... 23 PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act potassium chloride tab er 10 meq (K-tab)...... 23 (90mcg base equiv)...... 14 potassium chloride tab er 8 meq (600 mg)...... 23 PROAIR RESPICLICK – albuterol sulfate aer pow ba 108 pramipexole dihydrochloride tab 0.125 mg mcg/act (90 mcg base equiv)...... 14 (Mirapex)...... 22 prochlorperazine maleate tab 5 mg (base pramipexole dihydrochloride tab 0.25 mg equivalent)...... 18 (Mirapex)...... 22 prochlorperazine maleate tab 10 mg (base pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 22 equivalent)...... 18 pramipexole dihydrochloride tab 0.75 mg PROCRIT – epoetin alfa inj 2000 unit/ml...... 27 (Mirapex)...... 22 PROCRIT – epoetin alfa inj 3000 unit/ml...... 27 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 22 PROCRIT – epoetin alfa inj 4000 unit/ml...... 27

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 42 2019

PROCRIT – epoetin alfa inj 10000 unit/ml...... 27 REBIF TITRATION PACK – interferon beta-1a pref syr PROCRIT – epoetin alfa inj 20000 unit/ml...... 27 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 19 PROCRIT – epoetin alfa inj 40000 unit/ml...... 27 REBINYN – coagulation factor ix recomb glycopegylated PROFILNINE – factor ix complex for inj 500 unit...... 27 for inj 500 unt...... 27 PROFILNINE – factor ix complex for inj 1000 unit...... 27 REBINYN – coagulation factor ix recomb glycopegylated PROFILNINE – factor ix complex for inj 1500 unit...... 27 for inj 1000 unt...... 27 PROFILNINE SD – factor ix complex for inj 500 unit...... 27 REBINYN – coagulation factor ix recomb glycopegylated PROFILNINE SD – factor ix complex for inj 1000 unit...... 27 for inj 2000 unt...... 27 PROFILNINE SD – factor ix complex for inj 1500 unit...... 27 RECOMBINATE – antihemophilic factor (recombinant) for promethazine hcl syrup 6.25 mg/5ml...... 13 inj 220-400 unit...... 27 promethazine hcl tab 12.5 mg...... 13 RECOMBINATE – antihemophilic factor (recombinant) for promethazine hcl tab 25 mg...... 13 inj 401-800 unit...... 27 promethazine hcl tab 50 mg...... 13 RECOMBINATE – antihemophilic factor (recombinant) for promethazine w/ codeine syrup 6.25-10 mg/5ml...... 13 inj 801-1240 unit...... 27 proparacaine hcl ophth soln 0.5%...... 29 RECOMBINATE – antihemophilic factor (recombinant) for propranolol hcl tab 10 mg...... 10 inj 1241-1800 unit...... 27 propranolol hcl tab 20 mg...... 10 RECOMBINATE – antihemophilic factor (recombinant) for propranolol hcl tab 40 mg...... 10 inj 1801-2400 unit...... 27 propranolol hcl tab 80 mg...... 10 REPATHA – evolocumab subcutaneous soln prefilled PULMOZYME – dornase alfa inhal soln 1 mg/ml...... 15 syringe 140 mg/ml...... 11 REPATHA PUSHTRONEX SYSTEM – evolocumab Q subcutaneous soln cartridge/infusor 420 mg/3.5ml...... 11 quetiapine fumarate tab 25 mg (Seroquel)...... 18 REPATHA SURECLICK – evolocumab subcutaneous soln quetiapine fumarate tab 50 mg (Seroquel)...... 18 auto-injector 140 mg/ml...... 11 quetiapine fumarate tab 100 mg (Seroquel)...... 18 RETACRIT – epoetin alfa-epbx inj 2000 unit/ml...... 27 quinapril hcl tab 5 mg (Accupril)...... 9 RETACRIT – epoetin alfa-epbx inj 3000 unit/ml...... 27 quinapril hcl tab 10 mg (Accupril)...... 9 RETACRIT – epoetin alfa-epbx inj 4000 unit/ml...... 27 quinapril hcl tab 20 mg (Accupril)...... 9 RETACRIT – epoetin alfa-epbx inj 10000 unit/ml...... 27 quinapril hcl tab 40 mg (Accupril)...... 9 RETACRIT – epoetin alfa-epbx inj 40000 unit/ml...... 28 QVAR REDIHALER – beclomethasone diprop hfa breath REVCOVI – elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 act inh aer 40 mcg/act...... 14 mg/ml)...... 9 QVAR REDIHALER – beclomethasone diprop hfa breath REVLIMID – lenalidomide cap 5 mg...... 30 act inh aer 80 mcg/act...... 14 REVLIMID – lenalidomide cap 10 mg...... 30 R REVLIMID – lenalidomide cap 15 mg...... 30 REVLIMID – lenalidomide cap 20 mg...... 30 ramipril cap 1.25 mg (Altace)...... 9 REVLIMID – lenalidomide cap 25 mg...... 30 ramipril cap 2.5 mg (Altace)...... 9 REVLIMID – lenalidomide caps 2.5 mg...... 30 ramipril cap 5 mg (Altace)...... 9 risperidone tab 0.25 mg (Risperdal)...... 18 ramipril cap 10 mg (Altace)...... 9 risperidone tab 0.5 mg (Risperdal)...... 18 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)...... 15 risperidone tab 1 mg (Risperdal)...... 18 ranitidine hcl tab 300 mg (Zantac)...... 15 risperidone tab 2 mg (Risperdal)...... 18 RAPAMUNE – sirolimus oral soln 1 mg/ml...... 30 risperidone tab 3 mg (Risperdal)...... 18 REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml risperidone tab 4 mg (Risperdal)...... 18 (12mu/ml)...... 19 RIXUBIS – coagulation factor ix (recombinant) for inj 250 REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml unit...... 28 (24mu/ml)...... 19 RIXUBIS – coagulation factor ix (recombinant) for inj 500 REBIF REBIDOSE – interferon beta-1a soln auto-inj 22 unit...... 28 mcg/0.5ml (12mu/ml)...... 19 RIXUBIS – coagulation factor ix (recombinant) for inj 1000 REBIF REBIDOSE – interferon beta-1a soln auto-inj 44 unit...... 28 mcg/0.5ml (24mu/ml)...... 19 RIXUBIS – coagulation factor ix (recombinant) for inj 2000 REBIF REBIDOSE TITRATION – interferon beta-1a auto- unit...... 28 inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 19 RIXUBIS – coagulation factor ix (recombinant) for inj 3000 unit...... 28

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 43 2019 ropinirole hydrochloride tab 0.25 mg (Requip)...... 22 STIMATE – desmopressin acetate nasal soln 1.5 mg/ ropinirole hydrochloride tab 0.5 mg (Requip)...... 22 ml...... 9 ropinirole hydrochloride tab 1 mg (Requip)...... 22 STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero ropinirole hydrochloride tab 2 mg (Requip)...... 22 soln 2.5-2.5 mcg/act...... 15 ropinirole hydrochloride tab 3 mg (Requip)...... 22 STRENSIQ – asfotase alfa subcutaneous inj 18 ropinirole hydrochloride tab 4 mg (Requip)...... 22 mg/0.45ml...... 9 ropinirole hydrochloride tab 5 mg (Requip)...... 22 STRENSIQ – asfotase alfa subcutaneous inj 28 RYDAPT – midostaurin cap 25 mg...... 4 mg/0.7ml...... 9 STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml...... 9 S STRENSIQ – asfotase alfa subcutaneous inj 80 selenium sulfide lotion 2.5%...... 30 mg/0.8ml...... 9 SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)...... 9 STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)...... 9 2.5 mcg/act (base equiv)...... 15 SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)...... 9 SULFADIAZINE – sulfadiazine tab 500 mg...... 3 SEREVENT DISKUS – salmeterol xinafoate aer pow ba sulfamethoxazole-trimethoprim susp 200-40 50 mcg/dose (base equiv)...... 14 mg/5ml...... 3 sertraline hcl tab 25 mg (Zoloft)...... 17 sulfamethoxazole-trimethoprim tab 400-80 mg sertraline hcl tab 50 mg (Zoloft)...... 17 (Bactrim)...... 3 sertraline hcl tab 100 mg (Zoloft)...... 17 sulfamethoxazole-trimethoprim tab 800-160 mg silver sulfadiazine cream 1% (Silvadene)...... 29 (Bactrim ds)...... 3 SIMPONI – golimumab subcutaneous soln auto-injector sulindac tab 150 mg...... 21 50 mg/0.5ml...... 21 sulindac tab 200 mg...... 21 SIMPONI – golimumab subcutaneous soln auto-injector sumatriptan succinate tab 25 mg (Imitrex)...... 21 100 mg/ml...... 21 sumatriptan succinate tab 50 mg (Imitrex)...... 21 SIMPONI – golimumab subcutaneous soln prefilled sumatriptan succinate tab 100 mg (Imitrex)...... 21 syringe 50 mg/0.5ml...... 21 SUTENT – sunitinib malate cap 12.5 mg (base SIMPONI – golimumab subcutaneous soln prefilled equivalent)...... 4 syringe 100 mg/ml...... 21 SUTENT – sunitinib malate cap 25 mg (base simvastatin tab 5 mg (Zocor)...... 11 equivalent)...... 4 simvastatin tab 10 mg (Zocor)...... 11 SUTENT – sunitinib malate cap 37.5 mg (base simvastatin tab 20 mg (Zocor)...... 11 equivalent)...... 4 simvastatin tab 40 mg (Zocor)...... 11 SUTENT – sunitinib malate cap 50 mg (base simvastatin tab 80 mg (Zocor)...... 11 equivalent)...... 4 SKYRIZI – risankizumab-rzaa sol prefilled syringe 2 x 75 SYLATRON – peginterferon alfa-2b for inj kit 200 mcg...... 4 mg/0.83ml kit...... 30 SYLATRON – peginterferon alfa-2b for inj kit 300 mcg...... 4 SOOLANTRA – ivermectin cream 1%...... 29 SYLATRON – peginterferon alfa-2b for inj kit 600 mcg...... 4 sotalol hcl tab 80 mg (Betapace)...... 12 SYMBICORT – budesonide-formoterol fumarate dihyd sotalol hcl tab 120 mg (Betapace)...... 12 aerosol 80-4.5 mcg/act...... 15 sotalol hcl tab 160 mg (Betapace)...... 12 SYMBICORT – budesonide-formoterol fumarate dihyd SOVALDI – sofosbuvir tab 400 mg...... 2 aerosol 160-4.5 mcg/act...... 15 SPIRIVA HANDIHALER – tiotropium bromide SYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 monohydrate inhal cap 18 mcg (base equiv)...... 14 mg tab tbpk...... 15 SPIRIVA RESPIMAT – tiotropium bromide monohydrate SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor inhal aerosol 1.25 mcg/act...... 14 150 mg tab tbpk...... 15 SPIRIVA RESPIMAT – tiotropium bromide monohydrate SYMFI – efavirenz-lamivudine-tenofovir df tab inhal aerosol 2.5 mcg/act...... 15 600-300-300 mg...... 2 spironolactone tab 25 mg (Aldactone)...... 12 SYMFI LO – efavirenz-lamivudine-tenofovir df tab spironolactone tab 50 mg (Aldactone)...... 12 400-300-300 mg...... 2 STELARA – ustekinumab inj 45 mg/0.5ml...... 30 SYMJEPI – epinephrine soln prefilled syringe 0.15 STELARA – ustekinumab soln prefilled syringe 45 mg/0.3ml (1:2000)...... 13 mg/0.5ml...... 30 SYMJEPI – epinephrine solution prefilled syringe 0.3 STELARA – ustekinumab soln prefilled syringe 90 mg/ mg/0.3ml (1:1000)...... 13 ml...... 30

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 44 2019

T topiramate tab 100 mg (Topamax)...... 22 topiramate tab 200 mg (Topamax)...... 22 TAFINLAR – dabrafenib mesylate cap 50 mg (base torsemide tab 5 mg (Demadex)...... 12 equivalent)...... 4 torsemide tab 10 mg (Demadex)...... 12 TAFINLAR – dabrafenib mesylate cap 75 mg (base torsemide tab 20 mg (Demadex)...... 12 equivalent)...... 4 TOUJEO MAX SOLOSTAR – insulin glargine soln pen- tamoxifen citrate tab 10 mg (base equivalent)...... 4 injector 300 unit/ml...... 8 tamoxifen citrate tab 20 mg (base equivalent)...... 4 TOUJEO SOLOSTAR – insulin glargine soln pen-injector tamsulosin hcl cap 0.4 mg (Flomax)...... 16 300 unit/ml...... 8 TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 4 TRACLEER – bosentan tab for oral susp 32 mg...... 12 TARCEVA – erlotinib hcl tab 100 mg (base equivalent)...... 4 TRACLEER – bosentan tab 62.5 mg...... 12 TARCEVA – erlotinib hcl tab 150 mg (base equivalent)...... 4 TRACLEER – bosentan tab 125 mg...... 12 TASIGNA – nilotinib hcl cap 50 mg (base equivalent)...... 4 tramadol-acetaminophen tab 37.5-325 mg TASIGNA – nilotinib hcl cap 150 mg (base equivalent)...... 4 (Ultracet)...... 20 TASIGNA – nilotinib hcl cap 200 mg (base equivalent)...... 4 tramadol hcl tab 50 mg (Ultram)...... 20 TAZORAC – tazarotene cream 0.05%...... 29 trandolapril tab 1 mg (Mavik)...... 9 TAZORAC – tazarotene gel 0.05%...... 29 trandolapril tab 2 mg (Mavik)...... 9 TAZORAC – tazarotene gel 0.1%...... 29 trandolapril tab 4 mg (Mavik)...... 10 TECFIDERA – dimethyl fumarate capsule delayed release trazodone hcl tab 50 mg...... 17 120 mg...... 19 trazodone hcl tab 100 mg...... 17 TECFIDERA – dimethyl fumarate capsule delayed release trazodone hcl tab 150 mg...... 17 240 mg...... 19 TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol TECFIDERA STARTER PACK – dimethyl fumarate aepb 100-62.5-25 mcg/inh...... 15 capsule dr starter pack 120 mg & 240 mg...... 19 TREMFYA – guselkumab soln pen-injector 100 mg/ml..... 30 temazepam cap 15 mg (Restoril)...... 18 TREMFYA – guselkumab soln prefilled syringe 100 mg/ temazepam cap 30 mg (Restoril)...... 18 ml...... 30 terazosin hcl cap 1 mg (base equivalent)...... 12 TRESIBA FLEXTOUCH – insulin degludec soln pen- terazosin hcl cap 2 mg (base equivalent)...... 12 injector 100 unit/ml...... 8 terazosin hcl cap 5 mg (base equivalent)...... 12 TRESIBA FLEXTOUCH – insulin degludec soln pen- terazosin hcl cap 10 mg (base equivalent)...... 12 injector 200 unit/ml...... 8 terbinafine hcl tab 250 mg (Lamisil)...... 1 TRESIBA – insulin degludec inj 100 unit/ml...... 8 TEST STRIPS – ASCENSIA BREEZE 2, CONTOUR, TRETTEN – coagulation factor xiii a-subunit for inj CONTOUR NEXT...... 30 2000-3125 unit...... 28 tetracaine hcl ophth soln 0.5%...... 29 triamcinolone acetonide cream 0.025%...... 29 THALOMID – thalidomide cap 50 mg...... 30 triamcinolone acetonide cream 0.1%...... 29 THALOMID – thalidomide cap 100 mg...... 30 triamcinolone acetonide cream 0.5%...... 29 THALOMID – thalidomide cap 150 mg...... 30 triamcinolone acetonide oint 0.025%...... 29 THALOMID – thalidomide cap 200 mg...... 30 triamcinolone acetonide oint 0.1%...... 30 theophylline tab er 12hr 100 mg...... 15 triamterene & hydrochlorothiazide cap 37.5-25 mg thyroid tab 30 mg (1/2 grain) (Armour thyroid)...... 8 (Dyazide)...... 12 thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...... 8 triamterene & hydrochlorothiazide tab 37.5-25 mg thyroid tab 60 mg (1 grain) (Armour thyroid)...... 8 (Maxzide-25)...... 12 timolol maleate ophth soln 0.25% (Timoptic)...... 29 triamterene & hydrochlorothiazide tab 75-50 mg timolol maleate ophth soln 0.5% (Timoptic)...... 29 (Maxzide)...... 12 TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 2 trihexyphenidyl hcl tab 2 mg...... 22 TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 2 trihexyphenidyl hcl tab 5 mg...... 22 TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 2 trimethoprim tab 100 mg...... 3 tizanidine hcl tab 2 mg (base equivalent)...... 22 tropicamide ophth soln 0.5%...... 29 tizanidine hcl tab 4 mg (base equivalent) tropicamide ophth soln 1% (Mydriacyl)...... 29 (Zanaflex)...... 22 TRULICITY – dulaglutide soln pen-injector 0.75 tobramycin ophth soln 0.3% (Tobrex)...... 29 mg/0.5ml...... 7 topiramate tab 25 mg (Topamax)...... 22 TRULICITY – dulaglutide soln pen-injector 1.5 topiramate tab 50 mg (Topamax)...... 22 mg/0.5ml...... 7

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 45 2019

TRUVADA – emtricitabine-tenofovir disoproxil fumarate VIBERZI – eluxadoline tab 100 mg...... 16 tab 100-150 mg...... 2 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ TRUVADA – emtricitabine-tenofovir disoproxil fumarate ml)...... 7 tab 133-200 mg...... 2 VIDEX – didanosine for soln 2 gm...... 3 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VIREAD – tenofovir disoproxil fumarate oral powder 40 tab 167-250 mg...... 2 mg/gm...... 3 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VIREAD – tenofovir disoproxil fumarate tab 150 mg...... 3 tab 200-300 mg...... 3 VIREAD – tenofovir disoproxil fumarate tab 200 mg...... 3 TYMLOS – abaloparatide subcutaneous soln pen-injector VIREAD – tenofovir disoproxil fumarate tab 250 mg...... 3 3120 mcg/1.56ml...... 9 VONVENDI – von willebrand factor (recombinant) for inj 650 unit...... 28 U VONVENDI – von willebrand factor (recombinant) for inj UDENYCA – pegfilgrastim-cbqv soln prefilled syringe 6 1300 unit...... 28 mg/0.6ml...... 28 VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab UPTRAVI – selexipag tab 200 mcg...... 12 400-100-100 mg...... 2 UPTRAVI – selexipag tab 400 mcg...... 13 VOTRIENT – pazopanib hcl tab 200 mg (base equiv)...... 4 UPTRAVI – selexipag tab 600 mcg...... 13 UPTRAVI – selexipag tab 800 mcg...... 13 W UPTRAVI – selexipag tab 1000 mcg...... 13 warfarin sodium tab 1 mg (Coumadin)...... 28 UPTRAVI – selexipag tab 1200 mcg...... 13 warfarin sodium tab 2 mg (Coumadin)...... 28 UPTRAVI – selexipag tab 1400 mcg...... 13 warfarin sodium tab 2.5 mg (Coumadin)...... 28 UPTRAVI – selexipag tab 1600 mcg...... 13 warfarin sodium tab 3 mg (Coumadin)...... 28 UPTRAVI – selexipag tab therapy pack 200 mcg (140) & warfarin sodium tab 4 mg (Coumadin)...... 28 800 mcg (60)...... 12 warfarin sodium tab 5 mg (Coumadin)...... 28 V warfarin sodium tab 6 mg (Coumadin)...... 28 warfarin sodium tab 7.5 mg (Coumadin)...... 28 VALCHLOR – mechlorethamine hcl gel 0.016% (base warfarin sodium tab 10 mg (Coumadin)...... 28 equivalent)...... 30 WILATE – antihemophilic factor/vwf (human) for inj valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan 500-500 unit kit...... 28 hct)...... 10 WILATE – antihemophilic factor/vwf (human) for inj valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan 1000-1000 unit kit...... 28 hct)...... 10 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan X hct)...... 10 XALKORI – crizotinib cap 200 mg...... 4 VENCLEXTA STARTING PACK – venetoclax tab therapy XALKORI – crizotinib cap 250 mg...... 4 starter pack 10 & 50 & 100 mg...... 4 XARELTO – rivaroxaban tab 2.5 mg...... 28 VENCLEXTA – venetoclax tab 10 mg...... 4 XARELTO – rivaroxaban tab 10 mg...... 28 VENCLEXTA – venetoclax tab 50 mg...... 4 XARELTO – rivaroxaban tab 15 mg...... 28 VENCLEXTA – venetoclax tab 100 mg...... 4 XARELTO – rivaroxaban tab 20 mg...... 28 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) XARELTO STARTER PACK – rivaroxaban tab starter (Effexor xr)...... 17 therapy pack 15 mg & 20 mg...... 28 venlafaxine hcl cap er 24hr 75 mg (base equivalent) XIFAXAN – rifaximin tab 550 mg...... 3 (Effexor xr)...... 17 XTAMPZA ER – oxycodone cap er 12hr abuse-deterrent 9 venlafaxine hcl cap er 24hr 150 mg (base equivalent) mg...... 20 (Effexor xr)...... 17 XTAMPZA ER – oxycodone cap er 12hr abuse-deterrent VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act 13.5 mg...... 20 (90mcg base equiv)...... 15 XTAMPZA ER – oxycodone cap er 12hr abuse-deterrent verapamil hcl tab er 120 mg (Calan sr)...... 11 18 mg...... 20 verapamil hcl tab er 180 mg (Calan sr)...... 11 XTAMPZA ER – oxycodone cap er 12hr abuse-deterrent verapamil hcl tab er 240 mg (Calan sr)...... 11 27 mg...... 20 verapamil hcl tab 80 mg (Calan)...... 11 XTAMPZA ER – oxycodone cap er 12hr abuse-deterrent verapamil hcl tab 120 mg (Calan)...... 11 36 mg...... 20 VIBERZI – eluxadoline tab 75 mg...... 16 XTANDI – enzalutamide cap 40 mg...... 4

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 46 2019

XYNTHA – antihemophilic factor recombinant paf for inj kit 250 unit...... 28 XYNTHA – antihemophilic factor recombinant paf for inj kit 500 unit...... 28 XYNTHA – antihemophilic factor recombinant paf for inj kit 1000 unit...... 28 XYNTHA – antihemophilic factor recombinant paf for inj kit 2000 unit...... 28 XYNTHA SOLOFUSE – antihemophilic factor recombinant paf for inj kit 250 unit...... 28 XYNTHA SOLOFUSE – antihemophilic factor recombinant paf for inj kit 500 unit...... 28 XYNTHA SOLOFUSE – antihemophilic factor recombinant paf for inj kit 1000 unit...... 28 XYNTHA SOLOFUSE – antihemophilic factor recombinant paf for inj kit 2000 unit...... 28 XYNTHA SOLOFUSE – antihemophilic factor recombinant paf for inj kit 3000 unit...... 28 Y YONSA – abiraterone acetate tab 125 mg...... 4 Z zaleplon cap 5 mg (Sonata)...... 18 zaleplon cap 10 mg (Sonata)...... 18 ZARXIO – filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml...... 28 ZARXIO – filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml...... 28 ZELBORAF – vemurafenib tab 240 mg...... 4 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000 unit...... 16 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000 unit...... 16 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 10000-32000-42000 unit...... 16 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 15000-47000-63000 unit...... 16 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 20000-63000-84000 unit...... 16 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 25000-79000-105000 unit...... 16 ZENPEP – pancrelipase (lip-prot-amyl) dr cap 40000-126000-168000 unit...... 16 zolpidem tartrate tab 5 mg (Ambien)...... 18 zolpidem tartrate tab 10 mg (Ambien)...... 18 zonisamide cap 25 mg (Zonegran)...... 22 ZYTIGA – abiraterone acetate tab 500 mg...... 4

Blue Cross and Blue Shield October 2019 Multi Tier Enhanced Drug List 47