October 2018 Multi Tier Enhanced Drug List

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 ...... 5 How to use this list ...... I Heart and Circulatory Drugs ...... 9 Generic drugs ...... II Respiratory Agents ...... 13 Coverage considerations ...... III Gastrointestinal Drugs ...... 15 Specialty drugs ...... IV Genitourinary Drugs ...... 16 Abbreviation/acronym key ...... V 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

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

For Texas Residents only – Find and estimate prices for medicines on this drug list at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

4621-D HCSC © Prime Therapeutics LLC 10/18 Introduction Blue Cross and Blue Shield is pleased to present the 2018 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 the back of 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. To verify your payment amount for a drug, visit myprime.com and log in or call the number on the back of 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.

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.

For Texas Residents only – Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List I 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.

For Texas Residents only – Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List II 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.

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 the back of 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 will 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 will 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.

For Texas Residents only – Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List III 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 the back of 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 or fax your prescription to AllianceRx Walgreens Prime. Your doctor can call 877- 627-6337 or fax to 877-828-3939. • 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 the back of 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 and Blue Shield Association. BCBSIL, BCBSMT, BCBSNM, BCBSOK, and BCBSTX contract with Prime Therapeutics to provide pharmacy benefit management, home delivery pharmacy and specialty pharmacy 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.

For Texas Residents only – Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List IV 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

For Texas Residents only – Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List V 2018

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

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 1 2018

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 135 mcg/0.5ml 100-25 mg PEGASYS PROCLICK – peginterferon • • KALETRA – lopinavir-ritonavir tab • alfa-2a inj 180 mcg/0.5ml 200-50 mg SOVALDI – sofosbuvir tab 400 mg • • nevirapine tab 200 mg (Viramune) • VOSEVI – sofosbuvir-velpatasvir- • • NORVIR – ritonavir tab 100 mg • voxilaprevir tab 400-100-100 mg NORVIR – ritonavir oral soln 80 mg/ml • Herpes NORVIR – ritonavir powder packet 100 • acyclovir cap 200 mg (Zovirax) mg acyclovir tab 400 mg (Zovirax) ODEFSEY – emtricitabine-rilpivirine- • acyclovir tab 800 mg (Zovirax) tenofovir af tab 200-25-25 mg HIV/AIDS PREZISTA – darunavir ethanolate susp • 100 mg/ml (base equiv) ATRIPLA – efavirenz-emtricitabine- • tenofovir df tab 600-200-300 mg PREZISTA – darunavir ethanolate tab • 75 mg (base equiv) BIKTARVY – bictegravir-emtricitabine- • tenofovir af tab 50-200-25 mg PREZISTA – darunavir ethanolate tab • 150 mg (base equiv) CIMDUO – lamivudine-tenofovir • disoproxil fumarate tab 300-300 mg PREZISTA – darunavir ethanolate tab • 600 mg (base equiv) DESCOVY – emtricitabine-tenofovir • alafenamide fumarate tab 200-25 mg PREZISTA – darunavir ethanolate tab • 800 mg (base equiv) GENVOYA – elvitegrav-cobic- • emtricitab-tenofov af tab REYATAZ – atazanavir sulfate cap 150 • 150-150-200-10 mg mg (base equiv) INTELENCE – etravirine tab 25 mg • REYATAZ – atazanavir sulfate cap 200 • mg (base equiv) INTELENCE – etravirine tab 100 mg • REYATAZ – atazanavir sulfate cap 300 • INTELENCE – etravirine tab 200 mg • mg (base equiv) ISENTRESS – raltegravir potassium • STRIBILD – elvitegrav-cobic-emtricitab- • packet for susp 100 mg (base equiv) tenofovdf tab 150-150-200-300 mg ISENTRESS – raltegravir potassium • SUSTIVA – efavirenz tab 600 mg • tab 400 mg (base equiv) SUSTIVA – efavirenz cap 50 mg • ISENTRESS – raltegravir potassium • chew tab 25 mg (base equiv) SUSTIVA – efavirenz cap 200 mg • ISENTRESS – raltegravir potassium • SYMFI – efavirenz-lamivudine-tenofovir • chew tab 100 mg (base equiv) df tab 600-300-300 mg ISENTRESS HD – raltegravir • SYMFI LO – efavirenz-lamivudine- • potassium tab 600 mg (base equiv) tenofovir df tab 400-300-300 mg

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 2 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy TIVICAY – dolutegravir sodium tab 10 • hydroxychloroquine sulfate tab mg (base equiv) 200 mg (Plaquenil) TIVICAY – dolutegravir sodium tab 25 • MEFLOQUINE HCL – mefloquine hcl mg (base equiv) tab 250 mg TIVICAY – dolutegravir sodium tab 50 • PRIMAQUINE PHOSPHATE – mg (base equiv) primaquine phosphate tab 26.3 mg TRUVADA – emtricitabine-tenofovir • (15 mg base) disoproxil fumarate tab 100-150 mg WORM INFECTIONS TRUVADA – emtricitabine-tenofovir • ALBENZA – albendazole tab 200 mg disoproxil fumarate tab 133-200 mg BENZNIDAZOLE – benznidazole tab TRUVADA – emtricitabine-tenofovir • 12.5 mg disoproxil fumarate tab 167-250 mg BENZNIDAZOLE – benznidazole tab TRUVADA – emtricitabine-tenofovir • 100 mg disoproxil fumarate tab 200-300 mg BILTRICIDE – praziquantel tab 600 mg VIDEX – didanosine for soln 2 gm • OTHER ANTI-INFECTIVES VIDEX – didanosine for soln 4 gm • ALINIA – nitazoxanide tab 500 mg • VIRAMUNE – nevirapine susp 50 • ALINIA – nitazoxanide for susp 100 • mg/5ml mg/5ml VIREAD – tenofovir disoproxil fumarate • clindamycin hcl cap 75 mg (Cleocin) oral powder 40 mg/gm clindamycin hcl cap 150 mg (Cleocin) VIREAD – tenofovir disoproxil fumarate • tab 150 mg clindamycin hcl cap 300 mg (Cleocin) VIREAD – tenofovir disoproxil fumarate • IMPAVIDO – miltefosine cap 50 mg tab 200 mg metronidazole tab 250 mg (Flagyl) VIREAD – tenofovir disoproxil fumarate • metronidazole tab 500 mg (Flagyl) tab 250 mg SULFADIAZINE – sulfadiazine tab 500 VIREAD – tenofovir disoproxil fumarate • mg tab 300 mg sulfamethoxazole-trimethoprim susp ZIAGEN – abacavir sulfate soln 20 mg/ • 200-40 mg/5ml ml (base equiv) sulfamethoxazole-trimethoprim tab MALARIA 400-80 mg (Bactrim) CHLOROQUINE PHOSPHATE – sulfamethoxazole-trimethoprim tab chloroquine phosphate tab 250 mg 800-160 mg (Bactrim ds) chloroquine phosphate tab 500 mg trimethoprim tab 100 mg (Aralen) XIFAXAN – rifaximin tab 550 mg • DARAPRIM – pyrimethamine tab 25 mg • • CANCER DRUGS

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 3 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ACTIMMUNE – interferon gamma-1b • SUTENT – sunitinib malate cap 25 mg • • • inj 100 mcg/0.5ml (2000000 (base equivalent) unit/0.5ml) SUTENT – sunitinib malate cap 37.5 • • • anastrozole tab 1 mg (Arimidex) mg (base equivalent) bicalutamide tab 50 mg (Casodex) • SUTENT – sunitinib malate cap 50 mg • • • ERLEADA – apalutamide tab 60 mg • • • (base equivalent) KISQALI – ribociclib succinate tab 200 • • • SYLATRON – peginterferon alfa-2b for • • mg (base equiv) inj kit 200 mcg KISQALI FEMARA 200 DOSE – • • • SYLATRON – peginterferon alfa-2b for • • ribociclib tab 200 mg & letrozole tab inj kit 300 mcg 2.5 mg therapy pack SYLATRON – peginterferon alfa-2b for • • KISQALI FEMARA 400 DOSE – • • • inj kit 600 mcg ribociclib tab 200 mg & letrozole tab TAFINLAR – dabrafenib mesylate cap • • • 2.5 mg therapy pack 50 mg (base equivalent) KISQALI FEMARA 600 DOSE – • • • TAFINLAR – dabrafenib mesylate cap • • • ribociclib tab 200 mg & letrozole tab 75 mg (base equivalent) 2.5 mg therapy pack tamoxifen citrate tab 10 mg (base letrozole tab 2.5 mg (Femara) equivalent) LEUCOVORIN CALCIUM – leucovorin tamoxifen citrate tab 20 mg (base calcium tab 10 mg equivalent) LEUCOVORIN CALCIUM – leucovorin TARCEVA – erlotinib hcl tab 25 mg • • • calcium tab 15 mg (base equivalent) 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) VOTRIENT – pazopanib hcl tab 200 mg • • • (base equiv) RYDAPT – midostaurin cap 25 mg • • • XALKORI – crizotinib cap 200 mg • • • SUTENT – sunitinib malate cap 12.5 • • • mg (base equivalent) XALKORI – crizotinib cap 250 mg • • • XTANDI – enzalutamide cap 40 mg • • •

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 4 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ZELBORAF – vemurafenib tab 240 mg • • • DIVIGEL – estradiol td gel 0.25 ZYTIGA – abiraterone acetate tab 250 • • • mg/0.25gm (0.1%) mg DIVIGEL – estradiol td gel 0.5 ZYTIGA – abiraterone acetate tab 500 • • • mg/0.5gm (0.1%) mg DIVIGEL – estradiol td gel 1 mg/gm HORMONES, DIABETES AND RELATED DRUGS (0.1%) CORTICOSTEROIDS estradiol tab 0.5 mg (Estrace) CORTISONE ACETATE – cortisone estradiol tab 1 mg (Estrace) acetate tab 25 mg estradiol tab 2 mg (Estrace) dexamethasone tab 0.5 mg PROGESTINS dexamethasone tab 0.75 mg medroxyprogesterone acetate tab dexamethasone tab 1.5 mg 2.5 mg (Provera) dexamethasone tab 4 mg medroxyprogesterone acetate tab 5 mg (Provera) dexamethasone tab 6 mg medroxyprogesterone acetate tab prednisolone sod phosphate oral 10 mg (Provera) soln 15 mg/5ml (base equiv) BIRTH CONTROL prednisone tab 1 mg desogestrel & ethinyl estradiol tab • prednisone tab 2.5 mg 0.15 mg-30 mcg (Desogen) prednisone tab 5 mg ELLA – ulipristal acetate tab 30 mg • prednisone tab 10 mg levonorgestrel & ethinyl estradiol tab • prednisone tab 20 mg 0.1 mg-20 mcg MALE HORMONES MIRENA – levonorgestrel releasing iud ANDROGEL – testosterone td gel • • 20 mcg/day (52 mg total) 20.25 mg/1.25gm (1.62%) norethindrone & ethinyl estradiol tab • ANDROGEL – testosterone td gel 40.5 • • 1 mg-35 mcg (Norinyl 1+35) mg/2.5gm (1.62%) norgestimate & ethinyl estradiol tab • ANDROGEL PUMP – testosterone td • • 0.25 mg-35 mcg (Ortho-cyclen) gel 20.25 mg/act (1.62%) norgestimate-eth estrad tab • ESTROGENS 0.18-35/0.215-35/0.25-35 mg-mcg (Ortho tri-cyclen) COMBIPATCH – estradiol- norethindrone ace td pttw 0.05-0.14 NUVARING – etonogestrel-ethinyl • mg/day estradiol va ring 0.120-0.015 mg/24hr COMBIPATCH – estradiol- SKYLA – levonorgestrel releasing iud norethindrone ace td pttw 0.05-0.25 14 mcg/day (13.5 mg total) mg/day INFERTILITY

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 5 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy 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 GLYXAMBI – empagliflozin-linagliptin • KOMBIGLYZE XR – saxagliptin- • tab 10-5 mg metformin hcl tab er 24hr 5-1000 mg

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 6 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy metformin hcl tab er 24hr 500 mg Short-Acting Insulins (Glucophage xr) HUMULIN R U-500 (CONCENTR – • metformin hcl tab er 24hr 750 mg insulin regular (human) inj 500 unit/ml (Glucophage xr) HUMULIN R U-500 KWIKPEN – insulin • metformin hcl tab 500 mg regular (human) soln pen-injector 500 (Glucophage) unit/ml metformin hcl tab 850 mg NOVOLIN R – insulin regular (human) • (Glucophage) inj 100 unit/ml metformin hcl tab 1000 mg Intermediate-Acting Insulins (Glucophage) NOVOLIN N – insulin nph (human) • ONGLYZA – saxagliptin hcl tab 2.5 mg • (isophane) inj 100 unit/ml (base equiv) NOVOLIN 70/30 – insulin nph isophane • ONGLYZA – saxagliptin hcl tab 5 mg • & regular human inj 100 unit/ml (base equiv) (70-30) OZEMPIC – semaglutide soln pen-inj • • NOVOLOG MIX 70/30 – insulin aspart • 0.25 or 0.5 mg/dose (2 mg/1.5ml) prot & aspart (human) inj 100 unit/ml OZEMPIC – semaglutide soln pen-inj 1 • • (70-30) mg/dose (2 mg/1.5ml) NOVOLOG MIX 70/30 PREFILL – • pioglitazone hcl tab 15 mg (base insulin aspart prot & aspart sus pen- equiv) (Actos) inj 100 unit/ml (70-30) pioglitazone hcl tab 30 mg (base Basal Insulins equiv) (Actos) LANTUS – insulin glargine inj 100 unit/ • pioglitazone hcl tab 45 mg (base ml equiv) (Actos) LANTUS SOLOSTAR – insulin glargine • VICTOZA – liraglutide soln pen-injector • • soln pen-injector 100 unit/ml 18 mg/3ml (6 mg/ml) LEVEMIR – insulin detemir inj 100 unit/ • DIABETES - INSULINS ml Rapid-Acting Insulins LEVEMIR FLEXTOUCH – insulin • detemir soln pen-injector 100 unit/ml FIASP – insulin aspart inj 100 unit/ml • TOUJEO MAX SOLOSTAR – insulin • FIASP FLEXTOUCH – insulin aspart • glargine soln pen-injector 300 unit/ml soln pen-injector 100 unit/ml TOUJEO SOLOSTAR – insulin glargine • NOVOLOG – insulin aspart inj 100 unit/ • soln pen-injector 300 unit/ml ml TRESIBA FLEXTOUCH – insulin • NOVOLOG FLEXPEN – insulin aspart • degludec soln pen-injector 100 unit/ soln pen-injector 100 unit/ml ml NOVOLOG PENFILL – insulin aspart • soln cartridge 100 unit/ml

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 7 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy TRESIBA FLEXTOUCH – insulin • INCRELEX – mecasermin inj 40 • degludec soln pen-injector 200 unit/ mg/4ml (10 mg/ml) ml OMNITROPE – somatropin for inj 5.8 • • THYROID REGULATION mg levothyroxine sodium tab 25 mcg OMNITROPE – somatropin inj 5 • • (Synthroid) mg/1.5ml levothyroxine sodium tab 50 mcg OMNITROPE – somatropin inj 10 • • (Synthroid) mg/1.5ml levothyroxine sodium tab 75 mcg OTHER HORMONES AND RELATED DRUGS (Synthroid) alendronate sodium tab 5 mg • levothyroxine sodium tab 88 mcg alendronate sodium tab 10 mg • (Synthroid) alendronate sodium tab 35 mg • levothyroxine sodium tab 100 mcg (Synthroid) alendronate sodium tab 70 mg • (Fosamax) levothyroxine sodium tab 112 mcg (Synthroid) NITYR – nitisinone tab 2 mg • levothyroxine sodium tab 125 mcg NITYR – nitisinone tab 5 mg • (Synthroid) NITYR – nitisinone tab 10 mg • levothyroxine sodium tab 137 mcg ORFADIN – nitisinone susp 4 mg/ml • (Synthroid) ORFADIN – nitisinone cap 2 mg • levothyroxine sodium tab 150 mcg ORFADIN – nitisinone cap 5 mg • (Synthroid) ORFADIN – nitisinone cap 10 mg • levothyroxine sodium tab 175 mcg (Synthroid) ORFADIN – nitisinone cap 20 mg • levothyroxine sodium tab 200 mcg SENSIPAR – cinacalcet hcl tab 30 mg (Synthroid) (base equiv) levothyroxine sodium tab 300 mcg SENSIPAR – cinacalcet hcl tab 60 mg (Synthroid) (base equiv) methimazole tab 5 mg (Tapazole) SENSIPAR – cinacalcet hcl tab 90 mg (base equiv) methimazole tab 10 mg (Tapazole) STIMATE – desmopressin acetate thyroid tab 30 mg (1/2 grain) (Armour nasal soln 1.5 mg/ml thyroid) STRENSIQ – asfotase alfa • • thyroid tab 60 mg (1 grain) (Armour subcutaneous inj 18 mg/0.45ml thyroid) STRENSIQ – asfotase alfa • • thyroid tab 90 mg (1 1/2 grain) subcutaneous inj 28 mg/0.7ml (Armour thyroid) STRENSIQ – asfotase alfa • • GROWTH HORMONE subcutaneous inj 40 mg/ml

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 8 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy 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) enalapril maleate & trandolapril tab 4 mg (Mavik) hydrochlorothiazide tab 10-25 mg (Vaseretic) ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS enalapril maleate tab 2.5 mg (Vasotec) irbesartan tab 75 mg (Avapro) enalapril maleate tab 5 mg (Vasotec) irbesartan tab 150 mg (Avapro) enalapril maleate tab 10 mg (Vasotec) irbesartan tab 300 mg (Avapro) enalapril maleate tab 20 mg (Vasotec) irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) fosinopril sodium tab 10 mg irbesartan-hydrochlorothiazide tab fosinopril sodium tab 20 mg 300-12.5 mg (Avalide) fosinopril sodium tab 40 mg losartan potassium & lisinopril & hydrochlorothiazide tab hydrochlorothiazide tab 50-12.5 mg 10-12.5 mg (Zestoretic) (Hyzaar) lisinopril & hydrochlorothiazide tab losartan potassium & 20-12.5 mg (Zestoretic) hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab 100-12.5 mg (Hyzaar) 20-25 mg (Zestoretic) losartan potassium & lisinopril tab 2.5 mg (Zestril) hydrochlorothiazide tab 100-25 mg (Hyzaar) lisinopril tab 5 mg (Prinivil) losartan potassium tab 25 mg lisinopril tab 10 mg (Prinivil) (Cozaar) lisinopril tab 20 mg (Prinivil)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 9 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy losartan potassium tab 50 mg metoprolol tartrate tab 25 mg (Cozaar) metoprolol tartrate tab 50 mg losartan potassium tab 100 mg (Lopressor) (Cozaar) metoprolol tartrate tab 100 mg valsartan-hydrochlorothiazide tab (Lopressor) 80-12.5 mg (Diovan hct) propranolol hcl tab 10 mg valsartan-hydrochlorothiazide tab propranolol hcl tab 20 mg 320-12.5 mg (Diovan hct) propranolol hcl tab 40 mg valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) propranolol hcl tab 80 mg BETA BLOCKERS AND COMBINATIONS CALCIUM CHANNEL BLOCKERS AND COMBINATIONS acebutolol hcl cap 200 mg (Sectral) amlodipine besylate tab 2.5 mg (base acebutolol hcl cap 400 mg (Sectral) equivalent) (Norvasc) atenolol & chlorthalidone tab amlodipine besylate tab 5 mg (base 50-25 mg (Tenoretic 50) equivalent) (Norvasc) atenolol & chlorthalidone tab amlodipine besylate tab 10 mg (base 100-25 mg (Tenoretic 100) equivalent) (Norvasc) atenolol tab 25 mg (Tenormin) diltiazem hcl cap er 24hr 120 mg atenolol tab 50 mg (Tenormin) diltiazem hcl coated beads cap er atenolol tab 100 mg (Tenormin) 24hr 120 mg (Cardizem cd) bisoprolol & hydrochlorothiazide tab diltiazem hcl coated beads cap er 2.5-6.25 mg (Ziac) 24hr 180 mg (Cardizem cd) bisoprolol & hydrochlorothiazide tab diltiazem hcl tab 30 mg (Cardizem) 5-6.25 mg (Ziac) diltiazem hcl tab 60 mg (Cardizem) bisoprolol & hydrochlorothiazide tab diltiazem hcl tab 90 mg 10-6.25 mg (Ziac) diltiazem hcl tab 120 mg (Cardizem) bisoprolol fumarate tab 5 mg (Zebeta) ENTRESTO – sacubitril-valsartan tab • • 24-26 mg carvedilol tab 3.125 mg (Coreg) ENTRESTO – sacubitril-valsartan tab • • carvedilol tab 6.25 mg (Coreg) 49-51 mg carvedilol tab 12.5 mg (Coreg) ENTRESTO – sacubitril-valsartan tab • • carvedilol tab 25 mg (Coreg) 97-103 mg metoprolol succinate tab er 24hr nifedipine tab er 24hr 30 mg (Adalat 25 mg (tartrate equiv) (Toprol xl) cc) metoprolol succinate tab er 24hr nifedipine tab er 24hr osmotic 50 mg (tartrate equiv) (Toprol xl) release 30 mg (Procardia xl)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 10 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy verapamil hcl tab er 120 mg (Calan pravastatin sodium tab 10 mg sr) pravastatin sodium tab 20 mg verapamil hcl tab er 180 mg (Calan (Pravachol) sr) pravastatin sodium tab 40 mg verapamil hcl tab er 240 mg (Calan (Pravachol) sr) REPATHA – evolocumab subcutaneous • • • verapamil hcl tab 80 mg (Calan) soln prefilled syringe 140 mg/ml verapamil hcl tab 120 mg (Calan) REPATHA PUSHTRONEX SYSTEM • • • CHEST PAIN – evolocumab subcutaneous soln cartridge/infusor 420 mg/3.5ml isosorbide mononitrate tab er 24hr 30 mg REPATHA SURECLICK – evolocumab • • • subcutaneous soln auto-injector 140 isosorbide mononitrate tab er 24hr mg/ml 60 mg simvastatin tab 5 mg (Zocor) isosorbide mononitrate tab 10 mg simvastatin tab 10 mg (Zocor) isosorbide mononitrate tab 20 mg simvastatin tab 20 mg (Zocor) nitroglycerin cap er 2.5 mg simvastatin tab 40 mg (Zocor) CHOLESTEROL LOWERING simvastatin tab 80 mg (Zocor) atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) WELCHOL – colesevelam hcl tab 625 mg atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) WELCHOL – colesevelam hcl packet for susp 3.75 gm atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) FLUID RETENTION atorvastatin calcium tab 80 mg (base amiloride & hydrochlorothiazide tab equivalent) (Lipitor) 5-50 mg fenofibrate tab 54 mg (Lofibra) • bumetanide tab 0.5 mg gemfibrozil tab 600 mg (Lopid) • bumetanide tab 1 mg lovastatin tab 10 mg chlorothiazide tab 500 mg lovastatin tab 20 mg (Mevacor) furosemide oral soln 10 mg/ml lovastatin tab 40 mg (Mevacor) furosemide tab 20 mg (Lasix) PRALUENT – alirocumab • • • furosemide tab 40 mg (Lasix) subcutaneous soln pen-injector 75 furosemide tab 80 mg (Lasix) mg/ml hydrochlorothiazide cap 12.5 mg PRALUENT – alirocumab • • • (Microzide) subcutaneous soln pen-injector 150 hydrochlorothiazide tab 12.5 mg mg/ml

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 11 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy hydrochlorothiazide tab 25 mg guanfacine hcl tab 2 mg (Tenex) hydrochlorothiazide tab 50 mg hydralazine hcl tab 10 mg indapamide tab 1.25 mg hydralazine hcl tab 25 mg indapamide tab 2.5 mg hydralazine hcl tab 50 mg spironolactone tab 25 mg (Aldactone) methyldopa tab 250 mg spironolactone tab 50 mg (Aldactone) methyldopa tab 500 mg torsemide tab 5 mg (Demadex) minoxidil tab 2.5 mg torsemide tab 10 mg (Demadex) minoxidil tab 10 mg torsemide tab 20 mg (Demadex) OPSUMIT – macitentan tab 10 mg • • • triamterene & hydrochlorothiazide prazosin hcl cap 1 mg (Minipress) cap 37.5-25 mg (Dyazide) prazosin hcl cap 2 mg (Minipress) triamterene & hydrochlorothiazide terazosin hcl cap 1 mg (base tab 37.5-25 mg (Maxzide-25) equivalent) triamterene & hydrochlorothiazide terazosin hcl cap 2 mg (base tab 75-50 mg (Maxzide) equivalent) HEART RHYTHM terazosin hcl cap 5 mg (base amiodarone hcl tab 200 mg equivalent) (Cordarone) terazosin hcl cap 10 mg (base sotalol hcl tab 80 mg (Betapace) equivalent) sotalol hcl tab 120 mg (Betapace) TRACLEER – bosentan tab for oral • • • sotalol hcl tab 160 mg (Betapace) susp 32 mg OTHER HEART RELATED DRUGS TRACLEER – bosentan tab 62.5 mg • • • ADCIRCA – tadalafil tab 20 mg (pah) • • • 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) UPTRAVI – selexipag tab 400 mcg • • • doxazosin mesylate tab 1 mg (Cardura) UPTRAVI – selexipag tab 600 mcg • • • doxazosin mesylate tab 2 mg UPTRAVI – selexipag tab 800 mcg • • • (Cardura) UPTRAVI – selexipag tab 1000 mcg • • • doxazosin mesylate tab 4 mg UPTRAVI – selexipag tab 1200 mcg • • • (Cardura) UPTRAVI – selexipag tab 1400 mcg • • • doxazosin mesylate tab 8 mg UPTRAVI – selexipag tab 1600 mcg • • • (Cardura) ERECTILE DYSFUNCTION guanfacine hcl tab 1 mg (Tenex)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 12 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy CIALIS – tadalafil tab 2.5 mg • • promethazine-phenylephrine- • CIALIS – tadalafil tab 5 mg • • codeine syrup 6.25-5-10 mg/5ml CIALIS – tadalafil tab 10 mg • • ASTHMA/COPD CIALIS – tadalafil tab 20 mg • • ADVAIR DISKUS – fluticasone- • salmeterol aer powder ba 100-50 BEE STING KITS mcg/dose EPINEPHRINE (Mylan Products) – ADVAIR DISKUS – fluticasone- • epinephrine solution auto-injector salmeterol aer powder ba 250-50 0.15 mg/0.3ml (1:2000) mcg/dose EPINEPHRINE (Mylan Products) – ADVAIR DISKUS – fluticasone- • epinephrine solution auto-injector 0.3 salmeterol aer powder ba 500-50 mg/0.3ml (1:1000) mcg/dose EPIPEN 2-PAK – epinephrine solution ADVAIR HFA – fluticasone-salmeterol • auto-injector 0.3 mg/0.3ml (1:1000) inhal aerosol 45-21 mcg/act EPIPEN-JR 2-PAK – epinephrine ADVAIR HFA – fluticasone-salmeterol • solution auto-injector 0.15 mg/0.3ml inhal aerosol 115-21 mcg/act (1:2000) ADVAIR HFA – fluticasone-salmeterol • RESPIRATORY AGENTS inhal aerosol 230-21 mcg/act ANTIHISTAMINES albuterol sulfate syrup 2 mg/5ml promethazine hcl syrup 6.25 mg/5ml ANORO ELLIPTA – umeclidinium- • promethazine hcl tab 12.5 mg vilanterol aero powd ba 62.5-25 mcg/ inh promethazine hcl tab 25 mg ARNUITY ELLIPTA – fluticasone promethazine hcl tab 50 mg • furoate aerosol powder breath activ NASAL PRODUCTS 50 mcg/act fluticasone propionate nasal susp • ARNUITY ELLIPTA – fluticasone • 50 mcg/act (Flonase) furoate aerosol powder breath activ COUGH/COLD/ALLERGY 100 mcg/act benzonatate cap 100 mg (Tessalon ARNUITY ELLIPTA – fluticasone • perles) furoate aerosol powder breath activ 200 mcg/act benzonatate cap 200 mg ASMANEX HFA – mometasone furoate • promethazine & phenylephrine syrup inhal aerosol suspension 100 mcg/act 6.25-5 mg/5ml ASMANEX HFA – mometasone furoate • promethazine w/ codeine syrup • inhal aerosol suspension 200 mcg/act 6.25-10 mg/5ml ASMANEX TWISTHALER 120 ME – • promethazine-dm syrup mometasone furoate inhal powd 220 6.25-15 mg/5ml mcg/inh (breath activated)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 13 2018

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 110 fluticasone-salmeterol aer powder ba mcg/inh (breath activated) 55-14 mcg/act 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)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 14 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy SPIRIVA RESPIMAT – tiotropium • peg 3350-kcl-na bicarb-nacl-na bromide monohydrate inhal aerosol sulfate for soln 236 gm (Golytely) 1.25 mcg/act peg 3350-kcl-na bicarb-nacl-na SPIRIVA RESPIMAT – tiotropium • sulfate for soln 240 gm (Colyte- bromide monohydrate inhal aerosol flavor packs) 2.5 mcg/act polyethylene glycol 3350 oral STIOLTO RESPIMAT – tiotropium br- • powder olodaterol inhal aero soln 2.5-2.5 ULCER/GERD mcg/act cimetidine tab 300 mg STRIVERDI RESPIMAT – olodaterol • hcl inhal aerosol soln 2.5 mcg/act cimetidine tab 400 mg (base equiv) dicyclomine hcl cap 10 mg (Bentyl) SYMBICORT – budesonide-formoterol • dicyclomine hcl tab 20 mg (Bentyl) fumarate dihyd aerosol 80-4.5 mcg/ famotidine tab 40 mg (Pepcid) act misoprostol tab 100 mcg (Cytotec) SYMBICORT – budesonide-formoterol • fumarate dihyd aerosol 160-4.5 mcg/ misoprostol tab 200 mcg (Cytotec) act nizatidine cap 150 mg theophylline tab er 12hr 100 mg omeprazole cap delayed release • TRELEGY ELLIPTA – fluticasone- • 10 mg (Prilosec) umeclidinium-vilanterol aepb omeprazole cap delayed release • 100-62.5-25 mcg/inh 20 mg (Prilosec) VENTOLIN HFA – albuterol sulfate • omeprazole cap delayed release • inhal aero 108 mcg/act (90mcg base 40 mg (Prilosec) equiv) pantoprazole sodium ec tab 20 mg • OTHER RESPIRATORY DRUGS (base equiv) (Protonix) KALYDECO – ivacaftor tab 150 mg • • • pantoprazole sodium ec tab 40 mg • KALYDECO – ivacaftor packet 50 mg • • • (base equiv) (Protonix) KALYDECO – ivacaftor packet 75 mg • • • ranitidine hcl syrup 15 mg/ml (75 mg/5ml) PULMOZYME – dornase alfa inhal soln • 1 mg/ml ranitidine hcl tab 300 mg (Zantac) GASTROINTESTINAL DRUGS NAUSEA AND VOMITING LAXATIVES EMEND – aprepitant for oral susp 125 • mg (125 mg/5ml) lactulose solution 10 gm/15ml EMEND – aprepitant capsule 40 mg • peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor pack) EMEND – aprepitant capsule 125 mg • ondansetron hcl tab 4 mg (Zofran) •

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 15 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ondansetron orally disintegrating tab • metoclopramide hcl tab 5 mg (base 4 mg (Zofran odt) equivalent) (Reglan) DIGESTIVE ENZYMES metoclopramide hcl tab 10 mg (base CREON – pancrelipase (lip-prot-amyl) equivalent) (Reglan) dr cap 3000-9500-15000 unit VIBERZI – eluxadoline tab 75 mg • CREON – pancrelipase (lip-prot-amyl) VIBERZI – eluxadoline tab 100 mg • dr cap 6000-19000-30000 unit GENITOURINARY DRUGS CREON – pancrelipase (lip-prot-amyl) URINARY TRACT SPASMS dr cap 12000-38000-60000 unit bethanechol chloride tab 5 mg CREON – pancrelipase (lip-prot-amyl) (Urecholine) dr cap 24000-76000-120000 unit oxybutynin chloride syrup 5 mg/5ml CREON – pancrelipase (lip-prot-amyl) dr cap 36000-114000-180000 unit VAGINAL PRODUCTS ZENPEP – pancrelipase (lip-prot-amyl) ESTRACE – estradiol vaginal cream dr cap 3000-10000-14000 unit 0.1 mg/gm ZENPEP – pancrelipase (lip-prot-amyl) OTHER GENITOURINARY DRUGS dr cap 5000-17000-24000 unit alfuzosin hcl tab er 24hr 10 mg ZENPEP – pancrelipase (lip-prot-amyl) (Uroxatral) dr cap 10000-32000-42000 unit CYSTAGON – cysteamine bitartrate • ZENPEP – pancrelipase (lip-prot-amyl) cap 50 mg dr cap 15000-47000-63000 unit CYSTAGON – cysteamine bitartrate • ZENPEP – pancrelipase (lip-prot-amyl) cap 150 mg dr cap 20000-63000-84000 unit finasteride tab 5 mg (Proscar) ZENPEP – pancrelipase (lip-prot-amyl) tamsulosin hcl cap 0.4 mg (Flomax) dr cap 25000-79000-105000 unit CENTRAL NERVOUS SYSTEM DRUGS ZENPEP – pancrelipase (lip-prot-amyl) ANXIETY dr cap 40000-126000-168000 unit alprazolam tab 0.25 mg (Xanax) OTHER GASTROINTESTINAL DRUGS alprazolam tab 0.5 mg (Xanax) APRISO – mesalamine cap er 24hr 0.375 gm alprazolam tab 1 mg (Xanax) CANASA – mesalamine suppos 1000 alprazolam tab 2 mg (Xanax) mg buspirone hcl tab 5 mg CHENODAL – chenodiol tab 250 mg • buspirone hcl tab 10 mg lactulose (encephalopathy) solution buspirone hcl tab 15 mg 10 gm/15ml chlordiazepoxide hcl cap 5 mg metoclopramide hcl soln 5 mg/5ml chlordiazepoxide hcl cap 10 mg (10 mg/10ml) (base equiv)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 16 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy chlordiazepoxide hcl cap 25 mg doxepin hcl cap 10 mg clorazepate dipotassium tab 3.75 mg doxepin hcl cap 25 mg (Tranxene t) doxepin hcl conc 10 mg/ml clorazepate dipotassium tab 7.5 mg escitalopram oxalate tab 5 mg (base (Tranxene t) equiv) (Lexapro) diazepam tab 2 mg (Valium) escitalopram oxalate tab 10 mg diazepam tab 5 mg (Valium) (base equiv) (Lexapro) diazepam tab 10 mg (Valium) escitalopram oxalate tab 20 mg hydroxyzine hcl syrup 10 mg/5ml (base equiv) (Lexapro) 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 paroxetine hcl tab 20 mg (Paxil) (Wellbutrin sr) paroxetine hcl tab 30 mg (Paxil) bupropion hcl tab er 12hr 150 mg (Wellbutrin sr) paroxetine hcl tab 40 mg (Paxil) citalopram hydrobromide tab 10 mg sertraline hcl tab 25 mg (Zoloft) (base equiv) (Celexa) sertraline hcl tab 50 mg (Zoloft) citalopram hydrobromide tab 20 mg sertraline hcl tab 100 mg (Zoloft) (Celexa) (base equiv) trazodone hcl tab 50 mg citalopram hydrobromide tab 40 mg trazodone hcl tab 100 mg (base equiv) (Celexa)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 17 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy trazodone hcl tab 150 mg quetiapine fumarate tab 25 mg • venlafaxine hcl cap er 24hr 37.5 mg (Seroquel) (base equivalent) (Effexor xr) quetiapine fumarate tab 50 mg • venlafaxine hcl cap er 24hr 75 mg (Seroquel) (base equivalent) (Effexor xr) quetiapine fumarate tab 100 mg • venlafaxine hcl cap er 24hr 150 mg (Seroquel) (base equivalent) (Effexor xr) risperidone tab 0.25 mg (Risperdal) • PSYCHOTIC AND BIPOLAR DISORDERS risperidone tab 0.5 mg (Risperdal) • FLUPHENAZINE HCL – fluphenazine risperidone tab 1 mg (Risperdal) • hcl elixir 2.5 mg/5ml risperidone tab 2 mg (Risperdal) • FLUPHENAZINE HCL – fluphenazine risperidone tab 3 mg (Risperdal) • hcl oral conc 5 mg/ml risperidone tab 4 mg (Risperdal) • fluphenazine hcl tab 1 mg SLEEP AIDS fluphenazine hcl tab 2.5 mg BELSOMRA – suvorexant tab 5 mg fluphenazine hcl tab 5 mg BELSOMRA – suvorexant tab 10 mg fluphenazine hcl tab 10 mg BELSOMRA – suvorexant tab 15 mg haloperidol lactate oral conc 2 mg/ml BELSOMRA – suvorexant tab 20 mg haloperidol tab 0.5 mg estazolam tab 1 mg haloperidol tab 1 mg estazolam tab 2 mg haloperidol tab 2 mg phenobarbital tab 16.2 mg lithium carbonate cap 150 mg (Lithium carbonate) phenobarbital tab 32.4 mg lithium carbonate cap 300 mg temazepam cap 15 mg (Restoril) lithium carbonate cap 600 mg temazepam cap 30 mg (Restoril) (Lithium carbonate) zaleplon cap 5 mg (Sonata) • lithium carbonate tab 300 mg zaleplon cap 10 mg (Sonata) • olanzapine tab 2.5 mg (Zyprexa) • zolpidem tartrate tab 5 mg (Ambien) • olanzapine tab 5 mg (Zyprexa) • zolpidem tartrate tab 10 mg (Ambien) • olanzapine tab 7.5 mg (Zyprexa) • MULTIPLE SCLEROSIS olanzapine tab 10 mg (Zyprexa) • AUBAGIO – teriflunomide tab 7 mg • • prochlorperazine maleate tab 5 mg AUBAGIO – teriflunomide tab 14 mg • • (base equivalent) (Compazine) AVONEX – interferon beta-1a im • • prochlorperazine maleate tab 10 mg prefilled syringe kit 30 mcg/0.5ml (base equivalent) (Compazine) AVONEX – interferon beta-1a for im inj • • kit 30mcg (33mcg(6.6 mu)/vial)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 18 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy AVONEX PEN – interferon beta-1a im • • TECFIDERA STARTER PACK – • • auto-injector kit 30 mcg/0.5ml dimethyl fumarate capsule dr starter BETASERON – interferon beta-1b for • • pack 120 mg & 240 mg inj kit 0.3 mg OTHER CENTRAL NERVOUS SYSTEM DRUGS COPAXONE – glatiramer acetate soln • • CHANTIX – varenicline tartrate tab 0.5 prefilled syringe 20 mg/ml mg (base equiv) COPAXONE – glatiramer acetate soln • • CHANTIX – varenicline tartrate tab 1 prefilled syringe 40 mg/ml mg (base equiv) GILENYA – fingolimod hcl cap 0.5 mg • • CHANTIX CONTINUING MONTH – (base equiv) varenicline tartrate tab 1 mg (base PLEGRIDY – peginterferon beta-1a • • equiv) soln pen-injector 125 mcg/0.5ml CHANTIX STARTING MONTH PA – PLEGRIDY – peginterferon beta-1a • • varenicline tartrate tab 0.5 mg x 11 & soln prefilled syringe 125 mcg/0.5ml tab 1 mg x 42 pack PLEGRIDY STARTER PACK – • • donepezil hydrochloride tab 5 mg peginterferon beta-1a soln pen-inj 63 (Aricept) & 94 mcg/0.5ml pack donepezil hydrochloride tab 10 mg PLEGRIDY STARTER PACK – • • (Aricept) peginterferon beta-1a soln pref syr 63 NICOTROL INHALER – nicotine inhaler & 94 mcg/0.5ml pack system 10 mg (4 mg delivered) REBIF – interferon beta-1a soln pref syr • • NICOTROL NS – nicotine nasal spray 22 mcg/0.5ml (12mu/ml) 10 mg/ml (0.5 mg/spray) REBIF – interferon beta-1a soln pref syr • • NUEDEXTA – dextromethorphan hbr- 44 mcg/0.5ml (24mu/ml) quinidine sulfate cap 20-10 mg REBIF REBIDOSE – interferon beta-1a • • PAIN RELIEF DRUGS soln auto-inj 22 mcg/0.5ml (12mu/ml) NARCOTIC DRUGS REBIF REBIDOSE – interferon beta-1a • • acetaminophen w/ codeine soln • soln auto-inj 44 mcg/0.5ml (24mu/ml) 120-12 mg/5ml REBIF REBIDOSE TITRATION – • • acetaminophen w/ codeine tab • interferon beta-1a auto-inj 6x8.8 300-15 mg (Tylenol/codeine) mcg/0.2ml & 6x22 mcg/0.5ml acetaminophen w/ codeine tab • REBIF TITRATION PACK – interferon • • 300-30 mg (Tylenol/codeine #3) beta-1a pref syr 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml acetaminophen w/ codeine tab • 300-60 mg (Tylenol/codeine #4) TECFIDERA – dimethyl fumarate • • capsule delayed release 120 mg hydrocodone-acetaminophen tab • 10-325 mg (Norco) TECFIDERA – dimethyl fumarate • • capsule delayed release 240 mg

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 19 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy hydrocodone-acetaminophen tab • tramadol-acetaminophen tab • 5-325 mg (Norco) 37.5-325 mg (Ultracet) hydrocodone-acetaminophen tab • RHEUMATOID AND OSTEOARTHRITIS 7.5-325 mg (Norco) diclofenac sodium tab delayed hydrocodone-ibuprofen tab • release 50 mg 7.5-200 mg (Vicoprofen) diclofenac sodium tab delayed hydromorphone hcl tab 2 mg • release 75 mg (Dilaudid) ENBREL – etanercept for • • • hydromorphone hcl tab 4 mg • subcutaneous inj 25 mg (Dilaudid) ENBREL – etanercept subcutaneous • • • methadone hcl tab for oral susp • soln prefilled syringe 25 mg/0.5ml 40 mg ENBREL – etanercept subcutaneous • • • methadone hcl tab 5 mg (Dolophine • soln prefilled syringe 50 mg/ml hcl) ENBREL MINI – etanercept • • • methadone hcl tab 10 mg (Dolophine) • subcutaneous solution cartridge 50 MORPHINE SULFATE – morphine • mg/ml sulfate tab 15 mg ENBREL SURECLICK – etanercept • • • MORPHINE SULFATE – morphine • subcutaneous solution auto-injector sulfate tab 30 mg 50 mg/ml oxycodone hcl tab 5 mg (Roxicodone) • flurbiprofen tab 50 mg oxycodone w/ acetaminophen tab • flurbiprofen tab 100 mg 5-325 mg (Percocet) HUMIRA – adalimumab prefilled • • • OXYCONTIN – oxycodone hcl tab er • • syringe kit 10 mg/0.1ml 12hr deter 10 mg HUMIRA – adalimumab prefilled • • • OXYCONTIN – oxycodone hcl tab er • • syringe kit 10 mg/0.2ml 12hr deter 15 mg HUMIRA – adalimumab prefilled • • • OXYCONTIN – oxycodone hcl tab er • • syringe kit 20 mg/0.2ml 12hr deter 20 mg HUMIRA – adalimumab prefilled • • • OXYCONTIN – oxycodone hcl tab er • • syringe kit 20 mg/0.4ml 12hr deter 30 mg HUMIRA – adalimumab prefilled • • • OXYCONTIN – oxycodone hcl tab er • • syringe kit 40 mg/0.8ml 12hr deter 40 mg HUMIRA – adalimumab prefilled • • • OXYCONTIN – oxycodone hcl tab er • • syringe kit 40 mg/0.4ml 12hr deter 60 mg HUMIRA PEDIATRIC CROHNS D – • • • OXYCONTIN – oxycodone hcl tab er • • adalimumab prefilled syringe kit 40 12hr deter 80 mg mg/0.8ml tramadol hcl tab 50 mg (Ultram) • •

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 20 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy HUMIRA PEDIATRIC CROHNS D – • • • naproxen tab 500 mg (Naprosyn) adalimumab prefilled syringe kit 80 OTEZLA – apremilast tab starter • • • mg/0.8ml therapy pack 10 mg & 20 mg & 30 mg HUMIRA PEDIATRIC CROHNS D – • • • OTEZLA – apremilast tab 30 mg • • • adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml SIMPONI – golimumab subcutaneous • • • soln auto-injector 50 mg/0.5ml HUMIRA PEN – adalimumab pen- • • • injector kit 40 mg/0.8ml SIMPONI – golimumab subcutaneous • • • soln auto-injector 100 mg/ml HUMIRA PEN – adalimumab pen- • • • injector kit 40 mg/0.4ml SIMPONI – golimumab subcutaneous • • • soln prefilled syringe 50 mg/0.5ml HUMIRA PEN-CROHNS DISEASE • • • – adalimumab pen-injector kit 40 SIMPONI – golimumab subcutaneous • • • mg/0.8ml soln prefilled syringe 100 mg/ml HUMIRA PEN-PSORIASIS STAR • • • sulindac tab 150 mg – adalimumab pen-injector kit 40 sulindac tab 200 mg mg/0.8ml MIGRAINE HEADACHES ibuprofen tab 400 mg sumatriptan succinate tab 25 mg • ibuprofen tab 600 mg (Imitrex) ibuprofen tab 800 mg sumatriptan succinate tab 50 mg • indomethacin cap 25 mg (Imitrex) indomethacin cap 50 mg sumatriptan succinate tab 100 mg • (Imitrex) ketorolac tromethamine tab 10 mg • GOUT meloxicam tab 7.5 mg (Mobic) allopurinol tab 100 mg (Zyloprim) meloxicam tab 15 mg (Mobic) allopurinol tab 300 mg (Zyloprim) nabumetone tab 500 mg NEUROMUSCULAR DRUGS nabumetone tab 750 mg SEIZURES naproxen sodium tab 275 mg (Anaprox) clonazepam tab 0.5 mg (Klonopin) naproxen sodium tab 550 mg clonazepam tab 1 mg (Klonopin) (Anaprox ds) clonazepam tab 2 mg (Klonopin) naproxen tab ec 375 mg (Ec- DIASTAT ACUDIAL – diazepam rectal naprosyn) gel delivery system 10 mg naproxen tab ec 500 mg (Ec- DIASTAT ACUDIAL – diazepam rectal naprosyn) gel delivery system 20 mg naproxen tab 250 mg (Naprosyn) DIASTAT PEDIATRIC – diazepam naproxen tab 375 mg (Naprosyn) rectal gel delivery system 2.5 mg

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 21 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy divalproex sodium tab delayed pramipexole dihydrochloride tab release 125 mg (Depakote) 0.75 mg (Mirapex) divalproex sodium tab delayed pramipexole dihydrochloride tab release 250 mg (Depakote) 1 mg (Mirapex) 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) SABRIL – vigabatrin tab 500 mg • ropinirole hydrochloride tab 4 mg SABRIL – vigabatrin powd pack 500 mg • (Requip) topiramate tab 25 mg (Topamax) ropinirole hydrochloride tab 5 mg topiramate tab 50 mg (Topamax) (Requip) topiramate tab 100 mg (Topamax) trihexyphenidyl hcl tab 2 mg topiramate tab 200 mg (Topamax) trihexyphenidyl hcl tab 5 mg zonisamide cap 25 mg (Zonegran) MUSCLE RELAXANTS PARKINSON'S DISEASE baclofen tab 10 mg amantadine hcl syrup 50 mg/5ml carisoprodol tab 350 mg (Soma) benztropine mesylate tab 0.5 mg cyclobenzaprine hcl tab 5 mg benztropine mesylate tab 1 mg cyclobenzaprine hcl tab 10 mg benztropine mesylate tab 2 mg methocarbamol tab 500 mg (Robaxin) carbidopa & levodopa tab 10-100 mg methocarbamol tab 750 mg (Sinemet) (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

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 22 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ergocalciferol cap 50000 unit ADVATE – antihemophilic factor rahf- • (Drisdol) pfm for inj 4000 unit MEPHYTON – phytonadione tab 5 mg ADYNOVATE – antihemophilic factor • MULTIVITAMINS recomb pegylated for inj 250 unit KOSHER PRENATAL PLUS IRON – ADYNOVATE – antihemophilic factor • prenatal vit w/ iron carbonyl-fa tab recomb pegylated for inj 500 unit 30-1 mg ADYNOVATE – antihemophilic factor • PRENATAL PLUS – prenatal vit w/ fe recomb pegylated for inj 750 unit fumarate-fa tab 27-1 mg ADYNOVATE – antihemophilic factor • PRENATAL VITAMINS PLUS LO – recomb pegylated for inj 1000 unit prenatal vit w/ fe fumarate-fa tab 27-1 ADYNOVATE – antihemophilic factor • mg recomb pegylated for inj 1500 unit MINERALS AND ELECTROLYTES ADYNOVATE – antihemophilic factor • potassium chloride recomb pegylated for inj 2000 unit microencapsulated crys er tab 10 ADYNOVATE – antihemophilic factor • meq recomb pegylated for inj 3000 unit potassium chloride • AFSTYLA – antihemophilic fact rcmb • microencapsulated crys er tab 20 single chain for inj kit 250 unit meq AFSTYLA – antihemophilic fact rcmb • potassium chloride tab er 8 meq single chain for inj kit 500 unit (600 mg) AFSTYLA – antihemophilic fact rcmb • potassium chloride tab er 10 meq (K- single chain for inj kit 1000 unit tab) AFSTYLA – antihemophilic fact rcmb • BLOOD MODIFYING DRUGS single chain for inj kit 1500 unit ADVATE – antihemophilic factor rahf- • AFSTYLA – antihemophilic fact rcmb • pfm for inj 250 unit single chain for inj kit 2000 unit ADVATE – antihemophilic factor rahf- • AFSTYLA – antihemophilic fact rcmb • pfm for inj 500 unit single chain for inj kit 2500 unit ADVATE – antihemophilic factor rahf- • AFSTYLA – antihemophilic fact rcmb • pfm for inj 1000 unit single chain for inj kit 3000 unit ADVATE – antihemophilic factor rahf- • ALPHANATE/VON WILLEBRAND – • pfm for inj 1500 unit antihemophilic factor/vwf (human) for ADVATE – antihemophilic factor rahf- • inj 250 unit pfm for inj 2000 unit ALPHANATE/VON WILLEBRAND – • ADVATE – antihemophilic factor rahf- • antihemophilic factor/vwf (human) for pfm for inj 3000 unit inj 500 unit

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 23 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ALPHANATE/VON WILLEBRAND – • BENEFIX – coagulation factor ix • antihemophilic factor/vwf (human) for (recombinant) for inj kit 3000 unit inj 1000 unit BRILINTA – ticagrelor tab 60 mg ALPHANATE/VON WILLEBRAND – • BRILINTA – ticagrelor tab 90 mg antihemophilic factor/vwf (human) for inj 1500 unit CEREZYME – imiglucerase for inj 400 • unit ALPHANATE/VON WILLEBRAND – • antihemophilic factor/vwf (human) for cilostazol tab 50 mg (Pletal) inj 2000 unit cilostazol tab 100 mg (Pletal) ALPHANINE SD – coagulation factor ix • clopidogrel bisulfate tab 75 mg (base for inj 500 unit equiv) (Plavix) ALPHANINE SD – coagulation factor ix • COAGADEX – coagulation factor x • for inj 1000 unit (human) for inj 250 unit ALPHANINE SD – coagulation factor ix • COAGADEX – coagulation factor x • for inj 1500 unit (human) for inj 500 unit ALPROLIX – coagulation factor ix • CORIFACT – factor xiii concentrate • (recomb) (rfixfc) for inj 250 unit (human) for inj kit 1000-1600 unit ALPROLIX – coagulation factor ix • cyanocobalamin inj 1000 mcg/ml (recomb) (rfixfc) for inj 500 unit dipyridamole tab 25 mg (Persantine) ALPROLIX – coagulation factor ix • ELIQUIS – apixaban tab 2.5 mg • (recomb) (rfixfc) for inj 1000 unit ELIQUIS – apixaban tab 5 mg • ALPROLIX – coagulation factor ix • (recomb) (rfixfc) for inj 2000 unit ELIQUIS STARTER PACK – apixaban • tab 5 mg ALPROLIX – coagulation factor ix • (recomb) (rfixfc) for inj 3000 unit ELOCTATE – antihemophilic factor • (recomb) rfviiifc for inj 250 unit ALPROLIX – coagulation factor ix • (recomb) (rfixfc) for inj 4000 unit ELOCTATE – antihemophilic factor • (recomb) rfviiifc for inj 500 unit BEBULIN – factor ix complex for inj • 200-1200 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

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 24 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ELOCTATE – antihemophilic factor • HEMOFIL M – antihemophilic factor • (recomb) rfviiifc for inj 4000 unit (human) for inj 500 unit ELOCTATE – antihemophilic factor • HEMOFIL M – antihemophilic factor • (recomb) rfviiifc for inj 5000 unit (human) for inj 1000 unit ELOCTATE – antihemophilic factor • HEMOFIL M – antihemophilic factor • (recomb) rfviiifc for inj 6000 unit (human) for inj 1700 unit FEIBA – antiinhibitor coagulant • HUMATE-P – antihemophilic factor/vwf • complex for inj (human) for inj 250-600 unit FIRAZYR – icatibant acetate inj 30 • • HUMATE-P – antihemophilic factor/vwf • mg/3ml (base equivalent) (human) for inj 500-1200 unit folic acid tab 1 mg HUMATE-P – antihemophilic factor/vwf • GRANIX – tbo-filgrastim soln prefilled • (human) for inj 1000-2400 unit syringe 300 mcg/0.5ml IDELVION – coagulation factor ix • GRANIX – tbo-filgrastim soln prefilled • (recomb) (rix-fp) for inj 250 unit syringe 480 mcg/0.8ml 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

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 25 2018

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

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 26 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy NUWIQ – antihemophilic factor (bdd- • PROCRIT – epoetin alfa inj 20000 unit/ • • rfviii) for inj 500 unit ml NUWIQ – antihemophilic factor (bdd- • PROCRIT – epoetin alfa inj 40000 unit/ • • rfviii) for inj 1000 unit ml 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 RIXUBIS – coagulation factor ix • (recombinant) for inj 250 unit PROCRIT – epoetin alfa inj 10000 unit/ • • ml RIXUBIS – coagulation factor ix • (recombinant) for inj 500 unit

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 27 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy RIXUBIS – coagulation factor ix • XYNTHA – antihemophilic factor • (recombinant) for inj 1000 unit recombinant paf for inj kit 500 unit RIXUBIS – coagulation factor ix • XYNTHA – antihemophilic factor • (recombinant) for inj 2000 unit recombinant paf for inj kit 1000 unit RIXUBIS – coagulation factor ix • XYNTHA – antihemophilic factor • (recombinant) for inj 3000 unit recombinant paf for inj kit 2000 unit TRETTEN – coagulation factor xiii a- • XYNTHA SOLOFUSE – antihemophilic • subunit for inj 2000-3125 unit factor recombinant paf for inj kit 250 VONVENDI – von willebrand factor • unit (recombinant) for inj 650 unit XYNTHA SOLOFUSE – antihemophilic • VONVENDI – von willebrand factor • factor recombinant paf for inj kit 500 (recombinant) for inj 1300 unit unit warfarin sodium tab 1 mg (Coumadin) XYNTHA SOLOFUSE – antihemophilic • factor recombinant paf for inj kit 1000 warfarin sodium tab 2 mg (Coumadin) unit warfarin sodium tab 2.5 mg XYNTHA SOLOFUSE – antihemophilic • (Coumadin) factor recombinant paf for inj kit 2000 warfarin sodium tab 3 mg (Coumadin) unit warfarin sodium tab 4 mg (Coumadin) XYNTHA SOLOFUSE – antihemophilic • factor recombinant paf for inj kit 3000 warfarin sodium tab 5 mg (Coumadin) unit warfarin sodium tab 6 mg (Coumadin) ZARXIO – filgrastim-sndz soln prefilled • warfarin sodium tab 7.5 mg syringe 300 mcg/0.5ml (Coumadin) ZARXIO – filgrastim-sndz soln prefilled • warfarin sodium tab 10 mg syringe 480 mcg/0.8ml (Coumadin) TOPICAL PRODUCTS WILATE – antihemophilic factor/vwf • (human) for inj 500-500 unit kit EYE WILATE – antihemophilic factor/vwf • Anti-infectives (human) for inj 1000-1000 unit kit BACITRACIN – bacitracin ophth oint XARELTO – rivaroxaban tab 10 mg • 500 unit/gm XARELTO – rivaroxaban tab 15 mg • bacitracin-polymyxin b ophth oint XARELTO – rivaroxaban tab 20 mg • ciprofloxacin hcl ophth soln 0.3% (Ciloxan) XARELTO STARTER PACK – • rivaroxaban tab starter therapy pack erythromycin ophth oint 5 mg/gm 15 mg & 20 mg gentamicin sulfate ophth soln 0.3% XYNTHA – antihemophilic factor • (Garamycin) recombinant paf for inj kit 250 unit NATACYN – natamycin ophth susp 5%

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 28 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy ofloxacin ophth soln 0.3% (Ocuflox) proparacaine hcl ophth soln 0.5% polymyxin b-trimethoprim ophth (Alcaine) soln 10000 unit/ml-0.1% (Polytrim) tetracaine hcl ophth soln 0.5% tobramycin ophth soln 0.3% (Tobrex) tropicamide ophth soln 0.5% Steroids and Combination Products tropicamide ophth soln 1% DEXAMETHASONE SODIUM PHOS – (Mydriacyl) dexamethasone sodium phosphate MOUTH AND THROAT (LOCAL) ophth soln 0.1% chlorhexidine gluconate soln 0.12% neomycin-polymyxin- (Peridex) dexamethasone ophth oint 0.1% lidocaine hcl viscous soln 2% (Maxitrol) ANORECTAL AGENTS neomycin-polymyxin- dexamethasone ophth susp 0.1% CORTIFOAM – hydrocortisone acetate (Maxitrol) rectal foam 10% (90 mg/dose) sulfacetamide sodium-prednisolone hydrocortisone rectal cream 2.5% ophth soln 10-0.23(0.25)% (Anusol-hc) Glaucoma SKIN CONDITIONS/PRODUCTS brimonidine tartrate ophth soln 0.2% Acne dorzolamide hcl-timolol maleate FINACEA – azelaic acid foam 15% ophth soln 22.3-6.8 mg/ml (Cosopt) FINACEA – azelaic acid gel 15% latanoprost ophth soln 0.005% • SOOLANTRA – ivermectin cream 1% (Xalatan) TAZORAC – tazarotene cream 0.05% levobunolol hcl ophth soln 0.5% TAZORAC – tazarotene gel 0.05% (Betagan) TAZORAC – tazarotene gel 0.1% timolol maleate ophth soln 0.25% (Timoptic) Anti-infectives timolol maleate ophth soln 0.5% mupirocin oint 2% (Bactroban) (Timoptic) silver sulfadiazine cream 1% Other Eye Products (Silvadene) cromolyn sodium ophth soln 4% Corticosteroids cyclopentolate hcl ophth soln 1% hydrocortisone cream 2.5% (Cyclogyl) hydrocortisone oint 2.5% diclofenac sodium ophth soln 0.1% triamcinolone acetonide cream flurbiprofen sodium ophth soln 0.025% 0.03% (Ocufen) triamcinolone acetonide cream 0.1% ketorolac tromethamine ophth soln triamcinolone acetonide cream 0.5% 0.5% (Acular)

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 29 2018

Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy Drug Name Specialty Prior Authorization Dispensing Limits Step Therapy triamcinolone acetonide oint 0.025% EXJADE – deferasirox tab for oral susp • triamcinolone acetonide oint 0.1% 250 mg Other Skin Products EXJADE – deferasirox tab for oral susp • 500 mg COSENTYX – secukinumab • • • subcutaneous soln prefilled syringe JADENU – deferasirox tab 90 mg • 150 mg/ml JADENU – deferasirox tab 180 mg • COSENTYX SENSOREADY PEN – • • • JADENU – deferasirox tab 360 mg • secukinumab subcutaneous soln NARCAN – naloxone hcl nasal spray 4 auto-injector 150 mg/ml mg/0.1ml lidocaine hcl gel 2% • RAPAMUNE – sirolimus oral soln 1 mg/ lidocaine hcl soln 4% (Xylocaine) • ml selenium sulfide lotion 2.5% REVLIMID – lenalidomide caps 2.5 mg • • • STELARA – ustekinumab inj 45 • • • REVLIMID – lenalidomide cap 5 mg • • • mg/0.5ml REVLIMID – lenalidomide cap 10 mg • • • STELARA – ustekinumab soln prefilled • • • REVLIMID – lenalidomide cap 15 mg • • • syringe 45 mg/0.5ml REVLIMID – lenalidomide cap 20 mg • • • STELARA – ustekinumab soln prefilled • • • syringe 90 mg/ml REVLIMID – lenalidomide cap 25 mg • • • VALCHLOR – mechlorethamine hcl gel • THALOMID – thalidomide cap 50 mg • • • 0.016% (base equivalent) THALOMID – thalidomide cap 100 mg • • • MISCELLANEOUS CATEGORIES THALOMID – thalidomide cap 150 mg • • • DIABETIC SUPPLIES THALOMID – thalidomide cap 200 mg • • • TEST STRIPS – ASCENSIA BREEZE • 2, CONTOUR, CONTOUR NEXT INSULIN PEN NEEDLES – VARIOUS • INSULIN SYRINGES – VARIOUS • LANCETS – VARIOUS RESPIRATORY INHALER-ASSIST DEVICES BREATHERITE – spacer/aerosol- holding chambers - device MISCELLANEOUS DRUGS CHEMET – succimer cap 100 mg DEPEN TITRATABS – penicillamine tab • 250 mg EXJADE – deferasirox tab for oral susp • 125 mg

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 30 2018

ADYNOVATE – antihemophilic factor recomb pegylated for INDEX inj 1000 unit...... 23 ADYNOVATE – antihemophilic factor recomb pegylated for A inj 1500 unit...... 23 ADYNOVATE – antihemophilic factor recomb pegylated for acebutolol hcl cap 200 mg (Sectral)...... 10 inj 2000 unit...... 23 acebutolol hcl cap 400 mg (Sectral)...... 10 ADYNOVATE – antihemophilic factor recomb pegylated for acetaminophen w/ codeine soln 120-12 mg/5ml...... 19 inj 3000 unit...... 23 acetaminophen w/ codeine tab 300-15 mg (Tylenol/ AFSTYLA – antihemophilic fact rcmb single chain for inj kit codeine)...... 19 250 unit...... 23 acetaminophen w/ codeine tab 300-30 mg (Tylenol/ AFSTYLA – antihemophilic fact rcmb single chain for inj kit codeine #3)...... 19 500 unit...... 23 acetaminophen w/ codeine tab 300-60 mg (Tylenol/ AFSTYLA – antihemophilic fact rcmb single chain for inj kit codeine #4)...... 19 1000 unit...... 23 ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml AFSTYLA – antihemophilic fact rcmb single chain for inj kit (2000000 unit/0.5ml)...... 4 1500 unit...... 23 acyclovir cap 200 mg (Zovirax)...... 2 AFSTYLA – antihemophilic fact rcmb single chain for inj kit acyclovir tab 400 mg (Zovirax)...... 2 2000 unit...... 23 acyclovir tab 800 mg (Zovirax)...... 2 AFSTYLA – antihemophilic fact rcmb single chain for inj kit ADCIRCA – tadalafil tab 20 mg (pah)...... 12 2500 unit...... 23 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba AFSTYLA – antihemophilic fact rcmb single chain for inj kit 100-50 mcg/dose...... 13 3000 unit...... 23 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba ALBENZA – albendazole tab 200 mg...... 3 250-50 mcg/dose...... 13 ADVAIR DISKUS – fluticasone-salmeterol aer powder ba albuterol sulfate syrup 2 mg/5ml...... 13 500-50 mcg/dose...... 13 alendronate sodium tab 5 mg...... 8 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 alendronate sodium tab 10 mg...... 8 mcg/act...... 13 alendronate sodium tab 35 mg...... 8 ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21 alendronate sodium tab 70 mg (Fosamax)...... 8 mcg/act...... 13 alfuzosin hcl tab er 24hr 10 mg (Uroxatral)...... 16 ALINIA – nitazoxanide for susp 100 mg/5ml...... 3 ADVAIR HFA – fluticasone-salmeterol inhal aerosol ALINIA – nitazoxanide tab 500 mg...... 3 230-21 mcg/act...... 13 ADVATE – antihemophilic factor rahf-pfm for inj 250 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 500 vwf (human) for inj 250 unit...... 23 unit...... 23 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 1000 vwf (human) for inj 500 unit...... 23 unit...... 23 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 1500 vwf (human) for inj 1000 unit...... 24 unit...... 23 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 2000 vwf (human) for inj 1500 unit...... 24 unit...... 23 ALPHANATE/VON WILLEBRAND – antihemophilic factor/ ADVATE – antihemophilic factor rahf-pfm for inj 3000 vwf (human) for inj 2000 unit...... 24 unit...... 23 ALPHANINE SD – coagulation factor ix for inj 500 unit..... 24 ADVATE – antihemophilic factor rahf-pfm for inj 4000 ALPHANINE SD – coagulation factor ix for inj 1000 unit...... 23 unit...... 24 ADYNOVATE – antihemophilic factor recomb pegylated for ALPHANINE SD – coagulation factor ix for inj 1500 inj 250 unit...... 23 unit...... 24 ADYNOVATE – antihemophilic factor recomb pegylated for inj 500 unit...... 23 alprazolam tab 0.25 mg (Xanax)...... 16 ADYNOVATE – antihemophilic factor recomb pegylated for alprazolam tab 0.5 mg (Xanax)...... 16 inj 750 unit...... 23 alprazolam tab 1 mg (Xanax)...... 16 alprazolam tab 2 mg (Xanax)...... 16

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 31 2018

ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj ASMANEX HFA – mometasone furoate inhal aerosol 250 unit...... 24 suspension 200 mcg/act...... 13 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj ASMANEX TWISTHALER 120 ME – mometasone furoate 500 unit...... 24 inhal powd 220 mcg/inh (breath activated)...... 13 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj ASMANEX TWISTHALER 30 MET – mometasone furoate 1000 unit...... 24 inhal powd 110 mcg/inh (breath activated)...... 14 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj ASMANEX TWISTHALER 30 MET – mometasone furoate 2000 unit...... 24 inhal powd 220 mcg/inh (breath activated)...... 14 ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj ASMANEX TWISTHALER 60 MET – mometasone furoate 3000 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 4000 unit...... 24 50)...... 10 amantadine hcl syrup 50 mg/5ml...... 22 atenolol & chlorthalidone tab 100-25 mg (Tenoretic amiloride & hydrochlorothiazide tab 5-50 mg...... 11 100)...... 10 amiodarone hcl tab 200 mg (Cordarone)...... 12 atenolol tab 25 mg (Tenormin)...... 10 amitriptyline hcl tab 10 mg...... 17 atenolol tab 50 mg (Tenormin)...... 10 amitriptyline hcl tab 25 mg...... 17 atenolol tab 100 mg (Tenormin)...... 10 amitriptyline hcl tab 50 mg...... 17 atorvastatin calcium tab 10 mg (base equivalent) amitriptyline hcl tab 75 mg...... 17 (Lipitor)...... 11 amitriptyline hcl tab 100 mg...... 17 atorvastatin calcium tab 20 mg (base equivalent) amlodipine besylate tab 2.5 mg (base equivalent) (Lipitor)...... 11 (Norvasc)...... 10 atorvastatin calcium tab 40 mg (base equivalent) amlodipine besylate tab 5 mg (base equivalent) (Lipitor)...... 11 (Norvasc)...... 10 atorvastatin calcium tab 80 mg (base equivalent) amlodipine besylate tab 10 mg (base equivalent) (Lipitor)...... 11 (Norvasc)...... 10 ATRIPLA – efavirenz-emtricitabine-tenofovir df tab amoxicillin (trihydrate) cap 250 mg...... 1 600-200-300 mg...... 2 amoxicillin (trihydrate) cap 500 mg...... 1 AUBAGIO – teriflunomide tab 7 mg...... 18 amoxicillin (trihydrate) for susp 125 mg/5ml...... 1 AUBAGIO – teriflunomide tab 14 mg...... 18 amoxicillin (trihydrate) for susp 200 mg/5ml...... 1 AVONEX – interferon beta-1a for im inj kit 30mcg amoxicillin (trihydrate) for susp 250 mg/5ml...... 1 (33mcg(6.6 mu)/vial)...... 18 amoxicillin (trihydrate) for susp 400 mg/5ml...... 1 AVONEX – interferon beta-1a im prefilled syringe kit 30 amoxicillin (trihydrate) tab 500 mg...... 1 mcg/0.5ml...... 18 amoxicillin (trihydrate) tab 875 mg...... 1 AVONEX PEN – interferon beta-1a im auto-injector kit 30 anastrozole tab 1 mg (Arimidex)...... 4 mcg/0.5ml...... 19 ANDROGEL PUMP – testosterone td gel 20.25 mg/act azithromycin tab 250 mg (Zithromax)...... 1 (1.62%)...... 5 azithromycin tab 500 mg (Zithromax)...... 1 ANDROGEL – testosterone td gel 20.25 mg/1.25gm B (1.62%)...... 5 ANDROGEL – testosterone td gel 40.5 mg/2.5gm BACITRACIN – bacitracin ophth oint 500 unit/gm...... 28 (1.62%)...... 5 bacitracin-polymyxin b ophth oint...... 28 ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba baclofen tab 10 mg...... 22 62.5-25 mcg/inh...... 13 BARACLUDE – entecavir oral soln 0.05 mg/ml...... 1 APRISO – mesalamine cap er 24hr 0.375 gm...... 16 BEBULIN – factor ix complex for inj 200-1200 unit...... 24 ARNUITY ELLIPTA – fluticasone furoate aerosol powder BELSOMRA – suvorexant tab 5 mg...... 18 breath activ 50 mcg/act...... 13 BELSOMRA – suvorexant tab 10 mg...... 18 ARNUITY ELLIPTA – fluticasone furoate aerosol powder BELSOMRA – suvorexant tab 15 mg...... 18 breath activ 100 mcg/act...... 13 BELSOMRA – suvorexant tab 20 mg...... 18 ARNUITY ELLIPTA – fluticasone furoate aerosol powder benazepril hcl tab 5 mg...... 9 breath activ 200 mcg/act...... 13 benazepril hcl tab 10 mg (Lotensin)...... 9 ASMANEX HFA – mometasone furoate inhal aerosol benazepril hcl tab 20 mg (Lotensin)...... 9 suspension 100 mcg/act...... 13 benazepril hcl tab 40 mg (Lotensin)...... 9

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Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 32 2018

BENEFIX – coagulation factor ix (recombinant) for inj kit carvedilol tab 12.5 mg (Coreg)...... 10 250 unit...... 24 carvedilol tab 25 mg (Coreg)...... 10 BENEFIX – coagulation factor ix (recombinant) for inj kit cefadroxil cap 500 mg...... 1 500 unit...... 24 cephalexin cap 250 mg (Keflex)...... 1 BENEFIX – coagulation factor ix (recombinant) for inj kit cephalexin cap 500 mg (Keflex)...... 1 1000 unit...... 24 CEREZYME – imiglucerase for inj 400 unit...... 24 BENEFIX – coagulation factor ix (recombinant) for inj kit CHANTIX CONTINUING MONTH – varenicline tartrate tab 2000 unit...... 24 1 mg (base equiv)...... 19 BENEFIX – coagulation factor ix (recombinant) for inj kit CHANTIX STARTING MONTH PA – varenicline tartrate 3000 unit...... 24 tab 0.5 mg x 11 & tab 1 mg x 42 pack...... 19 BENZNIDAZOLE – benznidazole tab 12.5 mg...... 3 CHANTIX – varenicline tartrate tab 0.5 mg (base BENZNIDAZOLE – benznidazole tab 100 mg...... 3 equiv)...... 19 benzonatate cap 200 mg...... 13 CHANTIX – varenicline tartrate tab 1 mg (base equiv)...... 19 benzonatate cap 100 mg (Tessalon perles)...... 13 CHEMET – succimer cap 100 mg...... 30 benztropine mesylate tab 0.5 mg...... 22 CHENODAL – chenodiol tab 250 mg...... 16 benztropine mesylate tab 1 mg...... 22 chlordiazepoxide hcl cap 5 mg...... 16 benztropine mesylate tab 2 mg...... 22 chlordiazepoxide hcl cap 10 mg...... 16 BETASERON – interferon beta-1b for inj kit 0.3 mg...... 19 chlordiazepoxide hcl cap 25 mg...... 17 bethanechol chloride tab 5 mg (Urecholine)...... 16 chlorhexidine gluconate soln 0.12% (Peridex)...... 29 bicalutamide tab 50 mg (Casodex)...... 4 CHLOROQUINE PHOSPHATE – chloroquine phosphate BIKTARVY – bictegravir-emtricitabine-tenofovir af tab tab 250 mg...... 3 50-200-25 mg...... 2 chloroquine phosphate tab 500 mg (Aralen)...... 3 BILTRICIDE – praziquantel tab 600 mg...... 3 chlorothiazide tab 500 mg...... 11 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg CIALIS – tadalafil tab 2.5 mg...... 13 (Ziac)...... 10 CIALIS – tadalafil tab 5 mg...... 13 bisoprolol & hydrochlorothiazide tab 5-6.25 mg CIALIS – tadalafil tab 10 mg...... 13 (Ziac)...... 10 CIALIS – tadalafil tab 20 mg...... 13 bisoprolol & hydrochlorothiazide tab 10-6.25 mg cilostazol tab 50 mg (Pletal)...... 24 (Ziac)...... 10 cilostazol tab 100 mg (Pletal)...... 24 bisoprolol fumarate tab 5 mg (Zebeta)...... 10 CIMDUO – lamivudine-tenofovir disoproxil fumarate tab BREATHERITE – spacer/aerosol-holding chambers - 300-300 mg...... 2 device...... 30 cimetidine tab 300 mg...... 15 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd cimetidine tab 400 mg...... 15 ba 100-25 mcg/inh...... 14 ciprofloxacin hcl ophth soln 0.3% (Ciloxan)...... 28 BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ciprofloxacin hcl tab 750 mg (base equiv)...... 1 ba 200-25 mcg/inh...... 14 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)...... 1 BRILINTA – ticagrelor tab 60 mg...... 24 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)...... 1 BRILINTA – ticagrelor tab 90 mg...... 24 citalopram hydrobromide tab 10 mg (base equiv) brimonidine tartrate ophth soln 0.2%...... 29 (Celexa)...... 17 bumetanide tab 0.5 mg...... 11 citalopram hydrobromide tab 20 mg (base equiv) bumetanide tab 1 mg...... 11 (Celexa)...... 17 bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)...... 17 citalopram hydrobromide tab 40 mg (base equiv) bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)...... 17 (Celexa)...... 17 buspirone hcl tab 5 mg...... 16 clindamycin hcl cap 75 mg (Cleocin)...... 3 buspirone hcl tab 10 mg...... 16 clindamycin hcl cap 150 mg (Cleocin)...... 3 buspirone hcl tab 15 mg...... 16 clindamycin hcl cap 300 mg (Cleocin)...... 3 C clonazepam tab 0.5 mg (Klonopin)...... 21 clonazepam tab 1 mg (Klonopin)...... 21 CANASA – mesalamine suppos 1000 mg...... 16 clonazepam tab 2 mg (Klonopin)...... 21 carbidopa & levodopa tab 10-100 mg (Sinemet)...... 22 clonidine hcl tab 0.1 mg (Catapres)...... 12 carisoprodol tab 350 mg (Soma)...... 22 clonidine hcl tab 0.2 mg (Catapres)...... 12 carvedilol tab 3.125 mg (Coreg)...... 10 clonidine hcl tab 0.3 mg (Catapres)...... 12 carvedilol tab 6.25 mg (Coreg)...... 10

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 33 2018 clopidogrel bisulfate tab 75 mg (base equiv) dexamethasone tab 0.75 mg...... 5 (Plavix)...... 24 dexamethasone tab 1.5 mg...... 5 clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 17 dexamethasone tab 4 mg...... 5 clorazepate dipotassium tab 7.5 mg (Tranxene t)...... 17 dexamethasone tab 6 mg...... 5 COAGADEX – coagulation factor x (human) for inj 250 DIASTAT ACUDIAL – diazepam rectal gel delivery system unit...... 24 10 mg...... 21 COAGADEX – coagulation factor x (human) for inj 500 DIASTAT ACUDIAL – diazepam rectal gel delivery system unit...... 24 20 mg...... 21 COMBIPATCH – estradiol-norethindrone ace td pttw DIASTAT PEDIATRIC – diazepam rectal gel delivery 0.05-0.14 mg/day...... 5 system 2.5 mg...... 21 COMBIPATCH – estradiol-norethindrone ace td pttw diazepam tab 2 mg (Valium)...... 17 0.05-0.25 mg/day...... 5 diazepam tab 5 mg (Valium)...... 17 COPAXONE – glatiramer acetate soln prefilled syringe 20 diazepam tab 10 mg (Valium)...... 17 mg/ml...... 19 diclofenac sodium ophth soln 0.1%...... 29 COPAXONE – glatiramer acetate soln prefilled syringe 40 diclofenac sodium tab delayed release 50 mg...... 20 mg/ml...... 19 diclofenac sodium tab delayed release 75 mg...... 20 CORIFACT – factor xiii concentrate (human) for inj kit dicyclomine hcl cap 10 mg (Bentyl)...... 15 1000-1600 unit...... 24 dicyclomine hcl tab 20 mg (Bentyl)...... 15 CORTIFOAM – hydrocortisone acetate rectal foam 10% diltiazem hcl cap er 24hr 120 mg...... 10 (90 mg/dose)...... 29 diltiazem hcl coated beads cap er 24hr 120 mg CORTISONE ACETATE – cortisone acetate tab 25 mg...... 5 (Cardizem cd)...... 10 COSENTYX – secukinumab subcutaneous soln prefilled diltiazem hcl coated beads cap er 24hr 180 mg syringe 150 mg/ml...... 30 (Cardizem cd)...... 10 COSENTYX SENSOREADY PEN – secukinumab diltiazem hcl tab 90 mg...... 10 subcutaneous soln auto-injector 150 mg/ml...... 30 diltiazem hcl tab 30 mg (Cardizem)...... 10 CREON – pancrelipase (lip-prot-amyl) dr cap diltiazem hcl tab 60 mg (Cardizem)...... 10 3000-9500-15000 unit...... 16 diltiazem hcl tab 120 mg (Cardizem)...... 10 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)...... 22 12000-38000-60000 unit...... 16 divalproex sodium tab delayed release 250 mg CREON – pancrelipase (lip-prot-amyl) dr cap (Depakote)...... 22 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 1 mg/gm (0.1%)...... 5 cromolyn sodium ophth soln 4%...... 29 donepezil hydrochloride tab 5 mg (Aricept)...... 19 cyanocobalamin inj 1000 mcg/ml...... 24 donepezil hydrochloride tab 10 mg (Aricept)...... 19 cyclobenzaprine hcl tab 5 mg...... 22 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 cyclobenzaprine hcl tab 10 mg...... 22 mg/ml (Cosopt)...... 29 cyclopentolate hcl ophth soln 1% (Cyclogyl)...... 29 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 DEPEN TITRATABS – penicillamine tab 250 mg...... 30 doxepin hcl conc 10 mg/ml...... 17 DESCOVY – emtricitabine-tenofovir alafenamide fumarate DULERA – mometasone furoate-formoterol fumarate tab 200-25 mg...... 2 aerosol 100-5 mcg/act...... 14 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg DULERA – mometasone furoate-formoterol fumarate (Desogen)...... 5 aerosol 200-5 mcg/act...... 14 DEXAMETHASONE SODIUM PHOS – dexamethasone sodium phosphate ophth soln 0.1%...... 29 E dexamethasone tab 0.5 mg...... 5 ELIQUIS – apixaban tab 2.5 mg...... 24

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 34 2018

ELIQUIS – apixaban tab 5 mg...... 24 EPIPEN-JR 2-PAK – epinephrine solution auto-injector ELIQUIS STARTER PACK – apixaban tab 5 mg...... 24 0.15 mg/0.3ml (1:2000)...... 13 ELLA – ulipristal acetate tab 30 mg...... 5 EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj mg/0.3ml (1:1000)...... 13 250 unit...... 24 ergocalciferol cap 50000 unit (Drisdol)...... 23 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj ERLEADA – apalutamide tab 60 mg...... 4 500 unit...... 24 erythromycin ophth oint 5 mg/gm...... 28 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj escitalopram oxalate tab 5 mg (base equiv) 750 unit...... 24 (Lexapro)...... 17 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj escitalopram oxalate tab 10 mg (base equiv) 1000 unit...... 24 (Lexapro)...... 17 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj escitalopram oxalate tab 20 mg (base equiv) 1500 unit...... 24 (Lexapro)...... 17 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj estazolam tab 1 mg...... 18 2000 unit...... 24 estazolam tab 2 mg...... 18 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj ESTRACE – estradiol vaginal cream 0.1 mg/gm...... 16 3000 unit...... 24 estradiol tab 0.5 mg (Estrace)...... 5 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj estradiol tab 1 mg (Estrace)...... 5 4000 unit...... 25 estradiol tab 2 mg (Estrace)...... 5 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj EXJADE – deferasirox tab for oral susp 125 mg...... 30 5000 unit...... 25 EXJADE – deferasirox tab for oral susp 250 mg...... 30 ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj EXJADE – deferasirox tab for oral susp 500 mg...... 30 6000 unit...... 25 F EMEND – aprepitant capsule 40 mg...... 15 EMEND – aprepitant capsule 125 mg...... 15 famotidine tab 40 mg (Pepcid)...... 15 EMEND – aprepitant for oral susp 125 mg (125 FEIBA – antiinhibitor coagulant complex for inj...... 25 mg/5ml)...... 15 fenofibrate tab 54 mg (Lofibra)...... 11 enalapril maleate & hydrochlorothiazide tab 5-12.5 FIASP FLEXTOUCH – insulin aspart soln pen-injector 100 mg...... 9 unit/ml...... 7 enalapril maleate & hydrochlorothiazide tab 10-25 mg FIASP – insulin aspart inj 100 unit/ml...... 7 (Vaseretic)...... 9 FINACEA – azelaic acid foam 15%...... 29 enalapril maleate tab 2.5 mg (Vasotec)...... 9 FINACEA – azelaic acid gel 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...... 10 mcg/act (250/valve)...... 14 ENTRESTO – sacubitril-valsartan tab 49-51 mg...... 10 FLOVENT HFA – fluticasone propionate hfa inhal aero 44 ENTRESTO – sacubitril-valsartan tab 97-103 mg...... 10 mcg/act (50/valve)...... 14 EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg...... 1 fluconazole for susp 10 mg/ml (Diflucan)...... 1 EPINEPHRINE (Mylan Products) – epinephrine solution fluconazole tab 50 mg (Diflucan)...... 1 auto-injector 0.15 mg/0.3ml (1:2000)...... 13 fluconazole tab 100 mg (Diflucan)...... 1 EPINEPHRINE (Mylan Products) – epinephrine solution fluconazole tab 150 mg (Diflucan)...... 1 auto-injector 0.3 mg/0.3ml (1:1000)...... 13 fluoxetine hcl cap 10 mg (Prozac)...... 17 fluoxetine hcl cap 20 mg (Prozac)...... 17

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 35 2018 fluoxetine hcl cap 40 mg (Prozac)...... 17 glyburide-metformin tab 2.5-500 mg (Glucovance)...... 6 fluoxetine hcl solution 20 mg/5ml...... 17 glyburide-metformin tab 5-500 mg (Glucovance)...... 6 fluoxetine hcl tab 10 mg...... 17 glyburide micronized tab 1.5 mg (Glynase)...... 6 FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 glyburide micronized tab 3 mg (Glynase)...... 6 mg/5ml...... 18 glyburide micronized tab 6 mg (Glynase)...... 6 FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ glyburide tab 1.25 mg...... 6 ml...... 18 glyburide tab 2.5 mg...... 6 fluphenazine hcl tab 1 mg...... 18 glyburide tab 5 mg...... 6 fluphenazine hcl tab 2.5 mg...... 18 GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg...... 6 fluphenazine hcl tab 5 mg...... 18 GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg...... 6 fluphenazine hcl tab 10 mg...... 18 GRANIX – tbo-filgrastim soln prefilled syringe 300 flurbiprofen sodium ophth soln 0.03% (Ocufen)...... 29 mcg/0.5ml...... 25 flurbiprofen tab 50 mg...... 20 GRANIX – tbo-filgrastim soln prefilled syringe 480 flurbiprofen tab 100 mg...... 20 mcg/0.8ml...... 25 FLUTICASONE PROPIONATE/SA – fluticasone- guanfacine hcl tab 1 mg (Tenex)...... 12 salmeterol aer powder ba 55-14 mcg/act...... 14 guanfacine hcl tab 2 mg (Tenex)...... 12 FLUTICASONE PROPIONATE/SA – fluticasone- H salmeterol aer powder ba 113-14 mcg/act...... 14 FLUTICASONE PROPIONATE/SA – fluticasone- haloperidol lactate oral conc 2 mg/ml...... 18 salmeterol aer powder ba 232-14 mcg/act...... 14 haloperidol tab 0.5 mg...... 18 fluticasone propionate nasal susp 50 mcg/act haloperidol tab 1 mg...... 18 (Flonase)...... 13 haloperidol tab 2 mg...... 18 folic acid tab 1 mg...... 25 HARVONI – ledipasvir-sofosbuvir tab 90-400 mg...... 1 FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml...... 6 HELIXATE FS – antihemophilic factor (recombinant) for inj FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml...... 6 kit 250 unit...... 25 FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml...... 6 HELIXATE FS – antihemophilic factor (recombinant) for inj fosinopril sodium tab 10 mg...... 9 kit 500 unit...... 25 fosinopril sodium tab 20 mg...... 9 HELIXATE FS – antihemophilic factor (recombinant) for inj fosinopril sodium tab 40 mg...... 9 kit 1000 unit...... 25 furosemide oral soln 10 mg/ml...... 11 HELIXATE FS – antihemophilic factor (recombinant) for inj furosemide tab 20 mg (Lasix)...... 11 kit 2000 unit...... 25 furosemide tab 40 mg (Lasix)...... 11 HELIXATE FS – antihemophilic factor (recombinant) for inj furosemide tab 80 mg (Lasix)...... 11 kit 3000 unit...... 25 HEMLIBRA – emicizumab-kxwh subcutaneous soln 30 G mg/ml...... 25 gabapentin cap 100 mg (Neurontin)...... 22 HEMLIBRA – emicizumab-kxwh subcutaneous soln 150 gabapentin cap 300 mg (Neurontin)...... 22 mg/ml...... 25 gabapentin cap 400 mg (Neurontin)...... 22 HEMLIBRA – emicizumab-kxwh subcutaneous soln 60 gemfibrozil tab 600 mg (Lopid)...... 11 mg/0.4ml (150 mg/ml)...... 25 gentamicin sulfate ophth soln 0.3% (Garamycin)...... 28 HEMLIBRA – emicizumab-kxwh subcutaneous soln 105 GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab mg/0.7ml (150 mg/ml)...... 25 150-150-200-10 mg...... 2 HEMOFIL M – antihemophilic factor (human) for inj 250 GILENYA – fingolimod hcl cap 0.5 mg (base equiv)...... 19 unit...... 25 glimepiride tab 1 mg (Amaryl)...... 6 HEMOFIL M – antihemophilic factor (human) for inj 500 glimepiride tab 2 mg (Amaryl)...... 6 unit...... 25 glimepiride tab 4 mg (Amaryl)...... 6 HEMOFIL M – antihemophilic factor (human) for inj 1000 glipizide tab er 24hr 2.5 mg (Glucotrol xl)...... 6 unit...... 25 glipizide tab er 24hr 5 mg (Glucotrol xl)...... 6 HEMOFIL M – antihemophilic factor (human) for inj 1700 glipizide tab 5 mg (Glucotrol)...... 6 unit...... 25 glipizide tab 10 mg (Glucotrol)...... 6 HUMATE-P – antihemophilic factor/vwf (human) for inj GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj 250-600 unit...... 25 kit 1 mg...... 6 HUMATE-P – antihemophilic factor/vwf (human) for inj glyburide-metformin tab 1.25-250 mg (Glucovance)...... 6 500-1200 unit...... 25

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 36 2018

HUMATE-P – antihemophilic factor/vwf (human) for inj hydroxyzine hcl syrup 10 mg/5ml...... 17 1000-2400 unit...... 25 hydroxyzine hcl tab 10 mg...... 17 HUMIRA – adalimumab prefilled syringe kit 10 hydroxyzine hcl tab 25 mg...... 17 mg/0.1ml...... 20 hydroxyzine hcl tab 50 mg...... 17 HUMIRA – adalimumab prefilled syringe kit 10 hydroxyzine pamoate cap 25 mg (Vistaril)...... 17 mg/0.2ml...... 20 hydroxyzine pamoate cap 50 mg (Vistaril)...... 17 HUMIRA – adalimumab prefilled syringe kit 20 I mg/0.2ml...... 20 HUMIRA – adalimumab prefilled syringe kit 20 ibuprofen tab 400 mg...... 21 mg/0.4ml...... 20 ibuprofen tab 600 mg...... 21 HUMIRA – adalimumab prefilled syringe kit 40 ibuprofen tab 800 mg...... 21 mg/0.8ml...... 20 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA – adalimumab prefilled syringe kit 40 250 unit...... 25 mg/0.4ml...... 20 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled 500 unit...... 25 syringe kit 40 mg/0.8ml...... 20 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled 1000 unit...... 25 syringe kit 80 mg/0.8ml...... 21 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled 2000 unit...... 25 syringe kit 80 mg/0.8ml & 40 mg/0.4ml...... 21 IDELVION – coagulation factor ix (recomb) (rix-fp) for inj HUMIRA PEN – adalimumab pen-injector kit 40 3500 unit...... 25 mg/0.8ml...... 21 imipramine hcl tab 10 mg (Tofranil)...... 17 HUMIRA PEN – adalimumab pen-injector kit 40 imipramine hcl tab 25 mg (Tofranil)...... 17 mg/0.4ml...... 21 imipramine hcl tab 50 mg (Tofranil)...... 17 HUMIRA PEN-CROHNS DISEASE – adalimumab pen- IMPAVIDO – miltefosine cap 50 mg...... 3 injector kit 40 mg/0.8ml...... 21 INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)...... 8 HUMIRA PEN-PSORIASIS STAR – adalimumab pen- INCRUSE ELLIPTA – umeclidinium br aero powd breath injector kit 40 mg/0.8ml...... 21 act 62.5 mcg/inh (base eq)...... 14 HUMULIN R U-500 (CONCENTR – insulin regular indapamide tab 1.25 mg...... 12 (human) inj 500 unit/ml...... 7 indapamide tab 2.5 mg...... 12 HUMULIN R U-500 KWIKPEN – insulin regular (human) indomethacin cap 25 mg...... 21 soln pen-injector 500 unit/ml...... 7 indomethacin cap 50 mg...... 21 hydralazine hcl tab 10 mg...... 12 INSULIN PEN NEEDLES – VARIOUS...... 30 hydralazine hcl tab 25 mg...... 12 INSULIN SYRINGES – VARIOUS...... 30 hydralazine hcl tab 50 mg...... 12 INTELENCE – etravirine tab 25 mg...... 2 hydrochlorothiazide cap 12.5 mg (Microzide)...... 11 INTELENCE – etravirine tab 100 mg...... 2 hydrochlorothiazide tab 12.5 mg...... 11 INTELENCE – etravirine tab 200 mg...... 2 hydrochlorothiazide tab 25 mg...... 12 INVOKAMET – canagliflozin-metformin hcl tab 50-500 hydrochlorothiazide tab 50 mg...... 12 mg...... 6 hydrocodone-acetaminophen tab 7.5-325 mg INVOKAMET – canagliflozin-metformin hcl tab 50-1000 (Norco)...... 20 mg...... 6 hydrocodone-acetaminophen tab 5-325 mg INVOKAMET – canagliflozin-metformin hcl tab 150-500 (Norco)...... 20 mg...... 6 hydrocodone-acetaminophen tab 10-325 mg INVOKAMET – canagliflozin-metformin hcl tab 150-1000 (Norco)...... 19 mg...... 6 hydrocodone-ibuprofen tab 7.5-200 mg INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr (Vicoprofen)...... 20 50-500 mg...... 6 hydrocortisone cream 2.5%...... 29 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydrocortisone oint 2.5%...... 29 50-1000 mg...... 6 hydrocortisone rectal cream 2.5% (Anusol-hc)...... 29 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydromorphone hcl tab 2 mg (Dilaudid)...... 20 150-500 mg...... 6 hydromorphone hcl tab 4 mg (Dilaudid)...... 20 INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 3 150-1000 mg...... 6 for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 37 2018

INVOKANA – canagliflozin tab 100 mg...... 6 K INVOKANA – canagliflozin tab 300 mg...... 6 ipratropium bromide inhal soln 0.02%...... 14 KALETRA – lopinavir-ritonavir tab 100-25 mg...... 2 irbesartan-hydrochlorothiazide tab 150-12.5 mg KALETRA – lopinavir-ritonavir tab 200-50 mg...... 2 (Avalide)...... 9 KALYDECO – ivacaftor packet 50 mg...... 15 irbesartan-hydrochlorothiazide tab 300-12.5 mg KALYDECO – ivacaftor packet 75 mg...... 15 (Avalide)...... 9 KALYDECO – ivacaftor tab 150 mg...... 15 irbesartan tab 75 mg (Avapro)...... 9 ketoconazole tab 200 mg...... 1 irbesartan tab 150 mg (Avapro)...... 9 ketorolac tromethamine ophth soln 0.5% (Acular)...... 29 irbesartan tab 300 mg (Avapro)...... 9 ketorolac tromethamine tab 10 mg...... 21 ISENTRESS HD – raltegravir potassium tab 600 mg (base KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg & equiv)...... 2 letrozole tab 2.5 mg therapy pack...... 4 ISENTRESS – raltegravir potassium chew tab 25 mg KISQALI FEMARA 400 DOSE – ribociclib tab 200 mg & (base equiv)...... 2 letrozole tab 2.5 mg therapy pack...... 4 ISENTRESS – raltegravir potassium chew tab 100 mg KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg & (base equiv)...... 2 letrozole tab 2.5 mg therapy pack...... 4 ISENTRESS – raltegravir potassium packet for susp 100 KISQALI – ribociclib succinate tab 200 mg (base equiv)..... 4 mg (base equiv)...... 2 KOATE – antihemophilic factor (human) for inj 250 ISENTRESS – raltegravir potassium tab 400 mg (base unit...... 25 equiv)...... 2 KOATE – antihemophilic factor (human) for inj 500 isoniazid tab 100 mg...... 1 unit...... 26 isoniazid tab 300 mg...... 1 KOATE – antihemophilic factor (human) for inj 1000 isosorbide mononitrate tab er 24hr 30 mg...... 11 unit...... 26 isosorbide mononitrate tab er 24hr 60 mg...... 11 KOATE-DVI – antihemophilic factor (human) for inj 250 isosorbide mononitrate tab 10 mg...... 11 unit...... 26 isosorbide mononitrate tab 20 mg...... 11 KOATE-DVI – antihemophilic factor (human) for inj 500 IXINITY – coagulation factor ix (recombinant) for inj 250 unit...... 26 unit...... 25 KOATE-DVI – antihemophilic factor (human) for inj 1000 IXINITY – coagulation factor ix (recombinant) for inj 500 unit...... 26 unit...... 25 KOGENATE FS – antihemophilic factor (recombinant) for IXINITY – coagulation factor ix (recombinant) for inj 1000 inj kit 250 unit...... 26 unit...... 25 KOGENATE FS – antihemophilic factor (recombinant) for IXINITY – coagulation factor ix (recombinant) for inj 1500 inj kit 500 unit...... 26 unit...... 25 KOGENATE FS – antihemophilic factor (recombinant) for IXINITY – coagulation factor ix (recombinant) for inj 2000 inj kit 1000 unit...... 26 unit...... 25 KOGENATE FS – antihemophilic factor (recombinant) for IXINITY – coagulation factor ix (recombinant) for inj 3000 inj kit 2000 unit...... 26 unit...... 25 KOGENATE FS – antihemophilic factor (recombinant) for inj kit 3000 unit...... 26 J KOGENATE FS BIO-SET – antihemophilic factor JADENU – deferasirox tab 90 mg...... 30 (recombinant) for inj kit 1000 unit...... 26 JADENU – deferasirox tab 180 mg...... 30 KOGENATE FS BIO-SET – antihemophilic factor JADENU – deferasirox tab 360 mg...... 30 (recombinant) for inj kit 2000 unit...... 26 JANUVIA – sitagliptin phosphate tab 25 mg (base KOGENATE FS BIO-SET – antihemophilic factor equiv)...... 6 (recombinant) for inj kit 3000 unit...... 26 JANUVIA – sitagliptin phosphate tab 50 mg (base KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr equiv)...... 6 2.5-1000 mg...... 6 JANUVIA – sitagliptin phosphate tab 100 mg (base KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr equiv)...... 6 5-500 mg...... 6 JARDIANCE – empagliflozin tab 10 mg...... 6 KOMBIGLYZE XR – saxagliptin-metformin hcl tab er 24hr JARDIANCE – empagliflozin tab 25 mg...... 6 5-1000 mg...... 6 KOSHER PRENATAL PLUS IRON – prenatal vit w/ iron carbonyl-fa tab 30-1 mg...... 23

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 38 2018

KOVALTRY – antihemophilic factor (recombinant) for inj lidocaine hcl viscous soln 2%...... 29 250 unit...... 26 lisinopril & hydrochlorothiazide tab 10-12.5 mg KOVALTRY – antihemophilic factor (recombinant) for inj (Zestoretic)...... 9 500 unit...... 26 lisinopril & hydrochlorothiazide tab 20-12.5 mg KOVALTRY – antihemophilic factor (recombinant) for inj (Zestoretic)...... 9 1000 unit...... 26 lisinopril & hydrochlorothiazide tab 20-25 mg KOVALTRY – antihemophilic factor (recombinant) for inj (Zestoretic)...... 9 2000 unit...... 26 lisinopril tab 5 mg (Prinivil)...... 9 KOVALTRY – antihemophilic factor (recombinant) for inj lisinopril tab 10 mg (Prinivil)...... 9 3000 unit...... 26 lisinopril tab 20 mg (Prinivil)...... 9 L lisinopril tab 2.5 mg (Zestril)...... 9 lisinopril tab 30 mg (Zestril)...... 9 lactulose (encephalopathy) solution 10 gm/15ml...... 16 lisinopril tab 40 mg (Zestril)...... 9 lactulose solution 10 gm/15ml...... 15 lithium carbonate cap 300 mg...... 18 lamotrigine tab 25 mg (Lamictal)...... 22 lithium carbonate cap 150 mg (Lithium carbonate)...... 18 lamotrigine tab 100 mg (Lamictal)...... 22 lithium carbonate cap 600 mg (Lithium carbonate)...... 18 lamotrigine tab 150 mg (Lamictal)...... 22 lithium carbonate tab 300 mg...... 18 lamotrigine tab 200 mg (Lamictal)...... 22 lorazepam tab 0.5 mg (Ativan)...... 17 LANCETS – VARIOUS...... 30 lorazepam tab 1 mg (Ativan)...... 17 LANTUS – insulin glargine inj 100 unit/ml...... 7 lorazepam tab 2 mg (Ativan)...... 17 LANTUS SOLOSTAR – insulin glargine soln pen-injector losartan potassium & hydrochlorothiazide tab 50-12.5 100 unit/ml...... 7 mg (Hyzaar)...... 9 latanoprost ophth soln 0.005% (Xalatan)...... 29 losartan potassium & hydrochlorothiazide tab 100-12.5 letrozole tab 2.5 mg (Femara)...... 4 mg (Hyzaar)...... 9 LEUCOVORIN CALCIUM – leucovorin calcium tab 10 losartan potassium & hydrochlorothiazide tab 100-25 mg...... 4 mg (Hyzaar)...... 9 LEUCOVORIN CALCIUM – leucovorin calcium tab 15 losartan potassium tab 25 mg (Cozaar)...... 9 mg...... 4 losartan potassium tab 50 mg (Cozaar)...... 10 LEUKERAN – chlorambucil tab 2 mg...... 4 losartan potassium tab 100 mg (Cozaar)...... 10 LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector lovastatin tab 10 mg...... 11 100 unit/ml...... 7 lovastatin tab 20 mg (Mevacor)...... 11 LEVEMIR – insulin detemir inj 100 unit/ml...... 7 lovastatin tab 40 mg (Mevacor)...... 11 levetiracetam tab 250 mg (Keppra)...... 22 levobunolol hcl ophth soln 0.5% (Betagan)...... 29 M levofloxacin tab 250 mg (Levaquin)...... 1 MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg...... 1 levofloxacin tab 500 mg (Levaquin)...... 1 medroxyprogesterone acetate tab 2.5 mg (Provera)...... 5 levofloxacin tab 750 mg (Levaquin)...... 1 medroxyprogesterone acetate tab 5 mg (Provera)...... 5 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 medroxyprogesterone acetate tab 10 mg (Provera)...... 5 mcg...... 5 MEFLOQUINE HCL – mefloquine hcl tab 250 mg...... 3 levothyroxine sodium tab 25 mcg (Synthroid)...... 8 megestrol acetate tab 20 mg...... 4 levothyroxine sodium tab 50 mcg (Synthroid)...... 8 megestrol acetate tab 40 mg...... 4 levothyroxine sodium tab 75 mcg (Synthroid)...... 8 MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg levothyroxine sodium tab 88 mcg (Synthroid)...... 8 (base equivalent)...... 4 levothyroxine sodium tab 100 mcg (Synthroid)...... 8 MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base levothyroxine sodium tab 112 mcg (Synthroid)...... 8 equivalent)...... 4 levothyroxine sodium tab 125 mcg (Synthroid)...... 8 meloxicam tab 7.5 mg (Mobic)...... 21 levothyroxine sodium tab 137 mcg (Synthroid)...... 8 meloxicam tab 15 mg (Mobic)...... 21 levothyroxine sodium tab 150 mcg (Synthroid)...... 8 MEPHYTON – phytonadione tab 5 mg...... 23 levothyroxine sodium tab 175 mcg (Synthroid)...... 8 metformin hcl tab er 24hr 500 mg (Glucophage xr)...... 7 levothyroxine sodium tab 200 mcg (Synthroid)...... 8 metformin hcl tab er 24hr 750 mg (Glucophage xr)...... 7 levothyroxine sodium tab 300 mcg (Synthroid)...... 8 metformin hcl tab 500 mg (Glucophage)...... 7 lidocaine hcl gel 2%...... 30 metformin hcl tab 850 mg (Glucophage)...... 7 lidocaine hcl soln 4% (Xylocaine)...... 30 metformin hcl tab 1000 mg (Glucophage)...... 7

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 39 2018 methadone hcl tab for oral susp 40 mg...... 20 N methadone hcl tab 10 mg (Dolophine)...... 20 methadone hcl tab 5 mg (Dolophine hcl)...... 20 nabumetone tab 500 mg...... 21 methimazole tab 5 mg (Tapazole)...... 8 nabumetone tab 750 mg...... 21 methimazole tab 10 mg (Tapazole)...... 8 naproxen sodium tab 275 mg (Anaprox)...... 21 methocarbamol tab 750 mg (Robaxin-750)...... 22 naproxen sodium tab 550 mg (Anaprox ds)...... 21 methocarbamol tab 500 mg (Robaxin)...... 22 naproxen tab ec 375 mg (Ec-naprosyn)...... 21 methyldopa tab 250 mg...... 12 naproxen tab ec 500 mg (Ec-naprosyn)...... 21 methyldopa tab 500 mg...... 12 naproxen tab 250 mg (Naprosyn)...... 21 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base naproxen tab 375 mg (Naprosyn)...... 21 equiv)...... 16 naproxen tab 500 mg (Naprosyn)...... 21 metoclopramide hcl tab 5 mg (base equivalent) NARCAN – naloxone hcl nasal spray 4 mg/0.1ml...... 30 (Reglan)...... 16 NATACYN – natamycin ophth susp 5%...... 28 metoclopramide hcl tab 10 mg (base equivalent) neomycin-polymyxin-dexamethasone ophth oint 0.1% (Reglan)...... 16 (Maxitrol)...... 29 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) neomycin-polymyxin-dexamethasone ophth susp (Toprol xl)...... 10 0.1% (Maxitrol)...... 29 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) neomycin sulfate tab 500 mg...... 1 (Toprol xl)...... 10 NEUPOGEN – filgrastim inj 300 mcg/ml...... 26 metoprolol tartrate tab 25 mg...... 10 NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ metoprolol tartrate tab 50 mg (Lopressor)...... 10 ml)...... 26 metoprolol tartrate tab 100 mg (Lopressor)...... 10 NEUPOGEN – filgrastim soln prefilled syringe 300 metronidazole tab 250 mg (Flagyl)...... 3 mcg/0.5ml...... 26 metronidazole tab 500 mg (Flagyl)...... 3 NEUPOGEN – filgrastim soln prefilled syringe 480 minocycline hcl cap 50 mg (Minocin)...... 1 mcg/0.8ml (600 mcg/ml)...... 26 minocycline hcl cap 75 mg (Minocin)...... 1 nevirapine tab 200 mg (Viramune)...... 2 minocycline hcl cap 100 mg (Minocin)...... 1 NEXAVAR – sorafenib tosylate tab 200 mg (base minoxidil tab 2.5 mg...... 12 equivalent)...... 4 minoxidil tab 10 mg...... 12 NICOTROL INHALER – nicotine inhaler system 10 mg (4 MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg delivered)...... 19 mg total)...... 5 NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/ mirtazapine tab 15 mg (Remeron)...... 17 spray)...... 19 mirtazapine tab 30 mg (Remeron)...... 17 nifedipine tab er 24hr 30 mg (Adalat cc)...... 10 mirtazapine tab 45 mg (Remeron)...... 17 nifedipine tab er 24hr osmotic release 30 mg misoprostol tab 100 mcg (Cytotec)...... 15 (Procardia xl)...... 10 misoprostol tab 200 mcg (Cytotec)...... 15 nitroglycerin cap er 2.5 mg...... 11 MONOCLATE-P – antihemophilic factor (human) for inj kit NITYR – nitisinone tab 2 mg...... 8 1000 unit...... 26 NITYR – nitisinone tab 5 mg...... 8 MONOCLATE-P – antihemophilic factor (human) for inj kit NITYR – nitisinone tab 10 mg...... 8 1500 unit...... 26 nizatidine cap 150 mg...... 15 MONONINE – coagulation factor ix for inj 1000 unit...... 26 norethindrone & ethinyl estradiol tab 1 mg-35 mcg montelukast sodium chew tab 4 mg (base equiv) (Norinyl 1+35)...... 5 (Singulair)...... 14 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg montelukast sodium chew tab 5 mg (base equiv) (Ortho-cyclen)...... 5 (Singulair)...... 14 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 montelukast sodium tab 10 mg (base equiv) mg-mcg (Ortho tri-cyclen)...... 5 (Singulair)...... 14 nortriptyline hcl cap 10 mg (Pamelor)...... 17 MORPHINE SULFATE – morphine sulfate tab 15 mg...... 20 nortriptyline hcl cap 25 mg (Pamelor)...... 17 MORPHINE SULFATE – morphine sulfate tab 30 mg...... 20 nortriptyline hcl cap 50 mg (Pamelor)...... 17 mupirocin oint 2% (Bactroban)...... 29 nortriptyline hcl cap 75 mg (Pamelor)...... 17 MYLERAN – busulfan tab 2 mg...... 4 NORVIR – ritonavir oral soln 80 mg/ml...... 2 NORVIR – ritonavir powder packet 100 mg...... 2 NORVIR – ritonavir tab 100 mg...... 2

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 40 2018

NOVOEIGHT – antihemophilic factor (recombinant) for inj NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 4000 250 unit...... 26 unit...... 27 NOVOEIGHT – antihemophilic factor (recombinant) for inj NUWIQ – antihemophilic factor (bdd-rfviii) for inj 250 500 unit...... 26 unit...... 26 NOVOEIGHT – antihemophilic factor (recombinant) for inj NUWIQ – antihemophilic factor (bdd-rfviii) for inj 500 1000 unit...... 26 unit...... 27 NOVOEIGHT – antihemophilic factor (recombinant) for inj NUWIQ – antihemophilic factor (bdd-rfviii) for inj 1000 1500 unit...... 26 unit...... 27 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 – insulin nph isophane & regular human NUWIQ – antihemophilic factor (bdd-rfviii) for inj 3000 inj 100 unit/ml (70-30)...... 7 unit...... 27 NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ NUWIQ – antihemophilic factor (bdd-rfviii) for inj 4000 ml...... 7 unit...... 27 NOVOLIN R – insulin regular (human) inj 100 unit/ml...... 7 O NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ml...... 7 OBIZUR – antihemophilic factor (recomb porc) rpfviii for inj NOVOLOG – insulin aspart inj 100 unit/ml...... 7 500 unit...... 27 NOVOLOG MIX 70/30 – insulin aspart prot & aspart ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab (human) inj 100 unit/ml (70-30)...... 7 200-25-25 mg...... 2 NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & ofloxacin ophth soln 0.3% (Ocuflox)...... 29 aspart sus pen-inj 100 unit/ml (70-30)...... 7 olanzapine tab 2.5 mg (Zyprexa)...... 18 NOVOLOG PENFILL – insulin aspart soln cartridge 100 olanzapine tab 5 mg (Zyprexa)...... 18 unit/ml...... 7 olanzapine tab 7.5 mg (Zyprexa)...... 18 NOVOSEVEN RT – coagulation factor viia (recomb) for inj olanzapine tab 10 mg (Zyprexa)...... 18 1 mg (1000 mcg)...... 26 omeprazole cap delayed release 10 mg (Prilosec)...... 15 NOVOSEVEN RT – coagulation factor viia (recomb) for inj omeprazole cap delayed release 20 mg (Prilosec)...... 15 2 mg (2000 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 5 mg (5000 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 8 mg (8000 mcg)...... 26 ondansetron hcl tab 4 mg (Zofran)...... 15 NOXAFIL – posaconazole susp 40 mg/ml...... 1 ondansetron orally disintegrating tab 4 mg (Zofran NOXAFIL – posaconazole tab delayed release 100 mg...... 1 odt)...... 16 NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)...... 7 20-10 mg...... 19 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...... 8 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 500 ORFADIN – nitisinone cap 20 mg...... 8 unit...... 27 ORFADIN – nitisinone susp 4 mg/ml...... 8 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 1000 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 2000 mg & 30 mg...... 21 unit...... 27 oxcarbazepine tab 150 mg (Trileptal)...... 22 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 2500 oxybutynin chloride syrup 5 mg/5ml...... 16 unit...... 27 oxycodone hcl tab 5 mg (Roxicodone)...... 20 NUWIQ – antihemophilic factor (bdd-rfviii) for inj kit 3000 oxycodone w/ acetaminophen tab 5-325 mg unit...... 27 (Percocet)...... 20

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 41 2018

OXYCONTIN – oxycodone hcl tab er 12hr deter 10 PLEGRIDY STARTER PACK – peginterferon beta-1a soln mg...... 20 pen-inj 63 & 94 mcg/0.5ml pack...... 19 OXYCONTIN – oxycodone hcl tab er 12hr deter 15 PLEGRIDY STARTER PACK – peginterferon beta-1a soln mg...... 20 pref syr 63 & 94 mcg/0.5ml pack...... 19 OXYCONTIN – oxycodone hcl tab er 12hr deter 20 polyethylene glycol 3350 oral powder...... 15 mg...... 20 polymyxin b-trimethoprim ophth soln 10000 unit/ OXYCONTIN – oxycodone hcl tab er 12hr deter 30 ml-0.1% (Polytrim)...... 29 mg...... 20 potassium chloride microencapsulated crys er tab 10 OXYCONTIN – oxycodone hcl tab er 12hr deter 40 meq...... 23 mg...... 20 potassium chloride microencapsulated crys er tab 20 OXYCONTIN – oxycodone hcl tab er 12hr deter 60 meq...... 23 mg...... 20 potassium chloride tab er 10 meq (K-tab)...... 23 OXYCONTIN – oxycodone hcl tab er 12hr deter 80 potassium chloride tab er 8 meq (600 mg)...... 23 mg...... 20 PRALUENT – alirocumab subcutaneous soln pen-injector OZEMPIC – semaglutide soln pen-inj 1 mg/dose (2 75 mg/ml...... 11 mg/1.5ml)...... 7 PRALUENT – alirocumab subcutaneous soln pen-injector OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/dose 150 mg/ml...... 11 (2 mg/1.5ml)...... 7 pramipexole dihydrochloride tab 0.125 mg P (Mirapex)...... 22 pramipexole dihydrochloride tab 0.25 mg pantoprazole sodium ec tab 20 mg (base equiv) (Mirapex)...... 22 (Protonix)...... 15 pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 22 pantoprazole sodium ec tab 40 mg (base equiv) pramipexole dihydrochloride tab 0.75 mg (Protonix)...... 15 (Mirapex)...... 22 paroxetine hcl tab 10 mg (Paxil)...... 17 pramipexole dihydrochloride tab 1 mg (Mirapex)...... 22 paroxetine hcl tab 20 mg (Paxil)...... 17 pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 22 paroxetine hcl tab 30 mg (Paxil)...... 17 pravastatin sodium tab 10 mg...... 11 paroxetine hcl tab 40 mg (Paxil)...... 17 pravastatin sodium tab 20 mg (Pravachol)...... 11 PEGASYS – peginterferon alfa-2a inj 180 mcg/ml...... 1 pravastatin sodium tab 40 mg (Pravachol)...... 11 PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml...... 1 prazosin hcl cap 1 mg (Minipress)...... 12 PEGASYS PROCLICK – peginterferon alfa-2a inj 135 prazosin hcl cap 2 mg (Minipress)...... 12 mcg/0.5ml...... 2 prednisolone sod phosphate oral soln 15 mg/5ml PEGASYS PROCLICK – peginterferon alfa-2a inj 180 (base equiv)...... 5 mcg/0.5ml...... 2 prednisone tab 1 mg...... 5 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm prednisone tab 2.5 mg...... 5 (Colyte-flavor packs)...... 15 prednisone tab 5 mg...... 5 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm prednisone tab 10 mg...... 5 (Golytely)...... 15 prednisone tab 20 mg...... 5 peg 3350-kcl-sod bicarb-nacl for soln 420 gm PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 (Nulytely/flavor pack)...... 15 mg...... 23 penicillin v potassium tab 250 mg...... 1 PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe penicillin v potassium tab 500 mg...... 1 fumarate-fa tab 27-1 mg...... 23 pentoxifylline tab er 400 mg...... 27 PREZISTA – darunavir ethanolate susp 100 mg/ml (base perindopril erbumine tab 2 mg...... 9 equiv)...... 2 phenobarbital tab 16.2 mg...... 18 PREZISTA – darunavir ethanolate tab 75 mg (base phenobarbital tab 32.4 mg...... 18 equiv)...... 2 pioglitazone hcl tab 15 mg (base equiv) (Actos)...... 7 PREZISTA – darunavir ethanolate tab 150 mg (base pioglitazone hcl tab 30 mg (base equiv) (Actos)...... 7 equiv)...... 2 pioglitazone hcl tab 45 mg (base equiv) (Actos)...... 7 PREZISTA – darunavir ethanolate tab 600 mg (base PLEGRIDY – peginterferon beta-1a soln pen-injector 125 equiv)...... 2 mcg/0.5ml...... 19 PREZISTA – darunavir ethanolate tab 800 mg (base PLEGRIDY – peginterferon beta-1a soln prefilled syringe equiv)...... 2 125 mcg/0.5ml...... 19 PRIFTIN – rifapentine tab 150 mg...... 1 for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 42 2018

PRIMAQUINE PHOSPHATE – primaquine phosphate tab R 26.3 mg (15 mg base)...... 3 primidone tab 50 mg (Mysoline)...... 22 ramipril cap 1.25 mg (Altace)...... 9 PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act ramipril cap 2.5 mg (Altace)...... 9 (90mcg base equiv)...... 14 ramipril cap 5 mg (Altace)...... 9 PROAIR RESPICLICK – albuterol sulfate aer pow ba 108 ramipril cap 10 mg (Altace)...... 9 mcg/act (90 mcg base equiv)...... 14 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)...... 15 prochlorperazine maleate tab 5 mg (base equivalent) ranitidine hcl tab 300 mg (Zantac)...... 15 (Compazine)...... 18 RAPAMUNE – sirolimus oral soln 1 mg/ml...... 30 prochlorperazine maleate tab 10 mg (base equivalent) REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml (Compazine)...... 18 (12mu/ml)...... 19 PROCRIT – epoetin alfa inj 2000 unit/ml...... 27 REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml PROCRIT – epoetin alfa inj 3000 unit/ml...... 27 (24mu/ml)...... 19 PROCRIT – epoetin alfa inj 4000 unit/ml...... 27 REBIF REBIDOSE – interferon beta-1a soln auto-inj 22 PROCRIT – epoetin alfa inj 10000 unit/ml...... 27 mcg/0.5ml (12mu/ml)...... 19 PROCRIT – epoetin alfa inj 20000 unit/ml...... 27 REBIF REBIDOSE – interferon beta-1a soln auto-inj 44 PROCRIT – epoetin alfa inj 40000 unit/ml...... 27 mcg/0.5ml (24mu/ml)...... 19 PROFILNINE – factor ix complex for inj 500 unit...... 27 REBIF REBIDOSE TITRATION – interferon beta-1a auto- PROFILNINE – factor ix complex for inj 1000 unit...... 27 inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 19 PROFILNINE – factor ix complex for inj 1500 unit...... 27 REBIF TITRATION PACK – interferon beta-1a pref syr PROFILNINE SD – factor ix complex for inj 500 unit...... 27 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...... 19 PROFILNINE SD – factor ix complex for inj 1000 unit...... 27 REBINYN – coagulation factor ix recomb glycopegylated PROFILNINE SD – factor ix complex for inj 1500 unit...... 27 for inj 500 unt...... 27 promethazine & phenylephrine syrup 6.25-5 REBINYN – coagulation factor ix recomb glycopegylated mg/5ml...... 13 for inj 1000 unt...... 27 promethazine-dm syrup 6.25-15 mg/5ml...... 13 REBINYN – coagulation factor ix recomb glycopegylated promethazine hcl syrup 6.25 mg/5ml...... 13 for inj 2000 unt...... 27 promethazine hcl tab 12.5 mg...... 13 RECOMBINATE – antihemophilic factor (recombinant) for promethazine hcl tab 25 mg...... 13 inj 220-400 unit...... 27 promethazine hcl tab 50 mg...... 13 RECOMBINATE – antihemophilic factor (recombinant) for promethazine-phenylephrine-codeine syrup 6.25-5-10 inj 401-800 unit...... 27 mg/5ml...... 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% (Alcaine)...... 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 REVLIMID – lenalidomide cap 5 mg...... 30 quinapril hcl tab 5 mg (Accupril)...... 9 REVLIMID – lenalidomide cap 10 mg...... 30 quinapril hcl tab 10 mg (Accupril)...... 9 REVLIMID – lenalidomide cap 15 mg...... 30 quinapril hcl tab 20 mg (Accupril)...... 9 REVLIMID – lenalidomide cap 20 mg...... 30 quinapril hcl tab 40 mg (Accupril)...... 9 REVLIMID – lenalidomide cap 25 mg...... 30 QVAR REDIHALER – beclomethasone diprop hfa breath REVLIMID – lenalidomide caps 2.5 mg...... 30 act inh aer 40 mcg/act...... 14 REYATAZ – atazanavir sulfate cap 150 mg (base QVAR REDIHALER – beclomethasone diprop hfa breath equiv)...... 2 act inh aer 80 mcg/act...... 14 REYATAZ – atazanavir sulfate cap 200 mg (base equiv)...... 2

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 43 2018

REYATAZ – atazanavir sulfate cap 300 mg (base SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 equiv)...... 2 mg total)...... 5 risperidone tab 0.25 mg (Risperdal)...... 18 SOOLANTRA – ivermectin cream 1%...... 29 risperidone tab 0.5 mg (Risperdal)...... 18 sotalol hcl tab 80 mg (Betapace)...... 12 risperidone tab 1 mg (Risperdal)...... 18 sotalol hcl tab 120 mg (Betapace)...... 12 risperidone tab 2 mg (Risperdal)...... 18 sotalol hcl tab 160 mg (Betapace)...... 12 risperidone tab 3 mg (Risperdal)...... 18 SOVALDI – sofosbuvir tab 400 mg...... 2 risperidone tab 4 mg (Risperdal)...... 18 SPIRIVA HANDIHALER – tiotropium bromide RIXUBIS – coagulation factor ix (recombinant) for inj 250 monohydrate inhal cap 18 mcg (base equiv)...... 14 unit...... 27 SPIRIVA RESPIMAT – tiotropium bromide monohydrate RIXUBIS – coagulation factor ix (recombinant) for inj 500 inhal aerosol 1.25 mcg/act...... 15 unit...... 27 SPIRIVA RESPIMAT – tiotropium bromide monohydrate RIXUBIS – coagulation factor ix (recombinant) for inj 1000 inhal aerosol 2.5 mcg/act...... 15 unit...... 28 spironolactone tab 25 mg (Aldactone)...... 12 RIXUBIS – coagulation factor ix (recombinant) for inj 2000 spironolactone tab 50 mg (Aldactone)...... 12 unit...... 28 STELARA – ustekinumab inj 45 mg/0.5ml...... 30 RIXUBIS – coagulation factor ix (recombinant) for inj 3000 STELARA – ustekinumab soln prefilled syringe 45 unit...... 28 mg/0.5ml...... 30 ropinirole hydrochloride tab 0.25 mg (Requip)...... 22 STELARA – ustekinumab soln prefilled syringe 90 mg/ ropinirole hydrochloride tab 0.5 mg (Requip)...... 22 ml...... 30 ropinirole hydrochloride tab 1 mg (Requip)...... 22 STIMATE – desmopressin acetate nasal soln 1.5 mg/ ropinirole hydrochloride tab 2 mg (Requip)...... 22 ml...... 8 ropinirole hydrochloride tab 3 mg (Requip)...... 22 STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero ropinirole hydrochloride tab 4 mg (Requip)...... 22 soln 2.5-2.5 mcg/act...... 15 ropinirole hydrochloride tab 5 mg (Requip)...... 22 STRENSIQ – asfotase alfa subcutaneous inj 18 RYDAPT – midostaurin cap 25 mg...... 4 mg/0.45ml...... 8 STRENSIQ – asfotase alfa subcutaneous inj 28 S mg/0.7ml...... 8 SABRIL – vigabatrin powd pack 500 mg...... 22 STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml...... 8 SABRIL – vigabatrin tab 500 mg...... 22 STRENSIQ – asfotase alfa subcutaneous inj 80 selenium sulfide lotion 2.5%...... 30 mg/0.8ml...... 9 SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)...... 8 STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)...... 8 150-150-200-300 mg...... 2 SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)...... 8 STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln SEREVENT DISKUS – salmeterol xinafoate aer pow ba 2.5 mcg/act (base equiv)...... 15 50 mcg/dose (base equiv)...... 14 sulfacetamide sodium-prednisolone ophth soln sertraline hcl tab 25 mg (Zoloft)...... 17 10-0.23(0.25)%...... 29 sertraline hcl tab 50 mg (Zoloft)...... 17 SULFADIAZINE – sulfadiazine tab 500 mg...... 3 sertraline hcl tab 100 mg (Zoloft)...... 17 sulfamethoxazole-trimethoprim susp 200-40 silver sulfadiazine cream 1% (Silvadene)...... 29 mg/5ml...... 3 SIMPONI – golimumab subcutaneous soln auto-injector sulfamethoxazole-trimethoprim tab 400-80 mg 50 mg/0.5ml...... 21 (Bactrim)...... 3 SIMPONI – golimumab subcutaneous soln auto-injector sulfamethoxazole-trimethoprim tab 800-160 mg 100 mg/ml...... 21 (Bactrim ds)...... 3 SIMPONI – golimumab subcutaneous soln prefilled sulindac tab 150 mg...... 21 syringe 50 mg/0.5ml...... 21 sulindac tab 200 mg...... 21 SIMPONI – golimumab subcutaneous soln prefilled sumatriptan succinate tab 25 mg (Imitrex)...... 21 syringe 100 mg/ml...... 21 sumatriptan succinate tab 50 mg (Imitrex)...... 21 simvastatin tab 5 mg (Zocor)...... 11 sumatriptan succinate tab 100 mg (Imitrex)...... 21 simvastatin tab 10 mg (Zocor)...... 11 SUSTIVA – efavirenz cap 50 mg...... 2 simvastatin tab 20 mg (Zocor)...... 11 SUSTIVA – efavirenz cap 200 mg...... 2 simvastatin tab 40 mg (Zocor)...... 11 SUSTIVA – efavirenz tab 600 mg...... 2 simvastatin tab 80 mg (Zocor)...... 11

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 44 2018

SUTENT – sunitinib malate cap 12.5 mg (base THALOMID – thalidomide cap 50 mg...... 30 equivalent)...... 4 THALOMID – thalidomide cap 100 mg...... 30 SUTENT – sunitinib malate cap 25 mg (base THALOMID – thalidomide cap 150 mg...... 30 equivalent)...... 4 THALOMID – thalidomide cap 200 mg...... 30 SUTENT – sunitinib malate cap 37.5 mg (base theophylline tab er 12hr 100 mg...... 15 equivalent)...... 4 thyroid tab 30 mg (1/2 grain) (Armour thyroid)...... 8 SUTENT – sunitinib malate cap 50 mg (base thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)...... 8 equivalent)...... 4 thyroid tab 60 mg (1 grain) (Armour thyroid)...... 8 SYLATRON – peginterferon alfa-2b for inj kit 200 mcg...... 4 timolol maleate ophth soln 0.25% (Timoptic)...... 29 SYLATRON – peginterferon alfa-2b for inj kit 300 mcg...... 4 timolol maleate ophth soln 0.5% (Timoptic)...... 29 SYLATRON – peginterferon alfa-2b for inj kit 600 mcg...... 4 TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 3 SYMBICORT – budesonide-formoterol fumarate dihyd TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 3 aerosol 80-4.5 mcg/act...... 15 TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 3 SYMBICORT – budesonide-formoterol fumarate dihyd tizanidine hcl tab 2 mg (base equivalent)...... 22 aerosol 160-4.5 mcg/act...... 15 tizanidine hcl tab 4 mg (base equivalent) SYMFI – efavirenz-lamivudine-tenofovir df tab (Zanaflex)...... 22 600-300-300 mg...... 2 tobramycin ophth soln 0.3% (Tobrex)...... 29 SYMFI LO – efavirenz-lamivudine-tenofovir df tab topiramate tab 25 mg (Topamax)...... 22 400-300-300 mg...... 2 topiramate tab 50 mg (Topamax)...... 22 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...... 7 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...... 7 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)...... 9 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...... 18 240 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 TRESIBA FLEXTOUCH – insulin degludec soln pen- temazepam cap 15 mg (Restoril)...... 18 injector 100 unit/ml...... 7 temazepam cap 30 mg (Restoril)...... 18 TRESIBA FLEXTOUCH – insulin degludec soln pen- terazosin hcl cap 1 mg (base equivalent)...... 12 injector 200 unit/ml...... 8 terazosin hcl cap 2 mg (base equivalent)...... 12 TRETTEN – coagulation factor xiii a-subunit for inj terazosin hcl cap 5 mg (base equivalent)...... 12 2000-3125 unit...... 28 terazosin hcl cap 10 mg (base equivalent)...... 12 triamcinolone acetonide cream 0.025%...... 29 terbinafine hcl tab 250 mg (Lamisil)...... 1 triamcinolone acetonide cream 0.1%...... 29 TEST STRIPS – ASCENSIA BREEZE 2, CONTOUR, triamcinolone acetonide cream 0.5%...... 29 CONTOUR NEXT...... 30 triamcinolone acetonide oint 0.025%...... 30 tetracaine hcl ophth soln 0.5%...... 29 triamcinolone acetonide oint 0.1%...... 30

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 45 2018 triamterene & hydrochlorothiazide cap 37.5-25 mg verapamil hcl tab er 240 mg (Calan sr)...... 11 (Dyazide)...... 12 verapamil hcl tab 80 mg (Calan)...... 11 triamterene & hydrochlorothiazide tab 37.5-25 mg verapamil hcl tab 120 mg (Calan)...... 11 (Maxzide-25)...... 12 VIBERZI – eluxadoline tab 75 mg...... 16 triamterene & hydrochlorothiazide tab 75-50 mg VIBERZI – eluxadoline tab 100 mg...... 16 (Maxzide)...... 12 VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ trihexyphenidyl hcl tab 2 mg...... 22 ml)...... 7 trihexyphenidyl hcl tab 5 mg...... 22 VIDEX – didanosine for soln 2 gm...... 3 trimethoprim tab 100 mg...... 3 VIDEX – didanosine for soln 4 gm...... 3 tropicamide ophth soln 0.5%...... 29 VIRAMUNE – nevirapine susp 50 mg/5ml...... 3 tropicamide ophth soln 1% (Mydriacyl)...... 29 VIREAD – tenofovir disoproxil fumarate oral powder 40 TRUVADA – emtricitabine-tenofovir disoproxil fumarate mg/gm...... 3 tab 100-150 mg...... 3 VIREAD – tenofovir disoproxil fumarate tab 150 mg...... 3 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VIREAD – tenofovir disoproxil fumarate tab 200 mg...... 3 tab 133-200 mg...... 3 VIREAD – tenofovir disoproxil fumarate tab 250 mg...... 3 TRUVADA – emtricitabine-tenofovir disoproxil fumarate VIREAD – tenofovir disoproxil fumarate tab 300 mg...... 3 tab 167-250 mg...... 3 VONVENDI – von willebrand factor (recombinant) for inj TRUVADA – emtricitabine-tenofovir disoproxil fumarate 650 unit...... 28 tab 200-300 mg...... 3 VONVENDI – von willebrand factor (recombinant) for inj TYMLOS – abaloparatide subcutaneous soln pen-injector 1300 unit...... 28 3120 mcg/1.56ml...... 9 VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg...... 2 U VOTRIENT – pazopanib hcl tab 200 mg (base equiv)...... 4 UPTRAVI – selexipag tab 200 mcg...... 12 UPTRAVI – selexipag tab 400 mcg...... 12 W UPTRAVI – selexipag tab 600 mcg...... 12 warfarin sodium tab 1 mg (Coumadin)...... 28 UPTRAVI – selexipag tab 800 mcg...... 12 warfarin sodium tab 2 mg (Coumadin)...... 28 UPTRAVI – selexipag tab 1000 mcg...... 12 warfarin sodium tab 2.5 mg (Coumadin)...... 28 UPTRAVI – selexipag tab 1200 mcg...... 12 warfarin sodium tab 3 mg (Coumadin)...... 28 UPTRAVI – selexipag tab 1400 mcg...... 12 warfarin sodium tab 4 mg (Coumadin)...... 28 UPTRAVI – selexipag tab 1600 mcg...... 12 warfarin sodium tab 5 mg (Coumadin)...... 28 UPTRAVI – selexipag tab therapy pack 200 mcg (140) & warfarin sodium tab 6 mg (Coumadin)...... 28 800 mcg (60)...... 12 warfarin sodium tab 7.5 mg (Coumadin)...... 28 V warfarin sodium tab 10 mg (Coumadin)...... 28 WELCHOL – colesevelam hcl packet for susp 3.75 VALCHLOR – mechlorethamine hcl gel 0.016% (base gm...... 11 equivalent)...... 30 WELCHOL – colesevelam hcl tab 625 mg...... 11 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan WILATE – antihemophilic factor/vwf (human) for inj hct)...... 10 500-500 unit kit...... 28 valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan WILATE – antihemophilic factor/vwf (human) for inj hct)...... 10 1000-1000 unit kit...... 28 valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct)...... 10 X venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) XALKORI – crizotinib cap 200 mg...... 4 (Effexor xr)...... 18 XALKORI – crizotinib cap 250 mg...... 4 venlafaxine hcl cap er 24hr 75 mg (base equivalent) XARELTO – rivaroxaban tab 10 mg...... 28 (Effexor xr)...... 18 XARELTO – rivaroxaban tab 15 mg...... 28 venlafaxine hcl cap er 24hr 150 mg (base equivalent) XARELTO – rivaroxaban tab 20 mg...... 28 (Effexor xr)...... 18 XARELTO STARTER PACK – rivaroxaban tab starter VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act therapy pack 15 mg & 20 mg...... 28 (90mcg base equiv)...... 15 XIFAXAN – rifaximin tab 550 mg...... 3 verapamil hcl tab er 120 mg (Calan sr)...... 11 XTANDI – enzalutamide cap 40 mg...... 4 verapamil hcl tab er 180 mg (Calan sr)...... 11

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 46 2018

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

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...... 5 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 ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 3 zolpidem tartrate tab 5 mg (Ambien)...... 18 zolpidem tartrate tab 10 mg (Ambien)...... 18 zonisamide cap 25 mg (Zonegran)...... 22 ZYTIGA – abiraterone acetate tab 250 mg...... 5 ZYTIGA – abiraterone acetate tab 500 mg...... 5

for Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TX5TIERGEN/en/find-medicine.html

Blue Cross and Blue Shield October 2018 Multi Tier Enhanced Drug List 47