EmblemHealth Pharmacy Benefit Services 2019 Child Health Plus Formulary Summary (Effective October 1, 2019)

This is a list of the preferred drugs prescribed most often to members in your plan. It is a short version of the drug list that makes up your prescription drug benefit plan. alkT to your doctor about prescribing generic drugs when it’s possible. By doing this, you may save money.

NOTE: Brand-name drugs may come off this list if a generic version comes on the market during the year. Check your benefits to see which drugs we pay for and your copays. A copay is the amount you pay for health services or prescriptions. If you have questions, please call the phone number on the back of your ID card. You can find a key to this list on the last page.

A anastrozole bisoprolol fumarate cefaclor er COSENTYX 300MG (PA) dorzolamide-timolol abacavir (QLL) androxy bisoprolol fumarate/hctz cefadroxil COUMADIN doxazosin mesylate (QLL) abacavir-lamivudine (QLL) ANORO ELLIPTA (QLL) blisovi fe cefdinir CREON doxepin hcl (QLL) abacavir-lamivudine- antipyrine w/benzocaine bosentan (QLL) cefditoren pivoxil CRIXIVAN (QLL) doxycycline hyclate 75mg, zidovudine (QLL) anucort-hc bp-wash 10% liquid cefixime cromolyn sodium (QLL) 150mg tabs (PA) acamprosate aprepitant (QLL) bp-wash 8% treatment pk cefpodoxime proxetil crotan doxycycline hyclate caps acarbose apri BREO ELLIPTA (QLL) cefprozil cryselle doxycycline hyclate dr acebutolol hcl APRISO brimonidine tartrate cefuroxime axetil cyclobenzaprine hcl tabs (ST) acetaminophen w/ APTIVUS (QLL) bromfenac sodium (QLL) celecoxib (QLL) cyclopentolate hcl doxycycline monohydrate butalbital (QLL) aranelle bromipheniramin- cephalexin cyclosporine capsule doxylamine succ- acetaminophen w/codeine arbinoxa pseudoephed-dm cesia cyclosporine soln (QLL) pyridoxine hcl (QLL) (PA/QLL) aripiprazole (QLL) bromocriptine mesylate cetirizine hcl cyproheptadine hcl drithocreme hp acetazolamide aripiprazole odt (QLL) (QLL) CETROTIDE (PA) D dronabinol acetic acid/ armodafinil budesonide ec cevimeline drospirenone-eth estra- ARMOUR THYROID budesonide nasal spray CHANTIX (QLL) DALIRESP levomef DAPSONE ACTEMRA (PA) ARNUITY ELLIPTA (QLL) (QLL) chateal eq DULERA (QLL) ascomp with codeine (PA/ bumetanide CHEMET (PA) dasetta duloxetine hcl (QLL) ACUVAIL decadron acyclovir (QLL) QLL) buprenorphine-naloxone chlordiazepoxide hcl dutasteride aspirin-dipyridamole er (QLL) chlordiazepoxide- deferasirox (PA) acyclovir cream (PA) denta 5000 plus E adapalene cream, gel, gel atenolol bupropion hcl clidinium atenolol w/chlorthalidone bupropion hcl xl (QLL) chlorhexidine gluconate DESCOVY (QLL) econazole nitrate (QLL) pump (PA) desflurane EDARBI (ST) adapalene soln (PA) atomoxetine hcl (QLL) bupropion sr (QLL) chlorthalidone atorvastatin calcium (QLL) buspirone hcl chlorzoxazone 250mg tabs desipramine hcl EDARBYCLOR (ST) adapalene-benzoyl desloratadine EDURANT (QLL) peroxide atovaquone butalbital compound (PA) atovaquone-proguanil hcl butalbital compound w/ chlorzoxazone 500mg tabs desmopressin acetate efavirenz (QLL) ADDERALL XR (QLL) -ethinyl elinest adefovir dipivoxil (PA) (QLL) codeine (PA/QLL) cholestyramine ATRIPLA (QLL) butalbital w/ choline mag trisalicylate estradiol eliphos ADVAIR DISKUS (QLL) (PA) ELIQUIS ADVAIR HFA (QLL) atropine sulfate acetaminophen (QLL) ciclopirox ATROVENT HFA (QLL) butalbital/apap/caffeine cilostazol cream EMTRIVA (QLL) AIMOVIG AUTOINJECTOR (2 desvenlafaxine suc er tb enalapril maleate PACK) (PA/QLL) aubra eq butalbital/caff/apap/ cimetidine aurovela codeine (PA) cinacalcet hcl enalapril maleate/hctz AIMOVIG AUTOINJECTOR dexamethasone sodium ENBREL (PA/QLL) (PA/QLL) aurovela fe butalbital-asp-caffeine ciprofloxacin er AVANDAMET butorphanol tartrate (PA/ ciprofloxacin hcl phosphate endocet (PA/QLL) AJOVY (PA/QLL) dexmethylphenidate hcl enoxaparin sodium (PA/ albuterol sulfate (QLL) AVANDARYL QLL) ciprofloxacin otic AVANDIA BYDUREON (QLL) citalopram hbr (QLL) (QLL) QLL) dexmethylphenidate hcl enpresse dipropionate (PA) aviane BYDUREON BCISE (QLL) claravis AVONEX ADMINISTRATION BYDUREON PEN (QLL) clarithromycin er (QLL) entacapone alendronate sodium (QLL) dexmethylphenidate hcl entecavir alfuzosin hcl er PACK (PA/QLL) BYETTA (QLL) clarithromycin er AVONEX PEN (PA/QLL) BYSTOLIC (ST) clidinium w/ xr (QLL) ENTRESTO aliskiren dextroamphetamine enulose allopurinol azathioprine chlordiazepoxide azelastine hcl nasal spray C CLIMARA PRO (QLL) sulfate (QLL) EPCLUSA (PA/QLL) almotriptan malate (QLL) cabergoline (QLL) dextroamphetamine epinastine hcl (QLL) ALOMIDE (QLL) (QLL) clindamycin hcl azithromycin calcipotriene clindamycin palmitate hcl sulfate er (QLL) epinephrine auto inject alosetron hcl calcipotriene- dextroamphetamine- (mylan) (qll) ALPHAGAN P 0.1% azurette (QLL) dp amphetamine (QLL) EPIPEN (QLL) alprazolam clindamycin pediatric B calcitonin-salmon nasal (QLL) diazepam (QLL) EPIPEN JR. (QLL) alprazolam er bacitracin spray (QLL) diclofenac potassium EPIVIR HBV SOLN alprazolam xr clindamycin-benzoyl bacitracin-polymyxin CALCITRENE peroxide (QLL) diclofenac sodium oral eplerenone altavera baclofen calcitriol (QLL) diclofenac sodium topical eprosartan mesylate (QLL) alyacen emulsion (PA) BACTROBAN NASAL calcium acetate (PA) (QLL) erlotinib hcl (PA) amantadine hcl balsalazide disodium camila diclofenac sodium- errin ambi clomiphene citrate (PA) balziva camrese clomipramine hcl misoprostol erythromycin ambrisentan (QLL) belladonna-phenobarbital candesartan cilexetil dicloxacillin sodium erythromycin amethia/lo clonazepam elixr (QLL) clonidine hcl dicyclomine hcl ethylsuccinate amiloride hcl benazepril hcl candesartan- didanosine (QLL) erythromycin-benzoyl amiloride hcl w/hctz clonidine hcl er benazepril hcl-hctz hydrochlorothiazid (QLL) clopidogrel (QLL) diacetate (PA) peroxide amiodarone hcl benzonatate capecitabine diflunisal escitalopram oxalate AMITIZA clorazepate dipotassium benzoyl peroxide captopril digitek (QLL) amitriptyline hcl clorpres benztropine mesylate captopril/ clotrimazole digox esomeprazole magnesium amlodipine besylate (QLL) beser (PA) hydrochlorothiazide digoxin (QLL) amlodipine besylate- clotrimazole/ betamethasone CARAFATE SUSP betamethasone dihydroergotamine nasal estazolam benazepril (QLL) dipropionate crm/oint carbamazepine spr (QLL) estradiol, -patch (QLL) amlodipine-atorvastatin clozapine betamethasone carbamazepine er clozapine odt diltiazem 24hr cd (QLL) estradiol/noreth acetate (QLL) dipropionate gel/lotn carbamazepine xr diltiazem er (QLL) ESTRING amlodipine-olmesartan codeine sulfate (PA/QLL) (PA) carbidopa COLCRYS diltiazem hcl (QLL) estropipate (ST/QLL) betamethasone valerate carbidopa/levodopa dilt-xr (QLL) eszopiclone (QLL) amlodipine-valsartan colesevelam hcl crm/oint/lotn carbidopa-levodopa er colestipol hcl diphenhydramine hcl ethacrynic acid amlodipine-valsartan-hctz betamethasone valerate carbidopa-levodopa- diphenoxylate w/atropine etidronate disodium ammonium lactate colocort foam (QLL) (PA) entacapone COMBIGAN dipyridamole etodolac amoxicillin BETASERON (PA/QLL) carisoprodol (QLL) disulfiram etodolac er amoxicillin-clavulanate er COMBIPATCH (QLL) bethanechol chloride carisoprodol-aspirin- COMBIVENT (QLL) divalproex dr cap sprnk exemestane amoxicillin-clavulanate bexarotene (PA/QLL) codeine (PA/QLL) divalproex sodium ezetimibe-simvastatin potass COMBIVENT RESPIMAT (QLL) bicalutamide cartia xt (QLL) COMPLERA (QLL) divalproex sodium er (QLL) ampicillin trihydrate BIKTARVY (QLL) carvedilol donepezil hcl AMTURNIDE CORLANOR (ST) bimatoprost (QLL) cefaclor dorzolamide hcl (QLL) F anagrelide hcl COSENTYX 150MG (PA) fabb

See key on the last page of this formulary listing. EmblemHealth Pharmacy Benefit Services 2019 Child Health Plus Formulary Summary (continued) falmina glyburide-metformin hcl JANUMET XR (QLL) loryna moxifloxacin hcl olmesartan- famciclovir glycolax JANUVIA (QLL) losartan potassium (QLL) MULTAQ hydrochlorothiazide (ST/ famotidine glycopyrrolate 1.5mg tabs JARDIANCE (QLL) losartan- mupirocin QLL) (PA) jevantique hydrochlorothiazide mycophenolate mofetil olopatadine hcl eye drops FARXIGA (QLL) glycopyrrolate 1mg, 2mg jinteli etabonate (QLL) (QLL) fayosim tabs jolessa lovastatin (QLL) mycophenolic acid olopatadine hcl nasal felbamate GLYXAMBI (QLL) jolivette low-ogestrel MYDAYIS (QLL) (QLL) felodipine er (QLL) GONAL-F (PA) junel LUMIGAN (QLL) myferon-150 forte omega-3 acid ethyl esters femynor granisetron hcl (QLL) junel fe lutera mynephron omeprazole (QLL) fenofibrate griseofulvin JUVISYNC MYRBETRIQ ondansetron hcl (QLL) fenofibric acid guaifenesin ac M ondansetron odt (QLL) fentanyl (PA/QLL) guaifenesin dac K mafenide acetate N ONGLYZA (QLL) fentanyl citrate loz (PA/ guaifenesin with codeine kaitlib fe matzim la nabumetone oralone QLL) guanfacine hcl KALETRA TABS (QLL) MAXAIR AUTOHALER (QLL) nadolol orphenadrine citrate FIASP guanfacine hcl er (QLL) kariva MAYZENT (PA) naftifine hcl orphengesic forte FIASP FLEXTOUCH guiatussin ac kelnor 1-35 meclizine hcl naltrexone hydrochloride orsythia finasteride kelnor 1-50 medroxyprogesterone naproxen oseltamivir phosphate flecainide acetate H (PA) acetate (PA/QLL) naproxen sodium (QLL) FLOVENT DISKUS (QLL) halobetasol propionate ketorolac tromethamine mefloquine hcl naproxen sodium ds OTEZLA (PA) FLOVENT HFA (QLL) (PA) (QLL) (PA) naratriptan hcl (QLL) OTOVEL fluconazole (QLL) haloperidol klor-con meloxicam (QLL) NARCAN otozin flucytosine HARVONI (PA/QLL) klor-con m memantine hcl nateglinide OVIDREL (PA) acetate hc pramoxine KOMBIGLYZE XR (QLL) memantine hcl er nature-throid oxaprozin (QLL) heparin sodium (PA) KORLYM (PA) mercaptopurine necon oxazepam acetonide HUMIRA (PA/QLL) L mesalamine nefazodone hcl oxcarbazepine oil/crm/soln (PA) HUMIRA PEDIATRIC (PA/QLL) mesalamine dr (ST) neomycin/bacitracin/ oxybutynin chloride hydralazine hcl labetalol hcl metadate er (QLL) polymyxin lactulose oxybutynin chloride er ointment (QLL) hydrochlorothiazide metaproterenol sulfate neomycin/polymyxin/hc oxycodone hcl (PA/QLL) (QLL) (PA) hydrocodone bit-ibuprofen lamivudine (QLL) (QLL) neomycin-polymyxin- lamivudine-zidovudine oxycodone hcl-ibuprofen fluocinonide-e (PA) (PA) metaxalone dexamethaso (PA/QLL) hydrocodone w/ (QLL) metformin hcl (generic nevirapine (QLL) lamotrigine oxycodone w/ fluorouracil acetaminophen (PA/QLL) Glucophage) nevirapine er (QLL) acetaminophen (PA/QLL) fluoxetine hcl (QLL) hydrocodone/homatropine LANOXIN TABS metformin hcl er (generic niacin er (QLL) lansoprazol-amoxicil- oxymorphone hcl (PA/QLL) fluphenazine hcl (QLL) hydrocodone- Glucophage) (QLL) nifediac cc (QLL) oxymorphone hcl er (PA/ flurazepam hcl chlorpheniramine clarithro methadone hcl (PA/QLL) nifedical xl (QLL) lansoprazole (QLL) QLL) flurbiprofen hydrocortisone absorbase methamphetamine hcl nifedipine er (QLL) OZEMPIC (QLL) (PA) lanthanum carbonate (ST) (QLL) nisoldipine crm/oint hydrocortisone butyrate LANTUS methenamine hippurate nitrofurantoin P fluticasone propionate (QLL) (PA) LANTUS SOLOSTAR methimazole nitrofurantoin paliperidone er lotn (PA) hydrocortisone crm/lotn/ larin fe methocarbamol macrocrystal pancrelipase 5,000 fluticasone propionate oint larissia methotrexate tabs nitroglycerin panlor (QLL) nasal (QLL) hydrocortisone valerate LASTACAFT (QLL) methyldopa nitroglycerin patch pantoprazole sodium (QLL) fluvastatin (QLL) (PA) latanoprost (QLL) methylergonovine maleate nizatidine paricalcitol capsule fluvastatin er (QLL) hydromet layolis fe methylphenidate er (QLL) nolix paroxetine hcl fluvoxamine maleate hydromorphone er (PA/ leena methylphenidate hcl (QLL) nora-be peg 3350-electrolyte fluvoxamine maleate er QLL) leflunomide (QLL) methylphenidate hcl cd NORDITROPIN FLEXPRO (PA) PEG-INTRON/REDIPEN (PA/ (ST) hydromorphone hcl (PA/ lessina (QLL) NORDITROPIN NORDIFLEX QLL) FML FORTE QLL) letrozole methylphenidate la (QLL) (PA) penicillamine (PA) FORADIL (QLL) hydroxychloroquine leucovorin calcium tabs norethindrone acetate penicillin v potassium FORTEO (QLL) sulfate leuprolide acetate (PA) methyltestosterone norethindrone-ethin PENTASA fosamprenavir calcium hydroxyurea levalbuterol hcl soln (QLL) metoclopramide hcl estradiol pentoxifylline (QLL) hydroxyzine hcl LEVEMIR metolazone norethin-eth estra ferrous PERFOROMIST (QLL) fosinopril sodium hydroxyzine pamoate LEVEMIR FLEXTOUCH metoprolol succinate fum permethrin fosinopril- hyoscyamine sulfate levetiracetam metoprolol tartrate norgestimate-ethinyl perphenazine hydrochlorothiazide levetiracetam er metoprolol- estradiol phenazopyridine hcl frovatriptan succinate I levobunolol hcl hydrochlorothiazide norlyda phenobarbital (QLL) ibandronate sodium (QLL) levocarnitine tabs/soln metronidazole nortrel phenohytro furosemide ibuprofen (PA) mibelas nortriptyline hcl (QLL) phentermine hcl (PA) FUZEON (QLL) imipramine hcl levocetirizine microgestin NORVIR (QLL) phenylhistine dh fyavolv indapamide dihydrochloride microgestin fe NOVOFINE (QLL) phenytoin sodium indomethacin levofloxacin hemihydrate midodrine hcl NOVOFINE 32 (QLL) phrenilin forte G INTELENCE (QLL) levonorgestrel (QLL) NOVOFINE AUTOCOVER (QLL) phytonadione gabapentin INVIRASE (QLL) levonorgestrel-eth miglustat NOVOLIN products pilocarpine hcl galantamine INVOKAMET (QLL) estradiol mili NOVOLOG products pimecrolimus (ST/QLL) gatifloxacin INVOKAMET XR (QLL) levora millipred np thyroid pimozide gavilyte-c INVOKANA (QLL) levorphanol tartrate (PA/ minocycline hcl NUCYNTA (PA/QLL) pimtrea gavilyte-g iophen c-nr QLL) minocycline hcl er 105mg, NUCYNTA ER (PA/QLL) pindolol gavilyte-n ipratropium bromide (QLL) levothyroxine sodium 115mg, 55mg, 65mg, NUPLAZID (PA/QLL) pioglitazone hcl (QLL) gemfibrozil ipratropium-albuterol levoxyl 80mg (PA) NUVARING (QLL) pioglitazone-glimepiride generlac (QLL) lidocaine 5% patch (PA) minoxidil nystatin (QLL) gentamicin sulfate topical irbesartan (QLL) lidocaine-prilocaine (QLL) mirtazapine nystatin w/ pioglitazone-metformin GENVOYA (QLL) irbesartan- lillow misoprostol nystop (QLL) gianvi hydrochlorothiazide LINZESS MITIGARE piroxicam gildess (QLL) liothyronine sodium modafinil O PLEGRIDY (PA/QLL) gildess fe iron ag-ps-asc-b12-fa- lisinopril moexipril hcl ocella pnv-dha GILENYA (PA/QLL) thre-suc lisinopril-hctz moexipril- ocudox podofilox glatiramer acetate (QLL) ISENTRESS TABS (QLL) lithium carbonate hydrochlorothiazide ofloxacin polyethylene glycol glatopa (QLL) isoniazid LO LOESTRIN FE mono-linyah ogestrel polymyxin b sul- glimepiride isosorbide dinitrate lomedia 24 fe mononessa olanzapine trimethoprim glipizide isosorbide mononitrate loperamide hcl montelukast sodium (QLL) olanzapine odt portia glipizide er isotretinoin lopinavir-ritonavir soln morphine sulfate (PA/QLL) olanzapine-fluoxetine posaconazole (PA) glipizide xl itraconazole (QLL) (QLL) morphine sulfate er (PA/ olmesartan medoxomil potassium chloride (QLL) lorazepam (QLL) glipizide-metformin J QLL) (ST/QLL) PRALUENT (PA/QLL) glyburide lorcet (PA/QLL) MOVANTIK olmesartan-amlodipine- pramipexole di-hcl glyburide micronized jantoven lorcet plus (PA/QLL) hctz (ST/QLL) JANUMET (QLL) MOVIPREP pramipexole er See key on the last page of this formulary listing. EmblemHealth Pharmacy Benefit Services 2019 Child Health Plus Formulary Summary (continued) prasugrel hcl rajani sodium sulfacetamide hydrochlorothiazide (ST/ trientine hcl vicodin hp (PA/QLL) pravastatin sodium (QLL) raloxifene hcl (QLL) sodium sulfacetamide/ QLL) tri-estarylla VICTOZA (QLL) praziquantel ramelteon (PA) sulfur temazepam trifluoperazine hcl VIDEX PED SOLN (QLL) prazosin hcl ramipril solia temozolamide (PA) trifluridine vienva PRECISION (QLL) ranitidine hcl solifenacin succinate terazosin hcl trihexyphenidyl hcl vigabatrin PRECISION XTRA (QLL) ranolazine er soloxide (PA) terbinafine triklo VIIBRYD (ST) REBIF (PA/QLL) sotalol terconazole tri-legest fe vinate dha prednisolone acetate REBIF REBIDOSE (PA/QLL) spinosad testosterone cypionate tri-linyah viorele prednisolone sodium reclipsen SPIRIVA (QLL) (PA) tri-lo-estarylla VIRACEPT (QLL) phosphate RELENZA (QLL) SPIRIVA RESPIMAT (QLL) tetrabenazine (PA) tri-lo-marzia VIREAD TABS (QLL) repaglinide spironolactone tetracycline hcl tri-lo-mili virt-pn dha PREFEST REPATHA (PA/QLL) spironolactone w/hctz THALOMID (PA) tri-lo-sprintec virtussin ac pregabalin (QLL) REPATHA PUSHTRONEX (PA/ sprintec theophylline trilyte with flavor packets VOSEVI (PA/QLL) PREMARIN QLL) sronyx theophylline anhydrous trimethoprim vylibra PREMPHASE reprexain ssd thioridazine hcl tri-mili VYVANSE (QLL) PREMPRO RESCRIPTOR (QLL) stavudine (QLL) thiothixene trinessa prena1 pearl RESTASIS (QLL) STELARA (PA/QLL) tiagabine hcl trinessa lo W prenatal plus ribapak (PA) STIOLTO RESPIMAT (QLL) tilia fe tri-previfem warfarin sodium preplus ribasphere (PA) STRENSIQ (QLL) timolol maleate tri-sprintec X previfem ribavirin (PA) STRIBILD (QLL) tinidazole (QLL) trivora XARELTO, XARELTO STARTER PREZISTA (QLL) rifabutin subvenite tizanidine hcl tri-vylibra, -lo PACK primidone rifampin sucralfate TOBI PODHALER (QLL) trospium chloride XELJANZ (PA/QLL) probenecid RIOMET (QLL) sulfacetamide sodium TOBRADEX OINT trust natal dha XELJANZ XR (PA/QLL) probenecid w/colchicine risedronate sodium (QLL) sulfamethoxazole/ tobramycin sulfate tulana XIFAXAN 550MG (PA/QLL) procentra risedronate sodium dr trimethoprim tobramycin- tussigon XIGDUO XR (QLL) prochlorperazine maleate risperidone (QLL) sulfasalazine dexamethasone tydemy XIIDRA (QLL) proctosol-hc risperidone odt sulfasalazine dr tolcapone TYMLOS (QLL) xolox (QLL) proctozone-hc ritonavir (QLL) sulindac tolterodine tartrate er U xulane patch (QLL) PRODIGY INS SYRINGE (QLL) rivastigmine sumatriptan succinate topiramate XULTOPHY 100-3.6 PRODIGY PEN NEEDLE (QLL) rivelsa (QLL) toremifene citrate ULORIC (PA) rizatriptan (QLL) sumatriptan succinate torsemide urimar-t Y progesterone in oil (PA) ropinirole hcl nasal spray (ST/QLL) TOUJEO MAX SOLOSTAR uro-458 YUPELRI promethazine hcl roweepra sumatriptan succ- TOUJEO SOLOSTAR uro-l yuvafem ursodiol promethazine vc roweepra xr naproxen sod (PA/QLL) tramadol hcl (PA/QLL) Z promethazine vc w/ roxicet tabs (QLL) SUPREP tramadol hcl er (PA/QLL) V zafirlukast (QLL) codeine rydex syeda tramadol hcl- valacyclovir zaleplon (QLL) SYMBICORT promethazine w/codeine acetaminophen (PA/QLL) valgancyclovir zamicet (QLL) S SYMLINPEN (QLL) promethazine w/dm trandolapril valproic acid zarah salsalate SYNJARDY (QLL) promethegan trandolapril-verapamil valsartan (QLL) zatean-pn dha salvax SYNJARDY XR (QLL) propafenone hcl tranexamic acid valsartan- zenatane SAVELLA SYNTHROID propranolol hcl tranylcypromine sulfate hydrochlorothiazide zenchent propranolol hcl er selenium sulfide travoprost (QLL) SELZENTRY (QLL) T (QLL) ZENPEP propylthiouracil trazodone hcl vancomycin hcl capsule zflex SEREVENT DISKUS (QLL) tacrolimus capsule TREMFYA (PA) prudoxin cream (QLL) vandazole zgesic PULMICORT FLEXHALER (QLL) sertraline hcl (QLL) tacrolimus ointment (ST/ TRESIBA vasolex zidovudine (QLL) PULMOZYME (PA) sevelamer QLL) tretinoin (PA) sharobel tadalafil (PA) velivet ziprasidone hcl pyridostigmine bromide tri femynor venlafaxine hcl zolmitriptan (QLL) pyridostigmine bromide er sildenafil citrate (PA/QLL) tamoxifen citrate silver nitrate applicator tamsulosin hcl venlafaxine hcl er zolmitriptan odt (QLL) crm/oint/lotn (GENERIC ONLY) zolpidem tartrate (QLL) Q silver sulfadiazine tarina fe triamcinolone acetonide quasense SIMCOR (ST/QLL) tazarotene (PA) VENTOLIN HFA (QLL) zolpidem tartrate er (QLL) nasal spray (QLL) VERAMYST (QLL) ZOMIG NASAL SPRAY (QLL) quetiapine fumarate simliya taztia xt (QLL) triamcinolone acetonide quetiapine fumarate er simvastatin (QLL) TECFIDERA (PA/QLL) verapamil er zonisamide topical spray (PA) verapamil er pm zovia quinapril sirolimus TEKAMLO triamterene quinapril- sirolimus soln (QLL) TEKTURNA HCT verapamil hcl triamterene w/hctz veripred 20 hydrochlorothiazide SKYRIZI (2 SYRINGES) KIT telmisartan (ST/QLL) trianex (PA) (PA/QLL) telmisartan-amlodipine vestura R triazolam vicodin (PA/QLL) sodium polystyrene (ST/QLL) triderm rabeprazole sodium (QLL) sulfonate telmisartan- vicodin es (PA/QLL) Key: Capital letters Brand drug Lowercase bold letters Generic drug (PA) Prior Authorization – Your doctor needs to have us approve this drug before we will pay for it. (QLL) Quantity Level Limit – There may be a limit on how much of this drug you can get. (ST) Step Therapy – You will need to first try certain drugs before we will pay for other drugs. For example, if Drug A and Drug B can both be used, we may not pay for Drug B unless you try Drug A first. If Drug A does not work for you, we will then pay for Drug B. For the member: Generic drugs have the same active ingredients as their brand name versions. They are approved by the Food and Drug Administration. They may come in different colors or shapes. For the doctor: Please prescribe drugs on this list. Use generic drugs when you can. THIS DRUG LIST IS IN EFFECT OCTOBER 1, 2019 TO DECEMBER 31, 2019, AND MAY CHANGE AT ANY TIME. Find out more about our drug lists and our Pharmacy Services program at emblemhealth.com/pharmacy.

Formulary Disclaimer Please see your plan information for more about your drug benefits. The list of drugs we pay for is based on your plan. This is also the case for your copays. eW may not pay for all drugs on this list. Also, some drugs may need Prior Authorization before we will pay for them. For some drugs, we may limit the types of dosage and/or strengths. The drugs on this list may change at any time. And as new generics come on the market, the corresponding brand name drug will no longer be considered a “preferred” drug. Group Health Incorporated (GHI), Health Insurance Plan of Greater New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMB_MB_OTH_41464_2019_4Q_CHP_Formulary_WEB_1CCEK 9/19 ATTENTION: Language assistance services, free of charge, are available to you. Call 1-877-411-3625 (TTY/TDD: 711).

Español (Spanish) ATENCIÓN: Usted tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al 1-877-411-3625 (TTY/TDD: 711).

中文 (Traditional Chinese) 注意：我們免費提供相關的語言協助服務。請致電 1-877-411-3625 (TTY/TDD: 711)。

Pусский (Russian) ВНИМАНИЕ! Вам доступны бесплатные услуги переводчика. Звоните по тел. 1-877-411-3625 (служба текстового телефона TTY/TDD: 711).

Kreyòl Ayisyen (Haitian Creole) ATANSYON: Gen sèvis èd nan lang gratis ki disponib pou ou. Rele nimewo 1-877-411-3625 (TTY/TDD: 711).

한국어 (Korean) 주의: 귀하에게 언어 지원 서비스가 무료로 제공됩니다. 1-877-411-3625(TTY/TDD: 711)번으로 전화하십시오.

Italiano (Italian) ATTENZIONE: sono disponibili servizi gratuiti di assistenza linguistica. Chiami il numero 1-877-411-3625 (TTY/TDD: 711). (Yiddish) אידיש אכטונג: שפראך הילף סערוויסעס, אהן קיין פרייז, זיינען דא צו באקומען פאר אייך. רופט 1-877-411-3625 . . (TTY/TDD: 711)

বা廬লা (Bengali) মন োন োগ দি : ভোষো সহো붼তো পদিনষবো巁দি আপ োি জ য দব োমূনিয উপিব্ধ আনে। 1-877-411-3625 (TTY/TDD: 711) ম্বনি ফ ো ক쇁 ।

Polski (Polish) UWAGA: dostępna jest bezpłatna pomoc językowa. Prosimy zadzwonić pod numer 1-877-411-3625 (TTY/TDD: 711).

(Arabic) العربية ي رجى االنتباه: تتوفر لك خدمات المساعدة اللغوية مجانا ، اتصل الرقمعلى 3625-411-877-1 أو (TTY/TDD: 711).

Français (French) ATTENTION : une assistance d’interprétation gratuite est à votre disposition. Veuillez composer le 1-877-411-3625 (TTY/TDD : 711).

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. 10-9127 6/18

(Continued) (Urdu) اردو وجہ دیں: آپ کے لیے زبان سے متعلق اعانت کی ،خدمات مفت دستیاب ہیں۔ TTY/TDD 711( -1 877- 411-3625: ( پر کال کر یں۔

Tagalog (Tagalog) NANANAWAGAN NG PANSIN: Mayroon kang magagamit na mga serbisyo para sa tulong sa wika nang walang bayad. Tawagan ang 1-877-411-3625 (TTY/TDD: 711).

Ελληνικά (Greek) ΠΡΟΣΟΧΗ: Διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε το 1-877-411-3625 (για άτομα με προβλήματα ακοής (TTY/TDD): 711).

Shqip (Albanian) VINI RE: Shërbime ndihmore për gjuhën, falas, janë në dispozicionin tuaj. Telefononi në 1-877-411-3625 (TTY/TDD: 711). NOTICE OF NONDISCRIMINATION POLICY EmblemHealth complies with Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. EmblemHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

EmblemHealth:  Provides free aids and services to people with disabilities to help – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats)  Provides free language services to people whose first language is not English, such as: – Qualified interpreters Information written in other languages – If you need these services, please call member services at 1-877-411-3625 (TTY/TDD: 711).

If you believe that EmblemHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with EmblemHealth Grievance and Appeals Department, PO Box 2844, New York, NY 10116, or call member services at 1-877-411-3625. (Dial 711 for TTY/TDD services.) You can file a grievance in person, by mail or by phone. If you need help filing a grievance, EmblemHealth’s Grievance and Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights electronically through the Office of Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201; 1-800-368-1019, (dial 1-800-537-7697 for TTY services).

Complaint forms are available at hhs.gov/ocr/office/file/index.html.