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ÿÿ ÿ  ÿ 5657 Blue Cross Clinical Drug List - September 2021

Table of contents Blue Cross Clinical Drug List (Formulary) introduction 6 How to read the Blue Cross Clinical Drug List 12 Anti-infectives 1A Antifungals 14 1B Antimalarials 14 1C Antiparasitics and antihelmintics 15 1D Antiretrovirals 16 1E Antituberculars 17 1F Antivirals 18 1G Cephalosporins 18 1H Macrolides 19 1I Penicillins 19 1J Quinolones 19 1K Sulfonamides and combinations 19 1L Tetracyclines 20 1M Urinary tract agents 20 1N Miscellaneous anti-infectives 21 Cardiovascular, hypertension, cholesterol 2A ACE-Inhibitors and combinations 22 2B Alpha-adrenergic agents 22 2C Angiotensin II Receptor Blockers and combinations 23 2D Anticoagulants and hemostasis agents 24 2E Beta blockers and combinations 25 2F Calcium channel blockers and combinations 26 2G Cardiovascular treatment 26 2H Diuretics 27 2I Lipid-lowering agents 28 2J Nitrates and combinations 29 2K Renin-inhibitors and combinations 29 2L Miscellaneous antihypertensives 29

Page 1 Central nervous system 3A Alzheimer's therapy 30 3B Anticonvulsants 31 3C Antidepressants 32 3D Antipsychotics 33 3E Anxiolytics 34 3F CNS stimulants 34 3G Migraine therapy 35 3H Myasthenia gravis 35 3I Narcotic antagonists and withdrawal management 35 3J Narcotic mixed agonist and antagonist 36 3K Narcotic and analgesic combinations 36 3L Narcotics 37 3M Nonsteroidal anti-inflammatory drugs 38 3N Parkinsons disease and related disorders 39 3O Salicylates 39 3P Sedative and hypnotics 40 3Q Skeletal muscle relaxants 40 3R Miscellaneous CNS 41 Gastrointestinal agents 4A 5-Aminosalicylic Acid (5-ASA) agents 42 4B Antidiarrheals and antispasmodics 42 4C Antiemetics 43 4D Bile acids 43 4E Bowel preparation and cleansing agents 44 4F Digestive enzymes 44 4G H2-Receptor antagonists 44 4H Proton Pump Inhibitors (PPI) 45 4I Topical anti-Inflammatory agents 45 4J Tumor Necrosis Factor (TNF) blocking agents 45 4K Ulcer therapy 46 4L Miscellaneous gastrointestinal agents 46 Obstetrics and gynecology 5A Contraceptives-Biphasic 47 5B Contraceptives-Misc. 47 5C Contraceptives-Monophasic 48 5D Contraceptives-Postcoital 48 5E Contraceptives-Triphasic 48 5F Estrogen and progestin combinations 49 5G Estrogens 49 5H Infertility treatment* 50 5I Progestins 50 5J Vaginal anti-infective and antifungal 50 5K Miscellaneous OB-GYN 51

Page 2 Rheumatology and musculoskeletal 6A Corticosteroids 52 6B Gout therapy 52 6C Non-Tumor Necrosis Factor (TNF) blocking agents 52 6D Osteoporosis and bone resorption 52 6E Osteoporosis and hormonal treatment 53 6F Salicylates 53 6G Tumor Necrosis Factor (TNF) blocking agents 53 6H Miscellaneous rheumatologic agents 53 Endocrinology 7A Androgens 54 7B Antithyroid agents 54 7C Corticosteroids 55 7D Growth Hormone and related products 55 7E Insulins 56 7F Non-insulin hypoglycemic agents 57 7G Somatostatin analogs 58 7H Thyroid hormones 58 7I Urea cycle disorder agents 58 7J Vitamin D analogs 58 7K Miscellaneous endocrine 59 Antineoplastics and immunosuppresants 8A Adjuvant therapy 60 8B Alkylating agents 60 8C Antimetabolites 61 8D Hormonal agents 61 8E Immunomodulators 62 8F Kinase inhibitors and molecular target inhibitors 63 8G Miscellaneous antineoplastic agents 64 Immunology and hematology 9A Hematopoietic agents 65 9B Immunoglobulins 65 9C Interferons and MS therapy 66 9D Miscellaneous immunology and hematology 66

Page 3 Dermatology 10A Acne treatment 67 10B Antipsoriatic and antiseborrheic 68 10C Corticosteroids - very high potency 68 10D Corticosteroids - high potency 69 10E Corticosteroids - medium potency 69 10F Corticosteroids - low potency 70 10G Scabicides and pediculicides 70 10H Topical anesthetics 70 10I Topical antibacterials 71 10J Topical antifungals 71 10K Topical antineoplastic agents and immunomodulators 72 10L Topical antivirals 72 10M Wound and burn therapy 72 10N Miscellaneous dermatologicals 73 Ophthalmology 11A Cycloplegic mydriatics 74 11B Glaucoma agents 74 11C Ophthalmic anti-allergy agents 75 11D Ophthalmic anti-infective and steroid combinations 75 11E Ophthalmic anti-infectives 76 11F Ophthalmic anti-inflammatory agents 76 11G Ophthalmic beta blockers 77 11H Ophthalmic steroids 77 11I Dry eye agents 77 11J Miscellaneous ophthalmic agents 78 Otic and nasal preparations 12A Nasal preparations 79 12B Otic preparations 79

Page 4 Respiratory, cough and cold 13A Antihistamine and decongestant combinations 80 13B Antihistamines 80 13C Antitussives 81 13D Cystic Fibrosis agents 81 13E Epinephrine 82 13F Inhaled anticholinergics 82 13G Inhaled beta-agonist and anticholinergic combinations 82 13H Inhaled beta-agonists 82 13I Inhaled steroid and beta-agonist combinations 83 13J Inhaled steroids 83 13K Intranasal steroids 83 13L Oral beta-agonists 83 13M Pulmonary Hypertension Agents 84 13N Theophyllines 84 13O Miscellaneous respiratory agents 84 Urology 14A BPH Treatment 85 14B Ion-Removing Agents 85 14C Urinary Antispasmodics 86 14D Miscellaneous Urologicals 86 Vitamins and supplements 15A Potassium Replacement 87 15B Vitamins and Minerals 87 Diagnostic and other miscellaneous 16A Chelating Agents 88 16B Diabetes monitoring and management products 88 16C Vaccines 89 16D Diagnostics and Other Miscellaneous 90 Lifestyle modification 17A Sexual Dysfunction 91 17B Smoking Cessation 91 17C Weight Loss Preparations 91 Hemophilia 18A Antihemophilic Agents 92

Page 5 Blue Cross Clinical Drug List

Blue Cross Blue Shield of Michigan’s Clinical Drug List is a useful reference and educational tool for prescribers, pharmacists and members.

We regularly update this list with medications approved by the U.S. Food and Drug Administration and reviewed by our Pharmacy and Therapeutics Committee. The list represents the clinical judgment of Michigan doctors, pharmacists and other experts in the diagnosis and treatment of disease and the promotion of health. The committee selects medications based on safety, clinical effectiveness and opportunity for cost savings. This is how the Clinical Drug List helps maintain quality of care and contain costs for our members.

About this drug list

Use this list to find information about drug coverage and therapeutic options for Blue Cross members. It’s divided by chapter into major drug classes or indication for use. Products approved for more than one use may be included in more than one chapter. Within each chapter, drugs are identified according to their tier placement. Refer to the “How to Read” section for details.

We encourage doctors to prescribe preferred medications whenever possible. Blue Cross respects the judgment of dispensing pharmacists and expects them to contact the prescriber when a drug or dose may not be appropriate for a member. We also encourage pharmacists to contact the prescriber to suggest an alternative when a Blue Cross member’s prescription is written for a nonpreferred or excluded drug.

Coverage and applicable copayments for drugs on the Blue Cross Clinical Drug List are based on a member’s drug plan. Not all drugs included in the drug list are covered by each member’s plan. Drugs not listed on the Clinical Drug List may not be covered.

Some medications excluded by a Blue Cross member’s pharmacy benefits may be covered under his or her medical benefits. These are medications that are generally administered in a doctor’s office under the supervision of appropriate health care personnel and aren’t normally dispensed to the member for self- administration.

Drug list exclusions

Our goals are to provide you with safe, high-quality prescription drug therapies and keep your medical costs low. To accomplish this, we don’t cover some high-cost drugs that have comparable therapeutic alternatives with similar effectiveness, quality and safety, but at a fraction of the cost. For the most recent list of excluded drugs, refer to our Drug List Exclusions (PDF). If you have a question about a drug that isn’t covered and doesn’t appear on this list, call the Customer Service number on the back of your Blue Cross member ID card.

Several drugs and drug categories are excluded from coverage under this drug list. These include:

• Prescription drugs for which there is an over-the-counter equivalent in both strength and dosage form (unless considered preventive by the United States Preventive Services Task Force) • Drugs used for experimental or investigational purposes • Drugs prescribed for cosmetic purposes

Page 6 • Products covered as a medical benefit (for example, injectable drugs and vaccines that are usually administered in a doctor’s office) o Note: Most Blue Cross members can get multiple common vaccines at network retail pharmacies. Restrictions may apply. • Compounded products, with some exceptions • Replacement prescriptions resulting from loss, theft or mishandling • Drugs not approved by the FDA

Specialty drugs

For more information on specialty drugs, see the Specialty Drug Program Pharmacy Benefit Member Guide. Specialty drugs are limited to a 30-day supply. Select specialty drugs are managed by the 15-Day Specialty Drug Limitation Program. Drugs included on this list are limited to a 15-day supply for all fills. Members pay half their usual copayment for a 15-day supply. For more details, visit bcbsm.com/pharmacy.

Preventive drug coverage

Under the Affordable Care Act, also known as national health care reform, most health care plans must cover certain preventive services and drugs with no cost-sharing. These drugs appear as a $0 tier on the drug list. For a complete list of preventive drugs and coverage requirements, please refer to Preventive Drug Coverage or visit bcbsm.com/pharmacy.

How do I know what type of prescription coverage I have?

For details about your prescription drug benefits, please call the Customer Service phone number on the back of your Blue Cross member ID card. If you have online access, log in to your account at bcbsm.com or the Blue Cross mobile app. You can also find general information about Blue Cross prescription coverage at bcbsm.com/pharmacy.

Tier descriptions

• Preferred generics Members pay the lowest copay for generics, making them the most cost-effective option for treatment. • Preferred brands This tier includes preferred brand-name specialty and nonspecialty drugs. • Nonpreferred brands This tier includes nonpreferred brand-name specialty and nonspecialty drugs for which there’s a more cost-effective generic alternative or preferred brand-name drug available.

How do I fill my prescription?

The type of drug you take determines which pharmacy you may use.

• Specialty drugs o Local retail pharmacy ▪ Walgreens is our preferred specialty pharmacy. Find a location at walgreens.com/pharmacy/*.

Page 7 ▪ You can use any retail pharmacy in your applicable network. o Limited-distribution specialty drugs ▪ Pharmacy options vary based on the drug. Refer to the Specialty Drug Program Pharmacy Benefit Member Guide, and search for the drug you take. o Mail order for home delivery ▪ AllianceRx Walgreens Prime** Specialty Pharmacy ▪ Website: alliancerxwp.com* ▪ Telephone: 1-866-515-1355 • All other drugs o Local retail pharmacy — More than 2,400 retail pharmacies in Michigan and 70,000 retail pharmacies outside of Michigan accept your member ID card. o Mail order for home delivery ▪ Pharmacy: Express Scripts*** mail order pharmacy ▪ Telephone: 1-800-778-0735

If you have questions about which mail-order vendor to use, call the Customer Service number on the back of your Blue Cross member ID card or visit bcbsm.com/pharmacy.

*Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website. **AllianceRx Walgreens Prime® is an independent company that provides specialty pharmacy benefit management services for Blue Cross. ***Express Scripts® is an independent company that provides pharmacy benefit management services for Blue Cross and BCN.

New generics

When a generic version of a brand-name drug becomes available, the generic version is generally added to Tier 1. The original branded version will move to a nonpreferred tier.

Generic drug substitution Generic drug substitution occurs when a pharmacist dispenses a generic equivalent in place of the brand-name product. Generics approved by the U.S. Food and Drug Administration are listed in the “Generic name” column to the right of the brand-name drug. Generic substitution is required for most Blue Cross members. If both the generic and brand names are listed, the tier number matches the available generic. The brand-name tier is always higher, reflecting the higher copayment when there’s an available generic. Members are encouraged to receive the generic equivalent if available.

Some Blue Cross members, depending on their plan, may be required to pay the difference between the cost of the brand-name drug and its generic equivalent, in addition to the applicable brand-name copay, if they opt to not fill their prescription with the generic equivalent.

Authorized generics

Authorized generics are drugs that are considered brand-name drugs and don’t have generic equivalents. These drugs are the same as the brand-name drugs but are not true generic drugs. The respective brand copayment will apply for these medications. Some authorized generics may not be covered. For the most recent list of excluded drugs, refer to our Drug List Exclusions (PDF).

Page 8 Vaccines

The following select vaccines are covered at pharmacies without cost-sharing for most members whose pharmacies participate with Blue Cross and are certified to administer vaccines.

Chickenpox Varivax® None

Flu Influenza virus vaccine (various) None

ActHIB® None

Haemophilus influenzae type B Hiberix® None

PedvaxHIB® None

Havrix® None Hepatitis A Vaqta® None

Hepatitis A and B Twinrix® None

Energix-B® None

Hepatitis B Recombivax HB® None

Heplisav-B® None

Human papillomavirus (or HPV) Gardasil® 9 9 to 45 years old

Measles, mumps and rubella M-M-R- II® None

Measles, mumps and rubella; ProQuad® None varicella

Bexsero® None

Menveo® None

Meningitis Menactra® None

Menomune® None

MenQuadi® None

Trumenba® None

Pneumovax® 23 None Pneumonia Prevnar 13® 65 and older

Page 9

Common name

Polio Ipol® None

Rotarix® None Rotavirus RotaTeq® None

Shingles Shingrix® 50 and older

Diphtheria-Tetanus Tox None

Tetanus, diphtheria Tenivac® None

TDVAX® None

Adacel ® None Tetanus, diphtheria and whooping cough Boostrix® None

Daptacel® None

Infanrix® None

Kinrix® None Tetanus, diphtheria and whooping cough; polio Quadracel® None

Tetanus, diphtheria and whooping ® Pediarix None cough; hepatitis B; polio Tetanus, diphtheria and whooping cough; haemophilus influenzae Pentacel® None type B; polio Tetanus, diphtheria, and whooping cough; haemophilus influenzae Vaxelis® None type B; hepatitis B; polio

How prior approval, step therapy and quantity limits work

Prior approval

Prior approval may be necessary for coverage of certain medications. In these cases, the member must meet clinical criteria or additional information must be provided before coverage is approved. Clinical criteria are based on current medical information and approved by our Pharmacy and Therapeutics Committee.

Step therapy

Page 10

Drugs subject to step therapy may require previous treatment with one or more preferred drugs before coverage is approved.

To view a current list of drugs requiring prior approval or step therapy, please see the Prior Authorization and Step Therapy Coverage Criteria and refer to the column labeled “Clinical Drug List.”

Page 11 Quantity limits

Blue Cross sets quantity limits based on clinical appropriateness and manufacturer-recommended dosing for select drugs. For certain medications, Blue Cross limits the quantity that can be dispensed per fill.

To view a current list of drugs that have limits on the quantity that can be dispensed per fill, please see the Blue Cross Quantity Limit Program, and refer to the column labeled “BCBSM Clinical, Custom, Closed Drug Lists.”

How to request approval

For members:

Blue Cross members should consult their prescription drug benefit packet for information on how to get prior approval or request a review for coverage of a drug that isn’t included in their plan. Members can also call the Customer Service number on the back of their Blue Cross member ID card for more information. To request coverage of a drug:

• Fill out the Coverage Request Form online at bcbsm.com. • Write to: Pharmacy Services — Mail Code 512C Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd. Detroit, MI 48226-2998

For doctors:

Doctors can request approval for Blue Cross and BCN members. We notify the doctor of approved requests and process the member’s claim accordingly. If a request isn’t approved, we’ll notify the member and doctor in writing. The notification includes the reason for the denial, an explanation of the member’s appeal rights and the appeals process.

Physicians can request approval one of four ways:

® • Electronic prior authorization: Physicians can use their electronic health record or CoverMyMeds to submit electronic prior authorizations for commercial pharmacy members. • Call: 1-800-437-3803 • Fax: 1-866-601-4425 • Write: Pharmacy Services — Mail Code 512c Blue Cross Blue Shield of Michigan 600 E Lafayette Blvd. Detroit, MI 48226-2998

Page 12 How to read the Clinical Drug List

This drug list shows each drug’s copayment status and whether the drug has special requirements for coverage.

Drugs are listed alphabetically by brand name within each section. If a generic version is available, the name is included in the “Generic name” column next to the brand name in the “Trade name” column. The brand name is included for informational purposes. If only a brand name is listed, there isn’t a generic version available.

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1 Drugs are organized based on drug class or the drug list to indicate different strengths, indication for use. formulations and dosage forms of the listed 2 The generic drug raloxifene HCl is a drug. preferred generic drug, and quantity limits 6 Soltamox is a nonpreferred brand-name drug apply. Raloxifene is also a preventive drug and may be covered with no cost-sharing for that doesn’t have any restrictions on members who meet criteria. coverage. 3 The generic drug fulvestrant is a preferred 7 Limits: This section lists information, such generic drug and doesn’t have any as prior approval, step therapy and quantity restrictions on coverage. limits. 4 Erleada is a preferred brand-name specialty Prior approval: Plan approval is required drug (). Prior approval and quantity limits for coverage (listed as PA in the chart). apply. Step therapy: Previous treatment with 5 Trelstar is a preferred brand-name specialty preferred drugs is required (listed as ST in drug () and doesn’t have any restrictions the chart). on coverage. The coverage requirements Quantity limits: Prescriptions can’t exceed are the same for Trelstar, Trelstar Depot and a specific quantity per fill (listed as QL in the Trelstar LA. Commas are used throughout chart).

Page 12

This document is current at the time of publication and subject to change. Go to bcbsm.com/pharmacy and click on Drug Lists for the most up-to-date information about the Clinical Drug List.

This content was developed to comply with applicable federal and state regulations. To learn more about your plan, go to bcbsm.com and type “How Health Insurance Works” in the search field.

Editor’s note: Please send us your comments and suggestions about the Blue Cross Clinical Drug List. Your input is vital to its continued success. We review and consider all responses. Please send your comments to:

Drug Information Services — Mail Code 512C Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd. Detroit, MI 48226-2998

Page 13

1. Anti-infectives

1A. Antifungals Trade name Generic name Limits Preferred Generics Ancobon flucytosine Diflucan fluconazole Grifulvin V griseofulvin, microsize Gris-PEG griseofulvin ultramicrosize Lamisil tablet terbinafine hcl Mycelex Troche clotrimazole Nizoral ketoconazole Noxafil tablet posaconazole QL Nystatin nystatin Sporanox itraconazole Vfend voriconazole Preferred Brands Cresemba capsule QL Noxafil suspension Nonpreferred Brands Oravig QL

1B. Antimalarials Trade name Generic name Limits Preferred Generics Aralen chloroquine phosphate Lariam mefloquine hcl Malarone atovaquone/proguanil hcl Plaquenil hydroxychloroquine sulfate Primaquine primaquine phosphate Qualaquin quinine sulfate Preferred Brands Coartem QL Krintafel QL Primaquine Nonpreferred Brands Arakoda QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 14 1C. Antiparasitics and antihelmintics Trade name Generic name Limits Preferred Generics Albenza albendazole QL Alinia nitazoxanide Biltricide praziquantel Daraprim pyrimethamine PA Flagyl metronidazole Humatin paromomycin sulfate Mepron atovaquone Nebupent aerosol pentamidine isethionate Stromectol ivermectin Tindamax tinidazole QL Preferred Brands Alinia suspension Benznidazole QL Impavido QL Nonpreferred Brands Emverm QL Lampit QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 15 1D. Antiretrovirals Trade name Generic name Limits Preventive Drugs Truvada 200mg/300mg emtricitabine/tenofovir (tdf) PA, QL Preferred Generics Atripla efavirenz/emtricit/tenofovr df Combivir lamivudine/zidovudine Emtriva emtricitabine Epivir lamivudine Epzicom abacavir sulfate/lamivudine Intelence etravirine Kaletra lopinavir/ritonavir Lexiva fosamprenavir calcium Norvir ritonavir Retrovir zidovudine Reyataz atazanavir sulfate Sustiva efavirenz Symfi, Lo efavirenz/lamivu/tenofov disop QL Truvada emtricitabine/tenofovir (tdf) QL Viramune, XR nevirapine Viread tenofovir disoproxil fumarate Ziagen abacavir sulfate Preferred Brands Aptivus Biktarvy QL Cimduo QL Complera QL Delstrigo QL Descovy ST, QL Dovato QL Edurant QL Emtriva solution Evotaz QL Fuzeon Genvoya QL Intelence 25mg Invirase Isentress Isentress HD Juluca QL Lexiva suspension Norvir solution, packet Odefsey QL Pifeltro QL Prezcobix QL Prezista Reyataz packet Rukobia PA, QL Selzentry Stribild QL Symtuza QL Temixys QL Tivicay Tivicay PD QL Triumeq QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 16 1D. Antiretrovirals (Continued) Trade name Generic name Limits Tybost QL Vemlidy QL Viread 150mg, 200mg, 250mg tablet; powder

1E. Antituberculars Trade name Generic name Limits Preferred Generics Ethambutol ethambutol hcl Isoniazid isoniazid Mycobutin rifabutin Pyrazinamide pyrazinamide Rifadin rifampin Preferred Brands Cycloserine Pretomanid QL Sirturo PA, QL Nonpreferred Brands Paser Priftin Trecator

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 17 1F. Antivirals Trade name Generic name Limits Preferred Generics Acyclovir acyclovir Baraclude entecavir Copegus ribavirin Epivir HBV lamivudine Famvir famciclovir Flumadine rimantadine hcl Hepsera adefovir dipivoxil Rebetol ribavirin Symmetrel amantadine hcl Tamiflu oseltamivir phosphate QL Valcyte valganciclovir hcl Valtrex valacyclovir hcl Zovirax capsule, suspension, tablet acyclovir Preferred Brands Baraclude solution Epclusa PA, QL Epivir HBV solution Ledipasvir-sofosbuvir 90mg/400mg tablet (authorized PA, QL generic of Harvoni) Relenza QL Sofosbuvir-velpatasvir (authorized generic of Epclusa) PA, QL Zepatier PA, QL Nonpreferred Brands Harvoni PA, QL Mavyret PA, QL Prevymis tablet QL Sitavig ST, QL Sovaldi PA, QL Vosevi PA, QL Xofluza QL

1G. Cephalosporins Trade name Generic name Limits Preferred Generics Ceclor, ER cefaclor Ceftin cefuroxime axetil Cefzil cefprozil Duricef cefadroxil Keflex cephalexin Omnicef cefdinir Spectracef cefditoren pivoxil QL Suprax cefixime Vantin cefpodoxime proxetil Nonpreferred Brands Suprax chew tablet, 500mg/5ml suspension

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 18 1H. Macrolides Trade name Generic name Limits Preferred Generics Biaxin, XL clarithromycin E.E.S.; Eryped erythromycin ethylsuccinate Ery-tab erythromycin base Erythromycin Base erythromycin base Erythromycin Stearate erythromycin stearate Zithromax azithromycin Nonpreferred Brands Dificid QL

1I. Penicillins Trade name Generic name Limits Preferred Generics Amoxil amoxicillin Ampicillin ampicillin trihydrate Augmentin, ES, XR amoxicillin/potassium clav Dicloxacillin dicloxacillin sodium Penicillin VK penicillin v potassium Preferred Brands Augmentin 125mg-31.25mg/ml suspension Nonpreferred Brands Moxatag

1J. Quinolones Trade name Generic name Limits Preferred Generics Avelox moxifloxacin hcl Cipro suspension ciprofloxacin Cipro tablet ciprofloxacin hcl Floxin tablet ofloxacin Levaquin levofloxacin Nonpreferred Brands Baxdela tablet Factive

1K. Sulfonamides and combinations Trade name Generic name Limits Preferred Generics Bactrim, DS; Septra, DS sulfamethoxazole/trimethoprim Sulfadiazine sulfadiazine

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 19 1L. Tetracyclines Trade name Generic name Limits Preferred Generics Adoxa capsule doxycycline monohydrate PA Adoxa tablet doxycycline monohydrate Avidoxy 100mg doxycycline monohydrate Declomycin demeclocycline hcl Doryx doxycycline hyclate PA Dynacin minocycline hcl Minocin minocycline hcl Monodox doxycycline monohydrate Periostat doxycycline hyclate Tetracycline tetracycline hcl Vibramycin doxycycline hyclate Vibramycin suspension doxycycline monohydrate Nonpreferred Brands Doryx MPC PA Doxycycline IR-DR (authorized generic of Oracea) PA Nuzyra tablet QL Oracea PA Vibramycin syrup

1M. Urinary tract agents Trade name Generic name Limits Preferred Generics Furadantin nitrofurantoin Hiprex/Urex methenamine hippurate Macrobid nitrofurantoin monohyd/m-cryst Macrodantin nitrofurantoin macrocrystal Monurol fosfomycin tromethamine Trimethoprim trimethoprim Nonpreferred Brands Primsol

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 20 1N. Miscellaneous anti-infectives Trade name Generic name Limits Preferred Generics Bethkis tobramycin PA, QL Cleocin capsule clindamycin hcl Cleocin solution clindamycin palmitate hcl Dapsone dapsone Firvanq vancomycin hcl QL Neomycin neomycin sulfate Peridex chlorhexidine gluconate Tobi tobramycin in 0.225% sod chlor QL Vancocin vancomycin hcl Zyvox linezolid Preferred Brands Arikayce PA, QL Sivextro QL Xifaxan 200mg QL Nonpreferred Brands Aemcolo QL Cayston PA, QL Firvanq 25mg/mL QL Tobi Podhaler PA, QL Xenleta tablet QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 21 2. Cardiovascular, hypertension, cholesterol

2A. ACE-Inhibitors and combinations Trade name Generic name Limits Preferred Generics Accupril quinapril hcl Accuretic quinapril/hydrochlorothiazide Aceon perindopril erbumine Altace ramipril Capoten captopril Capozide captopril/hydrochlorothiazide Lotensin benazepril hcl Lotensin HCT benazepril/hydrochlorothiazide Lotrel amlodipine besylate/benazepril Mavik trandolapril Monopril fosinopril sodium Monopril HCT fosinopril/hydrochlorothiazide Prinivil; Zestril lisinopril Prinzide; Zestoretic lisinopril/hydrochlorothiazide Tarka trandolapril/verapamil hcl Univasc moexipril hcl Vaseretic enalapril/hydrochlorothiazide Vasotec enalapril maleate Nonpreferred Brands Epaned Prestalia QL Qbrelis QL

2B. Alpha-adrenergic agents Trade name Generic name Limits Preferred Generics Aldomet methyldopa Aldoril methyldopa/hydrochlorothiazide Cardura doxazosin mesylate Catapres clonidine hcl Catapres-TTS clonidine Dibenzyline phenoxybenzamine hcl PA, QL Hytrin terazosin hcl Minipress prazosin hcl Tenex guanfacine hcl

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 22 2C. Angiotensin II Receptor Blockers and combinations Trade name Generic name Limits Preferred Generics Atacand candesartan cilexetil Atacand HCT candesartan/hydrochlorothiazid Avalide irbesartan/hydrochlorothiazide Avapro irbesartan Azor amlodipine bes/olmesartan med Benicar olmesartan medoxomil Benicar HCT olmesartan/hydrochlorothiazide Cozaar losartan potassium Diovan valsartan Diovan HCT valsartan/hydrochlorothiazide Exforge amlodipine besylate/valsartan Exforge HCT amlodipine/valsartan/hcthiazid Hyzaar losartan/hydrochlorothiazide Micardis telmisartan Micardis HCT telmisartan/hydrochlorothiazid Teveten eprosartan mesylate Tribenzor olmesartan/amlodipin/hcthiazid QL Twynsta telmisartan/amlodipine Preferred Brands Entresto QL Nonpreferred Brands Edarbi QL Edarbyclor QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 23 2D. Anticoagulants and hemostasis agents Trade name Generic name Limits Preferred Generics Aggrenox aspirin/dipyridamole Agrylin anagrelide hcl Amicar aminocaproic acid Arixtra fondaparinux sodium Coumadin warfarin sodium Effient prasugrel hcl QL Heparin heparin sodium,porcine/pf Heparin heparin sodium,porcine Lovenox enoxaparin sodium Mephyton phytonadione (vit k1) Persantine dipyridamole Plavix clopidogrel bisulfate Pletal cilostazol Trental pentoxifylline Vitamin K ampule phytonadione (vit k1) Preferred Brands Brilinta QL Cablivi PA, QL Eliquis QL Xarelto QL Nonpreferred Brands Fragmin Pradaxa QL Savaysa QL Zontivity QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 24 2E. Beta blockers and combinations Trade name Generic name Limits Preferred Generics Betapace, AF sotalol hcl Blocadren timolol maleate Coreg CR carvedilol phosphate QL Coreg immediate-release carvedilol Corgard nadolol Corzide nadolol/bendroflumethiazide Inderal, LA propranolol hcl Inderide propranolol/hydrochlorothiazid Kerlone betaxolol hcl Lopressor metoprolol tartrate Lopressor HCT metoprolol/hydrochlorothiazide Normodyne labetalol hcl Sectral acebutolol hcl Tenoretic atenolol/chlorthalidone Tenormin atenolol Toprol XL metoprolol succinate Visken pindolol Zebeta bisoprolol fumarate Ziac bisoprolol/hydrochlorothiazide Preferred Brands Bystolic ST, QL Nonpreferred Brands Dutoprol Hemangeol QL Sotylize

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 25 2F. Calcium channel blockers and combinations Trade name Generic name Limits Preferred Generics Adalat CC; Procardia, XL nifedipine Azor amlodipine bes/olmesartan med Caduet amlodipine/atorvastatin QL Calan SR; Isoptin SR verapamil hcl Cardene nicardipine hcl Cardizem, CD, LA, SR diltiazem hcl Dynacirc isradipine Exforge amlodipine besylate/valsartan Exforge HCT amlodipine/valsartan/hcthiazid Lotrel amlodipine besylate/benazepril Norvasc amlodipine besylate Plendil felodipine Sular nisoldipine Tarka trandolapril/verapamil hcl Tiazac diltiazem hcl Tribenzor olmesartan/amlodipin/hcthiazid QL Twynsta telmisartan/amlodipine Verelan, PM verapamil hcl Nonpreferred Brands Cardizem LA 120mg Katerzia QL Prestalia QL

2G. Cardiovascular treatment Trade name Generic name Limits Preferred Generics Betapace, AF sotalol hcl Cordarone; Pacerone amiodarone hcl Lanoxin digoxin Mexitil mexiletine hcl Norpace disopyramide phosphate Northera droxidopa PA, QL Proamatine midodrine hcl Quinidex quinidine sulfate Quinidine Gluconate SA quinidine gluconate Ranexa ranolazine Rythmol, SR propafenone hcl Tambocor flecainide acetate Tikosyn dofetilide Preferred Brands Corlanor QL Multaq QL Norpace CR Vyndamax PA, QL Vyndaqel PA, QL Nonpreferred Brands Lanoxin 62.5mcg, 187.5mcg Sotylize Verquvo PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 26 2H. Diuretics Trade name Generic name Limits Preferred Generics Aldactazide spironolact/hydrochlorothiazid Aldactone spironolactone Bumex bumetanide Demadex torsemide Diamox, Sequels acetazolamide Dyazide; Maxzide triamterene/hydrochlorothiazid Dyrenium triamterene Edecrin ethacrynic acid Hydrodiuril; Microzide hydrochlorothiazide Hygroton; Thalitone chlorthalidone Inspra eplerenone Lasix furosemide Lozol indapamide Midamor amiloride hcl Moduretic amiloride/hydrochlorothiazide Zaroxolyn metolazone Nonpreferred Brands Aldactazide 50/50mg Carospir Diuril suspension

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 27 2I. Lipid-lowering agents Trade name Generic name Limits Preventive Drugs Crestor* 5mg, 10mg rosuvastatin calcium QL Lescol, XL* (all strengths) fluvastatin sodium QL Lipitor* 10mg, 20mg atorvastatin calcium QL Mevacor* (all strengths) lovastatin QL Pravachol* (all strengths) pravastatin sodium QL Zocor* 5mg, 10mg, 20mg, 40mg simvastatin QL Preferred Generics Antara fenofibrate,micronized Caduet amlodipine/atorvastatin QL Colestid colestipol hcl Crestor rosuvastatin calcium QL Fenoglide fenofibrate Lescol, XL fluvastatin sodium QL Lipitor atorvastatin calcium QL Lofibra capsule fenofibrate,micronized Lofibra tablet fenofibrate Lopid gemfibrozil Lovaza omega-3 acid ethyl esters QL Mevacor lovastatin QL Niaspan niacin Pravachol pravastatin sodium QL Questran cholestyramine (with sugar) Questran Light cholestyramine/aspartame Tricor fenofibrate nanocrystallized Trilipix fenofibric acid (choline) Vascepa icosapent ethyl QL Vytorin ezetimibe/simvastatin QL Welchol colesevelam hcl Zetia ezetimibe QL Zocor simvastatin QL Preferred Brands Lipofen Nexletol PA, QL Nexlizet PA, QL Praluent PA, QL Repatha PA, QL Vascepa QL Nonpreferred Brands Antara 30mg, 90mg Colestid granules, packet Fenofibrate capsule (authorized generic of Lipofen) Juxtapid PA, QL Livalo QL *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 28 2J. Nitrates and combinations Trade name Generic name Limits Preferred Generics Imdur; Ismo; Monoket isosorbide mononitrate Isordil isosorbide dinitrate Nitro-bid ointment nitroglycerin Nitro-Dur nitroglycerin Nitroglycerin capsule, patch nitroglycerin Nitrostat nitroglycerin Preferred Brands Bidil Dilatrate-SR Nonpreferred Brands GoNitro Minitran

2K. Renin-inhibitors and combinations Trade name Generic name Limits Preferred Generics Tekturna aliskiren hemifumarate Nonpreferred Brands Tekturna HCT

2L. Miscellaneous antihypertensives Trade name Generic name Limits Preferred Generics Apresoline hydralazine hcl Demser metyrosine Loniten minoxidil Nonpreferred Brands Vecamyl PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 29 3. Central nervous system

3A. Alzheimer's therapy Trade name Generic name Limits Preferred Generics Aricept 23mg donepezil hcl QL Aricept 5, 10mg; ODT donepezil hcl Exelon capsule rivastigmine tartrate Exelon patch rivastigmine Namenda memantine hcl Namenda XR memantine hcl QL Razadyne, ER galantamine hbr Preferred Brands Memantine hcl (authorized generic of Namenda dose QL pack) Namenda dose pack QL Nonpreferred Brands Namenda XR dose pack QL Namzaric ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 30 3B. Anticonvulsants Trade name Generic name Limits Preferred Generics Banzel suspension rufinamide Banzel tablet rufinamide PA, QL Carbatrol carbamazepine Depakene capsule valproic acid Depakene solution valproic acid (as sodium salt) Depakote, ER, Sprinkles divalproex sodium Diamox, Sequels acetazolamide Diastat 2.5mg diazepam Diastat Acudial diazepam Dilantin phenytoin Dilantin; Phenytek capsule phenytoin sodium extended Felbatol felbamate Gabitril tiagabine hcl Keppra, XR levetiracetam Klonopin, Wafer clonazepam Lamictal ODT, XR lamotrigine Lamictal, dispertabs lamotrigine Lyrica pregabalin QL Lyrica CR pregabalin PA, QL Mysoline primidone Neurontin gabapentin Onfi clobazam QL Phenobarbital phenobarbital Qudexy XR topiramate PA, QL Sabril vigabatrin PA, QL Tegretol, XR carbamazepine Topamax, Sprinkle topiramate Trileptal oxcarbazepine Zarontin ethosuximide Zonegran zonisamide Preferred Brands Dilantin 30mg capsule Nayzilam QL Valtoco QL Vimpat solution Vimpat tablet PA, QL Nonpreferred Brands Acthar H.P. PA, QL Aptiom PA, QL Briviact PA, QL Celontin Diacomit PA, QL Elepsia XR PA, QL Epidiolex PA, QL Equetro Fintepla PA, QL Fycompa QL Lamictal XR dose pack Oxtellar XR PA, QL Spritam PA, QL Sympazan PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 31 3B. Anticonvulsants (Continued) Trade name Generic name Limits Trokendi XR PA, QL Xcopri PA, QL

3C. Antidepressants Trade name Generic name Limits Preferred Generics Adapin; Sinequan doxepin hcl Amoxapine amoxapine Anafranil clomipramine hcl Aventyl; Pamelor nortriptyline hcl Celexa citalopram hydrobromide Cymbalta duloxetine hcl Desyrel trazodone hcl Effexor, XR; Venlafaxine hcl ER venlafaxine hcl Elavil amitriptyline hcl Etrafon perphenazine/amitriptyline hcl Fluoxetine 60mg fluoxetine hcl Irenka duloxetine hcl Lexapro escitalopram oxalate Limbitrol, DS amitriptyline/chlordiazepoxide Luvox, CR fluvoxamine maleate Maprotiline hcl maprotiline hcl Nardil phenelzine sulfate Norpramin desipramine hcl Parnate tranylcypromine sulfate Paxil, CR paroxetine hcl Pristiq desvenlafaxine succinate QL Prozac fluoxetine hcl Remeron mirtazapine Serzone nefazodone hcl Surmontil trimipramine maleate Tofranil imipramine hcl Tofranil-PM imipramine pamoate Vivactil protriptyline hcl Wellbutrin, SR, XL bupropion hcl Zoloft sertraline hcl Nonpreferred Brands Desvenlafaxine ER ST, QL Emsam PA, QL Fetzima ST, QL Marplan Paxil suspension Pexeva ST, QL Trintellix ST, QL Viibryd ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 32 3D. Antipsychotics Trade name Generic name Limits Preferred Generics Abilify aripiprazole Clozaril clozapine Etrafon perphenazine/amitriptyline hcl Fazaclo clozapine Fluphenazine decanoate fluphenazine decanoate Fluphenazine liquid fluphenazine hcl Geodon ziprasidone hcl Haldol decanoate haloperidol decanoate Haldol liquid haloperidol lactate Haldol tablet haloperidol Invega paliperidone QL Loxitane loxapine succinate Mellaril thioridazine hcl Molindone molindone hcl QL Navane thiothixene Orap pimozide Perphenazine perphenazine Prolixin fluphenazine hcl Risperdal, M-Tab risperidone Saphris asenapine maleate QL Seroquel quetiapine fumarate Seroquel XR quetiapine fumarate QL Stelazine trifluoperazine hcl Symbyax olanzapine/fluoxetine hcl Thorazine chlorpromazine hcl Zyprexa, Zydis olanzapine Preferred Brands Abilify Maintena Aristada QL Aristada Initio Invega Sustenna Invega Trinza QL Perseris QL Risperdal Consta Zyprexa Relprevv Nonpreferred Brands Caplyta ST, QL Fanapt ST Latuda ST Nuplazid PA, QL Rexulti ST, QL Secuado ST, QL Versacloz Vraylar ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 33 3E. Anxiolytics Trade name Generic name Limits Preferred Generics Ativan lorazepam Buspar buspirone hcl Equanil; Miltown meprobamate Librium chlordiazepoxide hcl Lorazepam intensol lorazepam Niravam alprazolam Serax oxazepam Tranxene T-Tab clorazepate dipotassium Valium diazepam Xanax, XR alprazolam

3F. CNS stimulants Trade name Generic name Limits Preferred Generics Adderall, XR dextroamphetamine/amphetamine QL Aptensio XR methylphenidate hcl QL Concerta methylphenidate hcl QL Desoxyn methamphetamine hcl QL Dexedrine dextroamphetamine sulfate QL Evekeo amphetamine sulfate PA, QL Focalin, XR dexmethylphenidate hcl QL Metadate CD methylphenidate hcl QL Methylin, ER methylphenidate hcl QL Nuvigil armodafinil QL Procentra dextroamphetamine sulfate QL Provigil modafinil QL Ritalin, LA, SR methylphenidate hcl QL Preferred Brands Daytrana QL Mydayis QL Vyvanse QL Nonpreferred Brands Adzenys ER PA, QL Adzenys XR-ODT PA, QL Amphetamine ER suspension (authorized generic of PA, QL Adzenys ER) Azstarys PA, QL Dyanavel XR PA, QL Jornay PM PA, QL Methylphenidate ER 72mg QL Quillichew ER PA, QL Quillivant XR PA, QL Relexxii QL Zenzedi QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 34 3G. Migraine therapy Trade name Generic name Limits Preferred Generics Alsuma sumatriptan succinate QL Amerge naratriptan hcl QL Axert almotriptan malate ST, QL Cafergot ergotamine tartrate/caffeine QL D.H.E.45 dihydroergotamine mesylate QL Esgic; Fioricet butalb/acetaminophen/caffeine QL Fioricet w/codeine butalbit/acetamin/caff/codeine QL Fiorinal butalbital/aspirin/caffeine Fiorinal w/codeine codeine/butalbital/asa/caffein QL Frova frovatriptan succinate ST, QL Imitrex sumatriptan succinate QL Imitrex nasal spray sumatriptan QL Maxalt, MLT rizatriptan benzoate QL Migranal dihydroergotamine mesylate QL Phrenilin 50mg/325mg butalbital/acetaminophen Relpax eletriptan hydrobromide ST, QL Treximet sumatriptan succ/naproxen sod PA, QL Zomig, ZMT zolmitriptan QL Preferred Brands Aimovig PA, QL Ajovy PA, QL Emgality PA, QL Ergomar QL Nonpreferred Brands Nurtec ODT PA, QL Onzetra Xsail ST, QL Reyvow PA, QL Ubrelvy PA, QL Zembrace Symtouch ST, QL Zolmitriptan nasal spray (authorized generic of Zomig) ST, QL Zomig nasal spray ST, QL

3H. Myasthenia gravis Trade name Generic name Limits Preferred Generics Mestinon, Timespan pyridostigmine bromide

3I. Narcotic antagonists and withdrawal management Trade name Generic name Limits Preferred Generics Naloxone hcl injection naloxone hcl Revia naltrexone hcl Preferred Brands Kloxxado QL Lucemyra QL Narcan nasal spray QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 35 3J. Narcotic mixed agonist and antagonist Trade name Generic name Limits Preferred Generics Butrans buprenorphine QL Ryzolt tramadol hcl QL Stadol NS butorphanol tartrate QL Suboxone buprenorphine hcl/naloxone hcl QL Subutex buprenorphine hcl QL Talwin NX pentazocine hcl/naloxone hcl QL Ultracet tramadol hcl/acetaminophen QL Ultram, ER tramadol hcl QL Preferred Brands Zubsolv QL Nonpreferred Brands Belbuca PA, QL Bunavail QL Tramadol 100mg QL

3K. Narcotic and analgesic combinations Trade name Generic name Limits Preferred Generics Esgic; Fioricet butalb/acetaminophen/caffeine QL Fioricet w/codeine butalbit/acetamin/caff/codeine QL Fiorinal butalbital/aspirin/caffeine Fiorinal w/codeine codeine/butalbital/asa/caffein QL Hycet hydrocodone/acetaminophen QL Ibudone hydrocodone/ibuprofen QL Norco; Vicodin; Xodol hydrocodone/acetaminophen QL Percocet oxycodone hcl/acetaminophen QL Phrenilin 50mg/325mg butalbital/acetaminophen Trezix acetaminophen/caff/dihydrocod QL Tylenol w/codeine acetaminophen with codeine QL Vicoprofen hydrocodone/ibuprofen QL Nonpreferred Brands Lortab solution QL Trezix QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 36 3L. Narcotics Trade name Generic name Limits Preferred Generics Actiq fentanyl citrate PA, QL Avinza morphine sulfate QL Belladonna & Opium opium/belladonna alkaloids QL Codeine sulfate tablet codeine sulfate QL Demerol meperidine hcl QL Dilaudid hydromorphone hcl QL Duragesic fentanyl QL Exalgo hydromorphone hcl PA, QL Hysingla ER hydrocodone bitartrate PA, QL Kadian morphine sulfate QL Levorphanol Tartrate levorphanol tartrate PA, QL Methadone methadone hcl QL MS Contin morphine sulfate QL MSIR morphine sulfate QL Nubain nalbuphine hcl QL Opana oxymorphone hcl QL Opana ER oxymorphone hcl PA, QL Oxycodone immediate release, solution oxycodone hcl QL RMS Suppository morphine sulfate QL Roxanol morphine sulfate QL Zohydro ER hydrocodone bitartrate PA, QL Preferred Brands Nucynta PA, QL Oxycontin PA, QL Nonpreferred Brands Fentanyl buccal tablet (authorized generic of Fentora) PA, QL Fentora PA, QL Nucynta ER PA, QL Oxycodone hcl ER (authorized generic of Oxycontin) PA, QL Subsys PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 37 3M. Nonsteroidal anti-inflammatory drugs Trade name Generic name Limits Preferred Generics Anaprox, DS naproxen sodium Ansaid flurbiprofen Arthrotec diclofenac sodium/misoprostol Cataflam diclofenac potassium Celebrex celecoxib Clinoril sulindac Daypro oxaprozin EC-Naprosyn naproxen Feldene piroxicam Indocin, SR indomethacin Ketoprofen (except 25mg) ketoprofen Ketoprofen 25mg ketoprofen PA, QL Lodine, XL etodolac Meclomen meclofenamate sodium Mobic meloxicam Motrin (Rx Only) ibuprofen Nalfon fenoprofen calcium QL Naprosyn (Rx Only) naproxen Pennsaid 1.5% diclofenac sodium Ponstel mefenamic acid Relafen nabumetone Tolectin, DS tolmetin sodium Toradol injection ketorolac tromethamine Toradol tablet ketorolac tromethamine QL Vivlodex meloxicam, submicronized PA, QL Voltaren gel diclofenac sodium QL Voltaren, XR diclofenac sodium Nonpreferred Brands Diclofenac 35mg capsule (authorized generic of Zorvolex PA, QL 35mg) Diclofenac epolamine patch (authorized generic of PA, QL Flector patch) Fenoprofen calcium 200mg (authorized generic of PA, QL Fenortho 200mg) Fenoprofen calcium 400mg (authorized generic of Nalfon PA, QL 400mg) Fenortho PA, QL Flector Patch PA, QL Indocin suppository QL Indomethacin 20mg (authorized generic of Tivorbex ST, QL 20mg) Nalfon 400mg PA, QL Pennsaid 2% PA, QL Tivorbex ST, QL Zipsor PA, QL Zorvolex PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 38 3N. Parkinsons disease and related disorders Trade name Generic name Limits Preferred Generics Artane trihexyphenidyl hcl Azilect rasagiline mesylate Cogentin benztropine mesylate Comtan entacapone Eldepryl selegiline hcl Lodosyn carbidopa Mirapex ER pramipexole di-hcl QL Mirapex immediate-release pramipexole di-hcl Parcopa carbidopa/levodopa Parlodel bromocriptine mesylate Requip, XL ropinirole hcl Sinemet, CR carbidopa/levodopa Stalevo carbidopa/levodopa/entacapone Symmetrel amantadine hcl Tasmar tolcapone Preferred Brands Duopa PA, QL Kynmobi PA, QL Nonpreferred Brands Inbrija PA, QL Neupro PA, QL Nourianz PA, QL Nuplazid PA, QL Ongentys PA, QL Rytary ST, QL Xadago QL Zelapar QL

3O. Salicylates Trade name Generic name Limits Preventive Drugs Aspirin; Ecotrin 81mg, 325mg* (OTC) aspirin Preferred Generics Disalcid salsalate Dolobid diflunisal *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 39 3P. Sedative and hypnotics Trade name Generic name Limits Preferred Generics Ambien, CR zolpidem tartrate QL Dalmane flurazepam hcl QL Halcion triazolam QL Intermezzo zolpidem tartrate PA, QL Lunesta eszopiclone QL Prosom estazolam QL Restoril temazepam QL Rozerem ramelteon QL Seconal secobarbital sodium Silenor doxepin hcl ST, QL Sonata zaleplon QL Versed syrup midazolam hcl Nonpreferred Brands Belsomra ST, QL Dayvigo ST, QL Edluar ST, QL Hetlioz, LQ PA, QL

3Q. Skeletal muscle relaxants Trade name Generic name Limits Preferred Generics Baclofen baclofen Dantrium dantrolene sodium Fexmid cyclobenzaprine hcl Flexeril cyclobenzaprine hcl Norflex orphenadrine citrate Parafon Forte DSC 500mg chlorzoxazone Robaxin methocarbamol Skelaxin metaxalone Valium diazepam Zanaflex tizanidine hcl Nonpreferred Brands Ozobax PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 40 3R. Miscellaneous CNS Trade name Generic name Limits Preferred Generics Antabuse disulfiram Cafcit caffeine citrate Campral acamprosate calcium Ergoloid Mesylates ergoloid mesylates Eskalith, CR; Lithobid lithium carbonate Intuniv guanfacine hcl QL Kapvay clonidine hcl QL Nimotop nimodipine Rilutek riluzole Strattera atomoxetine hcl QL Xenazine tetrabenazine PA, QL Preferred Brands Austedo PA, QL Enspryng PA, QL Evrysdi PA, QL Nuedexta PA, QL Ruzurgi PA, QL Tegsedi PA, QL Nonpreferred Brands Cuvposa Exservan PA, QL Gralise PA, QL Horizant PA, QL Ingrezza PA, QL Nymalize QL Qelbree PA, QL Savella PA, QL Sunosi PA, QL Tiglutik PA, QL Wakix PA, QL Xyrem PA, QL Xywav PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 41 4. Gastrointestinal agents

4A. 5-Aminosalicylic Acid (5-ASA) agents Trade name Generic name Limits Preferred Generics Apriso mesalamine Asacol HD mesalamine Azulfidine, EN-tab sulfasalazine Canasa mesalamine Colazal balsalazide disodium Delzicol mesalamine Lialda mesalamine QL SfRowasa enema mesalamine Preferred Brands Pentasa Nonpreferred Brands Dipentum

4B. Antidiarrheals and antispasmodics Trade name Generic name Limits Preferred Generics Bentyl dicyclomine hcl Imodium loperamide hcl Levbid hyoscyamine sulfate Levsin, SL hyoscyamine sulfate Librax chlordiazepoxide/clidinium br Lomotil diphenoxylate hcl/atropine Preferred Brands Mytesi PA, QL Nonpreferred Brands Motofen

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 42 4C. Antiemetics Trade name Generic name Limits Preferred Generics Antivert meclizine hcl Compazine suppository prochlorperazine Compazine tablet prochlorperazine maleate Diclegis doxylamine succinate/vit b6 PA, QL Emend aprepitant QL Kytril granisetron hcl QL Marinol dronabinol Phenergan promethazine hcl Tigan trimethobenzamide hcl Transderm-Scop scopolamine Zofran solution ondansetron hcl Zofran tablet, ODT ondansetron hcl QL Preferred Brands Emend suspension QL Nonpreferred Brands Akynzeo PA, QL Bonjesta PA, QL Sancuso PA, QL Syndros Varubi tablet PA, QL

4D. Bile acids Trade name Generic name Limits Preferred Generics Actigall ursodiol Urso; Forte ursodiol Preferred Brands Ocaliva PA, QL Nonpreferred Brands Chenodal PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 43 4E. Bowel preparation and cleansing agents Trade name Generic name Limits Preventive Drugs Bisacodyl OTC* bisacodyl QL Citrate of Magnesia OTC* magnesium citrate QL Colyte* peg3350/sod sulf,bicarb,cl/kcl QL Glycolax OTC * polyethylene glycol 3350 QL Golytely* peg3350/sod sulf,bicarb,cl/kcl QL Milk of Magnesia OTC* magnesium hydroxide QL Moviprep* peg3350/sod sul/nacl/kcl/asb/c QL Nulytely* sodium chloride/nahco3/kcl/peg QL Oral Saline Laxative liquid OTC* sodium phosphate,mono-dibasic QL Peg-Prep* bisac/nacl/nahco3/kcl/peg 3350 QL Preferred Generics Colyte peg3350/sod sulf,bicarb,cl/kcl Golytely peg3350/sod sulf,bicarb,cl/kcl Moviprep peg3350/sod sul/nacl/kcl/asb/c Nulytely sodium chloride/nahco3/kcl/peg Peg-Prep bisac/nacl/nahco3/kcl/peg 3350 Preferred Brands Suprep Nonpreferred Brands Clenpiq Nulytely Osmoprep Plenvu Sutab QL *Age restrictions apply.

4F. Digestive enzymes Trade name Generic name Limits Preferred Brands Creon Viokace Zenpep Nonpreferred Brands Pancreaze Pertzye

4G. H2-Receptor antagonists Trade name Generic name Limits Preferred Generics Axid (Rx only) nizatidine Pepcid (Rx Only) famotidine Tagamet (Rx only) cimetidine Tagamet liquid (Rx only) cimetidine hcl

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 44 4H. Proton Pump Inhibitors (PPI) Trade name Generic name Limits Preferred Generics Aciphex tablet rabeprazole sodium Nexium esomeprazole magnesium Nexium suspension esomeprazole magnesium ST Prevacid capsule (Rx Only) lansoprazole Prevacid Solutab lansoprazole Prilosec capsule (Rx Only) omeprazole Protonix pantoprazole sodium Nonpreferred Brands Aciphex Sprinkle ST, QL Dexilant ST Nexium 2.5mg, 5mg suspension ST Prilosec suspension

4I. Topical anti-Inflammatory agents Trade name Generic name Limits Preferred Generics Analpram-HC hydrocortisone/pramoxine Anamantle HC, Forte; Kit lidocaine/hydrocortisone ac Cortenema hydrocortisone Hydrocortisone 1% cream (Rx only) hydrocortisone Pramosone hydrocortisone/pramoxine Proctocort suppository hydrocortisone acetate Procto-pak hydrocortisone Proctosol-HC suppository hydrocortisone acetate Preferred Brands Analpram-HC 1-1% cream Epifoam Pramosone lotion Proctofoam-HC Nonpreferred Brands Cortifoam Pramosone cream, ointment Uceris foam ST

4J. Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits Preferred Brands Humira PA, QL Nonpreferred Brands Simponi PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 45 4K. Ulcer therapy Trade name Generic name Limits Preferred Generics Carafate sucralfate Cytotec misoprostol Pamine, Forte methscopolamine bromide Prevpac lansoprazole/amoxiciln/clarith Robinul tablet, Forte glycopyrrolate Nonpreferred Brands Omeclamox-pak Talicia QL

4L. Miscellaneous gastrointestinal agents Trade name Generic name Limits Preferred Generics Evoxac cevimeline hcl Gastrocrom cromolyn sodium Lactulose lactulose Lotronex alosetron hcl QL Metozolv ODT metoclopramide hcl Reglan metoclopramide hcl Salagen pilocarpine hcl Preferred Brands Amitiza QL Gattex PA, QL Linzess QL Stelara 45mg, 90mg PA, QL Viberzi PA, QL Xeljanz, XR PA, QL Xifaxan 200mg QL Xifaxan 550mg PA, QL Nonpreferred Brands Motegrity PA, QL Movantik PA, QL Rectiv QL Relistor tablet PA, QL Sucraid PA, QL Symproic PA, QL Zelnorm PA, QL Zeposia PA, QL Zorbtive PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 46 5. Obstetrics and gynecology

5A. Contraceptives-Biphasic Trade name Generic name Limits Preventive Drugs Loseasonique l-norgest/e.estradiol-e.estrad QL Mircette desog-e.estradiol/e.estradiol Seasonique l-norgest/e.estradiol-e.estrad QL Preferred Brands Lo Loestrin Fe

5B. Contraceptives-Misc. Trade name Generic name Limits Preventive Drugs Depo-Provera 150mg medroxyprogesterone acetate FC2 Female Condom QL Gynol II nonoxynol 9 QL Nuvaring etonogestrel/ethinyl estradiol QL Ortho Evra norelgestromin/ethin.estradiol QL Ortho Micronor; Nor-QD norethindrone Quartette l-norgest/e.estradiol-e.estrad QL Safyral drospir/eth estra/levomefol ca Today contraceptive sponge QL VCF film, gel QL Preferred Generics Ortho Evra norelgestromin/ethin.estradiol QL Preferred Brands Depo-subq Provera 104 Natazia Nonpreferred Brands Slynd QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 47 5C. Contraceptives-Monophasic Trade name Generic name Limits Preventive Drugs Alesse; Levlite levonorgestrel/ethin.estradiol Beyaz drospir/eth estra/levomefol ca Demulen ethynodiol d-ethinyl estradiol Desogen; Ortho-cept desogestrel-ethinyl estradiol Femcon Fe noreth-ethinyl estradiol/iron Generess Fe noreth-ethinyl estradiol/iron Levlen; Nordette levonorgestrel/ethin.estradiol Lo/Ovral norgestrel-ethinyl estradiol Loestrin norethindrone ac-eth estradiol Loestrin 24 Fe norethindrone-e.estradiol-iron Loestrin Fe norethindrone-e.estradiol-iron Lybrel levonorgestrel/ethin.estradiol Minastrin 24 Fe norethindrone-e.estradiol-iron Modicon norethindrone-ethin. estradiol Norinyl 1/35; Ortho-novum 1/35 norethindrone-ethin. estradiol Nortrel norethindrone-ethin. estradiol Ortho-Cyclen norgestimate-ethinyl estradiol Ovcon 35 norethindrone-ethin. estradiol Seasonale levonorgestrel/ethin.estradiol QL Taytulla norethindrone-e.estradiol-iron Yasmin 28 ethinyl estradiol/drospirenone Yaz ethinyl estradiol/drospirenone Nonpreferred Brands Balcoltra Nextstellis Tyblume

5D. Contraceptives-Postcoital Trade name Generic name Limits Preventive Drugs Ella QL Plan B One-step levonorgestrel QL

5E. Contraceptives-Triphasic Trade name Generic name Limits Preventive Drugs Cyclessa desogestrel-ethinyl estradiol Estrostep Fe norethindrone-e.estradiol-iron Ortho Tri-Cyclen norgestimate-ethinyl estradiol Ortho Tri-Cyclen Lo norgestimate-ethinyl estradiol Ortho-Novum 7/7/7 norethindrone-ethin. estradiol Trilevlen levonorgestrel/ethin.estradiol Tri-Norinyl norethindrone-ethin. estradiol

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 48 5F. Estrogen and progestin combinations Trade name Generic name Limits Preferred Generics Activella estradiol/norethindrone acet FemHRT norethindrone ac-eth estradiol Preferred Brands Climara Pro Combipatch Prempro, Low Dose; Premphase Nonpreferred Brands Angeliq Bijuva QL Prefest

5G. Estrogens Trade name Generic name Limits Preferred Generics Climara estradiol Delestrogen estradiol valerate Estrace estradiol Minivelle, Vivelle-Dot estradiol Vagifem estradiol Preferred Brands Alora Estring Estrogel Premarin, cream, Low Dose Nonpreferred Brands Delestrogen 10mg/ml Depo-estradiol Divigel Elestrin Evamist Femring Imvexxy Menest Menostar

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 49 5H. Infertility treatment* Trade name Generic name Limits Preferred Generics Clomid clomiphene citrate Ganirelix Acetate ganirelix acetate Preferred Brands Cetrotide Crinone 8% Gonal-F, RFF, Redi-ject Menopur Ovidrel Pregnyl PA Nonpreferred Brands Chorionic Gonadotropin PA Endometrin PA Follistim AQ PA Novarel PA *Drugs used for the treatment of infertility may not be covered for select benefits.

5I. Progestins Trade name Generic name Limits Preferred Generics Aygestin norethindrone acetate Progesterone In Oil (inj) progesterone Prometrium progesterone, micronized Provera medroxyprogesterone acetate Preferred Brands Crinone 4% Depo-subq Provera 104

5J. Vaginal anti-infective and antifungal Trade name Generic name Limits Preferred Generics Cleocin vaginal cream clindamycin phosphate Diflucan fluconazole Metrogel-Vaginal metronidazole Monistat 3 miconazole nitrate Terazol- 3, 7 terconazole Preferred Brands Gynazole-1 Nonpreferred Brands Cleocin vaginal ovules Clindesse Nuvessa

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 50 5K. Miscellaneous OB-GYN Trade name Generic name Limits Preferred Generics Brisdelle paroxetine mesylate QL Covaryx, H.S. estrogen,ester/me-testosterone Diclegis doxylamine succinate/vit b6 PA, QL Lysteda tranexamic acid QL Methergine methylergonovine maleate PA, QL Preferred Brands Lupron Depot 3.75mg, 11.25mg Orilissa PA, QL Nonpreferred Brands Bonjesta PA, QL Duavee Intrarosa Lupaneta Pack Oriahnn PA, QL Osphena Synarel

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 51 6. Rheumatology and musculoskeletal

6A. Corticosteroids Trade name Generic name Limits

Corticosteroids See Chapter 7C

6B. Gout therapy Trade name Generic name Limits Preferred Generics Colbenemid probenecid/colchicine Colcrys colchicine Probenecid probenecid Uloric febuxostat ST, QL Zyloprim allopurinol Nonpreferred Brands Colchicine capsule (authorized generic of Mitigare) Mitigare

6C. Non-Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits Preferred Brands Actemra Actpen, syringe PA, QL Otezla PA, QL Rinvoq ER PA, QL Stelara 45mg, 90mg PA, QL Taltz PA, QL Xeljanz, XR PA, QL Nonpreferred Brands Kevzara PA, QL Kineret PA, QL Olumiant PA, QL Orencia Clickject, sub-q PA, QL

6D. Osteoporosis and bone resorption Trade name Generic name Limits Preferred Generics Actonel risedronate sodium QL Atelvia risedronate sodium ST, QL Boniva ibandronate sodium QL Didronel etidronate disodium Evista raloxifene hcl QL Fosamax alendronate sodium QL Miacalcin calcitonin,salmon,synthetic Nonpreferred Brands Binosto ST, QL Fosamax Plus D ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 52 6E. Osteoporosis and hormonal treatment Trade name Generic name Limits Preferred Generics Climara estradiol Estrace estradiol FemHRT norethindrone ac-eth estradiol Minivelle, Vivelle-Dot estradiol Preferred Brands Alora Forteo PA, QL Premarin, cream, Low Dose Prempro, Low Dose; Premphase Tymlos PA, QL Nonpreferred Brands Duavee Menest

6F. Salicylates Trade name Generic name Limits

Salicylates and NSAIDS See Chapters 3O & 3M

6G. Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits Preferred Brands Cimzia syringe PA, QL Enbrel PA, QL Humira PA, QL Nonpreferred Brands Simponi PA, QL

6H. Miscellaneous rheumatologic agents Trade name Generic name Limits Preferred Generics Arava leflunomide Azulfidine, EN-tab sulfasalazine Depen penicillamine QL Gengraf; Neoral cyclosporine, modified Imuran azathioprine Methotrexate methotrexate sodium Methotrexate PF injection methotrexate sodium/pf Plaquenil hydroxychloroquine sulfate Preferred Brands Ridaura Trexall Nonpreferred Brands Azasan Otrexup PA, QL Rasuvo PA, QL Reditrex PA, QL Xatmep

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 53 7. Endocrinology

7A. Androgens Trade name Generic name Limits Preferred Generics Androgel testosterone PA, QL Android, Testred methyltestosterone QL Axiron testosterone PA, QL Danocrine danazol Delatestryl testosterone enanthate Depo-Testosterone testosterone cypionate Fortesta testosterone PA, QL Oxandrin oxandrolone PA Testim testosterone PA, QL Testosterone 1% packet, pump testosterone PA, QL Preferred Brands Androderm PA, QL Nonpreferred Brands Depo-Testosterone Jatenzo PA, QL Methitest QL Natesto PA, QL Testosterone 1% (authorized generic of Vogelxo) PA, QL Vogelxo PA, QL Xyosted PA, QL

7B. Antithyroid agents Trade name Generic name Limits Preferred Generics Propylthiouracil propylthiouracil Strong Iodine potassium iodide/iodine Tapazole methimazole Nonpreferred Brands SSKI

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 54 7C. Corticosteroids Trade name Generic name Limits Preferred Generics Cortef; Hydrocortisone hydrocortisone Decadron dexamethasone Deltasone prednisone Dexpak dexamethasone Entocort EC budesonide Florinef fludrocortisone acetate Medrol methylprednisolone Millipred prednisolone sodium phosphate Orapred ODT prednisolone sodium phosphate Orapred solution prednisolone sodium phosphate Pediapred solution prednisolone sodium phosphate Prednisolone solution, tablet prednisolone Prednisone prednisone Uceris tablet budesonide QL Nonpreferred Brands Alkindi Sprinkle PA, QL Emflaza PA Medrol 2mg Rayos PA, QL Solu-cortef

7D. Growth Hormone and related products Trade name Generic name Limits Preferred Brands Genotropin PA Norditropin FlexPro PA Nutropin AQ Nuspin PA Nonpreferred Brands Humatrope PA Increlex PA Omnitrope PA Saizen, Saizenprep PA Serostim PA Zomacton PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 55 7E. Insulins Trade name Generic name Limits Preferred Brands Fiasp, Flextouch, Penfill Humulin R U-500 (all forms) Lantus, Solostar Levemir, Flextouch Novolin (NDCs ending in -00, -01, -11, -15) Novolog (NDCs ending in -111, -312, -512, -619, -910) Soliqua 100-33 QL Toujeo, Max Solostar Tresiba, Flextouch Xultophy 100-3.6 QL Nonpreferred Brands Afrezza PA Basaglar Kwikpen U-100 Insulin lispro junior (authorized generic of Humalog Junior Kwikpen)

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 56 7F. Non-insulin hypoglycemic agents Trade name Generic name Limits Preferred Generics Actoplus Met pioglitazone hcl/metformin hcl Actos pioglitazone hcl Amaryl glimepiride Diabeta; Micronase glyburide Duetact pioglitazone hcl/glimepiride Fortamet metformin hcl PA Glucophage, XR metformin hcl Glucotrol, XL glipizide Glucovance glyburide/metformin hcl Glynase glyburide,micronized Glyset miglitol Metaglip glipizide/metformin hcl PrandiMet repaglinide/metformin hcl Prandin repaglinide Precose acarbose Riomet metformin hcl Starlix nateglinide Preferred Brands Farxiga QL Glyxambi QL Invokamet, XR QL Invokana QL Janumet QL Janumet XR QL Januvia QL Jardiance QL Jentadueto, XR QL Ozempic QL Qtern QL Rybelsus QL Segluromet QL Steglatro QL Symlinpen Synjardy, XR QL Tradjenta QL Trijardy XR QL Trulicity QL Victoza QL Xigduo XR QL Nonpreferred Brands Cycloset PA, QL Riomet ER QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 57 7G. Somatostatin analogs Trade name Generic name Limits Preferred Generics Sandostatin octreotide acetate Preferred Brands Sandostatin LAR Depot PA Signifor PA, QL Somatuline Depot PA, QL Nonpreferred Brands Bynfezia PA, QL Mycapssa PA, QL Signifor LAR PA, QL

7H. Thyroid hormones Trade name Generic name Limits Preferred Generics Armour Thyroid thyroid,pork Cytomel liothyronine sodium NP Thyroid thyroid,pork Synthroid levothyroxine sodium Westhroid thyroid,pork Preferred Brands Thyrolar Nonpreferred Brands Armour Thyroid Levothyroxine sodium (authorized generic of Tirosint) Tirosint Tirosint-Sol

7I. Urea cycle disorder agents Trade name Generic name Limits Preferred Generics Buphenyl powder sodium phenylbutyrate Buphenyl tablet sodium phenylbutyrate QL Preferred Brands Carbaglu PA Nonpreferred Brands Ravicti PA, QL

7J. Vitamin D analogs Trade name Generic name Limits Preferred Generics Calciferol (Rx Only) ergocalciferol (vitamin d2) Hectorol doxercalciferol Rocaltrol calcitriol Zemplar paricalcitol Nonpreferred Brands Rayaldee QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 58 7K. Miscellaneous endocrine Trade name Generic name Limits Preferred Generics DDAVP desmopressin acetate DDAVP desmopressin (nonrefrigerated) Dostinex cabergoline Glucagon Emergency Kit glucagon,human recombinant Kuvan sapropterin dihydrochloride PA Miacalcin calcitonin,salmon,synthetic Proglycem diazoxide Sensipar cinacalcet hcl Zavesca miglustat PA, QL Preferred Brands Baqsimi QL Cerdelga PA, QL Cholbam PA, QL Dojolvi PA Galafold PA, QL GlucaGen HypoKit Glucagon Emergency Kit Gvoke QL Korlym PA, QL Lupron Depot-PED Natpara PA, QL Palynziq PA, QL Revcovi PA, QL Somavert PA Strensiq PA, QL Xermelo PA, QL Nonpreferred Brands DDAVP solution Egrifta SV PA, QL Isturisa PA, QL Myalept PA, QL Synarel Zegalogue QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 59 8. Antineoplastics and immunosuppresants

8A. Adjuvant therapy Trade name Generic name Limits Preferred Generics Leucovorin tablet leucovorin calcium Preferred Brands Fulphila QL Leukine Mesnex tablet Neulasta QL Nivestym QL Nyvepria QL Procrit Retacrit Udenyca QL Zarxio Ziextenzo QL Nonpreferred Brands Aranesp Epogen Granix Mircera QL Neupogen

8B. Alkylating agents Trade name Generic name Limits Preferred Generics Alkeran tablet melphalan Cyclophosphamide capsule cyclophosphamide Temodar temozolomide Preferred Brands Emcyt Gleostine; Lomustine Leukeran Matulane Myleran Nonpreferred Brands Cyclophosphamide tablet (authorized generic of Cytoxan)

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 60 8C. Antimetabolites Trade name Generic name Limits Preferred Generics Methotrexate methotrexate sodium Methotrexate PF injection methotrexate sodium/pf Purinethol mercaptopurine Xeloda capecitabine Preferred Brands Lonsurf PA, QL Onureg PA, QL Tabloid Trexall Nonpreferred Brands Purixan Xatmep

8D. Hormonal agents Trade name Generic name Limits Preventive Drugs Arimidex* anastrozole PA, QL Aromasin* exemestane PA, QL Evista * raloxifene hcl PA, QL Tamoxifen* tamoxifen citrate PA, QL Preferred Generics Arimidex anastrozole QL Aromasin exemestane QL Casodex bicalutamide Eulexin flutamide Evista raloxifene hcl QL Fareston toremifene citrate Faslodex fulvestrant Femara letrozole Lupron leuprolide acetate Megace, ES megestrol acetate Nilandron nilutamide PA, QL Tamoxifen tamoxifen citrate QL Zytiga 250mg abiraterone acetate QL Preferred Brands Erleada PA, QL Kisqali Femara co-pack PA, QL Lupron Depot Trelstar Xtandi PA, QL Zoladex QL Nonpreferred Brands Eligard Lupaneta Pack Orgovyx PA, QL Soltamox *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 61 8E. Immunomodulators Trade name Generic name Limits Preferred Generics Cellcept mycophenolate mofetil Gengraf; Neoral cyclosporine, modified Imuran azathioprine Myfortic mycophenolate sodium Prednisone prednisone Prograf tacrolimus Rapamune sirolimus Sandimmune capsule cyclosporine Preferred Brands Somatuline Depot PA, QL Thalomid Nonpreferred Brands Arcalyst PA, QL Astagraf XL Azasan Envarsus XR Kineret PA, QL Pomalyst PA, QL Prograf granules Revlimid QL Sandimmune solution

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 62 8F. Kinase inhibitors and molecular target inhibitors Trade name Generic name Limits Preferred Generics Afinitor everolimus PA, QL Gleevec imatinib mesylate Tarceva erlotinib hcl PA, QL Tykerb lapatinib ditosylate PA Zortress everolimus Preferred Brands Afinitor 10mg, Disperz PA, QL Alecensa PA, QL Alunbrig PA, QL Ayvakit PA, QL Balversa PA, QL Bosulif PA, QL Braftovi PA, QL Brukinsa PA, QL Cabometyx PA, QL Calquence PA, QL Caprelsa PA, QL Cometriq PA, QL Copiktra PA, QL Cotellic PA, QL Daurismo PA, QL Fotivda PA, QL Gavreto PA, QL Gilotrif PA, QL Ibrance PA, QL Iclusig PA, QL Idhifa PA, QL Imbruvica capsule; 280mg, 420mg, 560mg tablet PA, QL Inlyta PA, QL Inqovi PA, QL Iressa PA, QL Jakafi PA, QL Kisqali, Femara co-pack PA, QL Koselugo PA, QL Lenvima PA, QL Lorbrena PA, QL Lynparza PA, QL Mekinist PA, QL Mektovi PA, QL Nerlynx PA, QL Nexavar PA, QL Ninlaro PA, QL Nubeqa PA, QL Pemazyre PA, QL Piqray PA, QL Qinlock PA, QL Retevmo PA, QL Rozlytrek PA, QL Rubraca PA, QL Rydapt PA, QL Sprycel PA, QL Stivarga PA, QL Sutent PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 63 8F. Kinase inhibitors and molecular target inhibitors (Continued) Trade name Generic name Limits Tabrecta PA, QL Tafinlar PA, QL Tagrisso PA, QL Talzenna PA, QL Tasigna PA, QL Tazverik PA, QL Tepmetko PA, QL Tibsovo PA, QL Tukysa PA, QL Turalio PA, QL Ukoniq PA, QL Venclexta PA, QL Verzenio PA, QL Vitrakvi PA, QL Vizimpro PA, QL Votrient PA, QL Xalkori PA, QL Xospata PA, QL Zejula PA, QL Zelboraf PA, QL Zokinvy PA, QL Zydelig PA, QL Zykadia PA, QL Nonpreferred Brands Inrebic PA, QL Zortress 1mg

8G. Miscellaneous antineoplastic agents Trade name Generic name Limits Preferred Generics Hydrea hydroxyurea Sandostatin octreotide acetate Targretin capsule bexarotene PA, QL Vepesid etoposide Vesanoid tretinoin Preferred Brands Droxia Erivedge PA, QL Farydak PA, QL Hycamtin capsule Lysodren Odomzo PA, QL Sandostatin LAR Depot PA Synribo PA, QL Xpovio PA, QL Zolinza PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 64 9. Immunology and hematology

9A. Hematopoietic agents Trade name Generic name Limits Preferred Brands Doptelet PA, QL Fulphila QL Leukine Neulasta QL Nivestym QL Nyvepria QL Procrit Promacta PA Retacrit Udenyca QL Zarxio Ziextenzo QL Nonpreferred Brands Aranesp Epogen Granix Mircera QL Neupogen Tavalisse PA, QL

9B. Immunoglobulins Trade name Generic name Limits Nonpreferred Brands Cutaquig PA Cuvitru PA Gammagard liquid PA Gammaked PA Gamunex-C sub-q PA Hizentra PA HyQvia PA Xembify PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 65 9C. Interferons and MS therapy Trade name Generic name Limits Preferred Generics Ampyra dalfampridine QL Copaxone glatiramer acetate QL Glatopa glatiramer acetate QL Tecfidera dimethyl fumarate QL Preferred Brands Actimmune Alferon N Avonex QL Gilenya QL Intron A Kesimpta QL Mayzent QL Pegasys, Proclick QL Plegridy QL Rebif, Rebidose QL Nonpreferred Brands Aubagio QL Bafiertam QL Betaseron QL Extavia QL Mavenclad QL Vumerity QL Zeposia PA, QL

9D. Miscellaneous immunology and hematology Trade name Generic name Limits Preferred Generics Firazyr icatibant acetate PA, QL Preferred Brands Benlysta PA, QL Empaveli PA, QL Haegarda PA, QL Palforzia packet PA, QL Takhzyro PA, QL Nonpreferred Brands Orladeyo PA, QL Oxbryta PA, QL Ruconest PA, QL Siklos PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 66 10. Dermatology

10A. Acne treatment Trade name Generic name Limits Preferred Generics Absorica 10mg, 20mg, 30mg 40mg isotretinoin QL Acanya clindamycin phos/benzoyl perox Accutane; Amnesteem; Claravis; Myorisan; Zenatane isotretinoin QL Aczone 5% dapsone QL Adoxa capsule doxycycline monohydrate PA Adoxa tablet doxycycline monohydrate Atralin tretinoin Avar sulfacetamide sodium/sulfur Avar-E sulfacetamide sodium/sulfur Avidoxy 100mg doxycycline monohydrate Benzaclin clindamycin phos/benzoyl perox Benzamycin erythromycin/benzoyl peroxide Cleocin-T, swabs clindamycin phosphate Differin cream, gel adapalene Doryx doxycycline hyclate PA Duac clindamycin phos/benzoyl perox Dynacin minocycline hcl Epiduo adapalene/benzoyl peroxide Erythromycin topical gel, solution, swab erythromycin base in ethanol Klaron sulfacetamide sodium Minocin minocycline hcl Monodox doxycycline monohydrate Ovace sulfacetamide sodium Retin-A; Avita tretinoin Rosanil sulfacetamide sodium/sulfur Rosula Cleanser sulfacetamide sod/sulfur/urea Tazorac tazarotene Vibramycin doxycycline hyclate Vibramycin suspension doxycycline monohydrate Preferred Brands Tazorac 0.05%; 0.1% gel Nonpreferred Brands Adapalene 0.1% lotion (authorized generic of Differin) Altreno QL Amzeeq QL Avita gel Azelex Differin 0.1% lotion Doryx MPC PA Doxycycline IR-DR (authorized generic of Oracea) PA Epiduo Forte PA, QL Fabior ST, QL Noritate Oracea PA Tazarotene 0.1% foam (authorized generic of Fabior) ST, QL Tretin-X Vibramycin syrup Winlevi PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 67 10B. Antipsoriatic and antiseborrheic Trade name Generic name Limits Preferred Generics Avar sulfacetamide sodium/sulfur Avar-E sulfacetamide sodium/sulfur Dovonex calcipotriene Klaron sulfacetamide sodium Ovace sulfacetamide sodium Oxsoralen-Ultra methoxsalen Rosanil sulfacetamide sodium/sulfur Selsun (Rx Only) selenium sulfide Soriatane acitretin Taclonex calcipotriene/betamethasone PA Tazorac tazarotene Vectical calcitriol Preferred Brands Duobrii QL Enbrel PA, QL Humira PA, QL Otezla PA, QL Skyrizi PA, QL Stelara 45mg, 90mg PA, QL Taltz PA, QL Tremfya PA, QL Nonpreferred Brands Calcipotriene foam (authorized generic of Sorilux) Enstilar PA, QL Otrexup PA, QL Rasuvo PA, QL Reditrex PA, QL Siliq PA, QL Sorilux

10C. Corticosteroids - very high potency Trade name Generic name Limits Preferred Generics Clobevate; Temovate clobetasol propionate Clobex, spray clobetasol propionate Diprolene gel, ointment betamethasone dipropionate Olux clobetasol propionate Olux-E clobetasol propionate/emoll Temovate Emollient clobetasol propionate/emoll Ultravate cream, ointment halobetasol propionate Vanos fluocinonide QL Preferred Brands Cordran tape Duobrii QL Nonpreferred Brands Bryhali QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 68 10D. Corticosteroids - high potency Trade name Generic name Limits Preferred Generics Apexicon E diflorasone diacetate/emoll Aristocort; Kenalog 0.5% triamcinolone acetonide Cyclocort amcinonide Diprolene cream, lotion; AF betamethasone/propylene glyc Diprosone cream, ointment betamethasone dipropionate Elocon ointment mometasone furoate Florone; Psorcon diflorasone diacetate Halog halcinonide Lidex fluocinonide Lidex E fluocinonide/emollient base Luxiq betamethasone valerate Topicort 0.25%; 0.05% gel desoximetasone Valisone ointment betamethasone valerate Nonpreferred Brands Halog ointment, solution

10E. Corticosteroids - medium potency Trade name Generic name Limits Preferred Generics Cordran flurandrenolide Cutivate fluticasone propionate Dermatop prednicarbate Diprosone lotion betamethasone dipropionate Elocon cream, lotion, solution mometasone furoate Kenalog 0.025% ointment, 0.05%, 0.1% triamcinolone acetonide Kenalog Spray triamcinolone acetonide QL Locoid hydrocortisone butyrate Locoid Lipocream hydrocortisone butyrate/emoll Oralone paste triamcinolone acetonide Synalar 0.025% fluocinolone acetonide Topicort 0.05% cream, ointment desoximetasone Westcort hydrocortisone valerate Preferred Brands Clocortolone pivalate (authorized generic of Cloderm) Cloderm Nonpreferred Brands Locoid Lipocream

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 69 10F. Corticosteroids - low potency Trade name Generic name Limits Preferred Generics Aclovate alclometasone dipropionate Ala-Cort hydrocortisone Ala-scalp HP hydrocortisone Dermacort, Hytone 2.5% hydrocortisone Dermacort; Hytone 1% (Rx Only) hydrocortisone Derma-smoothe-FS fluocinolone/shower cap Derma-smoothe-FS fluocinolone acetonide Desonate desonide Desowen desonide Kenalog 0.025% cream, lotion triamcinolone acetonide Synalar 0.01% fluocinolone acetonide Valisone cream, lotion betamethasone valerate Preferred Brands Capex shampoo Nonpreferred Brands Neo-Synalar Texacort Verdeso

10G. Scabicides and pediculicides Trade name Generic name Limits Preferred Generics Crotan crotamiton Elimite permethrin Lindane lindane Natroba spinosad Ovide malathion Sklice ivermectin QL Preferred Brands Eurax Nonpreferred Brands Ulesfia

10H. Topical anesthetics Trade name Generic name Limits Preferred Generics Emla lidocaine/prilocaine Lidoderm patch lidocaine Xylocaine Viscous Solution (Rx Only) lidocaine hcl

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 70 10I. Topical antibacterials Trade name Generic name Limits Preferred Generics Bactroban ointment mupirocin Gentamicin cream, ointment gentamicin sulfate Nonpreferred Brands Neo-Synalar Xepi PA, QL

10J. Topical antifungals Trade name Generic name Limits Preferred Generics Extina ketoconazole Loprox cream, suspension ciclopirox olamine Loprox gel, shampoo ciclopirox Lotrimin clotrimazole Lotrisone clotrimazole/betamethasone dip Mycostatin nystatin Naftin naftifine hcl PA, QL Nizoral cream, shampoo 2% ketoconazole Nystatin w/Triamcinolone nystatin/triamcin Oxistat oxiconazole nitrate PA, QL Penlac ciclopirox Spectazole econazole nitrate Preferred Brands Mentax Nonpreferred Brands Ecoza PA, QL Ertaczo Exelderm Luliconazole 1% cream (authorized generic of Luzu) PA, QL Luzu PA, QL Miconazole-zinc oxide-petroltm (authorized generic of QL Vusion) Naftin 2% gel PA, QL Oxistat lotion PA, QL Sulconazole nitrate (authorized generic of Exelderm) Vusion QL Xolegel PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 71 10K. Topical antineoplastic agents and immunomodulators Trade name Generic name Limits Preferred Generics Aldara imiquimod QL Efudex fluorouracil Elidel pimecrolimus Protopic tacrolimus Zyclara imiquimod PA, QL Preferred Brands Panretin Tolak QL Nonpreferred Brands Fluoroplex Imiquimod 3.75% pump (authorized generic of Zyclara) PA, QL Klisyri PA, QL Picato PA, QL Targretin gel PA Valchlor PA, QL Veregen Zyclara 2.5%, 3.75% pump PA, QL

10L. Topical antivirals Trade name Generic name Limits Preferred Generics Zovirax ointment acyclovir

10M. Wound and burn therapy Trade name Generic name Limits Preferred Generics Silvadene silver sulfadiazine Sulfamylon mafenide acetate Preferred Brands Santyl Nonpreferred Brands Regranex QL Sulfamylon cream

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 72 10N. Miscellaneous dermatologicals Trade name Generic name Limits Preferred Generics Condylox solution podofilox Finacea gel azelaic acid Lac-Hydrin ammonium lactate Metrocream, gel, lotion metronidazole Prudoxin, Zonalon doxepin hcl PA, QL Solaraze diclofenac sodium PA, QL Soolantra ivermectin ST, QL Preferred Brands Condylox gel Drysol Qbrexza PA, QL Nonpreferred Brands Dupixent PA, QL Eucrisa PA, QL Finacea foam ST, QL Xolair syringe PA, QL Zonalon 30g PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 73 11. Ophthalmology

11A. Cycloplegic mydriatics Trade name Generic name Limits Preferred Generics Cyclogyl cyclopentolate hcl Isopto Atropine atropine sulfate Isopto Homatropine homatropine hbr Mydriacyl tropicamide Nonpreferred Brands Cyclogyl 5ml Cyclomydril Paremyd

11B. Glaucoma agents Trade name Generic name Limits Preferred Generics Alphagan 0.2%, P 0.15% brimonidine tartrate Azopt brinzolamide Cosopt dorzolamide hcl/timolol maleat Cosopt PF dorzolamide/timolol/pf Iopidine drops apraclonidine hcl Isopto-Carpine; Pilocar pilocarpine hcl Lumigan bimatoprost Neptazane methazolamide Travatan Z travoprost Trusopt dorzolamide hcl Xalatan latanoprost Preferred Brands Alphagan P 0.1% Combigan Lumigan 0.01% Rhopressa ST, QL Rocklatan ST, QL Nonpreferred Brands Iopidine dropperette Simbrinza Vyzulta PA Xelpros PA, QL Zioptan

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 74 11C. Ophthalmic anti-allergy agents Trade name Generic name Limits Preferred Generics Bepreve bepotastine besilate Elestat epinastine hcl Opticrom cromolyn sodium Optivar azelastine hcl Pataday olopatadine hcl Patanol olopatadine hcl Nonpreferred Brands Alocril Alomide Lastacaft

11D. Ophthalmic anti-infective and steroid combinations Trade name Generic name Limits Preferred Generics Cortisporin eye drops neomycin/polymyxin b/hydrocort Cortisporin eye ointment neomycin/bacit/p-myx/hydrocort Maxitrol neomycin/polymyxin b/dexametha Tobradex suspension tobramycin/dexamethasone Vasocidin sulfacetamide/prednisolone sp Preferred Brands Blephamide Tobradex ointment Tobradex ST Zylet Nonpreferred Brands Pred-G

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 75 11E. Ophthalmic anti-infectives Trade name Generic name Limits Preferred Generics Bacitracin bacitracin Bleph-10 ointment sulfacetamide sodium Bleph-10, Sodium Sulamyde drops sulfacetamide sodium Ciloxan drops ciprofloxacin hcl Garamycin gentamicin sulfate Ilotycin erythromycin base Moxeza moxifloxacin hcl Neosporin ophthalmic ointment neomycin sulf/bacitracin/poly Neosporin ophthalmic solution neomycin/polymyxn b/gramicidin Ocuflox ofloxacin Polysporin bacitracin/polymyxin b sulfate Polytrim polymyxin b sulf/trimethoprim Quixin levofloxacin Tobrex drops tobramycin Vigamox moxifloxacin hcl Viroptic trifluridine Zymaxid gatifloxacin Preferred Brands Besivance Ciloxan ointment Natacyn Zirgan Nonpreferred Brands Azasite Tobrex ointment

11F. Ophthalmic anti-inflammatory agents Trade name Generic name Limits Preferred Generics Acular, LS ketorolac tromethamine Bromday; Xibrom bromfenac sodium Ocufen flurbiprofen sodium Voltaren ophthalmic solution diclofenac sodium Nonpreferred Brands Acuvail Ilevro Nevanac Prolensa

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 76 11G. Ophthalmic beta blockers Trade name Generic name Limits Preferred Generics Betagan levobunolol hcl Betoptic solution betaxolol hcl Istalol timolol maleate Ocupress carteolol hcl Optipranolol metipranolol Timoptic Ocudose timolol maleate/pf Timoptic, XE timolol maleate Preferred Brands Betimol Betoptic S Nonpreferred Brands Timoptic Ocudose 0.25%

11H. Ophthalmic steroids Trade name Generic name Limits Preferred Generics Decadron ophthalmic dexamethasone sodium phosphate FML fluorometholone Inflamase, Forte prednisolone sodium phosphate Lotemax loteprednol etabonate Pred Forte prednisolone acetate Preferred Brands Alrex Durezol FML Forte, S.O.P. Pred Mild Nonpreferred Brands Flarex Inveltys PA, QL Lotemax ointment Lotemax SM PA, QL Maxidex

11I. Dry eye agents Trade name Generic name Limits Preferred Brands Lacrisert Restasis Xiidra QL Nonpreferred Brands Cequa QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 77 11J. Miscellaneous ophthalmic agents Trade name Generic name Limits Preferred Generics Neo-Synephrine phenylephrine hcl Preferred Brands Cystaran PA, QL Oxervate PA, QL Upneeq PA, QL Nonpreferred Brands Cystadrops PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 78 12. Otic and nasal preparations

12A. Nasal preparations Trade name Generic name Limits Preferred Generics Astelin nasal spray azelastine hcl QL Astepro nasal spray azelastine hcl QL Atrovent nasal spray ipratropium bromide QL Dymista azelastine/fluticasone PA, QL Flonase (Rx Only) fluticasone propionate QL Nasalide flunisolide QL Nasonex mometasone furoate ST, QL Patanase olopatadine hcl QL Preferred Brands Qnasl ST, QL Nonpreferred Brands Beconase AQ ST, QL Omnaris ST, QL Zetonna ST, QL

12B. Otic preparations Trade name Generic name Limits Preferred Generics Acetasol HC; Vosol HC hydrocortisone/acetic acid Auralgan aa/antipyrin/bcaine/polico1/al Ciprodex ciprofloxacin hcl/dexameth ciprofloxacin 0.2% dropperette ciprofloxacin hcl Cortisporin neomycin/polymyxin b/hydrocort Dermotic fluocinolone acetonide oil Floxin Otic ofloxacin Vosol acetic acid Preferred Brands Ciprofloxacin-fluocinolone vial (authorized generic of Otovel) Otovel Nonpreferred Brands Cipro HC Cortisporin-TC

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 79 13. Respiratory, cough and cold

13A. Antihistamine and decongestant combinations Trade name Generic name Limits

Antihistamine/Decongestant Combinations See Chapter 13B

13B. Antihistamines Trade name Generic name Limits Preferred Generics Astelin nasal spray azelastine hcl QL Astepro nasal spray azelastine hcl QL Atarax hydroxyzine hcl Benadryl (Rx Only) diphenhydramine hcl Clarinex desloratadine QL Histex PD carbinoxamine maleate Patanase olopatadine hcl QL Periactin cyproheptadine hcl Phenergan promethazine hcl Phenergan w/Codeine promethazine hcl/codeine Rynatan phenylephrine/chlor-tan Tavist tablet (Rx Only) clemastine fumarate Vistaril hydroxyzine pamoate Xyzal levocetirizine dihydrochloride QL Zyrtec solution (Rx Only) cetirizine hcl Preferred Brands Zyrtec-D Nonpreferred Brands Clarinex-D QL Karbinal ER ST, QL Zyrtec

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 80 13C. Antitussives Trade name Generic name Limits Preferred Generics Bromfed-DM brompheniramine/pseudoephed/dm CPB WC bromphenira/pseudoephed/codein Guaitussin AC codeine phosphate/guaifenesin Hycodan hydrocodone bit/homatrop me-br Phenergan DM promethazine/dextromethorphan Phenergan VC phenylephrine hcl/prometh hcl Phenergan VC w/Codeine promethazine/phenyleph/codeine Phenergan w/Codeine promethazine hcl/codeine Relcof C codeine phosphate/guaifenesin Robitussin AC codeine phosphate/guaifenesin Tessalon, Perles benzonatate Tussionex hydrocodone/chlorphen p-stirex Virtussin DAC pseudoephed/codeine/guaifen Zonatuss benzonatate Preferred Brands Tussicaps QL Nonpreferred Brands Cheratussin AC Coditussin AC Coditussin DAC Histex-AC M-End Pe Obredon QL Tuxarin ER Tuzistra XR QL

13D. Cystic Fibrosis agents Trade name Generic name Limits Preferred Generics Bethkis tobramycin PA, QL Tobi tobramycin in 0.225% sod chlor QL Preferred Brands Kalydeco PA, QL Orkambi PA, QL Pulmozyme PA Symdeko PA, QL Trikafta PA, QL Nonpreferred Brands Bronchitol PA, QL Cayston PA, QL Tobi Podhaler PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 81 13E. Epinephrine Trade name Generic name Limits Preferred Generics Epipen, Jr. epinephrine QL Preferred Brands Epinephrine auto-injector (authorized generic of QL Adrenaclick) Symjepi QL

13F. Inhaled anticholinergics Trade name Generic name Limits Preferred Generics Atrovent solution ipratropium bromide Preferred Brands Atrovent HFA QL Incruse Ellipta QL Spiriva, Respimat QL Nonpreferred Brands Lonhala Magnair QL Tudorza Pressair QL Yupelri QL

13G. Inhaled beta-agonist and anticholinergic combinations Trade name Generic name Limits Preferred Generics Duoneb ipratropium/albuterol sulfate Preferred Brands Anoro Ellipta QL Breztri Aerosphere QL Combivent Respimat QL Stiolto Respimat QL Trelegy Ellipta QL Nonpreferred Brands Bevespi Aerosphere QL

13H. Inhaled beta-agonists Trade name Generic name Limits Preferred Generics Albuterol nebulizer solution albuterol sulfate Brovana arformoterol tartrate QL Perforomist formoterol fumarate QL Proair HFA albuterol sulfate QL Proventil HFA albuterol sulfate QL Xopenex solution levalbuterol hcl Preferred Brands Serevent Diskus QL Striverdi Respimat QL Nonpreferred Brands Levalbuterol tartrate HFA (authorized generic of Xopenex QL HFA) Xopenex HFA QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 82 13I. Inhaled steroid and beta-agonist combinations Trade name Generic name Limits Preferred Generics Advair Diskus fluticasone propion/salmeterol QL Preferred Brands Advair HFA QL Breo Ellipta QL Breztri Aerosphere QL Dulera QL Symbicort QL Trelegy Ellipta QL Nonpreferred Brands Fluticasone-salmeterol RespiClick (authorized generic of QL Airduo Respiclick)

13J. Inhaled steroids Trade name Generic name Limits Preferred Generics Pulmicort solution budesonide Preferred Brands Arnuity Ellipta QL Asmanex, HFA QL Flovent HFA, Diskus QL Pulmicort Flexhaler QL Qvar RediHaler QL

13K. Intranasal steroids Trade name Generic name Limits

Intranasal Steroids See Chapter 12A

13L. Oral beta-agonists Trade name Generic name Limits Preferred Generics Alupent metaproterenol sulfate Brethine terbutaline sulfate Proventil solution albuterol sulfate Proventil/Ventolin tablet albuterol sulfate Vospire ER albuterol sulfate

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 83 13M. Pulmonary Hypertension Agents Trade name Generic name Limits Preferred Generics Adcirca tadalafil PA, QL Letairis ambrisentan PA, QL Revatio sildenafil citrate QL Revatio suspension sildenafil citrate PA, QL Tracleer bosentan PA, QL Preferred Brands Adempas PA, QL Opsumit PA, QL Orenitram ER PA, QL Tracleer tablet for suspension PA Tyvaso PA, QL Uptravi PA, QL Ventavis PA, QL

13N. Theophyllines Trade name Generic name Limits Preferred Generics Theophylline anhydrous theophylline anhydrous Preferred Brands Theo-24 Nonpreferred Brands Elixophyllin

13O. Miscellaneous respiratory agents Trade name Generic name Limits Preferred Generics Accolate zafirlukast QL Intal solution cromolyn sodium Mucomyst acetylcysteine Singulair montelukast sodium QL Sodium chloride inhalation sodium chloride for inhalation Zyflo CR zileuton QL Preferred Brands Actemra Actpen, syringe PA, QL Daliresp QL Esbriet PA, QL Fasenra Pen PA, QL Glassia PA, QL Ofev PA, QL Nonpreferred Brands Grastek PA, QL Hyper-Sal Nebusal Nucala auto-injector, syringe PA, QL Odactra PA, QL Oralair PA, QL Ragwitek PA, QL Xolair syringe PA, QL Zyflo QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 84 14. Urology

14A. BPH Treatment Trade name Generic name Limits Preferred Generics Avodart dutasteride Cardura doxazosin mesylate Cialis 2.5mg, 5mg tadalafil PA, QL Flomax tamsulosin hcl Hytrin terazosin hcl Jalyn dutasteride/tamsulosin hcl QL Proscar finasteride Rapaflo silodosin QL Uroxatral alfuzosin hcl Nonpreferred Brands Cardura XL

14B. Ion-Removing Agents Trade name Generic name Limits Preferred Generics Fosrenol lanthanum carbonate Kayexalate sodium polystyrene sulfonate Phoslo calcium acetate Renagel sevelamer hcl Renvela sevelamer carbonate SPS sodium polystyrene sulfonate SPS (sorbitol free) sodium polystyrene sulfon/sorb Preferred Brands Lokelma QL Veltassa QL Nonpreferred Brands Auryxia Fosrenol packet Phoslyra Velphoro

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 85 14C. Urinary Antispasmodics Trade name Generic name Limits Preferred Generics Detrol, LA tolterodine tartrate Ditropan, XL oxybutynin chloride Enablex darifenacin hydrobromide QL Levbid hyoscyamine sulfate Levsin, SL hyoscyamine sulfate Sanctura, XR trospium chloride QL Urispas flavoxate hcl Vesicare solifenacin succinate ST, QL Preferred Brands Toviaz ST, QL Nonpreferred Brands Gelnique ST, QL Myrbetriq PA, QL Vesicare LS PA, QL

14D. Miscellaneous Urologicals Trade name Generic name Limits Preferred Generics Depen penicillamine QL Thiola tiopronin PA, QL Urecholine bethanechol chloride Urocit-K potassium citrate Preferred Brands Cystagon Elmiron Renacidin Thiola EC PA, QL Xuriden PA, QL Nonpreferred Brands Lithostat Lupkynis PA, QL Nocdurna PA, QL Noctiva PA, QL Procysbi 25mg capsule, packet PA, QL Procysbi 75mg capsule PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 86 15. Vitamins and supplements

15A. Potassium Replacement Trade name Generic name Limits Preferred Generics K-Lor; Klor-Con packet potassium chloride Klor-Con M15 potassium chloride K-Lyte; Klor-con/EF potassium bicarbonate/cit ac K-Sol; Potassium Chloride potassium chloride K-Tab; K-Dur; Slow-K; Kaon CL; Klor-con potassium chloride Micro-K potassium chloride Preferred Brands Effer-K K-Tab 10meq Nonpreferred Brands K-Phos No.2 K-Phos Original

15B. Vitamins and Minerals Trade name Generic name Limits Preventive Drugs Folic Acid 0.4mg, 0.8mg (OTC) folic acid Sodium Fluoride 0.25mg, 0.5mg, 1mg* fluoride (sodium) Preferred Generics Calciferol (Rx Only) ergocalciferol (vitamin d2) Complete Natal DHA pnv combo 52/iron/fa/omega-3/dha Cyanocobalamin injection cyanocobalamin (vitamin b-12) Folic Acid 1mg (Rx only) folic acid Hydroxocobalamin hydroxocobalamin Mephyton phytonadione (vit k1) M-Natal Plus pnv,calcium 72/iron/folic acid PNV 29-1 prenatal vit,calc76/iron/folic Prenatabs FA prenatal vit,calc78/iron/folic Prenatabs Rx prenatal vit,calc76/iron/folic Prenatal Plus pnv,calcium 72/iron/folic acid Prenatal vitamin plus low iron pnv,calcium 72/iron/folic acid PrePLUS pnv,calcium 72/iron/folic acid PreTAB prenatal vit,calc78/iron/folic Prevident fluoride (sodium) Sodium Fluoride 0.25mg, 0.5mg, 1mg fluoride (sodium) Trinatal Rx 1 prenatal vit27,calcium/iron/fa Vitamin K ampule phytonadione (vit k1) Nonpreferred Brands Accrufer PA, QL Clinpro 5000 Fluoridex Galzin Prenata Prenatal Plus-DHA Prevident, 5000 Thrivite Rx *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 87 16. Diagnostic and other miscellaneous

16A. Chelating Agents Trade name Generic name Limits Preferred Generics Depen penicillamine QL Desferal deferoxamine mesylate Exjade deferasirox PA, QL Ferriprox deferiprone PA, QL Jadenu deferasirox PA, QL Syprine trientine hcl PA, QL Preferred Brands Chemet Nonpreferred Brands Ferriprox 1000mg tablet, solution PA, QL

16B. Diabetes monitoring and management products Trade name Generic name Limits Preventive Drugs Contour Meter QL Contour Next EZ Meter QL Contour Next Meter QL Contour Next One Meter QL Dexcom G6 Receiver QL Dexcom G6 Transmitter QL One Touch Ultra 2 Meter QL One Touch Ultra 2 Meter with Delica Plus QL One Touch Verio Flex Meter QL One Touch Verio Flex Meter with Delica Plus QL One Touch Verio Reflect Meter QL Preferred Brands Contour Next Test Strips QL Contour Test Strips QL Dexcom G6 Sensor 3-Pack QL Freestyle Libre 2 Reader 14-Day QL Freestyle Libre 2 Sensor 14-Day QL Freestyle Libre Reader 14-Day QL Freestyle Libre Sensor 14-Day QL Freestyle Test Strips QL OmniPod DASH Pods QL One Touch Delica Plus Lancets, 30 & 33G QL One Touch Ultra Soft Lancets QL One Touch Ultra Test Strips QL One Touch Verio Test Strips QL Simplicity 2 Unit QL Simplicity Inserter QL VGo 20 QL VGo 30 QL VGo 40 QL *Coverage of diabetic test strips depends on your plan

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 88 16C. Vaccines Trade name Generic name Limits Preventive Drugs ActHIB QL Adacel QL Afluria QL Bexsero QL Boostrix QL Daptacel QL Diphtheria-Tetanus Tox QL Engerix-B QL Fluad QL Fluarix QL Flublok QL Flucelvax QL Flulaval QL Flumist QL Fluzone QL Gardasil 9* QL Havrix QL Heplisav-B QL Hiberix QL Infanrix QL Ipol QL Janssen Covid-19 vaccine Kinrix QL Menactra QL MenQuadfi QL Menveo QL M-M-R II QL Moderna Covid-19 vaccine Pediarix QL PedvaxHIB QL Pentacel QL Pfizer Covid-19 vaccine Pneumovax 23 QL Prevnar 13* QL ProQuad QL Quadracel DTAP-IPV QL Recombivax HB QL Rotarix QL RotaTeq QL Shingrix* QL TDVAX QL Tenivac QL Trumenba QL Twinrix QL Vaqta QL Varivax QL Vaxelis QL *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 89 16D. Diagnostics and Other Miscellaneous Trade name Generic name Limits Preferred Generics Acetic Acid acetic acid Carnitor levocarnitine Carnitor SF levocarnitine Carnitor solution levocarnitine (with sugar) Orfadin nitisinone PA Samsca tolvaptan PA, QL Preferred Brands Jynarque PA, QL Orfadin 20mg capsule, suspension PA Radiogardase Samsca 15mg PA, QL Tolvaptan 15mg (authorized generic of Samsca) PA, QL Vistogard QL Nonpreferred Brands Cystadane Endari PA, QL Keveyis PA, QL Nityr PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 90 17. Lifestyle modification

17A. Sexual Dysfunction Trade name Generic name Limits Preferred Generics Cialis tadalafil PA, QL Levitra vardenafil hcl PA, QL Staxyn vardenafil hcl PA, QL Viagra sildenafil citrate PA, QL Preferred Brands Caverject PA, QL Muse PA, QL Nonpreferred Brands Addyi PA, QL Edex PA, QL Stendra PA, QL Vyleesi PA, QL

17B. Smoking Cessation Trade name Generic name Limits Preventive Drugs Chantix* ST, QL Commit Lozenge OTC* nicotine polacrilex QL Nicorette lozenge* nicotine polacrilex QL Nicotine gum; Nicorette* nicotine polacrilex QL Nicotine patch* nicotine QL Nicotrol, NS* ST, QL Zyban* bupropion hcl QL Preferred Brands Chantix QL Nonpreferred Brands Nicotrol, NS ST, QL *Age restrictions apply.

17C. Weight Loss Preparations Trade name Generic name Limits Preferred Generics Adipex-P phentermine hcl Bontril phendimetrazine tartrate Didrex benzphetamine hcl Tenuate diethylpropion hcl Preferred Brands Imcivree PA, QL Nonpreferred Brands Contrave PA, QL Lomaira Qsymia PA, QL Saxenda PA, QL Xenical PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 91 18. Hemophilia

18A. Antihemophilic Agents Trade name Generic name Limits Preferred Brands Advate Adynovate Afstyla Alphanate Alphanine SD Alprolix Benefix Coagadex Corifact Eloctate Esperoct Feiba NF Hemlibra PA Hemofil M Humate-P Idelvion Ixinity Jivi Koate Kogenate FS Kovaltry Mononine Novoeight NovoSeven RT Nuwiq Obizur Profilnine Rebinyn Recombinate Rixubis Sevenfact Tretten Vonvendi Wilate Xyntha Xyntha Solofuse

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 92 1. Anti-infectives

1A. Antifungals Trade name Generic name Limits Preferred Generics Ancobon flucytosine Diflucan fluconazole Grifulvin V griseofulvin, microsize Gris-PEG griseofulvin ultramicrosize Lamisil tablet terbinafine hcl Mycelex Troche clotrimazole Nizoral ketoconazole Noxafil tablet posaconazole QL Nystatin nystatin Sporanox itraconazole Vfend voriconazole Preferred Brands Cresemba capsule QL Noxafil suspension Nonpreferred Brands Oravig QL

1B. Antimalarials Trade name Generic name Limits Preferred Generics Aralen chloroquine phosphate Lariam mefloquine hcl Malarone atovaquone/proguanil hcl Plaquenil hydroxychloroquine sulfate Primaquine primaquine phosphate Qualaquin quinine sulfate Preferred Brands Coartem QL Krintafel QL Primaquine Nonpreferred Brands Arakoda QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 14 1C. Antiparasitics and antihelmintics Trade name Generic name Limits Preferred Generics Albenza albendazole QL Alinia nitazoxanide Biltricide praziquantel Daraprim pyrimethamine PA Flagyl metronidazole Humatin paromomycin sulfate Mepron atovaquone Nebupent aerosol pentamidine isethionate Stromectol ivermectin Tindamax tinidazole QL Preferred Brands Alinia suspension Benznidazole QL Impavido QL Nonpreferred Brands Emverm QL Lampit QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 15 1D. Antiretrovirals Trade name Generic name Limits Preventive Drugs Truvada 200mg/300mg emtricitabine/tenofovir (tdf) PA, QL Preferred Generics Atripla efavirenz/emtricit/tenofovr df Combivir lamivudine/zidovudine Emtriva emtricitabine Epivir lamivudine Epzicom abacavir sulfate/lamivudine Intelence etravirine Kaletra lopinavir/ritonavir Lexiva fosamprenavir calcium Norvir ritonavir Retrovir zidovudine Reyataz atazanavir sulfate Sustiva efavirenz Symfi, Lo efavirenz/lamivu/tenofov disop QL Truvada emtricitabine/tenofovir (tdf) QL Viramune, XR nevirapine Viread tenofovir disoproxil fumarate Ziagen abacavir sulfate Preferred Brands Aptivus Biktarvy QL Cimduo QL Complera QL Delstrigo QL Descovy ST, QL Dovato QL Edurant QL Emtriva solution Evotaz QL Fuzeon Genvoya QL Intelence 25mg Invirase Isentress Isentress HD Juluca QL Lexiva suspension Norvir solution, packet Odefsey QL Pifeltro QL Prezcobix QL Prezista Reyataz packet Rukobia PA, QL Selzentry Stribild QL Symtuza QL Temixys QL Tivicay Tivicay PD QL Triumeq QL Tybost QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 16 1D. Antiretrovirals (Continued) Trade name Generic name Limits Vemlidy QL Viread 150mg, 200mg, 250mg tablet; powder

1E. Antituberculars Trade name Generic name Limits Preferred Generics Ethambutol ethambutol hcl Isoniazid isoniazid Mycobutin rifabutin Pyrazinamide pyrazinamide Rifadin rifampin Preferred Brands Cycloserine Pretomanid QL Sirturo PA, QL Nonpreferred Brands Paser Priftin Trecator

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 17 1F. Antivirals Trade name Generic name Limits Preferred Generics Acyclovir acyclovir Baraclude entecavir Copegus ribavirin Epivir HBV lamivudine Famvir famciclovir Flumadine rimantadine hcl Hepsera adefovir dipivoxil Rebetol ribavirin Symmetrel amantadine hcl Tamiflu oseltamivir phosphate QL Valcyte valganciclovir hcl Valtrex valacyclovir hcl Zovirax capsule, suspension, tablet acyclovir Preferred Brands Baraclude solution Epclusa PA, QL Epivir HBV solution Ledipasvir-sofosbuvir 90mg/400mg tablet (authorized PA, QL generic of Harvoni) Relenza QL Sofosbuvir-velpatasvir (authorized generic of Epclusa) PA, QL Zepatier PA, QL Nonpreferred Brands Harvoni PA, QL Mavyret PA, QL Prevymis tablet QL Sitavig ST, QL Sovaldi PA, QL Vosevi PA, QL Xofluza QL

1G. Cephalosporins Trade name Generic name Limits Preferred Generics Ceclor, ER cefaclor Ceftin cefuroxime axetil Cefzil cefprozil Duricef cefadroxil Keflex cephalexin Omnicef cefdinir Spectracef cefditoren pivoxil QL Suprax cefixime Vantin cefpodoxime proxetil Nonpreferred Brands Suprax chew tablet, 500mg/5ml suspension

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 18 1H. Macrolides Trade name Generic name Limits Preferred Generics Biaxin, XL clarithromycin E.E.S.; Eryped erythromycin ethylsuccinate Ery-tab erythromycin base Erythromycin Base erythromycin base Erythromycin Stearate erythromycin stearate Zithromax azithromycin Nonpreferred Brands Dificid QL

1I. Penicillins Trade name Generic name Limits Preferred Generics Amoxil amoxicillin Ampicillin ampicillin trihydrate Augmentin, ES, XR amoxicillin/potassium clav Dicloxacillin dicloxacillin sodium Penicillin VK penicillin v potassium Preferred Brands Augmentin 125mg-31.25mg/ml suspension Nonpreferred Brands Moxatag

1J. Quinolones Trade name Generic name Limits Preferred Generics Avelox moxifloxacin hcl Cipro suspension ciprofloxacin Cipro tablet ciprofloxacin hcl Floxin tablet ofloxacin Levaquin levofloxacin Nonpreferred Brands Baxdela tablet Factive

1K. Sulfonamides and combinations Trade name Generic name Limits Preferred Generics Bactrim, DS; Septra, DS sulfamethoxazole/trimethoprim Sulfadiazine sulfadiazine

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 19 1L. Tetracyclines Trade name Generic name Limits Preferred Generics Adoxa capsule doxycycline monohydrate PA Adoxa tablet doxycycline monohydrate Avidoxy 100mg doxycycline monohydrate Declomycin demeclocycline hcl Doryx doxycycline hyclate PA Dynacin minocycline hcl Minocin minocycline hcl Monodox doxycycline monohydrate Periostat doxycycline hyclate Tetracycline tetracycline hcl Vibramycin doxycycline hyclate Vibramycin suspension doxycycline monohydrate Nonpreferred Brands Doryx MPC PA Doxycycline IR-DR (authorized generic of Oracea) PA Nuzyra tablet QL Oracea PA Vibramycin syrup

1M. Urinary tract agents Trade name Generic name Limits Preferred Generics Furadantin nitrofurantoin Hiprex/Urex methenamine hippurate Macrobid nitrofurantoin monohyd/m-cryst Macrodantin nitrofurantoin macrocrystal Monurol fosfomycin tromethamine Trimethoprim trimethoprim Nonpreferred Brands Primsol

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 20 1N. Miscellaneous anti -infectives Trade name Generic name Limits Preferred Generics Bethkis tobramycin PA, QL Cleocin capsule clindamycin hcl Cleocin solution clindamycin palmitate hcl Dapsone dapsone Firvanq vancomycin hcl QL Neomycin neomycin sulfate Peridex chlorhexidine gluconate Tobi tobramycin in 0.225% sod chlor QL Vancocin vancomycin hcl Zyvox linezolid Preferred Brands Arikayce PA, QL Sivextro QL Xifaxan 200mg QL Nonpreferred Brands Aemcolo QL Cayston PA, QL Firvanq 25mg/mL QL Tobi Podhaler PA, QL Xenleta tablet QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 21 2. Cardiovascular, hypertension, cholesterol

2A. ACE -Inhibitors and combinations Trade name Generic name Limits Preferred Generics Accupril quinapril hcl Accuretic quinapril/hydrochlorothiazide Aceon perindopril erbumine Altace ramipril Capoten captopril Capozide captopril/hydrochlorothiazide Lotensin benazepril hcl Lotensin HCT benazepril/hydrochlorothiazide Lotrel amlodipine besylate/benazepril Mavik trandolapril Monopril fosinopril sodium Monopril HCT fosinopril/hydrochlorothiazide Prinivil; Zestril lisinopril Prinzide; Zestoretic lisinopril/hydrochlorothiazide Tarka trandolapril/verapamil hcl Univasc moexipril hcl Vaseretic enalapril/hydrochlorothiazide Vasotec enalapril maleate Nonpreferred Brands Epaned Prestalia QL Qbrelis QL

2B. Alpha -adrenergic agents Trade name Generic name Limits Preferred Generics Aldomet methyldopa Aldoril methyldopa/hydrochlorothiazide Cardura doxazosin mesylate Catapres clonidine hcl Catapres-TTS clonidine Dibenzyline phenoxybenzamine hcl PA, QL Hytrin terazosin hcl Minipress prazosin hcl Tenex guanfacine hcl

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 22 2C. Angiotensin II Receptor Blockers and combinations Trade name Generic name Limits Preferred Generics Atacand candesartan cilexetil Atacand HCT candesartan/hydrochlorothiazid Avalide irbesartan/hydrochlorothiazide Avapro irbesartan Azor amlodipine bes/olmesartan med Benicar olmesartan medoxomil Benicar HCT olmesartan/hydrochlorothiazide Cozaar losartan potassium Diovan valsartan Diovan HCT valsartan/hydrochlorothiazide Exforge amlodipine besylate/valsartan Exforge HCT amlodipine/valsartan/hcthiazid Hyzaar losartan/hydrochlorothiazide Micardis telmisartan Micardis HCT telmisartan/hydrochlorothiazid Teveten eprosartan mesylate Tribenzor olmesartan/amlodipin/hcthiazid QL Twynsta telmisartan/amlodipine Preferred Brands Entresto QL Nonpreferred Brands Edarbi QL Edarbyclor QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 23 2D. Anticoagulants and hemostasis agents Trade name Generic name Limits Preferred Generics Aggrenox aspirin/dipyridamole Agrylin anagrelide hcl Amicar aminocaproic acid Arixtra fondaparinux sodium Coumadin warfarin sodium Effient prasugrel hcl QL Heparin heparin sodium,porcine/pf Heparin heparin sodium,porcine Lovenox enoxaparin sodium Mephyton phytonadione (vit k1) Persantine dipyridamole Plavix clopidogrel bisulfate Pletal cilostazol Trental pentoxifylline Vitamin K ampule phytonadione (vit k1) Preferred Brands Brilinta QL Cablivi PA, QL Eliquis QL Xarelto QL Nonpreferred Brands Fragmin Pradaxa QL Savaysa QL Zontivity QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 24 2E. Beta blockers and combinations Trade name Generic name Limits Preferred Generics Betapace, AF sotalol hcl Blocadren timolol maleate Coreg CR carvedilol phosphate QL Coreg immediate-release carvedilol Corgard nadolol Corzide nadolol/bendroflumethiazide Inderal, LA propranolol hcl Inderide propranolol/hydrochlorothiazid Kerlone betaxolol hcl Lopressor metoprolol tartrate Lopressor HCT metoprolol/hydrochlorothiazide Normodyne labetalol hcl Sectral acebutolol hcl Tenoretic atenolol/chlorthalidone Tenormin atenolol Toprol XL metoprolol succinate Visken pindolol Zebeta bisoprolol fumarate Ziac bisoprolol/hydrochlorothiazide Preferred Brands Bystolic ST, QL Nonpreferred Brands Dutoprol Hemangeol QL Sotylize

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 25 2F. Calcium channel blockers and combinations Trade name Generic name Limits Preferred Generics Adalat CC; Procardia, XL nifedipine Azor amlodipine bes/olmesartan med Caduet amlodipine/atorvastatin QL Calan SR; Isoptin SR verapamil hcl Cardene nicardipine hcl Cardizem, CD, LA, SR diltiazem hcl Dynacirc isradipine Exforge amlodipine besylate/valsartan Exforge HCT amlodipine/valsartan/hcthiazid Lotrel amlodipine besylate/benazepril Norvasc amlodipine besylate Plendil felodipine Sular nisoldipine Tarka trandolapril/verapamil hcl Tiazac diltiazem hcl Tribenzor olmesartan/amlodipin/hcthiazid QL Twynsta telmisartan/amlodipine Verelan, PM verapamil hcl Nonpreferred Brands Cardizem LA 120mg Katerzia QL Prestalia QL

2G. Cardiovascular treatment Trade name Generic name Limits Preferred Generics Betapace, AF sotalol hcl Cordarone; Pacerone amiodarone hcl Lanoxin digoxin Mexitil mexiletine hcl Norpace disopyramide phosphate Northera droxidopa PA, QL Proamatine midodrine hcl Quinidex quinidine sulfate Quinidine Gluconate SA quinidine gluconate Ranexa ranolazine Rythmol, SR propafenone hcl Tambocor flecainide acetate Tikosyn dofetilide Preferred Brands Corlanor QL Multaq QL Norpace CR Vyndamax PA, QL Vyndaqel PA, QL Nonpreferred Brands Lanoxin 62.5mcg, 187.5mcg Sotylize Verquvo PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 26 2H. Diuretics Trade name Generic name Limits Preferred Generics Aldactazide spironolact/hydrochlorothiazid Aldactone spironolactone Bumex bumetanide Demadex torsemide Diamox, Sequels acetazolamide Dyazide; Maxzide triamterene/hydrochlorothiazid Dyrenium triamterene Edecrin ethacrynic acid Hydrodiuril; Microzide hydrochlorothiazide Hygroton; Thalitone chlorthalidone Inspra eplerenone Lasix furosemide Lozol indapamide Midamor amiloride hcl Moduretic amiloride/hydrochlorothiazide Zaroxolyn metolazone Nonpreferred Brands Aldactazide 50/50mg Carospir Diuril suspension

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 27 2I. Lipid -lowering agents Trade name Generic name Limits Preventive Drugs Crestor* 5mg, 10mg rosuvastatin calcium QL Lescol, XL* (all strengths) fluvastatin sodium QL Lipitor* 10mg, 20mg atorvastatin calcium QL Mevacor* (all strengths) lovastatin QL Pravachol* (all strengths) pravastatin sodium QL Zocor* 5mg, 10mg, 20mg, 40mg simvastatin QL Preferred Generics Antara fenofibrate,micronized Caduet amlodipine/atorvastatin QL Colestid colestipol hcl Crestor rosuvastatin calcium QL Fenoglide fenofibrate Lescol, XL fluvastatin sodium QL Lipitor atorvastatin calcium QL Lofibra capsule fenofibrate,micronized Lofibra tablet fenofibrate Lopid gemfibrozil Lovaza omega-3 acid ethyl esters QL Mevacor lovastatin QL Niaspan niacin Pravachol pravastatin sodium QL Questran cholestyramine (with sugar) Questran Light cholestyramine/aspartame Tricor fenofibrate nanocrystallized Trilipix fenofibric acid (choline) Vascepa icosapent ethyl QL Vytorin ezetimibe/simvastatin QL Welchol colesevelam hcl Zetia ezetimibe QL Zocor simvastatin QL Preferred Brands Lipofen Nexletol PA, QL Nexlizet PA, QL Praluent PA, QL Repatha PA, QL Vascepa QL Nonpreferred Brands Antara 30mg, 90mg Colestid granules, packet Fenofibrate capsule (authorized generic of Lipofen) Juxtapid PA, QL Livalo QL *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 28 2J. Nitrates and combinations Trade name Generic name Limits Preferred Generics Imdur; Ismo; Monoket isosorbide mononitrate Isordil isosorbide dinitrate Nitro-bid ointment nitroglycerin Nitro-Dur nitroglycerin Nitroglycerin capsule, patch nitroglycerin Nitrostat nitroglycerin Preferred Brands Bidil Dilatrate-SR Nonpreferred Brands GoNitro Minitran

2K. Renin -inhibitors and combinations Trade name Generic name Limits Preferred Generics Tekturna aliskiren hemifumarate Nonpreferred Brands Tekturna HCT

2L. Miscellaneous antihypertensives Trade name Generic name Limits Preferred Generics Apresoline hydralazine hcl Demser metyrosine Loniten minoxidil Nonpreferred Brands Vecamyl PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 29 3. Central nervous system

3A. Alzheimer's therapy Trade name Generic name Limits Preferred Generics Aricept 23mg donepezil hcl QL Aricept 5, 10mg; ODT donepezil hcl Exelon capsule rivastigmine tartrate Exelon patch rivastigmine Namenda memantine hcl Namenda XR memantine hcl QL Razadyne, ER galantamine hbr Preferred Brands Memantine hcl (authorized generic of Namenda dose QL pack) Namenda dose pack QL Nonpreferred Brands Namenda XR dose pack QL Namzaric ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 30 3B. Anticonvulsants Trade name Generic name Limits Preferred Generics Banzel suspension rufinamide Banzel tablet rufinamide PA, QL Carbatrol carbamazepine Depakene capsule valproic acid Depakene solution valproic acid (as sodium salt) Depakote, ER, Sprinkles divalproex sodium Diamox, Sequels acetazolamide Diastat 2.5mg diazepam Diastat Acudial diazepam Dilantin phenytoin Dilantin; Phenytek capsule phenytoin sodium extended Felbatol felbamate Gabitril tiagabine hcl Keppra, XR levetiracetam Klonopin, Wafer clonazepam Lamictal ODT, XR lamotrigine Lamictal, dispertabs lamotrigine Lyrica pregabalin QL Lyrica CR pregabalin PA, QL Mysoline primidone Neurontin gabapentin Onfi clobazam QL Phenobarbital phenobarbital Qudexy XR topiramate PA, QL Sabril vigabatrin PA, QL Tegretol, XR carbamazepine Topamax, Sprinkle topiramate Trileptal oxcarbazepine Zarontin ethosuximide Zonegran zonisamide Preferred Brands Dilantin 30mg capsule Nayzilam QL Valtoco QL Vimpat solution Vimpat tablet PA, QL Nonpreferred Brands Acthar H.P. PA, QL Aptiom PA, QL Briviact PA, QL Celontin Diacomit PA, QL Elepsia XR PA, QL Epidiolex PA, QL Equetro Fintepla PA, QL Fycompa QL Lamictal XR dose pack Oxtellar XR PA, QL Spritam PA, QL Sympazan PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 31 3B. Anticonvulsants (Continued) Trade name Generic name Limits Trokendi XR PA, QL Xcopri PA, QL

3C. Antidepressants Trade name Generic name Limits Preferred Generics Adapin; Sinequan doxepin hcl Amoxapine amoxapine Anafranil clomipramine hcl Aventyl; Pamelor nortriptyline hcl Celexa citalopram hydrobromide Cymbalta duloxetine hcl Desyrel trazodone hcl Effexor, XR; Venlafaxine hcl ER venlafaxine hcl Elavil amitriptyline hcl Etrafon perphenazine/amitriptyline hcl Fluoxetine 60mg fluoxetine hcl Irenka duloxetine hcl Lexapro escitalopram oxalate Limbitrol, DS amitriptyline/chlordiazepoxide Luvox, CR fluvoxamine maleate Maprotiline hcl maprotiline hcl Nardil phenelzine sulfate Norpramin desipramine hcl Parnate tranylcypromine sulfate Paxil, CR paroxetine hcl Pristiq desvenlafaxine succinate QL Prozac fluoxetine hcl Remeron mirtazapine Serzone nefazodone hcl Surmontil trimipramine maleate Tofranil imipramine hcl Tofranil-PM imipramine pamoate Vivactil protriptyline hcl Wellbutrin, SR, XL bupropion hcl Zoloft sertraline hcl Nonpreferred Brands Desvenlafaxine ER ST, QL Emsam PA, QL Fetzima ST, QL Marplan Paxil suspension Pexeva ST, QL Trintellix ST, QL Viibryd ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 32 3D. Antipsychotics Trade name Generic name Limits Preferred Generics Abilify aripiprazole Clozaril clozapine Etrafon perphenazine/amitriptyline hcl Fazaclo clozapine Fluphenazine decanoate fluphenazine decanoate Fluphenazine liquid fluphenazine hcl Geodon ziprasidone hcl Haldol decanoate haloperidol decanoate Haldol liquid haloperidol lactate Haldol tablet haloperidol Invega paliperidone QL Loxitane loxapine succinate Mellaril thioridazine hcl Molindone molindone hcl QL Navane thiothixene Orap pimozide Perphenazine perphenazine Prolixin fluphenazine hcl Risperdal, M-Tab risperidone Saphris asenapine maleate QL Seroquel quetiapine fumarate Seroquel XR quetiapine fumarate QL Stelazine trifluoperazine hcl Symbyax olanzapine/fluoxetine hcl Thorazine chlorpromazine hcl Zyprexa, Zydis olanzapine Preferred Brands Abilify Maintena Aristada QL Aristada Initio Invega Sustenna Invega Trinza QL Perseris QL Risperdal Consta Zyprexa Relprevv Nonpreferred Brands Caplyta ST, QL Fanapt ST Latuda ST Nuplazid PA, QL Rexulti ST, QL Secuado ST, QL Versacloz Vraylar ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 33 3E. Anxiolytics Trade name Generic name Limits Preferred Generics Ativan lorazepam Buspar buspirone hcl Equanil; Miltown meprobamate Librium chlordiazepoxide hcl Lorazepam intensol lorazepam Niravam alprazolam Serax oxazepam Tranxene T-Tab clorazepate dipotassium Valium diazepam Xanax, XR alprazolam

3F. CNS stimulants Trade name Generic name Limits Preferred Generics Adderall, XR dextroamphetamine/amphetamine QL Aptensio XR methylphenidate hcl QL Concerta methylphenidate hcl QL Desoxyn methamphetamine hcl QL Dexedrine dextroamphetamine sulfate QL Evekeo amphetamine sulfate PA, QL Focalin, XR dexmethylphenidate hcl QL Metadate CD methylphenidate hcl QL Methylin, ER methylphenidate hcl QL Nuvigil armodafinil QL Procentra dextroamphetamine sulfate QL Provigil modafinil QL Ritalin, LA, SR methylphenidate hcl QL Preferred Brands Daytrana QL Mydayis QL Vyvanse QL Nonpreferred Brands Adzenys ER PA, QL Adzenys XR-ODT PA, QL Amphetamine ER suspension (authorized generic of PA, QL Adzenys ER) Azstarys PA, QL Dyanavel XR PA, QL Jornay PM PA, QL Methylphenidate ER 72mg QL Quillichew ER PA, QL Quillivant XR PA, QL Relexxii QL Zenzedi QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 34 3G. Migraine therapy Trade name Generic name Limits Preferred Generics Alsuma sumatriptan succinate QL Amerge naratriptan hcl QL Axert almotriptan malate ST, QL Cafergot ergotamine tartrate/caffeine QL D.H.E.45 dihydroergotamine mesylate QL Esgic; Fioricet butalb/acetaminophen/caffeine QL Fioricet w/codeine butalbit/acetamin/caff/codeine QL Fiorinal butalbital/aspirin/caffeine Fiorinal w/codeine codeine/butalbital/asa/caffein QL Frova frovatriptan succinate ST, QL Imitrex sumatriptan succinate QL Imitrex nasal spray sumatriptan QL Maxalt, MLT rizatriptan benzoate QL Migranal dihydroergotamine mesylate QL Phrenilin 50mg/325mg butalbital/acetaminophen Relpax eletriptan hydrobromide ST, QL Treximet sumatriptan succ/naproxen sod PA, QL Zomig, ZMT zolmitriptan QL Preferred Brands Aimovig PA, QL Ajovy PA, QL Emgality PA, QL Ergomar QL Nonpreferred Brands Nurtec ODT PA, QL Onzetra Xsail ST, QL Reyvow PA, QL Ubrelvy PA, QL Zembrace Symtouch ST, QL Zolmitriptan nasal spray (authorized generic of Zomig) ST, QL Zomig nasal spray ST, QL

3H. Myasthenia gravis Trade name Generic name Limits Preferred Generics Mestinon, Timespan pyridostigmine bromide

3I. Narcotic antagonists and withdrawal management Trade name Generic name Limits Preferred Generics Naloxone hcl injection naloxone hcl Revia naltrexone hcl Preferred Brands Kloxxado QL Lucemyra QL Narcan nasal spray QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 35 3J. Narcotic mixed agonist and antagonist Trade name Generic name Limits Preferred Generics Butrans buprenorphine QL Ryzolt tramadol hcl QL Stadol NS butorphanol tartrate QL Suboxone buprenorphine hcl/naloxone hcl QL Subutex buprenorphine hcl QL Talwin NX pentazocine hcl/naloxone hcl QL Ultracet tramadol hcl/acetaminophen QL Ultram, ER tramadol hcl QL Preferred Brands Zubsolv QL Nonpreferred Brands Belbuca PA, QL Bunavail QL Tramadol 100mg QL

3K. Narcotic and analgesic combinations Trade name Generic name Limits Preferred Generics Esgic; Fioricet butalb/acetaminophen/caffeine QL Fioricet w/codeine butalbit/acetamin/caff/codeine QL Fiorinal butalbital/aspirin/caffeine Fiorinal w/codeine codeine/butalbital/asa/caffein QL Hycet hydrocodone/acetaminophen QL Ibudone hydrocodone/ibuprofen QL Norco; Vicodin; Xodol hydrocodone/acetaminophen QL Percocet oxycodone hcl/acetaminophen QL Phrenilin 50mg/325mg butalbital/acetaminophen Trezix acetaminophen/caff/dihydrocod QL Tylenol w/codeine acetaminophen with codeine QL Vicoprofen hydrocodone/ibuprofen QL Nonpreferred Brands Lortab solution QL Trezix QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 36 3L. Narcotics Trade name Generic name Limits Preferred Generics Actiq fentanyl citrate PA, QL Avinza morphine sulfate QL Belladonna & Opium opium/belladonna alkaloids QL Codeine sulfate tablet codeine sulfate QL Demerol meperidine hcl QL Dilaudid hydromorphone hcl QL Duragesic fentanyl QL Exalgo hydromorphone hcl PA, QL Hysingla ER hydrocodone bitartrate PA, QL Kadian morphine sulfate QL Levorphanol Tartrate levorphanol tartrate PA, QL Methadone methadone hcl QL MS Contin morphine sulfate QL MSIR morphine sulfate QL Nubain nalbuphine hcl QL Opana oxymorphone hcl QL Opana ER oxymorphone hcl PA, QL Oxycodone immediate release, solution oxycodone hcl QL RMS Suppository morphine sulfate QL Roxanol morphine sulfate QL Zohydro ER hydrocodone bitartrate PA, QL Preferred Brands Nucynta PA, QL Oxycontin PA, QL Nonpreferred Brands Fentanyl buccal tablet (authorized generic of Fentora) PA, QL Fentora PA, QL Nucynta ER PA, QL Oxycodone hcl ER (authorized generic of Oxycontin) PA, QL Subsys PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 37 3M. Nonsteroidal anti -inflammatory drugs Trade name Generic name Limits Preferred Generics Anaprox, DS naproxen sodium Ansaid flurbiprofen Arthrotec diclofenac sodium/misoprostol Cataflam diclofenac potassium Celebrex celecoxib Clinoril sulindac Daypro oxaprozin EC-Naprosyn naproxen Feldene piroxicam Indocin, SR indomethacin Ketoprofen (except 25mg) ketoprofen Ketoprofen 25mg ketoprofen PA, QL Lodine, XL etodolac Meclomen meclofenamate sodium Mobic meloxicam Motrin (Rx Only) ibuprofen Nalfon fenoprofen calcium QL Naprosyn (Rx Only) naproxen Pennsaid 1.5% diclofenac sodium Ponstel mefenamic acid Relafen nabumetone Tolectin, DS tolmetin sodium Toradol injection ketorolac tromethamine Toradol tablet ketorolac tromethamine QL Vivlodex meloxicam, submicronized PA, QL Voltaren gel diclofenac sodium QL Voltaren, XR diclofenac sodium Nonpreferred Brands Diclofenac 35mg capsule (authorized generic of PA, QL Zorvolex 35mg) Diclofenac epolamine patch (authorized generic of PA, QL Flector patch) Fenoprofen calcium 200mg (authorized generic of PA, QL Fenortho 200mg) Fenoprofen calcium 400mg (authorized generic of PA, QL Nalfon 400mg) Fenortho PA, QL Flector Patch PA, QL Indocin suppository QL Indomethacin 20mg (authorized generic of Tivorbex ST, QL 20mg) Nalfon 400mg PA, QL Pennsaid 2% PA, QL Tivorbex ST, QL Zipsor PA, QL Zorvolex PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 38 3N. Parkinsons disease and related disorders Trade name Generic name Limits Preferred Generics Artane trihexyphenidyl hcl Azilect rasagiline mesylate Cogentin benztropine mesylate Comtan entacapone Eldepryl selegiline hcl Lodosyn carbidopa Mirapex ER pramipexole di-hcl QL Mirapex immediate-release pramipexole di-hcl Parcopa carbidopa/levodopa Parlodel bromocriptine mesylate Requip, XL ropinirole hcl Sinemet, CR carbidopa/levodopa Stalevo carbidopa/levodopa/entacapone Symmetrel amantadine hcl Tasmar tolcapone Preferred Brands Duopa PA, QL Kynmobi PA, QL Nonpreferred Brands Inbrija PA, QL Neupro PA, QL Nourianz PA, QL Nuplazid PA, QL Ongentys PA, QL Rytary ST, QL Xadago QL Zelapar QL

3O. Salicylates Trade name Generic name Limits Preventive Drugs Aspirin; Ecotrin 81mg, 325mg* (OTC) aspirin Preferred Generics Disalcid salsalate Dolobid diflunisal *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 39 3P. Sedative and hypnotics Trade name Generic name Limits Preferred Generics Ambien, CR zolpidem tartrate QL Dalmane flurazepam hcl QL Halcion triazolam QL Intermezzo zolpidem tartrate PA, QL Lunesta eszopiclone QL Prosom estazolam QL Restoril temazepam QL Rozerem ramelteon QL Seconal secobarbital sodium Silenor doxepin hcl ST, QL Sonata zaleplon QL Versed syrup midazolam hcl Nonpreferred Brands Belsomra ST, QL Dayvigo ST, QL Edluar ST, QL Hetlioz, LQ PA, QL

3Q. Skeletal muscle relaxants Trade name Generic name Limits Preferred Generics Baclofen baclofen Dantrium dantrolene sodium Fexmid cyclobenzaprine hcl Flexeril cyclobenzaprine hcl Norflex orphenadrine citrate Parafon Forte DSC 500mg chlorzoxazone Robaxin methocarbamol Skelaxin metaxalone Valium diazepam Zanaflex tizanidine hcl Nonpreferred Brands Ozobax PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 40 3R. Miscellaneous CNS Trade name Generic name Limits Preferred Generics Antabuse disulfiram Cafcit caffeine citrate Campral acamprosate calcium Ergoloid Mesylates ergoloid mesylates Eskalith, CR; Lithobid lithium carbonate Intuniv guanfacine hcl QL Kapvay clonidine hcl QL Nimotop nimodipine Rilutek riluzole Strattera atomoxetine hcl QL Xenazine tetrabenazine PA, QL Preferred Brands Austedo PA, QL Enspryng PA, QL Evrysdi PA, QL Nuedexta PA, QL Ruzurgi PA, QL Tegsedi PA, QL Nonpreferred Brands Cuvposa Exservan PA, QL Gralise PA, QL Horizant PA, QL Ingrezza PA, QL Nymalize QL Qelbree PA, QL Savella PA, QL Sunosi PA, QL Tiglutik PA, QL Wakix PA, QL Xyrem PA, QL Xywav PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 41 4. Gastrointestinal agents

4A. 5 -Aminosalicylic Acid (5 -ASA) agents Trade name Generic name Limits Preferred Generics Apriso mesalamine Asacol HD mesalamine Azulfidine, EN-tab sulfasalazine Canasa mesalamine Colazal balsalazide disodium Delzicol mesalamine Lialda mesalamine QL SfRowasa enema mesalamine Preferred Brands Pentasa Nonpreferred Brands Dipentum

4B. Antidiarrheals and antispasmodics Trade name Generic name Limits Preferred Generics Bentyl dicyclomine hcl Imodium loperamide hcl Levbid hyoscyamine sulfate Levsin, SL hyoscyamine sulfate Librax chlordiazepoxide/clidinium br Lomotil diphenoxylate hcl/atropine Preferred Brands Mytesi PA, QL Nonpreferred Brands Motofen

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 42 4C. Antiemetics Trade name Generic name Limits Preferred Generics Antivert meclizine hcl Compazine suppository prochlorperazine Compazine tablet prochlorperazine maleate Diclegis doxylamine succinate/vit b6 PA, QL Emend aprepitant QL Kytril granisetron hcl QL Marinol dronabinol Phenergan promethazine hcl Tigan trimethobenzamide hcl Transderm-Scop scopolamine Zofran solution ondansetron hcl Zofran tablet, ODT ondansetron hcl QL Preferred Brands Emend suspension QL Nonpreferred Brands Akynzeo PA, QL Bonjesta PA, QL Sancuso PA, QL Syndros Varubi tablet PA, QL

4D. Bile acids Trade name Generic name Limits Preferred Generics Actigall ursodiol Urso; Forte ursodiol Preferred Brands Ocaliva PA, QL Nonpreferred Brands Chenodal PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 43 4E. Bowel preparation and cleansing agents Trade name Generic name Limits Preventive Drugs Bisacodyl OTC* bisacodyl QL Citrate of Magnesia OTC* magnesium citrate QL Colyte* peg3350/sod sulf,bicarb,cl/kcl QL Glycolax OTC * polyethylene glycol 3350 QL Golytely* peg3350/sod sulf,bicarb,cl/kcl QL Milk of Magnesia OTC* magnesium hydroxide QL Moviprep* peg3350/sod sul/nacl/kcl/asb/c QL Nulytely* sodium chloride/nahco3/kcl/peg QL Oral Saline Laxative liquid OTC* sodium phosphate,mono-dibasic QL Peg-Prep* bisac/nacl/nahco3/kcl/peg 3350 QL Preferred Generics Colyte peg3350/sod sulf,bicarb,cl/kcl Golytely peg3350/sod sulf,bicarb,cl/kcl Moviprep peg3350/sod sul/nacl/kcl/asb/c Nulytely sodium chloride/nahco3/kcl/peg Peg-Prep bisac/nacl/nahco3/kcl/peg 3350 Preferred Brands Suprep Nonpreferred Brands Clenpiq Nulytely Osmoprep Plenvu Sutab QL *Age restrictions apply.

4F. Digestive enzymes Trade name Generic name Limits Preferred Brands Creon Viokace Zenpep Nonpreferred Brands Pancreaze Pertzye

4G. H2 -Receptor antagonists Trade name Generic name Limits Preferred Generics Axid (Rx only) nizatidine Pepcid (Rx Only) famotidine Tagamet (Rx only) cimetidine Tagamet liquid (Rx only) cimetidine hcl

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 44 4H. Proton Pump Inhibitors (PPI) Trade name Generic name Limits Preferred Generics Aciphex tablet rabeprazole sodium Nexium esomeprazole magnesium Nexium suspension esomeprazole magnesium ST Prevacid capsule (Rx Only) lansoprazole Prevacid Solutab lansoprazole Prilosec capsule (Rx Only) omeprazole Protonix pantoprazole sodium Nonpreferred Brands Aciphex Sprinkle ST, QL Dexilant ST Nexium 2.5mg, 5mg suspension ST Prilosec suspension

4I. Topical anti -Inflammatory agents Trade name Generic name Limits Preferred Generics Analpram-HC hydrocortisone/pramoxine Anamantle HC, Forte; Kit lidocaine/hydrocortisone ac Cortenema hydrocortisone Hydrocortisone 1% cream (Rx only) hydrocortisone Pramosone hydrocortisone/pramoxine Proctocort suppository hydrocortisone acetate Procto-pak hydrocortisone Proctosol-HC suppository hydrocortisone acetate Preferred Brands Analpram-HC 1-1% cream Epifoam Pramosone lotion Proctofoam-HC Nonpreferred Brands Cortifoam Pramosone cream, ointment Uceris foam ST

4J. Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits Preferred Brands Humira PA, QL Nonpreferred Brands Simponi PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 45 4K. Ulcer therapy Trade name Generic name Limits Preferred Generics Carafate sucralfate Cytotec misoprostol Pamine, Forte methscopolamine bromide Prevpac lansoprazole/amoxiciln/clarith Robinul tablet, Forte glycopyrrolate Nonpreferred Brands Omeclamox-pak Talicia QL

4L. Miscellaneous gastrointestinal agents Trade name Generic name Limits Preferred Generics Evoxac cevimeline hcl Gastrocrom cromolyn sodium Lactulose lactulose Lotronex alosetron hcl QL Metozolv ODT metoclopramide hcl Reglan metoclopramide hcl Salagen pilocarpine hcl Preferred Brands Amitiza QL Gattex PA, QL Linzess QL Stelara 45mg, 90mg PA, QL Viberzi PA, QL Xeljanz, XR PA, QL Xifaxan 200mg QL Xifaxan 550mg PA, QL Nonpreferred Brands Motegrity PA, QL Movantik PA, QL Rectiv QL Relistor tablet PA, QL Sucraid PA, QL Symproic PA, QL Zelnorm PA, QL Zeposia PA, QL Zorbtive PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 46 5. Obstetrics and gynecology

5A. Contraceptives -Biphasic Trade name Generic name Limits Preventive Drugs Loseasonique l-norgest/e.estradiol-e.estrad QL Mircette desog-e.estradiol/e.estradiol Seasonique l-norgest/e.estradiol-e.estrad QL Preferred Brands Lo Loestrin Fe

5B. Contraceptives -Misc. Trade name Generic name Limits Preventive Drugs Depo-Provera 150mg medroxyprogesterone acetate FC2 Female Condom QL Gynol II nonoxynol 9 QL Nuvaring etonogestrel/ethinyl estradiol QL Ortho Evra norelgestromin/ethin.estradiol QL Ortho Micronor; Nor-QD norethindrone Quartette l-norgest/e.estradiol-e.estrad QL Safyral drospir/eth estra/levomefol ca Today contraceptive sponge QL VCF film, gel QL Preferred Generics Ortho Evra norelgestromin/ethin.estradiol QL Preferred Brands Depo-subq Provera 104 Natazia Nonpreferred Brands Slynd QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 47 5C. Contraceptives -Monophasic Trade name Generic name Limits Preventive Drugs Alesse; Levlite levonorgestrel/ethin.estradiol Beyaz drospir/eth estra/levomefol ca Demulen ethynodiol d-ethinyl estradiol Desogen; Ortho-cept desogestrel-ethinyl estradiol Femcon Fe noreth-ethinyl estradiol/iron Generess Fe noreth-ethinyl estradiol/iron Levlen; Nordette levonorgestrel/ethin.estradiol Lo/Ovral norgestrel-ethinyl estradiol Loestrin norethindrone ac-eth estradiol Loestrin 24 Fe norethindrone-e.estradiol-iron Loestrin Fe norethindrone-e.estradiol-iron Lybrel levonorgestrel/ethin.estradiol Minastrin 24 Fe norethindrone-e.estradiol-iron Modicon norethindrone-ethin. estradiol Norinyl 1/35; Ortho-novum 1/35 norethindrone-ethin. estradiol Nortrel norethindrone-ethin. estradiol Ortho-Cyclen norgestimate-ethinyl estradiol Ovcon 35 norethindrone-ethin. estradiol Seasonale levonorgestrel/ethin.estradiol QL Taytulla norethindrone-e.estradiol-iron Yasmin 28 ethinyl estradiol/drospirenone Yaz ethinyl estradiol/drospirenone Nonpreferred Brands Balcoltra Nextstellis Tyblume

5D. Contraceptives -Postcoital Trade name Generic name Limits Preventive Drugs Ella QL Plan B One-step levonorgestrel QL

5E. Contraceptives -Triphasic Trade name Generic name Limits Preventive Drugs Cyclessa desogestrel-ethinyl estradiol Estrostep Fe norethindrone-e.estradiol-iron Ortho Tri-Cyclen norgestimate-ethinyl estradiol Ortho Tri-Cyclen Lo norgestimate-ethinyl estradiol Ortho-Novum 7/7/7 norethindrone-ethin. estradiol Trilevlen levonorgestrel/ethin.estradiol Tri-Norinyl norethindrone-ethin. estradiol

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 48 5F. Estrogen and progestin combinations Trade name Generic name Limits Preferred Generics Activella estradiol/norethindrone acet FemHRT norethindrone ac-eth estradiol Preferred Brands Climara Pro Combipatch Prempro, Low Dose; Premphase Nonpreferred Brands Angeliq Bijuva QL Prefest

5G. Estrogens Trade name Generic name Limits Preferred Generics Climara estradiol Delestrogen estradiol valerate Estrace estradiol Minivelle, Vivelle-Dot estradiol Vagifem estradiol Preferred Brands Alora Estring Estrogel Premarin, cream, Low Dose Nonpreferred Brands Delestrogen 10mg/ml Depo-estradiol Divigel Elestrin Evamist Femring Imvexxy Menest Menostar

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 49 5H. Infertility treatment* Trade name Generic name Limits Preferred Generics Clomid clomiphene citrate Ganirelix Acetate ganirelix acetate Preferred Brands Cetrotide Crinone 8% Gonal-F, RFF, Redi-ject Menopur Ovidrel Pregnyl PA Nonpreferred Brands Chorionic Gonadotropin PA Endometrin PA Follistim AQ PA Novarel PA *Drugs used for the treatment of infertility may not be covered for select benefits.

5I. Progestins Trade name Generic name Limits Preferred Generics Aygestin norethindrone acetate Progesterone In Oil (inj) progesterone Prometrium progesterone, micronized Provera medroxyprogesterone acetate Preferred Brands Crinone 4% Depo-subq Provera 104

5J. Vaginal anti -infective and antifungal Trade name Generic name Limits Preferred Generics Cleocin vaginal cream clindamycin phosphate Diflucan fluconazole Metrogel-Vaginal metronidazole Monistat 3 miconazole nitrate Terazol- 3, 7 terconazole Preferred Brands Gynazole-1 Nonpreferred Brands Cleocin vaginal ovules Clindesse Nuvessa

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 50 5K. Miscellaneous OB- GYN Trade name Generic name Limits Preferred Generics Brisdelle paroxetine mesylate QL Covaryx, H.S. estrogen,ester/me-testosterone Diclegis doxylamine succinate/vit b6 PA, QL Lysteda tranexamic acid QL Methergine methylergonovine maleate PA, QL Preferred Brands Lupron Depot 3.75mg, 11.25mg Orilissa PA, QL Nonpreferred Brands Bonjesta PA, QL Duavee Intrarosa Lupaneta Pack Oriahnn PA, QL Osphena Synarel

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 51 6. Rheumatology and musculoskeletal

6A. Corticosteroids Trade name Generic name Limits

Corticosteroids See Chapter 7C

6B. Gout therapy Trade name Generic name Limits Preferred Generics Colbenemid probenecid/colchicine Colcrys colchicine Probenecid probenecid Uloric febuxostat ST, QL Zyloprim allopurinol Nonpreferred Brands Colchicine capsule (authorized generic of Mitigare) Mitigare

6C. Non -Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits Preferred Brands Actemra Actpen, syringe PA, QL Otezla PA, QL Rinvoq ER PA, QL Stelara 45mg, 90mg PA, QL Taltz PA, QL Xeljanz, XR PA, QL Nonpreferred Brands Kevzara PA, QL Kineret PA, QL Olumiant PA, QL Orencia Clickject, sub-q PA, QL

6D. Osteoporosis and bone resorption Trade name Generic name Limits Preferred Generics Actonel risedronate sodium QL Atelvia risedronate sodium ST, QL Boniva ibandronate sodium QL Didronel etidronate disodium Evista raloxifene hcl QL Fosamax alendronate sodium QL Miacalcin calcitonin,salmon,synthetic Nonpreferred Brands Binosto ST, QL Fosamax Plus D ST, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 52 6E. Osteoporosis and hormonal treatment Trade name Generic name Limits Preferred Generics Climara estradiol Estrace estradiol FemHRT norethindrone ac-eth estradiol Minivelle, Vivelle-Dot estradiol Preferred Brands Alora Forteo PA, QL Premarin, cream, Low Dose Prempro, Low Dose; Premphase Tymlos PA, QL Nonpreferred Brands Duavee Menest

6F. Salicylates Trade name Generic name Limits

Salicylates and NSAIDS See Chapters 3O & 3M

6G. Tumor Necrosis Factor (TNF) blocking agents Trade name Generic name Limits Preferred Brands Cimzia syringe PA, QL Enbrel PA, QL Humira PA, QL Nonpreferred Brands Simponi PA, QL

6H. Miscellaneous rheumatologic agents Trade name Generic name Limits Preferred Generics Arava leflunomide Azulfidine, EN-tab sulfasalazine Depen penicillamine QL Gengraf; Neoral cyclosporine, modified Imuran azathioprine Methotrexate methotrexate sodium Methotrexate PF injection methotrexate sodium/pf Plaquenil hydroxychloroquine sulfate Preferred Brands Ridaura Trexall Nonpreferred Brands Azasan Otrexup PA, QL Rasuvo PA, QL Reditrex PA, QL Xatmep

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 53 7. Endocrinology

7A. Androgens Trade name Generic name Limits Preferred Generics Androgel testosterone PA, QL Android, Testred methyltestosterone QL Axiron testosterone PA, QL Danocrine danazol Delatestryl testosterone enanthate Depo-Testosterone testosterone cypionate Fortesta testosterone PA, QL Oxandrin oxandrolone PA Testim testosterone PA, QL Testosterone 1% packet, pump testosterone PA, QL Preferred Brands Androderm PA, QL Nonpreferred Brands Depo-Testosterone Jatenzo PA, QL Methitest QL Natesto PA, QL Testosterone 1% (authorized generic of Vogelxo) PA, QL Vogelxo PA, QL Xyosted PA, QL

7B. Antithyroid agents Trade name Generic name Limits Preferred Generics Propylthiouracil propylthiouracil Strong Iodine potassium iodide/iodine Tapazole methimazole Nonpreferred Brands SSKI

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 54 7C. Corticosteroids Trade name Generic name Limits Preferred Generics Cortef; Hydrocortisone hydrocortisone Decadron dexamethasone Deltasone prednisone Dexpak dexamethasone Entocort EC budesonide Florinef fludrocortisone acetate Medrol methylprednisolone Millipred prednisolone sodium phosphate Orapred ODT prednisolone sodium phosphate Orapred solution prednisolone sodium phosphate Pediapred solution prednisolone sodium phosphate Prednisolone solution, tablet prednisolone Prednisone prednisone Uceris tablet budesonide QL Nonpreferred Brands Alkindi Sprinkle PA, QL Emflaza PA Medrol 2mg Rayos PA, QL Solu-cortef

7D. Growth Hormone and related products Trade name Generic name Limits Preferred Brands Genotropin PA Norditropin FlexPro PA Nutropin AQ Nuspin PA Nonpreferred Brands Humatrope PA Increlex PA Omnitrope PA Saizen, Saizenprep PA Serostim PA Zomacton PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 55 7E. Insulins Trade name Generic name Limits Preferred Brands Fiasp, Flextouch, Penfill Humulin R U-500 (all forms) Lantus, Solostar Levemir, Flextouch Novolin (NDCs ending in -00, -01, -11, -15) Novolog (NDCs ending in -111, -312, -512, -619, -910) Soliqua 100-33 QL Toujeo, Max Solostar Tresiba, Flextouch Xultophy 100-3.6 QL Nonpreferred Brands Afrezza PA Basaglar Kwikpen U-100 Insulin lispro junior (authorized generic of Humalog Junior Kwikpen)

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 56 7F. Non -insulin hypoglycemic agents Trade name Generic name Limits Preferred Generics Actoplus Met pioglitazone hcl/metformin hcl Actos pioglitazone hcl Amaryl glimepiride Diabeta; Micronase glyburide Duetact pioglitazone hcl/glimepiride Fortamet metformin hcl PA Glucophage, XR metformin hcl Glucotrol, XL glipizide Glucovance glyburide/metformin hcl Glynase glyburide,micronized Glyset miglitol Metaglip glipizide/metformin hcl PrandiMet repaglinide/metformin hcl Prandin repaglinide Precose acarbose Riomet metformin hcl Starlix nateglinide Preferred Brands Farxiga QL Glyxambi QL Invokamet, XR QL Invokana QL Janumet QL Janumet XR QL Januvia QL Jardiance QL Jentadueto, XR QL Ozempic QL Qtern QL Rybelsus QL Segluromet QL Steglatro QL Symlinpen Synjardy, XR QL Tradjenta QL Trijardy XR QL Trulicity QL Victoza QL Xigduo XR QL Nonpreferred Brands Cycloset PA, QL Riomet ER QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 57 7G. Somatostatin analogs Trade name Generic name Limits Preferred Generics Sandostatin octreotide acetate Preferred Brands Sandostatin LAR Depot PA Signifor PA, QL Somatuline Depot PA, QL Nonpreferred Brands Bynfezia PA, QL Mycapssa PA, QL Signifor LAR PA, QL

7H. Thyroid hormones Trade name Generic name Limits Preferred Generics Armour Thyroid thyroid,pork Cytomel liothyronine sodium NP Thyroid thyroid,pork Synthroid levothyroxine sodium Westhroid thyroid,pork Preferred Brands Thyrolar Nonpreferred Brands Armour Thyroid Levothyroxine sodium (authorized generic of Tirosint) Tirosint Tirosint-Sol

7I. Urea cycle disorder agents Trade name Generic name Limits Preferred Generics Buphenyl powder sodium phenylbutyrate Buphenyl tablet sodium phenylbutyrate QL Preferred Brands Carbaglu PA Nonpreferred Brands Ravicti PA, QL

7J. Vitamin D analogs Trade name Generic name Limits Preferred Generics Calciferol (Rx Only) ergocalciferol (vitamin d2) Hectorol doxercalciferol Rocaltrol calcitriol Zemplar paricalcitol Nonpreferred Brands Rayaldee QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 58 7K. Miscellaneous endocrine Trade name Generic name Limits Preferred Generics DDAVP desmopressin acetate DDAVP desmopressin (nonrefrigerated) Dostinex cabergoline Glucagon Emergency Kit glucagon,human recombinant Kuvan sapropterin dihydrochloride PA Miacalcin calcitonin,salmon,synthetic Proglycem diazoxide Sensipar cinacalcet hcl Zavesca miglustat PA, QL Preferred Brands Baqsimi QL Cerdelga PA, QL Cholbam PA, QL Dojolvi PA Galafold PA, QL GlucaGen HypoKit Glucagon Emergency Kit Gvoke QL Korlym PA, QL Lupron Depot-PED Natpara PA, QL Palynziq PA, QL Revcovi PA, QL Somavert PA Strensiq PA, QL Xermelo PA, QL Nonpreferred Brands DDAVP solution Egrifta SV PA, QL Isturisa PA, QL Myalept PA, QL Synarel Zegalogue QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 59 8. Antineoplastics and immunosuppresants

8A. Adjuvant therapy Trade name Generic name Limits Preferred Generics Leucovorin tablet leucovorin calcium Preferred Brands Fulphila QL Leukine Mesnex tablet Neulasta QL Nivestym QL Nyvepria QL Procrit Retacrit Udenyca QL Zarxio Ziextenzo QL Nonpreferred Brands Aranesp Epogen Granix Mircera QL Neupogen

8B. Alkylating agents Trade name Generic name Limits Preferred Generics Alkeran tablet melphalan Cyclophosphamide capsule cyclophosphamide Temodar temozolomide Preferred Brands Emcyt Gleostine; Lomustine Leukeran Matulane Myleran Nonpreferred Brands Cyclophosphamide tablet (authorized generic of Cytoxan)

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 60 8C. Antimetabolites Trade name Generic name Limits Preferred Generics Methotrexate methotrexate sodium Methotrexate PF injection methotrexate sodium/pf Purinethol mercaptopurine Xeloda capecitabine Preferred Brands Lonsurf PA, QL Onureg PA, QL Tabloid Trexall Nonpreferred Brands Purixan Xatmep

8D. Hormonal agents Trade name Generic name Limits Preventive Drugs Arimidex* anastrozole PA, QL Aromasin* exemestane PA, QL Evista * raloxifene hcl PA, QL Tamoxifen* tamoxifen citrate PA, QL Preferred Generics Arimidex anastrozole QL Aromasin exemestane QL Casodex bicalutamide Eulexin flutamide Evista raloxifene hcl QL Fareston toremifene citrate Faslodex fulvestrant Femara letrozole Lupron leuprolide acetate Megace, ES megestrol acetate Nilandron nilutamide PA, QL Tamoxifen tamoxifen citrate QL Zytiga 250mg abiraterone acetate QL Preferred Brands Erleada PA, QL Kisqali Femara co-pack PA, QL Lupron Depot Trelstar Xtandi PA, QL Zoladex QL Nonpreferred Brands Eligard Lupaneta Pack Orgovyx PA, QL Soltamox *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 61 8E. Immunomodulators Trade name Generic name Limits Preferred Generics Cellcept mycophenolate mofetil Gengraf; Neoral cyclosporine, modified Imuran azathioprine Myfortic mycophenolate sodium Prednisone prednisone Prograf tacrolimus Rapamune sirolimus Sandimmune capsule cyclosporine Preferred Brands Somatuline Depot PA, QL Thalomid Nonpreferred Brands Arcalyst PA, QL Astagraf XL Azasan Envarsus XR Kineret PA, QL Pomalyst PA, QL Prograf granules Revlimid QL Sandimmune solution

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 62 8F. Kinase inhibitors and molecular target inhibitors Trade name Generic name Limits Preferred Generics Afinitor everolimus PA, QL Gleevec imatinib mesylate Tarceva erlotinib hcl PA, QL Tykerb lapatinib ditosylate PA Zortress everolimus Preferred Brands Afinitor 10mg, Disperz PA, QL Alecensa PA, QL Alunbrig PA, QL Ayvakit PA, QL Balversa PA, QL Bosulif PA, QL Braftovi PA, QL Brukinsa PA, QL Cabometyx PA, QL Calquence PA, QL Caprelsa PA, QL Cometriq PA, QL Copiktra PA, QL Cotellic PA, QL Daurismo PA, QL Fotivda PA, QL Gavreto PA, QL Gilotrif PA, QL Ibrance PA, QL Iclusig PA, QL Idhifa PA, QL Imbruvica capsule; 280mg, 420mg, 560mg tablet PA, QL Inlyta PA, QL Inqovi PA, QL Iressa PA, QL Jakafi PA, QL Kisqali, Femara co-pack PA, QL Koselugo PA, QL Lenvima PA, QL Lorbrena PA, QL Lynparza PA, QL Mekinist PA, QL Mektovi PA, QL Nerlynx PA, QL Nexavar PA, QL Ninlaro PA, QL Nubeqa PA, QL Pemazyre PA, QL Piqray PA, QL Qinlock PA, QL Retevmo PA, QL Rozlytrek PA, QL Rubraca PA, QL Rydapt PA, QL Sprycel PA, QL Stivarga PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 63 8F. Kinase inhibitors and molecular target inhibitors (Continued) Trade name Generic name Limits Sutent PA, QL Tabrecta PA, QL Tafinlar PA, QL Tagrisso PA, QL Talzenna PA, QL Tasigna PA, QL Tazverik PA, QL Tepmetko PA, QL Tibsovo PA, QL Tukysa PA, QL Turalio PA, QL Ukoniq PA, QL Venclexta PA, QL Verzenio PA, QL Vitrakvi PA, QL Vizimpro PA, QL Votrient PA, QL Xalkori PA, QL Xospata PA, QL Zejula PA, QL Zelboraf PA, QL Zokinvy PA, QL Zydelig PA, QL Zykadia PA, QL Nonpreferred Brands Inrebic PA, QL Zortress 1mg

8G. Miscellaneous antineoplastic agents Trade name Generic name Limits Preferred Generics Hydrea hydroxyurea Sandostatin octreotide acetate Targretin capsule bexarotene PA, QL Vepesid etoposide Vesanoid tretinoin Preferred Brands Droxia Erivedge PA, QL Farydak PA, QL Hycamtin capsule Lysodren Odomzo PA, QL Sandostatin LAR Depot PA Synribo PA, QL Xpovio PA, QL Zolinza PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 64 9. Immunology and hematology

9A. Hematopoietic agents Trade name Generic name Limits Preferred Brands Doptelet PA, QL Fulphila QL Leukine Neulasta QL Nivestym QL Nyvepria QL Procrit Promacta PA Retacrit Udenyca QL Zarxio Ziextenzo QL Nonpreferred Brands Aranesp Epogen Granix Mircera QL Neupogen Tavalisse PA, QL

9B. Immunoglobulins Trade name Generic name Limits Nonpreferred Brands Cutaquig PA Cuvitru PA Gammagard liquid PA Gammaked PA Gamunex-C sub-q PA Hizentra PA HyQvia PA Xembify PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 65 9C. Interferons and MS therapy Trade name Generic name Limits Preferred Generics Ampyra dalfampridine QL Copaxone glatiramer acetate QL Glatopa glatiramer acetate QL Tecfidera dimethyl fumarate QL Preferred Brands Actimmune Alferon N Avonex QL Gilenya QL Intron A Kesimpta QL Mayzent QL Pegasys, Proclick QL Plegridy QL Rebif, Rebidose QL Nonpreferred Brands Aubagio QL Bafiertam QL Betaseron QL Extavia QL Mavenclad QL Vumerity QL Zeposia PA, QL

9D. Miscellaneous immunology and hematology Trade name Generic name Limits Preferred Generics Firazyr icatibant acetate PA, QL Preferred Brands Benlysta PA, QL Empaveli PA, QL Haegarda PA, QL Palforzia packet PA, QL Takhzyro PA, QL Nonpreferred Brands Orladeyo PA, QL Oxbryta PA, QL Ruconest PA, QL Siklos PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 66 10. Dermatology

10A. Acne treatment Trade name Generic name Limits Preferred Generics Absorica 10mg, 20mg, 30mg 40mg isotretinoin QL Acanya clindamycin phos/benzoyl perox Accutane; Amnesteem; Claravis; Myorisan; Zenatane isotretinoin QL Aczone 5% dapsone QL Adoxa capsule doxycycline monohydrate PA Adoxa tablet doxycycline monohydrate Atralin tretinoin Avar sulfacetamide sodium/sulfur Avar-E sulfacetamide sodium/sulfur Avidoxy 100mg doxycycline monohydrate Benzaclin clindamycin phos/benzoyl perox Benzamycin erythromycin/benzoyl peroxide Cleocin-T, swabs clindamycin phosphate Differin cream, gel adapalene Doryx doxycycline hyclate PA Duac clindamycin phos/benzoyl perox Dynacin minocycline hcl Epiduo adapalene/benzoyl peroxide Erythromycin topical gel, solution, swab erythromycin base in ethanol Klaron sulfacetamide sodium Minocin minocycline hcl Monodox doxycycline monohydrate Ovace sulfacetamide sodium Retin-A; Avita tretinoin Rosanil sulfacetamide sodium/sulfur Rosula Cleanser sulfacetamide sod/sulfur/urea Tazorac tazarotene Vibramycin doxycycline hyclate Vibramycin suspension doxycycline monohydrate Preferred Brands Tazorac 0.05%; 0.1% gel Nonpreferred Brands Adapalene 0.1% lotion (authorized generic of Differin) Altreno QL Amzeeq QL Avita gel Azelex Differin 0.1% lotion Doryx MPC PA Doxycycline IR-DR (authorized generic of Oracea) PA Epiduo Forte PA, QL Fabior ST, QL Noritate Oracea PA Tazarotene 0.1% foam (authorized generic of Fabior) ST, QL Tretin-X Vibramycin syrup Winlevi PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 67 10B. Antipsoriatic and antiseborrheic Trade name Generic name Limits Preferred Generics Avar sulfacetamide sodium/sulfur Avar-E sulfacetamide sodium/sulfur Dovonex calcipotriene Klaron sulfacetamide sodium Ovace sulfacetamide sodium Oxsoralen-Ultra methoxsalen Rosanil sulfacetamide sodium/sulfur Selsun (Rx Only) selenium sulfide Soriatane acitretin Taclonex calcipotriene/betamethasone PA Tazorac tazarotene Vectical calcitriol Preferred Brands Duobrii QL Enbrel PA, QL Humira PA, QL Otezla PA, QL Skyrizi PA, QL Stelara 45mg, 90mg PA, QL Taltz PA, QL Tremfya PA, QL Nonpreferred Brands Calcipotriene foam (authorized generic of Sorilux) Enstilar PA, QL Otrexup PA, QL Rasuvo PA, QL Reditrex PA, QL Siliq PA, QL Sorilux

10C. Corticosteroids - very high potency Trade name Generic name Limits Preferred Generics Clobevate; Temovate clobetasol propionate Clobex, spray clobetasol propionate Diprolene gel, ointment betamethasone dipropionate Olux clobetasol propionate Olux-E clobetasol propionate/emoll Temovate Emollient clobetasol propionate/emoll Ultravate cream, ointment halobetasol propionate Vanos fluocinonide QL Preferred Brands Cordran tape Duobrii QL Nonpreferred Brands Bryhali QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 68 10D. Corticosteroids - high potency Trade name Generic name Limits Preferred Generics Apexicon E diflorasone diacetate/emoll Aristocort; Kenalog 0.5% triamcinolone acetonide Cyclocort amcinonide Diprolene cream, lotion; AF betamethasone/propylene glyc Diprosone cream, ointment betamethasone dipropionate Elocon ointment mometasone furoate Florone; Psorcon diflorasone diacetate Halog halcinonide Lidex fluocinonide Lidex E fluocinonide/emollient base Luxiq betamethasone valerate Topicort 0.25%; 0.05% gel desoximetasone Valisone ointment betamethasone valerate Nonpreferred Brands Halog ointment, solution

10E. Corticosteroids - medium potency Trade name Generic name Limits Preferred Generics Cordran flurandrenolide Cutivate fluticasone propionate Dermatop prednicarbate Diprosone lotion betamethasone dipropionate Elocon cream, lotion, solution mometasone furoate Kenalog 0.025% ointment, 0.05%, 0.1% triamcinolone acetonide Kenalog Spray triamcinolone acetonide QL Locoid hydrocortisone butyrate Locoid Lipocream hydrocortisone butyrate/emoll Oralone paste triamcinolone acetonide Synalar 0.025% fluocinolone acetonide Topicort 0.05% cream, ointment desoximetasone Westcort hydrocortisone valerate Preferred Brands Clocortolone pivalate (authorized generic of Cloderm) Cloderm Nonpreferred Brands Locoid Lipocream

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 69 10F. Corticosteroids - low potency Trade name Generic name Limits Preferred Generics Aclovate alclometasone dipropionate Ala-Cort hydrocortisone Ala-scalp HP hydrocortisone Dermacort, Hytone 2.5% hydrocortisone Dermacort; Hytone 1% (Rx Only) hydrocortisone Derma-smoothe-FS fluocinolone/shower cap Derma-smoothe-FS fluocinolone acetonide Desonate desonide Desowen desonide Kenalog 0.025% cream, lotion triamcinolone acetonide Synalar 0.01% fluocinolone acetonide Valisone cream, lotion betamethasone valerate Preferred Brands Capex shampoo Nonpreferred Brands Neo-Synalar Texacort Verdeso

10G. Scabicides and pediculicides Trade name Generic name Limits Preferred Generics Crotan crotamiton Elimite permethrin Lindane lindane Natroba spinosad Ovide malathion Sklice ivermectin QL Preferred Brands Eurax Nonpreferred Brands Ulesfia

10H. Topical anesthetics Trade name Generic name Limits Preferred Generics Emla lidocaine/prilocaine Lidoderm patch lidocaine Xylocaine Viscous Solution (Rx Only) lidocaine hcl

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 70 10I. Topical antibacterials Trade name Generic name Limits Preferred Generics Bactroban ointment mupirocin Gentamicin cream, ointment gentamicin sulfate Nonpreferred Brands Neo-Synalar Xepi PA, QL

10J. Topical antifungals Trade name Generic name Limits Preferred Generics Extina ketoconazole Loprox cream, suspension ciclopirox olamine Loprox gel, shampoo ciclopirox Lotrimin clotrimazole Lotrisone clotrimazole/betamethasone dip Mycostatin nystatin Naftin naftifine hcl PA, QL Nizoral cream, shampoo 2% ketoconazole Nystatin w/Triamcinolone nystatin/triamcin Oxistat oxiconazole nitrate PA, QL Penlac ciclopirox Spectazole econazole nitrate Preferred Brands Mentax Nonpreferred Brands Ecoza PA, QL Ertaczo Exelderm Luliconazole 1% cream (authorized generic of Luzu) PA, QL Luzu PA, QL Miconazole-zinc oxide-petroltm (authorized generic of QL Vusion) Naftin 2% gel PA, QL Oxistat lotion PA, QL Sulconazole nitrate (authorized generic of Exelderm) Vusion QL Xolegel PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 71 10K. Topical antineoplastic agents and immunomodulators Trade name Generic name Limits Preferred Generics Aldara imiquimod QL Efudex fluorouracil Elidel pimecrolimus Protopic tacrolimus Zyclara imiquimod PA, QL Preferred Brands Panretin Tolak QL Nonpreferred Brands Fluoroplex Imiquimod 3.75% pump (authorized generic of Zyclara) PA, QL Klisyri PA, QL Picato PA, QL Targretin gel PA Valchlor PA, QL Veregen Zyclara 2.5%, 3.75% pump PA, QL

10L. Topical antivirals Trade name Generic name Limits Preferred Generics Zovirax ointment acyclovir

10M. Wound and burn therapy Trade name Generic name Limits Preferred Generics Silvadene silver sulfadiazine Sulfamylon mafenide acetate Preferred Brands Santyl Nonpreferred Brands Regranex QL Sulfamylon cream

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 72 10N. Miscellaneous dermatologicals Trade name Generic name Limits Preferred Generics Condylox solution podofilox Finacea gel azelaic acid Lac-Hydrin ammonium lactate Metrocream, gel, lotion metronidazole Prudoxin, Zonalon doxepin hcl PA, QL Solaraze diclofenac sodium PA, QL Soolantra ivermectin ST, QL Preferred Brands Condylox gel Drysol Qbrexza PA, QL Nonpreferred Brands Dupixent PA, QL Eucrisa PA, QL Finacea foam ST, QL Xolair syringe PA, QL Zonalon 30g PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 73 11. Ophthalmology

11A. Cycloplegic mydriatics Trade name Generic name Limits Preferred Generics Cyclogyl cyclopentolate hcl Isopto Atropine atropine sulfate Isopto Homatropine homatropine hbr Mydriacyl tropicamide Nonpreferred Brands Cyclogyl 5ml Cyclomydril Paremyd

11B. Glaucoma agents Trade name Generic name Limits Preferred Generics Alphagan 0.2%, P 0.15% brimonidine tartrate Azopt brinzolamide Cosopt dorzolamide hcl/timolol maleat Cosopt PF dorzolamide/timolol/pf Iopidine drops apraclonidine hcl Isopto-Carpine; Pilocar pilocarpine hcl Lumigan bimatoprost Neptazane methazolamide Travatan Z travoprost Trusopt dorzolamide hcl Xalatan latanoprost Preferred Brands Alphagan P 0.1% Combigan Lumigan 0.01% Rhopressa ST, QL Rocklatan ST, QL Nonpreferred Brands Iopidine dropperette Simbrinza Vyzulta PA Xelpros PA, QL Zioptan

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 74 11C. Ophthalmic anti -allergy agents Trade name Generic name Limits Preferred Generics Bepreve bepotastine besilate Elestat epinastine hcl Opticrom cromolyn sodium Optivar azelastine hcl Pataday olopatadine hcl Patanol olopatadine hcl Nonpreferred Brands Alocril Alomide Lastacaft

11D. Ophthalmic anti -infective and steroid combinations Trade name Generic name Limits Preferred Generics Cortisporin eye drops neomycin/polymyxin b/hydrocort Cortisporin eye ointment neomycin/bacit/p-myx/hydrocort Maxitrol neomycin/polymyxin b/dexametha Tobradex suspension tobramycin/dexamethasone Vasocidin sulfacetamide/prednisolone sp Preferred Brands Blephamide Tobradex ointment Tobradex ST Zylet Nonpreferred Brands Pred-G

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 75 11E. Ophthalmic anti -infectives Trade name Generic name Limits Preferred Generics Bacitracin bacitracin Bleph-10 ointment sulfacetamide sodium Bleph-10, Sodium Sulamyde drops sulfacetamide sodium Ciloxan drops ciprofloxacin hcl Garamycin gentamicin sulfate Ilotycin erythromycin base Moxeza moxifloxacin hcl Neosporin ophthalmic ointment neomycin sulf/bacitracin/poly Neosporin ophthalmic solution neomycin/polymyxn b/gramicidin Ocuflox ofloxacin Polysporin bacitracin/polymyxin b sulfate Polytrim polymyxin b sulf/trimethoprim Quixin levofloxacin Tobrex drops tobramycin Vigamox moxifloxacin hcl Viroptic trifluridine Zymaxid gatifloxacin Preferred Brands Besivance Ciloxan ointment Natacyn Zirgan Nonpreferred Brands Azasite Tobrex ointment

11F. Ophthalmic anti -inflammatory agents Trade name Generic name Limits Preferred Generics Acular, LS ketorolac tromethamine Bromday; Xibrom bromfenac sodium Ocufen flurbiprofen sodium Voltaren ophthalmic solution diclofenac sodium Nonpreferred Brands Acuvail Ilevro Nevanac Prolensa

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 76 11G. Ophthalmic beta blockers Trade name Generic name Limits Preferred Generics Betagan levobunolol hcl Betoptic solution betaxolol hcl Istalol timolol maleate Ocupress carteolol hcl Optipranolol metipranolol Timoptic Ocudose timolol maleate/pf Timoptic, XE timolol maleate Preferred Brands Betimol Betoptic S Nonpreferred Brands Timoptic Ocudose 0.25%

11H. Ophthalmic steroids Trade name Generic name Limits Preferred Generics Decadron ophthalmic dexamethasone sodium phosphate FML fluorometholone Inflamase, Forte prednisolone sodium phosphate Lotemax loteprednol etabonate Pred Forte prednisolone acetate Preferred Brands Alrex Durezol FML Forte, S.O.P. Pred Mild Nonpreferred Brands Flarex Inveltys PA, QL Lotemax ointment Lotemax SM PA, QL Maxidex

11I. Dry eye agents Trade name Generic name Limits Preferred Brands Lacrisert Restasis Xiidra QL Nonpreferred Brands Cequa QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 77 11J. Miscellaneous ophthalmic agents Trade name Generic name Limits Preferred Generics Neo-Synephrine phenylephrine hcl Preferred Brands Cystaran PA, QL Oxervate PA, QL Upneeq PA, QL Nonpreferred Brands Cystadrops PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 78 12. Otic and nasal preparations

12A. Nasal preparations Trade name Generic name Limits Preferred Generics Astelin nasal spray azelastine hcl QL Astepro nasal spray azelastine hcl QL Atrovent nasal spray ipratropium bromide QL Dymista azelastine/fluticasone PA, QL Flonase (Rx Only) fluticasone propionate QL Nasalide flunisolide QL Nasonex mometasone furoate ST, QL Patanase olopatadine hcl QL Preferred Brands Qnasl ST, QL Nonpreferred Brands Beconase AQ ST, QL Omnaris ST, QL Zetonna ST, QL

12B. Otic preparations Trade name Generic name Limits Preferred Generics Acetasol HC; Vosol HC hydrocortisone/acetic acid Auralgan aa/antipyrin/bcaine/polico1/al Ciprodex ciprofloxacin hcl/dexameth ciprofloxacin 0.2% dropperette ciprofloxacin hcl Cortisporin neomycin/polymyxin b/hydrocort Dermotic fluocinolone acetonide oil Floxin Otic ofloxacin Vosol acetic acid Preferred Brands Ciprofloxacin-fluocinolone vial (authorized generic of Otovel) Otovel Nonpreferred Brands Cipro HC Cortisporin-TC

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 79 13. Respiratory, cough and cold

13A. Antihistamine and decongestant combinations Trade name Generic name Limits

Antihistamine/Decongestant Combinations See Chapter 13B

13B. Antihistamines Trade name Generic name Limits Preferred Generics Astelin nasal spray azelastine hcl QL Astepro nasal spray azelastine hcl QL Atarax hydroxyzine hcl Benadryl (Rx Only) diphenhydramine hcl Clarinex desloratadine QL Histex PD carbinoxamine maleate Patanase olopatadine hcl QL Periactin cyproheptadine hcl Phenergan promethazine hcl Phenergan w/Codeine promethazine hcl/codeine Rynatan phenylephrine/chlor-tan Tavist tablet (Rx Only) clemastine fumarate Vistaril hydroxyzine pamoate Xyzal levocetirizine dihydrochloride QL Zyrtec solution (Rx Only) cetirizine hcl Preferred Brands Zyrtec-D Nonpreferred Brands Clarinex-D QL Karbinal ER ST, QL Zyrtec

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 80 13C. Antitussives Trade name Generic name Limits Preferred Generics Bromfed-DM brompheniramine/pseudoephed/dm CPB WC bromphenira/pseudoephed/codein Guaitussin AC codeine phosphate/guaifenesin Hycodan hydrocodone bit/homatrop me-br Phenergan DM promethazine/dextromethorphan Phenergan VC phenylephrine hcl/prometh hcl Phenergan VC w/Codeine promethazine/phenyleph/codeine Phenergan w/Codeine promethazine hcl/codeine Relcof C codeine phosphate/guaifenesin Robitussin AC codeine phosphate/guaifenesin Tessalon, Perles benzonatate Tussionex hydrocodone/chlorphen p-stirex Virtussin DAC pseudoephed/codeine/guaifen Zonatuss benzonatate Preferred Brands Tussicaps QL Nonpreferred Brands Cheratussin AC Coditussin AC Coditussin DAC Histex-AC M-End Pe Obredon QL Tuxarin ER Tuzistra XR QL

13D. Cystic Fibrosis agents Trade name Generic name Limits Preferred Generics Bethkis tobramycin PA, QL Tobi tobramycin in 0.225% sod chlor QL Preferred Brands Kalydeco PA, QL Orkambi PA, QL Pulmozyme PA Symdeko PA, QL Trikafta PA, QL Nonpreferred Brands Bronchitol PA, QL Cayston PA, QL Tobi Podhaler PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 81 13E. Epinephrine Trade name Generic name Limits Preferred Generics Epipen, Jr. epinephrine QL Preferred Brands Epinephrine auto-injector (authorized generic of QL Adrenaclick) Symjepi QL

13F. Inhaled anticholinergics Trade name Generic name Limits Preferred Generics Atrovent solution ipratropium bromide Preferred Brands Atrovent HFA QL Incruse Ellipta QL Spiriva, Respimat QL Nonpreferred Brands Lonhala Magnair QL Tudorza Pressair QL Yupelri QL

13G. Inhaled beta -agonist and anticholinergic combinations Trade name Generic name Limits Preferred Generics Duoneb ipratropium/albuterol sulfate Preferred Brands Anoro Ellipta QL Breztri Aerosphere QL Combivent Respimat QL Stiolto Respimat QL Trelegy Ellipta QL Nonpreferred Brands Bevespi Aerosphere QL

13H. Inhaled beta -agonists Trade name Generic name Limits Preferred Generics Albuterol nebulizer solution albuterol sulfate Brovana arformoterol tartrate QL Perforomist formoterol fumarate QL Proair HFA albuterol sulfate QL Proventil HFA albuterol sulfate QL Xopenex solution levalbuterol hcl Preferred Brands Serevent Diskus QL Striverdi Respimat QL Nonpreferred Brands Levalbuterol tartrate HFA (authorized generic of QL Xopenex HFA) Xopenex HFA QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 82 13I. Inhaled steroid and beta -agonist combinations Trade name Generic name Limits Preferred Generics Advair Diskus fluticasone propion/salmeterol QL Preferred Brands Advair HFA QL Breo Ellipta QL Breztri Aerosphere QL Dulera QL Symbicort QL Trelegy Ellipta QL Nonpreferred Brands Fluticasone-salmeterol RespiClick (authorized generic of QL Airduo Respiclick)

13J. Inhaled steroids Trade name Generic name Limits Preferred Generics Pulmicort solution budesonide Preferred Brands Arnuity Ellipta QL Asmanex, HFA QL Flovent HFA, Diskus QL Pulmicort Flexhaler QL Qvar RediHaler QL

13K. Intranasal steroids Trade name Generic name Limits

Intranasal Steroids See Chapter 12A

13L. Oral beta -agonists Trade name Generic name Limits Preferred Generics Alupent metaproterenol sulfate Brethine terbutaline sulfate Proventil solution albuterol sulfate Proventil/Ventolin tablet albuterol sulfate Vospire ER albuterol sulfate

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 83 13M. Pulmonary Hypertension Agents Trade name Generic name Limits Preferred Generics Adcirca tadalafil PA, QL Letairis ambrisentan PA, QL Revatio sildenafil citrate QL Revatio suspension sildenafil citrate PA, QL Tracleer bosentan PA, QL Preferred Brands Adempas PA, QL Opsumit PA, QL Orenitram ER PA, QL Tracleer tablet for suspension PA Tyvaso PA, QL Uptravi PA, QL Ventavis PA, QL

13N. Theophyllines Trade name Generic name Limits Preferred Generics Theophylline anhydrous theophylline anhydrous Preferred Brands Theo-24 Nonpreferred Brands Elixophyllin

13O. Miscellaneous respiratory agents Trade name Generic name Limits Preferred Generics Accolate zafirlukast QL Intal solution cromolyn sodium Mucomyst acetylcysteine Singulair montelukast sodium QL Sodium chloride inhalation sodium chloride for inhalation Zyflo CR zileuton QL Preferred Brands Actemra Actpen, syringe PA, QL Daliresp QL Esbriet PA, QL Fasenra Pen PA, QL Glassia PA, QL Ofev PA, QL Nonpreferred Brands Grastek PA, QL Hyper-Sal Nebusal Nucala auto-injector, syringe PA, QL Odactra PA, QL Oralair PA, QL Ragwitek PA, QL Xolair syringe PA, QL Zyflo QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 84 14. Urology

14A. BPH Treatment Trade name Generic name Limits Preferred Generics Avodart dutasteride Cardura doxazosin mesylate Cialis 2.5mg, 5mg tadalafil PA, QL Flomax tamsulosin hcl Hytrin terazosin hcl Jalyn dutasteride/tamsulosin hcl QL Proscar finasteride Rapaflo silodosin QL Uroxatral alfuzosin hcl Nonpreferred Brands Cardura XL

14B. Ion -Removing Agents Trade name Generic name Limits Preferred Generics Fosrenol lanthanum carbonate Kayexalate sodium polystyrene sulfonate Phoslo calcium acetate Renagel sevelamer hcl Renvela sevelamer carbonate SPS sodium polystyrene sulfonate SPS (sorbitol free) sodium polystyrene sulfon/sorb Preferred Brands Lokelma QL Veltassa QL Nonpreferred Brands Auryxia Fosrenol packet Phoslyra Velphoro

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 85 14C. Urinary Antispasmodics Trade name Generic name Limits Preferred Generics Detrol, LA tolterodine tartrate Ditropan, XL oxybutynin chloride Enablex darifenacin hydrobromide QL Levbid hyoscyamine sulfate Levsin, SL hyoscyamine sulfate Sanctura, XR trospium chloride QL Urispas flavoxate hcl Vesicare solifenacin succinate ST, QL Preferred Brands Toviaz ST, QL Nonpreferred Brands Gelnique ST, QL Myrbetriq PA, QL Vesicare LS PA, QL

14D. Miscellaneous Urologicals Trade name Generic name Limits Preferred Generics Depen penicillamine QL Thiola tiopronin PA, QL Urecholine bethanechol chloride Urocit-K potassium citrate Preferred Brands Cystagon Elmiron Renacidin Thiola EC PA, QL Xuriden PA, QL Nonpreferred Brands Lithostat Lupkynis PA, QL Nocdurna PA, QL Noctiva PA, QL Procysbi 25mg capsule, packet PA, QL Procysbi 75mg capsule PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 86 15. Vitamins and supplements

15A. Potassium Replacement Trade name Generic name Limits Preferred Generics K-Lor; Klor-Con packet potassium chloride Klor-Con M15 potassium chloride K-Lyte; Klor-con/EF potassium bicarbonate/cit ac K-Sol; Potassium Chloride potassium chloride K-Tab; K-Dur; Slow-K; Kaon CL; Klor-con potassium chloride Micro-K potassium chloride Preferred Brands Effer-K K-Tab 10meq Nonpreferred Brands K-Phos No.2 K-Phos Original

15B. Vitamins and Minerals Trade name Generic name Limits Preventive Drugs Folic Acid 0.4mg, 0.8mg (OTC) folic acid Sodium Fluoride 0.25mg, 0.5mg, 1mg* fluoride (sodium) Preferred Generics Calciferol (Rx Only) ergocalciferol (vitamin d2) Complete Natal DHA pnv combo 52/iron/fa/omega-3/dha Cyanocobalamin injection cyanocobalamin (vitamin b-12) Folic Acid 1mg (Rx only) folic acid Hydroxocobalamin hydroxocobalamin Mephyton phytonadione (vit k1) M-Natal Plus pnv,calcium 72/iron/folic acid PNV 29-1 prenatal vit,calc76/iron/folic Prenatabs FA prenatal vit,calc78/iron/folic Prenatabs Rx prenatal vit,calc76/iron/folic Prenatal Plus pnv,calcium 72/iron/folic acid Prenatal vitamin plus low iron pnv,calcium 72/iron/folic acid PrePLUS pnv,calcium 72/iron/folic acid PreTAB prenatal vit,calc78/iron/folic Prevident fluoride (sodium) Sodium Fluoride 0.25mg, 0.5mg, 1mg fluoride (sodium) Trinatal Rx 1 prenatal vit27,calcium/iron/fa Vitamin K ampule phytonadione (vit k1) Nonpreferred Brands Accrufer PA, QL Clinpro 5000 Fluoridex Galzin Prenata Prenatal Plus-DHA Prevident, 5000 Thrivite Rx *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 87 16. Diagnostic and other miscellaneous

16A. Chelating Agents Trade name Generic name Limits Preferred Generics Depen penicillamine QL Desferal deferoxamine mesylate Exjade deferasirox PA, QL Ferriprox deferiprone PA, QL Jadenu deferasirox PA, QL Syprine trientine hcl PA, QL Preferred Brands Chemet Nonpreferred Brands Ferriprox 1000mg tablet, solution PA, QL

16B. Diabetes monitoring and management products Trade name Generic name Limits Preventive Drugs Contour Meter QL Contour Next EZ Meter QL Contour Next Meter QL Contour Next One Meter QL Dexcom G6 Receiver QL Dexcom G6 Transmitter QL One Touch Ultra 2 Meter QL One Touch Ultra 2 Meter with Delica Plus QL One Touch Verio Flex Meter QL One Touch Verio Flex Meter with Delica Plus QL One Touch Verio Reflect Meter QL Preferred Brands Contour Next Test Strips QL Contour Test Strips QL Dexcom G6 Sensor 3-Pack QL Freestyle Libre 2 Reader 14-Day QL Freestyle Libre 2 Sensor 14-Day QL Freestyle Libre Reader 14-Day QL Freestyle Libre Sensor 14-Day QL Freestyle Test Strips QL OmniPod DASH Pods QL One Touch Delica Plus Lancets, 30 & 33G QL One Touch Ultra Soft Lancets QL One Touch Ultra Test Strips QL One Touch Verio Test Strips QL Simplicity 2 Unit QL Simplicity Inserter QL VGo 20 QL VGo 30 QL VGo 40 QL *Coverage of diabetic test strips depends on your plan

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 88 16C. Vaccines Trade name Generic name Limits Preventive Drugs ActHIB QL Adacel QL Afluria QL Bexsero QL Boostrix QL Daptacel QL Diphtheria-Tetanus Tox QL Engerix-B QL Fluad QL Fluarix QL Flublok QL Flucelvax QL Flulaval QL Flumist QL Fluzone QL Gardasil 9* QL Havrix QL Heplisav-B QL Hiberix QL Infanrix QL Ipol QL Janssen Covid-19 vaccine Kinrix QL Menactra QL MenQuadfi QL Menveo QL M-M-R II QL Moderna Covid-19 vaccine Pediarix QL PedvaxHIB QL Pentacel QL Pfizer Covid-19 vaccine Pneumovax 23 QL Prevnar 13* QL ProQuad QL Quadracel DTAP-IPV QL Recombivax HB QL Rotarix QL RotaTeq QL Shingrix* QL TDVAX QL Tenivac QL Trumenba QL Twinrix QL Vaqta QL Varivax QL Vaxelis QL *Age restrictions apply.

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 89 16D. Diagnostics and Other Miscellaneous Trade name Generic name Limits Preferred Generics Acetic Acid acetic acid Carnitor levocarnitine Carnitor SF levocarnitine Carnitor solution levocarnitine (with sugar) Orfadin nitisinone PA Samsca tolvaptan PA, QL Preferred Brands Jynarque PA, QL Orfadin 20mg capsule, suspension PA Radiogardase Samsca 15mg PA, QL Tolvaptan 15mg (authorized generic of Samsca) PA, QL Vistogard QL Nonpreferred Brands Cystadane Endari PA, QL Keveyis PA, QL Nityr PA

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 90 17. Lifestyle modification

17A. Sexual Dysfunction Trade name Generic name Limits Preferred Generics Cialis tadalafil PA, QL Levitra vardenafil hcl PA, QL Staxyn vardenafil hcl PA, QL Viagra sildenafil citrate PA, QL Preferred Brands Caverject PA, QL Muse PA, QL Nonpreferred Brands Addyi PA, QL Edex PA, QL Stendra PA, QL Vyleesi PA, QL

17B. Smoking Cessation Trade name Generic name Limits Preventive Drugs Chantix* ST, QL Commit Lozenge OTC* nicotine polacrilex QL Nicorette lozenge* nicotine polacrilex QL Nicotine gum; Nicorette* nicotine polacrilex QL Nicotine patch* nicotine QL Nicotrol, NS* ST, QL Zyban* bupropion hcl QL Preferred Brands Chantix QL Nonpreferred Brands Nicotrol, NS ST, QL *Age restrictions apply.

17C. Weight Loss Preparations Trade name Generic name Limits Preferred Generics Adipex-P phentermine hcl Bontril phendimetrazine tartrate Didrex benzphetamine hcl Tenuate diethylpropion hcl Preferred Brands Imcivree PA, QL Nonpreferred Brands Contrave PA, QL Lomaira Qsymia PA, QL Saxenda PA, QL Xenical PA, QL

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug Preventative drugs may be covered at $0 if criteria are met ver. 1 Blue Cross Clinical Drug List - September 2021 Page 91 18. Hemophilia

18A. Antihemophilic Agents Trade name Generic name Limits Preferred Brands Advate Adynovate Afstyla Alphanate Alphanine SD Alprolix Benefix Coagadex Corifact Eloctate Esperoct Feiba NF Hemlibra PA Hemofil M Humate-P Idelvion Ixinity Jivi Koate Kogenate FS Kovaltry Mononine Novoeight NovoSeven RT Nuwiq Obizur Profilnine Rebinyn Recombinate Rixubis Sevenfact Tretten Vonvendi Wilate Xyntha Xyntha Solofuse

PA - Prior approval may be required ST - Step therapy may be required QL - Quantity limits may apply - Specialty Drug ver. 1 Blue Cross Clinical Drug List - September 2021 Page 92 We speak your language Se tu o qualcuno che stai aiutando avete bisogno di assistenza, hai If you, or someone you’re helping, needs assistance, you have the il diritto di ottenere aiuto e informazioni nella tua lingua right to get help and information in your language at no cost. To gratuitamente. Per parlare con un interprete, rivolgiti al Servizio talk to an interpreter, call the Customer Service number on the Assistenza al numero indicato sul retro della tua scheda o chiama back of your card, or 877-469-2583, TTY: 711 if you are not il 877-469-2583, TTY: 711 se non sei ancora membro. already a member. ご本人様、またはお客様の身の回りの方で支援を必要とさ Si usted, o alguien a quien usted está ayudando, necesita れる方でご質問がございましたら、ご希望の言語でサポー asistencia, tiene derecho a obtener ayuda e información en su トを受けたり、情報を入手したりすることができます。料 idioma sin costo alguno. Para hablar con un intérprete, llame al 金はかかりません。通訳とお話される場合はお持ちのカー número telefónico de Servicio al cliente, que aparece en la parte ドの裏面に記載されたカスタマーサービスの電話番号 trasera de su tarjeta, o 877-469-2583, TTY: 711 si usted todavía no (メンバーでない方は877-469-2583, TTY: 711) es un miembro. までお電話ください。 Если вам или лицу, которому вы помогаете, нужна помощь, то إذا ﻛﻨﺖ أﻧﺖ أو ﺷﺨﺺ آﺧﺮ ﺗﺴﺎﻋﺪه ﺑﺤﺎﺟﺔ ﻟﻤﺴﺎﻋﺪة، ﻓﻠﺪﯾﻚ اﻟﺤﻖ ﻓﻲ اﻟﺤﺼﻮل ﻋﻠﻰ вы имеете право на бесплатное получение помощи и اﻟﻤﺴﺎﻋﺪة واﻟﻤﻌﻠﻮﻣﺎت اﻟﻀﺮورﯾﺔ ﺑﻠﻐﺘﻚ دون أﯾﺔ ﺗﻜﻠﻔﺔ. ﻟﻠﺘﺤﺪث إﻟﻰ ﻣﺘﺮﺟﻢ اﺗﺼﻞ ﺑﺮﻗﻢ информации на вашем языке. Для разговора с переводчиком ﺧﺪﻣﺔ اﻟﻌﻤﻼء اﻟﻤﻮﺟﻮد ﻋﻠﻰ ظﮭﺮ ﺑﻄﺎﻗﺘﻚ، أو ﺑﺮﻗﻢ TTY:711 2583-469-877، إذا позвоните по номеру телефона отдела обслуживания ﻟﻢ ﺗﻜﻦ ﻣﺸﺘﺮﻛﺎ ﺑﺎﻟﻔﻌﻞ. 如果您，或是您正在協助的對象，需要協助，您有權利免費 клиентов, указанному на обратной стороне вашей карты, или 以您的母語得到幫助和訊息。要洽詢一位翻譯員，請撥在您 по номеру 877-469-2583, TTY: 711, если у вас нет членства. 的卡背面的客戶服務電話；如果您還不是會員，請撥電話 Ukoliko Vama ili nekome kome Vi pomažete treba pomoć, imate 877-469-2583, TTY: 711。 pravo da besplatno dobijete pomoć i informacije na svom jeziku. ܵ ܿ ܿ ܿ ܿ ܵ ܿ ܿ ܿ ܿ ܿ Da biste razgovarali sa prevodiocem, pozovite broj korisničke ܸܐܢ ܼܐܚܬܘܢ، ܼܿܝܢ ܼܚܕ ܼܦܪܨܘܦܐ ܼܕܗ ܼܝܘ ܼܪܘܬܘܢ ، ܼܣܢܝ ܼܩܝ ܝܬܘܢ ܼܗ ܼܿܝܪܬܐ، ܿ ܵ ܵ ܵ ܿ ܵ ܿ ܿ ܿ ܵ ܿ ܿ ܵ ܿ ܿ službe sa zadnje strane kartice ili 877-469-2583, TTY: 711 ako već ܢܘܟܘ݂ ܢܫܠܒܸ ܐܬܘܢܼ ܥܕܘܵ ܡܘܼ ܐܬܪܝܼܿ ܗܼ ܢ ܘ ܬ ܝܼ ܠ ܒ ܩܼ ܕ ܐܬܘܩܼ ܗܼ ܢܘܟܘ݂ ܠܬܝܐܼ ܢܘܬܚܐܼ ܵ ܿ ܿ ܵ ܵ ܿ ܵ ܿ ܿ ܵ ܵ niste član. ܕ� ܼܛܝܡܐ. ܼܠܗ ܼܡܙܡܬܐ ܼܿܥܡ ܼܿܚܕ ܼܡܬܪܓܡܢܐ، ܩܪܘܢ ܼܿܥܠ ܹܬ ܼܠܝܦܘܢ ܸܡ ܵܢܝܢܐ ܵ ܵ ܿ ܵ ܿ ܵ �ܗ ܢܐܸ 877-469-2583 TTY:711 ܢܝܼܿ ܢܘܼ ܟ݂ܘܩܬܦܕܸ ܐܨܵ ܚ ܠܥܼ ܐܢܝܐܕܼ Kung ikaw, o ang iyong tinutulungan, ay nangangailangan ng ̈ ܵ ܿ .ܐܡܹ ܕܗܼ ܢܘܬܼ ܝܠܼ tulong, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang Nếu quý vị, hay người mà quý vị đang giúp đỡ, cần trợ giúp, quý vị tagasalin, tumawag sa numero ng Customer Service sa likod ng sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của iyong tarheta, o 877-469-2583, TTY: 711 kung ikaw ay hindi pa mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi số isang miyembro. Dịch vụ Khách hàng ở mặt sau thẻ của quý vị, hoặc 877-469-2583, TTY: 711 nếu quý vị chưa phải là một thành viên. Important disclosure Nëse ju, ose dikush që po ndihmoni, ka nevojë për asistencë, keni Blue Cross Blue Shield of Michigan and Blue Care Network comply të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. with Federal civil rights laws and do not discriminate on the basis Për të folur me një përkthyes, telefononi numrin e Shërbimit të of race, color, national origin, age, disability, or sex. Blue Cross Klientit në anën e pasme të kartës tuaj, ose 877-469-2583, Blue Shield of Michigan and Blue Care Network provide free TTY: 711 nëse nuk jeni ende një anëtar. auxiliary aids and services to people with disabilities to 만약 귀하 또는 귀하가 돕고 있는 사람이 지원이 필요하다면, communicate effectively with us, such as qualified sign language 귀하는 도움과 정보를 귀하의 언어로 비용 부담 없이 얻을 수 interpreters and information in other formats. If you need these 있는 권리가 있습니다. 통역사와 대화하려면 귀하의 카드 services, call the Customer Service number on the back of your 뒷면에 있는 고객 서비스 번호로 전화하거나, 이미 회원이 card, or 877-469-2583, TTY: 711 if you are not already a member. 아닌 경우 877-469-2583, TTY: 711로 전화하십시오. If you believe that Blue Cross Blue Shield of Michigan or Blue Care Network has failed to provide services or discriminated in another যিদ আপনার, বা আপিন সাহায뷍 করেছন এমন কােরা, সাহায뷍 �েয়াজন হয়, way on the basis of race, color, national origin, age, disability, or তাহেল আপনার ভাষায় িবনামূেল뷍 সাহায뷍 ও তথ뷍 পাওয়ার অিধকার আপনার sex, you can file a grievance in person, by mail, fax, or email with: রেয়েছ। েকােনা একজন েদাভাষীর সােথ কথা বলেত, আপনার ক া ে ড쇍 র েপছেন Office of Civil Rights Coordinator, 600 E. Lafayette Blvd., MC 1302, েদওয়া �াহক সহায়তা ন�ের কল কর‍ন বা 877-469-2583, TTY: 711 Detroit, MI 48226, phone: 888-605-6461, TTY: 711, যিদ ইেতামেধ뷍 আপিন সদস뷍 না হেয় থােকন। fax: 866-559-0578, email: [email protected]. If you need help filing a grievance, the Office of Civil Rights Coordinator is Jeśli Ty lub osoba, której pomagasz, potrzebujecie pomocy, masz available to help you. prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer You can also file a civil rights complaint with the U.S. Department działu obsługi klienta, wskazanym na odwrocie Twojej karty lub of Health & Human Services Office for Civil Rights electronically pod numer 877-469-2583, TTY: 711, jeżeli jeszcze nie masz through the Office for Civil Rights Complaint Portal available at członkostwa. https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, phone, or email at: U.S. Department of Health & Human Services, Falls Sie oder jemand, dem Sie helfen, Unterstützung benötigt, 200 Independence Ave, S.W., Washington, D.C. 20201, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer phone: 800-368-1019, TTD: 800-537-7697, Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, email: [email protected]. Complaint forms are rufen Sie bitte die Nummer des Kundendienstes auf der Rückseite available at http://www.hhs.gov/ocr/office/file/index.html. Ihrer Karte an oder 877-469-2583, TTY: 711, wenn Sie noch kein Mitglied sind.   

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