BLUE RX COMPLETESM FORMULARY HOW TO READ THE FORMULARY All drugs are listed by their generic names and/or most common proprietary (brand) name. Specific drug listings may be accessed either by generic (in lowercase) or brand name (in uppercase) and by therapeutic drug tier. Any drug not found in this formulary listing, or any formulary updates published by Wellmark, shall be considered excluded from your benefit. Once the product is located, the following items can be viewed: Drug Tier: Drugs are categorized within tiers on the formulary. Each tier is assigned a cost, which is determined by the member’s pharmacy benefit plan. Tier Designation in Formulary Below Formulary Tier 1 Formulary Tier 2 Formulary Tier 3 Formulary Tier 4 Complete Plan 4 Tier Tier 1 Tier 2 Tier 3 Tier 4 Complete Plan 3 Tier Tier 1 Tier 2 Tier 3 and Tier 4 combined Complete Plan 2 Tier Tier 1 Tier 2, Tier 3 and Tier 4 combined Complete Plan 1 Tier Tier 1, Tier 2, Tier 3 and Tier 4 combined Pharmacy Durable Medical Equipment (RxDME): Devices available on this tier include select durable medical equipment (DME) that are used in conjunction with a drug and may be obtained from a pharmacy. Specialty Drugs: Specialty drugs are high-cost injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient’s drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit. Specialty Drugs Preferred (SP-P): Drugs in this category will process with the preferred specialty drug cost-share. Specialty Drugs Non-Preferred (SP-NP): Drugs in this category will process with the non-preferred specialty cost-share, and will have a higher cost share than preferred specialty drugs. Specialty Medical (SP-M): Drugs in this category will be covered under your medical benefit. Drug Name: This lists the generic name for the product (lowercase) OR the brand name or common reference name for the product (UPPERCASE). Requirements/Limits: This lists Wellmark Pharmacy programs that may impact a particular drug or class of drugs and are described in the legend below. HEALTH CARE REFORM PREVENTIVE DRUGS Preventive drugs with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF) and immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not associated with any cost share for members on plans with this benefit. A complete list of recommendations and guidelines related to preventive services can be found at Healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management. BENEFIT COVERAGE AND LIMITATIONS This printed formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments or a lack of coverage, which are not reflected in the Blue Rx Complete formulary. Members should contact their Plan Sponsor or Wellmark Customer Service at the number on the back of their ID card if they have questions regarding their coverage. Please note that the formulary process is evolutionary, and changes can occur throughout the year. The following topics may or may not be applicable depending on the parameters of your specific benefits. ©2021 Wellmark, Inc. 1 FORMULARY EXCEPTION PROCESS Drugs not included in this list shall be considered non-formulary and are NOT COVERED. In some instances, Wellmark will consider coverage exceptions. Coverage of non-formulary drugs may be requested by the health care professional through an exception request for a non-formulary prescription drug (outlined below). Generally, one of the following guidelines must be documented for an exception to be granted: All covered formulary drugs on any tier will be ineffective; OR All covered formulary drugs on any tier have been ineffective; OR All covered formulary drugs on any tier would not be as effective as the non-formulary drug; OR All covered formulary drugs would have adverse effects COMMON DRUG EXCLUSIONS Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to: Over-the-counter (OTC) drugs or their equivalents unless otherwise specified in the formulary listing. Drug products used for cosmetic purposes Experimental drug products, or any drug product used in an experimental manner Replacement of a lost or stolen drug Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA) CONTACT INFORMATION The Blue Rx Complete formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Wellmark encourages your input and feedback on how we can assist in improving this document and the formulary management process. Please direct your communications to: Wellmark Blue Cross and Blue Shield 1331 Grand Avenue P.O. Box 9232 Des Moines, IA 50306 In addition to the Blue Rx Complete formulary, other quick reference guides are available at Wellmark.com. ©2021 Wellmark, Inc. 2 LEGEND TIER DESCRIPTION 1 TIER 1 2 TIER 2 3 TIER 3 4 TIER 4 5 SP-P 6 SP-NP 7 RX-DME 8 P&T 9 SP-M TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. Amounts over the QL Quantity Limit specified quantity limits are not a covered benefit unless Post- Quantity Limit Prior Authorization is available. This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our PA Prior Authorization Pharmacy program at 800-600-8065. Hours of operation are Monday- Friday: 8 a.m. to 6 p.m. CST. This prescription drug may only be covered if you meet the minimum AL Age Limit or maximum age limit. This indicates a preferred biosimilar or generic specialty drug. Please Specialty Biosimilars and SBG read your enrollment information to see how specialty biosimilars and Specialty Generics specialty generics are covered specific to your plan. This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 800-600- 8065. Hours of operation are Medical Necessity Prior MN-PA Monday - Friday: 8 a.m. to 6 p.m. CST. The intent of formulary Authorization medical necessity prior authorization is to confirm the appropriate coverage of the target drugs when evidence is provided documenting a trial and failure of the preferred formulary alternatives. A quantity limit on this drug limits the amount covered per prescription, or time period, and may vary based on the diagnosis. QLV Quantity Limit (Varies) Amounts over the quantity limit are not a covered benefit unless Post Quantity Limit Prior Authorization is available. ©2021 Wellmark, Inc. 3 This indicates a greater quantity may be covered under your benefit Post-Quantity Limit Prior if Post-Quantity Limit Prior Authorization is obtained. Your health PA-QL Authorization care provider will need to contact our Pharmacy program at 800-600- 8065. Hours of operation are Monday-Friday: 8 a.m. to 6 p.m. CST Indicates a generic equivalent is available for a brand name drug. In most cases, when you purchase a brand name drug that has an FDA-approved A-rated generic equivalent, Wellmark will pay only GA Generic Available what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug. Preventive drugs are prescribed to prevent the occurrence of a disease or condition and are defined by the Internal Revenue Service. The preventive drug enhanced benefit is available on PV Preventive specific high deductible health plans. This is an optional benefit that waives the deductible for preventive drugs. Please read your enrollment information to see how preventive drugs are covered specific to your plan. ©2021 Wellmark, Inc. 4 09/2021 BRAND NAME DRUG DESCRIPTION (RX) TIER LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ANAPROX DS 550 MG ANAPROX DS TAB TIER 4 GA naproxen sodium ARTHROTEC (50-0.2 MG TAB DR, 75-0.2 MG TAB ARTHROTEC TIER 4 GA DR) diclofenac w/ misoprostol butalbital-aspirin- butalbital-aspirin-caffeine TIER 1 caffeine 50-325-40 mg cap cataflam cataflam 50 mg tab TIER 1 CELEBREX (50 MG CAP, 100 MG CAP, 200 MG CELEBREX TIER 4 QL (60 PER 30 DAYS), GA CAP) celecoxib celecoxib (50 mg cap, 100 celecoxib TIER 1 QL (60 PER 30 DAYS) mg cap, 200 mg cap) choline-mag choline-mag trisalicylate TIER 1 trisalicylate 500 mg/5ml liquid DAYPRO 600 MG TAB DAYPRO TIER 4 GA oxaprozin diclofenac epolamine 1.3 % diclofenac epolamine TIER 1 PA, QL (60 PER 30 DAY(S)) patch diclofenac potassium 50 mg diclofenac potassium TIER 1 tab diclofenac sodium (25 mg diclofenac sodium tab dr, 50 mg tab dr, 75 mg TIER 1 tab dr) diclofenac sodium 1.5 % diclofenac sodium TIER 1 QL (300 PER 30 DAY(S)) solution diclofenac sodium er 100 diclofenac sodium er TIER 1 mg tab er 24h diclofenac-misoprostol (50- diclofenac- 0.2 mg tab dr, 75-0.2 mg TIER 1 misoprostol tab dr) diflunisal diflunisal 500 mg tab TIER 1 EC-NAPROSYN (375 MG EC-NAPROSYN TAB DR, 500 MG TAB DR) TIER 4 GA naproxen ec-naproxen (375 mg tab ec-naproxen TIER 1 dr, 500 mg tab dr) ©2021 Wellmark, Inc.