Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary

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Plan Year (Updated February ) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary The formulary is regularly updated. Please visit bcbsnd.

.. II Affordable Care Act... II Specialty... II... II... II... II... III Providers... III Abbreviation/acronym key... IV Therapeutic Class Drug List Anti-Infective Agents... Biologicals.

.. 59 Analgesics and Anesthetics... 74 Neuromuscular Drugs... 8 Nutritional Products... 90 Hematological Agents... 9 Topical Products... 97 Miscellaneous Products... 06 Index.

1 Plan Year (Updated February ) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary The formulary is regularly updated. Please visit bcbsnd.com or Prime Therapeutics website at for the most up-to-date information. Contents Introduction... I How formulary drugs are selected... I Coverage considerations... I Tiers... II Affordable Care Act... II Specialty... II... II... II... II... III Providers... III Abbreviation/acronym key... IV Therapeutic Class Drug List Anti-Infective Agents... Biologicals... Antineoplastic Agents... Endocrine and Metabolic Drugs... 9 Cardiovascular Agents... 4 Respiratory Agents Gastrointestinal Agents... 5 Genitourinary Agents Central Nervous System Drugs Analgesics and Anesthetics Neuromuscular Drugs... 8 Nutritional Products Hematological Agents... 9 Topical Products Miscellaneous Products Index... 0 To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. 66-D ND HIM Prime Therapeutics LLC 0/9

2 Introduction The Blue Cross Blue Shield of North Dakota (BCBSND) BlueCare, BlueDirect and BlueEssential/Simply Blue formulary contains covered drugs for a broad range of diseases. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand is a non-formulary (non-preferred) drug. Some generic products have no reference brand. Brand prescription drugs are shown in capital letters followed by the generic name. The BCBSND BlueCare, BlueDirect and BlueEssential/Simply Blue formulary is organized into broad categories (e.g. Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes). To save the most money on prescription drugs, take this Formulary with you each time you visit your physician. Consider asking your physician to prescribe generic and formulary drugs, if appropriate. Any and all decisions that require or pertain to independent professional medical judgment or training, or the need for, and dosage of, a prescription drug, must be made solely by you and your physician in accordance with the patient/physician relationship. The current version of this Formulary is available at the BCBSND website at bcbsnd.com or by calling the customer service number listed on your identification card. Online pharmacy tools are available through the Prime Therapeutics website at BCBSND members can find drug cost estimates or check if a particular drug is on the BCBSND formulary. How formulary drugs are selected Formulary drugs are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from your health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. Coverage considerations Most prescription drug benefit plans provide coverage for up to a 90-day supply of medication, with some exceptions. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction (example: Viagra) or infertility (example: Follistim AQ). You should refer to your benefit plan booklet for details about your particular benefits. Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary Plan Year (February ) I

3 Tiers This prescription benefit is multi-tiered, placing prescription drugs into one of four copay/coinsurance levels: Tier Generic Tier Preferred Brand Tier Non-preferred Brand Tier 4 Specialty Note: If a drug displays an A in the column, this indicates the drug may only be covered if a member meet the criteris for $0 copay under the Affordable Care Act. Affordable Care Act Drugs marked in the column are covered at $0 cost share when meeting the conditions outlined under the Affordable Care Act. Examples of categories of drugs that may be subject to limited or $0 cost share include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D supplements, and some contraceptive drugs and devices. If you do not find the drug you are searching for, consult or contact BCBSND to find out if the drug is available over the counter or is covered under your medical benefit. Specialty Products Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. Drugs marked as have restrictions on where you may obtain the drug. This may include requiring the use of a designated pharmacy to fill a prescription. Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. If a step therapy is required for a medication listed in this document, it will be noted next to the medication with a dot under the column. Your benefit plan may require prior approval for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a prior approval request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. If a prior approval is required for a medication listed in this document, it will be noted next to the medication with a dot under the column. Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary Plan Year (February ) II

4 Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies, it will be noted next to the medication with a dot under the column. Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in a given time period. If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows. There may also be limits for members within a certain age range, and coverage only for members of a specific gender. Providers Use of some products may be approved only after certain criteria are met. If prior approval is not obtained, benefits may be denied. A physician (or clinic personnel) should submit a written request for prior approval consideration. Products in certain drug categories may have dispensing limits to encourage appropriate prescribing quantities as recommended by the FDA approved product labeling, or as otherwise clinically appropriate. Requests for a quantity that exceeds the dispensing limit should be submitted for consideration on the Products in certain drug categories may have a program to encourage utilizing the most costeffective medication. This program requires the previous use of one or more drugs before coverage of a different drug is provided. Requests for medication that require a step therapy should be submitted on the forms available. Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary Plan Year (February ) III

5 Abbreviation/acronym key caps... capsules chew... chewable conc... concentrate cr... controlled release dr... delayed release ec... enteric coated effe... effervescent equiv... equivalent er... extended release inhal... inhalation inj... injection liq... liquid lotn... lotion nebu... nebulizer odt... orally disintegrating tablets oint... ointment ophth... ophthalmic osm... osmotic release powd... powder sa... sustained action sl... sublingual soln... solution sr... sustained release suppos... suppositories susp... suspension tab... tablets td...transdermal Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary Plan Year (February ) IV

In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the following disclosure: Blue Cross Blue Shield of North Dakota complies with applicable

Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

6 In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the following disclosure: Blue Cross Blue Shield of North Dakota complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of North Dakota: Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified sign language interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages If you need these services, please call Member Services at (toll-free) or through the North Dakota Relay at or 7. If you believe that Blue Cross Blue Shield of North Dakota has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator 450 th Ave S Fargo, ND or North Dakota Relay at or (fax) CivilRightsCoordinator@bcbsnd.com ( ) You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 00 Independence Avenue SW. Room 509F, HHH Building Washington, DC or (TDD) Complaint forms are available at Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: o 7). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: oder 7). 450 th Avenue South, Fargo, North Dakota 58 Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association Noridian Mutual Insurance Company

7 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務請致電 (TTY: 或 7) Oroomiffa (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: ykn 7). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: hoặc 7). Ikirundi (Bantu Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona (TTY: canke 7). (Arabic) العربية ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: أو 7.) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu (TTY: au 7). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: или 7). 日本語 (Japanese) 注意事項 : 日本語を話される場合無料の言語支援をご利用いただけます (TTY: または 7) までお電話にてご連絡ください न प ल (Nepali) ध य न द न ह स: तप र इ ल न प ल ब ल न ह न छ भन तप र इ क ननम तत भ ष सह यत स व हर नन श ल क र पम उपलब ध छ फ न गन ह स (द द व र इ: व 7) Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ou 7). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 또는 7) 번으로전화해주십시오. Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: o 7). Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring (TTY: eller 7). Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti go Diné Bizaad, saad bee áká ánída áwo dę ę, t áá jiik eh, éí ná hólǫ, kojį hódíílnih (TTY: éí doodagó 7.)

8 ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN - amoxicillin (trihydrate) chew tab 5 AMOXICILLIN - amoxicillin (trihydrate) chew tab 50 amoxicillin (trihydrate) cap 50 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) for susp 5 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) for susp 50 /5ml amoxicillin (trihydrate) for susp 400 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr (Augmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab (Augmentin) amoxicillin & k clavulanate tab (Augmentin) AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab AMPICILLIN - ampicillin cap 500 AUGMENTIN - amoxicillin & k clavulanate for susp 5-.5 /5ml dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 PENICILLIN V POTASSIUM - penicillin v potassium for soln 5 /5ml PENICILLIN V POTASSIUM - penicillin v potassium for soln 50 /5ml penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHALOSPORINS cefaclor cap 50 cefaclor cap 500 cefadroxil cap 500 cefadroxil for susp 50 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 00 Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

9 cefdinir for susp 5 /5ml cefdinir for susp 50 /5ml CEFDITOREN PIVOXIL - cefditoren pivoxil tab 00 (base equivalent) CEFDITOREN PIVOXIL - cefditoren pivoxil tab 400 (base equivalent) cefixime for susp 00 /5ml (Suprax) cefixime for susp 00 /5ml (Suprax) cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 00 /5ml cefpodoxime proxetil tab 00 cefpodoxime proxetil tab 00 cefprozil for susp 5 /5ml cefprozil for susp 50 /5ml cefprozil tab 50 cefprozil tab 500 cefuroxime axetil tab 50 (Ceftin) cefuroxime axetil tab 500 (Ceftin) cephalexin cap 50 (Keflex) cephalexin cap 500 (Keflex) cephalexin cap 750 (Keflex) cephalexin for susp 5 /5ml cephalexin for susp 50 /5ml MACROLIDES AZITHROMYCIN - azithromycin powd pack for susp gm azithromycin for susp 00 /5ml (Zithromax) azithromycin for susp 00 /5ml (Zithromax) azithromycin tab 50 (Zithromax) azithromycin tab 500 (Zithromax) azithromycin tab 600 (Zithromax) CLARITHROMYCIN - clarithromycin for susp 5 /5ml CLARITHROMYCIN - clarithromycin for susp 50 /5ml clarithromycin tab er 4hr 500 clarithromycin tab 50 (Biaxin) clarithromycin tab 500 (Biaxin) DIFICID - fidaxomicin tab 00 E.E.S erythromycin ethylsuccinate tab 400 ERY-TAB - erythromycin tab delayed release 50 ERY-TAB - erythromycin tab delayed release ERY-TAB - erythromycin tab delayed release 500 ERYPED erythromycin ethylsuccinate for susp 400 /5ml Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

10 ERYTHROCIN STEARATE - erythromycin stearate tab 50 ERYTHROMYCIN ETHYLSUCCINA - erythromycin ethylsuccinate tab 400 erythromycin ethylsuccinate for susp 00 /5ml (E.e.s. granules) erythromycin tab 50 erythromycin tab 500 erythromycin w/ delayed release particles cap 50 ZITHROMAX - azithromycin powd pack for susp gm TETRACYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 00 doxycycline hyclate cap 50 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab 0 doxycycline hyclate tab 00 doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 (Monodox) doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 (Adoxa) doxycycline monohydrate for susp 5 /5ml (Vibramycin) doxycycline monohydrate tab 50 (Adoxa) doxycycline monohydrate tab 75 (Adoxa) doxycycline monohydrate tab 00 (Adoxa pak /00) doxycycline monohydrate tab 50 (Adoxa pak /50) minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 00 tetracycline hcl cap 50 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) FLUOROQUINOLONES BAXDELA - delafloxacin meglumine tab 450 (base equiv) CIPROFLOXACIN ER - ciprofloxacin-ciprofloxacin hcl tab er 4hr 500 (base eq) CIPROFLOXACIN ER - ciprofloxacin-ciprofloxacin hcl tab er 4hr 000 (base eq) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXACIN HCL - ciprofloxacin hcl tab 00 (base equiv) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

11 ciprofloxacin hcl tab 50 (base equiv) (Cipro) ciprofloxacin hcl tab 500 (base equiv) (Cipro) ciprofloxacin hcl tab 750 (base equiv) levofloxacin oral soln 5 / ml (Levaquin) levofloxacin tab 50 (Levaquin) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) moxifloxacin hcl tab 400 (base equiv) (Avelox) OFLOXACIN - ofloxacin tab 00 ofloxacin tab 400 AMINOGLYCOSIDES BETHKIS - tobramycin nebu soln 00 /4ml KITABIS PAK - tobramycin nebu soln 00 /5ml neomycin sulfate tab 500 paromomycin sulfate cap 50 TOBI PODHALER - tobramycin inhal cap 8 TOBRAMYCIN - tobramycin nebu soln 00 /5ml tobramycin nebu soln 00 /5ml (Tobi) SULFONAMIDES SULFADIAZINE - sulfadiazine tab 500 ANTIMYCOBACTERIAL AGENTS CYCLOSERINE - cycloserine cap 50 ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 400 (Myambutol) ISONIAZID - isoniazid syrup 50 /5ml isoniazid tab 00 isoniazid tab 00 PASER - aminosalicylic acid er granules packet 4 gm PRIFTIN - rifapentine tab 50 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) RIFAMATE - isoniazid & rifampin cap rifampin cap 50 (Rifadin) rifampin cap 00 (Rifadin) RIFATER - isoniazid-rifampin w/ pyrazinamide tab SIRTURO - bedaquiline fumarate tab 00 (base equiv) TRECATOR - ethionamide tab 50 ANTIFUNGALS CRESEMBA - isavuconazonium sulfate cap 86 fluconazole for susp 0 / ml (Diflucan) fluconazole for susp 40 / ml (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 4

12 fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) flucytosine cap 50 (Ancobon) flucytosine cap 500 (Ancobon) griseofulvin microsize susp 5 /5ml griseofulvin microsize tab 500 (Grifulvin v) griseofulvin ultramicrosize tab 5 (Gris-peg) griseofulvin ultramicrosize tab 50 (Gris-peg) itraconazole cap 00 (Sporanox) itraconazole oral soln 0 / ml (Sporanox) NOXAFIL - posaconazole susp 40 /ml NOXAFIL - posaconazole tab delayed release 00 nystatin tab unit terbinafine hcl tab 50 (Lamisil) voriconazole for susp 40 /ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 00 (Vfend) ANTIVIRALS abacavir sulfate soln 0 / ml (base equiv) (Ziagen) abacavir sulfate tab 00 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab (Epzicom) abacavir sulfatelamivudine-zidovudine tab (Trizivir) acyclovir cap 00 (Zovirax) acyclovir susp 00 /5ml (Zovirax) acyclovir tab 400 (Zovirax) acyclovir tab 800 (Zovirax) adefovir dipivoxil tab 0 (Hepsera) APTIVUS - tipranavir cap 50 APTIVUS - tipranavir oral soln 00 /ml atazanavir sulfate cap 50 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) ATRIPLA - efavirenzemtricitabine-tenofovir df tab BARACLUDE - entecavir oral soln 0.05 /ml BIKTARVY - bictegraviremtricitabine-tenofovir af tab CIMDUO - lamivudine-tenofovir disoproxil fumarate tab COMPLERA - emtricitabinerilpivirine-tenofovir df tab Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 5

13 CRIXIVAN - indinavir sulfate cap 00 CRIXIVAN - indinavir sulfate cap 400 DESCOVY - emtricitabinetenofovir alafenamide fumarate tab 00-5 didanosine delayed release capsule 00 (Videx ec) didanosine delayed release capsule 50 (Videx ec) didanosine delayed release capsule 400 (Videx ec) EDURANT - rilpivirine hcl tab 5 (base equivalent) efavirenz cap 50 (Sustiva) efavirenz cap 00 (Sustiva) efavirenz tab 600 (Sustiva) EMTRIVA - emtricitabine caps 00 EMTRIVA - emtricitabine soln 0 /ml entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUSA - sofosbuvirvelpatasvir tab EPIVIR HBV - lamivudine oral soln 5 /ml (hbv) EPZICOM - abacavir sulfatelamivudine tab EVOTAZ - atazanavir sulfatecobicistat tab (base equiv) famciclovir tab 5 (Famvir) famciclovir tab 50 (Famvir) famciclovir tab 500 (Famvir) fosamprenavir calcium tab 700 (base equiv) (Lexiva) FUZEON - enfuvirtide for inj 90 GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab HARVONI - ledipasvirsofosbuvir tab INTELENCE - etravirine tab 5 INTELENCE - etravirine tab 00 INTELENCE - etravirine tab 00 INVIRASE - saquinavir mesylate tab 500 ISENTRESS - raltegravir potassium chew tab 5 (base equiv) ISENTRESS - raltegravir potassium chew tab 00 (base equiv) ISENTRESS - raltegravir potassium packet for susp 00 (base equiv) ISENTRESS - raltegravir potassium tab 400 (base equiv) ISENTRESS HD - raltegravir potassium tab 600 (base equiv) JULUCA - dolutegravir sodiumrilpivirine hcl tab 50-5 (base eq) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 6

14 KALETRA - lopinavir-ritonavir soln /5ml (80-0 /ml) KALETRA - lopinavir-ritonavir tab 00-5 KALETRA - lopinavir-ritonavir tab lamivudine oral soln 0 / ml (Epivir) lamivudine tab 00 (hbv) (Epivir hbv) lamivudine tab 50 (Epivir) lamivudine tab 00 (Epivir) lamivudine-zidovudine tab (Combivir) LEDIPASVIR/SOFOSBUVIR - ledipasvir-sofosbuvir tab LEXIVA - fosamprenavir calcium susp 50 /ml (base equiv) LEXIVA - fosamprenavir calcium tab 700 (base equiv) lopinavir-ritonavir soln /5ml (80-0 / ml) (Kaletra) MAVYRET - glecaprevirpibrentasvir tab MODERIBA 00 DOSE PACK - ribavirin tab 600 nevirapine susp 50 /5ml (Viramune) nevirapine tab er 4hr 00 (Viramune xr) nevirapine tab er 4hr 400 (Viramune xr) nevirapine tab 00 (Viramune) NORVIR - ritonavir oral soln 80 /ml NORVIR - ritonavir powder packet 00 NORVIR - ritonavir tab 00 ODEFSEY - emtricitabinerilpivirine-tenofovir af tab oseltamivir phosphate cap 0 (base equiv) (Tamiflu) oseltamivir phosphate cap 45 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) oseltamivir phosphate for susp 6 /ml (base equiv) (Tamiflu) PEGASYS - peginterferon alfa-a inj 80 mcg/ml PEGASYS - peginterferon alfa-a inj 80 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 5 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREVYMIS - letermovir tab 40 PREVYMIS - letermovir tab 480 PREZCOBIX - darunavircobicistat tab Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 7

15 PREZISTA - darunavir ethanolate susp 00 /ml (base equiv) PREZISTA - darunavir ethanolate tab 75 (base equiv) PREZISTA - darunavir ethanolate tab 50 (base equiv) PREZISTA - darunavir ethanolate tab 600 (base equiv) PREZISTA - darunavir ethanolate tab 800 (base equiv) REBETOL - ribavirin soln 40 /ml RELENZA DISKHALER - zanamivir aero powder breath activated 5 /blister RESCRIPTOR - delavirdine mesylate tab 00 REYATAZ - atazanavir sulfate cap 50 (base equiv) REYATAZ - atazanavir sulfate cap 00 (base equiv) REYATAZ - atazanavir sulfate cap 00 (base equiv) REYATAZ - atazanavir sulfate oral powder packet 50 (base equiv) RIBASPHERE - ribavirin tab 400 RIBASPHERE - ribavirin tab 600 RIBASPHERE RIBAPAK - ribavirin tab 00 & ribavirin 400 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 400 & ribavirin 600 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 400 RIBASPHERE RIBAPAK - ribavirin tab 600 ribavirin cap 00 (Rebetol) ribavirin for inhal soln 6 gm (Virazole) ribavirin tab 00 (Copegus) rimantadine hydrochloride tab 00 (Flumadine) ritonavir tab 00 (Norvir) SELZENTRY - maraviroc oral soln 0 /ml SELZENTRY - maraviroc tab 5 SELZENTRY - maraviroc tab 75 SELZENTRY - maraviroc tab 50 SELZENTRY - maraviroc tab 00 SOFOSBUVIR/ VELPATASVIR - sofosbuvirvelpatasvir tab SOVALDI - sofosbuvir tab 400 stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 0 (Zerit) stavudine cap 40 (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 8

16 SUSTIVA - efavirenz cap 50 SUSTIVA - efavirenz cap 00 SUSTIVA - efavirenz tab 600 SYMFI - efavirenz-lamivudinetenofovir df tab SYMFI LO - efavirenzlamivudine-tenofovir df tab TAMIFLU - oseltamivir phosphate for susp 6 /ml (base equiv) tenofovir disoproxil fumarate tab 00 (Viread) TIVICAY - dolutegravir sodium tab 0 (base equiv) TIVICAY - dolutegravir sodium tab 5 (base equiv) TIVICAY - dolutegravir sodium tab 50 (base equiv) TRIUMEQ - abacavirdolutegravir-lamivudine tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab -00 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TRUVADA - emtricitabinetenofovir disoproxil fumarate tab TYBOST - cobicistat tab 50 valacyclovir hcl tab 500 (Valtrex) valacyclovir hcl tab gm (Valtrex) valganciclovir hcl for soln 50 /ml (base equiv) (Valcyte) valganciclovir hcl tab 450 (base equivalent) (Valcyte) VEMLIDY - tenofovir alafenamide fumarate tab 5 VIDEX - didanosine for soln gm VIDEX - didanosine for soln 4 gm VIRACEPT - nelfinavir mesylate tab 50 VIRACEPT - nelfinavir mesylate tab 65 VIRAMUNE - nevirapine susp 50 /5ml VIREAD - tenofovir disoproxil fumarate oral powder 40 / gm VIREAD - tenofovir disoproxil fumarate tab 50 VIREAD - tenofovir disoproxil fumarate tab 00 VIREAD - tenofovir disoproxil fumarate tab 50 VOSEVI - sofosbuvirvelpatasvir-voxilaprevir tab ZIAGEN - abacavir sulfate soln 0 /ml (base equiv) zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 9

17 zidovudine tab 00 ANTIMALARIALS atovaquone-proguanil hcl tab (Malarone) atovaquone-proguanil hcl tab (Malarone) CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 50 chloroquine phosphate tab 500 (Aralen) COARTEM - artemetherlumefantrine tab 0-0 DARAPRIM - pyrimethamine tab 5 hydroxychloroquine sulfate tab 00 (Plaquenil) MEFLOQUINE HCL - mefloquine hcl tab 50 PRIMAQUINE PHOSPHATE - primaquine phosphate tab 6. (5 base) quinine sulfate cap 4 (Qualaquin) ANTHELMINTICS albendazole tab 00 (Albenza) ALBENZA - albendazole tab 00 BENZNIDAZOLE - benznidazole tab.5 BENZNIDAZOLE - benznidazole tab 00 BILTRICIDE - praziquantel tab 600 ivermectin tab (Stromectol) praziquantel tab 600 (Biltricide) ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 00 /5ml ALINIA - nitazoxanide tab 500 atovaquone susp 750 /5ml (Mepron) CAYSTON - aztreonam lysine for inhal soln 75 (base equivalent) clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 00 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 dapsone tab 00 FIRVANQ - vancomycin hcl for oral soln 5 /ml (base equivalent) FIRVANQ - vancomycin hcl for oral soln 50 /ml (base equivalent) IMPAVIDO - miltefosine cap 50 linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 75 (Flagyl) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) NEBUPENT - pentamidine isethionate for nebulization soln 00 Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 0

18 PRIMSOL - trimethoprim hcl oral soln 50 /5ml (base equiv) SIVEXTRO - tedizolid phosphate tab 00 sulfamethoxazoletrimethoprim susp /5ml sulfamethoxazoletrimethoprim tab (Bactrim) sulfamethoxazoletrimethoprim tab (Bactrim ds) tinidazole tab 50 (Tindamax) tinidazole tab 500 (Tindamax) trimethoprim tab 00 vancomycin hcl cap 5 (base equivalent) (Vancocin hcl) vancomycin hcl cap 50 (base equivalent) (Vancocin hcl) XIFAXAN - rifaximin tab 00 XIFAXAN - rifaximin tab 550 BIOLOGICALS VACCINES ACTHIB - haemophilus b polysaccharide conjugate vaccine for inj AFLURIA PF influenza virus vaccine split pf susp pref syringe 0.5 ml AFLURIA QUADRIVALENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml AFLURIA QUADRIVALENT 08 - influenza virus vaccine split quadrivalent im inj AFLURIA influenza virus vaccine split im susp BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled syringe ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) susp 0 mcg/ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/0.5ml ENGERIX-B - hepatitis b vaccine (recombinant) 0 mcg/ml FLUAD influenza vac type a&b surface ant adj susp pref syr 0.5 ml FLUARIX QUADRIVALENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUADRIVALENT 08 - influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUCELVAX QUADRIVALENT 0 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVAX QUADRIVALENT 0 - influenza vac tissuecultured subunit quadrivalent im susp Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

19 FLULAVAL QUADRIVALENT 0 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLULAVAL QUADRIVALENT 0 - influenza virus vaccine split quadrivalent im inj FLUZONE HIGH-DOSE PF 08 - influenza virus vac split high-dose pf susp pref syr 0.5ml FLUZONE QUADRIVALENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5 ml FLUZONE QUADRIVALENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUZONE QUADRIVALENT 08 - influenza virus vaccine split quadrivalent im inj FLUZONE QUADRIVALENT 08 - influenza virus vaccine split quadrivalent inj 0.5 ml GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im susp GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac susp pref syr HAVRIX - hepatitis a vaccine inj susp 70 el unit/0.5ml HAVRIX - hepatitis a vaccine inj susp 440 el unit/ml HEPLISAV-B - hepatitis b vaccine recomb adjuvanted pref syr 0 mcg/0.5ml HEPLISAV-B - hepatitis b vaccine recombinant adjuvanted 0 mcg/0.5ml HIBERIX - haemophilus b polysaccharide conjugate vac for inj 0 mcg IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection M-M-R II - measles, mumps & rubella virus vaccines for inj MENACTRA - meningococcal (a, c, y, and w-5) conjugate vaccine inj MENVEO - meningococcal (a, c, y, and w-5) oligo conj vac for inj PNEUMOVAX - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PNEUMOVAX / DOSE - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PREVNAR - pneumococcal -valent conjugate vaccine inj SHINGRIX - zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml TRUMENBA - meningococcal group b vac (recomb) im susp prefilled syr VARIVAX - varicella virus vac live for subcutaneous inj 50 pfu/0.5ml ZOSTAVAX - zoster vaccine live for subcutaneous susp 9400 unit/0.65ml TOXOIDS ADACEL - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml BOOSTRIX - tet tox-diph-acell pertuss ad inj lf-lfmcg/0.5ml Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

20 DAPTACEL - diph, acellular pert & tet tox inj 5 lf- mcg-5 lf/0.5ml DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed (dt) im inj 5-5 unit/0.5ml INFANRIX - diph, acellular pert & tet tox inj 5 lf-58 mcg-0 lf/0.5ml KINRIX - diph-tetanus tox adacell pert & polio virus, ipv vac inj QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj TENIVAC - tetanus-diphtheria toxoids (td) inj 5- lfu TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td) inj - lf/0.5ml BIOLOGICALS MISC ODACTRA - dust mite mixed ext sl tab sq-hdm ANTINEOPLASTIC AGENTS ANTINEOPLASTICS abiraterone acetate tab 50 (Zytiga) AFINITOR - everolimus tab.5 AFINITOR - everolimus tab 5 AFINITOR - everolimus tab 7.5 AFINITOR - everolimus tab 0 AFINITOR DISPERZ - everolimus tab for oral susp AFINITOR DISPERZ - everolimus tab for oral susp AFINITOR DISPERZ - everolimus tab for oral susp 5 ALECENSA - alectinib hcl cap 50 (base equivalent) ALKERAN - melphalan tab ALUNBRIG - brigatinib tab initiation therapy pack 90 & 80 ALUNBRIG - brigatinib tab 0 ALUNBRIG - brigatinib tab 90 ALUNBRIG - brigatinib tab 80 anastrozole tab (Arimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 400 BOSULIF - bosutinib tab 500 BRAFTOVI - encorafenib cap 50 BRAFTOVI - encorafenib cap 75 CABOMETYX - cabozantinib s-malate tab 0 (base equivalent) CABOMETYX - cabozantinib s-malate tab 40 (base equivalent) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

21 CABOMETYX - cabozantinib s-malate tab 60 (base equivalent) CALQUENCE - acalabrutinib cap 00 capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA - vandetanib tab 00 CAPRELSA - vandetanib tab 00 COMETRIQ - cabozantinib s- mal cap x 80 & x 0 (00 dose) kit COMETRIQ - cabozantinib s- mal cap x 80 & x 0 (40 dose) kit COMETRIQ - cabozantinib s- malate cap x 0 (60 dose) kit COTELLIC - cobimetinib fumarate tab 0 (base equivalent) CYCLOPHOSPHAMIDE - cyclophosphamide cap 5 CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 cyclophosphamide cap 5 (Cyclophosphamide) cyclophosphamide cap 50 (Cyclophosphamide) ELIGARD - leuprolide acetate ( month) for subcutaneous inj kit.5 ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit 0 ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 EMCYT - estramustine phosphate sodium cap 40 ERIVEDGE - vismodegib cap 50 ERLEADA - apalutamide tab 60 ETOPOSIDE - etoposide cap 50 exemestane tab 5 (Aromasin) FARESTON - toremifene citrate tab 60 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) FARYDAK - panobinostat lactate cap 5 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) flutamide cap 5 GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 40 (base equivalent) GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 40 GLEOSTINE - lomustine cap 00 Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 4

22 HYCAMTIN - topotecan hcl cap 0.5 (base equiv) HYCAMTIN - topotecan hcl cap (base equiv) hydroxyurea cap 500 (Hydrea) IBRANCE - palbociclib cap 75 IBRANCE - palbociclib cap 00 IBRANCE - palbociclib cap 5 ICLUSIG - ponatinib hcl tab 5 (base equiv) ICLUSIG - ponatinib hcl tab 45 (base equiv) IDHIFA - enasidenib mesylate tab 50 (base equivalent) IDHIFA - enasidenib mesylate tab 00 (base equivalent) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 400 (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 70 IMBRUVICA - ibrutinib cap 40 IMBRUVICA - ibrutinib tab 40 IMBRUVICA - ibrutinib tab 80 IMBRUVICA - ibrutinib tab 40 IMBRUVICA - ibrutinib tab 560 INLYTA - axitinib tab INLYTA - axitinib tab 5 INTRON A - interferon alfa-b inj unit/ml INTRON A - interferon alfa-b inj unit/ml INTRON A - interferon alfa-b for inj unit INTRON A - interferon alfa-b for inj unit INTRON A - interferon alfa-b for inj unit IRESSA - gefitinib tab 50 JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) KISQALI - ribociclib succinate tab 00 (base equiv) KISQALI FEMARA 00 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 400 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 600 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 (0 daily dose) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 5

23 LENVIMA MG DAILY DOSE - lenvatinib cap therapy pack 4 () ( daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 () (8 daily dose) LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 () (0 daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 0 () & 4 (4 daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4 () (8 daily dose) letrozole tab.5 (Femara) LEUCOVORIN CALCIUM - leucovorin calcium tab 0 LEUCOVORIN CALCIUM - leucovorin calcium tab 5 leucovorin calcium tab 5 leucovorin calcium tab 5 LEUKERAN - chlorambucil tab leuprolide acetate inj kit 5 /ml LONSURF - trifluridine-tipiracil tab LONSURF - trifluridine-tipiracil tab LUPRON DEPOT (-MONTH) - leuprolide acetate for inj kit.75 LUPRON DEPOT (-MONTH) - leuprolide acetate for inj kit 7.5 LUPRON DEPOT (-MONTH) - leuprolide acetate ( month) for inj kit.5 LUPRON DEPOT (-MONTH) - leuprolide acetate ( month) for inj kit.5 LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for inj kit 0 LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for inj kit 45 LYNPARZA - olaparib tab 00 LYNPARZA - olaparib tab 50 LYSODREN - mitotane tab 500 MATULANE - procarbazine hcl cap 50 megestrol acetate susp 40 /ml (Megace oral) megestrol acetate tab 0 megestrol acetate tab 40 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 (base equivalent) MEKINIST - trametinib dimethyl sulfoxide tab (base equivalent) MEKTOVI - binimetinib tab 5 melphalan tab (Alkeran) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 6

24 mercaptopurine tab 50 MESNEX - mesna tab 400 METHOTREXATE SODIUM - methotrexate sodium inj 50 /0ml (5 /ml) methotrexate sodium for inj gm methotrexate sodium inj pf 50 /ml (5 /ml) methotrexate sodium inj pf 50 /0ml (5 /ml) methotrexate sodium inj pf 000 /40ml (5 /ml) methotrexate sodium inj 50 /ml (5 /ml) methotrexate sodium tab.5 (base equiv) MYLERAN - busulfan tab NERLYNX - neratinib maleate tab 40 (base equivalent) NEXAVAR - sorafenib tosylate tab 00 (base equivalent) nilutamide tab 50 (Nilandron) NINLARO - ixazomib citrate cap. (base equivalent) NINLARO - ixazomib citrate cap (base equivalent) NINLARO - ixazomib citrate cap 4 (base equivalent) ODOMZO - sonidegib phosphate cap 00 (base equivalent) POMALYST - pomalidomide cap POMALYST - pomalidomide cap POMALYST - pomalidomide cap POMALYST - pomalidomide cap 4 PURIXAN - mercaptopurine susp 000 /00ml (0 /ml) RUBR - rucaparib camsylate tab 00 (base equivalent) RUBR - rucaparib camsylate tab 50 (base equivalent) RUBR - rucaparib camsylate tab 00 (base equivalent) RYDAPT - midostaurin cap 5 SOLTAMOX - tamoxifen citrate oral soln 0 /5ml (base equivalent) SPRYCEL - dasatinib tab 0 SPRYCEL - dasatinib tab 50 SPRYCEL - dasatinib tab 70 SPRYCEL - dasatinib tab 80 SPRYCEL - dasatinib tab 00 SPRYCEL - dasatinib tab 40 STIVARGA - regorafenib tab 40 SUTENT - sunitinib malate cap.5 (base equivalent) SUTENT - sunitinib malate cap 5 (base equivalent) SUTENT - sunitinib malate cap 7.5 (base equivalent) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 7

25 SUTENT - sunitinib malate cap 50 (base equivalent) SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 600 mcg SYNRIBO - omacetaxine mepesuccinate for inj.5 TABLOID - thioguanine tab 40 TAFINLAR - dabrafenib mesylate cap 50 (base equivalent) TAFINLAR - dabrafenib mesylate cap 75 (base equivalent) TAGRISSO - osimertinib mesylate tab 40 (base equivalent) TAGRISSO - osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) tamoxifen citrate tab 0 (base equivalent) TARCEVA - erlotinib hcl tab 5 (base equivalent) TARCEVA - erlotinib hcl tab 00 (base equivalent) TARCEVA - erlotinib hcl tab 50 (base equivalent) TASIGNA - nilotinib hcl cap 50 (base equivalent) TASIGNA - nilotinib hcl cap 50 (base equivalent) TASIGNA - nilotinib hcl cap 00 (base equivalent) temozolomide cap 5 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 00 (Temodar) temozolomide cap 40 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 50 (Temodar) TIBSOVO - ivosidenib tab 50 tretinoin cap 0 TREXALL - methotrexate sodium tab 5 (base equiv) TREXALL - methotrexate sodium tab 7.5 (base equiv) TREXALL - methotrexate sodium tab 0 (base equiv) TREXALL - methotrexate sodium tab 5 (base equiv) TYKERB - lapatinib ditosylate tab 50 (base equiv) VENCLEXTA - venetoclax tab 0 VENCLEXTA - venetoclax tab 50 VENCLEXTA - venetoclax tab 00 VENCLEXTA STARTING PACK - venetoclax tab therapy starter pack 0 & 50 & 00 VERZENIO - abemaciclib tab 50 Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 8

26 VERZENIO - abemaciclib tab 00 VERZENIO - abemaciclib tab 50 VERZENIO - abemaciclib tab 00 VOTRIENT - pazopanib hcl tab 00 (base equiv) XALKORI - crizotinib cap 00 XALKORI - crizotinib cap 50 XTANDI - enzalutamide cap 40 YONSA - abiraterone acetate tab 5 ZEJULA - niraparib tosylate cap 00 (base equivalent) ZELBORAF - vemurafenib tab 40 ZOLINZA - vorinostat cap 00 ZYDELIG - idelalisib tab 00 ZYDELIG - idelalisib tab 50 ZYKADIA - ceritinib cap 50 ZYTIGA - abiraterone acetate tab 50 ZYTIGA - abiraterone acetate tab 500 ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap (Entocort ec) CORTISONE ACETATE - cortisone acetate tab 5 DEXAMETHASONE - dexamethasone soln 0.5 /5ml DEXAMETHASONE - dexamethasone tab DEXAMETHASONE - dexamethasone tab dexamethasone elixir 0.5 /5ml DEXAMETHASONE INTENSOL - dexamethasone conc /ml dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab.5 dexamethasone tab 4 dexamethasone tab 6 fludrocortisone acetate tab 0. hydrocortisone tab 5 (Cortef) hydrocortisone tab 0 (Cortef) hydrocortisone tab 0 (Cortef) MEDROL - methylprednisolone tab methylprednisolone tab therapy pack 4 () (Medrol dosepak) methylprednisolone tab 4 (Medrol) methylprednisolone tab 8 (Medrol) methylprednisolone tab 6 (Medrol) methylprednisolone tab (Medrol) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 9

27 PREDNISOLONE - prednisolone syrup 5 /5ml (usp solution equivalent) prednisolone sod phos orally disintegr tab 0 (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 5 (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 0 (base eq) (Orapred odt) prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base) (Pediapred) prednisolone sod phosphate oral soln 5 /5ml (base equiv) PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate oral soln 5 /5ml (base eq) PREDNISONE - prednisone oral soln 5 /5ml PREDNISONE - prednisone tab therapy pack 5 () PREDNISONE - prednisone tab therapy pack 5 (48) PREDNISONE - prednisone tab therapy pack 0 () PREDNISONE - prednisone tab therapy pack 0 (48) PREDNISONE - prednisone tab 50 PREDNISONE INTENSOL - prednisone conc 5 /ml prednisone tab prednisone tab.5 prednisone tab 5 prednisone tab 0 prednisone tab 0 ANDROGEN-ANABOLIC ANADROL-50 - oxymetholone tab 50 danazol cap 50 danazol cap 00 danazol cap 00 METHITEST - methyltestosterone oral tab 0 oxandrolone tab.5 (Oxandrin) oxandrolone tab 0 (Oxandrin) testosterone cypionate im inj in oil 00 /ml (Depotestosterone) testosterone cypionate im inj in oil 00 /ml (Depotestosterone) testosterone enanthate im inj in oil 00 /ml testosterone td gel 5 /.5gm (%) (Androgel) testosterone td gel 50 /5gm (%) (Androgel) testosterone td gel.5 / act (%) (Androgel pump) testosterone td gel 0.5 /.5gm (.6%) (Androgel) testosterone td gel 40.5 /.5gm (.6%) (Androgel) testosterone td gel 0.5 /act (.6%) (Androgel pump) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February 0

28 testosterone td soln 0 / act (Axiron) ESTROGENS ALORA - estradiol td patch twice weekly 0.05 /4hr ALORA - estradiol td patch twice weekly 0.05 /4hr ALORA - estradiol td patch twice weekly /4hr ALORA - estradiol td patch twice weekly 0. /4hr ANGELIQ - drospirenoneestradiol tab ANGELIQ - drospirenoneestradiol tab 0.5- CLIMARA PRO - estradiollevonorgestrel td patch weekly /day COMBIPATCH - estradiolnorethindrone ace td pttw /day COMBIPATCH - estradiolnorethindrone ace td pttw /day DELESTROGEN - estradiol valerate im in oil 0 /ml DEPO-ESTRADIOL - estradiol cypionate im in oil 5 /ml DIVIGEL - estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL - estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL - estradiol td gel /gm (0.%) DUAVEE - conjugated estrogens-bazedoxifene tab ELESTRIN - estradiol gel 0.06% (0.5 /0.87 gm metered-dose pump) estradiol & norethindrone acetate tab (Activella) estradiol & norethindrone acetate tab -0.5 (Activella) estradiol tab 0.5 (Estrace) estradiol tab (Estrace) estradiol tab (Estrace) estradiol td patch twice weekly 0.05 /4hr (Vivelle-dot) estradiol td patch twice weekly /4hr (Vivelle-dot) estradiol td patch twice weekly 0.05 /4hr (Vivelle-dot) estradiol td patch twice weekly /4hr (Vivelle-dot) estradiol td patch twice weekly 0. /4hr (Vivelle-dot) estradiol td patch weekly 0.05 /4hr (Climara) estradiol td patch weekly /4hr (7.5 mcg/4hr) (Climara) estradiol td patch weekly 0.05 /4hr (Climara) estradiol td patch weekly 0.06 /4hr (Climara) estradiol td patch weekly /4hr (Climara) estradiol td patch weekly 0. /4hr (Climara) estradiol valerate im in oil 0 /ml (Delestrogen) estradiol valerate im in oil 40 /ml (Delestrogen) Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

29 ESTROGEL - estradiol gel 0.06% (0.75 /.5 gm metered-dose pump) EVAMIST - estradiol transdermal spray.5 / spray MENEST - esterified estrogens tab 0. MENEST - esterified estrogens tab 0.65 MENEST - esterified estrogens tab.5 MENOSTAR - estradiol td patch weekly 4 mcg/4hr MINIVELLE - estradiol td patch twice weekly 0.05 /4hr MINIVELLE - estradiol td patch twice weekly /4hr MINIVELLE - estradiol td patch twice weekly 0.05 /4hr MINIVELLE - estradiol td patch twice weekly /4hr MINIVELLE - estradiol td patch twice weekly 0. /4hr norethindrone acetateethinyl estradiol tab mcg (Femhrt low dose) norethindrone acetateethinyl estradiol tab -5 mcg PREFEST - estradiol tab (5)/estrad-norgestimate tab -0.09(5) PREMARIN - estrogens, conjugated tab 0. PREMARIN - estrogens, conjugated tab 0.45 PREMARIN - estrogens, conjugated tab 0.65 PREMARIN - estrogens, conjugated tab 0.9 PREMARIN - estrogens, conjugated tab.5 PREMPHASE - conj est 0.65(4)/conj estmedroxypro ac tab (4) PREMPRO - conjugated estrogen-medroxyprogest acetate tab PREMPRO - conjugated estrogen-medroxyprogest acetate tab PREMPRO - conjugated estrogen-medroxyprogest acetate tab PREMPRO - conjugated estrogen-medroxyprogest acetate tab CONTRACEPTIVES DEPO-SUBQ PROVERA A 04 - medroxyprogesterone acetate susp pref syr 04 /0.65ml desogest-eth estrad A & eth estrad tab /0.0 (/5) (Mircette) desogest-ethin est tab A / / (Cyclessa) desogestrel & ethinyl estradiol tab mcg (Desogen) drospirenone-ethinyl estrad-levomefolate tab (Beyaz) drospirenone-ethinyl estrad-levomefolate tab (Safyral) A A A Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

30 drospirenone-ethinyl A estradiol tab -0.0 (Yaz) drospirenone-ethinyl A estradiol tab -0.0 (Yasmin 8) ELLA - ulipristal acetate tab 0 A ethynodiol diacetate & A ethinyl estradiol tab -5 mcg ethynodiol diacetate & A ethinyl estradiol tab -50 mcg (Zovia /50e) FALESSA - levonorgest-eth estrad tab mcg & fa tab kit levonor-eth est tab A /0.05/0.0 &eth est 0.0 (Quartette) levonorg-eth est tab A (84) & eth est tab 0.0(7) (Loseasonique) levonorg-eth est tab A (84) & eth est tab 0.0(7) (Seasonique) levonorgestrel & ethinyl A estradiol (9-day) tab levonorgestrel & A ethinyl estradiol tab mcg levonorgestrel & A ethinyl estradiol tab mcg levonorgestrel tab.5 A A levonorgestrel-eth estra tab / /0.5-0mcg levonorgestrel-ethinyl estradiol (continuous) tab 90-0 mcg LILETTA - levonorgestrel releasing iud 9.5 mcg/day (5 total) LO LOESTRIN FE - norethineth estradiol-fe tab -0 mcg (4)/0 mcg () medroxyprogesterone acetate im susp prefilled syr 50 /ml (Depoprovera contrac) medroxyprogesterone acetate im susp 50 /ml (Depo-provera contrac) MIRENA - levonorgestrel releasing iud 0 mcg/day (5 total) NATAZIA - estradiol valeratedienogest tab /- /- / norethindrone & ethinyl estradiol tab mcg (Ovcon-5) norethindrone & ethinyl estradiol tab mcg (Brevicon-8) norethindrone & ethinyl estradiol tab -5 mcg (Norinyl +5) norethindrone & ethinyl estradiol-fe chew tab mcg (Femcon fe) norethindrone & ethinyl estradiol-fe chew tab mcg (Generess fe) norethindrone acethinyl estrad-fe tab -0/-0/-5 -mcg (Estrostep fe) A A A A A A A A A A A Blue Cross Blue Shield of North Dakota BlueCare, BlueDirect, BlueEssential, BluePartner and SimplyBlue Formulary February

ALABAMA S ADAP FORMULARY OFFERS 117 MEDICATIONS

ALABAMA S ADAP FORMULARY OFFERS 117 MEDICATIONS - 2014 Alabama s ADAP formulary offers a minimum of one medication from each HIV antiretroviral class approved by the U.S. Food and Drug Administration (FDA).