ABBREVIATED FORMULARY As of January 1, 2018

Transcription

1 ABBREVIATED FORMULARY As of January 1, 2018 fepblue.org

2 Review this abbreviated formulary to learn how to get the most from your pharmacy benefit such as: n Understanding the Formulary n How to use the Abbreviated Formulary n Abbreviated Formulary n Managed Not Covered Drugs n Excluded Drug List Your pharmacy benefit The Blue Cross and Blue Shield Service Benefit Plan works with Pharmacy Benefit Managers (PBMs) to administer your pharmacy benefit. n Retail Pharmacy Program - CVS Caremark n Mail Service Pharmacy Program - CVS Caremark n Specialty Pharmacy Program - AllianceRx Walgreens Prime General questions n See the Blue Cross and Blue Shield Service Benefit Plan brochure (RI ) n Visit fepblue.org n Call CVS Caremark Customer Service for Retail and Mail Service Pharmacy Programs toll-free at n Call the AllianceRx Walgreens Prime for Specialty Pharmacy Program toll-free at New for 2018 n Expanded Basic Option Managed Not Covered drug list See p. 2 n Cost share increases for certain Tier 3 drugs See p. 6 n Preventive benefit for cholesterol-lowering drugs See p. 48 n Lower cost share for certain asthma drugs See p. 48 n Medical Foods Benefit See p. 48 n Lower cost share for certain high blood pressure drugs See p. 49 n Dispense as Written cost share change See p. 49 2

3 TABLE OF CONTENTS Understanding the Formulary...2 n Formulary...2 n Managed Not Covered Drugs...2 n Excluded Drugs...2 n Quantity Limits...2 n Prior Approval...2 n How Tiers Relate to Costs...4 n How Prescription Drugs are Assigned to Tiers...5 n Cost share increases for certain Tier 3 drugs n Basic Option Cost Share Tiers...6 n Standard Option Cost Share Tiers How to use the Abbreviated Formulary...10 n Program Options...10 n Legend...11 Abbreviated Formulary (non-specialty by condition)...12 Abbreviated Formulary (alphabetic including Specialty)...24 Managed Not Covered Drug List Excluded Drug List...45 New for 2018 Pharmacy Benefit Highlights...48 n Preventive benefit for cholesterol-lowering drugs...48 n Lower cost share for certain asthma drugs...48 n Medical Foods Benefit...48 n Lower cost share for certain high blood pressure drugs...49 n Dispense as Written cost share change...49 How to Contact Us

4 UNDERSTANDING THE FORMULARY We continually review drugs in support of safe and appropriate therapies. This helps ensure that drugs in your benefit plan work well and are cost-effective. Formulary The formulary is a complete list of your covered prescription drugs. It includes generic, brand name, and specialty drugs, as well as Preferred drugs that will lower your outof-pocket costs. The formulary has 5 tiers of drugs. See p. 4 Managed Not Covered (NC) Drugs Some drugs are not covered on the Basic Option drug formulary. These Managed Not Covered drugs have Preferred alternative options in the same class. See p. 41 Excluded (NC) Drugs A few drugs are not covered on the Standard Option drug formulary. These excluded drugs have available covered options in the same class. Standard and Basic Option members taking an excluded or a Managed Not Covered drug should expect to pay the full cost of the prescription. See p. 46 Quantity Limits () Certain drugs on the formulary have quantity limits (for example, number of pills). This means your pharmacy benefit will only cover up to a specific amount per prescription or a limited amount per year. Quantity limits help ensure drugs are used safely and appropriately. Drug quantities are approved based on accepted standards of health care practice in the United States. Prior Approval (PA) Some prescription drugs and supplies need approval in advance, or prior approval before we provide coverage for them. We need to confirm: 2

5 UNDERSTANDING THE FORMULARY n Your use of the drug is related to a service or condition covered under the Service Benefit Plan. n Your doctor prescribes it in a way that matches generally accepted medical practices. Facts to Know about Prior Approval n You will need to renew your prior approval periodically. n Drugs and supplies on the Prior Approval list may change throughout the year. n Mail Service and Specialty Programs will not fill prescriptions that need prior approval until you receive prior approval. n Preferred retail pharmacies will fill your prescriptions, but you will pay the full cost of the drug until you get prior approval. Once you have received prior approval, you may file a claim for reimbursement of out-ofpocket costs paid while awaiting approval. Help with Prior Approval Visit fepblue.org/pharmacy. Or call toll-free any time at You will be able to: n See a list of drugs that need prior approval n Get a prior approval request form Your doctor can submit requests for prior approval by: n Submitting an epa (electronic prior approval) n Calling toll-free n Filling out the Prior Approval Form found at fepblue.org/priorapproval 3

6 UNDERSTANDING THE FORMULARY How Tiers Relate to Costs The costs of drugs vary. How much you pay is your cost share. Look for your drug in the 5-tier formulary for your Plan option. The tier level where your drug type is listed determines your cost. Basic and Standard Options Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 DRUG TYPE Generic Drugs: typically the most affordable, and are equal to their brand name counterparts in quality, performance characteristics and intended use. Preferred Brand Name Drugs: proven to be safe, effective, and favorably priced compared to Non-preferred brands. Non-preferred Brand Name Drugs: typically higher cost share since there is a generic or Preferred brand. Preferred Specialty Drugs: proven to be safe, effective, and favorably priced compared to Non-preferred specialty drugs. Non-preferred Specialty Drugs: typically higher cost share since there is a Preferred specialty drug. To see your cost share for a prescription drug: - visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs:

7 UNDERSTANDING THE FORMULARY How Prescription Drugs Are Assigned to Tiers The Pharmacy and Medical Policy Committee (PMPC) is an independent group of doctors and pharmacists. This group recommends drugs for each tier based on their: n Effectiveness n Safety n How they compare to other drugs in the same class The PMPC meets every quarter to review new drugs and other changes to the formulary. Based on that review, drugs may change tiers, be added or removed from the formulary. Check your formulary often to be aware of any changes. 5

8 UNDERSTANDING THE FORMULARY Basic Option Cost Share Tiers Basic Option members must use a Preferred retail pharmacy and will save by choosing generic drugs and Preferred brand name drugs when possible. Use the charts below to find your cost share. BASIC OPTION: Cost Share Based on Where You Fill Your Prescription Tier 1: Generic Drugs Tier 2: Preferred Brand Name Drugs Tier 3: Non-preferred Brand Name Drugs PREFERRED RETAIL PHARMACY --Up to $10 --You can get up to a 30-day supply for 1 copayment or up to a 90-day supply for 3 copayments -- Up to $50 -- You can get up to a 30-day supply for 1 copayment or up to a 90-day supply for 3 copayments --60% of the drug price when the price is $125 or greater --$75 copayment or the drug price when the price is less than $125 --You can get up to a 30-day supply for 1 copayment or up to a 90-day supply for 3 copayments NON-PREFERRED RETAIL PHARMACY & MAIL SERVICE PHARMACY Not covered* * Basic Option members with Medicare Part B coverage have Mail Service Pharmacy benefits and some lower cost shares. 6

9 UNDERSTANDING THE FORMULARY To see Basic Option with Medicare Part B cost shares: - visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs: BASIC OPTION: Specialty Drugs - Cost Share Based on Where You Fill Your Prescription SPECIALTY PHARMACY PREFERRED RETAIL PHARMACY Tier 4: Preferred Specialty Drugs Tier 5: Non-preferred Specialty Drugs --Up to $55 for a 30-day supply or $165 for a 31 to a 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get up to a 90-day supply after the third fill --Up to $80 for a 30-day supply or $240 for a 31 to a 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get up to a 90-day supply after the third fill -- Up to $65 for up to a 30-day supply only -- When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy --Up to $90 for up to a 30-day supply only --When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy 7

10 UNDERSTANDING THE FORMULARY Standard Option Cost Share Tiers Standard Option members save by using the Mail Service Pharmacy and Preferred retail pharmacies for filling prescription drugs. Members can also save by asking for generic and/or Preferred brand name drugs when possible. Use the charts below to find your cost share. STANDARD OPTION: Cost Share Based on Where You Fill Your Prescription MAIL SERVICE PHARMACY PREFERRED RETAIL PHARMACY NON-PREFERRED RETAIL PHARMACY Tier 1: Generic Drugs Tier 2: Preferred Brand Name Drugs Tier 3: Nonpreferred Brand Name Drugs --Up to $15* --20%* of our allowance --Up to $ % of our allowance --Up to $ % of our allowance --45% of the average wholesale price plus any difference between our allowance and the billed amount --If you use a Non-preferred retail pharmacy, you need to file a paper claim for reimbursement * Lower cost shares are available to Standard Option members with Medicare Part B. 8

11 UNDERSTANDING THE FORMULARY STANDARD OPTION: Specialty Drugs - Cost Share Based on Where You Fill Your Prescription SPECIALTY PHARMACY PREFERRED RETAIL PHARMACY NON-PREFERRED RETAIL PHARMACY Tier 4: Preferred Specialty Drugs Tier 5: Nonpreferred Specialty Drugs --$35 for up to a 30-day supply --$95 for a 31 to a 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get up to a 90-day supply after the third fill --Up to $55 for a 30-day supply --$155 for a 31 to a 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get up to a 90-day supply after the third fill --30% of our allowance up to a 30-day supply --When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy --45% of the average wholesale price plus any difference between our allowance and the billed amount --When you buy specialty drugs at a Non-preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy To see Standard Option with Medicare Part B cost shares: - visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs:

12 HOW TO USE THE ABBREVIATED FORMULARY Use the abbreviated formulary to find the most cost-effective drugs for your condition. 1. Find the tier related to your drug. The charts are organized by: n Drug category for nonspecialty drugs See p n Alphabetic for all drugs See p See if there are any limitations for your drug. 3. Review the cost share charts to find your copay or coinsurance. See p If your drug is in Tiers 2, 3 or 5, ask your doctor if there is a generic drug to treat your condition. If there is no generic drug, ask your doctor to prescribe a Preferred brand name drug. Program Options The benefit for Standard Option () and Basic Option () varies. The charts list both the and tier for each drug. In many cases the tier is the same, but not in every case. To see the current and full formulary: - visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs:

13 HOW TO USE THE ABBREVIATED FORMULARY Program Legend Some drugs are noted with letters in the columns next to them. The letters describe any limitations. Quantity Limit: benefit will only cover up to a specified, limited amount of the drug each time you fill a prescription or a limited amount per year. PA Prior Approval: needs approval in advance before a drug is covered. NC Excluded Drugs: drugs that are not covered under Standard Option but have multiple equivalent or alternative drugs available. Managed Not Covered : drugs that are not covered under Basic Option but have covered options in the same class. Standard Option Basic Option LD Bold type means there is a generic for this drug. ITALIC Italic type means this is a specialty drug. This abbreviated formulary lists the most commonly used drugs. Please note this list may change. 11

14 (NON-SPECIALTY BY CONDITION) Bold Type means there is a generic version for this drug. Drugs that are listed in capital letters are brand name drugs, while those in lowercase are generic versions. CONDITION/DRUG ALLERGY/COUGH & COLD acetaminophen/ codeine ASTEPRO 3 3 AUVI Q NC NC azelastine AZILECT 3 3 AZOR 3 3 BECONASE AQ 3 NC benzonatate budesonide nasal spray cetirizine solution 1 NC CLARINEX 3 NC CLARINEX-D 3 NC desloratadine 1 NC EPIPEN 2 PAK 2 2 DYMISTA 3 NC flunisolide spray fluticasone spray levocetirizine 1 NC NASACORT AQ 3 NC NANEX 3 NC OMNARIS 2 NC CONDITION/DRUG promethazine/codeine QNASL 3 NC RHINOCORT AQUA 3 NC triamcinolone spray VERAMYST 2 NC XYZAL 3 NC ZETONNA 3 NC ANTI-INFECTIVES ANTIBIOTICS/ ANTIFUNGAL/ANTIVIRAL amoxicillin amoxicillin/ clavulanate potassium azithromycin cephalexin ciprofloxacin clotrimazole/ betamethasone doxycycline hyclate ERTACZO PA 3 NC EXELDERM PA 3 3 fluconazole JUBLIA PA 3 NC KERYDIN* PA 3 NC ketoconazole PA * This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. 12

15 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG levofloxacin LOPROX 3 NC LOTRINE* 3 NC LUZU PA 3 NC MENTAX 3 NC metronidazole naftifine NAFTIN 2 NC oseltamivir phosphate OXISTAT PA 3 NC sulfame-thoxazole/ trimethoprim TAMIFLU CAPS 3 3 TAMIFLU LUTION 2 2 valacyclovir VALTREX 3 3 VUSION* 3 NC XOLEGEL* NC NC ZOVIRAX 3 3 ZYVOX 3 3 ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS anastrozole ASTAGRAF XL 2 2 azathioprine CELLCEPT 3 3 CONDITION/DRUG cyclosporine letrozole megestrol acetate mycophenolate mofetil MYFORTIC 3 3 NEORAL 3 3 PROGRAF 3 3 RAPAMUNE 3 3 sirolimus tacrolimus tamoxifen citrate ANTIVIRAL/HIV abacavir abacavir/ lamivudine/ zidovudine APTIVUS 2 2 ATRIPLA 2 2 COMBIVIR 3 3 didanosine delayed release EDURANT 2 2 EMTRIVA 2 2 EPIVIR 3 3 EPZICOM 3 3 GENVOYA 2 2 INTELENCE 2 2 * This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. 13

16 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG ISENTRESS 2 2 lamivudine lamivudine/zidovudine nevirapine/ delayed release PREZISTA 2 2 RETROVIR 3 3 REYATAZ 2 2 stavudine STRIBILD 2 2 SUSTIVA 2 2 TRIZIVIR 3 3 TRUVADA 2 2 VIDEX EC 3 3 VIRACEPT 2 2 VIRAMUNE/XR 3 3 VIREAD 2 2 ZERIT 3 3 ZIAGEN 3 3 zidovudine ASTHMA/COPD ACCOLATE 3 3 ADVAIR DISKUS 2 2 ADVAIR HFA 2 2 albuterol sulfate tablet/ solution ATROVENT HFA 2 2 CONDITION/DRUG COMBIVENT RESPIMAT 2 2 DULERA 2 2 FORADIL 3 3 FLOVENT HFA 2 2 INCRUSE ELLIPTA 3 NC MAXAIR AUTOHALER 3 3 montelukast sodium PERFOROMIST 3 3 PROAIR HFA 2 2 PROVENTIL HFA 2 2 QVAR 2 2 SINGULAIR 3 3 SPIRIVA 2 2 STRIVERDI RESPIMAT 3 3 SYMBICORT 2 2 TUDORZA PRESSAIR 3 NC VENTOLIN HFA 2 NC XOPENEX/ CONCENTRATE 3 3 XOPENEX HFA 2 NC zafirlukast CARDIOVASCULAR DRUGS HIGH BLOOD PRESSURE amlodipine besylate/benazepril hydrochloride ATACAND/HCT 3 NC atenolol 14

17 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG AVAPRO 3 NC AVALIDE 3 NC AZOR 3 3 BENICAR/HCTZ 3 3 BREVIBLOC 3 3 BYSTOLIC 2 2 candesartan/hctz carvedilol clonidine COZAAR 3 NC diltiazem cd DIOVAN/HCT 3 NC doxazosin mesylate EDARBI 3 NC EDARBYCLOR 3 NC ENALAPRIL MALEATE EXFORGE/HCTZ 3 3 furosemide hydralazine hydrochlorothiazide HYZAAR 3 NC irbesartan/hctz LEVATOL 3 3 lisinopril/hctz losartan/hctz metoprolol succinate CONDITION/DRUG metoprolol tartrate MEVACOR 3 NC MICARDIS/HCT 3 NC olmesartan/hctz propranolol ramipril spironolactone telmisartan/hctz TEVETEN/HCT 3 NC triamterene/hctz valsartan/hctz verapamil/er CARDIOVASCULAR DRUGS HIGH CHOLESTEROL ADVICOR 3 NC AGGRENOX 3 3 ALTOPREV 3 NC amlodipine/ atorvastatin atorvastatin calcium CADUET 3 NC CRESTOR 3 NC ezetimibe fenofibrate fenofibric acid FLOLIPID ACID NC NC gemfibrozil 15

18 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG LESCOL/XL 3 NC LIPITOR 3 NC LIVALO 3 NC lovastatin LOVAZA 3 3 omega-3 acid ethyl esters MEVACOR 3 NC niacin er NIKITA NC NC PRAVACHOL 3 NC pravastatin sodium rosuvastatin simvastatin TRIGLIDE 3 3 VYTORIN 3 NC WELCHOL 2 2 ZETIA 3 3 ZOCOR 3 NC ZYPITAMAG NC NC CARDIOVASCULAR DRUGS OTHER AGGRASTAT 3 3 clopidogrel COUMADIN 2 3 digoxin EFFIENT 2 2 ELIQUIS 2 2 CONDITION/DRUG enoxaparin sodium ENTRESTO PA 3 3 isosorbide mononitrate er NITROSTAT 3 3 PLAVIX 3 3 potassium chloride PRADAXA 3 NC warfarin YOSPRALA NC NC XARELTO 2 2 CENTRAL NERVOUS SYSTEM ANXIETY AND DEPRESSION alprazolam amitriptyline bupropion/xl citalopram CYMBALTA 3 3 diazepam duloxetine EFFEXOR XR 3 3 escitalopram oxalate fluoxetine LEXAPRO 3 3 lorazepam paroxetine OLEPTRO ER

19 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG PRISTIQ ER 3 3 sertraline trazodone venlafaxine/er WELLBUTRIN XL 3 3 CENTRAL NERVOUS SYSTEM ATTENTION DEFICIT DIRDER amphetamine salt combo PA DAYTRANA PA 3 3 dextro-amphetamine/ amphetamine salts PA FOCALIN XR PA 3 3 INTUNIV 3 3 METHYLIN PA 3 3 methylphenidate/er PA STRATTERA 2 2 VYVANSE PA 2 2 CENTRAL NERVOUS SYSTEM MIGRAINE AUVI Q NC NC RELPAX 3 3 rizatriptan sumatriptan succinate SUMAVEL 3 3 zolmitriptan ZOMIG/ZMT 3 3 CENTRAL NERVOUS SYSTEM OTHER ABILIFY 3 3 CONDITION/DRUG AMRIX 3 NC baclofen carisoprodol CHANTIX 2 2 cyclobenzaprine donepezil epinephrine injection EQUETRO 3 3 EXELON 3 3 methocarbamol NDA 3 3 naloxone NARCAN 2 2 ondansetron/odt quetiapine fumarate risperidone SAVELLA 3 3 SEROQUEL XR 3 3 tizanidine CENTRAL NERVOUS SYSTEM PAIN butalbital/apap BUTRANS 3 3 EMBEDA 3 3 fentanyl PA hydrocodone/ acetaminophen hydromorphone 17

20 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG MORPHAND 3 3 oxycodone/ acetaminophen OXYCONTIN 3 3 SUXONE FILM 2 2 tramadol/er ZUBLV 2 2 CENTRAL NERVOUS SYSTEM SEIZURE DIRDERS AZILECT 3 3 carbidopa/levodopa & er clonazepam gabapentin lamotrigine levetiracetam LYRICA 2 2 NEUPRO 2 2 pramipexole dihydrochloride ropinirole topiramate CENTRAL NERVOUS SYSTEM SLEEP AGENTS AMBIEN/CR 3 NC LUNESTA 3 NC EDLUAR 3 3 eszopiclone INTERMEZZO 3 NC CONDITION/DRUG ROZEREM 3 NC NATA 3 NC temazepam zaleplon zolpidem/er zolpidem tartrate/er CONTRACEPTIVES TRANSDERMAL** ORTHO EVRA 3 3 CONTRACEPTIVES OTHER NATAZIA 3 3 NUVARING 2 2 PARAGARD T 380A 3 3 DERMATOLOGY ALCORTIN A PA 3 NC BENZACLIN 3 3 betamethasone CARAC 3 NC ciclopirox clindamycin phosphate clobetasol propionate CLOBEX 3 3 CORDRAN 3 3 doxepin crm EPIDUO PA 2 2 ERYGEL 3 3 **Generic contraceptives are available to female members at no copay. 18

21 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG fluocinonide fluorouracil cream 0.5% 1 NC lidocaine methyl - prednisolone mupirocin NORITATE 3 NC NOVACORT PA 3 NC ORACEA 3 3 prednisone TAZORAC PA 3 3 tretinoin PA triamcinolone acetonide VOLTAREN GEL 3 3 DIABETES BLOOD GLUCOSE MONITORING ACCU CHEK TEST STRIPS BD ULTRA FINE PEN NEEDLES CONTOUR TEST STRIPS FREESTYLE LANCETS & STRIPS ONE TOUCH ULTRA TEST STRIPS DIABETES DRUGS AFREZZA PA 3 3 BYDUREON 3 3 BYETTA 3 3 CONDITION/DRUG glimepiride glipizide glipizide er glipizide xl GLUCOPHAGE/XR 3 3 GLUMETZA NC NC glyburide GLYSET 3 3 INVOKANA PA 3 3 JANUMET 2 2 JANUMET XR 2 2 JANUVIA 2 2 JENTADUETO 3 2 KAZANO 3 NC KOMBIGLYZE XR 2 NC metformin ER metformin ER (generic GLUMETZA) PA NESINA 3 NC ONGLYZA 2 NC OSENI 3 NC pioglitazone TANZEUM 3 3 TRADJENTA 3 2 TRULICITY 2 2 VICTOZA 2 PAK & 3 PAK 2 2 FORTAMET 3 NC 19

22 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG CONDITION/DRUG DIABETES INSULIN LOTEMAX 2 2 APIDRA/LOSTAR 2 NC BASAGLAR 2 2 HUMULIN/ KWIKPEN (EXCEPT HUMULIN U-500 CONCENTRATE) HUMULIN U-500 CONCENTRATE HUMALOG/ MIX/ KWIKPEN 2 NC NC LANTUS 2 3 LANTUS LOSTAR 2 3 NOVOLIN 2 2 NOVOLOG/ MIX 2 2 NOVOLOG MIX FLEXPEN 2 2 TOUJEO 2 3 TRESIBA 2 3 EYE/EAR ALPHAGAN P (0.15%) 3 3 AZOPT 2 2 brimonidine tartrate CIPRODEX 2 2 COMBIGAN 2 2 dorzolamide/timolol maleate DUREZOL 2 2 erythromycin latanoprost LUMIGAN 2 NC PATADAY 3 3 PATANOL 3 3 prednisolone acetate RESCULA 3 3 RESTASIS PA 2 2 timolol maleate travoprost TRAVATAN Z 2 2 VIGAMOX 2 2 ZIOPTAN 3 3 GASTROINTESTINAL DRUGS ACIPHEX 3 NC ALOXI 2 2 AMITIZA PA 3 3 ASACOL HD 2 NC DELZICOL 3 NC DEXILANT 3 NC dicyclomine EMEND 3 3 esomeprazole 3 NC FIRST LANPRAZOLE 3 NC FIRST OMEPRAZOLE NC NC lansoprazole LIALDA

23 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG LINZESS 2 2 MOVIPREP 2 2 omeprazole omperazole/sodium bicarbonate polyethylene glycol 3350 pantoprazole sodium PREVACID 3 NC NEXIUM 3 NC PRILOSEC 3 NC PROTONIX 3 NC rabeprazole ranitidine sucralfate SUPREP WEL PREP KIT 2 2 VARUBI 3 3 VISICOL 2 2 ZEGERID 3 NC ZUPLENZ 3 3 HORMONE REPLACEMENT ANDRODERM PA 2 2 ANDROGEL PA 2 NC AXIRON PA 3 3 calcitriol CONDITION/DRUG ESTRACE ORAL 3 3 estradiol EVISTA 3 3 FORTESTA PA 3 3 MINIVELLE 2 2 NATESTO PA 3 NC NILANDRON PA 3 3 PREFEST 3 3 PREMARIN 2 2 PREMPRO 2 2 progesterone PA STRIANT PA 3 3 TESTIM PA 3 NC testosterone gel PA testosterone cypionate PA VAGIFEM 3 3 VIVELLE DOT 3 3 VOGELXO PA 3 NC INFLAMMATION - CORTICOSTEROIDS CORTEF 3 NC deltasone 1 NC MEDROL 3 NC MILLIPRED 3 NC OLUX/OLUX E NC NC DEPO TESTOSTERONE (200mg) PA 3 3 ORAPRED ODT 3 NC prednisone 21

24 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG RAYOS PA 3 NC MISCELLANEOUS allopurinol COLCRYS 3 3 RELISTOR PA 3 3 ULORIC 2 2 ORAL CONTRACEPTIVES BIPHASIC* MIRCETTE 3 3 NECON 3 3 ORAL CONTRACEPTIVES MONOPHASIC* apri aviane cryselle DEGEN 3 3 GENERESS FE 3 3 gianvi junel/fe LOESTRIN/FE 3 3 loryna microgestin/fe MINASTRIN 24 FE 3 3 mononessa ORTHO NOVUM 3 3 SAFYRAL 3 3 sprintec zovia CONDITION/DRUG ORAL CONTRACEPTIVES TRIPHASIC* LO LOESTRIN FE 3 3 ORTHO TRI CYCLEN 3 3 ORTHO TRI CYCLEN LO 3 3 trinessa tri previfem tri sprintec OSTEOPOROSIS/NE DISEASES ACTONEL 3 3 alendronate ibandronate risedronate PRIASIS acitretin calcipotriene-betamethasone RIATANE NC NC TACLONEX NC NC RHEUMATOLOGY ANAPROX DS 3 NC ARTHROTEC 3 NC CELEBREX 3 3 celecoxib diclofenac DUEXIS NC NC FELDENE 3 NC *Generic Contraceptives are available to female members at no copay. 22

25 (NON-SPECIALTY BY CONDITION) CONDITION/DRUG ibuprofen meloxicam methotrexate inj PA NAPRELAN 3 NC NAPROSYN 3 NC naproxen CONDITION/DRUG RAPAFLO 2 2 tamsulosin tolterodine/er TOVIAZ 2 NC trospium/er VESICARE 2 2 OTREXUP PA 3 3 PENNSAID NC NC RASUVO PA 3 3 VIMOVO NC NC THYROID MEDICATIONS ARMOUR THYROID 3 3 levothyroxine SYNTHROID 2 2 UROLOGIC DIRDERS AVODART 3 3 DETROL 3 NC DETROL LA 3 NC ENABLEX 3 NC finasteride GELNIQUE 3 NC JALYN 3 NC MYRBETRIQ 2 3 oxybutynin/er OXYTROL 3 NC phenazopyridine 23

26 (NON-SPECIALTY (ALPHABETIC INCLUDING BY CONDITION) SPECIALTY) Bold Type means there is a generic version for this drug. Italic Type means this is a specialty drug. Drugs that are listed in capital letters are brand name drugs, while those in lowercase are generic versions. abacavir abacavir/ lamivudine/ zidovudine ABILIFY 3 3 ABRAXANE 4 4 ACCOLATE 3 3 ACCU CHEK TEST STRIPS acetaminophen/ codeine 2 2 ACIPHEX 3 NC acitretin ACTEMRA PA 5 5 ACTHAR HP PA 5 5 ACTIMMUNE PA 4 4 ACTONEL 3 3 ADCETRIS PA 4 4 ADCIRCA PA 5 5 ADEFOVIR 4 4 ADEMPAS PA 5 5 ADRIAMYCIN PFS 4 4 ADRIAMYCIN RDF 4 4 ADRUCIL 4 4 ADVAIR DISKUS 2 2 ADVAIR HFA 2 2 ADVATE/H/L/M/SH/UH 4 4 ADVICOR 3 NC ADYNOVATE 5 5 AFINITOR PA 4 4 AFINITOR DISPERZ TAB PA 4 4 AFSTYLA 4 4 AGGRENOX 3 3 albuterol sulfate tablet/ solution ALECENSA PA 5 5 ALCORTIN A PA 3 NC ALDURAZYME PA 4 4 alendronate ALFERON N PA 4 4 ALIMTA 4 4 ALKERAN INJ 5 5 ALKERAN TAB 4 4 allopurinol ALPHAGAN P (0.15%) 3 3 ALPHANATE 4 4 ALPHANINE SD 4 4 alprazolam ALPROLIX 4 4 ALTOPREV 3 NC AMBIEN/CR 3 NC AMEVIVE 4 4 AMIFOSTINE

27 (ALPHABETIC INCLUDING SPECIALTY) AMITIZA PA 3 3 amitriptyline amlodipine amlodipine/ astorvastatin amlodipine besylate/benazepril hydrochloride amoxicillin amoxicillin/ clavulanate potassium amphetamine salt combo PA AMPYRA PA 5 5 ANAPROX DS 3 NC anastrozole ANDRODERM PA 2 2 ANDROGEL PA 2 NC APIDRA/LOSTAR 2 NC APOKYN 4 4 apri APTIVUS 2 2 ARALAST /NP PA 4 4 ARANESP PA 4 4 ARCALYST PA 4 4 ARMOUR THYROID 3 3 ARRANON 4 4 ARTHROTEC 3 NC ARZERRA PA 4 4 ASACOL HD 2 NC ASTAGRAF XL 2 2 ASTEPRO 3 3 ATACAND/HCT 3 NC atenolol atorvastatin calcium ATRIPLA 2 2 ATROVENT HFA 2 2 AUBAGIO PA 4 4 AVALIDE 3 NC AVAPRO 3 NC AVASTIN PA 4 4 AVEED PA 4 4 aviane AVODART 3 3 AVONEX PA 4 4 AXIRON PA 3 3 AZACITIDINE 4 4 azathioprine azelastine azithromycin AZOPT 2 2 AZOR 3 3 baclofen BARACLUDE INJ 4 4 BARACLUDE TABS 5 5 BASAGLAR 2 2 BD ULTRA FINE PEN NEEDLES

28 (NON-SPECIALTY (ALPHABETIC INCLUDING BY CONDITION) SPECIALTY) BEBULIN 4 4 BECONASE AQ 3 NC BELEODAQ PA 4 4 benazepril BENEFIX 4 4 BENICAR/HCTZ 3 3 BENDEKA PA 4 4 BENLYSTA PA 4 4 benzonatate BERINERT PA 4 4 BETASERON PA 4 4 BETHKIS 4 4 BEXAROTENE 4 4 BICNU 4 4 BIVIGAM PA 4 4 BLEOMYCIN 4 4 BLINCYTO PA 4 4 SULIF PA 4 4 TOX PA 4 4 BRAVELLE PA 4 4 BREVIBLOC 3 3 brimonidine tartrate budesonide nasal spray BUPHENYL PWDR PA 5 5 BUPHENYL TAB PA 4 4 bupropion/xl butalbital/apap BUTRANS 3 3 BYDUREON 3 3 BYSTOLIC 2 2 CADUET 3 NC calcipotrienebetamethasone calcitriol CAMPTOSAR 5 5 candesartan/hctz CAPECITABINE 4 4 carbidopa/levodopa & er CARPLATIN 4 4 CARIMUNE NF PA 4 4 CARIPRODOL carvedilol CELEBREX 3 3 celecoxib CELLCEPT 3 3 cephalexin CEPROTIN PA 4 4 CERDELGA PA 4 4 CEREZYME PA 4 4 cetirizine solution 1 NC CETROTIDE PA 4 4 CHANTIX 2 2 CHORIONIC GONADOTROPIN PA 4 4 ciclopirox CIMZIA PA

29 (ALPHABETIC INCLUDING SPECIALTY) CINRYZE PA 4 4 CIPRODEX 2 2 ciprofloxacin CISPLATIN 4 4 citalopram CLADRIBINE 4 4 CLARINEX 3 NC CLARINEX-D 3 NC clindamycin phosphate clobetasol propionate CLOBEX 3 3 CLOLAR 5 5 clonazepam CLONIDINE clopidogrel clotrimazole/ betamethasone COAGADEX 4 4 COLCRYS 3 3 COMBIGAN 2 2 COMBIVENT RESPIMAT 2 2 COMBIVIR 3 3 CONTOUR 3 3 COPAXONE 40MG PA 4 4 COPAXONE 20MG PA 5 5 COPEGUS PA 5 5 CORIFACT 4 4 CORTEF 3 NC CORTICOTROPIN PA 4 4 COSENTYX PA 5 5 COSMEGEN 5 5 COUMADIN 2 3 COZAAR 3 NC CRESTOR 3 NC cryselle CUVITRU PA 5 5 cyclobenzaprine CYCLOPHOSPHAMIDE 4 4 cyclosporine inj CYMBALTA 3 3 CYSTAGON 4 4 CYTARABINE 4 4 CYTOGAM 4 4 CYTOVENE 5 5 DACARBAZINE 4 4 DACOGEN 5 5 DAKLINZA PA 5 5 DARZALEX PA 4 4 DAUNORUBICIN HCL 4 4 DAUNOXOME 4 4 DECITABINE 4 4 DEFEROXAMINE 4 4 deltasone 1 NC DEPO TESTOSTERONE (200mg) PA 3 3 DEPOCYT

30 (NON-SPECIALTY (ALPHABETIC INCLUDING BY CONDITION) SPECIALTY) DESFERAL 5 5 desloratadine 1 NC DEGEN 3 3 DETROL 3 NC DEXILANT 3 NC DEXRAZOXANE 4 4 dextro-amphetamine/ amphetamine salts PA diazepam diclofenac dicyclomine didanosine delayed release digoxin diltiazem cd DIOVAN/HCT 3 NC DOCETAXEL 4 4 DOFETILIDE 4 4 donepezil dorzolamide/timolol maleate doxazosin mesylate DOXIL 5 5 DOXORUBICIN HCL 4 4 doxycycline hyclate DUEXIS NC NC DULERA 2 2 duloxetine DUREZOL 2 2 DYMISTA 3 NC DYSPORT PA 4 4 EDARBI 3 NC EDARBICLOR 3 NC EDLUAR 3 3 EDURANT 2 2 EFFEXOR XR 3 3 EFFIENT 2 2 EGRIFTA PA 4 4 ELAPRASE PA 4 4 ELIGARD PA 4 4 ELIQUIS 2 2 ELITEK 4 4 ELLENCE 5 5 ELOCTATE 4 4 EMPLICITI PA 4 4 EMTRIVA 2 2 ENABLEX 3 NC ENALAPRIL MALEATE ENBREL PA 4 4 enoxaparin sodium ENTECAVIR 4 4 ENTYVIO PA 5 5 EPCLUSA PA 4 4 EPIDUO PA 2 2 EPIPEN 2 PAK 2 2 EPIRUBICIN 4 4 EPIVIR 3 3 EPOGEN PA

31 (ALPHABETIC INCLUDING SPECIALTY) EPZICOM 3 3 EQUETRO 3 3 ERBITUX PA 4 4 ERIVEDGE PA 4 4 ERTACZO PA 3 NC ERYGEL 3 3 erythromycin ESBRIET PA 4 4 escitalopram oxalate esomeprazole ESTRACE ORAL 3 3 estradiol eszopiclone ethinyl estrad ETHYOL 5 5 ETOPOPHOS 4 4 ETOPOSIDE 4 4 EUFLEXXA PA 5 5 EVISTA 3 3 EXELDERM PA 3 3 EXELON 3 3 EXFORGE/HCTZ 3 3 EXJADE PA 4 4 EXONDYS PA 5 5 EXTAVIA PA 5 5 EYLEA PA 4 4 FABRAZYME PA 4 4 FARYDAK PA 5 5 FASLODEX 4 4 FEIBA 4 4 FELDENE 3 NC fenofibrate fenofibric acid fentanyl PA finasteride FIRAZYR PA 4 4 FIRMAGON 4 4 FIRST LANPRAZOLE 3 NC FIRST OMEPRAZOLE NC NC FLEGAMMA/DIF PA 4 4 FLOVENT HFA 2 2 FLOXURIDINE 4 4 FLUCONAZOLE FLUDARABINE 4 4 flunisolide spray fluocinonide FLUOROURACIL 4 4 fluoxetine fluticasone spray FOCALIN XR PA 3 3 FOLLISTIM/AQ PA 4 4 FOLOTYN 4 4 FORTEO PA 4 4 FORTESTA PA 3 3 FREESTYLE LANCETS & STRIPS 3 3 furosemide 29

32 (NON-SPECIALTY (ALPHABETIC INCLUDING BY CONDITION) SPECIALTY) FUSILEV 4 4 FUZEON 4 4 gabapentin GAMASTAN S/D PA 4 4 GAMMAGARD PA 4 4 GAMMAKED PA 4 4 GAMMAPLEX PA 4 4 GAMUNEX-C PA 4 4 GANCICLOVIR 4 4 GANIRELIX ACETATE PA 4 4 GARDASIL 2 2 GATTEX PA 4 4 GAZYVA PA 4 4 GELNIQUE 3 NC GEL-ONE PA 4 4 GELSYN-3 PA 4 4 GEMCITABINE 4 4 gemfibrozil GEMZAR 5 5 GENERESS FE 3 3 GENOTROPIN PA 5 5 GENVOYA 2 2 gianvi GILENYA PA 4 4 GLASSIA 4 4 GLATOPA PA 4 4 GLEEVEC PA 5 5 glimepiride glipizide glipizide er glipizide xl GLUCOPHAGE/XR 3 3 GLUMETZA NC NC glyburide GLYSET 3 3 GONAL-F PA 5 5 GONAL-F RFF PA 5 5 GRANIX PA 4 4 HALAVEN PA 4 4 HARVONI PA 4 4 HELIXATE FS 4 4 HEMOFIL M 4 4 HEPAGAM B 4 4 HEPSERA 5 5 HERCEPTIN PA 4 4 HIZENTRA PA 4 4 HUMALOG/ MIX/ KWIKPEN 2 NC HUMATE-P 4 4 HUMATROPE PA 4 4 HUMIRA PA 4 4 HUMULIN/ KWIKPEN (EXCEPT HUMULIN U-500 CONCENTRATE) HUMULIN U-500 CONCENTRATE 2 NC 2 2 HYALGAN PA 4 4 HYCAMTIN CAP 4 4 HYCAMTIN INJ

33 (ALPHABETIC INCLUDING SPECIALTY) hydralazine hydrochlorothiazide hydrocodone/ acetaminophen hydromorphone HYPERHEP B 4 4 HYPERRHO S/D 4 4 HYQVIA PA 4 4 HYZAAR 3 NC ibandronate IBRANCE PA 4 4 ibuprofen ICLUSIG PA 4 4 IDAMYCIN PFS 5 5 IDARUBICIN HCL 4 4 IDELVION 4 4 IFEX 5 5 IFOSFAMIDE 4 4 ILARIS PA 4 4 IMATINIB PA 4 4 IMBRUVICA PA 4 4 INCRELEX PA 4 4 INLYTA PA 4 4 INTELENCE 2 2 INTERMEZZO 3 NC INTRON-A PA 4 4 INTUNIV 3 3 INVOKANA PA 3 3 irbesartan/hctz IRESSA PA 5 5 IRINOTECAN 4 4 ISENTRESS 2 2 isosorbide mononitrate er ISTODAX PA 4 4 IXEMPRA 4 4 IXINITY 5 5 JADENU PA 5 5 JAKAFI PA 4 4 JALYN 3 3 JANUMET 2 2 JANUMET XR 2 2 JANUVIA 2 2 JENTADUETO 3 2 JEVTANA PA 4 4 JUBLIA PA 3 NC junel/fe KADCYLA PA 4 4 KALBITOR PA 4 4 KALYDECO PA 4 4 KAZANO 3 NC KEPIVANCE PA 4 4 KERYDIN PA 3 NC ketoconazole PA KEYTRUDA PA 4 4 KINERET PA 5 5 KOATE-DVI 4 4 KOGENATE FS

34 (NON-SPECIALTY (ALPHABETIC INCLUDING BY CONDITION) SPECIALTY) KOMBIGLYZE XR 2 NC KRYSTEXXA PA 5 5 KUVAN PA 4 4 KYNAMRO PA 4 4 KYPROLIS PA 5 5 lamivudine lamivudine/zidovudine lamotrigine lansoprazole LANTUS 2 3 LANTUS LOSTAR 2 3 latanoprost LARTRUVO PA 4 4 LEMTRADA PA 5 5 LESCOL/XL 3 NC LETAIRIS PA 4 4 letrozole LEUCOVORIN LEUKINE PA 5 5 LEUPROLIDE PA 4 4 LEVATOL 3 3 LEVEMIR 2 2 levetiracetam levocetirizine 1 NC levofloxacin levothyroxine LIALDA 3 3 lidocaine LILETTA 5 5 LINZESS 2 2 LIPITOR 3 NC LIPODOX 5 5 LIVALO 3 NC lisinopril/hctz LO LOESTRIN FE 3 3 LOESTRIN/FE 3 3 LOPROX 3 NC lorazepam loryna losartan/hctz LOTEMAX 2 2 LOTRINE 3 NC lovastatin LOVAZA 3 3 LUCENTIS PA 4 4 LUMIGAN 2 NC LUMIZYME PA 4 4 LUNESTA 3 NC LUPANETA PACK 4 4 LUPRON DEPOT/ DEPOT-PED PA 4 4 LUZU PA 3 NC LYNPARZA PA 4 4 LYRICA 2 2 MACUGEN PA 5 5 MAKENA 5 5 MAXAIR AUTOHALER 3 3 MEDROL 3 NC 32

35 (ALPHABETIC INCLUDING SPECIALTY) megestrol acetate MEKINIST PA 4 4 meloxicam MELPHALAN HCL 4 4 MENOPUR PA 4 4 MENTAX 3 NC MESNA 4 4 MESNEX INJ 5 5 MESNEX TAB 4 4 metformin ER metformin ER (generic GLUMETZA) PA methocarbamol methotrexate inj PA methotrexate tabs METHYLIN PA 3 3 methylphenidate/er PA methylprednisolone metoprolol succinate metoprolol tartrate metronidazole MEVACOR 3 NC MICARDIS/HCT 3 NC MICRHOGAM 4 4 microgestin/fe MILLIPRED 3 NC MINASTRIN 24 FE 3 3 MINIVELLE 2 2 MIRCETTE 3 3 MIRENA 4 4 MITOMYCIN 4 4 MITOXANTRONE 4 4 mononessa MONONINE 4 4 MONOVISC PA 5 5 montelukast sodium MOVIPREP 2 2 MOZOBIL 4 4 mupirocin MUSTARGEN 4 4 mycophenolate mofetil MYFORTIC 3 3 MYOBLOC PA 4 4 MYOZYME PA 4 4 MYRBETRIQ 2 3 naftifine NAFTIN 2 NC NABI-HB 4 4 NAGLAZYME PA 4 4 NDA 3 3 NAPRELAN 3 NC NAPROSYN 3 NC naproxen NASACORT AQ 3 NC NANEX 3 NC NATESTO PA 3 NC NAVELBINE

36 (NON-SPECIALTY (ALPHABETIC INCLUDING BY CONDITION) SPECIALTY) NECON 3 3 NEORAL 3 3 NESINA 3 NC NEULASTA PA 5 5 NEUMEGA 4 4 NEUPOGEN PA 5 5 NEUPRO 2 2 nevirapine/ delayed release NEXAVAR PA 4 4 NEXIUM 3 NC niacin er NILANDRON PA 3 3 NIPENT 4 4 NITROSTAT 3 3 NORDITROPIN PA 4 4 NORTHERA PA 5 5 NORITATE 3 NC NOVAREL PA 4 4 NOVOLIN 2 2 NOVOLOG MIX FLEXPEN 2 2 NOVOLOG/ MIX 2 2 NOVOSEVEN RT 4 4 NPLATE PA 4 4 NUCALA PA 5 5 NULOJIX 4 4 NUTROPIN PA 5 5 NUVARING 2 2 NUWIQ 4 4 OCALIVA PA 5 5 OCTAGAM PA 4 4 OCTREOTIDE 4 4 OFEV PA 4 4 OLEPTRO ER 3 3 OLUX / OLUX E NC NC OLYSIO PA 5 5 omega-3 acid ethyl esters omeprazole OMNARIS 2 NC OMNITROPE PA 5 5 omperazole/sodium bicarbonate ONCASPAR 4 4 ondansetron/ odt ONE TOUCH ULTRA TEST STRIPS 2 2 ONGLYZA 2 NC ONIVYDE PA 5 5 OPDIVO PA 4 4 OPSUMIT PA 5 5 ORACEA 3 3 ORALAIR PA 5 5 ORAPRED ODT 3 NC ORENCIA PA 5 5 ORENITRAM PA 4 4 ORKAMBI PA 4 4 ORTHO EVRA

37 (ALPHABETIC INCLUDING SPECIALTY) ORTHO NOVUM 3 3 ORTHO TRI CYCLEN 3 3 ORTHO TRI CYCLEN LO 3 3 ORTHOVISC PA 5 5 OSENI 3 NC OTEZLA PA 4 4 OTREXUP PA 3 3 OVIDREL PA 4 4 OXALIPLATIN 4 4 OXISTAT PA 3 NC oxybutynin/er oxycodone/ acetaminophen OXYCONTIN 3 3 OXYTROL 3 NC PACLITAXEL 4 4 PAMIDRONATE 4 4 pantoprazole sodium paroxetine PATADAY 3 3 PATANOL 3 3 PEGASYS PA 4 4 PEGASYS PROCLICK PA 4 4 PEG-INTRON PA 4 4 PEGINTRON REDIPEN PA 4 4 PENNSAID NC NC PERJETA PA 4 4 phenazopyridine pioglitazone PLAVIX 3 3 PLEGRIDY/PEN PA 4 4 polyethylene glycol 3350 POMALYST PA 5 5 potassium chloride PRADAXA 3 NC PRALUENT PA 5 5 pramipexole dihydrochloride PRAVACHOL 3 NC pravastatin sodium prednisolone acetate PREFEST 3 3 PREGNYL PA 4 4 PREMARIN 2 2 PREMPRO 2 2 PREVACID 3 NC PREZISTA 2 2 PRILOSEC 3 NC PRISTIQ ER 3 3 PRIVIGEN PA 4 4 PROAIR HFA 2 2 PROCRIT PA 4 4 PROFILNINE SD 4 4 progesterone PA PROGRAF 3 3 PROLEUKIN

38 (NON-SPECIALTY (ALPHABETIC INCLUDING BY CONDITION) SPECIALTY) PROLIA PA 4 4 PROMACTA PA 4 4 promethazine hcl promethazine/codeine propranolol PROTONIX 3 NC PROVENTIL HFA 2 NC PULMOZYME PA 4 4 QNASL 3 NC quetiapine fumarate QVAR 2 2 rabeprazole ramipril ranitidine RAPAFLO 2 2 RAPAMUNE 3 3 RASUVO PA 3 3 RAVICTI PA 4 4 RAYOS PA 3 NC REBETOL PA 4 4 REBIF PA 4 4 REBIF REBIDOSE PA 4 4 RECLAST 5 5 RECOMBINATE 4 4 RELISTOR PA 3 3 RELPAX 3 3 REMICADE PA 5 5 REMODULIN PA 5 5 REPATHA PA 4 4 REPRONEX PA 5 5 RESCULA 3 3 RESTASIS PA 2 2 RETROVIR 3 3 REVATIO PA 5 5 REVLIMID PA 5 5 REYATAZ 2 2 RHINOCORT AQUA 3 NC RHOGAM 4 4 RHOGAM PLUS 4 4 RHOPHYLAC 4 4 RIASTAP 4 4 RIBAPAK PA 4 4 RIBASPHERE PA 4 4 RIBATAB PA 4 4 RIBAVIRIN PA 4 4 risedronate risperidone RITUXAN PA 5 5 RIXUBIS 4 4 rizatriptan ropinirole rosuvastatin ROZEREM 3 NC SABRIL PA

39 (ALPHABETIC INCLUDING SPECIALTY) SAIZEN PA 5 5 SAMSCA 4 4 SANDIMMUNE 3 3 SANDOSTATIN PA 5 5 SANDOSTATIN LAR PA 4 4 SENSIPAR PA 4 4 SEROQUEL XR 3 3 SEROSTIM PA 4 4 sertraline SILDENAFIL PA 4 4 SIMPONI/ARIA PA 5 5 simvastatin SINGULAIR 3 3 sirolimus SKYLA 4 4 DIUM PHENYLBUTYRATE 4 4 LESTA 4 4 LIRIS PA 4 4 MATULINE DEPOT PA 4 4 MAVERT 4 4 NATA 3 NC RIATANE NC NC VALDI PA 4 4 SPIRIVA 2 2 spironolactone sprintec SPRYCEL 4 4 STAVUDINE STELARA PA 5 5 STIMATE 4 4 STIVARGA PA 4 4 STRATTERA 2 2 STRIANT PA 3 3 STRIBILD 2 2 SUXONE FILM 2 2 sucralfate sulfame-thoxazole/ trimethoprim sumatriptan succinate SUMAVEL 3 3 SUPARTZ PA 4 4 SUPPRELIN LA PA 4 4 SUPREP WEL PREP KIT 2 2 SUSTIVA 2 2 SUTENT PA 4 4 SYLATRON PA 4 4 SYMBICORT 2 2 SYNAGIS PA 4 4 SYNTHROID 2 2 SYNVISC PA 5 5 SYNVISC ONE PA 5 5 TACLONEX NC NC tacrolimus TAFINLAR PA 4 4 TAMIFLU CAPS

40 (NON-SPECIALTY (ALPHABETIC INCLUDING BY CONDITION) SPECIALTY) TAMIFLU LUTION 2 2 tamoxifen citrate tamsulosin TARCEVA PA 4 4 TARGRETIN CAPS PA 5 5 TASIGNA PA 5 5 TAXOTERE 5 5 TECFIDERA PA 4 4 TECHNIVIE PA 5 5 telmisartan/hctz temazepam TEMODAR 5 5 TEMOZOLOMIDE 4 4 TESTIM PA 3 NC testosterone cypionate PA testosterone gel PA TETRABENAZINE 4 4 TEVETEN/HCT 3 NC THALOMID 4 4 THERACYS 4 4 THIOTEPA 4 4 THYROGEN 4 4 TICE BCG 4 4 TIKOSYN 5 5 timolol maleate tizanidine TOBI 5 5 TOBI PODHALER 4 4 TOBRAMYCIN INH LN 4 4 tolterodine/er topiramate TOPOSAR 5 5 TOPOTECAN 4 4 TORISEL 4 4 TOTECT 5 5 TOUJEO 2 3 TOVIAZ 2 NC TRACLEER PA 4 4 TRADJENTA 3 2 tramadol/er TRAVATAN Z 2 2 travoprost trazodone TREANDA PA 5 5 TRELSTAR PA 4 4 TRESIBA 2 3 tretinoin PA TRETTEN 4 4 tri previfem tri sprintec triamcinolone acetonide triamcinolone spray triamterene/hctz TRIGLIDE 3 3 trinessa 38

41 (ALPHABETIC INCLUDING SPECIALTY) TRISENOX 4 4 TRIZIVIR 3 3 trospium/er TRUVADA 2 2 TYKERB PA 4 4 TYSABRI PA 5 5 TYVA PA 5 5 TYZEKA 4 4 ULORIC 2 2 UVADEX 4 4 VAGIFEM 3 3 valacyclovir valsartan/hctz VALSTAR 4 4 VALTREX 3 3 VANTAS PA 4 4 VARIZIG 4 4 VECTIBIX PA 4 4 VELCADE PA 5 5 VELETRI PA 5 5 VEMLIDY 4 4 venlafaxine/er VENTAVIS PA 4 4 VENTOLIN HFA 2 NC VERAMYST 2 NC verapamil/er VESICARE 2 2 VICTOZA 2 PAK & 3 PAK 2 2 VIDAZA 5 5 VIDEX EC 3 3 VIGAMOX 2 2 VIMIZIM PA 4 4 VINBLASTINE 4 4 VINCASAR PFS 5 5 VINCRISTINE 4 4 VINORELBINE 4 4 VIMOVO NC NC VIRACEPT 2 2 VIRAMUNE/XR 3 3 VIREAD 2 2 VISTOGARD 4 4 VISUDYNE 4 4 VIVELLE DOT 3 3 VIVITROL 4 4 VOGELXO PA 3 NC VOLTAREN GEL 3 3 VOTRIENT PA 4 4 VPRIV PA 4 4 VUSION 3 NC VYTORIN 3 NC VYVANSE PA 2 2 warfarin WELCHOL 2 2 WELLBUTRIN XL

42 (ALPHABETIC INCLUDING SPECIALTY) WILATE 4 4 WINRHO SDF 4 4 XALKORI PA 4 4 XARELTO 2 2 XELJANZ PA 5 5 XELJANZ/XR PA 5 5 XELODA 5 5 XENAZINE PA 5 5 XEOMIN PA 4 4 XGEVA PA 4 4 XIAFLEX PA 4 4 XOLAIR PA 4 4 XOLEGEL NC NC XOPENEX/ CONCENTRATE 3 3 XOPENEX HFA 2 NC XTANDI PA 4 4 XYNTHA 4 4 XYNTHA LOFUSE 4 4 XYZAL 3 NC YERVOY PA 4 4 zafirlukast zaleplon ZALTRAP PA 4 4 ZANOSAR 4 4 ZARXIO PA 4 4 ZEGERID 3 NC ZELRAF PA 4 4 ZEMAIRA 4 4 ZERIT 3 3 ZETIA 3 3 ZETONNA 3 NC ZIAGEN 3 3 zidovudine ZINECARD 5 5 ZINBRYTA PA 5 5 ZIOPTAN 3 3 ZOCOR 3 NC ZOLADEX PA 4 4 ZOLEDRONIC ACID 4 4 ZOLINZA PA 4 4 zolmitriptan zolpidem/er zolpidem tartrate & er ZOMACTON PA 5 5 ZOMETA 5 5 ZOMIG/ZMT 3 3 ZORBTIVE PA 4 4 ZORTRESS 4 4 ZOVIRAX 3 3 ZYKADIA PA 4 4 ZYTIGA PA 4 4 ZYVOX

43 MANAGED NOT COVERED DRUG LIST BASIC OPTION These listed drugs are not covered under Basic Option. If you use any of these Managed Not Covered Drugs, you will need to pay the full cost of the drug(s). If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options. CATEGORY* DRUG CLASS ALLERGIES LESS SEDATING ANTIHISTAMINES ALLERGIES NASAL STEROIDS DRUG NOT COVERED IN 2018 FOR BASIC OPTION cetirizine solution, desloratadine, levocetirizine, CLARINEX, CLARINEX-D, XYZAL BECONASE AQ, DYMISTA, NANEX, NASACORT AQ, OMNARIS, QNASL, RHINOCORT AQUA, VERAMYST, ZETONNA COVERED OPTIONS** montelukast, zafirlukast, ACCOLATE, SINGULAIR budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray ANTICOAGULANTS PRADAXA warfarin, ELIQUIS, XARELTO ANAPHYLAXIS TREATMENT ASTHMA: BETA AGONISTS AUVI-Q PROVENTIL HFA, VENTOLIN HFA, XOPENEX HFA epinephrine injection (0.15 mg and 0.30 mg), EPIPEN, EPIPEN JR. albuterol solution, levalbuterol inhalation solution, proair HFA ASTHMA: INHALED CORTICOSTEROIDS BENIGN PROSTATIC HYPER- PLASIA (BPH) 5-ALPHA- REDUCTASE INHIBITOR/ ALPHA BLOCKER AEROSPAN, ALVESCO JALYN budesonide inhalation suspension, ASMANEX, FLOVENT HFA, PULMICORT, QVAR alfuzosin, dutasteride, dutasteride/ tamsulosin, finasteride, tamsulosin CARDIOVASCULAR: HEART YOSPRALA aspirin*** and esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole COPD LONG-LASTING MUSCARINIC RECEPTOR ANTAGONIST (LAMA) INCRUSE ELLIPTA, TUDORZA PRESSAIR Ipratropium, ATROVENT HFA, SPIRIVA CONTINUED ON NEXT PAGE 41

44 MANAGED NOT COVERED DRUG LIST BASIC OPTION CATEGORY* DRUG CLASS MANAGED NOT COVERED (NC) DRUGS COVERED OPTIONS** DERMATOLOGY - ROSACEA NORITATE clindamycin/benzoyl peroxide, doxycycline (except 20 mg), flurandrenolide, metronidazole cream/gel/lotion, FINACEA, METROCREAM, METROGEL, METROLOTION, MIRVA, ORACEA, OLANTRA DERMATOLOGICALS: OTHER DIABETES - BIGUANIDES DIABETES DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS DIABETES DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS DIABETES INSULINS CARAC, FLUOROUACIL CREAM 0.5% GLUMETZA, FORTAMET, RIOMET NESINA, ONGLYZA KAZANO, KOMBIGLYZE XR, OSENI APIDRA/LOSTAR HUMALOG diclofenac sodium, PICATO, TOLAK metformin ER alogliptan, saxagliptan, JANUVIA, TRADJENTA aloglliptan/metformin, alogliptan/ pioglitazone, saxogliptan/metformin ext-rel, JANUMET, JANUMET XR, JENTADUETO NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN 70/30 NOVOLIN 70/30 HUMULIN N HUMULIN R NOVOLIN N NOVOLIN R NOTE: HUMULIN R U-500 concentrate will continue to be covered FUNGAL INFECTIONS ERTACZO, JUBLIA, KERYDIN, LOPROX, LOTRINE, LUZU, MENTAX, NAFTIN, OXISTAT, VUSION, XOLEGEL ciclopirox, clotrimazole, clotrimazole/betamethasone, econazole, ketoconazole, LAMISIL, naftifine, nystatin, terbinafine, ECOZA, EXELDERM * This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. 42

45 MANAGED NOT COVERED DRUG LIST BASIC OPTION CATEGORY* DRUG CLASS GASTROINTESTINAL AGENTS PROTON PUMP INHIBITORS MANAGED NOT COVERED (NC) DRUGS ACIPHEX, DEXILANT, FIRST-LANPRAZOLE, FIRST-OMEPRAZOLE, NEXIUM, PREVACID, PRILOSEC, PROTONIX, ZEGERID COVERED OPTIONS** esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate, pantoprazole, rabeprazole GLAUCOMA PROSTAGLANDIN ANALOGS LUMIGAN latanoprost, travoprost, RESCULA, TRAVATAN, XALATAN, ZIOPTAN HIGH BLOOD PRESSURE ANGIOTENSIN II RECEPTOR BLOCKERS HIGH BLOOD PRESSURE ANGIOTENSIN II RECEPTOR BLOCKER / DIURETIC COMBINATIONS ATACAND, AVAPRO, COZAAR, DIOVAN, EDARBI, MICARDIS,TEVETEN ATACAND HCT, AVALIDE, DIOVAN HCT, EDARBYCLOR, HYZAAR, MICARDIS HCT, TEVETEN HCT candesarten, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICAR candesartan/hctz, eprosartan, irbesartan/hctz, losartan/hctz, telmisartan/hctz, valsartan/hctz, BENICAR/HCT HIGH CHOLESTEROL ADVICOR, ALTOPREV, CADUET, CRESTOR, FLOLIPID, LESCOL/XL, LIPITOR, LIPTRUZET, LIVALO, MEVACOR, NIKITA, PRAVACHOL, VYTORIN, ZOCOR, ZYPITAMAG amlodipine-atorvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin MUSCLE RELAXANTS AMRIX baclofen, cyclobenzaprine, dantrolene OVERACTIVE BLADDER/ INCONTINENCE URINARY ANTISPASMODICS PAIN AND INFLAMMATION - CORTICOSTEROIDS DETROL, DETROL LA, ENABLEX, GELNIQUE, OXYTROL, TOVIAZ deltasone, CORTEF, MEDROL, MILLIPRED, ORAPRED ODT, RAYOS darifenacin hydrobromide er, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, VESICARE cortisone, dexamethasone, fludrocortisone, hydrocortisone, methylprednisolone, prednisone CONTINUED ON NEXT PAGE 43

46 MANAGED NOT COVERED DRUG LIST BASIC OPTION CATEGORY* DRUG CLASS PAIN AND INFLAMMATION NON STEROIDAL ANTI-INFLAMMATORIES (NSAIDS) PAIN AND INFLAMMATION NON STEROIDAL ANTI-INFLAMMATORIES (NSAIDS) COMBINATIONS MANAGED NOT COVERED (NC) DRUGS ANAPROX DS, FELDENE, NAPRELAN, NAPROSYN, PENNSAID ARTHROTEC, DUEXIS, VIMOVO COVERED OPTIONS** choline magnesium trisalicylate, diclofenac dr/er, diclofenac gel/soln, etodolac/er flurbiprofen, ibuprofen, indomethacin er, ketoprofen/er, meloxicam, nabumetone, naproxen/er, oxaprozin, piroxicam, sulindac, VOLTAREN GEL diclofenac/misoprostol, esomeprazole, famotidine, ibuprofen, naproxen, ranitidine PRIASIS RIATANE, TACLONEX acitretin, calcipotrienebetamethasone, calcitriol, methoxsalen, DOVONEX, OXRALEN ULTRA SLEEP HYPNOTICS, NON BENZODIAZEPINES SKIN - CORTICOSTEROIDS TESTOSTERONE REPLACEMENT ANDROGENS ULCERATIVE COLITIS AMINOSALICYLATES (5-ASA) AMBIEN, AMBIEN CR, INTERMEZZO, LUNESTA, ROZEREM, NATA ALCORTIN-A, NOVACORT, OLUX, OLUX-E ANDROGEL, NATESTO, TESTAVAN, TESTIM, VOGELXO ASACOL HD, DELZICOL eszopiclone, zaleplon, zolpidem/er clobetasol propionate, clotrimazole/ betamethasone, fluocinoide, halobetasol proprionate, hydrocortisone/ iodoquinol, hydrocortisone/ iodoquinol/aloe, hydrocortisone/ pramoxine, PRAMONE testosterone gel, ANDRODERM, AXIRON, FORTESTA balsalazide, budesonide caps, mesalamine, sulfasalazine, APRI, LIALDA, PENTASA * This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. ** For more covered options, visit fepblue.org/pharmacy to find the 2018 Standard Option formulary. *** Low dose aspirin (81 mg) is covered for men age 45 through 79, women age 12 through 79 and for pregnant women at risk of preeclampsia. 44

47 MANAGED NOT COVERED DRUG LIST BASIC OPTION (ALPHABETIC) ACIPHEX DYMISTA LUMIGAN RAYOS ADVICOR EDARBI LUNESTA RHINOCORT AQUA AEROSPAN EDARBYCLOR LUZU RIOMET ALCORTIN A ENABLEX MEDROL ROZEREM ALVESCO ERTACZO MENTAX NATA ALTOPREV FELDENE MEVACOR RIATANE AMBIEN AMBIEN CR AMRIX ANAPROX DS ANDROGEL APIDRA/LOSTAR ARTHROTEC ASACOL HD ATACAND/HCT AUVI Q AVALIDE AVAPRO BECONASE AQ CADUET CARAC cetirizine solution CLARINEX CLARINEX-D CORTEF COZAAR CRESTOR deltasone DELZICOL desloratadine DETROL DETROL LA DEXILANT DIOVAN/ HCT DUEXIS FIRST LANPRAZOLE FIRST OMEPRAZOLE FLOLIPID fluorouracil cream 0.5% FORTAMET GELNIQUE GLUMETZA HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMULIN 70/30 HUMULIN N HUMULIN R HYZAAR INCRUSE ELLIPTA INTERMEZZO JALYN JUBLIA KAZANO KERYDIN KOMBIGLYZE XR LESCOL/XL levocetirizine LIPITOR LIVALO LOPROX LOTRINE MICARDIS/HCT MILLIPRED NAFTIN NAPRELAN NAPROSYN NASACORT AQ NANEX NATESTO NESINA NEXIUM NIKITA NORITATE NOVACORT OLUX OLUX E OMNARIS ONGLYZA ORAPRED ODT OSENI OXISTAT OXYTROL PENNSAID PRADAXA PRAVACHOL PREVACID PRILOSEC PROTONIX PROVENTIL HFA QNASL TACLONEX TESTAVAN TESTIM TEVETEN/HCT TOVIA TUDORZA PRESSAIR VENTOLIN HFA VERAMYST VIMOVO VOGELXO VUSION VYTORIN XOLEGEL XOPENEX HFA XYZAL YOSPRALA ZEGERID ZETONNA ZOCOR ZYPITAMAG NOTE: HUMULIN R U-500 concentrate will continue to be covered 45

48 EXCLUDED DRUG LIST STANDARD OPTION These listed drugs are not covered under Standard Option. If you use any of these Excluded Drugs, you will need to pay the full cost of the drug(s). If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options. CATEGORY* DRUG CLASS DRUG NOT COVERED IN 2018 FOR STANDARD OPTION COVERED OPTIONS** ANAPHYLAXIS TREATMENT AUVI-Q epinephrine injection (0.15 mg and 0.30 mg), EPIPEN, EPIPEN JR. CARDIOVASCULAR - HEART YOSPRALA aspirin***, esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole DIABETES - BIGUANIDES GLUMETZA metformin ER FUNGAL INFECTIONS XOLEGEL ciclopirox, clotrimazole, ketoconazole 2% cream, naftifine, nystatin, terbinafine, ECOZA, LAMISIL, NAFTIN HIGH CHOLESTEROL FLOLIPID, NIKITA, ZYPITAMAG amlodipine/atorvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin PAIN AND INFLAMMATION NON STEROIDAL ANTI- INFLAMMATORIES (NSAIDS) PAIN AND INFLAMMATION NON STEROIDAL ANTI-INFLAMMATORIES (NSAIDS) COMBINATIONS PENNSAID DUEXIS, VIMOVO diclofenac gel, diclofenac soln, VOLTAREN GEL diclofenac/misoprostol, esomeprazole, famotidine, ibuprofen, naproxen, ranitidine 46

49 EXCLUDED DRUG LIST STANDARD OPTION CATEGORY* DRUG CLASS MANAGED NOT COVERED (NC) DRUGS COVERED OPTIONS** PRIASIS RIATANE, TACLONEX acitretin, calcipotriene/betamethasone, calcitriol, methoxsalen, DOVONEX, OXRALEN ULTRA SKIN CORTICOSTEROIDS OLUX, OLUX-E clobetasol propionate, fluocinoide, halobetasol proprionate TESTOSTERONE REPLACE- MENT ANDROGENS TESTAVAN testosterone gel, ANDRODERM, ANDROGEL, AXIRON, FORTESTA, NATESTO, TESTIM * This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. ** For more covered options, visit fepblue.org/pharmacy to find the 2018 Standard Option formulary. *** Low dose aspirin (81 mg) is covered for men age 45 through 79, women age 12 through 79 and for pregnant women at risk of preeclampsia. 47

50 PHARMACY BENEFIT HIGHLIGHTS NEW: High Cholesterol-lowering Drug Benefit BASIC OPTION AND STANDARD OPTION Members of all ages can receive generic cholesterol-lowering drugs (known as statins) at no cost. This benefit applies when you use a Preferred retail pharmacy. NEW: Asthma Drug Benefit BASIC OPTION AND STANDARD OPTION Your cost share is reduced for generic and Preferred nonspecialty asthma drugs. This benefit applies when you use a Preferred retail pharmacy or through the Mail Service Pharmacy Program for all Standard Option members or Basic Option members with Medicare Part B. STANDARD OPTION BASIC OPTION BASIC OPTION MEDICARE PART B PREFERRED RETAIL Tier 1: up to $5 copayment Tier 2: 20% of our allowance Tier 1: $5 copayment Tier 2: $35 copayment (for each 30- day supply) Tier 1: $5 copayment Tier 2: $30 copayment (for each 30- day supply) MAIL Tier 1: $5 copayment Tier 2: $65 copayment No Benefit Tier 1: $5 copayment Tier 2: $75 copayment All cost shares are for up to a 90-day supply unless otherwise noted. NEW: Medical Foods Benefit BASIC OPTION AND STANDARD OPTION We now provide benefits for oral medical foods under the pharmacy benefit only. You must purchase the food using the Retail or Mail Service Pharmacy and receive prior approval. 48

51 PHARMACY BENEFIT HIGHLIGHTS NEW: High Blood Pressure Drug Benefit BASIC OPTION AND STANDARD OPTION Your cost share is reduced for generic high blood pressure drugs. This benefit applies when you use a Preferred retail pharmacy or through the Mail Service Pharmacy Program for all Standard Option members or Basic Option members with Medicare Part B. STANDARD OPTION BASIC OPTION BASIC OPTION MEDICARE PART B PREFERRED RETAIL Tier 1: up to $3 copayment Tier 1: $5 copayment Tier 1: $5 copayment MAIL Tier 1: $3 copayment No Benefit Tier 1: $5 copayment All cost shares are for up to a 90-day supply. NEW: Dispense as Written Cost Share Change BASIC OPTION AND STANDARD OPTION If you buy a brand name drug instead of a generic, you ll pay more out-of-pocket. You ll pay the brand name cost share plus the difference between the cost of the brand name and the generic drug. However, if your doctor tells us you can only take the brand name drug, you will not have to pay the difference between the cost of the two drugs. These are just a few of your pharmacy benefit highlights. Your Service Benefit Plan includes so much more, see: - The Service Benefit Plan brochure (RI ) - Our website at fepblue.org/pharmacy 49