2017 GenRx Prescription Drug Formulary and Over-the-Counter Drug List

Transcription

1 Blue Plus plans: Blue Advantage (PMAP, MSC+) and MinnesotaCare 2017 GenRx Prescription Drug Formulary and Over-the-Counter Drug List (List of Covered Drugs) Effective January 1, 2017, for members covered by Medical Assistance* *Please read: The drugs included in this drug list are covered by Medical Assistance for Blue Plus members without Medicare. If you have Medicare, some of your drugs are covered by Medicare Part D. There is a separate Part D formulary for Blue Plus members with Medicare. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. DHS_042517_DD01 DHS Approved 05/01/2017 Last updated: 1/1/17 Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. M00216 (5/17)

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4 Civil Rights Notice Discrimination is against the law. Blue Plus does not discriminate on the basis of any of the following: Race Disability (including Medical condition Color physical or mental Health status National origin impairment) Receipt of health care Creed Sex (including sex services Religion stereotypes and gender Claims experience Sexual orientation identity) Medical history Public assistance status Marital status Genetic information Age Political beliefs Auxiliary Aids and Services. Blue Plus provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner, to ensure an equal opportunity to participate in our health care programs. Contact Blue Plus at Civil.Rights.Coord@bluecrossmn.com, or call Blue Plus Member Services (651) (voice) or (toll-free) for SecureBlue or (651) or for Blue Advantage and MinnesotaCare, or your preferred relay service. Language Assistance Services. Blue Plus provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact Blue Plus at Civil.Rights.Coord@bluecrossmn.com, or call Blue Plus Member Services (651) (voice) or (toll-free) for SecureBlue or (651) or for Blue Advantage and MinnesotaCare, or your preferred relay service. Civil Rights Complaints You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by Blue Plus. You may contact any of the following four agencies directly to file a discrimination complaint. U.S. Department of Health and Human Services Office for Civil Rights (OCR) You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following: Race Color National origin Age Contact the OCR directly to file a complaint: Director U.S. Department of Health and Human Services Office for Civil Rights 200 Independence Avenue SW Room 509F HHH Building Washington, DC (voice) (TDD) Complaint Portal Disability Sex (including sex stereotypes and gender identity)

5 Minnesota Department of Human Rights (MDHR) In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following: Race Creed Public assistance status Color Sex Disability National origin Sexual orientation Religion Marital status Contact the MDHR directly to file a complaint: Minnesota Department of Human Rights Freeman Building, 625 North Robert Street St. Paul, MN (651) (voice) (toll free) 711 or (MN Relay) (651) (Fax) Info.MDHR@state.mn.us ( ) Minnesota Department of Human Services (DHS) You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following: Race Disability (including Medical condition Color physical or mental Health status National origin Creed Religion Sexual orientation Public assistance status Age impairment) Sex (including sex stereotypes and gender identity) Marital status Political beliefs Receipt of health care services Claims experience Medical history Genetic information Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint. DHS will notify you in writing of the investigation s outcome. You have a right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome period. Be brief and state why you disagree with the decision. Include additional information you think is important. If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administration actions. Contact DHS directly to file a discrimination complaint: ATTN: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box St. Paul, MN (651) (voice) or use your preferred relay service

6 Blue Cross and Blue Shield of Minnesota and Blue Plus If you believe that Blue Cross has failed to provide these services or discriminated in another way on the basis of medical condition, health status, receipt of health care services, claims experience, medical history, genetic information, disability (including mental or physical impairment), marital status, age, sex (including sex stereotypes and gender identity), sexual orientation, national origin, race, color, religion, creed, or public assistance, you can file a grievance with the Nondiscrimination Civil Rights Coordinator by at: Civil.Rights.Coord@bluecrossmn.com by mail at: Nondiscrimination Civil Rights Coordinator Blue Cross and Blue Shield of Minnesota and Blue Plus M495 PO Box Eagan, MN or by phone at: or use your preferred relay service Grievance forms are available by contacting us at the contacts listed above, by calling or by using the telephone number on the back of your member identification card. TTY users call 711. If you need help filing a grievance, assistance is available by contacting us at the numbers listed above. American Indians: American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For enrollees age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your health plan primary care provider prior to the referral.

7 What is the Blue Plus GenRx formulary? The Blue Plus GenRx formulary is a list of covered drugs selected by Blue Plus with the help of a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue Plus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Plus network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage, now called Member Handbook. Can the formulary change? We may remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug. The Food and Drug Administration (FDA) may decide a drug on our formulary is unsafe or the drug s manufacturer may remove the drug from the market. In these instances we will immediately remove the drug from our formulary and notify members who take the drug. To get updated information about the drugs covered by Blue Plus, please call Member Services: For Blue Advantage and MinnesotaCare, call (651) or toll free , Monday through Friday 8 a.m. to 5 p.m. TTY users call 711. Part D drugs If you have Medicare, some of your drugs are covered by Medicare Part D. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day, seven days a week. TTY/TDD users should call Or, visit How do I use the formulary? There are three ways to find your drug within the formulary: 1. Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Heart and Circulatory Drugs. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. 2. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the index that begins on page 52. The index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. I

8 3. Blue Plus Over-The-Counter Drug Listing Blue Plus covers certain over-the-counter (OTC) drugs at little or no cost to you if you re a member of Blue Advantage or MinnesotaCare. The OTC drug list begins on page 1a. The drugs in the OTC list are grouped into categories depending on the type of medical condition that they are used to treat. For example, drugs used to treat an eye condition are listed under the category Eye Products. The brand-name version of the drug is listed in the second column and may help you find the OTC drug the plan covers. What are generic drugs? The Blue Plus formulary drug list includes mostly generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brandname drugs, but work just as well and are equally as safe as the branded product. When a generic drug is not available to treat a specific medical condition or when the brand-name drug offers a significant advantage over generic drugs, a brand-name drug is included. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: : Blue Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Blue Plus before you fill your prescriptions. If you don t get approval, Blue Plus may not cover the drug. Drugs requiring prior authorization will have a in the column. : For certain drugs, Blue Plus limits the amount of the drug that Blue Plus will cover. For example, Blue Plus provides 120 tablets per prescription of oxybutynin immediate release tablets. Drugs with quantity limits will have a in the column. : In some cases, Blue Plus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Blue Plus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Blue Plus will then cover Drug B. Drugs with step therapy will have a in the column. Age Requirements: In some cases, there are age requirements for you to try certain drugs. A prior authorization is needed depending on your age and the specific drug prescribed. You can find out if your drug requires prior authorization, has quantity limits or requires step therapy by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at bluecrossmn.com. You can ask Blue Plus to make an exception to these restrictions or limits. See the section, How do I request an exception to the Blue Plus formulary? below for information about how to request an exception. II

9 What if my drug is not on the formulary? If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that Blue Plus does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Blue Plus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Plus. You can ask Blue Plus to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Blue Plus formulary? You can ask Blue Plus to make an exception to our coverage rules. There are several types of exceptions that your doctor or his/her staff can ask us to make. You can ask us to cover your drug even if it is not on the formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue Plus will limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more. Generally, Blue Plus will only approve your request for an exception if the alternative drug is included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 10 business days of getting your request for an exception including your prescribing physician s statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 10 business days for a decision. If your request to expedite is granted, we must give you a decision no later than 72 hours after we get your request for an expedited exception. If I am a new member, what do I do before I talk to my doctor about changing my drugs or requesting an exception? As a new member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug during the first 90 days you are a member of our plan. Please contact Member Services if you have questions regarding this coverage. III

10 For more information For more detailed information about your Blue Plus prescription drug coverage, please review your Member Handbook and other plan materials. If you have questions about Blue Advantage and MinnesotaCare you can: Call (651) or toll free , Monday through Friday 8 a.m. to 5 p.m. TTY users call 711. Visit bluecrossmn.com If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day, seven days a week. TTY/TDD users should call Or, visit Blue Plus formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Blue Plus. If you have trouble finding your drug in the list, turn to the index that begins on page 52. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., ZYTIGA) and generic drugs are listed in lowercase boldface (e.g., valproic acid). The information in the prior authorization, quantity limits and step therapy columns identify if Blue Plus has any special requirements for coverage of your drug. Below is the key for abbreviations within the drug list: KEY caps capsules chew tabs chewable tablets conc concentrate crm cream DR delayed-release ER extended-release IM intramuscular inhal inhalation inj injection IR immediate release IV intravenous liq liquid lotn lotion NF non-formulary ODT orally disintegrating tablets oint ointment SL sublingual soln solution supp suppositories susp suspension tabs tablets prior authorization may be needed due to age limits IV

11 ANTI-INFECTIVE AGENTS dicloxacillin sodium cap 500 mg PENICILLINS amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg CEPHALOSPORINS amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml (Augmentin) amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml (Augmentin es-600) amoxicillin & k clavulanate tab sr 12hr mg (Augmentin xr) amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg (Augmentin) amoxicillin & k clavulanate tab mg (Augmentin) AMOXICILLIN/CLAVULANATE POTASSIUM amoxicillin & k clavulanate chew tab mg AMOXICILLIN/CLAVULANATE POTASSIUM amoxicillin & k clavulanate chew tab mg ampicillin cap 250 mg ampicillin cap 500 mg dicloxacillin sodium cap 250 mg cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm CEFAZOLIN SODIUM cefazolin sodium for inj 20 gm cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml cefixime for susp 100 mg/5ml (Suprax) cefixime for susp 200 mg/5ml (Suprax) CEFOTAXIME SODIUM cefotaxime sodium for inj 1 gm cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg ceftriaxone sodium for inj 250 mg ceftriaxone sodium for inj 500 mg (Rocephin) ceftriaxone sodium for inj 1 gm (Rocephin) ceftriaxone sodium for inj 2 gm cefuroxime axetil tab 250 mg (Ceftin) cefuroxime axetil tab 500 mg (Ceftin) cephalexin cap 250 mg (Keflex) cephalexin cap 500 mg (Keflex) 2017 Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List 1

12 cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml MACROLIDES azithromycin for susp 100 mg/5ml (Zithromax) azithromycin for susp 200 mg/5ml (Zithromax) azithromycin tab 250 mg (Zithromax) azithromycin tab 500 mg (Zithromax) azithromycin tab 600 mg (Zithromax) clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml (Biaxin) clarithromycin tab 250 mg (Biaxin) clarithromycin tab 500 mg (Biaxin) TETRACYCLINES demeclocycline hcl tab 150 mg demeclocycline hcl tab 300 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg (Vibramycin) doxycycline hyclate tab 20 mg doxycycline hyclate tab 100 mg doxycycline monohydrate cap 50 mg doxycycline monohydrate cap 100 mg (Monodox) doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) doxycycline monohydrate tab 75 mg (Adoxa) doxycycline monohydrate tab 100 mg (Adoxa pak 1/100) minocycline hcl cap 50 mg (Minocin) minocycline hcl cap 75 mg (Minocin) minocycline hcl cap 100 mg (Minocin) FLUOROQUINOLONES ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) (Cipro) ciprofloxacin hcl tab 250 mg (Cipro) ciprofloxacin hcl tab 500 mg (Cipro) ciprofloxacin hcl tab 750 mg levofloxacin oral soln 25 mg/ml levofloxacin tab 250 mg (Levaquin) levofloxacin tab 500 mg (Levaquin) levofloxacin tab 750 mg (Levaquin) AMINOGLYCOSIDES neomycin sulfate tab 500 mg paromomycin sulfate cap 250 mg tobramycin nebu soln 300 mg/5ml (Tobi) TOBRAMYCIN SULFATE tobramycin sulfate inj 10 mg/ml (base equivalent) TOBRAMYCIN SULFATE tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv) TUBERCULOSIS ethambutol hcl tab 100 mg (Myambutol) ethambutol hcl tab 400 mg (Myambutol) ISONIAZID isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg PRIFTIN rifapentine tab 150 mg pyrazinamide tab 500 mg rifabutin cap 150 mg (Mycobutin) rifampin cap 150 mg (Rifadin) rifampin cap 300 mg (Rifadin) FUNGAL INFECTIONS Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List

13 fluconazole for susp 10 mg/ml (Diflucan) fluconazole for susp 40 mg/ml (Diflucan) fluconazole tab 50 mg (Diflucan) Hepatitis adefovir dipivoxil tab 10 mg (Hepsera) BARACLUDE entecavir oral soln 0.05 mg/ml fluconazole tab 100 mg (Diflucan) entecavir tab 0.5 mg (Baraclude) fluconazole tab 150 mg (Diflucan) fluconazole tab 200 mg (Diflucan) flucytosine cap 250 mg (Ancobon) flucytosine cap 500 mg (Ancobon) griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg (Grifulvin v) griseofulvin ultramicrosize tab 125 mg (Gris-peg) griseofulvin ultramicrosize tab 250 mg (Gris-peg) itraconazole cap 100 mg (Sporanox) NOXAFIL posaconazole tab delayed release 100 mg NOXAFIL posaconazole susp 40 mg/ ml nystatin oral powder nystatin tab unit terbinafine hcl tab 250 mg (Lamisil) voriconazole for susp 40 mg/ml (Vfend) voriconazole tab 50 mg (Vfend) voriconazole tab 200 mg (Vfend) VIRAL INFECTIONS Cytomegalovirus VALCYTE valganciclovir hcl for soln 50 mg/ml valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte) entecavir tab 1 mg (Baraclude) EPCLUSA sofosbuvir-velpatasvir tab mg HARVONI ledipasvir-sofosbuvir tab mg lamivudine tab 100 mg (hbv) (Epivir hbv) PEGASYS peginterferon alfa-2a inj 180 mcg/ml PEGASYS peginterferon alfa-2a inj 180 mcg/0.5ml PEGASYS PROCLICK peginterferon alfa-2a inj 135 mcg/0.5ml PEGASYS PROCLICK peginterferon alfa-2a inj 180 mcg/0.5ml ribavirin cap 200 mg (Rebetol) ribavirin tab 200 mg (Copegus) ZEPATIER elbasvir-grazoprevir tab mg Herpes acyclovir cap 200 mg (Zovirax) acyclovir susp 200 mg/5ml (Zovirax) acyclovir tab 400 mg (Zovirax) acyclovir tab 800 mg (Zovirax) valacyclovir hcl tab 500 mg (Valtrex) valacyclovir hcl tab 1 gm (Valtrex) HIV/AIDS abacavir sulfate tab 300 mg (Ziagen) abacavir sulfate-lamivudine tab mg (Epzicom) valganciclovir hcl tab 450 mg (Valcyte) 2017 Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List 3

14 abacavir sulfate-lamivudinezidovudine tab mg (Trizivir) APTIVUS tipranavir cap 250 mg APTIVUS tipranavir oral soln 100 mg/ ml ATRIPLA efavirenz-emtricitabinetenofovir df tab mg COMPLERA emtricitabine-rilpivirinetenofovir df tab mg CRIXIVAN indinavir sulfate cap 200 mg CRIXIVAN indinavir sulfate cap 400 mg DESCOVY emtricitabine-tenofovir alafenamide fumarate tab mg didanosine delayed release capsule 125 mg (Videx ec) didanosine delayed release capsule 200 mg (Videx ec) didanosine delayed release capsule 250 mg (Videx ec) didanosine delayed release capsule 400 mg (Videx ec) EDURANT rilpivirine hcl tab 25 mg EMTRIVA emtricitabine caps 200 mg EMTRIVA emtricitabine soln 10 mg/ml EPIVIR lamivudine oral soln 10 mg/ml EPZICOM abacavir sulfatelamivudine tab mg EVOTAZ atazanavir sulfate-cobicistat tab mg FUZEON enfuvirtide for inj 90 mg GENVOYA elvitegrav-cobicemtricitab-tenofov af tab mg INTELENCE etravirine tab 25 mg INTELENCE etravirine tab 100 mg INTELENCE etravirine tab 200 mg INVIRASE saquinavir mesylate cap 200 mg INVIRASE saquinavir mesylate tab 500 mg ISENTRESS raltegravir potassium tab 400 mg ISENTRESS raltegravir potassium packet for susp 100 mg ISENTRESS raltegravir potassium chew tab 25 mg ISENTRESS raltegravir potassium chew tab 100 mg KALETRA lopinavir-ritonavir soln mg/5ml (80-20 mg/ml) KALETRA lopinavir-ritonavir tab mg KALETRA lopinavir-ritonavir tab mg lamivudine oral soln 10 mg/ml (Epivir) lamivudine tab 150 mg (Epivir) lamivudine tab 300 mg (Epivir) lamivudine-zidovudine tab mg (Combivir) LEXIVA fosamprenavir calcium tab 700 mg LEXIVA fosamprenavir calcium susp 50 mg/ml NEVIRAPINE nevirapine susp 50 mg/5ml nevirapine tab sr 24hr 100 mg (Viramune xr) nevirapine tab sr 24hr 400 mg (Viramune xr) nevirapine tab 200 mg (Viramune) NORVIR ritonavir cap 100 mg NORVIR ritonavir tab 100 mg NORVIR ritonavir oral soln 80 mg/ml Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List

15 ODEFSEY emtricitabine-rilpivirinetenofovir af tab mg PREZCOBIX darunavir-cobicistat tab mg PREZISTA darunavir ethanolate susp 100 mg/ml PREZISTA darunavir ethanolate tab 75 mg PREZISTA darunavir ethanolate tab 150 mg PREZISTA darunavir ethanolate tab 600 mg PREZISTA darunavir ethanolate tab 800 mg RESCRIPTOR delavirdine mesylate tab 100 mg RESCRIPTOR delavirdine mesylate tab 200 mg REYATAZ atazanavir sulfate oral powder packet 50 mg REYATAZ atazanavir sulfate cap 150 mg REYATAZ atazanavir sulfate cap 200 mg REYATAZ atazanavir sulfate cap 300 mg SELZENTRY maraviroc tab 150 mg SELZENTRY maraviroc tab 300 mg stavudine cap 15 mg (Zerit) stavudine cap 20 mg (Zerit) stavudine cap 30 mg (Zerit) stavudine cap 40 mg (Zerit) stavudine for oral soln 1 mg/ml (Zerit) STRIBILD elvitegrav-cobic-emtricitabtenofovdf tab mg SUSTIVA efavirenz tab 600 mg SUSTIVA efavirenz cap 50 mg SUSTIVA efavirenz cap 200 mg TIVICAY dolutegravir sodium tab 10 mg (base equiv) TIVICAY dolutegravir sodium tab 25 mg (base equiv) TIVICAY dolutegravir sodium tab 50 mg TRIUMEQ abacavir-dolutegravirlamivudine tab mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab mg TRUVADA emtricitabine-tenofovir disoproxil fumarate tab mg TYBOST cobicistat tab 150 mg VIDEX didanosine for soln 2 gm VIDEX didanosine for soln 4 gm VIRACEPT nelfinavir mesylate tab 250 mg VIRACEPT nelfinavir mesylate tab 625 mg VIRAMUNE nevirapine susp 50 mg/5ml VIRAMUNE XR nevirapine tab sr 24hr 100 mg VIREAD tenofovir disoproxil fumarate oral powder 40 mg/gm VIREAD tenofovir disoproxil fumarate tab 150 mg VIREAD tenofovir disoproxil fumarate tab 200 mg VIREAD tenofovir disoproxil fumarate tab 250 mg VIREAD tenofovir disoproxil fumarate tab 300 mg VITEKTA elvitegravir tab 85 mg VITEKTA elvitegravir tab 150 mg 2017 Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List 5

16 ZIAGEN abacavir sulfate soln 20 mg/ ml zidovudine cap 100 mg (Retrovir) zidovudine syrup 10 mg/ml (Retrovir) zidovudine tab 300 mg ivermectin tab 3 mg (Stromectol) OTHER ANTI-INFECTIVES atovaquone susp 750 mg/5ml (Mepron) aztreonam for inj 1 gm (Azactam) Influenza aztreonam for inj 2 gm (Azactam) oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) oseltamivir phosphate cap 45 mg (base equiv) (Tamiflu) oseltamivir phosphate cap 75 mg (base equiv) (Tamiflu) TAMIFLU oseltamivir phosphate for susp 6 mg/ml TAMIFLU oseltamivir phosphate cap 30 mg TAMIFLU oseltamivir phosphate cap 45 mg TAMIFLU oseltamivir phosphate cap 75 mg MALARIA atovaquone-proguanil hcl tab mg (Malarone) atovaquone-proguanil hcl tab mg (Malarone) chloroquine phosphate tab 250 mg chloroquine phosphate tab 500 mg (Aralen) DARAPRIM pyrimethamine tab 25 mg hydroxychloroquine sulfate tab 200 mg (Plaquenil) mefloquine hcl tab 250 mg PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg (15 mg base) WORM INFECTIONS ALBENZA albendazole tab 200 mg BILTRICIDE praziquantel tab 600 mg clindamycin hcl cap 75 mg (Cleocin) clindamycin hcl cap 150 mg (Cleocin) clindamycin hcl cap 300 mg (Cleocin) clindamycin palmitate hcl for soln 75 mg/5ml (Cleocin pediatric gr) clindamycin phosphate inj 300 mg/2ml (Cleocin phosphate) clindamycin phosphate inj 600 mg/4ml (Cleocin phosphate) clindamycin phosphate inj 900 mg/6ml (Cleocin phosphate) clindamycin phosphate inj 9 gm/60ml (Cleocin phosphate) colistimethate sodium for inj 150 mg (Coly-Mycin M) dapsone tab 25 mg dapsone tab 100 mg IMPAVIDO miltefosine cap 50 mg linezolid for susp 100 mg/5ml (Zyvox) linezolid tab 600 mg (Zyvox) metronidazole cap 375 mg (Flagyl) metronidazole tab 250 mg (Flagyl) metronidazole tab 500 mg (Flagyl) sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg (Bactrim) sulfamethoxazole-trimethoprim tab mg (Bactrim ds) trimethoprim tab 100 mg vancomycin hcl cap 125 mg (Vancocin hcl) Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List

17 vancomycin hcl cap 250 mg (Vancocin hcl) XIFAXAN rifaximin tab 550 mg ZYVOX linezolid tab 600 mg ZYVOX linezolid for susp 100 mg/5ml IMMUNIZING AGENTS IMMUNIZING AGENTS AFLURIA PF influenza virus vaccine split pf susp pref syringe 0.5 ml AFLURIA QUADRIVALENT 2016 influenza virus vac split quadrivalent susp pref syr 0.5ml FLULAVAL QUADRIVALENT 201 influenza virus vac split quadrivalent susp pref syr 0.5ml FLUVIRIN influenza vac type a&b surface antigen susp pref syr 0.5 ml SYNAGIS palivizumab im soln 50 mg/0.5ml SYNAGIS palivizumab im soln 100 mg/ml CANCER DRUGS CANCER DRUGS ACTIMMUNE interferon gamma-1b inj 100 mcg/0.5ml ( unit/0.5ml) AFINITOR everolimus tab 2.5 mg AFINITOR everolimus tab 5 mg AFINITOR everolimus tab 7.5 mg AFINITOR everolimus tab 10 mg AFINITOR DISPERZ everolimus tab for oral susp 2 mg AFINITOR DISPERZ everolimus tab for oral susp 3 mg AFINITOR DISPERZ everolimus tab for oral susp 5 mg ALKERAN melphalan tab 2 mg anastrozole tab 1 mg (Arimidex) bexarotene cap 75 mg (Targretin) bicalutamide tab 50 mg (Casodex) BOSULIF bosutinib tab 100 mg BOSULIF bosutinib tab 500 mg CABOMETYX cabozantinib s-malate tab 20 mg (base equivalent) CABOMETYX cabozantinib s-malate tab 40 mg (base equivalent) CABOMETYX cabozantinib s-malate tab 60 mg (base equivalent) capecitabine tab 150 mg (Xeloda) capecitabine tab 500 mg (Xeloda) CAPRELSA vandetanib tab 100 mg CAPRELSA vandetanib tab 300 mg COMETRIQ cabozantinib s-malate cap 3 x 20 mg (60 mg dose) kit COMETRIQ cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100 dose) kit COMETRIQ cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140 dose) kit COTELLIC cobimetinib fumarate tab 20 mg CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg CYTARABINE cytarabine inj 20 mg/ ml EMCYT estramustine phosphate sodium cap 140 mg ERIVEDGE vismodegib cap 150 mg ETOPOSIDE etoposide cap 50 mg exemestane tab 25 mg (Aromasin) FARESTON toremifene citrate tab 60 mg FARYDAK panobinostat lactate cap 10 mg 2017 Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List 7

18 FARYDAK panobinostat lactate cap 15 mg FARYDAK panobinostat lactate cap 20 mg flutamide cap 125 mg GILOTRIF afatinib dimaleate tab 20 mg GILOTRIF afatinib dimaleate tab 30 mg GILOTRIF afatinib dimaleate tab 40 mg GLEEVEC imatinib mesylate tab 100 mg GLEEVEC imatinib mesylate tab 400 mg GLEOSTINE lomustine cap 5 mg GLEOSTINE lomustine cap 10 mg GLEOSTINE lomustine cap 40 mg GLEOSTINE lomustine cap 100 mg HEXALEN altretamine cap 50 mg HYCAMTIN topotecan hcl cap 0.25 mg HYCAMTIN topotecan hcl cap 1 mg HYDROXYPROGESTERONE CAPRO hydroxyprogesterone caproate im in oil 1.25 gm/5ml hydroxyurea cap 500 mg (Hydrea) IBRANCE palbociclib cap 75 mg IBRANCE palbociclib cap 100 mg IBRANCE palbociclib cap 125 mg ICLUSIG ponatinib hcl tab 15 mg ICLUSIG ponatinib hcl tab 45 mg imatinib mesylate tab 100 mg (base equivalent) (Gleevec) imatinib mesylate tab 400 mg (base equivalent) (Gleevec) IMBRUVICA ibrutinib cap 140 mg INLYTA axitinib tab 1 mg INLYTA axitinib tab 5 mg IRESSA gefitinib tab 250 mg JAKAFI ruxolitinib phosphate tab 5 mg JAKAFI ruxolitinib phosphate tab 10 mg JAKAFI ruxolitinib phosphate tab 15 mg JAKAFI ruxolitinib phosphate tab 20 mg JAKAFI ruxolitinib phosphate tab 25 mg LENVIMA 10 MG DAILY DOSE lenvatinib cap therapy pack 10 mg (10 mg daily dose) LENVIMA 14 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 mg (14 mg daily dose) LENVIMA 18 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4 (2) mg (18 mg daily dose) LENVIMA 20 MG DAILY DOSE lenvatinib cap therapy pack 10 (2) mg (20 mg daily dose) LENVIMA 24 MG DAILY DOSE lenvatinib cap therapy pack 10 (2) & 4 mg (24 mg daily dose) LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 4 (2) mg (8 mg daily dose) letrozole tab 2.5 mg (Femara) LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg leucovorin calcium for inj 50 mg leucovorin calcium for inj 100 mg leucovorin calcium for inj 200 mg leucovorin calcium for inj 350 mg leucovorin calcium tab 5 mg Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List

19 leucovorin calcium tab 25 mg LEUKERAN chlorambucil tab 2 mg LOMUSTINE lomustine cap 10 mg LOMUSTINE lomustine cap 40 mg LOMUSTINE lomustine cap 100 mg LONSURF trifluridine-tipiracil tab mg LONSURF trifluridine-tipiracil tab mg LYNPARZA olaparib cap 50 mg LYSODREN mitotane tab 500 mg MATULANE procarbazine hcl cap 50 mg megestrol acetate susp 40 mg/ml (Megace oral) megestrol acetate tab 20 mg megestrol acetate tab 40 mg MEKINIST trametinib dimethyl sulfoxide tab 0.5 mg MEKINIST trametinib dimethyl sulfoxide tab 2 mg mercaptopurine tab 50 mg MESNEX mesna tab 400 mg METHOTREXATE SODIUM methotrexate sodium inj 250 mg/10ml (25 mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) methotrexate sodium inj 50 mg/2ml (25 mg/ml) methotrexate sodium tab 2.5 mg MYLERAN busulfan tab 2 mg NEXAVAR sorafenib tosylate tab 200 mg NILANDRON nilutamide tab 150 mg nilutamide tab 150 mg (Nilandron) NINLARO ixazomib citrate cap 2.3 mg NINLARO ixazomib citrate cap 3 mg NINLARO ixazomib citrate cap 4 mg ODOMZO sonidegib phosphate cap 200 mg POMALYST pomalidomide cap 1 mg POMALYST pomalidomide cap 2 mg POMALYST pomalidomide cap 3 mg POMALYST pomalidomide cap 4 mg PURIXAN mercaptopurine susp 2000 mg/100ml (20 mg/ml) SPRYCEL dasatinib tab 20 mg SPRYCEL dasatinib tab 50 mg SPRYCEL dasatinib tab 70 mg SPRYCEL dasatinib tab 80 mg SPRYCEL dasatinib tab 100 mg SPRYCEL dasatinib tab 140 mg STIVARGA regorafenib tab 40 mg SUTENT sunitinib malate cap 12.5 mg SUTENT sunitinib malate cap 25 mg SUTENT sunitinib malate cap 37.5 mg SUTENT sunitinib malate cap 50 mg SYLATRON peginterferon alfa-2b for inj kit 200 mcg SYLATRON peginterferon alfa-2b for inj kit 300 mcg SYLATRON peginterferon alfa-2b for inj kit 600 mcg 2017 Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List 9

20 SYLATRON peginterferon alfa-2b for inj kit 4 x 200 mcg SYLATRON peginterferon alfa-2b for inj kit 4 x 300 mcg TABLOID thioguanine tab 40 mg TAFINLAR dabrafenib mesylate cap 50 mg TAFINLAR dabrafenib mesylate cap 75 mg TAGRISSO osimertinib mesylate tab 40 mg TAGRISSO osimertinib mesylate tab 80 mg tamoxifen citrate tab 10 mg tamoxifen citrate tab 20 mg TARCEVA erlotinib hcl tab 25 mg TARCEVA erlotinib hcl tab 100 mg TARCEVA erlotinib hcl tab 150 mg TARGRETIN bexarotene cap 75 mg TASIGNA nilotinib hcl cap 150 mg TASIGNA nilotinib hcl cap 200 mg temozolomide cap 5 mg (Temodar) temozolomide cap 20 mg (Temodar) temozolomide cap 100 mg (Temodar) temozolomide cap 140 mg (Temodar) temozolomide cap 180 mg (Temodar) temozolomide cap 250 mg (Temodar) tretinoin cap 10 mg TREXALL methotrexate sodium tab 5 mg TREXALL methotrexate sodium tab 7.5 mg TREXALL methotrexate sodium tab 10 mg TREXALL methotrexate sodium tab 15 mg TYKERB lapatinib ditosylate tab 250 mg VENCLEXTA venetoclax tab 10 mg VENCLEXTA venetoclax tab 50 mg VENCLEXTA venetoclax tab 100 mg VOTRIENT pazopanib hcl tab 200 mg XALKORI crizotinib cap 200 mg XALKORI crizotinib cap 250 mg XTANDI enzalutamide cap 40 mg ZELBORAF vemurafenib tab 240 mg ZOLINZA vorinostat cap 100 mg ZYDELIG idelalisib tab 100 mg ZYDELIG idelalisib tab 150 mg ZYKADIA ceritinib cap 150 mg ZYTIGA abiraterone acetate tab 250 mg HORMONES, DIABETES AND RELATED DRUGS CORTICOSTEROIDS budesonide delayed release particles cap 3 mg (Entocort ec) CORTISONE ACETATE cortisone acetate tab 25 mg DEXAMETHASONE dexamethasone soln 0.5 mg/5ml DEXAMETHASONE dexamethasone tab 1 mg DEXAMETHASONE dexamethasone tab 2 mg dexamethasone elixir 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 4 mg dexamethasone tab 6 mg fludrocortisone acetate tab 0.1 mg hydrocortisone tab 5 mg (Cortef) hydrocortisone tab 10 mg (Cortef) hydrocortisone tab 20 mg (Cortef) Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List

21 methylprednisolone sodium succinate for inj 40 mg (Solumedrol) methylprednisolone sodium succinate for inj 125 mg (Solumedrol) methylprednisolone sodium succinate for inj 1000 mg (Solumedrol) methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) methylprednisolone tab 4 mg (Medrol) methylprednisolone tab 8 mg (Medrol) methylprednisolone tab 16 mg (Medrol) methylprednisolone tab 32 mg (Medrol) prednisolone sod phos orally disintegr tab 10 mg (Orapred odt) prednisolone sod phos orally disintegr tab 15 mg (Orapred odt) prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) (Pediapred) prednisolone sod phosphate oral soln 15 mg/5ml prednisolone syrup 15 mg/5ml (usp solution equivalent) PREDNISONE prednisone tab 50 mg PREDNISONE prednisone oral soln 5 mg/5ml prednisone tab 1 mg prednisone tab 2.5 mg prednisone tab 5 mg prednisone tab 10 mg prednisone tab 20 mg MALE HORMONES danazol cap 50 mg danazol cap 100 mg danazol cap 200 mg testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone) testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone) testosterone enanthate im inj in oil 200 mg/ml testosterone td gel 25 mg/2.5gm (1%) (Androgel) testosterone td gel 50 mg/5gm (1%) (Androgel) testosterone td gel 12.5 mg/act (1%) (Androgel pump) ESTROGENS COMBIPATCH estradiolnorethindrone ace td pttw mg/day COMBIPATCH estradiolnorethindrone ace td pttw mg/day estradiol & norethindrone acetate tab mg (Activella) estradiol & norethindrone acetate tab mg (Activella) estradiol tab 0.5 mg (Estrace) estradiol tab 1 mg (Estrace) estradiol tab 2 mg (Estrace) estradiol td patch twice weekly mg/24hr (Vivelle-dot) estradiol td patch twice weekly mg/24hr (Vivelle-dot) estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot) estradiol td patch twice weekly mg/24hr (Vivelle-dot) estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-dot) estradiol td patch weekly mg/24hr (Climara) 2017 Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List 11

22 estradiol td patch weekly mg/24hr (37.5 mcg/24hr) (Climara) estradiol td patch weekly 0.05 mg/24hr (Climara) estradiol td patch weekly 0.06 mg/24hr (Climara) estradiol td patch weekly mg/24hr (Climara) estradiol td patch weekly 0.1 mg/24hr (Climara) estradiol valerate im in oil 20 mg/ml (Delestrogen) estradiol valerate im in oil 40 mg/ml (Delestrogen) ESTROGEL estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump) ESTROPIPATE estropipate tab 0.75 mg ESTROPIPATE estropipate tab 1.5 mg ESTROPIPATE estropipate tab 3 mg estropipate tab 0.75 mg estropipate tab 1.5 mg PROGESTINS medroxyprogesterone acetate tab 2.5 mg (Provera) medroxyprogesterone acetate tab 5 mg (Provera) medroxyprogesterone acetate tab 10 mg (Provera) norethindrone acetate tab 5 mg (Aygestin) progesterone im in oil 50 mg/ml progesterone micronized cap 100 mg (Prometrium) progesterone micronized cap 200 mg (Prometrium) BIRTH CONTROL ELLA ulipristal acetate tab 30 mg levonorgestrel tab 1.5 mg NUVARING etonogestrel-ethinyl estradiol va ring mg/24hr oral contraceptives - all generics XULANE norelgestromin-ethinyl estradiol td ptwk mcg/24hr DIABETES acarbose tab 25 mg (Precose) acarbose tab 50 mg (Precose) acarbose tab 100 mg (Precose) BYETTA exenatide soln pen-injector 5 mcg/0.02ml BYETTA exenatide soln pen-injector 10 mcg/0.04ml glimepiride tab 1 mg (Amaryl) glimepiride tab 2 mg (Amaryl) glimepiride tab 4 mg (Amaryl) glipizide tab sr 24hr 2.5 mg (Glucotrol xl) glipizide tab sr 24hr 5 mg (Glucotrol xl) glipizide tab sr 24hr 10 mg (Glucotrol xl) glipizide tab 5 mg (Glucotrol) glipizide tab 10 mg (Glucotrol) glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg INVOKANA canagliflozin tab 100 mg INVOKANA canagliflozin tab 300 mg JANUMET sitagliptin-metformin hcl tab mg Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List

23 JANUMET sitagliptin-metformin hcl tab mg JANUMET XR sitagliptin-metformin hcl tab sr 24hr mg JANUMET XR sitagliptin-metformin hcl tab sr 24hr mg JANUMET XR sitagliptin-metformin hcl tab sr 24hr mg JANUVIA sitagliptin phosphate tab 25 mg JANUVIA sitagliptin phosphate tab 50 mg JANUVIA sitagliptin phosphate tab 100 mg metformin hcl tab sr 24hr 500 mg (Glucophage xr) metformin hcl tab sr 24hr 750 mg (Glucophage xr) metformin hcl tab 500 mg (Glucophage) metformin hcl tab 850 mg (Glucophage) metformin hcl tab 1000 mg (Glucophage) nateglinide tab 60 mg (Starlix) nateglinide tab 120 mg (Starlix) pioglitazone hcl tab 15 mg (Actos) pioglitazone hcl tab 30 mg (Actos) pioglitazone hcl tab 45 mg (Actos) repaglinide tab 0.5 mg (Prandin) repaglinide tab 1 mg (Prandin) repaglinide tab 2 mg (Prandin) VICTOZA liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) DIABETES - INSULINS Rapid-Acting Insulins NOVOLOG insulin aspart inj 100 unit/ ml NOVOLOG FLEXPEN insulin aspart soln pen-injector 100 unit/ml NOVOLOG PENFILL insulin aspart soln cartridge 100 unit/ml Short-Acting Insulins NOVOLIN R insulin regular (human) inj 100 unit/ml NOVOLIN R RELION insulin regular (human) inj 100 unit/ml Intermediate-Acting Insulins NOVOLIN N insulin nph (human) (isophane) inj 100 unit/ml NOVOLIN N RELION insulin nph (human) (isophane) inj 100 unit/ml NOVOLIN 70/30 insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLIN 70/30 RELION insulin nph isophane & regular human inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 insulin aspart prot & aspart (human) inj 100 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus peninj 100 unit/ml (70-30) Basal Insulins BASAGLAR KWIKPEN insulin glargine soln pen-injector 100 unit/ml LANTUS insulin glargine inj 100 unit/ ml LANTUS SOLOSTAR insulin glargine soln pen-injector 100 unit/ml LEVEMIR insulin detemir inj 100 unit/ ml LEVEMIR FLEXTOUCH insulin detemir soln pen-injector 100 unit/ml TOUJEO SOLOSTAR insulin glargine soln pen-injector 300 unit/ml THYROID REGULATION 2017 Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List 13

24 levothyroxine sodium tab 25 mcg (Synthroid) levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 88 mcg (Synthroid) levothyroxine sodium tab 100 mcg (Synthroid) levothyroxine sodium tab 112 mcg (Synthroid) levothyroxine sodium tab 125 mcg (Synthroid) levothyroxine sodium tab 137 mcg (Synthroid) levothyroxine sodium tab 150 mcg (Synthroid) levothyroxine sodium tab 175 mcg (Synthroid) levothyroxine sodium tab 200 mcg (Synthroid) levothyroxine sodium tab 300 mcg (Synthroid) liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 25 mcg (Cytomel) liothyronine sodium tab 50 mcg (Cytomel) methimazole tab 5 mg (Tapazole) methimazole tab 10 mg (Tapazole) propylthiouracil tab 50 mg GROWTH HORMONE INCRELEX mecasermin inj 40 mg/4ml (10 mg/ml) OMNITROPE somatropin for inj 5.8 mg OMNITROPE somatropin inj 5 mg/1.5ml OMNITROPE somatropin inj 10 mg/1.5ml OTHER HORMONES AND RELATED DRUGS ALENDRONATE SODIUM alendronate sodium tab 40 mg alendronate sodium tab 5 mg alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 70 mg (Fosamax) cabergoline tab 0.5 mg calcitonin (salmon) nasal soln 200 unit/act (Miacalcin) calcitriol cap 0.25 mcg (Rocaltrol) calcitriol cap 0.5 mcg (Rocaltrol) calcitriol oral soln 1 mcg/ml (Rocaltrol) desmopressin acetate inj 4 mcg/ml (Ddavp) desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) desmopressin acetate nasal spray soln 0.01% (Ddavp) desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg (Ddavp) desmopressin acetate tab 0.2 mg (Ddavp) ibandronate sodium tab 150 mg (Boniva) levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) levocarnitine tab 330 mg (Carnitor) methylergonovine maleate tab 0.2 mg octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List

25 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin) benazepril & hydrochlorothiazide tab mg (Lotensin hct) octreotide acetate inj 200 mcg/ml (0.2 mg/ml) (Sandostatin) benazepril & hydrochlorothiazide tab mg (Lotensin hct) octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) ORFADIN nitisinone cap 2 mg ORFADIN nitisinone cap 5 mg ORFADIN nitisinone cap 10 mg raloxifene hcl tab 60 mg (Evista) SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 10 mg SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 20 mg SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 30 mg SENSIPAR cinacalcet hcl tab 30 mg SENSIPAR cinacalcet hcl tab 60 mg SENSIPAR cinacalcet hcl tab 90 mg STIMATE desmopressin acetate nasal soln 1.5 mg/ml STRENSIQ asfotase alfa subcutaneous inj 18 mg/0.45ml STRENSIQ asfotase alfa subcutaneous inj 28 mg/0.7ml STRENSIQ asfotase alfa subcutaneous inj 40 mg/ml STRENSIQ asfotase alfa subcutaneous inj 80 mg/0.8ml HEART AND CIRCULATORY DRUGS ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATI benazepril & hydrochlorothiazide tab mg benazepril & hydrochlorothiazide tab mg (Lotensin hct) benazepril hcl tab 5 mg benazepril hcl tab 10 mg (Lotensin) benazepril hcl tab 20 mg (Lotensin) benazepril hcl tab 40 mg (Lotensin) captopril tab 12.5 mg captopril tab 25 mg captopril tab 50 mg captopril tab 100 mg CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg enalapril maleate & hydrochlorothiazide tab mg (Vaseretic) enalapril maleate tab 2.5 mg (Vasotec) enalapril maleate tab 5 mg (Vasotec) enalapril maleate tab 10 mg (Vasotec) enalapril maleate tab 20 mg (Vasotec) fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium & hydrochlorothiazide tab mg fosinopril sodium tab 10 mg 2017 Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List 15

26 fosinopril sodium tab 20 mg ramipril cap 2.5 mg (Altace) fosinopril sodium tab 40 mg ramipril cap 5 mg (Altace) lisinopril & hydrochlorothiazide tab mg (Zestoretic) lisinopril & hydrochlorothiazide tab mg (Zestoretic) lisinopril & hydrochlorothiazide tab mg (Zestoretic) lisinopril tab 2.5 mg (Zestril) lisinopril tab 5 mg (Prinivil) lisinopril tab 10 mg (Prinivil) lisinopril tab 20 mg (Prinivil) lisinopril tab 30 mg (Zestril) lisinopril tab 40 mg (Zestril) moexipril hcl tab 7.5 mg moexipril hcl tab 15 mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg moexipril-hydrochlorothiazide tab mg perindopril erbumine tab 2 mg perindopril erbumine tab 4 mg (Aceon) perindopril erbumine tab 8 mg (Aceon) quinapril hcl tab 5 mg (Accupril) quinapril hcl tab 10 mg (Accupril) quinapril hcl tab 20 mg (Accupril) quinapril hcl tab 40 mg (Accupril) quinapril-hydrochlorothiazide tab mg (Accuretic) quinapril-hydrochlorothiazide tab mg (Accuretic) quinapril-hydrochlorothiazide tab mg (Accuretic) ramipril cap 1.25 mg (Altace) ramipril cap 10 mg (Altace) trandolapril tab 1 mg (Mavik) trandolapril tab 2 mg (Mavik) trandolapril tab 4 mg (Mavik) ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS irbesartan tab 75 mg (Avapro) irbesartan tab 150 mg (Avapro) irbesartan tab 300 mg (Avapro) irbesartan-hydrochlorothiazide tab mg (Avalide) irbesartan-hydrochlorothiazide tab mg (Avalide) losartan potassium & hydrochlorothiazide tab mg (Hyzaar) losartan potassium & hydrochlorothiazide tab mg (Hyzaar) losartan potassium & hydrochlorothiazide tab mg (Hyzaar) losartan potassium tab 25 mg (Cozaar) losartan potassium tab 50 mg (Cozaar) losartan potassium tab 100 mg (Cozaar) valsartan tab 40 mg (Diovan) valsartan tab 80 mg (Diovan) valsartan tab 160 mg (Diovan) valsartan tab 320 mg (Diovan) valsartan-hydrochlorothiazide tab mg (Diovan hct) valsartan-hydrochlorothiazide tab mg (Diovan hct) Blue Advantage and MinnesotaCare GenRx Formulary and Over-The-Counter Drug List