fepblue.org 2019 ABBREVIATED FORMULARY

Transcription

1 fepblue.org 2019 ABBREVIATED FORMULARY As of January 1, 2019

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 NEW FOR 2019 n Added new coverage option FEP Blue Focus. See p. 2 n Changed select cost shares. See pp n Expanded Standard Option excluded drug list. See p. 44 n Expanded Basic Option Managed Not Covered drug list. See p. 46 n Reduced cost share for Metformin, Tier 2 diabetic drugs, test strips and supplies. See p. 52 n Eliminated cost share for certain opioid reversal agents. See p. 52 n Certain auto-immune infusions are required to be obtained through the medical benefit. See p. 53 3

3 TABLE OF CONTENTS NEW FOR 2019: FEP BLUE FOCUS...2 UNDERSTANDING THE FORMULARY...4 n Formulary...4 n Non-Covered Drugs...4 n Quantity Limits...4 n Prior Approval...5 n How Tiers Relate to Costs...6 n How Prescription Drugs are Assigned to Tiers...7 COST SHARE S...8 n Standard Option Cost Share Tiers...8 n Basic Option Cost Share Tiers...10 n FEP Blue Focus Cost Share Tiers...13 HOW TO USE THE ABBREVIATED FORMULARY...14 n Program Options...14 n Legend...15 ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION)...16 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY)...28 EXCLUDED DRUG LIST...44 MANAGED NOT COVERED DRUG LIST...46 CHANGES FOR 2019 PHARMACY BENEFIT HIGHLIGHTS...52 HOW TO CONTACT US

4 FEP BLUE FOCUS We re excited to offer federal employees, retirees and their families a new coverage option called FEP Blue Focus! We ve designed this product to give you quality coverage at an affordable cost. FEP Blue Focus covers certain Preferred drugs mainly generics, and some Preferred brand name and Preferred specialty drugs. This is what s known as a closed formulary. Under this plan, there are two covered drug tiers. The amount you pay for your drug depends on the tier it s in. What You ll Pay for a 30-Day Supply Tier 1 - Preferred generics Tier 2 - Preferred brand name drugs and Preferred specialty drugs Up to $5 copayment 40% of our allowance up to $350 If you re currently taking a prescription, you should check whether your drug is covered under this plan since the plan only covers Preferred drugs. You can see some of the drugs covered on pages You can also view the full FEP Blue Focus formulary at fepblue.org/ formulary. If your drug is not on the approved drug list, you ll pay the full cost of the drug. Once you know that we cover your drug, getting your prescription filled is easy. For most drugs, all you ll need to do is go to a Preferred retail pharmacy and show your member ID card. If your drug is a Preferred generic specialty drug or Preferred brand name specialty drug, you ll need to use the Specialty Pharmacy Program. To learn more about the 2019 benefits prior to January 1, 2019, please visit whatsnew or call our Pharmacy Benefit Managers listed on page 56. 2

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6 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 out-of-pocket costs. The Standard Option and Basic Option formularies have 5 tiers of drugs. The FEP Blue Focus formulary has 2 tiers of drugs. See p. 6 NON-COVERED DRUGS There are certain drugs approved by the U.S. Food and Drug Administration (FDA) that we don t cover. We call these drugs excluded, Managed Not Covered or not formulary. These drugs all have Preferred alternatives that you can use. Standard Option has a comprehensive formulary. This means we cover almost all FDA approved drugs. There is a small list of excluded drugs that are not covered. See pp Basic Option has a managed formulary. This means that we cover most FDA approved drugs. There is a list of Managed Not Covered drugs that provides the Preferred alternatives that you may use. See pp FEP Blue Focus has a limited (or closed) formulary. This means that we only cover some FDA approved drugs. Any drug not on the FEP Blue Focus formulary is not covered. If you buy a drug that is not covered, you will pay full price. QUANTITY LIMITS (QL) 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 healthcare practice in the United States. 4

7 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: 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 AUT 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. If prior approval is received, you may file a claim for reimbursement of outof-pocket 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 5

8 UNDERSTANDING THE FORMULARY HOW S RELATE TO COSTS The costs of drugs vary. How much you pay is your cost share. Look for your drug in the formulary for your plan option. The tier level where your drug type is listed determines your cost. Standard and Basic Options Tier 1 Tier 2 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. Tier 3 Non-preferred Brand Name Drugs: typically higher cost share since there is a generic or Preferred brand. Tier 4 Preferred Specialty Drugs: proven to be safe, effective, and favorably priced compared to Non-preferred specialty drugs. Tier 5 Non-preferred Specialty Drugs: typically higher cost share since there is a Preferred specialty drug. FEP Blue Focus DRUG TYPE Tier 1 Preferred Generic Drugs: typically the most affordable, and are equal to their brand name counterparts in quality, performance characteristics and intended use. Tier 2 Preferred Brand Name Drugs and Preferred Specialty Drugs: proven to be safe, effective, and favorably priced compared to non-covered drug options. 6

9 HOW PRESCRIPTION DRUGS ARE ASSIGNED TO S 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. To see your cost share for a prescription drug: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs:

10 UNDERSTANDING THE FORMULARY STANDARD OPTION COST SHARE S 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 - GENERIC AND BRAND NAME DRUGS 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 - $15* for up to a 90-day supply - $90 for up to a 90-day supply - $7.50* for up to a 30-day supply - $22.50* for a 31 to 90-day supply - 30% 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 Tier 3: Nonpreferred Brand Name Drugs - $125 for up to a 90-day supply - 50% of our allowance * Lower cost shares are available to Standard Option members with Medicare Part B. 8

11 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 - $50 for up to a 30-day supply - $140 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 - $70 for up to a 30-day supply - $200 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 - 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: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs:

12 UNDERSTANDING THE FORMULARY BASIC OPTION COST SHARE S 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 - GENERIC AND BRAND NAME DRUGS Cost Share Based on Where You Fill Your Prescription* PREFERRED RETAIL PHARMACY NON-PREFERRED RETAIL PHARMACY & MAIL SERVICE PHARMACY Tier 1: Generic Drugs Tier 2: Preferred Brand Name Drugs Tier 3: Non-preferred Brand Name Drugs - $10 for up to a 30-day supply - $30 for a 31 to 90-day supply - $55 for up to a 30-day supply - $165 for a 31 to 90-day supply - 60% of our allowance with a $75 minimum for up to a 30-day supply and $210 minimum for a 31 to 90- day supply Not covered* * Basic Option members with Medicare Part B coverage have Mail Service Pharmacy benefits and some lower cost shares. 10

13 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 - $70 for up to a 30-day supply - $210 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 - $95 for up to a 30-day supply - $285 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 - $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 - $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 * Basic Option members with Medicare Part B coverage have some lower cost shares. To see Basic Option with Medicare Part B cost shares: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs:

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15 FEP BLUE FOCUS COST SHARE S Members who use generic medications will benefit the most from FEP Blue Focus. This plan has a limited (or closed) formulary of covered drugs. FEP Blue Focus Cost Share Based on Where You Fill Your Prescription Tier 1: Preferred Generic Drugs Tier 2: Preferred Brand Name Drugs and Preferred Specialty Drugs PREFERRED RETAIL PHARMACY AND SPECIALTY PHARMACY - $5 for up to a 30-day supply - $15 for a 31 to 90-day supply - 40% of our allowance up to $350 for up to a 30-day supply - 40% of our allowance up to $1,050 for a 31 to 90-day supply - You are limited to a 30-day supply for each specialty drug prescription. To learn more about FEP Blue Focus: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs:

16 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 pp n Alphabetic for all drugs See pp See if there are any limitations for your drug. 3. Review the cost share charts to find your copay or coinsurance. See pp 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 (), Basic Option () and FEP Blue Focus () varies. The charts list the, and tiers for each drug. In many cases the tier is the same, but not in every case. To see the current full formulary: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy - call CVS Caremark for Retail or Mail Order drugs: call AllianceRx Walgreens Prime for Specialty drugs:

17 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. Prior Approval: needs approval in advance before a drug is covered. * ** NC For certain drugs, this list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. Generic oral contraceptives and select brand contraceptives are available to female members at no copay. Not Covered Standard Option Basic Option FEP Blue Focus LD ITALIC Bold type means there is a generic for this drug. Italic type means this is a specialty drug. This abbreviated formulary lists the most commonly used drugs. Please note this list may change. 15

18 ABBREVIATED FORMULARY (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 CONDITION/DRUG ALLERGY/COUGH & COLD acetaminophen/ codeine ASTEPRO 3 3 NC azelastine BECONASE AQ 3 NC NC benzonatate CLARINEX 3 NC NC CLARINEX-D 3 NC NC desloratadine 1 NC NC flunisolide spray fluticasone spray levocetirizine 1 NC NC NANEX 3 NC NC promethazine/codeine triamcinolone spray VERAMYST 2 NC NC XYZAL 3 NC NC ANTI-INFECTIVES/ANTIBIOTICS/ ANTIFUNGAL/ANTIVIRAL amoxicillin azithromycin cephalexin ciprofloxacin clotrimazole/ betamethasone doxycycline hyclate ERTACZO 3 NC NC EXELDERM 3 3 NC fluconazole JUBLIA 3 NC NC KERYDIN* 3 NC NC ketoconazole tabs levofloxacin LOPROX 3 NC NC LOTRINE* 3 NC NC LUZU 3 NC NC MENTAX 3 NC NC metronidazole naftifine NAFTIN 2 NC NC oseltamivir phosphate amoxicillin/ clavulanate potassium OXISTAT 3 NC NC 16

19 CONDITION/DRUG CONDITION/DRUG sulfamethoxazole/ trimethoprim TAMIFLU CAPS 3 3 NC valacyclovir VALTREX 3 3 NC VUSION* 3 NC NC ZOVIRAX 3 3 NC ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS anastrozole ASTAGRAF XL azathioprine CELLCEPT 3 3 NC cyclosporine letrozole megestrol acetate mycophenolate mofetil MYFORTIC 3 3 NC NEORAL 3 3 NC NILANDRON 3 3 NC PROGRAF 3 3 NC RAPAMUNE 3 3 NC sirolimus tacrolimus tamoxifen citrate ANTIVIRAL/HIV abacavir abacavir/ lamivudine/ zidovudine APTIVUS ATRIPLA COMBIVIR 3 3 NC didanosine delayed release EDURANT EMTRIVA EPIVIR 3 3 NC EPZICOM 3 3 NC GENVOYA INTELENCE ISENTRESS lamivudine lamivudine/zidovudine nevirapine ext-rel PREZISTA RETROVIR 3 3 NC REYATAZ 3 3 NC stavudine STRIBILD SUSTIVA 3 3 NC 17

20 ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION) CONDITION/DRUG CONDITION/DRUG TRIZIVIR 3 3 NC TRUVADA VIDEX EC 3 3 NC VIRACEPT VIRAMUNE/XR 3 3 NC VIREAD ZERIT 3 3 NC ZIAGEN 3 3 NC zidovudine ASTHMA/COPD ALVESCO 3 NC NC ACCOLATE 3 3 NC ADVAIR DISKUS ADVAIR HFA albuterol sulfate tablet/ solution ATROVENT HFA COMBIVENT RESPIMAT DULERA FLOVENT HFA FORADIL 3 3 NC INCRUSE ELLIPTA 3 NC NC montelukast sodium PERFOROMIST 3 3 NC PROAIR HFA PROVENTIL HFA 2 NC NC QVAR SINGULAIR 3 3 NC SPIRIVA STRIVERDI RESPIMAT 3 3 NC SYMBICORT TUDORZA PRESSAIR 3 NC NC VENTOLIN HFA 2 NC NC XOPENEX HFA 3 NC NC XOPENEX/ CONCENTRATE 3 3 NC zafirlukast CARDIOVASCULAR DRUGS HIGH BLOOD PRESSURE amlodipine besylate/benazepril hydrochloride ATACAND/HCT 3 NC NC atenolol AVALIDE 3 NC NC AVAPRO 3 NC NC AZOR 3 3 NC BENICAR/HCTZ 3 3 NC BREVIBLOC 3 3 NC BYSTOLIC candesartan/hctz carvedilol 18

21 CONDITION/DRUG clonidine COZAAR 3 NC NC diltiazem cd DIOVAN/HCT 3 NC NC doxazosin mesylate EDARBI 3 NC NC EDARBYCLOR 3 NC NC enalapril maleate EXFORGE/HCTZ 3 3 NC furosemide hydralazine hydrochlorothiazide HYZAAR 3 NC NC irbesartan/hctz LEVATOL 3 3 NC lisinopril/hctz losartan/hctz metoprolol succinate metoprolol tartrate MICARDIS/HCT 3 NC NC propranolol ramipril spironolactone telmisartan/hctz triamterene/hctz valsartan/hctz verapamil/er CONDITION/DRUG CARDIOVASCULAR DRUGS HIGH CHOLESTEROL amlodipine/atorvastatin atorvastatin calcium CADUET 3 NC NC CRESTOR 3 NC NC ezetimibe fenofibrate fenofibric acid gemfibrozil LESCOL/XL 3 NC NC LIPITOR 3 NC NC LIVALO 3 NC NC lovastatin LOVAZA 3 3 NC niacin er omega-3 acid ethyl esters PRAVACHOL 3 NC NC pravastatin sodium rosuvastatin simvastatin TRIGLIDE 3 3 NC VYTORIN 3 NC NC WELCHOL 3 3 NC ZETIA 3 3 NC ZOCOR 3 NC NC 19

22 ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION) CONDITION/DRUG CONDITION/DRUG CARDIOVASCULAR DRUGS OTHER AGGRASTAT 3 3 NC AGGRENOX 3 3 NC clopidogrel COUMADIN 2 3 NC digoxin EFFIENT 3 3 NC ELIQUIS enoxaparin sodium ENTRESTO isosorbide mononitrate er NITROSTAT 3 3 NC PLAVIX 3 3 NC potassium chloride PRADAXA 3 NC NC warfarin XARELTO CENTRAL NERVOUS SYSTEM ANXIETY AND DEPRESSION alprazolam amitriptyline bupropion/xl citalopram CYMBALTA 3 3 NC diazepam duloxetine ER EFFEXOR XR 3 3 NC escitalopram oxalate fluoxetine LEXAPRO 3 3 NC lorazepam paroxetine PRISTIQ ER 3 3 NC sertraline trazodone venlafaxine/er WELLBUTRIN XL 3 3 NC CENTRAL NERVOUS SYSTEM ATTENTION DEFICIT DIRDER amphetamine salt combo DAYTRANA 3 3 NC dextro-amphetamine/ amphetamine salts FOCALIN XR 3 3 NC INTUNIV 3 3 NC METHYLIN 3 3 NC methylphenidate/er STRATTERA 3 3 NC VYVANSE CENTRAL NERVOUS SYSTEM MIGRAINE RELPAX 3 3 NC rizatriptan sumatriptan succinate 20

23 CONDITION/DRUG CONDITION/DRUG zolmitriptan ZOMIG/ZMT 3 3 NC CENTRAL NERVOUS SYSTEM OTHER ABILIFY 3 3 NC AMRIX 3 NC NC AZILECT 3 3 NC baclofen carbidopa/ levodopa & er cyclobenzaprine donepezil EQUETRO 3 3 NC EXELON 3 3 NC NAMENDA TABS 3 3 NC NEUPRO pramipexole dihydrochloride quetiapine fumarate risperidone ropinirole SAVELLA 3 3 NC SEROQUEL XR 3 3 NC CENTRAL NERVOUS SYSTEM PAIN butalbital/apap BUTRANS 3 3 NC EMBEDA 3 3 NC fentanyl patch hydrocodone/ acetaminophen hydromorphone MORPHAND 3 3 NC oxycodone/ acetaminophen OXYCONTIN 3 3 NC SUXONE FILM tramadol/er ZUBLV CENTRAL NERVOUS SYSTEM SEIZURE DIRDERS clonazepam gabapentin lamotrigine levetiracetam LYRICA topiramate CENTRAL NERVOUS SYSTEM SLEEP AGENTS AMBIEN/CR 3 NC NC EDLUAR 3 NC NC eszopiclone INTERMEZZO 3 NC NC LUNESTA 3 NC NC ROZEREM 3 NC NC NATA 3 NC NC temazepam zaleplon zolpidem/er 21

24 ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION) CONDITION/DRUG CONDITION/DRUG CONTRACEPTIVES OTHER** NATAZIA 3 3 NC NUVARING PARAGARD T 380A DERMATOLOGY BENZACLIN 3 3 NC betamethasone CARAC 3 NC NC ciclopirox clindamycin phosphate clobetasol propionate CLOBEX 3 3 NC CORDRAN 3 3 NC doxepin crm EPIDUO 3 3 NC ERYGEL 3 3 NC fluocinonide fluorouracil cream 0.5% 1 NC NC lidocaine topical methylprednisolone mupirocin NORITATE 3 NC NC ORACEA 3 3 NC TAZORAC 3 3 NC tretinoin triamcinolone acetonide DIABETES BLOOD GLUCOSE MONITORING ACCU CHEK TEST STRIPS ONETOUCH TEST STRIPS DIABETES DRUGS AFREZZA 3 3 NC BYDUREON 3 3 NC BYETTA 3 3 NC FORTAMET 3 NC NC glimepiride glipizide glipizide er glipizide xl GLUCOPHAGE/XR 3 3 NC glyburide GLYSET 3 3 NC INVOKANA 3 NC NC JANUMET JANUMET XR JANUVIA JENTADUETO KAZANO 3 NC NC 22

25 CONDITION/DRUG CONDITION/DRUG KOMBIGLYZE XR 2 NC NC metformin ER NESINA 3 NC NC ONGLYZA 2 NC NC OSENI 3 NC NC pioglitazone TRADJENTA TRULICITY VICTOZA 2 PAK & 3 PAK DIABETES INSULIN APIDRA/LOSTAR 2 NC NC BASAGLAR HUMALOG/ MIX/ KWIKPEN HUMULIN U-500 CONCENTRATE HUMULIN/KWIKPEN (EXCEPT HUMULIN U-500 CONCENTRATE) 2 NC NC NC NC LANTUS 2 3 NC NOVOLIN NOVOLOG MIX 70/ TOUJEO 2 3 NC TRESIBA 2 3 NC EYE/EAR ALPHAGAN P (0.15%) 3 3 NC AZOPT brimonidine tartrate CIPRODEX COMBIGAN dorzolamide/timolol maleate DUREZOL erythromycin latanoprost LOTEMAX LUMIGAN 2 NC NC PATADAY 3 3 NC PATANOL 3 3 NC prednisolone acetate RESCULA 3 3 NC RESTASIS timolol maleate TRAVATAN Z VIGAMOX 3 3 NC ZIOPTAN 3 3 NC GASTROINTESTINAL DRUGS ACIPHEX 3 NC NC ALOXI 3 3 NC AMITIZA 3 3 NC ASACOL HD 2 NC NC DELZICOL 3 NC NC DEXILANT 3 NC NC Generic versions of GLUMETZA and FORTAMET (metformin ext-rel tabs) require Prior Approval. 23

26 ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION) CONDITION/DRUG CONDITION/DRUG dicyclomine EMEND 3 3 NC esomeprazole lansoprazole LIALDA 3 3 NC LINZESS MOVIPREP NEXIUM 3 NC NC omeprazole omeprazole/sodium bicarbonate ondansetron/odt pantoprazole sodium polyethylene glycol 3350 PRILOSEC 3 NC NC PROTONIX 3 NC NC rabeprazole ranitidine RELISTOR sucralfate SUPREP WEL PREP KIT VARUBI 3 3 NC ZEGERID 3 NC NC HORMONE REPLACEMENT ANDRODERM ANDROGEL 2 NC NC ESTRACE 3 3 NC estradiol FORTESTA 3 3 NC MINIVELLE PREFEST 3 3 NC PREMARIN PREMPRO progesterone STRIANT 3 3 NC TESTIM 3 NC NC testosterone cypionate testosterone gel VAGIFEM 3 3 NC VIVELLE DOT 3 3 NC VOGELXO 3 NC NC INFLAMMATION - CORTICOSTEROIDS CORTEF 3 NC NC MEDROL 3 NC NC MILLIPRED 3 NC NC ORAPRED ODT 3 NC NC prednisone RAYOS 3 NC NC ZUPLENZ 3 3 NC 24

27 CONDITION/DRUG CONDITION/DRUG MISCELLANEOUS allopurinol calcitriol CHANTIX COLCRYS 3 3 NC epinephrine injection EPIPEN 2 PAK EVISTA 3 3 NC naloxone NARCAN ULORIC ORAL CONTRACEPTIVES BIPHASIC** MIRCETTE 3 3 NC ORAL CONTRACEPTIVES MONOPHASIC** cryselle DEGEN 3 3 NC gianvi LOESTRIN/FE 3 3 NC ORTHO-NOVUM 3 3 NC zovia ORAL CONTRACEPTIVES TRIPHASIC** ORTHO TRI-CYCLEN 3 3 NC ORTHO TRI-CYCLEN LO 3 3 NC OSTEOPOROSIS/NE DISEASES ACTONEL 3 3 NC alendronate ibandronate risedronate PRIASIS acitretin calcipotrienebetamethasone RHEUMATOLOGY ANAPROX DS 3 NC NC ARTHROTEC 3 NC NC CELEBREX 3 3 NC celecoxib diclofenac tablets FELDENE 3 NC NC ibuprofen meloxicam methotrexate inj NAPRELAN 3 NC NC NAPROSYN 3 NC NC naproxen OTREXUP 3 3 NC RASUVO 3 3 NC VOLTAREN GEL 3 3 NC THYROID MEDICATIONS ARMOUR THYROID 3 3 NC levothyroxine SYNTHROID

28 ABBREVIATED FORMULARY (NON-SPECIALTY BY CONDITION) CONDITION/DRUG CONDITION/DRUG UROLOGIC DIRDERS AVODART 3 3 NC DETROL 3 NC NC DETROL LA 3 NC NC ENABLEX 3 NC NC finasteride GELNIQUE 3 NC NC JALYN 3 NC NC MYRBETRIQ 2 3 NC oxybutynin/er OXYTROL 3 NC NC phenazopyridine RAPAFLO tamsulosin tolterodine/er TOVIAZ 2 NC NC trospium/er VESICARE To see the 2019 full formularies: - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/formulary - call CVS Caremark for retail or mail order drugs: call AllianceRx Walgreens Prime for specialty drugs:

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30 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING 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. NAME NAME abacavir AFINITOR abacavir/ lamivudine/ zidovudine AFINITOR DISPERZ TAB ABILIFY 3 3 NC ABRAXANE ACCOLATE 3 3 NC ACCU CHEK TEST STRIPS acetaminophen/codeine ACIPHEX 3 NC NC acitretin ACTEMRA ACTHAR HP 5 5 NC ACTIMMUNE ACTONEL 3 3 NC ADCETRIS ADCIRCA 5 5 NC ADEFOVIR ADEMPAS ADRIAMYCIN PFS ADRUCIL ADVAIR DISKUS ADVAIR HFA ADVATE ADYNOVATE AFREZZA 3 3 NC AFSTYLA AGGRASTAT 3 3 NC AGGRENOX 3 3 NC albuterol sulfate tablet/ solution ALDURAZYME ALECENSA alendronate ALIMTA ALKERAN INJ 5 5 NC ALKERAN TAB 5 5 NC allopurinol ALOXI 3 3 NC ALPHAGAN P (0.15%) 3 3 NC ALPHANATE ALPHANINE SD alprazolam ALPROLIX ALVESCO 3 NC NC AMBIEN/CR 3 NC NC AMIFOSTINE

31 NAME AMITIZA 3 3 NC amitriptyline amlodipine besylate/ benazepril hydrochloride amlodipine/atorvastatin amoxicillin amoxicillin/ clavulanate potassium amphetamine salt combo AMPYRA 5 5 NC AMRIX 3 NC NC ANAPROX DS 3 NC NC anastrozole ANDRODERM ANDROGEL 2 NC NC APIDRA/LOSTAR 2 NC NC APOKYN APTIVUS ARALAST /NP ARANESP ARCALYST ARMOUR THYROID 3 3 NC ARRANON ARTHROTEC 3 NC NC ARZERRA ASACOL HD 2 NC NC ASTAGRAF XL NAME ASTEPRO 3 3 NC ATACAND/HCT 3 NC NC atenolol atorvastatin calcium ATRIPLA ATROVENT HFA AUBAGIO AVALIDE 3 NC NC AVAPRO 3 NC NC AVASTIN AVEED AVODART 3 3 NC AVONEX AZACITIDINE azathioprine azelastine AZILECT 3 3 NC azithromycin AZOPT AZOR 3 3 NC baclofen BARACLUDE LN BARACLUDE TABS 5 5 NC BASAGLAR BEBULIN BECONASE AQ 3 NC NC BELEODAQ BENDEKA

32 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) NAME BENEFIX BENICAR/HCTZ 3 3 NC BENLYSTA BENZACLIN 3 3 NC benzonatate BERINERT betamethasone BETASERON BETHKIS BEXAROTENE BICNU BIVIGAM BLEOMYCIN BLINCYTO SULIF TOX BRAFTOVI 5 5 NC BREVIBLOC 3 3 NC brimonidine tartrate BUPHENYL 5 5 NC bupropion/xl butalbital/apap BUTRANS 3 3 NC BYDUREON 3 3 NC BYETTA 3 3 NC BYSTOLIC CADUET 3 NC NC calcipotrienebetamethasone NAME calcitriol CALQUENCE CAMPTOSAR 5 5 NC candesartan/hctz CARAC 3 NC NC carbidopa/levodopa & er CARPLATIN carvedilol CELEBREX 3 3 NC celecoxib CELLCEPT 3 3 NC cephalexin CEPROTIN CERDELGA CEREZYME CETROTIDE CHANTIX CHORIONIC GONADOTROPIN ciclopirox CIMZIA 5 5 NC CINRYZE CIPRODEX ciprofloxacin CISPLATIN citalopram CLADRIBINE CLARINEX 3 NC NC 30

33 NAME CLARINEX-D 3 NC NC clindamycin phosphate clobetasol propionate CLOBEX 3 3 NC CLOLAR 5 5 NC clonazepam clonidine clopidogrel clotrimazole/ betamethasone COAGADEX COLCRYS 3 3 NC COMBIGAN COMBIVENT RESPIMAT COMBIVIR 3 3 NC COPAXONE 20MG 5 NC NC COPAXONE 40MG 5 NC NC COPEGUS 5 5 NC CORDRAN 3 3 NC CORIFACT CORTEF 3 NC NC COSENTYX 5 5 NC COSMEGEN 5 5 NC COUMADIN 2 3 NC COZAAR 3 NC NC CRESTOR 3 NC NC cryselle CUVITRU NAME cyclobenzaprine CYCLOPHOSPHAMIDE cyclosporine CYCLOSPORINE INJ CYMBALTA 3 3 NC CYSTAGON CYTARABINE CYTOGAM CYTOVENE 5 5 NC DACARBAZINE DACOGEN 5 5 NC DACTINOMYCIN DAKLINZA 5 NC NC DARZALEX DAUNORUBICIN HCL DAYTRANA 3 3 NC DECITABINE DEFEROXAMINE DELZICOL 3 NC NC DESFERAL 5 5 NC desloratadine 1 NC NC DEGEN 3 3 NC DETROL 3 NC NC DETROL LA 3 NC NC DEXILANT 3 NC NC DEXRAZOXANE dextro-amphetamine/ amphetamine salts diazepam 31

34 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) NAME diclofenac tablets dicyclomine didanosine delayed release digoxin diltiazem cd DIOVAN/HCT 3 NC NC DOCETAXEL DOFETILIDE donepezil DOPTELET 5 5 NC dorzolamide/timolol maleate doxazosin mesylate doxepin crm DOXIL 5 5 NC DOXORUBICIN HCL doxycycline hyclate DULERA duloxetine ER DUREZOL DYSPORT EDARBI 3 NC NC EDARBYCLOR 3 NC NC EDLUAR 3 NC NC EDURANT EFFEXOR XR 3 3 NC EFFIENT 3 3 NC NAME EGRIFTA ELAPRASE ELIGARD ELIQUIS ELITEK ELLENCE 5 5 NC ELOCTATE EMBEDA 3 3 NC EMEND 3 3 NC EMPLICITI EMTRIVA ENABLEX 3 NC NC enalapril maleate ENBREL enoxaparin sodium ENTECAVIR ENTRESTO ENTYVIO 5 5 NC EPCLUSA EPIDUO 3 3 NC epinephrine injection EPIPEN 2 PAK EPIRUBICIN EPIVIR 3 3 NC EPOGEN 5 5 NC EPZICOM 3 3 NC EQUETRO 3 3 NC ERBITUX

35 NAME ERIVEDGE ERLEADA 5 5 NC ERTACZO 3 NC NC ERYGEL 3 3 NC erythromycin ESBRIET escitalopram oxalate esomeprazole ESTRACE 3 3 NC estradiol eszopiclone ETHYOL 5 5 NC ETOPOPHOS ETOPOSIDE EUFLEXXA 5 5 NC EVISTA 3 3 NC EXELDERM 3 3 NC EXELON 3 3 NC EXFORGE/HCTZ 3 3 NC EXJADE EXONDYS EXTAVIA 5 5 NC EYLEA ezetimibe FABRAZYME FARYDAK FASLODEX FEIBA NAME FELDENE 3 NC NC fenofibrate fenofibric acid fentanyl patch finasteride FIRAZYR FIRMAGON FLOVENT HFA FLOXURIDINE fluconazole FLUDARABINE flunisolide spray fluocinonide FLUOROURACIL fluorouracil cream 0.5% 1 NC NC fluoxetine fluticasone spray FOCALIN XR 3 3 NC FOLLISTIM /AQ FOLOTYN FORADIL 3 3 NC FORTAMET 3 NC NC FORTEO FORTESTA 3 3 NC FULPHILA furosemide FUZEON gabapentin GAMASTAN S/D

36 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) NAME GAMMAGARD GAMMAKED GAMMAPLEX GAMUNEX GAMUNEX-C GANCICLOVIR GANIRELIX ACETATE GATTEX GAZYVA GELNIQUE 3 NC NC GEL-ONE GELSYN GEMCITABINE gemfibrozil GEMZAR 5 5 NC GENOTROPIN 5 NC NC GENVOYA gianvi GILENYA GLASSIA GLEEVEC 5 5 NC glimepiride glipizide glipizide er glipizide xl GLUCOPHAGE/XR 3 3 NC glyburide GLYSET 3 3 NC GONAL-F 5 5 NC GONAL-F RFF 5 5 NC NAME GRANIX HALAVEN HARVONI HEMOFIL M HEPAGAM B HEPSERA 5 5 NC HERCEPTIN HIZENTRA HUMALOG/ MIX/ KWIKPEN 2 NC NC HUMATE-P HUMATROPE 5 NC NC HUMIRA HUMULIN U-500 CONCENTRATE HUMULIN/KWIKPEN (EXCEPT HUMULIN U-500 CONCENTRATE) NC NC HYALGAN HYCAMTIN CAP HYCAMTIN INJ 5 5 NC hydralazine hydrochlorothiazide hydrocodone/ acetaminophen hydromorphone HYPERHEP B HYPERRHO S/D HYQVIA HYZAAR 3 NC NC ibandronate 34

37 NAME IBRANCE ibuprofen ICLUSIG IDAMYCIN PFS 5 5 NC IDARUBICIN HCL IDELVION IFEX 5 5 NC IFOSFAMIDE ILARIS IMATINIB IMBRUVICA INCRELEX INCRUSE ELLIPTA 3 NC NC INLYTA INTELENCE INTERMEZZO 3 NC NC INTRON-A INTUNIV 3 3 NC INVOKANA 3 NC NC irbesartan/hctz IRESSA IRINOTECAN ISENTRESS isosorbide mononitrate er ISTODAX 5 5 NC IXEMPRA IXINITY JADENU 5 5 NC JAKAFI NAME JALYN 3 NC NC JANUMET JANUMET XR JANUVIA JENTADUETO JEVTANA JUBLIA 3 NC NC JYNARQUE KADCYLA KALBITOR KALYDECO KAZANO 3 NC NC KEPIVANCE KERYDIN* 3 NC NC ketoconazole tabs KEYTRUDA KINERET KOATE-DVI KOGENATE FS KOMBIGLYZE XR 2 NC NC KRYSTEXXA 5 5 NC KUVAN KYPROLIS lamivudine lamivudine/zidovudine lamotrigine lansoprazole LANTUS 2 3 NC LARTRUVO

38 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) NAME latanoprost LEMTRADA LESCOL/XL 3 NC NC LETAIRIS letrozole LEUKINE 5 5 NC LEUPROLIDE LEVATOL 3 3 NC levetiracetam levocetirizine 1 NC NC levofloxacin levothyroxine LEXAPRO 3 3 NC LIALDA 3 3 NC lidocaine topical LILETTA 5 5 NC LINZESS LIPITOR 3 NC NC lisinopril/hctz LIVALO 3 NC NC LOESTRIN/FE 3 3 NC LOPROX 3 NC NC lorazepam losartan/hctz LOTEMAX LOTRINE* 3 NC NC lovastatin LOVAZA 3 3 NC LUCENTIS NAME LUMIGAN 2 NC NC LUMIZYME LUNESTA 3 NC NC LUPANETA PACK LUPRON DEPOT LUZU 3 NC NC LYNPARZA LYRICA MACUGEN 5 5 NC MEDROL 3 NC NC megestrol acetate MEKINIST MEKTOVI 5 5 NC meloxicam MELPHALAN HCL MENOPUR MENTAX 3 NC NC MESNA MESNEX INJ 5 5 NC MESNEX TAB metformin ER methotrexate inj METHYLIN 3 3 NC methylphenidate/er methylprednisolone metoprolol succinate metoprolol tartrate metronidazole MICARDIS/HCT 3 NC NC Generic versions of GLUMETZA and FORTAMET (metformin ext-rel tabs) require Prior Approval. 36

39 NAME MICRHOGAM MIGLUSTAT MILLIPRED 3 NC NC MINIVELLE MIRCETTE 3 3 NC MIRENA MITOMYCIN MITOXANTRONE MONONINE MONOVISC 5 5 NC montelukast sodium MORPHAND 3 3 NC MOVIPREP MOZOBIL mupirocin MUSTARGEN mycophenolate mofetil MYFORTIC 3 3 NC MYOBLOC MYRBETRIQ 2 3 NC NABI-HB naftifine NAFTIN 2 NC NC NAGLAZYME naloxone NAMENDA TABS 3 3 NC NAPRELAN 3 NC NC NAPROSYN 3 NC NC naproxen NAME NARCAN NANEX 3 NC NC NATAZIA 3 3 NC NAVELBINE 5 5 NC NEORAL 3 3 NC NESINA 3 NC NC NEULASTA 5 5 NC NEUPOGEN 5 NC NC NEUPRO nevirapine ext-rel NEXAVAR NEXIUM 3 NC NC niacin er NILANDRON 3 3 NC NIPENT NITROSTAT 3 3 NC NORDITROPIN NORITATE 3 NC NC NORTHERA NOVAREL NOVOLIN NOVOLOG MIX 70/ NOVOSEVEN RT NPLATE NUCALA 5 5 NC NULOJIX NUTROPIN AQ 5 NC NC NUVARING NUWIQ

40 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) NAME OCALIVA OCTAGAM OCTREOTIDE OFEV OLUMIANT 5 5 NC OLYSIO 5 NC NC omega-3 acid ethyl esters omeprazole NAME oseltamivir phosphate OSENI 3 NC NC OTEZLA OTREXUP 3 3 NC OVIDREL OXALIPLATIN OXISTAT 3 NC NC oxybutynin/er omeprazole/sodium bicarbonate oxycodone/ acetaminophen OMNITROPE 5 NC NC ONCASPAR ondansetron/odt ONETOUCH TEST STRIPS ONGLYZA 2 NC NC ONIVYDE 5 5 NC OPDIVO OPSUMIT ORACEA 3 3 NC ORALAIR ORAPRED ODT 3 NC NC ORENCIA 5 5 NC ORENITRAM ORKAMBI ORTHO TRI-CYCLEN 3 3 NC ORTHO TRI-CYCLEN LO 3 3 NC ORTHO-NOVUM 3 3 NC ORTHOVISC 5 5 NC OXYCONTIN 3 3 NC OXYTROL 3 NC NC PACLITAXEL PALYNZIQ 5 5 NC PAMIDRONATE pantoprazole sodium PARAGARD T 380A paroxetine PATADAY 3 3 NC PATANOL 3 3 NC PEGASYS PEGINTRON PERFOROMIST 3 3 NC PERJETA phenazopyridine pioglitazone PLAVIX 3 3 NC PLEGRIDY /PEN polyethylene glycol

41 NAME POMALYST potassium chloride PRADAXA 3 NC NC PRALUENT 5 NC NC pramipexole dihydrochloride PRAVACHOL 3 NC NC pravastatin sodium prednisolone acetate prednisone PREFEST 3 3 NC PREGNYL PREMARIN PREMPRO PREVYMIS PREZISTA PRILOSEC 3 NC NC PRISTIQ ER 3 3 NC PRIVIGEN PROAIR HFA PROCRIT 5 5 NC PROFILNINE SD progesterone PROGRAF 3 3 NC PROLEUKIN PROLIA PROMACTA promethazine/ codeine NAME propranolol PROTONIX 3 NC NC PROVENTIL HFA 2 NC NC PULMOZYME quetiapine fumarate QVAR rabeprazole ramipril ranitidine RAPAFLO RAPAMUNE 3 3 NC RASUVO 3 3 NC RAVICTI RAYOS 3 NC NC REBETOL REBIF REBIF REBIDOSE REBINYN RECLAST 5 5 NC RECOMBINATE RELISTOR RELPAX 3 3 NC REMODULIN 5 5 NC REPATHA RESCULA 3 3 NC RESTASIS RETACRIT RETROVIR 3 3 NC REVATIO 5 5 NC 39

42 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) NAME REVLIMID REYATAZ 3 3 NC RHOGAM RHOGAM PLUS RHOPHYLAC RIASTAP RIBASPHERE RIBAVIRIN risedronate risperidone RITUXAN RIXUBIS rizatriptan ROMIDEPSIN ropinirole rosuvastatin ROZEREM 3 NC NC SABRIL TABS SAIZEN 5 NC NC SAMSCA SANDOSTATIN LAR SAVELLA 3 3 NC SENSIPAR SEROQUEL XR 3 3 NC SEROSTIM sertraline SIKLOS 5 5 NC SILDENAFIL SIMPONI /ARIA 5 5 NC NAME simvastatin SINGULAIR 3 3 NC sirolimus SKYLA DIUM PHENYLBUTYRATE LESTA LIRIS MATULINE DEPOT MAVERT NATA 3 NC NC VALDI SPIRIVA spironolactone SPRYCEL stavudine STELARA 5 5 NC STIMATE STIVARGA STRATTERA 3 3 NC STRIANT 3 3 NC STRIBILD STRIVERDI RESPIMAT 3 3 NC SUBLOCADE SUXONE FILM sucralfate sulfamethoxazole/ trimethoprim sumatriptan succinate SUPARTZ

43 NAME SUPPRELIN LA SUPREP WEL PREP KIT SUSTIVA 3 3 NC SUTENT SYMBICORT SYMDEKO SYNAGIS SYNTHROID SYNVISC 5 5 NC SYNVISC ONE 5 5 NC tacrolimus TAFINLAR TAMIFLU CAPS 3 3 NC tamoxifen citrate tamsulosin TARCEVA TARGRETIN CAPS 5 5 NC TASIGNA TAVALISSE 5 5 NC TAXOTERE 5 5 NC TAZORAC 3 3 NC TECFIDERA TECHNIVIE 5 NC NC telmisartan/hctz temazepam TEMODAR 5 5 NC TEMOZOLOMIDE temsirolimus NAME TESTIM 3 NC NC testosterone cypionate testosterone gel TETRABENAZINE THALOMID THERACYS THIOTEPA THYROGEN TICE BCG TIKOSYN 5 5 NC timolol maleate TOBI 5 5 NC TOBI PODHALER TOBRAMYCIN INH LN tolterodine/er topiramate TOPOTECAN TOTECT 5 5 NC TOUJEO 2 3 NC TOVIAZ 2 NC NC TRACLEER TRADJENTA tramadol/er TRAVATAN Z trazodone TREANDA 5 5 NC TRELSTAR TRESIBA 2 3 NC 41

44 ABBREVIATED FORMULARY (ALPHABETIC INCLUDING SPECIALTY) NAME tretinoin TRETTEN triamcinolone acetonide triamcinolone spray triamterene/hctz TRIGLIDE 3 3 NC TRISENOX TRIZIVIR 3 3 NC TROGARZO trospium/er TRULICITY TRUVADA TUDORZA PRESSAIR 3 NC NC TYKERB TYSABRI TYVA 5 5 NC TYZEKA ULORIC UVADEX VAGIFEM 3 3 NC valacyclovir valsartan/hctz VALSTAR VALTREX 3 3 NC VANTAS VARIZIG VARUBI 3 3 NC VECTIBIX VELCADE 5 5 NC NAME VELETRI 5 5 NC VEMLIDY venlafaxine/er VENTAVIS VENTOLIN HFA 2 NC NC VERAMYST 2 NC NC verapamil/er VERZENIO VESICARE VICTOZA 2 PAK & 3 PAK VIDAZA 5 5 NC VIDEX EC 3 3 NC VIGAMOX 3 3 NC VIMIZIM VINBLASTINE VINCRISTINE VINORELBINE VIRACEPT VIRAMUNE/XR 3 3 NC VIREAD VISUDYNE VIVELLE DOT 3 3 NC VIVITROL VOGELXO 3 NC NC VOLTAREN GEL 3 3 NC VOTRIENT VPRIV VUSION* 3 NC NC VYTORIN 3 NC NC 42

45 NAME VYVANSE warfarin WELCHOL 3 3 NC WELLBUTRIN XL 3 3 NC WILATE WINRHO SDF XALKORI XARELTO XELJANZ / XR 5 5 NC XELJANZ 5 5 NC XELODA 5 5 NC XENAZINE 5 5 NC XEOMIN XGEVA XIAFLEX XOLAIR XOPENEX HFA 3 NC NC XOPENEX/ CONCENTRATE 3 3 NC XTANDI XYNTHA XYNTHA LOFUSE XYZAL 3 NC NC YERVOY YONSA zafirlukast zaleplon ZALTRAP NAME ZARXIO ZEGERID 3 NC NC ZELRAF ZEMAIRA ZERIT 3 3 NC ZETIA 3 3 NC ZIAGEN 3 3 NC zidovudine ZINECARD 5 5 NC ZIOPTAN 3 3 NC ZOCOR 3 NC NC ZOLADEX ZOLEDRONIC ACID ZOLINZA zolmitriptan zolpidem/er ZOMACTON 5 NC NC ZOMETA 5 5 NC ZOMIG/ZMT 3 3 NC ZORBTIVE ZORTRESS zovia ZOVIRAX 3 3 NC ZUBLV ZUPLENZ 3 3 NC ZYKADIA ZYTIGA ZANOSAR

46 EXCLUDED DRUG LIST STANDARD OPTION These listed drugs are not covered under Standard Option. If you use any of these Excluded Drugs, you will 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 2019 FOR STANDARD OPTION COVERED OPTIONS** Anaphylaxis Treatment AUVI-Q epinephrine injection (0.15 mg and 0.30 mg), ADRENACLICK, EPIPEN, EPIPEN JR. Antidiarrheals opium tincture loperamide, diphenoxylate, diphenoxylate/atropine Anti-inflammatories Non Steroidal Anti-Inflammatories (NSAIDs) Anti-inflammatories Non Steroidal Anti-Inflammatories (NSAIDs) Combinations PENNSAID, VIVLODEX, ZORVOLEX DUEXIS, VIMOVO 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 Antirheumatics CUPRIMINE azathioprine, hydroxychloroquine, leflunomide, methotrexate Antispasmotics LIBRAX clidinium/chlordiazepoxide, dicyclomine, hyoscyamine Cardiovascular YOSPRALA aspirin*** and esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole Dermatology Antifungal ALCORTIN-A, XOLEGEL ciclopirox, clotrimazole, hydrocortisone/iodoquinol, hydrocortisone/iodoquinol/ aloe ketoconazole 2% cream, naftifine, nystatin, terbinafine, ECOZA, LAMISIL, NAFTIN 44

47 CATEGORY* DRUG CLASS* Dermatology Corticosteroids Dermatology Psoriasis Diabetes Metformin Diabetes Other DRUG NOT COVERED IN 2019 FOR STANDARD OPTION OLUX/OLUX-E RIATANE, TACLONEX GLUMETZA CYCLOSET COVERED OPTIONS** clobetasol propionate, fluocinonide, halobetasol propionate acitretin, calcipotriene/ betamethasone, calcitriol, methoxsalen, DOVONEX, OXRALEN ULTRA metformin ER alogliptin, alogliptin/metformin, alogliptin/pioglitazone, bromocriptine mesylate, chlorpropamide, glimepiride, glipizide, glyburide, glyburide/ metformin, pioglitazone, repaglinide, repaglinide/ metformin, rosiglitazone High Cholesterol FLOLIPID, ZYPITAMAG amlodipine-atorvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvasta tin, simvastatin Nausea And Vomiting Therapy (5HT-3 Blocker) Opthalmology Miscellaneous ANZEMET atropine sulfate eye ointment dolasetron, granisetron, ondasetron, palonosetron, promethazine atropine ophthalmic solution, cyclopentolate ophthalmic solution, homatropine ophthalmic solution * This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. ** For more covered options, view the 2019 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. 45

48 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 Antihistamines Allergies Nasal Steroids Anaphylaxis Treatment DRUG NOT COVERED IN 2019 FOR BASIC OPTION cetirizine solution, desloratadine, levocetirizine, CLARINEX, CLARINEX-D, XYZAL BECONASE AQ, DYMISTA, NANEX, OMNARIS, QNASL, VERAMYST, ZETONNA AUVI-Q COVERED OPTIONS** montelukast, zafirlukast, ACCOLATE, SINGULAIR flunisolide spray, fluticasone spray, triamcinolone spray epinephrine injection (0.15 mg and 0.30 mg), ADRENACLICK EPIPEN, EPIPEN JR Anticoagulants PRADAXA warfarin, ELIQUIS, XARELTO Antidiarrheals opium tincture loperamide, diphenoxylate, diphenoxylate/atropine Anti-inflammatories Non Steroidal Anti-inflammatories (NSAIDS) Anti-inflammatories Non Steroidal Anti-inflammatories (NSAIDS) Combinations ANAPROX DS, FELDENE, NAPRELAN, NAPROSYN, PENNSAID, TIVORDEX, VIVLODEX, ZORVOLEX ARTHROTEC, DUEXIS, VIMOVO 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 Antirheumatics CUPRIMINE azathioprine, hydroxychloroquine, leflunomide, methotrexate Antispasmotics LIBRAX clidinium/chlordiazepoxide, dicyclomine, hyoscyamine 46

49 CATEGORY* DRUG CLASS* Asthma Beta Agonist (Rescue Inhaler) Asthma: Inhaled Corticosteroid Benign Prostatic Hyperplasia (BPH) Bladder Agents DRUG NOT COVERED IN 2019 FOR BASIC OPTION PROVENTIL HFA, VENTOLIN HFA, XOPENEX HFA AEROSPAN, ALVESCO JALYN DETROL, DETROL LA, ENABLEX, GELNIQUE, OXYTROL, TOVIAZ COVERED OPTIONS** albuterol solution, levalbuterol inhalation solution, PROAIR HFA budesonide inhalation suspension, ASMANEX, FLOVENT HFA, PULMICORT, QVAR alfuzosin, dutasteride, dutasteride/tamsulosin, finasteride, tamsulosin oxybutynin, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, VESICARE Cardiovascular YOSPRALA aspirin*** and esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole COPD Inhaled Long Acting Muscarinic Receptor Antagonist (LAMA) Corticosteroids Dermatology Antifungal Dermatology Corticosteroids Dermatology Fluorouracil INCRUSE ELLIPTA, TUDORZA PRESSAIR CORTEF, DELTANE, DEXPAK, MEDROL, MILLIPRED, ORAPRED ODT, RAYOS, TAPERDEX ALCORTIN-A, ERTACZO, JUBLIA, KERYDIN*, LOPROX, LOTRINE*, LUZU, MENTAX, NAFTIN*, OXISTAT, VUSION*, XOLEGEL* NOVACORT, OLUX, OLUX-E CARAC, FLUOROURACIL CREAM 0.5% ipratropium, ATROVENT HFA, SPIRIVA cortisone, dexamethasone, fludrocortisone, hydrocortisone, methylprednisolone, prednisone ciclopirox, clotrimazole, clotrimazole/betamethasone, econazole, hydrocortisone/ iodoquinol, hydrocortisone/ iodoquinol/aloe, ketoconazole, naftifine, nystatin, terbinafine, ECOZA, EXELDERM, LAMISIL clobetasol propionate, fluocinoide, halobetasol propionate, hydrocortisone/pramoxine, PRAMONE diclofenac sodium, PICATO, TOLAK CONTINUED ON NEXT PAGE 47

50 MANAGED NOT COVERED DRUG LIST BASIC OPTION CATEGORY* DRUG CLASS* Dermatology Psoriasis Dermatology Rosacea Diabetes Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/ Combinations Diabetes Insulins DRUG NOT COVERED IN 2019 FOR BASIC OPTION RIATANE, TACLONEX NORITATE NESINA, ONGLYZA, KAZANO, KOMBIGLYZE XR, OSENI APIDRA/LOSTAR HUMALOG COVERED OPTIONS** acitretin, calcipotrienebetamethasone, calcitriol, methoxsalen, DOVONEX, OXRALEN ULTRA clindamycin/benzoyl peroxide, doxycycline (except 20 mg), flurandrenolide, metronidazole cream/gel/lotion, FINACEA, METROCREAM, METROGEL, METROLOTION, MIRVA, ORACEA, OLANTRA alogliptin, alogliptin/metformin, alogliptin/pioglitazone, JANUMET, JANUMET XR, JANUVIA, JENTADUETO, TRADJENTA 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 Diabetes Metformin Diabetes Other GLUMETZA, FORTAMET, RIOMET CYCLOSET metformin ER alogliptan, aloglliptan/metformin, alogliptan/pioglitazone, bromocriptine mesylate, chlorpropamide, glimepiride, glipizide, glyburide, glyburide/ metformin, pioglitazone, repaglinide, repaglinide/metformin, rosiglitazone 48

51 CATEGORY* DRUG CLASS* Diabetes SGLT2 Inhibitors DRUG NOT COVERED IN 2019 FOR BASIC OPTION INVOKAMET, INVOKAMET XR, INVOKANA, SEGLUROMET, STEGLATRO, STEGLUJAN COVERED OPTIONS** Farxiga, Jardiance, Syjardy, Synjardy XR, Xigduo XR Glaucoma LUMIGAN latanoprost, RESCULA, TRAVATAN Z, XALATAN, ZIOPTAN Granulocyte Colony Stimulating Factor NEUPOGEN GRANIX, ZARXIO Growth Hormone HEPATITIS C GENOTROPIN, HUMATROPE, NUTROPIN, NUTROPIN AQ, OMNITROPE, SAIZEN, ZOMACTON DAKLINZA, OLYSIO, TECHNIVIE, VIEKIRA PAK, VIEKIRA XR, ZEPA NORDITROPIN EPCLUSA, HARVONI, MAVYRET, VALDI, VOSEVI High Blood Pressure Angiotensin II Receptor Blockers/Combinations (ARBs) ATACAND, AVAPRO, COZAAR, DIOVAN, EDARBI, MICARDIS, ATACAND HCT, AVALIDE, DIOVAN HCT, EDARBYCLOR, HYZAAR, MICARDIS HCT candesartan, irbesartan, losartan, telmisartan, BENICAR, candesartan/hctz, irbesartan/hctz, losartan/hctz, telmisartan/hctz, valsartan/hctz, BENICAR/HCT, olmesartan/hctz High Cholesterol PCSK9 Inhibitors PRALUENT REPATHA High Cholesterol Statins ADVICOR, ALTOPREV, CADUET, CRESTOR, LESCOL/XL, LIPITOR, LIPTRUZET, LIVALO, MEVACOR, PRAVACHOL, VYTORIN, ZOCOR, ZYPITAMAG amlodipine-atorvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin Multiple Sclerosis COPAXONE glatiramer, GLATOPA CONTINUED ON NEXT PAGE 49

52 MANAGED NOT COVERED DRUG LIST BASIC OPTION CATEGORY* DRUG CLASS* DRUG NOT COVERED IN 2019 FOR BASIC OPTION COVERED OPTIONS** Muscle Relaxants AMRIX baclofen, cyclobenzaprine, dantrolene Nausea And Vomiting Therapy (5HT-3 Blocker) ANZEMET granisetron, ondasetron, palonosetron, promethazine Opthalmology Miscellaneous atropine sulfate eye ointment atropine ophthalmic solution, cyclopentolate ophthalmic solution, homatropine ophthalmic solution Pancreatic Enzymes PERTZYE, ZENPEP pancrelipase, CREON, PANCREAZE, VIOKACE Proton Pump Inhibitors Sleep Agents Testosterone Agents ACIPHEX, DEXILANT, FIRST-LANPRAZOLE, FIRST-OMEPRAZOLE, NEXIUM, NEXIUM PACKETS, PREVACID, PRILOSEC, PROTONIX, ZEGERID AMBIEN, AMBIEN CR, EDLUAR, INTERMEZZO, LUNESTA, ROZEREM, NATA ANDROGEL, NATESTO, TESTIM, VOGELXO esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate, pantoprazole, rabeprazole estazolam, eszopiclone, flurazepam, temazepam, triazolam, zaleplon, zolpidem/er testosterone gel, ANDRODERM, FORTESTA Ulcerative Colitis ASACOL HD, DELZICOL 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, view the 2019 Basic 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. 50

53 MANAGED NOT COVERED DRUG LIST BASIC OPTION (ALPHABETIC) ACIPHEX DIOVAN LUMIGAN PROTONIX ADVICOR DIOVAN HCT LUNESTA PROVENTIL HFA AEROSPAN DUEXIS LUZU QNASL ALCORTIN-A DYMISTA MEDROL RAYOS ALTOPREV EDARBI MENTAX RIOMET ALVESCO EDARBYCLOR MEVACHOR ROZEREM AMBIEN EDULAR MICARDIS SAIZEN AMBIEN CR ENABLEX MICARDIS HCT SEGLUROMET AMRIX ERTACZO MILLIPRED NATA ANAPROX DS FELDENE NAFTIN RIATANE ANDROGEL FIRST-LANPRAZOLE NAPRELAN STEGLATRO ANZEMET FIRST-OMEPRAZOLE NAPROSYN STEGLUJAN APIDRA ARTHROTEC ASACOL HD ATACAND ATACAND HCT atropine sulfate eye ointment AUVI-Q AVALIDE AVAPRO BECONASE AQ CADUET CARAC cetirizine solution CLARINEX CLARINEX-D COPAXONE CORTEF COZAAR CRESTOR CUPRIMINE CYCLOSET DAKLINZA DELTANE DELZICOL desloratadine DETROL DETROL LA DEXILANT DEXPAK FLUOROURACIL CREAM 0.5% FORTAMET GELNIQUE GENOTROPIN GLUMETZA HUMALOG HUMALOG MIX HUMATROPE HUMULIN N HUMULIN R U-100 HYZAAR INCRUSE ELLIPTA INTERMEZZO INVOKAMET INVOKAMET XR INVOKANA JALYN JUBLIA KAZANO KERYDIN KOMBIGLYZE XR LESCOL/XL levocetirizine LIBRAX LIPITOR LIPTRUZET LIVALO LOPROX LOTRINE NANEX NATESTO NESINA NEUPOGEN NEXIUM NEXIUM PACKETS NORITATE NOVACORT NUTROPIN NUTROPIN AQ OLUX OLUX-E OLYSIO OMNARIS OMNITROPE ONGLYZA opium tincture ORAPRED ODT OSENI OXISTAT OXYTROL PENNSAID PERTYE PRADAXA PRALUENT PRAVACHOL PRESSAIR PREVACID PRILOSEC TACLONEX TAPERDEX TECHNIVIE TESTIM TIVORDEX TOVIAZ TUDORZA VENTOLIN HFA VERAMYST VIEKIRA PAK VIEKIRA XR VIMOVO VIVLODEX VOGELXO VUSION VYTORIN XOLEGEL XOPENEX HFA XYZAL YOSPRALA ZEGERID ZENPEP ZEPA ZETONNA ZOCOR ZOMACTON ZORVOLEX ZYPITAMAG 51

54 NEW FOR 2019 PHARMACY BENEFIT HIGHLIGHTS LOWER COST SHARES FOR DIABETIC DRUGS AND SUPPLIES Your cost share for the Tier 1 Metformin is now $1 for up to a 90-day supply for Standard and Basic Option members. Remember, you must receive it from a Preferred retail pharmacy or the Mail Order Pharmacy Program. Additionally, there are lower costs for Tier 2 Preferred diabetic medications, Preferred test strips and Preferred supplies: Preferred Diabetic Medication and Supplies: Cost Share Based on Where You Fill Your Prescription MAIL SERVICE PHARMACY PREFERRED RETAIL PHARMACY Standard Option $40 for up to a 90-day supply 20% of our allowance Basic Option without Medicare B primary Not covered - $35 for up to a 30-day supply - $65 for a 31 to 90-day supply Basic Option with Medicare B primary $50 for up to a 90-day supply - $30 for up to a 30-day supply - $60 for a 31 to 90-day supply OPIOID REVERSAL AGENTS Your cost share for Narcan nasal spray/naloxone generic injectable is now $0 for up to a 90-day supply per calendar year when obtained through a Preferred retail pharmacy or the Mail Service Prescription Drug Program. Refills after a 90-day supply are subject to the Tier 1 cost share. 52

55 AUTO-IMMUNE INFUSIONS We now provide medical benefits for the infusion drug Remicade and its two biosimilars, Renflexis and Inflectra. For information about coverage contact customer service at the number on the back of your member ID card. These are just a few of your pharmacy benefit highlights. Your Service Benefit Plan includes so much more, see: - the Service Benefit Plan brochures (Standard and Basic Option: RI ; FEP Blue Focus: RI ) - prior to January 1, 2019, visit fepblue.org/whatsnew - after January 1, 2019, visit fepblue.org/pharmacy 53