ABBREVIATED FORMULARY

Transcription

1 ABBREVIATED FORMULARY As of January 1, 2017 RXABRFRM2017 fepblue.org

2 Review this abbreviated formulary to learn how to get the most from your pharmacy benefit. This includes information about: 3 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 CVS Caremark to administer your pharmacy benefit. CVS Caremark is an independent company called a Pharmacy Benefit Manager (PBM). The PBM manages your: n Retail Pharmacy Program n Mail Service Pharmacy Program n Specialty Pharmacy Program General questions If you have any questions about your benefits, please: n See the Blue Cross and Blue Shield Service Benefit Plan brochure (RI ) n Visit n Call CVS Caremark any time toll-free at New for 2017 n No change in cost shares n Drug exclusions added to Standard Option formulary n Drug classes added to Managed Not Covered drug list n Certain self-administered drugs must be filled through the pharmacy benefit, versus the medical benefit TABLE OF CONTENTS Understanding the Formulary...2 n Formulary...2 n Excluded Drugs...2 n Managed Not Covered Drugs...2 n Quantity Limits...2 n Prior Approval...2 n 5-Tier Drug Formulary...4 n How Prescription Drugs are Assigned to Tiers...5 n Basic Option Cost Share Tiers...6 n Standard Option Cost Share Tiers...8 How to use the Abbreviated Formulary...10 n Program Options...10 n Legend...11 Abbreviated Formulary (non-specialty by condition)...12 Abbreviated Formulary (alphabetic including Specialty)...22 Managed Not Covered Drug List Excluded Drug List...43 How to Contact Us

3 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 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 formulary has 5 tiers of drugs. Managed Not Covered (NC) Drugs Some drugs are not covered on the Basic Option drug formulary. These Managed Not Covered drugs have Preferred alternative options in the same class. See p. 39 Excluded (NC) Drugs A few drugs will no longer be covered on the Standard Option formulary. These excluded drugs have multiple equivalent or alternatives drugs. See p. 43 Standard and Basic Option members taking an excluded or a Managed Not Covered drug should expect to pay the full cost of the prescription. Quantity Limits () Certain drugs on the formulary have quantity limits (for example, number of pills). This means your pharmacy benefit will only cover up to a specified, limited amount of the drug each time you fill a prescription or a limited amount per year. Quantity limits help ensure drugs are used safely and appropriately. 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 about Prior Approval n You will need to renew your prior approval periodically. n Drugs and supplies on the Prior Approval list may change throughout the year. n Mail Service and Specialty Programs will not fill prescriptions that need prior approval until you receive prior approval. n Preferred retail pharmacies will fill your prescriptions, but you will pay the full cost of the drug until you get prior approval. File a claim for reimbursement with the Retail Pharmacy Program. Help with Prior Approval Visit pharmacy. Or call toll-free any time at to: n See a list of drugs that need prior approval n Get a prior approval request form Your doctor can submit requests to the Prior Approval program for quantities greater than the allowed amount by: n Calling toll-free n Filling out the Prior Approval Retail Pharmacy Form at pharmacy 2 3

4 UNDERSTANDING THE FORMULARY 5-Tier Drug Formulary Tiers are the different cost levels you pay for a drug. You will generally pay the lowest cost share for any Tier 1 generic drug or Tier 4 specialty drug. If your drug is in Tiers 2, 3 or 5, see if there is a generic or Preferred drug option, and discuss it with your doctor. Basic and Standard Options Tier 1 DRUG TYPE Generic Drugs: typically the most affordable, and are equal to their brand name counterparts in quality, performance characteristics and intended use. How Prescription Drugs Are Assigned to Tiers The Pharmacy and Medical Policy Committee (PMPC) is an independent group of doctors and pharmacists. This group recommends drugs for each tier based on their: n Effectiveness n Safety n How they compare to other drugs in the same class The PMPC meets every quarter to review new drugs and other changes to the formulary. Drugs may change tiers or prior approval status. Check your formulary often to be aware of any changes. Tier 2 Tier 3 Tier 4 Tier 5 Preferred Brand Name Drugs: proven to be safe, effective, and favorably priced compared to Non-preferred brands. Non-preferred Brand Name Drugs: typically higher cost share since there is a generic or Preferred brand. Preferred Specialty Drugs: proven to be safe, effective, and favorably priced compared to Non-preferred specialty drugs. Non-preferred Specialty Drugs: typically higher cost share since there is a Preferred specialty drug. To see the current and full formulary go to or call CVS Caremark any time toll-free at

5 UNDERSTANDING THE FORMULARY Basic Option Cost Share Tiers Basic Option members must use a Preferred retail pharmacy* and will save by choosing generic drugs and Preferred brand name drugs when possible. Use the charts below to find your cost share. To see Basic Option with Medicare B primary cost shares go to or call CVS Caremark any time toll-free at BASIC OPTION: Cost Share Based on Where You Fill Your Prescription BASIC OPTION: Specialty Drugs - Cost Share Based on Where You Fill Your Prescription Tier 1: Generic Drugs Tier 2: Preferred Brand Name Drugs Tier 3: Non-preferred Brand Name Drugs PREFERRED RETAIL PHARMACY --Up to $10 --You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments -- Up to $50 -- You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments --60% of the drug price when the price is $110 or greater --$65 copayment or the drug price when the price is less than $110 --You can get up to a 30-day supply for 1 copayment or a 90-day supply for 3 copayments NON-PREFERRED RETAIL PHARMACY & MAIL SERVICE PHARMACY Not covered* SPECIALTY PHARMACY PREFERRED RETAIL PHARMACY Tier 4: Preferred Specialty Drugs Tier 5: Non-preferred Specialty Drugs --Up to $55 for 30-day supply or $165 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill --Up to $80 for 30-day supply or $240 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill -- Up to $65 for up to a 30-day supply only -- When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy --Up to $90 for up to a 30-day supply only - - When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy * Basic Option members with Medicare B primary coverage have Mail Service Pharmacy benefits and some lower cost shares. 6 7

6 UNDERSTANDING THE FORMULARY Standard Option Cost Share Tiers Standard Option members save by using the Mail Service Pharmacy and Preferred retail pharmacies for filling prescription drugs. Members can also save by asking for generic and/or Preferred brand name drugs when possible. Use the charts below to find your cost share. STANDARD OPTION: Cost Share Based on Where You Fill Your Prescription Tier 1: Generic Drugs Tier 2: Preferred Brand Name Drugs Tier 3: Nonpreferred Brand Name Drugs MAIL SERVICE PHARMACY PREFERRED RETAIL PHARMACY --Up to $ % of the Plan allowance --Up to $ % of the Plan allowance --Up to $ % of the Plan allowance NON-PREFERRED RETAIL PHARMACY --45% of the average wholesale price plus any difference between the allowance and the billed amount --If you use a Non-preferred retail pharmacy, you need to file a paper claim for reimbursement STANDARD OPTION: Specialty Drugs - Cost Share Based on Where You Fill Your Prescription Tier 4: Preferred Specialty Drugs Tier 5: Nonpreferred Specialty Drugs SPECIALTY PHARMACY --$35 for up to 30-day supply --$95 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill --Up to $55 for 30-day supply --$155 for 31 to 90-day supply --You are limited to a 30-day supply for the first 3 fills of each specialty drug. You can get a 90-day supply after the 3rd fill PREFERRED RETAIL PHARMACY --30% of Plan allowance up to 30-day supply --When you buy specialty drugs at a Preferred retail pharmacy, you are limited to one 30-day supply for each prescription. You must get all refills through the Specialty Pharmacy NON-PREFERRED RETAIL PHARMACY --45% of the average wholesale price plus any difference between the 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 * Lower cost shares are available to Standard Option members with Medicare Part B primary. To see Standard Option with Medicare B primary cost shares go to or call CVS Caremark any time toll-free at

7 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 n Alphabetic for all drugs See p See p See if there are any limitations for your drug. 3. Review the cost share charts to find your copay or coinsurance. See p If your drug is in Tiers 2, 3 or 5, ask your doctor if there is a generic drug to treat your condition. If there is no generic drug, ask your doctor to prescribe a Preferred brand name drug. Program Options The benefit for Standard Option () and Basic Option () varies. The charts list both the and tier for each drug. In many cases the tier is the same, but not in every case. Program Legend Some drugs are noted with letters in the columns next to them. The letters describe any limitations. PA NC LD ITALIC 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. Excluded Drugs: drugs that are not covered under Standard Option but have multiple equivalent or alternative drugs available. Managed Not Covered : drugs that are not covered under Basic Option but have covered options in the same class. Standard Option Basic Option 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. To see the current and full formulary go to or call CVS Caremark any time toll-free at

8 (NON-SPECIALTY BY CONDITION) Bold Type means there is a generic version for this drug. ALLERGY/COUGH & COLD ACETAMINOPHEN/ CODEINE 12 ASTEPRO 3 3 AZELASTINE BECONASE AQ 3 NC BENZONATATE BUDENIDE NASAL SPRAY CETIRIZINE LUTION 1 NC CLARINEX 3 NC CLARINEX-D 3 NC DESLORATADINE 1 NC EPIPEN 2 PAK 2 2 DYMISTA 3 NC FLUNILIDE SPRAY FLUTICANE SPRAY LEVOCETIRIZINE 1 NC NASACORT AQ 3 NC NANEX 3 NC OMNARIS 2 NC PROMETHAZINE/ CODEINE QNASL 3 NC RHINOCORT AQUA 3 NC TRIAMCINOLONE SPRAY VERAMYST 2 NC XYZAL 3 NC ZETONNA 3 NC ANTI-INFECTIVES ANTIBIOTICS/ ANTIFUNGAL/ANTIVIRAL AMOXICILLIN AMOXICILLIN/ CLAVULANATE POTASSIUM AZITHROMYCIN CEPHALEXIN CIPROFLOXACIN CLOTRIMAZOLE/ BETAMETHANE DOXYCYCLINE HYCLATE ERTACZO PA 3 NC EXELDERM PA 3 3 FLUCONAZOLE JUBLIA PA 3 NC KERYDIN PA 3 NC KETOCONAZOLE PA LEVOFLOXACIN LOPROX 3 NC LOTRINE 3 NC LUZU PA 3 NC MENTAX 3 NC METRONIDAZOLE NAFTIFINE NAFTIN 2 NC OXISTAT PA 3 NC SULFAME- THOXAZOLE/ TRIMETHOPRIM TAMIFLU 2 2 VALACYCLOVIR VALTREX 3 3 VUSION 3 NC XOLEGEL NC NC ZOVIRAX 3 3 ZYVOX 3 3 ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS ANASTROZOLE ASTAGRAF XL 2 2 AZATHIOPRINE CELLCEPT 3 3 CYCLOSPORINE LETROZOLE MEGESTROL ACETATE MYCOPHENOLATE MOFETIL MYFORTIC 3 3 NEORAL 3 3 PROGRAF 3 3 RAPAMUNE 3 3 SIROLIMUS TACROLIMUS TAMOXIFEN CITRATE ANTIVIRAL/HIV ABACAVIR ABACAVIR/ LAMIVUDINE/ ZIDOVUDINE APTIVUS 2 2 ATRIPLA 2 2 COMBIVIR 3 3 DIDANOSINE DELAYED RELEASE EDURANT 2 2 EMTRIVA 2 2 EPIVIR 3 3 EPZICOM 2 2 GENVOYA 2 2 INTELENCE 2 2 ISENTRESS 2 2 LAMIVUDINE LAMIVUDINE/ ZIDOVUDINE NEVIRAPINE/ DELAYED RELEASE PREZISTA 2 2 RETROVIR 3 3 REYATAZ 2 2 STAVUDINE STRIBILD 2 2 SUSTIVA 2 2 TRIZIVIR 3 3 TRUVADA 2 2 VIDEX EC 3 3 VIRACEPT 2 2 VIRAMUNE/XR 3 3 VIREAD 2 2 ZERIT 3 3 ZIAGEN 3 3 ZIDOVUDINE 13

9 (NON-SPECIALTY BY CONDITION) METOPROLOL TARTRATE OMEGA-3 ACID ETHYL ESTERS ASTHMA/COPD ACCOLATE 3 3 ADVAIR DISKUS 2 2 ADVAIR HFA 2 2 ALBUTEROL SULFATE TABLET/LUTION ATROVENT HFA 2 2 COMBIVENT RESPIMAT 2 2 DULERA 2 2 FLOVENT HFA 2 2 MAXAIR AUTOHALER 3 3 MONTELUKAST DIUM PROAIR HFA 2 2 PROVENTIL HFA 2 2 QVAR 2 2 SINGULAIR 3 3 SPIRIVA 2 2 SYMBICORT 2 2 VENTOLIN HFA 2 2 XOPENEX/ CONCENTRATE 3 3 ZAFIRLUKAST CARDIOVASCULAR DRUGS HIGH BLOOD PRESSURE AMLODIPINE BESYLATE/ BENAZEPRIL HYDROCHLORIDE ATACAND/HCT 3 NC ATENOLOL AVAPRO 3 NC AVALIDE 3 NC AZOR 2 2 BENICAR/HCTZ 2 2 BREVIBLOC 3 3 BYSTOLIC 2 2 CANDESARTAN/HCTZ CARVEDILOL CLONIDINE COZAAR 3 NC DILTIAZEM CD DIOVAN/HCT 3 NC DOXAZOSIN MESYLATE EDARBI 3 NC EDARBYCLOR 3 NC ENALAPRIL MALEATE EXFORGE/HCTZ 3 3 FUROSEMIDE HYDRALAZINE HYDROCHLORO- THIAZIDE HYZAAR 3 NC IRBESARTAN/HCTZ LEVATOL 3 3 LISINOPRIL/HCTZ LOSARTAN/HCTZ METOPROLOL SUCCINATE MEVACOR 3 NC MICARDIS/HCT 3 NC PROPRANOLOL RAMIPRIL SPIRONOLACTONE TELMISARTAN/HCTZ TEVETEN/HCT 3 NC TRIAMTERENE/HCTZ VALSARTAN/HCTZ VERAPAMIL/ER CARDIOVASCULAR DRUGS HIGH CHOLESTEROL ADVICOR 3 NC AGGRENOX 3 3 ALTOPREV 3 NC AMLODIPINE/ ATORVASTATIN ATORVASTATIN CALCIUM CADUET 3 NC CRESTOR 3 NC FENOFIBRATE FENOFIBRIC ACID GEMFIBROZIL LESCOL/XL 3 NC LIPITOR 3 NC LIPTRUZET 3 NC LIVALO 3 NC LOVASTATIN LOVAZA 3 3 MEVACOR 3 NC NIACIN ER PRAVACHOL 3 NC PRAVASTATIN DIUM ROSUVASTATIN SIMCOR 3 NC SIMVASTATIN TRIGLIDE 3 3 VYTORIN 3 NC WELCHOL 2 2 ZETIA 2 2 ZOCOR 3 NC CARDIOVASCULAR DRUGS OTHER CLOPIDOGREL COUMADIN 2 3 DIGOXIN EFFIENT 2 2 ELIQUIS 2 2 ENOXAPARIN DIUM ENTRESTO PA 3 3 IRBIDE MONONITRATE ER NITROSTAT 2 2 PLAVIX 3 3 POTASSIUM CHLORIDE PRADAXA 3 3 WARFARIN XARELTO

10 (NON-SPECIALTY BY CONDITION) TIZANIDINE ROZEREM 3 NC CENTRAL NERVOUS SYSTEM ANXIETY AND DEPRESSION ALPRAZOLAM AMITRIPTYLINE BUPROPION/XL CITALOPRAM CYMBALTA 3 3 DIAZEPAM DULOXETINE EFFEXOR XR 3 3 ESCITALOPRAM OXALATE FLUOXETINE LORAZEPAM PAROXETINE OLEPTRO ER 3 3 PRISTIQ ER 3 3 SERTRALINE TRAZODONE VENLAFAXINE/ER WELLBUTRIN XL 3 3 CENTRAL NERVOUS SYSTEM ATTENTION DEFICIT DIRDER AMPHETAMINE SALT COM DEXTRO- AMPHETAMINE/ AMPHETAMINE SALTS PA PA FOCALIN XR PA 3 3 INTUNIV 3 3 METHYLIN PA 3 3 METHYLPHENIDATE /ER PA STRATTERA 2 2 VYVANSE PA 2 2 CENTRAL NERVOUS SYSTEM MIGRAINE RELPAX 3 3 RIZATRIPTAN SUMATRIPTAN SUCCINATE SUMAVEL 3 3 ZOLMITRIPTAN ZOMIG/ZMT 3 3 CENTRAL NERVOUS SYSTEM OTHER ABILIFY 3 3 BACLOFEN CARIPRODOL CHANTIX 2 2 CYCLOBENZAPRINE DONEPEZIL EQUETRO 3 3 EXELON 3 3 METHOCARBAMOL NDA 3 3 ONDANSETRON/ODT QUETIAPINE FUMARATE RISPERIDONE SEROQUEL XR 2 2 CENTRAL NERVOUS SYSTEM PAIN BUTALBITAL/ ACETAMINOPHEN BUTRANS 3 3 FENTANYL PA HYDROCODONE/ ACETAMINOPHEN HYDROMORPHONE OXYCODONE/ ACETAMINOPHEN OXYCONTIN 3 3 SUXONE FILM 2 2 TRAMADOL/ER CENTRAL NERVOUS SYSTEM SEIZURE DIRDERS CARBIDOPA/ LEVODOPA & ER CLONAZEPAM GABAPENTIN LAMOTRIGINE LEVETIRACETAM LYRICA 2 2 NEUPRO 2 2 PRAMIPEXOLE DIHYDROCHLORIDE ROPINIROLE TOPIRAMATE CENTRAL NERVOUS SYSTEM SLEEP AGENTS AMBIEN/CR 3 NC LUNESTA 3 NC EDLUAR 3 3 ESZOPICLONE INTERMEZZO 3 NC NATA 3 NC TEMAZEPAM ZALEPLON ZOLPIDEM TARTRATE/ER CONTRACEPTIVES TRANSDERMAL* ORTHO EVRA 3 3 CONTRACEPTIVES OTHER NUVARING 2 2 DERMATOLOGY ALCORTIN A 3 3 BETAMETHANE CICLOPIROX CLINDAMYCIN PHOSPHATE CLOBETAL PROPIONATE CLOBEX 3 3 EPIDUO PA 2 2 ERYGEL 3 3 FLUOCINONIDE LIDOCAINE METHYL- PREDNILONE MUPIROCIN NORITATE 3 NC ORACEA 3 3 PREDNINE TRETINOIN PA TRIAMCINOLONE ACETONIDE VOLTAREN GEL *Generic contraceptives are available to female members at no copay. 17

11 (NON-SPECIALTY BY CONDITION) COMBIGAN 2 2 LINZESS 2 2 DIABETES BLOOD GLUCOSE MONITORING ACCU CHEK TEST STRIPS BD ULTRA FINE PEN NEEDLES CONTOUR 3 3 FREESTYLE LANCETS & STRIPS ONE TOUCH ULTRA TEST STRIPS DIABETES DRUGS BYDUREON 2 2 GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER GLIPIZIDE XL GLUCOPHAGE/XR 3 3 GLUMETZA NC NC GLYBURIDE GLYSET 3 3 INVOKANA PA 3 3 JANUMET 2 2 JANUMET XR 2 2 JANUVIA 2 2 JENTADUETO 3 2 KAZANO 3 NC KOMBIGLYZE XR 2 NC METFORMIN/ER METFORMIN ER (generic Glumetza) PA NESINA 3 NC ONGLYZA 2 NC OSENI 3 NC PIOGLITAZONE TRADJENTA 3 2 VICTOZA 2 PAK & 3 PAK DIABETES INSULIN 2 2 APIDRA/LOSTAR 2 NC BASAGLAR 2 2 HUMULIN/ KWIKPEN (EXCEPT HUMULIN U-500 CONCENTRATE) HUMULIN U-500 CONCENTRATE HUMALOG/ MIX/ KWIKPEN 2 NC NC LANTUS 3 3 LANTUS LOSTAR 3 3 NOVOLIN 2 2 NOVOLOG/ MIX 2 2 NOVOLOG MIX FLEXPEN EYE/EAR 2 2 ALPHAGAN P (0.15%) 3 3 AZOPT 2 2 BRIMONIDINE TARTRATE CIPRODEX 2 2 DORZOLAMIDE/ TIMOLOL MALEATE DUREZOL 2 2 ERYTHROMYCIN LATANOPROST LOTEMAX 2 2 LUMIGAN 2 NC PATADAY 3 3 PATANOL 3 3 PREDNILONE ACETATE RESCULA 3 3 RESTASIS 2 2 TIMOLOL MALEATE TRAVOPROST TRAVATAN Z 2 2 VIGAMOX 2 2 ZIOPTAN 3 3 GASTROINTESTINAL DRUGS ACIPHEX 3 NC AMITIZA 3 3 ASACOL HD 2 2 DEXILANT 3 NC DICYCLOMINE EMEPRAZOLE FIRST LANPRAZOLE 3 NC FIRST OMEPRAZOLE 3 NC LANPRAZOLE LIALDA 2 2 MOVIPREP 2 2 OMEPRAZOLE OMPERAZOLE/ DIUM BICARNATE POLYETHYLENE GLYCOL 3350 PANTOPRAZOLE DIUM PREVACID 3 NC NEXIUM 3 NC PRILOSEC 3 NC PROTONIX 3 NC RABEPRAZOLE RANITIDINE SUCRALFATE SUPREP WEL PREP KIT 2 2 ZEGERID 3 NC HORMONE REPLACEMENT ANDRODERM PA 2 2 ANDROGEL PA 2 NC AVEED PA 3 3 AXIRON PA 3 3 CALCITRIOL DEPO TESTOSTERONE (200mg) PA 3 3 ESTRACE ORAL 3 3 ESTRADIOL EVISTA 3 3 FORTESTA PA

12 (NON-SPECIALTY BY CONDITION) TRI PREVIFEM OTREXUP PA 3 3 TRI SPRINTEC OSTEOPOROSIS/NE DISEASES PENNSAID NC NC RASUVO PA 3 3 MINIVELLE 3 3 RELISTOR PA 3 3 ACTONEL 3 3 VIMOVO NC NC NATESTO PA 3 NC ULORIC 2 2 ALENDRONATE THYROID MEDICATIONS NILANDRON 3 3 ORAL CONTRACEPTIVES BIPHASIC* IBANDRONATE ARMOUR THYROID 3 3 PREFEST 3 3 MIRCETTE 3 3 RISEDRONATE LEVOTHYROXINE PREMARIN 2 2 NECON 3 3 PRIASIS SYNTHROID 2 2 PREMPRO 2 2 ORAL CONTRACEPTIVES MONOPHASIC* ACITRETIN UROLOGIC DIRDERS PROGESTERONE PA STRIANT PA 3 3 TESTIM PA 3 NC TESTOSTERONE GEL PA TESTOSTERONE CYPIONATE PA VAGIFEM 2 2 VIVELLE DOT 2 2 VOGELXO PA 3 NC INFLAMMATION - CORTICOSTEROIDS CORTEF 3 NC DELTANE 1 NC MEDROL 3 NC MILLIPRED 3 NC OLUX/OLUX E NC NC ORAPRED ODT 3 NC PREDNINE RAYOS PA 3 NC MISCELLANEOUS ALLOPURINOL APRI AVIANE CRYSELLE DEGEN 3 3 GENERESS FE 3 3 GIANVI JUNEL/FE LOESTRIN/FE 3 3 LORYNA MICROGESTIN/FE MINASTRIN 24 FE 3 3 MONONESSA ORTHO NOVUM 3 3 SPRINTEC ZOVIA ORAL CONTRACEPTIVES TRIPHASIC* LO LOESTRIN FE 3 3 ORTHO TRI CYCLEN 3 3 ORTHO TRI CYCLEN LO 3 3 CALCIPOTRIENE- BETAMETHANE RIATANE NC NC TACLONEX NC NC RHEUMATOLOGY ANAPROX DS 3 NC ARTHROTEC 3 NC CELEBREX 3 3 CELECOXIB DICLOFENAC DUEXIS NC NC FELDENE 3 NC IBUPROFEN MELOXICAM METHOTREXATE INJ PA NAPRELAN 3 NC NAPROSYN 3 NC NAPROXEN AVODART 3 3 DETROL 3 NC ENABLEX 3 3 FINASTERIDE GELNIQUE 3 3 JALYN 3 3 MYRBETRIQ 2 3 OXYBUTYNIN/ER OXYTROL 3 NC PHENAZOPYRIDINE RAPAFLO 2 2 TAMSULOSIN TOLTERODINE/ER TOVIAZ 2 NC TROSPIUM/ER VESICARE 2 2 COLCRYS 3 3 TRINESSA 20 *Generic Contraceptives are available to female members at no copay. 21

13 (ALPHABETIC INCLUDING SPECIALTY) Bold Type means there is a generic version for this drug. Italic Type means this is a specialty drug. 22 ABACAVIR ABACAVIR/ LAMIVUDINE/ ZIDOVUDINE ABILIFY 3 3 ABRAXANE 4 4 ACCOLATE 3 3 ACCU CHEK TEST STRIPS ACETAMINOPHEN/ CODEINE 2 2 ACIPHEX 3 NC ACITRETIN ACTEMRA PA 5 5 ACTHAR HP PA 5 5 ACTIMMUNE PA 4 4 ACTONEL 3 3 ADCETRIS PA 4 4 ADCIRCA PA 5 5 ADEFOVIR 4 4 ADEMPAS PA 5 5 ADRIAMYCIN PFS 4 4 ADRIAMYCIN RDF 4 4 ADRUCIL 4 4 ADVAIR DISKUS 2 2 ADVAIR HFA 2 2 ADVATE/H/L/M/SH/UH 4 4 ADVICOR 3 NC AFINITOR PA 4 4 AFINITOR DISPERZ TAB PA 4 4 AGGRENOX 3 3 ALBUTEROL SULFATE TABLET/ LUTION ALCORTIN A 3 3 ALDURAZYME PA 4 4 ALENDRONATE ALFERON N PA 4 4 ALIMTA 4 4 ALKERAN INJ 5 5 ALKERAN TAB 4 4 ALLOPURINOL ALPHAGAN P (0.15%) 3 3 ALPHANATE 4 4 ALPHANINE SD 4 4 ALPRAZOLAM ALPROLIX 4 4 ALTOPREV 3 NC AMBIEN/CR 3 NC AMEVIVE 4 4 AMIFOSTINE 4 4 AMITIZA 3 3 AMITRIPTYLINE AMLODIPINE AMLODIPINE/ ASTORVASTATIN AMLODIPINE BESYLATE/ BENAZEPRIL HYDROCHLORIDE AMOXICILLIN AMOXICILLIN/ CLAVULANATE POTASSIUM AMPHETAMINE SALT COM PA AMPYRA PA 5 5 ANAPROX DS 3 NC ANASTROZOLE ANDRODERM PA 2 2 ANDROGEL PA 2 NC APIDRA/LOSTAR 2 NC APOKYN 4 4 APRI APTIVUS 2 2 ARALAST /NP PA 4 4 ARANESP PA 4 4 ARCALYST PA 4 4 AREDIA 5 5 ARMOUR THYROID 3 3 ARRANON 4 4 ARTHROTEC 3 NC ARZERRA PA 4 4 ASACOL HD 2 2 ASTAGRAF XL 2 2 ASTEPRO 3 3 ATACAND/HCT 3 NC ATENOLOL ATORVASTATIN CALCIUM ATRIPLA 2 2 ATROVENT HFA 2 2 AUBAGIO PA 5 5 AVALIDE 3 NC AVAPRO 3 NC AVASTIN PA 4 4 AVEED PA 3 3 AVIANE AVODART 3 3 AVONEX PA 4 4 AXIRON PA 3 3 AZACITIDINE 4 4 AZATHIOPRINE AZELASTINE AZITHROMYCIN AZOPT 2 2 AZOR 2 2 BACLOFEN BARACLUDE INJ 4 4 BARACLUDE TABS 5 5 BASAGLAR 2 2 BD ULTRA FINE PEN NEEDLES 2 2 BEBULIN 4 4 BECONASE AQ 3 NC BELEODAQ PA 4 4 BENAZEPRIL BENEFIX

14 (ALPHABETIC INCLUDING SPECIALTY) CINRYZE PA 4 4 COSMEGEN 5 5 CIPRODEX 2 2 CIPROFLOXACIN COUMADIN 2 3 COZAAR 3 NC BENICAR/HCTZ 2 2 BENLYSTA PA 4 4 BENZONATATE BERINERT PA 4 4 BETASERON PA 5 5 BETHKIS 4 4 BEXAROTENE 4 4 BICNU 4 4 BIVIGAM PA 4 4 BLEOMYCIN 4 4 BLINCYTO PA 4 4 SULIF PA 4 4 TOX PA 4 4 BRAVELLE PA 4 4 BREVIBLOC 3 3 BRIMONIDINE TARTRATE BUDENIDE NASAL SPRAY BUPHENYL PWDR PA 5 5 BUPHENYL TAB PA 4 4 BUPROPION/XL BUTALBITAL/ ACETAMINOPHEN BUTRANS 3 3 BYDUREON 2 2 BYSTOLIC 2 2 CADUET 3 NC CALCIPOTRIENE- BETAMETHANE CALCITRIOL CALCIUM FOLINATE 5 5 CAMPTOSAR 5 5 CANDESARTAN/HCTZ CAPECITABINE 4 4 CARBIDOPA/ LEVODOPA & ER CARPLATIN 4 4 CARIMUNE NF PA 4 4 CARIPRODOL CARVEDILOL CELEBREX 3 3 CELECOXIB CELLCEPT 3 3 CEPHALEXIN CEPROTIN PA 4 4 CERDELGA PA 4 4 CEREDASE 4 4 CEREZYME PA 4 4 CETIRIZINE LUTION 1 NC CETROTIDE PA 4 4 CHANTIX 2 2 CHORIONIC GONADOTROPIN PA 4 4 CICLOPIROX CIMZIA PA 5 5 CISPLATIN 4 4 CITALOPRAM CLADRIBINE 4 4 CLARINEX 3 NC CLARINEX-D 3 NC CLINDAMYCIN PHOSPHATE CLOBETAL PROPIONATE CLOBEX 3 3 CLOLAR 4 4 CLONAZEPAM CLONIDINE CLOPIDOGREL CLOTRIMAZOLE/ BETAMETHANE COLCRYS 3 3 COMBIGAN 2 2 COMBIVENT RESPIMAT 2 2 COMBIVIR 3 3 CONTOUR 3 3 COPAXONE 40MG PA 4 4 COPAXONE 20MG PA 5 5 COPEGUS PA 5 5 CORIFACT 4 4 CORTEF 3 NC CORTICOTROPIN PA 4 4 COSENTYX PA 5 5 CRESTOR 3 NC CRYSELLE CYCLOBENZAPRINE CYCLOPHOSPHAMIDE 4 4 CYCLOSPORINE INJ 4 4 CYMBALTA 3 3 CYSTAGON 4 4 CYTARABINE 4 4 CYTOGAM 4 4 CYTOVENE 5 5 DACARBAZINE 4 4 DACOGEN 5 5 DACTINOMYCIN 4 4 DAKLINZA PA 5 5 DAUNORUBICIN HCL 4 4 DAUNOXOME 4 4 DECITABINE 4 4 DEFEROXAMINE 4 4 DELTANE 1 NC DEPO TESTOSTERONE (200mg) PA 3 3 DEPOCYT 4 4 DESFERAL 5 5 DESLORATADINE 1 NC DEGEN 3 3 DETROL 3 NC 24 25

15 (ALPHABETIC INCLUDING SPECIALTY) EPIRUBICIN 4 4 FARYDAK PA 5 5 EPIVIR 3 3 EPOGEN PA 5 5 FASLODEX 4 4 FEIBA 4 4 DEXILANT 3 NC DYMISTA 3 NC EPZICOM 2 2 FELDENE 3 NC DEXRAZOXANE 4 4 DYSPORT PA 4 4 EQUETRO 3 3 FENOFIBRATE DEXTRO- AMPHETAMINE/ AMPHETAMINE SALTS PA DIAZEPAM DICLOFENAC DICYCLOMINE DIDANOSINE DELAYRED RELEASE DIGOXIN DILTIAZEM CD DIOVAN/HCT 3 NC DOCETAXEL 4 4 DOFETILIDE 4 4 DONEPEZIL DORZOLAMIDE/ TIMOLOL MALEATE DOXAZOSIN MESYLATE DOXIL 5 5 DOXORUBICIN HCL 4 4 DOXYCYCLINE HYCLATE DTIC-Dome 200 mg 4 4 DUEXIS NC NC DULERA 2 2 DULOXETINE DUREZOL 2 2 EDARBI 3 NC EDARBICLOR 3 NC EDLUAR 3 3 EDURANT 2 2 EFFEXOR XR 3 3 EFFIENT 2 2 EGRIFTA PA 4 4 ELAPRASE PA 4 4 ELIGARD PA 4 4 ELIQUIS 2 2 ELITEK 4 4 ELLENCE 5 5 ELOCTATE 4 4 ELOXATIN 5 5 ELSPAR 4 4 EMTRIVA 2 2 ENABLEX 3 3 ENALAPRIL MALEATE ENBREL PA 4 4 ENOXAPARIN DIUM ENTECAVIR 4 4 ENTYVIO PA 5 5 EPIDUO PA 2 2 EPIPEN 2 PAK 2 2 ERBITUX 4 4 ERIVEDGE PA 4 4 ERTACZO PA 3 NC ERYGEL 3 3 ERYTHROMYCIN ESBRIET PA 4 4 ESCITALOPRAM OXALATE EMEPRAZOLE ESTRACE ORAL 3 3 ESTRADIOL ESZOPICLONE ETHINYL ESTRAD ETHYOL 5 5 ETOPOPHOS 4 4 ETOPOSIDE 4 4 EUFLEXXA PA 5 5 EVISTA 3 3 EXELDERM PA 3 3 EXELON 3 3 EXFORGE/HCTZ 3 3 EXJADE PA 4 4 EXTAVIA PA 4 4 EYLEA 4 4 FABRAZYME PA 4 4 FENOFIBRIC ACID FENTANYL PA FINASTERIDE FIRAZYR PA 4 4 FIRMAGON 4 4 FIRST LANPRAZOLE 3 NC FIRST OMEPRAZOLE 3 NC FLEGAMMA/DIF PA 4 4 FLOVENT HFA 2 2 FLOXURIDINE 4 4 FLUCONAZOLE FLUDARABINE 4 4 FLUDARA 4 4 FLUNILIDE SPRAY FLUOCINONIDE FLUOROURACIL 4 4 FLUOXETINE FLUTICANE SPRAY FOCALIN XR PA 3 3 FOLLISTIM/AQ PA 4 4 FOLOTYN 4 4 FORTEO 4 4 FORTESTA PA 3 3 FREESTYLE LANCETS & STRIPS

16 (ALPHABETIC INCLUDING SPECIALTY) 28 FUDR 4 4 FUROSEMIDE FUSILEV 4 4 FUZEON 4 4 GABAPENTIN GAMASTAN S/D PA 4 4 GAMMAGARD PA 4 4 GAMMAKED PA 4 4 GAMMAPLEX PA 4 4 GAMUNEX PA 4 4 GAMUNEX-C PA 4 4 GANCICLOVIR 4 4 GANIRELIX ACETATE PA 4 4 GARDASIL 4 4 GATTEX PA 4 4 GAZYVA PA 4 4 GELNIQUE 3 3 GEL-ONE PA 4 4 GEMCITABINE 4 4 GEMFIBROZIL GEMZAR 5 5 GENERESS FE 3 3 GENOTROPIN PA 5 5 GENVOYA 2 2 GIANVI GILENYA PA 4 4 GLASSIA 4 4 GLATOPA PA 4 4 GLEEVEC PA 5 5 GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER GLIPIZIDE XL GLUCOPHAGE/XR 3 3 GLUMETZA NC NC GLYBURIDE GLYSET 3 3 GONAL-F PA 5 5 GONAL-F RFF PA 5 5 GRANIX PA 4 4 HALAVEN PA 4 4 HARVONI PA 4 4 HELIXATE FS 4 4 HEMOFIL M 4 4 HEPAGAM B 4 4 HEPSERA 5 5 HERCEPTIN PA 4 4 HIZENTRA PA 4 4 HUMALOG/ MIX/ KWIKPEN 2 NC HUMATE-P 4 4 HUMATROPE PA 4 4 HUMIRA PA 4 4 HUMULIN/ KWIKPEN (EXCEPT HUMULIN U-500 CONCENTRATE) HUMULIN U-500 CONCENTRATE 2 NC 2 2 HYALGAN PA 4 4 HYCAMTIN CAP 4 4 HYCAMTIN INJ 5 5 HYDRALAZINE HYDROCHLORO- THIAZIDE HYDROCODONE/ ACETAMINOPHEN HYDROMORPHONE HYPERHEP B 4 4 HYPERRHO S/D 4 4 HYQVIA PA 4 4 HYZAAR 3 NC IBANDRONATE IBRANCE PA 4 4 IBUPROFEN IDAMYCIN PFS 5 5 IDARUBICIN HCL 4 4 IFEX 5 5 IFOSFAMIDE 4 4 ILARIS PA 4 4 IMATINIB PA 4 4 IMPLANON 4 4 INCRELEX PA 4 4 INFERGEN PA 4 4 INLYTA PA 4 4 INTELENCE 2 2 INTERMEZZO 3 NC INTRON-A PA 4 4 INTUNIV 3 3 INVOKANA PA 3 3 IRBESARTAN/HCTZ IRESSA PA 5 5 IRINOTECAN 4 4 ISENTRESS 2 2 IRBIDE MONONITRATE ER ISTODAX PA 4 4 IXEMPRA 4 4 IXINITY 5 5 JADENU PA 5 5 JAKAFI PA 4 4 JALYN 3 3 JANUMET 2 2 JANUMET XR 2 2 JANUVIA 2 2 JENTADUETO 3 2 JEVTANA PA 4 4 JUBLIA PA 3 NC JUNEL/FE KADCYLA PA 4 4 KALBITOR PA 4 4 KALYDECO PA 4 4 KAZANO 3 NC KEPIVANCE PA 4 4 KERYDIN PA 3 NC KETOCONAZOLE PA 29

17 (ALPHABETIC INCLUDING SPECIALTY) LUZU PA 3 NC MICARDIS/HCT 3 NC KEYTRUDA PA 4 4 KINERET PA 5 5 KOATE-DVI 4 4 KOGENATE FS 4 4 KOMBIGLYZE XR 2 NC KRYSTEXXA PA 5 5 KUVAN PA 4 4 KYNAMRO PA 4 4 KYPROLIS PA 4 4 LAMIVUDINE LAMIVUDINE/ ZIDOVUDINE LAMOTRIGINE LANPRAZOLE LANTUS 3 3 LANTUS LOSTAR 3 3 LATANOPROST LEMTRADA PA 5 5 LESCOL/XL 3 NC LETAIRIS PA 4 4 LETROZOLE LEUCOVORIN LEUKINE PA 5 5 LEUPROLIDE PA 4 4 LEVATOL 3 3 LEVETIRACETAM LEVOCETIRIZINE 1 NC LEVOFLOXACIN LEVOTHYROXINE LIALDA 2 2 LIDOCAINE LINZESS 2 2 LIPITOR 3 NC LIPODOX 4 4 LIPTRUZET 3 NC LIVALO 3 NC LISINOPRIL/HCTZ LO LOESTRIN FE 3 3 LOESTRIN/FE 3 3 LOPROX 3 NC LORAZEPAM LORYNA LOSARTAN/HCTZ LOTEMAX 2 2 LOTRINE 3 NC LOVASTATIN LOVAZA 3 3 LUCENTIS 4 4 LUMIGAN 2 NC LUMIZYME PA 4 4 LUNESTA 3 NC LUPANETA PACK 4 4 LUPRON DEPOT/ DEPOT-PED PA 4 4 LYNPARZA PA 4 4 LYRICA 2 2 MACUGEN 5 5 MAKENA 4 4 MAXAIR AUTOHALER 3 3 MEDROL 3 NC MEGESTROL ACETATE MEKINIST PA 4 4 MELOXICAM MELPHALAN HCL 4 4 MENOPUR PA 4 4 MENTAX 3 NC MESNA 4 4 MESNEX INJ 5 5 MESNEX TAB 4 4 METFORMIN/ER METFORMIN ER (generic Glumetza) PA METHOCARBAMOL METHOTREXATE INJ PA METHOTREXATE TABS METHYLIN PA 3 3 METHYLPHENIDATE/ER PA METHYL- PREDNILONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METRONIDAZOLE MEVACOR 3 NC MICRHOGAM 4 4 MICROGESTIN/FE MILLIPRED 3 NC MINASTRIN 24 FE 3 3 MINIVELLE 3 3 MIRCETTE 3 3 MIRENA 4 4 MITOMYCIN 4 4 MITOXANTRONE 4 4 MONONESSA MONONINE 4 4 MONOVISC PA 5 5 MONTELUKAST DIUM MOVIPREP 2 2 MOZOBIL 4 4 MUPIROCIN MUSTARGEN 4 4 MYCOPHENOLATE MOFETIL MYFORTIC 3 3 MYOBLOC PA 4 4 MYOZYME PA 4 4 MYRBETRIQ 2 3 NAFTIFINE NAFTIN 2 NC NABI-HB 4 4 NAGLAZYME PA 4 4 NDA 3 3 NAPRELAN 3 NC 30 31

18 (ALPHABETIC INCLUDING SPECIALTY) OPDIVO PA 4 4 PATANOL 3 3 OPSUMIT PA 5 5 ORACEA 3 3 PEGASYS PA 4 4 PEGASYS PROCLICK PA 4 4 NAPROSYN 3 NC NAPROXEN NASACORT AQ 3 NC NANEX 3 NC NATESTO PA 3 NC NAVELBINE 5 5 NECON 3 3 NEORAL 3 3 NEOSAR FOR INJECTION 4 4 NESINA 3 NC NOVOLOG MIX FLEXPEN 2 2 NOVOLOG/ MIX 2 2 NOVOSEVEN RT 4 4 NPLATE PA 4 4 NUCALA PA 5 5 NULOJIX 4 4 NUTROPIN PA 5 5 NUVARING 2 2 OCTAGAM PA 4 4 OCTREOTIDE 4 4 ORALAIR PA 5 5 ORAPRED ODT 3 NC ORENCIA PA 5 5 ORENITRAM PA 4 4 ORKAMBI PA 4 4 ORTHO EVRA 3 3 ORTHO NOVUM 3 3 ORTHO TRI CYCLEN 3 3 ORTHO TRI CYCLEN LO 3 3 ORTHOVISC PA 5 5 PEG-INTRON PA 4 4 PEGINTRON REDIPEN PA 4 4 PENNSAID NC NC PERJETA PA 4 4 PHENAZOPYRIDINE PHOTOFRIN 4 4 PIOGLITAZONE PLAVIX 3 3 PLEGRIDY/PEN PA 5 5 POLYETHYLENE GLYCOL 3350 NEULASTA PA 5 5 OFEV PA 4 4 OSENI 3 NC POMALYST PA 4 4 NEUMEGA 4 4 NEUPOGEN PA 5 5 NEUPRO 2 2 NEVIRAPINE/ DELAYED RELEASE NEXAVAR PA 4 4 NEXIUM 3 NC NIACIN ER NILANDRON 3 3 NIPENT 4 4 OLEPTRO ER 3 3 OLUX / OLUX E NC NC OLYSIO PA 5 5 OMEGA-3 ACID ETHYL ESTERS OMEPRAZOLE OMNARIS 2 NC OMNITROPE PA 5 5 OMPERAZOLE/ DIUM BICARNATE OTEZLA PA 5 5 OTREXUP PA 3 3 OVIDREL PA 4 4 OXALIPLATIN 4 4 OXISTAT PA 3 NC OXYBUTYNIN/ER OXYCODONE/ ACETAMINOPHEN OXYCONTIN 3 3 OXYTROL 3 NC POTASSIUM CHLORIDE PRADAXA 3 3 PRALUENT PA 5 5 PRAMIPEXOLE DIHYDROCHLORIDE PRAVACHOL 3 NC PRAVASTATIN DIUM PREDNILONE ACETATE PREFEST 3 3 NITROSTAT 2 2 ONCASPAR 4 4 PACLITAXEL 4 4 PREGNYL PA 4 4 NORDITROPIN PA 4 4 ONDANSETRON/ ODT PAMIDRONATE 4 4 PREMARIN 2 2 NORTHERA PA 5 5 NORITATE 3 NC NOVAREL PA 4 4 NOVOLIN 2 2 ONE TOUCH ULTRA TEST STRIPS 2 2 ONGLYZA 2 NC ONTAK 4 4 PANTOPRAZOLE DIUM PAROXETINE PATADAY 3 3 PREMPRO 2 2 PREVACID 3 NC PREZISTA 2 2 PRILOSEC 3 NC 32 33

19 (ALPHABETIC INCLUDING SPECIALTY) RIBAVIRIN PA 4 4 MATULINE DEPOT PA 4 4 RISEDRONATE RISPERIDONE MAVERT 4 4 NATA 3 NC PRISTIQ ER 3 3 RAVICTI PA 4 4 RITUXAN PA 5 5 RIATANE NC NC PRIVIGEN PA 4 4 RAYOS PA 3 NC RIXUBIS 4 4 VALDI PA 4 4 PROAIR HFA 2 2 REBETOL PA 4 4 RIZATRIPTAN SPIRIVA 2 2 PROCRIT PA 4 4 REBIF PA 5 5 ROPINIROLE SPIRONOLACTONE PROFILNINE SD 4 4 REBIF REBIDOSE PA 5 5 ROSUVASTATIN SPRINTEC PROGESTERONE PA RECLAST 5 5 ROZEREM 3 NC SPRYCEL 4 4 PROGRAF 3 3 RECOMBINATE 4 4 SABRIL PA 5 5 STAVUDINE PROLEUKIN 4 4 RELISTOR PA 3 3 SAIZEN PA 5 5 STELARA PA 5 5 PROLIA PA 4 4 RELPAX 3 3 SAMSCA 4 4 STIMATE 4 4 PROMACTA PA 4 4 REMICADE PA 5 5 SANDIMMUNE 3 3 STIVARGA PA 4 4 PROMETHAZINE HCL REMODULIN PA 5 5 SANDOSTATIN 3 3 STRATTERA 2 2 PROMETHAZINE/ CODEINE 34 PROPRANOLOL PROTONIX 3 NC PROVENTIL HFA 2 2 PULMOZYME PA 4 4 QNASL 3 NC QUADRAMET 4 4 QUETIAPINE FUMARATE QVAR 2 2 RABEPRAZOLE RAMIPRIL RANITIDINE RAPAFLO 2 2 RAPAMUNE 3 3 RASUVO PA 3 3 REPATHA PA 4 4 REPRONEX PA 5 5 RESCULA 3 3 RESTASIS 2 2 RETROVIR 3 3 REVATIO PA 5 5 REVLIMID PA 4 4 REYATAZ 2 2 RHINOCORT AQUA 3 NC RHOGAM 4 4 RHOGAM PLUS 4 4 RHOPHYLAC 4 4 RIASTAP 4 4 RIBAPAK PA 4 4 RIBASPHERE PA 4 4 RIBATAB PA 4 4 SANDOSTATIN LAR 4 4 SENSIPAR 4 4 SEROQUEL XR 2 2 SEROSTIM PA 4 4 SERTRALINE SILDENAFIL PA 4 4 SIMCOR 3 NC SIMPONI/ARIA PA 5 5 SIMVASTATIN SINGULAIR 3 3 SIROLIMUS SKYLA 4 4 DIUM PHENYLBUTYRATE 4 4 LESTA 4 4 LIRIS PA 4 4 STRIANT PA 3 3 STRIBILD 2 2 SUXONE FILM 2 2 SUCRALFATE SULFAME- THOXAZOLE/ TRIMETHOPRIM SUMATRIPTAN SUCCINATE SUMAVEL 3 3 SUPARTZ PA 4 4 SUPPRELIN LA PA 4 4 SUPREP WEL PREP KIT 2 2 SUSTIVA 2 2 SUTENT 4 4 SYLATRON PA 4 4 SYMBICORT

20 (ALPHABETIC INCLUDING SPECIALTY) TRETTEN 4 4 VENTAVIS PA 4 4 SYNAGIS PA 4 4 SYNTHROID 2 2 SYNVISC PA 5 5 SYNVISC ONE PA 5 5 TACLONEX NC NC TACROLIMUS TAFINLAR PA 4 4 TAMIFLU 2 2 TAMOXIFEN CITRATE TAMSULOSIN TARCEVA PA 4 4 TARGRETIN CAPS PA 5 5 TASIGNA PA 4 4 TAXOTERE 5 5 TECFIDERA PA 4 4 TECHNIVIE PA 5 5 TELMISARTAN/HCTZ TEMAZEPAM TEMODAR 5 5 TEMOZOLOMIDE 4 4 TESTIM PA 3 NC TESTOSTERONE CYPIONATE PA TESTOSTERONE GEL PA TETRABENAZINE 4 4 TEVETEN/HCT 3 NC THALOMID 4 4 THERACYS 4 4 THIOTEPA 4 4 THYROGEN 4 4 TICE BCG 4 4 TIKOSYN 5 5 TIMOLOL MALEATE TIZANIDINE TOBI 5 5 TOBI PODHALER 4 4 TOBRAMYCIN INH LN 4 4 TOLTERODINE/ER TOPIRAMATE TOPOSAR 5 5 TOPOTECAN 4 4 TORISEL 4 4 TOTECT 5 5 TOVIAZ 2 NC TRACLEER PA 4 4 TRADJENTA 3 2 TRAMADOL/ER TRAVATAN Z 2 2 TRAVOPROST TRAZODONE TREANDA PA 4 4 TRELSTAR PA 4 4 TRETINOIN PA TRI PREVIFEM TRI SPRINTEC TRIAMCINOLONE ACETONIDE TRIAMCINOLONE SPRAY TRIAMTERENE/HCTZ TRIGLIDE 3 3 TRINESSA TRISENOX 4 4 TRIZIVIR 3 3 TROSPIUM/ER TRUVADA 2 2 TYKERB PA 4 4 TYSABRI PA 5 5 TYVA PA 5 5 TYZEKA 4 4 ULORIC 2 2 UVADEX 4 4 VAGIFEM 2 2 VALACYCLOVIR VALSARTAN/HCTZ VALSTAR 4 4 VALTREX 3 3 VANTAS PA 4 4 VARIZIG 4 4 VECTIBIX 4 4 VELCADE PA 4 4 VELETRI PA 5 5 VENLAFAXINE/ER VENTOLIN HFA 2 2 VERAMYST 2 NC VERAPAMIL/ER VESICARE 2 2 VICTOZA 2 PAK & 3 PAK 2 2 VIDAZA 5 5 VIDEX EC 3 3 VIGAMOX 2 2 VIMIZIM PA 4 4 VINBLASTINE 4 4 VINCASAR PFS 5 5 VINCRISTINE 4 4 VINORELBINE 4 4 VIMOVO NC NC VIRACEPT 2 2 VIRAMUNE/XR 3 3 VIREAD 2 2 VISTOGARD 4 4 VISUDYNE 4 4 VIVAGLOBUIN PA 4 4 VIVELLE DOT 2 2 VIVITROL 4 4 VOGELXO PA 3 NC VOLTAREN GEL 2 2 VOTRIENT PA 4 4 VPRIV PA 4 4 VUSION 3 NC VYTORIN 3 NC 36 37

21 (ALPHABETIC INCLUDING SPECIALTY) MANAGED NOT COVERED DRUG LIST BASIC OPTION VYVANSE PA 2 2 WARFARIN WELCHOL 2 2 WELLBUTRIN XL 3 3 WILATE 4 4 WINRHO SDF 4 4 XALKORI PA 4 4 XARELTO 2 2 XELJANZ PA 5 5 XELODA 5 5 XENAZINE PA 5 5 XEOMIN PA 4 4 XGEVA PA 4 4 XIAFLEX PA 4 4 XOLAIR PA 4 4 XOLEGEL NC NC XOPENEX/ CONCENTRATE 3 3 XTANDI PA 4 4 ZARXIO PA 4 4 ZEGERID 3 NC ZELRAF PA 4 4 ZEMAIRA 4 4 ZERIT 3 3 ZETIA 2 2 ZETONNA 3 NC ZIAGEN 3 3 ZIDOVUDINE ZINECARD 5 5 ZIOPTAN 3 3 ZOCOR 3 NC ZOLADEX PA 4 4 ZOLEDRONIC ACID 4 4 ZOLINZA PA 4 4 ZOLMITRIPTAN ZOLPIDEM TARTRATE & ER ZOMACTON PA 5 5 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 NASAL STEROIDS ALLERGIES LESS SEDATING ANTIHISTAMINES DRUG NOT COVERED IN 2017 FOR BASIC OPTION COVERED OPTIONS** BECONASE AQ, DYMISTA, NANEX, NASACORT AQ, OMNARIS, QNASL, RHINOCORT AQUA, VERAMYST, ZETONNA cetirizine solution, desloratadine, levocetirizine, CLARINEX, CLARINEX-D, XYZAL budesonide spray, flunisolide spray, fluticasone spray, triamcinolone spray montelukast, zafirlukast, ACCOLATE, SINGULAIR DERMATOLOGY - ROSACEA NORITATE doxycycline (except 20mg) metronidazole cream/gel/ lotion, sulfacetamide/sulfur, FINACEA, METROCREAM, METROGEL, METROLOTION, MIRVA, ORACEA, OLANTRA DIABETES - BIGUANIDES GLUMETZA metformin ER XYNTHA 4 4 XYNTHA LOFUSE 4 4 XYZAL 3 NC YERVOY PA 4 4 ZAFIRLUKAST ZALEPLON ZALTRAP PA 4 4 ZANOSAR 4 4 ZOMETA 5 5 ZOMIG/ZMT 3 3 ZORBTIVE PA 4 4 ZORTRESS 4 4 ZOVIRAX 3 3 ZYKADIA PA 4 4 ZYTIGA PA 4 4 ZYVOX 3 3 DIABETES DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS DIABETES DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS NESINA, ONGLYZA KAZANO, KOMBIGLYZE XR, OSENI JANUVIA, TRADJENTA JANUMET, JANUMET XR, JENTADUETO CONTINUED ON NEXT PAGE 38 39

22 MANAGED NOT COVERED DRUG LIST BASIC OPTION CATEGORY* DRUG CLASS DIABETES INSULINS FUNGAL INFECTIONS GASTROINTESTINAL AGENTS PROTON PUMP INHIBITORS MANAGED NOT COVERED (NC) DRUGS APIDRA/LOSTAR HUMALOG COVERED OPTIONS** 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 ERTACZO, JUBLIA, KERYDIN, LOPROX, LUZU, MENTAX, NAFTIN, OXISTAT, VUSION, XOLEGEL, LOTRINE ACIPHEX, DEXILANT, FIRST-LANPRAZOLE, FIRST-OMEPRAZOLE, NEXIUM, PREVACID, PRILOSEC, PROTONIX, ZEGERID ciclopirox, clotrimazole, clotrimazole/ betamethasone, econazole, ketoconazole, naftifine, nystatin, terbinafine, ECOZA, EXELDERM, LAMISIL esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate, pantoprazole, rabeprazole CATEGORY* DRUG CLASS HIGH CHOLESTEROL OVERACTIVE BLADDER/ INCONTINENCE URINARY ANTISPASMODICS PAIN AND INFLAMMATION - CORTICOSTEROIDS PAIN AND INFLAMMATION NON STEROIDAL ANTI-INFLAMMATORIES (NSAIDS) PAIN AND INFLAMMATION NON STEROIDAL ANTI-INFLAMMATORIES (NSAIDS) COMBINATIONS MANAGED NOT COVERED (NC) DRUGS ADVICOR, ALTOPREV, CADUET, CRESTOR, LESCOL/ XL, LIPITOR, LIPTRUZET, LIVALO, MEVACOR, PRAVACHOL, SIMCOR, VYTORIN, ZOCOR DETROL, OXYTROL, TOVIAZ CORTEF, DELTANE, MEDROL, MILLIPRED, ORAPRED ODT, RAYOS ANAPROX DS, FELDENE, NAPRELAN, NAPROSYN, PENNSAID ARTHROTEC, DUEXIS, VIMOVO COVERED OPTIONS** amlodipine-atorvastatin, atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, ENABLEX, GELNIQUE, MYRBETRIQ, VESICARE cortisone, dexamethasone, fludrocortisone, hydrocortisone, methylprednisolone, prednisone choline magnesium trisalicylate, diclofenac DR/ER, diclofenac gel/soln, etodolac/er, flurbiprofen, ibuprofen, indomethacin ER, ketoprofen/ ER, meloxicam, nabumetone, naproxen/ ER, oxaprozin, piroxicam, sulindac, VOLTAREN GEL diclofenac/ misoprostol, ibuprofen, famotidine, ranitidine, naproxen, esomeprazole GLAUCOMA PROSTAGLANDIN ANALOGS HIGH BLOOD PRESSURE ANGIOTENSIN II RECEPTOR BLOCKERS HIGH BLOOD PRESSURE ANGIOTENSIN II RECEPTOR BLOCKER / DIURETIC COMBINATIONS LUMIGAN ATACAND, AVAPRO, COZAAR, DIOVAN, EDARBI, MICARDIS,TEVETEN ATACAND HCT, AVALIDE, HYZAAR, DIOVAN HCT, EDARBYCLOR, MICARDIS HCT, TEVETEN HCT latanoprost, travoprost, RESCULA, TRAVATAN Z, XALATAN, ZIOPTAN candesarten, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICAR candesartan/hctz, eprosartan, irbesartan/hctz, losartan/ HCTZ, telmisartan/hctz, valsartan/hctz, BENICAR/HCT PRIASIS RIATANE, TACLONEX acitretin, methoxsalen, calcipotriene-betamethasone, calcitriol, DOVONEX, OXRALEN ULTRA SLEEP HYPNOTICS, NON BENZODIAZEPINES AMBIEN, AMBIEN CR, INTERMEZZO, LUNESTA, ROZEREM, NATA eszopiclone, zaleplon, zolpidem/er SKIN - CORTICOSTEROIDS OLUX, OLUX-E clobetasol propionate, fluocinoide, halobetasol proprionate * This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. 40 TESTOSTERONE REPLACEMENT ANDROGENS ANDROGEL, NATESTO, TESTIM, VOGELXO testosterone gel, ANDRODERM, AXIRON, FORTESTA ** For more covered options, visit to find the 2017 Basic Option formulary. 41

23 MANAGED NOT COVERED DRUG LIST BASIC OPTION (ALPHABETIC) EXCLUDED DRUG LIST STANDARD OPTION ACIPHEX ADVICOR ALTOPREV HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMULIN 70/30 OLUX OLUX E OMNARIS These listed drugs are not covered under Standard Option. If you use any of these Excluded Drugs, you will need to pay the full cost of the drug(s). AMBIEN AMBIEN CR ANAPROX DS HUMULIN N HUMULIN R HYZAAR ONGLYZA ORAPRED ODT OSENI If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options. ANDROGEL INTERMEZZO OXISTAT APIDRA/LOSTAR ARTHROTEC ATACAND/HCT AVALIDE JUBLIA KAZANO KERYDIN KOMBIGLYZE XR OXYTROL PENNSAID PRAVACHOL PREVACID CATEGORY* DRUG CLASS DRUG NOT COVERED IN 2017 FOR STANDARD OPTION COVERED OPTIONS** DIABETES - BIGUANIDES GLUMETZA metformin ER AVAPRO BECONASE AQ CADUET cetirizine solution CLARINEX, CLARINEX-D CORTEF COZAAR CRESTOR LESCOL/XL levocetirizine LIPITOR LIPTRUZET LIVALO LOPROX LOTRINE LUMIGAN PRILOSEC PROTONIX QNASL RAYOS RHINOCORT AQUA ROZEREM SIMCOR NATA FUNGAL INFECTIONS XOLEGEL ketoconazole 2% cream, ciclopirox, clotrimazole, ketoconazole, naftifine, nystatin, terbinafine, ECOZA, LAMISIL, NAFTIN PAIN AND INFLAMMATION NON STEROIDAL ANTI- INFLAMMATORIES (NSAIDS) PENNSAID diclofenac gel, diclofenac soln, VOLTAREN GEL DELTANE desloratadine DETROL DEXILANT DIOVAN/ HCT DUEXIS DYMISTA EDARBI EDARBYCLOR ERTACZO FELDENE LUNESTA LUZU MEDROL MENTAX MEVACOR MICARDIS/HCT MILLIPRED NAFTIN NAPRELAN NAPROSYN NASACORT AQ RIATANE TACLONEX TESTIM TEVETEN/HCT VERAMYST VIMOVO VOGELXO VUSION VYTORIN XOLEGEL XYZAL PAIN AND INFLAMMATION NON STEROIDAL ANTI-INFLAMMATORIES (NSAIDS) COMBINATIONS DUEXIS, VIMOVO ibuprofen, famotidine, ranitidine, diclofenac / misoprostol, naproxen, esomeprazole PRIASIS RIATANE, TACLONEX acitretin, methoxsalen, calcipotriene-betamethasone, claictriol, DOVONEX, OXRALEN ULTRA SKIN CORTICOSTEROIDS OLUX, OLUX-E clobetasol propionate, fluocinoide, halobetasol proprionate FIRST-LANPRAZOLE FIRST-OMEPRAZOLE GLUMETZA HUMALOG NANEX NATESTO NESINA NEXIUM NORITATE ZETONNA ZOCOR NOTE: Humulin R U-500 concentrate will continue to be covered * This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. ** For more covered options, visit to find the 2017 Standard Option formulary

24 HOW TO CONTACT US Call these numbers for prescription drug information: RETAIL PHARMACY PROGRAM (Basic and Standard Option) Toll-free any time at MAIL SERVICE PHARMACY PROGRAM (All Standard Option and Basic Option with Med B primary) Toll-free any time at OTHER BENEFIT OR CLAIMS INFORMATION Call your local Blue Cross and Blue Shield company. The customer service number is on the back of your Service Benefit Plan ID card. SPECIALTY PHARMACY PROGRAM (Basic and Standard Option) Toll-free at Monday-Friday: 7 a.m. to 9 p.m. Eastern time Saturday/Sunday: 8 a.m. to 6:30 p.m. Eastern time This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. Before making a final decision, please read the Plan s Federal brochure, RI All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure