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1 One mission: you s March 8, 2018 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for your care. Because the formulary is reviewed on an ongoing basis, we want to keep you informed of coming and recent changes to our covered drug lists. The following is a list of changes that have occurred. The online pharmacy tools and resources are updated with these decisions by the effective date of the change. This list applies to members of Plans and Health Plans. This list does not apply to Federal Employee Program members or Medicare Advantage members. TABLE A. TABLED MEDICATIONS: Plan Class/Category Tier = Benefit Level for Drug Under The Belsomra (suvorexant) Orexin Receptor Antagonist; Hypnotic, Miscellaneous Insomnia TABLE B. NEWLY REVIEWED MEDICATIONS: Plan Vyzulta (latanoprostene bunod) Class/Category Ophthalmic Agent, Antiglaucoma; Prostaglandin, Ophthalmic Elevated intraocular pressure Tier = Benefit Level for Drug Under The

2 Plan Ozempic (semaglutide) Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist 5/1/2018 Added Tier 4 with Tier 3 with Tier 3 with Tier 4 with Steglatro (ertugliflozin) Segluromet (ertugliflozin + metformin) Steglujan (ertugliflozin + sitagliptin) Biktarvy (bictegravir + emtricitabine + tenofovir alafenamide) Solosec (secnidazole) Benznidazole (SGLT2) Inhibitor (SGLT2) Inhibitor; Biguanide (SGLT2) Inhibitor; Dipeptidyl Peptidase (DPP-4) Inhibitor Antiretroviral, Integrase Inhibitor (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleoside (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Nucleotide (Anti-HIV) HIV-1 Antibiotic, Miscellaneous; Antiprotozoal, Nitroimidazole Bacterial Vaginosis Antiprotozoal, Nitroimidazole; Antitrypanosomal Chagas disease (American trypanosomiasis) 5/1/2018 Added Tier 4 Tier 3 Tier 3 Tier 4 5/1/2018 Added Tier 4 with PA Tier 3 with PA Tier 3 with PA Tier 4 with PA 5/1/2018 Added Tier 4 with PA Tier 3 with PA Tier 3 with PA Tier 4 with PA

3 Plan Calquence (acalabrutinib) Fasenra (benralizumab) Hemlibra (emicizumab-kxwh) Antineoplastic Agent; Antineoplastic Agent, Bruton Tyrosine Kinase Inhibitor; Antineoplastic Agent, Tyrosine Kinase Inhibitor Mantle Cell Lymphoma (previously treated) Interleukin-5 Receptor Antagonist; Monoclonal Antibody, Anti-Asthmatic Asthma Antihemophilic Agent; Monoclonal Antibody Hemophilia A, prophylaxis 5/1/2018 Added Tier 6 with PA Tier 3 with PA Tier 4 with PA Tier 6 with PA Gene Therapy, Adeno- Luxturna (Voretigene Associated Virus Neparvovec-rzyl) Retinal dystrophy Sinuva (mometasone) Corticosteroid, Nasal Implant Recurrent Nasal Polyps Mepsevii (vestronidase alfavjbk) Lutathera (lutetium) Prevymis IV (letermovir) Enzyme Mucopolysaccharidosis VII Radiopharmaceutical Gastroenteropancreatic neuroendocrine tumors Antiviral Agent Cytomegalovirus (prophylaxis) Prevymis Oral (letermovir) Antiviral Agent Cytomegalovirus (prophylaxis) 5/1/2018 Added Tier 6 with PA Tier 3 with PA Tier 4 with PA Tier 6 with PA

4 TABLE C. PREVIOUSLY REVIEWED/LINE EXTENSIONS: Plan Varubi (rolapitant HCL) Cinvanti (aprepitant IV) Qtern (dapagliflozinsaxagliptin) Bydureon BCise (exenatide extended release) Class Antiemetic; Substance P/Neurokinin 1 Receptor Antagonist Chemotherapyinduced nausea and vomiting (prevention) Antiemetic; Substance P/Neurokinin 1 Receptor Antagonist Chemotherapyinduced nausea and vomiting (prevention) Dipeptidyl Peptidase 4 (DPP-4) Inhibitor; (SGLT2) Inhibitor Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist Tier = Benefit Level for Drug Under The PREV = H.S.A. Preventive List ACA** = See Footnote Juluca (dolutegravir sodiumrilpivirine HCL) Antiretroviral, Integrase Inhibitor (Anti-HIV); Antiretroviral, Reverse Transcriptase Inhibitor, Non-nucleoside (Anti- HIV) HIV, whose virus is suppressed on a stable regimen for at least 6 months 5/1/2018 Added Tier 4 Tier 3 Tier 3 Tier 4

5 Plan Heplisav-B (Hepatitis B vaccine recombinant) Vaccine, Inactivated (Viral); Vaccine, Recombinant Hepatitis B prophylaxis Qvar RediHaler (beclomethasone dipropionate) Corticosteroid, Inhalant (Oral) Maintenance treatment of asthma 5/1/2018 Added Tier 3 with QL, PREV Tier 2, PREV Tier 2, PREV Tier 3, PREV Sublocade Injection (buprenorphine extended release solution) Clenpiq Solution (sodium picosulfatemagnesium oxidecitric acid solution) Lyrica CR (pregabalin controlled release) Analgesic, Opioid; Analgesic, Opioid Partial Agonist Moderate-to-severe opioid use disorder Laxative, Osmotic; Laxative, Stimulant Colonoscopypreparation of bowel procedure Anticonvulsant, Miscellaneous; GABA Analog Diabetic peripheral neuropathy, postherpetic neuralgia 5/1/2018 Added Tier 4, ACA Tier 3, ACA Tier 3, ACA Tier 4, ACA 5/1/2018 Added Tier 3 Tier 2 Tier 2 Tier 3 Impoyz cream 0.025% (clobetasol propionate cream 0.025%) Corticosteroid, Topical Plaque psoriasis (moderate to severe) Adzenys ER Suspension (amphetamine extended release suspension) Noctiva Spray (desmopressin acetate nasal emulsion spray) Central Nervous System Stimulant Attention deficit hyperactivity disorder Vasopressin Analog, Synthetic Nocturia 5/1/2018 Added Tier 4 with PA Tier 3 with PA Tier 3 with PA Tier 4 with PA ** Drugs prescribed for covered preventive services that may be available at no cost to members under the regulations of the Affordable Care Act. Some plans grandfathered under the Affordable Care Act may not be eligible for the ACA preventive drugs at no cost.

6 TABLE D. THERAPEUTIC CLASS REVIEW: Plan Class Tier = Benefit Level for Drug Under The No s