Blue Cross and Blue Shield of North Carolina Essential Formulary

Transcription

1 January 09 Blue Cross and Blue Shield of North Carolina Essential Formulary Please consider talking to your doctor about prescribing formulary medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The medication formulary is regularly updated. Please visit for the most up-to-date information. Contents Preface... I Member guide to covered medications on the Essential Formulary... I Formulary tiers... I Generic medications... II Compounded prescriptions... II Prior review, quantity limitations and restricted-access medications... II medications... III ffordable Care ct... III medications... III Using the member guide to the Essential Formulary... IV bbreviation/acronym key... V Therapeutic Class Medication List nti-infective gents... Biologicals... 9 ntineoplastic gents... 0 Endocrine and Metabolic Medications... 5 Cardiovascular gents... 9 Respiratory gents... Gastrointestinal gents... 5 Genitourinary gents... 9 Central Nervous System Medications... 5 nalgesics and nesthetics... 6 Neuromuscular Medications... 7 Nutritional Products Hematological gents Topical Products Miscellaneous Products Index To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. 55-M NC HIM Prime Therapeutics LLC 0/9

2 Member guide to covered medications on the Essential Formulary This guide lists the approved brand name and generic prescription medications that have been reviewed by Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Please refer to this formulary guide for information about medications covered by this formulary, and present this guide to your doctor if you require a prescription. This guide was current at the time of printing and is subject to change. The Formulary List is subject to change at any time. It is reviewed quarterly to examine new medications and new information about medications that are already on the market concerning safety, effectiveness and current use in therapy. There are varying reasons changes are made to the medications listed in the member guide to covered medications: The tier level of a medication included on the medication list may increase (change to a higher tier or noncovered) when an FD-approved bioequivalent generic medication becomes available. Newly marketed prescription medications may not be covered until the Pharmacy & Therapeutics Committee has had an opportunity to review the medication, to determine whether the medication will be covered and if so, which tier will apply based on safety, efficacy and the availability of other products within that class of medications. Change in the cost of the medication and/or in the classification of the medication by the U.S. Food and Drug dministration (FD) or nationally-recognized medication databases (e.g., Medispan). formulary is a list of prescription medications covered by a health plan. Blue Cross NC Pharmacy & Therapeutics (P&T) Committee reviews medications at least quarterly. This includes ongoing reviews of clinical information about new medications and reviews of new safety and efficacy information about older medications. The majority of Blue Cross NC s P&T Committee is composed of practicing physicians and pharmacists independent of Blue Cross NC. Tier placement of prescription medications in the formulary may be determined by: the effectiveness and safety of the medication, the cost of the medication, and /or the classification of the medications by the U.S. Food and Drug dministration (FD) or nationally-recognized medication databases (e.g., Medispan). For a more complete listing of medication coverage and costs, you may use our Find a Drug search at Please refer to your member guide for detailed information regarding your pharmacy benefits, including your benefit design, out-of-pocket costs, prior review, quantity limitation and restricted access medications, and applicable exclusions. You may also call Blue Cross NC Customer Service at the number listed on the back of your ID card to verify prescription medication benefits. Formulary tiers The Essential Formulary covers medications approved by the United States Food & Drug dministration (FD), within existing benefits. The plan design determines the member s payment obligation. Definitions for the benefit structure: Tier : The prescription medication tier which consists of the lowest cost tier of prescription medications, most are generic. Tier : The prescription medication tier which consists of medium-cost prescription medications, most are generic, and some brand-name medications. Tier 3: The prescription medication tier which consists of high-cost prescription medications, most are brand-name prescription medications. Tier : The prescription medication tier which consists of the higher-cost prescription medications, most are brand-name prescription medications, and some specialty medications. Tier 5 and Tier 6: The prescription medication tiers which consist of the highest-cost prescription medications, most are specialty medications. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary I

3 Generic medications In most cases, choosing a generic medication equivalent, when available, will mean significant savings to you. We encourage you to discuss with your physician whether a generic alternative is available as these medications represent safe, effective treatment options. Especially for medications that are taken daily and refilled frequently, you will experience the long-term savings of a lower medication payment month after month. If you choose a brand name prescription medication and a generic equivalent is available, you may be subject to a reduced benefit and a higher out-of-pocket expense. Compounded prescriptions Compounded prescriptions contain two or more medications mixed together. Compounded prescriptions are processed according to member benefits. To be eligible for coverage, compounded medications must contain at least one ingredient that is defined as a prescription medication and must not be a copy of a commercially available product. Compounded medications may be subject to prior review and benefit exclusion. Prior review, restricted-access, non-formulary exception and quantity limitations Under some benefit plans, certain medications may be subject to prior review, quantity limitations, or restrictedaccess programs. Blue Cross NC s P&T Committee reviews the clinical criteria for these programs. The different types of review include: (P)*: Your provider needs to review our clinical criteria and confirm that you meet the requirements. Quantity Limitations (QL)*: Your provider needs to review our clinical criteria and confirm that you meet the requirements for the amount requested. You can still receive the medication without our review and approval, just not over a set amount. /Step Therapy (R/ST)*: Your provider needs to confirm that you have tried specific, nonrestricted medication(s) first and that it was ineffective or harmful to you in the past (and the provider believes it will be ineffective or harmful again). You need to have this done before you can receive the other restricted medication. Nonformulary (NF)*: Providers will need to confirm that you have tried formulary alternatives first and they were ineffective or harmful to you. lso, medication-specific clinical criteria must be met before approval. nonformulary medication is one that is not included in the list of medication that are eligible for benefits under your Blue Cross NC plan. *Please see "Covered Services" and "Glossary" in your benefit booklet for more information. Blue Cross NC creates criteria for medications which fall under the review types listed above. This criteria explains what conditions must be met for a medication to be covered under your benefits. Some of this may be technical medical information, but it s available for you to read and discuss with your provider. Criteria is available at the following website: PLESE NOTE: If you change your health plan, your provider may need to tell us again that you have met our clinical criteria under your new plan. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary II

4 The FD is responsible for approving medications for use based on clinical data proving the medication is safe and effective for that specific use. Blue Cross NC s prior review, restricted-access, non-formulary exceptions and quantity limitations programs follow FD-approved uses for these medications. However, Blue Cross NC recognizes that in many cases, off-label (indications not approved by the FD) uses of prescription medications may be acceptable. In determining the acceptability of off-label uses, Blue Cross NC utilizes several sources of clinical information including but not limited to ) nationally recognized clinical references including merican Hospital Formulary Service Medication Information; ) the results of at least two randomized controlled clinical studies that support a specific off-label use, and that are published in peer-reviewed professional medical journals; and 3) consultations with internal and external physician experts regarding community standards. dditional searches for current supporting medical literature may be performed utilizing standard electronic databases. medications These medications, as classified by Blue Cross NC, generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more costly than alternative medications or therapies. Most specialty medications can be found on Tier 5 and/or Tier 6, but some may be found on a lower tier. Some of these specialty medications will need to be filled at a participating specialty pharmacy in our network. These medications are identified in the specialty column of the formulary guide. Call the customer service number on the back of your Blue Cross NC ID card to determine which pharmacy can fill your specialty medication prescription. ffordable Care ct Please note, some medications may have limited or $0 cost-sharing under the ffordable Care ct (); examples of categories of medications that may be subject to limited or $0 cost share include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, immunizations (influenza, shingles and pneumonia are covered in-network), and some contraceptive medications and devices. You may find additional information about these medications at: These medications are identified in the column of the formulary guide. If you do not find the medication you are searching for, contact the customer service number on the back of your Blue Cross NC ID card to find out if the medication is available over the counter or is covered under your medical benefit. medications medications (LD) are medications where the manufacturer chooses to limit the distribution of the medication to only a few pharmacies, or the Food and Drug dministration (FD) requires this restriction during the medication approval process. This type of restricted distribution helps the manufacturer keep track of medication inventory and ensure that special dosing or lab monitoring requirements are followed to minimize any risks associated with the LD medication. Medications which have restrictions on where the member may obtain them are identified in the LD column of the formulary guide. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary III

5 Using the member guide to the Essential Formulary The Medication List is organized into broad categories (e.g., NTI-INFECTIVE GENTS). The graphic below shows the information that is provided in each column of the medication list and is an example only. Please use the medication search function to find current information for medications on the medication list. The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface. Brand name medications are capitalized. Separate medication entries are required for some dosage forms such as extended-release and delayed-release. The second column indicates the Tier level. Note: If a medication displays an "" in the Medication Tier column, this indicates the medication may only be covered if a member meets the criteria for $0 copay under the ffordable Care ct. The third column indicates if the medication is a medication and needs to be filled at a participating specialty pharmacy in our network. The next three columns indicate the Pharmacy Program(s) that apply to the prescription medication (e.g.,, and Quantity Limitations). If an indicator is present in the column(s), then the Pharmacy Program applies. The seventh column indicates if the medication may have limited or $0 cost-sharing under the ffordable Care ct (). Benefits may apply. The last column indicates if the medication is considered. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary IV

6 bbreviation/acronym key cap... capsules chew... chewable conc... concentrate cr... controlled release dr... delayed release ec... enteric coated effe... effervescent equiv... equivalent er... extended release inhal... inhalation inj... injection liq... liquid lotn... lotion nebu... nebulizer odt... orally disintegrating tabs oint... ointment ophth... opthalmic osm... osmotic release powd... powder sa... sustained action sl... sublingual soln... solution sr... sustained release suppos... suppositories susp... suspension tab... tablets td... transdermal Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary V

7 Non-Discrimination and ccessibility Notice Discrimination is gainst the Law Blue Cross and Blue Shield of North Carolina ( BCBSNC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. BCBSNC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. BCBSNC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages If you need these services, contact Customer Service , TTY and TDD, call If you believe that BCBSNC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: BCBSNC, PO Box 9, Durham, NC 770, ttention: Civil Rights Coordinator- Privacy, Ethics & Corporate Policy Office, Telephone , Fax , TTY civilrightscoordinator@bcbsnc.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Civil Rights Coordinator - Privacy, Ethics & Corporate Policy Office is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 00 Independence venue, SW Room 509F, HHH Building Washington, D.C , (TDD). Complaint forms are available at This Notice and/or attachments may have important information about your application or coverage through BCBSNC. Look for key dates. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call Customer Service Marks of the Blue Cross and Blue Shield ssociation, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield ssociation. v. 0/6

8 TTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: ). TENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您講廣東話或普通話, 您可以免費獲得語言援助服務 請致電 (TTY: ) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. TTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. ppelez le (TS : ). ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم المبرقة الكاتبة: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). PUNW: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). સચન : જ તમ ગજર ત બ લત હ, ત નન:સલ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: ). ច ណ ប រស នបរ ប កអ នកន យ យជ ភ ស ខ ម រ បសវ កម ជ ន យខ នកភ ស ម ននតលជ នសប ម រ ប កអ នកប យម នគ តថ ល ស ម ទ ន ក ទ នងត ម រយ បលម (TTY: ) CHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). ध य न द: यदद आप द न द ब लत त आपक दलए मफ त म भ ष स यत सव ए उपलब ध (TTY: ) पर क ल कर ໂປດຊາບ: ຖາວາ ທານເວາພາສາ ລາວ, ການບລການຊວຍເຫອດານພາສາ, ໂດຍບເສຽຄາ, ແມນມພອມໃຫທານ. ໂທຣ (TTY: ). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Marks of the Blue Cross and Blue Shield ssociation, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield ssociation. v. 0/6

9 09 NTI-INFECTIVE GENTS PENICILLINS MOXICILLIN - amoxicillin (trihydrate) chew tab 5 MOXICILLIN - amoxicillin (trihydrate) chew tab 50 amoxicillin (trihydrate) cap 50 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) for susp 5 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) for susp 50 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (ugmentin) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (ugmentin es-600) amoxicillin & k clavulanate tab er hr (ugmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab (ugmentin) amoxicillin & k clavulanate tab (ugmentin) MOXICILLIN/CLVULNTE P - amoxicillin & k clavulanate chew tab MOXICILLIN/CLVULNTE P - amoxicillin & k clavulanate chew tab MPICILLIN - ampicillin cap 500 UGMENTIN - amoxicillin & k clavulanate for susp /5ml dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 MOXTG - amoxicillin (trihydrate) tab er hr 775 PENICILLIN V POTSSIUM - penicillin v potassium for soln 5 /5ml PENICILLIN V POTSSIUM - penicillin v potassium for soln 50 /5ml penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHLOSPORINS CEFCLOR - cefaclor for susp 5 /5ml CEFCLOR - cefaclor for susp 50 /5ml CEFCLOR - cefaclor for susp 375 /5ml cefaclor cap 50 cefaclor cap 500 cefadroxil cap 500 cefadroxil for susp 50 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 300 cefdinir for susp 5 /5ml Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary

10 09 cefdinir for susp 50 /5ml CEFDITOREN PIVOXIL - cefditoren pivoxil tab 00 (base equivalent) CEFDITOREN PIVOXIL - cefditoren pivoxil tab 00 (base equivalent) cefixime for susp 00 /5ml (Suprax) cefixime for susp 00 /5ml (Suprax) cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 00 /5ml cefpodoxime proxetil tab 00 cefpodoxime proxetil tab 00 cefprozil for susp 5 /5ml cefprozil for susp 50 /5ml cefprozil tab 50 cefprozil tab 500 cefuroxime axetil tab 50 (Ceftin) cefuroxime axetil tab 500 (Ceftin) CEPHLEXIN - cephalexin tab 50 CEPHLEXIN - cephalexin tab 500 cephalexin cap 50 (Keflex) cephalexin cap 500 (Keflex) cephalexin cap 750 (Keflex) cephalexin for susp 5 /5ml cephalexin for susp 50 /5ml SPECTRCEF - cefditoren pivoxil tab 00 (base equivalent) MCROLIDES ZITHROMYCIN - azithromycin powd pack for susp gm azithromycin for susp 00 /5ml (Zithromax) azithromycin for susp 00 /5ml (Zithromax) azithromycin tab 50 (Zithromax) azithromycin tab 500 (Zithromax) azithromycin tab 600 (Zithromax) CLRITHROMYCIN - clarithromycin for susp 5 /5ml CLRITHROMYCIN - clarithromycin for susp 50 /5ml clarithromycin tab er hr 500 clarithromycin tab 50 (Biaxin) clarithromycin tab 500 (Biaxin) DIFICID - fidaxomicin tab 00 ERY-TB - erythromycin tab delayed release 50 ERY-TB - erythromycin tab delayed release 333 ERY-TB - erythromycin tab delayed release 500 erythromycin ethylsuccinate for susp 00 /5ml (E.e.s. granules) erythromycin tab 50 erythromycin tab 500 erythromycin w/ delayed release particles cap 50 ZITHROMX - azithromycin powd pack for susp gm TETRCYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 300 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary

11 09 doxycycline hyclate cap 50 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab delayed release 50 (Doryx) doxycycline hyclate tab delayed release 75 doxycycline hyclate tab delayed release 00 doxycycline hyclate tab delayed release 50 doxycycline hyclate tab delayed release 00 (Doryx) doxycycline hyclate tab 0 doxycycline hyclate tab 00 doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 (Monodox) doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 (doxa) doxycycline monohydrate for susp 5 /5ml (Vibramycin) doxycycline monohydrate tab 50 (doxa) doxycycline monohydrate tab 75 (doxa) doxycycline monohydrate tab 00 (doxa pak /00) doxycycline monohydrate tab 50 (doxa pak /50) minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) minocycline hcl tab er hr 5 minocycline hcl tab er hr 90 minocycline hcl tab er hr 35 minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 00 tetracycline hcl cap 50 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) FLUOROQUINOLONES BXDEL - delafloxacin meglumine tab 50 (base equiv) CIPRO - ciprofloxacin for oral susp 50 /5ml (5%) (5 gm/00ml) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXCIN HCL - ciprofloxacin hcl tab 00 (base equiv) ciprofloxacin hcl tab 50 (base equiv) (Cipro) ciprofloxacin hcl tab 500 (base equiv) (Cipro) ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin-ciprofloxacin hcl tab er hr 500 (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er hr 000 (base eq) (Cipro xr) levofloxacin oral soln 5 /ml (Levaquin) levofloxacin tab 50 (Levaquin) levofloxacin tab 500 (Levaquin) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 3

12 09 levofloxacin tab 750 (Levaquin) moxifloxacin hcl tab 00 (base equiv) (velox) OFLOXCIN - ofloxacin tab 300 ofloxacin tab 00 MINOGLYCOSIDES BETHKIS - tobramycin nebu soln 300 /ml KITBIS PK - tobramycin nebu soln 300 /5ml neomycin sulfate tab 500 paromomycin sulfate cap 50 TOBI PODHLER - tobramycin inhal cap 8 TOBRMYCIN - tobramycin nebu soln 300 /5ml tobramycin nebu soln 300 /5ml (Tobi) SULFONMIDES SULFDIZINE - sulfadiazine tab 500 NTIMYCOBCTERIL GENTS CYCLOSERINE - cycloserine cap 50 ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 00 (Myambutol) ISONIZID - isoniazid syrup 50 /5ml isoniazid tab 00 isoniazid tab 300 PSER - aminosalicylic acid er granules packet gm PRIFTIN - rifapentine tab 50 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) 6 6 RIFMTE - isoniazid & rifampin cap rifampin cap 50 (Rifadin) rifampin cap 300 (Rifadin) RIFTER - isoniazid-rifampin w/ pyrazinamide tab SIRTURO - bedaquiline fumarate tab 00 (base equiv) TRECTOR - ethionamide tab 50 NTIFUNGLS CRESEMB - isavuconazonium 5 sulfate cap 86 fluconazole for susp 0 /ml (Diflucan) fluconazole for susp 0 /ml (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) flucytosine cap 50 (ncobon) flucytosine cap 500 (ncobon) griseofulvin microsize susp 5 /5ml griseofulvin microsize tab 500 (Grifulvin v) griseofulvin ultramicrosize tab 5 (Gris-peg) griseofulvin ultramicrosize tab 50 (Gris-peg) itraconazole cap 00 (Sporanox) ketoconazole tab 00 NOXFIL - posaconazole susp 0 /ml NOXFIL - posaconazole tab delayed release Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary

13 09 nystatin tab unit terbinafine hcl tab 50 (Lamisil) voriconazole for susp 0 /ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 00 (Vfend) NTIVIRLS abacavir sulfate soln 0 /ml (base equiv) (Ziagen) abacavir sulfate tab 300 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab (Epzicom) abacavir sulfate-lamivudinezidovudine tab (Trizivir) acyclovir cap 00 (Zovirax) acyclovir susp 00 /5ml (Zovirax) acyclovir tab 00 (Zovirax) acyclovir tab 800 (Zovirax) adefovir dipivoxil tab 0 5 (Hepsera) PTIVUS - tipranavir cap 50 5 PTIVUS - tipranavir oral soln 00 /ml atazanavir sulfate cap 50 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) atazanavir sulfate cap 300 (base equiv) (Reyataz) TRIPL - efavirenz-emtricitabinetenofovir df tab BRCLUDE - entecavir oral soln 0.05 /ml BIKTRVY - bictegraviremtricitabine-tenofovir af tab CIMDUO - lamivudine-tenofovir disoproxil fumarate tab COMPLER - emtricitabinerilpivirine-tenofovir df tab CRIXIVN - indinavir sulfate cap 00 CRIXIVN - indinavir sulfate cap 00 DKLINZ - daclatasvir dihydrochloride tab 30 (base equivalent) DKLINZ - daclatasvir dihydrochloride tab 60 (base equivalent) DKLINZ - daclatasvir dihydrochloride tab 90 (base equivalent) DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab 00-5 didanosine delayed release capsule 00 (Videx ec) didanosine delayed release capsule 50 (Videx ec) didanosine delayed release capsule 00 (Videx ec) EDURNT - rilpivirine hcl tab 5 (base equivalent) efavirenz cap 50 (Sustiva) 5 efavirenz cap 00 (Sustiva) 5 efavirenz tab 600 (Sustiva) 5 EMTRIV - emtricitabine caps 00 5 EMTRIV - emtricitabine soln 0 5 /ml entecavir tab 0.5 (Baraclude) 5 entecavir tab (Baraclude) 5 EPCLUS - sofosbuvir-velpatasvir tab Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 5

14 09 EPIVIR HBV - lamivudine oral soln 5 /ml (hbv) EVOTZ - atazanavir sulfatecobicistat tab (base equiv) famciclovir tab 5 (Famvir) famciclovir tab 50 (Famvir) 5 5 famciclovir tab 500 (Famvir) fosamprenavir calcium tab (base equiv) (Lexiva) FUZEON - enfuvirtide for inj 90 5 GENVOY - elvitegrav-cobicemtricitab-tenofov af tab HRVONI - ledipasvir-sofosbuvir tab INTELENCE - etravirine tab 5 5 INTELENCE - etravirine tab 00 5 INTELENCE - etravirine tab 00 5 INVIRSE - saquinavir mesylate 5 cap 00 INVIRSE - saquinavir mesylate tab 500 ISENTRESS - raltegravir potassium chew tab 5 (base equiv) ISENTRESS - raltegravir potassium chew tab 00 (base equiv) ISENTRESS - raltegravir potassium packet for susp 00 (base equiv) ISENTRESS - raltegravir potassium tab 00 (base equiv) ISENTRESS HD - raltegravir potassium tab 600 (base equiv) JULUC - dolutegravir sodiumrilpivirine hcl tab 50-5 (base eq) KLETR - lopinavir-ritonavir tab KLETR - lopinavir-ritonavir tab lamivudine oral soln 0 /ml (Epivir) lamivudine tab 00 (hbv) 5 (Epivir hbv) lamivudine tab 50 (Epivir) lamivudine tab 300 (Epivir) lamivudine-zidovudine tab (Combivir) LEXIV - fosamprenavir calcium susp 50 /ml (base equiv) lopinavir-ritonavir soln /5ml (80-0 /ml) (Kaletra) MVYRET - glecaprevirpibrentasvir tab 00-0 MODERIB - ribavirin tab 00 & ribavirin 00 tab therapy pack MODERIB - ribavirin tab 00 & ribavirin 600 tab therapy pack MODERIB 00 DOSE PCK - ribavirin tab 600 MODERIB 800 DOSE PCK - ribavirin tab 00 nevirapine susp 50 /5ml (Viramune) nevirapine tab er hr 00 (Viramune xr) nevirapine tab er hr 00 (Viramune xr) nevirapine tab 00 (Viramune) NORVIR - ritonavir oral soln 80 / ml NORVIR - ritonavir powder packet 00 ODEFSEY - emtricitabine-rilpivirinetenofovir af tab oseltamivir phosphate cap 30 (base equiv) (Tamiflu) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 6

15 09 oseltamivir phosphate cap 5 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) oseltamivir phosphate for susp 6 /ml (base equiv) (Tamiflu) PEGSYS - peginterferon alfa-a inj 80 mcg/ml PEGSYS - peginterferon alfa-a inj 80 mcg/0.5ml PEGSYS PROCLICK - peginterferon alfa-a inj 35 mcg/0.5ml PEGSYS PROCLICK - peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREVYMIS - letermovir tab 0 PREVYMIS - letermovir tab 80 PREZCOBIX - darunavir-cobicistat 5 tab PREZIST - darunavir ethanolate 5 susp 00 /ml (base equiv) PREZIST - darunavir ethanolate 5 tab 75 (base equiv) PREZIST - darunavir ethanolate 5 tab 50 (base equiv) PREZIST - darunavir ethanolate 5 tab 600 (base equiv) PREZIST - darunavir ethanolate 5 tab 800 (base equiv) REBETOL - ribavirin soln 0 /ml 5 RELENZ DISKHLER - zanamivir aero powder breath activated 5 /blister RESCRIPTOR - delavirdine mesylate tab 00 RESCRIPTOR - delavirdine mesylate tab REYTZ - atazanavir sulfate oral 5 powder packet 50 (base equiv) RIBSPHERE - ribavirin tab 00 5 RIBSPHERE - ribavirin tab RIBSPHERE RIBPK - ribavirin 5 tab 00 & ribavirin 00 tab therapy pack RIBSPHERE RIBPK - ribavirin 5 tab 00 & ribavirin 600 tab therapy pack RIBSPHERE RIBPK - ribavirin 5 tab 00 RIBSPHERE RIBPK - ribavirin 5 tab 600 ribavirin cap 00 (Rebetol) ribavirin for inhal soln 6 gm 5 (Virazole) ribavirin tab 00 (Copegus) rimantadine hydrochloride tab 00 (Flumadine) ritonavir tab 00 (Norvir) 5 SELZENTRY - maraviroc oral soln 0 /ml SELZENTRY - maraviroc tab SELZENTRY - maraviroc tab 75 5 SELZENTRY - maraviroc tab 50 5 SELZENTRY - maraviroc tab SOVLDI - sofosbuvir tab 00 stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 30 (Zerit) stavudine cap 0 (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 7

16 09 SYMFI - efavirenz-lamivudinetenofovir df tab SYMFI LO - efavirenz-lamivudinetenofovir df tab TECHNIVIE - ombitasvirparitaprevir-ritonavir tab tenofovir disoproxil fumarate tab (Viread) TIVICY - dolutegravir sodium tab 5 0 (base equiv) TIVICY - dolutegravir sodium tab 5 5 (base equiv) TIVICY - dolutegravir sodium tab 5 50 (base equiv) TRIUMEQ - abacavir-dolutegravirlamivudine 5 tab TRUVD - emtricitabine-tenofovir 5 disoproxil fumarate tab TRUVD - emtricitabine-tenofovir 5 disoproxil fumarate tab TRUVD - emtricitabine-tenofovir 5 disoproxil fumarate tab TRUVD - emtricitabine-tenofovir 5 disoproxil fumarate tab TYBOST - cobicistat tab 50 5 valacyclovir hcl tab 500 (Valtrex) valacyclovir hcl tab gm (Valtrex) valganciclovir hcl for soln 5 50 /ml (base equiv) (Valcyte) valganciclovir hcl tab 50 5 (base equivalent) (Valcyte) VEMLIDY - tenofovir alafenamide 5 fumarate tab 5 VIDEX - didanosine for soln gm 5 VIDEX - didanosine for soln gm 5 VIDEX EC - didanosine delayed 6 release capsule 5 VIEKIR PK - ombitas-paritapreriton & dasab tab pak & 50 VIEKIR XR - dasab-ombitparitap-riton tab er hr VIRCEPT - nelfinavir mesylate tab 50 VIRCEPT - nelfinavir mesylate tab 65 VIRED - tenofovir disoproxil fumarate oral powder 0 /gm VIRED - tenofovir disoproxil fumarate tab 50 VIRED - tenofovir disoproxil fumarate tab 00 VIRED - tenofovir disoproxil fumarate tab 50 VOSEVI - sofosbuvir-velpatasvirvoxilaprevir tab ZEPTIER - elbasvir-grazoprevir tab zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 300 NTIMLRILS atovaquone-proguanil hcl tab (Malarone) atovaquone-proguanil hcl tab (Malarone) CHLOROQUINE PHOSPHTE - chloroquine phosphate tab 50 chloroquine phosphate tab 500 (ralen) CORTEM - artemetherlumefantrine tab 0-0 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 8

17 09 DRPRIM - pyrimethamine tab 5 hydroxychloroquine sulfate tab 00 (Plaquenil) MEFLOQUINE HCL - mefloquine hcl tab 50 PRIMQUINE PHOSPHTE - primaquine phosphate tab 6.3 (5 base) quinine sulfate cap 3 (Qualaquin) NTHELMINTICS albendazole tab 00 (lbenza) BENZNIDZOLE - benznidazole tab.5 BENZNIDZOLE - benznidazole tab 00 BILTRICIDE - praziquantel tab 600 EMVERM - mebendazole chew tab 00 ivermectin tab 3 (Stromectol) praziquantel tab 600 (Biltricide) NTI-INFECTIVE GENTS - MISC. atovaquone susp 750 /5ml (Mepron) CYSTON - aztreonam lysine for inhal soln 75 (base equivalent) clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 300 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 5 dapsone tab 00 IMPVIDO - miltefosine cap 50 linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 375 (Flagyl) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) NEBUPENT - pentamidine isethionate for nebulization soln 300 sulfamethoxazole-trimethoprim susp 00-0 /5ml sulfamethoxazole-trimethoprim tab (Bactrim) sulfamethoxazole-trimethoprim tab (Bactrim ds) tinidazole tab 50 (Tindamax) tinidazole tab 500 (Tindamax) trimethoprim tab 00 vancomycin hcl cap 5 (base equivalent) (Vancocin hcl) vancomycin hcl cap 50 (base equivalent) (Vancocin hcl) XIFXN - rifaximin tab 00 XIFXN - rifaximin tab 550 BIOLOGICLS VCCINES FLURI PF influenza virus vaccine split pf susp pref syringe 0.5 ml FLURI QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLURI QUDRIVLENT 08 - influenza virus vaccine split quadrivalent im inj Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 9

18 09 FLURI influenza virus vaccine split im susp FLUD influenza vac type a&b surface ant adj susp pref syr 0.5 ml FLURIX QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUDRIVLENT 08 - influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUCELVX QUDRIVLENT 0 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVX QUDRIVLENT 0 - influenza vac tissue-cultured subunit quadrivalent im susp FLULVL QUDRIVLENT 0 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLULVL QUDRIVLENT 0 - influenza virus vaccine split quadrivalent im inj FLUMIST QUDRIVLENT - influenza virus vaccine live quadrivalent intranasal susp FLUZONE HIGH-DOSE PF 08 - influenza virus vac split highdose pf susp pref syr 0.5ml FLUZONE QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5 ml FLUZONE QUDRIVLENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUZONE QUDRIVLENT 08 - influenza virus vaccine split quadrivalent im inj FLUZONE QUDRIVLENT 08 - influenza virus vaccine split quadrivalent inj 0.5 ml PNEUMOVX 3 - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PNEUMOVX 3/ DOSE - pneumococcal vaccine polyvalent inj 5 mcg/0.5ml PREVNR 3 - pneumococcal 3- valent conjugate vaccine inj SHINGRIX - zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml ZOSTVX - zoster vaccine live for subcutaneous susp 900 unit/0.65ml BIOLOGICLS MISC GRSTEK - timothy grass pollen allergen ext sl tab 800 bau ODCTR - dust mite mixed ext sl tab sq-hdm ORLIR - grass mixed pollen ext sl tab 300 ir (index of reactivity) RGWITEK - short ragweed pollen allergen extract sl tab amb a -u NTINEOPLSTIC GENTS NTINEOPLSTICS CTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) 6 FINITOR - everolimus tab.5 FINITOR - everolimus tab 5 FINITOR - everolimus tab 7.5 FINITOR - everolimus tab 0 FINITOR DISPERZ - everolimus tab for oral susp FINITOR DISPERZ - everolimus tab for oral susp 3 FINITOR DISPERZ - everolimus tab for oral susp 5 LECENS - alectinib hcl cap 50 (base equivalent) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 0

19 09 anastrozole tab (rimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 500 BRFTOVI - encorafenib cap 50 BRFTOVI - encorafenib cap 75 CBOMETYX - cabozantinib s-malate tab 0 (base equivalent) CBOMETYX - cabozantinib s-malate tab 0 (base equivalent) CBOMETYX - cabozantinib s-malate tab 60 (base equivalent) CLQUENCE - acalabrutinib cap 00 capecitabine tab 50 (Xeloda) 5 capecitabine tab 500 (Xeloda) 5 CPRELS - vandetanib tab 00 CPRELS - vandetanib tab 300 COMETRIQ - cabozantinib s-mal cap x 80 & x 0 (00 dose) kit COMETRIQ - cabozantinib s-mal cap x 80 & 3 x 0 (0 dose) kit COMETRIQ - cabozantinib s-malate cap 3 x 0 (60 dose) kit COTELLIC - cobimetinib fumarate tab 0 (base equivalent) cyclophosphamide cap 5 (Cyclophosphamide) 5 cyclophosphamide cap 50 (Cyclophosphamide) ELIGRD - leuprolide acetate (3 month) for subcutaneous inj kit.5 ELIGRD - leuprolide acetate ( month) for subcutaneous inj kit 30 ELIGRD - leuprolide acetate (6 month) for subcutaneous inj kit 5 ELIGRD - leuprolide acetate for subcutaneous inj kit 7.5 EMCYT - estramustine phosphate sodium cap 0 ERIVEDGE - vismodegib cap ERLED - apalutamide tab 60 ETOPOSIDE - etoposide cap 50 5 exemestane tab 5 (romasin) FRESTON - toremifene citrate tab 60 (base equivalent) FRYDK - panobinostat lactate cap 0 (base equivalent) FRYDK - panobinostat lactate cap 5 (base equivalent) FRYDK - panobinostat lactate cap 0 (base equivalent) flutamide cap 5 GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 30 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GLEOSTINE - lomustine cap 0 5 GLEOSTINE - lomustine cap 0 5 GLEOSTINE - lomustine cap Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary

20 09 HYCMTIN - topotecan hcl cap 0.5 (base equiv) HYCMTIN - topotecan hcl cap (base equiv) hydroxyurea cap 500 (Hydrea) IBRNCE - palbociclib cap 75 IBRNCE - palbociclib cap 00 IBRNCE - palbociclib cap 5 ICLUSIG - ponatinib hcl tab 5 (base equiv) ICLUSIG - ponatinib hcl tab 5 (base equiv) IDHIF - enasidenib mesylate tab 50 (base equivalent) IDHIF - enasidenib mesylate tab 00 (base equivalent) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 00 (base equivalent) (Gleevec) IMBRUVIC - ibrutinib cap 70 IMBRUVIC - ibrutinib cap 0 IMBRUVIC - ibrutinib tab 0 IMBRUVIC - ibrutinib tab 80 IMBRUVIC - ibrutinib tab 0 IMBRUVIC - ibrutinib tab 560 INLYT - axitinib tab INLYT - axitinib tab 5 INTRON - interferon alfa-b inj unit/ml INTRON - interferon alfa-b inj unit/ml INTRON - interferon alfa-b for inj unit INTRON - interferon alfa-b for inj unit INTRON - interferon alfa-b for inj unit IRESS - gefitinib tab 50 JKFI - ruxolitinib phosphate tab 5 (base equivalent) JKFI - ruxolitinib phosphate tab 0 (base equivalent) JKFI - ruxolitinib phosphate tab 5 (base equivalent) JKFI - ruxolitinib phosphate tab 0 (base equivalent) JKFI - ruxolitinib phosphate tab 5 (base equivalent) LENVIM 0 MG DILY DOSE - lenvatinib cap therapy pack 0 (0 daily dose) LENVIM MG DILY DOSE - lenvatinib cap therapy pack (3) ( daily dose) LENVIM MG DILY DOSE - lenvatinib cap therapy pack 0 & ( daily dose) LENVIM 8 MG DILY DOSE - lenvatinib cap therapy pack 0 & () (8 daily dose) LENVIM 0 MG DILY DOSE - lenvatinib cap therapy pack 0 () (0 daily dose) LENVIM MG DILY DOSE - lenvatinib cap therapy pack 0 () & ( daily dose) LENVIM MG DILY DOSE - lenvatinib cap therapy pack ( daily dose) LENVIM 8 MG DILY DOSE - lenvatinib cap therapy pack () (8 daily dose) letrozole tab.5 (Femara) LEUCOVORIN CLCIUM - leucovorin calcium tab 0 LEUCOVORIN CLCIUM - leucovorin calcium tab 5 leucovorin calcium tab 5 leucovorin calcium tab 5 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary

21 09 LEUKERN - chlorambucil tab 5 leuprolide acetate inj kit 5 /ml LONSURF - trifluridine-tipiracil tab 5-6. LONSURF - trifluridine-tipiracil tab LUPRON DEPOT (-MONTH) - leuprolide acetate for inj kit 3.75 LUPRON DEPOT (-MONTH) - leuprolide acetate for inj kit 7.5 LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj kit.5 LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj kit.5 LUPRON DEPOT (-MONTH) - leuprolide acetate ( month) for inj kit 30 LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for inj kit LYNPRZ - olaparib tab 00 LYNPRZ - olaparib tab 50 LYSODREN - mitotane tab 500 MTULNE - procarbazine hcl cap 50 megestrol acetate susp 0 /ml (Megace oral) megestrol acetate tab 0 megestrol acetate tab 0 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 (base equivalent) MEKINIST - trametinib dimethyl sulfoxide tab (base equivalent) MEKTOVI - binimetinib tab 5 melphalan tab (lkeran) 5 mercaptopurine tab 50 MESNEX - mesna tab 00 5 METHOTREXTE SODIUM - methotrexate sodium inj 50 /0ml (5 /ml) methotrexate sodium for inj gm methotrexate sodium inj pf 50 /ml (5 /ml) methotrexate sodium inj pf 50 /0ml (5 /ml) methotrexate sodium inj pf 000 /0ml (5 /ml) methotrexate sodium inj 50 /ml (5 /ml) methotrexate sodium tab.5 (base equiv) MYLERN - busulfan tab 5 NERLYNX - neratinib maleate tab 0 (base equivalent) NEXVR - sorafenib tosylate tab 00 (base equivalent) nilutamide tab 50 (Nilandron) 5 NINLRO - ixazomib citrate cap.3 (base equivalent) NINLRO - ixazomib citrate cap 3 (base equivalent) NINLRO - ixazomib citrate cap (base equivalent) ODOMZO - sonidegib phosphate cap 00 (base equivalent) POMLYST - pomalidomide cap POMLYST - pomalidomide cap POMLYST - pomalidomide cap 3 POMLYST - pomalidomide cap Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 3

22 09 PURIXN - mercaptopurine susp 000 /00ml (0 /ml) 5 RYDPT - midostaurin cap 5 SOLTMOX - tamoxifen citrate oral soln 0 /5ml (base equivalent) SPRYCEL - dasatinib tab 0 SPRYCEL - dasatinib tab 50 SPRYCEL - dasatinib tab 70 SPRYCEL - dasatinib tab 80 SPRYCEL - dasatinib tab 00 SPRYCEL - dasatinib tab 0 STIVRG - regorafenib tab 0 SUTENT - sunitinib malate cap.5 (base equivalent) SUTENT - sunitinib malate cap 5 (base equivalent) SUTENT - sunitinib malate cap 37.5 (base equivalent) SUTENT - sunitinib malate cap 50 (base equivalent) SYLTRON - peginterferon alfa-b for inj kit 00 mcg SYLTRON - peginterferon alfa-b for inj kit 300 mcg SYLTRON - peginterferon alfa-b for inj kit 600 mcg SYNRIBO - omacetaxine mepesuccinate for inj 3.5 TBLOID - thioguanine tab 0 5 TFINLR - dabrafenib mesylate cap 50 (base equivalent) TFINLR - dabrafenib mesylate cap 75 (base equivalent) TGRISSO - osimertinib mesylate tab 0 (base equivalent) TGRISSO - osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) 5 tamoxifen citrate tab 0 (base equivalent) TRCEV - erlotinib hcl tab 5 (base equivalent) TRCEV - erlotinib hcl tab 00 (base equivalent) TRCEV - erlotinib hcl tab 50 (base equivalent) TSIGN - nilotinib hcl cap 50 (base equivalent) TSIGN - nilotinib hcl cap 50 (base equivalent) TSIGN - nilotinib hcl cap 00 (base equivalent) temozolomide cap 5 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 00 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 50 (Temodar) TIBSOVO - ivosidenib tab 50 tretinoin cap 0 5 TREXLL - methotrexate sodium tab 5 (base equiv) TREXLL - methotrexate sodium tab 7.5 (base equiv) TREXLL - methotrexate sodium tab 0 (base equiv) TREXLL - methotrexate sodium tab 5 (base equiv) TYKERB - lapatinib ditosylate tab 50 (base equiv) VENCLEXT - venetoclax tab 0 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary

23 09 VENCLEXT - venetoclax tab 50 VENCLEXT - venetoclax tab 00 VENCLEXT STRTING PCK - venetoclax tab therapy starter pack 0 & 50 & 00 VERZENIO - abemaciclib tab 50 VERZENIO - abemaciclib tab 00 VERZENIO - abemaciclib tab 50 VERZENIO - abemaciclib tab 00 VOTRIENT - pazopanib hcl tab 00 (base equiv) XLKORI - crizotinib cap 00 XLKORI - crizotinib cap 50 XTNDI - enzalutamide cap 0 6 ZEJUL - niraparib tosylate cap 00 (base equivalent) ZELBORF - vemurafenib tab 0 ZOLINZ - vorinostat cap 00 ZYDELIG - idelalisib tab 00 ZYDELIG - idelalisib tab 50 ZYKDI - ceritinib cap 50 ZYTIG - abiraterone acetate tab 50 ZYTIG - abiraterone acetate tab 500 ENDOCRINE ND METBOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap 3 (Entocort ec) CORTISONE CETTE - cortisone acetate tab 5 DEXMETHSONE - dexamethasone soln 0.5 /5ml DEXMETHSONE - dexamethasone tab DEXMETHSONE - dexamethasone tab dexamethasone elixir 0.5 /5ml DEXMETHSONE INTENSOL - dexamethasone conc /ml dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab.5 dexamethasone tab dexamethasone tab 6 fludrocortisone acetate tab 0. hydrocortisone tab 5 (Cortef) hydrocortisone tab 0 (Cortef) hydrocortisone tab 0 (Cortef) MEDROL - methylprednisolone tab methylprednisolone tab therapy pack () (Medrol dosepak) methylprednisolone tab (Medrol) methylprednisolone tab 8 (Medrol) methylprednisolone tab 6 (Medrol) methylprednisolone tab 3 (Medrol) PREDNISOLONE - prednisolone syrup 5 /5ml (usp solution equivalent) prednisolone sod phos orally disintegr tab 0 (base eq) (Orapred odt) prednisolone sod phos orally disintegr tab 5 (base eq) (Orapred odt) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 5

24 09 prednisolone sod phos orally disintegr tab 30 (base eq) (Orapred odt) prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base) (Pediapred) prednisolone sod phosphate oral soln 5 /5ml (base equiv) prednisolone sod phosphate oral soln 0 /5ml (base equiv) (Millipred) prednisolone sod phosphate oral soln 0 /5ml (base equiv) (Veripred 0) PREDNISOLONE SODIUM PHOSP - prednisolone sodium phosphate oral soln 5 /5ml (base eq) PREDNISONE - prednisone oral soln 5 /5ml PREDNISONE - prednisone tab therapy pack 5 () PREDNISONE - prednisone tab therapy pack 5 (8) PREDNISONE - prednisone tab therapy pack 0 () PREDNISONE - prednisone tab therapy pack 0 (8) PREDNISONE - prednisone tab 50 PREDNISONE INTENSOL - prednisone conc 5 /ml prednisone tab prednisone tab.5 prednisone tab 5 prednisone tab 0 prednisone tab 0 NDROGEN-NBOLIC NDROL-50 - oxymetholone tab 50 danazol cap 50 danazol cap 00 danazol cap 00 METHYLTESTOSTERONE - methyltestosterone cap 0 oxandrolone tab.5 (Oxandrin) oxandrolone tab 0 (Oxandrin) TESTOSTERONE - testosterone td gel 5 /.5gm (%) TESTOSTERONE - testosterone td gel 50 /5gm (%) testosterone cypionate im inj in oil 00 /ml (Depotestosterone) testosterone cypionate im inj in oil 00 /ml (Depotestosterone) testosterone enanthate im inj in oil 00 /ml TESTOSTERONE PUMP - testosterone td gel.5 /act (%) testosterone td gel 5 /.5gm (%) (ndrogel) testosterone td gel 50 /5gm (%) (ndrogel) testosterone td gel.5 /act (%) (ndrogel pump) testosterone td gel 0.5 /.5gm (.6%) (ndrogel) testosterone td gel 0.5 /.5gm (.6%) (ndrogel) testosterone td gel 0.5 /act (.6%) (ndrogel pump) testosterone td soln 30 /act (xiron) 5 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 6

25 09 VOGELXO - testosterone td gel 50 /5gm (%) VOGELXO PUMP - testosterone td gel.5 /act (%) ESTROGENS LOR - estradiol td patch twice weekly 0.05 /hr LOR - estradiol td patch twice weekly 0.05 /hr LOR - estradiol td patch twice weekly /hr LOR - estradiol td patch twice weekly 0. /hr NGELIQ - drospirenone-estradiol tab NGELIQ - drospirenone-estradiol tab 0.5- CLIMR PRO - estradiollevonorgestrel td patch weekly /day COMBIPTCH - estradiolnorethindrone ace td pttw /day COMBIPTCH - estradiolnorethindrone ace td pttw /day DELESTROGEN - estradiol valerate im in oil 0 /ml DEPO-ESTRDIOL - estradiol cypionate im in oil 5 /ml DIVIGEL - estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL - estradiol td gel 0.5 /0.5gm (0.%) DIVIGEL - estradiol td gel /gm (0.%) DUVEE - conjugated estrogensbazedoxifene tab ELESTRIN - estradiol gel 0.06% (0.5 /0.87 gm metered-dose pump) estradiol & norethindrone acetate tab (ctivella) estradiol & norethindrone acetate tab -0.5 (ctivella) estradiol tab 0.5 (Estrace) estradiol tab (Estrace) estradiol tab (Estrace) estradiol td patch twice weekly 0.05 /hr (Vivelle-dot) estradiol td patch twice weekly /hr (Vivelle-dot) estradiol td patch twice weekly 0.05 /hr (Vivelle-dot) estradiol td patch twice weekly /hr (Vivelle-dot) estradiol td patch twice weekly 0. /hr (Vivelle-dot) estradiol td patch weekly 0.05 /hr (Climara) estradiol td patch weekly /hr (37.5 mcg/hr) (Climara) estradiol td patch weekly 0.05 /hr (Climara) estradiol td patch weekly 0.06 /hr (Climara) estradiol td patch weekly /hr (Climara) estradiol td patch weekly 0. /hr (Climara) estradiol valerate im in oil 0 / ml (Delestrogen) estradiol valerate im in oil 0 / ml (Delestrogen) ESTROGEL - estradiol gel 0.06% (0.75 /.5 gm metered-dose pump) MENEST - esterified estrogens tab 0.3 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) January 09 Essential 6 Tier Formulary 7