Blue Cross & Blue Shield of Rhode Island Commercial 5-Tier Specialty Prescription Drug List

Transcription

1 < January Blue Cross & Blue Shield of Rhode Island Commercial 5- Prescription Drug List The Blue Cross & Blue Shield of Rhode Island Commercial 5- Prescription Drug List is updated in April and October. Please visit or Prime Therapeutics at for the most up-to-date information. Contents Introduction... I How formulary drugs are selected... I s... I Affordable Care Act... I products... II Step therapy... II Preauthorization... II Maximum monthly quantity... II Providers... II Key... III Therapeutic class drug list Anti-infective agents... Biologicals... 9 Antineoplastic agents... Endocrine and metabolic drugs... 8 Cardiovascular agents... 4 Respiratory agents Gastrointestinal agents... 5 Genitourinary agents Central nervous system drugs Analgesics and anesthetics Neuromuscular drugs Nutritional products... 9 Hematological agents Topical products Miscellaneous products... 7 Index... 8 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. 68-D RI Prime Therapeutics LLC /9

2 Introduction The attached Blue Cross & Blue Shield of Rhode Island Commercial 5- Prescription Drug List (Drug List) shows covered drugs for a broad range of diseases. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in capital letters followed by the generic name. The Drug List is organized into broad categories, like anti-infective drugs. Within most categories, drugs are subgrouped by drug class, like penicillins, or by use for a specific medical condition, like diabetes. Members can also use this list to check for a particular drug or find drug cost estimates using on line tools available through the Prime Therapeutics website at Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when appropriate for the member. However, decisions regarding therapy and treatment are always between members and their physician. The current version of this drug list is available at the Blue Cross & Blue Shield of Rhode Island website at or by calling the customer service number listed on back of your identification card. Online pharmacy tools are available through the Prime Therapeutics website at How formulary drugs are selected Drugs on this list are selected based on the recommendations of the Blue Cross & Blue Shield of Rhode Island (BCBSRI) Pharmacy & Therapeutics (P&T) Committee. The P&T membership includes local practitioners and pharmacists who provide direct member care. The physician members include a minimum of five contracted and board-certified physicians, one of which will be a primary care physician (PCP), and at least three specialists, two community pharmacists, and the BCBSRI Chief Medical Officer or designee, as the acting Chairperson. Drugs that are newly approved by the FDA, as well as those that have been on the market for some time, are considered based on safety, efficacy, cost, and how they compare to other drugs currently on the list. s This prescription benefit is multi-tiered, placing prescription drugs into one of the below copay/coinsurance levels: : Low-cost generic drugs : Higher cost generic and preferred brand name drugs : Highest cost generic and non-preferred brand name drugs 4: Preferred specialty drugs 5: Non-preferred specialty drugs Note: Drugs listed with an A in the drug tier column indicates the drug may be covered at $0 cost-sharing if you meet certain criteria under the Affordable Care Act. Drugs listed with an F in the drug tier column indicates the drug is included for coverage under the Fertility benefit and is typically subject to a % (percentage) cost-sharing or as outlined in your Certificate of Coverage. Affordable Care Act Please note, some drugs may have limited or $0 cost-sharing under the Affordable Care Act. If you do not find the drug you are searching for, contact BCBSRI to find out if the drug is available over the counter or is covered under your medical benefit. Plan limitations may apply, consistent with recommended or approved indications for use. Blue Cross & Blue Shield of Rhode Island Commercial 5- Prescription Drug List January I

3 products drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis, and rheumatoid arthritis. drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. drugs are distributed through our preferred specialty pharmacy providers. Drugs marked as limited distribution have been restricted by the drug manufacturer as to where you may obtain the drug. This may include requiring the use of a designated pharmacy to fill a prescription. Step therapy Your benefit plan may include a step therapy program. This means you may need to try another proven, cost-effective medication before coverage may be available for the drug included in the program. Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. If a step therapy is required for a medication listed in this document, it will be noted next to the medication with a dot under the step therapy column. Preauthorization Your benefit plan may require preauthorization for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a preauthorization request for coverage of these medications, and the request will need to be approved before the medication will be covered under your plan. If a preauthorization is required for a medication listed in this document, it will be noted next to the medication with a dot under the preauthorization column. Quantity limits help encourage medication use as intended by the FDA. These limits are placed on medications in certain drug categories. For the medications listed in this document, if a quantity limit applies, it will be noted next to the medication with a dot under the quantity limit column. Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in a given time period. There may also be limits for members based upon clinical criteria for eligibility. Providers If you have any questions on the following covered drug list, please contact our Member Service Center. Disclaimer Your health plan s benefit design determines what is covered and the applicable copayment. The medications listed on this Drug List are subject to change pursuant to the formulary management activities of BCBSRI. The presence of a medication on this Drug List does not guarantee coverage. Certain therapeutic classes are routinely designated as formulary exclusions and are not eligible for coverage. These classes include Weight Loss, Erectile Dysfunction, Smoking Cessation, over-the-counter status products and drugs with over-the-counter equivalents, Vaccines, products with DESI designations and experimental drugs. Most brand name drugs with generic equivalents are not covered. Blue Cross & Blue Shield of Rhode Island Commercial 5- Prescription Drug List January II

4 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... ophthalmic 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 & Blue Shield of Rhode Island Commercial 5- Prescription Drug List January III

5 ANTI-INFECTIVE AGENTS PENICILLINS AMOXICILLIN - amoxicillin (trihydrate) chew tab 5 AMOXICILLIN - 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 400 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr (Augmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab (Augmentin) amoxicillin & k clavulanate tab (Augmentin) AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab AMOXICILLIN/CLAVULANATE P - amoxicillin & k clavulanate chew tab AMPICILLIN - ampicillin cap 500 AUGMENTIN - amoxicillin & k clavulanate for susp 5-.5 /5ml BICILLIN L-A - penicillin g benzathine intramuscular susp unit/ml BICILLIN L-A - penicillin g benzathine intramuscular susp unit/ml BICILLIN L-A - penicillin g benzathine intramuscular susp unit/4ml dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 MOXATAG - amoxicillin (trihydrate) tab er 4hr 775 PENICILLIN V POTASSIUM - penicillin v potassium for soln 5 /5ml PENICILLIN V POTASSIUM - penicillin v potassium for soln 50 /5ml penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHALOSPORINS CEFACLOR - cefaclor for susp 5 /5ml CEFACLOR - cefaclor for susp 50 /5ml CEFACLOR - cefaclor for susp 75 /5ml cefaclor cap 50 Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January

6 cefaclor cap 500 CEFACLOR ER - cefaclor monohydrate tab er hr 500 cefadroxil cap 500 cefadroxil for susp 50 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 00 cefdinir for susp 5 /5ml cefdinir for susp 50 /5ml CEFDITOREN PIVOXIL - cefditoren pivoxil tab 00 (base equivalent) CEFDITOREN PIVOXIL - cefditoren pivoxil tab 400 (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 cefuroxime axetil tab 500 (Ceftin) CEPHALEXIN - cephalexin tab 50 CEPHALEXIN - 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 SPECTRACEF - cefditoren pivoxil tab 400 (base equivalent) SUPRAX - cefixime cap 400 SUPRAX - cefixime chew tab 00 SUPRAX - cefixime chew tab 00 SUPRAX - cefixime for susp 500 /5ml MACROLIDES AZITHROMYCIN - 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) CLARITHROMYCIN - clarithromycin for susp 5 /5ml CLARITHROMYCIN - clarithromycin for susp 50 /5ml clarithromycin tab er 4hr 500 clarithromycin tab 50 (Biaxin) clarithromycin tab 500 (Biaxin) DIFICID - fidaxomicin tab 00 E.E.S erythromycin ethylsuccinate tab 400 Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January

7 ERY-TAB - erythromycin tab delayed release 50 ERY-TAB - erythromycin tab delayed release ERY-TAB - erythromycin tab delayed release 500 ERYPED erythromycin ethylsuccinate for susp 400 /5ml ERYTHROCIN STEARATE - erythromycin stearate tab 50 ERYTHROMYCIN ETHYLSUCCINA - erythromycin ethylsuccinate tab 400 erythromycin ethylsuccinate for susp 00 /5ml (E.e.s. granules) erythromycin tab 50 erythromycin tab 500 erythromycin w/ delayed release particles cap 50 TETRACYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 00 doxycycline hyclate cap 50 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab delayed release 75 doxycycline hyclate tab delayed release 00 doxycycline hyclate tab delayed release 50 doxycycline hyclate tab 0 doxycycline hyclate tab 00 doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 doxycycline monohydrate for susp 5 /5ml (Vibramycin) doxycycline monohydrate tab 50 (Adoxa) doxycycline monohydrate tab 75 (Adoxa) doxycycline monohydrate tab 00 (Adoxa pak /00) doxycycline monohydrate tab 50 minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) tetracycline hcl cap 50 (Tetracycline hcl) tetracycline hcl cap 500 (Tetracycline hcl) VIBRAMYCIN - doxycycline calcium syrup 50 /5ml FLUOROQUINOLONES BAXDELA - delafloxacin meglumine tab 450 (base equiv) CIPROFLOXACIN ER - ciprofloxacin-ciprofloxacin hcl tab er 4hr 500 (base eq) CIPROFLOXACIN ER - ciprofloxacin-ciprofloxacin hcl tab er 4hr 000 (base eq) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) CIPROFLOXACIN HCL - ciprofloxacin hcl tab 00 (base equiv) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January

8 ciprofloxacin hcl tab 50 (base equiv) (Cipro) ciprofloxacin hcl tab 500 (base equiv) (Cipro) ciprofloxacin hcl tab 750 (base equiv) levofloxacin oral soln 5 /ml levofloxacin tab 50 (Levaquin) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) moxifloxacin hcl tab 400 (base equiv) (Avelox) OFLOXACIN - ofloxacin tab 00 ofloxacin tab 400 AMINOGLYCOSIDES BETHKIS - tobramycin nebu soln 00 /4ml KITABIS PAK - tobramycin nebu soln 00 /5ml neomycin sulfate tab 500 paromomycin sulfate cap 50 TOBI PODHALER - tobramycin inhal cap 8 TOBRAMYCIN - tobramycin nebu soln 00 /5ml tobramycin nebu soln 00 /5ml (Tobi) SULFONAMIDES SULFADIAZINE - sulfadiazine tab 500 ANTIMYCOBACTERIAL AGENTS CYCLOSERINE - cycloserine cap 50 ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 400 (Myambutol) ISONIAZID - isoniazid syrup 50 /5ml isoniazid tab 00 isoniazid tab 00 PASER - aminosalicylic acid er granules packet 4 gm PRIFTIN - rifapentine tab 50 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) RIFAMATE - isoniazid & rifampin cap rifampin cap 50 (Rifadin) rifampin cap 00 (Rifadin) RIFATER - isoniazid-rifampin w/ pyrazinamide tab SIRTURO - bedaquiline fumarate tab 00 (base equiv) TRECATOR - ethionamide tab 50 ANTIFUNGALS fluconazole for susp 0 /ml (Diflucan) fluconazole for susp 40 /ml (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) flucytosine cap 50 (Ancobon) flucytosine cap 500 (Ancobon) griseofulvin microsize susp 5 /5ml griseofulvin microsize tab 500 Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 4

9 griseofulvin ultramicrosize tab 5 griseofulvin ultramicrosize tab 50 itraconazole cap 00 (Sporanox) nystatin tab unit SPORANOX - itraconazole oral soln 0 /ml terbinafine hcl tab 50 (Lamisil) voriconazole for susp 40 /ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 00 (Vfend) ANTIVIRALS abacavir sulfate soln 0 /ml (base equiv) (Ziagen) abacavir sulfate tab 00 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab (Epzicom) abacavir sulfate-lamivudinezidovudine tab (Trizivir) acyclovir cap 00 (Zovirax) acyclovir susp 00 /5ml (Zovirax) acyclovir tab 400 (Zovirax) acyclovir tab 800 (Zovirax) adefovir dipivoxil tab 0 (Hepsera) APTIVUS - tipranavir cap 50 APTIVUS - tipranavir oral soln 00 /ml atazanavir sulfate cap 50 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) atazanavir sulfate cap 00 (base equiv) (Reyataz) ATRIPLA - efavirenz-emtricitabinetenofovir df tab BARACLUDE - entecavir oral soln 0.05 /ml BIKTARVY - bictegraviremtricitabine-tenofovir af tab CIMDUO - lamivudine-tenofovir disoproxil fumarate tab COMPLERA - emtricitabinerilpivirine-tenofovir df tab CRIXIVAN - indinavir sulfate cap 00 CRIXIVAN - indinavir sulfate cap 400 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 400 (Videx ec) EDURANT - rilpivirine hcl tab 5 (base equivalent) efavirenz cap 50 (Sustiva) efavirenz cap 00 (Sustiva) efavirenz tab 600 (Sustiva) EMTRIVA - emtricitabine caps 00 EMTRIVA - emtricitabine soln 0 /ml entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUSA - sofosbuvir-velpatasvir tab Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 5

10 EPIVIR HBV - lamivudine oral soln 5 /ml (hbv) EVOTAZ - atazanavir sulfatecobicistat tab (base equiv) famciclovir tab 5 (Famvir) famciclovir tab 50 (Famvir) famciclovir tab 500 (Famvir) fosamprenavir calcium tab 700 (base equiv) (Lexiva) FUZEON - enfuvirtide for inj 90 GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab HARVONI - ledipasvir-sofosbuvir tab INTELENCE - etravirine tab 5 INTELENCE - etravirine tab 00 INTELENCE - etravirine tab 00 INVIRASE - saquinavir mesylate cap 00 INVIRASE - 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 400 (base equiv) ISENTRESS HD - raltegravir potassium tab 600 (base equiv) JULUCA - dolutegravir sodiumrilpivirine hcl tab 50-5 (base eq) KALETRA - lopinavir-ritonavir tab 00-5 KALETRA - lopinavir-ritonavir tab lamivudine oral soln 0 /ml (Epivir) lamivudine tab 00 (hbv) (Epivir hbv) lamivudine tab 50 (Epivir) lamivudine tab 00 (Epivir) lamivudine-zidovudine tab (Combivir) LEXIVA - fosamprenavir calcium susp 50 /ml (base equiv) lopinavir-ritonavir soln /5ml (80-0 /ml) (Kaletra) MAVYRET - glecaprevirpibrentasvir tab MODERIBA 00 DOSE PACK - ribavirin tab 600 nevirapine susp 50 /5ml (Viramune) nevirapine tab er 4hr 00 (Viramune xr) nevirapine tab er 4hr 400 (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 0 (base equiv) (Tamiflu) oseltamivir phosphate cap 45 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) oseltamivir phosphate for susp 6 /ml (base equiv) (Tamiflu) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 6

11 PEGASYS - peginterferon alfa-a inj 80 mcg/ml PEGASYS - peginterferon alfa-a inj 80 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 5 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREVYMIS - letermovir tab 40 PREVYMIS - letermovir tab 480 PREZCOBIX - darunavir-cobicistat tab PREZISTA - darunavir ethanolate susp 00 /ml (base equiv) PREZISTA - darunavir ethanolate tab 75 (base equiv) PREZISTA - darunavir ethanolate tab 50 (base equiv) PREZISTA - darunavir ethanolate tab 600 (base equiv) PREZISTA - darunavir ethanolate tab 800 (base equiv) REBETOL - ribavirin soln 40 /ml RELENZA DISKHALER - zanamivir aero powder breath activated 5 /blister RESCRIPTOR - delavirdine mesylate tab 00 REYATAZ - atazanavir sulfate oral powder packet 50 (base equiv) RIBASPHERE - ribavirin tab 400 RIBASPHERE - ribavirin tab 600 RIBASPHERE RIBAPAK - ribavirin tab 00 & ribavirin 400 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 400 & ribavirin 600 tab therapy pack RIBASPHERE RIBAPAK - ribavirin tab 400 RIBASPHERE RIBAPAK - ribavirin tab 600 ribavirin cap 00 (Rebetol) ribavirin for inhal soln 6 gm (Virazole) ribavirin tab 00 (Copegus) rimantadine hydrochloride tab 00 (Flumadine) ritonavir tab 00 (Norvir) SELZENTRY - maraviroc oral soln 0 /ml SELZENTRY - maraviroc tab 5 SELZENTRY - maraviroc tab 75 SELZENTRY - maraviroc tab 50 SELZENTRY - maraviroc tab 00 SITAVIG - acyclovir buccal tab 50 SOVALDI - sofosbuvir tab 400 stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 0 (Zerit) stavudine cap 40 (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab SYMFI - efavirenz-lamivudinetenofovir df tab SYMFI LO - efavirenz-lamivudinetenofovir df tab Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 7

12 SYMTUZA - darunavir-cobicemtricitab-tenofov af tab tenofovir disoproxil fumarate tab 00 (Viread) TIVICAY - dolutegravir sodium tab 0 (base equiv) TIVICAY - dolutegravir sodium tab 5 (base equiv) TIVICAY - dolutegravir sodium tab 50 (base equiv) TRIUMEQ - abacavir-dolutegravirlamivudine tab TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab -00 TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab valacyclovir hcl tab 500 (Valtrex) valacyclovir hcl tab gm (Valtrex) valganciclovir hcl for soln 50 /ml (base equiv) (Valcyte) valganciclovir hcl tab 450 (base equivalent) (Valcyte) VIDEX - didanosine for soln gm VIDEX - didanosine for soln 4 gm VIRACEPT - nelfinavir mesylate tab 50 VIRACEPT - nelfinavir mesylate tab 65 VIRAMUNE - nevirapine susp 50 /5ml VIREAD - tenofovir disoproxil fumarate oral powder 40 /gm VIREAD - tenofovir disoproxil fumarate tab 50 VIREAD - tenofovir disoproxil fumarate tab 00 VIREAD - tenofovir disoproxil fumarate tab 50 VOSEVI - sofosbuvir-velpatasvirvoxilaprevir tab zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 00 ANTIMALARIALS atovaquone-proguanil hcl tab (Malarone) atovaquone-proguanil hcl tab (Malarone) CHLOROQUINE PHOSPHATE - chloroquine phosphate tab 50 chloroquine phosphate tab 500 (Aralen) COARTEM - artemetherlumefantrine tab 0-0 DARAPRIM - pyrimethamine tab 5 hydroxychloroquine sulfate tab 00 (Plaquenil) MEFLOQUINE HCL - mefloquine hcl tab 50 PRIMAQUINE PHOSPHATE - primaquine phosphate tab 6. (5 base) quinine sulfate cap 4 (Qualaquin) ANTHELMINTICS albendazole tab 00 (Albenza) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 8

13 ALBENZA - albendazole tab 00 EMVERM - mebendazole chew tab 00 ivermectin tab (Stromectol) praziquantel tab 600 (Biltricide) ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 00 /5ml ALINIA - nitazoxanide tab 500 atovaquone susp 750 /5ml (Mepron) CAYSTON - aztreonam lysine for inhal soln 75 (base equivalent) clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 00 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 dapsone tab 00 FIRVANQ - vancomycin hcl for oral soln 5 /ml (base equivalent) FIRVANQ - vancomycin hcl for oral soln 50 /ml (base equivalent) linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 75 (Flagyl) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) NEBUPENT - pentamidine isethionate for nebulization soln 00 PRIMSOL - trimethoprim hcl oral soln 50 /5ml (base equiv) SIVEXTRO - tedizolid phosphate tab 00 sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab (Bactrim) sulfamethoxazole-trimethoprim tab (Bactrim ds) tinidazole tab 50 (Tindamax) tinidazole tab 500 (Tindamax) trimethoprim tab 00 VANCOMYCIN HCL - vancomycin hcl for iv soln 00 gm (base equivalent) vancomycin hcl cap 5 (base equivalent) (Vancocin hcl) vancomycin hcl cap 50 (base equivalent) (Vancocin hcl) vancomycin hcl for iv soln 500 (base equivalent) vancomycin hcl for iv soln 750 (base equivalent) vancomycin hcl for iv soln gm (base equivalent) vancomycin hcl for iv soln 5 gm (base equivalent) vancomycin hcl for iv soln 0 gm (base equivalent) XIFAXAN - rifaximin tab 00 XIFAXAN - rifaximin tab 550 BIOLOGICALS VACCINES AFLURIA PF influenza virus vaccine split pf susp pref syringe 0.5 ml A Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 9

14 AFLURIA QUADRIVALENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml AFLURIA QUADRIVALENT 08 - influenza virus vaccine split quadrivalent im inj AFLURIA influenza virus vaccine split im susp FLUAD influenza vac type a&b surface ant adj susp pref syr 0.5 ml FLUARIX QUADRIVALENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLUBLOK QUADRIVALENT 08 - influenza vac recomb ha quad pf soln pref syr 0.5 ml FLUCELVAX QUADRIVALENT 0 - influenza vac tiss-cult subunt quad susp pref syr 0.5 ml FLUCELVAX QUADRIVALENT 0 - influenza vac tissue-cultured subunit quadrivalent im susp FLULAVAL QUADRIVALENT 0 - influenza virus vac split quadrivalent susp pref syr 0.5ml FLULAVAL QUADRIVALENT 0 - influenza virus vaccine split quadrivalent im inj FLUMIST QUADRIVALENT - influenza virus vaccine live quadrivalent intranasal susp FLUZONE HIGH-DOSE PF 08 - influenza virus vac split highdose pf susp pref syr 0.5ml FLUZONE QUADRIVALENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5 ml FLUZONE QUADRIVALENT 08 - influenza virus vac split quadrivalent susp pref syr 0.5ml A A A A A A A A A A A A A A FLUZONE QUADRIVALENT 08 - influenza virus vaccine split quadrivalent im inj FLUZONE QUADRIVALENT 08 - influenza virus vaccine split quadrivalent inj 0.5 ml MEDICAL PROVIDER SINGLE U - influenza vac tiss-cult subunit quad sus pref syr kit 0.5 ml SHINGRIX - zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml ZOSTAVAX - zoster vaccine live for subcutaneous susp 9400 unit/0.65ml PASSIVE IMMUNIZING AGENTS BIVIGAM - immune globulin (human) iv soln 5 gm/50ml BIVIGAM - immune globulin (human) iv soln 0 gm/00ml CARIMUNE NANOFILTERED - immune globulin (human) iv for soln 6 gm CARIMUNE NANOFILTERED - immune globulin (human) iv for soln gm CUVITRU - immune globulin (human) subcutaneous inj gm/5ml CUVITRU - immune globulin (human) subcutaneous inj gm/0ml CUVITRU - immune globulin (human) subcutaneous inj 4 gm/0ml CUVITRU - immune globulin (human) subcutaneous inj 8 gm/40ml FLEBOGAMMA DIF - immune globulin (human) iv soln 0.5 gm/0ml A A A A A Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 0

15 FLEBOGAMMA DIF - immune globulin (human) iv soln.5 gm/50ml FLEBOGAMMA DIF - immune globulin (human) iv soln 5 gm/00ml FLEBOGAMMA DIF - immune globulin (human) iv soln 0 gm/00ml FLEBOGAMMA DIF - immune globulin (human) iv soln 0 gm/400ml FLEBOGAMMA DIF - immune globulin (human) iv soln 5 gm/50ml FLEBOGAMMA DIF - immune globulin (human) iv soln 0 gm/00ml FLEBOGAMMA DIF - immune globulin (human) iv soln 0 gm/00ml GAMASTAN - immune globulin (human) im inj GAMASTAN S/D - immune globulin (human) im inj GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln gm/0ml GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln.5 gm/5ml GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 5 gm/50ml GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMMAGARD LIQUID - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMMAGARD S/D IGA LESS TH - immune globulin (human) iv for soln 5 gm GAMMAGARD S/D IGA LESS TH - immune globulin (human) iv for soln 0 gm GAMMAKED - immune globulin (human) iv or subcutaneous soln gm/0ml GAMMAKED - immune globulin (human) iv or subcutaneous soln.5 gm/5ml GAMMAKED - immune globulin (human) iv or subcutaneous soln 5 gm/50ml GAMMAKED - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMMAKED - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMMAPLEX - immune globulin (human) iv soln 5 gm/00ml GAMMAPLEX - immune globulin (human) iv soln 0 gm/00ml GAMMAPLEX - immune globulin (human) iv soln 0 gm/400ml GAMMAPLEX - immune globulin (human) iv soln 5 gm/50ml GAMMAPLEX - immune globulin (human) iv soln 0 gm/00ml GAMMAPLEX - immune globulin (human) iv soln 0 gm/00ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln gm/0ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln.5 gm/5ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 5 gm/50ml 5 5 Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January

16 GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 0 gm/00ml GAMUNEX-C - immune globulin (human) iv or subcutaneous soln 40 gm/400ml HIZENTRA - immune globulin (human) subcutaneous inj gm/5ml HIZENTRA - immune globulin (human) subcutaneous inj gm/0ml HIZENTRA - immune globulin (human) subcutaneous inj 4 gm/0ml HIZENTRA - immune globulin (human) subcutaneous inj 0 gm/50ml HYQVIA - immun glob inj.5 gm/5ml-hyaluron inj 00 unt/.5 ml kit HYQVIA - immun glob inj 5 gm/50ml-hyaluron inj 400 unt/.5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 800 unt/5 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 600 unt/0 ml kit HYQVIA - immun glob inj 0 gm/00ml-hyaluron inj 400 unt/5 ml kit OCTAGAM - immune globulin (human) iv soln gm/0ml OCTAGAM - immune globulin (human) iv soln.5 gm/50ml OCTAGAM - immune globulin (human) iv soln 5 gm/00ml OCTAGAM - immune globulin (human) iv soln 0 gm/00ml OCTAGAM - immune globulin (human) iv soln 5 gm/500ml OCTAGAM - immune globulin (human) iv soln gm/0ml OCTAGAM - immune globulin (human) iv soln 5 gm/50ml OCTAGAM - immune globulin (human) iv soln 0 gm/00ml OCTAGAM - immune globulin (human) iv soln 0 gm/00ml PRIVIGEN - immune globulin (human) iv soln 5 gm/50ml PRIVIGEN - immune globulin (human) iv soln 0 gm/00ml PRIVIGEN - immune globulin (human) iv soln 0 gm/00ml PRIVIGEN - immune globulin (human) iv soln 40 gm/400ml SYNAGIS - palivizumab im soln 50 /0.5ml SYNAGIS - palivizumab im soln 00 /ml WINRHO SDF - rho d immune globulin (human) inj 500 unit/.ml WINRHO SDF - rho d immune globulin (human) inj 5000 unit/4.4ml WINRHO SDF - rho d immune globulin (human) inj 500 unit/.ml WINRHO SDF - rho d immune globulin (human) inj 5000 unit/ml ANTINEOPLASTIC AGENTS ANTINEOPLASTICS ACTIMMUNE - interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January

17 AFINITOR - everolimus tab.5 AFINITOR - everolimus tab 5 AFINITOR - everolimus tab 7.5 AFINITOR - everolimus tab 0 AFINITOR DISPERZ - everolimus tab for oral susp AFINITOR DISPERZ - everolimus tab for oral susp AFINITOR DISPERZ - everolimus tab for oral susp 5 ALECENSA - alectinib hcl cap 50 (base equivalent) ALUNBRIG - brigatinib tab initiation therapy pack 90 & 80 ALUNBRIG - brigatinib tab 0 ALUNBRIG - brigatinib tab 90 ALUNBRIG - brigatinib tab 80 anastrozole tab (Arimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 400 BOSULIF - bosutinib tab 500 BRAFTOVI - encorafenib cap 50 BRAFTOVI - encorafenib cap 75 CABOMETYX - cabozantinib s-malate tab 0 (base equivalent) CABOMETYX - cabozantinib s-malate tab 40 (base equivalent) CABOMETYX - cabozantinib s-malate tab 60 (base equivalent) CALQUENCE - acalabrutinib cap capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA - vandetanib tab 00 CAPRELSA - vandetanib tab 00 COMETRIQ - cabozantinib s-mal cap x 80 & x 0 (00 dose) kit COMETRIQ - cabozantinib s-mal cap x 80 & x 0 (40 dose) kit COMETRIQ - cabozantinib s-malate cap x 0 (60 dose) kit COPIKTRA - duvelisib cap 5 5 COPIKTRA - duvelisib cap 5 5 COTELLIC - cobimetinib fumarate tab 0 (base equivalent) CYCLOPHOSPHAMIDE - cyclophosphamide cap 5 CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 cyclophosphamide cap 5 (Cyclophosphamide) cyclophosphamide cap 50 (Cyclophosphamide) DEPO-PROVERA - medroxyprogesterone acetate im susp 400 /ml ELIGARD - leuprolide acetate ( month) for subcutaneous inj kit.5 ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit 0 ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit 45 ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 EMCYT - estramustine phosphate sodium cap 40 Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January

18 ERIVEDGE - vismodegib cap 50 ERLEADA - apalutamide tab 60 ETOPOSIDE - etoposide cap 50 exemestane tab 5 (Aromasin) FARESTON - toremifene citrate tab 60 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) FARYDAK - panobinostat lactate cap 5 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) FIRMAGON - degarelix acetate for inj 80 (base equiv) FIRMAGON - degarelix acetate for inj 0 (base equiv) flutamide cap 5 GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 40 (base equivalent) GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 40 GLEOSTINE - lomustine cap 00 HYCAMTIN - topotecan hcl cap 0.5 (base equiv) HYCAMTIN - topotecan hcl cap (base equiv) HYDROXYPROGESTERONE CAPRO - hydroxyprogesterone caproate im in oil.5 gm/5ml hydroxyurea cap 500 (Hydrea) IBRANCE - palbociclib cap 75 IBRANCE - palbociclib cap 00 IBRANCE - palbociclib cap 5 ICLUSIG - ponatinib hcl tab 5 (base equiv) ICLUSIG - ponatinib hcl tab 45 (base equiv) IDHIFA - enasidenib mesylate tab 50 (base equivalent) IDHIFA - enasidenib mesylate tab 00 (base equivalent) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 400 (base equivalent) (Gleevec) IMBRUVICA - ibrutinib cap 70 IMBRUVICA - ibrutinib cap 40 IMBRUVICA - ibrutinib tab 40 IMBRUVICA - ibrutinib tab 80 IMBRUVICA - ibrutinib tab 40 IMBRUVICA - ibrutinib tab 560 INLYTA - axitinib tab INLYTA - axitinib tab 5 INTRON A - interferon alfa-b inj unit/ml INTRON A - interferon alfa-b inj unit/ml INTRON A - interferon alfa-b for inj unit INTRON A - interferon alfa-b for inj unit INTRON A - interferon alfa-b for inj unit IRESSA - gefitinib tab 50 JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) JAKAFI - ruxolitinib phosphate tab 0 (base equivalent) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 4

19 JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) KISQALI - ribociclib succinate tab 00 (base equiv) KISQALI FEMARA 00 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 400 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 600 DOSE - ribociclib tab 00 & letrozole tab.5 therapy pack LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 (0 daily dose) LENVIMA MG DAILY DOSE - lenvatinib cap therapy pack 4 () ( daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 0 & 4 () (8 daily dose) LENVIMA 0 MG DAILY DOSE - lenvatinib cap therapy pack 0 () (0 daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 0 () & 4 (4 daily dose) LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4 () (8 daily dose) letrozole tab.5 (Femara) LEUCOVORIN CALCIUM - leucovorin calcium tab 0 LEUCOVORIN CALCIUM - leucovorin calcium tab 5 leucovorin calcium tab 5 leucovorin calcium tab 5 LEUKERAN - chlorambucil tab leuprolide acetate inj kit 5 /ml LONSURF - trifluridine-tipiracil tab LONSURF - trifluridine-tipiracil tab LUPRON DEPOT (-MONTH) - leuprolide acetate for inj kit.75 LUPRON DEPOT (-MONTH) - leuprolide acetate for inj kit 7.5 LUPRON DEPOT (-MONTH) - leuprolide acetate ( month) for inj kit.5 LUPRON DEPOT (-MONTH) - leuprolide acetate ( month) for inj kit.5 LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for inj kit 0 LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for inj kit 45 LYNPARZA - olaparib tab 00 LYNPARZA - olaparib tab 50 LYSODREN - mitotane tab 500 MATULANE - procarbazine hcl cap 50 megestrol acetate susp 40 /ml (Megace oral) megestrol acetate tab 0 megestrol acetate tab 40 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 (base equivalent) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 5

20 MEKINIST - trametinib dimethyl sulfoxide tab (base equivalent) MEKTOVI - binimetinib tab 5 5 melphalan tab (Alkeran) mercaptopurine tab 50 MESNEX - mesna tab 400 METHOTREXATE 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 /40ml (5 /ml) methotrexate sodium inj 50 /ml (5 /ml) methotrexate sodium tab.5 (base equiv) MYLERAN - busulfan tab NERLYNX - neratinib maleate tab 40 (base equivalent) NEXAVAR - sorafenib tosylate tab 00 (base equivalent) nilutamide tab 50 (Nilandron) NINLARO - ixazomib citrate cap. (base equivalent) NINLARO - ixazomib citrate cap (base equivalent) NINLARO - ixazomib citrate cap 4 (base equivalent) ODOMZO - sonidegib phosphate cap 00 (base equivalent) POMALYST - pomalidomide cap POMALYST - pomalidomide cap POMALYST - pomalidomide cap POMALYST - pomalidomide cap 4 PURIXAN - mercaptopurine susp 000 /00ml (0 /ml) RITUXAN - rituximab iv soln 00 /0ml RITUXAN - rituximab iv soln 500 /50ml RUBR - rucaparib camsylate tab 00 (base equivalent) RUBR - rucaparib camsylate tab 50 (base equivalent) RUBR - rucaparib camsylate tab 00 (base equivalent) RYDAPT - midostaurin cap 5 SOLTAMOX - 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 40 STIVARGA - regorafenib tab 40 SUTENT - sunitinib malate cap.5 (base equivalent) SUTENT - sunitinib malate cap 5 (base equivalent) SUTENT - sunitinib malate cap 7.5 (base equivalent) SUTENT - sunitinib malate cap 50 (base equivalent) SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 600 mcg Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 6

21 TABLOID - thioguanine tab 40 TAFINLAR - dabrafenib mesylate cap 50 (base equivalent) TAFINLAR - dabrafenib mesylate cap 75 (base equivalent) TAGRISSO - osimertinib mesylate tab 40 (base equivalent) TAGRISSO - osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) tamoxifen citrate tab 0 (base equivalent) TARCEVA - erlotinib hcl tab 5 (base equivalent) TARCEVA - erlotinib hcl tab 00 (base equivalent) TARCEVA - erlotinib hcl tab 50 (base equivalent) TASIGNA - nilotinib hcl cap 50 (base equivalent) TASIGNA - nilotinib hcl cap 50 (base equivalent) TASIGNA - nilotinib hcl cap 00 (base equivalent) temozolomide cap 5 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 00 (Temodar) temozolomide cap 40 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 50 (Temodar) TRELSTAR MIXJECT - triptorelin pamoate for im susp.75 TRELSTAR MIXJECT - triptorelin pamoate for im susp.5 TRELSTAR MIXJECT - triptorelin pamoate for im susp.5 tretinoin cap 0 TREXALL - methotrexate sodium tab 5 (base equiv) TREXALL - methotrexate sodium tab 7.5 (base equiv) TREXALL - methotrexate sodium tab 0 (base equiv) TREXALL - methotrexate sodium tab 5 (base equiv) TYKERB - lapatinib ditosylate tab 50 (base equiv) VANTAS - histrelin acetate implant kit 50 VENCLEXTA - venetoclax tab 0 VENCLEXTA - venetoclax tab 50 VENCLEXTA - venetoclax tab 00 VENCLEXTA STARTING PACK - 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) XALKORI - crizotinib cap 00 XALKORI - crizotinib cap 50 XTANDI - enzalutamide cap 40 YONSA - abiraterone acetate tab 5 ZEJULA - niraparib tosylate cap 00 (base equivalent) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 7

22 ZELBORAF - vemurafenib tab 40 ZOLADEX - goserelin acetate implant.6 ZOLADEX - goserelin acetate implant 0.8 ZOLINZA - vorinostat cap 00 ZYDELIG - idelalisib tab 00 ZYDELIG - idelalisib tab 50 ZYKADIA - ceritinib cap 50 ZYTIGA - abiraterone acetate tab 50 ZYTIGA - abiraterone acetate tab 500 ENDOCRINE AND METABOLIC DRUGS CORTICOSTEROIDS budesonide delayed release particles cap (Entocort ec) budesonide tab er 4hr 9 (Uceris) CORTISONE ACETATE - cortisone acetate tab 5 DEXAMETHASONE - dexamethasone soln 0.5 /5ml DEXAMETHASONE - dexamethasone tab DEXAMETHASONE - dexamethasone tab dexamethasone elixir 0.5 /5ml DEXAMETHASONE INTENSOL - dexamethasone conc /ml dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab.5 dexamethasone tab 4 dexamethasone tab 6 DEXPAK 0 DAY - dexamethasone tab therapy pack.5 (5) DEXPAK DAY - dexamethasone tab therapy pack.5 (5) DEXPAK 6 DAY - dexamethasone tab therapy pack.5 () fludrocortisone acetate tab 0. hydrocortisone tab 5 (Cortef) hydrocortisone tab 0 (Cortef) hydrocortisone tab 0 (Cortef) MEDROL - methylprednisolone tab methylprednisolone tab therapy pack 4 () (Medrol dosepak) methylprednisolone tab 4 (Medrol) methylprednisolone tab 8 (Medrol) methylprednisolone tab 6 (Medrol) methylprednisolone tab (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) prednisolone sod phos orally disintegr tab 0 (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) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 8

23 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 (48) PREDNISONE - prednisone tab therapy pack 0 () PREDNISONE - prednisone tab therapy pack 0 (48) PREDNISONE - prednisone tab 50 PREDNISONE INTENSOL - prednisone conc 5 /ml prednisone tab prednisone tab.5 prednisone tab 5 prednisone tab 0 prednisone tab 0 UCERIS - budesonide tab er 4hr 9 ANDROGEN-ANABOLIC ANADROL-50 - oxymetholone tab 50 ANDRODERM - testosterone td patch 4hr /4hr ANDRODERM - testosterone td patch 4hr 4 /4hr ANDROGEL - testosterone td gel 0.5 /.5gm (.6%) ANDROGEL - testosterone td gel 40.5 /.5gm (.6%) ANDROGEL PUMP - testosterone td gel 0.5 /act (.6%) danazol cap 50 danazol cap 00 danazol cap 00 FORTESTA - testosterone td gel 0/act (%) METHITEST - methyltestosterone oral tab 0 METHYLTESTOSTERONE - methyltestosterone cap 0 oxandrolone tab.5 oxandrolone tab 0 STRIANT - testosterone buccal mucoadhesive system 0 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 (%) (Androgel) testosterone td gel 50 /5gm (%) (Androgel) testosterone td gel.5 /act (%) testosterone td gel 0/act (%) (Fortesta) Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 9

24 testosterone td soln 0 /act (Axiron) VOGELXO - testosterone td gel 50 /5gm (%) VOGELXO PUMP - testosterone td gel.5 /act (%) ESTROGENS ALORA - estradiol td patch twice weekly 0.05 /4hr ALORA - estradiol td patch twice weekly 0.05 /4hr ALORA - estradiol td patch twice weekly /4hr ALORA - estradiol td patch twice weekly 0. /4hr ANGELIQ - drospirenone-estradiol tab ANGELIQ - drospirenone-estradiol tab 0.5- CLIMARA PRO - estradiollevonorgestrel td patch weekly /day COMBIPATCH - estradiolnorethindrone ace td pttw /day COMBIPATCH - estradiolnorethindrone ace td pttw /day DELESTROGEN - estradiol valerate im in oil 0 /ml DEPO-ESTRADIOL - 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.%) DUAVEE - conjugated estrogensbazedoxifene tab estradiol & norethindrone acetate tab (Activella) estradiol & norethindrone acetate tab -0.5 (Activella) estradiol tab 0.5 (Estrace) estradiol tab (Estrace) estradiol tab (Estrace) estradiol td patch twice weekly 0.05 /4hr (Vivelle-dot) estradiol td patch twice weekly /4hr (Vivelle-dot) estradiol td patch twice weekly 0.05 /4hr (Vivelle-dot) estradiol td patch twice weekly /4hr (Vivelle-dot) estradiol td patch twice weekly 0. /4hr (Vivelle-dot) estradiol td patch weekly 0.05 /4hr (Climara) estradiol td patch weekly /4hr (7.5 mcg/4hr) (Climara) estradiol td patch weekly 0.05 /4hr (Climara) estradiol td patch weekly 0.06 /4hr (Climara) estradiol td patch weekly /4hr (Climara) estradiol td patch weekly 0. /4hr (Climara) estradiol valerate im in oil 0 / ml (Delestrogen) estradiol valerate im in oil 40 / ml (Delestrogen) ESTROGEL - estradiol gel 0.06% (0.75 /.5 gm metered-dose pump) EVAMIST - estradiol transdermal spray.5 /spray Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January 0

25 MENEST - esterified estrogens tab 0. MENEST - esterified estrogens tab 0.65 MENEST - esterified estrogens tab.5 MENOSTAR - estradiol td patch weekly 4 mcg/4hr MINIVELLE - estradiol td patch twice weekly 0.05 /4hr MINIVELLE - estradiol td patch twice weekly /4hr MINIVELLE - estradiol td patch twice weekly 0.05 /4hr MINIVELLE - estradiol td patch twice weekly /4hr MINIVELLE - estradiol td patch twice weekly 0. /4hr norethindrone acetate-ethinyl estradiol tab mcg (Femhrt low dose) norethindrone acetate-ethinyl estradiol tab -5 mcg PREFEST - estradiol tab (5)/estrad-norgestimate tab -0.09(5) PREMARIN - estrogens, conjugated tab 0. PREMARIN - estrogens, conjugated tab 0.45 PREMARIN - estrogens, conjugated tab 0.65 PREMARIN - estrogens, conjugated tab 0.9 PREMARIN - estrogens, conjugated tab.5 PREMPHASE - conj est 0.65(4)/ conj est-medroxypro ac tab (4) PREMPRO - conjugated estrogenmedroxyprogest acetate tab PREMPRO - conjugated estrogenmedroxyprogest acetate tab PREMPRO - conjugated estrogenmedroxyprogest acetate tab PREMPRO - conjugated estrogenmedroxyprogest acetate tab CONTRACEPTIVES desogest-eth estrad & eth estrad A tab /0.0 (/5) (Mircette) desogest-ethin est tab A / / (Cyclessa) desogestrel & ethinyl estradiol A tab mcg (Desogen) drospirenone-ethinyl A estrad-levomefolate tab (Beyaz) drospirenone-ethinyl A estrad-levomefolate tab (Safyral) drospirenone-ethinyl estradiol A tab -0.0 (Yaz) drospirenone-ethinyl estradiol A tab -0.0 (Yasmin 8) ELLA - ulipristal acetate tab 0 A A ethynodiol diacetate & ethinyl estradiol tab -5 mcg ethynodiol diacetate & ethinyl estradiol tab -50 mcg FALESSA - levonorgest-eth estrad tab mcg & fa tab kit levonor-eth est tab /0.05/0.0 &eth est 0.0 (Quartette) levonorg-eth est tab (84) & eth est tab 0.0(7) (Loseasonique) A A A Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January

26 levonorg-eth est tab (84) & eth est tab 0.0(7) (Seasonique) levonorgestrel & ethinyl estradiol (9-day) tab levonorgestrel & ethinyl estradiol tab mcg levonorgestrel & ethinyl estradiol tab mcg A A A A levonorgestrel tab.5 A A levonorgestrel-eth estra tab / /0.5-0mcg levonorgestrel-ethinyl estradiol (continuous) tab 90-0 mcg LO LOESTRIN FE - norethin-eth estradiol-fe tab -0 mcg (4)/0 mcg () medroxyprogesterone acetate im susp prefilled syr 50 /ml (Depo-provera contrac) medroxyprogesterone acetate im susp 50 /ml (Depo-provera contrac) NATAZIA - estradiol valeratedienogest tab /- /- / norethindrone & ethinyl estradiol tab mcg (Ovcon-5) norethindrone & ethinyl estradiol tab mcg (Brevicon-8) norethindrone & ethinyl estradiol tab -5 mcg (Norinyl +5) norethindrone & ethinyl estradiol-fe chew tab mcg (Femcon fe) norethindrone & ethinyl estradiol-fe chew tab mcg (Generess fe) A A A A A A A A norethindrone ac-ethinyl estradfe tab -0/-0/-5 -mcg (Estrostep fe) norethindrone ace & ethinyl estradiol tab -0 mcg (Loestrin /0-) norethindrone ace & ethinyl estradiol tab.5-0 mcg (Loestrin.5/0-) norethindrone ace & ethinyl estradiol-fe tab -0 mcg (Loestrin fe /0) norethindrone ace & ethinyl estradiol-fe tab.5-0 mcg (Loestrin fe.5/0) norethindrone ace-eth estradiolfe chew tab -0 mcg (4) (Minastrin 4 fe) norethindrone ace-ethinyl estradiol-fe tab -0 mcg (4) norethindrone tab 0.5 (Norqd) norethindrone-eth estradiol tab 0.5-5/0.75-5/-5 -mcg (Ortho-novum 7/7/7) norethindrone-eth estradiol tab 0.5-5/-5/ mcg (Trinorinyl 8) norgestimate & ethinyl estradiol tab mcg (Orthocyclen) norgestimate-eth estrad tab 0.8-5/0.5-5/0.5-5 mcg (Ortho tri-cyclen lo) norgestimate-eth estrad tab 0.8-5/0.5-5/0.5-5 mcg (Ortho tri-cyclen) norgestrel & ethinyl estradiol tab mcg NUVARING - etonogestrel-ethinyl estradiol va ring /4hr A A A A A A A A A A A A A A A Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January

27 OGESTREL - norgestrel & ethinyl estradiol tab mcg TAYTULLA - norethindrone aceethinyl estradiol-fe cap -0 mcg (4) XULANE - norelgestrominethinyl estradiol td ptwk 50-5 mcg/4hr PROGESTINS MAKENA - hydroxyprogesterone caproate im in oil 50 /ml MAKENA - hydroxyprogesterone caproate soln auto-injector 75 /.ml medroxyprogesterone acetate tab.5 (Provera) medroxyprogesterone acetate tab 5 (Provera) medroxyprogesterone acetate tab 0 (Provera) megestrol acetate susp 65 /5ml (Megace es) norethindrone acetate tab 5 (Aygestin) progesterone im in oil 50 /ml progesterone micronized cap 00 (Prometrium) progesterone micronized cap 00 (Prometrium) ANTIDIABETICS ANTIDIABETICS acarbose tab 5 (Precose) acarbose tab 50 (Precose) acarbose tab 00 (Precose) ACTOPLUS MET XR - pioglitazone hcl-metformin hcl tab er 4hr ACTOPLUS MET XR - pioglitazone hcl-metformin hcl tab er 4hr A ALOGLIPTIN - alogliptin benzoate tab 6.5 (base equiv) ALOGLIPTIN - alogliptin benzoate tab.5 (base equiv) ALOGLIPTIN - alogliptin benzoate tab 5 (base equiv) ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl tab ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl tab ALOGLIPTIN/PIOGLITAZONE - alogliptin-pioglitazone tab.5-5 ALOGLIPTIN/PIOGLITAZONE - alogliptin-pioglitazone tab.5-0 ALOGLIPTIN/PIOGLITAZONE - alogliptin-pioglitazone tab.5-45 ALOGLIPTIN/PIOGLITAZONE - alogliptin-pioglitazone tab 5-5 ALOGLIPTIN/PIOGLITAZONE - alogliptin-pioglitazone tab 5-0 ALOGLIPTIN/PIOGLITAZONE - alogliptin-pioglitazone tab 5-45 AVANDIA - rosiglitazone maleate tab (base equiv) AVANDIA - rosiglitazone maleate tab 4 (base equiv) BYDUREON - exenatide for inj extended release susp BYDUREON BCISE - exenatide extended release susp autoinjector /0.85ml BYDUREON PEN - exenatide extended release for susp peninjector Blue Cross & Blue Shield of Rhode Island Large Group 5 Formulary January