Blue Shield Rx Enhanced (PDP) Formulary Updates:

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1 Blue Shield Rx Enhanced (PDP) Formulary Updates: The enclosed table lists the changes made to your such as removing or adding: a drug, prior authorization, quantity limits or step therapy as well as any changes to a cost sharing tier. The table also includes the reasons for the changes and alternative drug(s) if. Abbreviation Key: AG: coverage limits based on age; BvD: requires prior authorization review to determine whether coverage is under Part B or Part D of the Medicare benefit; LA: prescription may be available only at certain pharmacies; PA: Prior Authorization; QL: Quantity Limit; ST: Step Therapy Key 1 / PG: Preferred Generic s 2 / G: Generic s 3 / PB: Preferred Brand s 4 / NPB: Non-Preferred s 5 / Inj: Injectable s 6 / Spec: Specialty s Y0118_18_174B NM Blue Shield of California 50 Beale Street, San Francisco, CA blueshieldca.com An independent member of the Blue Shield Association

2 (If for EPCLUSA MG TABLET Formulary Addition 01/01/18 6 PA, QL HARVONI 90MG-400MG TABLET Formulary Addition 01/01/18 6 PA, QL LYRICA 100MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 150MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 200MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 20MG/ML SOLUTION Formulary Addition 01/01/18 3 QL LYRICA 225MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 25MG CAPSULE Formulary Addition 01/01/18 3 QL

3 (If for LYRICA 300MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 50MG CAPSULE Formulary Addition 01/01/18 3 QL LYRICA 75MG CAPSULE Formulary Addition 01/01/18 3 QL MAVYRET 100MG-40MG TABLET Formulary Addition 01/01/18 6 PA, QL methadone 10mg tablet Formulary Addition 01/01/18 4 PA, QL methadone 10mg/5ml solution Formulary Addition 01/01/18 4 PA, QL methadone 10mg/ml solution Formulary Addition 01/01/18 5 BvD, QL methadone 5mg tablet Formulary Addition 01/01/18 4 PA, QL

4 (If for methadone 5mg/5ml solution Formulary Addition 01/01/18 4 PA, QL methadose 10mg tablet Formulary Addition 01/01/18 4 PA, QL MIACALCIN 200/ML VIAL 01/01/18 5 olopatadine 2mg/ml ophthalmic solution Formulary Addition 01/01/18 3 QL sevelamer carbonate 2400mg powder pack Formulary Addition 01/01/18 3 sevelamer carbonate 800mg powder pack Formulary Addition 01/01/18 3 sevelamer carbonate 800mg tablet Formulary Addition 01/01/18 3 VOSEVI MG TABLET Formulary Addition 01/01/18 6 PA, QL

5 (If for XARELTO 10MG TABLET Formulary Addition 01/01/18 3 QL XARELTO 15MG TABLET Formulary Addition 01/01/18 3 QL XARELTO 20MG TABLET Formulary Addition 01/01/18 3 QL XARELTO KIT 15MG-20MG TABLET DS PK Formulary Addition 01/01/18 3 QL ZEPATIER 50MG-100MG TABLET Formulary Addition 01/01/18 6 PA, QL ADACEL /.5 INTRAMUSCULAR SYRINGE Formulary Addition 03/01/18 5 ALIQOPA 60MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD ALUNBRIG 180MG TABLET Formulary Addition 03/01/18 6 PA, QL

6 (If for ALUNBRIG 90MG TABLET Formulary Addition 03/01/18 6 PA, QL ALUNBRIG 90MG-180MG TABLET Formulary Addition 03/01/18 6 PA, QL amlodipine besylate/valsartan 5 mg-160mg tablet Formulary Addition 03/01/18 2 QL amlodipine besylate-valsartan 10 mg-160mg tablet Formulary Addition 03/01/18 2 QL amlodipine besylate-valsartan 10 mg-320mg tablet Formulary Addition 03/01/18 2 QL amlodipine besylate-valsartan 5 mg-320mg tablet Formulary Addition 03/01/18 2 QL amlodipine-valsartan-hctz mg tablet amlodipine-valsartan-hctz mg tablet 03/01/18 4 QL 03/01/18 4 QL

7 (If for amlodipine-valsartan-hctz mg tablet 03/01/18 4 QL amlodipine-valsartan-hctz mg tablet 03/01/18 4 QL amlodipine-valsartan-hctz mg tablet 03/01/18 4 QL amnesteem 10mg capsule Formulary Addition 03/01/18 4 amnesteem 20mg capsule Formulary Addition 03/01/18 4 amnesteem 40mg capsule Formulary Addition 03/01/18 4 atazanavir sulfate 150mg capsule Formulary Addition 03/01/18 6 QL atazanavir sulfate 200mg capsule Formulary Addition 03/01/18 6 QL

8 (If for atazanavir sulfate 300mg capsule Formulary Addition 03/01/18 6 QL BAXDELA 300MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 BvD, QL BAXDELA 450MG TABLET Formulary Addition 03/01/18 6 PA, QL BENLYSTA 200MG/ML SQ AUTO INJCT Formulary Addition 03/01/18 6 PA, QL BENLYSTA 200MG/ML SQ SYRINGE Formulary Addition 03/01/18 6 PA, QL BENZNIDAZOLE 100MG TABLET Formulary Addition 03/01/18 4 QL BENZNIDAZOLE 12.5MG TABLET Formulary Addition 03/01/18 4 QL BESPONSA 0.9MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD

9 (If for bortezomib 3.5mg intravenous vial Formulary Addition 03/01/18 6 BvD BOSULIF 400MG TABLET Formulary Addition 03/01/18 6 PA, QL buprenorphine 7.5mcg/hour patch tdwk Formulary Addition 03/01/18 4 PA, QL butalbital-aspirin-caffeine 50mg-325mg-40mg tablet Formulary Addition 03/01/18 2 QL CALQUENCE 100MG CAPSULE Formulary Addition 03/01/18 6 PA, LA, QL carvedilol phosphate er 10mg cpmp 24hr Formulary Addition 03/01/18 4 ST carvedilol phosphate er 20mg cpmp 24hr Formulary Addition 03/01/18 4 ST carvedilol phosphate er 30mg cpmp 24hr Formulary Addition 03/01/18 4 ST

10 (If for carvedilol phosphate er 40mg cpmp 24hr Formulary Addition 03/01/18 4 ST caspofungin acetate 50mg vial Formulary Addition 03/01/18 6 PA, BvD caspofungin acetate 70mg vial Formulary Addition 03/01/18 6 PA, BvD clindamycin in 0.9 % sod chlor 300mg/50ml piggyback Formulary Addition 03/01/18 5 clindamycin in 0.9 % sod chlor 600mg/50ml piggyback Formulary Addition 03/01/18 5 clindamycin in 0.9 % sod chlor 600mg/50ml piggyback Formulary Addition 03/01/18 5 clobetasol 0.05% topical cream Formulary Addition 03/01/18 2 dactinomycin 0.5mg vial Formulary Addition 03/01/18 6 BvD

11 (If for desogestrel-ethinyl estradiol 0.15mg-0.03mg tablet Formulary Addition 03/01/18 2 diclofenac potassium 50mg tablet Formulary Addition 03/01/18 2 diclofenac sodium 25mg dr tablet Formulary Addition 03/01/18 2 diclofenac sodium 50mg dr tablet Formulary Addition 03/01/18 2 diclofenac sodium 75mg dr tablet Formulary Addition 03/01/18 2 digitek 125mcg tablet Formulary Addition 03/01/18 1 PA digitek 250mcg tablet Formulary Addition 03/01/18 1 PA digox 125mcg tablet Formulary Addition 03/01/18 1 PA

12 (If for digox 250mcg tablet Formulary Addition 03/01/18 1 PA digoxin 125mcg tablet Formulary Addition 03/01/18 1 PA digoxin 125mcg tablet Formulary Addition 03/01/18 1 PA efavirenz 200mg capsule Formulary Addition 03/01/18 3 QL efavirenz 50mg capsule Formulary Addition 03/01/18 3 QL elite-ob 50mg iron-1.25mg tablet Formulary Addition 03/01/18 2 ESBRIET 267MG TABLET Quantity Limit Update 03/01/18 6 PA, QL ethynodiol-ethinyl estradiol tablet 1mg-35mcg tablet Formulary Addition 03/01/18 2

13 (If for fosamprenavir 700mg tablet Formulary Addition 03/01/18 6 QL gemcitabine hcl 100mg/ml intravenous vial Formulary Addition 03/01/18 5 BvD HAEGARDA 2,000 UNITS SUB-Q VIAL Formulary Addition 03/01/18 6 PA, LA HAEGARDA 3,000 UNITS SUB-Q VIAL Formulary Addition 03/01/18 6 PA, LA haloperidol decanoate 100mg/ml intramuscular vial Formulary Addition 03/01/18 5 HERCEPTIN 150MG VIAL Formulary Addition 03/01/18 6 BvD HUMALOG JUNIOR KWIKPEN 100UNIT/ML SQ INS PEN HF Formulary Addition 03/01/18 3 IDHIFA 100MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL

14 (If for IDHIFA 50MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL indomethacin er 75mg xr capsule Formulary Addition 03/01/18 2 PA ISENTRESS HD 600MG TABLET Formulary Addition 03/01/18 6 QL isibloom 28 day mg tablet Formulary Addition 03/01/18 2 JULUCA 50MG-25MG TABLET Formulary Addition 03/01/18 6 QL lanthanum carbonate 1,000mg tablet chew Formulary Addition 03/01/18 6 lanthanum carbonate 500mg tablet chew Formulary Addition 03/01/18 6 lanthanum carbonate 750mg tablet chew Formulary Addition 03/01/18 6

15 (If for LARTRUVO 10MG/ML INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD LEVO-T 0.025MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.05MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.075MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.088MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.112MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.125MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.137MG TABLET Formulary Addition 03/01/18 2

16 (If for LEVO-T 0.15MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.175MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.1MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.2MG TABLET Formulary Addition 03/01/18 2 LEVO-T 0.3MG TABLET Formulary Addition 03/01/18 2 lidocaine 5% patch Formulary Addition 03/01/18 3 PA, QL lidocaine hydrochloride 10mg/ml injectable solution Formulary Addition 03/01/18 5 lidocaine hydrochloride 5mg/ml injectable solution Formulary Addition 03/01/18 5

17 (If for LYNPARZA 100MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL LYNPARZA 150MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL meropenem 1000mg intravenous vial Formulary Addition 03/01/18 5 mesalamine 1.2gm tablet Formulary Addition 03/01/18 3 QL mesalamine 4g/60ml rectal enema Formulary Addition 03/01/18 4 methotrexate 25 mg/ml 10ml vial Formulary Addition 03/01/18 5 BvD moxifloxacin hcl 0.5% eye drops Formulary Addition 03/01/18 2 MYLOTARG 4.5MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD

18 (If for NERLYNX 40MG TABLET Formulary Addition 03/01/18 6 PA, LA, QL NOVAREL 5,000UNIT VIAL Formulary Addition 03/01/18 5 BvD OPDIVO 240MG/24ML INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD oseltamivir phosphate 6mg/ml oral suspension Formulary Addition 03/01/18 3 QL oxaliplatin 100mg intravenous vial Formulary Addition 03/01/18 5 BvD piperacillin-tazobactam 2000mg-250mg intravenous vial Formulary Addition 03/01/18 5 prasugrel hcl 10mg tablet Formulary Addition 03/01/18 2 QL prasugrel hcl 5mg tablet Formulary Addition 03/01/18 2 QL

19 (If for PROLASTIN-C 2GRAM INTRAVENOUS VIAL Formulary Addition 03/01/18 6 BvD RITUXAN 10 MG/ML INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD RITUXAN HYCELA 1,400MG/11.7ML SUB-Q VIAL Formulary Addition 03/01/18 6 PA, BvD RITUXAN HYCELA 1,600MG/13.4ML SUB-Q VIAL Formulary Addition 03/01/18 6 PA, BvD romidepsin 10mg/2ml intravenous vial Formulary Addition 03/01/18 6 BvD RUBRACA 250MG TABLET Formulary Addition 03/01/18 6 PA, QL scopolamine 1.5mg patch td 3 Formulary Addition 03/01/18 4 SELZENTRY 20MG/ML SOLUTION Formulary Addition 03/01/18 4 QL

20 (If for SHINGRIX 50MCG/0.5ML INTRAMUSCLAR KIT Formulary Addition 03/01/18 5 QL telmisartan 20mg tablet telmisartan 40mg tablet telmisartan 80mg tablet 03/01/18 4 QL 03/01/18 4 QL 03/01/18 4 QL tenofovir disoproxil fumarate 300mg tablet Formulary Addition 03/01/18 6 QL TRACLEER BOSENTAN 32MG TABLET SUSPENSION Formulary Addition 03/01/18 6 PA, QL TREANDA 25MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 BvD TRELEGY ELLIPTA 100MCG- 62.5MCG-25MCG ACTUATION BLST W/DEV Formulary Addition 03/01/18 3 QL

21 (If for TRISENOX 12MG/6ML INTRAVENOUS VIAL Formulary Addition 03/01/18 5 BvD TWINRIX /ML INTRAMUSCLUAR SYRINGE Formulary Addition 03/01/18 5 BvD TYMLOS 80MCG/DOSE SQ PEN INJECTOR Formulary Addition 03/01/18 6 PA, QL VAQTA 25/0.5ML INTRAMUSCLUAR VIAL Formulary Addition 03/01/18 5 VAQTA 50 UNIT/ML INTRAMUSCLUAR VIAL Formulary Addition 03/01/18 5 VERZENIO 100MG TABLET Formulary Addition 03/01/18 6 PA, QL VERZENIO 150MG TABLET Formulary Addition 03/01/18 6 PA, QL VERZENIO 200MG TABLET Formulary Addition 03/01/18 6 PA, QL

22 (If for VERZENIO 50MG TABLET Formulary Addition 03/01/18 6 PA, QL vigabatrin 500mg powder pack Formulary Addition 03/01/18 6 PA, QL VYXEOS LIPOSOME 44MG- 100MG INTRAVENOUS VIAL Formulary Addition 03/01/18 6 PA, BvD XATMEP 2.5MG/ML SOLUTION Formulary Addition 03/01/18 6 PA, QL ZENPEP K CAPSULE DR Formulary Addition 03/01/18 4 ZENPEP UNIT CAPSULE DR Formulary Addition 03/01/18 4 zoledronic acid 4mg intravenous vial zoledronic acid 4mg/5ml intravenous vial 03/01/18 5 BvD 03/01/18 5 BvD

23 (If for zoledronic acid 5mg/100ml piggyback 03/01/18 5 ZYTIGA 500MG TABLET Formulary Addition 03/01/18 6 PA, QL BIKTARVY 50MG-200MG-5MG TABLET Formulary Addition 04/01/18 6 QL buprenorphine-naloxone 2mg- 0.5mg sublingual tablet buprenorphine-naloxone 8mg-2 mg sublingual tablet 04/01/18 3 QL 04/01/18 3 QL efavirenz 600mg tablet Formulary Addition 04/01/18 3 QL ELIQUIS 5MG TABLET Formulary Addition 04/01/18 3 QL ENGERIX-B ADULT 20 MCG/ML Formulary Addition 04/01/18 5 BvD

24 (If for FASENRA 30 MG/ML SUB-Q SYRINGE Formulary Addition 04/01/18 6 PA, BvD haloperidol lactate 5mg/ml syringe Formulary Addition 04/01/18 5 INFANRIX DTAP SYRINGE Formulary Addition 04/01/18 5 medroxyprogesterone acetate 150 mg/ml oral solution Formulary Addition 04/01/18 5 BvD MENVEO MenA COMPONENT PF 10MCG/0.5ML INTRAMUSCULAR SOLUTION MENVEO MenCYW 135 COMPONENT PF INTRAMUSCULAR SOLUTION Formulary Addition 04/01/18 5 Formulary Addition 04/01/18 5 REPATHA PUSHTRONEX 420 MG/3.5 WEAR INJCT Formulary Addition 04/01/18 6 PA, QL REPATHA SURECLICK 140 MG/ML PEN INJCTR Formulary Addition 04/01/18 6 PA, QL

25 (If for REPATHA SYRINGE 140 MG/ML SYRINGE Formulary Addition 04/01/18 6 PA, QL roweepra xr 500mg oral tablet Formulary Addition 04/01/18 2 QL roweepra xr 500mg oral tablet er 24h Formulary Addition 04/01/18 2 QL roweepra xr 750mg oral tablet Formulary Addition 04/01/18 2 QL roweepra xr 750mg oral tablet er 24h Formulary Addition 04/01/18 2 QL TENIVAC 5-2/0.5ML VIAL Formulary Addition 04/01/18 5 trientine hcl 250mg capsule Formulary Addition 04/01/18 6 PA VIVOTIF 2B UNIT CAPSULE DR Formulary Addition 04/01/18 3

26 (If for VIVOTIF BERNA 2B UNIT CAPSULE DR Formulary Addition 04/01/18 3 ZUBSOLV MG SUBLINGUAL TABLET ZUBSOLV MG SUBLINGUAL TABLET ZUBSOLV MG SUBLINGUAL TABLET ZUBSOLV MG SUBLINGUAL TABLET ZUBSOLV MG SUBLINGUAL TABLET ZUBSOLV MG SUBLINGUAL TABLET 04/01/18 4 QL 04/01/18 4 QL 04/01/18 4 QL 04/01/18 4 QL 04/01/18 4 QL 04/01/18 4 QL abacavir 20mg/ml solution Formulary Addition 05/01/18 4 QL

27 (If for BIKTARVY 50MG-200MG-25MG TABLET Formulary Addition 05/01/18 6 QL DALIRESP 250MCG TABLET Formulary Addition 05/01/18 4 PA, QL desmopressin acetate 10/spray pump Formulary Addition 05/01/18 4 ERLEADA 60MG TABLET Formulary Addition 05/01/18 6 PA, QL glatiramer acetate 20mg/ml syringe Formulary Addition 05/01/18 6 PA, QL IMBRUVICA 140MG TABLET Formulary Addition 05/01/18 6 PA, LA, QL IMBRUVICA 280MG TABLET Formulary Addition 05/01/18 6 PA, LA, QL IMBRUVICA 420MG TABLET Formulary Addition 05/01/18 6 PA, LA, QL

28 (If for IMBRUVICA 560MG TABLET Formulary Addition 05/01/18 6 PA, LA, QL IMBRUVICA 70MG CAPSULE Formulary Addition 05/01/18 6 PA, LA, QL isotretinoin 10mg capsule Formulary Addition 05/01/18 4 isotretinoin 20mg capsule Formulary Addition 05/01/18 4 isotretinoin 30mg capsule Formulary Addition 05/01/18 4 isotretinoin 40mg capsule Formulary Addition 05/01/18 4 kelnor 1mg-50mcg tablet Formulary Addition 05/01/18 2 LUPRON DEPOT-PED 11.25MG INTRAMUSCULAR KIT Formulary Addition 05/01/18 6

29 (If for LUPRON DEPOT-PED 11.25MG INTRAMUSCULAR KIT 05/01/18 6 LUPRON DEPOT-PED 15MG INTRAMUSCULAR KIT Formulary Addition 05/01/18 6 LUPRON DEPOT-PED 30MG INTRAMUSCULAR KIT Formulary Addition 05/01/18 6 LUPRON DEPOT-PED 7.5MG INTRAMUSCULAR KIT 05/01/18 6 memantine hcl 14mg capsule spr 24 Formulary Addition 05/01/18 3 QL memantine hcl 21mg capsule spr 24 Formulary Addition 05/01/18 3 QL memantine hcl 28mg capsule spr 24 Formulary Addition 05/01/18 3 QL memantine hcl 7mg capsule spr 24 Formulary Addition 05/01/18 3 QL

30 (If for methotrexate 25mg/ml 10ml vial Formulary Addition 05/01/18 5 BvD naloxone hcl 0.4mg/ml syringe Formulary Addition 05/01/18 2 QL ritonavir 100mg tablet Formulary Addition 05/01/18 4 QL sodium phenylbutyrate 500mg tablet Formulary Addition 05/01/18 6 PA SYMFI LO MG TABLET Formulary Addition 05/01/18 6 QL tiagabine hcl 12mg tablet Formulary Addition 05/01/18 3 PA tiagabine hcl 16mg tablet Formulary Addition 05/01/18 3 PA VIDEX EC 125MG CAPSULE Formulary Addition 05/01/18 3 QL

31 (If for ZENPEP 25,000 UNIT-79,000 UNIT-105,000 UNIT CAPSULE Formulary Addition 05/01/18 4 ZENPEP 5,000 UNIT-17,000 UNIT-24,000 UNIT CAPSULE Formulary Addition 05/01/18 4 CANCIDAS 50MG VIAL Formulary 06/01/18 caspofungin acetate 50mg vial 6 CANCIDAS 70MG VIAL Formulary 06/01/18 caspofungin acetate 70mg vial 6 CIMDUO MG TABLET Formulary Addition 06/01/18 6 QL COREG CR 80MG CPMP 24HR Formulary 06/01/18 carvedilol phosphate 80mg cpmp 24hr 4 COSMEGEN 0.5MG VIAL Formulary 06/01/18 dactinomycin 0.5mg vial 6 diltiazem er 180mg tablet Formulary Addition 06/01/18 4

32 (If for diltiazem er 240mg tablet Formulary Addition 06/01/18 4 diltiazem er 300mg tablet Formulary Addition 06/01/18 4 diltiazem er 360mg tablet Formulary Addition 06/01/18 4 diltiazem er 420mg tablet Formulary Addition 06/01/18 4 FABRAZYME 5MG INJECTION Formulary Addition 06/01/18 6 BvD FOSRENOL 1,000MG CHEW TABLET Formulary 06/01/18 FOSRENOL 500MG CHEW TABLET Formulary 06/01/18 FOSRENOL 750MG CHEW TABLET Formulary 06/01/18 Lanthanum carbonate 1,000mg chew tablet lanthanum carbonate 500mg chew tablet lanthanum carbonate 750mg chew tablet 6 6 6

33 (If for ibuprofen 600mg tablet Formulary Addition 06/01/18 1 ibuprofen 800mg tablet Formulary Addition 06/01/18 1 INTRON A-2B 10MM/ML INJECTABLE SOLUTION Formulary Addition 06/01/18 6 PA LEXIVA 700MG TABLET Formulary 06/01/18 fosamprenavir calcium 700mg tablet 6 LIALDA 1.2GRAM TABLET DR Formulary 06/01/18 mesalamine 1.2gram tablet dr 3 lillow 0.15mg-0.03mg tablet Formulary Addition 06/01/18 2 ORFADIN 20MG CAPSULE Formulary Addition 06/01/18 6 PA PATADAY 0.2% DROPS Formulary 06/01/18 olopatadine hcl 0.2% drops 3

34 (If for SABRIL 500MG POWD PACK Formulary 06/01/18 vigabatrin 500mg powd pack 6 SUSTIVA 50MG CAPSULE Formulary 06/01/18 efavirenz 50mg capsule 3 SYMFI MG TABLET Formulary Addition 06/01/18 6 QL SYNAGIS 100MG/ML INJECTION Formulary Addition 06/01/18 6 PA TAMIFLU 6MG/ML SUSPENSION Formulary 06/01/18 oseltamivir phosphate 6mg/ml suspension 3 TASIGNA 50MG CAPSULE Formulary Addition 06/01/18 6 PA, BvD TOUJEO MAX SOLOSTAR 300/ML (3) SUBCUTANEOUS INSULN PEN Formulary Addition 06/01/18 3 QL TRANSDERM-SCOP 1.5MG PATCH TD 3 Formulary 06/01/18 scopolamine 1.5mg patch td 3 4

35 (If for VIGAMOX 0.5% DROPS Formulary 06/01/18 moxifloxacin hcl 0.5% drops 2 VIRAMUNE 50MG/ML SUSPENSION Formulary Addition 06/01/18 3 QL baclofen 5mg tablet Formulary Addition 07/01/18 2 QL colesevelam hcl 62mg tablet Formulary Addition 07/01/18 3 COREG CR 10MG CPMP 24HR Formulary 07/01/18 COREG CR 20MG CPMP 24HR Formulary 07/01/18 COREG CR 30MG CPMP 24HR Formulary 07/01/18 carvedilol phosphate 10mg cpmp 24hr carvedilol phosphate 20mg cpmp 24hr carvedilol phosphate 30mg cpmp 24hr ganciclovir sodium 500mg/10ml intravenous vial 07/01/18 5

36 (If for HUMIRA 10MG/0.1ML SYRINGE KIT Formulary Addition 07/01/18 6 PA HUMIRA 20MG/0.2ML SYRINGE KIT Formulary Addition 07/01/18 6 PA HUMIRA 40MG/0.4ML SYRINGE KIT Formulary Addition 07/01/18 6 PA HUMIRA PEDIATRIC CROHN'S 80MG/0.8 ML Formulary Addition 07/01/18 6 PA HUMIRA PEDIATRIC CROHN'S 80MG/0.8 ML-40MG/0.4ML SYRINGEKIT Formulary Addition 07/01/18 6 PA HUMIRA PEN 40MG/0.4ML Formulary Addition 07/01/18 6 PA HYPERRAB 300UNIT/1 INTRAMUS CULAR VIAL Formulary Addition 07/01/18 5 BvD JYNARQUE 45MG-15MG TABLET SEQ Formulary Addition 07/01/18 6 PA, QL

37 (If for JYNARQUE 60MG-30MG TABLET SEQ Formulary Addition 07/01/18 6 PA, QL JYNARQUE 90MG-30MG TABLET SEQ Formulary Addition 07/01/18 6 PA, QL miglustat 100mg capsule Formulary Addition 07/01/18 6 PA, QL NARCAN 2MG/ACTUATION SPRAY Formulary Addition 07/01/18 4 QL NORVIR 100MG POWD PACK Formulary Addition 07/01/18 4 QL praziquantel 600mg tablet Formulary Addition 07/01/18 3 PROMACTA 50MG TABLET Quantity Limit Update 07/01/18 6 PA, QL PROMACTA 75MG TABLET Quantity Limit Update 07/01/18 6 PA, QL

38 (If for REYATAZ 150MG CAPSULE Formulary 07/01/18 atazanavir sulfate 150mg capsule 6 REYATAZ 200MG CAPSULE Formulary 07/01/18 atazanavir sulfate 200mg capsule 6 REYATAZ 300MG CAPSULE Formulary 07/01/18 atazanavir sulfate 300mg capsule 6 SHINGRIX GE ANTIGEN COMPONEN 50MCG INTRAMUSCULAR VIAL Formulary Addition 07/01/18 6 QL syeda 0.03mg-3mg tablet Formulary Addition 07/01/18 2 SYMDEKO 100MG-150MG (DAY)/150MG(NIGHT) Formulary Addition 07/01/18 6 PA, QL tri-vylibra 28day tablet Formulary Addition 07/01/18 2 VIREAD 300MG TABLET Formulary 07/01/18 tenofovir disoproxil fumarate 300mg tablet 6

39 (If for vylibra 28day tablet Formulary Addition 07/01/18 2 ZENPEP 15,000UNIT-47,000UNIT- 63,000UNIT CAPSULE DR Formulary Addition 07/01/18 4 ZENPEP 10,000UNIT-32,000UNIT- 42,000UNIT TABLET Formulary Addition 07/01/18 4 ARNUITY ELLIPTA 50MCG BLST W/DEV Formulary Addition 08/01/18 3 QL estarylla 28day tablet Formulary Addition 08/01/18 2 mono-linyah tablet Formulary Addition 08/01/18 2 subvenite 100mg tablet Formulary Addition 08/01/18 2 subvenite 150mg tablet Formulary Addition 08/01/18 2

40 (If for subvenite 200mg tablet Formulary Addition 08/01/18 2 subvenite 25mg tablet Formulary Addition 08/01/18 2 tri-mili 0.18mg/0.215mg/ 0.25mg/35mcg tablet Formulary Addition 08/01/18 2 tulana 0.35mg tablet Formulary Addition 08/01/18 2 ZENPEP K CAPSULE DR Formulary Addition 08/01/18 4 azelastine 137mcg 0.1% nasal spray Quantity Limit Update 09/01/18 2 QL BUPHENYL 500mg TABLET Formulary 09/01/18 sodium phenylbutyrate 500mg tablet 6 ertapenem 1gram vial Formulary Addition 09/01/18 5

41 (If for GABITRIL 16MG TABLET Formulary 09/01/18 tiagabine hcl 16mg tablet 3 GABITRIL 12MG TABLET Formulary 09/01/18 tiagabine hcl 12mg tablet 3 ketoprofen 25mg capsule Formulary Addition 09/01/18 2 NAMENDA XR 14MG CAPSULE Formulary 09/01/18 memantine hcl 14mg capsule 4 NAMENDA XR 21MG CAPSULE Formulary 09/01/18 memantine hcl 21mg capsule 4 NAMENDA XR 28MG CAPSULE Formulary 09/01/18 memantine hcl 28mg capsule 4 NAMENDA XR 7MG CAPSULE Formulary 09/01/18 memantine hcl 7mg 4 NORVIR 100MG TABLET Formulary 09/01/18 ritonavir 100mg tablet 4

42 (If for SUSTIVA 200MG CAPSULE Formulary 09/01/18 efavirenz 200mg capsule 3 SUSTIVA 600MG CAPSULE Formulary 09/01/18 efavirenz 600mg capsule 3 SYPRINE 250MG Formulary 09/01/18 trientine hcl 250mg capsule 6 vigadrone 500mg powd pack Formulary Addition 09/01/18 6 PA, QL ZIAGEN 20mg/mL SOLUTION Formulary 09/01/18 abacavir sulfate 20 mg/ml solution 4 Brand name drugs are capitalized (for example, AUGMENTIN) and generic drugs are listed in lower-case italics (for example, amoxicillin). Document Last Updated: 08/30/2018 Blue Shield of California is an HMO and PDP plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The Formulary may change at any time. You will receive notice when necessary. This is not a complete list of drugs covered by our plan. For a complete listing, please call [TTY 711], 8 a.m. to 8 p.m. seven days a week from

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