PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary October 1, 2018 Updates. Formulary. Alternatives

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1 PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select October 1, 2018 Updates efavirenz 600mg (Brand = Sustiva ) trientine (Brand = Syprine ) hydrocortisone lot 0.1% (Brand = Locoid ) sumatriptan-naproxen mg (Brand = Treximet ) memantine HCL ER 7mg, 14mg, 21mg, 28mg (Brand = Namenda XR ) minocycline ER 65mg, 115mg (Brand = Solodyn ) methylphenidate cap 10mg ER (Brand = Ritalin LA ) lansoprazole tab 15mg, 30mg (Brand = Prevacid solutab) tiagabine 12mg, 16mg (Brand = Gabitril ) ritonavir tab 100mg (Brand = Norvir ) miglustat 100mg (Brand = Zavesca ) G No Change Generic Addition No Change 2/5/18 G/SP* No Change Generic Addition No Change 2/19/18 G No Change Generic Addition No Change 2/19/18 G + QL + AL (18 per 30 days) No Change Generic Addition No Change 2/19/18 G + AL No Change Generic Addition No Change 2/26/18 G + QL No Change Generic Addition No Change 2/26/18 G + QL No Change Generic Addition No Change 3/5/18 G + PA + QL No Change Generic Addition No Change 3/19/18 G No Change Generic Addition No Change 3/19/18 G No Change Generic Addition No Change 3/19/18 G/SP* + PA No Change Generic Addition No Change 4/23/18

2 praziquantel 600mg G No Change Generic Addition No Change 4/30/18 (Brand = Biltricide ) Erleada 600mg NPD/SP* + PA No Change No Change No Change 2/19/18 Lonhala Magnair soln NPD + PA No Change No Change No Change 2/19/18 25mcg Symdeko NPD/SP* + PA No Change No Change No Change 2/19/18 Biktarvy NPD No Change No Change No Change 2/12/18 Bonjesta 20-20mg NPD + PA No Change No Change No Change 3/12/18 Zypitamag 1mg, 2mg, 4mg NPD + PA No Change Generic statins No Change No Change 3/26/18 Rhopressa Sol 0.02% NPD + PA No Change latanoprost, bimatoprost No Change No Change 4/2/18 Jynarque Pak 45-15mg, NPD + PA No Change No Change No Change 4/30/ mg, 90-30mg Namenda XR PB + AL NPD + AL Generic equivalent drug available Brand Uptier No Change 10/1/18 7mg, 14mg, 21mg, 28mg Norvir tab 100mg PB NPD Generic equivalent drug available Brand Uptier No Change 10/1/18 Sustiva tab 600mg PB NPD Generic equivalent drug available Brand Uptier No Change 10/1/18 oxycodone ER tablet Xtampza XR Drug Uptier No Change 10/1/18 30mg, 40mg, 60mg, 80mg Eucrisa NPD + PA PB + PA Brand Downtier No Change 10/1/18 hydromorphone tab 4mg, 8mg (Brand = Dilaudid tab) morphine sulfate IR 30mg morphine sulfate IR sol 20mg/ml oxycodone IR 15mg, 20mg, 30mg (Brand = Roxicodone) (6ml per day) (6ml per day)

3 oxycodone IR 100mg/5ml sol (6ml per day) (6ml per day) oxymorphone IR 10mg (Brand = Opana ) Nucynta 75mg, 100mg Promacta NPD/SP* NPD/SP* + PA Vasotec NPD NPD + PA Generic equivalent drug available Zestril NPD NPD + PA Generic equivalent drug available Lovaza NPD NPD + PA Generic equivalent drug available Zetia NPD NPD + PA Generic equivalent drug available Elidel NPD NPD + PA Protopic NPD NPD + PA Generic equivalent drug available oxycodone ER tablet 10mg, 15mg, 20mg Nucynta ER 50mg, 100mg morphine sulfate ER tablet 15mg, 30mg (Brand = MS Contin ) morphine sulfate ER capsule 10mg, 20mg, 30mg (Brand = Kadian ) Kadian 40mg morphine sulfate beads ER cap 30mg, 45mg, 60mg, 75mg Embeda mg, mg Drug Uptier PA Addition 10/1/18

4 oxymorphone ER 12HR 5mg, 7.5mg, 10mg (Brand = Opana ER) Belbuca Film 75mcg, 150mcg Zohydro ER 10mg, 15mg, 20mg, 30mg, 40mg Hysingla ER 20mg, 30mg, 40mg, 60mg, 80mg Arymo ER 15mg, 30mg Morphabond ER 15mg, 30mg Xtampza ER 9mg, 13.5mg, 18mg Oxycontin 10mg, 15mg, 20mg Brand name short acting opioids with generic alternatives (Percocet, Norco, Roxicodone, Demerol, Dilaudid, Tylenol/Codeine, Ultram, Ultracet, Ibudone, Fioricet/Codeine, Fiorinal/Codeine, Xodol, Opana ) methadone tablet 5mg, 10mg (Brand = Dolophine ) Varies G + PA PB + QL + PA (QL varies) G + PA + QL Brand Downtier PA Addition 10/1/18 Xtampza XR Generic equivalent drug available No Change QL Addition 10/1/18

5 methadone con G + PA G + PA + QL No Change QL Addition 10/1/18 10mg/ml (6ml per day) methadone sol G + PA G + PA + QL No Change QL Addition 10/1/18 5mg/5ml (60ml per day) methadone sol G + PA G + PA + QL No Change QL Addition 10/1/18 10mg/5ml (30ml per day) buprenorphine hcl sub G + QL G + QL No Change QL Update 10/1/18 8mg (4 per day) Firvanq soln NPD NPD + AL No Change AL Addition 10/1/18 tramadol-acetaminophen tab mg Flurazepam 15mg, 30mg Triazolam 0.125mg, 0.25mg (Brand = Halcion ) Quazepam 15mg (Brand = Doral ) Estazolam 1mg, 2mg Temazepam 7.5mg, 15mg, 22.5mg, 30mg (Brand = Restoril ) Lorazepam 1mg, 2mg (Brand = Ativan ) Oxazepam 10mg, 15mg, 30mg G + QL + AL (40 per 5 day) age less than 6) G+ QL + AL (8 per day) age less than 15) age less than 12) age less than 12) No Change QL Update 10/1/18

6 Alprazolam (Brand = Xanax ) alprazolam ER Varies No Change AL Addition 10/1/18 (Brand = Xanax XR) Dulera NPD + PA + AL NPD + PA No Change AL Removal 10/1/18 Linzess PB + AL PB No Change AL Removal 10/1/18 Opioids products containing the following active ingredients: codeine, dihydrocodeine, fentanyl, hydrocodone, hydromorphone, levorphanol, meperidine, methadone, morphine, opium, oxycodone, oxymorphone, tapentadol, and tramadol Select topical acne products Varies Varies + MME Varies MME Addition 10/1/18 age greater than 35) age greater than 25)

7 Abbreviation Key G LCG PB NPD SP NF PA MME D/S QL AL Generic Addition Generic Downtier Generic/Drug Uptier Brand Downtier Brand Uptier Brand Addition Brand/Generic Deletion Generic Low Cost Generic Preferred Brand Non-Preferred Drug Specialty Drug. Specialty Tier cost-share will apply for those benefits that have a prescription drug specialty tier. Non-. Non- refers to drugs not covered on the formulary. A formulary exception is available upon request. Prior Authorization is required. Morphine Milligram Equivalent Days Supply Limit Quantity Limits Age Limit A generic drug that recently became available in the marketplace This generic drug will be covered at the appropriate preferred drug level of cost-sharing. This generic drug will be covered at the appropriate non-preferred drug level of cost-sharing. These brand drugs were added to the formulary as of the date indicated and are covered at the appropriate preferred brand formulary level of cost-sharing. These brand drugs will be covered at the appropriate non-preferred drug level of cost-sharing. Coverage was added to this drug. Coverage was removed from this drug. alternatives are available. DL Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association.

8 Language Assistance Services Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al número telefónico de Servicio al Cliente que figura en el reverso de su tarjeta de identificación. Chinese: 注意 : 如果您讲中文, 您可以得到免费的语言协助服务 请致电您 ID 卡背面的客户服务电话号码. Korean: 안내사항 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 귀하의 ID 카드뒷면에있는고객서비스번호로전화해주십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para telefone do Atendimento ao Cliente que está no verso do seu cartão de identificação. Gujarati: ચન : જ તમ જર ત બ લત હ, ત ન: ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ પલ છ. પય તમ ર ડ ક ડ ન પ છળ હક સ વ ન બર પર ક લ કર. Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi số Dịch Vụ Chăm Sóc Khách Hàng ở mặt sau thẻ ID của bạn. Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Позвоните в службу поддержки клиентов по номеру телефона, указанном на обратной стороне вашей идентификационной карты. Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer Obsługi klienta znajdujący się na odwrocie Twojego identyfikatora. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiami il numero dell Assistenza clienti che troverà sul retro della sua tessera identificativa. Arabic: ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية متاحة لك بالمجان. الرجاء االتصال برقم "خدمة العمالء" الموجود على ظھر بطاقة ھويتك. French Creole: ATANSYON : Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Tanpri rele nimewo Sèvis Kliyantèl ki sou do kat idantifikasyon ou a. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Mangyaring tawagan ang numero ng Customer Service na nasa likod ng iyong ID card. French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Veuillez composer le numéro du service clientèle indiqué au dos de votre carte d'identité Médicale. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Number uff die hinnerscht Seit vun dei ID Card uff fer schwetze mit ebber as dich helfe kann. Hindi: य न द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए पल ह क पय अपन आईड क डर क प छ दए ग र हक स व न बर पर क ल कर German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Bitte rufen Sie unsere Kundendienstnummer auf der Rückseite Ihrer Identifikationskarte an. Japanese: 備考 : 母国語が日本語の方は 言語アシスタンスサービス ( 無料 ) をご利用いただけます ご自分の ID カードの裏面に記載されているカスタマーサービスの番号へお電話ください Persian (Farsi): توجه: اگر فارسی صحبت می کنيد خدمات ترجمه به صورت رايگان برای شما فراھم می باشد. لطفا با شماره خدمات مشتريان که در پشت کارت شناسايی شما درج شده است تماس بگيريد.

9 Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti go Diné Bizaad, saad bee 1k1 1n7da 1wo d66, t 11 jiik eh. T 11 sh--d7 h0d77lnih koj8!k1 an7daalwo j8 47 binumber naaltsoos nit[ izgo nantin7g77 bine d66 bik11. Urdu: توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں تو آپ کے لئے مفت ميں زبان معاون خدمات دستياب ہيں آپ کے شناختی کارڈ کے پيچھے دئيےگئے صارف خدمات نمبر پر برائے کرم کال کريں. Mon-Khmer, Cambodian: ស ម ម ត ចប រមមណ របស ន ប អនកន យ មន- ខមរ ខមរ ន ជ ន យ ផនក ន ងមនផ តល ជ នដល កអនក យ ត គ ត ថ ល ស មទ រសពទ លខ ស សមជ ក ដលមន ន ផនកខង រកយ នបណ ណសមគ ល ខ ល នរបស កអនក Discrimination is Against the Law This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides: Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats). Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan 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 our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA, 19103; By phone: (TTY: 711), By fax: , By civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator 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, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at