Blue Cross Blue Shield of North Carolina Enhanced 4 Tier Formulary

October 07 Blue Cross Blue Shield of North Carolina Enhanced 4 Tier 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 bcbsnc.com for the most up-to-date information. Contents Preface... I Member guide to covered medications on the Enhanced 4 Tier Formulary... I Enhanced Formulary tiers... I 4-Tier Formulary... I 3-Tier Formulary... I -Tier Formulary... II Generic Medications... II Compounded Prescriptions... II Prior review, quantity limitations and restricted-access medications... II medications... III Affordable Care Act... III medications... III Using the member guide to the Enhanced Formulary... IV Abbreviation/acronym Key... V Therapeutic Class Medication List Anti-Infective Agents... Antineoplastic Agents... 9 Endocrine and Metabolic Medications... 3 Cardiovascular Agents... 5 Respiratory Agents... 37 Gastrointestinal Agents... 4 Genitourinary Agents... 45 Central Nervous System Medications... 47 Analgesics and Anesthetics... 58 Neuromuscular Medications... 65 Nutritional Products... 7 Hematological Agents... 7 Topical Products... 79 Miscellaneous Products... 87 Index... 89 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. 554 NC Prime Therapeutics LLC 0/7

Member guide to commonly prescribed medications on the Enhanced 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 prescription medications listed in the formulary or their tier placement may change from time to time due to a change in the cost of the medication and/or in the classification of the medication by the U.S. Food and Drug Administration (FDA) or nationally-recognized medication databases (e.g., Medispan). For a more complete listing of medication coverage and costs, you may use our medication search at www.bcbsnc.com. 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. A 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 Administration (FDA) or nationally-recognized medication databases (e.g., Medispan). Please refer to your member guide for detailed information regarding your pharmacy benefits, including your benefit design, out-of-pocket costs, prior review and restricted access medication requests, and applicable exclusions. Enhanced Formulary tiers The 3-Tier and 4-Tier Formularies cover most medications approved by the United States Food & Drug Administration (FDA), within existing benefits. The plan design determines the member s payment obligation. Some members have a two-tiered benefit structure (Tier and Tier ), some members have a three-tiered benefit structure (Tier, Tier, and Tier 3), and some members have a four-tiered benefit structure (Tier, Tier, Tier 3, and Tier 4) depending on the plan in which they are enrolled. 4-Tier Formulary Definitions for a four-tiered 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 generics, and some brand-name prescription medications. Tier 3: The prescription medication tier which consists of higher-cost prescription medications, most are brand-name prescription medications, and some specialty medications. Tier 4: The prescription medication tier which consists of the highest-cost prescription medications, most are specialty medications. 3-Tier Formulary Definitions for a three-tiered 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 generics, and some brand-name prescription medications. Tier 3: The prescription medication tier which consists of higher-cost prescription medications, most are brand-name prescription medications, and some specialty medications. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary I

-Tier Formulary Definitions for a two-tiered benefit structure: Tier Tier, Tier 3, Tier 4 Generic medications In most cases choosing a generic medication equivalent, when available, may 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 co-payment month after month. For some benefit plans, 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, quantity limitations and restricted-access medications 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. Medications that have prior review requirements must be reviewed by Blue Cross NC before coverage can be authorized. Certain medications may also have limitations on the quantity and days supply coverage. Quantities in excess of the coverage limit must be reviewed and approved by Blue Cross NC before coverage can be authorized for amounts in excess of the limits. For coverage of restricted-access medications, Blue Cross NC requires that the member has tried nonrestricted-access formulary medications first. Coverage for restricted-access medications may be provided without the use of a non-restricted-access medication if the provider certifies in writing that the member has previously used non-restricted-access medications and the non-restricted-access medications have been detrimental to the member's health or have been ineffective in treating the same condition and, in the opinion of the provider, are likely to be detrimental to the member's health or ineffective in treating the condition in the future. Clinical rationale and documentation for exception requests may be required. The FDA 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 and quantity limitations programs follow FDA-approved uses for these medications. However, Blue Cross NC recognizes that in many cases, off-label (non-fda approved) 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 American 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. Additional searches for current supporting medical literature may be performed utilizing standard electronic databases. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary II

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 4, 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. Affordable Care Act Please note, some medications may have limited or $0 cost-sharing under the Affordable Care Act (); 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, vaccines, vitamin D supplements, and some contraceptive medications and devices. You may find additional information about these medications at: www.bcbsnc.com/preventive. These medications are identified in the column of the formulary guide. If you do not find the medication you are searching for, consult or contact the customer service number on the back of your ID card to find out if the medication is available over the counter or is covered under your medical and/or pharmacy 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 Administration (FDA) 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) October 07 Enhanced 4 Tier Formulary III

Using the member guide to the Enhanced Formulary The Medication List is organized into broad categories (e.g., ANTI-INFECTIVE AGENTS). 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 "A" in the Medication Tier column, this indicates the medication may only be covered if a member meets the criteria for $0 copay under the Affordable Care Act. 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 Affordable Care Act (). Benefits may apply. The last column indicates if the medication is considered. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary IV

Abbreviation/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... 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 and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary V

07 ANTI-INFECTIVE AGENTS PENICILLINS 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 00-8.5 /5ml amoxicillin & k clavulanate for susp 50-6.5 /5ml (Augmentin) amoxicillin & k clavulanate for susp 400-57 /5ml amoxicillin & k clavulanate for susp 600-4.9 /5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr 000-6.5 (Augmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab 500-5 (Augmentin) amoxicillin & k clavulanate tab 875-5 (Augmentin) ampicillin cap 500 dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 penicillin v potassium for soln 5 /5ml penicillin v potassium for soln 50 /5ml penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHALOSPORINS 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 cefdinir for susp 50 /5ml 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 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary

07 cephalexin cap 50 (Keflex) cephalexin cap 500 (Keflex) cephalexin cap 750 (Keflex) cephalexin for susp 5 /5ml cephalexin for susp 50 /5ml SUPRAX - cefixime cap 400 SUPRAX - cefixime for susp 500 /5ml MACROLIDES 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 for susp 5 /5ml clarithromycin for susp 50 /5ml clarithromycin tab er 4hr 500 clarithromycin tab 50 clarithromycin tab 500 DIFICID - fidaxomicin tab 00 erythromycin ethylsuccinate for susp 00 /5ml (E.e.s. granules) erythromycin w/ delayed release particles cap 50 TETRACYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 300 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 75 (Acticlate) doxycycline hyclate tab 00 doxycycline hyclate tab 50 (Acticlate) doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 (Monodox) doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 (Adoxa) doxycycline monohydrate for susp 5 /5ml (Vibramycin) doxycycline monohydrate tab 50 doxycycline monohydrate tab 75 doxycycline monohydrate tab 00 doxycycline monohydrate tab 50 minocycline hcl cap 50 (Minocin) 3 3 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary

07 minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) minocycline hcl tab er 4hr 90 minocycline hcl tab er 4hr 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 ciprofloxacin for oral susp 50 /5ml (5%) (5 gm/00ml) (Cipro) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) 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 4hr 500 (base eq) (Cipro xr) ciprofloxacin-ciprofloxacin hcl tab er 4hr 000 (base eq) (Cipro xr) levofloxacin tab 50 (Levaquin) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) moxifloxacin hcl tab 400 (base equiv) (Avelox) ofloxacin tab 400 AMINOGLYCOSIDES BETHKIS - tobramycin nebu soln 300 /4ml KITABIS PAK - tobramycin nebu soln 300 /5ml neomycin sulfate tab 500 paromomycin sulfate cap 50 TOBI - tobramycin nebu soln 300 /5ml TOBI PODHALER - tobramycin inhal cap 8 tobramycin nebu soln 300 /5ml (Tobi) ANTIMYCOBACTERIAL AGENTS ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 400 (Myambutol) isoniazid tab 00 isoniazid tab 300 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) rifampin cap 50 (Rifadin) rifampin cap 300 SIRTURO - bedaquiline fumarate tab 00 (base equiv) ANTIFUNGALS ANCOBON - flucytosine cap 50 ANCOBON - flucytosine cap 500 CRESEMBA - isavuconazonium sulfate cap 86 3 4 4 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 3

07 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 griseofulvin ultramicrosize tab 5 (Gris-peg) griseofulvin ultramicrosize tab 50 (Gris-peg) itraconazole cap 00 (Sporanox) ketoconazole tab 00 NOXAFIL - posaconazole susp 40 /ml NOXAFIL - posaconazole tab delayed release 00 nystatin tab 500000 unit terbinafine hcl tab 50 (Lamisil) VFEND - voriconazole for susp 40 /ml 3 3 VFEND - voriconazole tab 50 VFEND - voriconazole tab 00 voriconazole for susp 40 / ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 00 (Vfend) ANTIVIRALS abacavir sulfate tab 300 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab 600-300 (Epzicom) abacavir sulfatelamivudine-zidovudine tab 300-50-300 (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 ATRIPLA - efavirenzemtricitabine-tenofovir df tab 600-00-300 COMPLERA - emtricitabinerilpivirine-tenofovir df tab 00-5-300 COPEGUS - ribavirin tab 00 CRIXIVAN - indinavir sulfate cap 00 CRIXIVAN - indinavir sulfate cap 400 DAKLINZA - daclatasvir dihydrochloride tab 30 (base equivalent) DAKLINZA - daclatasvir dihydrochloride tab 60 (base equivalent) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 4

07 DAKLINZA - daclatasvir dihydrochloride tab 90 (base equivalent) DESCOVY - emtricitabinetenofovir alafenamide fumarate tab 00-5 didanosine delayed release capsule 5 (Videx ec) 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) EMTRIVA - emtricitabine caps 00 EMTRIVA - emtricitabine soln 0 /ml entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUSA - sofosbuvirvelpatasvir tab 400-00 EPZICOM - abacavir sulfatelamivudine tab 600-300 EVOTAZ - atazanavir sulfatecobicistat tab 300-50 (base equiv) famciclovir tab 5 famciclovir tab 50 famciclovir tab 500 GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab 50-50-00-0 HARVONI - ledipasvir-sofosbuvir tab 90-400 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) KALETRA - lopinavir-ritonavir tab 00-5 KALETRA - lopinavir-ritonavir tab 00-50 lamivudine oral soln 0 /ml (Epivir) lamivudine tab 00 (hbv) (Epivir hbv) lamivudine tab 50 (Epivir) lamivudine tab 300 (Epivir) lamivudine-zidovudine tab 50-300 (Combivir) LEXIVA - fosamprenavir calcium susp 50 /ml (base equiv) LEXIVA - fosamprenavir calcium tab 700 (base equiv) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 5

07 lopinavir-ritonavir soln 400-00 /5ml (80-0 / ml) (Kaletra) MAVYRET - glecaprevirpibrentasvir tab 00-40 MODERIBA - ribavirin tab 00 & ribavirin tab 400 dose pack MODERIBA - ribavirin tab 400 & ribavirin tab 600 dose pack MODERIBA 00 DOSE PACK - ribavirin tab 600 MODERIBA 800 DOSE PACK - ribavirin tab 400 nevirapine tab er 4hr 00 (Viramune xr) nevirapine tab er 4hr 400 (Viramune xr) nevirapine tab 00 (Viramune) NORVIR - ritonavir cap 00 NORVIR - ritonavir oral soln 80 /ml NORVIR - ritonavir tab 00 ODEFSEY - emtricitabinerilpivirine-tenofovir af tab 00-5-5 OLYSIO - simeprevir sodium cap 50 (base equivalent) oseltamivir phosphate cap 30 (base equiv) (Tamiflu) oseltamivir phosphate cap 45 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) PEGASYS - peginterferon alfa-a inj 80 mcg/ml PEGASYS - peginterferon alfa-a inj 80 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 35 mcg/0.5ml PEGASYS PROCLICK - peginterferon alfa-a inj 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 80 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 0 mcg/0.5ml PEGINTRON - peginterferon alfa-b for inj kit 50 mcg/0.5ml PREZCOBIX - darunavircobicistat tab 800-50 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 cap 00 RESCRIPTOR - delavirdine mesylate tab 00 RESCRIPTOR - delavirdine mesylate tab 00 REYATAZ - atazanavir sulfate cap 50 (base equiv) REYATAZ - atazanavir sulfate cap 00 (base equiv) REYATAZ - atazanavir sulfate cap 300 (base equiv) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 6

07 REYATAZ - atazanavir sulfate oral powder packet 50 (base equiv) ribavirin cap 00 (Rebetol) ribavirin for inhal soln 6 gm (Virazole) ribavirin tab 00 (Copegus) rimantadine hydrochloride tab 00 (Flumadine) SELZENTRY - maraviroc tab 5 SELZENTRY - maraviroc tab 75 SELZENTRY - maraviroc tab 50 SELZENTRY - maraviroc tab 300 SOVALDI - sofosbuvir tab 400 4 stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 30 (Zerit) stavudine cap 40 (Zerit) STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab 50-50-00-300 SUSTIVA - efavirenz cap 50 SUSTIVA - efavirenz cap 00 SUSTIVA - efavirenz tab 600 TECHNIVIE - ombitasvirparitaprevir-ritonavir tab.5-75-50 TIVICAY - dolutegravir sodium tab 0 (base equiv) TIVICAY - dolutegravir sodium tab 5 (base equiv) TIVICAY - dolutegravir sodium tab 50 (base equiv) TRIUMEQ - abacavirdolutegravir-lamivudine tab 600-50-300 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 00-50 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 33-00 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 67-50 TRUVADA - emtricitabinetenofovir disoproxil fumarate tab 00-300 TYBOST - cobicistat tab 50 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) VEMLIDY - tenofovir alafenamide fumarate tab 5 VIDEX - didanosine for soln gm VIDEX - didanosine for soln 4 gm VIEKIRA PAK - ombitasparitapre-riton & dasab tab pak.5-75-50 & 50 VIEKIRA XR - dasab-ombitparitap-riton tab er 4hr 00-8.33-50-33.33 VIRACEPT - nelfinavir mesylate tab 50 VIRACEPT - nelfinavir mesylate tab 65 VIRAMUNE - nevirapine susp 50 /5ml VIRAZOLE - ribavirin for inhal soln 6 gm Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 7

07 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 VIREAD - tenofovir disoproxil fumarate tab 300 VOSEVI - sofosbuvir-velpatasvirvoxilaprevir tab 400-00-00 ZEPATIER - elbasvir-grazoprevir tab 50-00 ZERIT - stavudine for oral soln /ml ZIAGEN - abacavir sulfate soln 0 /ml (base equiv) zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 300 ANTIMALARIALS atovaquone-proguanil hcl tab 6.5-5 (Malarone) atovaquone-proguanil hcl tab 50-00 (Malarone) chloroquine phosphate tab 500 COARTEM - artemetherlumefantrine tab 0-0 hydroxychloroquine sulfate tab 00 (Plaquenil) mefloquine hcl tab 50 PRIMAQUINE PHOSPHATE - primaquine phosphate tab 6.3 (5 base) quinine sulfate cap 34 (Qualaquin) ANTHELMINTICS ALBENZA - albendazole tab 00 ivermectin tab 3 (Stromectol) ANTI-INFECTIVE AGENTS - MISC. ALINIA - nitazoxanide for susp 00 /5ml 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 300 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 dapsone tab 00 linezolid for susp 00 /5ml (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 375 (Flagyl) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) PRIMSOL - trimethoprim hcl oral soln 50 /5ml (base equiv) sulfamethoxazoletrimethoprim susp 00-40 /5ml Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 8

07 sulfamethoxazoletrimethoprim tab 400-80 (Bactrim) sulfamethoxazoletrimethoprim tab 800-60 (Bactrim ds) tinidazole tab 50 tinidazole tab 500 (Tindamax) trimethoprim tab 00 vancomycin hcl cap 5 (Vancocin hcl) vancomycin hcl cap 50 (Vancocin hcl) ANTINEOPLASTIC AGENTS 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 3 AFINITOR DISPERZ - everolimus tab for oral susp 5 ALECENSA - alectinib hcl cap 50 (base equivalent) ALUNBRIG - brigatinib tab 30 anastrozole tab (Arimidex) bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) BOSULIF - bosutinib tab 00 BOSULIF - bosutinib tab 500 CABOMETYX - cabozantinib s-malate tab 0 (base equivalent) CABOMETYX - cabozantinib s-malate tab 40 (base equivalent) CABOMETYX - cabozantinib s-malate tab 60 (base equivalent) capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA - vandetanib tab 00 CAPRELSA - 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 (40 dose) kit COMETRIQ - cabozantinib s- malate cap 3 x 0 (60 dose) kit COTELLIC - cobimetinib fumarate tab 0 (base equivalent) CYCLOPHOSPHAMIDE - cyclophosphamide cap 5 CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 EMCYT - estramustine phosphate sodium cap 40 ERIVEDGE - vismodegib cap 50 ETOPOSIDE - etoposide cap 50 exemestane tab 5 (Aromasin) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 9

07 FARYDAK - panobinostat lactate cap 0 (base equivalent) FARYDAK - panobinostat lactate cap 5 (base equivalent) FARYDAK - panobinostat lactate cap 0 (base equivalent) FASLODEX - fulvestrant inj 50 /5ml flutamide cap 5 GILOTRIF - afatinib dimaleate tab 0 (base equivalent) GILOTRIF - afatinib dimaleate tab 30 (base equivalent) GILOTRIF - afatinib dimaleate tab 40 (base equivalent) GLEOSTINE - lomustine cap 5 GLEOSTINE - lomustine cap 0 GLEOSTINE - lomustine cap 40 GLEOSTINE - lomustine cap 00 HEXALEN - altretamine cap 50 HYCAMTIN - topotecan hcl cap 0.5 (base equiv) HYCAMTIN - topotecan hcl cap (base equiv) hydroxyurea cap 500 (Hydrea) 4 4 4 4 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 40 INLYTA - axitinib tab INLYTA - axitinib tab 5 INTRON A - interferon alfa-b inj 6000000 unit/ml INTRON A - interferon alfa-b inj 0000000 unit/ml INTRON A - interferon alfa-b for inj 0000000 unit INTRON A - interferon alfa-b for inj 8000000 unit INTRON A - interferon alfa-b for inj 50000000 unit INTRON A W/DILUENT - interferon alfa-b for inj 0000000 unit INTRON A W/DILUENT - interferon alfa-b for inj 8000000 unit INTRON A W/DILUENT - interferon alfa-b for inj 50000000 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 and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 0

07 JAKAFI - ruxolitinib phosphate tab 5 (base equivalent) KADCYLA - ado-trastuzumab emtansine for iv soln 00 KADCYLA - ado-trastuzumab emtansine for iv soln 60 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 KYPROLIS - carfilzomib for inj 30 KYPROLIS - carfilzomib for inj 60 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 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 8 MG DAILY DOSE - lenvatinib cap therapy pack 4 () (8 daily dose) 4 letrozole tab.5 (Femara) leucovorin calcium tab 5 leucovorin calcium tab 5 leuprolide acetate inj kit 5 / ml LONSURF - trifluridine-tipiracil tab 5-6.4 LONSURF - trifluridine-tipiracil tab 0-8.9 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 (4-MONTH) - leuprolide acetate (4 month) for inj kit 30 LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for inj kit 45 LYNPARZA - olaparib cap 50 LYSODREN - mitotane tab 500 MARQIBO - vincristine sulfate liposome iv susp 5 /3ml (0.6 /ml) MATULANE - procarbazine hcl cap 50 megestrol acetate susp 40 / ml (Megace oral) megestrol acetate tab 0 megestrol acetate tab 40 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary

07 MEKINIST - trametinib dimethyl sulfoxide tab 0.5 (base equivalent) MEKINIST - trametinib dimethyl sulfoxide tab (base equivalent) melphalan tab (Alkeran) mercaptopurine tab 50 methotrexate sodium for inj gm methotrexate sodium inj pf 50 /ml (5 /ml) methotrexate sodium inj pf 00 /4ml (5 /ml) methotrexate sodium inj pf 00 /8ml (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) NILANDRON - nilutamide tab 50 nilutamide tab 50 (Nilandron) NINLARO - ixazomib citrate cap.3 (base equivalent) NINLARO - ixazomib citrate cap 3 (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 3 POMALYST - pomalidomide cap 4 RUBR - rucaparib camsylate tab 00 (base equivalent) RUBR - rucaparib camsylate tab 50 (base equivalent) RUBR - rucaparib camsylate tab 300 (base equivalent) RYDAPT - midostaurin cap 5 STIVARGA - regorafenib tab 40 SYLATRON - peginterferon alfa-b for inj kit 00 mcg SYLATRON - peginterferon alfa-b for inj kit 300 mcg SYLATRON - peginterferon alfa-b for inj kit 600 mcg SYNRIBO - omacetaxine mepesuccinate for inj 3.5 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) TASIGNA - nilotinib hcl cap 50 (base equivalent) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary

07 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) tretinoin cap 0 VENCLEXTA - venetoclax tab 0 VENCLEXTA - venetoclax tab 50 VENCLEXTA - venetoclax tab 00 VENCLEXTA STARTING PACK - venetoclax tab therapy starter pack 0 & 50 & 00 VOTRIENT - pazopanib hcl tab 00 (base equiv) XALKORI - crizotinib cap 00 XALKORI - crizotinib cap 50 XATMEP - methotrexate oral soln.5 /ml XTANDI - enzalutamide cap 40 ZEJULA - niraparib tosylate cap 00 (base equivalent) ZELBORAF - vemurafenib tab 40 4 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 MEDICATIONS CORTICOSTEROIDS budesonide delayed release particles cap 3 (Entocort ec) dexamethasone elixir 0.5 /5ml dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab.5 dexamethasone tab 4 dexamethasone tab 6 EMFLAZA - deflazacort susp.75 /ml EMFLAZA - deflazacort tab 6 EMFLAZA - deflazacort tab 8 EMFLAZA - deflazacort tab 30 EMFLAZA - deflazacort tab 36 fludrocortisone acetate tab 0. hydrocortisone tab 5 (Cortef) hydrocortisone tab 0 (Cortef) hydrocortisone tab 0 (Cortef) methylprednisolone tab therapy pack 4 () (Medrol dosepak) methylprednisolone tab 4 (Medrol) methylprednisolone tab 8 (Medrol) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 3

07 methylprednisolone tab 6 (Medrol) methylprednisolone tab 3 (Medrol) 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 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 syrup 5 /5ml (usp solution equivalent) prednisone tab prednisone tab.5 prednisone tab 5 prednisone tab 0 prednisone tab 0 UCERIS - budesonide tab er 4hr 9 ANDROGEN-ANABOLIC ANDROGEL - testosterone td gel 0.5 /.5gm (.6%) ANDROGEL - testosterone td gel 40.5 /.5gm (.6%) 3 ANDROGEL PUMP - testosterone td gel 0.5 / act (.6%) danazol cap 50 danazol cap 00 danazol cap 00 methyltestosterone cap 0 (Testred) oxandrolone tab.5 (Oxandrin) oxandrolone tab 0 (Oxandrin) 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 td gel 5 /.5gm (%) (Androgel) testosterone td gel 50 /5gm (%) (Androgel) testosterone td gel.5 /act (%) testosterone td soln 30 /act (Axiron) ESTROGENS estradiol & norethindrone acetate tab 0.5-0. (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) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 4

07 estradiol td patch twice weekly 0.0375 /4hr (Vivelle-dot) estradiol td patch twice weekly 0.05 /4hr (Vivelle-dot) estradiol td patch twice weekly 0.075 /4hr (Vivelle-dot) estradiol td patch twice weekly 0. /4hr (Vivelle-dot) estradiol td patch weekly 0.05 /4hr (Climara) estradiol td patch weekly 0.0375 /4hr (37.5 mcg/4hr) (Climara) estradiol td patch weekly 0.05 /4hr (Climara) estradiol td patch weekly 0.06 /4hr (Climara) estradiol td patch weekly 0.075 /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) norethindrone acetate-ethinyl estradiol tab 0.5 -.5 mcg (Femhrt low dose) norethindrone acetate-ethinyl estradiol tab -5 mcg PREMARIN - estrogens, conjugated tab 0.3 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 0.65-5(4) PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.3-.5 PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.45-.5 PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.65-.5 PREMPRO - conjugated estrogen-medroxyprogest acetate tab 0.65-5 CONTRACEPTIVES desogest-eth estrad A & eth estrad tab 0.5-0.0/0.0 (/5) (Mircette) desogest-ethin est tab A 0.-0.05/0.5-0.05/0.5-0.05 (Cyclessa) desogestrel & ethinyl estradiol tab 0.5-30 mcg (Desogen) drospirenone-ethinyl estrad-levomefolate tab 3-0.0-0.45 (Beyaz) drospirenone-ethinyl estradiol tab 3-0.0 (Yaz) drospirenone-ethinyl estradiol tab 3-0.03 (Yasmin 8) ethynodiol diacetate & ethinyl estradiol tab -35 mcg ethynodiol diacetate & ethinyl estradiol tab -50 mcg levonor-eth est tab 0.5-0.0/0.05/0.03 &eth est 0.0 (Quartette) A A A A A A A Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 5

07 levonorg-eth est tab A 0.-0.0(84) & eth est tab 0.0(7) (Loseasonique) levonorg-eth est tab A 0.5-0.03(84) & eth est tab 0.0(7) (Seasonique) levonorgestrel & ethinyl A estradiol (9-day) tab 0.5-0.03 levonorgestrel & ethinyl A estradiol tab 0. -0 mcg levonorgestrel & ethinyl A estradiol tab 0.5-30 mcg levonorgestrel tab.5 A A levonorgestrel-eth estra tab 0.05-30/0.075-40/0.5-30mcg 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 (Depoprovera contrac) norethindrone & ethinyl estradiol tab 0.4-35 mcg (Ovcon-35) norethindrone & ethinyl estradiol tab 0.5-35 mcg (Brevicon-8) norethindrone & ethinyl estradiol tab -35 mcg (Norinyl +35) norethindrone & ethinyl estradiol-fe chew tab 0.4-35 mcg (Femcon fe) norethindrone & ethinyl estradiol-fe chew tab 0.8-5 mcg (Generess fe) A A A A A A A norethindrone acethinyl estrad-fe tab -0/-30/-35 -mcg (Estrostep fe) norethindrone ace & ethinyl estradiol tab -0 mcg (Loestrin /0-) norethindrone ace & ethinyl estradiol tab.5-30 mcg (Loestrin.5/30-) norethindrone ace & ethinyl estradiol-fe tab -0 mcg (Loestrin fe /0) norethindrone ace & ethinyl estradiol-fe tab.5-30 mcg (Loestrin fe.5/30) norethindrone ace-eth estradiol-fe chew tab -0 mcg (4) (Minastrin 4 fe) norethindrone ace-ethinyl estradiol-fe tab -0 mcg (4) norethindrone tab 0.35 (Ortho micronor) norethindrone-eth estradiol tab 0.5-35/0.75-35/-35 mcg (Ortho-novum 7/7/7) norethindrone-eth estradiol tab 0.5-35/-35/0.5-35 mcg (Tri-norinyl 8) norgestimate & ethinyl estradiol tab 0.5-35 mcg (Ortho-cyclen) norgestimate-eth estrad tab 0.8-5/0.5-5/0.5-5 mcg (Ortho tri-cyclen lo) norgestimate-eth estrad tab 0.8-35/0.5-35/0.5-35 mcg (Ortho tri-cyclen) norgestrel & ethinyl estradiol tab 0.3-30 mcg A A A A A A A A A A A A A A Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 6

07 NUVARING - etonogestrel-ethinyl estradiol va ring 0.0-0.05 /4hr YAZ - drospirenone-ethinyl estradiol tab 3-0.0 PROGESTINS 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 acarbose tab 5 (Precose) acarbose tab 50 (Precose) acarbose tab 00 (Precose) BYDUREON - exenatide for inj extended release susp BYDUREON PEN - exenatide extended release for susp peninjector BYETTA - exenatide soln peninjector 5 mcg/0.0ml BYETTA - exenatide soln peninjector 0 mcg/0.04ml glimepiride tab (Amaryl) glimepiride tab (Amaryl) glimepiride tab 4 (Amaryl) glipizide tab er 4hr.5 (Glucotrol xl) A glipizide tab er 4hr 5 (Glucotrol xl) glipizide tab er 4hr 0 (Glucotrol xl) glipizide tab 5 (Glucotrol) glipizide tab 0 (Glucotrol) glipizide-metformin hcl tab.5-50 glipizide-metformin hcl tab.5-500 glipizide-metformin hcl tab 5-500 GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj (base equiv) GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit glucose gel 40% glucose oral liquid 5 gm/59ml glyburide micronized tab.5 (Glynase) glyburide micronized tab 3 (Glynase) glyburide micronized tab 6 (Glynase) glyburide tab.5 glyburide tab.5 glyburide tab 5 glyburide-metformin tab.5-50 glyburide-metformin tab.5-500 (Glucovance) glyburide-metformin tab 5-500 (Glucovance) INVOKAMET - canagliflozinmetformin hcl tab 50-500 INVOKAMET - canagliflozinmetformin hcl tab 50-000 INVOKAMET - canagliflozinmetformin hcl tab 50-500 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 7

07 INVOKAMET - canagliflozinmetformin hcl tab 50-000 INVOKAMET XR - canagliflozinmetformin hcl tab er 4hr 50-500 INVOKAMET XR - canagliflozinmetformin hcl tab er 4hr 50-000 INVOKAMET XR - canagliflozinmetformin hcl tab er 4hr 50-500 INVOKAMET XR - canagliflozinmetformin hcl tab er 4hr 50-000 INVOKANA - canagliflozin tab 00 INVOKANA - canagliflozin tab 300 JANUMET - sitagliptin-metformin hcl tab 50-500 JANUMET - sitagliptin-metformin hcl tab 50-000 JANUMET XR - sitagliptinmetformin hcl tab er 4hr 50-500 JANUMET XR - sitagliptinmetformin hcl tab er 4hr 50-000 JANUMET XR - sitagliptinmetformin hcl tab er 4hr 00-000 JANUVIA - sitagliptin phosphate tab 5 (base equiv) JANUVIA - sitagliptin phosphate tab 50 (base equiv) JANUVIA - sitagliptin phosphate tab 00 (base equiv) JARDIANCE - empagliflozin tab 0 JARDIANCE - empagliflozin tab 5 JENTADUETO - linagliptinmetformin hcl tab.5-500 JENTADUETO - linagliptinmetformin hcl tab.5-850 JENTADUETO - linagliptinmetformin hcl tab.5-000 JENTADUETO XR - linagliptinmetformin hcl tab er 4hr.5-000 JENTADUETO XR - linagliptinmetformin hcl tab er 4hr 5-000 KOMBIGLYZE XR - saxagliptinmetformin hcl tab er 4hr.5-000 KOMBIGLYZE XR - saxagliptinmetformin hcl tab er 4hr 5-500 KOMBIGLYZE XR - saxagliptinmetformin hcl tab er 4hr 5-000 KORLYM - mifepristone tab 300 metformin hcl tab er 4hr 500 (Glucophage xr) metformin hcl tab er 4hr 750 (Glucophage xr) metformin hcl tab er 4hr osmotic 500 (Fortamet) metformin hcl tab er 4hr osmotic 000 (Fortamet) metformin hcl tab er 4hr modified release 500 (Glumetza) metformin hcl tab er 4hr modified release 000 (Glumetza) metformin hcl tab 500 (Glucophage) metformin hcl tab 850 (Glucophage) 3 3 3 3 3 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 8

07 metformin hcl tab 000 (Glucophage) miglitol tab 5 (Glyset) miglitol tab 50 (Glyset) miglitol tab 00 (Glyset) nateglinide tab 60 (Starlix) nateglinide tab 0 (Starlix) ONGLYZA - saxagliptin hcl tab.5 (base equiv) ONGLYZA - saxagliptin hcl tab 5 (base equiv) pioglitazone hcl tab 5 (base equiv) (Actos) pioglitazone hcl tab 30 (base equiv) (Actos) pioglitazone hcl tab 45 (base equiv) (Actos) pioglitazone hcl-glimepiride tab 30- (Duetact) pioglitazone hcl-glimepiride tab 30-4 (Duetact) pioglitazone hcl-metformin hcl tab 5-500 (Actoplus met) pioglitazone hcl-metformin hcl tab 5-850 (Actoplus met) repaglinide tab 0.5 repaglinide tab (Prandin) repaglinide tab (Prandin) SYNJARDY - empagliflozinmetformin hcl tab 5-500 SYNJARDY - empagliflozinmetformin hcl tab 5-000 SYNJARDY - empagliflozinmetformin hcl tab.5-500 SYNJARDY - empagliflozinmetformin hcl tab.5-000 SYNJARDY XR - empagliflozinmetformin hcl tab er 4hr 5-000 SYNJARDY XR - empagliflozinmetformin hcl tab er 4hr 0-000 SYNJARDY XR - empagliflozinmetformin hcl tab er 4hr.5-000 SYNJARDY XR - empagliflozinmetformin hcl tab er 4hr 5-000 TRADJENTA - linagliptin tab 5 3 VICTOZA - liraglutide soln peninjector 8 /3ml (6 /ml) Rapid-Acting Insulins NOVOLOG - insulin aspart inj 00 unit/ml NOVOLOG FLEXPEN - insulin aspart soln pen-injector 00 unit/ml NOVOLOG PENFILL - insulin aspart soln cartridge 00 unit/ ml Short-Acting Insulins NOVOLIN R - insulin regular (human) inj 00 unit/ml NOVOLIN R RELION - insulin regular (human) inj 00 unit/ml RELION R - insulin regular (human) inj 00 unit/ml Intermediate-Acting Insulins NOVOLIN N - insulin nph (human) (isophane) inj 00 unit/ml NOVOLIN N RELION - insulin nph (human) (isophane) inj 00 unit/ml NOVOLIN 70/30 - insulin nph isophane & regular human inj 00 unit/ml (70-30) NOVOLIN 70/30 RELION - insulin nph isophane & regular human inj 00 unit/ml (70-30) Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 9

07 NOVOLOG MIX 70/30 - insulin aspart prot & aspart (human) inj 00 unit/ml (70-30) NOVOLOG MIX 70/30 PREFILL - insulin aspart prot & aspart sus pen-inj 00 unit/ml (70-30) Basal Insulins LANTUS - insulin glargine inj 00 unit/ml LANTUS SOLOSTAR - insulin glargine soln pen-injector 00 unit/ml LEVEMIR - insulin detemir inj 00 unit/ml LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 00 unit/ml TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 00 unit/ml TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 00 unit/ml THYROID AGENTS levothyroxine sodium tab 5 mcg (Synthroid) levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 88 mcg (Synthroid) levothyroxine sodium tab 00 mcg (Synthroid) levothyroxine sodium tab mcg (Synthroid) levothyroxine sodium tab 5 mcg (Synthroid) levothyroxine sodium tab 37 mcg (Synthroid) levothyroxine sodium tab 50 mcg (Synthroid) levothyroxine sodium tab 75 mcg (Synthroid) levothyroxine sodium tab 00 mcg (Synthroid) levothyroxine sodium tab 300 mcg (Synthroid) liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 5 mcg (Cytomel) liothyronine sodium tab 50 mcg (Cytomel) methimazole tab 5 (Tapazole) methimazole tab 0 (Tapazole) propylthiouracil tab 50 SYNTHROID - levothyroxine sodium tab 5 mcg SYNTHROID - levothyroxine sodium tab 50 mcg SYNTHROID - levothyroxine sodium tab 75 mcg SYNTHROID - levothyroxine sodium tab 88 mcg SYNTHROID - levothyroxine sodium tab 00 mcg SYNTHROID - levothyroxine sodium tab mcg SYNTHROID - levothyroxine sodium tab 5 mcg SYNTHROID - levothyroxine sodium tab 37 mcg SYNTHROID - levothyroxine sodium tab 50 mcg SYNTHROID - levothyroxine sodium tab 75 mcg Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary 0

07 SYNTHROID - levothyroxine sodium tab 00 mcg SYNTHROID - levothyroxine sodium tab 300 mcg thyroid tab 5 (/4 grain) (Armour thyroid) thyroid tab 30 (/ grain) (Armour thyroid) thyroid tab 60 ( grain) (Armour thyroid) thyroid tab 90 ( / grain) (Armour thyroid) thyroid tab 0 ( grain) (Armour thyroid) TIROSINT - levothyroxine sodium cap 3 mcg TIROSINT - levothyroxine sodium cap 5 mcg TIROSINT - levothyroxine sodium cap 50 mcg TIROSINT - levothyroxine sodium cap 75 mcg TIROSINT - levothyroxine sodium cap 88 mcg TIROSINT - levothyroxine sodium cap 00 mcg TIROSINT - levothyroxine sodium cap mcg TIROSINT - levothyroxine sodium cap 5 mcg TIROSINT - levothyroxine sodium cap 37 mcg TIROSINT - levothyroxine sodium cap 50 mcg ENDOCRINE and METABOLIC AGENTS - MISC. alendronate sodium tab 5 alendronate sodium tab 0 alendronate sodium tab 35 alendronate sodium tab 70 (Fosamax) BRAVELLE Benefit Limits may 4 apply - urofollitropin purified for inj 75 unit cabergoline tab 0.5 calcitonin (salmon) nasal soln 00 unit/act calcitriol cap 0.5 mcg (Rocaltrol) calcitriol cap 0.5 mcg (Rocaltrol) calcitriol oral soln mcg/ml (Rocaltrol) CARBAGLU - carglumic acid tab 00 CETROTIDE Benefit Limits may apply - cetrorelix acetate for inj kit 0.5 CHORIONIC GONADOTROPIN Benefit Limits may apply - chorionic gonadotropin for inj 0000 unit desmopressin acetate inj 4 mcg/ml (Ddavp) desmopressin acetate nasal soln 0.0% (refrigerated) (Ddavp) desmopressin acetate nasal spray soln 0.0% (Ddavp) desmopressin acetate nasal spray soln 0.0% (refrigerated) desmopressin acetate tab 0. (Ddavp) desmopressin acetate tab 0. (Ddavp) doxercalciferol cap 0.5 mcg (Hectorol) doxercalciferol cap mcg (Hectorol) doxercalciferol cap.5 mcg (Hectorol) 4 4 Blue Cross and Blue Shield of North Carolina (Blue Cross NC) October 07 Enhanced 4 Tier Formulary