October Blue Cross and Blue Shield of Illinois Drug Formulary. Contents

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1 October 2012 Blue Cross and Blue Shield of Illinois Drug Formulary Contents Introduction... I How formulary drugs are selected... I How member payment is determined... I How to use this list...ii Drugs used to treat multiple conditions... III Generic drugs... III Consider talking to your doctor about generic drugs.. III Coverage considerations... III (DL) IV (PA)...X (ST)... X drugs... XI Prime Therapeutics Pharmacy Program... XI Abbreviation/acronym key... XI Therapeutic Class Drug List... 1 Anti-Infective Drugs... 1 Cancer Drugs...2 Hormones, Diabetes and Related Drugs...3 Heart And Circulatory Drugs...4 Respiratory Agents...6 Gastrointestinal Drugs...7 Genitourinary Drugs...7 Central Nervous System Drugs...8 Pain Relief Drugs...9 Neuromuscular Drugs Supplements Blood Modifying Drugs Topical Drugs Miscellaneous Categories Index 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 drug formulary is regularly updated. Please visit bcbsil.com for the most up-to-date information. 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 A IL Prime Therapeutics LLC 08/12

2 Introduction Blue Cross and Blue Shield of Illinois is pleased to present the 2012 Drug Formulary. This is a list of formulary drugs which includes Formulary Brand drugs and a partial listing of generic drugs. Members are encouraged to show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when right for the member. However decisions regarding therapy and treatment are always between members and their physician. Drug Formulary Updates This list is regularly updated as generic drugs become available and changes take place in the pharmaceuticals market. For the most up-to-date information, visit bcbsil.com and log in to Blue Access for Members SM or call the number on the back of your ID card. Physicians can access the list from the provider portal at bcbsil.com. How formulary drugs are selected Drugs on this list are selected based on the recommendations of a committee made up of physicians and pharmacists from throughout the country. The committee, which includes at least one representative from your health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA). Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on the list. How member payment is determined This list shows prescription drug products in tiers. Generally, each drug is placed into one of three or four member payment tiers: generic, Formulary Brand or Non-Formulary Brand (not listed in this document). drugs can either be within the previous three tiers or can be a separate fourth tier depending on your benefit design. To verify your payment amount for a specialty drug, visit bcbsil.com and log in to Blue Access for Members or call the number on the back of your ID card. Your pharmacy benefit includes coverage for almost all prescription drugs, although some exclusions may apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. I

3 How to use this list This list is organized into broad therapeutic categories. For example, Hormones, Diabetes and Related Drugs is a broad category. Within most categories, drugs are sub-grouped based upon drug class, for example under Hormones, Diabetes and Related Drugs you will find Estrogens. All drugs listed, whether generic or brand, are formulary drugs The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). The reference brand drug is a non-formulary (NF) brand and is only included as a reference to the brand. Some generic products have no reference brand. Example: budesonide ext-release (Entocort EC Formulary brand drugs are listed in all CAPITAL letters. Example: ZYTIGA The following examples are given to assist you and your doctor in reading listings that include specific strengths and dosage forms. These examples can be applied to other drugs on the formulary. Any exceptions are noted and some listings contain additional information about specific products or dosage forms. Extended-release and delayed-release products require their own entry. Example: DETROL LA The long-acting product Detrol LA is on the formulary, but requires a separate entry from the non ext-release product Detrol. Some products may show a strength, if so only that strength indicated is on the formulary. Example: XIFAXAN 550 mg The Xifaxan 550 mg is on formulary in this case, but the Xifaxan 200 mg is not because it is not listed. 2 The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs can be found in this document under the header for Drugs. 3 The remaining columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug (e.g.,,, and ). If an indicator is present in the column(s), then the UM program noted is possibly applied to your benefit. Some plans may have UM on additional medications beyond those noted in this document. II

4 Drugs used to treat multiple conditions Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances, each medication is classified according to its first FDA-approved use. Please check the index if you do not find your particular medication in the class/condition section that corresponds to your use. Generic drugs Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs must be approved by the FDA just as brand drugs are, and must meet the same strict standards. There are two types of generic drugs: A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug. A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s) differs from the brand drug. According to the FDA, compared to its brand counterpart, an FDA-approved generic drug: Is chemically the same Works just as well in the body Is as safe and effective Meets the same standards set by the FDA The main difference between the reference brand drug and the generic equivalent is that the generic often costs much less. Brand drugs in Tier 2 typically move to Tier 3 after a generic equivalent becomes available. You may be responsible for the generic member payment amount plus the difference in cost between the brand and generic drug if you or your doctor requests the reference brand rather than the generic. Generic drugs have the lowest member payment amount. Consider talking to your doctor about generic drugs If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an appropriate generic alternative is available. You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new prescription from your doctor. Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication. Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30- to 34-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Over-the-Counter Exclusions: Some benefit plans do not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan booklet for details about your particular benefits. Compounded Medications: Some benefit plans do not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded medications are covered and/or verify your payment amount. Repackaged Medications: Repackaged versions of medications already available on the market are not covered. III

5 (DL) Drug dispensing limits help encourage medication use as intended by the FDA. Coverage limits are placed on medications in certain drug categories. For the formulary medications listed in this document, if a dispensing limit applies, it will be noted next to the medication with a dot under the dispensing limits column as explained in the section How to Use This List. Limits may include: Quantity of covered medication per prescription Quantity of covered medication in a given time period Coverage only for members within a certain age range Coverage only for members of a specific gender If your doctor prescribes a greater quantity of medication than what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription beyond what your coverage allows. The following brand drugs, and their generic equivalents, if available, have dispensing limits. Some of these dispensing limits may not apply to all members or may vary based on state regulations. Some dispensing limits listed below may apply across multiple medications within a drug class. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction (example: Viagra). Some drugs may not be available through mail service. Coverage for some drug categories, such as specialty or other select non-specialty medications, may be limited to a 30-day supply at a time depending on your particular benefit plan. Please see your plan materials or call the number on the back of your ID card to verify if you are uncertain of any plan limitations or exclusions. This list is subject to change. Brand Name (Generic Name) Dosage Form Dispensing Limit Abilify 2 mg, 5 mg (aripiprazole) tabs 60 tabs/30 days Abilify 10 mg, 15 mg, 20 mg, 30 mg (aripiprazole) tabs 30 tabs/30 days Abilify Discmelt (aripiprazole) tabs 60 tabs/30 days Abilify (aripiprazole) oral soln 750 ml/30 days Abstral (fentanyl) sublingual tabs 120 tabs/30 days Accuneb 0.63 mg/3 ml, 1.25 mg/3 ml (albuterol) inhal soln 375 ml/rx Aciphex (rabeprazole delayed-release) tabs 60 tabs/30 days (limit one proton pump inhibitor in 30 days) Actiq (fentanyl) lollipops 120 lollipops/30 days Actonel 5 mg, 30 mg (risedronate) tabs 30 tabs/30 days Actonel 35 mg (risedronate) tabs 4 tabs/30 days Actonel 150 mg (risedronate) tabs 1 tab/30 days Adcirca (tadalafil) tabs 60 tabs/30 days Advair Diskus (fluticasone/salmeterol) inhaler 1 inhaler (60 doses)/rx Advair HFA (fluticasone/salmeterol) inhaler 1 inhaler/rx albuterol 0.083% inhal soln 375 ml/rx albuterol 0.5% inhal soln 60 ml/rx Aldara (imiquimod) crm 48 packets/365 days; 12 packets/rx Alinia (nitazoxanide) oral soln 60 ml/30 days Alora (estradiol) patches 28 patches/28 days Alsuma (sumatriptan) inj 12 syringe cartridges/30 days Alvesco (ciclesonide) inhaler 2 inhalers/rx Ambien (zolpidem) tabs 30 tabs/30 days (across insomnia agents) Ambien CR (zolpidem ext-release) tabs 30 tabs/30 days (across insomnia agents) Amerge (naratriptan) tabs 18 tabs/30 days (across all oral migraine agents) Ampyra (dalfampridine ext-release) tabs 60 tabs/30 days Androderm 2 mg, 2.5 mg (testosterone) patches 60 patches/30 days Androderm 4 mg, 5 mg (testosterone) patches 30 patches/30 days Androgel (testosterone) gel 4 bottles (300 g)/30 days IV

6 Brand Name (Generic Name) Dosage Form Dispensing Limit Androgel 2.5 g (testosterone) packets 30 packets/30 days Androgel 5 g (testosterone) packets 60 packets/30 days Anzemet 50 mg (dolasetron) tabs 6 tabs/30 days Anzemet 100 mg (dolasetron) tabs 3 tabs/30 days Arcalyst (rilonacept) inj 4 vials/30 days Arixtra (fondaparinux) inj 360 units/270 days (across Arixtra, Fragmin, and Lovenox) Asmanex (mometasone) inhaler 1 inhaler/rx Astelin (azelastine) nasal spray 2 bottles/30 days Astepro (azelastine) nasal spray 2 bottles/30 days Atralin (tretinoin) gel Under age 40 Atrovent 0.03% (ipratropium) nasal spray 1 bottle/30 days Atrovent 0.06%(ipratropium) nasal spray 3 bottles/30 days Atrovent HFA (ipratropium) inhaler 2 inhalers/rx Avinza (morphine sulfate ext-release) caps 30 caps/30 days Avonex (interferon beta-1a) inj 1 package/28 days Avita tretinoin crm, gel Under age 40 Axert (almotriptan) tabs 18 tabs/30 days (across all oral migraine agents) Bactroban Nasal 2% (mupirocin) oint 10-1 g single-use tubes Beconase AQ (beclomethasone dipropionate) nasal spray 1 bottle/30 days Betaseron (interferon beta-1b) inj 14 vials/28 days Biaxin XL (clarithromycin ext-release) tabs 28 tabs/30 days Boniva 3 mg/3 ml (ibandronate) inj 1 injection/90 days Boniva 150 mg (ibandronate) tabs 1 tab/30 days Bravelle (urofollitropin) inj 60 vials/rx butorphanol nasal spray 2 bottles/30 days Butrans (buprenorphine) patches 4 patches/30 days Bydureon (exenatide ext-release) inj 4 trays/28 days Byetta (exenatide) pen 1 pen/30 days Caverject (alprostadil) inj 8 units/30 days; males only (limit one agent for erectile dysfunction/30 days) Cayston (aztreonam) inhal soln 84 vials/56 days Celebrex 50 mg, 100 mg, 200 mg (celecoxib) caps 60 caps/30 days Celebrex 400 mg (celecoxib) caps 30 caps/30 days Cetrotide 0.25 mg (cetrorelix) inj 12 kits/rx Cetrotide 3 mg (cetrorelix) inj 1 kit/rx chorionic gonadotropin inj 20 ml/rx Cialis 2.5 mg, 5 mg (tadalafil) tabs 30 tabs/30 days; males only (limit one agent for erectile dysfunction/30 days) Cialis 10 mg, 20 mg (tadalafil) tabs 8 tabs/30 days; males only (limit one agent for erectile dysfunction/30 days) ciprofloxacin ext-release, 500 mg tabs 3 tabs/30 days ciprofloxacin ext-release, 1000 mg tabs 14 tabs/30 days Climara (estradiol) patches 28 patches/28 days Clomid (clomiphene) tabs 10 tabs/rx Cold and cough products various Age 5 or older Combivent and Combivent Respimat (ipratropium/albuterol) inhaler 2 inhalers/rx Copaxone (glatiramer) inj 30 syringes/30 days Crinone (progesterone) vaginal gel 60 applicators/rx cromolyn sodium inhal soln 240 ml/rx Cymbalta 20 mg, 60 mg (duloxetine) caps 60 caps/30 days V

7 Brand Name (Generic Name) Dosage Form Dispensing Limit Cymbalta 30 mg (duloxetine) caps 90 caps/30 days D.H.E mg/ml (dihydroergotamine) inj 10 ml/30 days Desoxyn (methamphetamine) tabs 150 tabs/30 days Dexilant (dexlansoprazole delayed-release) caps 60 caps/30 days (limit one proton pump inhibitor in 30 days) Diastat (diazepam) rectal gel 5 packages/30 days Differin 0.1% (adapalene) crm, gel Under age 40 Differin 0.3% (adapalene) gel Under age 40 Differin (adapalene) lotn Under age 40 Diflucan (fluconazole) tabs 90 tabs/180 days Diflucan (fluconazole) oral susp 35 ml/30 days Duexis (ibuprofen/famotidine) tabs 90 tabs/30 days Dulera (mometasone/formoterol) inhaler 1 inhaler/rx Duoneb (ipratropium/albuterol) inhal soln 540 ml/rx Duragesic (fentanyl) patches 15 patches/30 days Edex (alprostadil) inj 8 cartridges/30 days; males only (Limit one agent for erectile dysfunction/30 days) Edluar (zolpidem) sublingual tabs 30 tabs/30 days (across all insomnia agents) Ella (ulipristal) tabs 2 tabs/365 days Emend 40 mg, 80 mg, and 125 mg (aprepitant) caps 12 caps/30 days Emend Tri-Pack (aprepitant) caps 6 caps/30 days Epiduo (adapalene/benzoyl peroxide) gel Under age 40 Exalgo 8 mg (hydromorphone ext-release) tabs 240 tabs/30 days (across all strengths) Exalgo 12 mg (hydromorphone ext-release) tabs 150 tabs/30 days (across all strengths) Exalgo 16 mg (hydromorphone ext-release) tabs 120 tabs/30 days (across all strengths) Extavia (interferon beta-1b) inj 1 package/30 days Fentora (fentanyl) buccal tabs 120 tabs/30 days Flonase (fluticasone propionate) nasal spray 1 bottle/30 days Flovent Diskus, Flovent HFA (fluticasone) inhaler 2 inhalers/rx Flunisolide nasal spray 1 bottle/30 days Follistim AQ 75 units/vial (follitropin beta) inj 60 vials/rx Follistim AQ 150 units/vial (follitropin beta) inj 30 vials/rx Follistim AQ 300 units/cartridge (follitropin beta) inj 15 cartridges/rx Follistim AQ 600 units/cartridge (follitropin beta) inj 8 cartridges/rx Follistim AQ 900 units/cartridge (follitropin beta) inj 5 cartridges/rx Foradil Aerolizer (formoterol) inhaler 1 inhaler (60 doses)/rx Forteo (teriparatide) inj 1 pen/30 days Fosamax 5 mg, 10 mg (alendronate) tabs 30 tabs/30 days Fosamax 35 mg, 70 mg (alendronate) tabs 4 tabs/30 days Fosamax Plus D (alendronate/cholecalciferol) tabs 4 tabs/30 days Fragmin (dalteparin) inj 360 unit/270 days (across Lovenox, Fragmin, and Arixtra) Frova (frovatriptan) tabs 18 tabs/30 days (across all oral migraine agents) Ganirelix Acetate inj 12 syringes (0.5 ml/syringe)/rx Gelnique (oxybutynin) gel 30 packets/30 days Gilenya (fingolimod) caps 30 caps/30 days Glucose Test Strips (All) strips 204 strips/30 days Gonal F 450 units/vial (follitropin alfa) inj 10 vials/rx Gonal F 1,050 units/vial (follitropin alfa) inj 5 vials/rx Gonal F RFF 75 units/vial (follitropin alfa) inj 60 vials/rx Gonal F RFF Pen 300 units/cartridge (follitropin alfa) inj 15 cartridges/rx Gonal F RFF Pen 450 units/cartridge (follitropin alfa) inj 10 cartridges/rx Gonal F RFF Pen 900 units/cartridge (follitropin alfa) inj 5 cartridges/rx VI

8 Brand Name (Generic Name) Dosage Form Dispensing Limit granisetron tabs 15 tabs/30 days Granisol (granisetron) oral soln 30 ml/30 days Imitrex (sumatriptan) nasal spray 12 spray unit devices/30 days Imitrex STATDose (sumatriptan) inj 12 syringe cartridges/30 days Imitrex (sumatriptan) inj 12 vials/30 days Imitrex (sumatriptan) tabs 18 tabs/30 days (across all oral migraine agents) Insulins (All) inj 100 ml/30 days Insulin pen needles, syringes (All) pen needles, syringes 300 units/30 days Intermezzo (zolpidem) sublinqual tabs 30 tabs/30 days (across all insomnia agents) ipratropium inhal soln 375 ml/rx Janumet (sitagliptin/metformin) tabs 60 tabs/30 days Janumet XR mg, mg (sitagliptin/metformin ext-release) Janumet XR mg (sitagliptin/metformin ext-release) tabs tabs 30 tabs/30 days 60 tabs/30 days Januvia (sitagliptin) tabs 30 tabs/30 days Jentadueto (linagliptin/metformin) tabs 60 tabs/30 days Juvisync (sitagliptin/simvastatin) tabs 30 tabs/30 days Kadian 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg (morphine sulfate ext-release) Kadian 10 mg, 200 mg (morphine sulfate ext-release) caps caps 120 caps/30 days 120 caps/30 days ketorolac tabs 20 tabs/30 days Kombiglyze XR mg, mg (saxagliptin/metformin ext-release) Kombiglyze XR mg (saxagliptin/ metformin ext-release) tabs tabs 30 tabs/30 days 60 tabs/30 days Lamisil (terbinafine) tabs 90 tabs/180 days Latuda (lurasidone) tabs 30 tabs/30 days Lazanda (fentanyl) nasal spray 30 bottles/30 days Letairis (ambrisentan) tabs 30 tabs/30 days Levitra (vardenafil) tabs 8 tabs/30 days; males only (limit one agent for erectile dysfunction/30 days) Lovenox (enoxaparin) inj 360 units/270 days (across Lovenox, Fragmin, and Arixtra) Lumigan (bimatoprost) ophthalmic soln 2.5 ml/30 days Lunesta (eszopiclone) tabs 30 tabs/30 days (across all insomnia agents) Luveris (lutropin alfa) inj 14 vials/rx Marinol (dronabinol) caps 60 caps/30 days Maxair Autohaler (pirbuterol) inhaler 1 inhaler/rx Maxalt/Maxalt-MLT (rizatriptan) tabs 18 tabs/30 days (across all oral migraine agents) Menopur (menotropins) inj 60 vials/rx Menostar (estradiol) patches 28 patches/28 days Migranal (dihydroergotamine) nasal spray 8 vials/30 days Muse (alprostadil) supp 8 supps/30 days; males only (limit one agent for erectile dysfunction/ 30 days) Namenda 5 mg (memantine) tabs 30 tabs/30 days Namenda 10 mg (memantine) tabs 60 tabs/30 days Namenda Titration Pak (memantine) tabs 49 tabs (1 pack)/365 days no coverage at mail Nasacort AQ (triamcinolone) nasal spray 1 bottle/30 days Nasonex (mometasone) nasal spray 1 bottle/30 days VII

9 Brand Name (Generic Name) Dosage Form Dispensing Limit Nexium (esomeprazole delayed-release) caps, packets 60 caps, packets/30 days (limit one proton pump inhibitor in 30 days) Nucynta (tapentadol) tabs 180 tabs/30 days Nucynta ER (tapentadol ext-release) tabs 60 tabs/30 days Omnaris (ciclesonide) nasal spray 1 bottle/30 days ondansetron 24 mg tabs 4 tabs/30 days Onglyza (saxagliptin) tabs 30 tabs/30 days Onsolis (fentanyl) buccal film 120 films/30 days (not covered at mail) Ovidrel (choriogonadotropin alfa) inj 2 syringes/rx Oxycontin (oxycodone ext-release) tabs 120 tabs/30 days Oxytrol (oxybutynin) patches 8 patches/30 days Patanase (olopatadine) nasal spray 1 bottle/30 days Penlac (ciclopirox) nail soln 13.2 ml/30 days Plan B (levonorgestrel) tabs Covered for females age 16 yrs and under with Rx 4 tabs/365 days Plan B One-Step (levonorgestrel) tabs Covered for females age 16 yrs and under with Rx 2 tabs/365 days Pradaxa (dabigatran) caps 60 caps/30 days Prevacid (lansoprazole delayed-release) caps 60 caps/30 days (limit one proton pump inhibitor in 30 days) Prevacid Solutab (lansoprazole delayed-release) orally disintegrating tabs 60 tabs/30 days (limit one proton pump inhibitor in 30 days) Prilosec (omeprazole delayed-release) caps 60 caps/30 days (limit one proton pump inhibitor in 30 days) Pristiq (desvenlafaxine ext-release) tabs 60 tabs/30 days Proair HFA (albuterol) inhaler 2 inhalers/rx Prochieve (progesterone) gel 60 applicators/rx Promacta 25 mg (eltrombopag) tabs 90 tabs/30 days Promacta 12.5 mg, 50 mg, 75 mg (eltrombopag) tabs 30 tabs/30 days Protonix (pantoprazole delayed-release) granules 60 packets/30 days (limit one proton pump inhibitor in 30 days) Protonix (pantoprazole delayed-release) tabs 60 tabs/30 days (limit one proton pump inhibitor in 30 days) Proventil HFA (albuterol) inhaler 2 inhalers/rx Prozac Weekly (fluoxetine delayed-release) caps 4 caps/28 days Pulmicort Flexhaler 180 mcg (budesonide) inhaler 2 inhalers/rx Pulmicort Flexhaler 90 mcg (budesonide) inhaler 1 inhaler/rx Pulmicort Respules 1 mg/2 ml (budesonide) inhal susp 180 ml/rx Pulmicort Respules 0.25 mg/2 ml, 0.5 mg/2 ml (budesonide) inhal susp 180 ml/rx Pylera (bismuth/metronidazole/tetracycline) caps 120 caps/30 days Qvar (beclomethasone) inhaler 2 inhalers/rx Rebif 22 mcg/0.5 ml, 44 mcg/0.5 ml (interferon beta-1a) inj 12 syringes/28 days Rebif titration pack (interferon beta-1a) inj 1 kit/28 days Regranex (becaplermin) gel 60 grams/365 days Relenza (zanamivir) inhaler 1 inhaler (20 doses)/120 days Relpax (eletriptan) tabs 18 tabs/30 days (across all oral migraine agents) Repronex (menotropins) inj 60 vials/rx Retin-A (tretinoin) crm, gel Under age 40 Retin-A Micro (tretinoin microsphere) gel Under age 40 Revatio (sildenafil) tabs 90 tabs/30 days (across all strengths) ReVia (naltrexone) tabs 180 tabs/365 days Rhinocort Aqua (budesonide) nasal spray 2 bottles/30 days Rozerem (ramelteon) tabs 30 tabs/30 days (across all insomnia agents) VIII

10 Brand Name (Generic Name) Dosage Form Dispensing Limit Ryzolt (tramadol ext-release) tabs 30 tabs/30 days Samsca 15 mg (tolvaptan) tabs 30 tabs/30 days Samsca 30 mg (tolvaptan) tabs 60 tabs/30 days Sancuso (granisetron) patches 2 patches/30 days Savella (milnacipran) tabs 60 tabs/30 days Savella Titration Pack (milnacipran) pack 1 pack/30 days Serevent Diskus (salmeterol) inhaler 1 inhaler (60 doses)/rx Silenor (doxepin) tabs 30 tabs/30 days (across all insomnia agents) Simponi (golimumab) inj 1 syringe/30 days Sonata (zaleplon) caps 30 caps/30 days (across all insomnia agents) Spiriva Handihaler (tiotropium) inhaler 1 package (30 doses)/rx Sporanox (itraconazole) caps 360 caps/180 days Sporanox (itraconazole) soln 22 bottles (3,300 ml)/180 days Sprix (ketorolac) nasal spray 5 bottles/30 days Staxyn (vardenafil) tabs 8 tabs/30 days, males only (limit one agent for erectile dysfunction/30 days) Suboxone (buprenorphine/naloxone) sublingual films, tabs 90 films, tabs/30 days Subsys (fentanyl) sublingual spray 120 doses/30 days Subutex (buprenorphine) sublingual tabs 90 tabs/30 days Sumatriptan nasal spray 12 spray unit devices/30 days Sumavel DosePro (sumatriptan) inj 12 injection devices/30 days Symbicort (budesonide/formoterol) inhaler 1 inhaler/rx Symlin (pramlintide) inj 4 vials/30 days SymlinPen (pramlintide) inj 2 boxes/30 days Tamiflu 30 mg (oseltamivir) caps 40 caps/120 days Tamiflu 45 mg, 75 mg (oseltamivir) caps 20 caps/120 days Tamiflu 6 mg/ml (oseltamivir) oral susp 360 ml/120 days Testim (testosterone) gel 60 tubes (300 g)/30 days tizanidine 2 mg tabs 180 tabs/30 days Tobi (tobramycin) inhal soln 1 package (56 ampules)/56 days Tracleer (bosentan) tabs 60 tabs/30 days Tradjenta (linagliptin) tabs 30 tabs/30 days Travatan Z (travoprost) ophth soln 2.5 ml/30 days Tretin-X (tretinoin) crm Under age 40 Treximet (sumatriptan/naproxen sodium) tabs 18 tabs/30 days (across all oral migraine agents) Ultram (tramadol) tabs 240 tabs/30 days Ultram ER (tramadol ext-release) tabs 30 tabs/30 days Veltin (clindamycin/tretinoin) gel Under age 40 Ventolin HFA (albuterol) inhaler 2 inhalers/rx Veramyst (fluticasone furoate) nasal spray 1 bottle/30 days Viagra (sildenafil) tabs 8 tabs/30 days; males only (limit one agent for erectile dysfunction/30 days) Victoza (liraglutide) inj 3 pens/30 days Vimovo (naproxen/esomeprazole) tabs 60 tabs/30 days Vivelle-Dot (estradiol) patches 28 patches/28 days Vyvanse (lisdexamfetamine) caps 30 caps/30 days Xalatan (latanoprost) ophth soln 2.5 ml/30 days Xanax XR (alprazolam ext-release) tabs 60 tabs/30 days Xarelto 10 mg (rivaroxaban) tabs 35 tabs/90 days Xarelto 15 mg, 20 mg (rivaroxaban) tabs 30 tabs/30 days IX

11 Brand Name (Generic Name) Dosage Form Dispensing Limit Xenazine 12.5 mg (tetrabenazine) tabs 240 tabs/30 days Xenazine 25 mg (tetrabenazine) tabs 120 tabs/30 days Xifaxan 200 mg (rifaximin) tabs 9 tabs/30 days Xifaxan 550 mg (rifaximin) tabs 60 tabs/30 days Xopenex 0.31 mg, 0.63 mg, 1.25 mg (levalbuterol) nebulized soln 375 ml/rx Xopenex Concentrate 1.25 mg/ 0.5 ml (levalbuterol) nebulized soln 90 units/rx Xopenex HFA (levalbuterol) inhaler 2 inhalers/rx Xyrem (sodium oxybate) oral soln 540 ml/30 days Zanaflex (tizanidine) caps 180 caps/30 days Zanaflex (tizanidine) 4 mg tabs 180 tabs/30 days Zegerid (omeprazole/sodium bicarbonate) caps 60 units/30 days (limit one proton pump inhibitor in 30 days) Zegerid (omeprazole/sodium bicarbonate) powder 60 units/30 days (limit one proton pump inhibitor in 30 days) Zetia (ezetimibe) tabs 30 tabs/30 days Ziana (clindamycin/tretinoin) gel Under age 40 Zioptan (tafluprost) ophth soln 30 single-use containers/30 days Zithromax (azithromycin) tabs 60 tabs/150 days Zofran (ondansetron) oral soln 100 ml/30 days Zofran/Zofran ODT 4 mg, 8 mg (ondansetron) tabs 30 tabs/30 days Zolpimist (zolpidem) oral spray 1 bottle/30 days (limit one insomnia agent per 30 days) Zomig (zolmitriptan) nasal spray 2 bottle (12 spray units)/30 days Zomig/Zomig ZMT (zolmitriptan) tabs 18 tabs/30 days (across all oral migraine agents) Zuplenz (ondansetron) films 12 films/30 days Zyvox (linezolid) oral susp 600 ml/180 days Zyvox (linezolid) tabs 56 tabs/180 days (PA): Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for misuse. This means that your doctor will need to submit a prior authorization request for coverage of these medications, and the request will need to be approved, before the medication will be covered under your plan. For the formulary medications listed in this document, if a prior authorization is commonly required it will be noted next to the medication with a dot under the prior authorization column as noted in the section How To Use This List. Some plans may have prior authorization on additional medications beyond those noted in this document. (ST): Your benefit plan may include a step therapy program. This means you may need to try another proven, costeffective 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. For the formulary medications listed in this document, if a step therapy is commonly required it will be noted next to the medication with a dot under the step therapy column as noted in the section How To Use This List. Some plans may have step therapy programs on additional medications beyond those noted in this document. Remember, medication decisions are between you and your doctor. Only your doctor can determine which medication is right for you. Discuss any questions or concerns you have about medications you are taking or are prescribed with your doctor. X

12 drugs drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, 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. For a current list of specialty medications, visit myprime.com or bcbsil.com and log in to Blue Access for Members. Note that some drug classes may be excluded by some plans and therefore may not be covered under your pharmacy benefit. Your plan may have a different coverage level for specialty drugs. If you have questions about your coverage for specialty medications or your prescription drug benefit, call the number on the back of your ID card. Prime Therapeutics Pharmacy Program Through Prime Therapeutics Pharmacy, members can have covered specialty medications delivered directly to them or their doctor s office. When you receive specialty medications through Prime, you also receive at no additional charge the following services: Coordination of coverage between you, your doctor and your health plan Educational materials about your particular condition and information about managing potential medication side effects Syringes, sharps containers and other supplies with every shipment for self-injectables 24/7/365 phone access to a pharmacist for urgent medication issues To order through Prime Therapeutics Pharmacy: Have your doctor call or fax your prescription to Prime Therapeutics Pharmacy. Your doctor can call or fax to If you have an existing prescription for a covered specialty medication, you can call to transfer your prescription. A Prime Therapeutics coordinator will contact you to arrange delivery of your medication. The prescription can be shipped directly to you or your prescribing doctor s office. Each package is individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging. If you have questions, please contact Prime Therapeutics Pharmacy at , visit specialty, or call the number on the back of your ID card. * Blue Cross and Blue Shield of Illinois is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company ( HCSC ). HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC. Abbreviation/acronym key caps capsules oint ointment conc concentrate OSM osmotic release crm cream PA prior authorization DL dispensing limits SL sublingual ext-release extended-release soln solution inj injection supp suppositories lotn lotion susp suspension NF non-formulary ST step therapy ODT orally disintegrating tabs tabs tablets XI

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